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Studies in complete heart-block: II. A clinical analysis of 43 cases
541
ABSTRACTS
Master, A. M., and Jaffe, Harry: Rheumatoid (Infectious) Arthritis and Acute Rheumatic Fever. The Differential Diagnosis. J. A. M. A. 98: 881, 1932. In 17 patients with rheumatoid (infectious) arthritis, on whom eleetrocardiograms were taken daily for an average of iifty-three days, only the slightest evidence of myocardial involvement was recorded. In 63 cases of acute rheumatic fever, however, definite electrocardiographic evidence of myocardial involvement appeared in 100 per cent. These electrocardiographic evidences of myocardial involvement have been sino-auricular block, nodal rhythm, interference of the sinus and auriculoventricular nodes, auricular fibrillation, auricular flutter, auriculoventricular (P-R) intervals of 0.21 second or more, heart block with dropped beats, definite R-S-T abnormalities, T-wave inversions and transient widening, notching and slurring of the QRS group. It is concluded from these studies that rheumatoid arthritis, no matter what it may be, is not especially a disease of the heart; acute rheumatic fever is preeminently a carditis. If there is no electrocardiographic evidence of myoeardial involvement in a patient with joint symptoms, it would be best to suspect rheumatoid arthritis; whereas, when there are electrical tracings deiinitely indicative of myocardial involvement, it is probably due to an acute rheumatic fever.
13arnes, Arlie R., and Ball, Ralph G.: The Incidence and Situation of Myocardial Infarction in One Thousand Consecutive Postmortem Examinations. Am. J. M. Se. 183: 215, 1932. In 1,000 unselected consecutive postmortem examinations more or less localized myocardial infarction was recognized grossly in 49 subjects. Of 685 of these subThe jects, forty years of age or more, myocardial infarction was observed in 47. majority of the subjects who had sustained myoeardial infarction had had associated hypertension as judged by the cardiac weights and the records of blood pressure. Notable preponderance of arteriosclerosis in the left coronary artery over that found in the right was not observed in the hearts in which evidence of infarction Gross myocardial infarction resulting from coronary occlusion was was found. practically eonfined to the left ventricle. Myocardial infarction was observed in the posterior basal portion of the left ventricle in 24 instanees as compared with 28 instances in whieh it involved the apex and anterior portion. More careful pathological study of the posterior basal portion of the left ventricle is urged in order that infarctions in that region be not overlooked. In 28 instances infarction occurred in the region supplied by the anterior descending branch of the left coronary artery, as compared with 20 instances in which it occurred in the region of the left ventricle supplied by the right coronary artery. The designation of the anterior descending branch of the left coronary as “the artery of coronary occlusion” is no longer justifiable.
Bllis,
Laurence
43 cases.
B.: Studies in Complete Am.
J. M.
Se. 183:
225,
Heart-Block:
II. A Clinical
Analysis
of
1932.
An analysis is presented of 43 cases of complete auricuLoventricular block in patients ranging in age from nine weeks to seventy-eight years. Seventy per cent of the patients were over forty years of age and the same percentage were males. In 29 eases the block was permanent, while in the remainder it was intermittent or temporary. Fifty-two per cent of the eases of permanent block were due to arteriosclerosis; 31 per cent were of undetermined origin but in most of these instances were probably either congenital or dependent upon on acute infection. Diphtheria, syphilis aml’rheumatic infection were responsible for a small number
542
THE
AMERICAN
HEART
JOURNAL
DigitaIis was the chief etiologic agent producing transitory bloek; of cases. although arteriosclerosis and infections caused a lesser proportion. Complete heart-block per se may exist for very prolonged periods of time without damaging the health of the patient. Four cases are recorded in which the block is known to have existed for twenty-four, fifteen, fourteen and seven years The respectively, and 2 more in which it has almost certainly lasted nine years. chief factors governing the prognosis appear to be etiology, age, Adams-Stokes seizures, electrocardiographic abnormalities and cardiac size. A discussion of the significance of arterial blood pressure findings is presented. Young persons with complete heart-block may have essentially normal blood pressures. A systolic arterial hypertension and wide pulse pressure usually occur in heart-block in persons giving eviclence of peripheral arteriosclerosis. Gouley, Am.
Benjamin A., S. M. SC. 183:
and Eiman, 359, 1932.
John:
The
Pathology
of
Rheumatic
Pneumonia.
Nine cases of acute rheumatic fever are presented with reference to their pulmonary pathology. Eight of these showed an acute inflammation of lung tissue with consolidation; the ninth showed pleurisy with subacute lung invoIvement. All of them were associated with acute rheumatic heart disease. The inflammatory pulmonary reaction consists of an interstitial perivascular exudate of large endothelioid cells, identical in morphology with those found in rheumatic heart lesions and considered pathognomonic of rheumatic fever. Hemorrhage and fibrinous exudate are prominent features. Eight of these eases exhibited periearditis. Wetherby, Macnider, and to Intravenous Vaccine
Clawson, Therapy.
B. J.: Chronic Arch. Int.
Arthritis Med. 49:
With Special 303, 1932.
Reference
Intravenous streptococcic vaccination brings about in patients two conditions (desensitization and a high agglutinating titer) that are regularly associated with the protection experimentally developed in animals against streptococci by intravenous vaccination. This analogous condition in vaccinated animals and patients affords a basis for intravenous vaccination in patients having chronic arthritis. Since subcutaneous injections of streptococci in animals tend to increase hypersensitiveness and only produce a low agglutinating titer in the serum, the subcutaneous method of vaccination in chronic arthritis would seem to be of less value than the intravenous method if not contraindicated. No iII effeets have resulted from the intravenous vaccinations in the 100 cases studied. On the other hand, in 75 per cent of the cases the clinical improvement appears to be sufficient to justify the further use of this method of treatment for chronic arthritis. Goldring, William, I. Observations
and Chasis, on Its Toxic
Herbert: Effects.
Thiocyanate Therapy in Hypertension. Arch. Int. Med. 4.9: 321, 1932.
Of the 50 patients with hypertension in this series treated 74 different times with thioeyanate, 13 presented toxic manifestations. In 11 of these the toxic manifestations disappeared within a few hours to four days after discontinuance of the drug. Two of these patients died as the result of thiocyanate poisoning. The frequency and order of appearance of the various toxic manifestations are noted. A fall in the blood pressure, the occurrence of toxic manifestations and death were found to be unrelated to the amount of thiocyanate administered or to the amount of residual drug in the body. Data are presented showing that in some patients there is little or no margin of safety between the toxic and thera-
ABSTRACTS
Master, A. M., and Jaffe, Harry: Rheumatoid (Infectious) Arthritis and Acute Rheumatic Fever. The Differential Diagnosis. J. A. M. A. 98: 881, 1932. In 17 patients with rheumatoid (infectious) arthritis, on whom eleetrocardiograms were taken daily for an average of iifty-three days, only the slightest evidence of myocardial involvement was recorded. In 63 cases of acute rheumatic fever, however, definite electrocardiographic evidence of myocardial involvement appeared in 100 per cent. These electrocardiographic evidences of myocardial involvement have been sino-auricular block, nodal rhythm, interference of the sinus and auriculoventricular nodes, auricular fibrillation, auricular flutter, auriculoventricular (P-R) intervals of 0.21 second or more, heart block with dropped beats, definite R-S-T abnormalities, T-wave inversions and transient widening, notching and slurring of the QRS group. It is concluded from these studies that rheumatoid arthritis, no matter what it may be, is not especially a disease of the heart; acute rheumatic fever is preeminently a carditis. If there is no electrocardiographic evidence of myoeardial involvement in a patient with joint symptoms, it would be best to suspect rheumatoid arthritis; whereas, when there are electrical tracings deiinitely indicative of myocardial involvement, it is probably due to an acute rheumatic fever.
13arnes, Arlie R., and Ball, Ralph G.: The Incidence and Situation of Myocardial Infarction in One Thousand Consecutive Postmortem Examinations. Am. J. M. Se. 183: 215, 1932. In 1,000 unselected consecutive postmortem examinations more or less localized myocardial infarction was recognized grossly in 49 subjects. Of 685 of these subThe jects, forty years of age or more, myocardial infarction was observed in 47. majority of the subjects who had sustained myoeardial infarction had had associated hypertension as judged by the cardiac weights and the records of blood pressure. Notable preponderance of arteriosclerosis in the left coronary artery over that found in the right was not observed in the hearts in which evidence of infarction Gross myocardial infarction resulting from coronary occlusion was was found. practically eonfined to the left ventricle. Myocardial infarction was observed in the posterior basal portion of the left ventricle in 24 instanees as compared with 28 instances in whieh it involved the apex and anterior portion. More careful pathological study of the posterior basal portion of the left ventricle is urged in order that infarctions in that region be not overlooked. In 28 instances infarction occurred in the region supplied by the anterior descending branch of the left coronary artery, as compared with 20 instances in which it occurred in the region of the left ventricle supplied by the right coronary artery. The designation of the anterior descending branch of the left coronary as “the artery of coronary occlusion” is no longer justifiable.
Bllis,
Laurence
43 cases.
B.: Studies in Complete Am.
J. M.
Se. 183:
225,
Heart-Block:
II. A Clinical
Analysis
of
1932.
An analysis is presented of 43 cases of complete auricuLoventricular block in patients ranging in age from nine weeks to seventy-eight years. Seventy per cent of the patients were over forty years of age and the same percentage were males. In 29 eases the block was permanent, while in the remainder it was intermittent or temporary. Fifty-two per cent of the eases of permanent block were due to arteriosclerosis; 31 per cent were of undetermined origin but in most of these instances were probably either congenital or dependent upon on acute infection. Diphtheria, syphilis aml’rheumatic infection were responsible for a small number
542
THE
AMERICAN
HEART
JOURNAL
DigitaIis was the chief etiologic agent producing transitory bloek; of cases. although arteriosclerosis and infections caused a lesser proportion. Complete heart-block per se may exist for very prolonged periods of time without damaging the health of the patient. Four cases are recorded in which the block is known to have existed for twenty-four, fifteen, fourteen and seven years The respectively, and 2 more in which it has almost certainly lasted nine years. chief factors governing the prognosis appear to be etiology, age, Adams-Stokes seizures, electrocardiographic abnormalities and cardiac size. A discussion of the significance of arterial blood pressure findings is presented. Young persons with complete heart-block may have essentially normal blood pressures. A systolic arterial hypertension and wide pulse pressure usually occur in heart-block in persons giving eviclence of peripheral arteriosclerosis. Gouley, Am.
Benjamin A., S. M. SC. 183:
and Eiman, 359, 1932.
John:
The
Pathology
of
Rheumatic
Pneumonia.
Nine cases of acute rheumatic fever are presented with reference to their pulmonary pathology. Eight of these showed an acute inflammation of lung tissue with consolidation; the ninth showed pleurisy with subacute lung invoIvement. All of them were associated with acute rheumatic heart disease. The inflammatory pulmonary reaction consists of an interstitial perivascular exudate of large endothelioid cells, identical in morphology with those found in rheumatic heart lesions and considered pathognomonic of rheumatic fever. Hemorrhage and fibrinous exudate are prominent features. Eight of these eases exhibited periearditis. Wetherby, Macnider, and to Intravenous Vaccine
Clawson, Therapy.
B. J.: Chronic Arch. Int.
Arthritis Med. 49:
With Special 303, 1932.
Reference
Intravenous streptococcic vaccination brings about in patients two conditions (desensitization and a high agglutinating titer) that are regularly associated with the protection experimentally developed in animals against streptococci by intravenous vaccination. This analogous condition in vaccinated animals and patients affords a basis for intravenous vaccination in patients having chronic arthritis. Since subcutaneous injections of streptococci in animals tend to increase hypersensitiveness and only produce a low agglutinating titer in the serum, the subcutaneous method of vaccination in chronic arthritis would seem to be of less value than the intravenous method if not contraindicated. No iII effeets have resulted from the intravenous vaccinations in the 100 cases studied. On the other hand, in 75 per cent of the cases the clinical improvement appears to be sufficient to justify the further use of this method of treatment for chronic arthritis. Goldring, William, I. Observations
and Chasis, on Its Toxic
Herbert: Effects.
Thiocyanate Therapy in Hypertension. Arch. Int. Med. 4.9: 321, 1932.
Of the 50 patients with hypertension in this series treated 74 different times with thioeyanate, 13 presented toxic manifestations. In 11 of these the toxic manifestations disappeared within a few hours to four days after discontinuance of the drug. Two of these patients died as the result of thiocyanate poisoning. The frequency and order of appearance of the various toxic manifestations are noted. A fall in the blood pressure, the occurrence of toxic manifestations and death were found to be unrelated to the amount of thiocyanate administered or to the amount of residual drug in the body. Data are presented showing that in some patients there is little or no margin of safety between the toxic and thera-