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

Jarisch [Footnote: Jarisch: Deutsch. Arch. f. klin. Med., 1914, cxv, 376.] finds by personal investigations and by studying the literature that the node showed pathologic disturbance in less than half the cases. Consequently, although a pathologic condition of the node is a frequent, and perhaps the most frequent, cause of auricular fibrillation, other conditions, especially anything which dilates the right auricle, may cause it.

DIAGNOSIS

If the pulse is intermittent and there is apparently a heart block. Stokes-Adams disease should be considered as possibly present, and digitalis would be contraindicated and would do harm.

A scientific indication as to whether a heart is disturbed through the action of the vagi or whether the disturbance is due to muscle degeneration may be obtained by the administration of atropin. Talley [Footnote: Talley, James: Am. Jour. Med. Sc., October, 1912.] of Philadelphia shows the diagnostic value of this drug. It is a familiar physiologic fact that stimulation of the vagi slows the heart or even stops it. Stimulation of these nerves by the electric current, however, does not destroy the irritability of the heart; indeed, the heart may act by local stimulation after it has been stopped by pneumogastric stimulation. It is also a well known fact that anything which inhibits or removes vagus control of the heart allows the heart to become more rapid, since these nerves act as a governor to the heart's contractions. Under the influence of atropin the heart rate is increased by paralysis of the vagi. Talley states that a hypodermic injection of from 1/50 to 1/25 grain of atropin produces the same paralytic and rapid heart effect in man. He advises the use of 1/25 grain of atropin in robust males, and 1/50 grain in females and in less robust males, and he has seen no serious trouble occur from such injections. The throat is of course dry, and the eyesight interfered with for a day or more, but Talley has not seen even insomnia occur, to say nothing of nervous excitation or delirium. Theoretically, however, before such atropin dosage, an idiosyncrasy against belladonna should be determined.

The value of such an injection rests on the fact that atropin thus injected will increase the normal heart from thirty to forty beats a minute, and Talley believes that if the heart beat is increased only twenty or less, if the patient has not been suffering from an exhausting disease, it shows "a degenerative process in the cardiac tissue which makes the outlook for improvement under treatment unpromising." He also believes that when the heart in auricular fibrillation is increased the normal amount or more than normal, the prognosis is good. He still further advises in auricular fibrillation an injection of atropin before digitalis has been administered, and another after digitalis is thoroughly acting. Comparison of the findings after these two injections will determine which factor, vagal or cardiac tissue, is the greater in the condition present. The patients with a large cardiac factor are the ones who may be more improved by the digitalis treatment than those in whom the fibrillation is caused by vagus disturbance.

PROGNOSIS

The prognosis depends on the condition of the myocardium of the vagus. If this muscle is intact, and there is no pathologic condition in the sinus node (which can be proved by the successful results of treatment), the removal of all toxins that could increase the activity of the heart, and the administration of digitalis, which will slow the heart by stimulating the pneumogastric control of the heart, will produce a cure, temporary, if not permanent.

Although a patient with auricular fibrillation may have been incapacitated by this heart activity, he may not yet have dilated ventricles, and the digitalis need perhaps not be long continued. If on account of some heart strain or some unaccountable cause the fibrillation recurs, he of course must again receive the digitalis. If the auricular fibrillation is superimposed, or is followed by dilated ventricles and decompensation, the prognosis is bad, although the condition may be improved. In other words, auricular fibrillation added to these conditions is serious, but still, many times a patient may be greatly improved by rest, digitalis, careful diet, proper care of the bowels, etc. If the fibrillation occurs with or was apparently caused by the dilatation of the ventricles, the prognosis of improvement may be good. If the dilatation of the ventricles occurs following auricular fibrillation, the prognosis is not good.

White [Footnote: White: Boston Med. and Surg. Jour., Dec. 2, 1915.] after studying 200 heart cases, finds that auricular fibrillation and alternating pulse, as well as heart block, are more frequent in men than in women, and both auricular fibrillation and alternating pulse are more apt to occur after 50 years of age than before. Auricular fibrillation may occur in hearts which are suffering from valvular lesions, especially mitral stenosis, and may occur in syphilitic hearts, in various sclerotic conditions of the heart, and in hyperthyroidism.

Though disputed, it seems probable that fibrillation may be caused by the excessive use of tea, coffee and tobacco. Paroxysmal tachycardias are certainly caused by these substances, and the conditions of auricular fibrillation and auricular flutter may be found frequently present if such hearts are carefully examined with cardiographic instruments.