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412 pulsating movement in the jugulars that denotes tricuspid insufficiency. On percussion the præcordial area is frequently found to be enlarged, perhaps very greatly enlarged, especially to the right; and on auscultation loud bruits, usually systolic in rhythm, may be heard. Marked reduplication of the sounds, particularly of the second sound, is to be noted. The auscultator may be struck, in a large proportion of cases, by the peculiar spacing of the intervals between the sounds. It may be hardly possible to tell by the ear alone which is the first pause and which is the second. They seem alike in point of duration; so that the sounds of the heart are, like the beats of a well-hung pendulum clock, evenly spaced, and not, as they are in health, separated by a long and a short interval like the beats of a badly hung clock. It will also be observed that the heart is very irritable, becoming easily quickened by exertion. It will be judged, therefore, that, in addition to peripheral neuritis, there is serious disease in the circulatory system, particularly in its innervation; that there is dilatation of the right side of the heart; and that there is a state of relaxed arterial tension.

All these signs and symptoms vary in degree from time to time in the same case, and differ in degree in different cases.

Dropsical cases.— In the next bed, perhaps, to the patient whose picture I have tried to draw may be seen another man suffering from apparently quite a different affection (Fig. 76). He is propped up in bed. Instead of being thin and wasted, as the last patient, his face is puffy and heavy; his lips possibly are slightly cyanosed; and his arms, hands, trunk, legs, and feet are distended with œdema. It may be thought from the œdema that it is a case of acute nephritis; but an examination of the scanty, dark-coloured urine shows that it is of high specific gravity, and contains no albumin, or only a mere trace; so that the case cannot be one of acute Bright's disease. Careful observation will discover that the œdema is somewhat firmer than that of nephritis, and, in not a few instances, that it does not involve the scrotum.