Book Review

VERHANDLUNCXZN DER DEUTSCHEN GESELLSCHAFT FC?R KRE.SLAUFFORSCHUNG. Hauptthema:

Elektrokardiogramm. Darmstadt, 1952, Dr. Dietrich Steinkopff, Verlag. Vol. 18, pp. 331.

Pr. DM 40.

This volume, containing thirty-eight electrocardiographic papers together with the discus-

sions presented at the eighteenth meeting of the “Deutsche Gesellschaft fiir Kreislaufforschung,”

is an excellent cross section of the present work and thought in German electrocardiography. In general, the standard of most communications is impressive. One notes with a certain degree of

satisfaction that electrocardiography in Germany is as controversial as in this country, if not more

so. However, much of the controversy is centered on different problems, for instance, the com- patibility of vector analysis with the “difference theory.” This theory assumes that the electro-

cardiogram can be explained as the difference of two monophasic action currents of opposite po- larity and slightly different phase from two different parts (or areas) of the heart. It has never

found serious consideration in this country as a basis of electrocardiographic interpretation and, in the opinion of this reviewer, is open to objections even in its latest modifications by Schlitz and

Rothschuh (see book review “Rothschuh: Elektrophysiologie des Herzens, AM. HEART J. 45:315, 1953). Particularly, it appears that it cannot be easily reconciled with the concept of integrated

spatial vectors. Surprisingly enough, the adherents of the “difference theory” (Schiitz, Roth-

schuh, Weber) maintain that both concepts are compatible, that they constitute simply different aspects of the same phenomenon. This can be said, of course, for any method of analysis or in-

terpretation concerned with the surface electrocardiogram.

Schaefer points out that vector analysis is a quantitative method, while the difference theor) affords only a qualitative description. There is no need to go into details of this controversy in

view of the limited interest in the difference theory in American electrocardiography. The main presentations are those by Schaefer on the theoretical basis of the electrocardiogram

(pp. 12 to 41), and by Holzmann (Clinical electrocardiography, pp. 120 to 140). In nearly all

papers of that meeting reference is made to one or the other hypothesis advanced by Schaefer, either affirmative or controversial. It can be said, therefore, that Schaefer’s paper is the central

topic of discussion. It is an excellent condensation of his book “Das Elektrokardiogramm” ire- viewed AM. HEART J. 43:157, 1952), but contains also some new experimental material.

In comparison with comparable meetings of American societies, a much greater part (about

50 per cent) of the papers is concerned with vector analysis, including analysis of area vectors in

ten papers. In other words, the experimental and discussion material on the ventricular gradient presented at that meeting is very substantial compared to the recent American literature.

The opinions about the value of this method, however, are sharply divided; in no other

country has the ventricular gradient found such emphatic proponents (H. Schaefer) and such out- spoken criticism (Schlomka, Holzmann, Welsch and Spang). The objections are concerned with

clinical usefulness rather than with the theoretical background, but it is agreed that the ven-

tricular gradient may add important information in a few conditions such as the analysis of the orthostatic reaction (Gladewitz and Berg, p. 107), low voltage (Uhlenbruck, p. 160) and con-

strictive pericarditis (SchBlmerich and Heberer, p. 215). One of the difficulties in presenting the results of spatial vector analysis is the limitation of

the publishing medium to one plane. In most publications in this country, the projections of spatial vectors or loops on three planes (horizontal, frontal, sagittal) are shown. This presentation is not satisfactory, because it is still necessary to visualize or synthetize the spatial vectors from

these projections. From this point of view, the presentation of spatial vectors as done by Holz- mann (p. 136), Bayer and Effert (p. 182), Gillmann (p. 184), and Portheine (p. 196) represents

definite progress and appears to be superior, in certain aspects, to Grant’s procedure. Because of the limited space of this review, only a few arbitrarily selected examples of results

can be given. Polzer (p. 91) demonstrates remarkable differences in the loop projections in the

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160 AMEKICAN HEART JOURNAL

frontal, sagittal, and horizontal plane when the leads of Duchosal, Milanovich, Wilson and Con-

way, Schellong, and Polzer and Schuhfried are compared. Schuhfried (p. 94) confirms these re- sults in animal experiments where an artificial dipole was introduced into the dog’s heart through

a catheter. Wenger (p. 112) finds the formation of a double QRS loop (“Doppelschlingenbildung”) in the horizontal and sagittal plane to be an important feature of right bundle branch block and

stresses the value of spatial vector analysis for differentiation between this condition and right ven-

tricular preponderance. With the development of left ventricular hypertrophy, an increasing portion of the QRS loop moves above the horizontal null plane, and at the same time its shape

changes from oblong to circular, together with a reversal of the direction of rotation (Portheine,

p. 196). Effert (p. 201) applies spatial vector analysis to the P wave; increased load of the left auricle increases the P vector and turns it farther to the left and back, while increased load of the

right auricle turns the vector into the opposite direction. Bayer and Effert (p. 179) note a paral- lelism between mean QRS and T vector changes and pulmonary arterial pressure in right ven-

tricular preponderance. Exercise tolerance tests have been used in Germany for a long time and on a rather large

scale; it is not surprising, therefore, that Holzmann discusses this important functional test at some length. In his experience, the exercise test shows an abnormal response in 90 per cent of

patients with coronary artery disease, but whose electrocardiograms in rest were normal. This

seems to be very optimistic, but such optimism is shared also by some American authors. On the other hand, Holzmann warns against the use of ergotamine in exercise tests for the purpose of

differentiating between organic disease and functional heart disturbances. This was suggested

first by Nordenfeldt (1941) and recently by Master and associates (Circulation 1:692, 1950). Holzmann found that ergotamine may temporarily reverse the direction of abnormal T waves in

healing or healed myocardial infarcts. Kemmerer (p. 219) studied the protective value of nitrites and strophanthin in experimental

coronary insufficiency produced by anoxia, using as criterion S-T and T-wave changes. The pro- tective value of 0.2 Gm “Deriphyllin” or “Euphyllin” was greater than that of 0.4 Gm (intra- venous administration), and equivalent to oral administration of 3 Gm. “Strophoral” (Strophoral

contains 90 per cent strophanthine). Uhlenbruck (p. 160) found no evidence of heart disease in 21 per cent of 177 cases of low

voltage, which agrees with similar experience in this country. The ratio of the P-area vector to the QRS-area vector was valuable for the differentiation between normal and abnormal low QRS

voltage, and Uhlenbruck suggested a ratio of 1.0 as critical.

Autopsy evidence reveals that an absent R wave does not necessarily indicate a transmural infarct, since it was found in infarcts where up to 40 per cent of the myocardial wall was not in-

volved (Heinecker, p. 223). Schlomka (p. 165) presents some new evidence for his old hypothesis

that in cardiac decompensation the QRS axis changes in the direction opposite to the ventricle primarily involved, i.e., to the right during failure primarily of the left heart (hypertension), and

to the left in failure primarily of the right heart (mitral insufficiency). Hegglin (p. 149) found in all conditions of shortened Q-T interval he studied (anoxia, mono-

iodine acetate, digitalis, hypercalcemia), a decrease of the adenosine triphosphate content in the

heart. The importance of neurogenic factors has always been stressed in the German literature and

was discussed at this meeting by Holzmann and by Mueller (p. 237). However, when Schennetten

(p. 189) claims that the reflex stimulus elicited in sensitive cardiac patients just by putting the electrode on the chest may produce a myocardial infarct, this is stretching things a bit too far.

From a technical point of view it is of interest that in nearly all of the numerous illustrations

the electrocardiograms were taken with multichannel machines. At the end of his paper, Spang refers to Wilson’s well-known statement about the great deal

of harm which is done, on a rather wide scale, by a false diagnosis of heart disease from electro- cardiographic misinterpretation. He suggests that Wilson would have come to the same con-

clusion in Germany as in the United States. This is consolation (or desperation) on an interna- tional scale.

E.S.