Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . sonance. In the later stages, with effusioninto the pleural cavity (hydrothorax), flatness is presentover the lower portion of the chest. The percussionarea of the liver is also increased. Auscultation.—The distinctive sign of regurgita-tion at the mitral orifice is a murmur which occurs withthe ventricular systole, accompanies, replaces or followsthe first sound of the heart (Fig. 60), having its pointof maximum intensity at or near the apex, and isdiffused in all directions
Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . sonance. In the later stages, with effusioninto the pleural cavity (hydrothorax), flatness is presentover the lower portion of the chest. The percussionarea of the liver is also increased. Auscultation.—The distinctive sign of regurgita-tion at the mitral orifice is a murmur which occurs withthe ventricular systole, accompanies, replaces or followsthe first sound of the heart (Fig. 60), having its pointof maximum intensity at or near the apex, and isdiffused in all directions, especially to the left, to theaxillary line or beyond. Posteriorly it may be heard inthe left interscapular space, just below spine of scapula.(Pigs. 64 and 65.) DISEASES OF THE HEART. 329 The quality of the murmur is variable. It may beharsh, high pitched and whistling in character, or soft,low pitched and blowing. Some claim that it alwayshas a more or less musical quality. It also changesfrom time to time, and is influenced by posture, being-most marked when the patient is in the recumbentposition. Fig. Mitral regurgitation, second tracing of outline of the heart The quality and intensity of the murmur do not indi-cate the extent nor character of the lesion, which areestimated by the effect upon the heart and changes in thenormal cardiac sounds, and in the circulatory system. First Stage.—In slight regurgitation a murmur maynot be present, but the first sound of the heart at the 330 TBE CIRCULATORY SYSTEM. apex may be prolonged, due to change in the valvularelement (impure first sound). When a murmur accom-panies the first sound which retains its valvular element,the amount of regurgitation is small. The distinguish-ing sign of this stage is the absence of accentuation ofthe second sound of the heart in the pulmonic area, witha normal intensity of the aortic sound; also the absenceof right-side ventricular hypertrophy. Second Stage.—On the other hand
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