In rare instances there is even a cen tripetal venous pulse, seen best on the back of the hand.
Diagnosis.—As already stated, persons may have aortic regurgitation without symptoms; hence the disease may some times be discovered only upon physical examination. When the signs above enumerated have been detected, there is scarcely any doubt about the diagnosis.
A diastolic murmur at the base of the heart may be occasioned by an enlarge ment of the aorta, due to aneurism, but this lesion would have a different history and would present other signs peculiar to itself. Moreover, aneurism usually gives a systolic, rather than a diastolic, murmur. Examination with the x-ray would be conclusive.
Insufficiency of the pulmonary valves is a very rare lesion, and, if present, the murmur caused by it should be trans mitted downward and to the right, and there would be no hypertrophy of the left ventricle or "water-hammer" pulse.
Patency of the ductus arteriosus is a rare condition, and the murmur asso ciated with it has been described as "late systolic" or, again, as "continuous with the second sound, transmitted only very feebly to the left, and of a wavy character, sufficient of itself to distin guish it from an aortic regurgitant mur mur." At least 0.3 per cent. of the cases in which aortic reflux occurs the diastolic murmur is heard much more loudly at the second left interspace close to the sternum than in the position usually assigned to it, namely: the second right interspace.
There is no heart-murmur which more often eludes detection than regurgi tant aortic murmur. Of course, the ordinary loud sound of a double aortic murmur is audible without the least difficulty, and to this personal remarks do not apply. They are limited to that low-pitched, soft, aortic murmur which often accompanies, but does not replace, the second sound, and which is of evil significance.
The second left interspace close to the sternum is the locality in which the aortic reflux murmur is much more dis tinct than in the position ordinarily as signed to it. The point at which the murmur is loudest is almost invariably the middle of the sternum, and it is fre quently very loudly audible just above the xiphoid cartilage. H. W. Sayers
(Brit.. Med. Jour., June 1, 1901).
In pulsation of the uvula much cau tion is necessary in the examination, as muscular movements produced by at tempts at retching or swallowing may simulate pulsatile phenomena. The pa tient should be instructed to hold the mouth open steadily and to breathe quietly. It is well to make the exami nation both with and without the use of a tongue-depressor.
Two types of pulsation of the soft parts are distinguishable: a communi cated movement, connected with the throbbing of the carotids, and usually affecting the tonsils and fancial arches; and an independent movement, brought about by a systolic increase in the volume of the tissues. This manifests itself in a rhythmical turgescence of the soft parts. Schlesinger has observed the pulsation in the tongue, both by inspection and by palpation. It may likewise be discernible in the ha If-arches and in the uvula. At times the pos terior wall of the pharynx is pushed forward with each systole of the heart; in some eases the swelling is so marked as to produce a distinct rhythmical liar rowing of the oral and pharyngeal cavi• ties.
As a physical sign, pharyngeal pulsa tion has no special diagnostic value and possesses no greater significance than the capillary pulse. The knowledge of its existence merely adds one more point to be looked for in the critical study of a case. David Riesman (Amer. Medicine, June 15, 1901).
Etiology.—Aortic regurgitation is seen most often in middle-aged, vigorous men accustomed to considerable muscular ex ertion. It may be caused by endocar ditis, but is more often of insidious origin in connection with habitual over strain, and with the poison of gout, alco hol, or syphilis.
Atheroma of the aorta may extend into and deteriorate the valves.
The valves may be congenitally af fected. In most such cases they are still competent at birth; but they are apt to become impaired in later life.