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

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