Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . cute endocarditis affecting the mitral valve, or to tem-porary insufficiency resulting from cardiac muscularweakness (myocarditis). It is impossible to determinewhether these murmurs are organic or functional at firstexamination, and their nature can only be decided bynoting the changes that occur in the murmur and theeffect on the heart and circulation. Aortic stenosis may be attended by a murmur that isheard at the apex, with a quality different from thatpresent at the base
Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . cute endocarditis affecting the mitral valve, or to tem-porary insufficiency resulting from cardiac muscularweakness (myocarditis). It is impossible to determinewhether these murmurs are organic or functional at firstexamination, and their nature can only be decided bynoting the changes that occur in the murmur and theeffect on the heart and circulation. Aortic stenosis may be attended by a murmur that isheard at the apex, with a quality different from thatpresent at the base of the heart, and simulating themurmur of mitral regurgitation. This murmur is nottransmitted to the axilla nor associated with accentua-tion of the pulmonic second sound. DISEASES OF THE HEART. 333 Differential Diagnosis.— Exo-cardial murmurs maysimulate those of mitral regurgitation. Pericardialfriction sound may be localized at the apex, and besynchronous with the first sound of the heart. It isdifferentiated from the endocardial murmur by changesin the intensity and character caused by pressure and Fig. Anaemia, systolic murmur in mitral and pulmonary areas. position, and it is not transmitted beyond the apex beatnor heard behind in the interscapular space. Pleuritic friction sounds generally have more or lessof the friction quality, and are influenced also bypressure and position, and their rhythm is more de-pendent upon respiratory than cardiac action. Cardiorespiratory murmurs are also influenced by 334 THE CIRCULATORY SYSTEM. the respiratory movements, being intensified during in-spiration and generally inaudible at the end of expira-*tion. The point of maximum intensity does not corre-spond to the apex of the ventricle, but is somewhatremoved from it. The murmur does not replace thefirst sound of the heart nor change its valvular is also influenced by the position of the patient, beingmost marked in the recumbent position, although this isnot an in
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