19 



beat in the 4th intercostal space, 7.5 cm. 

 from the midsternal line ; right margin 3.5 

 cm. from the midsternal line; no increase 

 of the cardiac area. First sound muffled; 

 second reduplicated, with pulmonary acc- 

 entuation. No murmurs. Pulse very visible 

 in the veins of the neck. Pulse full and 

 unstable, accelerated on any emotion. Ex- 

 trasystolic arrhythmia. Number of pulsations 

 varying from 96 to 85 when lying down, the 

 extrasystoles being more numerous when 

 the pulse is more rapid. Standing, the 

 number of pulsations rises to 100 and after 

 slight exercise to 108. Tmx=140. 



Liver not enlarged. Spleen slightly en- 

 larged. Thyroid enlarged, with slight ex- 

 ophthalmus. Peripheral glands not enlarged. 

 Menstruation regular, generally accompanied 

 by slight pains. There are signs of double 

 ovaritis. 



July 15, 1913. General condition without 

 noticeable change ; but the indefinite malaise, 

 agony and following palpitation continue, 

 88 beats per minute. Tmx=130. 



Record no. 5. 



The radial tracing shows that extrasys- 

 toles interrupt the dominant rhythm fre- 

 quently and that the latter is also variable ; 

 the a waves not being perfectly rhythmic. 

 On the right side of the tracing the arrhy- 

 thmia of the a waves and of the pnlse are 

 accentuated by the movements of deglutition; 

 acceleration at the moment of swallowing 

 and subsequent retardation. 



The exlrasystoles are ventricular with 

 complete compensating period. This tracing 

 was taken at a time when the patient com- 

 plained of palpitation with strong feeling of 

 agony {''avexame" .) 



Observation no. 7. 



Ventricular extrasystole. 



E, A., Syrian; 20 years, male, single, res- 

 ident at Lassance for the last two years. 



Examined July 20, 1910. 



The patient is a native of Syria and has 

 been in Brasil for two years. About three 



weeks before being examined he noticed 

 that his thyroid had become enlarged and 

 felt uncomfortable. There were no other 

 morbid phenomena, or fever. 



Pulse regular, 64; the rhythm interrupt- 

 ted by extrasystoles. Slight signs of cardiac 

 insufficiency, with positive Katzenstein test. 



Record no 6. 



The rh>thm of the radial tracing inter- 

 rupted by a feeble extrasystolic beat which 

 according to the analyses of the jugular trac- 

 ing seemed to be an interpolated extra- 

 systole (marked c). 



Observation no. 8. 



Interpolated ventricular extrasystoles. 



E. A. , resident at Santa-Maria. 



April 2, 1911. 



Large goiter. Liver enlarged. Signs of 

 cardiac insufficiency. 57 pulse-beats, when 

 lying down. Tmx=lOO. Frequent extrasys- 

 toles. 



Record no, 7, 



Radial tracing rhythmic and regular, 

 with extrasystolic interruptions. Slow pulse, 

 53 beats per minute. The jugular tracing 

 shows that the extrasystoles are of ven- 

 tricular origin. There are two extrasystoles 

 to be seen in this tracing; the first rather 

 anticipated the c rise coinciding with the a 

 wave: the second still more anticipated the 

 c rise coinciding with the ascending phase 

 ofthe a wave. Auricular rhythm unchanged. 

 The a c interval lengthened after the extra- 

 systoles. 



Summary : ventricular extrasystole, slow 

 heart. At the extreme right of the tracing 

 an interpolated extrasystole. 



Observation no. 9. 



Ventricular extrasystoles. Cardiac insuf- 

 ficiency. 



M. R. , negress, 30 years, resident at 

 Santa Rita. 



