Tachycardia





Etymologically tachycardia means rapid heart. There are two forms of

rapid heart, that which is constant and that which occurs in

periodical attacks. It is for this latter that the term tachycardia

has been more particularly used, though occasionally the adjective

paroxysmal is attached to it to indicate the intermittent character of

the affection. With regard to the persistent type of rapid heart

something deserves to be said, however, because patients' minds are

often seriously disturbed by them. Often it has existed for years,

sometimes is known to be a family trait and probably has existed from

childhood, yet the discovery of it may be delayed until some

pathological condition develops, calling for the attendance of a

physician who may be needlessly alarmed and in turn alarm his patient

by his recognition of it. The cause for this persistent rapid pulse is

not well known and is difficult to determine. Heredity, as has been

suggested, sometimes plays an important role in it. Certain families

have one or more members in each generation with rapid hearts.

Whenever persistent rapid heart is a family trait the patient can be

assured, as a rule, without hesitation, that the general prognosis of

the case is that of the lives of the rest of the family. Usually the

symptom seems to mean nothing as regards early mortality or any

special tendency to morbidity.





Favorable Prognosis.--While a rapid pulse often and indeed usually has

some serious significance, it must not be forgotten that it may be an

individual peculiarity and be quite compatible with long life and hard

work. One of the first patients that I saw as a physician had a pulse

between ninety-six and one hundred. As there was a slight tendency to

irregular heart action also, I was inclined to think that there must

be some cardiac muscle trouble. There was apparently no valve lesion.

He told me that a physician ten years before had noted his rapid pulse

and had made many inquiries about it which rather seriously disturbed

him. He had been an extremely healthy man during his fifty-five years

of life and there seemed no reason to conclude, since his rapid pulse

had been in existence for ten years, that it meant anything serious.

He has now lived well beyond the age of seventy and still has a pulse

always above ninety. Contrary to what might be thought, he is an

extremely placid, unexcitable individual, who, under ordinary

circumstances, will probably live for many years to come. He has no

family history of tachycardia, though there is a history of rather

nervous irritable hearts in other members for two generations.



An interesting case of this kind came under my observation about

fifteen years ago in a clergyman whose pulse was never below ninety,

and who on slight excitement, or after a rapid walk, or after a heavy

meal, would have a pulse of 120. He knew that it was a family trait,

his father having had it yet living to be past seventy. He gave a

history of its having been recognized in his own person more than

twenty years before. His general health, however, was excellent. He

took long walks and, indeed, pedestrian excursions were his

favorite exercise. He was able to go up flights of stairs rather

rapidly without discomfort. He was the pastor in a tenement house

district so he had plenty of opportunity for such exertion. Infections

of any kind, colds and the like, disturbed his pulse very much, if the

ordinary standard was taken, but it was not irregular and the increase

in rapidity was probably only proportionate to the original height of

the pulse in his case. After all, as the normal pulse of sixty to

seventy rises to between ninety and one hundred even in a slight

fever, it is not surprising if a pulse normally above ninety should

rise fifty per cent. to one hundred and thirty-five under similar

conditions. He is now well past sixty, after over thirty-five known

years--and probably longer--of a pulse above ninety, yet he is in

excellent general health and promises, barring accident, to live

beyond seventy.



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.





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