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.





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