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The size and shape of the heart in Goitre
406
THE
AMERICAN
HEART
JOURNAL
figures which might prove useful for prognosis. Thirty patients were in the hospital, and twenty-six had been seen in consultation practice. The incidence was roughly 1 per cent of the total patients seen in the same time. No characteristic etiologies1 factor was found in the group. Thirty-six of the cases were men. The average age incidence was about sixty years. The symptoms and signs were those commonly found due to myocardial degeneration. In the hospital group, there was a ease mortality of 73 per cent of the eases which could be traced. The second or nonhospital group showed a case mortality of 42 per cent. Parkinson, Quart.
John, and Cookson, Harold: J. Med. 24: 499, 1931.
The
Size
and
Shape
of the Heart
in Goitre.
A consecutive series of 130 patients with goiter causing symptoms was examined with the primary object of deciding the size and shape of the heart by radiography. In addition a series of post-mortem records of 43 goiter cases was investigated to determine the incidence and distribution of cardiac hypertrophy. Of the forty-three eases of goiter all but three had shown the classical symptoms of thyroid intoxication. There proved to be hypertrophy of the heart in more than one-half. The increase involved both ventricles as a rule, sometimes the left more than the right, occasionally the left alone. A predominant or isolated hypertrophy of the right side was never seen. In general it was the younger patients and those with the shorter duration of symptoms who showed no hypertrophy. It was also in the younger patients, say under thirty years, that the rhythm had been normal throughout or fibrillation had come only as a terminal event. Established fibrillation occurred in older people with an average age of twenty-one years in eight cases at death. The heart weight was greater on the average in those with established fibrillation than in those with normal rhythm. The greatest increase in heart weight was registered in those with fibrillation and heart failure. When emaciation was extreme, the heart was only slightly or not at all hypertrophied. In the three eases of goiter where the gland had not been suspected of producing symptoms, there was cardiac hypertrophy in two, and perhaps in the third. Clinical and x-ray observations were made on 130 patients with goiter and symptoms from it. Without x-ray examination it is difficult to determine the size of the heart, especially when there is tachyeardia, and either a teleradiogram or an orthodiagram or both were taken of every patient. The criteria of emlargement applied to these records are discussed. Enlargement was found in about 45 per cent of cases, usually slight or quite moderate, but not rarely great. In most it involved both contours of the heart, but more particularly the left and sometimes the left only. Although several eases with striking displacement and some stenosis of the trachea were included, enlargement of the right side of the heart alone was never seen. Eleetrocardiograms, so far as they can be used as an indication of hypertrophy and its relative distribution, confirmed the radiographic and post-mortem l&dings. The incidence of auricular fibrillation, including both paroxysmal and established forms, was 27 per cent. Heart failure was present at some time in twelve, and all these had fibrillation, except one with a complicating hypertension. A few serial records showing progressive increase in the heart size were obtained, all from patients with permanent fibrillation. Comparison between records taken before and after thyroidectomy was made in eleven cases and gave variable results: there might be no change, an increase, or a decrease in the transverse diameter of the heart. After operation several factors come into play which render it difficult to accept the changes as evidence of actual alteration in heart size. The form of the heart is often affected in a characteristic way in goiter. Undue prominence of the pulmonary arc was a striking feature of about one-third of the
ABSTRACTS
407
series, sometimes appearing as a convexity on the left profile, sometimes combining with an enlargement of the heart to the left to render this profile straight. An exaggeration of this are is often an early ehange, preceding any enlargement of the heart chambers. Post-mortem measurements showed that the pulmonary art,ery was often dilated. The left auricle was not enlarged out of proportion to that of other chambers of the hea,rt-a sharp distinction from the heart of mitral stenosis. The superior vena cava was sometimes prominent; this would be expe&ed with the venous congestion The o’f heart failure, but such an explanation only applied to a small proportion. a.ortio arch reached too high a level in the chest in about one-third. The form of the vascular pediele was modified occasionally by a retrosternal goiter. When symptoms are mild or of short duration, the heart in goiter is normal in size and shape. When symptoms are severe and of long standing, it is in a fair proThe greatest enlargement is seen with portion both enlarged and modified in shape. aurieular fibrillation and failure. The special form characteristic of the goiter heart is based upon a combination of prominence of the pulmonary are, of the left ventricle, and to a minor extent of the right auricle. As a result of these changes, the heart may be generally enlarged, the contour retaining much the same shape as in the normal heart; whereas almost all other forms of cardiac disease causing enlargement greatly modify the shape. In their fully developed form changes in the left ares produce a distinctive picture with its straight left border and a right auricul,ar are only slightly enlarged. The heart so disposed, when seen from in front, has some resemblance to a ham. This picture differs from that of mitral stenosis in the relatively slight prominence of the right auricle and the fuller aortic knuckle as seen from the front and in the absence of left aurieular enlargement as seen in the first oblique position. It approximates more the cardiac outline of combined mitral stenosis and aortie incompetence. Radiological examination is a help. in judging the presence or severity of a cardiac lesion in a patient with goiter. The demonstration of cardiac enlargement is important from the standpoint of the surgical treatment of goiter. When present, it is an added reason for, rather than a contraindication to, surgical treatment. Though the greater the enlargement, the poorer is the prospect of a complete return to normal, yet the aid of surgery will often be required to cheek the progress of the lesion. In deciding the cause of obseure eardiae symptoms or enlargement, or of aurieular fibrillation with or without failure, the discovery of the ehara,cteristic radiographic pieture may suggest a goitrous etiology.
Harrison, T. R., Calhoun, J. Alfred, and Turley, F. C.: Congestive Heart Failure. XI. The Effect of Digitalis on the Dyspnea and on the ‘Ventilation of Ambulatory Patients With Regular Cardiac Rhythm. Arch. Int. Med. 48: 1203, 1931. The effect of digitalis has been studied in forty-three patients with regular cardiac rhythm. Most of the patients had never had congestive failure. None of them had more than slight edema at the time they were studied and the majority had none. The following results were obtained: Nineteen patients had paroxysmal nocturnal dyspnea. Sixteen of these persons were completely relieved and one was worse after the drug. Forty-three patients had dyspnea brought on by exertion. Definite benefit was obtained in fifteen of these, apparent benefit in fourteen and no improvement in twelve, and two patients were worse after the drug. In #eight subjects the vital capacity, ventilation per square meter on standardized exercise, and ventilation index were studied. Seven of the eight patients reported clinical improvement of some degree, and in all of them measurements of ventilation also indicated improvement.
THE
AMERICAN
HEART
JOURNAL
figures which might prove useful for prognosis. Thirty patients were in the hospital, and twenty-six had been seen in consultation practice. The incidence was roughly 1 per cent of the total patients seen in the same time. No characteristic etiologies1 factor was found in the group. Thirty-six of the cases were men. The average age incidence was about sixty years. The symptoms and signs were those commonly found due to myocardial degeneration. In the hospital group, there was a ease mortality of 73 per cent of the eases which could be traced. The second or nonhospital group showed a case mortality of 42 per cent. Parkinson, Quart.
John, and Cookson, Harold: J. Med. 24: 499, 1931.
The
Size
and
Shape
of the Heart
in Goitre.
A consecutive series of 130 patients with goiter causing symptoms was examined with the primary object of deciding the size and shape of the heart by radiography. In addition a series of post-mortem records of 43 goiter cases was investigated to determine the incidence and distribution of cardiac hypertrophy. Of the forty-three eases of goiter all but three had shown the classical symptoms of thyroid intoxication. There proved to be hypertrophy of the heart in more than one-half. The increase involved both ventricles as a rule, sometimes the left more than the right, occasionally the left alone. A predominant or isolated hypertrophy of the right side was never seen. In general it was the younger patients and those with the shorter duration of symptoms who showed no hypertrophy. It was also in the younger patients, say under thirty years, that the rhythm had been normal throughout or fibrillation had come only as a terminal event. Established fibrillation occurred in older people with an average age of twenty-one years in eight cases at death. The heart weight was greater on the average in those with established fibrillation than in those with normal rhythm. The greatest increase in heart weight was registered in those with fibrillation and heart failure. When emaciation was extreme, the heart was only slightly or not at all hypertrophied. In the three eases of goiter where the gland had not been suspected of producing symptoms, there was cardiac hypertrophy in two, and perhaps in the third. Clinical and x-ray observations were made on 130 patients with goiter and symptoms from it. Without x-ray examination it is difficult to determine the size of the heart, especially when there is tachyeardia, and either a teleradiogram or an orthodiagram or both were taken of every patient. The criteria of emlargement applied to these records are discussed. Enlargement was found in about 45 per cent of cases, usually slight or quite moderate, but not rarely great. In most it involved both contours of the heart, but more particularly the left and sometimes the left only. Although several eases with striking displacement and some stenosis of the trachea were included, enlargement of the right side of the heart alone was never seen. Eleetrocardiograms, so far as they can be used as an indication of hypertrophy and its relative distribution, confirmed the radiographic and post-mortem l&dings. The incidence of auricular fibrillation, including both paroxysmal and established forms, was 27 per cent. Heart failure was present at some time in twelve, and all these had fibrillation, except one with a complicating hypertension. A few serial records showing progressive increase in the heart size were obtained, all from patients with permanent fibrillation. Comparison between records taken before and after thyroidectomy was made in eleven cases and gave variable results: there might be no change, an increase, or a decrease in the transverse diameter of the heart. After operation several factors come into play which render it difficult to accept the changes as evidence of actual alteration in heart size. The form of the heart is often affected in a characteristic way in goiter. Undue prominence of the pulmonary arc was a striking feature of about one-third of the
ABSTRACTS
407
series, sometimes appearing as a convexity on the left profile, sometimes combining with an enlargement of the heart to the left to render this profile straight. An exaggeration of this are is often an early ehange, preceding any enlargement of the heart chambers. Post-mortem measurements showed that the pulmonary art,ery was often dilated. The left auricle was not enlarged out of proportion to that of other chambers of the hea,rt-a sharp distinction from the heart of mitral stenosis. The superior vena cava was sometimes prominent; this would be expe&ed with the venous congestion The o’f heart failure, but such an explanation only applied to a small proportion. a.ortio arch reached too high a level in the chest in about one-third. The form of the vascular pediele was modified occasionally by a retrosternal goiter. When symptoms are mild or of short duration, the heart in goiter is normal in size and shape. When symptoms are severe and of long standing, it is in a fair proThe greatest enlargement is seen with portion both enlarged and modified in shape. aurieular fibrillation and failure. The special form characteristic of the goiter heart is based upon a combination of prominence of the pulmonary are, of the left ventricle, and to a minor extent of the right auricle. As a result of these changes, the heart may be generally enlarged, the contour retaining much the same shape as in the normal heart; whereas almost all other forms of cardiac disease causing enlargement greatly modify the shape. In their fully developed form changes in the left ares produce a distinctive picture with its straight left border and a right auricul,ar are only slightly enlarged. The heart so disposed, when seen from in front, has some resemblance to a ham. This picture differs from that of mitral stenosis in the relatively slight prominence of the right auricle and the fuller aortic knuckle as seen from the front and in the absence of left aurieular enlargement as seen in the first oblique position. It approximates more the cardiac outline of combined mitral stenosis and aortie incompetence. Radiological examination is a help. in judging the presence or severity of a cardiac lesion in a patient with goiter. The demonstration of cardiac enlargement is important from the standpoint of the surgical treatment of goiter. When present, it is an added reason for, rather than a contraindication to, surgical treatment. Though the greater the enlargement, the poorer is the prospect of a complete return to normal, yet the aid of surgery will often be required to cheek the progress of the lesion. In deciding the cause of obseure eardiae symptoms or enlargement, or of aurieular fibrillation with or without failure, the discovery of the ehara,cteristic radiographic pieture may suggest a goitrous etiology.
Harrison, T. R., Calhoun, J. Alfred, and Turley, F. C.: Congestive Heart Failure. XI. The Effect of Digitalis on the Dyspnea and on the ‘Ventilation of Ambulatory Patients With Regular Cardiac Rhythm. Arch. Int. Med. 48: 1203, 1931. The effect of digitalis has been studied in forty-three patients with regular cardiac rhythm. Most of the patients had never had congestive failure. None of them had more than slight edema at the time they were studied and the majority had none. The following results were obtained: Nineteen patients had paroxysmal nocturnal dyspnea. Sixteen of these persons were completely relieved and one was worse after the drug. Forty-three patients had dyspnea brought on by exertion. Definite benefit was obtained in fifteen of these, apparent benefit in fourteen and no improvement in twelve, and two patients were worse after the drug. In #eight subjects the vital capacity, ventilation per square meter on standardized exercise, and ventilation index were studied. Seven of the eight patients reported clinical improvement of some degree, and in all of them measurements of ventilation also indicated improvement.