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

Sometimes a patient rises and walks about. Sometimes an ice-bag over the heart will stop the attack.

If there is no serious illness present, and no serious cardiac disease causing the condition, and a patient is known to have an overloaded stomach or bowels, an emetic or a briskly acting cathartic is the best possible treatment. The attack often terminates as suddenly as it begins, without leaving any knowledge as to which particular treatment has been beneficial. A patient who is well and has an attack of tachycardia should be allowed to assume the position which he finds to give him the most comfort, and to use the means of stopping his attack which lie has found the most successful. In the absence of his success or of his knowledge of any successful treatment, a hypodermic injection of 1/6 or even 1/4 grain of morphin sulphate is often curative. Atropin should not be given, as it may increase the cardiac disturbance. If an attack lasts more than an hour or so, one of the best treatments is the bromids, which should be given either by potassium or sodium bromid in a dose of 2 or 3 gm. (30 or 45 grains) at once. Sometimes one good-sized dose of digitalis may be of benefit, but it is often disappointing, and unless there is a valvular lesion with signs of broken compensation, it is rarely indicated. It should also be remembered that, if the patient is receiving digitalis in good dosage for broken compensation, tachycardia may be caused by an overaction of the digitalis. Such overaction would be indicated by previous symptoms of nausea, vomiting, intestinal irritation, a diminished amount of urine, headache and a tight, bandlike feeling in the head, cold hands and feet, and a day or two of very slow pulse. If none of these symptoms is present, though a patient has received digitalis for broken compensation, a tachycardia occurring might not contraindicate digitalis, as much of the digitalis on the market is useless; and a patient may not actually have been obtaining digitalis action.

If the tachycardia occurs in a patient with arteriosclerosis, especially if there is much cardiac pain, nitroglycerin is of advantage; also warm foot-baths. If there is prostration and a flaccid, flabby abdomen, a tight abdominal bandage may be of benefit.

Gastric flatulence, while perhaps not a cause of the tachycardia, is liable to develop and be a troublesome symptom. Anything that causes eructations of gases is of benefit, as spirit of peppermint, aromatic spirit of ammonia or plain hot water. If there is hyperacidity of the stomach, sodium bicarbonate or milk of magnesia will be of benefit.

The ability of some patients to stand a rapid heart action without noting it or being incapacitated by it is astonishing. It may generally be stated that a rapid heart is noted, and a pulse above 120 generally prostrates, at least temporarily, a patient who is otherwise well, provided the cause is anything but hyperthyroidism. A patient who has hypersecretion of the thyroid will be perfectly calm, collected, often perhaps not seriously nervous, and, with a heart beating at the rate of 140, 150, 160 and even 200 per minute, will state that she has no palpitation now, although she sometimes has it. A heart thus fast, with a patient not noting it and not prostrated by it, is almost diagnostic of a thyroid cause.

Some patients, both men and women, cannot take even a small cup of tea or coffee without an attack of paroxysmal tachycardia. Such patients, of course, quickly learn their limitations.

HYPERTHYROIDISM

The presence of a well marked case of exophthalmic goiter is not necessary for the secretion of the thyroid to be increased sufficiently to cause tachycardia; in fact, an increased heart rapidity in women often has hyperthyroidism as its cause. The thyroid gland hypersecretes in women before every menstrual period and during each pregnancy, and with an active, emotional, nervous life, social excitement, theaters, too much coffee, and, unfortunately today among women, too much alcohol, it readily gives the condition of increased secretion; and the organ that notes this increased secretion the quickest is the heart.

The tachycardia of a developed exophthalmic goiter is difficult to inhibit. Digitalis is of no avail, and no other single medicinal treatment is of any great value. The tachycardia will improve as the disease improves. On the other hand, nothing is snore serious for this patient than her rapid heart, and if it cannot be soon slowed, operative interference is absolutely necessary. If the rapid heart continues until a myocarditis has developed and a weakening of the muscle fibers occurs, or dilatation is imminent or has actually occurred, operative interference is serious, and most patients under these conditions die after a complete operation, that is, the removal of from one half to two thirds of the thyroid. In such cases the only excusable operative interference is the graded one, namely, the tying of first one artery and then another of the thyroid to inhibit the blood supply to the gland in order that it may not furnish so much secretion. If the heart then improves, a more radical operation may be done without much serious danger. Therefore the working rule should be that, if a heart does not quickly improve under medical management, operative interference should not be delayed until the heart has become degenerated.

If tachycardia is the only serious symptom present in a patient who is considered to have hyperthyroidism, it may generally be successfully treated by insistence on quiet, cessation of all physical and exciting mental activities, more or less complete rest, the absolute interdiction of all tear coffee or other caffein- bearing preparations, total abstinence from alcohol, the restriction to a cereal and fruit diet (the withdrawal of all meat from the diet), the administration of calcium, as the calcium glycerophospate in dose of 0.3 gm. (5 grains) in powder three times a day, and for a time, perhaps, the administration of bromids. If the depressing action of bromids on the heart is counteracted by the coincident administration of digitalis, they will act only for good by quieting the nervous system and more or less inhibiting the secretion of the thyroid gland.