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acoustics. After where to buy avanafil/extendra the observations recorded above had been made, it was found that Malet * had already reeog- * The Physical Differences between Binaural cheap stendra and Uniaural Stetho- scopes. British Medi'dl Journal, 188'2, ii. p. 774. nized and given an excellent synopsis of the physical differences between the two forms of stethoscopes, as regards the transmission of sound in its relation to pressure. Clinical Application of StetJioscopic Pressure. — I can find no definite record of clinical observations upon stendra cost the effects of varied pressure with the flexible stethoscope. The tyro in the use of the instrument is usually merely taught to apply the chest piece as light- ly and evenly as possible to the surface. The only fa- miUar use of varied pressure as an aid to diagnosis is in the discernment of the friction sounds of pericarditis, these sounds being usually intensified and brought nearer to the ear by pressure. Modification avanafil de 100 mg by pressure of the soimds heard generic stendra in auscultation of the blood-vessels has long been a familiar matter. In a clinical lecture de- livered more than forty years ago,* Sir W. Jenner sum- marized all purchase stendra avanafil online the results of varied pressure as performed by the rigid wooden stethoscope. He demonstrated the pressure modification of the mitral-regurgitant murmur at the apex of the heart, and called attention to the dampening effect upon fremitus of pressure upon the cheap avanafil thorax. He quotes a case of a patient having a flexible chest, in whom a pericardial friction murmur was an- nulled by pressure upon the base of the heart, due to the closer approximation of the rubbing surfaces; and he fiilly explained the origin of murmurs avanafil cost caused by pressure over the base of the heart as due to constriction of the pulmonary artery, which is favored by the three conditions — 1, narrowness of the chest from before backward; 2, flexibility of the thoracic parietes; 3, anaemia. Walshe f extensively studied the effect of pressure with the rigid stethoscope, and summarized the re- sults stendra tablets of his observations imder eighteen heads. He found the results of pressure to be more striking with the solid than with the hollow (wooden) stethoscope. buy stendra In I general, the murmur or sound was intensified and raised in pitch by increase of pressure. Walshe J also men- tions that the sound of the heart may be louder over a cavity at a distance from the organ than over the heart itself, on account of the purchase stendra online cavernous resonance. Balfour * states that the distinctness of the heart sound "is probably as much due to the resonating qiialities (thin- ness and flexibility) of the chest wall as to any particu- lar state of the ventricle." The clearest example of order stendra the effect of stethoscopie pressure in modifpng sound in the normal chest is gained by placing the beU of the flexible instrument under the second right generic avanafil costal cartilage close to the sternum, the site of the transmitted sound of aortic closure. Pressure \ipon the chest piece in this region obliterates or greatly reduces the buy stendra online intensity of the sound. * Medical Times stendra online and GfazeUe, 1856, vol. xii, p. 207. f Biseasis of the Heart, 1862, p. 102. X Op. cii., p. 66. » Tfte Senile Heart, 1894, p. 54. Dec. 4, 1897.] SEW ALL: STETnOSCOPIC PRESSURE IN HEART EXAMINATION. 761 Essentially the same effect is produced whether the rim of the bell includes either cartilage or intercostal tissue, though the higher conducting power of the former makes pressure upon it somewhat less effective. Pres- sure applied in this way with the wooden stethoscope, or any instrument having a solid, rigid chest piece, such as the lately exploited " phonendoscope," does not essen- tially diminish the sound. When the bell of the flexible stethoscope is trans- ferred to the region of the apex of the heart, within the area of the cardiac impulse, the results from pressure are quite different. The sound of the heart is maintained, though altered in quality and diminished in intensity chiefly by the obliteration of resonance tones, whatever degree of pressure is used. The vibration from the ven- tricle is in this case conducted by direct contact through the wall of the chest. As stendra price might be expected, the sound, avanafil de 200 mg with pressure, is more fully maintained in expiratory than in inspiratory phases of respiration. In fact, when a deep breath is taken, causing a thick section of lung to separate the heart from the chest wall, or constantly in avanafil 50 mg emphysematous subjects, the first sound is very im-

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