- 33 



the dominant rhythm are not perfectly rhyth- 

 mic, there being variations; the examina- 

 tion of the jngular pulse shows them to 

 arise from different causes. 



First of all, the rate of the a waves is 

 not regular, sometimes more rapid, some- 

 times slower. Some waves are so much anti- 

 cipated that they seen to be rather auricular 

 extrasystoles than beats of the dominant 

 rhythm. 



The conduction of the stimulus retarded, 

 and the delay of the conduction also contrib- 

 utes to the arrhythmia. The extrasystoles 

 are generally ventricular. II) Tracing 33-0 was 

 taken 15 days aftar the anterior one, and 

 does not differ from it substantially. The 

 rate is more rapid and the conduction slow- 

 er; the a waves often fall in the systolic 

 phase of the previous cycle. 



The extrasystoles are numerous and of 

 ventricular origin, and in the first part of the 

 tracing an interpolated extrasystole is seen. 



Observation no. 35. 



Partial block. Rhythm of 2:1 and of 1:1. 



J. C. de A., mulatto, male, 28 years old, 

 laborer, married, resident at N. S. da Gloria. 

 Previous history of attacks of malaria nearly 

 every year. Some attacks of bronchitis with 

 chills. He does not mention venereal disease 

 or rheumatism. This patient smokes and 

 takes coffee; formerly he drank spirits, but 

 he has stopped doing so for the last two 

 years. About two years a^o he had palpi- 

 tation, strong rapid and uncomfortable beats 

 and fluttering of the heart. The palpitation 

 came on in attacks sometimes after an 

 emotion and sometimes without any apparent 

 reason. Great irritability and nervous excit- 

 ability; he cannot stand being with many 

 people; any loud talking, or rapid nove- 

 ments or effort provoke an attack of pal- 

 pitation. This condition is accompanied by 

 trembling and a sensation of cold; the pa- 

 tient says he feels a ball in his stomach 

 which rises to the chest and throat, stopping 

 his breath and causing agony (avexame)_ 

 Frequent giddiness without causing him to 



fall. General weakness. Inability to work. 

 The slightest exertion fatigues him and 

 brings on palpitation and agony (ovexame). 

 He has good appetite, but the ingestion of 

 food causes uneasiness and abundant eructa- 

 tions. No edema. 



Heart enlarged. Apex beat in the fifth 

 space on a level with the mammillary line, 

 9,5 cm. from the midsternal line. Right edge 

 4 cm. from the midsternal line. Shock dif- 

 fuse. Pulse arrhythmic, with frequent pauses 

 which are not extrasystolic. The jugular 

 tracing shows the presence of a wave dur- 

 ing the long pauses of the ventricle. Pulse 

 ample, empty, soft, from 43 to 55. Tmx.=125. 

 The number of beats rises to 92 when stand- 

 ing and 100 after exercise. The neck veins 

 are not turgid; the jugular waves are very 

 visible. We proceeded to the atropine test. 

 The analysis of the tracings may be studied. 

 Liver enlarged, painful on pressure. Spleen 

 not palpaple. Thyroid without noticeable 

 enlargement. Inguinal glands slightly increas- 

 ed. Nervous system negative. Intellect nor- 

 mal. 



Record no. 34. 



I) The radial pulse is arrhythmic, uot only 

 on account of the lapses of the pulse after 

 three or four beats of the dominant cycle, 

 but also because the cycles of the dominant 

 rhythm are not exactly equal. In the venous 

 pulse, a waves are seen in regular success- 

 ion. There is also no ventricular systolic 

 wave in the venous pulse at the points 

 which correspond to the lapses of the radial 

 pulse. The lapses come from the block of 

 auricular waves. Immediately after a blocked 

 wave, the a c interval of the following cy- 

 cles is normal, but it lengthens gradually 

 in the following cycles until a new bl^ck 

 occurs; this goes on in succession. The grad- 

 ual retardation of the ventricular systoles 

 by the changed conductibility explains the 

 variation in the rhythm of the radial pulse. 



Record no. 34-A. 



II) In the tracing, which was taken half 

 an hour after the injection of a milligram of 



