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On a Case of Pulsus Bigeminus Or Cardiac Couple-Beat, Complicated by a Quadruple Aortic Murmur *

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On a Case of Pulsus Bigeminus Or Cardiac Couple-Beat, Complicated by a Quadruple Aortic Murmur * ON A CASE OF PULSUS BIGEMINUS OR CARDIAC COUPLE-BEAT, COMPLICATED BY A QUADRUPLE AORTIC MURMUR * By J. WALLACE ANDERSON, M.D., Physician to the Royal Infirmary, Glasgow. Mr. President and Gentlemen,?I am about to narrate shortly to you this evening a case which may be described as having just escaped being one simply of aortic obstruction and regurgitation, occurring as a consequence and a complication of repeated attacks of sub-acute rheumatism. This, I might say, is the proposition of my subject; and I ask your attention to it, as it is the key to what would otherwise be an obscure ?and difficult case. I say it narrowly escaped being one simply of ordinary obstruction and regurgitation. But there was in addition that peculiar rhythm of the heart?itself worthy of remark?known as "couple-rhythm," or the pulsus bigeminus; ?and these two associated conditions brought out a very rare, in my experience a unique, cardiac phenomenon, namely, <a distinct quadruple aortic murmur. T. P., aged 24, tinsmith, was admitted to Ward VII of the Royal Infirmary, on 28th October, 1890, complaining of pains in the chest and back of left shoulder, and also of indigestion. The family history has no special bearing on the case, except that his father had occasionally rheumatic pains in his knees. Personal History.?With the exception of his having had measles in early childhood, he enjoyed uninterrupted health till he had rheumatic fever when 12 years of age. This would be in 1878. The attack appears to have been followed by a transient chorea. He remained well till 1882, when he had another attack of rheumatism, and in January of 1885 he had a third attack. In May of the same year he suffered from pain in the chest and breathlessness, and was admitted to * Read before the Glasgow Medico-Chirurgical Society, 19th December, 1890. 124 Dr. J. W. Anderson?Case of Cardiac Couple-Beat, Ward VII, then under the charge of my colleague, Dr. Wood Smith. In the Journal of that date, the following is reported of the heart:?" No increase of cardiac dulness; apex beat in fifth interspace. There is a distinct thrill felt over the apex. On auscultation, a loud, coarse A.S. mitral murmur is heard, and also a softer V.S. mitral murmur. Lungs normal." He left " the Infirmary improved." Thereafter he kept well for two years, when he took a fourth attack of rheumatism, and was ill for four months. Recovering he continued fairly well again, " till last February, when he suffered from infhienza." About the same time he says his stomach began to fail, his appetite was poor, and he had frequently pain after taking food. About the month of April he began to suffer a good deal from breathlessness, and has never been quite free from this since. Present Condition.?The chest is fairly well formed, expan- sion good, lungs normal. The cardiac dulness, however, is increased a little to the left and downwards, and the apex beat is felt in the sixth interspace, immediately beyond the vertical nipple line. On auscultation, a loud, hissing systolic,, and a softer and more prolonged diastolic murmur, are heard at the base. Each murmur is characteristic, not alone in respect of quality, but also as regards distribution. The systolic is best heard over the second right costal cartilage* and is so loud there that it can be heard while the ear is still an inch or two from the stethoscope. It is carried upwards, faintly to the root of the neck, and becomes also rapidly weaker in passing down the sternum and towards the apex indeed, it can be traced even into the axillary region, so that here there is possibly in addition a mitral element in the murmur. The diastolic murmur is not carried upwards or towards the apex, but is heard with about equal intensity over the lower two-thirds 01 the sternum. Urine specmc gravity 1024 ; no albumen, no sugar. For a day or two after admission there was no change in the patient's condition, but on 3rd and 4th November he complained of pain over the stomach, especially after taking food, and of want of appetite; and on examining the heart on 5th November, there was heard for the first time, what might be described as one long murmur distinctly broken up into four component parts. On careful examination it was not difficult to appreciate. The first part, or first murmur, was the loudest and most hissing; the last was next in intensity, and the most prolonged; while the two murmurs that came between appeared to be equally faint, soft, and short. There could be no doubt of these two inner murmurs being distinct complicated by a Quadruple Aortic Murmur. 125 the one from the other, but to distinguish theni in any practi- * cal way as regards character was, I believe, impossible. And now, on directing our attention to the radial pulse, it was found to be distinctly bigeminous: a weaker impulse followed quickly on each primary beat, and then there was the longer interval, followed again by the primary beat, and so on. It was too palpable for dicrotism, but of course the con- clusive test was the fact of there being a synchronous double beat of the heart. The sphygmographic tracing, No. I, was taken on this date (5th November). For the next eight days there was practically no change in either the murmur or the pulse. Meanwhile my hospital assistant, Dr. Broom (to whom I am indebted for the careful pulse tracings and other observations), Dr. Oliphant, the majority ot the resident physicians, and the senior members of my clinical class, had listened to the murmur, and .quite agreed as to its character. The pulse tracing No. II, taken on the 11th, simply corrobates that taken on the 5th inst. On the evening of 13th November, Dr. Broom noticed for the first time that there was an occasional single beat of the radial pulse among the double beats, and we had previously remarked that the patient had been improving a little as regards the gastric symptoms. On 14th November the following note was made by Dr. Broom :?" The pulse is observed to be changing character. In the morning three double beats were followed by a single one quite regularly, which in the afternoon there were about an equal number of single and double beats. (See tracing No. III.) At night again there was a preponderance of single beats. It was evident that the single beats were increasing in frequency as the patient was improving in respect of his stomach symptoms. On 16th November only three murmurs could be distin- guished over the sternum, and to my mind there could be no doubt this was caused by the fusion of the two shorter and feebler middle murmurs already referred to. And now to the finger the radial pulse was once more single, although the sphygmographic tracing No. IV discloses a slightly marked second beat. On the following morning I summarised the patient's general condition, noting inter alia that (1), when the cardiac beat is * In this description I have been careful to keep within the mark, as the condition cannot be further verified now. But from the first, I rather deprecated any attempt at a more specific criticism of the murmurs as sounds. 126 Dr. J. W. Anderson?Case of Cardiac Couple-Beat, PULSE TRACINGS FROM THE CASE OF T. P. I.?Tracing of pulse on the first day on which the bigeminous character was noticed (5th November, 1890). I. Bigeminous tracing taken Nth November. III.?Tracing taken 14th November, when single and double beats were equally divided. IV.?Bigeminous pulse where the second beat is but slightly marked (16th December). v.?Tracing taken 16th December. Pulse-beat single. complicated by a Quadruple Aortic Murmur. 127 single, patient feels in better health (comparative freedom from stomach disorder) ; and (2), when the pulsus bigeminus is present, the rate of the heart, counting only primary beats, is much slower than when it is of the ordinary character, not more in averagingO O than 35 the minute. When beatingO single it averages about 70. On 18th November he complained to me of the rheumatism being back again in various joints, and as I thought he had possibly been too much under examination, I ordered his removal to a side-room, that he should be kept quiet and have 20 grain doses of salicylate of sodium every four hours. On the following morning I found him perspiring profusety; there was a slightly livid pallor of the countenance, and the temperature was sub-normal; but he said he felt better altogether, and had only a little pain in the right shoulder. I directed the nurse to sit by him for a little, gave some other general instructions, and left the ward. He expired almost immediately afterwards without any warning. A post-mortem examination was absolutely refused. And now, gentlemen, in reviewing the case for a few minutes there are these two distinct yet connected features of interest to be considered, namely, the curious, unique so far as I know, quadruple murmur, and the pulsus bigeminus or ' ' couple-rhythm of the heart. The last, as really determining the phenomenal character of the other, we shall take up first. The pulsus bigeminus was first systematically described by Traube, I think in 1872, although, he says, he had referred to it and named it so, some years before that. We shall see immediately that the late Hyde Salter, in 1871, speaks of the cardiac couple-rhythm.
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