. Physical diagnosis . e a very loudone, especially in the recumbent position; it is occasionally au-dible at some distance from the chest, and is often rough andvibrating, sometimes musical or croaking. Its length is unusually16 242 PHYSICAL DIAGNOSIS. great, extending throughout the whole of systole, but to this rulethere are occasional exceptions. The first sound in the aortic re-gion is altogether obliterated, as a rule, and the second sound iseither absent or very (2) The Pulse. Owing to the opposition encountered by the left ventricle inits attempt to force blood into the aorta,
. Physical diagnosis . e a very loudone, especially in the recumbent position; it is occasionally au-dible at some distance from the chest, and is often rough andvibrating, sometimes musical or croaking. Its length is unusually16 242 PHYSICAL DIAGNOSIS. great, extending throughout the whole of systole, but to this rulethere are occasional exceptions. The first sound in the aortic re-gion is altogether obliterated, as a rule, and the second sound iseither absent or very (2) The Pulse. Owing to the opposition encountered by the left ventricle inits attempt to force blood into the aorta, its contraction is apt tobe prolonged; hence the pulse wave rises gradually and late, and fallsaway slowly. This is shown very well in sphygmographic tracings(see Fig. 141). But further, the blood thrown into the aorta by theleft ventricle is prevented, by the narrowing of the aortic valves,from striking upon and expanding the arteries with its ordinaryforce j hence the pulse wave is not only slow to rise but small in. Fig. 141.—Sphygmographic Tracing of the Pulse in Uncomplicated Aortic Stenosis. Comparewith the normal pulse wave and with that of aortic regurgitation (page 174). height, contrasting strongly with the powerful apex beat (pulsusparvus ). Again, the delay in the emptying of the left ventricle,brought about by the obstruction at the aortic valves, renders thecontractions of the heart relatively infrequent, and hence the pulseis infrequent (pulsus ranis) as well as small and slow to rise. Thepulsus rarus, parvus, tardus is, therefore, a most constant andimportant point in diagnosis, but unfortunately it is to be feltin perfection only in the very rare cases in which aortic stenosisoccurs uncomplicated. When stenosis is combined with regurgita-tion, as is almost always the case, the above-described qualities ofthe pulse are greatly modified as a result of the regurgitation. It 1 Occasionally, as noted by W. H. Dickinson, there is a musical murmurof great intensity
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