366 HYPEETROPHY OF THE HEAET. 



seat of the hypertrophy. Leblanc says that there may be 

 very energetic impulse on the right side of the chest due to an 

 eccentric hypertrophy of the right side of the heart. He has 

 also noticed at the same time another coincidence, which is 

 a very manifest murmur, probably produced by the shock 

 between the columns of blood and semi-lunar valves, which 

 he calls bruit de claque. The impulse of the heart in cases 

 of hypertrophy is sometimes visible on looking from a dis- 

 tance at the region of the heart. Leblanc has also met with 

 reduplication of the second sound, a symptom which indicates 

 irregular muscular action. On the subject of the reduplica- 

 tion of the heart's sounds, Dr Barclay says, in his admirable 

 Manual of Medical Diagnosis, at page 383: "Keduplication, 

 like intermission, suggests some imperfection in the relation 

 of nervous force and muscular contraction, in so far as one 

 serves to regulate the other : but while we are able to draw 

 a distinction between intermission and irregularity, as indi- 

 cations of disease, we are not able to lay down the same 

 certain rules in reduplication. We may be very confident 

 that when both sounds are reduplicated there is some form 

 of disease present : reduplication of the second sound is very 

 often caused by imperfect closure of the auriculo-ventricular 

 aperture on one side, which causes the systole of one ventricle 

 to terminate more quickly than the other; but it is also 

 heard, like intermission, in what we call mere functional dis- 

 turbance. It will be readily understood that when either 

 sound becomes prolonged by the presence of a murmur, the 

 reduplication is lost in the continuous bruit. It is wise in 

 practice to restrict the term reduplication to cases in which 

 no bruit is detected; for example, when there is a slight 

 diastolic aortic murmur, the second sound of the heart, 

 formed at the pulmonic valves, may be heard quite distinct 

 and separate from the aortic bruit, which replaces the second 



