The signs of internal disease, with a brief consideration of the principal symptoms thereof . n occurs, then its auricle suffers and involvesthe right heart in the same order as was involved the left. With theleft ventricular dilatation comes enlargement of the mitral ring, andrelative incompetency of that valve. InspecMon. Even when considerable hypertrophy is present theapex impulse may be invisible, or if visible, may be feel^le. Moreoften, however, it is slow, forceful and heaving. It is displaced down-ward and outward into the sixth or seventh interspace. In old men considerable emphysema
The signs of internal disease, with a brief consideration of the principal symptoms thereof . n occurs, then its auricle suffers and involvesthe right heart in the same order as was involved the left. With theleft ventricular dilatation comes enlargement of the mitral ring, andrelative incompetency of that valve. InspecMon. Even when considerable hypertrophy is present theapex impulse may be invisible, or if visible, may be feel^le. Moreoften, however, it is slow, forceful and heaving. It is displaced down-ward and outward into the sixth or seventh interspace. In old men considerable emphysema of the lungs is present and DISEASES OF THE HEAi^T 215 serves to obscure the impact as well as to diminish the area of The impulse may be impalpable and feeble, or force-ful owing to causes given. The chief diagnostic symptom is the pres-ence of a well-marked thrill felt over the base of the heart, and cen-tering over the aortic region. It occurs with systole and may be ofgreat intensity. In some cases it may be felt with diminished inten-sity over the apex. (Anders.). Fig. 58—Mitral presystolic murmur, arsa and direction. Percussion. The area of dullness is increased transversely, b\itnever to the extent found in aortic insufficiency. Usually the areaas marked out by percussion falls much within the true cardiacboundaries, owing to the masking of the dulljiess by the emphysema. AuscuUation. A_harsh, loud, prolonged murmur is heard, syn-chronous with each systole. Its point of greatest intensity is either thesecond right or the second left interspace close to the sternum. Thesecond sound is obscured or more generally absent, since the lesion so 216 DISEASES OF THE HEART thickens and stiffens the valve leaflets as to prevent their closure. Asthe ventricle loses power with dilatation, the murmur softens in toneand late in the disease may disappear. Associated leakage and roughening are manifested by the some-times present diastolic murmur causing a see-saw
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