44 



I) Radial record, on the right side, in 

 which is seen the dominant rhythm is 

 rapid, 100 a minute. 



In this record are seen slow beats oc- 

 cupying the space of two cvcles of the dom- 

 inant rhythm; they are probably due to 

 extrasystoles which are not represented in 

 the radial pulse. At some points they are 

 shown by slight beats. The third beat is 

 succeeded by two consecutive extrasystoles. 



II) Taken about six months after the 

 first; radial record similar to the cardiac 

 one, slow beats interrupted in their success- 

 ion by cycles of shorter diastolic phases. 

 The long diastolic phases are perceptibiy 

 twice as long as the short ones 



In the cardiac record small waves of 

 auricular contraction are to be seen in the 

 long diastolic phase, but none of ventricu- 

 lar systole. 



In the jugular pulse the a waves are mark- 

 ed rhythmically. They do not however all 

 have a corresponding ventricular wave as 

 many are blocked . The block is in 2: 1 rhythm 

 correspondingto the slower ventricular beats 

 and returns to 1 ; 1 in the rapid ventricular 

 beats. The a c intervals, where the rhythm 

 is 1: 1, as in cycle XIX, perceptibly length- 

 ened, 



III) About iwo years later; the tracing 

 is already that of complete block. The ven- 

 tricles beat regularly at the rate of 40 per 

 minute; nothing noteworthy in the radial 

 and cardiac tracings. 



In the phlebogram are to be seen auric- 

 ular waves at an accelerated rate of 100 

 ■per minute; there is no constant relation 

 between the auricular and ventricular rhyth- 

 ms. 



IV) After an injection of 0,001 g. atropine 

 there was no change in the relation between 

 the auricles and ventricles, nor in the ca- 

 dence. There appeared however a ventri- 

 cular extrasystole at the left of the tracing. 



V) Tracing taken little more than a year 

 later, during an asystolic crisis. Auricular 

 waves in the venous pulse show increased 

 rate, 120 per minute. A and c waves com- 

 pletely independent. On the left side of the 



tracing the ventricular beats marked in the 

 radial pulse and in the cardiogram; they 

 are rhythmic and at a rate of 40 per min- 

 ute. On the right side they aie irregular, with 

 numerous extrasystolic beats. The patient 

 complained of umconifortable heart-beatings 

 at the time. 



Observation no. 50. 



Total block. 



J. M. S., mulatto, male, 38 years old, 

 widower, laborer, resident at Areias, (near 

 Curvello). 



Examined June 26, 1«)13. Previous his- 

 tory only intermittent fevers. He has been 

 ill for about three months. Until then he 

 worked regularly without fatigue. At the 

 time he had violent giddiness, with dark- 

 ened field of vision, but without loss of 

 consciousness or fall. This giddiness did 

 not return but there appeared dyspnea on 

 exertion, and agony with weight in the stom- 

 ach. Lack of appetite; the taking of food 

 in even small quantities often provoked a 

 feeling of fulness, anxiety and fatigue. These 

 symptoms became gradually wors*', and 

 lately he has had dyspnea when lying down 

 and at night, preventing him from sleeping, 

 and also edema of lower extremities. Does 

 not complain of palpitation, and does not 

 feel the heart beats. The patient is of medi- 

 um height, well built and robust. 



At present edema of the lower extrem- 

 ities, neck veins turgid. Abdomen dis- 

 tended. Dyspnea on lying down so that the 

 patient cannot occupy a horizontal posi- 

 tion. Very emotional, much impressed by 

 the examination. Heart much enlarged. 

 Apex beat in the sixth intercostal space, 

 between the mammillary and axillary lines. 

 Right margin 4 cm. from the midstemal 

 line. Transverse diameter 15,5 cm. Precor- 

 dial area very prominent. Precordial shock 

 slow, diffuse and undulated. First sound 

 muffled and lengthened. Second sound re- 

 duplicate, with pulmonary accentuation. No 

 murmur. Beats arrhythmic with extrasysto- 

 les and long pauses. During the long paus- 



