HYPERTROPHY OF THE HEART. 



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commonly felt in individuals with narrow spaces, and whose apices 

 point more inwardly. Even in the healthy subject, if the heart be 

 stimulated into more vigorous action, a feeble jar may be noticed, not 

 only over the apex, but throughout all that part of the chest which 

 comes into contact with the heart. So, too, when the heart is excited, 

 other conditions being normal, a shock may be observed in the epigas 

 trium, which, however, is not to be confounded with the so-called puL 

 satio epigastrica. This epigastric pulsation is produced by the left 

 lobe of the liver, which is driven downward a little by every systolic 

 movement. 



In hypertrophy of the heart, various deviations from this normal 

 cardiac impulse are met with. Very great intensity of impulse is 

 almost peculiar to hypertrophy, while a less violent pulsation may 

 arise from mere excited action of a heart of normal size. Skoda 

 recognizes two degrees of abnormal intensity in the beat of the heart, 

 one in which the head of the auscultator, when laid upon the chest of 

 the patient, perceives a strong, jarring sensation, but in which the 

 thoracic wall and the head of the listener are not lifted by the shock ; 

 the other, in which the thoracic wall is distinctly elevated during the 

 systole, and sinks again with the diastole. Here, too, if this lifting of 

 the thoracic wall take place rapidly, a shock is imparted to the head. 

 It is this second degree, this distinctly heaving heart-shock, which is 

 pathognomonic of hypertrophy, and which does not occur in any other 

 disease. (This heaving cardiac impulse, however, must extend over a 

 large area of the thoracic wall, to warrant a certain diagnosis of hyper- 

 trophy ; as the apex of a normal heart, when it beats upon an inter- 

 costal space, will produce distinct elevation of the point of impact, and 

 will lift the finger when laid upon it.) The jarring impulse, if a con- 

 stant and not merely a transitory symptom, is also decidedly indicative 

 of hypertrophy. As a rule, the beat of a healthy heart is only felt 

 over a spot covering one or two intercostal spaces, while the shock 

 caused by the organ when hypertrophied is often perceptible over a 

 region including several of these spaces. In total excentric hypertro- 

 phy it is diffused both longitudinally and transversely. In hypertrophy 

 of the left ventricle the heaving pulsation is most distinct at the apex, 

 and thence spreads somewhat longitudinally, less so in the transverse 

 direction of the organ. 



In excentric hypertrophy of the right side of the heart, the thoracic 

 wall between the apex and the lower edge of the sternum, or even the 

 sternum itself, is shaken. All these variations are attributable to dis- 

 placement of the lung, and to the more perfect contact thus existing 

 between the heart and the parietes of the chest. Observation of the 

 beat of a hypertrophied heart, moreover, reveals a displacement of its 



