37 



ute; the pulse became regular one hour 

 after the injection; arterial tension unchang- 

 ed. The analysis of the tracing shows the 

 details of the arrhythmia, and the influence 

 of atropine on the cardiac rhythm. Progress 

 of disease: on the day following the first 

 examination gave 70 beats lying down, and 

 60 standing, as the lapses were morfe fre- 

 quent in the latter position. Pills of quinine 

 and belladonna were prescribed. 



5, 3, 1913. 



Infiltration considerably diminished, ab- 

 domen less voluminous. Arrhythmia persist- 

 ing and mesosystolic murmur at apex is 

 audible when the patient is lying down, and 

 not when standing. 



6, 3, 1913. 



Standing 87 beats; lying on his back 76. 

 General condition much improved. 



7, 3, 1913. 



Size of heart diminished; apex a little 

 below and outside the mammillary line, 7,5 

 cm. from the midsternal line. Right margin 

 3,5 cm. from the midsternal line. Beats 85 

 lying down, the pulse ample, regular and 

 rhythmic. Liver measuring 10,5 cm. at the 

 mammillary line. Spleen unchanged. Stomach 

 dilated, prominent in the epigastric region. 

 The patient took the medicine referred to 

 on the third, fourth, and sixth. 



23, 3, 1913. 



General condition of the patient much 

 improved so that he can run about 200 

 meters wijiout fatigue. Size of heart dimin- 

 ished; transverse diameter 10,5 cm. Number 

 of beats lying down 96; standing 124: pulse 

 arrhythmic, with frequent lapses. Tmx.=:110. 

 The patient was not seen for a month and 

 a half and only returned on the fifth of June, 

 1913. His general condition was good, and 

 he no longer had fatigue or edema. Heart- 

 Apex in fourth intercostal space on a level 

 with the mammillary line. 7,5cm. from the 

 midsternal line. Right margin 3,5 cm. First 

 sound slightly muffled; mesosystolic murmur 

 at apex. Pulse regular and arrhythmic. 

 Beats lying down 70; standing 82; after 

 çxercise 96; decreasing rapidly to 82. The 



patient was re-examined in January 1919, 

 about six years later. He had signs of 

 slight cardiac insufficiency, dyspnea on exer- 

 tion, acceleration of the pulse after slight 

 exercise and change of position. Heart en- 

 larged, apex beat outside the mammillary line. 

 Precordial shock wide and somewhat vio- 

 lent. First heart sound slightly muffled and 

 lengthened. No murmur. Pulse rhythmic, 

 with no discordancy between the cardiac and 

 radial beats. The enlargement of the heart 

 was confirmed by an X-ray examination 

 made by Dr. R. Duque-Estrada. 



Record no. 39. 



The radial pulse and heart tracing show 

 frequent lapses which correspond to each 

 other; they appear irregularly, sometimes 

 alternately, sometimes after two or three 

 beats, followed by the dominant rhythm. 

 Tnese also do not occur in perfectly equal 

 cycles. In the venous pulse the a waves are 

 ata rapid rate, 115 per minute and rhythmic; 

 The a c interval is variable, augmenting 

 gradually after every lapse of tha pulse, as 

 may be seen more clearly from a XXI c 

 ouwards. The lapses of the pulse are due 

 to the irregular block of the auricular waves. 



Record no. 39-A, 39-B, 39-C,39-D,39-E,39-F.Il, III, IV.V.IV 



Show the effect of half a milligram of 

 atropine. In tracing II there is nothing note 

 worthy, besides what has already been 

 said of 1, except that the rate of the auric- 

 ular wave beats is less rapid. 



Record no. 39-B (III). 



Taken 20 minutes after the injection of 

 atropine shows that the rhythm of the radial 

 beats is already reestablished, and the a c 

 interval is normal. Acceleration of the beats 

 is minimal, 103 to 109, and the action of 

 the atropine on the conductibility lasted an 

 hour, although it is to be noticed that the 

 rate is slower, 103 to 100. 



Record no. 39-F (VI). 



Shows that the effect of the atropine 

 on the conductibility is diminishing; thcac 



