Carey F. Coombs,
Physician (with charge of Ou'-patienis),
C. E. K. Herapath, M.C., M.D. Lond. Assistant
the heart has to be con first, the effect of the l?sS
The effect of auricular failure sidered from two
of the auricular contraction, and abnormal
of auricular failure
the effect of the
The function of the auricles is to act
reservoirs for the
The blood which collects in them during ventricular systole passes into the ventricles at the commencement of diastole ; and as diastole goes on, first t^e ventricles fill and then the auricles. tion then
certain that the
full amount of blood shall be
maki11^ pumped ^0
^ie every time that Loss of the auricular contraction
ventricles contract. on
The effect of abnormal
filling of. of the
the ventricular contraction will be considered later. 1
We have to express our .sincere thanks to the Colston for helping us to defray the expenses of the investigations al to in this paper, as well as those of the illustrations ; to Dr. C ^.s> Hadlield for furnishing us with the photomicrographs ; and to ^ afic ' John Wright and Sons for the loan of blocks from a book on Rheuv Heart Disease which they are just bringing out.
Superior vena cava
of heart, showing position of sinu-auricular
?f auri ?t e
0tj'aPh Vent'*CHlnr VeUtr*cu^ar no^e and
cut cUt tfn, tfn-
?f heart with right auricle and ventricle opened to show position
The rectangular outline is that of kindle. bundle. to provide serial sections of these structures. The block is for this purpose.
CUt out CUt 0llt
Figs. 3 and 4. Sina-auricular Sinu-auricular node.
of The upper (low-power) photomicrograph shows the general structure ?f the node. The darker darker area is that of the general auricular muscle ;; the ?eS is that of the node, with its central vessels. The lower (high-power) one shoWs a nerve trunk N sending its fibres into the substance of the node, which mainly composed of bundles of fine muscle fibres.
The contraction of the heart is started at the upper Part of the right auricle by a collection of cells known as the sinu-auricular node (Fig. i). This node is situated in the wall of the
superior vena cava joins the right auricle and the base of the right auricular appendix. It is an elongated structure lying at right angles to the
and is continued
small distance down the sulcus terminalis.
of dense fibrous tissue in which
small fine muscle fibres
(Fig. 4). This collection oi cells has the property of originating a stimulus for the contraction of
nerve fibres lead into it
the heart muscle.
Much controversy which this stimulus is n?de.
has taken carried
from node electrical
auriculo-ventricular that there is
node, and this is said
to have been
set out to Three years ago means of serial sections of hearts. we
look for this path by Si* hearts were cut and examined, search
Work has been
to us that there was
and the results of this no
the stimulus passes to the A?V node by means of the ordinary auricular muscle, the contraction of the nodal fibres of the
by direct continuity of fibres. All the muscle fibres leaving the S-A node can be traced musculature. away into the ordinary auricular node
auri.cular walls. tion from the
to the auricles
of any specialised muscle path through the We also found that the spread of contrac-
to the left
n">ain paths (Figs. 5 and 6). Firstly, fibres from the node Passed down to the inter-auricular septum, where fibres from the right crossed the middle line and were continued round the back of the left auricle.
fibres, passing Vol
m No. 154.
the tail of 1^
Secondly, a broad band of the right auricular appendix,
CAREY F. COOMBS AND C. E.
the left auricle. in the
the back of
how the contraction
the contraction of both chambers.
passes from the sinus node into the auricular muscle of both auricles,.and by this means
The contraction wave,
reaches the base of the inter-auricular septum, where it meets another collection of cells termed the auriculoThis is situated
septum just to the right of the opening of the coronary (Fig. 2). The node is very similar to the sinus node, consisting of a network of fine muscle fibres embedded in the
many nerve fibres passing into it, cells can be seen amongst the muscle
and many ganglion fibres. From this node the
bundle of fibres passes across side of the inter-ventricular septum towards the
scpti. right one
the left branch
At this part it divides into two runs down the right side of the
its left side. These pass down to the apex and then subdivide into branches, which are distributed to the muscle
innumerable fibres of the
fibres of the ventricles contract in
at the apex and
definite order, com-
This sequence of contraction is only possible when the stimulus for contraction reaches the ventricular muscle by of the bundle.
in the ventricular muscle itself
other, and in this occur
the spread of contraction does not
in this sequence, with the result that the power of the
contraction suffers. This different
of contraction evokes If
cardiographic tracing (Fig. 7),
find that the waves, ?r
Figs. 5 and 6.
~?u'~power photomicrographs exhibiting the muscular bands which join the lu>o auricles.
Fig. 7. Normal
Llecir0C( ?^cci'?cardiogram cardiogram showing
in the ven'.vicles. ven'.ricle premature beats R'T' arising in
Venous pulse (jugular)
VJk kfV^o ad,al pulse Pol
^IG" IO' Fig. io. ("Us? ^le the lower from a acase upper normal, of auricular auricularfailure. failure. (5 ""is, tjle xippCr normal, the luwev from case of
CAREY F. COOMBS AND C. E.
of three kinds
is due to the auricular contraction and which occurs from R R denotes 0.14 to 0.18 of a second before the ; "
the onset of ventricular
the end of ventricular contraction ; a normal R and T denotes that the ventricular contraction was called forth by a
reaching the ventricle by the bundle, and is what a supra-ventricular complex. An abnormal
ventricular contraction a
arising from the complex (see Fig. 8).
way. it is
It is also
fibrillation, it is seen that the of the supra-ventricular type>
the ventricular contractions
of auricular failure
after the onset of auricular therefore
down the bundle in the
is absent, but
irregular waves which occur com tinuously, being interrupted by irregular spaced ventricular complexes. These correspond with the irregular ventricular beats that are perceptible clinically as the totally irregular pulse." It was this kind of irregularity that first attracted attention to the syndrome of auricular failure. Mackenzie' Wenckebach and Hering noted the occurrence of a kind small
by them they showed,
with the ventricular form
from which the usual
this further W the were found iu
showing that small irregular waves electro-cardiogram of total arrhythmia, "
perpetual," anf Failure.
endocarditis supervening on chronic cardiac rheumatism.
Slight cloudy swelling and fatty change.
Slight cloudy swelling and fatty change.
Nil except usual vascular changes of chronic cardiac rheumatism in neighbourhood of central fibrous
Chronic M., 30. rheumacardiac tism with mitral stenosis, etc.
Large hemorrhage into middle of node ; about a quarter of its length affected ; at the worst point the node was almost cut in two. The blood .appeared to come from the neighbouring part of the right auricle. Much of the clot was organised and had been, there some time. About one-fifth of the total nodal tissue was destroyed by this
I No abnormality :
No active in Ha mmation of myocardium
General Features of Case.
Chronic M., 50. cardiac rheumamitral ; ti s m stenosis.
fatty ! Fatty change j only slight in
Definite fatty change. Cloudy also swelling
Chronic F., 57. cardiac rheumatism ; decrescent cardiosclerosis ; recent endocarditis.
Passive hyperemia. Hypertrophy of A. to
in L.V. Inflam-
large lymphocytic focus in early part of bundle.
Chronic F., 5. cardiac rheumatism ; acute terminal carditis ; chronic interstitvcvl nephritis.
Months a' least.
Normal ; right auricle cavity closely approaches
Remarks. Old litis
Advanced fatty in left auricle. Definite fatty change in right auricle.
Definite fatty in both ventricles.
of recent onset.
C. AND COOMBS
I -. 55Chronic cardiac rheumatism with mitral and aortic fibrosis, and recent mitral endocarditis of doubtful character.
Duration jf Failure.
General Features of Case.
Kef. j No.
Chronic / Weeks. rheuma- / Terminal / with / influenza F., 4/. cardiac tism.
/ Great variation / Slight fatty
/ muscle fibres, which also / in size of fibres. / change. / show some fatty change / Extremely ad- j / and hypertrophy. Artery vanccd fatly j lo node shows hyper- | change. myotropliy. | Capillaries and arterioles mild
/ ative reaction in f artery to node,
Chronic M., .29. rheumacardiac tism, sudden death.
Months at least.
INI 17. Acute rheumatic carditis terminating cardiac rheu matism.
About year ?
hypertrophy. Slight fatty change in
No abnormality, except of doubtful increase connective tissue at lower pole.
Obi iterat ive in11 a m m atory changes in vessels to node.
No gross fatty changes. Many inflammatory
Acute obliterative changes in arterioles.
Partial Examinations. I
Nil, except acute proin liferative reaction artery to node.
(b) F., 21. cardiac
Fibres vary much in size.
Chronic rheumamatism with mitral and tricuspid stenosis.
F., 34. cardiac
tissue nective increased.
fibrosis. CardioM., 59. sclerosis with hyperpiesis and terminal streptococcic endocarditis.
Weeks or months.
No gross changes.
Saturated with in flam matory reaction.
Partially examined ; inflammatory
Chronic F., 31. rheumacardiac tism, with mitral
More thar a
stenosis ; terminal endocarditis. Chronic F., 41. rheumacardiac tism with mitral
More thai a
stenosis. M., 50.
Partially examined. change.
degeneration myocardium. 64
change. One or two submiliary
Chronic I7., 48. cardiac rhenmatism with mitral
C. AND COOMBS
Duration )f Failure.
Chronic 1 Years. 66 I M., 48. rheuma- \ \ cardiac \ tism, mitral steno- \ \ \ sis, etc.
Not examined. \
fatty change a n d cloudy swelling. Advanced
change. Definite h ange
cloudy swelling. Slight or definite
\ iatty change.
General Features of Case.
examination is that
the latter serial sections
n?de and the auriculo-ventricular
of the sinu-auricular whereas in
the partial examinations these series were omitted. In only one case of auricular failure that was
there any lesion of the sinu-auricular node that could conceivably have put an end to its effective
and of that case, even, it is
as true as
it is of the
?thers.that significant degenerative changes were freely throughout the auricular walls. Further, treasonable
scattered it is not that
part of the sinu-auricular node was a consequence, cause, of auricular failure. Apart from this one
free from gross morbid
^n the other hand, in every case of auricular failure the Musculature of the auricular walls had reached a pitch of
extreme that it
the readiest index of that deterioration was Most advanced in the parts of the auricular muscle that lay Mst under the endocardium. In some hearts the areas
in others the Mam auricular walls.
appendices displayed this most change was at its maximum in the
of the decadent muscle
brings into unnatural prominence the delicate interstitial
barely discernible, and only Patches. This contrast between the decadence
in small and scattered
of the ventricular walls is
of the auricles and
into greater with two other sets of facts ; first,
js compared Nlth the absence of any such marked contrast from the
CAREY F. COOMBS AND C. E. "
alluded to above, and second, with
the freedom of the auricular walls from inflammatory lesions in
generalisations there are exceptions. For example, records 58, 61 and 76 were of cases of chronic cardiac rheumatism, with predominating mitral lesions but no signs of auricular fibrillation
grossly degenerate, much more so than that of the ventricles, showing that in such cases this contrast becomes apparent even
failure sets in.
arrhythmia that is characteristic of auricular Again, record No. 46 is that of a case of acute
rheumatic carditis in which the auricular muscle
lesions of the
those of the ventricles both in
diffuseness and in
Yet both of these
support those generalisations which we feel justified in drawing from our observations of the histological changes that accompany auricular failure ; first, that it is the whole do but
auricular wall that
and not the sinu-auricular node ;
and, second, that failure is usually the tion
deterioration may be is well
How in the
failure, being practically always associated organic change, brings into any case of heart
gravity ; first, because it is itself strong evidence of serious myocardial deterioration ; second, a because its rapid irregular rhythm lays on the ventricle disease
this second fact that the
If the ventricles
1 It is true that the texture of the auricular wall is such that it is detect these changes in it than in the denser ventricular muscle, but t difference by no means explains away the whole of the contrast to \vh1L we refer.
and 12. 12.
in the the auricular auricular wall wall showing s^l0W^nS myocardial degeneration in auHUyiCr0Smphs atnf"Tc^aPhs iailme- The UPP the lower lower high-power failure. is low-power and the
?r Motorr'l ^hotograpk ?Syaph.
from IF ^Hpht>C^S rU?nkSA0m and
Rheumatic Heart Disease,"
seased and ineffective when the auricular functions fail, is unlikely that treatment will afford a large measure of
Some relief there will be if,
induced to beat regularly,
lng this, fewer stimuli are allowed to pass through into Ventricles ; and if the ventricles are still in fair condition, c?ntrol of auricular failure furnishes for
therapeutics one triumph in the whole
have many examples of persons whose cardiac
"-niptonis were so far alla37ed and kept in check by these eans, that they were enabled to carry on their business
of relief ;
and this is
often because the ventricles
for gone in disease that even when they have been ehe\ed of the burden thrown upon them by failure of the Uricular functions they cannot do their work effectively.
other elements may be introduced into a discussion prognostic significance of auricular failure ; but we
lmit ourselves here to
sets of facts to be considered
forecast truly the expectations of
which the syndrome of auricular fibrillation Those three are, first, the nature of the
under] v" ying lesion, whether it is transient or progressive, and, a> the state of the ventricles as far as this can be
ascertain 1 amed under tv, tne
influence of the
the behaviour of the
of cardiac disease
^a^ure the first indication is
sPeed and thus to
nbnllating appropriate drugs.
presenting signs to
This indication whose
CAREY F. COOMBS AND C.
only moderately severe moderate doses will suffice. l'?r example, people who are not so ill but that they can attend an out-patient department take 15 minims of the tincture or a pill containing one or two grains of the powdered lea*' But it is for those who, when they every four hours. come under treatment, are urgently and even dangerously ill, that we would specially urge the use of digitalis in massif doses. Two or three years ago Eggleston of New began to give the drug in a new way for cases of this kin He showed that it was safe to give the dose which was J11 below toxicity in a single mass. The equation relating are
dose to the
patient's body weight weight the dose would
of average of the tincture.
We have .secured modification of this
is such that for be three
method, followed for
experience of others of ourselves, independently adopted closely simi^1 modifications of the Eggleston method. Our plan 1S get three drachms taken in the first twenty-four ho111"5 results
down the heart rate in lives
shows how this
of this kind. more
have been lost
It is wonderful to see any less thorough treatment. relief afforded to the patient; and this, with reduction the heart and
rates, and increase in the
confidently looked for cases. We split our dose
urine, may be rheumatic a
good method is
and to follow this
intervals of four hours till three drachms in all have taken.
and then resumed
up in various initial dose of one draclun
at a rate of
fifteen minims ever}
This kind of
has been followed in somewhere
yet seen toxic symptoms, vomiting actually checked in massive doses. We wish to lay the. greatest Possible emphasis on this, that the syndrome of auricular cases, and
^lore than % digitalis
feilure constitutes digitalis ; that no n?
absolute indication for the
will take its
other syndrome is anything like
of relief from
use. APRIL 13 14 15
MAY 16 17 18 19 20
21 22 23
24 25 25 27 28 29 30
Heart Pulse /Pulse uncountable) ^
Tincture (3 ' ?f. Digitalis 2