50 



May 15,1911. 



Sign of cardiac insufficiency. Palpita- 

 tion. Rate standing 32, lying down 64. Ar- 

 rhythmic pulse, with numerous lapses. Liver 

 enlarged. Peripheral glands enlarged. Con- 

 siderable hypertrophy of thyroid . 



June 22, 1911. 



General condition without perceptible 

 change. Cardiac beats more regular, 44 

 when standing, 40 lying down. Tmx.— 125. 



In July, 1912, he came back to consult 

 us, complaining of strong dyspnea and pal- 

 pitations . 



Heart greatly enlarged, apex beat in 

 fifth space outside the nipple. Tachycardia 

 with arrhythmic pulse, number of pulsa- 

 tions varying between 120 and 130. Cardiac 

 excitability. A rapid examination was made, 

 and we decided to move the patient to the 

 Hospital. On the following day we heard that 

 he died suddenly at his own house in syn- 

 cope. 



Records nos. 55-A and 55-B. 



P The cardiac beats and those of the 

 radial pulse at slow rate, 55 beats, very ai- 

 rhxthmic, the diastolic pause varying from 

 one cycle to the other, although within nar- 

 row limits. In the radial record the a waves 

 accelerated, 230 a minute, not all ac- 

 companied by ventricular systole. A great 

 number blocked very irregularly, some- 

 times in 3:1, sometimes 4:1 rhythm The 

 change in the rhythm of the block explains 

 the irregular pulse. 



II) Taken 1 month after the former. 

 Pulse slower, 42 beats; some beats of 



extrasystolic aspect. The duration of the 

 diastolic phase is very variable. The auri- 

 cles beat with the same frequency, 230 to 

 the minute. The block is more intense, the 

 rhythm being 4.'1 or even 7:1. The most 

 frequent is 4: 1 . 



III) About a month later another re- 

 cord was made; it is not worthy of special 

 mention. The frequency of the auricles is 

 increased to 250. This is a case of auric- 

 ular tachystole with block of varying rhythm. 



Observation no. 57. 



Auricular tachy systole {auricular flutter) 

 Cardiac insufficiency . 



M. A., mulatto, female, 45 years old 

 married, resident at Curralinho. 



Examined Sept. 16, 1912. 



Until about two months ago she had 

 only waves of heat with abundant perspir- 

 ation. Five months ago menstruation, which 

 until then was quite regular, ceased. For 

 the last two months this patient has had 

 nervous excitement and sleeplessness. Dysp- 

 nea at night and when lying down so that 

 she can only sleep propped up; sleep is 

 agitated ;;!id broken by starts. Dyspnea on 

 exertion. General edema more marked and 

 in lower extremities and lower part of body. 

 Constant dyspnea and cough. 



Heart greatly enlarged. Apex beat 15 

 cm. from the midsternal line on a level 

 with the axillary line and much lowered. 

 Right margin 5 cm. from the midsternal 

 line. Systolic murmur at apex, audible at 

 the back. First sound audible in the tricus- 

 pid area. Second sound reduplicated. No 

 murmur in basal area. Pulse^entirely arrhyth- 

 mic. Tmx. =115. Liver much enlarged, 

 painful on pressure. Thyroid enlarged, 

 with cystic goiter. 



April 18, 1912. 



Improvement of all the symptoms. 

 Edema nearly disappeared. Dyspnea im- 

 proved, so that the patient lies down. The 

 cough has almost disappeared. Little change- 

 in the physical state of heart. Complete 

 arrhythmia. Incipient bigemim'sm. 64 ra- 

 dial pulsations. Tmx. =120. 



September 22, 1912. 



After she was discharged and getting 

 ready to leave the Hospital, she died sud- 

 denly. The post mortem showed that death 

 was due to a rupture of the anterior wall 

 of the right ventricle with intrapericardial 

 hemorrhage. T.^-e histopathologic examina- 

 tion was made by Professor Crowejl. 



