^*& Sf NATIONAL LIBRARY OF MEDICINE NLM DDlDEObT E iDiasw do Aavaan tvnoiivn SNioicidw do >n*. 2 CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAPr T^ I >iivn 3NiDia3w do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn snidiosw do ahv CINE " NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAPi \ I )I1VN 3NIDI03W dO AdVaaiT TVNOIIVN 3NIDI03W dO AHVaaiT TVNOIIVN 3NIDI03W dO >«' Q_ CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY 3I1VN 3NIDI03W dO AHVaaiT TVNOIIVN 3NIDia3W dO AHVaaiT TVNOIIVN 3NIOIC13W dO • 4 ■ On ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LI h P A P OI1VN 3NIDia3W dO AHVHaiT TVNOIIVN 3NIDI03W dO AdVaaiT TVNOIIVN 3NIDICI3W dO »d >Crf,\ I vOlD/n ? cCW,^ I A^i ik'\ NLM001020692 1TVNCX &J P- moiasw do Aavaan tvnoiivn 3nidici3w do Aavaan tvnoiivn 3nidio3w do Aavaan ATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME > iiDiasw do Aavaan tvnoiivn bnidiosw do Aavaan tvnoiivn 3nidi<]3W do Aavaan / i _____i A HANDBOOK / Physical Diagnosis vj Diseases of the Organs of Respiration and Heart, and of Aortic Aneurism. R. C. M. PAGE, M.D., Author of "A Chart of Physical Signs of Diseases of the Chest;" "A Text-Book of tne Practice of Medicine;" Professor of General Medicine and Diseases of the Chest in the New York Polyclinic; Consulting Physician to St. EhzaDeth's Hos- pital, and Attending Physician to the North-Western Dispensary, Department of Diseases of the Heart and Lungs ; Member of the New York Academy of Medicine and New York Pathological Society; Honorary Vice- President of the Congress held in Paris, 1891, for the Study of Tuberculosis, etc., etc. SPafttfe 4Z8RAB1 V Edition, NEW YORK: J. H. VAIL & CO., 5 EAST i7th STREET. 1895. WBB 1655 Copyright by R. C. M. PAGE, M.D. 1889. So ALFRED L LOOMIS, M.D., LL.D., WHOSE THOROUGH AND SYSTEMATIC TEACHINa, AS WELL AS MANY ACTS OF KINDNESS, ARE GRATEFULLY REMEMBERED, gMs Modest %xttXz Wolnmz IS RESPECTFULLY DEDICATED BY THE AUTHOR. • PREFACE. In compliance with the requests of students this volume is now placed before the medical profession. In it I have endeavored to treat the important subject of Physical Diagnosis from a logical standpoint,—the deductions in each case being drawn chiefly from per- sonal observation. By this means I have, in many in- stances, furnished the all-important missing links that necessarily occur in a mere printed list of physical signs, however ingeniously arranged. The student is thus saved much valuable time that would otherwise be lost in attempting to supply those links unaided. Besides a consideration of the physiology and normal anatomy of the organs involved, brief mention of eti- ology and pathology has been found necessary in many cases, as well as the proper classification of disease. This work may claim originality, it is believed, when the mode of exposition is considered, and whenever I have thought that I had cause to differ from even the most eminent writers on this subject, I have not hesi- tated, with due respect to them, to do so. To Dr. Henry Macdonald, 151 East 31st Street, New vi PREFACE. York City, I am greatly indebted for the illustrations, most of which are original and copied from life, or path- ological specimens. R. C. M. Page, M.D. 31 West 33rd St., New York City May, 1889. NOTICE TO THE EIGHTH EDITION. Since questioning students and obtaining answers from them has been found to be the best method of teaching the subject of Physical Diagnosis, a quiz for this purpose has been arranged in six lessons and added at the end of the book. The author believes that it will be of great service to students. R. C. M. P. February, 1895. CONTENTS. CHAPTER I. The Chest in Health—Regions—Methods of Physical Ex- amination — Inspection —Palpation— Fremitus— Per- cussion—Palpatory Percussion—Quality of Sound its most Important Property, as compared with Pitch, Duration and Intensity—Auscultation—Normal Res- piratory Murmur—Normal Pectorophony, or Vocal Resonance over the Chest—Other Methods of Physical Examination—Succussion—Auscultatory Percussion— Autophonia—Phonometry....... CHAPTER II. Diseases in which the Breath and Voice Sounds may be Obstructed in the Bronchial Tubes, and Refracted in the Lungs as much as, or more than, in Health, with Corresponding Diminution or Suppression of Fremi- tus, Respiratory Murmur, and Pectorophony—Bron- chitis—Adventitious Sounds—Asthma—Emphysema- Pulmonary Congestion and (Edema— Certain Forms of Atelectasis (Apneumatosis)...... CHAPTER III. Diseases in which the Breath and Voice Sounds are Con- ducted with more Force than in Health with Corre- sponding Increase of Fremitus, Respiratory Murmur, and Pectorophony—Bronchial Breathing—Broncho- phony—Solidification of Lung Tissue—Pneumonia— viii CONTENTS. Pulmonary Consumption—Cancer—Hydatid Disease— Hemorrhagic Infarction— Pulmonary Hemorrhage . 69 CHAPTER IV. Diseases in which the Breath and Voice Sounds are Inter- cepted in their Transmission to the Chest Walls with Consequent Diminution or Absence of the Fremitus, Respiratory Murmur, and Pectorophony—Pleurisy— Thickened Pleura—Pleuritic Effusion—Pyothorax or Empyema — Hydrothorax — Pneumothorax — Hemo- thorax—Pneumo-hydrothorax......135 CHAPTER V. Summary of Adventitious Sounds—Classification of Rales —Friction Sounds—Splashing Sounds—Changes Pro- duced by Disease in the Respiratory Murmur and Vo- cal Resonance—Pectorophony and Pectoriloquy . . 159 CHAPTER VI. The Heart—Outline on the Chest Walls—Position of the Valves—Normal Sounds—Valvular Lesions—Endocar- dial Murmurs, Organic and Functional—Mitral Mur- murs—Pericardial Murmurs—Intra-ventricular Mur- murs—Tricuspid Murmurs—Aortic Murmurs—Venous Hum—Pulmonic Murmurs—Anaemic Murmurs—Endo- carditis — Pericarditis— Hydropericardium — Myocar- ditis—Hypertrophy—Dilatation—Fatty Heart—Atro- phy—Exophthalmic Goitre—Angina Pectoris—Cardiac Diseases that Cause Sudden Death—Functional Dis- eases—The Sphygmograph—Aortic Aneurism . . 183 Quiz on the Foregoing Subjects......287 PHYSICAL DIAGNOSIS. CHAPTER I. THE CHEST IN HEALTH. Physical Diagnosis is the art of distinguishing health from disease, and one disease from another by means of the physical signs presented in each case. It approaches nearer to an exact science than any other branch, and may truly be termed the mathematics of medicine. It embraces various methods of examina- tion, including the use of instruments to be hereafter described. The Physical Signs of health, as well as of disease, are those that are to be recognized by the examiner's special senses, particularly sight, touch and hearing. There are certain physical signs characteristic of health and others that belong respectively to individual dis- eases. In order to understand the physical signs of disease it is evidently necessary first to know them in health. Then, by the application of principles of well-known physical laws, a logical and correct conclusion may be arrived at in each case, which is more reasonable than 1 2 PHYSICAL DIAGNOSIS. to attempt to commit isolated facts to memory, only to be forgotten. For the sake of convenience the chest walls are marked out into different regions, the limits of which, though arbitrary, should always be made with due re- gard to the anatomy of the underlying thoracic organs. There are an anterior, posterior, and two lateral regions of the chest, and each of these is subdivided into other regions. Anterior Region.—This is divided into two similar parts, right and left, and a middle part. The right and left parts comprise, each from above down, the following regions: 1, supra-clavicular; 2, clavicular; 3, sub-clavicular (infra-clavicular, supra- mammary); 4, mammary, and 5, sub-mammary (infra- mammary, hypochondriac). The middle part is divided into the, 6, supra-sternal; 7, superior (upper) sternal, and 8, inferior (lower) sternal regions. The supra-clavicular region is triangular in shape and is situated above the clavicle. It is bounded below by the upper border of the clavicle, within by the lower portion of the sterno-mastoid muscle, and without by a line drawn from the inner end of the outer fourth of the clavicle to a point on the sterno-mastoid muscle cor- responding with the upper ring of the trachea. On both sides the apices of the lungs rise into the neck above the sternal ends of the clavicles, according to Gray, about an inch and a half, but in persons with long necks as much as two inches; in women rather higher than in men, and on the right side than the left. The clavicular region corresponds to the inner three- fourths of the clavicle. The sub-clavicular region (also calLed infr.;-Hnvicu- REGIONS OF THE CHEST. 3 lar, or supra-mammary) is bounded within by the edge of the sternum (sternal line), without by a line let fall perpendicular from the inner end of the outer fourth of the clavicle, and continuous with the anterior axillary line; above by the lower border of the clavicle, and below by the upper border of the third costal cartilages and ribs, corresponding exactly with the base of the heart. In order to find the upper border of the third Fig. 1.—1. Supra-clavicular Region; 2. Clavicular; 3. Sub-clavicular; 4. Mammary; -5. Sub-mammary; 6. Supra-sternal; 7. Superior Sternal; 8. Inferior Sternal Region. rib, especially in fat people, feel for the horizontal ridge on the sternum that marks the line of union be- tween the manubrium and gladiolus. At this point, on either side, is the articulation of the second costal cartilage with the sternum. Immediately below is the depression between the second and third ribs, or the second intercostal space, the upper border of the third rib, as well as lower border of the second being dis- tinctly felt. The right and left second intercostal 4 PHYSICAL DIAGNOSIS. spaces, called respectively aortic and pulmonary, have special significance in the study of the heart, as we shall see. The sub-clavicular regions are chiefly occu- pied by lung tissue, but the right primitive bronchial tube, larger than the left, more superficially situated an- teriorly, and given off higher up, causes important dif- ferences in the physical signs of the two regions, as will be fully described. The study of these two regions in health is of the first importance, the more so as tuber- cular pulmonary consumption usually manifests itself first in one or the other. The mammary region is bounded above by the upper border of the third rib, belowT by the upper bor- der of the sixth rib, within by the edge of the sternum (also called the sternal line), and without by the anterior axillary line which is continuous with the outer boun- dary of the region above. The heart is chiefly situated in the left mammary region, the apex-beat correspond- ing to a point between the fifth and sixth ribs, one inch and a half below, and half an inch within the left nipple. Gray and others, however, place it two inches below, and one inch within the left nipple. The super- ficial area of cardiac dullness lies almost wholly within the left mammary region. The right mammary region extends down to the liver, the lower border of the former exactly corresponding with the upper border of the latter. The sub-mammary region (infra-mammary, hypo- chondriac) is bounded above by the upper border of the sixth rib, below by the free margin of the ribs; within it comes almost to a point at the edge of the sternum and without it is bounded by the anterior REGIONS OF THE CHEST. 5 axillary line. The region on the right side is occupied by the right lobe of the liver. On the left side, we have the left lobe of the liver and the large end of the stomach. The outer boundary of the region on the left side corresponds to the anterior border of the spleen from the ninth to the eleventh ribs. Between these two regions is the epigastrium. The supra-sternal region lies above the supra-sternal notch and between the supra-clavicular regions. In it lies the trachea, but by firm pressure downward with the finger, the patient's head being inclined for- ward, pulsations of the transverse portion of the arch of the aorta may be felt, especially in the case of an- eurism. The superior sternal region (upper sternal) corre- sponds to that portion of the sternum above the line of the upper border of the third ribs. The inferior sternal region (lower sternal) corresponds to that part of the sternum below that line. Posterior Region.—This is divided on each side, from above down, into the, 1, supra-scapular; 2, scapu- lar, and 3, sub-scapular (infra-scapular) regions, and between the scapulae is, 4, the inter-scapular region. The supra-scapular region corresponds to the supra- spinous fossa of the scapula, and is occupied by lung tissue. The scapular region corresponds to the infra-spi- nous fossa of the scapula, and is also occupied by lung tissue. It is much larger than the former, and extends, according to Gray, down to the eighth rib. The inter-scapular region is situated between the scapulas on both sides of the spinal column, which di- 6 PHYSICAL DIAGNOSIS. vides it into the inter-scapular regions of the right and left sides. It extends downward to a line drawn hori- zontally from the inferior angle of one scapula to the other. In front and on each side of the spinal column in this region the bronchi enter the lungs, the right bronchus opposite the fourth dorsal vertebra, accord- Fig. 2.—1. Supra-scapular iiegion; 2. Scapular; 3. Sub-scapular; 4. Inter-scapular Region. ing to Gray, and left opposite the fifth, about an inch lower. The sub-scapular (infra-scapular) region is bounded above by the lower borders of the scapular and inter- scapular regions, below by the lower border of the twelfth rib, within by the spinal column and outside by the posterior axillary line. REGIONS OF THE CHEST. 7 Lateral Regions.—These are divided, right and left, into, 1, the axillary and, 2, sub-axillary (infra-axillary) regions. The axillary region corresponds to the axilla. Fig. 3.—1. Axillary Region ; 2. Sub-axillary Region. It is bounded below by a line connecting the lower border of the mammary region with the lower border of the scapular region; in front by the anterior axillary 8 PHYSICAL DIAGNOSIS. line and behind by the posterior axillary line. They are both occupied by lung substance. The sub-axillary (infra-axillary) region is bounded below by the lower border of the twelfth rib, above by the lower border of the axillary region, in front by the anterior axillary line and behind by the posterior axil- lary line. On the right side is the liver, on the left is the spleen and large end of the stomach. A line drawn perpendicularly downward from the middle of the axilla is called the middle axillary line, or simply the axillary line. It is important in connection with aspiration or drainage in case of pleuritic effusion, whatever be the character of the latter. Other lines de- scribed by authors, but less frequently mentioned per- haps, are the mammillary line, drawn perpendicularly through the nipple on either side; the sternal line, cor- responding with either edge of the sternum; the para- sternal line, drawn between and parallel with the two preceding; the scapular line, drawn vertically through the inferior angle of the scapula, and the vertebral line, right and left, on each side of the spinal column. The methods adopted in the physical examination of the chest are, principally, inspection, palpation, per- cussion, and auscultation. There are other methods of less importance to be described hereafter. The use of the thermometer, or calormetation, as well as the ex- amination of the sputa, are well-known methods of physical examination. I. Inspection. Inspection is the act of looking at the patient and naturally comes first in order. In examining the chest INSPECTION. 9 in health the patient should ordinarily be stripped to the waist in a warm and comfortable room, and should stand in the erect position, the heels near each other and on the same line, the arms being dropped loosely by the side. The front of the chest should be inspected first. For this purpose the observer should stand di- rectly in front of the patient and at a convenient dis- tance for inspection. It is rare to find a perfectly symmetrical chest even in health. The right side may be a little larger than the left, especially in right-handed people with extra development of muscle, as among carpenters and black- smiths. Xot infrequently one shoulder is lower than the other owing to occupation, as is sometimes the case among hod-carriers and tailors; or to previous fracture of the clavicle, or curvature of the spine. Such deviations from the perfect symmetry of the chest may be compatible with perfectly healthy lungs. The apex- beat of the heart may, or may not, be seen, depending a good deal upon the thickness of the chest walls. There is general and even expansion on both sides dur- ing inspiration, forced or quiet, and respiratory move- ments are not usually more noticeable on one side than on the other. Abdominal respiration is more notice- able in men, superior costal respiration in women. The upper part of a woman's chest expands more on inspira- tion than a man's to allow for child-bearing, the dia- phragm in men being a more powerful and important muscle of respiration than in women. On the other hand, abnormal centres of pulsation, the presence of tumors, abnormal bulging or flattening of the chest walls, and exaggerated respiratory movements on one 10 PHYSICAL DIAGNOSIS. side with diminution of those movements on the other, would indicate disease. For examination posteriorly the patient may be turned around, but should stand in the same erect posi- tion. Sometimes a slight lateral curvature of the spine may be noticed, owing to the greater traction of the stronger muscles of one side drawing it in that direc- tion. The shoulders may not be on the same level, as already stated. The scapulas should move evenly dur- ing respiration, as a rule, but there are exceptions. In choreic children, for instance, nervous and hysterical women, or those who chance to be in a nervous condi- tion from the abuse of alcohol, tobacco, or the like, to say nothing of impostors who have heard lectures on the subject, we may find very uneven movements of the chest walls, and especially the scapulas, though the organs of respiration be perfectly healthy. The un- even movements due to these causes, however, instead of being uniform, as in disease, usually vary and change from one side to the other. When one side steadily and uniformly expands more than the other to any noticeable extent, it is usually indicative of disease, as we shall see hereafter. In lateral inspection the patient should place the hands on the head. Abnormal bulging or retraction of the sides would indicate disease. But these are ob- served better from the front, or posteriorly, than the side. II. Palpation. Palpation is the act of feeling, and has reference to the special sense of touch. It is the second step in the PALPATION. 11 regular order of examination. It is usually performed by laying the palms of the hands on the patient, but it is sometimes convenient to palpate with the ear in com- bination with auscultation. The palms of the hands, when they are used, should previously be warmed, if necessary, and then laid gen- tly, and lightly, on corresponding parts of the chest walls at the same time. This is usually sufficient, but some prefer to apply the hands alternately, or even to cross them, with or without closing the eyes, so as to make the test in every way, in doubtful cases. It is important that the examiner should stand directly in front of, or behind, the patient, according to circum- stances, in order to perform this act with proper care. For palpating in front, the patient should stand erect, as for inspection. But when palpating posteriorly, the patient should cross the arms in front and gently grasp the left shoulder with the right hand and the right shoulder with the left hand, keeping the elbows close in to the body, which should be bent slightly forward. In this position the scapulas are moved out of the way and the tissues on the back rendered more tense. Vocal Fremitus—-What is the object of palpation? Chiefly to ascertain the presence or absence of vocal fremitus, which is the vibration, thrill, or jarring of the chest walls caused by the sound of the voice. And if present, to know whether it is abnormally increased or diminished. Fremitus, or jarring of the«chest walls, may be pro- duced in various ways and is designated accordingly. If produced by the voice it is called vocal fremitus or voice thrill. From the fact that the chest walls vibrate 12 PHYSICAL DIAGNOSIS. it is sometimes called pectoral thrill. As vocal fremi- tus is the kind of fremitus by far the most commonly observed and referred to, it is often called fremitus simply, without being specified as vocal fremitus. It is more or less generally felt over the whole chest, but more marked on the patient's right side, as will be presently described at length. Other kinds of fremitus are tussive (or tussile) fremi- tus produced by the cough, and of use perhaps when the voice is much impaired or lost; rhonchal (or rhon- chial) fremitus caused by large rales, or gurgles, and more or less localized at that point; friction fremitus, sometimes felt over a pleuritic friction; and splashing fremitus produced by succussion in case of large cavi- ties containing air and fluid, as in pneumohydrothorax. Besides detecting fremitus we may also, by means of palpation, be enabled to accurately count the number of respirations to the minute, should it be impossi- ble to do this by inspection. For this purpose the hand should be lightly applied to the abdomen in men, or the upper part of the chest in women, for reasons already stated By palpation also we may be enabled to locate the apex-beat of the heart, and ascertain the character, frequency and rhythm of its movements, as well as of the radial pulse. To a very limited extent we may also conjecture the amount of expansion and contraction of the chest walls during respiration, but these are better told by inspection or measurement if necessary. The surface temperature should be noted. To determine the presence or absence of the vocal fremitus in any given case by palpation, it is necessary of course, for the patient to make use of the voice PALPATION. 13 For this purpose the patient should pronounce some- what loudly the words " one, two, three," during the act of palpation, and repeat them as often as necessary. Any short simple phrase would answer the purpose, but these words are as good as any others, and besides they have the sanction of time-honored custom. Some, however, prefer the words, "ninety-nine," or "nine- teen." The reason for speaking these words, or some simple phrase, is chiefly because they can be repeated over and over again on the same key by any one. This is very important. In ordinary conversation on any subject the key, or pitch, of the voice being constantly changed, the fremitus varies accordingly. The lower the pitch of the voice the more marked, as a rule, will be the resulting fremitus. It is important to understand that the normal vocal fremitus is more marked in the right than the left sub- clavicular region. In other words there is normal ex- aggerated vocal fremitus in the right sub-clavicular region of the healthy chest, How is this very impor- tant fact to be explained? Simply because the right primitive bronchial tube being larger than the left, a larger volume of voice is conveyed into the right lung than the left. The trachea, about four and a half inches in length, extends from the lower part of the larynx on a level with the fifth cervical vertebra to opposite the third dorsal, where it divides into the two primitive bronchi, right and left. The right bronchus, shorter, more hori- zontal, and larger than the left, enters the right lung opposite the fourth dorsal vertebra, just behind the upper border of the second costal cartilage of the right 14 PHYSICAL DIAGNOSIS. side. The left bronchus, longer, more oblique, and smaller than the right, passes under the arch of the aorta and enters the left lung opposite the fifth dorsal vertebra, one inch lower than the right. Moreover, the septum between the two is to the left of the median line, so that foreign bodies getting into the trachea naturally drop into the right bronchus or main chan- Fig. 4.—Division of the Trachea into the two Primitive Bronchi, showing the Right Bronchus much larger than the Left and given off higher up. (Schematic Diagram.) nel. It is reasonable to suppose, therefore, that a larger amount or volume of the voice is conveyed into the right lung, especially the upper part, than the left, and hence more vocal fremitus is obtained on the right side. For the same reason more fremitus is felt posteriorly in the inter-scapular region of the right side, as also slightly more in the right sub-scapular region than the left. There being no lung tissue over the superficial PALPATION. 15 area of cardiac dullness in the left mammary region, and over the liver, in front, below the sixth rib, we do not expect to find much fremitus at those points usu- ally, and then only so much as may be extended there by the chest walls. The normal spleen and kidneys do not perceptibly affect the fremitus. Over the scapulas the fremitus is interrupted more or less by the bone which intervenes. The amount of vocal fremitus differs in different healthy individuals, as it depends for its production on certain important factors. These may be embraced chiefly under two heads: (1) the character of the voice and 12) the conditions of the chest walls. In the first place, a loud, low-pitched, harsh voice will, other things equal, cause more vocal fremitus than a high- pitched soft voice. For this reason men have more fremitus as a rule than women, and grown people more than children. The bass notes of the large pipes of an organ produce more fremitus, or jarring, than the high notes, the vibrations of the former being more power- ful and longer. And in like manner the bass viol produces more fremitus or jarring, than the violin. Secondly, the chest walls. A person with chest walls covered with fat, or extra development of muscle, will, other things equal, have less vocal fremitus than one with thin chest walls, unencumbered with those tissues, thin chest walls requiring less force to be thrown into vibrations. In a man having a loud bass voice and a large chest, with thin chest walls, we should expect to find the vocal fremitus well marked, but more on his right side, for reasons already given. On the other hand, we may not be able to detect any vocal fremitus 16 PHYSICAL DIAGNOSIS. whatever in a fat, small-chested woman with a high- pitched soft voice. It is of the greatest importance to know that in health the vocal fremitus, usually ob- tained, is always relatively exaggerated on the patient's right side. The same amount of fremitus on the left side would probably indicate more or less consolidation of lung tissue. In marked deformities of the chest, however, such as those caused by marked spinal curva- tures, exceptions to the rule are usually met with in all the methods of physical examinations, though the lungs be perfectly healthy. This is what might be ex- pected, but it is well to bear it in mind. Finally, and what is difficult to explain, the vocal fremitus appears to be very slightly increased when the patient is in the recumbent position, a fact of very little practical im- portance, as it is not usually noticeable. III. Percussion. Percussion is the act of striking the patient one or more blows, to obtain accurate information regarding the underlying parts, and is the third step in the regular order of the physical examination of the chest. It should be performed gently so as not to cause pain to the patient. Although the history of inspection and palpation appears to be nowhere stated, it is well known that Auenbrugger was the author of per- cussion. He was born in Gratz, Styria, in 1722, and practiced medicine in Vienna, where he died in 1809. He discovered the value of percussion while engaged in the study of a case of empyema. He, however, made use of immediate percussion only, and pub- lished his views on that subject in 1761. But it PERCUSSION. 17 was not until Piorry of Paris invented the plexinieter in 1828 that mediate percussion was brought into gen- eral use. Piorry also drew attention to the increased sense of resistance wilich accompanies the dull sound elicited by percussing solidified lung tissue, and hence one of the advantages of palpatory percussion, with the finger as a pleximeter, over other methods. The percussion hammer was invented by Wintrich in 1841, and when employing this instrument, instead of the Fig. 5.—Percussion Hammers and Pleximeters. fingers, it is necessary frequently to use a pleximeter made of ivory or other material, which may be flat or otherwise. A solid piece of ivory about two inches long, a little larger than an ordinary lead pencil, and shaped somewiiat like an hour glass, is useful some- times in percussing just above and below the clavicles in cases of marked depression in those regions, and be- tween ribs, in some cases when it would be difficult to apply the finger, or other pleximeter. To perform pal- patory percussion, a finger of the left hand is placed as a pleximeter firmly against the chest walls and hori- 2 18 PHYSICAL DIAGNOSIS. zontally between ribs, rather than vertically. Then with one or more fingers of the right hand (in right- handed persons) curved so as to bring their tips in con- tact with the pleximeter, and moving the wrist joint only, three to five, short, sharp blows, are rapidly de- livered, which produce a certain sound. The pleximeter should be applied alike on both sides of the chest and the blows should be delivered with equal force. These rules are equally applicable when the percussion ham- mer and ivory pleximeter are used. The percus- sion sound differs for different parts of the healthy chest, and is composed of four elements or properties, (1) quality or timbre; (2) pitch; (3) duration or length, and (4) intensity or amount. Of these properties by far the most important is quality. Quality enables us to tell one kind of a sound from another regardless of all other properties. We thus distinguish the sound of a drum from the blowing of a horn and these two from piano music. It is not by the pitch, intensity or duration, that we recognize the sound of the drum, but by the quality of the sound. And so for all other musical instruments. The drum may be small and give a high-pitched sound. Or it may be large and give a low-pitched sound. Or the pitch may vary with tightening or loosening the head of the same drum. While the pitch may vary infinitely, the quality remains the same. In percussing over healthy vesicular lung tissue we know that the sound elicited is the normal vesicular, or pulmonary resonance, simply by the quality of the sound produced. The pitch will vary in different healthy people. A person with a large chest will - ain in the chest or epigas- trium. Fraentzel, of Berlin, operates usually when the fluid reaches up to the third rib, and cedema of the other lung is threatened. He takes out about fifty ounces of fluid and repeats the operation in three to five days when necessary. Aufrecht recommends (1) that a trial puncture by Pravaz's syringe be made before operating. This (ordi- nary hypodermic syringe) with a perfectly fitting piston and carefully adjusted long needle (disinfected) is sufficient. (2) If there is reason to believe that less than forty-five ounces of fluid will be discharged, the opera- tion had better be usually left undone. (3) Not more than eighty ounces of fluid should be evacuated. (4) The thoracentesis should not be repeated unless a vital indication demand it. (5) The operation of drawing off part of the fluid should be performed in all cases of large effusions as soon as the patient is seen, irre- spective of the degree of temperature. Other authors draw off the fluid at an earlier date than any of those mentioned, and do not hesitate to withdraw it all. In case of empyema (pyothorax) a permanent drain- age tube, securely fastened to prevent its dropping into HYDROTHORAX—EMPY KM A. 153 the pleural cavity, promises better results than repeated aspiration. The tube may be introduced through a free opening as Ioav down as the seventh intercostal space on the axillary line, whereas the trocar (needle) should not be pushed into the pleural cavity lower down than already mentioned. HYDROTHORAX. Hydrothorax is a dropsical and non-inflammatory affection, in which there is fluid in both pleural cavities. It is the result of a serous transudation and not of an inflammatory exudation, and is usually associated with general dropsy from some cause. Hydroperitoneum and hydro-pericardium may exist at the same time. The physical signs are similar to those of pleurisy with effu- sion, the later being generally unilateral, however, and hydrothorax bilateral. For this reason the heart is not noticeably displaced in hydrothorax, unless it be pushed doAvn. Hydrothorax is, of course, unattended by fric- tion sounds. EMPYEMA. Empyema, pyothorax, or suppurative pleurisy, is a disease characterized by pus in the pleural cavity. It may be due to traumatism, or an abscess opening into the pleural cavity from the liver, abdomen, the chest walls, or the lung. When it occurs without any7 of these causes it is probably due to some constitutional vice or to exhaustion of vitality. But why pleuritis should sometimes result in sero-fibrinous, and at other times in purulent effusion, is not exactly known. The physical signs are almost identical with those of 154 PHYSICAL DIAGNOSIS. pleurisy with non-purulent effusion. There is usually more emaciation in empyema, and the signs generally are more grave. But the only means of making a posi- tive diagnosis is by withdrawing some of the fluid with the hypodermic syringe, or other aspirating instrument. HEMOTHORAX. Hemothorax, or blood in the pleural cavity, may be due to traumatic causes, or it may result from cancer of the pleura or rupture of aneurism into the pleural sac. Very rarely it is caused by the withdrawal of fluid from the pleural cavity, causing rupture of vessels by the sudden removal of the pressure to which they had become accustomed. Wounding the intercostal artery by the aspirating needle may sometimes produce it. The physical signs of blood in the pleural cavity are similar to those of pleurisy with effusion. Neither in hydrothorax nor hsemothorax are there friction sounds. The former is usually bilateral, hsemothorax unilateral. In hsemothorax, also, the symptoms are sudden and urgent, whereas hydrothorax is always in- sidious. PNEUMOTHORAX. Pneumothorax is a disease in which there is air in' the pleural cavity. Generally it is unilateral. It may be due to traumatic causes, such as penetrating wounds of the thorax, injury to a lung from the end of a fract- ured rib, and the like. Or it may be due to openings into the pleural cavity from rupture or ulceration of the stomach or oesophagus, and from the lungs in the course of empyema, abscess, or hydatid disease. Ac- PNEUMOTHORAX. 155 cording to Walshe, however, ninety per cent, of all cases of pneumothorax are caused by the escape of air from the lungs into the pleural cavity, due to breaking down of tubercle. It is very doubtful if gas ever orig- inates spontaneously in a closed pleural cavity. The physical signs are as folloAAs: Inspection.— Dyspnoea and anxious countenance are usually noticeable. Sometimes there is more or less cyanosis. Bulging and Avant of respiratory movement on the affected side Avith displacement of the heart in the opposite direction, are marked in proportion to the amount of air in the pleural cavity. Respiratory movements on the unaffected side are exaggerated. If the opening be valvular, so that air enters the pleural sac Avithout escaping, the dyspnoea becomes extreme, and all the signs are marked. Palpation.—The vocal fremitus is diminished or ab- sent, according to the amount of air in the pleural cav- ity. The heart may be felt displaced and beating rapidly. Percussion.—Over the affected side there is tympani- tic resonance on percussion. The pitch will be high or low according to the volume of air in the pleural cav- ity and the tension of the chest walls. Over the other lung, exaggerated resonance is due to the extra Avork it is doing, and the state of vicarious emphysema. Auscultation,—The respiratory murmur over the affected side is usually diminished or absent, unless there are string-like adhesions. The vocal resonance is also diminished, and some- times, according to Walshe, has a metallic (amphoric) quality. 156 PHYSICAL DIAGNOSIS. The tympanicity on percussion at once distinguishes it from fluid in the pleural cavity from any cause. The diagnosis of pneumothorax from emphysema, has al- ready been considered. (See Emphysema.) PNEUMO-HYDROTHORAX. Pneumo-hydrothorax, or hydro-pneumothorax, as the name indicates, signifies air and fluid both in the pleural cavity. According to some authors, the fluid is always purulent, and they describe it as pneumo- pyothorax, or pyo-pneumothorax. As pneumothorax is ahvays followed by inflamma- tion and effusion into the pleural cavity within a few hours, or a day or two at most, the etiology of one dis- ease applies also to the other. Inspection.—Dyspnoea and anxious countenance, with bulging and want of respiratory movement of the affected side and displacement of the heart, maybe noticed, as in pneumothorax or pleurisy with effusion. If the opening into the pleural cavity be valvular, so that air enters more readily than it escapes, the signs are more marked. This may occur at different times in the course of the disease. Palpation.—-The vocal fremitus is diminished or ab- sent on the affected side. The heart may be felt out of its normal position. Percussion. -Above the level of the fluid the note is tympanitic, as in pneumothorax. Over the fluid there is marked dullness or flatness, as in pleurisy with effusion or hydrothorax. Not infrequently about the union of the two there is amphoric (jug, metallic) res- onance on percussion. The line of dullness or flat- PNEUMO-HYDROTHORAX. 157 ness and tympanicity, changes markedly with position of the patient. In these cases, also, the upper end of the fluid is horizontal, instead of being slightly curved as in pleurisy Avith effusion. Auscultation.—The respiratory murmur is weakened or absent, or else it is amphoric (jug, metallic). The Fio. 17.—Diagram of Pneumohydro-thorax, showing fluid and air in right pleural cavity, right lung compressed and displacement of organs to the opposite side. Also the supposed dropping of fluid. vocal resonance is also weakened, or sometimes am- phorophony, or even amphoriloquy, may be present. Succussion.—This is the act of shaking the patient while auscultating at the same time. On succussion the splashing sound of the fluid in the cavity is heard, often by the patient as well as the physician. Metallic (amphoric, jug) tinkle is often heard in this disease, and by many it is supposed to be produced by 158 PHYSICAL DIAGNOSIS. the dropping of fluid from aboATe into the fluid below. It may be possible that in such a large cavity as is usu- ally represented, fluid may have sufficient distance to fall to produce the sound; but even here it is more probably due to the bursting of bubbles formed by in- spiration, or by shaking the patient. The distinctive sign of the disease, and one which prevents its being mistaken for any other, is the splashing sound of the fluid in the cavity heard on succussion. It is impos- sible to obtain this sound in simple pleurisy with effu- sion, since there is no air in the cavity, and hence the fluid there cannot be shaken any more than it could be in a bottle, or other vessel, filled up to the cork. In all suspected cases, succussion should be tried. CHAPTER V. Summary of adventitious sounds, and of the changes in the nor- mal respiratory murmur and vocal resonance produced by disease. Adventitious sounds, as previously stated, are wholly new and abnormal sounds produced by disease, and are not modified normal sounds. They have been variously divided and arranged by different authors, but for simplicity as well as convenience they may be classified into (1) rales or rhonchi, (2) friction sounds, and (3) splashing sounds. I. Rales. Rales, or rhonchi (rattles), have also been grouped differently by different authors, but they may be re- duced to three Aarieties: (1) dry, (2) moist, and (3) in- determinate. Each of these varieties will now be con- sidered separately. 1. Dry Rales. There may be many varieties of dry rales, but two are sufficient to include them all: (1) the sonorous and (2) the sibilant. Sonorous Rales are loud, low-pitched, dry rales, made on inspiration, expiration, or both. They may be produced in the larynx, trachea, or larger bronchi. In the larynx they may be caused by spasm of the glottis, as observed in laryngismus stridulus, croup, and 160 PHYSICAL DIAGNOSIS. Avhooping-cough, growths Avithin the larynx, and press- ure on the recurrent laryngeal nerve from aneurism or other tumor. In the trachea they may be due to press- ure without from some tumor, aneurism for example, or growths within, as polypi, or cedema, inflammatory exudation, or constriction due to old cicatrices and the like. Such rales are termed stridor, and the breath- ing is said to be stridulous. If the pressure, or ob- struction, or constriction, be sufficiently marked, sibi- lant as well as sonorous rales may be produced in these localities. These rales made in the larynx or trachea are, however, conveyed all over the chest usually, and should be differentiated by means of the stethoscope; an easy matter, as they are much louder at the site of their production than elsewhere Sonorous rales are made in the larger bronchi from narrowing of their calibre by external pressure from some tumor, strict- ure due to old inflammation, spasm of the muscular coats, or tumefaction of the lining mucous membrane, or else the vibration of viscid mucus within the tubes. These rales are generally transient, and change on coughing. For this reason, it would appear that they are more frequently due to varying spasm or vibrating mucus that is removed by coughing. Where the cause is permanent, the rales are few in number, and often changeable, though less so, showing that even in these cases, vibrating mucus, from localized irritation, is often an important factor. Both sonorous and sibilant rales are heard, especially in the early or dry stage of bron- chitis and in spasmodic asthma. In the latter disease they are also sometimes said to be meAving and chirping. Sibilant rales are high pitched, whistling, dry rales, MOIST rales. 161 made on inspiration, expiration, or both. As already remarked, they may be made in the larynx or trachea, if the calibre be diminished sufficiently. For the same reason they may also be made in the larger bronchi. Usually, however, they are made in the smaller bronchi. The causes of their production are the same as for the sonorous (coarse dry) ra les, and, like them, are heard es- Fig. 18.—Sonorous and Sibilant Rales. SnR, Sonorous Rales ; SbR, Sibilant Rales. pecially in the dry stage of bronchitis, and in an attack of asthma. They are also changeable, being heard more distinctly now in one place and then in another. 2. Moist Rales. These may occur in the larynx, trachea, bronchi, air- cells, Or in the pleural cavities. Laryngeal and tracheal rales may also be moist as well as dry. Moist tracheal rales occurring just before death, as they often do, are 11 102 PHYSICAL DIAGNOSIS. commonly called death rattles. These rales may also be heard over the chest, and their locality should lie differentiated by means of the stethoscope. In cases where rales of any kind are heard over the chest, the patient should be directed to clear the throat, so as to get rid, if possible, of any laryngeal or tracheal rales that might exist. Many varieties of moist rales occurring in the bron- chi are described by various authors, but three are suffi- cient to include them all: (1) mucous, (2) submucous, and (3) subcrepitant. Mucous rales are large, moist, bubbling rales made in the larger bronchi, and are heard both on inspira- tion and expiration, since the tidal air acts on the fluid in the tubes both on entering and leaving them. These rales are usually attended with expectoration, and they change about on coughing. Fluid of any sort in the larger bronchial tubes will give rise to mucous rales, whether it be mucus, blood, or pus. We therefore find them in such diseases as bronchitis, unless the secretion be very scant, certain cases of pulmonary hemorrhage, abscess, and pulmonary consumption. In general bron- chitis the rales are bilateral, but usually few in number. If not heard at all on first listening, they may be de- veloped by coughing. In other diseases where the bronchitis would be local, the rales would also be lo- calized. Submucous rales are moist, bubbling rales, rather smaller than the mucous, and are made in the medium- sized bronchi. They are also heard both on inspiration and expiration, are attended with expectoration, and are changed by coughing. They are produced in the MOIST RALES. 163 same way, and are due to the same causes, as the mu- cous rales (see fig. 8, p. 38). Subcrepitant rales, or muco-crepitant rales, are the finest moist bronchial rales, and are made in the finer (ultimate) bronchial tubes, chiefly on inspiration, and are not as easily changed as the mucous and submucous by coughing. This is accounted for by the fact that in- spiration is a greater force than expiration, as affecting the finer tubes and air-cells. Hence the mucus in these localities is overcome Avith greater force on inspiration than expiration, and the subcrepitant rales are conse- quently produced on inspiration rather than expira- tion. They may be, and often are, entirely wanting during expiration. Instead of being caused by the bursting of very fine bubbles, these rales are sometimes caused by the forcible separation of agglutinated tube walls, and then they are invariably heard only on in- spiration. In capillary bronchitis they are heard on both sides, usually posteriorly and low down. In pul- monary cedema they are also sometimes heard as the serous fluid enters the tubes (see (Edema). The rale also occurs in the third stage of lobar pneumonia, due to secondary local bronchitis and liquefying exudation. In pulmonary hemorrhage from any cause these rales are produced if blood enters the finer tubes, and hence are often heard in hemorrhagic infarction. Pus in these finer tubes also gives rise to it, whether the pus be due to purulent bronchitis, rupture of an abscess, or perforation from empyema. This rale is also the adventitious sound usually heard in the first stage of phthisis, although it may evidently occur in any stage. Crepitant rales are made in the air-cells, and are the 164 PHYSICAL DIAGNOSIS. only vesicular rales that exist. They are very fine, uniform, crackling rales, heard only at the (tip) end of inspiration, and are unchanged by coughing. They are caused by the forcible separation of agglutinated cell walls, as in the first stage of lobar pneumonia, or agitation of thin fluid in the air-cells, as in pulmonary cedema. They are heard also in the third or resolving stage of lobar pneumonia, where it is known as the rale redux, or rale that has returned, or come back. The crepitant rale, then, and not the subcrepitant, as is so often erroneously stated, is the rale redux, or re- turned rale. The subcrepitant rale is not a part of the physical signs of any stage of pneumonia but the third, in Avhich it has not come back, but is heard for the first time. The crepitant rale, however, A\-hich Avas heard in the first stage, and lost in the second after the air-cells had become obliterated, now comes back, or is redux, in the third stage. The crepitant rales heard in pulmonary cedema are louder and more liquid in quality than those of pneumonia. The crepitant rale may also be heard in pulmonary consumption in any stage, if the conditions for its production exist, and other adventitious sounds, usually present, are not so loud as to obscure it. Mucous Click.—A single fine, high-pitched moist click that is usually unchanged by cough, may be heard at or near the end of inspiration over incomplete consol- idation in the first stage of phthisis. As Loomis says, it sounds like an isolated subcrepitant rale. When it is really of mucous origin, it is no doubt due to the sud- den passage of air through a fine bronchial tube ob- structed by pressure without, due to tubercle, for in- MOIST RALES. 1(55 stance, or viscid mucus within. It is a very important adventitious sound in the commencement of pulmo- nary consumption. But may it not sometimes also be of intra-pleural origin I Gurgles are moist, bubbling rales made in a cavity, and are large or small, or low and high pitched, accord- ing to the size of the cavity and amount of consolidated tissue intervening. They are made either during in- spiration or expiration, but inasmuch as the air usu- ally enters a cavity Avith more force than it leaves, gur- gles are consequently apt to be louder on inspiration than expiration. Sometimes they are heard only on inspiration. Moreover, during inspiration, the direc- tion of the current is toward the ear of the listener, in- stead of from it, as in expiration. If the cavity be full of fluid there may be no gurgles. Xone will be heard, also, if the cavity be empty, or if the opening into it be such as to prevent fluid from being agitated by the air entering or leaAdng it. If the opening into the cavity becomes stopped Avith a plug of viscid mucus, a clot of blood, or other material, gurgles Avhich Avere heard before now immediately cease. On coughing and re- moving the obstruction they at once return. (See col- ored plate showing cavity.) Metallic Tinkle, or Amphoric Tinkle.—-If the cavity, whether it be pulmonary or intra-pleural, have hard, smooth walls, and be of sufficient size to act as a reso- nant chamber, in other words, if it be an amphoric cav- ity, and if it contain a small amount of viscid fluid with the tube opening under it or into it, so as to pro- duce explosion of bubbles, metallic, or amphoric tinkle is apt to result. Or it may be produced by the vibra- 166 PHYSICAL DIAGNOSIS. tion of viscid mucus. It is usually heard most dis- tinctly on inspiration, like ordinary gurgles, and is not constant. It often disappears on coughing, or it may be developed by coughing. According to AValshe, such adventitious sound need not be situated in the cavity at all, if it be near enough so that the sound shall be echoed in the cavity. Metallic tinkle is also sometimes produced by speaking or coughing. It is probably never due to dropping of fluid in a pulmonary cavity, since there could hardly be distance enough for it to fall Avith sound sufficiently distinct to be heard. Even in pneumo-hydrothorax, metallic tinkle may be re- garded as a musical rale of amphoric quality, produced by the bursting of bubbles rather than the dropping of fluid. For that reason it has been classified with the moist rales. (Compare pp. 157, 180.) Intra-pleural Moist Rales.—Pleuritic friction sounds are easily distinguished from other adventitious sounds; but occasionally Ave hear sounds, eATidently of intra- pleural origin, that exactly imitate moist bronchial or vesicular rales. Some authors go so far as to say that the crepitant, as Avell as the subcrepitant rale, is al- ways intra-pleural. In the same Avay other intra- pleural adventitious sounds, resembling mucous and submucous rales, are sometimes heard, so that, as Da Costa says, no human ear can tell the difference by the quality alone. How are Ave to distinguish between them? This subject has already been alluded to (see Bronchitis). If the rales are localized, unilateral, unchanged by coughing, peripheral and superficial, and unattended with expectoration, they are usually intra-pleural. If, on the other hand, they are bilateral, INTRAPLEURAL RALES. 167 changed by cough, attended with more or less expecto- ration, deep-seated, and generally distributed over the chest, they are almost surely bronchial. But how can we distinguish the crepitant rale made in the air-cells from the intra-pleural crepitation? Sometimes it is difficult or even impossible. This, however, does not necessarily make the two identical any more, for in- stance, than it makes thoracic aneurism and pleurisy with effusion identical, because one has been mistaken for the other until post-mortem examination revealed the true state of the case. In pulmonary cedema we have the crepitant rale bilateral and low doAvn poste- riorly. There is also Avatery expectoration and the cause of cedema (see (Edema). Intra-pleural crepitation is rarely bilateral, and then is unattended with expec- toration, unless there be complication. In the first and third stages of lobar pneumonia it is more difficult to say that the rale is not intra-pleural. Even in these cases the rale sometimes follows the outline of the lobe too closely to say that it is always intra-pleural. Intra-pleural moist rales do not require actual in- flammation of the pleurae for their production. Per- verted nutrition of the membrane from any cause may give rise to a viscid, glutinous secretion, instead of the normal lubricating material, so that the pleune, in- stead of gliding noiselessly on each other during respi- ration, will produce sounds which, as already stated, may be, and often are, identical in quality Avith vesicu- lar, bronchial, tracheal, or laryngeal moist rales. 168 PHYSICAL DIAGNOSIS. 3. Indeterminate Rales. Indeterminate rales include all other rales not em- braced in the foregoing classes and varieties. They are crackling and crumpling sounds, partly moist and partly dry, produced on inspiration or expiration, or both, and it is impossible to determine with certainty whether they are of intra-pleural, pulmonary, or bron- chial origin. Flint states that they are found usually early in phthisis. They may be heard during any stage, but particularly, perhaps, after the disease has advanced sufficiently to give rise to broken-down tissue and complicated pathological conditions. The follow- ing table in regard to rales may be of use: Rales or Rhonchi. - 3 classes. 1. Dry Rales. ( Stridulous—produced in the Larynx. Sonorous—produced in the Large •< Bronchi. Sibilant — produced in the Small [ Bronchi. Laryngeal—produced in theLarynx. Tracheal—produced in the Trachea. Mucous — produced in the Large Bronchi. Submucous—produced in the Medi- um Sized Bronchi. Subcrepitant — produced in the Small Bronchi. Crepitant—produced in the Air-cells or vesicles. Mucous Click—produced in a Small Bronchus. Gurgles—produced in Cavities (pul- monary). Metallic (amphoric) Tinkle — pro- duced in Amphoric Cavities. Interpleural moist rales which may simulate any of the above moist rales. {Partly moist, partly dry, crackling and crumpling sounds, whose exact origin and mode of pro- duction are unknown. 2. Moist Rales. FRICTION SOUNDS—SPLASHING SOUNDS. 169 II. Friction Sounds. Friction sounds are due to pleuritic inflammation. Their true pathological significance was first pointed out about 1819 by Honore, of Paris, a contemporary of Laennec. The membrane, which in health was moistened with a lubricating secretion, so that the two opposite layers glided noiselessly upon each other dur- ing respiration, iioav becomes dry and rough, or agglu- tinated. For this reason, grazing, rubbing, rasping, grating, rumbling, or creaking sounds may be pro- duced. The sounds are heard chiefly on inspiration, and are usually interrupted, so that several may occur during one inspiration. They are also heard sometimes during expiration. As already stated, pleuritic friction sounds are heard more distinctly usually on inspira- tion than expiration (p. 140). As Flint correctly states, these sounds are usually more distinctly heard after removal of the fluid, if any exist, than before, as the surfaces of the pleurae are by that time more roughened than at first. These friction sounds are of variable duration, depending upon the pathological condition. When Avell - marked, especially in those having thin chest walls, friction fremitus may be felt on palpation. III. Splasiiixg Sounds. Succussion is the act by which splashing sounds are produced. It consists in shaking the patient while the ear is placed to the chest. By this means the splash- ing of fluid in a cavity containing air and fluid is heard, as in pneumo-hydrothorax (or pneumo-pyothorax). It might be possible, also, in a large pulmonary cavity 170 PHYSICAL DIAGNOSIS. containing air and fluid. It is usually, however, pathognomonic of pneumo-hydro (or pyo) thorax. CHANGES IN THE RESPIRATORY MURMUR. I. Changes of Intensity. The sound of the respiratory murmur, as well as of the voice, arrives at the chest walls in health, first, through convection along the tubes, and secondly, re- fraction (diffusion) in the air-cells. But for this refract- ing power of the healthy lungs, due to the presence of the air-cells, the intensity of the respiratory murmur and of the voice sounds would be greatly increased, as occurs in solidification. On the other hand, the sounds would be diminished or absent, according to the amount of obstruction in the tubes to convection, increased re- fraction, as in emphysema, and interception, as in pleu- ritic thickening or effusion. We see, then, that these, as Avell as other sounds on their way to the chest walls, may, according to the con- ditions present, be subjected to (1) convection, (2) ob- struction, (3) refraction (diffusion), (4) conduction, and (5) interception. On the chest walls, or along strings of adhesion, they may be transmitted, or extended. In health, then, when convection along the tubes is perfect, and there is only normal refraction (diffusion) in the air-cells, we hear the normal respiratory murmur, which will be laryngeal, tracheal, bronchial, vesiculo- bronchial, or vesicular, according to the locality. The intensity of this murmur will be weakened or suppressed (also termed diminished or absent); (1) in proportion to obstruction to convection in the tubes, either from growths, mucus, pus, blood, or other ob- CHANGES IN THE RESPIRATORY MURMUR. 171 stacles Avithin, or stricture, from old inflammation or compression of the tubes from aneurism, cancer, hyda- tids, or some other cause; (2) increased refracting (dif- fusing) power in the lungs, due to dilatation of the air- cells, as in chronic general emphysema; or (3) inter- ception from pleuritic thickening or effusion. Second- arily, it would be modified also by interference with the proper expansion of the lungs and chest walls from pain, pleuritic adhesions, and deformities. The intensity may be slightly increased (exaggerated) in two Avays. First, Avithout any change in quality or rhythm, as Avhen one lung or part of a lung is tempo- rarily vicariously emphysematous from doing extra work, OAving to crippling of the other lung or part of a lung. It is simply louder than normal, and is sometimes termed hyper-vesicular or supplementary. It differs someAvhat from puerile breathing, Avhich is heard in children under the age of puberty, Avhose lungs are not developed in proportion to their bronchial tubes. Both are loud (rude), but the puerile respiratory murmur has more of a bronchial element in it. Neither are necessarily harsh (rough), this quality depending on the roughness of the mucous membrane lining the larger bronchial tubes, and caused by the friction of the tidal air Secondly, it may be slightly increased (exaggerated), with change in the quality and rhythm, as seen in the vesiculo-bronchial breathing, due to incomplete consol- idation with corresponding increase of conduction, and diminution of refraction, in the lungs, owing to oblit- eration, in part, of some air-cells; as seen in the first stage of phthisis pulmonalis. 172 PHYSICAL DIAGNOSIS. The intensity of the murmur Avill be markedly in creased if refraction is replaced by conduction; in othei words, if the air-cells are replaced by solidified lung tissue, as occurs, for instance, in the second stage of lobar pneumonia, which offers a homogeneous medium for the conduction of sound. II. Rhythm. Prolonged expiration and divided respiration are the two principal changes in the rhythm. In the normal vesicular respiratory murmur, inspiration is about four times longer than expiration, and the two are continu- ous. Moreover, expiration is lower in pitch than in- spiration. Now, in a paroxysm of asthma, and in chronic emphysema, the expiration is prolonged, but is not usually changed in pitch or quality. In a par- oxysm of asthma the expiration is not only prolonged, but inspiration is much shortened by being deferred, that is to say, it is not heard in the commencement. The rhythm in such a paroxysm is just the reverse of what it is in health, that is to say, expiration is four times longer than inspiration, or even longer. In em- physema, expiration is also prolonged and inspiration deferred, but it is never observed that expiration is four times longer than inspiration, unless there be also marked obstruction to the exit of air from the presence of mucus, or other cause. In bronchitis, also, expiration is prolonged in proportion to the obstruction from mucus, especially in capillary bronchitis; but the respiratory murmur is not otherwise changed, unless in some cases it may become harsh or rough (see Changes in Quality). In asthma and bronchitis, the rhythm. 173 expiration is prolonged, because of obstruction to the egress of air, either from spasm of the muscular coats of the tubes, or mucus within the tubes, or tumefaction of the bronchial mucous membrane. In general em- physema, on the other hand, expiration is prolonged on account of the rigid dilatation of the thorax, caused by loss of resiliency of lung tissue, rigidity of the cos- tal cartilages, and crippling of the diaphragm, leaving the muscular coats of the bronchial tubes to perform the act. If obstruction in the tubes, due to co-existing bronchitis, also is Avell marked, the expiration will be still more prolonged, but usually the expiration of em- physema is not so much prolonged as to be four times the length of inspiration, as in a paroxysm of asthma, where obstruction is marked on account of spasm as well as mucus and tumefaction. The reason for pro- longed expiration in such cases has already been fully explained (see Asthma). In consolidation of lung tissue, expiration is also prolonged, but the murmur in these cases differs from those just mentioned by having the pitch always raised, on account of its passing from one medium to a denser medium, with shorter vibrations and the quality changed. Instead of being blowing in quality, it is more or less tubular. The prolongation is not due so much to the crippling Of the expiratory forces, or to obstruction to the egress of air, as it is to the fact that the incompletely or completely solidified lung tissue, being a better conducting medium, enables one to hear the murmur more distinctly and for a. greater length of time. The respiratory murmur may be divided—that is, 174 PHYSICAL DIAGNOSIS. the inspiration and expiration may not be continuous. This is usually, if not always, due to consolidation to a certain degree. In case of incomplete consolidation, inspiration and expiration are not continuous, by inspi- ration being unfinished. The gap between the two will be marked in proportion to the extent and complete- ness of consolidated tissue. When a whole lobe is consolidated, as in the second stage of lobar pneumo- nia, for instance, the break between inspiration and expiration is well marked. Wavy, jerky, or cog-wheeled respiratory murmur is sometimes heard in the first stage of phthisis. It is usually attributed to the sudden overcoming of strict- ure or obstruction in a bronchial tube, from pressure of tubercle, or mucus within. This, however, is doubt- ful, since it is often heard in perfectly healthy chests of those who are nervous, hysterical, or have palpitation. It is more often due to palpitation of the heart than any- thing else, and is oftener heard in women than men. Taken by itself as a physical sign of disease of the lungs, it is worthless. It is usually heard on inspira- tion, but may also be heard on expiration, or both. III. Quality. Besides being changed in intensity and rhythm, the respiratory murmur may also be changed in quality. Instead of its being purely vesicular in quality, as heard over the left subclavicular region, it may become vesiculo-bronchial. The late Dr. Austin Flint termed it broncho-vesicular, but, as Da Costa suggests, the order of occurrence, as actually heard, being first vesi- cular and then bronchial, it is more correct to call it QUALITY. 175 vesiculo-bronchial. It was formerly, and is now by some, termed rude (loud) respiration. Others, again, call it harsh or rough. Neither of these terms is de- scriptive of the true condition, nor is the murmur neces- sarily harsh, rough, or even rude. A respiratory mur- mur is harsh or rough if the mucous membrane of the larger tubes is in a harsh or rough condition, so that the tidal air, by friction against it, in passing in and out, has the quality of harshness or roughness imparted to it. For this reason, any respiratory murmur,exclud- ing the purely normal vesicular, may be harsh or rough. In vesiculo-bronchial breathing, expiration is pro- longed, raised in pitch, and more or less tubular in quality, in proportion to obliteration of air-cells, by which the vesicular element is lessened, as in incom- plete consolidation from some cause, or proximity to bronchial tubes. For the latter cause, we obtain a nor- mal vesiculo-bronchial breathing in the right sub- clavicular region of a healthy chest. Vesiculo-bron- chial breathing is also among the early signs of phthisis, while consolidation is incomplete. Bronchial breathing is significant of complete con- solidation of lung tissue, as in the second stage of lobar pneumonia. Here all vesicular quality is lost, and both inspiration and expiration become tubular in quality. Expiration is as long as inspiration, or longer; the pitch of both is raised, expiration being usually higher than inspiration, and the intensity is greatly increased in the sense, not of volume, but concentrated amount. It sounds somewhat like blowing across the mouth of the stethoscope. It may be imitated by put- ting a piece of liver in a tin, or other tube, covering 176 PHYSICAL DIAGNOSIS. both ends with a thin membrane, and then listening through it to tracheal respiration. Over a cavity we usually hear cavernous breathing, which is blowing in quality, giving the idea, as Flint states, of air passing in and out of a hollow space. It differs from bronchial breathing by being usually low pitched and blowing in quality, whereas bronchial breathing is necessarily high pitched, the sound of the murmur having passed from one medium to a denser medium, and tubular in quality. Both are more intense than the normal re- spiratory murmur, but cavernous breathing is more in- tense in the sense of volume, bronchial breathing in concentrated amount. When consolidated lung tissue is extensive near a cavity, there is sometimes heard a mixture of cavern- ous and bronchial qualities, or the caverno-bronchial breathing. Flint was the first to describe this kind of respiratory murmur, and termed it broncho-cavernous. In nearly all the cases cavernous quality comes first, and is followed by the bronchial, though there is no reason why this should always be so. For this reason, however, it is termed caverno-bronchial, rather than broncho-cavernous. Should the cavity be large, situated near the apex, and have hard, smooth walls, a free opening communi- cating Avith a bronchial tube, and not contain much fluid, amphoric respiration, or jug-breathing, may be heard. It sounds like blowing into the mouth of an empty jug (amphora) or bottle. The pitch of this breath sound will vary with the size of the cavity, its mouth and other conditions, but it is by its quality, not pitch, that it is distinguished. PECTOROPHONY. 177 CHANGES IN THE PECTOROPHONY OR VOCAL RESO- NANCE. The sounds of the patient's voice, as heard over the larynx, trachea, or any part of the chest walls by the auscultator, may be divided into two classes: (1) that in which only the voice is heard, and (2) Avhen speech or articulation is heard. To the first class the termina- tion -phony (phone, voice) is applied, to the latter, -loquy (speech). The sound of the voice, therefore, as normally heard over the larynx, is termed normal laryngophony, and over the trachea, normal tracheoph- ony or trachophony. As the speech is oftener heard in these localities than the voice simply, so do we more frequently hear normal laryngiloquy and normal tra- chiloquy over these organs. I. Pectorophony. Pectorophony, or chest voice, is the sound of the voice, or the vocal resonance, heard over the chest, Avithout our being able to distinguish the articulate words as spoken by the patient. Normal pectorophony, or normal vocal resonance, as it is more commonly called, when heard over pul- monary vesicular tissue, is a distant, diffused, indis- tinct, buzzing sound, with a somewhat low pitch, cor- responding to the pitch of the patient's voice. A low-pitched, loud, harsh voice, other things equal, yields more intense pectorophony than a high-pitched, weak voice, in the sense of volume. For this reason, men usually have normally more intense pectorophony than women, and grown people of both sexes than 12 178 PHYSICAL DIAGNOSIS. children. Thin chest walls, other things equal, also favor the production of pectorophony. Microphony, diminished pectorophony, weakened vocal resonance, occurs in cases of obstruction in the bronchi to the convection (conveyance) of the voice sound, as in bronchitis with abundant mucous secre- tion, pus or blood, polypi, stricture of the bronchi, from old inflammation, or their compression from some cause, as cancer, aneurism, hydatids, and other tumors. Also when there is increased refractive power of the lungs, as in chronic general emphysema, with permanent dilatation of the air-cells, or when there is interception to the transmission of the voice from pleuritic thickening or effusion. In some of these cases, whispering pectorophony may be entirely absent or suppressed. In general, the same condi- tions for weakening or suppressing the respiratory murmur apply to the whispered voice. Megophony, exaggerated pectorophony, exaggerated vocal resonance, occurs when the intensity is increased. It is heard normally in the right sub-clavicular re- gion, on account of proximity to the right bronchial tube, as already stated. But it is also heard over in- complete solidification of lung tissue, owing to the better conducting power of the latter. It is therefore one of the early signs of incipient phthisis. Under these conditions, the sound of the voice is nearer, less diffused, and more distinct and intense, in the sense of concentrated amount. Bronchophony, bronchial pectorophony, or bronchial voice, is heard when all vesicular quality is lost, owing to complete solidification of lung tissue. The PECTOROPHONY. 179 voice sound comes to the ear of the auscultator directly from the bronchial tubes, through the solidified lung tissue. It is near, concentrated, and distinct, or the very opposite of normal pectorophony (vocal reso- nance). The pitcli of bronchophony is necessarily high, owing to the transition of the sound from one medium to a denser medium. In some instances, bronchophony, instead of being near and strong, sounds as if it were distant and weak. Weak or dis- tant bronchophony is caused by the intervention usu- ally of pleuritic thickening or effusion. Obstruction to convection in the bronchi from compression, or stricture, or a plug of viscid mucus, might cause bronchophony to be weakened or even suppressed. JEgophony, or aegoid pectorophony, so named from its resemblance to the bleating of a goat, is broncho- phony made tremulous by vibrating fluid in the pleural cavity usually, though it may occur in some rare cases of pulmonary cavities and other disease. It is more of a clinical curiosity now than it is of any real value, since, in cases of doubt and necessity, the aspi- rating needle may be used to determine the presence of fluid. Besides being tremulous, segophony is more or less weakened by the pleuritic conditions present. It also usually possesses a nasal quality for some reason. Cavernophony, or cavernous pectorophony, is heard when listening over a cavity. It differs from bron- chophony, for while the latter is high-pitched and tubular in quality, with increased intensity in the sense of concentrated amount, cavernophony is often 180 PHYSICAL DIAGNOSIS. low-pitched, sepulchral in quality, and has its intensity increased in the sense of volume. Amphorophony, or amphoric pectorophony (jug voice), is cavernophony possessing the quality of am- phoricity, and resembles the sound of the voice in an empty jug or other vessel. It has a peculiar ringing, metallic, or amphoric quality, and may be attended, like the breathing, or the cough, by amphoric, or me- tallic echo. The terms amphoric and metallic are used to convey the same idea, the former referring to the particular kind of cavity, the latter to the material, which imparts the quality to sounds. Should the patient whisper instead of speaking out loud, as was first recommended by the late Dr. Austin Flint, Ave would have some variety of whispering pectorophony. In some cases, it might be absent or suppressed; in others, exaggerated, and then Flint termed it exagger- ated bronchial whisper. In the same way Ave would have whispering bronchophony, cavernous Avhisper or whispering cavernophony, and amphoric Avhisper or whispering amphorophony. The following table gives a summary of the voice sounds: Laryngophony Traeheophony Normal Pectorophony, or vocal resonance. Microphony, diminished or weak (the whis- per may be absent or suppressed). Megophony, exaggerated (slightly increased). Pectorophony J. Bronchophony—bronchial voice (may be weak). iEgophony—goat's voice (tremulous). Cavernophony—cavernous voice. Amphorophony—amphoric (jug) voice. II. Pectoriloquy. Pectoriloquy, or chest speech, is the speech (articu- late words) of the patient ;\s heard through the chest PECTORILOQUY. 181 walls by the auscultator. The term was first used by Laennec, of Paris, about 1820, and always had reference to cavities, since it was thought that only over cavities could the articulate words of the patient be heard. It is, however, quite evident that pectoriloquy may be obtained in other conditions than cavities. It is some- times heard over perfectly healthy chests, especially among those Avho have thin chest Avails and a loud re- spiratory murmur, as among some women and chil- dren. It is quite often heard over the larynx and trachea, normally. Bronchiloquy. or Bronchial Pectoriloquy.—Instead of bronchophony simply, Ave sometimes also hear the articulate Avords of the patient over consolidated lung tissue. Indeed, Guttmann states that there is no dif- ference betAveen bronchophony and pectoriloquy. But as bronchophony differs from cavernophony, both being pectorophony, so does bronchial pectoriloquy, or bronchiloquy, differ from cavernous pectoriloquy or caverniloquy, the former being necessarily high-pitched, the latter usually loAv-pitched. In case of Avhispered voice, the former is also tubular in quality, the latter blowing. The intensity of the former is also increased in concentrated amount, the latter in volume. Caverniloquy, or cavernous pectoriloquy, is the speech of the patient as heard over an ordinary cavity. As Flint truly remarks, one must not expect to be able to carry on a conversation Avith his patient through a cavity, but if some syllables of some simple phrase or words, as one, two, three, be heard, it is sufficient to establish pectoriloquy of any variety. Amphoriloquy. or amphoric pectoriloquy, is the 182 PHYSICAL DIAGNOSIS. speech of the patient Avith an amphoric or metallic in- tonation, as if speaking in the mouth of an empty jug. It is significant of amphoric cavity. If the patient whispers instead of speaking out loud, we then hear whispering laryngiloquy, trachiloquy, or pectoriloquy, of whatever variety the latter may be. The following table gives a summary of varieties of speech (articulate voice) sounds: Laryngiloquy. Trachiloquy. f Normal Pectoriloquy. Bronchiloquy—Bronchial speech (may be weak Pectoriloquy -J or tremulous). Caverniloquy—Cavernous speech. l_ Amphoriloquy—Amphoric speech. In concluding this chapter we observe that in aus- cultation of the organs of respiration we listen for three separate and distinct classes of sounds: 1. Respiratory murmur, whether normal or abnor- mal. 2. Vocal resonance, normal or otherwise. 3. Adventitious sounds. No form, or modification, of the respiratory murmur or vocal resonance can, therefore, be considered as an adventitious sound—and if the latter is present, it must be a rale, a friction, or a splashing sound. CHAPTER VI. THE HEART. The Heart is a hollow organ of striated or voluntary muscular tissue, but so presided over by the sympa- thetic nervous system that its movements are, Avith very rare exceptions, Avholly involuntary. Only in ex- tremely rare cases has the individual been able to cause the heart to beat fast or slow at Avill. The fact that it is of the striated or voluntary muscular tissue is of great importance in connection Avith certain dynamic cardiac murmurs, to be described hereafter. Normally, the heart is conical in shape, and, in the adult, five inches long, three and a half inches broad and two and a half inches thick. It weighs from ten to tAvelve ounces in men, and in women from eight to ten ounces. The heart is obliquely situated within the thorax, between the lungs, and is inclosed by the pericardium. The base, directed upward and backward to the right, is on a level with the upper borders of the third costal cartilages, extending half an inch to the right, and one inch to the left of the sternum; the apex, forward and downward to the left, corresponds to a point between the fifth and sixth costal cartilages (fifth intercostal space), two inches below and one inch within the left nipple, according to Gray. According to others, it is an inch and a half below, and half an inch within, the left nipple, and this is probably more nearly correct. 184 PHYSICAL DIAGNOSIS. According to Flint, the apex of the heart in health should fall a little within the mammillary line. Of course these rules apply only to those cases where the nipple is in its normal position, for sometimes it is dis- placed by deformity, or large size of the gland, as in nursing women or those avIio have borne children. The force of the normal apex-beat differs in different cases. In some it is perceptible on inspection, in others not, and in some cases it may not even be felt on palpation. This is accounted for chiefly by difference in the thick- ness of the chest walls and size of the ribs. Among those having thick chest Avails Avith Avide ribs, the im- pulse of the heart Avill not usually be so perceptible as among those who have thin chest walls and narrow ribs with correspondingly Avide intercostal spaces. The normal heart beats more forcibly in some persons than others, and the impulse also differs somewhat with position of the body. Outline of the Heart.—The base corresponds to a line drawn across the sternum along the upper borders of the third costal cartilages, extending half an inch to the right and one inch to the left of the sternum. A line so drawn is termed the base line of the heart. The left border corresponds to a line curving outward, but Avithin the left nipple, from the left end of the base line, down to the apex. This border is formed by the left ventricle. The right border of the heart consists of a right border proper, formed partly by the right auricle, and partly by the right ventricle, and a lower border formed chiefly by the right ventricle. Draw a line from the apex horizontally to the median line of the sternum, to correspond with the lower border, TIIK HEART. 185 thence curving upward and slightly outward to the right end of the base line, to form the right border proper. Areas of Cardiac Dullness.—Auscultatory percus- sion (p. 33) is the best method for accurately mapping out the limits of the heart, the patient being in the erect position, unless one has no assistant, and then the recumbent position is best. There are two areas of dullness, the deep and superficial. The whole area of dullness, including the deep and superficial, extends vertically from the upper borders of the third costal cartilages to the upper border of the sixth, and trans- versely from a point a little AA-ithin the left nipple to about half an inch to the right of the sternum. The deep area of dullness corresponds to that portion of the heart covered up by lung tissue, and is increased with enlargement of the heart from any cause. The superficial area of dullness is somewhat triangu- lar in shape, with little lung tissue over it. This area is bounded beloAv by a line drawn horizontally from the apex to the median line of the sternum; on the right, by the median line of the sternum up to the level of the upper borders of the fourth costal cartilages; and on the left, by a line drawn from the last-named point to the apex. This last line curves outward, but falls within the left nipple. The superficial area of dullness is diminished at the end of a full inspiration and in em- physema; it is increased by ventricular enlargements and pericardial effusion. It is formed by the right ventricle, except at the apex, which is composed of the left ventricle. This latter fact is A^ery important in connection with murmurs made within the left ventricle. 186 PHYSICAL DIAGNOSIS. The Circulation.—-The heart is divided lengthwise into right and left, or venous, and arterial halves, and these two are divided crosswise, so as to form two upper and two lower compartments—four in all—the two upper compartments being the right and left auri- cles respectively, and the tAvo lower being the right Fig. 19.—Normal Blood Currents in the Heart and Relative Position of the Ventri- cles, Auricles and Great Vessels. IVC, Inf. Vena Cava; SVC, Sup. Vena Cava; RA, Rt. Auricle; TV, Tricuspid Valves; RV, Rt. Ventricle; P, Pulmonary Valves; PA, Pulmonary Artery; Pv, Pulmonary Veins; LA, Left Auricle; MV. Mitral Valves; LV, Left Ventricle; A, Aortic Valves; Aa, Arch of Aorta. and left ventricles. The right (or venous) side of the heart is situated in front of, slightly above and to the right of the left side, so that in looking at the normally situated heart, from the front, Ave see the right ventricle and right auricle, and only a small part of the left auri- cle, and a narrow strip of the left ventricle, which ex- tends down further than the right ventricle, and forms the apex. PLATE VI. Schematic Diagram, representing the Normal Blood Currents in the Heart—A V C, Ascending Vena Cava; D V C, Descending Vena Cava; R A, Right Auricle; T VT Tricuspid Valves; RV, Right Ventricle; P, Pulmonary Valves; PA, Pulmonary Artery, P v, Pulmonary Veins; L A, Left Auricle; M V, Mitral Valves; LV, Left Ventricle. A, Aortic Valves; A a, Arch of Aorta. DOWN BY H. MACOOHALD M. D- N. Y. TTY fcvamLtR.UTH^ THE HEART. 187 The pulmonary artery is about two inches long, and arises from the left side of the base of the right ventri- cle, in front of the aorta, at a point corresponding to the junction of the left third costal cartilage Avith the sternum. The left auricle lies deeply behind it. It ascends obliquely upward and outAvard across the sec- ond left intercostal space near the sternum, and divides under the arch of the aorta, behind the second left cos- tal cartilage, into a right and left branch, one for each lung. The second left intercostal space is also called, therefore, the pulmonary (pulmonic) interspace. The pulmonary artery carries venous blood from the right ventricle into the lungs. The aorta arises from the upper part of the left ven- tricle behind, and a little below, the origin of the pul- monary artery, at a point on a level Avith the lower border of the left third costal cartilage, just behind the left edge of the sternum. It passes obliquely upward to the right, a little beyond the right edge of the ster- num, in the right second intercostal space, to the upper border of the right second costo-sternal articulation. A needle passed through the second intercostal space close to the right edge of the sternum would, after passing through the lung, enter the pericardium and the most prominent part of the bulge of the aorta (Gray). This second intercostal space on the right side of the sternum is therefore also called the aortic inter- space. The venous blood, emptying into the right auricle from the superior and inferior venae cavse, passes through the tricuspid orifice, into the right ven- tricle. The direction of the blood at first is toward the apex, but it suddenly curves upward to the left, and is 188 PHYSICAL DIAGNOSIS. driven by ventricular systole through the pulmonary orifice, and by the pulmonary artery it is conveyed into the lungs, for aeration. From the lungs the aerated (arterial) blood is conveyed by the pulmonary veins to the left auricle. Thence through the mitral orifice into the left A^entricle. Here the blood current, as in the right ventricle, is directed at first toward the apex, but immediately curves upward to the right, to the aortic opening, through which it is driven by ventricular sys- tole. Closure of the mitral and tricuspid valves occurs with ventricular systole, and prevents regurgitation from the ventricles into the auricles; and closure of the semilunar (sigmoid) valves guarding the pulmonary and aortic orifices occurs Avith ventricular diastole (arterial systole), to prevent regurgitation from the arteries into the ventricles. Situation of the Valves.—The pulmonary valves are situated highest up in the thorax of any of the valves of the heart. A needle pushed through the centre of junction of the left third costal cartilage with the ster- num, would penetrate about the centre of the pulmo- nary orifice. We do not, however, listen directly over this point for sounds connected with the pulmonary orifice in their loudest intensity, for the bone inter- venes ; but Ave listen in the second left, or pulmonary (pulmonic), interspace, Avhere the sounds are conveyed. The aortic valves are situated behind the pulmonary, a little lower down and to the right, just behind the left edge of the sternum on a level with the lower bor- der of the third rib. "We do not listen here through the bone for aortic sounds, but in the second right, or aortic, interspace where they are conveyed. THE HEART. 189 The mitral valves guarding the orifice betAveen the left auricle and left ventricle, are situated deeply Arithin, at a point corresponding with the upper border of the left fourth costal cartilage, near the left edge of the sternum. We do not listen here for sounds con- nected with the mitral orifice, for the right ventricle and Fig. 20.—Diagram showing Location of the Valves of the Heart, and Points of Maximum Intensity of Sounds connected with them. The triangle ab c is the area of superficial dullness. pulmonary tissue are in front of it; but Ave listen down at the apex, Avhich is made of the left A*entricle, and to this point mitral, as well as other left ventricular, sounds are conveyed. Lastly, the tricuspid valves a/e situated behind the median line of the sternum, between the fourth costo- sternal articulations. But we do not listen at this 190 PHYSICAL DIAGNOSIS. point for tricuspid sounds, but at the point where the lower border of the right ventricle crosses the sternum, about the base of the ensiform cartilage. The tricus- pid valves guard the orifice between the right auricle and right ventricle. A circle of one inch in diameter includes parts of all the valves of the healthy heart, but of course they are not in the same plane, those of the left side of the heart being behind the right. It is very important to ob- serve, also, that we do not, as a rule, listen directly over the orifices and their valves in order to best hear sounds connected wTith them, but over those points to Avhich such sounds are conveyed with greatest intensity, as follows: for pulmonary sounds, over the pulmonary (second left) interspace; for aortic sounds, over the aortic (second right) interspace; for mitral sounds, over the apex; and for tricuspid sounds, over the ensiform cartilage. Posteriorly, however, we do listen over the location of the mitral valves for the mitral regurgitant murmur, as will be fully described, as will also be the areas of transmission of various sounds. Sounds of the Heart.—There are two sounds of the heart—first and second. As the first sound is heard loudest at the apex, it is also called the apex or inferior sound of the heart; and because it occurs during sys- tole it is also called the systolic sound. The second sound is best heard at the base, and hence is sometimes called the basic or superior sound of the heart, and be- cause it occurs in diastole it is also called the diastolic sound. The first sound (inferior, apex, systolic) of the heart is a composite sound, partly due to closure of the mi- • THE HEART. 191 tral and tricuspid valves, and partly due to the apex- beat, the rush of blood, and the stretching of the chordae tendineae, to say nothing of other elements. But whatever elements take part in its production, it is necessary, and very important, to know and remem- ber that the first sound in the normal heart is synchro- nous with (occurs at the same time with) the closure of the mitral and tricuspid valves, the systole of the ventricles, and the apex-beat. The latter slightly pre- cedes, of course, the radial pulse. This first sound, though heard almost at any part of the chest in some cases, is best heard in all at the apex, as already stated, and sounds like ub, in the words tub or rub. But it does not sound like rub or tub, except when there is a praesystolic murmur, as we shall see. It is longer in duration and lower pitched than the second sound. TJie second sound (superior, basic, diastolic) of the heart, is produced by the simultaneous closure of the semilunar (sigmoid) valves of the aortic and pulmonary orifices, and is synchronous Avith diastole of the ventri- cles. It is heard best at the base of the heart, and is a shorter, sharper, and higher-pitched sound than the first, and resembles the word up, in cup. Rhythm of the heart is the repetition of all the suc- cessive phenomena which go to make up what is termed a complete circuit or revolution, each one of which is divided into a first sound, first rest, second sound, and second rest. Suppose a revolution to be ten-eighths of an inch long: the first sound would be, according to Walshe, four-eighths (half-inch), the first rest one-eighth, the 192 PHYSICAL DIAGNOSIS. second sound tAvo-eighths (quarter of an inch,), and the second rest three-eighths of an inch long, thus: ub dup Apex |--------\ • |----1 • • • • I; up tup Bask |--------1 • |—-J ■ • • • | Fig. 21.—Normal Rhythm of the Heart as heard at the Apex and Base. The heart's rhythm may be imitated by striking a table, for instance, with the palmar surface of the hand, near the wrist, for the first sound, and with the point of the finger for the second, observing the proper inter- vals for the periods of silence. In the accompanying diagram the consonants d and t are placed before the second sound, as heard at the apex and base respect- ively, merely for the sake of euphony, and not because there are really any such elements of sound in the nor- mal rhythm of the heart. Fig. 22.—Sphygmographic Tracing—Normal Heart. (Walshe.) We now proceed to consider the heart in its various abnormal conditions. Valvular Lesions of the Heart. Valvular lesions commonly give rise to enlargement of the heart. They usually result from one or more previous attacks of endocarditis. The latter disease frequently occurs in the course of acute articular rheu- matism, especially among the young, but it may also occur during an attack of diphtheria, scarlet fever, ty- phoid fever, measles, syphilis, lead poisoning, gout, PLATE VII. Fig. A. Fig.B. RV. Normal Heart. MlTRALREGURGITATION.- Showing enlargement of LA.LV & RV. FiG.C. Fig. D. R.V. ^ R-V Mitral Obstruction- Showing Aortic Obstruction*Regurgitation. enlargement of LA.& RV. Showing enlargement of LV. REFERENCE, R.A. Right Auricle. RV Right Ventricle. LA. Left---- LV. Left —— DRtWft BY H.MACOOHALD M.D.N.Y. valvular lksioxs of the heart. 193 erysipelas. Bright's disease of the kidneys, and other diseases, or it may be due to pyaemia, or surgical in- jury, or, finally, it may occur independently. In the latter case it is termed idiopathic endocarditis. Such cases are, however, very rare. Valvular lesions, es- pecially aortic insufficiency, may also be due simply to violence, as in lifting. Endocarditis during foetal life attacks the right side of the heart, because, in that state, the right side of the heart has more work to do than the left. For the same reason endocarditis attacks the left side of the heart after birth. It is extremely improbable, that, as Richardson, of London, states, the blood receives a poison in the lungs after birth, which it takes directly to the left heart, causing endocarditis of the left side of the heart; but by the time it gets back to the right heart, the poison has lost its virulence. If it be due to poison only, the right heart should be poisoned instead of the left, for the blood is supposed to be purified in the lungs, instead of being poisoned there. Endocarditis does not necessarily leave traces behind, but it usually does. It may, however, affect the valves or orifices, or, they remaining intact, it may leave some lesional traces on the Avail within the ven- tricle at some point, or points. From what has been said of foetal endocarditis, we conclude that children with valvular lesions of the tri- cuspid or pulmonary valves Avere born with them, though they may not have been discovered for several years afterward, when the changes in the heart pro- duced would make the signs more obserATable. But relative (or secondary) insufficiency of the tricuspid valves occurs in persons after thev are born. This is 13 104 PHYSICAL DIAGNOSIS. due. not to inflammation, but to enlargement of the right ventricle (dilated hypertrophy) as in general em- physema, and rhitral obstruction or regurgitation, where, owing to the dilated hypertrophy of the right ventricle, the tricuspid valves presently fail to close the orifice, on account of their being mechanically sep- arated too widely. Order of Frequency of Valvular Lesions.— All agree that mitral regurgitation is the most common. Regarding mitral obstruction authors disagree. Dr. Walshe places it last of the valvular lesions in the left heart, but I am disposed to think it is often present with regurgitation. The following is the order of fre- quency, according to Dr. Walshe: (1) Mitral regurgitation, (2) aortic obstruction, (3) aortic regurgitation, (4) mitral obstruction, (5) tricus- pid regurgitation (relative included), (6) pulmonary obstruction (most frequent inflammatory of the right heart), (7) pulmonary regurgitation (very rare), and (8) tricuspid obstruction (hardly known). I, myself, have never observed a case of pulmonary regurgitation, and tricuspid obstruction is, probably, only recognizable on post-mortem examination, if it should ever occur. Valvular lesions, instead of existing singly, may be, and often are, combined. Order of Frequency of Combinations.—According to Walshe they are as follows: (1) Mitral regurgitation and aortic obstruction, both giving rise to systolic murmurs. (2) Aortic obstruction and regurgitation. (3) Mitral regurgitation and aortic regurgitation. (4) Mitral regurgitation, aortic obstruc- tion and regurgitation. (5) Mitral obstruction and re- CARDIAC MURMURS. 195 gurgitation, and so on. From the foregoing, it will be observed that obstruction and regurgitation may, and do, exist at the same orifice. This is perfectly true, for while the orifice may be constricted, the valves may be prevented from closing by being fixed open by adhesion. As already mentioned, in a general way, valvular le- sions usually produce enlargement of the heart. It may noAv be further stated that each valvular lesion is followed by enlargement, peculiar to itself. This is of the greatest importance in making a diagnosis, and should never be lost sight of by the examiner. In speaking of enlargement, also, not only is dilatation, or hypertrophy, meant, but both—dilated hypertrophy, or hypertrophous dilatation. Now as to whether dilatation occurs first and hyper- trophy afterward, authors again disagree. It seems reasonable that the two should proceed together, until the time arrives when hypertrophy ceases. Then un- compensated dilatation alone remains. That is the usual, ineAutable tendency, if the patient lives long enough and does not die meantime of some complica- tion or fatal intercurrent disease. The particular enlargements (hypertrophous dilata- tions, or dilated hypertrophies) following the various lesions respectively, will be considered with each case of valvular disease. Cardiac Murmurs. Cardiac murmurs are adventitious sounds heard in connection with the heart in addition to, or in the place of, those sounds that exist in health. When due to organic disease they are termed organic murmurs. 196 PHYSICAL DIAGNOSIS. But when due to anaemia or perverted cardiac action they are said to be inorganic, or simply functional. Either of these two classes of murmurs may originate without or within the heart, the former being termed pericardial (exocardial), the latter endocardial mur- murs. They may also exist together or separately. ENDOCARDIAL MURMURS. Valvular lesions usually give rise to enlargement of the heart, and are generally accompanied by permanent murmurs. The latter assist greatly in making a correct diagnosis in each case, according to their location, areas of conduction and transmission, and also by their rhythm or time of occurrence with regard to the sounds of the heart. The properties, or elements, of murmur- sounds (quality, pitch, intensity, and duration) are also of some importance, particularly the quality, but these are secondary to other considerations, as Avill be seen. The loudness or feebleness of a murmur does not indi- cate the amount or gravity of the lesion giving rise to it. This is better told by the change in the form and size of the heart produced, and other considerations to be noted. The fact that a murmur is heard about the heart is no sign of itself that the heart is diseased at all, since there are many murmurs that are independent of actual cardiac disease, however closely they may imi- tate true organic cardiac murmurs. It is the business of the examiner to distinguish between them, as can usually be done by careful and intelligent observation. There are other considerations, therefore, far more im- portant than the mere fact of the presence of a mur- mur in connection with the examination of the heart. MITRAL MURMURS. 197 Individual murmurs usually have certain points of maximum intensity, as well as areas of convection, con- duction, or transmission, pro Added they are of the aver- age intensity. But it sometimes happens that any murmur may be so loud as to be heard all over the body, AAdiereas that Avhich is usually the loudest mur- mur may be, or become, so feeble as to be heard with difficulty, if at all, at its point of maximum intensity. We will now consider the murmurs and other physical signs characteristic of valvular lesions, in the regular order of their occurrence. Murmurs heard loudest at the Apex.—Mitral Murmurs. We have already shown that there are four points on the front of the chest wall where the various heart- sounds and murmurs may be heard respectively in their maximum intensity. Mitral murmurs, for instance, are heard loudest at the apex, tricuspid murmurs over the ensiform cartilage, aortic murmurs usually over the aortic interspace, and pulmonary murmurs over the pulmonary interspace. Omitting pericardial and pleuro-cardial friction sounds, to be presently considered, there are five mur- murs heard only, or loudest, at the apex, and are con- sequently referable to the mitral orifice and left ventri- cle. Four of these murmurs are systolic in time, and one presystolic. The four systolic murmurs are the mitral regurgitant, intra-ventricular, dynamic, and cardio-respiratory. Of these, the mitral regurgitant and intra-ventricular murmurs are organic, the dynamic and cardio-respiratory being inorganic, or functional. 198 PHYSICAL DIAGNOSIS. The prsesystolic murmur is also organic, being due to mitral obstruction. Of these five mitral apex murmurs, therefore, three are organic and two are inorganic, or functional. Compare the following table: Mitral or Apex Murmurs Systolic Mitral Regurgitant Intra-Ventricular (Muscular). Dynamic -( Neurotie origin. dynamic ( Due to Angemia Cardio-respiratory. Diastolic (presystolic). . Mitral Obstructive. Mitral Regurgitation. Mitral regurgitation (reflux, insufficiency) is the most frequent of all valvular lesions of the heart. It is usu- ally a primary result of endocarditis, although it may be relative or secondary to aortic regurgitation, or even marked aortic obstruction, which might lead to such dilated hypertrophy of the left ventricle that the mitral valves would become insufficient. Such cases are, how- ever, comparatiAely rare, and, as already said, it is nearly always the direct result of endocarditis affecting the mitral valves themselves. Mitral regurgitation leads to the folioAving change in the form of the normal heart: (1) enlargement (dilated hypertrophy) of the left auricle; (2) enlargement of the left ventricle, and (3) enlargement of the right ventricle. It is easy to understand why the left auricle and right ventricle become enlarged. The blood regurgi- tating back into the left auricle during ventricular sys- tole, instead of going on through the aortic orifice, gives the left auricle increased work to do, and it nec- essarily becomes enlarged (dilated hypertrophy). In the same way, the blood forced back on the lungs gives the right ventricle more work to do in driving blood MITRAL REGURGITATION. 199 through the lungs. But just Avhy the left ventricle be- comes enlarged also, the mechanism is not so clear. As Walshe says, the enlargement of the left ventricle in these cases "is plainly supplemental; though it is difficult to see hoAv a condition that makes regurgita- tion more forcible, can tend to balance the evils arising from it." In regard to this point, my attention Avas called by my clinical assistant, Dr. William C. Rives, to Vierordt, of Leipsic, avIio, says truly, that " the left ventricle first becomes dilated from having blood under abnormally high pressure, and increased in quantity, driven into it during its diastole by the enlarged left auricle. The ventricle then becomes hypertrophied in order to dispose of this extra quantity of blood, partly forward into the aorta, and partly backward into the left auricle." That seems to be the correct vieAv of the matter, but whatever theories there may be about it, one thing is certain, and that is that in mitral regurgi- tation the left ventricle becomes enlarged in some way from overwork. Another point is not to be overlooked. The second sound of the heart is louder, usually, than normal over both the pulmonary and aortic interspaces (second in- terspaces on the left and right side of the sternum re- spectively). But as heard over the pulmonary inter- space it is often someAvhat louder (accentuated) than that heard over the aortic interspace, the latter being the weaker of the two, owing to regurgitation at the mitral orifice. The reason for this accentuation of the second sound of the heart over the pulmonary inter- space is obvious. Owing to enlargement (dilated hy- 200 PHYSICAL DIAGNOSIS. pertrophy) of the right ventricle, the blood is thrown with increased force into the pulmonary artery, and owing to increased tension in that \ressel, the valves close more forcibly, until relati\Te tricuspid insufficiency occurs. This phenomenon is still more marked in mi- tral obstruction, as Ave shall see. The radial pulse will be found also in mitral regur- gitation to be irregular in size, sometimes large, some- times small, and generally compressible. It may also intermit, but irregular rhythm is not peculiar to any valvular lesion, as we shall see when speaking of ir- regular rhythm in general (p. 264). Fig. 23.—Diagram of Sphygmographic Tracing of Pulse in Mitral Regurgitation. (Walshe.) In the early existence of mitral regurgitation, before enlargement has had time to occur, as in other lesions, or toward the end, when there are dilation and feeble- ness of action, with perhaps pulmonary infarctions and other complications that are likely to arise, the phys- ical signs are not usually so clear. But in general they are as follows: Inspection.—The apex-beat is usually visible, owing to its force from enlargement, and is observed to be displaced downward and outside of the mammillary line, indicating enlargement of the left ventricle. This is of the utmost importance in the diagnosis of this disease. The heart's impulse is usually seen to be more MITRAL REGURGITATION. 201 forcible than normal. Sometimes, in persons Avith thin chest walls, left auricular impulse is observed in the pulmonary (left second) interspace, and will be one of two kinds: (1) systolic, if communicated to the auricle from the ventricle; or (2) prsesystolic (auriculo-sys- tolic), if due to hypertrophy of the auricle. As the case progresses, jugular pulsation on the right side of the neck may be observed, due to relative tricus- Fig. 24.—Diagram of the Heart in Mitral Regurgitation. Left Ventricle, Left Auricle, and Right Ventricle are seen to be Enlarged—compare normal heart. pid insufficiency from enlargement of the right ven- tricle. Palpation.—-The apex-beat will be felt downward and outward away from its normal position, and the heart's impulse will be felt to be generally increased in force. Pulsation near the ensiform cartilage is some- times seen and felt, and is due to enlargement and forcible action of the right ventricle. The latter sign is not so well marked here as in general emphysema, when the right ventricle alone is enlarged, and the 202 PHYSICAL DIAGNOSIS. whole heart is also pushed down by the increased vol- ume of the lungs. Purring Thrill.—In some cases of mitral regurgita- tion, a systolic purring thrill is distinctly felt, especially if the palm of the hand is placed very lightly over the lower prsecordium. It is usually felt in the fourth in- terspace, on or near the mammillary line. Purring thrill here, as in other cases of valvular disease, depends for its production upon three abnormal factors: (1) in- creased capacity of the heart, (2) increased propelling force, and (3) an abnormal orifice. It will not be pro- duced by increased force and an abnormal orifice alone. Besides hypertrophy, there must also be enlargement of the cavity of the heart, with a certain amount of thinness of its walls, as seen after dilatation has oc- curred to some extent. With increased capacity and force, and a stream of blood driven through a button- hole orifice, for instance, thrill is almost certain to oc- cur. But it may also be due in some instances, I think, to a ribbon-like vegetation, with one end free and vi- brating in the course of the blood current. However this may be, thrill is not a constant phenomenon. It will disappear from changes in the orifice, or after hy- pertrophy ceases to compensate, and the walls of the heart become weak. The disappearance of thrill, there- fore, after it has once been present, would seem to be not always a favorable sign. Percussion.—The areas of both deep and superficial dullness are enlarged, the latter especially, downward and to the left. Dullness over the left auricle, especi- ally among those with thin chest walls, is more marked MITRAL REG URGITATION. 203 and extends beyond the normal limits already men- tioned. Auscultation.—A blowing systolic murmur is heard, but loudest at the apex, for reasons already given (p. 189), and the second sound of the heart is usually more or less accentuated over the pulmonary (left second) interspace, since the enlarged right ventricle would cause greater tension in the pulmonary artery, with consequently more forcible closure of the pulmonary valves than Avould be the case in the aorta. After tri- cuspid insufficiency occurs, this accentuation is not so marked. This murmur has various other names, such as mitral systolic, mitral indirect, and mitral insuffi- cient. The mitral regurgitant (systolic, indirect, insuffi- cient) murmur is, as already stated, usually blowing in quality, and occurs Avith, or takes the place of, the first (systolic) sound of the heart. It also occurs, therefore, with the apex-beat. By paying attention to the last named point, the time of the murmur can usually be fixed, even if the heart's rhythm be irregu- lar. The following diagram represents the mitral re- gurgitant murmur: u-ph dup I-------II---1- • I Musical Murmurs.—Sometimes these and other murmurs are musical, instead of possessing a blowing, blubbering, rough, or other quality. This quality is of no particular import, but simply indicates that " prom- inent spiculse or fibrinous particles, of vibratile charac- ter, project into the current, or else that rigid vibratile edges bound a narrow, chink-like opening" (Walshe). 204 PHYSICAL DIAGNOSIS. Area of Transmission.—-If the murmur be a very feeble one, as may occur in cases of long standing, with marked dilatation of the heart and feebleness of its action, especially if the chest walls be thick and fleshy, it may be heard only at the apex, and then with diffi- culty. But if it be heard anywhere it will usually be at the apex, which is composed of the left ventricle, the right ventricle being in front of the body of the left. But if the mitral regurgitant murmur be a very loud one, especially if it be musical, as sometimes hap- pens Avith any murmur, as already described, then it may not only be heard at the apex, but all over the chest. The average mitral regurgitant murmur may, however, besides being heard loudest at the apex, be also heard over three other localities: (1) posteriorly, between the inferior angle of the scapula and body of the eighth dorsal vertebra, or thereabouts; (2) along the left lateral base of the chest; and (3) over the left auri- cle and to the left of it. In the first case, we are listen- ing directly over the site of the mitral valves, and this is perhaps the only case in which Ave listen directly over the site of the valves of the heart for sounds in connection with them. Though usually heard behind at that point, it is not necessarily heard there. The murmur may be too weak, as already stated; or the patient may have an emphysematous lung interposed; or, as in the case of a lady from Canada, whom I exam- ined, the murmur was distinctly heard behind, until accidentally falling ill with pleurisy with effusion, the murmur disappeared posteriorly, and though she made a fair recovery from the pleurisy, the murmur never again returned to that point. Enlarged bronchial MITRAL REGURGITATION. 205 glands and other acoustic impediments evidently might prevent such a murmur from being heard behind. (2) Besides hearing the mitral regurgitant murmur at the heart's apex, and posteriorly over the mitral valves, it is sometimes, not always, transmitted from the apex along the ribs to the left; but it is not so transmitted to the point behind that has been men- tioned. Why is it that this murmur is sometimes heard transmitted along the ribs to the left, and some- times not? There are tAvo classes of causes. First and chiefly, if the right ventricle becomes very much en- larged, it acts as a Avedge between the left ventricle and the chest wall, and pushes the left ventricle back so far that it is impossible for the ribs to take up the sound. In these cases it Avill be very distinct posteriorly, not so much as is usual at the apex, and not heard at all to the left. Such conditions wTould indicate a very large right ventricle. The second class of causes would be pleurisy with effusion, thickened pleura, emphysema, or some other acoustic impediment. (3) Lastly, if the left auricle be greatly enlarged and the murmur be communicated to it, the murmur may be heard in the third and even second, interspace on the left of the sternum, over the site of the left auricle, and thence transmitted to the left axilla. Diagnosis of Mitral Regurgitation.—-If the exist- ence of mitral regurgitant murmur can be established, the diagnosis is complete. But the extent of the lesion here, as elsewhere, cannot be accurately estimated by the properties of the murmur, but by the amount of cardiac enlargement produced. Pericardial (exo-cardial) friction sounds are super- 206 PHYSICAL DIAGNOSIS. ficial, rubbing, churning, grazing or creaking in quality, are not transmitted beyond the limits of the heart, change in intensity Avith position of the patient in leaning forward or backward, or by pressure with the stethoscope, and have no fixed relation in time to the heart-sounds. Pleuro-cardial, or pleuritic friction sounds, near by, may be kept up by the heart's impulse, and do not necessarily cease upon holding the breath, but are easily distinguished by their quality and the circumscribed area to which they are limited. There remain three other systolic apex murmurs, which may very closely imitate the mitral regurgitant, and it is necessary to know how to distinguish them. They are (1) intra- ventricular murmurs, termed also by Flint and others the mitral systolic non-regurgitant murmur, (2) dy- namic, and (3) cardio-respiratory murmurs. Intra-ven- tricular murmurs are organic, whereas the dynamic and cardio-respiratory murmurs are inorganic, or func- tional. (1) Intra-ventricular murmurs, when they exist, are usually so feeble that they may be heard at the apex only, or base. In either case they are always systolic, and due to lesions somewhere Avithin the ven- tricle, instead of affecting the orifices or valves. Some of the intra-ventricular murmurs are heard only at the apex, others at the base, others again more or less over the whole heart, They are due to roughening of the ventricular endocardium, misattachment of a chord, fibrinous shreds across the blood current, thickening and roughening of chords, twisting of columnse came*, inflammatory vegetations on the wall of the ventricle, MITRAL REGURGITATION. 207 and cardiac ventricular aneurism. In the latter case the ventricle is enlarged, and it may be impossible to make a diagnosis; but in all other cases of intra-ven- tricular murmurs the diagnosis is easy, since the cause of their production is not a cause for enlargement or perceptible interference Avith the circulation. The mur- murs of this variety are usually weak, and for that reason only are restricted to a spot over the apex, and are not transmitted anywhere, or heard posteriorly. The prognosis in the two cases would be entirely differ- ent. For Avhereas mitral regurgitation is usually fatal in course of time, OAving to pulmonary congestion, sec- ondary tricuspid insufficiency, hemorrhagic infarctions of the lungs, and cardiac dropsy, intra-ventricular lesions may be of little or no importance, though suffi- cient to produce a murmur. (2) Dynamic Murmurs.—These murmurs are due to some perverted action of the heart, and are observed sometimes in choreic subjects. The heart is a stri- ated muscle, and hence subject to choreic, irregular movements, like other striated muscles. Conse- quently, during systole, some of the columnse carnese tAvitch and pull the mitral valves open, causing a faint murmur, which is only audible at the apex. Not only so, but it is not necessarily associated with left ven- tricular, or other cardiac enlargement, and, moreover, the dynamic murmur from this cause is very incon- stant, dependent, as it is, upon choreic movements which are absolutely uncertain. It is sometimes found, also, in those who are nervous from other causes, as among hysterical women, tobacco smokers, and rarely among those nervous from abuse of alcohol. It is also 208 PHYSICAL DIAGNOSIS. heard sometimes in epileptic subjects. But in all such cases the murmur is weak, and hence limited to the apex usually, is not necessarily attended with enlarge- ment of the heart, and, above all, is inconstant. Dynamic murmurs, instead of being of neurotic ori- gin, may also be due to anaemia. Xo truly uremic murmur is ever heard at the apex, unless produced by heart clot, which is very rare. But haemic murmurs due to the watery condition of the blood are heard only at the base and over the pulmonary interspace, unless caught up by the aorta, and are caused by watery venous blood, as Avill be considered fully when speak- ing of basic murmurs. That anaemia does give rise indirectly, or dynamically, to a systolic apex murmur, besides causing all cardiac murmurs to be louder than they would be otherwise, by increasing vibratility of tissues, cannot be denied. But such a systolic apex murmur should not, strictly speaking, be termed an anaemic murmur, but a dynamic murmur due to anae- mia. The mode of its production is as follows: The heart becomes flabby, and the papillary muscles become weak from fatty degeneration, according to Guttmann and others, thus allowing the mitral valves to recoil too far, so as to cause a slight backward leakage; or else temporary dilatation from anaemia may allow a vortiginous (eddying) movement of the blood within the ventricle, or misdirection of its current, sufficient to give rise to a systolic murmur. The masturbator's systolic apex rnuimur, described by Walshe, and attributed by him to nervous in- fluence, may also be due to the anaemic condition of the patient. MITRAL OBSTRUCTION. 209 By curing such patients of their anaemia by means of iron and nutritious diet, these murmurs will disap- pear, it is true, but even then they are not to be regarded as true haemic murmurs, though Aenous hum be also present, but as dynamic murmurs due to the anremic condition. The venous hum in the neck, with which they are usually associated, will be fully considered in connection Avith basic heart murmurs. (3) Cardio-respiratory murmurs are always sys- tolic, and heard at the end of a full inspiration, as the heart's impulse may force air out of some vesicles or cavities near by, Avith a sound that sometimes imitates the cardiac systolic murmur; or the respiratory mur- mur itself may sound like a heart murmur during sys- tole. Simply have the patient hold the breath after expiration, and the imitation heart murmur at once ceases. It is ahvays a good rule, during auscultation of the heart, to have the patient hold the breath at least once for each point examined. Mitral Obstruction. Mitral obstruction (constriction, stenosis) is said by some authors to be idiopathic, or congenital, and not traceable to previous rheumatic endocarditis, or other disease. In these cases it chiefly affects women and children. But it not infrequently does result from rheumatic endocarditis in the young of both sexes. Aortic, rather than mitral lesions, are apt to occur after middle life. Mitral obstruction leads to enlargement (1) of the left auricle, and (2) of the right ventricle, and by en- 14 210 physical diagnosis. largement is meant here, as elsewhere, dilated hyper- trophy. The difference in enlargement, therefore, in mitral obstruction and regurgitation, is the left ventricle. In obstruction it is not only not enlarged, but, on the con- trary, somewhat smaller than normal, from diminished volume of blood entering it; but in mitral regurgita- tion it is enlarged, as already mentioned. In mitral obstruction the left auricle becomes enlarged, from the Fig. 25.—Enlargement of the Left Auricle and Right A'entricle in Mitral Obstruction. effort to drive blood through an obstructed orifice, and the blood, being prevented from leaving the lungs freely, the right ventricle becomes enlarged from the extra task of driving the blood through them. The fact that the left ventricle is not enlarged in mitral ob- struction is of the greatest importance in making a correct diagnosis. The second sound of the heart is usually accentuated in the pulmonary interspace, for reasons already given (p. 199), and weakened in the aortic interspace, for the reason that the left ventricle MITRAL OBSTRUCTION. 211 is somewhat atrophied, with consequent diminished tension in the aorta. The difference is more marked here than in mitral regurgitation. In addition to this accentuation, the second sound is also reduplicated at the base in about one third of all cases, as the pulmonary valves close not only more forcibly than the aortic, due to increased tension in the pulmonary artery, from enlargement of the right ventricle, but also earlier than the aortic valves, for the same reason. The radial pulse is not noticeably affected in mitral obstruction, nor is the heart's rhythm necessarily dis- turbed, but is generally regular. The physical signs of mitral obstruction are : Inspection.—The apex-beat, if seen at all, will usu- ally be within the mammillary line, as the left ventricle is not enlarged. It may be pushed out a little, how- ever, by enlargement of the right ventricle. The apex- beat Avill be observed to be not more forcible, perhaps, than in health. But there may be observed in those having thin chest walls a left auricular systolic im- pulse over the left third interspace, owing to enlarge- ment of the left auricle. This impulse immediately precedes the apex-beat, and with regard to the latter is prsesystolic. Pulsation of the enlarged right ventricle will not be observed usually, unless the heart be lowered from some cause, Avhen it will be observed near the end of the ensiform cartilage, as in general vesicular em- physema. Mitral obstruction occurring in children appears to be not infrequently associated with the so-called pigeon- breast. The flattening is especially well-marked in 212 physical diagnosis. the lower praecordial region on the left of the sternum. Whether this is mere coincidence in a certain number of cases, or due to atrophy of the left ventricle, or to lack of nutrition in general, from imperfect cardiac function, is not exactly known. As the case progresses and relative insufficiency of the tricuspid valves occurs, due to excessive dilated hypertrophy of the right ventricle, jugular pulsation on the right side of the neck, and afterward also on the left side, will be observed. Then follows cardiac dropsy, commencing in the feet. Palpation.—The apex-beat may be felt to be not markedly displaced or increased, and there may be some pulsation near the end of the ensiform cartilage, due to enlargement of the right ventricle, if the heart be sufficiently lowered. But Avhat is most distinctive is the praesystolic thrill often felt about the left fourth interspace. By placing the palm of the hand lightly over the part, the thrill may be felt immediately before the apex-beat, and it is characteristic of mitral ob- struction, though not always present. It is due to the forcible contraction of the enlarged left auricle in its endeavor to force the blood through an obstructed ori- fice. The general mode of production is the same here as in regurgitation (which see, p. 202) and elsewhere, and, like that, is not permanent. Auricular impulse, praesystolic in time Avith regard to trie apex-beat, is sometimes felt. Percussion.—The area of dullness over the left auri- cle and right ventricle is enlarged, but Avhat is knoAvn as the superficial area of cardiac dullness is not so much enlarged as in mitral regurgitation, since in mi- MITRAL OBSTRUCTION. 213 tral obstruction the left ventricle is not enlarged, and a small part of the superficial area of dullness is nor- mally formed of the left ventricle. Auscultation.—A blubbering praesystolic murmur, like vibrating the letter r Avith the tongue, or vibra- ting the flaccid lips by blowing forcibly (expiration) through them while they are closed (Flint), is usually heard loudest at the apex, and limited to that region, though it may be conveyed up to the fourth interspace by the blood current, and in some rare cases is so loud as to be heard behind—in fact, all over the chest. The second sound of the heart is usually accentuated over the pulmonary interspace. The murmur has various names, such as praesystolic, direct, constrictive, stenotic, and so on. As the murmur in regurgitation is termed regurgitant, so in obstruction it may be called obstruct- ant or obstructive. The mitral obstructive (direct, stenotic, constrictive, presystolic) murmur is usually blubbering in quality, as already stated, and unless it is blubbering it is usu- ally absent altogether, for this is the only organic heart murmur that may appear and disappear. All other organic heart murmurs are permanent. The reason why it is blubbering, as Flint explains, is because of the vibration of the free edges of the valves, the orifice between them being narrow and bottonhole-like. It is like throwing the flaccid lips into vibration, by forcibly expelling the breath while the mouth is gently closed, which, as Flint truly states, " represents not only the characteristic quality of the murmur, but the mode of its production." When the edges of the mitral valves, instead of being flaccid, become fixed from inflamma- 214 PHYSICAL DIAGNOSIS. tion, the murmur ceases and regurgitation follows. It also ceases if the circulation is feeble, but in that case it may return with thrill on exercising. The follow- ing diagram represents the mitral obstructive mur- mur: r-r-ub dup I-------II---1----I This blubbering murmur at the apex, according to Flint, is sometimes due to aortic regurgitation, causing a secondary, or relative, mitral obstruction. In this case the edges of the healthy mitral valves are thrown into vibration slightly by the blood from the left auri- cle, while they are being closed by the backward press- ure of blood due to aortic regurgitation. This is differ- ent from the aortic diastolic regurgitant murmur that is sometimes transmitted faintly to the apex. The mitral obstructive murmur is never due to anae- mia, or any other functional or inorganic cause. It is always an organic murmur, due usually to mitral ob- struction primarily, and rarely to aortic regurgitation, which causes a secondary, or relative mitral obstruction. The idea that there is no such thing, in fact, as a mitral obstructive (praesystolic, direct, stenotic, constrictive) murmur, but that it is really regurgitant, originated, it appears, with Barclay. Dickinson and others have followed Barclay in this notion, but Gairdner, Balfour, Bristowe, Flint, Loomis, and many others have demon- strated quite clearly that Barclay and his followers were mistaken. For according to Bristowe, for in- stance, if the mitral obstructive (praesystolic, direct, stenotic, constrictive) murmur is really regurgitant, due to prolonged contraction of the ventricle, then in MITRAL OBSTRUCTION. 21.r) aortic obstruction there ought also to be a praesystolic aortic obstructive murmur, a clear case of red actio ad absurdum. Moreover, post-mortem examination sets the whole matter at rest in favor of the mitral prae- systolic (obstructive) murmur. This murmur was pointed out, in 1841, by Gendrin, of Paris, avIio called it praesystolic. It was first claimed to be due to mitral obstruction by Fauvel, of Paris, in 1843. In 1861, Gairdner, of Glasgow, named it left auriculo systolic murmur. It is also sometimes called post-diastolic. Guttmann calls it a diastolic murmur. Flint, however, makes the mitral diastolic murmur to be different from the mitral praesystolic murmur proper, and says that it is caused by the rush of blood through and over abnormal structures before the auricle con- tracts. It is simply a part of the same murmur, and may be said to be a distinction without a difference. It is simply the first part of a prolonged mitral ob- structive murmur, AAdiich occupies the whole of diastole instead of being merely praesystolic. Area of Transmission.—The mitral obstructive murmur is usually limited to the region of the apex, or conveyed up the ventricle to the fourth interspace, unless it is very loud, when, in some cases, it may also be heard posteriorly. Why is not this murmur usu- ally heard posteriorly at a point between the inferior angle of the scapula and body of the seventh or eighth dorsal vertebra, as in the case of mitral regurgitation? Simply because the murmur, being made in the direc- tion of the blood current, and not against it, is not held at the mitral orifice long enough to be heard, but is at once carried down to the apex, wdiere it is heard. On 216 PHYSICAL DIAGNOSIS. the other hand, the mitral regurgitant murmur is con- veyed backward toward the ear, when auscultating posteriorly, and it is held there long enough to be heard. Why is not the mitral obstructive (praesystolic, direct, stenotic, constrictive) murmur transmitted along the chest walls to the left, as in the case of mitral re- gurgitant murmur? Simply because in mitral obstruc- tion, the left ventricle is not enlarged and the right ventricle, which does become enlarged, and is in front of the left, wedges off the latter from the chest walls, so that it does not come near enough for them to pick up the sound of the murmur. The murmur also is praesystolic, and occurs before the apex could reach the chest walls, even if the enlarged right ventricle were not between the apex and the chest walls. Diagnosis.—Mitral obstructive murmur would not be mistaken for mitral regurgitant, but that sometimes the cardiac rhythm is so irregular, and the sounds may so nearly resemble each other, that it is difficult to tell the first sound from the second. In these cases, as well as where the rhythm is perfectly regular, the changes effected in the form and size of the heart are not to be overlooked. For besides the fact that mitral obstruct- ive murmur is praesystolic in time, limited to the apex, and blubbering in quality, while mitral regur- gitant is systolic in time, usually heard behind, as Avell as at the apex, sometimes transmitted along the left lateral base of the chest, and blowing in quality, it must not be forgotten that in mitral obstruction the left ventricle is not enlarged, Avhile in mitral regurgi- tation it is enlarged, with corresponding displacement of the apex-beat downward and outward, usually out- MITRAL REGURGITATION AND OBSTRUCTION. 217 side of the mammillary line. Aortic regurgitant sounds, though sometimes conveyed to the apex, are attended with enlarged left ventricle, besides being purely diastolic in time, and are not heard loudest at the apex. A rather faint mitral praesystolic murmur may some- times be heard, due to relative or secondary obstruc- tion to the onward flow of blood in some rare cases of aortic regurgitation. The mitral murmur in such cases is not usually attended with appreciable enlargement of the right ventricle, and accentuation of the second sound in the pulmonary interspace, but there is great enlargement of the left ventricle which does not occur in mitral obstruction. Mitral Regurgitation and Obstruction. This combination of lesions not infrequently exists, for it is perfectly clear that while the mitral ori- fice is constricted the \Talves may be prevented from closure by adhesion. In such a case there would be both regurgitation and obstruction at the same orifice. Usually, there is but one murmur in these cases, the mitral regurgitant, since, as already remarked, the mi- tral obstructive murmur usually ceases Avhen the free edges of the valves become fixed and cannot vibrate. Sometimes, hoAveA^er, both murmurs are heard, the prae- systolic and systolic—the former at the apex and trans- mitted upward with the blood current toward the fourth interspace, the latter also at the apex, but trans- mitted around toward the left, and sometimes heard posteriorly. The left ventricle, the left auricle, and 218 PHYSICAL DIAGNOSIS. right ventricle are enlarged, and the second sound is more or less accentuated in the pulmonary interspace. Tricuspid Regurgitation. Tricuspid murmurs are usually so feeble that they are audible, as a rule, only over the ensiform cartilage. And inasmuch as the tricuspid obstruction (praesys- tolic, direct, stenotic, constrictive) murmur is so rare that it may practically be thrown out altogether, there remains only the tricuspid regurgitant murmur to be sought for in connection with suspected tricuspid lesions. Tricuspid regurgitation (reflux, insufficiency) is commonly secondary or relative to enlargement (di- lated hypertrophy) of the right ventricle, due to mitral regurgitation or obstruction, or to general vesicular emphysema. In all of these cases, as we have seen, the right ventricle in time becomes enlarged from the extra work put upon it in order to drive forward an impeded pulmonary circulation. After a while, in some of these cases, not all, the tricuspid \ralves become so widely separated that tricuspid regurgitation with jugular pulsation and cardiac dropsy result. Primary or actual tricuspid regurgitation sometimes is met with, and then it is the result of foetal endo- carditis, as has already been referred to. It leads to enlargement of the right ventricle. The tricuspid re- gurgitant murmur is systolic in time aad bloAving in quality, but is usually so feeble that, as has already been stated, it is confined to a small area over the ensi- form cartilage. Sometimes the aortic regurgitant mur- mur is so transmitted down the sternum that it is TRICUSPID REGURGITATION. 219 heard only over the ensiform cartilage, but tricuspid regurgitant murmur is systolic, Avhile aortic regurgitant is diastolic in time. The latter is also accompanied by enlargement of the left ventricle and other signs to be described. The mitral regurgitant murmur is systolic in time, but it is heard loudest at the apex and trans- mitted to the left, besides being usually heard pos- teriorly. It sometimes exists Avith tricuspid regurgita- tion, so that the tAvo murmurs run into each other. In this case the other signs of tricuspid regurgitation are to be considered, such as jugular pulsation, cyanosis, cardiac dropsy and pulmonary cedema. The character of the radial pulse is not affected by valvular disturb- ances of the right side of the heart. The rhythm is, however, sometimes irregular, especially in general vesicular emphysema (p. 266). There are no intra-ven- tricular, dynamic, or cardio-respiratory murmurs to be considered usually in differentiating the tricuspid re- gurgitant murmur. Should any such case arise, the same rules hold good in regard to them, and peri- cardial, or pleuro-cardial, friction sounds, as in mitral regurgitation, to which the reader is referred. Jugular Pulsation.—-This phenomenon was first observed by Lancisi, of Rome, in 1728. It is usually systolic, but is sometimes also praesystolic. Systolic jugular pulsation is accounted for as follows: In tricuspid insufficiency from any cause, venous blood is forced back during systole through the tricuspid orifice into the right auricle, and against the column of blood in the venae cavae. The superior vena cava, right vena innominata, and right internal jugular vein, form a sort of consolidated, straight, trunk line, so to speak, 220 PHYSICAL DIAGNOSIS. and there is no valve in the way until we come to the lower end of the internal jugular vein, just at the root of the neck. Consequently, this systolic pulsation of venous blood always first occurs on the right side at the root of the neck. After that valve gives way, the pulsation extends up to the second valve, and finally Fig. 26.—Jugular Pulsation. Position and Relation of the Veins of the Neck. may reach the angle of the jaw. Meantime, it begins to appear also on the left side, but not so forcibly, as the backward shock has to go round a curve. In time, all the veins about the neck may participate in this curious phenomenon. Slight systolic jugular pulsation may, according to Bamberger, sometimes be observed on the right side, at the root of the neck, even when the tricuspid valves are not actually insufficient. In right ventricular enlargement a slight backward shock AORTIC MURMURS. 221 may even be imparted through the tricuspid valves themselves. Praesystolic jugular pulsation is sometimes seen in cases of right auricular overflow, during contraction of the right auricle, and just before systole of the right ventricle, but it is rare. It sometimes occurs in tricus- pid insufficiency, but tricuspid obstruction would also favor its production. Tricuspid Obstruction. This lesion is very rare, and even when it is present there is usually no murmur heard with it. This is probably owing to the feebleness of the venous blood current as compared with the arterial, and the weak- ness of the right auricle as compared with the left. Usually, it is only on post-mortem examination that tricuspid obstruction is found to have existed. Should there be any murmur present it would be presystolic, as in the case of mitral obstruction, but the murmur Avould be limited to the region of the en- siform cartilage. The right auricle would be likely to become enlarged, but no particular change in the form and size of the heart is known. The radial pulse would be unaffected. Murmurs heard loudest at the base. Aortic Murmurs. We have seen that we listen over the apex and ensi- form cartilage, respectively, in order to hear mitral and tricuspid murmurs in their maximum intensity. We 222 physical diagnosis. now come to a third point on the front of the chest walls, which is the aortic interspace, or the right second interspace, being that between the second and third costal cartilages, on the right of the sternum. Here we listen for murmurs referable to the aortic orifice in their maximum intensity (pp. 187, 188). Omitting pericardial and pleuro-cardial friction sounds, already described under mitral regurgitation (p. 198), there are seven basic murmurs heard only, or loudest, over the aortic interspace, and are consequently referable to the aortic orifice, the aorta itself, or the left ventricle. Five of these murmurs are systolic in time, and two diastolic. The five systolic murmurs are the aortic obstructive, intra-aortal, intra-ventricu- lar, dynamic, and cardio-respiratory. Of these, the aortic obstructive, intra-arterial, and intra-ventricular murmurs are organic, the dynamic and cardio-respira- tory being inorganic, or functional. The diastolic mur- murs in this case, as in others, are always organic. Of these seven aortic basic murmurs, therefore, five are organic and twTo are inorganic, or functional. Compare the following table: Aortic Basic Murmurs Systolic Aortic Obstructive. Intra-Aortal (aortic non-obstructive). Intra-Ventricular (Muscular). Dynannc j i^lSS Cardio-respiratory. jy , r $ Aortic Regurgitant. diastolic -^ intra-Aortal (aortic non-regurgitant). By comparing this table with that of mitral apex murmurs (p. 198), we have here, in addition, the intra- arterial murmurs. We also have the aortic systolic AORTIC OBSTRUCTION. 223 obstructive murmur in place of the mitral systolic re- gurgitant murmur, and the aortic diastolic regurgitant instead of the mitral praesystolic (or diastolic, as it is called by Guttmann) obstructive murmur. In other words, the mitral regurgitant and aortic obstructive murmurs are systolic, while the mitral obstructive and aortic regurgitant are chiefly diastolic in time. Aortic Obstruction. Aortic obstruction (constriction, stenosis) is the cause of enlargement of only the left ventricle, as a rule. It is the least harmful of all valvular lesions. The reason for enlargement of the left ventricle in this disease is obAuous, as it has more work to do to drive blood through the obstructed aortic orifice, and the degree of enlargement Avill be in proportion to the amount of ob- struction. The second sound over the pulmonary inter- space remains normal, as the right ventricle is not af- fected, but the second sound over the aortic interspace is weak, owing to the obstruction and diminished amount of blood thrown into the aorta. The first sound at the apex may be strong. The radial pulse is regular, as a rule, but in marked cases it is small, hard, and rigid. The physical signs are: Inspection.—The apex-beat is displaced doAvnward and outward from its normal locality, in proportion to enlargement of the left ventricle. The cardiac impulse is usually seen to be more forcible than normal. Palpation.—The apex-beat is felt to be somewhat displaced downward and outward, and to be increased in force. Basic systolic thrill is sometimes felt, but 224 PHYSICAL DIAGNOSIS. only in those cases where dilated hypertrophy is well marked. Percussion.— The area of dullness is enlarged, es- pecially the area of superficial dullness, and the quality is more markedly dull, of course, in proportion to the amount of cardiac enlargement and displacement of pulmonary tissue. Auscultation.—The first sound is usually normal or louder, but the second sound over the aortic interspace Fig. 27.—Aortic Obstruction and Regurgitation, showing Enlargement of Left Ventricle. is weak, for reasons already given. A systolic basic murmur is heard, which has various names, such as aortic direct, obstructive, stenotic, and so on. This aortic obstructive (direct, stenotic, constrictive, sys- tolic) murmur is heard loudest, not directly over the site of the aortic valves (p. 188), but over the aortic or second interspace near the right edge of the sternum, where the most prominent part of the bulge of the aorta lies (Gray). The murmur is systolic in time, like the mitral regurgitant, and occurs with the first sound, AORTIC OBSTRUCTION. 225 or rather just before the second. It may be represented by the following diagram: ud ph- tup I " ' II---1- I Area of Transmission.—Though heard loudest over the aortic interspace, the murmur, if loud enough, and is caught up by the sternum, may be transmitted along that bone from one end of it to the other. Besides this, it is often conveyed by the arteries into the neck, and sometimes may even be heard behind over the aorta on the left side of the spinal column. If it be loud enough, as Avhen it is musical sometimes, it may be heard all OATer the chest. In rare cases it is heard equally loudly over the pulmonary interspace, simply because the pulmonary artery takes up the sound from the aorta, owing to their unusual proximity. But if the murmur is ATery feeble it will with difficulty be heard, even at the aortic interspace as sometimes hap. pens. The loudness or feebleness of the murmur Avill give little or no true idea of the real extent of the lesion. The murmur is rendered more distinct by walking rapidly, or in case there be co-existing anae- mia. In all cases of doubt as to whether a murmur be present or not it is well to have the patient walk briskly up and down the room several times, and then auscul- tate immediately upon stopping. Sometimes, however, a purely dynamic murmur may be produced by this means. Diagnosis of Aortic Obstruction.—There are other systolic murmurs to be heard at the base that very closely resemble the true aortic obstructive, just as there are systolic murmurs at the apex to imitate the 15 226 PHYSICAL DIAGNOSIS. true mitral regurgitant. Omitting the pericardial and cardio-pleuritic adventitious sounds already differen- tiated when speaking of mitral regurgitation (p. 206), there remain the (1) intra-arterial and (2) intra-ven- tricular organic murmurs, besides the inorganic, or functional murmurs, (3) the dynamic, and (4) the cau dio-respiratory. (1) Intra-aortal Murmurs. —These are organic sys- tolic basic murmurs, due to roughening of the lining membrane of the ascending portion of the aorta, in- flammatory vegetations, co-arctation (bending together) of the aorta, slight constriction, sacculation or pouch- ing of the vessel near the heart, and pressure on the aorta near its origin from tumors or fluid in the peri- cardial sac. Though sufficient to produce a systolic basic murmur, they might not materially interfere with the outward flow of blood, so that the left ventricle is, in such cases, not usually enlarged, whereas in aortic obstruction, unless of very recent occurrence, it is en- larged. Where no enlargement is observable, the his- tory of a recent attack of endocarditis Avould be of service; otherwise, it might be difficult, if not impossi- ble, to make an absolutely correct diagnosis, even by the pulse as traced with the sphygmograph, since it is but little altered in aortic obstruction. Intra-aortal murmurs are invariably loudest over the site where they are produced, as in case of aneurismal murmurs It might so happen that the cause of the murmur might be situated in the pulmonary artery, but caught up by the aorta. For that reason, it is thought better to term them intra-aortal murmurs. (2) Intra-ventricidar Murmurs.—The same remarks AORTIC OBSTRUCTION. 227 apply here as Avhen speaking of mitral regurgitation. (p. 206). Instead of the aortic orifice being affected by the endocarditis, a lesion someAvhere within the ventri- cle (intra-ventricular) may have been produced, suffi- cient to give rise to a systolic murmur, heard only, or loudest, over the aortic interspace. It is differentiated from aortic obstruction, not by the quality, pitch, or other properties of the murmur, but by the fact that if the murmur be purely intra-ventricular, the left ventri- cle is not enlarged. (3) Dynamic Murmurs.—These murmurs are caused by perverted action of the heart, and may be of neurotic or anaemic origin, as described Avhen speaking of them in connection Avith mitral regurgitation (p. 207). They occur more commonly at the base than the apex, but are always systolic in both localities. In a word, dias- tolic heart murmurs are organic, and all functional, or inorganic murmurs are systolic. These dynamic aortic systolic murmurs of neurotic origin are distinguished here, as elsewhere, by their being inconstant. They are observed not only among the choreic, nervous, and hysterical, but often among athletes, during or immediately after violent exercise. A perfectly healthy person, especially a young girl, after violently running up steps, will often have a tem- porary dynamic basic aortic systolic murmur. Some- times it is pulmonic also. A murmur may be some- times produced, also, with pressure of the stethoscope with those having thin and yielding chest walls, as among children. Such dynamic murmurs are told by their being inconstant, and by their not being neces- sarily associated with hypertrophy of the left ventricle. 228 PHYSICAL DIAGNOSIS. Dynamic aortic systolic murmurs may also be due to anaemia, as in the case of apex murmurs. They are distinguished by their not being necessarily associated with the left ventricular enlargement; by other and co-existing signs of anaemia, of which venous hum (soon to be fully described) is one of the most impor- tant ; by the non-existence of other murmurs; and by their disappearing under proper treatment for anaemia. (4) Cardio-respiratory murmurs, so-called, are thrown out by having the patient hold the breath, and they then cease at once, as already described when speaking of mitral regurgitation (which see). The aortic regurgitant murmur, having a different area of transmission, and occurring in diastolic time instead of systolic, besides other signs to be described, need not be dwelt upon here. Sometimes aortic obstruction is so marked that the left ventricle will, in time, become so enlarged as to cause the mitral valves to be some- what relatively insufficient, giving a slight mitral sys- tolic regurgitant murmur at the apex; but this con- dition appears to be someAvhat rare. Anaemic murmurs are usually placed here, so that a few remarks in regard to them at once become neces- sary. According to some authors, they are always produced at the aortic orifice. The theory is that in anaemia the heart muscle becomes weak and flabby, and stretches so that the cavities of the heart are larger than normal, while the tough rings around the orifices remain the same. Enlarged cavities, the ori- fices remaining normal, is relatively the same thing as normal cavities and constricted orifices, so that such a so-called anaemic murmur is, after all, simply a sort of AORTIC OBSTRUCTION. 229 temporary obstruction murmur, in other words, a dy- namic murmur due to anaemia, and not purely a blood, or haemic murmur. Purely haemic murmurs, due to anaemia, are heard over the pulmonary interspace rather than the aortic"'. Sometimes, it is true, they are caught up by the aorta, just as aortic organic obstructive murmurs are some- times caught up by the pulmonary artery when the two press closely on each other. Not only are these pulmonary haemic murmurs sometimes caught up by the aorta, but by it they may be and are, sometimes, conveyed into the arteries of the neck. Frequently, these murmurs in the arteries of the neck, however, are not conveyed there, but are simply created by pressure from the stethoscope disturbing the regular- ity of the calibre of the artery. How are basic dynamic murmurs due to anaemia to be distinguished from aortic obstructive murmurs, both being systolic? Not by their quality, pitch, or other properties, albeit murmurs dependent on anaemia for their production are usually lower in pitch, softer, more blowing in quality, and more diffused about the base of the heart, but are not transmitted so far as in the case of obstruction. But this is not always the case. The real difference is that aortic obstruction causes enlargement of the left ventricle, whereas anae- mia does not, although palpitation from chronic ame- ntia may give rise to a somewhat general enlargement of the heart from overwork long continued. Or else the enlargement would be due to dilatation from anae- mia, with feeble impulse, but in either case it would be general instead of limited to the left ventricle, as is 2'dO PHYSICAL DIAGNOSIS. usually the case in aortic obstruction. Only in rare cases of long standing does aortic obstruction give rise to relative (secondary) mitral regurgitation with se- quential enlargement of the left auricle and right ven- tricle. Dynamic murmurs, due to anaemia, whether heard at the apex or base, are also associated with other signs of anaemia, among which venous hum may be mentioned here. Venous hum, or bruit de diable, is a continuous though remittent roaring sound, heard over certain large veins, as the jugulars, subclavian, and femoral veins. From the fact that the sound is continuous it is readily distinguished from an arterial murmur. It is most convenient to listen for it in the neck, and it is best heard over the junction of the internal jugular and subclavian veins. Turn the patient's head to one side and elevate the chin, so as to render the tissues tense on that side of the neck. Now place the stetho- scope over the point mentioned, just at the root of the neck, and the continuous roar of venous hum (not rhythmical tracheal breathing) will be distinctly heard, usually in an anaemic person, especially a young anae- mic woman. Pressure with the finger, or otherwise, over the vein on the distal side of the stethoscope causes the hum to cease at once. Remove the pressure and it immediately returns. Guttmann, of Berlin, thinks that venous hum is due to the vortiginous (eddying, Avhirling) movement of blood in the ampullae (bulbs) formed by the union of the internal jugular and subclavian veins. The volume of blood, he thinks, is smaller in anaemia, and the am- pullae remain the same size, as they are adherent to AORTIC OBSTRUCTION. 231 the surrounding connective tissue. This would allow space in the ampullae for the vortiginous or eddying movement of the blood, as mentioned. According to Guttmann, venous hum is also heard more frequently and with greater intensity on the patient's left side of the neck, since the curved direction that the blood has to take on the left side would produce more vortiginous movement. Not infrequently, however, it is heard loudest on the patient's right side of the neck, and sometimes, indeed, Avhen it cannot be heard at all on the left. In the first place, it is highly improbable that the ampullae would be prevented from contracting, and becoming accommodated to the diminished volume of blood, by their being adherent to surrounding and rather loose connective tissue. In the second place, venous hum does not appear to be due to the vortigi- nous movement of venous blood, since it is produced best Avhere the blood has a straight and rapid course in large veins, and for that reason is heard best, or only, on the right side of the patient's neck. There are vari- ous other theories about the production of venous hum. According to Fothergill, many ingenious hypotheses have been raised regarding the causation of venous hum, but none as yet have been accepted. According to Walshe, the composition of the blood in the amende state cannot be overlooked. It appears that watery venous blood is soniferous, while arterial blood, under the same conditions, is not, the exact reason for which does not appear to be known. It would seem, there- fore, that venous hum depends upon the character of the venous blood in the anaemic state, rather than upon 2:52 PHYSICAL DIAGNOSIS. the supposed vortiginous movement of the blood in ampullae, the vibration of valves of veins, and so on. Aortic Regurgitation. Aortic regurgitation (reflux, insufficiency) is the cause of great enlargement of the left ventricle only, as a rule. Should relative insufficiency of the mitral valves occur, the left auricle, and, in time, possibly, the right ventricle also, would become enlarged, though the patient would hardly live long enough in such a marked case. It is one of the most hopeless and fatal of all valvular lesions of the heart. Walshe places it fourth in the order of relative gravity, but, leaving out tricuspid regurgitation, I should be in- clined to place it first. The reason why the left ventricle becomes enlarged in aortic regurgitation is obvious. The blood regurgi- tating back into the ventricle simply gives it double work to perform. The first sound of the heart may be louder than normal, or it may be absent. In other words, it varies, depending, no doubt, upon the amount of dilatation and whether or not it has brought about relative mitral insufficiency. The second sound over the pulmonary interspace is usually normal, unless the right ventricle becomes sequentially enlarged from rela- tive insufficiency of the mitral valves, and then the second sound over the pulmonary interspace will be accentuated. Over the aortic interspace the second sound is taken up by the aortic regurgitant murmur which occurs with it, being diastolic in time. The pulse of aortic regurgitation is characteristic. Owing to enlargement of the left ventricle, the blood is driven AORTIC regurgitation. 233 Avith great force into the aorta, but as that artery empties itself in two directions at once, back into the left ventricle and forward into the capillaries, the pulse, which started with such a thump, suddenly collapses from not being sustained, so that it is sometimes called collapsing, vanishing, unsustained, locomotive, or water- hammer pulse. There are various names by which it is known, and Ave have good authorities for them, but it would appear that water-hammer is the one now most commonly used. The physical signs of aortic regurgi- tation are: (See fig. for Aortic Obstruction.) Inspection.—The apex-beat is carried down and out, owing to enlargement of the left ventricle. The heart's impulse is usually seen to be more forcible than nor- mal. There is usually pulsation in the arteries about the neck, and all over the body where the arteries are superficially located and visible. If the patient be di- rected to hold the arm up, not infrequently the radial, ulnar, and other arteries of the upper extremity are seen to pulsate as in arterial sclerosis. Palpation.—The apex of the heart is felt displaced downward and outAvard, and sometimes basic diastolic Uu \J \1 I \i \J \J Fig. 28.—Sphygmographic Tracing of Aortic Regurgitation Pulse. thrill is felt. The radial pulse is unsustained, or col- lapses under the finger. The sphygmographic tracings of this impulse are characteristic. Percussion.—This shows an increased area of cardiac 234 PHYSICAL DIAGNOSIS. dullness, due to enlargement of the left ventricle. It may be still more increased if there be relative mitral insufficiency and consequent enlargement of the left auricle and also right ventricle. Auscultation.—This reveals the ruesence of the char- acteristic aortic regurgitant murmur. It is diastolic in time, and occurs with, or takes the place of, the sec- ond sound of the heart. It is sometimes termed the aortic indirect or insufficient murmur. The aortic re- gurgitant (indirect, insufficient, diastolic) murmur may be represented by the following diagram: up iu-pli I-------II---1 • I The quality of the murmur varies, but in most cases it appears to be harsher and higher-pitched than the aortic obstructive murmur. Sometimes they exist to- gether, forming what may be termed steam-tug mur- mur, hoo—chee. The combination is usually best heard on the sternum about the fourth or fifth cartilage. Area of Transmission.—The aortic regurgitant mur- mur is directed back from the current of blood, and for that reason is not usually heard so plainly in the aortic interspace as it is over the sternum about the fourth cartilage. It is sometimes heard only at the lower end of the sternum. Sometimes it is conveyed backward to the apex of the heart, Avhere it is to be distinguished by its diastolic time, diminished intensity, and the en- larged left ventricle, from mitral obstructive murmur (which see). If the murmur is loud enough, the ster. num will catch up the sound, so that it may be heard from one end of that bone to the other. Occasionally, the pulmonary artery takes up the murmur from its AORTIC OBSTRUCTION AND REGURGITATION. 235 proximity to the aorta, so that pulmonary regurgita- tion may be imitated (p. 239). Sometimes it is heard behind along the spinal column, but it may be loud and musical, so as to be heard as soon as one enters the room, and may be so audible to the patient as to prevent sleep. Diagnosis of Aortic Regurgitation.—This is based upon the characteristic unsustained (v/ater-hammer, collapsing, locomotive) aortic regurgitant pulse, en- largement of the left ventricle, and the accompanying diastolic regurgitant murmur. The latter, in rare cases, may be imitated by a murmur caused by rough- ness Avith dilatation of the ascending portion of the aorta. The late Dr. Austin Flint speaks of this as an aortic diastolic non-regurgitant, or prediastolic, mur- mur. It is usually preceded by an aortic direct mur- mur, but not always. This imitative murmur is not necessarily associated with enlargement of the left ven- tricle, and the pulse characteristic of aortic regurgita- tion is wanting. These diastolic murmurs may, in rare cases, be heard only at the lower end of the sternum, like tricuspid regurgitation, but the latter being sys- tolic in time, the diagnosis is easy. Aortic Obstruction and Regurgitation. This combination of lesions is second in the order of frequency, according to Walshe. Separately or to- gether, they cause enlargement of the left ventricle. When both lesions exist at the same time, the left ven- tricle is enlarged and there are two murmurs, the sys- tolic obstructive and the diastolic regurgitant already described. The two are often heard together, especially 236 physical diagnosis. on the sternum, usually about the fourth or fifth car- tilage, and form what may be termed the steam-tug murmur, hoo—chee, hoo standing for the obstructive, and chee for the regurgitant murmur. Pulmonary Murmurs. We listen over the apex, ensiform cartilage, and aortic interspace, respectively, for mitral, tricuspid, and aortic murmurs in their maximum intensity. We now come to the fourth and last point on the front of the chest walls, the pulmonary interspace, where we listen for pulmonary murmurs in their maximum in- tensity. The pulmonary interspace is the second inter- space, or the interspace between the second and third costal cartilages, at the left edge of the sternum. Theo- retically, we would have the same number of murmurs here as over the aortic interspace, with the addition of the purely anaemic or haemic murmur. But pulmonic diastolic regurgitant murmur is so rare that it may be practically thrown out altogether. Of the systolic pul- monary murmurs the same remarks would apply here to intra-ventricular, intraarterial, dynamic, and cardio- respiratory murmurs, as when describing aortic systolic murmurs. There remain two pulmonary murmurs, therefore, the pulmonary obstructive, and the anaemic. Pulmonary Obstruction. Pulmonary obstruction (constriction, stenosis) is not commonly observed among adults. It is due to fcetal endocarditis in which the right, instead of the left side of the heart is affected, as already stated (p. 193). Children are therefore born with pulmonary valvular PULMONARY OBSTRUCTION. 237 lesions, when they have them, and usually die early. It gives rise to a basic systolic murmur, as in the case of aortic obstruction, but heard on the left side of the sternum over the pulmonary (second) interspace in its maximum intensity, instead of on the right. The pulse is not affected by it. It leads to more or less enlarge- ment of the right ventricle. The diagram representing this murmur is the same as for aortic obstruction. The area of transmission is the same as for the aortic obstructive murmur so far as the sternum is concerned, but beyond that it differs materially. It is not con- veyed up into arteries of the neck, but back in the lungs by the pulmonary artery, and for that reason, when loud, is heard behind over both sides of the backs of children having thin chest Avails. It is also trans- mitted out toward the left shoulder sometimes. In a case of a girl of fourteen now under my observation, the murmur is so loud as to be heard distinctly all over the chest, though loudest and most distinct over the pulmonary interspace. Systolic basic thrill is some- times felt, as in aortic obstruction. How are we to tell it from the anaemic or other mur- mur? Simply because it is usually associated with more or less cyanosis or blue disease (morbus caeru- leus), OAving to the venous congestion over the body. Walshe says that true pulmonary obstructive murmur is very rare, except in cases of cyanosis. Fits of dysp- noea are likely to occur any time, owing to the lungs not being properly supplied with blood. Cyanosis it- self does not give rise to a murmur as anaemia does. True anaemic or haemic murmurs due to a watery condition of the blood are always systolic, and perhaps 238 PHYSICAL DIAGNOSIS. always basic. They are also apparently pulmonic in- stead of aortic, although they may sometimes be taken up by the aorta Avhen the two vessels are in close con- tact with each other. May not these murmurs be nothing more than venous hum in the pulmonary artery, thrown into rhythm by proximity to the heart? It is true that they do not always co-exist with venous hum in the neck, but that may be because the venous blood travels differently in those vessels. Another supposed cause of systolic anaemic murmurs heard over the pulmonary interspace would not be mentioned here but for the fact that Balfour's name is connected with it, although, according to Flint, it did not originate with Balfour, but with Naunyn. The latter thought that the murmur was not to be attrib- uted to the pulmonary orifice at all, but was due to a slight mitral regurgitation due to weakness of the heart from anaemia, with an accompanying mitral systolic anaemic murmur, not loud enough to be heard at the apex but loud enough to be taken up by the left auricular appendix, Avhich- had also become dilated and enlarged from anaemia! Yet in mitral regurgitation with a loud murmur and the left auricle very much more enlarged than in anaemia, the trans- mission of the murmur to this point is very rare, as already stated (see Mitral Regurgitation). Flint, per- haps justly, characterizes such reasoning as strained. Vierordt, of Leipsic, states that the explanation of these cardiac anaemic murmurs is very difficult, and thinks that in many cases Sahle's suggestion might be available, that these murmurs may arise from the large vessels concealed in the thorax. PULMONARY REGURGITATION. 239 Pulmonary^ Regurgitation. Pulmonary regurgitation (reflux, insufficiency) is such a rare disease that it is hardly worth mentioning. If it occurred it would give rise to a pulmonary regur- gitant murmur, which Avould be diastolic in time, and could not be confounded with any functional or inor- ganic murmur. As Flint states, a diagnosis could be made when other signs went to show the existence of pulmonary and the absence of aortic regurgitation. Diastolic thrill might be felt in both. But the pulse, of course, would be different, being unaffected by pul- monary regurgitation, and collapsing in the aortic lesion. Jugular pulsation would occur in time, with enlargement of the right ventricle in pulmonary regur- gitation, together with cyanosis and cardiac dropsy, none of which are characteristic of aortic regurgitation. As the disease is so rare, however, it is perhaps really more of a clinical curiosity than of any practical value. Relative Gravity oe Valvular Lesions. According to Walshe, the following is the descending order of gravity of valvular lesions: (1) tricuspid re- gurgitation, (2) mitral regurgitation, (3) mitral obstruc- tion, (4) aortic regurgitation, (5) pulmonary obstruction, (6) aortic obstruction. Very little is known about pul- monary regurgitation and tricuspid obstruction. Neither of the first three mentioned produce what is generally understood as sudden death from heart dis- ease. But all three are dangerous, from such complica- tions as pulmonary congestion, hemorrhagic infarction 240 PHYSICAL diagnosis. (p. 101), cardiac dropsy, and pulmonary oedema, which are likely to occur. But in aortic regurgitation not only is thoracic aneurism likely to be produced from the tremendous force with which the blood is thrown into the aorta (p. 271), and sudden death from cerebral apoplexy, but there is also liability to sudden death due to failure of the heart's action from some cause, sup- posed to be, by some, failure of blood to be conveyed by the nutrient arteries of the heart. For these reasons it would appear that aortic regurgitation, well-marked, is among the most dangerous of all valvular lesions of the heart. Endocarditis. Endocarditis, as already said, occurs most frequently in the course of acute articular rheumatism, especially among the young, but it may also occur in the course of any other disease, or independently. During foetal life it attacks the right side of the heart, but after birth it attacks the left side, as already stated (p. 193). It usually results in valvular disease of some kind (mitral regurgitation, most frequently with consequent enlarge- ment), or else some lesion elsewdiere Avithin the A'entri- cle, or finally it may possibly end in complete recovery. The physical signs of endocarditis are based chiefly on auscultation. Inspection usually is negative. Pal- pation is usually also negative, but may reveal the fact that the heart's action and pulse are excited, and sometimes irregular. If it be the first attack, percus- sion dullness will be very slightly, or not at all, in- creased in extent, as the heart will not be appreciably enlarged. Upon auscultation the sounds Avill be nor- mal or perhaps slightly increased in intensity, except PERICARDITIS. 241 at the site of the murmur, which will be heard at the apex or over the aortic interspace. The murmur occurs early in the disease, and is systolic in time and blowing in quality. It is due to roughening of the surface or deposit of lymph on or near the valves of the mitral or aortic orifices. The positive proof, according to Flint, is the presence of a mitral systolic murmur occurring during an attack of rheumatism If it be aortic it is in many cases inorganic. The mitral systolic murmur need not show actual regurgitation as yet, or it may be purely intra-ventricular. But if the left A-entricle be enlarged and endocarditis be suspected, it will not be the first attack, since the enlargement will be due to mitral regurgitation from a previous endocarditis. Pericarditis. Pericarditis usually occurs in connection with acute articular rheumatism, tubular nephritis, pleurisy, syphilis, pneumonia, tubercle, or cancer. Of course it may be due to surgical injury also, but it is rarely, if ever, an idiopathic affection. It is usually attended with more or less effusion, and is divided into three stages. In the first stage (congestion) the action of the heart is irritable and forcible. The area of dullness is as yet unchanged. Auscultation uniformly reveals the pres- ence of a pericardial (exocardial) friction sound. En- docardial murmurs may also exist. But pericardial (exocardial) friction murmurs are superficial, rubbing, churning, clicking, or creaking, never blowing, whis- tling, or roaring, and are limited to the cardiac region, and often vary in intensity with position of the patient, or pressure with ear or stethoscope, and occur inde- 16 242 PHYSICAL DIAGNOSIS. pendently of the heart sounds—that is, not fixed. Endocardial murmurs, on the contrary, are fixed in their time of occurrence Avith regard to the heart sounds, and are often conveyed or transmitted over cer- Fig. 29.—Diagram, Pericarditis with Effusion. tain areas, as already described. The second stage of pericarditis (effusion) is characterized by the effusion of liquid—acute hydro-pericarditis. Inspection now shows prominence of the precordial PERICARDITIS. 248 region in proportion to the amount of effusion, dimi- nution, or absence, of the apex-beat, and diminution of the respiratory movements on the left side. Palpation.—The apex-beat is raised upward and outward to the left, is feeble or suppressed, and may change Avith position of the patient. If not felt when the patient is on the back, it may be perceptible if the patient leans forward. An undulating impulse is sometimes felt, and the epigastrium may be bulging from depression of the diaphragm. Percussion,—The area of praecordial dullness is en- larged. If the effusion be great this area is found to be wider beloAv than above, on account of the shape of the pericardial sac. It may extend down to the seventh rib and up to the first rib, and from nipple to nipple, or even further. Auscultation.—The pericardial friction sounds have now disappeared, since the tAvo surfaces cannot rub together. The heart sounds are feeble and heard bet- ter at the top of the sternum than elsewhere, as the effusion occupies less space there than below. Some- times a basic systolic murmur, due to pressure of the effusion on the aorta, is heard. The respiratory mur- mur, pectorophony (vocal resonance), and vocal fremi- tus are diminished or absent over the central portion of the cardiac region. The third stage is that of ab- sorption. The friction sound returns—;frictio redux— the heart sounds become more distinct, and there is a gradual return to health in favorable cases. In other cases it may become subacute or chronic. Chronic pericarditis may be attended with adhe- sions simply, or there may be adhesions with hypertro- 244 PHYSICAL DIAGNOSIS. phy or atrophy (which see), or there may be chronic pericarditis with effusion, termed chronic hydro-peri- carditis. The physical signs of chronic hydro-pericar- ditis are similar to those of the acute variety just described. Pneumo-hydro-per icarditis, air and fluid in the peri- cardium, is rare, but may possibly result from decom- position of liquid effusion, or, usually, from perforation communicating with the oesophagus or lungs. In these cases the heart's action is accompanied by metallic (amphoric) tinkling, amphoric (metallic) buzzing, and splashing like a water-wheel (AValshe). Hosmo-pericardium, or blood in the pericardium, may result from cancer, scurvy, and the hemorrhagic tendency, or surgical injury, and rupture of aneurism. If the patient lived long enough the blood, Avhile fluid, would give the same signs as hydro-pericarditis. Hydro-pericardium, or dropsy of the pericardium, is merely 'associated with general dropsy from Bright's disease of the kidneys, or some other cause, Avithout inflammation of the pericardium. The physical signs are those of hydro-pericarditis, already described. Pneumo-per icard ium, or air in the pericardium, is due to gas arising from post-mortem changes, as a rule, and is rarely, if ever, seen during life, and pneumo- hydro-per i car dium, if such a thing could exist during life, would give the same physical signs as pneumo- hydro-pericarditis, already described. Myocarditis. Myocarditis, or carditis, signifies inflammation of the heart muscle itself. When present it is usually associ- HYPERTROPHY OF THE HEART. 245 ated Avith endocarditis or, more frequently, with peri- carditis. In the acute form, the pain in the cardiac region is extreme, the pulse rapid and Aveak. In the chronic form, the symptoms are those of a Aveak heart, with Avant of correspondence between the heart and pulse beat. Neither form is diagnosticated during life. Hypertrophy of the Heart. Hypertrophy of the heart differs from hyperplasia. In the former case the existing anatomical elements are enlarged, in the latter their number is increased (Flint). In both cases the heart is enlarged. Hypertrophy may be general, or limited to one or more of its compartments. In the latter case the left A-entricle is by far the most frequently affected, then the left auricle, then the right ventricle, and lastly the right auricle may sometimes be somewhat enlarged. Again, the hypertrophy may be concentric, simple, or eccentric. In the first case the walls are thickened and the cavities become smaller. This is so rare that it is more theoretical than practical, and may be thrown out altogether. Simple enlargement is not common either —that is, thickening of the walls—the cavities remain- ing the same. Indeed, hypertrophy or enlargement of the heart from any cause is so uniformly of the eccen- tric variety, that, unless otherwise specified, enlarge- ment of the heart will ahvays be meant to be eccentric hypertrophy—that is, hypertrophy Avith dilatation, usually termed hypertrophous dilatation, or dilated hypertrophy. Of the causes of enlargement of the heart, (^valvu- lar lesions, as previously stated, are the most frequent. 246 PHYSICAL DIAGNOSIS. Moreover, each of these lesions gives rise to its oavr characteristic enlargement, Avhich will be marked in proportion to the degree of the lesions. Thus, mitral regurgitation causes enlargement (dilated hypertrophy) of the left auricle, left ventricle, and right ventricle in the order named. Mitral obstruction causes enlarged left -auricle and right ventricle. Aortic obstruction gives rise to enlarged left ventricle and aortic regurgi- tation also, only the enlargement is usually more marked in aortic regurgitation; and in either case, but especially in aortic regurgitation, there may occur rela- tive insufficiency of the mitral valves, with consequent enlargement of the left auricle, if not the right ventri- cle, also, in time. Pulmonary (pulmonic) obstruction or regurgitation will lead to enlargement of the right ventricle as would also tricuspid regurgitation, relative, or resulting from foetal endocarditis, while tricuspid obstruction would cause enlargement of the right auri- cle only. (2)Brigh£s Disease of the Kidneys.—In the chronic interstitial variety there is enlargement of the left ven- tricle only, and this is not due to valvular lesion but simply to the fact that the left ventricle has extra work to perform in overcoming the obstruction due to the lessened calibre (lumen) of the arterioles through- out the body. In the chronic tubular variety of Bright's disease of the kidneys, there is liability to in- flammation of serous membranes generally, the endo- cardium included, with resulting valvular lesion. En- largement of the heart, therefore, in chronic tubular nephritis is usually due to valvular lesion, resulting from an endocarditis. HYPERTROPHY OF THE HEART. 247 (3) General Vesicular Emphysema.—In this case there is enlargement of the right a entricle, owing to obstruction to the pulmonary circulation. (4) Exophthalmic goitre, called also cardio-thyroid exophthalmos, BasedoAv's, or Graves' disease. Here Ave have general cardiac enlargement due to over nourish- ment from A*aso-motor dilatation of the nutrient vessels of the heart. According to Niemeyer, Bamberger, and others, the nutrient vessels of the heart in this disease are enlarged from vaso-motor dilatation due to some disturbance of the cervical ganglia of the sympathetic nervous system (see Exophthalmic Goitre). (5) Palpitation from anaemia, or other cause, may give rise to enlargement of the heart from its overwork. The alcoholic habit probably acts somewhat in this way. Habit, mode of life, occupation requiring pro- longed muscular exertion, as among athletes, and the like, also enlarge the heart to a certain extent, as well as excessive venery. The physical signs of hypertro- phy of the heart with dilatation are usually more marked than they are Avhen simple hypertrophy alone exists. They are: Inspection—-The enlargement is always more to the patient's left than right, and the line of the base is rarely, if ever, changed. The extent of the visible im- pulse is increased, and there is more or less prominence of the prsecordial region. The apex-beat is also seen to be more forcible than normal, and it may be as low as the ninth rib and outside the mammillary line. En- largement of the right ventricle pushes the apex fur- ther to the left than normal, but the apex is also low- ered when the left ventricle is enlarged. 248 PHYSICAL DIAGNOSIS. Palpation.—The impulse is heaving and lifting in character, with or without thrill, and its area is in- creased. Hypertrophy of the right ventricle usually gives a strong epigastric impulse. When the left ven- tricle is hypertrophied the apex-beat is carried down and out. Praesystolic impulse is sometimes felt over an hypertrophied left auricle, as may occur in mitral disease. The radial pulse in hypertrophy of the right side of the heart is not appreciably affected in character. But in hypertrophy of the left ventricle without regurgita- tion or obstruction, the radial pulse is full, prolonged, and sustained. Percussion.—Both areas of dullness are increased, laterally and vertically. General enlargement may give dullness on percussion from the third to the eighth rib, and from an inch to the right of the sternum to two or three inches outside the left nipple. Walshe mentions a case where enlargement (dilated hypertro- phy) of the heart Avas so extensive as to be mistaken for pleurisy of the left side Avith effusion. Hypertro- phy of the left ventricle gives dullness usually beyond the left nipple; of the right ventricle, considerably to the right of the sternum. In hypertrophy of the left auricle the area of dullness over that portion is en- larged and more marked. Auscultation,—-The first sound, dull, muffled, pro- longed, diffused over a larger area than in health, and increased in intensity, may indeed so closely resemble a slight systolic murmur as to make it sometimes diffi- cult to decide; and the second sound is also louder and more diffused than in health. If murmurs are DILATATION OF THE HEART. 249 present they will more or less obscure, or take the place of the heart sounds. There is diminution or absence of the respiratory murmur over the praecordial space. Hypertrophy of the right auricle rarely occurs, and then it is due to tricuspid regurgitation usually, as tricuspid obstruction (stenosis, constriction) is almost unknown during life (Walshe). Dilatation of the Heart. Dilatation of the heart may be one of three kinds: (1) hypertrophous dilatation, or dilated hypertrophy, which is the most common form, and just considered; (2) simple dilatation, where the walls remain the same but the cavities are enlarged; and (3) attenuated dila- tation (Walshe), where the cavities are not only en- larged, but the Avails are thinner than normal. It is the last variety that requires our attention. Attenu- ated dilatation, or dilatation without compensating hypertrophy, is a hopeless disease. It may result from valvular lesion, or general vesicular emphysema, where dilatation and hypertrophy of certain parts occur to- gether, producing the various enlargements character- istic of those diseases, as already fully described. Presently the time arrives, however, when hypertrophy ceases to compensate, and then the case becomes one of dilatation, since, evidently, enlargement cannot con- tinue to go on indefinitely. In other cases dilatation occurs from inherent weakness of the heart muscle itself, in other words, from no known cause. Thoracic aneurism causes dilatation in so far as it is a cause of obstruction to the outflow of blood, and in this way 250 PHYSICAL DIAGNOSIS. acts as valvular lesion would. But the underlying cause of aneurism, if it be gout, syphilis, or lead pois- oning, may cause weakness of the heart muscle also, and thus favor dilatation. The physical signs of car- diac dilatation are: Inspection.—The visible area of the apex-beat, if in- deed it be visible, is increased without any particular point of maximum intensity. Dyspnoea and cyanosis are sometimes observed, especially after attempted ex- ertion. Palpation.—-The cardiac impulse is feeble, its area is increased, rarely is there any thrill, but rather an un- dulating motion over the praecordial region, especially if there be mitral regurgitation. The radial pulse is feeble, sometimes irregular, small, and compressible. Percussion.—The area of cardiac dullness is in- creased in the direction of the part dilated, or generally increased if the dilatation affect the whole heart. In the latter case it is oval or somewhat square in shape, instead of being triangular, with the base downward, as in pericarditis with effusion. Auscultation.—Both sounds are short, abrupt, feeble, and equal in duration, the second being often inaudi- ble at the apex. The post-systolic or first period of silence is prolonged. Endocardial murmurs, when present, are indistinct. The respiratory murmur is diminished or absent over the praecordial region, owing to the cardiac enlargement. Fatty Degeneration of the Heart. Fatty heart is of two kinds, (1) that in Avhich the fat is added to the organ without or within, or between its FATTY DEGENERATION OF THE HEART. 251 fibres, and causing trouble by pressure; and (2) that in Avhich the muscular fibre is replaced by fatty tissue. The first is by Walshe termed fatty infiltration; and is simply an accumulation of fat. The second is known as Quain's fatty degeneration, and by Walshe is termed fatty metamorphosis of the heart. The first variety may give some inconvenience, but may be modified, if not entirely got rid of, by a Carlsbad course, or re- stricted diet, if thought necessary. The second is a serious and often fatal disease. There is no known cause for Quain's fatty heart. Obesity, though associ- ated with fatty infiltration, bears no relation whatever to fatty metamorphosis. Cardiac fatty metamorphosis occurs at middle Life, or past, and in men rather than women. It also occurs more frequently among the upper classes than among laborers. It is probable that any condition that interferes Avith the proper nutrition of the heart, such as sclerosis of its nutrient vessels from various causes, and leading to cardiac ischaemia (see Angina Pectoris), may predispose to fatty metamor- phosis. But in tuberculous and other wasting diseases the heart is more frequently normal than fatty, and hence they cannot be said to be causes of the disease. The real cause, whatever it may be, is probably inherited rather than acquired. The physical signs of fatty met- amorphosis of the heart (Quain's) are as follows: Inspection.—The heart's impulse is usually not ob- servable, owing to its feebleness. The patient may be observed to be suffering with a fit of dyspnoea and having a peculiarly anxious expression. The arcus senilis may be present, but appears to bear no fixed relation to the disease. 252 PHYSICAL DIAGNOSIS. Palpation.—-The impulse is so weak as to be scarcely felt, even though the patient be emaciated and leans forward. If the heart was hypertrophied first, there may be an undulating impulse, as in attenuated dilata- tion. The pulse is feeble and sometimes abnormally sIoav; or it may be irregular and intermitting, chang- ing from abnormal slowness to rapidity—from 20 to 30 beats per minute to 150, but always weak. Percussion.—The area of dullness will be normal, unless hypertrophy co-exists, when it would be larger, or smaller if there be atrophy. Auscultation.—The first sound of the heart, even at the apex, instead of being somewhat low pitched and of well-marked duration, as in health, now becomes short, high pitched, and weak, and the first rest is not- ably prolonged. The second sound is feeble but dis- tinct, and is accentuated in the aortic or pulmonary interspace, according as the right or left ventricle is chiefly affected. Of course, murmurs of various kinds may be present, but they are rare, and when they are present they are usually weak. The patient feels bet- ter, according to the late Dr. Alonzo Clark, lying down with the head low, as the heart would then have less to do. Atrophy of the Heart. Atrophy of the whole heart, unless it be senile, is of rare occurrence. It sometimes takes place in connec- tion with wasting diseases like phthisis, suppurating bone, calcification of the coronary arteries, tightly ad- herent pericardium, and, rarely, after pregnancy. Local atrophy of some part of the heart is more common, and CARDIAC DROPSY—EXOPHTHALMIC GOITRE. 253 occurs in connection Avith fatty heart. In mitral ob- struction, also, the left ventricle is somewhat atrophied, and when this lesion occurs in children, there appears to be usually more or less deformity of the chest, re- sembling the so-called pigeon breast. The flattening is particularly Avell marked in the lower praecordial region to the left of the sternum, but whether it be due to atrophy of the left ventricle, or a lack of gen- eral nutrition from imperfect cardiac function, is not exactly known. In case of general atrophy, the area of percussion dullness is diminished, the heart's sounds are clear, the impulse is feeble, the pulse quick and feeble, but regular, and there is a great tendency to palpitation (Da Costa). Cardiac Dropsy. Cardiac dropsy usually begins about the feet and ankles, and, gradually extending upward, is afterward met Avith in various localities. It is most constantly associated with dilatation of the right heart, as in tri- cuspid regurgitation, but there are exceptions. Albu- men, when present in the urine, is due to renal conges- tion simply, unless there be also co-existing structural lesion of the kidneys. Exophthalmic Goitre. Exophthalmic goitre (cardio-thyroid exophthalmos, Basedow's disease, Grave's disease), in order to be com- plete, consists of three factors: (1) palpitation and en- largement of the heart, (2) enlargement of the thyroid gland, with throbbing of the arteries about the neck, and (3) protrusion of the eyeballs. The disease is said 254 PHYSICAL -DIAGNOSIS. to be due to some change in, or pressure on, the cervi- cal ganglia of the sympathetic system of nerves, which send branches directly, or indirectly, to the three local- ities mentioned. The disease is usually classed among the neuroses, or functional disturbances, of the heart, but inasmuch as it leads to cardiac hypertrophy, I have thought it best to place it among the organic diseases of the heart. It occurs more frequently among women than men, and in most cases the women are usually nervous, if not hysterical, and anaemic. Sometimes it occurs in men, and Graefe mentions the case of a young man in whom it was suddenly developed on account of nervousness at the prospect of being married. (!) In most cases it develops slowly, but in some instances (as in the case of the young man just cited) it may develop very sud- denly. (1) Palpitation of the heart usually first attracts the attention of the patient. The heart is observed to beat 120 or even 140 times to the minute, instead of 60 to 70, Enlargement of the heart folloAvs, partly from palpitation, but chiefly from overnutrition of the organ. The nutrient vessels of the heart become dilated from vaso-motor disturbances, and the heart receives more blood supply than normal. Hence its palpitation as well as overgrowth. (2) The thyroid gland noAv begins to enlarge, and throbbing of the inferior thyroid, carotid, and, some- times, temporal arteries is observed. The enlargement of the thyroid gland may not be very perceptible, and when piesent, is due to dilatation of its vessels, serous infiltration, and hyperplasia of its EXOPHTHALMIC GOITRE. 255 tissues. The gland is rarely so much enlarged as in simple goitre (cretinism, Derbyshire neck), where it may be enormously hypertrophied or increased in size by fibrous or calcareous deposits. Cretinism (with goitre), so-called from deformity Fig. 30.—Exophthalmic Goitre. (After Eichorst.) or mutilation, supposed to result from intermarriage, is a local disease, and found not only among those who intermarry, but also among young girls and women who carry heavy burdens and are habitually subjected to bad hygienic conditions, as in certain parts of the old world. For these reasons it is thought that the thyroid gland becomes enlarged, as in foetal life, be- 256 PHYSICAL DIAGNOSIS. cause the lungs are not equal to the task put upon them of aerating tne blood, and not because of any particular lack of iodine in the water, which is the same as it was in those localities a thousand years ago. Hence cretinism (with goitre) is becoming less, thanks to the steam-engine, which enables people to leave home and marry elsewhere, and other advances made by Christian civilization, and not because of any change in the drinking water of certain localities. To return to exophthalmic goitre, AAdiich disease is not confined to any locality, but which may, and does, occur in all parts of the world. We have seen why the heart and thyroid gland are enlarged—on account of the vaso-motor dilatation of their blood-vessels. The arteries about the neck and temples sometimes throb because they become dilated, and the blood is sent through them with great force by the hypertro- phied heart. (3) Lastly, the eyes in this disease pro- trude, because of the increase of the fat at the bottom of the orbit. The intra-orbital fat is increased from hyperplasia, and, according to Niemeyer, it may be- come not only hyperaemic, but also cedematous. Some- times the eyes protrude so that the lids cannot be closed, and consequently ulceration of the cornea, from foreign particles, may result. The upper lid, according to Graefe, becomes fixed early in the disease, from spasm of the levator muscle, and consequently does not follow the eye in looking downAvard. All three factors of this disease are not equally pres- ent in every case. The heart may be chiefly affected, with scarcely perceptible change in the thyroid gland, Avhile the eyes remain perfectly normal, and so on. In ANGINA PECTORIS. 257 course of time, however, all the phenomena are apt to appear. Anaemia is observable in most cases before treatment, and marked venous hum, with or Avithout thrill, in the neck is pretty constant. Not infrequently a true anaemic (haemic) murmur is heard Avith systole over the pulmonary interspace; and over the aortic in- terspace a loud, systolic, dynamic murmur, oAving to the force, I presume, Avith Avhich the arterial blood is forced at times through the aortic orifice by the hyper- trophied left ventricle; but, unlike the anaemic murmur over the pulmonic (pulmonary) interspace, it is incon- stant, like all other dynamic murmurs. The physical signs of cardiac hypertrophy have already been con- sidered (p. 247). Unless the patient dies from apoplexy or rarely, suffocation due to pressure on the trachea, the prognosis is not bad. Recovery, according to Nie- meyer, is more common in this disease than death. Angina Pectoris. Angina pectoris, or suffocative breast-pang, is usually defined to be a paroxysmal neurosis of the heart, and always attended with pain, whatever other symptoms may be present. As it is usually accompanied or pre- ceded by organic changes in the heart, I have thought it best to place it among the organic, rather than func- tional, diseases of that organ. The disease is of two kinds, true and false. The latter is almost wholly confined to young hysterical women. In these cases the pain does not extend through to the back and up to the neck and down the left arm, but is simply located apparently in the chest 17 258 ' PHYSICAL DIAGNOSIS. wall, like an intercostal neuralgia, but attended with palpitation of the heart and dyspnoea. True angina pectoris, on the other hand, attacks men usually, and those in the upper walks of life, either at middle age or past. It depends upon what is termed ischaemia of the myocardium, Avhich is simply a local anaemia of the heart, due to periarteritis or sclerosis of its nutrient vessels, the latter resulting from en- darteritis, and often terminating in ossification. Pain is not always present in all cases of cardiac arterial sclerosis, for this condition gives rise to different varie- ties of symptoms, as we shall see; but wljen pain is present, it is analogous to the pain observed in senile gangrene due to arterial obstruction. The causes of localized anaemia or ischaemia of the heart are those which produce sclerosis of its nutrient vessels. These are, according to Huchard, of Paris, (1) toxic, as alco- hol, tobacco, especially cigarette smoking, malaria, and lead, (2) diathetic, as gout, rheumatism, and syphilis, and (3) physical, moral, and intellectual overpressure. Obliterating arteritis of the small coronary vessels of the heart is the lesion commonly found, and if this arteritis be slow, time for compensating hypertrophy may be allowed. But if the arteritis is rapid in its progress, dilatation from weakness of the heart's walls, or fatty degeneration, results. Tobacco, it would ap- pear, is more destructive to the heart than alcohol. Cardiac arterial sclerosis gives rise to five different forms of symptoms: (1) the pulmonary form Avith symptoms of cardiac' asthma, so-called (see Asthma); (2) the painful form of true angina pectoris; (3) the tachycardiac form, in which there is simply rapidity ANGINA PECTORIS. 259 and Aveakness of the heart's action; (4) the arythmic form, in Avhich the rhythm becomes irregular, as often occurs from the use of tobacco and on account of dys- pepsia ; and (5) the asystolic form, in Avhich rapid dila- tation occurs, due to Aveakening of the Avails of the heart from the nutrient arterial sclerosis. Of these five forms of manifestations of cardiac arterial sclerosis, and consequent ischaemia of the heart, only one, the painful form, or angina pectoris proper, Avill be consid- ered here. A patient, however, Avho has this disease manifested in one form, may have a return of it in any of the other four forms, for the same form does not necessarily return every" time, AA'hen once commenced. Angina pectoris usually comes on Avithout warning. The patient may be asleep in bed, or it may be after a heavy meal, or during a fit of anger, or AAhile walking briskly, especially up hill, against a stiff breeze. Sud- denly a pain, like a death pang, pierces him through and through in the lower praecordial region. It not only extends through to the back, but up to the neck and doAAm the left arm, usually, but sometimes both arms, and even one or both of the lower extremities. This fearful neuralgic pain is thought to originate in the cardiac plexus of nerves, and extends not only to the parts mentioned, but along the gastric branches of the pneumogastric nerve, as evidenced by the belching of wind and sometimes eATen vomiting. The pulmo- nary branches of the pneumogastric nerve, on the other hand, seem to escape in this painful form, since the patient not only can breathe freely, but sometimes a deep breath will give speedy relief. The attack may last from a few seconds or minutes to an hour or more, 260 PHYSICAL DIAGNOSIS. if the patient lives, and may consist of one prolonged attack or many separate and distinct attacks. In the latter case it may last several days or more. During the attack the pulse may not be notably affected, but if the attack be prolonged the pulse becomes more fre- quent and feeble, and the patient may die of sheer ex- haustion, or else suddenly from paralysis, and not spasm, of the heart. In either case it is a most cruel death. A patient who has had angina pectoris will surely have a return of it in time, unless the case be not far advanced, and the utmost care is observed. Death may occur in the first attack, or in any of those succeeding. It is absolutely uncertain. Arnold, of Rugby, died with it, as did the great John Hunter. In a lesser degree than just described, a patient may only have attacks of irregular rhythm (arythmic) or rapid pulse (tachycardia), with pain in the left arm. This pain may extend down the Avhole arm, or be con- fined to the left wrist only, or be indefinitely situated somewhere in the left breast. Or it may change from one of these localities to the other, now in the left arm, now only at the wrist, or even in one or more fingers of the left hand, now in the left shoulder. Diseases of the Heart that cause Sudden Death. Sudden death from heart disease is not so common as the laity generally suppose. There are certain forms of disease of the heart, however, which do undoubtedly cause sudden death, while other forms, though fatal from the first, give rise to complications which produce heart diseases causing scddex dkatii. 201 death indirectly rather than directly through the heart itself. (1) Aortic Regurgitation.—Not only may sudden death from cerebral apoplexy occur in this disease, due to the force Avith Avhich the blood is driven from the left ventricle, oAving to the existing dilated hyper- trophy of that part of the heart, but it may also occur in some Avay not yet thoroughly understood, but thought by some to be due to failure of the circulation in the nutrient vessels of the heart. It is claimed by some that, owing to the enormous enlargement of the left ventricle, which sometimes occurs in this disease, the coronary arteries are so pressed upon that blood cannot enter them, and the heart fails from want of blood supply. A case in point was that of a man of excellent habits, aged thirty-five, and otherwise in ap- parently good health. He was seen by Dr. Francis Delafield, of this city, at my request, and the diagno- sis confirmed. He died suddenly on his stairway, without cerebral lesion. (2) Angina Pectoris.—In this disease, as just de- scribed, the patient may die suddenly, not from spasm, but from paralysis of the heart, from failure of the cor- onary circulation, due to cardiac arterial sclerosis, and shock from the terrific pain. (3) Fatty Degeneration, or Metamorphosis (Quain's). —This also may lead to sudden death from sudden failure of the heart to act, or from rupture. (4) Extreme Dilatation,—hi this disease, also, the heart may suddenly fail or rupture. Dropsy and other complications, however, may and are likely to cause death before such a sudden catastrophe. 262 physical diagnosis. (5) Aneurism of the Heart.—Usually situated in the wall of the left ventricle near the apex, and almost impossible to distinguish between it and mitral regur- gitation. Both are accompanied with an apex systolic murmur, and both cause enlargement of the left ventri- cle. But in mitral regurgitation the murmur is usu- ally louder than in cardiac aneurism, and more fre- quently heard posteriorly, besides the accompanying enlargement of the right ventricle, with accentuation of the second sound over the pulmonary interspace, which are also usually observed in mitral regurgitation but not in cardiac aneurism. Sudden death in the latter disease is generally due to rupture of the heart. (6) Fibrosis of the heart, as sometimes results from syphilis, alcoholism, gout, rheumatism, and lead poi- soning. The muscular tissue becomes more and more replaced by connective tissue, instead of fat, as in fatty degeneration, until finally it fails to act. (7) Bright's Disease.—Lastly, in chronic interstitial nephritis, the left ventricle becomes enlarged, chiefly hypertrophied, while the arterioles are fibrosed and brittle. Hence cerebral apoplexy and sudden death not unfrequently occur in this disease. In many cases, it is preceded by retinal apoplexy, plainly to be ob- served with the ophthalmoscope, as in a typical case in which I called Dr. David Webster, of this city, in con- sultation about a year ago. Mitral regurgitation and obstruction are both almost necessarily fatal diseases when they occur early in life. They both lead to constant pulmonary congestion, with sequential dilated hypertrophy of the right ventricle and consequent hemorrhagic pulmonary infarction, or functional diseases of the hkakt. 263 cardiac dropsy, or both, as has been already described. The liver, spleen, kidneys, and gastro-intestinal tract are subject to refloated, if not chronic, congestion, Avith all the train of evils belonging to such a condition. Functional Diseases of the Heart. Palpitation, irregular rhythm, pain and syncope or fainting, are the chief so-called functional diseases of the heart. Little need be said about fainting and neu- ralgia as functional cardiac diseases, since they are found among the nervous and hysterical—chiefly anae- mic or spoilt and over-petted young women. Among the aged, or those having Aveak heart due to organic change, syncope has more significance. In any case, the patient lies down or falls, either one of which usu- ally causes reaction, as the heart has less to do with the body in the recumbent position. In those cases of neuralgia of the heart occurring in men of middle life or past, if the pain extend to the left arm and be ac- companied by palpitation or irregular rhythm, it usu- ally indicates cardiac arterial sclerosis, as already described. Palpitation.—All authors nearly agree that by pal- pitation of the heart is meant increased force of the heart's action as well as increased frequency. Flint, hoAvever, says that sometimes the heart's action may be feeble. Walshe describes three kinds of palpita- tion: (1) simple palpitation, where the heart's force is increased but the rhythm is regular and there is no increase of frequency; (2) irregularity in force and rhythm, occurring in paroxysms; and (3) increased frequency, with diminution of force. The second vari- 204 physical diagnosis. ety is the one usually referred to when speaking of palpitation. Of course palpitation of any kind may be coincident with, or due to, organic disease of the heart. But it may occur also in a perfectly normal heart, as proven by the normal size of the organ, which may be verified by the various methods of physical examination already described, the normal heart sounds, and the absence of adventitious sounds or murmurs. The causes of func- tional cardiac palpitation and irregular rhythm are so nearly allied that in stating one we state both. Irregular Rhythm.—This usually occurs with irreg- ular force also, and may be only momentary or last for several days or more. There is every conceivable kind of irregular rhythm, the enumeration of Avhich, as a learned author remarks, would allay curiosity rather than prove useful. Sometimes the heart intermits, with, of course, corresponding intermission in the radial pulse. Sometimes the radial pulse intermits when the heart does not. This may occur in two ways. If the heart is beating frequently and feebly, the pulse wave may not reach the wrist every time, though the heart does not intermit. This is termed false intermis- sion. Again, Avhile the left ventricle contracts once, the right ventricle may beat twice, giving two systolic cardiac shocks, with only one radial pulse. This is termed bigemmeny. These terms could be multiplied, but are of no practical use. Etiology.—Irregular rhythm, including intermission of the heart, may, like palpitation, be associated with, or even due to, organic cardiac disease. More fre- quently, however, they are both functional. There FUNCTIONAL DISEASES OF THE HEART. 2(55 appears to be no Aalvular lesion, in spite of the state- ment of authors, that is characterized by any particular palpitation or irregular rhythm. Cardiac arterial scle- rosis, fatty metamorphosis (Quain's), fibrosis, and aneu- rism of the heart, on the other hand, are productive of paroxysms of palpitation and irregular rhythm of every knoAvn kind. They are to be known by the physical and other signs of those diseases already described— never losing sight of the pain in the left arm. The causes of functional palpitation and irregular rhythm may be stated to be very much as Walshe has said. (1) Centric.—Chorea, epilepsy, hysteria, and cerebral and spinal irritation from any causes, especially cerebral irritation attended by insomnia, as from over study. The boy pianist, Joseph Hoffmann, recently Avas pre- vented from giving concerts in this city at the instance of the Society for the Prevention of Cruelty to Child- ren, one of the signs of his overwork being, as was testified to by one of his attending physicians, inter- mittent pulse, AAdiich proved to be due to cerebral as well as spinal irritation from overwork, both mental and bodily. (2) Reflex, or Eccentric Causes.—They include dys- pepsia in all its forms; intestinal irritation from worms or any other cause; articles of diet, as coffee, tea, and alcohol with many people; genito-urinary irritation, as seen in cases of gonorrhoea, cystitis, uter- ine catarrh, old stricture, ovarian diseases, and such like, including piles, fissure of the rectum, rectitis and proctitis. (3) Blood Poisoning and Ana mi'a.—Tobacco un- doubtedly plays a very important part in the produe- 266 PHYSICAL DIAGNOSIS. tion of heart diseases, both functional and organic. Except it be cocaine, there is, perhaps, no more perni- cious habit than the tobacco habit, especially, it is said, the smoking of cigarettes. Not all is positively known about the baneful effect of tobacco on the heait yet, but enough is known to make it certain that it causes palpitation, irregular rhythm, and cardiac ar- terial sclerosis with fatal angina pectoris. The mode in which this last condition is brought about from the tobacco habit is not certainly known, but it is so all the same. By tobacco habit is meant not one cigar or cigarette a day, or even two. Different people are dif- ferently affected by it. One or two cigars per day is habit for some, while others may smoke several, besides chewing. The Avorst cases of poisoning, and the so- called tobacco hearts, occur among tenement-house girls in this city who make cigars or cigarettes, or strip to- bacco, as it is called. Especially in the winter does this occur, when they work with the windows closed and are inhaling the dust and fumes of tobacco. Irregular rhythm, palpitation, and anaemia are common among those girls. Besides tobacco, there are the poisons of opium, malaria, and also of syphilis, lead, gout, rheumatism, and Bright's disease of the kidneys. (4) Mechanical.—'We see this in general emphysema, where, owing to obstruction to the pulmonary circula- tion, the heart becomes tired, and not only becomes irregular in rhythm at times, but often intermits so as to take a rest. In pressure from tight lacing, effusions from pleurisy, in pneumothorax, ovarian and other tumors, pregnancy, aneurism, and such like causes, the heart may palpitate, or intermit. In treating these THE SPIIYGMOGRAPH. 267 symptoms, therefore, the necessity of first ascertaining the cause in each case, with a view to its removal, if possible, is apparent. The Sphygmograph. The sphygmograph is an instrument used in obtain- ing graphic representations of the pulse. In like man- ner the cardiograph is used with regard to the impulse of the heart. Both instruments require great care in their use, as AArell as experience. Much time is often consumed in endeavoring to obtain these tracings, and as they are often quite unnecessary in making a diag- nosis such instruments are not likely to be of much value to the average practitioner. A few remarks re- garding the sphygmograph may not, however, be out of place. There are many of these instruments in use, but perhaps Marey's or Dudgeon's is as good as any. In fact, Dudgeon's is very readily applied, more so, in my experience, than any of the rest. According to Walshe, a pulse trace consists in a series of figures representing the successive cardiac circuits, or revolu- tions. Each figure consists of three parts for consideration: (1) the percussion stroke (up-stroke, line of ascent), (2) the apex, and (3) the downstroke (line of descent). The percussion, or upward stroke shoAvs the force and character of the pulse beat during ventricular systole. The apex is broad, medium or sharply pointed, accord- ing as the pulse is more or less sustained, so that it is broad in hypertrophy, the valves being perfect, but pointed in aortic regurgitation. Just as the point of the tracer falls a little, it rises again, forming what is 268 PHYSICAL DIAGNOSIS. termed the tidal wave. The percussion-stroke (up- stroke), the apex, and the tidal wave all belong to the first sound and systole. Noav comes the first period of silence, and the point of the tracer immediately drops into the aortic notch at the same time that the second sound is produced. Then follows the second period of rest, corresponding to the remainder of the downward- stroke (line of descent), marked first by the dicrotic wave, secondly, sometimes by a tricotic wave, or if there are many such waves, this part of the line of de- scent becomes polycrotic, or tremulous. Dicrotism, as well as tricotism, or even polycrotism, is due simply to the elastic recoil of the arteries, and need not be due to any abnormal condition, especially dicrotism. With the normal pulse, the percussion (up) strokes should be of the same length, so that the base, or respiration line, as it is called, of all the figures should be even and hori- zontal, as well as the apex line. In disease, however, these lines are subject to great irregularity. The sphygmographic tracings characteristic of various car- diac diseases are given at the time of describing those diseases, to which the reader is referred. Aortic Aneurism. The aorta is divided anatomically into three parts: (1) arch, (2) thoracic aorta, and (3) abdominal aorta. The arch consists of three portions, (1) ascending, (2) transverse, and (3) descending portion. (1) The ascend- ing portion of the arch, about two inches long, arises from the upper part of the left ventricle, on a level with the lower border of the left third costal cartilage, and behind the left edge of the sternum, behind and a AORTIC ANEURISM. 269 little beloAv, as well as to the right of the origin of the pulmonary artery (p. 187). It passes obliquely upward and to the right, to the upper border of the right second costo-sternal articulation. A needle pushed into the second interspace on the right, close to the right edge of the sternum, would penetrate the most prominent bulge of this portion of the aorta, and hence this space, as stated before, is termed the aortic inter- space. (2) The transverse portion of the arch com- mences at the upper border of the right second costo- sternal articulation, and arches from right to left, and from before backward, in front of the trachea and oesophagus, to the left side of the body of the third dorsal vertebra. (3) The descending portion of the arch extends from the left side of the body of the third dorsal vertebra doAAn to the loAver border of the left side of the body of the fourth dorsal vertebra. The thoracic aorta commences at the left lower bor- der of the fourth dorsal vertebra, and ends in front of the body of the last (twelfth) dorsal vertebra, at the aortic opening in the diaphragm, Avhere it becomes abdominal. Tlte abdominal aorta commences at the aortic open- ing of the diaphragm, in front of the body of the last (twelfth) dorsal vertebra, and descending a little to the left side of the vertebral column, terminates on the body of the fourth lumbar vertebra, commonly a little to the left of the median line, where it divides into the two common iliac arteries (Gray). Aneurism signifies a dilatation. According to Walshe, it is, in its widest sense, a local increase of calibre of an artery. Aortic aneurism, therefore, is a 270 PHYSICAL DIAGNOSIS. local increase of calibre, or a dilatation of the aorta in some part of its course. If it affect the aorta in any part of its course within the thorax, it is termed tho- racic aneurism, Avhether it be any portion of the arch, or thoracic aorta. It is termed abdominal aneurism when it affects the abdominal aorta in any part of its course. Classification.—There are various classifications of aortic aneurism, but the simplest is always the best. There are two classes, (1) dissecting and (2) circum- scribed. (1) Dissecting aortic aneurism usually be- longs to old age, and affects both sexes alike. It is caused by Aveakening and rupture of the internal and middle coats of the artery from fatty metamorphosis due to senile decay. Inasmuch as aneurism is said to be false Avhen all the coats of the artery are not dilated but some are ruptured or worn through, all dissecting aortic aneurisms are necessarily also false. Dissecting aneurism Avould also be said to be sacculated, fusiform, and the like, according to the shape assumed. (2) Circumscribed aortic aneurism is usually a man's disease, and occurring generally at middle life or past. Four fifths of the cases of thoracic, and about ninety per cent, of abdominal circumscribed aneurism, occur in men from forty to fifty years of age. This is due to the difference from women in the mode of life and occupation. About five per cent, of the cases occur before thirty, and in all such cases observed by me there has been a clear history of syphilis. Circumscribed aneurism may be false or true, ac- cording as to whether or not some of the coats have sustained solution of continuity from some cause. The AORTIC ANEURISM. 271 inner and middle coats usually give way in false aneu- rism, so that the sac is chiefly formed by the outer coat. But in case of wounds, the outer coat may yield, alloAving the middle coat to protrude, giving rise to Avhat is termed hernial false aneurism. If all the coats are ruptured, from Avounds or disease, a diffuse or, bet- ter, consecutive aneurism may result. When due to injury they usually occur in the case of smaller vessels than the aorta, since in the latter case the patient would be likely to bleed to death before the aneurism could be formed. Wherever they occur they usually become circumscribed. Other varieties are fusiform, cylindrical, or globular. Generally, hoAvever, circum- scribed aneurism is irregular in shape, causing it to be sacculated. And inasmuch as only the outer coat is often left to form the sac in such cases, circumscribed sacculated aneurism is also usually false. In the fusi- form variety, or AAhere there is slight and regular dila- tation, the aneurism is not infrequently true. Etiology.—Two classes of causes favor the produc- tion of aneurism: (1) increase of blood pressure, and (2) diminution of resisting power in the Avails of the ves- sel. (1) Increase of blood pressure is caused by heavy lifting or straining, occupations necessitating long- continued effort, compensating hypertrophy of the left ventricle in aortic regurgitation, and intemperance. The course of the artery must also be taken into con- sideration. The pressure will not be so great at any given point in an artery whose course is straight as it would be when the artery is curved. The sharper the curve is the greater will be the pressure, and this is always directed against the periphery. This is remark- 272 PHYSICAL DIAGNOSIS. ably well illustrated in cases of aortic aneurism. Of 880 cases collected by Sibson, 632 affected the arch, while only 71 occurred in the thoracic aorta, which is straight, as will be fully described presently. (2) The walls of the artery are weakened by surgical injuries, or by constitutional disease tending to produce arteri- tis, inherited or acquired. Of these causes, syphilis stands at the head and front. Lead poisoning proba- bly comes next. Then follow gout, rheumatism, and renal disease. Sometimes predisposition to aneurism seems to be inherited, so that it Avill be handed down from parents to children for several generations. Relative Frequency of Site.—-Of 880 cases collected by Sibson, 87 Avere situated in the sinuses of Valsalva, 193 in the ascending portion of the arch, 140 in the ascending and transverse portion of the arch, 120 in the transverse portion of the arch, 20 in the transverse and descending portion of the arch, and 72 in the de- scending portion of the arch. That is to sayT, of 880 cases of aortic aneurism, 632 occurred in the arch alone. Of these, 420 cases occurred in the ascending portion, 140 in the transverse, and 72 in the descending portion of the arch. The thoracic aorta was affected in only 71 cases, and the abdominal aorta in 177. The principal reason for this marked difference in the frequency of aneurism in the parts of the aorta, as just given, is OAving to the course which the vessel takes. In the arch, of course, and especially the ascending and transverse portions, the blood pressure is much greater than where the vessel is straight. Not only that, but the arch is nearest to the heart to re- ceive all its force. In the descending portion of the AORTIC ANEURISM. 273 arch the number of cases was only 72, and in the tho- racic aorta, only 71, both on account of the straight course of the vessel, and differing only by one case. But when Ave come to the abdominal aorta the number rises to 177. Here the artery is much more exposed to injury than it is in the thoracic cavity. Moreover, the abdominal aorta is subject to be bent on itself, or —Aom.— --------- ARCH ar/tORT*. T-------. ijj Tom/:._____________._ 68Q. Fig. 31.—Schematic Diagram of Relative Frequency of Site of Aortic Aneurism. put on the stretch, or tAvisted, and, in a word, to be changed in its direction with every movement of which the body is susceptible. In heavy lifting, wrestling, the performances of athletes, and the effort at recover- ing one's position when suddenly thrown off the bal- ance by simple accident, all put a strain on the ab- dominal aorta, the habitual reception of which not only tends to make that vessel brittle, but often is the immediate cause of abdominal aneurism. Bartholow 18 ~< 274 PHYSICAL DIAGNOSIS. states that he has never knoAvn a case of abdominal aneurism that could not be directly traced to some act of violence. Symptoms.—In thoracic aneurism these may com- mence suddenly, as if something had given way, but much more frequently they come on gradually, with failing health. There is pain, which is usually fixed, but radiating. Pain is one of the first and most fre- quent symptoms of aortic aneurism in any part of the vessel. It may and often does, exacerbate and remit, but it is usually an early and a persistent symptom. It is usually deep seated, extending through from before back. Instead of actual pain it is sometimes described by the patient as a feeling of soreness limited to a small area. Besides pain, there are dyspnoea, with more or less hoarse, stridulous cough, and alteration of voice. The dyspnoea is of two kinds, (1) constant and increasing and also (2) paroxysmal. The constant and increasing dyspnoea of course is due to the grow- ing aneurismal tumor pressing upon and displacing important portions of the organs of respiration. The paroxysmal dyspnoea, however, occurs in three ways: (1) it may be due to spasm of the glottis, owing to irri- tation of the recurrent laryngeal nerves from pressure of the aneurism; (2) paralytic closure of the glottis from paralysis of these nerves from pressure of the aneurismal tumor; and (3) pressure on the trachea with accumulation of mucus at that point. Paralytic closure of the glottis, due to pressure from the tumor, is neces- sarily a dangerous and often fatal symptom. The greater the effort at inspiration, the more completely are the walls of the larynx sucked together. Dys- AORTIC ANEURISM. 275 phagia from pressure on the oesophagus is not common, but headache due to obstruction to the return circula- tion of the blood is not infrequent. Sometimes there is disordered vision, owing to the change produced in the size of one or both pupils from pressure by the aneurismal tumor on the sympathetic nerves. One or both may be contracted or dilated, according as the sympathetic nerves are irritated or paralyzed. Slight haemoptysis is of ordinary occurrence, the blood being mingled Avith the sputa. This slight haemoptysis is due to bronchial congestion or pulmonary irritation, and is totally different from the rush of blood due to rupture of the sac. The patient gradually loses flesh and often has a careAvorn, Avearied appearance. We see, therefore, that in thoracic aneurism, inward press- ure signs, as they are termed, are ahvays more or less prominent. In abdominal aneurism, on the other hand, Avith the exception of pain, which is present here as well as in thoracic aneurism, there are very few symp- toms to be described by the patient. The onset of abdominal aneurism is, however, usually sudden. In- deed, Bartholow states that in all the cases of abdominal aneurism observed by him, the onset was sudden and definite, and traced to some act of violence, as sudden lifting of a heavy weight, wrestling, falling, or the like. Physical Signs.— These differ according to the part of the aorta affected, the arch, the thoracic aorta, or the abdominal aorta. We will therefore consider them in their regular order. 276 PHYSICAL DIAGNOSIS. I. The Arch of the Aorta. Inspection.—At first, inspection may be purely nega- tive. But after the aneurismal tumor has become suffi- ciently increased in size, a local bulging, or pulsating tumor, synchronous in its pulsations with the heart's systole, is usually observed at the right edge of the sternum in the second interspace, Avhen the ascending portion of the arch is affected. This is by far the most common site for aneurism of the arch, since the ascend- ing portion is most frequently affected. The tumor gradually increases downward to the right, pushing the apex of the heart downAvard and to the left. If the transverse portion of the arch is affected, the tumor may push forward the top of the sternum. Or it may appear on the left of the sternum, or at the base of the neck, according to the portion of the arch affected, and other circumstances. Pulsation may sometimes be noticed even in the interscapular region of the left side, if the descending portion of the arch be affected. The aneurismal tumor does not always pulsate. This occurs when the sac is filled to a great extent with fibrin, through which a small stream of blood flows, and especially if the descending portion of the arch be affected and the heart is weak. If the aneurism press on the superior vena cava, there will be enlargement of the A-eins on both sides of the neck, Avith more or less lividity of the face. But if the tumor press on one innominate vein only, enlargement of the veins and lividity of the face will be observed on the correspond- ing side only. The patient is not infrequently observed to have lost someAAhat in flesh. the arch of the aorta. 277 Palpation.—Two centres of pulsation, synchronous with systole, are usually felt, one due to the impulse of the heart, the other to the aneurism. The pulsation caused by the aneurism is usually accompanied by thrill, unless the sac is greatly filled with fibrin. In Fig. 32.—Aneurism of Ascending Portion of Arch in a German woman, set. 48. Death from Rupture into Pericardial Sac. that case, thrill may be, and usually is, entirely absent. Indeed, in these cases, also, the systolic impulse of the tumor may be so feeble that it can scarcely be observed. In aneurism of the transverse portion of the arch the pulse is weaker at the left wrist, and on the left side of 278 PHYSICAL DIAGNOSIS. the head and neck, than the right. This was beauti- fully illustrated in a patient recently examined at my request by Drs. Edward G. Janeway, Francis Delafield, Alfred L. Loomis, and John A. Wyeth, of this city. The patient Avas sent to Mt. Sinai Hospital, where Dr. Wyeth ligated the left common carotid and left sub- clavian arteries with every prospect of success, but the patient unfortunately died of pneumonia and syphilitic pulmonary deposits. Post-mortem examination showed the absolute accuracy of the diagnosis of aneurism of the transverse portion of the arch extending to the junc- tion of the descending portion. There was no dysphagia, but the aneurismal sac, filled Avith fibrin, Avas adherent to the trachea for about an inch and a half, causing most distressing dyspnoea. In these cases, as also hap- pens sometimes in aneurism of the descending portion of the arch, the pulsation of the aneurism may be felt in the suprasternal notch by pressing the finger well doAvn into it with the patient's head bent forward. The vocal fremitus over the tumor is usually dimin- ished or absent, according to the size of the aneurism and displacement of lung tissue. Pressure on a large bronchial tube also may so obstruct the convection of the voice sound that the vocal fremitus may be entirely absent over the corresponding area. Percussion.—This should be gently performed over the tumor, otherAvise it causes great suffering to the patient, to say nothing of the danger of rupture of the aneurismal sac. For this reason auscultatory percus- sion is the best method, since it is performed very gent- ly. Dullness is elicited over and immediately around the tumor, and the dullness Avill be marked in propor THE arch of the aorta. 279 tion to the size and locality of the tumor. If it be small and deep seated, the quality of the percussion note may be very little changed. On the other hand, if the tumor be large and superficial the quality may be nearly or quite flat. It is of great importance to observe Avhether the dullness extends continuously out toAvard the acromial angle, over pulmonary tissue, or across the median line. The latter sign would be a sure indication of the presence of a tumor of some sort in the mediastinum. If the descending or transverse portions of the arch be affected, but especially the de- scending, dullness on percussion may be obtained in the interscapular region of the left side. Auscultation.—The aneurismal sounds usually pres- ent are most audible directly over the tumor. The aneurismal systolic shock is usually accompanied by a bruit, or murmur, which is louder than the heart sounds and usually lower in pitch, especially when blowing in quality. The bruit or murmur may, however, be rasp- ing or filing in quality, and then the pitch may be high. Sometimes it is roaring or whistling. Besides the systolic bruit, there may be also a dias- tolic murmur, which is usually softer than the first, and causing with it the to-and-fro sound. The aneurismal bruit is usually heard in front, but it is sometimes even heard posteriorly, in the interscapular space of the left side, if the descending portion of the arch be affected. There is diminution or absence of the respiratory mur- mur over the tumor, and pressure on a bronchial tube may produce atelectasis for a corresponding area of pulmonary tissue (see p. 60). Owing to the presence usually of secondary localized bronchitis and a little 280 PHYSICAL DIAGNOSIS. solidified lung tissue from pressure or local inflamma- tion near the tumor, rales, bronchial breathing, bron- chophony, and increased vocal fremitus over a corre- sponding small area, may be obtained. Diagnosis.—To differentiate between aneurism of the three portions of the arch Ave must bear in mind, first, that the ascending portion is by far more fre- quently affected than the others, the transverse portion being next in order, and, lastly, the descending portion. When the ascending portion of the arch is the seat of the aneurism, the tumor, as already stated, usually ap- pears in the second interspace at the right edge of the sternum, and gradually increases downward to the right, pushing the apex of the heart downward and to the left. Occurring in the transverse portion, it pushes the manubrium forward or appears at the left of the sternum. Aneurism of the transverse portion of the arch causes a weaker pulse at the left wrist and on the left side of the head and neck than on the right, Avith pulsation in the suprasternal notch, and sometimes dullness on percussion, even in the interscapular region of the left side. Pressure on the trachea and oesophagus is more marked in these cases also. In case of aneurism of the descending portion of the arch of the aorta, there are pain in the interscapular region of the left side, dull- ness on percussion; and sometimes a pulsation is ob- served there, with a bruit on auscultation. Pulsation may also be sometimes felt in the suprasternal notch from aneurism of the descending portion of the arch, but not so distinctly as when the transverse portion is affected. THE ARCH OF THK AORTA. 281 Arteria Innominata.—Aneurism of this vessel pul- sates behind, or above, the inner part of the clavicle, causes weaker pulse on the right side than the left, and is rarely attended Avith dysphagia or tracheal pressure, but more frequently with pain or paralytic symptoms in the right arm. Pulsation of this aneur- ism diminishes or ceases from compression beyond the tumor. Consolidation of pulmonary tissue from phthisis or syphilis, would give rise to dullness, which, however, would extend outAvard to the acromial angle, but not across the median line. There Avould also be wanting the inward pressure signs of aneurism. In the case of suspected pulmonary syphiloma, the failure of proper antisyphilitic treatment would rather favor the pres- ence of aneurism. Cancer of lungs may be associated with cancer of the mediastinal glands, which, becoming enlarged, would give rise to dullness that extended across the median line. But infiltrated cancer causes retraction of the chest Avails instead of bulging, and there are no imvard pressure signs. The cancerous cachexia and appear- ance of cancer elseAvhere would establish the diagnosis. Mediastinal tumors are the most difficult to differ- entiate. But unless associated with infiltrated cancer of the lungs or elsewhere, they usually occur in women under twenty-five, which aneurism rarely, if it ever does. Such tumors are usually also associated with currant-jelly (cancerous) expectoration, distention of the superficial veins on the chest, sometimes cedema of the chest and arm, and they may also exist elsewhere. Coarctation and stricture of the aorta will give rise 282 PHYSICAL DIAGNOSIS. to a systolic murmur, but they cause no bulging to be observed on inspection, no dullness on percussion, and no pressure signs. They usually result from syphilis, and coarctation is sometimes a congenital malforma- tion. Pulsating empyema is easily distinguished by the equality of the radial pulse, the absence of murmurs and thrill, as well as of tracheal, oesophageal, and laryngeal symptoms. It might occur to the practitioner to explore with a fine needle in order to set the ques- tion at rest, but this should not be done unless abso- lutely necessary, which is rarely the case, since emboli might be detached which would prove to be trouble- some, if not fatal. Pericardial effusion gives rise to prominence of the praecordial region, with more or less dyspnoea some- times, and marked dullness on percussion; but the area of dullness is somewhat triangular, with the base down, aneurism, perhaps, never. Subperiosteal abscess of the sternum may cause some prominence of the sternum, with dullness on percus- sion, but the inward pressure signs and all other signs of aneurism are wanting. Cardiac hypertrophy causes only one centre of mo- tion ; when aneurism is present there are usually two. The aneurism may be situated, however, very close to the heart, and associated with aortic regurgitation and enlargement of the left ventricle. The absence of pressure signs and the presence of dropsy both favor cardiac disease. In aortic regurgitation, also, the pulse characteristic of that disease, and felt equally at both wrists, would be against aneurism. THORACIC AORTA. 283 II. Thoracic Aorta. Aneurism of the thoracic aorta is not so easily recog- nized as when it occurs in the ascending and transverse portions of the arch. From a number of cases reported by Deputy-coroner Jenkins, of this city, and referred to by Dr. H. M. Biggs in a Aery interesting paper on this subject, read before the Section in Practice, New York Academy of Medicine, in February, 1888, it ap- pears that not infrequently the cause of sudden death was due to rupture of unsuspected aneurism of the thoracic aorta. Owing to the position of the vessel, the physical signs are referable to the left side of the spinal column rather than the right, though an excep- tion to this rule is rarely met with. Pain in this case, as elsewhere, is one of the symptoms, and usually con- sists of a gnawing sensation felt in the dorsal vertebrae. These may become eroded in time, and give rise to curvature of the spine. Bulging in a few cases may be noticed posteriorly, but dullness on percussion, over a circumscribed area, corresponding to the aneurism, is much more frequent. On auscultation a bruit may be heard, but is often absent. Owing to want of physical signs the aneurism often escapes detection, as already stated. Laryngeal symptoms are, of course, usually wanting, but there may be dysphagia from pressure on the oesophagus. The disease may be mistaken for pleurisy with effusion in some instances, so that the exploring needle alone could enable one to distinguish between them. 284 PHYSICAL DIAGNOSIS. III. Abdominal Aorta. The symptoms in this case have reference to pressure on abdominal organs. Pain, as in aneurism elsewhere, is one of the first symptoms. It may be local, or it may extend along the branches of the lumbar plexus. Jaundice from pressure on the bile duct is not common, but sometimes occurs. Changes in the urine from pressure on the renal vessels is even more rare. But nausea and vomiting are not infrequent, due to press- ure against the stomach. Inspection.—This is usually negative in its results, but in case of an emaciated patient, pulsation of the tumor may be visible in the recumbent dorsal position. Palpation.—A pulsating tumor is usually felt some- what to the left of the median line. The pulsation is synchronous with the cardiac systole, and is described as expansile in character—that is, it expands in all directions under the grasp of the hand. Thrill may also be present. Some authors describe this pulsation as post systolic, or coming just after the systole of the heart. Others regard it as purely systolic. Percussion.—If the tumor is of considerable size there is dullness on percussion. But this is the least constant physical sign, owing to the presence of gas in the neighboring viscera. Auscultation.—A systolic bruit may or may not be present here as elsewhere. If the tumor be well filled with fibrin there will be no bruit. Diastolic bruit is rare, but Avhen present is thought to be diagnostic of the presence of aneurism. Pulsation of the abdominal aorta may be mistaken ABDOMINAL AOKTA. 285 for abdominal aneurism. But in the former case the pulsation will be along the course of the vessel, giving, under palpation, the sense of a pulsating cord rather than an expansile tumor. The fact that such pulsa- tions of the aorta usually occur in young and nervous women Avith thin abdominal Avails, rather than in middle-aged men, also is against aneurism. Pulsating tumors may also simulate aneurism and be even accompanied by a bruit. But by placing the patient in the knee-chest position the pulsation at once ceases if it be not aneurism, since the tumor simply graAutates aAvay from the aorta and no longer has its pulsations imparted to it. In case of a young hysteri- cal woman, recently examined by me at the Polyclinic, there was a distinct pulsating tumor felt over the ab- dominal aorta. The pulsation immediately ceased in the knee-chest position, and as she gave the history of constipation, I concluded that it Avas a case of impacted faeces. A dose of castor oil confirmed the diagnosis, by causing a large evacuation of the bowels and disap- pearance of the tumor. In this case I may add that the tumor had a distinctly boggy feeling, and was not expansile, but simply thumping under palpation. QUESTIONS ON PHYSICAL SIGNS OF THE HEALTHY CHEST, AND OF DISEASES COMMONLY MET WITH AS AFFECTING THE ORGANS OF RES- PIRATION AND THE HEART. ARRANGED IN SIX LESSONS. LESSON I. EXAMINATION OF THE CHEST IN'HEALTH. Q. What does the term diagnosis signify? A. The distinguishing health from disease and one disease from another, from the Greek dia between, and gnosis knowledge. Q. By how many ways do we chiefly arrive at a diagnosis in any given case? A. Two. The symptoms (also called the subjective or rational signs) and the physical signs. Q. The symptoms are related by the patient or friends and are often misleading. But what are the physical signs? A. The physical signs (also called the objective signs) are those that are to be recognized by the ex- aminer's special senses, particularly sight, touch, and hearing. Q. What, then, is physical diagnosis? A. The art of distinguishing health from disease 288 PHYSICAL DIAGNOSIS. and one disease from another by means of the physi- cal signs presented in each case. And in order to un- derstand the physical signs of disease, it is evidently necessary first to know them in health. Being emi- nently a logical science, it is by the application of principles of well-known physical laws, rather than memory, that a correct and logical conclusion may be arrived at in a given case. Q. The special senses used for the detection of physical signs be- ing chiefly sight, touch, and hearing, which of these would natu- rally come first in order, in the physical examination of the chest? A. Sight, so that naturally we would first inspect the patient. 1. Inspection. Q. What is inspection? A. The act of looking at, or examining by the spe- cial sense of sight. Q. In order to inspect the chest thoroughly it may become neces- sary to request the patient to strip off the clothing down to the waist, which should always be done in a warm and comfortable room. We begin by inspecting anteriorly. What do we notice here in a healthy chest? A. That even in a healthy chest, the two sides are not always exactly alike. In other words, a perfectly symmetrical chest is rare. Thus among laboring people, especially, the muscles of one side, the right for obvious reasons, are more developed than on the other. Q. Are both shoulders necessarily on the same level? A. No. One shoulder may be lower than the other owing to occupation, as is sometimes the case among INSPECTION. 289 hod-carriers, tailors, and the like; or to previous frac- ture of the clavicle or slight curvature of the spine. Such disparities may be compatible with perfectly healthy chests. Q. Do we always see the apex-beat of the heart in the healthy chest? A. No. It may or may not be noticed on inspection, depending a good deal on the thickness of the chest- walls. Or the costal cartilages may be closer together and broader in some than others, and the heart itself varies in depth of situation in the thorax. Q. If we do see the apex-beat, where should it be normally? A. Between the fifth and sixth ribs, or in the fifth intercostal space about an inch and a half below the left nipple and a half-inch within the nipple line. Authors differ somewhat, however, as to the exact lo- cality. Gray, for instance, puts it two inches below and one inch within the left nipple, but it requires a very tall person for such measurements. Q. What is the nipple line? A. The nipple (mammillary or papillary) line is a line drawn vertically through the nipple. Q. Suppose the nipple «is misplaced, as among nursing women, or congenitally, or suppose it is absent altogether from surgical operation, or otherwise, how then would you locate the apex-beat? A. By letting a line fall vertically from the middle point of the clavicle, or through a point in the fifth intercostal space about two and one-half inches from the median line of the sternum,—anterior median line. The point of the apex-beat varies in deformities from old age or other cause. 19 290 PHYSICAL DIAGNOSIS. Q. Do both sides expand alike on inspection of the healthy chest? A. They do. If any difference is noticed on inspec- tion, the probabilities are that one side is more or less restrained from pain due to fractured ribs, neuralgia, pleurodynia, or pleurisy, for instance, or else one lung is crippled by disease, or held down by pleuritic adhe- sion and the like, while the other does extra work. On measurement, however, the right lung is usually found to expand about a quarter of an inch more than the left. Q. Is there any difference between the breathing of men and women ? A. Yes. Abdominal respiration is more noticeable in men, superior costal respiration (the heaving chest) in women. Q. Why is this? A. The upper part of a woman's chest expands more than a man's to allow for child-bearing, the diaphragm in men being a more powerful and impor- tant muscle of respiration than in women. Up to puberty, boys and girls breathe alike. From puberty to the menopause the difference is most noticeable. After the menopause women breathe more and more like old men. Q. On inspection of the healthy chest posteriorly, what do we notice? A. That the shoulders, as already stated, may or may not be on the same level, that there is even ex- pansion of both sides, and the scapulae move up and down evenly. Sometimes there is a little general lat- eral curvature of the spine caused by the stronger INSPECTION. 291 muscles of one side pulling the spinal column in that direction. This is different from angular curvature, or kyphosis, which is due to caries of the vertebrae. Q. Is uneven movement of the scapulae always indicative of disease? A. No. It sometimes happens in choreic persons, or those addicted to drink, or nervous from any cause, also among the hysterical, and impostors, that first one scapula and then the other will move more notice- ably during respiration. Such movement is due to muscular contractions rather than thoracic expansion. Q. In lateral inspection what is the position of the patient's hands? A. The hand of the side inspected should be placed on the head. When inspecting anteriorly or posteri- orly, the patient's hands should hang loosely and nat- urally by the side. In fact lateral inspection is often best performed while examining the patient anteriorly or posteriorly. Q. While inspecting the chest in general, what are the chief points to be noticed ? A. The position of the apex-beat, the frequency, force and regularity of the cardiac pulsations, abnor- mal centres of pulsations, bulging or flattening of the chest walls, depression above and beloAV the clavicles, exaggerated respiratory movements on one side with diminution of those movements on the other, the fre- quency and character of respirations, the shape of the thorax, the presence of tumors, the general condition of the patient and of the superficial veins, also the number of respirations per minute. For the latter 292 PHYSICAL DIAGNOSIS. object the chest in Avomen and abdomen in men should be observed. 2. Palpation of the Healthy Chest. Q. Having inspected the thorax, or examined the patient physi- cally by the special sense of sight, what would naturally be the second procedure in the regular order of examination? A. Palpation. Q. What is palpation ? A. The act of touching or feeling. It has reference to the second special sense, or that of touch. It is usually performed with the hands, particularly the finger-tips, as the latter are specially adapted to feel- ing. But it is sometimes convenient to palpate with the ear while auscultating, so as to combine the two. Q. What is the usual position of the examiner and patient during palpation of the chest? A. The examiner should be directly in front of, or behind the patient. The hands should be warm. For palpating in front, the patient's hands should hang loosely by the side. For palpating posteriorly the pa- tient should place the right hand on the left shoulder and the left hand on the right shoulder and then bend slightly forward. In this way the scapulae are moved out of the way and the tissues in the back rendered more tense. This is known as Corson's position. For palpating laterally the patient's hands should be placed on the head. Q. What is usually the chief object in palpation of the thorax? A. To ascertain if the vocal fremitus be normal, in- creased, diminished, or absent. palpation of the healthy chest. 293 Q. What is fremitus? A. Vibration, thrill, or jarring. If made by the voice it is called Arocal fremitus, or fremitus simply, as it is the kind most commonly referred to. If made by the cough, where the patient has lost the voice, for instance, it is called tussive or tussile fremitus. When due to rales, as sometimes occurs, it is termed rhon- chal or rhonchial fremitus. In like manner there may be a friction fremitus as sometimes occurs with inflammation of serous membranes, as in pleurisy, and a splashing fremitus as may be produced on shaking the patient in pneumohydrothorax. Q. Is the vocal fremitus equally felt on both sides of the healthy chest? A. No, it is more marked on the patient's right side than the left, for the chief reason that the right primitive bronchial tube is larger than the left and so conveys more voice into the right side of the chest than the left. Moreover, the small left bronchus lies deeply under the arch of the aorta, and the septum between the two is to the left of the median line. The right bronchial tube is therefore the natural continu- ation of the trachea, and foreign bodies getting into the trachea naturally drift into the right bronchus. It is reasonable, therefore, to believe that a larger volume of the voice is conveyed by the right bronchial tube than the left. Consequently the fremitus is al- ways normally exaggerated (slightly increased) on the right side of healthy chests, as compared with the left. 294 physical diagnosis. Q. Of what value is it to know that there is exaggerated vocal fremitus under the right clavicle in the healthy chest? A. Because it is also a sign of incomplete solidifica- tion of lung tissue, as observed in the first stage of phthisis. Q. Do all people have the same amount of fremitus in health? A. No. Thus, other things equal, a person with a loud bass voice will have more fremitus than one with a sharp tenor voice for obvious reasons; hence, men generally have more fremitus than women, and grown people than children. Again, a raw-boned, large chest would yield more fremitus with the same voice than a chest covered up with fat or muscle. Q. What two factprs then chiefly determine the amount of frem- itus in health? A. The character of the voice and conformation of the chest walls. We would, therefore, expect to ob- tain the maximum amount of fremitus, among healthy people, in a large raw-boned man with a deep bass voice, and the minimum in a little fat-chested woman or child with a thready voice. Q. In order to detect vocal fremitus, of course, the patient has to make use of the voice. What is usually said ? A. Ninety-nine, nineteen, one, two, three, or any simple phrase that can be repeated over and over again on the same key or pitch. The lower the pitch the greater the fremitus as in the case of the bass voice, and vice versa in the case of the tenor voice, as already mentioned. Q. Why does a low-pitched sound, other things equal, give more fremitus than a high-pitched one? palpation of the healthy chest. 295 A. Because the lower the pitch the longer and stronger the vibrations, and conversely the higher the pitch the shorter and weaker the vibrations. Compare the bass-viol with the violin, for instance. Q. Of what importance is the vocal fremitus? A. It may be increased or diminished, or even ab- sent. Increase of fremitus usually indicates more or less solidification of lung tissue, which becomes a di- rect transmitter or better conductor of sound, as will be fully explained. Diminution of fremitus may be caused by obstruction to convection of sound in the bronchial tubes by accumulation of mucus, blood, or pus and the like in the tubes, or by pressure on the tubes, as, for instance, in thoracic aneurism sometimes, or other tumor. It is also diminished by increased re- fractive (or diffusive) power of the lungs, as seen in vesicular emphysema, where the air-cells are enlarged and the lungs are more spongy than in health. The fremitus may also be diminished or even absent by interception of the voice as in pleuritic thickening or effusion. The fremitus is particularly important in making a diagnosis between pleurisy and pneu- monia. Q. What are some other objects in palpation besides detecting vocal fremitus or other fremitus? A. Locating the apex-beat of the heart and ascer- taining the character of the cardiac impulse, detecting other centres of pulsation if any exist, feeling the pulse, and noting the apparent surface temperature, condition of the skin, and the like. 296 PHYSICAL DIAGNOSIS. Q. Having inspected and palpated the patient, what would be the next procedure? A. Percussion, unless examining for life insurance, and then measurement or mensuration of the chest may be done, chiefly to ascertain its size in proportion to the applicant's height, and amount of expansion. But it is not usually necessary as a means of diagnosis. 3. Percussion. Q. What is percussion ? A. The act of striking. Q. How may ways are there of percussing in physical diagnosis? A. Two, immediate and mediate; the former di- rectly Avith the percussion hammer or end of the finger, and mediate percusson by means of a pleximeter. Q. What is the history of percussion in physical diagnosis? A. Auenbrugger of Vienna first used percussion as a means in physical diagnosis in 1761. He died in 1809, and percussion was then forgotten. He made use of immediate percussion only. It was not until 1828 that Piorry, of Paris, invented the pleximeter. Q. What is palpatory percussion? A. It is percussion where the finger is used as the pleximeter. In this way the finger is not only a plex- imeter but it enables one to feel the sense of resistance offered by various tissues, as solidified lung, pleurisy with effusion, and the like. For this reason palpatory percussion, or percussion on the finger, was always preferred by Piorry. Q. What other modes of percussion are there? PERCUSSION. 297 A. Respiratory percussion is highly recommended by Da Costa, That is percussion at the end of expira- tion and inspiration, the patient holding the breath in each case, and noting the difference. This is gener- ally of little use, however, as it varies in different people and is impracticable in ordinary respiration. It is very important, on the contrary, sometimes, as for instance in determining enlarged spleen or liver, for these two organs move up and down with full respira- tion, while pleuritic effusions do not. Wintrich in 1811 invented the percussion hammer, and in 1810 Dr. Camman, of New York, introduced auscultatory percussion, or percussion while auscultat- ing with the stethoscope at the same time. Q. What are the elements or properties of sound? A. They are quality, pitch, duration, and intensity or amount. Of these, quality is by far the most im- portant. Q. Is the percussion resonance the same all over the healthy chest? A. No, it differs for different regions. Thus, under the left clavicle and in both axillae we obtain what is termed the normal pulmonary resonance, which is also called the normal vesicular resonance, or normal per- cussion resonance. Over the heart and scapulae it is more or less dull. But in general it is slightly duller over the right side than the left, notably under the right clavicle and right scapula. Q. Why is it duller in those localities? A. Because most people are right-handed, and the right muscles are harder if not thicker than on the 298 PHYSICAL DIAGNOSIS. left, especially among laboring people. Under the right scapula, the right lobe of the liver and thick muscles of the back usually cause a little more dulness than on the left side. Q. What other reasons have been given for this dulness under the right clavicle? A. One was that the right lobe of the liver acting as a solid foundation for the right lung would cause slight dulness over that lung as compared with the left, which is in relation to the large end of the stom- ach. But filling the stomach with water or milk does not cause any difference, and Guttmann by a series of experiments proved that the right lobe of the liver had no influence over percussion resonance at the top of the lung. Another reason given was that the right bron- chial tube and its branches with their muscular coats and connective tissue caused an anatomical difference which would account for the slight dulness on the right side. The right muscles being harder and thicker is at present the cause usually assigned. Q. Of what value is it to know that we often obtain slight dulness on percussion under the right clavicle in the healthy chest? A. Because it is a sign of incomplete solidification of lung tissue as observed in the first stage of phthisis. 1. Auscultation. Q. Having inspected, palpated, and percussed the chest, we now come to auscultation. What is auscultation? A. Auscultation is the act of listening. It may be done immediately with the ear or mediately by means of the stethoscope. auscultation. 299 Q. What is the history of auscultation in physical diagnosis? A. Hippocrates, 460-375 B.C., first made use of aus- cultation, but it was only to hear the splashing sound produced in a cavity containing fluid and air by shak- ing the patient. This shaking the patient while aus- culting is termed succussion. But Laennec, of the Necker Hospital in Paris, first made use of ausculta- tion as it is now understood. He invented the stetho- scope in 1816. It Avas, however, the single stetho- scope. In 1810 Camman, of New York, invented the binaural stethoscope. Q. What is the danger of the binaural stethoscope? A. The ear-pieces may not fit or else the spring may be strong, and either of those conditions may cause otitis and subsequent deafness. The spring should be guarded and the pressure regulated by means of a graduated screw or some other device. Q. On auscultation of the organs of respiration, in general what do we listen for? A. Three things: (1) the respiratory murmur; (2) the vocal resonance, and (3) adventitious sounds. Q. In the healthy chest the respiratory murmur is, of course, normal. Is the normal respiratory murmur the same all over the healthy chest? A. No. Under the left clavicle, in both axillae, and under the scapulae in health we expect to hear the normal vesicular respiratory murmur. Q. What is the normal vesicular respiratory murmur? A. It is composed of inspiration and expiration. Inspiration is breezy or rustling or vesicular in qual- ity, and about four or five times longer than expira- 300 PHYSICAL DIAGNOSIS. tion. In fact, the expiratory part of the murmur is sometimes unheard, it is so soft. Q. How does the normal respiratory murmur under the patient's left clavicle differ from that under the right? A. In the right there is a tubular element in the murmur not heard on the left, and expiration is pro- longed. It is, in fact, the normal vesiculo-bronchial respiratory murmur, and often resembles that heard over incomplete solidification of lung tissue, as observed in the early stage of phthisis. In health it is due to presence of the right bronchial tube and its branches. In disease, when heard on the left side, for instance, it would be due to incomplete obliteration of air-cells. Finally, when solidification is complete and the air- cells entirely obliterated, with nothing but bronchial tubes left, the breathing would become purely bron- chial. Q. Of what value is it to know that vesiculo-bronchial breathing already exists in the right infra-clavicular space in health? A. Because it might be mistaken as a sign of in- complete solidification of lung tissue, which it would indicate if it occurred on the left side. This is the third sign of early phthisis on the right side of the healthy chest, as we have already had exaggerated vocal fremitus on palpation, and slight dulness on percussion. Q. What does wavy, jerky, interrupted, or cog-wheel respiratory murmur signify? A. Nothing beyond palpitation of the heart or ner- vousness, and is chiefly observed among women, espe- cially on the left side over the heart. Formerly it was auscultation. 301 thought to be due to forcing air through tubes stric- tured by tubercles, but as observed by the author, Williams of the Brompton Hospital, London, and others, it is of no value, and often heard in persons whose lungs are perfectly normal. Q. What is puerile respiratory murmur? A. That heard in children before puberty. The chest walls are usually thin and the bronchial tubes more developed in proportion to the imperfect air-cells. The murmur is therefore louder, less vesicular, and more bronchial than it is afterward. Q. What is exaggerated respiratory murmur? A. It is also called supplementary and hypervesicu- lar. It occurs where one lung or portion of a lung is doing extra work from crippling the other lung. It is simply more distinct than the normal murmur. Q. What is harsh respiratory murmur? A. Harsh breathing is also called rough, and any variety of respiratory murmur may be harsh (rough) if the bronchial mucous membrane is harsh or rough, so that the tidal air rubbing against it imparts to it a harshness (roughness). Q. Having listened for the respiratory murmur, what then? A. Secondly, we listen for the vocal resonance. Q. What is the normal vocal resonance? A. It is the sound of the voice of the patient in health as heard while amsculting the chest. It is distant, diffused, indistinct, and buzzing. It is also called the normal pectoral voice, or normal pecto- rophony. 302 PHYSICAL DIAGNOSIS. Q. Do all healthy people have the same amount of normal vocal resonance? A. No. It varies with the character of the voice and the conformation of the chest walls, like the fremitus. Q. Is normal vocal resonance the same all over the healthy chest? A. No. It is slightly increased or exaggerated in the right infra-clavicular region and elsewhere, like the fremitus, and for the same reason. In fact, as the fremitus varies with the resonance, whatever has been said already about the former equally applies to the latter. Q. Of what value is it to know that normally we hear exaggerated vocal resonance in the right infra-clavicular region? A. On the left side it would indicate more direct transmission or better conduction of sound by lung tissue, due to incomplete solidification, as observed in early phthisis. On the right side in health it is due to better convection along the right bronchial tube and its branches. It is the fourth and last physical sign at the top of the right lung in health, which if ob- served on the left would indicate disease. These four signs summed up are: (1) exaggerated vocal frem- itus, (2) slight dulness on percussion, (3) vesiculo- bronchial breathing, and (1) exaggerated vocal reso- nance. Unless these facts are known, mistakes in diagnosis are almost certain. Q. What is auscultatory percussion 1 A. The act of percussing while ausculting with the stethoscope at the same time. It was invented by ADVENTITIOUS SOUNDS. 303 Dr. Camman in New York in 1810. It is chiefly use- ful in diagnosing thoracic aneurism. Unless performed correctly it is, however, misleading. Q. What is succussion? A. The act of shaking the patient while ausculting to detect the splashing sound of fluids in cavities that also contain air, as in pneumohydrothorax, large cav- ities in the lungs sometimes, and dilated stomachs. Q. What effect is produced on physical signs by deformities? A. In deformity of the chest from any cause, even including old age, we may find displacement of the heart and exceptions, in general, to the foregoing rules. LESSON II. ADVENTITIOUS SOUNDS.—BRONCHITIS, ASTHMA, EMPHY- SEMA. Q. When you auscultate the organs of respiration what do you listen for? A. Three things, (1) the respiratory murmur, (2) vocal resonance, and (3) adventitious sounds. Q. What is an adventitious sound? A. An abnormal foreign sound produced by disease, and not a modified normal sound. Q. Is bronchial breathing, cavernous breathing, amphoric or metallic breathing, or any kind of breathing to be regarded as an adventitious sound ? A. No. They are simply modifications of the nor- 304 PHYSICAL DIAGNOSIS. mal respiratory murmur. No variety of respiratory murmur is adventitious. Q. Is bronchophony an adventious sound? A. No, it is a form of vocal resonance. The same is true of pectoriloquy. No breath or voice sound is adventitious. Q. How would you classify adventitious sounds? A. Into three classes: 1, rales; 2, friction sounds, and 3, splashing sounds. On auscultation we listen for the respiratory murmur, vocal resonance, and adven- titious sounds. If it is an adventitious sound it must be a rale, a friction, or a splashing sound. Q. What do you mean by rales? A. It is a French word meaning rattles. The Latin is rhonchi. Bales, rhonchi, or rattles, they are the same. Q. How would you classify rales? A. Into three classes: 1, dry; 2, moist; and 3, in- determinate. The latter are also called mixed or un- classified. They are partly moist and partly dry, cracking and creaking sounds that simply cannot be classified. They are usually heard in old phthisis or chronic pleurisy. Q. We first consider dry rales. What are dry rales made in the throat called, whether they be coarse or fine? A. Stridulous rales, and such breathing is said to be stridulous, or stridorous breathing, or stridor. It is always well to listen about the throat for any rales in case they are made there. BRONCHITIS. 305 Q. The same sounding dry rales made in the bronchial tubes would be called by other names. What are the coarse dry rales made in the larger tubes called ? A. Sonorous rales. Q. Fine dry rales as made in the smallest or capillary tubes? A. Sibilant (whistling) rales. Q. Are these dry rales ever imitated by any sound made in the pleural cavities? A. No, because they require tubes to produce them in, and there are no tubes in the pleural cavity. Q. Are these dry rales heard on inspiration, expiration, or both? A. They are heard chiefly on inspiration in the dry stage of bronchitis if they are present at all. But in asthma they are heard chiefly on expiration. In any case, they are apt to change about from place to place. Q. Why are they heard chiefly on expiration in asthma? A. Because in asthma, expiration is prolonged and inspiration shortened. In other Avords, the rhythm of breathing in asthma is exactly reversed from what it is in health. In health inspiration to expiration is as 1 to 1; in asthma as 1 to 1 (p. 15). Q. We have seen that dry rales may be made in the larynx, tra- chea, or bronchial tubes, and are named accordingly. Where may moist rales be made ? A. In the larynx, trachea, bronchial tubes, air-cells, and in pulmonary and the pleural cavities. Q. What are moist rales made in the larynx and trachea called? A. Laryngeal or tracheal moist rales. Tracheal moist rales are sometimes called death-rattles, as is well 20 306 PHYSICAL DIAGNOSIS. known. They may be coarse or fine according to the consistency of the fluid giving rise to them, and so on. Q. What are moist rales made in the larger bronchi called? A. Mucous rales. They are made on inspiration. and expiration both, since the mucus, pus, or blood, or whatever fluid gives rise to them, is stirred up into these bubbling rales by the tidal air which goes in and out on inspiration and expiration. As a rule, how- ever, all rales are made louder on inspiration than ex- piration, except in asthma, as already stated. Mu- cous rales also change about with coughing, are at- tended with expectoration, and are bilateral over the chest, except when due to local injury or disease. Q. What is the name of moist rales made in the middle size bronchial tubes? A. Submucous rales. They are someAvhat smaller than the mucous rales, are heard on inspiration and expiration, change about with coughing, are attended with expectoration, and are more or less diffused over the chest. Q. Moist rales made in the capillary bronchial tubes? A. They are called sub-crepitant or muco-crepitant, generally sub-crepitant. They are heard more on in- spiration than expiration, except in asthma, and often are heard only on inspiration, especially the last half of inspiration. In capillary bronchitis they are bilat- eral and low down, especially posteriorly. But in phthisis they are localized at the seat of the disease, generally the top of the lungs and more frequently in front. They change about with more difficulty BRONCHITIS. 307 than the preceding and may not be attended with expectoration in very feeble subjects with viscid expectoration matter, as they have not the strength to raise it. Q. What is the name of the rale made in the air-cells? A. It is called the crepitant rale, sometimes the vesicular rale. Crepitant rales are made only on the end of inspiration except in cedema of the lungs, where fluidity of the serum allows it on beginning of expira- tion. The crepitant rale does not change with cough- ing, is not attended with expectoration necessarily, and in pneumonia is localized over the lobe affected. It is bilateral in oedema of the lungs. In the second stage of pneumonia the crepitant rale disappears, but returns or is redux in the third stage. Q. What is mucous click? A. It is a solitary sub-crepitant rale. It is often one of the first signs there is of phthisis. It is made in the smallest bronchial tubes, where phthisis often first begins, as we shall see. One sub-crepitant rale is called a mucous click, and, on the other hand, two or more mucous clicks would be called sub-crepitant rales. Mucous click may also be imitated in the pleural cav- ity in any stage of phthisis. Q. What are loud bubbling rales called when made in a cavity as in the third stage of phthisis? A. Gurgles; they are heard chiefly on inspiration, since the air enters the cavity more forcibly on inspi- ration than it leaves it on expiration. Q. What is metallic tinkle, or tinkling? 308 PHYSICAL DIAGNOSIS. A. It is a tinkling sound made in an amphoric cav- ity containing but little fluid of a viscid nature. A large bubble is formed and presently snaps with a force sufficient to be re-echoed in the amphoric cavity. It is not due to any dropping. The latter would not possess sufficient force, though it may be imitated by holding an empty bottle near the ear and dropping a shot or pin in it. Q. What is an amphoric cavity? A. An amphoric cavity is so named from the Latin amphora, a jug, bottle, or flask; that is to say, a cavity with hard, smooth, symmetrical walls like a jug. Q. By what other name then could metallic tinkle be called? A. Amphoric tinkle. If you call it metallic you refer to the metallic quality of the sound. If you call it amphoric you refer to the kind of a cavity it is made in. Metallic tinkle is made in an amphoric cavity. Q. Are any of the fore-mentioned moist rales ever imitated by intra-pleural rales? A. Yes. It does not require pleurisy to give rise to them. But they are often heard around old adhesions and sometimes without adhesions, but simply owing to perverted localized nutrition. In this way a viscid in- stead of lubricating material is formed, so that rales are produced by one sticky pleura rubbing on the other, instead of their gliding without noise. In like manner various abnormal sounds are produced, as in a diseased knee-joint, for instance. Q. How are we to tell intra-pleural moist rales from moist rales made in the respiratory tract? BRONCHITIS. 309 A. Intra-pleural moist rales are localized, do not change with coughing, are not attended with expec- toration, and are superficial. The sounds are so exactly alike according to the amount and consistency of the fluid, that, as Da Costa truly says, no human ear could distinguish between them. Indeed, some hold that the crepitant and sub-crepitant rale are always made in the pleural cavity—an evident mistake. Q. We have spoken of dry and moist rales ; what other class of rales is there? A. Indeterminate rales. Q. What are indeterminate rales? A. They are mixed or unclassified rales, partly dry and partly moist, cracking and creaking sounds heard sometimes in old pleurisy, or advanced phthisis. Q. What is the second class of adventitious sounds? A. Friction sounds as heard in pleurisy, pericarditis, and the like. They are caused by roughened serous surfaces rubbing against each other. Q. What is the third and last class of adventitious sounds? A. Splashing sounds. On succussion they are pro- duced in caATities containing fluid and air as in pneu- mohydrothorax. They are not heard in pleurisy with effusion because of absence of air in the pleural cav- ity in that case. Q. Having considered the methods of examining the chest and the physical signs in health as well as adventitious signs, we now come to the physical signs of individual diseases. We begin with diseases that may cause obstruction in the tubes, or increased re- fraction in the air-cells, both of which would tend to weaken sound and its vibrations on the chest wallsw What is bronchitis? 310 PHYSICAL DIAGNOSIS. A. Bronchitis is inflammation of the mucous mem- brane lining the bronchial tubes. Affecting the smaller tubes it is called capillary bronchitis. Q. In case broncho-pneumonia (also called catarrhal pneumonia, and lobular pneumonia) follows capillary bronchitis and is so scat- tered that there is no dulness, bronchial breathing, and the like, how are we to infer that pneumonia has set in? A. By the sudden rise of temperature as well as increased frequency of breathing. Bronchitis, as a rule, is not attended by rise of temperature. Even in severe cases of capillary bronchitis (unless it be grippe) the temperature is often not over 100° F. Q. Give the physical signs of ordinary bronchitis? A. Inspection, chiefly negative. Palpation, the same. Rhonchal fremitus is some- times felt in children, or those having thin chest-walls. Vocal fremitus may be lessened if the bronchial tubes are much obstructed. Percussion, the same as in health usually. Auscultation: (1) The respiratory murmur the same as in health, that is to say vesicular, since the air vesicles are not involved. It may be harsh if the tubes are much roughened. If a large tube be obstructed completely the murmur may be lost until coughing removes the plug, when it will return. (2) The vocal resonance is usually unchanged, though it may be diminished like the fremitus if the tubes are much obstructed. (3) Rales of various kinds are apt to be heard. If not, they may be developed by coughing. Q. What are the physical signs of asthma? ASTHMA. 311 A. In the interval they are negative. But during an attack or paroxysm they are as follows: Inspection shows labored breathing, the difficulty being in expiration, not inspiration, since the latter is more forcible so far as regards the smaller tubes and air-cells. Palpation, chiefly negative, as in bronchitis. Percussion elicits exaggerated resonance, the air- cells being acutely emphysematous. Auscultation: (1) Respiratory murmur generally ob- scured by rales, but if heard at all is about the same as in health, except that the rhythm is reversed. That is, inspiration is to expiration as 1:1 instead of 1:1. In other words, expiration is markedly prolonged. (2) Vocal resonance, like the fremitus, may be un- changed but may be diminished as in bronchitis. (3) Of adventitious sounds, rales, usually dry, that is to say sonorous and sibilant, are heard chiefly on expiration, for reasons already given. Q. How many kinds of pulmonary emphysema are there? A. Two, vesicular and interstitial. But inasmuch as the vesicular is more common it is usually called emphysema simply. It is abnormal distention of the pulmonary vesicles. Q. How many kinds of vesicular emphysema are there? A. Two, vicarious and general. In vicarious em- physema one lung or part of a lung becomes emphy- sematous from doing extra work owing to crippling of the other lung or portion thereof. It is also called compensating or compensatory emphysema. 312 PHYSICAL DIAGNOSIS. Q. How many kinds of general emphysema are there? A. Two, large-lunged and small-lunged. The for- mer is also called hypertrophous and the latter atro- phous. The atrophous form is observed among old people (senile emphysema) and as accompanying fibroid phthisis sometimes. It is in this form, but wrongly named, that we may get marked dulness on percus- sion instead of exaggerated resonance. Q. A person with large-lunged (hypertrophous) emphysema, suf- fers from dyspnoea—what are the causes ? A. They are three chiefly: (1) Rigid dilatation of the thorax, the lungs having lost resiliency of tissue, and the costal cartilages having become permanently elevated and hardened from degeneration. (2) Loss of capillary area, many of the pulmonary capillaries having become ruptured or obliterated from stretching, owing to the abnormal distention of the air-cells. (3) Crippling of the diaphragm owing to its permanent depression from enlarged volume of the lungs. Q. What are the physical signs of emphysema? A. Inspection. The chest is barrel-shaped; that is, the antero-posterior diameter is increased, causing the sternum to project. The intercostal spaces are wi- dened, the spinal column appears curved anteriorly, there are deep depressions in the supra-clavicular spaces, and throbbing near the ensiform cartilage from lowered and enlarged right ventricle is usually ob- served. Palpation: The vocal fremitus is diminished from increased refractive power of the lungs. If the bron- EMPHYSEMA. 313 chial tubes are obstructed from bronchitis also, and there is much loss of vibratility of tissues, we may get no fremitus on palpation. In some cases the fremitus may be unchanged, but if it be increased it is owing to some complication and not to the emphysema. Percussion: There is exaggerated (band-box, vesi- culo-tympanitic) resonance. Auscultation: (1) The respiratory murmur is a lit- tle more blowing and less vesicular than in health, but change of rhythm is chiefly observed. The expira- tion is prolonged from weakening of expiratory forces. Inspiration is also somewhat deferred; that is, the be- ginning of it is too soft to be heard so that it is ap- parently shortened. (2) Vocal resonance is diminished as the fremitus. (3) Of adventitious sounds none are heard unless there is some coexisting disease, as bronchitis, and then rales may be present as already described. Q. What becomes of the heart in general emphysema? A. Owing to the obliteration of capillary blood-ves- sels throughout the lungs and obstruction to the cir- culation thereby resulting, the right ventricle of the heart becomes enlarged (hypertrophied and dilated). In course of time as the disease progresses tricuspid insufficiency may occur, owing to mechanical separa- tion of the valves. Then jugular pulsation and car- diac dropsy follow. It is, therefore, a very serious disease. 314 PHYSICAL DIAGNOSIS. LESSON III. SOLIDIFICATION OF LUNG TISSUE - PHTHISIS - PNEU- MONIA. Q. What do you mean by solidified, or consolidated, lung tissue? What part of the respiratory apparatus would be solidified? A. By solidification, or consolidation of lung tissue, we ordinarily mean solidification or consolidation of the air-cells, the bronchial tubes remaining open. Q. How many degrees of solidification may we consider? A. Two; incomplete and complete. Q. In what disease do we ordinarily recognize incomplete solidi- fication of lung tissue better than any other? A. Phthisis. Q. What is phthisis? A. Phthisis is tubercular pulmonary consumption, a disease dependent upon a specific virus, the germ of which is Koch's bacillus; it is tubercular pulmonary consumption, or pulmonary tuberculosis. Q. How many forms of phthisis do we ordinarily meet with? A. Acute and chronic; acute phthisis, also called galloping consumption, phthisis florida, acute scrof- ulous pneumonia, tuberculo-pneumonic phthisis (Wil- liams), is very rapid in its course. It may begin at the base of the lung as well as at the top, and may closely imitate a severe case of ordinary lobar pneu- monia at first. Soon, however, the progress of the disease discloses its true nature. Q. How many forms of chronic phthisis do we ordinarily observe? A. Two; catarrhal and fibroid phthisis. Catarrhal PHTHISIS. 315 phthisis is also called caseous phthisis, caseous infiltra- tion, tubercular lobular pneumonia, and the like. Q. Do you know other names for fibroid phthisis? A. Chronic pneumonia, interstitial pneumonia. Q. How many stages may we consider in a case of ordinary catarrhal phthisis? A. Three: (1) A first stage or a stage of incomplete solidification of lung tissue, with localized capillary bronchial catarrh; (2) A second stage of complete solidification of lung tissue, commencing softening at some point or points, the bronchial catarrh continuing; and (3) a third stage which is characterized by the breaking down of tissue and the formation of cavities. Q. On inspection, what do we observe in the first stage of phthisis? A. Inspection may be negative, but even now, should there be pain or tenderness in the part affected, the unaffected side of the chest may be noticed to ex- pand a little more. The patient has not had time to become noticeably emaciated, and therefore we may or may not see the apex-beat of the heart, as in health. Q. If we do see the impulse of the heart, how is it beating? A. More rapidly than in health, with corresponding increased frequency of the pulse. Q. What do we ascertain on palpation? A. On palpation the vocal fremitus is slightly in- creased or exaggerated over the affected part. Q. Why is the vocal fremitus thus exaggerated? A. On account of the better conducting power of the incompletely solidified lung. 316 PHYSICAL DIAGNOSIS. Q. Do we not find exaggerated vocal resonance at the top of the right lung in health, as compared with the left? A. Yes, but this is due to better convection of the voice along the right bronchial tube, which is larger than the left. Q. On percussion what do we obtain in the first stage of phthisis, over the affected part? A. On percussion we obtain slight dulness. Q. Do we or do we not have a slight dulness at the top of the right lung in health? A. Yes. This is the second sign of incipient phthisis to be found in health at the top of the right lung. Q. What do you listen for when you come to auscultate the organ of respiration? A. Respiratory murmur, vocal resonance, adven- titious sounds. Q. What sort of a respiratory murmur do we get over the affected part in the early stage of phthisis? A. Vesiculo-bronchial breathing in which expiration is more tubular than in health and somewhat pro- longed. As the air-vesicles become more and more obliterated, so does the breathing become more and more bronchial. Q. Have we or have we not already vesiculo-bronchial breathing at the top of the right lung in health ? A. Yes, on account of proximity to bronchial tubes. Q. How is the vocal resonance affected ? A. Vocal resonance is slightly increased or exagger- ated, for the very same reason that the vocal fremitus is affected in that way. Q. We find at the top of the right lung in health the four signs of early phthisis, namely, exaggerated vocal fremitus, slight dul- PNEUMONIA. 317 ness on percussion, vesiculo-bronchial breathing, and exaggerated vocal resonance : supposing phthisis begins at the top of the right lung, how are we to make a diagnosis? A. By the adventitious sounds. Q. What adventitious sounds usually? A. They are usually subcrepitant rales, owing to the localized tubercular capillary bronchitis. Q. Suppose that you have only one subcrepitant rale, what do you call it? A. Mucous click. Q. What is the value of the bacillus in the early diagnosis of phthisis? A. Of very little value, inasmuch as we frequently do not find it. They are generally few, deeply im- bedded, and the sputa scant or wanting. Q. In what disease do we find complete solidification of lung tissue best exemplified? A. Lobar pneumonia, second stage. Q. How many kinds of pneumonia are there? A. Three kinds: lobar, lobular, and interlobular pneumonia. Q. By what name does interlobular pneumonia go? A. Interlobular, interstitial, or chronic pneumonia, and fibroid phthisis. Q. Under what other names is lobular pneumonia known? A. Broncho-pneumonia, catarrhal pneumonia, and infantile pneumonia. Q. Where does broncho-pneumonia begin? A. It begins in the capillary bronchial tubes and ex- tends down into the lobules here and there in spots. Q. What are some other names for acute lobar pneumonia? A. Sometimes it is called croupous pneumonia, fibri- 318 PHYSICAL DIAGNOSIS. nous pneumonia, parenchymatous pneumonia, pneu- monic feArer, and the like. Q. What is acute lobar pneumonia? A. A peculiar inflammation of the membrane lining the air-cells of a whole lobe. Q. How many stages are there in acute lobar pneumonia? A. Three: first, the stage of congestion, lasting from a few hours to twenty-four hours more or less; sec- ondly, the stage of complete solidification, lasting usu- ally to the fifth or eighth day; and third, the stage of resolution or gray hepatization, lasting until about the fourteenth day in ordinar}7 favorable cases. Q. What is the principal physical sign of the first stage? A. The crepitant rale. In a few hours the patient has usually passed into the second stage. Q. What is the pathological condition of the second stage? A. Complete solidification or red hepatization of the lobe affected, the bronchial tubes remaining open. Q. On inspection what do we notice in this stage? A. We notice increased frequency in respiration, commonly called panting breathing. On forced in- spiration the unaffected side may be noticed to expand more than the other. Q. What do we find on palpation? A. The vocal fremitus is markedly increased, owing to the fact that the solidified lung transmits (conducts) the sound directly to the surface of the chest-walls with more force than in health. Q. On percussion what do we obtain over the affected lobe? A. Marked dulness, with perhaps slightly exagger- PNEUMONIA. 319 ated resonance from the adjacent healthy lung tissue, owing to the latter being vicariously emphysematous. Q. Along with marked dulness over the affected lobe, may we obtain any other quality of percussion resonance? A. Along with dulness on forced percussion, rarely we may obtain a tubular resonance which is also, though wrongly, called tympanitic. In the case of infants especially, true tympanitic resonance on forcible percussion may be obtained, owing to the stomach or transverse colon being distended with gas. Q. On auscultation what sort of respiratory murmur do we get over this solidified lung tissue in the second stage of pneumonia? A. Bronchial breathing, which is tubular in char- acter, both on inspiration and expiration. This is owing to the fact that the air-vesicles are now com- pletely obliterated and nothing but bronchial tubes are left. Q. How is the vocal resonance affected over the solidified lung? A. Markedly increased and called bronchophony, or if the actual speech is heard, bronchiloquy. This in- crease of vocal resonance is accounted for exactly in the same way as the increase in the vocal fremitus, for what is true for one is exactly true for the other. Q. What do we listen for third and lastly in auscultation of the lungs? A. For the adventitious sounds. Q. Do we get any adventitious sounds in the second stage of lobar pneumonia? A. No, unless there be complication. Otherwise the sputa are too viscid and the respiratory force too fee- ble to produce rales. 320 PHYSICAI DIAGNOSIS Q. How long does this second stage of lobar pneumonia ast? A. On an average to the fifth or the eighth day, when the third stage or stage of resolution, or gray hepatization begins. This lasts usually, in an ordi- nary favorable case, until about the fourteenth day, the whole duration of such a case being about two weeks. Q. What is the first rale heard in the third stage? A. The first rale heard in the third stage is usually the crepitant rale, also called the rale redux, because it has returned after having disappeared in the second stage. The subcrepitant and even mucous rales may be heard afterward if the sputa become sufficiently abundant and liquid. Gradually the physical signs return to those of health. In like manner we have physical signs of complete solidification of lung tissue in the second stage of phthisis, accompanied usually, however, by adventi- tious sounds. Q. What, in conclusion, are the chief physical signs of solidifi- cation of lung tissue? A. They are increased vocal fremitus, dulness on percussion, bronchial breathing, and increased vocal resonance which may be bronchophony or even bron- chiloquy. CAVITIES IN THE LUNGS. 321 LESSON IV. CAVITIES IN THE LUNGS. Q. How many stages may be considered in phthisis? A. Three, as already stated. The third stage is characterized by the formation of cavities. Q. Does this mean that we have a cavity surrounded by healthy lung tissue, or do we mean that we have a complicated pathological condition to deal with? A. More or less complicated, the caAnty being sur- rounded usually by consolidated tissue, and there be- ing bronchial catarrh present, and sometimes the pleura involved. With such a complicated patholog- ical condition presented, while rules will generally hold good, we may expect to find exceptions. Q. On inspection in the third stage of phthisis, what do we usually observe ? A. More or less emaciation, retraction of the chest wall over the affected part, which usually being at the apex, leaves the clavicle more prominent than be- fore. Superficial veins are usually noticeable, as well as the apex-beat of the heart, owing to emaciation. Expansion of the unaffected side is greater than over the affected portion, especially noticeable on forced inspiration. Q. Why are the superficial veins particularly noticeable in this Btage of phthisis? A. The superficial veins are noticeable, not so much on account of obstruction to the pulmonary circulation as it is loss of adipose tissue, owing to emaciation. 21 322 PHYSICAL DIAGNOSIS. Q. If we see the apex-beat of the heart, will it be in the normal position or not? A. It may be normal, or it may be displaced, but wherever seen it is ordinarily observed to be rapid. Q. If it is displaced, what is usually the cause of the displace- ment? A. Pleuro-pericardial adhesion, with retraction of tissue. In this way the heart may become more widely displaced than in any other disease. Q. On palpation in the third stage of phthisis what do we ascer- tain? A. The vocal fremitus is usually increased over the affected part. Q. Why is the vocal fremitus increased over the affected part? A. Owing to the solidified lung tissue around the cavity. Q. How do you explain that we find this fremitus increased, and presently we find it diminished? Why is it that it varies? A. On account of temporary obstruction, in the bronchial tubes leading to the part, by mucus, pus, or blood. Should the patient cough and clear out the tubes, the fremitus, which had been diminished or even absent, immediately returns. Sometimes we can feel rhonchal fremitus. Q. On percussion, as a rule what kind of resonance do we get over the affected part in the third stage? A. Usually more or less dulness. Q. Why do we get dulness? A. Because of the solidified lung tissue surrounding the cavity, the fluid inside of the cavity, and perhaps thickened pleura. CAVITIES IN THE LUNGS. 323 Q. Instead of or along with dulness, what kind of resonance may we get on percussion ? A. Cracked-pot resonance. Q. What do you mean by cracked-pot resonance? A. Cracked-pot resonance is produced on rather for- cible percussion, by sudden expulsion of air from a cavity, with somewhat tense walls, through an open- ing into a bronchial tube, the patient's mouth being open. It may be present or absent according as the opening be plugged or not. Q. What other percussion resonance may we obtain? A. On gentle percussion we may get almost normal resonance, but on forcible percussion deep-seated dul- ness, if there be a small deep-seated cavity with healthy tissue intervening. Q. Do you know what other sound we may get on percussion? A. It may be tympanitic resonance. Q. How do you account for that? A. By a large, superficial cavity with tense walls, and filled with air. Q. What other sound may we get on percussion? A. Amphoric or metallic resonance. Q. What does amphoric mean? A. Pertaining to a jug, bottle, or flask; therefore, if we call it amphoric resonance we refer to the pecu- liar condition of the cavity; if we call it metallic reso- nance, we are referring to the quality of the sound. Metallic resonance is obtained in an amphoric cavity, and an amphoric cavity is one with hard, smooth, symmetrical walls, with an opening into it, like a jug- 324 PHYSICAL DIAGNOSIS. Q. Does a patient's mouth have to be open or not, in order to get an amphoric resonance on percussion? A. Yes, the patient's mouth must be open. It may be imitated by percussion on the cheek. This form of percussion resonance will also be present or absent ac- cording as the cavity be full of fluid or empty, or if the opening into it be plugged or not. Q. What other kind of resonance may we get on percussion? A. Flatness, provided there be a large superficial cavity full of fluid. Q. On auscultation, what are we going to listen for? A. Respiratory murmur, vocal resonance, adventi- tious sounds. Q. What sort of respiratory murmur do we generally get over the affected part? . A. Cavernous breathing. Q. What is the quality of cavernous breathing? A. It is blowing, giving you the idea of air passing in and out of a hollow space. Q. What other breathing may we hear over this cavity instead of the cavernous breathing? What may it be called? A. Bronchial breathing, if the cavity be small and the surrounding consolidated tissue be greatly in ex- cess. Q. What other kind of respiratory murmur may we hear over the affected part? A. Normal vesicular respiratory murmur, provided we have a deep-seated small cavity with a good deal of healthy lung tissue intervening. Q. What other kind of breathing may we hear? CAVITIES IN THE LUNGS. 325 A. Broncho-cavernous, or caverno-bronchial, if the cavernous and bronchial elements are both present. Q. What other breathing may we get? A. Amphoric or metallic. We call it amphoric if we refer to the cavity itself, metallic if the quality of the sound is meant. This is imitated by blowing into the mouth of an empty bottle, or flask, or jug. Q. Having decided as to the respiratory murmur, what do we listen for next? A. Vocal resonance. Q. How is vocal resonance affected over the diseased part? A. Usually increased, for the very same reason that the vocal fremitus is increased. If the patient whispers it is commonly termed cavernous whisper, which is simply a blowing sound. It is also subject to variations in the same way as the fremitus, if the bronchial tubes become obstructed. Q. What do we call the vocal resonance, provided we hear exactly what the patient speaks? A. Pectoriloquy. If it has a metallic quality we call it metallic speech or amphoriloquy. Q. Third and lastly, what do we listen for? A. Adventitious sounds. Q. What are bubbling rales called when made in a cavity? A. Gurgles. Q. Along with, or instead of, gurgles, what other adventitious sounds may we hear? A. Any of the bronchial moist rales. Q. What other adventitious sounds may be present in the third stage of phthisis? 326 PHYSICAL DIAGNOSIS. A. We may have pleuritic friction, or intra pleural rales. Q. What other adventitious sounds may we get? A. Indeterminate rales; that is to say, cracking and creaking sounds which it is impossible to classify. Q. What other adventitious sound may we get? A. Metallic or amphoric tinkle. They both mean the same thing. Q. How is this metallic or amphoric tinkle produced? A. By the bursting of a bubble in a cavity rather than by the dropping of fluid. Q. What then in conclusion are the diagnostic physical signs of pulmonary cavity ? A. (1) Cracked pot, amphoric, or tympanitic per- cussion resonance; (2) cavernous, caverno-bronchial or amphoric (metallic) breathing; cavernous whisper, whispering amphorophony or amphoriloquy, and (3) gurgles and metallic (amphoric) tinkle. LESSON V. PLEURISY—EMPYEMA, OR PYOTHORAX—HYDROTHORAX —PNEUMOHYDROTHORAX. Q. What is the pleura? A. Pleura is the serous sac covering the lung. Q. Do the two pleural cavities communicate with each other? A. No, but they do approach each other very closely behind the sternum, on the anterior median line from the second to the fourth rib. PLEURISY. 327 Q. Are the lower limits of attachment of the pleurae the same on both sides? A. No. The right pleura on the sternal line has for its lower limit the upper border of the sixth rib, on the nipple (papillary or mammillary line) the same, on the axillary line the upper border of the eighth rib, on the scapular or Bowditch's line the ninth rib, on the vertebral line the tenth rib. For the left side on the sternal line the fourth rib, on the nipple line the lower border of the sixth, on the axillary line the lower border of the eighth, scapular line the ninth rib, ver- tebral line the tenth rib. Q. What is pleurisy? A. Inflammation of the pleura. Q. How would you classify pleurisy? A. Into two classes: pleurisy with effusion, pleurisy without effusion. Q. What are the physical signs of idiopathic dry, circumscribed, adhesive pleurisy, or pleurisy without effusion? A. On forced inspiration the patient may be observed to have what is called a catch in the breath with more or less increased chest expansion on the unaffected side. On palpation, no perceptible change in the frem- itus. On percussion there would be no perceptible change in the resonance. On auscultation we may get crepitation on inspiration, but there would be lit- tle or no change in the respiratory murmur or the vocal resonance; all on account of the circumscribed area of the diseased portion and the slight pathological change present. 328 PHYSICAL DIAGNOSIS. Q. How many varieties are there of pleurisy with effusion? A. Three: acute, subacute, and chronic; empyema being described under a separate head. Subacute pleu- risy is similar to the acute variety and may result from it, but chronic pleurisy with effusion is frequently of tubercular origin. Q. What are the physical signs of acute pleurisy with effusion? A. In the first stage, which is usually of a few hours' duration, we get signs as we did in describing dry pleurisy, namely, on inspiration there is a catch in the breath, owing to pain in the affected side. Pal- pation and percussion give negative results usually, but on auscultation we will hear pleuritic friction, chiefly on inspiration. During the second stage effu- sion takes place, and is at its height from the fifth to the eighth day, when we get the physical signs of fluid in the pleural sac, to be presently described. During the third stage, or stage of absorption, the friction sound which had disappeared in the second stage now returns and is called frictio redux. The whole dura- tion of the disease, in an ordinarily favorable case, is about two weeks. Q. In pleurisy during the effusion, what do we notice on inspec- tion? A. Bulging of the lower intercostal spaces on the affected side, with diminished respiratory movements on that side and exaggerated on the other. The heart may or may not be noticed to be displaced. Some- times after absorption of the fluid collapse of that side may follow. PLEURISY. 329 Q. On palpation how is the vocal fremitus affected over the effusion? A. Diminished or absent, on account of its being intercepted by the fluid. Q. How is the vocal fremitus above the level of the fluid? A. Increased, owing to compression of the lung as in solidification. Q. On percussion what do we obtain over the seat of the effusion? A. Marked dulness or flatness; sometimes, especially in children, there may be tympanicity obtained from a distended stomach and colon. The line of dulness will often change slightly with position of the patient. Q. What kind of resonance on percussion do we get above the level of the fluid over the compressed lung? A. Dulness as a rule, but sometimes, that is in about one-third of the cases, especially in front, tympanitic resonance. This peculiar resonance is obtained from the bronchial tubes, the air vesicles being more or less compressed. Q. Over the unaffected side what is the resonance on percussion? A. Exaggerated resonance, due to vicarious emphy- sema. Q. On auscultation of the organs of respiration what do we listen for? A. Respiratory murmur, vocal resonance, adventi- tious sounds. Q. What becomes of the respiratory murmur over the seat of the effusion in this disease? A. Diminished or absent, unless it may be tele- phoned to some spot by a pleuritic adhesion, or trans- mitted along the chest-walls. 330 PHYSICAL DIAGNOSIS. Q. What sort of breathing do we get above the level of the fluid? A. Bronchial breathing over the compressed lung; over the dilated bronchial tubes we may get cavernous or even amphoric (metallic) breathing; over the un- affected side we get exaggerated breathing. Q. How is the vocal resonance affected over the seat of the effu- sion? A. Diminished or absent, for the same reason that the vocal fremitus was diminished or absent. Q. How is the vocal resonance affected above the level of the effusion over the compressed lung? A. Increased, for the same reason given in speak- ing of solidified lung tissue. Q. In cases of slight effusion the vocal resonance acquires a trill with a nasal element, like the distant bleating of a goat; what is that termed? A. JEgophony. Q. What adventitious sound do we get from the seat of the effu- sion in pleurisy ? A. None. Should there be any adventitious sounds, they would be due to some complication, as bronchitis. Q. What is empyema, or pyothorax, or suppurative pleurisy? A. Pus in the pleural cavity, which is best diagnosed from chronic pleurisy with effusion by means of the hypodermic syringe. Q. What are the physical signs of thickened pleura without effu- Bion? A. The same as in pleurisy with effusion, only to a less marked degree. The principle of interception of sound is the same. Q. What is hydrothorax? THE HEART. 331 A. A serous transudation in both pleural cavities, and is usually due to general dropsy from any cause. It is a non-inflammatory collection of fluid, but gives physical signs similar to those above described. Q. What is pneumohydrothorax? A. Air and fluid both in the pleural cavity. Ninety- five per cent of cases, according to Walshe, are due to pulmonary tuberculosis, the perforation into the pleural cavity being the result of tubercular ulcera- tion. Q. How do we make a positive diagnosis of pneumohydrothorax? A. By means of succussion, when we hear the splashing sound. Q. In conclusion, what are the chief physical signs of pleurisy as contrasted with pneumonia? A. Diminution or absence of the respiratory mur- mur and vocal resonance, instead of their increase. LESSON VI. THE HEART. Q. Where would you draw a line on the chest wall in front to correspond to the base of the normal heart? A. Along the upper border of the third rib, extend- ing half an inch to the right of the sternum and one inch to the left of the sternum. Q. Where is the apex-beat in health? A. Between the fifth and sixth ribs, one and one- half inches below the left nipple, and half an inch within the nipple line. 332 PHYSICAL DIAGNOSIS. Q. How many areas of dulness does the heart present? A. Two: superficial and deep; the latter correspond- ing to the base of the heart where it lies deeply under lung tissue; the superficial occupying the lower prse- cardial space. Q. What is the shape of the superficial area of cardiac dulness? A. Somewhat triangular. It is marked out by drawing a line from the apex along the upper border of the sixth rib to the median line of the sternum, then up the median line of the sternum to the fourth rib, and from that point back to the apex, curving slightly outward. This latter line falls within the left nipple. Q. What part of the heart, looking at it from before back, forms the greater portion of the superficial area of dulness? A. The right ventricle, which lies in front of the left; but the apex is formed by the left ventricle. Q. Where then would you listen in order to hear mitral sounds in their greatest intensity ? A. At the apex. Q. How many sounds has the heart? A. Two: first and second. Q. Where do we listen to hear the first sound louder than any- where else? A. At the apex, hence it is sometimes called the apex sound of the heart, or the inferior sound of the heart; and because it is made during systole it is also called the systolic sound of the heart. Q. What valves close during systole? A. Mitral and tricuspid, so that closure of these THE HEART. 333 valves, the impulse of the heart, and the first sound are all said to be synchronous. Q. Where do you listen to hear the second sound of the heart plainer than anywhere else? A. The base of the heart; and as it occurs during diastole it is sometimes called the diastolic sound; so also it is sometimes called the basic or superior sound of the heart. It is caused by the closure of the aortic and pulmonary semilunar or sigmoid valves. It is a shorter, sharper sound than the first or systolic sound. Q. Where would you stick a pin in order to strike the pulmonary valves? A. At the middle point of junction of the left third costal cartilage with the sternum. The pulmonary valves lie here superficially in front of the aorta, which lies deeply behind them. Q. Do we listen directly over the valves to hear pulmonary sounds in their maximum intensity? A. No, but over the left second interspace near the sternum crossing which the pulmonary artery runs. This interspace is, therefore, called the pulmonary interspace. Q. Where do we stick a pin to strike the aortic valves? A. Through the left edge of the sternum on a line with the lower border of the third left costal cartilage. The pin is to be forced in deeply, inasmuch as these valves lie behind the base of the right ventricle. Q. Do we listen over this point to hear aortic sounds in their maximum intensity? A. No, but over the right second interspace, cross- 334 PHYSICAL DIAGNOSIS. ing which the arch of the aorta runs just at the right edge of the sternum. It is, therefore, called the aor- tic interspace, and is just opposite the pulmonary. Q. Where do we stick a pin in order to strike the mitral valves? A. Near the left edge of the sternum, at the upper border of the fourth costal cartilage. Q. Do we stick the pin in deeply or superficially ? A. The pin must go in deeply through the right ventricle, which lies in front. * Q. Do we listen at this point to hear mitral sounds in their maxi- mum intensity? A. No; because the right ventricle lies in front, but we listen at the apex which is formed of the left ven- tricle. Q. Where do we stick a pin in order to strike the tricuspid valves? A. Through the median line of the sternum, be- tween the fourth costal cartilages. These valves lie superficially, being in the right heart. Q. Do we listen at this point in order to hear tricuspid sounds in their maximum intensity? A. No, but over the ensiform cartilage, which cor- responds nearly to the apex of the right ventricle. Q. How many points of maximum intensity, therefore, are there in regard to heart murmurs? A. Four. First, the point of maximum intensity for pulmonary sounds, which is the second left inter- costal space; secondly, the aortic interspace for aortic sounds; third, the apex for mitral sounds; fourth and lastly, ensiform cartilage for tricuspid sounds. Q. What do you mean by valvular lesion ? A. Obstruction or regurgitation at any given ori- THE HEART. 335 fice, or both at the same time. They are often asso- ciated together at the same orifice. Q. What is the most common valvular lesion? A. Mitral regurgitation; the next is mitral obstruc- tion, then aortic obstruction, and lastly aortic regur- gitation. Q. Instead of valvular lesion or along with it, what other en- docardial lesion may result? A. Intraventricular lesion, that is, a lesion some- where within the ventricle, instead of at the orifice. Q. What condition of the heart do valvular lesions always bring about? A. Enlargement of the heart. Q. Do intraventricular lesions necessarily cause enlargement of the heart? A. No, and for this reason we are usually enabled to make a diagnosis between them. Q. Is the fact that murmurs are heard about the heart proof that the heart is diseased? A. No, because there are a great many functional murmurs that are to be considered. Q. With what action of the heart are all functional murmurs made? A. With systole, this being a stronger force than diastole; so that while the diastolic murmurs are or- ganic, many systolic murmurs are functional. Q. Where do we listen to hear mitral regurgitant murmur louder than anywhere else ? A. At the apex. It is a systolic blowing murmur, made with the first sound. Q. Where else may we hear mitral regurgitant murmur? 336 PHYSICAL DIAGNOSIS. A. Usually along the left lateral base of the chest, and at a point midway between the lower angle of the left scapula and the vertebral column. Sometimes it is so feeble that it is only heard at the apex. Q. How then would you tell mitral regurgitant murmur from in- traventricular murmur, both being organic and both systolic? A. We can only tell by the difference in the en- largement of the heart. For Avhereas in intraventric- ular lesion there is no enlargement, usually in mitral regurgitation we do have enlargement of the left au- ricle, left ventricle, and the right ventricle. Q. What do you mean by dynamic murmur? A. The murmur due to perverted action of the heart, as seen among athletes during their performances, choreic subjects, and the like. Q. Inasmuch as all dynamic murmurs are systolic, how would you tell a dynamic murmur at the apex from an organic murmur or other functional murmurs? A. First, by absence of enlargement of the heart, and secondly because they are always inconstant. Q. How would you tell cardio-respiratory murmur from any other murmur? A. By simply getting the patient to hold the breath. Q. How would you tell an anaemic murmur from another func- tional murmur or organic murmur at the apex? A. In the first place, anaemic murmurs are very rare at the apex, but secondly there would be no nec- essary enlargement of the heart, and the absolute anaemic condition of the patient, as evidenced by ve- nous hum in the neck, would decide the question. THE HEART. 337 Q. Where do you listen for mitral obstructive murmur louder than any other place? A. At the apex. Q. Is it transmitted anywhere? A. Not as a rule, but is strictly an apex murmur. It is sometimes called prse-systolic, but should more properly be called diastolic. Q. We saw that mitral regurgitant murmur was blowing in quality. What is usually the quality of mitral obstructive mur- mur? A. Blubbering or fluttering. Q. What are some other names for mitral praes-systolic murmur? A. It is sometimes called mitral, obstructive, ste- notic, constricted, direct murmur. Q. Supposing the action of the heart to be very irregular, so that systole could not be told from diastole, and the mitral obstructive murmur was somewhat blowing in quality, as may sometimes hap- pen, how would you tell it from mitral regurgitant murmur? A. By the fact that there is enlargement of the left ventricle in mitral regurgitation, whereas it is usually somewhat atrophied in mitral obstruction. Moreover, in mitral obstruction, the second sound of the heart is more accentuated in the pulmonary interspace. Q. Where do you listen to hear tricuspid signs in their maximum intensity ? A. Over the ensiform cartilage. The tricuspid re- gurgitant murmur is the only one heard, and that is limited to the spot. Q. Where do you listen to hear aortic sounds in their maximum intensity? A. In the aortic or second right intercostal space. 22 338 PHYSICAL DIAGNOSIS. Q. Suppose we hear aortic obstructive murmur at this point, where else might we hear it? A. Sometimes in the arteries of the neck, and if it is caught up by the sternum we may hear it from one end of that bone to the other. Q. How would you tell aortic obstructive, stenotic constrictive, murmur from a murmur made in the aorta from roughening of the coats? A. An aortic obstruction gives rise to enlargement of the left ventricle, which would not be the case in roughening of the aorta. Q. How do you tell aortic obstruction or intra-aortal systolic organic murmurs from all functional murmurs? A. In the same way as we did when speaking of those murmurs at the apex. • Q. Where do you listen to hear aortic regurgitant murmur louder than anywhere else ? A. Over the mid-sternum rather than the aortic in- terspace. It is rarely if ever conveyed up into the arteries of the neck, but it may be heard up and down the sternum and at the apex of the heart. Q. Suppose the posterior leaflet of the aortic semilunar valves is insufficient, in which case the diastolic murmur is heard only at the apex, how would you tell this murmur from the mitral ob- structive ? A. In aortic regurgitation there is enlargement of the left ventricle, in mitral obstruction there is not. Q. How would you tell an intra-aortal diastolic murmur due to dilatation of the aorta from aortic regurgitation? A. By the enlargement of the left ventricle in regurgitation. Moreover, in the latter condition we have throbbing of the arteries in the neck and wher- THE HEART. 339 ever they are superficial, and also the water-hammer pulse, or pulsus celer. Q. Where do we listen to hear pulmonary sounds louder than anywhere else ? A. In the second left intercostal space near the sternum. It is at this point that we not infrequently hear anaemic murmurs. Of pulmonary organic mur- murs the pulmonary obstructive is the only one we may expect ever to hear, since children born with pulmonary regurgitation die very early. INTDEX. Abdominal aorta, 284. respiration, 9. Abscess of the lungs, 89. Accentuation of heart sounds, 211. Acute miliary tuberculosis, 107. Adventitious sounds, 37. Adhesions, pleuritic, 146. .Egophony, 127, 145, 179. Amphoric (jug, metallic) breathing, 126, 176. echo, 180. resonance, 124. tinkle, 128, 158, 165. voice, 180. Anaemic murmurs, 228, 237. Aneurism of aorta, 268. of the heart, 362. Angina pectoris, 257. Anterior region, 2. Anthrakosis pulmonum, 87. Aorta, 187. Aortic interspace, 190. murmurs, 222. obstruction, 223. and regurgitation, 235. regurgitation, 232. valves, 188. Apex murmurs, 197. Apices affected by tubercle, 113. Apneumatosis, 59. Apoplexy, pulmonary, 99. Arch of aorta, 276. Aspiration, 151. time for, 141. Aspirator, Potain's, 150. Areas of cardiac dullness, 185. Asthma, 42. Atelectasis, 59. Atrophous emphysema, 49. Atrophy of the heart, 252. Auenbrugger, 16. Auscultation, 25. Auscultatory percussion, 33. Autophonia, 34. Axillary line, 8. region, 7. Bacillus, Koch's tubercle, 106, 110, 117, 130, 134. Barry, 71. Basedow's disease, 253. Bell-metal resonance, 128. Bigemenny, 264. Blood-currents, 186. Bronchi, division of primitive, 14. Bronchial breathing, 79, 119, 175. hemorrhage, 101. respiratory murmur, nor- mal, 28. rales, 37, 162. Bronchitis, 35. Bronchiloquy, 80, 127, 178, 181. Bronchophony, 80, 120, 145. Broncho-cavernous breathing, 126. Broncho-pneumonia, 84. Bruit de diable, 230. 342 INDEX. Calormetation, 8. Camman, 25. Cancer of the lungs, 90. Capillary bronchitis, 39. Cardiac aneurism, 262. dropsy, 253. dullness, 185. murmurs, 195. thrill, 202. Cardio-respiratory murmurs, 209, 228. Catarrhal phthisis, 107, 113. pneumonia, 84. Cavernous breathing, 125, 145, 176. Caverno-bronchial breathing, 126. Cavernous voice, 179. Cavities, 121-130., Chronic pneumonia, 87, 134. Circulation, 186. Clavicular resonance, 22. Cog-wheeled respiration, 27. Cohnheim, 96. Compensatory emphysema, 48. Congestion of the lungs, 63. Congress at Paris, report on, 108. Consumption of the lungs, 106. Cracked-pot resonance, 123. Crepitant rales, 76, 163. Croupous pneumonia, 70. Cyanosis, 237. Dilatation of the heart, 195, 249. Divided respiratory murmur, 173. Dry pleurisy, 137. rales, 159. Duration of sound, 20. Dynamic murmurs, 207, 227. Dyspnoea in emphysema, 51. ECHINOCOCCI, 1C5. Effusion, aspiration for, 150. Eichhorst, 60. Elements of sound, 18. Embolism, 97. Emphysema, 47. Empyema, 153. Endocardial murmurs, 196. Endocarditis, 193, 240. Exophthalmic goitre, 253. Fatty heart, 250. Fibrosis of the heart, 262. Fibroid phthisis, 107, 131. First sound of the heart, 190. Flatness, 129. Fox, Dr. Wilson, 71. Fremitus, 11. Freund, 50. Friction fremitus, 12. Frictio redux, 141. Friction sounds, 140, 169. Functional cardiac diseases, 263. Gangrene of the lungs, 89. Gravity of valvular lesions, 233. Graves' disease, 253. Grisolle, 71. Gurgles, 128, 165. Htemic murmurs, 237. Heemopericarditis, 244. Haemoptysis, 100. Hemothorax, 154. Hay fever, 42. Heart, 183. diseases, sudden death from, 260. displaced in phthisis, 121. in emphysema, 53. Hemorrhage from the lungs, 102, 117. Hemorrhagic consumption, 107. infarction, 96. Hydatids of the lungs, 105. Hydro-pericardium, 244. INDEX. 343 Hydro-pericarditis, 244. Hydrothorax, 153. Hydro-pneumo (pyo-) thorax, 157. Hypertrophy of the heart, 195, 245. Hypertrophous emphysema, 49. Hypochondriac region, 4. Hypostatic congestion, 64. pneumonia, 72. Indeterminate rales, 129,168. Infarction. 96. Infantile pneumonia, 84. Infra-axillary region, 7. clavicular region, 5. mammary region, 4. scapular region, 6. Inspection, 8. Intermittent pulse, 264. Inter-scapular region, 5. Intra-arterial murmurs, 226. plural rales, 39,129,140,166. ventricular murmurs, 206, 226. Irregular rhythm (heart), 264. pulsation, 219. Koch's tubercle bacillus, 108. as an aid to early diagno- sis, 110, 117, 130. Laennec, 25. Laryngeal breathing, 28. phthisis, 107. Lateral regions of the chest, 7. Lobar pneumonia, 69. Lobular pneumonia, 84. Loomis, 71, 278. Mammary region, 4. Mammillary line, 8. Marasmic atelectasis, 60. Mensuration, 32. Metallic tinkle, 128, 158, 165. Mitral obstruction, 209. regurgitation, 198. and obstruction, 217. regurgitant pulse, 200. Moist rales, 161. Mucous rales, 38, 162. Muco-crepitant rales, 163. Mucous click, 164. Murmurs of the heart, 195. Musical heart murmurs, 203. Myocarditis, 244. Myoidema, 114. Normal respiratory murmur, 26, 170, 172. vesiculo-bronchial breath- ing, 28. vesicular resonance, 18. vocal resonance, 13. CEdema of the lungs, 66. Operation for aspiration, 151. Outline of the heart, 184. Palpation, 10. Palpatory percussion, 17. Palpitation of the heart, 263. Paracentesis thoracis, 33. Parasternal line, 8. Pectoriloquy, 126, 180. Pectorophony, 29, 177. Percussion, 16. Pericardial sounds, 241. Pericarditis, 241. Physical diagnosis, 1. signs, 1. Phthisis, 106. Phonometry, 34. Piorry, 17. Pitch of sound, 18. Pleurisy a cause or result of phthisis ? Ill, 138. classification of, 136. Pleurae, boundaries of, 136. function of, 136. Pleurisy, article on, 135. 344 INDEX. Pleurisy, dry, 137. acute with effusion, 138. subacute, chronic, 141. Pleximeter, 17. Pneumonia, 69. lobular, 84. interlobular, 87. Pneumo-hydrothorax, 156. Pneumothorax, 154. Pneumonokoniosis, 88. Posterior regions of the chest, 5. Puerile respiration, 29, 171. Pulmonary apoplexy, 99. collapse, 59. consumption, 106. congestion, 63. hemorrhage, 102. interspace, 190. (artery) murmurs, 236. oedema, 66. obstruction, 236. regurgitation, 239. Pulse, intermittent, 264. Purring thrill, 202. Puncture in pleurisy, 151. Pyo-pneumothorax, 157. Quain's fatty heart, 250. Quality of sound, 18. Rales (rhonchi), 37, 160. Rale redux, 81. Reduplication of heart sounds, 211. Regions of the chest, 2. Regional percussion, 21. Respiratory percussion, 20,149. murmur, normal, 27. changes in, 170, 176. Rhonchal fremitus, 12. Rhythm of the heart, 192. irregular, 264. Rude respiration, 116, 175. Scapular line, 8. region, 5. Scrofula, relations to tubercle, 112. Sibilant rales, 37, 160. Siderosis pulmonum, 87. Skodaic resonance, 78, 144. Sonorous rales, 37, 160. Sounds of the heart, 190, 192. Splashing sounds, 169. Sphygmograph, 267. Sputa, 8. Steam-tug heart murmurs, 234. Sternal line, 3, 8. Stethoscopes, 24, 25. Stokes, 115. Stridor, 160. Stridulous breathing, 160. Sub-axillary region, 8. Sub-clavicular region, 2. Sub-crepitant rales, 38, 162. Sub-scapular region, 5. Sub-mucous rales, 38, 162. Sub-mammary region, 4. Succussion, 33, 157, 169. Sudden death from heart dis- ease, 260. Summary of signs in health, 30. Superficial veins, 121. Superior costal respiration, 9. sternal region, 5. Supra-clavicular region, 2. Supra-scapular region, 5. Supra-sternal region, 5. Tait, Dr. Lawson, 115 Thermometry, 8. Thickened pleura, 146. Thoracentesis, 33. Thoracic aneurism, 283. Thrill, purring, 202. Thrombosis, 97. Tinkle, metallic (amphoric), 128, 158, 165. Tobacco heart, 258, 259, 266. Tracheal rales, 162. Trachiloquy, 182. Tricuspid obstruction, 221. INDEX. 345 Tricuspid regurgitation, 222. Tubercle bacillus, 110, 117. Tubercular consumption, 106. Tussile fremitus, 12. Tympanitic resonance, 124 Valves of the heart, 188. Valvular lesions, 192. Venous hum, 230. Vertebral line, 8. Vesicular rale, 164. respiratory murmur, 27. Vesiculo-bronchial breathing, 28. Vesicular emphysema, 48. resonance, 18. Vicarious emphysema, 48. Vocal fremitus, 11. resonance, 29. Wavy respiratory murmur, 27, 174. Webster, Dr. David, 262. Wintrich, 17. Wyeth, Dr. John A., 278. Zenker, 87. ) Aavaan tvnoiivn 3Noia3w jo Aavaan tvnouvn snidiqsw do Aavaan tvnoiivn ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE /Vv i iNiDiasw do Aavaan tvnoiivn 3NI3I03W do Aavaan tvnoiivn snidiqsw do Aavaan tvnoi I /\^\ N NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICI inoiqsw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snidiqsw do Aavaan NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE snidiqsw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snidiqsw do Aavaan tvni NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE inidiosw do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn snidiosw do Aavaan ? Uffu > » / yd? f 13i»w > °: / 7?fi ? -a NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIr NiDiasw do Aavaan ivnouvn snidio3Wv»6 Aa/f/aai\ tmnoiivn snidiosw do Aavaan tvno v 'Or MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDi _NE nlh ooioaobT a '$ ^ ■.-■•.v.; ■•.,•. .*K«{& :-'',.-;#1f •c* > vVc ''^ NLM001020692