. Diseases of the heart and thoracic aorta. cked, and repeatedhaemorrhage is commonly observed. In exceptional cases 550 Diseases of the Heart. included under this group, life may be prolonged for , for example, mentions that in one case of undoubtedcongenital stenosis, the patient attained the age of sixty-fiveyears.^ Third —Cases in which the lesion is slight.—In cases ofthis description, the usual symptoms of congenital heart diseasemay be slight or entirely absent. Years after birth cyanosisand shortness of breath and the other indications of a right-sided lesion may ari
. Diseases of the heart and thoracic aorta. cked, and repeatedhaemorrhage is commonly observed. In exceptional cases 550 Diseases of the Heart. included under this group, life may be prolonged for , for example, mentions that in one case of undoubtedcongenital stenosis, the patient attained the age of sixty-fiveyears.^ Third —Cases in which the lesion is slight.—In cases ofthis description, the usual symptoms of congenital heart diseasemay be slight or entirely absent. Years after birth cyanosisand shortness of breath and the other indications of a right-sided lesion may arise, and are usually due either to the failureof compensation, which has hitherto been perfect, or to theoccurrence of acute endocarditis, bronchitis or some otherpulmonary complication. When the pulmonary stenosis isacquired the same symptoms may arise. Physical signs.—In cases of acquired pulmonary stenosisthe physical signs are:—(i) A systolic murmur having its pointof differential maximum intensity in the second left interspace,. Fig. 230.—Outline figure showing the point of differential maximum intensity ofthe systolic pulmonary murmur, and the direction in which it is propagated. Ziemssctis Cycloltcdia, vol, vi. jx 317. Physical Signs of PiLlmonary Stenosis. 551 or at the junction of the third left costal cartilage with thesternum, and its direction of propagation upwards and towardsthe left (see fig. 230). The murmur, which is in some casesloud and harsh in others soft and faint, is not heard in thecarotids ; a thrill can in some cases be felt over the positionof the murmur. (2) A faint or inaudible pulmonary secondsound \ in those cases in which the valve is incompetent aswell as stenosed, a diastolic, as well as the systolic murmur, ispresent. (3) Increased dulness over the right heart, and theusual indications of right-sided hypertrophy and dilatation.(4) Fulness of, and in some cases pulsation in, the superficialveins, the external jugulars for example, toge
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