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Measurement in angio-neurotic oedema
Journal
of Psychosomatic Research,
1964, Vol. 8. pp. 207 to 211. Pergamon Press Ltd. Printed in Northern Ireland
MEASUREMENT
IN ANGIO-NEUROTIC
OEDEMA
A. CAMERON MACDONALD “Home they brought her warrior dead, She nor swoon’d nor uttered cry: All her maidens, watching, said, ‘She must weep or she will die’.” TENNYSON. FOR MEone of the most intriguing facets of psychosomatic medicine is the possibility that one may be able to demonstrate to our sceptical “organic” colleagues that emotional factors can produce physical and biochemical changes which can be measured, and which may eventually be correlated with the emotional stresses involved. Barnes and Schottstaedt (1960) noted that congestive cardiac failure could be precipitated by emotional upset. My clinical experience with patients suffering from angioneurotic oedema and other water retention syndromes, such as idiopathic ankle oedema and possibly pre-menstrual tension, suggested that this was a process which was emotionally based and which might be suitable for this type of measurement, especially as some of the emotional precipitants were relatively specific and fairly easily induced or reversed. I gained the impression clinically that almost all the patients with water retention syndromes admitted that they had never been able to weep-“1 never cry, Doctor” is a recurring statement. Indeed I believe that these syndromes fulfil the symbolism of internal weeping much more fully than does asthma, though the two conditions are often related. Their attacks are usually associated with a situation of bereavement or separation, especially if feelings of guilt or resentment are involved. Discussion of this situation results in a diuresis and frequently in complete relief of symptoms. With the help of my colleague, Dr. Glen, I have been attempting to make physiological measurements on these patients. We have found this surprisingly difficult and it may be helpful to report the snags we have encountered. Patients with this syndrome are mainly seen as outpatients between their attacks. Patients who are actually admitted to hospital are often in danger of oedema of the glottis (which appears to be a sophisticated form of suicide by drowning), and with these patients the humanitarian demands of symptomatic and psychotherapeutic treatment are more vital than the temptation to organise academic experiments. We have, therefore, worked mainly on those out-patients who have a tendency to water retention but are not in an exacerbation of the disturbance at the time of the investigations. We first attempted salt and water balance experiments, but the work involved in controlling diet and collecting specimens was unjustified as the measurements were too crude and cumbersome to correlate with the rapid changes in fluid balance which these patients seemed to experience. Our senior biochemist, Dr. E. B. Hendry, was at this time interested in the estimation of osmolarities of tissue fluids (Hendry, 1962) and he kindly agreed to cooperate in our investigations. 207
208
A. CAMERON MACDONALD
The first venture was to take repeated blood samples at half to one hourly intervals over a three to four hour period and to estimate the serum osmolarity. During this time the patients were interviewed by me. We embarked with the idea of conducting an interview which was stressful, but this I find difficult, and we compromised by conducting a psychotherapeutic type of interview and assessing afterwards whether We were initially impressed by this had been stressful or re-assuring to the patient. a drop in serum osmolarity following interview, but a control series produced a similar fall (Fig. 1). As neither group deviated from the normal range for serum osmolarity we concluded that no useful information could be obtained by this technique.
HOURS
FIG. 1. Serum osmolarity in patients and controls estimated at intervals over a period of three hours. The hatched area indicates the period of a psychotherapeutic type of interview.
We next collected hourly urine specimens and conducted interviews during the third hour of the collection. The patients were in a normal state of hydration and during the control period they were seated comfortably and allowed to read, knit or do anything they wished except smoke as this stimulates anti-diuretic hormone. The results of these measurements were compared with those of a very large series of normals investigated by Dr. Hendry in work to be published shortly (Hendry, 1963). He showed that up to an hourly output of 75 ml of urine the relationship between urinary output per hour and the milliosmol output per hour is constant. Above this hourly volume of 75 ml no such correlation exists. The estimations on our patients within this output limit (Fig. 2) suggested that these patients were abnormal in their method of coping with fluids. On the whole we confirmed the findings of previous workers such as Barnes and Schottstaedt (1960) Gibbons (1960) and Miles and de Wardener (1953). Situations of stress involving anger, defence and resentment, in which patients tended to withdraw, seemed to produce oliguria; whereas relaxed and re-assuring attitudes with easy communication produced an outgoing situation symbolic even in terms of urinary outflow. It seems likely that normal people have these responses also but do not react with the violent fluctuations which characterise patients with water retention syndromes.
Measurement in angio-neurotic oedema
209
FIG. 2. Relationship between milliosmol output per hour and rate of urine flow. The lines are derived from a large series of normal subjects; the dots are values from patients. OSMOLAR
URINE
OUTPUT
CrnOSrn) r75
VOLUME (mls)
HOURS
FIG. 3. Patient One. Urine flow (thick line) and urine milliosmol output per hour
(broken line). Interview at hatched area. To investigate the emotional factor one must revert to individual cases as the conflicts are always individual. In the few examples which follow, only the hourly urinary output and osmolarity are shown. Detailed biochemical analyses showed that urea, potassium, phosphate, uric acid and creatinine output were proportional to the osmolarity and only sodium and chloride very occasionally deviated therefrom.
Patient One (Fig. 3) Her angio-neurotic oedema and bronchospasm had been precipitated by the death of her fianct’s boy friend in a street accident, and she had attempted thereafter to persuade her fiance never to walk along that particular street. He refused to become involved in her fantasies and departed to work in England producing a separation situation with guilt feelings in the patient. Her angio-neurotic oedema had improved after earlier discussions and her engagement had been re-established. At the time of this interview I discussed her forthcoming marriage and she became upset on having to admit to feelings of frigidity and terror in sexual relationships. A fall in the urinary output and osmolarity followed.
A. CAMERON MACDONALD
210
300 1
“RINE
OSMOLAR
VOLUME
OUTPUT
CrnlS)
(mOsm)
rT5
I I I
FIG. 4. Patient Two. Urine flow (thick line) and urine milliosmol output per hour (broken line). The first two estimations are during the anticipation of an endoscopy which took place at the hatched area without premeditation.
FIG. 5. Patient Three.
Urine flow (thick line) and urine milliosmol output per hour (broken line). Stressful interview at hatched area.
Parient Two (Fig. 4) To confirm that this was retention symptoms, we did a a fibroscopy for peptic ulcer. was grossly stressful in terms the output to 3 ml per hour.
a response to stress even in patients without water similar series of collections on a patient about to have No pre-medication was used and even the anticipation of urinary output, and the actual endoscopy reduced
Patient Three (Fig. 5) This lady was a long term patient who had previously demonstrated angioneurotic oedema which had been relieved by psychotherapy. During this interview she began to speak of her daughter who had attempted suicide a few days previouslya stressful topic with a fall in the urinary output, followed perhaps by a therapeutic diuresis.
Measurement in angio-neurotic
oedema
211
OSMOLAR
URINE
OUTPVT
VOLUME lITI
hYo5rn
)
HOURS
FIG. 6. Patient Four.
Urine flow (thick line) and urine milliosmol
output per hour,
(broken line). Interview at hatched area. Patient
Four (Fig. 6)
This lady had a gross water retention syndrome in the form of idiopathic leg oedema. On reaching hospital for the tests she became involved in a heated argument with the ward sister who had not been warned of her arrival. During the control period she became more furious and resentful at her reception. The interview was extremely cathartic and involved suitable explanation and apologies from myself and the urinary output rose from 2-7 to 148 ml per hour. This was a longer interview than usual and at the end of it I suggested gently that further discussion might help her oedema. She became defensive and this may account for the subsequent fall in output.
These preliminary experiments suggest that hourly urinary output records may be a helpful additional means of measuring the emotional state in other types of psychosomatic investigation. A cautionary corollary emerges that the routine collection of hourly specimens in medical wards for the assessment of renal function are probably valueless’ unless the emotional factors are controlled or at least considered. _ REFERENCES BARNES R. and SCH~TTSTAEDTW. W. GIBBONS J. L. HENDRY E. B.. HARRISON 1. M. and FLETCHER M. J. MILES B. E. and DE WARDENEI~H. R.
1960 1960 1964 1953
Amer. J. Med. 29, 211-227. C/in. Sci. 19, 133-138. Clin. Chim. Acra IO, 243-252. L.atrcet 2, 539-544.
of Psychosomatic Research,
1964, Vol. 8. pp. 207 to 211. Pergamon Press Ltd. Printed in Northern Ireland
MEASUREMENT
IN ANGIO-NEUROTIC
OEDEMA
A. CAMERON MACDONALD “Home they brought her warrior dead, She nor swoon’d nor uttered cry: All her maidens, watching, said, ‘She must weep or she will die’.” TENNYSON. FOR MEone of the most intriguing facets of psychosomatic medicine is the possibility that one may be able to demonstrate to our sceptical “organic” colleagues that emotional factors can produce physical and biochemical changes which can be measured, and which may eventually be correlated with the emotional stresses involved. Barnes and Schottstaedt (1960) noted that congestive cardiac failure could be precipitated by emotional upset. My clinical experience with patients suffering from angioneurotic oedema and other water retention syndromes, such as idiopathic ankle oedema and possibly pre-menstrual tension, suggested that this was a process which was emotionally based and which might be suitable for this type of measurement, especially as some of the emotional precipitants were relatively specific and fairly easily induced or reversed. I gained the impression clinically that almost all the patients with water retention syndromes admitted that they had never been able to weep-“1 never cry, Doctor” is a recurring statement. Indeed I believe that these syndromes fulfil the symbolism of internal weeping much more fully than does asthma, though the two conditions are often related. Their attacks are usually associated with a situation of bereavement or separation, especially if feelings of guilt or resentment are involved. Discussion of this situation results in a diuresis and frequently in complete relief of symptoms. With the help of my colleague, Dr. Glen, I have been attempting to make physiological measurements on these patients. We have found this surprisingly difficult and it may be helpful to report the snags we have encountered. Patients with this syndrome are mainly seen as outpatients between their attacks. Patients who are actually admitted to hospital are often in danger of oedema of the glottis (which appears to be a sophisticated form of suicide by drowning), and with these patients the humanitarian demands of symptomatic and psychotherapeutic treatment are more vital than the temptation to organise academic experiments. We have, therefore, worked mainly on those out-patients who have a tendency to water retention but are not in an exacerbation of the disturbance at the time of the investigations. We first attempted salt and water balance experiments, but the work involved in controlling diet and collecting specimens was unjustified as the measurements were too crude and cumbersome to correlate with the rapid changes in fluid balance which these patients seemed to experience. Our senior biochemist, Dr. E. B. Hendry, was at this time interested in the estimation of osmolarities of tissue fluids (Hendry, 1962) and he kindly agreed to cooperate in our investigations. 207
208
A. CAMERON MACDONALD
The first venture was to take repeated blood samples at half to one hourly intervals over a three to four hour period and to estimate the serum osmolarity. During this time the patients were interviewed by me. We embarked with the idea of conducting an interview which was stressful, but this I find difficult, and we compromised by conducting a psychotherapeutic type of interview and assessing afterwards whether We were initially impressed by this had been stressful or re-assuring to the patient. a drop in serum osmolarity following interview, but a control series produced a similar fall (Fig. 1). As neither group deviated from the normal range for serum osmolarity we concluded that no useful information could be obtained by this technique.
HOURS
FIG. 1. Serum osmolarity in patients and controls estimated at intervals over a period of three hours. The hatched area indicates the period of a psychotherapeutic type of interview.
We next collected hourly urine specimens and conducted interviews during the third hour of the collection. The patients were in a normal state of hydration and during the control period they were seated comfortably and allowed to read, knit or do anything they wished except smoke as this stimulates anti-diuretic hormone. The results of these measurements were compared with those of a very large series of normals investigated by Dr. Hendry in work to be published shortly (Hendry, 1963). He showed that up to an hourly output of 75 ml of urine the relationship between urinary output per hour and the milliosmol output per hour is constant. Above this hourly volume of 75 ml no such correlation exists. The estimations on our patients within this output limit (Fig. 2) suggested that these patients were abnormal in their method of coping with fluids. On the whole we confirmed the findings of previous workers such as Barnes and Schottstaedt (1960) Gibbons (1960) and Miles and de Wardener (1953). Situations of stress involving anger, defence and resentment, in which patients tended to withdraw, seemed to produce oliguria; whereas relaxed and re-assuring attitudes with easy communication produced an outgoing situation symbolic even in terms of urinary outflow. It seems likely that normal people have these responses also but do not react with the violent fluctuations which characterise patients with water retention syndromes.
Measurement in angio-neurotic oedema
209
FIG. 2. Relationship between milliosmol output per hour and rate of urine flow. The lines are derived from a large series of normal subjects; the dots are values from patients. OSMOLAR
URINE
OUTPUT
CrnOSrn) r75
VOLUME (mls)
HOURS
FIG. 3. Patient One. Urine flow (thick line) and urine milliosmol output per hour
(broken line). Interview at hatched area. To investigate the emotional factor one must revert to individual cases as the conflicts are always individual. In the few examples which follow, only the hourly urinary output and osmolarity are shown. Detailed biochemical analyses showed that urea, potassium, phosphate, uric acid and creatinine output were proportional to the osmolarity and only sodium and chloride very occasionally deviated therefrom.
Patient One (Fig. 3) Her angio-neurotic oedema and bronchospasm had been precipitated by the death of her fianct’s boy friend in a street accident, and she had attempted thereafter to persuade her fiance never to walk along that particular street. He refused to become involved in her fantasies and departed to work in England producing a separation situation with guilt feelings in the patient. Her angio-neurotic oedema had improved after earlier discussions and her engagement had been re-established. At the time of this interview I discussed her forthcoming marriage and she became upset on having to admit to feelings of frigidity and terror in sexual relationships. A fall in the urinary output and osmolarity followed.
A. CAMERON MACDONALD
210
300 1
“RINE
OSMOLAR
VOLUME
OUTPUT
CrnlS)
(mOsm)
rT5
I I I
FIG. 4. Patient Two. Urine flow (thick line) and urine milliosmol output per hour (broken line). The first two estimations are during the anticipation of an endoscopy which took place at the hatched area without premeditation.
FIG. 5. Patient Three.
Urine flow (thick line) and urine milliosmol output per hour (broken line). Stressful interview at hatched area.
Parient Two (Fig. 4) To confirm that this was retention symptoms, we did a a fibroscopy for peptic ulcer. was grossly stressful in terms the output to 3 ml per hour.
a response to stress even in patients without water similar series of collections on a patient about to have No pre-medication was used and even the anticipation of urinary output, and the actual endoscopy reduced
Patient Three (Fig. 5) This lady was a long term patient who had previously demonstrated angioneurotic oedema which had been relieved by psychotherapy. During this interview she began to speak of her daughter who had attempted suicide a few days previouslya stressful topic with a fall in the urinary output, followed perhaps by a therapeutic diuresis.
Measurement in angio-neurotic
oedema
211
OSMOLAR
URINE
OUTPVT
VOLUME lITI
hYo5rn
)
HOURS
FIG. 6. Patient Four.
Urine flow (thick line) and urine milliosmol
output per hour,
(broken line). Interview at hatched area. Patient
Four (Fig. 6)
This lady had a gross water retention syndrome in the form of idiopathic leg oedema. On reaching hospital for the tests she became involved in a heated argument with the ward sister who had not been warned of her arrival. During the control period she became more furious and resentful at her reception. The interview was extremely cathartic and involved suitable explanation and apologies from myself and the urinary output rose from 2-7 to 148 ml per hour. This was a longer interview than usual and at the end of it I suggested gently that further discussion might help her oedema. She became defensive and this may account for the subsequent fall in output.
These preliminary experiments suggest that hourly urinary output records may be a helpful additional means of measuring the emotional state in other types of psychosomatic investigation. A cautionary corollary emerges that the routine collection of hourly specimens in medical wards for the assessment of renal function are probably valueless’ unless the emotional factors are controlled or at least considered. _ REFERENCES BARNES R. and SCH~TTSTAEDTW. W. GIBBONS J. L. HENDRY E. B.. HARRISON 1. M. and FLETCHER M. J. MILES B. E. and DE WARDENEI~H. R.
1960 1960 1964 1953
Amer. J. Med. 29, 211-227. C/in. Sci. 19, 133-138. Clin. Chim. Acra IO, 243-252. L.atrcet 2, 539-544.