22 



from pains in the legs and vague pains in 

 the body. These were followed by palpi- 

 tation, precordial pulsation which extended 

 to the veins of the neck and were felt in 

 the ears; the beats are strong and provoked 

 by emotion or exertion, or come on even 

 while the patient is quiet or during sleep, so 

 ihat he wakes with a start. He is fatigued 

 by ¡the slightest exertion and scarcely able 

 to walk 20 or 30 meters without fatigue ac- 

 companied by palpitations and cold sweat. 

 Abundant sweating even when quiet. Gas- 

 tric disturbances; the ingestion of food 

 causes much agony ("avexame"). 



Cardiac percussion area not increased. 

 Apex beat at the fifth intercostal space, 7.5 

 cm. outside the midsternal line; right mar- 

 gin 2,5 cm. from the midsternal line. Heart 

 sounds without noticeable change. No mur- 

 murs; 76 beals with numerous extrasystoles 

 in bigeminal series. 



Í before -7Ô ps. Tmx. 130 



Katzensteinj during-82 < < 130 



I after -72 « « 130 



Atropine test. Pulse 108 standing. 



Liver not enlarged nor painful on pres- 

 sure. Spleen not enlarged. Thyroid not no- 

 ticeably enlarged. Inguinal glands slightly 

 enlarged. Further examination on July 13, 

 1913. For some time the patient showed 

 marked improvement, but a fortnight ago 

 he became worse again. The old disturb- 

 ances appeared anew with increased edema 

 of the face. Cardiac area not modified. First 

 sound reduplicated ; the second accentuated 

 in the pulmonary focus. 70 pulsations with 

 extrasystoles. Tmx.=rl35. Liver slightly en- 

 larged and painful. 



July 24, 1913. 



Pulse in vertical position, 100. Occas- 

 ional extrasystoles. 



Ibefore-72 ps. Tmx. 145. 

 during -72 « « 140. 

 after -78 « « 140. 



Record no. 13. 



The radial pulse is irregular on account 

 of the interpolation of numerous ventric- 



ular extrasystoles, which are easily seen by 

 the legend. 



13 a) After the injection of atropine 

 the number of extrasystoles diminished 

 considerably, only one being recorded in a 

 number of tracings. It was of ventricular 

 origin. 



Observation no. 15. 



Ventricular extrasystoles. Fainting attacks. 



S. A., 36 years, female, resident à^ 

 Santa Rita. 



Examined April 2, 1911. 



Marked melanodermia. Absence of arter- 

 iosclerosis. Large goiter. Cervical glands 

 enlarged. In the last few days the patient 

 has had fainting fits. Liver not enlarged. 



Í before -91 ps. Tmx. 105 



Katzenstein ! during— 78 « « 105 



I after -91 « « 105 



Numerous extrasystoles. 



Record no. 14. 



The radial and cardiac tracings show 

 strong arrhythmia, but the dominant rhythm 

 is to be seen in the group of pulsations to 

 the right of the central vertical line. This 

 rhythm is interrupted by numerous extra- 

 systolic beats. The combined analysis of 

 the 3 tracings elucidates the nature of these 

 extrasystoles. In group I, II, III, IV. The 

 beat IV is of ventricular extrasystole as the 

 legend shows. The group a, b, c, d, f, is 

 more complex. To 5 auricular beats there 

 are 6 ventricular ones. This is because the 

 extrasystolic beats c and d succeed each 

 other rapidly. The a III wave falls within 

 the refractory period of the cycle and is 

 blocked. The premature beat c is anterior 

 to a IV being very much anticipated and 

 does not prevent the excitation of the lat- 

 ter being transmitted to the ventricle, increas- 

 ing only the time of conduction. The beat 

 of cycle (d) might he considered dependent on 

 a 111, with very much delayed rate of conduc- 

 tion of the stimulus. The polygraphic tracing 

 is not sufficient to elucidate the case. The 



