THE value of sublingual administration of nitroglycerin for relief of attacks of angina pectoris is well established. Nitroglycerin has also been advocated as a prophylactic — before exercise and so forth — to prevent pain.1 2 3 Objective measurements of the value of both these therapeutic uses have been reported.2 , 4 , 5 From a practical point of view, the stability of nitroglycerin tablets is important. In the past, many lots of nitroglycerin have been condemned as substandard, presumably because of deterioration. As a result, fresh tablets are recommended, to be dispensed in tightly stoppered bottles.The question of deterioration of nitroglycerin is still controversial. . . .

Article1 July 1943SOME LEGAL ASPECTS OF HEART DISEASE AND THE ELECTROCARDIOGRAMJ. E. F. RISEMAN, HUBERT WINSTON SMITHJ. E. F. RISEMANSearch for more papers by this author, HUBERT WINSTON SMITHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-19-1-81 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptI. NATURE AND VOLUME OF AMERICAN LITIGATION INVOLVING THE HEARTThe advent of comparatively inexpensive portable electrocardiographic machines has greatly multiplied the number of tracings being made in the practice of medicine, and the uses and abuses now seen by cardiologists will be secondarily reflected in court proceedings. We intend in the present paper to consider some of the pervasive problems regarding the use, value and shortcomings of electrocardiograms as evidence.1 As a preliminary step, it would seem wise to consider the nature and source of cardiac litigation, and certain legal principles which orientate the problem of proof.Most cases...1 How the electrocardiograph works is explained for the lawyer in Riseman, J. E. F., Principles of electrocardiography, 15 Rocky Mt. L. Rev. (April 1943) —. The present paper is a specially adapted and more ambitious version of Smith, H. W., and Riseman, J. E. F., Applied use of the electrocardiogram in legal proceedings, 15 Rocky Mt. L. Rev. (April 1943) —. Google Scholar2 SolomonSmith HCHWRegarding the proper measure of an actor's legal duty to idiosyncratic or hypersensitive individuals, see : Traumatic neuroses in court, Am. Jr. Psychiat., 1943, xcix (Sept.-Oct.); also, Cobb, S., and Smith, H. W.: Relation of emotions to injury and disease: A call for forensic psychosomatic medicine, ANN. INT. MED., 1943, xviii (Aug.). Google Scholar3 Hedley OFIn 1937, a number of lawyers, doctors and laymen were brought to trial in the Federal district court of New York City for participating in a giant conspiracy to obtain payments on disability insurance by feigning heart disease. The modus operandi was quite interesting. Financially embarrassed policy holders, located and secured as clients by "runners," were coached by doctors and lawyers in the symptoms of heart disorder (particularly angina pectoris and coronary thrombosis), so that they could give impressive histories to unsuspecting general physicians. Some policy holders would simulate cardiac collapse in public places in order to be sent to hospital. Oftentimes the medical record was built up further prior to making claim by sending the coöperative policy holder for an electrocardiogram immediately after his heart action had been deranged by administering digitalis or other drugs. This scheme succeeded for several years, involved life policies amounting to more than ten million dollars in forty different companies, and resulted in payments and cash settlements of several hundred thousand dollars, before the conspirators became incriminated through increasing boldness and recklessness. : The fraudulent use of digitalis to simulate heart disease, ANN. INT. MED., 1943, xviii, 154. Google Scholar4 Hawkins v. Powels Tillery Steam Co., Ltd. (Eng. 1911), 1 K.B. 988, 4 B.W.C.C. 178. (X, a 62 year old colliery worker, became sick at work ten minutes after finishing moderate exertions in pushing empty tramcars and died that night of angina pectoris. Held, vacating award: Since the medical evidence showed that angina pectoris attacks may be provoked by several causes, and the claimant did not rebut the possible operation of these, the proof of causation was too conjectural to permit a recovery of benefits. Timely electrocardiograms, made immediately after symptoms appeared, would have helped to resolve this ambiguity of causation.) Google Scholar5 This "completion use" of the electrocardiogram is strikingly illustrated in Brown v. City of Omaha, 141 Neb. 587, 4 N.W.(2d) 564 (1942). Plaintiff, a fireman, afflicted with preëxisting heart disease, filed claim for total and permanent disability. He alleged that his disabling coronary occlusion or thrombosis was an accidental injury received in fighting a basement fire for three hours on September 28, 1939, in the midst of dense smoke and fumes. Electrocardiograms made thereafter and up through November 29, 1939, showed that P had not yet developed coronary thrombosis. An electrocardiogram made on November 30 and December 1, 1939, furnished conclusive evidence of disabling coronary thrombosis. In view of this evidence, the Supreme Court of Nebraska held that the fire-fighting clearly was not a cause of the thrombosis and vacated an award made by the Board and affirmed by the lower court. Google Scholar6 One pressing need in medico-legal work is to avoid ambiguous terms; in the cardiac field this would include such ill defined diagnoses as endocarditis, myocarditis and acute dilatation. Courts should require pleadings to use accurate, specific terminology, for which see Nomenclature and Criteria for Diagnosis of Diseases of the Heart, 1940 (4th ed.), Am. Heart Assoc., N. Y. Google Scholar7 In Call v. City of Burley, 57 Ida. 58, 62 P (2d) 101 (1936), a personal injury case, a verified roentgenogram of plaintiff's pelvis was tendered without offer of any interpretation, and the court excluded it on the ground that "the average layman would get no information . . . unless the alleged fracture is pointed out and explained to him." Google Scholar8 Marvin HMIn future, many doubtful medico-legal claims involving the heart may be made on the basis of uncritical and extravagant use of the electrocardiogram if loose practices now current in the medical use of this diagnostic aid continue unabated. See : Use and abuse of the electrocardiogram in medical practice, New England Jr. Med., 1942, ccxxvi, 213-217. The author comments on the unquestioned value of electrocardiography in such conditions as irregularities of cardiac rhythm, involvement of the heart during the course of systemic diseases, acute myocardial infarction, digitalis intoxication, structural lesions and the various types of cardiac neuroses. He feels, however, that much harm is being done, in the new widespread use of the electrocardiogram, largely as a result of the general practitioner's failure to recognize the following limitations on its value: (1) Changes in the ventricular complex, including its terminal portion, have no special significance, with the exception of changes associated with myocardial infarction; (2) The electrocardiogram hardly ever gives helpful information on the functional state of the heart, so that therapeutic questions of the amount of rest and action, and of the quantity of digitalis proper for the patient cannot be decided by the electrocardiogram; (3) It is usually impossible to secure information about the prognosis from the electrocardiogram; (4) The graphic records must be interpreted in light of clinical evidence; (5) Many physicians are making unjustified diagnoses of heart disease solely on strength of minor variations in the electrocardiographic curves; these should never be accepted in absence of supporting clinical evidence; (6) Misuse of the electrocardiogram is prevalent throughout the country; (7) The American Heart Association has received a flood of letters from leaders in the cardiovascular field, asking for some board to establish certification of those physicians who are competent to interpret electrocardiograms. The primary intent would be to curb the present misuse of the electrocardiogram in the practice of medicine itself. See, also, Willius, F. A.: A talk on certain prevailing fallacies in the application of clinical electrocardiography, Proc. Staff Meet., Mayo Clin., 1942, xvii, 137-140. The author attributes some of the main vices to: (1) Naive assumption that fixed norms of interpretation can be employed automatically; (2) Divorcement of electrocardiographic interpretation from clinical examination, resuiting in errors of omission and commission since the electrocardiogram alone is not an adequate form of cardiac study; (3) Failure of medical schools to provide adequate instruction in electrocardiography. It goes without saying that this prevalent and growing misuse of the electrocardiogram is certain to be secondarily manifested in the courts of the land. The only safeguard is for courts to hold to the strictest standards of competency in testing a doctor's fitness to give an expert opinion or interpretation based on the electrocardiogram. Here signal help could be had from a "proficiency certificate" issued by the medical profession to those who propose to appear as electrocardiographic experts in legal proceedings. See Smith, H. W.: Scientific proof and relations of law and medicine, ANN. INT. MED., 1943, xviii, 450-491; Clinics, 1943, i, 1404. CrossrefGoogle Scholar9 When the electrocardiograph is properly standardized, a current of one millivolt will cause a deflection of the beam of the string shadow equal to one centimeter. Google Scholar10 If the technician is available, ordinarily he should be called to court, unless counsel stipulate in advance that the electrocardiograms to be used have been properly made and may be offered in evidence by agreement without formality of laying a predicate. The technician should be charged with the duty of filling out a standard record each time an electrocardiogram is made and this should show the name and address of the patient, the hour and date, position of the patient, and presence of any significant circumstances such as taking of drugs or indulgence in exercise, etc. Such a record has three important uses: (1) It may be used by the technician to refresh his memory before testifying; (2) In case the technician is unavailable, the record may be admissible in evidence as an entry made in the course of business, thus bringing the facts recorded within an established exception to the hearsay rule; (3) In some states, the record may be offered in evidence as a business entry without producing the technician, even though he is available locally. Google Scholar11 EslerWhite JWPDSee : The distortion of the electrocardiogram by artefacts, Am. Heart Jr., 1929, iv, 296-304; Hartwell, A. S., Burrett, J. B., Graybiel, A., and White, P. D.: Effect of exercise and of four commonly used drugs on the normal human electrocardiogram, with particular reference to T-wave changes, Jr. Clin. Invest., 1942, xxi, 409-417. In the New York conspiracy to procure payment of insurance disability benefits for simulated heart disease, policy holders were given moderate doses of digitalis. This was done prior to electrocardiographic examinations to be made by unwitting cardiologists. Some patients were even surreptitiously "dosed" while in hospital. In some cases the drug produced only a flattening of the ST intervals. In others, varying degrees of auriculoventricular block occurred. Premature contractions were frequently produced and in a few instances actual inversions of the T-wave occurred. The net effect was to produce an electrocardiographic tracing suggestive of heart damage. One insurance company doctor, after reading an electrocardiographic tracing so produced, said: "If the patient is not taking digitalis, I would say that he is totally disabled." Another insurance company doctor said regarding electrocardiographic tracings submitted in support of a different insurance claim: "Since digitalis administration has been denied, it must be assumed that this record is associated with myocardial damage of coronary origin." Hedley, O. F.: The fraudulent use of digitalis to simulate heart disease, ANN. INT. MED., 1943, xviii, 154. CrossrefGoogle Scholar12 X claimed workmen's compensation for cardiac disability allegedly due to accidental injury suffered from exposure to carbon monoxide in a mine, but an arbitrator made an award for the employer, finding that X's disability was due to chronic myocarditis. Dr. Y testified favorably to the employer, basing his opinion partially on electrocardiograms not produced in evidence, and the claimant, on this ground among others, sought to have the award set aside for misconduct of the arbitrator. Held: As in case of roentgen-ray plates, the electrocardiographic picture should be produced before an expert opinion is given interpreting it, but since a Kansas statute provides that the committee or arbitrator shall not be bound by technical grounds of procedure or evidence," nor is erroneous admission of evidence mentioned in the statute describing what constitutes "serious misconduct," this departure from proper practice is not a ground for setting aside the award. Lefebre v. The Western Coal and Mining Co., 131 Kan. 1, 289 P. 456 (1930). Electrocardiographic tracings are fully as complicated as roentgen-ray pictures, and the better view is that the latter must be offered in evidence before an expert opinion is given interpreting them. Marion v. Coon Construction Co., 216 N.Y. 178, 110 N.E. 444 (1915). (Cited with approval in the Lefebre case, supra.) Neill v. Fidelity M. L. Ins. Co., 119 W.Va. 694, 195 S.E. 860 (1938). A less desirable rule is that the physician, on direct examination, may give his opinion based on interpretation of roentgen-ray plates without simultaneously producing them, and that the opponent, on cross-examination, may require their production. Sullivan v. Minneapolis, St. P. & S. S. M. R. Co., 55 N.D. 353, 213 N.W. 841 (1927). Google Scholar13 The court in the Lefebre case, supra, seemed to consider the vice of non-production of the electrocardiographic tracing to be an infraction of the hearsay rule. This analysis hardly fits in with the customary and historical concept of the hearsay rule as a prohibition against offering unsworn verbal testimony of a third person not present in court. That the vice is in withholding the best evidence, is shown by the decisions which permit a doctor to give an opinion on a roentgen-ray picture, without producing the latter if proof first be offered that the picture is lost. Stiles v. McLean, Finch v. McLean, 103 N.J.Eq. 537, 138 Atl. 119 (1927); Vale v. Campbell, 123 Or. 632, 263 Pac. 400 (1928). Google Scholar14 Smith HW: Components of proof in legal proceedings, Yale Law Journal, 1942, li, 537. CrossrefGoogle Scholar15 Pardee Some leading major works on electrocardiography are: , Clinical aspects of the electrocardiogram, 1941, 4th Ed., Paul B. Hoeber, New York; Graybiel and White, Electrocardiography in practice, 1941, W. B. Saunders, Philadelphia; Katz, Electrocardiography, 1941, Lea & Febiger, Philadelphia; Katz, Exercises in electrocardiography, 1941, Lea & Febiger, Philadelphia. Google Scholar16 MasterDackJaffe AMSHL: The relation of effort and trauma to acute coronary occlusion, Indust. Med., 1940, ix, 359-364; Warburg, E.: Subacute and chronic pericardial and myocardial lesions due to non-penetrating traumatic injuries, 1938, Oxford Univ. Press, New York; Boas, Ernst P.: Angina pectoris and cardiac infarction from trauma or unusual effort, with a consideration of certain medicolegal aspects, Jr. Am. Med. Assoc., 1939, cxii, 1887-1892. Google Scholar17 LangendorfGoldberg RSThe necessity for "education" of the lay jury and court in the medical problems involved is obvious in each instance. The description below is not meant to be a complete discussion of pericarditis, but rather a presentation of those aspects necessary for better understanding of the rôle of the electrocardiogram in such cases. Pericarditis (inflammation of the outer surface of the heart) may be caused by local infection (pneumonia, tuberculosis, rheumatic fever); reaction to the toxemia of kidney disease (uremia); inflammation or damage to the heart (myocardial infarction); or direct injury with or without perforation of the chest wall. The diagnosis is based on: (1) The finding of specific signs, especially a "friction rub" (a rough, grating, reduplicated sound synchronous with cardiac contraction and relaxation). This is usually accompanied by symptoms of heart damage (pain, rapid heart rate, etc.) plus signs of inflammation (fever, elevated white blood cell count, elevated sedimentation rate, etc.). (2) Objective evidence in the electrocardiogram. The electrocardiographic picture may have one of three general forms: (1) A characteristic upward sloping of the RS-T segment seen in any or all of the four leads. This progresses rapidly (within days) to temporary inversion of the T-wave followed rapidly (within days) by return to normal. (2) Progressive changes in the electrocardiogram, especially the RS-T segment or T-wave, other than the specific upward sloping of the RS-T segment. Obviously, to show the changes outlined in (1) and (2) the tracings must be taken at the appropriate times. (3) A normal electrocardiogram with no changes. See : The electrocardiogram in traumatic pericarditis, Am. Heart Jr., 1942, xxiv, 412-416. Vander Veer, J. B., and Norris, R. F.: The electrocardiographic changes in acute pericarditis, Jr. Am. Med. Assoc., 1939, cxiii, 1483. CrossrefGoogle Scholar18 Heart block is an abnormality of rhythm occurring physiologically when the usual rhythmical impulses which cause the heart to beat at the normal rate (about 72 beats per minute) are "blocked" or fail to stimulate the ventricles to contract. As a result, new impulses arise at a slower rate (about 30 to 40 per minute) from a new location. This slow rate tends to reduce cardiac output of blood to a level insufficient to maintain normal physical activity. Furthermore, it is not uncommon for the heart to cease beating entirely or to beat erratically and inefficiently; as a result, loss of consciousness, convulsions and frequently death may ensue. The causes of heart block are several and include age (arteriosclerosis), infections (syphilis, rheumatic fever), tumors, myocardial infarction, and damage due to trauma. In the latter case the heart block is likely to occur soon after the trauma but may be delayed in its appearance. The electrocardiographic picture of heart block is typical and diagnostic. It consists of a complete dissociation between the usual impulses (P-waves) arising in the S-A node (which cause the heart to beat at the normal rate), and the new ventricular impulses (QRS and T-waves) arising in the A-V node or ventricle (which beats at the slow rate). The electrocardiogram tells little about the reason that the heart block has developed. Google Scholar19 Clinical Picture and Definition of Terms. According to present concepts, angina pectoris (heart pang) occurs in persons whose arterial blood flow to the heart muscle (coronary circulation) is unable to respond adequately when additional blood is needed. When the supply of blood to the heart is inadequate for the demands of the heart muscle, a state of relative anoxemia (oxygen deficiency) results, and the patient experiences heart pain. The most common cause of such an inadequate coronary circulation is arteriosclerotic narrowing of the coronary arteries. The most common causes for precipitating attacks of angina pectoris are exercise and emotion. With cessation of the precipitating exercise or emotion, the discrepancy between demand and supply of blood ceases, the physico-chemical changes secondary to anoxemia reverse themselves, and the pain disappears. Under conditions of physical or emotional fatigue, attacks of angina pectoris may occur more frequently. If anoxemia persists for a sufficiently long period of time (due to complete occlusion of a coronary artery or to prolonged angina pectoris), the physico-chemical changes become irreversible and permanent damage to the heart muscle occurs. This destruction of heart muscle is called myocardial infarction. Since it is due usually to coronary occlusion or coronary thrombosis, these terms are frequently used interchangeably. The electrocardiographic picture of myocardial infarction is quite typical. It consists in most cases of changes of the RS-T segments and T-waves progressive over days or weeks; in other instances, transient arrhythmias may indicate involvement of the ventricular muscle. Since these changes are transient and progressive, tracings should be taken soon after the onset of the illness and frequently thereafter. Google Scholar20 RisemanBrown JEMG: An analysis of the diagnostic criteria of angina pectoris, Am. Heart Jr., 1937, xiv, 331. CrossrefGoogle Scholar21 LevyBruennRussell RLHGNG: The use of electrocardiographic changes caused by induced anoxemia as a test for coronary insufficiency, Am. Jr. Med. Sci., 1939, ccxli, 241; Patterson, J., Clark, T., and Levy, R.: A comparison of electrocardiographic changes observed during the anoxemic test on normal persons and on patients with coronary sclerosis, Am. Heart Jr., 1942, xxiii, 837. CrossrefGoogle Scholar22 MastersFriedmanDack AMRS: The electrocardiogram after standard exercise as a functional test of the heart, Am. Heart Jr., 1942, xxiv, 777. CrossrefGoogle Scholar23 RisemanWallerBrown JEJVMG: The electrocardiogram during attacks of angina pectoris, its characteristics and diagnostic significance, Am. Heart Jr., 1940, xix, 683. CrossrefGoogle Scholar24 Taylor HF: The value of electrocardiography in medical underwriting, Proc. Assoc. Life Insur. Med. Dir. America, 1932, xviii, 165-201; Wilson, F. N.: Recent progress in electrocardiography and the interpretation of borderline electrocardiograms, Proc. Assoc. Life Insur. Med. Dir. America, 1938, xxiv, 96-156. Google Scholar25 Carbon Monoxide Poisoning and Electrocardiographic Evidence. Carbon monoxide poisoning results in impaired capacity of the corpuscles to transport oxygen, and the heart suffers from anoxemia. If the dosage of carbon monoxide be sufficient, heart damage will result, and this may be more extensive in the presence of a preexisting endocarditis, so as to warrant a professional opinion that the latter was substantially aggravated by the accidental poisoning. A number of cases of cardiac damage through carbon monoxide poisoning have been arising in the workmen's compensation field, and papers have been written devoted to specialized aspects of the electrocardiographic configurations one may expect to find. Google Scholar26 StearnsDrinkerShaughnessy WHCKTJ: Changes found in 22 cases of carbon monoxide poisoning, Am. Heart Jr., 1938, xv, 434-447. CrossrefGoogle Scholar27 LewisGilder TMD: The human electrocardiogram: A preliminary investigation of young male adults, to form a basis for pathological study, Philos. Trans. Roy. Soc. London, Series B, 1912, ccii, 351-376. See also Castellanos, I.: Personal identification by electrocardiography, Jr. Crim. Law and Criminol., 1932, xxiii, 356-360. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Boston, Massachusetts*Received for publication May 24, 1943.†M.D. Boston. Instructor in Medicine, Harvard Medical School and Tufts Medical School; Associate in Medical Research and Associate Visiting Physician, Beth Israel Hospital, Boston.‡LL.B., M.D. Boston. Associate in Medical-Legal Research, Harvard Law School and Department of Legal Medicine, Harvard Medical School. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byNonpenetrating chest injury and posterior myocardial infarction pattern 1 July 1943Volume 19, Issue 1Page: 81-106KeywordsCardiovascular therapyElectrocardiographyHospital medicineMedical law ePublished: 1 December 2008 Issue Published: 1 July 1943 PDF downloadLoading ...

S TUDIES of the heart in spontaneous myxedema”. lo, ‘l, “‘j ‘*, “7 3’ nuring the past decade have demonstrated that (1) the heart size, as measured by the seven-foot roentgenogram, is increased; (2) the voltages of the P, T, and QRS waves of the electrocardiogram are frequently diminished *18p 311 331 35, 3g and (3) cardiac contractions are less vigorous.2’ 3o Opinions differ concerning the clinical significance of these alterations. Zondek42* 43 and Fahr14 maintain that cardiac function is often impaired in patients with myxedema having such changes. Christian,lly I2 Willius and Haines,41 Case,lO Means, White and Krantz,28 however, studied a total of three hundred patients with myxedema and concluded that heart function is rarely, if ever, impaired. From a recent review of the literature and a comprehensive study of thirty additional cases at the Massachusetts General Hospital, Lerman, Clark and Means?’ conclude that “myxedema heart” in the sense of heart failure occurs rarely, if at all. The studies of the above investigators were confined almost entirely to patients without cardiovascular disease. In treating patients with chronic heart disease and other conditions by inducing hypothyroidism by total removal of the normal thyroid gland, we have been able to study the development of the cardiovascular changes associated with the development of myxedema. Two aspects of the heart in myxedema have been investigated: first, the character and rate of development of the changes in heart size and electrocardiographic tracings; and, second, the significance of these changes in terms of cardiac function. Studies before, and at varying intervals aft.er, total thyroidectomy have been ma.de in three groups of patients: one group comprising patients with congestive heart failure at the time of, or just before, operation; the second group, patients with angina pectoris ; and the third group, patients with no evident functional or anatomical abnormalities. The rationale, t,eehnie, and therapeutic results of total thyroidectomy in patients with chronic heart disease and no thyrotoxicosis have been described in previous communications.4* 8l gl 15, I63 37

This communication is a report on the therapeutic results of total ablation of the normal thyroid gland in a series of 10 patients with congestive heart failure or angina pectoris. Patient G. F. (case 11), on whom this procedure was first performed, was the subject of a previous report; 1 included here is an account of his subsequent clinical course. The clinical observations which provided the rationale for this procedure began in 1924 with the development of an accurate method for measuring the velocity of the blood flow through the lungs. 2 Measurements in more than 600 subjects demonstrated that, normally, the velocity of flow was directly determined by the metabolic demands of the body. 3 The metabolic demands of the body were gaged by the basal metabolic rate. When the metabolic rate was accelerated, as in thyrotoxicosis, 3d the speed of blood flow was proportionately increased; on the other hand, when the metabolic