Upon physical examination it is usu ally easy to recognize aortic insufficiency if it exists. Inspection shows an ex tensive and powerful cardiac impulse. The apex is seen to be in the sixth or seventh intercostal space in the nipple line or outside, and the chest-wall may he prominent over the hypertrophied left ventricle. Upon palpation, the pow erful action of the heart is evident, and exceptionally there may be a diastolic thrill. In this disease the heart may attain its largest dimensions.
Upon auscultation, there is heard a diastolic murmur, which may be loudest in the second intercostal space on the right, or in the third or fourth space at the left edge of the sternum. Exception ally it may be heard best at the left side near the xiphoid cartilage. This mur mur is of low pitch, and of a blowing character, and it may replace the second sound of the heart. If not, it begins immediately upon the occurrence of that sound. No cardiac murmur is audible over so extensive an area as may be that of aortic regurgitation. It may be heard all over the chest, and in the brachial and femoral arteries. In some cases it is difficult of detection, and, when this or any valvular lesion is suspected, it may be laid down as a general rule that no examination is complete unless ausculta tion has been carefully practiced when the patient was in a horizontal and also in a vertical position.
Sometimes the murmur can be heard best with the naked ear applied to the uncovered chest-wall. Exceptionally the murmur may be heard only at the apex of the heart, and the murmur described by Flint, presystolic in time and heard at the apex, should be borne in mind. This has been already described in dis cussing the diagnosis of mitral stenosis. Flint's murmur is of a blubbering char acter, and heard only over a limited area at the apex. The sound heard at the base of the heart is usually rather long; when it is short and gushing there, is (it is claimed) reason to infer an ex tensive lesion. It is stated that it is also unfavorable to find the murmur audible only in the midsternal region. Some times the murmur has a distinctly mu sical quality. This is explained as due to the perforation of a valve-segment in such a way that a. thin strip of valve is left intact and made to vibrate by the regurgitating blood. Frequently there, is an accompanying systolic apex-mur mur, due to relative incompetency of the mitral valve, although, of course, it may be a sign crf coexistent mitral disease. ,
Usually there is at the base a systolic murmur, and this occurs independently of aortic stenosis. One explanation of its development is that the first outflow of blood from the contracting ventricle meets the still regurgitating current fall ing through the incompetent valve, and thus gives rise to the murmur.
The diastolic murmur may sometimes be heard, as already stated, in the pe ripheral arteries. Sometimes the second sound of the heart may be heard in the carotid when not audible at the base of the heart. If so, its interpretation is favorable as implying a lesser lesion of the aortic valves. Sometimes a systolic and diastolic murmur may be heard in the femoral and other arteries (Duroziez). This is obtained by a slight pressure with the stethoscope, and is due to the out ward current of blood causing a systolic, and the returning blood a diastolic, sound, at the place of artificial stenosis. This is a very important diagnostic factor when found, but it is not always present in aortic regurgitation.
The femoral artery, and also the smaller arteries, such as the dorsalis pedis and the radial, usually afford a peculiar, sharp valvular "pistol-shot' sound with each cardiac systole. This sound may exceptionally be doubled.
The pulse is characteristic. It has been called the "water-hammer" pulse, or the "Corrigan" pulse, after Corrigan, who admirably described it, or the "shut tle" pulse. It is very quick and abrupt, and extremely ill sustained. These char acteristics are more evident if the arm is raised vertically, and they can be well appreciated by grasping the wrist with the hand (Osier) instead of by the ordi nary mode of palpation with the finger. III this disease there is also a capillary pulse: a phenomenon which may also be •observed in neurasthenia and profound ansemia, but much less often. It can be seen in the nails, in the vessels of the retina through the ophthalmoscope, upon a surface artificially reddened by firm rubbing as on the forehead, and it may also be well observed through a micro scopical glass slide placed upon the everted lower lip. It consists of an alternate flushing and paling of the part, corresponding with the sudden filling and emptying of the vessels.