the
evidences of heart failure, THE SIGNS AND SYMPTOMS OF THREE CASES PERSONALLY EXAMINED.* BY
P. Christine Vine.
Introduction. few words may be devoted to the term "heart ilure " and its underlying causes by way of intro?tion. Some explanation is, indeed, necessary, owing
the fact that heart failure is a term applied both a condition in which death occurs immediately, and "
^
?ne in which
"
symptoms appear in such
an
insidious
that the patient scarcely discerns their fanner spite of the apparent disparity of these extremes, onset,
two
e
Underlying principle
Muscle has been damaged.
is the same, i.e. the heart When an individual cannot
efficient circulation during the performance ^intain the usual activities of daily life he then suffers from an
art
1
failure.
During
Ure
recent years the whole
conception
of heart
has been revolutionised. The old school of ?Ught based their theories on the fact that a valve the heart had become defective. maintained ls
to be the
They
of the heart failure. They primary "eneVed that in time all four chambers of the heart
^came ether
involved,
cause
and
the
prognosis depended
established
not.
on
In the
^ ^er compensation case hypertrophy of the heart muscle occurred, in the latter dilatation. The new school holds that was
*
or
A British Medical Association Prize Essav.
98
Miss P. Christine Vine
heart failure is due to heart. a
Usually
valve is
injury
to the muscle wall of the
the extent of the
involved, though
damage
is such that
necessarily any considerable
this does not
If the muscle is damaged to failure will become evident even if all the heart extent, valves are intact. This damage is considered to be the occur.
primary The
cause causes
of dilatation. of
injury to the heart headings :?
muscle may be
classified under three 1.
Injections,
carditis and
as
rheumatism, ulcerative endo-
in
syphilis.
Intoxications, such as thyroid, alcohol and bacterial toxins, e.g. pneumococcal and diphtheria 2.
toxins. 3. blood
Degenerations, such as pressure and senility.
Clinical Evidences
of
those caused
by high
Cardiac Failure.
These maj^ be divided into two main groups, as ft generally manifests itself in one of two ways :? 1. By the onset of symptoms due to an inefficient flow of blood
through the organs of the body. Somethis is known as the times congestive type. 2. Ity the occurrence of pain due to exhaustion oi the heart muscle.
This is known
as
the
anginal typesigns and
Under the first of these headings several symptoms may be considered.
Dyspnoea.?This
is
important symptoms, manifestations of heart any individual heart failure.
perhaps as
it
failure,
suffering
is
one one
of
the the
most earliest
rarely absent congestive type
and is
from the
of
iia
by Peabody, Meyer and Du Bois a that patients suffering from cardiac dyspnoea have of slightly increased metabolic demand for the intake It has been shown
The Evidences
^xygen.
This, however, is
reathlessness during
^ability
Heart Failure not
sufficient to
The chief
rest.
99 cause
is the
cause
the
part of the heart muscle to pump blood to the medulla ; another result of the
on
Efficient Sanie
of
inability
aild in the
is
a
same
deficient
oxygenation
of the
blood,
acidosis is set up in the A second carbon dioxide.
an
way
Capillaries due to excess Cause, no doubt, exists in the pulmonary congestion, ailc^j if present, pulmonary oedema, both of which reduce the respiratory capacity. These factors, by
Producing to
state of deficient aeration of the
a
to
damage dangerous
cause
c?nsequence
the
blood,
are
and in
myocardium,
vicious circle may be set up. In order to determine whether shortness of breath
0ri
a
exertion be due
to cardiac disease
or
not, it
must be
COrriPared with the patient's previous powers of exertion
Without
the
production
of
respiratory
distress.
One
1Vldual may undertake a great deal more exercise 11 another without becoming short of breath. The ?
greats
_er
the
damage
to
the heart muscle the
more
a% will breathlessness be induced.
Orthopnoea.?If
^noea pr
on
gressive,
k^spncea, ?Wn
an
individual suffers from
exertion and the
in due
condition is
slight rapidly
he will suffer from constant i.e. he will be dyspnoeic during rest. This is course
as
orthopnoea, when the patient is compelled to sitting posture. An attack of orthopnoea may ^ ^r?ught on by prolonged over-exertion in cases onty a comparatively slight degree of cardiac fa'i re- This fact was illustrated by a case seen at the ^ *** General Hospital in June, 1926. The patient ^
a
.
a
girl aged 18, wTho had suffered from rheumatic
Ver when
3-^
years old.
For several years she had
tained fairly good health, but during the last six previous
to admission her work had been of
a
100
Miss P. Christine Vine
months of chamber-maid in one of the to the fact that she
somewhat strenuous nature. this time she had been
largest
a
hotels in Bristol.
During
two
Owing
carrying heavy loads, she had developed some
had been
scoliosis of the spine. On admission the patient stated that she walked several miles only a few days On examination she showed several signs of hear
previously*
failure, particularly orthopnoea.
improved
with rest and treatment.
Her condition Sometimes
greatly
sufficient
orthopnoea to disappear entirely. When orthopnoea occurs in patients who have not been over' exerting themselves it is a grave sign. It may mean that the heart has become arrhythmic ; for instance, i may signify the onset of auricular fibrillation some days or hours previously. In such cases it is usually accompanied by other signs of cardiac failure. Cheyne-Stokes Breathing.?By this is meant a for?1 a of periodic respiration in which at regular intervals period of apnoea {i.e. entire absence of respiration)
rest will
cause
At $l6 ^ recommences, but is The inspirations an
occurs, and may last from 10 to 60 seconds.
end of this time first
respiration
almost
imperceptible. expirations gradually become until
a
maximum is
in force until the
more
and
reached, after which they
period Cheyne-Stokes breathing failure, it is usually of myocardial degeneration,
forcib^
more
dimini^1
of apnoea is reached. occurs as a sign of serious
import.
It
Wkel1 cardi^0
signifieS
and is therefore often seen 111
It may occur in combination auricular fibrillation or with auricular flutter. It is not necessarily, however, a sign of cardiac failure
senile heart
cases.
apart from other signs. It may occur elderly people, living fairly active lives, and is then
if it
occurs
It may also occur in people with a M blood pressure and in cases of advanced arterioscleros13'
little
significance.
The Evidences
of
Oheyne-Stokes breathing
Ust the
Heart Failure is most
101
commonly
seen
is
patient sleeping, but it may occur whilst ^ patient is sitting quietly in a chair. Its presence ?uld be suspected when the patient complains of being
c?]istantly
awakened out of his
Suffocation.
sleep by
feeling
a
of
The individual may awake in such a ror-stricken state that he jumps out of bed. Somees a
patient will fall asleep during the apnoeic period, will awake and resume his trend of thought when
respirations Cardiac
return.
yspnoea which 0
form
of
manifestation of heart failure.
It
asthma.?This is
a
is
a
peculiar
occurs most
It is
the
frequently during night. severe dyspnoea, the onset extremely sudden. The patient awakes out
afacterised by very ^ls
]ch is
sleep
with
a
great sensation of suffocation. UP' an
No. 168.
power of flow of blood to the inefficient cause
of cerebral
This may be of
a
symptoms,
mild
degree 1
or
102
Miss P. Christine Vine
cause
the
patient
to fall.
of
In
complete
loss
syndrome
is sometimes seen,
severe cases
consciousness.
there may be
The Adams-Stokes
characterised by paroxysmal infrequency of the pulse associated with epileptiform attacks. This is usually a consequence of auriculo-ventricular heart block, and the blood supply to the brain may be completely arrested. Sometimes the patient exhibits unusually early fatigue a
condition
a
after mental
effort,
or a
loss of memory. Hallucinations present, the patient becoming
insanity may be restless, or even violent. This is also sometimes a characteristic of myocardial degeneration of senility. Cyanosis.?The diminished arterial supply, leading to deficient oxygenation of the blood and accumulation of carbon dioxide, results in a bluish flush of the skin? chiefly of the cheeks and extremities, known as cyanosis* Later these parts, the lobes of the ears and the nose* or
may show lividity. Cyanosis is more frequently seen cases of mitral disease than aortic, as in the formeI>
in
condition there is
to
great venous engorgement due obstruction or regurgitation of blood at the mitral vabre' a
CEdema.?Several factors appear to determine the i*1 appearance of this sign of heart failure. It occurs patients in whom there is a central obstruction to the circulation due to valvular disease of the heart, or general cardiac weakness. If the patient is up a11 7
about this oedema is but if the
first in the feet and legs'
is in bed it will be
patient the lumbar region parts of the lungs. one
seen
of the factors.
1
of the back
or
more
in the
This demonstrates that
marked
111
dependent gravity
In chronic heart disease there lS
always a long-continued increase of pressure in capillaries, and in cases in which there is great engorgement there is the additional factor of diminish? n] absorption by the veins. Cases have been recorded
veno1^
The Evidences
^hichbeencomplete found
Heart Failure
of
obstruction of the inferior
as
on
Patient has shown
103
vena
cava
post-mortem examination, but the
no
signs
greased
This proves that capillaries and decreased
of oedema.
pressure in the sorption by the veins are not the
only causal factors.
Mother, probably, is some damage to the capillary wall surrounding tissues caused b}^ the increased Pressure and the malnutrition of the tissues, which is arid
lnevitable result of the inefficient blood supply. possible that this injury to the capillary walls,
j^e
ls
mowing
of
an
increased transudation of
llla^n causal factor.
^Edema
'ndividuals ls
round the ankles
occurs
after
some
standing
for
lymph,
is the
in many healthy considerable time.
also present in certain other diseases, such
j^Phritis. Ure unless
It must not be taken other
Enlargement
kid neys.
The
sign
of heart disease
are
is that
as
of cardiac
present.
of the liver in One of the
to localised oedema.
Pr?duction
Clrcu^a^on
a
signs of the liver.?Swelling
ardiac disease is due ?rS *n
as
normally
the force of
least hi such organs as this and the commonest cause of chronic venous
Ollgestion Ur as
of the liver is mitral disease. It may also the result of obstruction to the pulmonary
?ulation.
If
pulsation of the liver is felt, the enlarge} cardiac in origin. When determining the cause IVer enlargement, an examination of the physical ss of the heart is important, as it should only be c" sidered a sign of cardiac failure when occurring in ls
filiation with dilatation of the heart. Albuminuria.?If albumen is found to be
es^imati?n of the amount should
an
be
^rille' tained
all
Alb
present in
always
bv Esbach's test. A considerable amount may he found in advanced heart failure.
as
len
Anuria
is
a
result of chronic
venous
congestion
of
104 the
Miss P. Christine Vine
kidneys;
the
more
severe
the
congestion
the
greater is the amount of albumen in the urine. (Edema of the lungs.?Finally, another sign due to a deficient output of blood is oedema of the lungs. The patient suffers at the same time from orthopnoea and,
owing
to the fact that he has assumed
a
sitting posture,
usually found at the bases of the lungs. I^s presence may be detected by auscultation ; in the early stages fine crepitations will be heard during the first deep inspiration. In time, if the condition is progressive,
oedema is
crepitations become persistent and are heard during every inspiration. The anginal form of heart failure, i.e. the second the
type mentioned under which another group of evidences be
may now be considered. heart failure is characterised by pain, the
can
This form 0f
placed,
cause
of
which
is exhaustion of the heart muscle ; the output of blood may not be altered to any extent from the normal. I11 some
cases,
present The
however, both forms of heart failure
at the
pain
same
may
are
time. be
a
full
constant
ache
in the
prsecordium, or a recurring sharp pain ; a more serious form of pain, however, is that known as angina pectoris* This latter occurs in attacks, and is brought on by effort. Usually the pain is an immediate result of the exertion. The typical pain of angina pectoris is always felt in definite regions, across the left side of the chest (including the region of the sternum), in the left arm, but in rare instances in the right arm ; it may als? occur
at the back of the neck behind the
ear
and alo11*?
usually' though it may remain localised in some part of the chest* It most commonly passes from the chest to the left armpit or shoulder (occasionally it passes to both arms)'
the
jaw.
The
pain is of
a
then it travels down the
radiating
arm
on
character
the ulnar side,
The Evidences
Usually as
far
farther than the elbow,
as
the
tips
r*ng fingers. The
Heart Failure
of
of the
although fingers, affecting
105
it may travel
the little and
of
angina pectoris are sclerosis of coronary syphilis. The associated cardiac condition present may be fibroid myocarditis or ai1 aortic lesion such as an aneurysm, syphilitic aortitis, 0r aortic incompetence. When angina pectoris occurs I*1asaily one of these it is a grave sign, as the condition usually advanced to an extreme degree before common causes
the
arteries and
0ccurrence of le
pain.
An estimate of the
damage
to
heart muscle can be obtained by finding out the a*Uount of effort the patient can make under favourable
.c?uditions,
and
by noting
the effect of treatment.
Other evidences of the above-named diseases will be
Und
on
careful examination of the
eulargenient a
of the heart.
great deal of
ypertrophy
stress
on
as
thought
the differentiation between
and dilatation.
erentiation is
patient, such
The old school of In
practice, however,
this
by easy. Another symptom accompanying or preceding an attack of angina pectoris is a sense of constriction of the est.
^0
Occasionally
no
means
this is
a more
tlie patient than the pain.
c?utraction *4
attaek
distressing symptom probably due to a
It is
of the intercostal muscles.
of depression sometimes accompanies an angina pectoris. The patient has a feeling of
sense
of
death. This depression ^pending ailgina pectoris, it sometimes
is not
occurs
}7aso-motor
disturbances
are
pathognomonic
in auricular flutter.
discernible in
some.
*s
may take the form of pallor or of flushing. Both of disturbances are followed by profuse perspiration. An increased flow of saliva occurs in some patients ^ 0Se
ring
an
attack.
This is
pain is in the jaw.
particularly
liable to
occur
106
Miss P. Christine Vine An increased
flow of urine frequently follows attack, and large quantities may be passed.
an
Physiological Types of Cardiac Failure, with Illustrative Cases. Various
and mechanical contrivances have whereby certain evidences of heart failure
means
been devised
For the purpose of dealing with these application, heart failure may be divided physiologically into three different groups. The heart can
be detected.
and their
composed of three parts, each having its own peculiar function. They are (a) the auricles, in which the contraction wave is originated, and which by their contraction drive the blood into the ventricles ; (b) the ventricles, which by their forcible contraction drive the blood through the body; (c) the regulating system* consisting of the sino-auricular node, auriculo-ventricul^1* is
The three groups then are termed auricular, ventricular and auriculo-ventricular failureThere is no fast line of demarcation between these three A patient suffering from auricular failure types. node and bundle.
eventually dies from ventricular failure. On the other hand, a patient suffering from advanced ventricular failure, as in syphilitic aortic incompetence, may suddenly develop an arrhythmia due to auricula1" Each fibrillation. however, has certain group, distinctive evidences. Auricular
failure
occurs
in its most
characterise0
form in advanced cardiac rheumatism. It has f?uf main features. The first is total arrhythmia, no tra^6
regular rhythm remaining. The pulse is usually rapid and very irregular in force and frequency ; ^ie heart beat, however, is even more rapid, as a numbe of the less forcible contractions fail to reach the wri^' The second sign is the loss of all evidence of auricula of
The Evidences
Systole.
eard,
Heart Failure
107
On auscultation no presystolic murmur is and on palpation no presystolic thrill is felt,
^though Case
of
these may have been marked features of the onset of auricular failure. If a polygram
before the
taken the jugular curve shows no evidence of an auricular sj^stolic movement. Its absence is also shown
by
an
%
electro-cardiogram.
means of the last two methods mentioned, the third sign, i.e. auricular fibrillation, can be demonstrated, Minute, rapid, irregular movements being recorded. The fourth sign is the increase in severity of dyspnoea, cyanosis, jugular distension, liver enlargement and
Crepitations in the lungs observable ?0r*set of auricular failure.
shortly
Case 1.?E. T., female, aged 54. Married. nstol General Hospital in September, 1925.
Admitted to the Died five weeks
Jater.
Diagnosis.?Chronic
^illation. History.?One
cardiac
after the
rheumatism
with
auricular
month previous to admission the patient bronchitis and remained in bed for a fortnight, ^en got up for three days, but was compelled to return to bed again, her cough being very troublesome. A severe ack of breathlessness and palpitations followed. During this a?k she vomited once.
eloped
^
attacks of rheumatic fever. During the^reV*?US history.?Four years she had suffered from heart trouble, and *ast seven
i
frequently
?ndition
complained
of
pains
round the heart.
admission :? 97-6? F. Pulse rate, 72. Respirations, 24 per The patient looked ill and pale, with slight cyanosis of cheeks. The posture assumed was semi-upright. Considerclean but dry. Slight oedema of H. 6^sPnoea present. Tongue an four inches from the mid-line. Ce
70.
Blood left sixth
frequency.
Apex beat in Very diffuse.
Miss P. Christine Vine
108
Area of cardiac dullness, left border of the sternum, four inches from the mid-line in the sixth left space ; in the third left rib above. A systolic murmur was and was loudest at the apex, but was also discernible, however, the This systolic area. base over aortic heard at the faintly murmur was conducted out to the axilla. Percussion note was found to be slightly impaired at the right base. Vocal fremitus, vocal resonance and breath sounds were normal. Abdomen.?Area of liver dullness was found to extend down No other abnormal as far as two inches below the costal margin. were found. signs Heart sounds
extremely irregular.
Nervous system, normal.
Urine.?Specific gravity 1008. Reaction, acid. No blood? albumen or sugar present. A fortnight after admission the patient showed greater cyanosis. Dyspnoea was very severe at times. She had assumed an almost completely upright sitting posture. An oedema of the arm had left developed, and the veins over the left side of hel chest were very dilated ; the right side was normal. During the last three weeks of life the patient became even more dyspnoeic, and she vomited several times. =
Ventricular
failure usually
occurs
as
the result of
high blood pressure or aortic incompetence, syphillS being a common cause. This is a more serious condition of affairs than signs of heart failure due to a bacterid intoxication as in diphtheria. In this latter conditio!1 there is always the possibility that with efficient nursing the patient may recover. In the former, however, death is the inevitable
result,
as
the condition is This
if not
gradually'
of failure
type rapidly, progressive. and which lS cyanosis, by dyspnoea 111 chiefly due to right ventricular failure, and is seen one of its deepest forms in pulmonary atheroma Pain is due to le^ (Edema is another early sign.
characterised
ventricular failure.
This
subject has been
discussed, except for the pain due bosis.
This takes the form of
a
previous!)
to coronary
thro#1'
sudden attack of
pal11
The Evidences lri
the chest and
of
Heart Failure
epigastrium, commencing
t
in the
109
night,
lasts for several hours, but gradually dies away, and the A few days patient partially recovers. ater, however, a second attack occurs with a fatal
result. The blood pressure taken
of
sphygmoventricular detecting manometer ailure. Some useful signs obtained by it are :? (?) A low systolic pressure in comparison to the lastolic, particularly significant when the systolic Pressure has fallen rapidly. (&) Alternation of the pulse can be detected if Present. This is called pulsus alternans," and is due is
often
useful
by
means
a
in
"
,?
inefficiency
of the left ventricle.
Certain signs
of ventricular failure can be obtained y examination of the chest. They consist in a dis-
placement arid
a
aint ?e-
of the apex beat outwards and to the left, rapid increase in the area of cardiac dullness.
heart sounds and tripling of the heart sounds when a third sound is heard between the first and
Second sounds) may indicate ventricular failure. Case
?g rist?l dis
2.?H. S., female, aged 59. Married. Admitted General Hospital on September 23rd, 1925.
to
^^a^nos^s-?Chronic cardiac rheumatism with aortic valvular
ease, in which auricular fibrillation had occurred.
history.?Patient
t
complained of severe breathlessness for Te previous to admission, worse at night than in (lay. This had recently increased in severity. For several S^e n?ticecl an increasing distension of her abdomen, 1 *?r four months had complained of swelling of her legs. Previous history. Rheumatic fever twenty five years months
an
Previously.
?ndition on admission :? eniperature, 96-5? F. Pulse, 88. Respiration, 28 per ute. Posture, semi-upright. Deep cyanosis and severe Pnoea. Considerable oedema of back and legs. Sleep, very rBowels opened regularly. Micturition normal.
110
Miss P. Christine Vine
Pulse, irregular in force and frequency. Tension fairly highSuprasternal pulsation present with a well-marked thrill. ApeX
beat in fifth left space, five and a half inches from the mid-line. Area of cardiac dullness, third left rib above ; right sternal border to five and a half inches from the mid-line in fifth left There was also an area of dullness over the space. manubrium. Heart sounds, irregular. At the apex, first sound replaced by a long systolic murmur. Second sound very faint. At the base, in the second right space (i.e. the aortic area), firS^ sound replaced by a long systolic murmur. Second sound At the second left space (i.e. at the pulmonary area) faint. first sound was replaced by a long systolic murmur. Second sound slightly accentuated. A diastolic murmur was heard in the fourth left space Lungs, normal.
near
the sternum.
Abdomen.?Distended and tense. Fluid thrill felt. Liver down about half an inch below the right
palpable, extending costal margin.
Nervous system, normal. Wassermann reaction negative. Shifting September 26th.?Abdomen soft and flabby. dullness but no fluid thrill. Blood pressure, right arm, systolic 135, diastolic 105; left arm, systolic 135, diastolic 115. October 10th.?The apex beat of the heart from the mid-line.
was
four inches
Area of cardiac dullness, third left rib above ; mid-sternal line to four inches external to the mid-line in fifth left spaceThe liver had decreased in size considerably. November 21st.?The rhythm of the heart was regularLoud systolic and soft diastolic murmurs present at the ape*Systolic and diastolic murmurs present over aortic areaThe diastolic murmur could be traced down the left border 0 the sternum to the apex, whilst the systolic could be traced up into the carotids. The patient was discharged on November 24th.
This results fro#1 failure. conducting system. Arterial lesio^8
Auriculo-ventricular disturbance of the and
gumma are the common manifested in three degrees :?
(1) The
lengthened.
a-c
interval in the
causes.
It
jugular pulse
may may
The Evidences
(2) Ventricular Occasional blocking auricle
(3)
of
Heart Failure
111
beats may be dropped owing to of the passage of the stimulus from
to ventricle.
A condition of heart block may exist when the at twice or even four times the rate of the
auricles beat
Ventricle,
or
in
cases
Ventricles each beat
of
complete
at their
block the auricles and
own
speeds.
Case 3.?G. P., male, age 51. Occupation, fish merchant. patient gave a history of Adams-Stokes syndrome. He
rp he
^oiiiplained.
had attacks of fainting for four years. attacks occurred every few minutes and ?ontinued for several weeks, after which a period free from tacks followed. He also complained of a tightness at times ln his chest but no pain. of
having
?ttietimes the
History of attack.?Patient suddenly caught
his breath, and Extreme pallor was consciousness for a few seconds. olio Wed by excessive flushing as consciousness returned, forwards he suffered from headache. st
Previous history.?(a)
Rheumatic fever three times ;
requent pains in joints. _
ls
Condition
a
on
Movements no oedema.
examination.?Patient was somewhat pale. slow. Attitude, stooping. No dyspnoea Marked pulsation on both sides of the neck.
were
Carclio-vascular system.?Pulse, 64 per minute, egular in force and frequency. Tension good. Blood pressure, systolic 1G0, diastolic 82. Cardiac impulse visible to the left of the nipple. Apex beat palpable five and a half inches from
the fifth left space. Area of cardiac dullness (mapped
lef^6 .(iifficulty5
out
^he patient was very above ; left sternal border to line in fifth left space.
.
as
lpple ^eari sounds, fa'
sv
the e
slightly
mid-line in
with third inch outside the
by percussion muscular), from one
very faint. At the apex both sounds were audible. A murmur of the nature of a pericardial rub heard in the fifth space over an area of two square inches It was from the nipple hne towards the axilla. *n ^meAt the base a similar murmur was heard over area, and it masked the first pulmonary sound. second pulmonary sound was slightly accentuated. Over
Uitly
e^,s
(b)
Pulmonary
The Evidences
112
of
the aortic area the first sound was faint. and
Lungs
was
Heart Failure
sound
heard, the second
not
abdomen, normal. knee-jerks active.
Nervous system,
No other abnormal
signs
present.
patient enlargement
examination of the chest by screening the showed the heart to be greatly enlarged, all the being left-sided. The greatest horizontal measurement was eight inches. The ratio of the greatest width of the heart to the width of the chest at that level was calculated to be 1 : 1' '*
X-ray
?
^jrHfH+TOJ-LU1 W 1 i
Electro-cardiogram (taken
on
the same was icas
day
uiri :.m
i
that the general examination examinati0'1
made).
66 per minute. ? (1) Heart rate, 00 t>_-B II and III show delayed conduction of the auriculo-ventricular auriculo-ventricular bundle, the the (2) Leads I, It ai It gradually increases frcm interval being more than 4/25 second. seconds^ 9/25 to 13/25 seconds occasionally conduction fails. Lead III therefore shows a dropped beat. It S shows notching in Lead I. (3) Q It I?P is probably Le:>d III?P is inverted. (5) Lead I?1' inverted. probabiy buried in T. Lend 1
was administered to this patient with excelled This proves that the several occasions. oI an was important factor in producing the depression conduction.
Atropine
results
vagu^
on
I have
to
thank
Dr.
Coombs and Dr. Carleton for of their
Symes, Dr. Carey permission to make
Odery
cases.
REFERENCE. 1
on
Medical Science; Abstracts and Reviews, Dyspnoea by J. H. Means.
Nov.,
1924:
Abstract
evidences of heart failure, THE SIGNS AND SYMPTOMS OF THREE CASES PERSONALLY EXAMINED.* BY
P. Christine Vine.
Introduction. few words may be devoted to the term "heart ilure " and its underlying causes by way of intro?tion. Some explanation is, indeed, necessary, owing
the fact that heart failure is a term applied both a condition in which death occurs immediately, and "
^
?ne in which
"
symptoms appear in such
an
insidious
that the patient scarcely discerns their fanner spite of the apparent disparity of these extremes, onset,
two
e
Underlying principle
Muscle has been damaged.
is the same, i.e. the heart When an individual cannot
efficient circulation during the performance ^intain the usual activities of daily life he then suffers from an
art
1
failure.
During
Ure
recent years the whole
conception
of heart
has been revolutionised. The old school of ?Ught based their theories on the fact that a valve the heart had become defective. maintained ls
to be the
They
of the heart failure. They primary "eneVed that in time all four chambers of the heart
^came ether
involved,
cause
and
the
prognosis depended
established
not.
on
In the
^ ^er compensation case hypertrophy of the heart muscle occurred, in the latter dilatation. The new school holds that was
*
or
A British Medical Association Prize Essav.
98
Miss P. Christine Vine
heart failure is due to heart. a
Usually
valve is
injury
to the muscle wall of the
the extent of the
involved, though
damage
is such that
necessarily any considerable
this does not
If the muscle is damaged to failure will become evident even if all the heart extent, valves are intact. This damage is considered to be the occur.
primary The
cause causes
of dilatation. of
injury to the heart headings :?
muscle may be
classified under three 1.
Injections,
carditis and
as
rheumatism, ulcerative endo-
in
syphilis.
Intoxications, such as thyroid, alcohol and bacterial toxins, e.g. pneumococcal and diphtheria 2.
toxins. 3. blood
Degenerations, such as pressure and senility.
Clinical Evidences
of
those caused
by high
Cardiac Failure.
These maj^ be divided into two main groups, as ft generally manifests itself in one of two ways :? 1. By the onset of symptoms due to an inefficient flow of blood
through the organs of the body. Somethis is known as the times congestive type. 2. Ity the occurrence of pain due to exhaustion oi the heart muscle.
This is known
as
the
anginal typesigns and
Under the first of these headings several symptoms may be considered.
Dyspnoea.?This
is
important symptoms, manifestations of heart any individual heart failure.
perhaps as
it
failure,
suffering
is
one one
of
the the
most earliest
rarely absent congestive type
and is
from the
of
iia
by Peabody, Meyer and Du Bois a that patients suffering from cardiac dyspnoea have of slightly increased metabolic demand for the intake It has been shown
The Evidences
^xygen.
This, however, is
reathlessness during
^ability
Heart Failure not
sufficient to
The chief
rest.
99 cause
is the
cause
the
part of the heart muscle to pump blood to the medulla ; another result of the
on
Efficient Sanie
of
inability
aild in the
is
a
same
deficient
oxygenation
of the
blood,
acidosis is set up in the A second carbon dioxide.
an
way
Capillaries due to excess Cause, no doubt, exists in the pulmonary congestion, ailc^j if present, pulmonary oedema, both of which reduce the respiratory capacity. These factors, by
Producing to
state of deficient aeration of the
a
to
damage dangerous
cause
c?nsequence
the
blood,
are
and in
myocardium,
vicious circle may be set up. In order to determine whether shortness of breath
0ri
a
exertion be due
to cardiac disease
or
not, it
must be
COrriPared with the patient's previous powers of exertion
Without
the
production
of
respiratory
distress.
One
1Vldual may undertake a great deal more exercise 11 another without becoming short of breath. The ?
greats
_er
the
damage
to
the heart muscle the
more
a% will breathlessness be induced.
Orthopnoea.?If
^noea pr
on
gressive,
k^spncea, ?Wn
an
individual suffers from
exertion and the
in due
condition is
slight rapidly
he will suffer from constant i.e. he will be dyspnoeic during rest. This is course
as
orthopnoea, when the patient is compelled to sitting posture. An attack of orthopnoea may ^ ^r?ught on by prolonged over-exertion in cases onty a comparatively slight degree of cardiac fa'i re- This fact was illustrated by a case seen at the ^ *** General Hospital in June, 1926. The patient ^
a
.
a
girl aged 18, wTho had suffered from rheumatic
Ver when
3-^
years old.
For several years she had
tained fairly good health, but during the last six previous
to admission her work had been of
a
100
Miss P. Christine Vine
months of chamber-maid in one of the to the fact that she
somewhat strenuous nature. this time she had been
largest
a
hotels in Bristol.
During
two
Owing
carrying heavy loads, she had developed some
had been
scoliosis of the spine. On admission the patient stated that she walked several miles only a few days On examination she showed several signs of hear
previously*
failure, particularly orthopnoea.
improved
with rest and treatment.
Her condition Sometimes
greatly
sufficient
orthopnoea to disappear entirely. When orthopnoea occurs in patients who have not been over' exerting themselves it is a grave sign. It may mean that the heart has become arrhythmic ; for instance, i may signify the onset of auricular fibrillation some days or hours previously. In such cases it is usually accompanied by other signs of cardiac failure. Cheyne-Stokes Breathing.?By this is meant a for?1 a of periodic respiration in which at regular intervals period of apnoea {i.e. entire absence of respiration)
rest will
cause
At $l6 ^ recommences, but is The inspirations an
occurs, and may last from 10 to 60 seconds.
end of this time first
respiration
almost
imperceptible. expirations gradually become until
a
maximum is
in force until the
more
and
reached, after which they
period Cheyne-Stokes breathing failure, it is usually of myocardial degeneration,
forcib^
more
dimini^1
of apnoea is reached. occurs as a sign of serious
import.
It
Wkel1 cardi^0
signifieS
and is therefore often seen 111
It may occur in combination auricular fibrillation or with auricular flutter. It is not necessarily, however, a sign of cardiac failure
senile heart
cases.
apart from other signs. It may occur elderly people, living fairly active lives, and is then
if it
occurs
It may also occur in people with a M blood pressure and in cases of advanced arterioscleros13'
little
significance.
The Evidences
of
Oheyne-Stokes breathing
Ust the
Heart Failure is most
101
commonly
seen
is
patient sleeping, but it may occur whilst ^ patient is sitting quietly in a chair. Its presence ?uld be suspected when the patient complains of being
c?]istantly
awakened out of his
Suffocation.
sleep by
feeling
a
of
The individual may awake in such a ror-stricken state that he jumps out of bed. Somees a
patient will fall asleep during the apnoeic period, will awake and resume his trend of thought when
respirations Cardiac
return.
yspnoea which 0
form
of
manifestation of heart failure.
It
asthma.?This is
a
is
a
peculiar
occurs most
It is
the
frequently during night. severe dyspnoea, the onset extremely sudden. The patient awakes out
afacterised by very ^ls
]ch is
sleep
with
a
great sensation of suffocation. UP' an
No. 168.
power of flow of blood to the inefficient cause
of cerebral
This may be of
a
symptoms,
mild
degree 1
or
102
Miss P. Christine Vine
cause
the
patient
to fall.
of
In
complete
loss
syndrome
is sometimes seen,
severe cases
consciousness.
there may be
The Adams-Stokes
characterised by paroxysmal infrequency of the pulse associated with epileptiform attacks. This is usually a consequence of auriculo-ventricular heart block, and the blood supply to the brain may be completely arrested. Sometimes the patient exhibits unusually early fatigue a
condition
a
after mental
effort,
or a
loss of memory. Hallucinations present, the patient becoming
insanity may be restless, or even violent. This is also sometimes a characteristic of myocardial degeneration of senility. Cyanosis.?The diminished arterial supply, leading to deficient oxygenation of the blood and accumulation of carbon dioxide, results in a bluish flush of the skin? chiefly of the cheeks and extremities, known as cyanosis* Later these parts, the lobes of the ears and the nose* or
may show lividity. Cyanosis is more frequently seen cases of mitral disease than aortic, as in the formeI>
in
condition there is
to
great venous engorgement due obstruction or regurgitation of blood at the mitral vabre' a
CEdema.?Several factors appear to determine the i*1 appearance of this sign of heart failure. It occurs patients in whom there is a central obstruction to the circulation due to valvular disease of the heart, or general cardiac weakness. If the patient is up a11 7
about this oedema is but if the
first in the feet and legs'
is in bed it will be
patient the lumbar region parts of the lungs. one
seen
of the factors.
1
of the back
or
more
in the
This demonstrates that
marked
111
dependent gravity
In chronic heart disease there lS
always a long-continued increase of pressure in capillaries, and in cases in which there is great engorgement there is the additional factor of diminish? n] absorption by the veins. Cases have been recorded
veno1^
The Evidences
^hichbeencomplete found
Heart Failure
of
obstruction of the inferior
as
on
Patient has shown
103
vena
cava
post-mortem examination, but the
no
signs
greased
This proves that capillaries and decreased
of oedema.
pressure in the sorption by the veins are not the
only causal factors.
Mother, probably, is some damage to the capillary wall surrounding tissues caused b}^ the increased Pressure and the malnutrition of the tissues, which is arid
lnevitable result of the inefficient blood supply. possible that this injury to the capillary walls,
j^e
ls
mowing
of
an
increased transudation of
llla^n causal factor.
^Edema
'ndividuals ls
round the ankles
occurs
after
some
standing
for
lymph,
is the
in many healthy considerable time.
also present in certain other diseases, such
j^Phritis. Ure unless
It must not be taken other
Enlargement
kid neys.
The
sign
of heart disease
are
is that
as
of cardiac
present.
of the liver in One of the
to localised oedema.
Pr?duction
Clrcu^a^on
a
signs of the liver.?Swelling
ardiac disease is due ?rS *n
as
normally
the force of
least hi such organs as this and the commonest cause of chronic venous
Ollgestion Ur as
of the liver is mitral disease. It may also the result of obstruction to the pulmonary
?ulation.
If
pulsation of the liver is felt, the enlarge} cardiac in origin. When determining the cause IVer enlargement, an examination of the physical ss of the heart is important, as it should only be c" sidered a sign of cardiac failure when occurring in ls
filiation with dilatation of the heart. Albuminuria.?If albumen is found to be
es^imati?n of the amount should
an
be
^rille' tained
all
Alb
present in
always
bv Esbach's test. A considerable amount may he found in advanced heart failure.
as
len
Anuria
is
a
result of chronic
venous
congestion
of
104 the
Miss P. Christine Vine
kidneys;
the
more
severe
the
congestion
the
greater is the amount of albumen in the urine. (Edema of the lungs.?Finally, another sign due to a deficient output of blood is oedema of the lungs. The patient suffers at the same time from orthopnoea and,
owing
to the fact that he has assumed
a
sitting posture,
usually found at the bases of the lungs. I^s presence may be detected by auscultation ; in the early stages fine crepitations will be heard during the first deep inspiration. In time, if the condition is progressive,
oedema is
crepitations become persistent and are heard during every inspiration. The anginal form of heart failure, i.e. the second the
type mentioned under which another group of evidences be
may now be considered. heart failure is characterised by pain, the
can
This form 0f
placed,
cause
of
which
is exhaustion of the heart muscle ; the output of blood may not be altered to any extent from the normal. I11 some
cases,
present The
however, both forms of heart failure
at the
pain
same
may
are
time. be
a
full
constant
ache
in the
prsecordium, or a recurring sharp pain ; a more serious form of pain, however, is that known as angina pectoris* This latter occurs in attacks, and is brought on by effort. Usually the pain is an immediate result of the exertion. The typical pain of angina pectoris is always felt in definite regions, across the left side of the chest (including the region of the sternum), in the left arm, but in rare instances in the right arm ; it may als? occur
at the back of the neck behind the
ear
and alo11*?
usually' though it may remain localised in some part of the chest* It most commonly passes from the chest to the left armpit or shoulder (occasionally it passes to both arms)'
the
jaw.
The
pain is of
a
then it travels down the
radiating
arm
on
character
the ulnar side,
The Evidences
Usually as
far
farther than the elbow,
as
the
tips
r*ng fingers. The
Heart Failure
of
of the
although fingers, affecting
105
it may travel
the little and
of
angina pectoris are sclerosis of coronary syphilis. The associated cardiac condition present may be fibroid myocarditis or ai1 aortic lesion such as an aneurysm, syphilitic aortitis, 0r aortic incompetence. When angina pectoris occurs I*1asaily one of these it is a grave sign, as the condition usually advanced to an extreme degree before common causes
the
arteries and
0ccurrence of le
pain.
An estimate of the
damage
to
heart muscle can be obtained by finding out the a*Uount of effort the patient can make under favourable
.c?uditions,
and
by noting
the effect of treatment.
Other evidences of the above-named diseases will be
Und
on
careful examination of the
eulargenient a
of the heart.
great deal of
ypertrophy
stress
on
as
thought
the differentiation between
and dilatation.
erentiation is
patient, such
The old school of In
practice, however,
this
by easy. Another symptom accompanying or preceding an attack of angina pectoris is a sense of constriction of the est.
^0
Occasionally
no
means
this is
a more
tlie patient than the pain.
c?utraction *4
attaek
distressing symptom probably due to a
It is
of the intercostal muscles.
of depression sometimes accompanies an angina pectoris. The patient has a feeling of
sense
of
death. This depression ^pending ailgina pectoris, it sometimes
is not
occurs
}7aso-motor
disturbances
are
pathognomonic
in auricular flutter.
discernible in
some.
*s
may take the form of pallor or of flushing. Both of disturbances are followed by profuse perspiration. An increased flow of saliva occurs in some patients ^ 0Se
ring
an
attack.
This is
pain is in the jaw.
particularly
liable to
occur
106
Miss P. Christine Vine An increased
flow of urine frequently follows attack, and large quantities may be passed.
an
Physiological Types of Cardiac Failure, with Illustrative Cases. Various
and mechanical contrivances have whereby certain evidences of heart failure
means
been devised
For the purpose of dealing with these application, heart failure may be divided physiologically into three different groups. The heart can
be detected.
and their
composed of three parts, each having its own peculiar function. They are (a) the auricles, in which the contraction wave is originated, and which by their contraction drive the blood into the ventricles ; (b) the ventricles, which by their forcible contraction drive the blood through the body; (c) the regulating system* consisting of the sino-auricular node, auriculo-ventricul^1* is
The three groups then are termed auricular, ventricular and auriculo-ventricular failureThere is no fast line of demarcation between these three A patient suffering from auricular failure types. node and bundle.
eventually dies from ventricular failure. On the other hand, a patient suffering from advanced ventricular failure, as in syphilitic aortic incompetence, may suddenly develop an arrhythmia due to auricula1" Each fibrillation. however, has certain group, distinctive evidences. Auricular
failure
occurs
in its most
characterise0
form in advanced cardiac rheumatism. It has f?uf main features. The first is total arrhythmia, no tra^6
regular rhythm remaining. The pulse is usually rapid and very irregular in force and frequency ; ^ie heart beat, however, is even more rapid, as a numbe of the less forcible contractions fail to reach the wri^' The second sign is the loss of all evidence of auricula of
The Evidences
Systole.
eard,
Heart Failure
107
On auscultation no presystolic murmur is and on palpation no presystolic thrill is felt,
^though Case
of
these may have been marked features of the onset of auricular failure. If a polygram
before the
taken the jugular curve shows no evidence of an auricular sj^stolic movement. Its absence is also shown
by
an
%
electro-cardiogram.
means of the last two methods mentioned, the third sign, i.e. auricular fibrillation, can be demonstrated, Minute, rapid, irregular movements being recorded. The fourth sign is the increase in severity of dyspnoea, cyanosis, jugular distension, liver enlargement and
Crepitations in the lungs observable ?0r*set of auricular failure.
shortly
Case 1.?E. T., female, aged 54. Married. nstol General Hospital in September, 1925.
Admitted to the Died five weeks
Jater.
Diagnosis.?Chronic
^illation. History.?One
cardiac
after the
rheumatism
with
auricular
month previous to admission the patient bronchitis and remained in bed for a fortnight, ^en got up for three days, but was compelled to return to bed again, her cough being very troublesome. A severe ack of breathlessness and palpitations followed. During this a?k she vomited once.
eloped
^
attacks of rheumatic fever. During the^reV*?US history.?Four years she had suffered from heart trouble, and *ast seven
i
frequently
?ndition
complained
of
pains
round the heart.
admission :? 97-6? F. Pulse rate, 72. Respirations, 24 per The patient looked ill and pale, with slight cyanosis of cheeks. The posture assumed was semi-upright. Considerclean but dry. Slight oedema of H. 6^sPnoea present. Tongue an four inches from the mid-line. Ce
70.
Blood left sixth
frequency.
Apex beat in Very diffuse.
Miss P. Christine Vine
108
Area of cardiac dullness, left border of the sternum, four inches from the mid-line in the sixth left space ; in the third left rib above. A systolic murmur was and was loudest at the apex, but was also discernible, however, the This systolic area. base over aortic heard at the faintly murmur was conducted out to the axilla. Percussion note was found to be slightly impaired at the right base. Vocal fremitus, vocal resonance and breath sounds were normal. Abdomen.?Area of liver dullness was found to extend down No other abnormal as far as two inches below the costal margin. were found. signs Heart sounds
extremely irregular.
Nervous system, normal.
Urine.?Specific gravity 1008. Reaction, acid. No blood? albumen or sugar present. A fortnight after admission the patient showed greater cyanosis. Dyspnoea was very severe at times. She had assumed an almost completely upright sitting posture. An oedema of the arm had left developed, and the veins over the left side of hel chest were very dilated ; the right side was normal. During the last three weeks of life the patient became even more dyspnoeic, and she vomited several times. =
Ventricular
failure usually
occurs
as
the result of
high blood pressure or aortic incompetence, syphillS being a common cause. This is a more serious condition of affairs than signs of heart failure due to a bacterid intoxication as in diphtheria. In this latter conditio!1 there is always the possibility that with efficient nursing the patient may recover. In the former, however, death is the inevitable
result,
as
the condition is This
if not
gradually'
of failure
type rapidly, progressive. and which lS cyanosis, by dyspnoea 111 chiefly due to right ventricular failure, and is seen one of its deepest forms in pulmonary atheroma Pain is due to le^ (Edema is another early sign.
characterised
ventricular failure.
This
subject has been
discussed, except for the pain due bosis.
This takes the form of
a
previous!)
to coronary
thro#1'
sudden attack of
pal11
The Evidences lri
the chest and
of
Heart Failure
epigastrium, commencing
t
in the
109
night,
lasts for several hours, but gradually dies away, and the A few days patient partially recovers. ater, however, a second attack occurs with a fatal
result. The blood pressure taken
of
sphygmoventricular detecting manometer ailure. Some useful signs obtained by it are :? (?) A low systolic pressure in comparison to the lastolic, particularly significant when the systolic Pressure has fallen rapidly. (&) Alternation of the pulse can be detected if Present. This is called pulsus alternans," and is due is
often
useful
by
means
a
in
"
,?
inefficiency
of the left ventricle.
Certain signs
of ventricular failure can be obtained y examination of the chest. They consist in a dis-
placement arid
a
aint ?e-
of the apex beat outwards and to the left, rapid increase in the area of cardiac dullness.
heart sounds and tripling of the heart sounds when a third sound is heard between the first and
Second sounds) may indicate ventricular failure. Case
?g rist?l dis
2.?H. S., female, aged 59. Married. Admitted General Hospital on September 23rd, 1925.
to
^^a^nos^s-?Chronic cardiac rheumatism with aortic valvular
ease, in which auricular fibrillation had occurred.
history.?Patient
t
complained of severe breathlessness for Te previous to admission, worse at night than in (lay. This had recently increased in severity. For several S^e n?ticecl an increasing distension of her abdomen, 1 *?r four months had complained of swelling of her legs. Previous history. Rheumatic fever twenty five years months
an
Previously.
?ndition on admission :? eniperature, 96-5? F. Pulse, 88. Respiration, 28 per ute. Posture, semi-upright. Deep cyanosis and severe Pnoea. Considerable oedema of back and legs. Sleep, very rBowels opened regularly. Micturition normal.
110
Miss P. Christine Vine
Pulse, irregular in force and frequency. Tension fairly highSuprasternal pulsation present with a well-marked thrill. ApeX
beat in fifth left space, five and a half inches from the mid-line. Area of cardiac dullness, third left rib above ; right sternal border to five and a half inches from the mid-line in fifth left There was also an area of dullness over the space. manubrium. Heart sounds, irregular. At the apex, first sound replaced by a long systolic murmur. Second sound very faint. At the base, in the second right space (i.e. the aortic area), firS^ sound replaced by a long systolic murmur. Second sound At the second left space (i.e. at the pulmonary area) faint. first sound was replaced by a long systolic murmur. Second sound slightly accentuated. A diastolic murmur was heard in the fourth left space Lungs, normal.
near
the sternum.
Abdomen.?Distended and tense. Fluid thrill felt. Liver down about half an inch below the right
palpable, extending costal margin.
Nervous system, normal. Wassermann reaction negative. Shifting September 26th.?Abdomen soft and flabby. dullness but no fluid thrill. Blood pressure, right arm, systolic 135, diastolic 105; left arm, systolic 135, diastolic 115. October 10th.?The apex beat of the heart from the mid-line.
was
four inches
Area of cardiac dullness, third left rib above ; mid-sternal line to four inches external to the mid-line in fifth left spaceThe liver had decreased in size considerably. November 21st.?The rhythm of the heart was regularLoud systolic and soft diastolic murmurs present at the ape*Systolic and diastolic murmurs present over aortic areaThe diastolic murmur could be traced down the left border 0 the sternum to the apex, whilst the systolic could be traced up into the carotids. The patient was discharged on November 24th.
This results fro#1 failure. conducting system. Arterial lesio^8
Auriculo-ventricular disturbance of the and
gumma are the common manifested in three degrees :?
(1) The
lengthened.
a-c
interval in the
causes.
It
jugular pulse
may may
The Evidences
(2) Ventricular Occasional blocking auricle
(3)
of
Heart Failure
111
beats may be dropped owing to of the passage of the stimulus from
to ventricle.
A condition of heart block may exist when the at twice or even four times the rate of the
auricles beat
Ventricle,
or
in
cases
Ventricles each beat
of
complete
at their
block the auricles and
own
speeds.
Case 3.?G. P., male, age 51. Occupation, fish merchant. patient gave a history of Adams-Stokes syndrome. He
rp he
^oiiiplained.
had attacks of fainting for four years. attacks occurred every few minutes and ?ontinued for several weeks, after which a period free from tacks followed. He also complained of a tightness at times ln his chest but no pain. of
having
?ttietimes the
History of attack.?Patient suddenly caught
his breath, and Extreme pallor was consciousness for a few seconds. olio Wed by excessive flushing as consciousness returned, forwards he suffered from headache. st
Previous history.?(a)
Rheumatic fever three times ;
requent pains in joints. _
ls
Condition
a
on
Movements no oedema.
examination.?Patient was somewhat pale. slow. Attitude, stooping. No dyspnoea Marked pulsation on both sides of the neck.
were
Carclio-vascular system.?Pulse, 64 per minute, egular in force and frequency. Tension good. Blood pressure, systolic 1G0, diastolic 82. Cardiac impulse visible to the left of the nipple. Apex beat palpable five and a half inches from
the fifth left space. Area of cardiac dullness (mapped
lef^6 .(iifficulty5
out
^he patient was very above ; left sternal border to line in fifth left space.
.
as
lpple ^eari sounds, fa'
sv
the e
slightly
mid-line in
with third inch outside the
by percussion muscular), from one
very faint. At the apex both sounds were audible. A murmur of the nature of a pericardial rub heard in the fifth space over an area of two square inches It was from the nipple hne towards the axilla. *n ^meAt the base a similar murmur was heard over area, and it masked the first pulmonary sound. second pulmonary sound was slightly accentuated. Over
Uitly
e^,s
(b)
Pulmonary
The Evidences
112
of
the aortic area the first sound was faint. and
Lungs
was
Heart Failure
sound
heard, the second
not
abdomen, normal. knee-jerks active.
Nervous system,
No other abnormal
signs
present.
patient enlargement
examination of the chest by screening the showed the heart to be greatly enlarged, all the being left-sided. The greatest horizontal measurement was eight inches. The ratio of the greatest width of the heart to the width of the chest at that level was calculated to be 1 : 1' '*
X-ray
?
^jrHfH+TOJ-LU1 W 1 i
Electro-cardiogram (taken
on
the same was icas
day
uiri :.m
i
that the general examination examinati0'1
made).
66 per minute. ? (1) Heart rate, 00 t>_-B II and III show delayed conduction of the auriculo-ventricular auriculo-ventricular bundle, the the (2) Leads I, It ai It gradually increases frcm interval being more than 4/25 second. seconds^ 9/25 to 13/25 seconds occasionally conduction fails. Lead III therefore shows a dropped beat. It S shows notching in Lead I. (3) Q It I?P is probably Le:>d III?P is inverted. (5) Lead I?1' inverted. probabiy buried in T. Lend 1
was administered to this patient with excelled This proves that the several occasions. oI an was important factor in producing the depression conduction.
Atropine
results
vagu^
on
I have
to
thank
Dr.
Coombs and Dr. Carleton for of their
Symes, Dr. Carey permission to make
Odery
cases.
REFERENCE. 1
on
Medical Science; Abstracts and Reviews, Dyspnoea by J. H. Means.
Nov.,
1924:
Abstract
