Recently, a new method of studying cardiac functions through the use of intramural lead electrocardiograms has been introduced. This method is especially useful in analysing local activity of the heart muscles and in studying the propagation process of ventricular activation. In this article, findings of the unipolar intramural lead ECG's at various points in the cannine ventricle, excepting the ventricular septum, under various conditions are reported. The electrodes used in this experiment were specially designed by Toyoshima, each consisting of six fine insulated wires with a small exposed region at each end.As a reference, leads II were always recorded simultaneously with the other six intramural leads.At the instant an electrode was inserted into the heart muscle, a monophasic wave with a significant S-T segment elevation was recorded, but after a few seconds this elevation began to decrease and finally disappeared altogether after several minutes. Slight elevation of the S-T segment occasionally was observed however even after ten minutes, and this slight elevation didn't disappear completely even an hour or more but kept the same elevation magnitude. In the left ventricular free wall, except in the apical region, the recorded ECG'S showed QS, rS, RS and Rs patterns respectively as the electrode moved from the endocardial to the epicardial surface through the ventricular wall, however, in the right ventricular free wall, they showed QS, rS and RS patterns and hardly an Rs pattern even in the epicardial surface. Consequently, the inner halves or more of both ventricular walls corresponded to the QS-zone displaying QS pattern and the remaining portions of the walls, to the RS zone displaying rS, RS, or Rs pattern; but, the ratio of the thickness of the QS zone to its corresponding RS zone was variable according to the portion of the ventricular wall.In order to examine the activation time and the conduction rate of excitation, the time duration from the beginning of the QRS complex to the onset of the intrinsic deflection was measured. In the RS zone in the direction rectangular to the epicardial surface, excitation is transmitted at the rate of 30∼90 cm/sec. from within to without. From the fact that the leads at a given level in the QS-zone showed nearly the same activation time, it was supposed that the Purkinje's network would play an important role in the appearance of the QS pattern in the QS-zone.In the apical region, the ratio of the thickness of the QS-zone to the RS-zone was larger than that in any other portion of the free wall. Although QS waves could be observed throughout most of a papillary muscle, rS waves almost always were recorded in the endocardial part near the head of the papillary muslce. This fact possibly would be responsible for the absence of Purkinje's fibres in such a part of the papillary muscle.When tracings from the infarcted area, experimentally reproduced, were recorded by use of electrodes inserted into the ventricular wall from an epicardial surface where QS or QR pattern was recorded, the following changes were observed.In through-and-through infarction, every lead displayed almost identical QS waves. However, in patchy infarction, occasionally there was a lead showing a qrS or qRS pattern resulting from a living muslce in contact with the electrode. In an infarcted area, the ECG's from a fibrotic area showed neither an injury current nor an ST deviation, and showed a lower voltage than normal.During ventricular fibrillation two types of fibrillation waves were observed. One types showed a synchronization in their rhythms, the other type showed asynchronization to each other.

抄録全体を表示

The author researched the effects of a positional change of the heart on electrocardiograms and vectorcardiograms in a bundle branch block complicated by myocardial infarctions.The heart positions examined in this report were as follows.1) A normal position (somewhat vertical with clockwise rotation).2) Two extreme vertical positions a) with marked clockwise rotation and b) with marked counterclockwise rotation.3) Two extreme horizontal positions a) with marked clockwise rotation and b) with marked counterclockwise rotation.I. In a left bundle branch block complicated by myocardial infarctions, most of the reconstructed electrocardiograms seldom showed the characteristic findings of myocardial infarction as reported by Wilson and many other authors.However, occasionally a deep S wave or an rSr' pattern was seen in Lead I, VL and V₆ as an effect of myocardial infarction in some specific conditions of the heart, i.e., when a heart having anterolateral or anteroposterior myocardial infarction is in a vertical or horizontal position with a marked clockwise rotation, or a heart having posterolateral infarction is in a vertical or horizontal position with marked counterclockwise rotation.In most of the cases of reconstructed vectorcardiograms in a left bundle branch block complicated by myocardial infarction, the characteristic findings of myocardial infarction also were not observed, but the characteristics of a left bundle branch block were able to be observed in any heart position ; however, when the infarcted area of the left ventricular wall displaced to the left as a result of positional alteration of the heart, the QRS loops were recorded displacing markedly to the right.II. The standard limb lead in a right bundle branch block complicated by a left ventricular myocardial infarction displayed the rare type of bundle branch block in all cases except those of anteroposterior, posterolateral and posterior infarction in both normal and vertical hearts with clockwise rotation.Leads VR and V₁ through V₃ showed tall late R waves and lead V₅ showed a deep S wave identical to the findings in an isolated right bundle branch block.The leads facing the infarcted area showed a Q wave, and when the position of the infarcted area was changed due to the rotation of the heart, the leads displaying an infarction Q, changed their position.The precordial leads were more sensitive, to the effects of cardiac rotation around the longitudinal axis of the heart, than the limb leads.When a heart was in counterclockwise rotation, the position of the leads which displayed the Q wave or the tall late R wave displaced to the right and when a heart was in clockwise rotation, they displaced to the left.Independently from the heart position, the initial and mid portions of the reconstructed vectorcardiograms of a right bundle branch block complicated by myocardial infarction, was displaced away from the infarcted area, but the terminal portion of these vectorcardiograms were recorded anteriorly to the right which is characteristic of an isolated right bundle branch block.

抄録全体を表示

Effects of the positional changes on electrocardiograms have been studied by many authors. However many questions still remain unsolved. The reason for this, as Goldberger says, is the difficulty of the determination of the heart position in a living human body.In this report, electrocardiographic changes of the heart under a positional change were studied by means of the reconstruction method of Toyoshima. The four heart positions examined in this article were as follows, extreme vertical and horizontal positions with marked clockwise or counterclockwise rotations respectively.Tne propagation processes of the ventricular activation used in this report were the same as those previously by the author et al. In the blocked heart, two possibilities of the spread of ventricular activation were taken into account, i.e. the anterior wall of the ventricle in the blocked side is activated earlier than the posterior wall of the same ventricle ; the posterior wall of the ventricle in the blocked side is activated earlier than the anterior wall.Of course it is questionable to assume that the heart always takes the same configuration as described in this report and does not show any deformation despite the occurrence of a positional change. However, by making the above assumption one may easily recognize the effect of a positional change without any other factors being involved.The following results were common to both normal and bundle branch blocks.1. The effect of the rotation around the long axis of the heart to the electrocardiogram was larger than that around the antero-posterior axis.2. In a vertical heart, the rotation around the long axis caused a displacement to the right or left of the transitional zone depending upon the counterclockwise or clockwise rotation, but in a horizontal heart, there was no definite change.3. Even in a heart with same position and form, the configuration of the QRS complex and the position of the transitional zone were variable depending upon the pattern of the postulated propagation process of the ventricular activation.4. The results of the reconstruction method were confirmed experimentally in dogs by adjusting the lead-points of the limb leads as analogously as possible to human limb leads.In a normal heart, the axis deviation of the electrical heart axis corresponded with that of an anatomical heart axis when the heart was vertical with marked clockwise rotation, or horizontal with marked counterclockwise rotation. On the other hand these axes did not corresponded with each other when the heart was vertical with marked counterclockwise rotation or horizontal with marked clockwise rotation.In a markedly horizontal heart, the QRS complexes in leads V₅ and V₆ did not always necessarily conform to the qR or Rs pattern, but occasionally to the rS pattern. This unexpected pattern is likely to appear as a result of a rather marked upward displacement of the apex, when the lead-points V₅ and V₆ view the heart from the postero-inferior aspect.In a left bundle branch block, a typical RI and SIII pattern type was observed in hearts having marked counterclockwise rotation rather than in hearts having vertical or horizontal displacements. Even when there was marked clockwise rotation in hearts assuming a horizontal position, the S wave in lead III was not as deep and the R wave in lead I was not as large and both waves indicated the decline of a common type of left bundle branch block. The concordant pattern of a left bundle branch block only could be observed in a heart in the vertical position, especially when the anterior wall of the left ventricle was activated earlier than the posterior wall.In a right bundle branch block, the rare type of an bundle branch block could be observed when a marked counterclockwise rotation of the heart was present.

抄録全体を表示

Results of clinical observations made on 310 cases of arrhythmia absoluta, are as follows : 1) In arrhythmia absoluta, there were 290 cases of auricular fibrillation and 20 cases of auricular flutter.2) In auricular fibrillation there were many cases between the ages of 50 to 69 years, while 80.9% of the total number were over 40 years of age.3) Arrhythmia absoluta was associated most often with arteriosclerotic or hypertensive heart disease, the proportion to the total number of cases was 73%.4) Complication of congestive heart failure was observed in 64% of chronic auricular fibrillation and in 20% of paroxysmal auricular fibrillation.5) There were 34 cases complicated with emboli, 29 of which had emboli in the brain.6) The mortality rate of chronic auricular fibrillation was 11.1% within 6 months, 14.2% within 1 year, 20.0% within 2 years, 27.3% within 3 years, 32.2% within 4 years, 38.3% within 5 years and 50.7% within 6 years.Survival rate was 88.9% within 6 months, 85.8% within 1 year, 80.0% within 2 years, 72.7% within 3 years, 67.8% within 4 years, 61.7% within 5 years and 49.3% within 6 years.Associated diseases, complication of congestive heart failure, formation of T wave and f wave influenced the prognosis in some degree.7) As to the working ability of patients with chronic auricular fibrillation, only 17% were able to work the same as normal subjects.Although including cases taking medication, only about one-half of the cases were working in a normal occupation.8) In 13 cases, several kinds of operations were performed. One case of prostate hypertrophy and one case of gastric cancer with carcinomatous peritonitis died and the remaining 11 cases were operated on successfully.

抄録全体を表示

Electrocardiographic observations in 310 cases of arrhythmia absoluta showed the following results : 1) In 10, 233 cases of electrocardiographic examination, there were 290 cases of auricular fibrillation (2.8%), and 20 cases of auricular flutter (0.7%).2) The f waves or F wave was observed the most visibly in 216 cases in lead V₁, and in 31 cases in lead a VF.3) The formation of f wave was related with associated diseases, and not with the duration of auricular fibrillation, but an irregular rugged form of f wave was found more often in arteriosclerotic or hypertensive heart disease as compared with mitral valvular disease.4) ff interval of auricular fibrillation was 0.10 to 0.15 seconds in 83% of the cases.5) There were 119 cases with abnormal ST segment in chronic auricular fibrillation (48%), and 41 cases of paroxysmal auricular fibrillation (56%), and 11 cases of auricular flutter (55%).6) Abnormal T wave was found in 220 cases of chronic auricular fibrillation (88%), in 29 cases of paroxysmal auricular fibrillation (71%) and in 19 cases of auricular flutter (95%).7) Complication of ventricular premature beats was observed in 23 cases (7.4%) of these arrhythmias. There were 2 cases of auricular flutter complicated with complete AV block.8) Diagnostic criteria of presence of ventricular premature beats in auricular fibrillation was based mainly upon its pause and not upon its coupling.9) When auricular fibrillation converted to sinus rhythm, the cases showed increased voltage, width of P wave, and prolongation of PQ interval, especially in cases of chronic auricular fibrillation.

抄録全体を表示

The author attempted to clarify the differences of the diagnoses between the Grishman's spatial vectorcardiography (G.) and its modification (Gm.), the distortion of vectorcardiography, the relation of vectorcardiography to electrocardiography and the validity of the vectorial interpretation of electrocardiography.Electrodes of the horizontal plane in the latter system were placed at the level of the fifth intercostal space on midclavicular line. Electrode C (-) was placed on the right suprascapular area.Most of the cases with normal electrocardiogram had normal vectorcardiogram by both methods, but Gm. showed more characteristic changes than G. in 3 of 35 cases. Anterior infarction was uncertain in 2 cases out of 4 in G. because the initial portion of the QRS loop did not direct posteriorly, however the initial and the midportion of the centrifugal limb in Gm. directed posteriorly sharply. In the left ventricular hypertrophy with aortic insufficiency the characteristic figure-eight-pattern was seen more frequently in the horizontal plane of Gm.. Also in the left ventricular hypertrophy due to hypertension the QRS loop in the horizontal plane displaced more posteriorly and leftward in Gm.. Initial vector of left bundle branch block directed more sharply posteriorly in Gm. than G. and the rotation of the QRS loop in the horizontal plane was figure-eight-pattern in G. but clockwise in Gm.. It was apparent that the abnormal left ventricular changes were more remarkable in Gm. than G..In the cases suggesting right ventricular hypertrophy clinically and electrocardiographically both methods of vectorcardiography were more superior than electrocardiography and Gm. was able to diagnose more frequently the mild right ventricular hypertrophy. Occassionally mild right venticular hypertrophy in G. changed to the pattern of right bundle branch block in Gm.. Posterior pip in G. was often seen in the cases of mitral valvular disease and pulmonary heart disease but posterior pip in Gm. was considered to be characteristic in pulmonary heart disease.Although these results suggested that Gm. had more distortion than G., Gm. had more superiority in the clinical application.Comparative study of the unipolar chest electrocardiogram and the scalar projection in the horizontal plane of vectorcardiogram was done. The both QRS patterns were concordant to a great extent in most cases. This was also true in the cases with myocardial infarction. The degree of concordance to the electrocardiogram was more excellent in Gm. than G.. But the concordance was poor in the cases with severe right ventricular hypertrophy.According to the above mentioned results, it was concluded that the vectorial interpretation of electrocardiogram was adequate except some cases with severe right ventricular hypertrophy and the vectorcardiogram was more useful than the electrocardiogram in clinical diagnosis. The author proposed the application of Gm. when G. failed to reveal abnormal findings distinctly.

抄録全体を表示

IV) ESSENTIAL HYPERTENSION Renal Function studies (especially renal clearance technique) in essential hypertension have been reported by many investigators. They generally agree that the renal blood flow is within the normal range in many individuals.The author studied the renal functions in 128 patients with essential hypertension. Renal blood flow was reduced in 74 patients (58%). The relationship between renal function and age was as follows : Below the age of 20 years, renal functions were over normal, at the age of 21-30 they were almost near mean normal, and over 31 years they were decreased with the age but the decrease was greater than in normal individuals. Most of the patients with malignant hypertension (primary or secondary) were from 31 to 50 years old.The findings of eyeground examination were compared with renal blood flow. It was found that a correlation existed between renal blood flow and eyeground changes (according to the classification of Keith-Wagener). One of the 17 cases that showed grade I eyeground changes died of cerebral hemorrhage. None of the patients with grade II eyeground changes died. 4 of 18 patients who showed grade III eyeground changes died; 2 patients had renal insufficiency and 2 patients had cerebral hemorrhage. 8 of 10 patients with grade IV eyeground changes died; 3 had renal insufficiency, 2 had cerebral hemorrhage and 3 had heart failure.Furthermore, a relationship between renal blood flow and electrocardiogram was observed. In general, there was parallelism between the myocardial damage and the reduction of renal blood flow.In patients with markedly decreased renal blood flow, it was difficult to decrease the blood pressure by rest, salt restriction or one anti-hypertensive drug, and it was necessary to administer two or more anti-hypertensive drugs.V) ATP-ATPASE SYSTEM According to Maekawa's postulation, the "true cause" of hypertension is the disturbances of ATP-ATPase system, especially the one present in the kidney which releases its ATPase into blood stream.Intravenous injection of ATPase in man could not be performed. Therefore, in this study, the effects of adenosine triphosphate on circulatory hemodynamics were observed, instead.Vasodilatation occurred with increased effective renal blood flow which was measured by PAH clearance. In 3 patients (2 with essential and 1 with renal hypertension), effects of adenosine triphosphate were studied. When 40-48mg ATPNa₄ was injected intravenously, blood pressure decreased markedly and renal blood flow increased during injection in all cases, with a tendency to return to normal during the recovery period. The thiosulfate clearance was increased, too. FF decreased in 1 out of 3 patients and urine flow increased generally.One patient suffering from renal insufficiency in chronic glomerulonephritis was treated with adenosine triphosphate. Under this treatment the blood NPN concentration decreased temporarily, the urine flow increased and the general condition of the patient became better. But at the end, in spite of increased doses of adenosine triphosphate, the patient died. It is assumed that ATPase decreases when reacting with ATP, and that the resulting fall in blood pressure is due to the diminution of ATPase, which is thought to be a pressor substance. Or it is assumed that the depressor effect of ATP is brought about by mere pharmacologic effects on blood vessels or by energysupply of ATP for dilatation of vessels.

抄録全体を表示

Changes in intramural lead ECG's, which follow acute obstruction of the coronary flow, were studied using a specially designed intramural electrode which permitted the operator to record six leads simultaneously.Marked ST deviation, due to local injury was observed immediately after the insertion of the electrode, thus producing a monophasic wave. This injury current receded however after 10 to 20 min. When the ECG became stable but with a slight ST deviation, the coronary artery was ligated and later released. Serial changes in the ECG's were observed when the coronary artery was ligated and later released.The QRS complex in the stable condition showed a QS pattern at the subendocardium (1/3 to 1/2 of the whole thickness) and at outside the subendocardium, rS, RS, or Rs pattern. This observation agreed in principle with the experiments performed by Prinzmetal.In most cases, the ST segments were gradually elevated immediately after ligation, and the ST deviations became maximum after approximately 3 minutes while the QS waves in the subendocardium and the S waves in the subepicardium became small, or disappeared. In some cases the ST elevations continued for quite some time after 3 minutes, and in other cases the ST elevated very rapidly. In the two latter situations, ventricular fibrillation was often induced by releasing ligation or merely by touching the inserted electrode.When the coronary artery was ligated near the base, ventricular fibrillation nearly always occurred and sometimes it occurred even by ligation at the mid portion of the anterior descending branch.From this experiment, it was impossible to decide whether or not the St deviation preceded or followed the T inversion after ligation. Changes, which occurred after the release of ligation, followed the reverse course of those after ligation, i.e. : the ST elevation receded and the QS or S wave became deeper and returned to the initial pattern after approximately 2 to 3 min., but occasionally even in as short a time as 30 seconds. The difference in the amplitude of the ST deviation by ligation between subepicardium and subendocardium was not constant in our experiment. Cases in which the ST deviation was greater in the subendocardium than in the subepicardium were more frequently observed and were in the ratio of 3 to 1 respectively.By means of injecting India ink into the ligated artery, the relationship between the stained portion and the location of the electrode, was investigated and correlated with electrocardiographic changes. The staining of the inner, middle, and outer layers of the cardiac wall and of the endocardium and epicardium was not uniform and in some individual cases quite different : namely, spot-like, patchy, or string-like. In some cases the stain appeared to completely permeate the cardiac wall; however, unstained parts were actually scattered throughout the stained area. On occation the ligation of an artery which did not appear to supply the area where the electrode had been inserted gave the expected results rather than an artery which was thought to supply this area. As Moore found in dogs, the course of the coronary artery was complicated and anastomosing branches were rather well developed; consequently, it was difficult to predict which artery supplied the infarcted area.An ECG recorded from an electrode in the stained area showed a marked ST elevation, whereas the ST deviation was very slight i. e. on an ECG recorded from an electrode in the unstained area. It was clearly recognized that an injured area having a ligation of the coronary artery was clearly distinguished from an uninjured area and the injured area showed ST deviations.The amplitude of the ST deviation varied with size and location of the injured area.

抄録全体を表示

Using rabbit's heart unipolar leads E. C. G. were taken simultaneously over the intra vena cava superior of its initial region and the atrial surface, and calculated the time of activation arrival at different points on the atrial surface, at the same time observing the morphology of the P wave on the E. C. G. led from the surface of the atria.Summary and conclusion of this study are as follows : 1) The form of the P wave in the unipolar lead E. C. G. led from the superior cava venous appendage's angle indicated a negative wave of the QS type and the activation arrival at this point was found to be the earliest point of all on the atrial surface, which made one to assume that this region must be the initial point of activation.2) The activation arrival at points lying along the taenia terminalis from the venous appendage's angle (above mentioned) downward to the right was rapid compared with those at other points on the atrium. Moreover, the form of the P wave at these points in the unipolar lead E. C. G. was found to be of the rS type with predominance of the negativity.3) Despite the fact that the distance between each points on the surface of the right appendage and the head of the sinus node was comparatively small, the activation arrival was late, and the P wave in the unipolar lead E. C. G. taken over those points indicated the RS type.4) Inferring from above facts and the activation times at various points on the atrial surface, it is proper to acknowledge the assumption that the activation of the atrium does not propagate from the head of the sinus node in proportion to distance in diffusiveness, but is carried out through some definite formation.II. In experiments with eight rabbits, the author recorded the E. C. G. intra atrial unipolar lead and the standard limb lead II simultaneously after injuring different points at localities in the atrial wall and the atrial septum thrusting them with a pointed knife through the atrial wall or the appendage, and studied how relationships are there between the injured points and the change in the E. C. G. Various observation were made on the different injured points. Summary and conclusion of this experiment are as follows : 1) When the previous part of the fossa ovalis or wall of the appendage were injured, the heart beating remained for about 30 minutes, and besides a presumption of the results of an acute heart failure due to bleeding, no particular change was observed in the E. C. G.2) When injury was given to the upper part of the right atrium near the Bachmann's bundle, it was observed that very soon after the administering of injury changes were seen to take place, such as a marked transformation of the P wave, an irregular beating of the heart, an appearance of two P waves of entirely different kind, disturbances in the a-v conduction, etc. From these observation, it was assumed that there existed activation pathways between the sinus node and the left atrium, and between the sinus node and the Tawara's node.3) An injury given to the border between the anterior wall of the atrium and the septum often caused such changes in the E. C. G. as the shortening or prolongation of the P-Q interval, an appearance of the a-v nodal rhythm, a sudden cease of the heart beat, etc. From above observations it may be assumed that the stimulus conduction of the atria is not one rendered through complete diffusion but through some stimulus conduction pathways running directly from the sinus node to the right and left atria and the Tawara's node.

抄録全体を表示