Some ten years ago I first saw another of these cases of fast heart, with a family history of the affection in a preceding generation. He was a man who had not taken good care of himself and had been especially over-indulgent in alcohol. This indulgence consisted not in rare sprees but in the persistent daily taking of large quantities of straight whiskey. In spite of warnings, he has not given up this habit; yet at the age of sixty-five he is apparently in good health and is able to fulfill the duties of a rather exacting occupation.
Persistent rapid pulse often occurs in connection with some disturbance of the thyroid gland. The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves' disease, but they are often only functional and the symptoms may pass away entirely. The rapid heart action may come and go, though usually the attacks last for some days and oftener for a week or more at a time.
Paroxysmal Tachycardia.—A rapid heart may not only exist continuously in an individual for many years without any impairment of general health or shortening of life, but there may be spasmodic attacks of this condition with the pulse running up so high as to deserve the name of paroxysmal tachycardia; yet the patient may live for many years and die from some affection not connected with his heart. Perhaps the most remarkable case of this kind on record is that reported by Prof. H. C. Wood of Philadelphia. The patient was a physician in his later eighties when he came under Dr. Wood's observation. His first attack of paroxysmal tachycardia came in his thirty-seventh year. These attacks had apparently always been similar to those he then suffered and were abrupt in onset and the pulse would rise rapidly to 200 a minute. The original prognosis had been, of course, very unfavorable. The physician had outlived all the prophets of evil in his case, however. When large numbers of these cases were studied, it was found that they always last more than ten years, and, while heart failure in such cases is reported, it is doubtful if this occurs with more frequency in these patients as the result of strong reflexes than in the general run of patients, for it must not be forgotten that there is a certain average number of deaths from so-called heart failure in people supposed to be in good health.
In connection with these attacks of paroxysmal tachycardia, there often come intense feelings of depression and even local disturbances of circulation. It is probable that in many cases there is a serious factor at work. MacKenzie has suggested that they are due to nodal rhythm of the heart in which the heart beat does not start at the root of the sinus as is usual, but in some other portion of the musculature and as a consequence there is serious interference with the regular rhythmic action. In a number of cases of heart failure, tachycardia becomes a prominent feature and it is probably due to some such disturbance as this. Such cases often look very serious for a time, yet frequently recover completely after a brief interval. This must not disguise the fact, however, that many of these cases, especially where acute dilatation of the heart can be demonstrated, are extremely dangerous and may end in a sudden fatal termination. The patient seems so much prostrated that occasionally the physician may doubt whether it is worth while to put him to the bother necessary in order to diagnose the acute dilatation of the heart. It always is, however. If it were nothing else but the occupation of the patient's attention with the doctor's manipulations, as far as that is possible, the effect would be good, besides whatever irritation may be caused to the heart muscle itself by percussion of the heart area will probably do mechanical good.
The most important element evidently is that the patient shall not be allowed to lose courage or to think that nothing can be done for him. Something must be done, and a combination of swallowing movements and deep breathing, as far as that is possible, with counter-irritation through the chest wall should be carried out. Drugs also should be employed and the aroma of strong coffee with the irritating effect of ammonia upon the nostrils should be employed. These act upon the vagus so as to stimulate the heart, but above all they act upon the mind, and nothing so stimulates the heart as reawakened hope.
CHAPTER VII
BRADYCARDIA
Bradycardia, or persistent slow pulse, is much rarer than the persistent rapid pulse discussed at the beginning of the chapter on tachycardia. Cases are, indeed, sufficiently rare to be medical curiosities. Prof. Clifford Allbutt has called attention to the fact that the status of bradycardia or brachycardia, as Osler (following Riegel because of the analogue tachycardia) prefers to call it, is very different from that of tachycardia. In the latter, especially, in the specific sense of the term, the symptoms occur paroxysmically, endure for a definite length of time and then there is a return to the normal pulse rate. For this, or at least for the condition known as essential tachycardia, there is no well-defined cause and no definite pathological lesion. Bradycardia or brachycardia, however, is usually present as the result of some known physiologic or pathologic condition; it endures as long as the cause continues to act and then ceases, usually not to return unless the same cause gives rise to it again.
There are some cases, however, of slow pulse that cannot be traced to any definite lesion and in which the pulse is much slower at certain times than at others, though without its being possible to trace any definite immediate cause. These cases seem to be physiological analogues of tachycardia. In tachycardia there is an irritation of the accelerator nerves to the heart, in brachycardia of the inhibitory nerves.