Symptoms. 1093 



no particular deviations, becoming weaker only in severe cases. 

 The transmitted systolic murmur may usually be heard also 

 over the larger arteries (carotis, first part of the abdominal 

 aorta). 



Owing to the continued increased blood pressure in the 

 lungs superficial and accelerated breathing is noted, and also 

 bronchial catarrh. The patients are inclined to pulmonary 

 edema. 



(d) Stenosis of the Left Auriculo- Ventricular Opening. 



In a narrowing of the left auriculo-ventricular opening the 

 entrance of the blood from the auricle into the ventricle during 

 the ventricular diastole is impeded, so that a dilatation of the 

 left ventricle is produced with subsequent hypertrophy. But 

 as in spite of the greater work accomplished by the thin-walled 

 auricle it is not capable of preventing the damming up of the 

 blood, the stasis is continued to the right ventricle through the 

 pulmonary veins and arteries. This leads in its turn to an 

 increase of pressure in the pulmonary circulation and to hyper- 

 trophy of the right ventricle, while the left ventricle rather 

 becomes smaller. 



The heart beat and cardiac dullness are the same as in the 

 preceding lesions. Of the heart sounds the first one is clear 

 everywhere, but the second is accompanied by a diastolic 

 murmur which is most marked in the left fifth intercostal space, 

 in the middle of the lower third of the chest (Fig. 193.1). The 

 murmur is not usually loud and either is heard through the 

 entire diastole, being separated from the systole only by a short 

 pause, or only at the commencement, eventually only near the 

 end of the diastole (presystolic murmur). Aside from the 

 murmur the second aortic sound may be, and the second pul- 

 monic sound always is, heard distinctly, the latter being even 

 more accentuated than in mitral insufficiency. The pulse is 

 always small and soft because the left ventricle forces less blood 

 into the aorta. The lungs show the same disturbances as in 

 mitral insufficiency. 



(e) Insufficiency of the Pulmonary Valves. 



In this condition the right ventricle receives blood from 

 two directions during each ventricular diastole, namely, the 

 blood which regurgitates from the pulmonary artery and that 

 which flows in from the right auricle ; and accommodative dila- 

 tation of the right ventricle occurs in consequence of the exces- 

 sive blood supply, which is soon followed by hypertrophy. 



The ventricle does more work than normally and forces 

 an increased amount of blood to a place where the blood" pres- 

 sure is lowered, the blood therefore flows more rapidly into the 



