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 [{334}] 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 rôle 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 [{335}] 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.
CHAPTER V
ANGINA PECTORIS
The two forms of this affection, known commonly as true and false angina, are characterized by pain or anguish in the precordial region with reflected pains in other portions of the body. It used to be said that whenever the precordial pain was accompanied by reflected pains in the neck, or down the arm, or, as they may be occasionally, in the jaw, in the ovary, in the testicle, sometimes apparently in the left loin, this was true angina and the patient was in serious danger of death. We know now that false angina may be accompanied by various reflex pains and that, indeed, a detailed description of the anguish and its many points of manifestation is more likely to be given by a neurotic patient suffering from pseudo-angina than by one suffering from true angina. True angina occurs in most cases as a consequence of hardening of the arteries of the heart or of some valvular lesion that interferes in some way with cardiac nutrition. The definite sign of differentiation is that in practically all cases of true angina, there are signs of arterial degeneration in various parts of the body. Without these, the "breast pang," as the English [{336}] call it, is likely to be neurotic and is of little significance as regards future health or its effect upon the individual's length of life.