32 



the normal cycle. The foUowyng extrasistole 

 is ventricular. The beat which follows the 

 extrasystole begins a series of beats of the 

 dominant rhythm; its cycle is lengthened by 

 the retardation of the following ventricular 

 Systole, on account of the delay in the con- 

 duction of the contractile stimulus. The a c 

 interval is lengthened. 



Thus the arrhythmia comes from ven- 

 tricular extrasysloles, interpolated or other- 

 wise, and from the alteration of the conduct- 

 ibility. 



I!) The tracing shows a tachycardia! 

 crisis with a rate of 130 beats per minute. The 

 radial pulse shows a very noticeable alter- 

 nation. Jugular pulse with high rhythmic 

 waves at the same rate as those of the ra- 

 dial pulse, which are the auricular waves 

 coinciding with the ventricular waves of the 

 anterior cycle that are marked at the origin 

 of the a waves. The tachycardial crisis is 

 therefore probably due to a succession of 

 auricular extrasysîolic waves at a rapid rate 

 transmitting themselves to the ventricle with 

 delay. The a c interval much lengthened- 

 At the right side of the tracing are seen 

 some beats of the dominint rhythm and 

 many extrasystolic beats. 



III) This shows bi and trigeminal rhythm 

 from ventricular extra-systoles. 



IV) Tracing 32-c shows the effect of 

 digitol. 



The effect on the conductibility is man- 

 ifest; the a c interval is much lengthened» 

 having apparently at some points "ventric- 

 ular escape". Numerous extrasystoles in bi- 

 and trigeminal groups. 



Observation no. 34. 



Vc?itricular extrasystole. Lengthening of 

 the a—c interval. Cardiac insufficiency. 



J. D., mulatto, male,^ laborer, married, 

 resident at Contria. Previous history only 

 mentions intermittent fevers. For a long time 

 he has been subject to attacks of palpitation, 

 without having his general condition affected. 

 About a year ago the patient began to feel 

 weakness in the legs and dyspnea on exer- 



tion which increased gradually, preventing 

 him from working. Lately he has had dysp- 

 nea from lying down, also at night, a cough, 

 and edema of the lower extrémités and face. 

 The palpitation has considerably increased 

 in frequency and intensity, it may be even 

 brought about by drinking water. Heart much 

 enlarged. Apex beat in the sixth space, near 

 the anterior axillary line, 13 cm. from the 

 midsternal line. Right margin 4, 5 cm. from 

 the midsternal line. Precordial shock intense 

 and wide. Epigastric beats intense. First 

 sound very muffled, with slight murmur at 

 the apex. Second sound muffled. Pulse very 

 irregular, with frequent extrasystolic lapses. 

 The number of pulsations is more or less 

 82 per minute. Tmx.=120. Pulse 95,',standing. 

 Liver considerably enlarged. Spleen not en- 

 larged. Thyroid enlarged, with voluminous 

 cysts of the lateral lobes. Edema. Bronchitis. 

 Glands enlarged. 



After a few days in hospital the patient 

 was discharged as he was much better. He 

 came back on June 5, 1913. Edema. Intense 

 dyspnea after the slightest effort. Nocturnal 

 dyspnea. Frequent palpitation. Heart contin- 

 ues much enlarged. Apex 12,5 cm. from 

 the midsternal line, within the anterior axil- 

 lary line. Right margin 4,5 cm, from the mid- 

 sternal line. Precordial shock ample and 

 violent, shaking all the' precordium. First 

 sound muffled, second reduplicated, with 

 strong pulmonary accentuation. Cardiac beats 

 very irregular, with slight repeated crises of 

 tachycardia; number of beats varying be- 

 tween 75 and 82 per minute. Tmx.^110. 

 Turgescence of the veins of the neck. (See 

 tracings). Liver much enlarged. Spleen^not 

 palpable. Slight : improvements ^oniy; the 

 treatment was interrupted. We heard that he 

 died in asystole a month. Rafter leaving the 

 hospital. 



Records nos. 33 nda 33-A. 



May 11, 1913. 



I) The radial pulse shows belts of the 

 dominant rhythm, their sequence interrupted 

 by extrasystolic cycles. The beats proper of 



