23 



beats marked on the left of the tracing are 

 susceptible of the same interpretation. 



Observation no. 16. 



Ventricular extrasystole. Cardiac insuf- 

 ficiency. Spasm of the esophagus. 



J. G. , white, male, 39 years old, res- 

 ident in Beltrão. 



April 7, 1911. 



The patient complains of palpitation, 

 fatigue on exertion and nocturnal attacks of 

 suffocation and giddiness. He also has dif- 

 ficulty in swallowing solid food, spasms of 

 the esophagus, which oblige him to drink 

 water after every mouthful. Well-marked 

 bronze coloring. Large goiter. Spleen slight- 

 ly enlarged. 110 beats 'when lying down, 

 130 standing. Tmx. 115. Numerous extra- 

 systoles. 



Record no. 13. 



April 7, 1911. 



Radial pulse with regular dominant 

 rhythm, with slightly increased rate, 83 per 

 minute; interrupted by extrasystolic beats 

 which occur irregularly. The extrasystolic 

 beats have a complete compensating period 

 of rest. Jugular pulse; the a c v waves 

 occur in the normal succession; wave c in 

 some points hardly noticeable. Wave a not 

 raised. In the cycles interrupted by extra- 

 svstoles, the latter only appear synchro- 

 nously with the auricular contraction, whence 

 the fusion of waves a and c indicated by 

 the legend. Auricular rhythm not modified 

 except slightly by the respiratory movements. 

 The extrasystoles are of ventricular origin 

 and more or less premature. 



Summary: ventricular extrasystoles oc- 

 curring irregularly. 



Observation no. 17. 



Ventricular extrasystole. Bigeminism. 



M.M.; 38 years old, female, resident at 

 Porto-Faria. 



April 19, 1911. 



Complains of lumbar pains and pains 



in the stomach. Frequent attacks of palpi- 

 tation. Large goiter. Melanic pigmentation 

 well-marked. Liver increased in size; 90 

 heart beats with extrasystoles in bigeminal 

 series. Tmx.=125. 



Record no. 16. 



This is a tracing of bigeminism of heart 

 and pulse with an intercalated trigeminal 

 group. The bigeminism is produced by the 

 regular succession of ventricular extrasys- 

 toles with compensating period of rest. The 

 trigeminal group is formed by the interca- 

 lation of an interpolated extrasystole in the 

 cycle. The a c interval which corresponds 

 to the beat of normal cycle which succeds 

 the exlrasystole is very much increased 

 and the next a wave is blocked. 



Observation no. 18. 



Ventricular extrasystole. Bigeminism. 

 Spasm of the esophagus {Mai de engasgo — 

 Difficulty in swallowing.) 



Examined May 23, 1913. 



Previous history; all that is worthy of 

 notice are pains in the joints which appear- 

 ed when the patient was 18 years old, and 

 which recur on cold and damp days. For 

 about three years the patient has had palpita- 

 tion. Feeling of limpness in the body and 

 pains in the legs. Dyspnea on exertion 

 and inability to work as well as his fellow- 

 laborers, being easily tired. Nocturnal dysp- 

 nea. Giddiness. Sensation of distension of 

 the stomach with acid eructations. Choking. 

 Sometimes the patient cannot swallow his 

 food without the help of water. Heart slight 

 ly enlarged. Apex beat in the fifth in- 

 tercostal space a little inside of the nipple, 

 9,5 cm. from the midsternal line. Apex 

 shock large and strong. No noticeable change 

 in the heart sounds. Pulse 65 per minute, 

 ample, full, and unstable, the number of 

 beats changing from one moment to an- 

 other. Acceleration of the pulse after swallow- 

 ing. Frequent extrasystoles, at times iso- 

 lated, at others in bigeminal series. 



