At times the edges of the valves may grow together from ulcerative inflammation, and the lumen thus be diminished in size; or projecting vegetations may interfere with the opening of the valve and with the flow of blood. With such narrowing the left ventricle more or less rapidly hypertrophies to overcome its increased work. The murmur caused by this lesion is a systolic one, either accentuated in the second intercostal space at the right of the sternum, or perhaps heard loudest just to the left of the sternum in this region. The murmur is also transmitted up the arteries into the neck, and may at times be heard in the subclavian arteries. It may also be transmitted downward over the heart. The pulse is slow, the apex of the rise of the sphymographic arterial tracing is more or less sustained and rounded, and the rise is much less than normal. If this lesion occurs in old age, there is general arterial disease present, and the tension and compressibility of the arteries vary, depending on how much they are hardened. The disturbed circulation is evidenced by imperfect peripheral circulation and capillary sluggishly, with at times pendent edema of the feet and ankles, but, perhaps, little congestion of the lungs. The left ventricle being sufficient, there is no damming back through the left auricle to the lungs. The left ventricle may, however, become weakened, either by some sudden strain or by a chronic myocarditis, and relative insufficiency of the mitral valve may occur. The subsequent symptoms are typically those of loss of compensation. This lesion may allow a patient to live for years, provided no other serious disturbance of the heart occurs, such as myocarditis or coronary disease; but sooner or later, with the failing force of the blood flow and the lessened aortic pressure, slight attacks of anemia of the brain occur, causing syncope or fainting. Also, sooner or later these patients have little cardiac pains. They begin to "sense" their hearts. There may not be actual anginas, but a little feeling of discomfort, with perhaps pains shooting up into the neck, or a feeling of pressure under the sternum. Little excitements or overexertions are likely to make the heart attempt to contract more rapidly than it is able to drive the blood through the narrowed orifice, and this alone causes cardiac discomfort and the feeling of cardiac oppression.