17, 4 Sison: Cardiac Reflex Symptoms 413 
ing, points toward reflex irritation. In such cases the disturb- 
ance of the heart action can be due only to direct irritation of 
the stomach, either mechanical or toxic in nature. It is possible 
that a stomach greatly distended with gas may directly affect 
the heart through the diaphragm, but this mode of irritation is 
probably unimportant, for in many cases there is absolutely no 
tympany of the gastrointestinal tract. I have seen, however, 
cases of stomach dilatation (atonic dilatation) confirmed by 
X-ray, in which the cardiac reflex symptoms were very prom- 
inent, that make me think that this atonic dilatation accompanied 
by distention was the main factor; as, once the accumulated gas 
was expelled by eructation, almost immediate amelioration of 
the symptoms was felt by the patient, in spite of the persistent 
dilatation of the stomach. 
- Anginoid pain in the precordial region radiating to the left 
arm and resembling in its character the pain felt in angina pec- 
toris may occasionally occur. This anginoid pain coming in 
paroxysmal attacks is differentiated from true angina pectoris 
by the greater number of attacks experienced by the patient. 
In true angina the patient rarely survives many attacks, while 
the attacks of anginoid pain that I call spurious angina may 
recur many times without endangering the life of the patient. 
Exercise is of no importance whatever as an etiologic factor, 
the ingestion of food being the exciting factor, as a rule. As 
I have mentioned, these anginoid attacks are never dangerous, 
and they disappear when the affection of the stomach has been 
relieved. 
A few words in regard to the effect of stomach diseases on 
the action of the heart. The pulse may be increased or de- 
creased; it is usually increased in stomach affection complicated 
by fever, and sometimes when there is marked distention. This 
acts as a mechanical stimulant and, as it were, irritates the 
heart. It is usually decreased in chronic cases where, on ac- 
count of the duration of the disease, there is more or less im- 
pairment of general nutrition and more or less general weakness ; 4 
it is observed in ulcers and in ectasy. 
Besides the changes in rate, disturbances of rhythm may occur, 
such as arrhythmia or irregularity of heart action, though not 
frequently. 
In liver affections bradycardia is one of the characteristic 
features observed in the heart, and occasionally there is chest 
oppression. These symptoms, strange to say, are observed in 
acute cases of short duration; but in chronic cases the brady- 
