370 DISEASES OF THE HEART. 



the left ventricle. The apex is displaced outward and somewhat 

 downward. Simultaneously with the shock against the thorax, the 

 epigastrium is also shaken rhythmically. We have considered each of 

 these symptoms while treating of hypertrophy of the right side of the 

 heart, to which they are due. Percussion reveals an extension in 

 width of the cardiac dulness. Upon auscultation, instead of the first 

 sound, we hear at the apex a murmur, generally somewhat loud, which 

 arises from the irregular vibrations of the valve, which, being rough- 

 ened and uneven, is in a very unfavorable state to vibrate normally. 

 Sometimes we hear the murmur better, if we listen more above and to 

 the outer side of the apex, as, from hypertrophy of the right heart, the 

 left ventricle of which the apex is formed is, as it were, pushed off 

 from the thoracic wall. As the second sound heard over the ventricle 

 is merely transmitted from the arteries, it presents no abnormity in 

 pure mitral insufficience. Above the aorta, the sounds are feeble ; 

 over the pulmonary artery, they are remarkably loud, especially the 

 second, and this intensification, which is still more marked by contrast, 

 is of great diagnostic value. Sometimes, even, we feel a distinct shock 

 at the root of the pulmonary artery, during diastole of the ventricle. 

 Pulsation of the veins, with rhythmical dilatation, does hot occur in mitral 

 insufficience, unless complicated by valvular derangement of the tri- 

 cuspid ; although we often may observe a rhythmical undulation of the 

 jugulars, isochronic with systole of the ventricle. 



This proceeds from transmission, the strong shock suffered by the 

 tricuspids being conducted along the column of blood above it, and 

 continues uninterrupted, excepting by the delicate valves, as far as the 

 jugulars. Although the valves in the veins prevent regurgitation of 

 the blood, they cannot check the transmission of a wave of vibration 

 along their contents (JBamberger). 



Physical signs of stenosis of the mitral. Here, too, inspection 

 and palpation show the signs of excentric hypertrophy of the right side 

 of the heart. The impulse is not usually as strong as it is in insuf- 

 ficience, as the left side of the heart does not take part in the hyper- 

 trophy. Besides this, it is much more common in insufficience than in 

 hypertrophy to perceive the fremissement cataire,tha,t slight, whizzing 

 sound at the apex, which immediately precedes the beat of the heart, 

 and which ceases suddenly as the beat commences. This phenomenon, 

 the praesystolic purring, is often perceptible through thick clothing, and 

 is so characteristic as in itself almost to suffice to establish the diagno- 

 sis of stenosis of the mitral. Upon auscultation we almost always 

 hear a long-drawn murmur at the apex during diastole. Although the 

 blood, as it pours through the normal spacious orifice, occasions nc 

 sound, this is by no means the case when it has to be driven forcibly 



