Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . Third Stage.—With failure of compensation themurmur at the apex becomes less intense. Its transmis-sion to the left is less marked, while the occurrenceof tricuspid regurgitation causes the murmur to heheard over a wider area to the right, it often beingimpossible to separate these two murmurs: at the sametime the pulmonic second sound diminishes in mitral murmur in some cases may entirely dis-appear, the tricuspid murmur only being heard. Inproportion to the fa
Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians .. . Third Stage.—With failure of compensation themurmur at the apex becomes less intense. Its transmis-sion to the left is less marked, while the occurrenceof tricuspid regurgitation causes the murmur to heheard over a wider area to the right, it often beingimpossible to separate these two murmurs: at the sametime the pulmonic second sound diminishes in mitral murmur in some cases may entirely dis-appear, the tricuspid murmur only being heard. Inproportion to the failure of compensation the physicalsigns of pulmonary oedema and effusion into the pleuralcavities occur. DISEASES OF THE HEART. 331 Diagnosis of the Pathological Condition.—The nature ofthe lesion at the mitral orifice cannot be determined bythe physical signs alone, although these may be in ameasure distinctive. When incompetency is due to arecent endocarditis there is very little change in thesize of the heart, and the murmur is of a soft, blowingquality. When the valves are distorted, thickened, or Fig. Anaemia—systolic murmur in mitral area. perfect coaptation prevented by contraction of thechordae tendinese, due to a previous endocarditis, theeffect upon the left and right heart is more marked, andthe murmur has a harsh, rough and more musicalquality. According to the degree of interference with thevalves, the murmur replaces the valvular element of thefirst sound at the apex. 332 THE CIRCULATORY SYSTEM. - Incompetency due to dilatation of the left ventricle(relative valvular insufficiency) rarely gives a loud,high-pitched murmur. When this condition is secondaryto disease of the aortic orifice, or changes in the arterialsystem, the mitral murmur is much less intense thanthose at the aortic orifice. Age is an important factorin determining the nature of the lesion. Under fortyyears of age, uncomplicated mitral regurgitation isgenerally due to a previous endocard
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