PACE'S CHART 
OF 
PHYSICAL SIGNS. A CHART 
OF 
PHYSICAL SIGNS 
OF 
DISEASES OF THE HEART 
AND 
RESPIRATORY ORGANS. 
COMPILED FROM THE WORKS OF VARIOUS AUTHORS, WITH 
ORIGINAL IDEAS AND OBSERVATIONS. 
BY 
R. C. M. PAGE, M.D., 
7 7 
31 VVest 33d St., New York. 
INSTRUCTOR IN THE NEW YORK POLYCLINIC IN THE DEPARTMENT OF 
GENERAL MEDICINE AND DISEASES OF THE CHEST, AND ATTEND- 
ING PHYSICIAN, DISEASES OF HEART AND LUNGS, 
NORTHWESTERN DISPENSARY, NEW YORK. 
Copyright, 1885, hy R. C. M. Page, M.D. 
NEW YORK r 
J. H. VAIL & CQ 
21 Astor Place. 
1886.  
I. 
The Lungs in Health. Left 
Apex Standard. 
II. 
Abnormal Distention of Pulmo- 
nary Vesicles. Emphysema. 
III. 
Incomplete Consolidation. In- 
cipient Phthisis. 
IV. 
Complete Consolidation. Pneu- 
monia, 2d. Stage. 
V. 
Cavities. Phthisis 3d Stage. 
VI. 
Pleurisy with or without Effu- 
sion. 
Auscultation. 
Normal Respiration. 
(a) Inspiration. 
Duration, varies in different 
healthy persons. 
Intensity, ditto, increasing to 
the end. 
Pitch, normal (somewhat low). 
Quality, vesicular. 
(b) Expiration. 
Duration, much shorter. 
Intensity, less. 
Pitch, lower. 
Quality, blowing, 
Continuous with inspiration 
when present, but often ab- 
sent. 
Varieties. May be exagge- 
rated (puerile, supplement- 
ary, hyper-vesicular). Usu- 
ally obscured by r&les in 
Respiration in Emphysema. 
(a) Inspiration. 
Duration, usually much shorter 
than normal. 
Intensity, feeble or suppressed. 
Pitch, varies, usually higher than 
normal (Loomis says lower). 
Quality, less vesicular. 
(b) Expiration. 
Duration, much longer. 
Intensity, varies, generally 
greater. 
Pitch, lower. 
Quality, blowing, often hissing. 
Continuous with inspiration 
which is deferred. 
Termed by Guttman indetermi- 
nate and is often accompa- 
nied by rales. 
Broncho-vesicular Respira- 
tion. (Flint). 
(a) Inspiration. 
Duration varies in different cases, 
but a little shortened. 
Intensity, slightly increased. 
Pitch, slightly raised. 
Quality, less vesicular. 
(b) Expiration. 
Duration, as long or longer. 
Intensity, increased. 
Pitch, slightly higher. 
Quality, more tubular. 
AW quite continuous with inspira- 
tion which is barely finished. 
Often interrupted (jerking, wavy 
cog-wheeled), and accompa- 
nied by subcrepitant rales. 
Bronchial Respiration. 
(a) Inspiration. 
Duration, shorter than normal. 
Intensity, increased. 
Pitch, raised. 
Quality, tubular. 
)b) Expiration. 
Duration, as long, or longer. 
Intensity, greater. 
Pitch, higher. 
Quality, tubular. 
Not continuous with inspiration, 
which is unfinished. 
Cavernous Respiration. 
{a) Inspiration. 
Duration, varies in different cases. 
Intensity, ditto. 
Pitch, low. 
Quality, blowing. 
(b) Expiration. 
Duration, as long or longer. 
Intensity, less. 
Pitch, lower. 
Quality, blowing. 
Usually continuous with inspira- 
ration, which is slightly de- 
ferred. 
Usually accompanied by r&les, of- 
ten gurgles, and sometimes 
metallic tinkle. 
Varieties : (i) Amphoric ; (2) 
Broncho-cavernous. In the 
latter, the pitch of inspiration 
may be higher and more tubu- 
Respiration in Pleurisy. 
The respiratory sounds vary, and 
are diminished or entirely 
absent, according to amount 
of effusion or pleuritic thick- 
ening. May simulate bron- 
chial, due to plastic adhesions, 
or cavernous, or both if also 
dilated bronchi. (Learning.) 
Often in circumscribed (dry) 
pleurisy, and in the first and 
declining stages of acute 
pleurisy, friction sounds. 
In pleurisy with effusion, the re- 
spiratory sounds are suppress- 
ed below the fluid level, exag- 
gerated above it. 
If effusion be great, there is ab- 
sence of respiratory sounds 
over the whole of affected 
side, except at the apex. 
May be interrupted. 
Inspiration. 
lar than expiration, or vice 
where there may be bron- 
versa. 
chial breathing due to com- 
B* >• Inspiration. 
■>■ Inspiration. 
pressed lung. Exaggerated 
respiratory murmer over 
healthy lung. (In Hydrotho- 
rax there is fluid in both 
pleural cavities which is sim- 
ply a transudation, associated 
with general dropsy.) 
Inspiration. >- 
00 
Normal Vocal Resonance. 
Distant, diffused, and indistinct, 
varies in different healthy 
persons. Usually more in- 
tense at right apex than left. 
Vocal Resonance. 
Varies, usually diminished, some- 
times absent, at other times 
increased. 
Heart sounds feeble. 
Vocal Resonance. 
Varies, but is usually exaggerated 
(slightly increased). Bronchial 
whisper is exaggerated. 
Vocal Resonance. 
Markedly increased. Voice sounds 
are near, concentrated and 
distinct, giving Bronchophony, 
and whispering Bronchophony. 
Vocal Resonance. 
Varies. Usually, there are pec- 
toriloquy, whispering ditto, 
cavernous whisper, amphoric 
voice and whisper. Broncho- 
phony may be also weak or 
absent. 
Vocal Resonance. 
Diminished or absent, according 
to amount of effusion or pleu- 
ritic thickening. Compressed 
lung at apex may give bron- 
chophony. 
Aigophony rare. 
Percussion. 
Norl. Percussn. Resonancce. 
Duration, varies in different 
cases. 
Intensity, ditto. 
Pitch, normal (somewhat low), a 
little higher at right apex 
than left. 
Quality, vesicular (pulmonary). 
Percussion Resonance. 
Increased. 
Duration, longer than normal. 
Intensity, greater. 
Pitch, lower. (Gutt. says higher.) 
Quality, vesiculo-tympanitic. 
(Also called Bandbox.) 
Percussion Resonance. 
Somewhat diminished 
Duration, shorter than normal. 
Intensity, diminished. 
Pitch, slightly raised. 
Quality, somewhat dull. 
Percussion Resonance. 
Markedly diminished. 
Duration, short. 
Intensity, much diminished. 
Pitch, raised. 
Quality, markedly dull. 
Exag. resonance over unaffected 
lobe of same side. 
Percussion Resonance. 
Varies, usually dull. May be am- 
phoric or cracked-pot. Gentle 
percussion may give normal 
resonance; forcible percussion, 
deep-seated dulness if there is 
a small deep-seated cavity with 
healthy lung tissue intervening. 
Percussion Resonance. 
Diminished, dull or fiat, accord- 
ing to the amount of pleuritic 
thickening and effusion. Often 
changes with position of patient 
Sometimes tympanitic above 
water level, usually in front. 
Oft increased on healthy side. 
Palpation | 
Normal Vocal Fremitus. 
Varies in different healthy cases. 
Usually more perceptible at 
right apex than left. 
Vocal Fremitus. 
Varies, usually diminished, but 
may be increased. 
Vocal Fremitus. 
Exaggerated (slightly increased) 
over affected part. 
Vocal Fremitus. 
Increased on the affected side. 
Vocal Fremitus. 
Usually increased over affected 
part, but varies. 
Vocal Fremitus. 
Diminished or absent, according to 
amount of pleuritic thickening 
and effusion. 
Inspection. | 
Perfectly symmetrical chest rare. 
There is general expansion 
of thoracic walls during in- 
spiration. Scapulte move 
evenly. Superior costal respi- 
ration in women, abdominal 
more noticeable in men. 
Chest barrel-shaped. Sternum pro- 
minent, shoulders stooping. 
Intercostal spaces widened. 
Expansion of chest-walls dimin- 
ished and they move up 
and down as a solid piece. 
Abd. retract, on forcible insp. 
Heart lowered, apex beat left and 
feeble. Epigast. pulsn. due 
to hypert. r. ventricle. 
May be negative. Usually expan- 
sion on affected side is dimin- 
ished, with flattening, or de- 
pression, of supra- and-infra- 
clavicular spaces. 
Expansive movements of chest- 
walls diminished on the affect- 
ed side, and increased on the 
other. 
Emaciation, rapid respiration, 
marked depression of supra- 
and infra-clavicular spaces on 
on affected side (or sides), 
marked diminution of respira- 
tory movements of chest-walls. 
Superficial veins prominent. 
Diminution or absence of respira- 
tory movements on affected 
side, according to amount of 
effusion, increased the other 
Bulging of intercostal spaces, if 
effusion is great, and displace- 
ment of apex-beat of heart. 
Collapse of affected side some- 
times follows absorption of 
fluid. 
N. B.-Bronchitis and Asthma prac- 
tically give no signs except on 
ausculation when the various dry 
and moist rilles may be heard 
Inspection gives labored respira- 
tion in Asthma, during paroxysm. 
N. B. -In the diagrams the length of 
normal inspiration is represented 
as one and one-half inches, expi- 
ration as three-eighths of an inch, 
or one-fourth as long. In emphy- 
sema it is just the reverse, and so 
on. 
N. B.-Guttman says " that the nor- 
mal vesicular respiratory murmur 
may be reproduced by merely 
closing the lips and gently draw- 
ing a current of air inward," 
etc. In like manner other respira- 
tory murmurs may be imitated by 
arranging the lips as in whisper- 
ing a tune, and by drawing in 
and expelling air on the proper 
key, etc. 
N. B.-Rude is a short but undescrip- 
tive term sometimes applied to 
Broncho-vesicular respiration. Da 
Costa terms it Harsh. Guttman 
calls Puerile resp'n harsh (rough 
It is evident that any resp'n may 
be harsh (rough) or even accom- 
panied by rales, if the necessary 
conditions of the respiratory mu- 
cous membrane exist for their pro- 
duction. 
N. B.-The affected parts are always 
meant when not designated. 
N.B.-The ist stage of pneumonia is so 
short that it is rarely seen. Usually 
there are crepitant rille', slight 
dulness and some diminution of re- 
spiratory movements on the affected 
side. Phthisis zd stage, and Pneu- 
monia 30 stage, practically give 
same signs as zd stage of pneumo- 
nia, except that they are attended 
with rales. Moreover, in 2d stage 
of Phthisis, there is emaciation, and 
the vocal resonance and fremitus 
vary, and in Pneumonia, qd Stage, 
there is gradual return to health. 
N. B.-Pneumo-thorax usually gives 
bulging of affected side, tympanitic 
percussion, diminution or absence of 
vocal fremitus and resonance, and 
respiratory sounds, but there may 
be amphoric respiration. 
N. B.-Pulm. CEdema gives some 
dulness and, during inspiration, 
liquid crackling rales over de- 
pendent portions of both lungs. 
Pulm. Hemorrhage may give moist 
rales over seat of effus on until 
coagulation occurs, and then dul- 
ness. 
N.B.-Empyema practically gives same 
signs as subacute pleurisy usually 
with less effusion and more marked 
emaciation. 
Pneumo-hydro-thorax gives same 
signs as pneumothorax above water 
line, with metallic tinkle, and pleu- 
risy with effusion below. 
Succussion gives the splashing sound. 
N.B -Flatness is absence of resonance. 
Duration, intensity and pitch of 
tymp. resonance vary with size, etc., 
of cavities. 
THE HEART. 
The Heart is obliquely situated. The base, directed upwards 
and backwards to the right, is on a level with the upper border of 
the third costal cartilages ; the apex, forwards and downwards to the 
left, corresponds to a point between the fifth and sixth costal cartila- 
The second (superior) sound, produced by closure of semi-lunar 
valves, is synchronous with diastole, and best heard at base. It is 
short, high pitched, and sounds like ta in Rosetta, the a being very 
short and barely sounded. 
Suppose a revolution V1 inch long. The first sound would be | 
(half-inch), first rest i, the second sound | (quarter inch), and the 
second rest f inch long, thus : 
S1 R1 s2 r2 
The mitral regurgitant (indirect, systolic) murmur is heard at 
apex, behind, and may be to left of apex. Accompanies or follows 
first sound, thus : 
iib-sh t£ 
ges, one inch to the inner side of, and two inches below the left nipple. 
The Aortic (semilunar) valves are situated behind left border of 
sternum, near lower margin of left third costal cartilage ; Pulmonic 
ditto, behind junction of left third costal cartilage with sternum ; Mi- 
tral valve, in left third intercostal space, near left border of ster- 
num ; and the Tricuspid valve behind middle of sternum, between 
the fourth costo-sternal articulations. 
The Rhythm of the heart is the repetition of all the successive 
phenomena which go to make up what is termed a revolution. Each 
complete revolution is usually described as consisting of a first sound, 
a second sound, and a period of rest (silence), the first sound occu- 
pying half a revolution, the second sound and the period of rest each 
a quarter. Walshe divides it into a first sound, first rest, a second 
Aortic (basic) murmurs, precede, accompany, or follow second 
sound at base. The aortic direct (obstructive, systolic) murmur may 
be diffused over whole length of sternum, into arteries of neck, and 
even behind. It precedes the second sound, thus 
tip sh-tif 
Rhythm, as heard at apex, may be imitated by striking palm near 
wrist on a table for first sound, then point of little finger for second, 
observing proper interval. Also at base, by substituting point of mid 
die finger for hand to produce first sound. (Hudson.) 
Endocardial or Valvular Murmurs. 
Tricuspid and Pulmonic Murmurs are rare ; the former are 
heard at ensiform cartilage, the latter usually limited to the location 
of Pulmonic valves. 
Mitral murmurs precede, accompany, or follow first sound at 
Functional, or anemic, murmurs are systolic, usually aortic, and 
are more or less diffused. 
The aortic regurgitant (indirect, diastolic) murmur may extend 
down the whole length of sternum. It accompanies or follows the 
second sound thus : 
tip tti-sh 
sound, and second rest. 
The first (inferior) SOUND, produced with closure of tricus- 
pid and mitral valves, is synchronous with systole and best heard at 
apex. Twice as long as the second, lower in pitch, it sounds like rib 
apex. The mitral direct (obstructive, presystolic) murmur is usually 
limited to apex region, but may be diffused over the heart, is never 
heard behind (Loomis), and precedes the first sound, thus : 
sh-tib tit 
Pericardial (exo-cardial) murmurs, according to Loomis, are 
superficial, rubbing, limited to cardiac region, vary in intensity with 
position of patient, and are independent of heart sounds. 
m / at oase, iiKe up in cup. 
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