40 



minutes after the atropine injection there is 

 some improvement in the conductibility; 

 there appear 2 beats in 1:1 rhythm. It is 

 remarkable that far from the auricular rhy- 

 thm being accelerated, it is on the contrary 

 slackened, 70: 65. 



Observation no. 43. 



Paitial block, 1, 2, 3. Agony, (avexame). 



I. N. C, mulatto, male, 20 years old, 

 laborer, single, resident at Jatobá. 



About ten years ago he had intermittent 

 fevers aud mentions nothing else. This pa- 

 tient has had fatigue, pains in the legs, pain 

 in hypochondrium, attacks of palpitation 

 with very rapid precordial beat accompan- 

 ied by agony Giddiness, especially when 

 getting up. He does not mention attacks. 

 Has had edema but not at the time of exam- 

 ination . 



Under-sized individual. Marked pale- 

 ness. Heart enlarged. Apex in fourth space 

 in the mammillary line. Right margin 4_cni. 

 from the midsternal line. Precordial shock 

 diffuse and strong, shock double as if re- 

 duplicated in the pulmonary area First 

 sound prolonged, weak, without murmur. 

 Second sound reduplicated and accentuated 

 in the pulmonary area. Mesosystolic mur- 

 mur in the pulmonary area. Pulse irregular, 

 arrhythmic and very variable. Sometimes 

 slow, about 50 beats, sometimes rapid, with 

 extrasystoles chiefly brought on by emotion. 

 Number of beats lying down 52; standing 

 62; after exercise 66. Beat of neck-veins 

 very clear with more waves than the radial 

 pulse. In the ventricular pauses is heard 

 a muffled tone of auricular contraction which 

 is not transmitted. 



j Before -65 fmx. 135. 

 Katzenstein | During 68 Tmx. 145. 

 I After -54 



When standing the number of pulsa- 

 tions rises to 76, and after exercise to 84. 



Liver not enlarged. Spleen enlarged. 

 Marked gastric dilatation. Thyroid much' en- 



larged. Inguinal and epitrochlear glands 

 slightly enlarged . 



Records nos. 42 and 42-A. 



The tracings are identical, varying only 

 as to the velocity of the record. 



The tracings of heart and pulse are 

 analogous and show irregular and arrhyth- 

 mic beats, the origin of which can be trac- 

 ed by the analysis of the jugular pulse. 

 Here the a waves are seen succeeding each 

 other very frequently; some of them are 

 blocked. The block is irregular, sometimes 

 in the proportion of 2:1, sometimes 3:1. 

 At some points, as at beat XI, it is difficult 

 to decide whether the rhylhni has returned 

 to 1 ; 1 with a greater lengthening of the a 

 c interval or whether the beat is extrasyslol- 

 ic. 



Observation no. 44. 



Partial block. Stokes-Adatns' syndrome. 

 Harmful action of digitalis. 



A. A. C , male, 39 years, resident at 

 Cúrvelo. 



Examined December 12, 1914. 



The patient dose not mention lues nor 

 are there any signs of it. He has had pal- 

 pitations now for four years, and for the 

 last two has had passing giddiness. About 

 one month ago he had giddiness causing 

 him to fall and lose consciousness; the 

 giddiness lasts for some seconds but occurs 

 rarely. After the use of digitalis had gid- 

 diness more often. 



Pulse slow, 34 radial pulsations to the 

 minute. Sometimes cardiac bigeminism, the 

 second beat not being perceptible in the 

 pulse. Cardiac area frankly increased. 



Liver enlarged. 



This patient came back to consult us 

 six weeks after the first examination. He 

 has had no more giddness. Pulse more rap- 

 id, 60 beats. There are lapses in the radial 

 pulse which correspond to long cardiac di- 

 astoles in which a tone, problably of block- 

 ed auricular systole, is heard. In the in. 



