-284 Chapter XIX 



(4) There is no increase in the amount of lactic acid in the 

 blood. It is about equivalent to the lactic acid found in control 

 cases. 



(5) There is no increase in other organic acids above those 

 present in control cases. But after the C0 2 has been shaken out 

 there is a change in the balance of acids to bases in the blood in the 

 acid direction. 



(6) The reports on the urea and other forms of nitrogen in the 

 blood and urine have turned out negative. 



The following is a report of a typical case. 



CLINICAL REPORT 



H. L. (Dr Lewis.) 



A maiTied woman of 66 years, admitted to hospital on April 22nd, 1913, com- 

 plaining of great shortness of breath, vomiting and pains in the sternal region. 



History. Several members of the family have died of tuberculosis. There is no 

 history of past illness. She had one child (now dead) ; there have been no mis- 

 carriages. The illness began two years before with shortness of breath and this has 

 increased ; it has been continuous and is increased by exercise. For several weeks 

 frequent vomiting and pain in the sternal region have been present. She has had 

 a cough for years and there has been a good deal of expectoration ; attacks of 

 palpitation and giddiness are common. Her appetite is poor ; she has been wasting 

 a good deal. Sleep is very disturbed ; she says she wakes repeatedly in the night with 

 a feeling of suffocation. She has had to get up to micturate four or five times each 

 night for two years. 



Condition on May 5th, 1913. A frail woman (weight 8 st. 4 Ibs.), who sits propped 

 up in bed with pillows. Modified Cheyne Stokes breathing is present ; the hyper- 

 pnoeic periods are very long (85 seconds, approximate rate 45 to 60), the breaths 

 gasping. During the hyperpnoeic period and especially towards the end of it the lips 

 and tongue are pink or but very slightly cyanosed, during the intermediate periods the 

 breathing is slower (rate 33), shallow and very irregular (from curves taken 1st May). 

 During the apnoeic period, the lips and tongue are but very slightly or only moderately 

 cyanosed. The hands are cold and moderately blue ; the finger tips are clubbed. 

 There is a slight yellowish tinge of the conjunctivae and skin ; the vessels of the 

 cheek are injected. Dropsy is present in the legs. The right apex of the lungs is 

 dull, there are no crepitations. No retinitis. 



The heart's limits of dullness are increased (if and 7 inches to right and left of 

 the mid line) ; the apex beat is in the 7th left interspace in the anterior axillary line. 

 A systolic murmur is heard at the apex ; the second sound is reduplicated and 

 intensified at the aortic cartilage. The arteries seem a little thickened, the blood 

 pressure is 1 50 mm. Hg ; the pulse rate is 90, extra systoles are present and a trace 

 of alternation follows them. 



