25 



which explains the lapses of the radial pulse. 

 The change in conductibility which appears 

 many hours after the action of the atropine 

 is interesting; this is not seen in other trac- 

 ings. Here also the variations of the domi- 

 nant rhythm are much greater. 

 Some beats (o^ c') are probably auricular 

 extrasystoles. 



Observation no. 20 



Interpolated extraventriciilar systoles. Pal- 

 pitations. Cardiac insufficiency. 



Examined December 29, 1912. 



M. F., mulatto, 40 years, female, married, 

 resident at Santa Rita. For some months the 

 patient has suffered from "agony" with 

 great fatigue, anxiety and uncomfortable 

 heart beats. Dyspnea when lying down. Pal- 

 pitation; attacks of strong and rapid beats, 

 sometimes provoked by exercise, by standing 

 or even coming on when the patient is 

 quiet without any special reason. Sometimes 

 the beats are slow and strong. Gastric uneas- 

 iness after swallowing, the ingestion of food 

 provokes agony. She feels better when she 

 is fasting. Frequent and abundant eructations. 

 A feeling of depression and general weak- 

 ness. Lack of appetite. Heart but slightly 

 enlarged, measuring 10,5 cm. at the base; 

 apex beat 8 cm. from the midsternal line, a 

 slight downward dislocation of the heart; 

 Sounds clear, the second somewhat tympani- 

 tic at the aortic area. Beats rhythmic, the rhy- 

 thm interrupted by extrasystoles, either in 

 series or singly. Pulse 60 per minute. Tmx. 

 140. Pulse small and hard. Liver much en- 

 larged. Spleen without noticeable enlarge- 

 ment. Thyroid gland with cystic goiter. 



Further examination January I, 1913. 



Frequent attacks of giddiness. Buzzing 

 in the head, vague pains in the body Fre- 

 quent palpitation, sometimes attacks of strong 

 rapid beats, at others strong and slow beats. 

 At the time of examination, the patient 

 complained of agony and had strong slow 

 beats but the objective examination revealed 

 nothing abnormal. Pulse 50 beats per min- 

 ute: no dyspnea. Sometimes the beats were 



so rapid that the heart seemed to tremble. 

 Condition of the heart same as before. 

 Generalised edema. Liver still much enlar- 

 ged. 



January 19, 1913. 



No more edema. Liver a little smaller. 

 Improvement of the subjective symptoms. 

 Physical state of the heart unaltered. 



June 4, 1913. 



After a period of improvement the pa- 

 tient, being worse, came to consult us again. 

 There was nothing, however, which called 

 for special interest. After a few days treat- 

 ment she got better. 



Record no- 19. 



This tracing is interesting because it 

 shows trigeminal rhythm caused by the in- 

 terpolation of ventricular extrasystoles every 

 four cycles, with a quartan rhythm. 



The indication of the waves shows that 

 the extrasystoles are interpolated, 



Observation no. 21. 



Interpolated ventricula<- extrasystoles. 



M. L do N. , white, female, 27 years 

 old, married, field-laborer. 



Examined October, 1914. 



The patient has been married for thirtem 

 years and has had three miscarriages at three 

 months and five children born at term; she 

 lost a child of three from sore throat. The 

 last child is 18 months. First menstruation at 

 the age of 12, regular and painless. Has 

 had intermittent fever. Heart beats, fatigue 

 and agony, she feels worse at rest and im- 

 proves with exercise. The heart-beats accom- 

 panied by giddiness and tremblings. Vague 

 headaches. Trembling. 



Heart. Apex beat in the fourth inter- 

 costal space, 7,5 cm. from the midsternal 

 line. Tmx=:150. 74 pulsations per minute. 

 Extrasystoles frequent after exercise and 

 exertion. Liver extending 19 cm. from mam- 

 millary line. Spleen not palpable. Goiter with 

 cysts of different sizes. 



