322 DISEASES OF THE HEART. 



With regard to concentric hypertrophy, from the great rarity o2 

 this form of the disease the very existence of which has been doubted 

 by authors of merit, we have no available clinical data whereon to base 

 an account of its symptomatology. If the capacity of a concentrically 

 aypertrophied heart be considerably reduced, symptoms essentially 

 different from those nitherto described must arise. In spite of the in- 

 crease of muscular development, the quantity of blood thrown into 

 the arteries can only be small ; the outflow from the veins into the 

 narrowed heart must be impeded, so that cyanosis and dropsy may 

 ensue. 



Physical Signs. In young subjects suffering from excentric hy- 

 pertrophy of considerable extent, we may sometimes observe a distinct 

 prominence over the region of the heart, which is not to be confounded 

 with the deformity which proceeds from rachitis. In older persons, 

 whose costal cartilages have become ossified, this symptom is not met 

 with even in cases of " enormitas cordis" Besides this, the shock of 

 the heart is observed to extend widely over the thorax, and is visible 

 at unusual places. "We shall consider this more attentively while 

 speaking of palpation. 



Palpation. In the majority of healthy persons, we see and feel^ 

 during systole of the ventricle, that the spot in the thoracic wall cor- 

 responding to the apex of the heart receives a concussion, is shaken, 

 and that a limited space between the two adjacent ribs is then made to 

 bulge forward. This phenomenon, the impulse of the heart, arises from 

 the force with which the heart is depressed and pressed against the 

 thoracic wall when the ventricle contracts. Although the views of the 

 different investigators may vary as to the cause of the systolic descent 

 of the heart, one side asserting it to be due to elongation, and stretch- 

 ing of the great vessels ; another that it depends upon the recoil which 

 the heart makes when the blood is forcibly expelled from it, somewhat 

 like that of an exploding gun ; yet all agree that the heart descends 

 during the systole. Now, if we bear in mind that the heart does not 

 hang free in the chest, but lies upon the diaphragm, a surface which 

 slopes forward, it will become apparent that the heart, when pressed 

 downward, must also be pushed forward against the wall of the chest. 

 If the apex of the heart then strike upon an intercostal space, it is 

 driven into it, and causes it to bulge. If, however, it meet a rib, or if 

 the intercostal spaces be too narrow to admit the apex between the 

 adjoining ribs, then, instead of the impulse of the apex, a feeble cir- 

 cumscribed shock is felt upon the ribs or intercostal spaces. It is very 

 plain, that the beat of the apex will be most often visible in persons 

 who have wide intercostal spaces, and the point of whose heart in- 

 clines more outwardly ; whereas the circumscribed concussion is more 



