in general, these are here somewhat com- 

 mon, indicating the exaggerated irritability 

 of the heart muscle. No common descrip- 

 tion of the tracings of extrasystoles would 

 be possible, and in each one of them we 

 find various factors which show the ex- 

 treme variability of this symptom and its fre- 

 quent association with other alterations of 

 rhythm. We here show some very demon- 

 strative analyses of tracings. 



The subjective symptoms that occur in 

 the course of this alteration of rhythm, or 

 consequent upon it, are of decided interest 

 aud will be referred to in the followiug 

 paragraphs. 



4. Auricular flutter. The alterations of 

 rhythm manifested by auricular flutter and 

 auricular fibrillation are among the rarer 

 observations, but are of the highest scientific 

 interest. We have various cases with alter- 

 ations of this nature and in them the es- 

 sential characteristics of these forms of ar- 

 rhythmia are well shown. Auricular flutter 

 has been observed in various degrees of 

 intensity with the number of auricular con- 

 tractions varying between one hundred sev- 

 enty and five hundred per minute. This 

 last figure is one of the highest yet regis- 

 tered in the medical literature and was seen 

 in a case that soon passed to the condition 

 of complete arrhythmia. The number of 

 auricular waves transmitted to the ventricle 

 has always been variable in the different 

 patients that we have observed, and no 

 fixed relation has existed between the 

 rhythm of the auricle and that of the ven- 

 tricle within the limits of the tracings. This 

 has given rise to irregularity of the radial 

 pulse and this fact also shows the high 

 grade of heart block of the cases of flutter 

 in this disease. 



Extrasystoles are also a somewhat fre- 

 quent simultaneous occurrence in the cases 

 that we are discussing, and their presence 

 also gives rise to a greater irregularity of 

 the cardiograms and of the radial pulse. 



Some of our patients exemplify the transit- 

 ion from flutter to auricular fibrillation, and 



other cases show intermediate phases be- 

 tween the two alterations of rhythm. 



6. Complete arrhythmia. The observat- 

 ions collected on complete arrhythmia have 

 been relatively small in number consider- 

 ing the high incidence of changes of the 

 heart rhythm in this disease. The cases in- 

 vestigated occur in more or less the classic 

 condition of this syndrome, as can be seen 

 from a study of the tracings. We see ven- 

 tricular venous pulse with waves of varia- 

 ble appearance, complete irregularity of the 

 radial pulse and of the cardiogram, and it 

 is sometimes possible to see in the jugular 

 tracing small undulations which indicates 

 the fibrillar state of the auricle. 



The two last forms of alterations of 

 rhythm without doubt express the greatest 

 intensity of the pathologic processes of the 

 myocardium in the disease, and also indi- 

 cate localisations of those processes in the 

 auricles, whose irritability becomes thus 

 manifestly augmented even up to absolute 

 inefficiency of the respective systolic move- 

 ments. 



From the beginning the affection of the 

 myocardium is most intense in the ventri- 

 cles as is well manifested by the extrasys- 

 toles originating in these regions. And when 

 the alterations of rhythm indicate marked 

 lesions of the auricles the prognosis be- 

 comes grave, as is shown by the termination 

 in death within a short time of all our cases 

 with auricular flutter and fibrillation. And, 

 on the other hand, we must emphasize the 

 relative scarcity of observations of these two 

 arrhythmias, a fact which is evidently at var- 

 iance with the constant intense lesions of 

 the heart muscle and with the great number 

 of other alterations of rhythm. On the best 

 of grounds we believe that the rarity of 

 these arrhythmias is only apparent as they 

 are difficult to be detected in clinical investi- 

 gations on account of the extreme gravity 

 of their prognosis. The patients affected with 

 them survive only a short time or remain in 

 extremely serious condition; and as they are 

 kept to their houses they escape the oppor- 



