45 



es sonietimes a muffled sound to be heard; 

 it coincides with wave in the veins of the 

 neck and not to a ventricular contraction; 

 an auricular contraction sound. During the 

 examination numerous extrasystoles occur- 

 red, almost all of them not shown in the 

 radial pulse. Heart hearts 59. Pulse 36. 



Í before -59 Tmx. 160 

 Katzenstein I during -66 Tmx. 160 

 I after -69 



The extrasystoles were probably due to 

 the strong emotion brought on by the exam- 

 ination. Liver enlarged and painful on pres- 

 sure. Spleen also (Previous malaria). Thyroid 

 enlarged, with large goiter. 



Examined June 27, 1913. Patient calmer. 

 Occasional extrasystoles. Auricular sound 

 very audible Pulse varying between 32 to 

 35. Standing: 40. 



J Before -36 Tmx. 168. 

 Katzenstein During-44. 

 I After 44. 



The increasing of the beats after com- 

 pression of the femorais is due to the nu- 

 merous extrasystoles. Atropine test: While 

 the effect lasted the pulse became regular. 

 Iliac compression hardly alters the number 

 of beats. 



Before compression: 36 

 During « : 36 



It is interesting to note that emotion and 

 compression of the femorais brings on ex- 

 trasystoles. 



Record no. 49. 



February 27, 1913. 



Pulse interrupted by a beat of a lesser 

 cycle followed by the dominant rhythm. 

 The cardiac record shows the same success- 

 ion of beats with the same rhythmic cycle 

 of 9, interrupted by a lesser one of 6. In 

 the diastolic phase are seen diastolic rises 

 corresponding to the rises of the jugular 

 record. Jugular record with a series of rises 

 of equal cycles not in constant relation to 

 t'iie c waves; son'ie are not accompanied by 



ventricular contraction. They are p waves 

 which are not transmitted to the ventricle. 

 Total block. 



Taken 35 minutes after 0,001g atropine. 



The number of ventricular beats has 

 not changed much; 34:35. The number of 

 auricular beats diminished 100:76. The in- 

 dependence between auricular and ventric- 

 ular contractions continues. 



Observation no. 51. 



Complete block. Sudden death. 



A. F. C, male, white, 29 years, old, 

 laborer, married, resident at Maquiné. 



Previous history : attacks of intermit- 

 tent fever and gonorrhea some years before. 

 Has been feeling ill for about a year, fa- 

 tigue on exertion, cannot walk fast, nor go 

 up-hill, as he is so easily tired. He could 

 however do ordinary farm work. About 

 five months ago he became considerably 

 worse, fatigue increased, his stomach seem- 

 ed to. have swelled and has pains like a 

 belt round his stomach and gastro-intestinal 

 pneumatosis. The dyspnea has become grad- 

 ually worse and comes on after the slight- 

 est effort or even when at rest, specially 

 when lying down and at night, so that he 

 can only sleep propped up. At times can- 

 not sleep at all on account of nocturnal 

 dyspnea and cough. Lately, he has had 

 edema of lower limbs, which afterwards ex- 

 tended. Palpitation with uncomfortable heart 

 beats. Has an uncomfortable feeling on ac- 

 count of the extrasystoles which he says 

 ''makes his heart beat twice in one beat" and 

 is accompanied by uncomfortable feeling 

 of fatigue. At times he feels rapid, strong 

 and very uncomfortable beats. 



Present condition, general edema. Dysp- 

 nea which gets worse aficr the slightest 

 effort or when lying down. 



Turgidity of neck veins with well-mark- 

 ed pulsation. Prominent swelling of the 

 precordial region. The area of cardiac dul- 

 ness very much increased. Apex beat in 

 sixth space, beyond the anterior axillary 

 line, 18 cm. from the midsternal line. Pre- 



