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ESSENTIALS
THE  PHYSICAL   DIAGNOSIS
Thoracic  Diseases.
                          \  f
      E. DARWIN HUDSON] Jr., A.M., M.D.,
Professor of General Medicine and Diseases of the Chest in the New York
    Polyclinic, Physician to Bellevue and St. Elizabeth Hospitals.
Prepared for the use of  the Physicians in the Class of General Medicine and
  Diseases of the Chest of the New York Polyclinic.  The system of Walshe
     has been largely followed, with modifications after Flint, Da Costa,
               Loomis, Learning, and others.
NEW  YORK
Styles & Cash, Printers and Stationers, 77 Eighth Avenue.

                 1885. 
7+68 5 e
  16€5
Entered according to Act of Congress, in the year 1885, by E. Darwin Hudson, Jr.
             in the office of the Librarian, at Washington.
0 
THORACIC  DISEASES.
PRINCIPLES   OF   PHYSICAL   DIAG-
                    NOSIS.
     REGIONAL ANATOMY OF THE CHEST.
  A knowledge of Thoracic Diseases is to be obtained main-
ly by physical diagnosis.
  Before entering upon  the study of physical signs, it  is
essential to have thorough knowledge of the structure of the
chest, its walls, and the situation and size of the organs  in
health—that is the regional anatomy or topography of the
chest.
TOPOGRAPHY OF  THORAX.

     REGIONS OF THE CHEST.
 1. Supraclavicular.
 2. Clavicular.
 3. Infraclavicular
 4. Mammary.
 5. Inframammary
j 6. Suprasternal.
| 7. Upper sternal.
[ 8. Lower sternal.
\ 1. Axillary.
[ 2. Infra-axillary.
 1. Upper scapular.
 2. Lower scapular.
 3  Infrascapular.
 ■4. Interscapular.
i.  Anterior Regions.   4
2.  Lateral  Regions.
3.  Posterior  Regions. 
4
               ANTERIOR REGIONS.

I.  Supraclavicular.            Boundaries.
    (a.) Internal   .    .    .    Trachea.
    (o.) Superior and external,  Line  drawn  from  upper
                                part of trachea to acro-
                                mion process.
    (c.) Inferior,   .    .    .    Upper border of clavicle.
  It is a triangular space,
          The Structures Contained are :
    (1) Apex  of  lung.         (4)  Subclavian artery.
    (2) Carotid  artery.          (5)  Subclavian vein.
    (3) Jugular vein.

2.  Clavicular.
    Location, behind the  inner three-fifths of the clavicle.
          The Structures Contained are :
(A.)   On right side.    (B.)  On left  side.
    1. Lung tissue.           1. Carotid artery.
    2. Subclavian artery.      2. Lung tissue.
    3. Arteria innominata.    3. Subclavian artery.

3.  Infraclavicular.           Boundaries.
    (a.) Internal,   .    .    .  Edge of sternum.
    (6.) Superior, .   .   .    Lower  border of clavicle.
    (c.) External,  ...  A line  falling vertically from
                              junction  of middle  and
                              outer third of clavicle.
    (d.) Inferior,   .   .    .  Lower  border of third rib.
          The Structures Contained are :

(A.)   On right side.    (B.)  On left  side.
    1. Superior lobe  of lung.  1. Superior lobe of lung. 
5
2.  Main  bronchi, behind
    second  costal carti-
    lage.
3.  Descending vena cava.
4.  Portion  of  arch  of
    aorta, behind second
    costo-sternal articu-
    lation.
2.  Main bronchi, a little be-
     low the second  costal
     cartilage.
3.  A portion of pulmonary
     artery immediately be-
     hind the second sterno-
     costal articulation.
4.  Base  of  heart  at lower
     boundary.
4.  Mammary.
    (a.)  Internal,
    (o.)  Superior,
    (c.)  External,
    Boundaries.
Edge of sternum.
Lower border of third rib.
A vertical line continuous with
  the outer boundary of third
  region.
Lower border of sixth rib.
    (d.)  Inferior,
    On the right side in this region the thin sharp border
of the lung very nearly  corresponds to the inferior bound-
ary.   But below the lower border of fifth rib the thin portion
of lung overlies the liver.   The liver is sometimes pushed
up into fourth intercostal space.
    On the left side a section is  taken out of lung to afford
space for the heart.  The lung extends in  front as far as the
fourth sterno-costal articulation, where the anterior border
passes outward to the  outer end  of  the fifth  cartilage, then
obliquely inward to lower border of outer end of  the sixth
costal cartilage, then outward.
     Structures  within  the Mammary Region.
(A.)  On  right side.     (B.) On left  side.
    1. Lung.                    1. Lung.
    2. Liver.                    2. Left  auricle. 
6
    3. Right auricle  and    3. Left ventricle.
        right superior angle
        of   right  ventricle
        close to sternum, be-
        tween third and  fifth
        ribs.
    4. Portion of apex of right
        ventricle, in fifth in-
        tercostal space,  one
        inch within and  two
        inches below nipple.
  (a.) Nipple varies somewhat in position.  May be said to
be, usually, on the fourth  rib, at junction of costal cartilage
and rib, or in fourth intercostal space.
  {b.) Fissure between upper and middle lobes of right lung
passes obliquely upward and backwards from  fourth cartil-
age ; fissure between middle and lower lobes, upwards and
backwards from fifth inter-space ; fissure between lobes  of
left lung begins at fifth inter-space, below the nipple.
Inframammary.	Boundaries.
(a.) Superior, .	. Lower border of sixth rib.
(o.) Inferior,	Curved line corresponding to
	the free border of ribs.
(c.) Internal,	. Inferior portion of sternum.
(d.) External,	The continuation of the ex-
                             ternal  boundary  of  mam-
                             mary region.
   Structures within the Inframammary Region.
(A.)  On right side.      (B.) On left side.
1. Lung on full inspira-	1.	Portion of left lobe of
tion.		liver.
2. Liver.	2.	Stomach.
	3.	Portion of spleen, sometimes.
 
                          7

6. Suprasternal.
  This region  is the hollow space immediately above the
notch of the sternum, and bounded on  either side  by the
sterno-cleido mastoid muscle.
   Structures within the Suprasternal Region.
  1.  Trachea.
  2.  Arteria innominata at lower right angle.
  3.  Arch of  aorta sometimes reaches  to  its lower border,
where it may often be felt, on firm pressure downward.
7. Upper sternal.
  This region includes the space  behind the sternum from
the notch to the lower border of the third  rib.
  Structures within the Upper Sternal  Region.
  1.  Lung in front.
  2.  Bifurcation of trachea at upper border of second rib.
  3.  Ascending aorta at lower end of region.
  4.  Transverse aorta, crossing on level with second rib.
  5.  Innominate artery, at junction of  second  right costal
cartilage.
  6.  Portion of right auricle in lower part.
  7.  Aortic valves, midway between  centre of sternum and
lower edge of left third costal cartilage.
  8.  Pulmonary valves, one half inch higher than the aortic,
on left edge of sternum.
  The position of the lung in mid-sternum varies somewhat
during inspiration and expiration.
8. Lower sternal.
  This region corresponds to that portion of the  sternum
which lies below the lower border of the third rib.
  Structures within the Lower Sternal Region.
  1.  Portion of body of lung on right side in front, on the
left side also as far as the fourth sterno-costal articulation. 
8
  2. Greater part of right ventricle.
  3. Smaller part of left ventricle.
  4. The mitral valves, in the upper part of this region, that
is just below the level of the third rib or  on a level with the
fourth rib, situated close to the left edge  of the sternum.
  5. The tricuspid valves, situated at  about the same level
as the mitral, but to the right, nearer to the median line and
more superficial.
  6. Attachment  of heart to diaphragm.
  7. Small portion of liver.
  8. Portion of stomach, sometimes.
                LATERAL REGIONS.
 .  Axillary.                   Boundaries.
                          .  The axilla.
                            A line carried backward  from
                              the lower boundary of mam-
                              mary  region  (sixth rib)  to
                              inferior angle of scapula.
                          . The vertical line  which forms
                              the common external bound-
                              ary of the anterior regions.
                            The external border of  scap-
                              ula.
  This region corresponds laterally with the mammary in
front and contains  on both  sides  lung substance, with the
main bronchi, deeply seated.
Axillary.
 (a.) Superior,
 (b.) Inferior,.
(e.) Interior,
(d.) Posterior,
2.  Infra-axillary.
    {a.) Superior,   .

    (b.) Inferior, .
    (c.) Anterior,

    (d.) Posterior,
    Boundaries.
Inferior boundary of axillary
  region.
Edges of false ribs.
Common vertical line, external
  boundary of inframammary.
External  boundary of  infra-
  scapular region. 
9
  This region corresponds laterally to the inframammary and
contains on both sides the lower edges of  the lung, sloping
downward and backward.  On the right  side is the liver;
on the left the stomach and spleen.

               POSTERIOR REGIONS.
i.  Suprascapular.
    (a.) Superior, .
    (b.) Inferior,
    (c.) Internal, .
    {d.) External,
  Occupied by lung substance.
    Boundaries.

Second rib.
Spine of scapula
Internal border of scapula.
External border of scapula.
  Lower scapular.
   {a.) Superior,  .
   (b.) Inferior, .
   (<;.) Internal,
   (d.) External,.
 Occupied by lung substance.

,  Infrascapular.
   (a.) Superior,
Boundaries.
Spine of scapula.
Inferior angle of scapula.
Internal border of scapula.
External border of scapula.


    Boundaries.
(b.) Inferior,
(e.) Internal,  -

(d.) External,
Inferior angle of  scapula and
  seventh dorsal vertebra?.
The twelfth  rib.
The spinous processes  of the
  vertebras.
Posterior  boundary  of  the
  infra-axillary.
    Structures within Supra-Scapular Region.
(A.) On right side.      (B.)  On left side.
    1.  Lung, to the eleventh     1. Lung, to eleventh rib.
         rib. 
10
Liver, immediately un-
  derneath the surface,
  between eleventh and
  twelfth ribs.
Small portion of kid-
  ney.
Interscapular.
 (a.) Superior,  .
 (b.) Inferior,.
     Internal.
2.  Intestines, internally.
3. Spleen, externally.

4. Descending aorta,close
    to the spine.
5. Portion of  the kidney,
    more than  on  right
    side close to spine.
Boundaries.
(<•)
                           .  The second rib.
                             The sixth rib.
                           .  Spinous processes of the dor-
                               sal vertebrae.
     (d.) External,    .    .    Inner border of scapula.
  This region contains, on  both sides, lung  substance, the
main bronchi, and the bronchial glands.   Opposite the third
dorsal vertebrae (the second rib in  front), is  the bifurcation
of the trachea.  It also contains on the left side the aesoph-
agus, and from the upper part of the fourth dorsal vertebrae
downward, the descending aorta.
  Useful  signs  are few.   From the second to the sixth rib
behind, sounds  of air in the  trachea and main  bronchial
tubes are heard.  At the seventh or eighth dorsal  vertebras
on the left side is the point corresponding to the situation of
the mitral valve.  It  is  in  this  neighborhood that  mitral
murmurs  are  readily heard.  They may also be  heard as
high up as the  fifth dorsal. 
                          11

METHODS OF  PHYSICAL  DIAGNOSIS.
    1. Inspection.           5. Auscultation.
    2. Mensuration.         6. Auscultatory Percussion.
    3. Palpation.            7. Succussion.
                            8. Determining situation and
    4. Percussion.              size of surrounding organs.

                    INSPECTION
Is the actual observation of a person's chest.   As a means
of diagnosis it is secondary in importance to auscultation
and percussion, yet is of considerable value.  By inspection
we recognize the form, size, and general  movements of the
chest.  In order to recognize changes of  disease it is neces-
sary to have exact knowledge of the features  presented in
health.
                        FORM.
   The natural form of a normal chest is a cone with apex
upward.   Let us look at the different regions of the chest.
   The supraclavicular region in health  is slightly concave,
The suprasternal  region  is always  a  deep  hollow.  The
infraclavicular slightly convex.  The upper sternal is about
level.   The lower sternal is always somewhat hollow.  The
mammary and inframammary are rotund.  The  intercostal
spaces are always slightly concave in both inspiration and ex-
piration, unless there be a superabundance of adipose tissue.
   The two  sides are very nearly  symmetrical.  It is esti-
mated that not over twenty per cent, of people have a perfectly
symmetrical chest.   The most  common  deviations from a
perfect  form are  slight curvatures of the spinal  column.
Slight modifications are  consistent  with  health.  The  main
point  is to see if the volume of  the two sides is about equal. 
12
                    MOVEMENTS.
  1.  Thoracic Movements.—In inspection, we observe
the sternum moves forward, all  the  ribs  except  the lower
four go upward and outward.   The lower four move  out-
ward  directly, or outward and downward.  The ribs all
separate  from each  other in inspiration.   In expiration,
reverse movements.
  2.  Abdominal  Movements.—Diaphragm ascends,  and
abdomen falls, in expiration ; reverse, in inspiration.

          DEPARTURES FROM HEALTH

    1. Expansion.          5. Procidentia.
    2. Bulging.             6. Elevation.
    3. Retraction.          7. Curvature.
    4. Depression.          8. Distortion.


            EXPANSION AND BULGING.

  By expansion we mean a general enlargement of one side
or of the whole chest; by bulging, a partial enlargement at
one  point—enlargement  due  to causes  within  the chest.
In Asthma and general vesicular Emphysema we have an
example of expansion.   The  shoulders are raised,  all the
muscles of respiration are  in a  state of tension,  that is, all
the muscles in  upper part of  thorax.  The  chest is en-
larged in every way.
   Ordinary Emphysema from  obstructive causes produces
bulging in the supra  and infraclavicular regions.  In pleuri-
tis, bulging occurs  in the mammary and  axillary  regions
after effusion has  taken place.   Enlarged  heart  causes
bulging in precordial  region.    Bulging  in inframammary
region  on  right  side  results  from enlarged  liver,  on the
left side from  enlarged spleen. 
13
         RETRACTION  AND DEPRESSION.
   Retraction implies general  reduction of the whole chest
 or of one side ;  depression  has  reference to a  more local
 drawing in of the chest wall.
   Pleuritic effusion occurs, filling up the pleural  cavity so
 that the lung is  compressed, and becomes  bound  down by
 inflammatory adhesions.  After the fluid  is absorbed  the
 lung does not again expand to its previous  dimensions.  In
 this case atmospheric pressure acts  upon the external  sur-
 face, causing a retraction of the side.
   Depression occurs from  a  cavity in the lung, from true
 croup, acute or chronic laryngitis, and from atelectasis, and
 local pleuretic adhesion.
   Expansion and bulging are due  to internal  and  not to
 external causes.   Retraction and depression  are due to the
 co-operation of  an external cause, namely : pressure of  the
 atmosphere.
         PROCIDENTIA  AND  ELEVATION.
   These terms may apply to changes either in the whole or
 a part of the chest.
   Procidentia.—Falling of the shoulders  and  lungs lower
 than natural, over atrophied or contracted lungs.
   Elevation.—The lungs  fixed  higher  than  normal, or
 raised in the inspiratory act, as in emphysema.
         CURVATURE AND DISTORTION.
   1. Lateral curvature of the spine  is  frequently the result
 of contraction of  one lung or  of  chronic changes in  the
 pleura with enfeeblement of the  respiratory muscles.   An-
 gular  curvature  is associated  with  early malnutrition, and
 the existence of chronic bronchitis, asthma, and emphysema.
  2. The most common form of  distortion is the''pigeon-
breast."   This  is  constituted  by  a flattening of chest
laterally, and an  arching forward of the sternum.  Causes :
rachitis, atelectasis or non-expansion of the bronchial tubes
in  early life, whooping cough, croup, and bronchitis. 
                           14

  The deformity is not  due wholly to rachitis, but  to  the
partial, and uneven filling of the bronchial tubes, to laryn-
geal, or bronchial  constriction  and co-operation with at-
mospheric pressure.

                     PALPATION.
  Palpation, the act of laying on the hand.   It is less useful
than  inspection, in  ascertaining general size, form,  and
movement, but is useful  in determining local expansion,
and the character of vibrations.
  The palmar surface of the hand should be laid gently and
evenly on the surface.   If the hand be applied to the sur-
face of the chest  while a person is speaking, a  tremulous
vibration will be felt.  If the individual  coughs a vibration
is perceived.  Bronchitic rales, pleuritic friction, and aneu-
rismal thrill will also  give  rise  to a vibration  or fremitus.
Hence we have,
    1.—Respiratory fremitus—Produced by breathing.
    2. Vocal fremitus—Produced by the voice.
    3. Tussal fremitus—Produced by cough.
    4. Bronchial fremitus—Produced by bronchitis.
    5. Pulsatile fremitus—Produced by aneurism.
    6. Friction fremitus—Produced by pleurisy.
  Ordinarily when we use the term fremitus we mean vocal
fremitus.
  Palpation may also detect fluctuation.  In pneumo-hydro-
thorax, or in a very large cavity where air passes in and out,
the sensation of fluctuation may  be felt by the hand.   Such
fluid is more often  detected  by succussion.   In order to
have succussion there  must  be  both  fluid  and  air in the
cavity.
  Respiration.—The frequency and rhythem of respira-
tion are also noted by palpation.  The average in the  adult
is eighteen to twenty respirations per minute.   Having 
15
 counted the respirations, put one hand  on the pulse and
 count pulsations, noting the relation between the two.
   Normally the ratio of respiration to pulse  is as one  to
 four.  It takes four times  as  long  for the blood  to go
 through the systemic as through the pulmonic circulation.
   In disease the pulse-respiration ratio is subject  to  much
 variation.  In chorea it has been observed to be—
   Pulse : respiration : : 9  : 1,  and in hysteria, pulse  : res-
 piration : :  5:1.

                   MENSURATION.
   There are  many  measurements, but the principal is the
 circular, taken on the level of the sixth costal cartilage. The
 average circular chest measurement of a healthy adult  male,
 five feet eight inches in height, midway between inspiration
 and expiration, is 33 inches.   It may go as high as  44, or  as
 low as 27 inches.  The average is a little less for women.

   Difference of  Respiration of  Men and  Women.
   Respiration in the male is mostly abdominal, in the female
 mostly thoracic.  This is in part owing to dress,  but chiefly
 to sex, as women in pregnancy are obliged to use the thoracic
 muscles in respiration.

                 Circular Expansion.
   In ordinary  quiet respiration, the circular  expansion
 varies from  one-fourth  or one-half an inch to one  inch.
 It may be as high  as  two inches.   If  a person  takes a
 forced  expiration,  and the chest be measured, and  then
 a  full  inspiration  and  the   measurement  be  taken, the
 difference will represent  the full expansive power.   It
varies from two and one-half to three and one half inches,
but may be more.   The expansive power for women should
be about the same, though their stature is less. 
1G
                  Quantities of  Air.
  The capacity for air is  measured by a spirometer.   The
air habitually in the lungs, or capable of being introduced
into them by respiration, is divisible into various quantities:
    1. Persistent air.         4. Tidal air.
    2. Residual air.          5. Complementary air.
    3. Supplementary air.

                      Definitions.
  1.  Persistent air is that which cannot  be removed from
the lung structure by any possibility, not  even  by heavy
pressure after  death.  It is removed by disease.
  2.  Residual air is that which is  never expired  while the
thoracic wall is intact, but which  escapes  when  the  chest
wall  is  opened on the cadaver, and atmospheric pressure
collapses the lungs.
  3.  Supplementary air, that which is not  expired in ordi-
nary breathing, but may be ejected by a forcible expiration.
  4.   Tidal air is that which goes in and  out in ordinary
respiration.
  5.  Complementary air is that which may be  inhaled  by a
forced inspiration after an ordinary inspiration.
  The first  three  Dr. Walshe  calls stagnant air; the  last
three represent the total breathing volume and are the  only
quantities which can be measured  by the  spirometer.  The
average amount of tidal air for  a healthy  adult male is 26
cubic  inches  for each inspiration.  The greatest amount
which the  average male  can inspire is 174  cubic inches.
Thus it is evident we do not use one-half our lungs, even in
health.
  Relative Length of  Inspiration and Expiration.
     Inspiration,  5.
     Expiration, 4.
     Rest, 1. 
17
  This relation is changed  in  disease.   In  advanced em-
physema expiration is two or three times as long as inspir-
ation.
            Character of the Two Acts.
  Inspiration begins gently, increases gradually in intensity,
till it  reaches  the  middle of the act, then gradually  dies
away, and is immediately followed by expiration.
  Expiration begins  actively, instantaneously, gently  pass-
ing into rest.
                   PERCUSSION.

   Percussion is the method of  eliciting sounds from the
 chest  in  health  and  disease,  by striking the chest wall
 with the finger tips or the percussing hammer.  We have :
   1. Immediate percussion.
   2. Mediate  percussion.
                Immediate Percussion
 Is the  direct striking of the surface of the chest with the
 hand or fingers.   This is seldom practiced.
                  Mediate Percussion
 Consists  in the interposition of some media between the
 striking  hammer  or  fingers and  the  chest.   This is by
 far the most common  mode of percussion.   It was rendered
 a science  by Piorry and Laennec.  When the  hammer is
 used the  interposed medium is a plate of  rubber or ivory,
 and is called  a pleximeter.  The hammer and pleximeter
 are useful for clinical  teaching,  to  elicit very clear  sounds
and for uniformity of stroke   It is better in practice  to
rely upon the fingers.
                 Mode of Percussing.
  One  finger of the left hand is  used  as a pleximeter  or
medium, and one  or  more fingers of the right hand as a 
18
 hammer.   The palmar  surface  of  the  interposed  finger
 should  be placed in accurate and  firm  contact  with  the
 surface.  Percussion with one finger may be performed by
 moving it at  the  metacarpo-phalangeal  articulation (the
 knuckle).   Such a method, however, requires much practice
 to perfect it, and the stroke will bring out only delicate
 sounds.
  The rule is to strike from the wrist, without moving elbow
 or shoulder.  We thus describe an arc of a circle and bring
 the  finger at  right  angles upon the  surface.   The blow
 should be quick and sharp, and the finger instantly removed,
 in order to let the chest vibration continue.   When per-
 cussing over cavities, and not desiring  the  sound to  rever-
 berate, the finger may be retained in contact.  A single per-
 cussion stroke  over a given point is better than  repeated
 strokes.
                 Percussion Develops
  Sounds  indicative of :
     1. The degree of elasticity or tension of the chest wall.
     2. The condition of  the contained organs.
        Properties of  the Percussion Sound.
  1.  Duration,  the length of sound as regards time.
  2.  Intensity, resonance, amplitude,  or volume of sound.
  3.  Pitch, referring to length of sound wave, the acuteness,
dullness or flatness of sound.
  4.  Quality,  what the sound  suggests as to the condition of
organs underneath.
                    (1)  Duration.
  The duration of the percussion sound varies  perceptibly
in different parts of the  chest.   It  is longer, for instance,
over the lung substance than  over the heart or liver.
  A  certain relation exists between the four properties of
sound : duration, resonance, pitch and quality. 
19
   With  high pitch  there  is  diminished resonance, hard
 quality and brief duration.  With low pitch, more resonance,
 softer quality and larger duration.

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

                        (3) Pitch
 Refers to  the length of the  sound  wave.   We define it
 ordinarily  by saying it is the  acuteness  or  dullness of  the
 sound.  Over anything  solid, as the heart  or liver, we  get
 high pitch ;  over  anything less solid,  as over the  normal
 pulmonary tissue, we get low pitch.
   The greater the quantity of air the lower the pitch.  Pitch
 is highest  over fluids, as over pleuritic  effusion, because
 fluids are most dense.  Over gases, pitch is very low indeed.
 In percussing we find pitch  high over the liver, heart and
 muscle;  low over lung tissue, and over stomach lower still.
  Pitch frequently  has connection with duration. When  the
pitch is high, the duration is  short ; when the  pitch  is low,
the duration is long. 
20
                     (4) Quality.
  Quality or timbre suggests the nature  of the subjacent or
underlying organs.   We have  hardness, softness, and  hol-
lowness.   The hollow type occurs under three varieties, the
tubular, amphoric, and cracked metal.
  The Hard quality is wooden, resembling  that yielded by
mediate percussion on a table.  It follows percussion  over
the solid viscera, or over an infiltrated or solidified lung.
  The Soft quality is that yielded by percussing over normal
pulmonary tissue and has been likened to the sound of the
drum covered with a coarse woolen cloth.
  The  Tubular quality  is that  produced   by  air in an
elongated defined cavity.   This quality is  to be detected
over the trachea, and over the primary bronchi.
  When anything solid lies between the  large bronchi and
the costal surfaces, this sound is sometimes obtained ;  thus
it may occur in the interscapular region from enlarged bron-
chial glands, over a great part of the back in cases of intra-
thoracic tumor.
  Small excavations in the lung may, and dilitation of the
bronchi will, produce this quality of percussion note.
  Amphoric  quality is the tubular on a  large scale.   It re-
sembles the sound produced by tapping the cheek when
the mouth is closed, and fully but not tensely inflated.  The
common source of this sound is a cavity of  large  size  near
the surface,  and provided with hard and thin walls.
  Cracked Metal.—Cracked pot or cracked metal quality is
an air impulse sound—air in a cavity rushing against its walls.
The amphoric quality is almost always coupled with this
quality.   In the same patient, percussion with  mouth  and
nostrils  closed produce amphoric sound, and percussion  with
the mouth and nose open will produce cracked pot sound.  It
resembles the sound resulting from striking the back of the
hands, loosely  folded across each other, against the knee, the
contained air being forced out quickly  between the fingers 
21
at each blow.  If the chest of a crying infant be percussed
in expiration the resonance will be of cracked metal quality,
and it can be produced by percussion on  the  elastic  chest
wall of most young persons.
  Tympanitic quality results from an unusual amount of air
contained within a cavity with elastic walls.  The sound is
drum-like.   Typical tympanitic sound exists in  pneumo-
thorax, and over stomach, or intestines distended by flatus.
  The sounds developed by percussion  are not always de-
pendent on  an organ lying immediately  beneath.  Sound
may be conveyed across the chest.  It must be remembered
the whole chest is an acoustic box—all the contained organs
modifying the sounds.
                        Muscles.
  The percussion note of muscles is non-resonant, high, hard,
and  brief  as  elicited  by  percussing  the muscles of the
shoulder or arm. ■
                        Heart.
  The heart is only a great muscle, hence its percussion
note (superficial area) is high-pitched  and hard.  These
qualities  are less marked where it is over-lapped by the lung
(deep area).  So we have superficial and deep sounds over
an organ.
                         Lungs.
  The breathing surface of the  lung is formed by the divid-
ing bronchi and bronchioles and  air vessels, with elastic  or
connective tissue to hold them  together.  The normal pro-
perties of percussion sound differ somewhat  over  different
places.
  In the infraclavicular region  the  resonance is  consider-
able, the quality is true pulmonary—pitch low—duration dis-
tinctly perceptible.  In the right mammary region the pitch
rises some,  even at the upper part, and  is  very perceptibly
elevated at and below the fourth intercostal space,  owing to 
22
the contiguity of that hard, solid organ—the liver  (law  of
consonance).  On the left side, the heart likewise modifies
the sound.
  The resonance of the right inframammary region, in con-
sequence of the presence of the liver beneath the surface, is
high in pitch, brief  in duration, hard, almost wooden  in
quality.
  The suprasternal region gives  tubular resonance.   In the
upper  sternal region the sound is  somewhat  of a mixed
character  as also  in the lower sternal region.   Here the
stomach may further modify the sound.   It is in this region
that difficulty is  often encountered  in tracing the line  of
demarcation  between the liver  and  the  heart.  The dia-
phragm intervenes between  the  two organs, but  the per-
cussion note of one differs so little  from  that of the other
that it is often practically impossible to  define the line of
union.
  A good rule in that case is  to draw a line  from  the point
of the heart's apex beat to the apex of the angle formed by
the union of the upper free edge of the liver with the  right
free edge of the heart.
  Over trachea and  large bronchial tubes  the percussion
sound is tubular, the  resonance full, owing partly to the con-
tained air and partly to the walls themselves of the tubes, the
pitch is low, not hollow nor tympanitic, and  the duration is
long and ringing.
  Over the aorta,  gentle percussion gives  true pulmonary
percussion note ;  deep percussion lessens the duration and
resonance, raises the pitch and makes the quality hard.  If
an aneurismal tumor  exists  the same modifications will  be
present over a larger area and intensified.
  The posterior thoracic regions do  not give the pulmonary
sounds so well as the anterior regions, because of  the thick-
ness of the dorsal  muscles.  When the scapulae are carried 
23
outward by the second position of Corson (see below), the
interscapular areas are nearly and sometimes more  than
doubled, and the muscles  being rendered tense and thin, a
normal pulmonary percussion  note  is elicited,  which  con-
tinues as we descend and percuss the infrascapular regions.
Below the eleventh rib of right side the note is high pitched,
hard, hepatic.   Resonance does not extend as far down on
the right side as on the left.    On the left side of the chest,
posteriorly, below the eleventh rib,  the  spleen, if  large, or
the stomach and intestines may modify the percussion  note.
  The lateral regions of the chest are more highly resonant.
On the right side the  percussion sound loses in volume and
rises in pitch as we go downwards toward the liver.  Below
the sixth rib on the left side the sound is modified by the
spleen and stomach.
  The sound over the stomach is  tympanitic,  and over the
intestines, according as  they are  empty, full  of  faeces, or
distended with gas, varies from tonelessness, to tympanitic
resonance.
  The spleen gives the same hard, toneless, hepatic, quality
of sound that the liver does.

 Positions  of  Patient for  Percussion.   {Dr. Corson.)
       First Position {for Anterior Examination).
  Shoulders well  thrown back; arms  folded behind the
back, to make tense the muscles on the front of the chest.
      Second Position {for Posterior Examination).
  Body bent slightly  forward; head bowed ;  arms crossed
in front of chest.   (Better still to clasp each shoulder with
opposite hand.)
        Third Position {for Lateral Examination?)
  Arms raised vertically upwards ; hands folded across top
of head. 
24
                  AUSCULTATION.
  Auscultation means the application of the ear to the chest
for the  detection of normal  and abnormal sounds, for, as
relates to the respiratory organs, we may hear
    1.  Normal breath sounds.
    2. Normal voice sounds.
    3. Abnormal breath sounds.
    4. Abnormal voice sounds.
    5. New sounds.
      {a.) Sounds resulting from a combination of above.
      {b.)  Sounds having no  connection with either voice
           or breath sounds.
  We distinguish in these sounds the following properties :
    1.  Duration.                4.  Quality.
    2.  Intensity.                5.  Rhythm.
    3.  Pitch.
             These Properties Defined.
  1. Duration, the period  or  persistence of the  sound,
usually proportionate to intensity.
  2. Intensity is the degree of resonance, the volume,  or
amplitude of the sound.
  3. Pitch  refers to the acuteness of sound, whether the
sound is high or low.
  4. Quality is that property which reveals something of the
character of  the substance,  emitting or  conducting  the
sound.
  Rhythm refers to the regular recurrence of sounds, whether
uniform or irregular and jerking.
             Methods of Auscultation.
  1. Immediate,  if the ear is applied to the chest.
  2. Mediate, if an instrument be used.
                  The Stethoscope.
  The instrument used in mediate auscultation is a stetho-
scope.   The  original  stethoscope of  Laennec was a hollow 
25
 cylinder  of wood, having  an  expanded  end,  its longi-
 tudinal axis being parallel with the grain of the wood.
   Stethoscopes have also been made of other materials, as
 glass, gutta-percha, metal, and ivory, but wood is preferable.
   Dr. Cammann's is a  double  flexible  stethoscope, having
 two ear pieces, uniting in a single tube.  Scott Alison's has
 two  distinct tubes united by a joint.  They pass one from
 each side of the  chest to either ear of the listener.  The
 advantage claimed is  the  facility afforded  in comparing
 the   sounds from the  two  sides.  Practically there is no
 advantage.  The mind, in attempting to take cognizance of
 the sounds on two sides, is confused.
   Dr. Cammann's stethoscope is used  very largely in this
 country ; its use  is discouraged by English and continental
 writers.  Their criticism is that it not only intensifies sounds
 but changes them, altering their pitch and quality.
   Snelling's soft  rubber cap is employed on  Cammann's
 stethoscope, in examining emaciated patients.
   Both immediate and mediate auscultation  have  their ad-
 vantages.
 Arguments in Favor of the Use of the Stethoscope,
              or Mediate  Auscultation.
   1.  It  localizes  a sound,  as when  produced  in  a small
 cavity, or a  heart  murmur.
   2.  The delicacy of  ladies  is favored.  It  obviates chest
 exposure.
   3.  It  avoids contact  of the head  with the bodies and
 clothes of uncleanly patients.
   4. Certain, otherwise not very distinct, sounds are by the
 stethoscope  rendered more intense.
  Arguments Against the Use  of the Stethoscope
   and Favoring  Dependence  on the Ear alone.
   1.  The  interposition of a solid  material  may  intensify
the sound at the  same time  that it modifies  or changes it.
This is especially true of the double stethoscope. 
26
   2. A person using the stethoscope as a clinical teacher, or
in practice, may lose the delicacy of his ear.

              Auscultation in Health.
   Putting the ear to the chest we listen, first, to the respiration.
In one-fourth of healthy persons inspiration alone is heard ;
in one-fourth of healthy persons expiration is wanting.
   Where inspiration and expiration are both heard, inspira-
tion is from three to four times as long as expiration, that is,
as they are  heard.  (Inspiration as a physical act is five-
fourths as long as expiration.)
        Ratio  of Inspiration  to Expiration.
   As physical act:
     Inspiration..................................5
     Expiration.................................. 4
     Rest.......................................1
   Ratio of inspiratory  to  expiratory sound, as heard over
chest wall:
     Inspiration...,..........................3 or 4
     Expiration..................................1
   Inspiration is  heard  to  be  a soft, breezy sound, neither
moist nor  dry,  which  is faint at  its  inception,  gradually
developed, increasing in intensity and volume to its mid-
period and gradually subsides.  Its rhythm is steady, uni-
form and continuous.
   The expiratory sound is harsher, more  hollow,  and only
one-third or one-fourth  as  long or  as loud.   Inspiration is
an active, expiration a  passive movement.  In inspiration
the chest walls are raised and  expanded by the contraction
of muscles—the abdomen distends from the pressure down-
wards of the  diaphragm.
  In expiration there  is  a  movement  of the abdominal
viscera upward, and subsidence of the bony structures of the
thorax. 
27
   Inspiratory sound is heard, and is long :
   1.  Because the currents of inspired  air  are  entering a
 system of tubes steadily decreasing in size, and developing
 air-and-tube friction.
   2.  The currents of air come towards the chest wall, and
 bring the sound towards the listener's ear.
   Expiratory sound is faintly heard and short:
   1.  Because the expiratory currents are  passing out of a
 system of tubes,  steadily increasing in size.  Hence  but
 little air-and-tube friction is developed.
   2.  The currents of expired air and the sounds which they
 create are receding from the chest wall  and away from the
 listener's ear.
   The last statement may be verified by listening with either
 the ear or the stethoscope at a person's mouth.  Expiratory
 sound is found to be there quite as distinct and as long as
 inspiratory sound.
   Various theories have been advanced to account for the
 respiratory sounds.
      Factors of Normal  Sounds  of  Respiration.
       1. Pharyngeal.        5. Vesicular.
       2. Laryngeal.         6.  Parenchyma of lung.
       3. Tracheal.          7. Muscular sussurus.
       4. Bronchial.
   The respiratory sounds have certain elements enumerated
 in the list above.   The  pharyngeal and  laryngeal elements
 are not heard except  when  there are some changes, as en-
 larged tonsils, laryngitis, etc.  We  do not  hear them nor-
 mally because they are slight, and not observed except when
 intensified  by  some  obstruction.   In inspiration, the air
 comes against the sides  and bifurcations of the trachea and
 bronchial tubes.
  The bronchial element of respiratory sound is thus pro-
 duced.  Its  character is  tubular—it has  an air-and-tube
friction  quality. 
28
  Vesicular breathing is a breezy, fine continuous sound, at
least continuous in inspiration.   There are many and op-
posing theories as to the cause  of  the  normal  vesicular
sound.  Some claim that air passing through the bronchial
tubes  produces  an  air-friction  sound,   and  in passing
through the ultimate bronchial tubes, by dilatation of their
walls produces the vesicular  murmur.
  According to the  views of others, as  the  air leaves the
ultimate bronchial tubes, which  are more  or less rigid, and
which  terminate  in the more expanded and elastic  infun-
dibuli, the  change or release from the confined tubes to the
air spaces is the cause of the sound termed vesicular.
                  Muscular Sussurus.
  The muscular action going on in the chest wall gives rise
in some persons to a  peculiar buzzing sound, termed mus-
cular sussurus ; its amount does not  seem to  be directly as
the  muscularity  of  the individual.  It is increased by
efforts of all kinds, as for instance, that of maintaining an
uncomfortable  posture ;  it  is continuous not syhchronous
with respiration, and rather increases than diminishes in in-
tensity when the breath is held.   It may  in some places be
suspended by putting the muscles in a state of relaxation, but
in the  infra-axillary regions, where it is  sometimes  highly
marked, it cannot be thus  arrested.
                         Sex.
  Women breath  largely by the upper part  of  the  chest ;
men more by the  lower part.  We are more likely to hear
the expiration of women, it is harsher in character.
                       Children.
  The tubular  or bronchial element is  more  marked  in
children, and both inspiration and expiration  may  be in-
tense and harsh—designated "peurile breathing."  Expira-
tion will  also  be heard  during its  entire period.   Such
sounds in an adult would denote  disease. 
29
                   Vocal Resonance.
  In health we say little about the auscultation of the voice ;
yet if we put our ear to a healthy chest while the person is
speaking we perceive  a  "vocal resonance," not  distinct
words.  The sound is vague and distant.  In consolidation
of the lung from any cause,  as exudation  in the second
stage of pneumonia, or a deposit of tubercle or cancer in  the
lung,  the voice is brought  directly to the ear.  This con-
stitutes  bronchial voice or bronchophony (see later),  and
replaces vocal resonance.
  The vocal resonance of males is greater  than  that of
females ; the deeper the voice, bass or baritone, the greater
the resonance.
                   Chest Acoustics.
  1.  Unison resonance.
  Reinforcement by thoracic walls.          Methods
  2. Consonance.                    Y of development  of
  Reinforcement by other organs.            sounds.
  3. Echo.
                (1.) Unison  Resonance.
  By unison resonance is meant the reinforcement of sound
by the thoracic walls, as occurs in the  box of a guitar or
violin, when notes are produced from their strings, or as when
a music box instead of being held in the  air is  placed on
a table.  There can  be little doubt but that in the natural
condition of the chest  the  principle  of unison resonance is
illustrated.
                   (2.) Consonance.
  By consonance in music is meant the reproduction of cer-
tain notes of instruments or of the voice by other instruments
standing near.  It is difficult to  prove  that  there is in  the
chest a repetition of sound by consonance, but  contiguous
structures exert a modifying  influence,  notably the liver,
stomach, and intestines, upon the chest sounds. 
30
                       (3.) Echo.

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

              Auscultation  in Disease.

  In disease we study changes from  normal conditions.
Respiratory sounds :

  1. Changes of duration and intensity:
    {a.)  Exaggerated.           {c.)  Suppressed.
    {b.) Weak.
  2. Changes in rhythm:
    {a.) Jerking.            {d.) Unfinished.
    {b.) Divided.            {e.) Altered  ratio  of inspira-
    {c.) Deferred.              tion to expiration.
  3. Changes in quality, pitch and rhythm combined :
    {a.)  Harsh.                 {b.)  Blowing.
        Rude.                      Tubular.
        " Broncho-vesicular."        Cavernous.
        Bronchial.                  Amphoric.

        Changes in Duration and Intensity.
  Sounds may be exaggerated, weak  or  suppressed.   Ex-
aggerated in bronchitis.  In convalescence quality may be
normal and  intensity  weak.  Suppressed—an  absence of
respiratory  sounds.

                 Changes  in  Rhythm.
  {a.) Jerking.—When the movement  of inspiration instead
of being accompanied by a continuous sound,  is attended
with an interrupted one, divided into several unequal parts,
the  respiration is called jerking.  Illustrated in asthma, from
obstruction in tubes,  in early stage of pleurisy, pleurodynia, 
31
intercostal neuralgia, hemiplegia, and  spinal irritation.  In
some cases of incipient tubercle, the rhythm of sound is dis-
turbed.
  {b.) Divided.—When the heart's action is such as to throw
the blood so violently into the lung as to cut the  act of
respiration into four or five parts, the character is remarked.
  {c.) Deferred  inspiration.—When the  inspiratory  action
commences and  continues for a short  time before  sound is
produced, it is said to  be deferred.   This is remarked in
emphysema.
  {d.)   Unfinished inspiration.—In certain cases the inspira-
tory sound ceases before the  chest  expansion  has been
completed.   This  occurs only over exceptional cases of
consolidation.
  (e.) The altered ratio of inspiration and expiration is to
be noticed.
  In health, expiration is  one-third or one-fourth of inspira-
tion.  In emphysema, expiration is greatly prolonged so that
it may be four times as long as inspiration..
  Changes in quality, pitch, and rhythm combined.
  (a.) Harsh.—Both  sounds  have  lost  their soft,  breezy
character, and have become sharper and more blowing in
character.  Harsh respiration  is heard  in condensation of
the lung to a slight degree, and in the dryness of mucous
membrane of bronchi.   The sound produced in bronchitis
we ordinarily understand as tube friction sound.
  {b.) Blowing sounds.—Low  and long—simple—may be
diffused or tubular.  Low, as though  blowing in a bottle—
amphoric. Cavernous sounds differ in degree as to intensity,
pitch and quality.
        Sounds  Produced in  Bronchial Tubes.
  The most ordinary sounds  are those produced in bron-
chial tubes. 
32
   Sounds produced in bronchial  tubes and having a dry
character are rhonchi j moist sounds are rales.
   1. Dry sounds :            2. Moist sounds :
       (Rhonchi.)                   (Rales.)
       Sibilant.                    Mucous.
       Sonorous.                  Sub-mucous.
                                  Sub-crepitant.
   1. Sibilant and  sonorous rhonchi differ only  in pitch.
The former being very high in pitch, almost hissing, the latter
lower  and  graver.   They are produced by air  passing
through contracted portions of the tubes, and the  more  re-
duced  the calibre  of the tube, the more sibilant  character
will the sound possess.   They are perfectly dry sounds, and
have nothing to do with mucus.  Irregular contractions  in
asthma give the greatest variety of sounds.
   2. The moist sounds, or rales, are produced in the tubes of
moderate or considerable calibre by the breaking of bubbles
of air in  fluid, either serum, sero-mucus, or mucus.  Their
distinguishing characteristic is that they disappear or are
modified  on coughing,  the action  having dislodged the
mucus.  They are common  in bronchitis, bronchial  hemor-
rhage, pneumorrhagia,  and  in evacuation of  pus into the
bronchi.
       Bronchorrhagia.—The Crepitant Rule.
   The  terms crepitant  and sub-crepitant  are  reserved for
sounds produced in the vesicles and terminal tubes.
   There are different theories in regard to the production
of these sounds.  One theory is that the crepitant rale is pro-
duced by  air coming down  into the air  cells  and breaking
through the  exudation matter.   Another theory is that the
air sacs being collapsed, on inspiration their glutinous walls
separate, giving rise to  the crepitant rale.  The same sound
may be simulated by pressing a piece of  sponge rubber close
to the ear  and then letting it relax.   In its relaxation it pro- 
33
duces far more  sound than  in  its compression.   Another
theory is that it is  due to  stretching of the intervesicular
tissue.  The inflammatory exudation, it is claimed, starches
or stiffens, as it were, the intervesicular  tissue, and renders
its expansion more difficult and productive of sound.
  Crepitant rale is  heard only  during  inspiration, and in
two diseases, viz. : croupous pneumonia and oedema of the
lung.
              The  Sub-crepitant Rale.
  The sub-crepitant rale  is distinguished from the crepitant
by being double.   It is heard in inspiration and expiration.
It is also less fine and more plastic or glutinous in quality.
It is  produced by minute air currents breaking through
mucus in small bronchial tubes.   It is heard in " suffocative
catarrh," or capillary bronchitis.   Sub-crepitant and plastic
rales,  unless uniformly  diffused over both lungs, are quite
likely to be of pleural origin.

   RECAPITULATION  OF CHEST SOUNDS IN
                      DISEASE.
  (1.) Abnormal  Sounds  Produced in Air Passages.
                       (Walshe.)
  Whistling  -i High-Pitched—Sibilant.
          s"   ( Low-pitched—Sonorous.
  Crepitating.
  Crackling.  \ ^
Moist.
Bubbling.
■o    11   j Sub-crepitant.
        ( Sub-mucous.
 Large.—Mucus, j ^j^
  Bronchial affections are the most numerous of all pulmon-
ary affections, so that their signs, mucous, and sub-mucous
rales, sibilant and sonorous rhonchi, are the most  common
signs heard by the practitioner. 
34
  Next to bronchial affections in relation to frequency, are
slight and severe attacks of pleurisy.

           (2.) Abnormal Pleural  Sounds.'
                       ( Walshe.)
  1. Single.                2. Jerking—Divided.
  1. Faint.                 2. Loud.

  (a.)  Attrition. {£««*
  {b.)  Creaking.              {d.) Rumbling.
  (c.) Crackling.
  In health there is no sound produced by  the colliding of
the two opposed pleural walls.  Their smoothness and moist-
ure allow them to glide noiselessly upon each other.  When
these conditions have become modified by disease  the glid-
ing is accompanied with different modifications of sound.

          Explanatory  of Pleural Sounds.
                       (Walshe.)
  1. Single sounds may be of  any character, variable in
intensity, pitch and duration.
  2. More usually the  sounds produce a series of abrupt
jerking noises, which also may be of  variable character and
duration, commonly  intensified by  the act  of inspiration,
generally heard also in  expiration.
  Again, these sounds  may be (1) Faint  or (2) Loud,  {a.)
Attrition.   The first condition in inflammation of the pleura
is a removal of the fluid or moisture which lubricates the
part.   The surfaces are next denuded of epithelium, tumefied
and roughened.  The movements of these surfaces give rise
to a grating, rubbing sound, found entirely  in  recent cases.
If two  denuded and villous surfaces have grown together at
points, the pulling or stretching of these adhesions may give
rise to sub-crepitant or plastic  rales. 
35
  {b.) Creaking  sounds are more leathery.  They indicate
dryness, firmness, and  toughness of  the  inflamed surfaces
and exudation matter.  Heard in chronic cases.
  {c.) Crackling sounds are produced when  there is moist-
ure in the plastic matter within the pleura.
  {d.) Rumbling: friction sound prolonged during the two
acts of respiration; a series of distinct, interrupted jerks.
  The signs  of  intrapleural pathology have  been system-
atized by Prof. James R.  Learning  in this country, and by
Sir Andrew Clarke abroad.

       Sounds  over Serum  in Pleural Cavity.
  A slight  amount  of serum  masks  respiratory  and voice
sounds, and gives aegophony.
  A large amount obscures all sounds—respiratory, vocal,
tussal—and may give  aegophony at upper border of liquid.

Abnormal Sounds Produced in Parenchyma of Lung.
  1. Changes of respiratory sounds.
     (1.)  Slight consolidation—feeble or  absent  vesicular
         murmur,  respiration  exaggerated,  rude,   harsh,
         "broncho-vesicular."  Inspiration and  expiration
         both raised in pitch and expiration prolonged.
     (2.)  Marked consolidation, absence  of vesicular mur-
         mur, high pitch  of both inspiration and expiration,
         the  latter clear and prolonged, bronchial breathing.
     (3.)  Cavity—cavernous breathing.
  2. Changes of voice sounds.
     (1.)  Slight consolidation, diminished vocal  resonance,
         raised pitch of voice, bronchial whisper.
     (2.)  Marked consolidation,  absence  of  normal vocal
         resonance ; bronchophony and bronchial whisper.
     (3.)  In  cavity, if  small—cavernous whisper ; medium,
         —cavernous voice; large—pectoriloquy. 
36
   3. Changes in cough sound.
     Tussal resonance lessened  by slight consolidation, and
         absent in marked consolidation, bronchial cough
         in  consolidation,  cough will  also  be cavernous
         when excavation is large.
   4. New sounds.
     Gurgles, mucus rales, creaking in  walls  of  cavities,
         metallic tinkles in large cavities.

              Auscultatory Percussion.
   The sixth method of physical exploration consists in de-
finitely  locating and determining  the  size  of organs by
listening over them with the stethoscope, while percussion is
made towards them from  all sides.  The points of impact are
detected by the listener, the moment the border of the organ
is reached, by reason of the definite conduction of  percus-
sion note.  The several points  so found are then connect-
ed by a line, and the periphery of the  organ determined
with accuracy.  The method is  specially applicable to the
heart, liver and spleen. 
                     37
SYNOPSIS OF ACUTE BRONCHITIS OF ADULTS.
Definition.	Inflammation of bronchial tubes.
Pathology.	Sub-mucous hyperemia : acute catarrhal process. 1st Stage.—Surface dry and tumefied. 2d Stage.—Surface bathed with serum, sero-mucus or muco-pus. Calibre of tubes j Sub-mucous congestive swelling. may be changed by 1 V« sPasm of muscular coat-° J { Adhesion of viscid mucus.
Causes.	"Taking cold"; chilling surface; inhalation of hot and cold air ; irritant vapors ; atmospheric causes (influenza). Secondary in specific blood states :— measles, typhoid and typhus fevers, variola, etc.
Symptoms.	May or may not be preceding coryza :— Soreness, rawness, tightness, oppression in upper sternal region, increased by cough ; little or no fever in most cases ; heavy, deep, sonorous, par-oxysmal cough ; no dyspnoea; inspiration long and full. Sputa in first stage scanty or absent. In second stage, at first, sputa is serous, transparent, frothy ; later, white, viscid, opaque—mucus; later, yellow tenacious, muco-pus. (Mucin and epithelial scales.)
Physical Signs.	Both stages, normal percussion resonance; normal, vesicular sounds by auscultation. First stage— tubular breathing—harsh, exaggerated, sonorous, sibilant rhonchi. Second stage—mucous and sub-mucous rales, of various degrees of liquidity; to and fro gurgles in main bronchi. All removed or modified by cough or expectoration.
Diagnosis.	Normal percussion resonance and vesicular sounds; rhonchi and rales bi-lateral. A symmetrical dis-ease. Absence of chill, ." stitch in side," or high fever; successive changes in sputa.
Prognosis.	Good. In adult does not extend to pneumonia, but some cases become chronic. Epidemics more severe—broncho-pneumonia.
Treatment.	Prophylactic—warm clothes, diet, air, exercise. Abor-tive—opiates, diaphoretics, saline purge. Pal-liative, anti-spasmodics and expectorants, sup-porting remedies.
 
                  38
SYNOPSIS OF CAPILLARY BRONCHITIS.
(Suffocative Catarrh.)
Definition.	A form occurring in young children. A bronchitis of small tubes. Often an obstruction of small (fine) tubes and collapse of lobules; sometimes extending to vesicles (lobular, catarrhal pneumonia).
Pathology.	Inflammation of smaller bronchi, catarrhal products, choking of tubes, more or less.
Causes.	Predisposing.—Early infancy, great weakness, errors of diet. Exciting.—Colds, measles, etc.
Symptoms.	Labored respiration, exhaustion, imperfect oxygena-tion, pallor, coolness, carbon dioxide poisoning, little pain or oppression. If any sputa, white small bodies, or tenacious mucus.
Physical Signs.	Percussion normal; auscultation—sub-crepitant rale in inspiration and expiration.
Diagnosis.	Age, labored breathing, asthenia; resonant chest, pathogonomonic sub-crepitus (double). If extend-ed to vesicles, crepitant rale. If plugging of bron-chus and collapse of lobule, there may be a local point of high pitch and bronchial breathing. If collapse is extensive, retraction of chest on in-spiration, and sinking at suprasternal notch and epigastrium.
Prognosis.	Always grave.
Treatment.	Support vigorously by diet, quinine, stimulants, as needed; oil silk jacket; mild counter irritants; warm, moist, uniform air ; oxygen. Emesis; if needed to eject mucus.
 
          39



CHRONIC BRONCHITIS.
Definition.	Acute attack often leaves bronchi liable to frequent sub-acute attacks, which may result ultimately in chronic bronchitis. A variable form of sequelae of previous bronchial catarrhs.
Pathology.	Varying in different cases, including one or more of the following pathological states : 1. Simple chronic catarrh or relaxed, thickened mucous surface. 2. Changes of calibre of bronchi. General relaxation or dilatation. Local relaxation. Local contraction or obliteration. (Cirrhosis of lung the result.) 3. Local ulceration of mucous surface. Local ulceration of all the coats. 4. Peri—or extra—bronchial inflammatory deposits. 5. The same broken down, leaving cavity opening into bronchus. 6. Resultant pneumonia, indurations.
Symptoms.	Chronic cough, for months and years, without great loss of flesh, strength or appetite. Chronic catarrh of bronchi; quantity, color, viscidity, determined by extent and kind of lesion.
Physical Signs.	Varying with simple bronchial, peri-bronchial or pul-monary lesions, with dilated bronchi, bronchial cavity, peri-bronchitis or cirrhosis of lung. Simu-late every form of phthisis.
Diagnosis.	To be differentiated from Tuberculosis.
Prognosis.	Persistent, often incurable, but slow progress; remis-sions and exacerbations.
Treatment.	Hygienic, tonic. Climatic. Palliate symptoms according to case. Balsamic inhalations. Iodide of potassium.
 
         40



SYNOPSIS OF ASTHMA
Definition.	A functional disease; labored obstructed respiration, due to spasm of bronchi, usually with bronchial catarrh.
Pathology,	Theory of hyperaemia of par vagum. No known lesion of asthma. May be co-existing lesions of acute or chronic bronchitis, em-physema, etc.
Causes.	Often obscure or unknown. May be hereditary. Excited by cold air, dust, vapor, fatigue, mental effort, excitement; especially indigestion and bad ventilation (foul air of sleeping room) flatulence, constipation, uterine disturbance (reflex action). Most common in men. Special form.—" Hay asthma " or autumnal catarrh, due to emana-tions of flowing, mature vegetation.
Symptoms.	Attack often sudden (rarely gradual, with preceding catarrh). Often at night in sleep. Increasing sense of obstruction to ad-mission of air ; suffocation ; face anxious ; respiratory muscles fixed; orthopnoea ; head thrown back ; gasping ; dilated nares; obstructed venous circulation ; in head and neck, symptoms of carbonic acid gas accumulation ; fatigue, exhaustion. Sudden relief, or gradual, with lingering bronchial catarrh.
Physical Signs. Diagnosis.	Normal pulmonary resonance, or vesiculo-tympanitic resonance on percussion. Fine tube and vesicular sounds wanting, or feeble. Expiration long and changing, composed of numerous sibilant and sonorous rhonchi, of varied and changing intensi-ty, pitch, and quality. Moist rales of bronchial catarrh exist. Paroxysms sudden; physical signs, definite recovery from attack, complete and speedy, seldom any permanent dyspnoea.
Prognosis.	May cause emphysema. Remotely effects the heart.
Treatment.	Of paroxysms: Oxygen, chloroform. Hypodermic use of morphia and atropia. Stramonium. Nitre cigarettes. Of intervals: Quinine. Iodide of potassium.
 
41
SYNOPSIS OF PLEURITIS.
Definition.	Inflammation of pleura with accumulation of inflammatory pro-ducts on free surface, or in the pleural cavity.
Pathology.	Hyperaemia of sub-serous vessels ; surface denuded of epithelium; rough, " hazy," later escape of exudation, may be plastic, sero-plastic or wholly serous. If adhesions, they are due to contact and adhesion of opposed villous surfaces. (Plastic exudation not material of adhesions. It may remain entangled and under-go caseous change—" tubercle of pleura," or become calcified, so-called " osseous plates.") General adhesions may obliterate pleural cavity. Local adhesions may incapsulate serum. Excess of serum—lung collapsed at hilus of lung. Too long col-lapsed, may be bound down by adhesions, expansion prevented, and air sacs agglutinated. Lesser adhesions—lesser results. Pleuritic serum may become purulent (empyema). Pleurisy often located near superficial tubercle. Tubercle perforating pleura causes pneumo-hydro-thorax.
Causes.	Acute—due to cold. Secondary—in blood states and acute disease. Local— co-existent with superficial tubercle
Symptoms.	ist Stage.—Chill, stitch in side, febrile action, incomplete restrain-ed breathing. Irritable, dry cough. Later—pain relieved and dyspnoea developed, due to pressure of serum on lung and diaphragm. If—empyema frequent chills, weakness, foul tongue, sallow skin. Tubercle' develops or typhoid state liable. If perforation-sudden, excessive dyspnoea; symptoms of collapse.
Physical Signs. Diagnosis.	Depend on plasticity and movement of exudation. Rough sur-face gives a to and fro friction sound. Adhesions give every variety of fine and coarse rales, unaffected by cough. Layers of thickened pleura and exudation give percussion dullness and render voice and breath sounds muffled, vague and distant. Over serum, chest wall is full and immovable. Intercostal spaces bulge, percussion flat—high in pitch, short duration, wooden quality. Upper line of dullness abrupt, horizontal, changing with position of the body. Over serum, absence of voice and breath sounds. Aegophony at surface of fluid. Vocal fremitus wholly absent. Over compressed lung, sounds harsh, raised in pitch. In perforation, signs of serum below. Above, air gives tympanitic resonance on percussion sometimes pectoriloquy, and splashing of serum or succussion. Friction double. Rales unaffected by cough. Dullness, with ab-sence of voice and breath sounds and fremitus. Distinguished from pneumonia: Sounds conveyed in pneumonia. Crepitant rale in pneumonia. Distinguished from hydro-thorax : Both sides involved. Non-inflammatory.
Prognosis.	Many evanescent cases unsuspected. Most serous and sero-plastic cases recover. Excessive plasticity cripples lung. Per-manent adhesions may cause local congestion or inflammation of lung, local or general emphysema. May, by causing irrita-tion favor infiltration and caseous masses ("crude yellow tubercle) in lung. Empyema often grave. Pneumo-hydro-thorax, bad.
Treatment.	Abortive.—Cups (dry) to side. Counter irritation active—prompt, cathartic (saline). Antiphlogistic—antispasmodic—anodynes for cough. When exudation is complete—Aid process of absorption. No depressing measures. Food, quinine, iron, alcohol, fresh air, exercise, Absorption aided by mild counter-irritation. Ol. tere-binthinae, or ungt. Iodini comp.: also by Iodide of Potassium. In slow absorption, perform paracentesis or aspirate.
 
                 42

SYNOPSIS OF PNEUMONIA.
      English Classification.

Pneumonia.            ~|
Pneumonitis.
Lobor Pneumonia.
Inflammation of Lungs.
Lung fever.
(Popular names.)
Chronic Pneumonia..................I
Cirrhosis of Lung...................j
Capillary  Bronchitis—with  Lobular j
    Pneumonia, and collapse of Lob- >
    ules...............................
German Pathological Classification




Croupous Pneumonia.



Chronic Interstitial Pneumonia.


Catarrhal Pneumonia.
                              PNEUMONIA.
      Pneumonitis, Inflammation of the Lung, Croupous Pneumonia.
Definition.      A local inflammatory disease of the lungs, usually idiophathic,
                  with exudation of coaguable lumph into the air sacs.
Pathology.
ist Stage.—Congestion,
2d Stage.—Red hepatization ;  solid, coagulated  cell contents ;
   white blood corpuscles (exudation corpuscles)—fibrin albumen,
   salts,  haematin.  Stasis in capillaries.
3d Stage.—Gray hepatization.  Fatty metamorphosis  of cell con-
   tents. Exudation removed by  absorption  and expectoration.
   Rarely leaves chronic consolidations.  Often pigmentation due
   to transuded haematin-melanine.  Usually  (slight or great) co-
   existing local pleuritis.
Causes.
Age.—More often in adults.
Sex.—More often in males.
Exposure to damp and coid.
Exhaustion.
 Secondary in acute fever, and septic blood condition.
Symptoms.
Marked chill or rigor—local stitch—rapid  respiration, 30, 40, 60.
    Increased temperature—pulse full, frequent; may be active
    delirium. Bloody,  "rust-colored," sputa.  Short  suppressed
    cough;  anxious, painful face;  dilatation of nares;  circum-
    scribed  flush of cheek;  asthenic cases  and  old age,  may
    be  no chill,  little fever and no pain; delirium  low, wan-
    dering ; sputa dark, " prune juice," mahogany-colored • pulse
    weak and rapid, or slow. Assumes a typhoid form.
Physical Signs.
Diagnosis,
Differ in the three stages.  Three stages usually co-exist in differ-
   ent lobes, hence physical signs vary in different parts of lung.
ist Stage.  (Hyperaemia.)   Slight dullness on percussion ; tube
   sounds harsh;  vesicular element of sound muffled.   Early
   signs  doubtful; with exudation  crepitant rale  present—fine
   crackles in inspiration only.
2d Stage.  (Solidification.)   Crepitus  ceases; flatness on  percus-
   sion (high pitch, short duration,  wooden  quality).  Ausculta-
   tion—bronchial breath and bronchial voice. Fremitus increased
   in  partial pneumonia.   Fremitus  diminished in general  or
   double pneumonia.
3d Stage.  (Liquefaction—resolution.)  Returned crepitant rale-
    rale  redux.    Sub-mucous and  mucous  rales.  Dullness on
   percussion. Gradual return of normal, " breezy," " vesicular"
   respiration.  Crepitus of local pleurisy may co-exist.
Chill, fever, pain ;  circumscribed blush, rapid breathing, bloody
   sputa; flatness; crepitant rale ; voice and  breath bronchial-
    rale redux."
Prognosis.
In healthy adults, recovery; resolution often by fifth day the rule
   is in nine to twelve days.  Weak and aged—typhoid form-
   often fatal.  Very rarely develops phthisis.
Treatment.
May abort early by derivatives-diaphoresis, cathartics, cuppine.

E"1oyulueces0,tild1kt.feVer-  AC°mte' amm°nia'  fom-taPtion!,
Later period.—Prevent asthenia, favor resolution.
Diet: Tonics, stimulants. 
             43
SYNOPSIS OF EMPHYSEMA.
Pulmonary, Vesicular Emphysema.
Definition.	A local chronic disease, due to rarefaction of pulmonary structure and dilatation of air sacs.
Pathology.	May be general vesicular emphysema or often of upper lobes only, or confined to a few lobules only. Lungs do not collapse on opening thorax. May be distinct cysts, or poutings on the sur-face; feel soft, elastic. Progressive lesions, enlarged air sacs, obliterated alveoli, perforation of cell walls, cells coalesce, cysts of small or large size. Fatty degenerations and destruc-tion of intercellular tissue. Capillaries obliterated ; their blood leaves pigmentation. Obstructed lung circulation causes dila-tation of right heart, hence general venous retardation, favor-ing chronic diseases of the viscera.
Causes.	Lobular emphysema, is " vicarious," caused in inspiration, com-pensating adjacent, atrophied, solidified, or collapsed lobules. General vesicular emphysema, always due to excess of inspired air, over air expelled in expiration as in chronic bronchitis, with thickening and relaxation of tubes. Usually fatty de-generation and atrophy of connective tissue. Emphysema of upper lobes only, due to expiratory force and ob-struction at glottis ; in pertussis, chronic cough, heavy lifting, gymnasts, porters, musicians, etc. Rarely fatty degeneration is primary. Very rarely due to rigid thorax.
Symptoms.	Dyspnoea, labored breathing, respiration and circulation easily disturbed. Often bad circulation, disease of heart, chronic dis-ease of distant parts.
Physical Signs.	Lobules, not often detected. General, and upper lobes,—resonance vesiculo-tympanitic. Respiratory sounds feeble. Expiration prolonged, blowing, low in pitch; variety of sibilant and son-orous rhonchi. Chest full, rotund ; intercostal spaces full. Expansion slight. Rising of chest "en masse." Muscles of neck and chest fixed. Broad, short neck. General emphysema, diaphragm depressed, heart also resting on it, falls, becomes horizontal.
Diagnosis.	Heart apex outward; liver may be depressed. Diag. from asthma, chronic bronchitis (often co-exists).
Prognosis.	Can be alleviated ; rarely cured.
Treatment.	Progress checked by removing cause; avoid cold. Cure laryngeal obstruction, also chronic bronchitis. Favor tone of elastic tissue by hygienics, diet, quinine, pot. iod.
 
                                 44


SYNOPSIS OF PULMONARY CONSUMPTION OR PHTHISIS.

Pulmonary Consumption considered according to  older pathology of school of
                          Laennec, Louis, etc.
Definition.	Wasting disease of the lungs. A local expression of a blood state, of a specific diathesis. Due to tubercular deposits and their complications.
Pathology.	ist Stage.—Tuberculization.—Deposit of tubercle usually yellow or crude; rarely miliary. Yellow tubercles coalesce, form caseous masses. Involved tissues atrophy. Caseous masses shrink ; compensative emphysema ; usually at apices co-exist-ing localized pleurisy, bronchitis, pneumonia. 2d Stage.—Softening.—Caseous masses become pultaceous by im-bibition of serum, and pus due to ulceration and infiltration of adjacent tissue. Tissue destroyed, vessels obliterated or eroded; usually opening into bronchi. 3d Stage.—Cavities.—Due to evacuation of tubercular pus. May be large or small, smooth or ragged. Wall may be exposed, lung tissue infiltrated with tubercles, exudation matter, or may be cicatricial tissue. Large vessels and bands of fibrous tissue may bridge over large cavities. Cavity may open freely into bronchus, or by a valvular opening. Cavities may contain mucus. Cavities may contract, granulate and heal.
Causes.	Great predisposing cause tubercular diathesis, usually heredit-ary ; sometimes induced by environnement. Obscure relation to scrofulous, strumous and eczematous diathesis. Developing and exciting causes.—All depressing influences—indi-gestion, bad diet, privation of food, over-work, exposure to cold and damp, dissipation, close confinement at work in foul air, sedentary occupations, stooping, inhaling dust, indoor life, want of exercise and chest expansion, damp changing climate, low altitude, depressing diseases, as typhoid fever, measles, small-pox, syphilis.
Symptoms of First Stage. Physical Signs of First Stage.	ist Stage.—Variable ; may be indigestion, debility, increased temperature, emaciation (loss of fat) and loss of strength. Short accelerated breathing, pallor, increase of temperature in the afternoon. May be early haemoptysis (bronchorrhagia), early pleural plastic exudation, fugitive or fixed pains due to dry pleurisy. Cough and expectoration of local bronchitis ; may be hoarseness. Inspection.—Small chest, sinking under clavicles, sinking in in-tercostal spaces. Frequent, shallow and feeble breathing. Mensuration.—Reduced circumference and expansion. Palpation.—Increased vocal fremitus, frequent breathing and feeble expansion. Percussion.—Dullness—slight or marked—raised in pitch, of short duration, of wooden quality. May be sense of resistance.
 
                               45

SYNOPSIS OF PULMONARY CONSUMPTION, Etc.—Continued.
 Auscultation.—Weakened respiration, absence of vesicular mur-
   mur, " bronchial breathing."  Inspiration raised in pitch.  Ex-
   piration prolonged  and  raised  in   pitch;  bronchial  voice,
   bronchial whisper and bronchial cough; increased vocal  fremi-
   tus ; respiration  may be wavy, jerking, divided—cog-wheel
   respiration; heart sounds conveyed.
 2d Stage.—Hectic more marked; expectoration  more free  ; con-
   tains muco-pus—pus, "tubercular pus," fibrous tissue, casts,
   shreds,  etc.—(Pulmonary  elements), fat granules, fatty cells,
   cholesterine.  Sputa is nummular, i.e., coin shaped masses at
   bottom  of frothy fluid ; decline of health, strength, flesh ; loss
   of menses in this or early stage, or later ; liability to hemor-
   rhage from the eroded vessels ; night sweats.
 Immediate Percussion.—" Myoidema."
 Auscultation.—Sub-crepitant rale over softened part.
 3d Stage.—Increased debility, emaciation, flatness of chest, short,
   quick, labored breath, bad appetite, weak  stomach—nausea
   especially from  fatty food—vomiting,  reflex  after  cough.
   Cough  hard and sputa  copious, especially  in the morning.
   Debility increased by severe  afternoon hectic, profuse night
   sweats,  excessive expectoration, anorexia.   Sometimes colli-
   quative diarrhoea; face sunken; cadaveric, eyes staring; breath
   gasping; tongue dry  and  brown;  fingers clubbed ; liability to
   severe or fatal hemorrhage, due to erosion of vessels in cavities.
 Inspection—May be flatness—retraction.
 Percussion—May be dullness; or resonance over large superficial
   cavities; cracked pot sounds.
 Auscultation—Cavernous, amphoric  respiration,  voice  whisper
   and cough ; gurgles, pectoriloquy, aegophony, metallic tinkle.
 From chronic bronchitis and  emphysema.
 Always uncertain and guarded.  Early stages most favorable, yet
   extreme cases may  be checked.  Prognosis  determined by
   temperament, family history, habits, treatment and climate.
 To prevent, cure, arrest, and  to prolong life :
 Preventive.—Attend to  ventilation, digestion, clothing, exercise,
   occupation, chest expansion, out-door life, climate.
 Lessen  cough  and secretion.—Anti-spasmodics, balsamics, ano-
   dynes, counter irritants.
 Regulate digestion and  bowels.—Create appetite, aid digestion,
   support  strength.  Bismuth, bark, pepsine, milk, cream, butter,
   kumyss, peptonized  milk, fats, ol. morrhuae, glycerine, pan-
   creatic emulsion, wine, whiskey, etc., hypophosphites, etc.
Stop fever and night sweats.—Quinine, sulphuric acid, ergot, atro-
   pine; sage infusion, " dry salted towels.'1
Relieve fugitive pain.—Anodynes, counter irritants.
Relieve occasional vomiting.—Check diarrhoea.
   Physical
      Signs.
(Continued.)
Second Stage.
Third Stage.
Symptoms.
Physical Signs.
Diagnosis.
Prognosis.
Treatment. 
46
Deep Cardiac
   Region.
                 HEART  DISEASES.
                        Heart.
  Location.— Upper border of third left costal cartilage to
lower border of sixth, one-half to three-quarters inch to
right  of  sternum, extends  to left  to  half  inch  within the
nipple.
              'Occupies all of lower sternal region.
                   "    part of right mammary region
                           "   left
                        slightly right and  left  infraclavi-
                 cular region.
                f Part not over-lapped by lung—a triangle
                   whose  apex is at fourth left  sternal
   Superficial    !   articulation, extends  downwards and
Cardiac Region, j   outwards to the union of fifth rib with
                |   cartilage, and  inward and  downwards
                I   to sixth rib.
             Location of Heart  Valves.
  Pulmonary.—Left edge  of sternum near lower edge of
third  cartilage.
  Aortic.—A little lower, midway from edge to median line.
  Tricuspid.—Middle of sternum, oblique from third left to
fourth right interspace.
  Mitral.—One  quarter  inch  below  aortic.  Horizontally
across sternum opposite fourth left articulation.
                 Anatomy of Heart.
  Distance of mitral from tricuspid, one-half inch.
  A radius of one-half inch includes a part of all valves.
  Behind.—Apex corresponds to seventh to eighth rib in
left vertebral groove.
                       Weight.
  Average male, 9^ oz.   (Walshe.)
             10-12 oz.   (Gray.)
      Female, 8-10 oz.
                          Size.
      Length..........................5 inches.
      Width...........................3*  "
      Thickness.......................2£  " 
47
Thickness of right auricle---1 line {^ of an inch )
    ^      "left     «    ............Hiine.
           " septum...........4 lines.
           " right ventricle.....2} to 3 lines.
           "left     "   .....4 to 5    "
Capacity of right ventricle......2 fl. oz.
    "    "left       "   ......2fl. oz.
METHODS OF EXAMINATION OF THE  HEART.
  1. Inspection.—Note the location and character of im-
                pulse or "apex beat."
  2. Mensuration.—Note  relative distance  of  nipple  from
                    median line on two sides.
                  Note vertical distance, on two sides, from
                    top of third rib to lower edge of sixth.
  3. Palpitation.—1. Note praecordial motion.
               {a.)  Force      1
               lb.)  Duration   !  -., T    ,
               \c.)  Rapidity   > Of Impulse.
               {d.)  Character J
               2.  Synchronism of impulse and  systole of
                   heart.
  4. Percussion.—Map out area of deep cardiac dullness.
              Superficial area of cardiac dullness.
              By mediate      )
              By immediate    >■ Percussion.
              By auscultatory )
  5. Ascultation.—Observe frequency of action.
                Rhythm  of action.
                Duration of first sound.
                         "   "   rest.
                         "  second sound.
                                   rest. 
48
   Rhythm, Duration and Character of  Normal
                   Cardiac Sounds.
   Whole period of heart's action, 10 :
       1 st sound...............................4
       1st rest.................................1
       2d sound...............................2
       2d rest.................................3—10
   First sound synchronous with systole and apex impulse.
   Second "               "   diastole (beginning).
   At apex, first sound—ou bb.—second sound, dup.
   At base,  "     "   —up.    —  "      "   tup.
                                       (Walshe.)
   Apex and over ventricles—Hug.   —second sound, te.
                                      (Learning.)

       Theories of  Cause of Cardiac  Sounds.
   (1.)  First sound, due to
     1. Muscular sussurrus and friction in cardiac wall.
     2. Blood motion (inter se)
     3.   "          against ventricular wall, columnae and
         chordae.
     4. Vibration of valves (mitral).
     5.          " chordae tendinae.
     6.     "    " chest wall.
     7. Impulse of heart.
     8. Praecordial  friction.
   The first sound is probably due to each and all of the
above causes—factors of a composite first sound.
   2.  The second sound is also composite, due  to the syn-
chronous closure of the aortic and pulmonary valves.
   The first  sound is  best heard over body  of heart and
over apex, that is in the superficial cardiac region.
   The second  sound is  best  heard at  the base  over the
valves. 
49
         Functional Diseases of the Heart.
   1. Anaemic blood murmurs.
                               (Intermission.
                              J Irregularity.
              'Hyperaesthetic.  | Palpitation.
 2. Neuroses. \                 l^Pas,m-
                               j Cardiac Tremor.
              ^Atonic.         j Syncope.
                               j Paralysis.
                               [Angina Pectoris.

             (1.) Anemic Blood Murmurs.
   In anaemia, the blood is in an  impoverished, watery con-
dition.  Women who  are pale, destitute of color in the face,
who suffer with cold feet, uterine disorders, globus hysteri-
cus, are the most frequent subjects.
   Motion of  the blood inter se  produces in the heart and
great vessels  a soft blowing sound, which may also range in
intensity  from  a  gentle  to a very violent  murmur; this
anaemic or   haemic   murmur, however, usually lacks the
friction, harsh grating, sawing character of  organic  mur-
murs.  It is best heard at the base of the heart, at the junction
of the third left cartilage, with the sternum, and is also heard
throughout the  large arterial trunks,  the innominate  and
sub-clavian arteries—and down the sternum to the tip of the
xyphoid.  The sound  is carried simply by convection.  In
cases of extreme anaemia, there are also venous murmurs in
the neck—a continuous humming, called "bruit du diable."

          Diagnosis of Anaemic Murmurs.
  1. Character—soft and blowing.
  2. Originated at  base and  carried by  large vessels.
  3. Occur in anaemic persons.
  4. Loudest when person exerciser violently. 
50
             (2.) Neurosis of  the Heart.
  Disorders due to nerve causes.
  Nerve power  of  heart.—The  heart is an involuntary
muscle, which receives a constant  supply of  motor power
from the pneumo-gastric nerve, and the superficial and deep
cardiac ganglia.
  All over the surface of the heart, and in its substance, are
numerous little ganglia, connected together and constantly
supplying stimulus for the heart's action and rhythm.
           Irregularity and Intermission.
  The most  common  of all causes of  irregularity, inter-
mission, and  palpitation, is indigestion.   Irritation of  one
branch of pneumo-gastric nerve—the gastric,—disorders the
other branches, and produces palpitation  and  dyspnoea.
  Excessive use of tea and coffee, and tobacco especially, is
a cause,—the latter acts not only by producing dyspepsia
through excessive action of the salivary glands, but directly
through the nervous system.
  Alcoholic habit causes first a violent, then an irregular heart
action.  Fright,  excitement, excessive mental effort, great
fatigue from overwork, or absence of sleep, will give rise to
irregularity in the heart's action.
                         Spasm.
  The action of the heart  in a child who has St. Vitus's
dance is typical cardiac spasm.  This  is  the condition in
which is often heard an intra-ventricular or functional apex
murmur.   This is produced  by irregular contractions of
the columnae carnae and layers of cardiac muscle, and is
heard either as a modification of the  first sound, or at the
completion of the second sound, at  the apex.
                        Tremor.
  When a person has indulged in dissipation  until the ner-
vous system  is exhausted, there will be a tremulous action of
the heart, discernible by palpation. 
51
                       Syncope.
  Syncope is that form of fainting which is due to failure of
the heart's action.   The cessation may be temporary, with
temporary cerebral  anaemia, from failure of the heart to
send blood  to  the brain, or the  cardiac relaxation may be
complete  and  death ensue.   The  failure to1 contract is
usually due to deficient nerve force.  If merely transient, its
cause being a temporary derangement of the nerve centres,
we  have vertigo, unconsciousness, feeble action of heart, or
action altogether inappreciable, face suffused; after  a brief
time the  heart resuming its work.   If  syncope continue a
long time, a heart clot may form; this will give  rise  to a
murmur for a considerable length of time;  it may lead to
embolism, the embolism occurring months later.
               Paralysis of the Heart.
  Shock or injury  to the sympathetic nerve may be so great
that it never reacts to supply stimulus for the heart's action.
  Diphtheria is a cause of paralysis of the heart, also cerebro-
spinal meningitis and typhus fever.
                    Angina Pectoris
Is placed among neuroses, because  its lesion is not known.
(All its symptoms may occur in organic disease.) Its pathol-
ogy is supposed to be in many cases embolism or occlusion
of the coronary vessels.
           Organic Diseases  of the Heart.
  List of organic diseases of the heart:
     Anaemia—congestion.
     Endocarditis—having valvular lesions. (1°
     Pericarditis.
     Myocarditis.
     Hydro-pericardium.
     Atrophy.
     Hypertrophy.
     Dilatation—having valvular  lesions/20 
52
     Fatty  degeneration.
     Atheroma—having valvular lesions/80
     Hemorrhage.
     Embolism.
     Aneurism.
     Rupture.
     Injuries.
     Malformations—having valvular lesions/40
     Syphilis.
     Tubercle.
     Cancer.
  Anaemia  and  congestion are hardly to  be regarded as
distinct diseases, being disturbances of cardiac vasculariza-
tion. 
53
VALVULAR  DISEASES OF THE HEART.
Systolic.
Diastolic.
               (1.) Systolic.
{a.)  Left side of heart:
 1. Aortic obstruction.—Obstacle  to outward
      flow of blood through aorta orifice.
 2. Mitral  regurgitation.—Leakage of  blood
      through mitral  valve into left auricle.
{b.) Right side of heart:
 1. Pulmonary  obstruction.—Obstacle  to out-
      ward flow of blood  through  pulmonary
      orifice.
 2. Tricusped regurgitation.—Leakage of blood
      through tricuspid valve into right auricle.
               (2.) Diastolic.
{a.) Left side of heart:
 1. Aortic  regurgitation.—Leakage  of  blood
      through aortic orifice into left ventricle.
 2. Mitral  obstruction.—Obstacle  to  flow of
      blood  from left auricle to left ventrical.
(b.) Right side of heart :
 1. Pulmonary   regurgitation. — Leakage   of
      blood  through pulmonary orifice into right
      ventricle.
 2. Tricuspid obstruction.—Obstacle  to  flow of
      blood  from right auricle to right ventricle. 
54
CARDIAC HYPERTROPHY.
Definition.	Enlargement of the heart as a whole, or of the walls of any one of its cavities—the result of increased effort of heart.
Pathology.	Hypertrophy of left ventricle most often—more often than right ventricle; rarely auricles. Increase of weight, size, thickness of walls. Concentric hypertrophy: Thickening of walls at expense of cavity. Excentric hypertrophy : Hypertrophy with dilatation. Due to hypertrophy of existing muscular fibres. Possibly new fibres developed. Hypertrophy, at first a conservative process, changes to dilata-tion and fatty metamorphosis after long standing.
Causes.	Of left ventricle : Aortic valvular lesions. Mitral valvular lesions. Atheroma of aorta and arteries. Obstructed circulation in viscera. Pericardial adhesions. Habitual violent work or exercise. Of right ventricle: Emphysema and other chronic lung disease; obstructive pul-monary valvular disease. Mitral lesions. (Indirectly.)
Symptoms.	Full, strong pulse in hypertrophy of left ventricle. Liability to congestion of brain if the heart is over active. With hypertrophy of right ventricle, a slow venous circulation, dyspncea, co-existing lung disease.
Physical Signs.	Inspection—Fullness of precordial region, and heaving apex beat. Apex lower and outward—hypertrophy of left ventricle. Mensuration.—Nipple carried outward ; increased distance from third to sixth rib. Palpation.—Detect violent apex beat—and changed location. Percussion.—Increased area of dullness to the left, and down, for the left ventricle, to right of sternum for right ventricle. Auscultation.—Detect valvular murmurs of lesion, causing hyper-trophy. Hear accentuated first sound. Hear sharp, loud, abrupt click of second sound.
Diagnosis.	Precordial fullness; increased area of dullness; full, strong pulse ; strong impulse ; displaced apex ; valvular lesion ; in-tensified normal second sound, due to aortic resiliency.
Prognosis.	Prognosis in simple hypertrophy good, if life be regular and no increase of lesion. Bad, if hypertrophy is associated with dila-tation. Danger of cerebral congestion, dilatation, fatty de-generation, etc.
Treatment.	Quiet life; light work ; temperance ; plain diet. Keep excretion free. Avoid causes of increased lesion.
 
55
CARDIAC DILATATION.
Definition.	Enlargement of the heart, or one or more of its cavi-ties, with thinning of their walls.
Pathology.	Increase of size of heart ; cavities increased in size and capacity ; walls thin, often in state of fatty de-generation ; lesion of mitral or aortic valve as a rule ; valve may be separated secondary to dilata-tion; rarely hypertrophy co-exists, second in order, and conservative ; more often walls are thin, even as parchment (rare).
Causes.	Mechanical internal dilating power of blood during diastole (rest—relaxation of heart). Usually due to mitral regurgitation or aortic regurgitation ; also due to softening, relaxation, fatty degeneration of heart walls, in acute fevers of low malignant type.
Symptoms.	Weak pulse—often intermittant, irregular; slow, im-perfect venous return circulation ; dyspncea ; bad digestion; passive congestion of lungs, kidneys and liver ; cold extremities ; pale or cyanosed face ; liability to syncope ; oedema of lungs; general anasarca.
Physical Signs.	Precordial fullness; weak, heaving, wavy motion over heart ; not a strong denned impulse ; nipple car-ried outward ; increased distance from third to sixth rib ; increased area of dullness; heart sounds weakened; loud abnormal sounds indicating mitral regurgitation or aortic regurgitation.
Diagnosis.	Weak pulse; weak, wavy impulse ; large area of dull-ness; regurgitation, dyspnoea; attacks of syncope; intermission and irregularity of pulse; general weakness; secondary disorders of other organs.
Prognosis.	Always bad.
Treatment.	A quiet life ; avoid heavy work, active exercise, ex-citement, dissipations, and indigestion. Preserve full action of bowels, kidneys and skin. Strengthen health and action of heart by plain food, quinine, strychnine, and iron. Regulate heart's action by digitalis, convallaria, cactus. Combat cardiac failure by alcohol, morphine, Hoff-man's anodyne, nitrite of amyl.
 
         56
  FATTY HEART.
Quain's Degeneration.
Definition.	A destructive metamorphosis of the muscular struc-ture of the heart. (Distinguished from mere de-position of adipose on the heart of obese persons.)
Pathology.	Heart.—Pale yellow, soft, small (unless dilatation co-exist). Striae of muscular fibres grow faint, dis-appear ; replaced by fatty granules, oil globules and atheroma.
Causes.	Indolent life; alcoholism; old age; acute fever of low type; climacteric changes, atheroma of coronary arteries; embolism of coronary arteries.
Symptoms.	Weak circulation; feeble pulse; cold extremities; pal-lor, cyanosis ; weak heart impulse ; liability to syncope; cerebral ansemia. Weak heart sounds, intermission, irregularity ; dyspncea, sighing, irregular breathing. (Cheyne's symptom.) (Co-existing arcus senilis, atheroma of arteries in old people.)
Physical Signs.	No precordial prominence ; no perceptible apex beat. May be reduced area of dullness; sounds feeble, often distant.
Diagnosis.	Age, general health, habits, arcus senilis, weak pulse, often syncope, faint heart sounds.
Prognosis.	Bad. Liability to death by syncope.
Treatment.	Arrest progress by good diet, temperance, tonics. Avoid syncope ; avoid dilatation ; avoid sudden or great effort. Treat syncope by stimulants.—Alcohol, ammonia, Hoffman's anodyne, amyl, etc.
 
        57
ENDOCARDITIS.
Definition.   Inflammation  of  the endocardium.—A local disease
                usually secondary to and complicating  overload-
                ing of blood with irritant morbid material.

Pathology.   Removal of epithelium.—Surface hazy, granular; con-
                gestion of sub-serous vessels; development of villi;
                infiltration  of tissue producing roughened, thicken-
                ed, villous surface, or masses (vegetations).  Maybe
                hair-like processes, or  pendunculated  polypoid
                bodies. Inflammatory products may be re-absorb-
                ed or remain;  may be fibrous or become calcarious;
                may cause atrophy,  hypertrophy,  distortion,  re-
                traction, etc.,  of valves.
             Polypoid  masses may be detached and cause embol-
                ism of other viscera.
             Endocarditis usually on left side of heart only.
             Endocarditis of foetus in utero, on right side of heart.
             Vegetations may grow from fibrin from the blood.

Causes.      Rheumatism,  Bright's  disease,  scarlatina.  Rarely
                typhus, typhoid, variola, rubeola, diphtheria, sepsis.
Symptoms.
Often none.  May be dyspnoea, irritable  action of the
   heart.  Often not diagnosed.
Physical
     Signs.
Diagnosis.


Prognosis.

Treatment.
Sounds induced  by valvular lesions.  Aortic direct
   friction; mitral murmurs.  Murmurs disappear if
   absorption results ; murmurs increase with extent
   of lesion.

By  daily  auscultation, during  course  of  causative
   diseases, to detect friction murmurs.

Not immediate danger.  Danger of valvular disease.
Treatment of primary  disease.  Subsequent use  of
   quinine, iodide of potassium, and mercury to pro-
   mote absorption. 
58
PERICARDITIS.
Definition.	Inflammation of the serous pericardium.—A local in-flammation rarely idiopathic or traumatic ; usually the result of overloading the blood with irritant, morbific matter.
Pathology.	Congestion of sub-serous vessels; removal of epithe-lium ; surface hazy, granular ; reddened patches; development of granulations; vascular villi; friction of surfaces; liable to adhere; patches of complete union; thin bands, fibres, etc., due to contact of granulating surfaces. Absorption maybe complete; may leave white patches on heart, hairy pro-cesses, fine or coarse adhesions. Serum com-presses heart, distends pericardium. Serum ab-sorbed, surfaces again in contact. Myocarditis may co-exist.
Causes.	Rheumatism, Bright's disease, scarlatina; other acute fevers; rarely tranmatic—rarely idiopathic (catch-ing cold).
Physical Signs.	Early.—To and fro pericardial friction murmurs ; heart sounds increased, apex beat violent, pulse full—fast. With effusion.—Fullness of precordial region ; in-creased area of dullness; friction sound lost; heart sounds feeble; may be distant. Later.—Muffled friction may return ; normal action of heart and normal area of dullness.
Diagnosis.	To and fro friction ; area of dullness. [Hydro-peri-cardium has no friction sound, no fever, and co-exists with general dropsy.]
Prognosis.	Generally good. Pericardial adhesions may cause hypertrophy.
Treatment.	Treat primary disease. Locally—anodyne, alkaline fomentations for pain. Lower frequency of pulse.—Aconite, digitalis, vera-trum. Later.—Quinine, iodide of potassium, and mercurials for absorption.
 
59
CARDIAC MURMURS.
(i) Functional.	Functional. 1. Systole of heart— Anaemic murmurs; blowing in quality; heard at base of heart and diffused over chest, especially in course of vessels. Intraventricular murmur, heard at early part of systole at apex. 2. Diastole 0/ heart— Re-duplicated second sound heard at aortic and pulmonary orifice ; due to nervous action of two sides of the heart; re-siliency of aorta and pulmonary arteries unequal, aortic and pulmonary valves do not close synchronously.
(2) Organic.	Organic. 1. Systole of heart—heft ventricle— 1. Obstructive.—Obstruction at aortic valves, friction, etc. : heard at aortic orifice and over arch of aorta (at third left and second right sterno-costal articulation.) 2. Regurgitation.—Insufficiency of mitral valve; regurgitation of blood into left auricle; heard at apex in front. May also be heard around left side and behind in the left vertebral groove, from the fifth to eighth ribs. Right ventricle— 1. Obstructive.—Obstruction at pulmonary valves; friction murmur, superficial, intense, localized over valve—third left sterno-costal articulation, may exist behind second left carti-lage. 2. Regurgitant.—Insufficiency of the tricuspid valve; heard at mid-sternum, opposite third or fourth cartilages. 2. Diastole of heart—Left ventricle— 1. Obstructive.—Obstruction at mitral valve ; friction mur-mur heard at apex only. Praesystolic, i.e., in latter part of diastole. 2. Regurgitant.—Insufficiency of aortic valves; murmur heard at base, and conveyed down sternum to apex of heart replaces second sound. Right ventricle— 1. Obstructive.—Obstruction at tricuspid valve ; friction of blood coming from auricle to ventricle ; murmur heard over central cardiac area. 2. Regurgitant.—Insufficiency of pulmonary valves ; heard over pulmonary valves and down right side of heart.
Where occurs.	ANAEMIC MURMURS. Occur in an anaemic woman mainly. " " feeble and aged. " " pregnancy. " " course of blood disease. " " convalescence.
When heard.	Heard during systole only. " widely diffused over chest. " loudest at base of heart. " over arch of aorta and (transmitted by convection) over thoracic aorta down side of sternum to zyphoid cartil-age; over innominate, carotids, sub-clavian. " loudest when patient is fatigued, active or excited. " less when quiet. Diminished by tonic treatment, digitalis, test.
Character.	Character.—Soft, blowing, or loud violent systolic murmur at base. May have grating, filing, rasping, sawing musical qualities. Distinguished from organic by absence of friction, and by test of time and treatment. Accompanied with symptoms of anaemia, debility, indigestion, hysteria, etc.
 
              60

   CARDIAC MURMURS.

Table of  Synonymous Terms.
1. Aortic.	3. Aortic.
Systolic.	Diastolic.
Obstructive.	Regurgitant.
Direct.	Insufficient.
	Indirect.
2. Mitral.	4. Mitral.
Systolic.	Diastolic.
Insufficient.	Obstructive.
Regurgitant.	Direct.
Indirect.	Presystolic.
  The most frequent and important  organic murmurs to
recognize are:
    1. Aortic systolic  (obstructive, direct).
    2. Mitral systolic (regurgitant, indirect).
    3. Mitral praesystolic (obstructive, direct).  Very much
        less frequently we meet with
    4. Aortic diastolic (regurgitant, indirect).
  The above are all murmurs of the left side  of  the heart,
products of endocarditis, atheroma, traumatism, and result-
ing from rheumatism, uraemia and acute diseases.
  Of the murmurs of the right  side  of the heart, two  are
definitely recognizable, but very rare, viz.:
    5. Pulmonary systolic (obstructive, direct.)
    6. Tricuspid systolic (regurgitant, indirect).
    7. Tricuspid praesystolic (obstructive, direct) is patho-
        logically and theoretically possible, but not likely to
        be  diagnosed.
    8. The pulmonary  diastolic  (regurgitant, indirect) is
        likely to be detected only when co-existent with well
        defined pulmonary systolic murmur. 
61
        ANEURISM OF THORACIC AORTA.
  1.  Of ascending arch within pericardium.
  2.  Of junction of ascending and transverse arch.
  3.  Of transverse arch.
  4.  Of descending arch.
  5.  Descending aorta within thorax.
  Definition.—Aneurism—aneuruno,  to  dilate—a  local
dilatation of the aorta, forming a tumor containing blood,
and having walls,  the  remnant of the vessels walls, and its
investing fibrous sheath usually hypertrophied.
  Pathology  and  Aetiology.—Usually  alteration  by
endarteritis, atheroma and calcification  of wall of artery,
and  atrophic  weakening ; syphilis, rheumatism, gout  and
local injury lead to these degenerations.  Aneurism may be
fusiform,  sacculated or  dissecting.  The cavity may be full
of fluid blood, or be partially or wholly filled with laminated
fibrin.
  The  aneurism, by pressure, may set  up inflammation of
adjacent part, as of apices of lungs, pleura, bronchi.  It may
cause absorption of ribs and costal  cartilages anteriorly, or
of vertebrae posteriorly;  may compress  trachea, bronchi,
oesophagus, vena cava  ascendens, innominate vein.  The
sac may rupture into  the pleura, trachea, bronchi, pericar-
dium—or externally, beneath or through eroded integument.
  Symptoms.—Aneurism of ascending portion as a rule pro-
duces irritation of apex of right lung and its investing pleura,
evidenced by cough, expectoration, local discomfort, dysp-
ncea, local lancinating and pulsatory pain.
  Aneurism of  ascending and transverse, also involves right
recurrent laryngeal, inducing laryngeal spasm, irritability
and aphonia.
  Aneurism of  ascending portion  may  obstruct right  pul-
monary bronchi or  bronchus to  upper lobe of right  lung.
Aneurism of transverse portion compresses trachea, cutting
of air  to lung and  irritating both  recurrent  laryngeals. 
62
Orthopncea, laryngeal spasm, shallow chest expansion, supra-
sternal and epigastric sinking, anorexia often marked.
  Aneurism of descending arch disturbs only left  recurrent
laryngeal and the apex of left lung, its investing pleura and
bronchi—discomfort is then on left side of sternum and in
the left scapular and interscapular regions.
  Physical Signs.—Inspection.—In early stage aneurism
may show nothing.  Later, vibration  and bulging are ob-
served in second intercostal space to  right of sternum, or,
if transverse, pulsation may appear in suprasternal notch and
extend up cervical vessels.  Aneurism of descending por-
tion, the bulging is to left  of sternum, at  second  cartilage.
Later, sternum, ribs and  cartilages may bulge over aneur-
ism  or  be eroded and the spheroidal pulsating  tumor is
seen to right or left of sternum.
  Palpation.—Vascular  swelling  and cyanosis of head,
neck, arms and thorax  from pressure  on  vena  cava des-
cendens—of right side only, if pressure on innominate vein.
Vibratile pulsation, or '' thrill," is  detected in intercostal
spaces or through  sternum, or in suprasternal notch; after
erosion, tumor gives distensile sensation.
  Percussion.—Area of dullness in  upper sternal region,
extending to right or left or up into  suprasternal notch.
  Auscultation.—Aneurism  of  Ascending  Arch.—
Double bruit on right side of sternum, in second space, both
sounds  of friction, rasping, sawing, or whistling, ringing,
booming,  musical quality; sounds  measureably conducted
down the sternum and up  into the cervical vessels.  The
second sound of heart usually discernible to left of sternum
thus differentiating  double aortic  murmur.  Pressure  on
apex may have developed local  plastic  pleuritic rales, local
pneumonic crepitus, or stridulus by pressure on bronchus;
respiratory sounds lessened or absent in lung.
  Aneurism  of Transverse Arch.—Double bruit, heard
with stethoscope, deep  in suprasternal notch, over upper end 
63
of sternum and up vessels of neck.   Heart sounds  heard
separately.  Tracheal  stridulus very  distinct  at point of
pressure, and  the  respiratory sounds very feebly developed
throughout both sides of chest.
  Aneurism of Descending Arch.—Double  bruit  heard
of " aneurismal quality," to left  of sternum, above base of
heart;  but best heard  in back, in left vertebral groove, and
in interscapular region.
  Diagnosis.—By tumor, area of dullness, pulsating, dis-
tensile and  thrilling sensations  to  touch, by characteristic
double  bruit.   When  present,  by associated symptoms of
pressure on air passages, pleura, lung apex, vertebrae and
nerves; also by exclusion of cardiac origin  of tumor, thrill
and bruits.
  Prognosis.—Always unfavorable; aneurism may rupture
externally or internally into  lung,  pleura, brpnchi, trachea
or  pericardium.   Death also by  inanition, asphyxia,  ex-
haustion.
  Treatment.—Diminish arterial tension by quiet living,
by  open  condition  of  bowels, by  avoiding   overloaded
stomach, avoiding  emotional excitement, fatigue  and  alco-
holism.   Enforced rest,  cardiac  sedatives  and exclusive
meat diet  favor hyperinosis and filling of sac with laminated
fibrin.


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