into a cab, and conveyed to one of our hospitals. Having arrived there, he was, either by a rule of the institution, or at the instance of an attendant, put into a hot bath. As his body became warm the oppression ceased; or, to use the patient's own words, " as my skin got hot and red, the distress rose, as it were, from me altogether." He stepped out of the bath into a warm blanket, went to bed, perspired freely, and rose next day as well as he ever was in his life. He was kept in the hospital a few days, and took a dose of castor oil, but nothing more. He told his physician that he had been under previous treatment, and that he believed his heart was affected. The physician listened to his heart, said there was nothing there wrong, and dismissed him cured.

I have met with two other cases besides this of reduplication; but in neither was the phenomenon clearly developed: it was fleeting and faint. In one of these cases, the patient was a man, who was phthisical; in the other, a woman, also phthisical. I lost sight, unfortunately, of both cases after they had been once or twice before me.

CAUSE AND CAUSATION OF REDUPLICATION.

The cause of reduplication of the heart-sounds has been most carefully studied by my friend and colleague Dr. Cockle, who has met with many cases; and whose explanation of the phenomenon varies but little from my own. The idea of cause can only be arrived at by considering each position of the ques

tion separately.

The first point to be settled is, whether the reduplication, as it occurs, is a reduplication of the first or of the second normal sound. I think no one who is accustomed to physical diagnosis could have doubted that, in the case I have given at length, it was the second sound that was repeated. The added sound was the same as the second in quality of tone -dup; while the first normal sound occupied its true position in regard both to time and to quality. The added sound, again, occupied the position of the natural pause, yet not entirely; for the briefest pause could be detected when the action of the heart was quieted by a forced and prolonged expiration. The pause thus discovered was found to occur at an interval between the reduplicate sound and the first sound.

Again, notwithstanding the double sound, the pulse was not intermittent, but was presented, as is natural, upon the systole of the heart coincidently with the systolic sound. This showed that the systole was perfected at one stroke on the arterial side, and that the aortic valves came down after the systole in correct time, and without suffering regurgitation of blood through them.

Lastly, the double sound was most prominent over the aortic and pulmonary orifices: lower, towards the apex, the first or systolic sound was, as is usual, most distinct.

In the other two cases to which reference has been made, the same proofs existed to show that the fact of reduplication was with the second or diastolic

sound. If, then, this point be proved, we must consider how the second sound admits of the modification which we have seen.

That the second sound of the heart is produced by the tension of the semilunar valves, is a fact which no one who has studied the subject physiologically can logically dispute. As little ought any one todispute that the first sound is the product of the tension of the tricuspid and mitral valves.* But, this latter point set aside, it is sufficient here to urge that the second sound is the result of the common tension of the aortic and pulmonary semilunar valves. When, therefore, this sound is doubled, as in the case above stated, the added sound must be due to one of three

sources.

It must be a reverberation of the second sound: It must be a repeated second or diastolic sound in full: Or it must be produced by a want of simultaneous action in the aortic and pulmonary semilunar valves.

The first of these suggestions is untenable, because there is no known acoustic law by which, in the closed circuit of the blood, a reverberation could be explained.

The second hypothesis is untenable, because the reduplication is confined to one sound; for, to produce a double simultaneous tension of the semilunar valves, there must be double ventricular action, and

* See, who will on this question, the overwhelming arguments of Dr. Halford, in his Physiological Essay on the Heart-Sounds—an essay which reduces the action and sounds of the heart to mathematical demonstration.

therefore a double systolic as well as diastolic murmur, in the period of one action of the heart; which is impossible.

We are driven thus to the third explanation, which seems, indeed, to answer every purpose. Thus, if in any given case there is set up an obstruction to the current of blood from the right auricle to the lungs, the current through the aorta from the left ventricle being free, the left ventricular systole will be made before the right ventricular systole; and the obstruction in the pulmonary circuit will prevent, for a period abnormally long, the return contraction of the pulmonary artery, and the closure with tension of the right semilunar valves. The two sets of semilunar valves will in this way be prevented from acting simultaneously, and the common sound produced by their tension will not be struck in the same period. The aortic valves coming down first, under these circumstances, will strike one diastolic sound, in the normal period of the diastolic sound; the pulmonary valves, lagging behind, will come down later, and strike a second sound in the period of the pause; and then the systolic sound will follow in its natural place, and in its natural intensity. This was, I believe, the order of events in the case which forms the text of this essay; and the same are the events, I presume, in all cases of reduplication.

The same view that accounts for the physical cause of reduplication, accounts also for the general symptoms which accompany the physical phenome

non.

The balance of the circulation is disturbed in

these examples, and the results are obvious. The oppression of respiration, amounting, as it did in my cases, to partial asphyxia, indicated with sufficient clearness the embarrassment of the pulmonary circulation; the deficient respiratory murmur defined the same fact the palpitating heart indicated the labour demanded to support two cardiac currents unfairly balanced; and the inability to sleep free of disturbance showed the perpetual necessity for constant and undiminished action of the forces of respiration and circulation to meet the difficulties in their way.

But that which most of all indicated the nature of the reduplicative phenomenon in the text case, was the result of the treatment. Let us mark the fact specially. As soon as a powerful derivation was set up by the hot bath; as soon as the vessels of the skin, expanding under the heat, claimed more blood, and so relieved the lungs; so soon was the pulmonary and systemic balance restored, and the patient cured. He felt, indeed, as he expressed, that the oppression which had wearied him for weeks passed from him altogether.

DIAGNOSIS OF REDUPLICATION.

I can recall no other abnormal sound, which could be confounded with that of reduplication. The absolute diagnosis is as follows: a physical condition of the heart during which, on listening to the cardiac sounds, three sounds take the place of two, the last of the three occupying, or nearly so, the period of pause.