. Diagnostic physique . peu au-dessus de ce point près de l'articulation sterno-claviculaire, mais il n'est en aucun cas rare de le trouver plus bas, c'est-à-dire, les LÉSIONS VALVULAIRES. 241 dans le troisième, le quatrième ou le cinquième interespace droit, et parfois il est entendu à gauche du sternum dans le deuxième ou le troisième espace intercostal, b) le temps du murmure est systolique en fin de systole ; C'est-à-dire, il suit l'impulsion de l'apex à un intervalle appréciable, contrastatingà cet égard avec le murmure systolique habituellement à être entendu régurgitation inmitral, (c) le murmure est généralement largement transmis-ted, souvent étant audible sur

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. Physical diagnosis . little above that point near the sterno-clavicular articulation, but it is by no means uncommon to find it lower down, i.e., VALVULAR LESIONS. 241 in the third, fourth, or fifth right interspace, and occasionally it isbest heard to the left of the sternum in the second or third inter-costal space, (b) The time of the murmur is late systolic ; that is, it follows the apex impulse at an appreciable interval, contrastingin this respect with the systolic murmur usually to be heard inmitral regurgitation, (c) The murmur is usually widely transmit-ted, often being audible over the whole chest and occasionally overthe skull and the arterial trunks of the extremities (see Fig. 140).It is usually heard less well over that portion of the precordia oc-cupied by the right ventricle, while, on the other hand, it is rela-tively loud in the region of the apex impulse, whither it is trans-mitted through the left ventricle. The same line of transmission Maximum intensityof systolic mur- mur and thrill.. Fig. 140.—Aortic Stenosis. The murmur is audible over the shaded area and sometimes oyer the whole chest. was mentioned above as characteristic of the murmur of aortic re-gurgitation in many cases. The murmur is also to be heard overthe carotids and subclavians, and can often be traced over the tho-racic aorta along the spine and down the arms. Until compensation fails the murmur is apt to be a very loudone, especially in the recumbent position; it is occasionally au-dible at some distance from the chest, and is often rough andvibrating, sometimes musical or croaking. Its length is unusually16 242 PHYSICAL DIAGNOSIS. great, extending throughout the whole of systole, but to this rulethere are occasional exceptions. The first sound in the aortic re-gion is altogether obliterated, as a rule, and the second sound iseither absent or very feeble.1 (2) The Pulse. Owing to the opposition encountered by the left ventricle inits attempt to force blood into the aorta, it

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