eo ee 
. 
754 
in 35. There were cardiac murmurs in 84. In reporting his observa- 
tions Stanley gives the following graphic description of heart failure 
and of the heart symptoms in beriberi: 
In both diphtheria and beriberi sudden heart failure is the most terrible com- 
plication, and one in which, as a rule, no treatment is available in preventing - 
death. * * * In both these diseases the occurrence of vomiting is almost the 
invariable herald of a rapid, fatal termination by heart failure. Practically 
speaking, the main signs met with in heart failure occurring in any of these 
conditions are vomiting, restlessness, lilac-tinted pallor, dyspnoea, increasing weak- 
ness of the pulse, and coldness of the extremities. * * * The syncopal attack 
is marked rather by duration than by intensity; loss of consciousness is rare. 
* * * The usual time of death from heart failure appears to be about the 
end of the first week in diphtheria and toward the end of the first month in 
beriberi. * * * The heart signs of myocardial degeneration are lowered pulse 
tension, feeble, short pulse wave, feeble heart impulse, short first sound and 
relatively accentuated pulmonary second sound. The second sound is almost 
always reduplicated. Reduplication of the first is not unusual and is the 
cause of the cantering rhythm so frequently met with just before death. Some 
dilatation of the heart is frequent but not invariable. The cardiac impulse is 
usually feeble and, when there is dilatation, diffuse. Not rarely the heart’s 
action is bounding and apparently forcible, but the actual circulatory output, as 
measured by the pulse, is remarkably feeble by comparison, there being a marked 
difference between the violent overaction of the heart and the small, feeble 
pulse. Some change in the heart rhythm is invariable; changes in the length 
of the pauses of the heart cycle being frequent and of great importance in. prog- 
nosis. Most common is a shortening of the long pause, giving rise to spacing 
of the heart sounds. The relative shortening of the long pause may be of all 
degrees up to tie-tac rhythm, where the short equals the long pause, so that the 
heart sounds are equidistant. The change in the relative length of the two heart 
pauses is almost always accompanied by a change in the character of the sounds, 
the first sound becoming like the second in quality, losing its deep, so-called 
muscular sound, and making more audible the valvular sound, which resembles 
the ordinary valvular second sound. In this way the two sounds and the two 
intervals tend to become alike. This tic-tae rhythm caused by the shortening 
of the long pause—the recuperative intervals—indicates diminished cardiae recu- 
perative power, and prognosticates danger ahead—danger of heart failure. But 
of worse prognosis is that condition where, in addition to the long pause being 
shortened, the short pause is likewise shortened, so that the second sound follows 
very closely on the first. This condition is almost always a fatal sign, and 
occurs with or may be followed by heart failure. A condition characterized by 
what may be termed delayed beats or “tumbling rhythm” is a common feature 
of irregularity of the heart’s action, both in diphtheria and beriberi. After a 
series of regular heart beats, a pause occurs, followed by a sudden scramble of 
two or more heart beats in order, as it were, to make up for lost time. This 
gives rise to an intermittent pulse, because all the beats do not reach the pulse. 
When the disease ends in recovery, the disturbances of circulation 
decrease in intensity. In the wet form a profuse secretion of urine 
occurs and the oedema gradually disappears. In both types which 
progress favorably, the disturbances of sensation and the paralysis grad- 
ually disappear and the patient regains the use of his limbs. 
