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Paroxysmal diaphragmatic flutter with symptoms suggesting coronary thrombosis
Clinical PAROXYSMAL
Reports
DIAPHRAGMATIC FLUTTER WITH SUGGESTING CORONARY THROMBOSIS
SYMPTOMS
FERRALL H. MOORE, M.D., REDWOOD CITY, CALIF., AND CHARLES S~HOFF, M.D., SAN FRANCISCO, CALIF.
F
ROM time to time, since 1936,,reports have appeared in the literature concerning a nomadic individual of various aliases, who presents the unusual association of recurring attacks of diaphragmatic flutter, symptoms suggestive Porter! of Virginia of coronary thrombosis, and psychopathic prevarication. first described the temporary relief of ‘severe angina1 pain in this patient by procaine infiltration of each phrenic nerve, after kymography and fluoroscopy had revealed the presence of diaphragmatic flutter. In his description of the syndrome he concluded that the term “cardiodiaphragmatic angina” was justified. In 1939, Whitehead and associates2of Colorado University published extensive observations on the same patient; during his hospital stay a left phrenicotomy and a right ‘phrenic crush were done to arrest the episode of diaphragmatic flutter, with evident temporary successand relief of precordial pain. An additional communication concerning this individual was included in the same article, in the form of observations by Lagen and others at the University of California Hospital on this patient a year later. At that time, left phrenic exeresis (31 cm.) and right phrenicotomy were done by the Califcrnia group with relief of the flutter episode and of the angina1 pain. During this latter period of observation evidence of hysterical or feigned hemiplegia were recorded ; frequently elevated temperature was thought due to malingering. In 1941, Goodman3 of Oregon University reported temporary relief of angina1 pain and flutter of the diaphragm in the same man by ethyl chloride refrigeration over the phrenics, and suggested this procedure for further trial in other forms of disturbed diaphragmatic motility. The last communication concerning the patient was submitted by Caine and Ware,4 who in 1944 treated him in an Army hospital for the same condition, the paroxysms of flutter, pain, and dyspnea finally ceasing after treatment with bed rest, morphine, and oxygen. In addition to the published reports just cited, it is known that this same patient has been seen and treated for his fluttering diaphragm and angina in at least six other institutions, mostly on the Pacific coast. In each instance house staffs have been intrigued Received for publication
Nov. 19, 1946. 889
890
AMERICAN
HEART
JOURNAL
bY the various callings and pursuits alleged by the subject, and the saga of 1iis
life as related in various hospitals has revealed him as a deep sea diver, a minter, tral pper, sheriff, and retired Army officer. In nearly all instances, evidences of PSYchopathy also have included malingering or belligerency. Identification h1% been possible by means of pictures, scars, and tatoo marks, as well as by mea.ns of the association of complaints. ‘The observations here submitted conf% -111 previous ones, and attempt to add further to the clinical picture of the attn ck as !ieen.
Fig.
I.-Ek%?trocardiogram
taken
during
the
height
of a paroxysm
of diaphragmatic
flutter.
MOORE
AND
SCHOFF
:
PAROXYSMAL
CASE
DIAPHRAGMATIC
891
FLUTTER
REPORT
On Aug. 14, 1946, a man was brought by the police to the emergency room of Palo Alto Hospital, stating that he had been seized by severe chest pain and had collapsed while getting was dressed in khaki enlisted men’s clothing and off a bus. He gave the name of “Lewis Allen”, Army garrison cap, and complained bitterly of agonizing precordial pain, clutching his left breast, Examination revealed a thin, undernourished man around 60 moaning, and gritting his teeth. years of age, with thin gray-brown hair; the eyes were light brown, with small but normally reacting pupils. Marked septal deviation occluded the right nostril, and complete dentures were present. A diagonal white scar traversed the central portion of the lower lip. On each side of the neck old transverse scars 5 cm. in length were present a short distance above the clavicle, just lateral to the sternomastoid insertions. An eagle was tatooed on the right forearm, and a wreath of flowers on the left. On auscultation over the precordium a loud rapid booming sound was heard, about 240 per minute in frequency, in the presence of a pulse rate of 72 at the wrist. Palpation over the lower thorax both back and front, conveyed a marked throbbing sensation to the hand synchronous with the sounds described. The blood pressure was 90/60. Physical examination was otherwise not remarkable. Because of the bitter complaints of “pain in my heart” a tentative diagnosis of coronary thrombosis was made, and morphine sulphate, g grain, was given hypodermically. Following this, an electrocardiogram was run (Fig. 1) which revealed a sinus rhythm with a rate of 70, and no changes suggestive of either coronary insufficienty or of infarction. At this juncture, the similarity existing between the patient and the one described in the literature occurred to us, and he was placed under the fluoroscope. Here both leaves of the diaphragm were seen to be fluttering rapidly in time with the palpable impulses and audible sounds previously noted. The excursion of the leaves was estimated as between 5 and 10 mm., and seemed slightly more marked on the right side. The left leaf of the diaphragm was elevated to the level of the fifth rib, with slight shift of the cardiac shadow to the right (Fig. 2). The patient continued to cry out with distress and evince hypodermically administered morphine. A second dose of vein, slowly, and with relief of pain. The flutter, however, to assume a more irregular rhythm at a somewhat slower rate, hours later not to recur. A routine complete blood count Kolmer was negative. A six-foot roentgenogram of the chest fluoroscopic observations of cardiodiaphragmatic relations. following day failed to show any interim changes.
all signs of severe pain despite the l/8 grain was given, this time b> was not stopped, but was noted disappearing spontaneously several was within normal limits, and the (Fig. 2) merely confirmed previous A recheck electrocardiogram on the
On further conversation with the patient, he stated that he was a retired Navy ensign, recently released from Santo Tomas internment camp in the Philippines, where he stated that he had been imprisoned by the Japanese since 1941. The scar on his lower lip, he explained, was due to a Japanese sniper’s bullet, and the scars at the base of his neck were due to old operations “for tuberculosis.” He also stated that he had served as a “radar installer” in the amphibious assaults on Tarawa, Saipan, Iwo Jima, and Okinawa, which seem to constitute a temporal paradox worthy of note. On being questioned as to previous attacks of chest pain or flutter of the diaphragm, and previous hospital admissions, he denied any such incidents but was quick to refuse us permission to photograph him. The next day after admission he stated that he felt fine and desired to go to a nearby city for his pension check. This he was allowed to do, since the need of hospital beds was urgent at the time. COMMENT
In particularly
view
of in
the regard
extensive to
the
phrenic left
nerve
interruptions and
left
carried leaf
of
the
out diaphragm,
on
this
man,
it
is felt
that the episodes of flutter may at present be due either to the presence cessory phrenic pathways, or to a myogenic tic of the diaphragm.
of
ac-
892
pig.
AMERICAN-HEART
3.-Teleroentgenogram
made
Lhr
day
after
JOURNAL
the
twmination
of a paroxysm
of diaphragmstic’
flulter.
Exclusive of electrocardiographic and fjuoroscopic findings, certain features of the clinical picture presented here have offered bedside evidence arguing against a diagnosis of acute coronary accident, should this same individual be encountered by the reader. Foremost was the absence of pain across the upper chest, and the alleged radiation of pain from the region of the cardiac apex into the left arm. Of almost equal significance was the behavior during the attack, the patient moving about more actively with his histrionics than does the usual victim relatively immobilized by angina. Finally, it is unlikely that an examiner palpating the throb, or hearing the loud bruit of
MOORE
AND
SCHOFF:
PAROXYSMAL
DIAPHRAGMATIC
FLUTTER
893
the rapidly contracting diaphragm, would associate the complaints with the heart for long in the presence of a normal pulse rate. This man will no doubt make more appearances in various hospitals throughout the country, and it is hoped that these observations, along with those previously published, may enable others more readily to arrive at a correct diagnosis, The possibility of diaphragmatic flutter may be called to mind in unusual types of paroxysmal precordial pain. SUMMARY
Further observations are submitted concerning an individual who presents the syndrome of associated diaphragmatic flutter and pain suggestive of acute coronary insufficiency. Practical differential diagnostic suggestions are made for bedside diagnosis. REFERENCES
1. 2. 3.
4.
Porter,
W. B.: Diaphragmatic Flutter With Symptoms of Angina Pectoris, J. A. M. A. 106:992, 1936. Whitehead, R. W., Burnett. C. T., and Lagen, J. B.: Diaphragmatic Flutter With Symptoms Suggesting Angina Pectoris, J. A. M. A. 112:1237, 1939. Goodman, Morton J.: Paroxysmal Flutter of the Diaphragm Simulating Coronary Occlusion: Further Observations of an Extraordinary Case Controlled by Refrigeration of the Phrenic Nerve, J. A. M. A. 116:1635, 1941. Cain, Edmund F., and Ware. E. Richmond: Diaphragmatic Flutter, J. A. M. A. 131: 10.58. 1946.
Reports
DIAPHRAGMATIC FLUTTER WITH SUGGESTING CORONARY THROMBOSIS
SYMPTOMS
FERRALL H. MOORE, M.D., REDWOOD CITY, CALIF., AND CHARLES S~HOFF, M.D., SAN FRANCISCO, CALIF.
F
ROM time to time, since 1936,,reports have appeared in the literature concerning a nomadic individual of various aliases, who presents the unusual association of recurring attacks of diaphragmatic flutter, symptoms suggestive Porter! of Virginia of coronary thrombosis, and psychopathic prevarication. first described the temporary relief of ‘severe angina1 pain in this patient by procaine infiltration of each phrenic nerve, after kymography and fluoroscopy had revealed the presence of diaphragmatic flutter. In his description of the syndrome he concluded that the term “cardiodiaphragmatic angina” was justified. In 1939, Whitehead and associates2of Colorado University published extensive observations on the same patient; during his hospital stay a left phrenicotomy and a right ‘phrenic crush were done to arrest the episode of diaphragmatic flutter, with evident temporary successand relief of precordial pain. An additional communication concerning this individual was included in the same article, in the form of observations by Lagen and others at the University of California Hospital on this patient a year later. At that time, left phrenic exeresis (31 cm.) and right phrenicotomy were done by the Califcrnia group with relief of the flutter episode and of the angina1 pain. During this latter period of observation evidence of hysterical or feigned hemiplegia were recorded ; frequently elevated temperature was thought due to malingering. In 1941, Goodman3 of Oregon University reported temporary relief of angina1 pain and flutter of the diaphragm in the same man by ethyl chloride refrigeration over the phrenics, and suggested this procedure for further trial in other forms of disturbed diaphragmatic motility. The last communication concerning the patient was submitted by Caine and Ware,4 who in 1944 treated him in an Army hospital for the same condition, the paroxysms of flutter, pain, and dyspnea finally ceasing after treatment with bed rest, morphine, and oxygen. In addition to the published reports just cited, it is known that this same patient has been seen and treated for his fluttering diaphragm and angina in at least six other institutions, mostly on the Pacific coast. In each instance house staffs have been intrigued Received for publication
Nov. 19, 1946. 889
890
AMERICAN
HEART
JOURNAL
bY the various callings and pursuits alleged by the subject, and the saga of 1iis
life as related in various hospitals has revealed him as a deep sea diver, a minter, tral pper, sheriff, and retired Army officer. In nearly all instances, evidences of PSYchopathy also have included malingering or belligerency. Identification h1% been possible by means of pictures, scars, and tatoo marks, as well as by mea.ns of the association of complaints. ‘The observations here submitted conf% -111 previous ones, and attempt to add further to the clinical picture of the attn ck as !ieen.
Fig.
I.-Ek%?trocardiogram
taken
during
the
height
of a paroxysm
of diaphragmatic
flutter.
MOORE
AND
SCHOFF
:
PAROXYSMAL
CASE
DIAPHRAGMATIC
891
FLUTTER
REPORT
On Aug. 14, 1946, a man was brought by the police to the emergency room of Palo Alto Hospital, stating that he had been seized by severe chest pain and had collapsed while getting was dressed in khaki enlisted men’s clothing and off a bus. He gave the name of “Lewis Allen”, Army garrison cap, and complained bitterly of agonizing precordial pain, clutching his left breast, Examination revealed a thin, undernourished man around 60 moaning, and gritting his teeth. years of age, with thin gray-brown hair; the eyes were light brown, with small but normally reacting pupils. Marked septal deviation occluded the right nostril, and complete dentures were present. A diagonal white scar traversed the central portion of the lower lip. On each side of the neck old transverse scars 5 cm. in length were present a short distance above the clavicle, just lateral to the sternomastoid insertions. An eagle was tatooed on the right forearm, and a wreath of flowers on the left. On auscultation over the precordium a loud rapid booming sound was heard, about 240 per minute in frequency, in the presence of a pulse rate of 72 at the wrist. Palpation over the lower thorax both back and front, conveyed a marked throbbing sensation to the hand synchronous with the sounds described. The blood pressure was 90/60. Physical examination was otherwise not remarkable. Because of the bitter complaints of “pain in my heart” a tentative diagnosis of coronary thrombosis was made, and morphine sulphate, g grain, was given hypodermically. Following this, an electrocardiogram was run (Fig. 1) which revealed a sinus rhythm with a rate of 70, and no changes suggestive of either coronary insufficienty or of infarction. At this juncture, the similarity existing between the patient and the one described in the literature occurred to us, and he was placed under the fluoroscope. Here both leaves of the diaphragm were seen to be fluttering rapidly in time with the palpable impulses and audible sounds previously noted. The excursion of the leaves was estimated as between 5 and 10 mm., and seemed slightly more marked on the right side. The left leaf of the diaphragm was elevated to the level of the fifth rib, with slight shift of the cardiac shadow to the right (Fig. 2). The patient continued to cry out with distress and evince hypodermically administered morphine. A second dose of vein, slowly, and with relief of pain. The flutter, however, to assume a more irregular rhythm at a somewhat slower rate, hours later not to recur. A routine complete blood count Kolmer was negative. A six-foot roentgenogram of the chest fluoroscopic observations of cardiodiaphragmatic relations. following day failed to show any interim changes.
all signs of severe pain despite the l/8 grain was given, this time b> was not stopped, but was noted disappearing spontaneously several was within normal limits, and the (Fig. 2) merely confirmed previous A recheck electrocardiogram on the
On further conversation with the patient, he stated that he was a retired Navy ensign, recently released from Santo Tomas internment camp in the Philippines, where he stated that he had been imprisoned by the Japanese since 1941. The scar on his lower lip, he explained, was due to a Japanese sniper’s bullet, and the scars at the base of his neck were due to old operations “for tuberculosis.” He also stated that he had served as a “radar installer” in the amphibious assaults on Tarawa, Saipan, Iwo Jima, and Okinawa, which seem to constitute a temporal paradox worthy of note. On being questioned as to previous attacks of chest pain or flutter of the diaphragm, and previous hospital admissions, he denied any such incidents but was quick to refuse us permission to photograph him. The next day after admission he stated that he felt fine and desired to go to a nearby city for his pension check. This he was allowed to do, since the need of hospital beds was urgent at the time. COMMENT
In particularly
view
of in
the regard
extensive to
the
phrenic left
nerve
interruptions and
left
carried leaf
of
the
out diaphragm,
on
this
man,
it
is felt
that the episodes of flutter may at present be due either to the presence cessory phrenic pathways, or to a myogenic tic of the diaphragm.
of
ac-
892
pig.
AMERICAN-HEART
3.-Teleroentgenogram
made
Lhr
day
after
JOURNAL
the
twmination
of a paroxysm
of diaphragmstic’
flulter.
Exclusive of electrocardiographic and fjuoroscopic findings, certain features of the clinical picture presented here have offered bedside evidence arguing against a diagnosis of acute coronary accident, should this same individual be encountered by the reader. Foremost was the absence of pain across the upper chest, and the alleged radiation of pain from the region of the cardiac apex into the left arm. Of almost equal significance was the behavior during the attack, the patient moving about more actively with his histrionics than does the usual victim relatively immobilized by angina. Finally, it is unlikely that an examiner palpating the throb, or hearing the loud bruit of
MOORE
AND
SCHOFF:
PAROXYSMAL
DIAPHRAGMATIC
FLUTTER
893
the rapidly contracting diaphragm, would associate the complaints with the heart for long in the presence of a normal pulse rate. This man will no doubt make more appearances in various hospitals throughout the country, and it is hoped that these observations, along with those previously published, may enable others more readily to arrive at a correct diagnosis, The possibility of diaphragmatic flutter may be called to mind in unusual types of paroxysmal precordial pain. SUMMARY
Further observations are submitted concerning an individual who presents the syndrome of associated diaphragmatic flutter and pain suggestive of acute coronary insufficiency. Practical differential diagnostic suggestions are made for bedside diagnosis. REFERENCES
1. 2. 3.
4.
Porter,
W. B.: Diaphragmatic Flutter With Symptoms of Angina Pectoris, J. A. M. A. 106:992, 1936. Whitehead, R. W., Burnett. C. T., and Lagen, J. B.: Diaphragmatic Flutter With Symptoms Suggesting Angina Pectoris, J. A. M. A. 112:1237, 1939. Goodman, Morton J.: Paroxysmal Flutter of the Diaphragm Simulating Coronary Occlusion: Further Observations of an Extraordinary Case Controlled by Refrigeration of the Phrenic Nerve, J. A. M. A. 116:1635, 1941. Cain, Edmund F., and Ware. E. Richmond: Diaphragmatic Flutter, J. A. M. A. 131: 10.58. 1946.