31 



Previous history of only blenorrhagia 

 and intermittent fevers. Until about two and 

 a half years ago the patient was strong and 

 hard working. About that time he began to 

 feel fatigue on exertion, dislike for work 

 gastric fulness almost always present, increas- 

 ed by the ingestion of food. Dyspnea on 

 exertion aud when lying down. Attacks of 

 dyspnea even when at rest. Nocturnal dys" 

 pnea which interrupts the sleep. Frequent 

 palpitation; attacks of strong, rapid, incon- 

 venient, uncomfortable, and at times painful, 

 heart beats coming on without noticeable 

 cause even during sleep, causing him to 

 wake with a start. These attacks are quickly 

 over, not lasting more than half an hour. 

 Frequent giddiness, but not enough to make 

 him fall. As to the feeling of gastric fulness, 

 the patient states that sometimes he feels 

 "as if he had a ball in his stomach which 

 came up to his throat and choked him". The 

 patient is below average height, of cretinised 

 appearance, his skin of a dirty yellow col- 

 or; large goiter. Generalised edema. Heart 

 much dilated. Apex beat in the sixth space^ 

 a little within the anterior axillary line. Right 

 margin 4,5 cm. from the midsternal line. 

 Precordial area with a rounded prominence. 

 First sound silent at the apex, replaced in 

 the tricuspid area by a systolic murmur. 

 Second sound reduplicated, with pulmonary 

 accentuation. Arrhythmic pulse, with frequent 

 extrasystoles. Pulse 88 to 90. Tmx.=120. 



Arteries slightly hardened. Liver enlarg- 

 ed and painful on pressure. Spleen slightly 

 enlarged. Examination of lungs negative. 

 Examination of nervous system negative. 



Feb. 21. All the subjective phenomena 

 are better. Diminished edema. Physical signs 

 not changed. 76 radial pulsations with nu- 

 merous extrasystoles. 



Feb 25. The patient is better and the 

 edema has largely disappeared. Size of heart 

 very little changed. No more tricuspid mur- 

 mur. Pulse arrhythmic, with attacks of tachy- 

 cardia. Liver not noticeably enlarged. He 

 came to consult us again on March 9, 1913. 

 Palpitation diminished. There had been no 



more dyspnea. There is no change in the 

 area of cardiac dulness. Pulse 72 with nu- 

 merous extrasystoles. Tmx.=ll5. Liver not 

 noticeably changed. Heart sounds muffled, 

 with very clearly heard tricuspid murmur. 



March 11, 1913. General condition better. 

 No more tricuspid murmurs. Arrhythmic 

 beats in bigeminal series, alternating with 

 series of rapid beats. Liver slightly dimin- 

 ished. 



March 14, 1913. 



Slight aggravation of (he subjective symp- 

 toms. The tricuspid murrrtur had reappeared. 



March 15, 1913. 



Improved again. Diminished palpitation. 

 The improvement is more evident, and the 

 patient left three days later. 



We heard that he died some months 

 afterwards in asystole. 



Records nos. 32, 32-A, 32- B, 32.C. 



1) The radial tracing is very arrhythmic, 

 also the cardiac one. 



The arrhythmia is of very complex ori- 

 gin and only the joint examination of the 

 three curves can explain it. 



At the left in the center, and at the 

 right side of the radial tracing are seen 

 groups of beats of the dominant rhythm, 

 with a rate of 83 beats per minute, but the 

 cycles are not perfectly equal. The exami- 

 nation of the waves of these cycles on 

 the venous tracing shows the a c interval 

 to be much lengthened, which indicates an 

 alteration in conductibility. In the cardio- 

 gram the auricular wave is clearly marked 

 in the diastolic phase of the ventricles. The 

 first extrasystolic beat which appears after 

 the fifth beat of the normal cycle is an ex- 

 trasystole, intervening between the fifth and 

 sixth beats of the dominant rhythm. The 

 a c interval of the sixth beat is lengthened; 

 the ventricular systole is so retarded that 

 it falls in a refractory phase and is blocked, 

 leaving a long pause between the sixth 

 and seventh beats. The interval between 

 the fifth and seventh beats in the dominant 

 rhythm is perceptibly equal to three times 



