Harold Feil

Accuracy in diagnosis and localization of myocardial infarction

Abstract Of 34 cases of recent myocardial infarction in which necropsy was performed, the clinical and electrocardiographic diagnosis was correct in 28 (82.05 per cent). In the 6 undiagnosed cases there was some electrocardiographic evidence in 3, and none in the other 3 cases. These diagnostic errors were due to lack of chest leads in one case, left bundle branch block in 2 cases, and intraventricular block in one case; in 2 cases the evidence was suggestive, but not conclusive. In 21 cases pericarditis was present at autopsy, but in none were the electrocardiographic changes typical of those seen in acute pericarditis. Multiple acute infarction without previous infarction was present in 8 cases (24 per cent), and in 22 cases the recent infarction, both single and multiple, was associated with older infarction.16 ∗ In the case of acute single infarction alone the accuracy of diagnosis and localization was 100 per cent. In the cases of recent and old infarction accuracy of diagnosis and localization was 73 per cent. In the diagnosed cases the accuracy of the electrocardiographic localization of the major acute infarction was 100 per cent (28 cases). The diagnosis of acute myocardial infarction should be made from the patients history, the physical examination, and laboratory findings.17 The electrocardiogram (especially when serial records and chest leads are taken) will assist in the diagnosis and localization of infarction in over 80 per cent of the cases.

Clinical observations on the dynamics of ventricular systole

Abstract Patients with mitral valve lesions were studied by means of the Wiggers modification of the Frank capsule and the measurements of the chief phases of systole were compared with the duration of these phases calculated from the formula S=.31 √c from which the following conclusions were drawn: Mitral Insufficiency .—The duration of the isometric and ejection phases and of total systole were within normal limits with one exception. Mitral Stenosis .—In eleven of the twelve cases with normal mechanism the phases of systole and of total systole were normal. In one instance with slight failure, ejection and total systole were abbreviated. In nine patients with auricular fibrillation but with no signs of failure the phases of systole and total systole were shortened. These clinical findings are in agreement with recent experimental data.Patients with mitral valve lesions were studied by means of the Wiggers modification of the Frank capsule and the measurements of the chief phases of systole were compared with the duration of these phases calculated from the formula S = .31 √c from which the following conclusions were drawn: Mitral Insufficiency.—The duration of the isometric and ejection phases and of total systole were within normal limits with one exception. Mitral Stenosis.—In eleven of the twelve cases with normal mechanism the phases of systole and of total systole were normal. In one instance with slight failure, ejection and total systole were abbreviated. In nine patients with auricular fibrillation but with no signs of failure the phases of systole and total systole were shortened. These clinical findings are in agreement with recent experimental data.

Digitalis and the normal work electrocardiogram

Abstract 1. 1. Exercise electrocardiograms were made of fourteen normal persons before and after digitalization. 2. 2. When the subjects were digitalized, exercise caused a general depression of the S-T junction which in four instances was distinctly abnormal. Changes in T waves and rhythm also occurred. 3. 3. It is therefore imperative that the digitalis effect on work electrocardiograms be not confused with work electrocardiograms which show the result of myocardial ischemia due to coronary artery disease.

A clinical study of the electrocardiogram and of the phases of cardiac systole in pellagra

Abstract In this study of 38 patients with moderate to severe pellagra, electrocardiographic abnormalities in the ventricular complex occurred in 50 per cent. In 14 of these 19 patients there was no complication which might alter the electrocardiogram (36.8 per cent). The chief abnormalities were inversion of T in Leads I or II or both, Pardee type of S-T, and large T-waves. Lead IV was abnormal in 12 instances out of 33 cases in which it was recorded (36.4 per cent). Lead IV was abnormal in 4 cases with normal Leads I, II, and III. The Q-T interval and mechanical systole were prolonged in some cases. These findings suggest that the heart is affected physiologically in pellagra. Twelve hearts (one of which was studied electrocardiographically and dynamically) exmined pathologically showed no gross or microscopic abnormality. Roentgenographic changes were lacking in the cases studied. Thus it may be concluded from these clinical, electrocardiographic, and dynamic studies that the heart is affected by pellagra.

The effect of exercise on the electrocardiogram of bundle branch block.

Abstract A systematic study was undertaken to determine the effect of the exercise test on the electrocardiogram of fifty-six patients with bundle branch block. Of twenty-seven patients with right bundle branch block, four showed a positive test; only two of the four positive reactors had definite evidence of heart disease, while six patients with arteriosclerotic heart disease had negative tests. Of six patients with incomplete right bundle branch block only one had arteriosclerotic heart disease and the exercise test was positive in this case. Of twenty patients with left bundle branch block seven showed positive tests, while five others with arteriosclerotic heart disease had negative tests. All three patients with Wolff-Parkinson-White syndrome had positive tests, despite the absence of other clinical evidence of heart disease in two. The exercise test was positive in approximately 50 per cent of patients with arteriosclerotic heart disease and complete bundle branch block. Presumably false positives occurred in two patients with right bundle branch block and in two with the Wolff-Parkinson-White syndrome, indicating a possible hazard in the evaluation of the effect of exercise in the presence of aberrant conduction.

Electrocardiographic changes in cases of infectious hepatitis.

Abstract 1. 1. In an epidemic of twenty-four cases of infectious hepatitis, eleven subjects were studied electrocardiographically at the height of the disease and after recovery. 2. 2. In nine cases the T wave was depressed during the disease and became normal after recovery. 3. 3. There was no correlation between the depression of the T wave and the height of the fever or the intensity of the jaundice. 4. 4. A study of a control group of persons after exercise revealed a depression of the T wave (with acceleration of heart rate), thus showing that the bradycardia was not responsible for the electrocardiographic changes. 5. 5. A review of the reports of experiments in which bile salts and whole bile were injected into animals revealed similar T-wave changes which were probably due to an effect either on the vagus endings in the heart or on the myocardium itself. The myocardial effect is probably important in cases of Weils disease, as evidenced by the reported pathologic findings in the myocardium.

The transformation of the central into the peripheral pulse in patients with aortic stenosis

Abstract The subclavian and radial pulses in patients with aortic stenosis were recorded simultaneously by the recently developed optical method. The contours were studied and analyzed with special reference to the transformation of the subclavian into the radial pulse. The graphic record of the subclavian pulse shows first a steep ascent ending in a sharp vibration about one-third of the way up the ascending limb; the rise following the vibration is less steep and has its peak near the end of systole. Small vibrations, irregular in amplitude and period, surmount the slower ascent but are significantly absent in the initial rise. The transformation of the subclavian into the radial pulse characteristic of this lesion is described and the factors responsible for this change are analyzed. Evidence is given to show that the anacrotic wave in the radial is the peripheral manifestation of the sudden break of the subclavian pulse occurring early in the ascent, the relation being the same as that existing between the incisura of the normal subclavian pulse and the dicrotic wave in the radial.

The effect of posture upon axis deviation in human bundle branch block

Abstract 1. 1. A case of bundle branch block is described in which the block apparently alternated between the right and left branches. The changes in the electrocardiographic pattern were subsequently duplicated by alteration of the patients posture. 2. 2. The effect upon the standard and augmented unipolar limb leads and upon the precordial leads of changing from the supine to either right or left lateral postures has been studied in forty cases of bundle branch block, twenty of the right and twenty of the left bundle branch. 3. 3. The position of the electrical axis has been measured in each case in the three postures and the electrical position of the heart determined from the augmented unipolar limb leads. 4. 4. In left bundle branch block the axis shifted more than 30° in eight of nineteen cases; in six instances the shift exceeded 60°. The greatest shift was 185°. The direction of shift was, with one exception, invariably to the right on assumption of a lateral posture. The electrical position of the heart became more vertical in all six patients in whom it was altered. 5. 5. In four patients with left bundle branch block, an upright QRS in Lead I became negative so that right axis deviation and apparent right bundle branch block appeared in the lateral posture. In three patients assumption of a lateral posture caused a negative QRS in Lead III to become upright so that the discordant pattern of left bundle branch block became concordant. In all of these patients the precordial leads showed delay in the intrinsic deflection over the left precordium in all postures. 6. 6. In right bundle branch block, assumption of one or the other lateral posture led to a shift of axis of more than 30° in seven of twenty patients; in six of these, the shift was to the right. In no case did the electrocardiographic pattern simulate left bundle branch block, and the electrical position of the heart was never grossly altered. 7. 7. It is concluded that the limb leads are unreliable as a guide to the side of bundle branch block in some cases, but that the precordial leads are little affected by changes of posture. The importance of taking electrocardiograms in a standard posture is re-emphasized.

On axis deviation in human bundle branch block.

Abstract Fifty-four cases with records showing both normal intraventricular conduction and bundle branch block have been collected; 192 records were available, ninety showing bundle branch block, ninety-two showing normal intraventricular conduction, and ten showing both bundle branch block and normal conduction. The axis deviation has been measured in each record and the average position of the electrical axis of QRS during normal conduction compared with that during bundle branch block. When right or left bundle branch block appeared or disappeared there was a significant change in the direction of the electrical axis of QRS (15° or more) in less than one-half of the cases, and the average change was 12° to the left in left bundle branch block and 12° to the right in right bundle branch block. When a significant change of axis was associated with the appearance of bundle branch block, the direction of the change was always to the left when the block was of the left bundle branch and, except in one case, to the right when the right bundle branch was blocked. Even in cases in which a significant change of axis was found, the general pattern of the bundle branch block electrocardiogram conformed closely to the pattern with normal intraventricular conduction. Factors, other than the bundle branch block, that might have caused a shift of the electrical axis have been discussed; it is believed that they did not materially influence the averaged results. It is concluded that the axis deviation and the general pattern of the electrocardiogram are not greatly modified by the appearance of bundle branch block, and that the axis deviation associated with right and left bundle branch block is due principally to the position of the electrical axis of QRS before the bundle branch block appeared. Certain implications arising from this conclusion have been briefly discussed.

The electrocardiogram in lupus erythematosus disseminatus

Abstract Abnormalities of the electrocardiogram in patients with lupus erythematosus disseminatus have been noted by several authors in case reports. These abnormalities have consisted of low voltage, increased P-R interval, increase in left axis deviation, low or inverted T waves and premature beats. This report presents the electrocardiographic findings in eight autopsied cases of lupus erythematosus disseminatus. All abnormalities noted above were found in this group with the exception of premature beats. In addition, change of axis from normal to right axis deviation occurred. There was also a general tendency toward prolongation of the Q-T interval; in two patients Q-T was abnormally prolonged. Low voltage was not as common as reported in other series. Electrocardiographic changes were seen as long as ten months before death. In those patients in whom a series of records was obtained the electrocardiograms became progressively and increasingly abnormal. In three of eight patients in whom there was anatomic abnormality of the heart there was no change in the electrocardiogram. In all of these, however, there was no series of records; only a single electrocardiogram was available for study.