. Physical diagnosis . in 20 of these there was adherent pericardiumat autopsy; in 9 nothing more than dilatation of the left ventriclewas found. In none of these cases was the snapping first sound,so common in mitral stenosis, recorded during life. It should be remembered that patients suffering from mitralstenosis are very frequently unaware of any cardiac trouble, andseek advice for anaemia, wasting, debility, gastric or pulmonarycomplaints. This is less often true in other forms of valvular dis- VALVULAR LESIONS. 229 ease. We should be especially on our guard in cases of supposednervous ar
. Physical diagnosis . in 20 of these there was adherent pericardiumat autopsy; in 9 nothing more than dilatation of the left ventriclewas found. In none of these cases was the snapping first sound,so common in mitral stenosis, recorded during life. It should be remembered that patients suffering from mitralstenosis are very frequently unaware of any cardiac trouble, andseek advice for anaemia, wasting, debility, gastric or pulmonarycomplaints. This is less often true in other forms of valvular dis- VALVULAR LESIONS. 229 ease. We should be especially on our guard in cases of supposednervous arrhythmia or tobacco heart, if there has been an at-tack of rheumatism or chorea previously. Such cases may presentno signs of disease except the irregularity—yet may turn out tobe mitral stenosis. IV. Aortic Regurgitation. Rheumatic endocarditis usually occurs in early life and mostoften attacks the mitral valve. The commonest cause of aortic dis-ease on the other hand—arterio-sclerosis—is a disease of late mid-. /tfitia/ fa*/. -Diastole in Aortic Regurgitation. The blood is flowing back through the stumpy andincompetent aortic valves. die life, and attacks men much more often than women. Whenwe think of aortic regurgitation, the picture that rises before us isusually that of a man past middle life and most often from theclasses who live by manual labor. Nevertheless cases occur at allages and in both sexes, and rheumatic endocarditis does not sparethe aortic cusps altogether by any means. Whether produced by arterio-sclerosis extending down from theaorta, or by rheumatic or septic endocarditis, the lesion which re-sults in aortic regurgitation is usually a thickening and shorteningof the cusps (see Fig. 133). In rare cases an aortic cusp may beruptured as a result of violent muscular effort, and the signs and 230 PHYSICAL DIAGNOSIS. symptoms of regurgitation then appear suddenly. But as a rulethe lesion comes on slowly and insidiously, and unless discoveredaccid
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