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abroad of Iqpuloo i& Bundle Dmnoh Block*«»••»»••• 117 
Bundle Branch Block <*<» illfltoyioel ••#.••*•••**«.•»«••«••• 1X8 
la tfcO l)O0««*t HO 
909UB0I of Activation of Ifeort***•••«•••*••••»«•• 181 
Cto«»Ioto and Bundle Branch 
Blook la th® mi 185 
Oraor of Fnoattig Got of Activa steta 
tbO !&««W m 
Itarelopmit of WtA«m Ooaoopt of Hl^kt 
nod loft Boodle Breach Block 109 
Oliaiool WM SGgpfGlag Bundle Braidk Stools ••••» 130 
Criteria for Bundle Brmoh Block la &m m& 
Vmimn fypmt of DuoSla emv<mh Blocks ««« jpc 
the JtaMOKlla& Lods in Iftmdlc Breach Block# «*••*»« *1£SG 
BlOOfef*1 **•»»»«***••*«*••***•••#•«*»«* 145 
loooilsofl Ooncltsotloa icefoot *»••••••<•*<••.•**•*•« MO 
Ohaicoo la also of Dofleotiosio la tho « 140 
.tell Dafloetlema in <«MI Goapl«eaa«* ••**»«* 150 
SafSaGtlcma la QM OmmXixmm •<««••*••«•**•» 101 
Mis and tea l&aatrloal Mia 
of Mia Dotiatloo#**♦•••#♦*♦• •♦•♦••••*•#•♦•• US® 
Mia Bov lotion ZM«k»**« ••««•** 1C1 Index Continued 
Pago 
Coapcriooa of Betornlaotlott of Boon Electric©! 
AkIb one! Axis Deviation Inc-ess ***. 161 
Right Ascls Deviation. 16C 
left Asia Deviation* • * • •«*«**••*•••••* 165 
Factors $&ioh DetorEdno Position of Moon 
Bloctricol Axis 167 
Procordlol Loads In Axis Deviation sad Sight end 
Left Ventricular Ilsrpcrtrophy* 171 
Changes in th© Itarevoa • **•*»"**••«**•*«* »••••• 180 
Significance end Detondnotion of Stectrocard torraphie 
ISO 
Itesplos of Relationship between QF*B Group and 
T-WOV© 0 105 
Inversion of f^ttsves****«*•*•»* .... .**.««••*•• 186 
The Vectorcardiogram*............... **««*••*•• 191 
ftoraol Ve<rfcoreepdlogroms *«.«••.... . .»••••«•* 198 
Abnormal VcKstorcordiogrwai® •»««••••» • «*«• 193 
Disadvantages of t’othod*.193 
l&octrocardiographio Change* In l&ocerdiftl Infarction.*....♦*.♦• 194 
R3~% Displacoiaont •**... ......... »*•**.*•*«*••»• 194 
Hsturo of USB Chang** In Ifyooerdial Infarction £03 
tmmrrn Changes In Infarct ion* ' £07 
IHoctrocord iograns in Patients with Angina Factor is **.««*•• *•* SOB 
Qhm ,m which occur in 1® during Attain of 
Andno Pectoris £08 
Ss&npl'm of HtO Changes in Angina Foe tori *• •«•••••••..•••* 809 
Ityoonrdlal Infarction 
Standard Lends In Anterior Infarction • •• •*••**.••* £14 
Standard Leeds in Posterior Infarction ***** £18 Xnlrac Ocmtlmiod. 
of laforeticn 
fTOTl irliCI •*•#•**•*••••*•**•»*»*•♦*•*•♦♦♦*••••* 2S0 
Bmplee of isMnr Infarction* ••«•*••♦#♦*•• •* « »•« • • • ■ £* 1 
togjplas of Bosrtorioaf Bifextst Ion* •....•♦*•* *«•••*• £84 
Other iaotoDoeo of Infarction* *••» # 331 
Bmcplm of Omplimtim 
AflntO .' -lili InfGZHUticsw • • • • • • • ••*<*••*•*••*•*♦ *• 233 
ftaqywttl Ventricular Sted&Qsrdia 
In XnfMMtaa 836 
Cnunon of Sudden Booth in I?if *rction ••••••* f£>? 
the Preccxpdial Loads in l$ooaEdiaI laforotioa* 
la Prscordiol Loads In Infarction*** 330 
StetfOxiQ of Procordisl Loads In /interior 
Btyosordli&I *•**•••**♦»*•• • • •*« **■•*♦*•*•• £43 
Leads end is! Leeds la 
Sanction*** •****.*•**•«»♦»*•* *351 
IBberpIob of K®Q|&a9M& Leeds 
IStacsd Inf&nstiixi * 
of Bland Infarction** • * * ♦ ■*■• ♦** • «« •«*-■■# • * * * <o« •• «> SOS 
3&e Seasons for Matiple Precordlsl Leeds In 
Infarction#*** **•■»*••■■*••»•*#•**♦**•***# *•♦**♦* £30 
OtwraSterlatlO Gbrngm in One Load 
ihst Freoordlal Leeds 3?sould he Taken* •*«#••**•*«••*•* 
Sbe la Itodlo Branch Block 
ar& Infarction* • • *«*»•***»*«• *.**•*•••••#••• SSO 
■ rXho€a?©tlcaX CkassMcamtions*** # **♦•»♦♦<*»*♦•♦**•*••*••*• ssi 
of RigLt Bandies Branch Block b 
8Hl! i&&erlor Iafsirction#*********«vj!S^V****»**«•♦*•••♦ SS6 jMcK fevatfirsard# 
J&smpl&n ot I&sadlc isranoa Blodr 
mH Vo&miav t^ocazdleX XRffcvstlofe*.«.*<»•«»•»••«••• 89B 
spies of loft fioeSSa Hp-ash Blook 
md XBravetSflo* m 
OXlniOfil Oal4os Fma the 3ileetroerirdiogms ia 
♦♦••**•***♦**•*••*• rm 
of Gmngqr Air iMsoltei* r^5 
ItM X* TOW OF imm$& 0/M 111 HUGE ARB OF ?«BUU 
1# the Ml is used to deterwtn# auricular m& ventricular 
activity# 
£• Most arrhythmias or® eessccamod with 0 disturbance of tha 
mqnom® between auricular end ventricular contraction* 
3# Ttm deotroecrd is the court of loot resort in the 
d Iff srentletie& of the various errhythialag* 
4# St Is also imltttM# to ditfwwtktfcai tfao various types 
of tachycardias end bredfcrcardlc# 
B* Xt is useful Is oontrolltug isodiostion* 
U Miltollo any result In* for ffmylgi* 
{n) %*mm changes* 
(b) BigcsiBjN 
Co) tetrodetolcs* 
(0) &etrwss digitalis Intorieetlon m& ohm that typo of 
Isvoplovllf In a&ich there is m slooter auricular Stott 
then vootrlculiwr ret#* this occurs In entasis with 
9t# of the lethal dose* 
B« QuiftMlri© result In T-wff# Mnei cud alterations la 
conduction* 
0* It is at ttaMi useful in the detection of valvular lesions 
md the effects of hypertension* 
1* alight a&ls deviation occurs in ttltrel stenosis* usually* 
however* only when there 1* an advanced lee left* mBm 
Bm Loft min deviation occurs la hypertension ead when cart©la 
accompanying change® ©re preooat, moh m Inverted 
la tod I md evidence ot ventricular hypertrophy, Indicate© 
that it is of eofao duration# 
3# of aortic end pulmonic toiane, by th© 
pmmmm of loft or right ©ado deviation# respectively, my bo 
poodbto 
D# fhe <&octrocaraiogr«m la useful la the detection of 
disturbances la pot lento who ahem no other objective evltoioo of 
heart dlooaac# 
I# to cimnct, however# mkn m etiological aiognoelc from the 
oieotrocf.rd togreo* It omool be mid whether the pathologist 
will find f ibrocic# d«&*omtto of none type, too, rheumatic 
imolv&mmt or tothw ho will fto anything at all# 
a# Svl4«OMi of ayccavdlcl nlmmm ore seen la two groope of coooo# 
(&) Mate infect too 
I# Acute rteMtic tmr bo nolo evidence 
of fever# 
£« Uiphthm^Si 
£>♦ tide M&mm patients occasionally 
die of ©cate i^ocordltio* 
4# Telto fever# 
. 5# Pneumonic# 
6# Starlet fover—it Is unlikely that the eabeeauost valvu- 
lar lonlcac which often appear are to to the scarlet 
fever per no, but nether ore uotaclly due to the coneo-i** 
t©at tomrllc favor* <•» 3 *• 
9* Changes of this typo or© umusUy tasapoiwpy mb 
tm& to oXeex»« 
8* If o patient I«sb am aooto ffifoeovdllli, he mot be 
kept la be£ uftUl the acute womm ouboiteo* 
©rtlon my monit in ImgHmiX* too^« 
(b) Artorloeileyatlo Com®* 
I* Thom my be aaySmio aim® so preront without phyei- 
ml oluftot It i* in peti gijto with eye*)torn and with* 
out ilfiM ilgM that the etotxoeeydiogrefn my 
bo of tool folaot 
S« %bo coronary crtolee do not have any effect on to 
¥ou eonnot mko the diagnosis 
of wvom%f MtosQils cod no on# otold ever mko 
Hat fro® the oXeotsooayc iogrea alone* 
One my pooelbly tofett that It So preaeot from to 
eXeatoeerdlog**pfcla avitoeo of apMisvdl«l domgo* 
5* the die&noaio of #yoeii*dtel Infarction oen be mto« 
IwwfaeiMP* 
4# The amort ton to to wle tot to dlaosioaia of 
coronary toaaoaift oennot bo cede Ib that of too© 
eaaaa with engine peotoyld who oho?-; elteretlono In 
to eto toflorS iogyea mhm pa In io present* 
B» Tba my give uoafnl tafermtto In otto 
disoeae date** !•©♦!* 
1, Hypocalcemia, wte?o a pyoXimoed %*T intowol Mf be necn* 
a# Parlatoitia, which my bo isoaoclato with btoem to ©to£o« 
and elevation of to to aenpont in all load** •» <& m 
3# Myae&soa, which may b© ©ooorapaaiod by horn vol%am of tbo 
<P0 coalesces In oil Iced® end flattenin*? of the 
4# associated with to? voltogo of the ip8 
pie?*©® oad flat 
5* i'Ti&aonary ei’s&ollan, which my star trmnimt right haAU blanch 
block# 
F# The Is of no vein© in ootimtin® ttm oardl,oe reserve# 
It emmt dotogmdtae the pri—B4i or abecnoo of connective failure# Tfm 
c&ac&roeordioftrvn my bo perfectly norml in tho preomco of osetrorw 
eordiae failure# 
0# Vhot does the? eleotrocer ilogmft record? It records* • 
1# The spread of the Inpuloe of the heart# 
2m The ©loctriocl activity of the heart* 
J5# There is m rloneat in the loeram which is dependent 
ur<m the s&chaniOal aspects of oerdioe activity# 
4# Tbo voltes the heart develops ore alt&metia® current volts®**# 
n# wumm m mmtms 
A* It was necessary to b$v© on inotrwBMiot sensitive enough and having 
a srmll enough inert Is to record the rapidly ohaoelttg cotton current* 
of the tat# Action currents or© produced by mny body tissue* moh 
m ’leads# nerve tissue# the brain# monies in mtim, and the heart* 
The action currents developed W the hmrt aro larger beoeuee boro wo 
arc dealing with o compact bundle of metis* Action currents of the 
he©rt ai-o in the vmm of 0#1 eilltaolt or mom* • 6 • 
B« Capillary electrometer ~ this lastmssmt devised by Weller* 
X* Zta principle id baad upas ©bangs# In snrtnm tendon Mw&sn 
a oolum of aeremry, wtoMk mMm op on© met of the circuit* 
end which la In contest with 0 tooth of sulphuric acid, *d*ich 
1® the ottmw end of the circuit* The column of mercury 
riotc of foil® os the surface tension ehoa^oe# 
(e) Bm slide # 
£• H14f # %o - till® ete on SBsnple of elect rotator record©* 
(a) Upper curve c • c » ©pc® oardio&rua* 
Lcror eare o ~ * a eleetvooefcer record. 
3* Slide # JPg$~ Mom electromotor record©* ffeo inertia of the 
neroKHqr leads to greet distortion* 
4. Slide# 
(a) flies* ore oxarplo® of corrections of the dectraBate* 
raeeroa* 
(to) The tmjtraaaat is sensitive and ©hasp tout it i® trouble* 
©one and Ineocurctc* 
0* Tho String aulfWMi—ter was developed by fcintboveo* 
lm Slide t*** *» ©ho??® one of the original modal®* 
E# Slia# • ate® photo of Slntbovon la Am Arbor at Hietool© Arboretum* 
m* mmmB 
A* of the Machine 
1* Speed of reeponuo 
Cal Mfcat be #€© sec* Cl/*?0 sec*) or lea® 
1/50 sec. or less <*» 6 m 
B* OritlooX Baling 
The overshooting suet bo lose than I m* 
(«} Aoeonplishod with string mlvoannstor by elr darling— 
friction with air* 
(b) Accorapliohed with maplifler by oil eeopmelm of coil 
and mirror* 
5* Adequate tlm oo&otsnt 
io) Applies to shifter type of machine* 
1, atth etrteralimemtcr 
string ramlno at this level# 
B* SBC amplifier mehtae* 
boos drift© book to baseline* 
i«) The Tim Ooaotoat i® the tine it tofcoo the 
be« oMkm to fall f*o» OteS.fi point B/3 
of the my bscfe to the bneelln#* This mot not 
be lea® thm I 1/2 seconds In order to ©void dis- 
tortion of low tm&maxy oscillations* 
(b) With the ¥ietor muoMxm Mo ttm constant otmm% bo 
tooled because the I m* ie thrown in for just m 
m* cannot bo bold la the circuit* 
(c) with the Smhom m®Mm ym om vm e trial rtm la 
order to toot out it© tloo constant* 
4* Boro* then* you beam the reeaou for ehoirloe the atdwliirdl$atio& with 
oooh record ta&sa©*-lt giro© the store 3 criteria an nell as standard l- 
sutler of X m* voapmoo for X nr« thrum Sato the circuit« m f *# 
B# Tho String Oclimnos^tcr# 
U forte 
(«) The String 
(11 8*3 in dionotori l/3~l/v. the diameter of a red blood coll# 
(B| A»© node of quarts coated with gold or plctinut>- though 
hum boon made of other Muriels, i«o# oilvor# 
(b) mm®tie field—*>cttppll©d by or pcwanant 
mo®act# 
(c) Current—to tiliftW elsin camatg, ©to# 
(d) Cenere with recording f 11® or paper noring at o conotant speed* 
(o) fiiaa*€3eiEiror indicating 0#0d mo« end 0*B ooe#—usually 
cormtently moving wheel with SI spares# 
it) Grid with space lino® to record m# cad on# distance© cm 
the paper# 
(g| liocns to throw 1 w* Into circuit for ot«ndardi»Qtlm# 
B# Boole for nm of atrlng galraiwraetcr* Bee elide # 
(a) Tho lino© of force about a wire In o magnet!* 
field ore- circular* 
{b| The string mvoc at right angle© to the lines of 
the ao&noiio ficM—»f0.lte?fii I&$c off loll; 
(Hasin®o toft Band Me) 
field 
Conductor 
1# • direction of field 
t* Forefinger-* direction of current In atria® 
3« Second finger*** direction ©trine will ito «• B m 
M Factors which assist mvmmt of the string# 
(1) Mr m9ietmm~*%be higher the Telocity, the higher the 
resistance# 
(B) Counter isicetmottve of moving a string 
cooSuetcr m%om n mm**ic field# 
C4> SfenoloB on the string vnrleo t he distcmcc it will SDTO* 
Thus the looser the string the greater the rawnomoBt# 
(#| Mofetamto of tlie string mot bo magnified since they ore 
vory ®mU-«origiiaeIly wmm *aoanificd 1000 time# 
if} UcmmmtB am recorded with the osmr®# 
(g) &eel«ti«oe of the string gaHmaewietoj* is the resistance of 
the striBff'xmsuelly 3,000 m 10,000 ohms# ISore recently 
strings of 6#000 * 3,000 dans resistance here boon m&& 
but they ore leas desirable# 
(li) fbe string suet bo standardised with the patient in the 
circuit for each 1m& ms&smately# 
(I) toll electrode each as needle electrodes ommt bo used 
with striae ®iltww*ft«r oince they arc polcrist&xc-*-' will 
giro weritootii^# 
(i) Foe* preparation of the skin with resultant high resistance 
will gtat oircrflbootlag# 
(k) If aa amplifier is placed In the circuit of m at ring dsleeMnetes* 
the resistance beeesee mofe b&'hcr--* 1,000,000 or acre ote©-~'thus 
a few thousand oto? difference m might .result from increased skin 
reolstanee, does not mtte* end does not have to etendaedlse with 
each lm&~~ (elthough one really should)* — 9 ~ 
0* The m&lttim apchin»~*oa8Ulos»8ph 3m suae© # 
1# fboy aw> of tbo DoddeXI typo—tbst la a jaoving coil mo* 
pended In a magnetic field# & snail mirror attached to the 
coil reflects e boom of light into th© 0mam§ thus giving 
tho record# 
(©) arc placed in the circuit no that the force 
om bo ccpliflad to the point where It will mm the coll# 
lb) Coil is sucoeoded in cU of proper consistency to provide 
critical tapping# 
£# It Is a high rooiotonoe electrodes can bo 
used cad slight imrmm& In reeiatenee resulting from 
proper skin proposition ao not nette* oc in cose of low* 
reeiftteac* string ealvanOTOtor# 
la) Itoovor, poor preparation of skin will yt8ft.lt in more 
alternating current being picked up# 
» 
U* Artefacts in | 
1# insole fmmam 
(«} aoon as fin© irregular Jiggles 
(b) Bat lent mist reload occur especially if pat lost fields 
sactvonitise niftfftar# 
(d) 3oen In !gFpert%roldijw% itaxfeinsooim 
E# Stray Alternating Current 
(s) "Fui** is roller 
lb) Obscure* os**** mmmtimt m& mtkm interpretation difficult# 
(o) Oon toll when you ero cottiag it hoomm otrim shadow 
does not focus sharply# 10 
(6) ttdi«Uy ecu be kept «t « minlsam by taking precautions r© 
AC apparatus or eleotrlool crjuipfaent ouch eo % tent* loops* 
ball cords# All such apparatus smot bo unplugged evea though 
mt on# Otto* ore fluorseope or X-ray 
apparatus la aora© nastby or name office# 
(o) Hurt stsplifylng typo, hove AC eltuslnotors# 
(1) Other eli&iaotiag my be grounding the rancMac 
to aooiby oto«® redlabor or plumbing, grounding tbo mmhim 
to the bod or grofonding it to the patient# 
3# Overshooting 
{») Mokes deflections leader the© they should bo# 
fb) Soon acot fluently with airing type galvtflonotor with 
poor prepMsttofi of the &liw 
(o) Mi patients mre apt to ohm? it tbrx others— I# c# 
dry e&ia, it^osoteae# 
4# iBCoestont, Irregular Jiggles mm nmwllf artefact 
to to ss« ebnormllty In tfee circuit c?r last nrswiK vt**1 •** i# o# 
batteries mn tom—in oppllfte# CMftteo 
m irre®ttlor Watifit in iit^Mas?disettoi 
s# macing tip UmI wires 
(a) If m pioaci m ha m& ha mM. 
t • - upside tern 
fjeoa else la 
dextrocardia 
II • ♦ boecoo® XII 
m - - boooros XI «* ** 
(b) If La. is placed cm IX and LL on LA 
I m m hommm II 
II ~ • bccosaeo I 
III - tootses upside desm 
0# Short Circuit in Coble 
tai Seoul** in a Hat lead with no donation ©t ©13 
IV* Afiatof of EviSf ABU fiaaftU whiofc Initiate end Conduct Electrical Activity# 
Bote: to Heart is a "Hdeaastlon CsolHsto** — $ucst like n Ceyoor# 
A# too—Is peculiar to to cftlft* 
ftalifti tort# 
X# It Is toft added hi#$i in to right auricle at to .iunotlon of 
the asperior vom &mm end the right auricle* 
E* Hoad of node is abovo, tail below* Xt la 
Bode im IS tan# In longth9 2~$ mm* 
ibldfe, 4W5 sKft# wlc^* 
Sino-auricular- 
node 
3* l&xio is mve aodpleg* mmM fibres are lots© dis- 
tinctly stvlstifti mm muplm. in mUm&t pattern toft other 
part© of tort mottle# &t to laaMtour to fibres peso cttau&t* 
ly or into to etnrloite fibres# It Iso© o rich blood 
and nerve supply# 
4# It I© hero that to tort tot or%totce*-glving rise to 
a rot© Mgber toft tot of mm ®tto? ©onto# Any pfttftt to to 
aode oon be to pesetoer* •» h? •» 
(a) The center which gives rise to the highest rate tends 
to dominate so long as the impulse can spread from that 
center. That center is called the "pacemaker*. 
(b) The Impulse from tie faster center destroys potential 
impulses arising at other points in the heart muscle. 
(c) All parts of the heart muscle probably have the ability 
to contract rhythmically in response to impulses which 
are generated rhythmically. 
5. Vagal Stimulation—tends to drive the center or pacemaker 
downward In the node* It has a greater influence over tl» 
head of the node and thus depresses the head more, so that 
one of the lower centers takes up the "pacenaaklng”. 
(a) As the center goes down in t e node, the FMsraves tend to 
be cone flatter in Leads XI and III—thus with a wandering 
pacemaker, it is possible to estimate where in the node 
the impulse arose. 
6. Syapat etio Stimulation — (this may be true, although we do 
not know for certain) —drives center upward in the node— 
tends to make IMwaves taller in Leads IX and XXX. 
7* S-A node present in mammalian hearts but not in more primitive 
hearts - l.e*, frog sinus venoeue beats before the auricles* 
B« Auricle 
!• Mo special conduction pathways haw been demonstrated in auricle 
2. Impulse spreads from S-A node to auricle and then in every 
direction through the auricle "just like a fir© in a field of 
grass** Generally speaking It spreads radically. - 15 « 
S* Bntm of Impulse tcenartssioii In mriolo Is 1000 s»u per second* 
4« It Is the of the t*0ttl*» and not the meonln* oontrfjotlcn 
tshich Is responsible for the 
0*. In reptile and acphibiaft, Isvxilso begins in sinus vcaocus, then 
tJwo Is a Interval, then auricular oontmotioo*- 
tons e ©operate ©harbor before auricle end also tftmouo 
arteriosus after the rontrlcIo--tJii© 4 iMm 
0« ** tlode (Hod© of fMm) 
1* Is InbeddeC at fees© of auricular septum, postorlorly, near 
tho coronary sinus where oovoctary wins eeptsr into right 
auricle* Only S5 ns* In disaster* 
S# It consists of the mm stmetnro as tho $*4 
node but la soaowhot mUaf« It is © knob m top of Hi® 
MUi« 
3# It iaoy hmmm tbs- $©ecn&er if the B*a nod© is depressed or 
tho activity of tho .MT nod© is enfesasod* 
0* Ms Bundle and Its BrniM3bee--~3Xide« %, f^rt 
1* It runs fro® tho Imer end of thm M0 node &MM9& through 
tho central fibrous portion of the heart until It corse© 
to ttm attflooler pert of the interventricular saptw at tho 
top of which. Just opposite the aortic velvee, It divides 
Into the right «od left bundle branches which then mm bo 
nmth the endocardium to reach tho 'foi&zinm twtomk* 
l» Its© right bundle branch is Sooner then tho loft before it 
the loft bundle broach bog lost to divide 
almost ismiietel^# •' 14 • 
3* Xa dog and ««» thorn arc so Ifitumeailoai botooft the to 
todlo braaoto nor vtoto penetrating to mptm or walla* 
tM* la fftoblftr not to ear* la the beef heart vberr bronoto 
th» aoptof tor* ar© both aneteleal «»4 pl$r«lo~ 
IvcSorX wmumm for thinking m» 
4# too© structure® are peotallar to to rsan alto tort# 
5# tfe#o© otsuotoes are vetsr difficult to toemotot© in the 
tern tort* 
E» M:te MMNto** f&ia© ,4g —tote ami * JD 
Ifeil* te i&Jeetteo# tod sartoa In 
shoos* msoX©# t» wisr &*t%m9 tv tbe ox tort — ©©Kf 
teomg>lc©oua In the tossa tort# 
F# ftirtto mmtmA&tiX OomoMorattea# 
X* fb© logical appearance of the mvtm& ©imtaraa differ la 
mvlm® m%ml&* Highest aifforentiatloa cod 8M©t©©l ©coo 
of 1® la' stop# tor aM beef# 
(») In ftiskio@ofe aoooriptica tof tort woo tsood# 
S# 2n itolto i*otwifes«* 
(ft) In to M&bftp torn to fibriHao ®r© amrcr ilia 
pe£tp$u$sr of to coll, to aacloi mm central# to mHa 
me lm&m$ to fibrlllae are »li f«wf to ©scoot of 
©aeroplatts is largo ena to otriottea are poor# • J5 - 
(b) Parking© fibres differ in that they contain 
mre glyo&ten* dsn be studied by giving o large doao of 
Cluoooo to e dog, killing it and staining the saiscle fibre© 
3* differentially* 
In its tomm heart differentiation la mob loss sharp* 
Ono anat follow the bundle dor® from above* 
4* fbare Is no His bundle in tbo prirsitiv© heert—frog sad tartlo~ 
only * tongue of tissue stamina ;lo® from the eurieles into 
tb© single ventricle* 
' * ■ ■■ ' ’ 
mm or 
0lyoogm 
Baft* or 
IftOgta of 
Fibre 
Oontoot 
3^0tol© 
Mea 
X 
I 
X 
4 
4 
VtmtTiiMl&P 
B 
M 
B 
3 
3 
Mri&uXar 
3 
3 
3 
0 
0 
Bxxkimm 
4 
4 
4 
X 
1 
I m leuat 
4 m mat 
BE&msm&m *lm of Oardiao ' Lewi® pg, 99 
0, gpratsd of Ispaiae Through the Heart, 
1* is ffcora aariale# apitlil receptors 
Into A*sr node~~Htoin etas of Hie lmdlo~*~ri$ht end left 
bundle of both ventricles* 
ttm TiMn Mm %w Mm m fsmMnim for e tap Id spread of tba 
lapelae wer the mhm&mrnt&iQl mmlo*~m % at all of It Is 
eotlvoteA @to>ot st the mm ttsse* 
S* tb® inside of both eerltiee hmoms active wm*y vapidly* • 16 ♦ 
4* the &9«&e» tvsvele slowly In tlio iMT iioao-~reeaoa for 
the wa iMtmsm!• 
a* Cfees the ispile© pumam the &*# node, the spread is vasy 
vapid* 
6# fins there 1® e vepld peeee&s of the in tbe file 
bundle ©ad tfe© whole lusts® of th© heart is etlmletod 
rapidly ts»d then the trowels ©ore slowly ttewJh 
tin© ogooerdlel tiasaeo to the opieordlum, 
7# The fsproed 1© fra® the inoldo of the hftftPt«*ltt the aub~ 
aodoonvdiol tt«i»ioe*-to the outside* Urn® the thieSmos© 
of the hoevt well is ee Is&ovtant footer in determining tho 
Mai© it will ts&e the fteptloe to reeeh the e$ieev31sl oovfeeo* 
S# If Bundle BXook is ispiloe gpoe dkwo the 
unblocked aid©, thee through the ordinary mode In the states, 
to rotieh the Vtodciii®® aefcmfe of tho opposite aide. If both 
boodle teeaebee ere out tho remit 1© octets heart bloofe* 
9, .All the foveoe which &Hm nmtmllz® ©eoh other esacoet 
those at the end at the best nmr the evtfieee* 
This in the retiooa that In the soma heart the rtesxi elootrlcol 
ozXb tends to be in tbs itveetlw of tbs cmetoiBifleX mis# 
Main Stem of 
His B. 
RB Br* 
%B Br. 
LV 
HV 
Mean Electrical Axis * 19 • 
H* Velocity of Xapalee 7ren«nleeioa tim Inpwise toes in 
in Varies type® of tori Sfeeele each timm 
111 toaX BDO Mi |>er *12 • *20 $m* 
(S) Tentrienlar 400 as* per coo. *06 m *10 aoc. 
(3) Ms&oiilor aoo - 1000 vxs« 
per ooo« #0S nao* 
(4) i*u3Ekln@e 4000 i®* per ace. *0® coo* 
v* muiWM oompm es omani or mimiM, toces xh to ii&ot# 
A# Kloctrieel farces arise by* 
3U ®adeottev«Hasi In a coil welsrtB& in a 
Usenetfte floM. 
E# At bcfeceu too flnMet too totals* etc.*— 
a ctOTosat arioso tore to to boundaries are not la 
cquUibrto, 
B* Potential 
X. Corroapoads to tmgmmtQT® in tot pmbXom* 
2m J&eototolty flon ttm to point of hl®fe potential to 
to point of 1m potential* 
fl* *Pbe forces tibleb profess o ©went in e coil tire et to touted 
between to ootto and resting pe*t of the coll. 
1» -ferrrst lo psofeood only ton to sell la $oto tom to 
aetto to resting or renting to aetto atoos* 
E« Bo current arises ton to fUXly active or folly feettet 
moole biit only in tot «feieh is oha&rin& ton one state 
to to other*. IS m 
D# the etotrioel tonge* with df*elopfl»t of « 
do not eorroap3®5a to to tortoise of the nnaeXe# 
1* to dnrlcafeg of to tnugele 1» deleted by the need far 
evercoMng .Internal friction first# 
£* to electrical epreed ropreweits to preparation for 
contocticm# 
5# This ie to reason for to etateoent tot It it to 
oproeA of to tepulee and not to contraction tdiich to 
roapcmsIMe for to electroeardfo^rtf*# 
B* to swr&soe of a dell is a boo«da«f* trio sell m the oatelde 
he® a different omipoaition tbsm m the Inside* toe the . 
coll id Msmded by e mrfeoi ooroaa which tore In e 
potential* 
1* the ie auoh tot the inside. i« 'negative and 
tlie ootalde ie positive 00 that if cell 1® mt9 ftm 
will be from oataMc to Isolde* 
B* ton a doll pttma Into to active etete* the MfKl 
eeapoee the active pert la different tern tot ever the 
vesting port# 
d* With n coil in to mntism etate there Is cn egpiUteicMb 
Stare no would Iwee two bettsrloe 
felt ccaneeted so tot tlm oppose 
each other* Tnae «9 *urM% 
*pt*M flow m 1,9 «* 
If mo of thorn batteries la rorweO It will tore 
otm offeet ne roroving the othav and stiiiiSng tfeo 
Moving A oebi omo mmlt no rojwlag 
B and turning A nroemd* 
fhtis ao soil become aetiv&i 
At tbo boundary yoo tom la offset ohet 
you %imM tore if pm oooiddevod the ctos$e 
ffon active to tooting as Ineteatmeoae# 
I, US m OMIMAtmOMb 
33U4#« wpwiflnoafi ElBttomafe orlfinol oorwe? k^t F& for 
acjrrsele eg to also of doflootima* 
4* B«wm 
U mwar mwivUm* 
s* licit a meXX of tie tot { fA tfove) 
|aat tnstovo tofe©"*off tC %* fcat it it Ufi&saXlf' 
tMpft % tbe Cilta too aU6t 
itt&t In totplctt fttttt block* 
3# IMtmt a»» tteiaelly ttaniift «3M*t isotohoa* 
to) aSUe$* notoMnt is not dmmsdU 
W msfetA xstMin# to e^5«®l* • £0 • 
4* Bi&o of 2»B or* - 3*0 sn* la load In wMeh It to 
s 
largest to upper limit of normal* If larger sneUf 
eoeee gBrteel«r eeletreeinaet* 
8# lBf«rsiei of f*Mm» 
(*) Xnvertoft f8 sot eternal* 
(h) liwr©rt*d f i or Pg Is eternal* 
C« Bm&ntim of Ptaev*** up to 0*10 see* Is noiml* 
B* CM OOCfhliQK 
1* BsewNwets eprm& of lapels* over mmtvtm&m muolo ns© It 
. i® peseta*? isto the aetiv© stete* 
to) X® ©00© o® ©XX of it Is sailn them Ib is© earnout* 
(h) Thee ©o It peaces toefe to the routine state get the 
Torero* 
B# IMS he troctod &b a -roup or tmlt* 
3* It 1® the melt of oXootrioel aetlrlr©tice of the Tsetrioloo 
and preeoios the actual omtmetim of the rwstriel©** 
4 * 8I@* 
(a) Upper limit** S4 m*** if largest deflection in QlW Ib 
sn? lead I® move thou this, o&eplese* ©to pmhvhly sb~ 
normal* ststoBwat la Ms •Meoheelafa end Cto&o&io 
is prohohlr to© mil **1S «•) 
(h) %&m* limit**® If lushest deflect lees in aesr Iced 
ore 6 m%* or Xoaoi dofleetioe* arc tmmmtiMp mmlU 
Co) Biggest defleetUm occur whoa you lead off ptfiUel 
to diction 1e which i%%*3tXm la titling# - El - 
S* labeling of coa£Ua«'->ia ootiroly axtoltmir* 
to) 0. m 6mmm& deflection mt pmm&9& by s» upward deflection* 
tb) E » first upward deflection* 
|o) a • first GmmmsA deflection after first upward deflection* 
If m. “final ugm&rd deflection* or 8* 
often of moh em&Xcmm m eraoll 
Q S Mteomi oocelaKca* 
$14* is ifoetohod E aare* 
Bo oot call tbia m B*mvo unices it 
gooo bolm the bacolino* 
Jlot cm ftaM* u&looo it noo«r aboro tho 
feooolltto* 
othia la a sotohodi Q*^vo* 
|fI %*wm& mm ooiaolljr tflotlly mil* 
(1) So stout people ay got <1 of 4*a as* In Lead III* 
(g) nsro tban SO Ena, 
Oi} iNiOffo usually not ramaally loxgcnp then 6 an* 
I** 
1* Itaprooeate mtzmt of t®mlm mm owmp of t«Wdo* 
toolts ao different fro %ES boocuoo it la ipsoed out (mv o 
lo&ger latowrai# 
£• os largo a# 6 an| often Ifti&Mr after ®teroiot to *» £& «► 
S« Direction 
% 
(n) Sot If upright the riot# 
{b> Imomim of % is not etaoxsaoiX# 
toj Xavoreioe of % or Tf or both is etoorml in m® 
laotmioee* 
(4) Zf *£*iratloa of %stoio yore evesguim* egue!** 
oouM bo usually iaverto&-~ it ie duo to local, variations 
in duration of that it Is uisselly upright# 
4# fho IMranre is the m&t easily offcotea. of the teflootloac 2a the 
elstteoiegaiegswiii 
©# Other tosns uooa in dossrlbiisa oicotroeord iograwe# 
*• wpe 
<o) Occurs In diastole* ceuiie not knoen. 
Ct>> 3hiof leportoiioe is that it ©taiM not bo sdetekeR foe 
aonsthtBij! Blm* U*mmm MR* no olloieel lapevtonoe m ft# 
m Immm* 
Occasionally or® larg© la ohout Ioe4o* 
s# ftgMP Junction 
3# Mb*® 
4# oesqpicac » QRS od4 T 
5# Initial ?«trJU«lar Deflection • OPS 
6« Fiml VoBtriatlor OoflootliR » t? 
?# jftmriculcf CoaploK » iMwvs • m m 
S# Oofstrsat of MO 00a amiad trooftn*# HU4e bo* 
I# MO Into no Oftreet booting m ncohaaftoal oetlirity of bo&rl 
( i»e* ©KbciEctio*i* not Cie&Boasfele turn i*)« 
(*) ffetos© c©» be- rco* fey lafarccfr* *Mh so mil mam^am 
aey norm esrftftca failure* 
(fe) fl*> MO ft© mrcly so electrical record end mat fee 
os mcbll 
a# First smna In ooirewS trseiEg occur© 00 <5©fle«ndt»o 
Ilab of S-^stro* 
(o) la «&* largely to clodur© of Efttrol ©s*i trftcacpftd t*avos# 
S» aocoi&a soueS ft* due to closure of eortfte *nft .putemorsr tElros# 
uaoollgr occur© »t and of 'JMaste*# 
II# Hat© 
A* Oftvftaftooa# 
I# Booh snail atTioion « 1/as ©00# or 0*04 too# Usoo pcs? aln*) 
I# 3Mh SlTisIoa m 1/5 aoo# or 0#BD 00©# (300 per bIe#) 
3# IfiOO inkU dfttrloftosia » I nbtttn# 
B# If rtsrtfen fta regular* 
I# Umollgr sp*t p$m&met port of ***** cm toey 3.ino anfl 
oc*mt ti» tto line* to to* tmst plnm fit sliicla the mm 
thisg occurs# 
1 £# tteo if 0 ctoile cycl© ft* W emll dMite 
1500 * 88 per min# or 1EQQ » 60 per nUu 
** a® 
5* Oa* ea a*ato up * cfeart# 
e m mtfmtoi 
10 * ISQ/isltt. 
W » 100/kIe etc# •» 84 <*■ 
0* If rbptbtt is Irregular* 
X* Count severe! B*H Intervals end the number of 3/5 see# intervale 
they cover. 
x noo • »t» 
i*o# of 2/5 aoe* intervals 
A ..»gflp » rot* 
Bo* of S/£8 see* totowelii 
or 
I • Ij » 6 8 «1 tatoTWBlo. 
P X 300 . xsooo im por bib. 
ib ip 
0* Set© is i£«xxrta&t In asking diagnosis* 
I* Auricular rate 
i* Auricular fitvllkltw** auricular pete 500*400 plus 
3* teehyeerdie-* rate XSKMTO* usually 18M89 
4# Soviets heart block— rate 50*35 
5* alms teehyeaMle** somd mchnnim hut fast* 
i* 3ims bredyoerdim~~mw.ml mo'mnlmi hut sloe* 
XIX* Snt«rreXa is the Elm%mmv€ioimm* 
A* Bote 09 to mmmwmmt of latoamlai* 
X* Qon be mrnmm& In mf of the 5 leads* 
A 
2* Cos take the lowest Interfax in any lead or the svemge 
of the interim Is in the tm Xeede In which tlmr om m®t 
SMflT alike* 
»• i*> not Me* the shortest toeoauae te that t«odif the ootael 
war bo $osp«»&i0ular to the booMaxy of activity and ttew sm 
got m looeleotrlo ourro at that point. <* 88 
4» iMwesUf spooking* iron ere lees 11 ely to have !o6~ 
electric deflect ime in that lead in which the deflect Iona 
or© largest# 
S« One met that there ia a phase difference 
in. the different lead© so that the pmt of R ia not the 
game in all leads* 
B* JV*B Interval { or IM| interval if there is a ci~wav©) 
1* Keesured from beginning of IMsava to first indication of the 
$RS g*eup«**th©t i® to beginning of o or beginning of i. 
if $ dees not ocw* 
It tMmmsmn ttm interval team the first ©vi3mm of aurioulor 
•ttitiritgr to first off vmtrlmlmr nativity* 
3* &•& mML activity doaa not in Km tetwme th© 
eooimt of mml® Involved is not large 
(a) the boundaty botnoen rooting and acting mmlo mot 
tew sufficient eroa to Infineon© the potential© of 
the vactrcedtlaa* 
(1) Ms ia the reason that thaw ere no deflection* 
from the A-*f node or the Bin tmale or the bundle 
branch©©# 
(2) Tl*© mt of mscl© which mat fee involved In 
order to cans© © deflection in the ©bps© for mat 
individuals* the emmsnt of mool© in the auricle 
which mat he involved before tm begin to got a 
F-wav©# and the in the ventricle before m 
get a £83 oonpleK* MBt b© relatively coBstent* m JSS mm 
M We begin to get ttm V~mve when a certain &momt of 
moolo is involved# 
4« Wev all practical purpose® the ©Is*.© of the auricle—that 
la the distance which the is&iXm met travel— to the mm 
for all individuals# 
8* Hossml INS interval# 
(a) Adults—0#1£ - 0#S0 (Don*t usually pay too met attest 
tloa to 0«E1 m 0#2S)# 
(c) If prolongad * 1° heart blocfe 
(d) If abort • it 0*10 see# or less, norm! sinus rhytbra 
probably not present but here nodal rhythm# 
Cm Prolongation of P~a lateral —See elide # A^# 
(a) The path which tho irspulo© travel® from the B*A node 
to the -MT node 1© broad no that it may vary and it is 
unlikely for disease to involve n wide enough area 
to effect the time Interval# "like trying to block 
Atlantic Ocean#*' 
(b$ The A-V node is especially aasecptibla, hmm®r, bo- 
couse here- the path is narrow m3 the ingwlao has no 
way to go ©round oo it is hero that most lesion* caus- 
ing a pTOlo®r?cd Ml Interval occur* 
(e) A mall mister occur in the mein stem of the His bundle# 
(d) Once the ftflpulao p®®ma from the large branches of the 
Hie 'bundle tho path in a&srlii breed# * m • 
(el For practice! purposes, the path which la m®t irssporttmi 
is fro® the top of th© 4-V node to the bifurcation of the 
Mm bundle, except In bundle branch block whore the unaffected 
bundle branch behaves Ilk© e prolongation of tb© His bundle* 
Thus* hevlag bundle branch block on one side, you ©an prolong 
the interval by effecting the bundle branch on the 
other side* 
(f) 4 certain ©raount of ventricular mccle met be Involved 
before the <£HS deflection begins* 
(a) 2n tcohycardla not duo to loosened vegsl ton© the Ml 
interval is usually longer— i*o* perosysrsal auricular 
tachycardia# 
(h) If MR interval got® longer ©ad longer, dropped beats 
' finally occur * Z° hcerfc block* 
(i) la noonanl people the MR interval tends to decreem m 
heart rate goes up and increase© cm heart slows, m long cm 
tills variation in rate io duo to the ortrlnslc cnrdloo 
nerves— l*e* doereoccd or lacreoeed vagal tee* 
a* om ®m elide % 
X« It® fvm first evMcmee of rm%riml®T activity 
to sar jimotioa# 
£• MormX limit®* 
(a) 0,05 - 0.00 see, 
(b) 0molly 0.06 - 0.08 000. 
$a) In aoocr.rlng It take lonreot ftilS In any lend or aronor# 
of two which are elonost. ~ m ~ 
0# The QMS intorval ordinarily the to the 
end of ventricular activity* 
{e| 51s© vital area In the spread of the impulse I® the 
bundle branches* Lesions s*st bo In ttm tipper portion 
of the bundle branches to amm o demonstrable change, 
(b) Generally cpoafclas* then, the QHS iatertsl is a «eesure 
of the integrity of the bundle bxisiM}}me-*«scept la 
&&***& diffuse depression in the ftufeinge tissue 
ae fro® Qulnldinc or urossie* 
(e) then the ojts Intorvcl ie over, all of the ventricular 
mael© has passed fro® the resting to the active state* 
(d| After the iiqpulce roaches the ©rboriaatioa of the bundle 
branches Its path Is wide and not easily effected* 
(©) However, if there is e area of subendocardial 
sclerosis, it might effect the Parkings tissue enough to 
Influence the Interval* Is infection the Puxfeiag© 
tissue is mm resistant to anoxemia then other 
cordial tissue* Usually in infection the. $R8 is sot 
smloogsd unless there la bundle busA block* 
4* The Q8S interval mmat be effected by increased vagal 
teas is as m/bh as the vagus does set effect the ventricle 
directly nor the bundl© brenohec. Therofpre, If it is 
prolosiged it is acre evideoee of organic difficulty than 
Is © pro,longed IMS interval* 
5* The QSS Interval assy shorten as the rate goes up* This say 
be due to eeeeleretor tone* The accelerator serves do heto 
mm diroot affect cm the ventricles* m 2® «• 
6* %pertrophy of the heart does tend to increase the QMS 
Interval but the effects are relatively insignificant* When 
the QMS Is over 0*10 doc* It Is probably not due to heart 
size alone (as ehown by Herrmann)* 
7* Definitions* 
(a) Intraventricular block—defect in conduction below 
bifurcation of the His bundle* 
(b) Bundle branch block—a variety of intraventricular block* 
(c) Arborization block—defect in conduction in Parking© 
tissue* 
(d) We speak of a prolonged kUB interval as intraventricular 
block* If wo can toll from the M& that there is block 
of one or the other bundle branch, we apeak of right 
or Xeft bundle branch block* 
D« Q!f interval See slide # A^0 
1* Ivoa eared from beginning of QMS group to ond of T-wave* 
(a) It represents the length of electrical systole. 
(b) It is highly variable depending on the heart rate- 
shortening a© the heart ©peed® up, levels off at high 
rotes, though. 
£• Bezett Index—Formula for measurement of Q-T interval. 
(a) K m Q~T Interval 
(b) Limits^ -0*42 
Aver*' *e Standard deviation 
£ » 0.374 0*0129 
p m 0*503 0*0166 
("Upper limit of normal* mecns, svorag© plus 2 to 5 times 
the standard deviation)* Standard deviation derived from 
squares of the individual differences from mem of the 
group* •» 30 
3* Prslantmtim of €HP interval occurs in*~ 
(o) 
(b) Chronic urorde 
Co) OoKsplote boert Is o .'Tjpcmp of popple with oosa- 
plate heart block whp here dh eartrcsely long (MP Internal but 
its sjeisntng is not clear* The tosmlo probably does not 
hoM for erlrfefloly alow or csttroaely fast retoe but In those 
people with collet© heart block there 1c probably some 
Other reason# 
Cd) aoe» cocos of coronary occlusion hare a long <Ht» 
(e) Cardieo failure toad* to lengthen it occasionally but rot mch# 
(f) mi&moly low tenpef«turee--ie«MxMg fcmiMat for 0© (Koa^%a)# 
4* Short WP MMmft occur# in:- 
(a) %porefileor:iia—oo In tuiaor of pearntfeyaoid rlaM# 
(b) M&itelle tends to eh rtea it slightly* 
5# Although electrical eM isochsnicol systole wary together this 1© 
not elamy* true# In hypoeelootala, the electrical uyetolo la rosy 
lom 9 mctmrdQ&l cpoiol* Is Of 3MM& lOftgUl m& <»d of V*wv» 
ocmc loac oftoo th© osoooa oooadU (3aa ®il«ae )• Usually 
tho loogth of olootriool ood ©wolmlool aystola are tho mm but 
m% almayo true# 
£ou&6 
1st sound 2nd sound 
6. Increase In %~T Intetfel often difficult to detect because it U 
oftm difficult to be certain Just whore the femm ends# 
time usually giro it no greet significance until it is quite 
definitely prolonged# ** 33. m 
i?* shb mm* 
A* Cteercl 
1# Load I * potential difference between HA and &u 
£* lead II w potential difference between HA and IX* 
5* load III » potential difference between JU and IX 
4* to are atoays measuring the difference la potential belasoen tee 
points* 
(a) Doesn’t ©attar if piste is m wrist# bleeps* 
triceps or up on the ana soar the trunk* 
(b) If the two pistes ore pieced m the mm axtvmity 
m get preetleeUr nothing* 
io} fho tapoxtmt thing about the extremity ia the 
point at which it hitches m to the tsnMr—tho 
eaftrcBitiee behave as linear conductors end are 
really nothing but eaeteasleas of the load wires# 
B» those three points ore roughly at %im apices of ® tricagl® which 
Is o§uiXg^mfa**QStot origin of the Eiathemn triangle* 
1• Aftycata&im of oueh looking evet* 
(el Shay are easy to nwwtee»f (Aire dealing with an entirely 
different situation with pmm:w&M loads whore 1 am* nay 
give a big difference)# 
(b> Are eomreniocit* 
C* Iintto?cn#c law 
1« am of deflections is heed t mi lead 111* at ejygl»m insteat* 
trill ensel deflection Is tend II9 but sines the peaks are sot 
oixmlimomot pis® % doss sot always equal %• <m m 
£# iroof f El&thoven’e %m 
M Olfforsnoe In potential con be mmmmod from S to 
F or froas H to L to F* 
It is 2»oh like a tcsaporeturo problem# 
If torap in tom Arbor « &Pf teep# in Saline » 40? toqp* in Tpsl » m° 
(I) AA (30°) - Saline (40°) - -10° ) 
| 
(III) Tpsl <3S°) - ton Arbor (30°) - 48 ) « - D° 
(11} Tpsl (3S°) - Mine («°) - -8 ) 
0# The polarity woo so obossn fey Elnthoven that in normals there 
were nprgird deflections in met loads# Ttmsi^ 
Load Z « L » B 
Load IX m W m M 
Lmd 111 m W m I, 
IS# Hbot do the standerd loads mm9 
U Tho three leodo are throe Afferent •‘plcterecf1 of the oXootorlcol 
eves to oocorrtag in the heart# 
(a) Xf yon loci: at the efeyeorapor from each of three potato 
A# B# and Ct one rote three different 
pictures* yet the remains 
the mm® til the time 
f* MMthmm Trlcrnglo 
1, The BlxithOT«B triangle postulates tbe hoert as a snail region 
at tbe osnter of a sphere* tbm the three ext realties ore st the 
©picas of on ©Qtiilotorftl triangle with points at the surface of the 
sphere lying m a plan© pa so tug through tho cantor of th© sphere* • so • 
S* Using the Elntbcvon triangle as a basic construction one cm 
determine what any force of any nagnitnda or direction will give 
In the standard load©* 
m » else of deflection in 1 and direction 
©s indicated » upward deflection* 
C® • ©iso of defleet ion in 11 and direction 
m indicated » upward deflection* 
EF © nine of deflection In 111 and direction 
as indicated « upmrd deflection* 
5* In tho mrml heart the nvomm direction of the excitation 
wave nasally follow© along the ©natOQlonl axle of the hoert 
|3oe peg® Id)/ 
4# la the vertical heart the mm electrical axle will be * 
S* In the tafenorerse heart the ssoan electrical axis will be 
Vertical 
frenewefo© 
6* St'Ctrloal forces which arc pyodcalaently K to I or I to H 
defloetioaa win be ftiggoot Isa 1* 
f* BXc*ftrioal force® which or© pretoaincntly txp to tom or 
tom to op, deflections will be bisect in III* » 34 • 
mnmaxasa m zewenr mm* 
1* aims Tachycardia 
A* Bo abaorraelity except rapid Ileart rate—4aoebsn&sn of boat 
is mrml* 
B* Cmm$ of aim** tachycardic--larg©ly due to decrease In 
vagal tons# 
/ 
X# fen* mmilly toemMf rate 10 boat® par iin« per dw 
of temperature deration# 
B# Atropine—"paralyeea tha vogue* 
3* Aisyl nitrite cap diminishes vagal tons* 
4* 3ho<fe--suad©a fell of blood pressure result® in rapid rat© 
through eerotid etnas* 
5# Womxrhnm 
6* Acute flfeee&litie—usually ocecwpenled by ® greeter Sacrscso 
In the heart rat® than would b© expected from the dcgro© of 
fever* 
?♦ In nervous state® and sxeitaae&t, tbpretacleeeli 
8* In moot chronic 61mmm& there is m striking tachycardia* 
0* •Tendency to Tachycardia* 
1# Occurs In effort syndrom* {!3ouro*olreulatory # 
These patient® have no tachycardia tinder basal condition® 
but only on exercise or stress* 
3* Slate goo® up to ISO per nimte or higher* 
4* Frequently occurs after influes®©* 
(a} Such tachycardia m exertion but not under basal con- 
ditions my last for maths* 
(b) It does not mm acute myocarditis* m m 
5* It is a deroneosaent of the vegetative nervous 
© syooasditis* 
6* thee© potients should not bo put to bod but should bo eo- 
ecurngod to mmmim* (Bxoopt the post»ixiflii«aeal typo)* 
7* Athletic training tends to increase vagal tone sad mko t?o 
heart rate slower* 
S# Patient© with effort ayadrotae also otwaplcln of t« 
Co) Oold sctiwdUti 
(b) Acrocyanosis 
Co) Procordial pain 
M lea© of fatigue 
0* If exercised# the rate in these people goes higher then in 
mrml individuals m& stays felgiier longer than S dmitos (whoa 
it return© in movmXa) sad the return to norm! is sudden* 
B* Bwwsml Sinus Taohycmrdl© 
1* There is m sodden onset op sadden ooooctioa 
fi* there la a gradual rise to a pods and then a gambol fall 
to mmmm3b 
5* There may bo * mboonoolouii oraotlsosl disturtooe which 
give® rise to it* 
4# It my occur la aa&iety nourosi@-~the Individual got© 
concerned or slstned m& bon e period of pcracysnal 
sinus toehyeerdis* 
H# Upper limit of norael ret# » 10) or saor© per nlast# over © 
period of tins© « tachycardia* 36 
tsu 
mm mmamm 
M Omm& 
Xm . flapisge 
St 
S* atbletiee~»Athletio training tend© to increase fapl tone* 
d# POgfc^ertBB 
5# ©la ago with ertwiocclercei0~~it mgr be that these old 
people have a sensitive carotid ctnaa reflex with aocooieted 
imrmmU vagal tone# 
6* It apparently depond© on vagal time* Athletic training seems 
tn Increase vagal tone no that by repeated period© of exorcise 
one can bring the rate dom* 
V* Intracranial lesion© causing Increased intracranial pressure* 
B« Signifiees>eft* 
1* It is of leee ®%aific®ae© thee tachycardia* 
People with brndyeerdla ore acid to lire longer* 
5# It is of little irspoftance unless extras*©# 
4* as a rule, it is lea® eonm. than sinus tachycardia* 
i xi* mm *Mmmu mum ah, a&$ 
A* Ifef i»ition—fluctuatIona In vagal teas© with respiration causing a 
waxing end mating of the heart rate# 
1* On inaplratleft**#©*# mm up? cm eaplretlon it goes tom* 
Bm Often If sinus arrhythmic is not present on mwml breathing 
it will appear on forced, deep breathing* 
5# At t&aee, if digitalis is given, it any bring out e sinus 
• «w HSf m 
B# Causes# 
X# Ctmmn in ehildwa*-"* aXnoot universal 
(a) If child torelopc rheumatic fever, aims fintrtmift umidly 
diMBP*M» renpposriag se the acute rheumatic citato doors up# 
S» Ommm whenever vagal ton© is MgWathXeticot in people with 
dear heart rates, in young people after infectious* with 
digitalis, which lucre©see regal tone, in old people with 
arteriosclerosis* 
5# It la rarely mm with heart rotes above X00# If the rate la 
raised to that level, the arrhythmia ia usually abolished# 
4# It la very eamm and very aasfesd in dogs# 
5« OH people often heve sinus atgbptlwta which dose not mx md 
w with the mmUmtUmB but with deep respirations it usually 
faUc in step# H r®ro inarlaasce* however, in such people, 
it does not# this ia ©spec idly tamo In old people with severe 
arteriosclerosis# 
6# It 1© mm in all conditions in which hr»dyc®Kila mey occur# 
B# Ohaago la P*mm>9 with Arrhythmia 
1# .Driving tho paosonteer tonn In the M node tends to flat*m 
the rxwwree in Me XX and XXI*"-not so meh in load I# 
(a) this is pxofeably tho reason that patients with bredycaftI® 
have fiat iMama end those with tachycardia have hi&h 
<b) this is errantly due to the level In the node at i*hleh 
tho impulse begins* than the pvomakm is forced tom In 
tho $4 node the btmniery between active and rant lag muscle 
beoome changed oo that it io mor© perpendicular to 
Bead XX m& III# fhis is celled *&smm in location of 
the Peoenafcer#* «* «* 
(1J Tims with paeemker ©t A# msole le octlvatod 
dom nad to tho loft os lino AO# 
(£) If xmoamkov Is at B# modi© la activated 
aoroos and to left &o that $»mm>s ore 
fasollor in 11 end inverted In HZ# 
(c| The vagus apparently eontrolo tho tipper port of tho 3-A 
node top® than the low port of It# Whotber the opposite 
:• : 
Is tsu* of the accelerator nerves is not kmm* 
8* la slims corns with inspiration# slowing 
with aspiration# 
1# v«pX tone—alow© amts* It op# 
2# lucres,sad accelerator tooo-spacds rate* decrease-slows it up# 
sr* janr* mmwmM msmm { ** mxm* mmm). 
A# fhe ft**W aM® nay boocuus the it the B~A node is dew 
p&eeeed oa? if the activity of the nod© 1« enhanced# 
1« XtmaXk? hoc © sloifcor set# than the allms nutto* 
B» Crm b© pve&ieed by tiffing etmptm* 
(aj XSmc-Xl& glT© 1/50 ipes> (b.) end etiniSote tenon by ttiiotM 
slim peeeenee IS Mmstsn inter# 
(b) Vhat 7m do la to the tegel ondinga that ge to 
tl'ie .V? nod© before theet at the 3*A node* m that by veenl 
sttoiintloaG the 8*A node lo without affecting the 
iwf node* thus when the atropine effeet lo Inoojaplet© 
i affecting mly %Jm h# tegel endings) tegel ettnilntie* 
eiU Blm almas node hut not the A*4T node, rmd time get 
la mtmX people# m m 
ts# Cm be produced by anything which disturb# tb© vegetative 
aorvous a© adrenalin* aconitine* mmthcmiat 
nicotine* digitalis* tosanlao, f«nwt 
4* Has no serious $1 laical noro oorsnonly 
after txxm drug or toxenie* convalescence from Infections end 
forced reap tret iaa« 
B« Criteria for IHtarmsis of MT l&ytbsu 
1* P*mmm* nmmlly inverted In IX end XIX end enell or laoeloetrlo 
in X* 
Ca) Seacm latawalott* 
Worm! <mtfcrntlon I Ml) 
2* Wi Interval ie etoPtenml cop w?«*aod« 
(a) Length of |MI' istmd depend* on where in eriT node IsapULoo 
is arising (See b©lo®> 
(b) abortenlag be so slight os to b© und©tcotable ealees yon 
have mmmX ouvte for coKgHsrlmu 
3# pr* fUUxan uses phrase only Asis 
(1) Both auricles and ventricles are responding to the Ipfulae 
arising in the MT node* because these ore the only oases 
whose you bxuwr Wtonm the center Ilea* 
(B) Rhythn is in mm&l fashion. «•» «» 
(i) Mt nodal Is erialag in the Mf cod© but la on 
acBoiwaA 
Cb) ttagr tort Mioreatrieulnr rhytha beginning in the A*4T node— as 
In ocelot© Mock# 
4* foatrloular slid® 
(a) aingl© beets of tor lap «itt# origin Ml boot® of 
IdimtrMit rtgrtisa* 
(b) Occur tadam there is ttiBft slowing of olnuo rfegtta** oa In 
ragal atimlatloa, orjrotid pressure# 
0# tfrfcoa of JMT HOdal abytfrj»>only slightly atortoto* IMl IlitafTol# Slide A&& 
1# %p* X 
(e) Mmi ftaroFtod SMwwm if XX and III «f*3 shorter 
M* tntesftil* la this typ& tM topaXm is ©rising hinb In 
the iMT siasd® on the auricular old© and tli© P-& iatorvcl 
is of nearly usual langtb* 
(b) so® transition frw M artytbw to atoa rbytlsa# 
Cl) a®® slide k| 
Co} At the tMOflitlon la the tmm B*a nodal 
ftorttn to A*V nodal the Insula®# item each nod# 
nmtimllss© mch other la to- atoytoulaff m&$%» oo that you 
m7 ®ot bo m&hmieol euricalalf systole occurs# 
(1) Hoc siitle best# 
(£) tkm&t la which M node tatam over *p$Gmmk®& activities* ** 43. •* 
(1) tPho /«-¥ nod® le fcrrilng iRpjlsos nt *s ©lightly fester 
«*te than tiio 3*4 node so that it finally dischargee the 
M. sods before the letter gets e ehenoo to st&mlete the 
anrloles end thus eXX of tlm auricle is responding to the 
4j*T node* 
£* tvp© XI £lid« Ml interval is 0. 
{») iMfefflM c*e suporinposod on complexes* 
<U Xf th® Impulse starts Xmr enough in the J&W node, the 
Mwrres awy s®% lost is the qM gm$®» 
(S| If jos ooald me the IMm®®* they would bo inverted 
In l-oeds XI and III* 
(b) .In this typo there is swporliiposftlen of the A ®*6 0 waves 
in the venous pule© tracings sod the diegasni® <tm be md® 
clinically from Xbvm» palsatlowi sees In the msdk* 
3* Eype III*~3llde A%f** be,VO IWP Sat«mdU 
(«) If inpileoe oris# still towor do® In nods, the P-kttoc 
cdsao ont m the other dido of tbs QE9 complex* 
(b) Is this typo* too, there Bey bo large. Aj®*r«® in the pales 
a 
trot lug' and *hm®& pulsations In the neck* 
(©) 13140 ritam « transition from tmvrnl rfeytha to 
type XIX A-4T nodel rtyth®# 
f» kmoxiw Mm wmmmmn 
■ k* A tof Mf aoftaX rtoyth§a* ** 4*5 <• 
1* MT rhythm to a patient with a slight defect to conduction 
to the upper part of the &Jf node m that the nodal to* 
pals © eonaet c?o back toto the auricles# 
(lioto) i’-R Interval fWto shorter ami shorter until finally 
en upfright l>«4»re cores out p& the other side* 
Here we hero 5 B-ewwree - 6 tup oonpleroc# 
(b) Hero# then, we here untoAlrcetionel block, the ventricles 
or© best tog factor than the auricles m& m hate asio cetre 
ventricular boat* It Is ©color for Inpulsoo to peso t vcmft 
the A»V node froo auricle to ventricle than from ventricle 
to auricle* 
B# It to theoretically lfit«itsll8g aince it prove© the occurrence 
ofttaHifeotlonal blocfe#* 
G« Bet* that eooo up clooor to rrroup ond finally cot-id 
out m the other oldo* But whm It coaoe out on the other oi<to 
it 4a at ill upri&ht, therefore It is oosslnft from tho 3*A not!© 
end not the tarn Muter* 
Oa Bote that P*«voa co®e up closer* I& ;or center boo on Inherent 
ret© here which in just e little footer then the 
nodal rhythn# 
J « fhua eo hove unidirectional hlocfc bocauce the ispilee oome ftwa 
auricle to ventricle hut eon not - “ct twm ventricle to mriclo* 
f* Hero th&ve mm two cmt&t® S»A aoa© ana the to?or eentor# 
G» ft* IMP Internal lo oonotent Hit the Ml interval to not tmomm 
in eecfc cycle there ere ©no or too roercmooo to the etnue mto« • 43 • 
to# amMmaoum »; aua« a^* 
4» Xspiloeo eto fossiod in the a»A node but ai occmtdmmX 
l&tomltt certain of those irpulaes fail to rot out into tho «mv 
ioulor «uolo» Thuc nothing below tho l<*ml of tho node ics 
activated cmd there to a ooraploto dropping out of both mriWutm and 
vontvieleo* Tho internal thus voanMag Is osoctiy (Ml» tho 
regular intouwal# 
B« Oiegnosiis ostt be mdc with certainty only when you taro two !:indo 
of tei%mvGXo**4omml m& s ttoso Msaol* 
1# It m$ fee difficult to distinguish froe sinus orrbyttialo* 
0# Boooo* 
1* Bloch p$obf*bl$r mams ot Junction between stioclo of fi«4 node 
«a6 auricular mode* 
5*A* Bloch 
8# More oomioaly produced by digitalis and is on midmm of men* 
dlcttollsmti«m# 
5* Ufiy bo dO0 to fbgoX fltiSSdfttiMK* 
0« la difficult booeuao how® no irecord is oarv® of S-A 
node activity* 
1« (Jonfbclon with elms© ai»>yfchaia 1© eea§r« 
f* If Veit* i© oonflaiit ot otho* time, that with blocked be&t; 
It iO SMMRt* 
mmmjmmmimM imm ms s. 
I* Qm&ml 
A/ Bloch my occur at one of fee plceeo or both# 
$X> In ApT node# 
(4 In ruin etem of Ills bundle# 44 •» 
B# If it occurs in tfao 
1* Mono likely to bo aue to 0 nodal aeproscioo** i*o*t 
8« Utcf roimlt tvosi digitalis or vugpA sttmlotlon or ointlnr 
Offsets* 
0* If it occurs is min atm of Hi© bundle it 1« rxsro apt to bo 
an ortcrlooolerotic process* 
XX* Xroloogftd Ml Intor^sl—first Ha@roo Ikmrt 
4* Consists of Xmffibmim of ooa&3Ctiea tine — IMI interval 
S&id* Agg>* 
1* Upper It*slt of mmmX is 0*00 ooc* (in adults) ho lorn 
than tlmt in Mi children and infanta* 
B« On© oamsm omm of gsliop xbgrtbos is 0 prolonged JMI interval 
©specially in preome© of o rapid beerl ret©* 
1* this is a ssRiast'on ©ftllop* 
C« Belief io that ©uricl© contacts just s© <vtf reive is about 
to open resulting In © sudden rush of bloa© and time © ®nllop 
sound which 1© loud i© produced* 
0* Qmmm of iroloneod Ml Interval* 
1*. mmxcmtio aiitl© with fever and stropt* 
throat* 
(0) Usually present In acute ate** m& wy bo used, as mm 
inaes of degree of activity* 
(b) lisy persist after mbaldonee of mote tbmmtio fmm* 
S# lAiotlO hoert dlcocoo* 
5« isrtorioaclorotio heart disenao# * 4H3 ** 
4* laer- need ?ngol ton© 
to) fliith «mlM| boart rot© to inarm m& m& $*& is 
shortened 00 tm$cX tom is docrocvtel-«<rith t*$$0Mqr# 
oodtoa cssoreloo* 
(b) X& taebpoanSleo not to© to dooraoooA mmX tooo*~ i*o«» 
pmxsya&nX aovtoolif intcrrnl to 
usually Xonfoaf* 
5# m#ttoils auae 
to) KopcwltOly eon a leog ’M interval bo attributed to 
digitalis if V dumped *&rnmmm cm ©too present* 
(b) Heoolto partly from tncrcoaod imwl ton® md portly frm 
direst offoot on ouoclo limit in iMT node# 
to) Bffcot on IM4 Interval ©on be ©bollab©0 vrttli atropine bat 
Mow* ehmmc emmt sine© tbof are too to digitalis 
offset on m&iOalte fact, it aoei no to laovonoe th* Musvo 
Qhmm®* 
XIX* P&etUiX Bmrt Dmmc Eoert Bloafe* 
iWX*^: teat© too to nro/'.re-oolvo prol&igettaB of Mi Interval 
aofl ofcortonlng of Ml latortfeX tmtil a boot 
is*$» ant* 
r.« The B*& iatoaml botwoo which tbe Ibwpoft test occur© io loon 
thon toie© tuo mmil Ml tntnmcX W the Intrnmm in tbo 
length of the preceding Ml tnt&rml m& the ohortealns of the 
P**M internal t&llmim It* 
mt* m m 
0* There in tin® a ;ui<3fconln£ of to heart rote before to dropped 
tot oaenro# 
•t* Thnv> mo cey oar* to IWl iatonrol get# tortor ee to IWI 
latoawal get* longer becotsao to kmI of Ibotoooc in to JMt 
interval gate torn to loon* 
5* to pfogroaotvo prolongation of to' F*»& interval tmr bo looked 
OBfiSfl SMltto Of fotigB© to mmmXfm 
(a) Ptotly to iM? %inm» mto mm to mm tn% into mid 
ton following the blocto Irspuloo, it mto o iTjreetor 
oppeetaettgr for recovery* to® Mt interval in meh 
abovto* iter fleet tm hmto again# 
Cb) iPBomxmW# lagxtlae t&ieh If? blotocl mo to with corfjlatoly 
%%&mm tfammm toe* with prolonto 3M* intervale 
saot with partially refracto®y tiemie to too gecaise 
1ST' etcr tlm to poaa thrwh# 
Site fto iolatlmraipo In Boot# to to 3MI Interval? «* 
ymtriol® 
B# Bcntf? mf amp mt withoot pm*%mo of pmm&too® $**B 
ixttosnmle* although tiiio i& mom. mm* U©e glide Agg# 
00 Wk?tm$ m&m of pextieX A-tf la for to blodc 
to aeon* ro^lorly# 47 
1* Hay toe 8*1# 5*1# 4*1# ©t©« block# a©e slide A 
p# If patient with 8*1 block io rivm assy! nitrite# Sil block 
my be convert©! Into 1*1 reepa&a© with piolonto Mi |at@rvil« 
(o) Effect toe is due to part id pefdyele of fipi by 
ref to of foot due to louring of the blood proocnro# 
(b) »too?er you too partial tort block# the rmtrimlnv rhythm 
la irrc&tlor mloon you too Sil, S*l, or 4*1 bloc?:* aloe© 
511 or 4*1 block an ran# If you to© tort block to am*, 
lev ftytlaa you too oithor £il bloat or corpiete boost block# 
3# the feet that the block dl ©appear© or deem©©© in ©cm© 
■ » 
with atropine or ©rpl nitrite tea no beertoa on the otlolory# 
4# Eooptocol loud© my e©m to brln$ out SM©m© in then© eeooa# 
alia© A$i 
D# ftol too© ©eft (ilniri be reduced with ©tropin© m that the prdoneo* 
tion of &*& iotenrd ©#n bo nchieed with it# 
1# Omanot tell# tower# to snob of proloomtion It flu© to 
orgeat© dim©© end tor mefe la flue to iacr a to! tone# 
1# i© ao not ordiaorlly mo p&eoleta»t (hot\rc or deya) tort block 
to to Ittoroeocd ts®el too# 
t# feroiatoat block one bo produced ©Mi digitalis which tee a 
read ©otto but deo a direct action on toe to nduv© 
©eaduotlvlty* 
0# Thao in partial tort block# th© tort ie &Xm&t always toplar 
unices to to© fs*l block <sapt in the nrjr nr© caeca of 3*1 
or 4*1 block# 
H# Xa 8*1 heart block tb© MR iateml© do not ctopc# ■* 48 «* 
Bf* Complete &MTt ©sird Dcttoo Heart Bleak# 
A* Ifedewlyiiig Wolfit* 
X# Unyf be due to teepeecr? itangM or to eectruettve witt 
pmtmmmt deoege la the mia etea of the Hie bundle or both 
bundle bronchos# 
2m Whoa block oeoifs, the potential center® la the bundle of 
Hirs or it© te®o 00 ere no loaner hold In chock W the 
footer mtev ©o they eecapo end not tip the!* one 
rhytto# the Inherent rote of these ocmtorc to 
30*35 per ills© to# 
1» 5&i>og of Collate Heart Block# 
X# Ocelot© heart block with »ml ocaaplcatee (-4BS loos than 09X£ ooe#)« 
(a) Hum that ispulao I© arising from e point abeto the 
bifurcation of the cnlo otoau of the HI® bundle end. coning 
doom to w&mm& into both bundle breach©® at the ecae tim# 
£« teJpXoto heart block with aba©*»al eoeplme (Breed « 
(a) CeaH mv whether lapaleo I© criaiag ©hove or just beta* 
bifurcation or in one of the bundle tomehee* 
(fe) In this typo of collate heart block you cannot sake 
the edettlml Ciagnooi® of bundle breach block* boeoune 
you do not too®’ ishethor the- ebaerwol ero ootuolly 
duo to 9IBI or to the abnormal location of the pMmrntemm 
(e) that is to sesv yoo do- not know whether the ie 
arising obwo the bifurcation end tec ©a cbsoMsl append 
or whether it is miaim below the bifurcation in am of 
the bondlo tmmohm thereby fitting the obnerml cpts 40 
(d) Boaelbilltiac for the origin of obnorml 44m oooplesec In 
cosspleto heart Mods* 
(« 
Bose tor* la block in both to ifcar 
node and mo of the bundle tamohmi oo 
tot mm though the toulso Is erlalng in 
the min otois of to ills bundle to 
coalesces tdll bo In torn* 
Bore both the bundle brentoe oro blocked* 
The Itapula© erlalng in one of thorn thuo 
give® rise to ebnomtsl QH8 coople&co* 
(f) 
Bore to block is high is the min stem 
of to U%o bundle but the in 
s 
seising In one of the bundle brene:ibes 
end to IHS la thus ateornedU 
C3» 
(4) 
Som Q&mm of oosplot© heart block hove o rapid rote# 
(a) Ssp©clG.Uy true in tot duo to itgttiUsi 
I# m& dlgltolie to biotic la usually hlghor up* 
B* Mgltslle cnheaooo the Inherent rote of toso 
tissue® «nft In aovot® Intoxication one m& mm 
ventricular mtm faster t boa to auricular ire too* 
B* Mhm diognoala of oonpleto tort block tornado it should be 
amplified W ?m%m? toto* or not to $MI oonploxee ere 
mrsmX m abnowraal* 
See following elides: plcto hoort block 
A$3«~OCtf$let* heart blecfe tilth canons mine 
%l«~£oeiilM0«*l loodn-eoo eortoKilnx1 iWiwoo* 0# JBffoot of Atropine and to.rolea on Ooqplct© Hocrt Block* 
1# la ©on© pat ients with oonploto hmvt block the rat© does 
Isdfeese with atropine ©score! so# This Is m otiwmtmm 
to the patient bosses* tbs heart can mot th© dcrende for 
SasMi blood flm by UMKpeMlae rpto end output per boot# 
(ol It 4a ounpoeted that thorn am the oo©« In which the 
IspjXooo or© aricine hlahor In the Ms bundle, 4# ©*t 
if the block 4c in the MT node, the center me® ho Just 
j 
tater tfeot level, still In the Mt nod© or hieh up la 
4 
the flic bundle# 
(b) these higher ©outer© arc mm opt to bo sftcctod by the 
castrlasio cordis c asms# 
£* In other pet lento there ie no ohes@e with ©tropin© or ©score ice# 
IJ# Voriatl©n la hoct of Ventricular Cospleas® in Collate Ooort Block* 
X# This 1© very apt to occur shea the block 4© mm to 
lesions In bo|h bundle bronchos because tbs iEimloo my bo 
ortclBB in various cantors, first in one bundle, thm in ths 
opposite bundle# 
£• AiirioaXor MyDMlIt in presence of Collet© ikmrt Block# 
X* Occurs ©areola Uy in young people who bets oosplsto tort blools# 
(rj It o$y bo ommimwm in children who fmm oonr*onital 
heart &t@mae with oonploto hmwt block* 
£# Ttm Pmt l&tsrvsl, vfelob cooloooo © ventricular hmtf ie 
shorter tbm that without om* 3# It I«t duo to variations in tt$©i tone, fbc voroI tons 
Inorcaood with oooh vcuMnUt boot so that the ouocooding 
3M? interval is longer* 
4* this variation Ml b© abolished with ©tropins* 
5* Sbo ratoon io that with ©eels boot the vagal tons* duo to tho 
great ooritao OQlptt Is dooreoood end than daring tho pouoee 
it io laomoocd again* Offset tlTOOgb tho vagus* 
f# Diagnosis of Gm-plato B&ort modi# 
1* Orltorio tot dlemlo and raodoe of rooo&iitiQn 
Co) If rootrielost is irregular than you or© not 
dealing with collate block* 
(b) If vcntrlolos arc bating eM relations 
botroen iMogfoo and Wi 0M9 arc changing then yaa 
met b© 4o«Uo$ t?lth oorgdete tesrt block* 
(c) Vonmio poise in nock to full ana coo 4 tiro* 
(4) tions In Sntmsity of first bsait sound can Iks hoard 
because of oheAglng relatione of auricular and vcatricnler 
pMN 
(o) $ho vantrlealer mto is aXm m& act emmatik? mt 
mail# Inf&ioncod by ©Kor-tlm* 
If) mz'imi&r sound© mm mmtitomm toirtwauli ttut* 
io) Bale© i« apt to be- high in block 
boaanso of talar *»to end mob iaoroeood oariioc output 
nor boot* a* Confusion of £*1 Block end Collate Heart Block 
(a) At tlacs there are cacao of Oil block which roocrfclo 
collate tesrt block end vt converse) • 
(b) fhio le especially tmo la then© cacao of complete 
block in tfhleb the ventricle mm® to bold the auricle 
in atop cither TOCbaaloally or by the influence of mml 
tmo* In tbom mmm vbarc the auricular rate is jfuot 
about tm ttema tbo vontricuXer rate* the apparent relation* 
iMp Ml n&tfilly be broken m md differentialIon m(m 
by wo© of etaM&n in partus*, orcrciao* atropine* etc* 
C* Afim»"aleftM Atteikji In OcqpM Heart 8Me« 3oo slide Agg* 
34 tbe attack® occur elmi there in a transition oe nbotu* 
i&l There in cs cheapo ftoa partial to complete block* 
(b| there 1® e transition frees mzml xfcptlfti to complete block# 
(c| there la a period of tmte&mx&U* aUM etope* 
s* Attack® arc ebcraotcrisaA by fainting ofelch ii? wily dee t© 
ventricular afeeadatlUU they arc nmicllp mMm in ooemmmm# 
Wmm it la ow petlaota are usually not awm that earthing 
lias hevpenxsAm 
imi Heart block my rwSd&sly with m&&m thence txm 
rnmml twtel® to complete block* Have hod patients 
with aortic dattosla in who® this occurred* 
5# wmtwtmlm? eteMetlll eemt 
(a) Mfttmlt to mjt mmttoum %tm alms to 8-40 p®& 
Situate, aomtimm thaf atop oltogether* 
(bj In mimln with bundle branch block, cutting tba other 
bundle la apt to podAlt la a period of ocwplote standstill* to) Ouatosay produced sscaplsts tart block In crstel© by at isolating 
the ventricle© ©rtifieielXy ond On ©topping tho 
Stintatta lis got a period of stadotill itass length do* 
psodoft on tho rats of artificial sttataMM end its 
duration# 
i&) SIMlnrly In patient© sitto oooploto block, theses ray 
occur a*period of toot<riculcr tcctoysnrdi© sod tan it 
©top© ttoors is s period of standstill# , 
4* t&xmpe <ta to aatidm ffellurs of tart to pssp 
blood to ssiatDia ocmeoiousocss la celled a lltata 
attack# 
4c) If they loot mors Stoss 4*5 fsiautss death is opt to occur 
0m to death of tho vital sontsrs# 
M Occurrence ta to 
l* Stawswiy slow tart rets# 
Bm C«£f>lotO standstill# 
S* Warmly rapid heart rats# 
II# Qmmn ot tag&cts IIesrt Bloc&• 
typo© of tart block are rout dss to ©starts* 
eolcamsi©stags*# 
to) tart block 1© tsportat m pointing to tfm dl~mmm 
tout not in end of itoolf# oo for eo tbs M function 
la 
ttol Om mwmXsi treat the tallying dtssta not the 
heart blods itoslf# 
(c) fho higher degrees of tat oapocicily lifilatti that 
the paticmt probably toss taoordiol disssss In other 
regions tta the sMtattaa tlosus# @# Cooronitol aeptal Defect# 
to) iTossy voloTotlo cte« In the xo&ioa of the 
septal defect noy esctcnd to torolvo the Hie boodle* 
3* Htaonctta Soar* Discs so—if Aschoff nodule* etc*, occurs 
at just the right place# 
4# JLmo—if jpuM occurs involving t¥» Mb bundle* 
3# Osloiflootion of aortic valve end rine*~ring lice very near 
ms bundle* 
6* Htphthorto 
(o) Feticmte with diphtheria t3io develop mgOcto or 
pertiol bloc& aoaelly dio bocenoe of mtomtm wyo» 
e&tt&lttl iwolveiaant* 
(b) fery rarely collet© boort blocfe begin with cod 
persist after diphtheria but ft io very rare to bavo 
chronic complete tort Mods: oe c recites of diphtheria# 
mmmmm tm so mm am mmm% mmrm* 
I# Hctrccyotolocu 
A* Qmmml 
1* EosmX &3|mlcoc tlmtoomeMa tto&ftom) erim in the intect 
mmmX hscrt in taws apcetoliaMMI timmew* Ao ym m &mm in 
ttm levels of ttmm specialised tissue ttm tabo-root rota of 
the tUMBfe ic eloper# 
a# Alsnorsiel icspuloo* usey ©Moo 
often outside the spoeicllacd tirnmm uinm mil pert of 
the iwi»t mml® mm mpsMm of producing teulaeo# Co) ISrtrtocie stSixiii «a«qr Mbor&to & boot which io not 
ve&mSUA mXom tbe stlraulua %9 repeated, 
M Ttmm ateoapetolAo boats or© called boteroRonotic bo- 
tooao they «t iooot appear to crioo la on abaorml 
Co) Ifauallar thorn boet-s ®m iaolotod* 
Cd) thou those boo to occur rt&t£»&OQllsr tho vomit is o rapid 
fist* (ooo of the abMi dad sod aoddcoly* 
Co) ffeftse boots arc proante^o* 
if) tb*r ordtoepily, but not necessarily, orioo outside tls© 
aosn&X foetus end arc thus caliM ectopic# 
CgJ topic boots ore act mmm&Mp I# o*, Mf 
rhythm arises outside t&o mm3. focao but is not m 
aboomsl focus* 
Ch) time if tfeaoo ®rlm ini 
%0 Auriclo—ouricule-r 
i# mstr^o^otoloa* 
5* A*& aodo or m$M &too of Hie boodle—*iWV ffictm^oystolci# 
3, I'TQmtzzm boot® arc hmt® ttawwa in hof®m 
tho tmmt m&m%ed tos&alm cM nm usually followed b7 n 
pmm of acm v&teh me& or any wHt ho om&mmtosy« 
4# 0mmm of mtom^stofam* 
(a) Occur Sr. way poop&o with rwml torto* 
(b) Sun be psoOoood esolir osporinoBfeii?* 
(c) m&t$m 
(&} Xnfeetlono^-m port of Mk*U* illzmm or with 
foot of tefoctios* 
(©) mm**~ U 0*t 6i6italla~*£«ar <msa gtf* rloc to 
twm mltiplc fool* in ooffoo 
{«) Aicouoi 
(I) arc often fouad in chiMren end with of*o* 
(1) TJw Iksimw la fw» olddlo life to 
odPCBOOd OgO# 
(©> if tho pveaatoim boot occurs eearli et tte tlrao of t. © 
ncsst eaowetod boot, gse®r cot bo ooaoeiouc of 
it ct @11# 
(b) If the «9rtwe»w«tole io vozrj it way occur wten 
► • *, 
boort tee oot ted mob cfeoe to fill altSi blood, and 
then bo foltaied br e Iobr p*VM of whleb pottrsxt my 
bo coercions* 
1* During WM lie boooro dtM? or bev» the te* 
pulse to ta&o o Scop breathl# 
t# boat ftffcMP tho peuaw Is apt to bo a forceful 
one cine© the ho&rt tec ted o pood ©banco to fill 
vifb blood# 
(c) Bpmiimm arc variable— ®ay be ,*oar- of tecirt 
MBlag error,* "tSnqptbtf1 "otefelnr: in ttamV* 
(I) fbttcsts tfltb mat ftaqvmt mter#er stole# be 
Mfttsiftp mmrnm of thors* 
(o) fte?o io a preet ftvHotSon mom imivitiml® m to 
mmftftntor to «str®^iitolo«* 
if) Bern. tadiirldUBlc mp ooimlei» *oiy mob about tteci oral, 
maul MHftbtna clone i*sont ttem* 
M in &omm1, pozioM* tilth hoort dimuio ore iwt opt to term 
but Italy ymmm® wttbmt &s& otter oridenc© 
of teart aioooiso reono little* 6. Diagnosis of lixtre-Systoics (Clinical) 
(a) Dropped beats at the wrist my be duo to eerfcre-sy stoles 
which are no premature that not enough blood la put out 
to giro as at the wrist. 
(b) May get bizarre heart sounds* 
(1) If extra-systole is very premature, may get only a 
1st heart sound (from closure of mitral and tri- 
cuspid valves) because there may bo no blood put out 
at all ©o that the semilunar valves ©re not opened 
. 
and there is time no second sound* la such beats there 
would be no fcapulsc at the wrist* of course* 
(S) Hey get 1st heart sounds which are louder then 
normal If ventricular extra-systole end normal 
auricular systole occur simultaneously* 
(o) The length of the ooaqponsatory pause may help* 
(1) Ventricular extra-systole usually followed by a 
fully compensatory pause Boreas auricular extra- 
i 
systoles are not* 
(2) To differentiate fibrillation of auricles and extra- 
systoles, if long pauses are preceded by quick boats, 
extra systoles, if long pauses are preceded by boats 
of apparently usual length » auricular fibrillation* 
(d) If the heart sounde are the seme m normal, that Is, if 
the first sound with the extra-systole is of the some 
intensity a® the normal sounds, you are probably dealing 
with auricular ©rtre-systoles; If they are not of the 
usual quality end intensity, probably ventricular extm-sy stoles* (e) foatrlcolar <artam*aystoloe are wore omrun than auricular 
adm-ayaftolou* 
(f) are very oorsaem as wo gsmr older— rarely 
aeon In youth* 
(g) Barely sea with vat# over 100* 
(W ftuvuly «etra -systoles after «Kmlo*« 
B* Voatriaolftr tildes %• 
1* Bo paiitil&e B»«iifift» 
t# OHS Ifttfea different than mmmt boats* 
3* 10be auricular r?ytte is usually not disturbed hm.mm th© 
Impulses ordinarily arising la the ventricle do not go bode 
to ths node to diactew any ispalco being fotraod there* 
4* llowever* the ventricle does not respond to the nest irurlcul&r 
imsuloa beoauo© it la r&fmctasy whan It rmehm it* 
5* then© Is thus s fully CMoqpecuMrtozy pauses- 
(a) fho oattaowaystoUtc beat is preceded by e abort p®nm and 
ffeUswod by a long which fully for the 
TtraeodSrg shortened Mt interval* 
6# Tim© the oaftvo'Npgtol.io beet la this tna la not an cart-a 
boat bat me fUdh just vapi#«oA the aotasal boat* 
?• In the olwrtvaftcil#iogram the romtrimalor eoimlcx appoar# 
mch different M the usual bcrt of 04pxuKsmtriaalar origin* 
(e) H» rmm&cm Is that the order a obioh the vmtrioulnr 
*#«#!» la aMaalcriM la meh diffomt that usual* (b) From the roochanioel standpoint it docs sot matter where 
the Impulse arises* It depends on the degree of pre- 
maturity of the best and the oraount of blood which the 
heart has in it when it contracts# 
Q* Sctte-Systolic Bigemljsy, Quadrlgcmlcy, etc* 
(a) Evory normal beet followed by extra-systole « blgeminy# 
(b) Ivory two noma! basts followed by castra~syetolo « trigeminy 
Every normal boot followed by tm extra-systole® » trigeminy 
(e) ©te*-~-~—as above for Qucdrigeainy* 
See olid© % 
(d) In people with myocardial disease, blg»i«y ©an bo pro- 
duced by digitalis, ccpectelly if fibrillation is present* 
(1) It is om of the toad© offsets of digitalis* 
i§) The tendency for digitalis to produce bigeeslay 
varies with different people* It m®m to occur 
particularly with extensive myocardial disease, 
even with amll doe©®* 
(3) When it occurs under these it is dan- 
gerous to continue the digitalis except under very 
closest supervision* 
(4) The variation of the form of the extra systoles in 
such bigcnlaqr due to digitalis is usually more 
striking then when it Is sot due to the drug# 
(©) Bigomisy may occur, however, in anyone with cectrcsystolos* 9# Vcatriculor i&tra-ay stole with Hetrogrsde Conduction- 
$m slide 87# 
(a) Occasionally retrograde auricular etiaulctlon assy occur, 
the inpolse having been transmitted fro© below upward, 
with auricular response after the ventricular contraction# 
(b) In such cases the Inpulse' forcing at the Sm/i node ere 
discharged, end the pouso following the extra systole is 
not fully coss^ensctory—the auricular rhythm having been 
disturbed# 
10# Interpolated Ventricular H»tro-3ystol©s--Soc slide Bg* 
(a) At* extra-systole sandwiched in between two normal beats# 
(bfr The Ml interval following the extra-systole is usually 
longer than usual# This la because the Impulse giving 
vtm to the extro-aystole reaches the HI® bundle, thece- 
fore, whoa the next normal impulse coma down from above 
it saeets s sooewhet refractory His bundle# 
(o) Sometime the ventricular cockle* following such an 
interpolated extra-systole la different became* of 
fatigue in the ventricular made# 
This Interval slightly 
longer than norml# 
b-e longer thm e-b beerruee of 
longer i?-E# 
c-d shorter than «s-b becsuoo of 
longer F-H U# Interference of formal Impulses end Srtro~sy stoles# Slide l%# 
(e) The beating of the node and the octopic 
rhythm center in the ventricle may be approximately 
the seme rate ©0 that at time© there my be 
effects# 
(b) Fart of the ventricular ausol© will be responding to 
the auricular impulses end part to the extra-systoltc 
canter in the ventricle# the (&R3 oemplmea will be 
transitional In form depending on which impulse gets 
there first# 
IB* Variations In form of Ventricular Slides 
(a) Moans that the extra-systole® era arising in many fool# 
Cb> This occurs especially with coccoaslve digitalis and Is a 
serious toaclc Indication# ©rug should be stopped* 
(c) Xt occurs very rarely in mrmX people with cactra~systoles# 
(d# Xt indicates n greeter irritability of the ventriculer 
xaasculnture# 
13# the Origin of Ventricular la determined from 8R0# 
(a) (Diether fyon right or loft ventricle# 
U) deflection up in Load X~~rlf>ht ventricle# 
(S) lor deflection dom In Load I—left ventricle# M Whether fro®* epical or basal portions* 
(XI If ©rising ot the base, averoge direction of Impulse 
will be dowmm:rd, giving upward deflections In 
Leeds II and III* 
(2) If arising near the epos* average direction of 1&» 
pulse will be upward, giving downward or negative 
deflect ions In Leeds IX m& III* 
14. ftist-floctrQcorstdXlc Pulsus Altomoa®. 
3lldO B|r,* 
C« Auricular Srtrfr*3rsteX*s* 3Xide B9. 
(1) I& those, tho ourlolea beet pveeaeturely sad the ventricles respond* 
(2) F«*wevos of auricular srt:m~systoloa* 
(a) Are usually different fro- those of mtml boats be- 
cause of nfenorraaX alto of origin and uhnemml screed 
over suriol®* 
{b) the shop© of the depends upon abort in the auricle 
the SspuXse arose. If it arises near the 3-A nod© 
it wlH bo Uko the norms! ]Mm* If It arise© near 
the JMf node the IMnme any ho inverted In Leeds 
II end III. 
(c) The pules tracing A and 7 nm superl£3)080d alia© BQ* 
Often cannot tell whet the P««rkv©» lock Ilk© because 
it is on the previous cycle* 3* The $$© Collar©® la Auricular isttrc-cystolco* 
(a) Uaoelly the QK3 cosaplox in the mm m that of the 
mrmX secueatlol boat© since the impulse hoe a oupre- 
ventrioular origin (above tbo bifurcation of the Hie 
bundle) mt1 its path over the ventricle 1© nosnol* 
(b) At time© the ourloular ispsilae m& oom very prematurely 
oo that ell the ventricular nuiole sacy not bo recovered 
and the QI&5 complex®® may be quite different due to 
eberraat conduction petlsmys, Tbeo© ere called eb- 
err© nt atoriculor cartro-ayatolce# 
4* The MV Bod© lii Auricular B&tracystoles# 
M If the csrtrosyctole 1© rosy premtur© the oonduetiiig 
tiacuo may ©till he Inconmletely recovered from the 
previous norm! heat onQ them tba© bo ® prolonged 
JWI Interval# 
(b) B,lodged preoetore ouricuicr boot©—Slide* $40,50* 
(X) So© evidence of auricular premature boats without 
ventricular rooponoe# 
(t) Thcac occur beosmoe at time the pronuturo mriml&f 
te&akm Is unable to jmum through the MV node bo** 
mmm the MV node ho© not had tlm to recover from 
the preceding boot# 
8* Tii© Fmm la Auricular iartro-gp*toloc 1© not folly eosfioaoeitory* 
(a) Ils© beats which follow © pp«toe mtrlculer beet do 
act occur at the mm place whore they would tor© occurred 
had there hem m prmmimm hmt* (b) fhi® ia hmmm auriculc*r eectreay stole® ®Xvmy® disturb 
tte© eiao-surloular paCMsker. 
(o) Wtoot happens la that the ectopic auricular impulse die- 
chargee the laspiXao which to© In the process of fonaine 
In tli© 34 node ao that now a now one mat ©tort forming# 
U) The pmiac than is equal to the normal internal plua 
the tin® It took the caetr© ay atoll© to got beck 
to the B*A node# (Hot always tite-ees below#) 
(o) Occasionally the extrn-ay atoll© iapol«© *wy disturb 
and depress the flNL nod© to a greater degree# 
(X) In mob imtmmo the «Ktr*»©y stole may bo follow 
by a longer pm a© which my be fully cmpmaetory# 
(B) There ««gr b© m mm mro profound depression of the 
Ml nod® after m auricular «Ktra-ay©tol© so tb&t 
there my be © ulngl© *W nodal beat# This i© then 
© "dialocatioa of the psesHtafeW#* 
(f| Blg«smiuy due to auricular metre-systoles does occur 
quit© frequently# HcRi«m?r, It doe© not Indicate digitalis 
UrtoaclCetiOD nor here the mm algnlflcaac© in that re- 
gard a© doe© bigoalny 0u© to ventricular e^rs-aystol©©# 
0# Atrio-drwntfioalar artjji <Til»T ®> are of two types. 
1# HI® bundle «tm-©y©tc1m (Br# Wilson doe® not cell tSmm h*& 
nod® oartra-oy stoics) 
(o) mitso tn MT node or In at®in ot«r of the Hi® bundle* 
Cb) Em® somm tom m other impolm arose 
above bifurcation# (e) Bo wldmso© of mrimlm contraction-- oro hidden In OBWP corbies* 
(&) Snrloular rhytlaa not dlotttrfcod- have fully cosixmootory pmao# 
<e) Zooks life* ventrioulcsr csrtmcystoXe tfith <UUy ecsapcmmtosy 
pouaet but QB3 oocplooc looks like other In tho record# 
It) Level Of toons cannot bo dotosnlrtod# 
Co) Auricles cantinas not reload to tho cjrtra- 
systolic izmim* 
SSJEiteSBmSE* 
(I) Qfti oqsvAsk is mxml* 
{2) Wmm is tolly mt&mmtomy* 
(3) $*m«t sot in $*wsr#* 
(4) Aurioloo continued tmaistohod-do not respond 
to tho ortrssjrstollc they do in 
Jytf nodal oor&rooystolos# 
£• ©rising la or mm h*$ code* 
(a) Both msi&Xm mi roatrlclos are psraaeturo# 
(h) M. interval is abort or iworood to £WP interval# 
M Wmmm Inverted In II @sd III# 
{&} WocitrloulGr ars ooxwil or sterreiit* 
{©> Bast toro.feoth toortod tg sp4, % and #®feooM 
orlM* Interval to safes tfeo dttognpsio* 
5# Thin typo in mm* B» ftoiftMl of IsstraaFstoIeo* 
1* KLiataste pooaibi© cau©e&~~aleo&>Xt mcfaim9 oto* if they 
m to have a clone assoc lotion* not otherwise* 
E# ;:w boeosae lose oonoolouo of them* 
hm uuiMjltoo 
(a) About too only drug of value* 
(b) Out© torn irritability of heart mmXo* 
(c) Usual moo 0*2 m t* 1* d« 
4* Giving the patients indication m& defeat four purposes 
It ney convince the patient that there la nothing wrom* 
5* #«&«&& they disappear on eacartim bat in mm eeom thisy 
appear cm mortim* These may be of greeter fcgposrtonee* 
&* Mtfm<*WMM end eKtre-ofotolO# frea aoltiple 
foci# first appearing after digitalis# or© both indications 
to ©top the drug* 
H« Techfcordia* 
4* General 
X, It is <3»o to a peragm of 4 mpM memmim 
of pmmturn boots* 
(a) It ia q condition la tmioh th© hmrt rate 
jm&o from a aonaal level to a higher level* 
(b) the tlr®t boat of the pgm&Mft ie joc?t life© a ©tel© 
mctomojrtttbii 
(o) Vasvx&m %b oftm followed Igr a s&ort pmw ordinarily 
Just iH:© poat-*02t'tooyotolie pottae* Cd) Hate I® rapid to regular udoally rmtoe botvjom I864S6 
though oocatooally slower or faster* Xa children It my be 
oyer SSO* Hat® my %» cssytMag, theoretically# m lm& 
as it is above the rat® of the aim® node at the tim it 
starts* Fmrta®t rate® in adults up to £20* 
Fastest rate® 4a eMMm up to 280** 
(o) Onset to affect is absolutely of 
hetasogotot# s&yttoi* 
(f) Attacks last greatly varying length® of tte»fma a run 
of 3 * 4 premature boats to several dies on to# 
% fhreo Forsa® of tfarwytol Teebyotoia doptote!: oo eita of 
jwnolaQ fossaotl#a* 
la) «tocml®p~smt oc^taon# 
(b) . owmau 
(cl Ventrlcals#*..aaoh lens oosrm then. otootor tmt too 
EDSt SOTiOttG# 
3# Clinical QmmM erstloas# 
(a) Hi#® ooDTJDTi la patients with heart &tmmm but boots of 
tachycardia m& bo the only witeo of heart dl.nceeo. 
(b) Ifcy ia chlMhto csv! oontlmx* for sko? years to 
then too* up la later Ilf#* 
(o) abort attacks of ttoyotoln, that is* a tort mn of 
toiteOrstolae, omm m mr® than a tool# 
SKtve$retolo« 4# usafimm 
li| Odessa vspm mot fmtom 
(l| tOtlOUt btGKOif# 
|S| Ckisuttloss ef hoailt-*««ti0tto os? rsot cmbosSo tsoost Sloooao 
io wmmmto* 
in) ffeto of tmtat tto «»tot in i©oo 
tffiftlaot tbo to«t isekS tte am?® agmotem 
of tfto otCcflk* 
(%l 
At oooot t&osfo iwir bo v%$&tmon* 
Co) Aftoe ettoflfe Ijoo tw ftoaoot fl*»»fefltlf to ooo boo* $«Hont 
n& Imm mmm m& tOBdtia#* 
(4) am pcrl&Mit* boiro Oftftos rhetorics# 
Hit wa tvotafely io tMoo laSIviAigl# «ho hm ocraoof^ 
sftier «bA latent m$0m pootcn© 00 t&ot t$am tt» 
WNBtff blood floa io totood totts$ t&o totfctooidlft* «£*> 
poft& HWtWfr 
Co) Itotf fitMl Ooaofibo gpoolol «t ooaot aoefc m 1 
md tboss ottejSc* *1 o at offoot* 
CD fool s • 0 oHtfirtirwtolo© at cnoot* 
(i) At offset* w fool oiisito *tCMtp# m Ml Set 
beoflr to to «ctoiitr«tel«t* 
(f) tm$m ttteafet mm mm it tfcar loti 
10 €teft os? mm* 
(I) tt? sot tsviiot fiilatottm, w&mm(f «oe^pK»*teif 
bopetlo irmm% odots»9 0io« 
(S) fbott shot to s«o& &otocd Htoi flow tOot 
sotolt frnxs wiipmo of 00 oastiwaitr* 
(3) After 0 ottodte tlio mil nsf bo obootml te 
porM of %m to t%mm l*we otasgon obSeli 
jmSil flat ttos# (s) Fotlonte who bier# tort Ottawa pmem,Uy have toss stem 
fluently to®oo© tone wbo havo lane attacks bate toe 
loco f-nqnantly* 
B» Parcayarsal fctoooraio of ®rb*liu 
1« Of tBO %$€?©• 
(a) $*ien9m& anrietiiov tolyeepSlo* 
(I) Pmm&mmX to&yccrdle* 
2m Qm&xeX oo&oitocticm©# 
(©) wai|^i^?cmtri<R2Xafw — am tot ippnlooc eve crtclap> tov© 
the bifurcation of tbo Hi© loaSU but do not toasr for ocr- 
to in totor to otto lo in tho ourloic or in the JMT nod© 
or Hio todlo min ©tors# This omtolon ia to to tho dif- 
ficulty in eafclng out the 0u© mot be ©bio to &m 
tbo IMeme «i Ml mmmxm tho JMl interval In osdor to oeak© 
to differentiation. ton vm cm me to P*woc mo 
ofton easset toll to t*hle& cycle toy belong* 
(b) If odo can rooord to becianlac or end of os attack it lo 
of oo&e Imlp is Mklfflft to different iatiosu . 
not 
(c) bousaliy to veateteeXer ©toJtoc© eve/vesy different free 
toco ton soastaal vfcgrto Is peasant# 
(d> Eto tbom&h to mm&temm cm easy dlffmat fMi to rnmml 
carpics£oof to differ®©© In toa bdsdoe to to fat too 
of MIPRMtovtetor «rteSaf the xoopooae* bolrg ebeetto* 
to tachycardia racy ©till b© of aajtfwostriciilar ovtfgfttt# 
{©) If to rate is bto* to paldk toeing my tow Mgb A wres 
to to elmUftaitecM eosrtkwlar- to ventricular contact im* 3# ABrioslo* 
(a} WR internal la alsont ctlvNQro Coo to fotl&ao 
of to oonttetiac tismo-lt So port idly 
■oil tlm ttne* The dogroo of polmptiett oorioo gtoot]? 
fw» potlont to patient# 
(fe) ttflWWSTO my one! ofttfe a bloc&od earlctilor boot or not# 
(o) In those Peso© In wlsleh Itowro* can bo taade cot, they arc 
often linrortcaS,—-but is the mjwity of mmm of auricular 
tajftyecgftla mo mmot safete* cut the IHto# 
1# 91m typScol coo©-*rato l£0»TO0t no ifcMf»m» acwl 
* r' >. iniJiLil'iiUffL #*■ it-kam i ■j-iiL At ttr_-L_ infUiU-ij'-rn it -—*■—- - v”k —— » ., . ■ JL tmiS mi ..m 
OCPplMeOf OQwuCBS OflOOt » -^pro^Ofit1?S€!Ul.oF 
M m.M0 % 
|X) Mv msMm ms® of «orl<mltt* tachycardia# 
(£) QBS mm of msml outline* 
(3) P*mmm Usvortoft} ©an ho coon# 
M l«ot boat of pommm in coupled «ttn to preceding 
inverted V*mm% and to JNH tatorrnl to long# too 
one can cay tot this in m mvimlm tachycardia# 
If wo dia&ft hero a record of this loot beet wo vould 
bar© to msy that this 1© o tobyeardio** 
✓ 
oooMiH my whether it is mirieulsr or nodol# 
C o) glide 
gfeooo attach hegtmlng tlfefe pmmtsxz© tot sM csaisg with 
& blodcod gmostmi feast# (f) diffcrnttiel bottom Bimn and 
mrimlar fert&ptteMift* 
(I) aisme teOtytterdlft* 
(o) nXmat tar&Hebly visible* 
Cb) JMeme @lmst store lorno* 
|e) Only ttz» B**jovee ore isvioiblo io 'turn JMS Interval 
to laag ossd tijoy ere eopwftigNSMMi os fbeme* 
(a) Xe duo to o reduction in vagel tooo—thc ootitcr 
stole is tto Bmk node mi tbe tonm* get btoor os 
the rot© rimm* 
M Onaot m& offset erodeol* 
if) CtoBtaoI slovriae os esrotld simio psoaouro# a©o slide o^q* 
(I) Pmasmm&l Mxrlmi%m TmWmMim* 
(©) ueonlly en&aot bo mac out. 
ib) &Mm onset M! offset* 
to) Hegr stop sbruptir «ttli carotid stoic pscaasro* 
9. Slide G%q of n%mm teebgrMftlie* mwtmltm toeissr* 
oox&ta Ml msriMtar flatter frees typo of response to carotid 
sinus sttolstieei*- 
r- (X) asoae first pcrtlnl &wl block, ttm 
ulmrim of rote* In wsmX mm mt tmmimt t&mim m 
the proolnont ffeeture* 
(e) eiarttwle* abrupt atop of 
p®ro»3r«a* or mqt be m oimmm at ell* 
(3) Ifaxm&mmX m*SmX®» immnm of tero© of 
Uddu sw*P*0 
% fypee of patients In ffecl-yoftrdl* oocurei 
(a) Hay occur in anyone* 
(b) Hay occur -In pot lento with heart disamx>~-not 
imooa son In riiCUBotlo heart die**** with mitral ctanoclo— 
If ao lacy well bo lorloua* 
(c) Slay occur in say miring* motive 
or at rent# 
(&) UsueUy no iloftaito pxmipiteting factor though in ocao 
pet loots there my bo om mdh m oacecoolvc alcohol In- 
take, infections# flacking, oto# 
(o) Boas pettenie my oho* m& be able to detect isolated 
pmmtoxm boot© before m attack begin* or after it is 
over# If tisey On» detoot tliara before the attach It m& 
bo mi&mhiM to git* proi^“l?ettcfHy* 
(f) If ottceko ore froguent they a? sometime be pvavanMI 
If elTtng oginiAlne or digital!® psoybflftetlaRllir* If they 
are there Is so point is giving thesis drags* 
&« of twatyms&im* 
M tt «tte«(E« oro of etanrt famtim %\mm I# ao point in 
using siMmi ooeauros* 
(b) teumi used ore mot of then Intended to increase 
*a«al tone* 
C2.) TOko e deep fcsmt&* 
|8| Mni a deep breath «w5 the* «trois> spinet a ciocod 
glottis italmlm or boM over end strain 
(3) Carotid elms sm89&xtH«*Mfcftblsr not wi«© to uoe 
bilcteal carotid oimis 
(4) Coaler prosaire* (o) IpocoOft 4 *6 oe* freshly prepared ©stop of Speend, repeated 
in SO stouten If noeosasxy* 
(a) Aposoxplto** 
(1> If ettsate* ere prolonged it my bo unwise to give 
esastlCG stone the pet lasts my bo unable to withstand 
****** vonittog to their already vmokmo& condition* 
(o) Digitalis* (Or* Wttosci .baa had. mro momno with It then 
with fBt8ite)« 
{1) Qtvm only to those patient© to 
wtaa you era aortato no digital to 2ms boon givesa to 
the prosed tog 10 • 14 days# 
{S) ®aml doco 0*0 gfoffla X*V* or large dose© 0«MU0 
pong hr/ aootlu 
(3) If not of festive to osMtelf hour, try earotid elms 
ettetottoxi age to hmmm it my be nore effective after 
digitalis* 
(f) ItoebolyX » 
(|| Gif© It X* K»«~dose 10*40 «v$3* depending on etas end eg** 
(r.) If not off cot iv© my be foilomd by eerotldt ©tons 
protsmx* or by m.%mm of tojaetlan site# 
(S) should Iwm Btvopim stsfUM* to turn m ©utiaot© if 
pottont bee reaction# 
(4) l&sy be repented In OKMMmlf hour if not affective* 
(g) Sodotlveei mwti m toatoi&KKUm or optotes bo helpful* 
(h) laid© %?93$* 
U) abftcm various sttsqpts st tfsstap& of o bout of taehyeeidto* 
(2) &mm ©lowing of n*to before actual suMon return to 
assml. mmii 6# BodoX Toot&oidNSUi* 
fc) mao 
(X) tow* larorto JMnivae* 
(S) Could -nao temm polaDtions is nod: Tmintoo ton ©tods began* 
(b) alideo 8jggt Bg$# %$ {VmmdL flta bdvefilft) 
&ro about a fettot on ton Or* Alnmtor operated m& 
•Kpoeod m& ©ttaiXated to tar 1 without affect* One of 
to mrme tone point at which atianXatloc wo© given* 
fncbOpatoia finally ©toped only often Xar®a dtoo of 
digitalis# 
0* fototonlar alldo %g# 
It OoaedmX 
M It Id a encototei of tricolor c^toa^stoloa* 
(b) It IS Of t¥;0 
(1) la auricles continue to boot at 
a amnA r«te m at least a ante different £m tot of 
to vmtri&Xoe* 
fa) It la in this %po tot tore is eerietSon in 
Istmtl? of to firat tat 3ound# it being 
teodor «tm the auricular and tontrtolor toot* 
arc tSno bedelde ateposl© 
poeolble {Imimi* 
i*\) fme&ymx&lm in which auricles respond to faMoleei 
lil# Slit ©to 
fc) In WN»id© differentiation of above tppo (I) tottotor 
tttoetola to! pooml aorlaolar to to 
latter the vsjytha ccntor is in to ratrielo so tot tore ie a mmmtinl maponm m& first beers nooode nm all of 
fleet Inteaoity* 
(d) Qfllego vou eon tell abet ..the arc out 
JMweo in aa3-~y«s cannot mfec the dlceneeia of ventricular 
toqbyecrgiii* 
(o) On© oa&oot deponA w almorml c>a© alee© to 
isoho the fttegflAiito*'*1*flee olid© %. 
X« ForoaytsooX msrimlnT toelgpesiAtfl with ©barveat ventrleolnr 
W Give obnorrnl Q!B> ccsb^Xcxkoo* 
£# ibxawer, if an©’ bee p?et* coaly recorded slcde mntricuXejp 
CHCtftsfiQfvtQios on the am potiowt which s?o lll*o in fom to 
those peasant with tho toolyeartlfl* the dicanoois of toaMtan* 
lor «©» thee be node* 
5* 3Xldo %$ abm-m both veBMealn* cbwS mMmiXar tmtzmtmlM 
in tbo sops fetleet* 
4# Mftent Might )m tattdle hv®mh block with nocnaX 
»fcytMe~*flO be will hove atom©! oor&Xoocfl* durlag the 
prawesyora of mAenlev ifletfqjflftvdla* 
a* It £9s)f be mommxf to kern who* the ©oaplraos loci: like 
between parcwyeo© to be certain of the dioGBoele# 
is) If ©beoscnl during tosml m well 
May be bimdie bmeb bleefe* 
Cb) If noifmX with nomsl tffcgrthB end ofenosssoX 
with ptma&m, my bo ventricular mmonmm 
m ventricular teebfeeHte# 
if) If ttmm tp pogt^swayaw1 vmm wbm tise attaok stops 
and Is roeordei* it sxwsno that we wave dmlim with vmt&imlm 
tmHtonv&ia md that the etoaa node wee to elagt 
off not bevies boon aiotustwdi by vmtrimMr activity* (1) If there ia « peum* lwmr» It my men that cither 
mmim&m or vmtriml&r tecfcycsmiia ws present* 
(!) Aboonco of a pause to the Important thing* 
B# Jhstlante to tto-i Occur©* 
(o) Hem* after nyooon&iol tel -rcticax—«lth infarct 
la In no condition te t?lthoteiid a mpiC Heart fate or tho 
mmltmt tocuffielont mmmaxf blood floe md qutototoc 
eftonXC bo fttcn vtteont laoltotlOD If ante a tacHfOorfla 
occurs* (Co&noa in tmfmX mzmrimz&ti]« 
(b) Hoy occur in absence of tocerfc Ctoosne esad trlthoot obviate esuno* 
Co) May occur In pat lent a t/itli ircXf# gteteraHtfh&tc syndromic- 
(@oo bote? «o4 ©loo tm$mp fm Heart £#* aopter-ber 1MU) 
CO) fhoro Is a cobII m?mp of toliviPusin ufcc &m cattwayirtole# 
an?! abort or te pmo&mm of vrastrloolar MfMilk on 
ceearticQ* 
Cl) ftey a®y tor© no other mMmm of heart &i®mm m& 
ho quite incapacitate* by moh ottec&e# 
( ) qutoMlno often is vary bslpfttl to pemnttog tee ©itoefes* 
Bf of VmMmUsr fa&jyo«*itto. 
(a) 3&tei6toc In the only occsuro of value* 
U) (X4*tttt • 0*3 00 0#G # 0*4 Of 0*5 0f Ote* at 4 hr# Intel* 
irate f&tiX otteofc stops*) 
|E) o»0 0 or 0*0 0 at X hr# toterolo for 5*6 dooos 
— until ttttocfe stops#) 
(3) (atm another msr cscoollcat »tw, la to ctro o*3 0 
«nre«7 X lap* for 4*5 aosao, than o*6 0 oro*y X hr* for 
4*0 'iosoa, teoa 0*9 0* max? I Hr* ote* until techy* 
©top©-* acteod of P* D* Tofcaotao) * E* Mey to given X* ¥* ia ccstrcm ©CMMMNt 
Ca) 0*0 G suiaidi&» mlptmtm my bo dimlmrt in no cc* 
of «e» aIntilled valor to vAlcb &*B gtte* of cone. 
Ml la ftidei* Vfcls is given os£ temt&mtily 
over course of KM riautou* 
(b) QolaSdlae oeor a3U» be used orally or ia 0*0 0 aococ 2* V* 
(c) &km«Iw ttdfetato 1# IV—£*0 oc# of OQl cols.itim htm 
hom ailwocotod by aooe* 
(d) tfc&oe WMBre« aot wi%:mt hamxI but sttoefet soar * 
be very cortex© ijecc*cafttat* wit treatowit* 
0* a&B&romt atari MR intern*.! «mS ter. Interim! 
witfa smawer to have poraeiyam! teofcp«©raiii* 
X* Cr^rriCtariotios* 
(e) MS interval Is abort 0*06 - 0*10 sec* or loos* 
(bj $Hg latoml in loan 0*31 ~ 0*!£f sec* or esdto* 
Co) First part of 3M natplm rlm& or foils steely era io 
thlckonod* 
(a) naa nmplm 1© eftea notohod* 
Vaml* 
tM armarono 
fhicfeesiad boro* 
(o) If five®, atrc$lne th* Ml end <$£$ iatwreln bco?»€f ncarac!** 
tmt MS totoswal is tb# sera© after etsopia© m it ie buffer©# 
MMm atfopim 
M*ter ntso^lm (?) Stay Iwo no othrsr ofitaMft of hoccrt dlaoowu ■ 
(g) foni* to Iwvo yttcdfed of 
irootftaslo? toebyeiisdlt be« boon scpoptcd (l«arlB«t Aa* Usov* *#t tot# 19CU 
(h) fUioR toabycsf?!le. occuro tho 3MI Intorsrrl 1$ nomnl* 
(i) Tbo H£Ofa $d not ©proof USso tbooo of mtftimTj bunaio br«*teh block# 
i* 
to) Msy cxplvrJttim mmit eeoc&mt ffcr ©11 the* stw© IMnmt* 
Abort P«fi# Imci OBa#. o&saca with tmZmcrj to tashpoax'dia* 
(h) Hoy bo cwicaital of the Els bunJla or A4 aoae« 
(e) Xfcgxiloe semi to est Into tbo *oati?icXa onrlioa? tbea it gtoold* 
(d) Buadlc of Eat* 
(X) Is prosoat &i lm»? f*ou pS^ht 
aoslolo to iCgM vmtriclo* 
(s) Hsus rirrht vmtrlolo miM bo etsudetod by 
** short oirouit** to it# 
(3) Hweiw \?o oocoeloaolly ao© a • W - P- r 
aywdroeio 'with tfm chlrf aoflsetfoa &m la 
X*a©A X# tlsus 
To crplein this ta& aoulft heflw> to poatuleto a 
short 0ip0o.it from loft «0fM« to loft rmtrlclo~- 
os in dor!0, t*ero a htsndlo of Host on opposite eMo# 
Col ftomm tm vom’W# bo dtoot oHocts-icol mtiwtim tsm aivMU> to Tontrlclo- 
m la 4o0ot tfaem trm anarlsI© oc»3 dom osw ti# restricts* Possibly in 
ds»ae people $bm mm ed‘mai<ms mwi&l& mA rosatpiolo ttiMb p®mit 
&iroot stlmlatbe olt'-er rieht or l*ft vmtalcl© op owrlclo* PsrQByasoX Auricular Tachycardia with ftortlel Unite* 
(1) In these eaaos the maatoemim is dfffMmt fern otupioulo* 
flutter fcoenuse tho mzrlmlav re.to is 600 or loos# 
Co) Tho MivIftHdL auricular coalesces ore quite ©operate — 
act contiimouo m la flutter# 
(t>) Wtom you Ml goo they lock like tho aorntel F*nm««"> 
only rarely ere they inverted or abneamBl* 
Ce| auricular rate in these patients ie mch %®m oonstoat 
then in auricular toofcyeerdia of the ortUmsy typo* 
ia| sJuet rule out otaao with block la the mm» 
of eloper ouriculor rates X® por the F*mvm are 
aorael in torn* 
p 9 
I e| AT© act of footed by carotid, sinus pressure# 
If) Aosiatlor flutter with mim of MO miM bohmm the 
««5r clinically but yets would estpeot to convert son* of 
tl:m to fibrillation with dt^ttuXio*.yot this does not 
liappon wtas dlgfttoiis I# aivon to them petlmte# 
W W»e It is probably neither nlm m&lmtm flutter or 
the usual teebyecrdle# 
B* QMMiml Oharuoteri oties* 
i®} **W lwt« 0 ato? rate wta at test whloh (Soubtleea Min 
oft or m*$loe« ffeoy eoo6 In oosplainlag of palpitation 
or* OKoroioo# 
tW Attoflfee last imioh I® weeks# 
(o| Are rmcli $oro end fatally* S* fmstMit# 
te) Am often My refectory 
It) Diftitolle la probably tho beat aoeaare to use# 
(If yoa ore goto® to h®m o rapid auricular rote* the 
boat thing to &ivf is a hfcgh os* oo; time bettor 
to lam® fibrillation than flutter and hotter to hmo flatter 
than this type of blotic)# 
4# Choao cosoo are vary ampins 'bmmm flAight changes la v®&sX 
ton© omm mfeeft changes in ventricular or rapid# 
8* SGUde&s rapid mrimlor Hid* 
taoeh mm ills© flutter# 
mm effective titan other usee ooroo^aXiMne 
ventricular rote m that they got along oil right# 
E momim my gat 1*1 mmonm* 
in# immu~ nm m& mmmim mmm. 
A* OflOorol* 
III fibrillation t® by far the »?s mmu 
(a) It mws in « ratio of 120*1 on ooopertft i?tth auricular flatter* 
(b) ft la tho mm-smmt the pm&ent teo^ulerltlea# 
Col Other items it ha® feecm given ex® *«4taml p&o## MoIMmi 
oov£Uf # P« I* S*#' (pulmia ImpleflB 
0« liistory# 
la) darieulor fibrillation w*« first moomtzml in mimln in 
mpmXamSM. wwfe* the oorielee (or ventricles) ©ro mm to atop 
boating coord la®tely and one aaoa ?mvm mos* the auricles# Those 
mm& aro at flint eegyu mtl Is tor beoom finer* Xfi the curio ion 
there ere ot@ iradntloaa* aom of the were* ogpeer oo&mm than 
others# Xn ftMUJUittoft eesmamt* fibre teslas appeal* to bo 
acting Inaopontetly# |b| &tHC0lsr flbrUktlW hnbH* la is pronounced vo&trloulnr 
Irregoloritar bat this m® not MBegatMA m o clinical entity 
until recent foeam# 
<e) Oftrous rbytte mo first described by Hcifcino with m circle 
of Jellyfish mcoXo* 
(a) HSaoo did m caperlwant with a olrealor strip of mHteolo* 
or mntrioolcap mmlo-§ In «Amioh bo f und tbet in o rinn of 
musole* once on IspaXao oss started at one point, It kept 
mtae, wamA m& round* 
(o) Bananas m& Ooatoy store mam tho first to sttsdy e pnticot 
with oorioute fibrillation in about 1000* 
(f) teoededtiss first b*@a& t© bo&m dorr ohm piloc 
troeinoD woio taken cad Mif etadioo withtht Ml woro 
IMtantnl In dotogedtoissc; the mot actors of art&yi&nla* 
(15) MmSMMIi did fundamental woife with ©rtorial paloo trocln&e* 
{h) Watikvmte did « great deal with oiiadtenoouc tom nod 
redid pulse records* 
{it In &nrtoulcr fibrillation bo first nods dlarsaosia of 
*awi<miar pardyeiif bceeaiMi of absence of frmmm In Tenons 
paisa* 
(s) Inter* after wc*& of fe« mvm%a& node m& hmmm 
of loir:© CMf pulsations in mil so with 
separation of C*>V9 for a tliac bo called it •aodsl rtgrttn**’ 
Cl) not until wwle of louts and tnwtm* and MfcW&mm? end 
i?|ntgffees& did tbo tro© aaalWBlMi stead repealed# file Bature of Cterua %♦ 
31 wg start of oiroua rhythm with tofmloo bXec&ed te 000 
direction and oblo to pooc in the other ao that circus 
thus begins and koepe (&im* 
a* Factors which ore lEjportent 1n ootntliohinr; and oontinu- 
tor, 0 oiroue rfcarfchn* 
(X) l/mrth of path—-or ©to© of flag# 
(a) If the path ie lengthened it cipfcoe the wider 00 
that by tlm togfttlae rate beds to ©torttog point 
tho Ttneole will hero pcsaacd mt of thcrofractory 
period and this teed# to perpetuate tho elrdteta vlflli$» 
(b) If path is abort©nod the gc$ become narrower 00 
that when the izpalm Me basis to the starting 
point tho sauaeXe will ©till be eefroetoesr thee 
tending to end the oircua rhytlaa* 
{B% Velocity of of the of eewdeotiocu 
(o) If rot© of crnmotim lo slowed, moolo «UI taf* 
p®mod mt of retTeetory ©tone ix&xlm note 
battle to starting point oad eiroue Hqrttn So perpetuated# 
(b) If rote of eonduetien So speeded up, Mr node 
nsmnar 00 that iwjmlae pate badk <30 mm that 
mmt® is atill refractory, trnAtxm to end the 
circus ttortln* (3) laagth of refractory period* 
(a) If it I© flfaartoaod, -op ftfii wider 00 that mettle 
no looser when Isgxsloe gets bock to 
starting point—elrouo ecmtlmioo# 
(b) If refractory period lengthened, gap nerrot?cr 
cud mode still refractory when iapsUi gets beds 
to otarttog tendc to and# 
(0) 5*he length of the rofveetoxy period rssot be ouch 
that tho tim it t$km torn m to got mmmA 
the ring raoot be longer than the rofraotosy period 
at o given point la order fox* a circus yfeytta to bo 
oatobliohod# 
(d) The mfttolofy period of a ansel* exma shorter ao 
the period of rest swg shorter up to 0 cortoia 
point, than the refractory period rooeboo o plcteca 
beyond which it will not shorten# 
(c) fho refractory period for various nteeb fibres le 
siot identical 00 that a point may when one pert 
is only partially refractory ©ad another oorplotoly 
refractory# 
Tfcn© A Bey be refractory 
whm 5 io oolf partially or not nt 
©11 refractory* 
from ouch 0 bools, a circus rhythm ms& start# 4* It is believed thet thorn is eone "mthoHmf in tho surlclo 
Mud the vena ©ova orifices froea which temlaeo are sent 
out to the rest of tho auricle# 
5* fho Circus Rbythra of Auricular Flat tor* 
Is) It is believed that the Hog Involved 1© larger, end 
whenever the 1 polo© corns oreund It Is traveling la 
msclo which hsa ooaple tely recovered from tho refractory 
period* Tin© eo&cct to got a constat nste~ftiiA w© do, 
300 per Minute* 
(b) Tho £p$ between the two ends of reeponeftve tissue 1© wide* 
(c) Tho mto is thu© rolativoly flower end coapletoly rermlsr# 
(d) The irgmlao io traveling 1b e bigger circle end in tho 
«tt»9 pethtwsy each tii9e*-*cmd get essie M& pittas ftt» ttae to tiiao# 
(o) Thus in flu tea?—tho conduction is alMf, tho refractory 
period Is itortcr or the ring in Terror* 
6* the Circus Rhytlg* of jmHouXar 
in) It Is believed that the ring involved Is roller, the mp 
In m& the taeniae* traveling in only pert tally 
recovered tiamo* 
(b) the ixssMm is picking its vaay, the pntfcthun vette* tvm 
cpola to cycle, every circuit betm mmmtrnt different** 
thus a&G pat tom verlod from time to tine* 
(e) xftartltt le fMtaamtally 
id) Thm mt* tend* to ho mr® r&pM 400*800 per mimto* 
to) The path tbc immlm travel* tends to be charter* 
|f| Tims & flbriXletion—tte conduction is foster, the 
refeeiotoisr period longer or the ring to aeaaller# 0* Tbo MiQ in Circus Wbytte* 
(n) Bo not ooc ordinary JMwvoo* 
(b) the circus rhythm destroys nay irisulses being fsmad In 
the S-A node* which for ell Intents end purposes is 
Inoperative* 
(c) Wo do oaa oscillations due to the circus tsfiulees* Ttelr 
fom depends on whether flutter or fibrillation is present* 
(1) Flutters get oscillation© with definite 
pattern* perfectly regular end alike* 
(J3) Fibrillations got highly variable* Irregular oacil* 
1st Ions which ere nakedly eacllcr then tteso of flutter* 
9# Venous puloo tracings my chow flutter or fibrillary wevee in 
aooa cnooot is otters they do noWolld© (%>* 
10* Oonvereicn of Fibrillation into flutter* 
If t?o do oomthinf? to shorten refractory period the 
rise: spy booone sailor time* Thio might bo <m» 
piloted ter digitalis* shortening the refractory period# 
If ring Cl) w prorwnt* Plight by giving quintain© 
lengthen th© refractory period ond get ring (2)* 
B« to?i<mlc.r Fibrillation Jalno tiuo ot Auricular HaftwrJ 
1* 0mwB in It occurs: - 
Co) Mitral steooul#*-<*>rnetice By all porsietant mrloulnr 
fibrillation is young people to duo to this nmm9 
(b) IbyretOKlc heart diaQsoa~»i8 mmm&y eeoeeictcd with mmUmim 
fibrillation, fibrillation often trtmmimt9 my ho- pgevmt 
when otter toxic uontfaatattee ore slight* (a) Ifepesdeaeftni heart when associated with 
ohoE&oe# 
id) Artorio solera tIc heart ti&marn* 
to) Aouto infections end tCBonioo”-* !•&•» smsuamio, rheeaatic 
fmm$ diphtheric, poisoning 1%S# Alcohol!# 
(f) Oonotrlctivo pertoardltie# 
tsJ m occur without any other evidence of heart diaoaoo-* 
peroKycenl auricular fibrillation in aorrsol haort# 
Va) Vmmemm int 
iX) luetic heart dinooso— 1* e», luetic aortic Insufficiency# 
(2) tfebacut© bacterid endocarditis esscept In torsimX str'-oo# 
(J5j timixm Pectoris 
is) Patients who start oat with online, rarely hors 
auricular fibrillation# 
lb) Patients with auricular fibrillation rarely have 
angina pectoris# 
lc) Must mm that typo of arteriosclerosis causing 
mttimXm fibriHatton oust be different fm that 
em&im «glM pectoris# 
Ul transient fibrillation or flutter not tmoonrasoa 
after coat© coronary tbror&oaio# 
£• Cherccterldlea ©f mxriml&t fibrillation# 
(e) X© IK0 ifm fibrillary mmm very greatly in ©is© and shape* 
tending to It seller, irregular and mro rapid thm 
In flutter# 
(b> mm it stops it atops mMmls* 
(c) The thing which sate it off is likely to bo mi tejrlmkr 
(H&RMyelo&t ditch foil© close to the end of the ro~ 
factory period* flUdo C& tftldoa* 9l c&owo auricular fibrillation with BimXtmmae vmmul polss 
treeing with large fibrillary (f| wms>* 
0|r5 fibrillation with lento tmn&m which mm not 
constant* hcmevor* fSs> JW« Is possible *tapm Huttos*5# 
iMaavcB In thaf5D curve© era- move prostoont m& rogttlor thou you 
ooo to ««>0t petlcatn# 
fibrillation with loro© f-ouroe (labeled 0 to slide) 
which are not ooastent* aaoh large fvwos aoc& to occur to 
patients who have been flbrllloting only e very short tlm* om 
also to mrim.lor fibrillation# 
auricular HbrillotiOB botoc oat off by 0 pmaotur© 
igurlciitor boot aeeurrtog st just the right point# It to believed 
t&ot both flutter m& flbfillQtto® ore set off by such prwaoturo 
tot© which occur st Just the right tine end with the auricular 
rsiaolo all ready for it* 
caveat*! Mtsess of fHNMtwni auricular beets setting 
off g&roa&cukl auricular ftMlXetlm* 
XmCa igtomim the f-cwes of flutter m& fibrillation: 
Flatter*«»gee Ihhbo l#«ktieftl Hutton t»voe which ere torg© bocnuoe 
0 Irmm mm of mm&m 1© involved, 
£HKIUsSlGft •aw yatUM aft on emmrntm of Hutton to fibrillation 
by raaen© of digitalis# Fibrillary vmm result which 
ere mil or tbm flatter wnveo and hot* toolbar* -'bom 
that the isspuloe io dodging around trying to find 
aiv® mode m that the mm total of mmlo mm 
mapmdi&ct is ©stall* 
(a) to aurioutor fIMISatlaa there to m of fmHtm a 
regular ventricular rets hmmm aotiilng regalar Is 
gotm os in the veatrtaliMt mmpt t has the fete become mmlvr 
you lemr that the ventricle* ore 00 laagor r**® ending to the cnrtolci>-» 
i«o*9 ooefiloto heart bloefe: to to digitalis* (8o« bolwii 8Udo |al onHoito fibrillation with o rapid irmtrieoler rate* 
(b) and (c) MOfimXxet fibrillation with a ruch slower 
ventricular mto os& very orsnll fibrillary wares# 
C» Mriculor Hotter 
1# Character! sties# 
(a) durioulor rat© is £40*380 in uatrectcd eapea, Oneillntlono 
arc perfectly regular end alike with no variation# fho 
mmm or© eontlsuemo go that you cannot tell th© 
n$m nor and boxy Cecily# 
Cl) In flutter treated with quiRldinc you can get flutter 
with *Mte» ten to 150 or tecs* duo to effect on eon&kotiea* 
(b) She ventricles respond to a certain wk? of those Irpilooe* 
Cl) Usually In adult, isvfcreetod hunsons* there in a 2*1 
roqpaaoe with ventricular rote of db 150 per etoato* 
S’ 
(2) She vtmtrieiee say reload rerulorly or Irregularly 
in fhsHih Tins the ventricular rate nay he ena-half 
or loss oorronly ©na»third to oae~fourth the auricular rate* 
(3) If- the degree of block Is variable lohm&m ftwn 3*1 to 
4*1 to 2*1, ate#) will have a gfeeely irmtilar vantrlcu- 
lar rfcartbB which aey bo difficult to diarnooo* 
<4) If the degree of block is ecaletant will hare ronuler 
ventricular 
CS) Occasionally do ?*et 111 ron&O&m in auricular flutter with 
ventricles aoeopting MU tBirlculer rate to :D0 per 
nlnnte hut vary tort end nrobably only In presence of 
wmh daermeed vn4 to# (e) Tim mritlm is flutter ore ell 
the mmlo roi$eedlsg o®cb rapidly# Tima In . 
the vououo pulso tmcte ini em ooe definite 
oorro<f*mdln@ to MO wrdealer activity# 
(a} Xa 7B-8E$ of cases of auxariteolor flutter the in 
l*oed 2 ere very fist end aef be herd to ooo in loads II cud III# 
to) the auricular flatter oeetllartlone here a "family ro» 
mm&XmmP from emm to esse* pmhably heeauoe the "author 
rtocf is in the wm loeetim in meay eaeee* 
e* sendees 
(a) (%j»-*mriculcsr flattop with £tl block* Bote super- 
Isposea CS» 9*H*eftt 
(b) 03*"Hmrioular flutter, with varying decree* of block end 
siaaltareoue pulse treeing shoring flutter ewieiu 
(c) flutter with 4s 1 block* Auricular rete^iW 
par minute*, INerres not os soiMsoothod so ximml* 
(a) nutter with v&x® mmll flutter wcvee is 
tod I* tends 11 sad 111 shear £il response* 
(o) — flutter with aocnr&loe of result# of va#sl pressure# 
tf)—Oj0-l:?feot of vugel stinnlotloo m aims tsoJsyocrdla, 
peregyassl tsobyoordlo and auricular nutter# 
1* slims may .slow meimUm rote or produce 
temporary Mode or produce oorfeiantion of standstill and 
Mock, thm original zmbmim restored# 
t# Peroayefael eurteule* tooHyenrdie—tse offset or stop attack 
md get sensei produce bloci'# 
9* jsrioulor block, e«ft mo Hatter eeveef 
cannot effect earloulnr rata# D« Dffeot of' toel StleaXetion on Circus Hbytiafr"*Bm elide 
X* ftcdtieoe refractor period in curloulnr eeecli* 
• , ' 1 * M e 
(a), ®hle aor toe to effect of speeding up to rot® of oondtsetiea 
boosAW tore ere fosor iolaede of refractory tissue standing 
in to wear of to laqpelee* 
C* Vugs! ettetletlon effects to node by depressing it® coeduo* 
« ' . ’ v ,'• * * * [ i. * • 4 * * * A < ' ’ * 
tlvity*-oltor prolonging to refr&etory period or delaying to 
recovery proeooo* 
£• Digitalis find ito affect on Clreo® Sbyto* 
X# Bttoot of digitalis in tot 
(a) It® direct offset oo Insert moo-la In to 6eX®y conduction 
(XanetWi to patowrt* decreeao to*speed of conduction, 
aM proXang to refraotoey period* 
(b) Its toe! offoote* te?c^f ore to oppo&it®~~to tort®m 
to pcttey, tor oae to speed of oosdoetto cod deevoaee 
to rofreetoey poriod* 
(o) il@iMI« is gtfUB ebiefly hmrmm of Ito effect in 
cutting dowi to vselvlsto fete* 
(d) Ordinarily if MBP clion'*e at oil secure an romilt of effect 
of digiteXI* on clrouc fbytfee* it la ito tod easy to Inereeee 
to circus fete. fete in true if to tonal effect® 
«f digital!® pto^oadneto* 
CU Bigltclia, by it® vmoX of tot, torto® to refteetwy 
period end time lasfeee to tepuloo accept ® aaoller ring 
of tiornso* time it toad® to tormoo to circus rate* 
m iMs i® to bools for it® oat in flutter* it oowrarta 
to flutter to fibrillation* |c} Malttilio by Its regeX effects mm heart miaole behove 
Ilk© firclotal sneele# 
CM Zfe with kti deeee of digitalis eon got ao 
great o tegel effect that got circus with rote of 
£,000 per odttfcte# 
S# aicltoUo in IfirMsr Flbrlllctioa* 
Co) knrlcelar rate beocroe fbeter end the wfroajerr period is 
shortened but the effect 1c not vow peoeootteed ymmlfy* 
(b) Tmtrntotor seto toms slower# 
(1) Oao in part to ettaftatlee by digitalis# 
( ) Usio in part to direct effect of digitalis m tha 
MV node with depression of mV oontetion# 
t . * 
3* Di/d tails In MNMUie flutter# 
p 
Co) nothing iritti happen taihwv the refractory period is 
* 
obertooed s» much that « am oefl shorter drone 
pathway to established# 
(b) Bwte flutter aassr bo cmVertaS to fiirUX^tion# 
(1) The ehea®e to a suite. OQe»*»m<taBl3r gocm into mil ring# 
{£) It eeanet bo tee with carotid slims ottesl^ttef 
(§} 0ooally am be am with digitalis, tower, which 
* . 
stimlatas the tm reduces the euriedimp refractory 
pearled and results in mMm shift to fibrillation# 
(4) Thm after fibrillation baa eeperrened, If tbi 
digitalis in atopoed# newel rhythm will u molly appear# {a) Hi© liroct affoet of digitalis on mvimlaT ay sol© is 
to im&tom 10m MftMtair pcrioa but the taral offset la 
mpTovm* It0 direct afreet on vertrlaulear aoaeio 
is to delay alishtly* 
4# tmtseoft of Circus wltli IH&ftalliN 
(a) It io sw tfaata&lo to tern fibrillation theft fluttea? 
hmmm cdtght ©hannae to tho aurtatlitir tatty It la 
rapid* tsito Imv lUeely to affect the ▼efttrlculer rate# 
(1>) In both fibrillation m& flutter digital!© le effective 
io) At h$#k rata© tb» teeyt la wositla® very laofflclmtlgw 
It la act filling util and la tmtiag a lot of «a*cgF« 
{£) Dlritelio can to umA to ©caveat flatter to fibrillation 
and thMl ©topped and as Its effect «ar» off on© anr 
. / 
not a aowaaX (a* tadtootoft aWrc?)* 
S# &Mm* of oachela oa wicalar fibrlll&tloa* 
49fS*HP©pid fibrillation 
aOOO—nte?or teatriaala* ret© ttwwflioMkir after ouabola* 
0€XK>«*oao bom?' later vontrimlar rat© ©till atom* 
Uoto3 1 «$• Ouabain » 10 cat uatt© of digitalis 
%H ***•! of Ouaboia os auricular ftNsillatlCR 
Eat© reduced fro® 119 to 93 In 53 ufasistoa* 
QrQ Mfoot of Ouabain* ©tropia© aafi digitalis cm 
auricular fiWUUatiiMU 
affect obtained la two houre* 
Mwitt*»* 1/19 gr* gtvciwnito letfuegMi 99 par 
fftin* la ft min# but thig we© not a greet 
laereeise pawing that the itodtog vMoh 
noma with digitalis 1© not entirely a 
9s®sl thing* 
gradual slaslag coos* course of 
SO hours* Bffeet of digitalis and ouabain cm ourtoXor fibrillation 
associated with 
It trkm tm&h mm digitalla to cot tiho Coairod affect and 
often era coimot rotoft© the rate tom to where taou want It 
cma with full Cocoa# 
6* lleert Block with fUrtUfttian and other points 
ro@83Kilii@ ftlQttdllo Intoxication* 
(a) Oomirs not because of abolition of mrimlor fibrillation 
but because of Independent ventricular rtqrtlm# 
(b) fantrioulrir rate Is footer them the usual corploto blocfe ( 60 ) 
to) le In port duo to Mumqt of ai&itolic to enhance and to 
spood tip the Inherent rats of tow nodal or htrsh ventricular 
cantors# 
(1) dftcitelio toed© to enhance the toMciwr of ventricular 
cantor® to oonft out Inp&ooo* 
(2) Mciltolic will minmm the tendency to hallucination© 
and Callsixm in people who already have core such <Sif* 
ricuitr# 
(3) If digitalis is gtWtt to enters, after about Wjl of 
the latlial do©© la there result© m 
ventricular tiwtlm which is footer than 
the auricular rate* 
(4) those iMopondmt ventricular rhythm iegr 
be weep fast— oo colled tachycardia induced tsgr 
%** (a) fboaa fast fbythB® not be eletesed with nor are they 
related to pcroocyeaal ventricole* tachycardia# 
(b) asm thins om bo done with adrenalin* If adrenal in la 
given in surionlar fibrillation it eetefelAched an Independent 
ventricular tfeyttn which in usually rapid* So® olid© 035* 
(a) Us eases with * rapid ventricular rhythm end alternation of 
the ventricular cocplcfcce* one slsould suspect digitalis 
intelootton# 
0« Slide &wiea&tt? fibrillation with oenplet# blooh due to dlgitells* 
(a) Vmtriouiar rote So royaler suggesting ourlclos nr© 
no tango* mmto the ventricles# 
(b) ga@ vary In fm* mm&trtlng that the n$t±aa 
10 in the ventricle Itself# 
in) Tho ret© la plus or minus 66 per nftontG# In mm of eanplwt* 
blocl? with ourieolnr fibrillation the T®to la usually In the 
lot? 60fs, though it aey bo mm 70 or 00# 
(d) fho clinician Kay thix& that the fibrillation 
■ 
has booeueo the iftetiHi la scalar msd con- 
tinue to giro digitalis* m mm and mom digitalis in 
given the sete jw become higher end higher* con- 
trol the high rot© ho my giro mm and mm digitalis* 
fho eeetriele s# become »ro irritable end eventually 
timm aay bo ventricular or fibrillation# 2* HIM© 0^* 
(a} fibrillation with Irregular ventricular aUsrUto* 
(b) X4ftV-«»curi color fibrUl© ion with ecmplete block* 
Ibis type of ©ooplote blade soy or nay not bo ooqplctely 
If corspXotely blocked, off* rhyt&a i© regular* 
If nor© digitalis to given irmsulerltioo my appear* It 
. Is usually not a© completely regular ©o the ardinaxy 
tom of collate heart blodc* 
F* ana Its Effect on Clrono ftftyt&ao# 
X* It $om two thing©* 
(a) Oeereeaoa the rate of cooamtios of tho InpuXoe* Thin tm&& 
to widen tho 0bi> of teapensive tiaauo end to perpetuate tho 
eivooa rhytira* It tend® to slow tho rote a® well# 
(b> It iBcrcaeee tho XcwetHi of the retectory period-* Thle topics 
to obortem the gogp of recpo&atfe tlaeee and thu® to tesi£txiett 
the olvms tferttas* 
2# fho effect of plattoi tfcm# will depend upm vtoitih of thorn too 
effect# will prcdoaj&oto* 
to) It mm atop tho otMSM oatlraly in mwtmloT ffibvllletior* 
$b) It my comrcrt the ffbtUktSl® Into flatter* 
til It mm&rtn tho oIrene to © letter ring* 
r 
($) file petiemt nay then ste? © atop in tho flutter or 
the Hotter ms centime end It m*r ho found noommvy 
to give digital!© to eewert the flutter back to 
IttMfftUatkMM M tham two of foots, them, wox& ©$atot each other la port* 
S# fhe effect ©blob it hoc cm the Btc dojwade rsore or lee© on the 
original rote* The blj?her the original ret© the greater it© off act. 
fins wore liholy to «oxt la fibrillation them in flutter# 
(©} Thee is ourlcular fibrillation which tuxiellgr -has a rate of 400* 
000 par nimitc, It al-wo redueeo the rut©# 
(b) In eurloolctr flatter which hoc a rot© of MNS90 per ndtaute 
the efftaei on the imrlcrular ret© 1© each lane pronounced# 
mutter la tbao probably harder to ©top them fibrillation# 
4# attaet of ■Qulnidln© on the iWT Hodo# 
(a) It deg&Basee conduction in tbo'sede directly by its 
actios cm the no£ol t learn# 
ft I Xto indirect effect in to eloer the auricular rate oM tlsue 
lamne* t © vnMesiar sate* 
5* ©jo efttoet of quintain© cm the ventricle to to t&olese tbo 
refractory period, <hmmmm the mto of conduction and deproc© 
conduction In.the fmfclikgft mteoife* 
(a) It my cause profound c In the restrict© vemx&tlag 
in Mo bundle bfnaebeo ana 
their divlBiono, oldening the tW ooeplcBt# 
(b) It my effect the ilia bundle broncho© amt omm bundle 
hmmh bloofc { I*©. t Right boodle branch bloclc in pot lent 
Dotty EsTbol) {Slid© &^# 
to aM Htn o# ftoMftcwet with t&laldlftft* 
* (a) Caooa in tMeb it is indicated* 
(1) Bsqphtliclsde- goitre with pwiwment fibrillation 
after tlyroidectoay* -oo» wo© qutaldino to atop it* 
(E) Injuries to heart cemoiag auricula* fibrillation, !• o*# 
ease of mn wheat ekeerl wm pierced by a piece of stool 
just teaching eplftairditia* 
{5) Caea* «HHi do not ms to do mil with digitalis* 
(b) It is oil H# to ttoo digitalis before ym give qutnid:In©# 
(X) fat lent soy bow congestive failure and you met 
wm digitalis to relievo it* 
(2) nee of digitalis my to prevent 
n rapid ventrical** rate fro» developing occasionally 
but It dooo not alweys do oo# 
(o) of %olaiiAi2»ft# 
* 
Cl) It emmn diasgrcoablo geuees* 
end vomiting, Ghaatom* 
(2) It to oftm ftftocolotod with s pronounced rise in 
ventricular set*, both in flutter and In fibrillation* 
riben It does occur the patient is werao off than bo woe 
before because of the reciting fatigue of the hmst* 
therefore, m do not like to give ciulaidine to on 
tnllfltel with fterdioe failure because it my tend 
to lacrcae© the feline** 
(S) If ® pnttmt hm hnA auricular fibrillation for mm tim tilth 
ceMieo ftoilmi sad mrie%mt them w be tMti 
la the auricular tfbSeb mt bwit off «dbc&l» 
there ha® been o gMMit deal of $sx$$mm% ©bout tblo point 
and it mot bo Mr&elMftft& that cssboli oecur In patients 
with tsurieulor fibrillation sad congestive fcllate «*» haw 
not reeoivod quiaidine* (4) Jtoot hmmm tho fibrillation cm bo stopped with Qolnldlna 
doco not ®qb it will stay stopped* It aoy recur in © for/ 
hotm of ap|p©* Dr* Wilaon aa&Sen woo© qutnidino if condi* 
tied© Ptiioh to aaHeniici* fibrilletioB are ©till 
jwsoeot# 
(8) liuinMino sscy be daily tilth idee in nlod of pro- 
WAttmi the rectirrone© of fibrillation* It owe be s!?m dolly 
for yoor® without 111 effect# It to harder* tower, to 
piema* it© mmmemm then it io to obolioh it one© it 
%b wmsmt* 
(d) Item* mmem in fibrillation with um of minMin® to abolish it 
will depend on tow herd tmoh the drag* 
7* iUdmn 
laMSMsMt In wnMMla* to 106 to 
114 after quintalm and ©losing of ccriaoler rate 
after it* flits Chmm in mtatontap ret© io tmnoicmt, the 
cpinidls® tending to peralyaa the angel aoctoniori, tha© nor© 
of the airems irmltmn cm gat to tto rentriolo® 
ne&ia® tho tentriofclisr rota fbetor* ftoa lotar m Um 
metoule* rot© bocoaao lonor the aantrioaaJUir rote iw alJO 
ham© slower* itecw, ii there cm fmzm ©iiricuto IwpkiXsmm 
Ci*9*f sao instead of 600) t oot sshioh do arias nay bo 
©tronger end thu* the vmxniclm W0 mnpcM to mam of 
than* ttoo laorooaiag the hoarl reto* 
%l--Conrorsicm of mwtmlm fibrillation to aosaal •bytha tilth 
culnldlae# net© inarae©© in ■wmtrimlnn rate*  of another tmmrBtm of mirimslap fibrillation to aorrvd 
v&ytiss $dtb culnldlne* Sbcwe incroooo in ventricular vote 
from S3 to 100 wlthia 30 Montes# Alao ta abort suae of 
ventricular after cuinidino# Then of ter 10 islxxutoe 
from tlflo 6mg m& cfaran, them to mmol xtgHthru Deep la- 
version of fheaevee la coon after QUinldlno in this coco. 
Gl? nbo bad subacute boetorlol endocarditis soft auricular 
flutter* Olvm S cm* quisiidine end later 6 ne»i qulnidinc 
X# V# end ooon developed ventricular fibrillation end died* 
0. Yentsieule* Fibrillation —Soe didos C43. and Cgg* 
(11 Fatloatc v.tso die of oogiaa pootoria ore believed to die of 
ventricular fibrillation* (Hof# Ivon SbonpeOB'e pepor in X* A« *1* A#) 
(e) leporlswatr of H« B* ftillieme feeve ohowa that death fron loir 
i 
voltage electric shoo&s is usually due to vontricolor fibrillation* 
(a) It tests found that if o ctiwit of abort duration fella 
m tho end of o the ventricle io p&msfm out 
of the refractory Gtcte—ono is opt to got ventricular fibril- 
lotion* If It fella Into? In diastole you get juot an QQEtxts- 
apetole* If it fella earlier in the atdot of tretele you rot 
no roqponse at oil# 
Zrgpulse felling ot 
(!) !lo response 
(B) Ymtvf.mlox fibrillation 
(3) Srtro^Mitolo 
(b) It nee also found f at one© ventricular fibrillation fee occurred, 
th© best treotooot for it is another, bl$*or ahoefe f&leh till 
ma&o the arholc heart refractory at me tine, thus stepping tbo 
0tm and vjbm heart h©gins egelii it ttIII have © normal rhythtt. 3* It my be that some hearts actually go bad before the ventricular 
fibrillation appears—thus the fibrillation may be the result of 
the condition of the heart ret her than th© cause* 
4* Chart of Effects of Vagus Stimulation, Digitalis and QulnlcUne 
on Heart Mi sole 
«■»— - - »—■ 
> 
Length of 
Path 
Velocity of ! 
Conduction 
Hofrectory 
Period 
' *S3 ' 11 ' m 
. ===== - 3 
Vegcl St inaction 
~ - - -fc. 
Digitalis 
Vagsl Elfect 
_ ■,mm r r | , -r 
MM 
|_ | 
Direct Effect on 
Heart Duccio 
t 
, n, r. 
•A* 
Direct Effect on 
Heart lluocle 
—— 
+ 
- -g, -1 
Indirect Effect by 
Paralysis of Vogue 
+ . 
+ 
-f. £ Increase 
r" 1—" ' 
—• a* decree no 
Reference: Leeds, Hochonical and Graphic 
Registration pp* 361-2 I* The IMS Of THE iSU-^IXJ^IODCim 
A# Tho fom of the oloc&roonidio&rnB Oopondo to a extent upon 
tho order of ootlvotion* 
X* If you tote© a strip of mode and stiaolato It at ono end 
yen will get one fora of curve; if you otimlnto it at tho 
other end you will get tho reverse; if you stlmlnte It 
at the rdddX© you will gat very little because there trill 
be nsro or lom neutralisation* 
BXoatrodO 
£• la the dioeusoioa of tom hero It will be e ©mired that tho 
irpiloo io being tmnmitted in the mmml imy# 
a* Before nay can bo ascribed to tho £bm of 
the you mst Imcm that tho iqpulao 1 a arising in 
tho alnuo node end io ©prondlnc over the auricle in 
the norml w*-or, as In the mm of tho tao, ono 
mot that tho feimlsoo arc oo&lag tom froa above 
in the oorsaol woy« 
b* Also In tho discuaolm it i@ mmsm& in oil mom 
that tho iapula© ia casing fm above the bifurcation of 
tho Hie bundle* 
3# In dlaoucolon of tho tom of tho veotrloular ooorjXcfiw j one 
mot lam that the irpulao lo ecaalng ton f*wi tho 
auriolo* 
4* In diomosiag tho fom of the miriculnr oooplat* one mot 
laws? that tho iopKilao la ooniag tom aosenlly fvoa tho 
oino*auriouler node# ©• Thao in SlsQfieslag bundle breach block one met knm t!v:t 
the isochrmlm Is mam! end tljot the aproad over the 
ventricles in nornel except for the defect In conduction 
below the bifurcation of the His bundle* 
6* In doolin& with ©loci record ioerano In which the cite of 
SapoXon foration In etakcnsnol* mo does not know whether 
the differences are duo to the abnoxml site of 
fomitlen or to an ebnomol spread over the heart. 
Co) Thus in tiuriculcr catrnr"stolon or ventricular ortro* 
systoles the cbnorssol for® of the V*mmn or oor>* 
pler:oGt reject ivoly* nry be due to (ftoorml sites of 
insulae forest Ion or to otnerasel agreed over the heart# 
B* The Potential Variations of the SctrailtAeel the central tnmlnol* 
1* If we te&e "direct loedfiP with one electrode directly on the 
heart Cor precordial leads with one electrode on the cheat) 
and the other electrode on a point quite distant frosa the 
beartf !•«•, the beeftt or the leg* m will not curves 
stenting the potential mrletteui of the electrode on the 
heart because of the nature of solid conductors* 
c* The curve will be dosinrtaA by the variations at the 
heart1 a surface and any effects produced by the Ice trill 
be only 1/40 as 'root* 
b# Compared with the potential variations of a single estmnlty9 
them at the heart*e surf see ere 40 time m large* 
o* la taklar each direct loads the sensitivity mist he re- 
duced to X/m n (arapi}« d# Thu® w© have a sort of uai-polsr curve, for although m 
arc rm&orim th© difference in potential of tuo point®, 
on© of those point© la for oil practical Intents and 
purpose© constant* 
e# In general* the eartrcs&ty will display the potential 
variation® of the pert of the heart facing that ertrorclty* 
2* In order to ©liistoate the effect of tbo distant electrode, 
tower, vm nay create a contra! point or central terminal 
to which ©11 three ©gtrcnitios eve connected through equal 
resietanee® (5000 elm coeh)# This will give then an in- 
dHTeront point whoso potential ie 0 end by using this 
point together with cm exploring electrode, w© e@& deternino 
ttm variations of potential at any single point# 
% « potential vrrlntlona of Hh 
VL « potential variations of IA 
Vy » potential vorietloni? of IX 
Vij* *» p oteailcl variation© of oontrel terminal » 0# 
+ 
2 » current - % # % x S Koa&off'a law » sun of 
♦ currents meting at © 
E « roslctono© -A?i, - % » %i % M single point is 0* 
I % » % * B 
If taeoe tlire© are added 
• % • Wfe ♦ % 4 f*) • 0 
OT ?T * % * % * % 
Therefore % * 0 
{by low—mi of %t Tl gM % • for reference seel- 
ftilnon, Mr cLood and Darkor, An# Heart J* 
Vol# V, !■&>* 2f pp# fiOMU, Deo. 1931# 
Lced I negativity of arm » upward novonont 
Positivity of Left em a upward aovencnt 
LLood II » V - Hogativlti of right am » upward osroMit 
Positivity of left log » vegmutii wav«p«*it 
Lead III » V • negativity of loft am » upward lambent 
Positivity of left lag a upward novonent 
Lend I a + Vj. upcidc dOM& 
Lead 11 a % + upside tom 
Loud III a % -f upside tom 
V. + V. + ?j, a 0 from alnthoven,e Lew 
Vv a •» V|.k • Vj, 
V - 7h a II 
Vy • VL » III 
Hina maa mi i 
2 % - % - m 
g Vr + (-?. - VL) a ZZ + III 
8 % + (%) » ii + m 
3 % »IU III 
Therefor© V} » XI + III 
~~r~~ 
upward mam nont 
upward novonont Similarly it can be obmm that! 
% “jL- JS 
3 
▼t -i=-£tt 
3 
C# The extremity Potentials la Right and Left Axle Deviation la Stomal 
Itotlonts# 3oe SIM© BgQ* 
!• It oca bo seen that in nil cdx eases % is osoontlaJUy the son©# 
o« It is negative during the greater pert of the 
It nay bo positive for a short tltao at the beginning or 
the end but It lo native throughout most of the period# 
b# this ic because the right nra lo opposite the great 
orifices at the base of the heart and the potential 
variations of the ventricular cavities ere thus re- 
flected to the arm# There lo no nusclo being activated 
betv ocn the eovltlco end the right shoulder# 
Dm On the other hand 7L and Vj. undergo aeny variations# 
3# In H# A# 0# in nomol people—upper re*—■ #30374 
Vx, looks like direct loads froo the right ventricle or the 
boss of the heart# 
% looks like direct leads fron the loft ventricle# 
This is because the heart la vortical and rotated about lie 
long axis oo that the Hf feces the lA aM the W feces the LL# 
4. In the next pot lent —# 59S7S 
Vjt looks small end indoterrdnoto# 
looks like direct leads fro® the loft ventricle# 
Iloro the heart is again vortical and rotated so that the Vf 
* rt 1 *n tJio previous patient, 
faces tho IX but not so/m 1 * 3* In tho Xcy 09X record # J59S73* 
YL looks Ilk© direct leads from t!ie LT (also llko 
% In # 39374)* 
% now look© 111?© direct lor ds fro. the K7 (r loo like 
VL in # 39374)• 
Hero the heart 4s transverse so thot the LV faces tho 
end the 37 faces tho IX# 
Yet 4a oil thee© patients the procordial leads t-ould bo th© none# 
Tho changes seen in tit© standard lead© ere duo solely to shift© in 
the position, of the heart rethor thou ebonies in tho heart itself* 
Korsrml Prooordlal Loads* 
A* With tho Tfoxfe on bundle branch block, tho need to take preoor'ial 
loads developed In order to got further ervi; caco bearing on this 
problem# 
1* la th© tew5let© neighborhood of the heart tho currants which 
flow or© ouch larger then those at the shoulders or at tho 
junction of the log with tho trunk* 
£• The currents generated by tho heart aro 1 ted by 
tli© body tissue* 
a* It in just os If you were to put e battery in e both-tub 
filled with water* 
b* However, mm current flows In ovary port of tho tub or 
©very part of th© body, mm though it diminishes rapidly 
ns you got ewny from th© battery or th© heart* 3# If on© olootrode io pin cod do no to the tort and the other 
ffcr cucy, It dooan't ranch natter whore you put the distant 
electrode boom?so tho near one dominates tho curve 06 mch* 
o# The difference in potential botnoon tho HA and LA la 
usually I • fiar* 
b# Tito difference in Twjtontlcl between the heart*a surface 
ond the LA is usually 40 rrsv* 
c# The situation is not Quite the nan© when tho electrode 
is pieced on tho prooorcUum because there the difference 
In not as $roat* However, tho procordlol eloctrodc under- 
$oeo variations which are 3*4 tiisos as greet os those of 
the distent electrode* 
$ Various Indifferent Points hove boon used* 
1* So© nlldo H49* 
o*It can b-.-> seen that there are istaor V? riations in tho preoordial 
electrocardiogram duo to the distant ©lestrode* 
b« It Is thoraforo wisest to uoc that distant electrode whoso 
potential is lor all practical purpose© sero* 
c» It cm he ©ton (am pmm 103) that Vt]. is scro and for 
that reason all precordial loads in tho laboratory are 
taken with the centre! terminal as tho indifferent or 
distant electrode* 
d# By using tho c -ntrol terminal we neko tho precordial leads 
ao oonparable as possible to direct leads where near 
electrode plays DO time m groat a role* o# With one m&T electrodo and one a intent electrode, the near 
r 
electrode le -f when the Inpulce lo approaching It end - tdion 
it ie 150'log «&<&# If electrode les cm lot point to bo 
activated It wiH bo —froci onoot; if on Inert point to bo 
ectlvetod It will bo-/-iron outlet* 
0* Iloraa Vlf VSf V5> r4, v5t Vg—000 Clide %5* 
1* Hormer of talcing pmoor-Hal leode* 
ft 4th Intoroor.tol HIM 
Vo ft 4th « • Im 
m 
Vs <» midway between Vjj ond 
»B Kg* at love! of GpOE 
% « IaaL ot level of cpox 
V.j » XHAL ct level of epcac 
8* . Over tho right procord im gaell end early J?«*mvoo and 
lorn© 3*<?evoo ero eem* 
5# An one coco eoxoee the ohoot to tho loft the 8"WVM ho* 
core larger sM Inter «md tho grow progressively anollor* 
4* $~mvos which arc dsell often oloo oppeer cm ono go©o to 
tho loft,* Thus? either ataoll Q or fsaell S or both nay bo 
present in % and Vj> 5* and Tg do not normally two C~mveo# 
6» la normls the Thieves cro upright escoept for Vx» which my 
bo Inverted* 
7* In children, however, Inverted nay bo soon In Tg 
V3 ond even V4* 
8* end Vg look like direct loads from the sight ventricle the* 
they or© probably aonewNat effected by the left ventricle* 
9* end Vg look like direct loads too the loft ventricle— 
thoo© loads era therefore nowl-diroct lead a* 
10# The point of ton alt ion varies a good dor-1 from patient to 
patient# It my be in 7g or in others ?4# This 1© the 
rcjseoa It In dootoblo to take nsiltiplo curves In order to 
get on both sides of the transition* 
0* It isras by using such curves in patients «tH bundle branch blod: 
that It ms hoped to bo able to detect which part of the heart 
bece&o set toted first* 
stlantos applied at X 
Z to none in which there ie a boundary between ootlvo and 
resting mode; this io where the effective 
•forces arc* 
fcapulao la traveling ton A to B* (ol With electrode at (1) m impulse is ©1v«ya traveling 
away, time this electrode ie always negative and record, from 
this point will bos , r " 
(b) With electrode at (3) ~~ irpulsa Ip always traveling 
toward it, thus this electrode is always positive and 
TVCOVH Cvor. thiB point nil b« 
„/v 
(o) With electrode ot (£) —•icpulse ie first traveling 
toward it then as soon ec it passes tho electrode It 
io traveling rjwcy* There will thug b© © sadder, shift 
whew the lapuloa arrives beneath the electrodes- 
This sudden dowmierd aonrorwot (Ml novonont) 
I© celled the intrinsic deflection* It 
represents th© tine of arrive! of tho 
Ingmlo© beneath the electrode* 
2% Bight ventricle is thin etui the Sisgmlae arrives at lie oar- 
fee© earlier; time the peak of the h-wave oc&xx*o early find 
tho H-wovo Is ©soil in end ?g* furthornoro nost of 
the nuncio is being activated ©ms? frori the electrode, 
therefor© the big S«wsv©© occur over the right precord turn* 
5* heft ventricle Is thicker and the arrives st its 
©orfcCG later (* 0*0£ mo»)m Therefor© the pock of 
the B*w©v© over the loft procord to <V4. %, V is Inter 
and larger# Since rest of the meole is being activated 
tward tho electrode the &*rnmm ere largo over the loft 
procordlum and since It ie usually tho lost or nearly 
the Inst pert of th© heart to bo activated, the S-wavoo 
oro absent or cBteH* 4* flange of vauml intrinsic Reflections In prooorfilsl lends* 
General Principle* Hoarding Direct Leeds* 
X* The Hornet! aprecd of Iramlso* 
The irmnlse ©toys abroad® f*m within outwards, fron 
endocardial surface toward the epioevdial s»irfoco* 
i# Thus if wo arc dealing with a single holiest sphere of 
Muscle th© junction between ootivo snd resting mu solo is 
always moving mmy from th© ..electrode* Thus tho direction 
of thb MS& 1© such ae to make th© cavity negative; and an 
electrode inside th© cavity gives only a negative 
deflection* 
HOHover* in the heart there io e septum so that actually 
you are deal in/? with tm edjnoent cavities end tho sop tun 
Is noasanily activated hell* from one side end holf from 
tl'sO otacr* 
a* Ifere tiie inpuloe in txrrixm wcy fvon the electrode X et 
1# g end 4 but moving toward tho electrode at 3« There- 
for©* the greetur port of the Jmisele Its boinc activated 
mmj from tho oloctrodo in the entity find Itc potent ini 
will therefore bo motive* 3, This may alm bo roproeentaA them 
o» lith electrode at X, the impalno 
is isovlne away from the elec trod© 
at 1, £ end 4, and toward tho olect xxi© 
ot 3# Thus the greatest part of tho 
missel© la beln$ activated cmy fror* 
X and its potential will b© negative 
fron the onset. 
4. If m electrode io placed inside the auricle opposite either 
the mitral or tricuspid valvo or over the pulmonary artery* 
there will be no maclo beneath the electrode or between 
the electrode and the ventricular cavity and we therefore 
get cavity potent tale* 
B, In direct lends end precordial leads the Intrinsic deflection- 
the sudden downward m&tmsmt from H to a—Indicotoo tho tins© 
of the arrival of the impulse beneath the cloctrodo. 
If you sro on o pert of the heart which is ncti- 
voted onrly, there will bo an S*wnet thougli it nny 
be «mU| followed by a large turn intrinsic 
deflection will occur oerly. 
If you ere on o port of the heart which is activated 
lets there will bo a larger B*wav# and only a 
snail or none at all. The Intrinsic de- 
flect 1cm will be late* 
a. If most of the UBS Is up, it sawn© you are on 
a region activated Into* 
b* "A® Iona o© there is an 3-wnvo it tsmm that 
there In aom rmsole which lc activated later 
than that upon which your electrode rests. 
c« If you ore m tho Iasi part of the heart to bo 
active tod, there will be no CMmvo* C* If, eo In this diajxon, we have electrodoc et A and B, that la 
one on the ondoc? rdiel ourfeco in tbe eovlty and one on the 
oploordlol surface, tho effect of potential variations ot 
diotont point© such as X and T will bo essentially the 
sea© on both of thorn* 
1* Therefore any diffcrone© between A and B will be duo to 
whnt f.poc on between thorn* 
$* ftils la what happens between A and B whan the 
nuncio boconea activated, B bcconea no-ativo end 
A boooaoo positive* 
3* Anything which hoppcnc bettfoeu then will rsko one 
noro negative then the other* 
4* Once the tepuloe roaches A, however, A and B will again 
be at the mm potential* 
B* If the sueels between A end B la thin it will not take lon£ 
for the activation to booom complete* Therefore the 
pod idil bo early# If the stiacle between A end B la thick, 
however, the tine It takes will be lone and the pock of the 
curve will bo later# 
6* Time with thin msclo the curve is 
belac duo to ell the mmlo 
which lo activated late* 
7* With thick mode the curve la 
the Intrinsic deflection coning; 
lator and the o being mil* B* The junction between active end resting meele Is always 
moving mt# from the cavity. In o direct ion such that the 
f ‘ 
cavity ic negative and on tho surface of the nomsi heart 
(over made at least) wo never set a negative deflect ion* 
a* Htxovor, parte of tbo body which arc opposite the 
greet valvular orifices my show pronounced negativity 
during moot of the QffiB interval boeeuoo they reflect the 
Cavity potentials —an does V,(>* 
D* Occasionally e direct Iced or precordial lend In the nomel heart 
will rliow a mil ie*ww^ 
1# Thin noons that the endocardial aurfec® beneath the electrode 
is being activated later then that of other oroos* 
£* Before the ferula* reaches Bf both A m& B «UJL bo ap- 
affected equally by wimteoca on nt X and Y* 
Ttnc if the ondocrrdtoi at £ m& Y or® activated c riior than 
ct Bt thcro isny be for a short tine c force directed 
away from A* thus accounting for the initial 
tire deflection* ftmfev» when the endocardium et 
B becomes active, then A will become positive to B 
and the curve will rise rapidly* 
In thin figure will therefore represent the instant 
nt which the endocardial mvfncc et B is activated and 
Xz will represent the instant nt which the Isgft&s* 
reached A, «Imb the cpioa»diisl ourfr-co wee activated* 3# Wo ra;jy 0X00 show tills with tm stripe of modes- 
s# The effect of atrip (X) on the electrode Is 
b* Tho effect of strip (IB) on the electrode Is — *— 
V n—for© (1) 
c# If atrip S is stimulated sllchtly before strip (1) them 
will bo first a <i than an H ns (1) beeoncs activated* •*, V— 
forri z» 
£* T!ws the fundamental patterns coon in direct lends nret- 
Those occur over tbo right ventricle where it 
is thin# 
This occurs over the thicker portion of 
the right ventricle. 
Transitional fom. 
Tills occurs over the left ventricle whenever 
loot portion is activated* 
Tim Q. wves hero wi that other endocardial surfaces 
aro boiaf; activated before that beneath the electrode# 
Theco occur in the ventricular cavities ox* over o 
noa-rau ocular pert of the heart opposite the greet 
orifices# 
Q. or m F* Tbooto principles c??nnot bo applied to the ©tenderd lends bcccuso 
both esrtronltlos ore changing potential* 
!• t'ho potentials of on© or the other raey donineto end tho 
curve any be right side up or upcido tom* 
B* fhic is beer,ue© you sr© doellng with tem electrode© ©t 
©ppimteitely the mem diet once from the hoert and they 
aim so connected to tho golvunoootor that negativity my bo 
ropresontod os m or dovmwerd deflection# Thus 
negativity of tiie RA gives on upward doflection in I whoron© 
negativity of the LA. gives © dmwra tofleotion In 1# Thu© 
with largo variations in tics potential of tho left nrci# 
Loed I mf bo tho inverse of toed III,b©o©u©o In I nativity 
of the LA gives a downward deflect loa» where**© In III 
negativity of the 1A gives m upward deflection* 
c* In otlier words. If the potential variations of on© 
ortrmity nvo mch greeter then those of tho other 
ostronity, lergo potential variations will donlnsto 
those curves obtained using thet csrtrcrdty* 
b« Thuo if land I boc&o like this: 
will bes 
because Vv4 dominates both I and X1Z9 
, than Load 111 
5# its polarity being reversed vfom III Is tf&m* 
3* Thus the pmk of the H«*mvoo does not tore the ann» sig- 
nifies r nee la the stAQdcii leads na It does in the prccordlal 
or diroot loads# 
4* Usaxjovcr, the farther you got from tho beertt the novo gon 
are apt to get avors&oo In variations of potential# G# In gflowil It any bo on id that procordlal lendo closely rooonblo 
ped loodo {token tilth a pod of potd aookod with m«m K nalino 
placed over the oplcardiun) 02? direct lends ttskoa ffcqa tba oia> 
foco of the heart directly under tho electrode* 
ii* mm& oi* im mvws xk BOR&ut Bunion bukeu 
At In right BBD1# 
X« Bar® tlsokc©vity nt X will bo pooitIWot tbo bof'lanino 
bocouoo th© 000turn la being activated toward tl«? 
©loctrodo* 
S« Thua ao the S&puXgo travels tron B to A# tho oXcotrode at 
A boconas positive o cooond tine* 
3« XSaio breaking dam tbs record obtained at in Rt* HBls 
(X)—doe to activation of oqptua 
fam left to right* 
(E)—duo to activation of lateral 
tmXX of loft ventricle* 
(3)--duo to activation of right 
ventricular wall* 
B. In loft BIBX* 
1* I {arc the cavity at Y (left ventricular orvity) Ic pooitlv© 
at the Ionianbocouoo tho entire eeptm# io being 
activated toward the cXcotrodo* mmm mmm mtm* 
X# Historical 
Am Tho bundle branches wore first doooribod by ftmm9 working 
la Aschoff*® laboratory# 
B# Aaoag early attempts to cut tlie bundle bronchos wave those 
of XXewollys Baikar* 
1* 3?2» bundle branches mm out in ea&mla and raochealccl 
records wore and©# 
S# Bo woo unable to te motmt© any delay In activation on 
the side of dnnoge# 
0* In 19X0 and Hothborr-or studied the effect of cutting 
tho bundle bronchos In dons with the MG# 
1« fboy uood m lead which Is on csiol load, 
laoro or loco parallel to tho long axis of tho heart and 
ooqpcrsbl* to Load II or load HI in iaan# 
£# Ttaay found that cutting erne of the bundle bronchos pro- 
duced which wore more or lose opposite thorn 
produced by cutting tho opposite bundle branch# 
D* loom thereafter Ifcplneer and atoesk reported siller S3# 
changes In patients# 
1# They distinguished right and left bundle branch block 
by comparing the curves with those they had produced in dogs* 
S# In the two oases they studied, at outoncy tho pathological 
changes wore found on tho expected side# fhey took that 
ns conclusive proof of their classification of 
right bundle branch block end left bundle branch block# mnm mmm mm* 
X* Mstorloal 
Am Tho bundle branches vmre first described by Vemara§ working 
in Aschoff1© laboratory# 
B* Assam early attests to cut tho bundle branches m tbooo 
of Ilewollys Barker# 
3U bundle branch©o war© cut in oalraoXe and laoehoaie&l 
record© « nad©# 
S# Eo uaoblo to doioaotrnt© any delay In activation on 
the ©Id© of dosjoge# 
G# In 1910 %p lager and Eothborgor studied the off cot of cutting 
tho bundle branches In doe© with the J3£$* 
1# X*boy ucod on gaowtoopbegcel load which la an axial loodt 
I3DP0 or loco parallel to tbo Icaar: axis of the heart and 
oorparabl© to Load XX or load XXX in mn# 
0* fhey found that cutting one of the bundle bronchos pro- 
duced changes which wore wore or loss opposite those 
produced by (jutting tbo opposite bundle branch# 
Dm Bom thereafter and stoerk reported ibaUar SK& 
changes In patients# 
1, They right and left bundle branch block 
by cosgparlng the curves with those they bad produced in logo# 
£« In tho two or><»o they studied, at autopsy tbo ptiholottenl 
change© war© found on the ©sspootod side# fhey took that 
as conclusive proof of their oicoclflcotloa of 
right bundle branch block ansi left bundle branch block# <1) This is, then, concordant bundle branch brlocfr—»the 
mein dofloctlons ore in tho mm direction In ell thro© 
lends* This is usually t|*o c go in doge* 
f* Tho i'JU couple:: consists of a single phase or tiny 
early phosa end second larger phase* 
w 
rdnglc phase 
m 
very emll early pheoo 
3# After injury to the Right Bundle Branch* 
o* Interval bounce two times nomol length* 
b« QBS becomes notched or slurred* 
o« Chief deflections oro all dcmmvd but In mam direction 
' in oil leMs* 
(1) Here, too, thero is concordant bundle branch block, tho 
no in deflection being in the sane direction in all 
leads, but it should bo noted that the direction is 
opposite that la loft bundle branch block* 
d« T-ufavo Is again opposite the chief deflect ions* 
o* The QES coli>1coc is bjpheaic* 
(1) Thoro is usually a snail, thin Wmmnm 
preceding the deeper, notched or slurred S-wsvo* 
4* See olide Dg* 
o* Hero tiq sec left bundle branch block followed by recovery and 
right bundle branch block follot/od by recovery* 
b« 3uoh curves can be obtained If tho bundle broach Is pressed 
upon and injured temporarily rather then cut across* III* Sequence of Activation of the lioort* 
A# Howanl fiewrl* 
1* normally the too aides of the heart are activated slmult neourly* 
2* Forts of the Ilonrt are active tod through the right tundlo branch 
and the root of the heart thro\igh the loft bundle brunch and the 
olectrooardlogrem I© in port a result of the spread of tho 
lagmlo® from tho sight bundle branch raid In port a result of 
the spread from tho left buedlo branch* 
B* In Bundle Branch Bloch* 
1* If one bundle branch la cut, tho impulse will travel down the 
. opposite uninjured bundle branch end then reach the made on 
tho old© of the Injury only by going through the centum* 
8* Thun If wo mt the loft bundle branch w® prevent the 
spread of the Impale* into the loft lustring* ay atom and 
th© curve will represent only right ventricular effects* 
Them after corse of a second the Impulse 
will peso from the right ventricular fjuacle through the 
septum to the Busking* network of tho loft ventricle and tho 
curve trill be the result of the spread of the impulse from 
right ventricle to left ventricle* 
b# Korsally the septum ie activate*! pert from the right and 
part of It from tho loft* 
c* In bundle branch block, however, the septum la ell activated 
in one direction* 
r» The first part of the qBB gro«p in BIBI thus represents tho 
normal ventricle—that which la activated at th© normal time; 
earlier than tn© opposite aide* 3* The second pert of the RQ rrowp in WBl reprommts the- activa- 
tion of the abaorrml ventricle—the delayed ventricle* 
4* It lo beeouee ia man end dog there are no Interconnect ions 
between the to Pmfclcse system© that this delay in active" Ion 
on the injured cldc occure* It is not the ooac in the ox 
whore interconnecting fibres do occur* 
5* Latin pointed oat that? 
a# If the loft handle branch In cut, the early port of tho 
Q$S oo&plcac will then represent the right ventricle end he 
called it dcactroeord legion* 
b# If the right bundle branch la cut* the early port of the 
Q&3 conplox will then represent tho left ventricle end it 
was celled the Icvoocrdloggcm* 
This la true* of course, only for the first few hundredths 
of a second; after that \m got effects which arc duo to 
tho ebnomsi spread over the other ventricle* 
c* Tho nom&l QM colics in c bloerdiogrnru 
(1) It 1© the algebraic aim of tho left ventricular effects 
by activation through the left bundle braaofe cad right 
ventricular effects by cctlveti.cn through tho right bundle 
branch* 
(£) Tho fact that the mmeX OicotrooovtSognMi tc a bloo.rdlo- 
iKfm is not m valuable a thing bq one might suspect, 
however, because one cannot Hsm that loft ventricular 
effects will be axogpretoi by loft ventricular hyper- 
trophy without other W& change®, or that right 
ventricular effects will be eJEcggermtcd without other 
changes by right ventricular hypertrophy* 6* T c reason that bundle branch block Is oo Interesting end 
significant io booouiMl it permits us to isolate in tho oerly 
port of the -its the contribution of either ventricle. It 
tbror/o a good ted of light on tho factors which determine tho 
farm of tho »tO. 
7* If in e dog with right bundle branch block sticuli ore applied 
to the right ventricle at the base of tho anterior peplUary 
lauscle, the impulse will pose throng tho musolo to tho right 
bundle branch st Its point of arborisation end sprood through the 
right Pushing# no ti axel: then through the septum to the left 
ventricle* so that here in a dog with right bxmdlo branch 
block you cm still get the right tevtrlculcr effects first 
by properly applied stimuli at tho right instant in diastole# (Slid© 0$) 
a* This is true boceus© the right bundle breach is on the 
cep tun close to the anterior vontriculer surface and nmr 
tho base of the anterior papillary mad# tho right bundle 
branch breaks up Into Its niboriantioa* Tl-us if # stimulus 
is applied her# at the bee# of tho anterior papillary muscle* 
it will get through th# thin nuscle wall end reach the 
right bundle branch at the point whore tho Impulse normally 
arrives when It comas tern from above. 
b. In slid© % —in dog with rt. B«B*B1* 
let. beat—result of tepulae from above—early part of 
CBS Is tovocordlogras* 
5th* beet—result of stimulation to right vmtr icle—ecrly part of 
qH3 is Bo^troeardlogna* 
End* boat—re cult of stimulation to right ventricle is added to 
loft ventricle « Bicardlogrem# S* Slide D 
V 
a* In this c*xp«ri»fisit right bundle branch block we® produced In 
the dog oad thou stimuli were applied to the right ventricle 
ot n rate slightly slower than the aoveal heart rate# 
b# Tho first boot shown »howo that the stimulus induced a 
pure ronponne, than an the sttmlotor gradually ftella behind 
tho <H*S coupler changes gradually *s store end r»ro of the 
rauoclo in activated by the impulse cording dowtt from tlio 
3A node end fron tho Vf through the ooptun to the fflf# The 
4th beet recorded la a norm! QBS because the atlmlst* and 
tho Otrprovcn tricolor Inpulce so coincided that the right 
ventricle roarondod to the former end the left ventricle to 
the latter and the result mo the normal bioardlogmu* Then 
m the stinuluo fells more and mrv behind* finally e point 
is reached where mm of the ausole responds to it end the 
kMS ooaplox 1b that usually soon in right bundle branch block* 
c# It can b© corns that every change in the QMS coup lex la 
accompanied by e corresponding ohan&o In tho T*wovoo* 
1# Therefor© tho Twwnvo change is secondary to the Q83 ofacago* 
fU On tho whole It my bo as Id that the order la which 
mx&elc paooco into the refractory state cannot bo 
oltorcd without also changing the order in which it 
paesae out of the refractory stats# 
9* With on induction coll and eUmlatlct applied et just th® 
proper tine In diastole wo can bundle branch block* 
a# If tho right tfaatriclo is ;eti£aaiot«d, especially 11* at the 
base of the anterior papillary Taisolo, we get H3 coraploros 
moh no those in left bundle branch block# b* If the left ventricle is stiailatid m ct <488 cocplaocoe 
like those of ri&ht bundle branch bloc's# 
0# Sequence of Aotlvetlon of Ox Heart# *lldaa 1>6C# 
1* It has bocal found that In the coif, cutting one of the 
bundle branches aafcee little difference# doraotlnoa there 
arc nlnor alteration* in the form of the curve b»t the Q;R3 
is not spread# 
fU This I® apparently because there are interconaoctlone between 
the two Burkina aotsposiico# 
a* The ox he a n highly developed Furklnfro system# 
b# Apparently the fibres actually penetrate the septtua so 
that the impulse om $p rlfht through to the other side# 
c# This is really to be expected when me renonfeere the greet 
also of the os? heart end yet notes that the fyt8 coalesces 
or© 230 lonyer then in man# Tim Fuxfcinrc network actually 
penetrates the veil «f the heart# 
tv# QowL&xk* m maomum mmm mmmi bukk m the dog# 
3oc elide 2X>—nornr-?!, loft bundle breech block; oosgplote left# 
ilp«ooxssol, Ivoowplete rt« bundle brooch block; complete right# 
Am Bomtisms if tVj bundle brooch is prtoaed upon we ct first 
complete them a Taduel return with the first Incomplete 
B# B# B1 oM finally aorfii&X QKS eesQpleKee* 
B* Complete end Incomplete B# B* BX# look alike in the cerly pheoao 
because in those phases of the Q88 the early ventricle In 
re a??onslble; but when the late ventricle ooaee in they ore different# 
1* The chi of difference is that the $B8 is not no brood end the 
notching la not os ooncpiolous# ®# 1'bc reason for this change Is that the interval, begins 
with the effectc of the subendocardial isiccle on the on- 
injured side# fho second or lots ventricle I© the on© which 
is activetod abixmneily—t.hua collate ond Incccplcte B# B* 01* 
ere the secae as far os initial deflect lens ore concerned 
and up to the instant tliet the second (obnern**!) ventricle 
oojscc in# 
C* Slide control* then rt# B# B* Bl. with complete recovery* 
1* It ci%n ho mm. in this oSKpe-rSanont thrst all the initial de- 
flections ore the mm because they arc due to the left ventricle* 
E* In cotasplete end Incomplete B, B* BX* the initial deflections 
mot bo the mvm in the now Individual* 
XV. The Order of Cut of Active State in B# B* 31#—fbc T*»mvc# 
A* In a geaerol way the In .hich c suede passes into the 
active {refractory ) state end that In which it passes out of 
the: active state are substantially the mm$ although not identical* 
1# Thuc, if the dursstl.cn of ny stole locally rector ins the setae 
after one of the bundle branches Is cut# every ehrnge In order 
of activation will cce(»$e&i«A by o change la the order of 
passing out of the active state# 
S« flats you cannot codify the group without modifying the 
f«w<3Ve* See did© %♦ 
£hcn one ooaplex-~the <$H0— Is largo, th; Stomve toads to be 
■ 
in the opposite direction* 
*'• ¥o» ° n the X-S.W0, f»;.«vur, without iwnfv1r„ th_ aa 
6T09 by swUtying th© length of systole locally# 
(a) If wo cool an urea on the serfcos of the heart v?o do not 
change the? order of active ties (do not change the t,:as rroup) 
but we do prolong the refractory period—change the t«wtfree 
thus prolonging the local duration of systole# B* Slice with rU B# B* Bl* with atloalue applied to HV, then LV, 
then both ventricles* 
1* Upper wore applied to right ventricle at a 
tat© slightly slower then the heart rr.to# It eon be seen thet 
the first rertpons / occurred whan the stirailuo fell at the end 
of the IVvflisvo and the form of the oospXcz is thet oooh no 
wo got in left B* B* Bl* 
£• Middle record---otimill wore applied to the left ventricle at 
o rate slightly slower than the heart rate* Here? wo enn me 
that tho first to*jponoo occvr® jponor* when the- stimulus fell 
©t the pos2c of the T-wro end the rooponoo ha® the form of 
thet mm In tho other beats* 
3# Lender record-'HTtlavll were applied to both ventricles at c 
rot© ©lightly slower than the normal heart reto* Hero we can 
Boo thet egaia the first response occurs nt the peak of the 
T-wavo end its fom Indicates that the response wee due to 
ootlvotioa of the left ventricle; in the later beets, however, 
when the lopuXoo falls later, at the md of the frwrtva (at 
the; end of the right ventricular refractory period!, wo then 
get note-1 cult complexes (bioerdlogio&o} because both ventricles 
arc. now responding slml tenuously to tho two ottaai* 
4* Hero, than, we can see thet tho surface of tho left ventricle 
peases out of the refractory period before the surface of tho 
right ventricle in rt* B* B* El* In other words, the order 
of rtKSovery is tho mm m t'm order of activation* C* 81 Ido £v>— stlsuletlcn cf both ventricles la 
novml Cor, heart* 
1# Tho point of crborisotion of the right bundle branch le opposite 
the* hvm of the enteric* peplllary awscXe* Thus m electrode 
placed on the oploordlnl surface nee* this point will 
hr mr.r this erbortentlon* itorthoTRsor© the nuoole is thin 
at thin point* 
&• In this (BparittOKt two et Isolators rerc applied, one at each 
taitvicle eirmletciieouoly* 
3trlp (I)--Here the right ventricle electrode mm pieced on 
this control ureo and tiso L¥ electrode on tho 
surface of tho Vf* Hoto that tho reaponoe is © 
right ventricular response becauee tho iapulfj© 
had only a short distance to travel through tho thin 
made end reach the arborisation of the lit* B* B* 
Strip (:*)- Sere the W electrode wnn kept In the mne piece 
but that or the W wee thrust dowi Into the 
ayoeerASiim so that now It wee much closer to tho 
Pttrtclnge nettriork* The response now is o loft 
ventricular reapanee because the Impulse of the 
(stimulus had ouch loss dlistener to taml than it 
had previously* 
I). Mean iiicotrioel Axis In B* B* Bl* / 
Monaol 
Bight Bundle Branch 
Loft 
Block VI# Development of Uodaxst Concept of Eight end Left Bundle Breach Block* 
“ A* In 19B0 #*hr on the basis of theoretical considerations ettra© to the 
oonclualon thr.t the old concept wo* wrong# 
B# In 19f.l Opnanhoincor mid Eoxde© hod t«o o***« in which tho lesions at 
poat saortesa cxsrdination vam not on the espeotod side# 
C# 8a s* of Boxfcor, KCLaod and Aloocoadcr—3oc slides %pf D^* 
1# This pet lent developed a purulent pericarditis after pneu- 
monia* requiring open drrinr.ro* The heart was exposed and 
with the pfttl’.srfcfs conoeat records mm obtelnot! when various 
pert© of the heart rerc *t imitated* Subsequently the pat!cent 
died of recurrence of the paeuiaoaifi end at autop sy it vmc 
possible to locnte the points raw© accurately. 
S# It %ec found that vehmover ttm right ventricle was sttmletod 
the chief deflection in lend I 1© upright# 
(a) Tide is tho order of active tim In loft bundle brrnch block* 
(b) Xtotat 6 in their studies oorroopondo boot to the point 
nearest tho anterior yeplUctxy msclo and near broaching 
of right bundle branch* and when stimulated it produced 
coalesce* like those of left bundle bmnoh block la tho dog* 
5* Whenever the left ventricle m& atinuletod tho chief deflect Ion 
in Lead X wa« dam* In other mvda9 the order is the warn© a* 
in aright bundle branch block end tho tmrvos those of t* B* B* Bl* 
in the dog* 
4* furthermore* stimulation of point* aoesr the bn so gevo upward 
deflect ion* in Iced III wheraac ntimilation of point* aonr 
tho opex gave doamazA dofloctloae in Lord XII* l>* Koirnts. later revived hmm hearts and with her*rUlun/; prenorot Iona 
he cut the bundle branotooo end obtained sir liar results* He also 
placed basting do& heerte In huaon chests and after cutting tho 
bundle brunches obtained similar results* 
I* Clinical liotog Beecrdiag Bundle Branch Block* 
A* Btiolojy* 
1* It lo corrion In ertorlosclerotic heart diocese* 
B* Occasionally it occurs os a part of scut© rhouMctio fever* 
3* Corronly occurs after coronary occlusion end at ouch ttaoe 
1® often transient* 
4* ifey be present in association with congenital heart dleeooo* 
eor»eo icily if there 1® « defect In tlvo ventricular '?octua* 
5* Oc0f2t»lcjn#HlX> occuro in luctlc heart discs®* If e carws 
hits one of the bundle breaches* 
6* ircnslsnt right B* B* BX/ jury occur following a pulmonary embolus* 
9* Occasionally «| sec; B* B* Bl* without other evidence of heart 
disease* 
e, Thee© arc apt to bo young or *3441# mM Individuals* 
b* It is dallied tfast this Is we apt to be rt* B* B* BX* 
o# statistics regarding such points or© inaccurate because 
they are la people do not cotao 
unless they or© HI* 
B* aigcifiottteo. 
1* nm. the clinical. standpoint It vmmly points out tfec-t tmm 
ayooerdlal oImm® is prosrnt which involves tho specialized 
tissue end probably the ordinary meole eo well# 
r* If there in o lesion transecting one of the bundle branch®® 
it mona that there arc probably an*y other similar lesions* 
b* It thus usually ammo widespread dogcncmtlvc proooeaos* £• It if! of especial Importance is elect rocnrdior-wphy becouae 
hero is an instance where the SKG can give infornatlon 
which would not othemi so he obte Suable* 
5* £lio rrrerage Ilf® (npeotemoy after B* B* Bl* is found is sold to 
b© S - 3 years* 
4* Occasionally B* B* Bl. is seen nhero it apparently me*au» nothing 
so far os the heart is concerned♦ Sqm vm harc B* B* Bl* without 
other evidence of heart disease* a*ch instances m>j bo ok~ 
plained as duo to on isolated lesion which just happened to hit 
one of the bundle branches* 
5* B* B* Bl* does not disturb cardiac function* 
6* There is e little evidence to chow that left B. B* Bl. carries 
e graver prognosis than rt* B. B* Bl* 
c* The right bundle branch Is longer cad travels farther be- 
fore dividing* 
b* Therefore tlscro is greeter livelihood for single Isolated 
lesions to hit the right bundle breach than the left* 
?• from q practical point of view we do not know whether right 
B* B* Bl# is less serious than left B« B* Bl* 
a* ttoct of previous studies ere not useful boor,use the die* 
tin/ ill shins feature of right ond left B* B* Bl* were not known* 
3* If the B* B* Bl* rcproccntc en old seer them it has no .greet 
significance but if it represents something which is gotm on 
actively it means mob aor»* This cannot bo determined fron 
the eloctrooerdiogmm, however* end met be inferred from 
cliniool nenifestetlMN 0# Diagnosis* 
1* The .HC0 is to only way to to din<jiools# 
2# It la true tot the ti'.'O ventricles ere activated at dlfferout 
■ tines end contract at different tiara* itey of to potlcata do 
shew o aplit first or second sound* However, meny of them do 
not and may nornd people do# 
3* Flociuently, too, e doable vpex impulse cna be scon end crcn 
felt* 
4# Iwcver, this split Is found to !•■ due to a preagnstollo 
gcllop and therefore cowaot be due to csynchronlon of the 
t%o ventricles* Set slide %q* toco essonplec of pro systolic 
• gallop In Bundle Br--nch Block* 
VIII* Orltorlo for Bundle Branch Block In Bon mid Various Sypes* 
A# toft- Bundle Branch Block 
1* Qft? interval 0*1? see. or rare* 
2* Bo a*w€»v© In toad I* 
3* Chief deflection in Lend X Is Upright end notched or slurred* 
4* tHwvo absent In Load X In 9O~O0;f> of the eases* 
a* When tore Is a % pros ant In « patient with loft 3* B* D3.# 
«c«sr of these pctlentc trill hove rn Infarction, c spec lolly 
opt to be coptnl in loos-Ion* 
G* Procordial loads my f$ww lots activetIon of the left ventricle* 
6* XWwevoo usually oppositely directed from ms gmsp* 
B« night B* B# Bl* 
1* QjRS Interval 0*12 see* or more* 
E* Prominent S-wavoa in teed 1 which arc usually broad and notched,# 
3* Procordiol loads oboe late activation of the right twitrlol©* C. Typos 01' Left Bundle Branch Block* 
!• lf$t Bundle Breach Block, Is mnt con on in nan* Slide 
’ o* In there eases the chief deflection is up la hoed I and 
tern in Lend 111 with the TMwaves In the opposite direction# 
b* There la no *V»ct n einablo la present only in 
about Sfr of these arses* 
c# It can be soon that Load III in this type of huaaa left 
B* B* Bl# does not look ct ell like that in the doc* Further 
Mro, in atony patients I<osd II is like bead III* 
(1) It 1c because of this that 2ppinger and Stoerk nlstoofc 
tide type of left B* B* Bl* for right B* B* Bl* because 
they were using only o single axiel load which was 
jsuch like Load II or Load III* Then they were further 
convinced when o esse with curvoc of this kind had 
a lesion on the loft side at autopsy* They did not 
appreciate bow difficult it is to locr.Xiuo bundle broach 
block pathologies Hy # 
d* Tlic reason for this difference between loft B* B* Hi* in the 
dog and in sen la the position of the heart# In the dog 
the heart la nuch more vertical, in mm it is usually 
ijoro transverse* 
o* This type is especially o&msm in hypertensives with 
tMunrerae heart®* 
B* Concordant left B. B* Bl# (Slid.© cm Prof* Boris)* 
q* This type Is ruch mere rare but coolly Is seen in individuals 
with mr© vertically placed hearts* 
b* These curves lock like those of left B* B# Dl* in the dog* 3# Slide 
. G* Hare m ms» tour of left B* B* Bl* 
b* 14osk? of thee© star m s-wrv© in Bead I* 
c* It em be 00m that (zmovelly in left B« B* Bl* tb© 
is laonophealc ocpocially in thoae lead© where the QliB is ler|$s* 
d* Umla II csid III ere usually of no value in dl sit luesilsbing 
between x*u$xt B* B« Bl* find loft B* B* Bl* 
o* la esnnpl© B, it Oon be seen that oecerlonnliy in B*B» Bl* 
the M? junction may be belosr the baseline* Thin is hoomim 
the ftmrt has already bd&m in ooiao pert® of the heart 
before the <£&£ 1© collated# 
4* Slide %^j* 
a« Before sad after loft B* B. Bl* 
b* am© a^. 
e* Two eases of left B* B* Bl* on© conoordeat (rare type) 
» 
one discordant (raoro connm type)* 
D* types of B< E* Bl* 
1* Comm. tree. 
E* Loos Co j*>n fype - Slide? 
cu In this wo ham eithw s awnaoX relation botvroea the 
ventricles or right mntriclo tiype-rtroplqr; ty;w of which 
v.o tioG wtooa vinht B* B* BJU is on axis 
•iovistlon* 3* Very mm type Soe elide Hof* atu Heart 1* 9« 47H, Apr* 1934. 
4* olid.® yisMt B* B# r,i* 
a* Four mmapleo of right B* B* Bl* ell hev© large 3*wevos in lend 1* 
5* Slid© %• 
e* Four eocanplee of right B* B* 31* 
b* All dm* conspicuous 3^* 
o* Sole that in those load® where tho $KS corplos lo largo 
It 1 b blphaoic or trlphnolc* 
(1) the imam tor this io that in Loft B* B* Bl. you hove 
only tho thin well of tho 89 being activated oppositely 
to tho ?»tui3 end tho left ventricular well* 
(B) In right B* B* Bl* you hnvo the thick well of tho W 
being eCttVatod opposite to the direction of activation 
of the oeptun end the thin well of the H7* 
(5) Thuc the dlfforcnco In thickness of the two ventricular 
mils lo responsible* 
6* Slid® K|0* 
a* Before and after right B# B* Bl* 
7* &Lido B^* 
e* of right end loft B* B# Bl* 
£• Tho tom of tho Q.flS donpionoo in Bundle Br noh Block cm bo 
Btodiflcd by Changes in position of the Heart* 
1* Slide 0 —is® coowsplo of changes in Itoxa of <iHS complexes in 
B* B* Bl. so remit of deep ronrplrotlon* 
g* Changes een occur with changes In posture* 
3* One aist be careful not to mistake thee© glmgfto for Etfocerdinl 
Infarction* F* These Criteria for B* B* Bl* will bo found accurate accept for s 
oraslX percenters of ceceo* 
I« Boot often this will be in pot Ion to with Infarction# 
B* In q few instances B* B* Bl* will be dioi’nosed from the standard 
3 lead© end precord id loads will foil to confirm the diagnosis* 
a* This Is most opt to occur with extensive orborixotian block: 
or general depression of the Fusirln.:-© tissue* 
S* Hoot cooes of B* B« Bl* will fell into tho above patterns but 
when unusual curves or© mm precordlal loads my help/ 
4* Those coses which ©ro not definitely B* B* Bl* my be; 
a* Oonorel dcprosslon of intrmrentriculor conduction such os 
oocn in qtsinidino or in urcraio, or sever*© tenoral tamia* 
b* Widssjprecd myocardial doaegs such ©a that due to multiple 
ayooordtal infarctions or widespread subendocardial sclero- 
sis damaging moh of the Burking© network* 
5* Inst© ncoa In which left B* B« Bl* Is sdstakon for right B* B* Bl* 
©ro usually those in which Infarction Ima occurred* 
6* Intraventricular block Is usuaLy dlsspoocA when the QKS Interval 
is 0*10 to 0*18 sec* If it mm over 0*18 see* m usually 
dlegnobo bundle branch block* 
?* Another instance in which diagnosis of introventrlcRilar block 
my have to be made without bettor localisation io oao in 
which fatigue eonoclntcd with © rapid rhythm occurs In presence 
of subendocardial aeloroelc* Thereby c latent Conduction 
defect my appear which only corns to the fore when the heart 
Is over burdened* G# Port id Bundle Broach Block* 
1* Svory other impulse my be blocked In Its passage through the 
Ills bundle • Stl partial B# B# Bl# 
E# Boo a llde 
H* Inooqpleto Bundle Branch Block (suspicious B» B# Bl#) Slide e40* 
1# This diagnosis cm be node only reroly in iscn# 
$• as an example, © ease with auricular fibrillation my show 
rather brood Q$S capiases with tbo short pauses but normal 
ooeaploKcs attar the Xonn psuoos. 
times 
If cmiaidlne ig tbm (s%tm end the ventricular rcto in still 
further speeded up end congestion shotm mm mm block* 
then diagnosis of incomplete bundle branch block eon be 
node**— Boo slide ii c • 
X43X"~efttricalcr fibrillation with inooipletc left bundle branch block with 
rapid roto md norml conduction after Iojvt diastole* 
1444—-efter quinidlnc* vontriculor mto footer thus effecting 
introvontrloulor conduction end the quinldinc itself has 
affected intrr?vor.tricuier conduction# 
1443—Auricular fibrillation has beau converted to norml rhythm 
but left B# B# Bl# still present# 
X48B~normX rhythm with mch narrower qK3 corplox nor| 
tkagb possibly dome defect persists* B# B* Bl* no lonror 
present# so my c- XI thin inoorpleta loft B# B# Bl# Just 
m inoosplet© left B* B# Bl* my am? be sold to have been 
present In #1451# 3. It la difficult to mko the diagnosis with my decree of 
certainty m& It can only bo done under spociol inces. 
4# If one takes oil curves with QR3 between o*10 and 0.1B, tm 
' will ferae B. B. Bl. 
' 6. Slides # %• and 
a « Case of alternating collate mid Incomplete right B. B. BX« 
b. Bote that the initial deflections of the QHS corplccroo arc 
exactly the smse In both collate and Incomplete B. B. Bl. 
o. flic end of the Q$8 io different, however, because In incam- 
plate B. B. Bl. the late ventricle cornea In sooner end 
the i'dts interval is therefor© sot os long# Thus It con bo 
mm that in incomplete rt. B* B* Bl* the is not sc broad 
nor as notched end the second in Yi is not nearly 
os prosainont. 
I. It be said that In eca moot of the delay in the spread of 
the tepulae Tito on© of the bundle branches I© blocked occurs 
when the impulse pass©® in the septan. It paeaee rapidly fro® 
the Parking© fibre© of the intact side to the sop tun but the 
spread through the septan 1® lauoh slower. Once it roaches the linking© 
fibres of the opposido (blocked) aide, it age in ©procd© rapidly. 
K* Sight Bundle Branch Block associated with fute»o*jr Ba&olism* 
and %»• 
1. Transient right B. B. Bl* is the cast specific 
In pulmnary ©RtboHoft. 
2. Often, also, transient nonspecific as-T ©orient dleplncoraont 
occurs in puliaonr.ry emboli eo. 3* Tho season for tho oocurrano© of these change a 4a not clear, 
e. It my bo possible that they are duo to sudden increase la 
pressure in tho right ventricle* 
b. Dixrant produced ouch changes in dogs by injecting zsercury I* V* 
4. It is significant that this type of bundle branch is very 
transient often clearing in a fcasr hours* 
IX. Tho Precordial Leeds la Bundle Breach Block. 
A. Eight Bundle Breach Block. 
X* Zb practically ell ccnee with QJt& Interval of O.lB soc# or 
more and e largo in end 7p, vm coo QMS coalesces 
~ ~ - \7 -,-~ 
15)50 ; 
- ' V2 v-~ 
a* Thor© io in tho QkS oorplcKon at 7% and VV a saU initial 
upstroke followed by on 8*wwret and thm a second larger 
fi*wi'ra« 
b. Tho mil initial IMrove ia duo to poeitivity of tho 
right ventricular cavity moulting frost the irpulo© 
easing through tho acptun frota left to right* 
c. Tho second, late upstroke is duo to tho irspulso prosing 
through tho right ventricular vail* Its peek in Into. 
2« In Tr, and Vg so© the B peek occurring at the nomol tine 
{0.038 roc.), but there ore large broad 3-esnvoc, time: 
A 4 
— — or ~ 
U W 
3. Sec slide 1%. 
e. Hero no hove o oomnvltxm of tho orcoordiol locda in St* B. B« 
Bl* m& Left B. B.« HI* with simltcnooos Lend I. 
b. . In rt. B* B. Bl.f the intrinsic deflection in occurs at 
0.114 ooc. whereas in V.} and ?s it in at 0.038 sec. It la 
time mch later over the right aide then ist norool nhcroaa 
it lo at the normal tine on the loft old©. 4* Slides and JB^* 
«• Standard leads end preoordtol leads before end after 
right B# B* Bl. 
b* The proeordiol leads are typical of those in right B* B* Bl* 
Mote that in V5 end tbo H-wovcs romined unchanged 
but that large appeared* 
5* Slide %9. 
«# Hero m am two of right B. B* BX* with very mall 
B-wms In Bead X* The procordial loads in both inotmccs, 
to?overt arc porfootly typical of right B* B* Bl* 
b* Curves of this typo may represent right B* B* Bl* in 
patients with tmuouclly vortical hearts* 
6# Slide 1^* 
c* Hero we aoe right B* B* Bl* of the concordant type with 
large in all the standard lemds* locate like 
V(. or the L? surface, and % la small* This patient boo 
an unusually vortical hoert* 
V« Slide 
s. In this curve lead I has a largo A«wre and only a very 
snail suwave and the Q88 Is 0*13 coo* Thus, orccpt for 
the 3? thin tracing looks much like th© usual loft B. B* Bl* 
b* Th© procordial leads, however, look like the usual right 
B* B* Bl* CKoapt for Tg Tiber© the fU?nvo is much mttXXtOf 
than umnl end a in large* Tho comet cause of this 
variation is aa yet undotorrilnod* 
0# PrccorcUol leads or© particularly useful in right B* B* Bl. 
because they noy uncover an criterion infarction which does 
not nokc itself evident in the standard Ism a# B« Loft Bundle Br?j»ch Block* 
1* In practically a 11 eases with dies Interval of 0*1£ ooc* or 
more without any S-wavo In Load I, tha pr©cordial lead# 
have a definite font* 
«• T and show activity throughout or el 
mat throughout the QHS interval* This is 
because tho Inrftjlpo is uwinr stay from the 
electrode oil of that tin©* 
b* Tg and % ate? positivity t‘ tho QBfl 
v 
iatorvcl# ft» Initial positivity Is due to 
the positivity of tho left ventricular Cav- 
ity reoulticr froo the Inputs© paaclar* through 
the oeptua fron ric-Jit to left* The late 
positivity Is duo to tho trpulec pcealttg tkrou&h 
the loft ventricular wall, 
c* If tho two ventricles were exactly alike and boro exactly 
tho mm rotation to tho lending off points, in rlcht 
B* B* Bl* and Vg in left B# B* Bl* should look alike mA V- 
In B* B* Bl and in loft B* B* Bl* should lode all&o, 
(1) But tho loft ventricle la end the right 
ventricle is thln-wnllod* 
(S) Oenerally speaking they sre different because In left 
B« B# Bl* they tend to be mnoptmclc whereee in sight 
B« B* Bl* the coalesces tend to bo diphasic or trl* 
phcslc* £• Slide ;SL# 
s# Her© In the oOEpririnon of the procord id lends In right 
B# B* Bl# and left B* B« El# with almltcnecmfi Load I in each 
ceso, it Is soon that tho Intrlnoio deflection over the 
right prooordiun (¥3, and ¥g) occur© ot the normal time 
{0 #015 m 0.019 goc#) whereas over tho loft preoordium 
in ¥5 end ¥~ it is touch Inter then normal (0.008 m 0.09B ooc#) 
b* Hot© that end 1L oho w only very tiny Itamvos and deep 
broad S*wav« whereas Vg end Vg show very broad notched 
&»v;nvos with no IMrarves at all# This is the characteristic 
pattern# 
3# Slide %# 
a* On 10-19~3f> the standard lends wore noxnal# The procordial 
loads on the mm date show inverted Treves In Vi c nd Vg# 
This in abnormal but tho (ills coalesces ore noivsol In form# 
b* On 10*TiB-*36 tho standard loads mm siw concordant loft 
) 
B# B# El# This is the uncommon type* Tho precordlel loads 
confirm the pro nonce of loft B* B# Bl# 
c# Hot® in the precordial loads that after the occurrence 
of loft B# B# Bl# the H-*mveo over tho right side <Ti end ?jj) 
become snob ffaaller* Thus It would appear that the loft 
ventricle contributes to those IMam® normally, for when 
it© effects arc cut out by the left B# B* Bl*, they bocon© 
smaller# 
4* Slide 
a* On 2MHM0 the standard loads war® noranl ©rcept for 
slight loft axis deviation# X>* On «e so© thet loft B* B# Bl* has oppecreft and the 
prooordicl leads token nt that tin© couflrr the diei*oaosis# 
o* Hot© that In the coctrorlty potentials Tj, locks liko V- 
end also like lead I, whereas loofco likes end like 
Load III. 
(1) Thio Indicate* that the hoort la In © tmamwm posJtim 
end that the Df potential© ©re being tmnssalttod to t!« 
14 wberoea the potential verlatioce at the oorfneo 
of the Idf cro bcia** tronoDittod to tho IX* 
(2) Since the potential variations of the 14 are largest, 
the standard lecdo char? discordant left B. B* Bl« 
d* It ©an also be soon that V7 (loft posterior ex* lino et 
level of apex), % (line of loft eoopiiXer angle ot level 
of apaz) m& V® (loft scapular m&Lo) ell look like tg, 
mid the ooxfhoo of the W» 
5* aim 
e« Ones of concordant left B* B« looks like 
mid the 33Tf locks &jrllt % locks liko the beet of tho 
heart or the SV* 
b* flu* tho hoert la vertical end beemoe tg is mm11, the 
curveo arc eoneordntxt* 
6. Old* %3# 
o« In this curve .Load 1 t$mm & hmm &**&** mid only a retry 
tiry TMsove# Ttsie it lode like rlght B« B# Bl* €c:eopt that 
the curve in nearly nonophofilc* 
b* Honerar, tho procordial lead© era typical of left B* B. B3U o* ftto MMnB M» b© W took# Sift* 
«&&§ life© T| «snA to toos*fe«e Iteft «» OMWHaUf 
WtftOBl fcftOVt* 
6* *%b® MM lead* to tola mm mxM mt pm&t 0m to 
diatlagateli betosswo B# B# Ift «e& loft &• B# &3U 
©* 9too to mmm with Mt B# B* oi« to ottMt too 
of the fl¥ «*e tototoAtoto to tin© &4 (toftfttoil toarto) 
fm. vlXi tom iiffloultgr to distto&itoft&r «*• 8* 5# as* and 
left a# l« El* twm toe etooAani Itods elm* 
a* ixmlifil iiMio to tom hob tog l» &• Hi* 
1# to toe otoiitovA toodg toe ec*$»e»fcle eutvoe took iHee t*4ei<» 
loft 8# B* Bi# 
It# B« B# 10# 
t# to v<m pmsmMlM Imstify the mmm f&* both nm 
wmh too mm* f&Mi I4&# 
3* fto it »-$r Bo iioM thet ti» dlffmpee Mm ftoaottianl 
«r4 b# a# bju mmm to set &*# to eng? dtffoswai* 
la too tomt Itoelf Hit imt&ar to to * flfftarae# la toe 
pooHioa of thm hm.rt to eh# toot# X* "Arborisation Block* 
A# Criteria for dtagaoeis and underlying nocteilca* 
1* The criteria which have boon advanced In the pact are not of 
ony particular use because recent advances re B« B* Bl* hnv© 
ncoocsarily modified them* 
S* It Is probably due to a block at the finer arborisations of 
the Parking© network ©M the bundle bronchos* 
3# Blight prolongation of the my be produced by !yi)ortrophy 
especially loft ventricular hypertrophy* la left ventricular 
hypertrophy we my sec © hE3 interval of 0*10 sec* but usually 
not mob over that* 
4* The presence of pronounced notching or slurring of tho Q88 
oonplaK oocsblncd with slight prolongation pf the QJR8 interval 
olwsya suggests that you ore dealing with son© conduction defect* 
5# The criteria onoo used were)* 
e* low voltage of QHS cobi>1oxos. 
b* Broadening of tljo Q&B conploxea* 
c* irenounced sotohlag of the UH3 ccc^lexos* 
B* Slidoo end &ets?plo0 of /oborlsetlon Block os well os B* B* Bl* 
previously dicgnoaod m arborisetion block* 
1* Slide previously called arborizatioa block* 
g* Coo© #1334—•oese of congenital heart disease with septal 
defect* The i.H3 Is 0*12 ooc* and there In a Ian];© %f This 
is probably rt* B* B* 131* but the pattern in unusual and chest 
loads would really b© required to bo certain* 
b* Case # end cooondcxy anornlc* The cone 
Is definite right B« B* Bl* Q&5 » 0.14; big %. o* Cose # 902—mourym gnfi luotic sortie insufficiency* 
QBS » 0*12 sec* and lore© %* Definite x*t. B* E* Bl* 
£i d* Co so # li^CS—Chronic nephritis utokIo* 
tiHS • 0*18 see* and large but pooullcr pattern* 
This Is probable rt* B* B* Bl* 
o* Cose #£150—*cnne of Luetic Aortic Insufficiency. 
a&S » 0*11 soc* end is This should thus bo 
classed os introvontricuier block* 
f* Case # SSa^-orterlooolorosis* 
• 0*11 30C* and there is n prominent brosd This 
met bo considered, therefore* cs ft questionable rt# B* B* Bl* 
g* Coco # 493—aortic apogur^lteticaa—'? luotlc* 
<*Ha » 0*10 occ* and hHS complexes notched* But sinco is 
not far beyond normal limits la its breath, thin mat bo cdlod 
questionable Intraventricular block* 
2* Slide K.r>* 
a* In period from 6-2£~£2 to kIM ©ad Inter fro© 
to B-B3-B4 (tine of death), this pet lent had loft B* B* Bl* 
However, during the period MUMS to 6-S6-&8 tho qHB 
through broadened with mzkod notching end slurring, tins loos 
then o.l£ eoc* 
b* Tims oo tore bore aoro then ono conduction defect* Stocn tho 
loft bundle breach block cleared the other defect was so- 
vealod* ¥rm its nature, it »« probably lavolvod th© sub- 
divisions of tho conducting system cad met be called intro** 
ventricular block* $• Slid® .■two Wpkfi of tthat was previously celled 
block #•* 
q* In the first cap© the OHS is 0*11 me* and there Is a snail 
but definite Sj# Because of this lest, this mot be celled 
probable rt# B* B#B1« but precordiel loads would hove to bo 
token to be certain# 
b# In the second can® the QM3 to 0#lf- doc* end tliero is no S^,# 
The Qfs ooiploecoo ore none of then larger then 5 rm« la 
hoi lit# This is loft bundle brcaoh block# 
4# Slide ISr£# 
a# This is picture of cnee (a) in slid© and shows nctfloslfo 
aycoardiel lesions with necrosis and e less* intraventricular 
thfQK&OS# 
5# Slide &$• 
c* This Is ti picture of eoao (b) la elide q nd chows e hugo 
area of liquefaction necrosis and c larg© intraventricular 
thrombus# 
e# Slide On !MMS standard loads not definitely ©booms!# 
U«1MT standard loads now havo definite l*kD rlth inverted T-j# 
lab# is not? *<?idor, though not yet 0*115 see# end thaw is alight 
notching and slurring of the co^lcawm# 
a# This cam m® a Umlom laborer who bad substemol pain and 
luetic aortic Insufficiency* lie wa« preamti tc heve luetic 
aortitis and linrQ&mnat of the amithe of the coronary ortorioe# 
He received vigorous eraphenerilno end jaomaly treatosat# 
Ho f:rcw teqpowr&ly wore® and, hie X'jO those changes* It was 
believed that this we® possibly due to refaction about tbo aowthe of 
Ms oorottaxy arteries, loading to this alt oration in lAtravoatvioalfllt 
conduction# 
b* Uiotic aortic in sufficiency should not bo treated la this fashion# 148 
7* glide SLn«4tacu with luetic A* I* who received vigorous cntl- 
**$ 
lactic treatment* 
10- Prior to thorapy-~«lig!it IAB with si* inverted Tr m& flat T.>* 
11- 1-2S aims teohyoofdlii with broadening of $H8 interval* 
UUM-CB CRB now increased from 0*06 to 0*10 noe* end T-wevoa shelly 
inverted In Lead I* 
7-20-;?5 After tijorapy* 7-wreg now upright but still slightly 
widened over that prior to treatment* 
o* Th© QBS changes represent minor conduction defects* 
b* The fMsgvg changes arc duo to local vorlotIons cad ore 
not or only la pert secondary to the ,.fl3 ohangoo In this case* 
XI* Localised Conduction slide I Hq* 
iU The defect iaey Involve only e snail part of the J plcecuo* 
B* la this ease soro loads show It, soesc do not# 
X* Lead I ttoom mesXl poefe In between R and Kwvoit 
2* la prooordicl leaaa very little of this pooh on tm mode out* 
3# In the coopbagoel load© wo oon anally so© the long t.HS internal* 
4* Thug v?hm the electrode t»s close to the heart la the region 
of the de) active conduction, w© mo the long <JH3 Interval* 
Changes la of Inflect lone In the IO.ec troc.nrcl logrcsa* 
I* Hormalo— soe Slide %• 
A* Hera m hove the ovorago deflections in 100 young, me la medical students* 
1* Utmimm thus £*5 zacu 
£* ttaxinuB a-*w© la II, up to 88*®3 an* 
3, Hinlmia lades (%pluc %) - (% plus %) « X?*B 
4* Mezimsa Index » 20 *5 B* Stetlationl Inform lion re thin wost# 
1« Stondsrd Depletion. 
Is obtained by taking all the deviations, squaring each, 
adding them end taking the square root of that &m* 
b. Then if on© tokos 3 standard deviations and adds it to mid 
subtracts It from tiio moan* one will obtain a range into which 
about 99*,> of oil cases will fall* 
o. It gives « kind of sprood, m averog© of ell the deviations 
fi'cm th* nssn# 
d* Th© U£aial Jaethod of taking o large nunbor of Gesso* end 
dotorsTiintng th© cmttgl and the end naxlrwr. for th© 
whole recoup for any single factor depends to a largo oEtcnt 
on to; many oases you have to begin with. * The use of the 
standard deviation afcoids this fault end oil statistic©! 
studies should bo saodo on this basis* 
A 2&3S... 
This is the / , 
limn 
These vo&retxmt Xt2 end 5 
* tinea the standard deviation. 
2* 8k«m&sos* 
o. This factor Is bused on ths cube of the deviations from the itssa* 
b. Sons© curves rasy be ippsldad, that la deviations 
above tho mm of n certain nocgiitodo my be rx>ro co ■ n thna 
thbso below the oeea* 
Smsum jssiei sl -mkM- 
If nvoi'r.m v;t • la 14C# 
standard deviation * 30, 
140 / 3{S0) » 890 i 
This would not bo too unsoomnu 
1*10 - 3(30) « SO# 
c» Sk&sn&BB 1b e mniraro ot this 
lopoidodnosa# 
This would be very rare. 0* One cm Hco snob as tljo.se in slide to detffCt nb- 
norssnlitles* 
1* ItovfWUT, it xmtrt be reweedbered that those fiewes \;orc de- 
temSaeS from s spec lei close of people* They do not in- 
dicate whet they sl|M have had a group of 
individuals haem used* 
S* Thun if wo found mo MB with % » 56 m*, w® r-ould know that 
if ho is a nowaal Individual he mat ho a vo:ry unusual one* 
5# Actually the value of any particular mesure&ent in ar&lng c 
die Thesis io detornlnod by its rarity in mmrJL people and its 
frequently in atmoawml people* 
|x* Smll Deflec t ions In the hRS Corploxeo in the Standard Z^oAa—low Tolies©* 
A* Crltorios- 
1* Xortest deflection irony lead swot he under 5* m* 
B* 0J88 ooEpleKes lany be assail yot nomrl in forrw-those we do not 
boliev© to be so ir^ortmt* 
3* QH3 cooplcsea m& be mmXX and bizarre in fom—these oro 
believed to be much noro aimlflernt* 
B* 3i$aifionnce* 
1* The of low voltage is uncertain because do 
find cmiron of this typo in normal Individuals* 
S* It is ufisosISy unimportant, relatively, unices the curve la 
unusual in other rejects# 
3« IT one inoreasos the bulk of the body, there la rare tissue to 
ah0rt-oiw.lt the currents* dovalopod by the heart and one will 
(tot crwll potential©—l*e** If the liman heart war® put into 
on elephant*3 body# 4# If the hoort is oncr.ecd In « hotter conductor or in s mrwjonduotor 
one will get mmll potentials* 
5* Ono raaf get mil deflection® in tho standard lends but nonanl 
slnod deflection® in the procordiol leads* Tills may mm that 
tho hor-rt Is in o sore plane then in the usual 
frontal plane* 
0* Occurrence of Low Volt-nga—uanally cssoolotod with chcnqos in Tom r.s 
mil* 
1# fflsry frequent In artorloaelcrosis- ®rtcrlo«el<Krotlo horrt disease with 
susdcodi heart failure* 
C. Ifea&cd p<rfiphorol edono* 
5* Coronary occlusion# 
* 4# Constrictive pwriserdltts* 
0# ftaartoovAlel effusion* 
6# IftnEGdeBslides *43 mui y^# 
©* In this condition the cc&pl&Tm m? be smell but narsaal in 
fam, nlthough usually there are other abrorrelltlrs ®ich os 
Inverted T-WfVeo or flat IVwwves* 
b# Tho deflections got larmr an the petient recovers aaft the 
Turovas boorssB nor© notnal* 
c* am believe thin obnorrality is duo to on actual hydro* 
p©ricardlunj others cttribute it to the dry dfcin In put louts 
* 
with qpM»iam/ 0* Slides 
X* cJXIdCJ Xi^jp* 
a* Those Ottwcs wore f-tsm e oozssol parson who wee very athletic* 
Hho was applying for s lor o e&onat of In&ironoa* 
b* The largest doilooticai in ©ay load 1© lees then 4 m* 
c. The TWf»ve« are practically flat in ©XI leads* 
' 8# Slide L^* 
a. This Is e curve on the brother of patient 
b* Here the deflections ere semll but m 9 &&* 
c* Tbore is rother striking right axis deviation* 
3* Sligo L|£« 
a* Her© the deflect lone are ©mall in ©XX Leeds* 
b* Thor© or© relotively long© Slaves In Leeds II end III* 
o* Haro there is rather striking loft oris deviation* 
II* %*&m» OoflectlottB in the CoripXc&os in the- Standard Leads* 
A* This is 000a chiefly la people with ler :o hearts, eopoc lolly 
young people* 
X* Most ooiizxm In congenital heart dit»soe or la rhounetlc heart 
d I sen so with sortie insufficiency and/or aortic eienoolc* 
2/ attch krp deflectIons are less likely to oocor in lugo broken- 
down hearts than In largo youa& hearts which are functioning 
3* Hot infrequently the deflections ere large but tho noon electorice1 
aris lo In the nomel position. This swans that «pdi? deviation 
has not yet developed* 152 
B* alleles* 
X* Slide * 64X3—represents acrlcod left axis deviation* 
Axis deviation index » plus 37 
T-wavee inverted in bead 2* 
auoh curves suggest left ventricular liypertrophy 
end oyooardicl obaagos; my mm aortic insuffi- 
ciency or bypertonolon* 
£• alia© 2T^0* 
» 
o* Mere the deflections era Ixigo* % • 30 m*» » 47 s$s* 
b* Axle deviation ideas • **?o 
c* is slightly inverted* this is unusual in curves of this type* 
d* fhs B-usves are tell but not brood; this is frequently seen 
in congenital heart disease* 
©• IJoto that the %«wavoa ere s»ot prominent where the H**waves 
oro largest* 
f* This curve is abnormal bedraieo of (X) the oine of end E^« 
(8) the position of the eXoctriool axis, and (3) the 
inversion of T^* 
g* 3uch curve© are 00m in merteod right ventricular hypertrophy* 
lls Deviation and '-loan Electrieal Axis* 
U Mooning of AsdLo 
Am Slnthovon postulated the heart eo a cmll region at tho chaster of 
a here. 
IX* fho three extrccdttee were than ot the apices of on equilateral 
triangle with points at the surface of the sphere lying on e 
plane passing thrombi the center of the cohere* 6# Tho heart ©t tho center cod any b© oonaldoreA a battery* 
«♦ fbi® battery is actually fictitious# Thom 1® © battery la 
omh fibre nod whet m mt lo o resultant# It la o ols&l* 
bottsof which give® tn tbs thro© loads whet the algebraic 
cm of oil the little bet tor low weald Hive# 
b# thin battery verlo* Tnm instant to lastent# 
c* Althssgh et eoy given iastnat there ore aultlpls electromotive 
fores® active la tho heart, you sen got e mmltmt for 
cay given instant which mm be vspresofttod so e battery with 
e oosstlvo pole sad a positivo polo# 
B# OvtnolBdtlot of tho Cordlcc from the dteodoxd loads# 
Deflection la lm& X* » pin© 20 
Inflection la tend II » 0 
Doflcetlo a la iced XU « ~ ID 
1« &lvcm tho deflection in «ngr two locdo «t soy Instant* by lm» 
p|a& m obtain tho cmx&lmo vector for thet lastont# 
B# If the arrow hem represent® ti» force doveloped by the battery, 
the roletioa oat the positive and aagetivo polos bola« o« oboem 
hero, thco m mp represent the sj&fpaltodo of the force by the 
length of « b arid tho direction of tho fore# by tho direction 
&imm tho arrow# Hilo 1® then « vector# 
(Veetorcl otfontitioo have 'both end direction, 
®» donaaotretod# la oeatrwot with senior qucntltieo which two* 
only iijpdbdttii 
5# By m&h m mm. mpmmmt the oerdlao vector for nay 
laotsat* C. In order to define the direction of this force Blnthovon sot op 
the following standard**- 
1* A force in a line pox’s!lal to Lead I hoe on electrical axis 
of 0 p. 
8* A force in e line above it Is represented m minus (*}» 
3# A force in e line bolovj It Is represented as pine (-/-). 
4. Tho eagle the fore© raskos with heed I » the electrical axis* 
Angle a » 30° ♦ 
Anglo b » 30°* 
Thne force (1) heo nxls of o°. 
force (P) has exle of -SO0* 
force (5) has eads of *30°* 
D« Umn Electrical ax in. 
1. However, m are not so much interested la tho instantaneous 
battery so in the average value of tho battery for the whole 
QMS Interval* 
2# Thus, wo a re more concerned with the average electrical axis 
during the QH3 interval; the average direction in which the 
mode units are a etivetod. 
3# If the QMS has this fom is plus part of the time and 
• pert of tho time. 
a# In seder to get tho overage boro, them, we vjcmld have to 
divide tho sum of all tho positive areas end the sum of all 
the negative sreos by the length of tho OHS interval. 
b. This is just as if you wore ait orating to determine the over* 
ago tonpomture fron a continuous tonporature curve; Iii order to got th© ovorogo temperature hero 
m raust mmwzm tho oroo of A m& divide fcy the 
length of tho baeoll&e XT# this will give ua the 
overmo height or the evetogo therefore* 
jLperatur© 
4* fins it thO Q.Ti3 is 
pooltivo area (I) 
sod the negative araa (2) 
and divide by tiio laogth of tho 0S8 interval* 
W© mat Jetarriln© the mza* 
5* But slaco til© QH8 interval to the ©era© is oil thr®o lends, w© 
Mi ©ubirtltuto the arm ©Xmm la our fort min* Tlrua by 
infection w© can dotonala© the nro® of tho sy&Si- 
©• Typm 
b» iSasz&le fov tbo throo lotxdo:~ 
6* If m wore dealing with a al splo aphore of mealo and Smoir 
that If *?hcn atlsmilatod at 4^ 
the average direct 1cm of 
the foroo la m indicated, If the stimulus l&nldo the aplior© 
at B, the em# direction will still be the mmi~ 7* Moon Kloctrioel Axle of • 30° as as eKaf^l©:~ 
a# Since both the HA and the LL ere closer 
to the negative polo of the battery than to 
the positive polo, they will both be negative# 
Furthermore, they will be equally normative since 
they ore equidistant from the negative polo of 
the battery# 
b« Th© Za will bo positive, bemmer, boomise 
it is closer to the positive polo of the 
battery# 
o# Xf w© let (potential of La) bo equal to plus 10, than » «6 
and % » -5, booms© Vx pXuo VH pl*x© % « 0 
a# Therefor©:- IA •* M » plus 10 • (-0) » pins IB 
XZ m U * -9 • (pins 10) « -IB 
©* In this caw© then Lead X « •-f- 
Lend OT « , - — 
B* Hemn I&octrical Asia at (P as an ©xorsplei 
a« HA is closer to th© naoetlve pel© of th© 
battery than to the poaitiv© polo* there- 
for© % will be newBtiTO* 
b* La in closer to the positive pole of the 
battery than to the negative polo* there- 
for© V|, will bo poeltive* 
o# Slnco the HA and lA arc squidletsnt fro® the 
aagativ* m& positive pol.ee ieaixxstlvnly 
\ - - % <3* Xt vm lot ♦ 10, then Yu « - 10, end % « 0 
o* Thant* 
Lead I**—**• Sfi • ♦ 10 • (-10) » 4 BO 
Lead III —— Lt - U • 0 - U10) a - 10 
Lead XI^—-IX «* It?* « 0 «• (<*lo) » 4 IX) 
t# Hi© curve will therefore look like this:- 
9 • SlffitUrly then eo can ietornln© the eppoarenoe of the ourvo with 
any man electrical axis# tltfe this inform tlon, from ©ay 
curro, m cm mstimte the men electrical axis to the 
nearest 3GP# 
n# The eigne mat of coarse fc© so that I ♦ HI « II 
b# The aortal rtm«e is between 0° end 90a* 
o* W® use the of th© Uom Kloctriocl .ftaril# 
{cither to fight or loft) only when the MSB shows no other 
ahnorefelltios in the ftRS 
{%} We of oourne, uno tho tam axis deviation with any 
otirw in which the mm electrical axis fr*lla outside 
the flMtol Unite* For with left B* B# 31», nsre 
of the motile i® eetiveted iron right to laft, than* 
rm tilting in curves which show loft oftie deviation end 
recoil© loft irntTieoltar hypoptrophy* In rt. B* B. Bl« 
raore of the msole io activated fwm left to right and 
result is cosvoo showing right axis deviation and ro* 
oec&IlAg right ventricular hypertrophy* (8) It is preferred, fao»onrort to use the phase exie deviation 
In tho no re United mam* Whm wo say arts deviation wo 
aoea that the 38S isj normal apart tvm the shift of the 
electrical osts* 
ID* If m determine the mom electrical nscla dependent upon tho 
ercus of Utm v**m%mu, m will jpt .the axis for the activation of 
the eiuridee* 
11* If m determine the area© of the */e cmn Cetcxneino the 
sseea electrical axis for the retreat of the aestivation of the 
ventricles—-‘tha return to the rooting state* 
If * In order to determine the noun ©lootricel oxlo according to the 
i&stfamn Ofstna* one met heve sftm&tasMao deflection© in 
at let?,at ttjo leads* 
£« Worn of the Q&S Coalesces for Varioue Mean Blectrioel Aeoss* 
I* Moor Kloctrloal Axis » 0° parallel to X-oe4 I* 
3* Kean xl*etrio«X Axfa of ♦ 30° - perpendicular to ImI HI, 
therefore &mXlo«i deflection* win be la Loo4 IH# 
5# liSam Bloctrlcal JMc of ♦ — poselliil to Load II, therefore 
largest deflect ion® will be la Lead IX* 4# Hem electrical Axis of ♦ 00 perpendicular to Load X, 
therefore smllost deflections will bo la Lend X# 
5# Moan Electrical Axis of ♦ ISO0*— parallel to Load XXX, tfceroforo 
lorrtoot deflections irf.ll bo In Load XIX# 
6# noon 3£L©otrlool Axia of ♦ ISO0 ♦ perpondiculor to Land XI, 
therefor© amlleat deflections will bo In Lead U* 
7# Mem SMMl Me of ♦ 3Bd° — pensUol to toad I, but opposite 
In direction to deflect Iona whan mcis is at o0* 
0* Hetm KLoctiflcol Axle of <450° — impend i«mlar to teed II 
(anno as ♦ISO but In opposite direction)# 
9# IImm i&eotrical Axis of -*60° - - - - parallel to toed III {aoa© ee 
♦ 1130 but in opposite direction) * 10* Iton Slootrlool &ds of - 90° porpcauUouler to LomSl 1 
i 
(tb@ twerp© of ♦ 90^)# 
II* Utm Sloclferlcfil Axis of parallel to Lmid II 
(tbo vmmm of ♦ go°)» 
2£« tkxm Blsetrloal Asia of -ISO0 perpeaadicular to Lend III 
(tlae wmmm of 
13. Utett tho ohtn i0 ** the m1™0 wa, towopd left astia 
deviation, it is csouiitercIoc3cwiso* 
14# When the shift ia to tho nor© positive swag#* tormra 
axis deviation. It Is clocfelno* 
15* the nonial vm®& is 0° to there will be occnsdkoml 
bosskIg of *<50° or ♦ XS0°* 
16* At tiffloa tho tmm* of the dotlections is oil teds will bo 
imXX and is ouch coco® tho mom electrical axis onnaot bo 
detoi^incd* II* 135© Axis Deviation Index* 
A* Jbrmla (Rj ♦ - (a, ♦ Rj) 
or 
(% m • (% • Aj) 
X* If the largest downward deflection In Load III 1© a Q*n«m9 them 
It should bo substituted for &,« 
2m If the largest dcrmmv& deflection in load I is © Q-w©vo, it 
should bo substituted for %# 
B Jtenge* 
X* Iho everago index io ©bout ♦ 8*6 (from study of 100 young males)* 
8* ffts upper limit of normal I® ©bout ♦ 80* 
ii* The lower limit of normal 1» from ©bout 4B to -80* 
0* Actually in pathologic right ©sis deviation, the negative axis 
depletion indices tend to run lor/ ( -8 to -10) when the 
deflections not Ir-rrc. as in mltrcl stenosis where frequently 
tho indices a r© smeller than **15 or -20* 
0* On the other hand, cases with loft axis dev let Ion usually ifevc lam® 
deflections* Therefore the indices ere usually above ♦ 80 when 
there Is pathologic left axis deviation* 
II* Ooetyerleon of HotoraUmtlon of Umn Electrical Axis ©ad Axis 
aprlntion Index* 
Am The position of the mm electrical axio 1© leas important then 
other criteria 00 tar a® normal fane abnormal curve© or© concerned* 
of creator vabtt* 
fir* Hileon believe® the cats Soviet ion Index i 
SAttijw then only the ©acts deviation index 1© out aid© 001ml 
limit©. It 1® probably on abnormal curve# C* Whm only the m&m oloc tried socle lo outside nomal limits, the 
curve lo not aocoooerlly abnormol* 
i 
D* 9hm both the mm eloctrleol reels end the axle deviation indess 
qz*o out old© nortaal limit©, the curve 1c usually definitely nbaorml* 
E* Thao nlso of the deflect ions eon also bo used to determine obnonaaXlty 
for by prediction tablet we o; n det«wv»lno the freinenagr particular 
oizod deflectlono* 
IV* Ri&bt Axis Deviation* 
A* i&OCtrOcard lOgftephie X'iadillge* 
1* Unm Electrical Axle is ebovo ♦ 9CP~~thst 1© ♦ 1£0P or more* 
&• li- lo thnn R^* 
3* S* la klKQf then S^* 
4* Axis deviation Into 1® ne<tnt iro, «1B or ~S0 or lessor, when abnornel* 
1* <U la larger than % whoa proamt* 
6* IWmveo cu*o lav rtud la LeecUl XI grad III* 
ii* fWoves tend to he inverted vim there 1» o 
positive area la the 0R& complex* Thus, Inverted 
ft-tsevee %eud to #K> with big ft»WT0«i 
b# In RaD, the ere son ce of inverted Itamvoa show Q,**?ovoq in 
Load© H Indicate* that you nr© dealing with on abnormal henrt* 
V* QBS interval U Ofe*®el# 
B* In RAD, n learee percenter of the cooes will abow in 
loads XI nafl III* 
o* In r*noreX, the larger the the larger the Q.^vo# 
b* In general* the larger the B*®«fVof the smeller the SM?ave* B* Oocurronco of Eight Asia jPovintion* 
1* Ur«ol2y got BaD in right ventricular hypertrophy hut tho 
of the heart ploys e larr*e role so that in popple ®o 
000 00m degree of BAD resulting from a vertical coition of tho 
heart* 
2# Curves with lore© % and anall or© oomon In nlcodor people* 
a* Stoch curves show slight rlrht axis deviation, the nonn 
electrical osis being lifted to tho right* 
b* auoh curios are cooaan in yoonr. people of slender build 
with vertically placed hearts* 
o* Be© slide IV# 
(1) Kero the arcs© in Load I is poetically 0. Bx and 
aro about equal sis© both m to ofUioic m& width* 
(1) In th© otto too leads, K is lasg* and S is smell* 
(3) Boro tho mom electrical axis is nearly vortical ♦90°* 
0* Iteqplos of MmomtX Eight Asia Oevtatioa* 
1* Slid© %• 
# 10126—Asia deviation lades Is (6 ♦ 4) • (10 ♦ 21) « -23 
# 9236 Asia deviation index ia (1 ♦ 1) - { 6 ♦ 17) * -21 
a* In both of thorn cases tho mi& deviation index la beyond tlio 
noron! limit of -20# 
b* la both oases tho mm olccti»icol axis la ebcwt *lTiCP. 
o* la both caoeo the T*wovos qto Inserted ia loads XI and III* 
d* Hot© that tho B-*mv©« am broad and notcheds such JMwrve© 
macost mitral stenosis* 
o* Tho 'B*mvcB ctofto together with tho ssic deviation ham 
congest mitral stenosis* £♦ Slid© — Case of Pulnonery 0t ononis* 
o* Axis deviation lades?: heix> Is *70 
b* Bare the T*wvos are slightly inverted la Load 1 and upright 
In XI end III—this is unuauel* 
0* R6te that the U-ouvos occur in those loads where the E 
vmvoo oro largoat* 
‘d# These curves oro ebnorsBl then for several ronoono:** 
(1) The greet also of 
(2) The repeat sla© of %• 
(3) The p coition of the noon electrical axis (♦120°) • 
(4) Tho inverted Tx» 
o« Each curves ere soon in saorScod rlrht ventricular hyportronhy. 
t* The P-*mvos her© or© very tell (S m*) but act so very 
brood—thus ournoetiac conrcnitel heert diocese* 
3* SPlld$ Fjo# 
o* Mean eloctrlcel oxis hero in ♦ ISCP# 
b# IMwvos in toed XI arc momma here « 7 m*t but not vesy 
broad—such B-smvos eixg&eat conrxsnltol heart dloeeoo* 
o* % Is large* and there ore inverted In IX and III* 
d* These curves strongly surest connmital heart dleeose* 
X)* aii’Blficonoe of Rlht Aada Deviation in Mltrel 3tonoe4o, 
1* Fronounoed HAD is of less diabetic velue theft, urn'noetic vdtio* 
2* Ptonmmccja SAD noro oomoaly occurs with nerkod adtml valve 
lesions afl rlrht ventricular Import ophy. f* left fixiQ Deviation* 
A* Bloctroer rdiorraphlc Findings* 
1* Utmn olootricel cstla is loos then 0°—that io—*30°t 
or Icon# 
C* Is larger then It.* 
3# Q§ la larger than Rj* 
4# Axis deviation iaclcoc la positive ♦ no or Inrgur, when obnomal* 
5* Is larger then vhcn prosoat* 
a# Zn X*i£) about 80$ of the ceoos show a %«wevt cornice: Is 
largest* 
6* XWuevos ere often inverted In lead X ©M oonetlmos la 
Load XX* 
a* Xa X»d>, the presence of inverted f-wavoe In Lord I 
indicates thot you ore decline with on ebaorml rt* 
7* fho OJrfiS interval tends to be slightly longer (0*10 mo 
or slightly saoro) than the «vorsr»o* 
i 
xx 
111 
4 
B* Occurrence of Left fcsto Deviation* 
1* LAD occurs in loft ventricular hypertrophy but boro too the 
p coition of the heart plays a ham rolo* tbus in norrsal 
people m my aoo LaD qb c result of a transverse heart, the 
rsoon electrical aslo being shifted to tie loft* 
i 
g. It nay often be difficult to clotcrolao whether the position of 
the heart 1c responsible or Mother It io duo to hypertrophy* 
3* Ourvoa showing largo % md soslX % oro wasson la short, stocky 
pooplo because they have e oUght loft tad.a deviation, the tionn 
aria having been shifted to tho left* o# Such curves ore eomoa in middlo-oncd .people end in yatmg 
stout individuals# 
b# fbolr hearts ore raor© transferee# 
c# Bee Slide F^# 
(1) Ikon the area of the QRS in Lor d OX is practically 09 
II3 end beftar: of «ppxaste*t©ly equal amplitude end 
rrldth# 
(2) la both loads 1 and XZt R id lorn© end 3 is mil* 
(3) Uote that there Is a a«wm in 1 where R io lorgoct# 
(4) Mem electrical axis hero Is ©boot (Pm 
4# Olden* people era apt to gst tronavorso hearts boom a© as the 
aorta gats tortuous end sclerotic it tends to push the boo© of 
tho heart tom# 
a# fl&rnplos of Jftnsmi Loft Aria Deviation# 
1# Slid© 87 • 
# 6413**o# Mean electrical axis tots io -3CP# 
b# Axis deviation index io ©3G# 
e# there io © snail Q.«*?ov0 in Leod X, v?hor© the B#eaivc lo 
lorrjoot# 
a. Ix la fcMM 
o« This patient bod aortic Insufficiency# 
#12013 e# Moan electrical axis hero is -30° • 
b# iteio deviation into is ♦ 21 
c# There lo o mil %x chore S io tho 
dm tonamm arc flat in XI and invited in III# 
o# This patient m& 75 years of am and bod Cl) ortori* 
scleretlft hma/t dtmmmt (0) layocardlol inmffic looey# 
osd (3) cm&njVkBQd arteriosclerosis# Hie blood prcj>» 
©are taoo 130/00# VI# factors which Dotcrnino tho Position of tho Moan Electrical Axis# 
A# Tho Motive Weights of the two ventricle©# 
1# At one tinop Xop?1o bolievod that tbe relative weights of the 
right and loft ventricle© v*bb one of tho chief or even oole 
factor in detcmlnirtf’ the ele ctrical axis# 
0# lewis found that infant© showed right axis deviation# 
©• At age of 4 rxmth® this changed to aonacl rode# 
b# Be found thot the right ventricular lausole weighed 
relatively mam during tho first four rrmtha* 
S# lmi& not up tho fallowing criteria:- 
a. BensaeH g. ytTy-ff .uor g.o 
it# Bight Ventricle 
b# Ratio above 2#0 Dcant left Axis Deviation# 
o# Katio bold? 1#4 noant right axis dcvlc ton# 
4# Fvm this work of Lewis* tho phresee left ventricular preponderance 
i 
end .right ventricular preponderance wore derived# 
0* Subsequent wcwfc of Hmm mxd Wilson showed that the relative 
t 
weights of tho two ventricles ami tho foiti of tho elcotrocordio- 
♦ 
Gras staged fairly good cowrolntion when tho heart weo large 
r 
(over 000 O# total weight) • 
j 
6# Data froa woife of Borxmm m& Wilson (Heart ITol* 9# p*91p 1900#} 
* 
a# Glide F^; 
(1) A social method woo used to asperate the right end 
loft vmtrioular Muscle# 
(2) Hovmllv the VW mmole weighcAjPioO end the loft 
ventricle 4 75 Ot tho mriml ratio being JUS to 8#0# (3) Cnee I. 
(e) W wt, * S35 Cl| BT wt, « 14$ G, , Ratio » 0,605 
(b) tg end f3 aro Inverted, 
<c) lleoa electrical aado 1© ♦ 1D0°, 
(d) Ascle deviation index » -19, 
(e> ZMeavee ©re broad end dofomod. 
(4) Oao© II (a child) 
(a) Wf wt, » 70 O; I3T wt, « 00 0* lfc*tio * 0,640 
(b) Kean electrical axis is elDCP - ©IT#0, 
lo) iMasvca ©re broad and tall, 
(5) Case HZ. 
(a) W wt. » 146 0} IAT wt. » 91 0, Hotlo * 0*906 
(b) Mcym elootrleel ©ado is elSOP, 
♦ ■ * - - , 
(c) fMaeves ©re brood and notched. 
All three of those case© bed mitral stenosis, la each 
r 
the ltf/&r ratio was below 1,8 so that they fitted 
Lewis1 crlterio satisfactorily. 
b. Slide 
{X) au&nexy of the 50 oc ®m reported by Wilson end Hermnm, 
(B) It ©da be soon that there ma © sstch hotter correlation 
hotvmm the relative vcaatrlculor weight© and the mm 
dootrloel axis ebon the total ventricular weight 
exceeded S50 0* 
o, aua« 
(1) This alia© shot?© four mm&loe which did not ©rro© with 
Leeds* work. {B) Coco A 1/H ratio is 3*59 yet £J£D is not &tmormX css&ept 
for the inverted $*wovoo and tho axis is at ♦30°• 
(3) Oaa© B—V& is 2.05 yet cede is at ♦90P« 
(4) Case ratio is 1.65 yet axis la at -300. 
(5) Coae &~~l/R ratio Is 1.45 yet axis is at OP and into ♦ 27. 
d* The ©aoos used by Hermann end Wilson did not ell have heart 
disease* 
(1) fhe cases used by Lewis ell fmd big hearts* 
(2) fhis no doubt accounts for the discrepancies# 
(8) Thio msk proved that ttoe oust bo otto factors besides 
relative vontriculsr might® in the dot Graduation of the 
men olootrlcel axis* 
2># Position of the heart eject play o largo role in the mom electrical axis* 
1* This Is ahovm by changes with rosplr«tioa~~ooo slides Fgg and *«• 
B# Posture 
S* Body habitue 
a* If the tort la there tends to bo IAD* 
b* If the heart la vertical the tcesdoncy la to IUD# 
4* Importrophy of tho heart itself may tend to change the position 
of the heart# 
5# As tho heart shifts from tho mro vertical to the more tranevoroi 
position, it also rotates about its long csdc ao that tho JUT la moved 
not only up bat also rotated about its long taels so that it feces the 
loft nm store then usual* 
Xeft Axi& Deviation 6* As tho tart shift* fror. tho move to the nor© 
vortical position it ©Iso rot©too so that the loft ventricle 
oama to Ho hotair the right ventricle tx>ro than it usually 
does and fee* the loft lar tta tsttcX* 
Kernel 
Hl~ht .Aria Owlet ion* 
7* The epox of the heart is formed by tbo left ventricle md this 
is another reason whey item the h&ert becomes u»re vortical the 
cptst taco© the l®p« 
C* Minor Conduction Defects my chines the Axis# 
X# Incomplete B« B* Bl* 
$• In doe cscporlBoeta the product5on of tseonplete B. B* BI« cmised 
largo ohnnros In tho direction of tbo spread of the 
b* 3o too In Bern* minor oban&es resulting In alteration® in tbo 
agreed of the iiptl# nay remit in chsniw in the moon 
©lodtrioaX axis not at ell duo to 
B* Slid© 
cu Hoc* in a potlont with Static A* !♦, prior to treatrzmt the 
noon electrical axis to® ♦30°# After treatment ehloh resulted 
In broodonino of tho <$8$ ooa®lmBa and o temporary period of 
tacreoo® In sycvtong, the o::is chocrod to -30°, 
b* Bor© tba ehorve occurred, not dw© to hypertrophy# but because 
of the dwolqptnent of minor conduction disturbances* D# Infarction laay alter the sxle by destroying the mnolo in on© 
region thus greatly changing the spread of the impulse and thora~ 
fore the position of the electrical axis* 
VIH ProooT&f.-il Leads In Aasin Dwrritirm raid Eight and left Tontrlculcr T&pnrtaopiqr* 
A* Prooardlnl Leeds in Axis Deviation in normals# 
1* In norncl people, the procordial leodc ere essentially tho 
mm la 0 series of individual© nhetbor the standard leads fltor 
fight axis deviation, left axis deviation, or no axis deviation# 
2# Proeustibly, therefore, tho onus© of minor deviations in tho standard 
loads ' .oos not rest in the heart itself but rathe* In tho 
p ositlon of the heart and its relation to the three eactamdttes# 
3# Because tho procordial leads ere net nearly 00 nuoh influenced 
by the position of the heart, they to a mch hotter correlation 
with clinical findings than do the usual standard lends* 
4# Because of those facts one w find patleato with rtrht axis 
deviation in the standerd loads who actually hove left axis 
deviation in tho procordial leads# 
r>* For noratel procordial loads am Slides %?, end for 
do ousaioa mo pages 103, 103, 110, 111* 
B* Freeovftfte& Iin left Fentriculc* abaoraal 
left aacte Deviation* 
I* v%m them la laaauesticnebl© hype;?*xt>phy# either rlsht or left, 
j . ” 
tho rmms&leX in dofinotly abnormal# 
B* Wtat is am in left ventricular hypertrophy in cm mgiratl«i 
of the m&anX differences in the lead* froo tho right procordtum 
end those frews tins left praonMIia** hoomm BMnsUy the I# is 
thicker than the H?# • 1HfU m 
8. AU tho deflections are usually larger then normal, racing it 
uoooaooiy to toko the records at »/£ sensitlrlty* 
a# IMc In true of loth procr adlnl and standard Seeds# 
b# This i« tho roc eon thet the aacia deviation Index is e rx>r® 
reliable guide than that the noun electrlccl cocls la JUS# 
P'3 lends 
4# fho on the rt;;ht side { in and becoeie ovon asaeller 
then usual nhereee those on the loft eld® (T„ end V ) becano 
mch larger tlion usual# 
8* intrinsic deflection (th© peak of the Hhmbvos and the 
mxMm UmS shift which la the Intrinsic deflect Ion) occurs at the 
usual tine over the right cldc but become present mch Inter then 
umt-X evor the loft cldc ( in end V^)# 
a* lriie usual difference Mnm sad left le plus or nlisua 0#o£ sec# 
b* 2n loft ventricular hypertrophy this difference my bo incroneed 
to 0#04 to 0#05 000# 
c# 'She pock of the B»«»ve aver th« ©id® mr be e 
little ««rUir then amend# 
d# $h© po«& of the &4jarves In Vg and Tg Bey be plus or nlnus 0#0G gqo#» 
Instead of 0*035 oec* 
o* In other words, the difference in the pooka of the H-wreo f 
vmicU occurs gasMcHy* booouoa 
f« fhlo difference in due to the difference In tte» of errlvnl 
of the lapaloe at tho surface© of the right end left voatriol® 
respectively, end as the left ventricular wall toeonit thicker# 
St tokos longer for the irgulee to resell tho mrfee# of the 
loft ventricle# 6# The T-wrc© sro likely to bo inverted in the lead® froa the 
loft precorfilaa (V^f and Vg)* 
9* lm$la of left Ventricular —-3ee Slide *8*. Coco B« 
a* ora aboaat In Vn, Tg ,.«d 
TS* 
b* E-wqvos aro laxfte in V5 slid V$* 
c * The deflections ere all large mm though td£«B nt H/S sensitivity* 
d# The intrinsic deflection in Vj la at 0*018 and in Vs at 0*003, 
whexmto in ?g end V$ it ia at 0*063 coo* 
©* The blew are Inverted la Vg* 
f* S-vavea get ©seller m om ©oa« to the left* 
8# Otto? oȣ$Xes of Loft Ventricular importrophy* 
a* slide F-fj 
(X) Hot® that dams disappear entirely in ?« end V$. 
(8) Bote that aonll appear in Vq end Vg* 
(3) there are inverts $»e«ves In V« end 
b* Slide 
(1) Thor® ere small %*tmvae In V$ end Vg* 
(2) %*mmt Inverted in v$ and 7g« 
(3) Beak of R in Vg and Vg occur® at 0*068 soc* 
C» Rreoordlcl leads in Ri$ht Ventricular i^r»^rt3«5p>^—th® eiwo/rea from 
CO«:il oret* 
1* The &-«r$vo8 an tbo right side become liipr than usual* 
2* The peak of the BMmvse cm the aright aide occurs Ictus? than usual* 
3* Tho cm tho left a|fle become ana11or than usual* 
4* The peak of the framas on the loft cldc occur q little earlier 
then boiqbI or at the aoxaal time* 0. fShare le thus © reveres! of the norrsol ocr on© rjooe fros 
right to left* 
o» In cf#t ventricular !$pcrtrophy f| nad fg easy d&or abet 
normally occurs In ?s nod %t ©Isoroac % end 1T$ ere apt to 
aboif abet norraclly occur© in end ?g* 
b« She right ventricular mool© m? even baccm thicker thm 
tfco left ventricular mode* 
6* Tb® Mffmmmm between th© intrinolo deflection© mm the risbt 
ventricle end over the loft vitriol© in rlr&t ventricular 
bypertroptay am not apt to be no &roat bo t*w oro In left 
ventricular boerwao there i© JMsoeUy a difference la 
favor of tho loft Mo. 
?# mm&Um of M# Vcmti&eular 
a * Slide Oam* a. 
il) Item® ere hmm 8*mvm in cad ?g# 
(a) Me of t In V* end % to at 0«06C m& 0*062 mo. 
{3} iioiKMl in Vg sM era jflwjwfuit grilles* tlMft nornrA 
sod occur at aoml tine 0*006 doc# 
(4) fmtfivm §m towled la Vfc and oil to % but not In %• 
b* ma&owm 
(i) Hot© largo in m& %f end the peek© of ti»ai 
»*wovo« occur at 0*006 coo* 
(S) fbero *12*0 mtm tiny end m Q*smm mm tho rlfM Mo. 
(3) tte load© <w tbe left oifi© ebw miller tommm tbect. 
usual* k*ro en<! the podfe© of tbo &*»*?©« ot 
the unKtal tfcao» 0*034 eoo* 
(4) She %mmm mm inverted in % to Vg but not in Vq. 13# Relation of Standard loads* lartronity Potentials end Procord lei 
Leeds and their value in determining the position of the heart* 
1# loft Ventricular esoocietcd with o Transverse Heart# 
O# O WnpJ m 
(1) In the standard Xm&& it oaa bo mm that them Is definite 
the 
loft oacls deviation, mi mm electrical axis being «Q0 * 
(2) The v»-:as interval in the standard 1 ads is slightly over 0*10 me 
(3) 1® flat or slightly laverted* 
(4) Thus the standard leads suggest left ventricular hypertrophy* 
(3) In the ortmalty leads «• see that % is onoll and Its 
area practically 0, therefor©*- 
(e) teed X looks like Vj, because VH is cmll* 
(b) load II looks like % hoomm % Is smll* 
(c) Iced III bos m r-3 form because la taking toed IH 
Tl Is turned qpoido &mm and added to V^* 
(6) The procordial load a ate? evidence of left ventricle 
hypertrophy* 
(e) rBm deflections ere vary lerro sv« though taken at 
U/& sensitivity* 
(b) Reaves era Into In Vg and % (at 0*003 r.oc*) 
(c) There 1 o no B-wsre at all in Vi# Vo or Vg# 
(d) IWaveo are inverted in ?6* (7) The relation between the extremity potentials and the 
procordial lends indicate that the heart is transveroel- 
(a) V|, lock® like V5 and Vg, moaning that the potential 
wnrietione at the surface of the left ventricle 
are being trmaesaitted to the left cm# 
(b) % looko like Vx mid Vg» Joining that tho potential 
v< stations at the surface of the right ventricle 
are being transmitted to the left leg* 
b* Whm VL looks like Vg and Vgp and % looks like ?i and Vgf 
It aesas that the heart is transverse* 
c* In order to get left axle deviation in the standard leads 
from left ventricular hypertrophy, you must have the heart 
in the transverse position. 
(1) In the transverse position the left ventricle is notated 
about its long axis as well os being pushed up and te?ard 
the left am* 
(8) This is the position which the heart usually does aMe 
In left ventricular hypertrophy* 
2* toft Ventricular Hypertrophy eeeoelcted with a Verticil Heart* 
®* Slice »» —patient with rheumatic heart disease with aortic 
n cM insufficiency end mitral stenosis* 
(1) Tho standard loads show right axis deviation of mm. 
degree, the mm electrics! mim being «t ♦ISO °aaa the 
axis deviation Index balng -86* 
(£) The f-wnvee are Inverted In Lords II nnd III mid tho 
JMvevee are brood and notched* (3) TH&# the otandovd loads st early oogrpet nitml stem ale 
(which the patient did have)* It wee known clinically, 
boaorer, that ho also ted a very free aortic wwaitotlon 
and aortic stcoosie eo vmH, 
(4) The procordlel lends show Ipt o deflections (even at H/g 
sensitivity), lexgo INw»w over tho left side, end 
inverted Tmbovoo in and. ??• T‘«a tho precordlol loads 
indicate that the patient had left ventricular hypertrophy* 
(t>) Sxtreaity potentials were not taken but they om easily 
be colonicted frosa the standard loads* 
a* % • jyutia 
3 
b* Tims since both II and III show lem© Itaamo and 
very tiny or no d-novoo* tie Isnosr that ff also wtmM 
'hove tfmm. toll Beeves with saeil Or ofeadJt 
c* Thus It can bo seen that % looked like % and 
the loft ventricular potent laic aolnn to to loft 
log* 
(6) Similarly since « I - XU it ecu be shorn that % 
5 
looked like and fight ventricular potentials 
being tronaraltteA to the loft am* 
(?) It s*y bo therefor# oonolndod tfeot hero boeeuo© tro are 
doollar with a very vortical heart, the standard lead© 
tibm rt?bt axis devSotion in opito of the prceonoe of 
left ventricular hypertrophy* 
b* lima the absence of left eala deviation in tho pmmmm of 
aortic disease does not mmeoevUgr asestt tbsit tho pot lent 
does sot have left ventricular Iypwt«^ty» S* Left vontrlemler hypertrophy associated with a hoert. 
o. The standard loede on ouch potlento will show lairto 
IMnsvee in oil throe leads. 
4. ventricular hypertrophy aoooointcd with a Imsvem heart, 
a# Slide (upper oet—lhith Hardy | 48M6) 
(1) This patient .had questionable pelrmnxy hyportonslon and 
a proeyotolic r»llof>~-cacnct ecme undetominod. 
? imlawery ortorinl disease. 
(2) the standard Mis dhow rlsht satis deviation with a 
acdB electrical axis of ♦ IBCP* 
(3) The preoordirl leads ore reversed tsm the noraol, the 
Umobww bote tall and Into o© the right aide and pbU end 
acroal on the loft aide. 
(4) la the eaetrenity lends it eon bo oocn that \ looks like 
?r* mtl V where©!* % looks like m& %; the left ven- 
tricular potentials ere Oruj bote tranenitted to the left 
am and the right ventricular potentials to the loft log* 
(0) Therefor© the heart lo fteamroe end the right axle 
deviation In this case is duo to rl-ht ventricular 
hy 'ortrophy# 
(o) If the heart wore nofisal or there wore loft ventricu- 
lar hypertrophy, tfilo position would moult la loft 
ratio deviation in the standard teds. 
8. Hlrtht too tricolor hypertrophy name latod with a mli*9iesrtieai heart, 
a* Boo Olid*. (lo@@r o^t—Hanicgr Cartwright # 46263ft)* 
(1) %le patient had rhouaotlo heart dices®© with ciitval 
stenosis and aortic insufficiency. (S) The ottoto lends ore unadacl since they ©to Ins*m Sewvee 
in all leads# 
The neon electrical axis is • 150# 
(4) Tho B*wmm are brto to note to# 
(5) ffeo prooordlol lends ere tho roveroe of naroal to oto 
definite evidence of rl/dit ventricular hypertrophy# 
(6) 1n. tho extrooity Itos, % looks ll&o Tg to the 
left procordlm, Boreas % looks like to fg# 
(7) too not look like either tho ririst or loft 
procord id leads but is mm of on Intertointo typo# 
(B) Thus bore the tort m& bo cold to bo scrtl-vcrtioal In 
position because the loft ventricular potentials are 
OOlnrt to the loft lee to the rl-ht ventricular potentials 
or© not &ola& to the loft tsm m tmiM he tho mm if tho 
tort nom vortical# 
b# In tho pro noose of ripht ventricular hypertrophy to a east* 
vertical heart, the standard londc eto losno is 
oil. throe lento . . ■ 
0# It is eeeeoivable that you might v&t left axis deviation in 
the presence of ventricular fepportroptsy, but this met be 
roro# aiofe vmM be tho cose in ventricular hyportiophy 
with a very vortical tort# 
?# Thus, the reason that the relative ventricular weights to the vx>m 
electrical m%B correspond bettor vtom dealing with Me torto I® 
hoomm vtimx tho tort is toLarto it ie mm opt to he in tbo 
tmmamtm position* On tho other hto# vihm tolls** with onell 
torts, tho mis to mam apt to bo clot©mined by the position of 
tho heart nether them fey the relative xmlrM® of tho tvo ven* 
trlcloo, tho tort frequently being in the vertical or s«csl~ 
vortical position. wmnm m tug 
I* There are tm foetore which datoirlnc whether the T-wdvoo shall bo 
up or tom# 
A# The nroo of tho t-BH coqplo* (the fom of the Q.H3 cockles:) # 
1# The area in the con bo raonaurod but it in 
no yet a todlown, pQiaatnfeto? procedure# For all poetical 
purponoa they am bo eetiaatod# 
2* As a direct consequence of chaniM in the feR3 coqplos, the T- 
wsv© may beeoeso altered# In B# B# Bl«# tf there nve larr*) pod- 
tivc Oils defleetions, the T-wovos nro olmoert certain to be Inverted# 
B# local Variations in the Esccitetoiy Prooosc# 
1# As lav; oo the local variations in the duration of the excitatory 
procooe remia the mm* the area ..of the corplereo will 
datomine the area of the JMmvoe# 
2# The area of the Q83 carplcx end the ere© of the T-rmvo# if added 
should be r.oro# If they do not# it aeone that there nro local 
variations in activation end deactivation which have caused 
independent alterations In the Itemveo# 
II, The esad Boternlaation of Arena# 
nor# t*ix son ot# olj a&# Heart J#f ?oi# io# p# 46# oot* 1984# 
A# 3oo elide 
1# Xn thin enm of loft B# B# 31#, Lend II won tniton, frith aimltmcous 
Icon I, and the® lead III with dmlt# Lord I# 
8# The original curves wore thee esaJkm*oA epproedteietoly olac dlcnotoro 
by projection m& then traced on thin paper* The croon were them mettirtd by moo of a pta&lsaoto** Cere hod to be token to 
first determine tho ioocloctrio lino; then ©11 the trot Above 
tho lino too considered positlv© end all that below the lino, 
native# 
3# In order that the erne could be expressed in unite t?Moh w»U 
not very with the film speed or with me atriar sensitivity 
or$loyod in record In# IndiTldual curves, n roetmvrlc mn 
sani&od off o 0,5 m* deflect ion, 0*£ second in 
durst 1cm, or to 100 nicrovolt seconds* £ho tree of thin rootsnglo 
Is them deteminod. In this instance £903 on# m#, and that ia 
orvunl to 100 microvolt seconds, our standard for that pcrttmlcsr 
curve* 
4* la this 00®© it wro found the 
AMI Of $HS in I » ♦ 0056 no# m. or 63*0 iw* aoo* 
* * • • m an* m, f* ».UOO*S ny« gap, 
• 960 eq* ns*' 50#3 nr« oee* 
• w * * XX • - 998 aim mu w 55,0 !W* eoo* 
>• ®tilo ia a Tory laborious end rather fepmotleal procedure* It 
ib poooitilt that & nothod of ttttagftBttas the elect roc?torron 
vbile it io h®im token will soon anise it seoh m&Mf to assure 
the oleotroor i*a ionrephle smis# 
B. the Vlmomtlcnl 3ffoots pro :uo<*S i.y ...a do FlbTo Sospotfoa la Ms** 
flOLluo 3Vs* 
laoo next terel 1* Here m here c oinrlo cardiac .uu-do fibre. In contact with it 
or© two aoa»poleriacd electrodes, at a m& t, connected to the 
terminals of a gsdiioaooctor* 
F* "The elect rone tivo force In the circuit will bo 
proportional to the difference between the intensity of polarisation 
boaor.th the electrode at R mid the Intensity of polarisation bo 
nor th tho electrode at L* If tJie latcnnlty of poldrlsetlcm ie the 
sens© beneath those two point© this BS will- bo zero; if it ia 
loan beneath one of then, thot electrode will bo relatively 
aogetivo with roqpoct to tho other," 
5* "There is an elcotroootlve fore© ©cross every boundary that do 
flats c difference In tho Intensity of polarise lion. If for asm* 
pi©i a plane through t& tin la* the mad© mmtrmo into porta, 
ono of vMch la polorlaed to on Intensity end the other to on 
intone!ty of Pg# the 2MS* in oil loads froB the oartomel tfuntooa 
will b© the ear© on if c surface coinciding with that portion of 
the specified plan© lyiar, inni o the fibre mro polarisad to m 
intensity Pg • Whore thoro la e radiant in the intensity of 
polarisation orar e given portion of the fibre, the effect ia the 
gams so If that portion of the fibre ware polarfeed in a dlroo- 
tion parallel to the oacio of the fibre.” 
4* If the electrode© li end L are sufficiently cloco tomthm mX & 
etlwulue la applied at point A, the curve recorded will $jow n 
sharp Initial deflection (I) oamapondlifte to the <4&S corniest end 
a *',r°''jd deflection (F) coryr ©ponding to the T-wsvc, a# This curve Is the algebraic sun of shod and of :h (two none- 
phoelo curves)• 
b* Curve shod roprooentc the curve which would be obtained if 
tho psamm of excitation nerve produced no change in tbo intenoity 
of polarisation beneath tbo edeetrodo at B* Tide curve would 
actually bo recorded If the eroitotory process wore begta* 
nldc at A and blocked between K and L* 
o* Curve offh represent© the curve which would be obtained 
if the poeae o of the excitation wo produced no chrnco 
in the intonnlty of polarisation beneath the electrode at H* 
It mild actually be recorded if the excitatory wave were 
blocked between t and B and tho electrode H wcue transferred 
to B* 
£* $o laegr sun up tho tm rmcpht'aiv curves sd&obrelcelly by 
Wising the elrjci Of tho second (cfnh) and subtract In- tho 
MU&otoc of t o rooultlsv* carve {of*g e) from tho first 
(abod)* TIi© nree of tho initial deflection (I) of the dl~ 
« 
phasic mu’vo will, than be reprocentod by the tvm ebf © mid 
the area of the fined deflection (F) by tho croc eg ltd* If 
« 
the curve et> end tho curve of aro clBco in fasts, tho first 
of theoo oroee Is &?uol to that of a roctenrde of which as1 
is ono olelo and no in tho other? if od and gfh ere alike In 
fora* tho eooond area is egual to that of « rect-iv,Xo of which 
an* la one old© and dh is tho other* It la therefore door that 
provided it does not chance from point to point* tho fom of the 
curve thet represents the senaor in which depolarisation tehee 
place cannot affect the area of the initial deflection I* If 
the for® of the curve that represents depolarization does not 
vary* it emanot effect the area of tho final deflection l\ 5# "The mm of the areas of tho initial and final deflections, I end F, 
of tho diphasic curve mot bo o mil to the so of tho arose of tho 
two ruonophesic curves (©bod ©nd ©fill) • Xr the arose of the latter 
are alike in absolute ao#aitudaf the «tn of F met bo cruel In 
nagnituda but opposite in aim to tho area of X, and tho mm of 
these two areas mot be aero* This gum mat o Iveys vsmm*T9 the 
difference in absolute between tho two noaopheaio 
curves; If it le not sero, m may conclude that the curve shod 
cmd tho curve of,gfh differ in fossa* There is then © difference 
batmm the changes In tho intensity of polarisation produced by 
the excitatory prowess at R and those produced by his process 
at L* Such a difference in tho behavior of tho moolo beneath 
the two contents mot depend chiefly. If not entirely, upon foe- 
tors that do not affect the suoelo an e whole but act upon it 
locally** 
6# Thus* *if nil tho ventricular mode psccod through tho period of 
excitation in tho mem %%m can la tho csdo way, tho «m of <iRS 
and the are© of T would bo omal la absolute but oppo- 
site in ol&B* ond the area of CiHEff would bo mvd«” 
©# ibo area of %8ST is a nonsure of thoolectrlelo effects pro- 
duced by loo 1 variations in tho excitatory psooom* Tim 
mum electrical axis of QMW gives the direction of the lino 
along which these local variations arc i$p©eteat* 
1* Tli© local variation# in tho excitatory process which deter- 
Kin© the mm electrical ojsia of QttST are dependent upon 
factor© that not upon different parts of tho ventricular 
nuncio with different inteno.ltloss* They ere sot materially 
influenced by tho course of the oscitntory process over the 
ventrical- r auoole* XXX* ftMi loo of Helotlonohlp (or lock of relationship) between <|ES group 
and fora of the T-im 
I« Slide 1.—aarnl* 
i# 
«• Xn tho JKHBttl elect roserdlogvea* tho .sun of %RS and T is 
net r.oro, duo to local variations in xr/oto:Ota* 
b* Wc enn seno idea of there variations from the sun of 
CiRS and 5*. 
c* llo-raclly* as In this curve, the orm of $H0 Is mm 11 end. tho 
direction of T ic deto&aincd by tho local variations* 
d# Hero it am bo scan t>iet (B9.1) ♦ $B$r$ <5*$) « QR‘%(3£*6). 
B* Old* OL. — Left B* B# Bl. 
II 
e* H ro tbo area of <JR3 Is Xarro and the T«*moo ore therefore 
neoomms$J& in the opposite direction, unions the orfoet of 
the loool vr.rlDt.ions in flqretal* is enough to overbalance the 
offset of the g)S cobles* 
b# In this m*m the stt opposite tho QBS coalesces. 
5* ttldo J19—Hinht Bt B. BI# 
e* Itee the Inrao positive nrm of <«ftd in III la oseocloted 
with inverted Stomvee whereas the lame negative aroe of 
QBS In 1 Is aomclf ted with uprldit T-*#?voo* 
b* Hero too, the or© opposite the QB9 oosyplmmu 
4« Slide Left Ve®trioula» Hypertrophy. 
o* How the Inverted IMwsptee in Lead I ere « direct 
of the large positive QBS area in that lead* 
5# aildo Bight B« B* Bit 
e« Bore bocraino C|KSS? in lend X io -11*1, ve fcnwp that the Itanstro 
would be imported If rU B. B* Bl* were not present* 
b* 11m* direction of ilia ploys no role In the Interpro* 
totiou Of the mm oonplox, 1*©*, in the OIckhosIb of 
bundle bro nch block* IV* Invasion of the T*vasveo fee to Local iferlctior.fi In Systole* 
A* The T*r.r»vo le the /oat easily hDiillad pert of the ventricular oowpXeau 
B* Local variations which alter the frame arc not necessarily etooroaX* 
they iacy be present In the aosmaX heart* 
X* They rsy be due to blood supply* tonporeture variations* vcrla* 
tloac in nerve mgp$3y« etc*, In the aorrscl heart* 
£* In the norm! heart* those variations are such ac to tend to nrfeo 
the f*ewrtrea upright in I end H even though the is upright* 
0* Critorts in dealing with Inverted Starne in the 3tr.ndr.rd Loads* 
1* Inverted T-u'evos aay occur sermlly in Lood III* 
&• If inverted*. XHame ore present in either Load I or Lord XI or 
both* it ie on aboora&I finding* 
5* At tiraoo re ney coo inverted Thbsvmi in 22 or X without other 
aboowanlltloe either clinically or in the elsetroclorpras* 
fo mist wnteh tho patient but cermet ocy whether there io do* 
finite discooo present* 
D* Inverted T«vwvoo isigr reeoXt fron e vd.dc Variety .of eircir^®a»een* 
X# Digitalis* 
a* There le usually no dlgplaoeiarmt of the 3*T juncti n bat 
retiior, the «te'v:o just beyond the junction, In tho 
Rswr ee^amt* 
b* With digitalte* the inversion of the fr*imre pro@r*o£iee from 
the early pari* of Vm !ea-T eetpoat toward the and of the 
$»>t*«vet wherenn with syocMardleX inferetim the inversion. 
bmina at the end of the f«w«ve end nro&reeeos toward the 
MP junction* 
-rot ion c. Usually with digitalis, inverted T-weves appear la all three 
leads, though usually affecting III, II and then I in that order* 
d* T-woves inversion due to digitalis may lest ©s long as 2-5 
weeks if e single lew:© dose has been given* 
e« See slide G^* 
A K Control* 
B a* Changes in INwos due to digitalis* Hot© that 
fLead I shows depression of the segment 
tencdletciy following the S-T junction* 
0 m Control* 
3) « Changes in T-wnvee due to digitalis* litre again 
it can be soon that the part depressed is that 
Iramed lately after the junction. The lust port to 
be Inverted by digitalis is the end of the iVwnre* 
2* larerted T-'-'eveo associated with small QBS in all leads* 
a« Soe dido F41 
(1) Here the T-xmvos are flat in I anu inverted in II ond 
III* 
{?) fho QHS complexes are of low voltage and bjUarr© fom 
in oil leads* 
b* Such curves are rom in marked congestive failure with 
extensive peripheral edema, pericardial effusion, constx’ictivo 
pericarditis, and similar states. They woy occur In 
BQCtedeoa although usually the QJxS coalesces are moi’o nors.nl 
in forsa* 3* Styxedcma* 
a# Scso Slide 
(1) Bote that filth fall btom qyawdoro ( # 11X2X5) ell the 
deflections in ell loads are smell, end the T-r*?voo 
ere flat In Mfl 1 end II end Inverted In Load 1X1* 
(£) It can also be seen that when the evidence a of ryacodon© 
wore present, the line deflect lone duo to mnalo tremor 
ore absent* 
(5) After twmtmn* (11037) the deflections ore moh larger 
in ell leads* the ttanrai nro lorror end upright 
In Leads X end II, inverted in III, and evidence of mselo 
tronor is rxm present* 
b* 306 Slide sm* 
(1) In curves # 9190 the f*wevoa ere Inverted In I end H, 
the deflections ere goraos&at onellor then uou-nl in oil 
leads and evidence of moclo brataor la eboont* 
(E) In curves # 9341, the T-*;nvea or© now qprlgbt in Lfr do I 
and II and the deflections cro larger end evidence of 
made tromr is now present* 
4* fenperotnro ohmtm r«y alter the form of the T-vmvos* 
a* Seo Olido oxporlriont* 
Cl) The first sot of curves are a control* fhoo© or© the 
standard lends token with the cheat open end the heart 
«spoood| this my nccount for the inverted f-drives in 
ell leads* 
(&) The left lateral vmtrlculor mxtece m$ then spreyod 
with ethyl chloride and th® second net of standard 
leads woo token* (3) After the ventricular surface wee cooled wo om so© 
very strife inr. changes In the T**mvoo~-deep inversion, 
without eoeeejpeaying am chojsros* These twweve changes 
are therefore Independent of chcnr.oo In the oonplexos. 
b# Boo Slide F49 Busicm Bqparlaeot# 
(1) Curves labelled A ore a normal control# 
(S) Curves labelled B wore taken after the subject had taken 
throe fleece© of loo enter# 
(a) It cm bo neon that T*> booonoc flatter end ©nailer, end 
% bocano inverted# 
(b) Her®, too, the team change© occurred Independently 
■ of any QW changes* 
5# Biphthcrle* 
e# The T-wave change© with diphtheric are nmolly only t orrery 
and only vary rarely 1© there ony permanent 
b# Changes in the occur only in thoco cnees 
with very cover© and serious isanifeete ttans of the discooo# 
c# See- Slitlo 
(1) Carve #ia&record mo token when the pet lent woo 
very seriously ill end shewed evidence of diphtheritic 
pejmlyeis* The T-woo ost Inverted in oil three lends# 
At this ttrac there were me physical sign® hop flgrapttim 
of sgoccrdlol Involvcvicnt# 
(2) Curve # SC3S—1The Smmsvwi ere new aorranl. This record 
was token B~3 wooha Inter after clinical tas&BWmmt 
occurred# 6* Hhoumotlo fever* 
c* The changes which occur during rtiounatic fever 
are usually temporary but they my be pesnsnent* 
b* Sco Slide 1^* 
(1) This patient had bed rtiaowrfelo fever which subsided with- 
out ovldonee of valvular damgo* 
(£) Here wo aoc T-vmves which arc flat in Lead I and inverted 
In Leads 21 and HI* Those were peraonent T-wevo changes due 
to permanent local alterations in tho excitatory process* 
7* Insulin* 
tt» This drug nay cause •mrsvo changes ©von though t#hm It Is 
** covered** with glucose* 
8* Variations in the ft-ion ecooentretion result in 
&mem changeo* 
a* Those changehk may oppocr in acidosis or alkalosis* 
b* The tMsavee can bo Changed at tiwo by ovco»broetking* 
9* Triohininolo may cause T*ncnre changes which are usually 
transient but bo permanent* 
10* day type of heart disease say couc© Itaave alterations which 
may bo permanent or not* 
£• of iheogroaelve T~wave dhnagoe over a period of tlrao* 
I* auoh changes suggest that ao&othlng active Is going on la the 
E$ooerdiucu 
8* Patients should bo kept at rest under two eirmmtmmB la the 
presence of heart dlsocuoi- 
(cl then activity cause® 4pnptoras« 
(b) fflioa an active, acute process im going on In the heart, 
whether the pot lent is having or not* 
S* If the elootrocardiogrea indicator* that $mm acute, active process 
is going on in the heart, it mans that the patient should be kept 
at rest* fhc Vcctox*cnrdlo?-:it5ja (Hof* Am* Hens* J#, Vol* 16, p. 14, July 1950 
Wilson and Joimoton} 
I* Prinolpl&fj or Method and ’locni uo Hood* 
A* *Thc Inner surface of the lens© cod of the oethodo-roy tube is coated 
with fluorescent notarial* Where the boom of electrons generated by 
the tube strikes the screen e brilliant hmlnous spot la produced* 
% varying tho voltages on the different electrodes, the been of 
electrons nay b© focused, the velocity of the electrons constituting 
tho boon nny be varied end the been current my bo controlled* The 
tube in provided with two cote of deflecting pint mi o dlftorenco In 
potential between tho pic too of tho first sot shifts the boon, end 
homo the lurdnous spot, in tho vertical direction, end c difference In 
potential between the pistes of the second sot shift© the hom la tho 
horlnontcl direction* Vithla wide Uslto the displacement of tho 
been in cither direct ion is strictly proportional to the voltage 
applied to tho corresponding set of plate :*" 
"®b# right am and loft am electrodes ore connected through a 
suitable amplifier to the deflecting plates which shift tho spot In 
tho horisontcl direction*** 
1* Tho tsmmam* of this spot. If recorded an © novlng filn will 
record lord I* 
f‘. Tb obtain tho vortical conponont, the control terminal to used* 
The control terminal and the loft lm electrode arc ttm con- 
nected through m ©rsplifter to the deflecting plates which 
afeift tho ©pot in the vortical direction* a. It hoo bcon shown that V « XX ♦ III 
V 
b* Thus wo dfttosnliui the vertical ronponent really by teSdtag 
XI end III slftatonooualy. 
o* Wo will m* an equivalent force aero or? the vertical plates 
if this second amplifier is adjusted to isrive o deflection 
1*7 tines a® front aa the horizontal one for the carso input* 
U) jELtm •> • r inc 0, tbs vortical oonneaeat of the 
3 
ccrclifvc vector divi og by Vj^. ( «« 1*?5 ) 
5* ®io direction in which the spot novas can be observed and , the 
loops inscribed con bo |&etocrephedu 
is* Here then wo have a, aeons of deteasalalng the cloctrict.il esio from 
instant to instant and also by photo twiphlnr: tIm loop, the mm 
oleotrioal axle for the oorploto cycle. It does show whr.t is raeant 
by doctrleol mi& m& how it from instant to Inctnnt, 
C* 3oo Slide %* 
1* This die rm represents the sat-up urod In toting vectored !o'z?oms* 
E* Load I is pit on the .plates which mlm up the horizontal oonponcat 
and Vp is put on the plates which ar#e up the vertical eoaponant* 
II. 
4* See Slide Kr 
" IK X* Here we con oee the different positions the electrical axis 
ames during the various phases of the cardiac cycle* 
0* By dropping perpendiculars frora tho loop inscribed upon the 
lino of sech load, the curve which would be written in each of 
the standard three leads em bo determined* 
5* Hero wo om mo shy tho petto of the leaves in tho standard 
loads (m for coooqplc, E. end above) ore not clultaneouo* 
4* Hero we here nil three lead® Inscribed In a alagle curve* 
B, Slide !%• 
1* Korrjal curve with standard leads ehcreau 
S# fhc inside loop reproaento the 
m* mmm& wammmmmmm* 
A* Slide loft code deviation* 
I* lloto that the different loops, each representing e different boot, 
oil look ollhe* 
8m In LAB, the qx»t—*the aris—<»vcg cx&mt ereloo toicm• 
B* Slide E 34 RipM ml© (legistloxu 
1. Hero the spot rwod in a clocltoise diroot ion* 
2. The tine mitclng —the dotted, loops—wore obtr inod by 
the apparatus every l/doo see* 
C. Slide Very complicated intricate loop end standard lead# 
showing i»tchlnp* 
IV* JftsGdvoatc&os of the &otbod* 
A* the tnritmii types of loops are vary difficult to clasoify* 
B* Wo do not know what odfeator© to Ik* obtained by thio technique, 
the experience with it being teMTSelont as yet# vm nsmmc.. mimmm m/mm m imo&aaM* 
I* Tho Cheapen or© of throe types? 
Cl) 'Those of acute injury, aenely, K3-ff eogneat displacement* 
(2) Changes in. the ajis complexes, chiefly the devoloprieat of 
(3) Chen'oo in the fom of the 
XI* T 01 <3^1cement* 
A* It is an amt* injury effect# 
1* It is due to the sudden cutting off of the blood isupply to e 
portion of the heart isusole so thet that eepnoat of the ryocor- 
dins suffers ecu to Injury* 
£* la aniBole ouch cent© Injury affects enn be obtained with miy 
ecu to tram* ouch os produced by boot, choniodo, wire®, ©to* 
3* It persist a so lone os there is injured living susclo* 
4* c* In ryecnrdlol infarction It lasts on long. no the active 
Injury loots, that let go lour ft® there Is meolo which in 
dyian but 1® not ooraplctcly dftead, or nuncio which is re- 
covering but not corplctoly reoororad* It assy last sem rol days* 
b. la fiyoecrdlal Inf erotica it assy aimppmv only to reappear* 
If this occurs it mm& that ffcrthc* auscle da: lags has 
occurred# 
c* T?aio the H3*flP dlsplaftemout to, m © rule, treasient* 
4# XT nyocerdiol nmxmin in produced in dona by or XI :$tlag 
an eatery, %m isnsdietoly not BW? diftpleoftfieat* 
a# If wt imediatoly reroOvo the clous*, the mocl© recovers end 
the so®nmt disappears* 
b* If leave the clerp on Xoasn enough* the music boconoe 
irreperobly dnraftod end it dooo not recover* b# In patients with angina pectoris we mey so© <i9JT dinplnoonont 
in records taken vhem pein is present which disappears vbm the 
pein doers# This H3*T dlcplaccttent mot bo due to sente ryo- 
cardial ioohcaiia# 
0# EM displacement which is terporory or changing Is the leper*- 
t ant thing In infarction# 
B« Pordotent E&-T ftlaplnoeoent* 
1* There is a typo of KS-T displacement which my b© called, 
pornenaat which is due to the fret that the IVwrvo begins 
before the QMS conspleK Is over# It is oomm in B* B# SI, 
end curves showing broad &RS o^plecscos# 
In this type the cinplaccrient is slight find 
usually opposite in direction to tho chief 
UiS deflection# 
b* It occurs because the frereve is large end 
hem begun before tho qB0 in ooqplote, 
c# It does not have any iaportnnoo so for cc 
©cut© Injury is concerned# 
fi, There Is, tawever, a second typo of persistent HM <11 o- 
pleceraaat which is men for long periods of tiro after 
rjyocnrdlol Infarction# 
a# It mjt possibly bo e purely accidental finding end bo duo 
to the son© cease os the permanent 8W displacement 
described in the above paragraph# 
b, It m? mm that the %mm> is no? altered and now beglaa 
before the Qi0 ends* 
o* Steiaa of those cases, though they ere IniPenucmt, ore. pending* 
It sany be that such per si ©tent DM dicplocosscnt following 
infarction is a bod siem but this is not definitely proven# 0* theoretical ConaldorotlOBs recording HS-T Displace cut* 
|X» 
(2) 
X* If A-03 in a olir>lo ©trip of meole, under renting conditions 
* It will ho charged m shown with pocitivc and negative chm. os 
distributed on cither side of it a nwabrone ne indicated* 
£• If the nooolo is injured at B, a current will flor* no stovn 
' beesaae the oteigee nt the injured end hsve been neutralised* 
di Ton get the name effect so if there «m now * boundary 
lotvoon active end renting nurcle at B* 
b* ffae injured ausole in new the active anode* 
c* Ta$ uninjured rurdc is the reetlng nuncio* 
d* 1M@ boundary bot.'ooa active (injured) and rooting (uninjured) 
moolo will perelrt, end the current of injury will therefor© 
flow, until the injured iwsele dies, end the end io coaled 
off, thereupon reentnbliahicg the situation present in A* 
o* This la the reason that H3-T if? temporary 
boocuao vfom the oolle die, there is desmrostiaa and a nasn 
mastonm is forracd, m that thou wa have the sm* situation 
rm trore dealing with before the In,fury, c&copt that m have 
loci a certain mat of mode which in aw deed* e* If electrodes nr© pieced on on injured mode fibre ouch no 
A-B cad OQBMotdd through » ipkXvamnstev, m we switch In th© 
gslvcnotaetor, the Injury current will fore© the string in 
the negative direction on atan et (1), 
b* We mat therefore neutralise this current of injury juct no 
wo neutralize £fi:ln currents* fhcroforo wo throw in comaa* 
ooting or current from the battery by neons of trio 
control bos and force the string bed; to the resting 'position 
oa Ml it (£)• 
o* If the mmlo in thou etlmlatod at point A, the te?uXne will 
travel from A to B end* in so Golan# it will 
dcpol#u*i5se the nuoclo fibre and there will be no injury 
current flowing* 
(1) She current of injury flows only during diastole, 
bsc~uoo dorian dfn stole the uninjured end of trie mad© 
(which mo rooting) hoc become active end therefor© 
dopolorlsod* 
(2) Tho effect is such so to rash© the injured nuccio pool- 
tivo throw-out systole* The effect 1c os it the 
boundary of activity were issoved tan to the injured 
region but not into it* end stayed thore throughout 
systole (as in (2) below)* 
(X) 
{2} d. The string shadow moves in the positive direction shown above 
at (3) because with the muscle fibre depolarised and 
the injury current no longer flowing, the compensating current 
is now unopposed. This is then the R3-T displacement which 
wo actually record. 
e. The RS-T segment remains displaced because of the unopposed 
compensating current until the imiscle returns to its resting 
state, becoming polarized once more and as it does so the 
current of injury flows once more. As it does, the string 
shadow returns to the resting position once more, as shown 
at (4)t 
f. Thus the compensating current serves to give an effect opposite 
that of the current of injury so long as the cell is in 
the act5,ve state. 
4. Another way of presenting the same thing is thus:- 
(1) If A-B is a simple muscle strip ivith two electrodes R ahd L 
connected through a galvanometer, and if the muscle is 
stimulated at A, the voltage which will develop will he 
the result of the changes at R plus the changes at L. (a) Tho curve abed » changes ot H* 
(b) Tho curve afgh » ohengoo at L* 
(o) sofb *5 ohongfro during activation « 
td) dhgc « ahsngos during recovery » 
(S) Of Mam« vjhcoQi dealing with the tort re are derltag 
with o KJodtei and c& c rule the electrodes arc not 
on the surface of tho lauoolo so that tho altnaiim is 
mmm&mt different* 
b# IT we out mo aid of tho made, ve will got a constant 
la July current# 
(11 an injury will interfere with the integrity of 
tho colls md cbi.am&& ia &<& in tho uvm which Might be 
clue to the smeaaoe of an ixapulsc will bo diminished* 
{it ) 'ms if tho meclo wore to be injured at B$ and tho 
rnoclo in tHm ctlmlotod at A, m will got tho 
Changes ot B but not those ot I** 
{3) Xa such a cent, t»c would .eat only the curve rbod, a 
raonophcelc response* 
(4) Hero, then, the v;is end !Mnmsc beoom fused 
into a nosrophasio VMgoiiM* 
c# Xn the heart «bm only part of tho i.ntnolc is lujuaped, tho 
(*RS and f bocoio only portly fused, thus 8* the electrical field produced by m injured section of tho 
ventricular well. 
A & healthy aioclo* 
B » inured nicolc* 
C m deed moolo* 
a* will be positive throughout just eo the injured 
oiid of the simple, Injured nuoclo fibre is positive through- 
out agrotoie# 2bo also of the aagli a: trill dotomiri© the 
dogroo of positivity of the latfjor tho (i»glo# the 
greater tlio positivity* 
b* 3Pr> «m bo negative throughout qy stole end its da too of 
negativity «HI bo detePEilnod by the ©iso of the nrvsX© 7# 
The larger this angle, that la, the closer i;g is to the 
area of injury, the greater its negativity* 
c« If the coloring electrode mro placed at tho 1M 
displacement would be upward* 
A* If the exploring electrode were placed at ?,,, the Ha-f 
dla&leoonont would bo dotHorard* 6* aqpolfanatfi were carried out on turtle heart to dcrenstamte 
thee* potato* 
a* See Slide % (Hot© old polarity need* 2ta the exploring electrode)* 
(1) In thin cecpcriracTit two electrodes were placed In contact 
with the turtle heart by trephining the plustron, the 
indifferent oloetroco betas pieced within the trephine 
opening eboit £ on* ftwis the heart and the cjsplorlnn 
electrode being wick electrode© directly on the heart* 
The tipper curve repronenta the electrode which wns placed 
near the loft mewglsx of the heart at the bane mid the lower 
record ip that taken with the electrode which mo placed 
aonr the right snrrcin of the hoort ot Its apical portion* 
(2) Curve A raprcaonts the oontrol* 
(3) A acsaU area beneath tlio left bo ami electrode vm then 
burned and reoord B ms tafeaft* Hot© that the electrode 
over the injured ere® etovod n loir?® looaophaclo response* 
The electrode which we« oppoatto showed e alight SMf 
dimiflfti 
(4) The floftoeedlng rooord* OF show a general recovery iMoh 
occurred over a period of on© hour* tlio Boaophaole vessMmm 
disappearing and the 83«9 elevation aleering* 
b# SOO Slide Xr;* 
(1) In this tha deotrodao wore pieced on the 
ventral surfcoo of t’o heart* The heart me lifted 
and Immod on its darea! surface mid the electrode 
then replaced an the teatml surface* tthea this 
wan done, mf.pant dopreeelon occurred (Sato In 
the slides tbla loeka like 3»T elevation beonuoe the 
old polarity ms uood) * o* Thcco CKporlsieato thuc indicate that there is positivity 
throughout systole over the injured. em« The electrode 
pieced over the injured nvm will civ© curve© tftmrin® 
RS-dli#lneorasnt Is s positive direction iupwcrd HS<*T 
diflpIdMirl according to the now polarity)* 
d* These cagporisuents further Indio©to that there Is negativity 
throughout systole in the area of tho heart opposite to 
the Injured ereo* Tho HMT dlsplnoomcat obtained frm 
this aro© opposite tu© injured region is in a negative 
direct lem* 
o* In cold-bloodod antaols ouch cs turtles, this injury effect 
woo found to lost ©lout oao-imlf hour* although there mB 
aooo eaoooietod bum change la oorso of the eaporlaantc of the 
nature of that which occur© in tsmm coronary occlusion, it 
io doubtful ?dicthor it lied o, similar origin* 
f • Slide I34 • 
(1) In this esporfcaent on 0 dog we 000 the dorelopmnt of 
B8*$ disploocnont upon libation of tho anterior descending 
coronary artery# 
(E) It ecu bo ocen that this diqpleooncnt appear# trswediotolyw- 
First curve ot 90 00c* shone It clearly# 
(3) In dogs this effect gradually disappear# and it con be 
soon to gradually diminish over the courro of W sin, hero* 
It usually le gone in three or four hours in the dog* 
g* Those H.VT segment chougoo enn bo cosily related to thoet 
uhloh occur in buses ryocordial infarction in which vo m$ coo 
Upward displacement in proeordlol lead© in onterior Infarction, 
end. dmaawcrd in procordlal leads in poctorlor 
liiforation# D* Changes la to Intrinsic Deflection with m*® JM.^Xaacmxt» 
1* fho intrinsic deflection, the sudden shift from positivity to 
negativity 00m in direct or prccordlal loads, indicates to 
proooncc of living nasals# 
S# Ac H3»T ocg&oat diaplsecrv-nt occurs, the intrinsic deflection 
boooiaos amUnr, if to displacement is upward, torsos it 
becomes larger if to displacement is downward* 
3# displace ent comes fyor*, the central part of the infarct* 
II* to Bator* of to Ghmnm in Myoosxdi«& Infarct loo* 
A* Origin of the tongas# 
X# fbe qSS chongog arc the re cult of the death of the taacelo in the 
region of to infarct* 
£• Iho *p$ tongas oodic fron the control part of the infarct# 
3* In direct lands over on infarct tot coco completely tooucb 
the ventricular mill, m act exactly to care thins tot ss would 
got from to ventricular cavity booms* tor# is no electro** 
motive force being developed in tot arc®, all of to susols being 
deed* It night bo acid tot in this nrm of dead muscle tore is 
no tottery** between to codocerdinl end eploordlal snrfoeos# 
4« If to mode is deed, to 488 changes 
3* If to undo in not killed but only *lcnotod out'* and it 
recovers, the $H8 changes ore toH*o»o*y# 
6* The big <,..-ocvoo which oro ehnrsotcrlstio of curves In ryoenrdial 
infarct ion ore therefor© 0 reflect tem of sovity potent ids end 
represent dead made which cannot be active tod* 7# These Q-wnvos which occur over cm infarct will occur only If 
tho ventricle its activated in the normal way* If there io bundle 
breach block on the side of tho inforot, you will not got largo 
• t,Mwe« over tine infer©tod region. This is bcomec during the 
early pbwaos of tho Q8S interval tlio cavity will bo pooltlvo, 
ell of tho septum being activated toward the dd© of tho block 
imU% tho aide oft c infarct)* 
S* In direct loads in Infarction, the changes in those leads tr&flc 
over tho infarct will bo choree tori otic and. the cam© whether tho 
inforet la in the right or loft ventricle* 
B* Chnrrctor of Curve© from various pert a of on inf ere ted cron* 
1* Tho distribution of on Infarction tends to bo in the ohspo 
i 
Of a con© with its bead toward tho endocardium 
Bploerdium 
SBdooisrdlum 
If direct Xomta were teke© from point A In this diagram, using 
a sherp electrode, the records would bo exactly the mm m you 
would get with a ooft*tipp©a electrode because In this region 
the media la completely dead# Furthermore, if the electrode 
mm thrust through this mm into the cavity G, tho record 
obtained within the cavity could be tho mm ec that obtained 
et A* This is within the. ervity* There ie jgg, tWP displacement 
in such curves* 
3» Occasionally there my bo ialaode of muscle which or© still dive 
In on info voted. ©r«e which will be r©presented by notches in 
the uhB ooqplestoe In lends te&en from ouch areoc, time making 
the curve© that meh different from the eevity curves* Curves fSNB areas with Isles of 
llvtac i-usolo 
Omlt& Curves 
4* If one potsfi to tho merlin of ouch an ssfen, so at point B, wimre 
there ie subendocardial Infarction but living angola (in a line 
perpendicular to the well) between the electrode and the cavity, 
wo will mt different euzwe with soft end sharp- elect redes. 
a* &lth a aoft-tlpoofi elected© vm will 
b» aith a sharp-tipped electrode vm will *ot5~ 
(1) Tho IJi-Kr aiaplaecront scon in such curves ueSn£ shoitv 
tipped electrodes is due to acute injury from the 
electrode* 
(2) Such B3-T displacement tells us that there is still 
llvinc nuncio present# 
c* Iloto her© that in thmm two cuwoo, one with o soft electrode 
and one with e sharp electrode, tho Initial 
doflootioao are the mm tor both* 
(% end % era alike) • 
(I) This io boomm the curve for both are oataotly the mm 
op until the ttm at which the lapilse reached the Injured a,roc# 
(0) An injury can mdlfy the eloctrecordiornm only after tho 
teniae reaches the injured ereoj it cannot effect tho 
curve which is inscribed up to tho tiims at which it 
reaches tho injured area# d* Ourvoo from croon whore eabcndeoordicl infarct ion in present 
ere frequently »v~shepod* 
(X) Mo cell them W shaped rather then to any the B-wave 
in absent bcoouse wo hme each e coraplcx in which 
*■** 
there in an IMaeve* moh no W * which hca the 
a S 
enae dpUieeMb 
<S) Mkeheped coeplcocee In interior infarct ion* 
(o) When they arc present In load I without ocr elated 
IWav© changee* they arc Tory suspicious of infarction* 
(b) 3acb complexes with associated Inverted iW/avon ere 
very olmmcteri otic in bond X and in the procord id 
leads in anterior tofnretloiu 
Vo) ows&lmem in posterior infarction* 
{&) amh wplmm with aoooolatefl f-woroe ore charoc- 
tori ctic in lends II end III end In the eaophogo»3l 
leads in rosterior Infarction* 
(b) anch con&loxoa without ®&moieted t*mweo when they 
occur only in Load III arc not very suspicious of 
posterior infarction; they may occur normally* 
C* fho QES which occur in Infarction tend to be mm pmmmmt 
whcrea® the m~t diaplnconont end T-wove cheats tend to he 
ter^orory* 
1« Oooifllomlly* however* m me patients in who® the changes 
nlso dieappear in the courro of tim* patient Libert Baxter# B% The Changes in l$oocrdiel Infarction# 
A# Origin of T-wnv© changes# 
1* They cooe from the mrgina of the lafr rated crocs , from the 
none of ran sole around the edge of the Inf ore t# 
£• They are the result of alterations in the recovery process# 
3* In direct Imsda In doge# the 2V*jcvco ere moot mni&rCly ohongod 
in loads frwa the asnaeulnn of the injured oroo# 
B* Blroctlon of the fweevoo in Infarction* 
1# They era oltocya opposite to t?»© direction of 
the original U3**i displace: sent# 
a# If the original H3-T diepJUMneot la x&mx6+ the 
T«*eavoa wl3JL bo Inverted; if the origins! HWP 
dljsplnccraont dowawnrft, the Itamves will 
tie upright# 
0# The ©tinagoe tm& to bo tcnporoxy# 
1# In infarction in dago, the T-wnve chengoc ore fuito evanescent 
and nmvllp feat only 24~&8 hours* 
B* In «mif the changes in Infarction ore © little slower 
in development* usually reaching their height in 10 days to 
3 Hecfeo and kiting 4 to 0 raonthc though they any clear ooonor or 
loot aiah longer* They never go beck to nezifnal tout m a 
yule' the chearoo ore not permanent. 
3* As lom »* the are chenginc? it mean® that acwetMns ia 
going m in the ryocordim anti the patlentfe activities 
eljouM be restricted# jbjboihoo At&zoorai#8 hi mtttxm um\ wmm sgofoma* 
X* General* 
A* Meny patients with angina .pectoris have msml oloctrocordiorra n* 
B. The records in other pmtimta with engine poetori# will ©to 
non~eroeiflc etange® toe to syoeardisl ctoro* 
X» Pnay patient® will have already hod no infarct cud the JBKO 
®ey show evidence of it* 
S* Bom my dbem hkwm ®*mvm in tod m demo, this belag the 
only evidence renolalnc: of en old posterior Infarct* Yet this 
alone is not certain evidence because Xgcqo gHrovee In XII do 
occur in aora&JL people with trenavereo torts* 
5* They nay show inverted B* B* Bl*f loft axis dcvictlon, 
or various degrees of jWV heart block* 
4* But these changes ere oao»®p@oific nM ©re duo to syocRrdiol 
changes* You ©enact my they Indicate ooirmory sclerosis* 
Such changes only permit you to ecy that this Is additional 
evidence of tort damage* 
C* gone cooes «ey sto USGf« with only very nlnor ehextges which 
arc of questionable sirr.lficonco* 
D* In occasions! cooes* curve® tefcen during m ettode of engine 
pectoris nay chow very definite change®* Those ere tho cnoos in 
which the diagnosis of coronary artery sclerosis cm be mde fron 
the alcotrocercUorjrsn# 
H* Changes In the Sloetjooaartiorjfea which occur during etteefee of Annina ioctoric# 
A* lloturo of otogoet usually they consist ofs 
1* Be* word dlcplnoerant of R8m9 eegimt la II end III, though 
occcaionslly upward dlaglec«cat of BMP is mmcu 
n* Iacnw*o la glee of la Lead* II end III* B« Tho chonnoo are duo to eon to Injury effects* duo to cutting off of 
the blood supply with resultant nyooordiol anoxenitt. 
1. Tho cWT diqplaoreflont is without doubt due to ono&eoio. 
8. To not such nroac Changes in the standard loads a a one conotlnos 
dooa, in the light of anted studies end direct loedo there mot 
bo 6|)n03 of tho largo* vesoolo with practically actual closure. 
3* Th© a-v/evo changes arc probably due to minor cii n*eo In intro- 
* ventricular oonfiaation. 
4. The chungeo arc ftiffiMBt fro© tiono of infarction in that they 
arc ravoroiblo. 
&• fho ohmicoc nry persist even after tho pels has subsided. 
XU. toqplco of >KO CbancGc in Aa&iaa Pretoria# 
Hofomnceos iilaon and 'ohnotoa, Tr* Ataerioon Association Fbys** 96i838f 1939. 
An. Heart I. 88* G4t 10*11 
A. aide Ox —iuglan icoterie on ««tion. 
1. In this o©o» m soft depression of tho SWT oor»nt 
ccsorcloe and the appearance of angina pectoris. 
&• Portion to 5ef as* with the aaoociatod increase in !vaert Into mojr 
nodify the electro©ardtoTO& in noawol people; there may oti 
bo niaor obento In the SWP junction. 
0.# la this ooo©# the change in the SMF is stIU 
prolint in # 0141 whoro the rate la very near tho rate in tho 
control curve# the ebrnpos dtenpenr after wtfk 
nitrite with tho re to ininn tho earn* These ehoncec nofco 
tbio oories of wrvoi nore significant. B. Slide nlo, ego 36, with luetic aortic Insufficiency and. 
angina pectoris, on exertion for about ol *ht maths* 
1# A—ahemo slight left nr.is devotion with rote of 80 per 
minute, end fairly largo Slaves in H end III. This curve in not 
outside norrrl Units. 
S. Series B~~this mtfe ms token after SKcrtloa efficient to 
produce ntld anginal pain# 
e. The heart rote Is now npproxlmtcly 150 per minute. 
b* fliers is pronounced downward 113*0 dlsplsocment In XI end 111 
*■ 
(Had slight similar displacement in Lo d I* 
c« The in 1 have bacons flat or slightly Inverted, 
d* There Is striking increase in simo of the S**ssvs in II cad III* 
3. The pet lent received 8 Injections ( 1. r.) of biamth mllcylnto 
(2 gr.} over 3 weeks end soon after t ey two bergm there m® n 
slight increase In his synptona. 
4# Throo maths after these curves were taken the patient went to 
thr cool stones of o tonsa who hod fallen end broken her lac* 
This effort won foUorsd by a ooverc attack of chest pain with 
drepnoe. He died c foe hours later. 
f>. It was believed that in this Once the capias pectoris wan due to 
Hcriwwlne of the tenths of the eoronrxy arteries* 
0* Slide &r,~~£%n, cro 53, with Igportcaaioa end mnmtmt ©typical 
onptea pectoris* 
1. Series C—Those curves show tiHSgh% loft dele dsvist ion, not outside 
aorarl Units; hsert ret© 94 per ala. T-«ve« are noSteel* B* Series D—these curves wore taken following exerttoB sufficient 
to Induce mild aubatemal distress; heart rate Is 130 per min* 
a* There Is acm pronounced dlspleceeacnt of ESwT In 
Leeds II and III* 
b* Tim T-rovce in X are now larger than in the control* 
o# The 8-wcves to II and 111 or© much larger* 
d* The P-H interval has become longer* 
©* Hstrecystoloc were noted after the oserelm toot but wore 
not recorded* 
• About one-half hour later tbe patient was found unconscious to a 
dressing room to the 1-roy Dept* after he hod hod an ortho- 
dlsgreaw Ho could not be revived# 
4* Because the changes to aeries A*© and series C-B ore similar to 
those t**> patients It seens likely that the anno artery was 
involved in both patlonto—probably the loft anterior descending 
coronary artery* 
l>* Dangers of Induced Attack® of Angina Pectoris# 
1* Any patient with angina poetorla may die during an attack* 
8# Any time you induce an attack tho patient is therefore endangered 
hut usually the patient to not being a dead to do ssor© then ho 
la doing oveacy day* 
Um Slide mm 66 with m&im pectoris of two montho duration* 
Ho had pain cm exertion and alao on excitement or emotion* 
B*P* was 160/90* 
X* Upper curve • control, show© slight loft axis deviation m& 
prrfc tally inverted T-«mvee in Lend X end slight flattening of 
the eognfmt in leads II ana XU* £* Second curvo—*tuk«n at the height of e spontaneous ottaCk; chowo 
pronounced downward diopl/scomont of the H3*£ ©cgjuant in IX end 
III, end appearance of large 8«wtffee in II md III* Heart ret© 
roe® from ?0 per rsln* to 100 per min* (In a oubsocpiont attack 
B*P roc© from 100 to 100 mm* of i%* eyotolic during attack) • 
3* Third curve—taken 5 min* later efter administration of 1/100 gr. 
of altrogiyceriaei curve now returning to original form, 
f<* sheiply inverted* 
tm 
4* Fourth €nrve-*-taken ten min* after 3rd curve5 now very moh like 
control* 
5* Hero, as in the two ocaco on slid© Ggt tho artery Involved is 
probably the anterior deaoending breach of the left coronary* 
E» Slide Orison, eg© 4K, angina pectoris for 1 yp* It had become 
IxMHPs&riasXar sever© so that it incapacitated him# lie was using 40- 
50 nitroglycerine tablets daily* B* P* 165/110* Slightly obese* 
•*T 
Booked plus or stimte £0 cigarettes dally* On stopping! evoking hi© 
angina pectoris stopped* 
1* Upper curv©~~controI curves show inverted T~wcvoe in II and III 
end slight dmmwerd H3*T displaceraeot in ell loads* 
g* tour days after control curve and after ho discontinued awaking 
patient was brought back to Heart Station end curves wor© token 
during m attack induced by ©racking* Uurtreo taken during the 
attach ©hem pronounced dewmevd BMP displacement which persisted 
oven after the pain was relieved with nitroglrcc-'lno, although 
it eventually ©leered* 
5* It 1® tme enough that here ssokinp; brought on the attach: but 
it C«n be uostioned whether It did so backus© ho nnticlpctod 
that ho would haw m attack, or poaolbly b©c«u«i it waa pro* 
cipitetod by the norc rapid heart rate which appeared cm snofclng 
or whether it we© actually duo to the choking ttodf# F* Slide 0.age ho, with atypical engine1 pain for nine months 
usually occurring sere comonly in the evening or while at rest, 
man awakening him from his sleep, rarely on oxortioa# 
(Victor Um) B# ?* X60/100# 
1# Bppor curve w twrmalj MDtvoU 
2# 2nd row** curve at onset of an attack, epontaneoua, seven days 
later# These show abort attack of ventricular tocbycrdlc# 
8# 3rd row « at height of mm attack, QBS ha© boc w broadened 
to 0#16 oeo«» B-wavet cm taller in II and III and there is 
striking 8a*T elevation in II and III, and depression of RS-C 
segment In I# 
4# 4th row » also at height of attack, showing two vcntriculfiT 
ortre ay stole© which or® practically nonophaslc responses# 
5# These alterations closely roooc&lo those tmm in the early stages 
of acute posterior infarction and It may therefore bo concluded 
that the vessel Involved was the posterior descending coronary 
artery* Curves bocemo neraal again very shortly after nitmglyoorlne# 
C* Slid© <%—som© patient oa slide %• 
1* Thom &!&& later the patlcdt returned et mm ami before lunch# 
Tho effoot of catsoklng was determined# 
8# Ourvo in 1st rcw al»**c control » nomil# 
3« Curves in fiaaci Mr were taken after he had smoked two cigarettes (Ph*&*s)# 
a, After he had smoked the puls© had changed only from 86 per £*5Uu 
to 94 per mini the B#P# from 150/88 to 140/80* Ko was corn- 
plaining of slight burning .pain along -tne lateral eopeet of 
the left am# 
b# The curvet show alight diaplseewoot of the FMP downward 
in I but pronounced upmr& dlopiscomnt of the MMF In II mAI III# 
c« Ten minute3 later tho com was normal* 4* A heavy luncheon did not affect these curves* 
5* He ms then connected to the cathode ray oceiUogriiph end the 
MS ms observed continuously* Xt woo found that the pronounced 
i;s»T diflg&oeengnt corse and went at frequent intervals while he 
was snoklng, a® if the defective erteiy vioro contracting* relax* 
im> contracting and relaxing* etc* 
m lam xh mmarbsal w&mmm. 
2. The standard leads in anterior infarction T3 typo) 
A* R94! dlaplctmeat* 
X* The M sepait l<s displaced upward In Load I end uauclly dom- 
mrd Us land III# 
£« This lo the first change to occur after Infarction occurs* 
3# It hoc it® origin fsoa the control portion of the infarct. 
4. The Ea-T consort displacement 1® nmml’kr gone after 4-5 days 
feat mety it ney pcrnlrt. The exact moaning of such persistent 
!s;>T orient Is doubtful} it may mean continuing Injury 
with failure for dcmereatlon to occur* It may be possible that 
it indicate® a peer preened** but this Is not at all definite* 
5. The BS-f dloplnccrxsit in I In interior infarction is usually 
1 m» striking thm that in XIX in posterior infarction* 
h* >-MS Oli- -m;Giu 
I* a prominent appears In hood X* 
H# ilia nay actaaUy fen «mU in wm only l-£ m»t 
but its ecnoeiatioa with mmXl i-r/wee in what mafeoe it significant* 
n. A CHmave of the alt© usually aeon would moan nothing alma# 
fe* the pT*!3ant)9 of of some sir.e together with H-wnvecs 
#M are mil* fMRMtly less than 5 ssa*# i® the peculiar 
su”ul Important sign hare# c* Usually $*e*ve* ere mm In those hHS ocs&pX&x&a which show 
% 
largo R-wavoe, m in Ml I in 1aD« auch ty-wwveo or© not 
important In this consideration# 
3# The entire <|B5 cwwfrl** In Lead I is usually awwll# frequently 
no- deflection In It will be larger than 5 m# 
7 
4* Usually prominent S-wevcs will eppoer in heeds II and tit but 
this Is not necessarily true# 
S# Occasionally a ft-abepwd will appear in load X* If it 
does* the vmmtm of It# cm coraplcK appears is Load XIX# 
6# In Q$a changes have their origin fress the control portion of tJsc infarct# 
7# The $MS coqplos: in Lead II nay look like that in I or that in III# 
8# The QBd changes ere the &cre ptmost changes# They ere usually 
a** 
all that reswina ultiiactoly# They ssoy persist for army years# 
0# TM?avo chance© in Anterior Infarction# 
1# Inversion of the T**tavea oocuss In Lead X, in that load which 
originally showed upward HB~T segment dleplecerm^t. 
S* the Inverted ore of a very character!at 1c type* 
a* They arc cherp end T-shaped* 
b* the initial domverfi trace of the $**«** has a shoulder on it# 
This is why they iievo been called cove-piano lam They 
have also boon called "Pardoe" or 
e# The inversion na it develops begins at the end of the 
f"mint end progresses toward the cornier# In Inversion 
of the tar«9 due to digitalis, the inversion batons Irnodi- 
atoly after the ti&»T Junction and proceed* towerd the end 
of the T-’vove* S* The XWmve ehfejrigoe ere peegreeelre reaching their mximl cine 
in 10 days to 3 eet&o* 
4* The fueeve changes usually disappear gradually over the course 
of S«6 rmtha# However, they swy porcist for *sony years 
but o® e rule they became loss iherceterlnilo over the came of timo» 
©• The T«wre chan?*®#* here their origin fm.i the eergiae of the ia> 
feret* They therefore ere not aoct prominent la the 
ee leede in ehieh the QM &m most pwawmflt 
0* Tho Ohra®** seen in VL~~ the loft era 
1« The change* in th® vcrloticmc of this MttveoKy cro 
votf frequently quite characteristic in anterior infcrotlon, 
because Inforcts of' the nnterlor Mvf&ce of the left msntrlclo 
calmly fm® til* left ®si%m This is ©specially true whm the 
isfovot is cm the loft <nt«MNlBteaM& surface* It is loos true 
ttfhea the tnlkset is mm anterior and nearer to the rmptun* 
2« It Is because those etasugee occur In VI. that Load t stave 
the cihereoterlstlc alteration©* 
S# If tlio infarct im oneUL end directly mterlor, near the eeptuft, 
a 4 the eh**ttie8 ere not tftunsBltteft to the left arm, than 
there may he no ebereMrteelfltle change* in the stcnAsrS ludii 
4* She ehevfeoterietle chengon 5n VLare Just ll&o thooo in Lend X, 
newly IMP eeftnaftt citation, appearance of presainmt $<-«efe 
with relatively tmXL Bmmm$ cM ohercctcrietioelly inverted 
tveaweefl# £• atnewna© of Characteristic Choice In Anterior Infarction in the 
Stm&r.rd Load** 
Acuto 
iftooiito (Hoeoct) 
Chronic {oXfi) 
t 
n 
in 
% 
II* The Standard te»da in Posterior Infarction (% % lype)# 
At IM BlisAa&raBt# 
1* flio 2S2MP oaeoant la displaced upmft In load HI and oft cm 
In Le A II v£msmG it Is dinpliiitt tossasmrd In lead X« 
2# She la usually aoa» striking in III In posterior 
infarction tbm it ie In I in anterior IbUbssHm* 
S# $h© diaplocaarat of the aa*ff flOgmot ia the trory earliest 
channo to ooctir; if the patlmt could bo studied ©rj?2y 
It Is that it night bo recorded without 
osac/clotod IPS change## 
4* Iforo too, of course, it It a transient thins and sacy doer 
in 4-0 d^y«« 
B« Ohn$00# 
1* jhjndkMttl appern* in tooda III tm& H« 
a« A psoqtoent in. IH alone is not algnlflcoRi* 
b* A pmolsfmt A-wrro In II nnd 1X1 1© «uch jaoro 
of poaterlor Infarction* E# Haro na in anterior infarction the fymm» which is associated 
with a flBoU. la the saw© significant thing# 
3# freqiKSitly tine ontiro QJBS oodles in Lc*sd HI booomo se&ll, 
often with no deflation larger than 6 on# 
4# Her© too* the tiuspi are the caoro pswnl changes 
aai may ultimately he the only midmoo ranalning# 
C# T—t-TTe Oferfflt *08# 
1# Invar. Ion of the occurs in II and IHf in those lends 
i 
it&Gh originally showed vp&ssd, &S-T fle&taaot displeccoont# , 
a* This is not tofarlobly true since the H3-^e 
mi tsm th« wastrel os®c of the toforct, wheroea the 
T~mrm oojso from the of tho infarct# 
l># Therefore* tb» Stomvoa m& mt ho mat mMmt vtoam the 
sm*W i&spIneeKwnt mm mot 0tfStlog« 
I# The ha*® th© mm ©harootarlsties so tijooo described in 
anterior infarction m regards their shape, the progress of 
their dmreiagssent, md their doration# 
3# fvust as with the BSMP th© changes core fjon 
the eotttvel portion of the Snf&ret and the Spares or© therata* 
not necessarily z&zl characteristically altered in those loads 
whore the vtfdl or® m&t mssfced* 
9, Ohassgeo in ?/r —> the loft leg potontiel# 
1* t&M* pootfjrlcr Infarcts are on tho diaphrogntis mxrfmm eM 
tiweitsro are fnelftg the loft leg* 1L will usually ohm lb© very 
otommeteviatics - the soma variations of the Infsrctmi mm %dth 
ISSNf aapamt atomtlm* iarg® md Inverted luw* 2» It is bocouao % dhows the potential vpjrtaticno of the infarctcd 
none which faces it that leede III md XX rtoi tho characteristics 
' of postforior infarction# 
I* of Characteristic Chonscs is Xcntorior Infz rot im is the 
AMflli Loadsn~ 
Amite (Fresh) 
MNMMit© (Moceot) 
Chronic (oia) 
i 
n 
m 
% 
III. BtafSJOsio frm Blcctwocrtflorsywa Mono—the of ®C 
Gbanron Id whtc& there in n surest ion of Infarction# 
A# The cloctroeexti la&mi Is cnljr eioryioatlc In the cento and subacuto 
ategoof whan both <0ts end f#*w5Vt oihmmmI aw present# 
B# In coder to neke the OiaftmUi of nyccerdlel lafteratlo® fwa the 
r&cmc without knowing about the patient wo mist Isew eitbm* 
1* Both <41 !S mid T#*wvo which arc typical# 
£• Curves in sequence showing the definite progressive character-* 
lotle ohp.tmm of infarction# 
0# The diagnosis mmot be mdo with, certainty fwm the mn alone if 
t or© ir only one of the three possible Datt|Ml| that ie* QMS Changes, 
lisJf mrvwnt aieplceaneots or tt-awre dtao&a* alone# 
D# Whm there ere only Q*wfe* elm© present without ©©©Delated 
titmvm* one can only ©napeot the dieftBcmia* SV# teniae of Anterior Infarction oh&m In the Standard Leads# 
Am Skid® (So© Fig* 1, Heart, Vol* IS, p# 17?, 19 3, fftlaea ot ©!♦) 
1# First m% Of curve© dbcm standard loads In anterior infarction*— 
curve taken on© racosth cftor Infarction end © for hour© before death# 
E# Vtmpo is upward diqplaecnmt of U&& in 1 cad slight upward die* 
platMMtt* la II# la IH there is very little change in th© 
E3-€ sogr«mt# 
3# 4a nearly & ns# in ©ire# Ordinarily It would have no greet 
oignificeno© but her© it 1© assoelatod with m 9*mow* of only 
4 ms* and it in therefor© mch oor© Irjportant# 
4# Thor© 4© beginning Inversion of th© terminal portion of th© 
T*mmo In lord I# 
0# fhio patient had an ooelueioa of th© left anterior descending 
coronary artery end had an anterior Infarct which cactondod 
to th© lateral wall# 
6# (So© oooeod oet of curve© on this slide for contract with 
pootortor infarct©#) 
B# flOLido Gjf> (See fig# St Progrea® of Moctrocardiography*- 
Anooc# hit® Irm» Directors, p# 12, Wilson, 1059#) 
1# Bore arc five of anterior Infarction# 
E# Set A—this mat be e *Mf early infarction b©er*ud© there i© 
©till striking elevation of BMP in I mtI depression of BMP 
la m# 
3# Sot B~~‘this 1© © later ©teg© beemieo no®? the M dcvntion he© cleared# 
4* Sot D—note that the <|B0 In II loots© like the QkS in in, but the 
Sm mom in H ©re inverted m they are in I* 
a# Load XI aay look Ills© I or III In anterior infarction# 
b# flu© %mgnm arc not necoamrlly com in the mm load© oc 
th® QBS ©him'-?©©* ©ft All too© msroa tow prowiaeat ©ad tm*H 8^* 
6ft Bote tot ants A, B and B tow long* SMngves la II to m« 
Oft SUOo 0j4— ( Boo n#ft 5, Bosrtft Vol* IS, p, M# 1WI9 VUUOH ot «&*) 
I, Ito eemrqptloa of satorior iaforetlon with initial Oefleetio© 
of to % t^pOft 
E# In to first sot in m mm® 1© with % of a mu, hut Cij la 4 on*, 
to to toenrwi ©r© tomotorlotio in ton# 
5* first sot—6 rooks after ©onto ottotie* 
aooont oot**3 aonth® after ©onto ©tto«fe« 
third sot— {do not fit mtrros la ortlole in Boto}« 
ihsarth aot—<m« mnth after ©tteMJfcl to Initial oofttrioalor do- 
flections la this toe* or® il^tftsli 
p# ma© (a** n«# e» Soto, voi* is. p# m$ i®, wiiscm ®t «M 
t* ma&Qlatt of anterior iafsrotto—tosr Initial 
Of to % tgrpn» 
E« Btnrt A #61, 51/B y«mrs «tor to ©ttto# 
3* $oeto to—Oeao B KB— E fcsw »ft«r to Isat of tmr ettofea 
of thw^bontB* 
Aft Eblsd sot— Os a© one sooth after to last of to 
nttiiBo of •wwncar too«teOBlo» 
8* foorth to—too 0 MM rxjato after on attack of ©oftoi? tootooto* 
l» mm {mm fig* 9, Cmm 13, ism*, iftiias, MM 
1* toon mwoa wow tton on a ska «o*A to who 4le& 10 hoim 
after to mmt of swto to stew* trptol of mmmw 
obstootim* 223 
E* Curves 4*0* fhslon of initial rmd final 
t$Ml MUtlona with conspicuous* deration of the M? aegaont 
in lead 1 3«d daptoeoim of the JWT cepMttt in Losde XZ and III# 
land X ©te© abort period© of ventrtculer tachycardia. 
5# At po-stDortea, the min steo of the loft mremsy ertory 
tioo found to bo ecepletefy occluded mnv it© mmVb W «a 
ontoohx& apparently derived fraa a perietal IMtoi la the 
loft auricle* ttma& ws e very largo, fresh Infcstt involving 
the entarior e?sd lateral mil of the loft ventricle end the 
anterior portion© of the laiemeiriaale* ooptua. 
t» Slide ft *— (see W#* 68, Ole. of Owe. Art- * C»*«leo ?nla 
levy, Ctep 12, p, 309, W!looo) 
1* aerioc of mmm in. 8 cueea which ©how the changes of the 
Mad encountered oheo the ontcrlor end left lateral walls 
of the heart hove hem infercted# 
$* vontriculor deflection® of the oortiinoa 
«lth upward H3«d? dioplaecaont la I end dorniemrd 8M die* 
4 pleOGBoat la XX md 111* 
3# tores B, C, *,®d 0 ore % type* 
4* tovso B mA f chow Initial deflection© of the typo hot 
the f*wes have receded to the point where they ore no longer 
distinctive* In Jft the QBS interval te sUntHy Increased, 
X# V# htosfe* 
3* Curve 0 ©hen* final deflection© of the type hut the Initial 
donation© ere not ehaomOU 
6* tore E indicate* that B* B, Bl* is preedit hut the fom of tho 
ventricular doflocticm© In Ued t aagrtoote ereecrlal Infarction? 
e large anterior Infarct woo found postHaortcfi* ?♦ IterpXco of ItMSftorlo? Ifcffcretioa a® stem la the Stsadsjra Load*. 
A# m&Sft %-x (3eo Ml IS? 179, 1033, Oooe B, ftULmi @t dl# Pig* 1). 
3U Oooe B—soooek5 set—thin eowe wo tavern 30 toiro ofti* the 
moot of m ettnefe ot momxy throrafcoolo m& Ui hom*a boforc 
dooth# autopsy showed MfegoHo* of the poirt rior nsd lateral 
*mXI of tbo loft veatrielo end oociunlon of the olreunflflK 
tMagh of the loft oorautty artery. 
9# Tbeoo OWWNMi she® lapsmra SSMf dtoplaimnTl la II e»d III aad 
of fHNf la I# 
3# ftew* saw* leasm QHBi wove© la II end IH. 
4* f3» %*m7m ore tororted la II end 111 oaO tbo towsloB ic 
Of tfm pomliwt kiM otoflag o steep, V*rihepo6 lOToroloa with 
0 t&onldor loot oo the tveoe tariae to deaoaad. 
B« aiide Ck* {3#o Pwarsrm® of B &, Aoeoo* Xna* l&reotorc, X930f p* 15 
Fig# 3|. fe iXoon at eX*0# 
1# tSusam tm of eum® of tfm % fg typo, dteiaootie 
of Ix&mtloa of the pooterlo* well of tfee IimvI# 
B# 0*ao AhIm qpMrtl dioptaomst of SS-® aopmt la II oaS III 
oaS 6c&*o*ete la I* daws ore peotstomt t la & wA III# 
la oft oa*Iy, frosh boooooe of the pvoemm of ms 
E;>T fim mrv mrlimH mam wM ohow SB-® 
without Qm oht'tmm* 
3* Coat Mm *m mMmm of &3*f fttqAooeaaat feei* pswotiioll? 
olosrod* fm Curves ere tnvorloft la those load® tdtere 
wo® pvmmt la Omm A* This la not 
the mm hmmm the BOt diaplneenoat ban its origin In the 
of tha lafvret* thnsoan the luOMCfO thnngei erla© f*o» 
the nanglMl of the iafarot* Thu© the any bo r»et 
erl'Jnttt .in other lm$m then thee® stating the met ©tricing 
IfiWf tl^Xaocr*mt, 6# SLL& %| continued# 
4# Cm® S**to tbere Is no m*% dipla—n«M st all# 
3# Onm mm in mm mm tometoriotle then cose C* 
beoaneo tom tlmm $m Imin $•# rravm in H and XIX to 
m Ut*mvm at ell* 
0# SUuO %« (tort Ui 389* 1933, YUm ©t al 
Ft#* U) 
X# Ogpro* tofcro and after posterior Inferetioav-oSsereetorletle 
of S3 tQfpo* 
i* Qw*m 3 yens* beftave the ottols $mm very tiny 
i4to»0» in. XXX to upright T*rnmm In HI# 
3# dean# Button B mntm after on attack of coronary ttorfcoslc, 
atom lem® &mmm in XX, lore® notched «*-6 wows In XXX 
to l»*C0te6 ftmNM Is XI to XXX# 
0# mm q%$ mm* Mi m$ vm, *it&m ©t *u nm 
at# Ousfcoc before to after posterior inf oration* 
2# Ml 188SBMfceiw Dec# K* 1931, etort sso <to*vee is 
31 to 231 suet flat v*menm in HI# 
0* Om %&WB* Jan* 38* 1938, atom lorso a*o©ve» 
is XX to, XXX oith etoMterteftS* tomrtedi f*om*»# 
4# ISds patient m a mm eto &4* to to typleal en#lm 
poctorio and tolellthifisie# A won inn^oisto 
on Deo* 39* 1932 to when h© t&oe eant beak to tho toicel 
service be one frao of both oocrleiate# 
a# Xt ntto tom tom mU that tot wan Istexpwtetod m 
engitte wo© estMlIy gall bladder dimmm* h# Tim &a3bmr&mt iMlcetod that h& bad 
Ml a pootarior syaoaf&tal laf&stttlaa 00 thot the die©* 
»o©is or ema«*v artexy dieese© le time *snfllM&# 
0# Xt wn© imooalblo to m& %ton the tafhretittl hsd oooomrt 
heoraiao ho hod so ©pvtM ©egg**ting it m& th© eh&rt 
i' * 
tfyym& m ohm-to© in th» clinlord couroe whloh would 
iadioot® it# 
a# It any hare boon tiiet tho mon&r? t&ro*o*lc to atari 
"curoa the ©figtan pectoris**, tbo sucolc 
teriag aiM# :to© inaiwiteii® tors oesiim before 
♦ 
iirf&rotlca, ooci® tore It oltcmrl| sea* haw* it both 
before ana alter, because, poosiblar, tho eoqplisialitg 
artcry 1® not the one to beeone occluded* 3oes© tore 
it neither before nor ofterwasdo* 
Mm 3U0o UHo* of Cos?* Art., Levy, Chap* la p* 306, Wllaoxi* 
We, m m* m* 
3U JShle m&im of 3 eloclapeooraiogrM* la ttt mb patient 
$£m* the umvXwmmt of tho eharocteriiitic eto^^e© 
la the final wootrioulor tatfUotioa ffcltodis& 
coronary occlualoa with Infarction of the 43tapltfa0ag%io mAI 
Of til© boast# 
a# At 19 dtgplaoMat «psv$ ha XX mi ixx 
rM lemma* in X# 
3# At 5 &&©—>ftMF aiecaLeMracat ha© now nmv%& ©leered and 
fNw©*©© are b©MRl©g inverted# 
4# At 35 w4tt**wsmm tom m rwtetol their aostanei invemiea 
end the JUMP he© Cleared* Thom ©t® tmm 
&*mmn in IX ml XIX# 227 
$« ©dta fctt&nt o r*mm mm$ as# who hod olasmio 
,aoplsrl%la* Hio Mte’ciica oogurrot vbilo tm m* la tb» 
leXMag yototiay he yotsnmod ham hat © short 
tt*» later rotupnod In aamm non ’©stive folltir# fsos vMeh 
bo did not procure** At pootEortom tho*# w.s © nee* 
la tbo posterior left *s®t*tdl*9 the pailerlo* vftfM voatrici# 
aod the posterior half of the sonfenu 
*« siM# m*? m?* ***** tovy, o*8>« xe§ p* sis, *n«m 
m 
I* S&ts series of cutvoo «m oo a ana, r?r*o<$ M, «gf» 
dr/olopod typioal ftpqptani of cowwiy occlusion oa 
hm& xm# 
E« Owm 14063—-taSam 18 hou«e after OMlv etsoe® IM fttamtioft 
la IX ®ss€ III iMH 4«IWIi ih II «ttft III an£ iat# 
3# Qarm 4 d*ys oftoy Oftoet* M OQMplet* 
a# Moos:# 
4, Curve UMMatm IS 4«pa after &wot9 cOaenre return of 
mmml fStrti* with #«a Mtorval 0#S0 aee# 
5# ©so QES m& &4R8V* oheagoo la this oopI#« »*o typlonX of 
pootaffior Mw^s« 
I# Omot oftor *900**3 lei tahem tm^mlmt 
partial honrt blotf:9 ooapXate heart block9 
tetvoTontsl&ila* bXoel:t op boMi© UoSr* llgfeurcatol* 
oaXoP block ia psartimXap lo opt to mm» foXtotag 
pootaiteP laffiPOtlocu 0* Hide (lla« Oor* Art*, iwy Ghnpt* 13, p« 30?» Fin 60) 
3.# fhom os’© tho aerial alaeftgoeefdlaiifii, e on & mu «ha bad e 
spHterdlal Infarct on at the a@a of 50 end «itao> lived fw® 
3W8 
f» toes 5X0, Doc# 08, HH, eorvee toifon S e«&® after 
typical attaefe of aomexy ocolneion* Oa&rm ©re cheractoaplo- 
tie of posterior infarction* 
3# Oorreo 9338, Oct* HI, 1939, the chaaeaa in tfeo via eoapleaceo 
two pemisted tat the $*asva ehsnrce two nc*? dtaappmred 
end fie ore now rxn&ol* 
4* Ousvcg 10549, march 3?, 1903, tlx? $8S ohoftpa are ©till proaoot, 
though fiosKWstint notified by the devolopnent of a olirbt Satoo* 
ventricular conduction defeat, m0m years after tho OHronasy 
accident* 
I* fie patient died m ftesefc 81, 1933 fMi easdiae failure and wmda* 
6* ©aooo dwrea dectoaetseito that the torsos induced by riyooasdiol 
iofferottea. in the initial ventricular deflection® ore usually 
pomfmmt and them in&icod la the final dafleotleoe or© 
troutalt* Vhte also dwe hoe It rA'iht bo po«rf%li for tbo 
ohnshto to ea old laforot to be caMxno& nlth EM* die* 
plaoemit or etamnl T*defloetlmo to to a recent infarct, 
thereby giving idea to very ooqpllcatad aloatimavdiogiane* 
a# $Li&& (i>ic* mr* jypt#, levy, chop* la, p* 304, lin* 64) 
I# Tmm mmm mm tehee m n xx&*>n9 63, who had m&im 
poctosto end arterial byjxneteaeloa (8*1* SOO/l&Ol* 229 
E* (tore a* te&fflR Ott tkom «Nm *#*y aoftetion© 
with EM lloplaoeawst of tb© pc«sir!JH«it tyy© in Xmdta I mi 
III* £m& IW ilmlae<«M»st io likely to bo omooi&toi with 
um emytomme whloh two p 3l oroo# The iimlmrnoot 1© 
opposite in Stesetloa to the img© Q$s ©too* than bos*© in 
Xoni I* Mi in « las*?© peo&Btwr o»o® mi tho WMP 
i&s$laommt ia ten* 
5« Mi B* t&km m IMMM» %hn mm® mm $mm l&rm 
in III with mmH U*mmm bat In the ahooooo of in II* 
them <wn» not m ol^llftent* 
4# Oosve 0~-tfeie mm too tfsfem on U*IK%| about 10 imtm 
after the meet of fatal mmttmy oeeXostau there ms aro 
Pixsatemt in hot& II oad III m& m*y eMfelag BteJMB 
in XX and XXX aM dcmmmt in X* fhaoo 
Qiwoe mm dtemstie of poatete aymN»*il©l tearotte* 
B* Bore me mi mm the ©Mot of the pmwmeoi left taxi* 
dos? latte BMMBt upon the form of the <nis &mm 
Miming tB» mmmem aooteat* 
J* aiMo (ma* op# .Art* IBi 3X7, BS@ 79) 
1* flmm mi ?«o tmm m © mm 4S* 
th Oaxvo A titon In X«sm* 19ES poftet me nmgtieiMim of 
attain of pa.in fey ayapm-o# tev© t© 
not definitely ol«M©l# 
S# Com B t-olrm cm Bob* 4* Itftt* On Oot «t IB8B h© Bod Bove&opoA 
oorebjml ttescfcooio Miami by M* % 198® 
im dmtagKril typiuel of eoycmosy amliurfM* This 
ct33wo titeoa two iayo latavf ctoio otacio© eOojmetoriolto 
of posterior Infastttion* 4* Owe*® ot tefena Hot# $„ 1089* loft bundlo twmh block la 
mm pmamt* but cmM bo ebollahod by alotdnc? 
%im hm#% vat** Ctai B* B# B3U im oiao MIM for tins 
opcfti of a ala&lt boost cycle ?sa «tttvafir«tol$ oocrmmkhI* 
and «*• foltoiod by a lint pom** Vtoi the 0« B* BX* tma not 
p»«t| clwrfoteriotio mad wo*e odc® 
la HI* ftsooe oim® of infoTOtloa wof* obnaaroft nblle Um 
block mn pmmmt by tfm ohnmm 4a the yrntriculai* 
iadaeod by it* 
E* Slid© %£ (Levy, Dia# 002?* Afft/ 28* p* Wt fl&* 90* $ 
1* ISktot ouvyoa inm* tM m 0 mm $6 yoaac* of vte doimlopoi 
<$a#toao tfptoal of teMiasqr ooeMn on ia*»&MS$« 
a* Curve jMfe&aii m iP~6*&&~~etto 0M3M of 
posterior tefosotim* 
0* auwo Mtoftwi m MMH| too ooourmw*? of 
tpsoataeft tatsmymtrlouto block# 
1 
4* Ourve Cv tfcteea I8m6M8» look© iNSfy mcli Xfeo mr*v0 & and 
show© ola$£MKSt *r44<saoo of poatorlor ittftotiitlQft* 
$* It mi Ixt mb tbot M tfe* latresflroBtrloalor IJM «m« 
the la tbe Mils me&mm la II #a*ft III due to to* 
tm&tim wem 
6* timrnmt tha m% mm of tt» ®tm.tmml Initial imtWi&s&m 
doflootioao ladtaeod W the PIimAe «&a oe»U lari all Xooda end 
the pmmmmtt in the Immmni totecM tgr tlio infeaso* 
tioa mmIoM tob $mtm popiad ot block* fX« temploo of otto inatftBOoo of %ocnsp&I«X Mtanfttlen in tool* tho 
Stwadora Xoodo «?oro to distinctly* 
A* aiMO (XOVft Bio* CkWP* Alt* 'Otap IB, p. 3Uf fie* w) 
X* fhoo* tms woaeo cm © Cfit who hod wre?9 
ptooric and had on attack of ooramvy tomfools 
ttew after oatolnc tho tor>4taX* 
s* Oto# A Mflktftoftm daft bairn t a infarct i<m 1© 
mm®t for Iwertad tews Is IX end XIX# 
0* Ousw B EMiMwa tdHBI os. tho dap tho nlcht 
““'i 
teing tooh th* coronary sooitet occurred* too mm 
t$'m:m thut Ml fp*ad© hlocfe hao dotclopod* 
4* Ousv© 0 006fi—■Meoii 8 to© aftw tho attadh ohm*o ©oraploto 
htot hXtxsfe* 
5* Ctevt? B M and B AMf tswi tafean 8 emd B days after tho 
attach* Both thooo oome show mill hisaiw mwfcmm 
with ptmemanA iwtohlltty in iho fora of tbs tmtrkruiof 
Ttoo ©to of tho typo aHrihotod to ©xtorlaotloo 
hlocfe* 
8* tile pattest Bovolopod attach* ©ad in mo of 
the* tho patiant died* 
?♦ At afotcpcr tfceso moo motva toforotioa of the anterior wall 
of tho loft vtorlftlo m& tho anterior half of the tmtelwte 
septe% 
B* OUm %e |Boa*t« VOX* 181 P* 19% 1933* fill* SB* ®Umm ot dU) 
X# ML© iM| «flid 64* hod WpMPtmnim for mny «od 
tmA mSfomA t&m ttoUtavo off sM ob the 
$swioftl»B yoar# S* Curve A te&css Dec* 3£, 1029 ©tmvft alight left ©acts delicticm, 
rather prosiinoat i&mmm in XXX end alirhtly inverted la 
X ma tU 
3* On 10«S5«3a be hail s typical attack of eoxonasy tMes^oeie* 
4* &&90 te&<m mo day after the attack, 1CK-3-30* It 
dbam metotme&p mmXL deflections with bl»«aw© :*$£ ootplessoo 
la all Xa-sla* 
5* £he petleat died andflealy 3 day© after the scute ettoch* At 
©Qtopqy there ws a lore© l&atarat iamtvtag the anterior nail 
of tlx left mtridft ami tbs anterior iialf cf tho veMoaht 
attain# The eaterlar descend branch of the loft coronary 
artery was ccnplo cly occluded by a recent tbraabus. 
c* nude am (Heart, vco* iet *. i9?t me** si®. ss, - tiara ©t oi.j 
X# Curve £©03 -4 - tskao Deo* 19EC# @t which tlm patient wbb 
4& i?mpn. oM m& bod uso evidooc© of o«a?ai«a 
2* Curve 9S40-C- Mm co Oct* 9, 198f a few #-*** tos after 
oRoot of typicel attceis of oorosaiy occlunioa* This curve 
a&Owc castll QBS deflections in sU leads with la 
t.lx laohrs* 
3* 0mm VaOMfc* MMt Oct* 192.6, ©t ufctieri tlzm the pettcot bail 
tesia to of ssIM eafestesmsl poin oe cseortioa* 
4* Curve 930CW5-* tide msa I wo<& eftcr the ceaet ax tho 
sited: tail, ttoam ts£k&& c&aagM t*oa the jwvicuii oanres 
to mr&ed ©basgae 3b X* V* conduction* 
5* g&o pottos* <3led of connective failure on Dec. 4# 198f but no 
autopsy nos obtained* 
6* iUm th© efoengaai la tho £EJeS beacon fife mch sc to «*£» that 
©exsXI m& btaarre* The Infarct taro mm mat psetonfaly anterior 
m location but em msmto aer m tvm tfee cXaetrocord lags&a* VII# of Jaatettata tafUnstlag Acute Myocardial Infarction* 
A. aisdo — (Heart* f6U 3t p. 71. IS8i* l%# X 
and Hobtaacail 
A doe espcrlnoot acrolopaesst after left 
antteHos* oorateiey artery ligation# 
lm ftgmI sot of onrvea star sorrel nytba before avtcay was olmyod* 
8* Ifepcar strip in &&etmA worn stars e sinsI* istwstold of 
TOBtrlaalar 
3* Second atrip onset of ventricular tidmib* 
4* Thttl strip atawi p&r&B&tml rmtrimltat tachycardia nith 
alternation of tho acaptam* 
3# Fourth strip pnrosycrrsl nfttrlwigr flbrillotim, 
4B MmU*& after me clasped# 
&• This mef tepen is axy patlcot t?bo suffers m mm%m infection 
and Is foot my be the tosnSncl went is asagr *£» die and- 
donly ooon after having bod as aonta corosasy teBfeoala» 
B. %3 ttafl MUB3* Fig 0t illaon et «!•) 
X* Itefe A tdm tooae days before death aod ebout two souths 
after tbs onset of typioel BjMUtmm of coroner? tbroafeosls* 
fboas curves are not of lafai'Ction, although 
the - S3 coalesces in M I aro w*y mil oM bterro nod the®* 
are prontaeot In U end IHt theroby snegestlng 
anterior infarction to acoo eetfcost* 
£• SiOTe B tdkMi om day before death aims os attack of 
mntricwlar tadyanrsSla# Definite npdb 
tlso other Mdiet'lfins oal et © ato?er rata c?.m be m$» out* 
therdy ostobMsIsirc tbo dle^sool«• 234 
3# The pet lent ms e ms. aged 44 years* Autopsy showed the 
anterior defend lag branch of the left coronary artery to be 
coaapletely occluded In its upper portion by m organised 
thzoo&us* The infarct involved the anterior and lateral sell 
of the left ventricle and the sstresas apex of the loft ventricle* 
The pericardium ms «ih«mt over the infarcted area* Both 
ventricles centsinod partially organised parietal throssbus 
attached to the endocardial surfaces of the heart Infarct* 
0* Slides end (Heart 8: 71, 1SS1, Herraana and BobInnon, Case !•) 
1* Slide ihows the standard leads about IS hours eftor m on- 
set of typical acute coronary throc&osls with acute pnlrttnnxy 
sdsns* Loed 1 shows the typical as-flf 
09*8*6 and early T«mve Inversion. Actually the patient 
entered the hospital with tachycardia which iMUS end this 
curve mm takes after it subsided* 
£t# 31 id© °47 stems carves te&ec during the pmoaysa of ventricu- 
lar fechyeardle which rase present on s&stssion* After it sub- 
sided spontaneously, curves were t#rca* Then about S4 hro* 
after his admission the tachycardia returned sod patient died* 
5* At mtopm heart bed as uaosnsl shape# because there was 
a definite forward bul|*o In the hx! r pert of the left rontrletiXor 
trail, which sreo hod s dull grayish color* This part of the isyo- 
cardium wee that supplied by the anterior dea-ending branch of 
the left corollary artssy* This weasel me found to be coispletely 
occluded by s fresh throrfeus ecasneeclng at n point 1*5 cm* fron 
the origin of the vessel and extending S csss* along the lueas* 
Tim wall of the weasel woe such thickened and a Epical syphilitic 
lesion was present.* 
4* The gosaae in the mil of the artery lied apparently mmsasmA 
it and the throflARia had forsasd at the narrowwd point* 235 
0* Sltdo (His* Of* Cor* Art*f levy* P* 321# tfig* 83, Wilson) 
1* Curve A taken 30 hours after the onset of syriptons typical of 
coronary occlusion in a mm aged 77 years, shotting emrlc* fibril* 
2« Curve B token 4 days after th© attack, shoring somni rhythsu 
3* deoh curieuler fibrillation ©t the onset of eoremasy 
t rtfflhosi© is oamm* 
4m It ees be seen here that the arrhythmic in this instance did 
jiot o baeuro the changes Is tfe© iU© cornier©© re salting fror* the 
infarctIon—because the curves during end efter fibrillation are 
© seat Icily the saa«* 
5* the changes hers sr© sherecteriatlc of posterior Infarction* 
IX* Feroasysail Ventricular toe&pcm&ie la lyocarlai Inf option* 
A* It is an ©aaxgoaoy ami in anise! experiaeat® it has been eJmrn to 
often toadlately precode ventricular fibrillation* 
B* It 1© also aerloua baeetis© of tm additional strain which tho 
tachycardia places upon th© injured heart* 
€U Qniaidlae in doses mfficlont to step the tochyoaidln rmiat by 
given if It hss to be given intravenously* 
I* Changes in the atenftard leads oaieh aey b© with those due- 
to Infarction. See slid© (Levy, Chap* p* 308, Fig* 70, dllocn) 
4* C&engea due to digitalis* 
I* Curve A-~b«for© digitalis 
S* Carve B—®ft©r ls«ge doses of digital!.a* 
a* Hote the Inversion of the $*43gv«s is II ©ad III and the 
depression of the U5-C aegeent is X* 
fe* Hot© that the inversion of the begins ircsod lately 
after the s-t4 jtmctim* S# Curve C—before digitalis* 
4# Curve B— after large doses of digitalis# 
a# JioK» that now there is definite downward dlaplscamnt of 
the as-f salient in cH leads without conspicuous dis- 
placement of the H3-CP iunctto# 
b# Ttm part dressed Is that toed lately after to H3-f Junction# 
c* Bote tot to terminal port 1cm of to T-mve in 1 end II 
la still upright* 
B* Changes du© to i'erloorditie—Curves £• 
1# this patient had © pericarditis with effusion; the exudate 
ms purulent, 
2# Ber© there is displacement in beads I sad II# 
e# fhio is very stellar to tot seat* in infarction# 
b* Eafnretlon end pericarditis cannot be differentiated 
on to basis of IMP displacement clone# 
3# ' fliers are no changes in to Q8B conplcxxos tee# die- 
plaoessoBt together with the QBS etews swat b© due to infarction# 
4# Such HS-f as this may be follomd by Inversion 
of the f-wrea* 
5# Usually the H3-f is concordant, 
o# It is In ell leads or In I end II# 
b# It is usually displaced in the rore direction in all leads 
or in at least to of theta# 
S# fhe HS-f digplacesieat is presusmbly doe to injury of the 
opioardlai surface by the Isfletssatofy process* ?♦ Occ; oionclly e layoeerdlol infarction my bo complicated 
by pericarditis* 
a, An isolated pericarditis would not confuse the oloetro- 
enrdiorTrophie picture because its effect is to dlepXecs 
the HS-f BG&mzt In the ssr<e direction iw the Infsrctcd 
msolo does* 
b, A diffuse pericarditis might confuse the c&sctrocsrfllographiS 
picture by resulting is concordant HS~T dioploccrscnt in ell 
leads--such as is sot mm In scut© infarction where the die- 
pleMWWBBt tends to be discordant* 
£U Causes of Sodden Death In Infarction* 
A* toping tho flrtst ten d«yo after infarction my 
bo due tos- 
lm Embolism from tho intrsvontrlculor ttaMfeus* 
&• Cardiac rupture end taapoiadft* 
3« Suddat onset of ventricular fibrillation* 
B* After the first tm dfsys ishm sadden doeth oeerrs it Is always 
her?! to soy just vbst happened* It is unlikely that It is duo 
to or.-bollem, or to cardiac rupture. W iiabs bi wswj&amm* 
I* Xhe Iksimzl Procordial Leads—3eo slide B^g* 
A* It c«a he ©eon that aorraally the B>waves free? laspr as os© goes 
from right tc left over the preoerdttsa* 
X* rfhas the H-c&ves sre snail or absent la Yj bat eppeer la % 
and Ys and reach their matimm Haight in V4 or T^# usually 
henriag mi B-wre which is aoiaowhct smller than t ct in Y4 or 
B« Bottanlly the grossr mullet? ss one r?oes fro® the right to 
the left pmc&tftixmm 
0* Hormlly there ere no la Yg to Yg which ©re of w& sig- 
nificant sis© is relation to the slae of the 
StoRlSy tlagr arc elsaost never lessor than 3 as* 
1* There my bo a largo Q«©rgfc la if there la no initial 
tiny upemrd deflectlaa* 
0* Tho fkesmo nay bo inverted la but aorraally they arc upright 
to T£ to V 
IX* fho General of the Changes la the Frooordlsl Leads is 
pfoear&lcl Infarction* 
Am Ghragos Is the S94 3egs»at* 
X* Bpsard fiflMf dlsplaeoiacnt occurs is the prccordicl leads 1b 
exterior infarction* 
s* It Is ft central effect ©ad therefore Is likely to ho 
mot mrfeefi In those leads which ahosr or wiH loots’ the 
mot striking QilS chonges* b* lust os In the atendard teds, it is m very transient 
manifestation of eeut© injury and Indicates a fresh Infarct* 
c* Th& load® nrhieh shoe? end the maabor of 
lof’ds ehe©isag it will depend to m large ccctont epos* tbo 
sis© and tent ion of the infarct* 
2* Boeasmrd M fltepT Hfiernnmt often occurs la the preeordtel teds 
in posterior infarction in the veiy early It is n 
temporary thing* ‘fhic, i© the only period. when procor*" ici teds 
ere of help ordinarily in posterior infarction* 
B* In tho QB8 Ooraplcses ia anterior laforeviou 
I* fbe dwwwes ImM of gmwiifriB leader an the t&Qttanda Is 
£* 4/iK> ieaas will show? only Q3 m 
Xaxgft 
or 
3* TS» tede which show the ohongee will depend os the ste sad 
Xocfit ion of the infarct* 
o* If the infarct is very largo, the epical change© Mgr 
he soen In fill the precordisl teds from to V^* 
b* If the infarct Is esaoll the e&ee&e© tss& be in only one of 
the teds* such os ¥3 or ¥4, or in only tao of the leads 
such as ¥g and ¥3, % attd ¥^t ¥4 and ¥3 or ¥3 end ¥g* 
c. Chawoea ere usually not soon In ¥3 micas the infarct 
©stands or la located quit© far laterally* 240 
4* In B&ey cases the preeordiel leads show choices characteristic 
of infarction when the standard leads do not* this fact is 
directly rotated to the question of the position of the 
Infarct sad the procordis! leads which show the character* 
idle changes* 
g* intorior infarcts ore cemoaly located soweehat laterally 
so that they fee© the left cm* Thus Vx. trill shoe? the 
chr-rrcteristie changes as will teed 1* In such canes* 
T^# sad aorsottos sto? the choree t eristic changes* 
b# If tower, the infarction la located nearer to the scgHtasa 
and is quit© anterior in position* it asy sot face the loft 
sra st ell and nsd Lead I will fall to ste? the chuaa* 
terlstic change* la snob cases, T£# and V4. will 
usually sto? the erldeacos of infarction* 
o* Tims tho sis® of the infarct does not determine whether 
or not the standard leads will after It bet rather its 
position Is the determining factor* 
5* Occasionally the procordial leads will stor W~&mpe& cotp tocos# 
0* Ifhose occur wftsre the infarct is SE&sndoscrd 1-1 in location 
with Itfisr sc sol® on the outside of the infarct* 
b* Stoeh fflean that there met be sosse islands or 
strands of mode between the weetricuta* cavity 
end the surface* 241 
The ch#mces arc due tc death of the heart cuscle# 
a* The preoordlcl loads show eho&gos when the ©lectrodo is 
over the infsreted erec because at such tto one Is 
leading fro® the cevlty# 
b« The lnrga represent the potential variations 
of the loft vostrlcular cavity boia$ transmitted through 
tli® deed motile which does sot produce electromotive 
force of its cm; these potential vsr tot ions ere trees- 
Bitted to those ports of the body vr&ieh are adjacent to 
the infaretod region# 
C# Gtom&m in T-ewvos in PrecorSisl heeds# 
1# Th© T*iwe ehaaees ore duo to sorsc disturbouc© in the order 
of recovery in those regions et the sargiss of the iafaxet 
whore the stisolo is mt deed but uhoee integrity has been 
interfered with by the circulatory disturbance* 
2# Those ehmvm in the TMam* are usually tosgorrjqr and olear 
in tire# 
a* In dote they are very transient lusting only 1-2 days# 
b# In rwa they progress for tern a eye to three wsofcs and oftm 
do mt raech their height for SW5 ac&tba* They aey eoo- 
p lately diaepnoer after a fee saeaths or they any persist 
for years* 
e# If the $*«mve*9 do per-; let for a long period of tlm, they 
beoone aoro end rsore non~deccript and not nearly so olierso** 
teristio# 
d* Bo eyaehd significance can bo attached to the ret© at 
*??hieh the %mm ohsages disappear or return to normal* 3. Heesllar the as ere preeettt it? those loads tee 
the tfJRB sro present Iwt since they cone from differ- 
ant yrrts of t e heart* tho tee my bo dleeoeifiteft* thet is* 
the CH*£V*e any be m&xtoml in Mi free one pi«ee whereas 
the SMsotto* aay be smsim! in other loede, 
4* Xbo %mmo changes neel3y cactend over s eider area then the 
'&mxvm9 tlvst is* ere present in aore leads tha» tbs %ES 
Chal^vOfW 
0* In order is Mfce e 4tsg**$ele of infarction ftces the proeowSial 
leadt* rjjone without kneeing anything -bout the patient, one 
gii vt Isms 
(1) Cfesxeeteeriwtte ebeages* 
Cherscterlstle SMewee ebstep&e* 
-either sloe* is net scfflelest to perm It the 
diAntosls free the oleeiroesraiograiB clone* 
1« Occasionally enrvoe la sequence a&oriag progressive ebasgee 
rsBjr pewit the diartaoeie fross only ehsnses or T-we ebongos* 
£* Occasionally curves storing gbs change* or f-were changes 
of characteristic fore* if taken together with the dlslcol 
history and finding** will s©ka possible a diagnosis or 
loud support to a dialed diagnosis* £43 
HI* of the Proeortllal loadc in Anterior lafnrctioa* 
A* Slid© Bjny— (Cyclop* Mod*# Bsrle, p# 0S7, Fig* 17 from BSC, Villoon) 
X* Cases A and B« 
a* Tnero er© lar.0© Q.B imns& in all load© fron Yg to V5 tael* 
b* Thor© is psoummcod upward HSU® aergsmt displacement in 
©11 lend© fro® Yg to T5 indicating that these ere cases 
of faeoob infarct Ion# 
c* In Gsse B, the taversiOBt of the $4*m* I© tigfmtnc to 
appear* 
d« fact that tho ebonies arc present in so aeaqr of the 
precordial lead© indicate© that these infarcts aro large* 
2m Gam Gm 
a* In this case the changes ©re present la characteristic 
fsoxsa la tbo qua eoEplexos in Ys a»d?4. wbcroeo the 
T*mmm nr© torertod la Ygf V*4 end T§« 
b* Because the changes arc aberacterist Ic is t«o s£ 
the lamia m ecjr that twi the Infereted are# is 
sml leaf# 
c* It is noted hero that the are altered in & 
larger ms&toaf of tl*e iced© than ©re the QH3 co^pleaees© 
3* Cano *)* 
a* Hero the nearer do disappear oraplataly c£ the 
electrode is md across the- chest* the B-wrea 
do not grow larger n» asm goon from to as is 
mmaH& the cm so* 
b« The $*«m iavorcloa ta this mm in quite charcctacrlotic* 844 
4* Case B* 
e# There Is pronounced toward H3-T aagsaot displacement in 
all the procardia! lends hero, especially V2 and 
b# Those chan toe or© very suggestive of racest, fresh 
posterior infarction# 
c. this Is the only period tihen procordlsl lends uso helpful 
In posterior infarction, that is, during the phase whoa 
H3-T depression Is present# It Is usually of only e foe 
’ 
hours to a few days in durst ion# 
B* glide %7# 
1# Curve of 8-7-34—slight LAB with nmnal Bot 
definitely ebmrml# 
2# Curves of 4-20-40# 
a# la. the standard lesds the tUnwres are flatter in I end H# 
while In III they are flat vSmnmmi they were previously 
inverted# 
b* la the procord iol Leeds there ere only %*mim changes 
present in ell loads free Tg to There ere no e!.jeroo- 
teristic Q88 chassis# 
{!) Frwa tho T-*3nvo ehango© alone one could not make the 
dlapyUi of infarction in this oos© although it night 
be strongly suspected# 
(2) Ikm&cr, la this ooae the patient had the classical 
and the T-*??ivo changes appeared at tho 
espocted tine# 3* Stores Of 0-1:3-40 
s* Those precordial Ms sto? slight $-wafe inverion in 
v and Vrr but it is such loss ehomcterictlc* 
t 
b* The Ismh tore stem s tendency to return to the 
wore nossaal fona* 
c* There are so QES changes* 
4« Garros of 18-13-40* 
a* The standard loads look essentially life© those of 4-25-40* 
b* The procord I©1 leads or© mm quit© norml In eppeamneof 
©IX alt orations having dlosppoared* 
c* Tims the ©ear of this Infarction iitell enough to 
escape the electrocard iogrm altogether* 
5# As a rule, oases Mb only shonr changes do not tor© 
serious syocGidial damage end the pat leasts got along quit© 
satisfactorily* 
C* Slide %$• 
1* Curves cm 5-21-30 taken two hours after the onset of 
a* Standard leads 306X4 ©to? no definite changes Indicative 
of infarction ©Except that the %S8 complex I is smll* 
b* Chest lead© 30615 show striking npsmrd ®S-T segment 
displeoeirient in ?2# end % but no QHS changes* 
2* Caries cm 5-E4-38* 
a* There era aavr no &mmm in lg 0T % the E-*ctqs In 
T4 hay© bocooe mch assaller* 
b* The H3-T is still present but is less naifeod* 
c* The T**mm ere beccssiag invert ad in Vn# y3f y, y £46 
3m ©SOTOS m &-S-88* 
a* 1&© QE3 changes eon still be seen bat aorr there mm tingr 
B-wsveo In Vgf aM T4* 
b* fteo are nos? quite ©herply inserted in ?$, VT4 end Vg« 
«• There is atill alight 83M? displac^mst* 
4* Curve® on &-10-39* 
a* The lMw*«e as?© atonal* 
b. Ttm only abiwmlitlfip ate In the Qgs oamlamB* 
W we 1bsb» OS iwros to VB snfl Ts aafl mU 
notebod Iteaanroo is T4* 
(S) These tepi alone without oeeaqpeispin# T«»ie©e change© 
ere not enough to sr&e possible the dlarsoolif of 
infarction fran th© elocrKeoeardl grsss alone* 
(3) Such changes is the $R8 coaplsaos najr occur Is 
loft hypertrophy* 
(4) la addition. Is ibis ease, there are so &*wmoe Is 
% either* If there were as fi-weve la oM It 
disappeared Is Tg and T^# fie would then hesm mam 
sellable inform! i<m aoggestive of infarction* 
5* At m tim did the SpS coelome change is ¥*, or %* 
a* la pat last whose procordlal leads shour so change* is 
¥c or lead I &mm no atsagcn because the Infarct ic 
sot facing the loft cm* 
b* This »mbs that the Infarct one located mi the septal aid© of 
the 1 ft vantrm© su«S is each ooees the standard Mh do not 
permit the diagnosis* 
e* If wo were dealing with os infarct of the asm sfee bat 
located ejdto IctorgHy ao that its potential variation* w 
reflected to the left crs% wo would see changes in lead X 
end they voold be in % sM f|» 247 
0. Slide 
1* This patient, a ml® (touts OwKsabo*®-## fifcltea?), ms S5 
years of ago at the tins at oms&t of Me Byooerdial Infarction. 
0# Curve© of 7-13-34« 
a* The stnadard loads shor a snsU CH&wa mB ittU 
as well as tezfsisal inversion of the in to>d X* 
b. Th© prooordtai loads ©to? characteristic %S-*&nfaa is V , 
?3*T4 sad T5 torothar with terertcd is ¥3, ¥4, 
t5 V 
c- algo ato?s deep $«wn»& ©nd Inverted T-wsroa. 
3* Curves of 2-6-37# 
a# Thero oro still ateffeetcrlstic QBS oheiyflw la Tg, % sad V*. 
b. Tba T-wre inversion has bok cleared. 
4# Carres taken m 5-17-41 cm the soj?e patient, ©evesi yaOT after 
the acuta episode, still stored dharncterlst ic <$UI change© hut 
jKxmal (soc slide) • 
B. said© Hjg* 
1* Cows© cm 10-7-36# 
m» The standard leads are not diagnostic. They show coaUL 
deflections sod flat Is lend I. 
b. In tho praoordlaX loads it eon be seem that the R-racvos 
%sm mailor as the electrode is ?CTad across the chest, 
finally disappearing la Thee?© is slight H8-T 
dlaplacasaeat and the T*ws*as mm upright. S48 
3* Curves on ll-a-36 
&» fiho fofwnroe hove now returned msd sow ear* quite 
b* flWMr* sharp characteristic fUogv* inversion fees aocr 
ggspearcd* 
3* Tisia is e V8*y uaasuol css© ta as m«h as It is mm 3or 
such striking retrogression of to <|BS changes to occur* 
f. siiao* 
X* Curves cm 7-1-41 shoe? norssel standard leads but largo 
wsvas is ?i» Vg and % sad Q-wr©* in end ?g* tor© are 
no T-aave changes* The patient, m ml® e&ed 59, bod had 
of a taferctio* about oae south prior 
to this ©lectroeardiognsa* 
S* Curves on l^MS 
a* file standard leads are eaeoatially as they were sevcm 
maths- before* 
b. The precordiol leads ore sen? quit© norml* 
3* la t&ls umistiel case, also, there nos striking retrogression 
of the CIES dumps* 
0. 3Ud© %0* 
Xm Those are thro® different oases la oech of tihioh all the pre- 
cordial loads ebm characteristic WB except possibly Vx» 
E. Is all of these mm® the infarct mat have hmn ln%m in order 
for to charges to bo present over m wide m area* 
3« la caa© 3X094*31994, to tort at ©atopey stood necrosis of 
the Xosaatr third of the apes mcclo* Z49 
IU 5H jdo 
1m Carves 35604 and 35615 on 11-30-30* 
a* Sho standard leads j?im* so characteristic changes* 
b* Only ¥g 8»d Tg show $88 ehsagea* whereas T3, T4 and V5 
sbor? f-wero toreralcn* 
e# This infarct is tbas very anterior and user the ceptel 
side of tho left ventricle* 
2* (tores 31370 and 31580 Da 9-43-3B* 
a* The slanted leads a&ocar only slight left axis dovieti<m» 
b. Only V3 ie SlasBotrtlo and T4 does abcv larRO ft-awec cad 
inserted 8-ewnraii, 
e* % is entirely aoaariU 
3* Curves 330G5 and 33068 cm £~U-30. 
«* The standard leads or© not dla-mostic* 
b# Is the precordial leads only la by virtue 
of the pre&temt %-wewo with mil 8*wa*© and sharply isrorted T. 
c# Sexv It &m be aeon that the sharpest* deepest ere 
act necessarily associated with tbe ssost characteristic 
4m Oaxvm 37407 and 38468 os 3~&«40* 
a* Here only % is diagnostic whereas la very an&ft&stlve* 
6# la these curves it ocn be seen that lead I looks like tg end 
for this reason if the infarct is m located that it docs not 
alter T^f that Is, if it is smr the mptvm, then the standard 
leads will not be die^aostic# 2S0 
F* Slide (Levy p* 310 # Fig* 7S, 
I* Those curves w?o Mm on © lags aged S5# tea days after the 
occ'irroncG of agtSQtoms suggesting « attack of wrmoxy occlusion. 
E» The standard leads shosr alight left axis deviation and a alight 
dip at the end of the t~m&m in heed I but or© not definitely 
outside normal Units* 
3» The precordial leads stor the characteristic signs of anterior 
infarction* To end ?s the typical chrngos* 
4# This infarction, also, woe located near the aeptoss* 
5, Sctc ttet T6 Is mtlPOly eon*. aa Tx met elao hnw te«u 
£.. Slide 1%^. 
1. Curves 5BS15, 3S516 on 12-16-38. 
tu Here the Host chnrnetorlstlc changes ore ▼4 and Ts* 
b* load 1 is mil sad bizarre* 
£• Curves 37004 and 37006 on &-S7-40 
a* Th® change® in this esse arc not typical until on© gets 
to % and ¥§• Bote that heed X looks like %• 
3# Curves &mm md mm® m 3-S5-37* 
a* Sore again the changes are not typical until one gets to 
▼s 004 v 
hm la this case f* is isorml except fbr slight lavarcica of 
the T-wvea* 
e* Her© the standard Iced® all atowr inverted l-wss but the 
QBS cheagee are met striking in U and XU* 
d* This is then a postcrio-lateral infarct# ML 
U alld© (Levy* p* SU, Fig. WUcrn/) 
1* fhese curves wore token on o Mi aged 68 on the day 
the occurrence of aynptom typical of ooraaery occlusion* 
8* Hi© standard lands show chaoses characteristic of very recent 
infarction of tha diaphragmatic wall of the heart* 
3* Hio preoordlal loads show pronounced Upwsrd of 
tbs I8WP segrmnt in VSf Ys and ?g end QS wove® In %• 
fhoeo choneos are charectcristio of very roccmt anterior infarction* 
4* fbe oxplonotisRi of these curve® Is very difficult* On© would 
aspect that if these chesses In the precordial lead® were duo 
to an anterior Infarct Mid the chsmo& in the standard loads 
wop© the result of a very vertical heart, the ehsaggee ought 
to be In Fg as well m in 1T^* 
3# It la barely possible that the Infarct was located cm the 
surface end extended up to involve s part of 
the anterior surface beneath fg* 
6* In any event, those ere very peculiar curves cad such 
records are very uscossoon* 
?* fhis patient's record was reviewed for date reprdisg Ms 
body habitus but no information was available* 
jug) iMma t&m m mmmm rnmmmta, 
X* General* 
A* Xn the standard leads In posterior Infarction Leeds II sad III 
the characteristic changes, the lostcm usually being 
lace.ted on the Mophrogrsotio surface of the heart*  
1* Because It is m the surface of the toast* it 
feces the left log sod % shows the characteristic QHS snd T 
wev© change©* 
2* Leeds U and XH look life© T> bocmiso the left leg electrode 
ic etteebed to the mam polo of tbs galrnwrlftr to taking 
both of these toads* 
B* The precordial loads to most eases of posterior Infarct lea 
ore aossaol* Iloucver* to q few instances they usay show changes* 
1* la very recent Infarctions* that Is, within the first tm 
tairo or days* the procordlal loads any show ISS-C 
soesaent ©meats to&to ore transient* 
2* In Gem to t&toh the toferct extends ©round to the letorol 
ejects of the left ventricle, toot is* to posterolateral 
infarcts* toeds fw» the axillary Unas (T§* % or Ty— 
tstos to the left posterior axillary line ot to© level of the 
©pax) aeor show Oboraetoristio or suggestive changes* 
C* Ssophnsosl Leads* 
1* Such toads ore not easy to toko booms© the patient murt 
mmUm the electrode* 
2* On© difficulty with esophageal toads is the fact that whan 
the oloetrode to close to the ©artools, to© ventricular 
lock very rsich life© those of tof©section* 
©* The reason for this Is that at the curlcutor torsi too 
electrode la opposite too aitral orifice* The isitral 
orifice acts like a gap to toe ventricular mscle just 
life© as infarct amt os e result the electrode delivers 
savlty potentials* ES3 
b* fbos lands from the eaQpita&fts ftt this love1 am sot 
satisfactory in tho diagnosis of a posterior infarct* 
o« 2b® earicalar level iaust b© located sad tbm leads, tstem 
3*45 cm* boles* this level, ’..ill be opposite the loft ventricle* 
3* Saopbsgaal iejisde fUtt the ventricular level in posterior in~ 
ferotiae will show the typical choices in the C|?tS conplosos 
end fiinWHib Such leads which ere tdm fro® the ventricular 
levels win show In posterior infarction the mm change seen 
In precordlel loads In anterior infarction* These lesda 
will also look U&o %« 
XX* of BsnphaQftfll Loads* 
a* auao fafixm*** slide) 
1* In bo»j1 individuals the esophagi loads fro® the saatHiinliiir 
levels lock Ilk© the precordial loads in tsaal people* 
£• 2a aorml Individuals leads fro® the «urlou1nr levels show 
longs with intrinsic deflections end large 0. ea? Q.-3 
w?ivos and inverted T«wvs8» 
B« Slide tPostsrlor Infarction (Oo^or)* 
1* In the standard Iss&s IX sad Ill graves arc seen 
associated with typical inverted tww» Tf also aherra tbe 
characteristic alterations of infarction* 
E* The precorulal leads ere normal escort that the f«im ore 
rathar tall* 
3* loads that msm %$km mt the vtaitriculaar levels 
( IB an* ms& 9 m* below the Leeds ©hish shaded P-weves with 
larK© Intrinsic dsfloot lena) also show the cheracterlatlc 
changes ©f infer©t ion* > £54 
C* Slide posterior infarction (Fetches) 
1* Ourves of 8-*£0-40 and 3-21-40* 
e. ateatievd leads shoe? characteristic ehea&eet HSMT displacement 
is still present and. f-c/svo inversion is lust appearing* 
b* Pveeott&Utl lead* sre aof&sl* 
Zm Ouvre® of 10-T8-40 
a« loads 12 eaft 111 shoe characteristic lame $*mf*e and 
inerted t wem a©d the SSWC dleplaMMat bes aor cleared, 
l>» Bests thast % shoes the classical abasias# 
3# Oarvee of ll-ls-40 
e» fha precoratsl leads arc aossael* 
b* % rsid % slscsf? ebonies* possibly because tb© 
infarct SKlasdod up onto the ©pex of the heart freza the 
IfalhHapdto Mfteee so that thus shove the ehesgee* 
Cm %5—an iwplHiftil lead tafeefi fraa the ventricular levels 
s&ows the chants (fe indicates- an SecaahaaeeX 
Xagjd tetaoL ©t e point 53 eat* hetaer the nostril*) 
D» Slide Minn 41770. 
X« This patient, s Ml seed 72, led had 0pfM dtorecterlatic 
of infarction three Ml previous to thee© records* 
S* The esophageal leads fress the ventrlnolav levels eh»r 
caaploxee over e l&rge region, suggesting mhendocardlel 
infarction, Ho inverted tMi ere ©sen# £♦ SIittoa (m&cmkt 41576-41599) 
1* IMs ptUttti s i&m sged hod had of m&tm 
pectoris for three aonths* Pour ssoeks ana aooSn three tsooks 
previously lie had feed pmto-oa attache of pals* Since that 
tino Isa had continued to hear© angina on occertlon* 
B* *he standard tods 41576 on II4M and precord iol tods 41599# 
@* tods 21 ma 211 oto? large $HWW whereas tod® I and 
11 ate* Ism’ilaa of the f</W3, those la III belnc: only 
rosy slightly iatrertod* 
b# Is the procordiel tods there are prosstost in 
both 7g m& t%# la Use lattto they are sore sl&alfioont 
iMwmr* bocetss© they are associated with amll&r Stessem 
than In %« 
c- are Inverted in T4> % aM % and this la 
they esse toor-ted is tosd £• 
3» 5ho mesial ppecordisi tods t&kaa is the left posterior 
aElUary Ito and at % {in the lino of the left seapolar 
•assle and at the tool of the apess taken with the patient 
lying prone) rise shew ehsrcietcristic Changes «lth large 
%-wwsse and inrorted T-szarss. 
4# Isophogecl toes the voatricuto tools shoe the 
ehajtoetsilstie QBS chrngcs ar.d ton inversion of reoent 
myocardial infarction# 
b« Is this ease the Infarction mat fee post«xo*4stoitI is 
location hmmm the ehcn®ea appear sot only in the 
eeophsgoal tods hot also Is fg» gae 
Mtotad afid Posterior Infarction in the mm pattest 
X* Occasionally It i« possible fsosc gtiBdai and prccordiel leads to 
detcntdao that the pot lest has had tro infcretlonn, ouo anterior end 
the other posterior In location, 
XI« tousles of disced InfisretfOR- 
1, Slid©. {Robert Bswn) 
1* Curros of S-15-39* 
a# The stand aid leads ©hour QSS chatr*©© In. H and III with 
trsirira RS-T soagestlag that this patient has a 
postsrloi* infarct iso* 
b* The |WflgflM lead* at t' s mm tirm indicate that the 
tofaret i« anterior, sinea those or© 
changes is both the QES eonplaxac aafl tbs T-wetes in % 
T4» ©ad TiWtffS Isrersioa In % and Tg as trail. 
£♦ Curses of 5-9-59 
a« la theso precord iel lands there hm been sane sstoogresstoiB 
of the Thoms and they era mm upright to, T- and % and 
lens deeply inverted In Vg end 
b» The %E3 cfcaa&e© are still present in Vg and T4* 
3* Curses of 10-14-40 
a. On 8-50-40, the petimt had a smisnfl sttsd: Epical of 
acuta coronary thrombosis* He observed by mass of 
the card Icecaps’ sM at that tlaa there wes pronounced up- 
ward 33-T ssgsmt in Leeds XI m& III and 
domwari $Mf QXs&X&QmBOkt in a single cheat lead taken 
at a point bet&eoa % and ?|« b« In the standard loads on 10-14-40, the curves or© raore 
or lass as they were previously except for slight Increase 
in the Q83 Interval* 
c* *!5m* precordial loads ote? quits striking changes,* fhc 
BHffaflWd have sow re turned la m& trhorc they were 
prorlously ebatert end grows larger In snfi la 7$ 
whore there was* no fytmmm* a snail on© hoe nm appeared 
and the E-wves which wore previously apsight hove new 
boeorsc Inverted* 
•" 
d* He, DttwHa»i had had a postextwlstarsX tafsret so that 
leads fro® the axilla wore from tfee Bea&timl rcglcms of 
the Inferot* 
4* In this patient* the oc©irrcnco of s posterior infarct 
following m anterior infarct caused the abnormal procardia! 
leads previously present to return to a wore aomsal 
0* In the hasrt we are always dealing with opposed forces in 
taking olcctiuccrdiasraas* If one group of forces is reduced, * 
the other group will get the upper braid* Reducing one &txx& 
of forces or increasing the second group of forces will yield 
results which are essentially the sane* 
B* aiido {Frank Scott 0520 and 0529 taken 11-17-41) 
X* This petiant wen a rsaa aged 52 at the tisss those records wore 
ti&acu In 1956 he hod the onset of angina pectoris* end after 
it hnd been presort for S months he had s iypleel attack of ayo- 
cardial infarction in October 1930. VhereaftcEr he had no further 
pain nor difficulty until .February 1941 when he Ml « second 
Infarction, following which he was amla free from distress whs© 
he baeaa© sabulotory after the umcl period of convnl&mener** 2m The standard I cods shew Q-woves and Inverted 
T-weves In leads II end III and in %• 
3* The preeordial loads show typical e changes In T5, V* 
and Vg* There are srsall in T4, Vg and 7^. 
4* In additional ©hast leads, those from the easifom shoe/ 
lorge QB-wavos and terminal Inversion of tbs T-wo. 
5* Curve3 at Y and ghow aofttll Q-tmves and inverted or 
flat T~wav»e, These changes are last of sufficient degree 
to fee diagnostic in these leads* 
6* It would appear from these records that this mn also h#sd 
bed m anterior and a posterior infarction* 
IBS EIMDHS Hi#? WKSWLB 3mO&&tA1 UW59 t» ISOCAHOIAL nnrjtWTPMI* 
I* The chief reason for mltiplc precordial loads is that there is 
apparently a • silent cron” between the rt-*ht sterr.nl border and 
the left sdd-clsvlenlcr line* 
A* Inf arete which are located on the side of the anterior 
left vent ride ere those which are saosrt rpt to escape attention* 
1* Since they do not face the left are end since Undoes not 
show the characteristic changes in tbea© eosos, the standard 
leads era usually not altered significantly# 
2m If a single precord lei land such as Iff is taken, the 
infarct will be to the right of the electrode and the chest 
lead thee taken will sot show the characteristic changes. 
B* Abnormalities which ore confined to prcoordlal lends t^9 Vg and 
% ere the onus which ere not apt to appear in the standard lends* 259 
II* There ere instances of Infarction when the characteristic change 
arc in only one of the precordial loads, and that particular lead 
rxsy ha any one of the usual slat prccordlel leads* 
A* tet .*>Io in aaloh STg was the inly diagnostic lead* 
1* Slide (Hoy £aywocd— 4BS035) 
o* This patient, aged 50, had a definite history of syooardiel 
infarction throe Boaths provlcmsly* Had «aglna or. escrtion 
for tiso wooks, then a rslld attack of infarction with pain 
off and on for 30 ?iours* Ho pain thereafter* 
b* The standard leads (40300) show no definite changes aad 
V j*ews only small Q-mrmi with Inverted Tavares* 
1# 
c* In the precordial leads, however, Tg shows e prominent 
*-wave with saall and sharp term&tel inversion of 
the leaves* 
a* There arc no 4~wavss in or in ©ay other prccorfiiel 
lends besides ?g* 
e* this infarct auat here been aaall and located near the 
septal side of the left ventricle. 
B* Bxoqplo in which was the only load showing 11.*-gnostic changes# 
1« Slide # {»m* Taylor 495422) 
a* This patient, aged 53, had g definite history of ryoeordisl 
infarction three days prior to first 2S3Q, He had had 
hypertension for two years previously* 
b« The standard loads sOam? ahnreo tor 1st ic changes in Bead* 
UsMIIIsM %* 
o» The longer strip of jLcsrd I indicates that thm patient had 
complete A*¥ heart block* This was gone sis days Is or* 2m 
. |hc usaol six procordlsl leads are Borsael except for 
Y which eto?c inverted 
o 
e. th© msitom leads, hoover, shmr clecricsl OSS ?M SWmvo 
changes of infarction* The©© sot present la either 
or Tg, Ms which T* usoslly resells, 
f. This infr ret rwy h«V€» extended eronnd to ap t for enough 
to b© rofiected In V- or th© heart my haw basn in such 
e position 8« to sake this th© caeo. 
III* What i.;roeoidial lead© should bo Icikw* 
A* If et oil possible, th© six precordial loads Ik, Ts? Y^9 
Vg and V?r should b© tmtm* 
B. OecoeSoaolly there 'Hll be- indications for additions! chert 
le*jds mob ©a ft., or Ty (loft posterior axillary tine at 
lomril of spex), or % (itac of loft aotptslcr at level of 
©pax), cec loods* 
0* If only two ehoot lead© pro token they should bo tV «md or fg* 
D« If only three ©hast lends are token they should bo h. V *5- 
E* If only four chest leads ore tsksa they stolid be ▼i. V V V 
«uk MGaB*U'.:,>iooa«t jw aamusc bh«ws bwok amd arociHswt. mr.wctiai. 
Heferoncos: Wilson ©t als Ass* Heart 3T* St 506, Jtmo 1984 
Hill; 1* Physiol. Bit 70, 19S4* 
flUson In Levy's Masses of th© toonary Arteries p 315-320. 
Soo. 
Johnston at sl» Abstract of Paper Aau/Cii&ical Investigation, 
1939. 
Srlengsr at alt Abstrect of paper by title, 
Ast* Boo. Clinical invest Ration, 1941. 261 
I* Theoretical Considerations —See Slide * 
Am Items! Activation# 
1* Shea both bundle brunches are intact, the oeptm la activated 
in pert fro© the right side and la part from tho left side* 
Tims* the right half of the septum Is activated from right to 
left, end the left half of the septum is activated from 
left to right* 
Bm The impulse in traveling sway from both the right ventricle 
md the left ventricle moves so that on electrode placed in- 
side either ventricular cavity would show largo QS-wavos# 
3* An electrode placed over tho thin right ventricle will show a 
asaell S-wvo and then as soon as the reaches the 
epicsrdial surface* tho electromotive force across the wall 
disappears and the curve will then reflect the cavity poten- 
tials, which at that sosent arc native due to the thick 
left ventricular wall which Is being activated ewey fro© tho 
right ventricle# 
B# Right Bundle Branch Block* 
1. Whm the right bundle branch la blocked* the septum Is all 
activated from left to right, all of it being activated by 
the left bundle branch block# 
2# Thus, the cavity of the loft ventricle will show largo QS- 
weves just ©s it docs nornally, except that they are broader 
and eomevhet notched# nm 
3* fh© cavity of the right ventricle, hroovor, will show initial 
positivity during the period is rlilch the Is conics 
toward it through the septum* The cavity tilll becorsc negative 
after the (nsdoocrdiuii has been activated and whthe impulse 
Is passing out through the right ventricular wall* 
4* tm&m freest the surface of the right ventricle show a aesU 
Initial B*wav© ishlch Is of the sarao origin a© the initial 
positivity of the cavity, then e large S-wavc due to passage 
of the impulse am& fro© the electrode as the wall of the 
left bsntriolo is activated, and then a second late B-wavo 
a 
du© to the delayed activation of the right ventricular mill. 
5* Load© froa the surface of the loft ventricle ohm? large S-«svee 
go usual but also broad S-waves due to late activation of the 
right ventricle* 
0* left Bftndlo Branch Block* 
1* &hon the left bundle branch is blocked, the septum io all 
activated from right to left* 
2m The cavity of the right ventricle shows large QS waves as it 
does normally except that they are tatmemimt broader* 
5* The cavity of the loft ventricle store initial positivity 
because during that period the impulse is coming toward it 
through the septua* itoring the later phases of ventricular 
activation the left caVity does hmam negative, when the 
irpulso is passing out through the left ventricular well* ms 
4* Leads from the surface of the right ventricle show tiny 
S-wsrrea and deep brood 3*swos, the latter duo to the large 
amount of muscle being activated Into sad spmy from the 
electrode# 
5* Leeds from the surface of the left ventricle show broad 
which ere notched or slurred, the initial part being 
due to the activation of oil tho aeptttm toward the electrode 
end the later phases of tho Qiis com lex being due to tho 
activation of the well of the left ventricle toward the 
electrode# 
XL Eight Bundle Breach Block and Infarction of the Left Tentriclo# 
1# with this combination of iecloas, tho potential variation* 
of the cavities ere the emm as In right bundle branch block 
alone and leads froa the right ventricular eovity show HS type 
of coiaplcses whereas those fro© the loft ventrieftiar cavity 
show broad Q.3 complexes# 
E# Loads from the right preoorditm or from tho surface of tho 
right ventricle show complexes of the typo or rs3£## 
a# cva type 
t 
b# r2K typ< 
c# Thor© is evidence to indieste that the left ventricle 
plays some part in the emU initial vihich occur 
over the right praoordteu In loft ventricular hype rtrophy 
those armlX nay dlaeppocr# It Is also possible that 
the rate of development of ©ctivctlea In the lateral wall of 
the ventricle my be different than it is in the septim, and 
if this difference is such that tho lateral wall is activated 
first or mere rapidly there my be larger initial 
then v-'onld be the cm m if the rates the nano or if the 
septum wore act Its ted wore rapidly# £64 
It may also be that la some eases of right bundle branch 
block and infarct ion* the septum nay also be infcrrctod* 
la which ease the force one to estivation of the septet 
from left to right (the force which is believed to be 
responsible for the small initial E-weves over the rl$ht 
ventricle in this condition) is diminished or absent* i 
d \ 
*-j ,, \ 
In mch a case the smell initial fi-wave would be absent \ 
X 
and leads from the right precord lain or surface of the 
right ventricle will have the QU form* 
3* loads from the left procordium or surface of the left ventricle 
in right bundle branch block and infarction will reflect tho 
potential Variations of the left ventricular cavity* 
a* 'This will be true because the muscle of the anterior 
well of the left ventricle is now deed and there will bo 
no living muscle between the ventricular cavity and the electrode* 
!• The records thus obtained will show broad* notched QS waves* 
o* These curves will fee very mch like those obtained in pro- 
cordial leads fro®, the left precord turn in anterior in- 
farction* uncomplicated by bundle branch block* 
4. Tims It ia possible to make the diagnosis of anterior infarc- 
tion in the presence of right bundle breach block because the 
precordial leads will shows 
a* From the right precordium there will bo large la to H or H# 
waves due to late activation of the right ventricle* 
b* From the left procord lum there will be initial dosn- 
ward deflections due to the reflect ton of the cavity poten- 
tials? through the ares, of infarctcd muscle* end these QHS 
ooeplexe* will have the character!stlea of those obtained 
la syooardlal infarction of the anterior wall of the 
left ventricle* c* The QH3 coqplexo© will, of corn*?©, he broad (0*12 soc or hngct), 
d# The standard lends will usually show the characteristic breed 
3-wcvos in Leed I but occasionally they will be absent* It 
Is In Just such cases that the criterion of the broad 
occasionally falls* 
E* Loft Bundle Branch Block and Anterior Myocardial Infarction. 
1* With this ccasblnation of lesions* the potential variations of 
the two ventricular cavities ere the sane as in left bundle 
branch block clone, the right ventricle showing brood QS waves 
and the left ventricle showing HS consplojcoo. 
Z* Leeds frofa the right ventricular surface or right procordiun 
show sniall E-wovcs due to early activation of the lateral wall 
of the right ventricle end deep broad Stare ces du© to the 
1st© activation of the loft ventricle* 
3* Leads fross too left ventricular surface or the left precordiusi 
will fall to show the characteristic changes of anterior ayo- 
cardial infarction* 
a* Bore again* beeeus© the mode interposed batseca the 
left boatrlcular cavity and the electrode is dead* the 
electrode will reflect the cavity potentials* 
b* Inst ead of obto Inins s record such as is usually recorded 
la ant rior isyocordid infarction* with characteristic 
deco Q-wavee, there will sow be no t-*wsves at all in the 
precordisl leads because the left ventricular cavity is 
actually positive during the initial phrse of ventricular 
activation* e* Furthermore, the large T-waves which remit fro* the bundle 
brench block will Qbaeore the fernm chenrcn which result 
tron the Infarct lem* 
4. ‘Thus, it Is that the presence of left bundle branch block sskos 
it to ask© the diagnosis of anterior 
infarction# 
5* Barely, if the infarct is extensive enough to Involve the 
septum, the fore© which mkea the positivity of the left 
ventricular cavity any thuc bo abolished end if ouch is the 
eroe, precordIrI leads from the left side say them reflect 
cevlty potentials with Initial negativity and large choroo- 
toristic Such crises arc apparently unconron, So /over. 
6* There is sense evidence to indicate that in standard loads In 
loft branch block which show prootnent $-wav«s in Lead I, 
anterior Inf r ret Ion is apt to be present* 
&• Such %-*mves occur in only about 5P of ordinary eases of 
left bundle branch block# 
XX* of Eight Bundle Branch Block end Anterior Infarction# 
A# Slid© 
X* Curves on 7-23-38 and 7-29-38. 
a. The standard loads show snail, bisorre coalesce in ell 
loads, with a brood QHS Interval and broad S-wwves la X. 
b# The procordiel leads show deep In Tg, and $4 
with pronounced upward BS»f segment dlspleceicnt* These 
changes arc characteristic of enter lor Infarction# o* shows a tiny initial and a very large late H# 
wr-vo; tlxe lottor is fiagnostlc of right bundle branch block 
in the presence of the #13 Interval of 0*12 see* 
Zm Curves 8-10-38* 
a* The curves are mm essentially as they were 11 days 
previously • 
b* The R3-T segment displacement Is Jm imich less erocdassit* 
c* Y5 also sherds deep now* 
d« The Treves are no?? chartsctort stieslly inverted. 
5* Curves on 8-20-38 sad 8-22-38* 
a. The standard leads no?? show a normal q23 Interval indicating 
that the conduction defect has cleared* Furthermore, they 
ore such aore characteristic of infarction than when right 
B* B* El. was present, showing smll complexes in hoed 1 
with form* 
b* The procorilol leads also indicate that the bundle branch 
block bos clem red. 
(1) &ad 75 show the typical change* of anterior infarct ion* 
(2) The «w£l Iwm have returned to leads 7g end 75* 
The reason for this is not clear* 
B* Slide 
1* The first set of standard loads were token on 11-7-54 «t 
which time the patient was 56 years of age end was conplain- 
of angina pectoris. 
B* The nor5 set of standard lends were taken on 11-20-38, four 
years later after he had had cryrpioas of coronary oeclurlon* 258 
e* It cm be seen thet mm there are deepj broad 
In Lead X which were not previously present# 
b* Snell <&*mwms here appeared la Lead I bat they or© not 
specially preasinont* 
S. The prccordicl leads • ere token on 12*1-38. 
a# There ere coop Q.-v?avcs in 7±, t8. y3 «* v4. 
b« The T-waves are inverted in all the precordial loads 
from to T$ and hav the characteristic form of the 
$-*jav©s In Infarction, 
c. There ©re largo, late H-wavos in and V... 
dm Thee© signs are definitely diagnostic of right bundle 
branch block and infarction. 
C* Other Slides Shoeing B. B* Bl* end Infarction. 
!• *%5» *%S* » » %*• 
2. mid** 043 and see Lory, Dlsessos of the Coronary Art erics 
p. 313 and 319). 
a. The standard leads in 843* 
(1) Curve A. 
a. The patient wss e w, egod 31 who had ggnptofaft 
typical of coronary occlusion on March 7t 1935* 
b« Thee© curves wore taken on 3-10*35, and show 
alternation is the length of the interval end 
is the fora of the C„‘.H3 ecraplccces {partial B. B. Bl.)# 
(2) Curves B 
a. fftMM* curves token on 4-2-1935 oho® so bundle 
branch block. 
b. Load I shows characteristic large end ssaall 
IMsaves srith inverted in I and II# nm 
(3) Curves d# 
a# Ihrr the bundle branch hitKit has returned# 
b* It oas b® «m that the bundle branch block does 
not cosapietely obscure the signs of infarction of 
the lateral mil of the left ventricle# 
o» So far so the nr® concerned, however, it 
abolished the inverted in lead XI In 
which the ofeoorBscl initial ventricular deflections 
induced by the conduction defect had a large net 
arms* but not In Lead I, In which the not ares of 
these deflections are small# 
b# ffea ?rocordiai Leeds —Slides Hgg • 
(1) those records were taken on 3-18-S6 vhen the patient 
was having alternation in the for® of the ventricular 
ccsap loses* 
(2) tlse conduction defect can be scon to have had little 
effect upon tbs general outline of the ventricular 
cobles: in leads fron the left side of the peroorcUuri 
(7$, V4, 7*5 and 7g) end did not obliterate the 
characteristic signs of infarction of the anterior 
well of the heart# 
(3) The conduction defect did alter the fora of the vm~ 
tricular coaplox in the leads from the right side of 
the procordtma bbe tom of the altered 
coKplestos indicates that the conduction defect involved 
the right branch of the His bundle# £70 
III# *3Bbm$iIo8 of Right Bundle Branch Block end Posterior Infarction# 
A# 3eo slide (Quinn) 
X# Th© standard lends show breed QBS complexes (015 sec*) nnd 
docp in Lead I# In addition there are deep Q-waves 
in II and IXX end sharply inverted T-rcvefi in III# 
2# % choirs deep Q-we?es# snail H-wsveg end sharply inverted 
T-waves# 
3# Thus the standard sad extremity leads Indies © in this 
instance that the patient has Right B# B# Bl# mid a posterior 
infarction# 
4* In the prc-cord id leads, has the characteristic tom. seen 
in right B« B# Bl. and leads fraa the left precordlast (T* end 
It shows deep, broad Slaves# 
5# Bone of the procordial leads show changes suggestive of infarction# 
&• Other chest loads token from the bock {» ) did show rather 
pror.’dnent mid flat to slightly invested T~mtrt0a but 
wore not absolutely diagnostic# 
17* of l#oft Bundle Branch Block and Infarct Ion. 
4* Slide &£, (Bevy, Disc?,cos of the Coronaiy Arteries, p 330, Wilson) 
Fig. 82 
1# These curves were taken on a man ego 62, sixteen smiths after 
he had h&d symptoms typical of a coronary occlusion# 
2# The standard leads aro characteristic of left B# B# Bl# 
3# In the precord iol loads: 
a# The first four presort lot leads Vg» %* V4) or© of 
the typical fora reea in loft B« B* Bl# 
b# The ventricular em&Xamm of V5 and shop/ 
(polarity reversed In t lose figures) indicating Infarction 
of the anterior r'tjonrdiuri, but not associated with 
inverted T-wcvoo# tfl 
4* At necropsy e very large Infarct involving the anterior, 
posterior and septal walls of the left ventricle sea found* 
5# It la probably because of the extensive infarct ion of the 
septum toai the usual findings of ont&rior infarction 
In the pracaralol loads were seen here «rl wears act obscured 
by the Loft &• 3* Bl« 
B* Slides am (Levy, fi@* 7d, p. 316-Oil eon} 
(patient Louis Barrett) 
1* This *&, aged 56, had systems typical of coronary occlusion 
on $ov* 14, 1933* 
2, Oorves on 12-5-23 showed changes typical of recent posterior infarction. 
3* Frecordicl loads or 32-6-32 showed Inverted T-wavos in end. at 
the emsiforsu A lead fro® tho right costal we&gim. in the nipple 
line showed QB waves end inverted *-waves» 
4* atenderd leads token cm 12-16-S5 showed intraventricular block with 
proninont 3-waves in Lead X* The changes of infarction wore 
obliterated by the block but the T-wre chanson persisted. So 
procord lei lends were taken (the block disappeared before they 
could be done)* 
5* Procardlel leads on 12-3B-3S were 0<—nttelly ns cm 12-6-33* 
6* Standard lead* on 18-19-53 end 13-21-33 wore such like thr»i?e 
of 12-5-33 except thet the T-wsves were deeply end sharply 
inverted* 
?♦ Standard leads on J6-SO-34 show %*wsr«t in XX end III end 
sharply inverted ‘f-amveo in IX and III* 
8* Standard lends on 3-11-34 were essentially as ob 2-30-34* Z72 
Standard loads on 10-&-37 (the second set on slid© H shot? 
'5*5 
iutruvontTlculcr blotik Tilth QPS interval of 0*17 uoc* &&d 
de«p* brooft S-wcves in M I* The Q£S changes of infarction* 
previously present in XI and III, hrrvo now becoise obscured* 
10* S&t&d&rd loads on 3-17-*'$ eg?* in sbcrrad oulnr block 
with vary brood* bisswm §HS ooiplazzQ and doe© broad S»t?sm* in I* 
IX* leads on 3*17-33, show* Instead of the right B* b* hi. 
iduch night be «s*pecied fro» the stoaderd loads* the 3h&rD«toaPt*» 
tic obssgse of loft bundle brsneb bloc - * 
cubical mim® mm $m mjmmom&m&m m ;&i?m mocm oM. nwx^mu 
Z* Th© ordinary jwsectiee is to keep tho patient who has fe.?d m Infarction 
In bod until the healing of the infarct Is collate* 
A* Tbo ratom of the oodiacmtatlon rate to aortml is on© such 
indication although It is quit© variable in its return to sorrasl 
from patient to patient* 
B* the collet© subsidence end absence of symptoms my mlso be 
used as a clinical soldo* 
0* The usual practice, is* of course* to keep the patient in bod 
for five tme!co* 
XI* fros the SSG which nsy be of value la amplest of 
the patient* 
A* The IWfRgres 
1. It is questionable whether it is advisable or not to keep 
the patient at rest until tho TtemNtm have bocccso stationery* 
It ssay take a tis© for this to occur* 278 
Z* *« cio sot know the differefcoo it* in thoa* whom 
retrogress# repldly a»& those vfhcso rertro- 
saorft slowly, 
E, The 83*3? HSBsamt diaploctsaent. 
I* in© of return of the ES-T sega#r*t to ao&nftl && be v.m& 
Gis ft cll&ioal guide, 
£♦ As Ifwg cs» olsv&tion of the &XT oagsent persists w icould 
usually that doeorc»t io& ic not collet#* 
3. Sisco the EiWf aagttesxt diopIocwiBt fil3e|>££ are, case of1 two 
thiBTtB i&sy &C$pQCL} 
si, ‘fbo injure*! aaaole m& die end tescdrestScai scocrc. 
fc, She injured Basel# msy recover* 
4. la & tea on# aon rmintrAn tlio Tf3~t hy ocottejea 
injury by aoejir of contlnn-od proasuro «*lt& s dhaap pointed 
elootrclo* 
5. If the 33-1 dlsepposrc eaft reftema, 
it a»sn« that further injury has occurred# 
a* ‘xh® significance of peroJUatoat dlspl&esrmt otcs? 
lew psaiods of tloo, loatg otUar all other orldeBeoe of the 
acute period of infarction hore subsided, is 
t&d qusstioasblo, 
Or 1X8 ( Dorest, A*S4* 1st* »-«cd, Si Juste 1935)* 
X» S&g slxdo 
A* Tale patient, *g$4 A4, easerod the OMpital with left s^loel 
tuberculosis and hlgtoxy of Xeftfcuge of hoert* 
V.:1CKl 
turns* Curve? 3—l—3£ was token soon aft or 'viniooion and ghowoiS definite 
right c2ctr> deviation* 
C* Curve M^S« 
1* ftae h©ui"f? «u*d 55 mimitos before this curve was taken as* 
at 101431 to Induce left jssoui;SDtbor?*s: wssc »de# the needle 
had just been introduced srhsa the patient of 
faint# Ibe needle was withdraw but a ge©omUsed 
convulsion lasted thirty seconds# Circulatory celtepae 
and respiratory depression then occurred but cleared after 
adrenalin sad oaffiene were given subcutaneously• On 
recovering consciousness the patient ccrmteteed of sub- 
starsfil pete and nee Sheet X-ray should no 
pneumothorax# 
2* Shea* curves shon terse <*-wwvos in I with’ &5-ll; etevsttea 
te I and daspreenten In XU* 
B# Curves of 8-HWOS and 8-fS-5S aim typical projspsacsive chores 
of anterior infarction* 
£» Curves of 9-2X-S3 s&mr rotussi of f-w*rvea to ao&aeX te both 
I cad. XI and reappeereiace of mill iMra os te I*  "raft.* 
•Tm y /P J 
L~_T ITZzT