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A
MANUAL
OF THE
PHYSICAL  DIAGNOSIS
OF
THORACIC  DISEASES
BY
     E. DARWIN HUDSON, Jr., A.M., M.D.
PROFESSOR OF GENERAL MEDICINE AND DISEASES OF THE CHEST IN THE NEW YORK POLYCLINIC,
           PHYSICIAN TO BELLEVTJE HOSPITAL, ETC.
            NEW YORK
WILLIAM  WOOD  &  CO., PUBLISHERS
         56 & 58 Lafayette Plage
               1887 

          Copyright by
WILLIAM  WOOD  & COMPANY
               1887.
       PRESS OF
STETTINER,  LAMBERT A CO.,
  22, 24 4 26 READE ST.,
      NEW YORK. 
TO
         JAMES  R. LEAMING, M.D.,






WHOSE WISE  COUNSEL AND WARM FRIENDSHIP  THE



    AUTHOR  HAS  ENJOYED  FOR MANY YEARS,



       THIS VOLUME, IN GRATEFUL ACKNOWL-



           EDGMENT, IS AFFECTIONATELY



                   INSCRIBED. 
 
PREFACE.
   In the preface of his book an author is expected to explain to his
 readers the object and aim of his work, together with its general plan,
 and often to make  due  acknowledgment of his obligations to other
 authors, or to friends who have assisted him in his undertaking.
   In the present instance, this common expectation cannot be rea-
 lized, since the talented author of this volume suddenly sickened
 and died just after the manuscript had been placed in the printer's
 hands.   On  me,  his friend, has devolved  the melancholy duty of
 correcting the  proof-sheets of the work, and also of speaking for him
 to his readers.
   The volume is the outcome of the  author's needs  as a teacher in
 the New  York Polyclinic.  In 1885, he  privately printed  a small
 book entitled  " Essentials of the Physical Diagnosis of Thoracic
 Diseases," which was circulated among the members of his class, and
 to a limited extent, also,  among his personal friends.   The work
 was found both convenient and useful, and therefore, by an  elabora-
 tion of its material, the present volume was prepared.
  He has  carefully collated the opinions of the best authors,  frankly
avowing his personal  preferences,  and has drawn freely upon his
own  experience and observation. 
Vi                          PREFACE.

  Keeping strictly in view the  object  aimed  at, he has  avoide
unnecessary verbiage and over-elaboration, presenting the essential
facts in a manner best calculated to fix the reader's attention.
  In the synopses of diseases,  this condensation is seen to  the best
advantage, and here, also, its value will  probably be  most highly

appreciated.
  Though lacking the advantage of his final  revision, the book is
presented to the profession with the firm conviction that it will meet

with a generous welcome.
                                     Laurence  Johnson, M.D.
  New York, July, 1887. 
CONTENTS.
                           CHAPTER I.

              PRINCIPLES OF PHYSICAL DIAGNOSIS.
                                                                PAGE
Topography of Thorax—Boundaries  and Contents of Various  Regions—
    Methods of Physical Diagnosis—Inspection of Healthy Chest;  Form,
    Movements— Unhealthy Chest, Bulging, Retraction, Procidentia, Dis-
    tortion ;  Abnormal Movements; Palpation—Fremitus,  Respiratory,
    Vocal, Tussal—Mensuration of Size, Motion,  and Volume of Air.... 1-18


                          CHAPTER II.

PRINCIPLES  OF  PERCUSSION,  AND APPLICATION  TO HEALTHY
                              CHEST.
Immediate and Mediate; Origin of Mediate Percussion—Forms of Ham-
    mer and  Pleximeter—Mode of Percussing—Properties of Percussion
    Sound—Duration,  Intensity, Pitch, Quality—Percussion Sound  over
    Muscle, Heart, Lungs—Over several Areas of Thorax—Corson's Posi-
    tions for Examination of the Chest—Composite Nature of Percussion
    Sound.............................................................19-31


                          CHAPTER III.

             PERCUSSION OF THE ABNORMAL CHEST.
Changes in Duration, Intensity, Pitch, Quality—Percussion in  Thickened
    Pleura, Pleuritic Effusions, Slight Pulmonary Consolidations, Ad-
    vanced Consolidations—Line of Dulness in Pleurisy; Old View,  New
    View—Ellis'  Line—Percussion  in  Bronchitis,   Emphysema—The
    Sense of Resistance in Percussion—Myoidema of  Graves and Stokes,
    Gairdner,  Tait....................................................  32-36


                          CHAPTER IV.

                       AUSCULTATION.

Definition.  Sounds to be Heard—Their Properties—Methods of Auscul-
    tation—The Stethoscope—Solid  Stethoscopes—The Binaural Stetho-
    scope—Arguments for  and  against Use of Stethoscope—Normal Re- 
viii
CONTENTS.
    spiratory Sound—Characteristics—Elements of Normal Breath Sound
    —Muscular Sussurus—Vocal  Resonance—Normal  Whisper—Normal
    Tussal Resonance.............................................37-49


                           CHAPTER V.

    ACOUSTICS OF NORMAL AND ABNORMAL CHEST SOUNDS.
Chest Acoustics—Abnormal Sounds  Referable to Respiratory Organs—
    Classification of these Sounds—Modification of Normal Sounds—Ad-
    ventitious  Sounds—Interpretation  of Modified and Adventitious
    Sounds—Their Special Study—Illustrations of Abnormal Respiratory
    Sounds—Study of Abnormal Voice Sounds—Study of Whisper Sounds
    —Study of Cough Sounds—Adventitious Sounds in Air Passages—Dry
    Rales—Moist Rales—Recapitulation of Rales—Abnormal intra-Pleural
    Sounds—Rules  for  Differentiating Them—Adventitious  Rales  Pro-
    duced in the Pulmonary Parenchyma—Auscultatory Percussion—The
    "Bell Metal"  Test—Succussion—Determining Size and Relation of
    Surrounding Organs—The  Microscope as an Aid to Diagnosis—Aspi-
    ration and Hypodermic  Puncture....   .......................  .. 50-76

                           CHAPTER VI.

              SYNOPSES  OF RESPIRATORY DISEASES.
1. Acute Bronchitis  of  Adults.  2.  Capillary Bronchitis.   3.  Chronic
    Bronchitis.  4. Asthma.   5. Pleuritis.  6. Empyema.   7. Pneumo-
    hydrothorax.   8.  Hydrothorax.    9. Pneumonia.   10.  OZdema of
    Lung.   11. Pulmonary Apoplexy.  12. Pulmonary Infarction.  13.
    Gangrene of Lung.   14. Emphysema.   15. Phthisis Pulmonalis.   16.
    Modern  View of Phthisis.   17. Syphilis of Lungs.  18. Brown Indura-
    tion.  19. Carcinoma of Lung, Pleura, and Bronchi..............77-96


                          CHAPTER VII.

                          HEART  DISEASES.
Anatomical and Topographical  Data—Location of Heart—Deep  Cardiac
    Region—Superficial  Cardiac Region—Location of Heart Valves—
    Anatomy of Heart—Methods of  Examining Heart, Inspection, Men-
    suration,  Palpation, Percussion,  Auscultation—Duration of Heart
    Sounds—Characteristics  of  Heart Sounds—Theories of Causes of
    Heart Sounds—Functional Diseases of. Heart................. ... 97-124


                          CHAPTER VIII.

                 SYNOPSES  OF  HEART  DISEASES.
 1. Valvular Diseases of the Heart.  2. Cardiac Hypertrophy.   3.  Cardiac
    Dilatation.  4. Fatty Heart.   5. Endocarditis.  6. Ulcerative Endo-
    carditis.  7. Pericarditis.   8. Hydro-pericardium.   9.  Synopsis of 
CONTENTS.
IX
    Organic Murmurs.  10. Anaemic Murmurs.   11. Extra Cardiac Mur-
    murs.   Aneurism of the Thoracic Aorta:  Different Portions of Arch
    of  Aorta.  Aneurism.   Definition,  Pathology, Symptoms, Physical
    Signs.   Special Symptoms  and Signs of Aneurism of  Ascending,
    Transverse, and Descending Portions............................125-143


                           CHAPTER IX.

        RELATION OF THE PULSE TO CARDIAC DISEASE.
1.  The Palpation  of  Pulse  in  the several Diseases of Heart.  2. Sphyg-
    mography.  Different Sphygmographs. Study of  Different Parts of
    Normal Tracing.   Changes due to Cardiac Obstructions and Insuffi-
    ciencies .   Dicrotism...........................................144-146 
 
LIST  OF   ILLUSTRATIONS.
FIG.
 1. Anterior regions of the chest, after Walshe,  .
 2. Contents of anterior regions of the chest, after Quain,
 3. Regions of the back,   .....
 4. Outline of contents of posterior thoracic regions, after Quain
 5. Contents of the posterior regions of the body,
 6. Flint's cyrtometer,
 7. Quain's stethometer,
 8. Barnes' spirometer,
 9. Hutchinson's spirometer,
10. Winterich's percussion hammer,
11. Ivory pleximeter,
12. Flint's percussor,
13. Flint's pleximeter,
14. Percussion resonance and dulness of front of chest, after Piorry,
15. Percussion resonance and dulness of posterior regions, after Piorry
16. Position for percussion of front of chest,
17. Position for percussion of lateral regions,
18. Position for percussion of posterior regions,
19 and 20.  Areas of dulness and  flatness of phthisis at  each apex, after
      Piorry,        .....
21, 22. Areas of flatness in pleurisy with effusion,
23-24. " Ellis " or " Letter S " line,
25. Myoidema,
26-31. Straight stethoscopes,
32, 33. Cammann's  stethoscopes,
34. Allison's differential stethoscope,
35. Air-passages and lobules,
36. Bifurcation of trachea and bronchi,
37. Terminal bronchus and vesicles,
38. Schematic representation of air vesicles,
39. Distribution of terminal tubes and vesicles,   .
40. Tracings of muscle waves, after Marcy,
41. Consolidation of apex,  ....
42. Consolidation with cavities,
43. Dilated bronchi, after Loomis, .
44. Emphysema, terminal tubes and air sacs dilated,
45. Advanced stage of the foregoing,
PAOE
    2
    4 
xii
LIST OF ILLUSTRATIONS.
46. Section of emphysematous lung,
47-49. Pleurisy with effusion,
50. Consolidations of lung,  .
51. Pneumohydrothorax,.
52. Diagram illustrating dry and moist rales,
53. Diagram of catarrhal process,   .
54. Transverse section of thorax,
55. Cammann's cylindrical auscultator,
56. Cammann's intra-costal auscultator,
57  58. Constantine Paul's stethoscope,
59. Page's percussion hammer,
60.  Dieulafoy's aspirator,
61, 62. Tiemann & Co.'s aspirator,  .
 63. Tubercular sputum, with bacilli, after Eichhorst,
 64. Tubercle bacilli with spores, after W. Cheyne,
 65. Asthma crystals, after Frankel,
 66. Peribronchitis, chronic,
 67. Thickened pleura,
 68. Location of the heart,  after Walshe,  .
 69. Relation of the heart to the great vessels,
 70. Relation of the heart to the diaphragm and left lobe of the liver,
 71, 72. Apex of the heart in hypertrophy with dilatation,
 73. Cammann's cardiometer,       ....
 74. Increase of pericardial area in hydropericardium,
 75. Hypertrophy of the left ventricle, after Loomis,
 76. Increased area in enlargement of heart, after Piorry,
 77. Hypertrophy of right ventricle, after Loomis,
 78. Hydropericardium,     .....
 79. Left ventricle in systole, after  Dalton, .
 80. Left ventricle in diastole, after Dalton,
 81. Line of propagation of heai't murmurs,
 82. Relation of the aorta to surrounding structures, after Gray,
 83. Relation of the aorta  to oesophagus, bronchi,  heart, and  valves,
      after Gray,   ........   139
 84. Area of dulness of aneurism, after Piorry,   ....   140-
 85. Aneurism of junction of ascending and transverse arch, after Doty,   141
 86. Relations of descending arch,  ......   142
 87. Thoracic aorta in the back,    ......   143
 88. Marcy's sphygmograph,       ......   144
89. Dudgeon's sphygmograph,     ......   145
 90. Holden's sphygmograph,      ......   145
91-93. Pulse tracing, after Loomis,       .                     .      145, 145,
   PAGE
      56
   57,58
      58
      59
      61
      62
      64
      69
      69
      70
      71
      73
      74
      75
      75
      76
     93
     93
     98
     99
    100
105,106
    109
    109
    113
    113
    114
    114
    132-
    132
    135
    138 
THORACIC   DISEASES.
                        CHAPTER  I.

             PRINCIPLES OF PHYSICAL DIAGNOSIS.
  Our system of physical examination of the chest, as developed by
Avenbrugger, Laennec, and Piorry, has received numerous amenda-
tions and  additions from a host of investigators  and teachers in
Europe and America.  The more prominent  of these abroad are
Skoda, Allison, G-airdner, and  Walshe; and not less valuable  and
original are the contributions in our own country, of Flint, DaCosta,
Loomis, Learning, Camman, and Clark.
  The profession has come to regard physical diagnosis, in the hands
of experts, as affording  exact  knowledge of the conditions of the
intra-thoracic organs.  It is accepted,  as a fact fully  established,
that, by the application of acoustic laws, certain combinations of phy-
sical signs lead to an immediate and correct diagnosis in most cases of
thoracic disease.

               REGIONAL ANATOMY OF THE CHEST.
  Before entering upon the study of physical signs, it is essential to
have thorough  knowledge of the normal chest, the structure of its
walls, and the situation  and size of the intra-thoracic organs—that
is, the regional anatomy or topography of the chest.

                   Topography  of Thorax.
                     regions  of  the chest.

                                1. Supraclavicular.
                                2. Clavicular.
                                3. Infraclavicular.
                                4. Mammary.
                                5. Inframammary.
                                6. Suprasternal.
                                7. Upper sternal.
                                8. Lower sternal.
1.  Anterior Regions. 
PRINCIPLES OF PHYSICAL DIAGNOSIS.
2.  Lateral Regions.
3.  Posterior Regions.
.1
1. Axillary.
2. Infra-axillary.
1. Upper scapular.
2. Lower scapular.
3. Infra-scapular.
L Interscapular.
               Fig. 1.—Anterior Regions of the Chest (Wai.shk).
a, Supraclavicular; b, clavicular ; c, infraclavicular ; d, mammary ; e, inframammary ; /,
                 suprasternal;  g, upper sternal; ft, lower sternal.
                       ANTERIOR REGIONS.
1. Supraclavicular.                   Boundaries
     (a) Internal,
     (b) Superior and external
  (c) Inferior,
It is a triangular space.
Trachea.
Line drawn from  upper part  of
   trachea to acromion process.
Upper border  of clavicle. 
PRINCIPLES OF PHYSICAL DIAGNOSIS.
3
THE  STRUCTURES CONTAINED ARE
(4)  Subclavian artery.
(5)  Subclavian vein.
  (1)  Apex of  lung.
  (2)  Carotid artery.
  (3)  Jugular vein.
Clavicular.
  Location, behind the inner three-fifths of the clavicle.
              THE STRUCTURES CONTAINED ARE :
(A) On right side.
     1. Lung tissue.
     2. Subclavian artery.
     3. Arteria innominata.
3. Infraclavicular.
     (a)  Internal,
     (b)  Superior,
     (c)  External,
     (d) Inferior,

                THE STRUCTURES
(A)  On right side.
     1. Superior lobe of lung.
     2. Main bronchus  behind
          second costal cartilage.

     3. Descending vena cava.
  4. Portion of arch of aorta,
       behind second  costo-
       sternal articulation.
Mammary.
  (a) Internal,
  {b) Superior,
  (<?) External,
(d) Inferior,
 (B) On left side.
      1. Carotid artery.
      2. Lung tissue.
      3. Subclavian artery.
   Boundaries.
 Edge of sternum.
 Lower  border of  clavicle.
 A line falling vertically  from
   junction of middle and  outer
   third of clavicle.
 Lower  border of third rib.
CONTAINED  ARE :
 (B) On left side.
     1.  Superior lobe of lung;
     2.  Main  bronchus  a  little
          below the second costal
          cartilage.
     3.  A  portion of pulmonary
          artery immediately be-
          hind the second sterno-
          costal articulation.
     4.  Base  of  heart  at  lower
           boundary.

   Boundaries.
 Edge of sternum.
 Lower  border of third rib.
 A vertical  line continuous with
   the  outer  boundary  of  infra-
   clavicular region.
Lower border of sixth rib. 
•4              'PRINCIPLES OF PHYSICAL DIAGNOSIS.

   On the right side in this region the thin sharp border of the lung
very nearly corresponds to the inferior boundary.   But below the
lower border of fifth rib the thin portion of  lung overlies the liver.
The liver is sometimes pushed up into the fourth intercostal space.
   On the left side a section is taken out of the lung to afford space
for the heart.   The lung extends in front as far as the fourth sterno-
costal articulation, where the anterior border  passes outward to the
outer end of  the fifth cartilage, then  obliquely  inward to lower
border of outer end of the sixth costal cartilage, then outward.
Fig. 2.—Showing Contents of Anterior Region of the Chest (after Quain).
            STRUCTURES  WITHIN THE MAMMARY REGION.
<A) On right side.                (B) On left side.
     1- Lung.                        1. Lung.
     2. Liver.                        2. Left auricle.
     3. Right auricle and  right       3. Left ventricle.
           superior angle of right
           ventricle close to ster- 
PRINCIPLES OF PHYSICAL DIAGNOSIS.
5
          num,  between  third
          and fifth ribs.
                                     4. Apex of left ventricle and
                                          portion of apex of right
                                          ventricle, in fifth inter-
                                          costal  space, one inch
                                          within and two inches
                                           below nipple.
   (a) Nipple varies somewhat in position.  May be  said to  be,
usually, on the fourth rib, at junction of costal cartilage and rib, or
in fourth intercostal space.
   (b) Fissure between upper and middle lobes of  right lung passes
obliquely upward and backwards from fourth cartilage ; fissure  be-
tween middle and lower lobes, upwards and  backwards from fifth
interspace ;  fissure between lobes of left lung begins  at  fifth inter-
space, below the nipple.
5. Inframamary.                   Boundaries.
     (a) Superior,   .     .     .  Lower border of sixth rib.
      (b) Inferior,      .     .     Curved line corresponding to  the
                                   free border of ribs.
      (c) Internal,   .     .     .  Inferior portion of sternum.
      (d) External,      .    .     The continuation of  the external
                                   boundary of mammary region.

         STRUCTURES WITHIN THE  INFRAMAMMARY  REGIONS.

(A) On right side.                (B) On left side.
      1. Lung on full inspiration.      1. Portion  of left  lobe of
                                          liver.
      2. Liver.                       2. Stomach.
                                     3. Portion of spleen, some-
                                          times.
6. Suprasternal.
   This region is the hollow space immediately above the  notch of
the sternum, and bounded on either side by the sterno-cleido mastoid
muscle.

          STRUCTURES WITHIN THE SUPRASTERNAL REGION.
1.  Trachea.
2.  Arteria innominata at lower right angle. 
€
PRINCIPLES OF PHYSICAL  DIAGNOSIS.
   3. Arch of  aorta sometimes reaches to its lower border, where it
 may often be felt, on firm pressure downward.
 *l.  Upper sternal.
   This region  includes the space behind the sternum from the notch
 to the lower border of  the third rib.

          STRUCTURES WITHIN THE  UPPER STERNAL REGION.
   1. Lung in front.
   2. Bifurcation of trachea at upper border of second rib.
   3. Ascending aorta at lower end of region.
   4. Transverse aorta,  crossing on level with second rib.
   5. Innominate artery, at junction of second right costal cartilage.
   6. Portion of right auricle in lower part.
   1. Aortic valves, midway between centre of sternum and lower
■edge of left third  costal cartilage.
   8. Pulmonary valves, one-half inch higher than the aortic, on left
edge of sternum.
   The position of the lung in mid-sternum varies somewhat  during
inspiration and expiration.
8. Lower sternal.
  This region corresponds to that portion of the sternum which lies
helow the lower border of the third rib.

         STRUCTURES WITHIN  THE LOWER STERNAL REGION.
  1.  Portion of body of lung on right side in front, on  the left side
:also as far as the fourth sterno-costal articulation.
  2.  Greater part  of right ventricle.
  3.  Smaller part  of left ventricle.
  4.  The mitral valves, in the upper part of this region, that is just
"below the level of the  third  rib or on a level with  the fourth  rib,
situated close to the left edge of the sternum.
  5.  The tricuspid valves, situated at about the  same  level as the
mitral, but to the  right, nearer to the median line and more super-
ficial.
  6. Attachment of heart to diaphragm.
  7.  Small portion of liver.
  8. Portion of stomach, sometimes.

                       LATERAL REGIONS.
1. Axillary.                         Boundaries.
      (a) Superior,    .     .     .  The axilla. 
PRINCIPLES OF PHYSICAL DIAGNOSIS.
7
     (b) Inferior,  ...     A line carried backward from the
                                   lower boundary of mammary
                                   region (sixth  rib) to  inferior
                                   angle  of scapula.
     (c) Interior,    .    .     .   The  vertical line which forms
                                   the common external boundary
                                   of  the anterior regions.
     (d) Posterior,      .     .     The external border of scapula.
  This region corresponds laterally with the mammary in front, and
contains on both sides lung substance, with  the main bronchi, deeply
seated.
2. Infra-axillary.                   Boundaries.
     (a) Superior,   .    .     .   Inferior  boundary of   axillary
                                   region.
     (b) Inferior,  .     .     .     Edges of false ribs.
     (c) Anterior,   .    .     .   Common  vertical  line, external
                                   boundary  of infra-mammary.
     (d) Posterior,      .     .     Line of external border of scapula
                                   continued downward.
  This region corresponds laterally to the inframammary, and con-
tains  above, on both  sides,  the lower  edges of the lung, sloping
downward and backward.   Below, on the right side, is the liver; on
the left, the stomach and spleen.

                      POSTERIOR REGIONS.
 Upper scapular.
   (a) Superior,
   (b) Inferior,   .
   (c) Internal,
   (d) External,  .
Occupied by lung substance.
 Lower scapular.
   (a) Superior,
   (b) Inferior,   .
   (c) Internal,
   id) External,  .
Occupied by lung substance.
 Infrascapular.
   (a) Superior,
   Boundaries.
Second rib.
Spine of scapula.
Internal border of scapula.
External border of scapula.

    Boundaries.
Spine of scapula.
Inferior angle of scapula.
Internal border of scapula.
External border of scapula.

   Boundaries.
Inferior  angle  of  scapula
   seventh dorsal vertebrae.
and 
PRINCIPLES  OF PnYSICAL DIAGNOSIS.
     (b) Inferior,
     (<?) Internal,

     (d) External,

4. Interscapular.
     (a) Superior,
     (b) Inferior,

     (c) Internal,

     (d) External,
The twelfth rib.
The  spinous  processes  of  the
  vertebrae.
Posterior boundary of  the infra-
  axillary.
   Boundaries.
Line of second rib.
Liue of  sixth rib and  inferior
  angle of scapula.
Vertebral column, dorsal spinous
  processes.
Internal border of scapula.
  By means of Corson's position for percussing the posterior surface
of the chest, these traditional  landmarks and regions are  changed.
The interscapular region is increased threefold (see Chapter on Per-
cussion.
                         Fig. 3.—Regions of Back.
 a a, Suprascapular; b b, scapular fincluding upper and lower scapular of Walshe); c coulter-
scapular; d d, infrascapular. 
PRINCIPLES  OF PHYSICAL DIAGNOSIS.
9
..O
-D
Fig. 4.—Outline of contents of posterior thoracic regions (from Quain).
STRUCTURES   WITHIN   THE   UPPER,   LOWER
                              REGIONS.
A.) Qn right side.
     1.  Lung, to  the  eleventh
         rib.
     2.  Liver, immediately  un-
         derneath  the  surface,
         between  eleventh  and
         twelfth ribs.
     3. Small portion of kidney.
AND  INFRASCAPULAR
(B.)  On left side.
     1.  Lung, to eleventh rib.

     2.  Intestines, internally.
Spleen, externally.
Descending  aorta, close
  to the spine.
Portion  of  the  kidney^
  more than on right side
  close to spine. 
10
PRINCIPLES OF PHYSICAL  DIAGNOSIS.
Fig. 5.—Contents  of posterior regions, relations of lungs to  ribs, by numbers, to  scapulae,
                            stomach, liver, and diaphragm. 
PRINCIPLES OF PHYSICAL DIAGNOSIS.
11
         STRUCTURES WITHIN THE  INTERSCAPULAR REGIONS.
  These regions contain, on  both sides, lung substance, the main
bronchi, and the bronchial glands.  Opposite the third dorsal  verte-
bras (the second rib in  front), is the bifurcation of the trachea.  The
left  also  contains the  oesophagus, and from the upper part of  the
fourth dorsal vertebra downward, the descending aorta.
  The useful signs posteriorly, in health, are few.  From the second
to the  sixth  rib behind, sounds  of  air  in the  trachea and main
bronchial  tubes are heard.   At the seventh or eighth dorsal vertebra
on the left side  is the  point corresponding to  the situation  of  the
mitral valve.   It  is in this neighborhood that mitral murmurs  are
readily  heard.   They  may also be heard as high up  as  the fifth
dorsal.

             METHODS OF PHYSICAL DIAGNOSIS.
     1. Inspection.                6.  Auscultatory Percussion.
     2. Mensuration.              7.  Succussion.
     3. Palpation.                 8.  Determining situation and size
     4. Percussion.                   of surrounding organs.
5.  Auscultation.
INSPECTION.
 Is the  actual observation of a person's chest.  As a means of diag-
 nosis it is secondary in importance to  auscultation and percussion,
 yet is of considerable value.   By inspection we recognize the form
 size, and general movements of the chest.   In order  to  recognize
 changes of  disease it is necessary to have exact knowledge of the
 features presented in health.

                    Form of Healthy Chest.
   The natural form of a normal chest is a cone with apex upward.
 Let us look at the different regions of the chest.
   The supraclavicular region in  health is  slightly concave.  The
 suprasternal  region is always  a deep hollow.   The  infraclavicular
 slightly  convex.   The upper  sternal is about  level.   The lower
 sternal is always somewhat hollow.   The mammary and inframam-
 mary  are  rotund.   The  intercostal spaces are always slightly con-
 cave  in  both inspiration  and  expiration, unless there be a super-
abundance of adipose tissue. 
12             PRINCIPLES OF PHYSICAL DIAGNOSIS.
  The two sides are very nearly symmetrical.   It is estimated that
not over twenty per cent of people have a perfectly symmetrical chest.
The most common deviations from a perfect form are  slight curva-
tures of the spinal column.   Slight modifications are consistent with
health.  The main point is to see if the volumes of two sides are
about equal.
                      Normal Movements.
  1.  Thoracic Movements.—In inspiration, we observe the sternum
moves forward, all the  ribs  except the lower four go upward and
outward.  The lower four move outward directly, or outward and
downward.  The ribs all separate from each other in inspiration. In
expiration, reverse movements.
  2.  Abdominal Movements,—Diaphragm  ascends, and abdomen
falls, in expiration; reverse,  in inspiration.
              Departures from Healthy Form.
    1. Expansion.               5.  Procidentia.
    2. Bulging.                 6.  Elevation.
    3. Retraction.               7.  Curvature.
    4. Depression.               8.  Distortion.

                   Expansion and  Bulging.
  By expansion we  mean a general  enlargement of  one side or  of
the whole chest;  by bulging, a partial enlargement  at one point—
enlargement due to causes within the  chest.  In asthma and general
vesicular emphysema we have  an  example of  expansion.   The
shoulders are raised, all the muscles of respiration  are in a  state  of
tension, that is, all the muscles in upper part of thorax.  The chest
is enlarged in every way.
  Ordinary emphysema from obstructive  causes produces  bulging
in the supra-  and infra-clavicular  regions.  In pleuritis,  bulging
occurs in the matnmary and axillary regions after effusion has taken
place. Enlarged heart causes bulging  in precordial region.  Bulging
in inframammary region on right side results from enlarged liver ;
on the left side, from enlarged spleen. 
principles of physical diagnosis.
13
                 Retraction  and Depression.
  Retraction implies general reduction of the whole chest or of one
side;  depression has reference to a more local  drawing in of the
chest-walls.
  Pleuritic effusion occurss filling up the pleural cavity, so that the
lung is compressed, and becomes bound down by inflammatory ad-
hesions.   After the fluid is absorbed, the lung does not again expand
to its previous dimensions.   In this case,  atmospheric  pressure acts
upon the external surface, causing a retraction of the side.
  Depression occurs from a cavity in the lung, from true croup, acute
or  chronic laryngitis, and from atelectasis, and local pleuritic ad-
hesion.
  Expansion and bulging are due to internal and not to external
 causes.  Retraction and depression are due to the co-operation of an
external cause, namely : pressure of the atmosphere.

                  Procidentia and  Elevation.

   These terms may apply to changes either in the whole or a part of
the chest.
   Procidentia.—Falling of the shoulders and lungs lower than
natural, over atrophied or contracted lungs.
   Elevation.—The lungs fixed higher than normal, or raised in the
inspiratory act, as in emphysema.

                  Curvature  and  Distortion.

   1.  Lateral curvature of the spine is frequently the  result of con-
traction  of  one  lung or of chronic changes in the pleura, with
enfeeblement  of the respiratory muscles.  Angular curvature is
associated with  early' malnutrition,  and the existence of chronic
bronchitis, asthma, and emphysema.
  2. The most common form of distortion is the "pigeon-breast."
This is constituted by a flattening of chest laterally, and  an arching
 forward of the sternum.  Causes: rachitis, atelectasis,  or non-expan-
sion of the bronchial tubes in early life, whooping cough, croup, and
bronchitis.
   The  deformity is not due wholly to rachitis, but  to the partial
 and uneven filling of the bronchial tubes, to laryngeal or bronchial
constriction and co-operation of external atmospheric pressure. 
14
principles of physical diagnosis.
                      Abnormal Movements.
   1.  The antero-posterior motion of sternum, and the upward and
 outward motion of the ribs, are diminished in all contracted chests,
 as in fibroid and tubercular phthisis; also in the atrophied chests of
 the  aged, with senile calcification and  rigidity of the  costal carti-
 lages; also in emphysematous (barrel-shaped) chest.
   2.  The costal motion is diminished unilaterally by phthisical and
 pneumonic  consolidations, by pleuritic effusion, and pleuritic adhe-
 sions and thickening.
   3.  Marked sinking in of the suprasternal notch, of the supraclavi-
 cular and infraclavicular spaces, of the intercostal spaces, and of the
 epigastrium—one  or all—synchronous with inspiration are indicative
 of diminished elasticity of the intrathoracic structures.  When more
 general or bilateral, then chronic diffuse disease, as extensive broncho-
 pneumonia, chronic bronchitis, peribronchitis, or fibroid phthisis are
 likely to exist.   Laryngeal or tracheal obstruction may be  the cause.
   When unilateral or local, thickened pleura or local pleuritic adhe-
 sions are likely to  exist.
                          PALPATION.
   Palpation—the  act of laying on the hand.   It is less useful than
 inspection, in  ascertaing  general  size, form, and movement, but is
 useful in determining  local  expansion,  and the  character of vibra-
 tions.
   The palmar surface of the hand should be laid gently and evenly
 on the surface.  If the hand be applied to  the surface of  the  chest
 while a person is  speaking, a  tremulous vibration will be  felt.   If
the individual  coughs, a  vibration is perceived.  Bronchitic  rales,
pleuritic friction, and aneurismal thrill will also give rise to a vibra-
tion  or fremitus.   Hence  we  have,
   1.  Respiratory fremitus—Produced by breathing.
   2.  Vocal fremitus—Produced by the voice.
   3.  Tussal fremitus—Produced by cough.
  4.  Bronchitic or mucous fremitus—Produced by bronchitis.
   5.  Pulsatile fremitus—Produced by aneurism.
   6.  Friction fremitus—Produced by pleurisy.
   Ordinarily when we use the term fremitus we  mean  vocal fre-
mitus.
  Palpation may also  detect  fluctuation.  In pneumo-hydrothorax,
or in a very large  cavity where  air passes in and out, the  sensation
of fluctuation may be felt by  the  hand.   Such  fluid is more  often 
principles of  physical diagnosis.
15
detected by succussion.   In order to have  succussion, there must be
both fluid and air in the cavity.
  Respiration.—The frequency and rhythm of respiration are also
noted by palpation.  The average in the adult is eighteen to twenty
respirations per minute.  Having counted  the respirations, put one
hand on the radial pulse and count pulsations, noting  the  relation
between the two.
  Normally the ratio of respiration to pulse is as one  to four.   It
takes four times as long for the blood to go through  the systemic as
through the pulmonic circulation.
  In disease the pulse respiration ratio is subject  to much variation.
In chorea it has been observed to be—
  Pulse : respiration :: 9 :1, and in hysteria, pulse  : respiration :: 5  :1.

                          MENSURATION.
  There are many measurements, but the principal is the  circular
taken on the level of the sixth costal cartilage.  The average  circular
                    Fig. 6.                               Fig. 7.

 Fig. 6.—Flint's Cyrtometer, with malleable arms of lead for mapping size and shape of
chest.
 Fig.:7.—Quain's Stethometer, with spring index, for measuring size of chest and degree of
respiratory motion.
chest measurement of a healthy adult male, five feet eight inches in
height, midway between inspiration and expiration, is 33 inches.  It
may go as high as 44, or as low as 27  inches.   The  average is  a
little less for women. 
16
PRINCIPLES OF PHYSICAL  DIAGNOSIS.
       Difference of Respiration of Men  and Women.

  Respiration in the male is mostly abdominal, in the female mostly
thoracic.  This  is  in  part  owing to  dress, but chiefly to  sex, as
women in pregnancy are  obliged to use the thoracic muscles in re-
spiration.
                      Circular Expansion.
  In ordinary quiet respiration, the circular expansion varies from
one-fourth or one-half an inch to one inch.  It may be as high as two
Fig. 8.—Barnes1 Spirometer.          Fig. 9.—Hutchinson'sISpirometer.
inches.   If  a person takes a forced expiration, and  the chest be
measured, and then a full inspiration and the measurement be taken,
the difference will represent the full expansive power.   It varies
from  two  and one-half to three  and one-half  inches, but  may be 
principles of physical diagnosis.
17
  more.  The expansive power for women should be about the same,
  though their stature is less.

                        Quantities of Air.
    The capacity for air is measured by a spirometer.  The air habitu-
  ally in the lungs, or  capable of being introduced into them by re-
  spiration, is divisible into various quantities:

      1. Persistent air.               4.  Tidal air.
      2. Residual air.                5.  Complementary air.
      3. Supplementary air.

                           Definitions.
    1. Persistent aw is that  which cannot  be removed from the lung
 structure by any possibility, not even by  heavy pressure after death.
 It is, however, removed by disease.
   2. Residual air is that which is never expired while the thoracic
 wall is intact, but which  escapes when the  chest-wall is opened on
 the cadaver, and atmospheric pressure collapses the lungs.
   3. Supplementary air is  that which is not expired  in ordinary
 breathing, but may be ejected by a forcible expiration.
   4. Tidal air is that which goes in and out in ordinary respiration.
   5. Complementary air is that which may be inhaled by a forced
 inspiration after an ordinary inspiration.
   The  first  three Dr. Walshe  calls stagnant air; the  last three
 represent  the total breathing  volume and are the  only quantities
 which can be measured by the spirometer.  The average amount of
 tidal air for a healthy adult  male is 26 cubic inches for each inspira-
 tion.  The greatest amount which the average male can inspire is
 174 cubic  inches.   Thus  it is  evident we do  not use one-half our
 lung power, even in health.

       Relative Length of Inspiration and Expiration.
   Inspiration, 5.
   Expiration, 4.
   Rest, 1.
   This relation  is changed in disease.   In advanced emphysema
expiration is two or three times as long as  inspiration.
          2 
18
principles of physical dagnosis.
                 Character of the  Two Acts.
  Inspiration  begins gently, increases gradually in intensity, till it
reaches the middle of the act, then gradually dies away, and is im-
mediately followed by expiration.
  Expiration begins actively, then instantaneously and gently passes
into rest. 
CHAPTER  II.
                          PERCUSSION.

  Percussion is  the method of  eliciting sounds from the chest in
health and disease, by striking the chest-wall with the finger tips or
the percussion hammer.   There are two methods :
  1. Immediate percussion.
  2. Mediate percussion.

                      Immediate Percussion
Is the direct striking of  the surface of the chest with the hand or
fingers.  This is  seldom practised.

                      Mediate Percussion
Consists in the interposition of some medium between the striking
hammer  or  fingers  and  the chest.   This is by far the most com-
Fig. 10. —Winterich's Percussion Hammer.    Fig. 11.—Ivory Pleximeter.
mon mode of percussion.   It  was  originated by Avenbrugger and
reduced to a science by Piorry and Laennec.  When the hammer
Fig 12.—Flint's Percussor.             Fig. 13.—Flint's Pleximeter.
is  used,  the interposed medium is  a  plate  of rubber  or ivory,
called  a pleximeter.  The hammer  and pleximeter are useful for 
20
PERCUSSION.
clinical  teaching, to  elicit very clear sounds and for uniformity of
stroke.
  The hammer of Winterich and the ivory pleximeter have  been
chiefly used abroad.  Flint substituted a hammer  of elastic rubber,
with handle of hard-rubber or ebony, and a pleximeter of hard-rubber.
  It is far better in practice to rely upon the fingers.

                     Mode of Percussing.

  One  finger of the left hand is used as a pleximeter or medium
and one or more fingers of the right hand are employed as  a  ham-
mer.  The palmar surface of the interposed finger should be  placed
in accurate and firm contact with the surface.  Percussion with one
finger may be performed by moving it at the metacarpo-phalangeal
articulation (the knuckle).  Such a method, however, requires much
practice to perfect  it, and  the stroke will bring out only dehcate
sounds.
  The rule is  to  strike from the wrist, without moving elbow or
shoulder.   We  thus describe an arc of a circle and bring the finger
at right angles upon the surface.  The blow should be quick and
sharp, and the  finger  instantly removed, in order to let the  chest
vibration continue.   When percussing over cavities, and not desir-
ing the sound to reverberate, the finger may be retained ^in contact.
A single percussion stroke over a given point is by many regarded as
better than repeated strokes.  Others, as Flint, prefer a succession of
five or seven  strokes.

                  Percussion Develops
Sounds indicative of:
    1. The degree of elasticity or tension  of the chest-wall.
    2. The condition of the contained organs.

             Properties of the Percussion Sound.
  1. Duration, the length of sound as regards time.
  2. Intensity, resonance, amplitude, or volume of sound.
  3. Pitch, referring to length of sound  wave, the acuteness, dul-
ness, or flatness of sound.
  4. Quality, what the sound suggests as to the condition of organs
underneath. 
PERCUSSION.
21
                          (1) Duration.
  The duration of the percussion sound varies perceptibly in  differ-
ent parts of the chest.  It is longer, for instance, over the lung sub-
stance than over the heart or liver.
  A  certain relation exists between the four properties of sound:
duration, intensity, pitch, and quality.
  With high  pitch there is diminished intensity, hard quality, and
brief duration.  With low pitch, more intensity, softer quality, and
longer duration.

                  (2) Intensity or Resonance.
  The resonance  is  not  due wholly to the underlying organ.  The
sound produced  by  percussing over the  lungs differs from that
caused by percussing over  the liver.  The difference is due, in
part,  to the proper tissue of the organs;  in part, to the fact that the
lungs contain air which modifies the sound, and in part, to their posi-
tion in the chest and relation to other organs.   Again, the sound over
the heart and the liver, both solid organs, is slightly different; that
which the  heart gives out is more intense,  of longer duration, and
lower pitch than that over the liver.
  Intensity or resonance, therefore, is due to :
     id) Consistency  of the organ.
     ib) Its contents—air or fluid.
     (c) The shape and elasticity of the walls encasing it.

                            (3) Pitch

Refers to the length of the sound wave.   We define it ordinarily by
saying it is the acuteness or dulness of the sound.   Over anything
solid, as  the heart or liver, we get high  pitch;  over anything less
solid, as over the normal pulmonary tissue, we get low pitch.
  The greater the quantity of air the lower the pitch.   Pitch is high-
est  over liquids, as over pleuritic effusion,  because liquids are most
dense.  Over gases, pitch is very  low indeed.   In  percussing,  we
find pitch high over the liver, heart, and muscle; low over lung
tissue, and over stomach lower still.
  Pitch frequently has connection with duration.  When the pitch
is high, the duration is short; when the pitch is low, the duration is
long. 
22
PERCUSSION.
                          (4) Quality.

  Quality or timbre suggests the nature of the subjacent or under
lying organs.  We have  hardness, softness, and hollowness.   The
hollow type occurs under three varieties, the tubular, amphoric, and
cracked metal!
  The Hard quality is wooden, resembling that yielded by mediate
percussion on a table.  It  follows percussion over the solid  viscera,
or over an infiltrated or solidified lung.
  The Soft quality is that yielded  by percussing over normal pul-
monary tissue and has been likened to the sound of  a drum covered
with coarse woollen cloth.
  The Tubular quality is  that produced by air in an elongated de-
fined cavity.  This quality is to  be detected over the trachea, and
over the primary bronchi.
  When anything solid lies between the large bronchi  and the cos-
tal surfaces, this sound is sometimes obtained ; thus it may occur in
the interscapular region from enlarged bronchial glands, and over a
great part of the back in case of  intrathoracic tumor.
  Small excavations in the lung, and dilatation of the bronchi may
produce this quality of percussion note.
  Amphoric quality is the tubular on a large scale. It resembles
the sound produced by tapping the cheek when the mouth is closed,
and  fully but  not tensely inflated.  The  common source  of this
sound is a cavity of large size near the surface, and  provided  with
hard and thin walls.
  Cracked Metal.—Cracked pot or cracked metal quality is an air
impulse sound—air in a cavity rushing against its walls. The  ampho-
ric quality is almost always coupled with this quality.  In the same
patient, percussion with mouth and nostrils closed will produce ampho-
ric sound,  and percussion with the mouth and nose open will produce
cracked-pot sound.   It resembles the sound resulting from striking
the back of the hands, loosely folded across each other, against the
knee, the contained air being forced out quickly between the fiDgers
at each blow.  If the chest of a crying infant  be percussed in expi-
ration, the resonance will be of cracked-metal quality, and it can be
produced  by percussion on the elastic chest-wall  of most young
persons.
  Tympanitic quality  results from an  unusual amount of  air con-
tained within a cavity  with elastic walls.  The sound is drum-like.. 
PERCUSSION.
23
 Typical tympanitic  sound occurs in  pneumothorax, and over the
 stomach, or intestines when distended by flatus.
   The sounds developed by percussion are not always dependent on
 an organ lying  immediately beneath.   Sound  may be conveyed
 across the chest.  It must be remembered that the whole chest is an
 acoustic box—all the contained organs modifying the sounds.

                            Muscles.
   The percussion note of muscles is  non-resonant, high, hard, and
 brief, as elicited by percussing the muscles of the shoulder or arm.

                             Heart.
   The  heart is  only a  great  muscle,  hence its  percussion note
 (superficial area) is high-pitched and hard.  These qualities  are less
 marked where it is overlapped by the lung (deep area).   Thus  we
 have superficial and deep sounds over an organ.

,                             Lungs.
   The  breathing surface of the lung is formed  by the dividing
 bronchi and bronchioles  and air-vessels, with elastic or connective
 tissue to hold them together.   The normal properties of percussion
 sound differ somewhat over different places.
   In the  infraclavicular region the intensity is considerable, the
 quality is true pulmonary—pitch low—duration  distinctly percepti-
 ble.  In the right mammary region the pitch rises some, even at the
 upper part, and is very perceptibly elevated at and below the fourth
 intercostal space, owing to the contiguity of that hard, solid organ,
 the liver (Walshe—Law  of  consonance).  Others explain this rela-
 tively high pitch of the right infraclavicular  region as due to the
 greater thickness of  the  pectoralis  major on this side, owing to the
 " right-handed" habit of  most persons.   A  third  explanation, and
 one quite generally accepted, is the proximity of the right primary
 bronchus and  its branches,  with peribronchial  structures, to the
 thoracic wall.  On the left side, according to the law of consonance,
 the heart will also influence the pitch of the percussion note of the
 superimposed pulmonary area.
   The left infraclavicular region is usually taken as affording the
 standard normal pulmonary percussion  note ("normal  pulmonary
resonance").  Flint  compares  the  normal percussion note to the
 sound elicited by percussing a loaf of bread covered with a napkin. 
24
PERCUSSION.
  The line of  pulmonary resonance at the base of the left lung  in
front, and  the  transition from resonance of  lung to flatness of the
liver on the right side, may be varied by forced inspiration and forced
expiration  as much as  three or four inches, and  Flint mentions as
great a variation as  seven  inches in exceptional  cases (see Flint,
"Manualof Auscultation and Percussion," p. 54, 4th edit., 1885).
  The intensity in the right inframammary region is diminished, in
consequence of  the presence  of the liver beneath the surface; the
pitch is high, the duration short, and the quality  is  " hepatic "  or
wooden.   The  note is  usually  regarded as superlatively." flat," as
distinguished from the lesser degree of high  pitch, " dull," and the
   Fig. 14.—Showing areas of percussion resonance and dulness of front of chest (Piorry).

opposite low-pitched condition  of lung, intestine, stomach,  etc.
—" resonant."
  The suprasternal region gives tubular resonance.  In the upper
sternal region the sound is of a somewhat mixed character ; and also
in the lower sternal region, where the stomach  may further modify
the sound.  It is in this region that difficulty is often encountered
in tracing the line of demarcation between the liver and the heart.
The diaphragm intervenes between the two organs, but  the percus-
sion note of one differs so little  from  that  of  the other that it is
often practically impossible to define the line of contact.
  A good rule  in that case is to draw a line  from  the point of the 
PERCUSSION.
25
heart's apex beat to the apex of the angle formed by the union of
the upper free edge  of the Hver  with the right free edge of the
heart.
  Over the trachea and large bronchial tubes the percussion sound is
tubular in quality, its intensity full, owing partly to the contained
air and partly to the walls of the tubes themselves; the pitch is low,
neither hollow nor tympanitic, and the duration is long and ringing.
  Over the aorta, gentle percussion gives a true pulmonary percussion
note; deep percussion lessens the duration and resonance, raises the
pitch and makes  the  quality hard.  If an aneurismal tumor exists,
the same modifications, intensified, will be present over a larger area.
        Fig. 15.—Percussion resonance and dulness of posterior regions (Piorry;.

  The posterior thoracic regions do not give the pulmonary sound
so well as the anterior regions, because of the thickness of the dor-
sal muscles.  When the scapulae are carried outward in the second
position  of  Corson  (see below), the interscapular areas  are nearly
doubled and sometimes more than  doubled, and  the muscles being
rendered  tense  and thin,  a normal  pulmonary  percussion note is
elicited, which continues as we descend and percuss the infrascapu-
lar regions.   Below the eleventh rib  of  the right side  the note is
high-pitched,  hard, hepatic.   By forced inspiration the Hver hne
may be lowered (behind) one or two inches.  Resonance does not
extend as far down on  the  right side as on  the left.   On the left 
26                         PERCUSSION.

side of the chest, posteriorly, below the  eleventh  rib, the spleen, if
large, or the stomach and intestines may modify the percussion note.
  The lateral regions of the chest  are more highly resonant.   On
the right side the percussion sound loses in volume and rises in pitch
as we go downwards toward the liver.  Below the sixth rib on  the
left side the sound is modified by the spleen and stomach.
   Fig. 16.-Position for percussion of front of chest; from a photograph by the author.
  The percussion note varies in character during the different peri-
ods of the respiratory act and according as the respirations are quiet
or exaggerated.
  The sound over the stomach is tympanitic, and over the intestines,
according as they are  empty, full of fseces, or distended with  gas^
varies from tonelessness to tympanitic resonance. 
PERCUSSION.
27
  The spleen gives the same hard, toneless, hepatic quality of sound
that the liver does.  It is located in the left inframammary region
from the eighth rib to the free border of the ribs and  back of the
axillary line.
       Positions of Patient for Percussion.  {Dr. Corson.)
           First Position  {for Anterior  Examination).
  Shoulders well  thrown  back; arms folded behind  the  back, to
make tense the muscles on the front of the chest (Fig. 16).
     Second and Third Position {for Lateral Examination).
  In  the one (Fig. 17) the hands are clasped upon  the top of  the
   Fig. 17.—Position for percussion of lateral regions; from a photograph by the author.
head, in  the other the arms are carried above the head and curved
horizontally, side by side, or each hand clasping the opposite wrist. 
28
PERCUSSION.
   The examination in the axillary hne high up, with the arm car-
ried over the head, should be made in all cases.   It must have  come
to the notice of very many physicians in  private practice, but more
often in the grouped cases  of general  hospitals, that in cases of
irregular  pleuro-pneumonia, and  in low and indefinite  forms of
pneumonia—the product of squalor, dissipation, malaria, or secondary
to phthisis—the initial area of pneumonic consolidation, as evidenced
by bronchial breathing (and percussion) has been  found only in the
axilla.

         Fourth Position {for Lyosterior Examination).
   Body bent slightly forward; head bowed ; arms  crossed in front
of the  chest;  or  better  still to clasp each shoulder with opposite
hand (Fig. 18.)
  Fig. 18.—Position for percussion of posterior regions; from a photograph by the author.

  I cannot better express my conviction that the resort to this fourth
position of Corson is a matter of the greatest importance in physical 
PERCUSSION.
29
diagnosis  than by quoting from  my monograph, on the  " Physical
Examination of Weak Chests." '
  " The importance of the interscapular exploration is such as to war-
rant a fuller consideration.  It is here that we have the larger bron-
chial trunks  and  the hilus  of  each lung  close to  the posterior
wall of the thorax.  But in the ordinary postures, with the  head
erect and  arms hanging  by the side, or even with the arms loosely
folded in front, the interscapular spaces are relatively valueless for
physical  diagnosis.  The scapula, on  either  side, covers the chest
from the first to the eighth rib, and comes within an inch of the pro-
cesses of the  vertebrae.   This intervening space on each side of the
spine is filled in deeply by the rhomboideus minor and major, which
span it obliquely from the vertebrae to the scapula, and to complete
the  muscular envelopment the trapezius extends from its median
origins at the occiput, the ligamentum nuchas, the cervical and twelve
dorsal  vertebrae, in converging bands, over the interscapular space
and  scapular blade, to its attachment on the spine of the scapula.
The value of the upper half of the back for percussion is therefore
slight, over these thick  flaccid  muscles and this interposed  bony
plate.  Most physicians recognize this condition and obviate it, in a
measure, by directing the patient to fold the arms.    By a forward
motion of the arms, the  claviculo-scapular  union, being  essentially
fixed, serves as a point of rotation, while the tension  of the deltoid
on  the spine of the scapula  directly antagonizes the  trapezius and
draws  the scapula laterally with slight rotation.   Dr. Corson,  more
than any other person, has emphasized the importance of taking ad-
vantage of the great mobility of  the scapulae as a means  of increas-
ing the interscapular area.
  " If the arms be crossed in front, each upward, at an angle of 45°,
and  the hand on either side is made to grasp the convexity of the
shoulder,  the clavicular  attachments  and the deltoid  so elevate, ro-
tate, and  draw outward  the scapulae, that the interscapular space is
increased  more than  twofold, and the previously flaccid and  thick
muscles are rendered tense and  thin, lying  firmly on the ribs, and
interposing no obstacle to percussion and auscultation of the bronchi,
and of the upper inner  borders  of the lungs.   Each intrascapular
area, before a rectangle of one inch width, extending  from the first

  1 " The Physical Examination of Weak Chests, and Differential Diagnosis
of the several Forms of Early Phthisis." New York Medical Record, May 9th,
1885. 
30
PERCUSSION.
to the eighth rib, is converted into a trapezoid whose upper truncated
apex is fully two inches wide and whose base is between three  and
four inches broad.  The lower angle of  the scapula is elevated to
the seventh rib.  This great gain in space, however, is not more
important than is the advantage from the thinning out of the trape-
zius and rhomboidei.  Finally, if the patient's head be  bowed, and
the  neck forcibly incurvated forward, the tension of  the  levator
anguli scapulae is added; it increases the elevation of the scapulae by
half an inch, and adds to the general tension of the dorsal muscles.
 The scapulas  have not only been  moved  laterally, but  the  thin
plates, as located, are firmly held between tense muscles, and inter-
pose a greatly diminished  obstruction to conduction of sounds.  I
would urge the resort to this position as greatly facilitating the study
of chronic bronchitis, peribronchial fibroid, and, indeed, of  all forms
of bronchial and pulmonary diseases."
  In properly interpreting the diagnostic significance of a percussion
note, we must remember  that the chest-wall and great vessels are
factors of the  sound.   I again quote from my paper on " The Physi-
cal Examination of Weak Chests."
  " Although  most authors and teachers of physical diagnosis recog-
nize the  composite nature of the pulmonary percussion  sound,  and
the several factors which unite to produce it, yet the impression  still
prevails that it is essentially the product and exponent of the under-
lying lung.  It would be undesirable to detract in the slightest de-
gree from the  confidence reposed in the diagnostic value of  percus-
sion.   But the exclusively pulmonary origin of percussion sound is
easily disproved.   This is most easily accomplished by a  brief refer-
ence to the percussion note of emphysema.   If, in emphvsema, the
percussion note were to correspond  to  the volume of air within the
coalesced air-vessels, and in the stretched  infundibuli and  dilated
terminal bronchi, we should obtain by  percussion the  prolonged,
low-pitched, tympanitic sound which the novice  in physical diag-
nosis is  always prepared  to hear.   To his surprise, the sound, al-
though possessed of some  tympanitic quality, is  curtailed in dura-
tion, and in its initial portion, at  least, is raised in pitch.  The
explanation is  simple.  The emphysematous lung  is an aggregation
of fused air-vessels and distended terminal air-passages; it  is a di-
lated lung,  with much of its  elastic  tissue  absorbed and deprived of
its expiratory contractibility.   The overlying bony thorax is, there-
fore, in a state of inspiratory fixation, and  so tense or rigid that it 
PERCUSSION.
31
does not vibrate.   Hence the  contact of the percussion finger tips
with a rigid thorax elicits a sound relatively high in pitch and de-
void of vibration or duration.  I will mention one further fact bear-
ing upon this question.   The middle and lower sternal regions over-
lie the anterior mediastinum, which contains  the great vessels, and
also cover  the body of the heart.  Yet, in some elastic chests, per-
cussion over the lower half of the sternum—the keystone  of the
elastic respiratory arch—elicits, not flatness, the product of under-
lying solid structures, but a sound essentially of pulmonary quality.
The elasticity of the chest-wall is undoubtedly an essential  factor
of,  or contributor to, the percussion note." 
                        CHAPTER  III.

            PERCUSSION OF THE ABNORMAL  CHEST.

  In percussing the abnormal chest, we note modifications or depar-
tures from the normal standard, viz.:
           Change in duration of the percussion note.
                 "    intensity   "        "       "
                 "    pitch      "        "       "
                 "    quahty    "        "       "
  The percussion note indicative of thickened pleura, pleuritic effu-
             Fig. 19.                             Fig. 20.
           Areas of dulness and flatness of phthisis at each apex.—Piorry.

sions, and pulmonary consolidations, becomes shortened in duration,
diminished in intensity, raised in pitch, and of lessened pulmonary
quality, or there may be entire  absence of  pulmonary quality with
a new quality diagnostic of the changed physical condition.  Dulness 
PERCUSSION OF  THE ABNORMAL CHEST.
33
and flatness are the terms usually employed to  indicate partial or
complete removal of " pulmonary resonance " or " normal percussion
note."
  Thus slight  consolidations give " dulness," i.  e.,  lessened  dura-
tion, diminished intensity, raised pitch, and  lessened or absent pul-
monary quality  (see  Fig.  19).   Pronounced  consolidation  gives
" flatness," i. e., short duration, want of intensity, high pitch, and
hepatic or wooden quality (see darker shaded centre of Fig.  19).
  In pleurisy with effusion  (see Figs. 20, 21, 22), there is absolute
Fig 21.                             Fig. 22.
flatness—a note  short, devoid of  intensity  or  volume,  superla-
tively high-pitchead, and wooden in quality.
  In pleurisy, also, the line of transition from pulmonary resonance to
flatness is often abrupt, as shown in Figs. 20-22, and  is changed by
change of position of the patient's body, as  illustrated in Fig. 21
(the shading of the left side of the chest indicating the  location of
the fluid when the patient is lying on the right side).
  Fig.  20  also illustrates  the flatness of pneumonia of the right
lower lobe—a percussion note superlatively short in duration, want-
ing in  intensity or volume, high in pitch, and wooden  in quality. In
thickened pleura, there are variable degrees of dulness and flatness.
           3 
34
PERCUSSION OF  THE ABNORMAL  CHEST.
In bronchitis, the percussion note is essentially normal.   In some
cases of acute  bronchitis, the resonance may be slightly intensified.
In chronic cases, there is often dulness or flatness due to interstitial
pneumonia and defective expansion of lung.
   In emphysema, as already stated, the rarefaction of the lung  tis-
sue lessens its elasticity and often renders the bony thorax rigid or
fixed.   Hence the percussion note is " vesiculo-tympanitic " (Flint),
i. e., short in duration, variable in intensity and pitch and of tym-
panitic quality.
   The statement with reference to the fluid level of percussion dul-
ness (and also of transition  from sounds to silence by auscultation)
in pleurisy demands modification.   Whereas  Piorry and  most  au-
Fig. 23.—Ellis line—front.                  Fig. 24.—Ellis line—back.
thors until recently described the hne of  dulness  as  horizontal (see
Figs. 20, 21, 22), it is now generally conceded that the "Ellis line,"
as shown  by  Garland and others,  is demonstrable  in  a consid-
erable number of effusions, half  or  two-thirds filling  the pleura.
Thus, as shown in  Figs. 23, 24, the hne  of  dulness  is a letter S, or
warped letter S, low behind near  the vertebral column, going  in a
curve obliquely upward and around the side,  where the fluid level is
highest, and again descending in a slightly curved hne in front to
the mid-sternum or part way across the opposite side, if the fluid accu-
mulation has compressed the opposing lung and displaced the heart.
The area of relative resonance behind near the spine is due to the
lung  near its  root  resisting the invasion of the fluid.   The  dif-
ference on the  side and in front must result from the distribution of 
PERCUSSION  OF THE  ABNORMAL CHEST.
35
the stiff bronchi in the lung, rendering its collapse less in the lateral
than in the antero-posterior axis.

             The  Sense of Resistance in Percussion.
  The subject of  percussion would be incomplete without mention
of the impressions received by the  interposed  finger, which is the
medium or intermedium employed as a substitute for the pleximeter.
The finger receives the  percussion  stroke, transmits it to the chest-
wall, and in return is met with a variable degree of resistance, ac-
  Fig. 25.—Myoidema—cutaneous reflex of Graves and Stokes, Gardner, Finlayson, and Tait.
Photographed by the author from a patient in Bellevue Hospital (four seconds exposure).

cording as the chest-wall is elastic  and yielding, or rigid and ossified,
and again  according as the intrathoracic contents  are  elastic and
cushion-like (normal lung), or hard and resisting in variable degree
(mildly so in a poorly expanded chest and in  early phthisis,  more
pronounced in advanced phthisis  and in  pneumonia, superlatively
hard  and resisting over  pleuritic fluid,  the liver, heart apex, or
tumors).  The interposed  finger  acquires a  trained expertness—a
" tactus eruditus " as applied to chest signs—in estimating the density
and resiliency of chest-contents and chest-wall. 
 36            PERCUSSION OF THE ABNORMAL CHEST.

        Myoidema  a Product  of Immediate Percussion.
   While  immediate percussion (direct  blows upon the  chest-wall,
 with no interposition of the finger or other medium) is not resorted
 to  to elicit acoustic  signs, it does develop an associated  sign—little
 reflexes of the skin  and also of  the pectoralis major.  They chiefly
 respond  to quick percussion with the  finger tips in actively pro-
 gressing  or  fully developed phthisis, and  are  indicative of the
 effect of elevated temperature and tissue waste upon the thoracic
 action of  the spinal  cord (Fig. 25).  The clinical coincidence of this
 " peculiar momentary starting and elevation of the skin " (Finlayson),
 these muscle  tumors (Graves and Stokes) or " myoidema "  (Law-
 son Tait),  with the  true tubercular  form of phthisis, renders the
 search for them of some  diagnostic value, though more important
 as bearing in prognosis.  Myoidema is chiefly  found over tuber-
 cular  deposits  and  areas of  softening and  cavity  in the  infra-
 clavicular and upper part of mammary region.   The muscle tumors
 are perceptibly  resisting  to  feel,  are conoidal,  blanched in  color,
 and remain raised from three to  five  seconds, in rare instances eight
to twelve seconds. 
CHAPTER IV.
                        AUSCULTATION.

  Auscultation means the application of the ear to the chest for the
detection of normal and abnormal sounds.
  By auscultation of the respiratory organs, we may hear
     1. Normal breath sounds.
     2. Normal voice sounds.
     3. Abnormal breath sounds.
     4. Abnormal voice sounds.
     5. New sounds.
       {a.)  Sound resulting from a combination of above.
       {b.)  Sounds having no connection with either voice or breath
           sounds.
  We distinguish in these sounds the following properties :
     1. Duration.               4.  Quality.
     2. Intensity.               5.  Rhythm.
     3. Pitch.
                  These Properties Defined.
  1. Duration, the period or persistence of the sound, usually pro-
portionate to intensity.
  2. Intensity is the degree of resonance, the volume, or amphtude
of the sound.
  3. Pilch refers to the acuteness of sound, whether the sound is
high or low.
  4. Quality is that property which reveals something of the char-
acter of the substance emitting or conducting the sound.
  5. Rhythm  refers to the recurrence  of sounds, whether  this be
uniformly regular, or irregular and jerking.

                  Methods of Auscultation.
  1. Immediate, if the ear is applied to the chest.
  2. Mediate, if an instrument be used. 
38
AUSCULTATION.
                        The Stethoscope.
  The  instrument used in mediate ausculation is  a stethoscope.
The original stethoscope of Laennec was a hollow cylinder of wood,
having an expanded end, its longitudinal axis being parallel with the
grain of the wood.
  Stethoscopes  have also  been made of  other materials, as glass,
gutta-percha, metal, and ivory, but wood is preferable.
  Their shape  has been modified by various  auscultators to  meet
fancied acoustic requirements, but the straight stethoscopes of Stokes
Fig. 26.        Fig. 27.        Fig. 28.         Fig. 29.          Fig. 30.
          Straight stethoscopes of various patterns (Hughes Bennett).
and  Dobell  abroad,  and of  Barclay,  Loomis,  and  others  in  this
country, are  essentially of one pattern.
Fig. 31.—Barclay's Stethoscope.
   The Barclay is simplest in form  and most generally used.   The
solid stethoscopes are usually perforated by a central bore, extending
the entire length; the necessity or advantage of this is doubtful, and
many  of the best,  as " Cammann's  auscultator" and " intercostal
auscultator " (see Figs. 55, 56, p. 69), are without bore.   The value of
the solid and straight perforated stethoscope  is not generally appre-
ciated, owing to the greater convenience, attractiveness, and appli-
cability  of the  binaural stethoscope  of  Canimann, which, in this
country at least, is  almost synonymous with stethoscope, so little
is any other used or known. 
AUSCULTATION.
39
            The Double or  Binaural  Stethoscope.
  The binaural stethoscope was invented by the late Dr. Cammann,
of New York, and is very largely used  in this country.  Its use is
discouraged by many  English  and Continental  writers.   Their
criticism is that it  not  only intensifies  sounds, but also materially
changes them, altering their pitch and quality.  While this criticism
is in a measure true, yet  the relative properties of different chest
    Fig. 32.                        Fig. 33.
Fig. 32.—Cammann's stethoscope with Snelling's rubber bell.
Fig. 33.—Cammann's stethoscope—Ford's spring.
sounds, normal and abnormal,  as  heard by the stethoscope can  be
compared, and the modification due to the instrument, as well as
adventitious sound developed in the  instrument itself, come to  be
excluded by the practised  ear.  The intensification  of sound  then
becomes a desideratum and the localization of  sound by the instru-
ment is of equal value. 
40
AUSCULTATION.
  The original instrument as devised by Cammann has been variously •
modified as  to shape of the ear tubes, the pectoral or receiving tube,
and the length of the intermediate flexible rubber tubes.  The in
terposition of  very flexible tubes, as figured in Da Costa, and of fric-
tion sockets of hard-rubber for separating the metal tubes,  injure
the acoustic qualities  of the  instrument.  The substitution of the
spring joint of Ford (see Fig. 33) for  the  elastic  band or spiral
spring is desirable, as the latter often  are vibrated by  the breath of
the listener or  his movements or those of the  patient.  A non-
disjointing or " one-piece " stethoscope,  with short, fine elastic rub-
ber tubes connecting pectoral tubes and  ear tubes (see Figs. 32, 33)
should be selected.
Fig. 34.— Allison's differential stethoscope.
  Snelling's soft rubber cup is employed on Cammann's  stethoscope
in examining emaciated patients.
  The Scott Allison differential  stethoscope is intended for coinci-
dent observation of the two sides.  It is still employed abroad, but
has never found favor in this country.  The sounds can be  better
appreciated and compared if heard consecutively by the Cammann
instrument.
  The habitual use of  the stethoscope to the exclusion of the ear is
to be deprecated.   I advise dependence upon the ear in most cases
of well-defined chest disease.  The stethoscope may be  further em-
ployed to confirm doubtful signs.  Most cases  may with advantage
be subjected to careful examination by the unaided ear  and stetho-
scope alike, but it is unfortunate to destroy the training of the  ear
and create a dependency on the stethoscope. 
AUSCULTATION.
41
Special Reasons for Use of the Stethoscope rather than the
                              Ear.

                     (mediate auscultation.)
  1. The localization of sound, as of a small cavity or heart-lesion.
  2. The intensification of certain sounds, not distinctly developed.
  3. The exclusion  of extraneous  sound  in  noisy  habitations or
lecture rooms.
  4. The avoidance of  chest  exposure.  The delicacy  of  ladies is
favored.
  5. In hospital  and dispensary,  or other charitable  practice,  it
obviates contact of the  lecturer with the bodies  and clothes of un-
cleanly patients.

          Objections  to the  Use of  the Stethoscope.
  1. The interposition of the stethoscope  may intensify and other-
wise modify and  change sounds.
  2. The training of the ear is liable to be neglected, and confidence
in its interpretations lessened.
  3. Too habitual use of the stethoscope, with  its intensification of
sounds, in clinical teaching and practice, may positively impair the
previous delicacy of the ear  for sounds of normal intensity.
  These objections  will not hold with  persons who employ  the
stethoscope for its legitimate use,  conjointly with direct listening.

                    Auscultation in  Health.
  We listen to the chest in health, to detect
     1.  Normal respiratory sounds.
     2.  Normal voice sound  (vocal resonance).
     3.  Normal whisper sound.
     4.  Normal cough (voluntary) sound (tussal resonance).

                 1.  NORMAL RESPIRATORY  SOUND.
  We first listen to the respiratory sounds.  The respiratory act is
double, yet  in one-fourth of all healthy persons  (in quiet breathing)
expiratory sound is wanting, /. e., in one-fourth of all normal chests
(in  ordinary respiration),  only inspiration is heard  (Walshe).  In
three-fourths of normal chests, expiration is faintly heard, and in but
one-fourth or one-third as long as expiration.   And yet expiration
as a physical act is four-fifths as long as  inspiration.   This is im- 
42
AUSCULTATION.
 portant to  remember, since the auscultator, while resting his head
 on the patient's chest, takes cognizance of the duration and rhythm
 of the thoracic movements, as well as of the respiratory sound.

               RATIO OF  INSPIRATION  TO RESPIRATION.
     1.  As a physical act.
                                 Inspiration......5
            Respiratory rhythm -\ Expiration......4
                                [Rest...........1

   •  2.  As producing sound (heard over the chest surface).
                       Inspiration, 3 to 4.
                       Expiration,   1.
   But if the stethoscope be  held to  the  slightly opened mouth of
 a person in normal breathing, the inspiratory and expiratory sounds
 will be found to  have the  same relative  duration  or  period  as the
 physical acts  which determine them.  The explanation  is simple:
 1st,  in inspiration the inspired air is drawn  into a system  of steadily
 diminishing tubes and against numerous bifurcations and septa, as
 well as into expanding alveoli and intervesicular structures ; thus air
 and   tube  friction  sounds  and tissue  expansion  sounds  are de-
 veloped:   2d, the  entire volume  of produced sound  is moving
 towards the chest-wall, and  the ear  or stethoscope of the listener.
 Reversely : 1st, in expiration the  air retreats out of a  system of
 steadily increasing tubes; a lesser air and tube friction sound is thus
 produced.   2d, the lesser sounds thus produced are receding away
 from the chest-wall and the ear of the listener.  Such an understand-
 ing  of inspiratory and expiratory forces and acoustics  is essential to
 the intelligent interpretation of the abnormal changes in  expiratory
 sound as to duration and pitch.

           CHARACTER OF  NORMAL  INSPIRATORY  SOUND.
   Inspiration  (as  heard over  the chest-wall) is  a soft, breezy sound,
 neither moist  nor dry.  It is faint at its  inception, increases in in-
 tensity  or  volume to its mid-period,  and gradually subsides.   The
 inspiratory sound occupies  the entire period of the physical  act of
 inspiration.  It has normal or full  duration, normal  intensity, low
pitch, and true pulmonary quality.   Its  rhythm is steady, uniform,
 continuous.  The inspiratory sound,  like  the inspiratory  movement
 of the  thorax upon its completion, is  immediately  followed by 
AUSCULTATION.                       43
 the  expiratory  sound.  Any  perceptible interval  following in-
 spiratory sound and preceding the expiratory sound is indicative of
 abnormal conditions, except  when patients  from  nervousness or
 fright of examination hold back the expiratory act.

            CHARACTER OF NORMAL  EXPIRATORY SOUND.
   The expiratory sound (as heard over the chest-wall) is  not one-
 third or one-fourth  as long as the  inspiratory sound.  It is more
 flowing, more hollow  (Walshe),  and the  vesicular  quality (breezy
 and  soft) is  wanting  (Flint).  By  some  it is described as higher,
 by  others as  lower  in  pitch than  inspiratory sound.   The  latter
 is  the  more  correct  statement.   Unlike  inspiratory sound,  the
 expiratory sound does not  extend over the  entire  period  of the
 expiratory physical act or expiratory movement of the thorax.  It
 begins coincident with the expiratory act, but continues over only
 the first third or at most half of the expiratory period.  The expira-
 tory sound  follows  immediately  after inspiratory  sound without
 interval,  but  expiratory sound  is followed by a distinct period of
 rest.

                   THE RESPIRATORY MOVEMENTS.
   Respiration  is  automatic  or  involuntary   under   most  circum-
 stances.   This is what we designate quiet or  normal respiration.
 When voluntary effort is superadded, we then have exaggerated or
forced respiration.
   Inspiration is the product of active forces;  the  expansion  of the
 bony thorax by muscular traction  increasing the volume  of the
 thoracic cavity, thus inviting, by suction and external atmospheric
 pressure,  an ingress  of air through the  mouth and air passages.
 Expiration is relatively a passive  act,  a subsidence  or collapse of
 thoracic and abdominal parietes and diaphragm, with contractility of
 pulmonary tissue and  air tubes, and consequent retreat of the expira-
 tory currents.

          ELEMENTS OF THE NORMAL RESPIRATORY SOUND.

     1. Air and tube friction sound, developed in the pharynx.
     2.   "       "     "       "        "       "     larynx.
     3.   "       "     "       "        "       "    trachea.
     4.  "       "     "       "        "       "     bronchi. 
44                       AUSCULTATION.
     5.  Sound developed in the air vesicles.
     6.    "       "       "    parenchyma of lung.
     7.    "       "       "    muscles   of  chest-wall  (muscular
                                  sussurus).
  1. The pharyngeal element of inspiratory sound may be heard by
gently placing the stethoscope beneath the ramus of the jaw.   It is
             Fig. 35.                             Fig. 36.
           Fig. 35.—Air passages and lobules—site of normal respiration.
           Fig. 36.—Showing bifurcation of trachea and bronchi.

faint if the pharynx  is not constricted or tumefied by mucous  or
submucous  swelling or enlargement of the  tonsils,  and does not
enter into normal respiratory sound as heard over the chest-wall.
  2. The laryngeal  element of  inspiration and  expiration is more
 
AUSCULTATION.
45
pronounced, and may be demonstrated in all persons, by placing the
stethoscope over the side of the larynx.   It also is  heard over the
upper part of the trachea, but is not  conveyed to the chest surface
over the lungs proper.  But laryngeal sound, when exaggerated and
stridulous  as  in laryngitis, stenosis, etc., may extend to the front
and sides of the chest.
  Obstruction or roughening is  therefore essential to sufficiently in-
tensify pharyngeal and laryngeal sounds to render them observable
as elements of respiratory sound.
  3. The  tracheal element is audible with the ear  or  stethoscope
over the upper sternal  region.  In  inspiration the incoming  air
comes against the sides and bifurcation of  the trachea, and  a  sound
            Fig. 37.                               Fig. 38.
               Fig. 37.—Terminal bronchus and vesicles.
               Fig. 38.—Schem atic representation of air vesicles.

 of tubular and hollow character is contributed to inspiratory sound,
 and in a lower degree to expiratory sound.
  4. The bronchial element.  In a precisely similar manner, but to
 a greater degree, owing to the repeated bifurcation or subdividing and
 branching of the bronchi, air and  tube friction sounds are devel-
 oped, and contribute  to the bulk of the respiratory  sound.
  The degree to  which  the tracheal and bronchial elements  are
present differs with age and  sex.
  The tubular or bronchial element is more marked in children, and
both inspiration and expiration may be intense and harsh, designated
" puerile breathing,"  and  expiration may also be  heard during the
entire period as a physical act.   Such sounds in an  adult would de-
 
46
AUSCULTATION.
note disease.  Women  breathe  largely with the upper part  of  the
chest.   We are more apt  to  hear the expiratory sound in women,
and the bronchial element is harsher in men.
   5. The vesicular element.
   Vesicular  breathing  is  a breezy, fine, continuous sound, at least
continuous  in inspiration.   It is essentially absent in expiration
Fig. 39.—Distribution of terminal tubes and vesicles (Woodhead).
(Flint).  There are many and opposing theories as to the  cause  of
the normal vesicular sound.  Some claim that air in passing through
the ultimate bronchial tubes, and by dilatation of their walls, pro-
duces the vesicular murmur.
  According to the views of others, as the  air leaves  the ultimate
bronchial tubes, which are more or less rigid, and which terminate 
                         AUSCULTATION.                       47

in the more expanded and elastic infundibuli, the changed pressure
or release from the confined tubes to the air  spaces is the cause of
the sound termed vesicular.
   6. The  parenchymatous  element.   Some authorities maintain
that the  inspiratory expansion  of  the air vesicles is adequate to
create fine sound in the interstitial or extra-vesicular tissues of the
lung, producing or contributing to produce the so-called " vesicular "
sound.
             7.  THE ELEMENT OF MUSCULAR  SUSSURUS.
   The muscular action going on in the chest-wall gives rise in some
persons to a peculiar buzzing sound, termed  muscular sussurus ; its
amount does not seem to be directly as the muscularity of the indi-
vidual.   It is increased by efforts  of  all kinds, as for instance, that
of maintaining an uncomfortable posture ; it is continuous, not syn-
chronous with respiration, and  rather increases  than diminishes in
intensity when the breath is held.  It may  in some places be sus-
pended by putting the muscles in a state of relaxation, but in the
infra-axillary regions, where it  is  sometimes highly marked, it can-
not be thus arrested.
  The recognition by all practitioners and  students  of the precise
nature of this sound is of the utmost importance.  I  am satisfied 
48
AUSCULTATION.
  that it is a common source  of error to misinterpret this fine, low-
  pitched, multitudinous sound as a product  of vesicular expansion,
  and to regard it as evidence of healthful lung expansion.
    The  habit  of having patients  " breathe deeply " or  " hold the
  breath," either exercising the muscles or placing them in a condi-
  tion of tension, invariably develops this  misguiding sound; quiet
  breathing and holding the breath at the end of expiration eliminate
  it.
                  2.  The Normal Voice  Sounds.
                        vocal resonance.
   If we put our ear to the surface of a healthy chest while the per-
  son is speaking, we  do not  distinguish the distinct and  separated
  syllables spoken, but instead the "vocal resonance."   It is a rever-
  beration of the  voice  in the  air passages,  and brought  to the ear
  through normal  lung, a medium of poor conducting quality.   It is
  therefore low in pitch, of about the quality  of  the speaker's voice,
  but disseminated, reverberating, resonant, and vague and distant. It
  varies according as  the speaker's voice is high pitched or a  low-
 pitched  bass or baritone, being more pronounced with low-pitched
 voices.  It also  depends largely upon  the  size or calibre  of the
 bronchi.   The custom with Prof. Flint was to direct his students to
 listen with the stethoscope, during phonation, first  over the larynx,
 next over the trachea and large bronchi, and finally over the pulmo-
 nary substance.  Such  a procedure gives one the most  correct  con-
 ception of the modification  of the laryngeal voice after dissemina-
 tion in the system of bronchi and transmission  through pulmonary
 structure.
   On  the other  hand,  changes in pulmonary structure modify the
 normal pulmonary resonance.  When the air sacs are dilated and
 the pulmonary tissues have  lost resilicency, as in emphysema, vocal
 resonance is lessened.  Reversely, in consolidation of  the lung from
 any cause, as inflammatory exudation of pneumonia or  a deposit of
 tubercle  in the lung, the vocal resonance is  modified and  raised in
 pitch by  the  better  conducting  mediums, and becomes bronchial
 voice or bronchophony.
  When fluid is present in the pleura, if but a thin stratum, it modi-
 fies the vocal resonance  by giving it a nasal or goat-bleating quality,
 designated aegophony;  if the fluid be abundant, being  a  bad con-
ductor, as a rule voice and vocal resonance are partially or complete-
ly masked. 
AUSCULTATION.
49
  When, however, the pleural cavity is tensely distended with fluid,
epsecially with  pus in empyema,  a marked degree  of bronchial
voice may be present.  This has been variously explained as: 1, con-
ducted by the  chest-wall  from the  compressed  lung above; 2, as
transmitted by  bands of  pleuritic adhesions;  3,  as  produced in  a
stratum of collapsed lung immediately above the fluid which  has
replaced it.
  In auscultating the voice, it is proper to stop the opposite ear with
the finger to exclude the external transmission of  the patient's voice.

                    3. THE NORMAL WHISPER.
  The very slight  whisper conduction in health  is  an important
negative sign.   Whispering is an expiratory act, and special syllables
or words phonated in whisper are heard distinctly by the stethoscope
over the larynx, but are not heard over the area of lung structure
except as faint, puffing sounds or exaggerated expiratory sound.

                    4. THE TUSSAL RESONANCE.

            Normal Conduction of the Cough Sound.
  The remarks made as to the production of vocal resonance and its
modification in disease will apply to tussal resonance.  It is a valu-
able corroborative sign.
  The above enumeration of the sounds to be observed and studied
in the  healthy  chest does not differ materially from that given by
Flint.
  It differs chiefly  in more fully emphasizing the composite nature
of normal  respiratory sound, especially inspiration, its reference to
the confusing element of muscular sussurus, and the addition of tussal
resonance (voluntary cough).
  Flint recapitulates the sounds as heard in health as follows:
  1. Normal laryngeal and tracheal respiration.
  2. Normal vesicular murmur.
  3. Normal vocal  resonance.
  4. Normal bronchial whisper.
  Before proceeding to the consideration of the sounds detected by
auscultation of the  respiratory organs in disease, it may be well to
state the acoustic laws applicable to  the chest in  both health and
disease.
          4 
CHAPTER V.
ACOUSTIC  LAWS  APPLICABLE  TO  NORMAL  AND ABNORMAL
      SOUNDS DEVELOPED IN THE RESPIRATORY  ORGANS.

                  Chest Acoustics.   (Walshe.)
1. Unison resonance.
Reinforcement by thoracic walls.                     Methods
2. Consonance.                                Y of development
Reinforcement by other organs.                      of sounds.
3. Echo.
                    (1) Unison Resonance.
  By unison resonance  is meant the reinforcement of sound by the
thoracic walls, as occurs in the box of a guitar or violin, when notes
are produced from their strings, or as  when a music  box, instead of
being held in the  air, is placed on a table.  There can be little doubt
that  in the  natural condition of  the  chest the principle of unison
resonance is illustrated.

                        (2) Consonance.
  By consonance in music is meant the reproduction of certain notes
of instruments or of the voice by other instruments standing near.
It is difficult to prove that there is in the chest a repetition of sound
by consonance, but contiguous structures, notably the liver, stomach,
and intestines, exert a modifying influence upon the chest sounds.

                           (3) Echo.
  Repetition of sounds.   The echo is not heard over the vesicles,
but in a cavity, as in phthisis or  pneumothorax.

  Abnormal  Sounds Referable to the Respiratory  Organs.
  We should study the abnormal sounds, as we did the normal, with
reference to their five essential properties (Walshe), viz. : 
ABNORMAL sounds.
51
       Duration,
       Intensity (volume, amplitude),
       Pitch,
       Quality,
       Rhythm (regularity of development and recurrence).
  The term resonance, as employed in both percussion and ausculta-
tion, cannot be said to correspond  exclusively to intensity, but com-
prises  elements of  full  duration, intensity, and low  pitch.   It  is
proper to speak of the resonance of sound, but the term is generally
descriptive rather than specific.

Classification of Abnormal Sounds Referable to  Diseases of
                    the  Respiratory Organs.

             1. modifications of the normal sounds.
1. Modifications  of  re-
     spiratory sounds.

2. Modifications of voice
     sounds.
h by
3.  Modifications of whis-
    pered sounds.      j

4.  Modifications of cough
    sounds.
 1. Change in shape and calibre of air pass-
      ages.
 2. Changes in mucous and submucous lining
      of air passages.
 3. Changes in  peribronchial connective tis-
      sue.
 4. Changes in air vesicles, as to expansion,
      contraction, and contents.
 5. Changes in pulmonary parenchyma, inter-
      vesicular or interstitial tissue.
 6. Changes in visceral and parietal pleura.
 7. Changes in the contents of the pleura.
[8. Changes in thoracic parietes.
Produced in -I
     2. ADVENTITIOUS SOUNDS.

                    j" a—large,
1. The air passages J b—medium,
                    [ c—small.
2. The air vesicles.
3. The parenchyma of interstitial lung structure.
4. The pleural cavity.
5. The pleural walls, either separated or adherent.
  The  above  classification is not an  arbitrary  or artificial  one;
neither is it theoretical.  It is logical and natural, based upon the
physical conditions with which we  have  to deal, of the structures
producing the sounds and |the structures transmitting or conducting
them to the ear. 
•   52
ABNORMAL  SOUNDS.
               Interpretation of Modified Sounds.
   The modification may be in development or conduction.  Laryngeal,
 bronchial, and  vesicular  abnormalities are the chief causes of modi-
 fied development of sound.   Pathological changes in the pulmonary
 parenchyma and vesicular arteries and in the pleura are the chief
 causes of modification of normal sounds by induction.   Frequently,
 auscultation alone  cannot determine  to what  extent the  modified
 sound is the product of developmental  causes,  or the  product of
 changes in the conducting media.   The  conjoined  methods  of
 palpation, percussion, and auscultation may be necessary in order to
 definitely or even approximately diagnosticate the diseased conditions
 which are  the  cause of the abnormal properties  or modifications
 which we observe.

            Interpretation of Adventitious Sounds.
   The interpretation of adventitious sounds must vary for different
 conditions.  In some instances, the sound is specific and pathognomo-
 nic of a single  underlying pathological condition or lesion.   More
 often it may  represent  several  possible morbid conditions  of  the
 subjacent structures,  and a process of differential diagnosis must be
 conducted.
   In such  a  differentiation we  may be compelled to  go beyond
 simple acoustic laws,  and include  clinical  history, symptomatology,
 and pathological data.
   Important points in the interpretation of adventitious  sounds will
 be:
   1. The co-existence of adventitious and normal  sounds in the same
 area.
   2. The replacement of normal by  adventitious  sounds  in a given
 area.
   3. The gradual transition from normal to adventitious sounds in a
 given area, or existence in marked contrast in adjacent areas, or on
 the corresponding parts of the opposite sides of the chest.
   4. Properties of  the adventitious  sounds which by acoustic law
 denote a definite condition.
   5. Empirical knowledge, based upon clinical  experience of dis-
 eases having the observed sounds  and pathological data as  to  the
lesions found to exist  associated with such  sounds. 
ABNORMAL  SOUNDS.
53
        Special Study of Abnormal Respiratory Sounds.
   The respiratory  sounds  in  disease may  undergo, according to
 Walshe,
                   1. Duration and intensity.
                     {a.) Exaggerated.         (c.) Suppressed.
                     (b.) Weak.
                   2 Rhythm:
                     {a.) Jerking.     {d.)  Unfinished.
   Changes of   -{    $') Divided.     (e-)  Altered ratio of inspira-
                     {c.) Deferred.         tion to expiration.
                    . Quality, pitch, and rhythm combined :
                     {a.) Harsh.           {b.) Blowing.
                         Rude.               Tubular.
                         Bronchial.            Cavernous.
                                              Amphoric.
   Flint gives a much simpler classification and that which is gener-
 ally followed  by teachers and practitioners  in  this country, viz.:
 Taking " vesicular respiration " as the condition of healthy breath
 sound, he classified the departures as
                 1. Broncho-vesicular respiration.
                 2. Bronchial             "
                 3. Vesiculocavernous    "
                 4. Broncho-cavernous    "
   " Vesicular  respiration" is indicative  of  normal activity of the
 vesicles and normal elasticity and structure of the interstitial tissues
 and other conducting media.
   " Broncho-vesicular respiration " denotes a diminution in the vesic-
 ular quality of respiratory sound, and a raised pitch with bronchial
 quality, the  product of slight  interstitial deposit, consolidation, or
 conditions for better conduction of sound.
   " Bronchial respiration " or " bronchial breathing " (see Fig. 41)
 denotes absence of the vesicular quality and  the  conduction to the
 ear of the bronchial or tubular element of  breath-sound, greatly raised
 in pitch by reason of the consolidated structures through which it
 it has to pass.
   " Vesiculocavernous respiration " (Fig. 42) designates a condition
 where pulmonary structure immediately surrounding a cavity  gives
 rise to normal or vesicular sounds, which are heard associated with
the cavernous sound. 
54
ABNORMAL sounds.
   "Broncho-cavernous  respiration" (Fig. 42) is the product of a
consolidated area immediately surrounding an excavation, the  two
sounds being heard associated or coincident.
   For the description of typical  diseases, this classification  is most
useful and practical.  The  term  " broncho-vesicular," devised by
Dr.  Flint, has  come to be  generally used  in place of the  terms
"harsh," "rude," and even " tubular," formerly employed to desig-
nate the  quality of respiration  existing in slight  pulmonary consoli-
dations.
   But for purposes of exact  differential diagnosis in  complicated
           Fig. 41.                                  FIG. 42.
                      Fig 41.—Consolidation of Apex.
  Bronchial breathing, voice, and cough; dulness on percussion, plastic pleural sounds, and
bronchial rales.
                   Fig. 42.—Consolidation with Cavities.
                Bronchial breath and voice cavity; also gurgles.

cases, as of chronic bronchitis, associated bronchitis and emphysema,
fibroid phthisis, the broader enumeration of  Walshe  serves  a most
useful purpose.
  1. Duration and intensity : a, exaggerated—in bronchitis.
                             b, weak in convalescence.
                             c, suppressed — in   fibroid   phthisis,
                                   pleuritic thickening,  and intra-
                                   pleural fluid.
 
ABNORMAL SOUNDS.                      55
2. Rhythm:  a, wavy breathing in  nervous  respiration, in slight
                 peribronchitis.
              b, divided breathing j in various  degrees of bron-
              c, jerking breathing j   chial thickening,  peribron-
                 chial  exudation, chronic interstitial pneumonia,
                 fibroid, and tubercular phthisis.
When the heart's action is violent,  throwing the blood into  the
  Fig. 43.—Dilated Bronchi (Loomis).
Retarded expiration; cavernous expiration.
lung with force sufficient to interrupt or divide the respiratory act,
we have a divided breathing, an inspiration with four or five parts.
Fig. 44.                               Fig. 45.
 Fig. 44.—Emphysema, terminal tubes and air sacs dilated.
 Fig. 45.—Advanced stage of .'above.
   {d) Deferred  Inspiration.—When the  inspiratory  action  com-
mences and continues for a short time before sound is produced, it
is  said  to  be deferred.  This is remarked in  emphysema.    (See
Figs. 44, 45, 46.)
43 
56
ABNORMAL SOUNDS.
  {e) Unfinished Inspiration.—In certain cases the inspiratory sound
ceases before the chest expansion has been completed.   This occurs
only over exceptional cases of consolidation.
  {f) Deferred expiration or altered ratio of inspiration and expira-
tion is to be noticed.
  In health,  expiration is one-third  or one-fourth of inspiration.
In emphysema, expiration is greatly prolonged, and may be twice or
even four times as long as inspiration.
  3. Changes in quality, pitch, and rhythm combined.
  {a) Harsh or Rude Respiration.—Both inspiratory and expiratory
sounds have  lost  their soft,  breezy character,  and have become
sharper, higher in pitch, and more blowing in character; the ex-
piratory sound is perceptibly  audible, raised  in pitch, and prolonged.
Harsh or rude respiration is heard in condensation of the lung  to  a
slight degree.   In the dryness of mucous membrane of bronchi, as
         Fig. 46.—Section of emphysematous lung showing portion of surface.

in the first stage of bronchitis, we have an air and a tube friction
sound, but not raised in pitch.   All the elements of normal respira-
tion are exaggerated.
   {b)  Blowing  Sounds.—Low  pitched  and prolonged may be dif-
fused or tubular.   Cavity, bronchial  cavity, or bronchiectasis may
be the cause.   When musical  or resonant, as though blowing in a
bottle, they are termed amphoric.  Cavernous sounds differ in de-
gree as to intensity, pitch, and quality.
   " Bronchial breathing" in all nomenclatures is respiration devoid
of vesicular quality, and high in pitch.

          Special  Study of  Abnormal Voice Sounds.
   As already described, in  health we have normal vocal resonance.
We may have:
   1. Exaggerated Vocal Resonance.—When one lung is expanded 
ABNORMAL SOUNDS.
57
unduly, as when vicariously performing the work of an opposite lung
crippled by pneumonia or  pleurisy.   Also in healthy persons with
unusually low-pitched bass or baritone voice.
  2. Diminished  Vocal  Resonance.—In most cases of  feebly-de-
veloped, poorly-expanded narrow  chests, also in fibroid phthisis,
thickened pleura  and pleuritic adhesions with  retraction of chest-
walls.
  3. Absence of Vocal resonance over pleuritic fluid.
  4. uEgophony  or  " goat-bleating."—Nasal  quality of the  con-
                              Fig. 47.

ducted voice.   Heard over  a thin stratum of  fluid in pleura or at
upper border of large accumulation of fluid in pleura.
  5. Bronchial Voice or " Bronchophony."—The product of con-
solidation of the  media between the bronchial tubes and the  ear.
The voice comes to the ear  raised in  pitch to a variable degree, ac-
cording as the infiltration  is  slight  or pronounced.  In absolute
solidification, the phonations  come high-pitched and distinct to the
ear.   In lobar pneumonia,  the high-pitched voice may seem under
the ear.
  6. Cavernous Voice.—The voice is directly under  the ear, but
low-pitched, and in quality  varying according as the cavity be large 
58
ABNORMAL SOUNDS.
or small, moist or dry, and ragged and irregular, or symmetrical and
well-defined, favorable to resonance and echo.
Fig. 48.
Fig. 49.
Fig. 50.
  7. Pectoriloquy (speaking in the chest).—A  quality of voice im-
mediately under the ear like that employed by ventriloquists.  The 
WHISPER SOUNDS.
59
low-pitched voice seems resonated in a chamber beneath the surface.
Pectoriloquy is produced in  exceptionally large cavities,  free of
secretions and  freely  communicating with a  bronchus.  It  more
often is produced in a pleural cavity distended with air and com-
       Fig. 51.—Pneumohydrothorax, amphoric breathing, pectoriloquy,'succussion.

 municating  freely with a bronchus, i.  e.,  in  pneumothorax  and
 pneumohyd roth orax.

             Special Study of the Whisper Sounds.
   As already stated, whisper is an expiratory act, and is a physical
 act productive of feeble sound waves.   Over a  healthy lung, whis-
 per, whether quiet or the result of special effort, is faintly heard as
 an exaggerated expiratory sound or puff.   In disease,  whisper  is a
 most delicate aid to careful diagnosis.
   1.  Whisper is enfeebled or absent in  dilatation of  the air sacs,
 emphysema, dilated bronchi, many cases  of  peribronchitis, chronic
 bronchitis, and fibroid phthisis, and especially thickened pleura and
 pleuritic effusions.
   2.  Whisper is raised in pitch by even slight  interstitial deposit.
 Hence "bronchial  whisper" or  " whispering bronchophony" is a
most valuable evidence of incipient lung disease. 
60
DRY  RALES.
   3.  Whisper is cavernous when resonated in a cavity, and as heard
with the small tube of the stethoscope, is often the surest means  of
distinguishing a very small cavity which would not  give cavernous
voice.
   4. A whisper resonated in  a large cavity, as  in the pleura  of
pneumothorax  or  pneumohydrothorax, with  communicating bron-
chus, is designated whispering pectoriloquy.

             Special Study of the Cough  Sounds.
   Cough in health is reverberated through the chest low in pitch.
   It may be " bronchial cough " when  transmitted through areas  of
consolidation.
   It may be " cavernous cough " when propagated from the bronchi
into a cavity beneath the ear.

                      Adventitious Sounds.
   It  remains  to  classify and  study the  adventitious  sounds with
reference to the portion of the respiratory apparatus  in which they
are developed.

                      ADVENTITIOUS SOUNDS.
   1. Adventitious sounds produced in the air passages.
   2.       "         "      "      "   air  vesicles.
   3.       "         "      "      "   pleura.
   4.       "         "      "      "   lung substance.

   Adventitious Sounds Produced  in the Air Passages and Air
                            Vesicles.
   These are ordinarily designated rales (the synonymous term rhon-
chi has been abandoned).  Rales are sounds produced by :
   1. Constriction of the air passages.
   2. Dryness of the air passages.
   3. Moisture or accumulation  of secretion in  the air  passages.

                          Dry Rales.
   Dry rales are produced in the bronchi only.  They result from
contracted  calibre  at different points.  If  due  to spasmodic contrac-
tion, as in  asthma, the rales  are temporary and shifting.  If due to
mucous and submucous tumefaction, as in the dry stage of bron-
chitis,  the  dry rales are  more persistent.  If due  to  permanent 
MOIST RALES.
61
contractions and thickening,  as  in  chronic bronchitis,  they  are
permanent.
  When produced in tubes of  large  calibre, the  dry rales are low-
pitched and resonant, and are designated :
  1. Sonorous rales.
   Fig. 52.—Diagram Illustrating" Dry and Moist Bronchial Rales (after Da Costa and
                               Loomis).
  Points of contraction; sonorous and sibilant rales;  bubbles denote the mucous, submucous,
subcrepitant, and crepitant rales.

   When produced in tubes of lesser calibre, they are higher pitched
—piping, cooing, hissing—and are designated :
   2.  Sibilant rales.
                            Moist Rales.
   They are the product of the action of currents of respired air upon
mucus, sero-mucus, or muco-pus lodged in the bronchi and blocking
the ingress and egress of  the  air.   Their coarseness or fineness is
determined by the size of the tubes in which they are produced and
the viscidity or liquidity of the secretion.
   1. Tracheal rales—as heard over the trachea in  the dying and in
excessive haemoptysis, or overloading of air passages with serum by
use of jaborandi.
   2. Mucous rales—heard over larger bronchi.
   3. Submucous rales—heard over medium bronchi. 
62
MOIST RALES.
  4. Sub-crepitant rales—heard over finer bronchi, chiefly in chil-
dren (capillary bronchitis) and broncho-pneumonia of adults.
  5. Crepitant  rales—heard over periphery of lungs or a limited
pulmonary area.
  Tracheal  rale or  gurgle is apt to be  both inspiratory  and  ex-
piratory ; the fluid lies in  the trachea, and ebbs and  flows with
respiration.
  Mucous and submucous rales are, as a rule,  only inspiratory, the
mucus being burst through by the inspiratory current.
  The subcrepitant rale of bronchial origin is distinguished from the
crepitant by being double.   It is heard in inspiration and expiration.
It is  also less fine and more plastic or glutinous  in quality.  It is
produced by minute air currents breaking  through  mucus  in small
Fig. 53.—Diagram of Catarrhal Process.
 Swelling of mucosa, proliferation of epithelia, and throwing off of mucoid corpuscles and
mucin (Thierfelder).

bronchial tubes.   It  is heard in suffocative  catarrh  or capillary
bronchitis.  Subcrepitant rales, however, unless uniformly diffused
over both lungs, are quite likely to be of pleural origin.
  The  subcrepitant rale, as heard over extensive areas of tubercular
lung, was formerly associated with the diagnosis of  softening  or
second  stage of phthisis.  It is in such cases either  a  subcrepitant
rale of bronchial  origin, due to collateral hypersemia or local catar-
rhal process, or, in other cases, a plastic intrapleural subcrepitus, due
to plastic pleuritis provoked by the tuberculosis reaching the pulmo-
nary surface and investing pleura.
  The crepitant rale is a single sound, high-pitched, fine, and crack-
ling at the end of the inspiratory act.  It is described as fine as the 
THE CREPITANT RALE.
63
crackling of salt on a hot stove, or the crackling of the hair rubbed
by the finger-tip on the temple or back of the ear.  It is best heard
in cases of acute lobar or croupous pneumonia in the transition period
from the first to second stage.  Until recently but one explanation
of crepitant rale was entertained;  that it was  produced  in  the  air
vesicles by the ingress of  inspired air.   This view is  still held by a
majority of authorities.

                      The Crepitant Rale.
   As to the mechanism of its  production there is  divergence  of
opinion.  One theory is that the rale is produced by air breaking
through exudation  matter.  Another, that the  air sacs  being col-
lapsed,  on inspiration their glutinous walls separate,  giving rise  to
the  crepitant rale.  The same sound may be simulated by pressing
a piece of sponge rubber  close to the ear and then letting it relax.
In its relaxation it produces far more sound than in its compression.
Still another theory is,  that  it is  due  to  stretching of the  inter-
vesicular tissue.   The inflammatory exudation, it is claimed, starches
or stiffens, as it were, the intervesicular tissue, and renders its  ex-
pansion more difficult and productive of sound.
   It has long been claimed by Learning that the crepitant rale of pneu-
monia is produced in the pleura, the product of an associated plastic
pleuritis.  Loomis takes the same view.  The general opinion yet
prevails, however, that crepitant rale as heard in pneumonia is vesic-
ular in origin.
   In addition to the above, certain crepitating and creaking sounds
are  developed  in thickened bronchial walls,  much as the  same
sounds are produced in thick walls of phthisical cavities.
   Walshe gives  a classification  of sounds  produced  in the air-
passages which differs but little from the one we have given,  but a
comparison of the two may help to call attention to the more essen-
tial  features of these adventitious respiratory sounds.

                        RECAPITULATION.

         Abnormal  Sounds Produced  in Air Passages.
                            (Walshe.)

   Whistling.  | High-pitched-Sibilant.
               I Low-pitched—Sonorous.
   Crepitating. 
64
PLEURAL SOUNDS.
Crackling,  j ^

            f Small.  |  Subcrepitant.
Bubbling.  I         (Submucous.
            I Large.—Mucus.  \ TT .f
            1    5            I Hollow.
Bronchial affections are most  numerous of all pulmonary affec-
■tAffiraaft; iT<ni
Pleura tnUmsntxHi

  Pleura. CaitCBH

TMrauta Duet
Vena. Azyffer Mojo r

Fig. 54.—A transverse section of the thorax, showing the relative position of the viscera and
                       the reflections of the pleurae.
tions, so that  their signs, mucous, submucous, sibilant, and sonorous
rales, are the most common signs heard by the practitioner.

         Adventitious  Sounds Produced in the Pleura.
  In health there is no  sound produced by the colliding  of the two
opposed pleural walls.  Their smoothness and moisture  allow them
to glide noiselessly upon each other.   When these conditions have
become modified by disease, the gliding is accompanied with differ-
ent degrees of sound, the product of pleuritic attrition, of tension of 
PLEURAL SOUNDS.
65
fine and coarse adhesion, of disturbance of plastic exudation matter,
or the warping and bending of thickened pleura.
   Walshe has recognized the frequent occurrence and  variety  of
intra-pleural sounds, and classifies them as follows :

                   Abnormal Pleural  Sounds.

                             (Walshe.)
   1.  Single.                      2. Jerking—Divided.
   1.  Faint.                       2. Loud. "
   (a.) Attrition, i ^razinS-
   v  ;           (Rubbing.
   {b.) Creaking.                  {d.) Rumbling.
   {c.) Crackling.

             Intra-Pleural  Sounds—When Heard.
   Intra-pleural sounds are chiefly inspiratory.
   When  due to attrition, they may occupy the entire period of in-
spiration.
   When due to tension of adhesions, they may be developed only at
the  end of the inspiratory act,  as the  adhesions are brought into
tension.
   When due to  tension of plastic exudation, whether  spread over
the pleura or interspersed among adhesions, the sounds are likely  to
occupy the middle and latter part of the inspiratory act, and also
may be present in a lesser degree during the expiratory act.

              Qualities of Intra-Pleural  Sounds.
   The sounds produced by attrition of pleural surfaces are, as a rule,
single or continuous, and may have the quality of friction, rubbing,
grazing, creaking, or even rumbling.   The more pronounced sounds
are the product of roughened, thickened, corrugated pleura.
  Quite as often there is a series of divided or jerking sounds, vary-
ing in character as above stated, heard most intensely in inspiration,
and to a lesser degree, if at all, in expiration.
  Again,  the intra-pleural  sounds may differ at  different periods  in
the same  chest,  according as we have recent,  acute, or subacute
pleuritis,  localized, secondary, or  intercurrent pleuritis, dry plastic
pleurisy, sero-plastic or serous pleurisy, or chronic pleurisy with ad-
hesion, agglutination, or pleuritic thickening.
           5 
6Q
PLEURAL SOUNDS.
   The first condition in inflammation of the pleura is a removal  of
 the fluid or moisture which lubricates  the  part.  The surfaces are
 next denuded of epithelium, tumefied,  and roughened.   The move-
 ments of these surfaces give rise to a grating, rubbing sound, found
 entirely in recent cases.  If two denuded and villous surfaces have
 grown together at points, the pulling  or stretching  of  these adhe-
 sions may give rise to subcrepitant or plastic rales.
   Creaking sounds are often pronounced.  They are only to be com-
 pared with creaking of thickened bronchus, or of the thick wall of a
 phthisical cavity.
   The recognition of the frequency  of  intra-pleural lesions, and the
 systematic  classification  of their  physical  signs,  have  resulted
 chiefly from the writing and teachings of Dr. James R. Learning,  of
 New York.  Most clinical  teachers  now acknowledge  the positive
 physical evidences of the different forms of local  and general pleu-
 ritis, recent and chronic.  Yet there is  much difference  of  opinion.
 The late Dr. Flint maintained  a conservative opinion, and did not
 admit  the  frequent occurrence  of intra-pleural sound, except the
 friction sound of the first or dry stage of subacute pleurisy (pleurisy
 with effusion).  He  regarded most  of the sounds, both  dry  and
 moist,  by  others referred to the pleura, as of  bronchial origin.
 Local  subcrepitus,  even if brilliant, explosive, high-pitched,  and
 " tearing," and directly  under the ear, he regarded, not  as evidence
 of local plastic pleuritis, but as produced in the  smaller bronchi  im-
 mediately beneath  the  pleural  investment  and lung surface.  Sir
 Andrew  Clark, on  the other hand,  has published in detail his ac-
 ceptance of the intra-pleural production of the great  variety of  dry
 and moist sounds as classified by Walshe and Learning.   As alreadv
 stated, Dr. Loomis has intimated that even the crepitus or crepitant
 rale  heard in pneumonia is the product of a co-existent plastic
 pleuritis.

      Rules for Differentiating  Intra-Pleural  Sounds.

  1.  Attrition,  simple  friction, high-pitched,  synchronous  with
 respiration, and  either single or double, is  due to dryness of  the
pleura.  Percussion resonance will be normal, and no auscultatory
 evidences of bronchial  catarrh   or pulmonary consolidation will be
 present.
  2.  Rubbing,   rumbling  sound,  usually divided  when  synchro-
nous with respiration and most often double, is likely to be of pleu- 
PLEURAL SOUNDS.
67
 ritic origin.   It is usually heard directly under the ear, and presents
 associated evidences of the roughened and thickened pleura and ad-
 hesions, viz. :  1. By inspection, retraction of  intercostal  spaces
 synchronous  with  inspiration.  2. By palpation, distinct pleuritic
 fremitus, or sense of contact of roughened surfaces.   3. By percus-
 sion, raised  pitch, i. e., dulness  or  even flatness.  4. By ausculta-
 tion, marked  diminution of  vocal resonance, obscuration of the
 whispered voice, obscuration of cough sound, and feeble, distant, or
 marked, or  even absent  respiratory sound.  The hypodermic  ex-
 ploring needle distinguishes between this thickening  of pleura and
 a stratum of fluid circumscribed.
   3. It is far more  difficult to positively distinguish the moist intra-
 pleural rales from sounds similar  in  nearly all respects, which have
 their origin in the fine bronchi.   Given a limited or diffused area of
 subcrepitus  or crepitus  beneath the  ear,  how  are  we to decide
 whether the cause is plastic pleuritis or localized pulmonary hyper-
 aemia or inflammation,  with  exudation of serum,  sero-lymph, or
 lymph into capillary bronchi '\
   a. As to the crepitant rale, when fine and high-pitched, and heard
 only in inspiration, when  co-existing  with  contiguous bronchial
 breathing, bronchial whisper,  bronchial  voice  and  cough, marked
 flatness on percussion, and  increased vocal fremitus, the  crepitus
 must be referred to pulmonary consolidation—pneumonia.   The his-
 tory of the attack and nature of sputum is often  of aid.
   When, however, the crepitus is localized, is over an area of  tuber-
 culosis  or other infiltration, and  is persistent for some time with-
 out pronounced bronchial  breathing or voice, flatness on percussion,
 and  when associated with constant tearing dry cough, i. e., no expec-
 toration, the rale must be regarded as of pleuritic origin.
   b. The subcrepitant rale  is more  typically  the  rale  of plastic
 pleuritis.   It may be single  or  double.  It is moist, brilliant,  ex-
 plosive, developed in the latter  part of inspiratory  effort, and is
 usually heard in inspiration only, although sometimes it is expiratory.
 It has been described by Learning as suggestive of the tearing of a
 piece of wet  flannel.
  How are we to determine whether the subcrepitus beneath our ear
is pleuritic or the product of a local catarrhal process, a local broncho-
pneumonia, or  transudation  of sero-albumin (bronchorrhoea)  in an
area  of infiltration, obstructed  circulation, and active irritation \
  1.  The subcrepitus of local catarrhal process is usually more liquid 
68
PULMONARY SOUNDS.
in quality, lower in  pitch, is associated with rales of coarser grade,
and with moist cough, i. e., some degree of expectoration. With such
catarrhal cause of the subcrepitus will exist  associated evidences of
slight infiltration, slightly raised pitch of percussion note, broncho-
vesicular breathing,  or even an element of bronchial whisper, voice,
and cough.   Even with all these evidences of local  infiltration and
adequate  cause for  local  catarrhal origin,  the  rales are often  so
brilliant, explosive, near the ear, and of such uniform and persistent
character, that local  plastic pleuritis over unsound lung must be the
diagnosis.
   When,  however, the subcrepitus is  tearing,  brilliant, explosive,
high-pitched,  near  the  ear,  the  rales are  of a uniform size and
character, are uninfluenced, neither modified, suspended, nor removed
by forced efforts at  cough and expectoration, are accompanied by
expectoration, are chiefly heard towards the end of the inspiratory
act, they can safely  be  asserted to be of  intra-pleural origin, a pro-
duct of plastic pleuritis.   (The subcrepitus  of the  finer bronchi is
developed earlier in inspiration  and runs through the act, and is
more often both inspiratory and expiratory.)
   Often too, there is slight dulness on  percussion, due to the tume-
faction  of the inflamed  pleura,  and the cough, voice, and  breath
sounds, instead of being raised in pitch and of bronchial quality,  are
marked and distinct.  The locality of the area of rales,  and the his-
tory of the attack as to initial chill, stitch in the side, and localized
pain may  also enter  into the diagnosis of  doubtful cases.  All pleu-
ritic ailments are peculiarly painful.  Areas of local hyperaemia and
catarrhal process develop, on the other hand, insiduously and pain-
lessly.

  Adventitious  Sounds  Produced in the  Pulmonary  Paren-
                             chyma.
  The very many typical and diagnostic physical signs of  changes
of the pulmonary parenchyma of pneumonia and phthisis  (tuber-
cular, catarrhal,  fibroid)  are  chiefly the result  of  change  in  the
characteristics  of normal voice, whisper, cough, and health sounds,
or alterations  incident  to their conduction, and  have been enu-
merated.  They are feeble or absent vesicular murmur, exaggerated,
rude, harsh, or broncho-vesicular respiration, bronchial breathing,
bronchial whisper,  bronchial voice and  cough,  cavernous whisper,
cavernous voice,  cavernous  breathing,  pectoriloquy.   The truly 
auscultatory percussion.
69
new or adventitious sounds as distinguished from the above are few,
and chiefly relate to cavities.  They are :
  1. Gurgles,  produced in large cavities  by  the ingress  of air
below the surface of accumulated liquid.
  2. Creaking in  the thickened walls  of large  cicatrized cavities,
associated with amphoric breathing, cavernous whisper and voice.
  3. Metallic tinkle and succussion—when the cavities are large and
symmetrical,  permitting of the  shaking  up of the liquid, and its
subsequent  dropping from  the dome of the cavern upon the fluid
surface below, with fine silvery or metallic tinkle or splash.

                   Auscultatory Percussion.
  The method  of  physical exploration  designated  " auscultatory
percussion "  was devised by Drs. Alonzo Clark and Cammann, of
New York, in 1840.  It consists in listening, by aid of  the  stetho-
scope, over a solid viscus, while percussion strokes are made over the
Fig. 55.—Cammann's Cylindrical Auscultator.     Fig. 56.—Cammann's Intra-Costal
             Solid Cedar.                       Auscultator.
organ, but more especially across the organ in the line of its various
axes—vertical, horizontal, and oblique.  The moment the border of the
organ is reached, immediate  cognizance  of  the fact  is taken by the
listener, owing to the direct conduction of  the sound by the organ.
By percussing towards the organ from various sides, and marking
the points of approach, we may map out with great exactitude the
contour  of the organ, and  determine its  precise size and shape.
While as a process it is most useful for defining the size  and  shape
of the liver, spleen, and  heart, yet  it is  also applicable to examina-
tion of the lungs, in determining the line of demarcation between
lung and liver, lung and spleen, lung  and heart, and the extent of
pleuritic effusions downward, the extent of pneumonic consolidations,
and the size and locations of neoplasms within the thorax or encroach-
ing upon it from the abdominal cavity.   Auscultatory  percussion,
to be well performed, requires :
   1st.  That the stethoscope be held firmly down upon the integu-
ment  over the organ. 
70                 AUSCULTATORY PERCUSSION.

  2d. That  the percussion be deep, that is, the interposed finger be
firmly pressed down  upon the  area  percussed, and the blow de-
livered with firmness and force.  Cammann employed  for  this
purpose the solid  cylindrical stethoscope (Fig.  55)  to  obviate the
transmission of the percussion note by the  ribs ; he further devised
the " Intra-Costal Auscultator," a wedge-shaped stethoscope, capable
Fig. 57.                          Fig. 58.
of being pressed down in  the  intercostal spaces upon the organ,
and avoiding deceptive transmission of sound by the ribs.   Such a
wedge-shaped tube has also been  employed in the binaural stetho-
scope.   From my use of this method, I regard it an invaluable and
essential aid  to  correct physical diagnosis, yet  not so  exact as its
originator and  many advocates would  assert.   I believe that  it at 
AUSCULTATORY PERCUSSION.
71
times tends  to  error, and hence its results  should always,  when
possible, be compared with those obtained  by simple deep percus-
sion, and by palpation also when this is admissible.
  For most thorough auscultatory percussion, the physician should
have  an assistant to percuss while he listens and holds the stetho-
scopic tube  firmly  over  the  part.  Or the patient may hold the
tube on, and the operator have both hands free to percuss.
  Heinemann's  attachment to the Cammann stethoscope is intended
to enable the physician to perform auscultatory percussion without
an assistant.   It consists  of  a chin  piece  adjustable at different
distances to suit the size  of the  listener's head,  with which, by his
chin and a rod or  stiffener going down to  the pectoral tube, he
keeps the instrument steady and firmly in  situ while  he percusses
and  listens.   Constantine Paul's  instrument  (see Figs. 57,  58)
Fig. 59.—Page's Percussion Hammer.
attempts  a similar result  in  another way,  by means  of  an  air
chamber outside of the pectoral tube and a rubber bulb for ex-
hausting the air; the pectoral tube is held in  place by suction, leav-
ing the listener's hands free for  percussion.   But the pectoral tube
is too lightly pressed on the integument for deep  percussion, and
will fail to give exact results.   The use of Cammann's wedge-shaped
solid  stethoscope, or  of his binaural  stethoscope with smaller tube,
and co-operation of an assistant, always give the  best results.
  I may add that for mapping out the contour of an  organ before
the class,  the ingenious percussion hammer of Page is of value.  It
is used as a hammer, and the point to be noted having been reached,
the hammer  is reversed and used as a marker.  A small cylinder
contains " stage paint," a gummous pigmented material which may
be ejected by turning the screw cap of the cylinder. 
72
ASPIRATION.
                        Bell Metal Test.
   For large cavities and pneumothorax, Gairdnerand Finlayson have
 described  a combination of  percussion and auscultation applicable
 to the study of large symmetrical cavities  of  the  apices with cica-
 tricial walls.   A  coin  placed over  the anterior apex region is  per-
 cussed  upon,  while the auscultator  applies his ear to the  supra-
 scapular or scapular region, and  perceives  a  brilliant  metallic or
 musical resonation of the stroke.  The sign is illustrated most typi-
 cally in pneumothorax, the compressed air intensifying the bell-like
 sound.
                          Succussion.
   Succussion consists in forcibly shaking  the patient's body with a
 view of eliciting  splashing sounds  of accumulated fluid partially
 filling cavities.  It  is  most pronounced  in pneumo-hydrothorax.
 The splashing fluid emits a brilliant succussion sound, intensified and
 raised in pitch  by the increased pressure to which the  retained  air
 is subjected by a distended and  tense chest-wall.  Rarely is succus-
 sion heard, to  a lesser degree,  in very large tubercular cavities of
 even interior and cicatrized.                 %

 Determining the Size and Situation of  Surrounding Organs.
   As an associated method of diagnosis, it becomes necessary to de-
 termine the location and size of  contiguous organs, at least in so far
 as they come in contact with the  lungs or  infringe upon the pul-
 monary area.  Thus the liver dulness  has  to be distinguished from
 pneumonia and pleurisy of the right side, as well as from thickened
 and carcinomatous pleura;  the left  lobe  of  the  liver from  the
 apex of heart;  the spleen, stomach, and heart from the left  lung ;
 the heart, great  vessels, aneurism and  mediastinal tumors from  dis-
 ease of either  lung.   Palpation, percussion, and auscultatory per-
 cussion are our means of determining the size and shape of organs
 contiguous to the lungs.

            Aspiration and Hypodermic Puncture.

   The physical diagnosis of pleuritic effusion, either free or circum-
scribed, of empyema and hydrothorax, often cannot be definitely
made without resort  to  exploratory  puncture.  The distinction be- 
ASPIRATION.
73
tween a thickened pleura and a thin stratum of fluid often can be
made only by this means.  In certain cases of empyema, and even
of serous  effusion, an element of bronchial voice and breathing is
present,  which  is misleading and  creates an impression of the
existence  of pulmonary consolidation  which only puncture  will
remove.   A long needle attached to the usual hypodermic syringe,
Fig. 60.—Dieulafoy's Aspirator.
or one of larger size, is to  be employed.   In all cases  the  needle
should be clean  and well carbolized.   No  harm results from such
exploratory puncture, even when repeated.
  The longer tubes of the aspirator (see  Figs. 60, 61,  62)  permit
deeper puncture and free rotation in various directions, and give  an
approximate  idea of the volume of liquid,  and of  the presence  or
absence of circumscribing adhesions. 
74
ASPIRATION.
Fig. 61.—Tiemann & Co.'s Aspirator.
Fig. 62, 
TUBERCULAR SPUTUM.
75
The Microscope as an Aid  to Diagnosis of  Respiratory Dis-
                              ease.
  The detection of tubercle bacilli is essential to  complete the phy-
sical study of a case of phthisis, influencing our interpretation of the
signs of consolidation as the  product of the specific tubercle or
Fig.
-Tubercular Sputum—with Bacilli (Eichhorst).
of simple  interstitial  inflammatory  process.  The causative  rela-
tion  of the  bacillus tuberculosis  to phthisis is as yet not fully
—     //
  X 330
\s'S,
X2350

               Fig. 64.—Tubercle Bacilli with Spores (W. Cheyne).

settled.  But its  presence so frequently coincides with the existence
of the true tubercular form and fatal cases, and its periodic appear-
ance  and disappearance  so often  coincide with periods of failing
health and  improvement, that it is most desirable both to detect it
as a cause, and also to exclude it as an aid to negative diagnosis. 
76
ASTHMA CRYSTALS.
  The technique of the bacillus search can be easily  acquired.  It
consists in compressing a drop of the suspected sputum  between thin
glass  covers, drying over the flame of a spirit lamp, staining in solu-
tion of fuchsin, subsequently bleaching with very dilute nitric acid
and examination  under high magnifying power (objective  from £
t0 TV).  The characteristic  beads and rod-like masses are seen in
Figs.  63, 64).
                       Asthma Crystals.
  In the sputum of many cases of asthma, chiefly those accompanied
by  much bronchial catarrh, we find  acicular or long octahedral
                 Fig. 65.—Asthma Crystals (Frankel). X 500.

crsytals.   Less frequently they are found in the  mucus and muco-
serum of simple catarrhal  bronchitis.  Whether  they sustain any
uniform  or  causative relation  to asthmatic paroxysms  or paroxys-
mal and spasmodic cough is undecided. 
CHAPTER VI.
SYNOPSIS OF ACUTE  BRONCHITIS  OF  ADULTS.
Definition.	Inflammation of bronchial tubes.
Pathology.	Submucous hypereemia; acute catarrhal process. 1st Stage.—Surface dry and tumefied. 2d Stage.—Surface bathed with serum, sero-mucus, mucus, or muco-pus. Calibre of tubes i Submucous congestive swelling. u i, ,3 u •{ Local spasm of muscular and elastic coats. may be changed by } Adhesi£n of viscid mucus
Causes.	"Taking cold;" chilling surface; inhalation of hot and cold air; irritant vapors; atmospheric causes (influenza). Secondary in specific blood states:—measles, typhoid and typhus fevers, variola, etc.
Symptoms,	May or may not be preceding coryza:— Soreness, rawness, tightness, oppression in upper sternal region, increased by cough; little or no fever in most cases; heavy, deep, sonorous, paroxysmal cough; no dyspnoea; inspiration long and full. Sputum in the first stage scanty or absent. In the second stage, at first, sputum is serous, transparent, frothy; later, white, viscid, opaque—mucus; later, yellow, tenacious, muco-pus. (Mucin and epithelial scales.)
Physical Signs.	Both stages, normal percussion resonance; normal vesicular sounds by auscultation. First stage—breathing dry, puerile, exaggerated; sonorous and sibilant rales. Second stage— mucous and sub-mucous rales, of various degrees of liquidity; to and fro gurgles in main bronchi. All removed or modified by cough or expectoration.
Diagnosis.	Normal percussion resonance and vesicular sounds; moist and dry rales, bilateral. A symmetrical disease. Absence of chill, of "stitch in side," and of high fever; successive changes in sputum.
Prognosis.	Good. In adult does not extend to pneumonia, but some cases become chronic. Epidemics more severe—broncho-pneumo-nia.
Prophylactic—warm clothes, diet,  air, exercise.  Abortive—
   opiates, diaphoretics,  saline purge.  Palliative—antispasmo-
   dics and  expectorants, supporting  remedies, fomentations,
   counter-irritants. 
78
          CAPILLARY BRONCHITIS.

SYNOPSIS  OF  CAPILLARY  BRONCHITIS.
         (Suffocative  Catarrh.)
Definition.
A  form  occurring  in  young  children.  A bronchitis of  small
   tubes.  Often an obstruction of small (fine) tubes and collapse
   of lobules; sometimes extending to vesicles (lobular, catarrhal
   pneumonia).
Pathology.
Inflammation of smaller bronchi, catarrhal products, choking of
   tubes, more or less lobular consolidation.
Causes.
Predisposing.—Early infancy, great weakness, errors of diet.
Exciting.—Colds, measles, etc.
Symptoms.
Physical
     Signs.
Labored respiration, sinking of suprasternal notch and epigas-
   trium,  exhaustion, imperfect oxygenation, pallor, coolness,
   carbon dioxide* poisoning, little pain or oppression.  If any
   sputum, white small bodies, or tenacious mucus.
Percussion normal; auscultation—subcrepitant rale in inspira-
   tion and expiration.
Diagnosis.
Age, labored breathing, asthenia;  resonant  chest, pathogno-
   monic subcrepitus (double).   If extended to vesicles, crepi-
   tant rale.  If plugging of  bronchus and  collapse of lobules,
   there may be a local area of high pitch and bronchial breath-
   ing.  If  collapse is extensive, retraction of chest on inspira-
   tion, and sinking at suprasternal notch and epigastrium.
Prognosis.
Always grave.
Treatment.
Support vigorously by diet, quinine, chloride and carbonate of
   ammonia, musk, stimulants, as needed; oil-silk jacket, poul-
   tices often renewed;  mild  counter-irritants;  warm,  moist,
   uniform air; oxygen.  Emesis, if needed to eject mucus. 
CHRONIC  BRONCHITIS.                     79
SYNOPSIS OF CHRONIC BRONCHITIS.
Definition.	Acute attack often leaves bronchi liable to frequent subacute attacks, which may result ultimately in chronic bronchitis. A variable form of sequelae of previous bronchial catarrhs.
Pathology.	Varying in different cases, including one or more of the follow-ing pathological states: 1. Simple chronic catarrh or relaxed, thickened mucous surface. 2. Changes of calibre of bronchi. General relaxation o£ dilatation. Local relaxation. Local contraction or obliteration. (Cirrhosis of lung the result.) 3. Local ulceration of mucous surface. Local ulceration of all the coats. 4. Peri- or extra-bronchial inflammatory deposits. 5. The same broken down, leaving cavity opening into bronchus. 6. Resultant chronic pneumonia, indurations.
Causes.	1. Predisposing.—Gouty and rheumatic diathesis, alcoholism, habitual indigestion and mal-assimilation, cardiac incom-petency. 2. Exciting.—Recurring attacks of acute and subacute bron-chitis; air laden with dust or foreign matter.
Symptoms.	Chronic cough, for months and years, without great loss of flesh, strength, or appetite. Chronic catarrh of bronchi; quantity, color and viscidity of secretion, determined by extent and kind of lesion.
Physical Signs.	Varying with simple bronchial, peri-bronchial, or pulmonary lesions, with dilated bronchi, bronchial cavity, peri-bron-chitis, or cirrhosis of lung. Simulates every form and stage of phthisis. Contractions give sibilant and sonorous rales: accumulations of mucus give all grades of moist rales and gurgles ; excava-tions and dilatations give cavernous and tubular blowing sounds, both inspiratory and expiratory; thickened bronchus gives creaking, "leathery" sounds; peri-bronchitis and chronic interstitial pneumonia give absence of vesicular sound, sometimes bronchial breathing, at other times feeble breathing, dulness on percussion, contracted chest, and diminished expansion.
Diagnosis.	To be differentiated from tuberculosis.
Prognosis.	Persistent, often incurable, but slow progress; remissions and exacerbations.
Treatment.	Hygienic, tonic. Climate. Chest expansion. Palliate symptoms according to case. Balsamic inhalations. Iodide of potassium.
 
80                         ASTHMA.
SYNOPSIS OF  ASTHMA.
Definition.	A functional disease ; labored obstructed respiration, due to spasm of bronchi, usually with bronchial catarrh.
Pathology.	Theory of hyperaemia of par vagum. No known lesion of asthma. May be co-existing lesions of acute or chronic bronchitis, em-physema, etc.
Causes.	Often obscure or unknown. Hereditary in forty per cent of cases. Excited by cold air, dust, vapor, fatigue, mental effort, excitement; especially indigestion and bad ventilation (foul air of sleeping room), flatulence, constipation, uterine disturb-ance (reflex action). Most common in men. Special form—" Hay asthma" or autumnal catarrh, sometimes due to emanations of flowering vegetation.
Symptoms.	Attack often sudden (rarely gradual, with preceding catarrh). Often at night in sleep. Increasing sense of obstruction to admission of air; suffocation; face anxious; respiratory muscles fixed ; orthopnoea ; head thrown back ; gasping ; dilated nares; obstructed venous circulation ; in head and neck, symptoms of carbonic acid gas accumulation ; fatigue; exhaustion. Relief sudden or gradual, with lingering bron-chial catarrh.
Physical Signs.	Normal pulmonary resonance, or vesiculo-tympanitic resonance on percussion. Fine tube and vesicular sounds may be want-ing or feeble. Expiration long and changing, composed of numerous sibilant and sonorous rales, of varied and chang-ing intensity, pitch, and quality. Moist rales of bronchial catarrh exist.
Diagnosis.	Paroxysms sudden ; physical signs, definite recovery from at-tack, complete and speedy, seldom any permanent dyspnoea.
Prognosis.	May cause emphysema. Remotely affects the heart.
Treatment.	Of paroxysms : Faulkner's method (iodine over pneumogastrics). Oxygen, chloroform, hot liquor, strong coffee. Hypodermic use of morphia and atropia. Stramonium. Quebracho. Nitre cigarettes. Of intervals: Quinine. Iodide of potassium. Tonics. Diet. Change of climate.
 
PLEURITIS.                          SI
SYNOPSIS OF PLEURITIS.
Definition.	Inflammation of pleura with accumulation of inflammatory products on free surface, or in the pleural cavity.
Pathology.	Hyperaemia of subserous vessels; surface denuded of epithelium; rough, hazy, later escape of exudation, may be plastic, sero-plastic, or wholly-serous. If adhesions, they are due to contact and adhesion of opposed vil-lous surfaces. (Plastic exudation not material of adhesions. It may remain entangled and undergo caseous change—tubercle of pleura, or become calcified, so-called osseous plates.) General adhesions may obliterate pleural cavity. Local adhesions may encapsulate serum. Excess of serum—lung collapsed at hilus of lung. Too long collapsed, may be bound down by adhesions, expansion prevented, and air-sacs agglutinated. Lesser adhesions—lesser results. Pleuritic serum may become purulent (see empyema). Pleurisy often located near superficial tubercle. Tubercle perforating pleura causes pneumo-hydrothorax (which see).
Causes.	Acute—due to cold. Secondary—in blood states and acute disease. Local—co-existent with superficial tubercle.
Symptoms.	1st Stage.—Chill, stitch in side, febrile action, incomplete restrained breathing. Irritable dry cough. Later—pain relieved and dyspncea developed, due to pressure of serum on lung and diaphragm. If empyema—frequent chills, weakness, foul tongue, sallow skin. Tubercle develops or typhoid state liable. If perforation—sudden, excessive dyspnoea; symptoms of collapse.
Physical Signs.	Depend on plasticity and movement of exudation. Rough surface gives a to-and-fro friction sound. Adhesions give every variety of fine and coarse rales unaffected by cough. Layers of thickened pleura and exudation give percussion dulness, and render voice and breath sounds muffled, vague, and distant. Over serum, chest-wall is f uU and immovable. Intercostal spaces bulge, percus-sion flat—high in pitch, short duration, wooden quality. Upper line of dul-ness abrupt, horizontal, changing with position of the body (old view). Recent view—upper border of dulness lowest in front, highest in side, lower behind; " the curved line of Ellis v or "letter S line.''1 Over serum, absence of marked breath and voice sounds.' Exceptionally bronchial voice and bronchial breathing are heard over serum, and especially over pus, vari-ously explained as due to adhesions, to unusual tension of chest-wall, and to section of condensed lung dipping into fluid. iEgophony at surface of fluid ; nasal quality of voice. Vocal fremitus wholly absent. Over the compressed lung, respiratory sounds are harsh and raised in pitch, vocal resonance intensified. In excessive accumulation of serum, the heart is dis-placed; especially serum in left pleura may push heart entirely to right of sternum. In perforation, signs of serum below and above tympanitic resonance on percussion, and by auscultation sometimes pectoriloquy, and splashmg of the serum, called succussion. See Figs. 23, 24.
Diagnosis.	Friction double at onset. Later, plastic, subcrepitant rales, unaffected by cough; dulness on percussion; absence of voice and breath sounds; ab-sence of fremitus and diminished chest movements over fluid. Positive diagnosis of presence and extent of fluid, whether serum or pus, by hypo-dermic syringe or exploring needle of aspirator. Distinguished from pneumonia: Sounds conveyed in pneumonia. Crepitant rale in pneumonia. Distinguished from hydrothorax: Both sides involved. Non-inflammatory.
Prognosis.	Many evanescent cases unsuspected. Most serous and sero-plastic cases re-cover. Excessive plasticity cripples lung. Permanent adhesions may cause local congestion or inflammation of lung, local or general emphysema. May, by causing irritation, favor infiltration and caseous masses (crude yellow tubercle) in lung. Empyema often grave. See p. 82. Pneumo-hydrothorax bad. See p. 83.
Treatment.	Abortive.—Dry cups to the side. Active counter-irritation—prompt saline cathartic. Antiphlogistic—antispasmodic—anodynes for cough. When exudation is complete.—Aid process of absorption. No depressing measures. Food, quinine, iron, alcohol, fresh air, exercise. Absorption aided by mild'.counter-irritation. 01. terebinthinse, or ungt. iodini comp.: also by iodide of potassium. In slow absorption, perform paracentesis or aspirate.
 
82                         EMPYEMA.
SYNOPSIS OF EMPYEMA.
Definition.	A form of subacute pleurisy in which the sero-plastic effusion becomes purulent.
Pathology.	Early lesions of pleurisy, viz.: removal of endothelium of pleu-ral surface; later surfaces become roughened and in patches eroded or ulcerated. Tendency to associated thickening of pleura, subserous tumefaction, concretion in thick pleura, miliary tubercles in pleura and lung.
Causes.	Traumatism, admitting air, as by broken rib, perforating wound, perforation from tubercular lung, communication with bronchus. Low states of system—scrofula, tubercle, syphi-lis, alcoholism, sepsis, secondary pleurisy in course of low-type disease. Admission of air or impurities on unclean ex-ploring or aspirating needles in simple pleurisy.
Symptoms.	Early symptoms of pleurisy with effusion, viz.: chill, stitch in side, dyspnoea, restricted breathing. Later, daily excursion of temperature (hectic), with high range, 102° to 105°, with or without chills, with sweating, failing strength and appetite, delayed and prolonged convalescence.
Physical Signs.	Early, the physical signs of,pleurisy with effusion, viz.: fulness of side and intercostal spaces, diminished respiratory move-ment, lessened or absent fremitus, dulness on percussion, line of aegophony, silence over fluid. Later, distention of side and intercostal spaces increases; flatness over entire side, extreme displacement of heart, and depression of liver and diaphragm, may be "pulsating empyema," heart mo-tions transmitted, andalso marked bronchial breathing, whis-per, and voice.
Diagnosis.	Diagnosis.—Daily excursion of temperature, high temperature, sweating, debility, prolonged convalescence or failing health. Definite diagnosis by hypodermic needle (long for explora-tion) or by aspiration.
Prognosis.	Always serious. Depends on efficiency of evacuation and intra-pleural antisepsis. Liability of death by exhaustion, by py-aemia, or tuberculosis.
Treatment.	In mild cases, repeated aspiration of the pus, and vigorous diet, tonics, stimulants, antipyretics to control temperature (qui-nine, antipyrin), sulphide of calcium, salicin, or glyco-phenic acid internally to limit tendency to suppuration. Serious cases—thorough aspiration and washing of cavity with bichloride solution (1 to 2,000), or counter-opening and drain-age under antiseptic dressings, with resection of rib, if necessary, for free drainage. Empyema is frequently cir-cumscribed, and, following successive aspirations, the adhe-sive process lessens the pus-cavity until obliterated.
 
         PNEUMO-HYDROTHORAX.

SYNOPSIS  OF  PNEUMO-HYDROTHORAX.
83
Presence of  fluid in pleura, with superimposed air.   Fluid usu-
   ally serum; may be pus (pneumo-pyothorax).
Associated lesions of causative disease, as of penetrating wound
   of chest, fractured rib, tuberculosis of lung, emphysematous
   pouch; fluid—serous, sero-purulent or purulent—in lower part
   of pleura.   Air (not gas) above.
Perforation of pleura.  1. Either internally from bronchus through
   normal  lung by violent paroxysmal cough (rare), or from
   softening tubercle  or cavity near lung surface, or rupture of
   emphysematous lobule of lung.  2.  Externally by penetrating
   wound or compound fracture of rib penetrating pleura.
Often sudden local pain or stitch, shock, apprehension or col-
   lapse at time of perforation.  Later—Extreme dyspnoea, may
   be orthopnoea (necessity to breathe in sitting posture), labored
   heart  action,  pallor, cold  extremities, cyanosis; extreme
   cases, collapse.
Distention of side, suspended respiratory motion, usually absence
   of fremitus over both fluid and air, percussion flatness over
   fluid, tympanitic  resonance over air; by auscultation, feeble
   or absent voice, whisper and breath sounds below (over area
   of fluid); above (over area of  air) may be to and fro, hissing
   sound of air entering and leaving cavity through valvular
   opening; if opening is larger, double blowing  or  cavernous,
   amphoric sound.   Voice admitted to cavity, if  connection
   with bronchus is free, and pectoriloquy results.  With per-
   cussion  on coin in front of chest,  ear behind detects bell-
   metal sound.  Shaking patient's body—by  listening we hear
   succussion or  splashing  of  fluid,  and often its metallic
   tinkle when dropping from dome of distended pleura upon the
   surface of fluid below.   The tension of cavity and compressed
   air intensify the sound.
Distended  thorax—tympanitic resonance, pectoriloquy, succus-
   sion.
Serious—if associated with pre-existing disease.
Energetic supporting measures—Carbonate of ammonia, musk,
   alcoholic stimulants to counteract shock.
Subsequently  maintain  strength by   rich  diet, milk punch,
   carbonate or chloride of  ammonia, quinine.  Control  tem-
   perature.  If fluid is  abundant,  possibly aspiration (not if
   point of perforation closes, better to allow fluid to remain for
   a time and by accumulation displace the air which  is ab-
   sorbed).  Great danger of gangrene of pleura from careless or
   uncleanly aspiration.   Data show best results from  support-
   ing measures and avoiding surgical interference (drainage). 
84
HVDROTHORAX.
SYNOPSIS  OF  HYDROTHORAX.
Serous transudation partially filling both pleural cavities—a non-
   inflammatory process.

Simple blood serum or sero-albumin filling both pleural cavities
   to the same extent, except where previous  adhesions in one
   cavity may limit its capacity.  Associated pathological causes
   of  dropsy,  as impoverished blood,  Bright's  disease,  and
   cardiac changes.
All the causes of  general  dropsical effusions—viz.,  anaemia,
   spanaemia. hydraemia—cardiac dilatation, renal disease.
General debility, impaired  strength  and appetite,  dyspnoea,
   orthopnoea, pallor, suffusion, cool surface, cold extremities.
Diminished chest expansion at base on both  sides.   Lessened
   vocal fremitus at base on both sides.  Zone or section at each
   base behind of flatness on percussion, with normal pulmonary
   resonance above; this line of  transition changed by changed
   position.  By  auscultation, normal vocal resonance and re-
   spiration down to line of flatness,  then aegophony or imme-
   diate transition to muffling or  absence of  voice,  cough, and
   respiratory  sounds.   Exploratory puncture demonstrates
   presence of serum on both sides.
Presence of dropsy elsewhere or  of  cardiac  or renal disease.
   Dyspnoea, flatness on percussion, absence of breath and voice
   sounds.   Serum detected by exploratory puncture.
Usually a grave complication of already serious disease.  If due
   to remedial systemic causes, with absence of organic changes
   in heart or kidneys, prognosis is more favorable.
If accumulation  is limited, improve  health by rest, feeding,
   stimulants, and active tonics.
When  dyspnoea is extreme, use drastic purge, active diuretics,
   favor sweating by vapor bath, etc., at the same time main-
   taining strength.   For critical disturbance of respiration and
   heart action, partially relieve each pleural cavity by aspira-
   tion.
Iodide of iron preferable as tonic and absorbent.  Digitalis and
   nux vomica to sustain heart action, alcohol and ammonia to
   keep up respiratory and circulatory functions. 
PNEUMONIA.
85
SYNOPSIS OF PNEUMONIA.
English Classification.
Pneumonia.
Pneumonitis.
Lobar Pneumonia.
(Popular names.
Inflammation of Lungs.
Lung fever.)
Chronic Pneumonia___
Cirrhosis of Lung.......
Capillary Bronchitis—with  Lobular Pneu- ^
   monia, and collapse of Lobules.........)
  German Pathological Classification.




Croupous  Pneumonia.



Chronic Interstitial Pneumonia.

Catarrhal Pneumonia.
                          PNEUMONIA.

Pneumonitis, Inflammation of the Lung, Croupous Pneumonia.
Definition.	A local inflammatory disease of the lungs, usually idiopathic, with exudation of coagulable lymph into the air-sacs.
Pathology.	1st Stage.—Congestion. 2d Stage.—Red hepatization ; solid, coagulated cell contents; white blood cor-puscles (exudation corpuscles), fibrin, albumin, salts, haematin. Stasis in capillaries. 3d Stage.—Gray hepatization. Fatty metamorphosis of cell contents. Exuda-tion removed by absorption and expectoration. Rarely leaves chronic con-solidations. Often pigmentation due to transuded haematin-melanine. Uusually (slight or great) coexisting local pleuritis.
Causes.	Age.—More often in adults. Sex —More often in males. Exposure to damp and cold. Exhaustion. Secondary in acute fever, and septic blood condition.
Symptoms.	Marked chill or rigor—local stitch—rapid respiration, 30, 40, 60. Increased tem-perature—pulse full, frequent; may be active delirium; bloody, "rust-colored," sputum; short suppressed cough ; anxious, painful face ; dilata-tion of nares ; circumscribed flush of cheek. Asthenic cases and in old age, may be no chill, little fever and no pain ; delirium low, wandering ; sputum dark, "prune juice," mahogany-colored ; pulse weak and rapid, or slow. Assumes a typhoid form.
Physical Signs.	Differ in the three stages. Three stages usually coexist in different lobes, hence physical signs vary in different parts of lung. 1st Stage. (Hyperemia.) Slight dulness on percussion ; tube-sounds harsh ; vesicular element of sound muffled. Early signs doubtful; with exudation crepitant rale present—fine crackles in inspiration only. 2d Stage. (Solidification.) Crepitus ceases ; flatness on percussion (high pitch, short duration, wooden quality. Auscultation—bronchial breath and bron-chial voice. Fremitus diminished. 3d Stage. (Liquefaction—resolution.) Returned crepitant rale—"rale redux." Sub-mucous and mucous rales. Dulness on percussion. Gradual return of normal, " breezy," " vesicular " respiration. Crepitus of local pleurisy may coexist.
Diagnosis.	Chill, fever, pain ; circumscribed blush, rapid breathing, bloody sputum ; flat-ness ; crepitant rale ; voice and breath bronchial—" rale redux."
Prognosis.	In healthy adults, recovery ; resolution often by fifth day ; the rule is in nine to twelve days. Weak and aged—typhoid form—often fatal. Very rarely develops phthisis.
Treatment.	May abort early by derivatives—diaphoresis, cathartics, cupping. Early period. Allay fever. Aconite, ammonia, fomentations, poultices, mild diet. Later period—Prevent asthenia, favor resolution. Diet, tonics, stimulants.
 
86                    02DEMA OF  LUNGS.
SYNOPSIS OF CEDEMA OF LUNG.
Definition.	Transudation of serum and sero-albumin into the finer air-passa-ges and pulmonary vesicles, either general or local, acute or chronic.
Pathology.	Pulmonary hyperaemia, either acute or chronic, active or passive. In chronic forms usually the associated lesions of chronic bronchitis, peri-bronchitis, and chronic interstitial pneumonia, often with condition of chronic arterio-capillary fibrosis throughout the body.
Etiology.	The acute form, due to arterial or active congestion, often devel-ops' in suffocative forms of broncho-pneumonia, pleuro-pneu-monia, and double pneumonia. The acute passive form is the common result of cardiac failure, in cardiac dilatation, fatty heart, uraemia. Also due to hypostasis in aged, bed-ridden, and persons exhausted by adynamic diseases.
Symptoms.	Dyspnoea, orthopnoea, labored respiratory movements, anxious look, suffused face and neck, cyanosis, cool, moist surfaces, cold extremities, feeble pulse and circulation. Temperature subnormal. Often serous or frothy sputum, may be sanious.
Physical Signs.	Inspection—labored respirations, sinking at epigastrium and supra-sternal notch. Palpation—mucous fremitus. Percus-sion—negative. Auscultation—moist rales in larger bronchi, with finer crepitating rales in smaller bronchi and vesicles. Sometimes there is dulness on percussion, and absence of aus-cultatory sounds at the base of both lungs, due to co-existing hydrothorax. Heart-sounds irregular, labored, and often evi-dencing associated or causative heart disease.
Prognosis.	Varies with character of attack. If actively congestive, may be relieved by bleeding, purging, counter-irritants, dry or wet cups, free diuresis, vigorous diaphoresis, etc. If occurring in the course of renal or heart disease, it is more serious and liable to recur.
Treatment.	If acute, congestive, suffocative, bleeding may give immediate relief. Full dose of calomel with addition of resin of podo-phyllum, elaterium, or pulvis purgans. Local and free use of dry and wet cups. If passive, due to heart failure, support heart with ammonia, Hoffman's anodyne, nitrite of amyl, alcoholic stimuli. Small hypodermics of Magendies's solution (n\, ii.-iii.) frequently repeated. Digitalis to sustain heart. Stimulating enemata (turpentine) to unload bowels, and stimulate splanchnic gan-glia ; dry cups, poultices over kidneys; hot-air baths, free dry cupping over dependent portions of chest.
 
        PULMONARY APOPLEXY.
SYNOPSIS  OF  PULMONARY APOPLEXY.
87
Definition.
The effusion of a large amount of blood from ruptured pulmon-
   ary artery, with laceration of pulmonary substance.
Pathology.
Usually associated with degeneration of the walls Of pulmonary
   vessels, the sequence of alcoholism, syphilis, or wasting dis-
   ease.  Pulmonary structure  much lacerated, extensive col-
   lateral hyperaemia and oedema.
Etiology.
May occur in persons deteriorated by chronic rheumatism, gout,
   syphilis, chronic uraemia, and especially if there be atheroma-
   tous arteries.  May be immediately induced by violent exer-
   cise, especially if the heart be hypertrophied.
Symptoms.
Sudden attack of extreme dyspnoea, suffocation, suffusion, col-
   lapse, expectoration of sanious serum, blood, or in fatal cases
   with extensive pneumorrhagia.
Physical
     Signs.
Unilateral evidences of the source of blood.  A large or  small
   area of  muffled  respiratory and voice sounds,  more or less
   abundant rales and gurgles, and sometimes perceptibly raised
   pitch on percussion.
Prognosis.
Usually bad.  Death often immediate or imminent.  Less often,
   recovery  with secondary  degenerative changes—inflamma-
   tory and phthisical.
Treatment.
Immediate—supine position,  blood  determined to extremities
   and surfaces by warmth and sinapisms.  Heart sustained by
   minute hypodermics (n i.-ii.-iii.) of Magendie's solution, by
   ammonia, nitrite of amyl, alcohol.
Ergot by the mouth or hypodermically at short intervals.  Ice
   bag to the site of apoplexy. 
8S                  PULMONARY INFARCTION.
SYNOPSIS OF PULMONARY INFARCTION.
Definition.	Primarily—the withdrawal of arterial blood from a limited area of lung substance by embolic plugging of the nutrient artery of the area. Secondarily, lessened nutrition and degeneration of the pulmonary structure.
Pathology.	The condition is usually the result of lodgment of extraneous plug (embolus). It may also result from thrombosis due to changes in arterial walls. The disintegrated blood subse-quently transudes the walls, the infarcted area softens or becomes cheesy, the veins fill with thrombi. Localized pneu-monia may ensue.
Etiology.	Any disease of the right side of the heart or venous circulation may lead to plugging of branches of pulmonary artery— dilated right ventricle, lesions of pulmonary orifice, aneur-ismal clots, phlebitis, clots from uterine sinuses, debris of foci of sepsis or pyaemia.
Symptoms.	If connected with sepsis, pyaemia, ulcerative endocarditis (of right side), aneurism, those diseases represented by symptoms. In other cases, attacks of failure of right side of heart permit of intracardial clots, subsequently washed into pulmonary arteries. Attack characterized by chill or chilliness, dyspnoea, local discomfort or pain, sometimes sanious expectoration.
Physical Signs.	Area corresponding to the area of discomfort or pain, dull on percussion, and on auscultation there is absence or muffling of respiratory, whisper, and voice sounds.
Diagnosis.	From lobar and lobular pneumonia, by lower temperature and less frequent respiration than either. Also by less harassing cough. Absence of crepitant rale and bronchial breathing, voice, whisper, and cough. Associated pyaemia, septic or cardiac phenomena.
Prognosis.	When occurring in course of puerperal state may be instantly fatal, usually with right heart obstruction. When associated with pulmonary valvular disease or phlebitis, may not recur, and ultimate recovery ensue. When occurring in sepsis, pyasmia, ulcerative endocarditis, or adynamic disease, prog-nosis bad.
Treatment.	Immediate efforts to maintain circulatory equilibrium. Perfect quiet on the back, avoidance of effort, movement, or excite-ment. Moderate restraint of thoracic movements by chest bandage. Use of antipyretic measures, should elevated tem-perature indicate secondary pneumonia. Sustaining treatment to counteract further sepsis, and secondary or recurring at-tacks. Chloride of ammonium, tincture of iron to maintain nutrition of blood and lessen coagulation, necrosis and sepsis.
 
       GANGRENE OF LUNG.                   89




SYNOPSIS OF  GANGRENE OF LUNG.
Definition.	Death of areas of lung tissue en masse, and either limited to lobules, or diffuse, including a larger area, as a part or whole of one lobe or one lung,
Pathology.	Varies with the form and cause. Hence in drunkards, maniacs, and senility associated with advanced degeneration of vessels and vitiated blood-elements; in sepsis, with embolic and thrombic sequelae; in congestive and pneumonic cases, co-existent diffused hyperaemia and pulmonary consolidation.
Etiology.	Of diffuse form—acute hyperaemia and inflammation, with lowered nutrition of blood and depressed vital powers—in-adequate to insure resolution. Hence occurring in the pneu-monias of drunkards, the aged, insane, or when secondary to typhoid, sepsis, pyaemia. More localized gangrene may result from infarction, or from foreign body in bronchus; still more circumscribed from fetid bronchitis.
Symptoms.	Symptoms of primary disease or etiological factor. Tendency to adynamic form of symptoms, collapse, and evidences of sepsis. 'Development of fetid breath and fetid, discolored sputum. In favorable cases, with completion of gangrenous process there is rapid recovery.
Physical Signs.	At first, evidences of areas of infarction, hyperasmia, or centric pneumonia, usually associated localized pneumonia, broncho-pneumonia, and pleuritis. Later, communication with bron-chus gives evidences of cavity.
Diagnosis.	Physical signs of local consolidation in a low type of disease, or in a patient with lowered vitality, together with irregularity of temperature, evidences of sepsis, fetid sputum, and later of excavation.
Prognosis.	Unfavorable when occurring in the course of low-type disease or sepsis, or when complicating extensive pneumonic process, or traumatism. More favorable when due to foreign bodies or fetid bronchitis.
Treatment.	Vigorous fortification of general strength against sepsis and exhaustion. Heroic use of food, stimulants, tonics. Ex-ternal antisepsis—sulpho-carbolate of soda, terebin, salicin, salicylates, sulphide of calcium, or glycophenic acid. Inha-lations of antiseptics and stimuli to bronchial surfaces and interior of antrum, viz., steam impregnated with turpen-tine, tr. benzoin co., carbolic or glycophenic acid; inhalation of oxygen.
 
EMPHYSEMA.
    SYNOPSIS OF EMPHYSEMA.
Pulmonary, Vesicular Emphysema.
Definition.	A local chronic disease, due to rarefaction of pulmonary struc-ture and dilatation of air sacs.
Pathology.	May be general vesicular emphysema or often of upper lobes only, or confined to but few lobules. Lungs do not collapse on opening thorax. May be distinct cysts, or poutings on the surface; feel soft, elastic. Progressive lesions, enlarged air sacs, obliterated alveoli, perforation of cell-walls, cells coalesce, cysts of small or large size. Fatty degenerations and destruc-tion of intercellular tissue. Capillaries obliterated; their blood leaves pigmentation. Obstructed lung circulation causes dila-tation of right heart, hence general venous retardation, favor-ing chronic diseases of the viscera.
Causes.	Lobular emphysema, is "vicarious," caused in inspiration, com-pensating adjacent, atrophied, solidified, or collapsed lobules. General vesicular emphysema always due to excess of inspired air over that expelled in expiration, as in chronic bronchitis with thickening and relaxation of tubes. Usually fatty de-generation and atrophy of connective tissue. Emphysema of upper lobes only, due to expiratory force and ob-struction at glottis; in pertussis, chronic cough, heavy lifting, gymnasts, porters, musicians, etc. Rarely fatty degeneration is primary. Very rarely due to rigid thorax.
Symptoms.	Dyspnoea, labored breathing, respiration and circulation easily disturbed. Often bad circulation, disease of heart, chronic disease of distant parts.
Physical Signs.	Emphysema of lobules not often detected; general and of upper lobes, resonance vesiculo-tympanitic. Pitch depends on as-sociated condition of pulmonary parenchyma and degree of distention and "inspiratory fixation," or bony rigidity of thorax. Respiratory sounds feeble. Inspiration deferred or shortened. Expiration prolonged, blowing, low in pitch; variety of sibilant and sonorous rales. Chest full, rotund; intercostal spaces full. Expansion slight Rising of chest en masse. Muscles of neck and chest fixed. Broad, short neck in typical case. Others, small, contracted chest. General emphysema, diaphragm depressed, heart also resting on it, and becoming almost horizontal.
Diagnosis.	Heart apex outward; liver may be depressed. Distinguished from asthma by the frequent co-existence of chronic bronchitis.
Prognosis.	Can be alleviated; rarely cured.
Treatment.	Progress checked by removing cause; avoid cold. Cure laryn-geal obstruction, also chronic bronchitis. Improve tone of elastic tissue by hygienics, diet, quinine, pot. iod.
 
pulmonary consumption  or phthisis.
91
    SYNOPSIS  OF  PULMONARY CONSUMPTION OR PHTHISIS.

Pulmonary Consumption considered according to the older pathology of the
                     school of Laennec, Louis,  etc.
Wasting disease  of  the  lungs.  A local expression of  a blood
   state, of a specific diathesis.  Due to tubercular deposits and
   their complications.
1st Stage.—Tuberculization.—Deposit of tubercle usually yellow
   or crude; rarely  miliary.  Yellow  tubercles coalesce, form
   caseous masses.  Involved tissues atrophy.  Caseous  masses
   shrink;  compensative emphysema; usually at apices coexist-
   ing localized pleurisy, bronchitis, pneumonia.
2d Stage.—Softening.—Caseous masses  become pultaceous by im-
   bibition of serum, and pus due to ulceration and infiltration
   of adjacent tissue.   Tissue destroyed, vessels  obliterated  or
   eroded;  usually opening into bronchi.
3d Stage.—Cavities.—Due to evacuation of tubercular pus.  May
   be large or small, smooth or ragged.  Wall  may be exposed,
   lung tissue infiltrated with tubercles, exudation matter, or
   may be  cicatricial tissue.  Large vessels and  bands of  fibrous
   tissue may bridge over large cavities.  Cavity may open freely
   into bronchus, or by a valvular opening.  Cavities may con-
   tain mucus or pus; they may contract, granulate, and heal.
Great predisposing cause tubercular diathesis, usually hereditary;
   sometimes induced  by environment.   Obscure relation to
   scrofulous,  strumous,  and  eczematous  diathesis.  Possibly
   contagious and  endemic through  agency  of the tubercle
   bacillus.
Developing and exciting causes.—All depressing  influences—in-
   digestion, bad diet, privation of food, overwork, exposure to
   cold and damp, dissipation, close confinement at work in foul
   air, sedentary occupations, stooping, inhaling dust, indoor
   life, want of exercise and  chest  expansion, damp changing
   climate, low altitude, depressing  diseases, as  typhoid fever,
   measles, small-pox, syphilis.
1st Stage.—Variable;  may be indigestion, debility, increased
   temperature, emaciation, and  loss of  strength.  Short ac-
   celerated  breathing, pallor, increase  of temperature in the
   afternoon.  May be early haemoptysis (bronchorrhagia), early
   pleural plastic exudation, fugitive or  fixed pains due to dry
   pleurisy.  Cough and expectoration of local bronchitis; may
   be hoarseness.
Inspection.—Small  chest,  sinking under  clavicles, and in in-
   tercostal spaces.   Frequent, shallow, and feeble breathing.
Mensuration.—Reduced circumference and expansion.
Palpation.—Increased  vocal  fremitus, frequent breathing, and
   feeble expansion.
Percussion.—Dulness—slight or marked—raised in pitch, of short
   duration, of wooden quality.  May be sense of resistance. 
92
pulmonary consumption.
SYNOPSIS  OF PULMONARY CONSUMPTION, Etc.—Continued.
Physical Signs. (Continued.)	Auscultation.—Weakened respiration, absence of vesicular mur-mur, bronchial breathing. Inspiration raised in pitch. Ex-piration prolonged and raised in pitch; bronchial voice, bronchial whisper, and bronchial cough; increased vocal fremitus; respiration may be wavy, jerking, divided—cog-wheel respiration; heart sounds conveyed.
Second Stage.	2d Stage.—Hectic more marked; expectoration more free; contains muco-pus — pus, tubercular pus, fibrous tissue, casts, shreds, etc.—(Pulmonary elements), fat-granules, fatty cells, cholesterin. Sputum is nummular, i. e., coin-shaped masses at bottom of frothy fluid; decline of health, strength, flesh; in women, loss of menses in this or early stage, or later; liability to hemorrhage from the eroded vessels; night sweats. Immediate Percussion.—Myoidema often observed. Auscultation.—Subcrepitant rale over softened part. Rales of collateral hyperaemia or associated catarrhal process.
Third Stage. Symptoms. Physical Signs.	3d Stage.—Increased debility, emaciation, flatness of chest, short, quick, labored breath, bad appetite, weak stomach— nausea, especially from fatty food—vomiting, reflex after cough. Cough hard and sputum copious, especially in the morning. Debility increased by severe afternoon hectic, pro-fuse night sweats, excessive expectoration, anorexia. Some-times colliquative diarrhoea: face sunken, cadaveric; eyes staring; breath gasping; tongue dry and brown; fingers clubbed; liability to severe or fatal hemorrhage, due to ero-sion of vessels in cavities. Inspection—May be flatness—retraction. Percussion—May be dulness; or resonance over large superficial cavities; cracked-pot sounds. Auscultation—Cavernous, amphoric respiration, voice whisper, and cough; gurgles, pectoriloquy, aegophony, metallic tinkle.
Diagnosis.	From chronic bronchitis and emphysema, by history, physical signs, and presence of bacilli.
Prognosis.	Always uncertain and guarded. Early stages most favorable, yet extreme cases may be checked. Prognosis determined by temperament, family history, habits, treatment, and climate.
Treatment.	To prevent, cure, arrest, and to prolong life: Preventive.—Attend to ventilation, digestion, clothing, exer-cise, occupation, chest expansion, out-door life, climate. Lessen cough and secretion.—Anti-spasmodics, balsamics, ano-dynes, counter-irritants. Regulate digestion and bowels.—Create appetite, aid digestion, support strength. Bismuth, bark, pepsin, milk, cream, but-ter, kumyss, peptonized milk, fats, ol. morrhuae, glycerin, pancreatic emulsion, wine, whiskey, hypophosphites, etc. Alterative and absorbent effect.—Bichloride of mercury, arsenic. Stop fever and night sweats.—Quinine, sulphuric acid, ergot, atropine; sage infusion, dry salted towels. Relieve fugitive pain.—Anodynes, counter-irritants. Relieve occasional vomiting.—Check diarrhoea.
 
    MODERN  CLASSIFICATION OF PHSHISIS  PULMONALIS.       93


MODERN CLASSIFICATION OF PHTHISIS PULMONALIS.

    (Niemeyer, Rindfleisch, Sir Andrew Clarke, etc.)
  1. Catarrhal phthisis.
  2. Fibroid phthisis.
  3. Tubercular phthisis.
  1. Cartarrhal phthisis is the most frequent form, developing prefer-
ably in persons of phthisical and strumous diathesis, but also in many
others, quite free from such dyscrasia, as the result of poor food, bad
       Fig. 66.                               Fig. 67.
Fig. 66.—Peribronchitis, chronic; fibroid phthisis; dilated bronchi and cavity.
Fig. 67.—Thickened pleura, adhesions; fibroid phthisis of pleuritic origin.
air, indoor life, sedentary and constraining occupations, impure exhala-
tions, and dust incident to special  trades, debilitating disease, either
acute or  chronic, dissolute habits, changeable climate, residence in
low, damp  situations.   The  choking  of terminal  bronchi  and air
sacs with catarrhal products, peribronchial and intervesicular hyper-
emia and infiltration, are first steps in  pathology.   Lobules and
areas of interstitial tissue thus consolidated tend  to caseation, soft-
ening, cavities.   Such cheesy matter (crude tubercle of older authors)
when  softened (tubercular pus) poisons  pulmonary lymphatics, set-
ting up lymphangitis with exudation of round-cell elements into the 
94:       MODERN CLASSIFICATION OF PHTHISIS PULMONALIS.

reticulum of lymphoid tissue, thus producing  the opalescent, semi-
opaque, gray tubercle, the miliary tubercle,  Bayles' tubercle, larger
tubercle cells of von Schoefel, etc.  The physical signs  of phthisis,
as already given, apply to the several stages of this form of phthisis.
  2. Fibroid phthisis, occurring as a product of chronic  bronchitis
in its various forms—peribronchitis, bronchiectasis, bronchial oblit-
eration—occurring as a product of thickened  pleura, chronic pleu-
risy, or more gradually as  a progressive infiltration of pulmonary
interstitial tissues, as a result of gouty or rheumatic vice, of habitual
alcoholism, or  syphilis.   Often coexistent with cirrhotic  liver and
spleen, or with contracted kidneys.
  Physical signs, those given in chronic bronchitis, thickened pleura,
and cirrhosis of lung.    Caseous nodules, softening,  and cavities,
may develop with the physical signs of these conditions.
  3. Tubercular Phthisis.  It develops  chiefly in persons of tuber-
cular parentage.  Less frequently it  appears as the result of great
shock to health, extreme privation, sepsis from bad food, water, or air,
emanations of drainage, and especially damp soil (Ltennec, Benedikt).
Tubercle bacillus would  seem to be a cause of  active contagion and
rapid  development of family groups and  local  endemics of acute
tubercular phthisis.
  It assumes two forms.   1. First and less  frequent, acute miliary
tuberculosis, gray  tubercle  disseminated  throughout the  lungs.
There is rapid failure of health, elevated temperature,  hectic, sweat-
ing, cough, exhaustion, and death, often without caseation or cavities.
The physical signs are often negative, the diagnosis being made  by
the symptoms  and by exclusion.   2.  More  often the deposition of
tubercles provokes bronchial catarrh, and after a brief period of rapidly
failing health and persistent high temperature, the physical signs of
bronchial  and pulmonary catarrh become pronounced,  and later the
signs of areas of consolidation (interstitial fibroid, later  caseation),
softening, and cavities.   The physical signs  of phthisis as described
under the old pathology now again apply.
  Summary.—It may,  therefore, be stated  that, while the modern
pathological distinctions  as to phthisis lead us to a broader and more
discriminating  consideration of the disease, the application of  the
rules of physical diagnosis has remained essentially unmodified.
  In pursuing the physical  diagnosis of any case of phthisis, we dis-
cover  the common  presence of associated  cirrhosis   of the lung,
thickened  pleura, and acute and chronic bronchial catarrh.   These 
BROWN INDURATION OF THE LUNG.
95
conditions  may in  some  cases be  antecedent  and  curative,  in
others concurrent, in others the sequel or complication of a true
tubercular phthisis.
  Originally, all  phthisis was regarded as  tubercular.  In the last
twenty years, the opposite view has prevailed, viz., that a large part
of phthisical cases are the product  of inflammatory diseases of the
chest,  leaving  crippling  lesions  and  tendencies  to   degenerative
changes.  The views of Niemeyer especially tended to this conclu-
sion, and so does our fuller knowledge of the intra-pleural lesions.
  But the detection of the tubercle bacillus (see Fig. 64) tends to give
strength to the  theory  of  the specific  nature  of phthisis rather
than its dietetic, inflammatory, and degenerative origin.
  These explanations have been so fully entered  into  to emphasize
the fact that the student of  physical  diagnosis  must  conjoin a most
careful history of his patient in order to rightly interpret the physi-
cal signs.
             SYNOPSIS OF  SYPHILIS  OF THE LUNG.
  Opinion  is divided as to  the  presence of  distinctive  syphilitic
lesions of the lungs, other than the presence of gummata.  Gummata
will give no physical signs or symptoms indicative of their presence.
They will  provoke  special  symptoms according to their size and
location, as irritative bronchitis and bronchorrhoea,  local pleuritis,
local  interstitial pneumonia.
  More often syphilis is merely a factor in deteriorating the general
health, and aids in inducing or hastening the  progress of phthisis.
The diagnosis is suggested by the  knowledge  of the syphilitic taint
in the patient, and confirmed by the  marked relief of the phthisical
symptoms  following free use of antisyphilitic  agencies—mercury
and iodide of potassium.

              BROWN INDURATION OF THE  LUNG.
  Definition  and Pathology.—A condition  of chronic interstitial
infiltration of pulmonary parenchyma, interstitial deposition of blood
pigment,   atrophy,  contraction,  and   obliteration  of  pulmonary
arterioles and alveolar structure, the  result of chronic passive hyper-
emia due  to cardiac disease.   There is often associated emphysema
of the periphery of the lungs, the  brown induration being  more
marked in the centre of the lungs around and in the  peribronchial
areas and nearer the inner borders of the lungs. The lung structure,
viewed macroscopically, is often of a  salmon or light copper-red hue. 
96
CARCINOMA OF THE LUNG.
  Etiology.  Due to cardiac incompetency, especially insufficiency
or stenosis, or both, of the mitral valve, with ventricular dilatation.
  Symptoms.—Diminished vital capacity,  chronic dyspnoea, often
dry  cough, " winter  cough,"  rarely   bronchorrhoea  or catarrhal
bronchitis.  Associated defective nutrition, poor digestion,  hepatic
and renal symptoms.
  Physical Signs.—Chest poorly expanded.  Respiratory  sounds
feeble,  percussion resonance lessened, raised pitch.   Inspiratory
sounds notably lessened, often with feeble, prolonged expiration of
associated emphysema.   Coexistent heart signs are mitral, systolic,
and  prsesystolic murmurs,  displaced apex, diffused apex impulse,
vibratile apex beat, and increased cardiac area, to the left.
  Diagnosis.—By the foregoing  physical signs  and  symptoms,
with coexistent mitral disease.  To be discriminated from  emphy-
sema, chronic bronchitis, fibroid phthisis, contracted chest of chronic
pleuritic thickening—chiefly by history and heart signs.
  Prognosis.—Slowly progressive, concurrent and co-operative with
primary, causative heart disease.
  Treatment.—Directed to sustaining the enfeebled heart and main-
taining the general nutrition of the body.  Milk  diet (peptonized
milk, kumyss), cod-liver oil, tonics, massage,  mild  regular exercise,
out-door life, dry pure atmosphere, cautious methodical chest expan-
sion.
  Long-continued use of bichloride of mercury and arsenic in small
doses is beneficial.

CARCINOMA OF THE LUNG, PLEURA,  AND  BRONCHIAL GLANDS.
  Cancer within the thorax is most  often secondary to cancer in
other parts.  It is usually the encephaloid  form, less often scirrhus
or epithelial.   When extensive pleuritic thickening or large areas of
flatness  on percussion with associated  absence of respiratory and
conduction sounds exist,  then  with exclusion of  phthisis,  and of
serous effusion by means of hypodermic  puncture or  exploratory
aspiration, cancer becomes a possible  cause  of physical signs.  If
solid growth is rapid and displaces other organs, a  suspicion of can-
cer is warranted.   If cachexia, rapidly failing health, carcinomatous
history or primary cancer, the diagnosis is  strengthened.  In cancer
of the pleura, there is usually a coexistent accumulation  of  sanguin-
eous serum in the pleural cavity. 
CHAPTER  VII.
                   DISEASES  OF THE HEART.

              Topography  of the Normal Heart.
   The correct interpretation of  cardiac physical signs presumes a
 correct  knowledge  of   the  anatomical  structure, topographical
 anatomy, and normal functional action of the heart.
   The heart is commonly regarded as located on the left side of the
 chest, whereas, in  fact, it is situated in part to the right of the
 sternum, underlies the entire mid-sternal region, and not more than
 half of its area is on the left side.   The location  of the heart  differs
 slightly in health in different individuals, according to development
 of the chest, muscularity,  short or long-chest,  etc.  Yet  a  pretty
 uniform average location  as cited below can be observed as a  stand-
 ard, and  any departure from it should not be considered a healthy
 deviation until further examination for evidences of disease has re-
 sulted negatively.   The size of the heart in cadavers varies  not only
 with previous robust health or  feeble  nutrition, but also accord-
 ing as the heart at the time of death was left in a  state of systolic
 contraction or diastolic relaxation.   The average size of the healthy
 heart, then,  is arrived at,  by combining post-mortem measurements
 with many accurate measurements made in health by means of care-
 ful percussion, and especially auscultatory percussion of the area of
 cardiac dulness.
  The vertical and transverse measurements of the heart are usually
 adequate  to estimate the normal or abnormal size of the heart.   The
 heart extends vertically from the upper border of the third left costal
 cartilage to  the lower border of the sixth left costal cartilage •  trans-
 versely, the  heart  extends from a point one-half to three-quarters
 of an inch  to  the right of the sternum across to a point  half an
 inch within the left nipple.   The left nipple has always been  taken
 as a landmark for the location of the left border of the heart, and
also  of the  apex  beat.   It  must,  however,  be  remembered that
the nipple varies in location in men according to development of
             7 
98
TOPOGRAPHY  OF THE HEART.
their thoracic muscles, adipose, etc., and also that many of the diseases
which chiefly change the size and location of the heart, as pericar
ditis  with effusion, dilatation, hypertrophy, also bulge the  prse-
cordial  area  of  the mammary region,  and displace the nipple.
Especially in women, owing to the variable size and pendulousness of
the breast, the nipple becomes an indefinite location.  By the nipple-
location, then, it is proper to say, we mean a point at the junction of
the fourth costal cartilage and rib.
Fig. 68.—Location of the heart (Walshe).
  With reference to the anterior chest regions, the heart is found as
follows.   See Fig. 68.
                Heart occupies all of lower sternal region.
                  "      "     part of right mammary region.
                  "      '"       "■  of left mammary region.
                  u      "     slightly right and left  infra-cla-
                  vicular region.

The exact contour of the deep cardiac  region is  to be determined
Deep Cardiac
   Region. 
TOPOGRAPHY  OF THE  HEART.
99
by  deep  (firm) percussion, or by careful auscultatory percussion,
especially with aid of Cammann's intra-costal auscultator  (see Fig.
56), and may be mapped out  on the patient's chest by pen  and ink,
or Page's admirable marking hammer (see Fig. 59).  But the left
lung  overlaps  the heart  invariably in inspiration and expiration.
The area of the heart not overlapped  by lung in quiet breathing is
designated the  superficial cardiac region.
Fig. 69.—Showing relation of thelheart tolthe great vessels, air passages, and lungs. The lungs
             have been pushed behind the heart to more fully show it.

   This is shown in  Fig. 68 (Walshe).   It may be thus stated :

                  Part not overlapped by lung—a triangle whose
                     apex  is at the fourth left costal articulation
                     with  the  sternum, one  side extending down-
                     wards and outwards to the  union of  the  fifth
                     rib  with its  cartilage, the  shorter side down-
                     wards and inwards to the sixth rib and sternum,
                     the long side being the left sternal border.

   In private practice and clinical teaching, to  demouztrate this tri-
Superficial
  Cardiac
 Region. 
100
TOPOGRAPHY OF THE HEART.
angle, I am in the habit of putting the tip  of  my left  index finger
at the junction of the fourth left cartilage with the sternum, letting
my hand drop so that the index finger lies along the left sternal
edge, the thumb extends upwards and outwards to  about the  junc-
tion of the  fifth rib with its  cartilage,  and with the index  fin-
ger of the right hand I inclose the remaining  side  of  the triangle.
This, as a rule, covers the  area of the  superficial cardiac region, and
superficial cardiac dulness  in health.   The normal topographical re-
lations of the heart to the great vessels at its base, to the oesophagus,
trachea, bronchi, the lungs, the pleurae investing  the inner borders
of the  lungs, the diaphragm, stomach, and left lobe of the liver are
to be considered.
  It is to be borne in mind that the heart is  pendulous, free  within
the pericardium, suspended by the great  vessels ; that the parietal
pericardium  is attached  to  the pleura  and indirectly with  the
diaphragm.
  Although most of the diseases of the heart, and most  of the car-
diac murmurs and other physical signs are connected with the left 
TOPOGRAPHY OF THE HEART.
101
side of the heart, yet it must be remembered that the right  side of
the heart  overlaps or masks the left, and approaches the anterior
chest-wall (see Fig. 69).  The apposition of the right ventricle and
anterior chest-wall, and especially of the diaphragm and left lobe of
the liver, are to be remembered, since epigastric pulsation or fulness
of cardiac origin is due to  the  transmission of cardiac pressure or
pulsation  from the right side  of the heart by  the  left lobe of the
liver.
            Topography of the Heart  in Disease.
   Changes in the location  of  the heart, it will be  seen,  therefore,
may result from :
                                 Hydropericardium.
                                 Hypertrophy.
                                 Dilatation.
                                 Atrophy.
                                 Aneurism of  the  aorta  pushing
                                   the heart  to one side.
Changes in size of the heart
  itself.
2.  Changes in the great vessels.
Changes in  the  mediastinal \  Enlarged glands.
   space (substernal region).  1 Malignant tumors.
4. Changes in the lungs.
5. Changes in the pleura.


6. Changes in the the stomach.


7. Changes in the liver.


S. Changes in the peritoneal cav-
      ity and abdomen generally.
 Emphysema of the lungs pushing
   the heart down.
 Atrophy of the lungs in phthisis
   uncovering the heart.
 Accumulation of serum pushing
   the heart to the opposite side.
 Adhesions pulling the heart out
   of place.
 Dilatation of the stomach lifting
   the diaphragm and heart.
 Fatty, waxy, malignant, hydatid
   liver,   hypertrophic  cirrhosis
[_  pushing the heart up.
 Ascitic fluid, malignant diseases,
   ovarian cysts crowding up the
[_  diaphragm and heart. 
102
topography of the heart.
                  Special Cardiac Topography.

                location of the cardiac  valves.
   Much confusion in  the  location and interpretation of  cardiac
murmurs results from the discrepancy in the statements of different
authors of prominence on physical diagnosis.   More  especially does
this remark apply to the location of the aortic valve, which has been
asserted  and pictured in a  standard  work as located at the right
border of the sternum ; and again by another, at the  mid-sternum.
   Practically, the aortic and pulmonary valves may be  stated to be
beneath the articulation of the third left costal  cartilage  with the
sternum, at its lowest point.   More  exactly, the  pulmonary valve
is  at this  point,  while the  aortic valve  is  half an inch nearer
the median line.  Almost at the same point, topographically, but
at different  antero-posterior depths  behind  the sternum, are the
higher portions of the  mitral and tricuspid valves.   As stated by
Walshe,  a radius of one-half an inch includes a part of all the valves,
and the mitral is but one-half an  inch  from the  tricuspid.  Refer-
ence to  Fig. 69, showing the relation of  the great  arteries at the
base of the heart, will indicate the contiguity of the two basic valves,
with the pulmonary slightly to the left.
   Fortunately, in  practice this  nearness of the pulmonary to the
aortic area, and of the tricuspid to the mitral, makes little or no con-
fusion, as the murmurs of the right side of the heart are so infrequent
as to be unimportant, and so associated with other symptoms and signs,
as cyanosis, venous pulsation in the neck, etc., as to prevent any error in
the interpretation of the local sounds,  even  if the direction of their
propagation is uncertain.  Even the  statement of normal  location
of valves may  lead  us astray in interpretating murmurs, if  too
rigidly adhered to ; for  it must be remembered that, associated with
the more pronounced  cardiac murmurs, there  is often such marked
hypertrophy and dilatation of the cardiac chambers that  the  left
ventricle and apex are changed in location, and a marked change of
location results in the site of the valves and  in the location and direc-
tion  of the line of  transmission or propagation of  the murmurs.
Again, the associated  dilatation of the  aorta and its  branches greatly
exaggerates the conduction of both normal cardiac sounds  and car-
diac murmurs.   The location of the aortic  and mitral valves, there-
fore, are always to be chiefly borne in  mind, and in proper time, as
the heart apex is deviated to left or  right, and the left ventricle 
TOPOGRAPHY OF THE HEART.
103
dilated, or the heart displaced on its side or upwards or downwards,
an estimate arrived at of the  distance these valves have been  re-
moved from their normal site.
  The normal location of the heart valves may be thus recapitulated :

                   LOCATION OF HEART VALVES.

  Pulmonary.—Left  edge of  the  sternum near the lower edge of
the third cartilage.
  Aortic.—A little lower, midway between the edge of the sternum
and the median line.
  Tricuspid.—Middle of the sternum, obliquely from the third left
to the fourth right interspace.
  Mitral.—One-quarter of an inch below  the aortic.  Horizontally
across the sternum opposite the fourth left articulation.
  It is desirable even in our study of physical signs to have in mind
some conception of the size of the organ, and its several parts,  pro-
ducing the sounds which we hear and  the  symptoms we  observe.
This is further  necessary  as  we  employ  morbid  specimens to
illustrate the changes causing the disease we are observing,  as  well
as to have normal  standards of measurement for such cases as we
follow to a fatal termination and autopsy.

                      Weight  of the Heart.
       Average male, 9^ oz. (Walshe).
           "     10-12  oz. (Gray).
          Female,  8-10  oz.   "

                              Size.
Length,.........5  inches.
Width,........       3i   "
Thickness,........2£   "
of Heart  Walls.
                   Thickness
Thickness of right auricle,
           " left,
    "      u septum,  .
    "      " right ventricle,
    "      " left,     "
1  line (y1^ of an inch)
1£ lines.
4  lines.
2£ to 3 lines.
4  to 5 lines. 
 104         METHODS OF EXAMINATION OF THE HEART.

                      Capacity of Ventricles.
 Capacity of right ventricle,       .     .     .     .     .     2 fl. oz.
    "     " left       "......       2 fl. oz.

          METHODS OF EXAMINATION OF  THE HEART.
   The methodical examination of the heart is  conducted in pre-
 cisely the same manner  as  already detailed for  the exploration of
 the chest.  It includes :
   1.  Inspection.
   2.  Mensuration.
   3.  Palpation.
   4.  Percussion.
   5.  Auscultation.
          And secondarily :
   6.  Auscultatory percussion.
   7.  Determining the relation  to contiguous organs.

                          1. Inspection.
   We notice : 1. The degree of precordial fulness or contraction.
   2.  The quiescence  or  movement  of the precordial region  as a
 whole.
   3.  The location of the apex beat or impulse.
   4.  The character of the apex  beat.
   5.  Retraction of intercostal spaces  synchronous with heart action.
   1.  Precordial  Fulness.—In a normal chest, the precordial  (left
 mammary) region should  be  slightly fuller than the right.
   In   case the  precordial  region be  symmetrically enlarged  or
bulging, it indicates hypertrophy, eccentric hypertrophy, dilatation,
or hydropericardium.
   In  case the precordial region be flat, it  indicates  fatty heart,
atheromatous heart, or atrophied senile heart.
   2.  Motion of Precordial Region  as a   Whole.—a. In  most
healthy adults, with moderate development of muscles and subcu-
taneous  adipose, the  precordial  region  is  quiescent in ordinary
activity of respiration  and circulation, /. e., no noticeable motion can
be observed synchronous  with the heart's action, except at the apex
beat in the fifth space.  Let the  healthy patient, however, exercise
violently, or  even breathe rapidly and forcibly a number of times,
and the entire precordial  region will  be seen to heave slightly with 
            METHODS of  examination OF the heart.          105

each systole of heart.   If the patient be lean, this is more percepti-
ble, whereas in persons with much adipose the heart motion will be
less marked, even under the stimulus of exercise or forced breathing.
  b. When the entire heart area is perceptibly shaken by each con-
traction of the heart, it suggests hypertrophy, though it may result
from intense cardiac excitement.
 Fig. 71.—Apex carried to the left of the nipple line by hypertrophy and dilatation (Von Dusch).

   c.  When the entire  precordial region is perceptibly moved by
each  heart movement, and the motion as observed is wave-like or
tremulous, eccentric hypertrophy or advanced dilatation is likely to
be present.  Exceptions  exist, as in very anemic and nervous  per-
sons as well as in  convalescents from exhaustive  disease.  A relaxa-
tion  of the left ventricular  wall probably exists in these states, which 
106         methods  of examination of the heart..

may be recovered  from  by discreet management, rest, and cardiac
tonics.
  d. When the precordial  region  up to the cardiac  base, without
being shaken, perceptibly displays in the third and fourth intercostal
spaces the cardiac motion, we infer that the overlapping edges of the
   Fig. 72.—Apex carried to the right. Hypertrophy or dilatation of the right ventricle
                            (Von Dusch).

lungs have been atrophied or contracted by phthisical processes, and
that the heart is wholly uncovered and permitted to move in direct
apposition with the chest-wall.  Thus, not only the whole ventricular,
but even the auricular wave  is perceived.  This  is an  important
diagnostic  inspection sign of  advanced  phthisis with cavity of the
left lung. 
             methods of examination ot the heart.         107

   e. When the entire precordial region is devoid of motion synchro-
 nous with the heart action, even under the excitement of exercise or
 forced breathing, it denotes an atrophied or fatty heart.
   3. location of the Apex Beat.—The location of the apex beat is
 one of the most important and most practical points  in the physical
 examination of the heart.  The normal location of the apex beat, in
 most cases, at once excludes hypertrophy, dilatation, pericardial effu-
 sion, and the displacements of the heart, down by emphysema, up by
 liver enlargements, and to either side by pleuritic effusions and ad-
 hesions.
   The apex beat, as a rule, is in the fifth intercostal space, one and
 a half inches below and within the left nipple (nipple location, junc
 tion of fourth cartilage and rib).  Various authors state this  differ-
 ently, as two inches below and  one inch within the nipple, etc.   But
 slight variations in the location of the apex are consistent with health,
 according as the patient be short or long chested (the ribs and their
 cartilages  standing well out from the  sternum, or  going down at
 acute angle).
   a. When the  apex beat is carried outward and downward beneath
 the nipple, or outward beyond the mammary line (linea mammillaris)
 the usual cause is either hypertrophy or dilatation of the heart.  See
 Fig. 71.   b. When the apex beat is carried far outside of the nipple
 line and  upwards around the side, dilatation usually is the cause,   c.
 When the apex beat is outside the nipple line and carried upward in
 the direction of the axilla, the heart is usually on its side and has been
 pushed up by enlarged left lobe of the liver, or drawn to the left by
 pleuro-pericardial  adhesions,   d. When the  apex beat  is  carried
 nearer the median line, or the cardiac impulse is chiefly transmitted
 to the  epigastrium, the cause  is usually enlargement of the  right
 ventricle, although simple hypertrophy of  the left lobe of the liver
 will account for the epigastric pulsation.
   e. When the  apex beat is removed vertically upward from the
 fifth to   the fourth  or  third   left intercostal  space, the cause  is
 usually pressure  of the diaphragm upwards either by greatly enlarged
 liver, or  hydroperitoneum, ovarian  dropsy, or  other  abdominal
 tumor  or accumulation.
  f. When the heart is pushed down by the overlapping and pres-
 sure of emphysematous lungs, the apex is depressed.   Some authors
state, as  I think erroneously, that the  apex goes to the right of its
normal site.  I have carefully  examined many cases of emphysema,, 
108         methods of  examination of the  heart.

both in my wards at Bellevue Hospital and in my clinics at the New
York Polyclinic, as well as in private practice, and believe, as held by
many authorities, that the apex of the depressed heart goes to the left.
The diaphragm loses its dome-like convexity when pressed down by
emphysematous lungs, and the depressed heart tends to lie on its side
with the apex outwards.

               4.  Character of the Apex Impulse.

  Second in application, and often more positively  diagnostic, is the
character of the apex beat.   In health, the apex should not only beat
in the fifth intercostal  space, but, as enunciated by good authority,
the beat should be  "punctuate " or definitely located, as it were, al-
most by a point which can be covered by one finger tip.  Departures
from  this punctuate apex beat are more or less  characteristic of
different cardiac diseases.
  a. When in  an  oblique light the apex  beat is seen to be not
punctuate but  diffused, it denotes  an  enlargement of the  heart.
If this  area of  diffused or disseminated apex beat be moved with
regularity and force, and appears essentially as a shaking or lifting
of the chest-wall over the  apex, hypertrophy is to be inferred.
  b.  If the area of  the apex beat be diffused, and also wavy in its
movement, dilatation is  to be inferred.
  c.  If the area of apex  beat moves but slightly,  or, as  often hap-
pens,  so slightly or  imperceptibly as to give no clue to the site of the
apex,  we infer  atrophied heart, fatty heart, senile heart, or great de
bility of the heart, as in invalidism.

       5. Retraction of Intercostal Spaces  over the Heart.
  When  in the precordial  region it is observed that intercostal
spaces, either as a whole or at  single points, are drawn in  or have
movement synchronous  with  the action of the heart, there is a strong
presumption that a former  pleuritis over the region of the  heart
has left  adhesions  which transmit the heart motion to the chest-
wall,  and even  that pericarditis may also have  occurred, and that
pleuro-pericardial  adhesions  are  the  cause  of   the  intercostal
movements.
                       2.  Mensuration.
  Mensuration or measurement has a limited application to cardiac
diagnosis, but is largely applied in connection with percussion and 
            methods of  examination of the  heart.          109

auscultatory percussion.   The following measurements of the precor-
dial area may be made, viz., the vertical measurement from the upper
border of the third rib to the inner border of the sixth; the transverse
Fig. 73.—Cammann's Cardiometer.
from the median line to the left nipple;  and that around the  entire
left side, as  contrasted with the  right.  Any great increase in the
size of the heart, as from advanced hypertrophy or  great dilatation,
will cause prominence of the  region, spreading of  the ribs, and in-
          Fig. 74.—Showing increase of pericardial area in hydropericardium.

crease of the distance from the third to the sixth rib.   It will also
carry the nipple somewhat outwards toward the axilla, and increase
the entire measurement of the left side; especially in extensive hydro- 
110
METHODS  OF EXAMINATION OF THE HEART.
pericardial  effusions  will  the  precordial region  fairly  bulge,
the nipple  being well carried to the left, and both vertical and
transverse lines  lengthened.  The left ventricular margin, as deter-
mined later by percussion, is carried far to the left.  The cardiometer
of Cammann (see Fig. 73) is  useful  to  definitely record in inches
and fractions of an inch the exact distance of the nipple and left
ventricular margin from  the median  line, as  also the vertical and
transverse measurements of the heart.
                  3.  Palpation of the Heart.

  Palpation of  the entire precordial region, and especially of  the
apex region, is often adequate alone to diagnosticate  the  normal
heart, or the particular form of cardiac disease.
  First, the hand may be flatly and firmly laid on over the entire
precordial region.   We thus  may take cognizance of  the  general
characteristics of the heart's  action, viz.:

           1.  The force
           2.  The duration               of the heart's
           3.  The rapidity or frequence '   impulse.
           3.  The character or quality

  a. If the heart is normal, the  force is firm  and well-defined,  the
duration of each impulse is perceptible and uniform in successive
beats ; the heart beats  about the normal 72 per minute, unless  ex-
cited by exercise, and  in quality its stroke is definite, free from
tremor or wave-like sensation.
  b. If the heart is hypertrophied, the force is greatly increased,
the duration is less—more abrupt—the stroke is  more rapid,  and
in quality is suggestive  of excited action.
  c. In dilatation, the force is apt to  be lessened, the duration may
or may not be lengthened, the frequency  of beat varies above  and
below normal, according as the heart is excited or quiescent,  and the
quality is especially wave-like or vibratile.
  d.  In fatty, atheromatous,  senile, and atrophied hearts the force
is greatly diminished, the  duration of the beat is  less, their frequence
often below normal, and the quality is chiefly feebleness only, some-
times with  tremor or waviness.  With the hand on the heart, we
also may observe the synchronism of  the heart action with the pulse 
METHODS OF EXAMINATION OF THE  HEART.         HI
at the wrist or in the  carotid artery.  This is sometimes essential
before  proceeding  to auscultate,  since  in  tremulous  and feeble
hearts, and in some cases  of disturbed  rhythm associated with ex-
treme dilatation, it is hard to say what period of the heart  sounds
is systolic, what diastolic.
   Even more practical than the application of the hand to the pre-
cordial  region is palpation of the apex beat  or apex impulse with
the tips of the fingers.  We thus again  study:
                1.  The force
2. The duration
3. The rapidity
4. The character    j
of the apex beat.
and also its:
  5. Synchronism with cardiac systole and the pulse  in the carotid
and radial arteries.  What has been  said as to full duration and
rapidity of precordial impulse suffices for the apex also.  But the
quality of the apex beat must be specially stated.
  a. In health, the apex properly located in  the  fifth intercostal
space must be  punctuate,  practically covered by one, or two at
most, finger  tips, it  must  have  normal  force, duration,  and fre-
quence, and  in  quality be  devoid of any trace of  vibration, weari-
ness, or thrill.
  b. In hypertrophy, the apex beat as felt by the finger tips has in-
creased area, or is disseminated or diffused, is increased  in force, is
abrupt, accelerated, and suggests in quality increased size,  strength,
and nearness of the impinging heart.
  c. In dilatation, the apex beat is diffused, may need all the finger
tips to cover it, is lacking in force, usually increased in duration, may
be rapid or slow, usually is irregular or intermitting, and in  character
is perceptibly vibratile or wave-like.
  d. When  mitral stenosis  or obstruction exists,  the apex beat is
peculiarly vibratile—a fine  vibration or thrill, generally  regarded
as diagnostic.
  e. In the several forms of feeble heart, palpation with the finger
tips often fails to find the apex.   The apex beat is wanting in force,
short in duration, often slow, and retreating or distant in quality.

                  4.  Percussion  of the  Heart.
  The percussion of  the heart consists essentially in mapping out:
  1. The deep cardiac region. 
 112         METHODS OF EXAMINATION  OF THE HEART.

   2. The superficial cardiac region.
   For this purpose, the use of the fingers as hammer and interposed
 medium are sufficient, although, if desired, the hammer and plexi-
 meter of Winterich or Flint (see Figs. 10, 13) can be employed.
   To be accurate, the percussion of the heart areas must be made
 with great care.  The index finger of the left hand must be placed
 in the intercostal space, and must be held firmly upon the part; the
 the blow must be delivered lightly and firmly with one or more
 finger tips of the right hand, thus constituting deep percussion as dis-
 tinguished from superficial or light percussion.   As already stated
 and figured (see  page  98, Fig. 68),  the deep  area  of cardiac
 dulness  or  deep cardiac region corresponds to the full size  and
 shape of the heart and its investing pericardium.   This extends in
 health from the upper border of the fifth rib to the lower border of
 the sixth, and laterally from half to three-quarters of an inch to the
 right of  the sternum  to within half  an inch of  the left nipple
 (fourth  articulation of rib and cartilage).
   The superficial cardiac region and area of dulness are variously
 stated and figured by different  authors; and undoubtedly this area
 varies in different healthy persons according to the width and length
 of the chest, the degree of development of the lungs, the  muscular
 development, and individual peculiarities.
  But it is essentially a triangular space from the articulation of the
 fourth left  costal  cartilage  with the  sternum  downwards and out-
 wards to the union of fifth cartilage and rib, then downward  and in-
 ward to sixth cartilage, and  the  longer side coinciding with the left
 border of the sternum.   As stated (see page 100), it may be inclosed
 by the index finger and thumb of left  hand and index finger of right
 hand.
  By percussion of the heart in  disease, we seek to determine :
  1. Changes in the size of  the heart.
  2. Changes in the location of the heart.
   1. CHANGES  IN SIZE OF THE HEART AS SHOWN BY  PERCUSSION.
  a. Diminished area of cardiac dulness in rare instances denotes a
 small heart, as senile atrophied, fatty or atheromatous heart.  As a
 rule, however, it is due  to the overlapping of emphysematous lungs.
  b. Increase of the deep cardiac area is usually to the left, as dis-
 ease of  the  left ventricle is most frequent.   As shown in Fig. 71,
the area of dulness is carried  far outside of  the  left nipple.  This
increase in size to the left is still more pronounced in advanced dila- 
             METHODS  OF EXAMINATION OF THE HEART.          113


tation.   The apex may descend  if  the diaphragm be depressed by

co-existing emphysema, but quite as often is carried laterally outward
 Fig. 75.—Hypertrophy of left ventricle; cardiac area of dulness increased to the left 'Loomis).

or even goes upward  in extreme cases, the heart resting somewhat
Fig. 76.—Dotted lines denote area of increased size .of the heart in enlargement of the left and
                           right sides (Piorry).

on its side, and reclining on  the side of the  dome-like diaphragm.

Niemeyer compares the displacement of the apex of enlarged hearts
           8 
114         METHODS  OF EXAMINATION OF  THE HEART.

to a gliding of the heart off the side of the  roof-like or dome-like

diaphragm in seeking greater accommodations within the chest.
   Fig. 77.—Increase of cardiac  dulness to the right.  Hypertrophy of the right ventricle
                                (Loomis).

   In extreme cases  of hypertrophy and  dilatation, the  deep cardiac

area extends far out to the axillary line (see Fig. 75).
Fig. 78.—Hydropericardium.
  c. In hypertrophy or dilatation of the right ventricle, the area of
dulness is increased to the right (see Fig. 77). 
METHODS OF EXAMINATION OF  THE HEART.
115
   d. When pleuritic fluid fills the left pleura, the heart may be dis-
 placed to  the right, even as far  as wholly beyond the right side of
 the sternum, and reversely, when the right pleura is full of fluid, the
 area of heart dulness will be carried well over to the left of the ster-
 num.^  Percussion alone may not suffice to demonstrate this without
 the aid or confirmation  of auscultatory percussion.
   e. Pleuritic adhesions may draw the heart far over to one or  other
 side;  the area of dulness will then be correspondingly displaced.

  /. The area of dulness in hydropericardium is  peculiar.   Owing
 to the gravitation of the fluid in the pericardium, the normal area of
 dulness—broadest at the base of the heart and  less at the apex—is
 inverted, as well as enlarged, downwards and to  the  left.   A pyri-
 form  area of dulness with  broad base below is the  result,  and the
 entire area is greatly enlarged.

   g. As already stated,  the superficial  area of dulness varies greatly
 in health.   In disease it is chiefly affected by :
   1. Changes in size of the  heart.
   2. Changes in location of the heart.
   3. Expansion or contraction of adjacent lung.

   1. In hypertrophy and dilatation, the triangle of superficial dul-
 ness is enlarged and swung to the left, i. e., the long side no longer
 coincides with the left  edge of  the sternum,  but  changes with the
 changed site of the apex.
   2. When the heart is pushed to the left or right by pleuritic fluid, or
 drawn  by adhesions, or  displaced by abdominal  accumulations  or
 growths, or lies on its side, the triangle is modified variably in size
 and location.
  3. Emphysema  of the  left lung  may  overlap  the heart and
 obliterate  the  superficial area, or, as often  occurs, greatly  reduce
 its size.
  Phthisis of the left lung may so  retract the borders of the  lung
 that the heart is more fully uncovered, comes  more fully in  apposi-
 tion with the chest-wall, and the triangular  superficial area is in-
creased.   This detailed study of the deep and  superficial areas is not
theoretical  or  merely to complete a  systematic classification, but
often contributes positively to settle a diagnosis, as well as to  com-
plete a clinical demonstration of a case before the class. 
116
METHODS OF EXAMINATION OF THE HEART.
               POSITION FOR  PERCUSSING THE HEART.
  The positions already described (see pp. 27, 28) and  pictured  (see
Figs. 16,17,18) for examination of the chest are of service in percuss-
ing the heart.  As a  rule, the heart  cannot be well mapped  out
when the patient is  reclining.  He should preferably stand with
arms  folded behind his back.   If  too  feeble, sitting  is next to be
preferred, or  if  in bed,  a semi-recumbent  position  supported by
pillows.  The heart thus is  brought in contract with the  anterior
chest-wall.

           Auscultatory Percussion  of the Heart.
  To confirm the results of deep percussion of the two cardiac areas,
auscultatory percussion is often of greatest value.   Either Cammann's
double  stethoscope (see Fig. 33), or his wedge-shaped  auscultator
(see Fig. 56) is placed over the  heart and held there by the  listener,
or an  assistant, or the patient.  The heart is  then approached from
every direction with a Hne of percussion strokes, and  the points of
arrival over the  heart are marked.  These several points are then
connected by a line of ink or other marking material, and  the  size
and contour of the heart accurately figured.

                5.  Auscultation of the Heart.
  The auscultation of the normal heart, and  a familiarity  with all
the acoustic phenomena of its healthy action, and of the deviations
from  the average standards  of cardiac  sounds within  the  range of
health in different individuals, are essential preliminaries to the study
and  proper  interpretation  of  abnormal  cardiac   sounds, termed
bruits or murmurs.

              auscultation  of the normal  heart.
  In listening to the normal  heart,  we observe :
  1. The frequence of the heart's action.
  2.    "  rhythm    "       "      "
  3.   "  duration of the first sound.
  4.   "      "     "     "   rest.
  5. •  "      "     "•    second sound.
  6.   "      "     "       "   rest.
  7.   " quality    "    first sound.
  8.   "    "      "    second sound. 
             METHODS OF EXAMINATION OF  THE HEART.         117

   1.  Frequence of the Hearts Action.—When sitting or standing,
or  walking or exercising quietly, the average  adult  pulse  ranges
from 72 to 80 per  minute.   It is proportionately more frequent  in
young adults, adolescents, and children, ranging from 80 to 90.  In
new-born  infants it ranges as high  as 112 to 124.   On the other
hand, in persons past 60 years, the heart beats below 70, 65, or even
60.   The stableness or unstableness of the  heart-beat under  excite-
ment is to be noticed.  This  is largely  a  matter of temperament.
Phlegmatic and stolid persons will evidence little or  no acceleration
of the heart's action even upon moderate exercise, quick walking, or
forced,  rapid breathing, while emotional and nervous persons will
exhibit  sudden increase in the heart-beats, even from  the influence of
a physician's examination. Again, certain normal hearts are but little
influenced by aggravated conditions of the patient,  as constipation,
gross errors of diet, alcoholism ; whereas other equally healthy hearts
in persons of neurotic habit  are  excited to  a frequency of  120 or
higher  by slight disturbing  causes, as the drinking of  ice-water,
flatulence, fatigue.  The persistent depression of the heart's action
in young  adults to 50, 40, or  even  30  is an occasional result  of
costiveness, inactive  liver,  acholia, cholemia, etc.,  a  condition  of
the heart usually relieved promptly  by the free use of cholagogue
cathartics.
  2.  Rhythm of the Hearts Action.—By the rhythm of the heart's
action we understand  the regular and uniform recurrence of succes-
sive  cardiac  beats,  without  intermission  or  irregularity.  It also
presupposes  that the periods of  the two sounds  and  two rests
are of proper and uniformly recurring duration.   It  is, however,  to
be remembered  that after 60 years  of age it is not indicative of
heart disease to have a uniformly recurring intermission, as an inter-
mission every ten,  twenty, or thirty  beats,  provided  the  heart's ac-
tion is otherwise normal.   The innervation  of  the  heart proceeds
primarily from the medullary centre, but the rhythm  is also  influ-
enced by the numerous ganglia (variously estimated from three hun-
dred to  five hundred in  number) imbedded in the heart substance.
It is further influenced or disturbed by the great splanchnic ganglia.
Hence a  regular recurring  intermission during a  term of  days,
months, or even years,  may be consistent with  normal heart, and be
the result of neurotic habit,  centric nerve  disorder, or of chronic de-
fect of assimilation—notably defective liver function.
  3-6. Duration of the  Two Sounds and Two Rests.—If the entire' 
118         METHODS OF EXAMINATION OF  THE HEART.

period of complete cardiac action be analyzed, it will be found an
easy task to estimate the portion of this period occupied by the con-
traction of the heart, its relaxation and rest, as well as the intervals
between the two acts.  The first sound  of the heart essentially
covers the period of heart contraction or systole.   The second sound
occupies the first portion of the period of heart relaxation or diastole,
while  the  second rest  or period of  silence completes the  diastolic
period.
  To illustrate,  let the whole period of heart action be represented
by 10.
  We shall then have :   Duration of the first sound, .     .   4
                         "       "    "  rest,  .    .     1
                         "       "   second sound,     .   2
                         "       "     "   rest,   .     3
                                                       — 10
If the listener,  still keeping his  ear or stethoscope over the heart,
will with the index finger of his right hand feel the radial pulse,
or better the carotid (remembering that the arterial pulses are in time
but slightly behind the cardiac systole), he will demonstrate:
  1. That the first sound is synchronous with the systolic or contrac-
tile period of the heart.
  2. That the second  sound  is synchronous with the diastolic or re-
laxing period of the heart.
  7-8.  The  Quality of the  First and Second  Sounds.—-The  ear
applied over the cardiac area at once recognizes  two distinct, regu-
larly recurring  sounds.  They have distinct and opposite charac-
teristics.  The first is long, the second is short.  The first is a boom-
ing sound, the second a " click."   The first is relatively low-pitched,
the second relatively high-pitched.  The first sound is recognized as
a sound  which " develops,"  /. e , has distinguishable parts ; thus it is
lower pitched at its outset or first half, whereas on its second half it
becomes a little higher in pitch and has greater volume or intensity.
Thus (Walshe) the first part of the first sound is like " ou," the second
part like "bb," the whole  first  sound  a  developed,  growing or
swelling sound like " oubb."   Dr. Leaming  has  described the first
sound as "Hug," of which the  formative parts would be  "11"  and
" ug."
  The  second  sound is  not a  complex, developed,   or  growing
sound, with  parts of differing pitch and intensity.   It is  a  single
sound, abruptly produced, of uniform pitch  and intensity.  It has 
            METHODS OF EXAMINATION OF THE HEART.         119

been  variously  represented,  as "dup,'' "tup,"  and  "ta"  (as in
rosetta).
  The first  sound is best heard over the anterior  ventricular waH
and apex; the second sound, over the base of the heart—the aortic
and pulmonary valves.  The  sequence of the normal heart sounds
thus may be represented  by letters, and I  think it of the utmost
value for the student and teacher to  bear these letters in  mind as
standards of normal sounds, and by  which to estimate departures,
slight or pronounced, constituting evidence of cardiac disease.
  Thus Dr. Flint describes the first sound as " lub," the second as
" dup," the whole heart's  action as " lub-dup,"  " lub-dup," " lub-
dup."
  Dr.  Leaming  would describe the heart's action as  "llug-te,"
"llug-te," "llug-te."
  Walshe makes a further distinction which is by no means fanciful
and will well repay any observer to  study and verify.  If we listen
over the left ventricle, we hear the first sound distinctly as  " oubb,"
and  the second sound less distinctly as " dup ;"  i. e., both sounds
" oubb-dup."
  But if we place the ear over  the basic valves, we now hear
the first sound less distinctly (because away from the seat of its pro-
duction) as  " up," and  the second  sound more  distinctly  (because
over the seat of its production) as " tup."   Hence the heart sounds
heard in health are :
  1.  At the apex and over ventricle, "oubb-dup."
  2.  At the base, " up-tup."
  As a rude way of simulating the rhythmic recurrence, general
quality, and duration of the heart's  sounds, I have been in the habit
of representing  the first sound by a sliding blow  of the palmar sur-
face of the  thumb on a table, and  the second sound by an  imme-
diately succeeding blow with the tip of the index finger of the same
hand.  These two strikes and the sounds which they elicit—the one
long, gliding, booming, and resonant, the other short, abrupt, high-
pitched—fairly illustrate the cardiac rhythm.
  To recapitulate:
                 ' Cardiac sounds (Flint) " lub-dup "—" lub-dup."
                     "     "    (Learning) "llug-te"—"llug-te/"
                     "     "    (Walshe)
                        at apex—" oubb-dup "—" oubb-dup."
                        at base—" up-tup "—" up-tup." 
120         METHOPS  OF EXAMINATION OF THE HEART.

   Either of  the foregoing may be taken as fairly representing the
normal heart-sounds.


                 Causation of Cardiac Sounds.

   A correct  conception of the causes of the first sound of the heart,
and a recognition of its composite character, I regard as essential to
a  proper  interpretation of various slight modifications of and de-
partures from the normal standard so often met with in practice.
   1. The first sound has been asserted by different authors to be the
product wholly or chiefly of each  one of the following causes:

1. Muscular  sussurus and friction upon each other  of  the  several
     muscular bands constituting the ventricular wall.
2. Movements of blood currents, and action of blood elements inter
     se, i.  e.,  Wave or current sounds.
3. Friction of blood currents within the left ventricle upon the tra-
     beculated structure of the  ventricle—its columne carnee and
     chorde tendinee.
4. Vibration of the  closing mitral  valves.
5. Vibration of the chorde tendinee, made tense by closure of mitra
     valves.
6. Vibration of the  chest-wall.
7. Impulse of the heart—its impact against the chest-wall.
8. Precordial friction, the gliding and turning of  the heart within
     the pericardium, in its systolic movement.

   Walshe regards the first sounds as in some degree due to each and
all of these  causes—constituting them the  factors of  a composite
first sound.   Flint regarded the impact  of the heart and  vibration
of the valves as chief causes, and  Leaming ascribes the first sound
as musically produced by vibration of the valves and chorde.  The
author regards the composite  or complex origin of the first sound,
as held by Walshe,  to be  substantiated by  many  temporary func-
tional  heart-sounds,  induced by disturbances of one or more of the
factors.  Irregular action of the muscular structures of the heart in
chorea  develops  a temporary murmur, which would strengthen the
belief that muscle friction  is a factor of heart-sound.   In anemic
and hydremic cases,  there is often developed a functional apex mur-
mur which passes away when the blood becomes normal. 
FUNCTIONAL DISEASES OF THE HEART.           121
  2. The second sound  is also composite, due to the  synchronous
closure of the aortic and  pulmonary valves.

            Auscultation of the Heart in Disease.
  1. In Functional Diseases of  the Heart.
  2. In Organic Diseases of the Heart.

             1.  FUNCTIONAL DISEASES OF THE HEART.
  1. Disturbed action incident to general anemia, causing hemic, or
anemic murmurs.
                                             { Intermission,
                                             J  Irregularity,
                                               Palpitation,
                                             I Spasm.

                                               Cardiac Tremor,
                                               Syncope,
                                               Paralysis,
                                               Angina Pectoris.
2.  Xeuroses of the heart. -
Hyperesthetic,
  Atonic,
I
             2.  ORGANIC
 1. Ancemia.
 2. Congestion.
 3. Endocarditis.
 4. Pericarditis.
 5. Myocarditis.
 6. Hydro-pericardium.
 7. Atrophy.
 8. Hypertrophy.
 9. Dilatation.
10. Fatty Degeneration.
DISEASES OF THE HEART.
         11. Atheroma.
         12. Hemorrhage.
         13. Embolism.
         14. Aneurism.
         15. Rupture.
         16. Injuries.
         17. Malformations.
         18. Syphilis.
         19. Tubercle.
        20. Cancer.
            FUNCTIONAL  DISEASES OF THE HEART.

                      1.  Anaemic Murmurs.
   In anemia,  the  blood  is  in  an  impoverished,  watery condition.
Examples of profound anemia are  often seen in young girls who
just after puberty become very pale, even to  their lips  and gums,
have palpitation of the heart, and difficult breathing on slight exer-
tion.  In such  persons the motion of the blood inter se produces in
the'  heart and  blood-vessels  a soft  blowing sound, which may also 
122
FUNCTIONAL DISEASES  OF THE HEART.
range in intensity from  a  gentle to a  very violent murmur; this
anemic or hemic murmur, however,  usually lacks  the friction,
harsh grating,  sawing character of organic  murmurs.  It  is best
heard at the base of the heart, at the junction  of the third left car-
tilage with the sternum,  and  is also  heard throughout the large
arterial  trunks, the innominate  and subclavian arteries, and down
the sternum to the tip of the xyphoid cartilage.   The sound is car-
ried simply by convection.   In cases of extreme anemia, there are
also venous murmurs in the neck—a  continuous humming, called
" bruit du  diable."

                Diagnosis of An.emic Murmurs.
  1. Character—soft and blowing.
  2. Originated at the base of the heart and carried along the course
of the large vessels.
  3. Occur in anemic persons.
  4. Loudest during or after violent exercise.

                  2. Xeuroses of the Heart.
  Disorders due to nerve causes.
  Nerve  power  of heart.—The  heart is  an involuntary muscle,
which receives a constant supply of motor power from  the pneumo-
gastric nerve,  and the superficial and deep cardiac ganglia.
  All over the surface of the heart, and  in its substance, are numerous
little ganglia, connected  together and constantly supplying stimulus
for the heart's action and rhythm.

                Irregularity  and Intermission.
   The most common of  all causes of irregularity, intermission, and
palpitation is indigestion.  Irritation of one branch of the pneumogas-
tric nerve—the gastric—disorders the other branches, and produces
palpitation and dyspnoea.
   Excessive  use of  tea  and  coffee, and especially of tobacco, is  a
cause; the latter acts not only by producing dyspepsia  through ex-
cessive action of the salivary glands, but directly through the nervous
system.
   Alcoholic  habit causes first a  violent,  then an irregular  heart.
action.   Fright, excitement, excessive  mental effort, great  fatigue
from overwork, or absence of sleep will give rise to irregularity  in
the heart's action. 
FUNCTIONAL DISEASES  OF THE HEART.
123
  It not infrequently happens that an organic murmur coexists with
great irregularity and intermission. The tendency is for the physician
to view the case with alarm, and estimate the case  as critical, ascrib-
ing the cardiac irregularity to the organic changes.  Yet rest, food,
digitalis,  and strychnia entirely  remove the irregularity,  leaving
only the murmur.  It is then evident  that the  same toxic  agents,
emotional and depressing influences, which disturb a normal heart,
still more disturb a diseased  heart.   In  extreme cases of  cardiac
irregularity, therefore, both with and without the  presence of  mur-
murs, it is necessary to defer the diagnosis as to an organic lesion and
actual weakening of the heart muscle until the heart has been rested,
the circulation equalized, cardiac and  general tonics employed, and
the patient examined under various conditions of rest, exercise, etc.

                              Spasm.
  The  action of  the heart  in a child  who has chorea  is  typi-
cal  cardiac spasm.  In  this condition  is often  heard an intra-ven-
tricular  or functional apex murmur.   It  is produced by irregular
contractions of  the  columne carnee  and strata of cardiac  muscle,
and is heard  either  as a modification  of the first sound or at the
completion of the second sound at the apex.   Distinct reduplication
of the first and also of the second  sound may thus result from a syn-
chronous action of the different portions of the heart's structure.

                             Tremor.
  When  a person has  indulged in  dissipation until the nervous
system  is exhausted,  there will  be a  tremulous action  of the heart
discernible by palpation.
                             Syncope.

  Syncope is that form of fainting which is due  to failure of the
heart's  action.   The  cessation  may be temporary, with temporary
cerebral anemia, from failure of the heart to send blood to the brain,
or the cardiac relaxation may be complete, and  death ensue.   The
failure to contract is usually due to deficient nerve force.  If merely
transient, its cause being a temporary derangement of the nerve cen-
tres we have vertigo, unconsciousness, feeble action of the heart,  or
action altogether inappreciable, face ashen or pallid, and surface cool;
after a brief time the heart resumes its work.  If syncope continue
a long time, a heart clot may form; this will  give  rise to a murmur 
124           FUNCTIONAL  DISEASES OF  THE HEART.

for a considerable length of  time ; and  it may lead to embolism, oc-
curring months later.

                   Paralysis of the Heart.
   Shock or injury to the sympathetic nerve may be so great that it
never reacts to supply stimulus for the heart's action.
   Diphtheria, cerebro-spinal meningitis,  typhus fever,  and  some
other diseases occasionally cause paralysis of the heart.

                       Angina Pectoris
is placed among neuroses because its lesion is not known.   Its path
ology is supposed to be in many cases embolism or occlusion of the
coronary vessels.  All its symptoms may occur in organic disease.

             The  Organic  Diseases of the Heart.
   The organic diseases of the heart are comprehensively considered
in the  following synopses.   The  pathology bears upon diagnosis,
and the prognosis  and treatment so  often have to be revised and
modified in relation to ultimate diagnosis that they have  in each
disease been included in its consideration. 
CHAPTER  VIII.
SYNOPSES OF  HEART DISEASES.

    CARDIAC HYPERTROPHY.
Definition.
Enlargement of  the heart as a whole, or of the walls of any one
   of its cavities—the result of increased effort of the heart.
Pathology.   Hypertrophy of left ventricle more often than of right ventricle;
                rarely auricles.  Increase of weight, size, thickness of walls.
             Concentric hypertrophy: Thickening of walls at expense of cavity.
             Eccentric hypertrophy: Hypertrophy with dilatation.
             Due to hypertrophy of existing muscular fibres.
             Possibly new fibres developed.
             Hypertrophy, at first a conservative process, changes to dilata-
                tion and fatty metamorphosis after long standing.
Causes.
Symptoms.
Physical
    Signs.
Of left ventricle:
   Aortic valvular lesions.
   Mitral valvular lesions.
   Atheroma of aorta and arteries.
   Obstructed circulation in viscera.
   Pericardial adhesions.
   Habitual violent work or exercise.
Of right ventricle:
   Emphysema and other chronic lung disease; obstructive pul-
     monary valvular disease.
   Mitral lesions.  (Indirectly.)

Full, strong pulse  in hypertrophy of left ventricle.  Fulness of
   carotids and temporals,  Liability to congestion of brain if
   the heart is over active.
With hypertrophy of right ventricle, a Blow venous circulation,
   dyspnoea, coexisting lung disease.

Inspection.—Fulness  of prsecordial region, and heaving apex
   beat.  Apex lower and outward—hypertrophy of left ventricle.
Mensuration.—Nipple carried outward;  increased distance from
   third to sixth rib.
Palpation.—Violent apex beat, and changed location.
Percussion.—Increased  area of dulness to the left, and down, for
   the left ventricle, to  right of sternum for right ventricle.
Auscultation.—Valvular murmurs of the lesion causing hyper-
   trophy.   The accentuated first sound  and the sharp, loud,
   abrupt click of  the second sound.
Diagnosis.    Prsecordial fulness: increased area of dulness;  full, strong pulse;
                strong cardiac impulse; displaced apex; valvular lesion; in-
                tensified normal second sound, due to aortic resiliency.
             Often associated hypertrophy of aorta and arteries of neck.
Prognosis.    In simple hypertrophy good,  if life be regular and no increase
                of lesion.   Bad,  if hypertrophy is  associated with dilata-
                tion.  Danger  of  cerebral congestion; dilatation, fatty  de-
                generation, etc.
,ment.   Quiet life; light work; temperance; plain diet.
         Keep excretion free.
         Avoid causes of increased lesion. 
126
CARDIAC DILATATION.
CARDIAC  DILATATION.
Definition.	Enlargement of the heart, or one or more of its cavities, with thinning of their walls.
Pathology.	Increase of size of heart; cavities increased in size and capacity; walls thin, often in state of fatty degeneration; lesion of mitral or aortic valves as a rule; valves may be separated sec-ondary to dilatation; rarely hypertrophy co-exists, second in order, and conservative; more often walls are thin, even as parchment (rare).
Causes.	Mechanical internal dilating power of blood during diastole (rest —relaxation of heart). Usually due to mitral regurgitation or aortic regurgitation; also due to softening, relaxation, fatty degeneration of heart-walls, in acute fevers of low ma-lignant type.
Symptoms.	Weak pulse—often intermittent, irregular; slow, imperfect ven-ous return circulation; dyspnoea, bad digestion; passive con-gestion of lungs, kidneys, and liver; cold extremities; pale or cyanosed face; liability to syncope; oedema of lungs; general anasarca.
Physical Signs.	Prsecordial fulness; weak, heaving, wavy motion over heart; not a strong defined impulse; nipple carried outward; in-creased distance from third to sixth rib; increased area of dulness; heart sounds weakened; loud abnormal sounds in-dicating mitral or aortic regurgitation. May be coexistent mitral direct murmur and thrill at apex.
Diagnosis.	Weak pulse; weak, wavy impulse; large area of dulness; re-gurgitation, dyspnoea; attacks of syncope; intermission and irregularity of pulse; general weakness; secondary disorders of other organs.
Prognosis.	Always bad.
Treatment.	A quiet life; avoid heavy work, active exercise, excitement, dis-sipation, and indigestion. Preserve full action of bowels, kidneys, and skin. Improve the general health by plain food, quinine, strychnine, and iron. Regulate the heart's action by digitalis or convallaria. Combat cardiac failure by alcohol, morphine, Hoffman's anodyne, nitrite of amyl.
 
FATTY  HEART.                     127




FATTY HEART.
Quain's Degeneration.
Definition.	A destructive metamorphosis of the muscular structure of the heart. (Distinguished from mere deposition of adipose on the heart of obese persons.)
Pathology.	Heart—pale yellow, soft, small (unless dilatation coexist). Striae of muscular fibres grow faint, disappear; replaced by fatty granules, oil globules, and atheroma. Sequel of myo-carditis.
Causes.	Indolent life; rheumatism, gout; alcoholism; old age; acute fevers of low type; climacteric changes; atheroma or em-bolism of the coronary arteries.
Symptoms.	Weak circulation; feeble pulse; cold extremities; pallor, cyano-sis; weak heart impulse; liability to syncope; cerebral an-eemia. Weak heart-sounds, intermission, irregularity; dyspnoea, sighing, irregular breathing (Cheyne's symptom). Coexisting arcus senilis, and atheroma of arteries in old people.
Physical Signs.	No precordial prominence; no perceptible apex beat. May be reduced area of dulness; sounds feeble, often distant. May be aortic or mitral murmurs due to atheroma on valves.
Diagnosis.	Age, general health, habits, arcus senilis, weak pulse, often syn-cope, faint heart-sounds. Often contracted liver and kidneys.
Prognosis.	Bad. Liability to death by syncope. Milder cases—impaired strength, general feebleness and emaciation.
Treatment.	Arrest progress by good diet, temperance, tonics. Avoid syn-cope; avoid dilatation; avoid sudden or great effort. Treat syncope by stimulants.-Alcohol, ammonia, Hoffman's anodyne, nitrite of amyl, etc.
 
128                       endocarditis.



                        ENDOCARDITIS.
Definition.	Inflammation of the endocardium.—A local disease usually sec-ondary to and complicating overloading of the blood with irri-tant morbid material.
Pathology.	Removal of epithelium.—Surface hazy, granular; congestion of subserous vessels; development of villi; infiltration of tissue producing roughened, thickened, villous surface, or masses (vegetations). May be hair-like processes, or pedunculated polypoid bodies. Inflammatory products may be re-absorbed or remain; may be fibrous or become calcareous; may cause atrophy, hypertrophy, distortion, retraction, etc., of valves. Polypoid masses may be detached and cause embolism of other viscera. Endocarditis usually on the left side of the heart only. Endocarditis of foetus in utero on the right side of the heart. Vegetations may grow from the fibrin of the blood.
Causes.	Rheumatism, Blight's disease, scarlatina. Rarely typhus, typhoid, variola, rubeola, diphtheria, sepsis.
Symptoms.	Often none. May be dyspnoea, precordial pain, irritable action of the heart. Often not diagnosed.
Physical Signs.	Sounds induced by valvular lesions. Aortic direct friction murmur; mitral murmurs. They disappear if absorption re-sults; or increase if the lesion extends.
Diagnosis.	By daily auscultation during the course of causative diseases, to detect friction murmurs.
Prognosis.	No immediate danger. Danger of valvular disease.
Treatment.	Treatment of primary disease. Subsequent use of quinine, iodide of potassium, and mercury to promote absorption.
 
ulcerative endocarditis.                129
ULCERATIVE ENDOCARDITIS.
Definition.	Inflammation of cardiac valves tending to disintegration. Prob-ably two forms—one due to a specific microbe; another, a chronic recurring inflammation in previously thickened valves.
Pathology.	In the non-specific form, the valves are the seat of old, fibroid vegetations which are poorly vascularized, and with the recurrence of the inflammatory process these become ne-crosed, either ulcerating or sloughing en masse. In the specific form, there are specific germs present, susceptible of culture and reproducing the disease when inoculated. The pathology includes the emboli and septic foci in other or-gans, resulting from carrying the debris of intra-cardial ulceration into the circulation.
Etiology.	1. Recurring rheumatic endocarditis, syphilitic endocarditis, and arthritis deformans. 2. Specific microbes.
Symptoms.	Usual symptoms of extreme endocarditis, viz., excited cardiac action, precordial discomfort, dyspnoea, orthopnoea, pulsation of the arch of the aorta and vessels of the neck. Superadded are recurring chilliness or chills with exacerbations of temperature, indicative of embolic or septic invasions or plugging of arteries. Hemiplegia from cerebral embolism, loss of pulse in an extremity, local spots of anaesthesia and ecchymosis. Characteristic septic temperature line, failing strength, exhaustion.
Physical Signs.	Usually pronounced cardiac murmurs, most often aortic and frequently double. Cardiac area increasing from dilatation. Apex impulse growing feeble and diffused.
Diagnosis.	By coincidence of cardiac murmurs, cardiac enfeeblement, pul-sating vessels, continued elevated and variable temperature, long period of illness, evidences of embolism and sepsis, local parts and patches of ecchymosis and petechias.
Prognosis.	Bad in all forms. Non-specific cases may recover. Syphilitic cases, even extreme, may do well under special treatment. Specific cases always bad.
Treatment.	Rest in recumbent position. Cardiac support—digitalis, conval-laria, caffeine. Control temperature by antipyrin or quinine. Salicin valuable when rheumatism is present. Iodide of potassium and mercurial baths for syphilitic form. In septic form, internal antisepsis—sulpho-carbolates, etc. In all cases vigorous diet, milk and stimulants.
9 
130                         PERICARDITIS.




                           PERICARDITIS.
Definition.	Inflammation of the serous pericardium.—A local inflammation rarely idiopathic or traumatic; usually the result of overload-ing the blood with irritant, morbific matter.
Pathology.	Congestion of subserous vessels; removal of epithelium; surface hazy, granular; reddened patches; development of granula-tions; vascular villi; friction of surfaces; liable to adhere; patches of complete union; thin btnds, fibres, etc., due to contact of granulating surfaces. Absorption may be com-plete; may leave white patches on heart, hairy processes, fine or coarse adhesions. Serum compresses heart, distends peri-cardium. Serum absorbed, surfaces again in contact. Myocarditis may coexist.
Causes.	Rheumatism, Bright's disease, scarlatina, other acute fevers, sepsis; rarely traumatic—rarely idiopathic.
Symptoms.	Praecordial pain, tenderness; often pain in left shoulder and arm; flushed face; throbbing temporals; rarely delirium. Full, bounding, cord-line pulse.
Physical Signs.	Early.—To-and-fro pericardial friction murmurs; heart-sounds increased, apex beat violent, pulse full and frequent. With effusion.—Fulness of praecordial region; increased area of dulness; friction sound lost; heart-sounds feeble; may be distant. Later.—Muffled friction may return; normal action of heart and normal area of dulness.
Diagnosis.	To-and-fro friction; area of dulness. [Hydro-pericardium has no friction sound, no fever, and coexists with general dropsy.]
Prognosis.	Generally good. Pericardial adhesions may cause hypertrophy.
Treatment.	Treat primary disease. Locally—anodyne, alkaline fomentations for pain. Lower frequency of pulse.—Aconite, digitalis, veratrum. Later.—Quinine, iodide of potassium, and mercurials for absorp-tion. For extensive effusions, aspirate the pericardial fluid with the "dome" trocar.
 
HYDROPERICARDIUM.
HYDROPERICARDIUM.
Definition,  j As distinguished from pericarditis with effusion, this is a non-
                inflammatory accumulation of serum in the pericardial sac,
                as a rule associated with general anasarca and serum in other
                cavities.
Pathology.
Etiology.
Negative; no inflammatory process, and serum  clear or straw-
   colored, free from flocculi of lymph.
Usually a watery condition of blood;  advanced anaemia, hydre-
   mia,  or  chlorosis.   Frequently  advanced  albuminuria.
   Scurvy, pernicious anaemia, and leucocythaemia are causes.
More often results from failing circulation from cardiac enfeeble-
   ment (dilatation,  valvular incompetency), with  associated
   venous retardation, and general lessened nutrition.
Symptoms.
Dyspepsia, orthopnoea, vertigo,  syncope, precordial  fulness,
   distress or pain (dull ,  cyanosed face,  weariness,  languor,
   sluggish  intellect,  feeble  pulse,  cool  surfaces.  Digestion
   poor;  bowels torpid; kidneys inactive.
Physical
     Signs.
Diagnosis.
Prognosis.
Treatment.
Inspection.—Praecordial fulness,  also absence of apex impulse
   and general praecordial motion.
Palpation.—Absence of cardiac  impact and apex impulse.  If
   fluid  is abundant,  no cardiac motion, or exceptionally the
   reverse, pronounced, wave-like cardiac thrill.
Percussion.—Area of cardiac dulness increased (superficial area)'
   and broadened in apex region.  Tendency to pyriform car-
   diac area of dulness.
Auscultation.—Heart sounds greatly enfeebled and distant.
Coexistence of  general oedema, fluid in pleurae and peritoneal
   cavity.   Increased  area  of dulness, feeble  heart-sounds,
   dyspnoea, feeble pulse.
Bad as a complication of primary disease and dropsy elsewhere.
Sustain the heart by brandy, ammonia, musk, Hoffmann's ano-
   dyne and  liberal diet.  Hasten absorption by iodide of iron
   and iodide of potassium.  Use laxatives or drastics carefully.
   In grave cases aspirate the pericardium. 
132 ENUMERATION OF  THE  VALVULAR  DISEASES OF  THE HEART.

 ENUMERATION  OF THE VALVULAR DISEASES  OF THE HEART.
Fig. 79.—Left ventricle in systole (Dalton).
        (1.)  Systolic.
(a.) Left side of the heart:
1.  Aortic obstruction.—Obsta-
     cle  to  outward  flow of
     blood through aortic ori-
     fice.
2.  Mitral  regurgi tation. —
     Leakage of blood through
     mitral  valve into left au-
     ricle.
(6.) Right side of heart:
1.  Pulmonary  obstruction. —
     Obstacle to  outward flow
     of blood through pulmo-
     nary orifice.
2.  Tricuspid regurgitation.—
     Leakage of blood through
     tricuspid valve into right
     auricle.
Fig. 80.—Left ventricle in diastole (Dalton).
       (2.) Diastolic
(a.) Left side of heart:
1.  Aortic regur git at ion .—
     Leakage of blood through
     aortic orifice into left ven-
     tricle.
2.  Mitral obstruction.—Obsta-
     cle to flow of blood from
     left auricle to left ventri-
     cle.
(b.) Right side of heart:
1. Pulmonary regurgitation.—
     Leakage of Dlood through
     pulmonary   orifice  into
     right  ventricle.
2.  Tricuspid obstruction.—Ob-
     stacle  to  flow  of blood
     from right auricle to right
     ventricle. 
CARDIAC  MURMURS.
133
ENUMERATION  OF  THE  CARDIAC  MURMURS.
(1) Functional.
                               Functional.

1. Systole of heart—
o. Anasmic murmurs; blowing in quality: heard at base of  heart and diffused
    over chest, especially in course of vessels.                            ^
b. Intraventricular murmur, heard at early part of systole at apex; " modified
    first sound," " smoker's murmurs," etc.
2. Diastole of heart—
  Reduplicated  second sound heard at aortic and pulmonary orifice;  due to
    nervous action of two sides of the heart; resiliency of aorta and pulmonary
    arteries unequal, aortic and pulmonary valves do not close synchronously.
                                Organic.

1.  Systole of heart—Left ventricle—
   1. Obstructive.—Obstruction at aortic valves friction, etc.;  heard at aortic
      orifice and over arch of aorta (at third left and second right sterno-costal
      articulation.)
   2. Regurgitation.—Insufficiency of mitral valve;  regurgitation of blood into
      left auricle; heard at apex in front.  May also be heard around left side
      and behind in the left vertebral groove, from fifth to eighth ribs.
Right ventricle—
   1. Obstructive.—Obstruction at pulmonary valves:  friction  murmur, super-
      ficial, intense, localized over valve—third left sterno-costal articulation,
      may exist behind second left cartilage.
   2. Regurgitant.—Insufficiency of the tricuspid valve;  heard  at mid-sternum,
      opposite third or fourth cartilages.
2.  Diastole of heart—Left ventricle—
   1. Obstructive—Obstruction at mitral valve; friction murmur at apex only.
      Prsesystolic, i. e., in latter part of diastole.
   2. Regurgitant. —Insufficiency of aortic valves; murmur heard at base, and
      conveyed down sternum to apex of heart replaces second sound.
Right ventricle—
   1. Obstructive.—Obstruction at tricuspid valve:   friction of blood  coming
      from auricle to ventricle; murmur heard over central cardiac area.
   2. Regurgitant.—Insufficiency of pulmonary valves;  heard  over  pulmonary
      valves and down right side of heart.
ANEMIC  MURMURS.
Occur in anaemic women mainly.
   "  " feeble and aged.
   "  " pregnancy.
   "  " course of blood disease.
   "  " convalescence.
Heard during systole only.
   ' •   widely diffused over chest.
   "   loudest at base of heart.
   "   over arch of aorta and (transmitted by convection) over thoracic aorta
        down side of sternum to zyphoid cartilage;  over  innominate, carotids,
        subclavian.
   "   loudest when patient is fatigued, active, or excited.
   "   less when quiet.
Diminished by tonic treatment, digitalis, rest.


Character.—Soft, blowing, or loud violent systolic murmur at base.  May have
   grating, filing, rasping, sawing, musical qualities.
Distinguished from organic by absence of friction, and by test of time and treat-
   ment.
Accompanied with symptoms of anaemia, debility,  indigestion, hysteria, etc.
PERICARDIAL MURMURS.
Pericardial  murmurs, when typical, are " double," " to-and-fro," "see-saw"
   sounds synchronous with the heart's action.  They may in quality be fric-
   tion-like, grating, rasping, sawing, humming, singing; heard over the praecor-
   dial area, and apparently near the ear of listener.  Single friction sounds,
   either single or double, may be pericardial or ■' pleuro-pericardial." 
134
CARDIAC MURMURS.
                    Extra-Cardiac Murmurs.
  These are faint; puffing, or blowing sounds, synchronous with the
heart's  action, but suspended  with  suspended  breathing;  also
termed  " cardio-respiratory " murmurs ; variously explained as due
to pressure of the heart in motion on the overlapping edges  of the
lungs, to pleuro-pericardial adhesions, etc.

                      CARDIAC MURMURS.

  Table of  Synonymous Terms Used  by  Different Authors.
ux
1.  At Aortic Orifice.
   Aortic Systolic.
     "    Obstructive.
     "    Direct.
At Mitral Orifice
Mitral Svstolic.
O
o
Insufficient.
Regurgitant.
Indirect.
3.  At Aortic Orifice.
   Aortic Diastolic.
     "    Regurgitant.
     "    Insufficient.
     "    Indhect.
At Mitral Orifice.
Mitral Diastolic.
   "   Obstructive.
   "   Direct.
   "   Prsesystolic.
  The most frequent and important  organic  murmurs to recognize
are:
     1. Aortic systolic (obstructive, direct).
     2. Mitral systolic (regurgitant, indirect).
     3. Mitral prsesystolic (obstructive, direct).   Yery much less fre-
         quently we meet with
     4. Aortic diastolic (regurgitant,  indirect).
  The above are all murmurs of the left side of the heart, products
of^endocarditis, atheroma,  traumatism, and resulting from rheu-
matism, ursemia, and acute diseases.
  Of the murmurs of  the right side of the heart, two are definitely
recognizable, but very rare, viz.:
     5. Pulmonary systolic (obstructive, direct).
     6. Tricuspid systolic (regurgitant, indirect).
  These two murmurs are  so infrequent that the  clinical presump- 
CARDIAC MURMURS.
135
tion, when physical signs are not conclusive, is always in  favor of
the origin of the murmurs on the left side of the heart.
     7.  Tricuspid prsesystolic (obstructive, direct)  is  pathologically
          and theoretically possible, but not likely to be diagnosed.
          Fig. 81.—Location and Line of Propagation of Heart Murmurs.
  A, aortic direct, up into aorta and vessels ; Ar, aortic regurgitant;  P, pulmonic direct up to
left second cartilage ; Pr, pulmonic regurgitant down over right ventricle ; T, tricuspid area ;
M, local, mitral direct; M, around sides and back, mitral regurgitant.

     8. The pulmonary diastolic (regurgitant, indirect) is likely to be
          detected only when coexistent with well-defined pulmonary
          systolic murmur.

                    On Localizing Murmurs.
   It is  desirable, in  localizing the point  of  origin of murmurs as
well as their line of conduction or propagation,  to bear in mind the
location of  the heart as a whole, the direction of its  vertical and
transverse axes (i. e., whether it is normally pendent or is turned on
its side, or deflected to the right or left), since with a change of loca-
tion the line of  propagation is changed.   Hence  palpation  for the
apex beat, and mapping out of the deep and superficial cardiac regions
by percussion,  must  have preceded  auscultation.  Thus an aortic
regurgitant murmur should be propagated  downwards from the site
of the aortic valve  to the apex  beat.   But  if,  by dilatation of the 
136
CARDIAC MURMURS.
left ^ventricle, the apex is carried far outside of the nipple or even to
the axillary line, then the base will have been dragged down, and the
murmurs heard  at least one space lower  than normal, viz., at the
fourth costal junction with the sternum, and be propagated, not down-
wards, but obliquely outward and  downwards  or almost outwards.
As a whole, the murmur is  so entirely to the left of the sternum as
to be over the line of propagation  of  pulmonary regurgitation, yet
the proofs of dilated left heart, the presumption always  in favor of
disease of the left heart rather than of the right, and the absence of
epigastric pulsation,  cyanosis, pulsating cervical  veins, and other evi-
dences of disease of the right heart, leave no doubt that the murmur is
aortic regurgitation.  So, too, an aortic direct murmur may seem to
be propagated directly upward, and may establish a strong presump-
tion of pulmonary obstruction.  Here again, if the heart is hypertro-
phied and dilated, and carried to  the left, the great  artery—aorta—
is also dilated, and may disseminate the  obstructive  sound.   Unless
other evidence of aortic stenosis, as reduplicated second sound, cya-
nosis, etc., exist, a basic murmur  can, in  a  large  majority of instan-
ces, be set down as aortic, despite its origin and line of conduction.
   The question of whether a  mitral regurgitant murmur  must be
conducted around the side and heard in the back may be answered as
follows:
   1.  A mitral regurgitant  murmur is always  systolic, and heard at
the apex.
   2.  It may or may not be transmitted by the chest-wall  around to
the axillary line or beyond.   Usually it is so transmitted.
   3.  It may also appear behind in the  left vertebral groove, between
the  fifth  and eighth  ribs.   When  thus heard,  it  conclusively
confirms the mitral regurgitant origin of the murmur, rather than
mitral diastolic, mitral prsesystolic, or functional apex murmurs.  But
its absence does not in the least disprove the murmur being in part
organic and mitral regurgitant.  It is pretty generally conceded that
the murmur, when heard  in the  left vertebral groove, does not get
there by conduction around the  side,  but  rather by convection, or
transmission by the   regurgitant  current of blood up  through the
insufficient mitral valve into the left auricle  (which is usually dilated),
and back through solid structures to the vertebral groove. 
CARDIAC MURMURS.
137
               Coexistence of  Several Murmurs.
   It is not uncommon for two, three, or even four murmurs to co-
 exist.  If the heart be pretty nearly  normal in position,  size,  and
 strength, and its rhythm be  regular, then the several distinct mur-
 murs can be recognized.  But when extreme dilatation of the part,
 together with displacement and marked irregularity and intermission
 of the organ, all coexist  with these several murmurs, the problem
 becomes most difficult.   A  double mitral and single aortic direct
 often coexist, less often double mitral and double  aortic, and occa-
 sionally double aortic  and single mitral.   Whether murmurs in the
 right side of the  heart can be  recognized in  the presence  of the
 louder murmurs of the left side, the author doubts.  They certainly
 can exist, but it is doubtful if they can be heard.

      Propagation of Heart Murmurs in Great Vessels.
   Heart murmurs are often heard with  astonishing clearness  over
 the arch of the aorta, the innominata, the carotid  and subclavians,
 as well as over  either lung apex, and behind,  above and  over the
 scapulse.  This is chiefly due to the fact that, with hypertrophy and
 dilatation of the heart accompanying the louder murmurs, there is
 usually a state of dilatation of the great vessels and a ready propaga-
 tion of the heart-sounds.

                  On Double Basic  Murmurs.
  When basic murmurs are double, the question always must be an-
 swered, are these murmurs :
                        1. Cardiac.
                        2. Pericardial.
                        3. Aneurismal.
  The pericardial murmurs can  be excluded by the absence of  the
history of pericarditis,  absence of prsecordial tenderness, and absence
of peculiar friction-like, " see-saw " quality, and  " nearness to ear "
which characterizes them.
  The aneurismal murmurs usually are more to the right or  higher
up, are  peculiarly booming in character, have associated thrill and
pressure evidences of aneurism, and often the coexistent heart-sounds
can be heard  over the heart in situ or displaced.   (See Aneurism.)
  Finally, it may be stated that in all complicated  cases of  cardiac
or extra-cardiac murmurs, long and careful study, repeated consecu- 
138
ANEURISM OF THE THORACIC AORTA.
tive examinations, with time for the heart to rest and regain equi-
librium, are requisite for a final diagnosis.

             ANEURISM  OF THE THORACIC  AORTA.
  1. Of ascending arch within pericardium.
  2. Of junction of ascending and transverse arch.
  3. Of transverse arch.
      Fig. 82.—Relation of several parts of aorta to surrounding structures (Gray).

  4. Of descending arch.
  5. Descending aorta within thorax.
  Definition.—Aneurism—properly a local dilatation of an artery,
forming a tumor containing blood and laminated fibrin.   Its walls
are the remnants of the vessel-walls, and the investing fibrous sheath,
usually much hypertrophied.
  Pathology  and  JEtiology.—Usually  caused by endarteritis,
atheroma and calcification of the wall of an artery, and atrophic weak- 
aneurism of the thoracic aorta.
139
ening; syphilis,  rheumatism,  gout, and  local injury lead to these
degenerations.  Cardiac  force then dilates the weakened part.  Vio-
lent exercise, and vocations causing extreme and continued vascular
and intracardiac  tension are especially liable to produce aneurism.
  Aneurism may be fusiform,  sacculated, or dissecting.  The cavity
may be full of fluid blood, or be partially or wholly filled with lami-
nated fibrin.
  An aneurism of  the aorta, by pressure, may set up inflammation
of adjacent parts,  as of apices of lungs, pleura, bronchi.   It may
Fig. 83.—Showing relation of aorta to oesophagus, bronchi, heart, and valves (Gray).
cause absorption of  ribs and  costal cartilages anteriorly,  or of ver-
tebrse  posteriorly, may compress  the  trachea, bronchi, oesophagus?
vena cava ascendens, innominate  vein.   The  sac may rupture into
the pleura, trachea, bronchi, pericardium—or externally, beneath or
through eroded integument.
   Symptoms.—Aneurism of the ascending portion of the  aorta, as a
rule, produces irritation of the apex of the right lung and its invest-
ing  pleura, evidenced by  cough, expectoration, local discomfort,
dyspnoea, local lancinating and pulsatory pain. 
140
ANEURISM OF THE THORACIC AORTA.
  Aneurism of the ascending and transverse aorta, also involves the
right recurrent laryngeal nerve, inducing laryngeal spasm,  irrita-
bility, and aphonia.
  Aneurism  of the ascending  portion  may obstruct the right pul-
monary bronchi or bronchus to the upper lobe of the right lung.
Aneurism of the transverse portion compresses the trachea, cutting
off air to the lung, and irritating both recurrent laryngeals.  Orthop-
ncea, laryngeal spasm, shallow  chest expansion,  supra-sternal and
epigastric sinking, and anorexia are often marked.
  Aneurism of the descending arch disturbs only the left recurrent
laryngeal and the  apex of  the  left lung, its investing pleura and
Fig. 84.—Area of dulness of aneurism (Piorry).
bronchi; discomfort is then on the left side of the sternum and of
the left scapula and interscapular regions.
  Physical Signs.—Inspection.—In  its early stage  aneurism may
show nothing.   Later,  vibration and  bulging are  observed in the
second intercostal space to the right of the sternum,  or, if of trans-
verse portion,  pulsation may appear in the suprasternal notch  and
extend up the cervical vessels.  In aneurism of the descending por-
tion, the bulging is to the left of the  sternum, at the second carti-
lage.  Later, the sternum, ribs, and cartilages may bulge over the
aneurism or be eroded, and the spheroidal pulsating  tumor is seen
to the right or left of the sternum.
  Vascular swelling and cyanosis of the head, neck,  arms, and thorax 
ANEURISM of the  thoracic aorta.
141
denote pressure on the vena cava descendens.   If the venosity exists
on the right side only, the pressure is over the innominate vein.
  Palpation.—Vibratile pulsation, or thrill, is detected in the inter-
costal  spaces, through  the  sternum, orin  the suprasternal notch;
after erosion, the tumor gives distensile sensation.
  Percussion.—Area of dulness in  the upper sternal  region, ex-
tending to the right or left or up into the suprasternal notch.
  Auscultatory percussion is often of greatest value in accurately
defining the exact size and contour of aneurismal tumors.
  Auscultation.—Aneurism of the  Ascending Arch.—Double
bruit on the right  side of the  sternum, in the second  space, both
sounds possessing the variable quality of friction, rasping, sawing,
        Fig. 85.—Aneurism of junction of ascending and transverse arch (Doty).

whistling,  ringing,  or booming; the  sounds are measurably  con-
ducted down the sternum and up into the cervical vessels.
  The conduction of the aneurismal bruit into  the vessels of the
neck, axilla, etc., depends upon the degree of associated  dilatation
of the arterial branches radiating from the aneurism.   The  systolic
sound or bruit of aneurism is caused by the  entrance of blood  into
the aneurismal sac;  the diastolic bruit is caused by the  recoil of the
sac and expulsion of blood into  the aortic current.  If the aneurism
is fusiform, there may be little or no bruit. The degree of bruit de-
pends upon the shape of  the sac and size of  its orifice.   An enor-
mous aneurism may be so filled in with laminated fibrin as  to have
but a small cavity and little or no bruit. 
142
ANEURISM OF THE  THORACIC AORTA.
  The second sound of the heart is usually discernible to the left of
the sternum, thus differentiating double aortic murmur.  Pressure
on the apex may have developed local plastic pleuritic  rales, local
pneumonic  crepitus,   or stridulus  by  pressure  on the  bronchus;
respiratory sounds are lessened or absent in the lung.
  Aneurism of the Transverse Arch.—Double bruit, heard with
stethoscope, deep in the suprasternal notch, over the upper end of
the sternum  and up the vessels of the neck.   Aneurism of the
transverse arch is quite apt to be fusiform,  or extremely dilatated,
and may or may not have a commensurate bruit and thrill.
Fig. 86.—Relations of descending arch.
  The heart-sounds are heard separately.  Tracheal stridulus is very
distinct at the point of pressure, and the respiratory sounds are very
feebly developed throughout both sides of the chest.
  Aneurism of the Descending Arch.—Double bruit of " aneur-
ismal quality," heard to the left of the sternum, above the  base of
the heart; but best heard in the back, in the left vertebral groovej
and in the interscapular region.
  Diagnosis.—By  tumor, area of dulness, pulsating, distensile  and
thrilling sensations  to touch, by characteristic double bruit, and asso-
ciated symptoms, as pressure on air passages, pleura, lung apex,  ver- 
I
                aneurism of the thoracic aorta.            143

tebrse, and nerves; also by  exclusion of the cardiac origin  of the
tumor, cardiac thrill, and cardiac bruits.
  The radial, axillary, subclavian, and carotid pulses, as well as the
pulsation  of the abdominal aorta  and femoral  arteries, are  to be
studied.   Modified, diminished,  or absent pulse in a given artery
denotes either obstruction of its origin and  continuity by a clot or
fibrinous process extending from the aortic tumor, or the dispersing
 of the cardiac force in the distensile aneurismal sac, thus aiding in
• differentiating the location of the aneurismal tumor and its contents.
   Prognosis.—Always unfavorable; aneurism  may rupture  exter-
 nally  or internally into  lung, pleura, bronchi,  trachea, or  pericar-
 dium.   Death also by inanition, asphyxia, exhaustion.
   Treatment.—Diminish arterial tension by quiet living ; keep the
 bowels open;  avoid overloading the stomach ; avoid, also, emotional
 excitement, fatigue,  and alcoholism.   Enforced rest  in the  recum-
 bent position,  cardiac sedatives and exclusive meat diet favor hyper-
 inosis and filling of the sac with laminated fibrin. 
CHAPTER X.
       RELATION OF THE PULSE TO CARDIAC DISEASE.

  The study of the pulse is an  essential part of  the observation of
cardiac disease.  The pulse is chiefly studied at the wrist.  For all
practical purposes its  palpation with the finger tips  is all that is re-
quired.   As related to cardiac disease we find in
Cardiac  hypertrophy, the radial pulse full, strong.
     "    dilatation,    "     "     "   compressible,  lacking   vol-
     ume, irregular, intermitting.
Fatty heart, the radial pulse is  feeble, small volume,  compressible.
Aortic obstruction with hypertrophy, t/ie radial pulse is full, strong,
     abrupt, shotty.
Fig. 88.—Marey's sphygmograph.
Aortic  regurgitation,  the  radial pulse smooth, rounded, lacking
     apex.
Mitral regurgitation, the radial pulse compressible, rounded, often
     irregular.
Mitral obstruction, the radial pidse presents nothing distinctive.
  The sphygmograph is an instrument chiefly  useful  for clinical
teaching and record,  to reproduce in tracing the  characters of the
pulse in health and  disease, and the behavior  of the  heart under
the influence  of drugs.  It is of no special value in the practice  of
medicine, beyond the above-stated uses.   Marey's sphygmograph was
first used and  still continues to be the most practical one we have.
  Dudgeon's is convenient, and, being less expensive, is  most  in use. 
           RELATION OF THE PULSE  TO CARDIAC  DISEASE.        145

  In  this  country, also Holden's and Pond's are  much used, but
neither afford so uniformly reliable tracings as Marey's or Dudgeon's.
Fig. 89.—Dudgeon's sphygmograph.
  The sphygmographic tracing consists of an up line, representative
in length and  uprightness of  the force and rapidity of the contrac-
tion of  the left ventricle; of an apex or crest  more or less  pointed
according as the heart is strong, the aortic orifice free of obstruction,
                      Fig. 91.—Pulse tracing (Loomis).

and the  cardiac valves intact (permitting no regurgitations during
diastole); and the line of descent to the vibratile curve, the first part
           10 
146        RELATION OF  THE PULSE TO CARDIAC  DISEASE.

of which represents  the falling  and closing with vibration of the
aortic valves under the superimposed blood in the aorta and the con-
traction of the elastic aorta.  The  remainder of the curve represents
the diastolic rest of the heart.  When the line of ascent is relatively
short, and the apex of the central vibrating curve is  relatively high,
a double tipped or  " dicrotic " pulse is demonstrated, and denotes
that  cardiac force  is less than aortic and vascular recoil.







                    Fig. 92.—Dicrotic tracing (Loomis).

  A vertical line  of  ascent with  sharp apex is often diagnostic of
cardiac hypertrophy, but may also result from febrile excitement.
  Aortic regurgitation lessens  the acuteness of the apex, giving a
rounded-tipped tracing.   Mitral regurgitation  does much the same
thing.  So often do these obstructions or regurgitations coexist with





              NKK

               Fig. 93.—Pointed tracing in hypertrophy (Loomis).

cardiac  hypertrophy  or dilatation, or  with cardiac enfeeblement,
irregularity, or intermission, that  the tracing becomes complex and
of doubtful representative meaning.
   The number of waves in a  tracing  represent the  frequency of
heart's action.
   Sphygmography is applied to other arteries than the radial, and to
the precordial area and apex impulse, but to no practical purpose. 
INDEX.
 Abnormal movements, 12
    respiratory sounds, 53
 Absence of vocal resonance, 57
 Acoustic laws, 50
 Acute bronchitis, synopsis of, 77
 Adventitious sounds, 52
 iEgophony, 57
 Air and tube friction sound, 43
    complementary, 17
    persistent, 17
    residual, 17
    supplementary,  17
    tidal, 17
 Anaemic murmurs, 121
 Aneurism of ascending arch, 141
    of descending arch, 142
    of transverse arch, 142
    of the thoracic aorta, 138
    physical signs of, 140
 Angina pectoris, 124
 Aorta, aneurism of,  138
 Aortic obstruction, 132
    regurgitation, 132
 Apex beat, location of, 108
    impulse, character of, 188
 Apoplexy, pulmonary, 87
 Aspiration, 72
Asthma, 80
    crystals, 76
Auscultation, 37
        immediate, 37
        mediate, 37
    in health, 41
    of aneurism,  141
    of the heart in disease, 121
    of the normal heart, 116
Auscultatory percussion, 96
    sounds, 37
        duration, 37
        intensity, 37
        pitch, 37
        quality, 37
        rhythm, 37
Axillary region, 6

Bacilli, tubercle, 75
Bell-metal test, 72
Bronchial cough, 60
    respiration,  53
    voice, 57
    whisper, 59
Bronchitis, acute, 77
    capillary, 78
    chronic, 79
Bronchophony,57
Broncho-cavernous respiration, 53
Broncho-vesicular respiration, 53
Brown induration of the lung, 95
Bulging and expansion of chest, 12

Capillary  bronchitis, 78
Carcinoma of the lung, pleura, and
  bronchial glands,  96
Cardiac dilatation, synopsis of, 126
    hypertrophy, synopsis of, 125
    murmurs, enumeration of, 133
    murmurs, synonyms of, 134
    region, deep, 98
    region, superficial, 99
    sounds, causation of, 120
    valves, location of, 102
Cardiometer, Cammann's, 109 
148
INDEX.
Catarrhal phthisis, 93
Cavernous cough, 60
    voice, 57
Chest, abnormal movements of, 14
    acoustics, 50
    anterior regions of, 1
    circular expansion of, 16
    curvature and distortion of, 13
    depression (and retraction) of, 13
    expansion and bulging, 112
    lateral regions of, 2
    posterior regions of, 2
    procidentia and elevation of, 13
    regional anatomy of, 1
    retraction and depression of, 13
Chronic bronchitis, 79
Clavicular regions, 3
Complementary air, 17
Consonance, 50
Cough sound, 49
Creaking, 69
Curvature and distortion of chest, 13

Deferred expiration, 56
    inspiration, 55
Depression (and retraction) of chest,
  13
Differential stethoscope, 40
Diminished vocal resonance, 57
Distortion (and curvature) of chest, 13
Divided breathing, 55
Dulness, 33
Duration of percussion sound, 2

Echo, 50
Elements of normal respiratory sound,
  43
Elevation (and procidentia) of chest, 13
Ellis line, 34
Emphysema, pulmonary, synopsis of>
      90
    synopsis of, 82
Endocarditis,  synopsis of, 128
    ulcerative, 129
Exaggerated breathing, 54
    respiration, 43
    vocal resonance, 56
Expansion and bulging of chest, 12
Extra-cardiac murmurs, 134
Fatty heart, synopsis of, 127
Fibroid phthisis, 93
Flatness, 133
Forced respiration, 43
Form of healthy chest, 11
Functional diseases of the heart, 121'

Gangrene of the lung, synopsis of, 89
Gurgles, 69

Harsh respiration, 56
Healthy chest, form of, 11
Heart, auscultation of, 116
    auscultatory percussion of, 116
    diseases of, 97
    diseases, synopsis of, 125
    examination of, 104
    inspection of, 104
    irregularity and  intermission of,
      123
    mensuration, 109
    neuroses of, 122
    organic diseases of, 124
    palpitation of, 110
    paralysis of, 124
    percussion of, 111
    sounds, duration of, 117
    sounds, quality of, 118
    spasm of, 123
    topography of normal, 97
    topography of, in disease, 101
    tremor, 123
    valvular diseases of, 132
    walls, thickness of, 103
    weight of, 103
Heart's action, frequence of, 117
    action, rhythm of, 117
Hydropericardium, synopsis of,  131
Hydrothorax, synopsis of, 84
Hypertrophy of left ventricle, 113
    of right ventricle, 114
Hypodermic puncture, 72

Infra-axillary region, 7
Infraclavicular regions, 3
Inframammary regions, 5
Infrascapular region, 7
Inspection, 11
Inspiration and  expiration, relative
      length of, 17
    and respiration, ratio of, 42 
INDEX.
149
 Intensity of percussion sound, 21
 Interscapular region, 8
 Intracostal auscultator, 69
 Intrapleural sounds, 65

 Jerking breathing, 55

 Lateral regions, 6
 Letter " S " line, 34
 Lower scapular region, 7
     sternal region, 6

 Mammary region, 3
 Mensuration, 15
 Metallic tinkle, 69
 Methods of physical diagnosis, 11
 Mitral obstruction, 132
     regurgitation, 132
 Modified sounds, 52
 Movements, abnormal, 12
     normal, 12
     thoracic, 12
 Murmurs, coexistence of  several, 137
     double basic, 137
     how localized, 135
     propagation of, in vessels, 137
 Muscular sussurus, 47
 Myoidema,  36

 Normal expiratory sound, 42
     inspiratory sound, 42
     movements, 12
     respiratory sound, 41
     voice sounds, 48
     whisper, 49

CEdema of the lungs, synopsis of, 84
Organic disease of  the  heart, 124

Page's percussion hammer, 71
Palpation, 14
Paralysis of the heart, 124
Pectoriloquy, 58
Percussion,  19
    auscultatory, 69
    hammer, 19
    immediate, 19
    mediate, 19
    mode of, 20
Percussion note of heart, 23
        of lungs, 23
        of muscles, 23
    of abnormal chest, 32
    positions for, 27
    sound, 20
        duration, 21
        intensity, 21
        pitch, 21
        quality, 22
        resonance, 21
Pericarditis, synopsis of, 130
Persistent air, 17
Phthisis, modern classification of, 93
    synopsis of, 91
Physical diagnosis, methods of, 11
        principles of, 1
Pitch of percussion sound, 21
Plastic pleuritis, 66
Pleural sounds, 64
Pleuritis, synopsis of, 81
Pleximeter, 19
Positions for percussion, 27
Posterior regions, 7
Pneumo-hydrothorax, synopsis of, 83
Pneumonia, synopsis of, 85
Procidentia and elevation  of chest,
  13
Properties of percussion sound, 20
Pulmonary apoplexy, synopsis of, 87
    consumption,  synopsis of, 91
    infarction, synopsis of, 88
    obstruction, 132
    regurgitation, 132
    resonance, 23
Pulse, relation to cardiac  disease, 144

Quality of percussion sound, 22
Quiet respiration, 43

Rales, 60
    crepitant, 63
    dry  60
    moist, 61
    mucous, 61
    sibilant, 61
    sonorous, 61
    subcrepitant, 62
    submucous, 61
    tracheal, 61 
150
INDEX.
Ratio of inspiration to respiration, 42
Relative  length of  inspiration  and
  expiration, 17
Residual air, 17
Resonance of percussion sound, 21
    tussal, 49
    unison,  50
Respiration  of men and women, 16
Respiratory movements, 43
Retraction and depression of chest, 13
    of intercostal spaces, 108
Rhonchi, 60
Rude respiration, 56
Sense of resistance in percussion, 35
Sounds, adventitious, 52
    modified, 52
Spirometer, 16
Sphygmograph, 144
Stethoscope, 38
    advantages of, 41
    disadvantages of, 41
Succussion, 69, 72
Suffocative catarrh, 78
Supplementary air, 17
Suppressed breathing, 54
Supraclavicular regions, 2
Suprasternal regions, 5
Sussurus,  muscular,  47
Syncope, 123
Syphilis of the lung,  synopsis of, 95
Synopsis of acute bronchitis, 77
    of capillary bronchitis, 78
    of chronic bronchitis, 79
    of asthma, 80
    of cardiac dilatation, 126
    of cardiac hypertrophy, 125
    of emphysema, 90
    of empyema, 82
    of endocarditis,  128
    of fatty heart, 127
    of gangrene of the lung, 89
    of heart diseases, 125
    of hydro-pericardium, 131
    of hydrothorax, 84
    of oedema of the lung, 86
Synopsis of pericarditis, 130
    of phthisis, 91
    of pleuritis, 81
    of pneumo-hydrothorax, 83
    of pneumonia, 85
    of pulmonary apoplexy, 87
    of pulmonary consumption, 91
    of pulmonary emphysema, 90
    of pulmonary infarction, 80
    of syphilis of the lung, 95
    of ulcerative endocarditis, 129

Thoracic movements, 12,
Thorax, topography of, 1
Tidal air, 17
Topography of normal heart, 17
Tricuspid obstruction, 132
     regurgitation, 132
Tubercle bacilli, 75
Tubercular phthisis,  93
Tubular resonance, 24
Tussal resonance,  49
Tympanitic resonance, 26

Ulcerative endocarditis, synopsis  of
  129
Unfinished respiration, 56
Unison resonance, 50
Upper sternal region, 6
Upper scapular region, 7

Voice sounds, normal, 48
Vesiculo-cavernous respiration, 53
Ventricles, capacity of, 104
Valvular diseases of the heart, 132

Wavy breathing, 55
Weak breathing, 54
Weight of the heart, 103
Whisper, cavernouo, 60
     enfeebled or absent, 59
     normal, 49
     raised in pitch, 59
Whispering bronchophony  59
     pectoriloquy,  60 
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