41 



terval between the two examinations the 

 patient stopped taking digitalis. 



Record no. 43. 



The radial pulse is irregular and arrhyth- 

 mic. In the jugular tracing the a waves 

 follow one another regularly but are irregul- 

 arly blocked, sometimes with rhythm 2:1, 

 and sometimes with 3:1. 



Observation no. 45. 



Total block. Stokes-Adams' syndrome. 



M. A. L., male, 54 years of age, resi- 

 dent at Cúrvelo. 



Examined October 22, 1914. Previous 

 history unclear; no sure indication of syphi- 

 litic infection, of which there are no traces. 

 The patient complains of epigastric anxiety, 

 sensation of oppression and vague pains in 

 the precordial region. For seven months he 

 has had attacks of giddiness for a minute 

 or more, without convulsions, brought on 

 by a short run or any other effort, some- 

 times coming on at short intervals for some 

 hours on stretch . Copulation always brings 

 on these attacks. Abundant eructation with 

 aerophagy. Pulse slow, 32 beats, lying down 

 or standing. Cardiac auscultation during the 

 long pause reveals a short tone of blocked 

 auricular contraction at varying intervals 

 from the cardiac systoles. 



Record no. 44. 



The radial pulse accompanies the car- 

 diac tracing in slow beat — 32 a minute. The 

 waves are regular and rhythmic. The venous 

 tracing shows more frequent auricular waves, 

 65 per minute, but not in constant relation- 

 ship to the ventricular systolic waves. The 

 block is total, the ventricle following its own 

 rhythm . 



Observation no. 46. 



Total block. Stokes-Adams' syndrome. 



J. 0.,male, white, 12 years, resident 

 at Gustave de Silveira. 

 Examined July 9, 1912. 



Family history: Mother strong, 45 years 

 old; father died suddenly; he suffered from 

 heart trouble. Eleven brothers and sisters 

 alive and strong; one brother died at the 

 age of three and one was still-born . Personal 

 history; the patient was strong until seven 

 months ago and does not mention having 

 had any illness until then. About seven 

 months ago he began to have dyspnea on 

 exertion, at first only when he had to walk 

 far and fast; now he has it even when he 

 walks slowly on flat ground. Weakness in 

 the legs. Giddiness. No edema. Has had 

 fainting fits and loss of memory, sometimes 

 with convulsions. 



The boy is well developed, pale and has 

 myxedema in a slight degree. No edema. 

 Heart enlarged; apex beat in fifth space, 

 9 cm. from the midsternal line. Sounds 

 quite audible. First sound is accompanied 

 by musical systolic murmur within the apex 

 not propagated. Second sound reduplicated 

 and reinforced in the aortic area; at times 

 an isolated tone of auricular systole, which 

 is not transmitted, is to be heard at the 

 ventricular diastole, 37-38 a minute. Liver 

 enlarged. Spleen not enlarged. Thyroid 

 enlarged. Nervous system negative. Re- 

 spiratory system negative. 



July 19, 1912. 



Between the two examinations the 

 patient had three attacks. Slight edema of 

 face and limbs. Pulse 37; physical condition 

 of the heart unchanged. 



Record no. 45. 



A classic total-block tracing. The radial 

 waves and the apex beats succeed each other 

 rhythmically; pulse slow; 37. In the jugular 

 tracing the c waves show no stable relation 

 to the a waves; they are more numerous, 

 100 per minute. The a waves succeed each 

 other rhythmically; sometimes they are ele 

 vated, at others less marked, according to 

 whether they do or do not fall within the 

 ventricular systolic period. C. V. (E inter- 

 val). No atropine test. 



