1. 1. The only available criterion for distinguishing between physiological third heart sounds and gallop rhythm is the status of cardiac function. Both types of sound are accentuated by the same procedures. They have similar time relations, quality and intensity. Their positions of maximum audibility are identical except that right-sided physiological third heart sounds are unknown. 2. 2. Gallop and physiological third heart sounds invariably fall in either the protodiastolic or the auriculosystolic time zone. 3. 3. When these two time zones become superimposed, either as a result of tachycardia, minor grade heart block, sinus arrhythmia or auricular extrasystoles, gallop sounds may either appear for the first time, or, if already present, become markedly accentuated. This effect is so pronounced as to constitute a summation phenomenon. 4. 4. The hypothesis of summation is in accord with all known facts regarding gallop rhythm. Moreover, it offers a reasonable explanation for some of the variations in gallop sounds hitherto unaccounted for. 5. 5. A classification of physiological third heart sounds and gallop rhythm, based on Potain's classification of gallop rhythm, but altered to correspond with objective phenomena, is proposed. The erroneous concept of mesodiastolic gallop is discarded, and summation gallop is recognized. The classification abolishes the practical difficulties, heretofore encountered so frequently, in placing cases into proper categories. 6. 6. There appears to be no great disparity in the incidence of presystolic or protodiastolic gallop. Summation gallop is little if any less frequent. In can be produced in cases with either of the other types of gallop, or in cases with a predisposition to gallop, by the simple expedient of accelerating the cardiac rate enough to bring about superimposition of protodiastolic and presystolic events. 7. 7. Potain's conception of right-sided gallop rhythm, disputed by certain observers, has been confirmed by our investigations. It tends to occur in cases exhibiting predominantly right-sided heart failure. 8. 8. In the differential diagnosis of gallop rhythm and the physiological third heart sound, errors have been encountered involving one or another of the following: (1) the opening snap of mitral stenosis; (2) mid-diastolic murmur; (3) presystolic murmur; (4) reduplicated first heart sound; (5) reduplicated second heart sound. Other possible sources of error are (a) pericardial friction sound; (b) mid-systolic click; and (c) the so-called systolic gallop rhythm. In the great majority of cases differentiation is possible by clinical methods alone. In occasional cases, however, accurate timing requiring graphic methods is necessary.
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