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Cardiac Palpitation And Gastro-intestinal Disturbance





Morgagni, whom Virchow greeted as the Father of Modern Pathology, made
a careful study of the pulse and especially of its irregularities. He
had learned from the most careful pathological studies that marked
intermission and even more decided irregularity of the heart may be
present in life, though there may be absolutely no organic affection
of the heart itself, either of the valves or of the muscle,
discoverable at autopsy. In his opinion the most frequent cause for
such irregularity is flatulency and disturbance of digestion
generally. He went still farther, however, and seems to have
understood very well that constipation was often one of the most
important links in the chain of causes leading up to such heart
disturbance, itself either a cause or an effect of other digestive
symptoms. This idea deserves to be borne in mind when there is
question of the significance of heart symptoms. What Morgagni thus
determined by precise studies in pathological anatomy had been
clinically observed by many of the distinguished old-time
practitioners of medicine, who knew the fatal tendencies of organic
heart symptoms, yet recognized that many cardiac cases associated with
gastric symptoms did not have an unfavorable prognosis.



In spite of the recognition of these conditions by old-time medical
investigators, there has always been a tendency to fear that heart
symptoms in these cases might be due to a cardiac affection. This has
invariably been true for patients themselves to whom the heart
disturbance became conscious, but has often made physicians hesitate
as to the diagnosis and rendered their prognosis more unfavorable than
is justified by actual knowledge.


Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal
cardiac neuroses usually run a typical course. As a rule, with young
folks, the beginning of cardiac unrest is found in some stomachic
symptoms. The distention of the stomach with gas is said to be a
mechanical reason for interference with the heart action. Whether this
is really gas that has formed within the stomach, or whether it is to
a great extent, at least, gas which has been diffused from the vessels
of the stomach walls in a disordered viscus, or in some cases at
least, air which has been swallowed because of certain gaspy habits of
neurotic individuals, is hard to determine. In many cases the absence
of all odor of decomposition, or of any disagreeable taste, makes for
serious doubt whether the substance is really due to fermentation.
Certainly the changes that take place in food in the stomach during
the course of an hour or two of digestion are not sufficient to
account for the volume of gas that exerts pressure upon the gastric
walls and is eructated in large mouthfuls. Fermentative processes are
slow gas producers, as anyone with experience in the chemical
laboratory knows.


Mechanical Cardiac Interference.--Every physician has seen the young
man who is sure that he has heart trouble when he is really suffering
from indigestion. Many of the feelings of discomfort accompanied by
palpitation and irregularity are really phenomena connected rather
with the stomach than the heart itself. The reason for this is not
always clear. In many cases there seems to be a mechanical
interference with the heart's action. This is due to the presence of
gas in the stomach pressing against the diaphragm. In many cases the
distention of the stomach by a heavy meal, especially if the heart has
been rendered sensitive by the taking of stimulants, will have the
same effect. This is particularly noticeable if the patients lie down
shortly after the meal, when there is distinct discomfort in the
cardiac region and noticeable irregularity of the pulse.

The most frequent phenomenon is a missed beat, or often simply a sense
of discomfort in connection with the heart action that makes its
beating very noticeable. This palpitation, as it is called, is usually
entirely subjective. There is nothing abnormal in the sensation
produced on the hand when the heart is palpated, nothing the most
delicate finger can detect in the apex beat and nothing uniform in the
change in the heart sounds produced in these cases. There is usually a
somewhat over-excited action of the heart, but this is not
characteristically revealed by either palpation or auscultation. The
rhythm is interfered with, but the arrythmia affects only an
occasional beat, usually rather regularly spaced, and does not
interfere with the heart's rate nor with its action in any way. This
represents the most familiar form of cardiac neurosis and may, of
course, be due to such substances as tobacco, or coffee, or tea, where
these are taken in excess. Excess is always a matter of individual
idiosyncrasy.



Cardiac Reflexes.--It is thought by some that this heart
irregularity and palpitation is a reflex action due to irritation of
the gastric terminal filaments of the vagus nerve reflected back along
this nerve and affecting the heart. The doctrine of reflexes is not as
popular, however, as it was, but there can be no doubt of the fact
that the vagus nerve has terminal filaments in all the large organs,
yet is so extremely important to the heart that it has a definite
physiological meaning and doubtless is meant to act in such a way as
to stimulate the heart when these important organs are overloaded or
are laboring in their functions, and, on the other hand, to depress it
or at least to inhibit it somewhat, whenever there is a tendency to
send too much blood to these parts. In any case, whether the positive
factor in the production of the heart trouble be mechanical, as it
surely often is, or whether it be reflex and due to the action upon
the vagus, it must not be forgotten that in all cases where heart
symptoms occur with considerable intervals of absolute freedom from
them and with large subjective elements in the case, the relation of
the stomach or the digestive organs in general to the heart may serve
as their best explanation.


Gastric Dilatation.--In dilatation of the stomach there is likely to
be an associated tendency to a cardiac neurosis. Unfortunately, enough
of these cases have not been followed up so as to be sure what the
outcome is and whether there may not really have been some affection
of the myocardium with a premature breakdown of the heart. As a
consequence of the excessive irritation of the terminal filaments of
the vagus nerve in the stomach wall, or because of the mechanical
interference with the heart's action as a consequence of the dilated
stomach pulling upon the esophagus and probably somewhat interfering
with the action of the diaphragm, an irregularity of the heart action
is established and a sense of discomfort in the precordia develops
that is often very marked. These patients sometimes suffer from
pseudo-angina and still more frequently from cardiac irregularity.
This cardiac irregularity is sometimes quite marked, and yet in 24
hours, as a consequence of the emptying of the stomach, will
disappear, so that only slight intermittency remains, which eventually
subsides. I have known a heart affected thus to be pronounced
absolutely without any lesion when examined by a competent heart
specialist within a month after it had been so irregular as to be
quite alarming to both patient and physician.


Upward Distention.--There is sometimes a tendency for the stomach to
distend upward rather than to dilate downward and toward the left.
Perhaps this is due to the fact that in certain individuals the
gastric ligaments are much stronger and more unyielding than they are
in others. One thing is sure--that there are great individual
differences in these cases. In some that are without any demonstrable
gastric dilatation, except that gastric tympany extends higher than
usual, there is marked interference with the heart action. The
physician needs to see these cases when they are so irregular that
there would seem to be absolutely no doubt of the existence of a
myocardial lesion and then to examine them some months afterwards when
the stomach had been restored to good conditions, before he is able to
realize how much interference with heart action is consonant with
complete return in a comparatively short time to the normal, at least
so far as heart function goes. This is a very different opinion from
that held by many heart specialists and especially certain
German authorities, who insist that any irregularity of the heart must
be considered as probably representing a muscular lesion; but the
evidence of careful observers may be adduced in support of it, and it
is an opinion that very much reassures the patients.


Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always
seemed to me wise to recur to the opinions of some of the old-time
clinicians who noted symptoms very carefully and studied out
particularly the connection of symptoms with prognosis.


Morgagni.--Morgagni, for instance, whose clinical remarks are always
precious, said:

Now that mention is made of the intermission of the pulse which
approaches more nearly to the nature of an asphyxia than even its
slenderness or weakness (for what else is the intermission of the
pulse but a very short asphyxia, or what is an asphyxia but an
intermission which lasts very long?) the causes of this disorder in
the pulse are not to be passed over without examination in this
place, as the greater part of physicians are very greatly terrified
thereby, often with good reason, yet frequently without any; as when
there is some cause of it in the stomach or intestines, which may
even vanish away of itself, or be easily removed by the physician.
For in what manner a palpitation of the heart may sometimes be
brought on by flatus distending these parts, and again carried off
by the dissipation of such flatus, I have already said; and in the
same manner, or one not very dissimilar, it is also evident, that an
intermission of the pulse has sometimes generated, and gone off of
itself, in many whom I have known. At another time, in these very
same viscera, there is a matter which produces the same effect, by
irritating their nerves, with which you know how easily the nerves
of the heart consent. And this matter is sometimes of such a nature
that it may readily be prevented from harboring itself there. Thus I
remember, when I attended to the cure of a young girl who had a
fever, and an intermission of the pulse was added to the other
symptoms contrary to my expectations, I was not at all deterred from
giving such a medicine as I had before determined upon, that the
stomach and intestines might be well cleansed; and even that I gave
it so much the more boldly; and that on the same day after these
parts had been deterged, the pulse returned to its former standard.
But you will read even in the Sepulchretum that Ballonius had not
only seen this disorder of the pulse, but also that of a languid and
small stroke, removed in the same manner. "According to the degrees
to which the purging was carried," says he, "the pulse was
restored." And, indeed, there is an intermission of the pulse, that
is of a far longer continuance as that with which Lancisi says he
had been troubled "for the space of six years"; yet if this
intermission should be, as it was in him, "from a consent with the
hypochondria," it may be entirely and perfectly taken away, by
perfectly restoring those parts.


Lancisi.--Lancisi was another distinguished clinical observer who
made special studies in neurotic heart disturbance. These studies are
all the more interesting because he himself was a sufferer from this
affection for many years. He was inclined to think that his heart
intermittency was due to disturbance in his digestive organs and
especially those lying in the upper part of the abdomen. He attributes
it himself to sympathy with these and said that it came ex
hypochondriorum consensu, as it were a reflex from his hypochondriac
regions. As Lancisi lived to a pretty good age in spite of noting this
symptom in early middle life, the significance of it will be well
understood. It would be perfectly possible to gather a series of such
cases from among the distinguished physicians of history, and as for
our contemporaries and colleagues, at least one out of four of them
will tell you that at some time he has suffered from an affection of
this kind and has been much worried about it, yet has recovered
without incident and without any serious development.


English Opinion.--The role of the stomach in disturbing the heart is
only less important than that of the nervous system itself. Of course,
individual peculiarities, as I have said, are extremely important.
Some people seem to suffer very little cardiac disturbance from a
distended stomach, while in others all sorts of heart affections may
be simulated as the result of the mechanical interference with the
heart action by the pushing up of the diaphragm. Sir William Broadbent
in the article on "The Conduct of the Heart in the Face of
Difficulties," already quoted from, does not hesitate to say that
heart symptoms secondary to gastric disturbance probably cause more
suffering than does actual heart disease. Expressions of this kind
need to be borne in mind when we reassure patients who have all sorts
of queer, uncomfortable, often even painful, conditions in their
cardiac region, "Heart disease" has been, perhaps, mentioned casually
to them and as a consequence worry is adding a nervous element to
hamper a heart already seriously disturbed by gastric distention. Sir
William Broadbent's own words are given because they carry so much
weight in this matter:

The difficulties arising out of flatulent distention of the stomach
or colon or intestinal canal generally, will require some attention,
since they are the cause of most of the functional derangements to
which the heart is subject, and give rise to the heart complaints
which occasion in the aggregate perhaps more suffering than does
actual heart disease. The heart often tolerates a considerable
degree of upward pressure of the diaphragm, and it is not uncommon
to meet with stomach resonance as high as the fifth space, and to
find the apex beat displaced upwards and outwards to the fourth
space and outside the nipple line, without conspicuous symptoms. But
the heart behaves very differently in different subjects in the
presence of flatulent distention of the stomach. It partakes of the
general constitutional condition of the individual; in the strong,
therefore, it is vigorous; in the weak it cannot be anything but
weak.


Prognosis.--Nothing sends a young person sooner to a physician than
this cardiac unrest and functional disturbance. He comes all
a-tremble, as if to hear the worst. Even in middle age and in those
whose education might be expected to steady them somewhat in the
matter, even in physicians of long experience, there is a tendency so
to exaggerate the condition and its possibilities of fatality as a
consequence of emotion that inhibitory action on the heart becomes
noticeable. It is a rule with very few exceptions that in these cases
when the heart is complained of by young persons who have no history
of rheumatism, the causative condition will be found in the stomach,
or at least in the digestive tract.

I know a number of physicians who have suffered in this way and who
have been badly frightened about themselves, yet who have had no
serious difficulty once they took reasonable care of their diet, and
paid attention above all to regularity of meals and slowness in
eating. Indeed, it is rare to find a physician of a nervous
temperament who has not had some trouble of this kind, and the demands
made on a busy professional man foster this. Some of them are sure
that if their cardiac uneasiness does not signify an actual heart
lesion, valvular or muscular, at least it portends a premature wearing
out of the heart. There are many evidences to show that this is
not so. I have had a distinguished physician, now well past his
seventy-fifth year, tell me of distinct irregularity in his heart
action as a young man which had rather alarmed him, and as this had
been preceded by an attack of acute articular rheumatism there seemed
to be every reason to think that he was a sufferer not from functional
but from organic heart disease; yet he has lived well beyond the span
of life usually allotted to man, has accomplished an immense amount of
work and is now in excellent general health almost at the age of
eighty. The case is all the more striking because, while rest and care
of the health and regular life and conservation of energy are usually
supposed to be essential for these cases, this colleague is noted for
having made serious inroads on the hours which should have been
devoted to sleep in order to accomplish certain medical literary work
while devoting himself to the care of a most exacting practice.

That the good prognosis of these cases which I suggest is not forced
and is not over-favorable nor the result of the wish to soothe
patients may be judged from recent studies of the heart as well as
from the older ones. In discussing extra-systole, MacKenzie in his
"Diseases of the Heart," [Footnote 28] says:

[Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D.,
1910, Oxford Medical Publications.]

Dyspeptic and neurotic people are often liable [to suffer from
them]. That other conditions give rise to extra-systoles, is also
evident from the fact that they may occur in young people in whom
there is no rheumatic history and no cardiosclerosis and whose
after-history reveals no sign of heart trouble.

It is well to note the frequency of such annoying symptoms in those
who have gone through rheumatic fever, and where patients have a
history of this it is well to be cautious, but even in these cases he
says that the trouble is often entirely neurotic and the one important
preliminary to any successful treatment is to get the patient's mind
off his condition, improve his general nervous state, and above all
relieve as far as possible the gastric symptoms that may be present.

He says further:

Some patients are conscious of a quiet transient fluttering in the
chest when an extra-systole occurs; others are aware of the long
pause, "as if their hearts had stopped"; while others are conscious
of the big beat that frequently follows the long pause. So violent
is the effect of this after-beat, that in neurotic persons it may
cause a shock, followed by a sense of great exhaustion. Most
patients are unconscious of the irregularity due to the
extra-systole until their attention is called to it by the medical
attendant. Both being ignorant of its origin, and its being
characteristic of human nature to associate the unknown with evil,
patient and doctor are too often unnecessarily alarmed.


Cardiac Stomach Disturbance.--On the other hand, as a word of warning,
it seems necessary to say here that later in life acute conditions
manifesting themselves through the stomach are often of cardiac
origin. Most physicians have been called to see some old man who had
partaken of a favorite dish which did not, however, always agree with
him and who suffered as a consequence from what at first was thought
to be acute gastritis. The severity of the symptoms and the almost
immediate collapse without any question of ptomaine poisoning,
however, usually make it clear that some other organ is at fault
besides the stomach itself. The real etiological train seems to be
that a weakened heart sometimes without any valve lesion but with a
muscular or vascular degeneration hampering its activity is further
seriously disturbed by the overloading of the stomach. The result is a
failure for the moment of circulation in the digestive organs with
consequent rejection of the contents of the tract, nature's method of
relieving herself of substances that cannot be properly prepared for
absorption. Unfortunately, the condition sometimes proves so severe a
shock to the weakened heart that it stops beating, and the physician
is brought face to face with a death from "heart failure."

In these cases it is important to remember that the gastric
disturbance may so mask the heart symptoms as completely to deceive
the physician. The prognosis of these cases, however, is most serious.
It seems worth while to give a warning with regard to these cases,
because anything that we may have to say as to the relations of the
stomach and the heart and the possibility of lessening the cardiac
depression due to unfavorable mental influence when palpitation occurs
as a consequence of gastric distention, has nothing to do with these
acute cases in older patients where the condition is serious and the
prognosis by no means favorable.


Treatment.--The role of psychotherapy in this form of cardiac
disturbance associated with gastro-intestinal affections is, after the
differentiation of neurotic from serious organic conditions, to give
the patient such reassurance as is justified by his condition. It is
surprising how many people are worrying about their hearts because
their stomachic and intestinal conditions give rise to heart
palpitation, that is to such action of the heart as brings it into the
sphere of their consciousness, sometimes with the complication of
intermittency or even more marked irregularity. The less the
experience of the physician the more serious is he likely to consider
these conditions and the more likely he is to disturb the patient by
his diagnosis and prognosis. Until there is some sign of failing
circulation, or of beginning disturbance of compensation, the
attachment of a serious significance to these conditions always makes
patients worse and removes one of the most helpful forms of
therapeusis, that of the favorable influence of the mind on the heart.
On the other hand, unless the patients' own unfavorable
auto-suggestions as regards the significance of their heart symptoms
are corrected, these people not only suffer subjectively, but bring
about such disturbance of their physical condition as makes many
symptoms objective.

While there are serious affections in which heart and stomach are
closely associated, these are quite rare and usually manifest
themselves in acute conditions and in old people. In the chapter on
Angina Pectoris attention is called to the fact that there are may
forms of pseudo-angina due to cardiac neuroses consequent upon gastric
disturbance and without heart lesion. Broadbent has not hesitated to
say that these forms of angina cause more suffering or at least
produce more reaction on the part of the patient and are always the
source of more complaint than the paroxysms due to serious cardiac
conditions which present the constant possibility of a fatal
termination.

Where the stomach is the cause of the cardiac neuroses psychotherapy
is an extremely important element in the treatment. The continuance
and exaggeration of their symptoms is often due to a disturbance of
mind consequent upon the feeling that they have some serious form of
heart disease. Without definite reassurance in this matter all
the experts in heart disease insist that it is extremely difficult to
bring about relief of symptoms in these patients. Whenever the general
health of the individual has not suffered from his heart affection, it
is quite safe to assume that no organic disease of the heart is
present, no matter what the symptoms, for, as Broadbent and many other
authorities emphasize, gastric cardiac neuroses can simulate every
form of heart disturbance. The older physicians insisted that what
they called sympathy with the hypochondriac organs might produce all
sorts of heart symptoms. The patient must be told this confidently.
The slightest exaggeration of the significance of his symptoms can do
no possible good and will always do positive harm.

After reassurance, the most important thing is, of course, regulation
of the diet and of the digestive functions generally. Unfortunately,
regulation of the diet to many patients and even to many physicians
seems to mean the limitation of diet. I have seen sufferers from
cardiac symptoms have these increased by excessive limitation of diet.
If they are lower than they ought to be in weight they must be made to
regain it. Above all, there must be no limitation of meat-eating
except in the robust. Very often the heart seems to crave particularly
that form of nutrition that comes through meat. It is especially
important that the bowels should be regular. Fast eating is very
harmful. Occupation with serious business immediately after eating is
almost the rule in these cases.

All of these elements of the case need special study in each
individual patient. The needed suggestions can then be made. Above
all, the patient is made to realize that his case is understood and
that it is only the question of a gradual acquirement of certain
habits, including proper exercise, that is needed for the restoration
of his heart to normal.





Next: Angina Pectoris

Previous: Cardiac Neuroses



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