. Medical diagnosis for the student and practitioner. nations.—It is evident that, if pulmonary stenosisand a defective ventricular septum co-exist, the blood, for- the most part,will pass directly from both ventricles to the aorta, and it would seem thatseptum defects and an open ductus arteriosus (ductus Botalli) both, would Open ductusbe necessary to life, as without them only a minimal amount, or, in high-grade stenosis or actual atresia, no blood at all could pass to the lungs. Asa matter of fact, however, though present in 90 per cent, of the cases, ven~ Botalli. MEDICAL DIAGNOSIS Patent
. Medical diagnosis for the student and practitioner. nations.—It is evident that, if pulmonary stenosisand a defective ventricular septum co-exist, the blood, for- the most part,will pass directly from both ventricles to the aorta, and it would seem thatseptum defects and an open ductus arteriosus (ductus Botalli) both, would Open ductusbe necessary to life, as without them only a minimal amount, or, in high-grade stenosis or actual atresia, no blood at all could pass to the lungs. Asa matter of fact, however, though present in 90 per cent, of the cases, ven~ Botalli. MEDICAL DIAGNOSIS Patent foramenorale. trkular septum defects are more often lacking in actual atresia completeclosure) than in stenosis. such instances the lungs are taken care of by a remarkable series ofanastomoses. In nearlv all of such cases the foramen ovale is broadlv defective butin rare instances this also is closed. The ductus arteriosus is nearly always open in atresia but closed instenosis, but it may be impermeable in either, in rare ins tan absent. MirkeiiT. ^^ ^^ j^mir ^TZ /^ ? = g ^ fc=^ . j w 1 Fig. 309.—Pulmonary stenosis inadults. (Sansom.) Shaded area repre-sents field of Tnavimiim intensity. Fig. 400.—Pulmonary point and direction oftransmission. MURMUR.—Time, systolic, representing right ventricular systole andclosure of tricuspid valve. Quality.—Extremely harshT blowing and superficial. Thrill.—Systolic, and present and distinct in the pulmonary area (left2d interspace) 20 per cent, of all cases, absent in nearly all of those presentingventricular septum defect with a closed foramen ovale, and most frequent,relatively, in those with both the auricular and ventricular septum intact.* Maximum Audibility.—Second left intercostal space near edge of be widely heard by reason of its intensity, but is transmitted obliquelyupward to the left clavicle, and downward, over the sternum. It is not conducted into the carotids or heard along the right
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