11 



transitory dizziness. Others refer to a con- 

 dition of general malaise, with unpleasant 

 perception of the heart beats, rapid or slow, 

 and painful sensations in the epigastrium 

 and larynx accompanied by respiratory dif- 

 ficulty, etc. Finally, a large number of pat- 

 ients only complain of the "agony" without 

 being able to define or localize the sensa- 

 tions that constitute it. 



In any case, what is the exact pathog- 

 nomonic value of this expression? Must we 

 find a relation between it and some defin- 

 ite cardiac mechanism, and so find its true 

 pathologic interpretation? Certainly not. 

 "Agony" means nothing to the student of 

 symptomatology but everything to the pa- 

 tient. This word includes the most varied 

 sensations, all of circulatory origin but 

 without the uniformity necessary for includ- 

 ing them in a joint definition. No doubt 

 can exist with regard to the relations be- 

 tween such phenomena and the processes of 

 myocarditis and tho various forms of ar- 

 rhythmia of the disease. The «agony > is no 

 nosologic novelty; it only reproduces here 

 on a large scale subjective symptoms that 

 are well known in cardiopathology and are 

 associated with the different cardiac arrhy- 

 thmias. 



In this disease those sensations are often 

 related to the extrasystoles and indicate the 

 circulatory results of the compensatory 

 pause, either alone or associated with an 

 unpleasant perception of the extrasystolic 

 beating. They may further be due to the 

 crises of symptomatic tachycardia, to the 

 alterations of conductibility, and to the 

 other arrhythmias observed. And even this 

 is not all of the pathologic conditions of 

 "agony", that is, of the more or less pain- 

 ful sensations referred to by the patient. 

 We believe in the interference of lesions 

 of the intracardiac sensory nerves and 

 are planning investigations to clear up 

 this point. And, furthermore, we must 

 add that "agony", or the sensations that 

 correspond to it, is often complained of in 

 the absence of appreciable arrhythmias. 



Palpitations form another symptom of 

 great frequence in the cardiac form of the 

 disease. They occur almost always in crises 

 of short duration, appearing and disaopear- 

 ing suddenly, and they subject the pa- 

 tient to the most painful sensations. The pal- 

 pitations are not always related to the accel- 

 erated rhythm of the heart; often they ap- 

 pear with a normal or even diminished 

 number of heart beats and radial pulsa- 

 tions. This symptom expresses the unpleas- 

 ant perception of the heart beats, and 

 for this very reason is not related to the 

 various types of arrhythmia but to the ana- 

 tomic processes that determine them. The 

 palpitations in the patients that we have 

 observed come on without any determining 

 cause, when they are in repose or in mo- 

 tion, excited by slight exertion or by sud- 

 den emotions. They also disappear without 

 any immediate cause. 



The characterization of the symptomatic 

 paroxystic tachycardia is clear, and is so 

 much the more admissible since it has been 

 possible in some crises of tachycardia to 

 detect in the tracings the beginning or the 

 end by an extrasystole. 



Faintness forms another symptom of 

 great frequency, complained of in various 

 degrees, sometimes limited to simple transi- 

 tory obscurity of vision and at other times 

 more intense and accompained by vertigo 

 with loss of consciousness. In any of the 

 forms of arrhythmia this symptom is observ- 

 ed, but its greatest frequency is related to 

 the circulatory changes caused by extrasys- 

 tole. In addition to the faintness syncopal 

 and convulsive attacks occur as nervous 

 syrhptoms of the cardiac form. These may 

 be observed in various of the anhythmias, 

 indicating the deficiency of irrigation of the 

 nervous centers caused by the arrhythmia. 

 However, such symptoms are better charac- 

 terized in the alterations of conductibility 

 and here complete the Stokes-Adams syn- 

 drome. 



In the patients with heart block the 

 nervous symptoms are very frequent in any 



