172 Disease of the Heart 



the opening after the blood has passed through ; thus, some of it slips 

 back again (regurgitates) when the vis a tergo has ceased to act. 

 There are various ways of expressing this doubly imperfect condition : 

 the valve is ' stenosed ' (orei/os, narrow), and is also ' inadequate ' ; there 

 is 'obstruction' with 'insufficiency' also, and, therefore, regurgitation. 

 Thus there are systolic and diastolic murmurs. An aortic obstruction- 

 murmur occurs during systole, and a regurgitant murmur during diastole. 

 But aortic obstructive and mitral regurgitant murmurs occur at the 

 same time ; so also is it with pulmonary obstructive and tricuspid 

 regurgitant. 



When the aortic or pulmonary aperture is both narrow and in- 

 competent there is a double murmur of obstruction during systole and 

 of regurgitation during diastole ; in the case of the aortic valve the 

 murmur of regurgitation accompanies or even takes the place of the 

 second sound, for the valve-segments have ceased to slam tightly 

 together. So also it would be with the pulmonary valve. 



An auricle and ventricle both being dilated, the fibrous ring to which 

 the bases of the valves are attached is stretched, and, as the valves do 

 not at the same time grow larger, they are necessarily incompetent to 

 prevent regurgitation. 



Disease of the tricuspid valve is so rare that we need not consider 

 the resulting murmur separately ; indeed, valvular disease of the right 

 side of the heart is quite uncommon ; but tricuspid regurgitation may 

 exist without valvular disease (v. z'.). In nineteen cases out of twenty, 

 valvular murmurs belong to the hard-worked left side of the heart to 

 the mitral or aortic orifice, the inlet and the outlet of the left ventricle. 

 The natural inlet has become an outlet also : or the natural outlet 

 is obstructed. (Watson.) 



A cardiac murmur, therefore, most likely exists in the left side of 

 the heart, and, as mitral obstruction is rare, it is either due to mitral 

 insufficiency or to aortic derangement. If the former, it occurs during 

 systole, and if it be due to aortic obstruction it will also be systolic, and 

 heard along the aorta (p. 173) ; if diastolic it will be due to aortic 

 insufficiency and will be heard over a more limited area. 



A tricuspid regurgitant murmur when associated with aortic or 

 mitral disease is a ' friendly' sound, for it means that the right ventricle 

 is pumping some of its belated contents back into the right auricle, and 

 so is lessening the risk of pulmonary apoplexy. It obviously occurs 

 with ventricular systole-r-with the radial pulse ; it is best heard near 

 the xiphoid, but it is of rare occurrence. The murmur of tricuspid 

 obstruction is still more rare, and may be left out of consideration. 



Notwithstanding the ' safety-valve arrangement' at the right aitri- 

 culo-ventricular opening, the energetic action of the right ventricle 

 sometimes throws more strain upon the pulmonary capillaries than they 

 could bear. Thus I have known of an athlete who, though apparently 

 in perfect health and strength, was liable to hemoptysis after any 



