. 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. At all events this case illustrates the influence of right heartlesions in the causation of general venous and visceral stasis, whilethe gangrene bore witness to the profound emptiness of the aorticsystem. Physical Signs.—Inspection.—A perusal of Herricks col-lected cases convinces one that there is nothing in the appearanceof these patients to distinguish them from those with mitral dis-ease in the last stages ofbroken compensation. InCase
. 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. At all events this case illustrates the influence of right heartlesions in the causation of general venous and visceral stasis, whilethe gangrene bore witness to the profound emptiness of the aorticsystem. Physical Signs.—Inspection.—A perusal of Herricks col-lected cases convinces one that there is nothing in the appearanceof these patients to distinguish them from those with mitral dis-ease in the last stages ofbroken compensation. InCase 27 of his series venouspulse was noticed, but ordi-narily there is nothing morethan the ocular evidence ofvenous and capillary stasis. Palpation.—The pulse issmall and weak, and may beregular or irregular, and mod-erately or greatly Broadbents case (N^o. 25of Herricks series) the pulsewas reported as 100, small,and irregular, while in EustisSmiths case (No. 29) it wasrecorded as only 60 and small. There is nothing in such statements that might not also apply to the pulse in mitral disease. Palpation of the prsecordia is usu-25. Fig. T3.—Location of Thrill and MurmukIN A Typical Case of Tricuspid Stenosis. 362 DISEASES OF THE HEART ally negative so far as the tricuspid lesion is concerned, but insome instances there may be a short, thumping impulse in the epi-gastrium similar to but distinct from that of the associated mitralstenosis. This was pronuunecd in the case I have narrated. Therewas also a short presystolic thrill in the sulcus between the ensi-form appendix and the left costal cartilages (Fig. 73), which Avasplainly shorter and less distinct than that felt at the apex. Be-tween these two tliere was a space in which no presystolic thrillcould be detected, and it was this fact that first riveted my atten-tion. This short thrill ran u]) to and ended abruptly with thethumping systolic shock mentioned. It is conceivable that, owing to the heart lying
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