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, 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; in fifth interspace. There is a distinct thrill felt over the apex. On , 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 , 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. Traube's views regarding its nature seem to have been based entirely on certain experiments on the lower animals, and were therefore purely hypothetical as regards its occurrence in man. Guttmann, in his Handbook of Physical Diagnosis (New Sydenham Society's Translations, p. 241), says:?"The cause of the bigeminate pulse has not yet been satisfactorily made out. This and other modifications of the rhythm of the pulse are sometimes discovered in animals in which the intracardiac blood-pressure is augmented. In men it is associated almost exclusively with the existence of some obstruction to the circulation (valvular defects, &cHere we have the asser- tion that practically it depends on cardiac valvular defects. Is it so ? It must be admitted that our case, with its serious organic lesion, lends support to that view; but I think a careful 128 Dr. J. W. Anderson?Case of Cardiac Couple-Beat, consideration of one or two points will lead rather to an opposite opinion. At any rate, if I were called upon to take a side, it would be on behalf of its functional origin. But I shall only say of such a difficult question, that I believe this disturbed rhythm belongs, like functional palpitation, to the spasmi; that it is purely a neurosis, a disorder of innervation. We are all familiar with that harmless form of palpitation that is so essentially transitory, so irregular that we can neither explain its coming or its going, unless we can ascribe it, as often we rightly do, to some gastric derangement; and there was something very like this in my case, as I have endeavoured to show. There was undoubtedly a very close relationship between the dyspepsia and the allorythmia. The former preceded the first discovery of the disturbed rhythm by forty-eight hours, and the latter as surely began to pass away as the stomach symptoms became less and less marked. It may have been a coincidence, but there is no doubt of the fact. This transitory character of the pulsus bigeminus is, I think, a common feature of it. It was noticed lately in one of my hospital patients, on one particular morning, and never occurred again, though carefully looked for. Hyde Salter also refers incidentally to this in speaking of a case of bigeminate pulse, so far back as 1871. Let me quote a few lines from the account he gives:?" These impulses thus running in couples were very conspicuous; two cardiac impulses were seen to succeed each other rapidly, and then a pause succeeded, followed by another pair of impulses, and so on The pulsation at the wrist due to the second beat was decidedly weaker than that due to the first. The interval between the pairs though quarter than that between the pulsations of each pair was not twice as great; so that it was evidently not an intromission of every third beat."* In a few days this remark- able rhythm, he tells us, ceased and never re-appeared. From considerations such as these, it is reasonable to con- clude that the disorder we are considering is a functional one, and not dependent on a structural lesion. It is characteristic of organic mischief to be more or less permanent, and so would wre expect its effects to be; it is characteristic of a functional disturbance rather to come and go. Besides, structural disease of the heart is common; the bigeminate pulse is a compara- tively rare phenomenon. I had got as far in my study of the question, when I was reminded of Professor Gairdner's case of disordered rhythm in the Glasgow Medical Journal, August, 1872, p. 547. It is * Lancet, 19th August, 1871. complicated by a Quadruple Aortic Murmur. 129

" entitled Rhythmical irregularity of pulse?strong and feeble alternating with a certain amount of constancy for minutes together "?&c., and sphygmographic tracings, similar to those I have shown you, and as typically of the bigeminous type, illustrate the account of the case. Let me quote the first half-dozen lines :?"Andrew A., aged 60, was admitted to the Glasgow Royal Infirmary on the 6th May, 1872, with the symptoms and physical signs of bronchitis. On admission, he did not complain of any cardiac affection, but when closely questioned, admitted that he was occasionally troubled with palpitation. After several examinations, Dr. Gairdner gave it as his opinion that there was no evidence either of hyper- trophy or of valvular lesion of the heart." The italics are mine. So far as could be made out, it was a case of bronchitis without organic change in the heart. Then there was the same in the disordered as in my case. We instability" rhythm are told, in the morning, for minutes together, it was often perfectly regular, then two or three irregular or feebler beats might be interposed, and then the regular rhythm again ? resumed. As the day wore on, the irregularity usually became greater, and in the evening, on one occasion, the rhythmical irregularity above described was observed to preserve its perfectly unchanged character for five consecutive minutes." The carefully taken tracings of Dr. Gemmell clearly illustrate this variability. All this, I think, is evidence enough against the acceptance of the valvular defect theory of Guttmann and in favour of a functional origin.* The more precise question, Through what particular nerve channels is this disturbed rhythm brought about ? is one which the clinical observer must approach with much reserve. And yet I think our every day experience of disease is fitted to throw some light on this difficult question. To begin with, we all know that under certain conditions the cardiac con- tractions will continue for a considerable time after the removal of the heart from the body; and the physiologist tells us that the cardiac rhythm is in all probability initiated and carried on by those minute ganglia which are found in the muscular walls, particularly the auriculo-ventricular septa. Now, what I think we may venture to maintain is, that while these ganglia initiate movement, the pneumogastric and sym-

* 1 am perhaps the more disposed to speak as if I were pleading for the functional origin of the 'pulsus bigeminus from the fact that authorities from Traube onwards seem to be entirely 011 the side of the structural explanation. 130 Dr. J. W. Anderson?Case of Cardiac Couple-Beat pathetic modify or control it. We may suppose it probable that while by these ganglia the heart acts, it acts in harmony, in touch, with the whole economy through the pneumogastric and sympathetic branches. And so I think it was through these channels that the gastric disorder affected the cardiac rhythm in the case before us. The connection between these two organs is, we know, very intimate, and it is remarkable how with all the apathy of the stomach to certain forms of irritation, some of its disorders speedily affect the heart, inducing well marked cardiac collapse. It is a far cry from the vulgar colic to the ablution secundum artem of the peri- toneal cavity, and yet we often find great cardiac prostration with the first, and may have seen sudden and permanent arrest of the heart s action believed to be due to the second. From such reflections as these, gentlemen, I think we may reasonably conclude not only that the pulsus bigeminus is, in the majority of cases, a functional disturbance; but that this disturbance, wherever it may happen to arise, in the stomach or elsewhere, is conveyed through the pneumogastric or sympathetic, or through both. With regard to the other feature of the case, the quadruple murmur, I have little to say. It is interesting mainly as a curiosity. I have no doubt that the first murmur was synchronous with the fairly complete ventricular systole of the primary beat, that the two faint intermediate murmurs represented the partial diastole and systole respectively con- nected with the second feeble beat, and that the last long soft murmur accompanied the complete diastole before the pause. The complexity of this might just at first sight make one doubt, but the complexity is chiefly in the descrip- tion. The mechanical difficulty in such a case would be really no greater than in that of a very rapid pulse. The sudden end is another example of the danger of aortic regurgitation. What else may have contributed, it is impos- sible, in a case so complicated, to say. But it reminds us that while all forms of valvular disease may spare longer than was till lately supposed, when aortic regurgitation does strike, there is but one way.