Disease of t/ic I f carl 



creases the amount of the refluent blood. The regurgitation murmur 

 occurs immediately after the radial pulse, that is during ventricular 

 diastole, and is heard at the second right cartilage, over the valve, 

 along the left sternum, and down to the apex, replacing, possibly, 

 the second sound, or all of it but that which is due to the slamming of 

 the pulmonary valves. Now, for some obscure reason the regurgitating 

 blood does not always carry this murmur down to the apex, but, throwing 

 the sternum into vibration, it is well heard over that bone, for the 

 sternum is a good conductor of sound. When the regurgitation con- 

 tinues until the ventricle is actually ready to contract again the 

 murmur lasts until the first sound. This means that a little blood is 

 squeezing its way back during the whole time that the aortic valves 

 are shut. When the regurgitant murmur is a short one the valve 

 must be desperately out of order, allowing the arterial tension to send 

 plunging back as much blood as it likes, and all in a lump, as it were. 

 Thus the short-lived aortic regurgitant murmur is of much graver 

 import than that which persists up to the next ventricular contraction. 

 When the aortic valve permits regurgitation the arteries cannot be kept 

 full, and so it is that the radial pulse collapses during diastole. Then 

 when the ventricle contracts again blood is injected into the half-empty 

 vessel, and the water-hammer, or whipping pulse, is produced a sign of 

 great clinical value. 



When an aortic murmur lasts only through the first half of the 

 diastole, and the radial pulse is seen to expand and collapse rapidly, 

 regurgitation is extreme. But when it lasts through tke whole 

 diastole, and the collapsing pulse is not very visible, even on raising 

 the wrist, the valvular insufficiency is but slight. Aortic obstruc- 

 tion very often co-exists with aortic insufficiency ; then a ' see-saw ' 

 murmur is produced. 



Engorgement of the superficial cervical -veins occurs when the 

 right ventricle is much embarrassed, as in pulmonary emphysema ; 

 in mitral insufficiency ; in tricuspid insufficiency ; or when an 

 aneurysmal or other thoracic tumour presses upon the superior vena 

 cava or the innominate veins. The engorgement is less noticeable 

 when the head and neck are raised, as then gravity helps to empty the 

 veins. Inspiration relieves the cervical congestion ; but with each 

 expiratory act, and markedly in coughing, the intra-thoracic pressure is 

 increased, and the veins stand out fuller than ever along the neck, 

 showing a respiratory undulation imparted to their contents. 



A definite venous pulse in the neck occurs when the right ventricle 

 is unable tp drive its contents through the lungs (p. 172) and some of 

 the blood escapes by the tricuspid valve into the right auricle, and 

 thence into the superior cava, the innominate and the jugular veins. 

 Regurgitation may occur through even a healthy tricuspid valve. As 

 already remarked, the right auriculo-ventricular orifice has a third flap 

 to provide for this safety-action ; through a healthy two-flap valve it 



