38 



interval is airead)' much lengthened, being 

 equal to four tenths of a second. On the 

 other hand, the rate is much less than be- 

 fore the injection of atropine, 92 to 103. 

 The conductibility is kept in good condition 

 by the use of belladonna with the rate com- 

 paratively slow: 85 beats per minute. 



Record no 39-H (VIII). 



Shows a return to the former state of 

 partial block, with varying lapses i!i the 

 conduction. The patient had left off taking 

 belladonna some days before this tracing 

 was taken. 



Record no. 39-1 (IX). 



Taken about six weeks after the last; 

 this tracing is quite normal: rhythmic beats; 

 conductibility reestablished as indicated by 

 an a c interval of normal length. 



Record 39-J (X». 



This tracing was taken six years after 

 the preceding- one. The pulse is perfectly 

 rhythmic, the restored conductibility contin- 

 ues. Compression of the eye-balls retards 

 the cardiac beats very much and remains 

 after the compression has ceased. The a c 

 interval is normal even after ocular compres- 

 sion. 



Observation no. 41. 



Partial block. Rhythm 2 : /. 



M. P. F., mulatto, male, 30 years old, 

 laborer, single, resident at Andrade Quicé. 



Examined May 4, 1913. The patient had 

 always been well until about two years ago 

 when his present illness began. Fatigue and 

 palpitation with heavy heart thumps. He 

 had edema which disappeared. Some two 

 years ago the patient had malaria. A few 

 days before he came to consult us he had 

 caught cold and had catarrh in the nose and 

 bronchi at the time of examination. Liver 

 and spleen much enlarged and painful on 

 pressure. Thyroid very much enlarged. 

 Glands generally enlarged. Heart much in- 

 creased in size. Apex 12 cm. outside the 



midsternalline; right margin 4 cm. Precord- 

 ial shock large being perceptible in the third, 

 fourth, fifth and sixth . Apex in the sixth 

 space, and passes the mammillary line by 2,5 

 cm. First sound lengthened and muffled. 

 Mesosystolic murmur, not propagated. Sec- 

 ond sound tympanitic and accentuated in 

 the pulmonary area. Pulse ample, full and 

 slow. Beats of the neck veins very easily 

 visible, twice more rapid than the radial 

 pulse. Atropine test. (See records). 



May 5, 1913. 



Yesterday's examination was made after 

 a long journey and an attack of malaria. 

 After a rest and quinine. 



Heart perceptibly diminished in size. 

 Apex in the fifth space, a little outside and 

 below the nipple, 11,5 cm. from the mid- 

 sternal line. First sound clearer, with incon- 

 stant murmur when lying down, which disap- 

 pears when the patient is standing. Number 

 of beats lying down 70; standing 40;. When 

 standing, the beats are regular and slower; 

 during the long pauses there are auricular 

 contractions to be heard. After the patient 

 has been standing for some time they be- 

 come irregular; there appear rapid and slower 

 series in succession. Number of beats vari- 

 able, ranging from 66 to 82. 



This takes away the value of the Katz- 

 enstein test, during which the following 

 interesting fact was noticed; at the beginning 

 of the compression of the femorais the heart 

 became perceptibily dilated; apex beat in 

 the sixth space. When the compression was 

 continued for five minutes, it returned to 

 the fifth space as before compression. 



Record no. 40. 



Partial ulock. Ventricular and nodal 

 extrasystole. The venous tracing shows 

 rhythmic a waves at a rate of 107 per min- 

 ute. Thee waves follow each other alternate- 

 ly after each a wave, the a c interval length- 

 ened. The retarding of the ventricular 

 systole thus caused, and the frequency of the 

 auricular rhythm, make the a waves fall 

 alternately in the refractory phase of the 

 former systole, so that they are blocked. 



