A CLINICAL GUIDE 
TO 
BEDSIDE EXAMINATION A CLINICAL GUIDE 
TO 
BEDSIDE EXAMINATION 
BY 
DR. H. £LIAS ■ 
Dozent and Assistant at the First Medical Clinic of the 
University of Vienna, Austria 
dr. N. jagic / 
Extraordinary Professor and Chief Physician to the 
Sofienspital, Vienna, Austria 
DR. A. LUGER ' 
Dozent and Assistant at the Second Medical Clinic of the 
University of Vienna, Austria 
ARRANGED AND TRANSLATED BY 
WM. A. BRAMS, M.D., 
CHICAGO, ILL. 
Adjunct in Medicine, Michael Reese Hospital 
Formerly Lieutenant Commander, Medical Corps, 
United States Navy 
NEW YORK 
REBMAN COMPANY Copyright, 1923, by 
REBMAN COMPANY 
New York 
Albrights reserved 
PRINTED IN AMERICA TABLE OF CONTENTS 
PAGE 
Introduction ix 
Scheme of a Physical Examination at the 
Bedside 1 
General condition 1 
The several parts of the body 2 
Detailed Consideration of the Foregoing 
Scheme and the Diagnostic Value of the 
Several Findings 4 
Inspection and Palpation 4 
General 4 
Of the various regions 16 
Head 16 
Neck 17 
Thorax 18 
Appendix; types of thorax 21 
Abdomen 22 
Extremities 34 
Appendix 36 
Zones of Head 38 
Points of tenderness 39 
V VI 
TABLE OF CONTENTS 
PAGE 
Percussion and Auscultation 43 
Percussion 43 
Auscultation 44 
Special physical examination 45 
Lungs 45 
Percussion 45 
Changes in the percussion tone 51 
Appendix; percussion of the para- 
vertebral and interscapular regions.. 54 
Auscultation 56 
Breath sounds 56 
Accessory sounds 59 
Voice 61 
Combined auscultation and percussion. 62 
Palpation 63 
Vocal fremitus 63 
Appendix; percussion and auscultation of 
the spinal column 65 
Diagnostic Value of Some of the Physical 
Findings 67 
Lungs ... 67 
Foci of thickening 67 
Appendix; physical signs of tuberculosis of 
the lungs 69 
Pleural effusion 72 TABLE OF CONTENTS 
VII 
Diagnostic Value of Some of the Physical 
Findings 
Lungs page 
Pleural and mediastinal adhesions and 
thickenings 76 
Pneumothorax 77 
Volumen pulmonum auctum 79 
Volumen pulmonum diminutum 80 
Heart and Vessels 81 
Heart 81 
Vessels 88 
Arteries 88 
Veins 90 
Pulsations 91 
Diagnostic Value of the Various Physical 
Findings at the Heart and Vessels 93 
Abdomen 117 
INDEX 125 FOREWORD 
This little volume was prepared with a view of fur- 
nishing the physician and student with a guide for the 
physical examination of a patient at the bedside. It 
is also intended to offer a nomenclature which may 
be used by the various schools and which may thus 
facilitate the recording and interpretation of history 
charts and reports of the results of the physical ex- 
amination. 
It is very important that the examination of the 
patient be thorough and that nothing escape observa- 
tion by the physician. It is equally important that the 
findings be reported in a uniform and orderly manner 
and that negative as well as positive findings be re- 
corded. 
No detailed descriptions, theories or procedures re- 
quiring laboratory, graphic or other instrumental aid 
are discussed in this booklet. The reader is referred 
to books on these various subjects for a comprehensive 
study of the more complicated methods, as only the 
findings on inspection, palpation, percussion and aus- 
cultation are included in this volume. 
This little booklet is offered to the profession with 
the hope that it will meet the requirements mentioned 
in the foregoing paragraphs. 
The Authors. INTRODUCTION 
It seems advisable, during a physical examination, 
to adhere to a certain schema so that the records will 
be uniform and complete, for which reason the follow- 
ing schema is suggested. Only the headings are men- 
tioned as the more detailed discussion of the various 
points will be taken up in the subsequent chapters and 
in accordance with the order of their occurrence and 
regional distribution. SCHEMA OF A PHYSICAL EXAMINATION 
AT THE BEDSIDE 
General Condition 
Age and sex. 
Dimensions and proportions of the body. 
Sensorium and position in bed. 
Bony framework, musculature, panniculus adiposas. 
Visible mucous membranes ficterus, cyanosis, other 
Skin colors. 
Edema. 
Pulse at radial artery 
Course and position of vessel. 
Size and filling. 
Wall. 
Height of pulse wave, “celerity.” 
Blood pressure. 
Frequency. 
Equality and rhythm. 
Dicrotism. 
Paradoxism. 
Comparison of the pulse on the right and left sides. 
Respiration. 
Temperature. 
1 2 
A CLINICAL GUIDE TO 
The Several Parts of the Body 
Form, hairy parts. 
Movements of the eye-ball, nystagmus. 
Pupils: width, shape, difference in size, reaction to 
light, pain, accommodation, consensual sense. 
Examination of the other cerebral nerves. 
Ears and nose. 
Tongue, throat, tonsils. 
Head 
Neck 
Shape. 
Arteries, veins and their course and pulsations. 
Thyreoid gland. 
Lymph glands. 
Larynx, voice. 
Phrenic and vagus nerves. 
Thorax 
Shape and symmetry. 
Epigastric angle. 
Supra- and infra-clavicular fossae. 
Spine. 
Lungs 
Topographic and comparative percussion. 
Determination of respiratory excursion of borders. 
Auscultation of breath sounds, spoken and whis- 
pered voice. 
Combined method of auscultation and percussion. 
Vocal fremitus. BEDSIDE EXAMINATION 
3 
Heart 
Inspection and palpation. 
Apex beat, position, resistance, width and thrills. 
Percussion. 
Boundaries of cardiac dullness and dullness in me- 
dian line (large vessels). 
Auscultation. At apex (mitral valve), pulmonary- 
artery, aorta, tricuspid valve, peripheral vessels. 
Abdomen 
Inspection and palpation. 
Shape—Abdominal walls; contour of organs; ab- 
normal resistance. 
Percussion and auscultation. 
Examination of the several organs as the liver, 
spleen, kidneys (pancreas). 
Hernial rings, rectum and genitalia. 
Motility—head, trunk and extremities. 
Sensibility—skin and deep sensibility, temperature 
and pain. 
Reflexes—skin, tendons, periosteum. 4 
A CLINICAL GUIDE TO 
DETAILED CONSIDERATION OF THE 
FOREGOING SCHEMA AND THE DIAG- 
NOSTIC VALUE OF THE SEVERAL 
FINDINGS. 
Inspection and Palpation. 
I. General. 
Position of the patient in bed (sitting, lying, active, 
passive, forced positions, etc.). 
General Habitus—Size of the body, consideration of 
the various proportions of the body (comparison of 
upper to lower half, etc.), asymmetries. 
Boney Framework (relatively large or small boned), 
configuration of the bones, condition of the epiphyses, 
swellings. Condition of the diaphyses. Exostosis. 
Bending deformities. Localized changes in consist- 
ency (infiltrations, hematoma, tumor, calcification, 
boney tumors). 
Panniculus adiposas (poorly or well developed), dis- 
tribution (generalized or localized to certain regionsy 
tenderness). Note localization and distribution if un- 
equally developed as, for example, to the abdomen, 
extremities, etc. 
Skin—General condition. Whether delicate or 
elasticity, ability to raise in folds (indicating emaciation BEDSIDE EXAMINATION 
5 
or loss of fluids), flabbiness, dryness, fragility, reaction 
to stimuli (dermatographia), moisture, if bloated, 
pasty, edematous, emphysematous (crepitus on pres- 
sure). Degree and localization of edema and em- 
physema. 
Edema—Color (pale or cyanotic). Degree, local- 
ization. 
(a) Generalized Edema—Chiefly in the dependent 
parts as in the retro-malleolar and sacral regions in 
circulatory disturbance. More generalized in renal 
edema but may be localized (often to lids). Edema of 
cachexia and severe anemia. Regional edema in ven- 
ous stasis .(is also cyanotic) as in thrombophlebitis, 
varices and stasis of the vena cava. 
(b) Localized Edema—Inflammatory, toxic, angio- 
neurotic. Collateral edema on the surface above a 
deep seated inflammatory process (see chest or abdo- 
men) and frequently in such processes in the muscles 
or nerves (myalgia, neuralgia). 
(c) Acute Circumscribed Edema (Quincke)—of the 
skin, often accompanied by effusions in the joints. 
Color 
(a) Pallor—Pseudo-anemia (pallor without corre- 
sponding anemia, findings in the blood), incomplete 
circulation of the blood in the skin, abnormally thick 
skin. Anemia (chlorosis with a tinge of green, per- 
nicious anemia with a tint of yellow). 
(b) Redness—Localized as in transitory dermato- 
graphia, hectic flush. Inflammatory redness in inflam- 6 
A CLINICAL GUIDE TO 
mation of the skin or underlying structures. Result 
of atmospheric conditions (coach driver’s face). 
Marked in erythremia. 
(c) Cyanosis—General, localized as in acrocyano- 
sis, local stasis (vena cava). 
(d) Icterus—Sub-icterus, pale yellow, dark yellow 
to greenish (melasicterus). Examination of the sclerae 
and hard palate. 
(e) Pigmentation—Generalized or local. Sunburn, 
result of chronic irritation (ulcus cruris, cutis vagan- 
tium, etc.), artificial after adhesive plaster, local heat 
or X-ray therapy. Addison’s disease (see mucous 
membranes), arsenical pigmentation, displacement of 
pigment (leucoderma, vitiligo, chloasma uterinum). 
(f) Other Forms of Skin Pigmentation—Yellow, 
due to picric acid poisoning, xanthosis of diabetes, 
karotin pigmentation (especially of the palmar and 
plantar surfaces). Smoke gray color in argyria, etc. 
Hair—Degree, localization, type (masculine or femi- 
nine), condition of the hair. 
Exanthemata—Efflorescences, scars, nodes. Neuro- 
fibromatosis, lipomatosis (Dercum’s disease, granular 
form, forms en plaques). Metastasis. 
Visible Mucous Membranes—Hemorrhages, pig- 
mentations, etc., as in skin. Addison’s disease (mucous 
membrane of mouth and lips). 
Pulse, Respiration, Temperature 
Pulse—At radial artery (see pages 12 and 14, for 
pulse at others). BEDSIDE EXAMINATION 
7 
1. Position (anatomical variations) — Course 
(straight, serpentine). 
2. Size (congenital narrowing of the vessels)—Fill- 
ing (poor filling in aortic stenosis). 
3. Condition of the Arterial Wall—Normally soft 
and smooth. Ability to obliterate pulse by compression 
with fingers. Generalized thickening in increased 
tonus of the vascular musculature, in hypertrophy of 
the musclaris (also in young individuals), in luetic 
meso-arteritis and arterio-sclerosis. Localized thick- 
enings as in necrosis of the media and calcification 
of this layer (“goose gullet artery”). Peri-arteritis 
nodosa. 
4. Height of Pulse Wave—Pulsus altus, pulsus par- 
vus, pulsus celer, pulsus tardus. So-called pseudo- 
celerity, i.e., hopping pulse in arterio-sclerosis of the 
aorta, in peripheral hypotonia as seen in infectious 
disease, and in thyreotoxicosis, etc. 
5. Tension—Use three fingers in which the third 
blocks the possible retrograde pulse from the arch 
while the first finger gradually increases the pressure 
from above. The middle finger palpates the pulse dur- 
ing the compression. The greater the required com- 
pression, the greater the pressure. 
6. Frequency—Rate per minute. The rate in ar- 
rhythmia should be determined by auscultation of the 
heart (see imperfect contractions, page 10). Change 
in frequency in different positions of the body. 8 
A CLINICAL GUIDE TO 
A. Increased Frequency (Tachycardia) 
Special Forms 
Normotopic (sinus) tachycardia, rapid rate as in 
infectious diseases, thyreotoxicosis, neuroses, etc. 
Heterotopic tachycardia in grouped extra systole as 
in auricular fibrillation or auricular flutter. 
Periodic attacks of rapid rate in paroxysmal tachy- 
cardia. 
B. Diminished Frequency (Bradycardia) 
Sinus Bradycardia—Characterized by pulse intervals 
of the same length as seen in icterus and in certain 
forms of infectious diseases and after infections. 
Vagus Bradycardia—Slow rate but not perfectly 
regular heart action as shown by graphic methods. 
Found in increased cerebral pressure or digitalis ef- 
fect. Stimulation of the vagus in its peripheral course. 
Experimental vagus bradycardia by pressure on this 
nerve, during which the pressure is carefully made 
and gradually increased on the vagus as it lies behind 
the carotid. Pressure on the right is more effective 
than on the left. This should be done only with 
simultaneous control by auscultation of the heart as 
the heart may cease to beat in cases where there are 
changes in the myocardium. 
Bradycardia Due to Imperfect Conduction (heart 
block or complete dissociation)—Pulse rate drops to 
40 or below. Lesion of the stimulus conducting sys- 9 
BEDSIDE EXAMINATION 
tern (bundle of His). Sometimes caused by stimula- 
tion of the vagus as by the effect of digitalis. 
7. Inequality—Unequal height of the pulse waves. 
8. Arrhythmia—The diagnosis of the finer arrhyth- 
mias is best determined by graphic methods. The 
changes discussed in this outline are those which can 
be determined by ordinary physical examination at 
the bedside. 
The more important forms of cardiac irregularities. 
A. Pulsus irregularis respiratorius—Sinus arrhyth- 
mia. 
Regular increase of pulse rate during inspiration and 
slowing in expiration (variation of vagus tonus). 
Experimental increase of this phenomenon by pressure 
on the vagus (see above). 
B. Extrasystole, as in groups in pulsus bigeminus 
and trigeminus. Characterized: 
(a) By pulsus intercidens, in which a small, low 
wave occurs between two pulse waves which occur at 
the normal interval. The normal wave which follows 
this phenomenon is also smaller. 
(b) Asa result of a too early, small, pulse beat with 
a following, complete, compensatory pause (both tones 
corresponding to the extrasystole are found to be early 
when the heart is examined). 
(c) By a pause unaccompanied, by a palpable wave 
which is too early (incomplete extra-contraction of 
the left ventricle and which can be demonstrated at 
the heart only by an extrasystolic tone). 10 
A CLINICAL GUIDE TO 
The wave following the pause in both “b” and “c” 
is very large and may be associated with a visible 
enlargement of the veins in the neck. (See tachycardia 
in regards to grouped extrasystole, page 8.) Certain 
cases of auricular and ventricular extrasystole may be 
differentiated by observation of the coincident pulsa- 
tion of the venous pulse in the neck and by comparison 
with the auscultatory findings at the apex of the heart. 
The visible abnormal engorgement of the veins which 
corresponds to the extrasystole appears in auricular 
extrasystole at the same time or before the acoustic 
impression of the first tone of the extra beat is found. 
(Explanation: retardation of the visible perception as 
compared with the acoustic.) The abnormal engorge- 
ment of the veins occurs immediately after the first 
tone of the extrasystole in cases of ventricular extra- 
systole where the succeeding auricular contraction oc- 
curs during the premature contraction of the ventricle. 
C. Pulsus irregularis perpetuus—Completely irregu- 
lar pulse with similar action of the ventricle (auricular 
fibrillation or auricular flutter, depending on the fre- 
quency). Most frequently but not exclusively in mi- 
tral stenosis. (See tachycardia, page 8 and venous 
pulse, page 90.) 
D. Disturbances in conduction—(a) Lucian’s peri- 
ods, larger pulse groups which are separated by pauses. 
The several intervals between the beats in one group 
gradually become smaller (gradual reduction in con- 
ductivity). This is accompanied by a continuous regu- BEDSIDE EXAMINATION 
11 
lar pulsation of the auricle which may be recognized 
by the venous pulsation in the neck. 
(b) Partial block—A strikingly slow regular or ir- 
regular pulse in severe disturbances of conductivity. 
Each pulse beat corresponds to a ventricular contrac- 
tion which may be demonstrated by palpation and aus- 
cultation. The auricle continues to beat independently 
in its own rhythm (audible auricular tones; the venous 
pulsation of the neck as a control). 
(c) Complete dissociation—(See bradycardia, page 
9.) 
9. Condition of the Pulse Quality on Both Sides of 
the Body (especialy at the radial and carotid arteries 
and relative to height and filling of the pulse wave and 
subsequent delay of same).—Physiological differences 
at the radial artery in variations and course are pos- 
sible. Also in pathological conditions as in localized 
arteriosclerotic or inflammatory changes in the vessel 
wall in the region where the larger vessels begin or 
even more peripherally. Also in compression of an 
artery as by tumors, by a greatly enlarged left auricle 
as in mitral stenosis, etc., and in changes in the lumen 
of a vessel as in aneurysm. The occurrence of the 
radial pulse at different times in the two extremities 
(delay of the pulse) is seen in large aneurysms of the 
aorta, subclavian or brachial arteries. The filling on 
the normal side may be better or worse. There may 
be a difference in filling without delay. 
10. Dicrotism—Two crests palpable in the periphe' 12 
A CLINICAL GUIDE TO 
ral pulse wave during its descent, occurring in infec- 
tious diseases, thyreotoxicosis, etc. 
11. Paradoxism—The pulse becomes smaller during 
inspiration. 
(a) Caused extra-thoracic ally by clavicles which are 
especially low and which are pressed against the sub- 
clavian artery during inspiration. 
(b) Dynamic cause—The thorax which is widened 
during inspiration aspirates blood in the lungs and 
allows a smaller quantity of blood to pass out from 
the lungs into the left heart (physiological paradox- 
ism). 
(c) Mechanical cause—In concretio cordis cum 
pericardio. The heart is covered by a thick layer of 
fibrous tissue and this, together with the filling of the 
lungs during inspiration, diminishes the space for the 
heart so that only a smaller quantity of blood can enter 
it at this time, The result is the expulsion of a smaller 
quantity of blood. (Pathognomonic paradoxia.) 
Differentiation of these three forms—The first form 
disappears upon raising the arms. The pulse wave 
in the second is lowest at the beginning of inspiration 
and highest at the end of inspiration or beginning of 
expiration. The last form has its lowest pulse wave 
at the height of inspiration and the highest during the 
pause in breathing. 
Respiration 
1. Type of breathing—Costal, abdominal or costo- 
abdominal. BEDSIDE EXAMINATION 
13 
2. Symmetry of breathing—Determination by in- 
spection, often better by placing a hand on each side 
of the thorax during inspiration. Recognition of local 
retractions as in peripneumonic retraction. (See in- 
filtration, page 66.) 
3. Rate of breathing — Oligopnea, polypnea (see 
dyspnea). 
4. Depth of breathing—Normal, deep or superficial. 
5. Comparison of the duration of inspiration and 
expiration.—Disturbance of this relation in inspiratory 
and expiratory dyspnea. Stenosis of the larger air 
passages often with expiratory dyspnea and stridor. 
6. Dyspnea (difficult breathing) (Sahli)—It is rare 
to see a pure subjective dyspnea (neurasthenia) or 
pure objective dyspnea as in well compensated mitral 
lesions. Both types are usually combined. Dyspnea 
may occur in inspiration, expiration or both phases 
(inspiratory, expiratory and mixed dyspnea). It may 
be associated with breathing which is superficial and 
rapid, slow and deep or rapid and deep. Slow and 
deep breathing is common in hindrance at the upper 
air passages and is not seldom accompanied by an 
inspiratory stridor. Rapid and superficial breathing 
occurs in painful pleuritis sicca, trichinosis of the in- 
tercostal muscles or diaphragm, peritonitis, etc. 
(a) Deep breathing (Kussmaul) in acidosis—Fre- 
quently in diabetic coma, coma in cholera, salicylic acid 
poisoning, uremia, etc. 
Special Forms of Breathing 14 
A CLINICAL GUIDE TO 
(b) Periodic breathing (Cheyne-Stokes)—Slowly 
increasing and then decreasing respiratory rate with 
a pause. 
(c) Biotic breathing—Deep and slow with intervals 
of pause. Found in cerebral disturbances. 
(d) Paradoxic respiration—A large effusion in the 
pleural cavity may cause the diaphragm to bulge 
toward the abdomen instead of being in the normal 
position of convexity towards the head. This may 
result in an in-drawing of the upper abdominal region 
when the diaphragm is shortened during inspiration 
instead of a bulging of the abdomen as occurs nor- 
mally. This is still further exaggerated by the in- 
creased respiratory excursion of the healthy side and 
by a displacement of the mediastinum to that side. 
The navel is displaced toward the diseased side dur- 
ing each inspiration (paradoxic breathing). 
The normal contraction of the diaphragm causes an 
equal pressure on the abdominal viscera and a sym- 
metrical widening of the lower thoracic aperture. 
This may be impossible in adhesive processes within 
the thorax, especially if there are also extensive adhe- 
sive pericarditis and mediastinitis. The resulting con- 
traction then serves but to bring together the anterior 
attachments at the sternum and the posterior attach- 
ments at the spine. The drawing-in of the lower ster- 
num is the result (Wenckebach). 
Litten’s phenomenon—The shadow of the moving 
diaphragm may be seen on the lateral wall of the 
thorax during respiration, with unilateral illumination BEDSIDE EXAMINATION 
15 
at the foot of the bed. The phenomenon may be 
absent on one side in pleuritis, paralysis of the 
diaphragm, etc. 
T em per at ure 
May be taken in the axillary space, mouth or rec- 
tum. Usually taken per mouth. Should always be 
taken per mouth if the patient is undergoing out-door 
treatment. Nothing hot or cold should be taken per 
mouth for one-half hour before taking the tempera- 
ture. Rectal temperature may be used as a control 
(hysteria, simulation). 
Sources of error in rectal temperature; higher rectal 
temperatures after bodily motion, inflammatory dis- 
ease of the pelvis or anal region. 
An abnormally great difference between the axillary 
and rectal temperatures may, in some cases, point to 
inflammatory disease of the pelvis. 
Oral and rectal temperature are several tenths of a 
degree higher than axillary. 
Higher morning temperature should be watched for 
in subfebrile conditions. The average temperature of 
an individual is of importance in judging the height 
of a fever. 
Types of fever; intermittent, continuous, remittent. 
The temperature curve should be plotted and notes 
should be made of chills and sweats. 16 
A CLINICAL GUIDE TO 
Inspection and Palpation of the Various Regions 
(a) Head 
Size and Shape 
Proportion of the portion of the head containing the 
brain to that of the face, as in hydrocephalus or acro- 
megaly. Asymmetry. Palpation of the skull; sutures, 
protuberances, exostosis, circumscribed tumors, meta- 
stasis. Edema of the hairy scalp in inflammations and 
stasis (stasis of the vena cava). 
Tenderness on percussion. 
Tenderness on pressure at the places of exit of the 
nerves, also at the mastoid process, frontal and maxil- 
lary sinuses (collateral edema). Determine percussion 
note of the vault. 
Eyeballs—Position as enophtalmus, exophthalmus, 
strabismus, conjugal deviation, weak convergence. 
Paresis of the lid, width of the palpebral fissure, lid 
edema, examination of the pupils. 
Nose and Ears—Shape and size, condition of the 
lobules, formation of nodes. 
Teeth—Shape and position, tenderness, looseness 
(caries), defects of the enamel. 
Tongue—Size, shape, movement, atrophy, surface, 
coating, color (typhoid tongue with gray or brown 
centre and clean tip and margin. Coated tongue espe- 
cially in stomach diseases. Strawberry tongue in scar- 
latina, etc.). Atrophy of the lingual mucous mem- 
brane as in pernicious anemia. BEDSIDE EXAMINATION 
17 
Mouth and Throat—Palpation of base of tongue. 
Soft and hard palate (shape, defects). Secretion of 
saliva. Oral mucous membrane (coating, ulceration, 
epithelial defects, pigmentations). Tonsils (size, 
crypts, plugged crypts, coating). Uvula, size, shape, 
position. Palpation of posterior pharyngeal wall. 
Granular appearance. Pharyngeal reflexes. Bulgings, 
etc. 
Length, width, contour. 
Thyreoid gland.—Size, shape, consistency, mobility 
on swallowing, thrills, pulsation. 
Lymphglands—Detailed palpation, also in supra- 
clavicular fossae. Size, shape, consistency, tenderness. 
Enlarged, isolated or grouped. Adherence to skin or 
underlying tissues. Infiltration, fistula. 
Larynx—Size, tenderness, shape, voice. Determina- 
tion of vocal fremitus anteriorly on thyreoid cartilage 
and with loud phonation. Absent or diminished fremi- 
tus on the side of recurrent paralysis. Swallowing 
movements (Oliver-Cardarelli). Pulsus laryngeus de- 
scendens (see page 77). Pulsus laryngeus ascenderis 
more rare. 
Neck Musculature—Development and tone. 
Evidence of Passive Congestion—Veins and lymph- 
atics (see pulse). 
Cervical Vertebrae—Course, mobility, tenderness on 
percussion and pressure, cervical ribs. 
(b) Neck 18 
A CLINICAL GUIDE TO 
(c) Thorax 
Lines of Orientation 
Vertical—Anterior median line, sternal line at mar- 
gin of os sternum, medio-clavicular line and para- 
sternal line (latter midway between the medio-clavicu- 
lar and sternal lines). Anterior, middle and posterior 
axillary lines. Scapular line through the angle of the 
scapula. Interscapular line between the spine and 
inner border of the scapula. Para-vertebral line close 
along the spinal column. Posterior median line. 
Horizontal—Ribs, intercostal spaces, spinous proc- 
esses, angle and spine of the scapula. 
Regions—Supra- and infra-clavicular fossae, inter- 
scapular region, axillary region, supra- and infra- 
spinatus regions, hypochondrial region. 
Dimensions—Length, breadth, depth of the entire 
thorax and its various portions. Position of the upper 
and shape of the lower thoracic apertures. 
Breathing—(See page 12)—Type, frequency, sym- 
metry, depth, duration of inspiration and expiration. 
Functioning of the various parts of the thorax. Local 
retraction during breathing. 
Bulgings—Aneurysms, tumor. Shape of the supra- 
and infra-clavicular fossae and of the jugular fossa, 
especially depth or bulging (supra-clavicular pulmo- 
nary emphysema) and filling out (glands, congested 
veins). 
Skin—Condition of the veins, arterial and venous 
collaterals (isthmus stenosis, mediastinal tumor). Lo- BEDSIDE EXAMINATION 
19 
calized edema; collateral in emphysema, abscess and 
inflammatory mediastinal tumors or pleural tumors. 
Tenderness of the skin and muscles (see Zones of 
Head and Painful Pressure Points). 
Ribs—Shape, course, floating and supernumerary 
ribs. Epigastric angle, width and depth of intercostal 
spaces. Bulging or resistence at the ribs, tenderness 
on percussion and pressure. Elasticity, abnormal soft- 
ness, rigidity (osteomalacia, osteoporosis, metastasis). 
Very distinct diaphragmatic furrow in non-resistent 
ribs. 
Sternum — Width, angulation, angle of Louis. 
Changes in shape. Tenderness on percussion and pres- 
sure, erosions, metastasis. Diseases of the bone mar- 
row (anemia, leucemia). 
Spine—Course and shape. Physiological lordosis of 
the cervical and lumbar vertebrae. Kyphosis of upper 
portion of thorax. Pathological kyphosis, lordosis, 
scoliosis. A moderate dextro-scoliosis is often seen 
in the upper part of the thorax. 
Scoliosis—Twisting due to disease of the spine or 
secondary to pleuritic adhesions. Sciatica, psoas ab- 
scess, etc. Projection anteriorly, latterally or poste- 
riorly of several vertebrae. Splitting of the spinous 
processes or vertebral arches (spina bifida, meningo- 
cele). 
Mobility of spine in all directions. Abnormal, re- 
gional or general limitation of motion. 
Tenderness of the entire spine, single vertebrae or 
segments:— 20 
A CLINICAL GUIDE TO 
(a) Overloading, especially in diseases of the ver- 
tebral bodies. 
(b) Active or passive movements (disease of several 
portions of the vertebrae and their joints). 
(c) Pressure. 
(d) On percussion as in spondylitis (rigidity of the 
neighboring musculature). 
(e) Prolonged application of warmth (application 
of heat to the spine increases pain in caries). 
Spinalgia is determined by percussion of the spine 
with a percussion hammer. In acute and chronic proc- 
esses of the bronchial glands, Petruschky’s sign in 
tuberculosis of the glands of the upper portion of the 
chest. Tenderness of the spine in tumor metastasis 
and erosions (aneurysm). 
Skin hyperesthesia as a segmental symptom (symp- 
tomatic intercostal neuralgia). Differentiation of bone 
tenderness from para-vertebral tenderness at the point 
of exit of the nerves. Test with short application of 
heat (hot test tubes). Increased sensitiveness to 
warmth especially in inflammatory processes. BEDSIDE EXAMINATION 
21 
APPENDIX 
Types of Thorax 
Thorax Paralyticus (asthenicus) 
Flat, long, marked downward curve of the ribs 
posteriorly and upward curve anteriorly. Wide inter- 
costal spaces, acute epigastric angle. Inferior thoracic 
aperture symmetrically narrower, upper thoracic aper- 
ture drops anteriorly. Abdomen flat, drawn in. Dis- 
tance between crest of ilium and last ribs relatively 
small. A form of thorax paralyticus with kyphosis 
may be seen in severe, chronic pulmonary tuberculosis 
due partly to a secondary process, shrinkage and loss 
of fatty and muscular tissue. 
Thorax Emphysematicus—Inspiratorius 
, Barrel shaped, short, wide, very deep. Bulges very 
much. Course of ribs horizontal. Intercostal spaces 
relatively narrow, wide epigastric angle. Upper thor- 
acic aperture placed horizontally, upper border of 
sternum near larynx, relatively large distance between 
last rib and crest of ilium. Occasional retraction of 
the lower thoracic aperture during inspiration. Abdo- 
men at same level, or bulges forward. 22 
A CLINICAL GUIDE TO 
In enteroptosis. Long upper portion bulges out- 
ward in both directions up to the fourth rib and again 
becomes flat and narrowed in the lower part (pear 
shaped). Upper thoracic aperture elevated, especially 
the sternal ends of the clavicles. The arms tend to 
hang more posteriorly. 
Rachitic Thorax—Chicken breast, wedge-shaped, 
sternum bulges anteriorly. 
Kypho-scoliotic Thorax—Acquired anomaly of ster- 
num and ribs. 
Shoemaker’s Chest—Only the lower part of the ster- 
num (xyphoid) drawn inwards. Ribs pushed inwards 
anteriorly. 
Funnel Chest—A congenital deformity of the skele- 
ton. Thorax and pelvis shortened in antero-posterior 
diameter. Lower sternum and epigastric region sym- 
metrically retracted in a funnel shape. Upper abdo- 
men drawn in and lower part bulging outward. 
Thorax Pyriformis (Wenckehach) 
(d) Abdomen 
General 
See above for continuations of the vertical lines of 
orientation from the thorax. The transverse lines are 
the line of the costal arch, the rib line which connects 
the lowest point on each side of the arch, the umbilical 
line which runs horizontally through the navel and the 
iliac line which connects the crests of the ilium. The 
Orientation BEDSIDE EXAMINATION 
23 
posterior lines of orientation pass through the various 
spinous processes and are numbered according to the 
latter. 
Regions 
The epigastric region is bounded by the line of the 
costal arch and rib line, the mesogastric region by the 
rib and iliac lines and the hypogastric region by the 
iliac line and Poupart’s ligament. The mesogastric 
region corresponds posteriorly to the lumbar region. 
Inspection 
Configuration of the abdomen and its relation to 
the level and size of the thorax. Globular, egg-shaped, 
pear-shaped. Bulging in the flanks, generalized dis- 
tention. 
Localized bulgings and unequal involvement of the 
various segments during respiration as, e.g., absence 
of movement during respiration of the lower right 
abdominal quadrant especially in appendicitis, but also 
in parametritis, pyosalpinx, torsion of an ovarian cyst 
or myoma and extra-uterine pregnancy. 
Skin of the Abdomen 
Striae, scars, localized edema, collateral veins (peri- 
umbilical caput madusae in stasis of the portal vein 
and in the flanks in stasis of the vena cava). Deter- 
mination of the direction of the current by compres- 
sion with the finger; the part of the vein between the 
source of the blood and the compressing finger be- 
comes engorged while the part between the compressing 24 
A CLINICAL GUIDE TO 
finger and the ultimate destination of the blood in the 
vessel becomes collapsed. 
The veins of the skin of the epigastric region may 
become visibly enlarged in a purely mechanical man- 
ner as a result of pressure by an enlarged liver against 
the rib margin. This must not be mistaken for stasis 
of the portal vein or vena cava. 
Abdominal Musculature 
Tension, rigidity, diastasis.—Reflexes of the abdomi- 
nal walls and cremasteric region. Position, retraction 
or bulging (hernia) of the navel. 
Method—Generally in full supine position, half late- 
ral position or standing with slight bending forward. 
Palpation with flat of hand (see palpation of the 
spleen), flat, thrusting or bimanual palpation. Local- 
ized or generalized muscular rigidity. The other por- 
tions of the abdomen should be first palpated if there 
is pain or tenderness in a certain area. Warm bath if 
marked rigidity. 
General Palpation for Orientation—Hernia, abnor- 
mal resistance or tumor of the abdominal wall. Dif- 
ferentiation of the latter from intra-abdominal tumors 
by palpation during active contraction of the abdomi- 
nal muscles by sitting up or raising the head while in 
the supine position. This will rule out suffusions, 
hematoma, tumors of the abdominal wall (Nelaton, 
Schloffer) and umbilical metastasis. 
Palpation BEDSIDE EXAMINATION 
25 
The abdominal aorta is often palpable in the epi- 
gastrium and the pulsation is more distinct in emacia- 
tion and enteroptosis. The sclerosed abdominal aorta 
may be palpated for a longer distance. Palpation of 
aneurysm of the abdominal aorta or abdominal vessels. 
Demonstration of meteorism and ascites (see per- 
cussion). Diffuse air-cushion-like distension in mete- 
orism. Trans-abdominal fluctuation in all directions 
in ascites. May be determined per rectum, vagina or 
patent inguinal ring. Similar findings sometimes in 
large, intra-abdominal unilocular cysts. 
The Various Abdominal Organs 
General orientation by systematic superficial and 
deep palpation of the organs normally reached by this 
method. Determination of size, shape, surface, con- 
sistency and respiratory and passive mobility of the 
palpable margin. 
The size of palpable organs and resistance are often 
thought to be larger than they really are. 
Liver 
Inspection—Skin in the liver region (see page 23). 
A considerably enlarged liver may be recognized by 
the bulging of the right hypochondrium and projection 
of the lower border of the ribs in this region. 
Lower margin of the liver visible in emaciation, 
ptosis, enlargement of the organ and the condition of 
the liver surface may at times be seen. The visible 
enlargement may be of the entire organ, single lobes, 26 
A CLINICAL GUIDE TO 
nodular enlargements or of the gall-bladder. Visi- 
bility of the respiratory excursion. 
Palpation—Position, course, and condition of the 
lower border (rounded, sharp, irregular, etc.). Super- 
ficial consistency, palpable rubs, hydatid thrill. 
The entire liver border is often palpable normally. 
Descent of the lower border in ptosis of the liver, low 
diaphragm or enlargement of the liver (determination 
of the lung-liver boundary by percussion). Sharp or 
rounded border (latter in passive congestion). Posi- 
tion of the notch between the lobes is variable but is 
usually between the right para-sternal line and medio- 
clavicular line. Abnormal projections or depressions. 
Ridel’s lobe. Asymmetrical enlargement of the lobes 
(left lobe often enlarged in syphilis). 
Surface—Smooth (liver of passive congestion, amy- 
loidosis, fatty liver, Hanot’s cirrhosis, cirrhosis due to 
biliary stasis, some forms of hepatitis, etc.). Finely 
or coarsely granular surface (former in atrophic Laen- 
nec’s cirrhosis or induration from chronic stasis of 
blood or bile and the coarse granulation is found in 
syphilis of the liver, cysts, ecchinococcus and meta- 
stasis of the liver). 
Consistency—Normal, increased or decreased. Dif- 
fuse or circumscribed changes. Circumscribed fluctua- 
tions (soft metastasis, etc.), local pulsations (angioma) 
and diffuse pulsations (see pulsating liver). 
Tenderness on pressure and percussion (best with 
a percussion hammer). Diffuse or localized. Circum- 
scribed tenderness in the region of the incisura, some- BEDSIDE EXAMINATION 
27 
times best demonstrated with the patient on left side 
and thrusting fingers under the ribs (cholecystitis). 
Circumscribed tenderness in the median line as a part 
of the dififuse tenderness in diastasia recti and conges- 
tion of the liver. Same in inflammatory or purulent 
processes (abscess, perihepatitis with occasional peri- 
hepatic rub). 
Diffuse Tenderness—Passive congestion of the liver, 
especially increased in acute congestion and sometimes 
resembling localized peritonitis. Also in diffuse par- 
enchymatous processes, catarrhal icterus, infectious 
icterus, hemolytic icterus, subacute yellow atrophy of 
the liver, etc. 
Tenderness on percussion of the hepatic region with 
the ulnar side of the hand or tenderness on thrusting 
palpation at the borders of the ribs in inflammatory 
or purulent processes in or above the liver (subphrenic 
abscess with descent of the liver, edema or redness of 
the skin and bulging of the hypochondrium. (See 
percussion. ) 
Palpation of the Gall-Bladder 
Hardly palpable under normal conditions. May be 
palpable under pathological conditions as a tense or 
hard resistance (hydrops of the gall-bladder, chole- 
cystitis, peri-cholecystitis, stone formation, tumors). 
Palpation of the gall-bladder often difficult in inflam- 
matory processes with rigidity or edema of the abdo- 
minal wall. 
Differentiation of a palpable gall-bladder from a 28 
A CLINICAL GUIDE TO 
kidney or other tumor of this region. Gall-bladder 
tumor may be pedicled or may be pushed laterally in 
pendulum manner. Distinct ballottement as in the 
kidney if the latter and the overlying gall-bladder are 
manipulated at the same time. • Large gall-bladder 
tumors may show “lateral ballottement” if the poste- 
rior palpating hand is placed more outwardly on the 
back instead of near the spine. Tumescence and tu- 
mor of the gall-bladder usually show distinct respira- 
tory excursion. (Method similar to palpation of the 
spleen.) 
Spleen 
Inspection—Forward bulging of the left hypochon- 
drium in large splenic tumor (compare with liver). 
The borders of the spleen and its notch may be 
visible in marked enlargement. The respiratory ex- 
cursion of the spleen is also sometimes seen. 
Palpation—Size, shape, course, consistency and con- 
dition of the borders. 
Method—Patient in half right lateral position, ab- 
dominal musculature relaxed as much as possible and 
left arm on head. Also in supine and standing posi- 
tions with slight stooping forward. The palpating 
hand is placed flatly on the abdomen, the finger tips 
towards the costal arch so that the lower pole of the 
spleen touches the tips of the fingers during deep 
inspiration. The palpating hand remains at rest. The 
fingers may be thrust under the ribs and the lower 
pole of the spleen may be felt under the ribs during BEDSIDE EXAMINATION 
29 
inspiration. This method may be aided by pushing 
the spleen forward from the left hypochondrium. 
Note size and shape.. sized spleen not pal- 
pable except in descent of the diaphragm (pleuritic 
exudate, pneumothorax, etc;). ”>-■ . 
Symmetrical enlargement of the spleen (splenic tu- 
mor) in passive congestion, infectious diseases and 
diffuse parenchymatous changes in the spleen as in 
diseases of the blood. Metastasis/ malignant tumors, 
etc. Notch in medial border prominent in marked 
enlargement. Length of the spleen in centimetres 
(distance between upper limit of splenic dullness and 
lower pole and not by measuring the.part projecting 
beyond the ribs). Surface; smooth, nodular (local- 
ized tumors or cysts), palpable rubs (perisplenitis). 
Consistency; normal, diminished (acute splenic tu- 
mor) ; increased (chronic splenic tumor of the spleen). 
Tenderness on palpation arid percussion. Respiratory 
excursion usually distinctly demonstrable. 
Differentiation of splenic tumor from tumors of 
the splenic flexure, of the left kidney and adrenal, tail 
of the pancreas, tumors of the omentum, mesenteric 
glands and stomach. 
Kidney 
Inspection—Visible bulging only in marked enlarge- 
ment of the organ (renal tumor, cysts, hydroneph- 
rosis). 
Palpation—Method; always bimanual, supine posi- 
tion and in right and left lateral position. 30 
A CLINICAL GUIDE TO 
Position—Right kidney normally lower than left and 
is more easily palpated even when normal. It is diffi- 
cult to palpate the left kidney, even in some cases of 
ptosis (higher position, covered by colon). Reduction 
of ectopic kidney (see percussion). 
'Mobility of the kidneys—Especially marked in 
ptosis, floating kidney (degree of mobility depends on 
extent of bimanual grasp of the kidneys). Respira- 
tory mobility (normally of slight degree). 
Shape, size, consistency and condition of surface. 
Palpation of tumors, either unilateral or bilateral 
cystic kidney. Variation in size in hydronephrosis, 
fluctuation, etc. 
Tenderness of the kidney region on palpation and 
percussion of the lumbar region with the ulnar side 
,of the hand or fist. (See zones of Head.) 
Collateral edema of the skin in the lumbar region 
(pyonephrosis, peri-renal inflammation). Tenderness 
on palpation also found in acute swelling (nephritis), 
renal stone, etc. 
Inspection and palpation of the region of the blad- 
der. Filling of the bladder, abnormal tenderness (peri- 
cystitis mistaken for cysts or pregnancy and proved 
on catheterization). Contractibility of the bladder in 
nervous diseases. 
Stomach 
Inspection—Bulging of the stomach in gastric me- 
teorism, dilatation, stiffening. Gastric peristalsis and BEDSIDE EXAMINATION 
31 
anti-peristalsis. The change in size, etc., may be noted 
by marking horizonal and perpendicular lines on the 
abdomen and comparing the position, distention, etc., 
at various intervals. Peristaltic waves may be stim- 
ulated by gently striking the abdomen with a moist 
towel or use of ether spray. Visible tumors. Dis- 
tention of stomach with soda bicarbonate and tartaric 
acid to make its contour visible. This may differen- 
tiate a long, narrow stomach with a low greater curva- 
ture (ptosis) from a stomach turned horizontally 
(dilatation). This may stimulate visible peristalsis. 
Effect on tumors (more or less distinct, displacement). 
Palpation—(See abdominal tumors page 34). 
Demonstration of clapotage by thrusting palpation 
of stomach. Tenderness (see pressure points and 
zones of Head, page 38). 
Intestine 
Inspection—Visible, physiological peristalsis in thin, 
relaxed abdominal walls. The bulging by distention 
of meteorism of the small bowel is peri-umbilical, of 
the colon in the right and left flanks and in the ileo- 
cecal region in atony or flatulence of the cecal portion 
of the colon. Differentiation of peristalsis of the 
small and large intestines. Tumors. 
Palpation—Portions of the intestines often normally 
palpable such as the descending colon, sigmoid (ab- 
normal distention above the symphysis and extending 
toward the ileo-cecal region) and the cecum (striking 
concavity at the ileo-cecal region in high position of 32 
A CLINICAL GUIDE TO 
cecum). Palpable fecal masses (plastic and can be 
moulded by pressure). (See next part for abdominal 
tumors.) 
Tumors of the Abdomen Not Caused by 
Enlargement of an Organ 
Size, shape, surface, consistency, tenderness and 
p ids at ion. 
Localisation—In the abdominal walls, extra-perito- 
neally, intra-peritoneally, retro-peritoneally. Disap- 
pearance of intra- and retro-peritoneal tumors in ten- 
sion of the abdominal wall (sitting up or raising the 
head). Position in relation to stomach, intestine (also 
after inflation of these) and to other organs. 
Respiratory Excursion—Descent of tumors in in- 
spiration if they are not fixed but are attached to 
organs which move on respiration. Most distinct in 
stomach, liver, transverse colon, spleen, omentum, and 
less marked in the kidney, mesenteric glands, cysts and 
retro-peritoneal tumors unless the tumors are of very 
large size. 
Fixation During Expiration—The tumor is grasped 
from above in inspiration and it is attempted to hold 
it in that place during expiration. Failure to accom- 
plish this speaks for direct or indirect fixation (adhe- 
sion of a tumor of the stomach to the liver) (Noth- 
nag el). 
General Passive Mobility—Especially marked in BEDSIDE EXAMINATION 
33 
tumors of the omentum and mesentery, pedicled cysts 
and myomata, etc. 
Exclusion of the existence of an ectopic organ by 
demonstrating by palpation and percussion that the 
organ is in its normal position. 
Demonstration on palpation and percussion of a con- 
nection with an abdominal organ or myoma of the 
uterus, tumor of the ovary, hypernephroma, intes- 
tinal tumor, gall-bladder tumor, etc. Border of the 
liver in tumor of the gall-bladder. 
Hernial Rings 
Examination of the hernial rings; hernia inguinalis, 
femoralis, ischiadica, umbilicalis, abdominalis, etc. 
(hernia of the abdominal wall). Description of size 
and shape of hernial protrusion, contents, ability to 
reduce. Changes of the covering skin; redness, swell- 
ing, tenderness. 
Inspection and digital examination.—Hemorrhoids, 
fistula, prolapse. Size and condition of the prostate. 
Position, size, shape of the uterus. Palpable and vis- 
ible tumors. 
Palpation of the pouch of Douglas.—Condition of 
the mucosa and its mobility over tumors. Palpable 
bulging in the pouch of Douglas; abscess, proctitis, ap- 
pendicitis, tumors, ascites. Degree of contraction of 
the sphincter. Spasm or relaxation as a symptom, 
especially in paresis of the bowel (peritonitis). Shape, 
Rectum 34 
A CLINICAL GUIDE TO 
size and filling of the ampulla. Fecal retention in 
torpor recti, dyschezia. Palpation of the sacrum. 
Genitalia 
Size and development of the external genitalia. 
Gynecological examination of the uterus and adnexa, 
vaginal palpation and recognition of processes limited 
to the extra-genital parts (ectopic organs, abscesses, 
peri-appendiceal tumors, etc.). 
Length of the extremities in relation to the trunk. 
Relatively long in large growth of eunuchoids and 
relatively short in chondro-dystrophy. Cartilaginous 
exostosis. Giant or dwarf types. Proportion of the 
various parts of the body. 
Position of the extremities as slight flexation of the 
right hip and knee in peri-typhilitis and also in acute 
right-sided parametritis, pyosalpinx, torsion of a cyst 
or myoma; extra-uterine pregnancy. 
Hypertrophic and atrophic processes of the skin 
(sclerodermia, nervous diseases, marasmus). Wave- 
like course of arteries and veins, aneurysm, varix. 
Local ciculatory disturbances, local asphyxia, bluish 
discoloration or pallor, vascular changes from em- 
bolus, thrombus, changes in the vessel wall or func- 
tional disturbances like spasm or paresis of the vessels. 
Examination of the dorsalis pedis (pulse difficult to 
feel or absent in intermittent claudication). 
(e) Extremities BEDSIDE EXAMINATION 
35 
Local edema—Stasis in the veins or lymph vessels 
(chronic lymphatic stasis or elephantiasis). 
Local rise in temperature—Redness, swelling, dif- 
ferences in temperature as in hemiplegia, sciatica. 
Determination of mobility or arrest of motion. 
Deformities of the bones (exostosis, callus forma- 
tion, tophi, Heberden’s nodes, drumstick fingers). 
—Shape of fingers and toes (changes in acromegaly). 
Shape and condition of the nails (fragility in tetany). 
Joints—General configuration, especially unilateral 
enlargements in arthropathies resulting from nervous 
diseases (tabes, syringomyelia). Active and passive 
motion, partial or complete limitation of motion. Red- 
ness, abnormal pallor of the skin (tumor albus), swell- 
ing, local edema. 
Tenderness on local pressure or movement. 
Determination of fluctuation as a sign of fluid in the 
joint (ballottement of the patella). 
Swelling about the joint—Condition of the tendon 
sheaths and serous sacs. Feeling of crackling of rub- 
bing in the joints. 
Condition of the musculature.—Development, atro- 
phy, hypertrophy, pseudo-hypertrophy. Tone, consist- 
ency (like dough in myositis and as hard as bone in 
myositis ossificans). Tenderness, local infiltration in 
trichinosis, cysticercus. Muscle hematoma in hemor- 
rhagic diathesis. 
Active and passive mobility of the extremities and 
increased or decreased muscle tone. 
Skin, tendon and periosteal reflexes. 36 
A CLINICAL GUIDE TO 
APPENDIX 
Hyperesthetic Zones of Head and Tender Points 
Hyperesthetic segments of the skin, muscle, tendons, 
cartilage and bones may be found in various diseases 
of the organs, especially those of inflammatory nature 
(cholecystitis, appendicitis, etc.). These are the so- 
called zones of Head and often correspond to the 
radiating pains from these organs. The pain or ten- 
derness goes from the organ to the spinal cord via 
the sympathetic fibres. The course is then via the 
sensory fibres of the posterior roots to the skin. The 
table on the following page shows these zones: BEDSIDE EXAMINATION 
37 
Organ 
Nerve Segment 
Localization of the Corresponding Zone on the Skin 
Heart 
Cervical 3 to Dor- 
sal 8 
From the supra- and infra-clavicular fossae downwards to the 
7th rib. Arm and forearm. Supraspinatus fossa on the back 
downwards to the level of the 8th thoracic vertebra. 
Lungs 
Cervical 3 and 4 
Dorsal 3 to 9 
From the supra- and infra-clavicular fossa downwards to the 
costal border. Dorsally: from supraspinatus fossa down- 
wards to the 11th dorsal vertebra. The arms same as above. 
Stomach 
Dorsal 7 to 9 
From the level of the xyphoid to nearly at a horizontal level 
of the navel. Dorsally: from the 8th to the 11th dorsal 
vertebra. 
Intestine 
Dorsal 9 to 12 
From horizontal line through navel to Pouparfs ligament. 
Dorsally: from the level of the spine of the 12th dorsal 
vertebra to the level of the 4th lumbar vertebra. 
Liver 
Dorsal 7 to 10 
From the 7th rib to the level of the navel. Dorsally: from the 
level of the 8th to 12th spine of the dorsal vertebra. 
Kidney 
Dorsal 10 to Lum- 
bar 1. 
From level of the navel to slightly below Poupart’s ligament. 
Dorsally: from level of spine of 12th dorsal to the coccyx 
and gluteal folds. 38 
A CLINICAL GUIDE TO 
The skin hyperesthesia may be demonstrated in its 
various areas by use of slight sticking with a pin or 
touching with a cold or hot object (test tubes filled 
with cold and hot water). 
Some practically important hyperesthetic zones of 
Head. 
The skin overlying inflamed tissues or organs is 
generally hyperesthetic but is not a zone of Head 
strictly speaking. 
Examples of Zones of Head 
1. Angina pectoris (stenocardia, aortalgia)—Hyper- 
algesia of left side of thorax and inner side of the 
left arm and left side of neck. 
2. Appendicitis—Hyperalgesia of the right hypogas- 
trium. 
3. Cholelithiasis—Hyperalgesia over the right costal 
arch and upper rectus. 
4. Nephrolithiasis—Hyperalgesia of the back above 
the iliac crests and anteriorly of the abdomen along 
Poupart's ligaments. 
5. Pleural disease—Hyperalgesia of the skin corre- 
sponding to the site of the lesion. 
6. Spondylitis— Hyperesthesia over and to the sides 
of the place corresponding to the diseased area. 
7. Acute tonsillitis—Hyperalgesia of the skin of the 
neck behind the jaw. BEDSIDE EXAMINATION 
39 
The Most Important Points of Tenderness 
There are definite points which are tender in dis- 
ease of deeply situated organs and which do not always 
lie over these organs. Tenderness of the organ itself 
is to be differentiated from the tenderness in the zone 
of Head and of the points of tenderness under discus- 
sion. This tenderness of the organ cannot be found 
if the overlying muscle is made tense. 
The points of tenderness under discussion are found 
by pressure with the tip of the finger or striking with 
the percussion hammer. (Hyperesthesia of the skin 
without accompanying tenderness on percussion speaks 
for a functional disturbance.) The following points 
of tenderness are listed alphabetically according to the 
name of the author and the disease: 
Alexander’s—(see gastroptosis in this chapter). 
Aortalgia—Tenderness of the plexus in the left 
supra-clavicular fossa (R. Schmidt). 
Appendicitis—1. Junction of middle and outer third 
of line from spine of the ilium to the navel {MeBur- 
ney) ; 2. About 4 cm. from the navel on the before 
mentioned line {Morris) ; 3. The junction of the middle 
and right thirds of the interspinal line {Lanz) ; 4. 
Tenderness of the navel in the midline and often more 
distinct at 2 cm. below the navel if appendix is on 
left side {Kiimmel) ; 5. Pain in the ileo-cecal region 
on gently stroking the hand from the sigmoid flexure 
towards the splenic flexure {Rovsing). 
Blumberg—(See peritoneal irritation). 40 
A CLINICAL GUIDE TO 
Boas—(See gastric ulcer, cholelithiasis). 
Charcot—(See ovary, hysteria). 
Chauffard—(See cholelithiasis). 
Cholelithiasis—1. The upper segment of the right 
rectus abdominis (Mackenzie) ; 2. Pressure point 
under the right clavicle (Chauffard) ; 3. Two to three 
finger breadths to the right of the 12th thoracic ver- 
tebra. This tender spot often extends to the axillary 
line. No tender point to the left of the spine in con- 
tradistinction to gastric ulcer (Boas, Gaultier) ; 4. Ten- 
derness of the phrenic as in diaphragmatic pleurisy. 
Located between the heads of the sternocleidomastoid 
(Rarnond). 
Gastroptosis—Tenderness in or near the middle line 
just below the xyphoid and more distinct on standing. 
Pain worse after drinking fluids. Disappears on pres- 
sure upwards with the hands (A. Alexander). 
Hilus (tracheo-bronchial)—Glandular disease in 
tuberculosis and acute diseases of the upper air pas- 
sages and lungs (tracheo-bronchitis, pneumonia). Ten- 
derness on pressure and percussion of the first to fifth 
thoracic vertebrae (Petruschky). 
Hysteria—Tenderness in the region of the ovaries 
(Charcot). 
Sciatica—Tenderness over the sciatic foramen, mid- 
point between tuber ischii and trochanter. 
Jaschke—(See obstipation and oophoritis). 
Kiimmel—(See appendicitis). 
Lanz—(See appendicitis, also pyelitis and urete- 
ritis). BEDSIDE EXAMINATION 
41 
Lumbago—Tenderness of the longissimus dorsi. 
MacBurney—(See appendicitis, also pyelitis and 
ureteritis). 
MacKenzie—(See cholelithiasis, also duodenal 
ulcer). 
Morris—(See appendicitis). 
Mussy, Guenau de—(See diaphragmatic pleurisy). 
Nephrolithiasis—Inner border of the psoas (see 
pyelitis) (Ortner). 
Obstipation—1. Deep tenderness in the sigmoid flex- 
ure ; 2. Chief point of tenderness just below the left 
sacro-iliac articulation in perisigmoiditis (chronic ob- 
stipation and left sided oophoritis) (Jaschke). 
Oophoritis—Tenderness over the ovaries and just 
above the sacro-iliac articulation {Jaschke). 
Ortner—(See nephrolithiasis). 
Ovaries—(See hysteria). 
Perisigmoiditis—Tenderness just above the left 
sacro-iliac articulation. 
Peritoneal irritation—Moderate pain on deep pres- 
sure over the region and severe pain on suddenly 
taking away the hand (Blumberg). 
Petruschky—(See hilus tuberculosis). 
Pleuritis, diaphragmatic—Tenderness at the cross- 
ing of the para-sternal line and the prolongation of 
the 10th rib; 2. The upper intercostal spaces near the 
sternum; 3. Where the phrenic nerve turns around 
the scalenus between the two heads of the sternoclei- 
domastoid (•Genau de Mussy) ; 4. Between the ribs at 
the attachment of the diaphragm. 42 
A CLINICAL GUIDE TO 
Pyelitis—Tenderness along the ureters to the kid- 
neys. Deep tenderness in the region of the kidney. 
The skin hyperesthesia is the same (Lanz and Mc- 
Burney). 
Ramond—(See cholelithiasis). 
Rovsing—(See appendicitis). 
5—Point of von Noorden; corresponds to MacBur- 
ney’s point but is on the left side, in irritative condi- 
tions of the sigmoid (sigmoiditis, colica mucosa) and 
in hard scyballa in the sigmoid. 
Schmidt, R.— (See aortalgia). 
Trigeminus neuralgia—Point of exit of the branches 
of the trigeminus (Valleix). 
Ulcus ventriculce—1. Tender point to the left of the 
spine near the 12th dorsal vertebra (Boas) ; 2. Upper 
middle and lower epigastrium, depending on the posi- 
tion of the ulcer (Mackenzie). 
Ulcus duodeni—To the right of the midline in the 
epigastrium (Mackenzie). 
Ureter—Tenderness in the region of the sacro-iliac 
articulation. Anteriorly at the intersection of the outer 
margin of the rectus and the horizontal line through 
the navel. 
Ureteritis—Tenderness along the ureter to the kid- 
ney. Skin hyperesthesia analogous (Lanz and Mac- 
Burney). 
Valleix—(See trigeminus). BEDSIDE EXAMINATION 
43 
PERCUSSION AND AUSCULTATION 
I. Percussion 
General 
Method—The finger-finger percussion is generally 
used. The percussion must not be too strong. “Super- 
ficial percussion” (light percussion on a finger which 
is lightly placed on the part) is used in examination 
of parts which are superficially located, as, for ex- 
ample, the boundaries of the lungs. “Deep percussion” 
is used for organs which are deeply located as in the 
determination of the size of the heart. In this method 
moderate force is used in percussion on a finger firmly 
pressed against the part. 
Percussion informs us of the air content and of the 
degree of tension of the walls of the air spaces (stom- 
ach, intestine, pulmonary alveoli). The boundaries of 
an organ may be established in this manner by deter- 
mining the air content (as the heart and liver in con- 
trast to the lung) (topographic percussion). The 
quality of the tones on both sides of the body may also 
be compared (comparative percussion). 44 
A CLINICAL GUIDE TO 
Qualities of Tones 
la. Full = loud, usually long 
and large vibrations. 
2a. High = high rate of vi- 
bration. 
3a. Tympanitic — distinct mu- 
sical tone. 
4a. Metallic — prominent, high 
tones in tympany. 
lb. Empty = soft, low. Short 
and small amplitude of 
the vibrations. 
2b. Deep = low rate of vibra- 
tion. 
3b. Not tympanitic. 
Various combinations of the tones as relatively dull 
or highly tympanitic. 
Generally, the first three qualities are used in de- 
scription of the percussion tone. Example: full, mod- 
erately high, not tympanitic tone. This tone is nor- 
mally heard over the lung. Loud, moderately deep 
tympanitic tone normally found in the space of Traube. 
Soft or low tone (absolute dullness), high, not tym- 
panitic percussion tone as on percussion of the thigh. 
II. Auscultation 
Method—Direct auscultation with the superimposed 
ear or indirect with the aid of a stethoscope. The 
latter method is necessary to definitely localize sounds 
which are heard within a small area (breath sounds, 
heart tones). 
The patient should breathe with the mouth open, 
slowly and deeply and with full expiration. 
General BEDSIDE EXAMINATION 
45 
III. Special Physical Examination 
Lungs 
The moderately full and moderately high non-tym- 
panitic tone which is found on percussion of the normal 
lung will be called the “pulmonary tone.” This tone 
becomes fuller and deeper toward the base of the 
lung. 
Topographic percussion — Determination of the 
boundaries in a chest with normal configuration. 
The pulmonary borders are determined by light per- 
cussion so that the tone of the lungs is not heard 
beyond the pulmonary borders. 
The lower, anterior margin of the lungs (liver-lung 
margin) is found in the parasternal line on percussion, 
normally at the level of the sixth rib but not at this 
place on lying down or standing up. The liver-lung 
margin is in a general way dependent on the position 
of the diaphragm. This margin may be higher on 
standing than on lying down (the liver and diaphragm 
are pushed up by strong abdominal muscles), or the 
reverse may be true if the abdominal walls are flaccid, 
especially in splanchnoptosis. The relations are more 
easily determined on the right side where percussion 
is more useful. 
It is best to have the patient sit on a stool instead 
of in bed in order to get most benefit from the changes 
in tone on percussion. 
A. Percussion 46 
A CLINICAL GUIDE TO 
Right 
Left 
Middle Axillary 
Line 
Medio-clavicular 
Line 
Parasternal 
Line 
Parasternal 
Line 
Medioclavicular 
Line 
Middle Axillary 
Line 
8th-9th ribs 
Upper border 
6th rib 
Upper border 
6th rib 
4th rib 
Lower border 
4th rib 
8th-9th rib, but 
usually lower 
than on right 
side 
Right 
Left 
Scapular Line 
Paravertebral Line 
Scapular Line 
Spine of 11th to 12th 
dorsal vertebra. Usu- 
ally higher than on 
left. 
About one fingerbreadth higher than in the 
scapular line. 
Spine of the llth-12tH 
dorsal vertebra. 
Topographic Percussion: Determination of Boundaries 
Anteriorly 
Posteriorly BEDSIDE EXAMINATION 
47 
The borders of the lung which overlie the heart 
run from the attachment of the 5th costal cartilage 
on the left side, upwards and along the left sternal 
border to the 4th rib and then in a diagonal curve, 
downwards and outwards to the 5th intercostal space 
in the medio-clavicular line. This is the so-called 
area of absolute or superficial dullness according to 
the old nomenclature. 
The borders of the lungs posteriorly are found at 
the level of the spines of the 11th and 12th dorsal 
vertebrae (about a hand’s breadth under the angle of 
the scapula). The right side is usually somewhat 
higher than the left (liver). The borders of the lungs 
in the long and narrow thorax are somewhat lower 
and are a little higher in the short wide thorax. (See 
page 80 for diminished volume of lungs.) 
The upper border of the lung can generally be deter- 
mined only in a few places. The position of the apices 
and the projection of the apical field on the upper and 
posterior surfaces of the thorax are determined by 
topographic percussion. 
Spedal Methods of Percussing the Apices of the Langs 
1. Jagic’s triangle—The base of the triangle is a 
horizontal line between the spines of the first and 
second thoracic vertebrae. A point, three finger- 
breadths distant from the median line and on the base 
of the triangle is marked on each side. Lines are 
drawn from these points to the lower margin of the 
hair at the median line, forming the sides of the tri- 48 
A CLINICAL GUIDE TO 
angle. These boundaries normally cut* across the bor- 
ders of the pulmonary apices at the upper margin of 
the vertebra prominens if the patient stoops slightly 
forward. 
2. Kronig’s Fields—These correspond to a projec- 
tion of the lung apices, are band-like and pass across 
the trapezius from anteriorly to posteriorly. The zone 
of the pulmonary tone is determined at the highest 
point of the trapezius contour and from the neck 
toward the acromion process. A symmetrical upper 
chest is indispensable for proper interpretation of these 
findings. 
Respiratory excursion—Determination of the size 
of the complementary space by determining the 
margins of the lungs in extreme inspiration and ex- 
piration. The respiratory excursion is determined in 
this way along all the lines of orientation anteriorly, 
laterally and posteriorly. It is also well to compare the 
respiratory excursion in the mid-axillary line during 
the supine and lateral positions. 
The complementary space or respiratory excursion 
is diminished in pleural adhesions and in abnormally 
high or low position of the diaphragm as in broncho- 
spasm or pulmonary emphysema. The left lower 
margin of the lung in the axillary line (lung-spleen 
margin) may be higher in adhesive changes of the 
pericardium and of the adjoining portions of the 
mediastinum and pleura when examined in the right 
lateral position. This is contrary to the normal change 
on change of position. BEDSIDE EXAMINATION 
49 
There is no respiratory excursion of the upper 
margins of the lungs but there is increased tympany 
during inspiration at the middle of the apex field in 
the supraspinatus fossa. There is also tympany during 
expiration toward the upper margin of the apex of the 
lung. 
The upper margin of the apex becomes more 
tympanitic normally if the patient stoops forward. 
The percussion tone becomes deeper and the upper 
margin of the lung frequently shifts cranially 
(Koranyi). 
Comparative Percussion 
Comparison of the tones over symmetrical parts of 
the body at the same levels and same distances from 
the median line. This is possible only in symmetrical 
thorax, equal muscular tension and symmetrical po- 
sition of the fingers on the parts. Moderately strong 
percussion is used in both supra-spinatus fossae, about 
three finger breadths to the side of the spine and at a 
level of a horizontal line passing between the spines 
of the first and second thoracic vertebrae. The thorax 
is then percussed downwards from these areas on both 
sides and along the interscapular lines. The pul- 
monary areas below the angle of the scapula are 
percussed along the scapular lines. The percussion is 
then carried along the axillary lines, then anteriorly in 
the supra- and infra-clavicular fossae, in the second 
intercostal spaces along the medio-clavicular lines on 
the left and right sides and in the axillary spaces 50 
A CLINICAL GUIDE TO 
beginning at the folds of these spaces and going 
downwards. 
There is often a slight impairment of resonance on 
the right and left sides. This may be caused by a dif- 
ference in the development of the musculature or 
condition of the tension of the muscles on the two sides. 
There is often a slight impairment of resonance on 
the right side even if the air content is the same in 
both sides at symmetrical place-s. This is found in 
the right interscapular space and right supraspinatus 
fossa (physiological dextro-scoliosis at the level of 
the interscapular region). Resonance is impaired by 
underlying organs as the heart or liver. The lower 
posterior region on the right -side is sometimes duller 
as a result of the presence of the liver. 
This percussion of all parts with moderately strong 
force may be followed by percussion with various de- 
grees of force. 
It must be remembered that edema of the skin of 
the back and front of the chest in nephritis or cardiac 
weakness or collateral inflammatory edema at this 
place may cause dullness on percussion and may lead 
to mistakes. The percussion tone is normally somewhat 
duller in the region of the lower, right half of the 
thorax with moderately strong percussion and espe- 
cially while sitting. This is caused by an elevation of 
the diaphragm and the effect of the liver which is 
under it. BEDSIDE EXAMINATION 
51 
CHANGES IN THE PERCUSSION TONE 
Pathological Dullness* 
A. Deep Percussion 
1. Absolute Dullness—In large effusions of fluid 
(exudate, transudate, hematoma), thick fibrous pleu- 
ritis, tumors between the lungs and chest wall, pleural 
tumors or tumors which extend from the lung). In- 
filtrating and solid tumors of the lung. New forma- 
tions against the chest wall such as aneurysms, neo- 
plasms, gland tumors, large substernal struma, etc. 
Also in occasional cases of inflammatory infiltrations 
(pneumonia) with coincident plugging of the corre- 
sponding bronchi (Grancher). 
2. Intense But Not Absolute Dullness—Frequently 
with a slight tympanitic ring in infiltrations such as 
croupous and caseous pneumonia, denser tuberculous 
infiltration, compression atelectasis (as above the 
effusion and with more marked tympany), over deep- 
seated, new formations which do not contain air as 
tumors, enlarged organs as the heart, aneurysms, peri- 
cardial exudate and also in high diaphragm, and over 
smaller pleuritic effusions which give absolute dullness 
on light percussion. 
* The tone over an area of dullness of the lungs is also 
somewhat higher pitched. 52 
A CLINICAL GUIDE TO 
3. Relative dullness in superficially or deeply placed 
parts which do not contain air such as infiltrations, 
infarcts and other conditions mentioned in paragraph 
2 as well as in larger but deep seated areas which do 
not contain air. 
B. Light Percussion 
1. Absolute dullness in interposition of a medium 
which does not contain air and which is not very thick 
(superficial foci of infiltration, fibrous masses and 
tumors of the pleura, small free or circumscribed 
effusions, thickenings of the chest wall), in edema of 
the skin and thickenings of the bones or muscles. 
2. Relative dullness in diminished air content of the 
superficial parts. The percussion tone in pleural 
effusions and fibrous pleuritis may give relative dull- 
ness with moderately strong percussion and absolute 
dullness with light percussion and both may be found 
over the s. ne area under these conditions. Deep 
seated foci of thickening may give a normal tone on 
light percussion and relative dullness on moderately 
strong per ussion. 
The Occurrence of a Tympanitic Tone 
Over the Lungs 
Percussion, especially of the lower half of the left 
side posteriorly and in the axillary region may produce 
a tympanitic quality as a result of accompanying 
vibration of air—containing abdominal organs such as 
the stomach or colon. This is especially likely in mod- BEDSIDE EXAMINATION 
53 
erately strong percussion. The boundaries of the 
lungs in such cases should be determined with light 
percussion. 
1. In relaxation of the lung as in the vicinity of foci 
of thickening, at the border of large pleural effusions 
and also in distant parts of the lung as in the supra- 
and infra-clavicular spaces and the second intercostal 
space anteriorly in large pleural effusions. 
2. Over large spaces containing air. 
(a) In intrapulmonary areas as cavities of any 
origin. 
(b) Pleural, mediastinal and subdiaphragmatic 
spaces as under certain conditions in pneu- 
mothorax, subphrenic gas abscess, diverti- 
culum of the oesophagus containing air, dia- 
phragmatic hernia, eventration, etc. 
Skin emphysema may cause tympany on percussion. 
Metallic Percussion Tone 
Over hollow cavities in the lungs containing air and 
with moderate or marked tension of the which 
must be smooth. These cavities either do lot com- 
municate at all externally or only through very narrow 
channels (cavities, pneumothorax). (See pleximeter 
percussion, page 61.) 
Cracked pot sound; a sign of stenosis in open cavi- 
ties or valve-pneumothorax. Normally on strong per- 
cussion of a very delicate thorax. 54 
A CLINICAL GUIDE TO 
APPENDIX 
Percussion of the paravertebral and interscapular 
regions. 
Comparative, moderately strong percussion close to 
and along the spine. 
There is frequently a softer tone normally on the 
right side at the level of the spine of the third thoracic 
vertebra and for a variable extent. It is indefinitely 
limited at its external border. This slight dullness 
may be continued to the interscapular space and is 
then due to the better developed musculature (analo- 
gous change on the left side in the left handed) or it 
may be due to physiological dextro-scoliosis. 
Pathological findings as dullness and increased 
resonance in displacement of the entire mediastinum. 
Demonstration of the displacement of the mediastinum 
by percussion. It it shifted toward the healthy side in 
paralysis of the diaphragm and toward the diseased 
side in stenosis of the bronchus, etc. 
A. A comparatively sharply circumscribed zone of 
dullness in dilatation of the aorta, especially of the 
ascending arch. It is found to the right, near the spine 
at the level of the 1st, 2nd and sometimes the 3rd 
thoracic vertebra, is about 2 fingerbreadths wide and 
4 fingerbreadths long and is sharply limited externally 
(Elias). BEDSIDE EXAMINATION 
55 
B. Circular zone, para-vertebral on the healthy side 
in interlobar empyema and at the level of the area of 
dullness (Ortner). 
C. Para-vertebral dullness to the left of the lower 
part of the spine in displacement and dilatation of the 
descending aorta. 
D. Triangle of dullness on the healthy side in 
pleural effusion (see pleuritis, page 72) (Koranyi). 
E. Triangular zone of tympany on the diseased side 
between the upper border of the area of dullness and 
the spine {Garland). This triangle of Garland cannot 
be differentiated on light percussion from pleuritic 
dullness. (Bilateral in effusion of both sides, see 
page 74.) 
F. Zones of impaired resonance to the left and right 
of the spine in areas of thickening in the region of the 
hilus of the lung. 
G. Zones of dullness at various levels in the para- 
vertebral region in diverticulum of the oesophagus and 
to the right and below, in diffuse dilatation of the 
oesophagus. Variation of the tone depending on the 
condition of filling of the diverticulum. Also unilate- 
ral or bilateral in large carcinomata of the oesophagus 
(Lnger). 
H. Para-vertebral zones of tympany on the healthy 
side in pneumothorax {Lager). 
I. Para-vertebral tympany on the diseased side in 
shrinking pleuritic processes with effusion. 
Dorsal zones of dullness due to the auricles (see 
page 102). 56 
A CLINICAL GUIDE TO 
AUSCULTATION 
I. Breath Sounds 
Vesicular inspiration and a soft, blowing expiration 
is normally heard over the lungs. The second phase 
is shorter. Expiration is normally louder, more rich 
in tones and almost bronchial in the medial portion of 
the right apical region close to the spine and in the 
para-vertebral region down to the 4th or 5th thoracic 
vertebra. Similar findings may be present in the 
corresponding left para-vertebral space. 
Pathological Breath Sounds 
The normal breath sound may be changed from the 
point of view of duration of the two phases, quality, 
loudness and duration of the entire cycle. The two 
chief types are vesicular and bronchial breathing. 
A. Pathologically Changed Vesicular Breathing 
1. Diminished vesicular breathing in decreased area- 
tion of the various parts of the lung or in poor conduc- 
tion of the breath sound to the surface of the thorax 
(effusion, thickening, tumor, changes in the thorax 
wall, etc.). 
2. Abnormally prolonged expiration and usually 
sharp, in narrowing of the bronchial tree by broncho- 
spasm (bronchial asthma), accumulation of secretion, BEDSIDE EXAMINATION 
57 
partial blocking of the bronchus by a foreign body, 
volumen pulmonum auctum and in emphysema. 
3. Sharp inspiration, usually with coincident sharp 
expiration in swelling of the bronchial mucous mem- 
brane (catarrh). 
4. Raw (gutteral) breathing in swelling of the 
mucous membrane and moderate increase of thin 
secretion. 
5. Cog-wheel vehicular breathing in unequal increase 
and decrease of the air current (moderate catarrh). 
(See systolic vesicular breathing, page 87 and page 113 
[pulmonary insufficiency]). 
B. Bronchial Breathing 
Bronchial breathing is heard over infiltrated or 
compressed areas of the lung (airless alveoli), over 
hollow spaces which communicate with the bronchial 
tree and over adjoining healthy lung, in which case it 
becomes weaken as the distance from the diseased part 
is increased. 
The bronchial breathing may be distinctly metallic 
in large cavities with smooth walls. It may also be 
heard beyond the actual phase of breathing (amphoric 
breathing). The bronchial breathing is higher and 
louder over infiltration (lobar pneumonia)* than over 
compression. 
C. Consonance Breathing 
The breath sound may approach a bronchial char- 
acter (broncho-vesicular or consonance breathing) 58 
A CLINICAL GUIDE TO 
over smaller areas of thickening, especially in the up- 
per lobe and in the apices. 
D. Mixed Breathing 
The two phases of breathing may not show the same 
type of breath sound. There may be inspiratory vesi- 
cular and expiratory bronchial breathing over distant 
or deep-seated foci. 
E. Metamorphosing Breathing 
Change of the type of breath sound during the same 
phase of respiration. Inspiration may begin with vesi- 
cular and end with bronchial breathing (over cavi- 
ties). BEDSIDE EXAMINATION 
59 
II. ACCESSORY SOUNDS 
A. Rales 
Often heard only after coughing a little. 
Dry 
Purring, whistling, crackling, 
etc. (ringing or not ringing) 
Moist 
Fine, medium, coarse 
(ringing or not ringing) 
There is a consonant (ringing) character of the 
rales if they are moist and arise in bronchi or hollow 
spaces which are surrounded by tissues that do not 
contain air as in thickening or compression. A similar 
ringing character may sometimes be heard under simi- 
lar conditions with dry rales. They are of diagnostic 
value according to the location (cavity at the apex, 
bronchiectasis at the base, etc.). 
Fine crepitant rales are heard in expansion of col- 
lapsed or abnormally moist alveoli which did not pre- 
viously contain air (atelectasis, pneumonia in the stage 
of engorgement). These rales are heard at the height 
of inspiration. They may also be heard at times dur- 
ing the first few deep breaths in the lower parts of the 
lung when the respiration was superficial for a long 
time previously. The rales under these conditions 
disappear after continued deep breathing. 
Rubs 
These occur in the presence of raw surfaces of the 
pleura when one layer rubs against the other. This 60 
A CLINICAL GUIDE TO 
may be due to abnormal drying, fibrinous inflamma- 
tion, tumor, etc. They seem to be near to the ear and 
show all varieties from soft rubbing to the sound 
produced by creaking leather. They may occur in 
inspiration or expiration without being strictly limited 
to the beginning or end of the breathing phases. They 
are usually not changed after coughing but become 
softer after repeated deep breathing and may even 
disappear. They may be made more distinct by pres- 
sure with the stethoscope. Pain may be produced by 
such pressure. Pleuro-pericardial and pericardial 
rubs (see page 87). BEDSIDE EXAMINATION 
61 
III. AUSCULTATION OF THE VOICE 
Direct auscultation of the lungs is performed for 
this procedure. The ear is placed on the chest and 
the opposite ear is stopped up with the finger and the 
patient says such words as ninety-nine, sixty-six, etc., 
and then whispers such words as thirty-six, etc. 
1. Loud spoken voice—The spoken words are heard 
as somewhat softer over the lungs normally, but the 
words are distinct and have the same tone. The voice 
is heard loudest over the upper regions of the lungs 
and in the para-vertebral regions. The spoken voice 
becomes weaker under the same conditions as dimin- 
ished breath sounds (see page 57). 
Increased ana “booming” over large areas of lung 
which is poor in air content (infiltration, compression). 
The voice takes on a bleating character (aegophony) 
at the upper limits of a pleural effusion. 
The patient is instructed to say the vowel “U” softly 
and for a prolonged period of time. Normally the 
sound which is heard over the lungs is like an “a” 
but it is changed to “ah” over infiltrated or compressed 
areas of lung or over large pleural effusions (Karplus). 
2. Whispered bronchophony (whispered voice) — 
The whispered voice is normally heard as an even 
tone, without resonance and ending sharply with the 
end of phonation. This is heard over the upper lobes 62 
A CLINICAL GUIDE TO 
and in the para-vertebral spaces to the 5th or 6th tho- 
racic vertebra. The tone becomes very soft and can 
hardly be heard over the lower lobes. The whispered 
voice becomes loud, high and distinctly resonant over 
areas not containing air, especially deep-seated foci of 
thickening, even if these areas are small. The tone 
may be somewhat metallic in pneumothorax or cavity 
formation. Thickened pleura and extensive pleural 
effusions do not as a general rule cause whisper-bron- 
chophony of an increased degree but such may be the 
case when the change comes from the depths, especially 
from the upper parts of the effusion. The same find- 
ing may be present in thickened pleura with coincident 
thickening or induration of the pulmonary tissue. 
Auscultation of the voice over the apices does not 
give reliable results. 
Combined Methods 
Coincident Percussion and Auscultation 
1. Pleximeter percussion—A distinct metallic tone 
may be heard over hollow cavities containing air 
(pneumothorax cavities) on auscultation near an area 
which is percussed with the aid of a pleximeter and 
hard object (percussion hammer). The stethoscope 
must be placed near the pleximeter. The normal tone 
is soft and without a metallic ring. Control by using 
the method on the corresponding area on the opposite 
side. 
2. Coin Sound—This is produced by placing a coin BEDSIDE EXAMINATION 
63 
on a part of the chest, preferably the posterior wall, 
and gently striking the coin with another one. The 
stethoscope or ear is placed on the opposite aspect of 
the thorax, the anterior. Normally the sound which 
is heard is without any ringing tone. The same is 
found over compressed or infiltrated parts of the lung. 
There is a metallic ringing sound over effusions and 
completely airless tissues (tumor, Grancher’s pneu- 
monia). The sound may be like a bell in pneumo- 
thorax and the same phenomenon may be heard at 
times over large cavities. 
The coin sound is normally heard over the region 
of liver dullness and care must be used that neither 
the site of auscultation nor that of the coin are near 
the area of liver dullness. 
C. Palpation 
Asymmetry of breathing (see breathing, page 12) — 
Palpable rubs or rales and conducted palpable phe- 
nomena from the heart and vascular systems. The 
splash of freely movable fluid in large spaces contain- 
ing air may be felt on shaking the body (sero-pneumo- 
thorax). 
Vocal Fremitus 
Vocal fremitus is determined by placing the hands 
or finger tips over the parts of the chest to be exam- 
ined and by having the patient say loud words as 
ninety-nine, etc. It may also be performed by placing 
a rounded retort (flask) over the parts to be tested. 64 
A CLINICAL GUIDE TO 
Deep phonation is best in testing the lower lobes and 
higher tones for the upper lobes. Vocal fremitus is 
often weak or absent over the lower lobes in women. 
Vocal fremitus is diminished if there is an inter- 
vening fluid or solid mass between the lung and chest 
wall (thick pleura, tumor, edema, etc.). The fremi- 
tus is increased if the conduction to the surface of 
the chest is favored by airless parts of lung around 
the bronchus (infiltration, compression). The method 
is of value only if the differences are great. BEDSIDE EXAMINATION 
65 
APPENDIX 
Percussion and Auscultation of the Spinal 
Column 
Method—Direct percussion of the spines of the ver- 
tebrae with ordinary finger percussion. 
The normal tone over the spines of the 1st, 2nd 
and 3rd thoracic vertebrae is dull. It is somewhat 
resonant and often slightly tympanitic over the 4th and 
then becomes more dull over the 5th to become more 
resonant again towards the 11th or 12th thoracic ver- 
tebra. 
The percussion tone over the spine in young indi- 
viduals with an elastic thorax is often more sonorous 
(box tone) and louder than over the neighboring parts 
of the lung. 
Enlarged glands, thickened fibrous mediastinitis, 
mediastinal tumor, etc., in the posterior mediastinum 
cause a dull sound on percussion. 
Auscultation of the Whispered Voice 
Whisper bronchophony in adults is normally found 
up to the spine of the 2nd or 3rd thoracic vertebra. 
Whisper bronchophony from the 3rd vertebra down- 
wards is always a pathological finding (improved con- 
duction of the sound to the surface of the thorax by 66 
A CLINICAL GUIDE TO 
enlarged tracheo-bronchial or mediastinal glands as 
caused by inflammatory or neoplastic processes (tuber- 
culosis, lymphogranuloma, sarcoma, etc.). Spinalgia 
is often found in these conditions. 
Heart tones and murmurs may also be heard over 
the spine (see page 115). BEDSIDE EXAMINATION 
67 
DIAGNOSTIC VALUE OF SOME OF THE 
PHYSICAL FINDINGS 
Present in the Lungs 
A. Foci of Thickening in the Lungs 
Inspection—Large foci produce diminished respira- 
tory excursion of moderate degree and no bulging or 
abnormal retraction of the intercostal spaces over the 
diseased parts. There may be inspiratory drawing in 
of the chest. 
Percussion—Dullness of variable intensity, shape 
and extent, depending on the position and size of the 
focus of thickening (corresponds to the boundaries 
of the lobes in lobar thickenings). The dullness never 
extends beyond the normal borders of the lung in 
contradistinction to effusions of the pleura. 
The foci of thickening do not displace the heart or 
mediastium and do not produce any appreciable dis- 
placement of the diaphragm. 
A tympanitic quality is present in the vicinity of the 
focus of thickening and in the zone of dullness itself 
in centrally placed foci. The dullness is seldom abso- 
lute even in large foci and does not resemble the tone 
heard over effusions or tumors of large size. 
Auscultation—All degrees of consonance breathing 68 
A CLINICAL GUIDE TO 
to bronchial breathing and often associated with all 
sorts of rales, especially ringing rales. 
Vocal Fremitus—Loud and the whisper-broncho- 
phony increased. The latter is a very good method 
for demonstrating small foci of thickening in the lung. 
The coin sound is negative. BEDSIDE EXAMINATION 
69 
APPENDIX 
Physical Signs in Foci of Tuberculosis of the Lungs 
Physical Examination of the Apices—Topographi- 
cal percussion (see page 47). Dullness of the apical 
region is caused by diminished air in these parts. This 
may result from an area of thickening or from dimin- 
ished volume as from pressure from a neighboring 
organ (struma), or by pleural effusion of the same 
side and in mitral stenosis (left auricle, bronchus 
stenosis. 
The following signs are found in the various stages 
and varieties of pulmonary tuberculosis: 
(a) Pneumonic form (caseous thickening)—No sign 
of shrinkage of thorax, no constant in-drawing. There 
are inspiratory in-drawing (peripneumonic in-draw- 
ing), massive dullness, consonance to bronchial breath- 
ing, increased vocal fremitus, whisper bronchophony 
and usually many ringing rales. 
(b) Nodular form—Dullness of variable intensity 
and often with a tympanitic ring. Auscultation: all 
degrees from raw breathing with prolonged expira- 
tion to consonance breathing (frequently diminished, 
especially with coincident fibrous thickening of the 
pleura). Genuine bronchial breathing only in cases 
of large confluent, nodular foci. Rales: small or me- 70 
A CLINICAL GUIDE TO 
dium sized and often ringing. The former is frequent 
in localization of the process to the apex while ring- 
ing rales come from the larger bronchi and cavities. 
(c) Cirrhotic (shrinking, indurative) form—Sink- 
ing-in of the spaces depending on the location of the 
focus as in the supra- or infra-clavicular fossae or 
intercostal space. Usually intense dullness, especially 
on light percussion and usually diminished breathing 
with soft consonance breathing and a few rales. Me- 
dium or coarse rales, often ringing in nature in bron- 
chiectasis. High position of the anterior left pulmo- 
nary margin caused by retraction of the upper lobe 
which covers the base of the heart and with resulting 
denudation of the pulmonic region (see HEART, page 
106). Closure of the pulmonary valves palpable with 
loud second pulmonic. Musculature of the neck on 
the diseased side atrophic and the muscle tone of the 
portion overlying the focus of shrinkage is diminished 
(Pottenger) in comparison to the increased tone of 
the overlying muscle in fresh, acute processes. 
(d) Miliary tuberculosis of the lung—Diffuse, hema- 
togenous deposit of miliary tubercles in all parts of 
the lungs as a result of entrance of a large number of 
tuberculosis bacilli in the blood. 
Percussion—There is sometimes a slight tympanitic 
ring to the tone over the lungs. Lung margins low, 
considerable covering of the heart (moderate volu- 
mum pulmonum, differentiate from typhoid). Auscul- 
tation: the breath sounds may be normal' but there is 
frequently prolonged expiration and raw or sharp BEDSIDE EXAMINATION 
71 
inspiration. Fine rales or dry crepitant rales may 
sometimes be heard. 
(e) Cavernous form—Cavernous formation in case- 
ous pneumonia as well as in the nodular type. Dull- 
ness of variable degree with a tympanitic ring in 
places, especially at the spot of most intense dullness 
(in contradistinction to a focus of infiltration or pleu- 
ral effusion in which the tympany is more at the bor- 
ders of the dullness). Coarse, ringing rales are the 
most important finding. (See the following part for 
other signs.) 
B. Symptoms of Cavity Formation in the Lungs 
Tuberculous or bronchiectatic cavities or cavities 
resulting from abscess or gangrene of the lung. 
Percussion—Variable, sometimes there is only dull- 
ness with change to resonance or tympany upon ex- 
pectoration of large quantities. 
Change of tone on change of position (Gerhardt). 
Changes in the level and volume of the tone. Exam- 
ine in the sitting posture and when on back and 
abdomen. 
Change of tone on opening and closing the mouth 
(Wintrich). Change of tone in expiration and inspir- 
ation {Friedreich). The two latter signs are not very 
reliable. 
Metallic ring with pleximeter percussion in large, 
smooth-walled cavities containing but little secretion. 
Cracked pot sound, clinking and tympany. The lat- 
ter is also found in relaxation in the vicinity of infil- 72 
A CLINICAL GUIDE TO 
trated portions of the lung and normally in children 
and young persons if the mouth is open. 
Auscultation—Coarse, ringing rales with a metallic 
character (reliable sound of cavity), frequently ac- 
companied by bronchial or amphoric inspiration and 
expiration. Loud whisper bronchophony with a me- 
tallic ring. Loud bronchophony (spoken voice) often 
similar to aegophony. The change of findings on 
change of position is characteristic for cavity. Exam- 
ine with the patient in the abdominal position. 
The various auscultatory phenomena may be much 
diminished or absent in plugging of a bronchus. So- 
called pseudo-cavernous signs may be found in the 
region of the treachea and large bronchi in the infra- 
clavicular and interscapular spaces if there is consid- 
erable secretion. The recognition of a genuine cavity 
in the infra-clavicular region is possible by ausculta- 
tion of the zone of tympany and coincident percussion 
of the trachea. Transmission of this sound towards 
the place of auscultation speaks for a cavity not far 
from the bronchial tree and communicating with it. 
C. Pleural Effusion 
The diseased side which is usually bulging ordinar- 
ily lags on respiration. The intercostal spaces bulge 
and appear widened. Absolute dullness with increased 
sense of resistance over the effusion. The overlying, 
compressed part of the lung gives a dull tympanitic 
sound. Marked tympany is frequent anteriority, under 
the clavicle and on the diseased side. The area of BEDSIDE EXAMINATION 
73 
dullness is larger with light percussion than with 
strong. The dullness of the upper portion on strong 
percussion is not absolute because of the wedge shape 
of the effusion. (See Garland’s triangle, page 55.J 
The upper border of the effusion descends obliquely 
as it approaches anteriorly, Demoiseau-Elliot line. It 
is only in very large transudates or exudates that the 
upper line tends to become horizontal. Effusions pro- 
duce a bulging of the walls and also the intercostal 
spaces, mediastinum and diaphragm causing a narrow- 
ing of the space of Tranbe from above and displace- 
ment of the neighboring organs as the heart, liver and 
spleen. The upper abdomen on the diseased side does 
not bulge forward as is usually the case during inspira- 
tion but is drawn inwards (paradoxical breathing, 
page 14), in high grade unilateral pleural effusions in 
which the diaphragm is pushed markedly downwards 
or is even palpable under the rib margin. There is 
but slight shifting of the boundaries of the effusion 
on change of position if due to exudate and then only 
in the early stages. The shifting is more complete 
with transudate and is always present if there is coin- 
cident pneumothorax. 
The apex of the lung on the same side as the effu- 
sion is often dull on percussion without there being 
pathological changes in the lung tissue but the other 
signs of involvement of the apex are absent. 
Auscultation—The breath sounds over the effusion 
are weak. This is more marked in the lower regions, 
to complete absence in the region at the base. The 74 
A CLINICAL GUIDE TO 
degree depends on the volume of the effusion. There 
may be distinct whisper bronchophony over the effu- 
sion of any sort (serous or purulent), Bacelli’s phe- 
nomenon. This may be louder in the upper parts than 
in the lower due to the compression of the lung. Loud 
bronchophony is diminished over the lower parts. 
Aegophony is found in the upper portions in variable 
degree. Vocal fremitus diminished. Compression 
breathing at the upper margins of the effusion, decreas- 
ing, soft consonance breathing to genuine but soft 
bronchial breathing, increased bronchophony for the 
whispered and spoken voice. Auscultation over the 
zone of compression shows a few fine crepitant and 
other fine rales. Pleural rub often heard at the margin 
of the effusion. Vocal fremitus often increased here 
(compression). 
A right angled triangle of dullness may be found 
in the para-vertebral region in the lower part of the 
healthy side in pleural effusion. This triangle is ab- 
sent in thickening of the pleura without effusion and 
in foci of infiltration. 
The upper, para-vertebral portion of the area of 
dullness has a louder tone on moderately strong per- 
cussion over a triangular area than the neighboring 
lateral part (Garland’s triangle). 
Sacculated exudate—Zones of absolute dullness of 
variable shape and localization with changing findings 
on auscultation. The findings correspond in general 
to those of exudate. The dullness is often demon- 
strable only on light percussion (thin fluid). BEDSIDE EXAMINATION 
75 
Interlobar exudate (often empyema). Dullness of 
variable shape and extent and may be relative or abso- 
lute, depending on the extent of the exudate and its 
proximity to the chest wall. It is often like a stripe 
or wedge in shape, following the interlobar fissure and 
with the tip at the spine. The upper and lower mar- 
gins of dullness run anteriorly and downwards, and 
usually diverge so that the wider part of the dullness 
is in the axillary space. This dullness extends over 
the entire lower part of the thorax and cannot be 
differentiated from interlobar dullness if there is a 
coincident, complicating, symptomatic exudate and also 
in compression and edema of the lung below the effu- 
sion (X-ray examination is very necessary in such 
cases as well as superficial and deep exploratory punc- 
ture). The para-vertebral circular segment is found 
near the spine (Ortner). (See page 55.) 
Pleuritis Diaphragmatica 
Dry, fibrinous, diaphragmatic pleuritis—The subjec- 
tive symptoms are a sharp, sticking pain on respiration, 
diminished respiratory excursion of the lower part of 
the chest on the diseased side and occasionally cyan- 
osis. There may be pain or tenderness of the liver 
region and neighboring parts of the abdomen up to 
the ileo-cecal region. This may be mistaken for gall- 
stones or appendicitis. The same things may be found 
on the left side. The longissimus dorsi muscle may 
be tender. 
Exudative Diaphragmatic Pleuritis—The exudate 76 
A CLINICAL GUIDE TO 
may be overlooked if the layers of pleura become ad- 
herent as the fluid then gathers between the lungs 
and diaphragm. This results in a descent of the 
diaphragm, liver and spleen. 
D. Pleural and Mediastinal Adhesions and Thicken- 
ing of These Structures Within the 
Thoracic Cavity 
Marked pleuritic adhesions may produce the follow- 
ing : the chest on the diseased side may appear smaller, 
especially in the antero-posterior diameter, the inter- 
costal spaces drawn in, narrow and resistant, and the 
supra- and infra-clavicular fossae may be sunken in. 
The muscles of the neck on the diseased side may be 
atrophic and the respiratory excursion of the entire 
diseased side or only a portion of it may be diminished. 
The chest wall may be entirely or partially drawn in. 
The diaphragm may be high or quiet (the upper por- 
tion of the abdomen on the diseased side quiet). The 
mediastinum and heart may be displaced towards the 
diseased side. 
Dullness of the region over the adhesions may be 
of variable intensity to complete dullness and the res- 
piratory and passive movement may be absent. There 
may be a louder percussion tone in the para-vertebral 
region on the diseased side as compared with the tone 
over the region of the adhesions. 
Auscultation—Diminished breath sounds. All vari- 
ations from rough breathing to veritable bronchial 
breathing, with all sorts of rales may be found in BEDSIDE EXAMINATION 
77 
coincident interstitial pneumonia and bronchiectasis, 
especially over the places where the thickening is not 
so marked (relative nearness of the lungs). The vocal 
fremitus is usually diminished over the thickening but 
it may be increased if the lung is infiltrated behind 
the thick pleura. Bronchophony and whisper bronch- 
ophony may also be increased. 
Signs of compression of the mediastinal structures, 
similar to those in mediastinal tumors, may occur in 
extensive and markedly shrinking thickenings. There 
may be stasis in the veins and lymphatics, collateral 
circulation on the chest wall, signs of stasis of the 
vena cava, congested veins of the neck or of the arms, 
cyanosis, swelling of the neck from chronic stasis of 
the lymphatics and Stokes’ collar. There may also 
be signs of compression of the arteries and bronchial 
or esophageal stenosis. There may be signs of irri- 
tation or paresis of the vagus (recurrens, pulse fre- 
quency) and of the sympathetic (difference in the 
pupils). Oliver-Cardarelli sign positive (Radoncic). 
This sign is elicited by grasping the thyreoid cartilage 
and slightly raising it. The larynx is tugged down- 
wards during systole of the heart. It is best done 
with over-extension of the head in the sitting or lying 
positions. It should not be mistaken for transmitted 
pulsation of the carotids. 
E. Pneumothorax 
The entire lung may be retracted from the chest 
wall by the ingress of air in the pleural cavity (com- 78 
A CLINICAL GUIDE TO 
plete pneumothorax). The process may be partial if 
there are adhesions (sacculated pneumothorax). The 
air in the pleural cavity may communicate externally 
(open pneumothorax) by an opening in the chest wall 
or by a tear of the lung tissue (superficial cavity, 
etc.). There is then, often, inflammatory irritation of 
the pleura with exudate (see sero-pneumothorax). 
The air in the pleural cavity may also be shut off from 
the outside by closure of the opening in the thorax or 
lungs (closed pneumothorax). The opening in the 
lung may be closed like a valve during expiration 
while the air is allowed to enter during inspiration 
(valve pneumothorax). 
The respiratory excursion in pneumothorax is 
diminished or absent but the chest itself is enlarged 
and the intercostal spaces bulge. The mediastinum 
and its organs are usually displaced. The diaphragm 
is low and the liver and spleen descend, depending on 
the degree of increased pressure within the pleural 
sac. 
The percussion tone is usually hypersonorous over 
the air pocket and often with a tympanitic ring if the 
air is not under too great pressure (as in valve pneu- 
mothorax). The tympany disappears in the latter case 
with occurrence of moderate dullness. The tympany 
is not very distinct if the air content is small but is 
to be found chiefly where the air collection is greatest 
as in the upper parts of the axilla. There is a more 
resonant tone in the para-vertebral space on the nor- 
mal side than normally (Luger). BEDSIDE EXAMINATION 
79 
The breath sounds are diminished and sometimes 
absent; especially in the lower portions. The breath 
sounds, when heard, show all varieties from rough- 
ened breathing to bronchial or amphoric type. Vocal 
fremitus and diminished bronchophony speak for 
closed pneumothorax. Whisper bronchophony sounds 
amphoric and is most distinct in open pneumothorax. 
There is vicarious volumen pulmonum of the other 
side in extensive pneumothorax. 
The symptoms of pneumothorax in the sacculated 
variety are found only in circumscribed portions of 
the chest. All the manifestations of pleuritic adhesions 
may appear alongside of the former. 
Air and exudate in the pleural sac. The upper 
level of the fluid is horizontal and this is the case all 
around the thorax if there are no adhesions. The 
exudate may shift slightly. Succussion on shaking 
of the patient. The upper limit of the exudate takes 
on a new horizontal level on change of position. The 
dullness may become resonant when the patient is on 
his back and the same happens to the posterior dull- 
ness if the patient is on his abdomen. “Gutta-cadens” 
and water sound. 
F. Volumen Pulmonum Acutum 
Enlargement of the pulmonary volume occurs acutely 
during an asthmatic attack or as a clinical expression 
of pulmonary emphysema. 
The thorax is wide, epigastric angle obtuse, costal 
arch raised, intercostal spaces narrow and bulging, 80 
A CLINICAL GUIDE TO 
the upper thoracic aperture raised and the respiratory 
excursion diminished. Tenseness of the thoracic 
compressors (outer margin of the latissimus dorsi). 
Rigid, dilated thorax in emphysema with frequent 
pillow-like bulging of the medial portion of the supra- 
clavicular fossa. Labored and prolonged expiration. 
Descent and diminished respiratory excursion of the 
lung margins. The cardiac part which normally lies 
against the thorax is often partially or completely 
covered by the distended lung. Hyperresonant per- 
cussion tone over the lung, especially over the lower 
parts. Auscultation reveals the characteristic pro- 
longed expiration and the frequently complicating 
bronchitis causes raw breathing with dry and moist 
rales, especially the former. There may be any variety 
of rales in this condition. 
In absence of function in a large part of the lungs 
there are all the signs of a localized volumen pulmo- 
num in the functioning parts (vicarious emphysema). 
G. Volumen Pulmonum Diminutum 
There may be a retraction of the margins of the 
lungs in chlorosis as a result of superficial breathing. 
The retraction may disappear after repeated deep 
breaths. Similar findings in Basedow’s disease. (See 
retraction of the lung margins in shrinking diseases 
of the lungs, page 47.) BEDSIDE EXAMINATION 
81 
HEART AND VESSELS 
Heart 
Inspection of the Cardiac Region 
Bulging or retraction of the thorax (see types of 
thorax), visible pulsations, visible apex beat, position, 
extent and intensity of the pulsation of the apex beat. 
Systolic indrawing at the apex in accretio and con- 
cretio cordis et pericardii. Differentiation from rota- 
tory indrawing (systolic sinking-in of the right and 
upper portion of the heart), especially with enlarged 
heart. There is also diastolic throwing forward in 
concretio cordis (Brauer). 
Visible pulsation over the rest of the heart, espe- 
cially over the large vessels, base of the heart, left 
margin of the sternum, at the lower part of the ster- 
num (epigastric pulsation, right ventricle, and abdom- 
inal aorta). (See page 116.) 
Palpation of th,e Cardiac Region 
Orientation palpation of the apex with the flat of 
the hand and then more detailed localization of the 
apex with the finger tips. Palpation of the entire 
precordial region, at the base and lower sternum. This 
is best done with the volar surface of the wrist. 
Apex beat often not palpable when lying down, 82 
A CLINICAL GUIDE TO 
hence examine with slight bending forward and also 
when on the left side. Variable displacement of the 
apex to the left in the left lateral position. 
Quality of the apex beat—Heaving in contradis- 
tinction to the normal beat. The slow heave with the 
powerful movement occurs in hypertrophy of the 
heart (renal affection, arterial hypertension, aortic 
stenosis). There is also a rapid forward heave as in 
aortic insufficiency and in hyperkinesis (especially in 
a Basedow’s heart or nervous tachycardia). 
Palpable closure of the aortic and pulmonary valves 
at the base of the heart and occasionally double beat 
of the valves (see doubling of tones, page 107). 
Palpable thrill during the various phases, presys- 
tolic at the apex in mitral stenosis. At other phases 
as presystolic-diastolic, systolic, rather continuous 
(see congenital disease, page 115), also presystolic, 
premature beat. Short thrills may be palpated as a 
vibration. 
Intensity and localisation of the thrill as in the 
aortic region, extending from the right, second inter- 
costal space, diagonally across the sternum to the at- 
tachment of the third rib to the sternum (Erb’s point). 
Systolic or post-systolic thrill in aortic stenosis and 
less frequently diastolic in aortic insufficiency. A 
thrill in the left second intercostal space in lesions 
of the pulmonary valves. Systolic thrills, often pro- 
longed into diastole in patent ductus Botalli. Thrill 
over the middle of the sternum in defect of the 
septum. BEDSIDE EXAMINATION 
83 
Abnormally strong heaving of the lower sternum 
in hypertrophy of the right ventricle and also epi- 
gastric pulsation. This is to be differentiated from 
visible and palpable pulsation of the abdominal aorta 
(especially in splanchnoptosis) and from liver pulse. 
Direct palpation of the hypertrophic right ventricle 
during resting of the diaphragm or by deep palpation 
under the rib margin at the height of inspiration. 
Method and procedure of the examination—The 
anterior lung-liver margin to the right should be first 
determined on percussion (see page 46), then the 
position of the right border of the heart on moderately 
strong percussion (the finger must be firmly held 
against the parts). (The tone becomes higher as soon 
as it is dull.) It is more difficult to determine the 
cardiac dullness in the cardio-hepatic angle (at the 
lower portion of the right border of cardiac dullness 
in the region of relative dullness of the liver). Dis- 
tinct dullness is the sign to be used in this determina- 
tion. The left border of the heart is determined with 
somewhat lighter percussion but also with the finger 
firmly against the chest. The left, upper border is 
determined by moderately strong percussion. By as- 
suming that the left lower border of the heart (apex) 
begins where the tone is nearly absolutely dull, it is 
possible to make the percussed dullness correspond 
the closest with the orthodiagram. The upper left and 
right borders of the heart (frontal projection) should 
Percussion of the Cardiac Region 84 
a clinical guide to 
be determined when the tone is distinctly dull as the 
structures in the hilus, especially in stasis of the lesser 
circulation, may interfere (Felsenreich). Non-consid- 
eration of these points may lead to the determination 
of the cardiac dullness over too large an area. 
Determination of the size of the heart is then taken 
up by percussion of the various intercostal spaces. 
The outline is thus ascertained as well as the medial 
area of dullness (large vessels). 
The normal configuration shows a concave outline 
in the region of the left auricle. The cardiac boun- 
daries should be determined on standing and lying 
down; the former is often best. 
The so-called absolute dullness is identical with the 
position of the anterior margins of the lungs (see 
page 46). 
Auscultation of the Cardiac Region 
Auscultation is performed in the lying, standing, 
left and right side positions, knee-elbow position and 
with the head bent slightly forward. The stethoscope 
is usually used except in soft diastolic aortic murmurs. 
The stethoscope may be tipped to one side or the ear 
slightly elevated from the stethoscope if there are 
murmurs which hide the heart tones or if other diffi- 
culties interfere with the latter. 
Auscultation at the usual places; the mitral valve at 
the apex, pulmonary valves at the 2nd and 3rd inter- 
costal spaces near the sternum, aortic valves in the 
2nd right intercostal space near the sternum and in BEDSIDE EXAMINATION 
85 
the aortic region (see page 86), and the tricuspid valve 
over the lower sternum. The second tone at the apex 
is composed chiefly of the 2nd aortic and shows the 
characteristics of that tone while the 2nd tone at the 
lower sternum corresponds more to the pulmonary 
valve. The first tone corresponds to the beginning of 
systole of the ventricle and follows the long pause be- 
tween the beats. The tone which comes with the apex 
beat or carotid pulse (not the radial pulse) may be 
considered as the first heart tone in rapid or irregular 
heart action. Shortening of the pulse (pendulum 
rhythm, embryocardia). Then auscultation of the 
entire precordial area, especially the lines connecting 
the previously mentioned points of auscultation. 
Description of the several tones according to loud- 
ness (accentuation), height, ringing or dull, sharp 
ending, not sharp ending and the maximum area over 
which the tone is heard. It is normally possible to 
differentiate between the 2nd aortic and pulmonic 
tones. The former is higher, shorter and more dis- 
tinctly limited as to time, while the pulmonary tone 
is deeper, duller, longer and does not end sharply 
(Heitler). These differences are also distinct in 
accentuation of the 2nd aortic and pulmonic tones. 
The acoustic characteristics of the tones may be 
modified by changes in the conducting media to the 
chest wall (diminution in pericardial effusion, pre- 
cordial effusions or thickenings, exudative pleuritis or 
thickening, tumors, etc.). The tones are increased, 
especially in infiltration of the overlying parts of the 86 
A CLINICAL GUIDE TO 
lung. The heart tones may be ringing or metallic in 
accumulation of air near the heart as in pneumo- 
pericardium, pneumothorax, cavity in the lung, large 
air bubble in the stomach, etc. Hypertrophy of the 
ventricle causes dull tones and a loud first tone occurs 
in poor filling of the ventricle (mitral or tricuspid 
stenosis, anemia with oligemia). The first tone is 
normally louder at the apex and tricuspid areas while 
the second tones are louder at the base of the heart. 
For splitting and doubling of the tones (see page 
107). 
Murmurs. Soft murmurs are best heard upon hold- 
ing the breath during expiration. 
A. Endocardial murmurs—These are limited to 
definite phases of the heart action, become somewhat 
fainter during inspiration and during the test of 
Valsalva; are not modified by pressure from without 
and have a definite localization and extent. 
More Detailed Description of Endocardial 
Murmurs 
1. Determination of location in general. 
2. Determination of place where most distinct. 
3. Determination of the phase of heart action. 
Systolic murmurs are synchronous with ventricular 
systole; diastolic with ventricular diastole and other 
murmurs such as presystolic, postsystolic (also called 
mesosystolic, occurs during systole but is separated 
from the first tone by a very short period) and post- BEDSIDE EXAMINATION 
87 
diastolic murmurs (in diastole and separated from 
the second tone). 
4. Changes in intensity of the murmur during its 
course; increase or decrease of the murmur at its end. 
5. Character—Raw, soft, blowing, flowing, rubbing, 
rolling, ringing, musical, etc. 
6. Loudness—Loud, soft, distant. 
7. Conduction—To the large vessels, axillary space, 
interscapular space, towards the spine at the lower 
cervical or upper thoracic vertebrae, liver region, etc. 
(see page 109). 
B. Pericardial Murmurs—They are not definitely 
associated with certain phases of the heart action, usu- 
ally shuffling in character or like scratching, often soft, 
appear near to the ear, may represent the ‘locomotive 
rhythm”, are unchanged during inspiration and are 
louder upon the Valsalva test or pressure with the 
stethoscope. They are often distinctly limited to a 
circumscribed region of the precordium so that they 
may be heard only after the rest of the precordium has 
been auscultated. They are changed to variable de- 
grees by change in position (bending forward or knee 
elbow position), and are independent of breathing in 
contradistinction to pleuro-pericardial murmurs (see 
page 60). 
C. Cardio-pulmonary Murmurs—These are soft, 
systolic, at the region of the anterior margin of the 
lungs, pulse rhythm, depend on the respirations and 
disappear on maximal inspiration. They occur in the 
borders of the lungs by suction of air during the sys- 88 
A CLINICAL GUIDE TO 
tolic contraction of the heart. (See cog-wheel breath- 
ing, page 57.) 
Vessels 
Arteries 
Inspection and palpation—Determination of the 
filling condition, changes in the wall and the various 
qualities of pulse (see page 6). Palpable thrills. 
Auscultation—Spontaneous tones and murmurs are 
to be differentiated from pressure tones and murmurs. 
The latter are the result of pressure of the stethoscope 
on the vessel while the former are heard without any 
pressure or even at some distance. Tones are heard 
over the large and middle sized arteries when there is 
moderate compression centrally from the site of aus- 
cultation (best heard by application of the elastic arm 
band of a blood pressure apparatus or pressure with 
the finger, taking care not to completely obliterate the 
pulsation). A pressure tone occurs at the site of com- 
pression of the large and middle sized vessels on very 
strong pressure. 
Carotid and Subclavian Arteries—Two tones are 
usually heard. One is softer and corresponds with 
heart systole and tension of the vessel while the second 
tone is usually louder and is the conducted aortic tone. 
The same tones are heard in the jugulum and three 
tones may sometimes be heard in this place (Ortner). 
Murmurs may be transmissions of the aortic tones 
either in systole or diastole. A pressure tone on very 
light compression of the carotid speaks for a change BEDSIDE EXAMINATION 
89 
in the wall of this vessel {Litton). Murmurs are some- 
times heard over the subclavian artery, especially in 
processes in the lung apex. They are systolic or pro- 
longed and usually increased or heard only during 
expiration (kinking of the arteries by adhesions with 
the pleura). 
Brachial Artery—Normally no tones. Aortic in- 
sufficiency may cause single and sometimes double, 
spontaneous tones. These findings are sometimes also 
observed in thyreotoxicosis, Basedow’s disease, pulsus 
celer and relaxation of the vascular wall in infectious 
or toxic processes. 
Abdominal Aorta—A spontaneous tone is often nor- 
mally heard and especially in aortic insufficiency, 
cardiac hyperkinesis, thyreotoxicosis, Basedow’s di- 
sease, fever, etc. Pressure murmur on slight 
compression speaks for change in the wall. Double 
murmur in aortic insufficiency. Aneurysm: compres- 
sion murmurs from compressing abdominal tumors. 
Femoral Artery—A soft tone is occasionally heard 
normally. Single or double tone in aortic insufficiency 
(Traube). Increasing pressure with the stethoscope 
produces at first a single murmur and the characteristic 
double pressure murmur {Duroziez). Still greater 
pressure produces a single compression murmur and 
still greater pressure produces a pressure tone. 
Double tones, and more rarely, double murmurs are 
also heard in excited cardiac action, fever and Base- 
dow’s disease. A split crural tone may be heard in 
dicrotic pulse. 90 
A CLINICAL GUIDE TO 
Small arteries of the hand and foot. Soft tones in 
aortic insufficiency (volar-tone), but these may be ab- 
sent if there is sclerosis of the vessels. 
Veins 
In addition to the veins of the trunk and extremities, 
the veins of the neck are also to be observed. All of 
these may show visible pulsation. Abnormal filling 
of the cervical veins may be due to a general venous 
congestion or local stasis in the region of the superior 
vena cava. 
The genuine venous pulse must be differentiated 
from the one transmitted to the veins by the carotid. 
The venous pulse has a more flat, undulating move- 
ment which may sometimes be seen to have two 
summits (auricular and ventricular stasis ridge, the 
former presystolic and the latter mesosystolic). The 
cervical veins become more distinctly filled with cer- 
tain positions of the head or trunk, especially with 
head lowered or turned to one side, but occasionally 
in the vertical position of the head and trunk. 
Condition of the large veins during respiration. 
Normal disengorgement during inspiration. Para- 
doxic condition, congestion on deep inspiration in 
pathological changes in the region of the mediastinum 
(mediastinal tumor, mediastinitis fibrosa, mediastino- 
pericarditis and substernal struma). BEDSIDE EXAMINATION 
91 
Pulsations 
1. Negative Venous Pulse 
A. Physiological collapse of the veins at the begin- 
ning of ventricular systole. 
B. Present pathologically in stasis of the right 
auricle without complete collapse of the veins. Stasis 
in the pulmonary circulation in paralysis of the right 
ventricle and tricuspid stenosis. The first crest in the 
venous pulse is especially prominent in tricuspid 
stenosis. 
2. Positive, ventricular systole, venous pulse, recog- 
nizable when the auricular crest disappears in 
auricular fibrillation. It is synchronous with systole 
of the ventricle and is especially distinct in insufficiency 
of the venous valves. It may be recognized on auscul- 
tation or palpation of the heart. It is either a con- 
gestion pulse by compression of the cervical veins (no 
refilling below the site of compression) or a genuine 
retrograde pulse wave (refilling proximal to the site 
of compression with previous smoothing out of the 
vein). 
It occurs in organic and functional insufficiency of 
the tricuspid, auricular fibrillation and tachycardia and 
extra-systole with normal nodal rhythm. Also in com- 
binations of mitral insufficiency with open foramen 
ovale and after perforation of an aneuryism into a 
vein. 
A positive liver pulse usually accompanies a positive 
venous pulse at the neck. The transervse expansile 92 
A CLINICAL GUIDE TO 
character in the change in volume due to the pulse may 
be demonstrated by bimanual palpation (systolic, 
diastolic or presystolic). To be differentiated from 
transmitted pulsation of the abdominal aorta, right 
ventricle, pulsating tumors of this region but with 
difficulty from arterial liver pulse (see aortic 
insufficiency). 
The liver should be grasped between the two hands 
to demonstrate a liver pulse, as from the flank towards 
the middle or from anteriorly to the posterior aspect. 
The separation of the hands during pulsation is the 
important feature. 
High grade aortic insufficiency may also produce 
visible, positive, venous pulse in the small peripheral 
veins of the extremities and liver (penetrating venous 
pulse, liver pulse). This may be due to a continuation 
of the celer pulse of the arteries into the veins. 
Auscultation of the cervical veins. 
A continuous, systolic murmur, increased during 
inspiration may be heard in anemia and especially in 
chlorosis. A bulbus-tone may occur in some cases of 
tricuspid insufficiency and in venous valves which can 
still close (Bamberger). 
Capillaries 
Capillary Pulse—Determined by causing a slight 
anemia of the nail bed or on a site of the skin which is 
made hyperemic by rubbing, especially on the skin of 
the forehead. Rhythmic redness and pallor in pulsus 
celer. BEDSIDE EXAMINATION 
93 
DIAGNOSTIC VALUE OF THE VARIOUS 
PHYSICAL FINDINGS AT THE HEART 
AND VESSELS 
1. Inspection and Palpation 
Pulsating Bulging in the Region of the Heart 
A. Apex beat. 
1. Position: normally palpable in the 4th or 5th in- 
terspace but may not be palpable under normal 
conditions, marked filling of the lungs or it may be 
hidden by overlying pericardial thickening, pleural 
effusion or effusion of the pericardium, tumors, ab- 
normal thickenings of the chest wall, etc. 
Determination of the Position of the Apex Beat— 
Measuremnt of the distance in centimetres from the 
midline or estimation of the distance to the left medio- 
clavicular line. There may be a difference of one or 
two fingerbreadths when the patient is on the left or 
right side. Suspect accretio cordis if this shifting does 
not occur. Shifting upwards in high position of the 
diaphragm (horizontal position of the heart) and 
towards the median line and downwards in descent 
of the diaphragm (vertical position of the diaphragm). 
The apex beat is more median in small hearts. Oliver- 
Cardarelli sign often present in perpendicularly sus- 
pended heart. (See page 77.) 94 
A CLINICAL GUIDE TO 
Displacemnt of the apex beat to the left or to the 
left and downwards is found in: 
(a) Shifting of the heart to the left in processes 
diminishing the space in the right thorax or right 
mediastinum (considerable effusion on the right side, 
high grade ascent of the diaphragm as in subphrenic 
abscess, large tumors of the liver, diaphragmatic even- 
tration, etc.). 
(b) Pulling of the heart by shrinking, connective 
tissue processes in the left half of the thorax (pleural 
and pleuro-pericardial thickenings, shrinking tumors). 
(c) Enlargement of the left ventricle. 
(d) Enlargement of the right ventricle with result- 
ing displacement of the left ventricle. 
2. Quality of the apex beat—Normally hardly pal- 
pable, may be covered by the tips of one or two fingers, 
rapid in hyperkinesis (neurasthenia, thyreotoxic 
hearts, etc.) sometimes with coincident, slight vibra- 
tion. The apex beat may be striking, short and hard 
as in mitral stenosis as a result of the rapid contrac- 
tion of the poorly filled ventricle as well as' in 
hemorrhage and anemia. There is a loud first tone in 
these conditions. 
Heaving in hypertrophy of the left ventricle (“loco- 
motive-like”). No displacement in simple hypertrophy 
if the heart muscle is in good condition (arterial hyper- 
tension, renal disease, aortic stenosis). The heaving 
is slow. Displacement in eccentric hypertrophy 
(rapid) in the before mentioned conditions with dila- 
tation. Also in practically all valvular diseases. It BEDSIDE EXAMINATION 
95 
is absent in pure mitral stenosis. It is found in affec- 
tions of the aorta as mesaortitis luetica, aneuryism and 
atheroma. 
Wide apex beat so that it takes several finger tips to 
cover it and may be felt in several intercostal spaces. 
Found in thin thorax, hypertrophied heart closely ap- 
plied to the chest wall and in partial aneurysm of the 
heart at the apex. 
The overlying ribs may be elevated during pulsation 
of a heaving and widened apex beat. 
Doubling of the apex beat, caused by premature, 
presystolic beat and in which the first tone is shorter 
and weaker (mitral stenosis). Double beat in asyn- 
chrony of the ventricle. 
B. Pulsating elevation of the lower sternum 
In hypertrophy of the right ventricle with dilata- 
tion ; as a sign of compensation in tricuspid or mitral 
lesions, double aortic and mitral lesions, disease of the 
pulmonic valves, septum defect, patent ductus Botalli, 
pulmonary emphysema and extensive thickening in the 
region of the lungs or pleura. Also in kypho-scoliosis, 
long-standing pneumothorax (increased pressure and 
increased resistance in the lesser circulation) and in 
hypertrophy of the entire heart. 
Lifting of the sternum and epigastric pulsation 
occurs in thyreotoxic hyperkinesis (Basedow, Base- 
dowoid, goitre heart) with and without hypertrophy 
of the right ventricle. 
A normal but excited heart may cause a vibrating 96 
A CLINICAL GUIDE TO 
heaving of the lower sternum in a delicate elastic 
thorax, especially in the young. 
C. Epigastric Pulsation 
C. Epigastric Pulsation—In descent of the dia- 
phragm, with and without hypertrophy of the right 
ventricle, in splanchnoptosis and in emaciation. 
Differentiation of epigastric pulsation caused by the 
heart from that caused by pulsation of the abdominal 
aorta, liver pulse, pulsating tumors or tumors to which 
the pulsation is transmitted. (See page 92. See page 
24 for technic of palpation.) 
D. Pulsation to the left of the sternum at the level 
of the second interspace may be of the pulmonary 
artery or normally in rare instances in delicate chest 
wall. May be conducted by interposition of infiltrated 
parts of lung or by fixation of the pulmonary artery 
by connective tissue to the wall. Also in abnormal 
condition of the wall of the pulmonary artery or de- 
nudation of this vessel by shrinkage of the left lobe of 
the lung or retraction of the margins of the lung by 
decreased volume (chlorosis, Basedozv), and in dila- 
tation of the pulmonalis (mitral stenosis, patent ductus 
Botalli, pulmonic insufficiency, congenital pulmonic 
stenosis, septum defect, aneurysm of the pulmonary 
artery, etc.). 
E. Pulsation of the aorta with conduction to the 
right of the sternum. Dilatation or aneurysm of the 
aorta and aortic insufficiency with overstretching of 
the aortic wall. BEDSIDE EXAMINATION 
97 
F. Pulsation in the region of the left auricle in 
hypertrophy and dilatation of the same as in mitral 
stenosis. 
G. Pulsation at various places as in double pulsa- 
tion in aneurysm (Stokes). 
Pulsating Indraivings 
Obliterating pericarditis with fixation to the pos- 
terior mediastinum may cause this phenomenon at the 
apex or in the region of the apex. The apex may be 
thrown forward in this condition (Broiler), or there 
may be a coincident systolic indrawing to the left, 
posteriorly and below (Broadbent). To be differen- 
tiated from systolic indrawing at the same place in 
descent of the diaphragm. This indrawing in peri- 
cardial obliteration is to be differentiated from ro- 
tatory indrawing. The indrawing of the latter is 
above and to the right of the apex but the apex beat 
may not be demonstrable or may be normal, resistant 
or heaving. 
Pulsation of the Jugular Fossa 
Visible and palpable in abnormal length of the aorta 
(high aortic arch in high diaphragm, elongation of the 
aorta or pulling or pushing of the arch), or result of 
pulsation of an eneurysm. The most common cause is 
a dilated arteria anonyma or one which is pushed 
upward. 98 
A CLINICAL GUIDE TO 
Palpable Thrills in the Heart Region 
1. At the apex. Systolic in mitral insufficiency or 
conducted as in aortic or pulmonic stenosis, patent 
ductus Botalli, septum defect. Short vibration in 
simple hyperkinesis. Present over a wide area and 
also in the axilla in the former condition. More 
localized to the apex in aortic stenosis. Presystolic 
and at times outside of the area of cardiac dullness in 
mitral stenosis and may be localized to a small area. 
Diastolic thrill in mitral stenosis or conducted from 
congenital malformations. 
2. An isolated thrill in the tricuspid region is rare 
(valvular lesion of the right heart). It is more 
frequent as a conducted thrill. 
3. At the aortic or pulmonic regions—Systolic in 
stenosis of the arterial ostia and diastolic in in- 
sufficiency of the semilunar valves. The thrill may be 
conducted to the large vessels and jugular fossa in 
aortic stenosis. Systolic thrill may be present in 
severe changes of the wall without stenosis (mesa- 
ortitis, atheroma, verrucous deposits). Systolic thrill 
of the pulmonary artery in patent ductus Botalli and 
reaching into diastole. It is also conducted from the 
sternal region in septum defect. 
Aneurysm may produce thrills in any phase of 
cardiac action, depending on the position in relation to 
the chest wall. (See pulsation and bulging, pages 18 
and 97.) BEDSIDE EXAMINATION 
99 
II. Percussion 
The right border of cardiac dullness reaches in a 
slight convex bow to the right border of the sternum 
or slightly beyond it. The distance from the midline 
varies according to the height of the diaphragm and 
the configuration of the thorax. It is useful to 
measure the right and left borders of cardiac dullness 
in centimetres, as from the median line. The left 
lower border of the heart is convex externally and 
does not normally extend beyond the left medio- 
clavicular line. Thg distance from the median line to 
the right border of cardiac dullness averages about 
4 cm., and to the left about 8 cm., but this is subject 
to variations depending on the position of the dia- 
phragm, vertical heart, etc. 
Displacement of the Heart 
In situs viscerum inversus totalis or partialis in 
which the apex beat is to the right and below. A 
similar finding is present in pulling or pushing of the 
mediastinum. The apex in this case is left and low 
in relation to the dullness. The cardiac dullness may- 
be displaced upwards or downwards by the level of the 
diaphragm. (See page 46.) 
Abnormal mobility of the heart may result in con- 
siderable shifting on assuming the left or right posi- 
tion. The dullness found on standing may disappear 
on lying down in such a heart, due to interposition of 
the lung margins when the heart drops backwards. 100 
A CLINICAL GUIDE TO 
Diminution in Size of the Cardiac Dullness, 
Especially at its Widest Diameter 
Occurs in vertical heart and is characterized by low 
diaphragm and abnormally small heart (also in normal 
position of the diaphragm). (See displacement of the 
apex inwardly, page 93.) 
Widening of the Cardiac Dullness to the Right 
1. Pushing or pulling of the entire heart to the right 
(control with left border or apex). Displacement of 
the right heart by greatly enlarged left heart (aortic 
insufficiency, renal disease). 
2. Enlargement of the right heart—Enlargement of 
the right auricle alone or normal sized auricle pushed 
to the right by a large right ventricle. Hypertrophy 
of the right ventricle with heaving or elevation of the 
lower sternum and step-like configuration of the left 
anterior margin of the overlying right lung (covering 
the right heart). 
The upper portion of the right border of the heart 
may occasionally be formed of an abnormally dilated 
left auricle which extends to the right (mitral 
stenosis). The lower portion of the right heart border 
may occasionally be formed of markedly enlarged 
right ventricle. 
The differential diagnosis may be very difficult be- 
tween cardiac dullness enlarged to the right from 
mediastinal exudate, tumor, thickening, areas of in- 
filtration of the lung and infarct. BEDSIDE EXAMINATION 
101 
Extension of the Cardiac Dullness to the Left 
and Dozvnwards 
In displacement of the entire or left heart by the 
right side, enlargement of the left ventricle and peri- 
cardial effusion (the apex beat may be within the area 
of cardiac dullness when stooping forward). Differ- 
entiation from extra-cardial dullness (see right border 
of the heart). Left sided pleural exudate at the base 
may be differentiated from cardiac dullness by the 
intensity of the dullness. (See condition of Traube’s 
space, page 73.) 
3. Enlargement of the Left Upper Part of the 
Area of Cardiac Dullness 
This may be caused by an enlarged left auricle or 
pulmonary artery. Differentiation is not possible on 
percussion alone but may be possible by palpation of 
the nature and phase of the pulsation. The enlarged 
left auricle is especially prominent in mitral lesions 
as mitral stenosis, etc. Enlarged pulmonary artery 
should be considered in pulmonary insufficiency and 
patent ductus Botalli. A stripe-like area of dullness 
may be present in the latter condition to the left of 
the sternum in the second interspace. 
A filling out of the concavity of the outline of 
cardiac dullness occurs in the several conditions men- 
tioned and leads to the so-called “mitral configuration.” 
Prominence of the lower left part of the cardiac dull- 102 
A CLINICAL GUIDE TO 
ness forms the “aortic configuration” (shape of a 
swimming duck). 
There is not uncommonly moderate dullness at the 
back, to the left of and near the spine in enlargement 
of the left auricle, especially in mitral stenosis. This 
may be present either high or low, that is, from the 
2nd to the 4th thoracic or from the 5th to the 7th 
thoracic vertebra (Ortner). There is occasional slight 
dullness in the region of the entire left upper lobe and 
left apex (diminished air content of these parts). 
4. Enlargement of the Area of Cardiac Dullness 
in All Dimensions 
5. Enlargement of all the parts of the heart in com- 
bined valvular disease and severe myocardial disease. 
The cardiac dullness in relaxed heart is like a triangle 
with the base on the diaphragm. 
Pericardial effusions may cause enlarged cardiac 
dullness. This dullness shows a pronounced increase 
towards both sides and the left lower margin often is 
outside of the apex beat while the right border forms 
a right angle or acute angle with the relative dullness 
of the liver (corresponding to the diaphragmatic 
cupula) (Luger). The demonstration of these con- 
ditions is seldom possible. 
The percussion tone over the entire area of cardiac 
dullness to the extreme margins is intensely dull. The 
area of absolute dullness nearly conforms to the con- 
tour of the heart. This is due to the pushing apart 
of the lung margins. The lung-liver margin forms an BEDSIDE EXAMINATION 
103 
obtuse angle with the lower portion of the right border 
of the absolute dullness (Rotch, Epstein). This angle 
does not correspond anatomically to the cardio-hepatic 
angle but is called by this name in spite of that. The 
liver dullness becomes more intense in the vicinity of 
the exudate. 
An increase of the absolute dullness in all directions, 
especially of the dependent parts, occurs if the patient 
changes from the lying position to the sitting posture. 
The upper parts of the dullness are increased in area 
on bending forward, especially with the knee-elbow 
position. 
A zone of dullness in the region of the lungs, pos- 
teriorly, to the left and below, may be found in large 
retro-cardial effusions {Bamberger). 
There may be a hypersonorous or tympanitic tone 
over the heart in pneumo-pericardium. Fluid with air 
in the pericardial cavity (pyo-, sero-, hydro-pneumo- 
pericardium), causes a zone of dullness in the lower 
part of the area of tympany, the upper border being 
horizontal, if the patient sits up. 
Enlargement of the Area of Median Dullness 
Diffuse dilatation of the ascending aorta, usually 
luetic, causes an area of dullness to the right of the 
sternal margin in the 2nd and 3rd interspace with the 
convexity to the right. Enlargement of the median 
dullness to the right may also be caused by mediastinal 
Large Vessels 104 
A CLINICAL GUIDE TO 
tumors with displacement of the vena cava superior 
or tumors with displacement of the aorta to the right. 
Dullness of the upper part of the sternum. The 
slight dullness which is normally found over the upper 
part of the sternum may be increased entirely or in 
parts (aneurysm or dilatation of the aortic arch in the 
median line, substernal struma). (The latter may 
show an elevation of the thoracic dullness on swallow- 
ing, increase of the intensity of the dullness during 
deep inspiration which is in contrast to aortic dullness 
in which the dullness is diminished by the increased 
air content of the lungs during inspiration). Extreme 
enlargement of the left auricle may occasionally cause 
dullness of the upper part of the sternum. 
Enlargement of the Area of Median Dullness 
to the Left 
Enlargement of the physiological dullness from the 
aorta at the junction of the left, second rib and 
sternum in widening of the sagittal aspect of the aorta 
(Kreuzfuchs). This place normally shows a rounded, 
vaguely outlined zone of dullness of a maximum 
diameter of 2 cm (Jagic-Kreuzfuchs). (See above, 
left auricle.) 
Aortic aneurysm may cause enlargement at any side 
of the median dullness regardless of from what por- 
tion of the aorta the aneurysm arises. BEDSIDE EXAMINATION 
105 
III. Auscultation 
(a) Cardiac Tones 
First tone'at the apex. Abnormally dull in damaged 
heart muscle, especially if there is also hypertrophy 
or by reason of overlying pulmonary emphysema, 
pericarditis, thickenings, etc. Abnormally snappy in 
mitral stenosis, severe anemia from hemorrhage, and 
extra-systole, either corresponding to the extra-systolic 
contraction or to the heart tone following the pause. 
The reason in the first is the small volume of the beat, 
and in the second the recuperation of the heart muscle 
after the pause. The first tone is also abnormally loud 
in hyperkinesis of the heart. 
The first tone may take on a ringing character in 
interposition of thickened lung. Metallic resonance 
may be due to an abnormally large air bubble in the 
upper part of the stomach, neighboring cavity, pneu- 
mothorax, pneumo-pericardium, emphysema of the 
skin, diaphragmatic hernia, etc. 
The first tone at the lower part of the sternum in 
comparison with the first tone at the apex may be 
somewhat prolonged and dull in hypertrophy of the 
right heart. 
The Second Heart Tone—The second tone at the 
apex is chiefly aortic in origin and that over the lower 
sternum is chiefly from the pulmonic area. The pul- 
monic tone should be localized and may be dull, deep, 
prolonged or vaguely distinct. Its optimum is in the 106 
A CLINICAL GUIDE TO 
region of the right ventricle or in the pulmonic region 
in the 2nd or 3rd left intercostal spaces. The differ- 
ence in the character of the tone will help to dis- 
tinguish the pulmonic 2nd from the aortic. 
A. Second Pulmonic Tone—Accentuation of the 
second pulmonic may mean increase of pressure in the 
lesser circulation (mitral disease, patent ductus Botalli, 
pulmonary emphysema, thickenings, scoliosis, etc.), 
together with hypertrophy of the right ventricle. The 
accentuation of the 2nd tone disappears if the right 
ventricle is weak or in tricuspid insufficiency. Both 
tones in the pulmonic region are abnormally loud in 
denudation of the pulmonalis following retraction of 
the pulmonary margins as in chlorosis or shrinking 
processes of the left upper lobe. 
The second tone is also accentuated in supraclavic- 
ular pulmonic stenosis but is softer in valvular pul- 
monic stenosis. An accentuated pulmonic second is 
often an expression of a physiological narrowing of 
the pulmonary artery in young, growing individuals. 
A ringing second pulmonic tone is sometimes found 
as a result of the rarely occurring pulmonary sclerosis 
with changes in the wall. This sign on auscultation 
may be hidden by the ringing aortic second which is 
transmitted. The cause of a ringing pulmonic second 
may be due to some special factors, in conduction as 
infiltrated lung tissue, cavity formation in the lungs, 
pneumothorax, emphysema of the skin, etc. 
B. Secotbd. Aortic Tone—Accentuated in higher 
pressure in the great circulation, arterial hypertension. BEDSIDE EXAMINATION 
107 
An abnormally loud second tone may occur in pendu- 
lous heart and if the large vessels are close to the 
chest wall. The tone may again become normal on 
Glenard’s test of pushing upwards on the abdomen. 
The second tone may be soft when the heart tones are 
weak as in pericarditis, thickenings, etc. The 2nd 
aortic may also be softer in aortic stenosis of valvular 
nature while it is accentuated in supravalvular steno- 
sis and may be normal in subvalvular stenosis. It 
may also be soft in peripheral hypotonia, severe acute 
hemorrhage (the first tone becomes loud) and in car- 
diac weakness. A poor prognosis may be expected 
if the 2nd tone which has been loud becomes soft 
during infectious disease as an expression of high 
grade toxic hypotonia, especially of the splanchnic 
vessels (Ortner). 
The 2nd aortic becomes ringing in changes in the 
wall of the aorta as in sclerosis, mesaortitis or aneu- 
rysm (Schroetter). For abnormal resonance see para- 
graph on pulmonic second tone. 
Splitting or Doubling of the Heart Tones 
Splitting or doubling of the first tone. 
1. Post systolic accessory beat (Geigel)—The acces- 
sory tone is short, soft as compared with the main 
tone. It may be ringing and raw in aortic sclerosis. 
No gallop rhythm. Often heard normally at various 
localized places. Found in increased pressure and 
aortic sclerosis. 108 
A CLINICAL GUIDE TO 
2. Presystolic Accessory Tone (Auricular Tone)— 
The tone is duller and softer than the main tone and 
occurs in disturbance in conduction, mitral stenosis, 
hyperkinesis of the heart, hypertrophy of the ventricle 
and ventricular dilatation. 
Note the interval of time between the accessory and 
main tones. 
3. Both tones may show the same accoustic qualities 
as a result of unequal contraction of the ventricles in 
regard to time. There may be gallop rhythm (arterial 
hypertension, especially in shrunken kidney and mitral 
disease). 
Splitting or Doubling of the Second Tone 
Caused by closure of the valves at the arterial ostia 
at different times. 
1. Inspiratory Doubling—Pulmonic tone too early, 
gallop rhythm not present. This doubling may be seen 
normally in excited heart action. 
2. Long Standing Doubling—Either the pulmonic 
or aortic tones may be too early. No gallop rhythm 
(increased pressure in the lesser circulation, mitral 
disease, especially mitral stenosis. Increased pressure 
in the greater circulation as changes in pressure in the 
ventricles, chronic nephritis, arterio-sclerosis and val- 
vular disease of the heart). 
In addition to the previously mentioned presystolic 
accessory tone, there is also a dull accidental diastolic 
or presystolic tone in mitral stenosis. Gallop rhythm 
possible. BEDSIDE EXAMINATION 
109 
(b) Murmurs 
Systolic Murmurs 
1. At the apex. 
A. In incomplete closure of the mitral valve as a 
result of endocarditic changes (valvular mitral 
insufficiency). 
Without anatomical changes at the margins of the 
valve in functional (relative or muscular) mitral 
insufficiency. 
Mitral murmurs are usually more distinct upon 
lying down than on sitting or standing and are usually 
transmitted to the axilla and toward the back under 
the left shoulder blade. There are all varieties and 
are usually decrescendo in character. They may be 
raw, soft, blowing or musical. They may come imme- 
diately after or cover the first tone. They may be 
heard over the entire precordial region with the maxi- 
mum intensity at the apex or in the 2nd or 3rd left 
interspace, as is often the case in fresh endocarditis 
and more rarely in special topographic conditions of 
the left auricle (Naunyn’s mitral insufficiency). 
B. As conducted murmurs from other ostia. Dif- 
ferentiated by determining the maximal point as well 
as by the varying character of the murmur. The 
murmur from aortic stenosis and from verrucous en- 
docarditis of the aortic valves is usually rawer and 
louder. The same is true in pulmonic stenosis. 
C. Accidental murmurs may be anemic and not due 
to muscular insufficiency or cardio-pulmonic murmurs, 110 
A CLINICAL GUIDE TO 
or they may be the so-called fever murmurs or tachy- 
cardia murmurs. These usually show their maximum 
at the base of the heart in the region of the pulmonic, 
are often inconstant and depend on the position and 
movement of the body. Accidental murmurs may be 
suspected if there is no sign of enlargement of any 
part of the heart or sign of circulatory disturbance of 
any sort. 
2. Over the Tricuspid. Systolic murmur at the 
lower sternum, usually conducted from the mitral or 
as a result of tricuspid insufficiency of valvular or 
functional nature. These murmurs are differentiated 
from mitral murmurs by the rough character. The 
maximal point is at the site of auscultation of the 
tricuspid and is increased by bending forward and 
pressing upward of the liver (Heitler). Often trans- 
mitted to the liver region or to the right and below. 
3. Systolic Murmur at the Base of the Heart 
(a) Pulmonic region. The majority of the func- 
tional murmurs are most distinct at this region. 
Systolic murmurs also occur in pulmonary sclerosis 
and pulmonic stenosis (conduction in the lungs, occa- 
sionally conduction along the large vessels in the 
neck). Also in the supra-valvular stenosis of the pul- 
monalis resulting from compression by glands, 
aneurysm, tumors, etc. These murmurs are usually 
somewhat late in systole. Systolic murmurs may be 
found in patent ductus Botalli or may be transmitted 
from other ostia. BEDSIDE EXAMINATION 
111 
(b) Aortic region. In aortic stenosis, roughness of 
the aortic valves or wall. The murmur is usually post- 
systolic. Systolic murmurs also occur in marked dis- 
proportion between the lumen of the aorta and left 
ventricle as an expression of relative aortic stenosis. 
It is almost constant in aortic insufficiency, even with- 
out stenosis, and in aortic aneurysm may also be 
transmitted from other ostia. These systolic murmurs 
are usually in contrast to mitral murmurs in the large 
vessels of the neck and in the jugulum, especially in 
aortic stenosis (conditions of the 2nd tone, peripheral 
vessels and pulse, see pages 6 and 106). 
A systolic murmur at the apex and aortic area may 
have two distinct causes and the murmurs may be 
separated by the difference in the tone (mitral murmur 
usually softer, aortic usually harsher) ; difference in 
phase (aortic murmur somewhat delayed and some- 
times distinctly post-systolic). The fact that the mur- 
murs are softer between the suspected areas of origin 
as compared with the tones at the apex and aortic area 
does not speak definitely for a double etiology if none 
of the foregoing signs are present. 
Diastolic Murmurs 
The most frequent and loudest are the diastolic 
murmurs at the aortic area (2nd right interspace near 
the sternum and diagonally to the attachment of the 
3rd rib on the left side), but it may be heard anywhere 
over the heart as at the apex, the pulmonic area or left 
auricle. 112 
A CLINICAL GUIDE TO 
1. Diastolic murmur as a sign or valvular aortic 
insufficiency. The murmur is blowing or flowing and 
decrescendo in character. It is often heard only on 
standing or at certain places, as at Erb’s point to the 
left of the sternum. It is frequently very soft. The 
murmur diminishes in intensity in all directions, as 
towards the large vessels of the neck and apex where 
it may again have a second point of maximum in- 
tensity. It may be heard in some cases as an isolated 
murmur of changed character at the apex and should 
be differentiated from mitral stenosis. The 2nd tone 
is usually retained except in severely damaged valves 
which cannot vibrate any more. 
There are rare instances in which diastolic murmurs 
at the aortic area are functional in nature as in func- 
tional insufficiency of the aortic valves as a result of 
extreme arterial tension (disappearance of the mur- 
mur in lowering of the pressure as after venesection 
and also in drawing away of the valves as a result of 
the aortic wall being drawn outwards by shrinking 
processes in the vicinity). It may also be due to de- 
generation and relaxation of the circumvalvular muscle 
fibres as in severe anemias (Ortner). 
The diastolic aortic murmur is best differentiated 
from the murmur of mitral stenosis by its decrescendo 
character. A diastolic murmur in the aortic region 
may be due to a transmitted murmur from the pul- 
monic area. It is possible to mistake the soft diastolic 
aortic murmurs for breath sounds but this may be 
prevented by auscultating between respirations. BEDSIDE EXAMINATION 
113 
2. In the Pulmonic Region—Most commonly in in- 
sufficiency of the pulmonic valves with variable 
character of the 2nd pulmonic tone (accentuated, 
normal or soft). 
The second pulmonic tone is abnormally loud or 
abnormally soft, pulsus celer absent at the peripheral 
arteries, high grade hypertrophy and dilatation of the 
right ventricle, murmur heard over the lungs, no 
transmission into the large vessels of the neck and es- 
pecially not in the right carotid. Pulsus celer in the 
pulmonary artery. A double tone may be heard over 
the lungs analogous to the double tone of Traube 
(Gerhardt). Cog-wheel breathing over the lungs 
synchronous with the pulse. 
The diastolic murmur in mitral stenosis may, in 
some cases, be heard only at or best at the base of the 
heart to the left of the sternum. 
3. At the Apex—Transmission from the base with 
decrescendo character (see above). Rarely transmis- 
sion to the aortic area in mitral stenosis, more fre- 
quently toward the lower sternum. 
4. In the tricuspid region as a sign of tricuspid 
stenosis with presence of other signs of this lesion, 
especially a large right auricle, loud first tone over the 
right ventricle, limited transmission, limitation to the 
lower and right border of the sternum, distinct pre- 
systolic, venous pulse or presystolic liver pulse. 114 
A CLINICAL GUIDE TO 
Presystolic Murmurs 
At the apex as a sign of mitral stenosis, typically 
rolling, crescendo character. The crescendo may be 
lost in auricular fibrillation and the murmur is 
separated from the first tone by a very short interval. 
This murmur may arise in insufficiency of the aortic 
valves as well as in mitral stenosis (Flint’s murmur). 
A presystolic murmur may occasionally be present in 
narrowing of the mitral opening as a result of throm- 
bus formation, surrounding calcifying ring (in peri- 
cardial obliteration), etc. 
The following varieties may be found in mitral 
stenosis in addition to the typical findings on ausculta- 
tion mentioned above. 
1. Continuous, diastolic murmurs, crescendo char- 
acter, reaching up to the first tone. 
2. Isolated, diastolic murmurs, especially in auricular 
fibrillation. 
3. Short, post-diastolic murmur, separated from the 
tone which follows it by a long interval. 
4. Absence of any murmur, the single sign of mitral 
stenosis being the accentuation of the first tone (dumb 
mitral stenosis). 
5. Doubling of the first tone by the presystolic early 
beat. 
6. Occurrence of an independent second diastolic 
tone. BEDSIDE EXAMINATION 
115 
Post-systolic or Meso-systolic Murmurs 
These are separated from the first tone by a short 
interval. Usually best heard at the aortic region in 
aortic stenosis and in roughness of the valves or aortic 
wall (arteriosclerosis, lues, endocarditic excrescences). 
It is not an absolute sign of aortic stenosis in which it 
occurs but such a condition may be suspected when 
there is a corresponding change in the pulse and ab- 
sence or weakness of the 2nd tone. 
It occurs in rare cases of mitral insufficiency, but 
the maximum point is at the apex. 
Analogous condition in pulmonic stenosis with 
localization of the murmur to the left of the sternum. 
Continuous Murmurs 
In defect of the septum (hissing and increased dur- 
ing systole), also as the so-called “Mill” murmur in 
the presence of air and fluid in the pericardial sac or 
entrance of air in the ventricle (air embolus). The 
murmur has a peculiar splashing metallic ring. 116 
A CLINICAL GUIDE TO 
APPENDIX 
Auscultation of the Tones and Murmurs at the Back 
These may be heard at the back in a thorax wall 
which is not too thick or if the tones or murmurs are 
sufficiently loud. Localization of the maximal point 
of the tone and murmurs on dorsal auscultation; 2nd 
pulmonic at the level of the 4th thoracic vertebra, to 
the right of the spine. Second aortic at the level of 
the 1st or 2nd thoracic vertebra to the left and right 
of the spine (the origin of an accentuated tone may 
be determined in this manner). Systolic murmur in 
aortic stenosis on both sides of the spine at the level 
of the first to the third thoracic vertebra. Murmurs 
in pulmonic stenosis (stenosis at the ostium or by 
compression of the pulmonary artery) in the midline 
at the level of the spine of the fourth thoracic vertebra. 
Mitral murmurs to the left of the spine at the level of 
the sixth to the eighth dorsal vertebra (dilatation of 
the left auricle (Kurt). 
The tones of the thoracic aorta (tone of the vascular 
tension as a result of the celer blood wave) may be 
heard as a cardiac systolic tone or soft post-systolic 
tone in the left para-vertebral space along the spine 
in insufficiency of the aortic valves. This may occur 
even if the first tone over the aorta is not heard. The BEDSIDE EXAMINATION 
117 
same may be true of the first tone at the apex if there 
is also mitral insufficiency. 
Abdomen 
Inspection arid Palpation (see pages 23 and 24) 
Percussion 
Determination of the percussion tone first in the 
median line and then in the navel-horizontal line. 
Dullness in the flanks is determined by this method. 
Percussion of the liver, spleen, stomach and then of 
the entire abdomen. 
Percussion of the Abdominal Organs 
Percussion of the Liver 
See page 46 for determination of the lung-liver 
margin. Determination of the “dome” of the liver 
usually possible only with strong percussion (relative 
dullness). The lower border with the lightest percus- 
sion and in some cases with moderately strong 
percussion if the colon lies over the liver. The border 
of the liver leaves the costal arch at the right medio- 
clavicular line and goes upwards and to the left 
towards the left costal arch at the left para-sternal 
line. 
Descent of the lower border of the liver is found 
in displacement or enlargement of the organ (controlled 
by determining the upper border of the liver). De- 
termination of enlargement of the liver as a whole or 118 
A CLINICAL GUIDE TO 
of certain parts. Ptosis of the entire liver in descent 
of the diaphragm, large pleuritic exudate, emphysema, 
ptosis and subphrenic abscess. Enlargement in pas- 
sive congestion, biliary stasis, diffuse parenchymatous 
changes and tumors. Lues attacks the left lobe by 
preference. 
There is an oval area of dullness attached to the 
lower border of the liver in enlargement of the gall- 
bladder or presence of a Riedel’s lobe. Two such 
separated areas of dullness may be present over a 
normal liver if there is a segment of bowel covering 
the liver. The connection between two such areas of 
dullness may sometimes be established by grasping the 
lower portion of the tumor bimanually and pushing it 
caudally as far as possible during inspiration. The 
lung-liver dullness is then determined on percussion 
and it is found to ascend higher in expiration after the 
tumor is liberated. 
The liver dullness becomes smaller in shrinking or 
atrophic processes, when the liver stands on edge, in 
meteorism, interposition of intestine between the liver 
and diaphragm, high grade tympany and presence of 
free gas in the abdominal cavity. In the latter in- 
stance the tympany may wander all over the abdomen 
on change of position and disappearance of the liver 
dullness as in perforation peritonitis. Another cause 
may be the accumulation of localized gas between 
the liver and diaphragm (gas containing subphrenic 
abscess). 
Traube’s space is a tympanitic zone which is BEDSIDE EXAMINATION 
119 
bounded on the left by the dullness of the anterior 
border of the spleen, to the right by the left border of 
the left lobe of the liver, below by the costal arch and 
above by the lower border of the lung or heart. 
The space is enlarged in meteorism, especially of the 
stomach, in small liver and shrinking pleuritic pro- 
cesses on the left side. 
Diminution from the right or left by enlargement 
of the spleen or liver or by tumors in this region. 
Diminution from above in descent of the left dia- 
phragm (large pleuritic exudate, hydro-pneumothorax, 
pericarditis, enlarged heart, normal but low heart 
and tumors in the vicinity). Diminution from below 
by encroachment by tumors in the vicinity, as carci- 
noma of the stomach. 
The tone on percussion over Traube’s space changes 
according to the filling condition of the stomach and 
may be different on standing or lying down. 
Percussion of the Spleen 
Best done with the patient on his right side and his 
left arm elevated and on his head. Determination of 
the upper and lower borders of splenic dullness in the 
mid-axillary line with very light percussion. Nor- 
mally from the 9th to the 11th rib. The anterior 
border of splenic dullness is determined by percussing 
from the centre of the dullness, downwards and 
towards the costal margin. The anterior inferior 
border is usually 2 to 4 finger breadths from the costal 
arch. The posterior border cannot be determined 120 
A CLINICAL GUIDE TO 
normally on account of the physiological dullness of 
the flank. s 
The thickness of the spleen may be estimated by 
the nature of the sound on percussion and various 
grades of intensity of percussion at the site of splenic 
dullness where it was most marked in the pervious 
determination. Determination of the actual size of 
the spleen with moderately strong percussion (relative 
dullness). This dullness ordinarily reaches about two 
finger breadths higher into the lungs as compared with 
the dullness previously obtained. 
Dullness of an enlarged spleen may be increased in 
all or only some directions, depending on whether it is 
a generalized or localized enlargement of the organ. 
Very large spleens cause a dullness which is con- 
tinuous and not interrupted by intestinal tympany. 
Percussion of the Kidney 
The kidneys cannot normally be percussed from the 
anterior aspect. It is frequently possible to determine 
the lower and lateral borders of the kidneys and they 
may be differentiated from the lumbar musculature 
and adjacent intestinal segments which give a dull 
tympany to the regions outside of the kidneys. Per- 
cussion of the kidneys is performed along the line of 
prolongation from the scapular line near the spine. 
This percussion should also be attempted in the knee- 
elbow position, sitting, stooping over and on the 
abdomen. The trunk should be supported on pillows 
in such a manner so that the back will be somewhat BEDSIDE EXAMINATION 
121 
kyphotic. This percussion may be of importance in 
determining ectopic or enlarged kidneys. 
Renal tumors are characterized by the fact that the 
overlying bowel (colon) tympany may hide the dull- 
ness on percussion. It may be necessary to inflate the 
colon. Another feature is the fact that the dullness 
posteriorly of the tumor is continuous with that from 
the kidney. 
Abnormal Regions of Dullness in the Abdomen 
(a) Free fluid (transudate or exudate). Dullness 
from fluid may be missed if the quantity is small and 
if the patient is on his back. The dullness may assume 
a circular outline in the most dependent regions, es- 
pecially at the navel if the patient assumes the knee- 
elbow position. 
Dullness in both flanks occurs in larger quantities 
of free fluid. The dullness may be limited horizon- 
tally at its upper border. The upper limits of 
horizontal dullness at the flanks may unite above the 
symphysis and form a continuous line with the con- 
cavity towards the head, if the fluid is present in large 
quantities. The entire abdomen may be dull under 
certain circumstances with the exception of a circular 
area of tympany in the middle or upper parts of the 
abdomen. This tympany is due to the floating intes- 
tines. Change of position from the supine to the side 
positions may produce change in the level of the fluid. 
The upper portion is tympanitic in free fluid. In the 
sitting and standing position the fluid gravitates to the 
pelvis and leaves the upper part of the flanks more 122 
A CLINICAL GUIDE TO 
tympanitic. It may then be possible to determine a 
horizontal line of dullness above the symphysis. It 
may take some time before the above mentioned 
changes take place. The changes may be limited if 
there are adhesions. 
Large quantities of fluid in chronic shrinking pro- 
cesses of the mesentery (tuberculosis, carcinoma) 
may produce a broad zone of tympany extending from 
the upper abdomen diagonally to the right and below, 
to the ileo-cecal region. This zone may be perma- 
nent (Thomayer’s sign; fixation of the small intestines 
to the oblique line of attachment of the mesentery of 
the small intestine with shrinkage of the mesentery in 
the lower right abdomen). Dullness of this region 
and in the presence of large quantities of fluid may 
produce dullness in the right lower abdomen if light 
percussion is used and if there is a thin layer of fluid 
between the intestines and abdominal wall, but the 
characteristic area of tympany in the right lower 
region is found if stronger percussion is used 
(Olhausen). 
Dullness may occur in the flanks normally if the 
large or small bowels are filled with feces, or are empty 
and contracted, as in obstipation, fecal tumors, inani- 
tion, meningitis and cholera. The dullness may clear 
up slightly in the upper regions in the flanks on as- 
suming a lateral position and is then due to the gravi- 
tation of the colon downwards, but there is no increase 
of dullness at the opposite flank and the horizontal BEDSIDE EXAMINATION 
123 
dullness above the symphysis is absent on sitting or 
standing. 
(b) Other varieties of dullness in the flanks. Bi- 
lateral dullness in the upper portions of the flanks in 
renal tumors symmetrically located (cystic kidney). 
Unilateral dullness in tumors of various sorts (in- 
flammatory, neoplastic, gravitation abscess, gland 
tumor, mega-sigmoid, invagination tumor, etc.). 
There may be change in tone on change in position in 
pedicled tumors (ovarian tumors, myomata, etc.), and 
in freely movable tumors as mesenteric cysts or tumors 
of the liver, kidney or spleen. 
2. Dullness in the Remaining Portions of the 
AbdomeH 
In the upper abdomen (see above for dullness of the 
spleen and liver). Tumors of the stomach, abnormal 
filling of the stomach, especially in dilatation and 
tumors of the omentum, pancreas, small and large 
intestine. 
In the lower abdomen: filled urinary bladder (proof 
by catheter), neoplasm of the intestine, female geni- 
talia and tumors caused by mechanical disturbances 
as in invagination, etc. 
Auscultation of the Abdomen 
Rubs—All varieties from soft murmurs to harsh 
rubbing depending on the nature of the surfaces and 
occur especially in inflammatory changes of the peri- 
toneum analogous to pleural rubs. Most frequent in 124 
A CLINICAL GUIDE TO 
the regions of the liver and spleen dullness (peri- 
hepatitis, peri-cholecystitis and peri-splenitis). 
There may be cardiac rhythm of the rub in peri- 
hepatatitis or the left lobe of the liver (pseudo-peri- 
cardial rub). 
In raw surfaces due to other conditions as 
carcinoma. 
Grinding murmur over the gall bladder in rare in- 
stances in the presence of stones. 
Vascular Murmurs—There are one or two tones 
over the abdominal aorta (see page 89). Pressure 
murmur with the cardiac systole on pressure over the 
vessel. This may be produced by tumors overlying 
the abdominal aorta. Systolic murmur or prolonged 
systolic murmur in aneurysm of the aorta or splenic 
arteries. 
Continuous buzzing murmurs at times increased 
during systole over dilated veins (buzzing cirrhosis). INDEX 
A 
Abdomen, general, 22; bulging, 23; inspection, 23; lines of 
orientation, 22; musculature, 24; palpation, 24; percussion, 
117; regions, 23; skin, 23; tumors, see Tumors, abdominal; 
tumors, not caused by enlargement of an abdominal organ, 32. 
Abdominal aorta, 89; general, 25; aneurysm, 25; palpation, 25; 
sclerosis, 25. 
Abdominal cavity, free fluid, 121; organs, general, 25. 
Absolute dullness on deep percussion, 51. 
Absolute dullness on light percussion, 52. 
Accidental murmurs, 109, 110. 
Acute tonsillitis, zone of Head, 38. 
Addison’s disease, 6; mucous membrane, 6; pigmentation, 5, 6. 
Aegophony, 61. 
Alexander’s point of tenderness, 39, 40. 
Anemic murmur, 109, 110. 
Angina pectoris, zone of Head, 38. 
Aortalgia, point of tenderness, 39. 
Aortic pulsation, 96. 
Aortic tone, accentuation of second, 106, 107. 
Apex beat, 93; displacement, 94; doubling, 95; heaving, 94; 
palpation, 81, 82; position, 94; quality, 94. 
Apex percussion, 47, 48. 
Apex tone, loud first, 105; ringing or metallic first, 105. 
Appendicitis, points of tenderness, 39; zone of Head, 38. 
Arteries, 88; ausculation, 88; inspection, 88; palpation, 88. 
Ascites, 25. 
Auscultation, abdomen, 123; back, for heart tones and murmurs, 
116; method, 44; voice, loud, spoken, 61. 
Auscultation, voice, whispered, 61. 
125 126 
INDEX 
B 
Biotic breathing, 14. 
Bladder, examination, 30. 
Blumberg, point of tenderness, 39, 41. 
Boas, point of tenderness, 40, 42. 
Boney framework, 4. 
Boundaries of lungs, 45, 46. 
Brachial artery, 89. 
Bradycardia, 8, 9; sinus, 8; imperfect conduction, 8, 9; vagus, 8. 
Bronchial breathing, 57. 
Brochiectasis, 71. 
Bulbus-tone, 92. 
Bulging precordial, 93. 
C 
Capillary pulse, 92. 
Caput Medusae, 23. 
Cardiac dullness, 83, 84, 99; diminution in size, 100; increase in 
all directions, 102; increase to left and above, 101; increase to 
left and downwards, 101; increase to right, 100. 
Cardiac irregularity, 9. 
Cardio-pulmonary murmurs, 87. 
Carotid artery, 88. 
Cavernous tuberculosis of lungs, 71. 
Cavity in lung, 71, 72; auscultation, 72; percussion, 71. 
Cervical veins, auscultation, 92. 
Cervical vertebrae, 17. 
Charcot, point of tenderness, 40. 
Chauffard, point of tenderness, 40. 
Cheyne-Stokes breathing, 14. 
Cholelithiasis, point of tenderness, 40. 
Cholelithiasis, zone of Head, 38. 
Cirrhotic tuberculosis of the lungs, 70. 
Cog-wheel breathing, 57. 
Coin sound, 62. 
Color, general, 5. 
Combined percussion and auscultation, 62. 
Comparative percussion, 49. 
Comparison of pulse on the two sides of the body, 11. 
Complementary space, 48. INDEX 
127 
Complete dissociation, 11. 
Conductivity disturbances, 10, 11; Lucian’s periods, 10; com- 
plete dissociation, 11; partial block, 11. 
Consonance breathing, 54. 
Consonant rales, 59. 
Continuous murmurs, 115. 
Cracked pot sound, 53. 
Crepitant rales, 59. 
Cyanosis, 6. 
D. 
Deformities, 35. 
Delayed pulse, 11. 
Demoiseau-Elliot Line, 73. 
Dercum’s disease, 6. 
Diaphragmatic pleuritis, point of tenderness, 41. 
Diaphragmatic pleurosy, 75. 
Diastolic murmurs, 111, 112, 113. 
Dicrotism, 11, 12. 
Difference in pulse on both sides of the body, 11; physiological, 
11; pathological changes in vessel wall, 11; compression, 11. 
Diminished vesicular breathing, 56. 
Displacement of heart, 99. 
Dullness, flanks, 121, 122, 123; large vessels of heart, 103, 104; 
lower abdomen, 123; upper abdomen, 123; upper sternum, 
103, 104. 
Duodenal ulcer, point of tenderness, 42. 
Dyspnea, 13. 
E 
Ears, general, 16. 
Edema, circumscribed, acute, 5; collateral, 5; general, 5; gen- 
eralized, 5; localized, 5; Quincke, 5; skin over kidney, 30. 
Endocardial murmurs, 86, 87. 
Epigastric pulsation, 96. 
Epigastric veins, visibility, 24. 
Exanthemata, 6. 
Expiration, prolonged, 56. 
Extrasystole, 9. 128 
INDEX 
Extremities, 34; deformity, 35; fluctuation, 35; general features, 
34; hypertrophic and atrophic processes in the skin, 34; joints, 
35; musculature, 35; mobility, 35; local edema, 35; local 
rise in temperature, 35; position, 34; tenderness, 35. 
Exudative diaphragmatic pleurosy, 75. 
Eye balls, 16. 
F 
Femoral artery, 89. 
Fibrinous, diaphragmatic pleurosy, 75. 
Fluid, free in abdominal cavity, 121. 
Foci of thickening in the lungs, 67, 68. 
Fremitus, vocal, 63, 64. 
Friedreich’s sign, 71. 
Funnel chest, 22. 
G 
Gall bladder, general, 27; differentiation, 27, 28; palpation, 27. 
Garland’s triangle, 55, 74. 
Gastric ulcer, point of tenderness, 42. 
Gastroptosis, point of tenderness, 40. 
Gaultier, point of tenderness, 40. 
Genau de Mussy, point of tenderness, 41. 
General condition, schema, 1. 
Genitalia, 34. 
Genitalia external examination, 34. 
Genitalia, vaginal examination, 34. 
Gerhardt’s sign, 71. 
Grinding murmurs in abdomen, 124. 
H 
Habitus, 4. 
Hair, 6. 
Head, general, 16; tenderness on percussion, 16; tenderness 
on pressure, 16. 
Head’s zones, 36, 37, 38. 
Heart, auscultation, 84; displacement, 99; inspection, 81; palpa- 
tion, 81; percussion, 83; tones, 105, 106, 107, 108. 
Heaving of lower sternum, 83. INDEX 
129 
Hernial rings, 33. 
Heterotopic tachycardia, 8. 
Hilus disease, point of tenderness, 40. 
Hysteria, point of tenderness, 40. 
I 
Icterus, 6. 
Improper conduction bradycardia, 8. 
Indrawings, pulsating, 97. 
Inspection of abdomen, 23. 
Inspection and palpation, general, 4. 
Inspiration, sharp, 57. 
Inspiratory doubling of second heart tone, 108. 
Intense dullness on deep percussion, 51. 
Interlobar exudate, 75. 
Intestine, distention, 31; inspection, 31; palpation, 31; per- 
cussion, 31. 
J 
Jagic’s triangle, 47. 
Jaschke’s point of tenderness, 40. 
Joints, 35. 
K 
Kidney, 120; characteristics, 30; dullness, 120; edema of skin 
over, 30; inspection, 29; mobility, 30; palpation, 29; position, 
30; tenderness, 30. 
Koranyi’s sign, 49. 
Kronig’s fields, 48. , 
Kiimmel, point of tenderness, 39, 40. 
Kussmaul’s breathing, 13. 
Kyphoscoliotic thorax, 22. 
L 
Lanz, point of tenderness, 39, 40. 
Larynx, 17. 
Lipomatosis, 6. . 
Litten’s sign, 14. 130 
INDEX 
Liver, 117, 118; consistency, 26; dullness, 117, 118; dullness 
diminution, 118; enlargement, 26; inspection, 25; lung boun- 
dary, 45; palpation, 26; positive pulse, 91, 92; percussion, 117; 
surface, 26; tenderness, 26, 27. 
Lucian’s periods, 10. 
Lumbago, point of tenderness, 41. 
Lung-liver boundary, 45. 
Lymph glands, 17. 
M 
MacKenzie, point of tenderness, 40, 41, 42. 
McBurney’s point of tenderness, 39, 41. 
Median dullness, enlargement, 103, 104; enlargement of large 
vessels of heart, 103, 104; enlargement to left of large vessels 
of heart, 104. 
Mediastinum, adhesions, 76; displacement, 54; thickening, 76. 
Mesosystolic murmurs, 115. 
Metallic tone on percussion over lungs, 53. 
Metamorphosing breathing, 58. 
Metastasis, 6. 
Meteorism, 25. 
Miliary tuberculosis of lungs, 70. 
Mixed breathing, 58. 
Morris’ point of tenderness, 39, 41. 
Mouth, general, 17. 
Mucous membranes, 6. 
Murmurs, 86, 109; aortic region, 111; buzzing, in abdomen, 124; 
conducted to apex, 109; continuous, 115; diastolic aortic, 111, 
112; diastolic apex, 113; diastolic pulmonic, 113; diastolic 
tricuspid, 113; endocardial, 86, 87; endocardial variation in 
character, 87; endocardial variation in conduction, 87; en- 
docardial variation in heart phase, 86; endocardial variation 
in intensity, 87; endocardial variation in loudness, 87; grind- 
ing, in abdomen, 124; mesosystolic, 115; postsystolic, 115; 
presystolic at apex, 114; pulmonic region, 110; systolic at 
apex, 109, 110; systolic at apex and aorta, 111; tricuspid, 110; 
varieties in mitral stenosis, 114; vascular in abdomen, 124. 
Muscle tension in tuberculosis of the lungs, 70. 
Musculature of abdomen, 24. 
Musculature of extremities, 35. 
Mussy, Genau de, point of tenderness, 41. INDEX 
131 
N 
Neck, general, 17; musculature, 17; passive congestion, 17. 
Negative venous pulse, 91. 
Nephrolithiasis, zone of Head, 38; point of tenderness, 41. 
Neurofibromatosis, 6. 
Nodular tuberculosis of lungs, 69. 
Normotopic (sinus) tachycardia, 8. 
Nose, general, 16. 
O 
Obstipation, point of tenderness, 41. 
Oliver-Cardarelli, 77. 
Oophoritis, point of tenderness, 41. 
Ortner’s point of tenderness, 41. 
Ovaries, point of tenderness, 41. 
P 
Pallor, 5. 
Palpation, 63. 
Palpation of abdomen, 24. 
Panniculus adiposas, 4. 
Paradoxic breathing, 14. 
Paradoxism, pulse, 12. 
Paravertebral dullness, 54, 55; aortic dilatation, 54; auricles, 55, 
hilus thickening, 55; oesophageal carcinoma, 55; oesophageal 
dilatation, 55; oesophageal diverticulum, 55; pleural effusion, 
55; space, percussion of, 54; tympany in Garland’s triangle, 
55; tympany in pleural effusion, 55; tympany in pleural 
shrinkage, 55. 
Partial block, 11. 
Percussion of apex, 47, 48. 
Percussion, comparative, 49; heart, 99; method, 43; source of 
error, 50; tones, 44; topographic, 45. 
Periarteritis nodosa, 7. 
Pericardial effusion, 102, 103. 
Pericardial murmurs, 87. 
Periodic tachycardia, 8. 
Perisigmoiditis, point of tenderness, 41. 132 
INDEX 
Peritoneal irritation, point of tenderness, 41. 
Petruschky’s point of tenderness, 40, 41. 
Petruschky’s sign, 20. 
Pigmentation, 6; gray, 6; yellow, 6. 
Pleura, adhesions, 76; thickening, 76, 77. 
Pleural disease, zone of Head, 38. 
Pleural effusion, auscultation, 73, 74; inspection, 72; percussion, 
72. 
Pleuritis diaphragmatica, 75; point of tenderness, 41. 
Pleximeter percussion, 62. 
Pneumonic tuberculosis of lungs, 69. 
Pneumopericardium, 103. 
Pneumothorax, 77, 78, 79. 
Position of patient, 4. 
Positive venous pulse, 91. 
Postsystolic accessory beat, 107. 
Postsystolic murmurs, 115. 
Presystolic accessory tone, 108. 
Presystolic murmur, 114. 
Prolonged expiration, 56. 
Pulmonary boundries, 45, 46. 
Pulmonic second tone, accentuation, 106. 
Pulsating elevation lower sternum, 95. 
Pulsating indrawings, 97. 
Pulsation of aorta, 96; of jugular fossa, 97; of region of left 
auricle, 97; to left of sternum, 96. 
Pulse, radial, 6, 7; comparison of both sides, 11; condition of 
arterial wall. 7; dicrotism, 11, 12; frequency, 7, 8; height of 
pulse wave, 7; paradoxism, 12; periarteritis nodosa, 7; posi- 
tion, 7; pseudo-celerity, 7; pulsus altus, 7; pulsus celer, 7; 
pulsus parvus, 7; pulsus tardus, 7; size, 7; tension, 7; un- 
equal, 9. 
Pulsus bigeminus, 9; intercidens, 9; irregularis perpetuus, 10; 
irregularis respiratorius, 9; trigeminus, 9. 
Pyelitis, point of tenderness, 42. 
Pyopneumothorax, 79. 
Q 
Quincke’s edema, 5. INDEX 
133 
R 
Rachitic thorax, 22. 
Radial pulse, see pulse radial. 
Radial pulse, schema, 1. 
Rales, 59. 
Ramond, point of tenderness, 40, 42. 
Raw breathing, 57. 
Rectum, 33; inspection, 33; digital examination, 33; fecal re- 
tention, 34; pouch of Douglas, 33. 
Redness, 5. 
Regions of the body, general schema, 2, 3; abdomen, 3; head, 2; 
heart, 3; lungs, 2; motility, 3; neck, 2; reflexes, 3; sen- 
sibility. 3; thorax, 2. 
Relative dullness on deep percussion, 51; on slight percussion, 
52. 
Renal tumors, 121. 
Respiration, 18; biotic, 14; Cheyne-Stokes, 14; deep, 13; dys- 
pnea, 13; Kussmaul’s, 13; paradoxic, 14; periodic, 14; rate, 13; 
schema, 1; symmetry, 13; type, 12. 
Respiratory excursion, 48. 
Retractions, pulsating, 97. 
Retro-cardial effusions, 103. 
Ribs, general, 19. 
Rings, see hernial rings, 33. 
Rovsing point of tenderness, 39, 42. 
Rubs, 59, 60. 
Rubs in abdomen, 123. 
S 
Sacculated exudate, 74. 
Schema of physical examination, 1, 2, 3. 
Schmidt, R., point of tenderness, 42. 
Sciatica point of tenderness, 40. 
Scoliosis, 19. 
Sharp inspiration, 57. 
Shoemaker’s thorax, 22. 
Sinus arrhythmia, 9; bradycardia, 8; tachycardia, 8. 
Skin, 4. 
Skin of abdomen, 23, 24. 
Spinal column, percussion and auscultation, 65. 134 
INDEX 
Spinalgia, 19. 
Spine, course and shape, 19; mobility, 19; tenderness, 19, 20. 
Spleen, 119, 120. 
Spleen, 28, 29. 
Splenic dullness, 119. 
Splenic tumor, 29. 
Splitting of first heart tone, 107; of heart tones, 107; of second 
heart tone, 108. 
Spondylitis, zone of Head, 38. 
Sternum, 19; heaving, 83; pulsating elevation of lower por- 
tion, 95. 
Stomach, 30, 31; ulcer, point of tenderness, 42. 
Subclavian artery, 88. 
Systolic murmurs, 109. 
T 
Tachycardia, 8. 
Teeth, 16. 
Temperature, 15; schema, 1. 
Tenderness, points of, 39, 40, 41, 42. 
Thickening, foci in lungs, see foci of thickening in lungs, 67. 
Thomayer’s sign, 122. 
Thorax, 18; types, 21, 22. 
Thrills, 82; at heart region, 98. 
Throat, 17. 
Thyreoid gland, 17. 
Tongue, 16. 
Tonsils, 17. 
Topographic percussion, 45. 
Traube’s space, 118, 119. 
Trigeminus neuralgia, point of tenderness, 42. 
Tuberculosis of lungs, 69. 
Tumors, abdominal, not caused by enlargement of an organ, 
32, 33. 
Tumors of kidney, 121. 
Tympany over the lungs, 52, 53. 
U 
Ulcer of duodenum, point of tenderness, 42; of stomach, point 
of tenderness, 42. INDEX 
135 
Umbilicus, 24. 
Unequal pulse, 9. 
Ureter, point of tenderness, 42. 
Ureteritis, point of tenderness, 42. 
V 
Vagus bradycardia, 8. 
Valleix, point of tenderness, 42. 
Vascular murmurs in abdomen, 124. 
Veins, 90; during respiration, 90. 
Venous collapse, physiological, 91. 
Venous pulse, 90; negative, 91; pathological, 9L 
Vesicular breathing, diminution, 56. 
Vocal fremitus, 63, 64. 
Volumen pulmonum auctum, 79, 80. 
Volumen pulmonum diminutum, 80. 
Von Noorden, point of tenderness, 42. 
Whisper bronchophony along spine, 65. 
Wintrich’s sign, 71. 
Z 
Zones of Head: see Head’s zones, 36» ORTNER 
CLINICAL SYMPTOMATOLOGY 
of 
INTERNAL DISEASES 
BY 
NORBERT ORTNER, M.D., Vienna 
Vol. I—Abdominal Pain Cloth $3.50 
Vol. II—Generalized Pain “ 5.50 
Both volumes if purchased together 8.00 
I 
Diffuse Abdominal Pain—Localized—Epigastralgia or Stomach 
Cramps—Pain in the Right Hypochondrium—Right Ileoce- 
cal Region—Acute Pains in the Left Iliac Region—Lumbar 
Region — Left Hypochondrium — Bilateral Hypochondrial 
Pain—Region of the Navel—Hypogastric Region—Ap- 
pendix. 
II 
Pain in the Heart—Sacrum—Shoulders—Back—Neck—Nape 
of the Neck—Chest—Extremities, Muscles—Bones—Joints 
Headache. 
ABSTRACTS FROM REVIEWS ON ORTNER 
“Generalized Pain” 
By this book it is possible for the physician to visualize the 
pathology causing the pain without the consultation of numer- 
ous text-books. Misinterpretation of the significance of pain 
often leads to unnecessary, yea, useless operations. It is not 
an uncommon occurrence of spinal cord irritation from tubercu- 
losis to announce itself by abdominal pain which mimics very 
closely appendicitis, ovarian inflammatory disease, etc. Many 
other conditions betray their presence by pain in a remote or- 
gan. Therefore pain must be interpreted correctly, if the 
patient’s best interests are to be served. The book is a very 
valuable contribution to the medical literature, and American 
physicians are indeed fortunate to have at hand in readily ac- 
cessible form a most excellent translation into English of the 
German.—Official Bulletin of Univ. of Maryland. The thoroughness of the author and the detail of his descrip- 
tion as here presented are seldom found in any study of pain, 
and the book should be kept as one of reference, and for close 
study in order to realize the vast amount of research, thought 
and experience found between the covers. 
—N. Y. State Journal of Medicine. 
We might vaguely say that we are here given an analysis of 
pain that will be of great advantage to every physician in mak- 
ing a diagnosis. The language is simple and can be easily 
understood. What is said shows that it is founded upon a very 
large clinical experience. Every practitioner should be a stu- 
dent of symptomatology if he expects to be successful in his 
work. This book will unquestionably meet with approval with 
the members of the medical profession and will be a valuable 
aid.—Indianapolis Medical Journal. 
We find the discussions of the painful sensations arising in 
portions of the body outside of the abdominal cavity admirably 
presented. Two volumes cover quite fully the subject of pain, 
and should form handy additions to the physician’s library.— 
U. S. Naval Med. Bulletin. 
Prof. Dr. Ortner has made it possible by this book for the 
physician to appreciate the selectiveness of the symptom pain, 
and the text may be used as a guidance in the differential diag- 
nosis of many pathological conditions that heretofore have been 
clouded by a multiplicity of vague, uncharted, painful sensa- 
tions. The language employed is simple and. not too tech- 
nical, a quality which will readily appeal to the profession. The 
book is devoid of padding and redundancies. Every sentence is 
carefully weighed and a necessity in its place, so that without 
it the totality of the subject would be disturbed, if not seri- 
ously injured.—Hahnemannian Monthly. 
... It is written in simple and attractive language. The 
vast majority of patients consulting a physician do so because 
of pain. Its cause is often one of the most baffling experiences 
of the physician. The chapters of this book deal each with 
pain in a different organ, thus covering most of the regions of 
the body. Many suggestions are enumerated as to origin of 
pain which might readily escape the attention of the average 
observer. . . .—North West Med. 
. . . The author’s keen analysis of pain and physiology, to- 
gether with the clear and concise manner of interpretation by 
the translator, Francis J. Rebman, make the reading of the 569- 
page book a pleasure. The book more than conveys the salient 
features and symptoms of painful internal disease. It is a work 
that every student of medical science should read. No library 
is complete without this excellent treatise on differential diag- 
nosis of body pains, which is presented in a very readable man- 
ner. . . .—Journal Missouri State Med. Soc. ABSTRACTS FROM REVIEWS ON 
ORTNER “ABDOMINAL PAIN ’’ * 
English readers are fortunate in being able to 
obtain a translation of Dr. Ortner’s little volume 
on differential diagnosis of abdominal pain. The 
translator, an American, through considerable con- 
tact with Dr. Ortner, has rendered a valuable 
service to a large number of readers unable to 
read the original. The arrangement of the text is 
such that one has merely to localize pain to any 
one of the various regions of the abdomen, and 
then consult this book. He will find a catalogue 
of all the possible causes of pain arising there. 
The most important or frequent cause is men- 
tioned first. This condition is then described in 
detail. If more than one organ or tissue which 
might give rise to pain lies in this region, diseases 
of each are given full consideration, following 
which is given differential diagnosis of all other 
conditions that might cause similar pain. These 
descriptions must, of necessity, be brief. The last 
chapter is devoted to a discussion of pain, accord- 
ing to radiation, effect of food, bowel movement, 
bodily movement, menstruation, etc. It is be- 
wildering to note how many varieties and causes 
of abdominal pain there are. and then realize the 
enormous experience the writer must have had. 
One feels, as he reads this volume, that he is 
getting first-hand information from a teacher, and 
not a rehash of other textbooks. Students, prac- 
titioners and specialists, either internists or sur- 
geons. should alike profit by this new addition to 
the English medical armamentarium. 
—A. M. A. Journal. 
This is not a book to pick up in an idle moment, 
but one to be read carefully, if one is to extract all 
the meat it contains. The author considers ab- 
dominal pain in the various localities in which it 
occurs. Hence we find first a discussion of diffuse 
abdominal pain; then a section on localized ab- 
dominal pain. This is followed by considerations of 
epigastralgia or stomach cramps, pain in the right 
hypochondrium, pain in the right ileocecal region, 
acute pain in the left iliac region, pains in the 
lumbar region, flanks and lateral parts of the ab- 
domen, pain in the left hypochondrium, bilateral 
hypochondrial pain, pain in the region of the navel 
and pain in the hypogastric region. In an ap- 
pendix various other phases of abdominal pain. are 
treated fully. —U. S. Naval Medical Bulletin. 
Professor Ortner, in writing about this symptom, 
has brought to bear all his knowledge and pro- 
fessional skill, based on an enormous clinical 
experience under conditions under the various 
types and location of the diagnosis either in the 
operating room or by post-mortem examination. 
For this reason, his book is a mine of valuable anti 
authoritative information. 
—Railzmy Medical Journal. 
* The black type in the text is ours. The author has covered his subject most 
thoroughly and has made a book that cannot fail 
to be of great assistance to the physician, especially 
the young one whose experience is not wide, in 
solving many a puzzling case of abdominal pain. 
The translation is in good English, free from the 
Teutonisms which so often mar the renderings 
from German into English. 
—N. Y. Medical Journal. 
Ortner is one of the most conspicuous pupils of 
Neusser, whom post-graduate students in Vienna 
may remember as a consummate clinician of almost 
encyclopedic mind. Neusser was a comparatively 
silent man and his writings are few. But he wiil 
be remembered by his pupils who have carried 
down his tradition for accurate clinical observation 
and precision in diagnosis. This work of Ortner’s 
admirably reflects the character of this school. 
Abdominal Pain is discussed from every possible 
phase, anatomical, regional and nosological. The 
text emphasizes, above all, the value of studying 
symptomatology, a much neglected field in these 
days of rabid intensity of interest in laboratory 
data. The book deserves a wide reception. 
—American Journal of Surgery. 
For purposes of description, pain as referred to 
the anatomical subdivisions of the abdomen is 
discussed as a clinical picture encountered at the 
bedside, and the method of arriving at a diagnosis 
is concisely stated. The work is based upon the 
wide personal experience and observation of the 
author, and most of the diagnoses it contains have 
been carefully verified by surgical and anatomical 
procedures. There will be found in these pages 
many practical observations, and. the will be 
of interest to every clinician—Military Surgeon. 
Never, in our remembrance, have we seen the 
question of abdominal pain so fully or more per- 
fectly discussed, nor have we ever seen its signifi- 
cance so nicely brought forward and shorn of 
mystery on top of mystery. The author goes into 
every possible point connected with the subject 
and in a way which should make for much better 
diagnosis, were pain the only symptom presenting. 
Every part of the abdomen is considered and from 
every viewpoint. Not only will this book be of 
great value to the surgeon, but the internist will 
find it of worth, for it will be of great assistance 
to him in his determination of many cases which 
may otherwise be vague and puzzling.. 
—Western Medical Times. 
This book surely has our unqualified endorse- 
ment and ‘many pages could be utilized in our 
abstract department with great advantage. It is a 
gem of enlightment in the field of diagnosis. 
—Indianapolis Medical Journal. 
This is an authorized translation of a remarkably 
good and full work on differential diagnosis in pain- 
ful abdominal affections. The work is well trans- 
lated and should be of immense value to both physicians and surgeons. Splendidly printed in 
good type and on good paper and attractively 
hound, it is a good. specimen of the bookmaker’s 
art—Eclectic Medical Journal. 
Incidentally, along with the consideration of 
pain, other points of differential diagnosis are ably 
discussed. The book is a diagnostic aid to medi- 
cine, unique but quite useful. 
—Southern Medicine. 
It is a volume that should be owned by every 
practitioner, for there is no practitioner who is 
not interested in this great subiect. 
—Medical Summary. 
One will hardly realize how large this subject is 
until he has read the book. The possible causes 
of abdominal pain are very numerous and it re- 
quires a considerable amount of space to cover 
even a few of them, which will be a revelation to 
those who have given little thought to the varieties 
and locations of pain. 
—Journal Kansas Medical Society. 
The book will have an immediate appeal to those 
familiar with the Viennese institutions, to whom 
Professor Ortner needs no introductoin. To others, 
it can be recommended. 
—Wisconsin Medical Journal. 
Had this work been written by a surgeon of 
longer experience, or by a group of surgeons, one 
would not be surprised at' its completeness and 
accuracy, but it is distinctly surprising to receive 
such a work from the pen of a medical man. The 
style is agreeable, the diction clear and concise, and 
every page is “meaty.” The work can safely be 
recommended to all physicians, and especially to 
the surgeons—Delaware State Medical Journal. 
It presents many points that are often neglected 
or ignored and not a few that are generally un- 
known._7'he Nation’s Health. 
Many practical points may be picked up by the 
practitioner from a perusal of its pages, which is 
made the more easy by the fame type and heavy 
leading resorted to by the printer. 
-—The Therapeutic Gazette. 
The book cannot fail to prove helpful to those 
having to decide upon the nature of abdominal 
pain..—Canada Lancet. 
Pain as a symptom fixes the attention of the 
diagnostician and is frequently the correct starting 
point for a diagnosis, thus it would seem very 
appropriate to have at one’s disposal a work of 
ready reference to aid him in difficult cases. 
—Journal National Medical Assn. 
This book is one of practical importance in diag- 
nosis of abdominal complaints. It may be the 
means of preventing the physician from making 
errors on diagnosis. 
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PELS-LEUSDEN—Surgical Operations'—668 Illustrations, 
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ROMER—MODERN BONESETTING—Illustrated... .$2.00 
SYPHILIS 
EHRLICH — EXPERIMENTAL CHEMO-THERAPY OF 
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FOURNIER—TREATMENT AND PROPHYLAXIS OF 
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TAYLOR — McKENNA — SALVARSAN TREATMENT— 
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ZINSSER—DISEASES OF THE MOUTH — SYPHILIS 
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WEGELE—THERAPEUTICS OF THE GASTROINTES- 
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THROAT AND MOUTH 
BRUCK—DISEASES OF NOSE AND THROAT — Illus- 
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FEIN—RHINOLOGY AND LARYNGOLOGY. .Price, $1.50 
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ZINSSER—DISEASES OF THE MOUTH—73 Plates (53 
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Price, $2.00