326 C. P. HOWAED 



insufficiency. Palpation will reveal a, pounding, violent impact and 

 sometimes a systolic thrill or diastolic shock. Curiously enough, the clin- 

 ical apex may not be much displaced, and even if far out, it can be lo- 

 calized in the fifth or even the fourth interspace. On percussion the 

 dullness is found increased, especially to the left, though as a rule this 

 increase is not proportionate to the severity of the tachycardia, palpita- 

 tion or area of visible precordial pulsation. In Swan's series, 50 per 

 cent of the patients revealed, clinically, an increased area of cardiac 

 dullness suggestive of a hypertrophy. 



On auscultation the heart sounds are usually loud but the first sound 

 is rarely clear and of normal tone, even in the absence of a murmur. The 

 heart sounds are sometimes audible to the patient, and often audible to 

 the examiner without applying the ear or the stethoscope to the chest: 

 thus Graves writes that : a ln one case I could distinctly hear the beating 

 when my ear was distant at least four feet from his chest." Redupli- 

 cation of the sounds and in severe cases gallop rhythm may be present. 

 Accidental murmurs, both systolic and diastolic, may be heard, especially 

 over the base. Apart from these so-called "hemic murmurs," it is not 

 uncommon to note the soft blowing apical murmur of a relative mitral 

 insufficiency from a stretching of the right auriculoventricular ring in 

 a moderately advanced goiter heart. The causes of the murmurs are vari- 

 ous: no doubt muscular insufficiency is the chief factor and anemia a 

 rare one. Sahli believes that "the systolic murmurs are arterial, depend- 

 ing upon the 'pulsus celer/ to be described later." It is not decided, 

 according to Bram's quotation of Sahli, whether the diastolic murmur 

 is arterial, resulting from the pulsus celer or whether it is a diastolic 

 portion of the venous murmur, isolated and strengthened because the 

 veins are compressed or closed by the arteries during systole. 



There is sometimes an associated valvular endocarditis or arteriosclero- 

 sis present. 



The goiter heart, though in the majority of cases due to thyroid in- 

 toxication, may sometimes depend upon pressure on the vagus nerves in 

 the neck, when it is known as "Rose's goiter heart" or the dyspneic 

 form of goiter heart. 



Upon Fluoroscopic Study. Bauer and Helm recognize the existence 

 of two main groups of heart disturbances in goiter. (1) The mechanical 

 goiter heart of Rose and (2) the thyrotoxic goiter heart which may be 

 subdivided into (a) the irritable goiter heart originally described by 

 Minnich and Kraiis and (b) the torpid goiter heart. They believe that 

 the fluoroscopic findings of the thyrotoxic goiter heart are characterized 

 by (1) a prominent outward bowing of that portion of the left border of 

 the heart which represents the pulmonary artery, (2) an active pulsation 

 of the entire left border of the heart, (3) a high, narrow aortic shadow, 



