There are two types of rhythms described by some authors; namely, intermittent rhythm and arrhythmia (irregular, lack of rhythm). Intermittent rhythm is where the pulse beat is suspended, or misses a beat occasionally. These missed strokes are usually followed by a more pronounced systol (contraction). The cause is enervation from stimulation. Perhaps, if there is one class of stimulants, more than another, inclined to produce this state of the heart, it is the coffee-and-roll or toast habit. It means a preponderance of food of acid potentiality.

Arrhythmia is marked by irregularity in the succession of pulses. Then there is a type presenting a prolongation of one of the heart beats or of one of the silent periods. Arrhythmia is also marked by cardiac bigeminate (double), and trigeminous (treble); which means the production of two or three beats, one after another, followed by a natural pause. Then there is the alternating pulse--one strong beat followed by a weak beat; then there are two short strong strokes followed by two weak strokes. The weak ones are not perceptible at the wrist.

There is the fetal rhythm, in which the two beats become similar, and the frequency is augmented so as to convey to the ear the sound given out by the heart of the unborn child.

The fetal rhythm is of unfavorable prognostic significance. lt develops in some cases of arteriosclerosis. Murmur of recall is a modified second sound which is divided into two short sounds. This occurs in a disturbed pulmonary circulation, which modifies the action of the valves, and is found in mitral stenosis.

Galloping murmur is found in two places. One place is at the left heart, a little above the apex beat, and means myocarditis or rheumatism of the heart. A second location, less frequent, is found in the right heart; this can be heard at the end of the sternum, and accompanies gastric and hepatic derangements, especially gallstone.

A murmur that accompanies normal heart sounds is of less gravity than one that replaces them.

Friction murmurs mean friction of the pericardium. They sound like the creaking of leather.

A blowing murmur is a sound like that of bellows. When accompanying the first heart sound, it is called systolic blowing; when with the second sound, it is called diastolic blowing; mesosystolic, when it occurs in the silence between the regular sounds of the heart; presystolic, when occurring before systole; in this case it may be called auricular systolic.

Heart murmurs that disappear on holding the breath are cardio-pulmonary, not endocardial.

Murmurs accompanying the radial pulsations are systolic; those that precede the pulse are presystolic; those following are mesosystolic. The diastolic murmurs accompany the second sound and are more quiet.

During the systole the ventricles contract. If the murmur is at one of the auriculo-ventricular orifices, it indicates that the blood flows backward from ventricle to auricle. This means insufficiency or incompetency of the auriculoventricular valves. When the sound is at the arterial orifices, it means stenosis of the aortic.

When the murmur is diastolic, it Corresponds with the second sound, and means that the blood flows back- ward from the arteries to the ventricle. This is aortic insufficiency. The rolling murmur heard at the apex means stricture or stenosis of the auriculo-ventricular orifice, usually the mitral.

Reduplication of sounds indicates that valve action is not simultaneous and that there is heart strain present, or high arterial tension, as in stenosis or kidney diseases.

Mitral insufficiency often gives out a whistling, musical piping sound. Aortic insufficiency is a mild, soft, and blowing sound. Mitral stenosis is a rolling sound.

When the murmur is heard outward or inward from the apex, or at the left border of the heart, it may be said that it is functional; when in the aortic area to the right border of the sternum, it is organic. Murmurs along the left border of the sternum are organic.

Before it is safe to say that a given murmur is organic, an apex murmur must be heard in the axilla and in the back, and basic murmurs must be heard through the vessels originating from the affected orifice or along the sternum. When aortic incompetency is suspected, the stethoscope may be applied to the femoral artery, and in these subjects to the abdominal aorta.

Table Of Heart Sounds, Location, and Significance
First Sound Short Silence Second Sound Long Silence
Ventricular systole. Heard at apex--apex beat. Felt at radial pulse. Systolic blowing murmer heard at this point.Mesosystolic. Blowing murmur.Closure of the semilunar valves between heart and arteries.Diastole, or auricular systole. Presystolic murmur.

At the first sound, the ventricles close (systole). If there is a murmur at one of the auriculo-ventricular orifices, it is because blood flows back to the auricle. This means insufficient closure of one of the valves.

When the murmur is heard at one of the arterial orifices, it indicates that the blood does not flow through so easily as it should. This means a diminution of caliber. Stenosis is the cause.

Diastolic murmur coincides with the second sound, and means that the blood regurgitates or flows back from the arteries to the ventricles. This means aortic insufficiency--occasionally pulmonary insufficiency. This murmur is heard at the apex and has a peculiar character--namely, a rolling, rather than a blowing or purring, sound. It means stricture of one of the auriculo-ventricular orifices, more often the mitral. Presystolic murmur means the same.

Mitral insufficiency is often a whistling, musical, or piping sound.

Aortic insufficiency is mild, soft, and blowing.

Mitral stenosis is like a rolling sound.

Congenital malformation is marked by a systolic, forcible, vibrating murmur, heard at times in the center of the chest, not accompanied by purring, and heard best over the fourth dorsal vertebra.

Mitral murmur should be looked for in the left axilla; also behind, under the angle of the scapula.

Murmurs of the pulmonary orifice are conducted toward the left clavicle; they stop before reaching the bone.

Aortic murmurs extend toward the right clavicle, and often reach beyond even in the neck.

The diastolic murmur of the aorta passes along the sternum to its end, the xiphoid appendix. The murmur is a soft, blowing sound. There is accompanying this murmur a jerking pulse--a throbbing or dancing pulse.

To sum up: In a weak heart, when both sides are affected, there is observed venous stasis, with functional disturbance of lungs, liver, kidneys, stomach, and brain, with their various symptoms: dyspepsia, dyspnea, local pain, vertigo, palpitation, etc.; with, as termination, dilation and collapse of the heart.

A valvular defect is important as regards accommodation, whereas a dilation has a very serious importance.

Venous stasis from dilation presents cyanosis, turgid veins, with and without pulsation of the jugular and other veins, cardiac asthma, hyperemia of the liver and lungs, catarrh, hemorrhage and edema of the dependent parts and cavities. Cardiac asthma may be due to swelling and stiffness of lung substance from congestion.

Heart weakness may be due to muscular or valvular insufficiency, or both. It may be primary or secondary to other derangements which obstruct the circulation. The liver and kidneys must receive attention.

Congenital Heart Defects

Potency of the foramen ovale, ductus arteriosus, defects of the ventricular system, and lesions of the pulmonary orifice. Prematurity is the usual cause of these defects.

Symptoms: Cyanosis (blue child-not always present), dyspnea, cough, convulsions, edema, and restlessness.