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On the cause of the respiratory variation of the ballistocardiogram, with a note on sinus arrhythmia
The authors discuss the role of heparin in this disease and believe that it is of doubtful value except in special circumstances. A table is given for the correlation of penicillin Perurn levels with twenty-four-hour dose. They feel that it is advisable to maintain a serum level of penicillin at least four times as high as the amount required to inhibit the growth of the organism in vitro. If this information is not available, they recommend a trial of 500,000 units by this metholl daily for two to three week8 If unsuccessful. recourse to an appropriately equipped laboratory become8 imperat.ive. M. \I’. STROITI. Scherlis, S. : Jnt. Xed.
The Recognition and Clinical 24: 254 (Feb.) 1946.
Significance
of Auricular
Heart Sounds.
.\nn.
The author discusses the difference betn-een presy-stolic ‘ ‘murmursz : and pry systolic. ’ i sounds ’ ’ confusion in this regard may lead to a mistaken diagno8i:: of heart diseaee. -2uricular ~ounrls are usually obscured by the normal first heart sound hut may 1~ heard as a low-pitched sound in diaetole in cases of A-V di8sociation. Tire mechani8m by which the two part,8 of the auricular round are producer1 is discuase~l. The first prt can be heard more easily in children, while the becond part is heard in some cakes of heart block. huricular sounds have been noted clinically in patients with hypertension, sickle cell anemia, hyperthyroiular corn ponent is softer and lower pitched than the ventricular component. The mechanism of the Austin-Flint murmur of nortic insufficiency is said to 1~ due to blood regurgitating through a damaged aortic valve again8t the anterior mitral curtain an11 pushing it in1.o the blood stream passing from auricle to ventricle. The presystolic murmur of mitral stenosis is dependent upon effcchtirc xuricular contraction but may br present in fast, aurirular fibrillation due to a summation of thr middiastolic murmur and the normal first sound with 8hortening of diastole. The importam~r of the left lateral position of tlic botl? to bring out s~)uu~l.~ is n~~te~l an11 jugular pulse is illurtrated to and the simultaneous use of c~lectrocartliogram, stethljgram. c-larify
the
~liwwsion.
Sensenbach, W., and Buie, R. M., Jr.: Persistent Ventricular parently Normal Hearts. .4m. J. M. SC. 211: 331 (Marrhl
Jf,
Bigeminal
TV.
Rhythm
sTrxir-Il.
in
Ap-
1946.
III a series of 33 patients presenting bigeminal rhythm, eight patients were observed in whom evidence of heart disease was lacking but who had frequent regularly nca13urrinq premature beat?;. Four of these patients presented evidence of advanced arieriosclerosis so that heart disease could not IW entirely excluded. Tn the remaining case*;, short periods of biyeminal rhythm n-ere present in tlf-o women in n-hom plooccasional found emotional factors Jyere found to be operative. The two remaining cases of persistent bigeminal rhythm were observed in a 1??-ear-old mentally defreient girl and in a 3%year-old woman with rheumatoid arthritis, assoc-iated n-ith marked emotional disturlpance related to the skeletal dcformit,v and the incapacil y caused by the arthritis. The cause for the occasional o(‘currcuce of per&rut bigeminal rhythm v ith apparently ~tormal hearts i:: unknown. BF:I.~xT.
Starr, I., and Friedland, C. IL: On the Cause of the Respiratory Variation cardiogram, With a Note on Sinus Arrhythmia. J. (.‘iin. In\-estigation
of the Ballisto25:
53 c.Jan.i
1946. Ballistoeardiographic impacts increase in size during inspiration and decrease iu size during expiration. Evidence is presented showing that this variation is due to change8 in pressure rather than to changes in the heart’s position. It is impossible to reverse the respiraposition on the table. tory efl’ects upon the ballistocardiogram by changing the 8ubject’s Inflation of the lungs by a blast of air is capable of reversing this respiratory variation even though the heart’s axis is brought closer to the axis of the recording instrument by the
diaphragmatic descent thus produced. Breathing through an obstruction and thw cxag gerating the pressure differences of thr cycle without, influwkng the change of the heart *with an ancur~sn position gwatly increases the respiratory x~ri:llion of irnp:t~~t 5 In :I patient of the left ventricle it was demonstrntcd that the right ventricle’s contribution to the ball&to cardiogram is greater than that of thv left ventricle (luring inspiration and is less than th:ir of the left ventricle during cspiratinn. TIIIX~ relationships r:jn he rcversrd h,v inflating thl, lungs with a blast of air. It i.q apparent, that blood iq su~.kvd inlo 111~ chest 1111~ing insl~i~~tiun thus enhancing right ventri~~ul:u~ filling: tcft rentriwh~r filling is ~liniini&~l ~luring inspir:l tion owing to the increaPec1 rluantity 01 hlon~l contaiuc~ll in the rsl~~n~le~l 1ungEr. Dnring cspir:i reduvc4 tion less blood flows into 111~~ cvhcst :ln(1 right \ wtricular filling is accordingly whereas left ventricular tilliq is t~nhancc~ti f,y 11~6 1111io~l hein: ” qucc~ze11 ” llrlt i)i’ tire piI1 t!bt:tincBd of ihe Hnmilt on monary reservoir. Rr~:or~ls <-:I :rrteri:i I pressure by mwns manometer support this thosia in that :Irtc~ri:~I prcssuw dcvlin~~~ during inspiration and rises during expiration. Sinus xrrhythmin is rlsl:itrd to rrlluced right ventricular filling during for the right ventricle to be filled heforc expiration : the heart ~~~~I:LvP,F :,s if it 11 IVY waiting FRWI)I.ANIL contracting.
J. R., Danowski, T. S., and Winkler, A. W.: Hemodynamic Changes in Salt Depletion a.nd in Dehydration. .J. Clin. Tnvestigation 25: l-00 (Jun.) l!ML
Elkinton,
Acute salt depletion in dogs produces a Rhocklike state resembling traumatic shock. There is a reduction in cardiac output, plasma volume, circulating plasma protein, blood pressure, circulatiou rate, am1 rstracc~lluk~r fluid rol~lmc,. W:&Tdcplcted :Lllirnals tllat hnvo :i comparable diminution in extracellular fluid volume do not display peripheral vascular collepre although cardiac output, plasma vulumrr~ mean arterial pressure, and circulation rate mav decline. The hemodynamic diflcrenccs between salt. and water tloplction may be related to complete maintenance or very blight wdurtion in the circulating plasma protein in the latter. The importance of salt deplcticm as a I~recur~. p of the shocklikc state in untraumatized animals FRIEDT,A~‘D. is emphasized.
Wiggers, H. C., and Ingraham, R. C.: Hemorrhagic Diagnosis. J. Clin. Investigation 25: 30 (Jan.)
Shock:
Definition
and Criteria
for Its
1946.
Hemorrhagic shock was produced in dogs by rapid bleeding from a femoral artery until t,he mean arterial blood pressure fell to 40 mm. of mercury. This level was mnintained for ninety minutes by additional bleeding as needed and all the blood withdrawn was reinfused at the end of this period. 9 classification for the shock thus produced is propused: (1) simple hemorrhagic hypotensive state in which the blood loss does not exceed 40 per cent of the total blood volume and from which the animal usually recowrs hy means of his inherent corn pensatory regulatory meuhanismc ; (2) impending shock state whr~: the blood loss exceed8 -&!I per cent of the tot,al circulating blood volume and from which the animal may recover if it is infused with suitable agents; and 13) irreversible shock state from which the animal Five critttria For the adequate diagnoriti does not recover despite infusion of suitable agents. of the irreversible shock slate are proposed: (a) spontnnerlus arterial prcs;;ure decline* below 40 to 45 mm. Hg dcapitc attempts to restore thr blood prewure to “standard” hype tensive level by means of infwious of saline or whole blood ; (bj relative llrInocoIlvcntrati[,II during the hypotension period [an unfavorable prognosis is indicated when the plasma specific* gravity declines to a static hive1 within the first sixty minute?; of the hypotensire perioll: rhould plasma qjecific gravity begin f0 an even more unfavorable proqjositi is in(lic:ated rise (after the initial dccsline) before the icrrrlination of the ninety-minute hypotenaive period / ; i C) diarrhea and passage of blood-tinged fecal materiul f~,llowiny the termination ol’ tlua postreinfusion heart raft of 150 heats per minute ninety-minute hypotensivc pc>riod ; (d) bhock : and (e) port reinfusiolt despite normal blood pressure, inllicating a statr of irreverriblc ;y:lvit\ . \vllirall ir: likely to lw higher ~hxn thv control value in the ani bloo~l or IJasma spwifiv tllals that die ~vhrrw!: in \blryi\-ing :Iuimals it ir lilivl?, to 1~. lvss than the rontrO1 V:LIUe. FRIEDLANIJ.
The Recognition and Clinical 24: 254 (Feb.) 1946.
Significance
of Auricular
Heart Sounds.
.\nn.
The author discusses the difference betn-een presy-stolic ‘ ‘murmursz : and pry systolic. ’ i sounds ’ ’ confusion in this regard may lead to a mistaken diagno8i:: of heart diseaee. -2uricular ~ounrls are usually obscured by the normal first heart sound hut may 1~ heard as a low-pitched sound in diaetole in cases of A-V di8sociation. Tire mechani8m by which the two part,8 of the auricular round are producer1 is discuase~l. The first prt can be heard more easily in children, while the becond part is heard in some cakes of heart block. huricular sounds have been noted clinically in patients with hypertension, sickle cell anemia, hyperthyroi
the
~liwwsion.
Sensenbach, W., and Buie, R. M., Jr.: Persistent Ventricular parently Normal Hearts. .4m. J. M. SC. 211: 331 (Marrhl
Jf,
Bigeminal
TV.
Rhythm
sTrxir-Il.
in
Ap-
1946.
III a series of 33 patients presenting bigeminal rhythm, eight patients were observed in whom evidence of heart disease was lacking but who had frequent regularly nca13urrinq premature beat?;. Four of these patients presented evidence of advanced arieriosclerosis so that heart disease could not IW entirely excluded. Tn the remaining case*;, short periods of biyeminal rhythm n-ere present in tlf-o women in n-hom plooccasional found emotional factors Jyere found to be operative. The two remaining cases of persistent bigeminal rhythm were observed in a 1??-ear-old mentally defreient girl and in a 3%year-old woman with rheumatoid arthritis, assoc-iated n-ith marked emotional disturlpance related to the skeletal dcformit,v and the incapacil y caused by the arthritis. The cause for the occasional o(‘currcuce of per&rut bigeminal rhythm v ith apparently ~tormal hearts i:: unknown. BF:I.~xT.
Starr, I., and Friedland, C. IL: On the Cause of the Respiratory Variation cardiogram, With a Note on Sinus Arrhythmia. J. (.‘iin. In\-estigation
of the Ballisto25:
53 c.Jan.i
1946. Ballistoeardiographic impacts increase in size during inspiration and decrease iu size during expiration. Evidence is presented showing that this variation is due to change8 in pressure rather than to changes in the heart’s position. It is impossible to reverse the respiraposition on the table. tory efl’ects upon the ballistocardiogram by changing the 8ubject’s Inflation of the lungs by a blast of air is capable of reversing this respiratory variation even though the heart’s axis is brought closer to the axis of the recording instrument by the
diaphragmatic descent thus produced. Breathing through an obstruction and thw cxag gerating the pressure differences of thr cycle without, influwkng the change of the heart *with an ancur~sn position gwatly increases the respiratory x~ri:llion of irnp:t~~t 5 In :I patient of the left ventricle it was demonstrntcd that the right ventricle’s contribution to the ball&to cardiogram is greater than that of thv left ventricle (luring inspiration and is less than th:ir of the left ventricle during cspiratinn. TIIIX~ relationships r:jn he rcversrd h,v inflating thl, lungs with a blast of air. It i.q apparent, that blood iq su~.kvd inlo 111~ chest 1111~ing insl~i~~tiun thus enhancing right ventri~~ul:u~ filling: tcft rentriwh~r filling is ~liniini&~l ~luring inspir:l tion owing to the increaPec1 rluantity 01 hlon~l contaiuc~ll in the rsl~~n~le~l 1ungEr. Dnring cspir:i reduvc4 tion less blood flows into 111~~ cvhcst :ln(1 right \ wtricular filling is accordingly whereas left ventricular tilliq is t~nhancc~ti f,y 11~6 1111io~l hein: ” qucc~ze11 ” llrlt i)i’ tire piI1 t!bt:tincBd of ihe Hnmilt on monary reservoir. Rr~:or~ls <-:I :rrteri:i I pressure by mwns manometer support this thosia in that :Irtc~ri:~I prcssuw dcvlin~~~ during inspiration and rises during expiration. Sinus xrrhythmin is rlsl:itrd to rrlluced right ventricular filling during for the right ventricle to be filled heforc expiration : the heart ~~~~I:LvP,F :,s if it 11 IVY waiting FRWI)I.ANIL contracting.
J. R., Danowski, T. S., and Winkler, A. W.: Hemodynamic Changes in Salt Depletion a.nd in Dehydration. .J. Clin. Tnvestigation 25: l-00 (Jun.) l!ML
Elkinton,
Acute salt depletion in dogs produces a Rhocklike state resembling traumatic shock. There is a reduction in cardiac output, plasma volume, circulating plasma protein, blood pressure, circulatiou rate, am1 rstracc~lluk~r fluid rol~lmc,. W:&Tdcplcted :Lllirnals tllat hnvo :i comparable diminution in extracellular fluid volume do not display peripheral vascular collepre although cardiac output, plasma vulumrr~ mean arterial pressure, and circulation rate mav decline. The hemodynamic diflcrenccs between salt. and water tloplction may be related to complete maintenance or very blight wdurtion in the circulating plasma protein in the latter. The importance of salt deplcticm as a I~recur~. p of the shocklikc state in untraumatized animals FRIEDT,A~‘D. is emphasized.
Wiggers, H. C., and Ingraham, R. C.: Hemorrhagic Diagnosis. J. Clin. Investigation 25: 30 (Jan.)
Shock:
Definition
and Criteria
for Its
1946.
Hemorrhagic shock was produced in dogs by rapid bleeding from a femoral artery until t,he mean arterial blood pressure fell to 40 mm. of mercury. This level was mnintained for ninety minutes by additional bleeding as needed and all the blood withdrawn was reinfused at the end of this period. 9 classification for the shock thus produced is propused: (1) simple hemorrhagic hypotensive state in which the blood loss does not exceed 40 per cent of the total blood volume and from which the animal usually recowrs hy means of his inherent corn pensatory regulatory meuhanismc ; (2) impending shock state whr~: the blood loss exceed8 -&!I per cent of the tot,al circulating blood volume and from which the animal may recover if it is infused with suitable agents; and 13) irreversible shock state from which the animal Five critttria For the adequate diagnoriti does not recover despite infusion of suitable agents. of the irreversible shock slate are proposed: (a) spontnnerlus arterial prcs;;ure decline* below 40 to 45 mm. Hg dcapitc attempts to restore thr blood prewure to “standard” hype tensive level by means of infwious of saline or whole blood ; (bj relative llrInocoIlvcntrati[,II during the hypotension period [an unfavorable prognosis is indicated when the plasma specific* gravity declines to a static hive1 within the first sixty minute?; of the hypotensire perioll: rhould plasma qjecific gravity begin f0 an even more unfavorable proqjositi is in(lic:ated rise (after the initial dccsline) before the icrrrlination of the ninety-minute hypotenaive period / ; i C) diarrhea and passage of blood-tinged fecal materiul f~,llowiny the termination ol’ tlua postreinfusion heart raft of 150 heats per minute ninety-minute hypotensivc pc>riod ; (d) bhock : and (e) port reinfusiolt despite normal blood pressure, inllicating a statr of irreverriblc ;y:lvit\ . \vllirall ir: likely to lw higher ~hxn thv control value in the ani bloo~l or IJasma spwifiv tllals that die ~vhrrw!: in \blryi\-ing :Iuimals it ir lilivl?, to 1~. lvss than the rontrO1 V:LIUe. FRIEDLANIJ.