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CLINICAL CAKDIOLOGY


•The

THE MACMILLAN COMPANY
NEW YORK

BOSTON CHICAGO
DALLAS
ATLANTA - SAN FRANCISCO


MACMILLAN &
LONDON







CO., Limited

BOMBAY CALCUTTA
MELBOURNE



THE MACMILLAN

CO. OF
TORONTO

CANADA,

Ltd.


CLINICAL CARDIOLOGY

BY

SELIAN NEUHOF,

B.S.,

M.D.

VISITING PHYSICIAN, CENTRAL AND NEUROLOGICAL HOSPITAL
ADJUNCT ATTENDING PHYSICIAN, LEBANON HOSPITAL

THE MACMILLAN COMPANY
1917
All rights reserved


Copyright, 1917,

By THE

Set

MACMILLAN COMPANY.

up and electrotyped.

J. S.

Published September, 1917.

Nortaooo ^reas
Cushing Co.
Berwick & Smith Co.
Norwood, Mass., U.S.A.




TO
i

MY PARENTS
IN TRIBUTE TO THEIR

CONSTANT SELF-

SACRIFICE, THIS BOOK
IS

AFFECTIONATELY DEDICATED



PREFACE
In the many recent books on cardiac disease, dealing chiefly with
polygraphy, electrocardiography, and orthodiascopy, there has been
much confusion regarding the proportionate value of graphic methods,
with the result that undue emphasis has been placed upon purely instrumental and technical considerations. The author has, therefore,
included in this book the graphic as well as the usual bedside methods,
while writing from the clinician's, rather than from the cardiologist's
standpoint, and he believes that this work will therefore supply a com-

book for both practitioner and student.
are devoted to a description of instrumental

prehensive,, practical reference

The opening chapters

and graphic methods in the study and examination of normal and
abnormal rhythms and of normal and abnormal silhouettes. From a
study of these chapters, the physician is enabled to discern the relaand application of instrumental methods to clinical cardiology and
bedside examination. Without minimizing their importance, I have
emphasized the fact that instrumental methods are not infrequently
subsidiary.
Indeed, as will be shown, graphic devices may sometimes
be dispensed with if their fundamental significance is comprehended.
Subsequent chapters are devoted to the purely clinical side of cardiology.
Careful consideration is given to the important subjects of the
pathology, etiology, diagnosis, prognosis, and therapy of endocarditis,
myocarditis, and cardiosclerosis.
Questions occurring in everyday
practice with reference to diet, exercise, and general management of
heart disease are fully dealt with. There are special chapters on precordial pains, blood pressure, and the heart in pneumonia.
I desire to express my sincere thanks to Dr. Alfred E. Cohn of the
tion

Rockefeller Institute for valuable aid and suggestions, especially on
the chapters dealing with the arrhythmias to my publishers, The Macmillan Company, for courteous cooperation
and to my wife, without
whose aid and stimulus this book could not have been written.
;

;

Vll



CONTENTS
PAGE

Chapter
Its

ology

Chapter

The Heart

I.



1



— Position in

Anatomy and Physithe Chest
Nerve, Lymphatic, and Arterial Supply.

Development

The Conduction System

II.

Position and Structure of the Pacemaker
Position, Distribution, Dissection,
Supply






— Nerve

7

and

and Structure

Course of
Auriculo-ventricular Conduction System
Neurogenic or Myogenic Impulse ?
Impulse

Chapter

Arterial

the

of the

Normal

III.
Polygraphic Tracings
Schematic
Venous Pressure Curves
Mackenzie Polygraph
Dicrotic Wave
Physiological Variations
Phlebogram
Curves
Radial Palpation.
Types of Pulse

12

The Electrocardiogram
IV.
Electrocardiographic
Fundamental Physiological Considerations
The
Methods of Taking the Electrocardiogram
Apparatus
Its Interpretation
Normal Electrocardiogram
Three Leads
Variations Due to
Normal and Abnormal Electrocardiograms
Squatty, Vertical, and Drop Hearts
Change of the Ventricular Axis
Ventricular Hypertrophy
Shift of the Interventricular Septum
Phasic Variation with
Congenital Dextrocardia
and Dilatation

22













Chapter























— Different Positions the Heart in the Chest — Intraventricular Block — Abnormally Wide R.


Breathing

of

Mathematical
Chapter V.
Electrocardiogram
.

" Manifest" Size
cal Axis

— Their

.

.

.

.

.

Effect of



.

.

.39

— Angles Produced by the Leads with the Electri-

Mathematical Measurement and Approximation.

....

Course of the Excitation Wave

Chapter VI.

the

Underlying

Considerations

44

Vagus and Accelerator Stimulation upon the Electro-

cardiogram.

T Wave

:

Its Variations

and

Clinical Significance.



.....—

Their Polygraphic, ElectroThe Arrhythmias
cardiographic, and Clinical Recognition
Ventricular Arrhythmias
Tabulation
Auricular Arrhythmias
Arrhythmias from Disturbances in the SinoTrue Bradycardia
auricular and the Atrio-ventricular Nodes.
Alternation
Pulsus Paradoxus.

Chapter VII.









ix

47


CONTENTS

x

PAGE

Chapter

The Arrhythmias, Their Etiology and Therapy

VIII.








96

.

Sino-auricular
Arrhythmia
Sinus
Considerations
General
True Bradycardia.
Extras y stoles
Block
Asphyxia
Drugs
Cardiac Disease
Etiology
Heart Block
Interference with Cerebral Circulation
Chemical Poisons
Abnormal
Abnormal Pressure on the Cardio-inhibitory Center
Increased Vagal Inhibition by Digital
Pressure on the Vagus
Pressure, and by Reflex Peripheral Excitation.
Shortened Conduction Time
Prolonged Conduction Time
Paroxysmal TachySimple Tachycardia
Auricular Fibrillation
Ventricular Escape.
Auricular Flutter
cardia



:














Chapter IX.











....

Orthodiascopy and Fluoroscopy

— Description the Orthodiascopic Apparatus
— Use Combined with Fluoroscopy — Normal Orthodiascopic
Measurement — Objections to Measurement as a
Tracing —
Standard — Abnormally Broad and Abnormally Slender Hearts —
Orthodiagrams and Fluoroscopy in Mitral and Aortic Valvular
Lesions — Aortitis Involving the First Portion, Arch and Descending
the Aorta —
Thoracic Aorta — Congenital Cardiac Malformations
Patent Ductus Arteriosus — Patent Interventricular Septum — PatTheir Advantages

110

of

Its

Its

of

ent

Foramen Ovale.
Physical Examination of the Heart

Chapter X.

.

.

.

— Palpation — Percussion — Rational Method for the
Determination of the Cardiac Outline — Auscultation — Valvular
Murmurs — Murmurs in Atherosclerosis — Non-organic " Functional" Murmurs of Intracardiac Origin — Third Heart Sound —
Extracardiac Inorganic Murmurs — Cardio-respiratory and Cardiopulmonary Murmurs — Reduplicated Sounds — Reduplicated Apical
Impulse — Reduplicated First and Second Sounds.

129

Inspection

Chapter XI.

Etiology of Endocarditis and of Cardiovascular

Disease

— Chemical Agents — Metallic Poisons — Lead —
Experimental Observations, Neurotropic AcAlcohol — Tobacco
Experimental and
tion — Diabetes — Gout — Food Metabolism
Myocardial
Clinical Evidence — Bacterial Toxins — Diphtheria
Changes, Heart Block, Milder Toxemia, Arrhythmias, Unexpected
PneuPneumonia, Effect
Death — Pneumonia — Heart Block
monia on the Heart Muscle, Experimental Evidence, Cardiovascular
— Relation
Disease as a Late Sequela — Rheumatism and
— Pyorrhea Alveolaris — Streptobetween Rheumatism and
coccus Viridans
the Mouth — Pyogenic Abscesses — Bacterial EndoOrganisms
Relation to Rheumatism — Classification
the Various Valves —
Affections
Their Frequency — Frequency
Streptococcus Viridans — Renal Infarction — Distinction between
Acute and Chronic Streptococcus Viridans — Spirochetal Infection —
Classification

:

:

:

of

in

Tonsillitis

Tonsillitis

in

carditis

:

of

Its

of

Syphilis: Pathological Changes,

of

Wassermann Reaction.

:

149


-

CONTENTS

xi

.......—

Chapter XII. Pathology of the Endocardium and Myocardium
Pathology of Cardiosclerosis

Symptomatology, Therapy, and Prognosis of Rheu-

Chapter XIII.

matic Endocarditis


Chronic RheuEndocardial Exacerbations — Clinical Phenomena
matic Endocarditis — Decompensation — Types of Dyspnoea —
"Acidosis " — Cyanosis — Visceral Congestion — Special Signs and
Symptoms of Decompensation in the Various Valvular Lesions —
Clinical

160

Phenomena and

165

Signs of Acute Rheumatic Endocarditis
of

Paralysis of

Recurrent

the Left

Laryngeal in Mitral Stenosis

Therapy in Acute and Chronic Rheumatic Endocarditis
in Acute and Subacute, Quiescent, and Chronic Stages.







Prognosis

Acute Bacterial Endocarditis

176



Symptomatology
Therapy.
Subacute and Chronic Streptococcus

Viridans Infection.
Pathology
Clinical Course
Heubner's Nodes
Petechias
Skin Gangrene
Hematology
Renal Manifestations
Neurological Manifestations
Cardiac Manifestations
Blood Culture
Bacteria-free Stage
Therapy.






















.......



Chapter XIV. Cardiac Syphilis
The Heart in Secondary and Tertiary

Syphilis

184

Myocarditis

Aortitis.

Physical Signs of Aneurismal Dilatation of the First Portion and
Arch of the Aorta
Diagnosis, Symptomatology, Prognosis, and
Therapy of Dilatation Aneurisms of the Descending Thoracic Aorta.



Chapter XV.

Symptomatology, Physical Signs, Diagnosis and
of Myocarditis and Cardiosclerosis
Physical
Signs and Diagnosis of Ventricular Hypertrophy

194

....

206



Prognosis

.

.

.

Therapy in Circulatory Disease
General Considerations, Use in Auricular Fibrillation
and Other Arrhythmias, Arrhythmias Produced by Digitalis, Cause of
Digitalis Vomiting and Its Prevention
Preparations and Dosage,

Chapter XVI.
Digitalis

:



Coupled Rhythm and Digitalis, Use of Digitalis in Decompensation
with Regular Pulse, Cumulative Effect, Continuance of the Effect of
the Drug, Possible Dangers, Other Therapeutic Indications, Summary and Conclusions.
Tincture Strophanthus
Strophanthin
Apocynum
Squills
Caffeine and Its Derivatives
Theobromin Sodium Salicylate.
Karrell Diet
Its Use, Indications, and Modification
Strych-



:





:



— Camphor — Alcohol — Aconite — Spartein —

— Acetate of Potash and Sodium — Purging
Salts — Calomel — Venesection — Vaccines — Sera — Silver Preparations — Massage — Passive Motion — Calisthenics — Medical Gymnastics — Resistance Exercises — Walking — Hydrotherapy — Baths
Carbonated and Oxygenated Baths — Tonsillectomy — Extraction
:

nine
Nitrite Group
Adrenalin
Sedatives

:

of

Teeth.


:

CONTENTS

xii

PAGE

Diet, Renal and Blood Tests in Cardiac Disease
Diet in Compensated Endocarditis
General Considerations
In
In Myocardial Insufficiency with and without
Obese Individuals
Tests for Renal Insufficiency
Edema
Phenolsulphophthalein
Nephritic Test Diets
Test Method of Administration, Conclusions
Estimation of Water, Salt, and Urea Output in the Urine
Chemical Examination of the Blood
Non-protein Nitrogen
Diet in
Cardiosclerosis and Nephritis
Sugar Solution and Bicarbonate of

Chapter XVII.









:

:







229




:

Soda in Nephritis.

Management of Cardiac Disease

Chapter XVIII.

.

235

....—

237

.

.

— Types Exercise and Occupation
— Functional Efficiency Tests — Indications for Drug Therapy.
Fundamental Considerations

Marriage

Women

in

of

with Valvular Lesions

General Considerations. Cardiac Symptoms during Gestation
Prognostic Consideration of the Various Valvular Lesions, Indications
for Terminating Pregnancy.

Chapter XIX.

Blood Pressure

242

Physiological Considerations Factors Involved, Cardiac Energy,
Peripheral Resistance, Elasticity of Arterial Walls, Volume of Cir;

culating Blood, Viscosity of Blood




Clinical Estimation of Blood
Pressure
Types of Instruments
Methods of Blood Pressure
Estimation
Auscultatory Method and Its " Phases "
Normal
Blood Pressure
Physiological Variations
Effect of Alcohol,
Excitement, Cyanosis, Smoking
Increased Intracranial Pressure
Hypertonus
Clinical Classification for Study of Blood Pressure
Hypertensive Cardiovascular Disease with Myocarditis
Hypertension and Myocardial Insufficiency with Labile Vasomotor Mechanism
Myocardial Disease and Insufficiency
Uremic Group
without Hypertension
Valvular Disease and Myocardial Insufficiency with and without Hypertension
Hypotension
Blood
Pressure in Cardiac Arrhythmias
Therapeutics of Hypertension
Vasodilators, Venesection, Hydrotherapy, Diathermy, Diet, Exercise.



:

:





















"Weak" Heart

Chapter XX.
Clinical





Symptoms

Chapter XXI.

255

— Illustrative Cases — Therapy.

Precordial Pains of Cardiovascular and Extracardiac Origin
Angina Pectoris
Historical
Cardiovascular Nerve SupConfusion of Terms
ply
Epigastric Pains and Heart Disease
Intra- and Extra-cardiac
Disease
Classification of Common Causes of Precordial Pain
Organic Cardiovascular Disease
ExtracarIllustrative Cases















:

diac Disease

Chapter XXII.
Standpoint

:

258



Illustrative Cases.

Therapy of Pneumonia from

the

Circulatory
273


LIST OF PLATES
Plate
Plate
Plate
Plate

Plate

Plate

Plate

7

opposite page

12

Fig. 32

opposite page

23

III

Fig. 33

opposite page

24

IV

Fig. 36

opposite page

2S

Fig. 39

opposite page

Fig. 40

opposite page

2S
2^

Fig. 41

opposite page

42

opposite page

28
30

Fig. 45

opposite page

30

Fig. 47

opposite page

30

Fig. 48

opposite page

30

Fig. 49

opposite page

30

Fig. 50

opposite page

33

Fig. 51

opposite page

33

Fig. 52

opposite page

33

Fig. 53

opposite page

33

Fig. 54

opposite page

33

Fig. 55

opposite page

33

56

opposite page

35

Fig. 59

opposite page

35

Fig. 60

opposite page

35

Fig. 61

opposite page

35

Fig. 62

opposite page

35

Fig. 63

opposite page

35

Fig. 65

opposite page

35

Fig. 66

opposite page

35

I

II

V — Fig.

VI

VII

Plate VIII

Plate

Fig.

IX

— Fig.

— Fig.

67

opposite page

Fig. 68

opposite page

Fig. 69

opposite page

Fig. 73

opposite page

Fig. 74

opposite page

37

Fig. 75

opposite page

37

37

Fig. 76

opposite page

52

Fig. 95

opposite page

52

Fig. 96

opposite page

Fig. 97

opposite page

Fig. 98

opposite page


LIST OF PLATES

XIV

Plate

Plate

Plate
Plate

Plate

Plate

X

99

opposite page

62

Fig. 130

opposite page

62

Fig. 131

opposite page

62

Fig. 132

opposite page

63

Fig. 134

opposite page

63

Fig. 135

opposite page

63

Fig. 137

opposite page

63

XII

Fig. 140

opposite page

64

XIII

Fig. 144

opposite page

66

Fig. 163

opposite page

66

Fig. 177

opposite page

66

XI

XIV —

XV

Plate
XVI
Plate XVII
Plate XVIII
Plate
XIX
Plate
XX

Fig.

Fig. 162

opposite page

74

Fig. 169

opposite page

74

Fig. 183

opposite page

74

179

opposite page

82

Fig. 197

opposite page

82

198

opposite page

91

Fig. 202

opposite page

110

Fig.

Fig.

203

opposite page

111

Fig. 233

opposite page

122

Fig. 234

opposite page

123

Fig.


COMPLETE LIST OF ILLUSTRATIONS
Fig.

— Heart of the human embryo.
— Diagrammatic position of the cardiac valves.
dog.
sino-aucurilar node
3 — Schematic view
4 — Detail of the S-A node of dog.
5 — Right ventricle of ox heart, showing the auriculo-ventricular
1

2

of

of

node

(A-V node) and the main stem.

— Left ventricle ox heart, showing conduction system.
— Plate — Mackenzie Ink Polygraph.
the jugular bulb.
the a-c-v waves and
8 — Schematic view
the normal polygraphia curve.
9 — Diagrammatic representation
10 — Normal venous and radial tracing.
11-13 —
the venous tracing.
waves
tracing
the jugular.
14 — Combined venous and
15-16 — h wave
the jugular tracing.
aortic regurgitation.
17 — Normal phlebogram
aortic stenosis and double mitral
18-19 — Normal jugular tracing
mitral
20 — Normal a and other peaks
mitral regurgitation.
21 — Normal a wave
exophthalmic
22-25 — Normal jugular tracings
26 — Normal radial pulse tracing.
aortic regurgitation.
27 — Low dicrotic notch
28 — Low dicrotic notch in aortic aneurism.
monophasic action current.
29 — Scheme
diphasic action current.
30 — Scheme
31 — Scheme
rheostat and connection with the galvanometer.
the Electrocardiographic Apparatus in
32 — Plate II — Photograph
Position.
patient with electrodes cbnnected with the
33 — Plate III — Photograph
galvanometer.
the three
34 — Diagram
a typical electrocardiogram.
35 — Schematic representation
the
36 — Plate IV — Electrocardiogram showing the deflection time
37 — Normal electrocardiogram.
38 — Scheme showing the angles made by the leads with the varying ventricular axes.
normal patient negative R in L III.
39 — Plate IV — Electrocardiogram
normal patient negative R in L III.
40 — Plate IV — Electrocardiogram
normal patient negative R in L III.
41 — Plate IV — Electrocardiogram
6

7

of

I

of

of

of

in

Split c(c-c)

in

arterial

in

in

lesion.

in

stenosis.

in

in

goiter.

in

in

of

of

of

of

of

leads.

illustrating

of

of

of

;

of

;

of

;

XV

string.


COMPLETE

xvi

LIST OF ILLUSTRATIONS

Fig.

— Plate V — Electrocardiogram patient with narrow heart.
— Orthodiascope tracing heart normal child lying on back (A),
(B) and right (C)
back (A),
normal child lying on
44 — Orthodiascopic tracing of heart
(B) and right
45 — Plate V — Electrocardiogram of a child whose orthodiascopic tracing
Fig. 148.
congenital dextrocardia.
46 — Electrocardiogram
acquired dextrocardia.
47 — Plate V — Electrocardiogram
respiratory phasic varia48-49 — Plate V — Electrocardiogram showing
50 — Plate VI — Electrocardiogram of marked respiratory phasic variation.
aneurismal dilatation of the aorta and
51 — Plate VI — Electrocardiogram
ventricular hypertrophy.
ventricular
aortic stenosis and
52 — Plate VI — Electrocardiogram
hypertrophy.
ventricular hypertrophy.
53 — Plate VI — Electrocardiogram of
ventric54 — Plate VI — Electrocardiogram of aortic regurgitation and
ular hypertrophy.
congenital ductus
55 — Plate VI — Electrocardiogram
56 — Plate VII — Electrocardiogram showing an interpolated extrasystole
and an abnormally wide R.
57 — Electrocardiogram of advanced mitral stenosis and auricular
advanced mitral stenosis and auricular
58 — Electrocardiogram
thickened R summit.
59 — Plate VII — Electrocardiogram
notched R summit.
60 — Plate VII — Electrocardiogram
R (M complex).
61 — Plate VII — Electrocardiogram
R {W complex).
62 — Plate VII — Electrocardiogram
R (W complex).
63 — Plate VII — Electrocardiogram
notched P wave in mitral
64 — Electrocardiogram
65 — Plate VII — Electrocardiogram of intraventricular block.
abnormal
66 — Plate VII — Electrocardiogram of ventricular complexes
width and normal form.
abnor67-69 — Plate VIII — Electrocardiograms of ventricular complexes
mal width and normal form.
to the
70-71 — Diagrams
relation
the ventricular
the direction of the leads to the
72 — Diagram
T
73 — Plate VIII -^ Electrocardiogram showing
than R.
74 — Plate VIII — Electrocardiogram showing T
75 — Plate VIII — Electrocardiogram showing negative T III.
76 — Plate IX — Electrocardiogram showing diphasic T II and negative T II
and T III.
77-82 — Diagrams showing the origin
physiological and pathological con83-87 — Polygrams
ventricular extrasystoles.
of

42
43

of

left

sides.

left

(C) sides.

of

its

of

its

is

of

of

slight

tion.

of

left

of

left

left

left

arteriosus.

of

fibrillation.
fibrillation.

of

of

of

of split

of split
of split

stenosis.

of

of

of

of

leads.

axis

of

electrical axes.

of

tall

II.

taller

of

tractions.

of


COMPLETE

LIST OF ILLUSTRATIONS

xvii

Fio.

— Polygrams auricular extrasystoles.
— Polygrams multiple auricular extrasystoles.
95-98 — Plate IX — Electrocardiograms of auricular extrasystoles.
99 — Plate X — Electrocardiogram of auricular extrasystoles coming from
two ectopic
100-101 — Polygrams of varying ventricular rates
exophthalmic
102 — Polygram
paroxysmal tachycardia.
103-106 — Polygrams of exophthalmic
107-120 — Polygrams
various types of auricular
121 — Polygram
auricular
with anacrotic radial pulse.
122 — Polygram of auricular
waves.
and
123 — Polygram
auricular
124 — Polygram
auricular
with rhythmical radial pulse.
125-129 — Arteriograms
auricular
pulse
130 — Plate X — Electrocardiogram showing small,
regular
waves.
131 — Plate X — Electrocardiogram showing very
waves.
132 — Plate XI — Electrocardiogram showing
regular
waves
88-92
93-94

of

of

foci.

in

goiter.

of

goiter.

of

fibrillation.

of

fibrillation

fibrillary (/)

fibrillation

of

fibrillation.

of

fibrillation

of

fibrillation illustrating

irregularities.

fairly

fibrillation

fine fibrillation

fairly

resembling

flutter.

fibrillation



— Electrocardiogram with
waves.
— Plate XI — Electrocardiogram with various types
waves.
135 — Plate XI — Electrocardiogram with very
waves.
136 — Electrocardiogram with
regular
waves.
137 — Electrocardiogram
showing tachycardia.
auricular
138 — Electrocardiogram
auricular
with ectopic beats.
139 — Electrocardiogram
auricular
with coarse waves.
140 — Electrocardiogram of auricular and ventricular extrasystoles, and auricular
141-143 — Polygrams of auricular
144 — Plate XIII — Electrocardiogram of auricular
incomplete heart
block (4:1).
145 — Electrocardiogram of paroxysmal auricular tachycardia and auricular
146 — Electrocardiogram
nodal extrasystole.
147-148 — Polygrams of nodal extrasystoles.
149-150 — Polygrams
ventricular extrasystoles with compensatory pauses.
151 — Polygram
ventricular extrasystole with decreased compensatory pause.
152-153 — Polygrams of ventricular extrasystoles without compensatory pauses.
154 — Schematic view of types
ventricular extrasystole showing the
tion of the corresponding R deviations.
155 — Electrocardiogram of ventricular extrasystole from right ventricle near
the base.
156 — Electrocardiogram
ventricle near
ventricular extrasystole from
the base.
157 — Electrocardiogram of ventricular extrasystole from wall of
133

fine fibrillation

134

of fibrillation

fine fibrillation

fairly

fibrillation

of

fibrillation

of

fibrillation

of

fibrillation

fibrillation.

flutter.

flutter

;

fibrillation.

of

of

of

direc-

of

of

left

left ventricle.


.

.

COMPLETE

xviii

LIST OF ILLUSTRATIONS

Fig.

— Electrocardiogram extrasystoles arising from various ventricular
with complete heart block.
coupled rhythm (pulsus bigeminus).
159 — Electrocardiogram
159 A-159 B — Polygram of frustrate ventricular extrasystoles (coupled rhythm)
paroxysmal tachycardia
ventricular
160 — Electrocardiogram
ventricular escape.
161 — Polygram
ventricular escape.
162 — Plate XIV — Electrocardiogram
the
branch of the con163 — Plate XIII —Electrocardiogram
duction system.
the right branch
the conduction system.
164 — Electrocardiogram
165-168 — Polygrams
true bradycardia.
true bradycardia.
169 — Plate XIV — Electrocardiogram
170-171 — Arteriograms
sinus arrhythmia.
sinus slowing.
172 — Arteriogram
sinus arrhythmia.
173 — Arteriogram
174-175 — Polygrams
sinus arrhythmia.
sinus arrhythmia, non-respiratory type.
176 — Polygram
respiratory
sinus arrhythmia
177 — Electrocardiogram
sino-auricular block due to smoking.
178 — Electrocardiogram
sino-auricular block.
179 — Plate XV — Electrocardiogram
nicotine upon the vagus and accelerators.
180 — Diagram showing the
blocked auricular beat.
181 — Electrocardiogram
182 — Electrocardiogram showing very slow ventricular rate and .prolonged
P-R time.
prolonged conduction time.
183 — Plate XIV — Electrocardiogram
backward conduction from ventricle to
184 — Electrocardiogram
incomplete block.
185 — Polygram
incomplete block and ventricular extrasystole.
186 — Polygram
187-192 — Polygrams
complete heart block.
complete heart block and irregular ventricular action.
193 — Polygram
complete heart block and ventricular extrasystole.
194 — Polygram
heart block, ectopic beats and auricular
195 A and B — Polygrams
prolonged conduction time and heart block.
196 A and B — Polygrams
complete heart block.
197 — Electrocardiogram
incomplete and complete heart block.
198 — Electrocardiogram
alternation.
199 — Arteriogram showing
200-201 — Arteriograms
alternation following extrasystoles.
202 — Plate XVII — Groedel Apparatus.
marking mechanism
Groedel apparatus.
203 — Plate XVIII — Details
normal heart.
204 — Orthodiascopic tracing
long and slender heart.
205 — Orthodiascopic tracing
a broad heart.
an orthodiascopic tracing
206 — Copy
207-208 — Orthodiascopic tracings
abnormally slender hearts ('drop'
hearts)
compensated mitral regurgitant
209 — Orthodiascopic tracing
of

158

foci,

of

of

of

origin.

of

of

of lesion of

of lesion of

left

of

of

of

of

of

of slight
of

of

of

of

origin.

of

of

effect of

of

of

of

auricle.

of

fibrillation.

of

of

of

of

of

:

of

of

of

slight

of

of

of

of

of

of

of

of

of

lesion.


COMPLETE
Fig.



LIST OF ILLUSTRATIONS

xix

Orthodiagram of compensated double mitral lesion.
210
211-213
Orthodiagrams of globular hearts of cases of decompensated double
mitral lesions with auricular fibrillation.
214



— Orthodiagram globular heart
— Orthodiascope tracings
of

215-216

of

extreme

size.

of slightly globular hearts

with moderate

enlargement.

— Orthodiagram extreme, rounded right-sided enlargement.
— Orthodiascope tracing double mitral
recent mitral regurgitant
219 — Orthodiascope tracing
mitral regurgitant lesion showing a somewhat ovoid
220 — Orthodiagram
contour.
old rheumatic double aortic
221 — Orthodiagram
aortic regurgitation.
222 — Orthodiagram
223-224 — Orthodiagrams
double mitral and aortic
dilatation
aortic arch with
225 — Orthodiagram
ventricular hypertrophy.
226 — Orthodiagram of
227 — Orthodiagram of dilatation
aortic arch and
ventricular hypertrophy.
228 — Orthodiagram
of
portion and arch
the aorta, and
extreme
ventricular hypertrophy.
and
229 — Orthodiagram
ventricular hypertrophy.
230 — Orthodiagram of enlargement and low implantation
the
portion
the
ventricle.
the aorta, and moderate enlargement
231 — Orthodiagram
and
ventricular hypertrophy.
232 — Orthodiagram
aneurismal dilatation
the descending thoracic
aorta.
233 — Plate XIX — Photograph from X-ray
showing aneurismal
tation
the descending thoracic aorta.
234 — Plate XX — Photograph from Roentgenogram
aneurismal dilatation
the descending thoracic aorta.
235 — Orthodiagram of aneurismal dilatation of the arch and descending thoracic
aorta.
236 — Orthodiagram
aneurism
the
portion
the aorta due to congenital aortic
237 — Orthodiagram
double mitral lesion and aortic aneurism.
238 — Orthodiagram
patent ductus arteriosus.
239 — Orthodiagram
congenital dextrocardia and patent interventricular
septum.
240 — Diagram
probable cardiac circulation
patent interventricular septum.
241 — Outline
heart with dilated right
242-246 — Diagrams
difference
percussion and orthodiascope outlines of
normal and abnormal hearts.
247 — Orthodiascope tracing from a case
recurrent
mitral stenosis and
217

of

218

of

lesion.

of

lesion.

of

of

lesion.

of

of

lesions.

of

of

left

aortitis.

of

of aortitis

left

of

first

left

of luetic aortitis

left

of

of

of

of luetic aortitis

first

left

left

of diffuse

of

dila-

plate,

of

of

of

of

of

of

first

stenosis.

of
of

of

of

in

of

auricle.

of

in

of

laryngeal paralysis.

left



CLINICAL CARDIOLOGY
CHAPTER

I

THE HEART



In very early fetal life the heart is
Development of the Heart.
by a simple tube, the cardiac tube. It consists of two disan inner, thinner layer, derived from the hypoblast, which
tinct strata
and an outer, thicker layer, derived from
later becomes the endocardium
the visceral mesoblast, which finally develops into the musculature.
Later, the cardiac tube elongates and becomes bent upon itself so as
to form an S-shaped loop, with an anterior right, and a posterior left
angle.
Slight constrictions soon appear, which serve to divide the loop
represented

:

;

the sinus venosus (sinus reuniens of His),
the common venThe sinus venosus
tricle, (4) the aortic bulb.
\L£FT
is at first situated transversely behind the common auricle and connects with the latter by a
median aperture it afterwards becomes oblique
ev
and divides into two projections or horns: the
line
of
right forms part of the right auricle, the
Heartc f thehuFiG 1>
man embryo 5 mm. long.
union being marked in the adult heart by a vertical crest, the crista terminalis of His; the left
(Modified from His.)
horn persists as the coronary sinus. The common auricle (C.A) becomes partitioned off into right and left auricles
by the gradual formation of a septal wall, the septum superius the
into four parts (Fig. 1)
(2)

the

common

(1)

:

auricle,

(3)

;

'

_

;

from a perforation of this wall. Another septal structure, the septum inferius, similarly forms, and separates^ the
common ventricle {C.V) into right and left chambers. For some time,
foramen ovale

however,

it

results

does not quite reach the auricular canal, thus leaving a
auricles and ventricles, the common auric-

foramen between the
ulo-ventricular orifice.

The formation

of a

septum

is

also responsible

for the division of the aortic bulb (A.B) into the two great vessels,
the aorta and the pulmonary artery.
In early fetal life, the heart lies imPosition of the Fetal Heart.
Later, it bemediately under the head and is of relatively large size.
assuming
gradually
then
vertically,
thoracic
organ,
lying
at
first
comes a





B

1


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