1921 Journal of the American Medical Association  
The case of high grade heart block herein reported has certain unusual features which make it of clinical and scientific interest. In the first place, there was an absence in the previous history of those diseases which so frequently induce heart block, such as syphilis, diphtheria or other long-continued or acutely severe infections. Secondly, the clinical laboratory and roentgen-ray examination confirmed, respectively, the negative findings of the clinical history and the positive findings of
more » ... ositive findings of the physical examination. In the third place, the phenomenon occurred in a young man of 20 years, Fig. 1.-Normal electrocardiogram of girl of 16 years, for comparison with Figure 2 and others of this series. The wave is produced by the impulse which precedes contraction of the auricles. In normal sequence, the auricular impulse is followed at a later interval (varying from 0.12 to 0.18 second) by the ventricular complex R and T, which represent, respectively, initial and final activity at the base of the ven¬ tricles. However, the contraction impulse may be blocked in its course so that no impulse gets through from auricle to ventricle, and the ventricles then contract utterly independently of the auricle; such complete dissociation produces the complete heart block shown in the following records. who is apparently in robust health and totally unconscious of such physical limitations as heart block may be expected to induce. Fourthly, the heart exhibited high grade block under various circumstances of test until the patient forcibly expelled the air from his Fig. 2.-Heart block in an apparently healthy youth of 20 years, sitting; ordinary quiet breathing; auricular rate, 100; ventricular, 44; grade of block, complete. (Time interval between the heavier per¬ pendicular lines = two-tenths second.) lungs; there then ensued the unquestionably normal sequence of atrioventricular events graphically recorded in Figure 6 . So far as I know, the combination of findings in one patient is unique. REPORT OF CASE History.-W. Z., an unmarried merchant, aged 20, and a Pennsylvanian by birth, came to Philadelphia to have an operation for the correction of a deflected septum and for Fig. 3.-Patient recumbent; ordinary quiet breathing: auricular rate, 84; ventricular, 42; grade of block, complete. the removal of a hypertrophied turbinate. It was discovered that his pulse rate was 48 beats per minute. He was placed under observation in a hospital for three days and, when there were no further developments and as the pulse showed no change in rate, the patient was referred for cardiovascular study. The youth had no symptoms whatever of which he could actively complain, and regarded with amusement the concern which his surgeon displayed over his physical condition. He had that week played baseball and had run the four bases with no more distress and with no more shortness of breath than his fellows. Being fond of dancing, he frequently danced Fig. 4.-Patient in knee-chest position (the patient's customary Lead II surmounts the experimental record for comparison) : auricular rate, 82; ventricular, 40; grade of block, complete. until the morning hours and had never felt physical discom¬ fort. He was symptom free. The father died at the age of 57 of cancer of the liver ; the mother is living and in good health at the age of 69. The patient is the youngest of a family of eight children who range in age from 40 to 20 years, all but one of whom are living and in good health, a sister having died in her eighteenth year of pneumonia. When 3 years of age, Mr. Z. was first found unconscious in the yard of his home. An elder sister recalls that he subse¬ quently had such periods of unconsciousness at unexpected moments and at intervals of perhaps three or four months for the next six years ; she described the child as suddenly turning white, falling heavily to the floor, lying motionless for five or six minutes, and shortly after resuming play. At the age of 7 the patient had measles and was in bed for nine days ; there were no complications or sequelae. At the age of 9 the last periods of unconsciousness occurred, one while at an evening wedding and the other on the follow¬ ing morning. These were similar to other attacks, but lasted for perhaps ten or fifteen minutes. Throughout his school Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/18/2015
doi:10.1001/jama.1921.02630010021006 fatcat:x5f4zcgxbfh55lqdjnvl2guz24