Arrhythmia may begin in comparatively early life, persist in spite of treatment, and yet continue up to old age. Sir William Osler tells of the case of the late Chancellor Ferrier of McGill University who died at the age of eighty-seven after having exhibited an extremely irregular heart action for the last fifty years of his life. He has seen several other patients who have had heart irregularity for many years without the slightest disturbance of their general health. His experience is not uncommon, and probably every physician who sees many cases of heart disease can recall a few of them. Ten years ago I saw a man past seventy suffering from distinctly irregular heart action, though he gave the history of having had cardiac irregularity for some years at least, and he is still alive, past eighty, and with his heart irregularity still present. I have a patient over seventy whom I know to have had irregular heart action for fifteen years, and he himself is sure that it has been present since he was about forty, at least. It is cases of this kind, together with MacKenzie's recent studies of the subject, that must be before the physician's mind when he makes his prognosis for these patients. There must be no hesitancy about his declaration. Patients think that physicians are prone to deny the significance of heart trouble so as to avoid disturbing their patients. The slightest hesitation, then, will be surely looked upon as of ominous import.
The Intellectual Life and Cardiac Palpitation.—It is curious how many people who give themselves to intellectual work and live an almost exclusively indoor life have subjective symptoms relating to their hearts. Many of the English literary men and women of the last century had complaints of this kind. Sir Walter Scott described very vividly his sensations as if his heart did not have room to accomplish its functions, and said that he used to feel within his chest a fluttering as if there were a bird there beating its wings against a cage too small for it. Other literary people have told of this sense of overfullness in the chest, as if somehow there were not room for all the organs. This discomfort is mainly referred to the precordial region. In oversensitive, nervous people it may be described as painful, though analysis of what they mean by the word pain will show that they have only a persistent feeling of pressure which is uncomfortable and gives a sense of crowdedness in that region rather than any genuine ache. Where the feeling is much dwelt on, however, it may be exaggerated into pain, as, indeed, will any sensation, however trivial, if attention is concentrated on it. On the other hand, in practically all of these cases, just as soon as the mind is strongly diverted by any pleasant occupation, the sense of discomfort disappears not to reappear again until the patient has time to think about himself.
Heart Surveillance.—Prof. Oppenheim of Berlin has in his usual direct way expressed the power of the mind to influence the heart beat, and he does [{324}] not hesitate to say that certain nervous people who have been watching their hearts overmuch, and continually thinking about them, are capable of playing all sorts of tricks on themselves and sometimes even on their physicians, by this concentration of mind upon their heart and its action. Prof. Oppenheim in his "Letters to Nervous Patients," writing to a patient complaining of irregular heart action, says:
Whenever you succeed in controlling the action of your heart by means of introspection, there flows from your brain to your heart a current of innervation which disturbs the automatic movement of the organ. You now know what you have to thank for the irregularity in the action of your heart. I have frequently proved this to myself in your case: if I succeeded in feeling your pulse without your becoming aware of it, holding your attention by a conversation which interested you, the action of your heart was always absolutely regular. If, however, I tried it under your control, while your attention was anxiously directed to your heart, its action at once became irregular, and you experienced the very unpleasant sensation of palpitation.
Irritable Heart of Athletes.—A curiously interesting form of heart neuroses has appealed to me very much because I have suffered somewhat from it myself and owing to circumstances I think I have seen a larger number of patients suffering from it than usually come to a single individual. I refer to the tendency to irritability of the heart which is so marked in men who have been athletes when they were younger, and have taken a large amount of exercise during the years between fifteen and twenty-five. If these men later settle down to a sedentary life they almost inevitably suffer from a marked sense of discomfort in the precordial region because of palpitation, and are apparently much more liable than other people to have an intermittent pulse. Just what these symptoms are due to is not always easy to discover, and in different individuals there seem to be different accessory causes at work. I have seen it particularly in professional men who while at college have been on the teams and have played such hard games as handball, hockey on the ice, and the like. I do not refer only to those who have played an occasional game, but who every day of the college year have had some severe muscular exercise.
Whether this irregularity of heart action has not at least been predisposed to by over-exertion remains to be determined. Strenuous athletics produce curious heart symptoms. Missed heart beats and irregular heart action and even leakages at the valves are not unusual even in the best of hearts after severe exertion. A careful examination of the hearts of those who took part in a Marathon run at Harvard some years ago showed that immediately after the race many of them were irregular and some of them had leakages at the mitral valve which lasted from one to twenty-four hours. These were probably due to irregularity in the action of the papillary muscles as a consequence of the fatigue. I had occasion to examine the hearts of some theatrical dancers a few years ago, immediately after they came off the stage. One of them is one of the most successful of modern dancers and is able to occupy the better part of an hour in the severest kind of exertion before an audience. Her heart was not only very rapid immediately after she left the stage, but there were missed beats and a distinct disturbance at the mitral valve. It was hard to determine absolutely, but the sounds at all the valves were impure and there [{325}] seemed to be imperfect closure or irregularity of action. In another case there was a regular missed beat at every sixth or seventh pulsation. This seemed to be due to an abortive systole. Usually within an hour regularity of heart action is restored and the valve sounds become normal. At times when the patient is run down for any reason, the cardiac disturbance may persist for many hours, or even until after long hours of sleep.
The patients I have mentioned seem to have developed their muscles to a noteworthy degree and have enlarged and strengthened their hearts by this exercise. Later on their occupation in life prevents them from taking any severe exercise, or at least furnishes no opportunity for it, and they often settle down to existence that, beyond a short, quiet walk perhaps once a day, affords no exercise at all. Under these circumstances the muscular development that they secured as young men and which kept them in such magnificent health during their adolescent years seems to prove a positive detriment to good health, or at least to good feeling. The muscular system seems to crave to be kept up. Occasionally I have been sure that the intermittent heart action so often seen in these cases was due to the fact that the appetite, or as I should rather put it, the habit of eating, which they formed while they were accustomed to taking vigorous exercise, remains with them during their sedentary life and as a consequence they overeat, particularly of proteid food materials. The large consumption of these materials gives rise to the presence of substances in the blood which make all the muscles more irritable than usual, and this seems to add particularly to the irritability of the heart.
Dietetic Regulation.—For many of these people a regulation of diet seems to be the best possible remedy. They must be made to eat less substantially, since they do not need the same amount of proteid material to make up for muscle waste, now that there is no longer the old use of muscles. Some of them become very heavy. These, however, are mainly individuals who, besides eating abundantly of proteids, also consume carbohydrates in large quantities. In these there is a distinct disturbance of digestion and a tendency to dilatation of the stomach with gas which interferes with the heart action and brings on the intermittent pulse so often seen in them. In a certain number, however, there are no accessory symptoms of indigestion, but the heart symptoms are most prominent.
Exercise.—For these people the only real relief is afforded by a certain amount of exercise every day. They become ever so much more comfortable just as soon as their physician insists that they shall have an hour's walk at least every morning and every afternoon and that this walk shall be brisk and always have some definite purpose in it, so that there is no mere sauntering or delaying on the way. Most business men to whom this prescription of an hour's walk is given will reply that it is impossible. Most clergymen will say that their duties are such that they cannot arrange their hours for this purpose. As a rule, it is not difficult to show the business man, however, that if instead of riding to his business, he should walk every day, and this will probably only take twenty minutes to a half-hour longer than if he goes by trolley or even by automobile, this walk will provide him with a full hour of brisk exercise in the open air. The walk back from business will provide the other hour, whenever golf or some other diversion cannot be provided instead. In most cities men live from three to five miles away from their [{326}] business, and it is not too much to ask them to take this walk. The muscular clergyman must be made to understand that there shall be no trolley cars for his ordinary clerical calls, or at least that none are to be taken unless he has had his full two hours of brisk walk.
There is always the fear in the patient's mind that exercise, by calling for heart exertion, is almost sure to make the condition worse. This fear of itself further hampers heart action. When exercise is first increased in those who have been living sedentary lives the heart action for a time is brought more and more into the sphere of consciousness and any irregularity that is present is likely to be emphasized. A little persistence, however, soon shows that what the heart actually was craving was the opportunity to expend some of its energy and it was this pent-up force that was disturbing its action. There is often the fear in physicians' minds lest the advising of exercise should really do harm to the patient. They fear the presence of perhaps a fatty condition, or of some obscure muscular condition, or of some other heart lesion not easy to detect, yet likely to produce serious symptoms. Stokes, who probably knew fatty heart disease better than anyone else in the nineteenth century, outlined his views of the therapy of it as follows: