AURICULAR
Carey F. Coombs,
FAILURE.1
F.R.C.P. Lond.,
M.D.,
Physician (with charge of Ou'-patienis),
Bristol General
Hospital-
AND
C. E. K. Herapath, M.C., M.D. Lond. Assistant
Physician,
Bristol
the heart has to be con first, the effect of the l?sS
The effect of auricular failure sidered from two
on
standpoints;
of the auricular contraction, and abnormal
rhythm
Royal Infirmary.
second,
of auricular failure
the effect of the
on
the
ventricular
contraction. Anatomy
and
Physiology.
The function of the auricles is to act
as
reservoirs for the
ventricles.
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
distends the
certain that the
aorta
a
and
full amount of blood shall be
that
ventricles. on
contra0
maki11^ pumped ^0
^ie every time that Loss of the auricular contraction
pulmonary
ventricles contract. on
already
The auricular
filled ventricles,
account, lead
to
arteries
an
insufficient
The effect of abnormal
rhythms
filling of. of the
aurideS
the ventricular contraction will be considered later. 1
Res^^
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.
Society
iSo
xX^ey
Superior vena cava
S-a node
J
Fig.
Photograph
.
;
???Bight auricle
i.
of heart, showing position of sinu-auricular
node.
Valve
Fig. 2.
?f auri ?t e
0tj'aPh Vent'*CHlnr VeUtr*cu^ar no^e and
block
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
Aversely Aversely
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.
l8l
FAILURE.
AURICULAR
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
where 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
^0r
a
length
right auricle,
of the
vena cava,
superior
and is continued
small distance down the sulcus terminalis.
It is
bedded
composed
of dense fibrous tissue in which
small fine muscle fibres
A
(Fig. 3).
large
are em-
number of
(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
proved
by
from node electrical
to the
to
proved
the
to
path by
auriculo-ventricular that there is
node, and this is said
a
to have been
set out to Three years ago means of serial sections of hearts. we
means.
look for this path by Si* hearts were cut and examined, search
as
published stating
Work has been
direct path
on
place
to us that there was
and the results of this no
direct
path,
but that
the stimulus passes to the A?V node by means of the ordinary auricular muscle, the contraction of the nodal fibres of the
S-A
by direct continuity of fibres. All the muscle fibres leaving the S-A node can be traced musculature. away into the ordinary auricular node
There is
spreading
no trace
auri.cular walls. tion from the
to the auricles
of any specialised muscle path through the We also found that the spread of contrac-
right
to the left
auricle took
place by
two
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
XI i
over
m No. 154.
the tail of 1^
Secondly, a broad band of the right auricular appendix,
182
DRS.
swept
backwards and
CAREY F. COOMBS AND C. E.
the left auricle. in the
right
passed straight
Thus
auricle
see
we
causes
K.
HERAPATH
the back of
across to
how the contraction
starting
the contraction of both chambers.
passes from the sinus node into the auricular muscle of both auricles,.and by this means
therefore,
The contraction wave,
reaches the base of the inter-auricular septum, where it meets another collection of cells termed the auriculoThis is situated
ventricular node.
on
the
right
surface of
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
sinus
fibrous tissue.
many nerve fibres passing into it, cells can be seen amongst the muscle
There
are
and many ganglion fibres. From this node the
bundle of fibres passes across side of the inter-ventricular septum towards the
right
pars
membranacea
branches ;
the
scpti. right one
the left branch
septum,
a
At this part it divides into two runs down the right side of the
pierces
the
septum
and
runs
down
its left side. These pass down to the apex and then subdivide into branches, which are distributed to the muscle
innumerable fibres of the
ventricles,
and
are so
arranged
fibres of the ventricles contract in
mencing
at the apex and
a
that the
muscle
definite order, com-
gradually reaching
the base.
This sequence of contraction is only possible when the stimulus for contraction reaches the ventricular muscle by of the bundle.
means
ates
In certain
cases
in the ventricular muscle itself
other, and in this occur
case
the stimulus
on
one
side
originor..
the
the spread of contraction does not
in this sequence, with the result that the power of the
contraction suffers. This different
type
of contraction evokes If
we
cardiographic tracing (Fig. 7),
we
kind of
electro-cardiogram.
look at
a
a
particular
normal electro-
find that the waves, ?r
Figs. 5 and 6.
^0^'~Powey
~?u'~power photomicrographs exhibiting the muscular bands which join the lu>o auricles.
AURICULAR FAILURE.
P R
183
T
Fig. 7. Normal
PR
T
electrocardiogram electrocardiogram,
RT
PR
T
Fig. 8.
,
Llecir0C( ?^cci'?cardiogram cardiogram showing
in the ven'.vicles. ven'.ricle premature beats R'T' arising in
Fig. (j.
Electrocardiogram showing
auricular
nr
fibrillation.
mrmnynr
r
mnr
rrrrnrnryi
v""\-rrrv
tnrvnnr*/
Venous pulse (jugular)
VJk kfV^o ad,al pulse Pol
?
6
?
' t
/l
??
c
.
ftJvu ^
."iVn'^Ni
aaKJW^n/ Rate
'||5
permm
^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
/
KRS.
184
.complexes
CAREY F. COOMBS AND C. E.
as
they
called,
are
K.
HERAPATH
of three kinds
are
"
:
P," which
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
contraction,
and
"
"
T
"
"
represents
the end of ventricular contraction ; a normal R and T denotes that the ventricular contraction was called forth by a
is
reaching the ventricle by the bundle, and is what a supra-ventricular complex. An abnormal
stimulus called
ventricular contraction a
very different
In
arising from the complex (see Fig. 8).
Symptom
and
Signs
tracing
from
a
a
of
ventricular
complexes
of stimuli
way. it is
It is also
are
passing
seen
(Fig. 9),
i-e'
fibrillation, it is seen that the of the supra-ventricular type>
the ventricular contractions
means
gives
Auricular Failure.
of auricular failure
case
after the onset of auricular therefore
muscle itself
are
originated by
down the bundle in the
that the
"
P
"
wave
normal
is absent, but
that
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
replaced by
"
arrhythmia associated,
named as
venous curve,
movements
by them they showed,
i.e.
were
one
"
total
"
"
or
with the ventricular form
from which the usual
absent.
waves were
By
caused by
these
successive
auriculo-systohc
this further W the were found iu
Lewis carried
showing that small irregular waves electro-cardiogram of total arrhythmia, "
perpetual," anf Failure.
F.,
A few
20.
Malignant
endocarditis supervening on chronic cardiac rheumatism.
days.
Sinn-Auricular Node.
No
abnormality.
|
|
Ventricular
Auricular Muscle.
Muscle.
Slight cloudy swelling and fatty change.
Slight cloudy swelling and fatty change.
A-V Connections.
Nil except usual vascular changes of chronic cardiac rheumatism in neighbourhood of central fibrous
body. 7A
Chronic M., 30. rheumacardiac tism with mitral stenosis, etc.
Months
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
hemorrhage.
Marked
change.
fatty
I No abnormality :
noted.
No
abnormality
Remarks.
No active in Ha mmation of myocardium
AURICULAR
General Features of Case.
FAILURE.
Ref No
CuMi'LETE Examinations.
189
((c)
DURING LIFE.
190 82
Chronic M., 50. cardiac rheumamitral ; ti s m stenosis.
Advanced
abnormality.
fatty
Years.
Fatty change.
No
change.
No
Advanced
abnormality.
change.
fatty ! Fatty change j only slight in
No
i
left ventricle.
Definite fatty change. Cloudy also swelling
One
i
,
Chronic F., 57. cardiac rheumatism ; decrescent cardiosclerosis ; recent endocarditis.
A-V
Connections.
abnormality.
Definite
Passive hyperemia. Hypertrophy of A. to
Days only
fatty
change.
node.
noted wall.
in L.V. Inflam-
matory
especially
abnormality
large lymphocytic focus in early part of bundle.
foci, in
I?V septum.
Chronic F., 5. cardiac rheumatism ; acute terminal carditis ; chronic interstitvcvl nephritis.
Months a' least.
Normal ; right auricle cavity closely approaches
i \
Remarks. Old litis
glomeru-
noted
kidney.
j 95
Ventricular Muscle.
it.
\
Advanced fatty in left auricle. Definite fatty change in right auricle.
change
1
Definite fatty in both ventricles.
change
in
DRS.
Probably
of recent onset.
Muscle.
F. CAREY
]
No
Auricular
Node.
C. AND COOMBS
i ,
I -. 55Chronic cardiac rheumatism with mitral and aortic fibrosis, and recent mitral endocarditis of doubtful character.
Sinu-Auricular
E.
|
Duration jf Failure.
K.
j
General Features of Case.
Normal.
HERAPATH
Kef. j No.
Chronic / Weeks. rheuma- / Terminal / with / influenza F., 4/. cardiac tism.
bronchopneumonia./
/ Relative
decrease
show
endothelial
of
/ 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
Chronic obliter-
/ ative reaction in f artery to node,
reaction.
Chronic M., .29. rheumacardiac tism, sudden death.
Months at least.
no
INI 17. Acute rheumatic carditis terminating cardiac rheu matism.
About year ?
No
67
tism.
heart,
Arterial
Slight fatty
hypertrophy. Slight fatty change in
change.
muscle fibres.
Chronic
Over
rheuma-
year.
Advanced
No abnormality, except of doubtful increase connective tissue at lower pole.
Not examined.
Fatty
mitral
Fatty
change,
advanced
in
places. change,
advanced
in
places.
Obi iterat ive in11 a m m atory changes in vessels to node.
No gross fatty changes. Many inflammatory
Acute obliterative changes in arterioles.
Definite
Not examined.
foci.
Partial Examinations. I
Advanced
i
change.
C011-
Advanced
fatty
1
Very large
fatty
change.
Nil, except acute proin liferative reaction artery to node.
(b) F., 21. cardiac
Fibres vary much in size.
abnormality.
AURICULAR
Yean
FAILURE.
Chronic rheumamatism with mitral and tricuspid stenosis.
F., 34. cardiac
fatty
change.
fatty
tissue nective increased.
fibrosis. CardioM., 59. sclerosis with hyperpiesis and terminal streptococcic endocarditis.
Weeks or months.
Not examined.
No gross changes.
Not examined.
change.
19I
3*
i
M., 5.
ting
changes.
Fulminarheumatic
Saturated with in flam matory reaction.
Partially examined ; inflammatory
Days.
some
infdtration.
carditis.
Chronic F., 31. rheumacardiac tism, with mitral
Not examined.
More thar a
Cloudy swelling
and segmentation.
year.
and inflamreactions,
Widespread intense
matory
Partially
amined.
ex-
Some
inflammatory
reaction.
Cloudy swelling
Not examined.
Definite
fatty
Not examined.
fatty
Not examined.
fatty
Not examined.
and segmentation.
stenosis ; terminal endocarditis. Chronic F., 41. rheumacardiac tism with mitral
Advanced
Not examined.
More thai a
fatty
change.
year.
?change.
E.
69
stenosis. M., 50.
Alcoholic of
Partially examined. change.
Months.
degeneration myocardium. 64
Child
dying diphtheria.
of
192
Not examined.
nodules.
stenosis.
46
No gross
change. One or two submiliary
A-V Connections.
I)RS.
|
Advanced fatty
Not examined.
5-io years.
Ventricular Muscle.
F. CAREY
Chronic I7., 48. cardiac rhenmatism with mitral
Auricular Muscle.
Node.
C. AND COOMBS
68
Sinu-Auricular
Duration )f Failure.
Not examined.
Days.
Chronic 1 Years. 66 I M., 48. rheuma- \ \ cardiac \ tism, mitral steno- \ \ \ sis, etc.
Not examined. \
No
Advanced
fatty
change. Advanced
fatty change a n d cloudy swelling. Advanced
\ change,
fatty
etc.
Definite
change. Definite h ange
c
a n
d
cloudy swelling. Slight or definite
\ iatty change.
Not examined.
K.
General Features of Case.
HERAPATH
Kef. No.
difference ln
between
AURICULAR
FAILURE.
193
and
complete
examination is that
partial
the latter serial sections
were cut
n?de and the auriculo-ventricular
of the sinu-auricular whereas in
connections,
the partial examinations these series were omitted. In only one case of auricular failure that was
Mvestigated
fully
there any lesion of the sinu-auricular node that could conceivably have put an end to its effective
action
;
was
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
destroyed
and not
Mstance
to
think
that
the
hemorrhage
scattered it is not that
had
part of the sinu-auricular node was a consequence, cause, of auricular failure. Apart from this one
a
a
the node
was
change.
entirely
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
deterioration
histological accepted
so
extreme that it
methods.
The
was
demonstrable
fatty change
that
by
routine
has
been
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
Jym?
as
near the
clearly,
tip
in others the Mam auricular walls.
?ells
appendices displayed this most change was at its maximum in the
of the
Shrinkage
of the decadent muscle
brings into unnatural prominence the delicate interstitial
-trorna
of
entricles,
the on
cTe
auricular the
other
walls.
hand,
In
the
changes
barely discernible, and only Patches. This contrast between the decadence
til e
walls such
of as
the these
in small and scattered
Mtegrity
e^ef
if
of the ventricular walls is
of the auricles and
into greater with two other sets of facts ; first,
brought
js compared Nlth the absence of any such marked contrast from the
DRS.
19\ 26
"
CAREY F. COOMBS AND C. E. "
control
HERAPATH
alluded to above, and second, with
1
specimens
K.
the freedom of the auricular walls from inflammatory lesions in
of
cases
cardiac
acute
infection.
To
each
of
these
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
in
In
life.
these the
auricular
muscle was
grossly degenerate, much more so than that of the ventricles, showing that in such cases this contrast becomes apparent even
before the
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
surpassed
diffuseness and in
inflammatory
Yet both of these
intensity.
exceptions
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
"
"
fails
and not the sinu-auricular node ;
and, second, that failure is usually the tion
of
the
muscle
cell
itself.
deterioration may be is well
photomicrographs (Figs.
11
Prognosis Auricular
seen
deterioraprofound that
outcome of
How in the
accompanying
and 12).
and
Treatment.
failure, being practically always associated organic change, brings into any case of heart
with advanced
gravity ; first, because it is itself strong evidence of serious myocardial deterioration ; second, a because its rapid irregular rhythm lays on the ventricle disease
new
an
burden.
element of
It is
auricular failure
on
this second fact that the
largely
turns.
If the ventricles
prognosis are
of
already
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.
to
easl?-s _
Figs,
z"n
ii ii
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.
er upper
from IF ^Hpht>C^S rU?nkSA0m and
"
a a
Rheumatic Heart Disease,"
Sons Ltd.)
a a
low-power
kindly
lent lent
by by
high-power
Messrs. Messrs.
John John
AURICULAR FAILURE.
IC)5
*
rl
Jt
seased and ineffective when the auricular functions fail, is unlikely that treatment will afford a large measure of
rehef.
Some relief there will be if,
*reatment,
the auricles
fail'
are
under
appropriate
induced to beat regularly,
or, .
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
the
most
striking opportunities
of
therapeutics one triumph in the whole
of medicine.
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
^
niany
years in
^susceptible
^stances,
Q0D 1
comparative
of relief ;
the
and this is
of which
drugs ineffective,
prove
comfort.
but
partly because,
we are
more
But others
wont to
in
expect
a
a
are
few
good
often because the ventricles
So
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.
^any
other elements may be introduced into a discussion prognostic significance of auricular failure ; but we
^ the
V]sll the
tn
lmit ourselves here to
there e
is
?
r
three
are
are to
principal
a
statement of
-aC C^Sease
belief
sets of facts to be considered
forecast truly the expectations of
discovered.
our
a
case
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
Poetically
cardUr^U^r ac
js
e
the behaviour of the
third, all
cases
of cardiac disease
^a^ure the first indication is
sPeed and thus to
hy the
nbnllating appropriate drugs.
use
of
lengthen
diastole.
For
patients
digitalis.
auricle
presenting signs to
reduce the
This indication whose
symptoms
196
DRS.
CAREY F. COOMBS AND C.
*E.
HERAPATH
K.
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
remarkable
really
or
four
drach111 from
results
method, followed for
adu^
an
tltfee
or
two
^l0'
in the
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
years ;
The
paralleled
chart
accompanying
brought have
seen
dozen
(Fig. 13)
down the heart rate in lives
prolonged
instances,
for
that would
a
shows how this
one case
year
or
indubitably
of this kind. more
least
in at
unde
have been lost
It is wonderful to see any less thorough treatment. relief afforded to the patient; and this, with reduction the heart and
pulse
rates, and increase in the
confidently looked for cases. We split our dose
urine, may be rheumatic a
good method is
to
give
an
majority
a
t
and to follow this
by
half-drachm
1nqeSat b&e
?
intervals of four hours till three drachms in all have taken.
The
drug
and then resumed
is
stopped
the
^^
?
tincture,
01f
^
up in various initial dose of one draclun
?
the
in
output
the ^
for
at a rate of
twenty-four
hours
or
m0re>
fifteen minims ever}
^ ^
AURICULAR FAILURE.
hours.
This kind of
about fifty
plan
197
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
once
we
feilure constitutes digitalis ; that no n?
we
have
have
an
never
seen
absolute indication for the
other
drug
will take its
other syndrome is anything like
use
of
and that
place,
of relief from
so sure
use. APRIL 13 14 15
MAY 16 17 18 19 20
21 22 23
24 25 25 27 28 29 30
7
2
3
4
5
6
Heart Pulse /Pulse uncountable) ^
3
70
2
50
40
Tincture (3 ' ?f. Digitalis 2
lurachms)
k Fig.
13.
M>r.9^art mn