PATHOLOGY. 249 
Jnginous incruftations which affefl: the valves of the heart, 
becaufe thofe fymptoms differ as they are iituated on one 
or other of thefe parts. 
The fymptoms of the edification of the mitral valve 
will be found to vary in fome degree from thofe which 
betoken odification in the figmoid valves. The chief 
token of odification in the mitral valve is, according to 
M. Corvifart, “ a peculiar refilling, difficult to defcribe, 
felt by the hand when applied on the precordial region.” 
But, though hard to defcribe, itis (as Laennec obferves) 
eafy to recognize after it has once been obferved, and 
Laennec compares it to the trembling of a cat when ftroked. 
Corvifart adds, that the pulfe is alio very peculiarly flut¬ 
tering ; it is moreover weak, without hardnels 'or fulnefs. 
and lefs irregular than in odification of the aortic fig- 
moids, but more fo than in the ftraitening of the orifices 
of the right cavities.” To thefe fymptoms are often 
added thofe which announce hypertrophy and dilatation 
of the left auricle and right cavities, becaufe the obftacle 
which the blood meets with in pafljng from the auricle 
to the left ventricle muff; neceflarily, after a certain time, 
produce thefe effe&s. 
Laennec, however, was never able to dete£l this pecu¬ 
liar character of the pulfe, even in thofe cafes where the 
ruffling or trembling in the precordial region was moll evi¬ 
dent ; neither was the latter fymptom evident to the touch 
except where the narrowing of the affe&ed orifice was 
very confiderable; for Laennec had often niet with cafes 
of extenfive odifications of the aortic and mitral valves, 
in which none of that ruffling could be perceived. 
In the edification of the figmoid valves, the pulfe, fays 
M. Corvifart, “may preferve a certain degree of hard- 
nefs and ftiff r nefs, but never much of fulnefs nor of regu¬ 
larity.” There will be ftrotig and frequent palpitations; 
befides “that peculiar fpecies of undulation, ruffling, or 
purring,” which has been already noticed in odification 
of the mitral valve. We fee, then, fays Laennec, that 
“thefe fymptoms are at length reduced to that peculiar 
fenfation which is felt by the hand applied over the re¬ 
gion of the heart, and which I call J'remiJJement cataire ; 
for the greater or lefs irregularity of the pulfe cannot 
be confidered as a pathognomonic fymptom, fuch 
irregularity being met with, in every poflible degree, in 
pericarditis, in the paroxyfmsof all difeafes of the heart, 
even when no odification is prefent, and alfo in difeafes 
of the lungs where the heart is not aftefted. 
“ Since I began my obfervations with ftethofcope, I have 
met with but three cafes wherein the odification of the 
mitral valve was fo confiderable as to conftridl the orifice 
of the left ventricle to a degree fufiicient to produce the 
frenriffemenl cataire; and, as thefe patients did not die, I 
had not an opportunity of verifying the diagnoftic by 
infpeftion. Nor have I met with that affection above 
three or four times, and that in a flight degree, in the 
aortic figmoids. The ruffling could not be difcerned in 
thefe cafes, which however were decided cafes of oflifica- 
tion, and all verified by necrotomy. On a comparifon of 
the few obfervations juft given with thofe which I had 
previouflyjnade without the help of the ftethofcope, I 
think I may prefent the following refults as exadf, or 
very nearly fo. 
“ The odification of the mitral and figmoid valves does 
not produce irregularity in the circulation, nor can it be 
difcovered by examination of the pulfe or by applying 
the hand over the region of the heart, until it has 
reached fuch a degree as to have confiderably nar¬ 
rowed the orifices of the left ventricle. The odification 
of the mitral valve does not produce the ruffling noife 
unlefs it is very confiderable ; and I never obferved it in 
odification of the figmoids, though I have often found 
them fo oflified as to have reduced the orifice of the 
aorta to one half or even one third of its natural fize. 
“A moderate degree of odification in the mitral valve 
may be detected by the cylinder (the ftethofcope), by the 
following fymptoms s the found which accompanies the 
contraction of the auricle is more prolonged, more dull, 
yet fomewhat rough like the itroke of a file upon wood ; 
fometimes the found refembles a blow or flap, but this 
when the induration is rather cartilaginous than bony. 
This peculiar found, of a file or of a blow, is very evi¬ 
dent even in thofe cafes where the fremijfemenl is not fen- 
fible to the touch ; but it is more fo when the latter is 
prefent, and has a degree of ftrength in proportion with 
it. The ofiification of the aortic figmoids may be de¬ 
tected by a fimilar found during the contraction of the 
ventricle. 
“ A flight degree of odification in the figmoid and mi¬ 
tral Valves produces neither of the founds we have men¬ 
tioned ; but it may be detected, or fufpeCted, from a fen¬ 
fation of hardnefs, roughnefs, or hardinefs, in the con¬ 
traction of the ventricle or the auricle; and this fenfa¬ 
tion is clearly independent of the force of impulfion in 
thefe organs. The fame fymptoms would probably oc¬ 
cur in flight odification of the tricufpid valve and the 
pulmonary figmoids. In thefe cafes, as in dilatation- 
and hypertrophy of the heart, an examination made 
(with the cylinder) alternately under the lower part of 
the fternum and between the cartilages of the iixth and 
feventh ribs, noticing alfo the ftate of the external jugu¬ 
lar veins, will be always fufiicient to decide in what part 
of the heart the difeafe is forming.” 
The arrangement of Dr. Good not giving us an oppor¬ 
tunity of fixing the remaining difeafes of the heart with 
nofological accuracy in theirproper places, we ffiall treat 
of them here, even though they do not exaCtly tally with 
the generic characters of Emprefma. 
Like all other mufcles, the heart increafes, in regard 
both to the number and force of its fibres, during un- 
ufual exertion. It is thus that thickening and general 
enlargement of the heart follows extraordinary and Jong- 
continued exercife. We may remark, however, that an 
unufual volume of the heart is fometimes congenital. 
Exercife operates in a fimilar manneron one cavity of the 
heart: thus, if obftruCtion exift in the lungs, the increafe 
of power acquired by the right ventricle requires alfo 
increafed fize of its contractile ftruCture; and the fame 
arifes in the left ventricle from obftruCtion in the aorta. 
This increafe of fubftance may be connected with parti¬ 
cular circumftances which may alter its fymptoms ; that 
is to fay, there is a difference in hypertrophy of one or 
that of both cavities. The fymptoms of this difeafe are 
taken chiefly from Laennec. There isa difference between 
hypertrophy with diminution of the cavity, and hyper¬ 
trophy with increafed calibre, and fo on. The varieties 
and fymptoms of hypertrophy which follow are chiefly 
extracted from the work of Laennec, wherein he conti¬ 
nually examines, the opinions and definitions of Corvi¬ 
fart. 
By hypertrophy, or “increafe of nourifliment,” of the 
heart, we are to underftand an increafe of thicknefs in its 
mufcular fubftance, and confequently of the fidesofits 
ventricles, at the fame time that thefe cavities are not in¬ 
creafed in the fame proportion ; moft commonly, indeed 
the cavities are diminiffied. This difeafe, which is not 
very common, feerns to have eluded the refearches of 
Monf. Corvifart; for he conftantly fuppofes a thickening 
of the fides of the heart to be accompanied with a pro¬ 
portionate dilatation of its cavities. The thickening, in 
this cafe, is always accompanied by confiderable increafe 
in the confidence of thie fubftance of that organ, unlefs 
the hypertrophy is combined with an affeCtion defcribed 
under the defignation of“foftening of the heart.” 
Hypertrophy may exift in one of the ventricles only, 
or in both at the fame time. Theauricles may beaffeCted 
at the fame time and in a fimilar manner; but moft fre¬ 
quently they remain as thin as in their natural ftate, even 
when the correfponding ventricle has acquired an enor¬ 
mous thicknefs. In fome few cafes, the auricles alone 
may be aft’eCted with hypertrophy. 
When the left ventricle is attacked with hypertrophy, 
4 the 
