Transient auriculoventricular dissociation with varying ventricular complexes caused by digitalis / Henry A. Christian.

  • Christian, Henry A. (Henry Asbury), 1876-1951
Date:
1915
Catalogue details

Licence: In copyright

Credit: Transient auriculoventricular dissociation with varying ventricular complexes caused by digitalis / Henry A. Christian. Source: Wellcome Collection.

    15/20 (page 13)
    sequently it cannot be said definitely what was taking place in the auricles. It may be that there was auricular fibrillation with a regular idiopathic ventricular rate or it may be that the auricles were beating and auriculoventricular disso¬ ciation was present, but the curves did not give distinct evidence of this. During the early part of the patient’s stay in the hospital she had had from time to time small amounts of digitalis. From January 29 to March 2, no digitalis was given. On March 2, 8 c.c. of an infusion of digitalis was begun at 10 a. m. and continued three times a day until 7 p. m. on March 5 when it was omitted owing to the character of the electrocardiographic record obtained on that day. The general condition of the patient was growing much worse during and prior to this period of digitalis therapy. Only one electrocardiographic record was taken after March 5. It showed auricular fibrillation without ectopic beats. This was taken on March 8 slightly less than twenty-four hours before the death of the patient. Case 4.—In this case (Medical No. 2361) the patient was in the Peter Bent Brigham Hospital from Feb. 18, 1915, to March 18, 1915, on which day he was discharged. This patient, a man aged 68, about a year before admission began to notice that, he was short of breath. Gradually this grew worse and he developed a cough with tenacious sputum. A distressed feeling in the region of his stomach with failing appetite and constipation ensued. No edema of his legs, however, developed. When he came into the hospital the area of cardiac dulness extended 3 cm. to the right and 14 cm. to the left of the midsternal line. A soft systolic murmur was heard at the apex and the heart sounds were fairly strong. The rate was moderately irregular of the extra systole type of arrhythmia as judged by the finger. The systolic blood pressure was 165 and the radial arteries showed pronounced sclerosis. In the bases of the lungs there were many coarse rales. The liver was slightly enlarged. No subcutaneous edema was made out. The case was regarded as one of chronic myocarditis and chronic nephritis. The patient improved in the hospital and was discharged in good condition. He received 5 c.c. of an infusion of digitalis three times a day from February 24 to February 27. Electrocardiograms on February 18, 20, 23 and 24 showed a moderate num¬ ber of ectopic beats of both auricular and ventricular origin and the ventricular complex of left ventricular hypertrophy.- Pulsus alternans was present. On February 26, having started on digitalis on February 24 as previously described, the electrocardiograms showed the varying type of ventricular complex which has been described in the previous cases. However, the variations in type of ven¬ tricular complex were far less marked than in the cases previously described. The relation of auricular to ventricular beat could not be made out very satis¬ factorily as the “P” waves were indistinct. However, in places the “P” wave came very close to or was partially incorporated in the “R” wave so that it seems reasonable to suppose that the relation of the contraction of the auricle to the ventricle was similar to that in the previously described cases. On the next day there were found slight variations in some of the succeeding ventricular complexes. Subsequently on March 1, 5, 10, 12 and 13 the electrocardiograms were similar to those of the first days in the hospital. Cohn offers three possible explanations for the varying ventricular complexes met with in his case. The first assumes a single permanent site in the main stem of the conduction system, above its division into right and left branches, as a source of stimulus to production and that this site is supposed to discharge impulses at regular intervals. Under this assumption the impulses are conducted now in one branch of the system and now in the other, the varying ventricular complexes depending on which branch the impulse traverses. The passage of the !