CIRCULATIONAn Officical Journal of the American Heart Association

VOLUME XXVJanuary-June 1962

AMERICAN HEART ASSOCIATION, INC.

do"

CIRCULATIONAN OFFICIAL JOURNAL OF THE AMERICAN HEART ASSOCIATION

EDITOR-IN-CHIEFHi MAN L. BLUMGART, Boston, Mass.EDITH E. PARRIS, ASSISTANT EDITOR

ASSOCIATE EDITORSSTANFORD WESSLER, Boston, Mass.PAUL M. ZOLL, Boston, Mass.

EDITORIAL BOARDWRIGHT R. ADAMS, Chicago, 111. Louis N. KATZ, Chicago, Ill.E. COWLES ANDRUS, Baltimore, Md. JOHN D. KEITH, Toronto, CanadaBENJAMIN M. BAKER, Baltimore, Md. JOHN W. KIRKLIN, Rochester, Minn.WILLIAM B. BEAN, Iowa City, Iowa CHARLES E. KoSSMANN, New York, N. Y.STANLEY E. BRADLEY, New York, N. Y. HOWARD P. LEWIS, Portland, Ore.EUGENE BRAUNWALD, Bethesda, Md. JERE W. LoRD, JR., New York, N. Y.BERNARD B. BRODIE, Bethesda, Md. H. M. MARVIN, New Haven, Conn.HOWARD B. BURCHELL, Rochester, Minn. VICTOR A. MCKUSICK, Baltimore, Md.ANDRt COURNAND, New York, N. Y. THOMAS M. MCMILLAN, Philadelphia, Pa.MICHAEL E. DE BAKEY, Houston, Texas FELIX E. MOORE, Ann Arbor, Mich.PAUL M. DENSEN, New York, N. Y. DAVID F. OPDYKE, Jersey City, N. J.ALBERT DORFMAN, Chicago, Ill. LYSLE H. PETERSON, Philadelphia, Pa.CHARILES T. DOTTER, Portland, Ore. OSCAR D. RATNOFF, Cleveland, OhioLUDWIG W. EICHNA, New York, N. Y. MINDEL C. SHEPS, Pittsburgh, Pa.J. RUSSELL ELKINTON, Philadelphia, Pa. SOL SHERRY, St. Louis, Mo.A. CARLTON ERNSTENE, Cleveland, Ohio ALBERT SJOERDSMA, Bethesda, Md.A. STONE FREEDBERG, Boston, Mass. HOWARD B. SPRAGUE, Boston, Mass.DAVID G. FREIMAN, Boston, Mass. FREDRICK J. STARE, Boston, Mass.HARRY GOLDBLATT, Cleveland, 07io EUGENE A. STEAD, JR., Durham. N. C.ROBERT P. GRANT, Bethesda, Md. SAMUEL A. TALBOT, Baltimore, Md.HANS H. HECHT, Salt Lake City, Utah HELEN B. TAUSSIG, Baltimore, Md.EDGAR A. HINES, JR., Oteen, N. C. LEWIS THOMAS, New York, N. Y.SIBLEY W. HOOBLER, Ann Arbor, Mich. EARL H. WOOD, Rochester, Minn.FRANKLTN D. JOHNSTON, Ann Arbor, Mich. IRVING S. WRIGHT, New York, N. Y.

D. B. ZILVERSMIT, Memphis, Tenn.

PUBLICATIONS COMMITTEE, AMERICAN HEART ASSOCIATIONCHARLES A. R. CONNOR, Chairman

New York, N. Y.WRIGHT R. ADAMS ROBERT H. FURMAN SIMS GAYNOR

Chicago, 111. Oklahoma City, Okla. New York, N. Y.

HANS H. HECHT RALPH E. KNUTTI PAUL H. LAVIETESSalt Lake City, Utah Bethesda, Md. New Haven, Conn.

PAUL MONTGOMERY W. HENRY RUSSELLNew York, N. Y. Mount Kisco, N. Y.

GEORGE E. WAKERLIN, Medical Director, American Heart Association, New York, N. Y.E. COWLES ANDRUS HERRMAN L. BLUMGART CARL F. SCHMIDTBaltimore, Md. Boston, Mass. Philadelphia, Pa.

ii

7LONDON, LONDON

producing changes in the T wave alone sug-gests that this is a possibility. In addition,compression of the subepicardial layers dueto sudden change in intrapericardial pressurenmay cause local ischemic changes. The situa-tion in acute hemopericardium is in markedcontrast to the gradual accumulation of fluidand corresponding electrocardiographic find-ings in inflamnmatory pericarditis with effusionor in hemorrhagic pericarditis associated withinyocardial infaretion. In the latter situation,slow accumulation of fluid, even though hem-orrhagic, follows local inflammatory changesin the pericardial or subepicardial layers ofthe heart. The typical signs of acute pern-carditis, gradual flattening of the T waves,and decrease in amplitude of the QRS conm-plexes, then follow. It would appear there-fore that a prerequisite for the appearanceof electrocardiographic signs of acute hemo-pericardium is a nornmal pericardium. Itshould be noted in all of our cases of hemo-pericardium secondary to rupture through amyocardial infaretion (figs. 6, 7, and 8) thatthere was no histologic evidence of pericar-ditis. An additional factor in production ofthe characteristic sign is sufficient survivaltime. Case 4 (fig. 4), for example, had anormnal tracing on admission but electrocar-

diographic findings of acute hemopericardiuniappeared in 3 hours and death occurred 1hour later.

ConclusionsThe electrocardiographic correlations in

eight autopsied cases of acute hemopericar-diuni secondary to rupture of the heart oraorta are presented.The characteristic electrocardiogram pre-

sents as an acute abnormality with tall andofteni peaked T waves in the precordial leads.This occurs despite depression of the ST seg-ment or prior configuration of the T wave,eveln causing reversal of previously negativeT waves.The occurrence of this electrocardiographic

finding in acutely ill patients should suggestthe presence of acute hemopericardium withits therapeutic implication.

References1. LONDON, S. B., AND LONDON, R. E.: Production

of aortic regurgitation by unperforated sinusof Valsalva aneurysm. Circulation 24: 1403,1961.

2. HELLERSTEIN, H. K., AND KATZ, L. N.: The elec-trical effects of inajury at various myocardiallocations. Am. Heart J. 36: 184, 1945.

3. LEPESCHKIN, E.: Modern Electrocardiography.Baltimore, The Williams & Wilkins Company,1951, p. 457.

.ii2Galvani and the Electrophysiology of Muscular Contraction

Galvani called attention to the incantesimo of the heart, a momentary cessation ofheart pulsations which he noted in frogs when a needle was inserted into their spinalcanals. He saw for the first time, the phenomenon of inhibition, the theory of whichlater became so important in physiology and psychology.-Giulio Pupilli. Commentaryon the Effect of Electricity on Muscular Motion. BY LUIGI GALVANI. Translated byRobert Montraville Green, M.D., Cambridge, Massachusetts, Elizabeth Licht, Publisher,1953, p. xvii.

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ATRIAL TACHYCARDIA AND DIGITALIS

year's experieniee. New England J. Med. 260:301, 1959.

5. LowN, B., WYATT, N. F., AND LEVINE, H. D.:Paroxysmial atrial tachyeardia wvith block. Cir-culation 21: 129, 1960.

6. ORAM, S., RESNEKOV, L., AND DAVIES, P.: Digi-talis as a cause of paroxysmal atrial tachy-cardia with atrioventricular block. Brit. M. J.2: 1402, 1960.

7. HARRIS, E. A., JULIAN, D. G., AND OLIVER, M. F.:Atrial tachyeardia with atrioventricular blockdue to digitalis poisoning. Brit. M. J. 2: 1409,1960.

8. BARKER, P. S., WILSON, F. N., JOHNSTON, F. D.,AND WISHART, S. W.: Auricular paroxysmaltachyeardia with auriculoventricular block. Am.Heart J. 25: 765, 1943.

9. DECHERD, G. M., JR., HERRMANN, G. R., ANDSCHWAB, 1E. H.: Paroxysmal supraventriculartachyeardia with a-v block. Am. Heart J. 26:446, 1943.

10. FREIERMUTH, L. J., AND JICK, S.: Paroxysmalatrial tachyeardia with atrioventricular block.Am. J. Cardiol. 1: 584, 1958.

11. KENNAMER, R., AND PRINZMETAL, M.: The cardiacarrhythmias. New England J. Med. 250: 509,1954.

12. EVANS, W.: The unity of paroxysmal tachyeardia

and auricular flutter. Brit. Heart J. 6: 221,1944.

13. CAMIPBELL, M.: Paroxysmal tachyeardia and2:1 heart block. Brit. Heart J. 7: 183, 1945.

14. SINioNsoN, E., AND BERMAN, R.: Differentiationbetween paroxysmal atrial tachyeardia withpartial a-v block and auricular flutter. Am.Heart J. 42: 387, 1951.

15. MACKENZIE, J.: Digitalis. Heart 2: 273, 1910-11.16. HEYL, A. F.: Auricular paroxysmal tachyeardia

caused by digitalis. Ann. Int. Med. 5: 858,1932.

17. SCHWARTZ, W. B., AND LEVINE, S. A.: A caseof paroxysmal auricular tachyeardia with blockpresent almost continuously for twenty-fiveyears. Circulation 1: 936, 1950.

18. CLAIBORNE, T. S.: Auricular tachyeardia withauriculoventricular block of 12 years durationin a 16-year-old girl. Am. Heart J. 39: 444,1950.

19. SHACHNOW, N., SPELLMAN, S., AND RUBIN, I.:Persistent supraventricular tachyea±-dia: casereport with review of literature. Circulation10: 232, 1954.

20. SPRITZ, N., FRIMPTER, G. W., BRAVEMAN, W. S.,AND RUBIN, A. L.: Persistent atrial tachy-cardia with atrioventricular block. Am. J.Med. 25: 442, 1958.

Thomas Sydenham1624-1689

Thomas Sydenham was not regarded as a great man in his own time. Born in 1624he had as contemporaries iniany medical nien of greater renown in their day, nmen wholorded it over him, but whose very names posterity has not remembered. Of his medicalcontemporaries only William Harvey and John Locke are today held in high esteem.Syndenham was a modest man like all the truly great, and cared little for the plauditsor the scoffing of men. No one would be more amazed than he himself could he knowhow the scientific world today regards him or with what universal acclaim it celebratedthe tercentenary of his birth.-DAVID RIESMAN, M.D. Thomas Sydenham, Clinician.New York, Paul B. Hoeber, Inc., 1926, P. 11.

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MICHAEIS

AcknowledgmentI wish to thank Dr. Jessica H. Lewis for re-

viewing this manuscript and for her helpful sugges-tions, and Drs. Albert Amshel, Leslie Morris, SidneyRosenberg, Irving Stutz, and Marvin Silverblatt,for permitting me to use records of their patientsfor this article. Cases 1 to 4 are from the MontefioreHospital, Pittsburgh, Pennsylvania; Case 5, OaklandV. A. Hospital, Pittsburgh, Pennsylvania.

References1. STERN, S., AND DRESKIN, 0. H.: Bleeding from

occult disease during anticoagulant therapy.Angiology 8: 337, 1957.

2. NICHOL, E. S.: The risk of hemorrhage in an ti-coagulant therapy. Ann. Western Med. &Surg. 4: 71, 1950.

3. NICHOL, E. S.: Personal experiences with anti-coagulants for coronary atherosclerosis. SYrn-posium on Anticoagulants. Circulation 19:129, 1959.

4. EDWARDS, E. A.: Migratory thrombophlebitisassociated with carcinoma. New England J.Med. 240: 1031, 1949.

5. BARKER, N. W.: Thrombophlebitis complicatingsystemic and infectious diseases. Proc. StaffMeet., Mayo Clin. 11: 513, 1936.

6. GOODMAN, D. H.: Early clue to visceral carci-noma-hemorrhage after intravenously givenWarfarin. J.A.M.A. 166: 1037, 1958.

7. HEMLEY, S. D., ARIDA, E. J., AND SCHWARTZ,M. J.: Occult lesions discovered during anti-coagulant therapy. J.A.M.A. 177: 153, 1961.

What the next turning point of our understanding of disease may be is a matter forsurmise and speculation. I would hazard the guess that the next interpretation of diseasewill in some way involve an increased emphasis on the ecological approach. Ecology isthe branch of biology which deals with the mutual relations between organisms and theirenvironment. The more we learn about living creatures, whether plant or animal, themore impressive becomes the evidence of the interrelatedness of living things. Theyobviously live on each other as predators or as parasites. Somnewhat less obviously,they live with each other in varying degrees of mutual aid and dependence. For all itscomplexity, ecology provides a fascinating kind of understanding of what goes on.Perhaps one of the first powerful results of interpreting disease as an ecologist would

regard it would be a greater interest in convaleseence and rehabilitation. Surely, it isno loss to medicine if the ecologist joins hands with the economist and the humanist inholding that the return to wage earning and independence forms part of the cure. Indeed,we are beginning to see rehabilitation as a growing fringe of Great Medicine.-ALANGREGG, M.D. Challenges to Contemporary Medicine, New York, Columbia UniversityPress, 1956, p. 38.

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CONDUCTION IN PATENT DUCTUS ARTERIOSUS

AcknowledgmentWe are indebted to Dr. Demetrio Sodi-Pallares

for his helpful criticism in the preparation of thispaper. We wish also to express our appreciation toDr. Helen B. Taussig for her observations andsuggestions.

References1. CABRERA, E., DE MURA CAMPOS, C., AND FERNAN-

DEZ CAMINERO, G.: La persistencia del con-ducto arterioso desde un punto de vistaelectrocardiografico. Arch. Inst. cardiol. Mdxico22: 151, 1952.

2. SODI PALLARES, D., AND MARSICO, F.: The im-portance of electrocardiographic patterns incongenital heart disease. Am. Heart J. 49:202, 1955.

3. MinowsKI, M., POLANSKY, B. J., ARIZA HERRERA,D., MEDRANO, G. A., AND CISNEROS, F. A.:First degree atrioventricular block. An analysisof 500 cases. To be published.

4. KOSSMANN, C. K.: The normal electrocardio-gram. Circulation 8: 920, 1953.

5. Report of Committee on Electrocardiography,American Heart Association: Recommendationsfor standardization of electrocardiographic andvectorcardiographic leads. Circulation 10: 564,1954.

6. ASHMAN, R., AND HULL, E.: Essentials ofElectrocardiography. Ed. 2. New York, TheMacmillan Company, 1944.

7. MIROWSKI, M.: Diagnostico cualitativo y cuanti-tativo del bloqueo A-V de primer grado. Unnuevo indice para valorar la conduccion auric-uloventricular. Arch. Inst. cardiol. M6xico 31:99, 1961.

8. SODI PALLARES, D.: New Bases of Electro-cardiography. St. Louis, The C. V. Mosby Co.,1956.

9. TAUSSIG, H. B.: Congenital Malformation ofthe Heart. New York, The CommonwealthFund, 1947.

10. BURCHELL, H. B1., Du SHANE, J. W., ANDBRANDENBURG, R. O.: The electrocardiogramof patients with atrioventricular cushion defects

(defects of the atrioventricular canal). Am.J. Cardiol. 6: 575, 1960.

11. BEDrORD, D. E., PAPP, C., AND PARKINSON, J.:Atrial septal defect. Brit. Heart J. 3: 37, 1941.

12. CABRERA, E., ACOSTA, A. R., AND DRAYER, A.:Correlacion electrocardiografica y hemodinamicade la comunicacion interauricular. Arch. Inst.cardiol. Mexico 28: 537, 1957.

13. VIZCAINO, M., VAQUERO, M., AND PELLON, R.:Comunication interauricular. Estudio de 20casos. III Congreso cardiologico interamericano,Chicago, U.S.A., 1948.

14. MARSICo, F., PENALOSA, D., TRANOHESI, J.,LIMoN LASON, R., AND SODI PALLARES, D.:The electrocardiogram in ventricular septaldefect. Scalar and vectorial analysis of thirty-two cases. Am. Heart J. 49: 188, 1955.

15. MASSIE, E., AND WALSH, T. J.: Clinical Vector-cardiography and Electrocardiography. Chicago,The Year Book Publishers, 1960.

16. MEDRANO, G. A.: Personal communication.17. MIROWSKI, M., AREVALO, F., AND ROMERO, A.:

Estudio estadistico del comportamiento delindice de P-R en los sujetos normales y enalgunas cardiopatias congenitas. Arch. Inst.cardiol. Mexico 31: 186, 1961.

18. ESPINO VELA, J.: Malformaciones cardiovas-culares congenitas. Instituto Nacional de Car-diologia, Mexico, 1959.

19. COURNAND, A., BALDWIN, J. S., AND HIMMEL-STEIN, A.: Cardiac catheterization in congenitalheart disease. A clinical and physiologicalstudy in infants and children. New York,The Commonwealth Fund, 1949.

20. SILVER, A. W., KIRKLIN, J. W., ELLIS, F. H.,JR., AND WOOD, E. H.: Regression of pulmo-nary hypertension after closure of patentductus arteriosus. Proe. Staff Meet., MayoClin. 29: 293, 1954.

21. AREVALO, F. B., URIBE, G. R., ROMERO, A., AND

CISNEROS, F.: El "indice de P-R" (conduc-cion A-V) en la comunicacion interauricular.Arch. Inst. cardiol. M6xico 31: 455, 1961.

Tt2Care more particularly for the individual patient than for the special features of the

disease.-SIR WILLIAM OSLER. Aphorisms From His Bedside Teachings and Writings.New York, Henry Schuman, Inc., 1950, p. 93.

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CHARMS, GIVERTZ, TOSHIHIKO

13. CHARMS, B. L.: Primary pulmonary hyperten-sion: Effect of unilateral pulmonary arteryocclusion and infusion of acetylcholine. Am.J. Cardiol. 8: 1 and 94, 1961.

14. CHIDSEY, C. A., III, FRITTS, H. W., JR., ZOCCHE,G. P., HIMMELSTEIN, A., AND COURNAND, A.:Effect of acetylcholine on the distribution ofpulmonary blood flow in chronic pulmonaryemphysema. Malattie Cardiovascular 1: 15,1960.

15. FISHMAN, A. P.: Respiratory gases in the regu-lation of the pulmonary circulation. Physiol.Rev. 41: 214, 1961.

16. HUCKABEE, E.: Spectrophotometrie analysis ofuncontaminated blood for oxyhemoglobin. J.Lab. & Clin. Med. 3: 46 and 486, 1955.

17. VAN SLYKE, D. D., AND NEILL, J. M.: Determi-nation of gases in blood and other solutionsby vacuum extraction and manometric measure-ment. J. Biol. Chem. 61: 523, 1924.

18. BORST, H. G., MCGREGOR, M., WHITTENBERGER,J. L., AND BERGLUND, E.: Influence of pul-monary arterial and left atrial pressures onpulmonary vascular resistance. CirculationResearch 4: 393, 1956.

19. CHARMS, B. L., BROMAIAN, B. L., ELDER, J. C.,AND KOHN, P. M.: Unilateral pulmonaryartery occlusion in man. 2. Studies in patientswith chronic pulmonary disease. J. ThoracicSurg. 35: 316, 1958.

20. RODBARD, S.: Bronchomotor tone, a neglectedfactor in the regulation of the pulmonarycirculation. Am. J. Med. 15: 356, 1953.

21. MIOUNSEY, J. P. D., RITZMANN, L. W., SILVERSTONE, N. J., BRIsCOi, W. A., AND MoLEMORE,G. A.: Circulatory changes in severe pulmo-nary emphysema. Brit. Heart J. 14: 153, 1952.

22. BISHOP, J. M., HARRIS, P., BATEMAN, M., ANDDAVIDSON, L. A. G.: The effect of acetyleholineupon respiratory gas exchange in mitral steno-sis. J. Clin. Invest. 40: 105, 1961.

Kt?

It is impossible to devise an experinment without a preconceived idea; devising anexperiment, we said, is putting a question; we never conceive a question without anidea which invites an inswer. I consider it, therefore, an absolute principle thatexperiments must always be devised in view of a preconceived idea, no matter if theidea be not very clear nor very well defined. As for noting the results of the experi-ment, which is itself only an induced observation, I posit it similarly as a principlethat we must here, as always, observe without a preconceived idea.

In the experimenter, we might also differentiate and separate the man who precon-ceives and devises an experiment from the man who carries it out or notes its results.In the former, it is the scientific investigator's mind that acts; in the latter, it is thesenses that observe and note.-CLAUTDE BERNARD. An Introduction to the Study ofExperimental Medicine. New York, The Macmillan Company, 1927, p. 23.

Circulation, Volume XXV, May 1962

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FISHER, AVILSON, THEILEN

could be found in our hospital ini the lastyears.

Summary and ConclusionsFifty patients with congenital heart disease

in the fifth to eighth decades of life have beenreviewed. Atrial septal defects were the mostcommon lesioiis and were compatible with loniglife. Symptonis may ocecur late but are oftenrapidly progressive. Despite large left-to-right shullts, p-nlmollarv arterv pressures areofteni lnornmal or only mioderately iniereased.Misdiagnoses are common. Atrial septal de-fects are confused mi-ost frequentlv with rheii-imiatic heart disease. A diagnosis of mitralstelnosis or l1iitral ilisnlfficieiiev was muade inover 50 per celit of this group before admis-sionl to our hospital. Somue patients wvith apatent ductuts arteriosus muay survive to oldage. The pullioniarv arterv pressure teiidsto he higher in this group than in those withatrial defects with a similar magnitude ofleft-to-right shunt. Patieiits with iiioderatelvsevere pulmionic steliosis muay be asynipto-niatic. Patients with ventricular septal de-fects show a high attrition rate before 40years of age, and those surviving past 40 seemnto have snmall and dynamiieally insignificaiitlesiolis. Cyaliotic congenital heart disease isvery rare after 40 years of age.Age alone should iiot be a deterrent to sur-

gical correctiomi of congenital heart defects.

Aloderate pulmlonary artery hypertelnsion isnot a contraindication either, and was rever-sible in a nuniber of our patients. In viewof these findings, it would seem inmportant toconsider congenital heart disease in the dif-ferential diagnosis of all patients with sus-pected cardiac disease, even in individuals ofmiddle age anid beyond. An accurate diagnosisshould be sought, sinice surgical correctioiimayx be possible with colisiderable benefit tothe patient.

References1. NADAS, A. S., SCOTT, L. P., HAIlK, A. J., AND

RUTDOLPH, A. M.: SpointaneoIus functionalclosing of ventricular septal defects. NewEngland J. Med. 264: 309, 1961.

2. HARNED, H. S., JR., AND PETERS, R. M.: Spon-taneous closing of ventricular septal defects:Two case reports. Abstract, Circulation 760,1961.

3. ELLIS, F. H., JR., BRANDENBURG, IR. 0., ANDSWAN, H. J. C.: Defect of the atrial septuinin the elderly; report of successful surgicalcorrection in five patienits sixty years of ageor older. New Enigland J. Med. 262: 219, 1960.

4. OICGOON, D. C., SWAAN, H. J. C., BRANDENBURG,R. O., CONNOLLY, D. C., AND KIRKLIN, J. W.:Atrial septal defect: Factors affecting thesurgical mortality rate. Circulationi 19: 195,1959.

5. SOIMMER, L. S., AND VOUDOUKIS, 1. J.: Atrialseptal dlefect in older age groups: Withespeeial referenee to atypical clintical anid elee-trocarcdiographic maniifestationis. Am. J. Cardiol.8: 198, 1961.

The ireater the ignorance the greater the dogmatism.-SiR W ILLIAMI: OSLER. APhorismsFrom His Bedside Teachings an(I writings. New York, Heiryiv Sehuinani, IncG., 1950. p. 88.

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GLEASON, BRAUNWALD

20. MITCHELL, J. H., SONNENBLIcK, E. H., AND

SARNOFF, S. J.: Pulsus alternans: Alternatingend-diastolic length as a causative factor. Fed.Proe. 20: 129, 1961.

21. FERRER, M. I., HARVEY, R. M., COURNAND, A.,A-ND RICHARDS, D. W.: Cardiocirculatory studiesin pulsus alternains of the systemiic andpulmonary circulation. Circulation 14: 163,1956.

22. McINTOSH, H. D.: Discordant pulsus alternans.Circulation 21: 214, 1960.

23. BRAUNWALD, E., FRYE, R. L., AND Ross, J., JR.:Studies on Starling 's law of the heart. II.Determinants of the relationship between leftventricular end-diastolic pressure and circum-ference. Circulation Research 8: 1254, 1960.

24. STRAUB, H.: Dynamik des Herzalternans. Arch.klin. Med. 123: 403, 1917.

Science -Pure and AppliedAnother reward, sometimes bestowed on the worker in science, is that of seeing

during his lifetime the value of his services in the relief of human need. When Davymade discoveries in combustion which enabled him to invent the safety lamp for miners,he knew that toilers in the darkness of the mines would thereby be protected in futuretiines from dangers of violent death. When Faraday, near the end of his life, saw thetower of a lighthouse illuminated by means of a huge dynamo, one of the results ofhis fundamental discovery of electrical induction, he experienced a deep satisfaction inthe thought that it might be the nieans of saving many human lives. And in the realmof medical science, how great must have been the joy of Koch and of Pasteur when,after age-long strivings to solve the mystery of disease, they saw the consequences oftheir research and could realize that in time humanity might no longer be scourgedwith plague and pestilence and driven hopelessly to death because of unknown agentsof infection. Similar satisfactions have doubtless been experienced by the discoverersof means of overcoming diabetes, pernicious anemia, general paresis, and many anotherdisorder.The reward of beholding useful consequences of my own scientific studies cannot be

regarded as great, because oI4ly in the common use of a heavy powder mixed with food-the bismuth meal-to reveal disorders of the digestive tract when it is examined withthe X-rays, have there been clear and definite consequences. In addition there was, tobe sure, some gratification in finding that the co-operative work on wound shock duringWorld War I and later in the Harvard Physiological Laboratory had values for thewounded in World War II. And it is said that our researches on the bodily effects ofemotions have been helpful because they give the doctor pertinent information in ex-plaining to his nervous patients the reasons for their functional disorders. All I cantestify is that in as far as the investigations with which I have been concerned have hadany practical utility, I am- mnuch pleased.-WALTER B. CANNON, M.D. The Way of AnInvestigator. New York, AW. W. Norton & Com-pany, Inc., 1945, p. 213.

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a loud apical systolic murmur. The differen-tial diagnosis and the possibility of correctivesurgery in a patient who survives the aeuteevent are discussed.

AcknowledgmentWe are grateful to Dr. L. Paul Ralph, Grand

Rapids, Michigan, who kindly supplied many of thedetails in eCase 1.

References1. STEVENSON, R. R., AND TURNER, W. J.: Rupture

of a papillary muscle in the heart as a causeof suddenL death. Bull. Johns Hopkins Hosp.57: 235, 193a.

2. DAVISON, S.: Spontaneous rupture of a papillarymuscle of the heart: A report of three casesand a review of the literature. J. Mt. SinaiHosp. 14: 941, 1948.

3. SANDERS, R. J., NEUBUERGER, K. T., AND RAVIN,A.: Rupture of papillary muscles: Occurrenceof rupture of the posterior muscle in posteriorniyocardial infaretion. Dis. Chest. 31: 316,1957.

4. ARVAY, A., AND TAKACSY, L.: A spontanszemolesizomszakadas. Orvosi Hetilap (Buda-pest) 98: 167, 1957.

5. DRENNAN, J. M.: Rupture of papillary musclewith twisting of chordae tendineae. ScottishM. J. 3: 318, 1958.

6. BUTTENBERG, H., AND DOLTER, J.: KlinischerBeitrag zu Infarkt und Ruptur der Papillar-muskeln des Herzens. Ztschr. Kreislaufforsch.48: 117, 1959.

7. STIRLING, G. A., AND LAMBERT, B. F.: Spon-taneous rupture of a papillary muscle of theheart. Brit. Heart J. 22: 594, 1960.

8. COOLEY, D. A., HENLY, W. S., AMAD, K. H.,AND CHAPMAN, D. W.: Ventricular aneurysmfollowing myocardial infaretion: Results ofsurgical treatment. Ann. Surg. 150: 595, 1959.

9. SPALDING, E. D., AND VON GLAHN, W. C.:Syphilitic rupture of a papillary muscle of theheart, Bull. Johns Hopkins Hosp. 32: 30,1921.

10. ASKEY, J. M.: Spontaneous rupture of a papil-lary muscle of the heart: Review with eightadditional cases. Am. J. Med. 9: 528, 1950.

11. FISCHER: Cited by Stevenson and Turner.112. MERkT, F. B.: Observations sur une lesion organi-

que du coeur, par rupture d'une des collonnescharnues du ventricule gauche. J. de med.,chir. et pharmacol., Paris, 6: 587, 1803.

13. SCHWARTZ, H., AND CANELLI, F. R.: Spontaneousrupture of papillary muscle of the left veni-triele: A clinical syndrome. Am. Heart J.40: 354, 1930.

14. WIGGERS, C. J., AND FEIL, H.: The cardio-dynamics of mitral insufficiency. Heart 9:149, 1922.

15. LowRy, F. C., AND BURN, C. G.: Spontaneousrupture of the posterior papillary muscle ofthe heart. Arch. Path. 31: 382, 1941.

16. OSM3UNDSON, P. J., CALLAHAN, J. A., AND ED-WARDS, J. E.: Ruptured mitral chordae tendi-neae. Circulation 23: 42, 1961.

Many think that the expectation of effecting an improvement in the treatment ofdiseases of the heart, is ehimerical.-J. HOPE, M.D. Diseases of the Heart and GreatVessels. London, William Kidd, 1832, p. 19.

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