Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . dly pre-systolic, and terminated with the accentuatedfirst sound of the heart, which is clear. In slight steno-sis the accentuated first, sound may only be present, orthe murmur may be temporarily absent when the patientis in bed and the cardiac action is quiet. Second —The murmur is harsh, occurs earlierin the diastole, with marked pre-systolic increase m in-tensity. The pulmonic second sound is accentuated,and there is a tendency to reduplication of the secondsound o
Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . dly pre-systolic, and terminated with the accentuatedfirst sound of the heart, which is clear. In slight steno-sis the accentuated first, sound may only be present, orthe murmur may be temporarily absent when the patientis in bed and the cardiac action is quiet. Second —The murmur is harsh, occurs earlierin the diastole, with marked pre-systolic increase m in-tensity. The pulmonic second sound is accentuated,and there is a tendency to reduplication of the secondsound over the base of the heart and absence of the DISEASES OF THE HEART. 341 second sound at the apex. Change in the second soundat the base or apex is due to increased pressure in thepulmonary artery, with diminished tension in the this stage, when the power of the left auricleis failing, two points of intensity may be noted (doublecrescendo) ; one mid-diastolic, and the other pre-systolic,depending upon the varying force of the blood current.(Fig. 81.) Auscultation of the lung during the early Fig. Mitral tracing of outline of the heart portion of this type shows a slight harshness of therespiratory murmur. Long-continued high tension inthe pulmonary circulation later produces signs ofcardiac pneumonia—brown induration. Third Stage.—In proportion to the feebleness of theleft auricular systole and lowering of the pressure inthe pulmonary circulation, due to failure of right heartcompensation, the murmur loses its characteristic rough- 342 THE CIRCULATORY SYSTEM. ness or disappears. Accentuation of the second soundis absent. The first sound becomes short, sharp andsudden; over the tricuspid area the soft systolic murmurof tricuspid regurgitation may be detected. Over thelungs, failure of the right heart is shown by the physicalsigns of pulmonary oedema and effusion into the serouscavities, as noted under Mitral Regurgitation. Differential Diagn
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