Diseases of the Heart and Organs of CirculatioJi. 303 



termittent contractions of the heart. Kussmaul's paradoxical 

 pulse is one in which the pulse is more frequent but less full dur- 

 ing inspiration than expiration. Seen in weak heart, during re- 

 covery from chest diseases, in chronic pericarditis, and when fi- 

 brous bands encircle the root of the aorta. Bigeminal and tri- 

 geminal when two or three beats follow each other rapidl}^ and 

 are separated from the preceding and succeeding beats by longer 

 intervals. This occurs in disease of the mitral valve, and in 

 other weak states of the heart. Foetal heart rythm in which the 

 pause is shortened and the two sounds of the heart are almost 

 identical, is seen in the later stages of fevers, and in extreme 

 dilation. A curious aberration of rythm is the repetition of either 

 the first or second sound. If of the first sound (anapestic bruit) 

 each beat will be accompanied by three sounds the first two of which 

 resemble the first sound of health. If the second sound is repeated 

 (dactylic bruit, bruit de galop) the first sound only will be pro- 

 longed and the last two sharp and quick. The repetition of the 

 la.st sound is probably due to impaired nervous supply which allows 

 the completion of the contraction of the ventricle and the closure 

 of the arterial (semilunar) valves sooner on one side than the 

 other. If due to diminution of the arterial orifice which re- 

 tarded the emptying of one of the ventricles, the first sound would 

 probably be accompanied by a blowing murmur. If the auriculo- 

 ventricular valves on one side were imperfect, allowing a reflux 

 into the auricle and a more rapid emptj'ing of the ventricle a 

 blowing murmur would equally accompany the first sound. In 

 either of these two last mentioned cases the murmur would mask 

 or hide the first of two doubled sounds. 



The repetition of the ist sound is often due to dilitatiou of one 

 ventricle, which in consequence is longer in reaching the same 

 sensation of plenitude, and in receiving the stimulus to contraction. 



Morbid Sounds. Murmurs. The distinct and superadded 

 sounds heard in disease are usually designated murmurs. They 

 originate in the interior of the heart (endocardial) or externally 

 to the heart (pericardial). The endocardial sounds mostly arise 

 from some abnormal conditions of the valves or orifices and con- 

 sist in a blowing or rushing noise which usualiy accompanies or 

 displaces one of the heart sounds, though it ma)^ precede or suc- 

 ceed these. The following table modified from that of Bartle 



