MANUAL 
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iD'SlCAL DIAGNOSIS. 
TYSON. BY THE SAME AUTHOR. 
GUIDE TO THE EXAMINATION OF URINE. Seventh Edi- 
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With a Colored Plate and 42 Illustrations Engraved on Wood. 
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THE CELL DOCTRINE : Its History and Present State, together 
with a copious Bibliography of the Subject. With a Colored Plate 
and other Illustrations. Second Revised Edition. Cloth. $2.00. 
''The first edition of Dr. Tyson's work appeared in 1870, and at once re- 
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IN PREPARATION. 
A TEXT-BOOK OF THE PRACTICE OF MEDICINE. For 
the use of Physicians and Students. MANUAL 
OF 
PHYSICAL DIAGNOSIS 
FOR THE USE OF 
STUDENTS AND PHYSICIANS. 
BY 
JAMES TYSON, M.D., 
PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA 
AND PHYSICIAN TO THE UNIVERSITY HOSPITAL; PHYSICIAN TO THE 
RUSH HOSPITAL FOR CONSUMPTION AND ALLIED DISEASES ; FELLOW 
OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER 
OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC. 
SECOND EDITION, REVISED AND E E D. 
PHILADELPHIA : 
P. BLAKISTON, SON & CO. 
IOI2 WALNUT STREET. 
I893. Copyright, 1893, by James Tyson, m. i>. 
Press of Wm F. Fell & Co. 
1220-24 Sansom St., 
PHILADELPHIA. PREFACE TO THE SECOND EDITION. 
The occasion for a new edition of this manual has 
given the author an opportunity to enlarge it in such 
manner as to cover more fully the title of Physical 
Diagnosis, while he has endeavored, also, to improve it 
in other respects. 
He has also seen fit to add, under the heading 
"Appendix," several subjects not strictly belonging to 
physical diagnosis, viz., the examination of blood, that 
for the more important bacilli associated with the infec- 
tious diseases, the various chemical examinations re- 
quired in diagnosis of diseases of the stomach, and 
directions for making an autopsy. These are added 
more especially because they form an important part of 
the instruction to the classes in the University of Penn- 
sylvania, but it is hoped that they may also prove useful 
to others. The shortest and simplest methods have 
been selected, with a view to maintaining the original 
purpose of the book, conciseness with practical suffi- 
ciency. 
October /st, 1893. 
V PREFACE TO THE FIRST EDITION. 
It cannot be said that the making of a new book on 
Physical Diagnosis is demanded by reason of the few- 
ness of existing treatises on the subject. It is, how- 
ever, but natural that it should occur to one, a part of 
whose duty it is to teach physical diagnosis to large 
classes of medical students, that he might accomplish 
more satisfactorily his task by having a text-book of 
his own preparation. In this I have sought to secure 
conciseness with sufficiency, a task acknowledged to be 
difficult, but which experience in teaching is, perhaps, 
best calculated to overcome. It is the object I especially 
sought in my Manual on the Examination of Urine, 
which has now reached its Seventh* Edition. The 
present book is not intended to be pretentious, and if it 
effects its simple purpose in being useful to students I 
will feel repaid. James Tyson. 
1506, Spruce Street, October 1st, 1891. 
*The Eighth Edition was issued April, 1893. 
VI LIST OF ILLUSTRATIONS. 
FIG. PAGE 
1. Regions of the thorax, anterior aspect, 12 
2. Regions of the chest, posterior aspect, 14 
3. Anterior view of the organs of the chest and abdominal 
cavity, 17 
4. Posterior view of the organs of the chest and abdominal 
cavity, . 21 
5. Transverse section of healthy adult chest at level of sterno- 
xiphoid articulation, • 28 
6. Pigeon-breast, child of seven years, 29 
7. Rickety chest, 30 
8. Percussion hammer or plexor, 33 
9. Ivory pleximeter, 33 
10. Sansom's pleximeter, 33 
11. Absolute and relative percussion dulness of liver and heart, 47 
12. Gerhardt's change of note, 55 
13. Hawksley's stethoscope 60 
14. Sansom's binaural stethoscope, 61 
15. Simpler form of Sansom's binaural stethoscope, 61 
16. Valentine's Binaural stethoscope, 62 
17. Bilateral enlargement in emphysema, 84 
18. Position of heart in relation to ribs and sternum, .... 110 
19. Absolute and relative percussion dulness of liver and heart,113 
20. Diagram showing the location of cardiac valves and points 
of maximum intensity connected with them, 117 
21. Normal sphygmogram enlarged, 136 
22. Sphygmogram showing prolonged arterial tension, .... 138 
23. Anacrotic pulse-curves from the radial artery, 139 
VII VIII 
LIST OF ILLUSTRATIONS. 
FIG. PAGE 
24. Tracing of pulse of aortic regurgitation, 140 
25. Tracing from case of prolonged arterial tension, showing 
dicrotic wave, 141 
26. Normal cardiac apex tracing, 142 
27. Tracing of pulse of mitral insufficiency, 148 
28. Tracings of pulse in mitral stenosis, 150 
29. Pulse tracing of aortic stenosis, 153 
30. Tracing of pulse of aortic regurgitation, 155 
31. Drawing showing regions of the abdomen, 182 
32. Group of 16 small squares, making one large square of the 
Thoma-Zeiss cytometer, magnified, 198 
33. Hcemoglobinometer of Fleischl, 202 TABLE OF CONTENTS. 
PAGE 
General Considerations, 9 
Inspection and Mensuration, . 26 
Palpation, 31 
Percussion, 33 
Percussion of the Normal Chest, 44 
Abnormal Percussion Lung Sounds, 50 
auscultation, 59 
Auscultation of the Normal Lung, 63 
Abnormal Modifications of Breathing Sounds, .... 66 
Auscultation of the Normal Voice, 73 
New or Adventitious Sounds, 76 
Physical Signs of Abnormal States of the Lungs, 81 
Acute Bronchitis, 81 
Chronic Bronchitis, 82 
Emphysema of Lungs, 83 
Spasmodic Asthma 85 
Tubercular Phthisis, 86 
Catarrhal Phthisis, 87 
Fibroid Phthisis, 91 
Miliary Tuberculosis, 92 
Pneumonia, 93 
Croupous 93 
Catarrhal, 96 
Embolic, 97 
Pulmonary CEdema, 98 
Collapse of the Lung, 98 
Cancer of the Lung, 99 
IX X 
CONTENTS. 
PAGE 
Pleurisy, loo 
Pneumothorax, 107 
Physical Examination of the Heart, 109 
Anatomical Relations of the Heart, 109 
Percussion and Auscultation of the Normal Heart, . . 112 
Abnormal Modification of the Heart Sounds, .... 120 
Organic Murmurs, 124 
Functional Murmurs, 130 
Vascular Murmurs, 132 
The Sphygmograph in Diagnosis, 135 
The Cardiograph in Diagnosis, 141 
Physical Signs of Different Forms of Heart Disease, .... 146 
Mitral Insufficiency, 146 
Mitral Stenosis, .... 149 
Mitral Insufficiency and Stenosis, 152 
Aortic Stenosis, 152 
Aortic Insufficiency, 154 
Aortic Stenosis and Regurgitation, 157 
Tricuspid Regurgitation, ... 157 
Tricuspid Stenosis, 159 
Pulmonary Stenosis, 160 
Pulmonary Regurgitation, 161 
Congenital Defects, 161 
Relative Frequency and Danger of Valvular Defects, . 162 
Acute Endocarditis, 167 
Pericarditis 168 
Diseases of the Myocardium, 169 
Thoracic Aneurysm 173 
Physical Examination of the Abdomen, 182 
Inspection, . 184 
Palpation, 185 
Percussion, 189 
Auscultation, 194 XI 
PAGE 
Appendix- 
Examination of Blood and Sputum, 196 
Counting of Blood Corpuscles, 196 
Staining of Tubercle Bacilli, 203 
The Pneumococcus, 206 
Bacillus of Diphtheria, 208 
Typhoid, 208 
Cholera, 208 
Syphilis, 208 
Gonorrhoea, 208 
Chemical Examination of Gastric Contents, 209 
The Making of an Autopsy, . . • 224 
Order of Examination of Patient 234 
Index, 239 
CONTENTS. MANUAL 
OF 
PHYSICAL DIAGNOSIS. 
GENERAL CONSIDERATIONS. 
The term physical diagnosis strictly defined would 
include the diagnosis or investigation of disease by the 
aid of all the special senses, but practically it is con- 
fined to eliciting such information as can be furnished 
by vision, touch, and hearing, whence come the terms 
inspection, palpation, and auscultation. The informa- 
tion acquired by hearing is further subdivided-ist. 
Into that gained by listening directly to the normal 
breathing sounds and heart sounds, and to their ab- 
normal modifications; and to certain new sounds pro- 
duced by diseased states. 2d. Information gained by 
striking or percussing the part to be investigated. 
Hence, too, the words auscultation and percussion 
are constantly used in association. 
The information furnished by inspection is also ren- 
dered more accurate by measuring or mensuration, 
when this can be applied. Thus constituted, physical 
9 10 
PHYSICAL DIAGNOSIS. 
diagnosis is applied to any portion of the body, but it 
is more especially in the study of diseases of the thoracic 
and abdominal contents, and particularly the former, 
that it is useful. The phenomena thus learned are 
known as physical signs. The use of the term " physi- 
cal " is based upon the fact that it is through alterations 
in the physical properties of the tissue or organ investi- 
gated that information is obtained, such as the shape, 
density, transparency. On the other hand, in its usual 
application there is a limitation inconsistent with strict 
accuracy. Thus there is no more accurate means of 
recognizing physical states than by thermometry, yet 
thermometry is not one of the measures employed in 
physical diagnosis. 
It is very true that physical signs cannot be acquired 
from books and must be learned at the bed-side; but 
we may record their import and significance in the 
recognition of disease and render somewhat easier their 
study. To this end is indispensable a familiarity with 
the physical condition of the organs of the body in a 
state of health. This, too, can only be learned on the 
living subject by giving the student an opportunity to 
listen until he is thoroughly familiar with the normal 
breathing and heart-sounds, to observe the normal shape 
and configuration of the body, and to learn the percus- 
sion note characteristic of different regions over impor- 
tant organs, as the heart, lungs, and various abdominal 
viscera. Such a study of the situation of internal organs 
in relation to external parts, for the purposes of the 
physician, constitutes medical anatomy. REGIONS OR SPACES OF THE CHEST. 
11 
The attainment of the objects of physical diagnosis 
is greatly facilitated by mapping out the chest into cer- 
tain spaces or areas known as the 
REGIONS OR SPACES OF THE CHEST. 
The clavicle itself is a useful landmark in physical 
examination, while above each clavicle in health is 
usually a slight depression known as the supra-cla- 
vicular fossa, and above the sternum another known 
as the supra-sternal notch. Below each clavicle is 
the infra-clavicular space, which is somewhat arbi- 
trarily bounded below by the upper edge of the third rib 
and adjacent cartilage, internally by the edge of the 
sternum, and externally by the base of the shoulder or 
a line drawn vertically from the inner end of the outer 
fourth of the clavicle. Below the clavicle, as well as 
above, in health, is usually a slight depression. All 
these depressions or spaces are liable to become deeper 
in emaciation, and are less conspicuous in fat persons. 
Below the upper edge of the third rib is the mammary 
region, bounded internally by the edge of the sternum, 
externally by the above-described vertical line, and 
below by the upper margin of the sixth rib. Nearly in 
the center of the mammary region is the nipple, which 
in males and young girls is just below the fourth rib. 
A line drawn vertically through it is known as the 
mammillary line. The mid-clavicular line co- 
incides with the mammillary line when the nipple is in 
its typical situation, and is therefore a better term. 12 
PHYSICAL DIAGNOSIS. 
Fig. i. 
Regions of the thorax, anterior aspect. REGIONS OR SPACES OF THE CHEST. 
13 
Below the mammary region, as far as the edge of the 
thorax, is the infra-mammary, or hypochondriac, 
region. In the center of the thorax anteriorly is the 
sternum, bounded by its notch above and the end of the 
ensiform cartilage below. It is divided into the upper 
sternal region, extending as far as a line drawn along 
the upper edge of the third cartilage, and the lower ster- 
nal, including the remainder of the bone. Laterally 
are the axillary and the infra-axillary regions, the 
former above and the latter below a line continuous 
transversely with the lower border of the mammary 
region (sixth rib) ; bounded in front by the external 
border of the mammary and infra-mammary regions and 
behind by a line drawn vertically downward from the 
insertion of the posterior fold of the axilla. The infra- 
axillary region extends downward to the edge of the 
thorax. 
Posteriorly are the scapular regions, including the 
supra-spinous fossa and the infra-spinous fossa 
of each scapula, the interscapular region, and the 
sub-scapular, or infrascapular regions. All except 
the last are sufficiently indicated by their names; the 
interscapular region is included between the scapulae 
posteriorly and bounded below by a line drawn through 
the angles of these bones in the position assumed by 
them when the arms are hanging at the side. Such line 
usually crosses the seventh rib. The infrascapular 
regions are bounded above by the line just described, 
below by the edge of the thorax, and extend from the 
median line to the posterior axillary line on each side. 14 
PHYSICAL DIAGNOSIS. 
Fig. 2. 
Regions of the chest, posterior aspect. MEDICAL ANATOMY OF THE THORAX. 
15 
In addition to the mammillary line, are lines drawn 
vertically down the middle of the axilla and through 
the angle of the scapula behind, called the mid-axil- 
lary and scapular lines-also landmarks useful in 
description. The parasternal line, frequently used, 
is a vertical line drawn midway between the edge of 
the sternum and the mammillary line. 
MEDICAL ANATOMY OF THE THORAX. 
For the intelligent study of the physical diagnosis of 
the chest, it is important that the student should know 
what viscera or parts of viscera are contained in the 
areas just mapped out. See Figs. 3 and 4. 
1. In the supraclavicular region is contained the apex 
of the lung (4, 10, Fig. 3), which rises above the upper 
border of the clavicle to the extent of a half inch to an 
inch and a half, and even two inches, varying in differ- 
ent persons. It is rather toward the inner end of the 
clavicle. One or other apex is usually a little higher 
than its fellow, the left more frequently. The apex of 
the lung is crossed by the subclavian vessels in the first 
part of their course. In the supraclavicular fossa near 
the outer border of the sterno-mastoid muscle, and 
about one inch above the clavicle, the beating of the 
subclavian artery can be felt. In this hollow, too, is 
the termination of the external jugular vein. 
2. Behind the clavicle, in the clavicular region, is also 
found the lung, but the first and second ribs are inter- 
posed between the clavicle and the lung, so that no 16 
PHYSICAL DIAGNOSIS. 
typical lung note on percussion can be expected in that 
situation. Behind the inner end of the clavicle is the 
commencement of the innominate vein ; behind this, 
on the left side, the common carotid; to the outside 
of this the left subclavian artery, and on the right side 
behind the sterno-clavicular joint, the bifurcation of 
the innominate. 
3. The infraclavicular regions are occupied almost 
purely by lung structure. The superior cava extends 
slightly beyond the right edge of the sternum in this 
region, the pulmonary artery and the left auricle some- 
what more to the left of the left edge of the sternum. 
The latter is in the second intercostal space and extends 
to the left parasternal line, covered by the edge of the 
lung. 
4. The structures occupying the mammary regions 
differ considerably on the two sides. The right side is 
the simpler. The fissure between the upper and middle 
lobes of the right lung begins in the quiescent state of 
the lung at the fourth costo-sternal junction and passes 
upward and outward behind the third rib. The fissure 
between the middle and lower lobes of the right lung is 
found laterally about the fifth rib. The fissure between 
the upper and lower lobes of the left lung is behind the 
fifth rib laterally, terminating in the lower edge of the 
lung at about the fifth chondro-costal junction ; but all 
these fissures change place with the act of deep breath- 
ing. To the right of the sternum is the right auricle, 
behind the third costal cartilage, the third interspace, 
the fourth costal cartilage, and fourth interspace, and Fig. 3. 
Anterior view of the organs of the chest and abdominal cavity with reference 
to their relations to the skeleton and the boundaries of the stomach, i. Larynx. 
2. Thyroid gland. 3. Trachea. 4. Right lung-apex. 5. Upper lobe, 6. 
Middle lobe, 7. Lower lobe of right lung 8 Upper, 9. Lower interlobular 
boundary of the right lung. 10. Apex, 11. Upper lobe. 12. Lingual process 
of the left lung. 13. Cardiac boundary of the anterior border of the left lung. 
14. Portion of the anterior aspect of the pericardium covered by the cardiac 
pleura. 15. Portion of same uncovered by diaphragm. Site for paracentesis. 
16. Anterior border of right mediastinum. 17 Anterior border of the left 
mediastinum. 18. Upper or true border of the liver partially covered by 
lung. 19. Right lobe of the liver. 20. Quadrate lobe of the liver. 21. Left 
lobe of the liver. 22. Gall bladder. 23. Upper end of the stomach. 24. 
Stomach cul du sac partially covered by lung. 25. Pyloric end of stomach. 
26. Larger curvature of stomach (right gastro-epiploic artery). 27. Trans- 
verse colon.-After Luschka, slightly modified. 18 
PHYSICAL DIAGNOSIS. 
extending almost to the right parasternal line, but cov 
ered by lung. The right ventricle extends at the outer 
inferior angle of its base very slightly, if at all, from 
behind the sternum into the sixth interspace. 
The left mammary region is occupied almost as far as 
the mid-clavicular line by the heart, including por- 
tion of the right and left ventricle. The cardiac line 
is an oblique one beginning at or near the junction of 
the left parasternal line with the lower border of the 
second rib and thence downward and outward to the 
apex formed by the left ventricle in the fifth interspace 
an inch below and within the nipple. The upper por- 
tion of this area is covered by lung, leaving only a 
tongue-shaped portion of the heart uncovered between 
the fourth and sixth ribs. Between the fourth and fifth 
ribs (at 15, Fig. 3) is a spot of the pericardium uncovered 
by the diaphragm, which is the usual site for paracen- 
tesis of the pericardium. The remainder of the left 
mammary region is occupied by lung. 
5. The infra-mamniary regions differ even more on 
the two sides in the structures comprehended in them. 
The right side is, however, mainly occupied by the liver, 
the dome of which reaches its highest point within the 
mammillary line in the fourth interspace, but is covered 
with lung down to the sixth rib. The lower border 
in health just reaches the edge of the ribs at the mid- 
clavicular line, and then extends obliquely upward 
toward the left, crossing the median line usually at one- 
third the distance between the ensiform cartilage and 
the umbilicus, and reaching the left border of the MEDICAL ANATOMY OF THE THORAX. 
19 
thorax at or near the left parasternal line. The lower 
edge of the liver varies somewhat in healthy individuals, 
and descends below the ribs with deep inspiration. 
The left infra-mammary region includes the anterior 
part of the lower lobe of the left lung, the left lobe of 
the liver, the cardiac end of the stomach, varying 
degrees of distention of the latter organ producing 
considerable variation in the percussion boundaries of 
these organs. 
Between the infra-mammary regions is the epigastrium 
in abdominal topography. In the right half of the epi- 
gastrium is the quadrate lobe of the liver, the gall 
bladder, the pyloric end of the stomach, at a point 
midway between the ensiform cartilage and the para- 
sternal line, behind the liver and adjacent to the gall 
bladder. The fundus of the gall bladder can some- 
times be felt at the edge of the liver. In the left half 
of the epigastrium is the left lobe of the liver and lower 
median part of the stomach. 
6. The suprasternal notch is solely occupied by the 
trachea in health, but is often encroached upon by a 
dilated aorta, or aorta pushed up by a hypertrophied 
heart. 
7. The lipper sternal region under the manubrium is 
occupied by the trachea, which bifurcates at the junc- 
tion of the first and second bone, by a part of the 
superior cava, the arch of the aorta, the left innominate 
vein, which joins its fellow to form the superior cava just 
below the cartilage of the first rib, close to the right 
edge of the sternum ; also by a part of the pulmonary 20 
PHYSICAL DIAGNOSIS. 
artery. The upper and central part of this region is 
uncovered by lung. 
8. The lower sternal region contains a part of the 
aorta, a portion of the right auricle, much of the right 
ventricle, beginning opposite the fourth cartilages, and 
behind this the left ventricle. The edges of the two 
lungs unite through the upper part of this region in the 
middle line, the left diverging at the fourth rib where 
the uncovered tongue-shaped piece of the heart com- 
mences. The primary bronchi are found diverging at 
the upper part of this region, where they penetrate the 
lung. The right, larger and shorter, passes downward 
on the level of the fourth dorsal vertebra; the left, 
longer and smaller, downward and outward to the level 
of the fifth dorsal vertebra. 
9. The scapular regions cover the lung, the incisure 
between the upper and lower lobes passing obliquely 
downward under the bone from the upper edge of the 
fifth rib behind to between the fifth and sixth ribs 
laterally. 
10. The interscapular region in its central portion is 
occupied by dorsal vertebrae, in front of which is the 
trachea, bifurcating at the fourth, whence its primary 
bronchi extend downward and outward surrounded by 
lung structure. 
11. The infra- or subscapular regions, extending from 
the angles of the scapulae to the edge of the thorax, 
include on the right side lung as far as the tenth rib in 
the mid-scapular line. Below this is the complemental 
pleural space (see p. 24) filled by lung only in deep in- MEDICAL ANATOMY OF THE THORAX. 
21 
Fig. 4. 
Posterior view of the organs of the chest and abdominal cavity, i. Upper 
lobe, 2. Lower lobe of left lung. 3. Interlobular boundary between them. 
4. Upper lobe of right lung. 6. Middle lobe of the right lung. 7. Line be- 
tween upper and middle lobes of the right hing. 9. Stomach demarked by a 
dark line. 10. Spleen in its relation to the lung in expiration, with the kid- 
ney showing behind and below it. n. Left kidney. 12. Horizontal upper 
part of the duodenum. 13. Descending portion of the duodenum. 14. Hori- 
zontal lower part of the duodenum. 15. Duodeno-jejunal flexure. 16. Liver. 
20. Pancreas.-After Luschka. 22 
PHYSICAL DIAGNOSIS. 
spiration, as far as the eleventh rib, where the lower 
border of the liver is met. The thick lumbar muscles 
separate the integuments to the right of the vertebrae 
from the upper end of the right kidney behind and the 
pyloric orifice of the stomach in front. The upper end 
of the right kidney is under the eleventh interspace and 
the short twelfth rib. On the left side there is pure 
lung tissue as far as the ninth rib, whence it dips down 
in deep inspiration into the complemental pleural space 
between the thoracic wall and that part of the dia- 
phragm covering the spleen, which extends from the 
ninth to the eleventh ribs inclusive. A small portion 
of lung tissue is interposed between the posterior edge 
of the spleen and the tenth dorsal vertebra. The 
cardiac orifice of the stomach is on the left side about 
opposite to the body of the ninth dorsal vertebra. 
Behind the eleventh rib is the upper end of the kidney, 
which extends a little higher on the left side than the 
right. The left end of the pancreas is close to the 
spinal column in the eleventh interspace and under the 
root of the twelfth rib. 
12. The axillary regions on both sides are occupied 
with lung structure, a part of the upper lobe of each 
lung. 
13. The infra-axillary regions are again more com- 
plex in the structures they cover. On the right side 
there is lung as far as the ninth rib in the mid-axillary 
line; below this is liver to the eleventh rib, or edge of 
the thorax in this line. 
On the left side there is lung as far as the ninth rib in MEDICAL ANATOMY OF THE THORAX. 
23 
the mid-axillary line. Below this is the spleen, which 
extends to the eleventh rib inclusive, or edge of the 
thorax at this situation. The cardiac end of the 
stomach, especially when dilated, is apt to protrude into 
the infra-axillary region and to influence the percussion 
note. 
The Borders of the Lungs.-It is to be remem- 
bered that these anatomical boundaries are of themselves 
rather approximate, and furthermore, that they do 
not necessarily coincide with the percussion boundaries of 
the same organ, as in many situations portions of lung 
protrude between the organs and the surface and pro- 
duce a modification of the note peculiar to the adjacent 
organ-the relative or deep-seated dulness of these 
organs. It is therefore useful also to know the correct 
anatomical boundaries of the lungs as a whole in rela- 
tion to the landmarks given : - 
In front the lungs extend above the clavicles from 
half an inch to an inch and a half or more; behind as 
far as a line drawn through the apex of the spinous pro- 
cess of the seventh cervical vertebra. Below and in 
front the right lung extends to the neighborhood of 
the sixth cartilage, the left to the fourth; in the mid- 
axillary line both extend to the lower border of the 
seventh rib, in the mid-scapular line to the tenth rib, 
and near the spinal column to the eleventh rib. On the 
left side at the inner end of the fourth cartilage the 
lung diverges from under the breast bone obliquely 
behind the fourth cartilage through the fourth inter- 
costal space and again turns toward the sternum behind 24 
PHYSICAL DIAGNOSIS. 
the fifth costal cartilage, but at the sixth cartilage 
again turns outward to form the tongue-shaped indenta- 
tions into the lung boundary, by which a portion of the 
heart is uncovered. Behind the breast bone, from the 
second to the fourth cartilage, the edges of the two 
lungs approach each other very closely. 
The summit of the dome of the liver in front reaches 
as far as the fourth interspace on the right side, but it 
is covered with a wedge-shaped extension of the lung as 
far as the sixth rib, where what is known as the absolute 
dulness of the liver begins. 
It is to be remembered that in quiet breathing, during 
which the boundaries above traced are supposed to be 
noted, the anterior edge of the left lung and the inferior 
edges of both lungs do not reach the extreme limit of 
the pleural space, so that between the edges of the 
lungs and the boundary of the pleural sac there remains a 
space which is only filled at the time of deep in- 
spiration. At other times the costal and pulmonary 
pleura below the lower edge of both lungs are in con- 
tact, as are also the costal and mediastinal pleura 
toward the median line at the anterior border of the 
left lung. The spaces thus formed are called comple- 
mental spaces. 
Above the cartilage of the fourth rib the anterior 
border of both lungs fills the pleural space, but below 
these the edge of the left lung deviates from the pleural 
border to form the tongue-shaped cardiac indentation 
referred to. The inferior border of the left lung ex- 
tends a little lower than that of the right, more particu- MEDICAL ANATOMY OF THE THORAX. 
25 
larly between the parasternal and the mammillary line, 
where it extends half an inch lower. 
It is less important to know the interlobular boun- 
daries of the lung. These begin on both sides posteri- 
orly at the level of the spines of the scapulae, or the 
second and third spinous processes of the dorsal verte- 
brae, and diverge downward and outward. The inter- 
lobular incisure of the left lung intersects the mid-axillary 
line at the level of the fifth rib, and terminates in the 
mammillary line at the fifth rib. The right incisure 
divides at about two or two and a half inches above the 
angle of the scapula into two branches, an upper and a 
lower, which separate the upper lobe from the middle, 
and the middle from the lower lobe of the lung. The 
upper branch passes nearly transversely forward to ter- 
minate in the edges of the lung at about the level of the 
fourth cartilage. The inferior branch passes sharply 
downward and slightly forward at the level of the sixth 
rib in the neighborhood of the mammillary line, and out 
at the lower edge of the lung. Hence it is that on the 
posterior aspect the lower lobes make up the larger part 
of the lung exposed to percussion ; in front, on the left, 
only the upper lobe, on the right the upper and middle 
lobes. Laterally, on the left side the upper and lower 
lobe, and on the right side the upper, middle, and lower 
lobes approach the surface. 26 
PHYSICAL DIAGNOSIS. 
INSPECTION AND MENSURATION. 
The appearances of the regions described, during and 
independent of the motions of breathing, are objects of 
inspection, but these are best described in connection 
with the conditions which modify them. In inspecting 
the chest from the front or behind, the patient should 
stand erect with the hands at his side; during lateral 
inspection the hands should be raised alongside of the 
head, or they may grasp opposite shoulders. Such rela- 
tions to light should be chosen as will obviate shadows 
as much as possible. It will be remembered that during 
breathing, a woman exhibits more motion in the upper 
part of the chest, while in men abdominal motion is 
marked. 
Mensuration is for the most part practised by an 
ordinary tape measure, and thus the circumference of 
the chest at different situations is determined ; also dif- 
ferences in the circumference at the end of inspiration 
and of expiration, and differences in the semi-circum- 
ference as the result of abnormal states. It is to be 
borne in mind that in right-handed persons the semi- 
circumference of the right side is often a quarter of an 
inch to an inch greater than that of the left, owing to 
the greater muscular development of that side. The 
reverse obtains to a less degree in left-handed individuals. 
The transverse and antero-posterior diameters of the 
chest may be determined by a pair of calipers; any 
deviations in the shape of the chest by the cyrtometer, 
a simple form of which may be made out of strips of THE SHAPES OF THE CHEST. 
27 
sheet lead, moulded to the chest-walls, and the outline 
thus produced be drawn on a large sheet of paper. More 
perfect appliances for chest measurement are the stetho- 
meter of Quain, the stetho-goniometer of Allison, the 
cyrtometer of Woillez and others, but they are not 
needed for the usual measurements. 
THE SHAPES OF THE CHEST. 
By inspection and mensuration we learn the shape of 
the chest. 
1. The normal shape of the infant's chest at birth 
is nearly cylindrical, but as development proceeds it 
acquires an oval shape well established by the time 
the child has cut its milk teeth. This increases slowly 
until development is complete, when the outline shown 
in Fig. 5 is attained :- 
During maturity the chest retains this shape, but with 
the wane of life and the effect of disease incident to it 
there come changes which cause the chest to again ap- 
proach the cylindrical shape of infancy. 
The effect of various affections on the shape of the 
chest will be considered in connection with the separate 
diseases, but there are several types in those in apparent 
health which are important, in that they favor tenden- 
cies to special diseases or are the result of weakness in 
childhood. 
2. Thus we have the alar or pterygoid chest, which 
is one of the forms of the so-called phthisical chest, be- 
cause supposed to favor the development of this dis- 28 
PHYSICAL DIAGNOSIS. 
ease. Such a chest is small; the angles of the scapulae 
project so as to give the appearance of wings. It is 
narrow, shallow, and long; but the ratio between the 
antero-posterior and transverse diameters is not neces- 
sarily changed. The ribs droop or are unduly oblique. 
Fig. 5. 
Transverse section of healthy adult chest at level of sterno-xiphoid 
articulation. (After Gee.) 
The throat is prominent, the neck long and the head 
bent forward. 
3. Then there is the flat chest, also phthisical, 
wherein the antero-posterior diameter is dispropor- 
tionately short, owing to the loss of convexity in the 
cartilages, which are even sometimes turned in so that 
the sternum is below the level of the cartilages, produc- 
ing a shape of chest which on section is kidney-shaped. INSPECTION AND MENSURATION. 
29 
In this form of chest there is not the increased degree 
of obliquity of the ribs characteristic of the alar chest. 
4. The transversely constricted chest is charac- 
terized by a depression of varying depth passing out- 
ward and slightly downward on a level with the xiphoid 
cartilage and extending as far as the mid-axillary line. 
It is produced in childhood by some obstruction to the 
entrance of air, usually a bronchial catarrh, as the 
Fig. 6. 
Pigeon-breast, child of seven years. 
Dotted lines indicate natural shape at same age. (/l/iter Gee.) 
result of which the upper part of the chest is not ex- 
panded, while the lower part is held expanded by the 
abdominal viscera. 
5. The pigeon breast is the result of higher degrees 
of obstruction than are produced by simple catarrhal 
conditions. Whooping-cough, with its prolonged par- 
oxysms, is probably the most frequent cause, but any 
chronic pulmonary catarrh may do it, as may also en- 
larged tonsils. In it the shape of the transverse section 30 
PHYSICAL DIAGNOSIS. 
of the chest is more or less triangular, the result of a 
straightening of the ribs and forward protrusion of the 
sternum, which takes place while the ribs are plastic and 
yielding. The pigeon breast is usually associated with 
the transverse constriction above described, both being 
the result of different degrees of the same cause. 
6. The rickety chest is characterized by a shallow 
Fig. 7. 
Rickety chest. 
Dotted line indicates the shape of the chest of an infant about the same age 
(After Gee.) 
longitudinal groove on each side of the chest, parallel 
and a little external to the sternum. It is due to 
external atmospheric pressure upon soft, rickety ribs be- 
fore the lungs are sufficiently filled to occupy the space 
rendered vacant by the descent of the diaphragm. The 
groove takes the position it does because the softest 
parts of the ribs are about the costo-chondral articula- 
tions. PALPATION. 
31 
PALPATION. 
After inspection and mensuration of the chest, palpa- 
tion is usually practised. This is done by applying the 
palm of the hand or the fingers, as may best serve the 
purpose, to the chest-wall. The chief value of palpa- 
tion lies in the fact that when the hand is thus closely 
applied, and the person "touched " speaks, a peculiar 
vibrating or trembling sensation is conveyed to the 
hand. This is known as vocal fremitus or vocal 
tactile fremitus. This fremitus or thrill, representing 
the vibrations in the air below the vocal cords, is com- 
municated to the walls of the air passages, from the larger 
to the smaller, until the ultimate structure of the lung is 
reached, whence it is conveyed to the chest-wall and 
hands. In health it is felt everywhere over the chest 
where lung-tissue reaches, but is more distinct where the 
chest-walls are thinnest, and especially in the infra- 
clavicular spaces. It is further often more plainly felt 
below the right clavicle than below the left, an impor- 
tant fact to be remembered in recognizing delicate 
shades of difference. This is usually explained by the 
fact that the right bronchus is shorter,- larger, and enters 
the lung higher up and more horizontally than the left, 
whence a larger volume of air is contained in the right 
lung, especially in its upper portion, and stronger vibra- 
tions are produced in speaking. For the same reason vocal 
fremitus is sometimes slightly more distinct posteriorly in 
the right half of the interscapular space, and even below 
the angle of the right scapula. In the axilla the same 32 
PHYSICAL DIAGNOSIS. 
difference may exist to a less degree. Tactile fremitus 
is, of course, more marked in persons with thin chest- 
walls than in those with thick muscular walls, or walls 
covered with fat, while it is feebler but still easily ap- 
preciable in women. It is also greatly influenced by the 
pitch or tone of the voice used, being more marked in 
a deep, low-toned speech than in a high one. It is 
further influenced by words selected for utterance. My 
favorites are "ninety-nine," as producing a longer vi- 
bration than words like "sixty-six," for instance. But 
"one, two, three," or "twenty-one," " twenty-two," 
and " twenty-three," and the like, are useful also to 
bring out vocal fremitus. 
Vocal fremitus is increased in abnormal states pro- 
ducing consolidation of the lung, as in pneumonia and 
tubercular deposit, and is diminished by conditions 
which separate the lungs from the chest-wall, as pleuritic 
effusions, plastic pleuritic thickening, and even solid 
tumors. 
Fremitus is also produced by the action of coughing, 
when it is called tussile, as distinguished from vocal; 
by rales, dry or moist, if the tubes are of sufficient 
caliber, when it is called rhonchal; also by pleural 
and pericardial frictions. PERCUSSION. 
33 
PERCUSSION. 
Percussion naturally succeeds palpation, and consists 
in striking a part with a view to eliciting sound. In its 
simplest form it is probably as old as diagnosis itself, but 
Auenbrugger, of Vienna, was the first to publish, in 
1761, results obtained from its application. Percussion 
is called immediate or mediate, according as the 
Fig. 8. 
Percussion Hammer or Plexor. 
Fig. to. 
Fig. 9. 
Ivory Pleximeter. 
Sansom's Pleximeter. 
blow is struck directly upon the part or upon some in- 
terposed medium. Immediate percussion is of limited 
application, but it is still sometimes very useful, and I 
much like to percuss the clavicular region by striking 
directly the bone rather than upon some interposed sub- 
stance. The hammer or agent by which the stroke is 
practised is the plexor, and the interposed material is 34 
PHYSICAL DIAGNOSIS. 
the pleximeter. By far the most common plexor, 
and for the most part the best, is the middle or index 
finger, or both of these, while one or the other of the 
same fingers of the other hand becomes the pleximeter. 
It is often useful, however, to have a specialized hammer, 
like that shown in Fig. 8, while more useful and even 
more indispensable at times becomes a pleximeter (Fig. 
9), in situations which the fingers cannot conveniently 
reach, or where there is much percussing to do, when 
the fingers sometimes become sore and tender from the 
constant pounding. By far the most satisfactory 
pleximeter, in my experience, is the little hard-rubber 
pleximeter suggested by Sansom. (See Fig. 10.) 
Either the larger or smaller end may be applied to the 
chest, and the stroke given to the other, with equal 
efficiency. 
The pleximeter was invented and first used by Piorry, 
of Paris, in 1828, and the hammer by Wintrich, in 
1841. 
The essential conditions of successful percussion are, 
first, the close application of the pleximeter, whether it 
be the finger or an artificial pleximeter, to the chest, so 
that it will form a part, as it were, of the area to be 
percussed ; and, as the two sides of the thorax are com- 
monly compared, precisely corresponding points should 
be selected. Then care should be taken to strike with 
equal force on each side. When the fingers are used as 
plexors, the stroke should be made from the wrist, and 
vertically on the pleximeter, while the hand should be 
raised quickly, and one, two, three, or more blows given PERCUSSION. 
35 
until the proper sound of the part is elicited. To this 
end the force of the stroke should be regulated, being 
made lighter on thin-walled chests and more forcible over 
thicker walls. When the proper note is brought out it 
should be remembered and compared with the sound 
elicited under the same conditions at the corresponding 
point on the opposite side. Practice with attention to 
these conditions can alone make perfect. 
The sound produced by percussing the chest is a 
mixed one, made up of the vibrations of the pleximeter, 
those of the thoracic wall, and those of the air in the 
lungs. The first, when the finger is used as a pleximeter, 
is scarcely noticeable, but when a pleximeter of ivory 
or hard rubber is used this element may be recognized, 
especially when the pleximeter is accidentally struck by 
the nail of the finger used as a plexor. In like manner 
the vibrations of the thoracic wall are insignificant and 
unnoticeable under ordinary circumstances, in com- 
parison with the vibrations of the air in the lungs, which 
are responsible for most of the sound produced in per- 
cussing the normal chest. These vibrations are set up 
by the blow, and it is the sound thus produced, variously 
modified in health and disease, which we are to study. 
Where the chest wall is very thick, however, the note of 
its percussion becomes more predominant and that of 
the lungs less. 
Auscultatory percussion is a term applied to a 
method introduced by Cammann and Clark, which con- 
sists in listening, with a stethoscope applied to the chest- 
walls, to the sounds obtained by percussion. 36 
PHYSICAL DIAGNOSIS. 
Respiratory percussion is a term proposed by 
Da Costa for the study of a note made by percussion 
while the breath of the patient is held after a deep 
inspiration or after a prolonged expiration. Constant 
reference will be made to the effect of the latter on 
sounds elicited by percussing normal organs. 
ATTRIBUTES OF PERCUSSION SOUNDS. 
Percussion sounds have attributes of quality, in- 
tensity or loudness, pitch, and duration. No one of 
these attributescan, strictly speaking, be so described as 
to enable it to be recognized by the ear. Practice and 
illustration must be associated with the description in 
order that an adequate idea may be obtained. 
Quality is the easiest indicated of the attributes of 
sound. Although Flint correctly says of it that " to 
attempt to describe the quality of sounds to one who 
has never heard them would be like describing colors to 
one whois blind," illustration happily comes to our as- 
sistance and helps greatly. Thus it is not difficult for 
any one who has heard it to recognize the note of a 
violin or piano and to name the instrument producing 
it. The attribute of sound, by which such recognition 
is made is quality, and each quality is produced by cer- 
tain conditions peculiar to the instrument producing the 
sound. It varies therefore with those conditions. 
Now the qualities of sound produced by percussing the 
normal chest are mainly two : First, the normal vesicu- 
lar resonance or clear sound; second, the dull sound or ATTRIBUTES OF PERCUSSION SOUNDS. 
37 
dulness. There are modifications of both of these. A 
third quality, not strictly speaking a normal thoracic 
sound, but so conspicuous in adjacent organs in health 
as to often influence the thoracic sounds, will also be de- 
scribed in this connection. I allude to tympany. Each 
of these is produced by conditions peculiar to itself. 
Vesicular resonance, or lung-clearness, as applied 
to the healthy chest, is produced by percussion over 
normal air-distended lung tissue, a structure contain- 
ing air in minutely divided spaces. Such structure is 
its condition, and the sound produced is as much sui 
generis as is.the violin's sound. It is of the nature of a 
reverberation, and is reverberation modified by minute 
subdivision of air spaces. It is not inaptly compared by 
Flint to the sound produced by percussing a loaf of 
bread over which a towel has been spread, the upper 
crust of the bread corresponding to the chest-wall; but, 
as a rule, normal resonance is characterized by less 
hollowness than the percussion of a loaf of bread. 
It differs in different parts of the chest of the same 
individual and in different individuals. Its typical 
quality may always be found in the left infra-clavicular 
space or below the angle of either scapula in healthy 
persons with chest-walls of moderate thickness. 
The chief cause which operates to produce the differ- 
ences alluded to in health is the varying thickness of the 
chest walls ; but the state of tension of the air in the 
air vesicles has to do with it, as has also the position of 
adjacent viscera and the mode of percussion, according 
as it is forcibly or lightly practised, according as it is 38 
PHYSICAL DIAGNOSIS. 
well or faultily done. The differences themselves con- 
sist in variations in the other three attributes named- 
intensity, pitch, and duration. 
Intensity means simply loudness and increases pari 
passu with the thinness of the chest-wall and the force 
of the percussion blow. The effect of the attributes of 
pitch and duration are best studied after the other 
qualities mentioned, dulness and tympany, are con- 
sidered. 
Dulness in general may be defined as diminished 
resonance, but the term is not used by all authors with 
a single meaning. Thus Da Costa says,* " a dull sound 
denotes the absence of air. It is the sound both of 
fluids and solids. It is, thus, the sound sent forth by the 
airless viscera; from the liver, spleen and heart." 
Others, however, would use the term " flatness" to indi- 
cate this condition, exhibiting its typical note in percus- 
sing the thigh. R. C. M. Page f applies the term flat- 
ness to the quality obtained by percussing over fluids 
contained in thin walls, and presumably, also, over pure 
solids. To retain the word flatness for the sound pro- 
duced by percussing an absolutely airless organ or fluid, 
and dulness for resonance diminished in positive degree, 
gives a desirable latitude in the use of terms, further in- 
creased by the application of the adjective terms slight, 
moderate, considerable, or marked. I shall therefore use 
the term in this sense. Dulness and flatness are both 
*" Medical Diagnosis," 7th ed.; 1890, p. 264. 
f " Physical Diagnosis," 3d ed.; p. 23. ATTRIBUTES OF PERCUSSION SOUNDS. 
39 
associated with increased resistance to the percussing 
finger, a sign also more or less valuable in diagnosis. 
Tympany or tympanitic resonance is the sound 
elicited by percussing over a large cavity filled with air 
-a cavity whose walls are rather thin, and neither very 
tense nor very yielding. The stomach and intestines 
furnish such a cavity, and it is in this region that we 
seek the tympanitic quality of resonance. Tympany 
also has variations in pitch due to variations in the size 
of cavities which will be better understood after this 
attribute of sound is considered. 
We are now ready to discuss and illustrate the attri- 
butes of pitch and duration, neither of which are so 
easily described as quality and intensity. They can, 
indeed, only be learned by practice and with varying 
facility by different ears, the musical ear having a deci- 
ded advantage. Perseverance, however, will enable any 
one to appreciate them sufficiently for practical pur- 
poses. 
First as to pitch. We speak of it as high or low and 
of intermediate degree. Pitch is higher the more rapid 
is the succession of the vibrations of the sounding body 
and of the sound waves which emanate from it, while 
intensity depends on the amplitude of the vibrations.* 
Shrillness is the acme of pitch, loudness of intensity. 
* Amplitude is the length of the excursion of the particles which 
at any time form the sonorous wave, and the motion of the particles 
or their width of swing must not be confounded with the motion of 
the sonorous wave itself. 40 
PHYSICAL DIAGNOSIS. 
The higher the tension of a percussed cavity containing 
air the more numerous the vibrations and the higher the 
pitch, but the shorter the amplitude of the vibrations 
the less the intensity. Vice versa, a high-pitched 
tympanitic resonance would indicate a smaller cavity 
with tenser walls than low-pitched tympany. The 
normal vesicular resonance is characterized by its low 
pitch, because the air vesicles, from their elasticity, are 
not in a state of high tension. If, however, the lungs 
be forcibly dilated, the air vesicles are placed in a state 
of higher tension and of diminished elasticity, a situa- 
tion akin to that of a distended stomach, and if percus- 
sion be now practised over such areas the pitch will be 
raised, but there will be added not only a higher pitch, 
but also a tympanitic quality, and a note will be pro- 
duced which was named by the late Dr. Flint vesiculo- 
tympanitic resonance. It is a mixed note, therefore, 
and its conditions are produced by any cause which 
over-distends the air vesicles, as prolonged crying in a 
child. It is also the note of the over-distended air 
vesicles in emphysema of the lung or of portions of a 
lung, supplementally active in consequence of impair- 
ment of function in other parts. A tendency to vesiculo- 
tympanitic resonance also exists at the right apex of the 
lung as compared with other situations of typical 
resonance, and is recognized by the shadowy higher 
pitch sometimes noticeable in that locality. 
Tympanitic sounds, although generally high-pitched, 
also vary in pitch, the latter increasing inversely as the 
size of the cavity and directly with the degree of tension. ATTRIBUTES OF PERCUSSION SOUNDS. 
41 
Thus the stomach, being a large cavity, gives on percus- 
sion a lower pitch than the small intestine distended to 
an equal degree. On the other hand, tension may be 
made so great by forcible distention, say of the stomach, 
that the tympanitic sound may be destroyed. Skoda 
explained these phenomena as follows: In the moderate 
distention which gives us good tympany, the stomach 
wall is not tense enough to be thrown into vibrations, 
the air within the cavity alone vibrates and true tympany 
results. If, however, the distention is excessive, percus- 
sion throws both walls and contained air into vibra- 
tion, and the two sets of vibrations interfering with 
each other, a non-tympanitic muffled sound results. 
This explanation cannot, however, be accepted, in fact, 
as stated by Adolf Weil,* is refuted by the instrument 
whence tympany takes its name, the drum, in the tapping 
of which both the membrane and the contained air are 
thrown into vibration, and yet a resonant sound results. 
So, too, human speech and human song are produced 
by the simultaneous vibration of membrane in the shape 
of the vocal cords and of circumscribed air masses. 
Both elements must therefore be admitted to enter into 
the production of the tympanitic sound, and it is easy 
to show that, given a membrane of equal tension, the 
larger the air space the deeper the tone or lower the 
pitch, as for example the bass drum ; while, given the 
* " Handbuch der topograph ischen Percussion." Zweite Auflage, 
Berlin, 1880. 42 
PHYSICAL DIAGNOSIS. 
same volume of air and membrane of different tension, 
the pitch is higher the greater the tension. 
Now when a bladder or stomach is so forcibly dis- 
tended that its percussion produces a dull sound instead 
of a tympanitic one, and such distention is only possi- 
ble when the air space is tightly closed on all sides, it 
is as though the air space were surrounded by unyield- 
ing walls. Percussion under these circumstances-a 
thoroughly closed cavity and firm walls-produces no 
tympany, because the waves of the contained air are re- 
flected back from the smooth wallsand the sound fails to 
be produced. The observer hears for the most part 
only the sound produced by the vibrations of the 
bladder walls, influenced in part by the convex shape 
of the bladder and in part by the condensed air within 
it. The pressure of this air resists the inward vibration 
of the bladder wall, and by shortening the amplitude of 
the air vibrations diminishes the intensity and resonance 
of the sound. In a word, it is shorter, duller, non-tym- 
panitic. 
If, however, the mass of air thus surrounded by a 
tense wall communicates with the exterior by an open- 
ing, the tympanitic note responds to percussion. 
Dull and flat percussion are high pitched in their 
note, and the pitch increases with the dulness and the 
area of the dulness, while the first suggestion of im- 
paired resonance is a slight heightening of pitch which 
the practiced ear readily recognizes, and attaches to it 
great importance. The tendency to a higher pitched 
note just below the right clavicle in health as compared ATTRIBUTES OF PERCUSSION SOUNDS. 
43 
with the left is also to be remembered in weighing slight 
differences in the percussion note of the two sides. It is 
associated with the tendency to increased vocal fremitus 
in the same situation, already referred to. 
The explanations of this tendency to slightly higher 
pitched resonance and slight dulness at the right apex 
are not uniform, and are therefore best considered in a 
footnote.* 
* First is the explanation of Flint, who, in ascribing it to a spe- 
cial character of vesiculo-tympany, implies some change in the elas- 
ticity of the air-vesicles. How this is brought about except by some 
greater functional activity of the right apex I do not know. 
The second explanation of this slight impairment of the resonance 
is based on the different arrangement of the bronchial tubes on the 
right side as compared with the left. The former are larger, extend 
higher up than the latter, and thus give us more tubular tissue, in- 
cluding a larger proportion of connective and muscular tissue to 
deal with in percussing, which would give us slightly less resonance. 
A third explanation, which certainly must be allowed to apply in 
some instances, is the greater muscular development of the right 
side of the body, and in consequence greater thickness of the pec- 
toral muscles of that side. This would also cause a slightly higher 
pitch. The opposite state of affairs in left-handed persons would 
go far to confirm this, but I am not aware of any systematic obser- 
vations intended to settle this question. 
Still another explanation of this difference is based on the fact 
that the right lung rests, through the diaphragm, upon the right lobe 
of the liver, which is a dense organ, and percussion of the lung 
would be modified, by such relation, toward a slight impairment of 
resonance. It is not impossible that any one or more of the first 
three causes might operate to produce the difference on the two 
sides, the last cause more particularly in explaining any slightly 
raised pitch in the lower right lobe as compared with the left. 44 
PHYSICAL DIAGNOSIS. 
Duration is the attribute of least importance, or at 
least comes little into play in the percussion of the 
human body. It varies inversely with the pitch, that is, 
the higher the pitch the shorter the duration, and vice 
versa. 
We are now ready to study the percussion sounds as 
heard in the different regions of the chest as already 
mapped out. 
PERCUSSION OF THE NORMAL CHEST-TOPO- 
GRAPHICAL PERCUSSION. 
First, in the supra-clavicular spaces. 
Satisfactory percussion here is difficult and results are 
not to be too much relied upon. The nearest approach 
to normal clear percussion or vesicular resonance is 
found above the center of the clavicles where the lungs 
rise from half an inch to an inch and a half or even two 
inches above the clavicle, being usually higher in women 
than in men. Toward the inner end of the clavicle 
the percussion may acquire a more tympanitic quality, 
on account of the proximity of the trachea, while 
toward the outer end a duller note obtains. 
On the clavicles themselves percussion is clear, 
almost typically so, over the middle of the bone, but 
becomes duller as the outer end is approached, while 
on the inner end it may be higher pitched. 
The infra-clavicular spaces furnish in health the 
typical clear percussion-note or vesicular resonance as 
far as the upper edge of the fourth rib. On the right PERCUSSION OF THE NORMAL CHEST. 
45 
side is to be looked for the shadowy higher pitch, the 
vesiculo-tympany of Flint, so that Page selects the left 
subclavicular as the typically normal. This difference 
is not invariable, but the fact is to be remembered in 
weighing shades of difference with a view to diagnosis. 
In the mammary region percussing down the right 
mammillary line, the clearness continues, possibly a 
trifle less on account of the greater thickness of the pec- 
toral muscle, until the fourth interspace or the fifth rib is 
reached, when there is a raised pitch and diminished 
intensity, which passes at the sixth interspace or seventh 
rib into a positive dulness which continues in health to 
the edge of the ribs. This impairment of the resonance on 
the right side is due to the liver, the lesser degree being 
known as the deep or relative dulness, and below this 
the absolute dulness. The upper border of the absolute 
dulness corresponds with the lower edge of the right 
lung. Close to the sternum on the right side there may 
be slight impairment of resonance from the third to the 
fifth rib, due to the relative dulness of the right auricle, 
passing at the fifth rib into the relative dulness of the 
liver, and at the sixth into the flatness of that organ. 
On forced inspiration the liver is pushed downward an 
inch or more, and on forced expiration there is a corre- 
sponding rise. 
On the left side, close to the sternum, normal vesicular 
resonance begins to lessen at the third interspace, owing 
to the deep or relative dulness of the heart, and at the 
fourth costal cartilage is replaced by the absolute dul- 
ness of this organ, which continues down along the left 46 
PHYSICAL DIAGNOSIS. 
edge of the sternum until it passes into the left lobe 
of the liver, from which it cannot be demarked ; but in 
general terms the cardiac dulness may be said to extend 
from the fourth to the sixth rib, and from the sternum 
to a curved line extending a short distance along the 
fourth cartilage and thence down within the nipple line 
to the seat of the apex beat. The cardiac area of dul- 
ness is also diminished on deep inspiration, because the 
organ becomes more fully covered by the distended 
lungs. Without the nipple on both sides there is, in 
health, resonance to the anterior axillary line, slightly 
lessened by the mammary gland and pectoral muscle. 
The infra-mammary or hypochondriac region 
on the right side is wholly occupied by the liver and 
furnishes flat percussion, beginning in the mammillary 
line at the sixth rib, and at the edge of the sternum a 
little higher, and extending to the edge of the thorax 
in this line. The width of the area of absolute dul- 
ness of the liver is three to four inches. On the left side 
the percussion in this region varies greatly in different 
persons and in the same person at different times. 
Toward the sternum the left lobe of the liver for the 
most part maintains its dulness, but even this is some- 
times replaced by the tympany of a dilated stomach, 
while to the outside of this, the stomach as normally 
distended with gases quite frequently imparts a tym- 
panitic note. On the other hand, the presence of solids 
and fluids in the stomach in varying amountscontributes 
dulness. A spleen of normal size does not extend into 
the infra-mammary region. In this connection it may Fig ii. 
Showing Absolute and Relative Percussion Dulness of Liver and Heart. 
i. Relative dulness of liver. 2. Absolute dulness. 3. Relative dulness of 
heart. 4. Absolute dulness. 48 
PHYSICAL DIAGNOSIS. 
be mentioned that the lower edge of the liver generally 
corresponds to a line drawn from the left sixth rib within 
the mammillary line obliquely across the epigastrium to 
the junction of the right mammillary line with the edge 
of the thorax. 
In the supra-sternal notch, also difficult to per- 
cuss, tracheal tympany may be brought out by vertical 
percussion on a suitably placed pleximeter. Over the 
upper sternal region, as far as the third rib, the per- 
cussion is resonant, with a slightly tympanitic note 
communicated by the trachea. Below this for a short 
distance there is a purer lung note, though perhaps 
slightly less resonant than typical lung structure because 
of the underlying heart. At the fourth rib the heart, 
though still covered in by the lungs, begins to deaden 
the note, but it is still fairly clear in the median line 
until the liver is reached opposite the sixth rib, where 
dulness is absolute and extends one-third to half-way 
to the umbilicus, although a tympanitic stomach may 
also influence this dulness. 
In the axillary spaces on both sides there is good 
pulmonary resonance. In the infra-axillary region of the 
right side, the relative dulness of the liver is noted at 
the eighth rib in the mid-axillary line and the absolute 
dulness at the ninth. On the left side there is also clear- 
ness until the spleen is reached in the mid-axillary line 
at the ninth rib, whence it extends to the eleventh. 
Laterally the spleen extends upward and backward 
between these two ribs from two to three inches, and 
sometimes it is so covered in as to escape recognition by PERCUSSION OF THE NORMAL CHEST. 
49 
careful percussion. The left infra-axillary region is also 
apt to be encroached upon by the tympanyof the stomach. 
Posteriorly, percussion is best practised with the 
patient leaning slightly forward and folding his arms. 
The upper border of the lungs behind is on a level with 
the spinous process of the seventh cervical vertebra. 
In the supra-spinous fossa the percussion reson- 
ance is markedly less than the typical, because of the 
bone and the thick muscles overlying it, and the same 
may be said of the infra-spinous region. At the same 
time percussion here is important because differences on 
the two sides are usually easily recognizable. 
In the interscapular region there is again better 
resonance than over the scapulae themselves, but still less 
intense than below the angles of the scapulae, on account 
of the tolerably thick muscles and the spinal column. 
In the upper portion the tympany of the trachea may 
influence the note. 
In the infra-scapular regions we have the nearest 
approach behind to the typical resonance as represented 
by the left infra-clavicular space. The information ob- 
tained here by percussion is most valuable, only second 
in importance to that obtained by percussing below the 
clavicles, and in consequence of this it is important to 
remember the inferior border of the normal resonance. 
The lower border of the lung on both sides corresponds 
to the tenth rib, where, on the right side, the absolute 
dulness of the liver is found, while the relative dulness 
on strong percussion is found a rib higher. On the left 
side resonance extends in the line of the angle of the 
scapula fully to the tenth rib, though sometimes a tym- 50 
PHYSICAL DIAGNOSIS. 
panitic quality may be imparted by a dilated stomach or 
the colon, or a-slightly dull sound if the spleen extends 
a little farther back than usual. Here as elsewhere on 
the thorax there may be slightly less intensity, and 
slightly higher pitch on the right side, on account of the 
greater muscular development in right-handed persons, 
and the effect of a deep inspiration in lowering the 
resonance, and in expiration of raising it an inch or more, 
is also to be remembered. In ordinary breathing the 
normal resonance posteriorly passes at the tenth rib into 
the absolute flatness of the lumbar region. 
The upper border of the kidneys under the eleventh 
rib, the left being a little higher than the right, cannot 
ordinarily be separated by percussion from the dulness 
of the spleen and liver, nor can the inner border be 
separated from the spinal column. The outer edge can, 
however, be defined, by percussion, from the colon on 
the right and the stomach and colon on the left, by per- 
cussing outward from the median line behind. The 
outer border of the kidney is about three or four inches 
beyond the median line. The lower border can some- 
times be defined by a line of tympany just above the 
crest of the ilium, produced in the colon. Forcible 
percussion is required, and it is desirable to place a 
pillow under the abdomen of the patient lying prone 
upon his face. 
It goes without saying that a sound which is normal 
in one situation becomes abnormal when heard in a 
ABNORMAL PERCUSSION LUNG SOUNDS. ABNORMAL PERCUSSION LUNG SOUNDS. 
51 
position unnatural to it in health, as dulnessor tympany 
below the clavicles or below'the angles of the scapulae, 
where vesicular resonance is ordinarily found. But in 
addition there are certain positive modifications of nor- 
mal sounds not heard anywhere in health, or at least 
under such exceptional conditions as do not permit 
them to be included among normal sounds. 
These are vesiculo-tympanitic resonance, am- 
phoric resonance, and cracked-pot sound. 
Vesiculo - tympanitic Resonance.-The vesi- 
culo-tympanitic resonance of Flint has already been 
alluded to, but requires to be further considered because 
it is not generally recognized by either American, Eng- 
lish, or German authors as something distinct and dif- 
ferent from tympany, and it requires to be conformed 
to their treatment of conditions supposed to cause it. 
In the language of its describer, "the resonance in- 
creased in intensity; the quality a combination of the 
vesicular with a tympanitic, and the pitch higher in pro- 
portion as the tympanitic quality predominates over the 
vesicular." According to him, also, the morbid condi- 
tion which especially illustrates this form of resonance 
is the over-dilatation of the air vesicles which con- 
stitutes vesicular emphysema of the lungs, but it is also 
present in interstitial or interlobular emphysema. Also, 
over the upper lobe of a lung when the lower lobe is 
solidified in the second stage of pneumonia, and over 
the lower lobe when the upper is solidified. So, also, 
if the lower part of a pleural sac contains fluid, even 
though the volume of the lung is diminished, the upper 52 
PHYSICAL DIAGNOSIS. 
part of the same lung may give the same vesiculo-tym- 
panitic note. Attention was first called to this by 
Skoda, and it is known as Skoda's sign. Too much of 
the intra-thoracic space must not be occupied, as the 
lung is thus compressed and rendered airless, but the 
resonance is vesiculo-tympanitic above the liquid when 
the latter is sufficient to fill a third, a half, or even two- 
thirds of the intra-thoracic space. 
Now these are essentially the conditions named by Da 
Costa, Paul Niemeyer, and Graham Brown as producing 
tympanitic resonance of lung tissue. Says Brown :* 
"Just as when the lung is removed from the body and 
allowed to collapse it gives a tympanitic note, so when a 
similar retraction and relaxation of the pulmonic tissue 
takes place within the thorax, that variety of percus- 
sion note may be heard. This is best marked in cases 
of pleuritic effusion which, gravitating to the lower 
portion of the cavity, floats up the lung and causes relaxa- 
tion of the upper portion. When the effusion is small 
in amount the tympanitic note can only be detected 
over that portion of the lung which lies immediately 
above the upper limit of the fluid, but when the effusion 
is considerable the whole upper lobe may be tympanitic 
on percussion. This is also called tympany by mediate 
relaxation. Similarly, effusion into the alveoli in pneu- 
monia or edema may produce a like result. This is 
* " Medical Diagnosis," 3d edition, Edinburgh, 1887, page 207. 
j- This can occur only in the first and third stages of pneumonia 
when the air vesicles contain air, the second stage being one of 
absolute airlessness and dulness. ABNORMAL PERCUSSION LUNG SOUNDS. 
53 
tympany by immediate relaxation. Niemeyer* adds, 
occasionally gangrene and infarct, also disseminated 
tubercular infiltration, emphysema, and nervous asthma, 
and that portion of the lung not inflamed but imme- 
diately adjacent to a hepatized part. In like manner 
phthisical consolidations of the apices may also occasion 
an obscurely tympanitic note over neighboring portions 
of the lung (mediate relaxation). Finally, Da Costa, 
who with Flint may be regarded as representing the 
American School, says: "But generally a tympanitic 
sound over the seat of the lungs is expressive of emphy- 
sema or of pneumothorax, or sometimes of a cavity or 
of edema of the lungs. Again, as Skoda has taught us, 
it occurs in moderate pleuritic effusions above the level 
of the liquid. "f 
It has seemed to me important to contrast these state- 
ments, both in order to give a better idea of what Flint 
intends to convey by vesiculo-tympanitic resonance and 
to avoid confusion in the minds of those who might with 
reason be confused by statements apparently so diverse. 
That there should be something different from typical 
tympany in the percussion note produced under the 
circumstances named seems likely, yet I am by no means 
certain that the words exaggerated resonance or hyper- 
resonance would not convey the idea sufficiently well. 
Pure Tympanitic Resonance.-Tympanitic re- 
* Grundriss der Percussion und Auscultation. Zweite Auflage- 
Erlangen, 1873, PaSes 38, 39- 
j- " Medical Diagnosis," 7th edition, 1890, page 265. 54 
PHYSICAL DIAGNOSIS. 
sonance is found in normal thoracic states only over the 
larynx and trachea and in the left infra-axillary region 
from encroachment of a tympanitic stomach. Else- 
where it becomes a sign of an abnormal state. 
The fundamental principle to be remembered in con- 
nection with tympanitic sounds is that their pitch 
depends inversely on the volume of circumscribed air 
and the transverse section of an opening communicat- 
ing with the exterior. 
In the chest, tympany is produced by percussing over 
air-containing cavities in the lung tissue, sufficiently near 
the surface and sufficiently large, and whose walls are not 
too tense. Bearing in mind the above principle, approxi- 
mate estimates as to size and shape of cavities may be 
even made by observations as to pitch. Thus a cavity 
of small size will give a higher-pitched tympanitic note 
than one of a large size. 
As these cavities usually communicate with a bronchus 
they are further characterized by differences in the pitch 
when percussed with the mouth open or closed. This is 
Wintrich's change of note, according to which percus- 
sion over a given cavity gives a higher-pitched tympa- 
nitic sound with the mouth open than when it is closed. 
This may be illustrated by percussing over the thyroid 
cartilage under the two conditions, when the difference 
will be very evident. It occurs in connection with 
superficially placed cavities in communication with a 
bronchus. If this change of sound is observed on lying 
down, but is not on sitting up, or vice versa, it means 
that the bronchus leading to the cavity is obstructed in ABNORMAL PERCUSSION LUNG SOUNDS. 
55 
the position in which the Wintrich change of note does 
not occur. This is the interrupted change of note of 
Wintrich. 
By what is known as Gerhardt's change of note we 
learn something about the shape of cavities. Cavities 
which have unequal diameters, or are oval in shape and 
are partially filled with fluid, alter their note on chang- 
Fig. 12. 
To Illustrate Gerhardt's Change of Note. 
ing the position of the patient from sitting to horizontal. 
Thus suppose A to represent an oval cavity in the ver- 
tical position with the contained fluid at the line c d. 
If the patient lies down the long diameter will become 
horizontal, as in B, and the level of the fluid will fall to 
a b. The percussion note is lower when the longer 
diameter is horizontal, higher when it is vertical. If, 56 
PHYSICAL DIAGNOSIS. 
therefore, the percussion note is lower when the patient 
is sitting up, the direction of the longer diameter is 
antero-posterior ; if it is higher while sitting up, the long 
diameter is vertical. 
Every cavity does not, of course, furnish the condi- 
tions of tympanitic percussion. Recent experiments also 
shed some doubt as to the correctness of the law origin- 
ally announced by Wintrich, that the pitch of oval cavi- 
ties partially filled with fluid depends on the direction of 
the greater diameter, while other conditions, too, have 
been suggested as capable of explaining the differences 
in pitch observed in cavities whose relations have been 
altered by changes in the position of the patient. 
Second, pure tympanitic resonance is also character- 
istic of pneumothorax if the distention is not too great. 
There being no free communication of such a space with 
a bronchial tube, no change of pitch occurs when per- 
cussing with the mouth open and closed. If there hap- 
pens to be liquid in the sac, Biermer's change of note may 
be produced as follows : In the vertical position of a 
pneumothorax containing fluid the cavity is larger be- 
cause the weight of the fluid pushes the diaphragm down- 
ward. Hence in this position the pitch is lower. If the 
position of the patient is now changed from the vertical 
to the horizontal the cavity becomes smaller by reason of 
the changed position of the fluid and the pitch becomes 
higher. 
Third, a pure tympanitic resonance may be produced 
in pneumonia and pleurisy when the hepatization is so 
complete or the pleuritic exudation is in such close rela- ABNORMAL PERCUSSION LUNG SOUNDS. 
57 
tion with the lung that percussion throws into vibration 
the air in the trachea and bronchi. 
Amphoric Resonance.-Amphoric resonance, a 
variety of tympanitic resonance, is a high-pitched me- 
tallic resonance, so called from its resemblance to the 
sound produced by striking the side of a jar, either 
empty or containing a small quantity of fluid. It may 
also be imitated by filliping the cheeks when the mouth 
is distended with air. It is an echoing sound, the waves 
being reflected from side to side of the closed vessel, as 
is speech in a vaulted chamber. Amphoric resonance is 
said to be produced or intensified by what is known as 
the bell-metal test of Gairdner, in which a coin of suf- 
ficient size is percussed by means of another on the 
anterior surface of the chest, while the auscultator listens 
posteriorly or vice versa. 
Amphoric resonance is not very often met; the con- 
ditions of its production in the human body are an air- 
filled cavity of considerable size, with firm and smooth 
walls, completely closed or communicating with the air 
by a small opening only. When thus communicating it 
is louder when the mouth is kept open. These condi- 
tions are fulfilled by certain phthisical cavities, and 
especially by pneumothorax or pyopneumothorax, some- 
times also by a distended stomach. If with such a pyo- 
pneumothorax the body be shaken, the splashing or 
succussion will sometimes have the same ringing 
character. The same conditions are sometimes fulfilled 
by a distended stomach containing fluid. 
The Cracked-pot Sound.-This sound is well- 58 
PHYSICAL DIAGNOSIS. 
named because it quite resembles that produced by tap- 
ping a cracked jar, and is therefore one of the most dis- 
tinctive and easily recognized of the abnormal percus- 
sion sounds. It is, too, a modification of tympany, and 
is caused by the expulsion of air from a cavity through 
a small opening by a sudden forcible blow. It is also 
imitated in mechanism as well as character by suddenly 
striking the back of the two palm-apposed hands against 
the knee, after the method used by the boys to imitate 
the clinking of coins. 
It may also be made by striking the pleximeter when 
the latter is not closely applied to the skin, an accident 
favored by a hairy skin. The cracked-pot sound may 
also be produced in the normal chest by percussing it 
sharply while the patient is in the act of speaking or 
crying out, the narrow glottis affording the condition of 
a small opening. This may more readily be done under 
these conditions in children who have thin, elastic chest- 
walls. 
The cracked-pot sound is produced in disease by per- 
cussing over a cavity which affords the conditions named, 
viz., a somewhat superficial position, sufficiently yielding 
walls, and communicating by a small opening with a 
bronchial tube and thence with the outside air. It is 
the most infallible sign of a cavity known. In produc- 
ing it, the mouth of the patient is kept open and a 
sudden forcible blow of the plexor given. Often it 
cannot be heard unless the ear is attentively turned near 
the chest to catch the sound. The same conditions 
exist in a pneumothorax, with a thoracic fistula into the AUSCULTATION. 
59 
lung, and under these circumstances a cracked-pot 
sound may be produced by percussing such a chest in 
the manner described. 
AUSCULTATION. 
Auscultation is the act of listening to sounds, more 
particularly those produced in the chest by the act of 
breathing or speaking, or in the course of the heart's 
action, or in the blood-vessels, to these sounds as modi- 
fied by disease, or to certain new sounds produced by 
disease. In so doing the ear is applied either directly 
to the chest or through the intermediation of an instru- 
ment known as a stethoscope. According as this instru- 
ment is employed or not, the auscultation is mediate 
or immediate. Both have their advantages. When 
it is desired to isolate or circumscribe a sound, especially 
in the study of the heart, the stethoscope helps us 
greatly, while in the study of more diffuse sounds, as 
many of those produced in the lungs, the direct appli- 
cation of the ear to the chest is generally to be pre- 
ferred. The stethoscope becomes also desirable in the 
examination of patients not especially clean. In inex- 
perienced hands, also, the patient is rendered uncom- 
fortable by undue pressure by the head on the instrument. 
The stethoscope was invented and used by Laennec, 
of Paris, in 1816, in its single shape. Through the 
labors of Laennec, by the aid of the stethoscope the 
diagnosis of diseases of the chest developed in a com- 
paratively short space of time to an accuracy scarcely 60 
PHYSICAL DIAGNOSIS. 
equaled with any other set of organs. The binaural 
instrument was devised by Cammann, of New York city, 
in 1840. There can be no doubt that, with the latter, 
sounds are more loudly heard. On the other hand, all 
noises, as that of the rubbing of linen or clothing, are 
so much exaggerated that the beginner 
is often confused. The double instru- 
ment is becoming more popular of 
late, but preference depends ontrain- 
ing. A man who has been brought 
up to use the double stethoscope soon 
grows to prefer it, while he who is 
trained to the single instrument would 
not have the double. When either 
form of the instrument is used, better 
results are obtained when the chest- 
end is applied directly to the bare 
skin, whereas in immediate ausculta- 
tion it is desirable that there should 
be a thin, soft towel, or some thin 
garment, interposed between the ear 
and the skin. The ear or stethoscope 
should also be applied closely to the 
chest-wall, so as to become a part of 
it or continuous with it; and yet, as 
stated, the stethoscope may be applied too strongly, so 
as to give pain to the patient. Successful auscultation 
requires that the attention should be closely concentrated 
on the matter in hand. 
The single stethoscope is made of wood or metal. 
Fig. 13. 
Hawksley's Stethoscope. AUSCULTATION. 
61 
That originally made by Hawksley, of London, out of 
gun-metal, and provided with a detachable hard rubber 
ear-piece, shown in Figure 13, is the most convenient 
Fig. 14. 
Fig. 15. 
Sansom's Binaural Stethoscope. 
Simpler Form of Sansom's Binaural 
Stethoscope. 
and neatest. A large variety of double stethoscopes 
have been suggested. The double instrument, Figure 
14 in the text, partly metal and partly rubber tubing, 62 
PHYSICAL DIAGNOSIS. 
was devised by Sansom, and is very conveniently carried 
when folded at the joint. It is 
especially suitable when the 
patient is inaccessibly placed in 
relation to the examiner, an 
advantage possessed in various 
degrees by all binaural stetho- 
scopes over the single instru- 
ment. A still simpler form is 
shown in Figure 15. In select- 
ing this shape, great care should 
be taken to secure an ear-piece 
which fits the ear properly; also, 
that the rubber tubing embraces 
closely the metallic chest-por- 
tion as well as the ear-pieces, 
and if it happen to become split 
the split end can be cut off and 
the tube reapplied. 
Recently Dr. H. K. Valen- 
tine, of Brooklyn, N. Y., has 
described * a form of binaural 
stethoscope which in my ex- 
perience conducts stethoscopic 
sounds more loudly to the ear 
than any I have ever used. The 
instrument (Fig. 16) is com- 
posed of hard rubber, the bell and ear-pieces being 
Fig. 16. 
* N. Y. Med. Record, July 16, 1892. AUSCULTATION OF THE NORMAL LUNG. 
63 
united by two pieces of ordinary soft-rubber tubing, 
each about three and a half inches in length. 
The bell is a cylinder five inches long, having an in- 
ternal diameter at the mouth of seven-eighths of an inch. 
At the top of the cylinder there are two openings, each 
one-quarter of an inch in diameter, separated by a sharp 
septum of hard rubber, and the same diameter is con- 
tinued the full length of the ear-pieces. 
When the instrument is in use, the divided waves of 
sound are carried from the cylinder in two straight lines 
along the ear-pieces to the curved ends, which lead them 
directly into the ears of the operator. The expense of 
making the stethoscope is largely due to the perfectly 
smooth finish of the interior of the hard-rubber tubing, 
throughout its entire length, by which means only are 
such good results obtained. 
It is provided with an accessory soft-rubber bell, also 
figured, which intensifies the sounds, but the instrument 
is, for the most part, best used without it. 
The ordinary soft-rubber tubing connecting the cylin- 
der and ear-pieces permits of folding, and thus the 
stethoscope is readily carried in the pocket. It is better 
dropped into the pocket with the sharply flexed rubber 
tubing uppermost, so that it will not crease. 
When the interior of the bell becomes very dusty, it 
may be easily cleaned by allowing cold-water to run 
through it. , 
The breathing sounds in health are separable into 
two distinct orders: first, the vesicular breathing or 
AUSCULTATION OF THE NORMAL LUNG. 64 
PHYSICAL DIAGNOSIS. 
respiratory murmur; second, bronchial breath- 
ing. Both are normal sounds, constantly produced in 
the act of breathing, but in certain parts of the chest 
one is heard more or less to the exclusion of the other. 
Thus the vesicular breathing is heard in its most typical 
character under the left clavicle, where it is best studied 
by immediate auscultation. 
Bronchial respiration is the easiest of description. 
It is blowing or tubal in quality, both in inspiration 
and expiration, and the two parts are nearly equal in 
length, the expiratory being often slightly the longer. 
It is heard in its purest form over the larynx and trachea, 
but also quite pronouncedly between the scapulae at the 
root of the lungs, where, however, it is more or less 
admixed with vesicular breathing. The pitch is high 
in both in- and out-breathing, and somewhat higher in 
the latter. 
Vesicular breathing is the sound produced by the 
movement of the air in the smallest bronchial tubes and 
air vesicles. It is also divided into two portions-the 
inspiratory and expiratory, the in- and out-murmur, 
the former being much the longer. Perhaps no language 
can give a correct notion of the vesicular murmur, but 
it is a soft, low-pitched sound, said to resemble the 
sighing of a gentle breeze through the leaves of a tree. 
It is the sound of the movement of the air in the finest 
bronchial tubes and air vesicles. As stated, when typi- 
cal the inspiratory murmur is much longer than the 
expiratory. The ratio is, however, not fixed. The ex- 
piration may be one-fourth as long, or it may be a mere 
whiff, as it were. It represents the recoil of the air AUSCULTATION OF THE NORMAL LUNG. 
65 
vesicles and the backward movement of the air. The 
precise mechanism of the production of the sound in 
question will be left to the physiologist, our present 
purpose being to consider the sound and its modifica- 
tions in disease. 
The vesicular murmur is not everywhere the same, 
even in health. As a rule, it is slightly louder, more 
purely vesicular below the left clavicle, and, assuming it 
to be typical in this situation, is nearest maintained in 
the axillae and below the scapulae. Under the right 
clavicle the slightest rise in pitch and a distinct pro- 
longation of the expiratory portion is often noted, and 
to be remembered as of great importance in diagnosis 
in doubtful cases. This is usually ascribed to an ad- 
mixture of the bronchial element due to the larger size 
of the right bronchus, and of its branches sent up toward 
the right clavicle. Over the scapular regions posteriorly 
the vesicular murmur is less intense, because of the 
thickness of the bones and muscles, but the same differ- 
ence between the two sides may sometimes be noted in 
the supraspinous fossae, as below the clavicles in front. 
For the same reason it is less intense in the mammary 
regions, and in all fat and muscular persons as compared 
with the thin and emaciated. Between the angles of 
the scapulae still more of the bronchial, element is added 
than below the right clavicle, and the sound is de- 
cidedly more blowing and the expiration longer. It is 
to be remembered that both vesicular and bronchial 
breathing are being constantly produced in the lungs, 
but that in certain situations one overshadows the other, 66 
PHYSICAL DIAGNOSIS. 
partly because of its proximity immediately under the 
point where the ear is applied, and partly because the 
normal lung is a poor conductor of sounds. 
ABNORMAL MODIFICATIONS OF BREATHING 
SOUNDS. 
Changes in the Vesicular Murmur.-The vesi- 
cular murmur is modified by diseased states as follows:- 
1. It is jerking or interrupted. 
2. It is increased in intensity or loudness. 
3. It is diminished in intensity, more indistinct. 
4. It is altogether absent. 
5. It is commingled with bronchial breathing, by 
which it is rendered harsh and its rhythm altered. 
6. It is substituted by bronchial breathing. 
1. Interrupted or jerking breathing is the least im- 
portant of the alterations in the vesicular murmur, being 
generally of no significance whatever. Such is its value 
in persons who are nervous or slightly alarmed during 
examination. The interruption affects most frequently 
the inspiratory act, but it may occur in either or both, 
and the act may be broken into two or three parts. 
More serious is its cause when it occurs in connection 
with severe pleurisy or pleurodynia, where the pain of 
the act of breathing causes the latter to be interrupted. 
It has here, however, no more significance than in 
nervousness. Finally, it may be present in incipient 
tuberculosis or emphysema, but even here its diagnostic 
value is merely confirmatory, and that only when it 
persists. ABNORMAL BREATHING SOUNDS. 
67 
2. Vesicular breathing is exaggerated or supplemental, 
or increased in intensity by any cause which compels 
the lung or a part of it to assume increased function. 
This happens in one lung or a part when the other or 
the remainder is deprived of its use by compression or 
destruction. In this change both the inspiratory and 
expiratory factors are proportionally increased in loud- 
ness and in length, the accentuation of increase being 
in the inspiratory sound rather than the expiratory. 
Its pitch is unaltered. From the resemblance of this 
exaggerated breathing, as it is also called, to the normal 
breathing in children it is often called puerile breath- 
ing. 
3. The vesicular murmur is feeble or diminished in 
intensity by various causes. Such feebleness affects the 
inspiratory murmur rather more than the expiratory, so 
that the latter may be relatively prolonged, but it is, at 
the same time, even feebler than in health. Such dim- 
inution may be due to feebleness in the inspiratory act 
from debility, or to obstruction in the bronchus leading 
to the ausculted area ; or to a loss of elasticity in the air 
vesicles, as in emphysema of the lungs or the very early 
stage of tubercular deposit. More commonly, in actual 
practice, it is due to the interposition of a liquid or a 
solid medium between the lungs and the ear, such as a 
pleuritic effusion or the plastic exudation of a pleurisy. 
Or it is due to the filling up of the air vesicles by an 
exudate, as in pneumonia, or tubercular infiltration in 
phthisis. More frequently it is obliterated by these 
causes. 68 
PHYSICAL DIAGNOSIS. 
4. The vesicular murmur is absent or altogether re- 
moved by the higher degrees of the last-named condi- 
tions, viz., pleuritic effusion, pneumonic and tubercular 
infiltrations. 
5. The vesicular murmur is altered by the addition 
of a bronchial element, the first effect of which is to 
lengthen the expiratory factor of the breathing sound, 
to alter, in a word, its rhythm. Coincidently with, or 
immediately succeeding upon this, is a roughening of 
both inspiration and expiration, at first slight and then 
positive. As long as this degree is maintained there is 
still a vesicular factor in the breathing, whence it was 
named by Flint broncho-vesicular breathing. Ex- 
pressive terms are also harsh respiration, rude respiration, 
or rough respiration. Such modifications of normal 
breathing are brought about by an infiltration of a cer- 
tain number of air vesicles with solid material, while 
others still maintain their function. The effect of this 
is also to improve the conducting power of the portion 
of the lung involved, so that it becomes a better con- 
ductor of the bronchial sounds elsewhere produced, 
which are thus brought to the ear. It means, therefore, 
that a certain small extent of consolidation has taken 
place. 
How shall we distinguish between puerile breathing 
and broncho-vesicular breathing, a most important re- 
quirement, since they indicate opposite conditions? 
Yet there is a certain similarity between them which 
inexperienced observers may mistake for identity, and 
which even an experienced man may sometimes have ABNORMAL BREATHING SOUNDS. 
69 
occasion to dwell on before deciding. Both are louder 
and rougher as to inspiration, but vastly different is the 
manner in which expiration is influenced. In puerile 
breathing it may be slightly longer and more distinct 
than in health, but it maintains its ratio to the length 
of the inspiratory murmur. Not so is it with the rude 
inspiration. Here the expiratory sound is roughened 
and prolonged out of all proportion to the inspiratory. 
And in catching slight degrees of difference the atten- 
tion must be concentrated on the expiratory murmur. 
If it is greatly prolonged in proportion to the inspira- 
tory, so as to nearly or quite equal it, and at the same 
time harsher than in health, not simply louder, then we 
have broncho-vesicular breathing and the conditions 
which produce it. And if to this is added a slight rise 
of pitch on percussion, a slight dulness, the condition 
is confirmed. Sometimes, however, these conditions do 
not go entirely pari passu. Then we must wait and 
watch. We must not forget, too, the physiological dif- 
ferences on the two sides, that there is the slightest 
higher pitch on the right in both percussion note and 
breathing sound, and that the expiratory murmur is 
slightly longer on the right. It must be remembered, 
too, that in simple feebleness of the respiratory vesicular 
murmur the expiratory element is less affected in its 
duration, but that here both inspiratory and expiratory 
sounds are less loud rather than more loud. 
6. Finally, the vesicular murmur may be altogether 
substituted by bronchial breathing. This means that a 
considerable area of lung has become obliterated as to 70 
PHYSICAL DIAGNOSIS. 
its vesicular structure, and in this change has also become 
an excellent conductor of the distant normal bronchial 
breathing, which is heard with a blowing tubal quality 
as though produced directly under the ear. Again, it 
is to be remembered, that there is no more bronchial 
breathing produced under these circumstances than there 
was before the consolidation took place. Jt is simply 
that the vesicular murmur has altogether vanished, for 
the reason named, and therefore cannot longer mask the 
bronchial breathing, while the latter also is better con- 
ducted to the ear. Acute croupous pneumonia furnishes 
the most characterestic bronchial breathing. Between 
this and broncho-vesicular breathing there is every de- 
gree, depending upon the degree of destruction of vesi- 
cular tissue and the extent of consolidation. When the 
consolidation is very intense the bronchial breathing is 
rendered more intense, more metallic even than the 
tracheal breathing sound, which maybe regarded as the 
type of bronchial breathing in disease, of which Da Costa 
truly says it resembles more the sound heard in health 
over the trachea than over the bronchial tubes.* 
Changes in Bronchial Breathing.-The more 
usual modifications of bronchial breathing are caver- 
nous breathing and amphoric breathing. 
i. Cavernous Breathing.-The beginner will not 
be discouraged at any difficulty he may have in dis- 
tinguishing between bronchial breathing and cavernous 
breathing when he learns that at the present day the 
* Op. citat., p. 277. ABNORMAL BREATHING SOUNDS. 
71 
German clinicians do not attempt to distinguish between 
them. English and American observers have, however, 
usually separated them ; both Flint and Da Costa, for 
example, say that the sign is more likely to be con- 
founded with the normal vesicular murmur than with 
bronchial breathing, differing, says Flint,* "from the 
former only in the absence in the inspiratory sound of 
the vesicular quality." 
In the first place the cavernous breathing is repre- 
sented as more hollow in character, less diffused, less 
tubal, and therefore of much lower pitch than bronchial 
breathing. The expiration is also commonly lower 
pitched than the inspiration, reversing, in this respect, 
the bronchial breathing, although this is not constant 
enough to be made a rule of difference. 
The conditions of its production are a cavity with 
yielding and resilient walls, by the collapse of which the 
air can be forced out, since the sound depends upon the 
entrance and exit of air. It is also often associated 
with gurgling, or may alternate with it. It may disap- 
pear to reappear after copious expectoration. Cavities 
at the apex of the lung in tubercular consumption are 
the most common causes, but whatever produces an 
excavation of the kind may cause it. A dilated bron- 
chus, an abscess, and even gangrene of the lung may 
be such a cause. 
2. Amphoric Breathing.-Amphoric breathing is 
* " Manual of Auscultation and Percussion," 5th Ed., Phila., 
1890, p. 107. 72 
PHYSICAL DIAGNOSIS. 
more easily recognized from its ringing metallic char- 
acter, like that of the amphoric percussion note, resem- 
bling also the sound produced by blowing upon the mouth 
of a bottle. It is produced by the same conditions, 
a cavity with firm walls-a large cavity. It is likewise a 
blowing sound, of high or low pitch, inspiratory or ex- 
piratory, or both. It is an echoing sound. Clinically 
its presence most frequently means pneumothorax, but a 
phthisical cavity may rarely furnish the same conditions. 
Every case of pneumothorax does not, however, produce 
it, since there must be a perforation of the pleura above 
the level of the fluid and free communication with a 
bronchial tube. 
There are other modifications of cavernous breathing 
more or less accidental and therefore of less importance. 
Thus it sometimes happens that either the inspiratory or 
the expiratory portion is absent, when the peculiar 
breathing may be still recognized by the pitch and 
quality of the portion remaining cavernous. Again, we 
may have a vesicular inspiration with a cavernous expira- 
tion, or there may be an admixture of cavernous and 
pure bronchial breathing, brought about by a combina- 
tion of conditions which need not be mentioned here. 
Another variety of modification is the Seitz-metamor- 
phosing respiration, in which the inspiratory sound 
is heard for about one-third of its time as harsh tubal and 
the remainder is of ordinary blowing, cavernous, or am- 
phoric quality. It is said to be caused by air entering a 
cavity through a narrow opening. Again, there is the 
broncho-cavernous respiration and the vesiculo-cavernous AUSCULTATION OF THE NORMAL VOICE. 
73 
breathing of Flint. In the former, the sound of expira- 
tion is bronchial, high pitched, and is said to indicate a 
cavity situated near consolidated lung. In the vesiculo- 
cavernous breathing the cavity is surrounded by a com- 
paratively intact pulmonary tissue which produces an 
admixture of sound. 
AUSCULTATION OF THE NORMAL VOICE. 
Normal Vocal Resonance.-When the ear is ap- 
plied below the clavicle of a person speaking, a confused 
monotonous humming sound is produced, of slight in- 
tensity, and low pitch. In the aged, it is apt to be 
tremulous or somewhat bleating. This is normal vocal 
resonance. It varies, however, in intensity and pitch 
in different persons, being almost inaudible in some. 
It depends also somewhat upon the manner in which 
the person speaks and the words he utters. It is in- 
creased not so much by loud speaking as speaking " from 
the chest." It is better noted also if the patient counts 
" one, two, three," or speaks the word "ninety-nine." 
It is also feebler in women than in men. It is accom- 
panied by a fremitus which is the same as that described 
under palpation. It is a tactile fremitus in which the 
ear is the touching part instead of the palm of the hand. 
Vocal resonance varies in different parts of the chest, 
being more marked where the walls are thin. Hence 
below the clavicles it is relatively loud, and more so 
below the right, just as is tactile fremitus, an important 
fact to be remembered in diagnosis, as well that every- 74 
PHYSICAL DIAGNOSIS. 
where on the right side it may be more marked. Toward 
the sternal portion of the clavicular region it is louder, 
the tracheal voice influencing it. Below the clavicles it 
diminishes with the greater thickness of the chest walls 
of the mammary region, it is again more marked in the 
axillae, less intense over the scapulae and louder below 
them. Between the scapulae it is also intense. 
The whispering voice also requires some allusion. 
It being borne in mind that whispering in most persons 
is an act of expiration, if the ear is applied to a thin- 
walled portion of the chest, as below the clavicle, and 
the patient asked to count in a whisper, there is heard 
a feeble, low-pitched blowing sound, unaccompanied 
by fremitus, with a pitch and quality the same as 
those of the expiratory vesicular sound in breathing. 
All that has been said of vocal resonance, as to its audi- 
bleness and the degree thereof in different persons and 
on the different parts of the chest, is true of the " nor- 
mal bronchial whisper," as it is called by Flint, because 
" the conduction of the sound produced by the whis- 
pered voice must be chiefly by the air contained in the 
bronchial tubes." 
Normal Bronchophony.-When the stethoscope 
is placed over the thyroid cartilage of the larynx of a 
person speaking, a much louder resounding sound is 
heard directly under the ear, accompanied also by a 
thrill or fremitus conveyed to the ear. But it is still 
confused and no articulate words are heard. It corre- 
sponds to bronchial respiration, as normal vocal reso- 
nance accords with vesicular breathing. AUSCULTATION OF THE NORMAL VOICE. 
75 
If the person thus ausculted over the larynx or trachea 
whispers instead of speaks audibly, a high-pitch tubal 
sound accompanied by feeble fremitus is heard. It is, 
in fact, the expiratory breathing sound, as heard in 
these air tubes, interrupted by the act of speech. 
Abnormal Modifications of the Ausculted 
Voice.-The correspondence of vocal resonance and 
normal bronchophony with normal vesicular breathing 
and normal bronchial breathing has been referred to. 
The same relation exists in pathological conditions. 
Thus any increase in the intensity of the normal vocal 
resonance implies a corresponding condensation of lung 
tissue, culminating in typical bronchophony when the 
consolidation is complete, just as the normal-vesicular 
breathing passing through broncho-vesicular terminates 
in bronchial breathing. Pari passu with increased 
vocal resonance and broncho-vesicular breaching goes 
increased bronchial whisper, the usual rule of health, of 
slightly greater intensity on the left, a higher pitch on 
the right being remembered. 
Pectoriloquy.-In addition there are certain special 
modifications of the normal vocal resonance corre- 
sponding more or less to certain morbid states. Thus 
there is the cavernous voice or pectoriloquy, in which 
articulate speech is heard as though coming directly 
from the chest into the ear. While this is sometimes 
the sign of a cavity, it is not always so, the voice being 
similarly transmitted by solidified lung. Whispering pec- 
toriloquy, in which whispered articulate speech is con- 
veyed to the ear, is a much more reliable sign of a cavity. 76 
PHYSICAL DIAGNOSIS. 
Amphoric voice is ringing and metallic, like the 
other amphoric sounds, and like them indicates the same 
conditions-a large cavity with firm walls. 
TEgophony is another very distinctive modification 
of the normal voice when ausculted. It is admirably 
likened to the bleating of a goat, and is produced dur- 
ing speech when there is a thin layer of liquid between 
the chest wall and the lung, in pleuritic effusions, or 
when there is liquid in the chest cavity from other 
causes. 
Diminished Vocal Resonance.-Finally, speech 
sounds may be diminished in intensity by the same 
causes which diminish the tactile fremitus; pleuritic 
effusions, pleuritic thickening, compression of the lung 
by fluid or air, and by over-distention of the lung. 
NEW OR ADVENTITIOUS SOUNDS. 
These sounds are not a modification of preexisting 
sounds, but something altogether new or additional. 
They include rales, or rhonchi, the friction sound, 
and metallic tinkling. 
Rales are new sounds produced in the trachea, bron- 
chial tubes or in cavities, concurrent with the movement 
of air inward or outward in the act of breathing. They 
are the direct result of some partial obstruction to the 
onward movement of the air, for the most part within 
the tube, but the narrowing may also be the result of 
extra-tubal pressure. They are divided into moist or 
dry rales, according as the obstructing substance is liquid NEW OR ADVENTITIOUS SOUNDS. 
77 
or the reverse. Both are influenced by coughing and 
may often be completely removed, for the time being, 
by this act. When not thus influenced by coughing 
they are probably due to pressure from without. 
Dry rales are due to the vibration produced in 
thickened adherent mucus or the swollen mucous mem- 
brane of the bronchi, by air moving over them. Sounds 
produced in the tubes of large lumen, like the trachea, 
are musical, low-pitched, and are called sonorous rales. 
Those produced in the small tubes are high-pitched and 
hissing, and therefore called sibilant rales. 
Moist rales are caused by the passage of air through 
liquid, which may be blood, mucus, or serum. They are 
therefore of the nature of bubbling sounds and are 
spoken of as large and small bubbling sounds, accord- 
ing as the bubbles are large or small, and as large bubbles 
can only form in tubes of large size or cavities, they 
indicate these conditions, while the small rales indicate 
smaller tubes. The bubbling sounds are further sub- 
divided, according to size, into gurgling, mucous, sub- 
mucous, subcrepitant, and crepitant rales, and crack- 
ling. 
Gurgling is a term applied to the largest bubbling 
sounds, and is produced in cavities containing fluid. It 
is also known as the cavernous rale, and has sometimes 
a metallic character when it becomes associated with the 
other metallic physical signs already mentioned as 
characteristic of a cavity with firm walls. 
The mucous rale is a bubbling sound smaller than 
the cavernous, but still of large size, produced in 78 
PHYSICAL DIAGNOSIS. 
the trachea and larger bronchi. The death-rattle is a 
tracheal mucous rille. The sub-mucous rale is a 
smaller bubbling sound produced in tubes of smaller 
size, and the sub-crepitant in still smaller. The 
crepitant rale is formed in tubes of smaller size and in 
the air vesicles. It may be a true bubbling sound, or 
it may be due to the separation of agglutinated air vesi- 
cles by entering air. From its extreme importance in 
the diagnosis of pneumonia, although it occurs also in 
edema of the lungs, it requires some further illustration. 
It is aptly compared to the crackling produced by 
throwing salt on the fire, or rolling the hair between 
the fingers alongside of the ear; also to the noise made 
by separating near the ear the moistened thumb and 
index finger. The first appears to me the best imita- 
tion. It is heard only in inspiration and is thus dis- 
tinguished from the sub-crepitant rale, which is heard 
in expiration as well. 
Crackling literally means the same as crepitation, 
and, in fact, the mechanism of the two signs is nearly 
the same. Both are inspiratory sounds, and both may 
be small bubbles. The main difference is really in the 
number of crackles which go to make up the rale, the 
crepitant consisting of several of these, while the crack- 
ling consists of but one, two, or three. " Crackling " 
is heard at the apices of the lungs, and the crepitant 
rale for the most part at the base. The interpretation 
ofcrackling is almost invariably tubercular consumption, 
and it means that the tubercle is beginning to break 
down. Yet we may have pneumonia of the apex. NEW OR ADVENTITIOUS SOUNDS. 
79 
What is known as " moist crackling " is a little larger 
rale than crackling, a pure bubbling sound produced in 
the smallest bronchial tubes, and is really a sub-crepita- 
tion. 
The friction sound is a noise produced by the rub- 
bing of two slightly roughened serous surfaces upon 
each other. The pulmonary and costal pleurse and the 
cardiac and pericardiac serous membranes move over 
each other smoothly and noiselessly in health, but let 
them be roughened in any way by an inflammatory ex- 
udate, an eruption of tubercles, or other morbid growth, 
and at once the friction sound is produced. In its 
simplest and most frequent form, representing the first 
stage of pleurisy, it also resembles somewhat the crepitant 
rale, and it is sometimes not easy to distinguish from it. 
In addition, however, to being more superficial in situa- 
tion, the friction sound is not influenced by coughing, 
while the crepitant rale is. The friction sound is heard 
more loudly if the stethoscope is pressed closely to the 
chest-wall and is localized, while the crepitant rale is 
heard over a large area of lung. It is also often a to- 
and-fro sound, being heard with expiration as well as 
with inspiration, while the crepitant rale is confined to 
the latter. The friction sound disappears with pleuritic 
or pericardial effusion, to return for a time with the 
subsidence of the effusion. 
In addition to its typical crepitant-like character, as 
heard in pleurisy, the friction sound assumes also at 
times greater roughness, which is more conspicuous in 
pericardial friction. Where organization has takSn 80 
place in an exudate there is sometimes a leather-like 
creaking produced under the same circumstances as the 
friction sound, and it is regarded as a friction sound. 
It is sometimes so loud as to be heard by the patient 
himself, and may also be recognized by palpation. 
Pleural friction may be found anywhere in the chest, but 
is more frequent in the sides. 
Metallic tinkling is the last of the adventitious 
sounds to be considered. It is another one of the am- 
phoric sounds, requiring a space with firm, tense walls as 
its condition. A pneumothorax will furnish such con- 
dition, as also do certain pulmonary cavities. Under 
these circumstances a drop of liquid falling into such a 
space will produce metallic tinkling. This sometimes 
happens in a pneumothorax when a drop of secretion 
will sometimes fall from a bronchial tube into a cavity. 
Allied to the metallic tinkling is the Hippocratic 
succussion produced in pyo-pneumothorax and very 
rarely in a cavity, when the patient is shaken. 
PHYSICAL DIAGNOSIS. ACUTE BRONCHITIS. 
81 
PHYSICAL SIGNS OF ABNORMAL 
STATES, OR DISEASES OF 
THE LUNGS. 
Acute bronchitis of the larger tubes is essen- 
tially a symmetrical disease, the bronchi of both lungs 
being generally more or less equally invaded. There 
may be absolutely no physical signs, inspection, palpa- 
tion, percussion, and auscultation being alike negative. 
In other cases inspection may discover increased fre- 
quency of respiratory movement, and possibly increased 
frequency in the cardiac apex beat if there be fever. 
Palpation may appreciate a rhonchal fremitus if there be 
sufficient narrowing of the breathing tubes. It may be 
found anywhere or on either side and may be very tran- 
sient. Percussion continues invariably clear so long as 
the bronchitis is uncomplicated. 
Auscultation furnishes the most distinctive and con- 
stant physical sign, the presence of dry rales, the sonor- 
ous and sibilant, which may invade either or both lungs, 
and may also be transient. To these may be added 
harshness of breath sounds. In the resolution of bron- 
chitis, bubbling rales may substitute the sonorous and 
sibilant, in consequence of the presence of liquid secre- 
tion. 
Capillary bronchitis involves the finer and finest 
tubules, into which it generally extends from the larger. 
The frequent breathing is more evident and constant; 
ACUTE BRONCHITIS. 82 
PHYSICAL DIAGNOSIS. 
so the frequent heart-beat with fever. Rhonchus may 
be felt, and there may be slight impairment of resonance 
in the affected area. Auscultation gives constant results 
in the shape, first, of dry rales of the finest kind, followed 
very soon by small bubbling rales, submucous and sub- 
crepitant, but dry rales are often absent. These signs 
are most frequent in the bases of the lungs posteriorly, 
but may extend all over. 
CHRONIC BRONCHITIS. 
Physical signs more constantly attend chronic bron- 
chitis, yet they afford no unchanging picture. To fzz- 
spection there may be nothing apparent, or the frequently 
associated complication of emphysema of the lungs 
may be the cause of a diminished excursion of respira- 
tory motion, and the roundness or barrel shape of the 
chest characteristic of this disease ; to palpation of a dim- 
inution of the normal vocal fremitus, and to percussion 
a hyper-resonance, unless in the vicinity of a superficial 
dilated bronchus filled with secretion, where there may 
be impairment of resonance. If such a dilated bron- 
chus be emptied of its contents by expectoration, the 
percussion signs of a cavity may be present, but in the 
middle or lower part of a lung instead of the apex. 
Vesiculo-tympanitic or even tympanitic resonance may 
be present from relaxation of lung tissue, especially in 
the lower posterior part of the lungs. 
Auscultation may also be negative, but much more 
frequently recognizes an alternation or combination of EMPHYSEMA OF THE LUNGS. 
83 
harsh and feeble breathing, sonorous and sibilant rales, 
with moist rales of all sizes, variously modified by dif- 
ferent distances from the ear and varying consistence of 
the secretion. 
EMPHYSEMA OF THE LUNGS. 
This condition, an over-distention and destruction of 
air vesicles with a like destruction of their covering of 
capillaries, is invariably the result of bronchitis and a 
complication of it. It also affects both lungs at the 
same time, but involves different lungs and different 
parts of the same lung unequally. 
The physical signs are more or less distinctive. In-- 
spection discovers a rounded chest anteriorly and pos- 
teriorly, with increased circumference, and wide inter- 
costal spaces, the highest degree of which is known as the 
" barrel-shaped chest." Fig. 17. But the emphysema 
may be so circumscribed as to produce local bulgings, by 
preference in the upper lobe of the right and lower lobe 
of the left lung. The excursion of expansion of the 
chest walls is diminished, while the scaleni and sterno- 
cleido-mastoid muscles stand out distinctly. The apex 
of the heart is displaced downward and to the right, but 
it is often difficult to find, because covered up by the 
enlarged lung. To palpation vocal fremitus is dimin- 
ished, while the natural resiliency of the chest walls is 
substituted by increased resistance. 
Percussion recognizes resonance exaggerated in vari- 
ous degrees, sometimes amounting almost to tympany, 84 
PHYSICAL DIAGNOSIS. 
the vesiculo-tympany of Flint. The cardiac dulness is 
extended to the right and downward, partly from 
displacement by the distended lungs, and partly from 
hypertrophy of the right ventricle. At the same time 
the cardiac area is more thoroughly covered by the 
lungs, and pretty strong percussion is often necessary 
Fig. 17. 
Bilateral Enlargement in Emphysema. (After Gee.) 
to bring it out. The hepatic area of dulness is also 
lowered by reason of the encroachment of the lungs. 
The distinctive auscultatory sign of the emphysema- 
tous area is the feeble inspiratory murmur due to the 
fact that the air vesicles are already distended with air 
and there is little further distention possible with the 
inspiratory act. The prolonged expiratory murmur is SPASMODIC ASTHMA. 
85 
the result of the lost elasticity of the air vesicles, in 
consequence of which they recoil but slowly on their 
contents. Vocal resonance is diminished because of 
the diminished motion in the air columns. Feeble 
crackling is said to be sometimes heard. If bronchitis 
is present its sounds are associated and often obscure 
all else. The pulmonary second sound at the second 
left interspace is accentuated on account of the hyper- 
trophy of the right ventricle, but the heart sounds are 
usually obscured by the extra covering of the lung. 
With dilatation of the right ventricle, which sooner or 
later succeeds, the increased accentuation disappears. 
Interlobular emphysema, in which the connective 
tissue between the lobules is infiltrated with air as the 
result of rupture of air vesicles from violent acts of 
coughing, or of wounds of the lung; the physical signs, 
except to inspection, are the same as those of vesicular 
emphysema, except that the crackling sound referred to 
is more common. The configuration of the chest in 
such cases is not usually altered. Suddenness of onset 
is characteristic of this form of emphysema, and it is 
apt to be associated with a similar infiltration of the 
tissues of the neck, which gives rise to a very distinctive 
crepitation to palpation. 
The physical signs of this peculiar neurosis reveal 
themselves to all the methods of physical diagnosis em- 
ployed. Thus inspection observes the most labored effort 
SPASMODIC ASTHMA. 86 
PHYSICAL DIAGNOSIS. 
in breathing, while the chest moves but slightly, because 
the lungs cannot be inflated. The spaces above and 
below the clavicle and above the sternum, the intercostal 
spaces, and the pit of the stomach are drawn in, for 
the same cause,-that is, the thoracic cavity not being 
filled from within, the external atmospheric pressure 
forces the yielding portions inward. 
Rhonchal fremitus is recognized by palpation, while 
vocal fremitus, obscured by the rhonchus, is otherwise 
diminished by a frequently associated emphysema. 
Percussion is negative in uncomplicated asthma, but if 
asthma is associated with emphysema it may produce 
abnormal resonance. 
Auscultation furnishes the most striking and easiest 
recognized of the physical signs. All over the chest 
are heard sonorous and sibilant rales, inspiratory and 
expiratory, but more commonly the latter. In fact, for 
the most part, they do not require the ear to be placed 
close to the chest for recognition. The vesicular mur- 
mur, on the other hand, is inaudible. 
It is to be remembered that chronic bronchitis, em- 
physema, and asthma may also complicate each other, 
and render correspondingly complex the physical signs. 
TUBERCULAR PHTHISIS OR CONSUMPTION. 
Accepting the modern doctrine, that all phthisis is 
tubercular, there are three ways in which it invades the 
lungs : - 
i. As catarrhal or broncho-pneumonic phthisis. TUBERCULAR PHTHISIS OR CONSUMPTION. 
87 
2. As fibroid phthisis. 
3. As miliary tuberculosis of the lungs. 
Catarrhal Phthisis.-This, the most common form 
of consumption, presents two varieties, differing mainly 
in the rapidity of their course,-whence acute and 
chronic phthisis. The former is also known as phthisis 
florida, or galloping consumption. Perhaps there should 
be added, as a distinctive feature of the latter, the 
diffuseness as well as the rapidity of the process. 
Catarrhal phthisis resolves itself, with more or less 
definiteness, into three separate stages, of which the 
physical signs, commonly sought at the apices of the 
lungs, are also more or less distinctive :- 
1. The incipient stage, or beginning deposit. 
2. Stage of complete consolidation. 
3. Stage of softening and cavity-formation. 
1. Inspection, in the incipient stage, is as often negative 
as not. A slight impairment of motion in the infra- 
clavicular space may be present, and more rarely a slight 
flattening of the same region. The clavicle becomes 
correspondingly conspicuous. The body may continue 
well nourished or slightly emaciated, or the heart-beat 
in the normal position may be somewhat accelerated, 
while the respirations are likely to be more frequent 
than in health. 
Palpation recognizes increased vocal fremitus in the 
same situation, although this may not always be notice- 
able in the first stage, while the physiological differ- 
ence in favor of the right side is to be remembered. 
Percussion in this stage gives slightly higher pitch and 88 
PHYSICAL DIAGNOSIS. 
impairment of resonance, which may be noted above, 
on, or below the clavicle. Dulness may sometimes be 
brought out by directing the patient to hold his mouth 
open during percussion, or to hold his breath at 
expiration. 
To auscultation above or below the clavicle, we have 
the first evidence of abnormality in a prolongation of 
the expiratory murmur and harshness in the inspiratory 
sound - the broncho-vesicular breathing described. 
Theoretically, this should be preceded by a diminished 
intensity in the inspiratory sound, owing to the inter- 
ference of the newly-deposited tubercles with the move- 
ment of the air into the air vesicles, but practically this 
is scarcely encountered, and if encountered, is of such 
indistinctive significance as to be of little value. 
Increased vocal resonance is a constant accompani- 
ment of these modifications in the normal breathing 
sounds, but it, as well as the vocal fremitus, may be 
masked by a pleuritic thickening, and the physiological 
difference so often referred to must be remembered. 
Da Costa also calls attention to the fact that in a certain 
number of cases, at this stage, there is a blowing sound 
in the subclavian or pulmonary artery, and that a mur- 
mur is sometimes present in the subclavian orpulmonary 
artery before any other physical sign is present. There 
are frequently concurrent with these signs those of a 
bronchitis more or less acute. 
2. In the second stage the changes discoverable by 
inspection are more easily recognized. There is evident 
loss of flesh, depression of surface, and impaired range TUBERCULAR PHTHISIS OR CONSUMPTION. 
89 
of respiratory movement. The hectic flush is intermit- 
tingly present. Palpation may also discover an in- 
creased warmth of skin. The increased vocal fremitus 
should be plainly recognized unless obscured by a 
thickened pleural membrane. Dulness on percussion is 
positive. 
To auscultation there is increased vocal resonance. 
The bronchial factor in the breathing now becomes 
conspicuous, showing itself by the harshness and relative 
shortening of the inspiratory element, with the decid- 
edly rough and blowing expiration; also a gradual 
diminution of the vesicular factor, until the latter dis- 
appears entirely, when we have the typical bronchial 
breathing of extended areas of tubercular infiltration. 
This sign will now be found in the supra-spinous fossa as 
well. The high degree of vocal resonance, known as 
bronchophony, is also superadded as a valuable confir- 
mation of the presence of complete consolidation. The 
auscultation signs of a concurrent bronchitis may also be 
present in this and the next stage. 
3. In the third stage the information furnished by in- 
spection is still more decided. Emaciation is extreme, 
and breathing and the pulse are rapid, the face often 
flushed. There is flattening over the affected area, and 
the excursion of respiratory movement is still more lim- 
ited. In this stage the superficial veins over the in- 
volved area may be prominent, partly from emaciation 
and partly from obstructed circulation. To palpation 
the vocal fremitus is still more marked, and even re- 
mains distinct over cavities, because of the consolida- 90 
PHYSICAL DIAGNOSIS. 
tion around them, unless there be some obstruction to 
the entrance of air in the bronchus leading to the in- 
volved area. Rhonchal fremitus may be added if 
adventitious sounds are present. The skin is hot and 
dry, unless succeeding one of the sweats which charac- 
terize this stage, when it may be moist and clammy. 
Dulness on percussion is always to be found in the 
third stage, but to it is constantly added some one of the 
varieties of tympanitic note referred to, viz., pure tym- 
pany, the "cracked-pot" sound or amphoric resonance, 
due to cavities. These require sufficient size and super- 
ficial situation on the part of the cavity, and the other 
conditions described on pages 54, 55, 56 and 57. On 
the other hand, resonance may even be normal over a 
cavity some distance from the surface, especially if the 
percussion be lightly made. 
Auscultation in this stage may continue to recog- 
nize the bronchial breathing of the second, but to it 
may be superadded the distinctive signs of a cavity, 
which may also supplant those of the bronchial breath- 
ing. These signs are cavernous breathing, cavernous 
voice, or pectoriloquy, either whispering or with the 
ordinary voice, amphoric breathing, and amphoric voice, 
the full import and conditions of all of which have been 
described. To these are often added the large bubbling 
sounds known as gurgling, caused by the air bubbling 
through the fluid in a cavity. Metallic tinkling maybe 
added to these phenomena, caused by the bursting of 
bubbles in a cavity with the amphoric conditions. TUBERCULAR PHTHISIS OR CONSUMPTION. 
91 
Fibroid Phthisis or Cirrhosis of the Lung.- 
Fibroid phthisis does not admit of the same sharp divi- 
sions into stages which characterize catarrhal phthisis. 
Frequently traceable in its initial symptoms to the inha- 
lation of irritating substances, and much more chronic 
in its course even than the chronic form of catarrhal 
phthisis, the general clinical history is of great value in 
distinguishing it from the latter. It is constantly asso- 
ciated in its beginning with pleurisy, and it may be a 
sequel of it. 
The degree of retraction as noted by inspection is 
greater and more easily recognized, and not confined to 
the apices of the lungs. The heart is frequently dislocated 
and its apex correspondingly displaced, sometimes to an 
extreme degree. The intercostal spaces are often nar- 
rowed, the diaphragm may be drawn up. The modifi- 
cations of vocal fremitus as revealed to palpation are not 
nearly as constant, being masked by the retraction and 
pleuritic complications, and may be absent. There is 
little or no elevation of temperature. 
Percussion is more constant in its phenomena, there 
being marked dulness and a wooden-like resistance. 
There is sometimes hypertrophy of the right ventricle 
due to the extra effort of the right heart to propel the 
blood through the obstructing lungs. Auscultation most 
frequently notes bronchial breathing and exagger- 
ated voice, but both of these may be lessened in inten- 
sity by thickened pleurae. 
A dilated bronchus is a frequent result furnishing the 
signs of a cavity, which may be in the middle or even 92 
PHYSICAL DIAGNOSIS. 
at the base of the lung, and furnishes a copious expec- 
toration characterized by a peculiar fetor, in which the 
microscope sometimes discovers fat-crystals. 
To the signs of the fibroid state in one part of a lung 
are frequently added those of emphysema in the re- 
mainder or in the other lung. 
The rarity with which the bacillus tuberculosis is 
found in the sputum in this condition is not regarded as 
sufficient to exclude it from the category of tubercular 
diseases. 
Acute miliary tuberculosis is not accompanied by 
any distinctive physical signs, and the diagnosis is made 
from the clinical and hereditary history rather than 
from such signs. A tympanitic or hyper-resonant per- 
cussion note is sometimes present throughout the lung 
in disseminated miliary tuberculosis due to the relaxed 
state of the air vesicles which such an infiltration 
favors. 
Not every case of tuberculosis of the lungs begins in 
the apex, nor even when it does thus begin are the 
physical signs always first discovered anteriorly. Ex- 
amination of every case should therefore include the 
posterior portion of the lung, and especially the supra- 
spinous fossae. Tuberculosis not very rarely succeeds 
upon a pneumonia as well as upon a pleurisy, and especially 
a catarrhal pneumonia, when the signs first make their 
appearance in the area which has been made vulnerable 
by the previous state. PNEUMONIA. 
93 
Acute croupous or lobar pneumonia, more 
common in the right lower lobe, presents three easily 
separated sets of physical signs corresponding to as many 
stages in the morbid process itself. 
The first, or stage of congestion, in which the air 
vesicles are still open, is of short duration, terminating 
within the first twenty-four hours, and may therefore 
be overlooked. Inspection notes the face flushed, 
increased frequency of respiration, with restricted move- 
ment upon the involved side and exaggerated motion on 
the sound side. The patient lies by preference on the 
affected side because of the greater comfort it gives him. 
This posture not only diminishes the pain by hindering 
the motion of the affected side, but also lessens the 
dyspnea by permitting unrestrained expansion of the 
other side which is doing the work. 
Palpation at first may even find vocal fremitus 
diminished on account of the relaxation of the air vesicles, 
but vocal fremitus becomes decidedly increased as the 
air vesicles fill up. The skin is hot and the pulse is fre- 
quent. Percussion obtains but slight if any impairment 
of resonance. In fact, tympany or the vesiculo-tympany 
of Flint is frequently present in this stage as the result 
of the relaxation of the partially filled air vesicles, 
giving resorance by immediate relaxation. See p. 52. 
Auscultation in the very earliest stage may find the 
vesicular murmur feeble, but very soon is heard the 
distinctive physical sign of pneumonia, the crepitant 
PNEUMONIA. 94 
PHYSICAL DIAGNOSIS. 
rale at the end of inspiration, or if there be coincident 
pleurisy-pleuropneumonia-the closely simulating fric- 
tion sound may be added. Over the normal part of the 
lung there is exaggerated vesicular breathing. 
But all of these physical signs, even if carefully sought 
for, may be wanting if the pneumonia is deep-seated, 
as is not infrequently the case. They appear as the 
surface is reached, or they may not be recognized at 
all if it remains central. 
The second stage, or stage of red hepatization or 
solidification, lasting four or five days, furnishes unmis- 
takable signs. All the signs pneumonia reveals to 
inspection in the first stage are intensified in the second, 
and the breathing is markedly abdominal. To palpa- 
tion, vocal fremitus is now intense, the skin is hot and 
dry, and the pulse continues frequent. 
Percussion gives absolute flatness over the solidified 
area, with high pitch and short duration, except in those 
very rare instances alluded to on p. 56, where the 
extreme consolidation throws the column of air in the 
trachea and bronchi into vibration, producing tympany. 
This explanation is perhaps the only one when it occurs 
in the upper lobe. In a lower lobe, tympany may result 
in the same way, from the proximity of a dilated stomach. 
Over the adjacent normal areas, also, resonance is ex- 
aggerated in consequence of the supplemental action of 
these parts. There may even be here tympany or vesi- 
culo-tympany due to the relaxation of the adjacent air- 
vesicles, an instance of resonance by mediate relaxation. 
Even cracked-pot sound may be produced by percussion PNEUMONIA. 
95 
over the solidified lung as the result of the sudden 
expulsion of air from a large bronchus leading to the 
solidified area. 
Atiscultation discerns high-pitched bronchial breath- 
ing over the solidified lung. Indeed, these are the 
circumstances which give the typical bronchial or tubal 
breathing. The air vesicles are obliterated, and the 
resulting excellent conducting medium brings the 
tracheo-bronchial blowing to the ear. The ausculted 
voice gives us typical bronchophony and occasionally 
even pectoriloquy, as well as whispering bronchophony 
and pectoriloquy. The heart sounds are also heard with 
great distinctness over the consolidated lung, owing to 
the improved conduction, while the sounds of a concur- 
rent bronchitis are similarly intensified. A lingering 
crepitant rale may also be heard. 
The third stage, or stage of gray hepatization or reso- 
lution, occupies six to ten days. It repeats largely, to 
inspection, palpation, and auscultation, the phenomena 
of the first. Resonance continues impaired for some 
time. The normal manner of breathing gradually 
returns, the temperature of the skin is noticeably less, 
the crepitant rale returns, technically known as the 
" crepitans redux," and is finally replaced by the normal 
vesicular breathing sound, by which time the dulness 
has disappeared. 
Croupous pneumonia may rarely terminate in abscess 
or gangrene, when the signs of the second stage con- 
tinue, the temperature does not fall, in a word, the crisis 
does not occur. The signs of a cavity which might 96 
PHYSICAL DIAGNOSIS. 
naturally be expected are rarely present, and it is rather 
by the general symptoms, the failure to recover, the 
continued high temperature, the expectoration of pus, 
and, in the case of gangrene, the intensely disagreeable 
odor, that informs us of the issue. These issues probably 
represent on a large scale what takes place in every in- 
stance in minute areas in the third stage of all pneu- 
monias which terminate favorably. The occasional 
termination in tubercular phthisis exhibits a similar 
arrest of the resolving process in the second stage, and 
the phenomena of the catarrhal or fibroid phthisis 
supervene. 
The obscuring effect of a thickened pleura upon all 
of these signs is to be remembered, and too much stress 
cannot be laid upon the fact that we may have a central 
deep-seated pneumonia which may give no physical 
signs, also that in old persons the physical signs of a 
pneumonia are very apt to be delayed from one to 
three days. 
Catarrhal or Lobular Pneumonia or Broncho- 
Pneumonia.-The physical signs of this form of pneu- 
monia are not nearly so distinctive as those of croupous. 
A circumscribed affection involving a few lobules, the 
physical signs are necessarily more obscure. Occurring 
most frequently in the course of a bronchitis in children 
and in old persons, as well as de novo in the former, the 
physician should be on the watch for it under these 
circumstances. It also occurs in adults, though more 
rarely, especially in those suffering from tuberculosis, as 
the result of insufflation of broken-down tubercular matter, which produces by inoculation and irritation a 
tubercular broncho-pneumonia. When superadded to a 
bronchitis under any of these conditions, there ensues 
increase of fever, embarrassed breathing, and associated 
increased inspiratory effort. Palpation should recognize 
increased vocal fremitus if the area involved be suffi- 
ciently large, percussion should reveal dulness and 
tympanicity of adjacent supplementally acting areas. 
Auscultation will also discover in the inflamed area the 
crepitant rale, the bronchial breathing, increased vocal 
resonance, and bronchophony, in addition to the physi- 
cal signs of the concurrent bronchitis. 
Embolic Pneumonia and Hemorrhagic In- 
farct.-Pulmonary Apoplexy.-The effect of the 
lodgment of an embolus from any source in a branch of 
the pulmonary artery is to produce an extravasation of 
blood in the conical area formerly supplied by the vessel. 
Such an extravasation is called a hemorrhagic infarct. 
It is, in fact, a circumscribed apoplexy, but the term 
apoplexy of the lung is better retained for such extrava- 
sations of blood, circumscribed or diffuse, as are due to 
rupture of branches of the pulmonary artery from other 
causes than embolism. Such is over-distention of 
blood-vessels in valvular disease of the heart, disease of 
the blood-vessel wall, or traumatism. 
Small infarcts of the lungs may give rise to no symp- 
toms whatever. When large enough they cause sudden 
embarrassed breathing, rusty expectoration, and circum- 
scribed dulness, all of which increase with the size of 
the infarcted areas. Palpation reveals increased vocal 
PNEUMONIA. 
97 98 
PHYSICAL DIAGNOSIS. 
fremitus, and auscultation crepitant and sub-crepitant 
rales, bronchial breathing, and bronchophony. These 
are the signs of a croupous pneumonia, which is indeed 
present, the consequence of the infarct, which acts as 
an irritant. The circumscribed area covered by these 
signs would exclude an ordinary croupous lobar pneu- 
monia, while the absence of fever, the suddenness of 
onset, and the presence of cardiac disease aid in the 
diagnosis. 
Similar symptoms may be caused by massive hemor- 
rhage of the lungs or pulmonary apoplexy, caused by the 
rupture of a large branch of the pulmonary artery, whose 
wall is weakened by tuberculous infiltration or the en- 
gorgement due to valvular heart disease. Such a vessel 
may suffer a further strain in consequence of some transi- 
tory congestion, and rupture occurs. A great mass of 
blood is poured out, which, besides entering the bron- 
chial tubes and producing haemoptysis and mucous rales, 
also infiltrates the lungs, coagulates, and produces con- 
solidation. If the patient lives, the blood in the 
bronchi may be insufflated into the vessels and there act 
as an irritant, producing intense inflammation followed 
by gangrene or abscess. 
Pulmonary oedema furnishes many of the signs of 
the first stage of croupous pneumonia, and is sometimes 
accompanied by a frothy, pinkish expectoration ; but 
the absence of fever, and the presence of dropsy else- 
where, or its causes, account for the condition. 
Collapse of the Lung.-In the course of a capillary 
bronchitis there sometimes occurs a collapse of a portion PNEUMONIA. 
99 
of the lung, owing to a valvular plugging of a bronchus, 
as the result of which air may pass out during expiration 
but cannot enter with inspiration, or it may occur as the 
result of a want of strength to fill the air-cells. The 
area of collapse often corresponds in size with that of 
lobular pneumonia. 
When such collapse occurs there is sudden difficult 
breathing noticed on inspection, but palpation gives no 
information. Percussion reveals dulness, but it is 
much less marked than in lobular pneumonia, while 
auscultation finds no bronchial breathing, or if present 
it is very feeble ; no bronchophony, but rather dimin- 
ished intensity of breathing sounds and diminished 
voice. Collapse of the lung is apt to be symmetrical. 
Compressed lung, most frequently due to pleural 
effusion, generally furnishes flattening, increased vocal 
fremitus, impaired resonance, increased vocal resonance, 
and bronchial or broncho-vesicular breathing. 
Cancer of the lung furnishes signs of consolidation 
very similar to those of the second stage of tubercular 
consumption. Flattening, increased fremitus, dulness, 
increased vocal resonance, bronchial breathing, all except 
elevation of temperature, may be present, and it is the 
history of the case and special symptoms that determine 
the diagnosis rather than the physical signs. History 
of heredity, cancer elsewhere, cachexia, more constant 
and severe pain, are symptoms of importance in the 
diagnosis. A peculiar currant-jelly-like sputum is much 
mentioned as characteristic. 100 
PHYSICAL DIAGNOSIS. 
PLEURISY. 
Acute pleurisy is also resolvable into three stages, 
each of which is characterized by physical signs more or 
less distinctive. They include a dry stage, a stage of 
effusion, and a stage of resolution or absorption. 
The first or dry stage is characterized anatomically by 
the presence of the so-called lymph or exudate on the 
pleural surfaces. During this is revealed to inspection 
a restrained expansion of the affected side, often thrown 
into jerks or catches because of the pain suffered in a 
continuous inspiration. The expansion on the opposite 
side, on the other hand, is full and unhampered. The 
patient is apt to lie on the affected side. Very rarely 
does palpation recognize a fremitus corresponding to the 
friction of the two pleural surfaces. Percussion in this 
stage is negative, but auscultation recognizes the friction 
sound already described. It may be at a single spot in 
the infra-mammary or infra-axillary space, and hence 
be overlooked. At other times it may be noted over a 
considerable area. 
The inflammatory process may stop here and resolu- 
tion take place, or it may continue into the second or 
stage of effusion. The signs of this stage vary with the 
amount of liquid in the sac. With a small amount, 
the lungs are slightly floated up, and there may be no 
signs unless there be a vesiculo-tympany above the line 
of the fluid, a Skodaic resonance by mediate relaxation 
of the air vesicles. 
The effusion, however, rarely remains so trifling, but PLEURISY. 
101 
commonly rises to the mid-chest. In the upright posi- 
tion of the patient, inspection discovers in a spare person 
shallowness and perhaps obliteration of the lower inter- 
costal spaces. The motion of the chest wall is lessened 
both in the vertical and transverse directions. 
To palpation vocal fremitus is diminished over the 
area of effusion, but may be increased in the lung 
above it. To percussion there is absolute flatness over 
the area of effusion, but the line of demarcation is 
not everywhere at the same level, being higher behind 
than in front. The late Dr. Calvin Ellis first called 
attention to an S-like curve in the line of demarcation 
which is said to be diagnostic. Very important in the 
diagnosis is the fact that the fluid changes its level, and 
with it the line of dulness, when the position of the 
patient is changed. There is also an abnormal sense of 
resistance to the finger in percussing over the area of 
effusion. Above the effusion, especially anteriorly, 
there is again Skodaic resonance by mediate relaxation, 
and even sometimes a cracked-pot sound. Tympany 
may also be present, due to the proximity of a distended 
stomach. 
To auscultation, the breathing sounds are inaudible 
or very feeble, as compared to the corresponding por- 
tion of the opposite side, but vocal resonance, though 
diminished, is still well heard where the collection of 
fluid is moderate. Above the line of dulness there is 
occasionally a friction sound, and close to the root of 
the lung bronchial breathing may be heard. This is, 
however, more apt to be the case when the effusion is PHYSICAL DIAGNOSIS. 
102 
larger and the lung is further compressed. Egophony 
is also sometimes heard. 
When the effusion is larger, filling up two-thirds or 
three-fourths of the pleural sac, the effects described are 
increased, while new ones are added. Inspection notes 
that respiratory movement is still more hampered, the 
intercostal spaces are widened and even bulging, while 
fluctuation may sometimes be recognized through them. 
The heart is displaced by the accumulated fluid, and if 
it be in the left sac, the apex is often found far over to 
the right of the median line, and if on the right, the 
apex is pushed further to the left. Its sounds are not, 
however, altered further than to be heard more intensely 
in the situation where they are not usually so heard, 
because sound is transmitted more readily through a 
single uniform medium than through two or more of 
different densities. On the opposite side, the breath- 
ing movements are supplementally increased. There 
is complete absence of vocal fremitus on the affected 
side. 
Percussion is absolutely flat all over the effusion, and 
Skodaic resonance is not now obtainable because the 
lung is too thoroughly compressed up into the apex of 
the sac. Resistance to pressure is marked. On aus- 
cultation bronchial breathing may be heard at the upper 
posterior of the lung, because the large tubes are still 
pervious to air, and the compressed lung intensifies the 
sound. Sometimes bronchial breathing is heard in 
more peripheral parts of the chest, probably conducted 
hither along a band of adhesion or along a rib. Else- PLEURISY. 
103 
where there is absence of breath-sounds. Vocal reso- 
nance and whispering voice are alike absent, or the 
former is very feeble. In certain situations, too, high 
up, where there is but a thin film between the chest-wall 
and the lung, there may be egophony, but this is more 
apt to be present as the fluid is being absorbed. 
In the third stage, if resolution takes place with a 
gradual retrocession of the fluid and the reexpansion of 
the lung, we have a return to normal physical signs. 
There may be, too, a friction redux. A considerable 
time is, however, required for absorption, and it is 
often many days before the normal breathing sounds 
are heard with their usual intensity or the natural fre- 
mitus is felt. Often resolution is not complete, and 
there then remain the symptoms and sequelae of a 
chronic pleurisy. 
Chronic Pleurisy.-Its symptoms and sequelae are 
not uniform. The simplest and most harmless expres- 
sion is a thickened pleural membrane. In this there is 
no adhesion between the opposite pleural surfaces, and 
the motion of the lung is not interfered with. There 
is, however, a general interference with the conduction 
of sound, and all the normal physical signs, including 
vocal fremitus, vocal resonance, normal percussion 
sounds, and normal breathing sounds are diminished in 
intensity. For the same reason many abnormal physical 
signs, as already more than once instanced, are also less 
plainly heard. 
The harmful symptoms of chronic pleurisy are more 
frequently manifested in the results of delayed absorp- 104 
PHYSICAL DIAGNOSIS. 
tion of effusion, and in a change of its character from 
serous to purulent. The resulting accumulation of fluid 
in the pleural cavity is not always a continuation of acute 
disease. A chronic pleurisy may originate de novo, and 
often without the consciousness of the patient, although 
a careful analysis of the case will not fail to find symp- 
toms of ill-health which are explained by the state of 
affairs ultimately found. Such pleurisies are known as 
latent. With the discovery of the effusion, which may 
depend more or less on the acumen of the physician, 
the latency disappears. 
Such fluid furnishes the physical signs which have 
already been detailed on p. 100. Its further effects vary 
very much according as it is serum or pus. In either 
event its speedy removal is desirable, because the longer 
it remains compressing the lung, the longer will the latter 
be in returning to its natural state. Hence, it is better 
done by aspiration than by the slower method of medi- 
cation. If the fluid be serous, and if it has not been too 
long retained, the lung gradually resumes its normal 
state, and a thickened pleura is all that remains, with 
the physical signs referred to as associated with it. Not 
infrequently, however, the two pleural surfaces, costal 
and pulmonary, remain permanently agglutinated, and 
then, although the lung slowly resumes its natural func- 
tion, there still remains some flattening over the lower 
part of the thorax, while the signs of a compressed lung 
may be found at the apex. 
If the liquid be pus, we have an empyema, and the 
consequences are much more serious. The occurrence PLEURISY. 
105 
of a chill and continued high temperature will sug- 
gest a purulent collection. Baccelli's test may be 
tried.* 
Medical treatment almost never removes it, and aspi- 
ration is as invariably followed by reaccumulation. 
Hence, permanent measures, as the introduction of a 
drainage tube or exsection of a rib, must be used. 
Even here, if the drainage tube be inserted early, the 
lung may resume its natural office, and there may be 
no more permanent damage than the agglutination re- 
ferred to, and subsequently a retracted thorax. More 
frequently, however, we have to do with a lung partly 
bound by adhesions into its new and unnatural position, 
while the pleural surface may be looked upon as an ex- 
tensive ulcer. The restrained lung is unable to expand 
to refill its natural space, while the huge ulcer referred 
to must heal slowly with a resulting cicatrix. This cica- 
trix has the property of all cicatricial tissue. It must 
contract, and with this contraction drags with irresistible 
force whatever is attached to it, including the ribs and 
even the spinal column, which is sometimes drawn out 
of line. Thus there results distortion, in various 
degrees, of the shape of the thorax, associated with a 
* Baccelli, of Rome, in 1875, suggested a method of distinguish- 
ing purulent accumulations from serous. He found that the whis- 
pered voice was often audible over these serous accumulations, while 
it was inaudible over pus collections. Douglas Powell, Transactions 
of International Medical Congress, 1881, failed to confirm this 
observation. I have sometimes noted the sign under the circum- 
stances described by Baccelli, but not always. 106 
PHYSICAL DIAGNOSIS. 
shortness of breath which is permanent, but which may, 
nevertheless, grow less as time rolls on. 
A result of empyema which remains to be alluded to 
is a circumscription of pus into two or more separate or 
communicating spaces. It is not always easy to recog- 
nize such a state of affairs. Most frequently it is ascer- 
tained by the attempt at removal by tapping, the with- 
drawal of a certain amount of fluid giving partial relief 
and leaving areas with physical signs unchanged. Da 
Costa gives us from Jaccoud* some points to assist 
toward such recognition. Given, in the area of dul- 
ness, a zone along which vocal vibrations are preserved, 
as from the spinal column toward the sternum, a separa- 
tion between two portions of fluid probably exists along 
such line. Again, if voice and fremitus continue, 
though feebly, except in a zone of a few finger-breadths 
behind, and at the lower border of the chest, while no 
tympanitic sound can be elicited under the clavicle, it 
may be concluded that the effusion is multilocular. 
When diaphragmatic adhesions exist, the normal move- 
ments at the epigastrium and hypochondrium are 
reversed, and the inspiration is accompanied by depres- 
sion in the lower intercostal spaces instead of a filling out. 
One other feature must be pointed out as associated 
with such collections, and that is, pulsation sometimes 
communicated to them by the heart. Hence the term 
pulsating empyema. Such a one recently occurred 
* Da Costa, op. citat., p. 366, from Bulletin de 1'Academic de 
Medecine, 1879. PNEUMOTHORAX. 
107 
to the writer. It was below the left clavicle, and so 
striking that he hesitated to puncture it lest it be a pul- 
sating auricle or an aneurism. The knowledge that 
there was pus elsewhere in the pleural sac, the elevation 
of temperature, and the absence of sound or murmur or 
thrill seemed to justify operation, and a large quantity 
of fetid pus was drawn through a communication made 
with a pus cavity lower down. The tumor and pulsa- 
tion and fever disappeared, and the patient, who was a 
girl, recovered. 
PNEUMOTHORAX. 
This comparatively frequent complication of tuber- 
cular consumption commonly results from the rupture 
into the pleural sac of a cavity in the lung, an accident 
usually brought about by a fit of coughing. This re- 
sults in a rapid filling of the pleural cavity with air, 
which is soon followed by an effusion of liquid, generally 
purulent. The result is a distended air sac occupied to 
a certain height with liquid, compressing somewhat the 
lung and displacing the heart, while the physical condi- 
tions are those of a resounding cavity. 
The effect on the physical signs is as follows: To 
inspection a bulging chest, a filling out of the intercostal 
spaces. The thoracic wall on the affected side dimin- 
ishes its excursion of respiratory movement, or it appears 
at a standstill. Palpation appreciates no vocal fremitus. 
Percussion furnishes over most of the half of the thorax 
involved the most striking of the percussion notes, the 
ringing, amphoric resonance, which contrasts strongly 108 
PHYSICAL DIAGNOSIS. 
with the absolute dulness due to the fluid below. To 
auscultation the breathing sounds are distant and feeble, 
the expiratory sound continuing short, but the voice is 
ringing, amphoric, and an unmistakable tinkling sound 
attends the dropping of fluid from the perforation into 
the fluid below. To a sudden shaking of the body there 
results a splashing sound similarly intensified by the 
reechoing to which it is subjected. PHYSICAL EXAMINATION OF THE HEART. 
109 
PHYSICAL EXAMINATION OF THE 
HEART. 
Anatomical Relations of the Heart.-The actual 
boundaries of the heart in the chest cavity demand 
some notice. The base of the heart is held fast by the 
great vessels coming from it, but the remainder of the 
organ has a certain freedom of motion chiefly rotatory, 
but slightly also of elongation limited only by the peri- 
cardial sac attached to the diaphragm and pleurae. The 
heart lies upon the central tendon of the diaphragm. 
The auricles are nearly transversely placed, on a level 
with the second interspaces and the third costal cartilages, 
both extending slightly beyond the corresponding bor- 
ders of the sternum. The ventricles are obliquely 
placed, the right being in front and directly under the 
sternum, extending a very little to the right of the 
sternum at the fifth interspace, but more to the left. 
The right ventricle is on a level below with the sixth 
cartilage. A much smaller portion of the left ventricle 
is turned to the front when the heart is zzz situ, and it is 
altogether within the line of the nipple, the apex cor- 
responding to a point between the fifth and sixth car- 
tilages and an inch to an inch and a-half below and 
within the nipple. The base of the heart corresponds 
behind with the fifth and sixth dorsal vertebrae, between 
which and it lie the aorta and esophagus. The heart, 
surrounded with its pericardial sac, is covered very 
largely by the lungs, the right extending to the middle 
of the sternum, the left also to the middle as low as a Fig. 18. 
Position of Heart in Relation to Ribs and Sternum, PHYSICAL EXAMINATION OF THE HEART. 
111 
line continuous with the lower edge of the fourth car- 
tilage, along which it passes, thence obliquely across the 
fourth interspace and the fifth rib, the lung covering 
the whole of the left ventricle, except the apex. 
The size of the heart approximates that of the fist 
of its owner. I am inclined to think it is frequently a 
little larger. Its weight in adults is for males 
grams (n ozs.) ; for females 255 grams (9 ozs). 
The Praecordium.-By the praecordial region 
or praecordium is meant that portion of the thorax 
covering the heart, and it may be said to be bounded 
above by a line drawn through the junction of the manu- 
brium with the blade of the sternum, below by a line 
drawn along the upper edge of the sixth cartilage, and 
laterally by a vertical line drawn through the seat of 
the apex-beat, and another three-fourths of an inch to 
the right of the sternum. In this region inspection and 
palpation recognize the apex-beat between the fifth and 
sixth ribs and an inch and a half below and within the 
nipple. In children it may be found an interspace 
higher, and in the aged and persons with long and 
narrow thoraxes it may be an interspace lower. Occa- 
sionally, in the second interspace to the left of the 
sternum in thin persons, a feeble impulse can be seen 
produced by the dilatation of the left auricle. The 
situation of the apex is slightly altered by changes of 
position or by distention of the stomach from any cause. 
The act of breathing, however, influences it most. With 
a deep breath the heart descends and is pushed inward 
by the inflated lung, and the impulse approaches the 112 
PHYSICAL DIAGNOSIS. 
epigastrium. On a deep expiration it rises slightly, and 
while the breath is held remains higher. The apex-beat 
is rendered more distinct by exercise or emotion. This 
is still more the case in pathological states where there 
is enlargement. Emphysema of the lungs and effusion 
into the pericardial sac render it more or less indistinct. 
Its position is also variously changed by morbid condi- 
tions, and a thrill or fremitus is sometimes communi- 
cated to the hand in valvular diseases. 
Fremitus is also sometimes noticeable as the result of 
pericardial friction. The whole praecordial region is 
sometimes abnormally prominent in hypertrophy and 
pericardial effusions, especially in the young, while 
retraction due to adhesion is also seen. In the neigh- 
borhood of the praecordium, at the root of the neck, pul- 
sations, arterial and venous, are noted, also epigastric 
pulsations, which will be explained under the head of 
the conditions that produce them. 
PERCUSSION AND AUSCULTATION OF NORMAL 
HEART. 
The percussion boundaries of the heart have 
been already mapped out on page 45, but it may not be 
amiss to review them at this point somewhat more in 
detail. 
The Percussion Borders of the Heart.-To 
map out the percussion borders of the heart, we begin 
percussing on a horizontal line at the left edge of the 
sternum, at about the second interspace, proceeding Fig. ig. 
Showing Absolute and Relative Percussion Dulness of Liver and Heart, 
i. Relative Percussion Dulness of Liver. 2. Absolute Percussion Dulness 
of Liver. 3. Relative Percussion Dulness of Heart. 4. Absolute Percussion 
Dulness of Heart. 114 
PHYSICAL DIAGNOSIS. 
downward by moderately strong percussion, only, until 
positive dulness is reached. This is usually found to 
be on the fourth costal cartilage, which is the upper 
border of the uncovered area of the heart, and where a 
line should be drawn. We then begin to percuss on a 
vertical line at the right edge of the sternum at about 
the level of the fifth rib and proceed across the sternum 
until evident dulness is reached, which is in most cases 
toward the left edge of the sternum, and this is the 
right border of the absolute dulness of the heart, and 
here a vertical line is drawn. The situation of the apex 
is then found by palpation or by the stethoscope. Per- 
cussion is again commenced on an oblique line in the 
direction of a line from the junction of the fourth carti- 
lage with the sternum toward the apex, but sufficiently 
beyond to be certain of clearness. Then parallel with 
such a line proceed downward until positive dulness is 
reached. The lower border of the heart cannot be 
satisfactorily separated by percussion from the liver, but 
such a boundary can be obtained with sufficient accuracy 
by drawing a line from the apex perpendicular to the 
sternum. Thus the area of absolute dulness in 
adults will correspond to a rude triangle of which the 
base is to 3 inches, the perpendicular inches, 
and the hypothenuse to 4 inches on a somewhat 
curved line. 
The area of relative dulness, elicited by stronger 
percussion, extends a short distance beyond the bounda- 
ries indicated in every direction except downward. The 
exact measure of this must depend somewhat on the PERCUSSION AND AUSCULTATION OF HEART. 
115 
delicacy of the ear of the examiner and the mode in 
which he percusses, but it may be put down approxi- 
mately as a finger's breadth, and on the left side still 
within the nipple line in adults. 
Various causes influence the area of cardiac percussion 
dulness in health. In children, the area of the cardiac 
dulness is decidedly reduced on account of the intense 
resonance of the child's thorax. In old age, on the 
other hand, the area of absolute cardiac dulness is 
increased on account of the shrinkage of the lungs. 
The upper border of absolute dulness may be at the 
third rib, and the apex may be in the sixth interspace. 
The effect of a deep inspiration is materially to diminish 
the area of dulness, while that of expiration enlarges it. 
Pathologically the normal area is increased down- 
ward to the left in hypertrophy of the left ventricle, 
downward toward the epigastrium and to the right in 
hypertrophy of the right ventricle. 
The Auscultation of the normal heart is very 
simple. It consists in the recognition of the normal 
heart-sounds, known as first and second. Both sounds 
are audible over the whole precordial region in health, 
but the first sound, characterized by its longer, boom- 
ing character and lower pitch, is heard most loudly at 
the seat of the apex beat, where it is the louder of the 
two. The second, shorter, sharper, higher-pitched, 
and more snapping in character, is most intense at the 
base of the heart, on the sternum opposite the second 
interspace. Both sounds are heard at both situations, 
but each has its situation of greatest loudness. Hence, 116 
PHYSICAL DIAGNOSIS. 
at the apex the rhythm may be said to be represented 
by the trochaic foot - while at the base it is repre- 
sented by the iambus -. The two sounds have also 
been long compared to the word lub-tup, the first 
syllable corresponding to the first sound, and the 
second to the second part. While this word cannot be 
said |to resemble the heart-sounds very closely, there 
seems to be no other that resembles them more. 
As to the mechanism of the sounds, while that of 
the first is probably somewhat complex, including the 
shutting down of the auricular ventricular valves, the 
apex beat, the rush of the blood through the aorta and 
pulmonary artery, and the noise of the muscular con- 
traction, it is sufficient for clinical purposes to consider 
it produced, as it undoubtedly is for the most part, by 
the shutting down of the auriculo-ventricular valves, the 
mitral or bicuspid on the left side, and the tricuspid on 
the right. Both sets of valves shut down simultaneously, 
both contribute to the production of the sound, while 
the greater muscular power of the left side gives to it a 
distinct predominance. 
The second sound is of simpler mechanism, and is 
caused solely by the shutting down of the semilunar 
valves of the aorta and pulmonary artery with the recoil 
of the blood upon them. On account of the more 
powerful recoil in the aorta, the aortic is the predomi- 
nating sound. 
We may isolate the part played by each set of valves by 
carrying the stethoscope to certain situations, and in 
diagnosis constant advantage is taken of this. Thus, PERCUSSION AND AUSCULTATION OF HEART. 
117 
in order to pick out the mitral part of the first sound, 
Fig. 20. 
Diagram showing the Location ot Cardiac Valves and Points of Maximum 
Intensity connected with them. The triangle, a b c, is the area of super- 
ficial or absolute dulness. A corresponds to the anatomical seat of the aortic 
valves, P to the pulmonary, M to the mitral, T to the tricuspid. The 
points of greatest intensity of the sounds are ai for the aortic, // for the 
pulmonary, wz for the mitral, /for the tricuspid. 
the stethoscope is placed at the seat of the apex beat, 118 
PHYSICAL DIAGNOSIS. 
while the tricuspid factor is best heard at the left sternal 
border, between the fifth and sixth cartilages. So with 
the second sound, the aortic factor is best heard at the 
second interspace to the right edge of the sternum ; and 
the cartilage just above this is known as the aortic 
cartilage, because this great vessel approaches next to 
the chest-wall in this situation. The pulmonary part 
of the sound, on the other hand, is heard at the left 
edge of the sternum at the second interspace, while the 
cartilage above this, behind which ascends the pulmon- 
ary artery, is called the pulmonary cartilage. These 
points, and a circle about an inch in diameter around 
them, are known as the mitral, tricuspid, aortic, and 
pulmonary areas. 
Topography of the Valves.-It is to be remem- 
bered, however, that these are not the precise seats of 
the valves themselves. These are all situated in wonder- 
fully close proximity to each other-in fact, a portion of 
each is contained within a space of less than half an 
inch square. The mitral valve is placed behind all 
the others, at a point corresponding to the left border 
of the sternum at the third interspace. It lies almost 
horizontally about a quarter of an inch below the 
attachment of the aortic valves. The tricuspid valve 
corresponds to a line drawn obliquely across the sternum 
from the third left interspace to the fifth costal cartilage 
of the opposite side. The aortic valve lies nearly 
horizontally behind a line joining the middle of the 
sternum and the end of the third left costal cartilage. 
The pulmonary valve, a little higher and to the left PERCUSSION AND AUSCULTATION OF HEART. 
119 
of the aortic, runs quite horizontally, corresponding to 
a line drawn along the upper border of the third left 
costal cartilage. Thus all of the valve attachments 
except the tricuspid are horizontal or very near horizon- 
tal. The want of identity of the auditory valve area, 
or place where the sounds are best isolated, with the 
actual sites of the valves, is due to the fact that the 
sounds are best heard at points on the chest-walls 
nearest the cavity or channel in which vibrating blood 
is flowing. 
The normal heart-sounds are heard less loudly over 
the normal areas during deep inspiration, when they 
are more completely covered by the fully expanded 
lungs, and the first sound is heard more loudly at a new 
point toward the median line, to which the apex is 
pushed by the inflated lungs. On the other hand forced 
expiration increases the area over which the sounds are 
heard. 
The time of the normal heart-sounds requires some 
further study because on a thorough understanding of 
this depends largely skill in diagnosis. The first sound 
begins with the systole of the ventricles and is coinci- 
dent with the apex-beat, the second occurs in the dias- 
tole, immediately after the first, with a short pause 
between. The second sound is succeeded by a longer 
pause occupied with the diastole of the ventricles, during 
the latter part of which occurs the systole of the auricles, 
terminating the diastole of the ventricles. Thus if a 
revolution of the heart's sounds and pauses be repre- 120 
PHYSICAL DIAGNOSIS. 
seated by a dash and interspaces we will have the fol- 
lowing :- 
Ishort Pause 
Long Pause 
Short Pause 
Long Pause 
1st sound 
2d 
sound 
1st sound 
2d 
sound 
1234 56789 IOI234 56789 io 
of which the first sound will occupy four-tenths, the 
short pause one-tenth, the second sound two-tenths, and 
the long pause three-tenths. 
It is to be remembered that each one of these sounds 
is double, two systolic occurring at the ventricular ori- 
fices, and two diastolic at the aortic and pulmonary 
orifices. It may be further conceded that the first 
sound is heard at the base of the heart and the second 
sound as heard at the apex are simply conducted from 
the seat of their production, and that they are in no part 
produced at the situation where they are less loud. 
ABNORMAL MODIFICATIONS OF HEART- 
SOUNDS. 
It is not impossible, even in health, to have these 
paired sounds separated, and thus is produced what is 
known as reduplications of the heart-sounds, a phe- 
nomenon more common in diseases of the heart. Thus, 
as the effect of running there may result such an en- 
gorgement of the lesser circulation and high tension in 
the pulmonary artery, that the pulmonary valve closes a 
little sooner than the aortic, and reduplication of the ABNORMAL MODIFICATIONS OF HEART-SOUNDS. 
121 
second sound occurs. In like manner the closure of 
the triscupid valve may be retarded, the synchronism 
destroyed, and reduplication of the first sound thus pro- 
duced. The first sound is reduplicated at the end of 
expiration and beginning of inspiration, the second at 
the end of inspiration and the beginning of expiration. 
The same and similar conditions operate to produce 
reduplication of the heart-sounds in disease. 
The intensity of the heart-sounds is greater in per- 
sons with thin chest-walls and under the influence of 
excitement. Abnormally the feverish state and general 
hypertrophy have the same effect, but the latter is more 
apt to influence the sound of the particular cavity which 
is hypertrophied. The heart-sounds are often heard 
with unusual distinctness at points distant from their 
normal areas because of consolidation of adjacent lung, 
and sometimes inexplicably. Intensification or accentua- 
tion, as it is called, of the aortic or pulmonary element 
of the second sound is caused by whatever produces in- 
creased tension in the arterial or pulmonary circulations. 
Heart-sounds are also sometimes made ringing by their 
proximity to a cavity with firm walls or even a tensely 
distended stomach. 
Abnormally, heart-sounds are rendered less intense by 
general and cardiac weakness, fatty degeneration of the 
myocardium, pericardial and pleural effusions, and 
emphysematous lungs, which cover up the heart more 
completely. 
Abnormal Heart-Sounds or Murmurs are 
modifications of the normal sounds, either superadded to 122 
PHYSICAL DIAGNOSIS. 
them or altogether substituting them. These are pro- 
duced within the cavity of the heart, and are accord- 
ingly known as endocardial. In addition an altogether 
new sound is engendered external to the heart, and 
therefore called exocardial or pericardial. To this the 
term murmur is also applied, although the mechanism 
of its production is so widely different it does not seem 
to me desirable to perpetuate the practice. 
The endocardial sounds or heart murmurs are 
sounds produced by an alteration in the conditions of 
normal blood currents either by structural changes in 
the heart or its valves, or in the composition of the 
blood. 
The former are called organic murmurs, the latter 
functional or accidental.* Both are the result of 
vibrations or oscillations in the blood stream produced 
by the causes referred to, and not of a friction between 
the blood current and the narrowed orifices or inequal- 
ities on them. Hydraulic laws teach us that when a fluid 
passes through a tube the inner surface of which it wets, 
a thin film of fluid becomes attached to this surface, 
over which the remainder of the fluid moves without 
friction. So it is with the cardiac cavity and its valves 
over which the blood moves. Further, while a fluid is 
passing along a tube of uniform diameter at a moderate 
* The term inorganic is sometimes applied to the functional mur- 
murs, but this word has another meaning so definite, that of mineral, 
that it seems almost misleading to apply it in the sense referred to 
in the text. ABNORMAL MODIFICATIONS OF HEART-SOUNDS. 
123 
speed, no murmur results, whether the inner wall of the 
tube be smooth or rough. A murmur is only produced 
when the tube becomes suddenly narrower and then 
widens again, and the greater the narrowing the less 
speed of current required to produce the murmur. Thus 
the vibrations arise, and thus the sound is produced. 
In the case of functional murmurs which apparently 
occur without the intermediation of sudden narrowing, 
we must suppose such a change in the composition of 
the blood, either as to its density or viscidity, which 
permits it to be more readily thrown into vibration. In 
either event there is a derangement of that normal 
adaptation of the column of blood to the orifices and 
cavities through which it has to pass, which, under 
ordinary circumstances, permits the function of the 
heart to be performed noiselessly except so far as its 
normal sounds are concerned. In the case of the 
organic murmurs the alteration is produced by the 
various valvular defects to which the heart is subject, in 
that of the functional murmurs by the various anaemias 
which are principally associated with such murmurs. 
The true valvular murmurs may be intensified by con- 
ditions of the blood. 
It should be mentioned that Ernest Sansom considers 
that the vibration of solids is by far the most important 
in the generation of murmurs, the influence of fluids 
being intermediate, and not immediate.* 
*" Diagnosis of Diseases of Heart and Aorta." Philadelphia 
1892, p. 236. 124 
PHYSICAL DIAGNOSIS. 
ORGANIC MURMURS. 
An organic murmur may be produced at any one of 
the four cardiac orifices, mitral, tricuspid, aortic, or 
pulmonary. They are far more common at the mitral 
and aortic. 
Murmurs are also classified as systolic and diastolic. 
Systolic murmurs occur during the systole of the ven- 
tricles, diastolic murmurs during their diastole, and 
these alternate with the apex beat. A diastolic murmur 
which immediately precedes the systole is called a pre- 
systolic murmur. Murmurs are further classified as 
direct and indirect. Direct murmurs are those which 
arise in the blood current as it is flowing in the normal 
direction; indirect are those which arise in a current 
flowing opposite to the natural direction. The order in 
which murmurs are considered is of little importance. 
Their great frequency seems a sufficient reason for tak- 
ing up mitral murmurs first. 
Mitral Murmurs.-The mitral systolic or mitral in- 
direct murmur.-During the systole of the ventricles the 
auriculo-ventricular orifices in a perfect heart are closed 
in order to prevent the return of the blood to the 
auricles, while the aortic and pulmonary orifices are 
wide open to carry the blood into these great vessels, 
and the ear placed at the apex hears mainly the first 
sound. If, however, there be a defect in the mitral 
valve as the result of which it closes imperfectly, then, 
during the systole a stream of blood will flow back- 
ward into the left auricle accompanied by a murmur. ORGANIC MURMURS. 
125 
This is the mitral systolic murmur, and it means incom- 
petency or insufficiency of the valve with consequent 
regurgitation of blood. The mitral systolic murmurs 
are almost invariably best heard in the mitral area at the 
apex, and are conducted into the left axilla and under 
the angle of the left scapula. Rarely, however, they 
are heard just to the left of the pulmonary area, prob- 
ably because the vibrations are conducted into the 
appendage of the auricle and are best heard where 
this approaches nearest the surface, namely, an inch 
and a-half to the left of the pulmonary area. This 
occurs more frequently, too, with functional murmurs. 
Mitral diastolic and pre systolic murmurs, or mitral 
direct murmurs.-During the diastole of the ventricles 
the aortic orifice is closed and the mitral orifice open, 
and the blood flows noiselessly into the left ventricle, 
the filling of which is finally completed by the systole 
of the auricle. If, however, the mitral orifice be nar- 
rowed from any cause, the blood column is thrown into 
vibration and a murmur results-a diastolic murmur. 
When, as frequently happens, the narrowing or stenosis 
is not sufficient to cause a murmur throughout the entire 
diastole, but only when the additional momentum is 
given to the blood by the systole of the auricle, a mur- 
mur occurs only at this time-that is, just before the 
systole commences. It is then called presystolic. These 
murmurs mean, therefore, mitral stenosis, which is, 
however, generally associated with incompetency of the 
mitral valve. The systolic mitral murmur is, for the 
most part, soft, but may have every variety of character 126 
PHYSICAL DIAGNOSIS. 
and be high pitched or low pitched, but the presystolic 
is always rough, and is variously characterized as rat- 
tling, rolling, churning, grinding, blubbering, and 
bubbling, being compared to the vibration by the 
lips caused by blowing the breath through them. 
The sound is further characterized by its abrupt 
termination, although this is not invariable. It may 
also disappear for a time or even altogether. A 
presystolic thrill, felt at the apex of the heart, often 
accompanies the murmur. These murmurs are best 
heard in the mitral area, and are not, as a rule, conducted 
thence in any direction. In Dr. Sansom's experience 
the murmur is heard rather to the right of the apex. 
A diastolic murmur heard in the mitral area may also 
be due to aortic regurgitation, the sound being con- 
ducted from the seat of its production to the apex; but 
the greatest difficulty in the recognition of the presys- 
tolic murmur is its separation from a systolic mitral 
murmur, a difficulty which is increased in mitral stenosis 
because in this condition the first sound is usually short, 
resembling the second. The point, therefore, is to get 
the exact time of the murmur by noting carefully in 
association with it the apex beat or the carotid pulse, 
not the radial, because the latter is often not synchron- 
ous with the systole of the ventricles. 
Aortic Murmurs.-Aortic systolic or aortic direct 
murmur.-During the systole of the ventricles in health, 
the aortic orifice is wide open, and the blood flows 
noiselessly through it. If any interference with the 
complete opening of the orifice, or roughness or inequal- ities exist, the stream of blood is thrown into vibration, 
and the aortic systolic murmur results, heard at the base 
of the heart. Such a murmur, therefore, means nar- 
rowing or stenosis of the aortic orifice or roughen- 
ing only of the beginning of the aorta. It is generally 
loud and harsh, sometimes musical, heard most loudly 
in the aortic area-second right interspace-but gener- 
ally all over the praecordium. It is conducted into the 
great vessels of the neck with great intensity. 
Aortic diastolic or aortic indirect murmur.-During 
diastole the aortic orifice should be closed and imper- 
meable to blood. If, however, as the result of disease, 
perfect closure be impossible, a stream of blood will flow 
backward into the left ventricle, accompanied by a 
murmur at the base of the heart which is the aortic 
diastolic, and means always insufficiency or incom- 
petency of the aortic valve. This murmur is gener- 
ally soft, long, and blowing, and varies more in the seat 
of its intensity than any other cardiac murmur. Gener- 
ally loudest in the aortic area, but often louder than this 
over the midsternum, it is even well heard as low as the 
ensiform cartilage, or at the apex itself. It has been 
mistaken in this situation for a presystolic mitral mur- 
mur. It is also transmitted downward along the 
sternum and toward the apex, because it is in this direc- 
tion that the column of regurgitant blood is moving. 
It is accompanied by a powerful heaving impulse, and 
the characteristic trip-hammer or Corrigan pulse, char- 
acterized by its rapid rise and sudden fall. It also oc- 
curs alone, but is frequently associated with the aortic 
ORGANIC MURMURS. 
127 128 
PHYSICAL DIAGNOSIS. 
systolic murmur, indicating stenosis as well as incompe- 
tency. 
Murmurs in the Right Side of the Heart.-The 
same conditions at the valve orifices on the right side of 
the heart produce similar murmurs, but they are very 
much rarer. Thus tricuspid regurgitation produces 
the tricuspid systolic murmur, and tricuspid stenosis 
produces the tricuspid presystolic murmur. These are 
heard in the tricuspid area at the lower part of the ster- 
num, at its junction with the fifth and sixth cartilage. 
Tricuspid regurgitation is apt to occur sooner or later in 
connection with mitral disease, but independent of mitral 
diseases it is very rare, being generally congenital. See, 
however, p. 157. Pulmonary stenosis scarcely oc- 
curring, except congenitally, produces the pulmonary 
systolic murmur, and pulmonary regurgitation, the 
rarest of all, would produce a diastolic murmur. Both 
are heard in the pulmonary area at th'e second inter- 
space, at the left edge of the sternum. 
Impurity of Heart-Sounds.-In addition to the 
easily recognizable abnormal sounds described, there 
occur more or less marked modifications of the normal 
sounds due to slight defects of the valves, which render 
them less typical, whence the term impurity of heart- 
sound. They may be caused by slight thickenings or 
other changes which modify the normal closure of the 
valves, and are of uncertain significance. On the other 
hand, very decided alterations in the valves and orifices 
are sometimes found at the necropsy when no modifica- 
tions of the normal sounds were detectable during life. ORGANIC MURMURS. 
129 
The Exocardial or Friction Sound.-The only 
true exocardial murmur is the pericardial friction 
sound caused by rubbing of the two surfaces of the peri- 
cardium upon each other, in health a noiseless act like 
that of the pleural surfaces. When roughened, however, 
by disease a to-and-fro sound of varying loudness and 
harshness is heard. The most frequent cause is peri- 
carditis, but any cause which roughens the two opposite 
surfaces, such as tubercular and other morbid growths, 
will produce a friction sound. 
The friction sound sometimes resembles the intracar- 
dial murmur, but a little experience enables one to dis- 
tinguish them. The friction sound is a superficial to- 
and-fro sound heard directly under the ear, commonly 
loud and rasping, never blowing, sometimes creaking. 
It is most loud over the middle of the heart, not syn- 
chronous with the normal heart-sounds and not con- 
ducted in the direction of the blood-current. It is often 
influenced by changes of position or by breathing. It 
may sometimes be felt by the hand placed over the 
heart. It is generally of short duration and disappears 
with the filling of the pericardium by effusion. 
A friction may be pleuro-pericardial, that is, given a 
local pleurisy, the pericardium in its motion over the 
rough surface of the pleura may produce a friction 
sound simulating pericardial, but such friction ceases 
with the complete holding of the breath. 
Cardio-respiratory murmurs are systolic mur- 
murs heard at the end of a full inspiration, and are 
caused by the heart's impulse forcing with its contrac- PHYSICAL DIAGNOSIS. 
130 
tion the air out of some adjacent air vesicles, or possibly 
even a cavity. The sound resembles a soft systolic 
murmur, but ceases when the breath is held in expira- 
tion. Similarly caused are pulsating crepitations. 
FUNCTIONAL, OR ACCIDENTAL, OR H7EMIC 
MURMURS. 
These are murmurs usually supposed to arise indepen- 
dently of any abnormality in the state of the cardiac 
valves or orifices. They have certain characters by which 
they are commonly distinguished from organic murmurs, 
although such distinction is not always easy. i. They 
are invariably systolic. 2. They are almost always soft 
and blowing, and greatly influenced by posture, being 
more pronounced in the recumbent position than in the 
upright, although this relation is sometimes reversed. 3. 
They are most frequently basic, and far more commonly 
pulmonary than aortic, but occasionally they are heard 
at the apex. 4. Functional murmurs are unattended by 
the unequal distribution of blood and the alteration in 
the size of the heart and its cavities, which always, 
sooner or later, accompany the organic murmurs. 
They have heretofore been regarded as due to some 
condition of the blood, as the result of which its parti- 
cles are thrown into vibration more readily than in 
health. Hence they are also called haemic murmurs. 
Such condition is generally accompanied by a watery 
state of the blood ; for this reason they are also called 
anaemic murmurs, being especially frequent in anaemia FUNCTIONAL, ACCIDENTAL, OR H7EMIC MURMURS. 
131 
and chlorosis, and in women immediately after child- 
birth. Whether it be this thinness of the blood which 
is responsible for the murmur, or some accompaniment 
of such a state is not known. These murmurs also 
occur in connection with various morbid states of 
the blood, such as that of the infectious fevers, 
leucocythsemia, chlorosis, and the various anaemias; 
also in certain neuroses, especially Graves' disease 
and allied affections. In these latter there are also 
arterial murmurs, which are ascribed to vaso-motor in- 
fluences producing inequalities of caliber, which engen- 
der murmurs. From these facts Sansom reasons to a 
similar origin of the murmurs in the great vessels in 
neuroses and anaemia. The ventricle, weakened by im- 
paired nerve force, toils to overcome an unusual resist- 
ance in the great vessels due to tension, and the muscu- 
lar fibrillae of the conus just below the valves are 
thrown into tremor. The valves themselves may vi- 
brate, and these vibrations are communicated to the 
area of the thorax adjacent to these vessels through 
the portions of the vessels immediately above the valves. 
The right ventricle and its conus are more superficial, 
its muscular walls are thinner, and in the conditions 
named it has to contend against relatively greater ob- 
struction, hence murmurs at its site are more frequent. 
Certain systolic murmurs at the apex, associated with 
anaemia and neuroses, but unaccompanied by valve 
lesions, Sansom ascribes to an actual mitral regurgita- 
tion, the result of weakness of the muscles concerned in 
closure of the mitral orifice. Other explanations than 132 
PHYSICAL DIAGNOSIS. 
theseare as signed by various authors, for information as 
to which the student is referred to Sansom's recent 
work on " Diseases of the Heart and Thoracic Aorta." I 
will only add that Balfour, for one, holds that the pulmon- 
ary murmur is not an arterial, but an auricular murmur. 
VASCULAR MURMURS. 
In the examination of arteries the stethoscope is ap- 
plied-for the carotid, at the insertion of the sterno- 
cleido mastoid muscle into the clavicle and sternum, 
and carried upward along the anterior edge of the muscle; 
for the subclavian, behind the clavicular insertion of the 
sterno-cleido mastoid muscle, the arm being dependent; 
for the brachial, on the inner border of the biceps at 
the bend of the elbow, with the arm partially flexed, 
and for the crural, in the popliteal space. Care should 
be taken to apply the stethoscope very lightly, as the 
pressure itself will engender a sound which is called the 
acoustic pressure murmur. This may be made self- 
audible at almost any time with sufficiently quiet sur- 
roundings by pressing upon the artery in front of the ear. 
Normal Arterial Murmurs. - Considering the 
apparent simplicity of the matter, there is a singular 
discrepancy in the statements concerning the so-called 
normal arterial murmurs. I am inclined to agree with 
W. Russell, who says no murmur originates in the 
great vessels of the neck in health, unless it be as the 
result of undue pressure with the stethoscope. On the 
other hand, there can be no doubt that two sounds are VASCULAR MURMURS. 
133 
commonly heard on such auscultation. My own obser- 
vations go to show the following : If a stethoscope be 
thus lightly placed over the carotid or subclavian arte- 
ries, so as not to compress the vessels, two sounds are 
heard with each movement of the heart-one corre- 
sponding to the systole of the ventricles and the expan- 
sion of the arteries, the other to the diastole of the heart 
and the contracting recoil of the arteries. The longer 
and louder is the second or aortic heart sound, con- 
ducted from the site of its production, the aortic valves. 
The second, shorter and fainter, is the first sound of the 
heart, similarly conducted. The first of these sounds is 
occasionally heard in the abdominal aorta, more rarely 
in the brachial and femoral. The second sound is not 
thus conducted. 
Abnormal Arterial Murmurs.-Abnormal sounds 
are conducted into the arteries in valvular disease of the 
heart, particularly aortic disease, both obstructive and 
regurgitant, and rarely also in mitral disease. The 
systolic murmur of aortic stenosis is that pre-eminently 
conducted into the great vessels of the neck. 
Finally, murmurs may arise in the arteries themselves 
from any causes which produce a change in the diam- 
eter of the vessel, such as aneurismal dilatation, con- 
genital narrowing, or narrowing due to thrombi or to 
compression caused by adhesions, contraction of cica- 
tricial tissue, morbid growths or inflammatory infiltra- 
tion, or the pregnant uterus. Thus a murmur may 
occur in a branch of the pulmonary artery from press- 
ure by a tubercular deposit or pneumonic infiltration 134 
PHYSICAL DIAGNOSIS. 
or enlarged bronchial gland, and a murmur may even 
be produced in the subclavian artery by a tubercular 
deposit at the left apex. A murmur in a branch of the 
pulmonary artery from such cause is intensified during 
expiration, while a murmur in the left subclavian from 
the same cause is said to be intensified by holding the 
breath at inspiration. Thyroid tumors in the neck also 
produce arterial murmurs by pressure. The placental 
murmur is a mixed venous and arterial murmur. 
Venous murmurs are distinguished from arterial 
murmurs by their continuousness as contrasted with the 
intermittent arterial murmur. An acoustic pressure 
murmur may be produced in any vein which is large 
enough, as the jugular and femoral, by pressing slightly 
upon it with the stethoscope, without, however, pressing 
so hard as to obliterate the blood current. 
Murmurs independent of such pressure are sometimes 
heard in these large veins, including the femoral, as 
the result of tricuspid regurgitation, but the principal 
pathological venous murmur is the venous hum or 
bruit de diable. It is compared to the sound heard 
on placing a sea shell of moderately large size against 
the ear. It is frequently heard in chlorotic females over 
the bulb or dilatation of the internal jugular vein ; also 
sometimes in the large intra-thoracic trunks, the superior 
cava, and the innominata. It is best heard on the right 
side by turning the head as far as possible to the left and 
then placing the stethoscope above the right clavicle 
behind the sterno-cleido mastoid muscie. It is a con- 
tinuous soft murmur resembling the humming of a THE SPHYGMOGRAPH IN DIAGNOSIS. 
135 
top, and by its continuousness can be readily distin- 
guished from an intermittent arterial murmur. This 
murmur cannot be regarded as always abnormal, since 
it is often heard in healthy individuals. Thus Winterich 
found it in 80 per cent, of the Bavarian cuirassiers whom 
he examined. It is much more frequent in women than 
men in the proportion of 7 to 1, according to Aran. 
Extreme loudness may be regarded as an indication of 
abnormality. Its presence may especially be regarded 
as corroborative. 
THE SPHYGMOGRAPH IN DIAGNOSIS. 
Whatever the diagnostic value of the sphygmographic 
tracing in valvular heart disease, and it is sometimes con- 
siderable, no study of a case of such disease is complete 
without it. While the original sphygmograph of 
Marey probably furnishes as good a tracing as any 
of the modern instruments, the latter have the ad- 
vantage of cheapness. That of Dudgeon is the most 
popular at the present day, especially Richardson's 
modification with sphygmometric attachment. Direc- 
tions for its use and the preparation of suitable paper 
always accompany the instrument. Space need not 
therefore be occupied by them. By means of the sphyg- 
mometer varying degrees of tension may be measured 
before the tracing is made. In the pulse of low tension 
the maximum movement of the lever is attained with 
slight degrees of pressure, and small increase of the 
same tends to extinguish the tracing. In pulses of high 136 
PHYSICAL DIAGNOSIS. 
tension the maximum excursion of the lever is brought 
only by rather strong pressure, and the strongest pres- 
sure will not extinguish the tracing. 
The Normal Pulse Tracing.-This is shown in 
the drawing. It consists, first, of a vertical or almost 
vertical upstroke, a b, a sudden oblique fall, soon in- 
terrupted by a notch, c, followed by a short rise to d, 
another fall, a second notch, e, and another rise to /, 
Fig. si. 
Normal Sphygmogram Enlarged, a b. Percussion upstroke, a b c. Percus- 
sion wave. c d e. Tidal or predicrotic wave. efa. Dicrotic wave. def. 
Aortic notch, f a. Diastolic notch. (Sansom.) 
followed by an undulating fall to the base line of the 
sphygmogram. The anacrotic or upstroke, or percussion 
stroke, as it is also called, is the effect of the sudden 
dilatation* of the artery upon the lever, which, having 
* It is held by Broadbent that no actual increase of the lumen of 
the artery takes place in the formation of the pulse, but that with the 
filling of the vessel it simply changes from the oval to the circular 
shape. This seems, however, to be an error, as an actual increase 
in diameter is easily demonstrable by suitable instruments. THE SPHYGMOGRAPH IN DIAGNOSIS. 
137 
reached its maximum height, falls to rise again and form 
the so-called tidal or predicrotic wave, c d e. This wave 
is still a part of the effect of the distending force of the 
vessel on the lever, which through its inertia is carried 
too high, then falls, and is again caught by the still 
dilating vessel and carried to d. Thus these two waves 
are really but one. The vessel now begins to collapse and 
the lever to fall with it, but soon rises again to form 
the curve, e f a, called the normal dicrotic wave, while 
the notch immediately before it is the aortic or predi- 
crotic notch. The dicrotic wave is the result of a 
second rise of the vessel wall due to the elastic recoil 
of the over-dilated aorta on the contained blood, which, 
being prevented from going backward by the closed aortic 
valves, moves forward, producing the dicrotic wave. The 
second sound of the heart is found to coincide exactly 
with the predicrotic notch, d e f. Subsequent slight 
waves, which may or may not be present, are ascribed 
to vibrations due to the elasticity of the vessel. The 
further the vessel tested is from the heart, the greater is 
the distance as a rule between the dicrotic and the 
predicrotic wave. The pulse wave reaches the more 
distant parts of the arterial system at successive inter- 
vals. 
The effect of increased pressure of the button of the 
sphygmograph on the artery is to shorten the first or 
percussion wave, and to render the dicrotic wave more 
distinct, also the smaller vibrations in the down stroke. 
Apart from this, the altitude of the percussion stroke 
depends upon the quantity of blood thrown from the 138 
PHYSICAL DIAGNOSIS. 
ventricle, but is more or less peculiar to the individual, 
and its smallness in one as compared with another does 
not necessarily imply that such person has an abnorm- 
ality in his circulatory apparatus, while the tracings, 
even in the two radials, of a person perfectly healthy 
may not be identical, because of difficulty in applying 
the instrument in precisely the same manner, or of ana- 
tomical differences on the two sides, making such applica- 
tion impossible. The special features of the sphygmo- 
gram in different cardiac affections will be given in con- 
nection with these. 
Fig. 22. 
Sphygmogram showing Prolonged Arterial Tension. (Sansom.') 
Two modifications of the normal sphygmogram 
require, however, special allusion, since they are the 
consequences of a variety of morbid states. They are 
the sphygmogram of high arterial tension, or, as Dr. 
Sansom prefers to call it, prolonged arterial tension, 
and low arterial tension. 
Prolonged arterial tension is a condition in 
which the pressure in the interior of a blood-vessel is 
unduly prolonged. The effect on the tracing is, in a 
word, to broaden the top of the primary curve, as shown 
in the accompanying sphygmogram. 
In some instances the ascending limb of the sphyg- 
mogram is broken into two, as shown in Fig. 22. THE SPHYGMOGRAPH IN DIAGNOSIS. 
139 
Such a pulse is called an anacrotic pulse. 
The pulse of prolonged arterial tension is produced 
by any cause of resistance to the motion of the blood 
through the capillaries and arterioles, and such causes 
are numerous. Chronic renal disease, especially inter- 
stitial nephritis, is one of them ; so are gout, lead poison- 
ing, constipation, atheroma of the arterial walls, and 
even anaemia. The anacrotic pulse is also produced in 
aortic stenosis, where it has diagnostic value. 
Fig. 23. 
Anacrotic Pulse-curves from the Radial Artery. (Landois and Stirling.') 
Low arterial tension is the reverse of prolonged 
arterial tension. Instead of the filled state of the vessel 
being maintained, the fulness is of short duration and the 
wall drops away at once. Such a pulse is easily oblit- 
erated by pressure, while the pulse of high tension is 
difficult to obliterate. As to the sphygmographic trac- 
ing, the up stroke is vertical, the apex angle is acute, 
the tidal wave is insignificant, while the dicrotic wave is 
the most conspicuous feature of the tracing. Fig. 24 
furnishes a marked example of such a tracing, in which 
the first wave of the down stroke is the dicrotic wave, 
the tidal wave being wanting. 140 
PHYSICAL DIAGNOSIS. 
Dicrotism in pulse of low tension may even exceed 
that indicated in the sphygmogram. Thus it may 
spring from the level of the base line, when it is called 
full dicrotic, or it may start from below the base line, 
when it is called hyperdicrotic, or even be in the ascending 
line of the succeeding trace, when it is called monocrotic. 
The pulse of low tension may be produced artificially 
by the administration of nitroglycerin or the applica- 
Fig. 24. 
Tracing of PuLe of Aortic Regurgitation. (Siriim/ell.) 
tion of heat to the surface of the body, as by the warm 
bath, the conditions being suddenness of cardiac im- 
pulse and absence of resistance to the onward move- 
ment of the blood; it is very characteristic of aortic 
regurgitation, of collapsed conditions, such as are the 
result of depressing emotions and colliquative discharges 
like diarrhea and copious diuresis. It is also found 
in fever of which the dicrotic pulse is more or less 
characteristic. Abnormal dicrotism is not, however, THE CARDIOGRAPH IN DIAGNOSIS. 
141 
confined to low tension. It varies within the limits of 
health, and occurs at times in connection with high 
tension, as shown by Roy and Adami, where there is a 
sharp, sudden systole of the ventricle leading to a cor- 
responding sharp and energetic rebound or reactionary 
wave, as shown in Fig. 25. 
Erroneous interpretations of such dicrotism may be 
avoided by increasing the pressure of the sphygmograph 
when, if the tension is low, the tracing is obliterated, 
Fig. 25. 
Tracing from Case of Prolonged Arterial Tension, showing Dicrotic Wave. 
(Sansom.) 
while if it is high the first wave becomes broadened and 
the dicrotism less. 
THE CARDIOGRAPH IN DIAGNOSIS. 
The cardiograph does not furnish as valuable assistance 
to diagnosis as the sphygmograph, chiefly because of 
the difficulty in getting typical tracings. Tracings are 
usually taken from the site of the apex, although they 
may also be obtained from the various chambers of the 
heart in a large animal like the horse by introducing an 
elastic bag and attached tube into the right cavities 
through an opening in the jugular vein, and into the 
left cavities through an incision in the carotid artery, con- 
necting each bag and tube with a Marey's tambour and 142 
physical diagnosis: 
thence to a revolving drum. Any pulsating part of the 
heart, as the left auricle, may be brought into connection 
with the cardiograph and a tracing therefrom secured, 
while without an appreciable impulse a tracing is impos- 
sible even at the apex. Appended are a number of 
normal apex tracings in which a represents the auricular 
systole, the ascent, a d, the contraction of the ventricle, 
def the continued systole, k the effect of the first 
Fig. 26. 
Normal Cardiac Apex Tracing. (Galabin.') 
sudden entrance of blood into the ventricles, Z the 
gradual ascent from the gradually increasing flow of 
blood into the ventricles during diastole, and a d 
again the systole of the ventricles. The notch, def, 
is constant, the height of the primary elevation being 
exaggerated by the velocity of the needle in the instru- 
ment employed. 
Considerable variation takes place in the apex cardi- 
ogram as the result of varying pressure, while partial 
and even complete inversion of the tracing may occur, THE CARDIOGRAPH IN DIAGNOSIS. 
143 
whence another source of difficulty in the way of clin- 
ical availability of the cardiograph, for it cannot be 
relied upon to express accurately the direction of the 
different events of the cardiac action. 
The position of the sounds of the heart in relation to 
points in the apex trace have, however, been deter- 
mined with some approach to accuracy. Thus the 
first sound, as determined by its muscular element, 
is regarded as commencing with the first ascent of the 
lever, and continuing until the termination of the 
rounded shoulder, f at which the muscle of the ven- 
tricular wall relaxes. So far as concerns the factor of 
valvular tension, the position of the first sound must be 
assigned to a point near the summit of the up stroke, 
where the sudden contraction of the papillary muscles 
begins, continuing to the beginning of the rounded 
shoulder f, where this contraction ceases, the muscle of 
the ventricular wall remaining still contracted. 
The second sound occurs somewhere between the 
shoulder, f, and the lower extremity of the descending 
line succeeding it. 
In the apex cardiogram of the normal heart-beat the 
systole is decidedly shorter than the diastole, occupy- 
ing two-fifths as compared with three-fifths. As the 
rate of the pulse increases the diastolic interval short- 
ens, until the systole and diastole become equal, 
although precise measurement of the absolute devia- 
tions of these phases by the cardiograph is as yet 
impossible. Their relative duration may, however, be 
thus measured, as may also be the force of the ventricu- 144 
PHYSICAL DIAGNOSIS. 
lar contraction by the height of the upstroke. The 
breadth of the summit of the trace measures the dura- 
tion of the systole and increases with hypertrophy of 
the ventricles. 
In abnormal states the diastolic portion of the 
tracing is (i) relatively diminished or (2) relatively 
increased. 
1. It is relatively diminished- 
(fl.) In hypertrophy. 
(£.) Where in addition to hypertrophy conditions exist 
in which the ventricle becomes too rapidly filled. 
This occurs in aortic regurgitation and in mitral 
regurgitation when there is hypertrophy of the left 
auricle ; also in the two conditions combined. 
2. The diastolic portion of the tracing is relatively 
increased- 
(a.) When the heart's action becomes slow, the differ- 
ence between a frequent pulse and a slow pulse be- 
ing chiefly in the length of the diastole. 
(z5.) Dilatation of the left ventricle, the conditions be- 
ing the opposite of those of hypertrophy. Herein 
we have one of the most valuable diagnostic 
uses of the cardiograph. It is not always easy by 
other clinical means to inform ourselves when this 
serious change has taken place which involves a 
loss of compensations. The cardiograph enables 
us to do so. 
(r.) In mitral stenosis, where the diastolic interval is 
often markedly prolonged, while at other times it 
is found to vary greatly in duration, two systoles THE CARDIOGRAPH IN DIAGNOSIS. 
145 
occurring without an appreciable diastolic interval, 
while between two others there may be a prolonged 
interval. Much more characteristic, according to 
Sansom, who has devoted much study to this sub- 
ject, are the number of vibrations in the diastolic 
part of the trace. " In fact," says Sansom, * " the 
vibrations which are heard by the ear as murmurs, 
or felt by the finger as thrills, may be written on the 
smoked paper by the needle of the cardiograph." 
Many other clinical facts of interest and impor- 
tance may be studied to advantage by the cardio- 
graph, but I must refer the student to the larger 
works for their consideration. 
* Lettsomian Lectures on " Valvular Diseases of the Heart," 1886. 146 
PHYSICAL DIAGNOSIS. 
PHYSICAL SIGNS OF THE DIFFERENT 
FORMS OF VALVULAR DISEASE. 
MITRAL INSUFFICIENCY. 
This is the most frequent of the uncombined forms of 
valvular disease. The valve leaks, the blood flows back- 
ward during systole from the left ventricle to the left 
auricle. The auricle first attempting to resist the back- 
ward flow hypertrophies slightly, but eventually dilates, 
and the blood is crowded backward into the lungs, 
which become engorged. The right ventricle, in its 
efforts to push the blood through the engorged lungs, 
hypertrophies, and the pulmonary factor of the second 
becomes louder and sharply accentuated. The compen- 
sating effect of the hypertrophied right ventricle for a 
time arrests the mischief. At this stage, perhaps, begins 
the hypertrophy of the left ventricle, which in all cases 
of mitral insufficiency presents itself sooner or later, 
although at first the double outlet for the blood from 
the ventricle would seem to demand less strength of the 
left ventricle. The right ventricle, however, in its 
hypertrophied state, delivers more blood to the left 
ventricle, which demands more power to drive it on, 
hypertrophy results, and thus compensation is a while 
longer maintained. Sooner or later the tricuspid valve 
becomes insufficient, the blood regurgitates into the 
right auricle, and thence into the great veins of the neck. 
The valves of these ultimately yield, the jugular pulse 
appears, and the general venous system is engorged. MITRAL INSUFFICIENCY. 
147 
In this engorgement the liver, stomach, and kidneys 
share. Then comes transudation, dropsy, albuminuria. 
Among the later phenomena in extreme cases are an 
enlarged, tender, and pulsating liver, a symptom 
which is pathognomonic of tricuspid regurgitation, 
but a liver lifted by some pulsating agency behind 
it must not be confounded with the true pulsating 
liver. More frequently the liver is visibly enlarged 
and tender without visible pulsation. Such enlarge- 
ment disappears in part after death, and is not notice- 
able at the necropsy. 
Inspection discovers the apex-beat to the left of its 
normal position and perhaps a little lower down. It 
may be in the line of the nipple or even beyond it, and 
more forcible and diffuse than in health. The outward 
dislocation of the apex-beat is due to the enlargement 
of the two ventricles. An auricular impulse may be 
present to the left of the pulmonic area in the second 
interspace, and may be presystolic and active for the 
auricle, or systolic and passive for the auricle. A bulg- 
ing praecordium may be looked for in young persons, 
and in advanced stages also a jugular pulse. 
On palpation the apex-beat is found more forcible than 
normal, and there may be a pulsation near the ensiform 
cartilage caused by the systole of the enlarged right 
ventricle. Sometimes an intermittent systolic thrill is 
felt in the fourth interspace in the left mammillary line. 
The radial pulse in the early stages is comparatively 
unaltered. Later it becomes frequent and irregular in 
volume. Appended, Fig. 27, is a sphygmogram of the 148 
PHYSICAL DIAGNOSIS. 
pulse in advanced mitral insufficiency. It is of the type 
of the pulsus parvus irregularis. 
Percussion discovers enlargement of both the relative 
and absolute areas of dulness, upward in the direction 
of the left auricle, downward to the left and also to the 
right, the right border of the heart reaching at times 
the right border of the sternum. 
Auscultation recognizes a systolic murmur in the mitral 
area, conducted with various degrees of loudness 
into the left axilla and under the angle of the scapula. 
This direction of its conduction is the distinctive feature 
Fig. 27. 
Tracing of Pulse of Mitral Insufficiency. (Da Costa.) 
of this murmur. It is usually soft, but occasionally 
rough, more rarely musical. It is also sometimes well 
heard to the left of the pulmonary cartilage, and rarely 
over the entire praecordium. Not always loud enough 
to be easily heard, it may be brought out by exertion on 
the part of the patient. 
The second sound of the heart is sharply accentuated 
at the pulmonary interspace until the tricuspid valve 
fails, when the accentuation vanishes. The aortic second 
sound is less strong, corresponding with the less degree 
of hypertrophy of the left ventricle. MITRAL STENOSIS. 
149 
This lesion occurs as an uncombined or simple form of 
valvular disease in young persons, especially women, but 
is very much more commonly combined with regurgita- 
tion. The orifice is stenosed and the blood is restrained 
from passing freely into the left ventricle. The same 
backward effect is produced upon the left auricle, the 
lungs, the right ventricle, and general venous circulation, 
as in mitral regurgitation, but the left ventricle is not 
hypertrophied in simple mitral obstruction, because no 
extra muscular effort is called for, while hypertrophy of 
the left auricle is one of the most characteristic signs of 
mitral stenosis. Theoretically, the left ventricle should 
even atrophy, but the absence of the enlargement is of 
great diagnostic value. 
Inspection, consistently with what would be expected 
in absence of hypertrophy of the left ventricle, recog- 
nizes little or no displacement of the apex. If there 
is any it is due to the hypertrophy of the right ventricle. 
Nor is the apex-beat increased in force. A left auricu- 
lar impulse, pre systolic, may be noted for the same 
reason as in mitral regurgitation, as may also a jugular 
impulse. The bulging praecordium occurs under like 
conditions as in mitral regurgitation, but is not often 
seen. 
Palpation discerns that the apex-beat is without undue 
force, but it may be diffuse, and an impulse may be felt 
in the situation of the apex of the right ventricle. The 
most marked feature of palpation when present is the 
MITRAL STENOSIS. 150 
PHYSICAL DIAGNOSIS. 
presystolic thrill at the apex. It is similar in rhythm 
to the presystolic murmur, but may be present without 
it, and is not always present. 
In moderate degrees of stenosis the pulse is not 
altered; in high degrees it is very small, from want of 
left ventricular power; also irregular, like that of mitral 
regurgitations. Two tracings from cases of mitral sten- 
osis are introduced in the text. 
Percussion recognizes cardiac enlargement in the 
Fig. 28. 
Tracings of Pulse in Mitral Stenosis. 
direction of the left auricle and right ventricle, but not 
of the left ventricle. 
Auscultation does not discover a murmur in every case 
of mitral stenosis, because of the feebleness of the auricu- 
lar contraction, especially at the beginning. Most char- 
acteristic is the abruptly terminating presystolic murmur 
described on p. 125, confined for the most part to the 
mitral area, though it may be conveyed upward, and it is 
even heard posteriorly, though rarely. Dr. Sansom 
places it rather at the right of the apex. MITRAL STENOSIS. 
151 
Accentuation of the second sound is marked, but 
confined to the pulmonary area, because there is no 
hypertrophy of the left ventricle. The second sound 
may also be duplicated, because of the want of syn- 
chronousness in the closure of the aorta and the 
pulmonary valves. Dr. Sansom regards this reduplica- 
tion as a seeming one only of the second sound. He 
regards it rather as the normal second sound followed 
by another sound due to a sudden tension of the mitral 
valve itself. He also says it occurs in at least a third of 
all cases of mitral stenosis, and is rare in other cardiac 
conditions. 
The murmur of mitral stenosis is sometimes difficult 
to distinguish from that of aortic regurgitation, but in 
the latter there is enormous hypertrophy of the left ven- 
tricle, which is wanting in mitral stenosis. The time of 
tricuspid stenosis is identical with that of aortic regurgi- 
tation, but it is heard in a different part of the praecor- 
dium,-in the epigastrium. On account of these difficul- 
ties, while the presystolic murmur is a valuable sign of 
mitral stenosis, it should not be alone relied upon for 
diagnosis, but should be taken in connection with other 
signs. Tricuspid stenosis may be associated with mitral 
stenosis, or insufficiency, or both. See p. 125 for further 
characterization of the presystolic murmur. 
Dr. Sansom lays great stress in the evidence of the 
cardiograph in the diagnosis of mitral stenosis, which 
enables one to judge of the relative length of systole 
and diastole. In stenosis the interval between the 
systoles may be greatly prolonged or the diastolic inter- 152 
PHYSICAL DIAGNOSIS. 
vals vary greatly in duration. In mitral regurgitation, 
on the other hand, a short interval only separates the 
systoles. 
MITRAL INSUFFICIENCY AND STENOSIS. 
More frequently stenosis is associated with insuffi- 
ciency when we have the double mitral murmur, some- 
times with difficulty divisible into its two parts. Extreme 
irregularity of rhythm and pulse, with frequency and 
smallness of the latter, conspicuous thrill, marked right- 
sided hypertrophy, and sharply accentuated pulmonic 
sound are characteristic. 
AORTIC STENOSIS. 
This is a frequent form of valvular disease, and when 
uncombined with regurgitation the least dangerous. 
The aortic orifice is narrowed and prevents the free dis- 
charge of blood from the left ventricle into the aorta. 
The ventricle attempts to overcome this, and its walls 
hypertrophy in proportion to the degree of resistance, 
and often for a long time compensate for the obstruc- 
tion-until dilatation occurs, when the danger really 
begins. 
Inspection and palpation recognize a forcible apex-beat 
beyond the normal situation and at varying distances in 
accordance with the degree of hypertrophy, while pal- 
pation adds occasionally a purring basic thrill with each 
beat of the heart when dilated hypertrophy is estab- 
lished. A bulging of the praecordium is also present. AORTIC STENOSIS. 
153 
The pulse is the pulsus tardus, slow in reaching its 
maximum volume, which is small. It is frequent but 
regular, contracting in the latter respect with the pulse 
of mitral disease. Fig. 29 is a sphygmogram. 
Percussion elicits dulness downward and laterally to- 
ward the left, since, as a rule, the enlargement is confined 
to the left ventricle. There may, however, be enlarge- 
ment upward to the left of the sternum. 
Auscultation discloses a systolic basic murmur, loudest 
at the aortic area-second interspace at the right of the 
sternum-which is conducted distinctly into the ca- 
Fig. 29. 
Pulse Tracing of Aortic Stenosis. 
rotids, and even sometimes along the course of the 
aorta, behind and to the left of the vertebral column, 
into the popliteals and dorsal arteries of the feet. 
It is not, however, confined to this area, but may 
be heard over the entire praecordium. It is usually 
rough, but may be soft and musical. It is made louder 
by exercise. The aortic factor of the second sound is 
weak if the constriction be at all decided, because of 
the feeble recoil, a necessary result of the small amount 
of blood in the aorta. The first sound is normal and 
somewhat louder and more prolonged than natural, be- 
cause of the powerful contraction of the left ventricle. 
Roughness of the aorta due to atheroma, dilatation, 154 
PHYSICAL DIAGNOSIS. 
or narrowing of the vessels by pressure or otherwise, 
may also cause a systolic murmur, and so may rough- 
ness within the ventricle in the course of the outgoing 
column of blood ; but these causes have generally a less 
positive effect upon the substance of the heart. At the 
same time, one of the most important points to be re- 
membered in diagnosis is that an aortic systolic murmur 
by no means always indicates aortic stenosis. In like 
manner anaemic or haemic murmurs, which are always 
systolic and for the most part basic, may simulate aortic 
systolic murmurs, but these occur in young, delicate 
persons, of both sexes, and are often intermittent and 
without other effect on the circulation. There may be 
roughness, too, in the pulmonary artery which can be 
localized to the left of the sternum. 
AORTIC INSUFFICIENCY. 
The most serious and irremediable of the valvular 
diseases of the heart commonly met with ; less frequent 
than aortic stenosis, with which it often exists in com- 
bination, it is still not uncommon even uncombined. 
It is the lesion most frequently followed by sudden 
death. The aortic valves are incompetent and the 
blood flows backward into the left ventricle during 
diastole. The ventricle, seeking to restore the balance, 
redoubles its energy, hypertrophies. The blood is thus 
driven into the aorta with great force, swelling the 
arteries to extreme fulness, which, however, falls away 
promptly, because of the backward flow into the ventri- AORTIC INSUFFICIENCY. 
155 
cle at the same time with the forward movement into 
arteries and capillaries. This sudden falling away of 
the pulse, from extreme distention to collapse, is very 
characteristic of this form of valvular disease, and is 
called the "trip-hammer" or "water-hammer pulse," 
also Corrigan pulse. It may even be visible to the 
casual observer in the exposed arteries, such as the 
carotid, temporal, and radial, while the aortic beat, 
Fig. 30. 
Tracing ot Pulse ot Aortic Regurgitation. (Strilntpell.) 
ordinarily beyond reach in the supra-sternal notch, may 
sometimes be felt in this situation. The abrupt jerking 
impulse with sudden recoil is easily recognized by the 
finger, which, however, fails to find the pulse as strong 
and hard as would be expected from the appearance. 
On the other hand, it is soft and receding. A tracing 
of this pulse is found in Fig. 30. It is the typical 
pulsus celer. 
The tremendous systole of the ventricle may ulti- 156 
PHYSICAL DIAGNOSIS. 
mately force the mitral valve to yield, and compensa- 
tion to be gradually lost pari passu with a growing 
dilatation. To this succeed the phenomena of mitral 
regurgitation, including hypertrophy of the right ven- 
tricle, which again comes for a time to the rescue, but 
weakens with the giving away of the tricuspid valve. 
Inspection often discerns the praecordium prominent, 
with the apex-beat lowered and to the left, and the 
visible pulsation far beyond the normal situation of the 
apex, all confirmed by palpation, to which is also 
evident at times a systolic thrill over the carotids and sub- 
clavians, and sometimes in the aorta at the suprasternal 
notch. A capillary pulse is also sometimes demonstra- 
ble in the skin and mucous membrane. This maybe 
brought out by drawing a pencil lightly across the skin 
of the cheek or forehead, and on the mucous membrane 
of the averted lower lip, by pressing a glass microscopic 
slide against it, as suggested by F. C. Shattuck. 
Percussion discloses increased dulness to the left and 
downward, and also, sometimes, in advanced cases, up- 
ward to the left of the sternum, not from hypertrophy 
of the left auricle, but to enlargement of the ventricle 
upward. 
Auscultation recognizes a diastolic murmur, long and 
various in quality, but usually blowing and harsher than 
the aortic obstructive murmur. Its area of maximum 
intensity is commonly at the aortic interspace or mid- 
sternum, sometimes as low as the fourth left costal carti- 
lage, and even at the ensiform cartilage. Hence it may 
be mistaken for the mitral obstructive murmur and for TRICUSPID REGURGITATION. 
157 
the murmur of tricuspid disease, but both of these, be 
it remembered, is unaccompanied by hypertrophy of 
the left ventricle. The murmur is naturally transmitted 
downward toward the ensiform cartilage or along the 
left edge of the sternum, and toward the apex in the 
direction of the regurgitating column, but it is also 
heard in the direction of the great vessels of the neck, 
though less loudly than the aortic systolic murmur. 
This double lesion is a comparatively frequent one, 
indeed, commonly regarded as the next in frequency 
after mitral obstruction, and therefore more frequent 
than either aortic stenosis or aortic insufficiency alone. 
It occasions a double basic murmur, systolic and dias- 
tolic, and is also a grave condition giving rise to the 
same dangers as aortic regurgitation, and the same 
enormous hypertrophy of the left ventricle. 
AORTIC STENOSIS AND REGURGITATION. 
Tricuspid regurgitation as a primary condition is 
extremely rare, and when present is probably the result 
of an endocarditis during foetal life, endocarditis at this 
period being more prone to attack the right than the 
left side. Endocarditis involving the tricuspid may, 
however, occur in children also, according to Byrom 
Bramwell,* more commonly than has been supposed. 
TRICUSPID REGURGITATION. 
*Amer. Jour. Med. Sci.,K\>x., 1886, p. 419. 158 
PHYSICAL DIAGNOSIS. 
Infectious or mycotic endocarditis also affects the tricus- 
pid valve, according to Osler, in 19 out of 238 cases. 
More frequently tricuspid regurgitation is one of the ter- 
minal events of mitral disease, the tricuspid orifice yield- 
ing to the tension upon the right ventricle, consequent 
upon the resistance to the movement of the blood through 
the engorged lungs. It is associated with the dilatation 
of the right ventricle which succeeds upon its hypertro- 
phy if the patient live long enough. It is also one of the 
possible sequelae of emphysema of the lungs and long- 
standing fibroid phthisis. Its effects, depending upon 
the venous circulation, have already been detailed, p. 
146. 
In primary tricuspid disease with regurgitation, 
inspection and palpation note an apex beat diffused 
about the normal area toward the epigastrium, and per- 
cussion detects enlargement toward the right end of the 
sternum. 
To auscultation the systolic murmur thus engendered 
is invariably feeble and is heard almost solely in the tri- 
cuspid area, just above and to the left of the ensiform 
cartilage. Occasionally only is the second pulmonic 
sound accentuated. There should be no confounding of 
this murmur with that of aortic regurgitation conducted 
toward the same situation nor with that of mitral regur- 
gitation heard at no great distance, for the reasons named. 
To these must be added a difference in quality and pitch 
between the tricuspid and the mitral murmur. The 
jugular pulse is also more or less constantly associated 
with tricuspid regurgitation. The presence of the TRICUSPID STENOSIS. 
pulsating liver is almost pathognomonic. The jugular 
pulse is systolic in time and does not appear until the 
valves situated at the opening of the internal jugulars 
into the innominate veins yield. These give way first on 
the right side because the communication is more direct. 
It is sometimes not easy to distinguish a true jugular 
pulse from a false one, but pressure on the vein above 
the valves will cause the false pulse to disappear while 
the true pulse, coming from the right ventricle, will 
remain. 
159 
Tricuspid stenosis is a still more rare condition, but 
it may occur in connection with left-sided heart disease 
as the result of rheumatic endocarditis and unknown 
causes. As in endocarditis of the right side, there is 
thickening, adhesion, narrowing. These cases are 
regarded as most frequently acquired, not congenital, 
although the diagnosis is seldom made because the 
murmur is masked by the coincident mitral systolic 
murmur. 
Tricuspid obstruction without coincident mitral 
disease is exceedingly rare. A presystolic tricuspid 
murmur pointing to such a condition in a case observed 
by Gardner was found due to a growth from the endo- 
cardium of the right auricle, so placed as to fall over 
the tricuspid orifice in the manner of a ball valve. 
Congenital defects would include other cases. 
Shattuck has met one instance of tricuspid stenosis 
with mitral stenosis and regurgitation, along with 
TRICUSPID STENOSIS. 160 
PHYSICAL DIAGNOSIS. 
adherent pericardium, hepatic cirrhosis, and slightly 
granular kidney, confirmed by autopsy. In this case 
there was a presystolic tricuspid murmur observed for 
three years before death. 
A presystolic murmur at the right edge of the 
sternum from the fourth costal cartilage to the ensiform 
cartilage and thence to the sixth left cartilage at its junc- 
tion with the sternum would be the murmur diagnostic 
of the condition, but frequently there is no murmur 
audible in connection with such a lesion found at 
necropsy. There should also be enlargement of the 
right auricle. A presystolic thrill may accompany the 
murmur. 
The great majority of systolic murmurs heard at the 
pulmonary orifice are functional. Pulmonary stenosis 
may, however, be present, and where it exists it is far 
more likely to be congenital from arrested develop- 
ment, although intra-uterine endocarditis may also 
cause it. So, also, may infectious endocarditis, and in 
rare instances atheroma. 
Pulmonary stenosis should furnish a systolic murmur in 
the pulmonary area, to the left of the sternum. The mur- 
mur may even be heard behind, between the shoulders, 
and it may be rough. It is accompanied by hyper- 
trophy of the right ventricle. There may be a basic 
thrill, as in aortic obstruction, but the pulse is unin- 
fluenced. Compensation may be set up by means of a 
patulous foramen ovale, an open ductus arteriosus, or 
PULMONARY STENOSIS. CONGENITAL DEFECTS. 
161 
interventricular communication. The invariable asso- 
ciation of cyanosis due to venous obstruction and of 
attacks of dyspnoea complete the picture and aid 
greatly in the diagnosis. Anaemic murmurs at the 
same time and place are unaccompanied by cyanosis. 
Walshe has described a case of death from throm- 
bosis of the pulmonary artery in which he heard a pul- 
monary systolic murmur before the end came. 
PULMONARY REGURGITATION. 
Simple pulmonary regurgitation is scarcely known, 
but it is easy from what has gone before to deduce the 
physical signs which are to be expected-a diastolic 
murmur heard in the pulmonic area, hypertrophy of the 
right ventricle, jugular pulse, venous congestion, and 
cyanosis. A few cases are related in which a diastolic 
murmur has been found associated with defects in the 
pulmonary valves, in one warty, which might have been 
the result of infectious endocarditis. All others are 
congenital. Among them is aneurismal dilatation. Such 
was a case reported to the Pathological Society of Phila- 
delphia by Edward T. Bruen. (See Transactions for 
1883.) 
Congenital defects in the cardiac valves and orifices 
deserve a passing notice. They may be the result of 
endocarditis during foetal life or of arrest of develop- 
ment. Their most frequent seat is the right heart and 
CONGENITAL DEFECTS. 162 
PHYSICAL DIAGNOSIS. 
the most frequent form is stenosis of the pulmonary 
orifice, the effects and signs of which have already been 
considered. Another is a permanently patulous foramen 
ovale; or there may be a defect of the septum of the 
ventricles, or a communication between the aorta and 
pulmonary artery-a persistent ductus arteriosus-or 
between the aorta and the vena cava or right auricle. 
All of these intercommunications produce murmurs dif- 
ficult to separate, and it is, after all, by attention to the 
general condition that the defect is recognized. The 
patient, a child of arrested development, more or less 
permanently cyanosed, with continued embarrassed 
breathing, all of these are conditions which point to the 
congenital defect. If there be added to these a persist- 
ent loud murmur at the base of the heart without other 
signs or symptoms of valvular disease, this may be due 
to congenital defect. 
RELATIVE FREQUENCY AND RELATIVE DAN- 
GER OF VALVULAR DEFECTS. 
The order of frequency of the various valvular defects 
is not entirely agreed upon. As to one, however, there 
seems to be universal concurrence, and that is that 
mitral regurgitation is the most frequent. After this, 
however, statistics differ. Thus of the older authors 
Walshe presents the following order of frequency for 
the single or individual murmurs: - 
1. Mitral regurgitation. 
2. Aortic stenosis. VALVULAR DEFECTS. 
163 
3. Aortic regurgitation. 
4. Mitral stenosis. 
5. Tricuspid regurgitation. 
6. Pulmonary stenosis. 
7. Tricuspid stenosis. 
8. Pulmonary regurgitation. 
As already stated, all agree that the mitral systolic 
murmur indicating mitral regurgitation is the most fre- 
quent. Dr. Frederick J. Smith, analyzing the registers 
and post-mortem records of the London hospitals for 
eleven years-1877-1887-and taking the fatal cases 
only, arrived at the following order: - 
1. Mitral regurgitation. 
2. Mitral stenosis. 
3. Aortic regurgitation. 
4. Aortic stenosis. 
5. Tricuspid stenosis. 
Out of the 705 cases Smith found 26, or 3.38 per 
cent., of mitral stenosis, and 25, or 3.25 per cent., of 
aortic regurgitation. So it cannot be said there is any 
practical difference in the relative frequency of these 
two lesions. Smith's statistics, being recent and based, 
as they are, upon the examination of registers and au- 
topsy records, might be reasonably regarded as correct. 
Yet it is not easy to disprove the presence of a coincident 
regurgitation in many cases of anatomical stenosis, 
which would, therefore, have to be deducted from the 
cases of simple lesion and added to those of combined. 
Two murmurs at one orifice are usually characterized 
as " double " murmurs, but Sansom suggests that the 164 
PHYSICAL DIAGNOSIS. 
term " combined " be applied to these murmurs, and 
the term " associated " retained for murmurs at more 
than one orifice. 
F. J. Smith's results as to associated murmurs are as 
follows: - 
1. Aortic regurgitation and stenosis; mitral regurgi- 
tation. 
2. Mitral stenosis and regurgitation. 
3. Aortic stenosis and mitral regurgitation. 
4. Aortic regurgitation and mitral stenosis. 
5. Aortic regurgitation and stenosis. 
6. Aortic regurgitation and stenosis; mitral stenosis 
and regurgitation. 
7. Mitral regurgitation and tricuspid regurgitation. 
8. Aortic regurgitation and stenosis; mitral regurgi- 
tation ; tricuspid regurgitation. 
9. Mitral stenosis and regurgitation ; tricuspid re- 
gurgitation. 
10. Aortic stenosis ; mitral stenosis and regurgitation. 
11. Aortic regurgitation; mitral stenosis and regur- 
gitation. 
12. Aortic stenosis; mitral regurgitation; tricuspid 
regurgitation. 
13. Aortic regurgitation and stenosis; mitral regurgi- 
tation ; pulmonary regurgitation. 
14. Aortic stenosis and regurgitation ; mitral stenosis. 
15. Aortic regurgitation ; mitral stenosis. 
16. Aortic regurgitation; mitral regurgitation; tri- 
cuspid regurgitation. 
17. Mitral stenosis; tricuspid regurgitation. 165 
VALVULAR DEFECTS. 
18. Aortic stenosis; mitral stenosis and regurgita- 
tion ; tricuspid regurgitation. 
19. Aortic stenosis; mitral stenosis. 
20. Aortic regurgitation and stenosis ; mitral stenosis 
and tricuspid regurgitation. 
21. Aortic regurgitation ; mitral stenosis and regurgi- 
tation ; tricuspid regurgitation. 
22. Aortic regurgitation and stenosis; mitral stenosis 
and regurgitation ; tricuspid regurgitation. 
23. Aortic regurgitation and stenosis ; mitral stenosis 
and regurgitation ; tricuspid stenosis and regurgitation. 
24. Aortic stenosis; pulmonary stenosis. 
25. Aortic stenosis; mitral stenosis and regurgita- 
tion ; tricuspid stenosis and regurgitation. 
26. Mitral stenosis and tricuspid stenosis. 
Of the 12th and 13th there are the same number, 5 out 
of 705 ; of the 14th, 15th, and 16th, each 4, and of the 
last 5 each 1. Of the double or combined murmurs, it 
is generally conceded that that at the mitral orifice, in- 
dicating stenosis and insufficiency, is the most frequent, 
and women are far more liable to this lesion than men. 
In an analysis of cases at the Glasgow Infirmary, Dr. 
George S. Middleton found a far larger proportion of 
the simple double aortic lesion than Dr. Smith, 22 per 
cent as against 4 per cent., and Walshe makes the 
simple double aortic lesion the second in frequency. 
But when we add together the cases of double aortic 
lesion and those of double aortic lesion combined with 
lesions at the other valves, as suggested by Dr. Sansom, 
we have also almost exactly 22 per cent., and it is well 166 
PHYSICAL DIAGNOSIS. 
known that in the majority of cases affecting the aortic 
valves, the mitral and tricuspid valves become sooner 
or later affected. 
Although but one case of tricuspid stenosis associated 
with mitral stenosis is found by Smith in his 705 cases, 
Bedford Fenwick has collected a large number of cases 
of stenosis of the tricuspid valve, in which the lesion 
was almost invariably accompanied by stenosis of the 
mitral orifice. Dr. Wilks regards the narrowing of the 
mitral orifice in these cases as secondary to that of the 
tricuspid, which allows only a small quantity of blood to 
pass into the right ventricle and lungs, in consequence of 
which a like small amount passes to the left heart, whence 
a reduction in the size of its cavities and orifices. 
The relative gravity of cardiac affections, beginning 
with the most serious, is also given by Walshe as fol- 
lows : - 
1. Tricuspid regurgitation. 
2. Mitral obstruction and regurgitation. 
3. Aortic regurgitation. 
4. Pulmonary obstruction. 
5. Aortic obstruction. 
It will be remembered, however, that I have said that 
aortic regurgitation is the most irremediable of the valv- 
ular defects, at least of the more common forms, and 
the most serious from the standpoint of tendency to 
sudden death. It will be noted that no place is assigned 
by Walshe to simple mitral obstruction, and it is indeed 
difficult to assign the final position of this lesion with a ACUTE ENDOCARDITIS. 
167 
good left auricle. Such cases run along for a long time, 
but the resulting congestion of the lung is troublesome 
and invites to circumscribed pneumonias, which are of 
frequent occurrence. 
The two well-acknowledged forms of endocarditis, 
simple and infectious or ulcerative, furnish no dis- 
tinctive physical signs by which they can be recognized 
one from the other. It is rather by the history and 
symptoms that such distinction is made, the almost 
invariable succession of the former upon rheumatism 
and of the latter on some coexisting infectious state 
being valuable aids. 
Both have their most frequent site on the left side, 
the most vulnerable, and in the mitral leaflets. . A sys- 
tolic mitral murmur, in the course of a rheumatism, 
means almost invariably an endocarditis. The aortic 
leaflets may also be the seat of inflammation, though 
more rarely, when a basic murmur is the consequence. 
But not every aortic murmur in the course of rheuma- 
tism implies endocarditis, as the condition of the blood 
predisposes to a haemic murmur ; nor every murmur at 
the apex, because the state of the muscle predisposes to 
imperfect closure of the auriculo-ventricular orifice. 
Unless there has been previous valvular disease, there is 
no enlargement, so that neither palpation, inspection, 
nor percussion gives any information. 
ACUTE ENDOCARDITIS. 168 
PHYSICAL DIAGNOSIS. 
PERICARDITIS. 
The only distinctive physical sign in the first stage of 
pericarditis is the friction sound, described on p. 129. 
In addition, the impulse may be strong. 
The second stage, or that of effusion, has usually, but 
not always, signs discoverable to inspection and palpa- 
tion. The prsecordium may be bulging and the inter- 
spaces obliterated, and the impulse undulating, tumultu- 
ous, and indistinct. Percussion furnishes the most 
striking change. The area of dulness is enlarged, and 
peculiarly enlarged. It becomes rudely triangular, with 
the apex toward the inner end of the left clavicle and 
the base as low as the seventh rib, and extending in 
extreme cases from nipple to nipple. Auscultation con- 
firms palpation; the impulse is feeble, indistinct, and 
often tumultuous. The heart-sounds are indistinct and 
best heard at the top of the sternum. 
The third stage consists in a gradual return to the 
normal state of affairs, which may be by the intermedi- 
ation of a friction redux or not. Adhesions may result 
between the heart and the sac, embarrassing its move- 
ments permanently, and producing retraction of the 
chest-wall with systole. On the other hand, necropsy 
has often revealed close adhesions between the heart 
and the pericardium which were not suspected during 
life. Permanent roughening by organization in chronic 
pericarditis may produce permanent friction sound. 
Hydropericardium, as a part of a general dropsy, DISEASES OF THE MYOCARDIUM. 
169 
is a rare condition, and furnishes the same physical 
signs as the inflammatory effusion. 
DISEASES OF THE MYOCARDIUM. 
The heart is subject to alterations in its muscular sub- 
stance independent of valvular defect. Simple hyper- 
trophy, fatty infiltration, and fatty metamorphosis, or 
true fatty degeneration, are the most important. Myo- 
sitis, abscesses, and aneurysms of the walls of the heart 
are such rare conditions that they need only to be men- 
tioned in passing, especially as there is no way to recog- 
nize them before death. 
Hypertrophy of the left ventricle, without val- 
vular disease, is always the result of obstruction to the 
movement of the blood through the aorta beyond the 
valves, or to some demand for compensation. The most 
common remote cause is chronic Bright's disease. Any 
variety of chronic Bright's disease may cause it, but it 
is most frequently associated with chronic interstitial 
nephritis. We have nothing to do here with the mechan- 
ism of its production, except to say that it seems likely 
that it is in some way compensatory. Atheroma and 
aneurysm of the aorta are attended by less degrees of 
hypertrophy, also compensatory, because of the loss of 
the elastic force in the arteries, requiring additional 
power on the part of the heart muscle. 
Inspection and palpation furnish much the same in- 
formation as in hypertrophy of the left ventricle from 
valvular disease. Percussion shows enlargement to the 170 
PHYSICAL DIAGNOSIS. 
left and downward. To auscultation there is no murmur, 
but a distinctive intensification of the aortic second sound 
is heard, quite characteristic, and itself of great diagnostic 
value. The first sound, while louder, is also duller, more 
prolonged, and diffuse, qualities which sometimes suggest 
a systolic mitral murmur which is not present. 
Pure hypertrophy of the right ventricle is the 
result of emphysema of the lungs, and sometimes, to a 
less degree, of fibroid disease of the same organs, com- 
pression of the lungs by effusion or adhesion, or of any 
cause which resists the movement of the blood from 
the right heart. We have here the signs of enlargement 
in the direction of the right heart, also without murmur, 
but with sharp accentuation of the second sound at the 
pulmonary interspace to the left of the sternum. 
General hypertrophy or physiological hypertro- 
phy or symmetrical hypertrophy of both sides of the 
heart may be brought about by severe muscular exercise, 
demanding extra nourishment. Exophthalmic goitre is 
often accompanied by the same condition, due to over- 
nourishment, the result of vaso-dilator influence on the 
blood-vessels. 
Dilatation of the Heart, either of its right or left 
ventricle, may occur independently of valvular disease. 
A heart cavity is said to be dilated when it is enlarged 
out of all proportion to the thickness of its walls, even 
though the latter may be somewhat thicker than normal. 
Commonly, however, the walls are thinner or no thicker 
than in health, and when the muscular wall is thick- 
ened while the cavity is enlarged we commonly speak DISEASES OF THE MYOCARDIUM. 
171 
of the condition as hypertrophy with dilatation. 
The term simple dilatation is used to indicate undue 
enlargement of the cavity while the walls remain of 
normal thickness; attenuated dilatation where the 
walls are thinned. 
Dilatation without valvular disease occurs rapidly and 
slowly : Rapidly in connection with grave cases of the 
acute infectious diseases attended with degeneration of 
the muscular substance of the heart. Such are typhus 
fever, typhoid fever, scarlet fever, smallpox, acute rheu- 
matism, and infectious endocarditis. More slowly in 
connection with vesicular emphysema, when, of course, 
it is in the right heart, and succeeds hypertrophy. In 
like manner the hypertrophied left ventricle of chronic 
Bright's disease may become dilated. Whatever causes 
obstruction to the outward flow of blood from a ventri- 
cle may cause dilatation, which is always, however, pre- 
ceded by hypertrophy. Aneurysm is such a cause, 
therefore, for the left heart. 
Inspection and palpation discover a diffuse feeble 
impulse and the pulse is weak. Percussion elicits signs 
of enlargement, while auscultation finds the sounds gen- 
erally feeble and indistinct. I speak now of dilatation 
without valvular disease. When valvular disease is 
present its signs are superadded. 
Fatty infiltration or obese heart is often a part of 
the condition of general obesity and has the same causes. 
It is something very different from the true fatty heart, 
or fatty metamorphosis, in which the muscular fasciculi 
are converted into granular fat. In the fatty infiltra- 172 
PHYSICAL DIAGNOSIS. 
tion the fat first covers the surface of the heart, then 
insinuates itself between the fasciculi, and although 
these are never themselves invaded, in extreme cases 
they undergo degeneration and atrophy from the pres- 
sure of the intervening fat. The heart is therefore not 
only embarrassed by the fat around and between its 
fibers, but the integrity of its essential substance may 
also be impaired by interference with its nutrition, and 
occasionally death results from sudden failure, just as in 
true fatty metamorphosis. 
Such a heart is usually somewhat symmetrically en- 
larged, but the heart-sounds are feeble and indistinct, 
and the same is true of the impulse. There are, of 
course, no murmursunless the condition be complicated 
with valvular disease. 
Its recognition is based chiefly on the association 
of the symptoms of cardiac weakness with general 
obesity. 
True fatty metamorphosis consists in an actual 
substitution, to a greater or less extent, of the muscular 
substance of the heart by granular fat. It is constantly 
associated with dilatation of the heart. Such a heart 
muscle is soft and flabby, and its contraction power is 
greatly impaired. 
The physical signs of such a condition are not at all 
distinctive. There is feebleness of sounds and impulse. 
The latter as well as the pulse may even be inappre- 
ciable. There may be some enlargement of the heart, 
the result of dilatation of the soft and yielding muscle. 
Nor is there murmur unless there be valvular disease. It is rather by watching a case over a considerable 
period of time that the truth is arrived at. Treatment 
is without result, and its total inefficiency is an aid in 
diagnosis. Fainting is frequent and sudden death the 
usual termination. 
Acute myositis associated with acute rheumatism 
or fever may be a cause of fatty degeneration, but there 
is no way of determining with certainty its presence. 
It may be suspected when, along with, or subsequent to, 
intense rheumatic fever, there is evidence of heart- 
failure. 
THORACIC ANEURYSM. 
173 
THORACIC ANEURYSM. 
Thoracic aneurysm occurs in the arch of the aorta, 
in its ascending, transverse, and descending portions, 
and in the thoracic aorta below the arch. The greater 
frequency of aneurysm in the male sex and during early 
middle life may be mentioned in passing. 
The pressure symptoms of thoracic aneurysm are 
so important, so frequently precede the physical signs, 
and so frequently are necessary to a correct diagnosis 
that their consideration is indispensable and will be 
added after a study of the physical signs. 
Inspection does not always discover changes, but if 
the sac grows outwardly, sooner or later a swelling 
makes its appearance, to the right of the sternum if in 
the ascending limb, possibly raising a rib or the end of 
the clavicle; above and behind the sternum, if in the 
transverse portion, raising the manubrium or boring its 174 
PHYSICAL DIAGNOSIS. 
way through it; and to the left of the sternum if in the 
descending limb of the arch. Such a tumor may pul- 
sate or not. The aneurysm is, as it were, a rudimental 
heart, dilating with every jet of blood that is shot into 
it so long as the wall is yielding, and contracting on 
the withdrawal of the intravascular pressure. Should 
this property be lost, either as the result of calcification 
or the lining of the sac with successive layers of coagu- 
lum, such dilatation becomes impossible, and pulsation 
does not occur. The pulsation is, however, of great 
importance in the diagnosis. When present it is syn- 
chronous with the systole of the ventricles. The heart 
itself is sometimes displaced downward, as may be 
recognized by the lowering of the apex. 
If the aneurysmal tumor press upon the great veins 
of the neck there may be venous engorgement on 
one side of the neck or both, according as the innomi- 
nate of one side only is compressed or the descending 
cava itself. 
Palpation also appreciates the impulse of the 
aneurysm if it is visible, and sometimes when it is not 
visible. This beating is somewhat peculiar, being expan- 
sile, and by this peculiarity differs from the rising of a 
tumor over a pulsating blood-vessel. A thrill is also 
often felt, a vibration in the walls of the sac caused by 
the whirl of the blood in it. It is by no means, how- 
ever, invariable, and it may come and go. 
Percussion over the swelling of an aneurysm invari- 
ably elicits dulness, varying greatly in extent. On the 
other hand, the adjacent lung may be compressed by an THORACIC ANEURYSM. 
175 
aneurysmal tumor, and the area of dulness thus extended 
beyond the tumor itself. In the absence of swelling 
there may be no impairment of resonance. 
Auscultation is no exception, as compared with the 
other modes of physical investigation, in the incon- 
stancy of its results, sometimes furnishing the most 
distinctive signs, while at others it is totally negative. 
The murmur or bruit heard over an aneurysm is 
various. Sometimes it is double, like the sounds of the 
heart, the first intense and prolonged, the second fainter 
and shorter. Sometimes but one murmur is produced, 
systolic, corresponding with the first sound over the 
ventricles, but more intense; more rarely it is diastolic 
only. More frequent than either systolic or diastolic 
is the combined or double murmur, both systolic and 
diastolic. It varies greatly, being sometimes rough, 
sometimes soft, sometimes musical. The murmur is, 
however, often absent. The mechanism of these sounds 
is not settled. The systolic is most easily explained. 
There can be little doubt that it is produced by the 
entrance of blood into the sac. When the aneurysm is 
at the beginning of the aorta, the diastolic murmur will 
probably be an aortic regurgitant murmur, due to 
stretching apart of the aortic valves. When the 
aneurysm is distant from the aortic orifice, the diastolic 
murmur may be due to the elastic recoil of the 
aneurysmal sac propelling the blood through the sac with 
additional force. Rarely there is a diastolic murmur 
only, probably thus caused. 
But any one or all of these signs may be wanting. 176 
PHYSICAL DIAGNOSIS. 
Particularly is this the case where the aneurysm occurs 
just after the aorta has left the heart. The most valua- 
ble are the pulsation, distinct and separate from that of 
the heart, and the sounds, separate and distinct from 
those of the heart, or, as graphically put by Da Costa, 
"two hearts, apparently, each with its own distinct 
beat, its own distinct sounds.'' * 
Pressure symptoms.-Not only may all these signs be 
wanting, but identical murmurs may be produced by 
double aortic disease, i. e., aortic stenosis with regurgita- 
tion, and I have known a case to be diagnosed as double 
aortic disease after weeks of study, when the autopsy dis- 
closed an aneurysm of the ascending limb of the arch of 
the aorta. It is most important, therefore, to place along- 
side of these the so-called pressure signs of aneurysm, 
some of which often precede the physical signs. 
The first of these is pain, which may be sharp and 
acute when nerves are directly involved, or dull and 
boring when the result of pressure on the bone. In the 
latter case, too, it is localized; in the former it may 
extend all over the chest and down the arms, simulating 
that of angina pectoris. It may be unilateral. It may 
occur in aneurysm of the ascending or descending part 
of the arch. 
Dysphagia from pressure of the tumor on the oesopha- 
gus is also an occasional symptom. 
Other signs are alterations in the voice, such as hoarse- 
ness, aphonia, stridor; also brassy cough, and defective 
* Op. citat., p. 451. THORACIC ANEURYSM. 
vocalization. Some of these symptoms may be produced 
by direct pressure on the trachea itself, others by pres- 
sure upon the left recurrent laryngeal nerve. A stridulous 
voice unaccompanied by dysphagia or aphonia was early 
pointed out by Tufnell, as indicating that the pressure is 
on the right side of the trachea and does not affect the 
oesophagus or recurrent laryngeal nerve. On the other 
hand, hoarseness, aphonia, and defective vocalization 
and various degrees of paralysis of the vocal cord are due 
to involvement of the left recurrent laryngeal nerve, 
which passes around the arch of the aorta. The paralytic 
phenomena may be present without any other laryngeal 
symptoms. Hence any alteration of voice or defective 
vocalization in a person presenting symptoms of heart 
disease demands a laryngoscopic examination. Such ex- 
amination may show little alteration in the position of 
the vocal cords in ordinary breathing, or the left may be 
a little nearer the median line. In total paralysis, which is 
one of abduction and adduction of the left vocal cord, this 
cord stands in the so-called cadaveric position, i. e., mid- 
way between the position of ordinary respiration and 
phonation. On deep inspiration, however, the right vocal 
cord is well abducted, the left remaining quiescent. The 
attempt at phonation is more or less abortive. During it 
the right vocal cord may go to the median line, leaving 
a small opening between it and the motionless left cord, 
or it may even cross the line to its paralyzed neighbor. 
If only the abductor twigs of the left recurrent laryn- 
geal nerve are involved in the pressure, there ensues 
gradually a permanent shortening or " paralytic contrac- 
177 178 
PHYSICAL DIAGNOSIS. 
ture " of the antagonistic abductors, and the paralyzed 
cord is drawn by this into aposition of constant phona- 
tion,-that is, into the median line. The result is that 
breathing may be entirely unobstructed and the voice 
natural, the paralyzed cord being in the position of ad- 
duction, while its tension is mainly regulated by the 
external branch of the superior laryngeal nerve, which is 
uninfluenced in aortic aneurysm. 
These phenomena imply, of course, a functional 
destruction of the nerve, which may either be the re- 
sult of simple pressure which will lead sooner or later 
to structural degenerative change, or the latter may 
result from a primary neuritis, the early stages of 
which, together with an associated irritation of the entire 
pneumogastric, may be held responsible for certain 
attacks of extreme dyspnoea sometimes experienced by 
subjects of aortic aneurysm. Associated with the neural 
degeneration is also found atrophy of the left abductor 
muscle-the crico-arytenoid,-while the adductors re- 
main nearly intact. Constant dyspnoea is more likely to 
be due to direct compression of the trachea. 
How shall these phenomena, which are, also, so much 
like those of a laryngitis, be interpreted as due to aneu- 
rysm instead of the latter affection in the absence of the 
physical signs of aneurysm? 
In acute laryngitis we have often the cause-exposure 
to cold-to help us,-in chronic we have not. In laryn- 
gitis there is more huskiness and less of stridor in the 
voice, nor is the cough so brassy, or the voice so uni- 
formly changed ; it is more apt to alternate with normal THORACIC ANEURYSM. 
179 
voice. In aneurysm the voice grows progressively worse 
until aphonia results. The dyspnoea is more apt to be 
attended with wheezing, and is sometimes relieved for 
a time by coughing. Stokes called attention to the fact 
that in aneurysm the stridor of the voice seems to come 
from the notch of the sternum rather than from the larynx 
itself. In aneurysm the breathing is more apt to differ 
in the two lungs. Then we have the laryngoscopic 
picture. There is no swelling of the cords in aneurysm 
and there may be the paralytic phenomena detailed. 
Finally, in laryngitis there is apt to be fever. 
Then there is the tracheal tugging of aneurysm. This 
is a dragging downward of the larynx with each systole 
of the heart. The trachea is held up by gently inserting 
the ends of the fingers under the edge of the cricoid carti- 
lage, when with each impulse the larynx is pulled down- 
ward. The patient sits with his head slightly thrown 
back and the examiner stands behind him. It is said 
that it may be the sole sign of aneurysm, and a sign, 
also, that the position of the aneurysm is such as to 
involve the posterior aspect of the arch. It is said 
never to be present in aneurysm of the innominate. 
Aneurysm of the arch of the aorta affects the pulse 
in distal arteries chiefly only when it involves the 
origin of blood-vessels leading to those arteries, as the 
innominate on the right and the carotid or subcla- 
vian on the left. If the right radial pulse is enfee- 
bled or delayed, the aneurysm will be on the right, 
involving the origin of the innominate; if on the left, 
involving the left carotid or subclavian. Great care 180 
PHYSICAL DIAGNOSIS. 
should be taken in these investigations, and they should 
be made from the center to the periphery; that is, the 
carotids, the subclavians, the brachials, the radials should 
be successively examined as recommended by Sansom. 
These effects are produced by the aneurysmal sac act- 
ing as the elastic air chamber in a pump, diminishing 
thus the pulsatile force, or by its obstructing the entrance 
of blood to the blood-vessel, or by pressure of the ex- 
ternal coat of the aneurysm upon the vessel itself. 
Osler calls attention to the fact that the pulse even in 
the abdominal aorta and its branches may be thus 
obliterated by a large thoracic aneurysm. 
Inequality of pupils is another valuable sign of aneurysm 
of the thoracic aorta, due to the involvement of the sym- 
pathetic, its organic or functional destruction, with result- 
ing paralysis of the dilator fibers of the iris, which is thus 
given over to the control of the third nerve. Hence the 
pupil is contracted, more frequently on the left side. 
Unilateral sweating is similarly caused. 
Aneurysm of the descending aorta below the arch, be- 
tween it and the diaphragm, has its most constant 
symptom in pain-boring pain-generally due to intru- 
sion on the vertebrae, and any persistent boring pain in 
this locality should suggest a thorough examination. 
The bruit, more apt to be systolic only, is often not 
heard, sometimes faintly. A bulging of the ribs in the 
posterior thoracic region should be sought for, and a 
dulness on percussion. 
Aneurysm of the innominate is especially indicated by 
its murmur, thrill, and an impulse in the vicinity of the THORACIC ANEURYSM. 
181 
inner end of the right clavicle, which is sometimes 
raised by the resulting tumor; also by the comparative 
absence of signs of pressure on the larynx or oesophagus. 
The differences in the right radial pulse alluded to are 
especially here present. 
If the subclavian is involved, the signs are further 
outward, on the outer side of the sterno-cleido mastoid. 
To those named may be added pressure symptoms upon 
the subclavian vein, producing swelling of the arm and 
neck; upon the right recurrent laryngeal, producing 
defective speech, cough, and dyspnoea; on the sympa- 
thetic, producing contraction of the right pupil, and on 
the brachial plexus of nerves, pain. Especially would 
these signs point to aneurysm of the subclavian if the 
pulse of the carotids is uninfluenced, while the right or 
left radial pulse is. 
The very rare condition of aneurysm of the pulmo- 
nary artery may produce a swelling, with the other local 
symptoms described, to the left of the sternum, in the 
second interspace. A murmur is less constant and is 
not conducted into the vessels of the neck, while the 
superficial pressure signs are more conspicuous. There 
is lividity of the face and oedema, and the dyspnoea is 
naturally very great. There is no cough or voice altera- 
tion. It is to be remembered, too, that the swelling of 
an aneurysm of the arch of the aorta may extend to the 
left of the sternum. A pulsating empyema in this 
vicinity in my experience resembled so closely a pulsa- 
ting aneurysm that I feared to tap it until suitable pre- 
liminary exploration was made. 182 
PHYSICAL DIAGNOSIS. 
PHYSICAL EXAMINATION OF THE 
ABDOMEN. 
In mapping out the abdomen for the study of the 
topography of its organs it is usual to divide it as we do 
Fig. 31. 
Drawing Showing Regions of the Abdomen. {After Gray.) 
the thorax, by a set of lines which apportion it into nine PHYSICAL EXAMINATION OF THE ABDOMEN. 
183 
regions. First, a line is drawn horizontally around the 
body at the level of the edge of the thorax ; another at 
the level of the crest of the ilium. Then two vertical 
lines are drawn through the outer end of the cartilage 
of the eighth rib above, and the middle of Poupart's 
ligament below. 
The following table of the viscera contained in each 
of the regions is from Gray's Anatomy :- 
Right Hypochondriac, 
lhe right lobe of liver 
and the gall bladder, 
hepatic flexure of the 
colon,and part of right 
kidney. 
Epigastric Region. 
The middle, and pyloric 
end of the stomach, 
left lobe of the liver 
and lobulus spigelti, 
the pancreas, the duo- 
denum, parts of the 
kidneys, and the supra- 
renal capsules (aorta 
and branches, vena 
cava, semilunar gan- 
glion, thoracic duct ) 
Left Hypochondriac. 
The splenic end of the 
stomach, the spleen and 
extremities of the pan- 
creas, the splenic flex- 
ure of the colon, and 
part of the left kidney. 
Right Lumbar. 
Ascending colon, part of 
the right kidney, and 
some convolutions of 
the small intestine. 
Umbilical Region. 
The transverse colon, 
part of the great omen- 
tum and mesentery, 
transverse part of the 
duodenum, and some 
convolutions of the 
jejunum and ileum, 
part of both kidneys 
(and the receptaculum 
chyli). 
Left Lumbar. 
Descending colon, part 
of the omentum, part 
of the left kidney, and 
some convolutions of 
the small intestine. 
Right Inguinal (Iliac). 
The caecum, appendix 
caeci (ureter, spermatic 
vessels). 
Hypogastric Region. 
Convolutions of the 
small intestine, the 
bladder in children, 
and in the adult if 
distended, and the 
uterus during preg- 
nacy (often the cae- 
cum, appendix vermi- 
formis, and sigmoid 
flexure of colon). 
Left Inguinal (Iliac). 
Sigmoid flexure of the 
colon (ureter, spermatic 
vessels). 
The middle region of the upper zone is known as the 184 
PHYSICAL DIAGNOSIS. 
epigastric region, the two adjacent the right and left 
hypochondriac. The central region is called the umbili- 
cal, and the lateral regions in this zone the right and 
left lumbar. The inferior central region is the hypo- 
gastric, and the lateral regions the right and left in- 
guinal or iliac. 
INSPECTION. 
Inspection notes alterations in the shape of the 
abdomen, from distention by gases or dropsical effu- 
sions, morbid growths, enlarged organs like the liver 
and spleen, pregnancy, distortions due to positions ne- 
cessitated by occupation or caused by tight lacing. 
The abdomen of the little child and that of the man 
past fifty are both more protuberant than that at an 
intermediate age; the lower or pelvic portion of the 
woman's broader than that of the man. There is in 
nature quite a decided difference in the length of the 
waist or distance between the lower edge of the thorax 
and the crests of the ilia. Apart from the effect of 
tight lacing in women there is naturally a good deal of 
difference in the width of their waists. In lacing the 
pressure is generally brought to bear on the hypochon- 
driac and the epigastric regions, the effect of which is 
to make the waist appear longer, or " wasp-like." After 
a full meal the upper part of the abdomen is fuller. 
Undue enlargement of the superficial veins is some- 
times observed in inspecting the abdomen, the result of 
obstruction to the flow of blood in the portal vein or PALPATION OF ABDOMEN. 
185 
vena cava, while epigastric pulsation is very commonly 
seen, being most frequently of no significance, but 
occasionally due to aneurysm of the abdominal aorta. 
When the abdominal wall is very thin the outline of 
certain organs may be traced, and even peristaltic mo- 
tions in the stomach and bowels are recognizable. 
Through such an abdominal wall the outline of an 
enormously distended stomach may even be recognized. 
The patient should also be examined in the knee- 
elbow position, which will permit movable tumors to 
fall forward and facilitate their recognition by inspec- 
tion as well as by palpation. 
PALPATION. 
Palpation of the abdomen should be practised by 
laying the hand flat upon the abdomen and depressing 
the ends of the fingers as the hand is moved about, 
rather than by "poking" with the fingers of the 
straight hand obliquely placed. The abdominal walls, 
too, should be relaxed by semi-flexing the thighs on the 
abdomen, and the legs upon the thighs. Thus we learn 
of the consistency and situation of various organs and 
abnormal growths, whether they are smooth or uneven, 
whether there is tenderness or tenseness. In so doing 
the degree of pressure must vary. Some pains are re- 
lieved by pressure, others aggravated. The former are 
more apt to be due to neuralgia or colic, the latter 
to be inflammatory. 
The presence of fluid may be settled by fluctuation, 186 
PHYSICAL DIAGNOSIS. 
which is produced by placing the hand on one side in 
the flank and tapping the other side gently with the 
fingers, by which a wave is produced and is felt by the 
palpating hand. Our knowledge of the more precise 
situation of fluid, and even of growths, is often aided 
by changing the position of the patient. Circum- 
scribed fluctuation may sometimes be detected in hy- 
datid cysts of the liver, ovarian cysts, and rarely cystic 
kidneys. Sometimes a friction or roughness can be felt 
in connection with enlarged liver and spleen. 
Under favorable circumstances the edge of the liver 
and even the end of the gall-bladder can be felt, espe- 
cially if the latter is distended with bile or gall-stones, 
or is itself the seat of morbid growths. Especially can 
the liver be felt if it is much enlarged. 
Only when enlarged can the spleen be felt downward 
and forward. 
Likewise the kidneys are too deep-seated to be felt in 
health. When movable or floating, the right, which is 
that almost invariably involved, is often felt more toward 
the median line, below the liver, and may sometimes be 
recognized by its kidney shape and easy mobility, while 
more rarely even the beating of the renal artery can be 
felt. A deep inspiration will generally cause such a 
kidney to move downward. Enlargements of the kid- 
ney may bring the organ into such position that it can 
be felt anteriorly. Pressure of the normal kidney gives 
rise to a peculiar sickening pain like that caused by 
bruising the testicle. 
The pancreas is beyond reach in health, and even PALPATION OF ABDOMEN. 
187 
when the subject of diseased enlargement is rarely felt. 
Sometimes, however, between the right mammillary line 
and the median line and behind the edge of the liver can 
be felt a tumor covered by intestine, which is either the 
enlarged head of the pancreas or a part of the duodenum 
with adjacent glands, and which, if associated with jaun- 
dice, is likely to be a tumor or cyst of the pancreas. A 
tumor of the pyloric orifice of the stomach, also com- 
monly higher up and more toward the median line, is 
characterized by its greater mobility and change of 
position with varying degrees of distention of the 
stomach. A peculiar rotary motion of such tumor is 
characteristic. 
Only under the most unusual conditions can enlarge- 
ments of the suprarenal capsules be felt. 
Enlargements of the mesenteric glands are character- 
ized by their smoothness and mobility. They differ 
from fecal tumors, which may often be felt in the right 
groin, by the softness and compressibility of the latter 
and their gradually forward motion. Only after great 
enlargement do the deep-seated or posterior abdominal 
glands come to the front, uniting with the more super- 
ficial glands to form large tumors, having communicated 
to them the impulse of the aorta from behind. 
The uterus and bladder, always behind the pubes 
in health, when empty, rise as palpable central tumors 
when distended by their physiological contents, whose 
distinctness depends largely upon the thinness of the 
abdominal walls, and is much more accurately investi- 
gated by percussion. 188 
PHYSICAL DIAGNOSIS. 
The ovaries, not to be felt in health, when enlarged 
from tumors, rising up from the pelvis into either flank, 
and thence toward the center of the abdomen. When 
their contents are liquid, circumscribed fluctuation 
may be recognized, although it is irregular and in- 
constant, and there is this difference between such 
liquid and liquid free in the abdominal cavity-the lat- 
ter falls away into the flanks as the patient lies down, 
while the ovarian tumor remains central. 
These latter organs, particularly the uterus and 
ovaries, are, however, even more satisfactorily investi- 
gated by palpation through the vagina, in the case of 
the uterus further aided by the uterine sound. In ab- 
dominal dropsy fluctuation may also be detected 
through the vagina, less commonly in ovarian cysts. In 
abdominal dropsy the uterus is not usually displaced 
unless simply prolapsed ; in ovarian tumor it is apt to 
be displaced. The aortic impulse is sometimes con- 
veyed to an ovarian tumor, heaving it forward with 
each pulse. This is not the case in an abdominal 
effusion. 
The rectum may be similarly explored, the hand 
being sometimes carried far up into it after careful and 
gradual dilatation of the sphincters. Rectal exploration 
in this manner should, however, be cautiously carried 
out, as the possibility of producing rupture exists. This 
organ as well as the uterus is also investigated by the 
aid of specula, to which modern invention has added the 
electric light. So, too, the bladder is now being simi- 
larly explored. PERCUSSION OF ABDOMEN. 
189 
PERCUSSION. 
Much more tangible in abdominal investigation are 
often the results of percussion. So far as the hypochon- 
driac, epigastric, and even lumbar regions are con- 
cerned, the normal percussion phenomena have been 
necessarily detailed under thoracic percussion. 
For abdominal percussion the patient should be 
placed in a relaxed position, like that described for pal- 
pation. A pleximeter is here conveniently employed, 
and the force of the blow must be judicious in accord- 
ance with the viscera to be investigated. Thus, if study- 
ing the lower boundary of the liver or spleen, too strong 
a blow will bring out the tympany of adjacent gas-con- 
taining viscera, while the upper borders of these organs 
require strong percussion. 
Percussion of the spleen requires some special 
consideration. Its dull sound is limited by the resonance 
of the adjacent lung and tympany of stomach and intes- 
tines, and at times it may even fail of detection. It may 
be percussed with the patient standing fully stripped or 
lying on the right side with the legs flexed. Pretty strong 
percussion should then be commenced in the mid- 
axillary line from the axilla downward toward the 
crest of the ilium. At the ninth rib, usually, some- 
times a little lower in health, the dull sound comes out, 
associated with greater resistance. It usually continues 
downward as far as the eleventh rib or a little below, 
where it is replaced by the tympany of the intestine. 
The anterior boundary of the spleen is determined by 190 
PHYSICAL DIAGNOSIS. 
percussing backward of a line drawn downward from 
the anterior fold of the axilla. The spleen is seldom 
found anterior to the mid-axillary line in health. Pos- 
teriorly the splenic dulness is not separable from that 
of the left kidney. Abnormal enlargements of the 
spleen are downward and anteriorly and may reach 
colossal proportions. 
The percussion borders of the kidneys have already 
been outlined on page 50. 
Of the remaining abdominal organs the stomach and 
intestines alone approach the surface in health in such 
way as to make their limitation possible by percussion. 
They require also some delicacy in discrimination of 
shades of sound, more particularly in pitch. The 
quality met in percussing these organs is, for the most 
part, tympanitic, and it is chiefly variations in the 
pitch of this which are to be discriminated. The same 
organ may exhibit different degrees of this under dif- 
ferent conditions. Thus, the stomach when moderately 
distended with gas gives a low-pitched tympanitic 
sound when percussed; when more distended it gives a 
higher pitch ; when more distended still it may give a dull 
sound. (See p. 41.) Given the stomach and intestine 
in an equal degree of tension, the stomach will respond 
to percussion with a lower-pitched tympany than the 
intestine because it is a larger cavity. This is some- 
times spoken of as less tympanitic; sometimes the 
stomach percussion note is ringing, amphoric, echo- 
ing. By means of these differences when present we 
can distinguish one hollow organ from another. Again, PERCUSSION OF ABDOMEN. 
191 
the presence of liquids or solids in the stomach influ- 
ences the percussion note. 
The hollow viscera en masse can be mapped out by 
determining the boundaries of the solid viscera just 
described. But we want to do more than this. Below 
this line is the tympany of the whole abdominal 
cavity. We want to separate one hollow organ from 
another - the stomach from the small intestine, the 
small intestine from the large. For this the patient 
must be recumbent. As stated, the stomach tympany 
is ordinarily lower pitched than bowel tympany. Bear- 
ing this in mind, we can generally determine the 
stomach boundaries when the organ is not overdis- 
tended with liquid, gas, or food. The upper border of 
the stomach, as recognizable by percussion, corresponds 
with the lower edge of the liver and inner border of the 
spleen, as above outlined. To the left of the apex of 
the heart the stomach tympany is mixed with the 
resonance of the lung. At this point, about the 
seventh rib, is the cardiac end of the stomach. Per- 
cussing downward from these boundaries, we are gen- 
erally able to find a difference of note-a higher pitch, 
a purer tympany, belonging to the transverse colon- 
in a curved line which crosses the left edge of the 
thorax at about the inner end of the tenth rib, the 
median line just above the umbilicus, and passes thence 
upward to the edge of the liver to the right of the 
median line. This is the boundary of the greater 
curvature of the stomach, and includes between it and 
the upper border alluded to a hand-breadth space 192 
PHYSICAL DIAGNOSIS. 
called by Traube the half-moon space of the stomach 
tympany, better termed crescentic shape, while Leich- 
tenstern has applied the name pulmono-hepatic angle to 
the point of junction between the lower edge of the 
left lobe of the liver and the lower border of the left 
lung. The tip of this angle is behind the sixth rib just 
below the apex seat, and is bisected by the pleural 
angle, which, it will be remembered, is not filled by the 
lung except in deep inspiration. (See p. 41.) This is the 
highest part of the chest wall reached by the stomach, 
and it is a point pretty constantly maintained. This 
half-moon tympanitic space may be converted into one 
of percussion-dulness by filling the stomach with food, 
or the line of demarcation may be made more distinct 
by having the patient drink a glass of water just before 
the examination ; or, as originally suggested by 
Frerichs, by taking in rapid succession the two por- 
tions of a Seidlitz powder, tartaric acid and sodium 
bircarbonate, or a glass of soda-water. The gas thus 
liberated rapidly distends the stomach even beyond 
the limits described. The normal limit of the lower 
curvature may, however, be put above the umbilicus, 
although it cannot be said to be abnormally low when 
at the umbilicus, an event not unusual after fifty 
years of age. In men the greater curvature is not 
quite as low as in woman, and in working women 
not so low as in others. When the lower curvature is 
much below the umbilicus the stomach may be said to 
be dilated. 
As stated, the percussion note of the large intestine PERCUSSION OF ABDOMEN. 
193 
is higher pitched and more purely tympanitic than that 
usual to the stomach. When containing faeces it is 
rendered duller, and in consequence of this fact there 
is often less resonance in the left iliac fossa than in 
the right, although faeces may also accumulate in the lat- 
ter, and an impaction in the head of the colon give 
positive dulness. The colon may also be artificially 
distended with gas, for examination, if desired. 
The percussion note of the small intestine is still 
higher pitched than that of the large, and by this it 
may be distinguished from that bowel, if not filled 
with solid matter or liquid. The differences in per- 
cussion note alluded to are not always equally marked, 
and it is not always possible, in consequence, to demark 
the organs. 
The bladder is recognizable by its dull note above 
the pubis when distended with urine. 
It remains to make some allusion to peculiarities in 
the percussion of ovarian cysts with fluid contents, as 
compared with dropsical effusions into the abdomen. 
In the former, the percussion note is dull in the central 
abdominal region, while in the flanks there is apt to be 
tympanitic percussion, from the fact that the intestines 
are pushed into them. With change of position, the 
dulness in ovarian dropsy does not change position, 
while in abdominal dropsies it does. 
The two may, however, be combined, when the diffi- 
culty is increased, and a preliminary tapping may be 
necessary to settle the question. 194 
PHYSICAL DIAGNOSIS. 
Auscultation, of all the means of physical diagnosis, 
gives us least information in abdominal investigation. 
An aneurysmal murmur may be heard over the aorta, 
and sometimes a murmur may be heard in an enlarged 
spleen, and even a friction sound may be heard. Bor- 
borygmi are sometimes audible at a distance, and metal- 
lic tinkling from the splashing of fluid in a distended 
stomach. 
Certain deglutition murmurs are described by Ewald. 
First there is a deglutition murmur, of no diagnostic 
significance, produced by swallowing a mouthful of 
liquid, propagated from the pharynx into the esopha- 
gus and heard all along the latter tube. In addition 
are heard, only near the cardia, during deglutition, two 
murmurs. The best site for auscultation is just below the 
xiphoid cartilage. The first, or hissing murmur (Durchs- 
pritzgerauscb), occurs almost immediately after the be- 
ginning of deglutition, and sounds as if fluid was being 
directly squirted into the stethoscope. The second sound, 
or pressure murmur (Pressgerausch), is heard six or seven 
seconds later, and described by Ewald as a series of 
tones rapidly following one another, either "gurgling, 
clucking, splashing, or sprinkling." 
These two sounds alternate. The first is heard but 
rarely, and is said to indicate a relaxation of the cardiac 
orifice. 
The second sound is quite constant, and is absent 
only when the first is heard. Its cause is not precisely 
AUSCULTATION. AUSCULTATION OF ABDOMEN. 
195 
determined, being ascribed by some to audible vibra- 
tions of the cardiac orifice, caused by the passage of 
food over it; by others to a " pressing through " of air 
swallowed with the food. 
It is on the absence, therefore, of the second murmur 
that diagnostic value depends; i. e., it is apt to be 
wanting in obstructive disease of the cardiac orifice, 
although too much stress must not be laid on this sign, 
since the murmur is not invariably present in health. 
The foetal heart beat and placental murmur should be 
mentioned as auscultatory abdominal phenomena. APPENDIX. 
EXAMINATION OF BLOOD AND 
SPUTUM. 
THE COUNTING OF BLOOD CORPUSCLES. 
Decidedly the most convenient instrument for esti- 
mating the number of corpuscles to the cubic millimeter 
is the cytometer of Thoma-Zeiss. The directions for its 
use appended are essentially those of the maker-Zeiss. 
The apparatus consists of three parts: - 
(1) A graduated pipette with india-rubber tubing and 
mouth-piece. 
(2) A divided cell upon an oblong slip. 
(3) A cover-glass with plane ground surfaces. 
In order to count the red corpuscles of human blood, 
the tip of any finger is cleaned with water and alcohol, 
and then rubbed between the fingers of the other hand. 
A slight arterial hyperaemia of the tip of the finger will 
arise, so that a fairly deep puncture with a lancet-like 
needle is sufficient to cause a drop of blood to appear. 
The point of the pipette is quickly placed into it and 
the blood sucked in up to division 1. Then the point 
of the pipette is cleaned from the blood sticking to it 
196 THE COUNTING OF BLOOD CORPUSCLES. 
197 
by a cloth kept ready for the purpose, and it is placed 
into a ty2 per cent, filtered solution of bichromate of 
potash, or 3 per cent, filtered solution of common salt. 
This also is immediately sucked up, so that the fluid 
enters into the spherical enlargement of the pipette. 
As soon as the sphere is filled up to division 101, the 
sucking is interrupted and the mouth-piece of the india- 
rubber tube closed by putting the finger upon it. The 
contents of the spherical enlargement are now to be 
mixed by careful shaking. Thus in this sphere ninety- 
nine parts by volume of the solution are mixed with one 
part by volume of blood, or 100 parts by volume of the 
mixture contain one part by volume of blood, for the 
fluid in the capillary tube does not enter into the mix- 
ture. 
If the blood is drawn in up to another division, say 
0.5, instead of division 1, then with the same mode of 
proceeding another dilution is obtained, viz., 1 : 200. 
Afterward, by blowing air into the india-rubber 
tubing, the solution may be removed from the capil- 
lary tube, and by constant shaking, about one-half 
of the sphere is emptied. The next drop of the mix- 
ture is emptied upon the middle of the bottom of the 
divided cell, after the latter has been carefully cleansed. 
The cover-glass is immediately placed over it, and the 
apparatus is transferred to the horizontal stage of the 
microscope and left standing quietly for some minutes, 
so that the blood corpuscles may settle down. 
It is necessary for a successful enumeration that the 
divided cell and cover-glass should be thoroughly 
cleaned. If this is done properly the Newtonian rings 198 
will be perceived along the edge of the cover-glass as 
far as it rests upon the wall of the cell, and this indicates 
that the cover-glass lies well upon it. At the same time 
it must be seen that no fluid enters between the cover- 
glass and the wall of the cell. On the contrary, the 
drop of blood should be placed in the center of the cell, 
and spread thence to fill up the space between the 
cover-glass and the bottom of the cell for some square 
millimeters. 
PHYSICAL DIAGNOSIS. 
Fig. 32. 
Group of 16 Small Squares, each of a Capacity of c.mm., Making One 
Large Square of the Thoma-Zeiss Cytometer, Magnified. 
Special care should be taken to keep the pipette in 
clean condition. Every time after having been used 
it should be rinsed with (i) the diluting fluid, (2) dis- 
tilled water, (3) absolute alcohol, and (4) ether. If 
dust or coagulated blood should still stick to the pipette, 
it should be removed with strong acids or alkalies by 
repeated rinsings, assisted, if necessary, by a bristle. 
The corpuscles may be counted by any object glass 
magnifying about 300 diameters. THE COUNTING OF BLOOD CORPUSCLES. 
199 
Every fifth square of each horizontal and vertical row 
of squares is crossed by an additional line to facilitate 
the counting. Each square occupies an area of sq. 
mm., and above each square there is a space of c. 
mm., since the distance of the bottom of the cell from 
the lower surface of the cover-glass amounts exactly to 
mm. The corpuscles which first were suspended in 
this space have now settled and are lying on the bottom 
of the cell, where they may be counted. The corpus- 
cles lying upon the lines should be counted, but, of 
course, only once. Thus, all corpuscles lying on the 
horizontal lines should be counted in the squares above 
them, and all corpuscles lying on the vertical lines 
should be counted in the squares to the right of them. 
The calculation is as follows: If by a dilution of the 
blood in the proportion of 1 : a, z corpuscles have been 
counted in n squares, then 1 c. mm. of undiluted blood 
will contain : 
3. Z 
4000 X blood corpuscles. 
If, for example, by a dilution of the blood in the pro- 
portion 1 : 100, as we supposed above, in 200 squares 
altogether 2570 red blood corpuscles were found, then 
the calculation will give for 1 c. mm. of blood- 
4000 X 100 X 257° -1 j 1 
& = 5,140,000 blood corpuscles. 
For counting the white blood corpuscles a pipette 
should be used which allows a dilution in the proportion 
of i : io, and instead of the salt solution an aqueous 200 
PHYSICAL DIAGNOSIS. 
per cent, solution of acetic acid should be chosen for 
diluting. The red corpuscles will disappear in this 
fluid, but the white ones will remain and are easily 
counted. The method of calculation is the same as 
that given above for the red blood corpuscles. 
Studies by Thoma and others, with a view to deter- 
mining possible errors with the instrument whose use 
has just been described, go to show the constant errors 
to be insignificant, less than one per cent., while the acci- 
dental and variable errors, which are unavoidable, 
diminish with the number of corpuscles counted. Thus, 
by counting 200 corpuscles they amount to five per cent, 
of the total result, by counting 
1,250 corpuscles amount to 2 per cent, of the total. 
5,000 " " 1 '' " " " 
20,000 " " " 
Recently, in 1885, Professor Blix, of Upsala, Sweden, 
suggested the use of centrifugal force in estimating the 
volume of red blood corpuscles, and Dr. S. G. Heden 
has devised an instrument called the hematokrit for this 
purpose. Dr. Judson Daland has further improved this 
instrument so that after the blood, diluted with an equal 
bulk of a 2.5 per cent, solution of bichromate of 
potash, has received the requisite amount of rotation, 
the percentage volume of red corpuscles may be read off 
from the cylindrical tubes in which the blood is placed, 
and from this deduced the number in each cubic milli- 
meter by simply adding six ciphers to the reading. 
Dr. Daland regards the hematokrit as both more TO MEASURE HAEMOGLOBIN. 
201 
speedy and more accurate than the cytometer, basing 
his conclusions on a very large number of comparative 
observations. He used also a great variety of fluids for 
dilution, and concluded that the above solution of 
bichromate of potash is, for many reasons, the best. 
The haematokrit also enables one to measure the volume 
of colorless blood corpuscles, but no method has yet 
been devised for calculating their number. 
TO MEASURE HAEMOGLOBIN. 
Such estimation is, of course, approximate. The best 
instrument for this purpose is the haemoglobinometer o 
Fleischl. It consists of a stage perforated by a central 
opening, below which is a gypsum reflector, .S', by which 
the light from a candle may be thrown directly into the 
opening. Into the latter is fitted a cylinder, G, divided 
by a partition into two equal parts, one half, a, being 
over the unobstructed opening, the other, a', over a 
wedge-shaped piece of glass interposed between it and 
the opening. The glass is colored with Cassius' gold 
purple, and presents, of course, a gradually increasing 
depth of color in passing from the thinner to the 
thicker end. The wedge of glass is movable by a rack 
and pinion alongside of a scale graduated in 100 equal 
parts, of which the figures 100 corresponds with the 
depth of color of a mixture of normal blood, and lower 
figures correspond with that of thinner blood. 
To use the instrument each demi-cylinder is filled 
with water, and into the one, a, opposite the unob- 202 
PHYSICAL DIAGNOSIS. 
strutted opening is put a quantity of blood measured in 
the little cylinder shown in the cut. The wedge of glass 
Fig. 33. 
Haemoglobinometer of Fleischl. 
is then moved along by the milled head, T, until the 
color of the blood solution exactly coincides with the STAINING OF TUBERCLE BACILLI. 
203 
color of the opposite half cylinder containing water 
only, but placed over the colored glass. The figure 
attained on the scale when the shades are identical indi- 
cates the percentage of haemoglobin. In point of fact, 
it rarely happens that a normal blood exceeds ninety 
per cent., a fact which should be borne in mind. 
STAINING OF TUBERCLE BACILLI. 
Of the various methods of staining tubercle bacilli 
that by the carbol-fuchsin solution of Ziehl-Neelsen, 
with or without Gabbet's counter stain of methyl blue, 
appears to stand the test of time as well, if not better, 
than any other. By this method the bacillus takes a 
bright red color from the fuchsin, the mordant being 
carbolic acid. 
The carbol-fuchsin sohition is made as follows:- 
Powdered fuchsin, I part. 
Alcohol, io parts. 
Five per cent, solution carbolic acid, 100 parts. 
Mix and filter. 
The older the solution the better. 
Two methods are practised with this staining fluid, a 
rapid and a slow, the former being more commonly 
practised for diagnostic purposes. 
i. The rapid method with carbolfuchsin without or 
with counter stain by methylene blue.-A very small 
clump of the most solid part of the sputum mass is 
selected and brought with forceps or platinum loop 204 
PHYSICAL DIAGNOSIS. 
on a clean cover glass. Upon this another cover glass 
is superimposed and the two are pressed and rubbed 
over each other until the specimen is thoroughly 
smeared over both. They are then separated and two 
specimens are thus obtained. When dry, one of these 
covers is passed, specimen side up, three times slowly 
over the flame of a spirit lamp or Bunsen-burner, by 
which the albumin is coagulated and the specimen 
fixed. The specimen is then completely covered with 
the staining fluid and held over the flame until the 
solution begins to vaporize, care being taken to keep all 
parts of the glass thoroughly covered. At the end of 
one minute it is washed in water. It is then decolorized 
in acidulated alcohol, eight or ten drops of HC1 or five 
drops HNO3 to a watch crystal of alcohol, and examined 
in the latter solution, preferably by a one-twelfth oil- 
immersion and Abbe's condenser, although a little 
experience with a dry lens of 350 diameters or higher 
will soon lead to the recognition of the bacilli, which 
are stained a handsome red. 
The preparation is more brilliant and its study rather 
less trying to the eyes if counter-stained, by Gabbet's 
acid blue, composed of- 
Methylene blue, 2 parts. 
Twenty-five per cent, solution sulphuric acid, . loo parts. 
After being washed in water, the specimen is im- 
mersed for one and a half to two minutes in the acid 
blue, washed off in water, dried between filtering paper, 
and examined in water. STAINING OF TUBERCLE BACILLI. 
205 
2. Slower method with carbolfuchsin, and counter- 
stain with Gabbet's acid blue. This slower method is 
always more satisfactory if time permits, and should 
alone be used for permanent preparations. 
The steps are the same until the staining stage is 
reached, when the cover-glasses containing the speci- 
men are placed in the carbol-fuchsin solution, say at 
five or six o'clock in the evening, and allowed to 
remain until next morning. They are then washed in 
water, counter-stained by Gabbet's acid blue solution, 
washed in water, dried between filtering paper, and 
studied in water, or if it is desired to mount the speci- 
men permanently, it is passed through alcohol, xylol, or 
oil of cloves into Canada balsam. Specimens stained 
in aniline colors should not be mounted in glycerin, as 
this gradually withdraws the stain. 
Sections are treated similarly by the slow method and 
mounted in balsam. 
When bacilli are very few, in viscid sputum, Biedert's 
method may be used. Fifteen centimeters of the sputum 
are mixed with 75 to 100 centimeters (about two tea- 
spoonfuls) water, four to eight drops, according to the 
density of the fluid, of liquor potassae added, and the 
whole boiled, four to six teaspoonfuls of water being 
gradually added, if necessary, until a thin fluid results. 
This is then allowed to stand in a conical glass for two 
days, when the supernatant fluid is removed and the sedi- 
ment examined as before. It is to be remembered that ba- 
cilli treated with alkalies stain slowly, and a longer immer- 
sion in the staining fluid may be necessary on this account. 206 
PHYSICAL DIAGNOSIS. 
THE PNEUMOCOCCUS. 
The Pneumococcus of Fraenkel- Weichselbaum is char- 
acterized by its lance-shape and capsulation as found 
in tissues and sputum. In cultures it is without cap- 
sule. Found most frequently in the lung in croupous 
pneumonia, it also occurs in the sputum of pneumonia, 
in fresh endocardial vegetations, and the pus of cerebro- 
spinal meningitis. It usually occurs in pairs (diplo- 
cocci), sometimes in filaments of three or four elements. 
The simplest extemporaneous stain is the carbol-fuchsin 
solution (p. 203). An immersion of a few minutes usually 
suffices, when the coccus itself will have become in- 
tensely red, while the capsule has assumed a light red- 
dish tint. The capsule may also be stained in the same 
way as that of Friedlander's bacillus, as below. 
The Fraenkel bacillus may also be stained by Gram's 
method, as follows :- 
1. The cover-glass preparation is placed for from two 
to five minutes in warm Ehrlich-Weigert's saturated 
anilin-water solution of gentian violet.* 
2. Transfer directly without washing into Gram's solu- 
tion (iodine 1, iodide of potas. 2, water 300) for from 
two to three minutes, where it becomes quite black. 
* Anilin oil, 4 parts. 
Distilled water, 100 parts. 
Shake, filter through moist filter and then add 
-Saturated alcoholic solution (stain 1, abso- 
lute alcohol 4) gentian-violet, or methyl-blue, 11 parts. 
Filter. THE PNEUMOCOCCUS. 
207 
3. Wash in absolute alcohol until the primary black 
color becomes pale gray. All the cellular elements 
are decolorized except the microorganism, which has 
assumed a deep blackish blue. 
4. Mount in Canada balsam. 
This method is particularly valuable in the differential 
diagnosis between this and the- 
Pneumococcus of Friedlander.-This bacillus is oval, 
encapsulated, and occurs, also, in pairs, and is some- 
times found in the lung of croupous pneumonia. 
It is also stainable in aqueous staining solutions as the 
bacillus of Fraenkel-Weichselbaum, the capsule remain- 
ing unstained. It cannot be stained by Gram's method. 
To stain the capsule in cover-glass preparations, 
Friedlander directs :- 
1. The prepared cover-glass, drawn three times 
through the flame, is placed in 1 per cent, acetic acid 
solution for two minutes. 
2. Remove the acetic acid by blowing on the cover- 
glass through a pointed glass tube, and allow to dry in 
the air. 
3. Stain for ten seconds in saturated anilin-water- 
gentian-violet solution. 
4. Wash in water, dry between filter paper, mount in 
balsam. 
For sections : - 
1. Stain for twenty-four hours in warmth in a solution 
composed of concentrated * alcoholic gentian-violet 
solution 50, distilled water 100, glacial acetic acid 10. 
* Ten grams of the powdered dye, 40 grams absolute alcohol. 208 
PHYSICAL DIAGNOSIS. 
2. Wash in one per cent, acetic acid solution. 
3. In alcohol to dehydrate. 
4. Mount in balsam. 
Bacillus of Diphtheria.-The short, curved bacil- 
lus assigned by Loffler as the cause of diphtheria is well 
stained by Lbffler's methylene blue solution of- 
Concentrated alcoholic solution methyl-blue 
(1-40), 30C.C. 
Caustic potash (1 : 10,000), too c.c. 
The Typhoid bacillus is stained by the same solu- 
tion. It is not stainable by Gram's method. 
The Cholera Bacillus is stained in the concen- 
trated aqueous solutions of fuchsin; sections by fuchsin 
solutions or methyl blue. A flocculent mass from a stool 
is treated between glass covers and dried and fixed as in 
the case of sputum. 
Bacillus of Syphilis.-De Giacomi's method. 
The cover-glass preparations made from the pus are 
warmed for a few minutes in the anilin-water fuchsin so- 
lution, then washed in water to which a few drops of a 
chloride of iron solution have been added, and decol- 
orized in a concentrated solution of chloride of iron. 
They are finally washed and studied in water. The syph- 
ilis bacillus remains red, while all other cells are decolor- 
ized. If desired to mount dehydrate rapidly in absolute 
alcohol, clarify in xylol and mount in Canada balsam. 
The gonococcus is very well stained by the carbol- 
fuchsin method already described for the tubercle bacil- 
lus. The true gonococcus is not stained by Gram's 
method. It is thus distinguished from similar microbes. EXAMINATION OF GASTRIC CONTENTS. 
209 
CHEMICAL EXAMINATION OF GAS- 
TRIC CONTENTS. 
A variety of test meals has been suggested, the pro- 
ducts of whose digestion are submitted to examina- 
tion. That which, on account of its simplicity, con- 
venience, comparative cleanliness, and easy manipu- 
lation of products, I prefer, is the test breakfast of 
Ewald. It consists of an ordinary dry roll,* weighing 
thirty-five grams (540 grains), and about one-third of a 
liter (ten ounces) of either warm water or weak tea with- 
out milk or sugar, taken fasting. 
One hour after the ingestion of the meal the product 
is removed by the flexible stomach tube. It is suf- 
ficiently lubricated by dipping into warm water, after 
which it is introduced by a process of deglutition. The 
tube should be about ninety-five centimeters (thirty- 
seven and a half inches) long. From the fundus of the 
stomach to the incisor teeth is sixty to sixty-five centi- 
meters (23.5 to 25.5 inches), and about this much 
should be taken up when the tube is well in place. 
The Ewald tube is usually marked at this place. 
A long tube allows the stomach to be emptied by 
syphonage after a little pressure on the abdomen has 
* Such a roll containing about 7 per cent, of nitrogen, .5 per cent, 
of fat, 4 per cent, of sugar, and 52.5 per cent, of non-nitrogenous 
extractive substances, and 1 per cent, of ash, includes, therefore, 
the usual elements of a mixed diet. 210 
PHYSICAL DIAGNOSIS. 
been exerted to start the motion of the contents, or 
they may be removed by aspiration. The amount 
withdrawn, which should be about 40 c. c., is first 
examined for blood or other abnormal constituents, and 
then filtered, being previously well shaken. This is 
done in order to diffuse uniformly the acid constituent. 
In healthful conditions, in ten or fifteen minutes after 
food ingestion the gastric contents are acid, the acidity 
depending on free acids or acid salts. At this stage 
the free acid recognized is lactic. Up to thirty to forty- 
five minutes the lactic acid predominates, while the 
color tests for hydrochloric acid are negative. Then 
comes a stage in which traces of HC1 can be demon- 
strated, co-existing with lactic acid. Finally, the lactic 
acid disappears altogether, and at the end of an hour HC1 
only should be present. HC1 is present from the be- 
ginning, but its recognition is interfered with because 
it is partly in combination, and because of the acid 
salts present. It gradually increases in amount until at 
the acme of digestion it reaches .15 to .2 per cent, after 
a light meal, and .2 to .33 per cent, after an abundant 
meal. 
To Determine the Total Acidity.-The reaction 
of the filtered fluid being determined by litmus or Congo 
red paper, the total acidity is then determined by titra- 
tion. A Mohr's burette is filled with a decinormal 
solution of caustic soda. Ten c. c. of the filtered solu- 
tion are placed in a beaker and one or two drops of an 
alcoholic solution of phenolphthallin added as an indica- 
tor. The solution is then slowly dropped from the burette EXAMINATION OF GASTRIC CONTENTS. 
211 
until the red color produced in the fluid by the action of 
the alkali on the phenolphthallin no longer disappears on 
shaking. As a rule, the acidity of the gastric contents, 
an hour after such a meal, requires four to six c. c. of the 
decinormal solution to neutralize it in normal digestion. 
Figures above and below this are therefore abnormal. 
The acidity may be expressed in percentage ; thus, if four 
c. c. were required to neutralize ten c. c. there would be 
40 per cent., or, if six c. c., 60 per cent, total acidity. If 
the acidity is due to HC1 alone its percentage is easily 
estimated. One cubic centimeter of the decinormal 
solution is equivalent to .003646 HC1.* If, therefore, the 
number of cubic centimeters used to neutralize ten c. c. 
of the solution be multiplied by .003646 and again by 
ten the result will be the percentage. Thus, if six c. c. 
of the deci-normal solution be used the percentage will 
be 6 X .003646 X 10 = .218, within the normal range, 
which is from .14 to .24 per cent.; if four c. c. be 
used the HC1 percentage will be 4 X-003646 Xio = .ii, 
or less than normal. 
To Determine Whether Acidity Depends on 
Free Acids or Acid Salts.-This may be roughly 
done by the anilin dyes, of which congo-red and tro- 
paeolin 00, I'orange Poirier of the French, are com- 
monly used. A saturated watery or alcoholic solution is 
made, or in the case of congo-red, strips of filtering 
* Decinormal solution of soda io NaH0=4 grams NaHO dis- 
solved in 1000 c. c. distilled water. Each c. c. of this solution 
exactly neutralizes 0.0036 gram HC1. 212 
PHYSICAL DIAGNOSIS. 
paper are dipped into such solution, dried, and thus pre- 
served for use. The paper is, however, less delicate than 
the solution, which strikes a beautifully sky-blue reaction 
with a solution containing but 0.02 per 1000. Acid 
salts produce no change. 
The tropseolin solution is dark yellowish red, and a 
solution of free acid, as HC1, .025 to 1000, changes it 
to a deep dark brown. It is slightly less delicate, 
therefore, than the congo-red. Acid salts, as acid 
sodium phosphate, make it straw yellow. In all of 
these tests it is necessary to use an excess of the fluid 
to be tested. This is accomplished by placing five or 
ten drops of the reagent in a test glass or porcelain 
capsule and adding one to two c. c. of the filtered con- 
tents. 
Only rough determinations can thus be made, as the 
delicacy of these tests is seriously affected by salts 
and albuminoids, especially albumose and peptones. 
It is better, therefore, to employ Leo's carbonate of 
calcium test, based upon the fact that CaOCO3 in 
cold solution neutralizes free acids only, not reacting 
with acid salts. A strip of blue litmus paper having 
been previously moistened with the filtrate as a standard, 
a few drops of the filtrate are thoroughly mixed in a 
watch-glass with a small amount of chemically pure 
powdered calcium carbonate. After the complete 
neutralization of the free acids and disappearance of 
the separated CO2, the reaction is tested with another 
piece of litmus and the result compared with the 
standard. If the litmus is no longer reddened the EXAMINATION OF GASTRIC CONTENTS. 
213 
acidity was due to free acids only, while if there is still 
redness, but less in degree than that of the standard, 
there are both free acids and acid salts. 
This test may be rendered still more delicate by ex- 
tracting the fatty acids by heat and the lactic acid by 
ether, when the free acid remaining will only be HC1, 
of which, according to Leo, .0002 per cent, may be de- 
tected if decided amounts of acid phosphates are not 
present, and even then .008 per cent. 
Determination of Hydrochloric Acid.-For this 
purpose Gunzburg's or Boas's test should be used ; the 
former is the more delicate. Gunzburg's solution is 
made as follows:- 
Phloroglucin,2 parts (gr. xxx). 
Vanillin,I part (gr. xv). 
Absolute alcohol,30 parts (f 
The solution is pale yellow and has a decided odor of 
vanilla. On exposure to light it assumes a dark golden- 
yellow, and it must therefore be kept in dark-hued 
bottles or be freshly made as required. 
A drop or two of the reagent is placed on a porce- 
lain plate or capsule with an equal quantity of the gas- 
tric filtrate, and a gentle heat applied, not to boil, but 
simply to evaporate. Very soon a beautiful rose-red 
tinge will appear at the edge of the mixture, or red 
stripes will be observed. Blowing at the edge will favor 
the appearance of the red stripes. This test is unmistak- 
able, and surpasses all others in delicacy, being avail- 
able when HC1 is present in the proportion of i to 214 
PHYSICAL DIAGNOSIS. 
20,000, or .05 per mille. Filtration of the gastric con- 
tents is not necessary. The reaction is not simulated 
by albuminates nor interfered with by salts in the nor- 
mal proportion, nor by organic acids. 
Gunzburg's test may even be used for quantitative esti- 
mation. By successively diluting the stomach contents 
until they no longer respond to the test, and bearing in 
mind that the limit of reaction is reached when there is 
but one part HC1 to 20000, we may make the required 
estimation. Thus, if it barely responds when the gas- 
tric fluid is diluted one-half, the proportion is 2 to 
20,000, or 1 in 10,000; if after being five times diluted 
it is 5 to 20,000, or 1 in 4000, and so on. 
Or Mintz's method may be used, as follows : Ten 
c. c. of the stomach contents are titrated with the deci- 
normal soda solution until a response with Giinzburg's 
reagent no longer occurs, testing a drop or two of the 
partly neutralized gastric contents with the addition of 
each one-tenth c. c., or fraction thereof. Then as one 
c. c. decinormal soda solution equals .0036 HC10., we 
have simply to multiply .0036 by the number of c. cs. 
used and the result will be the percentage required. 
Boas's test is based upon the fact that resorcin strikes 
a similar reaction with hydrochloric acid. The solution 
consists of 
Resublimed resorcin 5 parts (gr. Ixxv). 
White sugar, 3 " (gr. xlv), 
Dilute alcohol, 100 " iiiss). 
Three to five drops of the reagent are poured into a EXAMINATION OF GASTRIC CONTENTS. 
215 
porcelain dish and an equal quantity of stomach con- 
tents added. Heat is applied as in Gunzburg's test, 
and a purple red color appears at the edge of the drop. 
It is said also to detect .05 per mille of HC1. 
Determination of Organic Acids.-These in- 
clude lactic acid, acetic acid, and the true fatty acids, 
especially butyric. These acids, especially lactic, are 
normal in the early stage of digestion, but in the later 
stages, if detectable by the ordinary reagents, they are 
pathological. 
Lactic acid is recognized by its effect upon a very 
dilute, almost colorless, solution of neutral ferric chlo- 
ride, which is converted into a canary-yellow color by 
its action. This is LTffelman's test. It it rendered more 
certain when a few drops of a neutral ferric chloride 
solution are mixed with one or two drops of pure car- 
bolic acid, and adding water until the solution assumes 
an amethyst blue color. Instead of the pure carbolic 
acid about ten c. c. (fipjss) of a two to five per cent, 
solution of the acid may be used and the dilution com- 
pleted to the proper tint. A few drops of even a .05 
per mille solution of lactic acid (1 in 20,000) will 
change the blue to the distinctive yellow color. 
There are, however, sources of error. The lactates 
cause the same reaction, but this matters not, because 
we desire to recognize the lactic acid, whether in com- 
bination or not. The reaction, however, takes place 
with alcohol, sugar, and certain salts, especially phos- 
phates, which are often found in gastric contents. The 216 
PHYSICAL DIAGNOSIS 
color produced by phosphates is not identical, but if the 
filtrate operated with has a yellow tinge the resulting 
color may approximate very closely. Under these cir- 
cumstances the lactic acid must be extracted with ether. 
Two to five c. c. of the stomach contents are thoroughly 
shaken with three or four times the amount of ether. The 
ether is allowed to rise on top, which it does rapidly, and 
is then poured off into a glass beaker. More ether is 
added and the washing repeated until in all about 30 
c. c. (f§j) of ether have been used. The ether is then 
evaporated by placing the beaker, with its contents, in a 
vessel of hot water. The residue is redissolved in a few 
drops of water and one or two drops of Uffelman's re- 
agent allowed to fall from a pipette into the solution. 
Too much of the solution may mask the reaction. This 
test is much more delicate than tropaeolin, which may 
fail to show a reaction for free acid because of its con- 
cealment by acid salts. 
The fatty acids, especially butyric, strike a tawny yel- 
low color with a reddish tinge with Uffelman's chloride 
of iron solution, but .5 per 1000 or 1 in 2000 is re- 
quired before the reaction occurs. 
Fatty acids may also be detected by heating to the 
boiling point a few c. c. of the gastric filtrate in a test 
tube, over the mouth of which a strip of moistened 
neutral or blue litmus paper is placed. On this the 
vaporized acid will produce the usual change. 
The oily particles ofpure/lz/ may be recognized float- 
ing in the gastric contents or in the aqueous solution of EXAMINATION OE GASTRIC CONTENTS. 
217 
the residue after evaporating the ethereal extract. 
Butyric acid may also be separated in the form of drops 
by adding small pieces of calcium chloride. 
Acetic acid is easily recognized by its odor, but it 
may also be detected by neutralizing with sodium 
carbonate the watery residue after the removal of the 
ethereal extract, and then adding neutral ferric chloride 
solution. A striking blood-red color is struck, also 
produced by formic acid, but this is never a constituent 
of gastric contents. 
Alcohol, which is sometimes formed in the stomach 
in intense yeast fermentation, may be detected by 
Lieben's iodoform test applied to the distillate of the 
stomach contents, as follows: To a portion of the dis- 
tillate add a small quantity of liquor potassae, then a 
few drops of a solution of iodine and iodide of potassium 
(i, 2, 50). If alcohol is present a yellowish precipitate of 
iodoform takes place slowly. The same precipitate oc- 
curs with acetone, but rapidly. 
Examination of Products of Albumin Diges- 
tion.-The term proteolysis is applied to albumin 
digestion, in which all proteid substances are converted 
into peptone. It takes place partly in the stomach, but 
probably even to a greater degree in the small intestine. 
In this process the first step is the production of certain 
substances intermediate between albumin and peptone 
which are called albumoses or proteoses. Those which 
are of chief importance in the study of gastric digestion 
are syntonin or acid albumin, and propeptone or hemi- 
albumose. In the ordinary process of digestion with a 218 
PHYSICAL DIAGNOSIS. 
normal gastric juice some or all of these substances 
should be present at the end of a certain time. So far 
as they are the products of gastric digestion they 
may be studied by the aid of a test meal and removal 
of the gastric contents as already described. 
Propeptone and Peptone. - Propeptone at the 
maximum of normal digestion should be present only 
in traces and must be removed before peptone is tested 
for, since it responds to the same test,-the biuret test. 
To remove propeptone treat 2 or 3C.C. of the stomach 
filtrate with an equal quantity of a saturated solution of 
chloride of sodium and then add one or two drops of 
strong acetic acid. Propeptone if present is thus pre- 
cipitated, and may be filtered out. To the filtrate add 
one c.c. of liquor potassse, then a few drops of a one 
per cent, solution of sulphate of copper. A purple red 
color indicates the presence of peptone, and we may 
approximately estimate its amount by the intensity of 
the biuret reaction provided we always use the same 
proportion of stomach contents, solution of potash, and 
cupric sulphate. Should it happen that a handsome 
biuret reaction is struck before removing the propeptone, 
and but a faint one or none at all afterward, the pro- 
portion of propeptone is large and peptone small. Cahn 
has shown that in dogs, at least, the quantity of peptone 
remains at a certain percentage, being probably kept at 
that figure by its removal as formed. Hence the only 
index of the rapidity and extent of albumen transforma- 
tion is the amount of propeptone formed or remaining. 
Finally, Ewald and Gumlich conclude that the forma- EXAMINATION OF GASTRIC CONTENTS. 
219 
tion of true peptone in the human stomach is slight, 
albumoses being mainly produced, the chief transforma- 
tion of which is effected in the small intestine. 
To Estimate the Activity of Proteolysis, 
or Albumin Digestion.-By Ewald's method, 
coagulated white of egg is cut into thin slices and out 
of these small disks are cut by a cork borer or similar 
instrument. These may be prepared in quantity and 
kept for use in glycerin, which should, however, be washed 
off before using. An equal quantity of the filtered gastric 
fluid is placed in four small test-tubes and one or two 
disks of albumen put into each. To the first nothing 
else is added, to the second enough hydrochloric acid 
to make a solution of about* 0.3 to 0.5 per cent. This 
is accomplished by adding two drops of hydrochloric 
acid to five c.c. (90 minims) of stomach contents. 
To the third is added a definite quantity of pepsin, 
about 0.2 to 0.5 gram [gr. iij to gr. vijss], to the 
fourth both hydrochloric acid and pepsin. The test- 
tubes are placed in an incubator at about ioo° Fahr., 
and from time to time examined with a view to learning 
how far the liquefaction of the disks of albumen has 
proceeded. The rate of this will inform us whether 
digestion would have occurred without the addition of 
anything, or whether acid or pepsin or both were neces- 
* The difference between the strength of the acetic acid of the 
German pharmacopoeia (25 per cent, of the anhydrous acid), in- 
tended by Ewald, and that of the U. S. P. (32 per cent.) is not 
sufficient to necessitate a change of proportion. 220 
PHYSICAL DIAGNOSIS. 
sary. We will learn, also, whether by adding more 
hydrochloric acid we have made the acidity excessive. 
It must be remembered, however, that after the pep- 
tone has reached a certain percentage, its further 
production is retarded, or even suspended, so that there 
may be an apparently slow reaction with even a very 
active gastric juice. Ewald happily reminds us that all 
laboratory attempts to imitate digestion are defective 
in the important respect that with our test-tubes and flasks 
we can neither imitate absorption on the one hand, nor, 
on the other, allow for the onward movement to the in- 
testines of the gastric contents, two important functions 
by which the stomach strives to maintain a fairly uni- 
form degree of concentration of its contents. 
The Action of Rennet, the Milk-coagulating 
Element of the Natural Gastric Juice.-The sim- 
plest method of estimating the action of rennet is that of 
Leo. To ten c. c. of raw milk are added two to five 
drops of stomach contents. Raw milk is used because 
it coagulates ten times more rapidly than boiled milk, 
while neutralization is unnecessary because of the rela- 
tively small quantity of gastric juice used. The mixture 
is placed in the warm chamber at i oo° F., and coagulation 
should take place in from one minute to several hours. 
The characteristic coagulation of rennet is a cake of 
casein floating in clear serum, while acids produce 
lumpy and flaky masses. 
The rennet-ferment, or enzyme, does not exist pri- 
marily as such, but as a rennet-zymogen or proenzyme, 
which itself has no action on milk but is converted into EXAMINATION OF GASTRIC CONTENTS. 
221 
rennet by the action of any acid, as hydrochloric, or of 
warm chloride of calcium. This may be shown as fol- 
lows : If the spontaneous coagulating action of gastric 
juice on milk be destroyed by neutralization by an 
alkaline carbonate, this property may be restored by 
digesting with dilute hydrochloric acid or by the addi- 
tion of a five per cent, solution of calcium chloride. 
While fasting and at the beginning of digestion zymo- 
gen only is present in the stomach, but later both it and 
the ferment are found. An acid reaction for the cur- 
dling action of rennet is not absolutely necessary. 
Digestion of Starch and Sugar.-It is well 
known that during digestion starch is converted into 
grape sugar, and cane sugar is converted into invert 
sugar-a mixture of cane and grape sugar. This action, 
commenced in the mouth by the ptyalin of saliva, 
is continued to a less degree so long as the acidity is 
slight, (.01 per cent, for HC1, .1 or .2 per cent, for 
lactic, .4 per cent, for butyric) in the stomach, and is 
finished in the small intestine by the trypsin of the 
pancreatic juice. As in albumin digestion, there are 
intermediate substances between albumin and peptone, 
so between starch and grape sugar there are similar 
intermediate products. The order is as follows :- 
(1) Starch, (2) Dextrins (Erythrodextrin, Achroodex- 
trin), (3) Maltose, (4) Dextrose = grape sugar. 
Starch is recognized by the deep blue color struck 
with iodine or Lugol's solution (iodine 1, iodide of 
potassium 2, distilled water 200), and the reaction 
grows less vivid as the starch is converted. Of the PHYSICAL DIAGNOSIS. 
222 
dextrins, erythrodextrin strikes not a blue, but a purple 
color, while solutions of achroodextrin, maltose, and 
grape sugar take on only the yellow color of the iodine 
solution. Where a mixture of these substances occurs 
the first few drops of the iodine solution produce no 
color at all, or only a transitory one, being taken up by 
the dextrose and maltose, while the addition of more 
iodine strikes the purple of erythrodextrin or blue of 
starch. 
If, therefore, amylaceous transformation has pro- 
gressed normally in the mouth and stomach, so much 
starch should be changed into achroodextrin, maltose, 
or dextrose that the addition of small quantities of 
Lugol's solution does not strike the characteristic color. 
If, however, the blue or purple reactions appear, con- 
version has not been sufficiently rapid into maltose, 
the principal product of gastric conversion, the change 
into dextrose, being completed in the small intestine. 
This may be due either to a deficiency of ptyalin or a 
too rapid production of acid in the stomach. From 
such event we might also infer a hyperacidity of the 
gastric juice. 
To Determine the Rapidity of Absorption 
from the Stomach.-Penzoldt's method is that gen- 
erally followed. A capsule containing iodide of potas- 
sium (.i gram or gr. jss) is swallowed, being first care- 
fully wiped to remove any adherent particles. The ap- 
pearance of the iodide in the saliva indicates that ab- 
sorption has taken place from the stomach. To deter- 
mine this, starch paper is first prepared by moistening EXAMINATION OF GASTRIC CONTENTS. 
223 
with starch paste and drying. Then, after the salt is 
swallowed, a piece of the paper is moistened every five 
minutes with the saliva, and the moistened spot touched 
with fuming nitric acid. As soon as the iodine appears 
in the saliva the characteristic blue reaction is struck. 
When absorption is normal this reaction usually takes 
place in ten or fifteen minutes, but where absorption is 
abnormally delayed, the reaction is also delayed half an 
hour or more, or it may not occur at all. 
To Test the Motor Function of the Stomach. 
-Three methods are practised. First, remove the 
gastric contents six to seven hours after the ingestion of 
a large meal, or two and a half hours after an Ewald's 
breakfast, and note the amount of solid substance 
remaining. Second, salol is administered and the 
products of its lysis sought for in the urine. Third, 
a definite quantity of olive oil is introduced into the 
empty stomach and the remnant unabsorbed is with- 
drawn at the end of two hours. The second, though 
not without drawbacks, is preferred. Salol is com- 
posed of phenol and salicylic acid, into which it 
is broken up by the action of the pancreatic juice, 
but not by the acid gastric contents. Salicyluric 
acid, a product of decomposition of salicylic acid, ap- 
pears in the urine 40 to 60, or at most 75, minutes after 
taking one gram (15 grs.) of salol when gastric peris- 
talsis is normal. Salicyluric acid is readily detected in 
the urine by the violet color produced on the addition 
of neutral ferric chloride solution. The method em- 
ployed is to place a drop of urine on a piece of filter- 224 
paper and bring in contact with this a drop of a io per 
cent, ferric chloride solution. The edge of the drop 
will strike a violet color in the presence of a mere trace 
of salicyluric acid. 
The objection to the salol test is that the decompo- 
sition of the salol may be delayed by an undue acidity 
of the gastric contents discharged into the duodenum. 
But practically this is found not to be a serious drawback, 
tolerably constant results being obtained by Ewald and 
Sievers. To meet this objection, however, Huber sug- 
gested that the outside limit of excretion of salicyluric 
acid be determined, that is, the point noted when salicy- 
luric acid fails to appear in the urine after the ingestion 
of a gram (15 grs.) of salol. This should be at the end 
of twenty-four or thirty hours. If, therefore, it is con- 
tinued after this, peristalsis must be slow. 
In Klemperer's oil test 100 c. c. oz.) of olive 
oil are introduced into the stomach by the stomach 
tube after the stomach is thoroughly washed out. Two 
hours later the stomach is aspirated, and if there is 
motor sufficiency the remnant of oil should be a mini- 
mum. If any decided quantity remains peristalsis is 
slow. 
PHYSICAL DIAGNOSIS. THE MAKING OF AN AUTOPSY. 
225 
THE MAKING OF AN AUTOPSY* 
Previous to section a general survey of the body 
should be made with a view to noting marks, scars, 
state of the body as to obesity and emaciation, and 
degree of rigor mortis. 
A position to the right of the body is usually more 
convenient for the right-handed examiner, while the 
left side is more convenient to one who is left-handed. 
To the ambidexter it is indifferent on which side he 
stands. The appended directions imply that the knife 
is held in the right hand. 
The first incision is made with a strong, broad-hand- 
led knife by a sweeping traction movement down the 
median line from the suprasternal notch to the pubis. 
Then the skin and subjacent muscles of the thorax 
are cut back and the section through the abdominal 
walls carefully completed, avoiding perforation of the 
intestines. The muscles are also separated from the 
edge of the thorax and the abdominal walls laid back, 
so as to expose as much as possible the abdominal 
viscera before opening the thorax. This is done in 
order to preserve the natural relations of the abdominal 
viscera to each other and to the diaphragm, relations 
which are altered as soon as the thorax is opened by 
* The directions here given are for an autopsy for clinical pur- 
poses, and not for the medico-legal investigation, which is much more 
elaborate. The general plan adopted is that laid down by Virchow 
in his little book on " Post-mortem Examinations," which the writer 
has followed for many years with great satisfaction. 226 
PHYSICAL DIAGNOSIS. 
the removal of the sternum and attached cartilages 
An inspection of the abdominal contents is then made, 
the absence or presence of fluid or abnormality noted, 
without, however, as yet removing or making any section 
of the organs. 
Then the cartilages are cut through near their junction 
with the ribs from the second downward; this is 
often done on each side by one sweep of the knife in 
the hands of the skilled sectionist, if the subject is not 
too old. If not complete, the section of the cartilages 
and muscular interspaces should then be thoroughly 
completed, by the bone forceps if necessary, and the 
clavicle and first rib disarticulated from the sternum, 
bearing in mind that the articulation is an oblique one. 
Or, if it is preferred, the knife may be drawn through the 
middle of the second cartilage, when it will strike the 
junction between the first and second bones of the ster- 
num, leaving the manubrium, with the articulation of the 
clavicle and first rib, intact. This, however, restricts 
the space over the origin of the great vessels rather 
inconveniently, and the former method is to be pre- 
ferred unless the latter is necessitated for some special 
reason. The sternum should be raised, beginning with 
the tip, and the muscles and other tissues shaved close to 
its under surface. This act uncovers the mediastinal 
septum and opens the two pleural sacs, without, how- 
ever, incising the pericardium, if the section has been 
successful. 
The pleural sacs should now be examined by insert- 
ing the hand between the lungs and the ribs and the THE MAKING OF AN AUTOPSY. 
227 
diaphragm, with a view to finding adhesions or fluid, 
and the latter, if present, should be removed and 
measured. Outgrowths or inequalities of the pleural 
surfaces, pulmonary, costal, and diaphragmatic, should 
be looked for. The lungs should, however, be left re- 
maining in situ as yet. 
The pericardium should then be opened, and the 
position of the heart observed. If an abnormal amount 
of fluid is present, it should be removed and measured. 
The external appearance of the heart, its size, shape, 
and consistence, should be noted; also the state of ful- 
ness of the superficial vessels, the amount of superficial 
fat, adhesions, or other abnormality. 
The heart should then be opened in situ, with the pur- 
pose of examining the quantity and quality of blood in 
the separate cavities and the size of the orifices. In 
thus opening the organ it is held in the left hand with 
the index finger pressed well under and against the base, 
so that the ventricles project laterally. It is then 
rotated to the left until the right border comes into 
view, being easily recognized by the relative thinness of 
the wall here as compared with that of the left ventricle 
on the other side of the septum. At the right border, 
close to the base, the knife is deeply thrust into the right 
ventricle, and drawn to the apex. With the heart still 
thus held, the right auricle is incised midway between 
the entrances of the two venae cavae. The blood is then 
removed from the right auricle, its quantity and quality 
observed. The index and middle fingers of the left hand 
are now passed from the auricle through the tricuspid 228 
PHYSICAL DIAGNOSIS. 
orifice into the right ventricle. Then the blood is re- 
moved from the right ventricle. The right normal 
auriculo-ventricular orifice in the adult should receive 
three fingers, the index and middle finger of the left 
hand so far separated that the index finger of the right 
may be passed up between them from the right ven- 
tricle. 
To make the openings for the left side, the apex of 
the heart is drawn up to the left, and placed in the 
left hand in such way that the fingers encircle it 
at the base. Pressure is now made so that the wall of 
the left ventricle bulges out a little and separates itself 
from the septum, when the incision is made behind the 
base through the wall into the left ventricle and out at 
the apex. For the left auricle the incision begins at 
the left superior pulmonary vein, and ends in front of 
the base usually indicated by the coronary vein, 
which should not be injured. 
The blood is now removed from the left cavities, and 
the size of the auriculo-ventricular orifice determined. 
Here we have to consider the contraction of the ventri- 
cle which closes the orifice, and we have to gradually 
overcome this contraction, when we may introduce 
the three fingers named above with less facility than into 
the tricuspid orifice, the mitral being 4.5 cm. (1.8 in.) 
in diameter as against 5 cm. (2 in.) for the tricuspid. 
The fingers should be very carefully introduced and 
withdrawn, so that no abnormal vegetations or coagulse 
are removed, for the valves have not yet been examined. 
The next step is the removal of the heart. This is THE MAKING OF AN AUTOPSY. 
229 
done by thrusting the index finger of the left hand into 
the left ventricle and the thumb into the right through 
the existing openings. The heart is then raised and 
the venae cavae, pulmonary veins, the pulmonary artery, 
and aorta severed as far as possible from the heart. The 
orifices of the aorta and pulmonary artery are then 
examined with a view to discovering changes in their 
walls or lumen. 
The hydrostatic test is then applied for the suffi- 
ciency of the aorta and pulmonary valves by pouring 
water into each vessel while the heart is freely suspended. 
Previously, however, all coagula should be carefully 
removed from the orifices and ventricles. The plane of 
the orifice should also be exactly horizontal, and for 
this two hands are necessary to accomplish the proper 
support, and the water must be poured in by a second 
person. The aorta should also be cut again, short 
enough to enable one to see from above the state of 
the valves. Care should be taken to avoid wounding 
the coronary arteries, for if this accident happen, the 
water may run off into them and give the impression of 
insufficiency when it does not exist. 
There is no hydrostatic or other test available to 
show the sufficiency of the auriculo-ventricular valves. 
We are next ready to open the ventricles and exam- 
ine the interior, including the valves. The heart is 
placed on a board or table, as nearly as possible in its 
position in the body. A long pair of scissors is the 
most satisfactory instrument for this purpose. For the 230 
PHYSICAL DIAGNOSIS. 
right ventricle one blade is introduced into the apex 
end of the incision previously made in the right 
border and carried on to the middle of the exposed 
surface of the pulmonary artery, care being taken to 
pass in front of the anterior papillary muscle of the 
tricuspid valve with its chordae tendineae. 
To display the left ventricle is more difficult. We in- 
troduce one blade of the scissors at the apex close to 
the septum, and while drawing the pulmonary artery to 
the right, cut to the left and behind the vessel midway 
between it and the right border of the left auricle through 
the anterior wall of the left ventricle and the aorta. If 
we pass too far to the left we will cut through the right 
border of the base of the mitral valve, which corres- 
ponds with the right border of the left auricle ; if too 
far to the right we cross the pulmonary orifice and may 
cut through the valves of the pulmonary artery. 
The auricles can be further opened by cutting with 
the scissors on the right between the openings of the 
venae cavae, and on the left between those of the pul- 
monary veins. 
The adult heart weighs in health in the male 50 to 60 
years old about 335 grams (11.8 oz.); in the female 295 
grams (10.44 oz.). 
The average thickness of the wall of the left ventricle 
is 1.6 to 1.7 cm. (£4 to -/i in.); of the right ventricle 
.4 to .6 cm. to in.). 
The lungs are now removed, their surface examined 
for emphysematous distention or subpleural deposits, THE MAKING OF AN AUTOPSY. 
231 
and then incised longitudinally with a view to the dis- 
covery in their interior of tubercular infiltration, cavi- 
ties, changes in the bronchi, etc. 
The lungs weigh, in the male, the right, 859.5 grams 
(30.3 oz.) ; the left, 811.6 grams (28.6 oz.) ; in the 
female, the right, 552 grams (19.48 oz.); the left, 296 
grams (10.4 oz.). 
For the examination of the pharynx, larynx, oesopha- 
gus, and thyroid gland, the central incision should 
be carried up to an inch below the chin. The first 
three should be slit up with the enterotome, the last 
dissected off. The thyroid varies a good deal in weight, 
usually about 30 grams or oz. 
The Abdominal Organs are now examined in the 
following order:- 
1. The omentum. 
2. The spleen, which is longitudinally incised. 
The organ in health weighs about 176 grams (6.23 
oz.). 
3. The left and right kidney, with their suprarenal 
capsules and ureters ; the kidney being stripped of its 
capsule and longitudinally incised. 
The adult kidney weighs 124.7 t0 T54-3 grams (4.4 
to 5.4 oz.) ; the suprarenal capsules 4 grams to 8 grams 
(60 to 120 grains). 
4. The bladder, prostate gland, vesiculae seminales, 
urethra. The prostate weighs in health about 31 
grams (1% oz.). 
5. Testicles, spermatic cord, and penis. The testis 232 
PHYSICAL DIAGNOSIS. 
with the epididymis weighs about 24.5 grams to 
oz.). 
6. Vagina, uterus, Fallopian tubes, ovaries, parametria. 
The average weight of the uterus is 14 7 to 56 grams 
(1 to 2 oz.); of the ovaries 3.9 to 6.5 grams (60 to 100 
grains). 
7. The rectum. 
8. The duodenum, portio intestinalis of the ductus 
communis choledochus. 
9. Stomach. 
10. Hepato-duodenal ligament, gall ducts, venae 
portae, gall bladder, liver. 
The stomach and duodenum, under ordinary circum- 
stances, should be examined in situ. The duodenum 
should be opened first, its contents examined above and 
below the biliary papilla. The latter should be ex- 
amined, its contents expressed, and its patulousness 
determined by pressing gently on the gall bladder. 
Finally, the common bile duct should be slit up. The 
vena cava should be examined, and not until then 
should the liver be removed and examined. Sections 
should be made through the organ horizontally, from 
right to left, to display its interior. The gall duct should 
not be probed, as a duct essentially closed may thus 
be opened. 
The liver weighs in health, from about 1247.4 grams 
(44 oz.) in the female to 1569.7 grams (55 oz. avoir- 
dupois). 
11. The examination of the pancreas naturally fol- THE MAKING OF AN AUTOPSY. 
233 
lows the stomach and duodenum and liver, and after it 
the coeliac (semilunar) ganglia. 
The organ weighs 70 to 108 grams (2)4 to 3)4 oz.). 
12. Mesentery with glands, vessels. 
13. Small and large intestines. These, after the 
examination of the stomach and duodenum in situ, 
should be removed, placed on a board or in water, and 
laid open, care being taken on opening the small in- 
testines to keep on the line of the mesentery. The 
solitary glands and glands of Peyer should be carefully 
examined. 
14. Retro-peritoneal lymphatic glands, receptaculum 
chyli, aorta, vena cava inferior. 
Examination of the Brain.-The scalp is divided 
by an incision across the top of the head from ear to 
ear, and reflected backward and forward, noting the 
presence or absence of extravasated blood. The skull- 
cap is now sawn through by a horizontal cut, care being 
taken not to wound the dura mater. To this end the 
chisel and hammer are used to break through the inter- 
nal table. But it is sometimes impossible, to avoid in- 
juring the dura and it may even be necessary to cut it 
through in consequence of the difficulty in separating 
it from the skull-cap. The thickness of the cranial 
bones, their internal surfaces, and the condition of the 
diploe are examined; also the external surface of the 
dura mater and the state of the sinuses. The brain is 
then removed, severing the cord as low as possible 
through the foramen magnum, and effusion on the base 
of the cranium looked for. The dura is separated and 234 
PHYSICAL DIAGNOSIS. 
the appearance of the arachnoid and pia noted. Also 
that of the large arteries at the base ; atheroma is espe- 
cially sought. In health the visceral arachnoid presents 
a faint, opalescent appearance, and any turbidity or 
opaqueness beyond this points to meningitis. The 
state of the blood-vessels in the pia is carefully 
examined, and the presence or absence of effusion 
noted. As the pia mater is drawn aside the blood-ves- 
sels which dip down between the sulci into the fissure 
of Sylvius are examined, especially their sheaths. 
The pia being removed, the surface of the brain is 
examined, the depth of the sulci, flattening of the con- 
volutions, and any marked deviations in their arrangement 
noted. 
The dissection of the brain is now commenced, 
beginning with the opening of the lateral ventricles. 
This is done, after drawing apart the halves of the 
cerebrum, by an incision one millimeter inch) 
on each side of the median line in the corpus callosum 
directly downward, when the middle portion of the 
lateral ventricle is reached at the depth of two or three 
millimeters to | inch). The anterior and posterior 
cornua of the lateral ventricle are then opened by hori- 
zontal incisions from this point into the anterior and 
posterior lobes of the brain. Thus the lateral ventricles 
are exposed throughout their extent, and their contents, 
the state of their walls, and the venous plexuses ex- 
amined ; also the septum lucidum, with its contained 
fifth ventricle. 
The septum is then seized from behind the foramen THE MAKING OF AN AUTOPSY. 
235 
of Monro and the scalpel pushed in front of the fingers 
through this foramen, and the corpus callosum cut 
through obliquely upward and forward, and then these 
parts (the corpus callosum, septum lucidum, and fornix) 
are carefully detached from the velum interpositum and 
choroid plexus, which are examined as to the state of 
their vessels and tissue. 
The handle of the scalpel is then passed from the 
front under the velum, which is thus detached from the 
pineal body and corpora quadrigemina, which are 
examined. The third ventricle is then exposed. 
Finally, the corpora quadrigemina and the cerebellum 
are divided as far as the aqueduct of Sylvius and the 
fourth ventricle. 
The hemispheres of the cerebrum and cerebellum are 
now sliced by transverse incisions rather than longi- 
tudinal ones, because in this way the parts can again be 
more easily united if desired, with a view to determine 
the relation of parts or the seat of lesions. 
The optic thalami and corpora striata are cut by fan- 
shaped incisions radiating from the peduncle of the 
cerebrum. 
The adult brain of the male weighs on an average about 
1400 grams (49% oz. avoird.), of the female 1245 grams 
(44)4 oz. avoird.). The cerebrum alone weighs 1244 
grams (43 oz. 15 dr.) in the male, and 1098 grams (38 
oz. 12 dr.) in the female; the cerebellum grams 
(5 oz. 4 dr.) in the male, in the female 137 grams (4 oz. 
12)4 dr.). The pons and medulla oblongata weigh 28 236 
PHYSICAL DIAGNOSIS. 
grams dr.) in the male, and in the female 28.8 
grams (1 oz. dr.). 
The removal of the spinal cord is a laborious operation. 
The spinal canal is opened, preferably from behind, by 
dissecting back the skin from the median line and saw- 
ing upon each side of the spines of the vertebrae, or by 
using a double saw. The cord when removed is care- 
fully examined as to its membranes, and transverse in- 
cisions made at intervals of a half-inch or less, leaving 
the membrane intact at one spot, so that the pieces are 
all held together like the leaves of a book. 
The spinal cord weighs 37.2 grams (1 oz. 5 dr.) in the 
male, and 35.43 grams (1 oz. 4 dr.) in the female. 
Name, nativity, and residence. 
Age. 
Occupation. 
Social condition [married or single]. 
Habits of patient [z. e., as to mode of living, tem- 
perance in eating and drinking]. 
Family history. 
Health of parents, brothers, sisters, and children. 
History of previous diseases. [Previous history.] 
The diseases experienced by the patient before the 
present illness [z. e., diphtheria, scarlet fever, ty- 
phoid fever, rheumatism, malaria, pneumonia, 
pleurisy, venereal diseases, etc. 
ORDER OF EXAMINATION OF PATIENT. THE MAKING OF AN AUTOPSY. 
237 
History of present disease or of previous attacks of 
same disease. 
ist. Ask how long patient has been sick. Ascertain 
this definitely by suitable questions. 2d. Get the 
symptoms in regular order from the beginning to 
the present. 
Present condition, that is, the symptoms of which the 
patient complains at present. 
Physical examination. [Patient stripped.] 
1. General appearance of patient. 
2. Chest : Inspection, palpation, mensuration, per- 
cussion, auscultation. 
3. Abdomen. 
4. Special parts. INDEX. 
ABDOMEN, auscultation of, 194 
inspection of, 184 
percussion of, 189 
palpation of, 185 
physical examination of, 182 
Absorption, to determine rate of, 222 
Acids, fatty, 215 
organic, determination of, 215 
Acid, butyric, 215 
hydrochloric, determination of, 
213 
Acidity of gastric contents, determin- 
ation of total, 210 
Acute bronchitis, 81 
miliary tuberculosis, 92 
Adventitious sounds, 76 
iEgophony, 76 
Albumin digestion, products of, 217 
Amphoric breathing, 71 
resonance,57 
voice, 76 
Anatomy, medical, of thorax, 15 
Aneurism, thoracic, 173 
Aortic diastolic murmur, 127 
murmurs, 126 
obstruction, or stenosis, 152 
regurgitation, or insufficiency, 154 
stenosis and regurgitation, 157 
systolic murmur, 126 
Apoplexy, pulmonary, 97 
Arterial murmurs, abnormal, 133 
murmurs, normal, 132 
tension, prolonged, 138 
low, 139 
Asthma, spasmodic, 85 
Auscultation, 59 
of the normal lung, 63 
voice, 73 
Autopsy, making of, 225 
Bacillus of cholera, staining of, 208 
of diphtheria, staining of, 208 
Bacillus of pneumonia, staining of, 206 
of tubercle, staining of, 203 
Bell tympany, 57 
Biermer's change of note, 56 
Blood, examination of, 196 
corpuscles, counting of, 196 
Borders of the lungs, 23 
Breathing sounds, abnormal modifi- 
cations of, 66 
Bronchial breathing, 64 
breathing, changes in, 70 
Bronchitis, acute, 81 
capillary, 81 
chronic, 82 
Bronchophony, normal, 74 
Broncho-pneumonia, 96 
Bruit de diable, 134 
Cancer of lung, 99 
Cardiograph in diagnosis, 141 
Cardio-respiratory murmur, 129 
Catarrhal phthisis, 87 
pneumonia, 06 
Cavernous breathing, 70 
Chest, regions of, 11 
Cholera, staining of bacillus of, 208 
Cirrhosis of lung, 91 
Collapse of lung, 98 
Congenital defects of heart, 161 
Consumption, 86 
Cracked-pot sound, 57 
Crackling rales, 78 
Danger, relative of different forms of 
valvular heart disease, 162 
Dilatation of the heart, 170 
Diphtheria, staining of bacillus of, 
208 
Dulness, percussion, 38, 45, 114 
relative, of liver, 48 
Duration of percussion sounds, 44 
239 240 
INDEX. 
Emphysema, interlobular, of lung, 85 
vesicular, of lungs, 83 
Endocarditis, acute, 167 
Examination of patients, order of, 236 
Exocardial sound, 129 
Fatty infiltration, 171 
Fatty metamorphosis, 172 
Fibroid phthisis, 91 
Foetal heart beat, 195 
Frequency of different forms of val- 
vular heart disease, 162 
Friction sound, 79 
pleural, 79 
pericardial, 129 
Functional murmurs, 130 
Gastric contents, chemical examina- 
tion of, 209 
General considerations, 9 
Gerhardt's change of note, 55 
Gurgling, 77 
Haemic murmurs, 130 
Haemoglobin, to measure, 201 
Heart, absolute dulness of, 114 
anatomical relations of, 109 
auscultation of normal, 115 
congenital defects, 161 
dilatation of, 170 
fatty infiltration, 171 
metamorphosis, 172 
percussion borders of, 112 
physical examination of, 109 
relative dulness of, 114 
sounds, abnormal modifications 
of, 120 
impurity of, 128 
intensity of, 121 
mechanism of, 116 
reduplication of, 120 
time of, 119 
Hemorrhagic infarct, 97 
Hydrochloric acid, determination of, 
213 
Hydropericardium, 168 
Hypertrophy, general, of the heart, 170 
of the left ventricle, 169 
of the right ventricle, 170 
Inspection, 26 
Intensity of sounds, 38 
Intestines, percussion of, 190 
lactic acid, determination of, 215 
Lung, cancer of, 99 
cirrhosis of, 91 
collapse of, 98 
Lung, compressed, 99 
normal, auscultation of, 63 
Lungs, outline of, 23 
Mensuration, 26 
Metallic tinkling, 80 
Metamorphosing breath sound of 
Seitz, 72 
Mitral diastolic murmur, 125 
insufficiency, 146 
insufficiency and stenosis, 152 
murmurs, 124 
obstruction, or stenosis, 149 
presystolic murmur, 125 
systolic murmur, 124. 
Motor, function of stomach, 223 
Mucous rale, 77 
Murmurs, aortic, 126 
cardiac, 121 
cardio-respiratory, 129 
functional, 130 
mitral, 124 
organic, 124 
vascular, 132 
venous, 134 
Medical anatomy of the thorax, 15 
Myocardium, diseases of, 169 
Myositis, acute, 173 
Normal breathing sounds, modifica- 
tions of, 63 
chest, percussion of, 44 
CEdema, pulmonary, 98 
Ovarian cysts, percussion of, 193 
Palpation, 31 
Pectoriloquy, 75 
Peptone, 218 
Percussion, 33 
auscultatory, 35 
of bladder, 193 
dulness, 38 
of normal chest, 44, 
respiratory, 36 
sounds, abnormal of lung, 50 
attributes of, 36 
duration, 44 
intensity of, 38 
quality of, 36 
of stomach, 190 
topographical, 44 
Pericarditis, 168 
Phthisis, catarrhal, 87 
fibroid, 91 
tubercular, 86 
Pitch of sounds, 39 
Placental murmur, 195 INDEX. 
241 
Pleurisy, acute, too 
chronic, 103 
Pneumonia, 93 
acute croupous, 93 
catarrhal, 96 
embolic, 97 
lobar, 93 
lobular, 96 
Pneumothorax, 107 
Pneumococcus, staining of, 206, 207 
Praecordium, in 
Presystolic murmur, 124 
Propeptone, 218 
Pulmonary apoplexy, 97 
oedema, 98 
murmur, 128 
obstruction, or stenosis, 160 
regurgitation, 161 
Pulse tracing, normal, 136 
Quality of sounds, 36 
Rales, 76 
dry, 77 
moist, 77 
mucous, 77 
Regions of the chest, it 
Rennet, action of, 220 
Resonance, amphoric, 57 
tympanitic, 53 
vesicular, 37 
vesiculo-tympanitic, 40 
Seitz's metamorphosing breath sound, 
72 
Shapes of chest. 27 
Spleen, percussion borders, 189 
Skoda's sign, 53 
Sphygmograph in diagnosis, 135 
Sputum, examination of, 196 
Staining of bacilli of tubercle, 203 
cholera, 208 
diphtheria, 208 
pneumococcus, 
206, 207 
Starch, digestion of, 221 
Stomach, percussion, 190 
Sugar, digestion of, 221 
Tricuspid obstruction, or stenosis, 159 
murmur, 128 
regurgitation, 157 
Tubercle bacilli, staining of, 203 
Tubercular phthisis, 86 
Tuberculosis, acute miliary, 92 
Tympany, 39, 53 
Valves, cardiac, topography, 118 
Valvular defects, relative frequency 
of, 162 
gravity of. 162 
Vascular murmurs, 132 
Venous hum. 134 
murmurs, 134 
Vesicular murmur, 64 
breathing, 64 
murmur, changes in, 66 
resonance, 37 
Vesiculo-tympanitic resonance, 51 
Vocal resonance, diminished, 76 
normal, 73 
Voice, abnormal modifications of the 
auscultated, 75 
auscultation of, 73 
whispering, 74 
Wintrich's change of note, 54 
Whispering voice, 74