30 



marked. Headache and vague pains in the 

 body. Cardiac palpitation, dyspnea on exer- 

 tion and even attacks of dyspnea when at 

 rest and at night so that she cannot sleep. 

 Refractory cough, the last few days bloody 

 sputum. She has had edema of the legs. 

 Patient feels that the stomach is swollen. 

 For the last few days has had attacks of 

 vomiting accompanied by great anxiety. 

 Nearly incessant cough and dyspnea. Lack 

 of appetite. Constipation. Heart much enlarg- 

 ed, apex beat in the sixth space, slightly 

 within the axillary Une, 15 cm. from the 

 midsternal line. Right margin 5 cm. from 

 the midsternal line. Precordial region with 

 a rounded prominence. Strong precordial 

 shock, shaking the thoracic wall, its violence 

 being especially noticeable in the . fourth, 

 fifth and sixth spaces. First heart sound 

 muffled with slight murmur at the apex, 

 without propagation. Second sound accen- 

 tuated in the pulmonary area. Pulse weak, 

 soft and empty. Extrasystolic arrhythmia. 

 Number of pulsations varying from 88 to 

 92. Tnix^llO. Liver much increased in size, 

 painful on pressure. Spleen without not- 

 iceable enlargement. Thyroid enlarged. Con- 

 gestion of the bases of both lungs, the right 

 more marked. 



The patient was reexamined on )une 

 20, 27 and 28, and on July 3 and 5. She 

 was only slightly better and did not 

 come back for consultation after the fifth. 

 On that day her condition was as follows: 

 Dyspnea as well as general condition im- 

 proved. Pulse 82, sometimes in bigeminal 

 series. No more vomiting. 



Record no. 30 



The radial pulse is entirely arrhythmic but 

 not that of complete arrhythmia. Analysi*; 

 of the venous and pulse tracings shows 

 that the arrhythmia is produced by different 

 causes. The first is a change in the auricu. 

 lar rate, the a waves appearing irregularly 

 spaced. The conductibility is changed, the 

 a c interval lengthened; this induces a delay 

 in the conduction of the contractile stimulus. 



Extrasystolic beats of ventricular origin. The 

 legend of the tracings shows these alterna- 

 tions, as well as their interpretation clearly. 



Observation no. 32. 



Ventricular exlrasystolc. Lengthening oj 

 the a — c interval. Marked cardiac insufficiency. 



O. N. C; mulatto, male, 38 years, farm 

 laborer, resident at S. João da Ponte. 



Examined September 12, 1912. 



He has been ill for about two months; 

 fatigue on exertion gradually increased. Pale, 

 slight edema of face and lower extremities. 

 Dyspnea on exertion and at night. Cardiac 

 area nmch enlarged. Apex beat in the lifth 

 intercostal space, 12 cm. from the midster- 

 nal line. Right margin 4,5 cm. from the mid- 

 sternal line. Systolic murmur at apex, re- 

 placing the first heart sound with propaga- 

 tion towards the axillary line. The firts 

 sound can be heard in the tricuspid area. 

 Second sound reduplicated with pulmonary 

 accentuation. Pulse 88; seated 99. Numerous 

 extrasystoles. Tmx.=:105. Liver enlarged 

 painful on pressure. Spleen with noticeable 

 enlargement. Thyroid enlarged, with volumi- 

 nous goiter. 



Record no. 31. 



The radial pulse shows very clear al- 

 ternation, extrasystolic lapses and beat with 

 compensating complete repose. The jugular 

 pulse shows the premature beats c' of ven- 

 tricular origin, coinciding with the auricular 

 beats a of the dominant rhythm. 



It can be seen that the conductibility is 

 altered, there being delaying of the conduc- 

 tion which is indicated by the lengthening 

 of the a-c interval. 



Observation no. 33. 



Ventricular and nodal extrasystole. Tachy- 

 cardial crises. Lengthening of tht a—c inter- 

 val. Ventricular escape. 



P. A. S.; mulatto, male, 39 years, married, 

 resident at Contria. 



Examined February 17, 1913. 



