. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. Fig. 68.—Khythm of Aortic Obstructive Murmur. mitral defect, that percussion detects any increase of absolute andrelative cardiac dulness to the right. Auscultation.—The first sound at the apex is apt to bedull and muffled in conse-quence of the preponderanceof its muscular element, whilethe second tone is likely to beenfeebled. Over the base ofthe heart in the aortic areathe ear perceives a murmurwhich is synchronous with thefirst sound, an
. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. Fig. 68.—Khythm of Aortic Obstructive Murmur. mitral defect, that percussion detects any increase of absolute andrelative cardiac dulness to the right. Auscultation.—The first sound at the apex is apt to bedull and muffled in conse-quence of the preponderanceof its muscular element, whilethe second tone is likely to beenfeebled. Over the base ofthe heart in the aortic areathe ear perceives a murmurwhich is synchronous with thefirst sound, and is thereforesystolic (Figs. 68 and 69).In pure stenosis there is onlythis one bruit, but not infre-quently there is also a dias-tolic murmur due to accom-panying aortic regurgitation. rpi . T T1 j-l,^ Fig. 69.—Place of Maximum Intensity 1 he systolic murmur, like the , . x. ^ .„ ^. ^^ J _ (small circle) and Propagation of thrill, is of variable intensity, Aortic Stenotic 338 DISEASES OF THE HEART but as a rule it is heard with great distinctness, and is of aharsh or grating quality. Its direction of propagation is withthe blood-stream upward into the neck, and it is not rare for thebruit to be audible in the left interscapular region along thecourse of the descending aorta. In exceptional instances whenvery intense it is heard throughout the praecordia, particularlyupon and down the sternum, being sometimes most distinct in theleft third interspace over the anatomic seat of the aortic murmur generally replaces the first tone at the base, and whenthe valves are too stiff and thick to close, the second tone in theaortic area and in the cervical arteries is wanting or so enfeebledas to be merely a rudimentary click. Consequently, in those casesin which the aortic second sound is retained in its normal intensityand clearness, this fact suggests the possibility that the obstruc-tion is situated in the conus arteriosus or at the ostium, the valve
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