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Pulsations of the wall of the chest: IV. Pulsations associated with adhesive pericardial disease
248 Dressler, ciated
THE
Wilhelm: With
AMERICAN
Pulsations
Tricuspid
HEART
of the Wall-of
Regurgitation.
Arch.
JOURNAL
t8e Int.
AS in cases of aortic regurgitation, one finds regurgitation a diffuse systolic depression of the the complete emptying of the right ventricle.
Chest: III. Pulsations Med. 60: 441, 1937. in many precordium.
instances This
of
Asso-
tricuspid
is caused
by
The aspiratory effect on the thoracic wall due to the reduction of the ventricular volume during the systolic efflux is particularly pronounced in tricuspid regurgitation, since the dilated right ventricle empties during systole in two direction8 simultaneously. In addition, the most important factor for the neutralization of the systolic fall of the intrathoracic pressure, i.e., the influx of venous blood, is eliminated by regurgitation into the veins. Regurgitation into the liver lead8 to a forceful propulsion of the right upper and lower portions of the chest and occasionally also to a jerky shift of the whole chest from left to right’; the latter finding is particularly characteristic of this type of valvular lesion. The propulsion of the right side of the chest in association with the systolic depression over the cardiac area results in a seesaw movement, which Volhard was the first to describe for tricuspid regurgitation. No significance should be attributed to the systolic filling of the right auricle in the etiology of this pulsatory phenomenon. In contrast to aortie regurgitation, the apical thrust i8 absent a8 a rule in cases of tricuspid regurgitation. This is due to the fact that the left ventricle is poorly filled and is pushed away from the anterior wall of the chest by the much enlarged right ventricle. There is forceful filling of the right ventricle because of the high venous pressure, and occasionally one find8 an abrupt diastolic pulsation of the thoracic wall, very similar to the diastolic cardiac thrust in the presence of adhesive pericardial disease. Likewise, Friedreich’s reduplicated sound is occasionally heard. Confusion of tricuspid regurgitation with adhesive pericardial disease is therefore not uncommon, and only a careful observation of the forceful hepatic regurgitation pulse will insure against diagnostic error. The tricuspid change
systolic depression is often regurgitation with mitral in shape of the heart.
inhibited stenosis,
in the because
presence of the
of a combination of opposing force of the AUTHOR.
Dressler, Wilhelm: Pulsations of the Wall of the Chest: IV. Pulsations Associated With Adhesive Pericardial Disease. Arch. Int. Med. 60: 654, 1937. Diffuse pulsations of the thoracic wall in the presence of adhesive pericardial disease are by no mean8 necessarily associated with external adhesions. Two factors play the main role: (1) an inhibition of the systolic change of shape of the heart whereby the aspiratory forces due to reduction of the ventricular volume during the systolic efflux prevail and (2) a change in the mechanism of volumetric diminution so that the marginal movements of the ventricles prevail because the longitudinal Fluoroscopy in instances of obliterashortening of the ventricular cone is inhibited. tive pericardial disease associated with marked depression of the thoracic wall does not necessarily reveal a diminution of the marginal movement8 of the silhouette, as commonly accepted, but, on the contrary, rather strikingly large amplitudes may be observed. The inhibited systolic change in the shape of the heart due to internal adhesions is of decisive importance for the appearance of a diastolic propulsion of the thoraeic wall. External adhesions are not a prerequisite. adhesive pericardial disease is not rarely acSimilar to tricuspid regurgitation, companiedwith a pulsatory movement of the whole chest directed from left to right
SEIXCTED
ARRTRACTS
“49
during systole; this is due to a pulsatory associated movement of the right side of the chest. Tricuspid regurgitation is differentiated from adhrsivr perieardinl diaearr by the absence in the latter of a forceful systoli(s hepatic regurgitation pulse. it7J’lWOK.
Dressler, Wilhelm: Pulsations of the Wall of the Chest: V. Pulsations Associated With Mitral Regurgitation and Aneurysmal Dilatation of the Left Auricle. Arch. Int. Med. 60: F63, 1937. A pulsating propulsion of the right wall of the chc,st is observed in cases of aneurysmal dilatation of the left auricle to the right. Mitral regurgitation is a prerequisite, and the pulsations are caused by the impact of the blood regurgitatiog into the left auricle. The maximum of these pulsations as a rule is found in the right midclavicular line between the fourth and the sixth rib, and pulsations may he observed as far as the right axilla. ril-TIIOE:.
Bruger, Med.
Maurice: 61:
Cholesterol
Content of the Blood in Heart Disease.
Arch. lilt.
714, 1938.
There is a marked difference between the cholesterol content. of the plasma of patients with rheumatic heart disease and that of patients with arteriosclerotic or hypertensive heart disease. Patients with rheumatic heart disease frequently demon strate hypocholesteremia, although for all the patients as a group the results lack statistical significance when compared mith ‘the cholesterol content of the l~loocl In contrast is the hyperrholesteremia often observed for of normal subjects. patients with arteriosclerotic heart disease or hypertensiv~~ heart disease manifesting some evidence of arteriosclerosis; for these two groups, however, the increase in the plasma cholesterol value is of sufficient magnitude to he statistically signific*aut. For the most part, there is little or no difference between the ratio of ester t,o free cholesterol in the three types of heart disease stmlieI1.
VI. Greene, James A., and Swanson, L. W.: Clinical Studies of Respiration: Expiratory Inflation During Air Hunger and Dyspnea Produced by Physica! Exertion in Normal Subjects and in Patients With Heart Disease. Arch. Int. Med.
61:
720,
1938.
The expiratory volume of the chest has been studied during hyperpnea produced by The increase physical exertion in normal subjects and in patients with heart disease. observed in all instances was of greater degree and proportionately of longer duration in the patients. These results indicate that expiratory inflation per se is not the major factor in the production of air hunger and tlyspnea in cases of cardiac failure.
AUTIIOR. Donal, John S.: A Convenient Method for the Determination of the Approximate Cardiac Output in Man. J. Clin. Investigation 16: 879, 1937. A simplified oxygen method has been developed by which the cardiac output of either normal or clinical subjects may he estimated from a determination of metabolism and the analysis of the oxygen and carbon dioxide contents of only two samples, collected during a single rebreathing procedure. The effects of various errors inherent in the assumptions and technique have been Experimental results have shown that many of ihese errors are so investigated.
THE
Wilhelm: With
AMERICAN
Pulsations
Tricuspid
HEART
of the Wall-of
Regurgitation.
Arch.
JOURNAL
t8e Int.
AS in cases of aortic regurgitation, one finds regurgitation a diffuse systolic depression of the the complete emptying of the right ventricle.
Chest: III. Pulsations Med. 60: 441, 1937. in many precordium.
instances This
of
Asso-
tricuspid
is caused
by
The aspiratory effect on the thoracic wall due to the reduction of the ventricular volume during the systolic efflux is particularly pronounced in tricuspid regurgitation, since the dilated right ventricle empties during systole in two direction8 simultaneously. In addition, the most important factor for the neutralization of the systolic fall of the intrathoracic pressure, i.e., the influx of venous blood, is eliminated by regurgitation into the veins. Regurgitation into the liver lead8 to a forceful propulsion of the right upper and lower portions of the chest and occasionally also to a jerky shift of the whole chest from left to right’; the latter finding is particularly characteristic of this type of valvular lesion. The propulsion of the right side of the chest in association with the systolic depression over the cardiac area results in a seesaw movement, which Volhard was the first to describe for tricuspid regurgitation. No significance should be attributed to the systolic filling of the right auricle in the etiology of this pulsatory phenomenon. In contrast to aortie regurgitation, the apical thrust i8 absent a8 a rule in cases of tricuspid regurgitation. This is due to the fact that the left ventricle is poorly filled and is pushed away from the anterior wall of the chest by the much enlarged right ventricle. There is forceful filling of the right ventricle because of the high venous pressure, and occasionally one find8 an abrupt diastolic pulsation of the thoracic wall, very similar to the diastolic cardiac thrust in the presence of adhesive pericardial disease. Likewise, Friedreich’s reduplicated sound is occasionally heard. Confusion of tricuspid regurgitation with adhesive pericardial disease is therefore not uncommon, and only a careful observation of the forceful hepatic regurgitation pulse will insure against diagnostic error. The tricuspid change
systolic depression is often regurgitation with mitral in shape of the heart.
inhibited stenosis,
in the because
presence of the
of a combination of opposing force of the AUTHOR.
Dressler, Wilhelm: Pulsations of the Wall of the Chest: IV. Pulsations Associated With Adhesive Pericardial Disease. Arch. Int. Med. 60: 654, 1937. Diffuse pulsations of the thoracic wall in the presence of adhesive pericardial disease are by no mean8 necessarily associated with external adhesions. Two factors play the main role: (1) an inhibition of the systolic change of shape of the heart whereby the aspiratory forces due to reduction of the ventricular volume during the systolic efflux prevail and (2) a change in the mechanism of volumetric diminution so that the marginal movements of the ventricles prevail because the longitudinal Fluoroscopy in instances of obliterashortening of the ventricular cone is inhibited. tive pericardial disease associated with marked depression of the thoracic wall does not necessarily reveal a diminution of the marginal movement8 of the silhouette, as commonly accepted, but, on the contrary, rather strikingly large amplitudes may be observed. The inhibited systolic change in the shape of the heart due to internal adhesions is of decisive importance for the appearance of a diastolic propulsion of the thoraeic wall. External adhesions are not a prerequisite. adhesive pericardial disease is not rarely acSimilar to tricuspid regurgitation, companiedwith a pulsatory movement of the whole chest directed from left to right
SEIXCTED
ARRTRACTS
“49
during systole; this is due to a pulsatory associated movement of the right side of the chest. Tricuspid regurgitation is differentiated from adhrsivr perieardinl diaearr by the absence in the latter of a forceful systoli(s hepatic regurgitation pulse. it7J’lWOK.
Dressler, Wilhelm: Pulsations of the Wall of the Chest: V. Pulsations Associated With Mitral Regurgitation and Aneurysmal Dilatation of the Left Auricle. Arch. Int. Med. 60: F63, 1937. A pulsating propulsion of the right wall of the chc,st is observed in cases of aneurysmal dilatation of the left auricle to the right. Mitral regurgitation is a prerequisite, and the pulsations are caused by the impact of the blood regurgitatiog into the left auricle. The maximum of these pulsations as a rule is found in the right midclavicular line between the fourth and the sixth rib, and pulsations may he observed as far as the right axilla. ril-TIIOE:.
Bruger, Med.
Maurice: 61:
Cholesterol
Content of the Blood in Heart Disease.
Arch. lilt.
714, 1938.
There is a marked difference between the cholesterol content. of the plasma of patients with rheumatic heart disease and that of patients with arteriosclerotic or hypertensive heart disease. Patients with rheumatic heart disease frequently demon strate hypocholesteremia, although for all the patients as a group the results lack statistical significance when compared mith ‘the cholesterol content of the l~loocl In contrast is the hyperrholesteremia often observed for of normal subjects. patients with arteriosclerotic heart disease or hypertensiv~~ heart disease manifesting some evidence of arteriosclerosis; for these two groups, however, the increase in the plasma cholesterol value is of sufficient magnitude to he statistically signific*aut. For the most part, there is little or no difference between the ratio of ester t,o free cholesterol in the three types of heart disease stmlieI1.
VI. Greene, James A., and Swanson, L. W.: Clinical Studies of Respiration: Expiratory Inflation During Air Hunger and Dyspnea Produced by Physica! Exertion in Normal Subjects and in Patients With Heart Disease. Arch. Int. Med.
61:
720,
1938.
The expiratory volume of the chest has been studied during hyperpnea produced by The increase physical exertion in normal subjects and in patients with heart disease. observed in all instances was of greater degree and proportionately of longer duration in the patients. These results indicate that expiratory inflation per se is not the major factor in the production of air hunger and tlyspnea in cases of cardiac failure.
AUTIIOR. Donal, John S.: A Convenient Method for the Determination of the Approximate Cardiac Output in Man. J. Clin. Investigation 16: 879, 1937. A simplified oxygen method has been developed by which the cardiac output of either normal or clinical subjects may he estimated from a determination of metabolism and the analysis of the oxygen and carbon dioxide contents of only two samples, collected during a single rebreathing procedure. The effects of various errors inherent in the assumptions and technique have been Experimental results have shown that many of ihese errors are so investigated.