Diseases of the Heart and Orgvns of Circulation. 415 



sist in a blowing or rushing noise which usually accompanies or 

 displaces one of the heart sounds, though it may precede or suc- 

 ceed these. The following table, modified from that of Bartle 

 and Roger, presents at a glance the relations of these different 

 sounds and their significance. 



Blowing or Hissing Murmurs. 



JBlowing murmur 1 

 before the first \ . 

 sound. J 



Blowing murmur with 

 the first sound. 



Strongest toward the apex of 

 the heart. Not propagated 

 in Ihe great arteries No 

 marked venous pulse. 



Blowing murmur with 

 the second sound. 



Blowing murmur after 

 the second sound. 



{Najxowing of the auriculo-ventricular 

 orifice. Vegetations or coagula on 

 the valves, 

 f Strongest toward the base of "1 Narrowing of the 

 I the heart. Propagated / aortic opening. 

 I along the great arteries 



Narrowing of the 

 pulmonary artery 

 or insufficiency of 

 the left auriculo- 

 ventricular valves. 

 Insufficiency of the 

 tricuspid (right 

 a u r i c u lo- V entri- 

 cal) valve. 



No marked venous pulse in ] InsufiBciency of the 

 the jugulars : Congested I mitral (left auri- 

 lungs. I culo- ventricular ) 



J valve. 



} Double rushing sound heard ] Insufficiency of the 

 over the great arteries, at >■ arterial (semi- 

 each beat of the heart. J lunar) valves. 

 1 Double rushing sound in thel Aneurism (dilata- 

 [■ arteries with each beat of >■ tion ) of the great 

 j the heart. J aorta. 



Accompanied by venous pulse ' 

 in the jugulars. 



From the table it will be seen that each orifice in the heart 

 may become the seat of two perfectly distinct and independent 

 murmurs : one due to constriction of the orifice in which case the 

 sound is produced with the onward progress of the blood wave ; 

 and one due to dilatation of the orifice or insufiicient closure of it 

 by the valves, when the sound is due to a recoil or regurgitation 

 •of the blood. There is a further sound due to mere roughness of 

 the valves in cases of disease when the sound will be with the 

 normal current of blood, though a second or regurgitant hiss is 

 ■often heard from the valves being at the same time insufficient to 

 close the orifice. Another blowing murmur is usually heard over 

 the heart and coincident with its first sound in the bloodless state 

 (anaemia). This is not necessarily connected with any diseased 

 condition of the heart itself. 



