DISTURBANCES OF THE HEART RATE

ARRHYTHMIA

While this terns really signifies irregularity and intermittence of the heart, it may also be broadly used to indicate a pulse which is abnormally slow or one which is abnormally fast, a rhythm which is trot correct for the age, condition and activity of the patient. Irregularity in the pulse beat as to volume, force and pressure, except such variation in the pulse wave as caused by respiration, is always abnormal. While an intermittent pulse is of course abnormal, it may be caused in certain persons by a condition which does not in the least interfere with their health and well-being.

As to whether a slow or a more or less (but not excessively) rapid pulse in any one is abnormal depends entirely on whether that speed is normal or abnormal for that person. As a general rule the heart is more rapid in women than in men. It is always more rapid in children than in adults, and generally diminishes in frequence after the age of 60, unless there is cardiac weakness or some cardiac muscle degeneration. The average frequence of the pulse in an adult who is at rest is 72 beats per minute, but a frequency of 80 is not abnormal, and a frequency of 65 in men is common; 60 is infrequent in men but normal, while up to 90 is not abnormal, especially in women, at the time the pulse is being counted.' It should always be considered that in the majority of patients the pulse is slightly increased while the physician is noting its rapidity. Anything over 90 should always be considered rapid, unless the patient is very nervous and this rapidity is considered accidental. Anything below 60 is abnormally slow. In children under 10 or 12 years of age, anything below 80 is unusual, and up to 100 is perfectly normal, at least at such time as the pulse is counted and the patient is awake.

Referring to the first chapter of this book, it will be noted that many physiologic factors must enter into the production of the normal regularity of the pulse. The stimulus must regularly begin in the auricle, must be perfectly transmitted through the bundle of His to the ventricles, the ventricles must normally contract with the normal and regular force, the valves must close normally and at the proper time, the blood pressure in the aorta must be normally constant to insure the perfect transmission of the blood to the peripheral arteries and to insure the normal circulation through the coronary arteries, and the arterioles must be normally elastic. The nervous inhibitory control through the vagi must also be normal, and there must be no abnormal reflexes of any part of the body to interfere with the normal vagus control of the heart.

While the heart beats from an inherent musculonervous mechanism, nervous interference easily upsets its normal regularity. It may be seriously slowed by nervous shock, fear or sudden peripheral contractions, spasm of muscles, or convulsive contractions, or it may be stimulated to greater rapidity by nervous excitement. It may be slowed or made rapid by reflex irritations, and it may be seriously interfered with by cerebral lesions; pressure on the vagus centers in the medulla oblongata will make it very slow. Various kinds of poisons circulating in the blood, both depressants and excitants, may affect the rapidity or the regularity of the heart. Therefore, if it is decided that a given heart is abnormally slow or abnormally rapid or is decidedly irregular or intermittent, the various causes for such interference with its normal activity must be investigated and admitted or excluded as causative factors.

Many investigations of the rhythm of children's pulses have been made, and some of the later investigations seem to show that not more than 40 percent are regular, the remaining 60 percent varying from mild irregularity to extreme irregularity.

Scientifically to determine the exact character of a pulse which is discovered by the finger on the radial artery and the stethoscope on the heart to be irregular, tracings of one or more arteries, veins and the heart should be taken. Two synchronous tracings are more accurate than one, and three of more value than two in interpreting the exact activity and regularity of the heart.

ETIOLOGY

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.

Tallman, [Footnote: Tallman: Northwest Med., May, 1916] after examination of fifty-eight cases, classifies different types of auricular flutter: (1) such a condition in an apparently normal heart; (2) the condition occurring during chronic heart disease, and (3) an auricular flutter with partial or complete heart block.

The irregular pulse in auricular fibrillation is more or less distinctive, being generally rapid, from 110 upward. Occasionally the pulse rate may be much slower, if the heart is under the influence of digitalis. The irregularity of the pulse in this condition is excessive; the rate, strength and apparent intermittency during a half minute may not at all represent the condition in the next half minute, or in the next several minutes. If digitalis does not cure the irregularity, the condition has been termed the "absolutely irregular heart." Other terms applied to the condition have been "ventricular rhythm," "nodal rhythm" and "rhythm of auricular paralysis." The condition of the pulse has been Latinized as pulsus irregularis perpetuus.

While the condition is best diagnosed by tracings taken simultaneously of the apex beat, jugular and radial, still the jugular tracing is almost conclusive in the absence of the auricular systolic wave. The radial tracing is exceedingly suggestive, and if there is also a careful auscultation of the heart, a presumptive diagnosis may be made.

OCCURRENCE

This condition of auricular fibrillation occurs occasionally in valvular disease, and perhaps most frequently in mitral stenosis; but it can occur without valvular lesions, and with any valvular lesion. If it occurs in younger patients, valvular disease is apt to be a cause; if in older patients, sclerosis or myocardial degeneration is generally present.

It may also follow infections such as diphtheria, or some infection which has caused a myocarditis. Rarely this fibrillation may be caused by some of the drugs used to stimulate the heart.

It is astonishing how few symptoms may be present with auricular fibrillation and an absolutely irregular heart action. The patient may be able to perform all of his duties, however strenuous, until coincident, concomitant or causative ventricular weakening and dilatation of the ventricles or broken compensation occurs, and then the symptoms are those due to the cardiac failure. Often in the first stage of this weakening and later fibrillation of the auricles the patient may recognize the cardiac irregularity and disturbances. Generally, however, he soon becomes accustomed to the sensations, and, unless he has cardiac pains or dyspnea, he becomes oblivious to the irregularity. At other times he may be conscious of irregular, strong throbs or pulsations of the heart, as such hearts often give an occasional extra sturdy ventricular contraction. These he notes. Real attacks of tachycardia may be superimposed on the condition. Sooner or later, however, if the condition is not stopped, cardiac weakness and decompensation, with all the usual symptoms, occur. It seems to be probable that more than half of all cases of heart failure are due to auricular fibrillation, or at least are aggravated by it.

As previously stated, ventricular fibrillation is a very serious condition, and may be a cause of sudden death in angina pectoris, and is probably then caused by disturbed circulation in one of the coronary arteries causing an irregular blood supply to one or other of the ventricles. Absorption of some toxins or poisons which could act on the blood supply of the ventricles could also be a cause of this condition. This irregular ventricular contraction sometimes displaces the apex beat.

PATHOLOGY

Schoenberg [Footnote: Schoenberg: Frankfurt. Ztschr. f. Pathol., 1909, ii, 4.] finds that in auricular fibrillation there are definite signs in the node, such as round cell infiltration, showing inflammation, a fibrosis of the tissue, and perhaps a sclerosis of the blood vessels of that region. He also found that compression of this nodal region of the auricle from some growth or other disturbance in the mediastinal region could cause auricular fibrillation.

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.

TREATMENT

The condition may be stopped by relieving the heart and circulation of all possible toxins and irritants, and by the administration of digitalis. One attack is frequently followed by others, perhaps of longer duration. Occasionally, however, the patient may be observed for many years without the condition again being present. If the pulse, in spite of treatment, is permanently irregular, and auricular insufficiency is permanent, the patient is of course in danger of cardiac failure; but still he may live for years and die of some other cause than heart failure. The prognosis is better when the pulse is not rapid—below a hundred. This shows that the ventricles are not much excited and do not tend to wear themselves out.

Any treatment which lowers the heart rate is of advantage, such as the stopping of tea and coffee, and the administration of digitalis, together with rest and quiet.

While large doses of digitalis are advised, and large doses are given as soon as a patient with auricular fibrillation comes under treatment, such large dosage is dangerous practice. Many patients may be cured or may survive fluidram doses of the official tincture, but such large doses should never be used unless it is decided, after consultation, that, though dangerous, it may be a life-saving treatment.

If a patient has not been receiving digitalis, it is best to begin with a small close and gradually increase the dosage, rather than to give the heart a sudden shock from an enormous dose of digitalis. The preparation selected must be the best obtainable, but the exact dosage of any preparation can be determined only by its effect, as all preparations of digitalis deteriorate sooner or later. It is well to administer digitalis at first three times a day, then as soon as its action is thoroughly established, reduce to twice a day, and later to once a day, in such dosage as is needed to make a profound impression on the heart. The first dose may be from 5 to 10 drops, and the dosage may be increased by 5 drops at each dose, until improvement is obtained. If the patient is in a momentary serious condition and liable to die of heart failure, it is doubtful if digitalis pushed at that time will be of benefit. On the other hand, if, after consultation, it is deemed advisable to give half a fluidram or more of digitalis at once, it is justifiable. It should be emphasized that the proper dose of digitalis is enough to do the work. If within a few days there is no marked improvement, the prognosis is not good. Also, if the digitalis causes cardiac pain when such was not present, or increases cardiac pains already in evidence, and causes a tight feeling in the chest, nausea or vomiting, or a diminished amount of urine, and a tight, bandlike feeling in the head, digitalis is not acting well, and should be stopped, or the dose is too large. Also, if there is kidney insufficiency, or if the digitalis diminishes the output of urine, it generally should be stopped.

If the blood pressure is high, and perhaps almost always, even in those who are accustomed to the use of it, tobacco should be stopped. Tea and coffee should always be withheld from such patients.

The food and drink should be small in amount, frequently given, and should be such as especially to meet the needs of the individual, depending entirely on his general condition and the condition of his kidneys.

PULSUS ALTERNANS

By this term is meant that condition of pulse in which, though the rhythm is normal, strong and weak pulsations alternate. White [Footnote: White: Am. Jour. Med. Sc., July, 1915, p. 82.] has shown that this condition is not infrequent, as demonstrated by polygraphic tracings. He found such a condition present In seventy- one out of 300 patients examined, and he believes that if every decompensating heart with arrhythmia was graphically examined, this condition would be frequently found. The alternation may be constant, or it may occur in phases. It is due to a diminished contractile power of the heart when the heart muscle has become weakened and a more or less rapid heart action is present.

Gordinier [Footnote: Gordinier: Am. Jour. Med. Sc., February, 1915, p. 174.] finds that most of these patients with alternating pulse are suffering from general arteriosclerosis, hypertension, chronic myocarditis, and chronic nephritis, in other words, with cardiovascularrenal disease. He finds that it frequently occurs with Cheyne-Stokes respiration, and continues until death. He also finds that the condition is not uncommon in dilated hearts, especially in mitral disease, and with other symptoms of decompensation.

White found that about half of his cases of pulsus alternans showed an increased blood pressure of 160 mm. or more; 62 percent. were in patients over 50 years of age, and 69 percent. were in men. Necropsics on patients who died of this condition showed coronary sclerosis and arteriosclerotic kidneys.

The onset of dyspnea, with a rapid pulse, should lead one to suspect pulsus alternans when such a condition occurs in a person over 50 with cardiovascular-renal disease, arid with signs of decompensation, and also when such a condition occurs with a patient who has a history of angina pectoris.

While the forcefulness of the varying beats of an alternating pulse may be measured by blood pressure instruments by the auscultatory method, White and Lunt [Footnote: White, P. D. and Lunt, L. K.: The Detection of Pulsus Alternans, THE JOURNAL A. M. A., April 29, 1916, p. 1383.] find that in only about 30 percent. of the cases, the graver types of the condition, is this a practical procedure.

Pulsus alternans, except when it is very temporary, Gordinier finds to be of grave import, as it shows myocardial degeneration, and most patients will die from cardiac insufficiency in less than three years from the onset of the disturbance.

The treatment is rest in bed and digitalis, but White found that in only four patients out of fifty-three so treated was the alternating pulse either "diminished or banished." In a word, the only treatment is that of decompensation and a dilated heart, and when such a condition occurs and is not immediately improved, the prognosis is bad, under any treatment.

BRADYCARDIA

The first decision to be made is what constitutes a slow pulse or slow heart. A pulse below 58 or 60 beats per minute should be considered slow, and anything below 50 should be considered abnormally slow and a condition more or less suspicious. A pulse from 45 to 50 per minute occasionally occurs when no pathologic excuse can be found, but such a slow rate is unusual. Before determining that the heart is slow, it must of course be carefully examined to determine if there are beats which are not transmitted to the wrist; also whether a slow radial rate is not due to intermitence or a heart block. Auricular fibrillation, while generally causing a rapid pulse (though by no means all beats are transmitted to the peripheral arteries), tray cause a slow pulse because some of the contractions of the heart are not transmitted.

While any pulse rate below 50 should be considered abnormal and more or less pathologic, still a pulse rate no lower than 60 may, be very abnormal for the individual. For athletes and those who work hard physically, a slow pulse is normal. Such hearts are often not even normally stimulated by high fever, so that the pulse is unusually slow, considering the patient's temperature, unless inflammation of the heart has occurred.

Some chronic diseases cause a slow pulse; this is especially true of chronic interstitial nephritis. In fact, it may be stated that any disease or condition which increases the blood pressure generally slows the pulse, unless the heart itself is affected. This is true of hypertension, of arteriosclerosis, of nicotin unless the heart has become injured, and often of caffein, unless it acts in the individual as a nervous stimulant. Chronic lead poisoning causes a slow pulse on account of the increased blood pressure.

A slow pulse may occur during convalescence from acute infections, such as typhoid fever and pneumonia, and sometimes after septic processes. While it may not be serious in these conditions, it should always be carefully watched, as it may show a serious myocarditis.

While weakness generally and myocarditis, at least oil exertion or nervous excitation or after eating, cause a heart to be rapid, still such a heart may act sluggishly when the patient is at rest, so that he feels faint and weak and disinclined to attempt even the slightest exertion. In such a condition calcium, iron and strychnin, not too frequently or in too large doses, and perhaps caffein, are indicated. Camphor is always a valuable stimulant, more or less frequently administered, during such a period of slow heart. This slow heart sometimes occurs after rheumatic fever; it is quite frequent after diphtheria, and may show a disturbance of the vagi.

Although the prognosis of such slow hearts after serious illness is generally good, a heart that is too rapid after illness is often more readily brought to normal by proper management than a heart which is too slow. Either condition needs proper treatment and proper management.

It is well recognized that serious, almost major hysteria may be present and the heart not only not be increased, but it may even be slowed. The heart in this condition of course requires no treatment. In cerebral disturbances, especially when there is cerebral pressure, and more particularly if there is pressure in the fourth ventricle, the pulse may be much slowed. It is often slowed in connection with Cheyne-Stokes respiration. It may be very slow after apoplexy, and when there are brain tumors. It is often much slowed in narcotic poisoning, especially in opium, chloral and bromid poisoning. Serious toxemia from alcohol may cause a heart to be very slow. It is more likely, however, to cause a heart to be rapid, unless there is actual coma.

A frequent condition causing a slowing of the heart is the presence of bile in the blood, typically true of catarrhal jaundice. Uremic poisoning and acidemia and coma of diabetes tray cause a pulse to be very slow.

Not infrequently after parturition the heart quiets down from its exertion to a rate below normal. If the urine is known to be free from albumin and casts, and there are no signs of impending eclampsia, the slow pulse is indicative of no serious trouble; but the urine should be carefully examined and a possible uremia or other cause of eclampsia carefully considered. Sometimes with serious edema and after serious hemorrhage the heart becomes very slow, unless some exertion is made, when it will beat more rapidly than normal. This probably represents a diminished cardiac nutrition.

The cardiac lesions which cause a pulse to be slow are sclerosis or thrombosis of the coronary arteries, fatty degeneration of the myocardium, and Stokes-Adams disease.

It is seen, therefore, that when a pulse is slower than normal, even below 65 beats per minute, the cause should be sought. If no functional or pathologic excuse is discovered, it must be considered normal, for the individual, and, as stated above, even 58 or 60 beats per minute are in many instances normal for men. This is especially true with beginning hypertension, and may be true in young men who are athletic or who are oversmoking but are not being poisoned by the nicotin, as shown by the fact that their hearts are not rapid, that they are not having cardiac pains, that they do not perspire profusely, and that they do not have muscle cramps. A pulse of from 50 to 55 is likely to be seriously considered by an insurance company in deciding the advisability of the risk, and below 50 must be considered as abnormal.

SYMPTOMS

If a person has been long accustomed to a slow-acting heart, there are no symptoms. If the heart has become slowed from disease or from any acute condition, the patient is likely to feel more or less faint, perhaps have some dizzines, and often headache, which is generally relieved by lying down. Sometimes convulsions may occur, epileptiform in character, due possibly to anemia or irritation of the brain. If the slow heart does not cause these more serious symptoms, the patient may feel week and unable to attend to his ordinary duties. As previously urged an abnormally slow heart after serious illness should be as carefully cared for as a too rapid heart under the same conditions. Probably often a myocarditis and perhaps some fatty degeneration are at the base of such a slowed heart after serious infections.

A heart which has not always been slow but has gradually become slow with the progress of hypertension and arteriosclerosis will often disclose on postmortem examination serious lesions of the coronary arteries.

Deficiency in the thyroid secretion will always cause a heart to be slower than normal. The more marked and serious the hypothyroidism, the slower the heart is apt to be. When such a condition is diagnosed, the treatment is thyroid extract; or if the insufficiency is not great, small doses of an iodid should be given. In either case it is sometimes astonishing how rapidly a slow, sluggishly acting heart, improves and how much improvement there is in the mental condition of the patient.

In acute slowing of the heart, as in syncope, the patient must immediately lie down with the head low, possibly with the feet and legs elevated, and all constricting clothing of the abdomen and chest should be removed. Whiffs of smelling-salts may be given; whisky, brandy or other quickly acting stimulant, not much diluted, play also be given. Camphor, a hypodermic dose of strychnin or atropin if deemed necessary, a hot-water bag over the heart, and massaging of the arms and legs to aid the return circulation, are all means which are generally successful in restoring the patient's circulation to normal. Caffein is another valuable stimulant, perhaps best administered as a cup of coffee. Digitalis is not indicated: neither is nitroglycerin, unless the slow heart is due to cardiac pain or to angina.

Some patients have syncopal attacks with the least injury or with any mental shock. Such patients as soon as restored are as well as ever. Other patients who faint or have attacks of syncope should remain at rest on a couch or bed for some hours.

A tangible cause, being discovered for an unusually slow heart is sufficiently indicative of the treatment not to require further comment. While generally toxins from intestinal indigestion make a heart irritable and more rapid, sometimes they slow a heart, and in such cases the heart will be improved when catharsis has been caused and a modification of the diet is ordered.

PAROXYSMAL TACHYCARDIA

This condition is generally termed by the patient a "palpitation," and palpitation of the heart is recognized by most physicians as meaning a too rapidly acting heart, the term "tachycardia" being reserved for an excessive rapidity of the heart. Many of the so- called tachycardias are really instances of auricular fibrillation or flutter. Some persons normally have a pulse and heart too rapid; children more or less constantly have a heart beat of from 90 to 100. Women have more rapid heart action than men, and it becomes more rapid with their varying functions, specifically increasing its rapidity before, and perhaps during, menstruation. Many patients have a rapid heart action with the slightest increase in temperature and in any fever process. Some have a rapid heart action after the least exertion without any cardiac lesion or assignable excuse for such rapidity. Others have a rapid heart with mental activity and excessive excitement. Therefore in deciding that a heart is abnormally rapid one must individualize the patient.

During or after illness many patients are said to have palpitation when the real cause is an unhealed myocarditis. Tuberculosis almost invariably causes increased heart action, even when there is no fever. All high fever increases the heart's action, but not so markedly in typhoid fever as in other fevers; in fact, the heart in typhoid fever, during the early stages, is apt to be slower than the temperature would seem to call for. In anemia when the patient is active the heart is generally rapid. The rapid heart from cardiac disease has already been considered. For the palpitation or rapid heart Just described there is little necessity for other treatment than what the acute or chronic condition would call for. With proper management the condition will improve unless the patient has an idiosyncrasy for intermittent attacks of slightly rapid heart, as from 100 to 120 beats per minute.

A permanently rapid heart, when the patient has no heart lesion and is at rest, is generally due to hypersecretion of the thyroid, which will be discussed later. Paroxysmal tachycardia is a name applied to very rapid heart attacks in persons who are more or less subject to their recurrence. They may occur without any tangible excuse, and are liable to occur during serious illness, after a large meal, after a cup of tea or coffee, or after taking alcohol. The heart may beat as rapidly as from 150 to 200 times a minute, or even more, with no other symptoms than a feeling of constriction or tightness in the chest, an inability to respire properly and a feeling of "air hunger." The patient almost invariably must sit up, or at least have his head raised. Attacks of cardiac delirium (often auricular fibrillation) may occur with serious lesions of the heart, as valvular disease or sclerosis, but paroxysmal tachvcardia occurs in certain persons without any tangible cardiac excuse. The auricles of the heart may act more energetically than normal, and precede as usual the ventricular contraction; or the auricles and ventricles may contract almost together—a so-called "nodal" type of contraction. Rarely does a patient die of paroxysmal tachycardia. The length of time the attack may last varies from a few minutes to an hour, or even for a day or more.

MANAGEMENT

There is no specific treatment for paroxysmal tachycardia. What is of value in one patient may be of no value in another; in fact, drugs are rarely successful in ameliorating or preventing the condition. Patients who are accustomed to these attacks often learn what particular position or management stops the attack.

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.

If a patient has exophthalmic goiter fully developed, absolute rest in bed, with the treatment outlined above, should soon cause improvement. If it does not, the operative treatment as advised above should be considered. If myocarditis has been diagnosed, the minor operations should be done if the patient does not soon improve. The prolongation of the treatment depends on the condition and the amount of improvement.

If the physician is in doubt as to whether or not this particular tachycardia is caused by hyperthyroidism, the administration of sodium iodid in doses of 0.25 gm. (4 grains) three times a day will make the diagnosis positive within a few days. If the trouble is due to hyperthyroidism, all of the symptoms will be aggravated; there will be more palpitation, more nervousness, more restlessness, more sweating and more sleeplessness. In such cases the iodid should be stopped immediately, of course, and the proper treatment begun.