Physical Examination 
and 
Diagnostic Anatomy 
/ 
CHARLES B. SLADE, M. D. 
W) 
CHIEF OF CLINIC IN GENERAL MEDICINE AND INSTRUCTOR IN PHYSICAL 
DIAGNOSIS IN THE UNIVERSITY AND BELLEVUE HOSPITAL MEDICAL 
COLLEGE, NEW YORK, I907 TO I914; VISITING PHYSICIAN TO 
THE OTISVILLE SANATORIUM; MEDICAL EXAMINER OF THE 
NEW YORK CITY DEPARTMENT OF HEALTH 
THIRD EDITION, THOROUGHLY REVISED 
PHILADELPHIA AND LONDON 
W. B. SAUNDERS COMPANY 
1923 PREFACE 
This book, as its title implies, is intended to be 
a text-book on Physical Examination, its technic, 
fundamental methods and principles, to prepare 
the students for the study of any of the various 
able and comprehensive works already written 
upon Physical Diagnosis. 
The diagnosis of specific disease conditions has 
been carefully avoided, as this work deals chiefly 
with the normal subject, a few instances of the 
abnormal being mentioned here and there to 
emphasize the importance of certain procedures 
and to retain the interest of the student. 
The subject matter has been arranged to accord 
with what I believe to be the natural course that 
an average minded student pursues in acquiring 
knowledge regarding any subject which attracts 
spontaneous interest. 
My experience in the teaching of Physical 
Diagnosis has convinced me that the student’s 
initial course in this work should be chiefly prac- 
tical, with a minimum of text-book study. This 
book is intended to supply that text, and at the 
same time avoid placing before the student ex- 
haustive discussions and problems of diagnosis 
which he is not prepared to fully understand at 
5 6 
PREFACE 
this stage of his education. In other words, it 
has been my object herein not to divert the atten- 
tion from the fundamental and essential primary 
principles of the subject. The illustrations used 
herein (excepting photographs) were drawn by the 
writer, some are based upon his own investiga- 
tions and some upon well-established anatomical 
relations. It will be noted that each illustration 
contains only those lines which are absolutely 
needed to present the subject matter, excluding 
from the picture all features that might divert 
the attention. I am aware that some important 
facts and illustrations are repeated occasionally 
throughout this work, but this is done in order 
that they may be fixed more securely in the 
student’s mind, and from more than one point of 
view. 
It is expected that the instructor will augment 
much of the matter contained herein by remarks 
appropriate to the cases he has before the class. 
I wish to express my indebtedness for advice 
from my friends Professor Hermann M. Biggs, 
Professor William Elser and Dr. Bolduan, and 
Dr. McSweeney and Dr. Aikman for help in the 
preparation of photographs. 
CHARLES B. SLADE, 
New York City. CONTENTS 
SECTION I 
PAGE 
Introduction and General Rules Governing Inspection. . 11 
Introduction 11 
General Rules Governing Inspection 13 
Order of Inspection 14 
SECTION II 
General Rules Governing Palpation, Percussion, and 
Auscultation 24 
General Rules Governing Palpation 24 
Physics of Sound 27 
General Rules Governing Percussion 37 
General Rules Governing Auscultation 44 
SECTION III 
Surface Markings: Topography of the Head, Neck, Upper 
Extremities, and Chest 48 
Head and Neck 48 
Upper Extremities 50 
Chest 52 
Surfaces of the Chest 57 
Table of Underlying Contents of Regions 59 
SECTION IV 
Surface Markings and Inspection of the Chest (con- 
tinued), with Reference to the Lungs 63 
Surface Markings of the Chest 63 
Inspection with Reference to the Lungs 72 
7 8 
CONTENTS 
SECTION V 
PAGE 
Palpation and Percussion, with Reference to the Lungs. . 77 
Palpation for Expansion 77 
Palpation for Fremitus . 78 
Percussion 85 
SECTION VI 
Auscultation with Reference to the Lungs 92 
Normal Respiratory Sounds 92 
Abnormal Respiratory Sounds 96 
SECTION VII 
The Heart: Topographic Anatomy, Action, and Sounds. .. 104 
Outlines 104 
Normal Heart Action 109 
SECTION VIII 
Inspection, Palpation, and Percussion with Reference 
to the Heart 114 
Inspection 114 
Palpation 116 
Percussion 118 
SECTION IX 
Auscultation with Reference to the Heart and Blood- 
vessels 121 
Heart Sounds 121 
Adventitious Sounds 124 
Practical Exercise, to be Compared with a Normal Sub- 
ject 129 
SECTION X 
The Abdomen: Topographic Anatomy and General Rules 
Governing Physical Examination of the Abdo- 
men 133 
Abdominal Landmarks 133 
Table of Underlying Contents of Regions of the Abdomen. . 135 
Surface Markings 136 CONTENTS 
9 
PAGE 
Inspection of the Abdomen 139 
Palpation of the Abdomen 140 
Percussion of the Abdomen 140 
SECTION XI 
Specific Rules Governing Physical Examination of the 
Abdomen 142 
Inspection 142 
Palpation 144 
Percussion 148 
Auscultation 149 
SECTION XII 
Blood-pressure and the Sphygmomanometer 151 
Analysis of forces 152 
Index 169 PHYSICAL EXAMINATION AND 
DIAGNOSTIC ANATOMY. 
SECTION I. 
INTRODUCTION AND GENERAL RULES 
GOVERNING INSPECTION. 
INTRODUCTION. 
Physical examination (sometimes called phys- 
ical exploration) is the process of determining the 
gross anatomical condition and relations of the 
various parts and organs of the body by physical 
methods. 
Physical diagnosis is the detection of departures 
from the normal by physical examination. 
11 Normal.”—You must understand that in 
medical nomenclature the word 11 normal” is a 
negative term with a wide range of application. 
In physical examination we call that subject, 
or organ, normal in which we fail to discover any 
definite signs of disease, deformity, or anomaly. 
The term “negative” is frequently used with the 
same meaning. 
Methods.—The fundamental methods employed 
in physical examination are inspection, palpa- 
tion, percussion, and auscultation. Olfaction 
11 12 
RULES GOVERNING INSPECTION. 
is an aid to the diagnosis of some diseases. Special 
instruments, appliances, and methods employed 
are only complex ways of applying the above- 
mentioned fundamental methods. 
System is essential if physical examination is to 
yield the best possible results. You should at 
once acquire the habit of employing inspection, 
palpation, percussion, and auscultation in the order 
named—completing each method, as far as it is 
possible, before the succeeding one is begun. 
Furthermore, you should examine every subject 
in the same systematic anatomical order (see 
General Rules Governing Inspection—Order of 
Inspection). 
The Examiner.—At no time in the performance 
of a physical examination should you allow your 
body or limbs to assume an awkward or uncom- 
fortable position. A strained attitude interferes 
with acute perception. 
The room should be free from noise or other 
sources of distraction, of a comfortable tempera- 
ture, and well lighted. 
The Subject.—The parts examined should be 
freely exposed, or as freely as propriety and expe- 
diency will permit. Whether standing, sitting, or 
lying down, the body should rest equally, the arms 
straight and passive by the sides. The surface 
examined should face the greatest source of light. 
Note.—There are special positions and arrangements 
of light necessary for some parts of physical exam- 
ination which will be described hereafter. RULES GOVERNING INSPECTION. 
13 
GENERAL RULES GOVERNING INSPECTION. 
Inspection is using the sense of sight in physical 
examination. 
Inspection should begin as soon as the subject 
enters your presence. It should be completed, 
as far as possible, before palpation is begun, 
but intelligent inspection should continue un- 
interruptedly throughout all methods that fol- 
low it. 
There is no method of physical examination 
which will yield more valuable information than 
inspection, if it is applied with concentrated care 
in systematic order and with thoroughness. 
The value and amount of information obtainable 
by inspection grows steadily with the experience 
and knowledge of the examiner. There is no 
fixed limit to the valuable results this method 
may yield, and it is frequently the capable em- 
ployment of inspection by a talented physician 
which places him above his fellows in accuracy 
of diagnosis. The results obtainable by palpa- 
tion, percussion, and auscultation have more or 
less definite limits, to which many may reach, 
and beyond which none can go; whereas the 
value of inspection is only limited by the knowl- 
edge, experience, and skill of the individual who 
employs it. The power to correctly interpret 
what is seen may be improved in all by careful 
study and observation, although some are sure 
to possess this power to a greater degree than their 
fellows through natural talent. It is usually 14 
RULES GOVERNING INSPECTION. 
this, the capacity to correctly interpret by inspec- 
tion, highly developed, which is the chief reason 
for some physicians’ possessing what has been 
called a strong diagnostic intuition. 
Always compare corresponding parts, on the 
right and left sides, for there is no fixed standard 
of the normal body, either in contour, proportions, 
size, or color. 
ORDER OF INSPECTION. 
To avoid oversight, your inspection should 
proceed in the following order: 
1. Artificial Aids to Posture or Progression.—• 
The subject who walks into your presence by the 
aid of a stick or crutch may have locomotor 
ataxia, hip-joint disease, or some other dis- 
turbance of nervous, osseous, or muscular system. 
You should note carefully the extent and exact 
nature of assistance he receives from such arti- 
ficial aid to progression. The presence of any 
brace to back, neck, or limbs should receive your 
careful scrutiny to determine the cause of its use. 
2. General Bearing and Attitude.—The general 
bearing may indicate bodily health and vigor on 
the one hand, or bodily weakness indicative of 
some recent or present depleting illness on the 
other. It is also characteristic in many mental 
diseases. The subject may be well nourished, 
extremely fat, or emaciated; note the condition 
he presents. 
The attitude is of great importance and should ORDER OF INSPECTION. 
15 
be closely observed as it not infrequently suggests 
the presence of a specific disturbance which 
your further examination reveals. For instance, 
occasionally the first indication of an acute 
pleurisy will be the fact that the subject keeps 
his hand pressed against one side and persistently 
leans toward that side. Furthermore, the subject 
who remains sitting when you enter his presence 
or who is brought before you in a roller-chair 
and whose face and other attitudes, on close 
inspection, suggest no other special ailment, is 
apt to have paraplegia, neuritis, or some disease 
or disturbance of his lower extremities. 
(3) The gait is of great significance and often 
absolutely diagnostic in diseases of the nervous 
system; for instance, the ataxic heel gait of loco- 
motor ataxia, where the subject is apt to keep his 
gaze fixed upon his feet while walking. Many 
other types of gait exist which are diagnostic of 
special disease conditions. 
(4) The speech* is also of great importance. 
Besides being of help in the diagnosis of many ner- 
vous diseases and deformities of the upper air 
passages and mouth, it may lead us to the diagno- 
sis of laryngitis by hoarseness or hypertrophied 
adenoid growdh in the naso-pharynx by a so-called 
nasal tone. 
* The action of some of the muscles of speech is noted 
by inspection, so that although it does not belong entirely 
under the head of inspection, it is mentioned here because 
it should be noted at this stage of physical examination. 16 
RULES GOVERNING INSPECTION. 
(5) Head (Cranium).—(i) Hair.—Note whether 
the hair is normally glistening and lifelike, or 
lustreless, like dried fine fibre, as is often seen 
following any general disease which depletes the 
whole system; whether the color is normal for the 
subject’s age or prematurely gray. If the hair is 
white in isolated spots, with sharp lines of demar- 
cation, not symmetrically placed, it is strongly 
suggestive of previous alopecia areata, ringworm, 
or syphilis. 
Note the absence or presence of sores or scars, 
their character and position if present. A healed 
lesion of the scalp may be the first sign observed 
which leads us to a correct diagnosis of the cause 
of serious disturbances in brain function or of 
tetanus or other infections. If sores are observed, 
determine whether due to accidental injury, vermin 
(the vermin may be seen), or to general disease. 
(2) The contour of the head (cranium) may be 
changed by congenital deformities of the bones, by 
the accumulation of an abnormal quantity of fluid 
in the ventricles (hydrocephalus when the cranium 
is large and rounded, forehead abnormally promi- 
nent, and fontanels open beyond the normal time 
for their closure), or by injury or disease of bone 
or soft parts; for instance, syphilitic gumma or 
sarcoma may form beneath the scalp in the bone 
or soft tissues. An abscess beneath the scalp will 
change the contour of the head. Remember that 
a prominent change in the contour of the face or the 
neck near the head may give a false impression of ORDER OF INSPECTION. 
17 
change in the contour of the head itself. In such 
cases a careful examination of the cranium, while 
the face and neck are covered with a cloth, will 
give unbiassed results. 
(6) The Face.—Careful inspection of the face 
may give so many valuable signs of various disease 
conditions that it is only possible to mention a few 
here. For instance, the expression, besides being 
absolutely diagnostic of some mental diseases, is 
an aid to the diagnoses of many other conditions, 
such as the expression of pain, which is familiar 
to all; the listless expression of typhoid fever; the 
pinched features of cholera and cholera morbus; 
the anxious, expectant expression of pneumonia; 
the dull expression of chronic nasal obstruction, 
and many others. 
The color and condition of the skin—waxy 
and puffy in some cases of nephritis, sallow and 
wrinkled in chronic liver disease, and jaundiced 
where the flow of bile is obstructed; cyanosed 
(especially on the lips, nose, and ears) in cardiac 
or respiratory diseases—is of great importance in 
the diagnosis of many other diseases which the 
scope of this work excludes. Muscle tonicity: note 
if the wrinkles in the face are equal on the two sides 
or if they are more or less absent on one side, as 
in Bell’s palsy or hemiplegia of central origin. 
The ears may show tophi (small, yellowish- 
white lumps) between the skin and cartilage in 
gout. The ears may be deformed by past frost- 
bite, or injury, cyanosed as mentioned, or abnor- 18 
RULES GOVERNING INSPECTION. 
mally pale in anaemia. They are abnormally 
small or deformed in some subjects who are of 
abnormal mind. 
The Eyes.—Among the numerous signs of disease 
revealed by inspection of the eyes, we need only 
mention a few: i.e., the prominence of the eye- 
balls in Graves’ disease; the unequal, abnormally 
contracted or dilated pupils of cerebral disturb- 
ances, syphilis or aortic aneurism; yellowness of the 
sclerotics, which shows so early in jaundice; the 
pallor of the conjunctiva in anasmia; and strabismus, 
due either to local disturbance of the motor oculi 
muscles or to central nervous disease or accident. 
The tongue often bears evidence of present or 
past syphilis by mucous patches or scars along its 
margin. By the degree and character of coating 
upon its surface we are aided in diagnosing cer- 
tain gastric disturbances, though a slight coating, 
especially when confined to the posterior portion 
of the tongue, does not necessarily indicate digest- 
ive disturbance, nor does a clean tongue exclude 
it. Hyperacidity may be associated with a very 
clean tongue. The position of the tongue when 
protruded is often of importance in diagnosing a 
nervous disease. In hemiplegia it is turned toward 
the paralyzed side and away from the side of the 
cerebral lesion. It may show marked tremor when 
protruded, as in alcoholism. 
The Teeth.—Note carefully the presence or 
absence of teeth, and the condition of the teeth 
which are present, as this has an important bear- ORDER OF INSPECTION. 
19 
ing upon digestion. The notched-peg teeth of in- 
herited syphilis aid us in diagnosis when observed. 
The gums are pale in anaemia. The blue line of 
chronic plumbism (seen, on close scrutiny, to be 
a series of fine gray-black dots i mm. from free 
margin of gum) should be excluded or noted 
in every complete examination. The tonsils 
and pharynx should also be examined, as it is not 
uncommon to find here visible and obvious signs 
of local or general disease, which will explain or 
help materially in the correct understanding of the 
condition we have in hand. The isolated white 
spots of follicular tonsilitis, so easily recognized 
when we inspect the tonsils, have not infrequently 
explained a very elaborate group of symptoms. 
The Nose.—Inspection of the nose often gives 
valuable information in acute and chronic diseases; 
for instance, there may be herpes about the nasal 
meatus, like that seen on the lips in some acute 
fevers; and the saddle-back nose of syphilis, 
though it must be remembered that a similar 
depression of the nasal bridge occasionally occurs 
as a result of traumatism. 
By the blood vessels, such as abnormal prominence 
of the superficial temporal or facial arteries, we 
suspect arteriosclerosis. Ectasia of capillaries 
of nose and cheeks is a frequent accompaniment 
of prolonged and liberal indulgence in alcoholic 
beverages. Dilatation of these capillaries is oc- 
casionally due to prolonged exposure to severe 
weather. Local or general dilatation of the sur- 20 
RULES GOVERNING INSPECTION. 
face capillaries may be caused by local or general 
interference with the circulation. The pink or 
red nevus (“strawberry mark”) is usually a con- 
genital angioma of the skin and has no general 
significance. 
(7) The Neck.—Upper half, front and back 
(contour, muscles, blood vessels, and larynx). 
Inspection of the neck may reveal enlarged 
lymph glands (so often observed in tubercular 
subjects) or scars resulting from past suppuration 
of the glands (also a common result of tuberculous 
infection); the thyroid enlargement of Graves’ 
disease; the quick, thumping pulsation of the 
carotid arteries of aortic regurgitation; venous 
pulsation in the external jugular veins, of tricuspid 
regurgitation; prominent and rigid sterno-cleido- 
mastoid muscles of asthma or other obstruction 
to respiration, and many other valuable signs to 
help and guide the remainder of our examination. 
8. Hands and Arms.—Contour of Fingers.—Ob- 
serve distal ends of fingers; note whether normally 
tapering or clubbed and cyanosed (see Fig. 1). 
If the fingers are clubbed and cyanosed, note 
whether all the fingers on both hands are equally 
involved, as occurs in some chronic pulmonary 
diseases and in some cases of malformation of the 
heart. If only one or two fingers are involved, 
the cause is local. 
Skin and Nails.—Color and condition. Where 
all the fingers are clubbed at their extremities, 
the skin along the margin and base of the nail ORDER OF INSPECTION. 
21 
is thin and glistening and the nail is prominently 
arched from above downward and cyanosed. 
Transverse ridges on all nails of both hands, 
at an equal distance from the base of the nail 
in all, suggest some recent severe illness. This 
condition, which is due to the death of the old 
Fig. i.—a, Clubbed finger; b, normal finger. 
and growth of new nails, follows some cases of 
scarlet fever, and the ridge reaches the end of 
the nail and disappears, in about six months 
after its appearance at the base of the nail. Such 
a ridge on only one or two nails is due to local 
injury or disease. 22 
RULES GOVERNING INSPECTION. 
Compare the size and muscle tonicity of the 
two arms. Asymmetry may be met with here 
as a result of accidental injury or nervous 
disease. 
The blood vessels of the hands and arms often 
yield valuable indications of disease just as those 
of the face and neck. 
The joints may show the visible signs of rheu- 
matism or gout. 
The characteristic enlargement of the finger- 
joints with outward displacement of the phalanges 
and limited motion render it possible to diagnose 
rheumatoid arthritis by inspection alone. 
Note.—Only a few of the many important signs of 
disease to be gained by inspection of the above struc- 
tures have been mentioned. The normal contour of 
the above structures admits of no word description 
of practical length: this must be learned by repeated, 
careful and prolonged inspection of many normal types 
in comparison with the abnormal. 
9. Chest.—Contour. (Compare the two sides.) 
Respiratory and cardiac movements (character, 
type, location, and frequency). Compare the 
respiratory movements on the two sides; they 
should be equal. 
Blood vessels: Relative prominence and direction. 
10. Abdomen.—Contour. (Compare the two 
sides.) 
Respiratory movements, character, and amount. 
Epigastric pulsation, present or absent? and 
character. ORDER OF INSPECTION. 
23 
Blood vessels: Relative prominence and direction. 
The Recti Muscles.—Note whether either is un- 
duly rigid and prominent as occurs in localized 
inflammation of peritoneum, or viscera. 
Recount in your mind each and every abdom- 
inal organ and muscle as you inspect its region. 
Note.—Inspection of the chest and abdomen will be 
considered further in the sections on examination of 
these parts. 
(n) Lower Extremities.—Same as of the hands 
and arms. 
External genitals and anus. 
Note.—When “blood vessels” are mentioned above, 
both the veins and arteries are referred to. 
If any peculiar or offensive odor is detected, 
its character should be noted and its source 
determined. 
The normal appearance and surface color of the 
skin and mucous membranes, including the 
tongue, are variable and no description could 
suffice. This must be learned by observation. SECTION II. 
GENERAL RULES GOVERNING PALPATION, 
PERCUSSION AND AUSCULTATION. 
GENERAL RULES GOVERNING PALPATION. 
Palpation is using the sense of touch in physical 
examination. This method should follow the 
systematic completion of inspection. 
The Subject’s Feelings.—Consider the subject’s 
feelings. Avoid harshness and awkwardness, and 
be on the constant lookout for any indication of 
pain or local tenderness on the part of the subject. 
The examiner’s hands should not be cold. 
Laying on the Hands.—Lay your hands on 
gently, and where pressure is necessary, increase it 
very gradually; never apply more pressure than is 
required to palpate the structure which is being 
examined. Remember that light palpation usually 
yields more information than forcible pressure, 
because it gives rise to less resistance on the part 
of the subject and also because the examiner’s 
sense of touch is more acute the less pressure exists 
upon his fingers. The foregoing applies especially 
to palpation of the abdomen. 
The position and manner of laying on the hands 
varies according to the structure examined, and 
again in the same structure according to the infor- 
mation we seek; and the beginner cannot give 
24 RULES GOVERNING PALPATION. 
25 
too much care and attention at the start, to ac- 
quire proper technic in palpation. Always 
apply this method of investigation in a manner 
appropriate to the structure and condition ex- 
amined. For instance: 
The pulse rate may be obtained by placing the 
index finger over the radial artery at the wrist 
without careful attention to the position of the 
finger or the degree of pressure exerted; whereas, 
if we wish to determine the qualities of the pulse, 
we must apply several fingers over the artery, 
pressing it against the lower smooth surface of 
the radius in a special manner, which will be 
described in a subsequent lesson. 
Enlarged lymph nodes beneath the skin may be 
detected by palpating with one hand, just as one 
may locate a marble in a pillow; but careful, 
bimanual palpation is often necessary to deter- 
mine the absence or presence of fluid in the mass 
(fluctuation). 
The Chest.—The manner of laying on the hands 
is still different when palpating the chest; and here, 
when we are estimating the expansion or respira- 
tory movement, the hands are applied m a manner 
different from that employed to estimate vocal 
fremitus, as will be later on described. (See 
palpation with reference to the lungs, Section V.) 
Points of Tenderness.—When palpating for 
points of tenderness one or two fingers or the 
thumb may be used, and pressure should be 
increased with due regard for the subject’s feelings, 26 
PALPATION, PERCUSSION, AUSCULTATION. 
as, for instance, in pressing behind the ear for 
tenderness due to mastoid disease. Where neuri- 
tis or nerve tenderness is suspected, apply the 
pressure over the nerve trunks or, as is the case 
with the intercostal nerves, where the cutaneous 
branches pierce the deep fascia. 
Tumors.—When palpating a tumor mass in 
any locality, learn whether circumscribed or 
diffuse, freely movable or adherent to the skin, 
bone, muscle or other fixed structure, and the 
nature of the structures adjacent to it. Also de- 
termine the palpable character of the mass itself 
(i.e., size, form, consistency, and automobility).* 
Order of Palpation.—Palpation should be applied 
in the same anatomical order that is given for 
inspection. (See General Rules Governing Inspec- 
tion—Order of Inspection.) In the head, neck, 
and extremities the two methods may proceed 
together. 
Note.—Just as the student must first familiarize 
himself with the appearance, landmarks, contour, and 
movements of the normal body by inspection, so must 
he become familiar with the impressions gained by 
palpation of the normal structures and organs before 
he will be able to recognize departures from the normal. 
We apply this as well as the other methods of physical 
examination to each structure in health, in the manner 
which is peculiarly adapted to detect and estimate 
changes in that structure resulting from disease or 
accident. 
* By automobility is meant any movement or pulsation 
which is not caused from without nor by a change of 
position (gravity). PHYSICS OF SOUND. 
27 
PHYSICS OF SOUND 
Physics treats of the properties of matter and 
energy, and in its medical application has to do 
largely with sound. That branch of physics 
which deals with sound is known as acoustics. 
Physical diagnosis, then, is information gained 
through an appreciation of the laws of acous- 
tics. 
Sound.—An examination of a sounding body 
will show that it is in a state of vibratory motion. 
When a particle of matter is displaced by the 
application of a force it quickly returns to its 
original position when the force is removed. 
The repetition of this displacement and return 
constitute the oscillations or vibrations which 
produce sound. The ability to regain equilibrium 
is owing to the quality of elasticity. The greater 
the elasticity of a body, the more quickly will 
the equilibrium be restored, i.e., the more rapid 
will be the vibratory rate. (The rate of vi- 
brations varies as the square root of the elas- 
ticity.) 
Sound is, therefore, the oscillations of elastic 
bodies (air, metal, etc.). 
To be perceived by the human ear these vi- 
brations must have a certain frequency, which 
has been estimated at about 30 per second for 
th*e lower range, and at about 38,000 for the 
upper limits of audition. It is necessary also 28 
PALPATION, PERCUSSION,' AUSCULTATION. 
that a certain mass of air be set in motion, the 
vibrations of very minute masses making in- 
sufficient impression on the organ of hearing to 
register as sound. A practical demonstration 
of this is seen in the use of sounding boards. 
The vibrations of a violin string (without the 
sounding box) give but a feeble sound. When 
attached to the sounding box, however, the vi- 
brations of the string start vibrations in the 
sounding box which are in turn communicated to 
a relatively large mass of air, which greatly am- 
plifies the sound. These devices for augmenting 
sound are known as resonators. 
Characteristics of Sound.—Pitch.—It was re- 
ferred to above that sound was the vibration of 
elastic bodies, and that the rate of vibration was 
dependent upon the elasticity of the sounding ma- 
terial. (The rate of transmission, too, varies as 
the square root of the elasticity of the transmitting 
medium.) The vibration rate determines one of 
the fundamental characteristics of sound—viz., 
pitch. The pitch is dependent upon and varies 
directly with the vibration rate. 
In percussion, it is through variations of pitch 
that many of our deductions are made. 
Loudness or Intensity.—Sounds may differ in 
loudness without alteration of other character- 
istics. In medical acoustics (in auscultaton) a 
raising of the pitch is frequently associated with 
an intensification of the sound, and students PHYSICS OF SOUND. 
29 
sometimes conclude that this relationship is 
causal. It is not. The intensity depends on the 
amount of displacement of the elastic masses, 
which geometrically expressed is the amplitude 
of the wave. The vibratory rate determines the 
pitch. 
Note.—In air there is actually no wave motion. Air has 
only elasticity of volume—not of form. So that what really 
occurs in air is the production of areas of condensation and 
rarefaction. This, however, may be expressed in the form of a 
wave. 
Quality.—It is difficult to describe the quality 
of sound, but it is that characteristic by which 
the tinkling of a bell may be distinguished from 
the beating of a drum, or the notes of a canary 
from those of a robin. 
The quality may be graphically represented by 
the form which the wave assumes, a simple tone 
giving a simple wave form; a complex sound, a 
complex wave form. Any form of wave whatever 
can be compounded of a number of simple waves 
of different lengths (Fourier’s theorem), and when 
once compounded remains so. (The rate of trans- 
mission is the same for long and short waves.) 
It follows, therefore, that the quality of a sound, 
once produced, will be difficult to change. 
Note.—Efforts to change the quality of a sound have been 
made by the use of mechanical filters, but with rather limited 
success. 30 
PALPA TION, PERCUSSION, AUSCULTA TION. 
When a string vibrates as a whole (being 
fixed at either end, these points being called 
nodes) the sound produced is called its funda- 
mental note. If now a node be placed midway 
it will vibrate in its halves, and the vibrations 
will be twice as rapid. In musical instruments 
there are obtained the fundamental note and the 
notes from the vibrations of the alequot parts, 
whose vibration rates bear to the fundamental 
vibration rate the simple relationship of 2: 3: 4: 
5, etc. These are called the overtones or upper 
partials—and when these overtones are regular 
and rhythmic, and with the above simple re- 
lationship, the effect on the ear is pleasant and 
the sound is said to be musical. When the over- 
tones are irregular and not rhythmic, the effect 
is unpleasant, and in this way metallic sounds are 
produced. A noise is distinguished from a musical 
note, physically, in that it consists of a number 
of tones whose vibration frequencies are too 
near together to be separated by the human 
ear. 
As the sound becomes more complex the wave 
form changes and the quality with it. 
In a few instances the wave forms for a few 
sounds have been plotted, and it has been found 
that a mellow soft sound (tuning-fork) has a wave 
form that is gently undulating. 
Harsh metallic sounds are associated with 
abrupt wave forms. PHYSICS OF SOUND. 
31 
The qualities of the sounds met with in physical 
diagnosis can only be learned by experience, just 
as one gets to know the voice of a friend. When 
the quality for any particular region is altered 
we know that a physical change has occurred. 
By attention to these alterations we can very 
TUNI NG 
FORK 
VIOLIN 
STRING 
frequently deduce the nature of the physical 
change. 
Sound is thus seen to have three funda- 
mental characteristics — Pitch, Loudness, and 
Quality. 
Production of Sounds.—The sounds utilized in 
physical diagnosis are produced as follows: 
1. Percussion.—Percussion of a region under in- 
vestigation sets up vibrations in that region with 
the creation of sound. If the region being in- 
vestigated be situated close to a body of matter 
of different structure, a heavy percussion stroke 
may cause vibrations of the adjacent body, and 
the sound produced will be a composite one, the 
resultant of the vibrations of the two structures. 
Where knowledge is sought of an organ situated 
close to another, or where the investigation is 32 
PALPATION, PERCUSSION, AUSCULTATION. 
concerned with small areas, the percussion stroke, 
therefore, should be light. 
2. The respiratory act sets in motion air cur- 
rents, which in turn cause various tissues, par- 
ticularly the air vesicles, to vibrate, Sound-pro- 
ducing motion, as a result of the respiratory act, 
is excited then in the columns of air and in the 
vesicular tissues. 
3. Use is made of the voice (whispering and 
articulate) and of cough, the vibratory motion 
thus produced arising in the larynx. 
Modifications of Sound.—1. Radiation or Dif- 
fusion.—The intensity of sound is lessened by radi- 
ation. The greater the distance from a sounding 
body, since sound spreads radially in all directions, 
the more diffuse will it be. 
The intensity varies inversely as the square root 
of the distance. 
2. Reflection.—Sound waves may be turned 
back upon themselves, as seen in the production 
of echoes. 
3. Refraction and Absorption.—In passing from 
one medium to another of different density, 
energy is lost both by refraction and absorption. 
Sound waves in traversing the vesicular structure 
of the lung pass through vesicular wall, then to 
the air contained in the vesicle, and then through 
vesicular wall again, with many repetitions of 
this process. In consequence, much of the in- 
tensity may thus be lost. The behavior of a PHYSICS OF SOUND. 
33 
feather pillow in lessening sound is well known. 
The feathers represent the myriads of vesicular 
walls (there are estimated to be about 400,000,000 
vesicles in a human lung) and the air be- 
tween the feathers, the air contained in the ves- 
icles. 
The pleura (normal or thickened) and the chest 
wall also cause refraction. 
4. Resonance. — The term resonance or re- 
sounding refers to the production of a second 
sound by the stimulus of a first, and reference 
was made to the use of resonators in amplifying 
sound. In the violin the resonator is so made 
that its wave lengths are in harmony with the 
note of the string and so amplify the sound. In 
the human body, however, the resonators (lung 
cavity, pneumothorax, etc.) are not so con- 
structed, and frequently very unrhythmic over- 
tones are produced, causing metallic sounds. In 
pneumothorax and pulmonary cavities metallic 
sounds are thus produced. 
Percussion.—It has been referred to above that 
an important characteristic of sound, valuable in 
percussion, is that of pitch. It was also pointed 
out that pitch was dependent upon the rate of 
vibrations and that the rate, in turn, varied with 
the square root of elasticity. The quality of elas- 
ticity may be regarded as fundamental and no 
effort to resolve it will be made. Two kinds of 
elasticity may be spoken of: that of form and 34 
PALPATION, PERCUSSION, AUSCULTATION. 
that of volume. When a force is applied to a 
rigid body, and its form altered, it quickly be- 
comes restored when the force is removed. This 
restoration is proportional to and in consequence 
of its elasticity. This quality is marked in steel. 
The sounds of a tuning-fork are due to its elas- 
ticity of form. Air has no elasticity of form, 
only elasticity of volume, so that the vibrations 
of air which produce sound are really volume 
changes, i.e., rapid condensations and rarefactions. 
The sounds of a pipe organ are due to the volume- 
elasticity of air. Liquids, as water, have a very 
high degree of volume elasticity, any condensa- 
tion being immediately and completely restored. 
The (volume) elasticity of water is considerably 
higher than that of air, and in consequence the 
pitch yielded by fluid on percussion will be higher 
than that of air. The elasticity of lung tissue 
while less than that of fluid, is greater than that 
of air, so that the pitch over lung tissue without 
air is higher than that of lung containing air and 
lower than that over fluid. We thus see that the 
percussion note over fluid is very high pitched— 
spoken of as flat; that over solidified lung, con- 
taining very little air, the note is relatively high 
pitched—spoken of as dull; that over small areas 
of consolidation, with more air, the note will be 
lower pitched—relatively dull or impaired reso- 
nance; and that over well aerated lung the pitch 
is low, spoken of as resonance. PHYSICS OF SOUND. 
35 
When air is under considerable tension, i.e., 
compressed, its elasticity is increased, and there- 
fore the pitch raised. In some cases of asthma, 
where there is great distention of the air vesicles, 
the percussion pitch is elevated. 
Auscultation.—The air as it enters the glottis 
is put in vibration, and on listening over the 
trachea, a sound, the result of this vibration, 
is heard. This sound is transmitted along the 
air column down to the smaller bronchial tubes. 
Some of this sound is lost by radiation. It is 
here that the vesicular structure of the lung is 
met, and through the process of absorption and 
refraction (see above) the sound originating at 
the glottis is largely dissipated. The sounds 
heard over the chest—i.e., over vesicular lung 
—differ from those heard over the trachea and 
are produced (probably) by the vibrations of the 
air vesicles. 
If any of the tracheal sound is transmitted to 
the ear, it is obscured by the vesicular sound 
just referred to. 
When consolidation of the lung occurs, the air 
vesicles as air vesicles are done away with, and 
replaced by a homogeneous transmitting medium, 
viz., solidified lung. Little sound is lost by re- 
fraction or absorption, nor is there (over this 
area) the obscuring vesicular sound. There is 
thus transmission (with very slight loss) of the 
tracheal sound. 36 
PALPATION, PERCUSSION, AUSCULTATION. 
What has been said above of the respiratory 
sound applies equally to the voice sounds. 
An accumulation of a considerable quantity 
of fluid in the chest offers a reflecting surface, 
and the sound is reflected back into the lung 
(as in the familiar phenomenon of echo pro- 
duction). At the level of the fluid there may 
be a condensation of vibrations, with an in- 
crease of sound. Below the fluid, little or no 
sound. 
Note.—The physical explanations of some of the commonest 
sound phenomena have been given. A more complete con- 
sideration of the acoustics of physical diagnosis is beyond 
the scope of this book. The student is advised that in 
his interpretation of the various sound phenomena met with 
the physical explanations should be kept constantly in view. RULES GOVERNING PERCUSSION. 
37 
GENERAL RULES GOVERNING PERCUSSION. 
Percussion, in physical examination, is strik- 
ing the surface of any part to determine the 
quality, intensity, pitch, and duration of sound 
produced thereby. 
Resistance.—The sense of resistance appreciated 
by the percussing fingers, during the act of percus- 
sion, often aids us materially in determining the 
consistency of underlying structures. 
Percussion may be immediate or mediate. 
Immediate percussion is striking the surface 
directly with the percussing fingers or hammer 
(plessor), and is, at the present day, confined to 
the percussion of superficial osseous structures 
and the detection of fluid waves (fluctuation), 
as an adjunct to palpation. 
Mediate percussion, the method commonly 
employed, is striking an object (pleximeter), 
which is applied directly to the surface. 
Plessor (Hammer).—It is claimed here that the 
fingers or finger (index, middle, and ring, or either 
one or two of these) should be employed as plessor 
in preference to any artificial instruments. The 
reasons being that one often obtains valuable 
impressions from the sense of resistance felt by 
the percussing fingers which are lost when an 
artificial hammer is used. It also obviates the 
necessity of having a special instrument at hand 
to employ this method of physical exploration. 
Pleximeter (the Mediate Substance, or Me- 
dium).—The pleximeter is the object which is 38 
PALPATION, PERCUSSION, AUSCULTATION. 
applied directly against the surface and receives 
the blow of the plessor in mediate percussion. 
Here also the finger is preferable to artificial 
materials, for the same reasons given in the case 
of the plessor; though the finger possesses addi- 
tional advantages here, namely, it adds no 
foreign quality to the percussion note elicited, 
•—and it is capable of being more accurately 
adjusted to the surface percussed than is pos- 
sible with any artificial instrument. 
General Technic of Percussion.—The finger em- 
ployed as a pleximeter must be applied evenly 
to the surface with slight pressure, which must 
be equal throughout. Be especially careful that 
no air space remains between the finger and the 
surface percussed at any point. 
In applying the blow, the forearm of the per- 
cussing hand must be held fixed and motionless. 
The hand must move antero-posteriorly at the 
wrist—motion taking place at the wrist-joint 
only. The fingers used must be adjusted firmly 
and rigidly' against one another, so that their 
ends are on the same plane and come in contact 
with the pleximeter simultaneously and with equal 
force. You must practice the above motion until 
you can accomplish it without having your mind 
centred upon your own hand and arm. 
The plessor must recede from the pleximeter the 
instant after the biow is struck, for if they remain 
in contact after the blow the vibrations elicited will 
be interfered with, the resulting sound is muffled. RULES GOVERNING PERCUSSION. 
39 
The Percussion Blow.—When tissues at the 
same depth from the surface, or corresponding 
regions on the two sides, are compared, the per- 
cussion blow should be of uniform force. 
The more forcible the blow, the deeper and 
more diffuse will be the area of tissues set in 
vibration, and vice versa. 
To obtain the percussion note of a superficial 
organ, or a restricted area, employ light percussion 
•—a light blow—and vice versa. 
The blows must follow each other not too 
rapidly, else the duration of the sounds elicited 
cannot be appreciated. 
Fundamental Elements of Sound.—Percussion 
sounds, in common with all other sounds, are 
made up of four fundamental elements: quality, 
pitch, duration, and intensity. 
Quality.—In physical examination, quality 
is by far the most important element of sound. 
It is the quality which enables us to know any 
given sound from every other sound. Quality 
suggests the source of a sound in general life, 
and enables us to tell the sound produced by one 
musical instrument from that produced by an- 
other instrument, regardless of pitch, intensity, 
and duration, (e.g., a violin from a horn). Fur- 
thermore, everyone has the power to distinguish 
the differences in quality, but few have an ear 
which enables them to determine with certainty 
the finer differences of pitch, duration or intensity 
in sounds of the same quality. So we estimate 40 
PALPATION, PERCUSSION, AUSCULTATION. 
the physical condition and relations of internal 
structures and organs of the human body, more 
by the quality of percussion sounds than by any 
other elements of these sounds. 
Terms of Quality.—Terms used to signify the 
quality of sounds may be general, restricted, oi 
specific in meaning and application. 
General.—Some general terms of quality are: 
FLAT, DULL RESONANT, and TYMPANITIC. 
Restricted.—Such terms as dull tympanitic, 
vesicular, amphoric, cracked-pot, and the like 
have a more restricted application. 
Specific.—Osseous, normal pulmonary reso- 
nance, emphysematous, and others are specific in 
their application. 
Most of the terms given above are self-explana- 
tory. The three terms “flat,” “dull,” and 
'‘resonant” apply to three arbitrary divisions of 
sound quality, there being no sharp line of de- 
marcation between them. In actual fact, all 
sound is resonant to some degree. In practice 
we apply the term flat to those sounds which 
have so little resonance that it can hardly be 
appreciated. 
The student must understand that flatness and 
resonance are the two extremes in body percussion 
sounds, that flatness suggests solidity (by solid 
or fluid), and resonance space or spaces containing 
air or gas; and that dullness is the common ground 
between, where the qualities of flatness and 
resonance are blended in varving degrees. RULES GOVERNING PERCUSSION. 
41 
We elicit flatness over a solid mass or accumula- 
tion of fluid of considerable size where they are 
in contact with the chest or abdominal wall. If 
the mass or accumulation of fluid is small and in 
3d intercostal space. 
Pulmonary reso- 
nance. 
- 5th intercostal space. 
Dullness. 
7 th intercostal space. 
Flatness. 
Fig. 2.—Diagram showing how pulmonary resonance, 
dullness, and flatness is produced on light percussion along 
the right mammillary line in the normal subject. 42 
PALPATION, PERCUSSION, AUSCULTATION. 
direct contact with hollow viscera or lung tissue, 
as in the case of the heart, even a light percussion 
stroke will elicit a dull (not flat) sound, because 
the neighboring structure is set in vibration to a 
slight degree, adding an appreciable resonant 
quality to the sound. 
In some subjects, percussion over the liver in the 
seventh intercostal .space, right nipple line, if the 
stroke is light, does not add either tympanitic 
resonance from the abdomen nor pulmonary 
resonance from the lung to any considerable 
extent. Therefore, the percussion sound elicited 
at this point is practically flat, though not abso- 
lutely flat, as is elicited over a large amount of 
fluid in the pleural or peritoneal cavity. In view 
of the fact that in many cases it is quite impossi- 
ble to elicit an absolutely flat note over the nor- 
mal liver with even the lightest stroke, it is 
advisable to use the term ‘ ‘ absolute liver dull- 
ness ” (not “liver flatness”) in this connection. 
The best available illustration of flatness in the 
normal is obtained by percussion over the fleshy 
part of the thigh. 
Pitch.—The percussion note elicited over a 
given region may be normal, elevated, or lowered 
in pitch. The greater the tension of the under- 
lying tissues, the higher will be the pitch of the 
percussion sound, and the lower the tension the 
lower the pitch. 
All else being equal, the greater the amount 
of solid or fluid in proportion to air or gas in a RULES GOVERNING PERCUSSION. 
43 
given region or part, the higher will be the pitch 
of the percussion sound elicited over that region, 
because the tension of the tissue set in vibration 
is proportionately greater. 
A “flat” sound is high in pitch. 
A “dull” sound, though high, is not so high in 
pitch as a “flat” sound. 
A “resonant” sound is low in pitch. 
Duration.—The duration of a sound (from a 
single blow) corresponds to its pitch. The higher 
the pitch, the shorter the duration, and vice 
versa. 
Intensity.—The stronger the blow over a given 
region in a given subject the greater will be the 
intensity (volume) of sound produced, if the deep 
relations remain the same. 
All else being equal, the greater the degree of 
elasticity of the tissues percussed, the greater 
the intensity of the percussion sound, and vice 
versa. 
Intensity is also increased by an increase in the 
relative amount of air or gas, and decreased by the 
relative amount of solid or fluid under the region 
percussed. In most instances, the higher the 
pitch the less the intensity of a percussion sound, 
and vice versa. 
So that, all else being equal, a flat sound has the 
least intensity, a dull sound more than the flat, 
and a resonant sound still more. Intensity in- 
creases with increase of resonance. 
Order of Percussion.—CHEST.—Consider lungs  PALPATION, PERCUSSION, AUSCULTATION. 
44 
and pleura, heart, pericardium and great vessels, 
glands and parietes, including surface blood vessels. 
ABDOMEN.—Consider all abdominal contents 
and structures and each organ separately from 
above downward, parietes and surface blood ves- 
sels. 
Note.—Percussion of the nervous and osseous systems 
will not be considered in this work. 
GENERAL RULES GOVERNING AUSCULTATION. 
Auscultation, in physical examination, is listen- 
ing to the various sounds produced within the 
body to ascertain their significance. 
Immediate and Mediate.—As in percussion, 
auscultation may be immediate, with the ear 
applied directly to the surface of the body with 
or without a thin layer of cloth between; or 
mediate, by the use of a stethoscope, which should 
always be applied directly to the skin, to avoid 
extraneous friction sounds. 
There are undoubtedly some sounds the char- 
acter and significance of which can best be deter- 
mined through the stethoscope (especially in the 
heart and blood vessels), yet there will be occa- 
sions when it is necessary to auscultate and a 
stethoscope may not be at hand. Therefore, you 
should, by practice, make yourself familiar with 
both immediate and mediate auscultation. The 
condition of the subject in some cases and in 
others the dictates of modesty will demand the 
use of the stethoscope through all of auscultation. RULES GOVERNING AUSCULTATION. 
45 
Many writers claim that immediate auscultation 
is best for examination of the lung, and mediate 
auscultation best for examination of the heart. 
Fig. 3.—A stethoscope. 
Choice of a Stethoscope.—When choosing a 
stethoscope, select one which has the broadest 
possible range of usefulness. This, I believe, is 46 
PALPATION, PERCUSSION, AUSCULTATION. 
accomplished by the simplest form of binaural 
instrument (see Fig. 3). (The monaural stetho- 
scope is used almost exclusively in Europe, but 
I believe it to be of less practical value than the 
binaural instrument). 
The ear-pieces of your stethoscope should fit 
the ears comfortably, and the spring be only strong 
enough to hold the instrument in position; if it 
should be too strong, the pressure in the external 
auditory canal soon becomes very uncomfortable 
and interferes with hearing. 
A flexible stethoscope (with rubber tubes) has 
the advantage that it can be easily folded and 
carried in the pocket, but the tubing should not 
be too small nor too flimsy. 
The flat chest-piece of the Bowles’ stethoscope 
is convenient for examining parts of the chest 
which, for any reason, cannot be freely exposed. 
Phonendoscopes (instruments with a drum to 
magnify sound) should not be used in the early 
years of your study and practice of physical ex- 
amination, because they would establish a false 
idea of the relative character and volume of the 
various sounds. 
When applying either the stethoscope or the 
ear in auscultation, you should take care that 
it fits evenly to the surface, touching in all its 
circumference, so as to shut out all extraneous 
sounds. Never press the chest-piece of the stetho- 
scope against the surface with sufficient force to 
cause discomfort to the subject. RULES GOVERNING AUSCULTATION. 
47 
Order of Auscultation.—Here you should fol- 
low the anatomical order observed in percussion. 
Auscultation should be applied to the vessels of 
tne neck, in connection with auscultation of the 
heart. 
Note.—In physical examination of the abdomen, auscul- 
tation is of very limited use, as will be hereafter explained. 
Auscultatory percussion is, as the term implies, 
the simultaneous employment of auscultation and 
percussion combined. The stethoscope is applied 
over the organ to be outlined and percussion ap- 
plied about it. The instrument may or may not 
be moved from point to point, but the pleximeter 
must be moved about. The character of sound 
elicited changes as the percussion blow is struck 
beyond the margin of the organ under examina- 
tion. Auscultatory percussion is often service- 
able in marking out the limitations of hollow ab- 
dominal viscera. The transmission of metallic 
sounds through the chest in pneumothorax (coin 
test) is a modification of auscultatory percussion. SECTION III. 
SURFACE MARKINGS. 
TOPOGRAPHY OF THE HEAD, NECK, UPPER 
EXTREMITIES, AND CHEST. 
Definition.—By surface markings, or topography, 
is meant the prominences, depressions, and imag- 
inary lines and points upon the surface of the body, 
by which we may locate the position and limita- 
tions of underlying structures. 
No reference will be made herein to surgical or 
neurological topography. 
HEAD AND NECK. 
The superficial temporal artery lies just beneath 
the skin, in the temporal fossa (“temple”), 
following a generally vertical course, where it is 
available for palpation and often for inspection, 
as in marked arteriosclerosis when it is seen as a 
tortuous, throbbing cord; and aortic insufficiency 
when its pulsations are often distinctly visible. 
The facial artery lies just beneath the skin, 
crossing the lower border of the inferior maxilla 
at the anterior border of the masseter muscle, 
where it is available for palpation; and occasion- 
ally for inspection, as in arteriosclerosis and aortic 
regurgitation. 
48 HEAD AND NECK. 
49 
The carotid artery ascends along the outer side 
of the trachea. The sterno-cleido-mastoid muscle 
lies over it in the lower part of the neck. This 
artery is available for palpation and frequently 
for inspection (and auscultation in some con- 
ditions) . 
The external jugular vein descends vertically 
from the angle of the jaw nearly to the upper 
border of the clavicle, in the supraclavicular 
fossa. It is superficial to all muscular tissue and 
is available for inspection, palpation, and auscul- 
tation in some conditions. 
It is in this vessel that the venous hum of anaemia 
is heard and venous pulsation observed, when they 
exist. 
The subclavian artery and vein lie deep in the 
lower part of the supraclavicular fossa. 
The parotid gland, covered partially by the lobe 
of the ear, extends over the posterior portion of 
the masseter muscle and back behind the posterior 
border of the ramus of the inferior maxilla. 
Swelling of this gland tilts the lobe of the ear 
outward (as in mumps). 
The submaxillary gland lies deep in the sub- 
maxillary triangle, close to the inner surface of the 
inferior maxilla. It is distinctly palpable when 
enlarged. 
The Lymphatic Nodes.—Generally speaking, 
the superficial nodes of the head and neck lie pos- 
terior to a vertical line dropped through the 
external auditory meatus, and the deep nodes lie 50 
SURFACE MARKINGS. 
anterior to this line: the superficial auricular, be- 
ing an exception, lies just in front of the lobe of 
the ear. A small node lies over the mastoid 
process just behind the ear and is usually palpable 
early in mastoid suppuration. 
The Thyroid Body.—The isthmus of the thyroid 
crosses over in front of the trachea just below the 
larynx, the two lateral lobes lying close to the 
upper part of the trachea on either side. 
The thyroid, lymph, and salivary glands are not 
palpable when normal. 
The larynx and trachea are in the median line, 
with the oesophagus descending between them and 
the cervical vertebras. 
Note.—The internal jugular vein, which runs down 
just to the outer side of the carotid artery, is very 
rarely of importance in the usual physical examination. 
The radial and brachial arteries, median basilic 
vein, ends of fingers, and lymph nodes are of spe- 
cial importance in general physical examination. 
The radial artery, as it lies upon the smooth 
anterior surface of the lower end of the radius, is 
easily palpable. In some cases, such as extreme 
emaciation, arteriosclerosis or aortic regurgitation, 
its outline and pulsations are visible. 
One or both radial arteries may take an anoma- 
lous course, the commonest being that the artery 
turns outward at a point one to two inches above 
the lower end of the radius, passing to the dorsal 
UPPER EXTREMITIES. UPPER EXTREMITIES. 
51 
surface; this must be remembered when palpating 
for the pulse. 
The pulsations of the radial artery cannot 
usually be seen in health. 
The brachial artery, descending along the inner 
side of the arm, is not usually available for inspec- 
tion,* though it may be palpated by pressing it 
outward against the humerus above, and back- 
ward in the lower part of the arm. 
The median basilic vein, quite superficial and 
easily seen, except when imbedded in a great 
amount of adipose tissue or oedema, runs obliquely 
upward and inward in front of the elbow-joint; 
it is distended and made to become prominent by 
digital pressure just above and anterior to the 
internal epicondyle of the humerus. This is the 
most convenient vessel from which to draw blood 
(for diagnostic or therapeutic purposes) as well 
as for intravenous injections. 
You should familiarize yourself with the range of 
normal shape and color of the ends of the fingers 
(including the finger nails). Note also the degrees 
of prominence of the superficial veins in the upper 
extremity, as well as in other parts of the body, 
compatible with health. 
Lymph Nodes.—The most frequently enlarged 
and palpable group in the arm is the supratrochlea 
(epitrochlea), which lies rather superficially just 
above the internal epicondyle of the humerus. 
* Except where there is arteriosclerosis or aortic regurgi- 
tation. 52 
SURFACE MARKINGS. 
The anti-cubital group is in front of the elbow- 
joint. 
The axilla contains lymph nodes, but none of 
the lymph nodes are palpable when normal 
THE CHEST. 
Contour.—The general shape and contour of 
the chest varies so widely within the normal 
that any word description of practical length is 
Fig. 4.—Thin normal subject; clavicles prominent. 
inadequate. Even in health the prominence of 
bony landmarks and the presence of surface 
depressions depend upon peculiarities of build in 
different individuals, as well as the amount of adi- THE CHEST. 
53 
pose tissue and the various attitudes habitual to 
different people, due to occupation or habit. 
To illustrate the range of normal contour, ex- 
amine a thin man who is in perfect health. His 
clavicles will be moderately prominent. Another 
man who is stout, but in no better health, will 
present depressions or grooves over the course 
Fig. 5.—Fat normal subject; clavicles not prominent. 
of the clavicles (see Figs. 4 and 5). Furthermore, 
the thin man may gain forty pounds in weight, 
when his clavicles, instead of forming a ridge, will 
be marked by a depression along their course. 54 
SURFACE MARKINGS. 
Another equally healthy subject of average 
build may relax his muscles, allowing his shoulders 
to slouch forward, and his clavicles will form 
prominent ridges with marked depressions above 
and below them. But when he throws his 
Fig. 6.—Normal subject; shoulders erect, clavicles not 
prominent. 
shoulders back, allowing his chest to expand, the 
clavicles relatively recede, leaving depressions 
along their course (see Figs. 6 and 7). 
Besides the conditions mentioned above, the 
contour of the chest is influenced in health by THE CHEST. 
55 
sex, age, muscular development, and occupation 
or habit. 
Only careful and repeated observation can 
teach one the variations in normal contour of 
any compound part of the body. 
Fig. 7.—Same normal subject; shoulders slouched forward, 
clavicles prominent. 
There are numerous set types of chest deformi- 
ties to which special names have been applied 
(e.g., rachitic, pterygoid, phthisical, barrel, pigeon- 
breast, and others) which you will learn in the 
course of your medical study. 56 
SURFACE MARKINGS. 
Ascending aorta. 
Right phrenic nerve. 
Superior vena cava. 
Right pulmonary artery. 
Right bronchus, 
f Lymph glands. 
I Right vagus. 
Bronchial artery. 
CEsophagus. 
Fig. 8.—Diagram showing antero-posterior relations of the important structures in the thorax on a 
level with the lung roots, the heart is placed below and anterior to this region (after Le Fevre). 
Right pleural sac. 
Right pleural sac. 
Mediastinum. 
Left pleural sac. 
Left phrenic 
nerve. 
Left pulmonary- 
artery. 
Left bronchus. 
Lymph glands. 
Left vagus. 
Descending 
aorta. 
Left pleural sac. SURFACES OF THE CHEST. 
57 
Surface Veins.—The veins of the upper anterior 
surface of the chest are tributaries of the internal 
mammary veins, which are in close relation to the 
pleura near the apices of the lungs, just before they 
join the innominate veins. Therefore if the lumen 
of the internal mammary vein is compromised by 
inflammatory processes centred in the adjacent 
pleura (as is seen in some cases of pulmonary 
tuberculosis), or by pressure from enlarged lymph 
nodes or neighboring viscera, distention of the 
anterior superficial veins on the corresponding 
side of the chest will be observed. If the innomi- 
nate vein is involved in a similar way, the veins 
of the arm and neck on the same side take part in 
the distention and prominence. 
Many of the superficial veins of the lower part of 
the anterior and antero-lateral walls of the chest 
descend to join the abdominal veins. 
Note.—The superficial capillaries of the chest wall, 
so ably discussed by Sahli, will not be considered in 
this work. 
SURFACES OF THE CHEST. 
The surfaces of the chest are anterior, 
posterior, and two lateral. 
Anterior surface is bounded above by a line 
curved upward, connecting the outer ends of the 
middle thirds of the clavicles; laterally by vertical 
lines dropped through the ends of the curved line 
mentioned; and below by the inferior costal 
margin. 58 
SURFACE MARKINGS. 
Regions of the Anterior Surface.—Centrally lies 
the sternal region, limited by the borders of the 
sternum and subdivided into upper sternal and 
lower sternal by the angulus sterni (junction of 
manubrium and gladiolus, an easily palpable trans- 
verse ridge), where the second costal cartilage 
articulates with the sternum. The suprasternal 
region is that area lying immediately above the 
sternum. 
Laterally the supraclavicular region (right and 
left) is that part of the anterior surface above the 
clavicle. The clavicular region is that limited 
by the inner two-thirds of the clavicle. The 
infraclavicular region extends from the clavicle 
to the upper border of the third rib, and from this 
to the sixth rib is the mammary region; below which 
lies the inframammary region extending to the 
inferior costal margin. 
Posterior surface, bounded above by a horizontal 
line through the spine of the seventh cervical 
vertebra (vertebra prominens); laterally by a 
vertical line through the upper end of the posterior 
axillary fold; and below by the twelfth rib. 
Regions of the Posterior Surface.—The inter- 
scapular region is that portion between the 
scapulae. The scapular regions, right and left, 
over each scapula. The infrascapular region is 
all that portion of the posterior surface of the 
chest lying below the inferior angles of the 
scapulae. 
Lateral Surfaces.—The areas lying between the 
anterior and posterior surfaces on either side. CONTENTS OF THE CHEST. 
59 
They are subdivided into axillary and infra- 
axillary regions by a horizontal line through upper 
border of the sixth rib in the nipple, or mammary 
line. 
TABLE OF UNDERLYING CONTENTS IN THE REGIONS 
OF THE CHEST. 
ANTERIOR SURFACE. (See Fig. 9.) 
Right Supraclavicular 
The apex of the right 
lung. 
The subclavian vessels. 
The termination of the 
external jugular vein. 
The pleura. 
Lymph nodes. 
Suprasternal 
The trachea. 
The oesophagus (very 
deep). (The aortic 
arch may be dis- 
placed up into this 
region by path- 
ological changes. 
The common carotid 
artery and internal 
jugular vein lie on 
the boundary be- 
tween this and the 
supraclavicular re- 
gion.) 
The thyroid. 
Left Supraclavicular 
The apex of the left 
lung. 
The subclavian vessels. 
The termination of the 
external jugular vein. 
The pleura. 
Lymph nodes. 
Right Clavicular 
The lung. 
The innominate vein. 
The pleura. 
Lymph nodes. 
Upper Sternal 
The trachea and pri- 
mary bronchi. 
The ascending and 
transverse arch of 
the aorta. 
The innominate artery. 
The superior vena cava. 
The left innominate 
vein. 
Both lungs. 
The pulmonary artery. 
The pulmonary valve, 
(at the extreme left 
border). 
The pleura. 
The appendix of the 
right auricle. 
The apex of the peri- 
cardium. 
(The right innominate 
vein is on the bound- 
ary between this and 
the right infracla- 
vicular region.) 
The thymus. 
Lymph nodes. 
Left Clavicular 
The lung. 
The innominate vein. 
The common carotid. 
The subclavian artery. 
The pleura. 
Lymph nodes. 
Right 1 nfraclavicular 
The lung. 
The right primary bron- 
chus. 
The superior vena cava. 
The arch of the aorta. 
The pleura. 
Left 1 nfraclavicular 
The lung. 
The primary bronchus. 
The left auricle. 
The pleura. 60 
SURFACE MARKINGS. 
Right Mammillary 
The lung. 
The right auricle. 
The diaphragm. 
The right bronchus and 
its branches. 
The liver. 
The pleura. 
Lower Sternal 
Both lungs. 
The pericardium. 
The base of the right 
ventricle. 
The base of the left 
ventricle. 
The left auricle (deep). 
The right auricle. 
The mitral, aortic and 
tricuspid valves. 
The inferior vena cava. 
The pleura. 
Left Mammillary 
The lung. 
The right and left ven- 
tricle. 
The left bronchus and 
its branches. 
The diaphragm. 
The stomach. 
The pleura. 
Fig. 9.—Regions of the anterior and lateral surfaces of the 
chest. LATERAL SURFACES. 
61 
Right Inframammary 
The lung. 
The diaphragm. 
The liver. 
The pleura. 
Left Inframammary 
The lung. 
The diaphragm. 
The liver. 
The stomach. 
The pleura. 
Fig. io.—Regions of the posterior surface of the chest, 
Right Axillary 
The lung. 
The pleura. 
Lymph nodes. 
LATERAL SURFACES. (See Fig. 9.) 
Left Axillary 
The lung. 
The pleura. 
Lymph nodes. 62 
SURFACE MARKINGS. 
Right Infraaxillary 
The lung. 
The diaphragm. 
The liver. 
The pleura. 
Left Infraaxillary 
The lung. 
The diaphragm. 
The spleen. 
The stomach (this gives a 
tympanitic quality to the 
percussion sound in this 
region, if it contains gash 
The pleura. 
POSTERIOR SURFACE. (See Fig. 10.) 
Right Scapular 
The lung. 
The pleura. 
Interscapular 
The lungs. 
The trachea and 
bronchi. 
The aorta. 
The oesophagus. 
The thoracic duct. 
The venazygous major. 
Left Scapular 
The lung. 
The pleura. 
INFRASCAPULAR. 
Right Side 
The lung. 
The diaphragm. 
The liver. 
The kidney. 
The pleura. 
Median Area 
The aorta. 
The oesophagus. 
The thoracic duct. 
The venazygous major. 
The diaphragm. 
Left Side 
The lung. 
The diaphragm. 
The spleen. 
The kidney. 
The pleura. 
Lines.—When a line is mentioned in citing the 
location of a structure or phenomenon, a vertical 
line is meant, unless otherwise stated. 
For instance, the median line, mammary or 
nipple line, midclavicular line, midaxillary line, 
midscapular line, and the parasternal line which 
is midway between the outer edge of the sternum 
and the midclavicular line. 
It is obviously necessary to mention the side—• 
right or left—when applying the above terms, 
except in the case of the median line. SECTION IV. 
SURFACE MARKINGS (CONTINUED), AND INSPEC- 
TION OF THE CHEST, WITH REFERENCE 
TO THE LUNGS. 
SURFACE MARKINGS OF THE CHEST. 
The sterno-clavicular articulation on the right 
side marks the termination (bifurcation) of the 
innominate artery. 
The angulus sterni is a palpable, and in many 
cases visible, transverse ridge on the anterior sur- 
face of the sternum at the junction of the manu- 
brium and body. It marks the level of the second 
costal cartilage and rib, the bifurcation of the 
trachea and the under surface of the arch of the 
aorta, with the structures forming the root of 
each lung just beneath it. The sternal angle, 
marking the level of the second costal cartilage 
and being palpable in nearly all subjects, is usually 
the best starting point from which to count the 
intercostal spaces or ribs. 
The junction of the xiphoid cartilage with the 
sternum marks the sternal articulation of the 
seventh rib. It is easily palpated in most sub- 
jects and is therefore a good fixed landmark. 
The nipple, though a fairly reliable landmark 
in men of average build, is totally unreliable as a 
landmark in most women. 
63 64 
SURFACE MARKINGS AND INSPECTION. 
The tip of the spinous process of the seventh 
cervical vertebra (vertebra prominens) is on a 
level with the apices of the lungs. 
The interval between the spinous processes 
of the second and third dorsal vertebras is the level 
at which the main fissure (separating the upper 
and lower lobes) of the lung reaches the surface 
posteriorly. This fissure passes outward, for- 
ward, and downward on the surface of the lung, 
to join the inferior border of the lung in the 
parasternal line. It is therefore seen that the 
third intercostal space, in the interscapular 
region, contains the extreme apex of the lower 
lobe near the vertebral column and a small 
portion of the upper lobe near the scapula. 
The area of upper lobe available for accurate 
physical exploration, on the posterior surface 
of the chest, is very small, and is confined to the 
first, second, and outer part of the third inter- 
costal spaces. The remainder of the posterior 
surface, not covered by the scapulas, is occupied 
by the lower lobes, which extend down to the 
tenth rib on both sides. The pleural reflec- 
tions extend about an inch and a half further 
down on both sides; to the twelfth rib posteriorly 
(see Fig. n). 
When the angle of the scapula (inferior angle) is 
referred to as a fixed point, it is understood to be 
in its anatomical position (over the seventh rib). 
The Trachea and Bronchi.—The trachea, near 
its lower extremity, turns slightly to the right of SURFACE MARKINGS OF THE CHEST. 
65 
the median line to give place to the transverse 
arch of the aorta. On a level with the angulus 
sterni anteriorly, and the lower part of the 4th 
dorsal vertebra posteriorly (a little to the right 
Fig. ii.—Topography of lungs, pleura, and fissures in the 
posterior surface of the chest. 
of the median line) it divides into right and left 
primary bronchi. The right primary bronchus, 
larger and shorter than its fellow, continues down- 
ward and to the right in almost the same direc- 
tion as the final portion of the trachea. The left 66 
SURFACE MARKINGS AND INSPECTION. 
primary bronchus, smaller, longer, and nearer 
horizontal, leaves the trachea with a sharp change 
of direction. (See Figs. 12 and 13.) The first 
branch (the eparterial bronchus) from the right 
primary bronchus, is given off near the tracheal 
Fig. i2. showing relations of trachea and bronchi 
to anterior chest wall (after Le Fevre). 
bifurcation, and before the primary bronchus has 
entered lung tissue. This branch is rather large, 
and takes a course directly toward the apex of the 
right lung. 
The left primary bronchus, longer and smaller 
in calibre than the right, is surrounded and muf- SURFACE MARKINGS OF THE CHEST. 
67 
fled by lung tissue before any branch springs 
from it. The left bronchus is further muffled by 
the arch of the aorta, which hugs it above at its 
very origin. 
Fig. 13.—Diagram showing relations of trachea and bronchi 
to posterior chest wall (after Le Fevre). 
Note.—The primary bronchi (the right more than 
the left) impart a varying degree of tubular quality 
to the respiratory sounds heard, anteriorly at the 
inner portion of the infraclavicular regions and pos- 
teriorly in the fourth intercostal spaces (in the inter- 
scapular region). 68 
SURFACE MARKINGS AND INSPECTION. 
Lungs and Pleura.—The apices of the lungs 
extend one-half to one and one-half inches above 
the clavicles, rising with inspiration. The ante- 
rior borders of the two lungs are in apposition in 
the median line from the middle of the manubrium 
Fig. 14.—Diagram showing the position of the heart, 
great vessels, and valves. The borders of the lungs are 
indicated by green dotted lines. Note.—The arrows indicate 
the direction of normal blood currents at the valves. 
to the level of the fourth costal cartilage. At this 
point the left turns outward and downward nearly 
to the site of the apex beat (fifth intercostal space, 
about three inches to left of the median line), then 
downward and inward to the sixth costal cartilage, 
exposing part of the heart and pericardium. The SURFACE MARKINGS OF THE CHEST. 
69 
anterior border of the right lung continues down 
in the median line to the sixth costal cartilage, 
(see Fig. 14). 
The lower borders of both lungs follow the sixth 
costal cartilage and rib to the mammillary or 
nipple line and continue backward crossing the 
eighth rib in the midaxillary line, being on the 
level of the tenth rib posteriorly (see Fig. 15). 
The main fissure, indicating the upper border of 
the lower lobe on both sides, appears in the lower 
border of the lung in the parasternal line, and runs 
obliquely upward and outward on the surface of 
the lung to its posterior border by the side of the 
vertebral column, crossing the third intercostal 
space in the interscapular region (see Fig. 11). 
The short fissure (usually present) on the right side, 
runs from the fourth costosternal articulation 
horizontally outward to join the main fissure 
(see Fig. 16). 
The capacity of the right lung is greater than 
the left, in the ratio of eleven to ten. 
The pleura covers most of that part of the peri- 
cardium not covered by lung. Both pleural sacs 
extend below the inferior borders of the lungs, 
to the tenth rib in the midaxillary line and to the 
twelfth rib posteriorly near the vertebral column. 
So that, with the subject erect, the pleural reflec- 
tions reach their lowest level in the midaxillary 
line (see Fig. 15). All of the pleural reflections 
are encroached upon by lung, during inspiration, 
and permanently so when there is pulmonary 70 
SURFACE MARKINGS AND INSPECTION. 
emphysema, in which condition the area of abso- 
lute cardiac dullness may be almost completely 
replaced by pulmonary resonance. 
Fissure. 
Inferior border of lung 
(descends with 
inspiration). 
Soleen (descends 
with inspiration). 
Pleural reflection. 
Fig. i 5.—Diagram showing the position of the inter- 
lobular fissure, the inferior border of the lung, and the 
pleural reflection, laterally (similar on both sides); and the 
position of the spleen. SURFACE MARKINGS OF THE CHEST. 
71 
The Apex Beat.—Since the presence or absence, 
faintness or prominence, and the position of the 
visible, palpable, and audible apex beat of the 
heart is of importance in determining the condition 
of neighboring lung and pleura in many cases, you 
Fig. i 6.—Diagram showing absolute dullness and relative 
dullness of liver and heart; and the approximate position 
of interlobular fissures of the lungs—anteriorly. 
should note these points during physical examina- 
tion of the lungs and pleura. The normal site of 
the apex beat is in the fifth intercostal space about 
three inches to the left of the median line. The 
area of visible motion is normally confined to a 
circle about one inch in diameter. 72 
SURFACE MARKINGS AND INSPECTION. 
INSPECTION WITH REFERENCE TO THE LUNGS. 
The subject should be stripped to the waist. 
If his condition permits it, he should stand or sit 
erect facing the greatest source of light, with his 
arms hanging passively by his sides. The examiner 
should stand three to six feet in front of the 
subject. 
Attitude and Contour.—Observe first the general 
attitude and contour of the chest. A perfectly 
healthy chest may not be exactly symmetrical on 
the two sides. One shoulder may be higher than 
its opposite, or one side of the chest may be slightly 
larger than the other; though such asymmetry 
should be carefully noted as they are not infre- 
quently the result of past or present disease or 
accident in lung or pleura. Look carefully for 
any unilateral or circumscribed deformities, bulg- 
ing or depression. Besides the set types of chest 
deformities, we may observe unilateral or cir- 
cumscribed enlargements or retractions as a result 
of disease of the lung or pleura. Depression or 
retraction of the supra- and infraclavicular re- 
gions is frequently seen as a result of disease 
at the apex of the lung, especially in pulmonary 
tuberculosis. 
It must not be forgotten that circumscribed 
bulging, depressions, or deformities are occasionally 
seen in this as in other parts of the body, as a 
result of disease or injury of the bones or soft 
tissues making up the parietes. 
The color and condition of the skin and veins, INSPECTION OF THE LUNGS. 
73 
especially the degree and extent of any venous 
distention, should be carefully observed. 
Note the cardiac apex beat, whether visible 
or not; its position (it is displaced to the right 
when there is considerable fluid in the left pleural 
sac); whether prominent or only faintly visible or 
absent (as noted in some cases of pulmonary 
emphysema); if normally circumscribed and con- 
fined to an area one inch in diameter, or diffused 
over a greater area (as seen in some cases of pul- 
monary tuberculosis with retraction of the anterior 
border of the left lung). 
Respiratory Movements.—Observe the respira- 
tory movements, first when the subject breathes 
naturally and again when he is told to breathe 
deeply. 
Anatomically, there are two types of breathing: 
superior costal, or costal; and diaphragmatic, or 
abdominal. The former is usually more promi- 
nent in women and the latter in men. 
Compare the prominence and movement of 
the ribs on the right with those on the left side. 
They should be of the same prominence on the 
two sides, rising and receding equally in corre- 
sponding regions, on both sides simultaneously. 
Special notice should be given to the supra- and 
infraclavicular regions in this connection. 
Expansion with inspiration may be normal, 
diminished or limited, increased or exaggerated, or 
absent on one side. If both sides are either in- 
creased above, or diminished below the average 74 
SURFACE MARKINGS AND INSPECTION. 
over the entire chest, it does not signify that 
the subject is diseased; for, so long as the two 
sides expand equally, variations in the degree 
of expansion may be due to habit. If, however, 
the lower part of the chest expands normally 
and the upper part poorly or not at all, the supra- 
and infraclavicular regions on one or both sides 
remaining depressed throughout the respiratory 
act, we should be suspicious of the existence of 
disease of the lung in those regions. 
There may be retraction of the lower ribs with 
the inspiratory effort instead of expansion. Re- 
traction of the lower ribs and the episternal notch 
with the inspiratory effort is due to partial or 
complete occlusion of the glottis or trachea. 
If the respiratory movements are not uniform 
on the two sides, note which is limited, which 
exaggerated and whether inspiration is suddenly 
checked on either side because of pain, as occurs 
in pleurisy. 
You must learn to distinguish between true 
eccentric expansion of the chest and simple ele- 
vation of the sternum and ribs by the extraor- 
dinary muscles of respiration with little or no 
expansion. The latter occurs with each in- 
spiratory effort in those cases of barrel-shaped 
chest in the asthmatic or aged, where the chest 
is rounded, the sternum prominent, the antero- 
posterior diameter increased, and the sterno- 
cleido-mastoid muscles stand out prominently. 
Where the expanding capacity of one lung is INSPECTION OF THE LUNGS. 
75 
compromised and diminished, there is usually a 
corresponding exaggeration of the expansion on 
the opposite side. 
Note the frequency of respirations (they should 
be sixteen to nineteen per minute in a healthy 
adult); whether shallow or full or jerky, stertorous, 
labored, and whether or not the extraordinary 
muscles of respiration stand out prominently (the 
sterno-cleido-mastoid muscles especially). 
After complete inspection of the anterior 
surface the subject should turn about for equally 
careful inspection posteriorly, then to either side 
for inspection of those surfaces. 
The diaphragmatic phenomenon (Litten’s sign) 
is the visible depression of the sixth and seventh 
(and in some cases the eighth) intercostal spaces, 
placed horizontally, in the infraaxillary regions, 
during inspiration. This depression is caused by 
the suction force produced by the descent of the 
diaphragm, which is, as it were, peeled away from 
the chest wall at the site of the inferior reflections 
of the pleural sacs, during inspiration. The 
same suction force, or negative pressure, causes 
expansion and descent of the inferior borders of 
the lungs, thus filling out the depressed inter- 
costal spaces from above downward. The de- 
pressions travel downward along the intercostal 
spaces one to two inches during the inspiratory 
act, and disappear when inspiration is complete. 
This phenomenon can be observed in most normal 
chests (not in all) by the following technic: 76 
SURFACE MARKINGS AND INSPECTION. 
Have the subject lie upon his back on a flat 
surface, with his arms raised above his head. 
Have a single source of light entering the room 
from the direction of the subject’s feet. The 
observer standing to one side will see, when the 
subject breathes deeply, a shadow (formed against 
the lower wall of the depressions) descend with 
inspirations along the interspaces mentioned. 
Absence of the diaphragmatic phenomenon can 
be of material significance in diagnosis only when 
it is unilateral, since it cannot be observed at 
all in a small percentage of normal subjects. 
Any condition which causes immobility of the 
diaphragm, paralysis of this muscle, or pathologi- 
cal changes in the abdomen or chest sufficient to 
prevent its descent or to prevent expansion of the 
inferior part of the lung, will obviously be asso- 
ciated with an absence of this phenomenon on 
the side affected, as, for instance, in pleurisy 
with effusion. Litten called attention to the 
fact that this phenomenon was absent in empy- 
ema, but present in subphrenic abscess. This 
phenomenon is best observed in spare subjects. SECTION V. 
PALPATION AND PERCUSSION, WITH REFER- 
ENCE TO THE LUNGS. 
PALPATION FOR EXPANSION. 
The expansion of corresponding regions on the 
two sides may be compared by palpation, although 
one can usually make a more accurate estimate 
and comparison of expansion by inspection. 
When palpating for expansion of the anterior 
surface, the examiner should stand close behind 
the subject. Place in the right supraclavicular 
region as many, and as much of each, of the tips 
of the fingers of the right hand as will fit snugly 
in this region, the thumb resting against the 
vertebral column, with the left hand in a similar 
position on the left side. Then have the subject 
take several ample respirations, when the supra- 
clavicular regions will be filled out from within 
by expansion of the apices of the lungs, and the 
examiner, by carefully adjusting the slight force 
he applies with his fingers, may detect any dif- 
ference between the centrifugal or expanding 
movement of the two sides. 
To compare the expansion in the infraclavicular 
and in the mammary regions, reach over the sub- 
ject’s shoulders, taking care to place the hands, 
77 78 
PALPATION AND PERCUSSION. 
fingers together, similarly and over corresponding 
areas on the two sides. For the inframammary 
regions and lateral surfaces, reach under the arms. 
To palpate the expansion of the posterior surface 
of the chest, the examiner must stand in front of 
his subject. 
The expansion of corresponding regions on oppo- 
site sides should be compared in the same respira- 
tory act, because the force of different inspirations 
varies greatly, even when the subject tries to 
make them equal. 
Never compare the expansion of one region on 
the right side with a different region on the left. 
Corresponding regions on the two sides should 
expand equally in the same respiratory act. 
PALPATION FOR FREMITUS. 
Normal Fremitus.—We may also palpate for 
surface vibration, called fremitus, which is caused 
by the spoken voice and called vocal fremitus, or 
by coughing and called tussive fremitus. 
Vocal fremitus is the palpable vibration from 
sound waves, produced by the vocal cords while 
speaking. These waves or vibrations are trans- 
mitted down the column of air in the trachea and 
bronchi, and along the walls of the trachea and 
bronchi to the lung tissue and thence outwards 
to the surface of the chest. They are naturally 
greatest at the point of their origin (the larynx), 
and diminish in force as the distance they travel 
increases. They are further diminished in force PALPATION FOR FREMITUS. 
79 
by every change in the direction of their course 
and by passing from a medium of one density to 
a medium of a different density. So that they are 
greatly dissipated by passage through normal 
lung tissue, and the vocal fremitus felt over the 
surface of the normal chest is much less than that 
felt over the larynx or trachea. 
One might suppose that when palpating for 
vocal fremitus both of the examiner’s hands should 
be applied to corresponding regions on the two 
sides simultaneously, and base their opinion upon 
the fact that different vocal acts of the same 
subject vary in force—essentially the same reasons 
previously given for the advisability of the 
simultaneous testing of the respiratory expansion 
of corresponding regions of the chest. This 
argument would apply, if in palpating for vocal 
fremitus we compared the force of a single vibra- 
tion on one side with the force of a single vibration 
on the other side, as we compare single expansions 
on opposite sides; but we do not. When palpat- 
ing vocal fremitus, we compare the thrill, or sum 
of innumerable vibrations of variable individual 
force. The surface vibration is not dependent 
entirely upon the force of the vocal act. The 
pitch of the voice is one governing factor, namely, 
the lower the pitch of the voice, the stronger the 
surface vibrations—vocal fremitus. 
Other conditions being equal, when the subject 
monotonously repeats “one-two-three” or “ninety- 
nine,” time-after time, the palpable sum of the 80 
PALPATION AND PERCUSSION. 
resulting vibrations over any given area does not 
vary perceptibly, from moment to moment. 
Furthermore, the tactile sense is more acute in 
one hand than the other in nearly every individual; 
being more acute in the right hand of right-handed 
people and in the left hand of left-handed people. 
Therefore the examiner should palpate for fremitus 
only with the hand (right or left) which possesses 
the finest sense of touch; placing the hand in a 
similar position in corresponding regions on the 
right and left sides alternately. The direction of 
the fingers must bear the same relation to the 
underlying bones on both sides. 
Normal Variations of Vocal Fremitus.—The 
rule which applies to expansion, namely, that 
in the normal it is the same in corresponding 
regions on both sides, does not apply to vocal 
fremitus. 
Vocal fremitus is considerably more forcible 
over the apex and upper lobe on the right than it 
is on the left side, and it is slightly more over the 
right lower lobe than it is over the left lower lobe. 
Many reasons have been given by various authors 
for the above-stated difference in the normal vocal 
fremitus on the two sides. 
There are four reasons for the predominance 
of fremitus on the right side which are widely 
accepted, namely: 
1. The right lung is larger than the left. 
2. The right bronchus is larger and shorter 
than the left (see Fig. 17). PALPATION FOR FREMITUS. 
81 
3. The right bronchus has a direction almost 
continuous with that of the trachea (see Fig. 17). 
4. The right bronchus sends a large branch 
(eparterial bronchus) much more directly to the 
Fig. 17.—Diagram showing relations of trachea and bronchi 
to anterior chest wall (after Le Fevre). 
apex of the lung and by a shorter route than 
does the left (see Fig. 17). 
By the above it will be seen that a larger volume 
of vocal vibrations enter the right lung by a 
shorter route and with less deviation from their 
course down fhe trachea than the left. 82 
in ALP AT ION AND PERCUSSION. 
Another reason for this predominance of vocal 
fremitus (as well as vocal resonance) over the 
right upper lobe will be detected by a short study 
of Fig. 18. This was made from a sagittal section 
of a frozen subject through the trachea. It there- 
Fig. i 8.—Relation of trachea to lungs. 
fore represents the normal lateral relations. It 
will be noted that although the right upper lobe 
contained a tuberculous cavity in its outer por- 
tion, the inner half of the lobe was almost, if not 
quite, free from disease, and the pleura approxi- 
mate to the trachea was normal. Therefore the PALPATION FOR FREMITUS. 
83 
normal relations of the trachea to the two lungs 
are correctly illustrated. It will be seen that 
while the right upper lobe is in essentially direct 
contact with the trachea almost to its apex, the 
left upper lobe is separated from the trachea by 
the arch of the aorta and other less important 
structures. Thus, vocal vibrations pass directly 
from the wall of the trachea into the upper lobe 
on the right side, while on the left side they must, 
at this level, pass through and be diffused and 
diminished in force by the aorta. In the opinion 
of the author this difference in the normal ana- 
tomical relations on the two sides is the chief, if 
not the entire, reason for the predominance of 
vocal fremitus and vocal resonance over the right 
apex and upper lobe. 
The last two reasons make it clear why the 
difference in normal vocal fremitus on the two 
sides is more marked over the apices and in the 
infraclavicular regions than over the lower lobes. 
In the normal subject, vocal fremitus is dimin- 
ished by an increase in thickness of the adipose 
or other tissue in the chest wall. 
As has been previously referred to, a bass voice 
produces stronger vocal fremitus than a high- 
pitched voice. The louder the enunciation in a 
given subject, the stronger will be the vocal 
fremitus. 
Abnormal Variations of Vocal Fremitus.—- 
lung tissue, as is often found in 
disease, allows the vocal vibrations to reach the 84 
PALPATION AND PERCUSSION. 
surface with less changes of media through which 
they pass than is normal. So that the vocal 
fremitus palpable over the consolidated area is 
greater than is normal for that region. Hence 
the statement that consolidation of the lung 
causes an increase in vocal fremitus. 
Thickened, roughened, or adherent pleura, as 
is often present in disease, diminishes the vocal 
fremitus below the normal for the region involved. 
Accumulation of fluid in the pleural sac abolishes 
or greatly diminishes the vocal fremitus over the 
fluid. 
Air in the pleural sac (pneumothorax) causes 
absence of vocal fremitus over the air. 
Complete occlusion of a large bronchus, as well 
as a large infarction, causes absence of vocal 
fremitus over the area supplied by the occluded 
bronchus, or over the infarction. 
Loss of voice from any cause very naturally 
causes loss of vocal fremitus. This is not un- 
common in phthisical subjects, who have a tuber- 
culous laryngitis. 
Adventitious Fremitus.—A palpable surface frem- 
itus may be caused by some pathological ob- 
struction to the current of air in a large bronchus 
and called bronchial or rhonchial fremitus, or by 
roughened pleural surfaces moving against one 
another and called friction fremitus. A grating 
fremitus is felt over the surface wdiere the two 
rough ends or surfaces of a fractured bone rub 
against each other. There is a crackling fremitus PERCUSSION. 
85 
detected if we press under our fingers soft struc- 
tures containing air or gas in the cellular tissue. 
Note.—Palpable rigidity of the chest muscles indica- 
tive of inflammatory processes in the lung, to which 
Pottenger has called attention, will be left for more 
advanced work. 
PERCUSSION. 
Pulmonary Resonance.—The percussion sound 
elicited on the surface of the chest over a normal 
lung is called normal pulmonary resonance. 
Pulmonary resonance is the fundamental quality 
of all percussion sounds of the normal chest, 
being present to some degree in them all. It 
would be just as absurd to attempt to describe 
pulmonary resonance by words or simile as it 
would be to attempt a description of the color 
blue. Special sounds, colors, odors, and the 
finer and special impressions of touch cannot 
enter our mind nor be accurately appreciated in 
any way except through the special organs adapted 
for their reception. To know just what pul- 
monary resonance is, you must listen to it when 
produced by percussion over the lung; there is 
no other way. 
Pulmonary resonance varies in shades of quality, 
intensity, pitch, and duration, with the region; 
because the arrangement of subjacent anatomical 
structures is different in the different regions. 
It is also different over the same region in different 
individuals, according to peculiarities of build, 
habit, amount of adipose tissue, sex, and age 86 
PALPATION AND PERCUSSION. 
(the amplitude of resonance diminishes as age 
advances). 
The volume and degree of resonance, with a 
stroke of given force, is great according to the 
nearness of the air containing lung tissue to the 
surface, the amplitude of the air cells and the 
depth or amount of lung tissue beneath the area 
percussed, as well as the remoteness of large 
solid organs, such as the liver, the heart, or the 
spleen. 
Resonance is greatest in the infraclavicular 
regions, and is obviously more marked at the 
height of inspiration than in any other part of 
the respiratory act. 
With a percussion stroke of moderate force in 
the right mammary line, the volume or intensity 
of resonance diminishes and the pitch of the 
sound rises gradually (relative liver dullness in- 
creasing), from the fourth intercostal space 
downward as the arched superior and anterior 
surface of the liver approaches nearer and nearer 
the anterior chest wall. At the sixth inter- 
costal space, where the liver comes in contact 
with the chest wall, resonance practically ceases, 
giving absolute liver dullness, except during 
inspiration, when the lung descends carrying 
pulmonary resonance an inch to an inch and a 
half lower down (see Fig. 19). This change in 
the percussion note from the fourth to the sixth 
intercostal space on the right side is a blending of 
flat quality from the liver with pulmonary reso- PERCUSSION. 
87 
nance, the former increasing and the latter de- 
creasing in amount as we descend. 
The lighter the percussion stroke along this line, 
the purer the resonant quality of the sound elicited, 
as a strong blow sets the solid liver beneath in 
vibration to a greater degree. 
Fig. 19.—Diagram showing absolute dullness and relative 
dullness of liver and heart and the approximate position of 
interlobular fissures of the lungs anteriorly. 
Relative liver dullness (only brought out on 
forcible percussion) extends, in the right mam- 
mary line, from the fourth intercostal space to 
the sixth intercostal space during expiration (see 
Fig. 19). 
Absolute or superficial liver dullness, sometimes 88 
PALPATION AND PERCUSSION. 
called liver flatness, is elicited in all of the right in- 
framammary region during expiration (see Fig. 
19). It is by the position and extent of absolute 
liver dullness that you should learn to estimate 
the size and position of the liver. 
Note.—On very light percussion over the area of 
absolute liver dullness in some subjects there is no 
appreciable resonant quality, so the note is flat. 
Pulmonary resonance extends over all of the 
chest surface that has lung in contact with the 
chest wall. It is elicited behind as low as the 
tenth rib on both sides, and lower during extreme 
inspiration. 
Cardiac dullness, absolute and relative (or 
superficial and deep), is governed and limited 
by the same principles of anatomical arrange- 
ment, or relations, that govern and limit liver 
dullness. 
Absolute or superficial cardiac dullness (not 
flatness) is confined to a small triangle, bounded 
above and below approximately by lines connect- 
ing the site of the apex beat with two points in the 
median line—one at the level of the fourth and 
one at the level of the sixth costal cartilage; the 
median line bounding it to the right (see Fig. 19). 
This triangle is diminished in size during forced 
inspiration, from above and the left, by the dis- 
tended border of the lung. It is continuous 
with liver dullness below. It is almost com- 
pletely obliterated in cases of marked pulmonary 
emphysema. PERCUSSION. 
89 
Splenic dullness is only relative, and is elicited 
by forcible percussion over the site of the spleen 
(see Fig. 20). 
Fissure. 
Inferior border of lung 
(descends with 
inspiration). 
Spleen (descends 
with inspiration). 
Pleural reflection. 
Fig. 20.—Diagram showing the position of the inter- 
lobular fissure, the inferior border of the lung, and the 
pleural reflection, laterally (similar on both sides), and the 
position of the spleen. 90 
PALPATION AND PERCUSSION. 
Tympanitic resonance is elicited over the greater 
pouch of the stomach when it is moderately dis- 
tended with gas. This area of tympanitic reso- 
nance, sometimes called the semilunar space of 
Traube, is found in the lower part of the left infra- 
mammary region, anterior to the spleen and external 
to the left lobe of the liver. In this region tym- 
pany predominates in the note elicited, although 
the neighboring lung adds a pulmonary quality 
which modifies the note slightly. 
Furthermore, the pulmonary percussion note is 
less resonant—more dull—according to the amount 
or thickness of tissue, adipose, muscle, or bone, 
in the chest wall over the area percussed. 
Over superficial bones, as clavicles, ribs, or 
sternum, an osseous quality is imparted to the 
percussion sound, so that in pulmonary and car- 
diac percussion one should avoid percussing over 
bones when practical. 
Fluid accumulations in the pleural sac give 
flatness or extreme dullness over the fluid, besides 
a sense of resistance. This sense of resistance is 
an important aid to the detection of fluid in the 
pleural sac. 
Overdistention of the air cells, as in pulmonary 
emphysema, gives exaggerated pulmonary reso- 
nance, combined, as a rule, with a peculiar boxy* 
quality which results from the loss of elasticity 
of the bones of the chest. 
Consolidation of lung tissue diminishes resonance 
* Suggestive of the sound caused by striking an empty box. PERCUSSION. 
91 
and gives dullness in proportion to the complete- 
ness and extent of the consolidation. There is 
also felt a sense of resistance where the consolida- 
tion is complete and extends over a considerable 
area. The sense of resistance felt by the percussing 
fingers over consolidated lung tissue is not so marked 
as that felt over fluid in the pleural sac. 
A thickened pleura causes dullness in propor- 
tion to the increase in thickness. A sense of 
resistance may be detected here, when the pleura 
is greatly thickened. 
Consolidation of lung tissue is the only condition 
which diminishes pulmonary resonance (causing dull- 
ness) and exaggerates vocal fremitus over the same 
area. However, if the large bronchus which supplies 
the consolidated area is completely occluded, as occurs 
in some instances, the vocal fremitus will be absent, 
or greatly diminished. Furthermore, if the pleura is 
thick and adherent, or there is fluid over the consoli- 
dated area, vocal fremitus will be proportionately 
diminished. 
Cracked-pot and the amphoric percussion sounds 
elicited over various kinds of cavities will be left for 
complete consideration in more advanced study. SECTION VI. 
AUSCULTATION WITH REFERENCE TO THE 
LUNGS. 
The normal respiratory sounds are two in num- 
ber : inspiratory and expiratory, in each respiratory 
act. Inspiration is followed by expiration with 
no appreciable time intervening. 
There are sixteen to nineteen respirations per 
minute in the normal adult when at rest. 
The inspiratory sound, originating chiefly at the 
glottis, is caused by the inrush of air. It is car- 
ried down along the trachea, into the bronchi, 
and thence, after innumerable subdivisions and 
deflections, it enters the air vesicles with the in- 
spired air. The tubular quality heard over the 
trachea and bronchi is replaced by a vesicular, 
breezy murmur, which is heard on the surface of 
the chest over the lung tissue—the normal inspira- 
tory murmur. 
The expiratory sound, originating first at the 
mouths of the collapsing alveoli as the expired 
air is forced on into the bronchioles, is augmented 
as the current of air gains velocity and passes on 
into the bronchi and trachea. It travels in a 
direction way from the surface of the chest, and 
THE NORMAL RESPIRATORY SOUNDS 
92 THE NORMAL RESPIRATORY SOUNDS. 
93 
away from the listening ear. Except at the right 
apex, over primary bronchi and trachea, the normal 
expiratory murmur is only heard, on the chest sur- 
face, in one out of every five normal subjects, 
when the subject’s attention is not directed to his 
breathing. The expiratory sound varies in dura- 
tion, intensity, and quality with the individual 
and with the chest region. 
Over the surface of the lung (except over apices 
and bronchi) the expiratory sound, when heard 
in the normal, is less intense, of shorter duration 
and softer in quality than the inspiratory mur- 
mur. Over the trachea in the suprasternal re- 
gion it is always heard, where it is long, loud, 
high-pitched, harsh, and tubular in quality. 
Elements of Respiratory Sounds.—In ausculta- 
tion, as well as in percussion, the sounds have 
four elements: quality, intensity, pitch, and dura- 
tion. The respiratory sounds should also bear a 
certain relation to each other, called rhythm. 
Rhythm.—Over the surface of a normal chest, 
the expiratory sound, when audible, follows almost 
immediately upon the inspiratory. 
Types of Breathing.—The two fundamental types 
of respiratory sounds in the normal are bronchial 
or tubular breathing, which is heard most intense 
over the trachea and less intense over primary 
bronchi, front or back (see Figs. 21 and 22 for these 
areas); and vesicular, or normal respiratory mur- 
mur or breathing, heard purest in the left infra- 
clavicular region. 94 
AUSCULTATION. 
Bronchial or tubular breathing consists of the 
two respiratory sounds, inspiratory and expira- 
tory, separated by a distinct interval of time. 
They both have a more or less harsh tubular 
quality, are of high pitch, and more intense than 
Fig. 21.—Diagram showing relations of trachea and bronchi 
to anterior chest wall (after Le Fevre). 
vesicular breathing. Here also the duration of 
the expiratory sound is greater than in vesicular 
breathing. 
Only by continued practice in listening to the 
respiratory sounds in the various regions will you THE NORMAL RESPIRATORY SOUNDS. 
95 
be able to recognize the normal for these regions, 
and learn how the various elements of respiratory 
sounds vary in different normal subjects. For 
instance, when the duration of the expiratory 
Fig. 22.—Diagram showing relations of trachea and bronchi 
to posterior chest wall (after Le Fevre). 
sound is prolonged beyond the normal for the 
region given. 
It is frequently the location of a type of breath- 
ing that signifies pathological change. For in- 
stance, if the type of breath sounds normally 96 
AUSCULTATION. 
heard directly over a primary bronchus is detected 
in the infrascapular region, we know that there is 
a change in the lung at that point (consolidation 
of lung tissue). 
Normal Bronchovesicular Breathing.—Over the 
apex of the right lung, in most subjects, the 
respiratory murmur is normally different from 
that over the apex of the left lung. Over the 
right apex during ample respiration the breath- 
ing is a blending of the bronchial and the vesic- 
ular sounds: it is bronchovesicular. The inspi- 
ratory sound is more intense, higher in pitch, 
and of a harsher quality than on the left side, 
and the expiratory sound is more intense, higher 
in pitch, of a harsher quality, and longer in 
duration than the expiratory sound on the left 
side.* 
ABNORMAL RESPIRATORY SOUNDS. 
1. A normal sound, bronchial or broncho- 
vesicular breathing, heard in a locality where it 
is not naturally located. 
2. Intensity, exaggerated, diminished, or absent. 
* The student must familiarize himself with the type of 
breathing normal to the right apex. It is especially 
marked where the chest wall is thin, and is the same as that 
heard over a small area of partial consolidation of lung 
tissue in other regions, such as occurs in the incipient stage 
of pulmonary tuberculosis; and since the right apex 
is the most frequent site of the primary involvement, in 
this condition, it is at once obvious that an error in diagnosis 
might occur readily, unless we use extreme care and keep 
the above in mind while examining the apices of the lungs. ABNORMAL RESPIRATORY SOUNDS. 
97 
3. Rhythm interrupted, interval between in- 
spiratory and expiratory sounds prolonged or 
expiratory sound prolonged. 
4. Amphoric (musical) and cavernous breathing. 
Bronchial, or tubular breathing, like the sound 
caused by blowing through a tube, with no vesic- 
ular element, signifies complete consolidation of 
lung tissue (obliteration of air vesicles), unless 
heard over trachea or bronchi. 
Bronchial breathing may be very harsh, in- 
tensely tubular, and sound as if produced very 
near the ear where there is a considerable area 
of complete consolidation, as in acute lobar 
pneumonia; or it may be faint and distant, as in 
small or central areas of consolidation. It is 
not the volume or nearness, but the quality 
(tubular) which gives this type of breathing its 
name and primary significance. 
In proportion to the increase of the bronchial 
or tubular element in the respiratory sounds 
heard over a region is the degree and extent of 
the consolidation of lung tissue beneath. 
Bronchovesicular breathing, called also harsh, 
or rude, is heard in a normal thin-walled chest 
in the right supra- and infraclavicular regions. 
It is only by prolonged study and practice that 
one comes to know when the bronchial element 
of this sound in this locality is sufficiently promi- 
nent to indicate a change in lung tissue (partial 
consolidation). In bronchovesicular breathing 
the expiratory sound is of higher pitch and longer 
duration than is normal for the region. 98 
AUSCULTATION. 
In the absence of other signs or symptoms, 
bronchovesicular breathing at the apices cannot 
be accepted as indicating disease of the lung. 
If this type of breathing—bronchovesicular—is 
heard in any other part of the chest, it signifies 
partial consolidation of lung tissue; that some, 
but not all, of the air vesicles in the area are 
obliterated (filled with exudate). 
Exaggerated, diminished, or absent respiratory 
sounds obviously signify exaggerated, diminished, 
or absent respiratory function of the lung tissue 
from some cause. These conditions may be 
circumscribed in a small area or general over an 
entire side. 
For instance: Respiratory sounds are exagger- 
ated over the healthy lung when other parts of 
the lung or lungs are compromised by disease or 
injury. They are diminished over areas of inter- 
stitial infiltration in many cases of pulmonary 
tuberculosis. They are also diminished over areas 
of thickened pleura, moderate accumulations of 
fluid in the pleural sac and where the supplying 
bronchus is partially occluded. The respiratory 
sounds are absent over large accumulations of 
fluid in the pleural sac, where the supplying 
bronchus is completely occluded, extreme cases 
of thickened pleura, some cases of pneumothorax 
with collapsed lung, and over large solid growths 
within the chest or large infarctions or large pul- 
monary abscess. 
Interrupted rhythm, called cog-wheel or wavy ADVENTITIOUS SOUNDS. 
99 
breathing, is of comparatively slight significance. It 
is said by some authorities to be suggestive of begin- 
ning infiltration early in some cases of pulmonary 
tuberculosis. Prolonged interval between inspira- 
tory and expiratory sound, as well as prolonged 
expiratory sound is the result of either consolida- 
tion of lung tissue, loss of elasticity of the vesicle 
walls or obstruction to the air current. The pitch 
and quality of the sound, and other physical signs 
enable us to determine which of these three 
conditions is present. 
Amphoric respiratory sound has a musical 
quality like that produced by blowing gently 
into the mouth of a bottle. Cavernous is only 
less musical; both depend for origin upon a cavity 
of some kind communicating with a bronchial 
tube. The cavity must be occupied completely 
or partially by air. It may be formed within the 
lung tissue or in the pleural sac, as in pneumo- 
thorax. In the latter there is a distinctly metallic 
quality to the breath and voice sounds. 
ADVENTITIOUS SOUNDS WHICH ARISE IN THE RES- 
PIRATORY APPARATUS. 
By the above is meant sounds which are entirely 
abnormal; not modifications of the normal re- 
spiratory sounds. These adventitious sounds 
may be rales, gurgles, pleuritic friction sounds, 
or splashing sounds. 
Rales, gurgles, and friction sounds are caused 
by the normal respiratory air currents and move- 100 
AUSCULTATION. 
ments. They are heard with either inspiration, 
expiration, or with both. Splashing sounds are 
caused by artificial or forced shaking of the chest. 
Rales may be dry or moist. 
Dry Rales.—There are two kinds of dry rales: 
sibilant and sonorous, both of which are produced 
by localized narrowing of the lumen of bronchi 
by: 
a. Tenacious mucus. 
b. Swollen mucous membrane. 
c. Contraction of the muscular coat, 
or d. Pressure from without. 
Sibilant rales are fine and high pitched; they 
arise in tubes of small calibre, or where the con- 
striction leaves a very small opening through 
which the inspired and expired air can pass. 
Sonorous rales are snoring and low in pitch; 
they arise in tubes of large calibre, or where the 
constriction is not so marked. 
Moist rales may be large, medium, or -small, 
and are produced by air passing through fluid 
or mucus in the bronchi or abnormal cavities. 
Usually the size of the tube in which they are 
produced governs the size of the rales; which are 
heard. Gurgles are the largest of moist rales; they 
are caused by air passing through very liquid 
mucus, usually in a cavity or large bronchus. 
The smallest moist rales are called subcrepitant, 
and they are produced in the bronchioles of very 
small calibre. 
The crepitant rale is a fine high-pitched sound, VOICE SOUNDS. 
101 
similar to the sound produced by rubbing the hair 
above the ear between our thumb and forefinger. 
This rale is heard only at the very end of inspira- 
tion. It occurs in the first stage of lobar pneu- 
monia, and sometimes in the third stage of this 
disease as the “rale redux.” 
Here it occurs in the air vesicles which contain 
mucus; and the mechanism of its production is 
probably the sudden separation of the aggluti- 
nated walls of the air vesicles. The crepitant 
rale also occurs in some cases of acute pleurisy; 
so that it may arise either intrapleural or intra- 
pulmonary. 
Pleuritic friction sounds are produced by the 
movement of the two surfaces of diseased or in- 
jured pleura against each other. There are numer- 
ous kinds of friction sounds, dependent upon the 
character of pathological change causing them. 
Splashing sounds, sometimes called “succus- 
sion,” are the result of the succussion of fluid in 
a cavity which contains some air. They may 
therefore arise intrapleural, as in hydropneumo- 
thorax, intrapulmonary, as in tuberculous or large 
abscess cavities, or in the hollow abdominal vis- 
cera, such as the stomach or large intestine. 
VOICE SOUNDS CALLED VOCAL RESONANCE. 
Vocal resonance is the sound heard upon the 
surface of the chest when the subject speaks or 
whispers (the latter is called “whispered reso- 
nance”). Normally, its intensity or distinctness 102 
AUSCULTATION. 
depends upon the character or force of the voice 
and the region auscultated, and also varies in 
different individuals. 
Vocal resonance in a given subject is greatest 
over the trachea and primary bronchi, and more 
intense over the right than the left apex. 
The subject should repeat “ one-two-three, one- 
two-three” and so on, or “ninety-nine” over and 
over several times in monotone. The student 
must listen to the voCal resonance in every region 
to learn the normal for each region. He should 
listen also while the subject whispers the same 
words, to become familiar with the normal whisper 
resonance in the various regions. Then listen to 
the resonance of cough, as changes in this sound 
are often of value in diagnosis. 
Normal vocal resonance may be altered as 
follows by various disease changes: 
Exaggerated or increased. 
Diminished. 
Distant. 
Absent. 
or It may be changed in quality (i.e., bron- 
chophony, pectoriloquy, amphoric or cavernous 
voice and egophony). 
Vocal resonance is the audible analogy of vocal 
fremitus which is palpable; its seat of origin is 
the same (the vocal cords), its method and route 
of transmission to the surface the same, and the 
conditions governing the force or degree of vocal 
resonance heard upon the chest surface are the VOICE SOUNDS. 
103 
same as those governing vocal fremitus. The 
same conditions increase or diminish both to an 
equal degree. 
Note.—You should understand that both vocal 
fremitus and vocal resonance are greater over their 
point of origin (the glottis) than at any other point 
upon the body surface; that no change in the lung 
actually increases them above their original force; 
and that when we say they are “increased” or “ex- 
aggerated” we mean above the normal for the region 
named. 
In absolute consolidation of considerable lung 
tissue each word may be heard distinctly upon the 
chest surface; this is called bronchophony. If 
the whisper is heard as distinctly, as is usually 
the case, it is called whisper-broncho phony* 
Pectoriloquy is an advanced degree of bronchoph- 
ony. 
Amphoric and cavernous voice sounds occur 
with cavities associated with amphoric or cavern- 
ous breath sounds. 
Note.—Egophony will be left for a more advanced 
study. 
* In some cases the whisper will give more satisfactory 
results than the spoken voice. Bronchophony is heard in 
association with bronchial breathing, not with broncoves- 
icular breathing. SECTION VII. 
THE HEART. TOPOGRAPHICAL ANATOMY, 
ACTION AND SOUNDS. 
OUTLINES. 
The Area of Absolute or Superficial Cardiac 
Dullness.—A £mall triangle, the base of which is 
formed by a midsternal line from the level of the 
upper border of the fourth costal cartilage down to 
the level of the lower border of the sixth costo- 
sternal articulation. The other sides of this triangle 
are lines connecting the extremities of the base line 
with the inner edge of the visible or palpable apex 
beat. It represents the portion of the anterior sur- 
face of the heart (right ventricle) which lies in con- 
tact with the chest wall and gives an almost flat 
note on percussion (see Fig. 23). It is important 
that the student learn to mark out this, the area 
of absolute or superficial cardiac dullness by percus- 
sion. It is by the size, shape, and position of this 
area of absolute dullness that we may learn 
whether the heart is normal in size and position 
by estimation. 
The area of relative or deep cardiac dullness, that 
in which cardiac dullness is mixed with pulmonary 
resonance, • on forcible percussion only, extends 
well beyond the above triangle in all directions 
104 OUTLINES. 
105 
except downward and to the right (where it blends 
into liver dullness). This triangle represents the 
true anatomical outline of the heart, and is marked 
upon the surface with fair accuracy as follows: 
A point over the true apex, about 3I inches to 
left of the median line in the fifth intercostal 
Fig. 23.—Diagram showing absolute dullness and 
relative dullness of liver and heart, and the approximate 
position of interlobular fissures of tne lungs anteriorly. 
space, is connected by a slightly curved line, 
convex to left, with a point i inch to left of ster- 
num on the inferior border of the second costal 
cartilage (left border); a straight line connecting 
the latter point with a point | inch to right of 
sternum on upper border of third costal cartilage 106 
THE HEART. 
(upper border); a straight line from this point to 
the right sixth costosternal articulation (right 
border); then a straight line from this point to the 
starting-point (inferior border) (see Fig. 23). 
Apex Beat.—The normal position of the apex 
beat is in the left fifth intercostal space, 2-f to 
31 inches from the median line; this coincides in 
the average male to a point inches within the 
left nipple line in the fifth intercostal space. It 
is due to the striking of the lower part of the right 
ventricle (near its apex) against the chest wall. 
The apex beat may not be visible where there is 
much adipose tissue, even in the normal. There 
are some subjects with only an average amount of 
adipose tissue in whom the apex beat is not visible. 
The beat may or may not be palpable in such 
cases, though it is always audible, in the normal. 
The apex moves an inch or two to right or left when 
the subject lies on his right or left side, moving 
more in expiration than during inspiration. 
Immobility of the apex beat is strongly suggestive 
of some disease change, especially adhesive or 
obliterative pericarditis. 
Displacement of the Apex Beat.—The apex may 
be displaced by disease or deformity, or anomalous 
positions of the heart, as in those rare cases of 
transposition of viscera, in which all of the internal 
viscera are usually transposed; it may also be 
displaced by disease of neighboring viscera or by 
change of the subject’s position. 
The true apex and left border of the heart con- OUTLINES. 
107 
sists of left ventricle. The most superior portion 
of the heart is the left auricle. The extreme right 
portion is right auricle. The inferior border and 
most of the anterior surface is right ventricle. 
The left ventricle and auricle lie mostly posterior 
Fig. 24.—Diagram showing the position of the heart, 
great vessels, and valves. The borders of the lungs are 
indicated by green dotted lines. Note: The arrows indicate 
the direction of normal blood currents at the valves. 
(see Fig. 24). From left ventricle to left auricle 
through the mitral orifice the direction is upward 
and backward from the apex. 
From left ventricle to aorta through aortic 
orifice is upward and forward and to right. 108 
THE HEART. 
From right ventricle to right auricle through 
tricuspid orifice is to right. 
From right ventricle to pulmonary artery is 
upward and forward and to left. 
The under surface of the heart is separated from 
the stomach by the diaphragm. 
Fig. 25.—Diagram showing the horizontal relations 
of the orifices at the base of the heart (after Le Fevre). 
Valves.—The pulmonary, aortic, mitral, and tri- 
cuspid valves are placed in the order given, from 
above downward, all behind the left half of the 
sternum from the level of the upper border of the 
third costal cartilage to the fourth intercostal 
space, the mitral being farthest to the left. The NORMAL HEART ACTION. 
109 
pulmonary valves lie behind the third costosternal 
articulation (see Fig. 24). 
The sites of the valves are not the points at which 
the sounds produced at these valves can be heard 
with greatest intensity. 
The pericardium is reflected up to embrace the 
first two inches of the great vessels. The sac is 
conical, its base being attached to the diaphragm 
(see Fig. 24). 
The aorta is nearest the anterior chest wall in 
the second intercostal space just to the right of 
the sternum. The transverse portion of the arch 
of the aorta passes from before backward and to 
the left above and in contact with the left primary 
bronchus. It reaches the side of the vertebral 
column just to the left of the lower border of the 
fourth dorsal vertebra. 
NORMAL HEART ACTION. 
In physical exploration of the heart, it is neces- 
sary for the student to have in his mind a clear 
picture of the action, shape, and position of this 
organ, and the direction of its blood currents as 
associated with the sounds and intervals between 
sounds (see Fig. 26). 
With the first sound both ventricles contract 
simultaneously, the apex of the right ventricle 
strikes the chest wall, the mitral and tricuspid 
valves are closed and the aortic and pulmonary 
valves forced open by the blood in the ventricles. 
Blood rushes from the left ventricle into the aorta DESCRIPTION OF FIG. 26. 
Diagram showing the relations between the heart sounds, 
muscle contractions, blood currents, position of valves and 
apex, in one complete heart cycle. (Applies to either right 
or left side of heart.) 
A. When the first sound is heard, ventricles contract, 
apex strikes the anterior chest wall, auriculo-ventricular 
valves close, aortic and pulmonary valves open, blood is 
forced into aorta and pulmonary artery, the columnse 
carnas and chordae tendineae are on tension and blood flows 
passively into auricles from the veins. 
B. When the second sound is heard, aortic and pulmonary 
valves close, ventricles relax, blood continues to flow pas- 
sively into auricles from veins, auriculo-ventricular valves 
begin to open, apex recedes from chest wall. 
C. Aortic and pulmonary valves remain closed, auriculo- 
ventricular valves open, blood flows passively into ven- 
tricles from auricles and into auricles from veins. 
D. Auricles contract, auriculo-ventricular valves thrown 
wide open, blood flows forcibly from auricles to ventricles, 
ventricles distended, aortic and pulmonary valves remain 
closed. . . . Then the cycle is repeated. Fig. 26. 
Blood Currents, 
Position Of Valves 
And Apex 112 
THE HEART. 
and from the right ventricle into the pulmonary 
artery. This period is called systole (A, Fig. 26). 
Here the columnse carnae, and chordae tendineae are 
on tension and prevent the mitral and tricuspid 
valves from being forced back into the auricles. 
The first sound is longer in duration, lower in 
pitch than the second, its termination is not so 
sharp and it has a different quality. It is caused 
by the impact of the apex against the chest wall 
and closure of the mitral and tricuspid valves. 
The contraction of the ventricle walls and the rush 
of blood may add elements that soften the quality 
of this sound. It is heard with greatest intensity 
at the apex and with diminishing intensity in all 
directions from the apex, transmitted farthest in 
the direction of the blood current, over the great 
vessels. 
Following the first sound is a very short period of 
silence, during which the ventricles are still con- 
tracted and the auricles filling with blood from 
their veins, then the ventricles relax and the 
second sound is heard. 
With the second sound the aortic and pulmonic 
valves snap closed by the weight of the columns 
of blood in aorta and pulmonary artery, and the 
gradually increasing amount of blood in the 
auricles begins to force open the mitral and tri- 
cuspid valves. There is no muscular contraction 
with the second sound (B, Fig. 26). 
The second sound, short, sharp and high pitched, 
is caused by the closure of the aortic and pul- NORMAL HEART ACTION. 
113 
monary valves. It is heard with greatest inten- 
sity over the third left costosternal articulation 
and is transmitted with diminishing intensity 
in all directions, especially into the great vessels 
and to the apex, where it is heard distinctly. 
Period of Silence.—Following the second sound 
is a period of silence, during which the heart is 
passive, the blood flowing into the auricles from 
their veins freely, and freely but passively from 
the auricles into the ventricles (C, Fig. 26). The 
auricles and ventricles both are slowly distended 
during this period, called diastole, which is length- 
ened by slow heart action and shortened when 
the heart action is fast. The duration of systole 
is much less affected by changes in rapidity of 
heart action than is diastole. 
Auricular Systole.—In the end of this period of 
silence, the auricles contract without causing 
audible sound. This contraction of the auricles 
is of very short duration; it forces the blood 
they contain into the ventricles, distending them, 
so the cycle is completed (D, Fig. 26); and im- 
mediately comes systole* and the first sound 
again. 
* “Systole” or “diastole” unqualified refer to the 
ventricles. SECTION VIII. 
INSPECTION, PALPATION, AND PERCUSSION 
WITH REFERENCE TO THE HEART. 
INSPECTION WITH REFERENCE TO THE HEART. 
The chest and arms should be freely exposed. 
The subject should be examined sitting or stand- 
ing, and lying down. Inspect first from in front 
of the subject, then step to the side away from 
the source of light and inspect from this position. 
Venous and Arterial Pulsation.—Note the absence 
or presence of venous pulsation in the external 
jugular vein, and the degree and character of 
visible pulsation in the carotid and brachial, 
temporal and radial arteries. Also note the con- 
dition of the peripheral circulation, as shown by 
presence or absence of cyanosis of lips, ears, nose, 
fingers, or oedema of feet and legs. 
Contour of Precardial Region.—Inspect closely 
the precardial region and note whether the con- 
tour is normal or if there is deformity, diffuse 
or localized, of any shape. If there is any localized 
bulging, (as is seen in some cases of cardiac hy- 
pertrophy in a young subject and in some cases 
of pericardial effusion of great amount); note 
whether or not it visibly pulsates, and if any part 
of it is retracted synchronous with the apex beat 
(as sometimes occurs in obliterative pericarditis). 
114 INSPECTION OF THE HEART. 
115 
We may observe pulsation in the fourth and 
third interspaces, due to retraction of the lung 
from disease of this structure, or extreme dilatation 
of the heart. Note also the absence or presence 
of pulsation in the epigastric region, its degree 
and character if present. Heaving pulsation of 
the epigastric region is seen in some cases of 
tricuspid regurgitation, where the right side of 
the heart is dilated. 
The Apex Beat.—Observe the apex beat, its 
position and extent or character, whether regular 
or irregular or intermittent in rhythm and force 
of visible pulsation. The visible apex beat 
should be confined to an area not more than one 
inch in diameter. The apex beat may be dis- 
placed downward, upward, to left or right; by 
disease of the heart itself, pericardium, pleura, or 
neighboring tumor formation. When there is a 
large amount of fluid in the left pleural sac, the 
apex may be displaced to the right, even as far 
as the right nipple line in some cases. It is never 
displaced to the right by disease of the heart 
itself, although pulsations may be seen to right 
of the apex from this cause. 
Have the subject lie first on his right and then 
on his left side and note the mobility of the visible 
apex beat.* 
Extensive adhesions between the two pericar- 
* When examining a patient, it is well also to. employ 
palpation, percussion, and auscultation at this time to 
determine cardiac mobility; it avoids unnecessary annoy- 
ance. 116 
INSPECTION, PALPATION, PERCUSSION. 
dial surfaces is naturally associated with immo- 
bility of the apex. 
Inspect the back of the chest and note carefully 
the contour along the side of the spine overlying 
the course of the descending thoracic aorta, to 
exclude or detect swelling from aneurysm of this 
structure. 
PALPATION. 
The Pulse.—The radial artery is the one best 
adapted to palpate in most subjects. The tem- 
poral, facial, or dorsalis pedis arteries may be 
palpated for the pulse. Corresponding arteries on 
both sides should be palpated for the pulse. If 
the two sides are of decidedly unequal force, there 
is either anomaly of the arteries, pressure upon, or 
disease of an artery or arterial trunk nearer the 
heart; as, for instance, aneurysm of the arch of the 
aorta is usually associated with inequality of the 
radial pulse on the two sides. 
Method of Palpation of the Pulse.—Place the 
tips of three fingers upon the radial artery and the 
thumb on the dorsum of the wrist, thus compress 
the artery gently against the smooth anterior 
surface of the lower end of the radius.* The 
subject’s arm and hand should rest comfortably 
on some surface, or his hand be held firmly by the 
examiner’s other hand. 
Palpable Elements of the Normal Pulse.— 
Frequency.—Count the pulsations. The average 
* Some writers state that the examiner’s index finger should 
be placed proximad. PALPATION. 
117 
is seventy-two per minute in a normal adult male 
when at rest; it is a little faster in women, and 
much faster in early childhood. 
Force.—Note carefully the strength of each 
impulse: they should all be the same. 
Rhythm.—They should follow each other with 
uniform intervals. 
Compressibility.—The lumen of the artery should 
be easily obliterated, and the wall of the artery 
should not be palpable between beats. 
Size, Duration.—Each impulse has volume or 
size, taking some time to rise to its full height and 
time to descend; it does not spring up instan- 
taneously nor disappear abruptly when normal. 
Tension.—The artery is felt partially distended 
between pulsations. 
Dicrotism.—The dicrotic wave should not be 
palpable. 
Note.—Any or all of the above may be changed by 
disease of heart and vessels; some of them may be altered 
by excitement or exercise. 
Tracheal tugging, a condition which occurs where 
there is aneurysm of the aortic arch, is a rhythmical 
tug downward of the trachea, synchronous with 
the cardiac systole, the pulse; it may be detected 
in the following manner: 
Have the subject throw his head well back, the 
chin elevated, and head resting against a firm 
support; then if the examiner stands behind the 
subject, with his thumbs applied to either side 118 
INSPECTION, PALPATION, PERCUSSION. 
of the inferior maxilla and gently but firmly 
applies his index and middle fingers to the side of 
the trachea, he will feel the trachea drawn quickly 
down with each contraction of the subject’s 
heart. Do not mistake the pulse in your own 
finger tips for tracheal tugging, as one is liable to 
do. 
Palpation of the Heart and Aorta.—Palpate the 
apex beat gently with the tips of one or two 
fingers to determine the features mentioned for 
inspection. Palpate the precardial area with 
the palm of the hand or with fingers. Palpate for 
the aorta in the second intercostal space just to 
right of sternum. Then palpate for the aortic arch 
with one finger pressed down into the episternal 
notch, while the subject inclines head forward. 
The thoracic aorta is not usually palpable unless 
displaced or dilated from disease. Palpate the 
epigastric region for pulsation. 
If any local bulging is observed, palpate to learn 
if it is hard or soft or fluctuates or whether it 
pulsates, and, if so, whether the pulsation is expan- 
sile with the cardiac systole.* Also note if it is 
enlarged by cough or crepitates under digital pres- 
sure, due to air or gas within it, and whether it is 
tender or not (whether manipulation causes pain). 
PERCUSSION. 
The aorta normally does not alter perceptibly the 
percussion note along its course. If aneurysm of 
* As occurs in a palpable aneurysm. PERCUSSION. 
119 
the aorta exists, it will give dullness to a degree 
and extent in proportion to the size of the tumor. 
The Heart (Area of Absolute Dullness or Flat- 
ness) .—Here the finger (pleximeter) should be 
placed parallel with the sternum at some distance 
from the borders of the heart, and light percussion 
Fig. 27.—Diagram showing absolute dullness and relative 
dullness of liver and heart, and the approximate position of 
interlobular fissures of the lungs—anteriorly. 
applied, with one or two fingers as plessor, then the 
finger (pleximeter) moved in toward the center 
of the cardiac area until the pulmonary resonance 
is replaced by absolute dullness. The area should 
be mapped out above and on both sides, below it 
merges into liver flatness toward the median line. 120 
INSPECTION, PALPATION, PERCUSSION. 
This area indicates that portion of the heart 
which is not covered by lung tissue. In the nor- 
mal, with the subject erect or supine, it is limited 
above by an oblique line from the left fourth costo- 
sternal articulation to the apex beat, on the right 
by the median line and below by a horizontal line 
through the apex beat (see Fig. 27). Although 
it is diminished by pulmonary emphysema and 
by extreme inspiration, it is comparatively easy 
to map out by percussion, and in most cases it is 
more reliable to estimate the size and position of 
the heart from this than by the area of relative 
dullness. 
The area of absolute cardiac dullness may be 
changed in position, shape, or size (increased or 
diminished) by disease of the heart, pericardium, 
or neighboring viscera. SECTION IX. 
AUSCULTATION WITH REFERENCE TO THE 
HEART AND BLOOD VESSELS. 
The stethoscope should be employed in auscul- 
tation of the heart. 
The subject should be standing, sitting, or lying 
flat on his back. 
THE HEART SOUNDS. 
If the stethoscope is placed over the site of the 
apex beat, two sounds are heard: one, the first, 
synchronous with the apex beat, is the loudest, 
lowest in pitch, softest in quality, slightly rumbling 
and longest in duration. After a very short 
period of silence, the short, sharp second sound is 
heard, followed by a longer period of silence. If 
the stethoscope is moved, say one inch at a time, 
toward the base of the heart, the first sound 
becomes less intense as the second sound grows 
more intense, until at the third left costosternal 
articulation, where the second sound is heard 
with greatest intensity. 
The student should listen to these sounds over 
the whole pericardium and over the aorta, in the 
second right intercostal space, until he is familiar 
with their character in every region as well as 
121 122 
AUSCULTATION. 
their duration and rhythm. Listen especially at 
the four points of greatest importance: 
Valve Sound Areas.—The areas on the surface 
of' the chest where the sounds, or elements of 
sounds, originating at the respective valves are 
heard with greatest intensity. They are as fol- 
Fig. 28.—Surface areas where the different valve elements 
predominate in heart sounds. 
lows: Fig. 28.—1. The apex, which is the surface 
center of sound originating at the mitral valve— 
the mitral area. 
2. The second right intercostal space close to 
the sternum—the aortic area. 
3. The second left intercostal space close to 
the sternum—the pulmonary area. THE HEART SOUNDS. 
123 
4. The left sixth costosternal articulation—the 
tricuspid area. 
These are not the anatomical locations of the 
several valves (see Fig. 29), but are approximately 
the surface centers of sounds orignating at the 
respective valves named. 
Fig. 29.—Diagram showing the position of the heart, 
great vessels, and valves. The borders of the lungs are 
indicated by green dotted lines. Note: The arrows indicate 
the direction of normal blood currents at the valves. 
Modification of Heart Sounds by Exercise.—* 
The heart sounds are more intense and higher in 
pitch immediately after vigorous exercise of any 
kind, because the tension of its walls is increased 
by temporary engorgement with blood. 124 
AUSCULTATION. 
Cardiac sounds may be modified in rhythm, 
intensity or by the occurrence of adventitious 
sounds, murmurs. 
Rhythm may be modified as follows: Inter- 
mittent, irregular, gallop rhythm, reduplication, and 
some other varieties of restricted significance0 
Not uncommonly, some of the ventricle con- 
tractions are not of sufficient force to cause a 
palpable pulsation in the radial artery and give an 
erroneous impression of intermittent or abnormally 
slow heart action. 
Intensity.—Both or either one of the heart 
sounds may be increased or diminished in intensity 
by disease. Normally they are heard more intense 
in individuals with thin chest walls, and less intense 
where the chest wall is thick and contains much 
adipose tissue. 
ADVENTITIOUS SOUNDS. 
Murmurs are sounds which accompany or 
replace the normal heart sounds. They may be 
pericardial or endocardial. 
Pericardial murmurs are caused by roughening 
of the pericardial surfaces from disease. They 
occur synchronously with the heart movements, 
are confined to part or all of the precardial area, 
are usually of a rubbing quality, and may be single 
or double. They are most intense during expira- 
tion and are increased if the subject leans forward. 
The usual point of maximum intensity is the left ADVENTITIOUS SOUNDS. 
125 
fourth costosternal articulation, and they are not 
transmitted beyond the limits of the pericardium. 
Endocardial murmurs may be hcemic, valvular, 
or congenital. 
Hcemic murmurs, caused by changes in the 
blood, are systolic in time, accompany and follow 
the first sound, are soft in quality, heard over the 
body of the heart or the great vessels, transmitted 
in the direction of the normal blood current and 
often of greatest intensity over carotid arteries. 
They may be associated with a venous hum heard 
over the external jugular veins and are not asso- 
ciated with change in the size and position of the 
heart unless other disease coexists. 
Valvular murmurs are caused by obstructed or 
abnormal currents of blood as a result of roughen- 
ing or deformity of the valves or orifices from 
disease. 
Note.—Congenital murmurs, which are caused by congenital 
deformity of the heart or the great vessels, will not be discussed 
in this work. 
In order to determine the seat and gross method 
of origin or cause of a murmur, we must observe 
three points: 
(1) Its rhythm (relation to the normal cardiac 
sounds, time). 
(2) The point where it is heard with maximum 
intensity, and 
(3) The direction in which it is best transmitted. 
Rhythm.—In isolating a murmur, we must first 
make sure which is the first and which the second DESCRIPTION OF FIG. 30. 
Diagram showing the relations between the heart sounds, 
muscle contractions, blood currents, position of valves and 
apex, in one complete heart cycle. (Applies to either right 
or left side of heart.) 
A. When the first sound is heard, ventricles contract, 
apex strikes the anterior chest wall, auriculo-ventricular 
valves close, aortic and pulmonary valves open, blood is 
forced into aorta and pulmonary artery, the columns? 
carnse and chordeae tendinae are on tenson and blood flows 
passively into auricles from the veins. 
B. When the second sound is heard, aortic and pulmonary 
valves close, ventricles relax, blood continues to flow pas- 
sively into auricles from veins, auriculo-ventricular valves 
begin to open, apex recedes from chest wall. 
C. Aortic and pulmonary valves remain closed, auriculo- 
ventricular valves open, blood flows passively into ven- 
tricles from auricles and into auricles from veins. 
D. Auricles contract, auriculo-ventricular valves thrown 
wide open, blood flows forcibly from auricles to ventricles, 
ventricles distended, aortic and pulmonary valves remain 
closed. . . . Then the cycle is repeated. Fig. 30.—Graphic illustration of heart sounds and action: Red, muscular element; orange, valvular ele- 
ment; blue, impact of right ventricle against chest wall. 128 
AUSCULTATION. 
sound. This is not always easy in a diseased heart, 
and it is well to run the stethoscope by degrees 
from apex to base and back to apex, moving it an 
inch or less at a time, watching the visible apex 
beat closely all the while. It is obvious that we 
must first be sure with which sound the murmur 
is associated. Here also the student must at 
once acquire the habit of carrying in his mind a 
clear picture of the normal relation of the heart ac- 
tion and the direction of the blood currents to the 
normal sounds throughout auscultation (Fig. 30). 
Murmurs may be caused by a blood current 
passing through an orifice in the normal direc- 
tion (direct) or by a current which leaks backward 
(a regurgitant current) from a ventricle to an 
auricle or from the aorta or pulmonary artery 
to a ventricle (indirect). In either case the mur- 
mur will either immediately precede, accompany 
and follow, or entirely replace one of the normal 
heart sounds. 
The points of maximum intensity of the several 
murmurs are the points on the surface to which 
the vibrations are conducted with least resistance. 
The direction of transmission of every murmur is 
always with the current of blood which produces 
it, whether normal in direction or regurgitant, 
(direct or indirect). 
Note.—A systolic puff is occasionally heard, over the sub- 
clavian artery, and is usually of little or no diagnostic signifi- 
cance ; it usually accompanies either inspiration or expiration, 
and is rarely persistent throughout both. Such a puff is occa- 
sionally a result of distortion of the arterial calibre by adhesive PRACTICAL EXERCISE. 
129 
Fig. 31.—Normal heart sounds and graphic illustration of cardiac 
murmurs, regurgitant, left side: M, Muscular element; V, valvular 
element; I, impact of right ventricle against chest wall. 
bands resulting from tuberculous or other disease at the apex 
of the pleura. 
PRACTICAL EXERCISE, TO BE COMPARED WITH A 
NORMAL SUBJECT. 
Mitral Regurgitant Murmur (Fig. 31): 
Rhythm accompanies and follows the first 
sound (systolic). 
Point of maximum intensity: the apex. 130 
A US'C TJLT ATI ON. 
Direction oj transmission: upward to the left, 
toward the axilla. 
Heard posteriorly, in the left interscapular 
region, over the fifth rib. 
Aortic Regurgitant Murmur (Fig. 31): 
Rhythm accompanies and follows the second 
sound or replacing it (diastolic). 
Point of maximum intensity: third left inter- 
costal space at the border of the sternum. 
Direction of transmission: downward along 
the left border of the sternum. 
Heard at apex. 
Mitral Obstructive Murmur, Direct (Fig. 32): 
Rhythm: immediately preceding, and ending 
abruptly with, the first sound (presystolic). 
Point of maximum intensity: the apex. 
Direction of transmission: confined to the 
region of the apex. 
Palpable thrill: it is this murmur (mitral 
obstructive) which is often associated with a 
presystolic thrill, palpable over the apex. 
Aortic Obstructive Murmur, Direct (Fig. 32): 
Rhythm accompanies and follows the first 
sound (systolic). 
Point of maximum intensity: right second 
intercostal space at the border of the sternum. 
Direction of transmission: upward into the 
great vessels. 
Right side murmurs corresponding to the above 
are differentiated from them by their points of 
maximum intensity and the directions in which PRACTICAL EXERCISE. 
131 
Fig. 32.—Direct cardiac murmurs, left side: M, Muscular element; 
V, valvular element; I, impact of right ventricle against chest wall. 132 
AUSCULTATION. 
they are transmitted. The rhythm is obviously 
the same on the two sides (Fig. 33). 
Fig. 33.—Right side murmurs: M, Muscular element; V, valvular ele- 
ment; I, impact of right ventricle against chest wall. SECTION X. 
THE ABDOMEN. TOPOGRAPHICAL ANATOMY 
AND GENERAL RULES GOVERNING 
PHYSICAL EXAMINATION 
OF THE ABDOMEN. 
ABDOMINAL LANDMARKS. 
The xiphoid cartilage, 
Tip of the ninth costal cartilage, 
Inferior border of the tenth costal 
cartilage, 
Chest of the ilium, highest point, 
Anterior superior spine of the ilium, 
Poupart’s ligament, 
Symphisis pubis. 
Fixed 
Landmarks 
Movable 
Landmarks 
Umbilicus, 
External border of rectus muscle. 
Lines. 
1. Subcostal line, through inferior 
border of the tenth costal car- 
tilage. 
2. Intertubercular, through highest 
point of crest of ilium. 
Besides the Median Line: 
Horizontal 
Lines 
Through the 
middle of 
Poupart’s 
ligament. 
Vertical 
Lines 
1. Right Poupart line 
2. Left Poupart line 
133 134 
THE ABDOMEN. 
Regions.—The surface of the abdomen is thus 
divided into nine regions, namely, from above 
downward: 
Fig. 34.—Regions of abdomen (after Le Fevre). CONTENTS OF THE ABDOMEN. 
135 
Centrally—i epigastric, i umbilical, and i 
hypogastric. 
Laterally—2 hypochondriac, 2 lumbar, 2 iliac 
(see Fig. 34). 
TABLE OF UNDERLYING CONTENTS OF REGIONS OF 
THE ABDOMEN. 
Right Hypochondriac 
The liver. 
The gall-bladder. 
The hepatic flexure of 
the colon. 
The right kidney. 
Epigastric 
The stomach. 
The liver. 
The transverse colon. 
The omentum. 
The pancreas. 
The duodenum. 
Both kidneys and 
suprarenal capsules. 
The coeliac axis. 
The aorta. 
The posterior extrem- 
ity of the spleen. 
Lymph nodes. 
Left Hypochondriac 
The spleen. 
The stomach. 
The pancreas. 
The splenic flexure of 
the colon. 
The left kidney. 
The left extremity of 
the liver. 
Right Lumbar 
The ascending colon. 
The right kidney. 
The small intestine. 
Umbilical 
The transverse colon. 
The omentum. 
The duodenum. 
The small intestine. 
Right kidney (left kid- 
ney occasionally). 
The aorta. 
Lymph nodes. 
Left Umbilical 
The descending colon. 
The omentum. 
The left kidney (occa- 
sionally). 
The small intestine. 
Right Inguinal 
{or Iliac) 
The caecum (the origin 
of the appendix is 
behind the right Pou- 
part line). 
Hypogastric 
The small intestine. 
The sigmoid flexure 
(the bladder in chil- 
dren or if greatly- 
distended, and the 
uterus in pregnancy). 
The caecum. 
Lymph nodes. 
Left Inguinal 
{or Iliac) 
The sigmoid flexure. 136 
THE ABDOMEN. 
SURFACE MARKINGS 
of Some Viscera or Parts of Viscera of Special Importance 
in Physical Exploration. 
Cardiac Orifice of Stomach.—Seventh costo- 
sternal articulation, left side. 
Pylorus.—Just to right of median line, i 1/4 
inches above the subcostal line.* 
Inferior Border of Stomach.—About 1 inch above 
the subcostal line (it is lower when distended). 
Inferior Border of Liver.—Approximately a line 
from the lower extremity of the right costal margin 
to a point 1 inch below the left nipple. 
Gall Bladder.—Where Poupart’s line crosses the 
right costal margin (i.e., the angle formed by the 
outer border of the rectus muscle and the free 
border of the ribs. Also near the tip of the ninth 
rib, right side). 
The Spleen.—Between the ninth and twelfth 
ribs—left side, parallel with the tenth rib. It does 
not project beyond the costal margin. 
Kidneys.—The epigastric region contains most 
of both, deep, against the posterior abdominal 
wall. The right kidney is the lower and projects 
slightly into the umbilical region; the left to, or a 
little below the subcostal line. 
Head of the Pancreas.—Just to the right of the 
median line and just above the subcostal line. 
The Duodenum.—Beginning at the pylorus, 
* Many x-ray photographs of the stomach containing bismuth 
show the pylorus displaced downward. Sometimes it is found 
on a level even below the umbilicus. This is not normal. SURFACE MARKINGS. 
137 
it embraces the head of the pancreas to right and 
below, ending nearly an inch above the subcostal 
line just to left of the median line; its lowest or 
Fig. 35.—Diagram showing the position of the super- 
ficial abdominal viscera and the vermiform appendix. 138 
THE ABDOMEN. 
middle section lying in the extreme upper portion 
of the umbilical region. 
The Ccecum.—Chiefly in the right iliac region. 
Fissure. 
Inferior border of lung 
(descends with 
inspiration). 
Spleen (descends 
with inspiration). 
Pleural reflection. 
Fig. 36.—Diagram showing the position of the inter- 
lobular fissure, the inferior border of the lung, and the 
pleural reflection, laterally (similar in both sides), and the 
position of the spleen. INSPECTION OF THE ABDOMEN. 
139 
Base of the Appendix.—On the right Poupart 
line, i 1/4 inches below the intertubercular line 
(i.e., the mid-point in a straight line connecting 
the anterior superior spine of the ilium with the 
umbilicus in the average abdomen. 
The Coeliac Axis.—About the centre of the 
epigastric region. 
The Bifurcation of the Abdominal Aorta.—About 
the centre of the umbilical region. 
INSPECTION OF THE ABDOMEN. 
On inspection the normal abdomen varies 
greatly in contour with the individual—sex, age, 
and amount of adipose tissue being important 
factor which control the normal contour within the 
limits of health. The position of the subject 
controls the contour especially in those with loose 
or fat abdominal walls. The general and detail 
contours of the normal can only be learned by 
practical observation. When the average subject 
reclines upon his back, the contour in the erect 
posture is fairly well maintained, but in those with 
loose, flabby, and fat abdominal walls, the centre 
of the abdomen is flattened and the sides bulge. 
The umbilicus in the average subject occupies 
nearly the centre of the umbilical region, but falls 
much lower in those with loose, flabby abdominal 
walls. 
The borders of the recti muscles are only visible 
in those with moderate or little adipose tissue; the 
prominence of these muscles in health is usually 140 
THE ABDOMEN. 
in proportion to the general muscular develop- 
ment of the subject. They will stand out more 
prominently if we ask the subject to try to raise 
his chest up from the surface upon which he lies, 
while his lower extremities are held extended. 
The respiratory movements of the abdomen must 
be observed. The upper portion of the abdomen 
should rise and fall evenly with respirations, more 
in men than women. Although the liver, stom- 
ach, and spleen descend with inspirations, their 
change of position cannot be seen in the normal 
subject. 
The pulsations of the abdominal aorta may be 
seen when the abdominal walls are very thin and 
flabby. 
PALPATION OF THE ABDOMEN, 
The subject should lie upon his back, his thighs 
flexed, and he should breathe naturally. In the 
normal subject, palpation is negative; none of the 
abdominal viscera is palpable in health, except 
the abdominal aorta, which may be palpated; 
its pulsations being very easily felt in thin sub- 
jects with flabby abdominal walls, where it is 
occasionally mistaken for abdominal aneurism. 
The pelvic organs are palpable by vaginal or 
rectal examination only. 
PERCUSSION OF THE ABDOMEN. 
The subject should lie upon his back. The 
liver, spleen, stomach when distended with gas, PERCUSSION OF THE ABDOMEN. 
141 
the urinary bladder when distended, and the 
gravid uterus are the only abdominal organs 
which can be mapped out by percussion in the 
normal subject. 
To percuss for the spleen the subject must lie 
on his right side if recumbent. 
Auscultation reveals nothing in the average 
normal abdomen. SECTION XI. 
SPECIFIC RULES GOVERNING PHYSICAL 
EXAMINATION OF THE ABDOMEN. 
INSPECTION. 
Contour.—Note whether normal or distended; 
its shape if distended, whether dome-like (due to 
Fig. 37.—Normal abdomen. 
Note the subcostal depression 
and muscle outlines. 
Fig. 38. — Abdomen dis- 
tended by gas. Note the 
dome shape. 
gas) (see Fig. 38), or flat centrally with bulging 
sides (due to fluid or fat flabby walls) (see Fig. 
37); whether the rectus muscle is more prominent 
on one side than the other as occurs in localized 
peritonitis and is so commonly observed in cases 
of appendicitis. 
Superficial veins, if prominent, which group, 
142 INSPECTION. 
143 
the central (due to obstruction to portal vein) or 
the lateral (due to obstruction to the vena cava), 
or both (due to obstruction of the vena cava and 
portal vein), as seen in some abdominal tumors 
and where there is a great accumulation of fluid 
in the peritoneal cavity (ascites). 
The umbilicus, whether depressed or protruding, 
with a cluster of distended veins about it—caput 
medusae (seen in portal obstruction). 
Note whether there is any localized prominence, 
mass, or protrusion at any point and, if so, whether 
it moves with respiration. Tumors of liver, spleen 
Fig. 39.—Abdomen distended by fluid in the peritoneal 
cavity. Note flattened top and bulging sides. 
and stomach, and other loosely attached tumors 
in the upper part of the abdomen may descend 
with inspiration. 
Whether there is any visible pulsation, its site 
and charcter, if observed. 
Intestinal Peristalsis.—Is intestinal peristalsis 144 
EXAMINATION OF THE ABDOMEN. 
visible ? If so, in what regions and to what degree ? 
Note carefully the direction and limits of the 
movements. This may help determine the pres- 
ence and location of intestinal obstruction in 
some cases. Are the lower intercostal spaces 
and costal margin equally prominent on the two 
sides? (Liver abscess may render the right 
hepatic area prominent, causing the lower inter- 
costal space to bulge.) 
PALPATION. 
Be sure your hand is not cold. Lay your hand 
on gently and first compare the muscle tonicity or 
rigidity on both sides (especially of the recti 
muscles); they should be equal. Then with 
gentle pressure search the entire surface for any 
abnormal mass or resistance. Then apply mod- 
erate pressure with the two fingers or thumb 
in the nine regions to learn the absence or presence 
of undue tenderness (the epigastric region may 
be slightly tender without the presence of 
disease). 
Then palpate for abnormal mobility or enlarge- 
ment of liver, spleen, and kidneys. For the liver 
and spleen, place the fingers of one hand evenly 
about two inches below the costal margin in the 
proper region, press first backward and then up- 
ward beneath the costal border during expiration. 
Then the subject should take a deep breath while 
the pressure is applied; this forces the liver and 
spleen downward, but they must be enlarged or 
displaced to be felt. PALPATION. 
145 
In palpating for some deep structures, such as 
kidneys or spleen, or deep abdominal tumors, con- 
siderable pressure is required. In such instances, 
lay the hand on lightly and increase the pressure 
very gradually. Where great force is needed, the 
tactile sense of the palpating fingers will remain 
more acute if the required pressure is applied by 
superimposing the fingers of the free hand upon 
the palpating fingers. 
I give here a method of palpating an enlarged or 
depressed liver, when the abdominal walls are 
tense from fluid or gaseous distention of the abdo- 
men, which has proven of service to me in some 
cases. 
In the condition mentioned, when the anterior 
surface of the liver is smooth and its lower portion 
thin, the usual method—pressing the fingers in 
more or less gradually—will reveal nothing in 
most instances, because the lower portion of the 
liver, that portion below the costal margin, recedes 
so easily. This is specially true when the liver 
floats in ascitic fluid. The steadily increasing 
resistance of the overstretched abdominal parietes 
as we increase our pressure, renders the sense of 
touch in the palpating fingers less acute. 
In such a case, if we lay the tips of the fingers 
on the surface, below the free border of the ribs, 
without pressure, and suddenly jab them in with 
moderate force, the impact with the surface of the 
liver is felt distinctly (Fig. 40); the liver recedes 
promptly; but by repeating the above over various 
neighboring places, we easily determine the margin 146 
EXAMINATION OF THE ABDOMEN. 
of the liver. The fingers must be raised com- 
pletely between each jab, to allow the liver and 
abdominal wall to resume their former relations. 
Fig. 40.—To palpate the liver; one quick jab in direction of 
arrow. 
This same method may be applied to the palpa- 
tion of other solid and movable abdominal organs 
or tumors. 
To palpate for the kidneys, stand on the side 
palpated; place the left hand behind, just below 
the ribs and press forcibly forward, with the right 
hand in front at the upper boundary of the lumbar 
region; press moderately under the costal margin 
and have the subject take a deep breath. If the 
kidney is movable or enlarged, it may be felt 
to descend with inspiration, but in most cases it 
is more distinctly felt, as it glides up from under 
the fingers, with expiration. The right kidney is 
more often palpable than the left; neither is 
palpable when absolutely normal. PALPATION. 
147 
Then palpate carefully any abnormal mass, 
if one is detected, to determine its size, shape, 
mobility (with respiration or by your hand), and 
character, also to which abdominal organ it is 
attached or is part of. Note whether hard or soft, 
smooth, rough, nodular, or furrowed; whether it 
fluctuates or pulsates with the heart beat; if it 
pulsates grasp it cautiously to learn whether the 
pulsation is expansile (suggesting aneurysm) or 
only projectile. New growths and inflamma- 
tory masses may be any shape, although the 
shape of a mass may be significant; for instance, 
a sausage-shaped mass suggests intussusception. 
Surface Veins.—If the surface veins are distended, 
we should apply digital pressure to them in order 
to make sure the direction of their flow; this will 
help to determine the site of the obstruction caus- 
ing their distention. 
Abdominal Distention.—If there is abdominal 
distention, palpate to detect absence or presence of 
fluid in the peritoneal cavity,* with the subject 
on his back. Apply the palm of one hand to the 
side of the abdomen in the lumbar region and tap 
the opposite side with the fingers of the other hand 
several successive blows. If there is fluid, a wave 
is felt by the hand that rests on the opposite wall, as 
a quivering impact following each succeeding blow. 
To avoid confusion by a wave which may be 
transmitted across a fat abdominal wall, a third 
hand should be pressed gently (by an assistant); 
its ulnar side applied vertically in the median line. 
* Ascites. 148 
EXAMINATION OF THE ABDOMEN. 
PERCUSSION. 
With alternating strong and light percussion 
strokes percuss down the entire length of the abdo- 
men, in the median line and on either side, noting 
the variation of sounds elicited; there should be 
various degrees of tympany in all parts. The 
tympany is more marked where the viscera are 
distended with gas and the note duller according 
to the absence of gas beneath. 
Keep in mind the anatomical position and 
limits of the several viscera as you proceed. 
Then, by percussion, mark the limits of the solid 
viscera, liver and spleen and any masses detected 
(by dullness present in an unusual position). A 
large solid organ or mass (solid or fluid) in apposi- 
tion to the abdominal wall, as well as fluid in the 
peritoneal cavity, yields a flat note on percussion. 
A small mass or organ yields a dull or dull 
tympanitic note. 
The stomach and intestine when they contain 
gas yield a tympanitic note. 
A mass covered by gas containing viscera yields 
a dull note on strong or forcible percussion. A 
light stroke over the same area yields a tympanitic 
note. 
Forcible percussion over the spleen yields dull 
resonance, called dullness. Percussion of the 
spleen is not satisfactory in many cases, because 
this organ lies between the resonant lung without 
and tympanitic stomach within. AUSCULTATION. 
149 
The distended bladder and the gravid uterus give 
a flat note on percussion over them. 
The pancreas and kidneys do not affect the 
percussion note when normal. When the kidney 
is greatly enlarged, a path of tympany may be 
elicited over it along the course of the colon. This 
is not the case where the spleen is enlarged, as it 
is in contact with the abdominal wall throughout. 
Gas free in the abdominal cavity yields a tym- 
panitic note over the entire surface; tympany 
supplanting the usual liver dullness. (This is 
observed in most cases where there is perforation 
of the intestine.) 
As the fundamental quality of all percussion 
sounds of the normal chest is pulmonary reso- 
nance, so is tympany the fundamental quality of 
all percussion sounds of the normal abdomen. 
This quality, tympany, is normally present in 
all abdominal percussion sounds, in varying 
degrees; in some localities the tympanitic element 
being very slight, for instance over the liver 
where it can scarcely be detected at all, especially 
when the colon and stomach contain little or no 
gas. 
Over the stomach, caecum, ascending and 
descending colon, we usually elicit the greatest 
degree of tympany in the normal abdomen. 
AUSCULTATION. 
Auscultation is not usually applied in the 
routine physical exploration of the abdomen. 150 
EXAMINATION OF THE ABDOMEN. 
Over an abdominal aneurysm we may detect the 
sounds characteristic of this condition (aneurys- 
mal bruit). In rare instances peritoneal friction 
sounds are heard over intra-abdominal growths. 
We may listen to detect the sounds caused by 
abnormal movement of intestinal gas, which 
occurs in some pathological conditions, which 
will not be considered herein. 
In pregnancy the foetal heart beats may be 
heard and counted by the eighteenth or twentieth 
week of pregnancy. 
The uterine bruit, a blowing sound synchronous 
with the maternal pulse, may be heard by the 
fourth month of pregnancy. 
Haemic murmurs may be heard over the ab- 
dominal aorta in anaemic subjects with thin 
abdominal walls, and should not be mistaken 
for aneurysmal bruit, which exists when aneu- 
rysm of the abdominal aorta is present. 
In some cases of peritonitis a friction rub is 
heard, with respiratory and forced movements. 
Finally, it must be said that no routine physical 
examination is complete without searching for 
spinal tenderness by pressure upon the vertebrae. 
Examination of the lower extremities by in- 
spection and palpation for skin changes, condition 
of superficial veins, the arteries, joints, muscles, 
and tendon reflexes. It is also advisable to 
inspect the external genitals and anus, and pal- 
pate for lymph-nodes above and below Poupart’s 
ligament on both sides. SECTION XII 
BLOOD-PRESSURE AND THE SPHYGMOMAN- 
OMETER 
The term blood-pressure, through custom and 
usage, has come to mean arterial pressure, usually 
that of the brachial or radial arteries, vessels 
which are convenient for estimations. Measure- 
Fig. 41.—Where A represents the output of the heart per 
minute; B, the elastic recoil of the arterial wall, and C, the op- 
position to the arterial flow. The combined effect of these 
forces produces the arterial pressure. 
ments, however, have been made for other arteries, 
as well as for capillaries and veins, the greatest 
pressure being found in the large arteries near 
the heart, as the carotid, less in the medium 
sized, as the radial, much less in the capillaries, 
while in the large veins of the neck the pressure 
may be negative. 
151 152 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
Arterial Pressure.—In its practical application 
the arterial pressure is the one that is almost 
exclusively used. In simple terms, an artery may 
be likened to a piece of elastic rubber tubing 
and the forces concerned in producing the press- 
ure may be diagrammatically represented thus: 
ANALYSIS OF FORCES 
A. Output of Heart.—It is readily apparent that 
the amount of blood per minute that is being 
sent into an artery and the force with which it is 
driven are important factors in causing the press- 
ure. The output depends upon (i) the amount 
of blood available for each contraction of the 
ventricle; (2) on the ventricular rate; (3) the 
capacity of the ventricle; and (4) on the force 
of its contractions. 
1. Amount of Blood.—The amount of blood 
that is returned to the left ventricle depends on 
various factors, among which are the rate of the 
return flow in the veins, which, in turn, is de- 
pendent upon the degree of patency of the ar- 
terioles and capillaries; upon the rate of blood- 
flow through the lungs; upon the presence or 
absence of obstruction at the mitral valve; 
and upon the presence or absence of the au- 
ricular systole (it is absent in auricular fibril- 
lation) . 
Note.—For a full description the reader is referred to works 
on physiology. ANALYSIS OF FORCES. 
153 
2. Rate of the Heart.—Other things being equal, 
a heart beating at the rate of 90 per minute will 
propel more blood into the arteries than one 
beating at 60 per minute; in other words, will 
have a greater output per minute. 
3. Capacity of the Left Ventricle.—The more 
blood the ventricle holds, the more will it be 
able to expel. The blood-pressure in the male 
is slightly higher than in the female, and one of 
the factors is the greater capacity of the ventricle 
in the male. In aortic regurgitation, where the 
capacity of the ventricle is materially increased 
(the expelling force is also increased) we find the 
arterial pressure markedly raised. 
4. Force of Ventricular Contractions.—The more 
forceful the contraction, the greater will be the 
pressure. In strong, athletic men, due to more 
forceful contractions, the arterial pressure is 
found to be slightly above the average. It was 
seen above that in aortic regurgitation, with 
hypertrophy of the left ventricle, there was an 
increase of pressure partly due to more forceful 
contractions. In that condition of irregular 
heart known as auricular fibrillation some of 
the ventricular contractions are so weak that 
the force is insufficient to open the aortic valves. 
B. The Elastic Recoil of the Arterial Wall.— 
In the walls of the arteries, especially in the 
larger ones, in contradistinction to the veins, 
there is a considerable amount of elastic tissue, 
which when stretched will recoil, and within cer- 154 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
tain limits the greater the stretching, the greater 
the recoil. The artery is most stretched, of 
course, when most filled, which is just at the end 
of systole, so that during diastole this force of 
elastic recoil is available for propelling the blood, 
acting as an adjunct to the heart. It is to be 
remembered that the function of the arterial 
pressure is the carrying of blood to all the tissues, 
and supplying their needs, and when this is 
satisfactorily done the circulation is said to be 
efficient. If for some reason the elastic recoil of 
the arteries were impaired, an increase of pressure 
would be necessary to maintain the circulation 
as efficient. In old age the elasticity of the 
arterial wall is impaired, and an increase of press- 
ure (within limits) ensues, which is to be re- 
garded as compensatory. 
C. The forces, represented in the diagram by 
C, oppose the arterial flow, and consist of (i) 
the peripheral resistance (denoted in the dia- 
gram by narrowing of the tube) and (2) the 
viscosity of the blood. 
1. Peripheral Resistance.—This is an important 
factor in the production of arterial pressure, and 
there is some difference of opinion whether the 
retardation of the flow occurs in the arterioles 
or in the capillaries. Starling holds that it is 
very largely in the arterioles. Some recent views 
tend to the belief that the capillary resistance 
may play quite an important role. Probably 
both factors are concerned. ANALYSIS OF FORCES. 
155 
The arterioles have nerve connection with the 
vasomotor center in the medulla, and their con- 
dition of constriction is regulated through the 
center. The mechanism of capillary constriction 
(whether central or automatic) is not definitely 
determined. Carbon dioxid and lactic acid, the 
result of metabolic processes, cause ready dila- 
tation of the capillaries. 
2. Viscosity of the Blood.—The higher the 
viscosity, the more friction will be offered in 
the passage of the blood through the arterioles 
and capillaries, and hence a greater resistance 
to the flow. Carbonic acid increases and oxy- 
genation diminishes the viscosity of the blood. 
The resultant of these various forces, described 
above, is the arterial blood-pressure. 
Relationship of Forces.—It was previously 
pointed out that in advanced years there is a 
lessening or impairment of the elasticity of the 
arterial wall, but this is a very gradual process 
over a period of years, so that from week to 
week there is no appreciable difference. There- 
fore for practical considerations the elastic re- 
coil of the artery may be regarded as a constant. 
However, the other factors concerned in the main- 
tenance of arterial pressure are subject to ready 
change, and it would be natural to conclude 
that with so many variables involved, the re- 
sultant (pressure) would be anything but fixed 
and uniform. There is, however, a regulating 
mechanism, so that when any force becomes un- 156 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
duly active in raising the pressure, counter-in- 
fluences are brought to bear with a lowering 
effect, and thus the pressure is more or less stabil- 
ized. It is to be pointed out that fluctuations 
of pressure, within limits, do occur which are 
physiologic and not indicative of disease. 
Effect of Exercise on Pressure.—A brief ex- 
amination of the sequence of events induced by 
exercise will disclose the interaction of the various 
forces and the manner of stabilizing the pressure. 
During quiet periods the amount of blood flowing 
to the left ventricle does not quite fill it to ca- 
pacity, so that the output for each contraction 
is not the maximum. The mental attention, in 
preparing for exercise, as awaiting the word “go” 
in a foot-race, initiates the change. This mental 
process, through reflex action, stimulates the 
adrenal secretion, which causes splanchnic con- 
striction, and a greater return flow to the ventricle 
with capacity filling. When the amount of return- 
ing blood becomes greater than will fill the ven- 
tricle, there follows a rise of pressure in the great 
veins next the heart. This reflexly, by inhibiting 
the vagus and stimulating the sympathetic, will 
quicken the heart-beat. The cardiac output is 
thus increased in two ways, viz., by a larger out- 
put at each contraction and by an increase in 
the number of contractions per minute. Increased 
output causes a rise of arterial pressure. As a 
result of exercise there is produced in the muscles 
carbonic acid and lactic acid, which, as we have ANALYSIS OF FORCES. 
157 
seen, cause a dilatation of the arterioles and capil- 
laries, with a lowering of the pressure. The arterial 
blood, during exercise, is somewhat better oxy- 
genated than during repose, reducing the vis- 
cosity and thus lowering the pressure. Thus we 
see that forces are brought to bear which are 
mutually corrective, and tend to stabilize the press- 
ure. During exercise we find that the pressure is 
first raised, that later it begins to fall, and that 
after the exercise it may reach a point below the 
starting-point, depending somewhat on the severity 
and duration of the exercise. 
Note.—For a full description the works on physiology must 
be consulted. 
Systolic and Diastolic Pressures.—The pressure 
in the aorta is highest immediately following sys- 
tole, when the ventricular contraction has driven 
a volume (about 60 c.c.) of blood into the aorta. 
This is known as the systolic pressure. There is 
then a gradual fall, the minimum being reached 
at the end of diastole. This is known as the dias- 
tolic pressure. The difference between the sys- 
tolic and diastolic is spoken of as the pulse press- 
ure. Measurements of blood-pressure usually 
include both systolic and diastolic readings. 
Measurements of Blood-pressure.—The sim- 
plest way of estimating the arterial pressure is 
with the finger. The radial artery is compressed 
with the tip of the index-finger against the radius 
until pulsation ceases. The amount of force 158 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
required to obliterate the pulse can be gauged, 
and constant practice will educate the palpating 
finger until tolerably accurate estimations may be 
made. It is, however, difficult to convey to 
another any accurate quantitative idea by this 
method. Care must be taken to exclude any 
reflux wave from the palmar arch. Pressure made 
distally by another finger will prevent this. 
Instruments.—The first measurements with an 
instrument were made by inserting a cannula 
into an artery, and connecting the cannula with 
a mercury manometer. This was done largely 
in animals and occasionally in man just before 
the amputation of a limb. The measurements 
are absolutely accurate, but the method, of 
course, is clinically impracticable, von Basch, 
using a bulb instrument on one femoral of a dog, 
and the cannula method on the other, made 
simultaneous readings and found they coincided, 
and thus was the first to introduce a practical 
sphygmomanometer. 
Bulb Sphygmomanometer.—von Basch’s in- 
strument consists of a small rubber bulb filled 
with air and connected by tubing with a manom- 
eter (either mercurial or aneroid). The rubber 
bulb is placed over an artery (most easily the 
radial) and pressure is made on the bulb until 
pulsation in the artery is obliterated. The press- 
ure communicated to the manometer is then 
read off. Numerous modifications of this instru- 
ment have been made, von Basch’s, however, ANALYSIS OF FORCES. 
159 
will serve as a type of instrument for compressing 
single arteries. For accurate results extreme care 
must be used in applying the bulb instrument. 
Band Sphygmomanometer.—With the band 
type (the one used almost exclusively in this 
country) a limb is compressed, the upper arm 
usually being selected. The band or armlet con- 
sists of a flat rubber bag covered with canvas or 
some unyielding substance, and connected with 
a bulb or small metal air pump, with which it 
may be inflated, and also with a manometer, 
which may be mercurial or aneroid. A valve is 
placed conveniently close to the air pump, so that 
air may be allowed to escape very gradually, and 
the pressure in the armlet regulated with accuracy. 
The armlet should be not less than 12 cm. in 
width. In taking the pressure the patient should 
be comfortably seated and reassured, as anxiety 
in nervous individuals may elevate the pressure. 
The armlet is then applied snugly to the arm 
above the elbow, and the pressure in the armlet 
gradually raised until the radial pulse is obliter- 
ated. The height of the mercury column is read 
off in millimeters and the blood-pressure in the 
brachial artery is expressed in millimeters of mer- 
cury. 
Auscultatory Method.—In the above method 
the closure of the brachial artery (systolic pressure) 
was denoted by the absence of the radial pulse 
at the wrist. In the auscultatory method a 
stethoscope or phonendoscope is placed just 160 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
below the armlet and the pressure gradually 
raised as before. 
As the pressure is raised there will come a 
place at which a faint sound is heard, and as the 
Fig. 42.—Auscultatory method of determining blood-pressure. 
pressure is increased the sound becomes louder, 
until, with still more pressure, the sound ceases. 
The upper limit at which the sound disappears 
corresponds with the systolic pressure; the lower 
limit, approximately with the diastolic. ANALYSIS OF FORCES. 
161 
Note.—The sound heard below the armlet is not uniform, 
but passes through successive changes as the pressure is altered. 
These changes comprise five phases: i. The appearance of a 
clear sound (thud) which lasts for a fall of about 14 mm. of 
mercury. 2. The sound becomes longer in duration with the 
quality of a murmur, and persists for a fall of about 20 mm. 
3. The murmur quality is lost, and a louder sound is heard, over 
a further fall of 25 mm. 4. Marked muffling of sounds over a 
fall of 5 to 6 mm. 5. The disappearance of the sound. Some 
observers take the beginning of the fourth phase as the equiva- 
lent of the diastolic level; others, the end of the fourth phase. In 
some cases the distinction between the third and fourth phases 
is not evident, and the beginning of the silence is then used. In 
aortic regurgitation the fourth phase may be continued down 
to 5 or o mm. of mercury pressure, and then the beginning of 
the fourth phase must be used. 
Measurement of Diastolic Pressure by Oscil- 
lations.—It was stated previously that the sys- 
tolic pressure was the highest pressure in the 
artery immediately following the cardiac systole, 
and that the diastolic was the minimum pressure 
at the end of diastole. There is; therefore, a rise 
and fall alternately of pressure, which may be 
noted in the mercury column, and since the dias- 
tolic is the minimum pressure, it will be denoted 
when the oscillations are greatest. Any pressure 
above the diastolic would lessen the extent of 
the oscillations. Instruments have been devised 
by which the oscillations can be graphically re- 
corded and measured, and the pressure noted for 
maximum oscillations. 
In a general way the systolic pressure depends 
upon the cardiac output and the diastolic upon 162 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
the degree of contraction of the arterioles and 
capillaries. They are, however, in a measure 
mutually dependent. 
Normal Systolic Pressure.—There is no fixed 
standard for the normal pressure, but within 
limits, for various ages, certain approximations 
have been made. The pressure varies, too, with 
the weight of the individual, increasing with the 
weight. 
The greatest amount of collected data has 
been furnished by the life insurance companies, 
and some of their results are here given in table 
form: 
Systolic 
Age. 
Low. 
High. 
Average. 
15-20 years 
114 
131 
1235 
20-30 “ 
117 
131 
1245 
30-40 “ 
Il8 
132 
125 
40-50 “ 
135 
130 
50-60 and over 
X40 
135 
These statistics are for presumably healthy 
persons. Life insurance examiners regard with 
suspicion a systolic pressure of 140 mm. in a per- 
son under forty years of age, and 145 at any age 
is held to be pathologic. While these findings 
cannot be ignored, the medical profession is dis- 
posed to consider the limits for health, set by 
the insurance experts, as too rigid and restricted. 
Several formulae for estimating blood-pressure 
have been advanced, as (1) the age plus 100; (2) 
120 mm. being the normal pressure for a person ANALYSIS OF FORCES. 
163 
of 20; i mm. is added for each year (others say 
i mm. for each two years). 
As previously stated, there are numerous in- 
fluences, some but poorly understood, that may 
affect one or other of the forces concerned in 
the maintenance of blood-pressure, so that it 
seems unwise to too definitely fix the limits of 
physiologic systolic pressure. 
Lauder-Brunton says that in advanced years 
pressures of 150 or higher are met with in ap- 
parent health. 
Normal Diastolic Pressure.—In healthy in- 
dividuals, at least, the diastolic pressure varies 
much, as does the systolic, and for various age 
periods has a proportionate increase. What was 
said concerning the limiting too narrowly the 
systolic pressure is equally applicable to the 
diastolic. A diastolic pressure of 95 mm. is re- 
garded unfavorably by the insurance examiners. 
TABLE OF DIASTOLIC PRESSURES 
(Compiled by Insurance Examiners) 
Age. 
Low. 
High. 
Average. 
x 5-20 years 
75 
84 
79 
20-30 “ 
77 
86 
81 
30-40 “ 
79 
88 
83 
40-50 “ 
89 
85 
50-60 and over 
82 
90 
87 
High Blood-pressure. — Reference has been 
made to the effect of exercise upon the pressure. 
Emotions of various kinds, especially anger and 
fear, elevate the pressure. 164 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
Note.—Emotions, particularly anger and fear, often initiate 
violent exercise, and so the pressure is already being raised 
before the exercise begins. 
In old age there is a raising of the pressure, 
and, as was pointed out, within limits, it is com- 
pensatory. The pathologic conditions promi- 
nently associated with arterial hypertension are 
chronic Bright’s disease and arterial sclerosis. 
Two somewhat opposed views relating to the 
heightened pressure may be briefly summarized. 
The first is that a poison (metabolic or other- 
wise) acting on the vasomotor center causes 
a constriction of the arterioles and capillaries, 
and there ensues a rise of blood-pressure. The 
arterioles and capillaries (and finally the ar- 
teries) thus subjected to pressure, undergo a 
thickening of their muscular coat, which, in turn, 
causes a further rise of pressure, and thus a 
vicious circle is established. A second view is 
that the thickening of the arterioles is primary, 
and that these thickened arterioles, by obstruct- 
ing the arterial flow, produce a hypertension 
which, in turn, causes further thickening. It is 
a matter for future investigations to determine. 
Cerebral compression, as in apoplexy, causes 
a rise in pressure. 
Low Pressure.—A lowering of the blood-press- 
ure is met with in shock and syncope; after hem- 
orrhage, and following exhausting diseases, as 
typhoid and influenza. Low pressure is found 
early in pulmonary tuberculosis, and in tuber- ANALYSIS OF FORCES. 
165 
culosis of the adrenals (Addison’s disease) ex- 
ceedingly low pressures are common. Excessive 
use of tobacco (in small amounts it may cause 
an elevation) is sometimes associated with low 
blood-pressure. A condition met with chiefly 
in women, in which asthenia, visceroptosis, and 
low blood-pressure are associated, is not infre- 
quent. 
In cardiac disease, when dilatation occurs, a 
drop in pressure frequently ensues. However, 
when cardiac decompensation occurs without 
dilatation, there may occur an elevation (as- 
phyxial rise) of the pressure. 
Occasionally low pressures (90 to 100 systolic) 
are seen in healthy persons. 
Note.—For a full consideration of high and low pressures 
the reader is referred to more complete works. 
Pulse Pressure.—The difference between the 
systolic and diastolic pressures is known as the 
pulse pressure. This is not an actual force, but 
merely the relationship of two forces—in a sense 
the relationship of the strength of the heart to 
the resistance to be overcome. A mathematical 
ratio commonly given for expressing this re- 
lationship is 3:2:1—denoting the systolic, dias- 
tolic, and pulse pressures respectively. A systolic 
pressure of 120 mm., a diastolic of 80 mm., and 
a pulse pressure of 40 mm. represent the above 
ratio. It is frequently found, however, that 
this 3:2:1 ratio is not maintained, and attempts 166 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
have been made to deduce the condition of the 
heart and peripheral circulation from the dis- 
ordered ratios, it being held that a large pulse 
pressure indicated a strong heart, and a low 
pressure a weak one. However, it is readily ap- 
parent that a long diastolic period (slow heart) 
allowing a more complete emptying of the ar- 
teries into the veins will be associated with a 
low diastolic pressure, and, in consequence, with 
a greater pulse pressure. Conversely, a rapid 
heart will have a small pulse pressure. Other 
variable factors are concerned and deductions 
from pulse pressure variations are to be drawn 
with considerable reserve. At most they are to 
be regarded as general indications. 
The condition most prominently associated 
with a large pulse pressure is that of aortic re- 
gurgitation. In this condition the cavity of the 
left ventricle is enlarged, i.e., its capacity is in- 
creased, and its walls are hypertrophied, and 
hence its expelling power is enhanced. In 
consequence, a greater quantity of blood is 
driven with increased force into the aorta, both 
factors combining to raise the systolic pressure. 
During diastole, however, a reflux leak of pressure 
is permitted to escape back into the ventricle 
through the incompetent valves (some blood 
flows back also), and so there is a marked and 
rapid fall in the diastolic pressure. A high sys- 
tolic with a low diastolic and a large pulse pressure 
are thus characteristic of aortic regurgitation. ANALYSIS OF FORCES. 
167 
Conversely, aortic obstruction will have a small 
pulse pressure. 
Venous Blood-pressure.—If the hand be allowed 
to hang at the side it will be noted that the veins 
become filled and prominent. If the arm now be 
raised the veins will become less prominent and 
the level at which they empty can be noted. 
Normally this occurs about the level of the third 
rib. The greater the venous pressure, the higher 
must the arm be raised. 
Instrumental Measurements.—A ready way is 
by applying the armlet of a sphygmomanometer 
over a superficial vein of the arm. The armlet 
is inflated until the flow in the vein is stopped. 
The portion of the vein proximal to the cuff is 
then emptied with a finger. The pressure in the 
armlet is gradually relaxed, and when blood be- 
gins to flow again in the vein the pressure in the 
manometer is noted. 
Note.—Instruments for giving greater accuracy have been 
devised and the student is referred to works on the subject. 
Capillary Pressure.—Several methods of esti- 
mating capillary pressure have been devised. A 
brief description is here given of that used by 
Danzer and Hooker. 
An air chamber, with a glass roof, and a floor 
made of gold-beater’s skin, is connected by tub- 
ing with an air bulb and also with a mercury 
manometer. Screw devices for bringing the floor 
of the pressure capsule into contact with the 168 
BLOOD-PRESSURE AND SPHYGMOMANOMETER. 
finger are used. Air is now forced into the capsule, 
the floor of gold-beater’s skin becoming more con- 
vex, and so exerts pressure on the finger-nail. 
Fig. 43.—The microcapillary tonometer. 
When the flow in the capillaries is stopped, as 
visualized through a microscope (magnifying 
about 70 diameters) the pressure is read off on 
the manometer. 
The average capillary pressure is 18 to 2 2 mm. of 
mercury. The clinical application of venous and 
capillary pressures is, as yet, limited. INDEX 
Abdomen, auscultation of, 149 
contour of, 142 
distention of, 147 
examination of, 142 
inspection of, 22, 136, 140 
landmarks of, 133 
lines on, 133 
palpation of, 140, 144 
percussion of, 140, 148 
regions of, 134 
respiratory movements of, 140 
superficial veins of, 142 
surface markings of viscera, 136 
table of contents of regions, 135 
Abdominal aorta, 140 
tumors, inspection of, 143 
palpating, 147 
veins, superficial, palpation of, 
147 
significance of, 142 
viscera, palpation of, 144 
Acoustics, 27 
Adventitious sounds in heart, 124 
in respiratory apparatus, 99 
Alcoholism, tongue in, 18 
Amphoric percussion sound, note 
concerning, 91 
respiratory sound, 99 
Aneurysm, inspection for, 116 
Angioma of skin, congenital, 20 
Angulus sterni a landmark, 63 
Aorta, 109 
abdominal, 140 
bifurcation of, 139 
Aorta, abdominal, pulsations of, 
140 
level of, under surface of arch, 
63 
palpation of, 118 
percussion of, 118 
Aortic regurgitation, carotid, pul- 
sations in, 20 
pulse and blood-pressure in, 
166 
Apex, true anatomical, 106 
beat affected by disease of lung 
and pleura, 73 
displacement of, 115 
immobility of, 106 
mobility of, 115 
position of, 106 
relation to lung and pleura, 
71 
Appendix, surface markings of, 
139 
Arterial pressure, 152. See also 
Blood-pressure. 
tension, 117 
wall, elastic recoil of, in blood- 
pressure, 153 
Arthritis, rheumatoid, deformity 
in, 22 
Ascites, 147 
Asthma, sterno-cleido-mastoid 
muscles in, 20 
Ataxic gait, significance, 15 
Attitude, importance of examin- 
er’s, 12 
169 170 
INDEX 
Attitude in acute pleurisy, 15 
of patient, 14 
Auricular systole, 113 
Auscultation, 35 
definition of, 44 
general rules governing, 44 
immediate, 44 
mediate, 44 
of abdomen, 149 
of heart, 121 
of lungs, 92 
order of, 47 
pitch in, 28 
Auscultatory method of deter- 
mining blood-pressure, 159 
percussion, 47 
Automobility of tumors, 26 
Band sphygmomanometer, 159 
Barrel-shaped chest, sign of, 74 
Basilic vein, median, surface 
markings of, 51 
Bearing of patient, 14 
Bladder, distended, percussion of, 
149 
Blood, amount of, in blood-press- 
ure, 152 
viscosity of, in blood-pressure, 
155 
Blood-pressure, 151 
amount of blood available, 
152 
analysis of forces in, 152 
arterial, 152 
capacity of left ventricle in, 153 
capillary, 167 
diastolic, 157 
measurement of, by oscilla- 
tions, 161 
normal, 163 
effect of exercise on, 156 
Blood-pressure, elastic recoil of 
arterial wall in, 153 
force of ventricular contrac- 
tions in, 153 
formulae for estimating, 162 
high, 163 
low, 164 
measurements of, 157 
by auscultatory method, 159 
by band sphygmomanome- 
ter, 159 
by bulb sphygmomanome- 
ter, 158 
capillary, 167 
instruments for, 158 
venous, 167- 
output of heart in, 152 
peripheral resistance in, 154 
rate of heart in, 153 
relationship of forces in, 155 
systolic, 157 
normal, 162 
venous, 167 
viscosity of blood in, 155 
Blood-vessels of hands and arms, 
inspection of, 22 
Brachial artery, surface markings 
of, 51 
Breath sounds, importance of 
location of, 95 
normal types of, 93 
Breathing, bronchial, character 
of, 94 
significance of, 97 
bronchovesicular, normal, 96 
significance of, 97, 98 
cog-wheel, 98 
harsh, 97 
rude, 97 
tubular, character of, 94 
significance of, 97 INDEX 
171 
Breathing, types of, anatomic- 
ally, 73 
wavy, 98 
Bronchi, course and characteris- 
tics of, 65 
influence upon breath sounds, 
67 
Bronchial breathing, character of, 
94 
significance of, 97 
Bronchophony, 103 
whisper, 103 
Broncho vesicular breathing, nor- 
mal, 96 
significance of, 97, 98 
Bruit, aneurysmal, 150 
uterine, 150 
Bulb sphygmomanometer, 158 
Caecum, surface marking of, 138 
Capillaries, dilatation of, 19 
ectasia of, 19 
superficial, of chest, 57 
Capillary blood-pressure, 167 
Caput medusae, 143 
Cardiac cyanosis, 114 
diastole of ventricle, 113 
dulness, 88 
absolute or superficial, 88 
murmur, 124 
systole of ventricles, 112 
Carotid artery, surface markings 
of, 49 
Chest, anterior surface, boundary 
of, 57 
regions of, 58 
attitude and contour of, 72 
barrel-shaped, signs of, 74 
circumscribed deformities of, 72 
contour of, 52 
deformities of, 55 
Chest, inspection of, 22 
landmarks of, 63 
lateral surfaces, boundary of, 58 
regions of, 59 
lines on, 62 
posterior surface, boundary of, 
58 
regions of, 58 
superficial capillaries of, 57 
surface markings of, 63 
veins of, 57 
surfaces of, 57 
table of contents, 59 
Cholera, facial expression in, 17 
morbus, facial expression in, 17 
Circulation, peripheral, 114 
Circulatory oedema, 114 
Clavicles, range of prominence of, 
53 
Clubbed fingers, 20 
Cceliac axis, surface markings of, 
139 
Cog-wheel breathing, 98 
Coin test in pneumothorax, 47 
Consolidation of lung, ausculta- 
tion in, 97, 98, 103 
palpation in, 83, 84 
percussion in, 90, 91 
sound in, 35 
vocal fremitus in, 83 
resonance in, 103 
Contour of abdomen, 142 
of cranium, 16 
of head, 16 
Cough, resonance in, 102 
Crackling fremitus, 84 
Crack-pot percussion sound, note 
concerning, 91 
Cranium, contour of, 16 
inspection of, 16 
Crepitant rale, 100 172 
INDEX 
Crepitant rale, origin of, 101 
Cyanosis, cardiac, 114 
of face, significance, 17 
Cycle of heart, 111 
Dan/er and Hooker’s method of 
determining capillary pressure, 
167 
Deformities of chest, 55, 72 
Diagnosis, physical, definition of, 
11 
Diaphragmatic phenomenon, 75 
significance of, 76 
Diastole, cardiac, of ventricle, 
113 
Diastolic pressure, 157 
measurement of, by oscilla- 
tions, 161 
normal, 163 
Dicrotism of pulse, 117 
Dilatation of capillaries, 19 
Displacements of apex beat, 
115 
Distention of abdomen, 147 
Dry rales, kinds of, 100 
production of, 100 
Dulness, cardiac, 88 
absolute or superficial, 78 
general significance of, 40 
splenic, 89 
Duodenum, surface marking of, 
136 
Duration of sound, factors gov- 
erning, 43 
Ears, inspection of, 17 
position of, in mumps, 49 
tophi in, 17 
Ectasia of capillaries, 19 
Edema, circulatory, 114 
Egophony, note concerning, 103 
Elastic recoil of arterial wall in 
blood-pressure, 153 
Elasticity of air, lung tissue, and 
water, 34 
Emphysema of lung, percussion 
in, 90 
Endocardial murmurs, 125 
region, pulsation of, 115 
Enlarged liver special method of 
palpating, 145 
Epigastric pulsation, 115 
Equilibrium, 27 
Examination, physical, definition 
of, 11 
methods employed in, 11 
system in, 12 
Examiner, attitude of, 12 
Exercise, effect of, on blood- 
pressure, 156 
practical, in murmurs, 129 
Expansion, alterations of, 73 
palpation of, 77 
Expiratory sound, 92 
External jugular vein, surface 
markings of, 49 
Eyes, inspection of, 18 
Face, color and condition of skin, 
17 
cyanosis of, 17 
expression of, 17 
muscle tonicity of, 17 
Facial artery, surface markings 
of, 48 
expression in cholera, 17 
in pneumonia, 17 
in typhoid fever, 17 
Fingers, clubbed, 20 
nails and skin of, 20 
Flatness, general significance of, 
40 INDEX 
173 
Flatness, liver, 88 
Fluid in pleura, palpation of 
vocal fremitus in, 84 
percussion in, 90 
Fourier’s theorem, 29 
Fremitus, caused by, 78 
crackling, 84 
friction, 84 
rhonchial, 84 
vocal. See Vocal fremitus. 
Friction fremitus, 84 
sounds, peritoneal, over intra- 
abdominal growths, 150 
pleuritic, 101 
Gait, ataxic, significance of, 15 
of patient, significance, 15 
Gall-bladder, surface markings of, 
136 
Graves’ disease, eyes in, 18 
thyroid in, 20 
Gravid uterus, percussion of, 149 
Gums, inspection of, 19 
Gurgles, 99 
H.emic murmur heard over ab- 
dominal aorta, 150 
Hair, inspection of, 16 
Hands, contour and condition of, 
20 
Harsh breathing, 97 
Head and neck, surface markings 
of, 48 
contour of, 16 
inspection of, 16 
Heart, action of, 109 
anatomical outline of, 105 
apex beat of, 106 
area of deep dulness of, 104 
of relative dulness, 104 
of superficial dulness of, 104 
Heart, auscultation of, 121 
cavities of, their position, 107 
cycle of, 111 
inspection with reference to, 
114 
output of, in blood-pressure, 
152 
palpation of, 118 
percussion of, 119 
rate of, in blood-pressure, 153 
relations of sounds and action, 
109 
sounds, 112 
auscultation of, 121 
intensity of, 124 
modified by exercise, 123 
rhythm of, 124 
topographical anatomy of, 104 
valves and orifices of, 108 
Hemiplegia, tongue in, 18 
High blood-pressure, 163 
Hoarseness in laryngitis, 15 
Hooker and Danzer’s method of 
determining capillary pressure, 
167 
Hum, venous, 49 
Hydrocephalus, inspection of, 16 
Hyperacidity, tongue in, 18 
Immediate percussion, 37 
Innominate artery, bifurcation 
of, 63 
Inspection, definition of, 13 
for aneurysm, 116 
general rules governing, 13 
of abdomen, 22, 139, 142 
of abdominal tumors, 143 
of blood-vessels of hands and 
arms, 22 
of chest, 22 
of cranium, 16 174 
INDEX 
Inspection of ears, 17 
of eyes, 18 
of gums, 19 
of hair, 16 
of head, 16 
of hydrocephalus, 16 
of joints, 22 
of lymph nodes of neck, 20 
of nose, 20 
of pharynx, 19 
of recti muscles, 139 
of respiratory movements, 73 
of scalp, 16 
of superficial temporal artery, 
19 
of teeth, 18 
of tongue, 18 
of tonsils, 19 
order of, 14 
with reference to heart, 114 
to lungs, 72 
Inspiratory sound, 92 
Instruments for measurement of 
blood-pressure, 158 
Intensity of sound, factors gov- 
erning, 43 
Internal jugular vein, note con- 
cerning, 50 
Intestinal peristalsis, 143 
Intestine, perforation of, percus- 
sion in, 149 
Joints, inspection of, 22 
Jugular vein, external, 49 
internal, 50 
Kidney, percussion of, when en- 
larged, 149 
position of, 136 
Landmarks of abdomen, 133 
Landmarks, of chest, 63 
Laryngitis, hoarseness in, 15 
tuberculous, effect on vocal 
fremitus, 84 
Larynx and trachea, surface 
markings of, 50 
Ligament, Poupart’s, palpation 
for lymph nodes above and be- 
low, 150 
Lines on abdomen, 133 
on chest, 62 
Litten’s sign, 75 
Liver, chronic disease of, skin in, 
17 
dulness, absolute and superfi- 
cial, 87 
relative, 87 
enlarged, special method of pal- 
pating, 145 
flatness, 88 
surface markings of, 136 
Low blood-pressure, 164 
Lungs, anterior borders of, 68 
auscultation of, 92 
consolidation of. See Consoli- 
dation of lung. 
diseases of, apex beat affected 
by, 73 
emphysema of, percussion in, 
90 
fissure of, 69 
inferior borders of, 69 
level of apices posteriorly, 64 
of roots anteriorly, 63 
relation of trachea to, 82 
surface markings of, 68 
of fissure posteriorly, 64 
Lymph nodes above and below 
poupart’s ligament, pal* 
pationfor, 150 
of neck, inspection of, 20 INDEX 
175 
Lymph nodes of neck, surface 
markings of, 49 
of upper extremity, impor- 
tant groups of, 51 
Median basilic vein, surface 
markings of, 51 
Mediate auscultation, 44 
percussion, 37 
Metallic sounds, transmission 
through chest, in pneumo- 
thorax, 47 
Microcapillary tonometer, 168 
Moist rales, 100 
kinds of, 100 
Mumps, position of ear in, 49 
Murmurs, cardiac, 124 
congenital, 125 
direction of transmission of, 128 
endocardial, 125 
haemic, 125 
heart over abdominal aorta, 
150 
how to determine seat of lesion 
causing, 125 
maximum intensity of, 128 
pericardial, 124 
practical exercise in, 129 
valvular, 125 
Muscle rigidity in abdomen, 23 
tonicity of arms, 22 
of face, 17 
Muscles of respiration, extraor- 
dinary, 75 
Nails and skin of fingers, 20 
Nasal tone, significance, 15 
Neck, inspection of, 20 
lymph nodes of, inspection of, 
20 
surface markings of, 49 
Neck, surface markings of, 48 
Negative, definition of term, 11 
Nephritis, skin in, 17 
Nerves, pink or red, 20 
Nipple a landmark, 63 
Nodes, 30 
Normal, definition of term, 11 
diastolic pressure, 163 
systolic pressure, 162 
Nose, inspection of, 19 
saddle-back, of syphilis, 19 
Odors, 23 
(Edema, circulatory, 114 
Oscillations, measurement of dias- 
tolic pressure by, 161 
Palpation, definition of, 24 
enlarged lymph nodes by, 25 
for chest expansion, 77 
for lymph nodes above and be- 
low Poupart’s ligament, 150 
general rules governing, 24 
of abdomen, 140, 144 
of abdominal viscera, 144 
of aorta, 118 
of expansion, 77 
of heart, 118 
of pelvic organs, 140 
of pulse, 116 
of superficial abdominal veins, 
147 
of tumors, 26 
of vocal fremitus, 79 
order of, 26 
pulse rate by, 25 
technic of, 24 
Pancreas, position of head, 136 
Parotid gland, surface markings 
of, 49 
Patient, attitude of, 14 176 
INDEX 
Patient, bearing of, 14 
gait of, significance, 15 
Pectoriloquy, 103 
Pelvic organs, palpation of, 140 
Percussion, 31, 33 
auscultatory, 47 
blow, force of, 39 
definition of, 37 
general rules governing, 37 
technic of, 38 
immediate, 37 
in consolidation of lung, 90, 91 
in emphysema of lungs, 90 
in perforation of intestine, 149 
in thickened pleura, 91 
mediate, 37 
of abdomen, 140, 148 
of aorta, 118 
of distended bladder, 149 
of gravid uterus, 149 
of heart, 119 
of kidney when enlarged, 149 
of spleen, 148 
order of, 43 
over bones of chest, 90 
pitch in, 33 
resistance felt on, 37 
sounds, elements of, 39 
with reference to lungs, 85 
Perforation of intestine, percus- 
sion in, 149 
Pericardial murmurs, 124 
Pericarditis, adhesive, immobil- 
ity of apex in, 115 
Pericardium, 109 
Peripheral resistance in blood- 
pressure, 154 
Peristalsis, intestinal, 143 
Peritoneal friction sounds over 
intra-abdominal growths, 150 
Pharynx, inspection of, 19 
Phonendoscopes, 46 
Physical diagnosis, definition of, 
11 
examination, definition of, 11 
Physics of sound, 27. See also 
Sound. 
Pitch of sound, 28 
factors governing, 42 
in percussion, 33 
Plessor, 37 
Pleura, diseases of, apex beat 
affected by, 73 
fluid in, palpation of vocal 
fremitus in, 84 
percussion in, 90 
surface markings of, 69 
thickened, percussion in, 91 
Pleurisy, acute, attitude in, 15 
with effusion, displacement of 
apex in, 115 
Pleuritic friction sounds, 101 
Pleximeter, 37 
Plumbism, chronic, gums in, 19 
Pneumonia, facial expression in, 
17 
Pneumothorax, coin test in, 47 
metallic quality to breath and 
voice sounds in, 99 
Posture, artificial aids to, 14 
Poupart’s ligament, palpation for 
lymph nodes above and below, 
150 
Praecordial region, contour and 
movement of, 114 
Pressure, diastolic, measurement 
of, by oscillations, 161 
normal, 163 
pulse, 157,165 
systolic, 157 
normal, 162 
Progression, artificial aids to, 14 INDEX 
177 
Pulmonary resonance, 85 
effect of chest wall on, 90 
of liver on, 86 
normal variations of, 85 
Pulsation, epigastric, 115 
of abdominal aorta, 140 
of epigastric region, 115 
venous, 114 
where observed, 49 
Pulse, dicrotism of, 117 
elements of normal, 116 
frequency of, 116 
palpation of, 116 
pressure, 157, 165 
Quality, terms of, in percussion, 
40 
Radial artery, anomalous course 
of, 50 
surface markings of, 50 
Rale, crepitant, 100 
origin of, 101 
dry, kinds of, 100 
kinds of, 100 
moist, 100 
“redux,” 101 
sibilant, 100 
sonorous, 100 
Recti muscles, inspection of, 139 
Regurgitation, aortic, pulse and 
blood-pressure in, 166 
Resistance felt on percussion, 37 
Resonance, 34 
general significance of, 40 
pulmonary. See also Pul- 
monary resonance. 
vocal, 101 
alterations of, in disease, 102 
in consolidation of lung, 103 
reason for predominance, 82 
Resonance, whispered, 101 
Resonators, 28 
Respiration, muscles of, 75 
Respirations, rate and character 
of, 75 
rate of, 92 
Respiratory movements, inspec- 
tion of, 73 
of abdomen, 140 
sounds, abnormal pathological, 
96 
absent, 98 
diminished, 98 
elements of, 93 
exaggerated, 98 
interrupted rhythm in, 98 
normal, 92 
rhythm of, 93 
Retraction with inspiratory effort, 
significance of, 74 
Rheumatoid arthritis, deformity 
in, 22 
Rhonchial fremitus, 84 
Right apex of lungs, note con- 
cerning importance in auscul- 
tation of, 96 
Rude breathing, 97 
Saddle-back nose of syphilis, 19 
Scalp, inspection of, 16 
Semilunar space of Traube, 90 
Sibilant rales, 100 
Sign, Litten’s, 75 
Skin, angioma of, congenital, 20 
in chronic disease of liver, 17 
in nephritis, 17 
Sonorous rales, 100 
Sound, 27 
breath, importance of location, 
95 
influence of bronchi on, 93 178 
INDEX 
Sound, breath, normal types, 93 
characteristics of, 28 
diffusion of, 32 
fundamental elements of, 39 
note of, 30 
loudness or intensity of, 28 
modification of, 32 
overtones, 30 
physics of, 27 
pitch of, 28 
production of, 31 
by percussion, 31 
by respiratory act, 32 
by voice and cough, 32 
quality of, 29 
radiation of, 32 
reflection of, 32 
refraction and absorption of, 32 
resonance of, 33 
valve, areas of, 122 
Sounds of heart, 112 
Speech, import in diagnosis ,15 
Sphygmomanometer, 151 
band,159 
bulb, 158 
Splashing sounds, 101 
Spleen, percussion of, 148 
position of, 136 
Splenic dulness, 89 
Sternoclavicular articulation, a 
landmark, 63 
Sterno-cleido-mastoid muscles in 
asthma, 20 
Stethoscope, choice of, 45 
Stomach, surface markings of, 136 
Strawberry mark, 20 
Subclavian artery, surface mark- 
ings of, 49 
systolic puff in, 128 
Submaxillary gland, surface 
markings of, 49 
Succussion, 101 
Superficial capillaries of chest. 
note concerning, 57 
Supraclavicular regions, retrac- 
tion of, 72 
Surface markings, definition of, 
48 
veins of chest, 57 
Syphilis, inherited, teeth in, 19 
saddle-back nose of, 19 
Systolic, auricular, 113 
cardiac, of ventricles, 112 
Systolic pressure, 157 
normal, 162 
puff in subclavian artery, 128 
Teeth in inherited syphilis, 19 
inspection of, 18 
Temporal artery, superficial, in- 
spection of, 19 
surface markings of, 48 
Tenderness, points of, 25 
Tension, arterial, 117 
Test, coin, in pneumothorax, 47 
Theorem, Fourier’s, 29 
Thickened pleura, percussion in, 
91 
Thyroid in Graves’ disease, 20 
surface markings of, 50 
Tongue in alcoholism, 18 
in hemiplegia, 18 
inspection of, 18 
Tonometer, microcapillary, 168 
Tonsils, inspection of, 19 
Tophi in ears, 17 
Topography, definition of, 48 
Trachea and larynx, surface 
markings of, 50 
bifurcation of, 63 
course of, 64 
relation of, to lungs, 82 INDEX 
179 
Tracheal tugging, 117 
Traube, semilunar space of, 90 
Tuberculous laryngitis, effect on 
vocal fremitus, 84 
Tubular breathing, character of, 
94 
significance of, 97 
Tugging, tracheal, 117 
Tumors, abdominal, by inspec- 
tion, 143 
automobility of, 26 
palpating abdominal, 147 
palpation of, 26 
Tuning-fork, 30 
Tympany, where greatest, in 
normal, 149 
Typhoid fever, facial expression 
in, 17 
Umbilicus, position of, 139 
veins of, 143 
Upper extremities, surface mark- 
ings of, 50 
Uterine bruit, 150 
Uterus, gravid, percussion of, 149 
Valves, position of, 108 
sound areas of, 122 
Valvular murmurs, 125 
Veins of chest, superficial, 57 
of umbilicus, 143 
superficial abdominal, palpa- 
tion of, 147 
significance of, 142 
Venous blood-pressures, 167 
Venous hum, where heard, 49 
pulsation, 114 
where observed, 49 
Ventricular contractions, force 
of, in blood-pressure, 153 
Viscera, palpation of abdominal, 
144 
Viscosity of blood, 155 
Vocal fremitus, conduction of, 78 
effect of tuberculous laryngi- 
tis on, 84 
of voice on, 83 
in consolidation of lung, 83, 
84 
normal variations of, 80 
palpation of, 79 
pathological variations of, 83 
produced by, 78 
why greatest on right side, 
80 
resonance, 101 
alterations of, in disease, 102 
in consolidation of lung, 103 
reason for predominance, 82 
Voice sounds, 101 
von Basch’s bulb sphygmoman- 
ometer, 158 
Walking, artificial aids to, 14 
Wavy breathing, 98 
Whisper-bronchophony, 103 
Whispered resonance, 101 
Xipho-sternal articulation a 
landmark, 63