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A MANUAL OF DIAGNOSIS
OF THE

DISEASES  OF THE  HEART:
PRECEDED BY CLINICAL RESEARCHES,
CALCULATED TO
FACILITATE THE STUDY OF THESE RESEARCHES.
             BY

    DR. FELIX  ANDRY,
FORMER " CHEF DE CLINIQUE " AT LA CHARITE HOSPITAL.
TRANSLATED FOR THE "WESTERN LANCET,"
BY
W. S. C H I P L E Y, M. D.,
ANI>
R. P. HUNT, M. D.
7^72^
CINCINNATI:
ROBINSON & JONES
1847.
 
W  G
 A577m
 1*47
   ROBINSON AND CO., PRINTERS,
Corner of Third and Main Streets. 
PREFACE.
  Much has been written  on the  heart, especially in the
course of the few past years.   But can this be a reason for
ceasing to call public attention to the subject ?  Perhaps so,
if all the problems that attach themselves to this study were
at present resolved; if, upon all the principal features of the
physiological and clinical history of the heart, a  universal
concert  had replaced the discord which, for so long a time,
checked the progress of the science.  But it is not thus; we
may be even justified in declaring, that at the present moment
few organs contribute so much to differences of opinion and
multiplied discussions, as the heart.   Those who have been
willing to undertake this part of our art, and who have even
consecrated lengthy researches to it, have encountered doubt
and hesitation  in  all the  divers  systems,  and  with very
little certainty in the diagnosis.
   This scepticism, this incredulity, constitutes, in my opinion,
anachronism.   I say it persuaded of its truth; and it  is this
happy belief in the certainty of our actual means of explora-
tion, and the disease, to proclaim aloud that which may place
the science upon a footing that will no longer permit it to be
said that it  advances by hazard, that  have induced  me to add
 this small  volume  to those  which  have preceded it from
 others, in a great  part  from different  and  even  contrary
 schools.
    I am aware that among these last  there  are  those who
 announce this confidence in the validity of their theories, and
 give the assurance that to them alone  appertains the  thread
 of Ariadne, without which the clinical study of the heart is a 
[  iv  ]
 labirynth where one would  be  lost.   Between them and us
 the  public will determine.  The dispute, it seems to  me, is
 very well worthy of its interest.
   I have been impressed by  another idea in the composition
 of this work—a desire to simplify, as  much as  possible, the
 study which is so often truly arid and repulsive, thick set, as
 it is, with difficulties proper to it, and still more so with those
 that are  added to it by a bad system of observation.
  This  small  volume addresses itself, then,  to physicians,
 who will find in it a collection of clinical facts, of which the
 analysis, verified by autopsies, will demonstrate to them to
 what a degree of precision  the  diagnosis of  diseases of the
 heart is  capable of attaining at the present  time ; and  to
students, who, in this manual of diagnosis will learn how we
arrive at these  practical  results, the veritable conquests of
 contemporaneous clinic. 
CLINICAL  RESEARCHES
                         FOR

FACILITATING  THE  DIAGNOSIS

                         OF

     ORGANIC  DISEASES OF THE HEART.
  Of all  those  diseases  of  which the progress of medicine
has latterly improved the diagnosis, but few can, in my opin-
ion, compare with the organic affections of the centre of cir-
culation.   Such at least is the conclusion drawn from a series
of observations that I have made in the wards of Professor
Bouillaud, for near six consecutive years, either as a simple
observer  of the successful  practice  of this  gentleman,  or,
during the last two years as chef de clinique*   I would even
say the diagnosis of these  affections seems to  me to offer a
degree of certainty almost mathematical,  if I did not fear
that such an assertion, made so  prematurely, would appear
to my readers as an exaggeration.
   And, indeed, the variety  of opinions held by the majority
of practitioners relative to the theory of the normal sounds
of the heart, have this unfortunate result, that so far as sev-
eral of them are concerned, the morbid sounds of this organ,
to which especially, as we will hereafter see, diagnos'13 at pres-
ent owes its certainty, are far from having that semeiological
value which so properly belongs to them, and  that  some of
them are at the present stage of science enveloped in mystery.
One of those practitioners, whose talent for observation I am
far from questioning, has  said,  "that  we can no more ex-
plain,  by the theory of Mr. Roaunet,  than by that of others,

  * There is no English term,  by which this can be translated. The chef de
clinique is found only in those wards which are attended by a professor of
clinical medicine; he is a graduate, and without residing in  the hospital building
has charge, under the professor, of the service.
            B 
[  io   ]
all the anormal sounds heard in  the heart, and thus arrive at
the  diagnosis of the  special seat of the disease.'"  (Chomel's
Pathological  Gencrale, 3rd. edition,  1841.
  This assertion I shall  submit  to the test of facts.  I shall
endeavor  to ascertain if, on the  contrary,  science  does not
possess means  of exploration by the aid of which lesions ol
the heart may be diagnosticated, not only  in their ensemble*
but often decomposed by the observer, into their anatomica
minutiae; and if the most  faithful and most precise  of  those
means, is  not  auscultation based upon the  theory of Mr.
Roaunet; a theory which, thus put in connexion with patho-
logical facts, if it explains all of  them, will receive a brilliant
confirmation.
  After this clinical part, I will commence a succinct study of
the means of investigation, which may have furnished us the
principal diagnostic signs; I will note  their respective value,
their semeiological bearings, in such a manner that those who
in their turn  may desire to investigate diseases of the heart,
may find in this summary a kind of compendium  of diagnosis.
Finally, I  will point  out  the practical utility of these investi-
gations and show that far from being intended only  to gratify
foolish curiosity,  they  are susceptible of therapeutical appli-
cations of the  highest  importance.    Moreover, I  wish it
to be understood that what I am about to publish are clinical
researches.  I will recur with the reader to a train of facts
that we will  examine together,  gradually  passing  from the
most simple, to the more complex, analyzing all with the same
care, and  receiving from some the where-with-all to clear up
the history of others; and  then, whilst all these facts  will thus
furnish us what they can of information and practical lights,
in carefully collecting  the results  of this examination,  in
assembling these sparse materials, these successive  acquisi-
tions, we can not fail to  verify the deficits  which may  exist.
We  will  thus at the same time, alike discover what is pos-
sessed  and what  is yet wanting in the science; and  this sort
of inventory, if I may thus express myself, this comparative
approximation of our wealth and of  our poverty, will have, I
hope, the advantage  of showing  some observers  that we  are
less poor than they  suppose, and of pointing out  to others
that which  still  remains to be acquired, so as forcibly to
address the zeal of all, and direct more profitably the efforts
of those who desire to devote themselves to the  development
of our art.   Such  is in  short  the  essential  design of this
memoir. 
FIRST   PART.
              EXPOSITION  OF  FACTS.

  Before commencing the clinical review, I think it necessary
first to establish as succinctly  as  possible, the theory which
shall direct us in appreciating the sounds of  the heart.  And
here perhaps more than elsewhere, a minute knowledge of the
normal  state  should  necessarily precede the  study of the
anormal.
  Four elements, in my opinion, should be admitted as enter-
ing into the production of the sounds of the heart.
  1st.  The  shock of  the  apex of the organ  against the
parietes of the chest;
  2nd.  The gliding upon each other of the  opposite surfaces
of the pericardium;
  3rd. The friction (frottement,) of the sanguinenous column
against  the interior of the cavities of the heart;
  4th. And  lastly, the sudden readjustment of the valves,
valvular clacking.
  Of  these four conditions, the  last  is the essential, the pre-
dominant.   But, if the  other three are habitually masked by
it, if each of the three  first is  normally aphonic, it is never-
theless  true, that, in  pathological conditions, each can  in its
turn predominate.  This is a fact susceptible of demonstration,
and which  it is especially necessary to bear in mind  in the
appreciation of the morbid sounds which occupy us.
  Thus, 1st., the  shock of the  point  of the heart habitually
takes place, in my opinion, without any distinguishable sound;
but in  pathological circumstances  we see  this shock, by its
exaggeration, produces sometimes a dead, dull, distinct sound,
readily distinguishable, very different from the ordinary sounds
of the heart, and sometimes a peculiar  tinkling, (the auriculo-
metalick,) a sound of  but  little symptomatic value, as we will
hereafter see, and really compatible with the normal state.
  2nd.  The  gliding  of the opposite surfaces of the pericar-
dium.   So  long as these surfaces are lubricated, humid, and
perfectly polished, no sound results from their friction, but let 
[  12  ]
this polish become effaced, let false  membranes be deposited
upon these  opposed surfaces,  and there will immediately
result a  morbid sound  which I shall here  be content with
having mentioned.
  3rd. The  friction  of  the blood against the  interior of the
cavities of the heart.  As the last this friction is  not in my
opinion the cause, in the normal state, of a perceptible sound,
the endocardium, a polished membrane, too readily facilitates
this friction  for it to produce marked sounds; but if this endo-
cardium becomes partially thickened, or covered with vegeta-
tions, or encrusted with a chalky deposit, or its orifices become
contracted,  etc., all of  these new  conditions, by increasing
the friction of the sanguineous  wave, become  so many pow-
erful causes  of anormal sounds.
  It is to this cause that we must refer all the sounds produ-
ced by any derangement in our  fourth condition, the valvular
clacking, no lesion  whatever of the valves  producing any
decided sound, save as a consequence of increased friction.
One more word upon this clacking as it takes place normally,
and  we  will have finished these preliminary  considerations.
  The action of  the heart is divided into two successive and
distinct times or sounds.   Now what  passes in the first time?
Let  us take, for instance, the left heart; whatever we may say
of the left side being applicable to the right, whose movements
are exactly  synchronous.  In the first time, the left ventricle
contracts, and the greater part  of  the column of  blood
escapes by the open orifice of the aorta, whilst some little of
it strikes the  bicuspid valve, and  thus adjusting it, stops all
flow towards the auricle.  It is this sudden adjustment of
the bicuspid valve which produces the first sound.
  Mr. Bouillaud adds to this  re-adjustment, the  collision of
the valvular lamina, which he says are struck  by  those oppo-
site.  I acknowledge that it has always been  difficult for me
to appreciate  this circumstance; doubtless because I explain
with a slight difference, the  mechanism  of the play of the
valves.   According to Mr. Bouillaud, the adjustment of the
auriculo-ventricular valves would be caused,  not solely by the
shock of the sanguinenous wave, but principally by the action
of  the chorda tendinece which are inserted in  the valves, and
which would thus have  a double use—1st, to replace and to
stretch these moveable lamina, by exerting traction upon them
from their circumference to their centre; and 2d, this re-adjust-
ment having taken place, to prevent  their inversion by the
shock of the  blood  towards the corresponding auricle.  Of 
[   13   ]
these two uses, I acknowledge  that the second  has  always
seemed to me to be the principal.   For how are we to con-
ceive that tendons fixed more or less perpendicularly  to the
ventricular face of the valves can  be able, by contracting,  to
draw these  valves in a horizontal direction?  Is it not more
natural to regard these chordae tendineas only as  ingenious
accessories, the necessary complement of a pump,  both suc-
tion and forcing, but which is destined only to  the  support
of one of the valves of this pump, to give it a solid  prop, and
a sufficient resistance against the action of the liquid which
strikes against it?  If this theory is true, the tendinous appa-
ratus will be proportionably stronger, as the valve  may have
to sustain a  more decided impulsion.  This is what does hap-
pen; for we observe that the bicuspid valve is furnished after
this manner, with the two most vigorous columnce; and that
it receives the insertions of  about twenty-five  tendons, the
marked inferiority of the tendinous system of  the bicuspid,
being in proportion  to  the less powerful contractions of the
right ventricle.  Moreover, if  a tendinous apparatus is ne-
cessary to valvular occlusion,  why are  the aortic and  pul-
monary valves unprovided  for?   Do not the arterial orifices
require occluding as perfectly as do the auriculo-ventricular?
Let us see in the chordae tendinece, only a  means  of  resistance
and not an arrangement for closing, and the absence that we
have just noted will no  longer astonish us, when we remem-
ber how slight the systolic  force of the aorta and pulmonary
arteries is, compared to  the ventricular systole, how unnatural
it  is to displace from  the direction of  the ventricles those
valves which the influence of the blood has just readjusted  by
its  reflux movement after having displaced them by its issue.
But this leads now to the consideration of the second sound.
   Xow what takes place in the second sound?  The ventricle
dilates, and  thus gives rise to a tendency on the part of the
blood to flow thither.   But it can come from two directions;
1st, from towards the auricle, and there is nothing to oppose
this, for the species of suction  exerted by  the  dilating ven-
tricle, depresses  towards its interior the bicuspid valve, and
the sanguineous contents of the auricle thus enter freely into
the ventricular cavity; 2d, this suction, of which I have just
spoken, is also exerted  upon the  blood already thrown  into
the aorta, a part of this blood then returns, thus obeying both
the attraction of the ventricle, and the  pressure exerted  by
the elastic walls of the vessel, but the return of this retrograde
wave immediately gives rise to the adjustment  of the aortic
             B* 
[  14  ]
valves, and this abrupt adjustment is the cause of the second
sound.  Thus then: the first sound, is the clacking of the bi-
cuspids, the second sound, clacking of the aortic valves. Be it
mentioned, however, more with reference to the  pathological
than to the normal  heart, that at the moment when one of
these valvular arrangements is adjusted, that when one of these
orifices is closed, the other valvular apparatus becoming de-
pressed, the corresponding orifice is traversed by a jet ot blood,
first, the aortic orifice, and in  the second time, the bicuspid.
And furthermore, let it be borne in mind, that this condition is
itself so favorable to the production of anew sound, that even
physiologically, if ever so  little exaggerated, if,  for instance,
the column of blood should be expelled with a little too much
quickness  by the aortic orifice, an accessory sound can take
place during the first time;  as an example of this,  we  find
sometimes, a slight, soft, aortic souffle, during the first time in
persons who have just run or walked rapidly a short distance;
a souffle that 1 have more than once found in patients at the
moment of their arrival at the hospital, but  which  has  disap-
peared after several hours rest.  But it  will be asked:  if the
swiftness of the flow of the blood, suffices for the production
of a souffle, how comes it that this takes  place only at  the
aortic, and never at the bicuspid orifice?  Why should it hap-
pen only during the  first time, and never during the second?
I think that there are two reasons for this fact.  The first is,
that the blood should leave the heart more quickly  than it en-
ters, the  ventricular systole which drives it out, being moi'e
powerful than the auricular systole which forces  it in, aided
as much as  may be by the  diastolic aspiration of  which 1
have just spoken.   The second reason is the difference in the
normal dimensions of the  two orifices, the circumference of
the aortic being only 31 lines, and that of the bicuspid orifice
4G£  lines, thus it is evident  that the first is less able than the
second to  contract  without  a perceptible effect being  the
result.
   In fine, let us remember that, of the two sounds of the heart,
the first is naturally a little obtuse and prolonged, the second
shorter and  clearer; for in  this difference  there  exists  a
new  proof in support of  the theory  of  valvular clacking.
In  fact, the  first  sound is obtuse, "because  the  bicuspid
and tricuspid valves have  no ambient bodies to propagate
their vibrations, except the  fleshy walls of the heart itself;
and because, moreover, the chordae tendineae, which connect
with each of them, stiffened both by  the contraction of the 
[  15  ]
calumnae carneae, which put them in play, and by the fact of
the readjustment of these valves, probably moderating, and in
part extinguishing this vibration.  The clearness of the second
sound, results from conditions precisely opposite, in which we
find the aortic and pulmonary valves, which are alike unpro-
vided with chordae tendineae, and adhering  to two  arterial
tubes, eminently elastic  and vibratory.   1  come now to  the
clinical facts.
  The number of organic affections of the heart  of which  I
have collected  observations, exceeds sixty.   Desiring to con-
sider  here, these diseases principally in reference to diagno-
sis, I have  felt  obliged  to  put aside all  those which  have
not received the verification of post mortem  examination.
This condition  reduces  the  facts, that I am  about  to ana-
lyze,  to about twenty.
   In order  to proceed, as I have already remarked, from the
simple  to  the  complex, 1  will begin  with  a case of  hy-
pertrophy  of the heart, without a lesion of the valves, suffi-
ciently prominent  to  have  been  remarked  in the diagnosis.
These cases are rare.   We conceive, in fact, that the valves
are parts so essential to  the heart, that this organ  cannot be-
come hypertrophied to a certain degree, without these  mem-
branous vails participating with it; and  after the  details into
which we  have entered, it  is readily perceived that in  our
opinion  the least deformity, the least thickening  of  the val-
vular lamina?, should be expressed by sounds sufficient  to be
trasnformed into diagnostic signs.
    Observation 1.—Simple  Hypertrophy  without  any re-
markable valvular lesion.  (Edema of the glottis.—A laborer,
aged 14 years, was received, on the 26th of September, 1840.
 He was of a medium constitution, and of a temperament more
lymphatic than  sanguine.   He had labored for  twenty-one
 vears  in a quarry, had been  crushed by a fill I, and his  chest,
at the time of  his  reception, was still a little prominent be-
fore, and notably depressed  behind; seeming to carry thus the
traces of an accident, which  had detained him nearly four
 months in Saint Louis, where  he was  treated by the  appli-
 cation of eighty leeches to  the right side, and thirty to the
 neck.  Five years had elapsed since he contracted  what he
 called a catarrh; and without further specification  in reference
 to this malady,  he said  it required  the application of fifteen
 leeches  to the proecordial  region.   Apart  from these  two
 epochs  of his  previous life, his health had  been habitually
 quite good.  Even at this moment he complains only of a slight 
[  16  ]
dyspnoea, which began eight days ago, a little cough without
expectoration, and a cephalalgia with some dizziness; there is
no other notable phenomenon, neither anorexia, fever, or even
palpitations.
  I examined him with care, and the following are the prin-
cipal results of that exploration:
  The digestive functions are well performed; temperature of
the body normal;  pulse  from 40 to 44,  of medium  develop-
ment, unequal,  intermittent, irregular, the regular pulsation
being sometimes followed by a small pulsation which imme-
diately succeeds it; no precordial  prominence, nor anormal
dullness in that region, nor vibratory tremor.  The sounds of
the heart are remarkable for the same anomaly of rhythm as
the pulse, and still more so for  their dry  tone, somewhat like
the rustling of parchment, but  without souffle; they may be
heard  as far as under  the right  clavicle.   The cough is
quite rare,  and  without expectoration; no pain  in the chest;
the resonance  and respiration  are good  before;  behind idem,
also on the right side, except at the base, where  we hear a
sub-crepitant rale  with very numerous bubbles a rale; which
is found iii  all the left side, accompanied on that side by a lit-
tle  obscurity in  the resonance; a little cephalgia and heaviness
of the  head; a slight oedema of the inferior portion of the right
leg; the patient was able  to walk to the hospital  without
difficulty.   With  the symptoms which we have enumerated,
before us, what shall be our diagnosis?   An acute lesion of
the respitatory apparatus?   This idea is scarcely  compatible
with the number of the pulsations.
  But for the present let us remark in  anticipation,  that in
this case there  was pulmonary oedema,  a disease but little
known, considered as an active malady,  but little  studied up
to the present period, and of which, I confess,  the idea had
not occurred to my mind.   Mr. Bouillaud who  repeated the
examination the next morning, remained in the same doubt
on  his part.  Nevertheless,  he  prescribed a bleeding, to the
extent of twelve ounces, a pectoral tisan, un julep et le quart.
As to the heart, what had we a right to  admit with  the signs
I have enumerated, except  a medium hypertrophy without
any grave  lesions of the valves?  And yet we could presume
this hypertrophy only with a certain reserve, deprived as we
were, and  that  perhaps by the accidental deformity  of the
chest, of its most ordinary signs: which are as we shall see,
an increase of dullness, praecordial prominence, a displacement
of  the apex of the heart, and as we had  here, in place  of all 
[  17  ]
other  symptoms of that morbid state, irregularities of the
pulse and a parchment tone of the sounds, characters which
we will find always responding to a  certain thickning of the
valves, and very rare without hypertrophy of the heart itself.
   For some days the state of the patient remains stationary.
The blood drawn is normal.  A plaster of pix burgund. with
an addition of ant. tar. was applied to the anterior portion of
the  chest.  Yet, the stethescopic phenomena persisted; the
pulse became more regular, but it is also  more tense, a little
vibrating  and has gradually risen to 60—64.  At the same
time  the  infiltration  of  the inferior extremities  insensibly
augments, and the scrotum has become cedematous.
   October 16th.  The patient complains of more pain.  Since
yesterday  he has suffered with  quite  an intense affection
of the throat;  his voice is guttural;  deglutition painful; the
posterior  part  of the mouth very red,  with  swelling of the
uvula, but no enlargement  of the  amygdalae; countenance
quite animated; heat of the skin moderate, but  the pulse is at
eighty with some intermittence.   Prescribed thirty leeches to
the neck.
   At my  evening visit, I found the patient seated upon his
bed, laboring under a well marked dyspnoea, with the  inspira-
tion a little hissing.   In ausculting  the chest I heard only a
rhonchus which appeared to eminate from a point in the larynx.
There is considerable  anxiety.  The skin is hotter and the
pulse from 96 to  100.  The leech bites  still bleed,  neverthe-
less, I ordered a bleeding to the extent of sixteen ounces, and
applied sinapisms to  the feet.  Notwithstanding these means
the dyspnoea  persisted, and the patient died  at one o'clock,A.M.
   Autopsy.—The epiglottis was remarkable for its apparently
cedematous thickning, a thickning in which the adjacent parts
participated,and especially the arytaeno-epiglottidian ligaments.
We incised  these different  parts,  and there  escaped from
them a yellowish pus, recently formed, and infiltrating all the
ambient cellular tissue.   The glottis  was sensibly contracted;
the  vocal cords  were puffed, cedematous, without any trace
of suppuration;  the  ventricular cavities  were  effaced;  the
laryngo-tracheal  mucous membrane  was  very pale.   The
lungs, quite flexible  and  crepitant, were only  engorged pos-
teriorly and very abundantly infiltrated with  serum.  The
heart was remarkable for its volume, the hypertrophy affect-
ing especially the left ventricle.   There was a slight thickning
of the bicuspid  valve.   The aortic valves preserved their
normal thickness; we  remarked  only that the tubercle  of 
L  13  ]
Arantius of each of them, was rather more developed and
harder than natural.  The entire endocardium, the origin of
the aorta and of the pulmonary artery were of a very lively
red and faded  only slightly by washing.  This  observation,
which I have thought it  my duty  to reproduce entire on ac-
count of its interesting character, is calculated to give matter
for numerous reflections, above all in relation to the oedema of
the lungs;  but do not let us forget that  what we  were partic-
ularly interested  in was the diagnosis of the disease of the
heart.  Observe, then, that  the  autopsy fully  verified the
symptomatic indications.  The signs  noted during life  were
those of simple hypertrophy,  they indicated scarcely any
thickning of the  valves.  In this respect the necropsy sus-
tained the diagnosis, neither exceeding or falling short of it.
I will content myself with this remark, only adding in refer-
ence to the cause of the  disease,  that  we may be  permitted
to hesitate  between  the external violence and  the acute
thoracic affection;  but the second cause appears to me more
probable than the first.
   Observation 2.—Left  Auriculo-ventricular lesion  exclu-
sively,  with Insufficiency.   Laurena  Bavaux, laborer,  aged
thirty-nine years, entered into our service on the 22d of Sep-
tember, 1840.   Her sickness  dates six months past; she has
tubercles in the summits of both lungs, and particularly the
right  side.  After having satisfied myself in this  respect, I
passed to an examination of the heart.   The patient says she
is free from  palpitations;  the  pulse is slightly developed, but
this circumstance corresponds with the general emaciation;
the praecordial  dulness is normal; there is neither  an increased
prominence of the chest or vibratory tremor; I was then much
astonished upon applying my ear over the region of the heart
to hear a bruit de souffle sufficiently marked, seeming at first
to be present alone  in the second time, but becoming  more
and more pronounced,  as I auscultated  nearer and more near
to the left auriculo-ventricular region, and in this point marking
the two sounds and moreover not  being continued  either  in
the carotids or in the course of the aorta.  With these signs I
did not  hesitate to announce the existence of a lesion of the
left auriculo-ventricular valve exclusively, accompanied  by a
slight hypertrophy of the heart,  the  diseased valve should
necessarily be  patent.   The  double  souffle  I explain, by
saying:  the  column  of blood rubs  against  this  thickened,
puffed and imperfectly mobile valve, 1st. when a part of the
column under the influence of the ventricular systole  flows 
[  19  I
back into the  auricle through the  imperfectly closed orifice
(souffle of the first time;) 2nd. when the entire column, influ-
enced by the auricular systole, and especially by the disastolic
aspiration  of  the left  ventricle,  enters  into  this  ventricle
through  the scarcely open orifice (souffle of the second time;)
and if this second souffle is more marked than the first, it is
from being caused by the friction of the entire wave of blood,
the first  being the result of the friction of a part of it  only.
From this difference of intensity between the two souffles, it
resulted  that the first and more  feeble should become imper-
ceptible  at a short distance from its seat,  and masked by the
clacking of the tricuspid valve, whilst the second and stronger
is heard even where the clacking of  the aortic and pulmonary
valves might replace it.   Thus there is a blowing sound during
the second  time of the heart, throughout the whole praecor-
dial region, and  during both times in the region of the dis-
eased  orifice only.   One month after  her arrival at the hos-
pital the patient died from the progress of the phthisis; and to
speak  only of that which now  occupies us, we found at the
autopsy, the heart of its natural size, perhaps a very little en-
larged,* when we remember the emaciation of  the  subject
and the tubercular affection; the right cevities distended by
newly formed clots; the  tricuspid" and  pulmonary  orifices
perfectly healthy;  the  aortic valves  likewise healthy,  very
thin and normal; the left auriculo-ventricular valve thickened,
patent, it represents a kind of fibrocartilaginous excrescence.
Now, is not one such fact an irrefutable proof of  the truth of
our theory?   Let us mention, in passing, this peculiarity, that.
certain grave diseases of the heart, sometimes exist without
very marked  functional disorder, and  that  in some  degree,
without the knowledge of those who are afflicted.
   Observation 3.—Lesion of the Aortic Valves without Insuffi-
 ciency.—Ann Prudhomme, a   washer-woman aged seventy,
 on the 19th of May, 1841, entered the wards of the charity
 hospital.  She is a woman of strong constitution, sanguinenous
 temperament, has been sick but three or four times in her life.
 and does not know  of  what diseases, but is certain they were
 not rheumatism or affections of the chest.   For two months
 she has been subject to  headache,  restlessness, dyspnoea,
 palpitations, slight cough, and for the last three weeks, with
 swelling of the inferior extremities.
   Upon her  arrival 1  examined  her carefully, and so far as
 concerns the circulation, found the pulse  60, moderately de-
 veloped and regular.  The prsecordial  region,  covered in a 
[  20  ]
great part, by large mammae, seems to offer neither increased
prominence, anormal dullness, nor tremor.  The beats of the
heart are deep seated, slightly perceptible to the touch; the
two sounds, difficult to hear on account of the fleshiness of the
patient, are separate, but the first is accompanied by a souffle,
rather rude, sufficiently prolonged, reaching  its maximum in
the region  of  the aortic orifice, and of the ascending aorta,
and being propagated into the carotids without being there
compounded  with the bruit de  diable.   The patient com-
plains of palpitations from time to time, even when in a state
of repose; her sleep is often troubled by dreams, accompanied
with starting.  Her legs, and especially the right, are the seat
of swelling, with tension and even a slight erysipelatous red-
ness  of the skin of the two inferior thirds—no ascites.
   What was our diagnosis?
   A  medium degree of hypertrophy of the  heart, with lesion of
the aortic orifice especially, without insufficiency of that orifice.
   Let us state, in few  words, the grounds for the  different ,
elements of this  diagnosis.  And  first, of the medium hyper-
trophy of the heart; there is hypertrophy, for, as we shall soon
see, there is valvular lesion;  and  the one almost constantly
supposes the existence of the other; medium  for, there is nei-
ther  vibration of the  pulse, nor dullness, nor very  sensible
beats, etc.; lesion  of  the aortic orifice, for  to  what time does
our souffle correspond?  To the first time.  Now what occurs
during the first  time?  The left  ventricle contracts, as we
have  said, and the  column of blood escapes by the aortic
orifice, without being accompanied by any other  sound than
that  which results from  the sudden re-adjustment of the bi-
cuspid valve.   We have here a souffle in the first time; what
does it indicate?   An excess of friction (frottement) of a part
of the column of blood against one of the orifices of the heart;
now, which is the o'rifice?  Evidently, in the first time, there
is as  much probability of its being the bicuspid orifice incom-
pletely closed, as  the aortic orifice imperfectly opened.   How
then, shall we determine this difficulty?   By  examining with
care  the point with which the maximum of the souffle corres-
ponds; particularly if this souffle extends towards the base of
the heart, between the mammae and the sternum, and is pro-
longed in the direction of the ascending aorta, as far as to the
carotids, its point of departure is at the aortic orifice.
   But we have said that the lesion was especially  seated in
the aortic orifice.  Why then, this reserve,  which seems to
indicate  the possibility of a lesion of the other orifice?  It is 
[  21   ]
because rigorously, this complication is not entirely impossi-
ble.   In ausculting beyond the bicuspid region,  the  embon-
point of the patient did not permit us to analyze the sounds
with sufficient precision, to be well assured that no  trace of
souffle mingled with the clacking of that valve.  Hence we
were justified in inquiring if a slight bicuspid insufficiency did
not coincide with  the aortic lesion.
  Finally, we  have said without insufficiency of the aortic
valves.  And, why?   Because the second sound,  that is to
say, the result of the readjustment of these valves, was min-
gled with no souffle, which would have been inevitable, if a
portion of the sanguineous wave had reentered the left v n-
tricle, through the imperfectly closed aortic orifice.
  This patient, who was very promptly restored to her habit-
ual state of health, by  repose and digitalis, prolonged  her stay
in our ward, where  she shared the occupations of the  infir-
mary.  But at the end of about nine months, she was attacked
with general acute bronchitis, and died on the 22d  of  Feb-
ruary.  During her long stay, I  had carefully ausculted her,
without even  finding  any  modification  in  the  seat of the
souffle of the first time.   The following is  the  result of the
autopsy:
  The heart is enveloped in a very thick bed of fat.  After
the  removal of the fat,  its volume is not much more consid-
erable than natural; nevertheless, the auricles are dilated and
the left ventricle  evidently hypertrophied.  The walls of this
ventricle, towards its base, have a thickness of about  thirteen
lines.  (The medium normal  thickness  is about seven lines.)
Water poured into the aorta rises and preserves its level per-
fectly.  Yet, the aortic  valves, although sufficient and well
formed, are incrusted with a hard  osseous like matter, creak-
ing under the  scalpel,  lineally disposed in a vertical direction
to the valves.   The internal face of the aorta is smooth and
polished.   The left auriculo-ventricular orifice appears  nor-
mal; its valve, of a blackish red, from cadaveric imbibition, is
well formed but a little thickened, especially in the part near
the aortic valves.   It  is, however, neither fibrous nor ossified.
The right valves are normal.
   Is not this case  exactly analogous to the preceeding, in the
unity of the principal  lesion, and in the perfect  agreement of
the diagnosis and the autopsy?
   Observation 4.—Lesion of the Aortic Valves Exclusively,
tvith Insufficiency.—A woman thirty-six years old, a seams-
tress, was recieved into our service on the 11th of December,
             C 
[  22  ]
1841,  having  an  abdominal  tumor, of  a  very  obscure
diagnosis, the history of which would draw us too far from our
subject.  Let us come then to that part  of this observation,
which, at this moment, must be of predominant and exclusive
interest to us.   I refer to the examination of the heart.  Here
again, as with the patient in our second observation,  nothing
seemed to point to the existence of an  affection  of  that or-
gan.  There were no previous maladies,, such as rheumatism,
acute affections of the  chest, palpatations or  dyspnoea.   Yet
we heard with  her, a very distinct double souffle, in all the
praecordial region, but  especially in the  region of the aorta
and its orifice; a souffle quite light in the  first time, but more
rude and prolonged in  the second; and moreover, propagating
itself  into the  carotids, with  accompaniment of bruit de
diable in the right.  Further, the praecordial region, covered,
it is true, by quite a voluminous  breast, presented nothing
very notable.   The pulse is remarkable for its smallness.
   The developements made in the preceding case, will enable
us to dispense with any lengthy statement of the  reasons for
our diagnosis in this.   Who does not perceive, 1st, from the
seat of the souffle, that there is a lesion of the aortic valves;
2nd, from its existence  in the second time,  that this lesion  is
accompanied by insufficiency of these valves?  Have we at
the same time any considerable hypertrophy of the  heart?
No! doubtless,  there is  nothing which leads us to admit it.
Let us, then, now form our diagnosis; medium hypertrophy of
the heart, thickning and deformity of  the aortic valves, from
which results their insufficiency;  let us add: without notable
deformity of the bicuspid valve. Such are, in fact, the terms
of  the diagnosis, which I copy  exactly from my observation.
   Let us see now, what  we will encounter in the autopsy,
which was made nine days after the patient entered.
   The heart is very voluminous, but it presents externally a
tolerable quantity of fat, and in the interior some blackish,
flabby, unorganized concretions.  Freed from these clots and
washed, it weighs 11  ounces, (about  2£ ounces  more than
its normal weight.)  The left ventricle is  nearly the exclusive
seat of this  hypertrophy:  its walls are more than § inch
thick towards the base.  Nevertheless, the columnae carneae do
not present a proportional development.  Before opening this
ventricle, water was poured  into the aorta, and immediately
it penetrated into the  ventricular cavity.  In fact the aortic
valves are thickened,  almost fibrous, especially at their free
border,  which  is puffed, without adherences between them, 
[  23  ]
but a little  shrunk upon themselves.   The  circumference of
this  is  nearly  2:1 inches.  The internal  face  of the aorta,
above the valves, presents some rugose, unequal plaques, of a
very deep yellow—rudiments of cretaceous plates.
  The bicuspid valve is well formed, scarcely any thickened, or
rather, presenting only some small puffs, under  the form of
little reddish points.  The circumference of the orifice is from
3i to 4  inches.   The auricle offers nothing remarkable.  The
same is  true of the right side of the heart, which is perfectly
normal.   The circumference of the pulmonary orifice is  3
inches, and  that of the tricuspid orifice is from 4 to 4f inches.
The perfect agreement  which again exists here, between the
diagnosis  and the autopsy, has  no need of being demonstra-
ted.   I  will call attention  only to the rugose plates which
existed  on the internal face of the aorta.   These  are causes
of friction,  (frottement,) and consequently of souffle, to be
added to  that, which the  state of the aortic valves offers us.
Let us take  a passing  notice of those small reddish points,
disseminated on the borders of the bicuspid valves.  I do not
hesitate to  consider them  as  so many fibrous concretions,
plastic,  fixed there, become adherent, living in some sort a
parisitic life; and  which, at  a  later period, would not have
failed to become  nuclei for  cartilagenous and osseous forma-
tions, such  as  we  are  often presented with when valvular
deformity has reached a high degree.   In  fine, let  us  remark
the localisation of the disease in  the left heart.  To conclude,
the orifices of this heart, (the left,) like those of the right side,
have their circumference in exact proportion with the mea-
sures of the normal state  established by Mr. Bouillaud.
   Observation 5.—Lesion  of the  Aortic  Valves especially,
with a cretaceous state  of the Aorta.—A  porter, aged forty-
eight years, of a strong constitution and sanguineous temper-
ament, was recieved in our wards on  the 27th of December,
1841.   The  only important  peculiarity furnished by his  pre-
vious history is, that in 1819, whilst serving in  the cavalry,
where he  had been for eight years, he was kicked by a horse, on
the anterior and outer region of the lower false ribs of  the left
side, and as a consequence was  obliged to enter the hospital
of Gros-Caillou.  There treated by two or three applications
of leeches, and as many of scarified cups;  he came out at the
end of  two months, desiring to continue  in  the service,  but
was not able to stand the jarring necessarily consequent upon
riding,  being  subject  to  palpitations and  suffocation,  on
account of which he was discharged by Baron Larrey.  Since 
                        [  24   ]

then, his health has been pretty good, except in 1821, when he
was  sick, but does not  know of what disease—neither an
affection  of the chest nor rheumatism.   Since that period,
as before, his occupation has been laborious  and fatiguing,
and  often  caused him  to experience,  momentally,  violent
palpitations  and dizziness.
  It  is on account of these latter phenomena that he came to
the hospital.  Fifteen  days  before, there had supervened a
decided infiltration of the superior and inferior extremities,
of the genital organs, and even of the face.
  Condition upon admission.—The face still  presents some
remains of the aforementioned puffiness.   There is no ascites.
The  lower limbs are infiltrated.   The pulse is  68, vibrating,
developed, resisting—if I may so express myself, hypertrophied.
There is a diffuse but evident praecordial prominence—a prom-
inence established by the cyrtometre, (an instrument of which
I will speak in the article on the  means of exploration,) by a
difference of two degrees.   The  point of the  heart  slightly
elevates the  sixth intercostal space, a little without the nipple.
The  beats of the heart are sufficiently expansive,  but deep
seated; and, at this  time, without vibratory tremor.   Dulness
on percussion for three inches vertically, and three inches four
lines transversely.   Throughout all the praecordial  region a
double bruit de souffle  has completely taken  the place of the
normal tic-tac.  Towards the bicuspid orifice the two souffles
are short, the second sharp, the first mingling with a dull sound,
caused by the shock of the soft point of the heart,.  The nearer
we approach the aortic orifice, the more pronounced do these
two  souffles become; that of the second time being more
marked than that  of the  first; both are rude, uneven, very
evident in all the track of the  ascending aorta, as high as
the clavicles,  without valvular clacking in any part  of the
chest.  The subclavian and  carotid arteries  present strong
pulsations, with a propagation of the double blowing sound
already indicated.   There is also a simple souffle, only caused
by pressure, in the abdominal aorta, and in the crural arteries.
The  jugular veins are well dilated.  There is nothing remark-
able  in the respiratory apparatus,  except a fine mucous rale
at the inferior posterior part of the left lung.
  Such were the  signs collected upon  his arrival,  and con-
firmed the next day by Mr. Bouillaud, who added a  vibratory
tremor in the carotids and subclavian arteries.
   What was our diagnosis?  Considerable hypertrophy of
the heart, (one pound and upwards.)   Thickening and defor- 
[  25   ]
 mation of the left valves, with insufficiency of the aortic.  Hy-
 pertrophy and chalky state of the aorta and arteries gener-
 ally.   Let us now endeavor to specify with  care the basis of
 this diagnosis.
   Considerable hypertrophy of the heart.   Vibrating pulse.
 Prominence.   Displacement of the point of the heart.  Dif-
 fused pulsations.  Augmented dulness.
   Weight of the heart over one pound.   Its medium normal
 weight is from nine  to ten ounces; we  have here a praecordial
 dulaess,  at  least twice  as  extensive  as ordinary; we  may
 therefore suppose the organ at least double its natural weight.
 Let us add, however, that these estimates never have a math-
 ematical accuracy,  especially when the weight  of the heart
 surpasses, as we will see in  this case, the ordinary limits of
 hypertrophy itself.  In cases of this kind, in predicting what
 the heart will weigh, we mean that it  will at least reach that
 weight and may possibly exceed it.
   Thickening and  deformation of the left valves.—As there
 is no  valvular  clacking,  the valves are  not only thickened,
 the lesion which they always first present to us, but deformed.
   Of the valves.—Why both?   Because wre hear no clacking
 either in the  first or second  time, but in  place  of  it, two
 souffles.   Nevertheless,  let us remark, that this double souffle
 is not always a proof of duplicate valvular lesion, as the same
 orifice, if it be  insufficient,  may produce a souffle  at each
 time.   It is  evident,  in fact,  that in this case, the normal
 clacking of  the other orifice may be masked by the souffle of
 the first, however  slight this  souffle may  be.  But if it is
 the nature of a souffle to be louder than the valvular clacking,
 it is much less capable  of propagating  itself to a distance.
 If, then,  the clacking is smothered by the souffle, remove your
 ear from  the  point of departure  of these two  sounds, and
 auscult above the praecordial region, (and it will sometimes be
 necessary to do so, as high up even as  the right clavicle,) and
 then the clacking will resume its place, and become percepti-
 ble, because the souffle will have ceased to be heard;  and as
 soon as you can distinguish the precise times  of this clacking,
 you may conclude, with  assurance, the  corresponding valve
 preserves its integrity.
  There  is,  however, a case in  which  this  precaution itself,
 this verification of praecordial auscultation, by means of con-
ducting it  a  greater  or less   distance, may  leave  us  in
default. This occurs where there is a coincident valvular lesion
of the right heart, and consequently a new souffle, with the
             C* 
[  26   J
 clacking  which I suppose  to be normal.   This additional
 souffle, augmenting  that  of the left orifice,  may propagate
 itself so far as no longer to permit, or only at rare intervals,
 the normal clacking to emerge into distinctness.   This morbid
 coincidence, to which I now refer, will, in fact, present itself
 in the case now under consideration.  We will  see  by  the
 autopsy that  there existed an insufficiency of the tricuspid
 valve; that thus it was a cause  of souffle in the first time added
 to that furnished by  the aortic  orifice,  and that these two
 souffles, by augmenting each other, sufficed to mask completely
 the  clacking,  supposed to be normal, of the tricuspid valve.
 I say supposed to be, since so far, there is nothing to warrant
 us in admitting the  integrity of  this valve.  But I will sup-
 press this restriction by adding  that, during  the  residence of
 the patient at the hospital, the normal clacking  became dis-
 tinct by intervals at the first time.
  I perceive this  peculiarity noted  for the first  time on the
 25th of February,  in the following  terms,  dictated  at the
 morning visit:
  Same sounds of the heart as on  the first day.   We finished
 the exploration by distinguishing the first sound on the lat-
 ter al parts of the neck, and adjacent thereto.  We may per-
 haps be surprised to see a  souffle, that is to say,  the effect of
 a constant organic cause, thus vary in its intensity.  But it is
 a clinical fact, daily  observed, and of which I will  give the
 reasons a little farther on, when treating  of the stethoscopic
 signs.
 1 have stopped to develope, to some extent, the semeiological
 bearing of our double souffle, and  the  habitual absence of
 valvular clacking; and yet I cannot consent to quit the subject,
 without having responded to an objection, which  might be
 addressed to  me.   A double  souffle,  I have said, does not
 indicate disease of two orifices, unless it is double at  every
 point where it can  be heard.  If there  be but  one orifice
 involved, there will be a point more or less removed from the
 praecordial region where the normal clacking, marked nearer
 its seat, will reappear.  Well! ought it not to be  thus in all
 cases where the  lesion of the left  heart  may  be single or
double?  For,  if the normal clacking cannot be furnished by
 either of the two left valves, may it not be by one at least, if
not by  both of the two right valves?  How shall we distil
guish this second case from the preceding?
  I acknowledge that this  difficulty  may be met with.  I be-
 heve that it is the cause of possible error in certain cases 
[  27  ]
But I will add, that if this cause is not impossible, it is at least
not frequent, as we will ascertain in the course of these clini-
cal studies.   This variety appears to me to be owing  to the
fact, that the normal sounds  of the right  heart are probably
much less striking than  those of the left; and this is; without
doubt, a consequence of the habitual difference in the relative
force of  the  contractions of the two  ventricles, whether in
a normal or morbid state.  If this be true, it is apparent that
these sounds may  not  be sufficiently  distinct to be  heard
beyond the acoustic sphere of the souffles of the left heart.
   Let us now return to our diagnosis.   We have said, insuffi-
ciency of the aortic valves.   Why so?   For the  twofold rea-
son, that the  maximum of the souffle  corresponds with the
second time, and to the region of the aortic orifice.
   Finally, we have admitted with our patient a chalky  condi-
tion and hypertrophy of the aorta and of the arteries in gen-
eral.  The vibration of  the pulse, the force of  the beatings of
the sub-clavian and the carotids, the vibratory tremor of these
last, cannot permit much doubt of the existence of a hyper-
trophy  of these  vessels.  As to  the cretaceous  state  of the
aorta, we  may be  lead to suppose it, by the intensity and
rudeness of  the souffle  in  the aortic  region, a souffle very
intense,  truly, to be the result only of valvular insufficiency,
the degree of importance of which is somewhat restricted by
the development of the radial pulse.  Our patient after some
alternations of momentary assuagement and suffocating par-
oxysm, was attacked, in the month of February, by an almost
general  oedema, complicated by erysipelas of the inferior ex-
tremities, and albuminuria, and  finally died on  the 2nd of
March.
   Autopsy.—The heart is enormously  hypertrophied.  Dis-
embarassed of its clots and washed, it weighs, with the origin
of the large vessels, over one pound and a half.
   Right Cavities.—The right heart participates in the hyper-
trophy,  by  which, however, the left is more   particularly
affected.  Thus, the muscular substance of the right ventricle
is firm  enough and the  columns quite robust.   The dilated
pulmonary artery,  offers at  its  orifice  a circumference of
3$ inches, (instead  of about 2ij.)   Its valves otherwise sound
and well formed have a  depth of nearly 10 lines, (instead of 6.)
The auricle is sensibly dilated, and its  orifice is 6 inches, (in-
stead of  4g,) in circumference.   Moreover, its valve is suffi-
ciently thin and well formed, but  its size is not in proportion
to the increased extent of the  orifice which it  should close; 
]  28   ]
 for its  maximum height is scarcely 1 inch,  that is to say,2£
 lines more than usual; now the circumference of this orifice
 is about 2  inches too much, and the normal relation between
 the height of the valve and the orifice, being as 2 is to 10, it
 is evident that an excess, on the part of the orifice represented
 by 2 inches, would  require on the part of the valve an in-
 crease, represented  by 5 lines, and not  2£ as is  here the
 case. The valve was then in default, that is to say, insufficient
 by a quantity re presented by 2£ lines.
   Left Cavities.—Water  poured into the aorta seemed to
 maintain its level, or at best to penetrate but slowly, and the
 aortic  valves  thickened, hypertrophied, and  even slightly
 fibrous, seemed not to have been insufficient.   The circumfer-
 ence of the aortic  orifice was near 4 inches and 4 lines, (in-
 stead of 2| inches,) but the valves are proportionably enlarged,
 their height being near 10 lines, (instead of 6 or 7.)  In the
 substance of the partition separating these from the pulmon-
 ary  valves, was  found a  cretaceous production about twice
 as large as  a cherry stone, difficult to enucleate, adherent to
 the aortic  valve nearest to the pulmonary artery, leaving
 after its removal a  little  hole in the thickness of the  aortic
 valve.  Upon the inner face of the aorta, there was remarked
 some roughness, and even two small ulcerations, with irregu-
 lar borders, from 1  to 1£  lines  in diameter.  In the thoracic
 aorta we found three small prominent yellow patches.
   The left auricle was less dilated than the right.   The bicus-
 pid valve  was healthy, possibly a little puffed  upon its free
 border.  A portion of this orifice having been cut, it was  im-
 possible to  measure  its  circumference;  but no matter how
 much it may have been developed, the valve was  evidently
 sufficient, for its heighth varied from 10 lines to,  in its maxi-
 mum, even  15.
   The left ventricle was essentially the seat of hypertrophy.
 The thickness of its walls, from the base to the point, is 1 inch.
   The large arteries, and particularly the carotids and cru-
 rals,  are hypertrophied; their walls, without being encrusted,
are firmer and  more resisting than normally.   An almost
perfect accordance  between this autopsy and our diagnosis
is  readily perceived; yet there are two points of disagreement'
and especially one which 1 prefer to mention frankly myself
Thus the weight of the heart considerably exceeded our esti-
mate.  In reference  to this matter, I will content myself by
referring to the reflections which follow that  estimation   A
more  essential  point is the slight probability, or at least  the 
[  29   ]
slight importance of the aortic valvular insufficiency, indica-
ted by a souffle, rude, noisy, and much more evidently marked
in the second time, than in the first.  Here, I confess our er-
ror, remembering, at the same time, that we suspected the
cretaceous state of the aorta,  and 1 said that this souffle was
not owing  to  aortic  insufficiency.  And I  make  this ac-
knowledgment frankly,  because  it furnishes us, for the first
time,  a piece of useful information, which contributes to per-
fect what we have said above, on the souffle of  the second
time.   It shows us that the souffles in the aortic region may
be owing, not only, as is ordinarily the  case,  to the reflux of
the blood into the ventricle,  but also to the  friction, (frotte-
ment) of  the sanguineous column during its return shock,
upon  the inequalities with which the aorta is  covered.  This
was the case with  our patient.   And who does not see that
this friction is equally possible in the first  time.
   Further, this clinical point is so very important, that lean-
not consent to pass it, without having demonstrated it by new
facts, as precise as possible.   We  proceed then, to see the
cretaceous state of the aorta expressed:
   1st. By a souffle in the second time as we admitted in the
preceding case.
   2d. By a souffle in the first  time.
   3d. By a double souffle.
   Observation 6.—Souffle in the  second time caused especial-
ly by  a cretaceous state of the aorta.—Fracois  Laforge, sixty-
five years old, laborer, was received on the 2Sth of February,
1842.  This man complained,  at his  entrance, only of pretty
severe epigastric pains, of three or four days duration, caused
by having inadvertently swallowed a small quantity of aqua-
fortis.  I designedly omit the details  relating to  this  acci-
dent,  the consequences of which were fatal  at the end of a
month,  to take up that which more especially interests  us..
Interrogated in reference to his previous history, our patient
only  said that he had suffered with an  affection of the right
side of the chest, fifteen years  before.  Since then, his health
was good, but he  continued  to  be subject  to palpitations.
Having reached, in our examination,  the circulatory appa-
ratus, we were first struck by the notable displacement of the
apex of the heart.   The finger perceived  it with facility in
the sixth intercostal space, a little without the mammae, there
was no increased praecordial prominence; no vibratory tremor,
nor notable augmentation in the extent of the dulness.   As to
the sounds of the heart, a little unequal, a little less distinctly 
[  30  ]
struck, than naturally, they offered in the praecordial region,
properly speaking, no perceptible souffle; but in the region ot
the ascending aorta, a very distinct souffle replaced  the se-
cond time—a souffle very rude, and augmenting in intensity
towards the superior part of the chest.   Quite above the
sternum, the second time itself, was  accompanied by a little
souffle.   The pulse, not febrile, intermitted every five  or six
pulsations; it was but slightly developed, taking into  account
the very strong constitution of the subject, but it was hard
and very vibrating.
  With these signs before us, what ought to be our diagnosis?
  In the first place we must admit that there is hypertrophy.
The displacement of the apex of the heart, thrown  without
the nipple, and  into  the sixth intercostal  space, is a sign in
this respect, in  some sort pathognomonic.   But ought we
to admit a considerable degree of hypertrophy?  I think not
in the absence of increased prominence, augmented dullness,
etc.  I  say,  then, there is  a medium hypertrophy  of the
heart.   Let us  pursue this analysis.  The sounds are une-
qual, less distinct than natural, but without souffle in the
praecordial region; we hear them both there.   At present we
can say that the valves are injured, but their play is not pre-
vented, and neither of them is sensibly insufficient.  But, in
the aortic region, we have two souffles, and one of them
exists,  especially,  in  the  second time.  This  consideration
causes  us, in some measure, to lose sight of what we have es-
tablished, in saying that there was insufficiency of the aortic
valves.  I know that we  added with a cretaceous state of the
arch of the aorta; I know that returning  more than once to
to this diagnosis, with the students who  then followed my
evening visits, I  insisted, before them, on the cretaceous state
of the aorta, as a predominating lesion; showing them, in sup-
port of this localization,  how very positively the maximum
of the souffle corresponded with the  aortic region;  at the
same time I could not forbid myself the idea that an insuffi-
ciency  of the  valves themselves, also contributed to  this
souffle.   And yet I was obliged to ask myself: if aortic insuf-
ficiency exists here to a notable degree, why is the souffle not
more distinct in the region of the aortic orifice itself?  Why
could I not  perceive  it in that point during  the first time?
Why is the first time  accompanied by a little souffle, only at
a point quite above the sternum?  Would not all difficulties
have been avoided, if I  had admitted only  the cretaceous
state of the  aorta, as the essential cause of the souffle in 
[  31  ]
question?   But it may be said, if it be thus, if the souffle of
the second time has not for its principal cause, the reflux of
a certain quantity of blood into  the  ventricle, why then this
feeble development of the pulse, which  is not proportionate
to the  constitution  of the subject,  or  the vibrations of the
radial pulsation?  This peculiarity might be explained by an
aneurismal dilatation of the  aortic arch, and this dilatation
did, in fact, exist.   It is apparent that our aortic insufficiency
excludes, in our diagnosis,  the necessity of this explanation.
   Now let us enter into the details of the post mortem exam-
ination.
   Autopsy, the "Mst of March,  1842.—The heart is sensibly
more voluminous than natural.  Freed from its clots, and
washed, it weighs, with the origin of the large vessels, over
seventeen ounces.
   Right Heart.—The right ventricle is not dilated; it seems
even  relatively contracted,  the maximum  thickness of its
walls, towards the base, is scarcely  4? lines.  The auricle is
a little enlarged; the auriculo-ventricular orifice has a circum-
ference of 5ij- inches.   Its valve is  slightly thickened.   No-
thing notable about the pulmonary artery.  The circumfer-
ence of its orifice is 3$ inches.
   Left heart.—The left ventricle is the essential seat of hy-
pertrophy.   Towards the  base  its  walls  are nearly 1  inch
thick, (nearly 5 lines, more than natural).  The auricle is not
sensibly developed.   Its thickened valve, puffed in many
points, presents a transverse extent of from 35  to 4 inches,
(9h to  10 centimetres.)
   The aorta is remarkable for the volume of its  arch, which
is nearly  double its normal size.  Water being  poured into
this vessel slowly penetrates into the ventricle.   In fine, the
valves sensibly thickened, almost fibrous on their free border,
are well shaped  and free in  their play.  The circumference
of the  orifice, closed by them, is 3^ inches;  that of the arch, at
the commencement of its curvature, is 5g- inches.  Between
these two points,  and  in  fact, through almost its whole
length, the descending aorta  is notably hypertrophied, firm,
and thickened, its inner face incrusted with cretaceous plates
or patches so confluent towards its origin, that no space can
be distinguished between them, unless there be, in this same
point, some small solutions of continuity, apparently verita-
ble ulcerations of the internal membrane.
   The heart and large vessels contain some sanguineous con-
cretions, in part formed, anterior to death. 
[  32  ]
  Let us, in a few words, review some points of this autopsy.
In the first  place I said  medium hypertrophy;  and I must
frankly acknowledge  that over one pound exceeds this esti-
mate; but I will add, that it is very rare for a hypertrophy to
reach such a degree of development, with so few signs of  its
existence.  This is an exception that it would be well to note.
  Now, after the preceding details, as to the inner  face of
the aorta and the state of the aortic valves, we cannot doubt
but that the blowing sound was caused principally, not to say
essentially, by the first of these causes.  So, by a species of
anticipation, justified by the autopsy, I have previously said,
in referring the souffle to this cause, that the rest would not,
offer any serious difficulty.   We can readily understand how
the seat  of the souffle did not correspond to the orifice of the
aorta, but to the arch of this vessel;  and how the pulsation
in the radial was so feeble, the systolic effort of the hypertro-
phied left ventricle being in part neutralized  by the aneuris-
mal dilatation of the aorta.  Still  there  are  two  things of
sufficient importance to arrest our attention.  How does it
happen  that the souffle was stronger in  the second than in
the first time?   How were the praecordial sounds exempt
from  souffle,  the valves of  the left  heart being altered?  To
the first question, I can only answer by an hypothesis, that is
to say, by supposing that the aortic incrustations had such a
direc-tion or configuration, (that I did not notice it is true, but
which is not at all impossible,) that the friction of the blood
was greater as the wave returned, than when it jetted forth
from  the ventricle.   To the second question my answer will
be  more formal, more solidly based upon clinical experience.
  Every valvular lesion is not sufficient to produce  a souffle.
As we have more than once said, this sound presupposes an
excess of friction,  for instance, a constriction of one of the
orifices.  But here we have seen that the  orifices were suffi-
ciently well formed, the valves were thickened, nearly fibrous,
but free  in their play, consequently  they fell sufficiently to
form  no  obstacle to  the exit  of the blood.  But, it may be
asked, will valves, thickened as these are, give a normal clack-
ing?  Let us recall that, from the first day, we noticed in the
praecordial region sounds unequal, and less distinctly struck,
than  normally.  I  know,  however, that thickning of the
valves, when no souffle is produced, does generally make itself
known by a peculiar modification that we  will  discuss for the
first time in the following case, I mean the parchment sound,
(bruit de parchemin.)  But this degree of sound seems to me 
[  33  ]
to require for its production a precise amount of thickening
which it is impossible to determine exactly, but beyond which,
the sounds gradually loose their distinctness, thus arriving by
a kind of transition even  to the complete effacement  of all
clacking, and the production of new sounds.
  The case  that I am now going to report, offers striking
analogy to the two facts just mentioned.  But independant
of its  diagnostic importance it  affords another  species of
interest.
  This case which I noted almost six years since, at the visit
of Mr. Bouillaud will show us,  that  even at that epoch, the
precision and aptitude of this able observer was not improv-
able.  One can readily imagine that  I should seize with avid-
ity this  occasion of paying a debt of gratitude to  a master
whose pupil I will ever feel proud of  having been.
  Observation 7.—Souffle in the first time, especially with a
cretaceous state of the ascending aorta, and the adjacent large
arteries.—George Thomas, locksmith, 48 years  old, was re-
ceived on the 13th of  April, 1837,  complaining, (especially
for  two months  past, and without  any important anterior
malady, in an  etiological point of view) of palpitations  and
panting, on the least exercise, of syncope or numbness, and of
very intense headache.
  Actual state  on the  morning  visit of the  14th.—Evident
prominence  above and within the left nipple, prolonging it-
self slightly towards the superior part of the sternum.  No
vibratory tremor.  Praecordial dulness over a space of more
than 4| inches  in diameter.  Impulse of the heart moderate.
The apex beats 15 lines below  the nipple.  Jn  the region of
the heart, the two sounds of the valves are very dry, parch-
ment  like, especially the second; a light souffle accompanies
the first towards the level of the aortic orifice.  In rising to-
wards the arch, this souffle becomes  more intense, like  filing,
and tends to become sibilant,  and is followed by a dry parch-
ment clacking.   The same  souffle extends into the sub-clav-
icular region of the  right  side; we distinguish  it also on the
left, but more feebly.   Towards the point of the heart,  and a
little below, the sound of souffle ceases.  Above, and within
the right clavicle, we perceive pulsation  sensible to the eye,
and a perfectly distinct vibratory tremor.  There is a dilata-
tion of the right jugular vein; a branch goes off to anastomose
with the left which is not dilated.  The  pulse of the two ra-
dials is sensibly the same,  although perhaps a little more de-
veloped in the right; it is at sixty-four, regular, wiry, gradua- 
[  34   ]
   ted and vibratory.  The coats of the crural arteries, are like
   cartilage with  some  inequalities on their surfaces; their pul-
   sations are  vigorous  and resisting.  Under a rather  strong
   pressure, their sound is transformed into  one of very  pro-
   nounced souffle; under a moderate pressure  there is a jerk-
   ing sensation.  We feel  there no vibratory tremor.
    Diagnosis.—Hypertrophy of the left heart, especially of the
  ventricle, with dilatation.  Thickening of the valves.  Dila-
  tation of the aorta, of the brachiocephalic trunk, of the origins
  of the sub-clavian and of that of the right carotid, with a cre-
  taceous state of the arteries.  General hypertrophy of  the arte-
  rial system,  with cartilaginous induration of the wall, partic-
  ularly those  of the crural.
    The same evening of his entrance, this patient, with no in-
  dication of so speedy a dissolution, complained of chills  along
  the back, and regained his bed with considerable suffocation-
  and notwithstanding the aid of bleeding, died at half past
  10 o'clock in the evening.
    Autopsy.—Surface of the heart not covered by the lun<*s
  is 4* inches transversely,  and 4*  vertically.   The left  ven-
  tricle,  considerably hypertrophied,  constitutes about seven
  eighths of the whole organ; its cavity is dilated, and its walls
  are nearly 15 lines thick at the  base, and nearly 5 lines to-
  wards  the  point.  The bicuspid  valve  is well formed, but
  thickened; the tricuspid is opaque, a little thicker than natu-
 ral, and is roughened by some small tubercle like productions.
  lhe  valves  o  the pulmonary  artery are thin and normal.
  lhe aortic valves  are thickened, presenting also some tuber-

 The^Hn Ctl°nS',bKt  {ty, Ere SUmdent and not formed.
 Svdila  d' C°Tte    ,by  tHe '?"g in d3 its extent' is considera-
 and  hi, thii  C°at• ^ at-leaS]tdple their normal thickness,
 On t£p n     wng 13,countinued ^ong the descending aorta
 On the internal face of this artery, especially towards its ori

 So^oftnT'r8 CalCare°US1 Plates;  and f-ther> * the r -
 Snrfin £  ^f — S°me  redness and rents' whi<* we also
 find m the arteria innominata.  This artery is also dilated

  he1 IhV^ThT'th3 T alS° ^ SUb"ClaVian and ™Sd of
 p! ?1.     ,    thlckemng and cretaceous state of the ar-
  arotid  Ta lTeSA the °rigin of the ^b-clavian and
^™  K  1 I   5?ht radml  artery is a littIe m«re developed
than the left   The crurals do not present any Plates on ?he
interior, but their coats  are thickened

,JoaiSk'P!!!eil,We com^fe these necroscopic results with the
details of the d.agnosis, if one is not tempted to  supple that 
[  35  ]
the latter were specified after a sight of the  former.  I will
ever remember the admiration of the  assistants, and I may
also  say, my  own astonishment at the sight of this  sort  of
divination, to which a long experience had  not then given
the key, and which appeared to all of us so much more mar-
vellous, as the diagnosis,  so detailed, so precise,  and  so
promptly proved  by the necropsy, was in some fashion the
impromptu of a single exploration.
  I will make on  this autopsy, only a very  lew reflections.
It was in this  observation that we encountered, for the first
time, the dry parchment sound; we perceive the thickening of
the valves  corresponding with these sounds.  A light souffle,
towards the aortic orifice, accompanies the first sound.  We
have seen that the aortic valves were not only thickened, but
also  roughened by small vegetations, fibrinous rudiments, de-
posited there,  without doubt, by the coagulation of the blood,
more rare, as  we have already said, on these  valves, than on
those to which are attached the chordae tendineae.  But as the
tricuspid valve also presents these vegetations, I may be asked
why it does not  also give a souffle, if not in the first time,
since it was sufficient, at least, in the  second?  Because this
souffle, if it did exist, must have been so light as to be masked
by the clacking  of the aortic  and pulmonary valves, and
moreover deeper   seated, in as much as it is  a souffle of  the
right heart, than  were it one of the aortic orifice.
  The farther we got from this orifice, in following the  arch
of the aorta, the more this  blowing of the first sound predom-
inated. Then it  was in the artery, and not at its orifice, that
its cause  resided.  But  why  should it not exist during the
second time?  Here I must make the  same answer as in the
preceding  observation.
  Here, in fine, we again find the pulse vibrating and but lit-
tle developed, wiry; vibrating, because of the hypertrophy of
the  left heart; wiry, because of the aneurismal dilatation of
the aorta.   It then stands demonstrated, by this observation,
that the aortic souffle of the first time may be caused by the
condition of the vessel itself, rather than by  the state of the
valves.  I have proved by the preceding observation, that the
souffle of the  second time can have the same cause, and con-
sequently  simulate  patency  of the aortic orifice.  Now let
us see if this same chalky state of the aorta, cannot give rise
to a double bruit de souffle.  The following  case  will teach

   Observation 8.—Double souffle from aneurism, and creta- 
                        [  36   ]

ceous state of the thoracic aorta.—I  have published in the
Revue Medicate (May number,  1841) the detailed observa-
tion of an aneurism of the thoracic aorta, which offered this
particularity, a development from before  backwards, giving
rise to a prominence, under the form of a double tumour in
the region of the back.  The entire absence of prominence,
except a slight arching of the praecordial region,  the increase
of dulness of the heart, the obscurity of its two sounds, caused
us at first to diagnosticate upon the admission of the patient,
March 20th, 1838, an  hypertrophy of the heart, with slight
thickening of the  valves without patency.  A slight friction
sound, believed to be pericordial,  and which specially existed
in the second time, caused  us moreover, to suspect the exist-
ence of some plates or  adhesions of the pericardium.
   In a short time pain  supervened in the region  of the left
scapula, and  the examination of this part showed a pulsation
that raised the  fingers with force, and produced upon  auscul-
tation, a sound of collision, accompanied by a slight souffle.
From  that time  the diagnosis could be  completed, and we
added: aneurismal dilatation below the arch of the aorta, with
patches (plaques) in the artery. The tumour, the first indica-
tion of which we have just signalized, at first developed itself
slowly.  At  the  end of the first  three months, it was  even
pressed down, as it were upon itself.  At  this time we heard
in the heart a double bruit de souffle, dry, rasping, with its
maximum in the first time, and towards the aortic orifice.
   Thus it  continued during the long  duration of this painful
affection which terminated in  death on the 18th September,
1840.   For my part I have often verified the existence of this
double souffle,  as often at the posterior part of the trunk, as
in the praecordial region itself, even until, as a consequence
doubtless of the thickness of the fibrous layers amassed in the
interior of the aneurismal pouch, this double bruit became so
obtuse, so distant, that it ceased almost entirely  to be heard.
   I will not here repeat the circumstantial details of the au-
topsy; but I will mention what is at this time for us the  most
essential feature of the case, that the aorta alone gave us the
key to the  double bruit de  souffle, for it was dilated in such a
remarkable way, that  I caused the specimen to be moulded,
and it was moreover rough, thickened, and riddled with fibro-
cartilaginous, and even osseous plates.  As to the heart, be-
sides its hypertrophy, it offered no other valvular lesion than
a slight thickening of the bicuspid valve, and especially of the
aortic, but without deformation of these valves, or any consid-
erable relative dilation  of the corresponding orifices. 
[  37  ]
  We perceive by  the  preceding facts, that certain lesions
of the aorta, and particularly a cretaceous state of  its arch,
may simulate, in the stethescopic signs, some valvular lesions.
It is a cause of  error, of which it is well to  be warned, and
against which we have seen that it is not impossible to guard.
A question  to which  we are  naturally brought by this diffi-
culty is, how shall we diagnose the cases in which  valvular
and aortic  lesions  coincide?   Is this double diagnosis possi-
ble?  Yes, doubtless, I avow  it in advance,  and besides, we
have already seen it in  our fifth observation.  But in  those
cases only,  when each of these lesions presents a certain de-
gree of importance, unless there be a  marked predominance
of aortic  lesion, the advantage in a semeiological  point of
view, will always be on the side of valvular lesion.   This we
will now proceed to demonstrate by facts.
  Observation  9.—Conincidence of valvular lesions, and a
cretaceous stale of the  aorta.—Lebbois Jean-Baptiste,  printer,
aged  17 years, entered into our service on the 14th Septem-
ber, 1841.  The subject, for twenty years past, of rheumatic
pains, generally apyretic.  He had intense  catarrhs,  often
accompanied by fever and  paroxysms of dyspnoea, with pal-
pitations,  which at first  separated by long intervals, gradu-
ally became more frequent,  and for six months past, were
reproduced  by the least exercise.
  Present condition.—General pallor.   The face is neither
pulled or  discolored.  Slight oedema of the inferior  extremi-
ties.  Cutaneous heat normal.  Pulse 112, developed, vibra-
ting,  strikes forcibly.  No  very notable praecordial promi-
nency.  The apex  of the heart perceptibly elevates the sixth
intercostal space,  but within  the nipple.  The impulsion of
the organ, is moreover extended,  without vibratory tremor,
and the  dulness is nearly 3j  inches square.  In ausculting
the praecordial  region,  we note at first, three very distinct
phenomena: a heavy and very dull sound in the first time, the
result of the shock of the point of the heart; effacement of the
two valvular clackings,  and especially of the second; and, in
fine, a souffle.   In  the region of the left auriculo-ventricular
orifice, this souffle is little pronounced; it is distinguished espe-
cially in the first time, whilst in the region of the aortic  ori-
fice, and particularly of the ascending aorta, it exists during
both  times,  particularly in the second.  It  propagates itself
but feebly into the carotids.   The  pulsation  of these arteries
is very strong,  are perceived in the abdominal aorta, and es-
pecially in the crurals,  of which the sound gives to the  ear 
[  38   ]
the sensation of a very detached fillip.  No distension of the
jugular veins.  Nothing  very notable in the respiratory ap-
paratus, except a subcrepitant rale, very fine and numerous,
behind, and at the base of both lungs.
  The next morning M.  Bouillaud, who had requested me to
make the visit, verified what we have just indicated, without
adding any thing, and left me in charge of  the diagnosis.  I
I then dictated it in the following terms:
  General and  very  considerable hypertrophy of the heart,
(about one pound.)   Thickening and induration  of the left
valves, and especially of the aortic, without a  contraction of
the  corresponding orifice,  or insufficiency of the bicuspid valve.
  Why do I not add to this  diagnosis, insnfficiency of the
aortic orifice?  Because  it would  be contradictory to admit
this insufficiency with a pulse  so developed, and  so forcibly
struck.  But  from  the moment  that I did  not attribute the
souffle of the second  time to this cause, was I not  compel-
led, in order  to explain it, to admit the existence of a creta-
ceous state of the aorta? Yes, without  doubt, I confess the
omission.   But I go further,  should I not have admitted, at
the same  time,  both  these lesions?  For  it appears to me,
from observation, that a  cretaceous state of the aorta implies,
generally, a certain degree of hypertrophy of the coats of the
aorta itself.  Would not  this hypertrophy explain those qual-
ities of the pulse, which seemed to me incompatible with a
reflux of the  blood into the ventricle?  Yes, if  the pulse had
been only vibrating—no, if the vibration was accompanied
by  a very considerable  development; at any rate, I could
reconcile-these two elements of diagnosis, only by admitting
an  aortic insufficiency, little pronounced.  It is evident  that
it is this same development  of the pulse which leads me to
exclude an aortic contraction, and  bicuspid  insufficiency.  If
this hypertrophy of the  left  ventricle  could always explain
the vigorous pulsations of the radial and carotids, there would
still remain those of  the  abdominal aorta  and the crurals,
which, as  we have already seen, and as we will see again, do
themselves imply  a  certain hypertrophy  of  the  arterial
system, that I ought also to have specified.   This is another
omission which 1 will  not seek to justify.
  Let us return to our patient.   Notwithstanding the use of
digitalis, diuretics, praecordial vesication, ect., he grew gradu-
ally weaker.   The infiltration  increased; it  affected the scro-
tum and penis  to a degree  that impeded  the  excretion of
the urine.  The pulse remained quite vibratory, but it lost its 
[  39   ]
volume.   I  found, at  intervals,  a slight  vibratory tremor in
the praecordial region; as to the souffle always replacing per-
fectly the second time, it became sensibly more contracted,
constantly attaining its  maximum in the region  of the aortic
orifice,  much less distinct in  that of the bicuspid orifice,  and
manifestly propagating itself into the carotids.  The first time
was quite dull and imperfectly struck, and perhaps even ac-
companied, towards the bicuspid region, with a little souffle.
He died on the 17th of November.
   This patient having been to me the object of clinical study,
frequently repeated, at my afternoon visit, on the eve of the
autopsy, I made before my pupils, a resume of the diagnostic
signs which we had noticed together in our last  explorations,
and I rectified or completed in writing, before them, my first
diagnosis, thus:
   General  and  very  considerable hypertrophy  of the heart,
(at least about  one pound;)  the hypertrophy  affecting, espe-
cially, the left ventricle, of which the walls must  be very much
thickened; medium dilatation of the  auricles, and of the auri-
culo-ventricular orifices.   Thickening and induration of the.
left valves.   A little restraint in the play of the bicuspid valve,
without any  very notable insufficiency.  More  considerable
deformation of the aortic valves,  which imperfectly close their
orifice, and perhaps present some small vegetations.   No con-
siderable effusion in the pericardium.   Perhaps some peri-
cardiac plates.   Pulmonary oedema.
   Let us show briefly, the reasons for this definite diagnosis.
   Hypertrophy, etc.   Displacement of the point of the heart.
 Expanse of impulsion and increased dulness.
    The hypertrophy affecting especially the left  ventricle, etc.
 The pulse in  general, vibrating and  forcibly struck.   Bruit de
 choc of the  point  of the heart, very  heavy and dull.
    Medium dilatation of the auricles.—Dilatation, because 1st,
 generally in all cases of any  considerably hypertrophy, there
 is a dilatation of  the auricles; 2d, infiltration of the extremi-
 ties, of  the penis, and  of the  lungs, producing a stasis of the
 blood,  which gives rise  to  dilatation of the auricles; these
 losing in contractility,  what  they gain in capacity; or, there
 may be a stasis of the blood from the contraction of the aortic
 orifice, or in consequence of bicuspid insufficiency; but here we
 would have neither; therefore, I might have added that it was
 especially the right auricle which was dilated.   Medium di-
 latation.  Because in great dilatations, the pulse is very small,
 and it is not so here.   And of the auriculo-ventricular orifices. 
[  40  ]
 When the auricles are dilated, the  orifices ordinarily partici-
 pate proportionably.
   Thickening and induration of the left valves.—Effacement
 of the two valvular clackings.
   A little restraint in the play of the bicuspid valve.—Efface-
 ment of the first sound, with a  little souffle, perhaps bicuspid.
   Without  any  notable insufficiency.—This souffle is very
 slight, I might even probably have attributed it to  the tricus-
 pid orifice; moreover the pulse is developed and vibrating.
   More considerable deformation  of the aortic valves.—The
 souffle attains its  maximum in the aortic region, and propa-
 gates itself into the carotids.
    Which imperfectly  close their  orifice.—Because of  the
 souffle in  the second time,  by  the return of the blood from
 the aorta into the left  ventricle.   I did not have, this time,
 so many reasons for admitting a cretaceous state of the aorta,
 as in my first diagnosis, but if I had made this diagnosis at first,
 I would have persisted in it.
   And presenting, perhaps,  some small vegetations.—Because
 there has been at  intervals, a  little vibratory  tremor.   If I
 had admitted cretaceous plates, I would not have made this
 supposition.
   No considerable effusion in the pericardium.—The sounds
 are not distant from the ear,  and there is no considerable
 prominence.
   Perhaps some pericardial plates.—In the  praecordial  re-
 gion, towards the base of the heart, on applying the ear, I of-
 ten heard a sort of dry rale, of which I did not, at first, dare to
 affirm the nature and seat, supposing that itmight be a bron-
 chial  rale; nevertheless, its  persistance,  difficult to seize, on
 account of the sounds of the  heart, but which appeared to me
 independent of the respiratory movements,  ended by  giving
grounds to suspect a pericardial friction, (frottement.)
   Finally, Pulmonary cedema.  Sub-crepitant  rale towards
 the base of the lungs.
   Let us now proceed to the autopsy.
   The pericardium contains  a very small quantity of serosity
On the external face of the  heart,  towards the middle of the
heighth of the right ventricle, we remark two  or three peri-
cardial plates, forming a relief little pronounced.
   The heart is considerably  distended by recent clots,  which
especially fill the right cavities,  and give to the whole organ
a  globular aspect.  Its apex  is soft  and  rounded.   Well
washed, it weighs  with  the  origin  of the large vessels over 
[  41   ]
one pound.   The hypertrophy occupies, particularly, the left
ventricle, of which the walls have a  thickness of about  10
lines.
  The left auricle is but little or not at all dilated.   Its bicus-
pid orifice has a circumference of 9h lines.
  The right auricle, on  the  contrary, is much dilated.  It
might contain a medium sized  orange,  The circumference
of the tricuspid orifice is five inches, (instead of4f.)
  The bicuspid valve is a little thickened, but quite sufficient.
  The tricuspid has its normal thickness.
  The enlarged aortic orifice  presents a circumference of 3|
inches, instead of 2|.
  The sigmoid valves are very thick, fibrous and insufficient:
for water poured into  the aorta, penetrates  the  ventricle.
The aortic orifice  is, moreover,  bordered on the aortic side,
and to the heighth of about 14 lines,  by cretaceous  plates,
quite prominent, creaking under the nail, which raises them
with difficulty, representing a sort of unequal, wavy ribbon;
we also find some of these  plates in the descending aorta.
   The pulmonary artery is sound, the  circumference of its
orifice is nearly  3i inches,  its valves  are thin  and well
formed.
   The right ventricle is a little dilated, and its walls are less
 than five lines in thickness.
   The lungs present a general and decided serous engorge-
 ment, an abundant spumous serosity issuing from the surfaces
 of the incisions upon the slightest pressure.
   I omitted assuring myself of the hypertrophy of the arte-
 rial system.
   Notwithstanding  this  hiatus, which I regret, and  the be-
 fore mentioned omissions in my diagnosis, 1 ask every honest
 observer, if there are many organs in the  economy,  whose
 morbid  alterations we can analyze  in advance, and  decom-
 pose their diseases into their different elements so minutely
 and with so much precision?   But still some discrepances ex-
 isted between our last diagnosis and the necropsy.   Thus I
 was wrong in saving dilatation  of the auricles, the right au-
 ricle alone being dilated.   I explained the  effacement of the
 first sound, and the slight souffle heard during  the first time
 in the left  auriculo-ventricular  region, by a constraint in the
 play of the bicuspid valve, the  autopsy showed  us that this
 valve was  free, only a little thickened; so I prefer thinking
 that this moderate  souffle came either from a little msuffi-
 ciencv of the  tricuspid orifice, or as is more probably the case, 
[  42  ]
  from the aortic orifice, in the region of which it was so evi
  dent.
    The cretaceous state of the aorta, the  study of which has
  been the peculiar object of the last four observations, has thus
  led us into a kind of digression, which I am far from believing
  useless, but which we cannot longer pursue  without losing
  sight of the methodical order which we  wish, as much as pos-
  sible, to  follow  in these clinical  researches.   So now let us
  recur to the properly so called lesions of the heart.  We have
  passed in review, the alterations  of its two principal ,'orifices
  separately; let us now take up those cases in which  the two
  orifices  are simultaneously  affected.  During the  study of
  these, out-of-the-way and unexpected clinical deductions may
  possibly present themselves; we  will not refuse to answer to
  these calls, but will only do so when these sorts of digressions
 are authorized by the importance of the object.
   Observation  10.—Double  contraction without patency of
 the aortic orifice.—Sophia Boulleau,  a seamstress aged 17
 years, was received on the 25th of March, 1841.  She dated
 the commencement of her disease ten months back.   About
 that time she was seized with an acute general articular rheu-
 matism, which confined her to her bed for nearly two  months,
 and since then she has suffered from palpitations of the heart,
 which she says  had their commencement during this  disease.
 In the course of  last February there was an addition  of pain,
 with swelling  of the  abdomen,  slight diarrhoea and cough.
 These last symptoms decided her  to come  to  the hospi-
 tell*
  ^ Present condition.—Pallor,  anemia, and general  emacia-
 tion.   Considerable ascites.   Heat of the skin rather  greater
 than  normal.    Pulse 124,  very  small and  readily com-
 pressed.   Palpitations even in a  state of repose.  A little
 praecordial prominence expressed on the cyrtometre by a dif-
 ference of about three degrees.  The  pulsations are  strong,
 visible to the eye, and  extend, as  does the dulness, from the
 tilth intercostal space, almost immediately below the breast ud
 to the second intercostal space above, the hand there perceiv-
 ing a third concussion due to the  abrupt passage of the  col-
 umn of blood without, strictly speaking, cats purr, (fremis-
 sementcata.re)   The ear applied below the breast,  distin-
guishes a double bruit de. souffle, rude and rasping, without
 valvular clacking;  above the breast, and  especially  in  an
 preaching the left clavicle, we can only hear a souffle in the
 nrst time, and the second sound is then made up by a hard 
[  43  ]
quick, and essentially parchment like  clacking.  The souffle
of the first time is continued into the carotids unmixed, at this
time, with the (bruit de diable) sound of the  humming top.
The beats of the left sub-clavian artery are visible to the eye.
The jugular veins are sensibly developed.  The respiration
is rapid, difficult, without any very notable morbid bruit, ex-
cept a slight moist rale, very fine, at the base of the left lung.
The feet are cedematous.
  The ensuing morning, the 26th, Mr. Bouillaud,  verified in
his  turn, the preceding signs, and he dictated  the  following
diagnosis.
  General hypertrophy of the heart, (12 to 14 ounces.) Thick-
ening and probably  vegetations with deformation of the left
valves.—Let us analyze this diagnosis and  see  if our antece-
dent observations  will not permit us to add to it  still some
accessories.
  The hypertrophy of the heart, the exageration of its weight,
are too evident for it to be  necessary that we should now re-
peat the reasons.
  Thickening  and probably vegetations  of the valves of the
left side.—Why  of the valves?  I say that this double lesion
is evident.  And in fact, we have in the region of the aorta,
a rude blowing sound in the first time, and this sound extends
into the  carotids, then the aortic orifice is diseased; but in the
praecordial region, properly so called, we have two souffles;
whence  comes the second?   Is it from this same aortic ori-
fice, patent and consequently incapable of  producing a valvu-
lar  clacking?  No; for in approaching the clavicle we reach a
point where is heard a second clacking, harsh, quick, like parch-
ment, evidently  produced by  the  thickened  but sufficient
valves of the aorta.  Then the bicuspid orifice is the seat of
this second souffle.
  We have said that the hand perceived  a rather rude con-
cussion,  which appeared to be owing to the abrupt passage
of the sanguineous column?  What does this concussion indi-
cate?  A prominent obstacle to the escape of the sanguineous
wave through  the aortic  orifice.  What may constitute this
obstacle?  Is it a simple  contraction?  Then we should have,
in the first time, a peculiar souffle,  contracted and fine.   But
the souffle does not present this character; it is rude and un-
polished.  Is it a cretaceous state of the sigmoid valves?  This
is possible; but generally this  cretaceous state  is complicated
with  that of the aorta; but here we probably have  no plates
in the aorta,  since there is  no souffle in  the  region of this 
t  44  ]
artery, that which commonly occurs.  It is more likely, then,
that we have some vegetations about this orifice, and perhaps,
(but I give this as a mere gratuitous  supposition,) about the
opposite orifice.
  Let us  now  remark that the analysis  of this fact alone
brings us  to add to  the diagnosis a new  element, viz: suffi-
ciency of  the aortic valves.
  What shall we say ©f the other orifice?   Nothing positive.
Nevertheless, it is probably not greatly  insufficient.   For,
how should we then have, by  the escape of the sanguineous
column through the aortic orifice, that rude concussion, which
moreover announces that the hypertrophy is seated  espe-
cially in the left ventricle?   But will it be  said that the  pulse
is very small?   With a young girl, so emaciated, this circum-
stance is of little importance; yet it may be a reason for sup-
posing a little  contraction of the bicuspid orifice or of the
aortic itself.
  But shall we say nothing here of the  right heart?  Yes,
without doubt, with a hypertrophy so  considerable; with so
many signs of a notable restraint in the vernous  circulation,
the ascites, the distension  of the jugulars,  the serous conges-
tion of  the lungs, it is very probable  that the right auricle is
distended, if only passively, and that, on that side, we will
encounter a dilatation of the auricle, and perhaps of the cor-
responding orifice.
  We  were promptly enabled to verify our diagnosis.  The
infiltration  progressed, then acquired an  enormous  volume,
to such a  degree, that the heart was pressed upward, until we
perceived it beating  in the first intercostal  space, and not-
withstanding two paracenteses which produced only momen-
tary assuagement, the patient succumbed on the 18th of May.
  Autopsy.—I  proceed to that which concerns the  heart.
Freed from its clots, this organ weighs over \\  pounds.  The
hypertrophy affects the right and  left cavities.   The  right
ventricle is fully a third larger than natural; the thickness of
its walls is about 5 lines in its medium part.
  The tricuspid orifice is large in proportion to the  ventric-
lar  cavity.  The laminae of its valve  are thickened and per-
haps a little too short to close  the dilated orifice.   There are
some small vegetations on the free border of this valve.
  The auricle is dilated in the  same proportion.   Its colum-
nar carneae are very strong.   There is nothing very notable
about the-pulmonary  artery.
  Water  poured into the aorta reflows immediately; and in 
[  45  ]
fact the three valves are well formed, of at least triple their nor.
mal thickness; but on the ventricular side oftheir free border,
there is a train of small warts or cauliflower vegetation. The
aortic orifice is small, absolutely and relatively, to the magni-
tude of the ventricle.
  This  is vast;  it might  contain an  ordinary sized  egg ;  its
walls are 15 lines thick towards the base.  The two  columns
of the bicuspid valve are enormous, one of them is  as large as
the ring finger.
  This  valve is very thick and hypertrophied.   The  orifice is
quite well formed, yet, the angles of the valve are united by
the agglutination of their opposite edges.  All the free border
of this valve is studded by many vegetations, gravelous and
resembling the cauliflower.  The cavity of the left auricle is
dilated  in proportion to the ventricle.  Its  walls  are also
thickened.
  The mitral and aortic orifices are both contracted  relative-
ly to the augmented capacity of both the auricle and the ven-
tricle.
  I do not think it necessary  to make any lengthy comments
on this autopsy.  1 can but regret that  the dilations were not
expressed numerically.   But I will say, in order to shelter
from all  suspicion  my reputation as editor, that this  autopsy,
such as I have detailed it, was dictated in the ampitheatre by
M. Bouillaud himself.
  Observation 11.—Deformation of the valves without Con-
traction.—Joseph  Doumere, shoemaker, aged  48  years, en-
tered on the 28th of October, 1841.   This patient, heretofore
treated in this service, reports that although habitually healthy
he was attacked nine years ago with febrile articular  rheuma-
tism, which affected all  the  principal  articulations, and  of
which he was cured at the end of three  months.
  About twenty months since he began to experience  palpi-
tations, which gradually increased and forced him for the last
nine months to discontinue his occupation.  Since  that epoch
he has not been able to remain in bed during the  night, and
moreover, very frequently passing  entire days in  an  arm-
chair.   During the latter months a notable infiltration, of the
inferior  extremities  and  abdomen, occurred.   He had, also,
during four or five  months past, some symptoms of sero-san-
o-uineous congestion of the lungs, such as a stitch  in the side
and  very rusty  expectoration,  symptoms which were corn-
batted  by two  bleedings, two applications of leeches, and
numerous vesications. 
r  46   ].
   Present condition.—Almost seated in  bed, the patient is a
prey to a very intense dyspnoea, his respiration being sensibly
accelerated and his responses very brief.   His face  is pale, a
little puffed ;  the lips slightly bluish ; the abdomen is remarka-
ble for its volume, and is a little sensible in consequence of the
distension of its walls.   The least shock produces  the most
evident fluctuations, and it is only at the distance of about one
hand's breadth above the umbilicus, which is almost entirely
effaced, that percussion  ceases to produce a dull sound.   The
semi-circumference of the abdomen, passing the umbilicus, is
nearly two feet.   The urine is passed with much difficulty,
the penis being infiltrated in all its length and twisted upon
itself.  The secretion is also  remarkable for the infiltration of
its  coats.  The limbs, even  the superior,  participate  in this
condition, the thighs and legs are of a considerable volume.
   The pulse,  difficult to feel on account of the  oedema of the
wrists and its smallness, is evidently disproportioned  to  the
force  of the  subject, sufficiently equal, but intermittent and
from 116 to 120.   There are six degrees of precordial promi-
nency by the cystometre. The point of the heart beats in the
fifth intercostal space, but a little without the nipple.  From
this point, the pulsations extend as far as  two or two and a
quarter inches above  the nipple, the  heart being, moreover,
perhaps  pressed back by the abdominal effusion; they (the
pulsations) are visible but in moderate force.  The dullness
corresponding to  the- region of the heart is from  2|  to  3$
inches vertically  and from 3i  to  4 transversely.  There
is no vibratory tremor.  The sounds of the heart a little mas-
ked by the interposition  of a lamina of the  lungs, are  be-
sides imperfectly struck, without distinct clacking, and at the
same  time without notable souffle at this moment, neverthe-
less in proceeding along the ascending aorta, we distinguish
in the first times, a sort  of creak, very distant, and shorthand
which may be followed into the precordial  region  as far as
the aortic orifice itself,  but  does not propagate itself in the
carotids.  These   last arteries pulsate only very feebly.  The
jugulars  are notably distended.  In the respiratory apparatus
we note a little diminution of sonority toward  the base of
both lungs, and a desseminated subcrepitant  rale quite  nu-
merous, especially in the left.
   M. Bouillaud being then  absent,.I  dictated  the following
diagnosis.                                                °
   Considerable hypertrophy  of  the  heart  (about U  pounds).
Relative and absolute dilation  of  the auricles.  Thickening 
[  47  J
deformation, and perhaps adherences of the left valves, especial-
ly vdthout very notable absolute contraction  or vegetations.—
Perhaps diminution of the pulmonary orifice in particular.—
Slight  effusion in  the pericardium.   Oedema of both lungs.
Ascites  and ansarca.
   Twelve days after, we were  able to submit this diagnosis
to the verification  of an autopsy, the punctum which had gi-
ven issue to a great quantity of fluid, having procured only a
momentary assuagement.  As to the sounds of the heart, they
remained the same, save a little  purring of the first time,
which was at first  only  reproduced  at intervals and  finally
entirely disappeared.
   Autopsy, on the 4th of November.
   Thoracic cavity. OZdema of both lungs behind and below.
The heart  is uncovered to  the  extent  of about 5h  inches
transversely,  and from 3 inches to  3J  vertically.   It con-
tains about a glass of limpid serosity.
   The heart is enormously and generally hypertrophied.  Op-
ened and washed it weighs,  with the origins of the large ves^
sels, nearly two pounds.
   Right heart.   Dilated so as to contain a small orange;  the
right auricles presents a vermillion tissue and some stout co-
lumns.  The circumference of the tricuspid'orifice is nearly five
inches.  The valve is thickened, but very well shaped, although
a little  adherent  to the  ventricle,  towards its middle.  The
ventricle is dilated proportionally with very stout columns; its
wall isabout-^of an  inch thick near the base.  The orifice of
the   pulmonary  artery  has a  circumference  of 3|  inches.
The valves are proportionally enlarged, but are very thin and
wrell shaped.
   The  inter-ventricular partition is nearly one inch thick.
   Left  heart.  The left auricle is rather larger than the right.
The circumference of its orifice is nearly 5 i inches.   The
valve is  thickened; almost  fibro-cartilaginous,. the  lamina
being so approximated as to give it the appearance of a ribbon;
not  adherent to  the ventricle, but  bridled by short tendons
which must incommode its play.                     _
   The  ventricle, the peculiar seat of the hypertrophy, is first
remarkable  for the strength of its fleshy columns  which are
short and thick.    From the base of one of them there starts
a small tendinous band, very thin, which goes to insert itself
upon the corresponding side of the  ventricle, about 15 lines
below  the aortic orifice ; towards the point of this insertion
 the endocardium,  opaline  in this region,  presents a kind ot 
[  48   ]
little  plate  slightly projecting,  about two and a half lines
in extent, and a half line thick, apparently fibrous.  The wall
of the ventricle is firm and ten lines in thickness;  it does not
commence to decrease except in the neighborhood of the point
of the heart, which is soft and rounded.
  Water being poured into the aorta runs over, showing that
the valves are sufficient: they  are thickened, however, and
notably enlarged, their height is a little more than 10 lines,
instead of from 6 to 7 lines, that is to say at least from 3 to 4
lines.  The circumference of this orifice is about 3 inches.
   Like the right heart the left contains black, soft and unor-
ganized concretions.
   Now let  us  compare the lesions found in the  dead body
with the principal assertions  of our diagnosis.
   I had said: considerable hypertrophy of the heart, \% pound,
we found it  to weigh nearly 2 pounds.   I will not repeat the
general reason of this error, but I will say that here a spe-
cial reason for this under-valuation, was the situation of the
point of the heart, in consequence of the ventral  effusion, in
the fifth intercostal space, and only a  little without the nipple.
   Relation  and absolute dilatation of the  auricles.   I said:
the auricles are dilated  not only relatively as regards their
usual capacity with reference to that of the ventricles, but ab-
solutely, that is to  say, independent of that relation.   The hy-
pertrophy is general;  for a long time there has existed a sta-
sis of the blood; but we have no signs of mitral or tricuspid
insufficiency; then if the blood remains long in the auricles, it
is because these, being dilated, have lost their contractility.
   The autopsy has confirmed this view, in showing us, it is
true, a dilatation no less pronounced of the ventricles than of
the auricles themselves, the  former having their walls much
diminished  in thickness  and consequently but  little  force  in
their contraction.   What  is  a thickness of ten lines  towards
the base of  the left ventricle  of a heart weighing nearly two
pounds, instead of about f of  a pound, when the average thick-
ness of this ventricle is 7£ lines?  This circumstance was doubt-
less the cause in our patient, of the moderate impulsion  of
the heart, the smallness  of the  pulse at the wrist, the imper-
fect beats, and consequently of the stasis of a part of the blood,
all the serous infiltration that we have noted,  the  distension
of the jugulars,  the dyspnoea, &c.
   Thickening,  deformation and perhaps adherence of the left
valves especially.   Why these lesions ? Because the two beats
  re imperfect, as we no where have the valvular clacking; we 
[  49; ]
should consequently suppose the play of  the valves to be im-
peded; and as the absence of souffle  and  of vibratory tremor
excludes the idea of calcareous deposit or of vegetations, then
it remained as probable that there were adhesions of the val-
vular lamina, either with each other or with a neighboring part
of the ventricle.
  What in effect did we find ?  A tricuspid valve thickened,
enlarged in proportion to the orifice, but adhering towards its
middle part; a mitral valve also thickened but bridled  by ten-
dons too short,  evidently  insufficient  for an orifice so much
enlarged, (5 inches instead of  about  4,) permitting  in con-
sequence a part of the blood to retrograde in the first time, as
is proved by  the considerable  dilation of the left auricle.
  If I am asked how it was  that this bicuspid patency was
not  betrayed by a souffle in the first time, I will say the cause
was doubtless  in  the feebleness  with which the sanguineous
column was expelled from the dilated left ventricle.
   How did we  find the arterial orifice ?   The aortic and es-
pecially the pulmonary valves are  enlarged,  and thus  less
adapted than  in the normal state to  the production  of clack-
ing.
   Without absolute contraction or vegetation.   I should have
added, or cretaceous deposits.  I have just  remarked that the
absence of souffle and of tremor put this fact beyond all doubt.
The necropsy fully confirmed this point of the diagnosis.
   Perhaps smallness  of the pulmonary orifice.  This was a
pure supposition based upon a slight whining, distant from the
ear, not continued into the carotids; and which  I  heard at
two or three different times between the nipple and the ster-
num.   The autopsy did not verify this hypothesis.  I confess
however, that I am not yet unconvinced that the pulmonary
orifice was not the seat  of this feeble and distant, but still,
well heard sound, under the influence, not of a fixed lesion,
but  simply of some momentary and  moveable obstacle ; such
as a small sanguineous concretion afterwards carried away by
 the  torrent of the circulation.
   Inconsiderable effusion  into the pericardium.   No one, I
think, will object to this on account of the glass of the serum,
found after death.  For what is this quantity compared to the
 increased size of  the pericardium?  The point of the heart
 which we felt striking under our finger in the fifth  intercostal
 space, prevented our admitting a considerable effusion, which
 would have been  incompatible with the  superficial location
 of this organ. 
[  50  ]
   I say nothing of the pulmonary oedema.
   As in the preceding observation, I will terminate this analy-
 sis by asking, if the concordance  between the diagnosis and
 the autopsy is not sufficiently complete to prove the value  of
 means of observation by the aid of which we can attain a like
 practical result?
   Observation 12.—Thickening and deformation of the left
 valves. Moderate diminution of the aortic orifice. Joseph Veis-
 in, a porter, aged 53 years, was received Aug. 20th, 1841.
   This man, of a very strong constitution, and heretofore a sol-
 dier during twenty-five years, had generally, very good health.
 He had, nevertheless, two attacks of intermittent  fever,  one
 in 1808, and the other in 1815, each of which lasted only one
 month.  In 1818, he appeared to have had an affection of the
 bft lung, which continued three months, and finally in 1826,
 ,jome rheumatismal pains in  the arms and especially  in the
 calves of the legs, with fever and abundant sweats.  He was
 then  treated  at  Val-de-Grace by cups and a bath, and left,'
 supposed to be cured, in eight days.   He said his  health had
 been very  good from that time to the present; but yet re-
 marked  that for a year past, his respiration was shorter, and
 that he had palpitation in ascending.  These symptoms have
 increased  during the  past month especially, and to them has
 been added a little turgidness of the inferior extremities, which
 disappears in  the horizontal position.    He has kept his bed
 for three weeks, but not constantly.
   Present condition.  No puffing of the face.  Very notable
oedema of the feet, legs, and left wrist;  no positive signs of
 ascites, pulse at 76, vibrating, especially the right,  which  is
 more  developed than the left, in consequence, without doubt,
 of oedema of the latter.
   The pulsation of  the  right radial are remarked  in a very
great extent.
   A prominence of about six degrees between the  left nipple
and sternum.
   The beatings of  the heart  are very greatly extended, al-
 though the point of that organ, not readily seized at first, beats
only in the fifth intercostal space, and rather within than with-
out the nipple.  The hand firmly applied  to the precordial re-
gion perceives a very distinct but profund vibrating tremor.
The dullness appears to be only about 2$ to 3 inches square,
 but the presence of the lung presents a very exact determina-
tion of this matter.  In the precordial  region, and especially,
towards the apex of the heart, we distinguish in the first time 
[  51   ]
-a bruit de souffle,  very contracted, and which from time to
time almost simulates a whining.   The second  clacking is
quite dull, and in its place we discover a little, but much shor-
ter souffle.   Towards the base of the organ, and in approach-
ing the aortic orifice, the first souffle persists, but the second
in becoming more pronounced, is accompanied by a very  dis-
tinct  clacking.  Setting out from this point, if we follow an
oblique line, directed towards the right clavicle,  the double
souffle becomes yet more marked, and its  maximum  appears
to ba about the middle of the track  we have indicated.  Yet
there exists there neither tumors or tremor under  the heart.
The souffle is  propagated into the carotids, these arteries beat-
ing strongly and visibly.  The same is true of the subclavian:
and in the right subclavian we  even verify a very notable vi-
brating tremor.  No well-marked distension of the jugular
veins.  Very strong pulsation of the coeliac trunk, the abdo-
minal aorta, and the crurals, without souffle.  Nothing very
remarkable  about the respiratory apparatus.
   If  the  reader has attentively  followed the analysis of  our
preceding observations, it is impossible, in  our opinion, not to
read, in the simple expose of the symptoms  we have enume-
rated, and thus to speak, as through a transparent veil, the al-
most perfect diagnosis of our patient.  Let us further seek to
extract the principal features of the case, and we will afterwards
see if our  present diagnosis corresponds  with that made at the
bedside, and especially with the rigorous testimony of the au-
topsy.
   We have noted, at first, a little partial oedema; there is then
a restraint upon the venous circulation.  But we have, as in
the preceding case, neither general anasarca or ascites, we do
not therefrom, expect a sanguineous stasis so pronounced. We
cannot specify further until we shall have finished our exami-
nation.
   Without  any doubt,  there is  general and considerable  hy-
pertrophy.  I  think we cannot deceive ourselves much in esti-
mating the heart at double its normal weight; let  us say at
from  20 to 22 ounces.   But what kind of hypertrophy is it ?
Is it,  as with the  preceding patient, in some sort  a passive
hypertrophy,  with dilation and thinning of the walls?
   No, certainly, the vibration of the pulse indicates to  us an
active hypertrophy affecting, very probably, the left ventricle
particularly.  Let us comernow, to  the orifices.  This vibra-
tion and developement of  the pulse excludes all idea of any
considerable contraction of the aortic orifice, and any well pro- 
[  52  ]
nounced insufficiency of the mitral valve  itself.   Yet, by the
application of the hand on the precordial region, we perceive
a tremor ; hence some of the valves must be injured in a high
degree.
  Now, what shall we say of the auscultation ?
  Towards the  apex of the heart, that is to say in some  man-
ner, between the bicuspid and aortic orifices, there is quite a
limited souffle in the first time and a much shorter one in the
second ; there is no clacking.   To which orifice do these souf-
fles appertain?  Do they both proceed from  the aortic orifice
insufficiently opened  and  imperfectly closed?  We cannot
know it yet; to assure ourselves of it, let us approach our ear
to that orifice.   The first souffle  persists and the  second be-
comes more pronounced; but what is very  singular this is
now  accompanied  by a  very  distinct  clacking.   Whence
comes this singularity ?    A moment since when the souffle
was short there was no clacking,  now it is stronger and  we
have valvular clacking.
  The response is easy.  It is, without doubt, because the two
souffles of the second time, are from different origins; the first
was produced at the bicuspid orifice, and however short it
may have been, it sufficed, by its proximity, to veil the clack-
ing  of the aortic orifice.  When we approached this last ori-
fice this clacking was unmasked, and if it is still mingled with
a souffle, and especially with a souffle stronger than that which
we at first verified, it is probable that this second souffle is
owing to  a peculiar state of the internal face of the aorta.
Let us pursue further our examination  and  this hypothesis
will become a certainty, when in following the track of the
ascending aorta, we perceive that it is, in fact, in this region
that a double souffle presents its maximum of intensity.
  Let us then resume and now  say ; Deformation of the two
left orifices, the  bicuspid  valve being, perhaps, insufficient  (no
clacking in the  first time,)  but in a feeble degree,  (develop-
ment of the pulse ;) the sigmoid  valves not being insufficient
(clacking of the second  time); but the orifice that  they  close
being contracted (whining of the first time towards  the aortic
orifice).  Let us  add :  cretaceous places  in  the  aorta,  and,
in fine, to  express that which is indubitably anounced to us,
by the strong pulsation of  the arterial system, hypertrophy of
the principal arteries.
  Let us now see, what was our first diagnosis.   It was  not
so perfect.   M. Bouillaud being absent, I  at first dictated
the following at the bedside of the patient. 
[  53   ]
   General and considerable hypertrophy of the heart.—Thick-
ening and deformation of the left valves.—Hypertrophy of the
principal arteries.
   Afterwards determined by the persistence of the whining I
added:  the principal lesion is at the aortic orifice, and it con-
sists in a contraction.
   Let us now see what the autopsy will show.  It was made
on the 24th of September, the patient having died suddenly
the day before.
   Autopsy.  No serosity in the pericardium.
   The heart globular,  rounded  and soft at its apex, weighs
with the origins of the large vessels, 24 ounces.  The  hyper-
trophy affects, especially, the left ventricle. The four cavities
contain no remarkable sanguineous concretions.
   Right heart.  The auricle is sensibly dilated, it would con-
tain a very large egg.   It is firm and plump, and of a Vermil-
lion color on the  interior.
   The  tricuspid valve is a little  thicker than  natural,  but
without  deformation.  The circumference of  the orifice is
nearly 4% inches.
   The ventricle presents only a medium capacity, contracted,
relating to that of  the auricle.   Nothing remarkable  about
its walls, which, even towards the base, are not five lines.
   The valves of the pulmonary  artery are well  shaped;  the
orifice is nearly 3i inches in circumference.
   Left  Heart.  The left auricle is dilated so as to be capable
of containing a small orange.
   The bicuspid orifice,  which  participates in  this dilation,
is nearly 4f inches in circumference, (instead of 4\); its valve
is considerably thickened, almost cartilaginous, roughened on
its free edge by small vegetations,  yet fleshy without creta-
ceous matter; the same kind of vegetations on  the chordae ten-
dineae  which terminate  in  it.   The  columnar corneae are
remarkable for their force and magnitude.
   The ventricle is less remarkable for its  dilation than for the
thicknesss of its walls.  These are, in fact, a little more than
15 lines towards the base, and this thickness declines only in
an almost insensible manner to the apex.  The  tissue is firm
and of a vermillion red, and recalls  by its aspect the most
rigorous muscles.   The endocardium presents a slightly opa-
line tint.                                          i  ♦■  i
   The aortic orifice is manifestly contracted  both relatively
and absolutely; its  circumference  is 2| inches,  (5 lines  less
than the pulmonary orifice, when normally they are about 
[  54   ]
 equal.)  Its valves are very  notably thickened, especially to-
 ward their free border, which  is rugous, a little unequal, pre-
 senting small  vegetations like atheroma,  or even,  many of
 them like ostropetrons, small and more sensible to the finger
 than to the sight.  The origin of the aorta also  presents some
 clusters, in plates yet more  prominent,  of this same  matter
 which grates  under the finger when rubbed upon  it; we find
 it as far as the middle of  the  descending aorta.   The aorta
 is besides remarkable  for its thickness, and all the large arte-
 ries, particularly in  this  hypertrophy.  One of  the crurals
 opened and placed by the side of a normal  crural  offers a
 capacity at least double.
   What shall we say of this autopsy, if it is not  that its his-
 tory is found  almost  perfect  in advance,  in our analysis of
 the  symptoms ?  We have seen, moreover in the  mean time,
 the  dilation  of the   auricles,  and  especially  the left one,
 which is an additional reason for admitting the insufficiency
 of the bicuspid  valve, the corresponding orifice being, besides,
 notably dilated  (4i\ inches instead of 4\).  This  dilation of
 the  auricles, the probable but rather secondary course of san-
 guineous  stasis, will, without doubt, explain the limited, but
 incontestible infiltrations, which we have noted. Yet another
 feature which is wanting in our analysis, is the existence of
 those small vegetations, which  the vibratory tremor  should
 lead us to suppose; a tremor  which in fact,  had  no other
 cause unless the aortic orifice might also have contributed to
 it in a feeble manner.   Let us again remark  in reference to
 these small fibrineous  concretions, veritable rudiments of cal-
 careous and other  concretions, that their deposition  on the
 free   border of the bicuspid valve and along the chordae ten-
 dinae, of this valve, seems to give us  the key to their formation.
   What, in truth, could be more analogous to the deposition
 of the fibrin of  the blood  on broom straws, as it occurs in
 our laboratories, than these curds, so delicate, agitated without
 ceasing in the  midst of blood, which is so violently shaken by
 the  energetic contractions of the hypertrophied ventricle.
   Observation 13.—Double contraction with  bicuspid and
perhaps aortic insufficiency.—Pericardiac adherencies.
  Lucien Bonde, tailor, aged 27 years, entered on the 2d of
 September,  1841.
  This young  man of a medium constitution,  rather delicate
 and  of a lymphatic temperament, was attacked at the age of
 nine or ten, by  general acute  rheumatism, which  has  reap-
 peared almost  every year, except the last five.   At an epoch 
[  55   ]
which he could  not exactly specify, but at least six years be-
fore,  he began  to  experience  palpitations  and  suffocations
which  persisted  until  the  present time,  but which put no
remarkable restraint upon him until about eight months since.
Since then, also, very frequent  cough, and latterly there was
cedematous  tumefactions of the inferior  extremities,  then of
the scrotum, and then of the abdomen.  He has kept  his bed
for three months.
   Present condition.  The patient  is seated on his bed.  The
face is pale and puffed.  Considerable cedematous swelling of
the feet, legs, thighs, scrotum and penis.  Tumefaction of the
abdomen, with a little dullness  in the lower  parts.  The ex-
tremities are cold.   The  pulse is at 88, little developed and
rather unequal.   Three or four degrees of  precordial promi-
nence.  The pulsation  very deep, but extended, accompanied
at intervals  by a little vibratory  tremor beneath the nipple.
The apex of the heart  strikes the fifth intercostal space, or
between that space and the sixth, and the pulsations extend
themselves from this point some distance above the nipple and
to the neighborhood  of the sternum; the precordial dullness
being about 2| inches square.  As  to the sounds of the heart,
instead of clackings there is only a double souffle, very rude
and raspy, much more  pronounced in the first time  than in
the second, of which the  sound is almost entirely effaced ;
this souffle attains its maximum near the inferior hollow of the
sternum.  At other points  we distinguish  a bruit de choc,
very heavy and dull,  mingling with  the souffle of the first
time.   No  notable souffle in  the  carotids.  These arteries,
as well as the  subclavian, pulsate  with remarkable  fervor.
The jugulars are a little distended.  There is a subcrepitant
rale with very numerous bubbles behind, at the base on both
sides.
   With these signs what  lesions shall we diagnosticate ?   I
avow that, at first,  this  case  seems more difficult of  perfect
analysis than the preceding.  Yet, if we consider that there
is an absence of valvular clacking,  an absence more complete
in the first than  in the second, we will be brought, alreadv,
to admit a double valvular lesion, affecting especially the  bi-
cuspid valve.  From  this complete  absence of bicuspid clack-
ing we shall conclude  besides,  that there  is insufficiency of
tins valve.   As to the aortic orifice, we may  perhaps hesitate
in reference to its insufficiency; but, the almost, if not entire
eflacement of its valvular clacking will not permit us to over-
look a certain degree of alteration of this valve.  The vibra- 
[  56   ]
tory tremor, itself, will also indicate a pronounced alteration
of "an orifice;  but of which ?   In recollecting the situation of
this  tremor,  below rather than above  the nipple, we shall
have some reason to attribute it, in preference, to the bicuspid
orifice.
   Now, such a detailed analysis is not always possible at  the
bedside of a patient and under inspiration of a first examination.
Such, moreover,  was  not the  diagnosis  of  M. Bouillaud.
That clever observer verified, in his turn, what we had noted
the day before, and dictated the following:
   Hypertrophy of the heart and of the principal arteries.—
Induration and thickening of the left valves, with contraction of
the orifices.—Suspicion of adherences to the pericardium.
   Why this contraction of these orifices ?  Because this, or a
well marked insufficiency,  is necessary to explain the coinci-
dence of a pulse so little developed and so  unequal, with pul-
sations, in appearance, so extended; because,  without doubt,
the contraction appeared, to M. Bouillaud, more probable
than the insufficiency, seeing the tone of the souffle, that tone
of which  the character  could be seized only by a practical
ear; because in fine, the vibratory tremor  of itself, gave suf-
ficient grounds for the diagnosis.
   Finally, why suspect pericardial adherences ?  Because as
M. Bouillaud  caused  us to observe,  there  were  pulsations,
very deep, extended, and restrained; because we did not find,
under the hand or ear,  that open exagerated  play, that free
impulsion of  a simply hypertrophied  heart. I avow that  no-
thing less than all the habitual and consumate experience of
our modern Corvisart, could  have enabled one to seize these
shades of diagnosis, which were, nevertheless, expressed only
under the form of suspicions.
   Again the verification  of the autopsy was not long delay-
ed. On the evening of the 9th of September, the  patient died
in a state of orthopny and general depression.
   Autopsy.   The pericardium contains five or six tablespoon-
fulls of  a reddish liquid, as though bloody.  The opening of
this cavity  on its anterior face is accomplished only with  dif-
ficulty in consequence  of the  intimate adherences  and very
short filaments, which unite  the pericardium to  the heart,
especially to   its  anterior  and  left lateral faces, adherences
which it is necessary  to dissect in order to expose the heart
naked.  In the remainder of its  extent, and  especially  the
right ventricular face, the heart presents many thick whitish
plates, which we can detach only with difficulty. 
[  57  ]
 ^ The  heart  is  considerably  and generally hypertrophied.
This hypertrophy effects, especially, the left ventricle and the
two  auricles.   In the interior it contains only some soft and
blackish  concretions.   Washed, it weighs,  after some  mo-
ments drying, about 1? pounds.
  Right Heart.  The auricle enormously dilated, might  con-
tain  a very large orange.   It is  firm, fleshy and very red.
The  circumference of  the tricuspid orifice is 4\ inches (nor-
mal).  Its valve  is  greatly thickened,  fibro-cartilaginous,
especially  towards  its  free border,  and  adherences  to the
ventricle  by the  extremity  nearest to the pulmonary artery.
The  tendons which  are inserted  therein  are stout, firm and
join  to some very robust and  thick columns.  Yet the right
ventricle is but little dilated, proportionally, and its maxi-
mum thickness, which corresponds with its base, is only 5
lines.
  The valves  of  the pulmonary artery are well shaped.  The
orifice is 3^- inches in circumference.
  Left Heart.  There is nothing very notable about the cali-
bre  or the internal  face of the aorta.  The valves, sensibly
thickened, preserve a little  transparency towards their me-
dium part, but their free border is transformed into a cartila-
ginous  excresence,  creaking under the  scalpel,  hard to the
finger,  without  ossification or notable  deformation,  unless
these valves adhere together by their adjacent border in such
a manner  as to contract the opening of that orifice, which
in preserving  these adhesions offers a circumference of  only
2j inches.
  The left ventricle is dilated and might lodge a  large egg.—
Its walls are thickened, firm and red; are nearly ten lines thick
almost as far as the apex, which is quite soft and rounded.  The
columnae corneae are generally stout, especially  those which
terminate by their tendons in the bicuspid valve.
  This valve,  not having been cut, presents in its centre a
rather oval opening  nearly  seven  lines in extent, which, as a
sort of vent hole, allows the light to penetrate to the bottom
of the  ventricle.  This opening is, moreover,  entirely cir-
cumscribed by a cluster of cretaceous  matter, forming a circu-
lar series of concretions or nuclei, of which  many have the
volume of large  peas.  They are  besides, unequal, very hard,
rough and almost  perfectly replace  the valve,  thus become
unrecognizable, and some of them  descend even like stalactites
in the thickness  of the tendons which are there  fixed.  The
circumference of the  auriculo-ventricular  orifice, measured 
[  58  ]
without opening it, is  3| to 3J inches (instead of4J).  The
corresponding  auricle  is large enough, but rather less than
the right.  It is nevertheless very firm, fleshy and red.
   The two lungs, and especially the left, are engaged pos-
teriorly.
   This autopsy has little need of comment.   Save the  hy-
pertrophy of the arteries, which I do not find noted, and that
perhaps because we  omitted to seek it, the diagnosis  of M.
Bouillaud,  is confirmed in  every point;  adherences of the
pericardium, contractions of the left  orificies.  Let  us  re-
mark, that the insufficiency of the bicuspid and the predomi-
nance of lesion of that valve  are also  verified.  The signs
which had  fixed our attention on this double circumstance did
not then deceive us.
   I now no longer doubt, that the adherences of  the  aortic
valvular laminae to each other, whence resulted, in  some sort,
the corrugation and contraction of the corresponding orifice,
may have had no other result than a certain insufficiency of
these valves; and that  our feeble  clacking  of the second
sound may have been produced  much less by these  valves
than by those more remote, but normal, of the pulmonary
artery.
   But shall we say nothing of the tricuspid orifice ?  Its cir-
cumference, which,  though of the same size as in the normal
state, was,  in fact relatively contracted, diminished still more
by the adherence of a part of its valve to the ventricle, did it
not find itself by this double cause morbidly  contracted, im-
perfectly closed with patency, which we should remember to
explain, both the dilation of the right auricle and  the  obsta-
cle to the venous circulation, the cause of the  serous infiltra-
tions noted above ?   For my part I am inclined to think so.
We may,  moreover, ask if it was  not the tricuspid  lesion
which gave rise to the  souffle we heard in the inferior hollow
of the  sternum, a region frequently indicated, and first by
Laennec, as the seat of the morbid sound of the right  heart.
This is a question which I am content for  the moment with
having suggested.
   Thus, then, to  resume our principal morbid phenomena,
vibratory tremor; cretaceous state of the bicuspid orifice.
   Souffle of the first time : aortic  narrowness, bicuspid  in-
sufficiency, and perhaps  tricuspid, the two last orifices  beinc
incapable of producing  clacking.
   Souffle of the second time : bicuspid and  tricuspid narrow-
ness, and a little aortic insufficiency. 
[  59  ]
  A little clacking in the second time : imperfect play of the
aortic valves, the clacking of the pulmonary being masked by
the souffle.
  It now  remains for me  to obviate an objection.   If the^
aortic orifice contributed to the production of the first souffle,
why did the latter not propagate itself into the carotids?  Be-
cause, without doubt, the sanguineous column, divided in the
left ventricle between the  bicuspid  orifice, remaining open,.
and  the aortic  orifice,  did  not beat  in sufficient quantity
against  this last orifice to cause the souffle resulting from this
friction, to propagate  itself as far as the carotids.  This is
proven  by  the feebleness of the pulse.  And now if one should
oppose  to this explication, the forcible beatings of the carotids
and subclavians, I would respond that this force is not always
in proportion to the column of blood which  traverses  them ;
witness the localized  partial pulsations of the  coeliac trunk
and of the  carotids themselves which often occur in chlorotic
persons, and which have  sometimes imposed  themselves as
aneurismal pulsations, or which we  have signalized in many
cases of notable disturbance of innervation, and in the cholera
itself. (See the memoir of MM. Serres and Norat on Cholera.)
   Observation li.^Bicuspid contraction and insufficiency.
—Thickening of  the aortic valves.—Tricuspid insufficiency.
—Pericardial adherences.
   Joseph Viard, varnisher, aged 22 years, was received  the
4th of October, 1840.
   This  young  man, of a  lymphatic  temperament, enjoyed
good health until 18 years old, at  which time he had general
acute articular rheumatism, which  lasted three  months, and
for  which he was treated  in this hospital.  During that at-
tack there  were palpitations and  very severe precordial pain.
He  said he recollected that in being  ausculted, a bruit de
souffle was heard.  These last accidents detained him a month
longer  in the hospital,  where they were met by cups and opi-
ate cataplasms.  Finally the patient  was discharged cured,
feeling  no  more, he says, either palpitations or suffocation —
At  the  end of  two years  another attack of rheumatism oc-
curred, with yet more severe palpitations.   This time it was
only after  a sojourn of six months that the. patient was able to
leave the hospital, and  ever since then he remained subject to
 palpitations, which, for eight  months, have prevented  him
 from returning to his occupation, and to which has been added,
within   eight°days,  infiltration  of the inferior extremities,,
 the genitals and the abdomen. 
[  GO   ]
   Present condition.—The patient is seated, his legs suspend-
ed out of bed; they are  infiltrated, especially in their inferior
third, as well as the scrotum and skin of the penis.  The ab-
dominal cavity distended by a considerable effusion, gives a
perfectly dull sound as far  as  about ten lines above the um-
bilicus.  The face is also notably puffed, it is moreover pale
and anemic;  the lips are  rather violet, and the extremities
cold.
   The pulse is at 96, small but very regular.   No precordial
prominency or  vibratory  tremor,  but  the impulsion is very
strong and extended.  The  apex of the heart beats in the sixth
intercostal space, a little without the nipple. The vertical dull-
ness is about 3g- inches, and more than 3| transversly.  We
hear in all the  precordial region, but especially in that of the
left cavities, a double souffle, rude, raspy, following the valvu-
lar sounds, prolonged, especially in the second time, and ac-
companied by a mixture of auriculo-metalic  tinkling and  a
heavy, dull sound, the double result of the shock of the  heart
against the pectoral walls.   We note, in fine, on the part of
the respiratory  apparatus,  a  subcrepitant rale, well formed
behind in both lungs, especially the right.
   The  next day M. Bouillaud added to the  preceding, that
in approaching the  right subclavicular  region, second sound
is  relieved, and it is there heard very distinctly giving a slight
parchment tone.
   This addition is important, for it puts us in a condition to
diagnosticate the disease in a manner probably complete and
precise.  We have a double souffle, does this alone indicate
a double lesion ?  No! without doubt, or, if it is double, it is
capable of  predominating at one of the  two orifices.  Which
is  that orifice?   On one side we have no very distinct souffle
in the carotids;  on the  other, in receding from the heart we
reach a point, where is found the clacking of the second time
modified only in its tone.   There  it is  the bicuspid  orifice
which is especially injured, and of which the  valve is proba-
bly insufficientj and the diameter contracted* the aortic valves
being thickened but sufficient.  Fortified by the results of our
anterior observations,  we  may  add, that "the  extent of the
serous infiltrations, induces  us to admit, besides, a dilation of
the right auricle (without detriment  to the  left) with dila-
tion and perhaps insufficiency  of the tricuspid orifice.
   M. Bouillaud  contented himself the first  day in diagnosti-
cating: a general hypertrophy  of this heart, with thickening 
[  61   ]
and deformation of the left valves.   Some days  after, he dic-
tated the following:
  " The raspy sound, which  absorbs the valvular clacking, is
very rude, as if contracted in the left cavities, where we rath-
er feel a shock, than distinguish sounds; but towards the in-
ferior part of the sternum,  the  double raspy souffle  becomes
 more pronounced  and ample; it seems as  though  the heart
 were restrained in the pericardium which envelops it."
  On the  22d of November, the patient succumbed.  Having
been prevented, by indisposition, from assisting at the autopsy,
it was dictated by M. Bouillaud.
  Autopsy.—The  parietal fold of the pericardium adheres  in
all its extent to the cardiac, a circumstance which explains the
restraint in the movements of the heart, which was manifested
 in the living subject.   This adherence is  very  intimate and
strong by means of very close cellular tissue.
  The heart is gorged with  clots.  Hypertrophy, with dila-
 tation of the right ventricle  and auricle; the auricular  col-
 umns are  double their normal size.   The thickened  tricuspid
 valve forms a kind of narrow ribbon,  fibro-cartilaginous, in-
 capable of closing the orifice, which is a third larger than  in
 the ordinary state.  The pulmonary valves are  sound.
   Water  poured  into the aorta rises; the  aortic valves pre-
serving nearly their normal form, are  only  a  little  shrunken
and  opaque in consequence of  their fibro-cartilaginous thick-
 ening.  They are  four times their normal thickness, and are a
little  red   on their free   border.   The orifice is  not  no-
 tably contracted.
  The left ventricle is of a volume and weight at least double
 that of its normal  state, with dilatation of its cavity; its walls
 have a thickness of about  I inch.
  The two laminae of the bicuspid valve are united at their
 commissure in such a manner as to form a fibro-cartilaginous
 rinf, the lips verv  thick, analogous to those of the glottis, with
 contraction of tlie corresponding orifices, which very readily
 admits the end of the index-linger.
  The internal membrane of the left auricle is thickened in
 all its extent,  wrinkled and a little shagreened.  The muscu-
 lar bed is  about 2 J lines thick.
   In both  luno-s we have only  to note a serous  or sanguine-
 ous congestion toward  the dependent parts.
   It is apparent that the reflections, which the proceeding ob-
 servation  presented to me, are in a great part  applicable to
 this    I therefore  refer the reader to it. And in fact, we have
                            F 
[  02  ]
in this again, pericardial adherencesdiagnoslicated, or at least
suspected; the contraction and bicuspid insufficiency; tricuspid
insufficiency, with which, by the by, we will again see coinci-
dinc, a souffle towards the inferior hollow of the sternum ;  in
fine, an aprtic lesion, without  carotidian souffle.    As in the
preceding observation, I attribute this last anomaly to the re-
flux of the blood by the  bicuspid orifice; I doubt not, that
without this circumstance the aortic souffle would be propa-
gated to  the carotids.
  Observation 15.—Bicuspid and tricuspid contraction.  Bi-
cuspid insufficiency.   Slight aortic thickening.
  Julian Choisy,  keeper of a coffeehouse, aged 49 years, en-
tered our service  on  the 29th of May,  1841.
  Of a medium constitution and lymphatic temperament; at
the age of 9 he was affected by a general articular rheumatism
which lasted five  or six months.   At 21 there was a new at-
tack which had the same duration.   In  1826  a third attack
occurred which  lasted many months.  Seven years ago, for
the first time he experienced suffocation and palpitations, which
required  a great many applications of leeches to the epigastri-
um and several bleedings.  Four years ago  there was a new
general rheumatism of five months duration.  Since thenlhere
have been palpitations from time to time, more intense dur-
ing the last five months, with dimness of sight  and stupor;
some cough since one month, and for a few days past a little
oedema of the feet.
  Present condition.  Face a  little pale and puffed ; no as-
cites or  oedema of the inferior extremities ; heat moderate.
The pulse at 80, rather unequal, quite regular, of medium de-
velopement and not  vibrating.
  The precordial region presents a prominency of 4 to 5 de-
grees by the cystometre.  The  apex of the heart beats directly
below the nipple  in  the sixth intercostal  space.   We also re-
mark some pulsations in the inferior sternal hollow.   The im-
pulsion of the heart is of a medium force, but of very notable
extent,  the  precordial dulness being  about  3  inches square.
No vibrating tremor.. The first sound of the heart is perfectly
replaced  by a raspy souffle, very contracted, recalling to mind
the whining. This souffle extends into all the precordial re-
gion, but above all into the region of the left cavities, and es-
pecially the auriculo-ventricular orifice.   In proportion  as we
ascend along the aorta, this souffle decreases and  even disap-
pears very promptly, giving place to a heavy and dull sound.
It is not propagated into the carotids.  As to the second  sound. 
[  03   ]
distinct in the precordial region itself, it  consists,  instead of
clacking, of a very hard and heavy  sound  without souffle.
The jugulars are a little distended, the dyspnoea is moderated
by repo.se.   We note, on the part of  the respiratory appara-
tus, only a little sub-crepitant rale disseminated behind, espe-
cially to the left, and some small, dry creaking, probably pleu-
ral, before and  above the left nipple.
  The patient reports that a month since his habitual dysp-
noea become so strong as to require a bleeding, and that it was
accompanied by a very acute pain.
   L';l us now analyze these  different symptoms, and we shall
see to what diagnosis they will conduct us.  Do we find at
first, in the habitual exterior, an indication of anv verv con-
siderable, obstacle to the venous circulation ?  We have the
puffing of the face, a little distention  of  the jugulars, and  a
slight pulmonary oedema; but no ascites or infiltrations of the
limbs. We ought then to suppose a certain degree of restraint
to  the circulation of the right heart,  and as  a consequence a
slight dilatation of the auricle of that side;  but not  yet those
considerable dilatations which we have seen  bound, for  ex-
ample, to tricuspid insufficiency ; rather then a little narrow-
ness, at least relative to that orifice.   The pulsation that  we
noted in the inferior sternal  hollow.,  puts us in a position to
think that the right ventricle participates in  the hypertrophy,
otherwise considerable, of the entire heart.
   Let us now come to the left cavities.   In  the region which
corresponds to them, especially in that of the bicuspid orifice,
that which  strikes us of course  is a very  rude and contracted
souffle, predominating in the first time, not even  encroaching
sufficiently  on  the second time, to prevent the appreciation of
the valvular clacking, which, moreover, becomes  more  pro-
nounced as we  approach nearer to the aortic region, but with
a very hard and heavy tone.
   Can we here overlook a bicuspid insufficiency with a certain
degree  of contraction of that orifice  at the same time, and a
certain thickening of the  aortic valves which does not pre-
vent  this adjustment,  (for they are not insufficient,)  but which
obscure* their clacking; r thickening which may  well be sup-
pose!  to have some influence in the production of !!♦; souffle
of  the first  sound; but this  influence is necessarily limited,
since the souffle  does not extend to  the carotids, the otifice
being, moreover, sufficiently open topennitthecolur.vi 11 Mood
feebfv decreased bv the bicuspid insufficiency, to pre auce pul- 
[  04  ]
sations at the wrist, not vibrating and rather unequal, but still
sufficiently developed ?
  But what is the dull, dead sound along the aorta, which is
by degrees disengaged in proportion as the souffle  of the first
time decreases? It is the imperfect clacking of the bicuspid
valve, which, insufficient to some extent, has not  lost all its
play and to which moreover is associated the more distant, and
doubtless somewhat modified, clacking of the tricuspid valve.
Besides, we have no vibratory tremor ; nor have we either ve-
getations or a cretaceous state of the orifices, nor of the aorta.
   Let us give now the diagnosis dictated at the bedside of the
patient by M. Bouillaud.
   General hypertrophy of the heart,  (18 ounces) thickening,
induration and deformation of the left  valves, especially of the
bicuspid, with the contraction of  the corresponding orifice.
   The patient died the 15th of  June without presenting any
new local symptoms.
   Autopsy.  The cardiac layer of pericardium presents sever-
al plates, particularly three,  one towards the base of the left
ventricle, another towards the base of the right, and the  third
towards the summit  of the left ventricle.   These three plates
are in more or less bold relief.
   The heart is generally and considerable hypertrophied, the
morbid developement affecting especially the left heart.
   All its cavities  contain  sanguineous concretions, of which
several were fibrinous before death.    Disembarassed of these
clots, and after having macerated in water for near five hours,
the  heart  weighed 22 ounces.   The water with which it is
impregnated evidently adds to its weight.
   Right heart.   The auricle  is  sensibly dilated, sufficiently
firm and vermillion in  its  tissue.  The circumference of the
tricuspid orifice is only 4 inches, instead of  4\.   Its valve is
thickened, and, on the side nearest the pulmonary artery,  it
is slightly adherent to the  corresponding part of the ventricle.
This is but little dilated, either absolutely or proportionally.
   The  maximum  thickness of its walls is 5 lines. The pulmo-
nary valves are well shaped, only a little stronger than nor-
mal.  The  corresponding orifice is  3£ inches in circumfe-
rence.
   Left heart.   Water poured  into  the aorta immediately
 overflows.  The calibre of the vessel offered nothing extraor-
 dinary.  We remarked only on its internal face and towards
 its origin  some slight rudiments of cretaceous matter, not as 
[  05   ]
yet protruding notably.   The sigmoid valves perfectly form-
ed, are  firm  and sensibly thickened without having comple-
tely lost their transparency.   The aortic orifice is  3 inches
in circumference.
   The  left ventricle, the essential seat of the hypertrophy, is
sensibly enlarged in its cavity, which could hold an egg, and
thickened in its walls, which are  12 lines  thick  at  the base
and 10 lines  towards the summit,  which  is softened and
rounded.  The columnae-eorneae are proportionally robust.
   The auricle  is likewise sufficiently larger, its tissue is Ver-
million and fleshy.   The circumference of its orifice is 3| in-
ches, (instead of 1 j).  The very much thickened valve, more
than all  the others, fibro-cartilaginous, creaking under  the
scalpel, adheres strongly to the  ventricle  by a part  of the
internal face of its  free border, and especially in a third of
its extent;  it is then  insufficient.  The two columns which
are inserted there, are strong and terminated by voluminous
tendons.
   The  two lungs present a little  serous engorgement at their
posterior parts.
   First let  us remark, that I was deceived  in  taking for a
pleural friction that which  was evidently  due to the  patches
found on the pericardium.  This error  had been easily avoid-
ed if the dyspnoea  of the patient, though moderate,  did not
prevent us from obtaining a complete and slightly prolonged
suspension of respiration, and  especially if the morbid sound
in question,  partly  masked  by the souffle,  had itself been
more  persisting  than it was; this circumstance owing per-
haps to the inequality of the  ventricular contractions, was
evidenced by the inequality of  the pulse.
   Now with exception of this inexact appreciation of an ac-
cessory phenomenon,  and relatively to what concerns the
orifices of the heart, has  not the autopsy, in all points, con-
firmed  the diagnosis ?
   We  had  here, too, a tricuspid lesion, and we did not notice
a souffle in the inferior sternal  depression;  this is a negative
reflection to be put in opposition  with  the remarks that two
of our anterior facts have suggested.
   Observation 16.—Contraction of the two orifices. Bicuspid
 vegetations, cretaceous concretions on the aortic valves.
   Auguste  Camuset, aged 16, was received, into our service
on the 21st of Mav, 1841.
   This  young  patient, of a delicate  constitution  and lym-
phatic  temperament, has heretofore habitually enjoyed good 
[  06  ]
 health.  A year ago he had general  articular  rheumatism,
 which  detained  him in bed two or three months, and since
 then he has remained subject to articular pains, from time to
 time ; and especially for three months past he has experienced,
 palpitations, dyspnoea and many symptoms of cerebral con-
 gestion.  Finally, for some time there has been turgidness of
 the inferior extremities, extending even as far as the trunk.
   Present condition. A little puffing of the face.  Infiltration
 of the  the feet and the inferior portions of  both  legs.   (Ede-
 matous infiltration of the coats  of the scrotum, with general
 swelling and transparency, which at first sight simulates  hy-
 drocele.  The skin on the  trunk rather warm, being 38° (cen-
 tigrade) on the abdomen.   The pulse is 136, very small,  but
 quite distinct, a little vibrating and regular.  General piecor-
 dial prominence imperfectly circumscribed.  We remark some
 pulsation in this region, which are propagated as far as to the
 inferior hollow of  the  sternum ; those of the apex  of  the
 heart raising the sixth intercostal space  a little  without  the
 nipple.  These  pulsations  are  very  strong,  but  especially
 remarkable for their extent, accompanied by a sort  of heavy
 and distant tremor, which is prolonged in the track of the as-
 cending aorta.  The dullness over the heart is about 2| to 3
 inches  square.
   In applying the ear to the precordial region we are struck,
 and in  some manner astonished,  at the truly exceptional in-
 tensity of a souffle, at the same time raspy and analogous to a
 jet of vapor, a double souffle, extending itself equally into the
 right and left breast, reaching as far as to a point under  the
 left clavicle, and ceasing to mark the second sound only under
 the right clavicle.  It is, in fact, only at  that  point that we
 hear the clacking of the second  time, a hard, dry, essentially
 parchment clacking analogous to a very vigorous fillip.  The
 souffle of the first time which  we again  distinguish in this
 region  is propagated, but  feebly, into the carotids.  These
 arteries, and especially the right subclavian  beat with force,
 in a manner sensible to  the eye.  The jugulars are manifestly
 distended.   No notable souffle in the coeliac trunk nor in the
 abdominal aorta or  crurals; the sound of these  last also
 reminds one of the sensation of a very distinct fillip.   The
 respirationjs restrained, a  little plaintive, from 44 to 48. No-
 thing else to note in the  sounds  but a little disseminated sub-
 crepitant rale.
  At the visit of_the next day, M. Bouillaud also verified all the
preceding signs.   He noted farther that the precordial souffle 
[  07   ]
extended to the distance of 2 or 2f inches  from the pectoral
walls, under  the form of a slight  whining, which, when we
applied the ear, was effaced  by the rudeness  of the bruit  de
souffle.  As on the evening  before the second sound disen-
gaged itself only towards  the right clavicle,  under  the form
of a parchment clacking, a little  veiled, the  first remaining
masked by the souffle.  Behind the chest, on both sides, the
double souffle is  heard  with  force, completely  covering  the
two normal clackings.
   From all the signs we have  enumerated,  let us try to 'form
a diagnosis.
   As in the preceding -observation we have at first some rear-
son to admit a stasis of the  venous blood  and a'medium  di-
lation of the left auricle.  The left orifices are evidently both
injured.   A souffle so intense, and which remains double and
without mixture of clacking in so great an extent, excludes
the idea of an unique lesion.  Yet a little  clacking is  beard
in the second time under the right clavicle  and the souffle of
the first time propagates itself only feebly, into the carotids.
Then, the principal seat of this enormous souffle is not in  the
aortic  orifice, of which it  seems  the valves, without  doubt
 thickened and like parchment, have not lost all  clacking.  We
 willingly  admit, then,  that  if our two valves are insufficient,
at least the bicuspid is more so than the aortic, since we find
some vestiges  of aortic clacking, and that  of the bicuspid is
 nowhere encountered.
   But let us remark, that in placing ourselves in certain Con-
 ditions, our souffle  presents a certain degree of Contraction
 and  resembles whining;  then, without doubt, 'one of  our
 orifices is much contracted.   Which is it?    We have admit-
 ted that the insufficiency, that is to say, the enlargement pre-
 dominates at the bicuspid orifice ; then it is to the aortic that
 we  must  especially attribute the contraction.
   Finally we have a profound and as it were distant vibratory
 tremor, but also extending  itself  along the ascending aorta.
 This is a reason for suspecting vegetations, or a cretaceous
 state perhaps of both valves, but especially of the aortic.
   The diagnostic of M. Bouillaud was not less detailed.   It
 •is as follows, dictated at the bedside of the patient.
   General hypertrophy of the heart.  Thickening, hypertrophy
 and probably vegetations of the left valves.   Contraction of the
 orifices, especially relatively  to the volume of the heart and to the.
 capacity of its left cavities.   Dilatation of  the right auriculo-
 ventricular orifice, and perhaps insufficiency of its valve. 
[  08  ]
   The following days the  signs above noted  persisted.   On
 the 24th of May, the souffle imitated the chirping of a young
 chicken, mingled moreover with a raspy souffle and profound
 vibratory tremor.
   On the 27th, the tremor wras  yet more pronounced, the
 pulse vibrating, but at the same time, very small and  rather
 soft.  The infiltration of the  extremities, scrotum and abdo-
 men made continual progress; the oppression was extreme ;
 finally, on the 31st, the  patient died.
   Autopsy.  The heart, freed from  some clots, weighed  only
 10  ounces.   (The heat being very elevated, one  may  sup-
 pose that  this low figure was owing to the transudation of
 the  fluids.)   It  is, nevertheless, generally hypertrophied, es-
 pecially in its left cavities.
   The right auricle is dilated; its valve is a little thickened,
 and its circumference is 4^  inches.   The maximum thickness
 of the walls of the right ventricle is rather  more than 2£
 lines.
   On the  contrary, the left  ventricle  is notably dilated, it
 might contain a small  hen egg.  Its tissue is firm and resist-
 ing.   Its walls have a  maximum thickness of  rather more
 than 10 lines.  Its columnae corneae are strong in proportion.
   The bicuspid orifice presents an extent of 3|  inches.
   The valve is of  a medium thickness, but we remark on its
 surface, and over an extent as large as a franc, a  group of
 small vegetations, yet fibrous and strongly adherent;  others,
 also numerous, are fixed on the  tendinous cords which  ter-
 minate in that valve.
   The aortic orifice is small and very narrow, both absolutely
 and  relatively to  the capacity of the ventricle.  Its valves
 are  notably thickened.   The  two nearest  the  auricle give
 insertion to a globular mass of the volume of a large filbert,
 evidently composed of fibrous granulations, which are succes-
 sively  deposited  around a  central nucleus, as  by  a sort of
 organic crystalization.  This  mass,  in which we find  some
grains as hard as gravel, makes a prominence of about 5 lines
in the  ventricle, being deposited like grafts on the ventricular
 face  of the valves and upon  their free border.  There re-
mains of these only some  vestiges ; they are crisped, retracted
 and  confounded, except at their adherent border, which  the
 mass indicated.  On the  aortic side we distinguish their free
face, that is to say, that upon which the fibro-calcareous mass
is not inserted.
  I ask of all readers in  good  faith, save  that curious aortic 
[  09  ]
 concretion, which could not have been otherwise  indicated
 but under the  name of vegetations, is it possible for a diag-
 nostic to  approach more nearly a  cadaveric description?
 Will  it  be said  that  the tricuspid  orifice was not dilated,
 because  its circumference was only 4% inches, i. e., 2s lines
 more  than the normal?  But I wish it observed that the
 question here is of a heart of 16 years ; of a heart, all hvper-
 trophied as it is, weighing not H or H pounds, but 10 ounces ;
 of  a heart, in fine, of  which the right cavities are not the
 predominant  seat  of the  hypertrophy; I wish it  remarked
 that the   normal   relationship between  the  two  auricular
 orifices, being represented by one, the difference here is 2',
 so that the tricuspid is much dilated, or the bicuspid greatly
 contracted.  I know that the tricuspid valve could not well
 have been insufficient, and yet I would not have been willing
 to answer for it; but let us remark,  that this peculiarity was
 announced only under doubt.   As  to  that which  concerns
 the left orifices, their  narrowness is too palpable to require
 remark.
   And now that all the lesions of the heart are known to us,
 is it necessary to return to the morbid sounds that it presented,
 to  analyze again  their  mechanism and the value  of the
 signs?  Who does not perceive  that our double souffle had
 its cause at the same time in both the left orifices,  that is to
 say, in the collision of  the  sanguineous wave against  the
 bicuspid  vegetations and  the  aortic concretions;  that the
 cause of the whining was also in the  narrowness of the bicus-
 pid orifice, incompletely  closed,  perhaps, by a valve whose
 play was  restrained by vegetations, and especially in  the
 smallness of the passage which the state of the deformation
 of the  aortic valves left to the sanguineous column; that the
 souffle of the first time, propagated itself only feebly into the
 carotids, because the state of the aortic valve was  only one
 of the elements of  this souffle, to the  production of which,
 without doubt, the  bicuspid orifice contributed, and perhaps
 even the insufficiency of the tricuspid valve;  that our souffle
 was equal in both  times, because  we had, at the two orifices,
 two anatomical states almost  identical, vegetations of one
 and a cretaceous state of  the other, the first souffle having
 in part for its cause, aortic contraction, bicuspid and perhaps
 tricuspid  insufficiency, and on the other hand, the second
souffle being produced by the very probable insufficiency, at
least partial, of the aortic valves, and especially by  the onset
of the blood against the bicuspid vegetations ?  Who does 
[  70  ]
not see, in fine, that if very far from the heart, we hear  a
little valvular clacking in the second time, that it appertains
in a feeble manner to  the aortic valves,  perhaps yet a little
moveable, and especially to the normal valves of the pul-
monary artery.
  But we have  said  enough  on  this  observation, which,
although rather more  complex  in  appearance  than any of
the others, is not less  susceptible of a rigorous and positive
analysis.
  Observation 17. — Bicuspid contraction.—Aortic insuffi-
ciency.
  A patient aged 48 years, was  received into our wards on
the 8th of December, 1841.  He was  sent  to us  as having
been  attacked  at  home, about  twelve days  before, with  a
pneumonia fruitlessly  treated by repeated bleedings.  The
examination of the patient did not fully confirm this diagnosis,
and what, for us, was most positive was the fatal  result of a
very  active  treatment (5  bleedings in  four  days,  then  25
leeches and  two  blisters)  directed against a doubtful dis-
ease.   And in effect,  the patient, of a constitution  other-
wise  deteriorated, presented to  us all the characters of the
most complete  anemia, a general palor, extreme  feebleness,
respiration doubtless full rapid, difficult, plaintive,  but every
where the resonance was good, and nothing else notable in the
way of morbid bruits,  than  some  disseminated rales  more
bronchial  than vesicular.  As to  his anterior diseases, they
seemed to  us to consist specially in an intermittent fever of
near one year's duration, with which he was attacked in 1814,
and a disease of the chest in 1821.
   After the exploration of the respiratory apparatus, the  re-
sults  of which  I have  just given, we  examined the circula-
tory system, I found the following:
   The pulse  88, languid,  feeble,  scarcely striking  the  finger,
unequal, and from time to time becoming almost impercepti-
ble.   The precordial dullness is fully one third more extend-
ed than normally.  No vibratory tremor.   The impulsion of
the heart  is deep seated, it beats scarcely perceptible  to the
touch.  Consequently, the sounds themselves are very feeble,
difficult to seize, the patient  being  able,  but with  difficulty,
to suspend, or even to  moderate his respiration.  However,  I
distinguished at the time of his entry, and M. Bouillaud, on
the following morning, with me, a souffle, double in the aortic
region, unique in the left auriculo-ventricular region, existing
there  particularly  in the second  time, and  slightly file- 
[  71   ]
like.   At  this  time there was no  bruit  de diable  (hum-
ming-top  sound); but a  distinct propagation of the aortic
souffle.
  The diagnosis of this affection of the heart is so simple that
I hesitate  to join it in advance.
   Preoccupied by the respiratory apparatus of the  patient,
and justly indignant at  seeing to  some extent compromised
his method of repeated bleedings, and a very precious method
for the skillful physician, but a very dangerous one in inexpert
hands, M. Bouillaud was content to dictate  relatively to the
heart, the following diagnosis :  organic affection of the hearty
and especially of  the left valves.
   For my part, as  the nature  of  my  lessons  each  evening
obliged me to be more  minute, I added the following to the
diagnosis :  Deformation of the two  orifices, and particularly
of  the aortic.   Insufficiency of the aortic valves ; sufficiency
of the bicuspid.
   In a few words I can give  the  reason of  this diagnosis.—
We  hear a souffle in the region of the aortic orifice, during
the first time, and it is continued  into  the carotids; so the
aortic orifice is  incompletely open, but this souffle is likewise
 reproduced during the second time; then lhe orifice is besides
 incompletely closed.  We hear a souffle in the bicuspid region,
which souffle, single at this point,  exists only during the sec-
 ond time;  then this orifice,  though it may  be sufficiently
 closed, can be but incompletely opened.  From its sound like
 filing, I  ought to concluded that this orifice is ever decidedly
 contracted, and if in place of deformation I had said bicuspid
 contraction, my diagnosis would have perfectly agreed with
 the lesions found  after death.
   The autopsy which shows us this, took place December 12;
 four days after his arrival at the hospital.
   Autopst/. — The  lungs offer  nothing  notable  except  some
 old adhesions, a posterior engorgement, a little redness of the
 bronchial tubes, and an emphysematous state to the extent ot
 2 or 2|{  inches square of the layer  of the left lung nearest the
 precordial region.   The heart.is distended with clots, partly
 of recent formation, and in part formed anterior to death.—
 Disembarrassed of  these clots, it weighs 21  ounces.
    Rigid heart.—There is nothing remarkable in the pulmo-
 ary artery, its valves are healthy,  and  the circumference of
  its orifice is 3 inches.
    The ventricle  is a little dilated, its walls are scarcely 22
 lines thick.   The auricle on the contrary, is  notably dilated 
[  72   ]
   —its valve is sufficiently thin; the circumference of its orifice
   is 5 inches.
     Left hear/.—-The auricle is so much dilated that it could,
   like the other hold a middle sized orange.   The valve is sen-
   sibly thickened, but free, without adhesions, and well formed.
   1 he circumference of its orifice is onlv 4 inches.   The walls
   of the ventricle, towards the  base, are JO  lines thick.  Be-
   sides tne  ventricular cavity is  considerably augmented.—
   Largely open, this ventricle presents transversiy an extent of
   near 8 inches (20 centemitres).
    The aorta is notably dilated in its arch.   It presents on its
   interior a rough, unequal surface, studded wilh  chalky depo-
  sits which are prolonged even into the descending aorta.   As
   to Us valves they are thick, almost fibrous, adherent by their
  corresponding edges, puffed in their  free edges, and finally
  manifestly insufficient, for water poured intothe aorta Se-
  dately penetrates into the  ventricle.  The  circumference of
  the aortic orifice is moreover Si inches

  theTeft orifiT7 «'? S™ 0Urr dia§n0sis S0 far as <™cerns
   he  eft onfices. But  it likewise furnishes two elements omit-
  ted by us, on account of the absence of the  signs which we
  finnnf itf  ° "I? t0 ?I!nounce them, I mean the notable dilata-
  tion of the  right auricle and of the corresponding orifice on
  the one part; on the other, the chalky  state of the f orta   We
  conceive without difficulty that this last lesion could not have

  ^vnandP:rSed' Cltl7 by " Vlbl'at0ry  tr—' °'- ^ ^ i"  en-
  he^ract of°iheSS °f a i^'PS souffle Prolonging itself alon*
  the tiact of  the aorta, for these signs  pre-suppose a vigor in
  the^contractions of the left ventricle, not compatible  w fh the
  ^bleness and anaemia  of our subject.  But how happens  it
 that the dilatation o  the right auricle had not brough  on   n
 of those  serous infliltration offered by  the preceding observa-
 tions ? I confess that this is more difficult to explain.   We can
 conceive, however, that these two morbid elements revealed bv
 the autopsy, have  nothing incompatible with the stethescopic
 signs  noted  by us during the life of  the patient.  It 2
 only two additional conditions to  add  to those before men
 tjoned as the cause of the souffles  both of first and secTd

   The following observation is another one of  these  that I
collected under the dictation of M. Bouillaud, at the epoch
when I commenced to  follow the visits of this  professor  a
source  fertile m clinical instruction of every nature, espedalk
upon the subject which now occupies us.          especially 
[  73   ]
  Observation  18.—Double insufficiency and contraction.—
Cretaceous state of the bicuspid.—Ad'lies ions of'the pericardium.
  Jean Hans, a cabinet-maker, aged 28 years,  was  received
December  13th, 1836.
  This patient is of a feeble constitution, and of a sanguinec-
lymphatic temperament.   I  find that amongst other disea>es
he lias had two attacks of rheumatism, and a bronchial affec-
tion accompanied by spitting of  blood.  At the time  of his
entry, he was as follows:
  Slight precordial prominence.   Dullness  over the heart
for  more than ."> inches both vertically and  transversely.  A
double souffle accompanies the two sounds but especially the
last.   The  first  sound  is a bruit de rape (^ound of a ra*p)
sufficiently short, and particularly audible in the  region of the
left auriculo-ventricular orifice.  The second is a prolonged
bruit de souffle, analagous to a jet of steam as it escapes  from
a safety valve ; it corresponds especially to the sternal  region
of  the aorta.  In spite of the general  feebleness,  pulse is a
little  wirey,  it is  regular, and of mediocre development.—
There is no infiltration of the legs.
  M.  Bouillaud dictated the following diagnosis:
   Enormous  hypertrophy of  the  heart, with thickening and
 insufficiency of the left valves.
   On the 28th of December,  we discovered a vibratory tre-
mor well marked below the breast, and  a peculiar sound like
 that caused by a curry-comb, which made M. Bouillaud sup-
 pose  that the pericardium  was diseased.
   Having gone out on the 6th of January  in some measure
 relieved, the patient returned February 15th, attacked  with
 an  epidemic bronchitis, with  some  fever.  The   bruits  de
 souffle of the heart are the same as heretofore.  M.  Bouillaud
 is still of the opinion that a friction of the pericardium  is min-
 gled  with  it.
   Nothino- essential was observed during the following weeks,
 except, at the commencement of March, a little pufiings of
 the face, a pulse still small, disproportioned to the beats of the
 heart, but very distinct, and offering of itself  account  a little
 vibralory tremor.  Towards  the aortic orifice and  the  tract
 of the aorta, the souffle of the first  time  is  mingled  with a
 stifled clacking; the second  souffle  is unmingled   and  as  it
 were by aspiration.
    May" 19th, we discovered a swelling of the legs,  commen-
 cing to invade the thighs.  The two sounds of the  heart re-
 semble a double bruit de scie (sound of a saw.) 
[  74   ]
  22d, a double souffle  is heard in the bicuspid region, and
there completely covers the  valvular clacking.  In the region
of the aortis orifice, and, on mounting towards the aorta,  the
souffle still predominates during the second time, the first  be-
ing  mixed with a  little clacking.
  M. Bouillaud thinks that there is a  considerable contraction
of the  left auriculo-ventricular orifice and insufficiency of
the aortic valves.
  The  following days  an intense oppression set  up, then
puffiness of the cheeks and lips, oedema of the  superior  ex-
tremities, diarrhoea,  and finally on  the 29th of May, death
supervened.
  Autopsy made by M. Bouillaud.—The pericardium is  un-
covered to the extent  of 6 inches transversely, and rather
more than 6J vertically. The parietal layer adheres through-
out its  whole extent  to the cardiac,  by fully  organized and
dense cellular tissue.  The heart, disembarrassed of the clots
which distended it, and washed, weighed 27 ounces.  All of
its cavities are hypertrophied and  dilated.
  The orifice of the pulmonary artery is free, a little dilated,
its circumference is 3f inches.  Its valves are thickened, espec-
illy their free edges, and at their base they are opaline.  The
right ventricular cavity is one third larger  than usual.  The
same is true of  the corresponding  auricle, the walls of which
are towards the base  of  the ventricle 5 lines thick (instead of
I or 1? lines).   The  tricuspid valve is well formed, but of  a
triple thickness  and fibro-cartilaginous; the circumference of
the corresponding orifice is 5| inches; neither the tricuspid  nor
pulmonary valve is insufficient.
  Water poured into the aorta partly overflows, but some of
it  penetrates into the ventricle.  The aortic orifice is 2$
inches  in circumference.  The aortic  valves become finer,
form a  sort of fibro-cartilaginous fold, rigid  and 3? to 4 lines
in height, (in place of about 7i>.)
  The cavity of the left ventricle  is smaller than that of  the
right, though rather  larger than normal.  Its walls towards
their base are about 7 lines thick.   The left ventricle is dilated
and  thickened; its internal  membrane  is  opaline and com-
posed of several layers.
  The auriculo-ventricular orifice is so contracted as hardly to
admit the point of the ring finger.   The two plates  of  the
valve are united so  a^ to form a ring, and  are trau formed
into  a fibro-cartilaginous tissue.   On both sides the surface is
roughened by calcareous concretions  and horny productions, 
[  75  ]
some of which protrude from 2h to 3 lines, and are suspended
like  stalactites.  On the side of the auricle the right leaf of
the valve  is transformed  almost entirely into  a calcareous
concretion, friable  and very hard to the touch.  The valvular
tendons are thickened, shortened, and the summits of their
fleshy columns are themselves transformed into a tendinous
tissue.
  The pectoral aorta i> perfectly healthy.
  Is not this autopsy, in some sort, an anatomical translation
or paraphrase of the diagnosis ?  Pericardial  adherences had
been suspected, and they were verified ; bicuspid contraction
and aortic insufficiency were announced, and  both existed..
I may  perhaps fall into useless repetitions, but I cannot resist
the desire of drawing the parallel between the  physical signs
and the basis.
   Souffle of the first time; contraction of the  aortic  orifice,.
and bicuspid insufficiency.
   Souffle of the second time  ; bicuspid contraction and aortic
insufficiency.
   In reflecting on  the contraction  of the two orifices, we
explain without trouble, the  tone of the souffles, that double
saw sound, that puff of steam, that aspirant  sound  of the
second time in the aortic region.
   In reflecting on the cretaceous state of  the bicuspid valve
we comprehend that raspy sound, so often verified.
   In the  aortic region, the souffle of the first time declined,
because we had then only the souffle produced by the aortic
contraction, that which the  bicuspid  insufficiency produced
being, doubtless, too feeble to reach our ear; the second, on
the  contrary, predominated  because  it was the  product of
both the contraction and  the cretaceous state of the bicuspid,
of  which the sound was able to reach the  car, and of aortic
insufficiency.   This second souffle was strong enough to mask
all  clacking and did  not  permit us  to hear that of the pul-
monary valves; the first  .souffle, more feeble, allowed us, on
the  contrary, to distinguish, but distant and obscurely, the
clacking of  the tricuspid orifice, of which the dilated valve
was not insufficient.
   Finally from our anterior observations, save the la-t, the
infiltration that we had noted  daring life gave in  reason to
expect a  notable dilatation of the right auricle and this lesion
was not in default.
   Obsekvation 19.—Clots in the heart.  Considerable dilata-. 
[  76  ]
Hon of the  right heart.   Aortic vegetations.  Bicuspid con-
tractions.
   Bouillon,  41 years old, brewer's servant, was received  on
the 2d of March, 1838.
   He is of a strong constitution, heretofore in good  health,
and declares that he has never had any other maladies than
three attacks of rheumatism, of which  the last, and the
gravest,  occurred eighteen months since.
   Eleven months ago he  experienced dyspnoea  and palpita-
tions  for the first time,   ]\ine months since a little swelling
of the feet occurred,  now disappearing and anon  recuring,
until during the last two months it has become permanent.
For some days past he has been a  prey to a very pronounced
dyspnoea.  He has  had many attacks of faintings with com-
plete  loss of consciousness.
   Present condition.   The patient is seated on the edge of
his bed,  his  legs pendent and supported on a chair.  The
respiration is panting 40 to  44.  The face is  pale and  little
livid; the lips  large  and bluish;  the eyes prominent; the
jugulars distended, especially in expiration ;  the inferior ex-
tremities strongly infiltrated and rather cold.
   The precordial region, more prominent than  the opposite
one, is  overrun by  some venous branches  which are  not
observed on the latter.  The beatings of the heart are much
more  extended than natural, but embarrassed as if the  organ
was confined to a narrow compass.  The point  of  the heart
is felt 2§ to  2| inches below the nipple,  and quite without, so
as to be transverse.   The dullness is 4|  inches vertically and
about 6i transversely.  The hand  feels a slight tremor.
   In the region of the left cavities a double rasp or saw sound
replaces, perfectly, the valvular tic-tac, and extends into all
the precordial region and the environs. The souffle is stronger
and more prolonged in the first time.  The pulse is small, very
difficult to feel on the left side, more distant on the  right,
irregular, unequal and intermittent.  We count  from  124 to
128 pulsations, of which some escape  by their smallness;
others are a little vibrating.  The pulsations of the  heart
seem to be less unequal and irregular than those of the pulses.
   In view of all these morbid phenomena,  M. Bouillaud diag-
nosticates ; Enormous hypertrophy of the heart.  Thickening,
induration and insufficiency especially  of the left valves.__
Clots in the heart.
   After the  detailed diagnosis of our preceding  observations 
[  77   ]
the reader may, perhaps, be surprised at not finding the same
precision in the terms of this.   The last element of this diag-
nosis is, nevertheless, of such a nature as to explain fully this
absence of localization  to all who are in the  habit of auscul-
ting the heart. And, in fact, when the blood  concretes in the
interior of its cavities, there often results no less disorder in the
sounds of the organ, whether normal or morbid, than derange-
ment of its functions.
   Now, since it is the first time that the occasion has offered
us an opportunity to particularize the symptoms of these san-
guineous concretions, let us say, in a few words, what deter-
mined M. Bouillaud to admit them here.
   Let  us remark, first, that this patient presents to us the most
intense orthopnoca that we may have yet encountered.  This
anhelation, this anxious countenance,  this distension  of the
jugulars ;  all these signs, in fine, of a considerable restraint  in
the venous circulation and especially the long duration of all
these morbid  phenomena,  the prolongation of this stasis  of
the venous blood, is there not already great reason to suppose,
the blood  being checked  in its course,  that the coagulation
must be an imperious  necessity?   But let us come to some
more formal indication.  These indications are furnished  to
us by the restraint in the movements of the heart, movements
extended, but which, according to M. Bouillaud, seem yet  in
a narrow compass ; the inequalities  and irregularity of these
pulsations; and finally the characters of the pulse, generally
small,  sometimes  imperceptible, at  others, on the contrary,
almost vibrating,  more unequal and irregular than the heart
itself.  Then  must there be, between the radial pulsation and
the impulsion of the left ventricle, independently of the or-
ganic  lesion of the valves themselves,  some  other obstacle,
sometimes fixed, but often moveable, breaking and intercepting
more or less completely the effort of the sanguineous wave.
   Such are, in fact, the principal  signs of clots in the heart;
si<ms very important to be known,  for  they may give us a
key to functional  disorders, which without them  we would
not  know how to explain ;  and  at the  same time, moreover,
suggest to us  an active and energetic medication, as powerful
agamst these  temporary  disorders  as powerless against the
organic lesions properly so called.
   Let us now return to our patient.
   The  following  days a  little amelioration declared  itself
under  the influence of a bleeding  and digitalis, but the infil-
tration made new progress; the scrotum and the penis became 
[  78   ]
  cedematous; the cavity of the peritoneum filled with serum ;
  the pulse remained small and even more and more impercep-
  tible;  the  sounds of the heart, always accompanied  by a
  double souffle, became heavier and more smothered ; the dys-
  pnoea reappeared,  so violent and frightful, that  the patient,
  almost erect on his bed, demanded to be strangled rather than
  be left to suffer thus;  finally* on the 27th of March, death
  came to  put an end to this frightful agony.
    Autopsy.  The pericardium is uncovered to an extent  of
  7  inches transversely.   It  contains  about the fourth of a
  glass of  turbid  serosity.  The heart* of which the point is
  turned almost directly to the left* is distended so much as to
  present the appearance  of a calf's heart.  These clots  are, in
  part, soft and discolored-—half organized.  Freed  from these
  concretions, the heart, with the origins of the large vessels,
  weighs nearly 25-ounces.
   The right ventricle  is dilated so as to be capable of con-
 taining the fist.  It is hypertrophied in proportion to its dila-
 tation.  The parietes are,, in their maximum thickness, about
 5" lines.
   The right auricle is dilated  and  thickened  nearly  in the
 same proportion.   The tricuspid orifice  has a circumference
 of nearly 6i inches.  The valve moreover presents its nor-
 mal conformation.   It  is  thickened,  hypertrophied,  nearly
 sufficient.
   The  valves of the pulmonary artery are thin, larger than
 natural.   The circumference of the orifice is over 4 inches.
   The left  ventricle? is  dilated3 so as to contain a duck  egg..
 Its parietes  are about 9dines  thick, and, what is  very remark-.
 able, they are much less  firm and of a less lively red than the
 parietes of the right ventricle*
   Water  poured  into the aorta approximates the valves and
 does not penetrate into the ventricle.   These valves are quite
 well shaped and thickened>;- their free border is  strewed with
 small granular vegetations, looking to the ventricular cavity,
 organized1 under  the fever  of venereal  warts.   The circum-.
 ference of this orifice is 3"i inches.  The  mitral valve  offers
 a very considerable thickness and is transformed into a  fibro-
 cartilaginous tissue.  The  orifice  that  circumscribes  this
 valve is contracted so as  to admit the extremities of two fin-.
gers. Its circumference is 3| inches. On the auricular side the
thickened  valve  forces a sort of wrinkled  fold,  like the skin,
about the anus.   The borders, where  the tendons  are insert^
ed, present, small vegetations, but less numerous. 
[  79   ]
  The parietes of the left auricle are thickened  in the same
proportion as the corresponding  ventricle; its internal mem-
brane offers rather an areolar aspect, and is a little thickened.
  The reflections we have heretofore  made will free us from
the necessity of comment on this autopsy.  We comprehend,
without  trouble, that without the  clots of which we have
specified the effect, it would  not  have been less possible here
than  in  our previous observations  to perceive that narrow-
ness, so notable, of the bicuspid orifice, and these vegetations
of the aortic valves;  the cause of the vibratory  tremor, and
their insufficiency, and perhaps  even  that insufficiency  and
that enormous dilatation of the  tricuspid orifice  and of the
corresponding auricle, coinciding again here with a consid-
erable infiltration and with oedema of the lungs, that I also see
noted in the autopsy of which I have  thought  it my duty to
reproduce only so much as related to the heart.
  We perceive in this fact an example of fixed sanguineous
concretions, if I may be allowed thus to speak, persisting and
surviving the subject.   In the following observations we will
encounter those of a temporary character.  This is one of the
reasons why I think it proper to add it  to the preceding cases.
  Observation 20.—Temporary Clots.   Contraction and  a
little bicuspid insufficiency.   Slight aortic thickening.
  Frederic Piquois,  founder,  aged 36,. entered  our  service
23d December, 1841.
  This patient, of quite a strong constitution and lymphatic
temperament, says he has  habitually enjoyed good  health.
He is only subject, since eight or ten years, to headache and
giddiness.  During the  past year  there  has. been added  a
cough, suffocation  in ascending, oedema, which at first limited
itself  to the left jaw, and attacked  afterwards the; superior
extremities, then  the  inferior of the  same side, and since six
weeks the right inferior extremity, and finally vomiting which
has become more  frequent during the last, few weeks.   All
these symptoms have obliged him to cease from  his occupa-
tion for six months, and even several times to keep his bed.
  Present condition*.   The face, the trunk itself, the fore-arm,
the left wrist, and  the two inferior  extremities  are  swollen
and doughy to the touch.  The   inferior extremities, in par-
ticular, preserve deeply the  impress of the finger.  The skin
is moreover of adull tint generally.  Some nausea at intervals.
The epigastrium and abdomen indolent.  No pain in the renal
region.   Urine scarce.. The penis a little cedematous.  Heat
of the skin little raised.   The pulse  rapid, unequal, scarcely 
[  so   ]
seizable at 120 to 124, contrasting by its smallness with the
force of the subject.  The precordial region presents a pro-
minence of about  four degrees, but  the pectoral parietes, of
the left side especially, are a little infiltrated.  In  consequence
of this circumstance, without doubt,  it  is difficult to find the
point of the heart, and its beatings are  irregular.  We never-
theless finally succeeded in perceiving them in the sixthint er-
costal space, from 10 to 15 lines without  the nipple.   The
pulsations of the heart are  scarcely  felt by the hand firmly
pressed over  it, and  there  is  no  appearance  of vibratory
tremor.  The dullness has a vertical  extent of about three
inches and 3£ transversely.   In ausculting  the sounds of the
heart we remark that the first seems to be effaced, whilst the
second is drier than  natural.   In the  origin of the aortic ori-
fice and the aorta this contrast is at its  maximum, the second
sound being then especially hard and like parchment.  In the
region of the auriculo-ventricular  orifice   the same  absence
of the first clacking,  the  clearness of the second being less
sensible, and besides, especially at intervals, a little souffle,
quite rude, mingling itself sometimes  with the first, at others,
with  the second sounds.  This souffle is not propagated into
the carotids, nor is there any visible distension of the jugulars.
The respiration is embarrassed and with difficulty limited to
28 per minute. There is only a slight sub-crepitant rale in the
inferior and posterior part of the left  side.
  The next day M.  Bouillaud verified the following:
  The pulse is at 124, felt with great difficulty, but  is tense
and without notable irregularity at this moment.  As yester-
day, the point of the heart is felt quite  obscurely in the  sixth
intercostal space, a  little  without the  nipple, and  the first
clacking is superceded by a souffle.   The second is rude, of a
slight parchment tone, and at present without souffle.   The
souffle disappears as we recede from the left auriculo-venticu-
lar orifice, and, towards the clavicle,  is heard a single sound
corresponding to the second time.
  M. Bouillaud dictated then the following diagnosis:
   Very  considerable  hypertrophy  of  the  heart (about  If
pounds).   Induration and thickening of the left valves, with
deformation of the bicuspid and contraction of the correspond-
ing orifice.
  Evidently, in making the diagnosis, M. Bouillaud takes into
consideration both that which I had verified the day before and
what he himself observed.  The  first clacking was superceded
by a souffle, growing feeble as we receded  from  the bicuspid 
[  81   ]
orifice; then there  was deformation  of the  bicuspid valve,
and  even a little  insufficiency.  In this same  region  there
existed no souffle  at the  moment, but I had verified  it the
evening before; then there might be a certain degree of con-
traction of that orifice, a lesion which coexists so often with
the deformation and insufficiency of a valve.
  Is this diagnostic  definition, and does  it give the key  to all
the symptoms observed?   No, doubtless.
  The dyspnoea,  the general infiltration, the  irregularity of
the pulsations,  observed at least at intervals, the smallness  and
especially the rapidity of the pulse (124) indicated certainly
a notable obstacle to the venous circulation.   But what was
that obstacle?  Perhaps a  right ventricular lesion, but  possi-
blv also some sanguineous  concretions. Certain ulterior signs
ought  to decide this question.  Let us remark, moreover, that
this anasarca of our patient had not followed its usual march.
It appeared to have  begun  at the face and reached the inferior
extremities only in the later  periods.  Was this not a reason
for making the inquiry, whether there had  not existed, as a
complication of the disease  of the heart, and as an essential
cause of the serous  infiltration of the  extremities  and trunk,
that affection of the kidneys,  called the disease of Bright ?
Under this impression  M. Bouillaud  directed the patient to
preserve his  urine.
  The next  day it was found pale,  opaque, slightly  acid,
a little frothy, nitric acid and heat producing a white  preci-
pitate  nearly of the consistency of the  syrup orgeat.   The
patient had vomited several  times.
   We add to the diagnostic: albuminuria.
  These  morbid phenomena, and especially the vomitings,
persisted almost  constantly  until the death  of the  patient,
which event  they doubtless hastened.   But  the  sounds of
the  heart presented an important modification, which should
be noted.
  On  the 30th and  especially on the  31st of December,  and
consequently a few days after the entrance,  M. Bouillaud, in
ausculting the  precordial region, was  much astonished to
find the  two sounds of the heart quite distinct, especially the
second, alwavs resounding and  of a  slight parchment tone,
the  second being only a little rude; further, there was  none,
or only a slight and soft souffle in the first time, particularly
in the'aortic3region.  The apex of  the  heart is thrown into
the fifth intercostal space.   There is no  oppression in a state
of repose.   The swelling  of the extremities has diminished. 
[  82   ]
Finally let us  add, for this is essential, that the pulse has fal-
len to 60.
  I repeat, that this last fact is  of the highest importance;
for it no more permits us to doubt that at the entrance of the
patient, the pathological phenomena,  that we have indicated
above, were caused by clots of blood which produced, among
others, this triple effect:
  1st.  To distend the heart sufficiently to cause its point to
descend to the sixth intercostal space.
  2d.  To restrain the valvular play,  so as to suppress the
clacking  of the bicuspid valve, much more submitted to their
contact than the  aortic valves, in consequence of its confor-
mation and of its more central position.
  3d.   To produce  on the part of the ventricular contrac-
tions and consequently in the sanguineous wave itself, an ex-
agerated quickness, a  condition so favorable,  perhaps almost
essential  here, to  the excess of friction (frottement)  which all
species of bruit de souffle presuppose.
  M. Bouillaud now completes the diagnosis by this last fea-
ture.
  A probability of temporary polypi-like concretions in the ca-
ties of the heart.
  But we may be asked, perhaps, if these clots are once ad-
mitted as the cause of the morbid phenomena noted during
the  first  days, and which have, in fact, disappeared since,
what will become of our first diagnosis relative to the bicus-
pid and aortic valves ?
  I respond, we  will  still  maintain  that diagnostic.    And
why?  Because if it be true that the souffles have disappeared,
save that of the first   time, which  rigorously  speaking may,
perhaps  be considered a souffle  of anemia,  it is not less true
that the valvular  sounds  have not rebecome normal.
  The first sound is yet a little rude and the second has a parch-
ment tone; then the corresponding  valves  are  not  sound.
Do we desire yet new proof of this, which will triumphantly
demonstrate the  validity  of our  preceding considerations ?
I find it in the course of this observation.
  February 14th. The swelling has made new progress ; the
pulse has attained 92;  and  we find a very distinct raspy
souffle in the  first time.
   February  23d. There  is  considerable infiltration, even
ascites for some time past;  pulse 88; the raspy souffle persists.
  Further, in order to arrive, finally, at a still more positive 
(  83   j
demonstration, let us now seek, in the necroscopic lesions the
proof of our diagnostic.
  The preceding  reflections will allow me  to  content my-
self  with  their  exposition, without  comment.  It  will be
readily perceived, that our  diagnosis was correct in all
points.
   Our patient died on  the 4th  of March.
   Autopsy.   Considerable  infiltration of  the  extremities
and  trunk.
   Thoracic cavities.   Very notable serous  engorgement  of
both lungs and especially of the left.
   The heart is hypertrophied,  but to  a medium extent.   It
weighs,  with  the origins  of  the large  vessels,  nearly  17
ounces; the hypertrophy  particularly involves the left ven-
tricle.
   Neither the pulmonary  or tricuspid orifices,  nor the right
ventricle offer any thing special.
   The  left ventricle is enlarged; and its parietes  present,
from the base almost to  the apex, a thickness of  9 lines.
Its  columnse-corneae,  sufficiently  robust, are  inserted, by
rather short tendons, into the  bicuspid valve,  which is sen-
sibly puffed at its free  border,  and which  appears a little
shrunken and narrower than natural.   In fact  the circumfe-
rence of the corresponding orifice is only  3$ inches  (instead
of 4.1).
   The circumference of the aortic  orifice is 3$ inches; its
valves are quite well-formed and sufficient, (which  is proven
bv pouring  water into the vessel.)  They present only  a
sort of small  fibrous patch towards their base ; and, above
their  free border the  internal membrane of the aorta pre-
sents  a  line,  almost circular, of a nankin yellow, which di-
vides, more by its color than by its feeble relief, the smooth
and  polished surface of the arterial tunic.
   Abdominal cavities.  Both kidneys  are  remarkably small;
they resemble those of  an  infant.   Their vertical diameter
is 4  inches, and the semi-circumference, taken from the mid-
dle  of their convex edge to the center of the  fissure, is 2-.
inches-  They are equal in weight.   United together with
their fibrous capsule and a portion of the ureters 4 or 5 inches
loner, they weigh  about half a pound.   They present nothing
remarkable interiorly,  but on their exterior they are granu-
lar,  red, and in many points adherent  to their capsules which
cannot be removed without rupturing.   The alteration in-
dicated, occupies  in some manner, only the superfices of the 
[  84   ]
organs, which at  the depth  of half a line resumes its nor-
mal  texture.
  The  ureters  and bladder are remarkably pale.  The urine
contained in the bladder was collected with care and treated
with nitric acid,  and there resulted a very abundant white
precipitate.
  Let us now finish this analysis, perhaps already too far ex-
tended, by a last observation  interesting, less on account of
the anatomical  lesions, the  same  as those we have already
seen very often, than even the  existence of a symptom that
we have not yet encountered, the triple and quadruple sound.
We see, moreover,  death produced by a clot  in  the  heart.
This is a new feature in the history of that morbid product;
and also a point of contact between it and the  cases we are
about to relate.
  This observation is one of those, which I collected under
the dictation of M. Bouillaud  before I entered his service.
  Observation 21.—Contracted,  insufficient  and calcareous
condition of the bicuspid valve.   Hypertrophy of the left au-
ricle.   Triple sound.   Death by a clot.
  Garret, a butler, aged 38, was received into our service on
the 4th of January, 1838.
  He has rather a delicate constitution, and  a lymphatico-
nervous  temperament.   Heretofore, usually in  good health,
he has complained of palpitations only since about one year;
and no  antecedents appear to account sufficiently  for the in-
vasion of an organic disease of the  heart.  The articulation of
the left shoulder is in a semi-anchylosed condition, with a ci-
catrix towards the middle of the arm, which seems to have been
the conseqnence of a violent phlegmonous inflammation, that
occured at the age of 12 or  13 years.  The entire  limb is a
little atrophied.    The patient  himself attributes the palpita-
tions of his heart to an influence  which lasted five weeks.
  Present condition.  (Noted  by  M. Bouillaud).  The face
exhibites lassitude  and is pale as well  as all the  remainder of
the skin.  There  exists neither oedema of the extremities,
ascites, or dilation of the jugulars.   The pulse is  rather small,
but distinct and regular, at 56-60.   No  very  distinct pro-
minency.  The apex of the heart strikes the sixth intercostal
space and forcibly repels the finger.   In  all the  precordial
region,  properly speaking, that is  to say,  from the base of
the heart to its  apex,   we percive great  vibratory tremor.
The corresponding dulness is 4\ inches vertically and 5 trans-
versly.  The valvular sounds are replaced by a double souffle; 
[  85  ]
the second more prolonged than the  first, is accompanied by
a sort  of  scraping, or snoring, similar  to  that attendant on
sleep.  In ascending along the track of the  aorta this  double
souffle is heard but without mingling with the snoring alluded
to.   Further, there is about  the heart an amphoric tinkling
which is heard at a distance,  and is analogous to the sound of
boiling water.  Receeding from the precordial region,  the
double bruit de souffle ceases  to be heard  and  the  amphoric
sound  disappears.   The double  souffle  propagates itself to
the posterior part of the  left side of the  chest.   There is no
vibratory tremor in the arteries.  Respiration is perfect.
   M. Bouillaud dictated the following diagnostic:
   General hypertrophy of the heart {about one pound).  Thick-
ening  and  induration of the left valves, with a contraction
of the  auriculo-ventricular orifice.
   The next day a very  distinct triple sound is  heard in
the  precordial  region  which  may be traced as  far as to
the  right side  of  the chest.  This  is the result of a decom-
position  of  the second sound, and is accompanied  by the
souffle alreadv noted.
   The amphoric sound  of the previous  evening is  no longer
distinguished.  The  pulse is only 4S-52 ;  it is always tense
and vibrating and not increased.
   During the following days, there is persistence of the trip-
le sound° which is even more and more distinct.   The  two
last sounds do not occupy more time than the first, which
is svnehronous with the pulse.   The last  is always made
up by a souffle.  In the  track of the aorta there exists only
the  usual double sound.                    #
   January  23d.  The triple sound extends into the  carotid.
Under the  influence of digitalis  the pulse has  fallen to 31..
During  the  examination the  patient  was  restless, and, a
few moments  after,  M. Bouillaud  discovered  tour  sounds,
which were soon  superseded by the usual triple sound.
   The 31st.  The triple sound  persists ever  with a raspy
souffle which ends it.  It may be represented by tic- - - - tec - - - -
s s s-s   M Bouillaud made some remarks on this subject, and
explained  the third sound by saying that,  without  doubt, the
Eride emptied itself through a contracted onfice^yhen
  he ventricular diastole was  already  accomplished.   Thi
morning the pulse has risen to 48.  The  patient  is  affected
ly ver/ nten  e salivation which he has contracted by  mui-
 curalMictions on the pubis.   February  4th.   He  died at the 
t  "86  ]
moment of our visit; no  signs had foreshadowed this  sud-
den death.
  Previous to developing the results of the autopsy, let us for
a moment, review some of the peculiarities of the symptomato-
logical history of this patient.
  Is it necessary to state the grounds for the diagnosis?  With
this double souffle, so rude, that it is accompanied by a vibra-
tory tremor evidently located 'in the region of the heart itself,
so strong, that it propagates itself as  far as to  the posterior
part of the chest, and that the valvular clacking can nowhere
be heard; who does not perceive, as aconsequence, that both
orifices are affected, or, if only  one, that it is injured in a  very
high degree ?  If now we consider that the rudest of these
souffles, which is mingled  with a  sort of scraping, does not
offer this accompaniment along the track of the  aorta, ought
we not to conclude that this bicuspid orifioe is  the point  of
departure of this morbid sound?  Finally, since this sound is
heard in the second time, should we not  conclude also that
the lesion of this orifice  is especially a contraction?
  In reference to the amphoric tinkling noted only  on  the
first day, had  it any relationship with  the lesion which  we
are about to diagnosticate ?   Was it, for example, a phenom-
enon of the same nature as  the vibratory tremor?  I  do not
think so.  I prefer to view it as a peculiar sound, of which I
will speak with  some minuteness hereafter,  which, although
studied in other regions, has not, to our knowdedge, been dis-
cribed as existing in the precordial.  I allude to  the bruit ro-
tatoire.*  I am justified in this idea by the description dictated
to us by M. Bouillaud, without  pronouncing on its cause, and
especially by its feeble propagation beyond the precordial re-
gion, and finally, its prompt disappearance.
  One word now on the triple  sound of which this observa-
tion offers us the first example.   We will  speak hereafler, of
the different interpretations, of which  this  curious modifica-
tion in the rhythm of the  sound of the heart, is susceptible.
Let us remark here that on  which  M.  Bouillaud  dwelt,  and
which we will presently see fully sustained by the  autopsy;
and let us note this peculiarity  that, for the triple sound to be
heard, the succession of  the sounds of the heart must probably
present a certain degree  of slowness, since it did not exist  on
  * A sound attendant on the first sound of the heart, and so called because it
was thought to resemble the rumbling of distant wheels.  It has also been at-
tributed to muscular contraction, and is  hence sometimes termed bruit muscu-
iaire.—Translators. 
L  87   ]
the first day when the pulse was 56-60, and became percepti-
ble the next day, the pulse being at 48, and that afterwards
it  appeared  to  become  more  and more distinct as the pulse
gradually diminished in frequency.  May this not explain why
we have not before encountered this  triple sound in cases so
anatomically analagous to the present?  For if I  am not de-
ceived, no case  has presented a similar slowness of pulse.
   Finally, let us come to the recapitulation  of the cadaveric
lesions.
   Autopsy, (25  hours after death.)  The pericardium  is ex-
posed to the extent of about 5 inches  square.
   The heart, lying almost transversely, is  nearly  triple  its
normal volume, depending in part on  the  distension of its
cavities, especially of the auricles, by sanguineous concretions.
In fact, on  dividing the vessels of the base of the  heart,  an
enormous quantity of half coagulated blood was discharged
from the  auricle, and this  evacuation  reduced the volume of
the heart at least one-third.
   The right auricle still retained an unctious looking clot, ol
a  yellow  amber color, of the size  of an  egg, prolonging itself
into the right ventricle, where it is one-half  less.   M.  Bouil-
laud believes this  clot to have been  the immediate  cause of
death.  Freed  from all  its concretions,  the  heart weighed,
with the  origins of the large vessels, about 14 ounces.
   Right heart.   The valves of the pulmonary artery are thin,
large and well formed.  The circumference of ibis orifice is 4
inches.   The cavity of the right  ventricle is dilated to a me-
dium extent; its parietes are less than 5 lines in thickness.
   The right auricle is dilated, and might contain a large egg ;
but its parietes are of a good thickness  at every point, its col-
umnas-cornea)  well  developed and hypertrophied.  The tri-
cuspid  orifice  has a circumference of 6 inches.   The  valve
preserves its normal shape;  it is evidently enlarged and a lit-
tle opaque.
   Left Heart.   The aortic valves are sufficient, well formed,
a little hypertrophied, especially at the middle of  their free
border, and of a tint rather opaque  and lactescent.   The  cir-
 cumference of the aortic orifice is nearly 4 inches.
   The cavity of the ventricle is but slightly or not  at all di-
 lated.                             ,  .           .     .
   The bicuspid orifice is transformed into an  oval apertuie,
 capable of admitting the end of the little finger, and ot which
 the large diameter  is nearly  10 lines, and that of the small 
[  88  ]
 rather more than 5.  The two laminae of the valve, adhere by
 their angles, and circumscribe the orifice.  They are thick and
 fibro-cartilaginous.  At the posterior part, they are more than
 5 lines thick, and  in  consequence of the presence of  a calca-
 reous concretion, as seen from the auricle, it is divided into two
 valves so as somewhat to resemble  a  shell.  The edges are
 rugose and unequal, made up of calcareous granulations.  The
 columnse-cornea:, which are inserted into the valve, are strong
 and their tendons hypertrophied.  The summit of these  col-
 umns are transformed into tendinous substance.  The endocar-
 dium adjacent to the  valve  is thickened,  and changed into a
 fibrous tissue.   It is unequal and resembles  shagreen.  Sepa-
 ted at its circumference, the valve weighs 180 grains.
   The auricle is so much dilated as to  be capable of contain-
 ing a goose egg. Its parieties are  generally thickened (1£ lines)
 the result of the hypertrophy of the muscular tunic,  which
 is of a deep red.   The endocardium is easily detached, and is
 nearly double  its normal thickness.
  The origin of the aorta is slightly dilated, and sown with
 spots of yellowish white, without calcareous  incrustations. At
 certain points  we remark a pale red color.  This same color
 is also observed, and it is even  more marked on the aortic
 valves.
  There exists no  traces of cadaveric imbibition.
  This autopsy agrees so well with  its semeiology and with
 the diagnosis, that it cannot suggest  any very numerous re-
 flections.
  There is  perhaps  but  a single point which demands our
consideration:  viz : the very  considerable  dilatation  of the
 right auricle, coincident here with the complete absence of any
 notable  infiltration.  Is this  fact calculated  to  invalidate  our
 antecedent observations?  I think  not; and why?   Because
here we  have  not  only a dilatation of  this auricle, but also a
proportionable  hypertrophy of the muscular tissue;  the tri-
cuspid orifice is adequately  enlarged and closed  by  a  well
formed valve; finally, the right ventricle is  not  dilated, and
the pulmonary  orifice itself is quite free ; all, circumstances
 but little favorable to that stasis of the venous blood which is
 the cause of infiltration.   In our antecedent observations we
had what may be termed a passive dilatation ;  here, we have
in some manner a veritable active  aneurism, probably the re-
sult of that  inflammation of which we have found so many
scattered vestiges,  in the thickening of the endocardium, the 
[  89  ]
redness of the aorta and in the amber colored and fibrous con-
cretions, the formation of which must have been promoted by
the stomatitis of our patient; aided, moreover, as it undoubted-
ly was,  by that obstacle, so evident, to the arterial  circula-
tion, located  at the  bicuspid orifice, the approximate, if not
the only cause  of the dilatation of  the left auricle,  and the
influence of which was gradually extended to the right heart,
the obstructions in which,  as we  have  seen, appear  to have
produced the  asphyxia of the patient.
   Here ends the first part of this memoir; the exposition of
facts.  I might readily add to this list, many facts not less au-
thentic than the preceding.   But I am fearful of fatiguing my
reader and of falling  into  wearisome repetitions.  I think I
have exhibited almost complete, all the chief alterations, or at
least the most common that the heart  can present, and after-
wards sufficiently demonstrated, by cadaveric  examinations,
the possibility in all  cases, of a positive and exact diagnosis.
Have we not seen,  in almost all, as perfect agreement between
the diagnosis  and  the  autopsy, and, when there has  been an
omission, or even an error on our  part,  have  we not frankly
confessed it, in  such a  manner as to promote  the interest of
the science—an error clearly pointed out, being the best pre-
cept for  avoiding future mistakes of  a similar character?
   Let us now recur to all these facts in order to unfold and to
study successively the means of explanation,  by  the aid  of
which we have  succeeded  in analyzing, so minutely,  diseases
heretofore reputed  as impenetrable.  But, before we approach
this didactic part of our subject, let us take a  general glance
at the  divers  lesions  which we have enumerated, and see if
this view of the ensemble will  not give  rise to some consider-
ations which have not yet occurred  to us.
   And, first,  let us observe the  wonderful difference in the
frequency, and  especially in the gravity of the affections of the
pericardiums and those of the heart itself. Of our twenty cases,
there is not an example of open acute pericarditis or of consid-
erable effusion in the envelope of the heart, capable, of  itself, of
producing a fatal termination.   I have followed, for nearly six
years, the clinic of M. Bouillaud,  and during all that time I
have observed, only five or six times, the complication here al-
iuded to.  I have not cited these facts because  my object here
was to study the heart itself,  rather than its serous envelope,
of which the symptomatological history  is well known, and
because, under the aspect of the subject which occupied our 
[  ^  ]
attention, these facts could not have added any thing essentiai
to our observations.
  If, as I have  just remarked, the grave lesions of the peri-
cardium are very rare, the  same  is not true of latent lesions
which are revealed to us at the autopsy in the form of slight
and circumscribed adherences  or small, prominent and iso-
lated plates.  These, if I may  be allowed the expression, are
almost necessary accessories of grave lesions of the heart, and
which,  in  our  necropsies,  have rarely been in default,  al-
though we may have-generally passed them in silence, except
when these adherences, or false  membranes were of such a
character,  as to become themselves causes of functional dis-
turbances, or give rise to  a suspicion  of their existence by
certain palpable signs, as in our observations 9,13, 14 and 18.
  Let us now  come  to the heart, properly speaking.  The
first remark by which we must be struck, is the singular pre-
dominance of the left over  the right heart* in respect to its
morbid alterations.
  True, we have often seen the right heart participate in the
hypertrophy of the left; but has there not always been a dif-
ference between the two, sufficiently marked to render it ap-
parent that the hypertrophy  of  the left heart had been the
capital and primitive lesion, and that of the right only acces-
sory and secondary ?   Have we not encountered valvular al-
terations almost exclusively in the left heart, those in the right
consisting,  most frequently, only  in a passive enlargement of
the orifices, especially that  of the tricuspid ?
  What can be the cause of a difference, so decided, between
two cavities bordering  on each other, and which are so analo-
gous in their structure ?   It can be owing only to.  the diffe-
rence in the qualities of the blood which traverses them  re-
spectively.   Approximating each other anatomically, the right
and left cavities are very far removed from each other in phy-
siological point of view.
  They differ  as widely, in this  respect, as arterial and ve-
nous blood.  Relative  to  the pathogeny  of the  affections,
which engage our attention, I rank myself, without hesitation,
by the side of M. Bouillaud; the inflammation  of the internal
membrane  of the  heart, the  sanguineous congestion of the
different parts of this organ, and I will add the molecular com-
position of the  blood  which flows through it,  appear to me
to be the essential points of departure of the structural altera-
tions  which the muscular tissue and the valves present to us.
  There is, nevertheless, still  another circumstance, which, 
[  91   ]
should enter into the account,  in studying the anatomo-pa-
thology of the centre of circulation.   This circumstance, se-
condary, it  is true, and which always presupposes some other
previous morbid condition, is the force of the blood in the in-
terior and on the walls of the cavities of the heart—an effort
of dilation altogether mechanical, and from which results the
enlargement of its cavities and their orifices, but which, "it is
well understood, does not exclude, for the explication of what
has been termed eccentric hypertrophy," an exaggerated nutri-
tion submitted fortuitously, perhaps, in the pathological growth
of the organ, to the same laws as in its normal  evolution,
that is to say, having simultaneously augmented its substance
and enlarged its capacity.
  This mechanical dilation occurs, especially, in those partial
enlargements which either of the cavities or orifices may  pre-
sent to us, beyond which  is the free flow, of the sanguineous
wave finds itself more or less completely intercepted.  I have
said^ that the right heart  offers those passive alterations, if I
may be permitted  thus to designate them, more frequently
than  the left.   One word, now  on the mechanism  of their
formation.
  If it were  common  to encounter an  organic lesion of the
pulmonary artery, and a contraction of the corresponding ori-
fice, we should readily conceive that, behind this obstacle, the
right  ventricle  and the auricle itself must become dilated.
But as we may determine for ourselves, by  the facts that we
have passed in review, this lesion of the pulmonary valves is
of very rare occurrence.   And yet we have very often  wit-
nessed a  dilation of the right cavities.  Why ? because, ac-
cording to M. Bouillaud,.an obstacle, situated in the left cavi-
ties, gradually exerts.on the circulation of the right, an influ-
ence which, though distant, is not less sure and real.  Let us
develope this idea bv  giving it the support  of an example.
  A lesion exists at'the orifice of the aorta. This lesion ar-
rests or at least, impedes the passage of the blood projected by
the left ventricle.  A portion of this blood remains then in
the ventricle and becomes an obstacle to the ingress of  that
which should be received, from the  auricle of the  same side.
This  auricle.in  its turn retaining a  part of the blood in re-
serve, the pulmonarv  veins, which  there terminate,  are, tor
the same reason, only imperfectly emptied ;  as a consequence
the same must: be true of the pulmonary parenchyma which
sustains them.   If this parenchyma remains  thus charged
vith a quantity  of  blood, which should have  passed freely- 
[  92  ]
forward, it cannot receive all the venous blood,  which  the
ramifications of the pulmonary artery conveys to it, and hence,
retrograding in its turn, the venous wave must distend, suc-
cessively, the pulmonary artery, the right ventricle, the au-
ricle of the same side, and eventually the entire venous sys-
tem, from which soon  result serous infiltrations, sometimes
partial, at others general.
   Let us remember, that by duly considering the extent or
the importance of the serous effusions,  that wre have, more
than once, diagnosticated dilations of  the right  heart, and
especially of the auricle, diagnosis afterwards verified by the
autopsy.  Let us add, that if at the beginning of this arresta-
tion of the venous circulation,  the right  ventricle can  re-
double its efforts, and,  by this excess  of the muscular  con-
traction, cause the palpitations  and dyspnoea of which the af-
flicted complain at this period;  if it contributes then without
doubt  to hypertrophy its tissue, a moment may, nevertheless,
arrive, when  its dilation will be such, that having  lost in con-
tractile force what it may have gained in capacity, the fee-
bleness and impotency of its contractions will become a new
cause of stasis of the blood, added to those we have already
pointed out, and strengthened,  moreover, by another morbid
circumstance, of which I have  not yet said any thing, and
which  is the result of the dilation of the right cavities: I allude
to insufficiency of the tricuspid  valve, which we have proven
many times   after death, and  even anounced its existence
during life.
   Thus, then, to sum up what concerns the right heart ac-
cording to our observations : most  frequently, I will not say
constantly, eccentric hypertrophy,  passive dilation, and of-
ten simple hypertrophy, that is to say, without any very no-
table  valvular  lesions,  constitute  its  anatomo-pathological
history.
   In the left  heart, on the  contrary, hypertrophy, without
valvular lesions, is almost an anomaly.   We have cited one
example of it, (Observ. lst,)and yet in that  case  we could
only perceive that the valves were not perfectly round.  As in
the right heart, so here, the auricular orifice is most frequent-
ly injured or the  lesion predominates  at this orifice when
there  are  conincident  aortic lesions.   More then once we
have shown  the  probable reason of  this predominance in
the influence■, which the chordae  tendineae, that are insert-
ed in the bicuspid valve, may exert on the coagulation and
deposition  of the fibrin of  the  arterial  blood.   As in the 
[  93   ]
right heart,  we  often meet  with partial dilations, sometimes
of the ventricle, at others of the auricle; but we have less fre-
quently found the orifices free  or dilated in the left than in
the right heart.  The contraction of these orifices is certain-
ly one of the most common lesions which we have observed,
whether there existed concomitant insufficiency or not.  As,
apropos,  may  I not  refer  to  that  peculiarity,  curious,
perhaps, to  those who believe in final causes, that by the ar-
rangement even of the morbid lesions  which the two  hearts
present to  us,  and of which we have spoken,  it seems that
nature may have, in some  manner, endowed  herself, by  a
great foresight, so that the fatal term, inevitable sooner or la-
ter as a consequence of the disease, might  be, at least as
much as possible, procrastinated? I will explain myself.
   Of all the mortal  perils which may result from  hypertro-
phy of the heart and lesions of the valves, there are two prin-
cipal ones—an  afflux of too large a quantity of blood  to the
brain, producing apoplexy,  and  too  great  a diminution of
the  quantity sent to  the lungs, causing asphyxia.   I  repeat
that such as they usually present themselves,  the lesions of
the orifices  seem to be>  at least, as  favorable as possible to
the  prevention  of this  double accident.
   Thus  the right orifices, which lead to the  lungs, are, as
we have seen, almost always free and open.   Thus, also, are
not the left  orifices which open towards  the brain, most ge-
nerally  contracted or  insufficient;  so that, as a consequence,
there is an  imperfect issue of the sanguineous  column at
the  first time, through the contracted aortic  orifice; or a
division of that column  itself by  a reflux movement, some-
times into the auricle in the first time, and at others into the
ventricle in the second time.
   I  repeat  it, this  peculiarity is, in my opinion, a curious
and fortuitous occurrence, rather than a precaution of nature,
a vestige of order in  the midst of disorder ;  but I dwell upon
the fact, in passing  from  this motive  only—that  the fact
should  not  be entirely  neglected, in  relation to prognosis,
and in a general study of the diseases of the heart.
   Let us now begin the examination  of our means of explo-
ration, not for the°purpose of composing here a complete trea-
tise on  diagnosis,  but  especially to indicate  the  practical
views which the clinical facts themselves, that we have ana-
lyzed, may  suggest'.
H 
SECOND PART.
 A  succinct consideration of the means of Diagnosis in di-
                    seases of the Heart.

   The first sign which we have, remarked almost constantly
 in advance of  those of which the  ensemble constituted our
 symptomatological history, was the state of the pulse.  There
 is, as we know, two things to study in the pulse; quantity and
 quality.  It is generally essential to note the quantity only in
 the acute affections, pericarditis, endocarditis, &c.   In those
 cases the pulse may attain an extreme quickness—it has sur-
 passed 130 and 140.   The. twenty cases  related above have
 not furnished one of this kind.
   I  will  refer only  to the fact of sanguineous  concretions
 (Obs.  19) in which the heart beat. 124 times per minute,  as
 if to compensate, by the multiplicity of its contractions, tor
 the insufficiency of each of them.  In those cases then,.there
 was generally nothing remarkable about the pulse in this first
 point of view.   But  this  is not the case in reference, to its
 qualities.
  The qualities of the pulse should,.doubtless, be properly es-.
 Unrated in the acute disease, and most especially in the chro-
 nic affections of the center  of the circulation,  Let qs remem-
 ber that more than once, the pulse has been the  first index
 we have had of an affection of the heart, and has awakened
 within us a suspicion, transformed by the subsequent exami-
 nation, into a certainty.   We have sometimes seen a vibrat-.
 ing, developed, and resisting pulse immediately announce  to
 us (see Obs. 5 and others)  the existence of  an hypertrophy
 of the  heart and particularly of the left ventricle'; and from
 this development of the pulse we have been led to conclude
 that there was apparently neither pronounced contraction  of
 the orifices, nor very considerable valvular insufficiency, and
far less a great hypertrophy  of the arterial system.   Some-
times the opposite characters have caused us to foretejl oppo-. 
[  95  ]
site lesions.   Almost always we  have been able  to discerm
a perfect accordance between the  state of the pulse and that
of the heart;  it  seemed  that the first was but the echo  of
the second.  We have, however, sometimes noticed between
the  two signs a discordance which  became of itself anew.
sign, announcing, for instance, the presence of some obstacle
between the ventricular contraction and the radial pulsation.
(Ons. 19.)
   Have the qualities of the pulse been modified in all of our
cases ?  No, unquestionably  not: and  it is well to be aware
of this practical  truth,  that,  if certain disorders  of the pulse
correspond often  to  certain  lesions  of the heart,  it is no
less  true  that the absence of these first does not necessar-
ly  suppose the  absence  of the, second.  With  some of our
patients the pulse remained  regular up  to the last moment.
This brings us  to  the  reflection,  that  if the ancients—de-
prived, it is true, of such  positive physical signs as more  mo-
dern times and other methods of examination have furnished
lls—considered the pulse as truly the compass of the observer
in the study which now  occupies us ;  that if Corvisart him-
self thought proper to develop  with  so much  pains and so
minutely all the indications  of  the pulse, we must acknow-
ledge that the progress of science has not sanctioned,in every
respect, their confidence and their praise.   Who is there at
the present time  would  dare  to diagnosticate  a lesion of
the heart,  on  account only of the intermissions or irregula-
rities of the  pulse?  Deceptive characters which may coin-
cide with  lesions purely dynamic  or nervous.
   I know  that it has, notwithstanding,, been pretended  that
these signs were capable of specializing  the lesion  of such,
or such of the  orifices,  or  such  valve, and that  thus  an
irrecrular,  unequal, small, intermittent pulse,  announced an
aortic rather  than a bicuspid contraction.   A rapid glance at
our different patients will show us that this law, which in
some cases may be true, is at least not without exception.
   In our twenty-one cases, the pulse has been found more or
less unequal and intermittent,, only seven times, viz: in the
following  cases.
   Hypertrophy without very notable valvular lesion (Obs. 1.)
Pulse of medium developement, unequal, intermittent and ir-
regular.
   Medium hypertrophy.  Thickening of the valves. Cretace-
 ous state of the aorta (Obs. 6.)  Pulse  intermittent, little, de-
veloped, but  hard and vibrating. 
[  96   ]
   Considerable hypertrophy.  Deformation of the valves. Bi-
cuspid insufficiency. (Oits. 11.)   Pulse sufficiently equal,  but
intermittent and disproportioned to the force of the subject.
   Double contraction with biscuspid insufficiency and perhaps
aortic. Pericardiac adherences. (Obs. 13.)  Pulse rather un-
equal and little developed.
   Bicuspid and tricuspid contraction. Bicuspid insufficiency.
Slight aortic thickening. (Obs.  15.) Pulse sufficiently regular,
but rather unequal, of medium developement and not vibrating.
   Dilatation of the right heart.  Aortic vegetations.   Bicus-
pid contraction.  Clots in the heart. (Obs. 19.)  Pulse small,
unequal, intermittent and irregular.
   Narrowness and a little bicuspid insufficiency. Slight aortic
thickening.  Clots in the heart.  (Obs. 20.) Pulse rapid, very
small and unequal.
   Do we not perceive, as a consequence, the intermittence or
inequality  of the pulse coexisting  with the most diversified
lesions, from simple hypertrophy to the most complex valvu-
lar alterations and sanguineous concretions  in the interior of
the heart? and as we  may be asked if, at least in the seven
cases that we have cited, there was not a necessary relation-
ship between the organic lesions and the characteristics of the
pulse, we may  add that  in the  remaining fourteen the pulse
is noted  as preserving its regularity.  I will cite in particular
among them, the bicuspid insufficiency (Obs. 2), thickening of
the aortic  valves without  insufficiency  (Obs.  3), the same
lesion with insufficiency  (Obs. 4), contraction of the two ori-
fices, with  vegetations  of the bicuspid valve and a cretaceous
state of  the aortic valves (Obs. 16), etc.
   We must then recognize the  pulse as a useful auxiliary,
important  even in the study of the lesions of the heart;  but
we should  not on this account exaggerate its importance and
expect from it information which it cannot furnish, and thus
accord to  it a degree  of confidence, to  which other more
precise methods may be  able to challenge a just title.
   I  will, nevertheless, make an exception in favor of one
quality of  the pulse,  of  which  I  have yet said nothing; I
allude to the vibratory tremor, which the sanguineous wave
sometimes presents to us, and that more frequently, it  is true,
in the arteries  adjacent  to the heart,  than in those more dis-
tant. This quality of the pulse coincides very frequently with
the causes  of the purring tremor  (fremissement catoire,)  in
general; or, even in particular with a contraction of the aor-
tic orifice.   (See  especially our observations 5, 12 and 18.) 
[  97   ]
  Let  us  pursue our rational exploration.   We have noted
the pulse of our patient;  let us now uncover his chest and
examine the precordial  region.   I designedly say examine, for
a simple view will furnish us with more than one sign.  These
signs are prominency, displacement of the point of the heart,
and the pulsations of this organ.
  Prominence of the precordial region is not always a mor-
bid phenomenon.  With certain individuals the left mammary
region is more developed and prominent than the right, and
this anomaly may have been congenital or produced by the
oft repeated exercise of the  muscles of that  side, as for in-
stance occurs with left  handed persons.  Again, a precordial
prominency may owe its existence to a deviation of the spi-
nal column ; we perceive, for example, that under the influence
of a deviation of this column in which the convexity is thrown
forward and to the left, the precordial region must become
prominent.  But if it be  true that this prominence is, in certain
cases, without symptomatological  value, there is no reason to
conclude that it is always so.   Almost  constantly in pretty
extensive hypertrophies of the heart, and in hydro-pericardi-
tis, the more or less circumscribed elevation of the precordial
region is an incontestible pathological phenomenon, suscepti-
ble even, although rarely, in the course of certain acute mala-
dies of the centre  of circulation,  of presenting like  precor-
dial dullness itself, a sort  of augmentation and  decline, ap-
mvriable  during a very short lapse of time.
   This precordial prominence, sometimes easily perceived at
first sight, is not always so evident.  In order to be able, not
onlv to verify its existence in doubtful cases, but also to mea-
sure the degree of it, I have caused M. Charriere to construct a
small and very simple instrument, which I have called cyrtome-
tre. It is a plate of steel, surmounted, on its middle part, by a
oraduated scale, along  which a slide glides,  with two  blades,
parrallel to the plate of brass, and  fixed to a certain extent.  It
is  understood that this  instrument can verify a precordial
prominence only  on condition of a previous application to the
right mammary region, varying its application to many  points,
and taking great care,  in the these different applications, to
 employ equal pressure.
   Bv  the aid of these precautions, the cyrtometre has always
appeared to me to fulfill its object properly.   Moreover, the
precordial region which first suggested  the idea of that instru-
 ment to me, Is not the  only point to which it may be applied, 
[  98   ]
for wherever  it may be of practical interest to measure a
limited pathological  prominence, the cyrtometre may be use-
fully applied.
   Displacement  of the point of the heart.  Some  observers
have said that the point of the heart beats,  normally, about
li inches below the nipple.  This localization, true in a good
number of cases, does often fail in fact; and why I  The mam-
ma is  susceptible of very extended  congenital transposition,
especially in a verlical direction.  I have seen the point of the
heart at a distance almost double that indicated, the organ being
perfectly sound. If we desire to adopt the nipple as the mark,
let us take it rather as a lateral limit, and we may then say that
the point of the heart  beats between the nipple and sternum,
nearer to the former, than to the latter: but let us add, as an
essential localization, and almost  infallible, in the fifth inter-
costal space.  This is so exactly true  that many years of close
observation have not  furnished me with a single  exception
to the  rule,  and  although I have sometimes had reason to sus-
pect the existence of an organic affection  of the heart, which
nothing  caused  me to anticipate but that the apex of the
heart presented  itself more without, or lower  than the point
I have indicated^
   Let  us remark that,  in the organic affections proper to the
heart, it  is in both directions or only in one that the displace-
ment occurs.  In other cases lhe morbid  lesion is  generally
seated  elsewhere.  Thus 1 have seen pleural  effusions of  the
left side press  the heart even into the right mammary region.
I have also seen abdominal  tympanetes or ascites,  elevate it
as high as the second intercostal  space; and  that, even, not-
withstanding the coexistence of  a considerable hypertrophy
of the  organ,of which our 10th observation has fuinished us
an example.
  Let  us add, in fine,  that we  do not always see the move-
ments of the apex of the heart, and  that frequently it is only
by a strong  pressure of the finger that we are able to perceive
them.
  This  reflection is not less applicable to the third sign, of
which we are  about  to speak, and which I have indicated as
capable of being presented to us by an inspection of the pre-
cordial region.  I allude to the pulsations of the heart itself.
   With an emaciated subject, and with whom  under the influ-
ence of any  cause whatever, the contractions of the  heart are
accelerated, we will  see the  precordial region  elevated, not
only by the point, hut also, although more feebly,  by the base 
[  99   ]
of that organ.   This elevation may be more  or  less abrupt
and strongly pronounced ;  but, save in morbid cases, it will
be little extended,  generally  circumscribed in a  surface of
from 2s to 3i inches square, at most.  In organic affections,
on the contrary, these pulsations may be much more extend-
ed ; they  may  possibly be felt to an extent  almost double :
they may even  propagate  themselves by means  of the dia-
phragm, to the pit of the stomach, at the same time that their
impulsion raises abruptly and visibly the stethescope, or even
the head of the observer.   The extent of these pulsations is
here the principal fact; their  force  is only a  secondary con-
sideration ; this impulsion,  unless  it exceeds  certain limits,
which practice teaches us to recognize, being compatible with
the physiological condition. Every one knows, in fact, under
the influence of rapid movement, the heart beats strong, as it
is vulgarly termed, but it does  not beat on this account with
a proportionably augmented extent.  These expanded pulsa-
tions  constitute then a morbid phenomenon, and I can say,
that  they characterize essentially, a peculiar state of  the
heart—hypertrophy.  The  same is true of  the preceding
signs.   As for  these, besides the existence of this last sign,
(expanded pulsations,) it is not so necessary  in hypertrophy
that its absence must immediately exclude  the  idea of aft
affection which its presence  characterizes.   This sign may
fail more or less perfectly, and  that  in consequence of  the
embonpoint  of the patient, or  of  the coincidence of  some
other affection, such as effusion, either pleural  or pericardiac;
or even in consequence of  the feeble degree of the hypertro-
phy or the limited energy of the ventricular contractions.
enfeebled by the progress  of  the malady  or  the medication
employed to combat it.
   May I also say that if hypertrophy of the heart is charac-
terized by the extent and vigor  of the pulsations,  that  the
absence  or slight  degree  of energy of these, may be owing
to an opposite  condition, that  is  to say, atrophy, a condition
very  rare, and which the  preceding observations  have not
presented us an instance;  this condition of  the  heart, con-
trary to hypertrophy, existing most frequently  above, and
even supposing, almost necessarily, the absence of all valvu-
lar lesion ?
   Finally, when it is by the application of the hand that  we
appreciate the  pulsations of the heart, a special  peculiarity
may offer itself to  our observation ; I allude to a certain sen-
sation of restraint-, or embarrassment, in the ventricular con- 
[  ioo  ]
 tractions, a sensation difficult to describe, and which, I confess.
 requires for its perception a high degree of practice, but which
 expresses then, to the experienced  hand, the existence of
 pericardiac bridles, or adherences, which obstruct  the move-
 ments of the heart.  I will refer, in  support  of  this remark,
 to our 13th observation in particular.
    If the anormal extent of the pulsations of the heart, in the
 strongest marked cases, may sometimes  conceal itself  from
 our sight, or escape  the  perception of the  hand, there is an-
 other mode of exploration from which hypertrophy cannot, in
 general, remain latent; I allude to percussion.
   Normally,  the  dullness which corresponds to  the presence
 of the heart is from L to2i inches square,  when this dullness
 exists.  I add this reserve ; for very often, percussion, the  most
 cleverly  practiced,  will not encounter  a dull sound in the
 precordial region ; it may be that, the stomach distended  with
 gas, makes, by the clearness of its  resource, the  obscurity of
 the sound that you seek ;  or, that which  is most common, a
 portion of the lung may interpose before the heart, and of suf-
 ficient thickness to produce the same effect.   In morbid cases,
 on the contrary, and especially in rather notable  cases of hy-
 pertrophy of the heart, percussion not only  verifies, but also
 measures, and that often with mathematical  precision, the en-
 largement of the organ.   There is but a small number of  clin-
 ical facts where this mode of exploration has been in default;
 and we have seen  in two cases, among others, how exactly its
 teachings may conform to the results of the  autopsy (see ob-
 servations 7 and 21).  We  have seen that  it was especially
 this anormal dullness which served as data for estimating the
 weight of the heart, a  secondary part of the diagnosis, yet
 often  confirmed after death.  The limits of this dullness have
 varied in our observations between the normal, and 6 inches
 in one of its diameters, (Obs. 19.)  Generally it is  in the trans-
 verse  diameter that we have found the  extent of the dullness
 most considerable.
   Up to the present, and in all that which  preceeds, we see
 only some signs of hypertrophy.  Let us come now to some
 more  profound lesions.  And first,  if we always suppose that
 one of our hands is applied on the region of  the heart, a new-
 sign may yet present itself then to  our observation.   I allude
 to vibratory tremor.
  This phenomenon, signalized for the first time, by Corvisart.
supposes necessarilly, or at  least most generally, as well as
most of the morbid sounds of which we will  speak presentlv
two conditions ;                                        * ' 
[  101   }
   1st.  A certain degree  of quickness and  of volume in the
sanguineous wave, and as a consequence a certain force in the
ventricular contractions.
  2d.   An obstruction, more or less powerful, which imper-
fectly  checks the passage of the blood and augments the col-
lision of its particles.  Let us remark,  in anticipation, that
we will find these  two  same elements in all our  bruits de
souffle.  Thus then if it is not true that  all souffle  supposes
necessarily  a vibratory tremor, it is incontesti'ule,  on the
other hand, that all vibratory tremor necessarily supposes  a
bruit de souffle.
   Vibratory tremor is not a rare phenomenon.   In our twen-
ty-one  cases, we have  encountered it six times  (Obs. 12, 13,
16, IS, 19, 21).   If now we inquire, what are the lesions with
which it coexists,we will perceive that in our observations, they
were constantly either fleshy vegetations  or  concretions at
one of the left orifices, or more  frequently  at both.
   M. Bouillaud  says  that there have been some inexplicable
cases of vibratory tremor of the heart without organic lesion.
It, in this respect, the sign of  which we have just spoken can
sometimes be equivocal,  it will not be thus with those whose
history I am now about  to commence, or rather, resume, and
which  is entirely auscultatory.
   Sounds of the Heart.—The stethescopic minutia) into which
we entered, in relating each individual case, and  the summary
considerations  with  which we  have prefaced our exposition
of facts, might  perhaps  excuse us from the performance  of
our remaining task.   I believe,  however, that the collecting
at present, of all that these practical reflections may offer ot
a  general  character; that the gathering together of  these
disseminate traits, and uniting them in a table which resumes
them,   or  which  may  develop,  will  be adding  to  these
diagnostic studies a useful at least, if not a necessary compli-
ment,  the clinical interest of which may cause  to be forgot-
ten our repetitions and vicious composition.
   I divide into six principal categories, the diverse sounds per-
ceived by our ear when  we auscult a heart.  These sounds
are normal, super-normal, sub-normal, modified,  replaced, or
accompanied.  Let us rapidly  run  over these six  divisions.
   1st I hvisiox.—Normal sounds of the heart.—1 will not here
repeat all that. I said at the commencement of this work, upon
the four causes which seem to me  to contribute to the produc-
tion of these  sounds ; upon the  predominance  of valvular 
[  102  ]
 clacking which our clinical studies have since so fully demon-
 strated ; upon the anatomical reason for the first sound  being
 deeper and longer, and the  second, clearer and shorter, etc.
 I will only recall that of these two sounds1; the first is  heard
 in its maximum below, and a little without the nipple, and the
 second above and within, at the same time  acknowledging
 lhat this difference is often more easily seized in  the morbid
 than  in the normal state-; and  I will advise the student who
 desires to improve himself in the diagnosis of the diseases  of
 the heart,  to auscult carefully, and for a  long time  healthy
 hearts before ausculting diseased ones.  Indeed,  one would
 scarcely believe that the normal heart could be susceptible  of
 slight differences so various and so  difficult to describe, and
 how  much the knowledge of these  various differences  after-
 wards, facilitates the study of anormal sounds.
   One word more, before quitting  the normal condition, or a
stethoscopic peculiarity which I have not seen pointed out any
 where, of which I think it is well to be warned.
   It has happened to me, rarely it is true, only three  times
 during my two  years  of clinique, to hear at the  moment
 when I applied  my ear to the precordial region, a confused
 buzzing sound,  which at first, I did  not know how to explain,
 when, after having continued so long that I thought it my duty
 to noteitinmy  observations,  it disappeared  gradually and
did not return.   This buzzing appeared  to me to be a rumbling
sound, (bruit rotatoire) resulting probably  from  some febrile
contractions  of the pectoral  muscles;  and in fact, the  third
time that I encountered it (it was in a patient attacked  by
 apyretic gastro-intestinal  embarrassment)  after  having use-
lessly essayed the interposition of the stethescope, the suspen-
sion of respiration, etc., I caused the patient to  be seated  at
ease on the bed, the arms supported, and almost immediately
the sound ceased, to reappear no more, and permitting me then
to distinguish the sounds of the heart,  which  were  perfectly
normal.  Of my other two patients, one  was affected  by a
cerebral hemorrhage, in process of resorption,  the other was
a woman with a mixture of hemorrhage and softening of the
left hemisphere, with  partial  meningitis.   I inquired  of my-
self if the rigidity and contraction of the left superior extrem-
ity was not a reason for supposing some  analogous and pro-
found contraction of the  precordial muscles.   But it was not
long before I perceived that this was not a valid hypothesis,
when  I discovered the rigidity of the arm  persisting and my 
[  103   ]
rotatory sound disappearing.  It would be useless to say thai
at the autopsy I found nothing special about the heart.
  Besides the three facts that! have cited, there was another
example of the same sound in our observation 2-1 (see above).
I have specified it in this instance, however, only with doubt,
having been simply  editor of that observation, which dates, as
the reader may perceive, at an epoch much anterior to that of
my entrance  into the service.
  But I have said enough, I think, of a phenomenon  essenti-
ally accessory.  Let us come now to the morbid sounds, prop-
erly so called.
  2d Division.—Sounds super-normal. — The sounds of the
heart may surpass the normal state, Lf I may thus express my-
self, in relation to their clearness, their fullness and force ; in
a word, they may be clearer or fuller than normally.
  The exaggeration in the clearness of these sounds has not al-
          oe
ways a very positive clinical value.  It may be owing to the
thickness of the pectoral  parietes, or to the proximity of the
stomach distended with gas, as is  very often observed  with
chlorotic girls.  Sometimes, however, it is caused by a dilata-
tion of the cavities of the heart, especially if  this dilatation,.
coincide with emaciation of the parietes (passive aneurism of
Corvisart) a rare lesion, considered as coexisting, with that
complete absence of valvular deformation,  that the sound of
which we speak, suppose.   It is more common in a heart or-
ganically affected, for one of these sounds only  to present us
this character of  clearness, and then most frequently  it is the
second.   We conceive  that  this last  being naturally the
smallest of the two, however little the  first sound may be ob-
served pathologically, by  this  fact alone, the contrast between
them  will become sufficiently striking to astonish our ear.
   The stronger and well struck sounds, as they are sometimes
termed, arc not incompatible with the physiological condition.
or at  least with the absence of all organic lesion.   As a con-
sequence o^  rapid  motion,  in some cases palpitation, purely
nervous,  the heart often beats with sufficient force  for the
sounds to feel  necessarily the efleets of the vigor of  the im-
pulsion.   If this be true in cases  where the force of the ven-
tricular contractions is only momentarily exalted, it is so, tor
a stronger reason, where the exaltation is  permanent and
organic—in cases of hypertrophy.  But we will then rarely
be°able to note the sounds of which I now speak, for however
little the valves partake of the hypertrophy of the fleshy tissue
itself, a new shade  immediately presents itself and the sounds 
[  104  ]
are dry and parchment like.   I will refer, for example, to our
1st observation, in which the  sounds were described and
where the autopsy showed us such a feeble thickening of the
valves that we noted it as a case of almost simple hypertrophy.
  3d Division.—Sub-normal sounds.—In this division, diamet-
rically opposite to  the preceding, we may admit two sub-
divisions :  the sounds may become simply enfeebled or en-
tirely null.  We should remark, of course, that in the  latter
event, two conditions are possible : the  heart may cease  to
beat, as for example in complete  syncope: or, its beatings
may be distant from the ear and separated from it by a liquid—
a feeble conductor of sounds.   We  know that  in a consider-
able hypertrophy, the absence of the  sounds of  the heart is
not a symptom less characteristic than  precordial prominence,
the extent of dullness, etc.
  If the sounds, instead of failing entirely, are only enfeebled,
that is to  say, if they are less thrilling and not so strong  as
natural; if they are, as they are then termed, heavy, hoarse,
veiled, or distant, different conditions, either morbid or physio-
logical, are possible;  thus, to begin with these last, the em-
bonpoint of the patient, the interposition of a thick lamina of
the lung or a semi-syncope, are  so  many circumstances that
necessarily effect an enfeeblement of the sounds of the  heart.
And let it not be believed that this is a puerile remark, with-
out practical value : I have very often seen cases where even
a practiced ear was permitted to hesitate in the  interpreta-
tion of the sound of which we speak, between  one of the cir-
cumstances which  we have  cited, and a lesion that we are
now about to particularize.
  These lesions are very various,  and as one may readily
conceive,  many of  them are, in some respect,  indicated  in
advance by the category of the opposite  cases, that we have
studied above.
  Thus if the dilatation of the cavities of the  heart, with
emaciation of its  parietes, may exaggerate to our ear the
shrillness of the sounds of that organ, it is evident  that sounds
entirely opposite must be the result of  opposite anatomical
conditions, the thickness of the walls of  the heart coinciding
or not with the contraction of its cavities;  if simple  hyper-
trophy manifests itself by sounds  forcibly struck, atrophv is
expressed by sounds feebly marked.
   But further, and it  is the first time  since we spoke of the
auscultation of the heart, that the play of the valves, so im-
portant in the stethescopic history of  that organ is presented 
[  105   ]
to us, the beginning endocarditis sometimes enfeebles the val-
vular sounds—renders the valves hoarse, if the expression may
be used ; as if, in this respect, there existed a sort of sympto-
matic analogy between the slight tumefaction of these mem-
braneous veils and that of the vocal cords, the first indication
of a laryngitis.
   We have shown, in the course of our clinical analysis, how
the blood, cut by the tendinous cords of the heart, sometimes
leaves a fibrinous deposite on the interior of that organ, and
especially on the tendons themselves,  or on the valves into
which they are inserted.  This  coagulation, molecular in its
principle, this first  rudiment of fibrinous concretions, which
may become  sufficiently voluminous to  completely obstruct
the play of the heart, also produces a partial extinguishment
of the  vibrations of the valves and deadens their clacking.
   Finally, before a hydrops pericardii becomes sufficiently
abundant to smother completely the sounds of the heart, we
perceive that the first effect must be a gradual enfeeblement
of them, so that they are  heard as if at a distance, which is.
in some  sort, the  prelude, more or less  graduated, of their
complete effacement.
   4th Division.—Modified sounds of the heart.   This modi-
fication may have respect to the seat of  the sounds, to their
tone, to their rhythm, and to their number.
   1st.  Sounds of the heart modified in their seat.—This sub-
division corresponds to the displacements of the heart, may
be either congenital or acquired.  We  know that in congeni-
tal displacements of the heart, the other  organs contained in
the thoracic and abdominal cavities, present the same trans-
position.  As to acquired displacements, they result almost
exclusively from pleural effusions.   I have seen  in our wards.
(St. I de Dieu) a patient with whom, under the influence of
this  cause, the  heart beat  immediately beneath the  right
breast.  I have seen, with another, the heart situated in the
region of the inferior hollow of the sternum.   In these dif-
ferent cases, and the first itself, as  remarkable for the dis-
placement of the heart, would justify us in believing that the
diagnosis would not at first find itself  indicated by the com-
plete absence of the sounds of the heart  in the precordial
region.  This would be an error.  These sounds, on the con-
trary, are often distinct at that point, owing to the propaga-
tion, that I have  seen,  more  than once,  deceive  the  ear,
momentarily, at least, and until a more  prolonged explora-
tion had exactly ascertained, sometimes by ausculation alone. 
[  106  ]
and at others by the inspection and application of the hand,
the anormal point of  departure of these sounds.  Now, 1
specify this  subdivision only as a memorandum, and it is evi-
dent that it  ought not to detain us here.
  2d.  Sounds of the heart modified in their tone.—It may be
thought that this  subdivision is a repetition of those relative
to the  augmentation or  diminution of  the  clearness of the
sounds of the heart, if I did not define the terms and exactly
precise the  spirit of this new subdivision.   When I say that
the sounds of  the heart may be modified in their tone, I do
not intend to express an impression, in  relation to either an
excess or defect of one of the qualities of the sound perceived
by our ear;  I  allude to a new quality, a modification of the
sounds of the  heart, that M. Bouillaud designates under the
name of dry or parchment like sounds:-not, as it is sometimes
believed, that there is the least relationship between this shade
of sound and the parchment or new leather sound, which we
will find  hereafter; but because to an ear,.practiced in aus-
culting the  heart, the sounds then present  a character of
dryness and hardness, analogous to that of the clacking of
parchment valves.
  I do not doubt but the reader, as yet but little accustomed
to our method  of explanation, will consider this remark rather
too minute,  perhaps presumptuous.
   I acknowledge on my part that time and long experience
were necessary to  enable  me to  comprehend the clinical
value of this denomination, and especially to familiarize my
ear to  a shade of sound, sometimes  so difficult to appreciate.
But, I  may add, that to me now, this morbid sound is one of
the most incontestible  that I know,  and  the expression bruit
parchemine  one  of the  most correct  in  our  stethescopic
vocabulary.
   I will say more ; the sound of which we are now speaking
is, in my opinion, one of the best reasons for relying on the
theory of M. Roannet.  And, in fact, the lesion to which this
sound corresponds, a lesion constant and unique moreover, is
nothing else than a thickening of the valves, without defor-
mation ;  neither is  this slight puffing, the  result of a com-
mencing endocarditis, which we have seen above  produce a
hoarseness of  the valvular sounds, but a^> little more indura-
tion without doubt, in these membranous lamina1, a little ex-
aggeration of their nutrition;: in one word, not a congestion
of the valves, but rather their hypertrophy.   I will refer, for.
examples, to our observations 1, 7, 10, etc. 
[  107   ]
  3d.  Sounds of the heart  t&odirjed in their rhythm.—We
nave seen above that the  pulse was susceptible of becoming
unequal, irregular, and  intermittent, which well understood5.
have their point of departure and cause in a sort of corres-
ponding ataxy of the contractions of the heart.   We should
expect, then, to find, in these cases the  same disorder in the
valvular sounds.  And, in fact, these sounds may offer to us,
in their succession and in  their rhythm, quite as many analo-
gous disorders.  They may even offer them yet  more  nu-
merous; and  the reason of this difference is very  clear.  In
order that the  radial pulsation, that kind of  distant echo of
the ventricular systole, may be perceptible under the finger,
it is  necessary that there  should be at the same time a cer-
tain volume of the sanguineous wave and a certain force of
impulsion on the part of the heart.. We conceive  that these
two conditions are necessary in a less degree, in  order that
the result nearest to the systole or even, to the arterial dias-
tole, that is  to say,, the readjustment of the valves,  may
become sensible to  our ear.. Then we will  be able to per-,.
ceive a greater number of valvular sounds, normal  or not,
than we can count  radial pulsations with the fingers.  It is
that which  takes  place, for  instance, in what  M. Bouillaud
has named the faux-pas of the heart, that is to say when the
ventricle, incompletely filled, as a consequence of  an.auricu-
lo-ventricular contraction, beats whilst almost  empty.  It is
that which takes place in false intermittence of the beats of
this organ, that is to  say  when,.instead of  being completely
absent, as in. the true intermittence (stoppage or hesitation of
the heart,) the ventricular systole is only more feeble.  It is
the same that may happen in,those disturbed and ataxic move-
ments  of the heart, when  its beats of unequal force,  and re-
peating at intervals also unequal, present to the ear  nothing
but confusion, tumult, and, if I may thus express myself, a
chaos so much the more  inextricable  at times, as it is  not
rare for the  two times to participate and that thus for  a single
systole there are two or three diastoles, as, in other instances,
for a  single diastole there  may be  two or  three  systolic
movements.
  Disturbances, so pronounced as  these, coincide, we  may
say necessarily, with one or more organic lesions of the heart.
We  have shown in  reference to the  pulse that they cannot
furnish us any positive indication of the species  or special
seat of these lesions.  I will now go farther;  there are some-
of these disorders which  may coexist, with a complete  ab-. 
[  108  ]
sence of these lesions, with palpitations, the result of causes,
purely nervous.  I have  been more than once warned, by
the defect of the rhythm of which I speak, of the existence
of this sort of palpitations with patients who did not Care to
inform me in reference  to them.   In these cases it is in gen-
eral the  intermittence that we observe ; sometimes also there
are  other irregularities, but which seemed,  at least, to  be
subjected to a certain order of periodicity, being reproduced,
for example, in  the state of the usual  calm of the  patient,
often nearly a uniform number of regular contractions. Now,
there is only one secondary  consideration in the differential
diagnosis of these nervous irregularities and those that depend
on organic lesions.  The latter are  always  accompanied by
a train of other symptoms, such as the abrupt, but otherwise
vigorous and massive impulsion of the point of  the heart;
such as souffles  and other morbid sounds, etc., symptoms, the
absence  of which characterises the palpitations which result
from the neuroses.
  4th. Sounds of the heart modified in their number.—In aus-
culting the heart  we sometimes  hear  three and  even,  but
more rarely, four sounds instead  of two.  This peculiarity
is rather curious than  of any  very  notable clinical impor-
tance.   It is not rare, at least for the triple  sound.  Thus
in the wards of M. Bouillaud I have sometimes  seen  two
or three examples  of it  at  the same time.   In almost  all
the cases, that I  have observed the anormal  duplicity  ex-
isted at  the  second time, and  the two  last  sounds were
sufficiently approximated and brief, in relation to the first,
to remind us of the dactyl of the Latin verse, composed as
every  one knows  of one long and  two short.   It is this
triple sound,  this bruit  dactyloide, if I  may  be allowed  the
expression, that M. Bouillaud  has compared to  the roll on
the drum, or to the triple sound of a hammer that rebounds
on an anvil.
  It is with organic lesions of the heart only  that this modi-
fication of the rhythm of the sounds has been observed to co-
incide; but with what particular  lesions ?  This we are not
able to determine in a very  positive manner, M. Bouillaud,
in his  Treatise on the diseases of the heart, says that he has
never encountered  the  rhythm  of three or four sounds, but
with  patients  afflicted with contraction of some one of the
orifices of the heart, with induration of the valves,  accom-
panied ordinarily  with  the sequences of pericarditis.  More
than once-, at the  bedside of the  patient, he  has  appear- 
[  109   ]
ed  to  us  disposed to  refer the triple sound  to  a contrac-
tion of the bicuspid orifice, with  hypertrophy of the  left
auricle, supposing, without doubt, that the auricle contracted
twice on the sanguineous wave intercepted by the narrow-
ness of the orifice, whence resulted  the third sound, which
was necessarily, (and in fact  it is what ordinarily occurs in
the triple sound,) a souffle quite  short.  I  have  among  my
observations only a single  case of triple sound submitted to
an autopsy.  I have cited it above (Obs. 21);  we have there
seen a contraction of the bicuspid orifice and  a hypertrophy
of the left auricle.  I have  seen this same special hypertrophy
existing in the heart of a horse, with which Dr. Leblanc had
many times verified a very distinct triple sound.  These, then,
are facts favorable to the explication that I have given.  But,
on the other hand, how often  have we seen this hypertrophy
of  the  left auricle, with contraction of the bicuspid orifice,
and our own  observations have furnished us more than  one
example of it, unaccompanied by supernumerary sounds.  Can
we say that the quickness of the circulation has been the sole
cause  of this absence ?   For my part, in agreeing that there
have been cases  in which the triple  sound was  really  pro-
duced by the cause that we indicate, the fourth sound appears
to me to have been sometimes also the result of pericardiac
friction, which was added to the  sound of the  first time, I
prefer to say, (and M.  Bouillaud is not far removed from this
idea,)  that these disorders in the rhythms of the sounds of the
heart are the effects of a corresponding disorder in the syn-
chnonism of its usual  sounds, or in  their relative duration, a
derangement that may be owing to a lesion of any one of the
orifices.  Let  us  suppose, in effect, that at the  second time,
for  example, the clacking, normal or not, of the aortic or pul-
monary valves having ceased, a little souffle  still continues,
produced by the retarded  passage of a jet of blood restrained
by the narrowness of an orifice ; evidently this orifice maybe
either the bicuspid, contracted, or the aortic, insufficient.  Let
 us  now suppose, and  I have  seen  examples of it, but more
 rarely, that the  doubling of the first time may be the cause
 of the triple sound, it  is still evident that this doubling of the
 first sound may be the result of insufficiency  of the bicuspid
 orifice, (against which a little bloods till rubs when the clack-
 ing more or less normal, of its valves, has ceased—a clacking
 no°t incompatible with its insufficiency,) or the  tricuspid clack-
 ing ; oftener still it will be the result of contraction of the
 aortic orifice whose souffle, it will  be readily perceived,  may 
[  no  ]
be more prolonged than the bi or tricuspid's  clacking—or
finally, that the left ventricle, contracting at two efforts upon
the column of blood incompletely expelled, the bicuspid valve
thus clacks twice immediately and successively.
  It is well  understood that, in order that  this doubling- of
the times may be perceptible to our ear, it is necessary that
a certain interval exist between this  double time  and the
return of the other;  it is only necessary that the  rapidity in
the succession of the sounds should  not be so great as to
reproduce the simple sound before the double may have been
perceived.   This remark, suggested by reason, is moreover
proved by observation.
  There is, then, no difficulty in accounting for these multi-
plied sounds, and in showing that they weaken in no respect
our valvular theory.   I will go farther; in reflecting on the
possible if  not efficient  duplex conditions of sound, which
naturally prevail at the production  of  each of the sounds of
the heart, that is to say, the simultaneous escape of the blood
by one orifice, and its arrival by another, wre may be aston-
ished that the triple or quadruple sound does not exist more
frequently, if we do not remember the silence that exists
between the two sounds that I  have just pointed out.
   In opposition to this multiple sound, M. Bouillaud has re-
marked that there is often, on the  contrary, unity of the
sounds of the heart, a unity, if not real, at least apparent and
depending upon a two-fold circumstance :
   1st. The existence at one of the times of quite a prolonged
souffle.
   2d.  Brevity of the interval that separates the two times.
   In these cases the souffle absorbs, in some sort, the other
sound, and does not permit it to be appreciated, because it
either still continues or is repeated when the other sound is
produced.   We have, in the observations above cited, speci-
fied many examples of this fact.  We have noted that we
may often be wrong in. supposing the  existence of  a double
souffle, and that a good precaution,, before settling upon this
idea, consists in removing the ear from the precordial region,
in order to ascertain if the  moment will not occur when the
souffle, enfeebled by distance, will not  permit the clacking of
the  other  sound to  be  distinguished.  We may,  but less
promptly,.arrive at the same result, in retarding the move-.
ments of the heart by means, for instance, of digitalis.  By
this means the interval between the two sounds is extended,
and they are rendered distant from  each other. 
[  111   ]
  There does, nevertheless, appear to exist  some cases in
which the  second sound  really fails, the  movements of  the
heart being extremely feeble.   I have observed no such facts.
But M.  Bouillaud  specifies them, and adds that, well under-
stood, the absence of the second sound supposes only a  fee-
bleness  and not  a  complete  failure  of  the  corresponding
movement of the heart—a movement without which we can-
not conceive of the circulation.
  5th Division.—Replaced  sounds  of the heart.—In  all  the
morbid  sounds that we have passed in review up to the pre-
sent point, it was  possible to find and to  recognise, more or
less clearly, the primitive character of the normal sounds of
the heart—the valvular clacking.   In  one word,  all these
sounds  might  be  considered, with  more or less  reason, as
altered  clacking.   In those which are the object of the section
upon which we now enter, there is no more  clacking, or at
least, the clacking, if we still find it, will be no more than an
accompaniment—an accessory often itself unnatural, a sound
altogether of a different nature, both in relation to its sonor-
ous qualities and to its cause.
  And, in  fact, as we  have already said, the valvular clack-
ing is the result of the readjustment and of the vibration of
the valves  of the heart: this new sound  proceeds  most fre-
quently from the  fact that  the valves are no  more able to
readjust themselves or to vibrate properly.  In the clacking
there was a shock of blood against a valve: in the sound of
which we are about to speak  there  is friction of the blood
ao-ainst  this  valve.  Clacking  indicates  to us  only  that  an
orifice closes: this sound indicates in general that the orifice
is not closed.  Clacking has its point of departure only at the
orifice through which the sanguineous wave passes ; this sound
has its point&of departure sometimes in the same orifice badly
closed,  but  more frequently at that through which the blood
escapes, and which is  imperfectly opened.  The seat of  the
first then is single, that of the  second may be  double.  (It is
understood that I  speak here of only one  of the valves of the
heart)   I mean to say that the  indications of the second will
be less easily gathered and less precise at first than the seme-
iosis  of the first.  Every one has, doubtless,, divined  this
morbid  sound ; it is the souffle.  The souffle, primitive y called
bruit de souffle, comprehends all the valvular sounds that now
remain  to occupy our attention.   The veritable proteus of
the stethoscope, it is it which under the influence of such or
such  modification  in the mobility of a valve, in the contrac- 
[  112   ]
 tion of an  orifice, let us rather say, under  the  inspiration,
 more or less happy, more  or less poetic, of the observer,
 that I say we will see it transform itself now into the sound
 of a rasp, then into that of a file or a saw; now flexible and
 soft, anon rude and creaking; sometimes chirping like a young
 chicken, at  others warbling like a turtle-dove, or yelping as
 a little dog, etc.  Let  one not believe  that  all this is but a
 sport of the imagination or unnatural metaphors; no, they
 are, on  the contrary, only faithful translations of impressions
 really perceived—the  veracious  and positive interpretation
 of a sound observation.
   Are we to conclude, hence, that the souffle is a sign easily
 appreciated, which requires only a slight attention, and that
 it strikes the least practiced ear?  This would be an error;
 for, more than all others, perhaps, this morbid sound offers to
 us shades and degrees, we may almost  say, indefinite.   But
 to speak first of the best characterized souffles, of those raspy
 sounds,  if you will, or of the cries imitating those of certain
 animals, these do generally,  doubtless, present themselves
 readily  to our ear.  But who can tell if they occur in  the
 heart or in its envelop, if their seat be not  in the  pleura
 itself, of which the movements are not always so easily sus-
 pended  as some think ?  Who can tell even, in some cases at
 least, to which of the two times of the heart the sound in
 question corresponds ?  And if it is permitted sometimes to
 hesitate thus* when at  least we are assured of the existence
 of this morbid sound, how will it  be with those light, rapid,
 fugitive  souffles, which we must seize on the wing, if I may
 be allowed the expression,and to localize the same; that one
 may so  readily allow to escape, or may confound now with
a slight  grazing of  the pericardium, and then with a pleural
friction, and who  knows but sometimes  even, in a too hasty
 exploration, with one of the vesicular sounds.
  I cannot impress too strongly on those who desire to study
 the maladies of the heart attentively and conscientiously, to
 exercise the ear  to the bruit de souffle, and, as I have  re-
 marked  above, the  best preparation for this is the frequent
auscultation of the normal heart.   And, in the second place,
 and when once the ear knows well what a souffle  is, and of
 what principal shades this morbid  sound is susceptible  it is
 necessary to know how to recognise the special time to which
 it corresponds ; if it is simple or double ;  if it is really or only
 apparently double ; if it does or does not mingle with valvu-
lar clacking, or friction of  the precardium, or pleura, etc 
[  113   ]
Thirdly, and finally, and it is not the point most easily de-
termined, it  is necessary to  ascertain to what  point of the
precordial region the maximum of the souffle, is  to be re-
ferred ; is it heard most distinctly without or within the nipple ?
1^ it towards the point or towards the base of the organ; or
yet towards the left border and in the inferior hollow of the
sternum ?   Finally, does it or not propogate itself into the
ascending aorta and into the carotids ?   We are about to see
that each of these indications has its peculiar value and diag-
nostic bearing; or rather, have we not already seen it many
and many times in our clinical analyses ?   It is here especi-
ally that I would have cause to fear very frequent repetitions
if I had not imposed on  myself very contracted limits, and  if
 I did not remember that 1 ought to resume now rather than
 to develop the practical considerations which  attach them-
 selves to our subject.  Let us then  study the souffle suc-
 cinctly, in each of the times of the heart isolated, and also in
 the two.
   1st.  Souffle ofthe first time.—We must acknowledge  that
  this souffle is often, by  itself, one  of the most insufficient
 signs that we have yet encountered.   In truth it  may  exist
 with  or without organic lesion of the heart. In the first case,
 the cause may be  simply an increased rapidity of the san-
 guineous  column ; I have  spoken of this fact, in the com-
 mencement of  this memoir, with sufficient details   to obviate
 the necessity of recurring to it here.   But most frequently it
 is acompanied by special alteration of the  blood-chlorosis  or
 chloro-anemia.
    Bv what characteristics  shall we recognize the chlorotic
  souffle ?                              ,,.,i-
    Bv the following; like that produced  by quickness,  this
  souffle never exists but at the first time;  it is  generally very
  slight and short;  it accompanies the clacking of the  first ra-
  ther  than masks it; it is heard especially in the region of the
  aortic orifice and  very  often exclusively at this point; some-
  times, in truth, it is propagated  along the ascending aorta,
  and now and then as far as the carotids, but  in these cases,
  it is stronger and not so brief  as I have just supposed  it;
  and, in fact, (I  speak only of chlorosis, properly so called,) it
  may be sufficiently prolonged, intense and even rude enough to
  simulate a souffle  of organic origin: in fine, it is  very often
  inconstant and variable in respect to its intensity and even
  in regard to its existence;  such a souffle, now very distinct,
  may immediately  become entirely inappreciable. 
[  114   ]
   What  is the determining cause of this souffle?   Let  us
 seek, in the characters themselves that we have assigned to it,
 if we cannot encounter some of the elements of this problem.
 We have said that the maximum of this souffle was heard in
 the region of the aortic orifice ; thus, then, is its seat already
 anatomically  fixed.  It exists at  the first time ;  then it is at
 the moment that the sanguineous column passes  this orifice,
 that it is produced.  But, as we have seen, all species of bruit
 de souffle  suppose an excess  of friction;  to what  then can
 this exaggerated friction be owing?   Evidently  we  should
 seek for the reason only in an anormal condition of the san-
 guineous column, or of  the  aortic orifice.  The condition of
 the blood  should first  receive our attention ; for every one
 knows that it is precisely the grave modification that this fluid
 undergoes in its  composition that constitutes the most essen-
 tial element of chlorosis.  Certain observers have dwelt upon
 this point, and they have said :  Physics teaches  us that the
 friction of a fluid is in an  inverse ratio  to its density; then
 blood becoming less dense, such as chlorotic blood,ought to pro-
 duce  more friction ; but they have not anticipated this objec-
 tion, that if it were thus, the friction, and by consequence the
 souffle, ought to cease only  when the blood shall have resumed
 its normal density, and that this  fluid does not momentarily
 vary in its composition, whilst  however the  souffle in ques"-
 tion  has an inconstancy and variability but little  compatible
 with this fixity of chemical constitution.  There remains then
 the aortic orifice.  Do we not find here some possible  condi-
 tions  of narrowness, of contraction, transient, variable and
 intermittent?   Yes! if  we  consider  on one hand, in virtue
 doubtless of the old adage : sanguis frerat nervos,  chlorosis
 is a disease remarkable for infinite  troubles or disorders, essen-
 tially nervous ; and on the other hand, that by means of the
 ramifications of the great sympathetic, which  distributes it-
 self to their coats,  there exists between the arteries and the
 nervous system the most intimate connection, a very frequent
 cause of arterial  disorders  essentially  local.  Hence  those
 flushes of  facial heat, hectic flushes, those circumscribed pul-
 sations now of the carotids and anon of the coeliac trunk, etc.
 Hence those  anomalous arterial  contractions, those spasms,
 those contractions semi-convulsive, variable and very extend-
 ed, like the apparent and external phenomena that I have just
 cited, and like all that, moreover, which is owing to a nervous
 ataxia, and which  will produce here, the bruit de  diable and
its numerous variations;  there, a simple souffle, acoustic phe- 
[  11*   J
nomena so evidently in proportion to the calibre of the vessel
in which they are seated, and of which the shades of differ-
ence are so very  dependent, upon the greater or less contrac-
tion that the tunics of these vessels may undergo.
   In our opinion, then, the chlorotic souffle is  nothing but a
nervous  spasm of the aorta.  It is the bruit de diable of this
large vessel—bruit de diable which does not generally go be-
yond a bruit de  souffle, but which  however  sometimes, in
cases of  chlorosis of the highest degree, of which I have my-
self seen  an example, may extend to  a  musical whizzing ; this
souffle moreover  tending generally to become sibilant, there is
a coexistence of  chlorosis and organic lesion, a cause itself of
a permanent narrowness of the aortic orifice.
   If I insist  somewhat in detail on this chlorotic souffle, it is
because  the  observations that we have  reported, essentially
consecrated  to the study of the symptomatology of the organ-
ic affections  of the heart, offered us  no occasion to particular-
ize it, and that however we might pass in silence a sign which
so nearly affects the study  in which we are engaged, a  sign
which may often present so  high  an  interest in reference to
 the differential diagnosis.
    We can scarcely believe, in fact,  how many errors in diag-
 nosis this souffle daily causes, how many anemice women, or
 young chlorotic girls, in  whom  we every day see combat-
 ting by  repeated vene section, an imaginary  affection of the
 heart, diagnosticated principally from this fatal bruit de souffle,
 of which the treatment itself becomes then, in some sort, the
 best aliment.
    We understand this error when we see it so often renewed,
 or when we know how little habit  of auscultation  so  many
 practitioners bring  to the exercise of their profession.  But
 what I  cannot comprehend—and I  acknowledge that it is re-
 volting  to common sense—is, that there are young writers, so
 very badly  instructed, as to accuse  of a similar blunder, who?
  M Bouillaud himself; M. Bouillaud who has  so often pointed
  out this source  of error ;  these  gentlemen tell  us seriously
  that the pretended lesions of the heart,  which, according to
  this professor, coincide with rheumatism, are  only  simple
  cases of anemia, and that the  souffle  which  diagnosticates
  them is only a souffle of impoverishment of the blood, the
  result of  the medication to which the patient has been sub-

  mBut  we will not dwell any longer on an accusation, all the
  shame  of which must recoil upon those who  have raised )t; 
[  116   ]
we will now pass to the souffle of the first time with organic
lesion.
   Contrary to that of which we have  spoken,  the organic
souffle, located in the first time, is generally more or less pro-
longed;  it may replace entirely the valvular clacking, which
may not really exist, or may not be distinguished  from the
souffle that makes it; like the preceding, its maximum  may
exist in  the aortic region; but contrary to it, it may also re-
spond  more especially  to  the bicuspid orifice ;  like the pro-
ceeding it may be  prolonged into  the ascending aorta, and
along the carotids;  contrary to it,  it does not momentarily
vary, and especially does not entirely cease to exist when it
has been once verified.
   Does  this souffle, separated  from that of  the  other time,
often exist ?  No !  in all our observations, I  perceived it only
in the the third and seventh  thus isolated.  With what lesions
does it especially coexist ?   In the two cases to which I  refer
it was with aortic lesions; valvular  thickening in  the  first,
and a cretaceous state of the aorta in the second.   This  last
lesion, however, is  now frequently expressed by  a souffle of
the second time, or better by a double souffle.  As to the bi-
cuspid orifice, we conceive that the exclusive souffle of the first
time very rarely responds to its alteration.   For what would
then be that lesion or insufficiency ? a lesion but little compati-
ble with the free play of that same  valve, at the other time,
save always the exceptional  circumstance of ,an  insufficiency
owing to a discrepancy between the valves remaining normal
and an enlarged  orifice.
   As we see it, then, and I have more than once made this re-
mark, the time to which a souffle responds does  but  indicate
the orifice diseased.   Here, however, we may say, empirically,
that this will be, ordinarily, the aortic orifice.  Now we may
be assured of this by the seat of the maximum of  the souffle,
and by its propagation into the carotids; the absence of  this
propagation and a  difference of seat indicating to us a lesion
of the bicuspid orifice.  As to the species of  this aortic lesion
we may readily comprehend that it  will always be a contrac-
tion, either absolute or relative.   The last will coincide, for
example, with general hypertrophy, or  with a dilatation of
the left ventricle ;  the first will be  occasioned by a  thicken-
ing of the valves, either by a deposit of cretaceous matter on
their surface, the presence of vegetations on their free border, or
concretions between their lamina.  It is sometimes possible,
in the diagnosis, to discriminate more or less exactly one of 
[  in   ]
the lesions that we have indicated.  Sometimes, for example,
the limit and  acuteness of the souffle gives us, in some sort,
the measure of the contraction.  It is then, according to the
expression of M. Bouillaud, a raspy  souffle.  We  have seen
that when chlorosis coexists, the  souffle may be sibilant.  In
all cases of extreme narrowness, the pulse  moreover comes to
our aid by its smallness and slenderness, if there be vegetations,
and especially of a cretaceous matter on the valves, the souffle
will be less pure in its tone, harsher, less polished, accompanied
often  by a vibratory tremor, that, in fact,  we have more than
once seen in our observations, establish the diagnosis confirm-
ed by the autopsy.  If there are clots only  (they  are  rarely
located at the aortic orifice exclusively,)  the dullness of the
souffle, its variations sometimes, the palpitations and dyspnoea
of the patient, the character of the pulse,  the coldness of the
extremities, etc., will develop to us this morbid peculiarity.
   I have said above, that the souffle, limited  to the first time,
is very rare.  This remark, in my  opinion  incontestible in
cases of rather ancient organic lesions, will be less so as appli-
cable to forming lesions, to those, for example, which  begin
under our observation  during the existence of some acute mal-
ady, most frequently a rheumatism.   Often,  in fact, we are
warned of the imminent peril by a souffle yetslight, and which,
for my part, I have seen more than once then existing only at
the first  time.  How shall we discriminate between this  in-
flammatory souffle—this veritable sign of  endocarditis  and a
chlorotic souffle ?  To an  experienced ear, this souffle has at
first very often  a special tone—a peculiar  stamp  which will
not permit it  to be mistaken.   May  we  then believe in a
chlorosis or anemia; if the patient has been but little or not
at all bled; if  the blood drawn  from the  vein is rich and
openly inflammatory; if it makes more than 5C on the areometre
of Baume, a limit above which the  anemic souffle  cannot be
produced according to the experiments made in the wards of
M. Bouillaud; if this souffle diminishes and  is enfeebled, in-
stead of increasing, under the influence of emissions of blood ;
and,  finally, if the patient's face is strongly and generally col-
ored, his pulse vigorous  and developed, the  impulsion  of his
heart energetic, all circumstances but little compatible  with a
state of chloro-anemia, and especially with the production of
a souffle from impoverishment of the blood; if,above all, we
find the precordial  dullness enlarged, the point of the heart
displaced, etc. ?  These are the cases in  which  some have
dared to assert  that M. Bouillaud mistook an  anemia  for an 
[  118  ]
endocarditis.   Shall we say  that the distinction, of which 1
speak, between the two souffles of the first time is always so
striking?  No!  doubtless, I frankly acknowledge it, there are
some difficult cases;  but what are these  cases?   They are
those, in which the individual copiously bled before our  ex-
amination, or already debilitated by protracted disease, present
at once the  palor of anemia  and the acuteness of  repeated
rheumatism, inflammation of the lungs, etc. It may be the case
with a young chlorotic with whom one of the maladies that
I have cited, declares itself in  an acute form.  Then, in truth,
and only then, will we be  permitted to hesitate, at least  at
first, on the nature of the souffle.  Then we cannot have had
too long a practice, or too  consumate clinical experience  to
surmount this difficult diagnosis.  Then, again, the impartial
and attentive observer, who  may  have long followed  M.
Bouillaud to the bedside of the afflicted, must admire the  ex-
quisite tact and shrewdness in diagnosis of that clever  practi-
tioner, the certainty and penetration of his glance.
   One more thought before we terminate this long paragraph.
Such a souffle may be really simple, that is to say, being actu-
ally produced only in  one of  the  times of the heart, and for
example,  at the first time,  and yet may  appear to us to  be
double, if on the one hand, it  is sufficiently loud  to mark
the clacking which is isochronous, and, on the other, is re-
peated so quickly as not to  permit the ear to seize the sound
that succeeds it.  We have  seen that the  means of  discrimi-
nating between this apparent and real duplicity is simply to
auscult beyond the precordial  region.  A souffle propagating
itself to a less distance than  the  valvular clacking,  will  not
fail, if the souffle be single,  to enfeeble it sufficiently  by dis-
tance, to disengage the  valvular clacking.
   We will now take up the subject of the souffle of the  second
time.
   2d. Souffle of the second time.-—If we are permitted to hesi-
tate, in regard  to an organic  affection  of the heart, because
we only perceive a souffle at  the first time, the same  uncer-
tainty does not attach  to that of the second.  Then there is
always  valvular lesion, an obstacle to the free  play of the
valves.   This first  consideration  already  simplifies, in a re-
markable degree, the history  of this morbid sound, which is
moreover, somewhat sketched  in advance by that of the preced-
ing souffle. Who does not perceive, in fact, that like the former,
the cause of the second souffle  may reside either in the narrow-
ness of an imperfectly  opened  orifice, or in the insufficiency 
[  119   ]
of a valve imperfectly closed.   It is then, still true bere,  that
the sound to which the  souffle responds, no  longer indicates
the injured orifice ; but, however, with  the  addition  of this
remark, which the other souffle has suggested to us, that the
insufficiency of a valve being scarcely compatible, save in the
cases that I have specified, with a disproportion between the
valve and the dilated orifice, with the integrity of the other
sounds, which  the unity of  the souffle supposes;  we will be
led then, to infer from a souffle of the second time, a contrac-
tion of the bicuspid orifice rather than an insufficiency of the
aortic valves ;  always, however, proving this inductive, first
by an appreciation of the anatomical seat of our souffle, and
by absence of  propagation  into the carotids.  As to the par-
ticular kind of valvular lesions that this souffle supposes, what
is the need of indicating them here ?  And what would this
enumeration be, but a repetition of the corresponding part ot
our preceding paragraph, presenting no  other difference  than
a transposition of the two orifices ?
   Further, such  as we will at present consider  it, that is to
say, isolated, the souffle of  the second time  is still more rare
than the first.  I do  not even find it pure from all  mixtures
in any of our observations.  I will indicate, nevertheless, an
example  of  this  souffle, if not  single, relative to  the two
times, at least  so  in reference  to the play of the same valve,
our observation 6 in  which this souffle appears to have  been
produced by the cretaceous state  of the aorta ;  and our ob-
servation 17 where  this souffle, single in  the region of the
bicuspid orifice, corresponded evidently  to the contraction ot
that orifice,  without  mixture of  insufficiency.   We will find
even well indicated,  in this last case, that  character of raspy
souffle that we have  declared to be an almost certain  indica-
tion of the degree of the contraction of the altered orifice.
   Apart  from the sibilant souffle of chlorosis, all the other
shades of the first souffle may  be produced  by this, and diag-
nosticated in the same manner.  I will not then dwell on this
point; less still  will I  insist  on the apparent doubling that
this souffle may present. All that I have said  on this subject, in
reference to the preceding souffle is exactly applicable to this.
   3d. Souffle of both times.—Having studied successively the
souffle of the first time, and that of the second, we are  pre-
pared to comprehend those cases in  which a double souffle is
 the result only of a succession of these two, each  of them
coinciding, by hypothesis,  with  the corresponding  clacking,
 which is only more  or less completely  marked.  Evidently, 
[  120   ]
 in effect, for the history of this fact we can only refer to the
 two preceding histories.   But if this state of things be possi-
 ble ;  if, for example, we may  have simultaneous contraction
 of the two orifices, without insufficiency of either; or, recip-
 reoally double insufficiency  without contraction; we may say
 that it is not common.  1 refer in this matter to our twenty-one
 observations.  Among  them scarcely a tenth could give us an
 idea of this sort of pathological anomaly.   Much more fre-
 quently  the two  souffles  have their cause  in the  double
 lesion of only one of the orifices, or of both, or in the double
 lesion of one accompanied by simple  lesion in the other.  1
 will explain myself by  some examples ; the double souffle be-
 ing very common in organic affections of the heart, our obser-
 vations will furnish them abundantly.
   1st Suppose a single valve  be at the same time, sufficiently
 thickened to effect a certain contraction of the corresponding
 orifice, and so deformed as to  re-adjust itself only imperfect-
 ly ; will  we not then have successively the  souffle of contrac-
 tion and that of insufficiency ?   This is established  by our
 observation. We think the same result will occur if the valves
 adhering either  to each other, (observations 13 and  17,) or
 even partially to the adjacent  parietes of the heart, (observa-
 tions  13 and 15,) offer either a narrow passage, unfavorable to
 the ingress of the blood, or a passage always open, too favor-
 able to its reflux.
  2d.  Let one of  the  two valves  present  this condition  of
 double souffle, the other  may also be altered, but in such a
 manner as  to offer only one of the two morbid conditions of
 which we will speak presently; we will still have a double
 souffle, so much  the more marked, be it understood,  as we
 approach nearer to the  orifice principally affected.  (See ob-
 servation 14.)
  3d. Finally, for a stronger reason,  we hear a double souffle
 if there be  a double lesion of each  orifice.   Our observation
 16 furnishes a beautiful example of it.
  We should remember that the clots in the heart may yet
powerfully  concur in  the  production of a  double  souffle, it
may be by  combining  their influence with that of the valves
already injured, or in constituting  themselves the principal
cause of restraint on the valvular plays.
  Shall I say, in fine, that very often  it is without the heart,
in the aorta itself, in the cretaceous state of its internal mem-
brane, that we must seek the cause of the double souffle that
now occupies our attention ? We have insisted often enough, 
[  121   ]
in view of our facts, upon this pathological circumstance, and
upon  the means of diagnosticating it, to be content  with
mentioning it here.  (See among others, observation 8.)
   Let us close with  a last morbid lesion, a possible but excep-
tional cause of a double souffle.  I allude to an anormal com-
munication  between the  cavities of the right and left heart.
Now  this  case  is so rare that I only  mention it  here as a
memorandum.
   Such are, if  I mistake  not, the  principal  circumstances,
either anatomical or semieological,  that attach to the history
of the bruit de souffle.  A last touch is, perhaps, wanting to
the picture.  We have seen in the  beginning that there were
some souffles possible without organic lesion;  let us now say
that we have seen some organic lesions,  and even some of
those that we have  enumerated, which had existed without
souflle.   How shall  we reconcile this fact with all  that pre-
cedes, and  is it not sufficient  to put in  question  the validity
of our theory ?  No, doubtless this  difficulty is more specious
than real. What is the material physical condition of all kinds
of souffle ?  An excess of friction, as we have said. But in order
that this result may  be produced, who does not perceive mani-
festly that  there is necessary at the  same time, a certain obsta-
cle to the passage of the blood, and  a certain quickness of mo-
tion in this fluid?  Can we consequently be astonished, that,
if sometimes the excess  of quickness  may produce a souffle
in the absence of organic  lesions;  in other  cases also  the in-
sufficiency of this same quickness may have  had  for result the
absence  of souffle,  notwithstanding the  existence  of  these
lesions ?  This is, at least, as frequent and quite as simple to con-
ceive of as the opposite proposition ; and for my part I have had
frequent opportunities to verify its exactitude, at the bedside
of the patient.   I remember,  in particular, one of those with
whom the  pulse diminished most notably  under  the influence
of digitalis: with   him we witnessed repeatedly, the disap-
pearance and return of a souffle  of the second time, coincid-
ing with the administration and suppression of that  medicinal
substance.
   What shall we now say, and where, in fact, is the necessity
of speaking  separately of the sounds of the rasp, of the file,
of the saw? of chirping, etc., which we have specified above ?
Do we not know that all these sounds and all analogous ones
that  may  hereafter  be introduced  into our vocabulary, can
never  be any thing more than shades of the same bruit de souf-
fle, in relationshipwith such or such a degree of valvular indu- 
[  122   ]
   ration or contraction of the orifices ? It is, without contradic-
   tion, the sole special feature in their history, which would  be
   only an useless repetition of that of the souffle properly called.
     And now that we have traversed the details of this vast en-
   semble, can we fail to appreciate all the value of this morbid
   sound, all the  predominance of this symptom ?  Can we not
   comprehend that if other signs, like this, may reveal to us the
   existence of organic diseases of the heart, this alone can ena-
   ble us to penetrate the inmost recesses, indicate to us the ori-
   fice diseased, and show us the lesion; that to it, without any
  doubt, we are indebted in the largest degree,  for our success
  in diagnosis.   How then are we to conceive of  practitioners
  so lagging as to treat, as  chimerical  and fabulous, the legiti-
  mate pretensions of our art in this matter, and who maintain
  that all is yet to be learned in reference to the special  seat of
  the maladies of the heart?  Must we not regard a scepticism
  so blind,  as constituting really a sort of flagrant ingratitude
  for the beneficence of our epoch ?  As  to ourselves, we are
  grateful to her for having furnished us thus a means of explo-
  ration, which  the most precise methods  of surgery  might
  itself perhaps desire.  Thanks  to those of our predecessors,
  I may also say  of our contemporaries, who have endowed
  the service with  so  handsome an  inheritance,  and  let us
  endeavor  to honor their  memory,  not only by  paying to
  their  names a merited tribute of gratitude, but above aff by
  making every day new efforts to fertilize and develop  in our
  hands the treasure that they have bequeathed to us.
    This  brings me to confess frankly, that there exists in these
 clinical researches a  real  void,  so  much  the  more to be
 regretted  as it is difficult to  believe  that we shall  ever
 be able  to fill it properly. I speak of what concerns the local
 and precise diagnosis of affections  of the right  heart.  I am
 aware that it has been said, that these diseases being infinitely
 more rare  than those of the left heart, we may generally, and
 without much risk of error, disregard its diagnosis as of a lesion
 constituting in some sort an exception. But independently of
 the scientific inconvenience  that there may be in this omis-
 sion, reflected upon and empirically calculated, I will make the
 remark, according  to the evidence of our facts  themselves,
 that it is true  that  they are rare,  as primitive and  capital
 lesions, but they are no less sufficiently common as secondary
ones; and to disdain  their solution is to abandon an element
of this diagnostic problem often very worthy  of itself to fb
the attention of the observer. 
[  123   ]
  To what then can this inferiority of the semieological his-
tory of the  right  heart, as compared  to that of the left, be
owing?  To many reasons, without doubt.  Thus first to the
less frequency of lesions of the right side, which for this rea-
son must  be less known ; then because the right being  more
central, in some fashion in regard to its destination, and at the
same time less powerful in its contractions than the left, its
valvular sounds  must be more distant perhaps and  less dis-
tinctly struck ; finally, because its disorders always coinciding
with the more grave  disorders of the left heart,.the morbid
results of the latter readily mark  to our ear those of the for-
mer.
  All these practical difficulties are assuredly grave  ; but are
they insurmountable ?  I think not.   We have ever seen, in
the analysis of our clinical facts, that our efforts at  diagnosis
in that respect have not been altogether unproductive.   Let
us sum them up then in a  few words and  ascertain what is
the actual state  of the science in that respect.
  Certain practitioners have said:  Divide the precordial re-
gion by  an  imaginary  vertical  line; the  morbid  sounds
which predominate on the right side of this line, between it
and the sternum,  will appertain to the right heart, those that
predominate on  the  opposite, side of the line will belong to
the left.  This mode of  exploration is  far from being infal-
lible. That the distinction upon which it rests may be true as
applied to the normal sounds, or when  the sounds of the right
heart are only modified or replaced, I dare not either  affirm
or deny.  But I can say, with an  assurance supported  by nume-
rous observations,  that  when  the left valvular  sounds are
gravely altered,  they engross in  some part our ear, and ex-
clusively absorb our attention, may be  on one  or  the other
side of the line indicated.   I will refer, however, to  our obs.
13  and 14, in which in fact a bruit de souffle, towards the in-
ferior hollow of the sternum, was  noted during life, and a le-
sion of the tricuspid  orifice  verified after death.   But, also,
and in  opposition to those two cases, I  will  refer to obs. 15,
in which  a lesion  perfectly analogous coincides with the com-
plete absence of this special souffle.
   The want of certainty  then in this sign, was a reason for
seeking in others indications more constant and less unfaith-
ful.   These other signs are all more or less the immediate re-
sults of functional disturbances by valvular contractions  oC
the  right heart.. 
[  124   J
  These disturbances affect then, principally, two great func-
tions, respiration and venous circulation.
  If we were permitted to assist at the beginning and to fol-
low all the symptomatic phases of an organic affection of the
right heart,  I do not doubt but the first disorder would be
furnished by the respiratory apparatus, and these by  conse-
quence more  or less generalized  by the stasis of the venous
blood.   But these things do not  occur commonly, and like
the lesions of which I will speak are  consecutive, sometimes
terminal; the  same is true also of the symptoms that they oc-
cassion, showing themselves  only at  an epoch more or less
remote of  the stage  of the disease  and  sometimes only in the
last days  of the patient.
  Now, what I say  of the right heart, ought not to cause us to
lose  sight of the relation,  yet more intimate, perhaps, which
also exists between the lung and the left heart.   This re-
ceiving directly the blood  that the lung  sends to it, cannot
be obstructed in the least degree,  without this arterial stasis
communicating itself gradually to the pulmonary parenchyma.
The right  heart or the contrary sending the blood to the lung,
however little the propulsion may be  suspended, the  nervous
stasis reaches  the  pulmonary parenchyma through  the me-
dium of the vena cava superior into which the veins that have
nourished  the lung itself,  empty, and yet  it is perhaps true in
consequence of this  suspension of  the vis  atergo,  that under
the influence  of the  right ventricle, the venous column exerts
upon the movement  of the blood which has previously reached
the thickness  of the  pulmonary tissue.
  To sum  up, then, we have on the part  of the respiratory func-
tions direct disorders, if I  may  use  the expression, only in
cases of very considerable ventricular  hypertrophy, if certain
valvular conditions  do not  intervene  to  neutralize its influ-
ence either by breaking the sanguineous wave (contraction
of the pulmonary  orifice,) or by turning it from its course
(tricuspid  insufficiency).    These disorders  in  the  lungs, are
sanguineous  effusions, more or  less  extensive, haemoptysis
alone, or  even apoplexy.   At other  times on the contrary,
and this is more common, there is, as  in the preceding cases,
cough and dyspnoea on the least   exercise, but  the lung is no
longer infiltrated with blood, which  is  effused;  it is engor-
ged with  serum,  which speedily  accumulates  at every point
where the venous blood ceases to have a free course,  it be-
comes cedematousi  Then,  also, there soon supervenes many 
[  125   ]
other analogous results, produced by the  same cause; thus
the purple color of the lips,  the swelling of the  face, the
infiltration of the extremities, that often open the scene gradu-
ally, invades  from below upwards the inferior extremities, then
the parietes  of the abdomen, and  even complicating itself
with ascites.   Then also the jugulars  are distended, and we
may note the venous pulse, that  almost  infallible indication
of the retrograde movement of the sanguineous wave, through
the imperfectly closed tricuspid orifice.   I repeat it, to those
who have followed the developement of these different symp-
toms,  added  to some  of  those that indicate to  us tha't the
heart is organically affected, as prominence, displacement
of the apex of the organ, extent of the dullness, etc. the diag-
nosis  of the lesions of the right heart cannot be doubtful: and
I remember that in  a large number of our observations these
were  the  signs  that caused us to admit disorders that  were
demonstrated by the autopsy.
   We should remark, however, that  all  the  signs are only
the results of functional disturbances, effects more or less re-
moved  from  the anatomical  seat of the pathological cause.
Should  we compare, under this view, these signs always indi-
rect,  to the  signs of the immediate product  of that lesion
itself, which  have the same anatomical  seat, if I  may thus
speak, as that lesion to, the morbid  sounds, in  a  word,  in-
herent  to  the   more  or less deranged  play of the diseased
valves ?
   However  we should  note,  en passant,  that  these  were
the signs, par excellence,  before  the discovery of ausculta-
tion.   They were  the characteristic pathognomonic symptoms
of diseases of the heart in general in  the school  of Corvisart,
and many of these constituted, what that illustrious observer
called the  fades propria of the disease, adding that these/a-
cies were the surest guide  of  the practitioner ;  signs  of but
little fidelity, nevertheless,  when we consider them, in  that ex-
tended  sense, since they are, if not exclusively,  at least prin-
cipally  affiliated to  diseases of the  right heart, diseases that
are in general secondary,  and that  in  these  diseases them-
selves they  appear only more or  less  removed  from the  be-
ginning ; we may  say,  that  they sometimes fail altogether;
witness our  17th case, with which  the notable dilatation of
the tricuspid orifice  and  of the corresponding auricle was not
indicated by  any of these signs.
   This  digression, rather lengthy perhaps, but which merited 
[  126   ]
a place in the symptomatological study of the lesions of the
heart,  has caused us to loose sight,  for some moments, of
the categorical order that  we have pursued.  Let  us  then
now return to it and  enter  upon  our  last division  of the
sounds of the heart.
  6th Division.—-Accessory sounds of the heart.—Whatever
may be the tone of the sounds of the heart, whatever may be
the modifications which they  present us, in whatever manner
they may find themselves replaced, it can  so happen, at the
same time, certain other sounds appertaining  either  to the
heart itself or to its serous envelop may present themselves.
We are now about to consider especially the accessory sounds,
at the same time bearing in mind, that  most frequently they
coexist   with one or several of  the morbid  sounds which
we have just reviewed.   One other remark  is common  to
them, it is that  they may all be considered  as finally redu-
cible to the exaggeration of normal phenomena.
  Thus to speak first of the heart itself, normally the point
of the organ strikes,  during its  contraction, the  walls  of
the chest, and this percussion, at least according to our  theo-
ry, does not produce any perceptible sound,  or any that we
can distinguish from the valvular  clacking which is isochro-
nous with  it* but, let us admit that this percussion becomes
exaggerated*  it  may  be from its  quickness,  it may be  by
the mass of the  organ, then  two distinct  sounds  can strike
the  ear.  Sometimes it will   be  a clear, silvery or metallic
tinkle,  called auricuhrmetallic,  not to  indicate, as  I  have
sometimes seen  it supposed,  that the auricle  contributes to
its production, but to distinguish it  from the metallic tinkling
which has its cause in  a lesion of the respiratory apparatus,
or because it is almost  indispensably necessary, to place the
ear  immediately against the chest, to perceive it.
  This  sound is easily simulated  in gently  percussing the
back of the hand, its palm   embracing one  of the ears of
the  experimenter.  This experiment in  explaining  to us the
production of this sound,  at the same  time shows us its lit-
tle  symptomatic value.  What  does it  indicate, in effect,.
except  that the  point of the heart strikes in a hurried,  or in
a sufficiently  distinct manner, a sufficiently  thin pericordial
parietes, whose thickness  is  not of a nature  to destroy its
vibration
 That is to say, and experience proves it, if this phenomenon
can take place in hypertrophy of the heart, it is equally pos^ 
[  127   ]
sible in the absence of this hypertrophy and of all lesion. It is
then an accompaniment  little worthy  of interest, in a prac-
tical point of view.  Let us add, by way of completing  its
history, that  generally  it  is  heard  only  in  the  systole.
Sometimes, however, but by very rare exception, it is double;
when  that  is  the case,  we are compelled to admit that the
base of the heart has a see-saw motion equal to that of the
point.
  If the auriculo-metallie tinkling is  compatible  with a nor-
mal  state, it is not thus of another sound of which I am
to speak, and  which is, we may say, characteristic of hy-
pertrophy, of which it often not only assures us the existence,
but to  some extent even  the degree.   This bruit is a dull, dead
sound, the impression of which often accompanied by a visible,
anormal impulsion,  announces by  its tone and its peculiar
characters the hypertrophy  of the point of the organ.  There
is something pathognomonic in the sensation of  this sound,
which  permits  us to  seperate it easily from the clearest  bruit
de souffle  that we  find connected with it, though  sometimes
it may itself be sufficiently strong partly to mask them.
  The pericardium, is normaly the seat of a serous  exudation,
which, lubricating the inner surfaces of the opposed leaves,
soften  them and facilitate gliding motion,, so that  no percep-
tible friction sound reaches  the  ear.   But let this serous va-
por become suppressed or  condensed ; let the glutinous sur-
face  of the pericardium yield with difficulty to the alternate
movements which oppose one to the other; let them become
roughened, unequal, shaggy; let them be locked by adhesions,
tied  by false  membranes, there will necessarily result new
sound, whose tone is relative to the nature and qualities of
their anatomical cause; there it is a single brushing,  a gentle
rumpling  analogous  to that  of a silken tissue;  here it is a
sound  of rasping*or scraping, more  or less rude; now again
it is  a  sound as of  new leather recalling the analogous variety
of pleural friction,
  All  these sounds are, evidently, only varieties of the  bruit
de frottement, (friction sound,) they constitute the last morbid
accompaniment which  we  have to notice, an, accompani-
ment which it  is not always  easy  at first sight  to perceive.
We  will devote a  few moments to their consideration.
  The pericardiac sounds, whatever they may be, are gene-
rally perceptible during the  two times,, but most especially in
the first;  they axe more superficial  and nearer  the ear than 
[  128   ]
 those of the heart properly  so  called;  they are  somtimes
 accompanied by certain general  or local  phenomena peculiar
 to pericarditis.   Amongst the first I will  recall the febrile
 condition, the anxiety, the agitation of the patient, &c, and
 amongst the second the palpitations,  the irregularities of the
 heart,  and, under  the hand,  a  certain sensation,  either of
 friction, or of difficulty in the movements of the organ, which
 we have mentioned in some  of our  preceding observations,
 (viz. Obs. 13, 14 and 18.)   Sometimes very  loud,  they  can
 mask the valvular sounds, whether they  be normal or anor-
 mal.  At other times,  as when they  are reduced to a simple
 rumpling, they can, on the contrary, escape the most attentive
 ear, or embarrass the most  skilled practitioner, in almost per-
 fectly imitating the bruit de souffle.  I am aware that in  this
 last case, the souffle has been supposed to be caused by a con-
 comitant endocarditis ; but  I know of  some facts, which cause
 me to think that,  independent  of this complication,  a false
 membrane can  of itself give  rise to a bruit analogous, if not
 identical, to that of a souffle, doubtless more superficial, more
 circumscribed, and propagating itself, if I  am not deceived, to
 a less distance;  but in good  faith, not capable  of being ex-
 actly diagnosticated  save in a special habitude.
   The morbid sounds whose   history  we have just written,
 the last  signs belonging to  the auscultatory  domain,  end
 the list  of the different methods  of  exploration, applicable
 to the diagnosis of diseases   of  the  heart.   As we have
 just seen, these  methods are  sufficiently numerous.  Those
 furnished by auscultation being, undoubtedly, the  most  im-
 portant  of them all.    I  have collected  them for  the pur-
 pose  of  facilitating their study and recollection, within  the
 limits of a portable  table,  the habitual  accompaniment  of
 this part of my  course  of  diagnosis. *   To  it then I refer
 the  reader,  as   to  a succinct recapitulation of the more
 developed  of the principles  which we have just  reconsi-
 dered.
   If now  we  cast  a coup d'ceil  upon the various  data
 furnished by stethoscopic and  other signs, must  we not  ac-
 knowledge that of our principal  organs, either intern or  ex-
 tern,  there  is not  one whose diseases are revealed  to  us,
 both  generally and minutely  by not only so numerous but
by  such  precise  signs, that  the heart  is at  the present time
one of  these organs whose diagnosis is most positive and
* Synoptical table of the sounds of the heart. 
[  129  ]
most complete 1   This  conclusion  would doubtless appear,
at first  sight,  very  rash and presumptuous  to certain prac-
titioners,  and such that I should have been cautious about
publishing in the commencement  of this work,  but  which
I now  feel quite  sure  none  of my readers will desire to
gainsay.
   Let us  now pass to the third part of this memoir. 
THIRD  PART.
 Practical application of  the  Diagnosis  of  Diseases  of the
                 Heart  to their  Treatment.

   Though  the diagnostic result of our clinical researches is
 well calculated to satisfy an observing lover  of his art, there
 exists an objection to the practical value of these researches;
 an objection grevious to a friend of humanity,  and which, for
 my part, I have heard repeated so often that  1  would not be
 astonished if it presents itself at this very moment to the mind
 of the reader.  The objection is this.  The organic affections
 of the heart are now, and will always be  beyond the resour-
 ces of medicine.  What then is the advantage of this  nicety of
 precision, and of analysis in incurable  diseases ?   What then
 is the good of ascertaining so perfectly the diagnosis of that
 which you will always fail to cure ?  What is the  advantage
 of your paliative therapeutics,  and your knowledge of the ana-
 tomical seat, or even the nature and degree of the lesion?
   If  all the diseases of the heart offered us these grave defor-
 mations of the valves, or of the orifices, which we have char-
 acterized  by the double souffle,  the  vibratory tremor,  the
 anasarca, &c,  I would not endeavor to rebut  the  whole
 range of this  objection.   Indeed,  without doubt,  in cases of
 this nature, a local diagnosis is of  small importance, when, on
 the one hand the general diagnosis, if I may so  call  it,  is so
 easy ; when on the  other hand, the cure is so evidently  im-
 possible.   But how true  is it that  all of these  cases of disease
 of the heart are identical, under this double relation !  Have
 we not just seen,  in relation to  pericarditis, of how  many
 difficulties its diagnosis was sometimes susceptible?   But will
 it  be said  of pericarditis, that it is one of the  affections, in
 which the physician  can shelter his defective  diagnosis,  be-
 hind the incurability of the disease ?  But  treat  only of the
 heart properly so called,  though pericarditis  associates  itself
without doubt, very intimately with its history;  is it not only 
[  131   ]
in a differential point of view that to all the lesions of this
organ, the terrible decree of Corvisart «• Hceret lateri lethalis
arundo,"  applies itself equally and without appeal ?   Has any
one forgotten  the sanguineous concretions in  relation  to
which there was questions  in  our last  observations ?  It is
true that in almost all of these cases we have seen them followed
by a fatal result.  But can any one  think  that it will be al-
ways so ?   Does any one think that a proper course of medi-
cine  will never  overcome  these kinds of foreign bodies? —
This would be a serious error against which I  can  appeal to
our twentieth observation.   Finally this  practical  fact is of
so much importance  that I  cannot hesitate supporting it here
by two  observations  which  appear definative to me,  and
which will complete the clinical history of this  morbid pro-
duction.
   Observation  22.—Temporary clots of blood in  a  patient
attacked with an organic affection of the heart, and with em-
physema.—An old man aged 61 years, of a strong constitution
 but enfeebled by age, was  brought to the hospital  upon a lit-
 ter, on the 17th of May,  1840.  Having  suffered  for some
 days, and especially at this  time,  with a decided dyspnoea,
 the patient answered my questions with  great difficulty, and
 in a  broken voice.  He said  that he had always  been very
 healthy.   He complained only of a little weakness in his legs
 during the preceding year, and some dizziness  for the  past
 months.   In going up stairs he also felt a little oppression and
 some palpitations.  Since three or  four  days,  this dyspnoea
 has  so  much  increased as to decide him to  come  to  the
 hospital.                                            ni
    Present condition.—His  face was rather pale, his lips bluish,
 as were  also his hands, which were  cold ;  the jugulars were
 dilated, especially during expiration; there was no oedema ot
 the lower limbs.                         .
    His inspirations rapid, not deep, dyspnceie, were 3b to 4J
 per  minute.  The  resonance is quite good over  the whole
 chest  but on both sides of the vertebral column there may be
  remarked a little prominence and  the  respiration  is  accom-
  panied before, and especially  behind, by a mixture of  sibilant
  and even of disseminated subcrepitant rale.
    The pulse is S9 per minute, irregular, intermittent, at one
  time small, at another well developed; there  is no precordial
  prominence.   The dullness is 4| inches in both directions -
  The point of the heart is  felt in the 5th intercostal space but
  obscurely.   Its beats are  of medium force.  Its sounds, from 
[  132   ]
time to time, deep seated, quite dull intermittent,  are never-
theless accompanied,  almost all  the time by a double souffle,
very distinct in all the precordial region, propagating itself even
beyond that, effacing the two clackings in the region of the bi-
cuspid and aortic orifices, continuing itself in the  region of
the aorta, even to the upper  portion of the sternum, but at
this point, permitting  the second beat to be heard, which is
dry, and a little like parchment.   In the  carotids,  the souffle
of the first time  is scarcely heard.   Nothing very remarkable
in the other conditions. I prescribed bleeding of sixteen ounces,
and warm applications to the lower limbs.
   The following morning the state of the patient was almost
the same.   The pulsation  of the heart as it  was  on the
preceding day ;  the  dyspnoea still considerable;  the speech
broken;  the  patient  breathes only when half  sitting up in
bed.
   M. Bouillaud  orders two blisters on  the posterior part of
the chest.
   On the following day the expression was diminished, the
pulse was regular, it became fuller, and its intermissions were
few and  far between, it fell  to 68-72, and the respiration to
20 per minute without any remarkable rale.   The souffle
covers only the first sound, it has lost much of its intensity.
Finally  he says he is well,  and on the first of June demands
his discharge.
   I  think  it is  useless for me to make any long  comments
on this observation.   Who cannot  see that in this patient we
had all the signs of a  medium  hypertrophy of the heart  with
lesion of the left valves and especially of the bicuspid ?  It is
not our purpose  to insist on this  point  of the diagnosis; but
what I assert, is, that independently of  these fixed and   per-
manent lesions, we here had clots of blood temporarily arrest-
ed in the cavilies of the heart, and it is by  them that I ex-
plain this extreme dyspnoea, the anxiety, the coldness of the
extremities, the dilatation of the jugulars, and  the intermit-
tence and  irregularity in  the contractions of the heart, the
pulse at one time small, and at another, more  developed ; it
may be that the bronchial rales will justify us in the  belief of
the existence of  an emphysema.
   Such was my  diagnosis ;  and especially so when the ame-
lioration in the symptoms was so plainly visible, when I com-
pared the souffle  noted towards the end to that  which I  had
verified at the beginning; this  difference having appeared to
me much too decided not to have some other cause than the 
[  133   ]
difference,  comparatively so small, the 8-1 pulsations of the
day of his  entry, and the 72 of the day of his departure.
  Finally,  if this fact may strictly leave some doubts, it will
not be thus with  the following case, which  appears  to me
protected from every objection in  the  point of view which
now occupies us:
  Observation 23.—General hypertrophy of the heart, with
thickening of the valves.—Triple sounds.—Clots of blood in
the heart.—Pulmonary GZdema.
  Antoine  Cambrowne, nineteen years of age, a cabinet ma-
ker by trade, was received  into our service on  the  15th of
January, 1841.
  This patient, of a delicate constitution and lymphatic tem-
perament, said he was attacked two years since, with palpita-
tions, with dyspnoea, upon ascending an elevation, phenomena
preceded, and, to all appearances, caused,  as the patient him-
self said, by a general acute  articular rheumatism, which had
existed  for two  months.  The following are  the  practical
symptoms which  I noticed on his entry:
  No swelling of the face nor infiltration  of the limbs.
  The pulse at 80, of a  medium fullness, with some inequali-
ties or rare intermissions.   Precordial  prominence of two or
three degrees of the cyrtometer.  The  point of the heart
beats in the fifth intercostal space ;  and  this beating extends as
far as the lower portion of the sternum, where the finger feels
some tolerably strong pulsations.   The precordial dullness  is
about 3i inches square.   The impulsion is strong and pretty
well extended.  No vibratory tremor.   In ausculting the pre-
cordial region, one  is struck at first with the hardness of the
two sounds which are dry and like parchment—very distinct,
without a very decided  morbid sound;  nevertheless the  first
sound is accompanied by a sort of roughness or friction, which
somewhat  resembles the souffle, especially so in approaching
the lower  part of the sternum.  No souffle  in  the  carotids:
cough very rare,  two sero-mucous expectorations. Resonance
good throughout.  The same is true of the respiration, which
is nevertheless accompanied, partially,  on  the left and almost
in all the height on the right, behind, by a  moist rale  with
small bubbles, heard only at the end of respiration,  and re-
calling in some degree, crepitant rale.   On the next  day M.
Bouilfaud noted,  in his turn, the following phenomena.   The
pulse 64, tolerably full vibrating, regular, not  double.   The
valvular sounds are rather dull, and at  the same time, loud
without distinct souffle, but they divide themselves clearly into 
[  134   ]
three by the doubling of the second sound.   This triple sound,
well marked in  all the precordial region and the adjacent
parts, is most distinct in the submammary  region.   The same
crepitation a little humid.   The chest is a  little  prominent
behind and very sonorous.   Some glairy, semi-transparent ex-
pectorations without tinge of blood.
  Up to this time nothing is plainer than the diagnosis of this
disease.  We have, without a doubt, general and very consid-
erable  hypertrophy.  We  have, moreover a  fibro-cartilagi-
nous thickening of  the valves without any sensible  contrac-
tions of the orifices, and in the lungs perhaps an inflammation
of the bronchiae with tendency to emphysema.
  Such at least was the diagnosis made by M. Bouillaud who
prescribed, consequently, a bleeding of ten ounces, and cup-
ping on the back, and both sides to the same  extent, some
pectoral ptisans and a portion with tincture of digitalis.
  We remark,  in relation to this diagnosis, that M. Bouillaud,
contrary to his custom, does not point out the left valves as
exclusively affected.  Was it because the rudeness of the first
sound, noted towards the inferior portion of the sternum,  in-
duced him to suppose  that  the  right heart would  naturally
partake of the disease?  I do not know but I  would  be so
much less surprised if  soon after we  see him  diagnosticate
clots in the right cavities especially.   As for myself, I confess
that the lesion  of the right valves appeared to me to be here
a very probable coincidence, and I was even tempted to think
that this lesion  was concerned in the production of the bron-
chial rale, which, in this hypothesis would be rather  a sign of
oedema resulting from a little hindrance of the cardiopulmon-
ary circulation, and would rather be a sign of  oedema  than a
symptom of the bronchitis  with emphysema admitted by  M.
Bouillaud.
  As to the nature of the valvular lesion,  the tone of  the
sounds, and the absence of the souffle did not allow any one
to mistake a considerable thickening of  the laminae, without
deformity, vegetations,  &c,  and  as  M. Bouillaud  said,
without any considerable contractions of the orifices.   I wish
it to be observed in relation to this subject, that we here have
the triple sound; this triple sound may exist without that  bi-
cuspid contraction which I have mentioned above.
   I  will  add  finally  this last  remark,  which confirms those
already made,  viz: that the triple sound  is perceptible onlv
in the condition of a certain abatement  of the pulse;  absent
at the entry of the patient with  eighty  pulsations,  whilst 
[  135   ]
there then  existed especially  in the right  cavities a sort of
raspy friction in the first time; this triple sound displayed it-
self on the next morning,  the pulse having  fallen to 64,  and
the rude sound of the day  before having cleared.
   The phenomena noted the following days sustain this re-
mark, at least as far as it concerns the rasping sound.
   Thus on  the morning of the 15th, the  pulse is at 72, the
triple sound continues, but with a hard and  rude tone. These
are the expressions of M. Bouillaud; the following days the
pulse falls  to 56, and  there is no  longer a question of  this
peculiarity, the triple sound being noted, on the contrarv, as
perfectly distinct.  Finally, under  the  influence of cupping
and bleeding on the back  part of the chest,  the crepitation
disappeared completely; and  on the 20th of January the
patient felt well  enough  to remain out of bed without our
permission during more than three  hours of the afternoon.
   Here commences that part of this observation which especi-
ally interest us, and in fact  in consequence of this imprudence,
the patient, who  had had cold feet,  was seized with consider-
able dyspnoea : and when I arrived to visit him that evening,
I found him suffocating, his respiration  anxious, 36 per mi-
nute, his face and body covered with a profuse prespiration.
the pulse 128 and vibrating, the sounds of the heart distinct
with rude souffle in the first time; the resonance is good over
the entire surface of the chest,  but I heard on both sides, even
in front, a  humid and  abundant crepitation with a mixture
of sibilant rale,  behind and to the left, without pain in the
side, the expectoration purely  mucous.   I  prescribed imme-
diately a  bleeding of twelve ounces and mustard plasters to
the ftet.
   On the morning of the 21st M. Bouillaud noticed the follow-
ing.
   The relief afforded by the  bleeding  was but  momentary.
The oppression and  anxiety are very  great  this  morning:
sleeplessness; abundant sweat  during  the  night;  paleness;
pulse 120,  regular, sufficiently vibrating, and  contrasting by
moderate developement with  the force  of the  beatings of the
heart.   The sounds of this organ are perceptibly more obscure
and more concealed  towards the right than towards the left.
The first is a little rough but without any  distinct  souffle at
this time.   The triple sound no longer exists.  Respiration is
at 40.  Crepitation in the whole chest with tendency to souf-
fle behind, which is owing  to the frequency  and force of the
respiratory movement. 
[  136   ]
  The resonance is tolerably  good throughout.   Expectora-
tion is glary.   The clot of yesterday firm and glutinous and
without buff.  The serosity is somewhat turbid.   Bleeding of
eight  ounces, cupping upon the chest of ten ounces.
  The 22d; the patient is better ;  the dyspnoea and anxiety
have disappeared; the pulse is at 84 and well developed ; the
sounds of the heart less forcibly struck and not so rude ; the
triple sound has not again reappeared ; crepitation less abun-
dant behind, none  before; resonance pretty  good ; the  clot
firm, glutinous and covered with a thin buff; the  rondells of
the cupping glasses are united in a clot of medium resistance.
  The 23d; Improvement continues; the pulse is  at 76 to 80;
return of the triple sound but not so marked as before ; yet a
little crepitation behind.
  The 24th; Patient doing well; triple sound returned ; pulse
at 68.
  The 29th; Being charged with the morning visit, I find our
patient in a state of dyspnoea worse than any  we  had obser-
ved.  Half setting up in bed,  he tossed about, uttering groans
and even cries; his  face  pale and covered  with sweat, as
was also his body;   his lips blue, his eyes half closed, and
his  nostrils dilated.  Respiration at 48.    Crepitation has re-
appeared in the whole chest.   The pulse is small, contracted
at 128 to 132.   The sounds of the heart  were rudely struck,
without notable souffle, owing, perhaps, to the difficulty of
analyzing them, resulting from the excessive quickness.   The
triple sound has disappeared.
  We were told  that this crisis commenced the evening be-
fore,  the  patient  having  eaten an excess of food brought
from  without.
  I presci ibed a bleeding of eight ounces, and blisters to the
interior surface of the thighs.
  The 30th; Continuance of the condition of yesterday, which
has continued  without  interruption.  The pulse, almost im-
perceptible, is  at 108 to 112.   The beats of the heart  strike
the hands with  force.  Nothing new in regard to the sounds
of the heart except that they are notably concealed.   Respi-
ration is still accelerated and very high.  Before as well as
at the back of  the chest there is heard,  throughout, the firm
and humid crepitation before  spoken of.   The extremities are
cold ; the  patient is restless : says he is suffocating.
   Persuaded for my part that he is devoted to an inevitable
death, I  deplored the slowness of the approach of asphyxia;
and not daring to return to blood letting, I ordered two blis- 
[  137   j
ters to the posterior part of the  thorax, mustard plasters  to
the feet, an infusion of Linden-flowers and a potion of asther.
  The 31st; The symptoms are abated.   Patient is stretched
on his bed ;  the pulse is full, regular and at 68  to 72 ;  the
sounds of the heart are perfectly defined;  they are no longer
concealed,  and  in  this respect  they differ singularly  from
those of yesterday.
  M. Bouillaud added then to  his first diagnosis,—■
   Latterly Capilary Bronchitis to the left and diseminated
pneumonia.  Probable concretion of the heart and especially
in the right cavity.
  We will add at once to terminate this history, which has
been rather long perhaps, but the interest of which will pro-
bably excuse the narration, that these crises of dyspnoea re-
turned no more ; but that first an erysipelas of the right arm
and  afterwards  a rheumatismal swelling of the left knee, and
of the right wrist kept the patient in our  service until the 2d
of the following May.   During this stay I noticed many re-
turns of the triple  sounds spoken  of; and I found,  besides,
on the 24th of February, a souffle of the first time in the infe-
rior hollow in the sternum, ceasing to be hard when you pas-
sed  that point.   The 2d of April this sternal souffle is even
accompanied by a distinct purring.  Finally, the 2d of May
the  day  of his discharge, there could yet be  noticed  a souffle
of the first time in the right cavities; and some sounds, very
dry and like parchment in the region of the left cavities.
   What need is there of commenting  on this observation ?
Can not any one tell that it presents to  us a perfect history
 of concretions in the heart.
   And finally,  is not his interest assuredly  very small, who
 does not see, after this fact,  that if clots of blood can  be de-
 posited in the heart before death, it is not less true that, with
 suitable treatement,  they can be  removed  or absorbed, and
 often very quickly?   Of what great importance then  is this
 point of diagnosis to the practitioner ?   Let us remark also
 that in the point of view of the symptomatological study  of
 lesions of the right side of the heart, this  fact is to be  added to
 those we have  pointed out above, in which the morbid sounds
 were heard, especially towards  the lower hollow of  the ster-
 num.                                               .
   Let us also note the gradations presented in our patient m re-
 lation to the constancy and tone by the morbid sound so well
 localized and perhaps responding,  according to  my notion, to
 the  orifice  of  the pulmonary artery, increasing gradation 
[  138   ]
 with him, and to which the sanguineous concretion could not
 have being  foreign.
   I will finally conclude with a last remark.  It is, that I con-
 fess it is difficult for me to explain, with M. Bouillaud, the hu-
 mid and general  crepitation, so ready to reappear at each of
 the crises ;  so ready also to disappear with them, by a disse-
 minated pneumonia and even by a  capillary bronchitis,  an
 affection always  so  tenacious and often so rebellious  against
 the most energetic medications.
   The characteristics of the expectoration,  the  absence of
 dullness  and some previous observations, analogous and veri-
 fied by  autopsy, induced  me to view it rather as a case of
 acute pulmonary oedema,  a disease better known, and more
 observed in general under a slow and chronic form, but, in
 my opinion, not the less real; at other times very rapid  in its
 progress, compromising, in some instances,  the  existence of
 the patient, but also having this  advantage;  that connected
 sometimes, as in the present case, with  a  stoppage,  sudden
 and momentary, of the venous circulation,  it will disappear
 very quickly if the obstacle itself is removed-  This  and the
 preceding observation demonstrate, then, the great practical
 importance  of knowing how to  diagnosticate, and how  to
 separately  oppose,  when necessary, these sanguineous clots,
 an epiphanomenon grave and, it may be said, very frequent
 in the organic diseases of the heart.   But how  much more
 apparent does the importance of this become when we reflect
 that these morbid productions are not less possible in a large
 number of  other  diseases, such as pneumonia,  pleurisy,
rheumatism, &c.; diseases  in which  a daily  examination
 of  the  heart  can   only, very often, give  us  the key  of
 certain febrile conditions which seem to survive their original
 cause and in which every one has so often seen an astonished
examiner recur, for want of a  more  exact  diagnosis, to the
idea, so often chimerical, of a diathesis.
  Again, how much better will this necessity of an exact ap-
preciation of what passes in the heart, be demonstrated to us
if 1 add that in all of these  diseases, frequently, in the place
of sanguineous  concretions, that is to say of disorders  with
very decided physical signs,  we meet, as a complication  of
them,  a  beginning  endocarditis;  the primary  origin of so
many incurable lesions, and which then only reveals itself to
us by signs which a practiced ear alone can catch ; this disease
being, I may say, as difficult to diagnosticate at its commence-
ment as it is important to oppose  at this  period of its devef- 
[  139   ]
opment.   I have at hand very numerous observations corrob-
orating this coincidence between a disease of the heart and
a phlegnasia.  I have even among other facts, not only in my
recollection  but under my eyes at this moment, a  case, the
only  one, it  is true, of a typhoid fever, in the course  of
which an organic souffle announced to us the very unexpected
complication of a disease of the heart.   I cannot relate all of
these  cases,  but will content myself with merely mentioning
them, There is one, however, which I will take as an exam-
ple, because it will offer this curious  peculiarity  which  we
will then perceive  without a possibility of a doubt, a disease
of the heart commencing under our  eyes,  and very  soon,
thanks to  the active treatment  suggested by  its diagnosis,
to disappear  in some way  without leaving  any traces of its
existence.
   Observation 24.—Acute  articular rheumatism;  rasping
souffle at the bicuspid orifice  soon after the entry of the patient.
Chlorotic souffle at his depart ure.
   Edward Papier, a hair-dresser, aged twenty three  years,
was received into  our service on the 25th of May, 1841.
   This young man of an average constitution, of  a lymphat-
ico-sanguineous temperament, was attacked one year since
by an articular rheumatism, general and febrile, which  deprived
him of all movement during seven or  eight  days, and  lasted
six weeks.
   Treated at  the " la Pitie" hospital by bleeding, laudanum,
cataplasms  and opium pills, he was discharged relieved, but
some pains still remaining in the fingers and toes.  He  re-
 mained  besides subject since then to feeling vague pains, and
 experiencing  palpitations whenever the weather changed.—
 Six days before, without any  known  cause,  he was  attacked
 by pains in the two wrists,  which quickly localized themselves
 in the right wrist; accompanied by a little chillness  and feb-
 rile heat.   The following  was  the state  in which  we saw
 him  :
   The ri^ht wrist as well as the hand was of a diffused red-
 ness  and of a temperature manifestly  higher than that of the
 opposite side.  It  presented an evident tumefaction, expressed,
 in comparison with the left  wrist, by  a difference of 2* lines.
 The  subcutaneous veins on  the diseased  side were more prom-
 inent than those of the sound.  The pain  was almost contin-
 ued, very acute and increasing on the least movement.  The
 face  generally quite pale and meagre as Ls also the whole body.
 Nothing remarkable in the  digestive  or respiratory passages.
 The  heat of the trunk is moderate and  a  little  moist.  The 
[  140   ]
pulse is at 96-100, full and vibrating, especially in the  right
radial where  it is preceptibly  more developed  than in the
left.   No precordial prominence.  No  displacement of the
point of the heart—no abnormal dullness.   The  impulsion  is
very distinct, but moderately extended and without vibrating
tremor.   Finally, the sounds of the  heart are  regular, well
struck and very distinct, without souffle—no bruit de diable  in
the carotids.   I prescribed a bleeding of 12 ounces.
  In the morning (26th) the patient feels himself relieved; he
had slept better;  the hand and  the  wrist are  less red, and
rather less swollen; there might be remarked a slight roseolar
eruption towards the middle of the posterior face of the radio-
carpal articulation.  The veins are still developed ;  the pulse
is at 84, tense full, resisting, and, like it was yesterday, evi-
dently fuller in the right than the left; the precordial dull-
ness is perfectly normal;  but in the region of the left cavities
there was heard this morning for the first time a  well marked
souffle, concealing almost  entirely the valvular clacking a lit-
tle rude, rather rasping, perfectly distinct towards  the left
auriculo-ventricular orifice, then diminishing in intensity as the
sternum was approached and even disappearing  almost en-
tirely towards the summit  of the chest, and  then being re-
placed by a very distinct clacking sound.   The  clacking  of
the second time is, on the contrary,  without souffle and dis-
tinct.  No trace of souffle in the carotids  or subclavians,  in
which there was  heard, by propagation, a double  clacking,
the first sound of which is without notable souffle.   No  pre-
cordial pain.   The clot  of  yesterday showed a very thin buff.
The serosity is rather turbid.
  Let us stop  here some moments.  The results of this se-
cond examination were, relatively  to  the  condition  of the
heart, so different  from those of the  day  before,  that M.
Bouillaud desired very much, before dictating that which pre-
cedes, that I should auscultate in my turn ;  and  hardly had I
applied  my ear,  when I heard and announced, in fact, a
souffle of the first time, such as had been  described.  I was
even so much  struck  with its  rudeness, that  not being able
to think that it dated only from the preceding night, 1 attrib-
uted it immediately to the attack of rheumatism which super-
vened one year before, and since  which the  patient had still
some palpitations, presuming that this  souffle had apparently
escaped me the evening before, I even  avowed  this  supposi-
tion to M. Bouillaud, who  repeated it in his public lecture  in
terms too flattering for me to mention here.  And, notwith-
standing this supposition, I only stopped myself with  reluc- 
[  141   ]
tance from denying the existence of a souffle,  the existence
of which so many reasons had induced me, in advance, to ad-
mit and almost positively to assert, when  I thought of the mi-
nute care which I had used the day before,  having decided  only
after  prolonged  examination, and after being well convinced
of its absence.  Finally we shall now see what will happen
from this souffle.
  M. Bouillaud, wishing suitably to oppose  both  the  actual
local manifestation of rheumatism, and the internal inflamma-
tion shown by the fullness and  vibration of the  pulse,  and
the state of the heart itself, recent, perhaps,  and indicated by
the souffle, prescribed a bleeding of 12 ounces, and  cupping
on the wrist and hand of 8 to 12 ounces.
  The 27th, the patient was better ;  he moved his hand much
more easily, and the swelling and redness of it  were again di-
minished.  He,  however, felt some  new pains towards the
shoulders, in the right arm and in the left  fingers.   Besides
this, the heat of the skin was very moderate ;  the pulse, less
tense, less prominent than the day before, had fallen to 72-76.
Auscultation often tried,  could hardly distinguish, at the end
of  the  first time, any vestige of the rasping souffle, which,
the day before,  entirely concealed the clacking.   There was
heard on the contrary  the first  sound well struck, and the
change since yesterday, to use the words of M. Bouillaud,
could not have been greater.  There was no souffle in the
carotids or subclavian arteries.   The clot is very much re-
tracted, with the buff coat a little cupped up, and  of medium
thickness.  The  rondelles are united in a mass tolerably gluti-
nous, and the serosity is not red.
  Could any one doubt even that the souffle of the preceding
dav was not really a souffle of new formation, and the posi-
tive index either of a  begining  endocarditis, having already
thickened the  bicuspid  valve in a manner  to impede its proper
action ; or of some fibrinous  concretions deposited upon the
lamina?, and producing the same result ?   No ! doubtless none
but a morbid sound of very recent date could disappear in so
short a time ;  but this success was also a powerful motive for
following and  completing the cure even at the  risk of impov-
erishing "momentarily the  mass of the blood.  M. Bouillaud
then did not hesitate to order a new  bleeding of 12 ounces,
induced moreover, besides the important  indication I  have
mentioned, by these new pains, vague as yet, but which could
well  show that  the rheumatismal flame was not  yet  extin-
guished. 
[  142  ]
  And, in fact, that which proved to us that this second indi-
cation was as real as the first, was that on the 28th, the pains
of the  left shoulder were  more acute  than on the previous
day.  There has supervened, moreover, a little soreness  of
the throat, with a slight swelling of the right amygdala, a red-
ness of the  pharyngeal  membrane.   The clot  is very  much
retracted with thick and cupped buff.   Nevertheless, the dis-
eased hand and wrist have returned to a normal state.   The
pulse is at 68-72,  and the first sound of the  heart is  even
more distinct.
  This time the only danger which existed was that of a re-
turn of the rheumatism, but even  this was a sufficient motive
for action.   M. Bouillaud therefore ordered a final bleeding of
12 ounces.
  The  29th.   The patient is well; there existed no pain ex-
cept that of a slight sore  throat.   The pulse is at 68; the
first sound is as well struck as the second, without the mix-
ture  of any  distinct souffle.   M.  Bouillaud gave him  some
broth.
  The  30th.   Improvement continues ;  the pulse  is  at 60 ;
nothing new in relation to the heart.
   The  31st.  The pulse is at 60;  there was noticed a very
slight souffle, soft, chlorotic, and terminating  the first sound,
the clacking of which is  very distinct.   This  souffle which
extends in to the substernal aorta, coincides with a well marked
bruit de diable in  the  left carotid.  With this exception the
patient does very well.
   The 15th of June he  demanded his  discharge, being  per-
fectly cured.  There was yet heard a distinct bruit de diable
on the left, in the sitting position  only,  and a  slight souffle,
very distinct but  chlorotic at the first  time of the heart  to-
wards  the aortic orifice, whence it extended into the  subster-
nal aorta.   There  existed no sign of any organic lesion of
the heart.  Is it possible, I ask, to meet a fact more  remark'
able in every respect? and was not each particular of it wor-
thy of interest, even to  this chlorotic souffle, supervening to-
wards  the end of the treatment as if to dispose of itself in fa-
vor of  the organic nature of the rasping souffle which had
preceded it, and to  confound for once more those critics of
whom  I have spoken above, who  assert that M. Bouillaud in
his observations could not well know how to distinguish these
two souffles from one  another?
   I conclusion ; that which I wish to be well observed in this
case is, that instead of knowing how to make a precise  di-
agnosis, M. Bouillaud  has been able to cure an  organic  dis- 
[  143   ]
ease of the heart in its commencement;  that there  are  then
amongst these grave lesions some cases in  which our thera-
peutics are not purely palliative.
   But  without  wishing to dwell  here   for an etiological
discussion,  which would  take  us too  far from our subject,
let us examine our twenty-three  preceding observations  on
the diseases of  the heart, in reference to the  probable cause;
and what do we find ?  Seven times this cause was unknown,
twice it was traumatic, five times a  catarrh or an acute bron-
chitis, and nine  times a iheumatism.  Here then are 16 out of
23 where every thing induces us to believe that an endocarditis,
which doubtless passed  unoticed,  was  the starting point of
these sad diseases becoming at a later date the opprobrium of
our art, which when commencing might have been arrested it
we had known  how, first to diagnosticate, and then to com-
 bat them.
   These practical considerations respond  victoriously to the
objection which we contradict, and are sufficient to sanction
all that our diagnostic studies can seem to offer of scientific
 precision, and, I will say, almost of exaggerated pretensions.
 Who in fact does not understand the usefulness or, I should
 rather say, the  necessity, in cases such as  I have analyzed, ot
 the habit of these special explorations, of these minute analy-
 ses in the  most complex cases, of  which we have shown the
 means and the  result ?
   But I now say more; in exercising ourselves in this kind ot
 diagnosis of the diseases of the heart, whatever may often be
 the symptomatological obscurity   in  which  they  envelop
 themselves, in studying to discover these affections whenever
 they are present, we prepare ourselves even by this, to know
 how to  determine with certainty the cases in which they are
 not, whatever may  be  the functional disorders which seem to
 announce  formally  to us their existence; and in how many
 cases does this negative diagnosis require as  much experience
 as  the  affirmative !  It may be divined that in this place 1
 wish to speak of nervous palpitations,  and in  particular of
 chlorosis, a disease insidious in its symptomatological manifes-
 tations, and which, under different forms, causes inexperienced
 practitioners to imagine it one of the affections of the centre
 of circulation.   Shall I mention in  relation to this, one of our
 most distinguished  apothecaries of Paris, who, believing him-
 self from the opinion of his physician,  affected with an  or-
 ganic lesion of the heart, referred to this cause, very frequent
 palpitations, pains in the precordial region, suffocating sensa-
 tion*, &c,  and in  whom all these  symptoms have disap- 
[  144   ]
 peared two years ago without returning, because I persuaded
 him to  oppose them only by means of antispasmodics, or
 rather because I told him, and I have  been happy  enough to
 make him believe, that his organic lesion was purely illusion-
 ary ?  Shall I mention one  of our chlorotics, received into
 our service and come to Paris to be cured of an hypertrophy
 of  the heart which did not exist, and against which the  prin-
 cipal physicians of one of our northern  cities had expended
 all  the   resources of antiphlogistic  medication, and all the
 pharmaceutic  combinations  of digitalis?
  I cannot tell with how many similar facts I might support
 this demonstration.  I do not exaggerate in affirming that, in
 the two years of my practice, not a week passed without our
 receiving into our service many of the unhappy victims of the
 error in diagnosis of which we speak.  Shall I say also, that if
 simple cases of chlorosis were very often seht  to us as dis-
 eases of  the heart, sometimes, also, in consequence  of an in-
 verse mistake, I  have seen, what is more astonishing, real or-
 ganic diseases  of the heart, very grave and already far ad-
 vanced, sent to us for chlorosis ?
  And it is when like errors happen every day; when some
gave iron in cases which  need  bleeding and digitalis;  when
 others bleed, when, on the  contrary, the  blood  should be
strengthened, that they ask  us what is the advantage of our
 precise studies, and our minute researches upon questions so
 teeming with mistakes not less shameful to the physician than
 dangerous to the patient!   And it is this very class of people,
who err in this way, who  reproach us with wishing to throw
an excess of light, a  superfluous glare, upon the  path which
 they so blindly tread.
  Finally, I believe I have said enough to reduce their objec-
tion to its proper value.  I believe that I have sufficiently de-
monstrated, that, if in presence of certain organic  lesions of
 the  heart we are all now, and ever will be, it is true, equally
powerless, it is not less incontestible that, with the exception,
of these  sad  circumstances, there are yet some therapeutic
palms to cull—more of practical success to attain; and that this
part is large enough to repay us worthily, the pains and efforts
it will cost.
  Happy am I in my own estimation, if I have  thrown any
light, in this memoir, upon any clinical questions; and especi-
ally if I have  stimulated  the zeal of our young practitioners,
for  the diagnostic studies  which constitute, in  my mind, one
of the most beautiful parts of our art. 
 
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