SOME FORMS OF ARRYTHMIA:
(1) The heart beat increased during deep respiration.
(2) Extra-systole, in old age, or from excess of tea, coffee, tobacco, etc. Here the cardiac muscle is involved.
(3) Stokes-Adams syndrome, combined with loss of consciousness and cramps.
(4) End result of valvular disease.
(5) Pulsus-alternans. Beats alternately strong and weak, e.g. in chronic nephritis, and has the same significance as “gallop- rhythm.”
(6) Sinus irregularity. Deflate the chest and stop breathing; the heart becomes regular, owing to the action of the vagus. Or, try increased exercise, pulse rate increases but the heart becomes regular, owing to the action of the sympathetic.
(7) Auricular flutter. If we find a patient whose pulse is about 150 per minute, and effort or exercise cause no increase: this is probably a case of “auricular flutter.” Or, if we find that the pulse rate falls below 150, and the heart at once becomes regular, this is another sign of “auricular flutter”.
It will be observed that there is a marked difference in these reactions from any other known condition. In persons with a normal heart the rate varies with the effort, and in its variation the rhythm is regular. In auricular fibrillation the rate varies on effort, but the heart is never regular.
AURICULAR FIBRILLATION is usually found in mitral stenosis of rheumatic origin. Also in cardio-sclerosis of middle-aged and elderly people. There is complete irregularity of the pulse and absence of the “a” wave.
THE PHRENIC NERVES AND THE HEART. These nerves have some very intimate and important relations with the heart. The nerve on each side springs from the fourth cervical nerve, and, as a rule obtains also a root from the fifth or the third, and sometimes from both. If the root from the fifth fails, then it usually receives a twig from the nerve to the sub-clavius muscle a point well worth remembering. Before entering the thorax it is usually joined by a small sympathetic twig. It is the most important branch given off by the cervical plexus: its old name was “the internal respiratory nerve of Sir Charles Bell.”
Its chief use, motor nerve of diaphragm. It is, however, a mixed nerve being made up of motor, sensory and sympathetic fibres. It gives sensory, as well as motor fibres, to the diaphragm, sensory to the extra-pleural and extra-pericardial connective tissue, and to the supra-renal body of the corresponding side. The phrenics pierce the diaphragm, and are distributed to the under, or peritoneal, side. The right phrenic has a specially wide distribution, giving branches to the liver and its sub-peritoneal covering, the inferior vena cava, and the right auricle. Occasionally only this nerve sends a twig to the cystic duct and neck of gall-bladder.
Hence affections in these regions may cause pains in the other half of the right clavicle and tip of the acromion, the skin of these parts being supplied by the superficial descending branches of the third and fourth cervical nerves, from which the phrenic takes its origin. The pain passes down the outer side of the arm, and not along the inner side as in angina pectoris. It will be easily understood that in many forms of “acute abdomen,” when blood, or other discharges, reach as high as the diaphragm,pain will be felt in the same regions, either on right or left side according to which phrenic is irritated.
A word of caution, therefore, is necessary: dont run away with the idea that shoulder tip pain is always due to the liver and gall-bladder; indeed it is rather rare from this cause. Along with shoulder-tip pain there will very often be pain also in right or left supra-spinous fossa, in the various abdominal disorders.
I do not propose to say much as to drug treatment of cardiac diseases. But in passing I would advise every physician to possess a copy of Sir James Mackenzies small book, “Principles of Diagnosis and Treatment in Heart Affections” (Oxford Medical Publications). This is quite a small book, but in the section on treatment (the last three chapters) it contains more common sense, and useful everyday hints, than any other book I know, however large, or by whomsoever written. It is a pity that our allopathic brothers do not read, mark, learn and inwardly digest it, lay it to heart and follow its directions closely. There would probably be fewer “regrettable incidents” if they did.
Digitalis. I only intend to make a few general remarks. Lately most of the large drug manufacturing firms have been making much of the statement that their Digitalis preparations are “Physiologically Standardised.” Now, what on earth is the use or value of that to the medical practitioner? It is absolutely of no value whatever. Doctors have no use for physiological or healthy hearts (in their patients, I mean). The doctor is concerned entirely with diseased organs, and we have to “standardise” the drug for ourselves in every single and separate case.
We cannot possibly trust the recommendations of the experimental pharmacologist who deals only with physiological organs leaving out, for the moment, the huge doses he uses. I suppose we must include all such “booming” to be a mere cog in the wheel of “commercialism” detestable word and neither for the benefit of the doctor nor his patient. There is a commerce that is honest and true, but I do not believe that “commercialism” is either the one or the other.
Further it involves the practice of that cruel, cursed, useless, and misleading vivisection; and all for what? Absolutely nothing, as far as the cure of disease is concerned, which ought to be the only object both of the doctor and pharmacologist, for both exist for sick persons, and not sick persons for them, though “commercialism” says otherwise.
If Mackenzies method of administration of digitalis be followed, no harm can come to the patient. Hahnemann, himself, in the early days of Homoeopathy, used the doses he had been accustomed to use as an allopath. But he had “brains,” and when he saw the severe aggravation that followed such a dose, he gave no more but simply waited till the aggravation passed off and the cure began. This is what Mackenzie did, and in his hands the effects were only good.
Nitro-glycerine (Trinitrin). This is the medicine one would think of first in the pain of the “effort syndrome.” This is due to the gradual loss of the elasticity of the cardiac muscle, or rather the result of its unwillingness to “give,” or stretch, just as in other forms of visceral pain. Now, does this drug affect the heart directly, or does it merely cause dilatation of the blood vessels, and thus relieve the tension on the cardiac muscle, in other words relieve it indirectly? I believe it does both.
I am fairly certain that it does affect the cardiac muscle directly. That it should do so, is most reasonable when we remember that the heart is merely pulsatile bulbs developed in, or on, the course of the original arteries, and presumably constructed of the same materials, more or less.
It has always seemed passing strange to me that the action of nitrites, such as Ethyl nitrite (in Spiritus Aetheris nitrosi) sodium nitrite, Trinitrin (glonoine, or nitro-glycerine), Nitrite of Amyl and so on, should be so different to the action of nitrates: in other words, that the acid radicle of the nitrates, with its negative charge (-NO2) should be so different in action from the acidic radicle of the nitrates (-NO3).
Quinidine. This is an isomer of quinine, but quinidine turns the ray of polarised light to the right, whereas quinine turns it to the left. Few remedies have sprung so rapidly into favour, in allopathic therapeutics, as quinidine. This was probably due to the fact that it was, more or less, homoeopathic to the condition for which it was prescribed. But if this be true, then it was necessary for safety that the dose should be small, and its effects carefully watched. It was recommended by Frey in 1918 in cases of complete cardiac arrhythmia. To began with, the dose should never be larger than one grain, and the effects of that carefully watched.
There has been a growing record of “general toxic symptoms, cardiac failure, and embolism” produced by the large doses given. Why is it so dangerous, as compared with ordinary quinine? For this reason, that ordinary quinine is hardly ever remotely homoeopathic to the various conditions for which it is so freely given, whereas quinidine has a more or less homoeopathic relation to cardiac arrhythmia. It is most remedial when the doses are small, according to allopathic observations.
Sir James Mackenzies great drug for auricular fibrillation was digitalis, administered by his intelligent method. At the same time, it is stated, that digitalis has no effect whatever on the auricular fibrillation itself, but that it merely controls the ventricular rate within normal limits. That is as it may be, and I have some doubts about this explanation. But, quinidine is said to arrest the auricular fibrillation itself, directly, by its action on the auricle. If this be true it ought to be a very valuable medicine; though I fear that the disasters following its large and unintelligent dosage, will soon bring it into disrepute, as usual if they have not already done so.