364 DISEASES OF THE HEART. 



a sound, during their expansion, by the vibration of their walls. Then 

 tortuous course and their pulsation, visible at the radial artery, and 

 even in smaller arteries, are also strikingly characteristic symptoms of 

 aortic insufficience. All these phenomena, excepting the diastolic 

 murmur conducted to the carotids, occur also in hypertrophy of the 

 left side of the heart, when there is no insufficience of the aortic valves ; 

 but there is one symptom appearing in the arteries which is pathog- 

 nomic of the valvular disorder in question. This consists in a re- 

 markably rapid subsidence of the arterial expansion, which, indeed, is 

 of but momentary duration. This jerking pulse (pulsus celerrimus) 

 depends upon the fact that the artery, distended during systole of the 

 ventricle, is emptied in two directions during diastole. In some cases 

 of insufficience of the aortic valves the physical signs of excentric hy- 

 pertrophy of the left heart are less distinctly marked. The apex beats 

 in the fifth or sixth intercostal space, the impulse is not of a heaving 

 character. Such patients usually suffer from dyspnoea because the 

 valvular disease is not compensated for, and the lungs are loaded with 

 blood. We are unable to account for this exception to the rule, which 

 is not uncommon. 



Physical signs of stricture of the aortic valves. Inspection 

 and palpation show signs of simple hypertrophy of the left heart. 

 The impulse is stronger, the apex dislocated downward and outward, 

 but not as much so as in insufficience. Upon palpation we often feel 

 a distinct whizzing about the aorta accompanying systole, which is 

 rare in insufficience. Upon auscultation we hear a systolic murmur 

 over the valves of the aorta, which is usually very loud, and extends 

 so as to be heard all over the region of the heart, masking the other 

 signs. During diastole of the ventricle, as the stricture is seldom 

 uncomplicated, sometimes we hear a feeble sound, but far oftener a 

 murmur. In the carotids, the systolic murmur is sometimes, but not 

 always, conducted to the ear from the aorta ; or we sometimes hear a 

 short, ringing sound in its place. The second sound, too, is usually 

 inaudible in the carotid. The pulse is as small and compressible as 

 it is hard and full in insufficience. 



TREATMENT. Treatment of insufficience of the aortic valves is 

 essentially like treatment of cardiac hypertrophy. Immoderate eating 

 and drinking, and bodily and mental excitement, are to be avoided with 

 care ; determination to the head is to be averted, by daily evacuations 

 of the bowels ; venesection is never to be practised, unless the brain 

 be endangered by immoderate " rush of blood." In this respect we 

 should be the more cautious, as it is almost certain that the practice 

 of bleeding favors degeneration of the heart ; and attenuation of the 

 blood undoubtedly promotes the tendency to dropsy. 



