. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. ^ region. Upon careful study of thismurmur it was found to have two areas of maximum intensity, onein the second right interspace near the sternum, the other in thevicinity of the left nipple. Moreover, in these two areas the pitchAvas slightly yet distinctly different, being lower and harsher inthe aortic and more musical inthe mitral area. The heartsrate was 90, and its rhythmregular. The liver was pal-pable. The audible pulmonarvsecond to
. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. ^ region. Upon careful study of thismurmur it was found to have two areas of maximum intensity, onein the second right interspace near the sternum, the other in thevicinity of the left nipple. Moreover, in these two areas the pitchAvas slightly yet distinctly different, being lower and harsher inthe aortic and more musical inthe mitral area. The heartsrate was 90, and its rhythmregular. The liver was pal-pable. The audible pulmonarvsecond tone and hj^pertrophicdilatation of the right ventri-cle confirmed the evidenceobtained from the mitral mur-mur and established the ex-istence of mitral regurgita-tion. The aortic systolic bruitand loss of the aortic secondsound, together with the sys-tolic thrill, gave evidence ofstiffness, and perhaps steno-. FiG. 33.—Kelative Uulness, Case ofCheonic Endocaeditis (p. 201). sis of the aortic valves. The absence of a rheumatic history, thepatients age, the late development of symptoms, the moderatearteriosclerosis, and lastly, the heart findings, all seemed to war-rant the opinion that the valvular changes were due to scleroticendocarditis. The condition of the kidneys was not ascertainedat that time, as the son had not examined the urine, but inasmuchas there was nocturnal micturition, renal cirrhosis was thoughtprobable, and it was advised to have the urine collected for twenty-four hours and examined. In this case I believe the cause lay in the strain to which thevalves of the left heart had been subjected for man}- years in con-sequence of the abnormal blood-pressure brought about by his ex-cessive consumption of food and alcoholic liquids without suffi- 204 DISEASES OF THE HEART cient physical exercise. How much, if any, influence can be attrib-uted to tobacco and waste products I can
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