Vascular Sounds

VASCULAR SOUNDS, tones. Tones and murmurs on the aorta and pulmonary artery—see Heart Diseases. Over the large peripheral arteries—carotid and subclavian arteries—two tones are heard in the majority of healthy people. The first tone depends on the systole of the heart and on the local stretching of the vessel, the second tone, usually stronger, is the transmitted second tone of the aortic valves. These tones are heard directly by the ear or with a stethoscope or phonendoscope applied without pressure (spontaneous tones); with slight pressure on the stethoscope an artificial murmur (stenotic) is obtained, and with stronger pressure (when the lumen of the artery is completely or almost closed) a tone (tones) from pressure. Over the brachial and femoral arteries, abdominal aorta, etc., there are usually no tones and only a murmur or tone from pressure (with a stethoscope) is heard. With aortic valve insufficiency, the second tone over the carotid and subclavian arteries disappears and a tone appears over the other peripheral arteries (brachial, radial, palmar arch, abdominal aorta, crural artery, etc.), where normally there are no tones. The mechanism of this tone is explained by the increase in pulse pressure with moderate tension of the vessel walls, thanks to which it quickly passes from a state of tension to relaxation. Vascular tone is also heard in other conditions where there is a rapid pulse (in febrile patients, in Basedow's disease, etc.). Sometimes (with aortic valve insufficiency) over the brachial and femoral arteries a second tone (Traube's double tone) is also perceived, which is probably caused by the snapping of the venous valves (Janovsky). The double tone is sometimes heard over the femoral artery also in febrile patients, with lead poisoning, in the 4th and 5th months of pregnancy, in Basedow's disease, chlorosis, mitral stenosis. Arterial tones have no diagnostic value. Vascular murmurs. (Regarding tones and murmurs on the aorta and pulmonary artery, see Heart Diseases.) Normally, without pressure on the stethoscope, a systolic murmur is heard only: 1) over the large fontanelle in infants aged from 4 months to 17½ years, which arises due to the tortuosity and kinking of the arteries at the base of the skull, and 2) over the uterus at the end of pregnancy, arising in the uterine or placental arteries. Under pathological conditions, vascular murmurs may be heard over large arteries: 1) Conducted murmurs from the heart—systolic and diastolic with disappearance or preservation of the corresponding tone. With aortic valve insufficiency, a diastolic murmur is heard over the carotid and subclavian arteries, with aortic stenosis and atheromatosis, with aneurysm of the aorta—a systolic murmur. Murmurs are better conducted along the direction of blood flow than in the opposite direction, and therefore systolic murmurs over the carotid arteries are heard more often than diastolic murmurs. 2) Systolic murmurs over large arteries are also heard with acceleration of blood flow and hydrodynamia and arise due to the rapid flow of blood and the resulting oscillations of the walls— in Basedow's disease, with mental excitation, with anemia, primarily chlorosis (Lang). 3) Systolic murmurs of local origin from narrowing or dilation of arteries over a limited space and due to roughness of the vascular wall are observed significantly less often, e.g., with arteriosclerotic or syphilitic changes in vessels. Sometimes systolic murmurs are also heard over the subclavian arteries from compression of the latter by pleural adhesions in the area of the apices in pulmonary tuberculosis. This murmur itself has no diagnostic value. 4) In neurotics, a systolic murmur of angioneurotic origin from changes in the tone of the vessels under the influence of irritation or, conversely, paralysis of the vasomotor nerves is sometimes heard. With aortic valve insufficiency, as well as with chlorosis and Basedow's disease, a so-called Duroziez double murmur (see Duroziez sign) is sometimes heard when the femoral and brachial arteries are gradually compressed with a stethoscope. Diastolic and systolic murmurs depending on artery dilation are often heard over a vascular goiter in Basedow's disease. A systolic murmur over a significantly enlarged spleen is heard significantly less often. Sometimes systolic murmurs are heard over the skull with breath holding; they are observed with intracranial processes—narrowing of the lumen of cerebral arteries and sinuses over a limited area, more often due to a tumor, with aneurysms, thrombosis, embolism, local sclerotic changes in vessels, also with anemias (chlorosis), Basedow's disease, heart diseases, aneurysms of the carotid and innominate arteries and other diseases. The mechanism of cranial murmurs is the same as that of other vascular murmurs (acceleration of blood flow, local changes in vessel walls—narrowing and dilation). The diagnostic value of cranial murmurs for intracranial aneurysms and tumors is small, as they are often encountered in other diseases (Koster, Zenchenko). Oppenheim expresses the opinion that with intracranial organic processes the character of the murmur is harsh (buzzing), and with anemias—more like blowing. Gershensonich notes the appearance of a systolic murmur over the eyeball in a number of diseases, most often with anemias. This orbital murmur arises outside the eyeball, in the vessels of the fat tissue branching from one of the ocular branches of the carotid artery—the orbital artery. The diagnostic value of vascular murmurs, since they occur in different diseases, is small in itself. Over large veins normally there are no tones and only a stenotic murmur (from compression with a stethoscope) is heard. With insufficiency of the three valves over the jugular bulb, and with reflux over the femoral vein, a systolic tone from the snapping of the venous valves by the reverse blood wave is heard. With coughing over the femoral vein, a tone from the snapping of the venous valves by the reverse blood wave caused by contraction of the abdominal muscles is sometimes also heard. With vein dilation, when the valves become insufficient, a systolic murmur is heard (Janovsky). These venous tones have no diagnostic value. In anemias of various origin and only rarely in healthy people, in the vertical position of the body, best on the right, over the jugular bulb, a spontaneous (without pressure on the stethoscope) so-called whirlwind murmur, or nun's murmur, is heard. This blowing murmur has the character of a continuous sound, increasing when the head is turned in the opposite direction, during systole and diastole, and also during inspiration, and weakening in the horizontal position of the body. If the whirlwind murmur is heard only during systole or during diastole, it is easily confused with arterial murmurs, but with weak pressure on the stethoscope or turning the head to the left, the intermittent murmur can usually be converted into a continuous one (Lang). Its occurrence is probably explained by the fact that with acceleration of blood flow in anemia, blood rushes too quickly from the narrow internal jugular vein into the wide bulb. Sometimes similar murmurs are also heard over other veins (brachial, femoral, and also inferior vena cava). The whirlwind murmur has diagnostic value in anemias of various origin. I. Kabakov.