10 



tunîty of medical observation, under the con- 

 ditions under which our work was done. 

 Another interesting thing with regard to 

 the cases of auricular fibrillation is the ab- 

 sence of valvular lesions, since these lesions, 

 especially of the mitral, are the most prom- 

 inent features in the present medical liter- 

 ature on this chapter of cardiopathology. 



7. Alternation. Alternating pulse figures 

 in many of our observations accompanying 

 various of the arrhythmias referred to. Its 

 greatest frequence is observed in the cases 

 of extrasystolcs where it characterizes the 

 post-extrasystolic alternation and where it 

 almost always represents a transitory con- 

 dition, disappearing after a few cycles of 

 dominant rhythm. 



The alternation is rarely observed as an 

 isolated symptom, and from what we have 

 observed we cannot estabish a relation, in 

 the cardiac form of the disease, between this 

 symptom and any certain prognosis of great 

 gravity. 



General symptomatology of the cardiac 

 form. 



Although extremely variable in the dif- 

 ferent patients the clinical symptoms of the 

 affection of the myocardium in trypanoso- 

 miasis can be considered in a joint descrip- 

 tion, leaving aside the details and using 

 only the principal facts or, rather, those that 

 are repeated with the greatest frequency in 

 the manifestation of the cardiac form. 



The symptoms of insufficiency of the 

 organ occupy' the first place and are indic- 

 ated by their usual features: low arterial 

 tension, visceral congestion, dyspnea, fatig- 

 ue on exertion, edemas, etc., all express- 

 ing the progressive exhaustion of the heart's 

 activity. Of these symptoms the edema de- 

 serves special mention as regards its ap- 

 pearance. 



Even in the cases of most intense af- 

 fection of the myocardium we rarely find 

 here the extensive infiltrations seen in Bright's 

 disease. The edemas in these cases are 

 relatively slight, doubtless on account of the 



absence of renal changes, and on account 

 of this and the intense toxic conditions the 

 origin of the infiltration in this disease is 

 essentially limited to the weakness of the 

 heart muscle. The great generalized infiltrat- 

 ion is only observed in some relatively 

 rare cases of cardiac asystole. And even at 

 the time of the death agony with progessive 

 weakening of the myocardium the edema is 

 not present to the extent of that of renal 

 origin. 



As a physical sign of great frequency 

 we must refer to the increase in volume of 

 the heart. This sign is observed in any of 

 the groups of the arrhythmias referred to, 

 and sometimes indicates the hypertrophy of 

 the muscle and at others the dilatation of 

 its cavities or the two conditions simultan- 

 eously. We must also refer to other cardiac 

 signs, such as the murmurs of relative val- 

 vular insufficiency, the obscuring of the 

 heart sounds, especially of the first sound, 

 the alterations in intensity and amplitude of 

 the apex beat, etc. . 



Other cardiac and circulatory physical 

 signs occur with frequency and ought to 

 merit attention. But let us consider some of 

 the more characteristic subjective symp- 

 toms, especially those directly related to 

 the different forms of arrhythmia or, better, 

 to the lesions of the myocardium. 



Avexame (anxiety, agony, angor aniiní). 

 This is the expression by which the pa- 

 tients characterize subjective phenomena, 

 doubtless of circulatory origin, which figure 

 in the history of numerous clinical cases 

 whatever be the form of the arrhythmia. 

 There is no uniformity in the facts included 

 under this denomination, and it would 

 therefore not be possible to refer them to a 

 single origin. The patients indicate in var- 

 ious ways the subjective phenomena that 

 they suffer which constitute the "agony." 

 Some complain of precordial anxiety, of a 

 sense of constriction originating in the epi- 

 gastrium or the precordium and ascending 

 to the throat, where it is most intense and 

 causes phenomena of dyspnea and oppres- 

 sion frequently followed by fainting and 



