. Diseases of the heart and thoracic aorta. icmurmur indicative of regurgitation. In other cases, wherethe stenosis is more considerable, both presystolic and systolicmitral murmurs are present. In others again, a presystolicmurmur is present, but no systolic murmur. When this chapter was written I had not read Dr Galabins instructive paperon the Cardiograph in Guys Hospital Reports, 1875, p. 261. In that paper hevery clearly points out the causation of murmurs of this description, and also statesthat Dr Fagge explained their occurrence by the auricular contraction occurringimmediately aft-ei-
. Diseases of the heart and thoracic aorta. icmurmur indicative of regurgitation. In other cases, wherethe stenosis is more considerable, both presystolic and systolicmitral murmurs are present. In others again, a presystolicmurmur is present, but no systolic murmur. When this chapter was written I had not read Dr Galabins instructive paperon the Cardiograph in Guys Hospital Reports, 1875, p. 261. In that paper hevery clearly points out the causation of murmurs of this description, and also statesthat Dr Fagge explained their occurrence by the auricular contraction occurringimmediately aft-ei-, instead of immediately before, the ventricular systole. Diseases of Heart, p. 139. 488 Diseases of the Heart. (2) Reduplication of the second soitnd.—This condition,which is diagrammatically shown in fig. 201, is probablypresent in at least one-third of all the cases of mitral stenosis,and is of considerable diagnostic value. The different viewswhich have been advanced to explain its production, neednot be again detailed. (See p. 162.). Fig. 201.—Diagrammatic representation of the mu7m2tr and redttplicatedsecond sound in mitral stenosis. (3) Accentuation of the pitlnionary second sound.—This isa most important physical sign in cases of mitral stenosis, forit is to some extent a measure or gauge of the extent of themitral lesion. But this point will be more appropriately con-sidered under the prognosis. (4) Physical signs which are due to alterations in the sizeand shape of the heart.—The left apex is usually ill defined andindistinct, but is not displaced downwards and outwards as itis in mitral regurgitation ; an exception, of course, occurs inthose cases of mitral stenosis in which the left ventricle ishypertrophied either as the result of intrinsic or extrinsiccauses ; cases of this description are however rare. Dulness,or rather an impaired percussion note is sometimes presentover the area of the dilated left auricle, viz., in the second andthird left interspaces
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