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Related post: which are intra-cardial. The principal extra-
cardial causes of arhythmia are : (a) Cortical ;
(b) toxic;- (c) mechanical; (4) reflex from
pathology in other organs; (e) vagopathic.
Cortical. — This refers to forces acting from
without the body by putting the nervous sys-
tem in an unstable state. On account of the
lack of equilibrium and poise of the nervous
system in children this disturbance is exceed-
ing common among them. It is ol'ten the case
that children will sufifer from arhythmias from
anything which will upset their nerve poise.
Just as this is the case in children so it is with
all persons who are of a psychaesthenic or neu-
raesthenic temperament. This class of suf-
ferers is often much distressed with the heart
when it really has no pathological significance,
and may be a reflex action from any real or
imaginary ill.
*Rr!ad in Section on Medicine, Southern Medi-
cal Association, Eif;lilli Annual Meeting, Richmond,
Va., Noveniher 9-12, 1914.
Toxic. — Poisons which produce arhythmias
may be either of bacterial or chemical origin.
In toxemias from acute infections such as men-
ingitis, pneumonia, typhoid fever, the exan-
thems in children, endarteritis, endocarditis
and so forth, Buy Enhance9 the arhythmias are not at all un-
common and are always danger signals. The
chemical poisons which produce this effect are
principally caffein, tobacco and whisky. The
source of caffein poison is usually from coffee
and tea, but in the South it often comes from
coca cola. Tobacco produces the most dis-
tressful symptoms of any of the chemical poi-
sons. It brings one promptly to his physician
and he feels that he has a heart lesion that
will prove fatal at any moment. Whisky, from
the writer's experience, is less apt to produce
disturbances of rhythm in the heart than the
other chemical poisons mentioned, though
often it will produce symptoms of this sort.
One of the peculiarities of these poisons is
that the disturbance usually comes on while
one is at rest, and exercise will correct it. I
have often seen the most profound arhythmias
relieved by having the patient hop a few times
across the floor. This procedure often enables
one to difl^erentiate this type from absolute
arhythmias, which arc organic and are made
worse by any form of exercise.
Mechanical. — Anything which will interfere
with the influx or outflow of blood through the
heart, or that will handicap it by pressure or
compression, will not infrequently interfere
more or less with its rhytlim. There mav lie
fluid ni either one of the pleural cavities which
may press the heart out of its normal position
and disturb its mechanism. I have seen several
cases of arhythmia brought about from arti-
ficial pneumothorax in the treatment of pul-
monary tuberculosis, due to belaboring the
heart from gas pressure. Tumors may also
disturb its normal function by pressure either
upon the heart or pneumogastric nerve,
though Buy Enhance9 Online a case of this kind has never come un-
der the writer's observation.
Accumulation of gas in the gastroenteric
tract often produces irregularities of this na-
ture. One of the most common sources of this
gas is caused from aerophagia. People who
find relief by belching usually get into the
habit of swallowing air and eructating it under
the impression tliat they are relieving their dis-
tress, when they are only adding to it. as they
invariably swallow more air than they eructate.
It is a habit that will get one in its grip more
readily than almost any other, as it is so easily
done that one .soon begins to accomplish it un-
consciously. All that is necessary to accom-
plish this feat is to press the tongue in the
roof of the mouth and swallow while one is
taking an ins|)iration. The gas then passes
into the esophagus, part of it is eructated and
the rest swallowed. A vicious circle is soon
established whereby the disturbance of the
heart is kept up by this gas pressure.
Adhesions of the pericardium to the sur-
rounding viscera is a common .source of arhy-
thmia. If the adhesions are anterior the flow
of blood through the vena cava is disturbed by
deflating the lungs, therefore the arhythniia
takes place upon expiration. This is due to
the tugging upon the large veins which arc sit-
uated somewhat anterifirly and the blood flow
distur!)e(l. If these adhesions arc posterior,
the movement of the lungs upon insjiiration
will produce a traction ujion the aortas and
interfere with the outflow of blood from the
heart, and in this way disturb its rhythm.
Tiiese are respiratory arliythmias. linl ibc ili^
turbance is largely mechanical.
Ptoses of the abdominal viscera are fruill'ul
sources in the production of an irregular heart.
This is causcfl by the jjulling down ujion the
diaphragm to which the pericardium is at-
tached and in this way disturbing the heart-
beat. The principal ones of these arc gaslro
and splenoptosis.
Reflex from ralhnloi^y in Oilier Oriiiins. —
Disease of almost any organ of the body may
reflect upon the heart and interfere with its
rhythm. This has been found to occur even in
cystitis, inflamed prostate or rhinitis, but it is
especially apt to do so in the organs innervated
by the vagus nerve.
Vagopathic. — In the course of the vagus
nerve along the mediastinum it often becomes
so enmeshed in tubercular processes — especial-
Iv adhesions of the visceral to the mediastinal
pleura — that its functions are much disturbed. I
have done post-mortems in cases having previ-
ously suffered with profound arhythniia where
the visceral pleura would lie so firmly adherent
to the mediastinum that they scarcely could be
separated, and when the parts were pulled
asunder the vagus nerve would be torn and
broken up. Often the tubercles would show

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