A Benign Type Of Paralysis Of The Auricle
( Originally Published 1921 )
I am making this the subject of special attention in the study of the heart because it has considerable importance, and also because I want to have it on record, so that I can use it for the encouragement of people with this particular trouble.
The modern heart patient, in the course of time, becomes well informed as to his particular disease; indeed he knows as much about it in particular as many physicians know about it when their knowledge is only part of a general medical training. He goes from city to city and from country to country, and consults first one and then another, until it becomes impossible to pursue the policy of concealing from him the nature of his trouble.
At the time when I began the work I am now doing which was before our modern knowledge of the heart had come to us I read a paper before the American Medical Association, in which I said that myocarditis was characterized by a rapid, irregular, and somewhat inefficient heart. I also said that this heart was characterized, on examination, chiefly by what you could not hear. This condition was called chronic myocarditis in those days, and was believed to consist of degenerative changes in the whole heart muscle. For that reason every one with this condition was told that he was in danger, and when he lived on for a long time it was considered a matter of surprize and good fortune. We now know that the rapid and irregular heart does not necessarily mean great weakness of the bulk of the heart muscle, but only that there is a functional disorder of the auricle.
A prophecy was made by a heart specialist more than fifty years ago, that if the time ever came when we understood the auricle, on that day a flood of light would be thrown upon the diseases of the heart. But during the intervening time so little was known of the auricle that it was hardly mentioned in medical education.
The auricle is not a particularly important part of the heart from a mechanical point of view. As a machine, the heart gets along pretty well if the auricle does not contract. The blood flows toward the heart and, when the ventricle expands, fills it whether the auricle contracts or not. A much more important function of the auricle is that of originating the impulse of the heart to contract.
I wish to describe a number of people now under observation, who are getting along well in spite of a trembling paralysis of the auricle. Instead of contracting, in these cases the auricle remains in a condition of distention; and yet there are ineffective attempts at contraction starting all the time from different parts of its surface, each one of which is an attempt to originate a beat that naturally would be carried out by the ventricle. In other words, there is a trembling palsy of the auricle.
The first person I wish to speak of is a physician who is about to return to his work after a, serious attack of influenza. The picture of his heart beat told of the absence of any evidence of a contraction of the auricle, but showed the ventricle contracting much too often and without any regularity, so that, instead of the three important electric waves that we ought to get with each heart beat, we find only two. We find the R wave representing the contraction of the ventricle, and the T wave representing the work of the ventricle.
We find that this picture differs from the natural picture, in that there is an unsteadiness of the picture between the beats, which consists of an almost indefinite number of little waves. This shower of small electric currents that comes from the heart is due to the trembling of the paralyzed auricle, and is always present in people who have paralysis of the auricle.
Entirely aside from the heart, the chemical activities of the body cause electric currents. In healthy, well people, this so-called body current is steady, and before we take the picture of heart currents we neutralize it by throwing a little reverse electricity into the circuit from a small battery. Then we do not have to think anything more about it. In nervous people this body current is irregular and interferes with our photograph of the heart beat, just as it is difficult to photograph a restless child.
So, to recognize the picture of the heart beat as being due to this trembling palsy of the auricle, it is necessary to look where the wave from the auricle ought to be and find it absent. It ought to be about a tenth of a second before each of the church-steeple shaped R waves that indicate the contraction of the ventricle.
The second person is L.I.M.I., a woman fifty six years of age, who is executive manager of a large fashionable publication business. She complained of throbbing in the back and palpitation of the heart, which apparently dated from a severe attack of typhoid fever twelve or fourteen years ago. 'When she first came under observation, her heart was rapid and irregular, but under the careful administration of digitalis and a course of Nauheim baths, she has been restored so that she carries on her occupation with comparative comfort. Her heart, as shown by the accompanying electrocardiogram, is completely irregular, but is functionally competent without definite auricular contraction.
The third is Mr. L. B. S. O., sixty two years of age, manager of a large iron business. He came under observation about a year ago, during an attack of severe heart failure, characterised by dropsy, shortness of breath, and congestion of the lungs and liver. He responded promptly to full doses of digitalis and ipecac, according to a formula' that I have published elsewhere. He was able to go back to his business and, in spite of much trouble due to loss of employees in the war and large army orders, has had good success. At present his heart remains completely irregular, but the ventricle is slow and his general condition is fairly good.
The fourth is Mr. H. H. D., forty six years of age, who came under observation in July, 1915, with complete irregularity of the heart, which was demonstrated by the electrocardiogram to be due to paralysis of the auricle. He has been under observation ever since, has remained at the head of the accounting department of a large manufacturing plant, and has carried on his work without impairment or inefficiency. His condition is as good as it was three years ago.
The fifth is Mr. M. B., who came under observation in November, 1918. He is thirty-seven years old, a lawyer of active practise, engaged in public philanthropy as well. His heart was completely irregular, and the electrocardiogram showed fibrillation of the auricle. He has gone on ever since under careful supervision, and remained apparently as well as he was at the beginning.
These are people who are under observation just at the moment. I am sure that I could easily, by a little effort, bring under review many similar ones who were observed on only one or two occasions.
The important point is the proper classification of people suffering from this particular type of functional heart disorder and placing them in a group that should be known as benign fibrillation of the auricle.