CLINICAL STUDIES ON INCOORDINATION OF THE CIRCULATION, AS DETERMINED BY THE RESPONSE TO ARISING Isaac Starr J Clin Invest. 1943;22(6):813-826. https://doi.org/10.1172/JCI101455. Research Article Find the latest version: https://jci.me/101455/pdf CLINICAL STUDIES ON INCOORDINATION OF THE CIRCULATION, AS DETERMINED BY THE RESPONSE TO ARISING' By ISAAC STARR (From the Research Department of Therapeutics, and the Medical Division of the Hospital of the University of Pennsylvania, Philadelphia) (Received for publication March 11, 1943) Diseases of the heart and circulation have often explore the clinical field by means of it. We been divided into the organic and the functional. have, therefore, devised a test, similar in design In the former, characteristic lesions are found at to that used to detect muscular incoordination, i.e., necropsy; in the latter, such lesions are lacking. a familiar demand is made on the circulation by Thus, the diagnosis of "functional" diseases has having the subject, after lying recumbent for 15 been a negative one; the patients suffered from minutes, arise and stand upright. The assump- certain symptoms but no organic lesions could be tion of the upright position requires complicated demonstrated. As long as interest in structural circulatory adjustments to prevent the blood from pathology dominated clinical medicine, doctors pooling in the lower portions of the body and to were content with this classification, but to physi- maintain the circulation to the brain. The nicety cians endowed with physiological interest, these of circulatory adaptation to this task can be stud- "functional" conditions present a challenge; have ied by observing the changes in cardiac output these patients a real abnormality or are they imag- and blood pressure which follow the change of ining their symptoms? position. Both my interest in this subject and the begin- The clinical literature abounds with compari- ning of this investigation antedated the war by sons of the blood pressure and pulse rate in the several years, but there is especial point to such a erect and recumbent positions and the method of study in wartime, for experience has shown that testing which we used was quite similar to that patients with "functional" abnormalities of the of Crampton (2) and to the first part of Schneid- circulatory apparatus are not equal to the rigors er's fitness test (3), except for the use of the of military life. Therefore, objective methods for ballistocardiographs. By employing these instru- their detection are of special importance. ments to estimate the amount of the circulation, In planning this study, I was much influenced in addition to the more familiar measurements, we by an analogy with the usual clinical investigation hoped and expected to advance rapidly the knowl- of neuromuscular mechanisms. A muscle may be edge of the circulatory abnormalities to be found strong or weak, but irrespective of its strength, in sick persons. the movements may be incoordinate; the latter ab- Normal standards have been secured by making normality is demonstrated by assigning a familiar 120 tests on 75 healthy persons, while abnormali- task like touching the nose with the finger tip and ties have been sought by about 200 tests on 150 observing the nicety with which the movement ambulatory patients. Indeed, it soon proved that is performed. One may think of the circulation circulatory incoordination was common in many in a similar fashion. Evidence has been presented conditions of disease. that the circulation of resting subjects may be normal, above normal, or below (1), but there METHODS have been almost no data concerning its co- Selection of subjects ordination, that is, the patient's ability to adapt The healthy persons tested were all young adults; they the flow of blood to the performance of a task. were chiefly medical students, hospital technicians, and The purpose of this investigation was to supply stenographers. A few subjects, about to receive drug in- a simple test for such circulatory coordination and jections in class demonstrations, were excited when the test was made. The sexes were approximately equal in 1 This work was assisted by grants from the Penrose number. 6 and Daland Funds of the American Philosophical Society. The patients studied were drawn from the wards, and, 813 814 ISAAC STARR +60- -50 -40 -30 -20 -1 +0l +310 +50 I I1 I I +210 +10 +50- +40- -K- +30- . ;- * . I +20- L *0 I. +I0- *0 ~00 0- 9 -I 0- 0 0 * .00:*:~~~:.: ~~~,10 -20- CHANGE *~0 -30- ON -50v-_a_ ARISING I -50- 1 I II II I I I I I CARDIAC OUTPUT WHEN RECUMBENT FIG. 1. NORMAL STANDARDS FROM RESULTS OBTAINED ON HEALTHY PERSONS Abscissa: Cardiac output per minute when recumbent, expressed in percentage devia- tion from the expected normal. The vertical broken lines indicate the accepted normal limits for resting subjects, derived from other data (6). Ordinate: Change in the cardiac output per minute after arising, expressed as a per- centage of the recumbent value. The slanting solid line is the calculated best line for the data (regression y on x). The slanting broken lines are placed at a distance of twice the standard deviation about the regression and they constitute the usual statistical limits of normality for the change of the circulation on arising. to a lesser extent, from the Out-Patient Department of For routine clinical purposes, the "H" ballistocardio- the University Hospital. Many patients who were weak, gram is more satisfactory than the "V," for the latter is and this includes the great majority of bed patients, much more subject to distortion from movements of the could not stand without enough muscular movement to patient. In our patients, such movements often ruined ruin the "V" ballistic record, so those whose cardiac out- the record for short periods and sometimes so over- put is reported numerically were almost all ambulatory whelmed it that the cardiac complexes could hardly be cases. identified. Examples of such distorted records are given Technique of tests in Figure 3. With a single exception there described, un- less a good series of normal complexes was recorded, the The subjects were never examined within 2 hours after calculation of cardiac output was never attempted. a meal. They lay at rest on the horizontal ("H") bal- listocardiograph (4) for 15 minutes, blood pressure being taken towards the end of this period. Immediately after RESULTS taking the "H" ballistocardiogram, the subjects arose, Normal standards walked 3 paces to the vertical ("V") ballistocardiograph (5), which stood at the foot of the "H" instrument, and The results obtained on the first 56 normal sub- stepped up 8% inches to its platform. The "V" ballisto- jects have been published (5), the average change cardiogram was taken between 1 and 3 minutes after the of the circulation on arising was + 1 per cent and subject took his stance. Blood pressure was taken im- mediately before or after the "V" ballistocardiogram. the standard deviation about this mean was 14 Cardiac output was calculated by the area method (6).2 per cent. Therefore, in healthy persons, the aver- age circulation is maintained on arising, and indi- 2 mathematical error has been detected in this paper (6). Giving directions for calculating cardiac output altitudes of the waves as measured on the record. The from records secured from ballistocardiographs with a former being derived from the square root of the latter. calibration different from ours, we said (p. 438), "If 280 our statement is obviously erroneous. grams displaces the light spot image 2 cm. the estimations As we have always adjusted our ballistocardiographs of cardiac output from our formulae must be halved." to the same calibration, the erroneous correction was never Since, in our apparatus, 280 grams displaces the image used, and so the error was not discovered for some time. 1 cm., inspection of our formulae shows the error at once. For the same reason, the results given in our papers do The value to be halved is not the cardiac output, but the not need correction. INCOORDINATION OF THE CIRCULATION 815 vidual subjects whose change of circulation falls neurotic edema, were all judged abnormal. A between + 29 per cent and -27 per cent can be similar consistency was found in 15 other patients. considered normal. On the other hand, repetition of the test some- However, the discovery of a trend within the times indicated that the status had changed. normal group permits a more exact definition of Sympathectomy made 2 cases incoordinate, as will the normal response. In persons whose "H" cir- be described. At times, circulatory coordination culation is in the upper half of the normal range, returned to normal as the patient's condition im- the circulation tends to diminish when they arise; proved. This occurred once as a patient with in those with "H" circulation in the lower half, rheumatic heart disease recovered from failure, it tends to increase. To make use of this discov- and again as a patient with hypertension improved ery, the results obtained more recently were added with rest in bed. One patient was improved by to those published before (5), making a total of an abdominal binder, another became normal when 120 estimations on healthy persons, and the result benzedrine was omitted. Variable results were of statistical analysis is given in Figure 1. The found in a case of myxedema receiving thyroid normal limits may now be defined as the zone and in a severe diabetic receiving large doses of shown in Figure 1 and we have not hesitated to insulin. But as a rule, unless some obvious dis- extrapolate it into territory not encountered in nor- turbing factor was present, when circulatory co- mal subjects.