. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. ge-ment of the liver. Thus farthere was nothing in the ex-amination of the patient toimpress me as unusual. When, however, explora-tion of the heart was begun, Iwas at once struck by the for-cible and extensive cardiacimpulse, which reached fromthe left nipple into the epigas-trium, quite across the medianline to the right costal carti-lages, and as far downward asto the level of the eighth. This was not at once recognised as theimpulse of t
. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. ge-ment of the liver. Thus farthere was nothing in the ex-amination of the patient toimpress me as unusual. When, however, explora-tion of the heart was begun, Iwas at once struck by the for-cible and extensive cardiacimpulse, which reached fromthe left nipple into the epigas-trium, quite across the medianline to the right costal carti-lages, and as far downward asto the level of the eighth. This was not at once recognised as theimpulse of the enormously hypertrophied right ventricle, but bycarefully studying the apex-beat, and by determining the area ofdeep-seated cardiac dulness (Fig. 75), I became convinced that itwas the right and not the left ventricle which was enlarged. Then upon resorting to auscultation I at once distinguished adiastolic murmur, which was located at the left of the sternum inthe third interspace, was transmitted downward, and possessedthe peculiar quality of the aortic regurgitant bruit (Fig. 76).This was quite naturally taken to be aortic, until pondering on. Fig. 76. — Area of Maximum Intensity (.SMALL CIRCLEj AND OF PkOPAGATION OF Murmur in Case of Pulmonary Kegur-GITATION (p. 368). 370 DISEASES OF THE HEART the size of the right ventricle and the smallness of the pulse with-out any suggestion of a collapsing character or of other vascularsigns of aortic incompetence, the conviction was at length forcedupon me that I had to do with pulmonary regurgitation pure andsimple. I may add that both sounds at the apex were clear, while bothsecond sounds at the base were feeble, and both heart-tones wereaudible in the cervical arteries. If secondary tricuspid insuffi-ciency existed, it was not recognised. I do not believe it was pres-ent, but that the enormous hypertrophy of the right ventricularwall prevented such a degree of dilatation as would have beennecessary to set up tricuspid regurgit
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