STETHOSCOPY. 199 



ble and fairly expressive of sounds actually and distinctly beard, for 

 which a verbal rendering is necessary. 



The loudness and clearness of the murmurs are by no means pro- 

 portionally indicative of their gravity ; since one barely audible may 

 from its location and character be a low premonition of mischief, while 

 a more demonstrative one may have no important significance. 



In a rare case, a musical murmur was heard exactly resembling the 

 notes of the cuckoo ; it was so loud as not to be the exclusive prop- 

 erty of stethoscopists, for it could be heard at a distance of several feet. 

 Moreover, it was shown by the " demonstrator," 2^ost longam vitam, 

 that the heart whence the sound had proceeded was entirely free from 

 all organic disease. 



The mechanism concerned and the method of determining the kind 

 and location of a murmur may be referred to very briefly. 



As an example, organic disorder of the aortic semilunar valve will 

 be presumed. Imperfections of this valve are among the more fre- 

 quent diseases of circulation, and are of import more or less serious 

 according to their extent ; its total failure nullifies every anatomical 

 perfection in all the other organs of circulation. 



With the stethoscope suitably placed, a distinctly audible murmur 

 will be detected. On observing the rhythmic succession of " first " 

 and "second" sounds the murmur will be found to occur exactly with 

 or in place of the latter, whose sudden click will at least be notably 

 weakened. The murmur is found over the position of the semi-lunar 

 valve and extending downward in a line toward the middle of the 

 chest ; it is slightly prolonged after the " second sound." No other 

 murmurs are discovered. These are suflicient data for a diagnosis. 



The observer has seen, as it were, two ounces of blood destined for 

 the wants of the system driven through the semilunar gateway into 

 the great vessels ; this movement was accompanied by the normal 

 booming " first sound " and was attended by no murmur. There was, 

 then, no obstruction or narrowing of the orifice, nor roughness of the 

 valve, that by consequent vibrations could produce a murmur. But 

 the observer has seen the measure of blood, under the elastic pressure 

 of the vessels, returned upon the semilunar valve for momentary sup- 

 port, where, instead of being promptly arrested by the three-winged 

 leaflets, a portion passed between their narrowed or irregular edges 

 into the heart, and at this instant of regurgitation the murmur w^as 

 heard. The blood could flow unobstructedly from the heart, but its 

 unfavorable retroversion was made possible by the organic imperfec- 

 tion called insufficiency of the semilunar valve of the aorta. 



The sphygmograph alone would have written the above diagnosis 

 in this uncomplicated case with entire completeness, and its tracings 

 would have shown also, as a part of the pathological history, that the 

 valvular defect originated many months ago ; that, through the natu- 

 ral curative processes the heart had gradually increased in strength 



