The pulse is of great importance.both in regard to diagnosis and prognosis. It is apt to be frequent, ill-sustained, and irregular in both force and rhythm. The I number of radial pulsations may be con siderably less than the number of heart beats as counted with the stethoscope. The pulse-wave is apt to be small, but in cases where previous high tension, as in arteriosclerosis, has dilated the periph eral arteries, the wave may be of con siderable volume. Any approach to ten sion in the arteries is of favorable import.
The phenomenon known as bigeminal pulse is quite frequent in cases of dilata tion. Often the second and weaker of these twin cardiac impulses fails to reach the radius in perceptible strength. In spection of the cardiac region shows no such bulging as may be present in cases of hypertrophy, except when the pre cedent hypertrophy has left its traces behind it. It may. be difficult to locate the apex-beat by the eye, or the impulse may seem to be diffuse and not to im pinge upon exactly the same point with every beat.
Over other portions of the heart than the apex.the intercostal spaces may some times be seen to protrude and recede with the action of the heart, and sometimes an extensive wavy motion may be ob served over the cardiac area. When the right ventricle is dilated, there is more than a usual amount of impulse in the epigastrium below and to the right of the xiphoid cartilage.
Upon palpation the heart-beat is found not to be of a strong and heaving char acter, but feeble and resembling a quick tapping or slapping of the chest, some times with more or less of a tremulous sensation imparted to the hand. Even when the eye has detected the apex-beat, the hand may not be able to distinguish it. The most satisfactory mode of prac ticing palpation is by resting the whole hand, as lightly as possible, over the prtucordium, and then testing the im pressions thus received by firmer pressure and by digital touch.
Percussion shows an increase in the area of cardiac dullness yarying some what according to the portion or portions of the heart mainly dilated. Increase in the size of the right ventricle makes the heart broader than normal, but not much longer. The right limit of dullness may, in such a case, reach or even extend be yond the right nipple. Enlargement of
the right auricle is associated with in crease of dullness at the right edge of the sternum, corresponding to the second and third intercostal spaces. The dilated left ventricle presents an area of cardiac dullness not much wider toward the right than normal, but extending downward to the seventh or eigiith intercostal space, and perhaps an inch or two to the left of the normal position of the apex.
By means of auscultation we may, in the first place, be able more exactly to locate the position of the apex-beat than by either inspection or palpation, assum ing that it corresponds to that point where the first sound of the heart is loud est. The first sound of the heart in cases of dilatation may be louder than normal, but it is devoid of muscular quality, be ing short and valvular; that is, closely resembling the normal second sound of the heart. It is heard with more dis tinctness in the aortic area than is the first sound of the hypertrophied heart. Frequently there is also heard a systolic murmur at the apex, due to regurgita tion through the mitral valve or tricus pid, because the auriculo-ventricular opening is dilated as well as the ven tricle, and consequently has become too large for the valve, even though normal, to close it efficiently (relative insuf ficiency). The second sounds at the base of the heart are of variable character in different cases. If they are tolerably sharp and distinct they are somewhat reassuring, as indicating that the ven tricles still possess muscular power. Another important point (W. H. and J. F. H. Broadbent) is the length of the pause between the first and second sounds of the heart as compared with the pause separating one cardiac cycle from another. If the first and second sounds are separated by a shorter interval than in health, we must infer that the dilated ventricles are able to make only an in effective effort at systole, while, if there is a longer pause between the first and second sounds of the heart, it is evident that the cardiac muscle still possesses sufficient vigor to make a prolonged ef fort to overcome the obstacles which it meets in propelling the blood-current.