Triple Heart Rhythm.

Triple heart rhythm stands for the cadence produced when three sounds recur in successive cardiac cycles, just as two sounds compose the familiar dual rhythm of cardiac auscultation, and more rarely, four sounds a quadruple rhythm. The conflicting views on the subject have long served to discourage attempts at a clinical perception of the problem. Disagreement is perhaps best illustrated by recounting the varied terminology employed to describe it. Thus we have gallop rhythm, canter rhythm, and trot rhythm; presystolic gallop, systolic gallop, protodiastolic gallop, and mesodiastolic gallop; complete summation gallop and incomplete summation gallop; auricular gallop, ventricular gallop, and auriculo-ventricular gallop; true gallop; left-sided gallop and right-sided gallop; rapid-filling gallop; diastolic echo; mitral opening snap; reduplication of first sound and reduplication of second sound; Potain's murmur; third heart sound and fourth heart sound. Others may have escaped my notice. This muddled nomenclature, as long as it stands, will frustrate any attempt to unify the many views held on triple rhythm. There is need of a simplified terminology based on clinical findings. It is indeed clear that a neglect of the clinical aspect on the one hand, and a persistence on the part ofmany to explain the mechanism of the supernumerary sound on the other hand, and to classify triple rhythm in accordance with sound records, have been largely responsible for obscuring this common form of cardiac rhythm. Phonocardiography need not become a routine test in clinical cardiology; when it has helped to establish a classification of triple rhythm it will have achieved its main purpose, though it will still serve in other auscultatory problems. In the present investigation it has been a condition that the supernumerary heart sound should be elicited first by clinical auscultation. No phonocardiogram was taken as a preliminary test, and it was only recorded later in order to confirm or correct the clinical impression that had already been gained. Among patients attending the Cardiac Department of the London Hospital during a recent period, and known to have heart disease or referred for an opinion on the heart, there were 270 who presented triple rhythm. These were placed in a special series for which a set method of inquiry had been prepared. A regularized history was taken and a general examination was made. A special record was taken of the heart rate at rest and after exercise, the presence of cardiac enlargement, the symptoms and signs of heart failure, and the blood pressure. As to the supernumerary sound, its site, distribution, and character, were separately noted, as well as the effects upon it of respiration, change of posture, and induced tachycardia. The apical impulse was examined by palpation and direct auscultation. Cardioscopy was a routine method of examination by which the size of the separate heart chambers was assessed. At the start certain measurements were taken; these included the width of the heart and thorax, and the height of the right auricle and diaphragm, but they were discontinued when it was realized that they brought no valuable information. Sometimes, however, use was made of