. Physical diagnosis . ch and quality of the murmur as we neared the tricuspid orifice,and may be confirmed by the discovery of other evidences of a doublelesion. • No diagnosis is satisfactory which rests on the evidence of mur-murs alone. Changes in the size of the hearts chambers or in the pulmo- AUSCULTATION OF THE HEART 183 nary or peripheral circulations are the most important facts in the the effort to ascertain and graphically to represent theintensity of cardiac murmurs as one listens along the line connectingthe valve areas has its value. An hour-glass murmur, such
. Physical diagnosis . ch and quality of the murmur as we neared the tricuspid orifice,and may be confirmed by the discovery of other evidences of a doublelesion. • No diagnosis is satisfactory which rests on the evidence of mur-murs alone. Changes in the size of the hearts chambers or in the pulmo- AUSCULTATION OF THE HEART 183 nary or peripheral circulations are the most important facts in the the effort to ascertain and graphically to represent theintensity of cardiac murmurs as one listens along the line connectingthe valve areas has its value. An hour-glass murmur, such as thatrepresented in Fig. 137, generally means two-valve lesions. A similarhour-glass may be found to represent the auditory facts as we movefrom the mitral to the pulmonic or to the aortic areas (see Fig. 138)and, as in the previous case, arouses our suspicion that more than onevalve is diseased. It must not be forgotten, however, that a murmur may travelsome distance underground and emerge with a change of quality. X Fig. 137. Fig. 138. Fig. 137.—Mitral and Tricuspid Regurgitation. The intensity of the systolic murmuris least at the waist of the shaded area and increases as one approaches either end of it. Fig. 138.—Mitral Regurgitation and Aortic Stenosis. The systolic murmur isloudest at the extremities of the shaded area and faintest at its waist. (Allbutt). This is especially true of aortic murmurs, which areoften heard well at the apex and at the aortic area, and faintly in the in-tervening space, probably owing to the interposition of the rightventricle. In such cases we must fall back upon the condition of the heartitself, as shown by inspection, palpation, and percussion, and upon thecondition of the pulmonary and peripheral circulation, as shown inthe other symptoms and signs of the cases (dropsy, cough, etc.). (4) Intensity of Murmurs.—Sometimes murmurs are so loudthat they are audible to the patient himself or even at some dis-tance from the chest. In one
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