IJEk’C)IIMITY OF THE (:HEST ASSOCIBTED X’JTII ESTRE3,lE

DIL.1TXTION OF THE LEFT .1URIC!I,E. REPORT

OF TWO C:ASII:S*

S CKVlE degree of dilatation 01 the left ;l,uricle js present in most, pa- tients with mit,ral disease, and extreme dilatation has heen described

in it number of cases allci is Ilow generally recognized iIS presenting a characteristic s-ray picture. h the more advanced stages such dilata- tion may cilusc symptoms : tlysldmgia I’rom pressure on the esophagus ; v(JUgh, dppnea. hemoptysis, atelectusis or recurring attacks of hron- dlitis from pressure on the tradlca or bronchi : or hoarseness from pres- sure on the recurrent lui~yngw11 ncrvc. In some cases the symptoms IlAVe been So trouldesome tllilt opcr;dion has been ])trformed-gastros- tomy fur a supposed ciireinonia oi: the csopha,gusl or tli~roidectomy.~ Ncetlless to say, surgical intervention failrcl to relieve the symptoms. Bwanse the IeI’t auricle is sitwltcll ]wtcricwly its enlargement, when this is sufficient to give signs, is m;lrked I)- physic:~l signs over the back -OII the left, the right, or on lath sitles--nut1 in the right asilla. The most vliaracteristic of these signs ilre clullness or dull tympany in one or both in terseapular regions ;woci;lttd with diminished breath sounds and c*le:lt*l;v transmitted Ileilrt sounds and murmurs and. when dilata- tion is estrcmc, a p~ll~d~le systolic impulse in the right asilla. Thcsc signs may be tlifficult~ to illtcrpret ant1 ;1 mistilkcn di;lgnosis of hydra- thorax has let1 to talrping 01’ thv right chest.“, ,1 Post-mortem csamina- t ion sllobvcztl thal the blood \vliic,h \VilS ohtainrtl came from the left, ;ulriple. ill1 OherWti~Jll that seems ;IlIllOSt iticredil~lc until we realize that tllc Ei]JilCitp of the left auricle in SLIP11 CilSeS has been relwrtetl ilS 1,760 ~.(a..~ two liters.” two and OllP-llilll’ litcw7 three litewS ant1 forty ounces it ft(‘r fi?Z3ti#11.4

.\t tile Ne\\- J’ork Hosl)it;ll two patients II:L\T rer(>ntl>- bee11 1111(ler Ol~S~~~ViltiOll who IlilVC showIi cvitlenw Of extreme dilatation Of the left auricle iiiid also il deformity of the chest wall, not merely ii lmlgitig ol the precordiill iirw wliicdli is seen in so many patients with large hearts or an asymmetry 01’ the nil)~blcs as 1lilS lweii described h;- Schwartz!’ in cases of mitral disease, but :I great increase in the nntcroposterior &am- rtcr of tlit thorax, a~)pcariiy as if the sternum and the vertebral col- umn had been pushed alJill’t_ Tu one cast the increase in the depth of the chest was followccl over ;I perid of five )-cnrs until the antero-

around the auricle. There was no delay in the passage of barium through the

esophagus. F,lectruc;~rdiogranl showed right axis deviation and some slurring of

QRS. Rlood pressure was approximately l-lU/tiO mm. 1Ig. Ulood Wassermann

reaction was negative; l,lood count sl~owrd slight ar~~mdary anemia. Vrinc showed

an inconstant trace of albumin.

After a month in the hospital the patient rc%urned to her home, rcmaincd in 1rc1

usual health for six months and t,hrn died rather suddenly. The esart mode ant1

cause of death vould not be ascertained.

cc3E 2.--h schwlgi~l, native lx~rn OF (;erman pawnts, was unllvr 01 wrxttion

from the age of thirtern years until her death at nineteen ytars. At the age of

four years she had :I febrile attack with joint pains, called “grippe. * ’ At the age

of eight years shcs had pertussis and at that time was said to hart: heart trouble.

She had no other rhtwnmtic attacks, no chorea, nu tonsillitis, indeed no acute

illness. When she WIS tl~irteen years old, it was noted that she had siisns of mitral

stenosis and an unusually large heart. A\ few munths l:tt<sr the rhythm lwcarnr~

totally irregular, arid thrb pxtiflnt was admittrd to t,hc New York Hospital (in

Sovemher, 1924).

Fig. l.-Case 1. Teleruentgenograms taken in March, 1929. (a) Anteroposterior view showing the great cardiac mlar‘gernrnt with the sh:rtl~w

of the left auricle extending to the right of the heart almost to the chest wall. (b) Lateral view show-ing the large heart filling the SP:WC~ bct\vecn spine an,1

stemurn and the incre:tsc~: clrpth of the chwt.

At this time tlw :rlwx im[~ulse was in the sixth space and the cxdiac borders, as

detrrmincd by lwrcussiun and by x-ray examination, extended 10 cm. to thv Icft, aucl

ti cm. to the right of the midline. The rhythm was irregular. The first sound at

the apes was shanp and was preceded by a rumbling diastolic murmur. Elcctro-

cardiogram showed auriculsr fibrillation, right axis deviation and no alnmrmulity of

the ventricular wavw. Quinidine scstored sinus rhythm trmporarily, IBut fibrillation

promptly reappcarrd, and. the patient was discharged on maintt,nanw doses of

digitalis. In .June, 1925, she stopped taking digitalis and was readmitted to thus hospital ~wause of cardiac decompensation. The heart was slightly lmger than it

had been nine months carli~~r, IJut there were no new findings. After a month in

the hospital the patient was sent to a convalescent liomr, and in Novemlwr, 192.7,

she was admitted to the children’s cardiac clinic. She attended this clinic irregularly until her death iu J:maar;v, 1931. A C’hristinn Scirntist, slit “did not lwlieve in

taking medicine, ” and for weeks at a timo omitted the* digit:llis or took lws tllm

ti cm. to the right of the midline. Over tllc right chest there was dull t,vmpang

anteriorly and posteriorly with dullness in th<s asilla, wlrc~re in the fourth and fifth

spaces there was a distinct systolic impulse, cnsily palpable and recordctl on poly-

graphic tracing. At the apes the first sound was sharp, prrcedcd 117 a diastolic

rumble and followed by a systolic blow; the s~ond sound was tapping. At the base

the second pulmonic sound was nceentuatcd. Thr beart sounds and murmurs wcw

heard over the left chest posteriorly and in thz right axilla. E’luoroscopiv t,snmina

tion showed a, greatly enlarged heart witl) the dmdow of the left auricle extending backward, as seen in tJ)e first oblique position, and to the rjght almost to the chest

wall. A year later the anteroposterior diamrtcr of the chest, as measnrcd with a

pelvimeter, exceeded the transverse diamctcr; cardiac dulln~s extended 4 cm. tn the

left in the second space and r-cached the midasilla iu the fifth and sixth spaces;

on the right it cmtended 6 cm. in the soeond sJ~,ce. S cm. in the third, 9 cm. in the

fourth and to the axilln in the fifth. Thcrc was also dullness in the third and

fourth spaces in the right asilla with dull tympany in both interscapular regions

and at both bases posteriorly. Over the area of dull tympany the breath sounds

were diminished and the heart sounds bare heard. There was little change in the

patient’s condition until the fall of IoX mben, owing to unusual stress at home,

she became exhausted and h:ld iwrcased dyspnen. Late in December she caught

cold and had a very troublcsomc cough. This cough kept her a\J-akc most of one

night, and the nest day shv l~~ame acutely dyspneie and cyanotic and died rather

suddenly. On the day of her death the heart signs were as they had been except

that the rate was wry rapid; llubbling rhlrs wre heard over the entire chest: there was

no edema of the extremities. Au autopsy was not permitted.

In each of these cases the most striking feature of the physical es- amination was the great increase in the anteroposterior diameter of the chest, and, in the absence of other factors which might explain this

Fig. S.-Case 2. Appearance of patient in October, 1930. Note the bulging of the precordial area, the asymmetry of the breasts, the poor muscle development and par- ticularly the increase in the anteroposterior diameter of the chest.

cleformity, it, wits hclieved that the change in t,he contour of the chest was secondary to the great eularg!:c~ment of the heart. The change in the shape of the chest was so remarkable that for a period of about two years every child attending the children’s cardiac clinic at the New York EIospita.1 was esamined for clicst deformity, and in most eases measure- ments of 6he auteroposterior and transverse diameters were made and recorded. Many children showed aspmmctry, bulging of the precordial area or old rachitic deformities, but no other case showing any such increase in the anteroposterior diameter as is described here was dis- covered. Nor was there discovered anot,her case of extreme dilatation of the left auricle.

ItIwI’I<I~~s(‘I’s 1 1 I I

1. Nichols, C!. F., and (M~IIJ>I, 11. \Y.: 1‘1111sw11 I)il:it:ctioll of tlw Idxft. Aurivl~~, AM. HEART J. 8: 505, 1032.

2. Personal obscrrntion. 3. Owen, I., and Fenton, IV. J.: A Case of Extreme Dilatation of the Left Auricle

of the IIrart, Tr. Clin. Sot. Ilondon 31: 1X:4, 1901. 4. Emanuel, J. CT.: Extreme Dilatation of thaw I,cft Auricle, Lancet 1: 691, 1923. 5. Hland, E. F., Galboni, G. %I., and White, I’. L).: Enornlous Invrcase in Heart

Volume With Mitral Stenosis, J. A. M. .4. 96: 840, 1931. 6. Goedel, A. : Eine ungewijlmlichc Form der Tlerzrrryriiszernng hei ~Mitralstcnose.

Wien. klin. Wchnschr. 43: 197, 1929.

*No attempt is made to summarize the literature on the subject of extreme Lila- tation of the left auricle. Reports of cases may be found in the works aleady cited as well as in the nrticles by Brammell and Duguid’l, Bedfordla, Lutembacher’3, and others, and from these papers ZI bibliography of the more noteworthy cases may be xzxmbled. Other cases have been reported by men whose interest was in the pressul’~ symptoms rather than in the heart, and doubtless man;v casts have been seen but not wcorded in print.