43 



ternation in the functioning of the heart. 

 One brother with goiter, extrasystolic ar- 

 rhythmia and cardiac insufficiency. Four 

 daughters with signs of trypanosomiasis . Wife 

 of healthy appearance, has had no mis- 

 carriages . 



At time of examination: Robust ap- 

 pearance, below medium height, well-proport- 

 ioned, muscular. Hypertrophy of thyroid 

 gland . Liver and spleen enlarged . No edema . 

 Extrasystolic arrhythmia. In ihis phase the 

 exlrasystoles. were frequent after groups of 

 five, six or seven normal systoles. 



April 9, 1910. 



Cardiac pulsations 62; radial 45. The 

 patient only came back to consult us on the 

 22nd of November; he had rare extrasys- 

 toles, evident alterations of conductibility; 

 pulse lying on his back 48; standing 45. 



At present no crises of giddiness. 



February 7, 1911 . 



The alterations of conductibility are very 

 distinct. Pulse 44. The patient was not seen, 

 again until 1913, when he came back on the 

 fifth of March with the following symptoms: 

 Dyspnea on exertion and when lying down 

 so that he can only rest propped up. Noc- 

 turnal dyspnea marked. General weakness, 

 no giddiness, nor vertiginous crises. Ap- 

 petite good. Liver enlarged and painful on 

 pressure in" the epigastric region. Spleen 

 slightly enlarged. Heart : apex in sixth 

 space, below and outside the nipple, 11 

 cm. outside the midsternal line. Right 

 margin 5 cm. outside the midsternal line. 

 Precordial shock ample, with perceptible 

 beats in fifth and sixth intercostal spaces. 

 First sound very muffled, accompanied by 

 inconstant murmur in the strong beats, 

 with slight propagation towards the axilla. 

 In the long intervals after the second sound 

 are heard short slight tones without reper- 

 cussion on the radial puls-e, coinciding with 

 the rises of the neck veins. The second 

 sound reduplicated with pulmonary accen- 

 tuation, muffled in the aortic area. Pulse 

 ample, slow and regular. Extrasystoles at 

 long intervals. Forty-two beats. Venous 

 pulse very clear. 



Like the cardiac beats, it shows that 

 there is complete disconnection between the 

 auriculo-ventricular beats. 



May of the same rear. 



Condition of the heart the same. Liver 

 diminished. Subjective signs much better. 



July of same year. 



Fatigue on exertion and walking. The 

 patient sleeps well and has no dyspnea at 

 night or when lying down; some attacks of 

 giddiness. Examination of heait: Apex in the 

 sixth space a little outside the mammillary 

 line and 10 cm. from the midsternal line. 

 Shock but slightly perceptible. Right margin 

 4 cm. from the midsternal line. First sound 

 muffled but with irregular tone, sometimes 

 being much higher and more intense. Auric- 

 ular tone audible in different phases of di- 

 astole, sometimes nearer and sometimes fur- 

 ther from the next ventricular systole. The 

 coincidence of the auricular and ventricular 

 beats seems to explain the greater intensity 

 of the sound at times. Pulse: lying down 

 42; standing 46, Tmx.=135. Liver slightly 

 enlarged, painless. Thyroid perceptibily en- 

 larged. 



September 9, 1913. 



Dyspnea on exertion, even when walk- 

 ing normally at ordinary pace and on even 

 ground, much worse when he goes uphill. 

 No nocturnal dyspnea. Heart much enlarged, 

 first sound lengthened and muffled. Second 

 sound also muffled, somtvimes reduplicated. 

 The auriculai beats are also heard well and 

 are not followed by veniricular contractions. 

 40 beats with a few extrasystoles. Terminal 

 phase: The patient was not seen for some 

 months. In May, 1914, he came back in 

 asystole with general edema, dyspnea, con- 

 gestion of the bases of the lungs, turgid neck 

 veins, liver enlarged, etc. Heart greatly en- 

 larged with dilatation of all the cavities. He 

 died at home in this state, and a post-mor- 

 tem was not made. 



Records no. 48, 48-A, 48B, 49-C, 48-D. 



These tracings show the evolution of 

 alteration of the rhythm from extrasystoleto 

 complete block. 



