Diseases of the chest and the principles of physical diagnosis . he arrow indicates the direction of the regurgitant blood stream. the first heart sound. If the auricle goes into a state of fibrillation or ifit loses its contractile force because of extreme dilatation, the presystolicmurmur disappears and instead of it a murmur is heard earlj^ in presystolic murmurs can arise only at the auriculo-ventricular ori-fices. Phonetic equivalent: R-R-R-upp, Dupp (presystolic rumble);Rup-Tut-Rarou (mid-diastolic rumble) (see Fig. 202). 5. The systolic tricuspid murmur is heard at the tri
Diseases of the chest and the principles of physical diagnosis . he arrow indicates the direction of the regurgitant blood stream. the first heart sound. If the auricle goes into a state of fibrillation or ifit loses its contractile force because of extreme dilatation, the presystolicmurmur disappears and instead of it a murmur is heard earlj^ in presystolic murmurs can arise only at the auriculo-ventricular ori-fices. Phonetic equivalent: R-R-R-upp, Dupp (presystolic rumble);Rup-Tut-Rarou (mid-diastolic rumble) (see Fig. 202). 5. The systolic tricuspid murmur is heard at the tricuspid area, be-cause both the right auricle and ventricle lie immediately beneath thispoint. It is also often heard over the mitral area, and cannot always be HEART MURMURS 239 differentiated from the murmur of a mitral insufficiency, with which itis usually associated. The presence of marked right heart dilatation,of a positive venous pulse, of an enlarged or even pulsating liver, pulmo-usltj^ congestion, ascites, etc., enable us to definitely state that the. Fig. 198.—AIiteal insufficiency. The left ventricle is hypertrophied, the left auricledilated. The direction of the regurgitant blood flow, as indicated by the arrow, is upwardand backward, but the murmur is transmitted chiefly downward and forward through thevibrating_ chordae tendinese and the papillary muscles. A, aorta; , left auricle; ,part of right auricle; P, portal vein; , right pulmonary artery; , left pulmonaryartery; T, trachea; , right subclavian artery; , right subclavian vein. tricuspid valve is incompetent. A diagnosis of tricuspid insufficiency,based merely upon the fact that a systolic murmur is clearly audible atthe tricuspid area is not justified. Such a diagnosis may on the con-trary be eminenth^ warranted in the absence of a tricuspid murmur if 240 THE EXAMINATION OF CIRCULATORY SYSTEM the presence of a positive venous pulse or a pulsating liver can bedemonstrated. Phonetic
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