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 [{331}] 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.