When tricuspid regurgitation exists, the veins in the neck are dark and turgid. Their valves show like knots. Often act ual pulsation in them may be demon strated, especially if the patient takes a horizontal position. Pressure upon the congested liver magnifies the engorge ment of the jugulars.
Diagnosis. — From pure hypertrophy dilatation can be clearly distinguished by the general aspect of the patient, and the evidences of imperfect and failing circu lation already detailed. In both condi tions the area of cardiac dullness is in creased, but in dilatation we do not ob serve the strong heaving impulse of hy pertrophy. In general, it may be said that the two are opposites. Hypertrophy is an exaggeration of the normal state, while dilatation is a condition of weak ness and failure.
The first sound of the fiypertrophied 'heart at the apex may not be so loud or distinct as in dilatation, being low and muffled, and, as already stated, it may be inaudible at the base; but there is present in it a muscular quality, dis tinguishable in a less degree over the apex of a normal heart, and not heard in cases of dilatation.
The hypertrophied heart must at last, however, enter into the state of dilata tion,—unless its owner is the victim of intereurrent disease,—and the important practical question for diagnosis in most cases is to determine what degree of de terioration has already been reached and how much longer the circulation can be maintained.
Very valuable information in doubtful cases with regard. to the integrity or otherwise of an enlarged heart may be obtained by causing the snbject under examination to make somewhat brisk muscular exertion, as by ascending and descending a flight of stairs or by hop ping six or eight yards upon one foot. The degenerated heart will become unnaturally accelerated and irregular, while a well-nourished heart will act even better than before.
In certain cases retraction of the lung, as in chronic phthisis, leaves a compara tively-normal heart more exposed than in health and might occasion a mistake of the condition for one of dilatation. 'Factors in this diagnosis would be the history of the case, the signs of pulmo nary disease, the absence of venous stasis in other parts of the body, and the fact that the border of the lung near the heart did not extend inward over the cardiac area on full inspiration, as under normal conditions it should.
Mediastinal tumors may cause dullness in the cardiac region, but they are apt to extend upward and to the right or left side; and the heart-sounds are not audible over them in the same way as over the dilated heart. In thoracic aneu rism we should expect to find a heaving impulse in the neighborhood of the base of the heart, with other positive signs of aneurism and without the changes in the cardiac sounds and impulse or in the creneral circulation seen in dilatation.
A more difficult question is to dis tinguish pericardial effusion from cardiac dilatation. In certain cases this seems to the writer almost impossible, although in the great majority of instances a defi nite conclusion can undoubtedly be reached. In pericarditis we are more apt to have a history of an acute onset with fever and pericardial friction-sounds, and perhaps, also, knowledge of a nephritis or tuberculosis or acute pneumonia as etiological factors in the production of pericarditis.
The pericardial effusions give an area of dullness somewhat more pear-shaped than that seen in dilatation of the heart, which is, more or less, cinadrilateral. Pericardial effusion also raises the apex beat upward and outward toward the third or fourth spaces in the neighbor hood of the left nipple, and it renders the heart-sounds less distinctly audible than in dilatation. It may also cause a paradoxical pulse. Yet, in case of val vular heart disease with a fresh attack of rheumatism, a recent pericarditie fric tion-sound, and evident failure of com pensation, it may be very difficult to determine whether the increased area of dullness on the right side of the sternum is referable to pericardial effusion or to dilatation of the right ventricle.
In the cases already spoken of there has been a question of mistaking the en larged area of dullness in the cardiac region due to other causes for a dilated heart. There is a contrary danger in cases of emphysema that a dilated heart may not be recognized because of un natural pulmonary resonance encroach ing upon the true cardiac area. Here we may be saved from error by the his tory of chronic bronchitis, and of al ready-established and slowly-increasing dyspncea, as well as by the characteristic pulmonary signs.