46 



cordial shock ample and slow. First sound 

 lengthened and muffled, substituted in the 

 tricuspid area by a systolic murmur which 

 is hardly audible at the apex. Second sound 

 muffled in the pulmonary and aortic areas. 

 Cardiac rate slow, 48. At the beginning of 

 the examination there were numerous extra- 

 systoles which became rarer in the course 

 of examination. Beats of the neck veins 

 more frequent than the ventricular systoles. 

 Venous pulse positive with systolic thrill in 

 the veins at the right side of the neck. In 

 the intervals of the ventricular systoles, at 

 times an isolated tone is heard; it is syn- 

 chronous with the venous wave of the jugu- 

 lar, without ventricular <-ontraction. at times 

 producing a slight diastolic impulse; isolat- 

 ed systoles of the auricles. Pulse irregular 

 and arrhythmic on account of the extrasys- 

 toles which are sometimes perceptible in 

 the jugular pulse and at others not. Liver 

 enlarged. Slight peritoneal effusion. Broncho- 

 pulmonary edema. Thyroid enlarged, princi- 

 pally the right lobe. 



October 31, 1913. 



Improvement of all the symptoms, both 

 subjective and objective. Dyspnea decreased, 

 as also paliilation and edema. The patient 

 still feels his heat ''beat twice in one stroke". 

 No more tricuspid murmur. Area of duiness 

 much diminished: apex 12,5 cm. from the 

 midsternal line; right margin 5,5 cm. Car- 

 diac beats irregular and arrhythmic with 

 frequent extrasystoles; 47 beats per minute, 

 but the number varies according as to wheth- 

 er there are more or fewer extrasystoies. 



November 3, 1913. 



Improvement continues. Ascites dimin- 

 ished, though not entirely gone. Slight edema 

 of body. Cardiac duiness not modified in 

 relation to last examination. 



Tricuspid murmur again to be heard. 

 Heart beats 33, 44, or 46 according to the 

 number of extrasystoles. Al beginning of 

 examination extrasystoles in bigeminal 

 series. 



November 5, 1913. 



Improvement more marked. No more 

 tricuspid murmur. Heart area reduced, prin- 

 cipally at the right side. Cardiac beats slow 

 and regular. 



November 6, 1913. 



Improvement. Cardiac area reduced; 

 apex 11.5 cm. from the midsternal line; 

 right margin 4 cm. from the same. Cardi- 

 ac beats regular and slow. Sounds more 

 distinct. No murmur. Neck veins no longer 

 turgid. Extrasystoles, sometimes in bigemin- 

 al series. 50 beats. The reduplication of 

 the first and second sounds clearly heard, 

 the latter with pulmonary reinforcement. 

 Palpitation rare. 



November 10, 1913. 



After a relapse brought on by neglect 

 of treatment, the patient improved again. 

 He was not observed for about two months. 



Examined January 12, 1913. 



Condition like at the last examination 



wilh symptoms of asystole. Number of 



beats varies around 50, according to the 



greater or lesser frequency of extrasystoles. 



January 16, 1916. 



General condition improved without re- 

 duction of the area of duiness. Number of 

 beats: 46 per minute. On the 20th when 

 going to the Hospital, he died suddenly. 

 A histopathologic examination of the heart 

 was made by Professor B. C. Crowell who 

 confirmed the existence of the lesions char- 

 acteristic of Chagas' disease, which he has 

 described in his paper on the subject. 



Record no. 30. 



The beats of the cardiac and pulse trac- 

 ing show a slow rate with some extrasys- 

 tolic beats, which are not all marked on 

 the latter, producing long pauses of the 

 pulse. The extrasystoles are ventricular as 

 is shown by the venous record. In this the 

 a waves are seen completely dissociated 

 from the c waves. It is a case of complete 

 block with frequent extrasystoies which the 

 patient felt as uncomfortable beats. 



