be distinguished as intra-ventricular murmurs, and the inference to be drawn from them is that the valves are not affected to the extent of interrupting materially their functions.

In treating of the subject of endocardial organic murmurs in this chapter, reference has been had, for the most part, to those occurring in connection with chronic valvular affections of the heart. Organic murmurs, as will be seen hereafter, also occur in connection with heart-clots, in cases of congenital malformations, and their production becomes an important physical sign of the development of endocarditis. Without due attention, murmurs taking place within an aortic aneurism situated near the heart, are liable to be mistaken for endocardial murmurs.

INORGANIC MURMURS.

As already defined, a murmur is inorganic when it is produced. independently of organic or structural lesions. An endocardial murmur may be present when there are no lesions. The practical importance of being able to determine whether an existing murmur be organic or inorganic is sufficiently obvious. This discrimination, happily, can be made in practice in the great majority of cases. The points involved in the discrimination claim attention in this connection.

An inorganic murmur, as a rule, proceeds from an abnormal change in the composition and properties of the blood. The precise nature of the change is perhaps not positively ascertained. At all events, a discussion of this subject need not be here introduced. Whatever be the requisite conditions, they occur in a certain proportion of cases of anæmia and chlorosis. The murmur in these instances is said to be of hamic origin. It was observed by Marshall Hall, in his researches on the effects of the loss of blood, that the sudden abstraction of a large quantity of blood led to the development of a transient bellows-murmur. Other observers have verified this fact. It is occasionally observed under circumstances which seem to render it probable that it proceeds from deficient or irregular contraction of the papillary muscles, involving temporary

Intra-ventricular, in distinction from murmurs produced at the orifices and propagated for a greater or less distance beyond the heart, either above the base, if the lesions are aortic, or to the left of the heart if the lesions are mitral and involve insufficiency.

insufficiency and regurgitation. Its occurrence in some cases of chorea has been accounted for in this way. Thus produced, the murmur is said to be of dynamic origin. It is produced in some persons in health by the violent action of the heart which follows active muscular exertion, disappearing when the organ resumes its usual tranquillity. It is occasionally observed in the course of a variety of affections, when post-mortem examinations in cases of death, and its disappearance, leaving no signs or symptoms of cardiac disease, after recovery, show that it does not proceed from organic causes. The continued and eruptive fevers, uræmia, and hysteria, are among the affections in which it sometimes occurs. Its occurrence is not infrequent during pregnancy. What are the characters which distinguish these murmurs from those of organic origin?

Inorganic murmurs are uniformly systolic, i. e., they accompany only the first of the heart-sounds. Diastolic murmurs are always of organic origin.

In the vast majority of cases, inorganic murmurs are heard at the base of the heart, and are not propagated far above, and, more especially, not below this point. They are very rarely heard at the apex, but if propagated to the apex, their maximum is at the base. This, at least, is true of all cases of inorganic murmurs of hæmic origin. It is only the very rare and somewhat dubious instances of murmurs of dynamic origin, that are produced at the auriculo-ventricular orifices, and, consequently, heard at the apex. These are characterized by temporary duration or intermittency. Hence, it may be stated that, as a rule, every persistent, constant murmur referable to the mitral orifice, denotes organic lesion of some kind, and, as a rule, organic murmurs are constant and persistent, while inorganic murmurs, wherever produced, are fluctuating and variable, being sometimes discoverable only when the body is in a certain position. An inorganic murmur is uniformly soft. If this rule be not invariable, the exceptional instances are exceedingly infrequent, and the roughness in exceptional instances is not marked, nor constant, occurring only when the action of the heart is unusually excited. Roughness, therefore, may be considered as evidence that the murmur is organic. This statement will apply equally to an endocardial musical murmur. An inorganic murmur is always feeble. Intensity is evidence of organic origin.

An inorganic murmur may be produced either at the aortic or pulmonic orifice, or simultaneously at both orifices. If it be pul

monic, as shown by its being either limited to, or having its maximum of intensity in the left second or third intercostal space, it is probably inorganic, in view of the great infrequency of lesions situated at this orifice. Congenital malformations are to be excluded from this statement, for these are more liable to affect the pulmonic than the aortic orifice. In this connection it may be mentioned. that pressure with the stethoscope in these intercostal spaces over the pulmonic artery, will sometimes develop a bellows murmur in that vessel. This is observed in young persons whose costal cartilages are flexible. The murmur is due to pressure on the artery, as in the case of other arteries, more accessible, such as the carotid, iliac, femoral, etc. It is well known that light pressure on these arteries frequently develops a bellows murmur.

Inorganic murmurs occur in anæmic persons, and the palpable indications of anæmia are generally manifest. The coexistence of anæmia is a point to be considered in the discrimination. This condition, it is true, may coexist with valvular lesions, and contribute to render more intense and diffused the murmurs due to the latter. Anæmia alone by no means warrants a conclusion that a murmur is inorganic, but, added to other evidence, it strengthens this conclusion.

Concurrent bellows murmurs emanating from the large arterial trunks, the subclavian, carotids, etc., not due to pressure with the stethoscope, are evidence that an endocardial murmur is inorganic, This evidence is by no means complete in itself, but adds weight to that derived from other sources. A continuous murmur or hum produced in the jugular veins is very frequently associated with an endocardial murmur of hæmic origin. This venous hum, called, after Bouillaud, by the French writers, bruit de diable (from its resemblance to the sound of the humming-top, which is known popularly in France as le diable), has heretofore given rise to considerable discussion as regards its source. Laennec, who first observed it, referred it to the arteries. In this he has been followed by most French writers. Its origin in the veins was first demonstrated by Dr. Ogier Ward. It is a sufficient demonstration of the correctness of the latter view that the murmur is invariably suspended by interrupting the circulation through the veins, the arterial circulation continuing. The murmur is a continuous humming sound, having frequently a musical intonation. It is best heard over the jugulars, just above the clavicles, the patient being in the sitting or standing posture. It is highly characteristic

of anæmia, and its presence in conjunction with an endocardial murmur suspected to be inorganic, gives strength to this suspicion. Venous hum and arterial inorganic murmurs are not infrequently combined.'

Inorganic endocardial murmurs are much oftener observed in females than in males, a fact probably due to the greater frequency of anæmia in the former. Sex, therefore, is entitled to some weight in determining whether a murmur be organic or inorganic.

The heart-sounds, in connection with inorganic murmurs, retain their normal intensity and characters, or, if affected at all, their intensity is augmented; whereas, in connection with organic murmurs, they often present abnormal modifications, which are to be presently considered.

Finally, organic murmurs, in the great majority of the cases of chronic disease, when these first come under the cognizance of the physician, are associated with more or less cardiac enlargement. This is owing to the fact that valvular lesions do not, as a rule, occasion much inconvenience until they have induced enlargement of the heart. A murmur, under these circumstances, may have existed for many months or years, and escaped observation because the patient has never presented himself for examination. Coexisting enlargement, then, alone, renders it altogether probable that an endocardial murmur proceeds from organic lesions. It is true that enlargement of the heart, uncomplicated by valvular disease, may be associated with inorganic murmurs, but it is evident that this coincidence must be rare when it is considered that enlargement without lesions of the valves is by no means frequent. If, in connection with cardiac enlargement, a murmur be either mitral regur gitant or diastolic, it is certainly organic. Doubt can only arise when the murmur is an aortic direct murmur. On the other hand, in the vast majority of the cases in which a murmur is inorganic, the heart is not enlarged, a fact which can be positively determined by means of physical exploration.

With due attention to the several points which have been briefly considered, the auscultator need not be at a loss, in most instances, in discriminating with positiveness between organic and inorganic endocardial murmurs.

Dr. Walshe remarks, with reference to the coexistence of an endocardial murmur and venous hum: "I do not remember ever to have observed an intra-cardiac spanæmic murmur unattended with venous hum."-On Diseases of the Heart and Lungs, second London edition, p. 242.

ABNORMAL MODIFICATIONS OF THE HEART-SOUNDS IN CASES OF
VALVULAR LESIONS.

The study of the murmurs has so much engrossed the attention of clinical observers of late years, that the heart-sounds have not received that attention which their importance claims. Abnormal modifications of the heart-sounds afford, in certain cases, as has been seen, valuable aid in the localization of murmurs. They also serve to supply, in some measure, information, which, in a pathological point of view, is far more important than to determine the existence, situation and character of lesions, viz: respecting the amount of damage which the valves have sustained. The important practical points pertaining to these two objects have been already incidentally noticed, but it will not be amiss to recapitulate them under a distinct heading.

The results of the clinical study of the heart-sounds in health, show that the second or diastolic sound, consisting solely of a valvular element, is in fact composed of an aortic sound and a pulmonic sound, which are generally distinguishable from each other when the stethoscope is applied in the second intercostal space near the sternum on the two sides successively, the aortic second sound being heard on the right, and the pulmonic second sound on the left side. The first sound of the heart differs from the second, in being compounded of a valvular element and an element of impulsion. The valvular element, however, like the second sound, is composed of a mitral and a tricuspid valvular sound, which are distinguishable from each other when auscultation is practised successively in different situations. For further details the reader is referred to Chapter first, where this subject is fully considered.'

The abnormal modifications of the first sound may affect, either separately or conjointly, the two elements into which this sound is resolvable, and the two subdivisions of the valvular element of the sound; and the aortic and pulmonic sounds which make up the second sound of the heart, may also be affected singly as well as combined. It is in connection with valvular lesions more especially, that the different elements and their subdivisions are liable to be modified separately.

Mitral lesions impair the mitral portion of the valvular element of the first or systolic sound, other things being equal, in propor

Vide page 58, et seq.