THE DETAILS OF THE PHOTOGRAPHICALLY RECORDED VENOUS PULSE IN AURICULAR FIBRILLATION.

While auricular fibrillation is easily recognized by arterial and jugular tracings or by electrocardiograms, it is not possible to interpret all the waves found in these records. The venous tracings may in general be placed in one of two classes: (a) those in which prominent systolic waves predominate or occur alone; and (b) those in which large or small diastolic waves occur occasionally, in groups, or in a continued series averaging 250 to 500 per minute. The prominent systolic waves have generally been attributed to tricuspid regurgitation, the inference being that tricuspid regurgitation is a common state in auricular fibrillation. The diastolic waves are so numerous and so many electrocardiograms show diastolic waves that it is impossible to account for them on the assumption that the auricle is in a dilated and finely fibrillating state. It has been suggested that in these instances a condition of coarse fibrillation, which is closely allied to auricular flutter, obtains. The systolic and diastolic waves of the venous pulse of twenty-five clinical cases of auricular fibrillation, recorded by photographic methods, were studied. Six types of systolic waves (Text-Fig. 1) were found: (1) an intensified impact wave, the most common and often the only characteristic feature, indicating vigorous ventricular action; (2) a peaked impact followed by a rapid systolic drop due to light pressure of the tambour; (3) the intra-auricular type of systolic variation, so called from its resemblance to intra-auricular pressure curves found in animals, occurring in clinical cases only when ventricular systole is weak; (4) double systolic waves, attributed to a systolic tug of the ventricle on the auricles and large veins; (5) a systolic impact followed by a stasis wave, present when intravenous pressure is high; (6) a regurgitation wave composed of a steep rise continued into a systolic plateau with murmur vibrations superimposed. Our study showed (1) that tricuspid regurgitation, as indicated by the presence of regurgitation waves, is a rare accompaniment of auricular fibrillation; and (2) that the contrary opinion, arrived at by the frequent presence in polygraph tracings of ventricular types of waves, is due to the fact that the contour of intensified impact waves is distorted by polygraph levers so that they simulate regurgitation waves. Recurrent diastolic waves were frequently present in our records. Their relative size depended, to a considerable extent, on the pressure of the tambour. There was no constant relation to similar waves in the recorded electrocardiogram, nor is it proven that they are indicative of a coarse type of fibrillation or an associated flutter.