52 



rhythmic pulse. In fact there is no method 

 whatever in the order of beats which suc- 

 ceed each other in a completely arrhythmic 

 and irregular way; the cycles vary in dura- 

 tion from one to the other and the ampli- 

 tude is not in direct proportion to the dur- 

 ration of the preceding pause. In the ju- 

 gular pulse are seen little waves which re- 

 cur with great frequency, about 500 a min, 

 ute. These represent auricular contractions- 

 alrr.ost fibrillation, which appear in the fol- 

 lowing record . 



HI) Was made about one month after 

 lhe last one. In the jugular pulse it is seen 

 that the ventricular waves appear as acute 

 rises in some points and that the signs of 

 movement of the auricles are marked by 

 small undulations. The pulse is completely 

 arrhythmic. 



IV) Two days afterwards, under the in- 

 fluence of digitol, the venous pulse has the 

 appearance of a ventricular venous pulse; 

 there are series of bigeminal pulsations, 

 one of which is seen in the record. 



Observation no 60. 



Auricular fibrillation. Cardiac insuffici- 

 ency . 



E. J M., mulatto, 50 years old, mar- 

 ried, laborer, resident at Lassance 



Examined December 8, 1912. Previous 

 history, malaria. For about five months he 

 has been feeling ill with fatigue on exertion, 

 which he had never felt before No dysp- 

 nea on lying down or at night, sleeps well. 

 He has had slight and transitory edema. 

 His legs feel heavy. Giddiness at times 

 very marked. Attacks of palpitation which 

 come several times a day; strong and rapid 

 heart-beats, coming on without apparent 

 cause and causing agony. Sometimes the 

 beats are strong and slow, ''measured"; his 

 heart seems to be ''pushing". At present 

 edema of legs and abdomen. Heart much 

 enlarged; apex in the seventh space on a 

 level with the midaxillary line, 16 cm. from 

 the midsternal line. Inside apex there is 

 systolic retraction of the fifth, sixth and 



seventh spaces. Right margin 4 cm. from 

 the midsternal line. First sound lengthened, 

 dull, without murmur. Second sound redu- 

 plicated. Beats arrhythmic and slow. Pre- 

 cordial shock strong, shaking the whole 

 precordium. 



j before 51 Tmx. 125. 

 Katzenslein during -52 Tmx. 

 I after- 48 



Liver enlarged and painful on press- 

 ure. Spleen same. Thyroid much enlarged. 



Dec. 9, 1911. 



^Palpitation during the night and early 

 in the morning; 47-48 beats Complete ar- 

 rhythmia Tmx. 125. Atropine did not 

 perceptibly modify the pulse. 



December 10, 1912. 



Slight improvement. 



December 12, 1912. 



More marked improvement; was dis- 

 charged. He died months later in asystole. 



Record no. 59. 



Pulse absolutely irregular. The beats 

 succeed each other in varying spaces, so 

 that it cannot be foreseen where any given 

 beat will fall. There is also no direct and 

 constant relation between the preceding 

 pause and the amplitude of the beat. At 

 first sight it seems to be abi-and trigemi- 

 nal pulse, but there are many variations. In 

 some points there are pauses which seem 

 to be compensating pauses and do not ap- 

 pear in other points. The jugular pulse 

 has the characteristic appearance of a ven- 

 tricular venous pulse. The only really dis- 

 tinct waves are c and v. The a wave does 

 not appear on the record . Rate of beats 

 slow. At some points of the long diastolic 

 phases (before and after the beat) are seen 

 small undulations, which might he consider- 

 ed as the auricular fibrillations which exist 

 in these ca^es. The same aspect of fibril- 

 lation is seen in the heart record. It is a 

 case of complete arrhythmia; with ventricu- 

 lar venous pulse and auricular fibrillation. 

 The records I, II, and III show slow rate 

 with complete arrhythmia and ventricular 



