104 
FR. BLAZEKOVIC. 
of the ostia and alteration of the valves always appear at the sana 
time, a corresponding combined murmur arises, which falls eitliej 
on the first or second tempo of the heart-beat and supplants the 
cardiac sound and attains the following diagnostic importance: 
(1) Murmur of the first tempo: change of the arterial ostia 
insufficiency of the orifices of the auricle. 
(2) Murmur of the second tempo: change of the orifice of the 
auricles, insufficiency of the arterial ostia. 
(3) Double murmur: simultaneous affection of the different 
ostia, insufficiency of several valves. 
A. Insufficiency of the Bicuspid Valves. 
The percussion sound is dulled to a greater extent owing tc 
the constant developing of eccentric hypertrophy; the impulse 
of the heart is more forcible, clearly felt, and corresponds to the 
expansion of the dullness. Upon auscultation the first cardiac 
sound is scarcely perceptible, changing into an undistinguisliable 
murmur which supplant the pure sound. The second sound inter¬ 
rupts the murmur upon the setting in of the diastole. In a violent 
form of the disease the first and second sound follow another so 
closely as to make a distinction impossible. 
B. Stenosis of the Ostia. 
More energetic heart-beat; percussion indicates an intense 
dullness; auscultation shows that the diastolic sounds (2d sound) 
are occasionally lengthened to such a degree that they consume 
the first or systolic sound. The murmur is caused by friction on 
the rough surfaces of the valves of the blood flowing in and out 
of the ventricle. The audible and sensible scraping and whizzing 
indicate a roughness of the altered ostia. The blood must force 
its way through the narrowed space. 
If, at the same time, stenose be united with insufficiency, then 
an abnormal murmur is audible during systole and diastole. 
C. Insufficiency of the Aortic Valves. 
They give the appearance of simple or eccentric hypertrophy 
of the left ventricle which are perceptible by means of ausculta¬ 
tion and a more violent heart-beat; a murmur which supplants 
the second cardiac sound. 
