Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . cle may be noted inthe second and third left interspaces. In the second stage, especially during the early period,the apex beat is displaced upward and to the left, evenbeyond the nipple line. (Fig- 79.) With dilatation ofthe right ventricle there is increase in the area ofvisible apex beat and extension toward the median the disease occurs in early life there may be slightenlargement of the prsecordia. In the third stage the apex beat is diffused and indis-tinct. I
Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . cle may be noted inthe second and third left interspaces. In the second stage, especially during the early period,the apex beat is displaced upward and to the left, evenbeyond the nipple line. (Fig- 79.) With dilatation ofthe right ventricle there is increase in the area ofvisible apex beat and extension toward the median the disease occurs in early life there may be slightenlargement of the prsecordia. In the third stage the apex beat is diffused and indis-tinct. Interference with the pulmonary circulationcauses marked cyanosis of the membranes and a dusky DISEASES OF THE HEART. 337 appearance of the skin. Interference with return cir-culation causes the veins of the neck to become promi-nent, and pulsations are noted when tricuspid regurgita-tion is present. Palpatiox. First Stage.—The apex beat may benormal or slightly decreased in force. Over the apexbeat a thrill may be felt. The characteristic feature ofthe thrill is its sudden termination at the moment that Fig. Displacement of apex upward and to the left in mitral stenosis. the apex beat is felt. The duration of the thrill and itslength will depend upon the degree of obstruction andthe force of the current during different periods of ven-tricular diastole. The pulse may be normal or show slight emptiness ofthe artery. Second Stage.—Hypertrophy of the right ventriclecauses the apex beat to be more diffused. Over the leftintercostal spaces the closure of the pulmonary valves22 338 THE CIRCULATORY SYSTEM. may be felt as a shock. The thrill is more marked. Thepulse may be normal and regular when patient is quiet,becoming irregular on exertion. Third Stage.—With failure of right-side compensa-tion the apex beat becomes more diffused and wave-like,the thrill weaker or absent, or, if present, is felt but fora short time before the apex beat. The pulse is small,irregular, and t
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