James J. Waring 625 



disappearance of the pericardial effusion. On 3-6-35 ihe venous pressure was 

 4 cm. water, well within normal limits. At this time the BMR was —25. 



In spite of the large size of the pericardial effusion, the pulse pressure was 

 good. Before aspiration of 560 cc. on 1-30-35, the blood pressure was 160/95, 

 after aspiration 135/90. After complete disappearance of the effusion the blood 

 pressure (2-3-35) "^^^ ioo/55- O^i 7-22-35, when the BMR was —41 due to 

 omission of thyroid medication, the blood pressure had risen to 132/84, the 

 pulse was 46, the patient's condition again noticeably myxedematous. At this 

 time significant electrocardiographic changes were: very low P and T waves 

 in all leads, inverted Q-R-S, and P-R time .25 second. The area of cardiac 

 dullness was larger to percussion, the heart sounds were fainter. Although 

 at this time aspiration of pericardial fluid was not attempted, it was felt these 

 signs indicated a reaccumulation of pericardial fluid. During the next two 

 and a half months, thyroid therapy was pushed vigorously. The general con- 

 dition improved greatly. The "heart" became reduced in size judged by phys- 

 ical examination and by measurement of the cardiac silhouette on the X-ray 

 film. The heart sounds improved in quality. The pulse rate increased to 66, 

 the BMR increased to —2, the voltage of Q-R-S complexes increased in all 

 leads. The P-R interval diminished to .20 second. 



During all of 1936 the patient reported regularly at the Out-patient De- 

 partment and took from 1 1/2 to 2 gr. desiccated thyroid daily. In the spring 

 of 1937, he wearied of well-doing, stopped his medication and slowly resumed 

 the myxedematous state. On 8-13-37, ^^^^ weight had increased from his 1936 

 average of 142 to 1581/9 pounds. His whole appearance was again typically 

 myxedematous. His BMR had fallen to —36, blood cholesterol was 300, pulse 

 rate 50, the "heart" was increased in size by physical examination, the heart 

 sounds were more faint. The voltages of Q-R-S complexes in all leads were 

 diminished; P and R waves in all leads w^ere very low or isoelectric; the PR 

 time had increased to .24 second. 



During the next two months, thyroid therapy again restored this man's 

 condition to normal. When last seen in the early part of 1939 his condition 

 was good. The BMR was +2. The pulse rate 74. The voltage was good in all 

 three leads, the P-R interval was about .19 second. 



In general, the cholesterol determination did not closely follow the basal 

 metabolic rate. Body weight and pulse rate were useful indicators of metabolic 

 level. In the electrocardiogram, improvement in P and T waves lagged behind 

 improvement in Q-R-S complexes. The P-R time increased with increase in 

 the myxedematous state. Reduction in cardiac size lagged behind the improve- 

 ment in metabolism. 



The somewhat elevated blood pressure and increased pulse pressure at the 

 time the pericardial effusion was greatest declined with the disappearance of 

 the effusion, decreased still more during thyroid therapy, and increased as the 

 "cardiac" size increased with the return of the myxedematous state. 



It is ob\ ious that much of the controversy about "myxedema heart" has been 



