Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

The cause of an irregularly acting heart in an adult may be organic, as in the various forms of myocarditis, in broken compensation of valvular disease, Stokes-Adams disease, coronary disease, auricular fibrillation, auricular flutter, cerebral disease, and toxemias from various kinds of serious organic disease. The cause may be more or less functional and removable, such as tea, coffee, alcohol, tobacco, gastric indigestion and intestinal toxemia; or it may be due to functional disturbances of the heart, such as that due to what has been termed extrasystole, or to irregular ventricular contractions. A frequent cause of irregular heart action in women, more especially of increased rapidity, is hyperthyroidism.

There may be an arrhythmia due to some nervous stimulation, probably through the pneumogastric, so that the pulse varies abnormally during respiration, being accelerated during inspiration and retarded during expiration more than is normally found in adults. This condition is frequent in children, and is noticed in neurotic adults and sometimes during convalescence from a serious illness. Nervous and physical rest, with plenty of sleep and fresh, clean air so that the respiratory center is normally stiniulated, will generally improve this condition in an adult.

Extrasystoles causing arrhythmia give a more or less regularly intermittent pulse, while the examination of the heart discloses an imperfect beat or the extrasystole which is not transmitted or acted on by the ventricles, and hence the intermittency in the peripheral arteries. This condition may be due to some toxemia, nervous irritability, or some irritation in the heart muscle. Good general elimination by catharsis, warm baths to increase the peripheral circulation, a low diet for a few days, abstinence from any toxin which could cause this cardiac irritation, extra physical and mental rest, sometimes nervous sedatives such as bromids, and perhaps a lowering of the blood pressure by nitroglycerin, if such is indicated, or an increase of the cardiac tone by digitalis if that is indicated, will generally remove the cardiac irritation and prevent the extrasystoles, and the heart will again become regular. It should be carefully decided whether there is beginning heart block or beginning Stokes-Adams disease, in which case digitalis should not be used. This disease is not frequent, while extrasystoles of a functional character are very frequent. Sometimes this functional disease persists without any apparent injury to the individual as long as the ventricle does not take note of these extra auricular systoles and does not also become extra rapid. If the ventricle does contract with this increased rapidity, it soon wears itself out, and the condition becomes serious.

In this kind of arrhythmia, if there are no contraindications to digitalis, it is the logical drug to use from its physiologic activities, slowing the heart by its action on the vagi and causing a steadier contraction of the heart; clinically this treatment is generally successful. If digitalis should, however, cause the heart to become more irritable, it is acting for harm, and should be stopped.

TREATMENT

One has but to refer to the enumerated causes of irregular heart action to determine the treatment. In that caused by extrasystole, the treatment has just been suggested. In irregular heart caused by serious cardiac or other lesions the treatment has already been described, or is that of the disease that has a badly acting heart as a complication. If the irregularity is caused by toxins, the treatment is to stop the ingestion of the toxin and to promote the elimination of what is already in the system; how much of the irregularity was due to the toxin and how much is inherent disturbance in the heart can then be determined. If the cause of a toxemia developed in the system, perhaps most frequently from intestinal putrefaction, increased elimination and a regulation of the diet will cure the condition.

The valvular lesions most apt to cause irregular action of the heart are mitral insufficiency or mitral stenosis. The lesion which is most apt to cause auricular fibrillation and more or less permanently irregular heart is perhaps mitral stenosis. Another frequent cause of more or less permanent irregularity is the excessive use of alcohol.

While an irregular pulse and an irregular heart are always of more or less serious import, still, as the extrasystoles of the auricle are better understood and more frequently recognized, and the habits and life of the patients (most frequently men) are regulated and revised, frequently a pulse and heart which would be rejected by any medical examiner for an insurance company becomes, in a few weeks or a few months, a perfectly acting heart, and remains so sometimes for years. It also is not quite determinaible whether a heart that is so misbehaving has a recurrence of such misbehavior more readily than a heart which has never been so affected. However this may be, the cause having been determined or presumed by the physician, it should be so impressed on the patient that he does not again repeat the insult to his heart.

AURICULAR FIBRILLATION: AURICULAR FLUTTER

Auricular fibrillation is at times apparently a clinical entity much as is angina pectoris, but it is often a symptom of some other condition. At times auricular fibrillation is only a passing symptom, and is rapidly cured by treatment. A real auricular fibrillation shows a semiparalysis of the auricles, and during this condition normal systolic contractions do not occur, although there are small rapid twitchings of different muscle fibers in the auricles. Although it was once thought that the auricle was paralyzed in this condition, it probably simply loses its coordinate activity. Auricular fibrillation and auricular flutter are probably simply different degrees of the same condition, and any contractions of the auricles over 200 per minute may be termed an auricular flutter, and below that the term auricular fibrillation may be used. When ventricular fibrillation occurs, the condition is serious and the prognosis bad. Both auricular fibrillation and auricular flutter may be temporary or permanent, and the exact number of fibrillations or tremblings of the auricular muscle can be noted only by electrical instruments.