The X, Y, Z leads of Schmitt's SVEC III lead system are considered quite an accurate representation of the horizontal, vertical and sagittal components of the electrical activity of the heart on the basis of model experiments. In this study, this lead system was applied to patients having various ECG abnormalities in conventional leads in order to assess its clinical applicability. About 230 tracings recorded on 173 patients are included. The scalar recordings were evaluated with reference to the normal range limits of the X, Y, Z leads which were obtained from the recordings on 303 healthy men and the deviations from the normal limits thus found were compared with the findings in the conventional leads.In normal patterns, the QRS and T of lead X are upright and similar to the left-sided precordial leads. The pattern of lead Y is similar to lead II, though the polarity is reversed. The QRS of lead Z is RS, the S usually being greater than the R, and the T of lead Z is almost always upright.In LVH, the composite voltage Rx+Sz, which has a correlation with the mean spatial QRS magnitude, increased and the presence of Rx+Sz>2.4 mV (normal limit) coincided with that of Sv₁+Rv₅>3.5mV in 28 of the 34 cases in which either one of these two items was present. The "strain-type" ST-T changes in the left precordial leads and in lead I were manifested in lead X.In the 14 cases examined having definite RVH which was confirmed from clinical findings and venous catheterization, in all the cases, the R/S ratio of lead was X below 1.2 which is outside its lower normal limit of 1.3; therefore, there can be no possibility of a false positive diagnosis. The S of lead X exceeded its normal limit of 0.4mV in 12 of these 14 cases. The positiveness of the above two items was much better than any of the individual criterion of the previously esta. blished criteria for RVH of conventional leads The "strain-type" ST-T changes in the right precordial leads were manifested in lead Z.The pattern of LBBB was characterized by a broad notched R in lead X and a small R followed by a wide deep S in lead Z. The pattern of RBBB was characterized by a wide and somewhat deep S after the R in lead X and an RsR' pattern of lead Z.The pattern of anterior wall infarct was characterized by a QS wave in lead Z and that of posterior wall infarct, by an initial R in lead Y. The serial ST-T changes typcial of recent infarcts were clearly recognized. Diagnotic accuracy for infarcts of this lead system was comparable to that of the conventional leads.The uniformity in the direction of the normal T vector in this lead system permitted clear distinction between normal and abnormal T waves. Abnormalities in the T waves of conventional leads were easily recognized with this lead system, excepting very few cases where only minor T abnormalities were present.The ST-T changes in the anterior wall are manifested in lead Z, those in the lateral wall, in lead X, and those in the posterior wall, in lead Y.Abnormal P waves including flutter and fibrillation waves and increased P amplitudes were also easily recognizable.The scalar display of the SVEC III leads was proven, by this study, to provide information superior or at least comparable to that from conventional leads. The minimal angular distortion and quantitative reliability of this lead system were most favorable and helpful in diagnosing ventricular hypertrophies; the tentative criteria for hypertrophies proposed in this lead system appear accurate and yet they are simple. The other abnormal patterns as well as the ST-T changes were all reflected very clearly in the SVEC III leads.

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In preceding report I, the sinus node and the Tawara node were investigated histologically. This report was on the examination of the specific conducting systems to the right and left atriums from the sinus node. The materials and methods were the same as those stated in report I.Results : The findings are summarized as follows.1) The specific muscular fibers in the atrial portion are not so prominent as the sinus node, the Tawara node and Purkinje's fibers in the ventricle.2) The main pathways of the atrial portion are as follow.A) A pathway, arising from the projection of the head of the sinus node, surrounding the base of the V. cava superior.B) One of the projection of the head of the sinus node is distributed in the right atrial appendage.C) The pathway arising from the head of the sinus node along the intermediate right atrial artery near the junction of the right appendage with the right atrial body.D) The pathway arising from the tail of the sinus node along the Arteriola sini (dorsal right atrial artery) near the junction of the V. cava inferior with the right atrial body.E) In addition, the further fine branches from the above chief pathways are distributed in the anterior and posterior bodies of the right atrium.F) The above mentioned pathways are more prominent near the sinus node, not so peripherally.3) The main pathways in the left atrium : This system is found as fine muscular bundles consisting of a few muscular fibers, arising from the projections of the head of the sinus node, passing over the cava venous appendage's angle and going to the left side of the atrial septum along the Bachmann's bundle in the subendocardium and subepicardium of the right atrial wall of the aortic side. Further, the system is extended to the left atrium and distributed in the left atrial appendage and around the pulmonary veins.

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As reported in part I, it could not be determined that the excitation was spread by which of the proper muscle or the specific muscle at the interatrial septum. Then, in this report, the specific conduction muscles which were related by Osawa as the systema sino-Tawara were cut by a small messer and the PQ intervals were mesured before and after cut.The summary and conclusion of this study are as follows : 1) The cut of the area of the systema septoangularis posterior were performed in 15 cases. In 13 cases, the PQ interval was prolonged or shortend less than 0.010 of a second after cut, that is, the change of the PQ interval was only a little.2) The cut of the area of the systema septoangularis anterior was performed in 23 cases. Then in 17 cases, which cut this system, the PQ interval was prolonged 0.011 to 0.042 of a second (histological examination in 9 cases) and in the cases which it could not be cut, the PQ interval practically did not change.3) In 17 cases, the cut was performed under the sinus coronarius which included the right auricular bundle and the left auricular bundle and the atrio-ventricular node. Then, in 8 cases which the right auricular bundle was cut (histological examination in 5 cases), the PQ interval was prolonged 0.020 to 0.157 of a second. In one case which the both auricular bundle were cut, the PQ interval was prolonged 0.033 of a second. In 4 cases which the atrio-ventricular node was injured, 2 cases A-V block, other 2 cases prolongation of the PQ interval 0.136 to 0.198 of a second (histological examination). In one case which the right and left auricular bundle and atrio-ventricular node were not injured by histological examination, it was recognized the prolongation of the PQ interval was slightly 0.007 to 0.016 of a second.4) In 2 cases in which the cut of the Torus Loweri was performed, the prolongation or shortening of the PQ interval was only 0.002 of a second.5) By contrast, when the right atrial free wall was cut, the PQ interval was prolonged or shortend only 0.008 of a second.6) In 7 cases, the PQ interval was prolonged 0.080 to 0.058 of a second by Bachmann's bundle (histological examination in 4 cases), and in cases which the prolongation of PQ interval was evident, the systema septo-angularis anterior was ligated with it or previously other systems had been ligated.From the above data, it was thought that the 4 specific atrial muscles which were noticed by Osawa, plaied an important role as the stimulus conduction system between the sinus node and the atrio-ventricular node. And in these 4 systems, particularly the systema septo-angularis anterior was most important and the system along the arteriola sini was next in normal conduction. And it seemed that the systema septo-angularis posterior was not so important and the system through the left atrium might play a role at specific occations. And the Torus Loweri was not significant as the stimulus conduction system.

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I have observed the influence of high pressure surrounding the electrocardiograms of rabbits and its pathological changes on various conditions experimentally. Forty rabbits were used for this experiment.They were put in the "compression-box" by compression air and pressure was put on them by various methods to observe influences on electrocardiograms and electrolyte in serum.The results obtained are as follows : 1. In 4 cases, when the air pressure was lowered gradually in a step-like fashion, one case revealed coronary T wave after undergoing the procedure 15 times. In cases where severe pressure was applied, the author observed many increased R and P waves.2. In 16 cases that were performed the air pressure was lowered gradually in straight-line fashion. In two cases the I or III leads showed occassional coronary T waves, but potassium in blood serum was not increased.3. Rabbits with electrocardiographic changes showed some changes also pathologically. The author observed the callosity and degeneration in the heart muscles. In groups with the heart callosity of the right ventricle there showed coronary TIII wave, moreover in groups with the heart callosity of the left ventricle there showed TI wave an electrocardiograms.4. In the group presenting experimental caisson disease, serum K concentration increased in half of the cases, and in other cases decreased. But K concentration in myocardium increased slightly in many cases. Natrium and karium concentration in serum increased in a few cases, but in many cases were found more frequently to decrease after the pressure.No appreciable correlation was found between the electrocardiographic changes and the electrolytes in serum. The electrocardiographic changes on experimental caisson disease were caused by the fact that the physical conditions were caused by compression and depression, causing thereby the pathological-histological changes of the heart and lung.

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The mechanism of reactive increase of coronary blood flow (CBF) occurring during experimental coronary embolization was studied on a total o^f 43 closed chest dogs anesthetized with amobarbital sodium, with special reference to the myocardial oxygen consumption, myocardial energetics and neurohumoral aspects.Coronary sinus outflow was measured by electromagnetic flowmeter through Morawitz's canula. (a) Coronary embolization was produced using the suspension of Lycopodium spores and the changes in CBF were determined. In some experiments the relationships of CBF with the myocardial oxygen metabolism and cardio-dynamic indices were detected. The indices used were mean arterial pressure, cardiac work, the product of heart rate and mean arterial pressure (Katz), its modification (the product of heart rate and systolic mean pressure of left ventricle), and the tension-time index (T.T.I.) of Sarnoff. The last one is equal to the product of systolic mean pressure of left ventricle, duration of systole and heart rate. The influences of the autonomic nerves on CBF were investigated under the bilateral cervical vagotomy or bilateral cervical sympathetic ganglionectomy, and compared with the control group. (b) Coronary obstruction was produced using the catheter devised for this purpose. The reactive hyperemia occurring after the release of temporal obstruction was observed under the influences of blood pressure, section of the autonomic nerves and some drugs previously administered. (c) Effects on CBF of various substances injected into the coronary artery were investigated. Substances injected were several drugs including catecholamine, acetylcholine etc and coronary venous blood of another experimental dog collected before and after the coronary embolization.Results obtained were as follows : 1) Following the coronary embolization, CBF was temporarily decreased and then increased by an average of 40% after 3 minutes. This reaction was neither abolished by the vagotomy nor by the sympathectomy. The degrees of average increase, however, seemed to be reduced by the vagotomy and augmented by the sympathectomy; and these tendencies were thought to be the results of influences of both nervous systems upon the tenes of the coronary vessels.2) T.T.I. was proved to correlate best with the myocardial oxygen consumption among the cardio-dynamic indices (r=0.90). Thus, it was confirmed that the myocardial oxygen consumption was related to all the mechanical energy including the intracardiac tension rather than to the external effective work alone.3) Myocardial oxygen consumption was reduced compared with the T.T.I. immediately after coronary embolization, and therefere the myocardial oxygen debt was suggested to be produced. This oxygen debt was supposed to introduce the increase of CBF, and during this period the oxygen supply to myocardium far exceeded the myocardial oxygen consumption.4) Increase in CBF following the release of coronary obstruction was independent on the autonomic nerves, was related with the myocardial ischemia produced, and was limited to the local area. By the intravenous administration of eserine, the response was markedly increased. Thus, the contribution of localized myocardial metabolism, particularly of the acetylcholine-like substance, was suggested to play a very important role in the production of reactive hyperemia. Coronary dilator substance has been supposed to exist in the coronary sinus blood during the embolization, but this failed to be proved in this experiment.5) As to the reactive increase in CBF following coronary embolization, fundamentally myocardial energy requirement, that is, myocardial oxygen requirement was thought to result in the augment of myocardial oxygen supply. As the regulatory mechanism of coronary circulation which mediated such a reaction, the important role of the above-mentioned localized myocardial metabolic factor was emphasized.

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Since Babcock has called attention to the frequent association of gallstone disease and cardiac disease in 1909, many workers have studied the relationship between these diseases. It has been known that the patients with gall-bladder disease often exhibit cardiac symptoms, particularly "anginal pain" and that those symptoms disappear after removal of the affected gall-bladder. Furthermore, it was found that abnormal electrocardiogram of patients with gall-bladder disease occasionally returned to normal after such an operation. Gilbert and his associates published experimental data which suggested a decrease in coronary blood flow upon distention of the gall-bladder, which disappeared by cutting the vagi. He explained these facts by a viscerocardiac reflex in which reflexes arising from the gall-bladder might at times cause decrease of cronary blood flow, resulting in symptoms of angina pectoris. Several investigators noted that pre-existent abnormalities of the coronary system appeared to facilitate the viscerocardiac reflexes. The present investigation was conducted in order to see the effect of distention of the gall-bladder on coronary blood flow and other vasomotor system in normal and coronary constricted dogs. The urinary bladder was also distended in normal dogs to compare its effect with that of the gall-bladder distention.Open-chest dogs weighing 10-15 kg were anesthetized with sodium thiopental (0.03-0.05 g/kg) intravenously. Coronary inflow of the left coronary artery was measured by rotameter. Blood pressure was recorded from the left femoral artery by a mercury manometer. The dogs were divided into two groups. Group I represented 25 normal dogs. Group II represented 8 dogs which underwent the operation of coronary artery constrictions 10 days prior to the gall-bladder stimulation. Below the bifurcation of the first ventricular branch the ramus descendens of the left coronary artery was constricted with U-shaped silver clamp. A toy balloon attached to a vinyl tube was placed in the gall-bladder through an incision in its dome. The tube was connected with a mercury manometer for recording its pressure. The balloon was distended for 15-20 seconds with air or water injected through a syringe. (Fig. 1) Distention of the urinary bladder was carried out similarly.Following results were obtained.(1) No uniform changes of the blood pressure were observed following the distention of the gallbladder. Of total 33 cases, elevation was observed in 6, and depression in 14. In 13 cases no change of blood pressure was found. (Table I.) The results were similar even in cases with coronary artery constriction.(2) The responses of the coronary blood flow were variable, but they were always in the same direction as the blood pressure. In no instance the blood pressure and the coronary flow changed in the opposite direction.(3) Changes of the heart rate were not observed. However, in 11 experiments on 9 dogs ventricular premature systoles were recognized after distention of the gall-bladder.(4) It was found that appearance of ventricular fibrillation was more common in the experiment of distention of the gall-bladder than in any other experiment of the coronary circulation.(5) The effects of distention of gall-bladder on coronary blood flow, blood pressure and heart rhythm were not essentially different between the normal dogs and the dogs with coronary artery constriction.(6) Changes of the blood pressure on distention of the urinary bladder were also variable, but it was noted that in several cases the common response was an initial rise in blood pressure followed by depression. Changes of the coronary blood flow were parallel with the blood pressure. The effects of distention of the urinary bladder on the circulatory system, therefore, were essentially identical with that of the gall-bladder except appearance of the arrythmia.

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The concept of a cardiovascular reflex originated with the discovery of the depressor nerve by Cyon & Ludwig in 1866. At about the same time von Bezold and Hirt described the powerful depressor effect caused by the injection of veratrine, which was elicited from the heart through a reflex via afferent fibres in the vagus. Seventy years later Jarisch and his colleagues investigated this problem in detail, confirming that the mechanism of the depressor effect was a reflex in nature. Dawes showed that the intracoronary injection of veratrine evoked the Bezold reflex with very small doses. The exact location of the receptors of the veratrine is still uncertain, but they should be accessible only through the coronary artery.The Bezold reflex had been considered a coronary chemoreflex and its significance was debated. On the other hand pressoreflex from the coronary artery has never been reported. The author has experimentally investigated the problem and has found a pressoreflex arising from the left coronary artery.Dogs weighing 10-15 kg with open-chest and artificial respiration were used under sodium thiopental or morphine-urethane anesthesia. Heparinized (10 mg/kg) blood was circulated from the right femoral artery into the left coronary orifice. A syringe was attached to this perfusing system and was fiilled with heparinized blood taken from the circuit. The stimulation, which raised the pressure in the coronary artery, was given by injecting 10-15 cc of blood from the syringe into the circuit during 3-6 seconds. The changes in the systemic pressure by the procedure were observed on soot paper as determined in the left femoral artery.(1) A rise of coronary perfusing pressure caused a fall of systemic pressure. The depressor effect was found in 62 of 106 cases. It was reflex in origin, because it was completely abolished after cutting cervical vagi without any exception. No marked changes in the heart rate were found.(2) These depressor effects were still obtained after cutting the sinus nerves or the aortic nerves.(3) In order to establish the afferent pathway, the ventricular branches of cardiac nerves which innervate the left ventricle were blocked on the surface of the ventricle or auricle. The author refered the ventricular nerves as the anterior and posterior ventricular branches. After blocking the anterior branch the depressor effects could be abolished in 12 of 16 cases, while it was abolished in only one of 7 cases after cutting the posterior branch.From these results it was concluded that the pressoreflex arised from the left coronary artery, and that the anterior ventricular branch participiated more in the reflex than the posterior one as the afferent pathway.

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As there is a lack of agreement concerning the role of the heparin-clearing factor system in the pathogenesis of atherosclerosis, a method was presented for the determination of endogenous clearing activity. Then the endogenous clearing activity was investigated with respect to serum lipid levels, function of various endocrine organs and various diseases.The following results could be obtained : 1) Endogenous clearing activity was not related with serum levels of total fatty acid, neutral fat, phospholipid, nonesterified fatty acid and total lipid.In cases with high serum cholesterol levels and high atherogenic index, the endogenous clearing activity was below normal.There was an inverse correlation between the endogenous clearing activity and cholesterol/phopholipid ratio.2) Endogenous clearing activity decreased with age.3) In hypertension cases, the endogenous clearing activity became lower as the distolic pressure increased and the inhibition of clearing activity was stronger in hypertensive subject with pathological findings in eye grounds than in those with normal eye grounds.4) As for endogenous clearing activity and plasma protein-bound iodine level, no significant relationship was found between them.5) Cases with high levels of plasma 17-OH-corticosterone gave lower values for endogenous clearing activity, and the adminstration of ACTH, cortisone, prednisolone and lipomobilizing factor resulted in its marked decrease.6) Lower values for endogenous clearing activity than any obtained in the controls were noted in patients with diabetes mellitus, angina pectoris, myocardial infarction cerebro vasucular lesion and hypertension.Endogenous clearing activity was slightly highes in cases with liver cirrhosis than normal subjects.The sesults obtained support the view that the heparin-clearing factor system has an inportant role in disturbing the lipid metabolism in cases of atherosclerosis.

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Adrenal secretion and cardiac uptake of catechol amine (C.A.) were studied on 32 dogs anesthetized with amobarbital and 4 dogs with morphine-chloralose, to clarify the role of C.A. played at the time of various stresses, especially on the heart. In addition, the effect of some agents on C.A. secretion was investigated.Adrenal vein catheterization without laparotomy was performed to collect adrenal venous blood. Weil-Malherbe & Bone's methods were used to determine C.A. concentration of plasma.Thus, following results were obtained on amobarbital anesthetized dogs : I. C. A. concentrations of adrenal venous plasma collected by this technique were much lower than those of plasma collected after laparotomy.II. Remarkable increase of C.A. concentration in adrenal venous plasma was observed transiently in following conditions. (a) After cervical vagotomy and sympathectomy. (b) At the time of hemorrhagic shock. (c) 1. After coronary embolization. 2. During and/or after the transient occlusion of the left coronary artery. (The increase in both conditions was delayed or could not be found after sympathectomy, whereas it was not affected by vagotomy.) (d) After intravenous administration of Theraptique or acethyl choline.III. During adrenaline or noradrenaline infusion after hemorrhagic shock, C.A. was taken up by the heart muscle at the time when the blood pressure was elevating, and was released from it, when the blood pressure reached a constant level.From these facts, the author concluded that the impulse from the heart was transmitted to the adrenal glands via sympathetic nerve, resulting in the increased secretion of C.A., a part of which was taken by the heart muscle, and that the increase of C.A. secretion was, therefore, not only a mechanism to overcome various stresses, but also regulated cardiac performance.

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In cardiac surgery, the degree of pulmonary hypertension is an important feature to determine the severity of the diseases, and the functional and pathological abnormalities of the small pulmonary vessels are the important factors to influence the hemodynamics, operative indications and prognosis. While many authors have reported about the correlation between the pathological findings of small pulmonary vessels and hemodynamics, some authors recognized recently that the vasoconstriction of pulmonary vessels causes, maintains and in some instances aggravates the pulmonary hypertension with or without the pathological changes of pulmonary vessels.The author studied on the pulmonary hypertension in special reference to its reversibility in standpoint of pulmonary vasoconstriction from both functional and anatomical aspects of small pulmonary vessels.Seven cases of V.S.D., three cases of A.S.D., three cases of P.D.A. and eleven cases of M.S. were studied. After the routine right heart catheterization was performed at rest, 1 mg/kg of Hexamethonium bromide (C₆) was administered through the catheter, the tip of which remained slightly distal to pulmonary bifurcation, and the pulmonary hemodynamic changes were observed after 15 minutes. At operation, the lung biopsies were obtained immediately after thoractomy, and microscopic preparations were all stained with Verhoeff's elastic tissue stains counterstained with Van Gieson's connective tissue stains. Histological studies were confined to small muscular arteries and arterioles, and the lumen : wall ratios (L/W) were measured separately by eyepiece micrometer and their ratios were averaged. The immediate or remote postoperative pulmonary hemodynamic changes were studied about three cases of V.S.D., three cases of A.S.D., one case of P.D.A. and four cases of M.S. The pulmonary hemodynamic data were expressed by % ratios to systemic ones.The results obtained are as follows.1) The higher the initial levels, the more profound the % fall of the ratios of pulmonary to systemic systolic pressure and resistance after the administration of Hexamethonium. In those cases where the pulmonary vessels were well responsive to the administration of Hexamethonium, and so the marked fall of the ratios of pulmonary to systemic systolic pressure and resistance and increase of pulmonary flow ratio or shunt flow ratio were obtained, the medial muscular hypertrophies of small pulmonary vessels, especially of pulmonary arterioles were the most characteristic findings. This fact suggests that the medial muscular hypertrophy is the anatomical expression of pulmonary vasoconstriction which is thought to maintain the pulmonary hypertension.2) In non-responsive cases where the fall of the ratios of pulmonary to systemic systolic pressure and resistance and the increase of pulmonary flow ratio were not obtained, the medial muscular tissues of small pulmonary vessels were very scanty and in addition, the intimal proliferations were present in various degrees. In this group, therefore, pulmonary vasoconstrictive factor is thought not to operate.3) In responsive group, there is an intimate correlation between the ratios of pulmonary to systemic systolic pressure after the administration of Hexamethonium and those after the closure of shunt or mitral commissurotomy.4) Thus, it seems to be possible to anticipate in some degree the reversibility of pulmonary hypertension preoperatively from the pulmonary hemodynamic changes before and after the administration of Hexamethonium.

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In previous report the Kidney-ATPase was injected intraperitoneally and subcutaneously into albino rats repeatedly, but the blood pressure did not rise. In this report the Kidney-ATPase was therefore injected into tail vein of rats.(1) The crude Kidney-ATPase was injected repeatedly in 45 rats. There were only 14 rats (4 normal and 10 uninephrectomized) which were injected more than 13 times, because the others died by shock after intravenous administration of the Kidney-ATPase, got the necrosis of tail or died by illness during the experiment.a) In 3 of 4 normal rats treated with 1% NaCl, the blood pressure was elevated moderately, because the crude Kidney-ATPase was injected intravenously more repeatedly, but their blood pressure had a tendency to fluctuate. Histologic changes in kidney were slight.b) Of 10 uninephrectomized rats treated with 1% NaCl, the blood pressure was elevated temporary or not in 3, elevated morderately or slightly in 2, and elevated markedly in 5. In 2 of these rats, the pressure remained hypertensive at about 200 mm. Hg. even after withdrawal of injections as in post-DCA-hypertension. Histologic changes in kidney revealed exudation into Bowman's capsule, degeneration of tubuli, hyaline casts and cell infiltration. These changes were marked in rats with severe hypertension and slight in other animals. No atheromatous changes in coronary artery in and aorta were found in rats treated with ATPase and cholesterol for a long time.c) 26 rats died by snock after intravenous administration of the crude Kidney-ATPase. At autopsy hemorrhagic exudate in the abdominal cavity was found in many rats, and small hemorrhage in intestine, lung and stomach in some rats.(2) The Kidney-ATPase semi-purified with Alumina Cream C_γ (fraction C and K) is possible to be given intravenously more safely than the crude Kidney-ATPase. Semi-purified ATPase was injected repeatedly into 4 uninephrectomized rats with 1% NaCl, and the blood pressure was elevated moderately during injecticns, but did not sustain after withdrawal of injections. Histologic changes in kidney showed atrophy of glomeluli, degeneration of tubuli, hyaline casts and cell infiltration in the interstitium.

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