The signs of internal disease, with a brief consideration of the principal symptoms thereof . s been generally ascribed tothe enlarged left auricle. This is very probably erroneous, the pul- 206 DISEASES OF THE HEART sation being in reality due to the impulse of the conus arteriosus ofthe right ventricle. Engorgement and pulsation of the jugulars indicate failure of theright ventricle to maintain equilibrium. Palpation. The heart impact is diffused and is felt most forciblyin the region to the right of the lower sterniim. Epigastric pulsationis not rare. Palpation furnishes the most definite,
The signs of internal disease, with a brief consideration of the principal symptoms thereof . s been generally ascribed tothe enlarged left auricle. This is very probably erroneous, the pul- 206 DISEASES OF THE HEART sation being in reality due to the impulse of the conus arteriosus ofthe right ventricle. Engorgement and pulsation of the jugulars indicate failure of theright ventricle to maintain equilibrium. Palpation. The heart impact is diffused and is felt most forciblyin the region to the right of the lower sterniim. Epigastric pulsationis not rare. Palpation furnishes the most definite, significant andtrustworthy sign of mitral stenosis. It is the sharp thrill which isfelt over a very limited area whose center^ is the fourth interspacejust within the nipple line. It may extend as high as the third or aslow as the fifth. It is rough and rasping in qualitj^ begins duringdiastole as a purring fremitus, gathers force -with the auricular systole,which is its true cause, and terminates as an abrupt shock with thebeginning of ventricular systole. The sign is pathognomonic. When. Fig. 51—Pulse tracing in a case of mitral stenosis (Patton). not appreciable during repose it may be elicited by slight states that turning the patient upon the left side and elevatingthe arms accomplishes the same result. When compensation fails thethrill disappears and the lesion may be overlooked. With reestablish-ment of equilibrium the murmur returns. Percussion. The increase in percussion dullness is principally tothe right and may extend as far as two inches beyond the the left it seldom extends beyond the^nipple-line and is due for themost part to increase in the size of the right ventricle. The verticalboundaries are also increased and the base-line moves up to the secondinterspace. Auscultation. A rough, vibrating thrill or purr is heard in theapex circle or a little within and above the apex point. In time it isdiastolic and may occupy the entire diasto
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