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CORNELL UNIVERSITY
MEDICAL LIBRARY
ITHACA DIVISION.
PUKCHASBD BY THE DEPARTMENT OF
yrte^. ff^o.
;e>//g/g^
Cornell University Library
arW950
Physical diagnosis.
3 1924 031 522 372
olln.anx
Cornell University
Library
The original of this bool< is in
the Cornell University Library.
There are no known copyright restrictions in
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http://www.archive.org/details/cu31924031522372
COPTRIOHT,' 1909,
By WILLIAM WOOD AND COMPANY,
TO
FEEDEEICK G. SHATTUCK, M.I).
Jackso}i Proft'ssay of Clinical Medicine
ill Harvard JJ iiiverKltij
IN EVIDKNCE OP MY APPKECIATION OF
THE EXAMPLE OF SINCERITY, COMMON SENSE, AND ENTHUSIASM
ESTABLISHED BY HIM IN THE TEACHING AND
THE PRACTICE OF MEDICINE
PREFACE TO THE FOURTH EDITION.
A (ioiin many small changes have lieeii ]iiaile, most of them em-
Inidying laiticisms suggested liy those who were good ejiough to
vead the honk ^\'ith eai'e.
Tlie most imjiortant changes coneern the use of the free ear in
anseultidion, the disr-ussion fjf P.ronehiectasis and the differences
lietween the two sides of the normal cliest. Some of the pictures
have lieen changed, and I h(i]ie improved.
l'.)0 Marlhoroi"(:h Street,
Boston, .June. 1.909.
PREFACE.
This book emleavors to luvsent an aoeount of the diagnostic
metlunls aiul processes needed by competent iiractitioneis of the
present date. It differs from other books on the subject in that it
makes no a-ttempt to describe technical processes witli wliich the
writer has no personal familiarity and gives no s}iace to the descrip-
tion of tests which he believes to be iiseless.
To gain genuine familiantv «ith all the technical processes de-
scribed in most books on physical diagnosis - such familiarity as
makes one competent to use theiu with due regard for the sources
and limits of error inherent in them — needs more thnii the life-time
of one man. lint unless one has one's self used a terhuical process
long enough to gain this sort of mastery over it. one cannot prop-
erlv describe it. far less recoiniueiid it to others, liecause of my lack
of personal aciiuamtanee with such metliods as cystoscoiiy, ophthal-
moscopy, and laryngoscopy I have attempted no description of them.
althongh I liclic\'e they should sooner or later be mastered by every
internist. All that 1 have described I know by lu'olonged use.
A book constructed on this basis should make obvious what its
writer considers important and what unimportant, and reveal
therein not ouh' his opinions but his jiersonal liuiitatious. lUit I
believe there is no longer a demand for books that attempt impar-
tiallv to present all that has been or is now thought of value by
some one. The personal ei.[iiation caiiuot and should not be ig-
nored. In diagnosis as in therapeutics " U'lmt t/ii i/oii v'lul vahni-
l>h>?" is the question that our conteiuiioraries ask of any one of us.
not" Wluit ll'l.'i Inoi rcrniiniii'/llh'd ? "
In the endeavor frirther to break down the false distinction be-
VI PREFACE.
tweeii cliuieal diagnosis and labdiatm-v iliat;ii(isis T liavo (Icscribcil
all the inetliods of L;pttiiiL;' at an ortjaii — <■.'/., tlif Iviilney — in a sin
gle section. I'alpatidn. tlicrnionieti'v, urinalysis an' dil'i'erciit prdc-
esses liy wliich we ina\' ,L;-athci' infciriuatidn almnt tlie kidney. 'Die
stndent should he acciistonied to tliiidv of theiu and practise Iheui
in (dose seijueuce.
For the same reason the most important lui'thods oi in\'estiL;at-
mi;- the stomarh ]ia\e been grouin-d toij'ethcr without, any dislinetion
of "elinieal" anil " lalioratory " proeeilure.
For the illustrations I owe uumy thanks to nuiuy persons, espe-
cially to l>rs. iM-auk Ihllings, A. K. lloycott, K. II. Bradford, K.
K. Carson, d. Kverett Dutton, K. T. Kdcs, doel Iv <;<ddthwait,
J. S. Haldaue, Frederiik T. T>ord, ll, W. i.ovett, 11. C, i\Iaslaiul,
S. J. :\reltzer, Percy :\liis-rave. ]{. h\()'Ncil. d. K. Sidiadle, Will-
iam H. Smilh, \\'. S. Thayer, aud<i. h. \\'allou ; also to the edi-
tors of the Ihiston Miilii'iil uml SiirijlrKl .Imininl. the >*t. I'aul
j\Icdt('iil JiiiD-iiiil , ^iiiii-rii-rui Jli'i/iciiif, I'hf Jiiiinidl nf K.i-jiri-'niii-ntiil
j)l('ilii-iiir, aiul 7'//c Liiiirct.
Jfy assistant, I)r. ^[ary \V. Rowley, has heljied nie very much
with the iiulex as well as with other parts of the book.
190 JIarlboko St.. Boston.
Jhiw, rjo5.
TABLE OF CONTENTS.
CHAPTER I.
DATA RPXATINfi TO THE BODY AS A WHOLP]
\Vi:i«nT, ........
(«) Causes of Gain in Weiglit, ...
{b) Causes of Loss in Weight
TeMPER.ITL'RE — TkCIINIQUE and SoCRCKS of Ellltoi!
(a) Causes of Fever
(h) Types of Fevev,
(cj Subnormal Temperature
(d) Chills and Their Causes
PAGE
1
1
2
2, 3
CHAPTER II.
THE HEAD, FACE, AXD XECK.
I.
The Cranial Vault, .
1. Size, Shape,
2. Fontanels,
3. Hair,
II.
The Forehead, . . .
III.
Tlie Face as a Whole,
IV.
Movements of the Head aiK
V.
The Eyes
(«) Ocular Motion,
(6) The Retina,
VI.
The Nose
VII.
The Lips
VIII,
The Teeth,
IX.
The Breath,
X.
The Tongue,
1 Face
5
5
6
7
8
9
13
13
16
16
17
18
20
31
09
vni
TABLE OF CONTENTS.
XI. The Gums,
XII, The Buccal Cavity, ,
XIII. The Tonsils aDcl Pharynx,
XIV. The Neck
(a) Glands,
(b) Abscess or Scars,
(c) Tumoi's and Cysts, .
(d) Vertebral Tulterculosis,
(e) Actinomycosis,
(/) Cervical Rib, .
31
PAGE
24
25
26
29
29
31
-1
CHAPTER III.
THE AEMS ANLt HANDS; THE BACK.
The Arms.
I. Paralysis, .
11. Wasting of One Arm,
III. Contractures,
IV. CEdema, .
V. Tumors,
VI. Miscellaneous Lesions of the Forearm
The H.vxds
I. Evidence of Occupation, .
II. Temperature and Jloisture,
III. Movements,
IV. Deformities,
The NAn.s, .
The B.\ck. .
I. vStifl Back,
II. Sacroiliac Disease,
III. Spinal Curvature,
IV. Tumors of the Back,
V. Prominent Scajiula,
VI. Spina Bifida,
TABLE OF CONTENTS.
CHAPTER IV.
THE CHEST.
TECHNIQUE AND GENERAL DIAGNOSIS.
Introduction, ............ 50
I. Methods of E.xamiuing tin; Tlioracic Organs, 56
II. Regioual Anatomy of the Chest, ....... 56
INSPECTION.
I. Size 60
II. 8n.\PK 61
(a) The Kachitio Chest 63
(b) The Paralytic Chest (i3
(r) Tlie Barrel Chest 64
III. Dbfokmities 66
(a) Curvature of tlie Spine, 66
(b) Flattening of One Side of the Chest 66
(c) Prominence of One Siile of the Chest, . . . . .67
(d) Local Prominences, 6y
IV. Respiratouv Movements <)9
((f) Normal Kespiration, 'i9
(A) Anomalies of Expansion, ........ 69
1. Diminislied Expansion, 70
2. Increased Expansion, 71
(o) Dj'spnoea, . 71
V. The Respikatouy Riivtii.m 74
(«) Asthmatic Breatliing, 74
(b) Cheyne-Stokes Breathing 74
(c) Restrained Breathing, ........ 75
(rf) Shallow and Irregular Breathing 75
(«) Stridulous Breathing 76
VI. Diaphragmatic Movements (Litteu's Phenomenon), . . .76
VII. The Cardiac Movements 79
1. Normal Cardiac Impulse, 79
2. Displacement of the Cardiac Impulse, 82
H. Apex Retraction 84
4. Epigastric Pulsation, 85
5. Uncovering of the Heart, ........ 85
TABLE OF CONTENTS.
VIII. Aneurtsm and Other Causes of Abnormal Pulsation
THE (UiEST Wall,
IX. The Pekii'heuai, Vessels,
(.() VeuoHs Pheuonit'ua,
{/>) xVrteriiil Plii'iionicna,
((') Capillary Plienomuna.
X. The Skin and JIucous Mejiukanes,
1. Cyanosis
3. (Edema
3. Pallor
4. Jamidice
5. Scars and Eruptions, .
XL Enlarged Glands
CHAPTER V.
PALPATION AND STUDY OF THE PULSE.
I. Palpation
1. Till' Cai'diac Iniiudsc,
3. Thrills
3. Tactilf FreiiH'tiis,
4. Frictidii, Pleural oi' Pericardial,
5. Palpable Rales, ....
6. Tender Points
7. Abnormal Pulsations,
8. Tumors
9. Temperature and Quality of the Skin
II. The Pulse
L Tlie Kate,
3. Rbytlim
8. Coinpressiliility,
4. Size and Slia|ie of Pulse Wave,
Vi. Tension
(>. Si/.e and Position of Artery,
7. Condition of Artery Walls,
111. Arterial Pkessuki-, and the Instrumen
1. Gaertnei's Tonometer,
3. The Riva Uoeri Inslruinent.
3. The Instrument of Hill and Barnard
4. The Oliver Instrument,
OR Measukin
TABLE OF CONTENTS.
XI
CHAPTER VI.
PERCUSSION.
I. Tbchnique,
(,()
.', Mediate Percussion,
I Immediate Percussion,
(h) Auscultatory Percussion, ....
(c) Palpatory Percussion, ....
II. Pbkcussion-Kbson.^nce op the Nokmal Chest,
(a) Vesicular Resonance,
(b) Dulness and Flatness,
(c) Tympanitic Resonance,
(d) Cracked-pot Resonance,
(e) Amplioric Resonance,
(/) The Lung Relle.x, .
III. Sense of Resistance,
PAGE
. 118
■ 118
. 12.'5
. 127
. 127
. 128
. 129
. 130
. 131
. 135
. 1.30
. 1.36
CHAPTER VII.
AUSCULTATION.
rTATION,
to Disregard,
1. Mediate and Immediate Aiisctji.
2. Selection op a Stethoscope,
3. The Use op the Stethoscope,
A. Selective Attention and What
B. Muscle Sounds,
C. Other Sources of Error, .
4. Auscultation op the Lungs,
I. Respiratory Types, .
(a) Vesicular Breathing,
(b) Tubular Bi'eathing, ,
(c) Br-oncho-vesicular Breathing
(d) Emphysematous Breathing,
(e) Asthmatic Breathing,
(/) t!og-wheel Breathing,
(g) Amphoric Breathing,
(/t) Metamorphosing Breathing,
II. Differences between the Right and the Left Chest
137
1.38
143
143
14(5
147
149
150
151
1.53
1.54
155
155
150
150
150
1.57
TABLE OF CONTENTS.
III. Patliological Modilications of Vt'sicular Breatbiu
((() Exaggerated Vesicular Breathing,
(?)) Diiuiuisheil Vesicular Breatbiug,
IV. Bronchial Breathing in Disease,
V. Broncho-vesieular Breathing in Disease,
VI. Amphoric Breathing, . , . ,
VII. Uaies
(if) Moist,
(*) Dry
((•) JIusieal
VIII. Cough. Effects on Respiratory Sounds,
IX. Pleural Friction
X. Auscultation of the Voice Sound, .
((() The Whispered Voice,
(/)) The Spoken Voice, .
(<■) Egojihony, ....
XI, Phenomena Peculiar to Pneuino-hydrothora:
((() Succus.sion, ....
(b) Metallic Tinkle,
(c) The Lung Fistula Sound, .
CHAPTER VIII.
AUSCULTATION OF THE HEART.
1. The Valve Are.\s,
2. norm.\l huart sounus,
3. .modikicattons in the intensity
((-I) Mitral First Sound, .
IE Till'; Heaut Soitnds
1. Lengthening
3. Shortening, ......
3. Doubling, .......
((!)) Tlie Second Sounds at the Base of the Heart.
1. Physiological Variations, ....
3. Pathological Variulinns, ....
(ti) Accentuation of Puliiioiiic Second Sound
(J) Weakening of Pulmonic Second Sound,
(p) Accentnatii}n of tlie Aortic Second Sinind
(d) Weakening of the Aortic Second Sound,
(e) Accentuation of Both Second Sounds,
(/) Sununary
TABLE OF CONTENTS.
(<•) Modifications in Rliyflim of C'urdiuc Sounds ami Doulillng of
Second Sounds, . , . . . . . , . .181
(d) Metallic Quality of the Heart Sounds, .
(e) " Muffled " Heart Sounds
4. Sounds Audible Ovek tiik Pekiiuibrau Vksse:.s,
(ii) Arterial Sounds, ......
(b) Venous Sounds,
. 183
. 182
. 183
. 182
. 183
CHAPTER IX.
(Auscultation of tuk Heaut, Continued.)
CARDIAC MURMURS. '
I. Terminology, ....
1. Mode of Production.
3. Place of Murmurs in the Ciardiac Cycle,
3. Point of Maximum Intensity,
4. Area of Transmission, .
5. Intensity, Quality, and Length,
6. Relation to Heart Sounds,
7. Effects of Respiration, E.xertion, and Position,
8. Metamorphosis of Murnmrs, .
II. Functional Murmurs,
III. C audio-Respiratory Murmurs,
IV. Venous Murmurs,
V. Arterial Murmurs,
184
184
180
187
188
19U
193
193
194
194
197
198
198
CHAPTER X.
DISEASES OF THE HEART.
VALVULAR LESIONS.
1. Valvular and Parietal Disease 199
3. The Establishment and Failure of Compensation, . . . 203
3. Hypertrophy and Dilatation 20">
4. Valvular Disease, 310
I Mitral Regurgitation 310
(a) Pre-compensatory Stage, . . . . - . 313
(i) Stage of Compensation, ...... 313
XIV
TABLE OF CONTEm'S.
(c) Stage of Failing Co]ni)cnsiit,ioi
(d) Differential Diagnosis,
II. Mitral Stenosis,
1. First Stage,
3. Second Stage, .
y. Third Stage, .
4, Dilferential Diagnosis,
III. Aortic Regurgitation,
1. Inspection,
(a) Arterial Jerking,
(h) Capillaiy Pulsation,
2. Palpation,
3. Percussion,
4. Auscultation. .
5. Summary and DilVerential Dia
6. Prognosis,
7. Coniplieations,
IV. Aortic Stenosis,
1. («) TliC Mui'niur, .
{h) The Pulse,
(c) The Thrill,
(d) Feeble Aortic Second Sound,
2. DifTerential Diagnosis,
V. Tricuspid Regurgitation,
1. (it) The Murmur, .
(b) Veniius I'ulsation,
(c) Cardiac Dilatalion
(fZ) Feeble Pulmonic Sicoml Sound,
2. Difl'eiential Diagno.sis,
VI. Tricuspid Stenosis,
VII. Pulmonary Regurgitation,
VIII. Pulmonary Stenosis,
IX. Condjincd A'alvular Lesions,
(«) Double Mitral Disease,
(h) Aortic and Mitral Regnrgitatidn,
(c) Aortic Stenosis and Regurgitation
PAGE
217
218
320
222
224
325
326
229
230
231
332
333
234
234
237
238
338
3:»
340
342
243
244
243
240
247
247
248
248
240
250
251
252
253
354
255
256
niAPTEK XL
PARIETAL DISEASE AND CARDIAC NEUROSES.
I. P.vnrKT.'M. Disi;.\SK of Tin-; IIr;,\TtT,
1. Acufi' M\'neardi(is, ... . . . .
TABLE OF CONTENTS.
'i. L'hroiiir JlyiU'iinlitis,
ii. Fiitty Ovt'igrinvtli,
4. Futty Dcgi'iicrutiou,
II. Caudiac Nkvkoses.
1. Ttit'liycaidiii, .
2. Bradycardiii, .
3. Ai'i'hytlimia, .
4. P;il|iitatiou, .
III. CONUEN'ITAL HeAKT DiSE.VSE
CHAPTER XII.
DISEASES OF THE PERICARDIUM.
I. Pericarditis,
((;) Dry or Fibrinous, .....
(4) Pericardial Effusion, ....
1. The Area of Dili lu'ss
3. The Cardiac Imimlsc and tin- Pulse,
3. Pressure Signs, .....
(c) Adherent Pericardium, ....
1. Ketraction of Interspaces, .
2. Limitation of Respiratory Movements,
3. Absence of Cardiac Displacement -with Change of Position
4. Hypertrophy and Dilatation not Otherwise Explained,
5. Capsidar Cirrhosis of the Liver, . ...
CHAPTER XIII.
THORACIC ANEURISM.
1. Abnormal Pulsation,
2. Tiunor, .
3. Thrill, .
4. Diastolic Shock, .
5. Tracheal Tug.
G. Pressure Signs,
7. Percussion Duluess,
8. Auscuitatuni,
(/() ^lunnurs,
(6) Diastolic Shock Soi
nd.
XVI
TABLE OF CONTENTS.
9. Ra(lioi3copy,
10. Summary,
11. Diagnosis,
287
287
288
CHAPTER XIV.
DISEASES OF THE LUNGS AND PLEUKA.
BRONCHITIS, PiNEUMUNIA, TL-BEHCULOSIS.
Tlt.VCIIEITlS,
. 292
Bko^ciiitis
. 292
(a) Physical Sigii.s,
. 293
(i) Differential Diagnosis,
. 294
Ciioupous Pneu.monia, .
. 296
(it) Inspection,
. 296
(b) Palpation,
. 297
(e) Percussion,
. 297
((?) Auscultation, .
. 298
((') Summary,
. 301
(/) Differential Diagnosis, .
. 301
BRONCnO-PNEUMONI,\,
. 302
PuLMONAitY Tuberculosis, .
. 304
(a) Incipient Tuberculosis, .
. 304
(h) Moderately Advanced Cases,
. 308
(e) Advanced Phthisis,
. 311
(J) Anomalous Forms of Pulmona
rv T
i])ereul<")Si
s,
. 31.5
CHAPTER XV.
.Dtseases of tuk Lungs, Continued
1. Emphysema
{a) Small-Liiiiged Emphysema, .
(h) Large-Lunged Emphysema, .
((■) Emphysema with Bronchitis and Asthma.
(d) Interstitial Emphysema
{(•) Complementary Emiihj'seiua, .
(/) Acute Pulmonary Tympanites,
2. Bronchial Asthma
817
317
317
320
321
321
321
322
TABLE OF CONTENTS.
XVll
3. Syphilis of the Lun(J.
4. Bronchiectasis,
5. CiHuiiosis OF THE Lung,
6. Examination ob^ Sputa,
(«) Origin,
(6) Odor aud Appearances,
(c) Staining, .
(d) Microscopic Examination
(«) Description of Commone
Orga
PAf4p:
333
333
334
834
324
325
326
327
838
urnoliviliotlior
CHAPTER XVI.
DISEASES AFFECTING THE PLEURAL CAVITY
I. Hydrothorax,
II. Pneuraotliorax, .....
III. Pneumoserotliorax and Pneumopyotliorax,
Differential Diagnosis of Piieumotl)orax and Pne
IV. Pleurisy
1. Dry Pleuri.sy,
2. Pleuritic Effusion,
(a) Percussion,
(6) Auscultation,
(e) Inspection and Palpation,
3. Pleural Thickening, .
4. Encapsulated Pleuial Effusions,
5. Pulsating Pleuri.sy and Empyema Necessil.ilis,
6. Differential Diagnosis of Pleural Effusions,
V. CytoDiagnosis of Pleural and Otlicr Fluids,
(«) Teclinique
(Ii) Interpretation of Itesults.
. 330
. 330
. 332
. 334
. 336
. 336
. 338
. 339
. 34.5
. 347
. 350
. 350
. 350
. 354
. 3.54
. 3.54
. 356
CHAPTER XVII.
ABSCESS, GANGRENE, AND CANCER OF THE LUNG, PUL:\I0-
NARY ATELECTASIS, (EDEMA AND HY^POSTATIC
CONGESTION,
1. Abscess and Gangrene of the Lung, 3,59
2. Cancer of tlie Lung, 360
3. Atelectasis, 361
4. GEdema aad Hypostatic Congestion, . 363
TABLE OF CONTENTS.
CHAPTER XVIII.
THE ABDOMEN IN GENERAL,
NEUM, OMENTUJr,
THE
AND
liELLY WALLS
^MESENTERY.
Examination of tiik Abdomen in Gknkrai.,
1. The Oiuentuni. Mesentery, and Peritoneum, .
3. Technique, ........
3. Inspection,
4. Palpation, .
.5. What can be felt Beneath the Normal Abdominal Walls,
6. Palpable Lesions of the Belly Walls,
7. Abdominal Tumors, .......
8. Percussion, ........
Diseases of the Pekitoneum, .....
1. Peritonitis, Local or General, .....
2. Ascites
3. Cancer and Tuberculosis, .....
The Meskntery, ........
1. Glands, .
2. Thrombosis,
"PERITO-
PAGE
364
364
364
36.5
366
367
369
370
371
372
373
374
374
(■■>
375
CHAPTER XIX.
THE STOMACH, LIVER, AND i'ANCREAS
The Stomach
1. Inspection and Palpation,
2. Estimation of the Size, Position, Secretiu'v .-md .Mutui- ]
3. Examination of Contents,
((() Qualitative Tests
(b) Q\iantitative Estimation of Free HCl and of Total Acidi
4. Incidence and Diagnosis of Gastric Diseases,
The Livek
((() Pain,
{b) Enlargement
(c) Atropliy
((?) Portal Obstruction,
(e) Jaundice,
(/) Loss of Flesli and Strengtli, .
(g) Tlie Infection Group of Syui|itoms,
(7() Cerebral Symptoms of Liver Disease,
376
376
878
381
382
382
384
386
387
388
391
391
393
394
394
3>J.j
TABLE OF CONTENTS.
XIX
PAGK
The Gali, Bladder and Bile Ducts 395
1. Differential Diagnosis of Bili-M-y ('(.lie,
. 395
3. Enlarged Gall Bladder, .
. 396
8. Cholecystit-is
. 396
4. Kesults of Cholecystitis, .
. 397
The Pancreas,
. 397
1. Cancer,
. 397
2. Aeute Pancreatic Disease
. 398
3. (^yst, .,
. 398
4. Bronzed Diabetes, ....
. 398
CHAPTER XX.
THE INTESTINES, SPLEEN, AND KIDNEY.
The Intestines 399
1. Data for Diagnosis, . . . . 399
2. Ap])eudicitis - . 401
3. Obstruction 403
4. Cancer, ............ 404
.^. Examination of Contents, . 404
6. Parasites, ............ 400
The Si'leen, 413
1. Palpation, 413
3. Percussion, 414
3. Causes of Enlargement, 414
4. Differential Diagnosis of the Various Causes of Enlargement, . 415
The Kidney, 416
1. Incidence and Data , 416
3. Characteri.stics Common to Most Tumors of the Kidney, . . 417
3. Malignant Disease, 417
4. Hydronephrosis and Cystic Kidney, 417
5. Perinephritic Abscess, 418
6. Abscess of the Kidney, ......... 418
7. Floating Kidney, . . . .419
8. Renal Colic and Other Benal Pain, . 119
9. Examination of the Urine, . . 4-0
(a) Amount and Weight, 4'Jl
{!>) Optical Properties, 423
(c) Significance of Sediments (Gross) . 433
10. Pyuria 423
XX
TABLE OF CONTENTS.
11. Ha'maturia,
12. Chemical Examinatiou of the Uriue,
((() Reaction of Normal UiinC;
(b) Tests for Albuminuria,
13. Significance of Albuminuria, .
14. Glucosuria and Its Significance,
15. The Acetone Bodies,
16. Other Constituents, .
17. Microscopic Examination of Urinary Sediments,
18. Summary of the Urinary Pictures Most Useful in Diagnosis,
PAGE
424
425
425
426
427
428
4'M
430
431
436
CHAPTER XXI.
THE BLADDEi;, RECTUM, AND GENITAL ORGANS.
The Bladdeh,
1. Incidence and Data
2. Distention,
3. The Urine as Evidence of Bladder Disease,
The Recti'm,
1. Symptoms which should S
2. Methods, .
3. Results, .
The Male Genitals,
1. The Penis,
2. The Testes and Scrotum,
The Female Genitals,
1. Methods, .
2. The External Genitals,
3. The Uterus,
4. The Fallopian Tubes,
5. The Ovaries,
uggest an Examination,
439
439
439
441
442
442
443
443
444
445
446
447
447
448
449
4511
451
CHAPTER XXII.
THE LEGS AND FEET.
The Leos 454
I. Ilip 454
II. Groin 454
III. Thigh 455
IV. Knee 460
TABLE OF CONTENTS.
XXI
V. (a) Lower Leg,
{h) The Feet, .
(c) The Toes, .
PAGE
■ 460
. 463
. 465
CHAPTER XXIII.
THE BLOOD.
lOxA.NdNATION OF THE BlOOD, .
1. Hsemoglobin, ....
2. Study of the Stained Blood Film,
3. Counting the White Corpuseles,
4. Counting the Ked Corpuscles,
5. Inteipretiition of These Dalu,
(a) Secondary Ansemia,
(b) Ciilorosis, .
(c) Pernicious An;emia,
(d) Leucocytosis,
(e) Lymphocytosis,
(/) Eosinophilia, .
(g) Lcukiemia,
6. The Widal Reaction,
7. Blood Parasites,
(a) Malaria,
(i) Trypanosoma, .
(f) Filaria,
8. Estimation of Coagulation Time
466
466
469
475
470
477
477
478
478
480
481
481
483
483
484
484
485
485
487
CHAPTER XXIV.
THE JOINTS.
Examination op the Joints,
1. Methods and Data, .
3. Technique,
Joint Diseases, .
1. Infectious Arthritis, .
2. Atrophic Arthritis, .
3. Hypertrophic Arthritis,
4. Gouty Arthritis,
5. Hiemophilic Arthritis,
6. Relative Freciuency of the
Various Joint Lesions,
488
489
493
494
498
500
503
.505
506
TABLE OF CONTENTS.
CHAPTER XXV.
THE NERVOUS SYSTEM.
Pai:f
Examination of the Nervous System 507
I. Disorders of Motion , 507
II. Disorders of Sensation, . .511
III. Reflexes, 512
IV. Electrical Reactions, 517
V. Speech and Handwriting 518
VI. Tropliic Vasomotor Disorders, 519
VII. The Examination of Psychic Functions; Coma, . . . 519
APPENDICES.
Appendix A. — Diseases of the Mediastinum,
1. Mediastinal Tumors, ....
3. Mediastinitis
3. Tviljerculosis of Mediastinal Glands,
Appendix B. — Acute Endocarditis,
Appendix C. — Examin.ation of Infants' Chests,
Appendix D. — Radioscopy of the Chest,
Appendix E, — The SpitYGMOGRAPH,
Appendix F. — Tub ParatertebraIj Trtanoui.ak Area of Dulness
IN Pleural Effusion, ,
523
523
526
526
537
538
529
536
m"!
PHYSICAL DIAGNOSIS.
CHAPTER I.
DATA RELATING TO THE BODY AS A
WHOLE.
I. WEIGHT.
To weigh the }iatieiit shonhl be part of every physical examina-
tion, and every physician's office should contain a good set of
scales.
1. Gain in ireif/Iit, aside from seasonal changes, the increase in
normal growth, and convalescence from wasting diseases, nreans
usually :
(a) Obesity.
(ft) The accumulation of serous fluid in the bodj' — dropsy, evi-
dent or latent.
The first of tliese needs no comment. Latent accumulation of
fluid, not evident in the subcutaneous tissues or serous spaces, oc-
curs in some forms of uncompensated cardiac or renal disease, and
gives rise to an increase in weight which may delude the phj'sician
with the false hope of an improvement in the patient's condition,
but in reality calls for derivative treatment (diuresis, sweating).
Obvioirs dropsy has, of course, the same effect on the weiglit
and the same significance.
(c) Myxcedema is occasionally a cause of increased weight, i.e.,
when the myxoedematous infiltration is widespread (see below, page
10).
2 PHYSICAL DIAGNOSIS.
2. Loss of JJ e!f//if. — The aging process is so often associat,ed
with loss of weiglit tliat some writeis speak of the " cachexia of old
age.'' lu some, a rapid loss of superfluous fat may occur at moiler-
ate age, e.g., at tifty-tive, and may give rise to grave appreliension
though the general health remains good and no known disease de-
velops.
Aside from this jdiysiological change of later life, most cases of
loss of weight are due to :
(a) Malnutrition.
(Ji) Loss of sleep (whether from pain or other cause).
('•) Infectious fevers and other toxjeujii' states.
Under tlie liead of molinitrifioii come the cases of esophageal
stricture, elironic d3S[)epsia (with or without gastric ulcer or dila-
tation) and gastric cancer, chronic dianhica, tlie atrojihies of in-
fancy, diabetes mellitus, and the rare cases of anorexia nervosa.
Loss of sleejj is, I believe, the chief factor in the emaciation oc-
curring in many painful illnesses as well as in various other types
of disease. It is only in this Avay that I can account for the marked
emaciation in many cases of thoracic aneurism.
Toxo'iiiia is, 1 suppose, accountable for part at least of the ema-
ciation in typhoid, cirrhotic liver, and tid)erculosis.
II. TEMrERATURE.
The method of taking temperature is too familiar to n(>ed expla-
nation, but the student should lie aware of the fact that hysterics
and malingerers can and often do raise the mercury in the bulb by
various manceuvies, unless they are vigilantly watched. Dipping
the bulb into hot Avater, shaking tlie mercury upward toward the
higher degrees of the scale, and possibl}' friction Avith the tongue
(?) are to be suspected.
In comatose jiatients and in infancy the temperatuic is best
taken by rectuni. In others we must be sure that the lips do not
reanain open during the test, so as to reduce the temperature of the
mouth.
1. L'crcr, i.e., a temperature above 99.5" E., in adults has much
TEMPERATURE. 3
more diagnostic value than in infancy and childhood. In the lat
ter it is often impossible to make out any pathological condition to
account fov a fever. After childhood the vast majority of fevers
are found to be due to :
(ff) Infectious disease or inflammation of any type.
(b) Toxaemia without infection — a much less common and less
satisfactory explanation .
(o) Disturbance of lieat regulation — as in sunstroke, after the
use of atropine, and in nervous excitement, e.f/., just after entering
a hospital.'
For sucli causes we search when the thermometer indicates
fever.
Types of fever often referred to are : >
(a) " Cotdinued fever ," one whicli does not return to normal at
any period in the twenty-four hours, as in many cases of typhoid,
pneumonia, and tuberculosis.
(J) "Intermittent,^' " lieetie," or ^''septic" fever, one which disap-
pears once or more in twenty-four hours, as in double tertian mala-
ria and septic fevers of various types (including mixed infections in
tuberculosis).
A fever which disappears suddenly and permanently is said to
end by "crisis," while one wliich gradually pisses off in the course
of several days ends by " hjsis."
Long-continued fevers — i.e., those lasting two weeks or more —
are usually due (in the temperate zone) to one of three causes : —
Tijjihoid, tiibercidosis, sepsis.
In 1,000 "long fevers" (as above defined) the following causes
were found in the medical records of the Massachusetts General
Hospital :
Typhoid Fever .586 j
Tuberculosis 192 I 926, or 92.6 per cent.
Pyogenic Infections . 148 )
1 The latter event ma}' also reduce (temporarily) a high fever to normal or
below it. In coma from any cause (ursmia, cerebral hemorrhage, diabetic
coma) fever often occurs.
PHYSICAL DIAOXOSIS.
Epidemic Jleningitis
"Influenza '"
Infectious Arthritis .
(" I'lieumatisin'')
Leucieniia
Cancel'
^yi'liilis
^liscellaneous
_ (
10
9
4
17
n, or 1 .4 per cent.
2. Sithnormal tonjierufiirf is often seen in wasting disease (can-
■<!ev), nephritis, uncompensated lieart disease, and myxcedenia. It
is rarely of diagnostic value, but is a i-ougli measure of the degree
of prostration.
o. Cliills ("due usually to a sudihni I'ise in temperature) are seen
chiefly in: ('") Sepsis of any type; (A) ^Malaria; [c) Onset of
acute infections; ('</) " Xervous " states.
After the passage of a catheter, after or during labor, and after
infusion of saline solution, a chill is often seen, but not easily ex-
plained.
True cJiill, with shivering and chattering teeth, is distinguished
from chllline.^.i without any shivering. Chilliness is far less signifi-
cant and often goes without fever; true chill rarely does.
The cause of true chills can usuallj' be determiired hj blood
examination (leucocj'tosis, malarial parasites) and bj- the general
physical examination.
4. Xiijhf Sivfdtft ami I>(n/ Sireats.
Sweating in disease seems to be conditioned by: {a) Fever (in-
fection); (/;) Weakness; (<•) Sleep.
A phthisical patient wlio falls asleep in the daytime will sweat
then and there, and the sweating will stop when he wakes. In ty-
phoid fever and pneumonia sweating often begins in convalescence
when the temperature is nearly or quite normal. In alcoholism,
hvperthyroidism, and neurasthenic states we sometimes see sweating
witliout fever.
Sepsis, acute rheumatism, and tuberculosis are the infections
most often accompanied by sweating. In rickets the head sweats
especially.
CHAPTER 11.
THE HEAD AND FACE; THE NECK.
THE HEAD AND FACE.
Almost all that we can leani about the iiiauifestatious of dis-
ease on the head and face is to be learned bj' the use of our eyes,
hy inspi'<:tlo7i, as the term is. Other
methods — percussion, a"-ray, jialpa-
tion — yield but little. I sliall begin
at the top.
I. The Cranial Vault.
1. Tlic Sliajx?' and Size of the
Craniiun.
The shape and size of the cranium
concern us, especially in children.
(a) AhnormaUij small crania (mi-
crocephalia) are apt to mean idiocy,
especially if the sutures are closed.
(Jj) An ahnormaUy large head is
seeu in hydrocephalus (see Fig. 1),
associated with enormous " open "
areas uncovered by bone and a pe-
culiar downward inclination of the
eyes, which are partly covered by the eyelids and show a white
margin above the iris. This condition is to be distinguished from the
Fig. 1.— Hydrocephalus.
6
PHYSICAL DIAGNOSIS.
(f) Rachitic head, wliicli is flatter at the vertex and more pro-
tuberant at the frontal eminences, giving it a xqiiarigh outline, con-
trasted with the (jhihular shajie and rounded vertex of the hydro'
cephalic. In rickets there are no changes m tlie eyes.
((/) In adidt life an enlargement of the skull, due to bony thick-
Fic ~. — Paffet's Disease. (Edes.) d, Before onset of hyperostosis craiiii. /j, After onset of hy-
perostosis craiiii.
einng, forms part of the rare disease, osteitis dcfonimns (Paget's
disease), associated with thickening and bowing of tlie long bones
(see Fig. 2).
2. y/ic Foiifit iicls.
The anterior and larger f(jiitaiiel remains about the same size for
the first year of life, then diiuiiiislies, and closes about the twenti-
eth montli. The posterior closes in about six weeks. In rickets,
hydrocephalus, hereditary sj-philis, and cretinism, the fouttmels
and sutures lemain open after the normal tinu' limit.
(^a) liiilyiiKj fontanels mean increased iutrticranial tension (hy-
drocephalus, hemorrhage, meningitis, or any acute febrile disease
without dyspnoea), (li) Dejircsscd fontanels are seen iu severe diar-
THE HEAD AND FACE. ^
rhoea, wasting diseases, collapsed states, and a(;ute dyspnoeic condi-
tions.
3. Tlie, JIa'ir.
(<f) A rarhhlc cJiild often ruLs tlie haiv off the back of its liead
by constant rolling on tlie pillow. (Tliis is associated witli profuse
Fig. 3. — Syphilis of the Frontal Bone. (Curschmann.)
sweating of the head.) Patchy baldness occurs in the skin disease
alopecia ureata, and occasionally over the painful area in trigem-
inal neuralgia.
(li) Gancrdl loss of Jioir occurs normally after many acute fevers
and witli advancing age. Early baldness (under tliirty-live) is often
hereditary. Si/philis may produce a rapid loss of hair, local or
8
PHYSICAL DIAOXOSIS.
general, and the same is true of m iixivdciiin : but in botli tliese dis-
eases the hair usually grows again iu conxalescenee.
((') Fitrdsiti's (jic(llciili) are worth looking for in the dirtier
classes and those associated with them (teachers). Their eggs ad-
Flii. 4.— Acl'onicLTiilia.
here to the hairs and are familiarly known as "nits." An eczema
or itchingr dermatitis often results.
II. The Cokehead.
Soars, ernptions, and bony nodes are important,
(a) Scars may be due to trauma or to old syphilitic periostitis.
The epileptic often cuts his forehead in falling.
THE HEAD AND FACE.
(/>) Eriqjtlons often seen on the forehead are those of acne,
syphilis, and smallpox. These may resemble each other closely,
and are to be distinguished by the history, the presence of lesions
Fig. 5.— Typical Face ia Acromegaly.
on other parts of the bodj-, and the concomitant signs (fever, pros-
tration, etc.).
(c) Nudes may be the result of many bumps in childhood or may
be caused by a syphilitic periostitis (see Tig. 3j. The history must
decide.
III. The Face as a Whole.
Verjr characteristic even at a glance is the face of (a) acrome-
galia. A strong family likeness seems to pervade all well-marked
10
PHYSICAL DIAGNOSIS.
eases ^see Figs. 4 aiul 5). The liuge, bony '" whopper jaw " is tlie
most stviliiiig item, then the prominent cheek bones, anil the riilge
above the eyes. Tlie nose and chin are very large.
(A) j]Ii/.rirdt'ma (see Fig. 6) is not so characteristic aiul might
easily be mistaken for nephritis or normal stupiilit}' with obesity.
Tlie presence of dry skin, falling
liair, ]iiental dulness, and subnormal
teni[]crature, all sn|H'i'vcning simul-
taneously \\ithin a few weeks or
months, make lis suspect tlie disease. I'alpation shows that the
pnthness of the face is not true oedema, as it does not jiit on press-
ure.
i^c) Cfi'tliiixiii — the infantile form of myxiedema — can generally
be recognized by sight alone (see Fig. 7). Here the tongue is
often protruded, and there are often pot-belly and deformed legs.
(f/) In ((ih'niiu]s of the nasopliarynx the child's mouth is often
open, the nose looks ]iiiiclR'd, the exju'cssion is stupid (see Fig. 8).
THE HEAD AND FACE.
11
There is a history of mouth-breathing and snoiing, with frequent
"colds," a liigh-arched palate, and perhaps deafness.
(c) 1\\ paralysis agitans the ^'mask-like" face shows almost no
change of expression, whatever the patient says or does. The neck
is usually inclined forward, and so rigid tliat when tiie patient
Fic. 8.— Adenoid Face. (Schadle.)
wishes to look to right or left his whole bod}' rotates like a statue
on a pivot.
( /') In Gi'uiU's disease (exophthalmic goitre) the startled or
frightened look is characteristic, though the expression is almost
wholly due to tlie bulging of the eyes and their quick motions
(Fig. 9).
(rj') In leprosy the general expression is of a siqjvrahundance of
skin on the patient's face, reminding us of some animal ("leonine
face") (Fig. 10).
(//,) In early phthisis one often notices the clear, delicate skin,
12
PHYSICAL DIAGNOSIS.
Hue luiir, long ryelashfs, wide pupils — •' apjiealiiig ej'es." Pallor
and a felirik' tiusli ( liertie) eoine later in some cases.
(/) .(/■/(■/■ ni:ii!/iiii/ the faee has often a drawn, pinched, anxious
look, which has often l.)een supi)osed to be characteiastic of general
peritonitis, intestinal obstruction, or other diseases accompanied by
voniiting; but I do not recognize
any single expression as charac-
teristic of ])eritoneal lesions.
(./') Clirnnic ii/ro/iolLiin niay
Fig. n.— E.\fiphthaliiiif Guitre. (Moltzer.)
Fig. Iti.— Faet' in Loprosy.
be shown not oulj- in a red nose, but oftener in a ]ieculiar, siiinntlii'd-
oiif look, due, I suppose, to an extra but e\eul3' distributed ac-
cuniulatiuu of subcutaneous fat.
(/,■) An crilr/i/iifii/is or swollen face is much more easilj' noticed
by the patient or his friends tlmn by one who is not familiar with
his noruml look. It usually points to nephritis, but may occur in
heart disease, ajid sometiuu's (esiiecially in the morning) without
any known cause. When combined with ana;mia, the puffy face
gives a peculiar " pasty "" look (^chronic diffuse nephritis).
THE HEAD AND FACE. io
IV. Movements of the Head and Pace.
1. 2'lie S/i((Jiiii;/ Jfead.
This occurs often in old age, occasionally in puni] i^/sis agitans
(which oftener affects tlie hands), and in toxic conditions (alcohol,
tobacco, opium). In some cases no cause can be found.
2. S/msms of til 6 Fiiff.
Spasms of the face, i.i\, sudden, qiiiek contractions of certain
facial muscles, sucli as \vinl-cing-spasm, jerking of a corner of the
mouth, or sniffing, occur chiefly:
(«) As a matter of Juihlt without other disease.
(J) As a part of the disease eli.orcit, associated witli similar
"restless" motions of the hands and feet. We often see these
spasms in school-children; occasionally in pregnant women.
(c) By imitation, in schools and institutions, these spasms may
spread like an epidemic.
From habit spasms, wdiich persist for months or years in one or
two groups of muscles, true chorea is distinguished by its involve-
ment of the liands, feet, and other parts, by its frequent association
with joint pain and endocarditis (see page 493), and by its short
course (eight to ten weeks on the average).
In hysterical conditions and hereditary brain defects, various
other spasms occur (see below, page 506).
V. The Eyes.
I shall not attempt to deal with lesions essentially local (such
as a "sty"), and shall confine myself to data that have diagnostic
value in relation to the rest of the body.
1. (Edema, of tlie Lids.
Oedema of lids, especially the low^er, often accumulates in the
night and is seen hi the early mor)iing, without known cause or
14 PHYSICAL DIAO^'OSL■i.
after a debaucli. In other cases it usually points to the existence
of:
(«) 2\"ej I /iritis (prove bj- urinarj' examination).
(?') Ana'mia (prove by blood examination).
((') Measles and whooping-cough (eruption, paroxysms of cough).
Rarer causes are trieli bilusis, oiigloneiirofie o-deinu, and eri/sipe/as.
Trichiniasis is recognized b}' the presence of fever, muscular ten-
derness, and an excess of eosinophiles in tlie blood.
In angioneurotic o?dema there is usually a [u'evious historj- of
similar transitory swellings in other parts of tlie body.
The acute onset, red blush, high fever, and general ]irostration
distinguish the cedeu'a of erysipelas.
^ 2. Duel; Cirelcs iiiider the Ki/es
may appear in any debilitated stage, e.g., from loss of sleep, hun-
ger, menstruation, masturbation, etc.
3. Conjunctivitis.
This affection forms part of hay fever, measles, yellow fever,
and some cases of influenza. It may also occur as an independent
infection. It follows overdoses of iodide of potash or arsenic.
The u'JioIe cunjunetiro is reddened, in contradistinction from the
reddening about the iris seen in iritis.
4. Juuudiee.
Jaimdice, the yellow coloration of the white of the eye by bile
pigment, is easily recognized and can be confounded only with sub-
conjunctival fat, which differs from jaundice in that it appears in
spots and patches, not covering the whole sclera, as jaundice does.
The skin, mucous membranes, urine, and sweat are also bile-
stained in most cases, and the circulation of tlie bile in the blood
often produces shnv pulse, itcliing, and mental depression. Lack of
bile in the gut leads t(j flatulence and clay-coloved stools.
The commonest causes are: (a) Biliarg obstruction (catarrh,
THE HEAD AND FACE. 15
stone or tumors obstructing the bile ducts, liepatic cirrhosis, or
syphilis constricting them).
(li) Toxiemia, (malaria, sepsis, icterus of the new-born, perni-
cious anjemia).
6. T]ie Piqnh.
The noriiiiil reflexes to light and distance are tested as follows:
Let the patient face tlie light and cover one eye with the hand.
On withdrawing the hand, the pupil contracts. Then turn tlie j)a-
tient awa}' from tlie light and let liim look at tlie farthest corner of
the room. The pujjil expands. Make liini look at your hnger a
few inches distant from his ej'cs. Tlie pupil contracts. Each pu-
pil should be examined separately.
The value of the ])npils in diagnosis has been greatly overesti-
mated. There are, in fact, comparativeljr few conditions in which
they yield us important diagnostic evidence, for, although they are
very often abnormal, the abnormalities are seldom clmracteristic of
anjr single pathological condition and throw little light on the diag-
nosis.
A. The Akgyll-Eobebtson pupil reacts to distance, but not to
light. It is of great value as a factor in the diagnosis of tabes dor-
sahs and dementia paralytica.
B. Dilated Pupils. — (a) Many phthisical patients show a
more or less fninsient dilatation of one or both ]iupils. (&) Btlrid-
ness or deficient sight (from any cause) may cause dilatation of the
pupil, (f) Other common causes are distress or strong emotion fi'om
any cause, many fevers and comatose states, and the Tise of mydri-
atic drugs.
C. Contracted pupils are common in old age and in photo-
phobia from aiijr cause. Disease high up in the spinal cord (tabes,
geuei'al paralysis, etc.) may produce contraction (spinal myosis) by
])aralyzing the sympathetic dilators. Aortic anenrisrn may produce
in the same way contraction of one pupil (see below, page 284).
D. Contraction with irregulak outline and sluggish reac-
tions is often seen in iritis as a result of adhesions to the lens (pos-
terior synechiaj).
16 PHYSICAL DIAGXOSIS.
(i. JV/c t'tinii'ci.
(ii) Arciif si')u/is. a grayish viiig at the eivcumference of the
cornea, is one oi the ehissieal signs of ohl age and arteriosclerosis.
1^/') Si/]iJiillflr l-fraf If is, uswMy fieen in the liereditar_y form of
the disease, produces an irregnhirly distributed haziness of tlie cor-
nea, usually- in both eyes and before the sixteeutli year. Diagnosis
depends on otlier evidences of syphilis.
YI. OCULAK iI(.1TI0XS.
Qi) Ffosis, or dropping of the eyelid, is usually- unilateral and
dependent on paralysis of the third nerve. Its most frequent cause
is sy]iliilis. The eye is usually drawn out by the action of the un-
paralyzed external rectus. IModerate, bilateral ptosis is commou iu
hysterical and neurasthenic conditions.
(^!j) Squint (strabismus') is called c.rfi'nui/ if the ej'e turns out,
intcrnnl if it turns in. Of its inany types and causes I mention
only the acute cases due to intracranial lesions, such as tuberculous
and epidemic meningitis, syphilis, tumors.
((') Xi/gfi"jiiiiis is a rajtid horizontal oscillation of both eyeballs.
It may be the result of albinism or of various local eye troubles, but
is an important member of the symptom group characteristic of
riniltiplc sricfi'fis. It may, however, occur in many other brain le-
sions. Karely the oscillation is vertical.
YII. The Eettxa.
The lesions which are of greatest interest in general medicine
are: Retinal hemorrhage, optic neuritis, and optic atrophy.
(rt) Brfi'nal Jii'i}io)-rIi(ii/is, "with or "without other retinal changes,
are important signs of nrjiJinfis. i/rm-c a iiiriii iii.<:. and diahrt(:i.
(/i) Ojifii- jiciirifi.-i (usually bilateral) is of great value iu the
diagnosis of hmiii fiiiimrs, fi/hiiu-K/ous iiien'oKjitis. and brain abscess.
It also forms part of the lesions iu many cases of nephritis and
diabetes.
(r) Ojitii- ntvophij may be the end result of any of the types of
optic neuritis just mentioned, or in a primary form is important
THE HEAD AND FACE. 17
evidence of tabes ilovsalis. Many cases occur witliout any known
cause.
VIII. TlIK NOSK.
1. Sixi'- (iiiil ,S/iii/>r. — 'Tlie enlargement of all the tissues of the
nose occurving in ((I'j'oji/rt/iili/ has already been mentioned. In
iin/.r(P(li'/)i(i the nostrils are sometimes thickened and the whole nose
loses its deli(;acy of shape. A red nose is popularly and correctly
associated with (dcoluilisin , but iu many cases identical appearances
are produced by acne rosacea or b}- lui)us er3-tli('matosus, as well as
by circulatorj' anomalies without any other disease.
FaU'uKj ill of the hrhlge of the nose may be due to Kijiili'dk of
the iKisal /nines, es[iecially when there are scars over the sunken
portion, but is sometimes present without any disease.
The snmll, narrow nose associated with aitenoiil i/roiefhs has
already been menlioued.
2. The vostri/s move visibl}^ in many conditions involving dijsji-
vd'ii (diseases of the heart and lungs, acute infections, etc.), and
this is sonu^tiines useful in suggesting to the pihj'sician the possibil-
ity of pneumonia, hitherto unsuspected. Dried Mood in the nostrils
may be of value as evidences of recent nosebleed.
3. Nose/i/eed suggests especially trauma, infectious fevers (par-
ticularly typhoid), and hemorrhagic diseases (purpura, hsemophilia,
acute leukaMuia).
4. A ?i(isid disrliii rije in a 3-oung infant (''snuffles") suggests
hereditary .</////( ///.S-. In adults the familiar "cold in the head" may
need a bacteriological exajuination to exclude the pwssibility of
nasal dijiJitheria or to conttrm a diagnosis of influenza.
5. A small, indolent, lonif-sfnndiiir/ sore on the nose or near the
corner of the eye should always suggest epitJielioma and tidjerculo-
sis. Microscopic examination may be necessary to determine the
diagnosis.
6. The consideration of local disease within the nose does not fall
within the scope of this book, but is suggested by local pain, difli-
culty inbreathing through the nose, frequent "colds," and asthma.
(For the examination of the ears, see below, p. 505.)
18 PHYSICAL DTAGXOSTS
IX. TiiK, Lirs.
1. J'((Ilor of the inuc.dus meiubraiie of du' )i]i» .sngyests, tliougli
it never proves, aiueiaia. No diagnosis of aii;viiiia should he made
without at least testing tlie li;enioglohin (Tallqvist's scale). One
minute suttiees.
12. (/iianosU, a pui'plisli or slatey-buie color of the lips, occurs
in some healthy persons from simple " weathi'ring." W lien well
marked, howevi^r, it should always suggest: — (n) Heart disease
(especially initi-al or congenital lesions). — (A) Lung disiMses ( espe-
cially emphysenui and ])iieuuuinia). — (r) roisoning hy aci'tanilid or
other coal-tar antipyretics, producing )nethaMuoglol)ina'niui.'
The last is easily tested by noting the brownisli (not red) tint
of the lilood when soaked into lilter paper, as in perfurming Tall-
qvist's luemoglobin test; the test should be cdntirmed by the his-
tory. Disease of the heart or lung is identihed hy ])h}'sieal exami-
nation of the chest.
o. Farfril lip^j an open mouth, may be a mere haliit or may be
due to nasal obstruction (adenoids). Idiots and ci'clins are very
apt to keep their nuuitlis open, «diethcr thci'e is euhii'genu'nt of the
tongue (U' not. Dyspu(ea maj' compel a ])atient to kee[) his mouth
open so as to get luore air.
lu cold weather a cruck oi\t^.tsiire nmy ajipear, usuall}^ in the
centre of the lower lip, and in poorlj^ m)urished individuals may
persist for weeks. At the corners of the mouth fissures tn- ei-acks
maybe due to chapping or " rolj-sdrrs" (^herjies), b>it if they ]ieisist
for weeks iu j'oung children they are very suggesti\e of syphilis.
White linear scars radiating from the corners of the mouth aie (tre-
sumptive evidence of healed syphilitic lesions, oftenest congeiutal.
4. T'he iiiiicitiis jKifflirn of syi)lnlis — white, sharply bounded
areas about the size of the little-bng-er nail — are often seen at the
junction of the skin with the labial mucous membrane, especiall}' at
the corners of tlu' month.
/i. //cry/cs- (" cold sores ") is due to a lesion of the Gasst'riau
1 Oyann.sis of inlcslinal oiiuia occurs in ('iiniicclien willi cerlaiii disca.scs
involving excessive inlcstinal dcconiposition. (Sec (iilison, Qimrterly Joui'-
ual of Jlcdicinc, Oct,, 1907, p. 2'J.)
THE HEAD AND FACE.
19
Fig. 11.— Epitlielioma ol tbe Lip.
gangliiiii, with resulting " trophic " distui-ljaiices of the regions suj)-
Ijlied by tlie trigemuial nerve. Appearing iirst as a cluster of vesi-
cles ( " water blisters " ) which break and lea\'e a sn.all soj'e near the
mouth, herpes is to be distinguished by: («) its distribution, near
the terminations of some branch or branches of the trigeminal neive
("herpes frontalis, nasalis,
labialis"); (Jj) by its lasting
but a few da3'S; and (c) by
the absence of similar lesions
elsewhere. It may be con-
nected with a "cold" (which
is often a disease of the tri-
geminus), but it frequently
occurs without any discov-
erable cause. Herpetic stomatitis ("canker sores") may accom-
pany it.
6. EpUhelloma ' of tJie lijj and chancre should be suspected when-
ever a long-standing sore is discovered there. Epithelioma occurs
almost always on the lower lip in a mau past middle life (see Fig.
11). It lasts longer than chancre, is slower in producing glandular
enlargement at the angle of tlie jaw,
and is not associated with other S3'ph-
ilitic lesions.
7. Cliaiirre of f/ie lip is L'ommoneY
in women and may occur at any age,
especially under forty. The sore
usually lasts but a few weeks, ex-
cites early enlargement of the glands,
and is usually associated with other
manifestations of syphilis (see Fig.
12).
8. Angioneurotic (cdema appears
as a sudden, painless, apparently causeless swelling of the whole
' It does liarra to call this lesion "cancer" because this term is so iirnily as-
sociated in the lay mind with metastasis, recurrence, and death that unnec-
essary suflfering may result when the patient or his family learns that he has
"cancer."
Fig. 12.— Chancre ol the Lip.
20
PHYSICAL DIAGXOSIS.
lip (see Fig. l.S\, -wliicli may attain double its normal size. The
diagnosis depends on the exclusion of all known causes (trauina,
infection, insect bites) and on
the history of similar swellings
(on the lip or elsewhere) in the
past.
9. The enhn-gevieitt nf flic
Iljis in myxoedema and cretin-
ism has been mentioned above
(page 18").
10. Jfarc-Iijt is a vertical
slit (congenital deficiency) in
tlie upper lip oiiposite to the
nostril; it is often connected
witli an antero-posterior cleft
througli the hard palate ("cleft
palate''). Tlie lesion maj- be
double, leaving a small island
of tissue continuous with the
nasal septum (internmxillary
bone). Diagnosis is made at a glance.
X. The Teeth.
Tlie first set of teetli is fairly constant in its order and date of
appearance. In Fig. 14 the number of tlie montli when eai-h tooth
is most apt to appear is marked on the tooth. Tlie second set (per-
manent teeth) arrives (less regularh-) between the sixth and the
fifteenth year, exce]it tlie " wisdom
teeth," which appear about the twenty-
first year.
1. BicJ.-rtg or cretinism often de-
la)'s <lentition considerably.
2. Congniittil st/iiliUls may be as-
sociated with deformities of the cen-
tral incisors (permanent). The most F'g- u.-DiaKram showmg the Month
,.,,,, ■ -n- II- at which Each Tooth Cot the First Set 1
constant is that shown m i^ig. 15. should Appear.
Fig. 13.— Ansrioneurotic CEdenia of Lower Lip.
THE HEAD AND FACE.
21
3. Teeth-firinduig. — Nervous, delicate, oversensitive oliildren
often grind their teetli in tlieir sleep. There is no foundation for
the popular superstition that this act indicates " worms."
Fiu. 15.— Notched Incisors in Congenital Syphilis.
XI. The IhiEATH.
Foul breath is oftenest due to :
(«) Foul teeth and gums (neglected).
(/() Stomatitis of any variety.
(c) Gastric fermentation (with or without constipation).
Barer causes are abscess or gangrene of the lung, in which the
breath may be intensely foul; the source of the odor is made evi-
dent by tlie sputa.
Acetone breath has a faintly sweetish odor, which has been com-
pared to that of chloroform, new-mown hay, and rotting apples.
It occurs not only in diabetes, but in various conditions involving
starvation (vomiting, fevers), and especially, but not only, a lack
of carbohydrates.'
In urmniia a foul odor is often noticed, and an ammoniacal
("urinous") smell has been mentioned by many writers. In fy-
phoid and in si/pliilis some persons seem to detect a characteristic
odor, but the evidence is insufficient. Alcoholic breaili is often of
' See Taylor ; " Studies on an Ash-free Diet. " University of California
Publication, July 30tb, 1904
22 PHYSICAL DIAa.\'OSIS.
value ill correetiiig the false statements of its possessor. In coma-
tose persons a\ e must leuiembev tliat a drink may liave been taken
just befoie an attaelc of apoplexy or any other cause for eonia, so
that an alcoholic breatli in comatose patients does not prove that
the coma is due to alcohol.
In jiiii.sniii III/ /ii/ ill iiiiiin.it iiiij I/IIS the gasenus odor of the breath
may be noticed.
XII. The Toxguk.
The iirf of protnidinrj the fomjiie niay give us valuable informa-
tion on the condition of tlie nervous system.
(«) Tlie liisitatiiKj, tremulous tongue of typhoidal states is very
characteristic. Simple tremor is seen in alcoholism, dementia par-
alytica, and weakness.
(li) If the tongue is protruded to one side, it nsually means facial
paralysis as part of a hemiplegia; rarely it is due to lesions of tlie
hypoglossal nerve or its nucleus (in liulhar paralysis or tabes).
((•) A eiiiited toiii/iie i^due mostly to lack of saliva) is not often of
much value in diagnosis, and there is no need to distinguish the
varieties and colors of coats ; but a few suggestions may be obtained
from it. j\[an J' persons who seem otherwise perfectly health}' have
coated tongues in the early morning. This is especially true in
mouth-breathers, in smokers, and in those who keep late hours.
In those whose tongues are usually clean the appearance of a
coat is associated often with gastric fermentation, constipation, or
fevers.
A cleiui tongue in a dgspejitie suggests hyperacidity or gastric
ulcer. This point I have found of more value than any inference
from a coated tongue.
A dri/, liniirii-eoiited, perlia[>s cracked tongue goes with serious
exhausted states and wasting diseases with or without fever.
{d) C'l/Knosis AwAJiuindice may be seen in the tongue, but bet-
ter elsewhere.
(tf) Indentation of the edges of the tongue bj- the teeth occurs
especially in foul, neglected mouths, but has no diagmistic value.
(/) Herpes (''canker ") often occurs on the tongue; it begins as
THE HEAD AND FACE.
23
a group of vesicles, but these rupture so soou tliat we usually see
iirst a very suiall, grayish ulcer with a red areola. It heals iu a
.day or two, i.i'., more quickly thau the syphilitic mucous patch or
any other lesion with which it is likely to be confounded.
(,'/) Cani-er, fiilierculosis, and si/jj/it/is may attack the tongue and
form deep, long-standing ulcerations. Si/phl/is can usually be diag-
nosed by the histiny, the i)resence of other syphilitic lesions, and
the therapeutic test (see Fig. Ki). Cniici'r and tiilx-rcidusis should
Fig. IC— Syphilis of tie Tonffue.
be diagnosed by microscopic examination, though cancer is more
commonly found in men (especially smokers) past middle life and
on tlie side of the tongue.
(//) '" Si III Jill- iiJi-crs" are due to irritation from a tooth or to
trauiua, and lieal readily if their cause is removed.
(/) Finsni-rs of the tongue are usually due to syphilis, whi(th is
recognized in other lesions.
* (,/') Li'iikiijihi];iii hticearis (lingual corns) refers to whitish,
smooth, hard patches of thickened epithelium, usually on the dor-
sum of the tongue in smokers, running a chronic course without
pain or ulceration, but important because epithelioma has been
known (and not very rarel}^) to develop in them.
(Ji) Geoijruplilc tori'jue is a desquannatiou of the lingual ei)itlii -
24
PHYSKPAL DIAGXOSIf^.
lium in sinuous lt eiieinare areas, wliioh spread and fuse at their
edges, while the central iiortions heal, giving- a look something like
the ]uountaiu ranges in a geograpliieal laap. It usually gi\es no
trouble unless the i)atieut's attention becomes concentrated on it.
(/") Hi/jirrfj'ojj/ii/ of the tongue has already been mentioned in
connection with ia_vxccdema and cretinism. It may occur iudejiend-
entlv as a congenital affection.
XII [. The Gums.
l^i!) A /'■''(/ liiit' should be looked for in every patient as a matter
of routine, as it may not be suggested by anything in the piatient's
svmptonis or history, yet may be the key to tlie whole case.
Tlie deposit of lead suljdiide in (^not on~) the gums is not blue,
but tj-rav or black; and is not a line, but a Sv'rics of dots and lines
^iJUlilii'^^
-Lfiid-iiuts iu Uio ciLims
arranged near the free nuxrgin of the gums and about one millimetre
from it. Where there are no teeth tliere is no lead line. In faini
or doubtful cases a luind leus is of great assistance and shows up
the dotted arrangement of the deposit very clearly (see Fig, 17"). It
is unfortumde that the term ''blue line" has become attached xo
these gr.iv-blaidv dots.
THE HEAD AND FACE. 'Zj
(//) Sort/cs, a eolk'i^tiou of epitlieliuui, bacteria, ami food ])ai'ti-
cles, accumulates about tlie roots of the teetli with great rapidity iu
febrile cases, but has no considerable diagnostic importance.
((') Spiiiii/i/ and hlceduKj (jiims occur as part of the disease
"scitrri/," after overdoses of mercury or jiotassic iodide, in various
debilitated states, and sonu'tinies without known cause. Tlie teeth
are loosened and the flow of saliva is usually profuse. The stench
from such cases is often intolerable.
('/) iSi/jipiirafioii about the roots of the tA'eth Qti/nrrhceit idreo-
/(uv'.v) is common in neglected mouths, and seems in some cases to
injure digestion, but in most cases its effects appear to be wholly
local.
((') GhiiiIioU {itlrcnlttr (thgci'ss), originating in a carious tooth, is
easily recognized by the familiar signs of abscess associated with a
diseased tooth and sometimes witli a surprising amount of swelling
of the face.
(/) " Epulis " is a word applied to various soft tumors spring-
ing from the jaw bone or occasionally from the gums themselves.
Many of them are sarcomatous, but microscopic examination is nec-
essary to distinguish these from fibroma, granuloma, and angioma.
XIV. TuK Buccal Cavity.
1. /'Jriq>f id/is.
(a) /sTo/J ?//.''■< ■ipotn in ^H(v^s7(■.s• are of much importance. They
appear chiefly in the inside of the cheeks, opposite the line of clos-
ure of the molars, and consist of minute, bluish-wliite spots, each
surrounded by a red areola and sometimes fusing intcj larger red
areas.
(/<) The si/pliltitif iiiiiroiis pafcli (see above) should be looked
for in suspicious cases, not only in easily accessible parts of tlie
moutli, but round the roots of the gums, where the cheeks or lips
have to be pushed away to afford a good view.
26 PHYSICAL DIAGXOSIS.
'2. J'iillllCllfllfiollS.
In Addison's disease Ihmwii simts or [latelies often oeeuv on any
part of the niueous nienibvane of tlie mouth. 'L'hey nniy also oeeur
in negroes without any disease and after uleerations (^c.y., from a
tooth), so that they are not distinetive of Addison's disease.
o. (Umii/ri'iii'.
Ganarveiie ("stomatitis Gangrenosa, "noma""), a rare disease of
wealvly ehildren, starts as a hard red spot insich' the eheek and
usually not far from the eorui'r of tlie nioutli. There is a swelling
of the whole eheek, especially under the eye. The odor of gan-
grene is usually the first thing to make clear tlu' diagnosis. Then
the gangrene appears e.vternally as a Itlack patch on the cheek, sur-
rounded by a red halo.
X^'. TUK TOXSTT.S .VN11 PlIARYXX.
IMethop of Ex.vjux.vtiox. — I'lace the patient facing a good
light, natural or artificial. Ask him to open his nmutli irithmit
jirofnidliii/ f/ir fninjiii'. Ask liim to say " Ah." Then gently jiress
down and forward on the dorsum of the tongue (not too far back")
with a S[ioon or tongue depressor,' until a gt)od view of the throat
is obtained.
Look especially for:
1. Infianuuations (redness, eruptions, spots, or membranes).
1'. Ulcerations.
.'!. Swellings.
4. Refiexes.
1. Jiit/iriiniiiitioiis.
(rt) General mliirss means a mild or early jihavyngitis, but maj'
precede severe diseases like diphtheria and scarlet fever.
' If the jiaticiit is ('s|ircially iirrvcms, it is souietimcs well to let liim press
dmvn his teugue with his uwii forclhigcr.
THE HEAD AND FACE. 27
(U) Yenoiolsh-ichitr. spofs on the tonsils, moi'e or less confluent,
mean fotlicuhir tunslUifis in the vast majority (jf cases, but only by
culture can we exclude diphtheria with certainty. Fever and head-
ache are usually present.
(c) A wemhraue, continuous and grayish-white over one or both
tonsils, especially if it extends to soft palate and uvula, means
diphtheria in almost every case.' Rarely a similar membrane is
seen in streptococcus throats with or without scarlet fever. Cult-
ures alone can decide.
(rf) The enijjfionn of smallpox and chickenpox may be distributed
in the pharynx as well as over the rest of the respiratory tract.
They are recognized by association with more characteristic skin
lesions and constitutional signs.
2. Ulcerations.
(«) Deep ulcerations of the tonsils or soft palate are oftenest
due to sijpliUh. Improvement under potassium iodide and the
manifestations of syphilis elsewhere make the diagnosis possible.
(i) Tuh(»'Gulosk may produce similar deep ulcerations, recog-
nized by their association with obvious tuberculosis of the lung or
larynx. Occasionally smaller "miliary" tubercles, not unlike
"canker sores," are seen in the tonsillar region. Their chronic
course and the preseiice of other tuberculous lesions identify them.
(c) Maliijnant disease (oftenest sarcoma) maj' attack the tonsil,
and forms a rapidly growing and finally ulcerating tumor. No
other lesion of the tonsil grows so fast and invades surrounding
parts so extensively except abscess ; in abscess the pain, fever, and
constitutional manifestations are far greater.
' Tlintsh, a ratlier rave disease of ill-nourished infants, due to a fungus of
the yeast order, may produce on the pharynx, tongue, or in any part of the
mouth, patches of white membrane. As the disease is almost wlioUy local
and witliout constitutional manifestations, it is passed over briefly here.
Streaks of inneus or bits of milk codgulum are sometimes mistaken for a
membrane.
28 PHYSICAL DIAGNOSIS.
■3. SlIM'lli IIIJS.
((f) Chronic awollen tonsil (unilateral or bilateral) without fever
or coustitutioual symptoms represents usually tlie residual hyper-
trophy following many acute attacks of tonsillitis or may Ije part of
the general adenoid hypertrophy so common in children's throats.
Karely it forms part of the leukcemic or pseudo-leuksemic jirocess.
(/») Aindc swollen tonsil is usually part of follicular tonsillitis (see
above), but may occur without spots, and often accompanies scarlet
fever. Swelling, jiain in swallowing, and fever are the essentials
of diagnosis. Our cliief care should be to exclude :
(f) TonsiUitr nhsci^ss (quinsy sore throat). Here the swelling is
usually unilateral and greater tlian in follicu.lar tonsillitis. The
jxiin, which is often severe, is continuous and not merely on swal-
lowing. Fever, constitutional symptoms, and swelling of the
glands at the angle of the jaw are all more marked than in follicu-
lar tonsillitis. The voice is nasal or suppressed, and there is often
salivation. The pillars of the fauces and the soft palate take part
in the swelling and the throat may be almost blocked by it. The
suffering increases until the abscess breaks or is opened. Fluctu-
ation is often late and indefinite, but should always be sought for.
((/) lietrophariintjeal Abscess. — A swelling in the back of the
pharynx near the vertebrae occurs not infrequently during the first
year of life. A 2)eeuliar cry or cough, like the l)ark of a puppy or
the call of a heron, is very often associated (the French " cri de
canard"). The parents are often unaware that the throat is the
seat of tlie trouble, and onl}' digital examination proves the j^i'es-
ence fif bulging and fluctuation, usually on one side of the poste-
rior pharyngeal Avail.
A similar a))soess of chronic course may complicate cervical
caries (see below, page .SI).
(<') iSwolli'ii. vi'iilii, with transparent ccdema of its tip, often com-
plicates a pbarj-ngitis or any lesion with violent cough. Elonga-
tion of tlie itniilii, may bring it into contact with the tongue and by
tickling excite cough.
THE NECK. 29
(,/") Pcrforatlo7i nf fJu> .taft palate or its adlic^'ioii to tJie. lac];, af
the pharynx means sijpliillH almost invariably, and, as it may be tlie
only sign of an old infection, it is a valuable piece of evidence.
4. Bj'flexcs.
(a) Lioelij or v:taij(jerati\l pliarynijcdl refcxi-s, such that the jia-
tient gags and coughs as soon as one tonches the dorsum of the
tongue, are seen in many jiervous persons and in many alcoholics
without nervousness. It is this condition, coml)ined witli a smok-
er's pharyngitis, that leads to many cases of morning vomiting in
alcoholics.
(V) Diminished or aJiseiit refc:rrs (with paralysis of the jialate)
occur in postdiphtheritic neuritis and bulbar jiaralysis. Fluids are re-
gurgitated through the nose and the voice has a ])eculiar intonation.
To test for paralysis, ask the jiatient to say "Ah." In unilat-
eral paralysis one side of the palate remains motionless; in bilate-
ral pyaralysis the whole palate is still.
THE NEGK.
Long, thin necks are often seen in phthisical individuals, and
short necks in the emphysematous, but nothing more than a bare
hint can be derived from such facts. The lesions oftenest searched
for in the neck are : 1. Enlarged glands (cervical adenitis). 2. Ab-
scesses and scars. 3. Thyroid tumors. 4. Pulsations (see below,
page 88). 5. TorticoUis and other lesions simulating it. 6. Tu-
berculosis of the cervical vertebrae.
Rarer lesions will be mentioned below.
/. Cha/ms af Enlarged Glands
radiate in all directions from the angle of the jaw — upward, in
front of the ear and behind it, forward along the ramus of the jaw,
and downward to the clavicle. The areas drained by the different
groups overlap so much that it is not necessary to distinguish them.
30 PffYSICAL DIAGNOSIS.
The commonest causes of enlargement are :
((7) TniisiH itis and iifjirr intfiniiiintfioiit: irif/u'ii or around the
tiioiith (diplitheria, the exanthemata, " cankers/' carious teeth,
etc.). Ghinduhir swellings due to tliese causes are usually acute
and more or less tender; most of them disappear in a fortnight or
less, but some persist (witliout pain) indetinitel}-.
(/') Tuhercuhisis ; long-standing cervical adenitis in children
and young adults, with a tendency to involve the skin ainl to suiniu-
rate, is usual]}- due to this cause. Certain diagnosis depends on
microscopic examination, animal inoculation, and tlie tuljerculin
test.
(<•) Si/ji/ii/is : small, non-sujipurating glands, occurring in the
neck and ahout tlie occijmt in adults, often accompanj' sj'philis, l)ut
tlie diagnosis depends on tlie presence of unmistakable S3-phi]itic
lesions elsewliere.
(d) Hodi/kiii't: disease; chronic, large, rarely suppurating glands
in tlie neck, axillaj, and groins, with slight splenic enlargement and
normal blood, suggest Hodgkin's disease, but microscopic examina-
tion is necessary to exclude tuberculosis. ' A superficial gland can
be excised under cocaine, with very little pain.
( '■) Lijmphatic Lciiko'iuia. No distinguishing characteristics
can be found in the glaiuis, but aiiy nodular enlargement in the
neck should lead us to examine a film specimen of blood, and the
lenksemio blood changes are easily and quickly recognized.
if ) Jlo/ajnaiit disease (near by or at a distance) may enlarge
the cervical glands. Cancer of the lip or tongue, sarcoma of the
tonsil, and, among distant lesions, cancer of the stomach and sar-
coma of the lung have caused enlargement of these glands in cases
under my observation.
(g) If the parotid gland alone is swollen and there are fever and
(lain on chewing, the case is probably one of mumps, especially if
there are other cases in the vicinity. Malignant disease may also
attack the parotid.
(/() German measles may be accompanied by swelling of the pos-
terior cervical or occipital glands without the involvement of any
other.
THE NECK.
31
II. Ahsce.'i.'s or Scars.
Abscess or scars in tlie sides and front of tlie neck generally re-
sult from glandular tuberculosis; lience the ])resence of scars may
he of value in tlie diagnosis of doubtful cases with a suspicion of
tuberculosis in later life. Aside
from glanchilar abscesses (tuber-
culous or septic) it is rare to find
-any sup[)>iration in the neck, ex-
cept in the nape, where deep,
septic abscess (carbuncle) and
superficial boils are common.
High Pott's disease majMte com-
plicated by abscess (see Fig. 18).
JII. Tliijroid Tumors
occur chiefly in two diseases :
((() Simple goitre (unilateral
or bilateral).
(l>) Goitre with- exopldliahnos,
tacliycardia, and tremor (Graves'
disease).
The tumor may look the same
in these two diseases (see Fig.
10); it varies in outline and con-
sistency according to the amount
of gland tissue and fibrous or
cystic degeneration tliatis present,
larynx it moves up and down somewhat wlien the patient swallows,
but is not attached to any other structures in the ]ieck. The en-
largement is often unilateral or largely so. If very vascular, the
tumor may vary greatly in size from moment to moment or at
certain times (i.e., menstruation, pregnancy).
Since the normal thyroid can rareh' be felt, utrojilnj of the (jhiint
(as in myxcedema) is unrecoguizpblo.
Fi(;. 18,— Cervical Abscess in Pott's Disease.
(Bradford and Lovett.)
Owing to its connection with the
32
PHYSICAL DIAGNOSIS.
Cancer or sarcoma ]iave occuri-ed in the thyroid and may be diffi-
cult to distinguish from goitre. Malignant tumors are usually
painful, grow fast, are ac-
companied ]>y emaciation
and ansemia, are often
harder and more nodulated
than benign goitres, and
invade the neighboring tis-
sties and lymphatics. His-
tological examination
should decide in doubtful
cases.
IV. T<irtlcolUs ( Wrif-nvck)
and Otlier Lesions Re-
semhlnKj It.
(a) jSjjosdi (tonic, rarely
clonic) of the sterno-mas-
toid and trapezius may be
■y nerve by swollen glands,
Fig. 19.— Simple Goitre.
due to irritation of the spinal accessor
abscess, scar, or tumor, but
more often occurs without
known cause (" rlieumatic "
and " nervous " cases). The
muscle is rigid and tender.
(Zi) Congenital torticollis (a
counterpart of club-foot) is
due to s/ioiine.'i.s of the muscle
vithout spasm. It is almost
always right-sided and associ-
ated with facial asymmetry.
(c) Dislocation of the upper
cervical vertehrcK causes a dis-
tortion of the neck much like
that of torticollis (see Fig. 20).
The diagnosis depends on the
FIG. 20.-
Dislocatlon of the Cervical Vertebrse.
(Waltou.)
THE NECK. 33
history of injury, the absence of true muscular spasm, and the ^'-ray
picture.
(d) Conipensatoi'i/ cervical deviations : (1) When there is marked
lateral curvature of the spine, with or without Pott'' s disease, the
head may be inclined so far to the opposite side that torticollis is
simulated (see below, page 71). (2) When the power of the two
eyes is markedly different, as in some varieties of astigmatism, the
head may be habitually canted to one side to assist vision. (3) lu
some cases due to none of the above causes, habit or occupation
(heavy loads on one shoulder) seem to produce the condition.
(e) Forced attitude from cerebellar disease may resemble torti-
collis. Tlie diagnosis depends on the other evidences of intracranial
disease.
V. Cervical Potfs Disease ( Vertehral Tuberculosis)
has the characteristics alluded to below in the section on joint tu-
berculosis, viz., stiffness due to muscular spasm, malposition of the
bones and of the head, and abscess formation (see page 31).
Diagnosis depends on wry-neck with stiffness of the muscles of
the back and neck and pain in the occiput — a very characteristic
symptom-group. Tlie chin is often supported by the hand.
''Rheumatic" or traumatic torticollis, however, may present all
these symptoms, and diagnosis may be impossible without the aid
of time and therapeutic tests.
VI. Branchial Cysts and Fistulce.
These, due to persistence of parts of the fcetal branchial clefts,
are not very uncommon (see Fig. 21).
A branchial cyst is a globular or ovoid fluctuating sac, hanging
or projecting from the side of the neck or the region of the hyoid
bone, jjainless and slow of growth. It may transmit the motions
of the carotids and be mistaken for aneurism, but has no expansile
pulsation and occurs in youth, when aneurism is practically un-
known. Some such cysts may be emptied by external pressure."
' A patient of mine can produce a gush of foul fluid in the mouth by
pressure over a small cyst in the neck.
3
34
PHYSICAL DIAGNOSIS.
]'>i-anf.Iiial cysts may contain serous, mucous, or sero-saiiguineoaw
fluid, or luiii- and sebaceous material, according as tlieir lining wall
is derived from ectoderm or entoderm. Diagnosis depends on tlic
position ;uid consistency of the growth and on the results of as-
piration.
UraiirJ/ifil Jisfiilir {^(•ongi'mtid) niay o[)en externally intlienech,
and occasionally are c(-im-
plete from neck to p)har-
ynx. Tliey may become
orcluded and supjiuratioii
result.
I'Jf. Art
I tit) ill i/rosfs.
-BliiOeLial (Jy^^i.
.Vi'ti)iom3-iu)sis, though
it usually ai'ises in the
lu\\'cr jaw bone, may a[)-
pear externally in the
neck. A dense infiltra-
tion with bluish-colored,
semifluctuating areas in
it, but without any distinct lumps or sharp outlines, is strongly
suggestive of actinomycosis, and should always lead to a micro-
scopie examination of excised poi'tions or of the discharge.
Fistuke may form, but are less common than in tuberculosis.
VUJ. A Crriuai/ Bih,
springing from the seventh cervical vei-teln'a and ending free or at-
tached 111 the lii'st thoracic rib, ap[)ears in the neck as an (nu/ulur
fulness irlilcJi- jjiflsates, owing to the presence of the subclavian ar-
tery on to[) of it. It rarely jn'oduces any sj'mptoms and is gener-
ally encountered when percussing the a])ex of the lung. The bone
can be felt behind the artery by careful palpation and demonstrated
by I'udiograpli}-. Pain or wasting in tlie arm, and occasionally
tliromliosis may occur.
CHAPTER III.
THE ARMS AND HANDS; THE BACK.
THE AKMS.
Most of the lesions of these parts aie j<nnt lesions and are dealt
ivith in the section on Joints. Others fall under tlie province of the
neurologist or tlie dermatologist, but must be briefly mentioned here.
/. l-'orali/sls of One Arm,.
Paralysis of most or all the muscles of one arm occurs oftenest
in: (a) Hemiplerjla — with paralysis of tlie leg and often of the face
on- the same side. (h) Fressvra neuritis — traunratiu or from new
growths, (r) Oljstet rieiil po rul ijsis — neuritis from injury during par-
turition, (f/) Lead or aleohoUc neuritis — extensors of wrist espe-
cially, and often in both arms, (i?) Anterior 'poliomyelitis^ infantile
pai'alysis. (/') Tli/steria. and traumatic neuroses.^
Pressure Neuritis. — The history of tlie case is of the greatest im-
portance. During surgical antesthesia the brachial plexus or the
musculo-spiral nerve may be compressed, and paralysis is noted as
soon as the patient comes out of anesthesia. In a similar way in
deep sleep, especially drunken sleep with the arm hanging over a
bench or doubled under the bod}^, tlie nerves may be injured.
Pressure from a crutch or from tlie head of the humerus ra. fractures
or dislocations, or even a violent fall on the shoulder without injury
of bones, may result in a paralyzed arm.
' Less common are paralyses due to lesions of the arm centre in the cerebral
cortex (tumor, softening, cyst, abscess, hemorrhage, thromboses, or emliol-
ism).
36 PHYSICAL DIAGNOSIS.
Diagnosis rests on tlie liistoiy, and on tlio fact that-, not only the
muscles of tlie sliouhler groui) and tlie extensors of the wrist are
affected, but also the xiiiniuttui' Im/t/iis, wliile in the toxic paralyses,
especially lead, the supinator longus is spared. To (.est the func-
tion of this muscle, grasp the jiatient's wrist with the thumb side
uppermost, and resist while he attenqits to flex the arm at the
elbow. If the supinator is intact it will spring into relief on the
thumb side of the forearm.
Oh^trtririil Kciii'itix. — In instrumental deliveries or Avlieu forci-
ble traction on the child's arm has bt'en necessarjf, with or witliout
fractures, a paralysis of the arm often results, and, what is impor-
tant, is often not noticed till some years later, and then thonglit to
have just arisen; tluis it may be mistaken for anterior jioliomyelitis
or other lesions.
Toxic Noirifis. — Lead or alcolu)! prodiu'cs tisually a weakness of
hoth forearms, esi)ecially the extensors of tlie Avrist (" wrist-drop "),
but one side may be predominantly alfected and otlier muscles are
involved in ]uost severe cases. The history, the other signs of lead
poisoning, and the soundness of the snpinatin- hmgus distinguish it
from other jiaralyses.
All these forms f)f neuritis are apt to be accompanied by ]>ain,
an;esthesia, or para^sthesia, which ludps to distinguish them from
the cerebral and spinal paralyses nt!xt descrilted.
Ariitc Anterior I'oliom.ijelitis. — I'aralysis attacks a child suddeidy
and without apjiarent cause, ])erhaps after "a feverisli turn."
Either the upper anu group (deltoid, biceps, braehialis autieus, and
sui)inator longus) or the lower arm grouj) (flexors and extensors of
wrist and fingers) maybe affected. The arm is flaliby and jiiiiuless,
the muscles waste ra]iidly, and the electrical reactions show degen-
eration, often within a week.
JI ijxtcr'iriil itnil TntiiDtiii'ir Nfiij'osru. — The histiu'y and mode of
onset, the frecpient association of sensory symjitoms which do
not fit the distribution of any j)eripheral nerve, spinal segment,
or cortical area, the nornud reflexes and electrical reactions dis-
tinguish most cases of tliis type, but diagnosis is sometimes imjios-
sible.
THE ARMS. 37
Fanih/sis of both anus is mnch. less coiumon than paralysis of
one avni, and occnrs chiefly in poisoning by lead and in multiple
neuritis. Rarely it is seen in the late stages of chronic diseases of
the spinal cord.
21. Wasting of One Arm.
(a) Bap'ul atropliij occurs in all the types of neuritis mentioned
above, as well as in poliomyelitis and progressive muscular atrophy.
In the latter it occurs without complete paralysis, though the
wasted muscles are, of course, weak. Progressive muscular atro-
phy usually begins in the muscles at the base of the thumb and be-
tween it and the index finger. Less often the disease begins in
the deltoid. In either case the rest of the arm muscles are later
involved.
In all tlie atrophies just mentioned a lack of the trophic or
nourishing functions which sliould flow down the nerve is assumed
to explain the wasting (f' tropliic atrophij^'' ). From this we distin-
guish the atrophy due simply to disuse of the muscles without nerve
lesions.
Qj) Slow atvojjliij of disuse occurs in the arm in liemiplegla, in-
fantile or adult, and in other cerebral lesions involving the arm
centre or the fibres leading down from it.
(c) The atrophy often seen in Iii/sterieal cases is probably due to
disuse and is similar to that occurring in an arm that has been
splinted after fracture or dislocation.
///. Contractures (f the Arm.
After cerebral lesions involving the arm centre, and in almost
any spinal or peripheral nerve lesion which involves one set of mus-
cles and spares another, the sound muscles contract (or ovei-act)
and permanent deformities result. In hysteria similar contractares
occur. Contractures have in themselves little or no diagnostic
value, but indicate a late and stubborn stage of whatever lesion is
present.
38 PHYSICAL DIAONOSIS.
IV. (Jidciiiii iifihr^ Arm.'
C'KK.fcs. — 1. Tlirouiliosis (if axillary or bracliial vein, usually
the lesiilt of heart disease. 'J. Pressure of tumors — aneurism, eau-
eer of axillary glands, llodgkiu's diseases, sarcoma of lung or medi-
astinum. .'!. Nephritis, when the patient has lain long on one side.
4. luflanmiation, usually with evidence of lymphangitis sjjreading
up the arm from a septic wound on the hainl.
The diagnosis of the ciiv.^r. af <rih'iii(i is usually easy in the light
of the facts brought out by the general ]>liysical examination (heart,
urine, local lesions, etc.).
[The tiiicrir.'i of Hie (inn (brachial and radial) are to be investi-
gated for changes in the vessels (see page DO) and for the evidence
given by their [lulsations as to the work of the heart (see jtage lU.'i). j
J'. Tumors iif ijic U/)/irr ylriii.
In tlie upi)er arm we have: 1. l'"atty tumors. 2. Sarcoma of
the Jiumei'us. .'!. JUiptured biee]is. ■{. Sypliilitic luxles on the
hunieiiis. 5. Tuberculosis of the humcius. (J. ( iouty deposits in
the trice])S tendon.
F((fti/ tiniiors are recognized by the history of long duration and
very slow growth, by their su))erficial ])osition, usiuilly external to
the muscles, and soft, lobulated feel.
SiirriiiiKi foi'ms the only large tumor springing from tlie hu-
mems. It is \isiudly bard and ob\'ious]y (lee|i seated (see I'^ig. l-'l.').
h'ujiiiii'i'il /licr/is. The lowei' half of i,]u' bicteps ]n'ojects sha.i-ply
when the nius(;le is conl-racteil, looking as if the biceps had slid
ilowii from its normal site. 'I'his a,[ipea.rancc^ suddenly following a
^vreneb oi- strain of the bieej)S is diagnostics
Si//)/ii/i/lr ■iiikIi's are Hattened elevations on the bone, usually
about the size of a half-dollar, and feel like the (callus after a fract-
ure, l)ut jiroject only from one side of the lione. There are ]iaiu,
' Dislhi^iiislicil, like ;ill (I'llnua, hy Hie I'lii'l, tlial. a denl. iniidc )iy jircssini;
w illi llii^ fmgcr dors not al (iiicr ilisaiipcai' ■wlicii the jiressurc is ri']n<)\'cd.
THE ARMS.
39
especially at night, and moderate tenderness. A history or other
and more characteristie lesion of syphilis is neeessar}' for diag-
nosis.
TiiI>e)'c-ii/oits lesions' are much more common on the forearm
Fig, ^™.— Sarcoma uJ; nLmierus.
bones, but are occasionally seen on the humerus near the epjijjhyseal
ends. They usually involve and perforate the skin, leaving an in-
dolent, supjjuratiug sinus leading to necrosed bone. The evidence
' A rare disease dinicall}' identical with tuberculosis, but due to a wholly
different organism, an animal parasite resembling a coccidiuhi, lias been de-
sciibed hj- Rixford, Gilchrist, Montgomer}-, and otlicr Califoinian pliysicians.
40
PHYSICAL DIAGNOSIS .
of tuberculosis in other organs and tlie slow, " cold " progress of the
lesion assist the diagnosis.
(Jioufij toplii are sometimes seen along the fascije covering the
triceps tendon. They are hard and painless. The diagnosis de-
pends upon the peculiar situation of the lesions and their association
with other evidences of gout.^
VI. Miscellani'ous Lesions oftlie. Forearm.
Bowirifj of tlif forcdrin hniics occurs in rickets and in Paget's dis-
ease (see Fig. 204). The lesions in the other parts of the body make
the diagnosis clear.
Local lesions of the bones of the
forearm are chiefly tidjerculosis and
syphilis, both of which have been suf-
ficiently described in the last section.
In the wrist bones we find:
1. Sachific eiilnrr/ciiiriit of tlie ejii-
plii/scs. In rickets the terminal epi-
physes at tlie wrists take part in the
general epiphyseal enlargement so com-
mon in the disease. The diagnosis is
easy, for there is no other disease of
infancy producing general enlargement
of the e[)ipl)yses (see Fig. 23).
2. I-J)jpert)'op]i.io pid inonary osteo-
arthropathy (Figs. 24, 25, and 26). An
enlargement of the lower ends of the
radius and ulna, with clubbing of the
fingers (see below, page 47), is recog-
nized by its association with pulmonary
or pleural diseases of many years' duration (chronic bronchitis, em-
pyema).
3. Acromegalia (see page 9) affects chiefly the bones and soft
tissues of the hand.
' Bursitis Dver thu olecranon ("miner's elbow") iiroduces a tender Huetu-
atiug swelling over the tip of the elbow.
Fifi. 23.— Rachitic Epiphysitis.
THE HANDS.
41
4. Hi/jierfroj-Jiii', (ifi'up/iir, oi' ti'lirrriilims i/isnise (if tlin wiist-
joint will be descrilied below (see Examination of the joints,
page 486).
5. " iri'fpi/ir/ .«/;/('((' " 01' "ganglion " (tenos3'iiovitis) fornis a fluc-
tuating, s[)inille-shaped swelling along one of the tendons of the
Fig. ~4. — Hypertrophic Pulmonary Osteo-arthropatliy. (Thayer.)
wrist, slow and almost painless in its course. It may be tubercu-
lous, in which case the sac is generally divided into several parts
("compound ganglion ") ; bacilli may occasionally be demonstrated
in the exudate.
THE HANDS.
I. EviiiEXCE OF Occup.iTiox. — The horny, stiffened hands of
the " son of toil," tlie stains of paint in house painters, tlie flat-
tened, calloused finger-tips of the violinist, the worn fingers of the
42
PHYSICAL DIAGNOSIS.
sewing woman, afford as items of iiifonuatiou which are sometimes
useful and wortli a rapid glance in routine examination.
II. 'rEMl'EUATUIJK AXI) JlIoISTrUE. — ((/) The ciild, iiioisf luind
is must commonly felt in "nervous" people under forty. It is
almost never seen in lieart dis-
ease, which its possessor often
fears, and does imt mean
"poor circulation," but vaso-
nujtor disturbances of neuro
tio origin.
(h) Coll], <Jr)j ('3'tre))iitu;n —
hands, feet, nose, ears — may
mean simply fatigue, expos-
ure to low tenqseratui'e, or
insufficient exej'cisc ; but in
the course of chronic disease
they usually mean weakness
of the heart, and hence are
serious.
(o) Wiir)», i)ii>int hiinds
are felt in Gntreti' disease (ex-
ophthalmic goitre), and if the
warmth and moisture are
present most of the time and
)iot only as a temporar}' jihase
— ''.,'/■) fi-fter violent exercise
— this disease is strongly sug-
gested, and a search for trem-
or, raitid lieart, goitre, and
l)ulging eyes should be made.
III. Mo^'EMKXTS or THE
IIaxos. — (ii) The iinniiicr aj
slial^iiKj liinids gives us vague
but useful impressions of the
patient's temjierament. The nervous, cramped, lialf-ojiened haiul,
which never really gras[)S and gets awaj' as soon as possible ; the
Fir;. 2"). - Radioffrapbs of tlie Hand and Arm of
a Case of Hypertropliif-' Pulmonary Osteo-
arthropathy (the left flgure) compared with
the hand and arm of a normal individual of
the same height (the riffht llffure). Niite espe-
cially the thickeuint,^ (.>f the radius and ulna.
(Thayer.)
THE HANDS.
43
tiriu, hearty grasp; tlie liuiii, ''willed" liaiid — fiiriiisli hiid:.s of
character that every physician iiiiiKt lake account of.
In fevers or toxteuiic! states (ty])lioid, alcoholism) there are two
sets of movements which recur so often tliat names have been given
them, viz. : 1. Carphologia — picking and fumbling at the bed
Fig. 26.— RadiOKraph of (lie Wrists in Hypertroplilc I'uliunnary Osteo-artbropatliy. (v. Ziems-
sea's AUas.)
clothes. 2. Siihsiilfiis tcnditium — iiivoluntai'y twitching and jerking
of the tendons ia the wrist and on the back of the hand, usually
associated with tremor and carphologia.
(h) Tremor of the Handa. — To test for ordinary tremor, we ask
the patient to extend and si'[)arate his lingers widely. The motions
are then apparent.
Causes: 1. Nervousness, cold, or old age. 2. Fever and tox-
44 PHYSICAL DIAGNOSIS.
a-'mi;i. 3. Alcolml (less often lead, toliaceo, morpliine, or other
drugs'). 1. Uraw's' disease, o. I'aralysis agitaiis. (>. JSTultiple
sidei-osis. 7. liystei-ia.
^Mdst oE these tremors need no comment. The iii/ni/idii trriiinr
tif multipk' stder(_)sis (sometimes seen also in h^-steria) is exagger-
ated into eoarse shaknig juovements wlien the patient tries to pick
up a pin, drink a glass of water, or do any otiier act calling for the
volitional coordination of the small hand muscles. In the presence
of suehatrenu)r we shoulil look fur iii/s/iii/iiiiia (see above, page 1(1),
a spastic gait (^see page r)(l8), anil a slow, staccato si)eecli. This
group of symptoms suggests nuiltiiile (or insular) sclerosis.
In direct contrast with tliis is tlie y'///-/vy///»f/ tri'imir of paralysis
agitaus, wliich usually ith.-h-^ ihirimj ni/inifuri/ iimi-i'iiir/ifs. Tlie
thumb and forefinger are near or touch one anotlier, and move as
if tliey Avere I'nlling a bread-pill. Tdiis tremor is usually assocnated
with an immo\-able, ex])ressiiinless face, a stiffened neck and back,
and a peculiar attitude and gait (see below, page 509).
The other varieties of tremor can usuall}' be recognized by the
history and associated sjunptoms.
(r) Sjm.'iiiis til- raiti'^r 1 ii'ifflt iiKjs of tlif liinid due to:
1. Jdrkmmin II ('p'llfiiaij — I'ouN'ulsive attacks which begin in and
may remain conhued to one set of nuiscles, often preceded bj' jirick-
liug or other i)ara'stliesia of the jiart affected, but iritlioiit /"ss of ron-
xcioii.siir.ss. Tliesc uuiscle spasms are due usually to an irritation of
the corresponding motor area in tlie c<u-te.\ cer(d)ri (tuuu)r, soften-
ing, chronic meningitis, etc.), I)ut umy also occur in uuemia and
dementia paralytica. Coma a.ud general sjtasms nu\y follow.
2. I'rof-ssioiia/ S/Kisiii. — Writers, violin-[)layers, and others
will) use one set of muscles continually are often attacked with
jiiiiiij'ii/ ci-iiiii/ift in tin' ]uuscles used (" writer's cramp "). Weakness
or semi-paralysis of tlie muscles may follow.
.'!. ('jioriii mill ( 'liorrij'onii Morriiifiifs. — True, acute chorea
(Sydenham's) occurs in children between live and fifteen, generally
in those who liave joint troubles oi' lieart disease, and ends in eight
or ten weeks. The liamls are usually affected first, and their
movements are like those c,)f restlessness and are (piasi-jiurjiosive.
THE HANDS
45
i.i\, movements that might have been made intentionallj', though,
they are not. At first sight one would surely thuik the child was
simply fidgety.
Similar movements occur iw 2yregnant ivomen or sometimes after
parturition, but the
tyjie is much severer
and is apt to be asso-
ciated with maniacal
symptoms.
Fiist-h em ipleg ir
c7(o;vv( refers to similar
movements in tlie
paralyzed hands of
hemiplegic cases (chil-
dren or adults).
In hysteria or by a
sort of psyrliic coii-
tagion similar move-
ments are sometimes
taken up in schools
and institutions, and
last till their cause
is uirderstood and re-
irroved.
67i ron Ic cli oreifonn
movements occur also
in the rarer congeni-
tal forms of jiaral-
ysis with or without
idiocy.
4. Athetosis (see
Fig. 27) ]neans slow
twisting and bending
movements of the
fingers, quite involuntary and always secondary to orgairic cerebral
lesions (hemiplegia, infantile cerebral paralysis).
Fig. 27. — Athetosis.
Successive positions of the hunds.
(Cursehmami.)
46
PHYSICAL DIAGNOSIS.
5. Tftcnii/ (sec Fig. 28) — a peculiar spasm of the hands (often
of the feet as well), occuning in the course of diseases of tlie
stomach and intestine in chil-
dren, iu nui-sing women,
after gastric lavage, and aftei
thyroidectomy,' usually last-
ing minutes or hours — rarely
days.
•
IV, Deformities of the
Hands.
1. " t'/(in' Iidiicl" results
fi-diiL paralysis of the inter-
ossei and lundjricales witli
contractures, and occurs when
the median or ulnar nerves are
paralyzed and in ^jrogressivc
muscular atrophy, syringo-
myelia, and chronic polio-
m3'(ditis.
2. "J-'/ljqin- Ii/nid" (see
Fig. -0), a ciimmou result of
tlie ciiutracliires in late cases
(if atr(j[)liic arthritis. Other
deformities of the fingers are
common in this disease and
in gout (see below, page 50.')).
.S. ^^ llemiplcgic hand," a
result of tlte contractures following hemiplegia from any cause.
4. MijxmdeiiKj results in thickening and coarsening of tlie tis-
sues of the hand ("spade hand'') without bony enlargement ; but
the spade hand is a fairly common type without myxcedejna, and
one needs to see it i-apidly develop in connection with other niyxa'-
dematous lesinns before it can luive diagnostic significance. (The
saiiKMS i rue of tlie ]nyx(edeniatous face.) (Sec f^ig. .HO.)
' When tlic iiiii-iiUiyroid y-laiuls arc accideiilallv removed.
Fig. 28.— Tftany. (MasUind.)
THE HANDS.
47
5. Acromrijid'iH produces general enlargement of the bones and
other tissues of the hands and feet.
6. Fill moiKirij Ostpo-arthropiitliij. — Any long-standing disease
of the heart, lungs, or pleura nuiy be followed by this peculiar liy-
pertrophic change in all the tissues of the extremities. Mild forms
produce ^'' chibbcd fingers," a bulbous enlargement of the finger-tips
with double curvation of the nails, lateral and ante i-o-posterioi' (see
Fig. ™'9.- Atrophic Arthritis with " i'iiiiper Hand.'
Fig. 31). In severer forms the bones of the hand and wrist are albo
(jonsiderably enlarged (see Figs. 25 and 20).
7. Heherden s nodes, later described under the head of hyper-
trophic arthritis, are here pictured (Fig. 32). The distinction
from (joiit has already Ijeeu referred to (page 505).
8. Atrophic arthritis (Fig. 29) (further described on page 498)
presents its most typical lesions in the liaiids and wrists. The con-
striction line opposite the ai-tic\ilatioii is observed in late cases, but
^ Clubbed fingers are occasionally seen in a variety of otlier diseases; e.g.,
hepatic abscess, uepliritis; and even in apparently liealtliy persons.
48
PHYSICAL DIAGyOSTP
ordiuai-ily inultijile spiiulle-joints syinnietiirally ai-ranged are all
that we see. Tlie boggy feel, the tropliie disturbances, and the
chronic course are diagnostic.
9. Si/jj/iilitic and tul)C)rii!oiit: dacti/litis (see Fig. oo), seen as a
Fig. 30.— Spade Hand iu Myxcvdema.
rule in young children, are not distinguished from each other by
the physical signs. Diagnosis rests upon tlie history, the course,
THE HANDS.
49
the results of giving tubei'culin or potassio iodide, and the evidence
of syphilitic or tubercnloas lesions elsewhere. In either disease we
have a chronic, almost painless, boggy, red enlargement of one
phalanx, or more, due to an indolent inflammation which starts
from the bone or periosteum and usually burrows to tlie surface, to
produce a chronic discharging sinus or ulcer.
10. Itaynnud's Jisense attacks tlie lingers more often than any
other }iart. Osier distinguishes three grades of intensity : A. Local
0m
Kf^^"--3
^^
K-;,-.;.,-
P
^^^^^' «
[m^ '
^^^1
•it
J|JM^mJ'.-^|B|
H^I^P'
9
%
Hpi
as-w. '
0mB
Fig. 31.— Clubbed Fingers.
syncope ("dead fingers) following exposures to slight cold or emo-
tional strain. The fingers become white and cold. The condition
usually passes off in an hour or two. From similar causes we may
have: B. Local asphyxia ("chilblains"), producing congestion and
swelling with or without pain and stiffness and with heat or coldness
of the part. C. Local or symmetrical gangy-ene. If local asphyxia
])ersists, gangrene results. (See also under Erythromelalgia, p.
402.)
4
50
PHYSICAL DIAGNOSIS.
11. JlJtirrriii's Disease. — As a part of syringomyelia multij)le
arthropathies (atrophic arthritis) and painless felons may develop
Fig. 33.— Heberclen's Nodes.
in the hands (see Fig. .34). The appearances may strongly suggest:'
12. Leprosij, in which there is likewise anEesthetic necrosis of
Fig. 33.— TubtTculuus Dactylitis.
THE HANDS.
51
phalanges, but the two diseases can usually be distinguished by a
study of the lesions and symptoms in other parts of tlie body.
13. Diqviijtren's contraction of the palmar fascia is commonest
Fi«. 34, — Morvan's Disease.
in adult men, and gradually produces a j^ermanent, painless flexion
of the little linger in one or lioth hands. A tense band is felt
in the palm. The ring finger may also be affected ; less often
52
PHY.'i ICA r. DIA GXOS: TS.
the others. If Inun aiul felon are exchnloJ. Ilie iliaLrimsis is
obvious.
TiiK Naii.s.
1. 'I'lie initrifinii of flic nui/s suffers in ehrdnie skin diseases,
in niyX(vJenia. in many nerve lesions (^neuritis, heuiiplegia, s\'viu,t;-o-
lUVi'lia, ete.V ilenuMitia paralyt-
ica ; also in afi-oiiliii' arthritis.
L'. .V /ni iisi-ii:-::' riihjr mid
(jroiu-i- on the nails often form
when their gro\\ th is resumed
after an aeute illness. The
niovenient of this ridge from the
matrix to the free edge is said to
take ahout six numths (see Fig.
M. //(I iii/-ii<i !/s possess a eer-
taiu medical interest, hecause
in some individuals they lieeonie
sore '\\lieu the general condition
is below ]iar. and constitute a
Fic. 3o.—iiioovea Nails after Ai'utf Illness. rough index of the degree of re-
sistance to infection. They may
liccome infected and lead on to supi>uration (jxa-oiii/cJi la).
4. lud<ih'iit suns around the nail should rouse the suspicion of
tiiberculosis oi' syphilis, especially in a child.
."i. (■') L'i/ui/i:sis, the shitey oi- pur}>lisli-blue eohn- of venous con-
gestion, can be well seen in the nails. {^/i") .[niiiiihi , if well
marked, blanches the tint of flu' tissues seen through the nail, hut
the diagnosis should invariably lie continued by a luviuoglobin esti-
mate.
('). Jin'iirrufhin of the nails has already been referred to as a part
of the conditiiui known as " clubbed tiugcrs "' (^jiage 47).
7. Ciijiil/iiri/ jiii/sr (see below, page Ul).
THE BACK. 53
THE ISAGK.
The evidences of spinal tuberculosis, spinal curvature, and of
the spinal form of hypertrophic arthritis will be described later
(pages 491 and 504).
1. Stiff Back.
" Stiff back " may be due not only to the joint troubles just
mentioned, but also and more commonly to lumbago, a painful
affection of the lumbar muscles without known pathologic basis.
Clinically it is characterized by pain when the muscles are used, as
in bending forward to tie one's shoes and in recovering the upright
position. There is no bony soreness, and sideways bending is usu-
ally freer than in hypertrophic arthritis. The pain of lumbago
does not radiate around the chest or clown the legs, and is not espe-
cially aggravated by cougliing or sneezing, but it sometimes extends
down low into the fascia of the lumbar muscles over the sacrum.
The age of the patient (usually over thirty) distinguishes most cases
of lumbago from spinal tuberculosis.
11. Sacro-iliac Disease.
Tuberculosis of this joi?it ha^s long been known and calls atten-
tion to its presence by pain, psoas spasm, and a limp. If the wings
of the ilium are forcibly pressed together, the pain iu the joint is
' much increased. Abscess formation is often the iirst distiuctive
sign. The motions at the hip-joint are not restricted and the local
signs of vertebral caries are absent. The duration of the disease
aud the formation of abscess distinguish it from other lesions of the
sacro-iliac joint.
Goldthwaite ' has recently shown that the sacro-iliac joint is
subject to most of the diseases of otlier joints, and that some (e.g.,
hypertrophic arthritis) are not at all uncommon there. Many of
the pains in the back complained of by women during menstruation
'Goldthwaite: Boston Medical and Surgical Journal, March 9th, 1905.
54 PHVSIC^-iL DIAGNOSIS.
or in pelvic disordei'S are referred precisely to the sacro-iliac articu-
lation and are probably due to lesions of that joint. i\laiiy (tases
diagnosed as "luial)ago" are ]jrol)ably due to one or another sacro-
iliac lesion. The subject is a new but very fruitful one.
III. SpiiKil Ciimitiircs.
Diagnosis is not ditticnlt, in-dvideil we are led to examine the
baek at all.
(") J\i/jiJiosis or lidcl-iiyird convexity of the spine, if sharply an-
gular, means I'ott's disease (tuberculosis). If the curve is gentle
and gradual it may be due to " VDiind shoulJers," to ]iyj)erfrnplilc
artlirltls, to emphysema, Paget's disease, or rickets. The rachitic
curve is flaccid, is due simply to muscular weakness, and is asso-
ciated with other evidences of rickets. In eiujihysema and I'aget's
disease the kyphosis goes with the other signs of those diseases.
In hypertrophic arthritis the curve is rigid, irreducible, and usually
painless. "Round shoulders" can be straightened by muscular
exertion, and represent a habit of i)osture.
(h) Lordosis, an (^\:aggeration of the nornuil forward convexity
of the lumbar spine, is seen in tuberculosis of the hi[) or sjiine, in
paralysis of the dorsal or abdominal muscles (especially muscular
dystrophy), and in abdominal tumors (pregnancy), which need to
be counterbalanced by backward bending.
(c) Scoliosis is a combination of lateral curvature with twisting
of the spine. In slight or doubtful cases the tips of the spinous
jirocesses should be marked with a colored pencil, whicli makes the
deviation easily visible. Severe cases cannot be mistaken.
I]'. T'liiiiors of the lUirl;.
(a) Aneurism of the descending aorta may point in the back
near the angle of the left scapula (see below, page 289). It is the
only pulsating tumor of this region.
(b) I'i'rincjt/iritic a/isei'ss usually points between the crest of the
ilium and the twelftli rib, a few iuclies from the spine (see paga 41H).
THE BACK. 55
(c) Tuho-ciilous (ihttcess {"' cold abscess"), originating in verte-
bral tuberculosis, may point in the same region, though more often
it follows down the sheath of the psoas and points near Toupart's
ligament. "Cold abscess," starting from a neci'osed rib, is often
seen in the bade. The piobe leads to dead bone at tlie end of tlie
sinus. INlicroscopic examination of excised pieces is the only way
of excluding actinomycosis, though this disease is less apt t(j form
sinuses.
(d) Sarcoma of the scap}iht , tlie only tumor of the scapula that
is often seen, occurs in children and rarely after the second decade.
With a solid, nearly painless tumor of tliis bone in a child, sarcoma
should always be suspected. Benign exostoses are possible, but
usually occur later in life. Histological examination will decide.
(e) Epithelioma, arising from the skin of the back, presents the
ordinary evidences of this form of cancer.
V. Prominent Sca^jula.
This is due usually to :
(a) Lateral ciirratiire of tlie spine (see above).
(b) Serratus jxirali/sis, recognized l)y the startling prominence
of the scapula if the patient pushes forward with both hands against
resistance ("angel-wing" scapula).
VI. Spina Bifida.
A congenital, saccular tumor, connecting through a bony defect
with the interior of the spinal canal at any point between the occi-
put and the sacrum; nine-tentlis of all cases occur in the lowest
third of the spinal column. There is no other congenital tumor in
this position communicating with the spinal canal.
In the sacral region there are other congenital tumors, dermoid
cysts, lipomata, and otliers. Their nature can be learned only by
incision, but they ai'e all distinguished from spina bifida by the lack
of communication with the si)inal canal.
TH E CH EST.
INTRODUCTION.
I. Methods of Examixjng the Thoracic Okgaxs.
To carry out a tlioiougli examination of tlie uliest we do five
tilings; 1. We look at it; technically called " inspection." 2. We
feel of it; technically called "palpation." '.'<. We listen to the
sounds produced by striking it; technical]}' called "percussion."
4. We listen to the sounds produced within it by phj'siological or
pathological processes; technically called "auscultation." 5. W^e
study pictures thrown on the fluoroscoi)ic screen or on a photo-
graphic plate by the Roentgen rays as they traverse the chest;
technically called "radioscopy."
Measuring the dimensions or the movements of the chest (" men-
suration ") is often mentioned as co-ordinate with the above meth-
ods, but it yields very little information of jiractical value, and is
at present very little used.
Without some knowledge of the regional anatomy of the chest
no intelligent investigation of the condition of tlie thoracic organs
can be carried on. Accordingly, I shall begin by recalling very
briefly some of the most essential anatomical relations.
II. Regional Anatomv oe the Chest.
It seems to nui a mistake to divide the chest into arbitrary pior-
tions and to describe ])hysical signs with reference to such division.
INTRODUCTION.
57
The seat of any lesion can best be described by giving its relation
to the clavicle, sternum, or ribs on the front and sides of the chest,
and to the scapulae and ribs behind. Thus we may speak of rales
as heard "above the left clavicle in front," "below the right scap-
ula behind,'' "between the seventh and ninth ribs in the axilla,"
and so on. When we want to state more exactly what part of the
axilla anteroposteriorly is affected, we may refer to the "mid-axil-
ary line " (see Fig. 3G) ; or better, we may place the lesion by meas-
uring the number of centimetres or inches from the median line of
the sternum. In a similar way the place of
the apex impulse of the heart (whether in
the normal situation or farther toward the
axilla) can be determined by measuring from
the median line of the sternum. IMeasure-
ments referring to the nipple are entirely
useless in women and not very reliable in
men. It is better to measure as above.
If, then, we confine ourselves chiefly to
the bones of the chest as landmarks, and
fix, with reference to them, the position of
any portion of the internal organs which we
desire to study, it becomes unnecessary to
memorize any technical terms or to learn
the position of any arbitrary lines and divi-
sions such as are frequentlj^ forced upon the
student. The only points which it is neces-
sary to memorize once for all are :
1. The position of the heart, lungs, liver,
and spleen with reference to the bones of the
chest.
2. The position of certain points which
experience has taught ns have a certain
value in physical diagnosis. I mean (a) the
so-called " valve areas " of the heart, which
do not correspond to the actual position of the valves, for reasons
to be explained later on, and (/<) tiie percussion outlines of the
Fig. SB.— The Mid-Axillary
Line.
^
r,8
PHYSICAL DIAGNOSIS.
heart, liver, aiul siileen. Tliese outlines do not correspoiul in size
with the aetuiil dimensions of the organs within, yet there is a
definite relation between the two which remains relatively constant,
so that we can infer the size of tlie organ itself from the outlines
which we determine bj' percussion. Tlie position of the organs
themselves is shown in Figs. .'17, ',<S, and ;>9. It will be noticed in
Upper lobe of left
liiun.
Left ventricle.
Lower lobe of left
lung.
FIG. 37.— Position of the Heai't, Lunc:s, Liver, and Stomach. The dotted lines correspond to the
outlines of the lunsr; the heavy conliuuons line represents the heart; while the position of
the liver and of the lower iiurder of ilie stomach is indicated b,v liyrltt eontiuuous lines. The
ribs are numbered.
Fig. "7 that tlie lungs extend up above the clavicles anil overlap
tlie liver and the lieart — facts of coiistderable importance in tlie
pliysical examination of tliese organs, as will lie later seen. It
is also to be noticed how small a portion of thi> stomach is
directly accessible to pli^'sical examination, the larger part of it
lying Ijeliind the ribs and covered by the liver. The normal jiau-
creas and kidneys are practically inaccessible to physical examina-
tion.
Tlie percussion outlines — correspoudiug to those portions of
the heart, liver, ami spleen which lie immediately beneath the
INTRODUCTION.
59
,,- rpper lobe.
, Lower lol)e-
Splecl
Lowvr lobe. ''
Fig. 3s.— Position of the Left Lung from the Fig. 3a.-Positiou of the Right Lung fn.iri the
Sides and of the Spleen. Side, and of the Liver.
chest walls — will be illustrated in tlie section on Percussion (see
page 118).
CHAI^TKPv, W.
TECHNIQUE AND GENERAL DIAGNOSIS
INSrEUTION.
Much may lie leariu'd bj- a careful inspection of all jiarts of the
elicst, but only in case tlie clothes are wlioll}^ removed. A good
light is essential, and this does not ah\'ays mean a direct light; for
example, when examining the front of the chest it is often better
to have the patient stand with his side to the window so that the
light strikes obliquely across the cliest, accenting every depression
and making every pulsation a moving shadow. In searching foi;
abnormal pulsations, tliis oblique light is especially important.
In examining tho thovAx we look for the following points :
1. The size.
2. The general shape and nutrition.
3. Local deformities or tumors.
4. Tlie res|)iratory movements of the chest walls.
5. The respiratorjr movements of the diaphragm.
6. The normal cardiac movements.
7. Abnormal pulsations (arteiial, ■^'enous, or capillary).
S. Tlie peripheral vessels.
9. The Color and condition of the skin and mucous nunnbranes
10. Tlie ]iresenee or absence uf glandnhir enlargement. "
I. Size.
Rmall chests are seen in jiatients who have lieeu long in bed
frfini whatever cause ; also in those who luive suffered in infancy
from rickets, adenoid growths in the naso-]iharynx, or a combina-
tion of the two diseases. Abnormally large chests a.re seen chiefly
in emjihysema. Of course the chests of healthy individuals vary
INSPECTION.
61
a great deal in size at any given age, and 1 ]ia\'e been referring in
the last seutenees onljr to variatiuus greater than those normally
found.
II. Shat'e.
There are marked differences in shape bet"ireen the cliild's and
the adult's chest in health. A child's truidc, as compared with
Fifi. 4n.— runnel Breast.
that of an adult, is far more nearly cylindrical; that is, the antero-
posterior diameter is nearly as great as the lateral. The adult's
chest is distinctly flattened from before backward, although indi-
vidual variations in. this respect are considerable, as Woods Hutch-
inson has shown.
In childhood the commonest pathological modifications are due
62
PHYSICAL DIAGNOSIS.
to adenoids or to rickets; in middle and later life to emphysema,
phthisis, or old pleuritic disease
(a) The Eachitic Chest
The sternum generally projects {" pigeon breast"), but in some
cases, especially when rickets is coml:)ined with adenoid hyper-
trophy, there may be a depression at the root of the sternum re-
sultmg in the condition known as '\funnel breast"' (Figs. 40 and
Fig. n .—Funnel Breast.
41). The sides of the chest are compressed laterally and slope in
to meet the stei-iiuui as the sides of a shij) slope down to meet
the keel ( pectus carlnatam) (Figs. 43 and 44). From the origin
of the ensiform cartilage a depression or groove is to be seen run-
ning downward and outward to the a.xilla and corresponding
nearly to tlie attachment of the diaphragm., Tliis is sometimes
spoken of as "^Harrison's r/i'nnre." The Imrer iiiarg'm of tlie ribs
' lu some, cases this coudition appears to be congenital.
INSPECTION.
63
in front often flarr.'; out, owing to the enlargement of the liver and
spleen below and the pull of the diaphragm above. Along tlie line
of the chondi-o-costal articulation there is to be felt, and sometimes
Fig. 42.— Acquired Depression at tiie Root of the Ensiform OartiiaKe. Tiie patient is a sliue-
maker of seventy, who has all his life pressed against his breast bone the shoe on which he
woiked.
seen, a line of eminences or swellings, to which the name of "ra-
chitic rosanj" has been given.
(?/) The. "-Paralytic Thora:r."
Fig. 45 conveys a better idea of this form of chest than any
description. The normal anteroposterior flattening is exaggerated
so that such persons are often spoken of as "fat-cJiested.'" The
clavicles are very prominent, owing to fallmg m of the tissues
64 PHYSICAL DIAGXOSIS.
above aiul below them; the sliouLlers are stoopinp;. the scapulre
proiumeut, aiul the neek is generally long. The angle where the
ribs meet at the eusitorni cartilage, the so-ealled " co,-:f,t! uiiij/f. " is in
such cases very sharji. This type of chest has often been supposed
to be characteristic of phthisis, but may be found in persons with
perfectly healthy lungs. On the other hand, idithisis frequeutly
Fig. 4'"1.— Fiirenn Rreiisr.
exists in persons with normally shaped chests or with abnormally
deep chests (^^^'oods Hutchinson "i. (See Fig. 1(>2, i>age 310. )
i^c) The '-Banrl Client."
jSTothing is less like a barrel than the "harrri chest.'" Its most
striliiug characteristic is its greatly increased anteroposterior diam-
eter, so tliat it a|>proaches the form of the infant's chest. The
costal angle is very obtus(\ tlie shoulders are Ingh, and the neck
is short. The respiratory movements of the barrel chest will be
spoken of later (see Figs. 40 and 47).
iA'SPE(:rio,\.
65
Niitriflnii oftJie Clicst Walls.
Emaciation is readily appreciated by inspection. The ribs are
unusually prominent, tlie scapulte stand out, and the clavicles pro-
ject. All this may be seen independently of any change in the
Fiu. 44.— Pigeon Breast.
shape of the chest such as was described above under the title of
Paralytic Thorax. Tuberculosis of the apices of the lungs may
produce a marked falling in of the tissues above and below the
clavicle independent of any emaciation of the chest itself.
5
66 PHYSICAL DIAGNOSIS.
III. Defoeimities.
The abnormalities just enumerated are symmetrical and affect
the whole thorax. Under the head of Deformities, 1 shall consider
chiefly such abnormalities as affect particular portions of the cliest
and not the thorax as a whole.
(d) Spinal Curvatures (nul Twists.'
A good view of the patient's hacl^ brings out best the lesser de-
gi'ees of lateral curvature, which are not at all infrequent in persons
who are not aware of them. Slight degrees of deformity are best
seen by marking with a skin-pencil the jjosition of the spinous proi'-
esses (see Fig. 49). The more marked cases of lateral curvature,
which are usually accompanied by a certain amount of ticistiiKj,
give rise to considerable displacement of the thoracic organs and
render unreliable the usual bony landmarks, with reference to
which we judge of the position of the intrathoracic organs. ]>y
such deformities the apex of the heart may be pushed up into
the fourth space or out into the axilla, or portions of the lungs
may be compressed and made atelectatic. The bulging on the
convex side of the curve may simulate an aneurismal tumor.
Pott's disease of the spine should be looked for as a part of
the routine inspection of the chest. It is sometimes better felt
than seen.
(I)) Fluttcniiuj of One Side of the Chest.
In chronic phthisis, cirrhosis of the lung, or long-standing pleu-
ritic effusion, marked falling in of one side of the chest is often to
be seen. This may be apj)arent in the upper and front jicrtion, be-
' See also page 54. The k^sions arc referred to here only iu iclation to
their effects on heart aud lungs.
INSPECTION.
67
neath the clavicle, or in the axilla, or in both situations (see Figs.
45 and 51). The shiinkage of the affected side is made more obvi-
FiG. 45.— The Paralytic Thorax.
Oils by contrast with the compensatory hj-pertropliy of the sound
lung, which makes the sound side unusually full aud prominent.
(c) Prominence of One Side of the Chest.
In pneumothorax or pleural effusions, and sometimes in malig-
nant disease of the lung or pleura, there is a marked increase in the
size of the affected side of the chest. Very rarely emphysema
RR
PHr.SJC.4L DIAGXOSTS
may affect one lung preclominantlj'. In pneumothnrax or pleuritic
effusion we usually see, in addition to the above enlargement of the
affected side, a smoothing out of
the intercostal depressions so that
the surface of that side is much
more uniform than the other side.
Bulging of the hiterspaces from
great pressure within the chest
rarely occurs. I have never seen
it.
(rf) Local I'riri)ii)ie/U'es.
In nearly one-quarter of all
healthy chests that part of the
thoracic wall whidr o^'erlies the
heart (the so-called "precordial
region ") i.s abnormally promi-
nent. The cause of this condi-
tion is much disputed. A similar
promiuence ma)' l^e brouglit about
in children, whose thoracic bones
are Yer}^ flexible (and occasionally
in older patients), by the outward
pressure of an enlarged heart or
of an effusion in the pericardial
sac. The prominences due to
spmal curvature have beeji al-
readj' mentioned. Less com-
mon causes of local promineucc
are :
1. Auein-ism of the arch of
the aorta.
2. Tiniiirr of the cliest wall
(lipoma, sarcoma, gumma) or of the lung, mediastinum, or of the
thoracic glands pressing their way outward.
-HaiTt-l Clicsl in i\ Case of Bru
chial Astliiiia Itvt. 13).
INSPECTION.
69
3. " Cold ahsei'ss " ( taberculosis) of a rib or of the sternum.
4. Empiinma perforating the eliest wall, the so-called "empyema
necessitatis."
IV. The Respiratory ]\[ovkments.
(a) Normal Respiration .
During normal respiration, one sees the ribs move outward and
upward with inspiration, and downward and inward with expira-
tion. Possibly one catches some
hint of the movements of the
diaphragm at the epigastrium.
In men, diaphragmatic breath-
ing is more marked, while in
women Ijreathing is mostly of
the " costal type " ; that is, is
done by the intercostal muscles.
In certain diseases an exaggera-
tion of the costal or of the dia-
phragmatic type of breathing
may be seen. In emphysema,
for example, and in some cases
of asthma, the ribs move very
little, and most of the work of
respiration is performed by the
diaphragm, whose pull upon the
lower ribs can sometimes be distinctly seen during inspiration. On
the other hand, when the movements of the diaphragm are impeded
by the presence of fluid or a solid tumor, as in cirrhosis of the
liver or leukaemia, the breathing has largely to be performed by the
ribs, and becomes, as we say, costal in type (see below, jj. 72).
Fig. 47.— Barrel Chest, (.lironic broncliitis
and emphysema.
(5) Anomalies of Expansion.
If we watch the patient while he takes a full breath, we may
notice certain variations from the normal type of respiratory move-
70
PHYSICAL DIAGXOSTS
nieiits. We iua_y see: {I) Dimiuislied expausiou of inic side (as a
-whole, or at the apex). (2) Increased exijaiision of one side.
(1) If dniiijiislii'il i\rpai)sii)}i of one side is due to pleuritic effusion,
pneumothorax, or solid tumor of the lung or pleura, the affected
side is \isually dhtendcd as well as iintudhile. When, on the other
Fia. IS.— Latonil Curviitiiro Before Cor-
RX'tiOIl.
Fio. 4V1.— T.nteni] rni-v:itiifo Ttin^e Weeks
.\ftei' Oonvi'li.m.
hand, the lung is retracted or bound down by adhesions, as in
phthisis, old pleurisy, occlusion of the bronchus, or from the pres-
sure of an aneurism, we liave immobiliit;y combined witli a rcfnicfldii
of the affected side. In tuberculous diseasi> at the apex of the
lungs wo may see one side or both sides fail to expand at the top.
liestriction of the motion of one side of the chest may also be due
to pain or to pressure from below the diaphragm. An enlarged liver
IXSPKCTION.
71
or sploon :\iul (nniovs of llic liopalii' or splenic region may in tliis way
[Movent the normal expansion of one ov the other side of the thorax.
Oeeasioiially a hemiplegia or a
unilateral paralysis of the
diaphragm results in dimin-
ished movement of one side of
(he chest.
(^2) liicrciiSi'd f.rpdiisioii of
one side of the chest is observed
princiiially as a compensatory
or vicarious overfnnctiouing of
tliat side -wlien the other side
of the chest is thrown out of
use liy a large pleuritic effusion,
by iineumothorax, long-staud-
ing pleuris}- -with contraction,
or other causes.
((•) I)l/s/>lliril.
This term is often used
rather loosely to include: (1)
Difficult breathing, whether
rapid or slow. (12) I'nnsually
deep breathing, whether ditti-
tniltornot. (.■->■) Kapid breath-
ing.
Tfiii' (Ii/.'i/iiiira III- tlijfifiilt
hri-iillihiij is almost always rapid as well, and does not diiTer at all
from the well-known phenonuMu>n of being "out of lu'cath" after a
hard run or any violent exertion. Conceive these coiulitions as per-
sisting over hours or days, and we have the pheiuuueuon known as
dyspuiva. The breathing is not only quick but labored; that is,
performed with dittieulty, and unusual muscles, not ordinarily called
\ipon for respiration, couu^ into play ami are seen working above
the claviide and elsewhere, ^fore or less distress is generally ex-
]n-essed in the face, and there is often a blneness of the lips or a
dusky color throughout the face. I'lie comnuuiest causes of dysp-
Fio. sn. -Severe Lateral Curvatuiv (V\\-
ti-entoili.
72
PHYSICAL DIAGNOSIS.
noea are the various forms of licavt disoasp, ])neuinoiiia, large
l>leuritic. etfusioii, (Miiiiliysciiia, astluiui, and i)litliisis.
DyspiKi'a may aJ'fi'ct I'sjiccially ii/sjiij'd/idii, as, for example,
when a foreign body lodges in the larynx, or in ordinai'y "eroup."
In such cases we speak of " 'msjiirdtovi/ (h/sjiiiir<i,^' disti)iguishing it
ivoin ^^ cc^tii'dfari/ (/i/s/in(rii '' such as oeciii's in asthma and emphy-
sema. In the latter condition the breatJi seems to enter the chest
readily, hiit the difficulty is to get it out again. Expiration is
greatly prolonged and often Udisy.
Combined tyjics also oeeui' in wliicli l)otli respiratory acts are
difficult.
jUinornidUi/ (/ci'ji din/ full ri'sjiird/ iaii , without any a]>pearance of
difficvdty in tlie jirocess, is sometimes seen near the fatal termina-
tion of cases (if cliah<'tes,
the SO - called ilidhctic
dys]ina'a.
Siii/jile fdjilit!/i/ of
hredtliiiiij should he dis-
tinguished from dyspnosa
of any type. In adults
the normal rate of respi-
ration is al)out 18 ]ier
minute. In children, it is
considerably quicker and
mor(! ii'i-egular. It is not
desirable to attempt here
to enumerate all the
causes wliich nia,y leail to
a quickening of the respi-
ration. Among the eom-
nioncr ai'e nniscuhir exer-
tion, emotion, hyst.eria.,
diseases of tbe hcaii, and lungs, and fluid or solid accuuiuliil ions
l)elow the diaphi'agui, wliicli |mis1i u|i llial niusclc and cause it
to encroach abnonualiy upmi llie Ihoi'acic ca\il\'. iMesI of ilie in-
fectious fevers are also apl, l,o he acconi panii'd li\' (|uii'lieuei| lireatli-
•ti f l.i'tt ihrst. Eiiipycnia.
ly.sPECTioy.
73
iiig, especially but not exclusively Tvlieii tlie fever is associated -ivith
a disease of the heait, lung, pleura, or pericardium.
Sucking-in of the interspaces in the lower axillary regions or
beknv the cla^-icles may
'^^■-i^' ^^_^ lie seen in connection
■\\-ith dysjincea when-
ever the lungs are pre-
vented \)j some cause
from properly expand-
ing during inspiration.
Xegative pressure i s
thus in'oduced witliin
the chest, and the at-
mosi:ilieric p r e s s u r e
without piushes in the
more elastic parts of
tlie thorax. This phe-
nomenon is seen in col-
lapse or atelectasis of
a portion or the whole
of a huig, such as may
occur in oLstruction at
the glottis (^in whicli
case lioth sides are
equally retracted) or
from occlusion of a
bronchus. In the lat-
ter event, the suckiug-in of the interspaces during inspiration oc-
curs only on the affected side.'
' Slight retraction of tlie lower interspaces in the axilla during inspiration
is often seen in health. In disease this phenomenon is greatly exaggerated.
Fis.
-Prominenoe of Ki£rht Side. Pleural Effusion.
7-t PHYSICAL DIAGNOSIS.
V. Changes in the Eespiratory Ehythm.
((/) ^[stlimatic ISreatliing.
In asthma the normal rhythm is reversed; aiulilih' expiration
becomes longer, instead of shorter, than inspiration. Inspiration
may be represented only by a short gasp, while expiration becomes
a prolonged wlieeze lasting several tunes as long as inspiration.
Dyspnea is usually very marked. In emphysema we get very
much the same ty|:)e of breathing so far as rhythm is concerned,
but the dyspnoea is not usually so extreme and the auxiliary mus-
cles of respiration are not so apt to be called into use. In many
cases of emphysema one sees the thorax move all as one piece, "en
cuirasse," owing to a senile fixation of the bones of the thorax from
ossification of the cartilaginous portions. In hereditary syphilis or
phthisis this fixation may occur in youth or early middle age.
(b) C/iei/)ie-Sfokcs Breathing.
An anomaly of respiratory rhythm in which short, recurrent
paroxysms of dyspnoja are preceded and followed by periods m
which no respiration occurs (apucea). If we represent the normal
respiratory movement by an up-and-down line, as seen in Fig. 53,
VvWxAAAAA/
Fro. TkJ.— Diagram ti) Represent Nonnal Breathiiig-Rbythm.
the Cheyne-Stokes type of breathing would appear as in Fig. 54.
The period of apucea may last from oue to ten seconds ; then short,
shallow respirations begin and increase rapidly, both in volume and
ui rate, mitil a maximum of marked dyspnoea is reached, when a
diminution in the rate and depth of the act begins, and the patient
gradually returns to the apnoeic state. The length of the whole
paroxysm may be from 30 to 70 seconds. During the apnceic
period the jiatient is apt to droji asleep for a few seconds and the
pupils may become contracted. When the paroxysm of dyspnoea
INSPECTION.
75
is at its height, he is apt to cough and shift his position restlessly,
or in case the whole phenomenon occurs during sleep he moves un-
easily in his sleep at this period. Modified types of the phenome-
non also occur, in which there is a rhythmic increase and decrease
in the depth and rapidity of respiration but without any interven-
ing period of apnoea. This type of breathing is most often seen m
severe cases of cardiac, renal, or cerebral disease. It is generally
more marked at night and may occur only at that time. In chil-
dren it appears sometimes to be physiological durhig sleep. As a
Fig. 54.— Cheyne-Stokes Respiration.
rule, it is a sign of grave prognostic significance, but patients have
been known to recover completely after weeks or even months of
Cheyne-Stokes breathing.
(c) Restrained or " Catchy " Breathing.
When the patient has a "stitch in the side," due to dry pleu-
risy, intercostal neuralgia, or to other causes, the inspiration may
be suddenly ruterrupted in the middle, owing to a seizure of pain
which makes the patient stop breathing as quickly as he can. The
same conditions may produce very shallow breathing as the patient
tries to avoid the pain whicli a fall inspiration will cause. This
type of restrained breathing is often seen in j^leurisy and joneumo-
nia, and in the latter disease expiration is often accompanied by
a little moan or grunt of discomfort
{(T) Shallow and irregular breathing is often seen in states of pro-
found unconsciousness from any cause, such as apoplexy or poison-
ing. A few deep respirations may be followed by a number of
shallow and irregular ones.
(e) Sterno-mastoid breathing. When death is imminent in any
disease, the respiration may become very irregular and gasping, and
it is apt to be accompanied by a peculiar nodding movement of the
76 PHYSICAL DIAGNOSIS.
head, the chin being thrown quickly uj^warcl during inspiration, and
falling slowly during expiration. I have known but one patient to
recover after this type of breathing had set in.
After severe hemorrhage the breathmg may be of a slgldng type
as well as very shallow.
(e) Stridnlous Breathing.
A high-pitched, crowing or barking sound is heard during inspi-
ration when there is obstruction of the entrance of air at or near
the glottis. This type of breathing occurs in spasm or oedema of
the glottis, " croup," laryngismus stridulus, and forms the " whoop "
in the paroxysms of whooping-cough. Laryngeal or tracheal ob-
structions due to foreign bodies, or tumors within or pressure from
without the air-tubes, may cause a similar type of resjjiration. It
is in these cases especially that we see the sucking-in of the inter-
spaces mentioned above (see p. 73).
VI. DiAPHKAGMATIC iVIoVEMENTS.
Till' Pli yen k- Wave.
The normal movements of the diaphragm may be rendered vis-
ible by the following procedure, suggested by Litten in 1892: The
patient lies upon his back with the chest bared and the feet pointed
directly toward a window. Cross lights must be altogether ex-
cluded by darkening any other windows which the room may con-
tain' (see Fig. 55). The observer stands at the patient's side
and asks him to take a full In'eath. As the ribs rise with the
movement of inspiration, a short, narrow shadow moves doi\ai along
the axilla from about the seventh to about the nintli or tenth rib.
During the expiratif>n the shadow rises again to the point from
which it started, but is less easily seen. This phenomenon is to be
seen on both sides of the chest and sometimes in the epigastrium.
1 If it, is inconvenient to move the patient's bed into the proper position
with relation to the window or if the foot-board interferes, or if the observa^
tion has to be made after dark, a dark lantern or other strong light held at the
foot of the bed answers very well. All other light must, of course, be ex-
cluded.
INSPECTION.
11
It is best seen in spare, muscular young persons of either sex, and
is never absent in health except in those who are very fat, or who
cannot or will not breathe deeply. The latter condition occurs in
Fig. 55. — Litten's Diaphragm Shadow. Proper position of patieut and of obsen'er. The
shadow is best seen near L.
hysteria and in some very stupid persons who cannot be made to
understand what is meant hj a full breath. In the observation of
several thousand cases, I have never known it al^sent in health
except under these conditions.
In normal chests, the excursion of the shadow is about two and
a half inches; with very forced breathing three and a half inches.
The mechanism of this phenomenon is best understood by imagin-
ing a coronal section of the thorax as seen from the front or back
(see Fig. 56). At the end of expiration, the diaphragm lies
flat against the thorax from its attacliment up to about the sixth
rib. During insj)iration it "peels ojf" as it descends and allows
the edge of the lung to come down into the chink between the dia-
phragm and thorax. This "peeling off" of the diaphragm and the
descent of the lung during inspiration give rise to the moving
shadow above described.
By thus observing the excursion of the diaphragm we can obtain
a good deal of information of clinical value.
78
PHYSICAL DIAGNOSIS.
In pneumonia of tlie lower lobe, pleuritic effusion, extensive pleu-
ritic adhesions, or in advanced cases of emphysema, the shadow is
absent. This is explained by tlie fact that in pneumonia, pleuritic
effusion, and empliysema the diaphragm is held oft' from the cliest
wall so tliat its movements communicate no shadow. In pleuritic
adliesions the movements of the diaphragm are prevented. In
early phthisis I have generally found the excursion of the dia-
phragm diminished upon the affected side, owing to a loss of
elasticity in the aff'ected lung arid in jiart probably to pleuritic
aiUiesious. On the other hand, fluid or solid tumors below the dia-
jihragm, miless very large, do not prevent the descent of that muscle,
and so do not abolish the diaphragm shadow. In cases in wliich
the diagnosis is in doubt between fluid in the right pleural cavity
and an enlargement of the liver upward or a subdiaphragnuitic ab-
ssess, the preservation of the Litteu's phenomenon in the latter two
affections may be of great value in diagnosis. Very large accumu-
lations of ascitic fluid may so far restrain the diaphragmatic move-
ments that no shadow can be seen. Great muscular weakness or
debility may greatly diminish, but rarely if ever prevent, the excur-
FiG. .56.— Exourelon of tlie Dinpliratrm during Forced Respiration. Ji, Ribs; E. ixisition of
tbe diaphratjm at end of expiration ; J, position of diaphrajrin at end of inspiration.
sion of the shadow. In persons who cannot be made to breathe
deeply enough to bring it out, a hard cough will frequentlj' render
it visible.
Tlve use of this method of examination tends, to a certain ex-
tent, to free us from the necessity of using the ic-rays, inasmuch as
INSPECTION. ' 79
it furnishes us with the means of observing the diaphragmatic
movements, on tlie importance of which so much stress has been
laid by F. H. Williams and others, much more easily and cheaply
than with the a;-rays, and upon the left side, more plamly as well.
It also frees us to a considerable extent from the need of using
the spirometer to determine the capacity of the lungs.
By measuring the excursion of the phrenic shadow and taking
account of the thoracic movement, we obta.in a very fair idea of the
respiratory capacity of the individual.
VII. Obsekvation of the Caediac Movements.
(1) The Normal Cardiac Ivipulse.
With each systole of the heart there may be seen in the great
majority of normal chests an outward movement of a small portion
of the chest wall just inside and below the left nipple. This phe-
nomenon is known as the cardiac impulse.' It is now generally
admitted that the " apex impulse " is caused by the impact of a
portion of the right ventricle against the chest wall and not by the
apex of the heart itself. [The bearings of this fact, which have
not, I think, been generally appreciated, will be discussed pres-
ently.] The position of the maxivium impulse in adults is usually
in the fifth uitercostal space just inside the nipple line. In chil-
dren under the age of six it is often in the fourth interspace or
behind the fifth rib; while in persons of advanced age it often de-
scends as low as the sixth interspace. In adults it is occasionally
absent even in perfect healtli and under certain pathological condi-
tions to be later mentioned.
(a) The position of the impulse varies to a certain extent ac-
cording to the position of the body. If the patient lies upon the
left side, the heart's apex swings out toward the axilla, so that
the visible impulse shifts from one to two and one-half inches to
the left (see Fig. 57). A slight shift to the right can also be
brought about by lying upon the right side, and, as a rule, the im-
pulse is less visible in the recumbent than in the upright jjosition.
1 For a more detailed description of the normal position of the cardiac
impulse, see next page.
/
80
PHYSICAL DIAONOSIS.
Since the heart is lifted with each expiration by the rise of the dia-
phragm and falls durhig inspiration, a corresponding change can be
observed in tlie ajH'x beat, ■wliicli, in forced breathing, may shift as
mnch as one interspace. Oi the cluuiges in the position of the im-
pulse brought about by disease, I shall speak in a later ])aragraph.
Fig. 57.— Showing Amount of Shifting of the Ape,x Impulse with Ohanfre of Position. The In
ner dot reprost^nts the position of the impulse when the pjitleut lies on his back ; the outei
dot corresponds to the positiim of the :ipe,\ with patient on li'ft side.
(/>) Belution of the inaxlmuni cardiac iinpuhe to the apex of the
heart. — I mentioned al)ove that the maximum cardiac impulse is not
due to the striking of the apex of the heart tigahist the chest wall,
but to the impact of a portion of tlie right ventricle. The jiractical
importance of this fa(^t is this: "When we are trying to localize the
ajiex of the heart in order to determine liow far the organ extends
to the left ;ii)d downu'ard, it will not du io he g-udcd by tlie jiosi
INSPECTION.
81
bioii of the maximum impulse, for the apex of the heart is aliuosl
always to be found three-fourths of an inch or more farther to the
left (see Fig. 58). This may be jjroved by percussion (vide infra,
Fig. 58.— The Inner Dot Is tbe Maximum Cardiac Impulse. That to tlie rigbt is the true apei
of the heart, as obtained by percussion. Tbe ribs are uunibered.
p. 58). The true position of the cardiac apex thus determined cor-
responds usually not with the maximum impulse, but with the point
farthest out and farthest down at which a«y rise and full sjai-
chronous with the heart beat can he felt (for further discussion of
this point see below, p. 272).
(c) Besides the definite and localized impulse which has just
been described, it is often possible to see that a considerable section
of the chest wall in the precordial region is lifted " e?i manse."
The phenomenon is the ^' Herzenstuss" of the Germans, with which
6
82 PHYSICAL DIAGNOSIS.
the '' Spitzenstoss" or apex impulse is contrasted. A variable
anioimt of " Herzenstoss" can be seen and felt over any normal
lieart when it is acting rapidly and forcibly, and in thin, nervous
subjects or in children even when the heart is beating quietly. It
is more marked in cardiac neuroses or in cases in which the heart
is hypertrophied and in which there is more or less stiffening of the
ribs with loss of their natural elasticity. At times it may be
impossible to localize any one point to which we can give the
name of apex impulse, and what we see is the rhytlimical rise and
fall of a section of the chest as large as the palm of the hand or
larger.
(cT) CliaracteT of the cardiac tDipjulse. — Palpation is considerably
more effective than inspection in giving us information as to the na-
ture of the cardiac movements which give rise to the " ajjex beat,"
but even inspection sometimes suffices to show that the imp)ulse has
a heaving character or is of the nature of a short tap, a pieristaltic
wave, or a diffuse slap against the chest wall. In some cases a dis-
tinct undulation can be seen passing from the apex region upward
toward the base of the heart, or less often in the opposite direction.
(2.) Dispjlaccment of the, Cardiac Iriipnhe.
To one familiar with the position, extent, and character of the
normal cardiac impulse, any displacement of this impulse from its
normal site or any superadded pulsation in another part of the chest
is apparent at a glance. I will consider first the commonest forms
of dislocation of the apex impulse.
(a) Displacement of the cardiac impulse due to hypcrtropjUy and
dilatation of the heart. — By far the most common directions of dis-
placement are toward the left axilla, or downward. As a rule, it
is displaced in both these directions at once. I shall return to this
subject more in detail under the heading Cardiac Hypertrophy, but
here I may say that enlargements of the left ventricle tend espe-
cially to displace the apex impulse downward, while enlargements of
the right ventricle are more commonly associated with displacement
of tlie impulse toward the axilla.
(li) Next to liyi)ertro])by and dilatation of the heart ])erhaps the
commonest cause of dislocation of the cardiac impulse is pressure
INSPECTION. 83
from below the diaphragm. ^Mien the diaphragm is raised by a
large accumulation of gas or fluid or ])y suliil tumors of large size,
we may see the apex beat in the fourth interspace and often an inch
or more inside the nipule Ime.
(c) Of nearly equal frequency is displacement of the heart due
to pleuritic effusion or to pjneumothorax (see below, p. 336).
When a considerable amount of air or fiuid accumulates in the
left pleural cavity, the heart bodily is displaced to the right so that
it may be concealed behind the sternum or Vie visible beyond it to
the riglit; in extreme cases it niay be dislocated as far as the right
nipple. Itiglit pleuritic effusions Jiave far less effect upon tlie posi-
tion of tlie cardiac impulse, Ijut when a very large amount of fluid
accumulates we may see the impulse displaced cunsideralily toward
the left axilla.
(d) I have mentioned causes tending to push the heart to the
rirjJit, to tlie left, or upward. Occasionally the heart is pmshed
downward by an aneurismal timior or a neoplasm of the mediasti-
num. In these cases there is usually more or less displacement to
the left as well. As a result of arteriosclerosis or cardiac hyper-
trophy the aorta may sag or stretch a little, and the diaphragm
stands lower, and hence tlie apjex beat may descend to the sixth in-
terspace, or (more often) it may be lost to sight and touch behind
the bunch of convergent costal cartilages just to the left of the
ensiform. Very frequently in men past forty-five the whole heart
sinks considerably, so that a marlced systolic retraction (less often
pulsation) is seen below the ensiform in the epigastrium.
(e) Dispilacement of the cardiac impulse resulting from adhesions
of the pericardium, or of the pileura, with subsequent contraction,
occurs in. fibroid phthisis and in some cases of long-standing disease
of the pleura. Through the effect of negative pressure the heart
may be sucked into the space formerly occupied by a portion, of the
lung, when the latter has become contracted by disease. It seems
likely, however, that in the majority of cases adhesions between
the pdeura and pericardium jday a part ui such displacement. By
these means the heart may be displaced to the right of the sternum,
as it is by left-sided pleuritic effusion. It is often drawn upward
84 PHYSICAL DIAGXOSIS.
as well as to the right in such eases by the contraction which takes
place in the upjier jiart of the limy. JNIoie rarely we may see the
heart drawn toward the left clavicle in fibroid phthisis of the left
apex.
(/') Distortion of the thorax due to spinal curvature or other
causes may bring about a considerable displacement of the heart
from its normal position.
(7) T>c.vtrocan/ii( ami Situs Inrcrfn/.i. — In rare cases a displace-
ment of the apex impulse to the right of the sternum may be due
either to a fiviiyKisitinji of aU nxceni [the liver being found upon
the left, the spleen upon the right, etc.], or to dn-trocdnlia, in which
the heart alone is transposed while the other A-iscera retain their
normal places.
Summary.
The apex impulse is displaced by
(rt) Hypertrophy and dilatation of the heart.
(Ji) Pressure from below the diaphragm.
(c) Air or fluid in one pleural cavity, especially the left.
((/) Aneurism, mediastinal growths, and sagging of the aorta.
(f) Fibroid phthisis.
(/) Spinal curvature.
(;/) Transposition of the heart or of all the viscera.
(3) Apex Itctrdcfioii.
Before leaving the subject of the cardiac impulse it seems best
to speak of those cases in which during systole we see a retraction
of one or more interspaces at or near the point where the cardiac
imjjulse normally appears.
(a) In by far the greater number of instances such retraction is
due to negative pressure produced within the cliest by the vigorous
contraction of a more or less hypcrtrophied and dilated heart In
these cases the letractiou is usiuilly balanced by an impulse in the
next interspace so tliat a " walking lieain '" aiipeavance is tlie
result.
(/() In rarer cases several iutorspaccs, both in the precordial
INSPECTION. 86
region and in the left lower axilla anil back, may be drawn in as a
result of adhesions between the pericardium and tlie chest wall,
such as form in cases of adherent perioardiuni and tibrous niedias-
tinitis\see below, pages 270 and 303.)
(4) Jiji!(jiisfrir I'lilsiition.
In a considerable portion of healthy adults a pulsation or retrac-
tion at the epigastrium synchronous with the systole of the heart is
to be seen from time to time. Such pulsation lias often been treated
as evidence of liypertrophy of the right ventricle of the heart, but
this I believe to be an error. It is not at all uncommon to find,
post mortem, considerable hypertrophy of tlie right ventricle in cases
in which during life no epigastric pulsation lias been \isible. ^^•]lile,
on the other hand, tl\e heart is freciuently found normal at autop.sy
in cases in whicli during life tliere has been nmrked epigastric pul-
sation. In some cases such pulsation is to be explained as the
transmission of the lieart's impulse through the liver, or as a lifting
of that organ by the movements of the abdominal aorta. In other
cases it is due to bathycardia ("low heart '' — a condition verv com-
in arteriosclerosis).
mon
(5) TiiihJc PiiLt(itinii,< due til T'nrori'riiii/ of I'iirf!ii/i.<t of the Heart
2\ormoll ij Covered hij tlie Linuj^.
One of the commonest causes of visible }iulsations in parts of
the chest where normally none is to be seen is retraefiou ef the
luiiij.
{o') It is in chlorosis, perhaps, that we most frequently see
such pulsations. In that disease, as in other debilitated states, the
lungs are often not adequately expanded owing to the superficiality
of the respiration, and accordingly their margins do not cover as
much of the surface of the heart as they do in healthy adults.
This results in rendering visible, in the second, third, or fourth left
interspace near the stermrm, pulsations transmitted from the conns
arteriosus or from the right ventricle. Less commonly, similar pul-
sations may be seen on the riglit side of the sternum.
' Or moio oflcii lis ;i result ct simple cardiac liypertropliy. ^[oie cases of
acvrtic regurixitatioii in tliin yoiins; |iaticius show this systolic retraction iu the
loft lower liack.
86
PHYSICAL DIAGNOSIS.
(/>) A rarer cause of retraction of tlie lungs is fibroid plitliisis
or clironic interstitial i)neumonia. In these diseases a very large
area of pulsation may be seen in the ijrecordial region owing to the
entire uncovering of the heart by the retracted lung, even when the
heart is not drawn out of its normal position.
VIII. Aneueism and Other Causes of Abnormal Thoracic
Pulsation.
So far I have spoken altogether of pulsations transmitted di-
rectly to the thorax by the heart itself, but we have also to l^ear in
Fig. 59.— Position When Loolimg lor Slight Aneurismal Pulsation.
mind that a dilated aorta may transmit to the chest wall pulsations
which it is exceedingly important for us to recognize andiu-operly to
interpret. No disease is easier to recognize than aneurism when the
growth has perforated the chest wall and appears as a tumor exter-
nally, but it is much more important as well as much more difficult
to recognize the disease while it is confined within the thorax. In
such cases, the movements transmitted from the aorta to the chest
wall may be so slight that only the keenest and most thorough in-
INSPECTION.
87
spection contioUed l)y palpation will detect tliem. When slight
pulsations ave seavohed for, the patient should he put in a positiou
shown in Fig. 59, and the observer should place himself so that his
eye is as nearly as possible on a level with the chest and looks
across it so that he sees it in profile. In this position, or in a sitting
position with tangential light, he can make out pulsations which are
totally invisible if the x^atient sits facing the light.
I'ulsations due to aneurism are most apt to be seen in tJie first
or second right interspace near the sternum, and not infrerpiently
the clavicle and the adjacent parts maybe seen to rise slightly with
every beat of the heart, but in any part of the chest wall pnilsa-
tions due to an aneurism are occasionally to be seen, and should be
looked for scrupulously whenever the symptoms of the case suggest
the possibility of this disease (see below, p. 281).
Pulsating Pleurtsi/.
In cases of purulent pleurisy in which the pus has worked its
way out betwen the ribs so that it is covered only by the skin and
subcutaneous tissues, a ]3ulsation transmitted from the heart may
become visible, and the resemblance to the pulsation seen in aneu-
rism may be confusing. Such pulsation is ^)t to be seen in the
upper and front portions of the chest. Very rarely a pleuritic effu-
sion which has not burrowed into the chest wall may transmit to
the latter a wavy movement corresponding to the motions set up
in the fluid by the cardiac contractions.
IX. In^spectioit of the Peeipheeal Vessels.
In the study of all diseases of the heart and lungs it is import-
ant to take account of all vascular phenomena apparent in the
neck or in the extremities, since such phenomena have a very direct
bearing upon the interpretation of the conditions obtaining within
the chest. Inspection plays a very large part in the study of these
vascular phenomena. We should look for : (a) Venous phenomena ;
{h) Arterial phenomena; (c) Capillary phenomena.
88 PHYSICAL DIAGNOSIS.
(a) Inspectimi. of the Veins.
1. Tlie condition of the veins of the neck is of considerable im-
portance in the diagnosis of diseases of the heart and lungs. Where
the tissues of the neck are more or less wasted the veins may be
quite prominent even when no disease exists within the chest, and
in such eases they may be luore or less distended during each expji-
ration, especially if dyspnoea or cough is pjresent. If the over-
distended veins are completely emptied during deep inspiration
and on both sides of the neck, we can usually infer tliat there is an
overdistention of the right side of tlie heart. When a similar
phenomenon occurs on one side only, it may mean pressure upon
one innominate vein. So far I have spoken of venous changes
synchronous with respiration, Init we may have also
2. A 2})'es>/sfolic pulsation or nndulation seen either in the ex-
ternal jugular vein or in the bulbus jugularis between the two
attachments of the sternomastoid muscles. Such pulsation or
undulation, which is to be seen just before each systole of the
heart, is not necessarily anything abnormal and must be carefully
distinguished from
3. Sijstolh' venous pvlsation, such as occurs in one of the most
common valvular diseases of the heart — tricuspid regurgitation.'
Systolic venous pjulsation is more often seen upon the right side
than upon the left side of the neck. There may be a wave during
the systole of the auricle and another during the systole of the ven-
tricle, the latter closely following the former. In any case in
which a doubt arises whether a pulsation in the veins of the neck
is due to tricuspid regurgitation, it is ■\\'ell to try the experiment of
emptying the vein fjy stroking it from belii'\\' upward. If it unme-
diately fills from below, we may be practically certain that tricus-
pjid regurgitation is pjresent. In the vast majority of cases of ve-
nous pulsation due to other causes or occurring in healthy persons
'A pulsating carotid may transmit an up-and-down motion to the veins
overlying it. In svicli cases, if tlie veins be emptied by "milking" them up-
ward, tliey will not retill from below.
INSPECTION.
89
a vein will not refill from below if emptied in the manner above
described.
4. Rarely, superficial veins may be seen to pulsate in other parts
of the body, especially in aortic regurgitation, and occasionally
large and tortuous veins may be seen pulsating upon the thoracic
-Tortuous Veins on Chest and Abdomen (Autopsy showed obliteration of the ven i
cava infenui.)
or abdominal wall, rej^resenting an attempt at collateral circulation
when one or the other vena cava is compressed (Fig. 60).'
(Z)) Arterial Phenomena.
\. In thin or nervous persons pulsations are not infrequently to
be seen in the carotids independent of any abnormal condition of
the heart.
' Enlarged veins about tlie navel, the so-called "cainit Meduste," are com-
monly found in text-books, but rarely in cirrhosis of the liver.
90
PHYSICAL DIAOXOSIS.
2. Yerv violent tlirolibiug of the carotids, move noticeable than
the normal, occurs ni severe auivmias iu many eases and occasion-
ally in simple hypertrophy of the heart without any valvular dis-
ease. From the same causes, visible pttlsation may occur iu the
subclavian, axillary, bracliial, and radial arteries, as well as iu the
large arterial trunks of the lower extremity.
I lately exammed a blacksmith whose heart "svas considerably
enlarged by hard work, but vrithotit any Tal-stilai' disease. Tulsa-
jk i\^
Fig. GL— Eularired Torluuiis BuK-liial Arteries tArterio-scleivsis).
tion was ^iolent in all the peripheral arteries which I have just
nanred,
3, In arterio-sclerosis occurring in spare, elderly luen, with ov
w-ithotit aortic regurgitation, one often notices a lateral excursion of
the tortuous brachial arteries synchronous with everj- heart beat.
An up-and-do^vn pulsation may occur at the saine time. Not infre-
quently the arteries which are stiffened by depositioir of lime salts
(see below, page 110) stand out visibly as enlarged, torttrous cords
upon the temple and ah)ng the inner sides of the biceps junscle.
(see Figs. 61 aiul 02 ) and occasionally the course of the radial arter_\
INSPECTION.
91
may be traced over a considerable distance in the forearm. In rare
eases inequalities produced in the arterial wall by deposition of
lime salts may be visible as well as palpable.
(c) Cajnllarij Pulsation.
If a microscoi^ic slide is placed against the mucous membrane of
the lower lip so as partially to blanch its surface, one may see, with
Fig. 62. -Enlarged and Tortuous Urachlal Artery ( Arterio-sclerosis) .
each beat of the heart (in cases of aortic regurgitation and sometimes
in other conditions), a delicate flushing of the blanched surface Ije-
neath the glass slide. The same pulsation is sometimes to be ol)-
served under the finger nails, or may be still better brought out by
drawing a pencil or other hard substance across the forehead so as
to cause a line of hyperaemia, at the edge of which the systolic flush-
ing occurs. This phenomenon will be referred to again when we
come to speak of aortic regurgitation. Here it suffices to say that
it is not in any way peculiar to that disease, and occurs occasion-
92 PHYSICAL DIAGNOSIS.
ally ill health, in aiiEemia, in exophthalmic goitre, aiul in condi-
tions associated with low tension in the peripheral arteries, as well
as in any area of inflammatory hypersemia (jumping toothache,
throbbing felon, etc. ).
X. Inspectiox (IF THE Skix and Mucous Membranes.
Light may be thrown upon the diagnosis of very many diseases
by observing tlie color and condition of the cutaneous surfaces as
well as of the mucous membranes. We should look for the follow-
ing conditions :
(1) Cyanosis.
(2) CEclenia.
(3) Pallor.
(4) Jaundice.
(5) Scars and eruptions,
(1) Cyanosis.
By cyanosis we mean a purplish or grayish-blue tint notice-
aole especially in the face, in the lips, and under the nails. There
are many degrees of cyanosis, from the slight purplish tinge of the
lijjs, which a little overexertion or slight exposure to cold may bring
out, up to the gray-blue color seen in advanced cases of pulmonary or
cardiac disease, or the dark reddish-blue seen in congenital malfor-
mations of the heart. Cyanosis makes a very different impression
upon us when it is combined with pallor on the one hand or with
jaundice on the other. ^^Hien combined with pallor, one gets vari-
ous ashy-gray tints, while the achnixture of cyanosis and jaundice
results in a color very difficult to describe, sometimes approaching
a greenish hue The commonest causes of cyanosis are :
(rr) Valvular ox varietal disease of the heart.
(J)) Emphysema.
(r) Asthma.
((?) Pneumonia.
\e) Phthisis.
(/) In some persons a certain degree of cyanosis of the lips
exists despite perfect health. This is especially true of weather-
beaten faces and those of the so-called "full-blooded" type.
INSPECTION. 93
((/) ]\[etlipemoglolniu¥iiiia, sucli as oecurs after the excessive use
of coal-tai' analgesics (autifebiiue, etc.).
A rare but very striking type of cyanosis is tliat seen in cases
of congenital heart disease, in which the lips may be incUgo blue
in color or almost black while yet no dj'spnoja is ju'esent.
('2) (EdciiKi.
Oedema, or the accumulation of serous ifuid in the subcutaneous
spaces, is usually appreciated by palpation rather than by inspec-
tion, but sometimes makes the face look very putty, especially
Mnder the eyes This is not a comun)n occurrence in diseases of
the chest, in connection with which such redema as takes place is
usually to be found in the loA\'er extremities and is appreciable
rather by palpiation than by inspection. If we are not familiar with
a patient's face, we often do not perceive in it the changes of out-
line due to o?dema which a friend would notice at once. Clothing
is apt to leave grooves and marks wherever it presses tightly upon
the a?dematous tissues, as around the waist or over the shoulders.
In the legs, the presence of (pdema may be suggested by an unnatu-
rally smooth, gioRSj^ appeara.nce of the skin Such impressions,
however, may be false imless controlled by palpation, for simple
obesity may produce very similar appearances.
(.") Pallor.
Pallor suggests, though it does not in any way prove, anpemia,
and anajmia is a characteristic of the commonest of all diseases of
the chest — phthisis. It is also seen in certain varieties of cardiac
disease. Pallor of the mucous membranes, as seen in the lips and
conjunctivte, is much more apt to be a sign of real ana?mia than is
pallor of the skin. At best, pallor is only a sign which suggests to
us to look further into the case in one or another direction, and of
itself proves nothing of importance.
(4) Jaundice.
The yellowish tint which appears in the skin, and especially in
94
PHYSICAL DIAGNOSIS.
the conjunctivae, when the escape of bile from the liver is hindered,
is sometimes to be seen in connection with uncompensated heart
disease when the liver is greatly distended by passive congestion
Pneumonia is occasionally complicated by jaundice; but beyond
this 1 know of no special connection between this symptom and
diseases of the chest.
(5) Scars and Eruptions.
In cases of suspected syphilis of the lung or bronchi the pres-
ence of scars and eruptions suggestive of syphilis may be useful in
diagnosis.
FiCJ. f>3.— Sarcoma of SU^rnuui and Cervical Glandy. tcursclmiann.)
XI. Enlarged Glands.
Koutino inspection of the cliest may reveal the presence of en-
larged glands in the neck or axilla, and may thereby give us a clew
INSPECTION. 95
to the nature of some iiitratlioi-acic disease; for examjjle, the i:jres-
ence of enlarged glands in the neck, especially if there are any
scars, sinuses, or other evidence that suppuration is going on or
has formerly taken place in them, suggests the p)ossibility of pul-
inonary tuberculosis or of an enlargement of the bronchial and me-
diastinal glands. Again, malignant disease of tlie chest is some-
times associated with the metastatic nodules over the clavicle (see
Fig. 63), and a microscopic examination of tliem may thus reveal
the nature of the intrathoracic disease to which they are secondary.
Very large and matted juasses of glands above the clavicle, which
liave never suppurated and have been painless and slow in their
growth, suggest the presence of similar deposits in the mediastinum
as a part of the sym])toni complex known as "Hodgkin's disease."
The presence of a goitre or enlargement of the thyroid glaud may
account for a well-marked dyspncea.
Syphilis i)roduces general glandular enlargement; the posterior
cervical and the epitrochlear glands are often involved, but this is
also the case in many diseases other than syphilis.
CHAPTER V.
PALPATION AND THE S^FUDY OP THE PULSE.
I PaI.I'ATION,
Thk most important points to be determined by palpation — that
is, by laying the hand upon the siu'face of the chest — are :
(1) The position and charactei- of the uiicx lent of the heart.
(2) The i)resence of a "tlivill" (see below).
(.3) The vibrations of the sjjoken voice (^^ tactile fremii'us").
(4) The presence of pleuritic or pericanlial ,/"/'/r^io«.
Other less important data furnished by palpation will be men-
tioned later.
(1) Tin; Jpi'x JJeof.
(a) In feeling for the apex imimlse of the heart, one should
first lay the palm of the hand lightly upon the chest just below the
left ni])ple In this way we can api^reciate a good deal aVjout the
movements of the heart, and confirm or modify what we have
learned by inspection. One learns, in the first place, whether the
heart beat is rcfinhir or not, aiid in case it is iri-cgulai', whether the
beats are une(iual in force or whether some are skipped; further,
one gets a moi-e accurate idea than can be oljtained through inspec-
tion regarding the character of the cardiac movenicnfa. Tlie power-
ful heaving impulse suggesting a hypertrophied heart, the diffuse
slap often felt in dilatation of the right ventricle, tlie sudden tap
characteristic of mitral stenosis, the deliljerate thrust oc^casionally
met with in aortic stenosis, juay be thus appreciated.
{h) After tliis, it is best to lay the ti])S of two or tliree fingers
over the point where the maximum impulse is to be seen, and fol-
low it (jutward and downward until one arrives at the point farthest
to the left and fartlu;st down at wlii(-h it is still possible to feel
PALPATIOX AXD THE STUDY OF THE PULSE. 97
any >ni-aiul-ilown moveiuoiit. Tliis jioiut usually eovrespouds with
(he apox of tlu- heart, as ili'teniiiiu'd bv jievfussiou. Jt dot's not
fon-i's/iiUK/ irif/i tlw iiio.riiiiinii vordinc ini/iii/sr. hut is ofteu to be
found at least an inch farthei- to the loft and do^vu^va^'d (see aboye,
Fig. o8h
8ouu"tinios i>iu' eau localize by iialpatiou a eavdiae impulse
wliieh is not visible; on the otlu'v hand, in some eases we can see
pulsations that we eannot feel. r>oth methods must be used in
every ease.
The rosidts obtained bv ]>alpatiou and inspeetion of the a}>ex
region give us the most r^'liable data that we have regarding the
size of the heart, reveussion may be interfered with by the pres-
ence of gas in the stomach . of tlnid lu- adhesions in the jdeural cav-
ity, i>r by the ineptness of tlu' ol 'server, but it is alnuist always pos-
sible with a little care to make out by a combination of palpation
and inspcUion the position ot the apex of the heart. When we
can neither feel it nor sec it. «e may have to fall back upon auseul-
tatiou. eonsuhnang the aj'cx of the heart to be at or near the point
at which the heart sounds are heard loudest. '\'Mien endeavoriug
to find the apex of the heart, we must not forget that the position
of the ]xitient intlucuccs considerably the relation of tlie heart to
the I'hest walls If the jiatient is Icaiung toward the left or lying
on the left side, the apex will swing out several centimetres toward
the left axilla.
(^■2) '-77/ /'///.v."
^^dlcn feeling for the cardiac impulse with the palm of the
hand, we are in a good position to notice the presence or absence
of a \"ery important ]>hysical sign to which we give the name of
"thrill" The feeling im]iarted to the fingers by the thriiat of
a purring cat is very much like the ]ialpable "tJrrill" over the pre-
eordia in certain diseases of the heart to be mentioned later. It is
a \ibration of the chest wall, usually confined to a small area in the
region of the apex impulse, but sometimes felt in the second right
intercostal s]iace or elsewhere in the precordial region. This vibra-
tion or thrill almost alwa_ys occurs intermittently, /.('., only during
7
98 PHYSICAL DIAGNOSIS.
a portion of the cardiac cycle. When felt in the apex region, it
usually occurs just before the cardiac iin|)ulse ; this fact we express
by calling it a "]) res //.•italic tlirill"; but occasionally we may feel a
si/sfolii; thrill at the apex — one, that is, which accompanies the car-
diac impulse. The word ihrill should be used to denote only a
purring, vibrating sensation communicated to the fingers by the
chest wall. It is incorrect to speak of a tlirill as if it were some-
thing audible.
We must also distinguish a purring thrill from the slight shud-
der or jarring which often accompanies the cardiac impulse in func-
tional neuroses of the heart or in conditions of mental excitement.
As a rule we can appreciate a thrill inore easily if we lay the
fingers very lightly upon the chest, using as little pressure as pos-
sible. Firm pressure may prevent the occurrence of the vibrations
which we desire to investigate. Oi tlie tlirills felt over the Ijase of
the heart, more will be said in Chapter X.
(3) Vibrations CoiiiJiiitiiicated to tJiu Chv.st ll'iill hij tlie Voice.
" Tactile fremitus " is the name given to the sense of vibration
communicated to the hand if the latter is laid upon the chest while
the patient repeats some short phrase of words. The classical
method of testing tactile fremitus is to ask the patient to count
"one, two, three," or to repeat the words "ninety-nine " while the
palm of the hand is laid flat upon the chest. The amount of fre-
mitus to be oljtained over a given part of the thorax varies, of course,
according to the loudness of the words spoken, and is influenced
also by the vowels contained in them. A certain uniformity is ob-
tained by getting the patient to repeat always the same formula.
Thus, he is likely to use the same amount of force each time he re-
peats them and to use approximately the same pitch of voice.
Other thuigs being equal, the fremitus is greater in men than
in women, in adults than in children, and is more marked in those
whose voices are low pitched than in those whose voices are rela-
tively shrill Tlie amount of fremitus also varies widely in differ-
ent parts of the liealthy chest A glance at Fig 64 will help us to
realize this The parts shaded darkest communicate to the fingers
PALPATION AND THE STUDY OF THE PULSE.
99
the most marked fremitus, while iu the parts not shaded at all, lit-
tle or no fremitus is felt Intermediate degrees of vibration are
reju-esented l)y intermediate tints ot shading. From this diagram
we see at once («) that the maximum of fremitus is to be obtained
over the apex of the right lung in front, (b) that it is greater in the
up])er "[lart of the chest than in the lower, and somewhat greater
throughout the right chest than in corresponduig parts of the left.
Fio. W.— Distribution of T;ictlle Fremitus.
Th!.i 7t(Uurid inequnrUij of tlui tivo aides of the chest cannot ha too
si roil 1)1 ij eiiipliaslaed.
Comparatively little fremitus is to be felt over the soapulte be-
liind, and still less in tlie pirecordial region in front. The outlines
of the lungs can be quite accurately mapped out l)y means of the
tactile fremitus in adults of low-pitched voice. In children, as has
been already mentioned, fremitus is usually very slight and may be
entirely absent, and in many women it is too slight to be of any
I consideralde diagnostic value. Again, some very fat persons and
j those with thick chest walls transmit but little vibration to their
' chest walls when they speak. On the other hand, in emaciated
])ati('nts or in those with thin-walled, flexible chests, the amount
of fremitus is relatively great.
100
PHYSICAL DIAG.XOSIS.
Bearing in iniiul all these disparities — disparities botli between
persons oi different age and different sex, and between the two
sides of the chest in any one
jierson — we are in a position to
appreciate the modifications to
which disease gives rise and
Avhicli may be of great impor-
tance ill diagnosis. These vari-
ations are :
((/) Diminution or absence
of fremitus.
(Ji) Inerease or absence of
fremitus.
[a) If the lung is pushed
away from the chest wall by the
presence of air or fluid or tumor
in the pleural cavity, we get a
diminution or absence of tactile
fremitus — diminution where the
layer of fluid or air is very thin,
absence where it is of consider-
able thickness.
(/') Solidification of the lung
due to phthisis or imeumonia is
the commonest cause of an iii-
cri'dse in tactile fremitus. Fur-
ther details as to the variations
in amount of fremitus in different diseases may be found in later
chapters of this book.
(4) Frirfiiii), Pleural or T'ci'lccinUiiI.
In many cases of inflammatory roughening of the pleural sur-
faces (" dry pleurisy ") a grating or rubbing of tlie two surfaces
upon each other may be felt as well as heard during the movements
of respiration, and especially at the end of inspiration. Such fric-
tion is most often felt at the bottom of the axilla, on one side or
Fig. a5.-Sliowiiig Point (F) at Wliii-li Pleural
Friction is Most Ofteu Heard.
PALPATION AND THE STUDY OF THE PULSE.
101
the otlier, where the diaphragmatic pleura is in ck)se apposition
with the costal hxyer (see Fig. 65, p. 100).
Siuiihirljr, in roughening of the pericardial surfaces ("dry" or
"plastic" pericarditis) it is occasionally p)0ssible to feel a grating
or rubbing in the precordial region more or less synchronous with
the heart's movements. Such friction is most often to be felt in
the region of the fourth left costal cartilage (see Fig. 66).
Palpable friction is of great value in diagnosis because it is a
sign about which we can feel no doubt ; as such it frequently con-
FiG. l>6.— Sboning Point (P) at Wliieli Pericardial Friction is Most Often Heard.
firms our judgment in cases in whicli the auscultatory signs are less
clear. Friction sounds heard with the stethoscope may be closely
simulated by the rubbing of the stetlioscope upon the skin, but pal-
pable friction is simulated by nothing else, unless occasionally by
(5) Fidpiihle Bales.
Occasionally coarse, dry rales communicate a sensation to the
hand placed upon the chest in the region beneath which the rales
are produced ; to the practised hand this sensation is quite differ-
ent from that produced by pleural friction, although the difference
is hard to describe.
105
PrrSICAL DIAGMOSIS.
{(')) Tender points upon tlie thorax.
In mitral disease, drj' pleurisy, necrosis of the rili, and some-
times in plithisis, one finds areas of marked tenderness in different
parts of the chest. The position of tlie tender points in intercostal
neuralgia generally corresjjonds with the point of exit of the inter-
costal nerves. These points are shown in Fig. 67.
The tenderness in phthisis is most apt to be in tlie upper and
front portions of the chest. In neurotic individuals we sometimes
find a very superficial tenderness over parts of the thorax ; in such
Fig. C7.— Showing Points of E.xit ol tlie Intercostal Nerves.
cases pain is produced by very light pressure, but not by firm press-
ure at the sanre point.
(7) Tlie presence of pulsations in parts of the chest where nor-
mally there should be none is sirggested by inspection and con-
firmed by palpation. It is not necessary to repeat what was said
above as to the commonest carrscs of such abnormal pulsations.
When searching for slight, deep-seated pulsation (e.;/., from an
aortic aneurism), it is well to use bimanual }>alpation, keeping one
hand on the front of the chest and the other over a correspondmg
area in the back.
(8) Fluctuation or elasticity in any tumor or projection from
PALPATION AND STUDY OF THE PULHE. 10?>
tlio cliost is a vi'iy impdi-taiit; picco of infoi'iiiation wLioh palpation
may give us.
(U) Tlie tuinperatiire ami rpiality oi' tlio sl-ciii aic often lirouglit
to our atteutiou dui-ing palpation. A ft<u' a little pi'actico one can
usnally judge the temperatiiie witliin a degree or two winijdy from
the feeling (jf the skin. Any roughness, dryness, (u- loss of elas-
ti(nty (tf the skin (myxoidenm, dialiete.s, long-stauding pyri^xia, or
wasting disease;) is easily appreciated as we pass the hand over the
surface of tins thorax or down the arms. 'I'he sanui manipnlation
often brings to our attention in cases of alcoholism an nniisnally
sm(Kjth and satiny fpudity of the cntaneous surface'.
If. Tnn I'liLSE.
Fifty yeai'S ago the study of the pulse fnrnislied thu jihysician
with most of the available evi(h^nce regarding tin; condition of the
In-art. At jjresent this is not the case. With the increase of our
knowledge of the direct i)hysical examhiation of the heart and of
the various methods of measuring the systolic or diastolic pressure
on the peripheral arteries, the amount of information furnished
exclusively by the ])nlse has proportionately decreased, until to-
day, I think, it is a fact that there is but little to be learned by
studying the pulse which could not be as well or better ascertained
by exanuning the heart and measuring the arterial pressure.
Nevertheless, the radial pulse is still an important factor in diag-
nosis, prognosis, and treatnuiut, and will remain so, because itgives
ns ipiickly, snecinc^tly, and in almost every case a great deal of valu-
able inforjnation whie^h it would tak(^ inore time ami trouble to ob-
tain iu any other way. As we feel the pulse, wo get at once a fact
of central importance in the case; by the i)ulse the stejjs of our sub-
secpient examination are guided. In emergencies or accidents the
pulse gives us our bearii}gs and tells us whether or not the patient's
condition is one demanding immediate succor — r.r/., hypodermic
stimulation — and Avhethcr the outlook is bright or dark. To gather
this same information in any other way would involve losing valu-
able time.
Agahi, when one has to to see a large number of patients in a
104 PHYSICAL DTAGNOSTS.
short time, as in visiting ;i liospital ward or on the crowded days of
private practice, tlie pnlse is an invaluable short cut to some of the
most important data.
Moreover, there are some important inferences which the pulse
and oii/i/ the pulse enables us to uudve. They are not numerous, but
their value may be great. Delay in one radial i)ulse when taken in
connection with other signs may furnish derisive evidence of aneu-
rism of the aortic arch; aortic stenosis is a lesion which cannot be
diagnosed unless the pulse shows certain characteristic features;
arterial degeneration may betray its ^iresence chiefly in the jjeriph-
eral arteries.
Since, then, the condition of the pulse furnishes information of
crucial importance in a few diseases, and is a quick, reliable, and
convenient indication of the geneial condition of the circulation in
all cases, it is essential that we should study it most carefully both
in health and in disease.
How to Feel the Fiihe.
(a) We usually feel for the pulse in the radial artery because
this is the most superficial vessel which is readily available. Oc-
casionally, as when the wrists are S'ivathed in surgical dressings or
tied up in a straight-jacket, we make use of the temporal, facial,
or carotid arteries.
(b) Both radials should always be felt at the same time. By
making this a routine ju'actice many mistakes are avoided and any
difference in the two pulses is appreciated.
((•) The tips of three fingers (never the thumb) should be laid
upon the artery, and the following points noted :
1. The rate of the pulse.
2. The rhi/thin. of the pulse (regular or irregular).
8. The, amount of force necessary to obliterate it (eoi)ij»rssi-
hilittj).
4. The size^ <ind sJiaj'e of tlie piihe leave.
5. The extent to which the artery collapses betw^een beats
[tension).
t>. The size and jjositioii of the arten/.
PALPATION AND THE STUDY OF THE PULSE. 105
7. The condition of the artery uuiUs.
Each of these jDoints will now be considered in detail.
1. The Rate of the Pulse.
In the adult male the pulse averages 71! to the minute, in the
female 80. In children it is considerably more frequent. At birth
it averages about loO^ and until the third year it is usually above
100. lu some families as low jjulse, 60 or less, is hereditary ; on the
other hand, it is not very rare to observe a permanent pulse rate of
ibO or more in a normal adult (see below, p. 261). Exercise or emo-
tion quickens the pulse very markedly, and after food it is somewhat
accelerated. Some account of the causes of pathological quicken-
ing or slowing of the pulse will be found on pages 261 and 262.
S. liliijtlim.
The pulse may be irregular in force, in rhythm, or (as most
commonly happens) in botli respects. As a rule, irregularities in
force are the more serious. Intermittence or irregularity in rhythm
alone, means that the heart ski})S one or more beats at regular or
irregular intervals. This may be a mere idiosyncrasy not associ-
ated with any evidence of disease. I have known several instances
in which a perfectly sound person has been aware of such an irregu-
larity throughout life — the heart dropping regularly every third or
fourth beat. Such rhythmical intermittence m health is not un-
common.
A\^ien beats are dropped, not at fixed intervals, but irregularly,
the pulse waves usually vary in force as well. This combination
of irregular cardiac rhythm with variations in the strength of the
individual beats is very rarely seen in health and usually pomts to
functional or structural disease of the heart.
Special tyi)es of irregularity will be discussed later.
In general it may be said (a) that irregularity in the force of
the pulse beats is a serious sign, if overexertion and temporary
toxic influences (tobacco, tea, etc.) can be ruled out; (&) that it is
far more serious when occurring in connection with diseases of the
106 . PHYSICAL DIAGNOSIS.
aortic valve than in mitral disease ; and (c) that it often occurs in
couuectiou with sclerosis of tlie coronary arteries and myocarditis.
3. Conipressibilifi/) or Systolic Arterial Pressure.
There is no single datum concerning the xaulse more important
than the amount of force needed to obliterate its beat. Until
recently we have had no more accurate method of measuring the
systolic blood pressure than the following : Let the tips of three
fingers rest as usual on the radial artery. Then gradually increase
the pressure made upon the A'essel with the finger nearest the pa-
tient's heart until the pulse wave is arrested and cannot be felt by
the other fingers which rest loosely on the artery. The degree of
force necessary to arrest the wave varies a great deal in different
cases and at different times of day, but by trying the above manoeuvre
day after day in as many cases as possible, and especially by com-
paring one's impressions with accurate measurements of blood press-
ure (^vide infra), one comes to possess a fairly accurate mental
standard with which to compare abnormal cases. Sometimes the
circulation tlirough the palmar arch is so active that one must cut off
the radial pulse below as well as above tlie point at which we are
palpating it.
The compressibility of the pulse is a rough measure of the mus-
cular power of the heart's beat, and therefore gives us direct infor-
mation about this important element in the patient's condition.
4. The, Si-:e and Shajoe of the Pulse Wave.
Of the use of the sphygmograph for representing piulse waves
I shall speak later. The points discussed in this section are appre-
ciable to the fingers.
I. The size of the pulse wave — the height to which it lifts the
finger — depends on two factors:
(rt) The force of the cardiac contractions (systolic arterial
pressure).
(b) The tightness or looseness of the artery (tension, or diastolic
pressure).
If tlie arteries are contracted and small, the pulse wave corre-
PALPATION AND THE STUDY OF THE PULSE. 107
sponds, while if they are large and relaxed, it needs only a moder-
ate degree of power in the heart to produce a high pulse wave. If
the tension remains constant the size of the pulse wave depends on
the force of the heart's contraction. If the heart power remains
constant, the size of the pulse wave depends on the degree of vas-
cular tension. Vascular tension is estimated in ways to be de-
scribed presently, and after allowing for it, we are enabled to esti-
mate the power of the heart's contractions from the height of the
pulse wave.
II. The shape of the indse wave is also of importance.
(«) It may have a very sharp summit, rising and falling back
again suddenly; this is known as an ill-sustained pulse, and may
be due to a lack of sustained propulsive power in the contracting
heart muscle, to low vascular tension, or to a combination of the
two causes. A weak heart with low arterial tension often produces
such a pulse wave — deceptively high and giving at first air impres-
sion of power in the heart wall, but ill sustained and easily com-
pressible. This is the " bounding pulse" of early infectious ptroc-
esses. An exaggeration of this type of pulse is to be felt in aortic
regurgitation (see page 2.32).
(h) In sharp contrast with the above is the pulse wave which
lifts the finger gradually and slowly, sustains it for a relatively
long period, aird then sinks gradually down again. Such a pulse
with a " long plateau " instead of a sharp peak is to be felt most
distinctly in aortic stenosis, less often in mitral stenosis and other
conditions (seepage 242).
(c) The dicrotic pulse wave is one in which the secondary wave,
which the sphygmograph shows to be ])resent in the normal pulse,
is much exaggerated, so that a distinct " echo " of the primary
wave is felt after each beat. If the heart is acting rapidl}-, this
dicrotic wave does not have time to fall before it is interrupted by
the primary wave of the next beat, and so appears in the sphygmo-
graphic tracing as a part of the up-stroke of the primary wave.
This is known as the " ((nacrotic pulse."
(fZ) The shape, of the liigli-tension pulse ivave v/iWYiQ dQnaAhtd.
ii the next paragraph.
108
PHYSICAL DIAGNOSIS
Tens
Diastolic Arterial Pressure.
The degree of contraction of tlie vascular muscles cleterinmeE
the size of tlie artery and (to a great extent) the tension of the
blood within it. But if the lieart is acting feebly, there may be so
little blood in the arteries that even when tightly contracted they
do not subject tlie blood within them to any considerable degree of
tension. To produce high tension, then, we need two factors- a
Fig. 68.-Sphygmographii? Tracing of Low Tension Pulse.
certain degree of power in the heart muscle, and contracted arteries.
To produce low tension we need only relaxation of the arteries, and
the heart may be either strong or weak.
The pulse of low tension collapses between beats, so that the ar-
tery is less palpable than usual or cannot be felt at all. Normally,
Fig. 69.— Siihygmographlc TradnK of High Tension Pulse.
the artery can just be made out between beats, and any consider'
able lowering of arterial tension makes it altogether impalpable
except during the period of the ]n'iniary wave and of the dicrotic
wave, which is often very well nuxrked in pulses of low tension.
The shape of the wave under tliese conditions has already been
described (see Fig. 68).
PALPATION AXD THE STUDY OF THE PVLSE. 109
Theindseofhiijli !■*-««■/»» is perceptible between beats as a dis-
tinct cord which can he rolled hetwcen tlte fingers, lilie one of the ten-
dons of the wrist. It is also difficult to compress in most cases, but
this may depend rather on tlie heart's power than on tlie degree
of vascular tension. A high-tension pulse is often indistinguisliable
from one stiffened by arteriosclerosis {ride ivfrn). The pulse wave
is usually of moderate heiglit or low, and falls away slowly with
little or no dicrotic wave (see Fig. 69).
6. The Size and Position of the Artery.
I have often known errors to occur because a small artery is
mistaken for a &m^l\ jmlse ware. The size of the branches of the
arterial tree varies a great deal in different individuals of the same
weight and height, and if the radial is unusually small and a hur-
ried observation gi-s'es us the impression (true, so far as it goes) that
there is very little in the way of a pulse to be felt, we are apt to
conclude (wrongly, perhaps j that the heart's work is not being
properly performed. The effort to obliterate such a pulse, how-
ever, mcuj set us right \)y showing that despite the small size of the
vessel (and consequent!}' of the pulse wave) it takes as much force
as it normally does to obliterate it. But in manj- cases we can
determine the question satisfactorily often bj- using some instru-
ment for measuring arterial jiressure. Thus, a small, jndse wave (in
a congenitally small artery) maj' be distinguished from a veal:
pulse. From the contracted artery of high vascular tension we dis-
tinguish the confjenitallij small artery because the latter is not to lie
rolled beneath the fingers, and is not more than normally palpable
between the pulse beats.
ISTot infrequently the nurse reports ui alarm that the patient has
no pulse, when in reality the pulse is excellent Ixit the artery mis-
X^laced so as to be impalpable in the ordinary situation. It may be
simply more deeply set than normal, so that the fingers cannot get
at it, or it may run superficially over the end of the radius toward
the "anatomical snuff box." Other anomalies are less common.
As a rule, the other radial artery is normally placed and can be used
110 PHYSICAL DIAGNOSIS.
as a standard, but occasionally both radials are anomalous and we
may be compelled to use the temporal or facial iusteaitl.
7. Tlie Condition of till} Ai-teru Walls.
Arterio-sclerosis is manifested in the peripheral arteries in the
follownrg forms :
(ft) Simple stiffeviiifj of the arteries without calcification.
{h) TortHonity of the arteries
(c) Calcification.
Simple stiffenuig without calcification is due to fibrous thicken-
ing of the Ultima and produces a condition of the arteries not al-
ways to be distinguished from high tension. The artery can be
rolled under the fingers, stands out visibly between the heart's
beats, but is not incompressible, has a smooth surface, and is not
always tortuous. If it is tortuous as well as stiff, we may con-
clude that there is endarteritis at any rate, whether or not there is
increased tension as well. In the vast majority of cases the two
conditions are asssociated and do not need to be distinguished.
The normal radial artery is straight ;^ lieuce any deviation is
evidence of changes in its walls and is easily recognized as we run
our fingers up and down the vessel.
Calcification of the radial produces usually a heading of its sur-
face. As we move the fingers along the artery, quickly and with
very slight pressure, a series of transverse ridges or beads can be
felt. Tire equalities of the pulse wave within can usually be appre-
ciated fairly well, in this type of artery, but in very advanced cases
the calcification is diffuse and converts the radial into a rigid "pipe
stem " — absolutely incompressible — luiless we break the calcified
coat — and easily mistaken for a tendon. In such an artery no
pulse can be felt.
Such are the points to be observed in feeling the pulse. To
enumerate the cluxracteristics of tlie pulse in the many diseases in
which it affords us valuable information is beyond the scope of this
book. The qualities to be expected in tlie pulse in connection with
the different diseases of the heart are described in the sections on
' Tortuo.sity in tliu k'liipoml urtci'y, lnjwevei', is iiuriiiul.
PALPATION AND THE STUDY OF THE PULSE. Ill
those diseases. Here it will suffice to enumerate some of tlie con-
ditions in which vascular tension is usually increased or diminislied.
Low tension is produced by moderate exercise, by warmth [e.//.,
a warm bath), by food. Among pathological conditions wo may
mention, Addison's disease, tuberculosis, debility, and fever.
JSiffh tension is produced by cold {e.g., cold bathing, malarial
chills), and by constipation (in some cases). As a rule, the tension
of the pulse increases with age and is high after the fiftieth year.
Hysteria and migraine are often associated with increased vascular
tension. Most fre(|uent among pathological conditions as causes
of high tension are chronic nepJiritis and arteriosclerosis with the
various diseases in which arterio-sclerosis is a factor (gout, alcohol-
ism, lead poisoning, diabetes of fat old people, chronic Ijronchitis
with emphysema).
In valvular heart disease without ne[ihritis or arterio-sclerosis
the tension is usually normal or sliglitly lowered.
Akteiual Pkessuke and the Instkumbnts fok Measukixg It.
Within the past few years a number of instruments have come
into use, the object of which is to tell us with some approach to
accuracy the lateral pressure in the peripheral arteries. We have
long attempted to estimate this pressure, by simple digital com-
pression and palpation, and no doubt these methods in the hands of
skilled observers will always have a field of usefulness; but it seems
to me clear that by the instruments about to be described we can
obtain data in regard to the force of the heart's contractions and the
tension of the peripheral arteries more accurate and more reliable
than those furnished by digital examination. This is especially
true of comparative records, as, for example, if one attempts to
compare the tension of the pulse to-day with what it was yesterday,
when one has felt many jjulses in the interim. Another objection
to estimates of pulse pressure based on digital examination results
from the fact that the size of the artery itself is apt to be a confus-
ing factor.
Among the many instruments introduced within the past few
years we may distinguish (1) those which aim to estimate the
112 PHYSICAL DIAGNOSIS.
amount of compression which has to be exerted upon a given artery
in order to arrest the onward flow of blood in it, and (2) those
which seek to estimate the amount of pressure in a given artery
at the moment when its wall makes the widest excursion or oscilla-
tion.
Instruments of the first type are said to measure systolic 2') rvss-
tire, and those of the second type to measure diastolic jrressure.
Under the first heading I shall describe the Riva-Rocci and Gaert-
ner instruments. Under the second that of Oliver and that of Hill
and Barnard.
1. Gaertner^ s Tonometer. — The end of a finger is made blood-
less by rolling up over it a tight rubber ring. Over the blanched
finger tip one next applies a pneumatic ring, wliich can be inflated
by means of a rubber bulb, while the tension within is meas-
ured by a manometer connected with it. The manometer may be
either of the mercury or the spring type. To use the instrument
we inflate the pneumatic ring until the pressure recorded in the
manometer is considerably aljove what we exjiect in the case dealt
with. (The tip of the finger all this time remains blanclied. ) Next
we relax the tension within the pneumatic ring, by gradually releas-
ing the pressure exerted upon the inflation bulb, until the red color
reappears in the finger tip. Just as the color reappears we note the
pressure in the manometer. This figure was supposed by Gaertner
to represent the average or mean pressure in the arteries, but it
has been very generally conceded by other observers that the figures
given by this instrument are much nearer to those of systolic press-
ure, tliat is, to tlie pressure during the systole of the left ventricle
or to the crest of the pulse wave.
The advantages of the Gaertner instrument are its compactness
and portability. Its disadvantages are that (in this climate at any
rate) it is very apt to get out of order, that it is not suited to esti-
mating ju'essures in any of the dark-skinned races, and that its
readings are very jnuch affected l)y vasomotor infinences, such as
nervousness or cold. If the fingers are cold it may be almost im-
possible to make a satisfactory record with the instruirrent. Further,
the spring manometer, like all instruments of this ty])e, is very apt
ARTERIAL PRESSURE.
113
to get out of order, and if the iiiercury manometer is employed the
instrument loses its only advantage, namely, its compactness.
2. 17ie THiui-Rocci Ingtruiiiriit. — This instrument consists esseii-
tialljr of an inflatable rubber armlet, so arranged that it can be fitted
closely around the upper arm, a mercury manometer of the ordinary
type, and au air-pump (see Fig. TO). Tlie air forced from tlie
Fig. 70. — Stanton's Modifleation of tlie Riva-Rocci Instrument. (By permission from the Uni
versity of Pennsylvania Medical Bulletin.)
pump is distributed into the rubber armlet and into the man-
ometer at the same time, and experiments have shown that the
actual pressure in the armlet is practically identical at any given
time with that in the manometer. To use the instrument we punrp
in air until the radial pulse stops, and at that instant note the
height of the mercuiy column. The reading thus obtained is
8
114 PHYSICAL DIAGNOSIS.
talvt'ii to lejivesent the systnlicor iiiaxiimun pressure in the Inachial
arteiy.
It is true that the air -within the rubber armlet lias to overcouie
not only tlie pressure within the radial arterjr, but the resist;uiee of
the artery Avail and the elasticity of the soft parts arouiul it. The
former factor has lieeu slio\yn to represent a pressure of not more
than 2 or 3 mm. Hg, provided the artery walls are nornuil. If
arterio-selerosis is present, it has been estimated by Herringham
that the artery nuiy oppose a resistance of 15 to 20 mm. Hg. The
amount of error thus introduced, however, is not of importance
except when wo arc trying to distinguish arterio-selerosis from
ne])liritis as a cause of high tension. Here the iustnuaent is unre-
liable and we must fall back upon the data of arterial paljiation
(roughness, tortuosity), urinary examination, etc.
The resistance of the soft parts around the artery is a factor of
considerable imp(U'tance, provided the compressing armlet is as
narrow as many of those supplied with Eiva-Rocci instruments.
But if a wider armlet of about seventeen centimetres width is
used, according to the recommendation of von Eecklinghausen and
Stanton, we find that the pressure is practically the same in a given
individual whether the armlet is applied round the upper arm,
round the forearm, or round the thigh. Now if the resistance of
the tissues of the thigh exerts no greater influence than that of the
npiier arm or forearm, it seems safe to conclude that this factor may
bo neglected as a source of error in comparative measurements with
arms of different sizes.
The instrument is a very simple and (puck one to use, needing
very little practice and not more than a minute or a minute and a
half for a single reading. The chief objection to it is its bulk and
fragility.
8. The lu.'itrii incut af Hill ami BnrnnrJ. — In essentials this in-
strument is like the Kiva-Rocci, except that all the connecting tubes
are rigid, and that in place of the mercury numometer a very deli-
cate aneroid instrument is employed to record the pressures within
the armlet (see Fig. 71). The delicacy of this form of manometer
is so great that with rigid connections it is possible to register the
ARTERIAL PRESSURE.
115
oscillations of the artery wall and to estimate the amount of press-
ure within the armlet at the time when the arterial oscillations are
widest ; in other words, when the arteries are slackest. The work
of Howell and Brush has demonstrated to my satisfaction that the
pressure at the time of tlie maximum oscillation corresponds to the
minimum or diastolic pressure within the arteries.
The Hill and Barnard instrument, when in good order, seems to
Fig. 71.— Hill A Barnard's Sphygmometer.
me on the whole the best among those that are clinically available
for measuring diastolic pressure. The difficulty of reading it is less
than with most other instruments designed for this purpose, and
the only serious drawback to the instrument is tlie likelihood that
the mauometer will get out of order, a difficulty to which all in-
struments of this type are very prone.
4. The Olicer Instrument. — This instrument is intended, like the
last, for estimating the pressure in the arteries during the period of
maximum oscillation. This, as I have said, corresponds in my
ojjinion to the diastolic and not to the average or mean pressure.
A small rubber capsule filled with water is placed upon the radial
artery, and through this the pulsations of the artery, under differ-
ent pressures, are transmitted directly by a straight rod to a spring
116
PHYSICAL DIAGNOSIS.
luaiioiiietei', where tlie oscillations and pressures are recorded in
mm. llg (see Fig 72). The instrument is a very compact and
simple one, and if it were not constantly getting out i)f order, would
be, I think, of considerable value, although it is a difficult instru-
FIG. 7~.— Oliver's H;pinodynamometer.
ment to use. Its readings, however, soon Ix'conie inaccurate and
cease to correspond with the nuuxniry column.
Stanton (Uiitrrrsiti/ of Foni. JIfiiL Bull., February, 190.") has
succeeded in fitting a Eiva-Rocci instrument with rigid connecting
tubes, so that with this single instrunuuit he can record both nurxi-
mum and minim\im jiressures. The maximum or systolic pressure
he records in the ordinary w'ay. To get the nunimum or diastolic
pressure he clamps off the tube leading to the inflation bulb, and
then lets out the air little by little until the mercury begins to oscil-
late in the tulie. Tlie oscillations increase in exti'ut up to a maxi-
nunu as tlie air is steadily let (uit, and then decrease again until
they are lost. The rca,<ling for diastolic pressure is taken when the
mercury shows the greatest extent of oscillation in the tube.
' ARTERIAL PRESSURE. 117
The )-eadings thus dljtaiiied, however, are very inaccurate. The
instrument devised \>y Krlanger (Johns Hopkins Hospital Eeports,
1904, A'lil. Xil. ) gi\-es very aceurate readings l)oth for systolic and
for diastolic pressure. Its bulk, delicacy, tlie difficulty of keeping
it in good order, and the amount of time needed to secure a reading
will prevent its general use in clinical work.
The Use oftlie Uafa Ohtained hij fJiese Instruments.
Whenever it is important for us to know the tension of the
peripheral arteries, a sphygmomanometer is indispensal)le. The
more 1 use the instrument, tlie more firmly 1 ajn convinced tliat
digital measures of blood pressure are often ludicrously "wrong. The
Eiva-Eocci instrument as modified by Janeway or Stanton has now
secured a firm position in the routine work of good clinicians all over
this country. Especially in relation to the diagnosis of neiiliritis
the instrument is often indispensable, yielding results more signifi-
cant than ni'inary examination, and setting our diagnosis riglit when
it would otherwise have been wrong.
For tlie detection of arterio-sclerosis, Addison's disease, tuber-
culosis, intracranial hemorrhage or tumor, in the study of uraemia,
eclamp)sia, and other causes of coma, the instrument is also of great
value.
\
CHAPTER VI
PEKCUSSIOK
I. Technique.
There is no other method of physical examination wliich needs
so much practice as percussion, and none that is so seklom thor-
oughly learned. Many physicians never succeed in acquiring a
facility in the use of it sufficient to make them rely upon their
results. Undoubtedly one of the greatest difficulties arises from
the necessity of being at once active and passive — at once the jwr-
cussor and the one who listens to the percussion. Students half
unconsciously get to treat the percussion as an end in itself, and
hammer away industriously without realizing that two-thirds of the
attention must be given to listening, while the percussion itself
should become semi-automatic.
It is undoubtedly an advantage to possess a musical ear, but this
is by no means a necessity. Some of the most accurate percussors
that I know possess absolutely no musical ear — no ear, that is, for
Ijitch — and form their judgments in percussing iipon the quality or
intensity of the note, and upon the sense of resistance.
In this country practically all ])evcussion is done with the fin-
gers ; in Germany instruments are still used to a considerable ex-
tent.
(rt) Mediate, and Iiiniicdiafe Pi'rnif:si())i.
Percussion may be either "mediate" or " immediate, " tlie lat-
ter term referring to blows struck directly upon the chest with the
flat of the hand, or upon the clavicles with the tip of the second
finger.
PERCUSSION.
119
{h) Mrthodn.
Mediate percussion (wliicli is used ninety -nine hundredths of
the time) is i)erformed as follows:
The patient should either lie down or sit with liis back against
some support. The reason of this is that for good percussion one
Fig. 7;J.— Pdsitioii of tile Hanils Wlien i'l'Ti'iissiuy the Kiflit Apex.
needs to press very firmly with the middle finger of the left hand
upon the surface of the chest, so firmly that if the patient is sitting
upon a stool without support for liis Ijack, it will need considerable
exertion upon his jtart to avoid losing his balance.
120
PHTSTCAL DTAGXOSTS.
In pereussiiiii' the front of the chest it is important to luive the
jiatient sitting or lying- //( ir tii/m iiictrii;il jHisitimi — that is, witliont
any twist or tilting to one siile. His heail shonld jmint straight
forwavil anil hi.-i miisr/if: iini.st hi- flinrniiijldi/ rrhi.vcil . ]\[any pa-
tients, when stripped for examination, swell out their cliests luul
Fig. 74.— Positiou of the Hands Wben I'l'ivussius the Left Apex.
sit up with a military ereetness. Tlie museulav tension thus pro-
duced modifies the piereussioii note and causes an embarrassing
multitude of muscle sounds which greatly disturb auscultation.
Ilax'ing jda.ccd the })atient in an easy and symmetrical position,
our percussion shonld proceed according to the following rules :
(1) Always pu'ess as firmly as possible upon the surface of the
PERCUSSION.
121
chest with the second finger of the left hand ' on the dorsum of
which the blow is to be struck. Eaise the other fingers of the left
hand from the chest so as not to interfere with its vibrations.
(2) Strike a quick, perpendicular, rebounding blow with the tip
of the second finger of the right hand upon the second finger of the
left just behuid the nail, imitating as far as possible with the right
hand the action of a piano-hammer. The quicker the percussing
Fig. 75.— The Rigbt Way to Percuss— i. e., From the Wrist.
finger gets away again after striking, the clearer will be the note
obtained.
(3) Let all the blows struck in any one part of the chest be
uniform irr force.
'Left-handed percussors will, of course, keep the right hand upon the
chest and strike with the left.
' When percussing the right apex I prefer to strike upon the thumb (see
Figs. 73 and 74) as it is almost impossible when standing directly in front
of the patient to fit any of the fingers comfortably into the right supraclavicular
fossa,
122
PHYSICAL DIAGNOSIS.
(■i) Strike from the wrist and not from the elbow (see Figs. 75
and 76). The wrist must be held perfectly loose.
(5) Keep the percussing finger bent at a right angle as in Fig.
77.
The force to be used in percussion depends upon the purpose
Fig. 76.—Thr; AVrnnj? Way to Perruss— i. c, From the Elbow.
for which the percussion is used — that is, upon what organ we are
])ercirssing — and also upon the thickness of the muscles covering
that part of the chest. For example, it is necessary to percuss
very strongly when examiniirg the back of a muscular man, where
au inch or two of muscle intervenes between the finger on which
PERCUSSION.
123
we strike and the lung from wliicli we desire to elicit a soiuid.
Over the front of the chest and in the axilhe the niuscvdar coveruig
is much thinner, and hence a lighter blow suffices. In children or
emaciated patients, or in any case in which the muscular develop-
ment is slight, ijercussion should be as light as is sufficient to elicit a
clear sound. Heavy percussion is sometimes necessary but always
unsatisfactory, in that the sound which it elicits comes from a rela-
tively large area of the chest and does not therefore give us infor-
FiG. 77. — Proper Position of the Right Hand During Perenssion.
mation about the condition of any sharply localized area. If a car-
penter, in tapping the wall to find the position of the studs, strikes
too hard, he will fail to find the beam, because the blow delivered
over the spot behind which the beam is situated is so forcible as to
bring out the resonance of the hollow parts around. It is the same
with medical percussion. Heavy percussion is always inaccurate.'
It may be necessary where the muscles are very thick, but its value
' Sec also below, page 13G, the lung reflex.
124
PHYSICAL DIAOiXUtilti.
is then proportionately diminished. On the other hand, it is jios-
sible to strike so lightly that no rei-ognizable sound is elicited at
all. The best percussion, therefore, is that wlriclr is just forcible
enough to elicit a clear sound without setting a large area of chest
wall in vibration.
The position of the p)atient above described applies to percus-
sion of the front. When we desire to percuss tlie back, it is iur-
FiG. 78.- Proper PusitiuQ uf the Patient During Percussion of tlie Back.
portant to get the scapula out of the way as far as possible, since
we cainiot get an accurate idea of sounds transmitted through them.
To accomplish this, we put the patient in the position shown in
Fig. 78, the arms crossed upon the chest and each hand upon the
opposite shoulder. The patient should be made to bend forward ;
otherwise the left hand of the percussor will be uncomfortably bent
backward and his attention thereby distracted (see Fig. 79).
When the axillae are to be percussed, the patient should put the
hands upon the top of the head.
PERCfUSSION.
125
(I)) A^isculfatnrij Percussion.
If while percussing one auscults at the same time, letting the
chest piece of tlie stethoscope rest upon the chest, or getting the
patient or an assistant to hold it there, the sounds produced by
percussion are greatly intensified, and changes in their volume,
pitch, or quality are very readily appreciated. The blows must be
Fig. 79. —Wrong r<isition for Percussing the Back. The patient should be bent forward.
very lightly struck, either upon the chest itself or upon the linger
used as a jilexinieter in the ordinary way. Some observers use a
short stroking or scratching touch upon the chest itself without
employing any pleximeter.
This method is used especially in attempting to map out the
borders of the heart and in markhig the outlines of the stomach.
In the hands of skilled observers it often yields valuable results,
126
PHYSICAL DIAGNOSIS.
but one suurce of error iiuist be especially guarded against. The
11)16 tiloiKj ir/iirh. ive 2'<-'i'<'ii'<>>, ■tolien iiiqir<><ic]i.'m(j an orijaii wliose bor-
ders ti'ii desire to mark out, must 'neltli.er aiiproaeh tlie chest ineee oj
tlie stetJitisedpe nor recede from, it. In other words, the line along
whieli wo percuss must always describe a segment of a circle whose
centre is the chest piece of the stethoscope (see Fig. 80). If we
percuss, as we ordinarily do, in straight lines toward or away from
the border of an organ, our results ai'e wholly unreliable since
every straight line must bring the point percussed either closer to
Percussion arc.
Chest-piere (jf
Stethuscopt!.
fIG. mi.— Auscultatory Percussion, Sliowiiifc (lie An^ alouK wlilch sui-li Percussion should be
made.
the stetlKjscope or farther from it, and tlie intensity and quality
of the sounds conducted through the instrument to our ears vary
directly with its distance from the jjoiiit ]iercussed.
It will be readily seen tliat the usefulness of auscultatory per-
cussion is limited by this source of error, and that considerable
I^ractice is necessary before one can get the best results from this
method. Nevertheless it has, I believe, a ]dace, though not a very
important one, among serviceable methods of physical exandnation
PERCUSSION.
127
(c) Palj'iitor// Percussion.
Some German observers use a method of percussion in wliich
attention is fixed directly or primarily on the amount of I'esistance
offered by the tissues over which percussion is made. Even in or-
dinary percussion the amount of resistance is always noted by
experienced percussors, but the element in sound is usually the
main object of attention. Palpatory percussion is rather a series
of short imshes against various points on the chest wall, but some
Normal dulness
of the right apex. "-^-^ ^
Liver dulness.
Liver flatness.
Deep cardiac
dulness.
Superllcial cardiac
dulness.
Trnube's semilu-
nar tympanitic
space.
Fig. 81.— Percussion Outlines in the Normal Chest.
sound is elicited and j)robably enters into the rather complex judg-
ment which follows.
In this country palpatory i:)ercussioii is but little employed.
II. Pbecussion Kesonance of the Noumal Chest.
The note obtained by percussing the normal chest varies a great
deal in different areas. In Fig. 81, the parts shaded darkest are
those that normally give least sound when percussed in the manner
described above, while from the lightest areas the loudest and clear-
est sound may be elicited.
128
PHYSICAL DIAGNOSIS.
Upivr lolK*.
--- Lower lobe.
,- Splenic- urea.
(n) The sound elieited in the Latter areas is known as normal oi
" vesiciilor" resonance, and is due to the presence of a norma)
amount of air in the vesicles of the lung underneath. If tliis air-
coutaiuiug luiiy is replaced by a fluid or solid juedium, as in ])len-
ritic effusion or pueumoiiia, it is much more ditticult to elicit a
sound, and such sound as is produced is
short, high ])itched, antl has a feeble carry-
ing power when compared with the s(_>und
elicited from the normal lung. This
short, feeble, high-pitched sound is
known technically as a "dull" or
"flit " sound, flatness designating
the extreme of the qualities that
characterize dulness. Over the
parts shaded dark in Fig. Sl> we
normally get a dull or flat tone, the darkest
portions being flat and the others dull.
The heavy shadow ou the light corresponds
to the position occupied by the liver, or
rather by that jiart of it Avhich is in imme-
diate contact with the chest wall. The up-
per portion of the liver is overlapped by the
right lung (see Fig. 81), and hence at this
point we get a certain anrount of resonance
on percussion, although the tone is not so
clear as that to be obtained higher up. Be-
low the si.xth rib we find true, //f/^«c,s-.s- near
the sternum and for a few inches to the right
of this pohit. As we go toward the axilla,
the line of lung resonance slopes down, as is seen in Fig. 82. Il'
the back resonance extends to the ninth or ti'uth ribs.
Fig. ;3.— Position oftlie Left
Lung iQ tlie A.xilla.
NoniKil jyiill ^trraa.
(h) (^u the left side, the main dull area corrcspimds to the heart,
which at tliis ]ioint ai)proaches the chest wall, and over the por-
tion shaded darkest is uncovered by the lung. The part here
PERCUSSION. 12U
lightly shaded corresj^onds to that portion of the heart which is
overlapped by the margin of the right and left lungs.
Over the portion of the heart not overlapped by the lung (see
Fig. 81, p. 127) the percussion note is nearly flat to light percus-
sion, and very dull even when strongly percussed. This little
quadrangular area is known as the " s^iperficial cardiac sjmce," and
the dulness corresponding to it is referred to as the " siqjerjiciul"
cardiac duhiess, while the dulness corresponding to the outlmes of
the heart itself beneath the overlapping lung margins is called the
" deep " cardiac dulness.
When the heart becomes enlarged, both of these areas, the deep
and the superficial, are enlarged, the former correspondmg to the
increased size of the heart itself, while the superficial cardiac space
is extended because the margins of the lungs are pushed aside and
a larger piece of the heart wall comes in contact with the chest
wall. Accordingly, either the superficial or the deep duhiess may
be mapped out as a means of estimating the size of the heart.
Each method has its advantages and its advocates. The superficial
dulness is easier to map out, but varies not only with the size of the
heart, but with the degree to which the lungs are distended with
air, or adherent to the pericardium or chest wall. What we are
percussing is in fact the borders of the lungs at this point.
On the other hand, the deep cardiac dulness is much more satis-
factory as a means of estimating the size of the heart but much
more difficult to map out. It needs a trained ear and long practice
to percuss out correctly the borders of the heart itself, especially
the right and the upper borders, since here we have to percuss
over the sternum where differences of resonance are very deceptive
and difficult to perceive.
It is a disputed point whether light or forcible percussion should
be used when we attempt to map out the deej) cardiac dulness.
Heavy percussion is believed by its advocates to penetrate through
the overlapping lung margins and bring out the note corresponding
to the heart beneath, a note which, they say, is missed altogether
by light percussion. On the other hand, those who employ light
percussion contend that heavy percussion sets in vibration so large
9
130 PHYSICAL DIAGNOSIS.
an area of lung su})ei-fieially tliat fine distinctions of note are made
impossible (see above, p. 123j.
Good ol)ser\'er,s are to be found on eaeh side of tins question,
and I have no doubt that either metlxjil Avorlvs well in skilled
hands. Personally I have found light percussion preferable.
AVhatever method we use we must percuss successive points
along a line running at right angles to the border of the organ
which we wish to outline luitil a change of note is perceived.
Thus, if we wish to p)ercuss out the upjier border of the liver, ^vn
strike successive points along a line running parallel to the ster-
num and about an inch to the right of it.' When a change of note
is perceived, the point should be marked with a skin pencil; then
we percuss along a line parallel to the first one, and peihaps an
in('h farther out, and again mark with a dot the point at which the
note first changes. A line connecting the i^oints so marked n])on
the skin represents the border of the organ to be outlined.
If now we look at the upper part of the chest in Fig. 81, we
notice at once that the two sides are not shaded alike : the left apex
is distinctly lighter colored than tlie right. This is a veiy impor-
tant point and one not sufficiently apj^reciated by students. The
apex of the normal right lung is distinctly less resonant than the
apex of the left in a corresponding position.
In percussing at the bottonr of tlie left axilla, we come upon a
small oval area of dulness corresponding to that outlined in Fig. 82.
This is the area of sjitcn'ic (hi/ncss, so called, and corres})onds to
that portion of the spleen which is in contact with tlie chest wall.
This dull area is to be made out oidy in ease the stomach and cnbiu
are not overdistended with air. Wlu'n these organs are full of gas
as is not infrequently the case, there is no area of splenic dulness
and the whole region gives forth, wdien percussed, a in)te of a qiial
ity next to be described, namely, " ti/inpaiiitk."
(c) Tympanitic resonance is that obtained over a hollow body,
like the stonrach when moderately distended with air.' It is usu-
' Or we may reverse the procedure; percuss first over the liver and then
work toward ihe lung above until the note becomes more resonant.
'•Extreme distention licre, as in a snare drum, is associated with a dull
percussion nolc (see below, p. '■Vol).
PERCUSSION. 131
ally of a higher pitch than the resonance to he oljtained over the
normal lung, and may be elicited by percussion lighter than that
needed to bring out the lung resonance. It differs also from the
vesicular or pulmonary resonance in quality, in away easy to appre-
ciate but difficult to describe. Tympanitic resonance is usually to
be heard when one percusses over the front of the left chest near
the ensiform cartilage and for a few inches to the left of this point
over an area corresponding with that of the stomach more or less
distended with air. This tympanitic area, known as "Tnothe^s
son il Hilar space," varies a great deal in size according to the contents
of the stomach. It is bounded on the right by the liver flatness,
above by the pulmonary resonance, on the left by the splenic dul-
ness, and below by the resonance of the intestine, which is also
tympanitic, although its pitch is different owing to the different
size and shape of the intestine.
(The right axilla shows normal lung resonance down to the
point at which the liver flatness begins, as shown in Fig. 81.)
In the back, when the scapulae are drawn forward, as shown in
Fig. 78, page 121, percussion elicits a clear vesicular resonance from
top to bottom on each side, although the top of the right lung is al-
ways slightly less resonant than the top of the left, and sometimes the
bottom of the right lung is slightlj^ less resonant than the corre-
sponding portion of the left, on account of the presence of the liver
on the right.
It should be remembered, however, that in the majority of cases
the resonance throughout the back is distinctly less than that ob-
tained over the front, on account of the greater thickness of the
back muscles. Yet in children or emaciated persons, or where the
muscular development is slight, there may be as much resonance
behind as in front.
Imj}orta)ici> of Peirusshir/ Si/)n»ietrical Foiiits. — Since we depend
for our standard of resonance upon comparison with a similar spot
on the outside of the chest, it is all-important that in making such
comparisons we should percuss sjinmetrical points, and not, for
example, compai-e the resonance o^'er the third rib in the right front
with that over the third interspace on the left, since more resonance
can always be elicited over an interspace than over a rib. This
132 PHYSICAL DIAONOSIS.
comparison of symmetrical points, however, is interfered with hy
the presence of the heart on one side and the liver on the other, as
well as hy the fact that the apex of the right lung is normally less
resonant than that of the left. A resonance which would he patho-
logically feeble if obtained over the left top may be normal over the
right. Where both sides are abnormal, as in bilateral disease of
the lung, or where fluid accumulates in both pleural cavities, we
have to make the best comparison we can between the sound in the
given case and an ideal standard carried in the mind.
It must always be remembered that the amount of resonance
obtained at any point by percussion depends upon how hard one
strikes, as well as upon the conditions obtaining within the chest.
A powerful blow over a diseased lung may bring out more reso-
nance than a lighter blow over a normal lung. To strike with per-
fect fairness and with equal force upon each side can be learned only
by considerable practice. Furthermore, the distance from the ear
to each of the two points, the resonance of which we are compar-
ing, must be the same — that is, we must stand squarely in front or
squarely behind the patient, otherwise the note coming from the
part farther from the ear will sound duller than that coming from
the nearer side.
The normal resonance of the different parts of the chest can be
considerably modified by the position of the patient, by deep breath-
ing, by muscular exenion, and by other less important conditions.
If, for example, the patient lies upon the left side, the heart swings
out toward the left axilla and its dulness is extended in the same
direction. Deej) inspiration pushes forward the margins of the
lungs so that they encroach upon and reduce the area of the heart
dulness and liver dulness After muscular exertion the lungs be-
come more than ordinarily voluminous, owing to the temporary dis-
tention brought about by the unusual amount of work thrown upon
them.
The area of cardiac dulness is increased in any condition involv-
ing insufficient lung expansion. Thus, in children, in debility,
chlorosis, or fevers, the space occupied by the lungs is relatively
small and the dull areas corresponding to the heart and liver are
PERCUSSION. 133
proportionately enlarged. In old age, on the other hand, when the
lungs have lost part of their elasticity and sag down over the heart
and liver, the j)ercussion dulness of these organs is reduced.
Conditions Modifying the Percussion Note in Health. — The de-
velopment of muscle or fat as well as the thickness of the chest
wall will influence greatly the amount of resonance to be obtained
by percussion. Indeed, we see now and then an individual in no
part of whose chest can any clear jiercussion tone be elicited. In
women, the amount of development of the breasts has also great
influence upon the percussion note In children, the note is gener-
ally clearer, and only the lightest percussion is to be used on ac-
count of the thinness of the chest wall. In old people whose lungs
are almost always more or less,emj)hysematous, a shade of tym-
panitic quality is added to the normal vesicular resonance. The
distention of the colon with gas may ol:)literate the liver dubiess by
rotating that organ so that only its edge is in contact with the chest
wall, and if there is wind in the stomach, a variable amount of
tympany is heard on percussing the lower left front and axilla or
even in the left back.
If a patient is examined while lying on the side the amount of
resonance over the lung corresponding to the side on which he
lies is usually less than that of the side which is uppermost, because
there is more air in the latter.' Whatever the patient's position,
the amount of resonance is also greater at the end of inspiration
than at the end of expiration, for the reason just given. As the
lungs expand with full inspiration, their borders move so as to
cover a larger portion of the organs which they normally overlap.
Portions of the chest which at the end of expiration are dull or
fiat, owing to the close ju.xtaposition of the heart, liver, or spleen,
become resonant at the end of inspiration For example, the lower
margin of the right lung moves down during inspiration so as to
cover a considerably larger portion of the liver
Percussion as a Means of Ascertaining tlie Movahility of the L-ung
Borders. — It is often of great importance to determine not merely
' There is also a shade of tj'inpaiij' associated with the duhiess of tiie
feebly expanded luug i>f the lower side.
134 PHYSICAL DIAGXOSIS.
the position of tlie resting lung but its power to expand freely.
This can be ascertained b}^ percnssion in the following way : The
lower border of the lung resonance, say in the axilla, is carefully
marked out. Then percussion is made over a point just /ir/mr the
level of the resting lung and at the same time the patient is directed
to inspire deeply If the lung expands and its border moves down,
the percussion note will change suddenly from dull to resonant
during the inspiration. An excursion of two or three inches can
often be demonstrated by this method, which is especially impor-
tant for the anterior and posterior margins of the lung. In the
axilla Litten's phrenic shadow will give us the same information.
The mobility of the borders of the lung, as determined by this
method, is of considerable clinical im])ortance, for an absence of
such mobility may indicate pleuritic adhesions. Its amount de-
pends upon various conditions and varies much in different indi-
viduals, but complete absence of mobility is always pathological.
((Z) Cracked-Pot Besonance
"Wlien percussing the chest of a crying child, w^e sometimes
notice that the sound elicited has a pecirliar " cliiiikinr/" qualitj-,
like that produced by striking one coin with another, but more
muffled. The sound may be more closely imitated, and the mode
of its production illustrated, by clasping the hands palm to palni
so as to enclose an air space wliicli communicates with the outer air
through a chink left open, and then striking the back of the inider
hand against the knee By the blow, air is forced out through the
chink with a sound like that of metallic coins struck together.
In disease, the cracked-pot sound is usnally produced over a
I>ulmonary cavity (as in advanced phthisis) from which the air is
suddenly and forcibly expelled by the percussion stroke.
It is much easier to hear this peculiar sound if, while percuss-
ing, one listens with a stethoscope at the patient's open mouth.
The patient himself holds the chest ]uece of the instrument just in
front of his open mouth, leaving the auscultator's hands free for
percussing.
PERCUSSION. 135
(e) Amj^lioric Besonnnce.
A low-pitched hollow sound approximating in quality to tym-
panitic, resonance, and sometimes obtained over pulmonary cavities
or over pneumothorax, has received the name of amphoric reso-
nance It may l)e imitated l)y jjercussing the trachea or the cheek
when moderately distended with air.
Suiumarij
The varieties of resonance to be obtained by percussing the nor-
mal tliorax are :
(1) Vesicular resonance, to be obtained over normal lung tissue.
(2) T ijmpanitic resonance, to be obtained in Traube's semilunar
space
(3) DhiiinisJied resonance or diilncss, such as is present over the
scapulffi, and
(4) Absence of resonance or flatness, such as is discovered when
we jiercuss over the lowest ribs in the right front
(5) Crached-pot resonance, scanetinies obtainable over the chest
of a crying child.
(6) Amphoric resonance, obtainable over the trachea.
Any of these sounds may denote disease if obtained in jDortions
of the chest where they are not normally found. EacJi lias its
pjlace, and heco m es pathologiccd iffonnd elsewliere Tympanitic reso-
nance is normal at tlie bottom of the left front and axilla, but not
elseivhere. Dulness or flatness is normal over the areas corre-
sponding to the heart, liver, and spleen, and over the scapulas, but
not elsewhere unless the muscular covering of the chest is enor-
mously thidv. Vesicular resonance is normal over the areas corre-
sponding to the lungs, but becomes evidence of disease if found
over the cardiac or hepatic areas.
Cracked-pot resonance may be normal if produced while per-
cussing the chest of a child, but under all other conditions, so far
as is known, denotes disease.
Amphoric resonance always ineans disease, usually pulmonary
cavity or pneumothorax, if found elsewhere than over the trachea.
136 PHYSICAL DIAG^'0S1S.
(/) TIiP Lung Reflex.
It must also be remembered, when percussing, that in some cases
every forcible percussion blow increases the resonance to be ob-
tained by subsequent blows. Any one who has demonstrated an
area of percussion dulness to many students in succession must
have noticed occasionally that the more we percuss the dull area,
the more resonant it becomes, so that to those who last listen to
the demonstration the difference which we wish to bring out is much
less obvious than to those who heard the earliest percussion strokes.
Abrams has referred to this fact under the name of the "lung re-
flex," believing, partly on the evidence of fluoroscopic examination,
that if an irritant such as cold or mustard is applied to any part of
the skin covering the thorax, the lung expands so that a localized
temporary emphysema is produced in response to the irritation.
Apparently percussion has a similar effect.
III. Seistse of Eesistance.
While percussing the chest we must be on the lookout not only
for changes in resonance, but for variations in the amount of resist-
ance felt underneath the finger. Normally the elasticity of the
chest walls over the upper fronts is considerably greater and the
sense of resistance considerably less than that felt over the liver.
In the axillae and over those portions of the back not covered by
the scapulae, we feel m normal chests an elastic resistance when
percussing which is in contrast with the dead, woodeny feeling
which is communicated to the finger when the air-containing lung
is replaced by fluid or solid contents (pleuritic effusion, pneu-
monia, phthisis, etc.). In some lAysicians this sense of resistance
is very highly developed and as much information is obtained
thereby as through the sounds elicited. As a rule, however, it is
only by long practice that the sense of resistance is cultivated to a
point where it becomes of distuict use in diagnosis.
CHAPTER VII.
AUSCULTATION
Auscultation may be practised by placing one's ear directly
against the patient's chest (immediate auscnltation) or with the
help of a stethoscope (mediate auscultation).
Each method has its place. Immediate aiiscultation is said to
have advantages similar to those of the low power of the micro-
scope, in that it gives us a general idea of the condition of a rela-
tively large area of tissue, while the stethoscope may be used, like
the oil immersion lens, to bring out details at one or another point.
On the other hand, I am firmly convinced that the unaided ear
can perceive sounds conducted from the interior of the lung — sounds
quite inaudible with any stethoscope — and that in tlris way the
faint tubular breathing produced by deep-seated areas of solidified
lung may be recognized.
Immediate auscultation may be objected to
(a) On grounds of delicacy (when examining persons of the
opposite sex).
{I) On grounds of cleanliness (although the chest may be cov-
ered with a towel so as to protect the auscultator to a certain
extent).
(c) Because we cannot conveniently reach the supraclavicular
or the upper axillary regions in this way.
{d) Because it is difficult to localize the different valvular areas
and the sites of cardiac murmurs if immediate auscultation is em-
ployed.
On account of the latter objection the great majority of observ-
ers now use the stethoscope to examine the heart. For the lungs,
both methods are employed by most experienced auscultators.
I have already mentioned t]ie importance of immediate auscul-
tation in the search for deep-seated areas of pneumonia. Atten-
138 PHTSIfAL PTAGNOSIS.
tinu has also liet'ii^ealU'd liy Conner (Assoc, of AnuM-ican Physifians,
1907, 11. Ho) to the fact that the diastolic luurnuiv of aoitic insuf-
ficiency is sometimes audil)le to the unaided ear when it cannot he
heard witli any form of stetlioscope. Faint, high-pitclu^d lilowing
sounds are tliose which the free ear is especially adapted to delect.
This is doulitless due, as Conner e.\i)lains, to the fact that tlie
tulics of the stethoscope do not conduct high-pitched sounds well.
Willi tlie free ear we have also the oppcu'tunity to detect the hone-
coiiducted sounds w-hich are missed in mediate stethoscopic auscul-
tation,
jNTedtate Auscultation.
1. Sc/cction (if (I Strtliosiuijie.
(1) It is as rash for any one to select a stethosco}ie without first
trying the fit of the car pieces in his ears as it would be to buy a
new hat without trying it on. What suits iV. very well is quite im-
possible for 1). It is true that one can get used to almost any
stethoscope as one can to almost any hat, but it is not necessary to
do so. The ear pieces of the ordiimry stethoscojie are often too
small and rarely too large. In case of doubt, therefore, it is better
to err upon the side of gettiirg a stethoscope with too large rather
than too small ends.
(2) The binaural stethoscope, which is now almost exclusively
used in this country, nurintaius its position in the ears of the aus-
eultator cither through the pressure of a rubber strap stretched
around the metal tubes leading to the ears, ^n^ by nu^uis of a steel
sju'ing connecting the tubes. Either variety is usually satisfactory,
but I prefer a stethoscope made with a steel spring (see Fig. 80)
because such a spring is far less likely to break or lose its elasticity
than a rublicr strap. A rubber strap can always be added if this
is desirable. It is important to luck out an instrunu'ut possessing
a spring not strong enough to cause pain in the external nu^atus of
the ear ami yet strong enough to hold the ear pieces tirnily in jdace.
Persons with narrow heads need a much mm-e powerful S])ring or
strap tliau would be convenient for persons with wide heads.
AUSCULTATION.
139
(3) The rubber tubing used to join the metallic tubes to the
chest piece of the instrument should be as Hexible as possible (see
Fig. 83). Stiff tubing (see
Fig. 84) makes it necessary
for the auscultator to move
his head and body from
place to place as the exam-
ination of the chest pro-
gresses, while if flexible
tubing is used the head need
seldom be moved and a great
deal of time and fatigue is
thus saved. Stiff stetho-
scopes are especially incon-
venient when examiuuig the
axilla.
(4) Jointed stethoscopes
which fold up or take apart
should be scrupulously
avoided. They are a delu-
sion and a snare, apt to
come ajiart at critical mo-
ments, and to snap and creak
at the joints when in use,
sometimes producing in this way sounds which
may be easily mistaken for rales. Such an in-
strument is no more portable nor compact than
the ordinary form with flexible tubes. It has,
therefore, no advantages over stethoscoi:(es made
in one piece and possesses disadvantages which
are peculiarly annoying.
(5) Tlie Chest Piece.— The majority of the
stethoscopes now in use have a chest piece of
hard-rubber or wood with a diameter of about seven-eighths of an
inch. Chest pieces of larger diameter than this are to be avoided
as they are veiy difficult to maintain in close apposition with thin
Fia. 8i. — C a m m a n
Stethoscope With Stiff
Tubing and Eubber
Strap.
Fig. si — Stethoscope
Fitted With Long
Flexible Tubes, Espe-
cially Useful When
Examining Children.
140
PHYSICAL DIAGNOSIS.
chests. To avoid this difficulty tlie eliest piece is sometimes made
of soft-i'ubber or its diameter still further reduced.
(6) Tlte Bowles Stet/wsmpe.—i^ee Figs. 85 and 86). Within
recent years there has been introduced an instrument which, for
many purposes, seems to me far superior to any other form of stetho-
scope with which I am acquainted. Its pe-
culiarity is the chest piece,
which consists of a very shal-
low steel cup (see Fig. 87)
I over the mouth of which a
thin metal plate or a bit
of pigskin is fastened. The
metal or pigskin diaphragm
serves simply to prevent the
tissues of the chest from pro-
jecting into the shallow cup
of the chest piece wdien the
latter is pressed against the
chest, and does not in any
other way contribute to the
sounds which we hear with
the instrument. This is
proved by the fact that we
can hear as well even when
the diaphragm is cracked
across in several directions.
With this instrument al-
most all sounds produced
within the chest can be heard
t',u. 85.-Bowies' stetho."™ch more distinctly than hi
scope. Front view, any other variety of stetho-
scope. Cardiac murmurs
which are inaudible with any other stetho-
scope may be distinctly heard with this. Espe-
cially is this true of low-pitched murmurs
due to aortic regurgitation. Yet it is useful for examination
not merely of the heart, but of the lungs as well. For any one
Fig. 86.— Combination
Bowles' Stetboscope.
AUSCULTATION.
141
who has difhculty in hearing the ordinary cardiac or respiratory
sounds, or for one who is partiallj^ deaf, tlie instrument is invalu-
able. As the metal rim of the chest is apt to get unpleasantly
cold, it is best to cover it with a bit of rubber or kid. This saves
the patient some discomfort and also tends to prevent the instru-
ment from slipping on the skin. The flat chest piece makes the
instuinient very useful in listening to the posterior portions of tlie
lungs in cases of pneumonia in which the patient is too sick to be
turned over or to sit up. Without moving the patient at all we can
Fifi. 87.- Chest Piece of Buwles' Stetboscope. On the right the shallow cup coirimiinirating
with the ear tubes. On the left the diaphragm which covers the cup, and the ring which
holds it in place.
work the chest piece in under the back of the patient by pressing
down the bed-clothes, and in this way can listen to any part of
the chest without moving the patient. A further advantage of
the instrument is that it enables us to gain an approximately ac-
curate idea of the heart sounds without undressing the patient, Ee-
spiratory sounds cannot well be listened to through the clothes,
as the rubbing of the latter may simulate rales.
There are two purposes for which I have found the Bowles
stethoscope inferior to the ordinary stethoscope :
(1) For listening over the apex of the lung for fine rales, e.g., in
incipient phthisis.
(2) For listening for superficial sounds, such as a friction rub or
142
PHYSICAL DIAGNOSIS.
a presystolic murmur.' "When I desire to listen for fine rales at
an apex, for a friction rub, or for a presystolic murmur, 1 separate
the chest piece of the Bowles stethoscope from the hard-rubber
bell into which it is inserted, therebjr converting the instrument
into one of the ordinary form. With an extra hard-rubber bell
attached, the instrument is
uo moi'C bulky than an
ordinary stetlioscope, and
far more efficient. When
used for listening to the
respiration, tire Bowles in-
strument gives us informa-
tion similar in some re-
spects to that obtained by
the use of the free ear —
that is, we are througli it
enabled to ascertain by lis-
tening at one sjiot the con-
dition of a much larger
area of the chest than can
in any other way be inves-
tigated.
Owing to the fact that
both cardiac and respiratory
soiuids are magnified by the
Bowles stetlioscope, this
instrument is especially well
adapted for use with some
sort of an attachment whereby several sets of ear pieces are so
joined by tuliiiig to one chest piece that several persons may listen
at once. Bowles' multiple stethoscope, fitted for six and for twelve
observers, is seen in Figs. 88 and 89, and the method of its use in
' It has frequently been observed, when listening with the ordinary stetho-
scope, that a presystolic murmur can be better heard if only the very lightest
pressure is made with the stethoscope. The fact that a thrill is communicated
to the chest wall, and tli.at that thrill is connected with the audible murmur
explains my calling this murmur a superficial one.
88. - Bowles' Multiple Stethoscoije fur Six Stu-
dents.
AUSCULTATION.
143
Fig. 90. In the teaching of auscultation this instnimeut is of great
vahie, saving as it does tlie time of the instructor and of the stu-
dents and the strength of the patient. Tlie sounds conducted
through any one of the twelve tubes used in this iustrumeat are
as loud as those to
be heard with a
single instrument of
the ordinary form,
although far fainter
than those to be
heard with a single
Bowles stethoscope.
II. The Use of the
Stethoscope,.
Having secured
an instrument
which lits the ears
satisfactorily, the
beginner may get a
good deal of prac-
tice by using it up-
on himself, especi-
ally upon his own
heart. The chief
Fig. 89.— Bowles' Multiple Stethoscope Tor Twelve Stud^ts.
point to he learned is to disregard vnrioKs irrcJi'i'unt sounds and to
concentrate attention upon those which are relevant. Almost any
one hears enough with a stethoscope, and most beginners hear too
much. No great keenness of hearing is required, for the sounds
which we listen for are not, as a rule, difficult to hear if attention
is concentrated upon them.
A. Selective Attention and What to Disregard.
Accordingly, the art of using a stethoscope successfully depends
upon the acquisition of two powers —
(«) A knowledge of what to disregard.
(i) A selective atten-
144
PHYSICAL DIAGXOSIS.
tion or concentration upon those sounds wliich we know to be of
impoi'tance.
Among the sounds which we must learn ti^ disregard are the
following :
(1) Noises ])roduced in the room or its immediate neiglilwrhood,
but not connected with the jiatient himself. It is, of course, easier
■
iy^jlP^ '*'^/
r 1
5- -"'^^
1' t '
' ^
|H
m
^^^^^^gSSBsU
Hi
1
Fni. 90.— Buvvk-s' Multiple Stethoscope iu Use. Twelve stadeuts llsteumg at ouee
to listen in a perfectly quiet room where there are no external
noises which need to be excluded from attention, but as the greater
part of the student's work must be done in more or less noisy
places, it is for the beginner a practial necessity to learn to with-
draw his attention from the various sounds Avhich reach his ear
from the street, from other parts of the building, or from the room
AUSCULTATION. 145
ill which he is working. This is at first no easy matter, but can
be accomplished witli practice.
(2) When tlie power to disregard external noises has been ac-
quired, a still further selection must be made among the sounds
which come to the ear througli the tubes of the stethoscoj^e. Noises
produced by friction of the chest piece of the stethoscope upon the
skin are especially deceptive and may closely simulate a pleural or
pericardial friction sound. It is well for the student to experiment
upon the nature and extent of such " skin rubs " by deliberately
moving the chest piece of the stethoscope upon the skin and listen-
ing to the sounds so produced. Mistakes can be avoided in the
majority of cases by holding the chest ijieee of the stethoscope very
firmly against the chest. This can be easily done when the patient
is in the recumbent position, but when the patient is sitting up it
may be necessary to press so hard with the chest piece of the
stethoscope as to throw the patient off his balance unless he is m
some way supported; accordingly, it is my practice in many cases
to put the left arm around and behind the patient so as to form a
support, against which he can lean when the chest piece of the
stethoscope is pressed strongly against his chest. When listening
to the back of the chest, the manoeuvre is reversed. If the skm
is very dry, the ribs are very prominent, or the chest is thickly
covered with hair, it may be impossible to prevent the occur-
rence of adventitious sounds due to friction of the chest piece
upon the chest, no matter how firmly the instrument is held. In
case of doubt, and in any case in which a diagnosis of pleural or
pericardial friction is in question, the surface of the chest, at the
point where we desire to listen, should be moistened and any hair
that may be present thoroughly wetted with a sponge, so that it
will lie flat upon the chest. Otherwise the friction of the hair
under the chest piece of the stethoscope may simulate crepitant
rales as closely as " sldn rubs " simulate pleural friction.
(3) The friction of the fingers oi the auscultator upon the chest
piece or on some other part of tlie stethoscope frequently gives rise
to sounds closely resembling rales of one or another description.
The nature of these sounds can be easily learned by intentionally
moving the fingers upon the stethoscope. They are to be avoiled
10
146 PHYSICAL DIAONQSIS.
by wetting the fingers, grasjjing tlie bell firinly, and by toucliing it
with as few fingers as will suffice to lioUl it close against the chest.
(4) Noises produced by a shifting of the parts of the stetho-
scope upon each other are especially frequent in stethoscopes made
in several pieces and jointed together. A variety of snap]:)ing and
cracking sounds, not at all unlike certain varieties of rales, may
thus be produced, and if we are irot upon our guard, may lead to
errors iir diagnosis. Stethoscopes which have no hinges and which
do not come apart are far less likely to trouble us in this way.
(6) Wlieir a rubber band is used to 2>i'ess the ear jjieces more
firmly into the ears, a A'ery ])eculiar sound may be produced by the
breathing of the auscultator as it strikes ujion tlie rubber straj). It
is a loud musical note, aiul may be confused with coarse, dry rales.
When one has learned to recognize and to disregard the noises
produced in the ways above indicated, there is still one set of
sounds which are very frequently heard, yet which have no signifi-
cance for physical diagnosis, and must therefore be disregarded; I
refer to
B. Muscle Soinids.
Patients who hold themselves very erect while being exam-
ined, or who for any reason contract the muscles of that ptu'tion of
the chest over which we are listening, produce in these muscles a
very peculiar and characteristic set of soimds. The contraction of
any muscle in the body i)roduces sounds similar in quality to those
heard over the chest, but of less intensity.
Those who have the faculty of contracting the tensor tympaiii
muscle at will can at any time listen to a typical muscle sound.
Or close both ears with the fingers and strongly contract the mas-
seter muscle, with the teetli clenched. A high-pitched muscle
sound will be heard.
It is well also to have a patient contract one of the pectorals
and then listen to the sound thus produced. In some cases a con-
tinuous, low-pitched roar or drumming is all that we hear ; in other
cases we Iiear nothing but the breath sounds during expiration,
while during inspiration tlie breath sound is obscured by a series of
AUSCULTATION. 147
short, dull, rumbling sounds, following each other at the rate of
from five to ten in a second. Occasionally the sound is like the
puffing of the engine attached to a pile-driver, or like a stream of
water falling upon a sheet of metal just slowly enough to be sepa-
rated into drof)S and heard at a consideralile distance. As already
mentioned, we are especially apt to hear these muscle sounds dur-
ing forced inspiration, owing to the contraction of voluntary mus-
cles during that portion of the respiratory act. They are most
often heard over the upper jjortion of the chest (over the pectorals
in front and over the trapeziiTS behind), but in some persons no
part of the chest is free from them. It is a curious fact that we
are not always able to detect by sight or touch the muscular con-
tractions which give rise to these sounds, and the patient himself
may be wholly unaware of them. Under such circumstances they
are not infrequently mistaken for rales, and I am inclined to think
that many of the sounds recorded as "crumpling," "obscure,"
"muffled," "distant," or "indeterminate" rales are in reality due
to muscular contractions. The adjectives "muffled " and " distant "
give us an inkling as to the qualities which distinguish muscular
sounds from rales. Rales are more clean cut, have a more distinct
beginning and end, seem nearer to the ear, and possess more of a
cracklmg or bubbling quality than muscle sounds.
I have made no attempt exhaustively to describe all the sounds
due to muscular contractions and conducted to the ear by the steth-
oscope, but have intended simply to call attention to the importance
of studying them carefully.
C. Other Sources of Error.
Another source of confusion , which for beginners is very trouble-
some, especially if they are using the ordinary form of stethoscope
with a bell-shaped chest piece, arises in case the chest piece is not
held perfectly in apposition with the skin. If, for example, the
stethoscope is slightly tilted to one side so that the bell is lifted
from the skin at some point, or if one endeavors to listen over a
very uneven part of the chest on which the bell of the stethoscope
cannot be made to rest closely, a roar of external noises reaches the
148
PHYSICAL DIAGNOSIS.
ear tlivougli the chink left between tlie chest piece and the chest
After a little jiractice one learns instantly to detect this condition
of things and so to shift the position of the chest piece that exter-
nal noises are totally- excluded ; hat by the beginner, the peculiar
babel of external noises which is heard whenever the stetlioseo])e
fails to ht closely agauist tlie chest is not easily recognized, and
hence he tends to attribute some of these external sounds to diseased
conditions within the chest.
Again, it is not until we have had considerable practice tliut
Fig. 91.— stethoscope Held RiRht Side Ui
Fig. 02.— Stethosoope Held Wrong Side I p
our sense of hearing comes instantly to tell us when something is
wrong about the stethoscope itself ; when, for example, one of the
tubes is blocked, kinked, or disconnected, or when we are hold-
ing the stethoscope upside down, so that the ear pieces point
downward instead of upward (see Figs. 91 and 92). It is only
when we have learned through long })ractice about how much we
ought to hear at a given point in tlie normal chest that we recognize
at once the fact that wo are not hearing «*■ much (ts ive should, in
case some one of the above accidents has ha])pened. Many begin-
ners do not listen long enough in any one place, but move the chest
piece of the stethoscope about rapidly from ])oint to point, as they
have seen experienced auscultators do ; l)ut it is remarkable how
much more one can hear at a given point by sinqily persevering and
AUSCULTATION. 149
listening to beat after beat, or breath after breath. It is sometimes
ditheult to avoid tlie impression that the sounds tliemselves liave
grown louder as we eontiuue to listen, especially if we are in any
doubt as to what we hear. Therefore, if we hear indistinctly, it is
important to keej) on listening, and to fix the attention successively
upon each of the different elements in the sounds under consideration.
In difficult cases we should use every possible aid toward concen-
tration of the attention, and where it is possible, all sources of dis-
traction should be eliminated. Thus, in any case of doubt, I think
it is important for the auscultator to get himself into as comfort-
able a position as he can, so that his attention is not distracted by
Ills own physical discomforts. Many auscultators shut their eyes
when listening in a difficult case so as to avoid the distraction of
impressions commg through the sense of sight. It goes without
saying that if quiet can be secured in the room where we are work-
ing, and outside it as well, we shall be enabled to listen much more
profitably.
AUSCULTATIOlSr OF THE LUNGS.
In the majority of cases ordinary quiet breathing is not forcible
enough to bring out the sounds on which we depend for the diag-
rrosis of the condition of the lungs. Deep or forced breathing is
what we need.
A>s a rule, the patient must be taught how to breathe deejily,
which is best accomplished by i^ersonally demonstratmg the act of
deep breathing and then asking him to do the same. Two difficul-
ties are encoimtered :
(a) The patient may blow out his breath forcibly and with a
noise, since that is what he is used to doing whenever he takes a
long breath under ordinary ci'cumstances; or
(5) It may be that he cannot be made to take a deep breath at
all. The first of these mistakes alters the sounds to be heard with
the stethoscope in any part of the chest by disturbing both the
rhythm and the pitch of the respirat(jry sounds In this way the
breathing may be made to sound tubular or asthmatic throughout a
sound chest. This difficulty can sometimes be overcome by demon-
strating to the patient that what you desire is to have him take a
150
PHYSICAL DIAGNOSIS.
full breath and tlien simply let if ffi\ but not blow it forciblj' out.
In some cases tlie patient cannot be taught this, and we have to get
on the best we can despite his mistakes. ^ATien he cannot be made
to take a full breath at all, we can often accomplish the desired re-
sult by getting him to cough. The breath just before and after a
cough is often of the type we desii'e. The use of voluntary cough
in order to bring out rales will be discussed later on. Another use-
ful ulanoeu^Te is to make the patient count aloud as long as he can
with a single breath. The deep inspiration which he is forced to
take after this task is of the type which we desire.
I. Eespieatoky Types.
In the normal chest two types of breathing are to be heard:
(1) Tracheal, bronchial, or tubular breathing.
(2) A^esieular breathing.
TracJieal, ln'onc/iioJ, or fuhuhir hreiitliimj is to be heard in normal
cases if the stethoscope is pressed agauist the trachea, and as a rule
Fig. 93.— Situation of the Trachea and Primary Bronchi.
it can also be heard over the situation of the jirimary bronchi, in
front or behind (see Figs. 93 and 94).
I Vesicular hreatlting is to be heard over the remaining portions of
AUSCULTATION. 151
the lung — that is, iu the front of the thorax except where the lieart
and the liver come against the chest wall, in the back except where
the presence of the scapuhe obscures it, and throughout both axillte.
(1) Characteristics of Vesicular BrcutJbing.
Vesicular breathing — that heard over the air vesicles or paren-
chyma of the lung— has certain cliaracteristics wdiich I shall try to
describe in terms of intensity, duration, and jiitch.
Fig. 94.— Situation of tlie Trachea and Primary Bronchi.
Of the qualitij of the sounds heard over this portion of the lung
there is little can be said ; it sounds something like the swish of the
wind in a grove of trees some distance off, and hence is sometimes
spoken of as "breezy."
The hitensity, duration, and pitch of the inspiration as compared
with tliat of the expiration may he represented as in Fig. 95. In
tliis figure, as in all those to be used in description of respiratory
sounds —
(1) I represent the inspiration by an upi-stroke and the expira-
tion by a down-stroke (see the direction of the arro^vs iu Fig G.'J).
(2) The leiKjtU of the up-stroke as compared with that of the
down-stroke corresponds to the length of inspiration compared with
expiration.
152
PHYSICAL DIAGNOSIS.
(3) The ihicl-ness of the np-stroke as compared with the down-
stroke represents the intciisiti/ of the inspiration as compared with
the expiration.
(4) Tlie j)itch of inspiration as compared with that of expi-
ation is represented by the sharjyness of the angle which the up-
FiG. 95.— Vesicular Breatt-
ing.
Fig.
96.— Distant Yesicular
Brea tiling.
Fig. 97.— Exaggerated Ve-
sicular Breathing.
stroke makes with the perpendicular as compared with that which
the down-stroke makes with the perpendicular. The piicJi of a
/■oof may be thought of in this connection to remind us of the mean-
ing of these sj'mbols.
If now we look again at Fig. 95 we see that when compared
with expiration (the down-stroke), the inspiration is —
(ff) More intense.
(J) Longer.
(c) Higher pitched.
Our comparison is invariably made between inspiration and ex-
piration, and not with any other sound as a standard.
Now, this tyi^e of breathuig (which, as I have said, is to be
heard over every portion of the lung except those portions imme-
diately adjacent to the primary bronchi), is not heard everywhere
with equal intensity. It is best heard below the cla^-icles in front,
in the axilke, and below the scapulie. behind, but over the thin,
lower edges of the lung, whether behind or at the sides, it is
feebler, though still retaining its characteristic type as revealed ill
the inspiration and expiration in resjiect to intensity, duration, and
pitch. To represent distant vesicular breathing graphically we
Ciave only to draw its symbol on a smaller scale (see Fig. 96). On
AUSCULTATION. 153
the other hand, when one listens to the lungs of a person who has
been exerting himself strongly, one hears the same type of respira-
tion, hut on a lunjer scale, which may then be represented as in
Fig. 97. This last symbol may also be used to represent the respi-
ration which we hear over normal but thin-walled chests ; for ex-
ample, in children or hi emaciated persons. It is sometimes known
as "exaggerated" or "puerile" respiration. When one lung is
thrown out of use by disease so that increased work is brought
upon the other, the breath sounds heard over the latter are uicreased
and seem to be produced on a larger scale. Such breathing is some-
times spoken of as " rough " breathing.
It is very important to distmguish at the outset between the
different types of breathing, one of which I have just described, and
the different degrees of loudness with which any one type of breath-
ing may be heard.
(2) Broncliial or Tracheal Breathinr/ in Health.
Bronchial breathing may be symbolically rej^resented as in Fig.
98, in which the increased length of the down stroke corresponds
CO the increased duration of expiration, and the greater tliickness
\
Fig. 98.— Bronchial Breath- FIG. 9!).— Distant Bronchial PiG. 100.— Very Loud Bron-
Ing of Moderate Intensity. Breathing. chlal Breathing.
of both lines corresponds to the greater intensity of both sounds,
expiratory and inspiratory, while the sharp pitch of the " gable " on
both sides of the perpendicular corresponds to the high pitch of
both sounds. Expiration, it will be noticed, slightly exceeds mspi-
ration both ur intensity and pitch, and considerably exceeds it in
duration, while as compared with vesicular breathing almost all the
164 PHYSICAL DIAGNOSIS.
relations, are reversed. Bronchial breathing has also a peculiar
quality which can be better appreciated tlian described.
In the healthy chest tliis type of breathing is to be heard if one
listens over the trachea or primary bronchi (see above, Fig. 91),
but practically one hardly ever listens over the trachea and bronchi
except by mistalie, and the importance of familiarizing one's self
with the type of respiration heard over these portions of the chest
is due to the fact that in certain diseases, especially in pneumonia
aaid phthisis, we may hear bronchial breathing over the jxnr/iclii/ma
of tlie lung where normally vesicular breathing should be heard.
The student slionltl familiarize liimself with each of these types
of breathing, the vesicular and the bronchial, concentrating his at-
tention as he listens first upon the inspiration and then upon the
expiration, and comparing them with each other, first in duration,
next in intensity, and lastly in pitch. To tliose wlio have not a
musical ear, high-pitched sounds convey the general imijression of
being shrill, while low-jjitched sounds sound hollow and empty, but
tlie distinction between intensity and pitch is one comparatively
difficult to master. Distant bronclual breathing may be repre-
sented in Fig. 99, and is to be heard over the back of the neck
opposite the position of tlie trachea and bronchi. Fig. 100 repre-
sents very loud bronchial breathing such as is sometimes heard in
pneumonia.
(3) Broncho- Veskuhir Bivufhiiif/ in Health.
As indicated by its name, this type of breathmg is intermediate
between the two just described, hence the terms " mixed breath-
ing," or "atypical breathing " ("unbestimmt "). Its characteristics
may be symbolized as in Fig. 101. In the normal chest one can be-
come familiar with broncho-vesicular breathing, by examining the
apex of the right lung, or by listenhig over the trachea or one of the
primary bronchi, and then moving the stethoscope half an inch at
a time toward one of the nipjjles. In the course of this journey
one passes over points at which tlie breathing has, in varying de-
grees, the characteristics intermediate between the bronchial type
from which we started and the vesicular type toward which we are
AUSCULTATION.
155
moving. Expiration is a little longer, intenser, or higher pitched
than in vesicular breathing, and inspiration a little shorter, feebler,
A
r
Fig. 101. — Two Common Types of Broncho- Fig. 102.— Distant Broncho-Vesicular Breath-
Vehicular Breathing. ing.
or lower pitched ; but since these characteristics are variously com-
bined, there are many subvarieties of broncho-vesicular breathing.
Fig. 102 represents two tyjies of distant broncho-vesicular breath-
ing.i
(4) IVie Breatliintj in Kinplnjiiema.
A glance at Fig. 103 will call up the most important features of
this type of respiration. The inspiration is short and somewhat
feeble, but not otherwise remarkable. The expiration is long,
feeble, and low pitched. This type of breathing is the rule in
elderly persons, particularly those of the male sex.
(5) The Breatliiiiij in Asthma,
Fig. 104 differs from emphysematous only in the greater intensity
of the inspiration. In this type of breathing, however, both sounds
Fig. 103. — Emphysematous Breathing.
Fig. 104.— Asthmatic Breathing, .s, s,
squeaking (musical) rales.
are usually obscured to a great extent by the presence of piping and
squeaking rales (see below).
' The right-liund tj'pe is often termed "sharp " or "Tougb."
156 PHYSICAL DIAGNOSIS.
(6) Iiifrrriijifi'd or " CoijivJiccI " lirciifliiiif/.
As a rule, t)nly tlie inspiration is interrupted, being transformed
into a series of short, jerky puffs as sliown in Fig. 105. Very rarely
tire expiration is also divided into segments. When heard over the
entire chest, cogwheel breathing is usually the result of nervous-
ness, fatigue, or eliilliness on the patient's 2)art. With the removal
of these causes this type of respiration then disappears. If, on the
other hand, cogwheel respiration is confined to a relatively small
portion of the chest, and remains present despite the exclusion of
y
^n
Fig. 10.5.— Cogwheel Breathing. Fic. 10il.—Metamurphi>sing Breathing.
fatigue, nervousness, or cold, it points to a local catarrh in the finei
bronchi such as to render difficult the entrance of air into the alve-
oli. As such, it has a certain significance in the diagnosis of early
phthisis, a significance similar to that of rales or other signs of
localized bronchitis (see below) .
(7) Aniphoric or Curernoiis Breathing (see below, p. 101).
(8) JSh'tii nHtrpliDs'inij lirrnthliuj.
Occasionally, while we are listening to an inspiration of normal
pitch, intensity, and rpiality, a sudden metamorphosis occurs and the
type of breathing clianges from vesicular to bronchial or aniphoric
(see Fig. 10fi),or the intensity of the breath sounds may suddenly
be increased without otlier change Th(>se metamorphoses are usu.-
ally owing to the fai't tluit a ])lugged bronclnis is suddenly opened
by the force of tlie inspired air, so that the sounds couductea
through it become audible.
.4 use ULTA TION. 157
II. Differences between the Two Sides of the Chest.
(a) Over the apex of the right king — that is, above the right
clavicle ia front, and above the spine of the scapula behind — one
hears in the great niajcnity of normal chests a distinctly Ijronoho-
vesicular type of breathing, in a smaller number of cases this
same type of breathing may be heard just below tlie right clavicle.
Tliese facts cannot be too strongly insisted upon, since it is only
by bearing them in mind that we can avoid the mistake of di;ignos-
ing a beginning consolidation of the right apex where none exists.
Breath sounds ivhich are 'perfect} ij normal over the rigid apex would
mean serious disease if heard over similar portions of the hft lung.
It will be remembered that the apex of the right lung is also duller
on percussion tlian the corresponding portion of the left, and that
the voice sounds and tactile fremitus are normally more intense on
the right (see Fig. 64).
(/>) At the base of tlie left lung posteriorly one often hears a
slightly rougher or more noisy type of breathing than in tlie corre-
sponding portion of the right lung.'
III. Pathological Modifications of Vesicular Breathing.
Having now distinguished the different types of breathing and
described their distribution in the normal chest, we must return to
the normal or vesicular breathing in order to enumerate certain of
its modifications which are important in diagnosis.
(1) Exaggerated Vesicular Breathing Q' Compensator]/ " Breathing).
(a) It has already been mentioned that in children or iu adults
with very thin and flexible chests the normal breath sounds are
heard with relatively great distinctness ; also that after any exer-
tion which leads to abnormally deep and forcible breathing a simi-
lar increase in the intensity of the respiratory sounds naturally
occurs.
(b) The term " compensatori/ hreathing," ov "vicarious " breath-
ing, refers to vesicular breathing of an exaggerated type, such as is
' If the patient lies on the side, tliat side shows a slightly more tubular
respiration with increased voice, wliispei', and fremitus. This must be allowed
for in all comparisons made iu this |)ositi(jn.
158 PHYSICAL DIAGNOSIS.
lii'avd, fov exaiiipli', cvrv the whole of one hnij; wlieii the other lung
is thrown out of use by the pressure of an accuiuulatiou of air ot
fluid in the pleural cavity. A similar exaggeration of the breathing
upon the sound side takes place when the other lung is solidified,
as by tuberculosis, pneumonia, or malignant disease, or when it is
compressed by the adhesions following ])huiritic effusion, or by
a contraction of the bones of that side of the chest such as occurs
in spinal curvature.
(2) Dliiiinhhrd Vcslciihiv Brrathhig.
The causes of a diminution in the intensity of the breath sounds
without any change in their typi^ are very numerous. I shall men-
tion them in an order corres])ouding as nearly as possible to the
telative frequency of their occurrence.
(rt) Fluid, Air, itr iSollil ill till', rifiiriil Cai'Hi/. — Probably the
commonest cause for a diminution or total abolition of normal
breath sounds is an accumulation of fluid in the pleural cavity such
as occurs in iuflaiumation of the pleura or by transudation (hydro-
thorax). In such cases the layer of fluid intervening between the
lung and the stethoscope of the auscultat(u- I'auses retraction of the
lung so that little or no vesicular murnuir is produced in it, and
hence none is transmitted to the ear of the auscultator. An ac-
cumulation of air in the pleural cavity (pneumothorax) may dimin-
ish or abolish the breath sounds precisely as a layer of fluid does ;
in a somewhat different way a thickening of the costal or pulmo-
nary pleura or a malignant growth of the chest wall may render
the breath soun<ls feelile or prevent their being lieard bei'auso the
vibrations of the thoracic sounding-boa-rd are thus deadened. Which-
ever of these causes, fluid or air or solid, intervenes between the lung
and the car of the auscultator, tlu^ breath S(mnds are deadened or
diminished without, as a rule, any modification of their ty]ie. The
amount of such diminution depends roughly on the thickness of the
layer of extraneous sxibstauce, whether fluid, air, or solid.
Total absence of breath sounds may therefore be due to any one
of these causes, provided the layer intervening between the lung and
chest wall is of sufficient thickness to ])roduce complete atelectasis
of the lung or to deaden the vibrations of the chest wall.
AUSCULTATION. 159
(//) EinjiJiijsema of -the Iuikj, by destroying its elasticity and re-
ducing the extent of its movements, makes the breath sounds rela-
tively feeble, but seldom, if ever, abolislies them altogetlier.
{(■) In liroiirliitis the breath sounds are sometinres -considerably
diminished owing to the filling up of the bronchi with secretion.
This diminution, however, usually attracts but little attention,
owing to the fact that the bubbling and squeaking sounds, which
result from the passage of air through the bronchial secretions, dis-
tract our notice to such an extent that we find it difficult to con-
centrate attention upon the breath sounds, even if we do not forget
altogether to listen to them. When, however, we succeed in listen-
ing tlii'oiKjh the, rales to the breath sounds. themselves, we usually
notice that they are very feeble, especially over the lower two-
thirds of the chest. Qidema of the linuj may diminish the breath
sounds in a similar way.
(rf) Pain in the tliovax, such as is produced by dry pleurisy or
intercostal neuralgia, diminishes the breath sounds because it leads
the patient to restrain, so far as possible, the movements of his
chest, and so of his lungs. If, for any other reason, the full ex-
pansion of the lung does not take place, whether on account of the
feebleness of the respiratory movements or because the lung is me-
chanically hindered by the presence of pleuritic adhesions, the
breath sounds are proportionately feeble.
(e) Occlusion of the upjMr air jxissmjes, as by spasm or oedema
of the glottis, renders the breathing very feeble on both sides of
the chest. If one of the primary bronchi is occluded, as by a for-
eign body or by pressure of a tumor or enlarged gland froirr without,
we get a uirilateral enfeeblement of the breathing over the corre-
sponding lung.
(/) Occasionally a paralysis of the muscles of respiration on one
or both sides is found to result in a unilateral or bilateral enfeeble-
ment of the breathing.
It should be remembered, when estimating the intensity of the
breatliing, that the sounds heard over the right base are, as a rule,
slightly more feeble than those heard over the left base in the nor-
mal chest.
160 PHYSICAL DIAGNOSIS.
IV. Bronchial or Tubular Breathing in Disease.
(«) I have already described the occui-rence of bronchial breath-
ing in parts of the normal chest, namely, over the trachea and jjri-
mary bronchi. In disease, broncldal breathing may be heard else-
where in the chest, and usually jioints to solidification of that portion
of lung from which it is conducted. It is heard most commonly in
jihthisis (see below, p. 304).
(/() Croupous piiiiUj)io)iia is probably the next most frequent
cause of bronchial breathing, although by no means every case of
croupous pneumonia shows this sign. For a more detailed account
of the conditions under which it does or does not occur in croupous
pneumonia, see below, p. 296. Lobular pneumonia is rarely mani-
fested by tubular breathing.
(c) In about one-third of the cases of pleuritic effusion distant
bronchial breathing is to be heard over the fluid. On account of
the feebleness of the breath sounds in such cases they are often
put down as absent, as we are so accustomed to associate iatensity
with the bronchial type of breathing. One should be always on
the watch for any degree of intensity of bronchial breathing from
the feeblest to the most distinct.
{d) Barer causes of bronchial breathing are hemorrhagic infarc-
tion of the lung, syphilis, or malignant disease, any one of which
may cause a solidification of a portion of the lung.
V. Beoncho-Vesicular Breathing in Disease.
Eespiration of this typie should be carefully distinguished from
puerile or exaggerated breathing, in which we hear the normal vesic-
ular respiration upon a large scale. I have already mentioned
that broncho-vesicnlar breathing is normally to be heard over the
apex of the right lung. In disease, broncho-vesicular breathing is
heard in other portions of the lung, and usually denotes a moderate
degree of solidification of the lung, such as occurs in early phthisis
or in the earliest and latest stages of croupous pneumonia. In cases
of pleuritic effusion, one can usually hear broncho-vesicular breath'
AUSCULTjiTION. 161
ing over the upper portion of the aft'ected side, owing to the retrac-
tion of the lung at tl^at point.
VI. Amphokic BEEATHTNr4 (Amphora = A Jar).
Res})irations having a hollow, empty sound like that produced
by blowing across the top of a bottle, are occasionally heard in dis-
ease over pulmonary cavities (<?.//., in phthisis) or in pneumothorax,
■I.e., under conditions in which the air passes in and out of a large
empty cavity within the chest. Amphoric breathing never occurs
in health. The pitch of both sounds is low, hit that of expiration
lower than that of iiisjnratioii. The intensity and duration of the
sounds vary, and the distinguishing mark is their quality which
resembles that of a whispered "wAo."
VII. Eales.
The term '' rales " is applied to sounds produced by the passage
of air through bronchi which contain mucus or pus, or which are
narrowed by swelling of their walls.' Kales are best classified as
follows :
(1) Bubliliiig rales, including (a) coarse, (h) medium, and (c)
fine rales.
(2) Crackling rales (large, medium, or fine).
The smallest varieties of this type ai-e known as "crepitant" or
" subcrepitant" rales.
(3) Musical rales (high or low pitclied).
Each of these varieties will now he described inoi-e in detail.
(1) Buhblinij Rules.
The nature of these is .sufficiently indicated by their name.
The coarsest or largest bubbles are those produced in the trachea,
and ordinarily known as the ^^ death rattle." Tracheal rales occur
' Kales are of all au.scultatory phenomena the easiest to appreciate, pro-
vided we exclude various accidental sounds which may be transmitted to the
ear as a result of friction of the stethoscope against the skin or against the
fingers of the observer. (See above, page 145.)
11
162 PHYSICAL DIAGNOSIS.
in any condition involving either profound unconsciousness or very
great weakness, so that the secretions which accumulate in the
trachea are not coughed out. Tracheal rales are by no means a
sure precursor of death, although they are very common in the
moribund state. They can usually be heard at some distance from
the patient and without a stethoscope. In catarrh of the larger
bronchi large bubbling rales are occasionally to be
heard. In phthisical cavities one sometimes hears
coarse, bubbling rales of a very metallic and gurgling
quality (see below, p. 311). The finer grades of rales
i correspond to the finer bronchi.
I In the niajorit}- of cases these rales are most nvimer-
Fi(i 11)7 — Ex- o^^s during inspiration and especially during the latter
plosion "f Fine part of this act. Their relation to respiration may lie
ofVnspiration. represented graphically as in Pig. 107, using large dots
for coarse rales and small dots for fine rales. Musical
rales can be symbolized by the letter S (squealvs).
(2) CracMlng Rdles.
These differ from the preceding variety merely by the absence
of any distinct bubbling quality. They are usually to be heard rn
cases of bronchitis in which the secretions are unusually tenacious
and viscid. Tliey are especially apt to come at the end of inspira-
tion, a large number being evolved in a very short space of time, so
that one often speaks of an " explosion of fine crackling rftles " at
the end of inspiration. Crackling rales are to be heard in any one
of the conditions in which bubbling rales occur, but are more fre-
quent in tuberculosis than in simple bronchitis.
Crepitant rale.'', which represent the finest sounds of this type,
are very much like the noise which is heard when one takes a lock
of hair between the thumb and first finger and rubs the hairs upon
each otlier while holding them close to the ear. A very large num-
ber of minute crackling sounds is heard following each other in
rapid succession. To the inexperienced ear they may seem to blend
into a continuous sound, but with practice the component parts may
AUSCULTATION. 163
be distinguished. This type of rales is especially apt to occur dur-
ing inspiration alone, but not very infrequently they are heard
during expiration as well. From subcrepitant rales they are dis-
tinguished merely by their being still finer than the latter. ' Sub-
crepitant rales are often mixed with sounds of a somewhat coarser
type, while crepitant rales are usually all of a size. If the
chest is covered with hair, sounds precisely like these two varieties
of r§,les may be heard when the stethoscope is placed upon the hairy
portions. To avoid mistaking these sounds for rales one must
thoroughly wet or grease the hair.
Crepitant EuIks in Atelectasis.
Crepitant and subcrepitant rales are very often to be heard along
the thin margins of the lungs at the base of the axillae and in the
back, especially when a patient who is breathing superficially first
begins to take deep breaths. In such cases, they usually disappear
after the few first respirations, and are then to be explained by the
tearing apart of the slightly agglutinated surfaces of the finer bron-
chioles.
It is by no means invariably the case, however, that such sub-
crepitant rales are merely transitory in their occurrence. In a large
number of cases they persist despite deep breathing. The fre-
quency of subcrepitant rales, persistent or transitory, heard over
the inferior margin of the normal lung at the bottom of the axilla,
is shown by the foUowmg figures : Out of 356 normal chests to
which I have listened especially for these rales, I foimd 228, or 61
per cent, which showed them on one or both sidf s. They are very
rajely to be heard in persons under twenty years Oi age. After
forty-five, on the other hand, it is unusual not to find them.
In my experience they are considerably more frequent in the situa-
tion shown in Fig. 158 than in any other part of the lung, but they
may be occasionally heard in the back or elsewhere. In view of
■A distinction was formerly drawn between crepitant and subcrepitant
rales, on the ground that the latter were heard during both respiratory sounds
and the former only during inspiration, but this distinction cannot be main-
^flined and is gradually being given up.
164 PHYSICAL T'lAOyOSIS.
these facts, it seems to me that we must reeogiiize that it is almost
if not t|iute i>hysiokigieal to timl the finer varieties of eraekliug
rales at the base of the axilhe in persons over forty years ohl. I
have supjiosed these rales to be due to a partial atelectasis result-
ing from disuse of the thin lower margin of tlie lungs. Such por-
tions of the hmg are ordinarily nor exiianih'.! unU'ss t he respirations
are forced and deep.' d'his oxidauation wouhl agree with tlie obser-
vations of Abrams, to which 1 shall refer later (see below, p. 3(31).
(h) Crepitant or subcrepiiant rales are also to be lieard in a
certain portion of eases of imcunuinia. in the very earliest stages
and when resolution is taking jdace (" crepitans redux"). ^lore
rarely tliis tyjie of rale may be lieard in connection with tubercu-
losis, infarcti.in, or cedema of tlie lung.
In certain cases of dry jdeurisy tliere occur fine crackling
sounds wliieli can scarcely be differentiated from subcreintant rales.
I shall return to the description of theiii in s]ieakiiig <if pleural
friction (see below, p. Sotil-
The passage of air through broiudiial tubes narrowed bv iutlam-
matory swelling of their lining membrane (bronchitis'), or bv S]ias-
modic contraction (asthma). gi\'es rise not infrequently to a mul-
titude of musical sounds. Sucli a stenosis occurring in relatively'
large bronchial tubes produces a deep-toned ijroanbnj sound, while
narrowing of the finer tubes results \\\ ji'qihuj, siji/cali'in/. ir/iisti!ii;/
noises of various qualities. Such sounds are often known as "(/;■//
i-'i'i's" in contradistiuetion to the "biil'bUn'j nl/is" above di's.-rihed,
but as many nou-musieal crackling rales have also a very diy sound,
it seems to me best to apply the more distinctive teiiu " ^n^s'/cvf/
;v;/(\s " to all adventitious sounds of distinctly musical quality, giv-
ing uyi the term "dry " altogether. JLusical rales are of all adven-
titious sounds the easiest to recognize but also the most fugitive
and (diangeablc. Thc\' aiqiear now here, now there, shifting fiout
miiutte til minute, aiul uuiy totall}' disa|ipear from the eliest atid
reappear again within a very short time. This is to some extent
' Sn as to expand the lung and jirciduco the " cntf:dtungsgcr:iuscli " of the
Gcrmaua.
AUSCULTATION. 165
true of all varieties of rales, bat especially of the squeaking and
groaning varieties.
Musical rales are heard, as a rule, more distinctly during expira-
tion, especially when they occur in connection with asthma or em-
pliysenia. In these diseases one may hear quite complicated cliords
from the conihiiiatious of rales which vary in pitch.
VII. Tjie Effects of Coufiii.
The influence of coughing upon rales may be either to intensify
them and bring them out where they have not previously been
licavd, or to clear them away altogether. Lateral decubitus multi-
plies and intensifies rfiles on the lower side. Other effects of
coughing upon physical signs will be mentioned later (pp. 297,
306).
VIII. Pleural FpacTioN^.
The surfaces of the healthy pleural cavity are lubricated with
sufficient serum to make them pass noiselessly over each other dur-
mg the movements of respiration. But when the tissues become
abnormally dry, as in Asiatic cholera, or when the serous surfaces
are roughened by the presence of a libruious exudation, as in ordi-
nary pleurisy, the rubbing of the two pleural surfaces against one
another produces peculiar and very characteristic sounds known as
"jileural friction sounds." The favorite seat of pleural friction
sounds is at the bottom of the axilla, i.e., where the lung makes
the widest excursion and where the costal and diaphragmatic j^leura
are in close apposition (see Fig. 65). In some cases pleural fric-
tion sounds are to be heard altogether below the level of the lung.
In others they may extend ub several inches above its lower mar-
gin, and occasionally it happens that friction may be apj^reciated
over the whole lung from the top to the bottom. Very rarely
friction sounds are heard only at the apex of the lung in early
tuberculosis.
The sound of pleural friction may be closely imitated by hold-
ing the thumb and forefinger close to the ear, and rubbing them
past each other with strong pressure, or by pressing the pabn of
one hand over the ear and rubbing upon the back of this hand with
166 . PHYSICAL DIAGNOSIS.
the fingers of tte other. Pleural friction is usually a catch
jerky, interrupted, irregular sound, and is apt to occur during ra-
spiration only, and particularly at the end of this act. It may,
however, be heard with both respiratory acts, but rarely if e%'er
occurs during exjiiration alone. The intensity and quality of the
sounds vary a great deal, so that they may be compared to grazlmj,
rubbing, rasping, and creaking sounds. They are sometimes spoken
of as " leatherg." As arule, thej^seem verynear to the ear, and are
sometimes startlingly loud. In many cases they cannot be heard
after the patient has taken a few full breaths, probably because the
rough pleural surfaces are smoothed do-wn temj)orarily by the fric-
tion which deep breathing produces. After a short rest, however,
and a period of superficial breathing, pleural friction sounds often
return and can be heard for a short time with all their former in-
tensity. They are increased by pressure exerted upon the outside
of the chest wall. Such pressure liad best be made with the hand
or with the Bowles stethoscope, since the sharp edges of the chest-
piece of the ordinary stethoscope may give rise to considerable
pain; but if such pressure is made with the hand, one must be
careful not to let the hand shift its position upon the skin, else
rubbing sounds may thus be produced which perfectly simulate
pleural friction. In well-marked cases pleuritic friction can be
felt if the palm of the hand is laid over the suspected area; occa-
sionally the somid is so loud that it can be heard by the patient
himself or by those around him.
In doubtful cases, or when a friction soimd appears to have
disappeared, and when one wishes to bring it out again, there are
several manoeu\Tes suggested by Abrams for obtaining this enr
(a) The Arm Ilananivre.
The patient suspends respiration altogether, and the arm upon
the affected side is raised over the head by the patient himself or
by the physician, as in performing Sylvester's method of ai-tificial
respiration. During this movement we listen over the suspected area.
" By this mano3u\T.'e the movement of the parietal against the -^is-
ceral pleura is opposite in direction to that occurring during the
AUSCULTATION. 167
respiratory act, and for this reason the pleuritic sound may often
be elicited after it has been exhausted in the ordinary act of breath-
ing."
(V) The Decubital Manoeuvre.
" Let the patient lie upon the affected side for a minute or two,
then let him rise quickly and suspend respiration. Now listen over
the affected ai-ea, at the same tune directing the patient to take a
deep breath."
Pleuritic friction sounds are distinguished from rales by their
greater superficiality, by their jerky, interrupted character, by the
fact that they are but little influenced by cough, and that they are
increased by pressure. It has already been mentioned, however,
that there is one variety of sounds which we have every reason to
think originate in the pleura, which cannot be distinguished from
certain varieties of crackling bronchial rales. Such sounds occur
chiefly in connection with phthisical processes, in which both pleu-
risy and bronchitis are almost invariably present, and it is seldom
of importance to distinguish the two.
IX. AUSCULTATIOIT OF THE SpOKEN OB WHISPERED VoiCE SoUNDS.
The more important of these is :
(a) The Whisjyered Voice.
The patient is directed to whisper "one, two, three," or
"ninety -nine," while the auscultator listens over different portions
of the chest to see to what degree the whispered syllables are trans-
mitted. In the great majority of normal chests the whispered
voice is to be heard only over the trachea and primary bronchi in
front and behind, while over the remaining portions of the liuig
little or no sound is to be heard. When, on the other hand, solidi-
fication of the lung is present, the whispered voice may be dis-
tinctly heard over portions of the lung relatively distant from the
trachea and bronchi; for example, over the lower lobes of the lung
behind. The usefuhiess of the whispered voice in the search for
small areas of solidification or for the exact boundaries of a solidi-
168 PHYSICAL DIAGNOSIS.
fied area is very great, especially when \ve desire to save the patient
the i>aiii and fatigue of taking deep breaths. AMuspered voice
sounds are practicallj^ equivalent to a forced expiration and can be
obtained with very little exertion on the patient's ^lart. The in-
creased transmission of the whispered voice is, in my opinion, a
more delicate test for solidification than tnljular breathing. The
latter sign is yiresent onlj- when a considerable area of lung tissue
is solidified, while the increase of the whispered voice may be ob-
tauied over much smaller areas. Eetraction of the lung above the
level of a pleural effusion causes a moderate increase in the trans-
mission of the whispered voice, and at times this increased or bron-
chial whisper is to be heard over the fluid itself, probaljly by trans-
mission from the compressed lung above.
\Miere the lung is completely solidified the whispered words
may be clearly distinguished over the affected area. In lesser de-
grees of solidification the syllables are more or less blurred.
(Ij) The SjioJccii J'oice.
The evidence given us by listening for the spoken voice in vari-
ous parts of the chest is considerably less in value than that obtained
through the whispered voice. As a rule, it corresponds with the
tactile fremitus, being uicreased in intensity by the same causes
which increase tactile fremitus, viz., solidification or condensation
of the lung, and decreased l^y the same causes which decrease tac-
tile fremitus — namelj', by the presence of air or water in the pleu-
ral cavity, by the thickeuiug of the pleura itself, or b}' an ob-
struction of the bronchus leading to the part over which -w-e are
listening. In some cases the presence of solidification of the lung
gives rise not merely to an increase in transmission of the spoken
voice, but to a change in its quality, so that it sounds abnormally
concentrated, nasal, and near to the listener's ear. The latter
change may be heard over areas where tactile fremitus is not in-
creased, and even where it is diminished. "SMiere this change in
the quality of the voice occurs, the actual words spoken can often
be distingviished in a way not usually ]iossib]e over either normal
or solidified lung. "Bronchophony," or the distinct transmission
AUSCULTATION. 169
of audible words, and not merely of diffuse, unrecognizable voice
sounds, is considerably commoner in the solidilications due to pneu-
monia than in those due to phthisis; it occurs in some cases of
pneumothorax and pulmonary cavity.
(c) JS/jojjJioni/.
Among the least important of the classical physical signs is a
nasal or squeaky quality of the sounds which reach the observer's
ear when the patient speaks in a natural voice. To this peculiar
quality of voice the name of " egoj^hony " has been given. It is
most frequently heard in cases of moderate-sized pleuritic effusion
just about the level of the lower angle of the scapula and in the
vicinity of that point. Less often it is heard at the same level in
front. It is very rarely heard in the upper portion of the chest
and is by no means constant either in pleuritic effusion or in any
other condition. A point at which it is heard corresponds not, as
a rule, with the upper level of the accumulated fluid, as has been
frequently supposed, but often with a point about an inch farther
down. The presence of egophony is in no way distmctive of pleu-
ritic effusions and may be heard occasionally over solidified lung.
X PiiENOMEXA Peculiar to Pneumohydrothorax and Pneu-
MOPrOTHORAX.
(1) tSuccussion Sounds.
'Now and then a patient consults a physician, complaining that
he hears noises inside him as if water were being shaken about.
(.)ne such patient expressed liimself to nie to the effect that lie felt
"like a half-empty bottle." In the chest of such a patient, if one
presses the ear against any portion of the thorax and then shakes
the whole patient strongly (succussion), one maj- hear loud splash-
ing sounds due to air and fluid within. The sound itself is often
miscalled "succussion." Such sounds are absolutely diagnostic of
the presence of both air and flidd. Yery frequently they may be
detected by the physician when the patient is not aware of their
170 PHYSICAL DIAGXOSIS.
presence. Occasionally tlie splasliiiiir of the fluid wiiliiu may be
felt as well as lieavil. It is essential, of course, to distinguish
splashing due to the pvesence of aii' and fluid in the pleuval
cavity from similar sounds produced in the stomach, but this is not
at all ditiicult in the majority of cases. It is a bare possibility that
snccussion sounds may be due to the pnesence of air and fluid in the
piericardial cavity.
It is important to remember that splashing is never to be heard
in simple pdeuritic effusion or hydrothorax. The piresence of air, as
well as liquid, in the pleural cavity is absolutely essential to the
production of suecnssion soimds.'
(2) JMalJic Thil-Ir or Fa 11 i ii ;/- 1^ mp Sound.
When listening over a pileural cavity which contains both air
and fluid, one occasionally hears a liquid, tinkling sound, due pos-
sibly to the impact of a drop of liquid falling from the relaxed lung
above into the accumulated fluid at the bottom of the pleural cavity,
but probably to rales jn-ivlucediii the tissues around the cavity. It
is stated that tliis physii-al sign may in rare cases be observed in
large-sized phthisical cavities as well as in pueumohydrothorax and
pmeumopyothorax.
(3) The Luuff-Fisfula Sou?id.
Wlien a pierforation of the lung occurs below the level of the
fluid accumulated in the pleural cavity, bubbles of air may be forced
out from the lung and up through the fluid with a sound reminding
one of that made by children when blowhig soap-bubbles.
' It is well for tlie student to try for himself the following experiment,
wliich I liave found useful in impressing these facts upon the attention of
classes in physical diagnosis: Fill an ordinary rubber hot-water bag to the
brim with water. Invert it and squeeze out forcibly a certain amount (per-
haps half) of the contents, by grasping the upper end of the bag and compress-
ing it. While the water is thus being forced out, screw in the nozzle of the
bag. Now shake the whole bag, and it will be found impossible to produce
any splashing sounds owing to the fact that there is no air in the bag. Un-
screw the nozzle, admit air, and then screw it in again. Now shake the bag
again and loud splashing will be easily heai'd.
CHAPTER VIII.
AUSCUI/rATlON OF THE HEART.
I. '■VaLVK AlvKAS."
In the routine examination of the heart, most observers listen I
in four places : 1
(1) At the apex of the heart in the fifth intercostal space neai
the nipple, the "mitral area." i
Aortic area. * "
Tricuspid area.
_i — Pulmonic area.
Mitral area.
Fig. 108.— The Valve Areas.
(2) In the second left intercostal space near the sternum, the
'' fulmotih; area."
QV) In the second right intercostal space near the sternum, the
''^aortic area."
(4) At the bottom of the sternum near the ensiform cartilage,
the "triciisjnd area."
These points are represented in Fig. 108 and are known as
(172 PHYSICAL DIAGNOSIS.
I
I
j "valve areas." They do not correspond to tlie anatomical position
of any one of the foiir valves, but experience has shown that sounds
heard best at the apex can be proved (by post-mortem examination
or otherwise) to be produced at the mitral orifice. Similarly sounds
heard best in the second left intercostal space are proved to be
produced at the pulmonary orifice ; those which are loudest at the
second right intercostal space to be produced at the aortic orifice ; '
while those which are most distinct near the origin of the ensiform
cartilage are produced at the tricuspid orifice.
II. The jSTokmal Heart Sounds.
A glance at Fig. 109, which represents the anatomical positions
of the four valves above referred to, illustrates what I said above ;
namely, that the traditional valve areas do not correspond at all
with the anatomical position of the valves. If now we listen in
the "mitral area" that is, in the region of the apex imjDulse of the
heart, keeping at the same time one finger on some point at which
the cardiac impulse is palpable, one hears with each outward thrust
of the heart a low, dull sormd, and in the period between the heart
beats a second sound, shorter and shar^jer ra quality.'
That which occurs with the cardiac impulse is known as the
first sound ; that which occurs between each two beats of the heart
is known as the second sound. The second sound is genei illy ad-
mitted to be due to the closure of the semilunar valves The cause
of the first sound has been a most fruitful source of discussion, and
no one explanation of it can be said to be generally received. Per-
haps the most commonly accepted view attributes the first or
systolic sound of the heart to a combination of two elements —
(rt) The contraction of the heart muscle itself.
(b) The su.dden tautening of the mitral curtains.
Following the second sound there is a pause corresponding to
' For exceptions to this rule, see below, page 235.
' The first sound of the heart, as heard at the apex, may be imitated by
holding a linen handkerchief by the corners and suddenly tautening one of the
borders. To imitate the second sound, use one-lialf the length of the border
instead of the whole.
AUSCULTATION OF THE HEART.
173
tlie diastole of the heart. Normally this pause occuj)ies a little
more time thau the first and second sounds of the heart taken to- 1
gether. In disease it may be much shortened.
The first sound of the heart is not only longer and duller than
the second (it is often spoken of as "boommg " in contrast with the
" snapping " quality of the second sound) but is also considerably
more intense, so that it gives us the impression of being accented
like the first syllable of a trochaic rhythm. After a little practice
one grows so accustomed to this rhythm that one is apt to rely upon
— Pulmonic valve.
Aortic valve.
Tricuspid valve. ---'
Mitral valve.
Fig. 109.— Anatomical Position of the Cardiac Valves.
his appreciation of the rhythm alone for the identification of the
systolic somid. This is, however, an unsafe jiractice and leads to
many errors. Our impression as to which of the two sounds of each
cardiac cycle corresponds to systole should always be verified either
by sight or touch. We must either see or feel the cardiac impulse
and assure ourselves that it is synchronous with the heart sound
which we take to be systolic' This point is of especial importance
in the recognition and identification of cardiac murmurs, as will be
seen presently.
' When the cardiac impulse can be neither seen nor felt, the pulsation of
the carotid will generally guide us. The radial pulse is not a safe guide.
174 PHYSICAL DIAGNOSIS.
So far, I have been describing the normal heart soimds heard
in the "mitral area," that is, at the apex of the heart. If now we
listen o'^-er the pulmonary area (in the second left intercostal
space), we tind that the rhythm of the lieart scjunds has changed
and that here the stress seems to fall upon the '" second sound,"
ie., that corresponding to the beginning of diastole; in other
words, the first sound of the heart is here heard more feebly and
the second sound more distinctly. The sharp, snapping cpiality of
the latter is here even more marked than at the apex, and despite
the feebleness of the first soimd in this area we can usually recog-
nize its relativelj' dull and prolonged quality.
Over the aoftic area {i.e., in the second right interspace) the
rhythm is the same as in the pulmonary area, although the second
sound may be either stronger or weaker than the corresponding
sound on the other side of the sternum (see below, p. 176).
Over the tricuspid area one hears soimds practically iadistm-
guishable in quality and in rhythm from those heard at the apex.
IMien the chest walls are thick and the cardiac sounds feeble,
it may be ditRcult to hear them at all. In such cases the heart
sounds may be heard much more distinctly if the patient leans for-
ward and toward his own left. Such a position of the bodj- also ren-
ders it easier to map out the outlines of tlie cardiac dulness by per-
cussion if we allow for the swing of the heart to the left.
In cardiac neuroses and during conditions of excitement or emo-
tional strain, the first sound at the apex is not only very loud but
has often a curious rnetallie rererherafion {" cliqiietis mefal/ique")
corresponding to the trembling, jarring cardiac impulse (often mis-
taken for a thrill) whicli i)alpation reveals.
III. MODIFICATIOXS IX THE IxTEXSITY OF THE HeAKT SoUXDS.
It has already been mentioned that in young persons with thm,
elastic chests, the heart sounds are heard with greater intensity
than in older persons whose chest walls are thicker and stifler.
In obese, indolent adults it is sometimes diiiieult to hear any heart
sounds at all, while in young persons of excitable temperament the
sounds may have a very intense and ringing quality. Under dis-
AUSCULTATION OF THE HEART. 175
eased coiulitions either cif the heart sounds may be increased or
diminished in intensity. I shall cunsider
(1) The First iSiiiiiid tit ilir ^Ijiix (sojiii'tiiiicti Culled the Mitral First
iSoiiiiil^
((() Increase in the length or intensity of the first sonnd at the
apex of the heart occurs in any condition which causes the heart
to act with mnisual degree of fiu'ce, such as bodily or nu'utal exer-
tion, or excitement. In the earlier stages of infectious fevers a
similar increase in the intensity of this sound may sometimes be
noted. Hypertrophy of the left ventricle soiuetimcs has a similar
effect upon the sound, but less often than one would su]ii>ose, while
dilatation of the lei?t ventrich-, contiary to wliat one would suj)iiose,
is not infrequently associated with a haul, fovcibh^ first sound at
the apex. In mitral stenosis the first sound is usually vt'ry iid^ense
and is often spoken of as a "tluimiiing first siiund " or as a "sharp
slap."
(l>) Shortening and Aveakening of the first sound at the apex,
In the course of continued fevers and especially in tyjihoid fever
the granuhir degeneration which takes place in the heart muscle is
manifested by a shortening and weakening of the first sound at the
ajicx, so that the two heart souiuls come to seem much more alike
than usual. In the later stages of tyjihoid, the first soinid may
become almost inaudible. The sharji " valvular " (pudity, which
one notices in the first apex sound mulcr these conditions, has been
attributed to the fact that weakening of the myocardium has caused
a suppression of one of the two elements which go to make u]i the
first sound, namely, tlie muscular (dement, so that we hear only the
short, sliar]) sound due to the tautening of the mitral curtains.
Clironic myocarditis, or any other change in the heart wall which
tends to enfeeble it, produces a Aveakening and shortening of the
first sound similar to that just described. Simple weakness in the
mitral first sound without any change in its duration or ])itch may
be due to fatty overgrowth of the heart, to emphysema or juuicar-
dial effusion in case the heart is covered l)y the distended lung or
by the accumulated fluid. Among A-ah'ular diseases of the heart
176 PHYSICAL DIAGNOSIS.
the one most likely to be associated with a dimuiutiou in intensity
of the tivst apex sound is mitral i-egurgitation.
((■) Doubling of the first sound at the apex.
It is not uncommon iir healthy hearts to hear in the region of
the apex impulse a doubling of the first sound so that it may be
suggested by pronouncing tlie syllables ''turrupp" or "trupp." In
health this is especially apt to occur at the end of expiration. In
disease it is associated with many different conditions involving an
increase in the work of one or the other side of the heart. It
seems, however, to be unusually frequent in myocarditis.
(2) ]\I(>dlficatlons in ilia iSmmd Smnnls as Heard at tJie Base of the
Heart.
PJ/i/sioIoffieal Vai-iaf!n)is. — The relative intensity of the pid
monio second sound, ■iN'hen compared with the second sound heard
in the conventional aortic area, varies a great deal at different pe-
riods of life. Attention was first called to this liy Yierordt,' and
it has of late j^ears been recognized by the best authi;)rities on dis-
eases of the heart, though the uiajcuity of current text-books still
repeat the mistaken statement that the acu-tic second sound is always
louder than the pulmonic second in health.
The work of Dr. Sarah E. Creighton, done in my clinic during
the summer of 1899, showed that in 90 per cent of healthy chil-
dren under ten years of age, the pulmonic second sound is louder
than the aortic. In the next decade (from the tenth to the twen-
tieth year) the pulmonic second sound is louder in two-thirds of
the cases. About half of 207 cases, between the ages of twenty and
twenty-nine, showed an accentuation of the pulmonic second, 'ndiila
after the thirtieth year the number of cases showing such accentr^r
tion became .smaller with each decade, until after the sixtieth year
we found an accentuation of the aortie second in s!xfi/-sir out ofsij-ti/-
eir/Iif eases examined. These facts are exhibited in talmlar form in
'Vierordt: "Die Messung der Intensititt der Herztoiie" (Tubingen,
1885). See also Hochsinger, "Die Auscultation des kindliolien Herzens";
Gib.son, "Diseases of tlie Ileurl" (1898) ; Uoseubach, "Diseases of the Heart"
(1900) ; AUbutt, "System of Medioiue."
AUSCULTATION OF THE HEART.
177
Figs. 110 and 111 ami appear to sliow that the relative intensity of
the two sounils in the aortic and pulmonic arteries depends yn-
marily upon the age of the individual, the ])ulnionic sound predomi-
nating in yorrth and the aortic in old age, while in the period of
middle life there is relatively little discrepancy between the two
-100%
-80%
-80%
-vo%
— co%
50%
40%
30%
20%
10%
Fig. llO.-Sliowing the Per Cent of Afcentuated Pulmonic Second Sound In Each Decade;
Based on 1,000 cases.
ifin 0/
0-9
10-lfl
20-29
DECADES.
30-30 [40-49
.50-59
60-09
70-79
90%-
80%-
V0%-
\
\
\
V
m
o
m
\
TAQES
\
I
30%-
20%-
10%-
\
\
V
-A
.^^
It is, therefore, far from frne to suppose that we can obtain evi-
dence of a pathological increase in the intensity of either of the
second sounds at the base of the heart simply by comparing it with
the .other. Pathological accentuation of the pulmonic second
sound must mean a greater loudness of this sound than should
be expected at the age of the patient in question, and not simply a
greater intensity than that of the aortic second sound. The same
12
178
PHYSICAL DIAGNOSIS.
observation obviously applies to accentuation of the aortic second
sound.
Both the aortic and the pulmonic second sounds are sometimes
100%-
i o-n
10-10
20-29
80-39
40-49
50-59
CO- CO
70-79
90%--
80%-
.r"
^
/
/
/
70 <•/—
/
/
/
m
O
n
/
>
o
/
/
30%-
20%--
loJJ^T- -
/
/
/
/
/
Fig. 111.— ShowinR the Per Cent of Accentuated Aortic Sccunil SiHiml in Kacli Decade.
Based on 1,000 cases.
very intense during great emotional excitement or after muscular
exertion, and sometimes without any obvious cause.
Path olofficril J'a riiitious.
A. Accentuation of the Pulmonic Second SonmJ.
Pathological accentuation of the second sound occurs especially
in conditions involving a backing up of blood in the lungs, sucli as
occurs in stenosis or insufficiency of the mitral valve, or in obstruc
AUSCULTATION OF THE HEART. 179
tive disease of the lungs (emphysema, bronchitis, phthisis, chronic
interstitial pneumonia). Indirectly accentuation of the pulmonic
second soiuid points to hypertrophy of the right ventricle, since
without such hypertrophy the work of driving the Ijlood through
the obstructed lung could not long be performed. If the right ven-
tricle becomes weakened, the accentuation of the pulmonic second
sound is no longer heard.
S. Weahenbiij of tlie Pulmonic Second Sound.
T^'eakenmg of the pulmonic second sound is a very serious symp-
tom, sometimes to be observed in cases of pneumonia or cardiac
disease near death. It is tlius a very important indication for
prognosis.
Pulmonarj' stenosis also weakens or abolishes tlie second sound.
C. Accent iiaf ion of the Aortic Second Sound.
I have already shown that the aortic seooiul sound is loudei'
than tlie corresponding sound in the pulmonary area in almost every
individual over sixtj' years of age and in most of tliose over forty.
A still greater intensity of the aortic second sound occurs —
(«) In nephritis, arterio-sclerosis, or an)' condition which in-
creases arterial tension and so throws an increased amount of work
ujion tlie left ventricle. Directly, therefoi'e, a ]i;itli()liigically loud
aortic sound jioints to increased resistance in the peripheral ar-
teries and indirectly to liypertrophy of the left ventricle.
(//) A similar increase in the intensity of the aortic second
sound occurs in aneurism or diffuse dilatation of tlie aortic arch.
D. JJiminution in tlie lutcn.^iti/ of tJie Aortic Second Sound.
"Whenever the amount of blood thrown into tlie aorta by the
contraction of the left ventricle is diminished, as is the case esi)e-
eially in mitral stenosis and to a lesser degree in mitral regurgita-
tion, the aortic second sound is weakened so that at the apex it
may lie inaudible. A similar effect is produced Ijy any disease
which weakens the walls of the left ventricle, such as tibrous myo-
180 PHYSICAL DIAGNOSIS.
carditis, fatty degeneration, and cloudy swelling. Eelaxation of
the peiiiilieral arteries has the same effect. In conditions of col-
lapse tlie aortic second sound may be almost or quite inaudible.
In persons past middle life the second sounds are ofteir louder
in the third or forrrth interspace than in the second, so that if we
listen only in the second space we may gain the false rmpression that
the second sounds are feeble.
Accentuation of both the second sounds at the base of the
heart may occur in health from nervous causes or when the lungs
are retracted by disease so as to uncover the conns arteriosus and
the aortic arch. Under these conditions the second sound may be
seen and felt as well as lieard. In a similar way, air apparent in-
crease in the intensity of either one of the second sounds at the
base of the heart nvdj be produced by a retraction of one or the
other lung.
iSiiiiniiiiri/. — (1) The mltrul firsf noiiiid is increased by hyper-
trophy or dilatation of the left ventricle, and among vahiilar dis-
eases especially by mitral stenosis. It is weakened or reduplicated
by parietal disease of the heart. Any of these changes may occur
temporarily from physiological causes.
(2) The puJinonlc seeond sound is usually more intense than
the aortic in children and up to early adult life. Later the aortic
second sound predominates. Pathological accentuation of the sec-
ond pulmonic sound usually p(iints to obstruction in tlie pulmonary
circulation (mitral disease, emphysema, etc.). Weakening of the
pulmonic second means failure of the right ventricle and is serious.
(3) The aortic second sound is increased pathologically by airy
cause which increases the work of the left ventricle (arteriosclero-
sis, chronic nephritis). It is diminished when the blood stream,
thrown into the aorta bj^ the left ventricle, is abnormally small
('mitral disease, cardiac failure).
(4) Changes in the tricuspid sounds are rarely I'ecognizable,
while changes in the first aortic and pulmonic sounds have little
practical siguLticance.
AUSCULTATION OF THE HEART. 181
Modifications in tlie lUtijtluii of the Cardiac Sounds.
(1) Whenever the walls of the heart are greatly weakened bj
disease, for example, in the later weeks of a case of typhoid
fever, the diastolic pause of the heart is shortened so that the car-
diac sounds follow each other almost as regularly as the ticking of
a clock; hence the term ''tivk-turk heart." As this rhythm is not
unlike that heard iir the fojtal heart, the name of " emhrijocardia ''
is sometimes applied to it. The " tick-tack " rhythm may be heard
in any form of cardiac disease after compensation has failed, or m
any condition leading to coUajjse.
(2) A less common change of rhythm is that prodaced by a
shortening of the interval between the two heart sounds owing to
an incompleteness of tlie contraction of the ventricle. This cliange
may occur in any disease of the heart when compensation fails.
(3) Tlie " Ga^iCj^ lUi ijtlun." — Shortening of the diastolic ])ause
together with doubling of one or another of the cardiac sounds re-
sults in our hearing at the apex of the heart three sounds instead
of two, which follow each other in a rhythm suggestmg the hoof
beats of a galloping horse. Such a rhythm may occur temporarily in
any heart which is excited or overworked from any cause, but when
permanent is usually a sign of grave cardiac weakness. The rhythms
so produced are usually anapeestic, ^^ ^^ — ', -^^ ^ — ', ^^-^ — ', or of
DotMing of the Second Sounds at the Base of the Heart. — At
the end of a long insp)iration this change may be observed in al-
most any healthy person if one listens at the base of the heart. ■ It
is still better brought out after muscular exertion or by holding the
breatli. In such cases it probably expresses the non-synchronous
closure of the aortic and pulmonic valves, owing to increased press-
ure ui the pulmonary circulation. Similarly in diseased condi-
tions, anythmg which urcreases the pressure either in the periph-
eral arteries or in the pulmonary circulation, and thus throws
increased work upon one or the other ventricle, will cause a doub-
ling of the second sound as heard at the base of the heart.
In mitral stenosis a double diastolic sound is usually to bp
182 PITYSJCAL DIAGNOSIS.
heard at the apex, and in the diagnosis of this disease this " double
shock sound" during diastole uiaj' be an important piece of evi-
dence, and may sometimes be felt as well as heard. The "double
shock sound" of mitral stenosis is not generally believed to repre-
sent a doubling of the ordinary second sound, although it corre-
sponds with diastole. Just what its mechanism is, is disputed.
I have said nothing about modifications in the second sound at
the apex, since this sound is now generally agreed to represent the
aortic second sound transmitted by the left ventricle to the apex.
The first sounds at the base of the lieart have also not been dwelt
upon, since they have no special importance in diagnosis.
Metallic Heart Sounds.
The presence of air in the immediate A'icinity of the heart,
as, for example, in pneumothorax or in gaseous distention of the
stomach or intestine, may impart to the heart sounds a curious
metallic quality such as is not heard under any other conditions.
'^ Jiliifflinff," "Prolongation," or " Zhiclearncss" of the Heart Sounds.
These terms are not infrequently met with in literature, but
their rrse should, I think, be discontinued. The facts to which
they refer should be explained either as faintness of the heart
sounds, due to the causes above assigned, or as faint, short mur-
murs. In their present usage such terms as " muflled " or " unclear "
heart sounds represent chiefly an rrnclearness in the mind of tlie
oliserver as to just what it is that he hears, and not any one recog-
nized pathological condition in the heart.
T^ . Sounds AuninnE (^veu tiik rERiPiiERAL Vessels.
(1) The normal heart souiuls are in adults audil)le over the
carotids and over the subclavian arteries. In childhood and youth
only the second heart sound is thus audible.
(2) In about 7 per cent of normal persons a systolic sound can
be heard over the femoral artery. This sound is obviously not
AUSCULTATION OF THE HEART. 183
transmitted from the heart, and is usually explained as a result of
the sudden systolic tautening of the arterial wall.
In aortic regurgitation tliis arterial sound is almost always
audible not only in the femoral but in the brachial and even in the
radial, and its intensity over the femoral becomes so great that the
term "pistol-shot" sound has been applied to it. In fevers,
exophthalmic goitre, lead poisoning, and other diseases, a similar
arterial sound is to be heard much more frequently than in health.
Venous Souiuls.
The violent closure of the venous valves in the jugular is some-
times audible in cases of insuiRciency of the tricuspid valve. The
sound, has no clinical importance, and is difiicult to distinguish owing
to the presence of the carotid first sound mentioned above.
CHAPTER IX.
AUSCULTATION OF THE HEAET: CONTINUED.
Cardiac Mukmubs.
(«) Tcr)ninolo(jij.
The word "murmur" is one of the most unfortunate of all the
terms used in the description of physical signs. No one of the
various blowing, whistling, rolling, rumbling, or piping noises to
which the term refers, sounds anything like a "murmur" in the
ordinary sense of the word. Nevertheless, it does not seem best
to try to replace it hj any other term. The French word " soujfle "
is much more accurate and has become to some extent Anglicized.
Under the head of cardiac murmurs are included all abnormal
sounds produced within the heart itself. Pericardial friction
sounds and those produced in tliat portion of the lung or pleura
which overlies the heart are not considered "murmurs."
(b) Mode of Production.
With rare exceptions all cardiac murmurs are produced at or
near one of the valve orifices, either by disease of the valves them-
selves resulting in shrivelling, thickening, stiffening, and narrowing
of tlie valve curtains, or by a strctcluug of the orifice into which
the valves are inserted.
Diseases of the valves themselves may lead to the production of
murmurs :
(a) Wlien the valves fail to close at the proper time (incompe-
tence, insufficiency, or regurgitation).
{b) When the valves fail to open at the proper time (stenosis
or obstruction) .
AUSCULTATION OF THE HEART. 185
(c) When the surfaces of the valves or of the parts immedi-
ately adjacent are roughened so as to prevent the smooth flow of the
blood over them.
((/) When the orifice which the valves are meant to close is di-
lated as a result of dilatation of the heart chamber of which it forms
-e-
FiG. 112.— Diagram to Illustrate the Production ol a Cardiac Murmur Tlirough Regurgitation
from the Aorta or in an Aneurismal Sao. The arrow shows the direction of the blood cur-
rent and the curled lines the audible blood eddies,
the entrance or exit. The valves themselves cannot enlarge to
keep pace with the enlargement of the orifice, and hence no longer
suiiice to reach across it.
The piresence of any one of these lesions gives rise to eddies
in the blood current and thereby to the abnormal sounds to which
we give tLe name murmurs.' (SeeEigs. 11-!, 113 aud 114.) When
:^-
Fii.. 1J3. Di;igraui to Illustrate the Production of a Cardiac Murmur Through Stenosis of a
Valve-Oriflce.
valves fail to close and so allow the blood to pass back through
them, we speak of the lesion as refjurgitation, insufficiency, or in-
competence ; if, for example, the aortic valves fail to close after
the left ventricle has thrown a column of blood into the aorta,
some of this blood regurgitates through these valves into the ven-
' The method by which functional murmurs are produced will be discussed
later. (See page 194.)
186 PHYSICAL DIAGNOSIS.
trii'le from Avliieli it lias just been expelled, and we speak of tlie
lesion as " aorfir rf(iiiriiltiilU>ii," and of the nuivnnir so produced as
an itortii- ri-ijunjUdiit niiiniiiir or a murmur of aortic regurgitation.
A similar regurgitation from the left ventricle into the left auricle
takes place in I'ase the mitral \alve fails to close at the beginning
of systole. If, on the other hand, the mitral valve fails to open
pro]ierly to admit the blood which slionld How during diastole from
the left auricle into the left ventricle, we speak of the condition as
initnd xtciiosli or initi'al ohal ruction. A similar narrowing of the
aortic valves such as to hinder the egress of blood during the systole
of the left ventricle is known as imrtlc atciiiisia or obstruction. Val-
FIG. 114.— Diiignnu In llUlstniU^ thr l'ri)durUoii of Ciiriliac. Muriliurs Tliniuilll Uougitienlng of a
Viilvc.
vular lesions of the right side of the heart (tricuspid and pulmonie
vaU'cs) are comparatively rare, Imt are produc^ed and named in a
way similar to those just described.
The facts most important to know about a murmur are :
(1) Its i)lace in the cardiac cycle.
(2) Its point of maximum intensity.
(0) The area over which it can be heard.
(4) The effects of exertion, respiration, or position upon it.
Less important tiian the above are:
(fi) Its intensity,
((i) Its (piality.
(7) Its length.
(8) Its relation to the normal sounds of tlu^ heart.
Each of these iioints will now be taken up in detail:
(1) T'niir iif Dfurtimrs. — The first and most important thing to
iscertain regarding a murmur is its relation to the normal cardiac
cycle; that is, whether it occurs during systole or during diastole,
or in case it does not lill the whole of one of those jjcriods, in what
AUSCULTATIOX OF THE HEART. 187
part of systole or diastole it occurs. It must be borne in mind that
the period of systole is considered as lasting from the beginning of
the tirst sound of the heart up to the occurrence of the second
sound, while diastole lasts from the beginning of the second sound
untd the beginning of the first sound in the next cycle. Any mur-
mur occurring with the first sound of the heart, or at the time when
the first sound should take place, or in any part of the period inter-
vening between the first somid and the second, is held to be si/stoUc.
]\Iurmurs which distinctly follow the first soimd or do not begin
until the first sound is ended are known as lute sijstoUc murmurs.
On the other hand, it seems best, for reasons to be discussed
more in detail later on, not to give the name of diastolic to all
murmurs which occur within the diastolic period as above defined.
!Murmurs which occur during the last part of diastole and which
run up to the first somid of the next cycle are usually known as
"jyresi/sfi'lic " murmurs. All other murmurs occurring during dias-
tole are kno\nr as diastolic.
The conimi:inest of all the errors in the diagnosis of disease of
the heart is to mistake systole for diastole, and thereby to misin-
terpret the significance of a murmur heard during those periods.
This mistake would never happen if we were always careful to
make sure, by means of sight or touch, just when the systole of
the heart occurs. This may be done by keeping one finger upon
the apex impulse of the heart or upon the carotid artery while
listening for murmurs, or, in case the apex impulse or the jjulsa-
tions of the carotid are better seen than felt, we can control hj the
ej-e the impressions gained by listenmg. It is never safe to trust
our appreciation of the cardiac rhythm to tell us which is the first
heart sound and which the second. The proof of this statement
is given 1)}- the numberless mistakes made through disregarding it.
Equally untrustirorthy as a guide to the time of systole and dias-
tole is the radial pulse, which follows the cardiac systole at an
interval just long enough to mar our calculations.
(2) Localizations of Murmurs. — To localize a murmur is to find
its pomt of maxmiiun intensity, and this is of the greatest impor-
tance in diagnosis. Long experience has shown that mm-mm-s
188 PHYSICAL DIAGyOSTS.
lieavd loiulest in the vegion of the aiiex beat (wheflier this is in the
imnual situation ov disphieed), are iu the vast luajoiity of eases ]iro-
dueed at the mitral \al\e. In ahoiit tive per eeut of the eases mitral
murmurs maybe best heard at a point midway between the jiosition
of the normal eardiac impulse and the ensiform cartilage, or (rarely)
an ineh or two above this situation.
iMurnuus heard most loudly in the second left intercostal space
are almost invariably piroduced at the pulmonic orifice or just above
it in the conus arteriosus.
jMurinurs whose nu^ximum intensity is at the root of the ensi-
form cartilage or within a radius of an inch and a half from this
point are usually produced at the tricuspid orifice. IMurmui's pro-
duced at the aortic orifice nuiy be heard best in the aortic area, but
in a large proportion of cases are loudest on the other side of the
steinnm at or about the situation of the fourth left costal cartilage.
OccasiiMially they are best heard at the apex of the heart in the
axilla or over the lower part of the sternum (see below, Fig. 137).
(3) TriDisinissioii of Jliinniirs. — If a murmur is audible over sev-
eral valve areas, the questions uatirrally arise: "How are ive to
know ■ndiether we are dealing with a single valve lesion or with
several? Is this one murmur or two or three murmurs? " Obvi-
ously the C[uestiou can be asked only iu case tlie murmirr which we
find audible iu various places occupiies everywhere the same time
in the cardiac cycle. It must, for exampile, be everywhere systolic
or everywhere diastolic. A systolic mrrrmur at the apex caiiuot
be srrpposed to point to the same lesioir as a diastolic murmur, uo
matter where the latter is heard. But if we hear a systolic mur-
mur in variorrs parts of the chest, say over the aortic, mitral, and
tricusind regions, how are we to know whether the sound is sim]ile
or compound, whether produced at one valve orifice or at several?
This question is sometimes difficult to answer, and iu a given
case skilled observers nmy differ in their \'erdict, but, as a rule, the
difficulty may be overcome as follows :
(1) Experience and post-mortem examination have sho^\ai that
the murmur jiroduced by each of the val\-ular lesions has its own
characteristic area of propagation, over which it is heard with aii iu-
AUSCULTATION OF THE HEART.
189
tensity which regularly (liiiiiiiishes as we recede from a maximum
whose seat correspoiiils with some one of tlie valve areas just de-
cribed. These areas of propagation are shown in Figs. 125, 1'2(>, 129,
and 134. Any murmur whose distribution does not extend beyond
one of these areas, and which steadily and progressively diminishes
in intensity as we move away from the valve area over which it is
loudest, may be assumed to be due to a single valve lesion and no
Fig. 115.— Mitral and Tricuspid Regurgitation. The intensity of the systolic murmur is least at
the '' waist " of the shaded area and Increases as one approaches either end of it.
more. Provided but one valve is diseased, this course of procedure
gives satisfactory results.
(2) When several valves are diseased and several murmurs may
be expected, it is best to start at some one valve area, say in the
mitral or apex region, and move the stethoscope one-half an inch
at a time toward one of the other valve areas, noting the intensity
of any murmur we may hear at each of the different pomts passed
over. As we move toward the tricuspid area, we may get an im-
pression best expressed by Fig. 115. That is, a systolic murmur
heard loudly at the apex may fade awa)^ as we move toward tlie
ensiform, until at tlie point x (Fig. 115) it is almost inaudible. But
as we go on in the same direction the inurniur i.iay begin to grow
190 PHYSICAL DIAGXOSIS.
louder (and perhaps to change in pitch and quality as -well") until a
maximum is reached at the tricuspid area, beyond which tlie mur-
mur again fades out.
Tliese facts justify us iu siisjicrtini/ that we are dealing witli two
murmurs, one produced at the tricuspid and one at the mitral ori-
fice. The suspicion is more lHvely to be correct if tliere has been
a change m tlie pitch and quality of tlie murmur as we ncared the
tricuspid orifice, and may be confirmed by the discovery of other
evidences of a doirble lesion. JVo diagnosis is sat isf actor// tr/iich
risf.-i on the evidence of iniiniuirs ahnie. Changes in the size of
the heart's chambers or iu tlie pulmonary or peripheral circulations
are tlie most important facts iu the ease. Nevertheless the eifort
to ascertain and graphically to represent the intensity of cardiac
munuurs as one listens along the line connecting the valve areas
has its value. An "hour-glass" murmur, such as that represented
in Fig. 115), generally means tico-ealve lesions. A similar "hour-
glass " may be found to represent the auditoiy facts as we move
from the mitral to the pulmonic or to the aortic areas (see Fig.
IIG) and, as in the previous case, arouses our suspicion that more
than one valve is diseased.
It must not be forgotten, however, that "a murmur may travel
some distance underground and emerge with a change of qiuility "
(AUbutt). This is especially true of aortic murmurs, which are often
heard well at the apex and at the aortic area, and faintly iu the in-
tervening space, probably owing to the interposition of the right
ventricle.
In such cases we must fall back upon the condition of the heart
itself, as shown by inspection, palpation, and percussion, aiul upon
the condition of the pulmonary and peripheral circulation, as
shown in the other sj'iuptonis and signs of the cases (dropsy, cough,
etc.).
(4) Intensit!/ of Jfiiniiiirs. — Sometimes murunirs are so loud
that they are audible to the patient himself or even at some dis-
tance from the chest. In one case I was able to hear a murmur
eight feet from the patient. Such cases are rare and usually not
serious, for the gravity of the lesion is not at all proportional to
AUSCULTATION OF THE HEART.
191
the loudness of the murmur; indeed, otlier things being equal,
loud murmurs are less serious than faint ones, provided we are sure
we are deaUug with organic lesions. (On the distinction between
the organic and functional murmurs, see below, p. 19G. )
A loud murmur means a powerful heart driving the blood
strongly over the diseased valve. When the heart begins to fail,
the intensity of the murmur proportionately decreases because the
blood does not flow swiftly enough over the diseased valve to pro-
FiG. 116.— Mitral Repurffitation and A nrtic Stenosis. The systolic murmur is loudest at the ex-
tremities of the shaded area and faintest at its "waLst."
duce as loud a sound as formerly. The gradual disappearance of
a m.urmur known to be due to a vahoilar lesion is, therefore, a very
grave sign, and its reappearance revives hope. Patients are not
infrequently admitted to a hosjiital with valvular heart trouble
which has gone on so long that the muscle of the heart is no longer
strong enough to produce a murmur as it pumps the blood over the
diseased valve. In such a case, under the influence of rest and
cardiac tonics, one may observe the development of a murmur as
the heart wall regains its power, and the louder the murmur be-
comes the better the condition of the patient. On the other hand,
when the existence of a valvular lesion has been definitely deter
192 PHYSICAL DIAGNOSIS.
mined, and yet the compensation remains perfectly good (for exam
pie, in the endocarditis occurring in chikben in connection with
chorea), an increase in the loudness of the murmur may run paral-
lel witlr the ad^-ance in the -i'ahiilar lesion.
In general the most important point about the intensity of a
mnrmnr is its increase or deo-ease while under observation, and not
its loudness at any one time.
(5) Qitalifi/ of Heart 3Iiirnturs. — It has been already mentioned
that the quality- of a heart murmur is never anything like the
sound which we ordinarily designate by the word "murmur." The
commojiest type of heart murmur has a blowing quality, whence the
old name of ''helloics soujid." The sound of the letter ''f " pro-
longed is not imlike the quality of certam murmurs. Blowing
tniirmurs may be low-pitched like the sound of air passing through
a large tube, or high-pitched approaching the sound of a whistle.
This last ty}>e merges into that known as the musical murmur, in
which there is a definite musical sound whose pitch can be identi-
fied. £as2}inrf or tearing sounds often characterize the louder
varieties of murmurs.
Finally, there is one tj^^e of sound which, though included
under the general name murmur, differs entirely from any of the
other soiuids just described. This is the "_/;rtw/«fo//(3 roll," which,
has a rumblini/ or bluhhering quality or may remind one of a short
drum-roll. This murmur is always presystolic in time and usuallj
associated with obstruction at the mitral or tricuspid valves. Not
infrequently some part of a cardiac mxirmur will have a musical
quality while the rest is simply blowing or rasping in character.
Musical murmurs do not give us evidence either of an especially
serious or especially mild type of disease. Their chief importance
consists in the fact that they rarely exist without some valve
lesion,' and are, therefore, of use m excluding the tjqie of mur-
mur known as "functional," presently to be discussed, and not
due to valve disease. Very often rasping murmurs are associated
either with the calcareous deposit upon a valve or very marked
narrowing of the valve orifice.
' Kosenbach holds that they may be produced by adhesive pericarditis
AUSCULTATION OF THE HEART, 193
Murmurs may be accented at the beginning or the end; that is.
they may be of the crescendo type, growing louder toward the end,
or of the decrescendo type with their niaxiniuni intensity at tlie
beginning. Almost all murmurs are of the latter type except tliose
associated with mitial or tricusjnd obstruction.
(6) Length of Murmurs. — Murmurs may occupy the whole
of systole, the wh(.)Ie of diastole, or only a portion of one of
these periods, but no conclusions can be drawn as to the severity
of the valve lesion from the length of the murmur. A short mur-
mur, especially if diastolic, may be of very serious prognostic im-
port.
(7) Itelatioiis to the Nornuil Sounds of the Heart. — Cardiac mur-
murs may or may not replace the normal heart sounds. They may
occur simultaneously witli one or both sounds or between the
counds. These facts have a certain amount of significance in prog-
nosis. Murmurs whicli entirely replace cardiac soiuids usually mean
a severer disease of the affected valve than murmurs which accom-
[lany, bnt do not replace, tlie normal heart sounds. Late systolic
murmurs, which occur between the tirst and the second sound, are
usually associated with a relatively slight degree of valvular dis-
ease. Late diastolic murmurs, on the other hand, have no such
favorable significance.
(8) Effects of Position, Exercise, and Respiration upon Cardiac
Ifnrmurs. — Almost all cardiac murmurs are affected to a greater
or less extent by the position which the patient assumes while he
is examined. Systolic murmurs which are inaudible while the
patient is in a sitting or standmg position may be quite easily
heard when the i^atient lies down. On the other hand, a pre-
systolic roll which is easily heard when the jjatient is sitting up
may entirely disap)pear when he lies down. Diastolic murmurs
are relatively little affected by the position of the jjatient, but
in. the majority of cases are somewhat Louder ui the upright posi-
tion.
The effects of exercise may perhaps be fitly mentioned here.
Feeble murmurs may altogether disappear when the patient is at
restj and under such circumstances may be made easily audible by
13
194 PHYSICAL DIAGXOSIS.
getting the patient to walk briskly up and doAvn the room a few
times. Such lesions are usually comparatively slight.' On the
other hand, murmurs which beeome more marked as a result of rest
are generally of the severest type (see above, p. 190).
Organic murmurs are usually better heard at the end of expira-
tion and become fainter during inspiration as the expanding limg
covers the heart. This is especially true of those produced at the
mitral valve, and is in marked contrast with the variations of func-
tional murmurs which are heard chiefly or exclusively at the end of
inspiration.
(9) Siidde/i Mefamor/iliosis of Mitfiinirs. — In acute endocarditis,
when vegetations are rapidly formuig and changing their shape
upon the valves, murmurs may appear and disajipear very sud-
denly. This metamorphosing character of cardiac murmurs, "wlicn
taken in connection with other physical signs, may be a very im-
portant factor in the diagnosis of acute endocarditis. In a similai
way relaxation or rupture of one of the tendinous cords, occurring
in the course of acute endocarditis, may effect a very sudden change
in the auscultatory phenomena.
" Fiinctioiiiil IIurnuDS."
ISTot every m^irmur which is to be heard over the heart points to
disease either in the valves or in the orifices of the heart. Perhaps
the majority of all murmurs are thus unassociated with vahiilar
disease, and to such the name of "accidental," "functional," or
" hsemic " murmurs has been given. The origin of these " functional "
murmurs has given rise to an immense amount of controversv, and
it cannot be said that any one explanation is now generally agreed
upon. To me the most plausible view is that which regards most
of them as due either to a temporary or iiermanent dilatation of
the conus arteriosus, or to pressure or suction exerted u]Hin the
overlapping lung margins by the cardiac contractions. This ex-
plains only the systolic functional nuirmnrs, which make up ninety-
nine per cent, of all functional murmurs. The diastolic functional
murmurs, which undoubtedly occur, although with exceeding rarity,
> For exception to this see below, page 216.
AUSCULTATION OF THE HEART. 195
are probably due to stretcliing of tlie aortic ring or to sounds pro-
duced in the veins of the neck and transmitted to the vena cava.
Characteristics of Functional Murmurs. — (1) Ahnost all func-
tional murniurs are systolic, as has before been mentioned.
(2) The vast majority of them are heard best over the pulmonic
valve in the second left intercostal space. From this point tliey
are transmitted in all directions, and are frequently to be heard, al-
tliGugh with less intensity, in the aortic and mitral areas. Occa-
sionally they may have their maximum intensity in one of the latter
positions.
(•3) As a rule, they are very soft, short, and blowing in quality,
though exceptionally they may be loud and rough.
(4) They are not associated with any evidence of enlargement
of the heart nor with accentuation of the pulmonic second sound. '
(5) They are usually louder at the end of inspiration.
(6) They are usually heard over a very limited area and not
transmitted to the left axilla or to the back.
(7) They are especially evanescent in character ; for example,
they may appear at the end of a hard run or boat race or during
an attack of fever, and disappear within a few days or hours. Ees-
piration, position, and exercise produce greater variations in them
than in "organic" murmurs.
(8) They are especially apt to be associated with anceinia^
although the connection between anaemia and functional heart mur-
murs is by no means as close as has often been supposed. The
severest types of anaemia, for example pernicious anaemia, may not
be accompanied by any murmur, while, on the other hand, typical
functional murmurs are often heard in patients whose blood is nor-
mal, and even in full health. Yet in three cases of intense anaemia
I have heard diastolic murmurs loudest at the fourth left costal car-
tilage and leading to a diagnosis of aortic regurgitation. At au-
topsy the aortic valves were in each case sound, and I am at a loss
' 111 chlorosis the second pulmonic sound is often very loud (owing to the
retraction of the lungs and uncovering of the conus arteriosus) and associated
with a systolic murmur.
196 PHYSICAL DIAGXOSIS.
to ;a\'oiiiit f'ni- the luuniuirti. ' It sliould not be fuvgotteu that a
real, though tempoi-arv, leakage through the mitral or trieu>|ail
valve may he associated ^vitll aii;¥mia or debilitated eouditions
owing to wfidcening of tlie papillary muscles or of the uii; ::il
sphincter. lu such cases we tiiid lift tlie signs of a functional
murmur, as above described, but the evidence of an organic valve
lesion hereafter to be described.
The distinctions between organic and functional heart murmurs
may be summed up as follows :
Onjuiiie iiiitniiurs may occupy anj^ part of the cardiac cj'cle ; if
systolic, fhey are usually traitsiuitted either into the axilla and
back or into the great vessels of the neck; they are usually asso-
ciated with evidences of cardiac enlai-gement and changes ia the sec-
ond sounds at the base of the heart, as well as with signs and sjinp-
toms of stasis in other organs. Organic murmurs not infrequently
have a musical or rasping qualitj-, although this is by no means al-
ways the case. They are rarely loudest in the pulmonic area and
are relatively uninfluenced by respiration, positiou, or exercise.
Functional murmurs are almost always systolic in time and
usually heard with maximum intensity in the piulmonic area. They
are rarely transmitted beyond the precordial region and are usually
loudest at the end of inspiration. They are not aecomjianied by
e-^-idences of cardiac enlargement or pathological accentuation of
the second sounds at the base of the heart, nor by signs of venous
stasis or dropsy. They are veiy apit to be associated with anaemia
or with some special attack upon the resources of the body {e.g.,
physical overstrain or fe^-er), and to disapjiear when such forces are
removed. They are usually soft in quality ; ne^'er musical. The
verj' rare diastolic functional murmur occurs exclusivelv, so far as
1 am aw^are, in conditions of profound ana?niia; i.e., when the li;¥mo-
globin is twenty-five per cent or less. It can sometimes lie abolished
by jiressiug the jugular bulb ;iiid can tlien be obser\-cd, if foUowed
to the necl;, to pass over gradually into a continuous venous luun with
a diastolic accent.
' Cabot and Lmkr, .Inhiis Ilt.pkins Bulletin. Jlay, 11103.
AUSCULTATION OF THE HEART. 197
Cd r(] io-Ilespirat'ir}j BTitrmiirs.
When a portion of tlie free margin of the Inng is iixed by ad-
hesions in a position overlapping the heart, the cardiac movements
may rhythmically displace the air in sucli i)iece of lung so as to
give rise to sounds wliich at times closely simulate cardiac jinir-
niurs. These cnuditions are most often to be found in the tongue-
like projection of the left lung, which normally overlaps the heart,
but it is probably the case that cardio-respiratory murmurs may be
produced without any adlresiou of the lung to the pericardiuju
under conditions not at present understood. Such murmurs may
be heard under the left clavicle or below the angle of the left scap-
ula, as well as near the apex of the heart, — less often iir other jDarts
of the chest.
Cardio-respiratory murmurs may be either systolic or diastolic,
but the vast majority of cases are systolic. The area over which
they are audible is usually a very limited one. They are greatly
affected by position and by respiration, and are heard most distinctly
if not exclusively during inspiration, esjiecially at the end of that
act. (This fact is an important aid in disturguishing them from
true cardiac murmurs, which are almost always fainter at the end
of inspiration.) They are also greatly affected by cough or forced
respiration or by holding the breath, whereas cardiac murmurs
are relatively little changed thereby. Pressure on the outside
of the thorax and in their vicinity may greatly modify their in-
tensity or quality, while organic cardiac murmurs are but little
influenced by pressure. As a rule, they have the quality of nor-
mal respiratory murmur, and sound like an inspiration interrupted
by each diastole of the heart.
In case the effect of the cardiac movements is exerted upon a
piece of lung in which a catarrhal jjrocess is gomg on, we may have
systolic or diastolic explosions of rales, or any type of respiratory
murmur except the bronchial type, since this is produced in solid lung
which could not be emptied or filled under the influence of the car-
diac movements. Cardio-respiratory murmurs have no special diag-
nostic significance, and are mentioned here only on account of the im-
If'S PHYSICAL DIAGNOSIS.
povtance of not eonfasing them vritii true cardiac murmurs. They
were formerly thought to indicate phthisis, but such is not the case.
Jlin-iiiiirs of J'eiioiis Oriijin.
I have already mentioned that the venous hum so often hetxrd
in the neck in cases of anemia may be transmitted to tlie j-egiou of
the base of the heart and heard there as a diastolic murmur owing
to the acceleration of the venous current by the aspiration of the
right ventricle during diastole. Such murmurs arc very rare and
may usually be obliterated b^y pressure upon the bulbus jugnlaris,
or even by the compression brought to bear upon the veins of the
neck when the head is sharply turned to one side. They are heard
better in the upright position and during inspii-ation.
Art IT id I JIiir»nirs.
(1) Eoughening of the aich of the aorta, due to chronic end-
aortitis, is a freipient cause in elderly men of a systolic murmur,
heard best at the base of the heart and transmitted into the vessels
of the neck. Such a murmur is very rarely accompanied by a pal-
pable thrill. From cardiac murmurs it is distinguished by the lack
of any other evidence of cardiac disease and the presence of marked
arterio-sclerosis in the peripheral vessels (see further discussicm
under Aortic Stenosis, p. 239, and under Aneurism, p. 282).
(2) A narrowing of the lumen of the subclavian artery, due to
some abnormality in its course, may give rise to a systolic mur-
mur heard close below the clavicle at its outer end. The mur-
mur is greatly influenced by movements of the arm and especially
by respiratory movements. During inspiration it is much louder,
and at the end of a forced expiration it may disappear altogetlier.
Occasionally such murmurs are transmitted through tbe clavicle so
as to be audible above it.
(3) Pressure exerted upon any of the superficial arteries (carot-
id, femoral, etc.) produces a systolic murmur (see below, p. 237).
Diastolic arterial murmurs are peculiar to aortic regurgitation.
(4) Over the anterior fontanelle in infants and over the gravid
uterus systolic murmurs are to bo heard which are probably arterial
in origin.
CHAPTER X.
DISEASES OF THE HEART.
VALVULAE LESIONS.
Clinically it is convenient to divide the ills whicli befall the
heart into three classes :
(1) Those which deform the cardiac valves (valvular lesions).
(2) Those which weaken the heart wall (parietal disease).
(3) Congenital malformations.
Lesions which affect the cardiac valves without deforming them
are not often recognizable during life. The vegetations of acute
endocarditis' do not usually produce any peculiar physical signs
until they have so far deformed or obstructed the valves as to pre-
vent their opening or closing properly.
The murmurs which are often heard over the heart in cases of
acute articular rheumatism cannot be considered as evidence of
vegetative endocarditis unless vahiilar deformities, and their re-
sults in Ai-ahTilar obstruction or uicomjjetency, ensue. The chordae
tendinese may be ruptured or shortened, thickened, and welded to-
gether uito shapeless masses, but if these deformities do not affect
the action of the valves we have no means of recognizing them dur-
ing life. Congenital malformations are practically unrecognizable
as such. If they do not affect the valves, we cannot with any cer-
tainty make out what is wrong.
For physical diagnosis, then, heart disease means either de-
' See Appendix.
200
PHYsTf'AL DTAOyOSIS.
• fonuetl val\-es or \\'e:ikeiied ^^•alls. ^Vhateve^■ else may exist, wt
are none the wiser for it unless the autopsy enlightens us.
In this chapter I shall confine myself to the discussion of ^-ahTi-
lar lesions and their results.
Valvular lesions are of two tvvies :
('() Those which jnodu'e partial o instruction of a valve orifice
or ]irevent its opening fully {'' t;ti-iiot^in'') .
■ '^"^
atr.i &, r""l'
onalj^
VaJrula
■seniilQnan>
f
■ Trl<;
■PS fi)>rf.-.; -
^-^.
Cu.iil.
bicui
[mil
anlortoi-
nine ■ J,
i.Ulis-
'^'
Xqf'
Valvuln flpmilunaris
\ Valvalft Bomilu-uarig
^ yl^.^tL•^i<>^ iicrto.0
\
!^ CiiFpls
\ _ . Vulvuiie
_^, \ C'i^.Pl^ ' triocs-
CiLspis
\ \
\
1
\
\
-_
...J-"-'"
\
Fig. 117.— The Base of tlie Ci'iiirartpd Heart Sliowfnsr Siii'inrti-ric .\etion of the :Mu.'ic'Ular Fibres
surniLuidinfr the Mitral and Tricuspid Valves. The outer dotted line is the outline of the
rela.xed heart. The inner dotted cireles show the size of the mitral and tricuspid valves
during diastole, a. Outline of the heart when relaxed ; b, outline of the relaxed tricuspid
valve; c, outline of the mitral orifice during diastole. (Af er Spalteholz.)
(7() Those which produce leakage through a valve orifice or
prevent its closing effectively (" i-ci/iir(^/it<(tioii," " liii:iijficii'iici/,"
" iiicomjjctenci/ ").
VALVULAR LESIONS.
201
Stenosis results always from the stiffening, thickening, and con-
traction of a valve.
Kegurgitation, on the other hand, may be the result either of —
(«) Deformity of a valve, or
(h) Weakening of the lieart muscle. .
The mitral and tricuspid orifices are closed not simply by the
shutting of their valves, but also in jjai't by the sphincter-like
Mitral curtains.
Chordea
tendineEe.
Papillary
muscle.
Myocardium.
Pericardium.
Fig. 118.— The Mitral Valve Closed, Showing tbe Action of the Papillary Muscles. (After
Spalteholz.)
action of the circular fibres of the heart wall (see Fig. 117) ami ii.e
contrartion of the papillary muscles (Fig. 118).
In birds the tricuspid orifice has no valve and" is closed' wholly
by the muscular sphincter of the heart wall.
In conditions of very acute cardiac failure, such as may occur
after a hard run, the papillary muscles are in all probability relaxed,
so that the valve-flaps swing back into the auricle and permit regur-
gitation of Itlood from the vertricle.
202 PHYSICAL DIAOXOSIS.
Valvular ineompetence, then, differs from valvular oIi.<:fnii'fion
in that the latter ahva^-s involves deformity and stiffening of valves,
while ineompetenee or leakage is often the result of deficient inus-
cnlar action on tlie part of the heart wall. An osbtructed valve is
almost always leaky as well, since tlie same deformities a\ liich ])re-
vent a valve from opening usually prevent its closure; hut t/iis rule
docs not irorl- hackivard. A leaky valve is often not obstructed.
It is leaky but not osbtructed if the valve curtain has been practi-
cally destroyed by endocarditis; or, again, it is leaky but not ob-
structed if the leak represents muscular weakening of the mitral
sphincter or of the papillary muscles. Pure stenosis is very rare.
Pure regurgitation is very common. esiie(^iallv at tlie mitral.
Wlien valves are so deformed that their orifice is loth leaky and
obstructed, we have what is known as a " combined " or " double "
valve lesion.
Since vahmlar lesions are recognized largely by their rcstdts,
first upon the walls of the heart itself and theu upon the other
organs of the body, it seeiffe best to give some account of these
results before passing on to the description of the indi^-idual le-
sions in the heart itself.
The results of vahuilar lesions are first conservative and later
destructive. The conservative results are known as:
Tlie cstahllsliminit of conijjensatio)). tliroin/Ji liijpi-rtropJnj.
The destructive or degenerative results are known as :
The failure of co»ij)ensatio>i tlivough {or witliout) dilatation
I shall consider, then,
((') The establishment and the failure of compeiisatiou.
ill) Cardiac hypertropihy.
(r) Cardiac dilatation.
ESTABLISHMENT AND FAILURE OF COMPENSATION IN
VALVULAR DISEASE OF THE HEART.
We may discriminate three periods in the pirogress of a case oi
valvular heart disease :
VALVULAR LESIONS. 203
(1) The period before the establishment of compeiisatiou.
(2) The period of compensation.
(3) The period of failing or ruptured compensation.
(1) Compensation Not Yet Established.
In most cases of acute val^arlar endocarditis, whether of the
relatively benign or of the malignant type, there is a time when
the lesion is perfectly recognizable despite the fact that compensa-
tory hypertrophy has not yet occurred. In some cases this period
may last for months ; the heart is not enlarged, there is no accentu-
ation of either second sound at the base, there is no venous stasis,
and our diagnosis must rest solely upon the presence and character-
istics of the murmur. For example, in early cases of mitral regur-
gitation due to chorea or rheumatism, the disease may be recog-
nized by the presence of a loud musical murmur heard in the back
as well as at the apex and in the axilla. Lr the earlier stages of
aortic regurgitation occurring in young people as a complication of
rheumatic fever, there may be absolutely no evidence of the valve
lesion except the characteristic diastolic murmur. In most text-
books of physical diagnosis I think too little attention is given to
this stage of the disease.
(2) The Period of Compensation.
Valvular disease would, however, soon prove fatal were it not
for the occurrence of compensatory hypertrophy of the heart walls.
To a certain extent the heart contracts as a single muscle, and in-
creases the size of all its walls in response to the demand for in-
creased work ; but as a rule the hy[)ertropliy affects especially one
ventricle — that ventricle, namely, upon which especially demand is
made for increased power in order to overcome an increased resist-
ance in the vascular circu.it which it supplies with blood. What-
ever increases the resistance in the lungs brings increased work
upon the right ventricle ; whatever increases the resistance in the
aorta or peripheral arteries increases the amount of work which the
left ventricle must do.
204 PHYSICAL DIACrXOSIS.
Xow, any disease of tlie mitval valve, whether obstnietioii or
leakage, results in engoigemeiit of the lungs with blood, and hence
demands an increased amount of woik on the part of the right
ventricle in ordei- to force the Llood through the overcrowded pul-
monary vessels ; hence it is in mitral disease that we find the great-
est compensatory hypertrophy of the light ventricle.
On the other hand, it is obvious that olistruction at the aortic
valves or in the peripheral arteries (arterio-sclerosis) demands an
increase in power in the left ventricle, in order that the requisite
amount of blood may be forced through arteries of reduced calibre,
while if the aortic valve is so diseased that a part of the blood
thrown into the aorta by the left ventricle returns 'into that ven-
tricle, its work is thereby greatly increased, since it has to contract
upon a larger volume of blood.
In response to these demands for increased work, the musculai
wall of the left ventricle mcreases in thickness, and com|)ensation is
thus established at the cost of an increased amount of work on the
part of the heart.'
(3) Failure of Comjiensation.
Sooner or later in the vast majority of cases the heart, handi-
capped as it is by a leakage or obstruction of one or more valves,
becomes unable to meet the demands made upon it by the needs of
the circulation. Failure of compensation is sometimes associated
with dilatation of the heart and weakening of its walls. Not in-
freipieutly recurrent <'?'/ar7,'.s- nf ^\f<iiliiiij ciiiiijieii.-nition " i-i'prrscnt a
fldffi-iip rif a siii'iiildi/ri iKj injni-iifdtfis us tin' (ii:ciimpa)ujin(j li'iicoci/-
tosis (irit/i or irtfhoiit ferer) siiijijrsfs. Tliis is especially common in
children but occurs also in young adults. Sometimes, however,
neither mechanical mu' infectious changes can be found. Whatever
the cause may be, the result of rujitured compensation is venous
stiisit:; that is, (edenu\ or dropsy of various organs appears. If the
left ventricle is especially weakened, dropsy appears tirst in the
legs, on account of tlie influence of gravity, soon after in the geni-
' Roseiibach brings forwaril c\i(U'iue to sliow that tlio arteries, tlie lungs,
and other organs actively assist in maintaining compensation.
VALVULAR LESIONS. 205
tals, lungs, liver, and the serous cavities. Engorgement of tlie
lungs is especially marked in eases of mitral disease Tvitli weakening
of the right ventricle, and is manifested hy dyspmea, cyarosis,
cough, and htemoptysis. In many eases, liowevei', dropsy is very
irregularly and unaccountably distributed, and does not follow the
rules just given. In pure aortic disease, uncomplicated by leakage
of tlie mitral vah-e, dropsy is a relati\-ely late symptom, and pre-
cordial pain (angina ]iectnrisj is more [iromiuent.
HYPERTROPHY AXD IIILATATIOX.
Since cardiac hypertrophy or dilatation are not in themseh-es
diseases, but may occur in any disease of the heart (vahiilar or
parietal), it seems best to give some account of them and of the
methods by which they may be recognized, before taking up sepa-
rately the different lesions with which they are associated.
1. Cardiac Hypertropli ij.
Hypertrophy of the heart is usually due to the following causes :
First (and most frequent) : Vahmlar disease of the heart itself.
Second: Obstruction of the liow of blood through the arteries
owing to increase of arterial resistance, such as occurs in chronic
nephritis and arterio-sclerosis. Third : Obstruction to the circula-
tion of the blood through the lungs (emphysema, cirrhosis of the
lung, fibroid phthisis). Fourth: Severe and prolonged muscular
exertion (athlete's heart). Fiftli : Adlu-reut Pericardium.
In vahoilar disease the greatest degree of hypertrophy is to be
seen usually in relatively young persons, and es23ecially when the
advance of the lesion is not very rapid.
Hypertrophy of the heart in vaharlar disease is also influenced
by the amount of muscular work done bj' the patient, by the de-
gree of vascular tension, and by the treatment. In the great major-
ity of cases of hypertrophy, from whatever cause, both sides of the
heart are affected, but we may distinguish cases in which one or the
other ventricle is predominantlij affected.
206 PHYSICAL DIAGNOSIS.
(1) Cardiac liijjjertropli ij ajfcctiiuj espcciaVl ij tin; left ventricle.
(a) The apex impulse is usually lower than normal, often in
the sixth space, occasionally in the seventh or eighth.' It is also
farther to the left than normal, but far less so than m cases in
which the hypertrophy affects especially the right ventricle. The
area of visible pulsation is usually increased, and a considerable por-
tion of the chest wall may be seen to move with each systole of the
heart, while frequently there is a systolic retraction of the inter-
spaces in place of a systolic impulse.
(b) Palpation confirms the results of inspection and shows us
also that the apex impulse is unusually powerful. Percussion
shows in many cases that the cardiac dulness is more intense and
its area increased downward and to a lesser extent toward the left.^
(c) If we listen in the region of the maximum cardiac impulse,
we generally hear an unusually long and low-pitched first sound,
which may or may not be of a greater intensity than normal. A
very loud first sound is much more cliaracteristic of a cardiac weak-
ness or neurosis than of pure hypertrophy of the left ventricle.
The second sound at the apex (the aortic second sound trans-
mitted) is usually much louder and sharper than usual. Ausculta-
tion in the aortic area shows that the second sound at that point is
loud and ringing in character. Not infrequently the peripheral ar-
teries (the subclavians, brachials, carotids, radials, and femorals)
may be seen to pulsate with each systole of the heart. This sign is
most frequently observed in cases of hypertrophy of the left ven-
tricle, which are due to aortic regurgitation, but is by no means
peculiar to this disease and may be repeatedly observed when the
cardiac hypertrophy is due to nephritis or muscular work. I have
frequently observed it in healthy athletes, {d) Peripheral blood
pressure is increased (see above, p. 111).
The radial pulse wave has no constant characteristics, but de-
' This is due partly to a stretching of the aorta, produced by the increased
weight of the heart.
" Post mortem enlarged left ventricle is often found despite the absence of
the above signs in life because it extends backward out of our reach.
VALVULAR LESIONS. 207
pends rather upon tlie cause which has produced the hypertro2:iliy
than upon the hypertrophy itself.
(2) Cardiac Hypertrophy Ajfectiiuj Espieclally tlie Rigid Ventricle.
It is much more difficult to be certain of the existence of en-
largement of the right ventricle than of the left. Practically we
have but two reliable physical signs :
(a) Increase in the transverse diameter of the heart, as shown
by the position of the apex impulse and by percussion of the right
and left borders of the heart ; and
{h) Accentuation of the pulmonic second sound, which is often
palpable as well as audible.
The apex beat is displaced both to the left and downward, hut
especially to the left. In cases of long-standing mitral disease, the
cardiac impulse may be felt in mid-axilla, several inches outside the
nipple, and yet not lower down than the sixth intercostal space.
In a small percentage of cases {i.e., when the right auricle is en-
gorged), an increased area of dulness to the right of the sternum
may be demonstrated. Accentuation of the pulmonic second sound
is almost invariably present in hypertrophy of the right ventricle,
though it is not peculiar to that condition. It may be heard, for
example, in cases of pjneumonia when no such hypertrophy is pres-
ent, but in the vast majority of cases of cardiac disease we may
infer the presence and to some extent the amount of hypertrophy
of the right ventricle from the presence of a greater or lesser ac-
centuation of the pulmonic second sound. The radial pulse shows
nothing characteristic of this type of hypertrophy.
Epigastric pulsation gives us no evidence of the existence of
hypertrophy of the right ventricle, despite contrary statements in
many text-books. Such pu.lsation is frequently to be seen in per-
sons with normal hearts, and is frequently absent when the right
ventricle is obviously hyp)ertrophied. It is perhaps most often due
to an unusually low position of the whole heart.
208
PHYSICAL DIAGXOSIS.
A
^
I'lLATATTOX OF THK HkAET.
(1) Acute I>i]iitiifii>ii. — Immediately after severe inus«ular exer-
tion, as, for example, at the finisli of a lioat race, or of a two-mile
run (es|ieciallY in jiersons not properly trained', an aente cardiac
dilatation is said to occur, and in deliilitated or iioorly nourished
subjects such an acaite dilatation may he serious or even fatal in its
results. I have never seen this in healthy persons.
(2) Chronic dilatation comes on. gradually as a result of vahij-
FiG. 119. —Dilated Heart. From v. Ziemssen's Atlas.
lar disease or other cause, and gives rise to practicallj' tlie same
pihysical signs as those of acute dilatation, from 'which it differs
chiefly as regards the accompanying physical phenomena and the
prognosis. Briefly stated, the signs of dilatation of the heart,
whether acute or chronic, are :
(fi) Feebleness and ivrcgulai'itij of the apex inijiulse and of the
radial impulse, (b) enlnri/enient of the heart, as indicated by inspec-
tion, palpation, and percussion, and (sometimes) (r) wiirmui-s indi
cative of stretching of one or another of the vahnilar orifices.
VALVULAR LESIONS. 209
DUotaftiiii of till- Left Vcntiide.
Inspection shows little that is not better brought out by palpa-
tion. Palpation reveals a "tiapjiing" cardiac impulse, or a vague
shock disi)laeed both downward and to the left and diffused over
an abnormally large area of the chest wall. Percussion verifies
the position of the cardiac impulse and sometimes shows an unusu-
ally blunt or rounded outline at the apex of the lieart.
Ou auscultation, the first sound is usually I'crij s/iort and sharp,
but not feehle unless it is aocoiupanied by a murmur. In case the
mitral orifice is so stretched as to render the valve incompetent, or
in case the muscles of the heart are so fatigued and weakened that
they do not assist in closing the mitral orifice, a systolic murmur is
to be heard at the apex of the heart. This murmirr is transmitted
to the axilla and back, but does not usually replace the first sound
of the heart. The aortic second sound, as heard in the aortic area
and at the apex, is feeble.
Di/atiifioii (if tlic right ventricle of the heart is manifested bj^ an
increase in the area of cardiac dulness to the right of tlie sternum
(corresponding to the position of tlie I'ight auricle), by feebleness of
the pulmonic second sound together with signs of congestion and
engorgement of the lungs, and often l)y a systolic nuirnuir at the
tricuspid valve; i.e , at or near tlie root of the ensiform cartilage.
When this latter event occurs, one may have also s^'stolic pulsation
in the jugular veins and in the liver (see lielow, p. 248).
Incases of acute dilatation, such as occur in infectious fevers or
in chronic latent jiiyocardial disease, there is often to be heard a
systolic niurniur loudest in the puhuonary area and due very possi-
bly to a dilatation of the con us arteriosus.
The diagnosis of dilatation of the heart seldom rests entirely
upon physical signs referable to the heart itself. In acute cases
our diagnosis is materially aided by a knowledge of the cause,
which is often tolerably obvious. In chronic cases the best evi-
dence of dilatation is often that furnished by the venous stasis
which results from it.
14
210 PHYSICAL DIAGNOSIS.
(4) CHKONIC VALVULAR DISEASE.
I. Mitral Kbgukgitation.
The commonest and probably one of tlie least serious of valvular
lesions is iiicoinpeteucy of the mitral. It results in most cases
from tlie shortening, stiffening, and thickening of tlie valve pio-
dnced \tj rheumatic endocarditis in early life. It is the lesion pres-
ent in most cases of chorea (see Figs. 120 and 121).
Temporarij and curable mitral regurgitation may result from
weakening of the heart muscle, which normally assists in closing
the mitral orifice through the spihincter-like contraction of its cir-
cular fibres.
Great muscular fatigue, such as is jjroduced by a hard boat
race, may result in a temjiorary relaxation of the mitral sphincter
or of the papillary muscles sufficient to allow of genuine but tem-
porary and curable regurgitation through the mitral orifice. In
conditions of profound nervous debility, excitement, or exhaustion,
similar weakening of the cardiac muscles may allow of a leakage
through the mitral, which ceases with the removal of its cause.
Stress has been laid upon these points by Prince, and recently by
Arnold.
Mitral insufficiency due to stretching of the ring into which the
valve is inserted occurs not unfrequently as a result of dilatation
of the left ventricle, and is commonly known as relatire insufficiency
of the mitral valve. The valve orifice can enlarge, the valve can-
not, and hence its curtains are insufficient to fill up the dilated ori-
fice. This type of mitral insufficiency frequently results from
aortic regurgitation with the dilatation of the left ventricle which
that lesion produces, or from myocarditis, which weakens the heart
wall until it dilates and widens the mitral orifice.
The results of any form of mitral leakage occur in this order:
1. Dilatation or liypertroplnj of the left auricle, which has to
receive blood both from the lungs and through the leaky mitral
from the left ventricle.
2. The overfilled left auricle cannot receive the blood from the
VALVULAR LESIONS.
211
lungs as readily as it should ; hence the blood " backs u]} " in the
hmgs and thereby increases the work which the right ventricle
must do ia order to force the blood through them. Thus result
cedema of the lungs, and —
Fig. 120.
^-Z)/jdaJira<J/(/}a/.
Fig. 131.
F'.G. 120.— Normal Heart flurlng Systole. Mitral valve closed ; blood flowing ttirough the open
aortic valves into the aorta.
Fig. 121 .—Mitral Regurgitation. The heart is in systole and the arrows show the current flowing
bacli in the lelt auricle as well as forward into the aorta.
212 PHYSICAL DIAGNOSIS.
(3) Hi/jierfrn/ihi/ and dilatation of the right ventricle, which in
turn becomes sooner or later overcrowded so that the tricuspid
valve gives way and tricuspid leakage occurs.
(4) The capacity for hypertrophy possessed by the right auricle
is soon exhausted, and we get then —
(5) General venous stasis, which shows itself first as venous
pulsation in the jugulars and in the liver and later in the tissues
drained by the portal and peripheral veins. This venous stasis in-
creases the work of the left ventricle, and so we get —
(6) Hypertrophy and dilatation of tlie left ventrieJe. Hyper-
trophy of the left ventricle is also produced by the increased work
necessary to mauitain some vestige of sphincter action at the lealiy
mitral orifice, as well as by the labor of contracting upon the extra
quantity of blood delivered to it by the enlarged left auricle.
At last the circle is complete. Every chamber in the heart is
enlarged, overworked, and failure is imminent.
Eeturning now to the signs of mitral regurgitation, we shall find
it most convenient to consider first the type of regurgitation pro-
duced by rheumatism and resulting in thickening, stiffening, and
retraction of the valve.
Phvsioatj Signs.
(a) First Stage — Prior to tlie £stalilislinient of Compensation.
We have but one characteristic i^hysical sign :
A systolic murmur heard loudest at the apex of the heart, trans-
mitted to the back (below or inside the left scapula) and to the left
axilla. The murmur is not infrec_[uently musical in character, and
when this is the case diagnosis is much easier. Systolic musical
murmurs so transmitted do not occur without valvular leakage.
Eosenbach belie\'es that adherent pericardium is capable of produc-
ing such a niurnmr, but only, if I understand him rightlj^, in case
there is a genuine mitral leakage due to the embarrassing embrace
of the pericardium which pre"\'ents the mitral orifice frmu closing.
"Functional" or "ha?mic" murmurs are rarely heard in the
back, and very rarely, if ever, have a musical quality.
VALVULAR LESIONS. 213
Cases of mitral regurgitation are not very often seen at this
stage, but in acute endocarditis after the fever and ansemia have
subsided, or in chorea, such a murmur may exist for days or weeks
before any accentuation of tlie jjulmonic second sound or any en-
largement of the heart appears. I have had the opportunity of
verifying the diagnosis at autopsy in two sucli cases.
(b) Second Stage — Conqjensatlon Ustahlished.
As long as compensation remains perfect, the only evidence of
regurgitation may be tliat obtained by auscultation, and I shall
accordingly begin with this rather than in the traditional way with
insjjection, palpation, and percussion.
The distmguishing auscultatory phenomena in cases of well-
compensated mitral insufficiency are :
(a) A systolic murmur whose maximum intensity is at or near
the apex impulse of the heart, but which is also to be heard in the
left axilla and in the back below or inside tire angle of the left
scapula (so far the signs are those of the first stage, above de-
scribed).
(h) A pathological accentuation of the pulmonic second sound.
This is the minimunr of evidence upon which it is justifiable to
make the diagnosis of compensated mitral regurgitation. lu the
vast majority of cases, however, our diagnosis is confirmed by the
following additional data:
(c) Enlargement of the heart as shown by insj)ection, palpation,
and percussion.
The pulse in well-compensated cases shows no considerable
abnormality. Wlien compensation begins to fail, or sometimes be-
fore that time, the most characteristic thing about the pulse is its
marked irregularity both in force and rhythm. Such irregularity
is at once more common and less serious in viitral disease than in
that of a,mj other value ; it may continue for years and be compat-
ible with very tolerable health.
214
PHYSICAL DIAGNOSIS.
Eetiirning now to the details of the sketch just given, we will
take lip first —
(«) 17ie Murmur. — In children the murmur of mitral regurgita-
tion may be among the loudest of all murmurs to be heard in val-
l8t
2nd
1±.
Slid.
Fig. 12^.— Diagram to Represent Systolic Mitral Murmur. Tbe heavy lines represent tbi normal
cardiac sounds and the light Hues the murmur, which in this case does not replace the first
sound and '* tapers " off characteristically at the end.
^'^.^lar disease, but this does not necessarily imply that the lesion is
a very severe one. A murmur which grows louder under observa-
tion in a well-compensated valvular lesion may mean an advance of
the disease, but if the case is first seen after compensation has
failed a faint, variable whiff in the mitral area may mean the se-
verest type of lesion. As the patient improves under the influence
of rest and cardiac tonics, sucli a murmur may grow very much
louder, or a murmur i:)reviously inairdible may appear.
The lenijtJi of the nuirmur varies a great deal in different cases
and is not of any great practical importance. It rarely ends
abruptly, but usually " tails off " at the end of systole (see Fig. 122).
2I(isic(tl murmurs are heard more often in mitral regurgitation than
in any other valve lesion, but the musical quality rarely lasts
throughout tlie whole duration of the murmur, contrasting in this
respect with musical murmurs produced at the aortic valve. The
2iia
II I I .
Fig. 123.— Systolic Mitral Murmur Replacing the Fii-st Sound of the Heart.
first sound of the heart may or may not be replaced by the murmur
(see Fig. 123). When the sound ]iersists and is heard either with
or before the murmur, one can infer that the lesion is relatively
slight in comparison with cases in which the first sound is wholly
VALVULAR LESIONS.
215
obliterated. Post-systolic or late si/stollo murmurs, which are occa-
sionally heard in mitral regurgitation, are said to point to a rela-
tively slight amount of disease in the valve (see Fig. 122). Rosen-
Ist
I
2nd
Ist
1
2nd
Fig. ]24.— Late Systolic Murmur. The first sound is clear and an interval intervenes between
it and tlae murmur.
bach claims that the late systolic murmur is always due to organic
disease of the valves and never occurs as a functional murmur.
When compensation fails, the murmur may altogether disappear
for a time, and if the patient is then seen for the first time and
dies without rallying under treatment, it may be impossible to
Pulmonic second
accented.
Systolic raunaur
loudest here.
Fig. 12.5.— Mitral Regurfcltation.
Ttie murmur is heard over the shaded area as well as in the
bacli.
make the diagnosis. The very worst cases, then, are those in which
there is no murmur at all.
The murmur of mitral regurgitation is conducted in all directions,
but especially toward the axilla and to the back (not around the
chest, but directly). In the latter situation it is usually louder
■216
rHYSU'AL niAGXOSIS.
than it is in mid-axilla, and oeeasii_)nally it is heard as loudly in the
bai'k as anywhere else. This is no doidit owing to the position of
tlie left auriele (see Figs. 125 and 126).
(^li) After compensation is established and as hjng as it lasts an
(iccenfuatiiiii of tlie inihiKinic tirrond amiitd is almost invariably to
be made out,' and may be so marked tliat we can feel and see it, as
well as hear it. Not infrequently one can also see and feel the
pulsation of the conus arteriosus — tiai the left auricle— in the second
and third left intercostal si)ace. (It may be well to mention again
Systolic munnur.
Fig. 126.— Mitral Regurgitation. Murmur lieard over the sliaded area.
here that by accentuation of the pulmonic second sound one does
not mean merely that it is louder or sharper in quality than the
aortic second soimd, since this is true in the vast majority of cases
in healthy individuals imder thirty years of age. Pathological ac-
centutition of the pulmonic second sound means a greater intensltii
oftlie sciiiiid tlicii ive liare a riijlit to expert ett the age of the in.dirid-
iia! ill question.) Occasioutilly the pulmonic second sound is redu-
plicated, but as a rule this pouits to an accompanying stenosis of
tlie mitral valve. At tlic iqiex the second sound (/.<•., the trans-
mitted aortic second) is fei'hle or even wanting tiltogethcr, owing
VALVULAR LESIONS. 217
to the relatively small amount of blood whicli recoils upoa the
aortic valves.
(c) Eidarijeiiient of tJie huart, and more especially of the right
ventricle, is generally to be made out, and in the majority of cases
hnis enlargement is manifested by displacement of the apex impulse
both downward and toward the left, but more especially to the
left. Percussion confirms the results of inspection and jjalpation
regarding the position of the cardiac impulse. The normal sub-
sternal dulness is increased in intensity, and we can sometimes
demonstrate an enlargement of the heart toward the right (see
Fig. 123).
In children (in whom adhesive pericarditis often complicates
the disease) a systolic theill may not infrequently be felt at the
apex, and the precordia may be bulged, and even in adults such a
systolic thrill is not so rare as some writers would have us sup-
pose.
{(l) The pulse, as said above, shows nothing characteristic at any
stage of the disease. While compensation lasts, there is usually
nothing abnormal about the pulse, although it may be somewhat
irregular in force and rhythm, and may be weak when compared to
the powerful beat at the apex in case the regurgitant stream is a
very large one. Irregularity at this p)eriod is less common in pure
mitral regurgitation tliau in cases complicated by stenosis.
(c) Tliird Stage — FhAIukj Compensation.
When compensation begins to fail, the pulse becomes weak and
irregular, and many heart beats fail to reach the wrist, but there
is still nothing characteristic about the pulse, which differs in no
respect from that of any case of cardiac weakness of whatever
nature.
(e) Evidence of venous stasis, first in the lungs and later in the
liver, lower extremities, and serous cavities, does not show itself
so long as compensation is sufficient, but when the heart begins to
fail the patient begins to complain not only of palpitation and car-
diac distress, but of dyspncea, orthoj)nrea, and cough, and examina-
tion reveals a greater or lesser degree of cyanosis with pulmo-
218 PHYSICAL DIAGNOSIS
nary cedema manifested by crackling rales at the base of tbe lungs
posteriorly, and possibly also by hsemoptysis or by evidences of
hydrotliorax (see below, p. 330). If compensation is not re-estab-
lislied, the right ventricle dilates, the tricuspid becomes incompe-
tent, the liver becomes enlarged and tender, dropsy becomes gen-
eral, the heart and pulse become more and more rapid and irregular,
the heart murmur disappears and is replaced by a confusion of
short vahailar sounds, " /jalloj) rJit/tliiii" or '" ddirium cordis," often
considerably obscured by the noisy, labored breathing with numer-
ous moist rales. In a patient seen for the first time in such a con-
dition diagnosis may be impossible, yet mitral disease of some type
may usually be suspected, since murmurs produced at the aortic
valve are not so apt to disappear when compensation fails. The
relative tricuspid msuiSciency which often occurs is likely to mani-
fest itself by an enlargement of the right auricle, sometimes demon-
strable by percussion and later by venous pulsation in the neck and
in the liver.
((/) Differential Diagnosis.
The murmur of mitral regurgitation may be confused with
(1) Tricusj)id regurgitation.
(2) Functional murmurs.
(3) Stenosis or roughening of the aortic valves.
(1) The ijost-mortem records of the Massachusetts General
Hospital show that in the presence of a murmur due to mitral re-
gurgitation it is very easy to fail altogether to recognize a tricuspid
regurgitant murmur. Only 5 out of 29 cases of tricuspid regurgi-
tation found at autopsy were recognized during life. AUbutt's
figures from Guy's Hospital are similar. In tlie majority of these
cases, mitral regurgitation was the lesion on which attention was
concentrated during the j^atient's life. This is all the more excus-
able liecause the tricuspid area is so wide and uncertain. Murmurs
produced at the tricuspid orifice are sometimes heard with maxi-
mum intensity just inside the apex impulse, and if we have also a
mitral regurgitant murmur, it may be impossible under such cir-
cumstances to distinguish it from the tricuspid murmur. Some-
VALVULAR LESIONS. 219
times the t"wo are of different pitch, but more often tricuspid regur-
gitation must be recognized indirect/ >/ if at all, i.e., through the
e\'idence given by venous pulsation in the jugular veins and in the
liver. Tricuspid murmurs are not transmitted to the left axilla
and do not cause accentuation of the puLmonic second sound, al-
though they are compatible with such accentuation. They are to
be distinguished from the murmurs of mitral regurgitation by their
different seat of maximum intensitj^, piossibly bj^ a difference in
pitch, but most clearly by the concomitant phenomena of venous
pulsation above mentioned.
(2) "Functional" murmurs are usually systolic and may have
their maximum intensity at the apex of the heart, but in the great
majority of cases they are heard best over the pulmonic valve or
just inside or outside the apex beat (Potain). They are faint or
inaudible at the end of expiration, and are more influenced by
position than organic murmurs are. In the ujjright position they
are often very faint. They are rarely transmitted beyond the
precordia and are unaccompanied by any evidences of enlargement
of the heart, by any pathological accentuation of the pulmonic
second sound,' or any evidences of engorgement of the lungs or
general venous system.
(3) Eoughenmg or narroTving of the aortic valves may produce
a systolic murmur with maximum intensity in the second right in-
tercostal space, but this murmur is not infrequently heard all over
the precordia and quite plainly at the apex, so that it may simulate
the murmur of mitral regurgitation. The aortic murmur may in-
deed be heard more plainly at the apex than at any other point ex-
cejjt the second right intercostal space, owing to the fact that the
right ventricle, which occupies most of the precordial region be-
tween the aortic and mitral areas, does not lend itself well to the
propagation of certain tyjies of cardiac murmurs. Under these
circumstances " a loud, rough aortic murmur may be heard at the
' It must be remembered that in cblorosiis, a disease in which functional
murmurs are especially prone to occur, the pulmonic second sound is often
surprisingly loud, owing to a retraction of the left lung, -which uncovers the
root of the pulmonic artery.
220 PHYSICAL DIAGNOSIS.
apex as a smooth imirmui- of a different tone " (Broadbeut) . Such
a niurumr is not, lio\\'e\er, likely to be conducted to the axilla or
heard beneath the left si'apuhi, nor to be accompanied bj' accentua-
tion of the pulmonic second sound nor evidences of engorgement
of the lungs and general venous system.
II. Mitral Stenosis.
Narrowing or obstruction of the mitral orifice is almost invari-
ably the result of a chronic endocarditis which gradually glues to-
gether the two flaps of the valve until only a funnel-shaped op)en-
ing or a slit like a buttonhole is left see Figs. (127 and V2S). As we
examine post mortem the tuiy slit which may be all that is left of
the mitral orifice in a case of long standing, it is difficult to con-
ceive how sulficient blood to carry on the needs of the circulation
could be forced through such an insignificant opening.
Usually a slow and gradually developed lesion, mitral stenosis
often represents the later stages of a process which in its earlier
phases produced pure mitral regurgitation. By some observers the
advent of stenosis is regarded as representing an attempt at com-
pensation for a reduction of the previous mitral leakage. Others
consider that the stenosis simply increases the damage which the
valve has suffered.
A remarkable fact never satisfactorily explained is the predilec-
tion of mitral stenosis for the female sex.' A large proportion of
the cases — seventy-six per cent in my series — occur iu women.
It is also curious that so many cases are associated with jml-
monary tuberculosis.
P/u/sic((I SilJIIS.
Mitral stenosis may exist for many years without giving rise to
any physical signs by which it may be recognized, and even after
signs have begun to show themselves they are more fleeting and
inconstant than in any other vahuilar lesion of the heart. In the
early stages of the disease the heart may appear to be entirely nor-
' Fenwick's explanation, viz., tliat the sedentary life of women favors
tlie .slow adhesive inflammation of llie valve and its curtains, resulting in
stenosis, does not seem to me to hr satisfactory.
VALVULAR LESIONS.
221
mal if the patient is at rest, and especially if examined in the re-
cumbent position, cliaracteiistic signs being elicited only by exer-
tion; or again a nmrmur which is easily audil)le with the patient
in the upright position may disappear in the recumbent position ;
or a murmur may be heard at one visit, at the next it may be im-
/ffe/fa/^f/t
7Ml!/it/J/i'/^.
Fig. 128.
Fig. 137.— Diagram to Represent ttie Position of the Valves in the Normal Heart during Hiastole.
the Open Mitral Allowing the Blood to Flow Down from tlie Left Auriclr, the .Aortic Closed.
Fig. 12H.— Jlitral Stenosis— Period of Diastole. The lilood llowiiig fioni the left aiirlele is ob-
structed by the thickened ami adherent mitral cuiiains.
222
PHYSICAL DIAGNOSIS.
passible to elicit it by auy mauceuvre, while at the tliiid visit it may
be easily heard again. These characteristics explain to a certain
extent the fact that differences of opinion so often arise regarding
the diagnosis of mitral stenosis, and that out of forty-eight cases in
which this lesion was found at autopsy at the jMassaehusetts General
Hospital, only twenty-three were recognized during life. Xo com-
mon lesion (^with the exception of tricuspid regurgitation) has been
so frequently overlooked in our records.
I shall follow Broadbent ui dividing the symptoms into three
stages, according to the extent to which the lesion has progressed.
I.
In the first stage inspection and palpation show that the apex
beat is little if at all displaced, and percussion reveals no inorase
ruhuonic second
ai't'euted.
" Iioiible-sbock '
Snund.
Presystolic murmur
heard in limited
area.
Fig. 129.— Mitral Stenosis.
i/i the ari'ii of cardinr di/liifss: there is often local tenderness to be
elicited near the apex. If one lays the hand lightly over the origin
of the apex beat, one can generally feci the jiinTiiKj prcsi/Molic tlirlll
which is so characteristic of this disease, more common indeed than
in anjr other. This thrill is more marked in the second stage of
the disease, but can generally be appreciated even in the first. It
runs up to and ceases abru^itly with the very sharp first sound,
VALVULAR LESIONS. 223
the sudden shock of "which may be appreciried even by palpation.
The thrill is sometimes palpable even when no murmur can be
heard, and often the thrill is transmitted tr the axilla when the
murmur is confined to the apex region. On auscultation one
hears, esj)ecially after the patient has been exerting himself, and
particularly if he leans forward and to the left, a short low-pitched
rumhle or roll iminediateli/ preceding the systole and increasing
in intensity as it approaches the first sound. At this stage of
the disease the second sound can still be heard at the apex. The
first sound is very sharply accented or snapping, and communi-
cates a very decided shock to the ear when a rigid stethoscope
is used. As a rule, the murmur is closely confined to the region
of the apex beat and not transmitted any considerable distance in
any direction. I have seen cases in which it was to be heard only
1st 1st
2nd
12nd ,|||{|{|l
I rllllllllllllll
FiG.130.— The Murmur ol Mitral stenosis— First stage. The placed the murmur and its cres-
cendo character are indicated by the position of the light lines just before the first sound
and by their increasing length.
over an area the size of a half-dollar.' Very characteristic of mi-
tral stenosis is a prolongation of the diastolic pause so that the inter ■
val between the second sound of one cycle and the first sound of the
next is unduly long. JVie jnilnio/eic second sound is accented and
sometimes reduplicated ("double-shock sound" — Sansoni) at this
stage of the disease, but this doubling is much more frequent later.'
Irregularity of the heart beat both in force and rhythm is very
frequently present even in the early stages of the affection. The
heart may be regular while the patient is at rest, but slight exer-
tion is often sufficient to produce marked irregularity.
' It may, however, be widely transmitted to the left axilla and audible in
the back or even over the whole of the left chest, especially when the stenosis
is combined with regurgitation.
^ This is the opinion of iTiost observers. Sansom states that the "double-
shock sound " may precede all other evidences of mitral stenosis.
224 PHYSICAL DIAGNOSIS.
II,
In the second stage the murmur ami thrill are usually longer and
may oceupy th whole of diastole, beginning with considerable in-
tensity just after the leduplieated second somid, quickly diminish-
Ist 1st
M I iiillllHHIIIIIIMIIl Lj_
I
Fig. 131.— Type ot Presystolic Murmur Often Heard in tLe Second Stage ol Mitral Stenosis.
Here tbe uuirmur Alls the whole of diiistole, with a gradual increase of intensity as it ap-
proaches the first sound. No second sound is audible at the apex.
mg until it is barely audible, and then again increasing with a
steady crescendo up to the first sound of the next cycle.' These
changes may be graphically represented as in Figs. l.SO and 131. Dia-
stole is now still more prolonged, so that the characteristic rhythm
of this lesion is even nioi-e niarkeil than in the earlier stages of the
disease. In many cases at this stage no second soiuid is to be heard
at all at the apex, although at the pulmonic orifice it is loud and
almost invariably double. (This is die of the reasons for believing
that the second sound which we usually hear at the apex is the
transmitted aortic second souml. In mitral disease the aortic valves
1st
2nd , I 2na
ir.Miiiiiiimniiminniiiii nni U
Fig, 132.— Type ot Presystolic Muruuir Sometiuics Heard in the Second Sla.u'e of Mitral Stenosis.
There is a double crescendo. The second sound seems reduplicated.
shut feebly owing to the relatively small amount of blood that is
thrown into the aorta.)
At this stage of the disease enlargement of the heart begins to
make itself manifest. Th apex impulse is displaced to the left —
' Rarely one finds u crescendo in tlie middle of a long presystolic roll with
a diminuendo as it approrxlies the first sound.
VALVULAR LESIONS. 225
sometimes as far as the mid-axillary line, and often descends to
the sixth interspace. Occasionally the cardiac diilness is increased
to the right of the sternum.
The instability and fleeting character of the murmur in the ear-
lier stages of the disease are much less marked in this, the second
stage. The first sound at the apex still retains its sharp, thump-
ing quality, and is often audible iviihoitt tJi,.", muy-mAir in the back.
The irregularity of the heart is gene'-alJy greater at this stage
than in the earlier one.
III.
The third stage of the affection is marked by the disappearance
of the characteristic murmur, and is generally S")Tichronous with
the development of tricuspid regurgitation. Tiie right ventricle
becomes dilated sometimes very markedly. Indeed, it may produce
a visible pulsating tumor below the left costal border and be mis-
taken for cardiac aneurism (Osier). The snapping first sound and
the " double-shock " sou.nd usually remain audible, but the latter
may be absent altogether. Diagnosis in this stage rests largely upon
the peculiar snapping character of the first sound, together with the
prolongation of diastole and the very great irregularity of the heart,
both in force and rhythm. At times a presystolic thrill may be
felt even when no miirmur is to be heard.
The pulse shows nothing characteristic in many cases except
that early and persistent irregularity which has been already al-
luded to. In other cases the wave is low, long, easily compressed,
but quite perceptible between beats; but for the lack of snf&eient
power in the cardiac contractions the pulse would be one of high
tension.
As the disease advances the irregularity of the pulse becomes
more and more marked, and sometimes presents an amazing contrast
with the relatively good general condition of the circulation. Even
when not more than a third of the beats reach the wrist, the patient
may be able to attend to light work and feel very well Such cases
make us feel as if a pulse were a luxury rather than a necessity.
Under the influence of digitalis the pulse is especially apt to
15
226 PHYSICAL DIAGNOSIS.
assume tlie hir/emiiKiI ty]ie in mitral stenosis. Every otlier beat is
then so abortive that it fails to send a A^'ave to the wrist, and the
weak beat is succeeded by a pause. According to Broadbeut the
wealt beat corresponds to an abortive contraction of tlie left ven-
tricle accompanied by a normal contraction of the right ventricle,
so that for each fico strong beats of the right side of the heart we
have one strong and one weali beat of the left side of the heart.
jMitral stenosis is in the great majority of cases combined with
mitral regxirgita.tion, and it often hajipens that the signs of regur-
gitation are so much more prominent than those of stenosis that
the latter escape observation altogether, especially in the third
stage of the disease, when the typical ju'csystolic roll has disap-
peared. In such cases combined stenosis and regurgitation is to be
distmguished fi'oni pure regurgitation by the sharpness of the first
somid, which would be very unusual at this stage of a case of pure
mitral regurgitation. Tlie presence of reduplicated second sound, a
" double-shock sound " at the outset of the prolonged diastolic pause,
and of great irregularity in force and rhythm, is further suggestive
of mitral stenosis.
IMitral stenosis is apt to be associated with ha?moptysis, with en-
gorgement of tlie liver and ascites, and especially with arterial em-
bolism. JS^o ot/ier valve lesion is so fri'quently found associaied
-iviili eviholism. The lungs are generally very voluminous, and
may therefore mask an increase in area or intensity of the cardiac
dulness.
Different iid Diagnosis.
I have already discussed the difficulty of distinguishing a double
lesion at the mitral valve from a simple mitral regurgitation (see
above, p. 215V
Otlier murmurs which may be mistaken for the murmur of mi-
tral stenosis are :
((f) The Austin Elint murmur.
(li) The murmur of tricuspid stenosis.
(r) A rumbling murmur sometimes heard in children, after an
attack of pericarditis.
VALVULAR LESIONS. 227
(a) The Austin Flint murmur.
In 1862 Austin Flint studied two cases in which during life a
typical presystolic roll was audible at the apex of the heart, yet in
which post mortem the mitral valve proved to be perfectly normal,
and the only lesion j^resent was aortic insuiiiciency. This observation
has since been verified by Osier, Braniwell, Gairdner, and other com-
petent observers. At the Massachusetts General Hospital we have
had seven such cases with autopsy. Yet, despite repeated confir-
mation, Flint's observation has remained for nearly forty years un-
known to physicians at large. Its importance is this : Given a case
of aortic regurgitation — a presystolic murmur at the apex does not
necessarily mean stenosis of the mitral valve even though the mur-
mur has the typical rolling quality and is accompanied by a pal-
pable thrill. It may be only one of the by-effects of the aortic
incompetency. How it is that a presystolic murmur can be pro-
duced at the apex in cases of aortic regurgitation has been much
debated. Some believe it is due to the impact of the aortic regur-
gitant stream upon the ventricular side of the mitral valve, floating
it out from the wall of the ventricle so as to bring it into contact
with the stream of blood descending from the left auricle. Others
suppose that the muigling of the two currents of blood, that from
the mitral and that from the aortic orifice, is sufficient to produce
the murmur.
Between the " Austui Flint murmur " thus defined and the mur-
mur of true mitral stenosis, complicating aortic regurgitation, diag-
nosis may be impossible. If there is jio dilatation of the mitral
orifice and no regurgitation, either from this cause or from deformi-
ties of the mitral valve itself, any evidence of engorgement of the
pulmonary circuit (accentuation of the pulmonic second sound,
cedema of the lungs, haemoptysis, and cough) speaks in favor of an
actual narrowuig of the mitral valve, while the absence of such
signs and the i:)resence of a predominating hypertrophy of the left
ventricle tend to convince us that the murmur is of the type de-
scribed by Austin Flint, i.e., that it does not pouit to any sten-
osis of the mitral valve. The sharp, snapping first sound and
systolic shock so characteristic of mitral stenosis are said to be
228 PHYSICAL DIAGNOSIS.
modified or absent in connection witli murmurs of tlie Austin Flint
type.
[h) Tricuspid obstruction.
Luckily- for us as diagnosticians, stenosis of the tricuspid \alxe
is a very rare lesion. Like mitral stenosis it is manifested l)j' a
presystolic rolling murmur wliose point of maximum intensitj' is
sometimes over tlio traditional tricuspid area, but may be at a point
so near the mitral area as to be easily confused with stenosis of
the latter valve.
The difficulty of distinguishing tricuspid stenosis from mitr;;l
stenosis is further increased by the fact that the two lesions almost
invariably occur in oonjmiction. Hence we have two presystolic
murmurs, perhaps with slightly different points of maximum inten-
sity and possibly with a difference in quality, but often quite un-
distinguishable from each other. In the vast majority of cases,
therefore, tricuspid stenosis is first recognized at the autopsy, and
the diagnosis is at best a very difficult one.
(e) Broadbent, Eosenbach, and others have noticed in children
who have just passed through an attack of pericarditis a rumbling
murmur near the apex of the heart, which suggests the murmur ot
mitral stenosis. It is distinguished from the latter, however, hj tlie
absence of any accentuation of the first sound at the apex, as well
as by the conditions of its occurrence and by its transiency. Such
cases are important, since their prognosis is much more favorable
than that of mitral stenosis.
Phear {Lancet, September 21, 1895) investigated 46 cases in
which a presystolic murmur was observed during life and no mitral
lesion found at autopsy. In 17 of these there was aortic regurgi-
taticm at autopsy ; m 20 of these there was adherent peiicardiuni
at autojisy ; in 9 nothing more than dilatation of the left ventricle
was found. In none of these cases was the sna])iiing first sound,
so common in mitral stenosis, recorded during life.
It should be remembered that patients suffering from mitral
stenosis are very frequently unaware of any cai'diac trouble, and
seek advice fcir aniiemia, wasting, debility, gastric or pulmonary
complaints. This is less often true in other forms of valvular dis-
VALVULAR LESIONS.
229
ease. We should be especially on our guard in cases of supposed
"nervous arrhythmia" or "tobacco heart," if there has been an at-
tack of rheumatism or chorea previoasly. Such cases may present
?io signs of disease exceiit the irregularity — yet may turn out to
be mitral stenosis.
IV. AoKTK; l\E(iUK(iITATION'".
Rheumatic endocarditis usually occurs in early life and most
often attaclvs tlie mitral valve. The coinnionest cause of aortic dis-
ease on the other hand — arterio-sclerosis — is a disease of late mid-
Mi^a/ {^wi/.
Fig. 133.— Diastole iu Aoi'ilc Ki'!.'ui'f,nt;itlon. The blood is flowing back througli the stumpy and
Incompetent aortic valves.
die life, and attacks men much more often than women. When
we think of aortic i-egurgitation, tlie picture that rises before us is
usually that of a man jiast middle life and most often from the
classes wlro live by manual labor. ISTevertlieless cases occur at all
ages and in both sexes, and rheumatic endocarditis does not spare
the aortic cusps altogether by any means.
Whether produced by arterio-sclerosis extending down from the
aorta, or by rheumatic or septic endocarditis, the lesion which re-
sults in aortic regurgitation is usually a thickening and shortening
of tlie cusps (see Fig. 133). In rare cases an aortic cusp may be
ruptured as a result of violent muscular effort, and the signs and
230 PHYSICAL DIAGNOSIS.
symptoms of regurgitation then appear suddenljr. But as a rule
tlie lesion comes on slowly and insidiously, and unless discovered
accidentally or in the course of routine jihysical examination it may
exist unnoticed for years. Dropsy and cyanosis are relatively late
and rare, and the sym^jtoms which first appear are usually those of
dyspnoea and precordial distress.
It is a disputed point whether relative and temporary aortic
insufficiency due to stretching of the aortic orifice ever occurs. If
it does occur, it is certainly exceedingly rare, as the aortic ring is
very tough and inelastic.
Dilatation of the aortic ftrcA— resembling diffuse aneurism — oc-
curs in almost everi/ case of aortic regurgitation, and produces sev-
eral important physical signs. This complication is a very well-
known one, but has not, I thinlx:, been sufficiently insisted on in
text-books of pliysical diagnosis. It forms part of that general
enlargement of the arterial tree which is so cliaracteristic of the
disease.
Plnjsical Signs.
Inspection reveals more that is important in this disease than
in any other vahiilar lesion. In extreme cases the patient's face
or hand may blush visiljly with every systole. Not infrequently
one can make the diagnosis across the room or in the street by not-
ing the violent throbbing of the carotids, which may be such as to
slialiB the person's whole head and trunk, and even the bed on
which he lies. No other lesion is so apt to cause a heaving of tlie
whole chest and a bobbing of the licad, and no other lesion so often
causes a bulging of the precordia, for in no other lesion is the en-
largement of the heart so great (cor horiiiinii or ox-heart). The
throbbing of the dilated aorta can often be felt and sometimes seen
in the suitrasternal notch or in the second riglit interspace. Not
only tlie carotids l)ut the subclavians, the bracliials and radials,
tlie femoral and anterior tibial, and even the digital and dorsalis
pedis arteries may visil)ly pulsate, and tlie characteristic jerliiug
quality of the pulse may l)e seen as well as felt. This visible pul-
sation in the peripheral arteries, while very characteristic of aortic
VALVULAR LESIONS.
231
regurgitation, is occasionally seen in cases of simple hypertrophy of
the heart from hard muscular work {e.r/., in athletes). If the ar-
teries are extensively calcified, their jiulsation become much less
marked.
The peculiar conditions of the circulation whereby it is " changed
into a series of discontinuous discharges as if from a catapult" (All-
butt) throws a great tensile strain upon all the arteries, and results,
in almost every long-standing case, in increasurg both their length
Pulsation at the jugulum.
Dulness and pul-
sation cor re- -'
spending to the
dilated aortic
arch.
Pulsating car-
otids.
Diastolic murnuir.
Displaced cardiac
impulse.
Fig. 134.— Aortic Regurgitation, Showing Position ot the Diastolic Murmur and Areas of Visible
Pulsation.
and their diameter. The visible arterial trunks become tortuous
and distended, while the arch of the aorta is diffusely dilated so as
to resemble an aueurisia (see Fig. l.'U). With each lieai't beat the
snaky arteries are often jerked to one side as well as made to
throb.
Inspection of the region of the cardiac impulse almost always
shows a very marked displacement of the apex beat both downwanl
and outward (but especially the former), corresponding to the hy
pertrophy and still more to the dilatation of the left ventricle,
-•-)'J PHYSICAL DIAGXOSIS.
whifli is usually- very great, and to tlie downward sagging of the
enlarged aorta. Dilatatimi is in tliis disease an essentially helpful
and eoiujieiisatoiy pmeess In a small proportion of the cases no
enlargement of tlie heart is to he denumstrated. This was true of
5 out of tlie last 07 eases ^\hich I have notes of, and generally
denotes an eai'ly and slight lesion Xot at all infre(iuentl_y one
tinils a systolie nfnirh'nn of the interspaces near tlie apex beat
instead of a systolic iiiij>ii/sr. This is probably due to the negative
pressure produced within the chest by the powerful contraction of
an bypertvophied heart. In tlie suprasteiiuil notch one often feels
as well as sees a marked systolic pulsation ti-ansmitted from the arch
of the dilated aorta, and soinetinies mistaken toi- saccular aneurism.
Arterial pulsation of the liver and spleen are rarely denion-
strahle by a combination of sight and touch.
Cdjitlld fii rii/sdtinii.
If one jiasses the end of a pencil or other hard substance once
or twice across the })atient's forehead, and then watches the red
mark so produced, one can often see a systolic tiusihing of the hyper-
»mic area "with each heat of the heart. This is by far the best
method of eliciting this phenomenon. It may also be seen if a glass
slide is pressed against the mucous membrane of the lip so as par-
tialljr to blanch it, or if one presses upon the finger-nail so as par-
tially to drive the blood from under it ; but in both these manoeuvres
error may result from iueipiality in the pressure made by the ob-
server upon the glass slide or upon the nail. Very slight movements
of the observer's fingers, even such as are caused by his own pulse,
may give rise to changes simulating capillary inilsation. Capillary
pulsation of normal tissues is not oftcm seen in any condition other
than aortic' regurgitation, yet occasionally one meets with it in
diseases "which produce very low tension of the pulse, such as
]ihthisis or typhoid, aiuemic and neurasthenic conditions, and I
have twice seen it in perfectly healthy persons. In such cases the
p'llsation is usually less marked than in aortic regurgitation.
J;arely pulsation may lie detected in the peri]>heral veins.
' .Juni]iiiig liiiitliaclie and llirobbiuL; felon are coininon examples of capil-
lary pulsatitMi in inflamed areas.
VALVULAR LESIONS.
Palpation.
Palpation verifies the position of the cardiac impulse and the
heaving of the whole chest wall suggested by inspection. The
shock of the heart is very powerful and deliberate unless dilatation
Fig. 135.— Sphygmographic Tracing from Normal Pulse.
is' extreme, when it becomes wavy and diffuse. In the supraclavic-
ular notch a systolic thrill is often to be felt. A diastolic thrill
in the precordia is very rare.
The 2Ji'^se is important, usually characteristic. The wave rises
FIO. 136.— Sphygmograpbie Tradng of the "i';(te«.s Celer" in Aortic Regurgitation. Its col-
lapsing character Is well shown. •
very suddenly and to an unusual height, then collapses completel-'-
and with great rapidity (pulsus celer) (see Figs. 135, 136).
This type of pulse, which is known as the " Corrigan pulse " or
"water-hammer pulse," is exaggerated if one raises the patient's
arm above the head so as to make the force of gravity aid in enip-
tying the artery. The quality of the pulse in aortic regurgitation
234 PHYSICAL DIAGNOSIS.
is due to the fact that a hirge voliuiie of blood is suddenly and for-
cibly thrown into tlie aorta by the hypertrophied and dilated left
ventricle, thus causing the cliaracteristically sharp and sudden rise
in the peripheral arteries. The arteries then emjity themselves in
tiro directions at once, for-ward into the capillaries and backward
into the heart through the incompetent aortic valves ; hence the
sudden collapse in the pulse which, together Avith its sharp and
sudden rise, are its important characteristics. The arteries are
large and often elongated so as to be thrown into curves.
Not infrequently one can demonstrate that the radial pulse is
delayed or follows the apex impulse after a longer interval than
in normal persons. While compensation lasts, the pulse is usually
regular in force and rhythm. Irregularity is therefore an esjjecially
grave sign, much more so than in any other valvular lesion.
Percussion.
Percussion adds but little to the information obtained by inspec-
tion and palpation, but verifies the results of these methods of in-
vestigation respecting the increased size of the heart, and especially
of the left ventricle, which may reach enormous dimensions, espe-
cially in cases occurring in young piersons. The heart may be
increased to more them four times its normal weight.
Auscultation.
In rare cases there may be absolutely no murmur and the diag-
nosis may be impossible during life, though it may be suspected
by reason of the above-mentioned signs in the peripheral arteries.
Unless the free ear is used the nmrniur is often so faint as to be
easily overloolicd. Tliis is especially true in cases occurring in
elderly people, and when the patient has been for a considerable
time at rest. The diffictiU}- of recognizing certain cases of aortic
regurgitation during life is sliown by the fact that out of sixty-five
cases of aortic regurgitation demonstrated at autopsy in the IMassa-
clnisetts General Hospital, onlj' forty-four were recognized during
life.
VALVULAR LESIONS.
235
In the majority of cases, however, the characteristic diastolic
niuriiuir is easily heard if one listens in the right place, and when
heard it is the most distinctive and trustworthy of all cardiac niur-
miirs. It almost invariably pomts to aortic regurgitation and to
nothing else.
The murmur of aortic regurgitation, as has been already men-
tioned, is diastolic in time.' Its maxiiiiam intensity is usually 7ioi
Fig. 137. —Position of the Point of Maximum Intensity of the Murmur of Aortic Regurgitatloa
The dots are most thickly congregated where the murmur is oftenest heard.
in the conventional aoi-tie area (second right interspace^) , but on the
left side of the sternum about the level of the fourth left costal carti-
lage. In about one-tenth of the cases, and especially when the
aortic arch is much dilated, the murmur is best heard in the con-
ventional aortic area. Occasionally there are two jjoints at which
it may be loudly heard — one in the second right interspace and the
other at or outside the cardiac ap)e.x, while between these points
'Another murmur, systolic in time, which almost always accompanies
the diastolic murnuir, is usually due to roughening of the edges of tlie aortic
valves or to dilatation of the aortic arch. This murmur must not be assumed
to mean aortic stenosis (see below, j]. 243).
236 PHYSICAL DIAOiXOSIS.
the uuinnui- is faint. Tliis is probably due to the fact that the
left vi'Htnclt', tlirougk which the murmur is conducted, approaches
the surface i_if the chest only at the apex, while the intermediate space
is occupied by the right ventricle, which often fails readily to trans-
mit murmurs ]iroduced at the aortic orifice. Less frequently the
murmur of aortic regurgitation is heard with maximum intensity
at the second or third left costal cartilage or in the region of the
ensiform cartilage (see Fig. 137).
From its seat of maximum intensity (i.e., usually from the
fourth left costal cartilage) the murmur is transmitted iu all direc-
tions, but not often beyond the precordia. In about one-third of
the cases it is transanitted to the left axilla or even to the back.
It is sometimes to be heard iu the subclavian artery and the
great vessels of the neck; in other cases two heart sounds are
2nd
1
end
Imnmiii
Fig. 138. - Short Diastolic Murmur Not Replacing the Second Sound.
audible in the carotid, but no murmur. The niurmnr is nsually
blowing and relatively high pitched, sometimes musical. Its inten-
sity varies much, but is most marked at the beginning of the mur-
mur, giving the impression of an accent there. It may occupy the
whole of diastole or only a small portion of it — usually the earlier
portion (see Fig. 138). Late diastolic murmurs are rare. The mur-
mur may or may not replace the second soiuul of the heart. Broad-
bent believes that when it does not obliterate the second sound,
the lesion is nsually less severe than when only the murmur is to
be heard. AUbutt dissents from this opinion.
In listening for the aortic second sound with a view to gauging
the severity of the lesion, it is best to apply the stethoscope over the
right carotid artery, as here we are less apt to be confused by the
murmur or by the pulmonic second sound.
The position of the patient's body has but little effect upon the
inurmur — less than upon murmurs produced at the niitraJ. orifice.
VALVULAR LESIONS. 237
The first sound at the apex is generally dull and long. There
is no accentuation of the pulmonic second.
Over the larger peripheral arteries, especially over the femoral
artery, one hears in most cases a sharp, short systolic sound ("pis-
tol-shot sound ") due to the sudden filling of the unusually empty
artery ; this sound is merely an exaggeration of what may be heard
in health. Pressure with the stethoscope will usually bring out a
systolic murmur (as also in health), and occasionally a diastolic
murmur as well (Duroziez's sign). This diastolic murmur in the
peripheral arteries, obtamed on pressure with the stethoscope, is
practically never heard except in aortic regurgitation. It is thought
by some to be due to the regurgitant current in the great vessels
which in very marked cases may extend as far as the femoral ar-
tery. Duroziez's sign is a comparatively rare one, not present in
most cases of aortic regTirgitation, and usually disappears when
compensation fails.
Summmy and Differential Diagnosis.
A diastolic murmur heard with the maximum intensity about
the fourth left costal cartilage (less often in the second right inter-
space) gives us almost complete assurance of the existence of aoitie
regurgitation. From mitral stenosis and from pulmonai'y regurgi-
tation, an exceedingly rare lesion, tlie disease is distinguislied by the
presence of predominating hypertrophy of the left ventricle with a
heaving apex impulse and by tlie following a,rte)%al plienomena:
(a) Visible pulsation in the peripheral arteries.
(b) Capillary pulsation.
(c) "Corrigan " pulse.
(d) " Pistol-shot sound " in the femoral artery.
(e) Duroziez's sign.
Cardiopulmonary murmurs (see page 197j&ie occasionally dias-
tolic, but are very markedly influenced by position and by respira-
tion, while aortic murmurs are but slightly modified.
The very rare functional diastolic murmur, transmitted from the
veins of the neck and heard over the base of the heart in cases of
grave anaemia, may be obliterated by pressure over the bulbus jugu-
laris. Such pressure has no effect upon the murmur of aortic regur-
238 PHYSICAL DIAGNOSIS.
gitation. I have recently reported (Johns Hopkins Bull., May,
1903) three cases of intense anaemia associated with diastolic mur-
murs exactly like those of aortic regurgitation, but proved post
mortem to be independent of any valvular lesion The arterial
phenomena were not marked, but the diagnosis of such cases is
very hard. Luckily they are rare. The origin is obscure.
It must be remembered that aortic regurgitant murmurs are
often exceedingly faint, and should be listened for with the greatest
care and under the most favorable conditions.
Estimation of tlie, Extent and G-ravity of the Lesion.
The extent of the lesion is roughly jn-oportional to — ■
(ft) The amount of hypertrophy of the left ventricle.
(5) The degree to which the pulse collapses during diastole
(provided the radial is not so much calcified as to make collapse
impossible) .
(c) The degree to which the murmur replaces the second sound
as heard over the right carotid artery (Broadbent) .
Irregularity of the pulse is a far more serious sign in this dis-
ease than in lesions of the mitral valve, and indicates the beginning
of a serious failure of compensation.
Another grave sigir is a diminution in the intensity of the
murmur.
Complications.
(1) Dilatation of the Aorta.. — Diffuse dilatation of the aortic arch
is usually associated with aortic regurgitation and may produce a
characteristic area of dulness to the right of the sternum (see Fig.
1.34). Not infrequently this dilatation is the cause of a systolic
murmur to be heard over the region of the aortic arch and in the
great vessels of the neck.
(2) Roughening of the Aortic Valves. — In almost all cases of aortic
regurgitation the valves are sufficiently roughened to produce a
systolic murmur as the blood flows over them. This murmur is
heard at or near the conventional aortic area, and may be trans-
mitted into the carotids. (The relation of these murmurs to the
diagnosis of aortic stenosis will be considered with the latter lesion.)
VALVULAR LESIONS. 239
(3) The return of arterial blood through the aortic valves into
the left ventricle produces in time both hypertrophy and dilatation
of this chamber, and results ultimately in a stretching of the mitral
oritice which renders the mitral curtains incompetent. The result
IS a " relative mitral ■iiisitffi.cienci/," i e. , one in which the mitral valve
is intact but too short to reach across the orifice which it is in-
tended to close. Such an insufficiency of the mitral occurs in most
well-marked cases ; it temporarily relieves the overdistention of the
left ventricle and often the accompanying angina, although at the
cost of engorging the lungs.'
(4) The Austin Flint Murmur. — The majority of cases of aortic
regurgitation are accompanied by a presystolic murmur at the apex,
which may be due to a genuine mitral stenosis or may be produced
in the manner suggested by Anstm Fluit. (For a fuller discussion
of this murmur see above, p. 227- )
(5) Aortic stenosis fre(iuently accompanies cases of aortic re-
gurgitation, especially in tlie rheumatic and choreic and septic types
occurring in young persons. It has the effect of increasing the in-
tensity of the diastolic murmur, since the regu.rgitating stream has
to pass through a smaller opening.
The excessive arterial pulsation may be less marked if stenosis
accompanies regurgitation, but this is not always the case (see
below, p. 243).
AOETIC STENOSIS.
Uncomplicated aortic stenosis is by far the rarest of the valvu-
lar lesions of the left side of the heart, as well as the most difficult
to recognize. Out of two hundi-ed and fifty-two autoj^sies made at
the Massachusetts General Hospital in cases of vahiilar disease
there was not one of uncomj)licated aortic stenosis. Twenty-nine
cases occurred in combination with aortic regurgitation. During
life the diagnosis of aortic stenosis is frequently made, but often on
insufficient evidence — i.e., upon the evidence of a systolic murmur
heard with maximum intensity in the second right intercostal space
• This relative insufBcienoy of the mitral valve has been termed its " safety-
vahe" action, but the safety is but temporary and dearly bought.
240
PHYSICAL DTAGXOSIS.
and transmitted into the vessels of the neck. Sucli a murmui- does
indeed occur in aortic stenosis, but is liy no means peculiar to this
condition. Of the other diseases Avhicli i)roduce a similar murmur
more will be said under Differential Diagnosis.
For the diagnosis of aortic stenosis we need the following evi-
dence :
(1) A systolic murmur heard best in the second right intercostal
space and transmitted to the neck.
(2) The characteristic pulse (riJi' hifni).
(3) A palpable thrill (usually).
(4) Absence or great enfeeblenieut of the aortic second sound.'
Of tlu'se signs the characteristic j>i/lt:i:' is the most important.
J^Sfe/^^c/^
Fig. i:>S).— -Vortlc Stenosis. The heart is in systole and the blood column is obstructed by the
narrowed aortic ring. The mitral is closed (as it sltould be).
riie heart ma}^ or may not be enlarged.
, Each of these points '\A-ill now be described more in detail.
(1) yiir ilfiiriiiKr.
(ri) The iiia.rimum vifrnsif;/ cf tlie murmur, as has already been
said, is usually in the second right intercostal space near the ster-
num or a little above that point near the sterno-clavicular articula-
tion, but it is by no means uncommon to find it lower down, i.e.,
' A;,'aiiist all reason I liave twice seen ataulniisy an aortic stenosis iles|)il'
the fact that the "aortic second sound " liad been loud iu life.
VALVULAR LESIONS.
241
in the third, fouvth, or fifth right iiiterspaoe, and oceasioiially it is
best lieai'd to the left of the sternum in the second or tliird inter-
costal space, (li) The time of the murmur is late si/stolic ; that is,
it follows the apex impulse at an appreciable interval, contrastuig
in this respect with tire systolic murmur usually to be heard in
mitral regurgitation, (e) The nrurmur is usually widelij tran.smlt-
ted, often being audible over the whole chest and occasionally over
the skull and the arterial trunks of the extremities (see Fig. 140 ).
It is usually heard less well over that portion of the precordia oc-
cupied by the right ventricle, while, on the other hand, it is rela-
tively loud m the region of the apex unpulse, whither it is trans-
mitted through the left ventricle. The same line of transmission
Maximum intensity
of systolic mur-
mur and ttirili.
Fig. 140.— Aortic Stenosis.
The murmur is audible oyer the shaded area and sometimes ovei
the whole chest.
was mentioned above as characteristic of the murmur of aortic re-
gurgitation in many cases. The murmur is also to be heard over
the carotids and subclavians, and can often be traced over the tho-
racic aorta along the spine and down the arms.
Until compensation fails the murmur is apt to be a very loud
one, esi^ecially in the recumbent j)osition; it is occasionally au-
dible at some distance from the chest, and is often rough and
vibrating, sometimes musical or croakuig. Its length is unusuallv
16
242 PHYSICAL DIAGNOSIS.
great, extending tlu-oughout tlie whole of systole, but to this rule
tliere are occasional exceptions. The first sound in the aortic re-
gion is altogether obliterated, as a rule, and the second sound is
usually eitlier absent or very feeble.'
(2) T//e Pulse.
Owing to the opposition encountered by the left ventricle in
its attempt to force blood into the aorta, its contraction is apit to
be prolonged ; hence the pulse wave rises gradually and late, and falls
uicaij sloidy. This is shown very well in sphygmographic tracings
(see Fig. 141). Bu.t further, the blood thrown into the aorta by the
left ventricle is prevented, by the narrowing of the aortic valves,
from striking upon and expanding the arteries with its ordinary
force ; hence the pulse wave is not only slow to rise but small in
Fig. 141.— Sphyj^o^aphic Tracing of the Pulse In Uncomplicated Aortic Stenosis. Compare
with the normal pulse wave and with that of aortic regurgitation {page 171).
height, contrastuig strongly with the powerful apex beat {"pulsus
2Mrvus "). Again, the delay in the emjjtying of the left ventricle,
brought about by the obstruction at the aortic valves, renders the
contractions of the heart relatively infrequent, and hence the pulse
is infrequent (^imlsus varus) as well as small and slow to rise. The
"pulsus varus, parvus, tardus" is, therefore, a most constant and
important pomt in diagnosis, but unfortunately it is to be felt
in perfection only in the very rare cases in which aortic stenosis
occurs uncomplicated. "Wlien stenosis is combined with regurgita-
tion, as is almost always the case, the above-described t^ualities of
the pulse are usually modified as a result of the regurgitation.
' "Occasionall}', as noted by W. II. Dickinson, there is a musical murmur
of great iutensitj' in the region of the apex, probably due to a slight regurgi-
tation at high pressure through the mitral valve." — Osler.
VALVULAR LESIONS.
243
But I liave in two oases observed a well marked " Corrigan " pulse
ill life and been confronted j^oat viortem with a narrowed, rigid aortic
valve !
A less characteristic, but decidedly frequent, variation in the
pulse wave of aortic stenosis is the anacrotio curve. The slow,
long pulse with a long j)lateau at the summit is seen also in some
cases of mitral stenosis and renal disease, and is not peculiar to
aortic stenosis, but taken in connection with the other signs of the
disease it has great value in diagnosis.
(3) The Thrill.
In the majority of cases an intense purring vibration may be
felt if the hand is laid over the upper portion of the sternum, espe-
cially over the second right intercostal space. This thrill is con-
tinued into the carotids, can occasionally be felt at the apex, and
rarely over a considerable area of the chest. It is a very important
aid in the diagnosis of aortic stenosis, but is by no means pathog-
nomonic, since aneurism may produce a precisely similar vibration
of the chest wall.
The heart is slightly enlarged to the left and downward as a
rule, but the apex impulse is unusually mdistinct, " a well-defined
and deliberate push of no great violence " (Broadbent) . Corre-
sponding to the protracted sustained systole the first sound at the
ajiex is dull and long, but not very loud.
Dijferential Diagnosis.
A systolic murmur heard loudest in the second right intercostal
space is by no means peculiar to aortic stenosis, but may be due to
any of the following conditions :
(a) Eoughening, stiffness, fenestration, or slight congenital mal-
formation of the aortic valves.
{b) Eoughening or diffuse dilatation of the arch of the aorta.
(c) Aneurism of the aorta or innominate artery.
(d) Functional murmurs.
(e) Pulmonary stenosis.
(/) Open ductus arteriosus.
(gr) Mitral regurgitation.
244 PHYSICAL DIAGNOSIS.
{a and h) The great majority of siieh systolic murmurs at the
base of the heart, tirst appearing after middle life, are due to the
causes mentioned above under <i, h, and c In such cases it is usu-
ally combined witli accentuation and ringing quality of the aortic
eecoiul sound owing to tlie aiterio-sclcrosis and higli arterial tension
associated -with tlic changes "which produce the mnrniur, This
avcentuatiDii of flic unrtif sccniul miiiiid enables us, except in extraor-
dinarily rare cases, to exclude aortic stenosis, in which the intensity
of the aortic second sound is almost always much reduced.
Diffuse dilatation of the aorta, such as often acconijianies aortic
regurgitation, is a frequent cause of a systolic murmur loudest ui
the second right interspace. This may be recognized in certain
cases by the characteristic area of dulness on percussion and by its
association with aortic regurgitation of long standing (see Fig. 134).
Eougliening of the intima of the aorta (r/idiiortifif^) is always to
be suspected in elderly patients with calcified and tortuous periph-
eral arteries, ami such a condition of the aorta doubtless favors the
occurrence of a mui-mur, especially when accompanied by a slight
degree of dilatation. The absence of a thrill and a long, slow
pulse "\\-ith a low maxiuiTmr serves to distinguish such murmurs
from those of aortic stenosis.
('■) Aueuiism tif the ascending arch of tlie aorta or of the in-
nominate artery may give rise to every sign of aortic stenosis except
the characteristic jmlse and the dfminutiou of the aortic second
sound. In aneurism avc may have a well-marked tactile thrill and
a loud sjrstolie murmur transmitted into the neck, but there is
usually some abnormal pulsation to be felt, an .r-ra_y shadow to be
seen, and often soni(> difference in the pulses w in the pujiils, as well
as a liist{ny of p;iin and syin]itonis of ju'essure upon the trachea
and bronchi or reruncnt larj-iigeal ner\e. In aneurism the aortic
second simnd is usually huul and accouipanied by a shoclc, and tlie
pulse shows none of the characteristics of aortic stenosis.
((/) FunctioiKil nmrnnirs, sometimes known as "luemic,'' are
occasionalljr best licard in the aortic area, instinul of iu their usmrl
situatinn {second leit, iiilercosial space). They occur es])ecially in
young, anaemic persons, arc not accomjianied by any cardiac en-
VALVULAR LESIONS. 245
largement, by any palpable tln-ill, any diminution in tlie aortic
second souiul, or any distinctive abnormalities in the pulse.
(e) Pidnionary stenosis, a rare lesion, is manifested by a sys-
tolic niurmur and by a tlirill whose niaxinumi intensity is usually
on the left side of the sternum. In the rare cases in wliicli this
murmur is best heard in tlie aortic area it may be disthiguished
from the murmur of aortic stenosis by the fact that it is not trans-
mitted into the vessels of tlie neck, has no effect upon the aortic
second sound, and is not accompanied by the characteristic changes
ill the pulse.
(/) The murmur due to laersistence of the ductus arteriosus
may last through systole and into diastole ; it may be accompanied
by a thrill, but does not affect the aortic second sound nor the
pulse.
([/) The systolic murmur of aortic stenosis may be heard loudly at
the apex, and hence the lesion may be mistaken for mitral regur-
gitation. But the maximum intensity of the murmur of aortic
stenosis is almost invariably in the aortic area, and its association
with a thrill and a long, slow pulse should enable us easily to dif-
ferentiate the two lesions.
By the foregoing differentiae aortic stenosis may be distinguished
from the other conditions which resemble it, provided it occurs
imcoviplicated, but unfortunately this is very rare. As a rule, it
occurs in connection with aortic regurgitation, and its cliaracteristie
signs are therefore obscured or greatlj^ modified by the signs of the
latter disease. We may suspect stenosis : (a) In all young (ilieu-
matic) patients with long-standing aurtic regiiigitatidu.'- (I>) In
older (arterio-sclerotic) patients who show, besides the signs of aor-
tic regurgitation, palpable tlirill in the aortic area transmitted into
the great vessels, a modification of the Corrigan pulse in the direc-
tion of the '^pulsus tardus, ntriis, p'trvus" and less visible arterial
pulsation than is to be expected in pure aortic regurgitation.
Occasionally one can watch the develojjment of an aortic steno-
sis out of what was formerly a pure regui'gitant lesion, tlie stenosis
gradually modifying the characteristics of the previous condition.
'Because post-mortem expciii-ncc shows that in cases of this tj-pe steno-
sis and InsufHciencj' are usually combined.
24(1 PHYSICAL DIAGNOSIS.
One iimst he eai'eful, however, to exclude a relative mitral iiisuHi-
ciency which, as has been already mentioned above, is very ajDt to
supervene in cases of aortic disease, owing to dilatation of the mi-
tral oritice, and which may modify the characteristic signs of aortic
regurgitation very much as aortic stenosis does.
TRICUSPID EEGUECtITATION.
Endocarditis affecting the tricuspid valve is rare in piost-fcetal
life ; in the fcetiis it is not so uncommon. In cases of ulcerative
or malignant endocarditis occuring in adult life, the tricuspid valve
is occasionally involved, but the majority of cases of tricuspid dis-
ease occur as a result of disease of the mitral valve and in the follow-
ing manner : Hypertrophy of the right ventricle occurs as a result
of the mitral disease, is followed in time by dilatation, and with
this dilatation comes a stretching of the ring of insertion of the
tricuspid valve, and hence a regurgitation through that valve. Tri-
cuspid regurgitation, then, occurs in the latest stages of almost
every case of mitral disease and sometimes during the severer at-
tacks of failing compensation.
Out of 405 autopsies at Guy's Hospital in which evidence of
tricuspid regurgitation v^^as found, 271, or two-thirds, resalted from
mitral disease, 68 from myocardial degeneration, 55 from puhuonary
disease (Ijronchitis, emphj-sema, cirrhosis of the lung). Very few of
these cases had been diagnosed during life, and in all of them the
valve was itself healthy but insufficient to close the dilated oritice.
Gibson and some other writers believe that temjiorary tricuspid
regurgitation is the commonest of all valve lesions, and results from
weakenuig of the right ventricle in connection with states of anae-
mia, gastric atony, fever, and many other conditions. It is very
difficult to prove or disprove such an assertion.
Tricuspid regurgitation is often referred to as serving like the
opening of a " safrti/ nil re" to relieve a temporary pulmonary en-
gorgement. This "safety-valve" action, however, may be most
disastrous in its consecpiences to the organism as a whole, despite
the temporary relief which it affords to the overfilled lungs. The
engorgement is siiiiply transferred to the liver and thence to the
VALVULAR LESIONS. 247
abdominal organs and the lower extremities, so that as a rule the
advent of tricuspid regurgitation is recognized not as a relief Ijut
as a serious and probably fatal disaster.
JPh/jsical Signs.
(1) A systolic murmur is heard loudest at or near the fifth left
costal cartilage.
(2) Systolic venous pulsation m the jugulars and in the liver.
(3) Engorgement of the right auricle producmg an area of dul-
ness beyond the right sternal margin.
(4) Intense cyanosis.
(1) The Murmur. — The maximum intensity of tine systolic mur-
mur of tricuspid regurgitation is usually near the junction of the fifth
or sixth left costal cartilages with the sternum. Leube finds the
murmur a rib higher vip, but it is generally agreed that the tricuspid
area is a large one, so that the murmur may be heard anywhere
over the lower part of the sternum or even to the right of it. On the
other hand, there are some tricuspid murmurs which are best heard
at a poiat midway between the apex impulse and the ensiform carti-
lage. The murmur is not widely transmitted aiul is usually inaudi-
ble in the back; at the end of expiration its intensity is increased.
In some cases we have no evidence of tricuspid regurgitation
other than the murmur just described, but —
(2) Of more importance in diagnosis is the presence of a sys-
tolic pulsation in the external jugular veins and of the liver, which
unfortunately is not always present, but which when present is
pathognomonic. I have already exp)lamed (see ]). 88) the distinc-
tion between true si/.stolio jugular pulsation, which is practically
pathognomonic of tricuspid regurgitation, and simple presystolic
undulation or distention of the same veins, which has no necessary
relation to this disease. The decisive test is the effort permanently
to empty the vein by stroking it upward from below. If it in-
stantly refills from below and continues to pulsate, tricuspid regur-
gitation is almost certainly present. If, on the other hand, it does
not refill from below, the cause must be sought elsewhere.
U8
PHYSICAL DIAGXOSIS.
Pulsation in tlie liver must be distinguished from the "jogging "
motion ^xliich may be transmitted to it from the abdominal aorta or
from the right ventriek--. To eliminate these transmitted impulses
one must be able to grasp the li\-er binuuiualh', one hand in front
and one resting on the lower ribs behind, and to feel it distinctly ex-
pand with every systole, or else to take its edge in the hand and
to feel it enlarge in one's grasp with every beat of the heart.
Dilated right
auricle.
oystolic mu'Tuur.
Enlarged and nu'
sating liver.
Fig. 142.— Tricuspid Regurgitation. The murmur is heard best over the shaded area.
Pressure upon the liver often causes increased distention and pulsa-
tion of the external jugulars if tricuspid regurgitation is present.
(3) Enlargement of the heart, both ti.i the right and to the left,
as well as downwaid, can usually be demonstrated. In rare cases
a dilatatiijn of the light auricle may be suggested by a percussion
outline such as that shown in Pig. 142.
The pulmonic second sound is usually not accented. The im-
portance of this in differential diagnosis will be mentioned pres-
ently. If a progressive diminution in the intensity of the sound
occurs under observation, the prognosis is very grave.
(4) Cj-anosis is usually very great, and dj-spna^a and general
dro}isy ofleu make tlie jiatieut's coiiditioii a desjierate one.
VALVULAIi LESIOAS. 249
Differential Diagyiosis.
The statistics of tlie cases autopsied at the Massachusetts Gen-
eral Hospital show that tiieuspid regurgitation is less (jften recog-
nized during life than any other vahailar lesion. The diagnosis
was made ante mortem on only five out of twenty-nine cases.
This is due to the following facts :
(a) Tricuspid regurgitation may be j^resent and yet give rise to
no physical signs which can be recognized during life.
(h) Tricuspid regurgitation occurs most frequently in connec-
tion with mitral regurgitation ; hence its signs are frequently
masked by those of the latter lesion. It is, therefore, a matter of
great importance as well as of great difficulty to distinguish tricus-
pid regurgitation from
(1) Mitral Regurijitation.
The difficulties are obvious. The murmur of mitral regurgita-
tion has its maximum intensity not more than an inch or two from
the point at which the tricuspid murmur is best heard. Both are
systolic in time. They are, therefore, to be distinguished only —
(a) In case we can demonstrate that there are two areas in
which a systolic murmur is heard with relatively great intensity,
with an intervening space over which the murmur is less clearly to
be heard (see Fig. 143).
(h) Occasionally the two systolic murmurs are of different pitch
or of different quality, and may be thus distinguished.
(c) Tricuspid murmurs are not transmitted into the left axilla
and are rarely audible in the back, and this fact is of value iu case we
have to distinguish between uncomplicated tricuspid regurgitation
and uncomplicated mitral regurgitation. Unfortunately these le-
sions are very apt to occur simultaneously, so that in practice our
efforts are generally directed toward distinguishing between a pure
mitral regurgitation and one complicated by tricuspid regurgitation.
(fZ) In cases of doubt the phenomena of venous pulsation iir the
jugulars and in the liver are decisive if present, but their absence
proves nothiirg.
250
PHYSICAL DIAGNOSIS.
(e) Accentuation of the pulmonic second sound is almost inva-
riably present in uncomplicated mitral disease and is apt to disap-
pear in case the tricuspid begins to leak, since engorgement of the
lungs is thereby for the time relieved, but in many cases the pul-
monic second sound remains most unaccountably strong even when
the tricuspid is obviously leakuig.
(2) From " functional " systolic murmurs tricuspid insufficiency
may generally be distinguished by the fact that its murmur is best
Fig. Ii3,— Two Systolic Murmurs (ilitrtil and Tricuspid) with a " VauisLiing Point " between.
heard in the neighborhood of the ensiform cartilage, and not iii the
second right intercostal space where most functional murmurs have
tlieir seat of maximum intensity. Functional murmurs are unac-
companied by venous pulsation, cardiac dilatation, or cyanosis.
(3) ( )ccasionally a pericardial friction rub simulates the mur-
mur of tricuspid insufficiency, but, as a rule, pericardial friction is
much more irregular in the time of its occurrence and is not regu-
larly synchronous with any definite portion of the cardiac cycle.
TKicusriD Stenosis.
One of the rarest of valve lesions is narrowing of the tricuspid
valve. No case has come under my observation, and in 1898, Her-
VALVULAR LESIONS. 251
rick was able to collect but 154 cases from the world's literature.
Out of these 154 cases, 138, or 90 per cent, were couibined with
mitral stenosis, and only 12 times has tricuspid stenosis been known
to occur alone.' These observations account for the fact that tri-
cuspid stenosis has hardly ever been recognized during life, since the
murmur to which it gives rise is identical in time and quality and
nearly identical in position with that of mitral stenosis. ISTarrow-
ing of the tricuspid valve is to be diagnosed, therefore, only by the
recognition of a presystolic murmur best heard in the tricuspid area
and distinguished either by its i^itch, quality, or position from the
other presystolic murmur due to the mitral stenosis which is almost
certain to accompany it.
The heart is usually enlarged, especially in its transverse direc-
tion, but the enlargement is just such as mitral stenosis produces,
and does not aid our diagnosis at all.
The diagnosis is still further complicated in many cases by the
presence of an aortic stenosis in addition to a similar lesion at the
tricuspid and mitral valves, so that it seems likely that in the future
as in the past the lesion will be discovered first at autoyDsy.
PULMONAEY ReGUEGITATION.
Organic disease of the pulmonary valve is excessively rare in
post-fretal life, but may occur as part of an acute ulcerative or
septic endocarditis. A temporary functional regurgitation through
the pulmonary valve may be brought about by any cause producing
very liigh pressure in the pulmonary artery. I have known two
medical students witli perfectly healthy hearts who were able, by
prolonged holding of the breath, to produce a short, higli-pitched
diastolic murmur Ijest heard m the second and third left intercostal
spaces and ceasing as soon as the breath was let out. Of the occur-
rence of a murmur similarly produced under iDathoTogical condi-
tions, especially in mitral stenosis, much has been written by
Graham Steell.
' Out of 87 cases collected from the post-mortem records of Guy's Hos-
pital, 85, or 97 per cent, were associated with still more extensive mitral
stenosis.
^52 PHYSICAL DTAGNOSIS.
Frdin tlie diastnlid inunnui- (if aurtii^ i'(\L:;ur,L;itati(iii we may ilis-
tiugnisli {he ihastdlir iimniiur i>t' |i\ilui(iiiarv inc(iiu|K'triicy liy the
t;u t tluit the latU'r is licst licard ovci' the luihiKuiavy vahi', is never
tfaiisuiitted in the a[iex ol' tlie heart nor to the threat vessels, and
is never assoeiated with a Corrig'au pulse nor with ea|iillarv [mlsa-
tion.' The riijlit ventrieh> is hypertropliied, the ])nlnuiuie seeond
sound is sharply aeci'nti'd and followed ininiediatidy liy the murmur.
Evidenees t)f septie. embolism of the Iuulis are fri'ipuMitly jiresent
and assist us in diagnosis. The retj-urLjitation which may take
jdaee through the rigid etiue of congenital ]iulnionary stenosis is
not recognizable during life.
l'ULMOX.\KY StEXOSIS.
Among the rare congenital lesions of the heart valves this is
probably the commonest. The heart, and particularly the right
ventricle, is usually much enlarged. There is a histo-ry of cyanosis
and d3rspna'a since birth. Tnhuonary tuberculosis complicates from
one-fourth t i one-third of all cases. A systolic thrill is usually to
be felt in the second left intercostal space, and a loud systolic mur-
mur is heard in the same area. The puhnoniu second sonnd is weak.
The region in which this uiurmur is best lieard has been happily
termed Wio ^^ rcijlun of roiimiicc'' on acct)unt of the multiplicity of
mysterious nuirniurs which have been heard there. The systolic
murmur of pulmonary stenosis must be distinguished from
((/) Funetitinal murmurs due to aniemia and debility or to severe
muscular exertitm, and possibly associated with a dilata.tion of tlie
conus arteriosus.
(7)) Uncovering of the conus arteriosus through lack of expan-
sion of the lung.
(c) Aortic stenosis.
((/) Mitral regurgitation.
(e) .\neurism.
(/') Roughening of the intima of the aortic arch.
' Uy registering the variations of pressure in the tracheal column of air
Gerhardt has shown graphically that a systolic pulsation of tlie pulmonary cap-
illaries may occur in pulmonary regurgitation. With the stetho.scope a sys-
tolic whiff may be heard all over the lungs.
VALVULAR LESIONS. 253
(a and 5) Functional murmurs, and those produced in the conus
arteriosus, are rarely if ever accompanied by a thrill, are rarely so
loud as the murmur of pulmonary stenosis, and are not associated
with dyspnrea, cyanosis, and enlargement of the rigiit ventricle.
(r) The murmur of aortic stenosis is usually upon the right side
of the sternum and is transmitted to the neck, whereas the murmur
of pidmonary stenosis is never so transmitted and is not associated
with characteristic changes in the pulse (see above, p. 242).
((/) The murmur of mitral regur<jitatlon is occasionally loudest
m the region of the pulmonary valve, but differs from the mimnur
of pulmonary stenosis in being, as a rule, transiuitted to the back
and axilla and associated with an accentuation of the pulmonary
second souud.
(<?) Aneurism may present a systolic murmur and thrill similar
to those found in pulmonary stenosis, but may usually be distin-
guished from the latter by the presence of the positive signs of aneur-
ism, viz. — pulsation, and chihiess in the region cf the murmur, and
signs of pressure on the trachea or on other structures in the medi-
astinum.
(/) Roughening of the aortic arch occurs after middle life,
while pulmonary stenosis is usually congenital. The murmur due
to roughening may be transmitted into the carotids ; that of jiul-
monary stenosis never. Enlargement of the right ventricle is char-
acteristic of pulmonary stenosis, but not of aortic roughening.
COMBINED VALVULAR LESIONS.
It is essential that the student should understand from the first
that the number of murmurs audible in the precordia is no gauge
for the number of valve lesions. We may have four distinct mur-
murs, yet every valve sound except one. This is often the case in
aortic regurgitation — systolic and diastolic murmurs at the base of
the heart, systolic and presystolic at the apex, yet no valve in-
jured except the aortic. In such a case the systolic aortic murmur
is due to roughening of the aortic valve. The systolic apex mur-
mur results from relative mitral leakage (with a sound valve). The
presystolic apex murmur is of the "Flint" type. Hence in this
254 PHYSICAL DIAGNOSIS.
case the diastolic murmur alone of the four audible murmurs is clue
to a valvular lesion.
It is a good rule not to multiply causes irnnecessarily, and to
explain as many signs as possible under a single hypothesis In
the above example the mitral leak might be due to an old endocar-
ditis, and there viigJit be mitral stenosis and aortic stenosis as well,
but since we can explaui all tlie signs as results — direct and indirect
— of one lesion (aortic regurgitation) it is better to do so, and post-
mortem experience shows that our diagnosis is more likely to be
right when it is made according to this principle .
The most frequent combmations are :
(1) Mitral regurgitation with mitral stenosis.
(2) Aortic regurgitation with mitral regurgitation (with or with-
out stenosis).
{?>) Aortic regurgitation with aortic stenosis, with or without
mitral disease.
(1) Doiibhi Mitral Disease.
(a) It very frequently hapjiens that the mitral valve is found
to be both narrowed and incompetent at autopsy when only one of
these lesions had been diagirosed during life. In fact mitral steno-
iiilliminii I d
Fig. 144.— Mitral Stenosis and Regurgitation, showing relation ot murmur to first heart sound.
sis is almost never fomid at autopsy with mt an associated regurgi-
tation, so that it is fairly safe to assume, whenever one makes the
diagnosis of mitral stenosis, that mitral regurgitation is present as
well, whether it is possible to hear any regurgitant murmur or not
(see Fig. 144).
(h) On the other hand, with a double mitral lesion one may
have only the regrrrgitant murmur at the mitral valve and nothing
to suggest stenosis unless it be a surprising sharpness of the first
mitral sound. In chronic cases the changeableness of the murmurs
both in type and position is extraorduiary. One often finds at one
VALVULAR LESIONS.
255
visit evidences of mitral stenosis and at another evidences of mitral
regurgitation alone. Either murmur may disappear altogether foi
a time and reappear subsequently. This is peculiarly true of the pre-
systolic murmur, which is notoriously one of the most fleeting and
uncertain of all physical signs.
As a rule the same inflammatory changes 3vhich produce mitral
regurgitation in early life result as they extend in narrowing the
mitral valve, so that the signs of stenosis come to predominate in
later years. Coiiicideutly with this narrowing of the diseased valve
a certain amount of improvement in the patient's symptoms may
take place, and Eoseubach regards the advent of stenosis in such a
case as an attempt at a regenerative or compensatory change. In
many cases, however, no such amelioration of the symptoms foUows-
(2) Aortic Ilefjurgltiitlon irifh Ilitrul Diseusn.
The signs of mitral disease occurring in combination with
aortic regurgitation do not differ essentially from those of pure
Systolic murmur
over dilate(i-*if-
aortlc arcb.
Maximum intensity
and diastolic mur-
m u r, conducted
up and down.
■Systolic murmur.
FiQ. 14,5.— Aortic and Mitral Regurgitation. Tlie sliaded areas are those in wlaich tbe murmurs
are loudest.
mitral disease except that the enlargement of the heart is apt to
be more general and correspond less exclusively to the right ven-
tricle (see Figs. 145 and 146). The manifestations of tlie aortic le-
256 PHYSICAL DlAOyOSIS.
sion, on the other hand, are considerably modified by their associa-
tion with the mitral disease. The C'orrigan pulse is distinctly less
sharp at the summit and rises and falls less abruptly. Capillary
1st 1st
llli "'"' III I '"''
lillUHIII iHiummn milllUllliiii llUHHHiiinih
Fig. U6.— Showing Relation ot Murmurs to Heart Sound in Regurgitation at tbe Aortic and
Mitral Valves.
pulse is less iikelj^ to be present, and the throbbing of the peripheral
arteiies is less often visible.
(3) Aortic Iic(/urf/it(itioii iritli Aortic Stenosis.
If the aortic valves are narrowed as well as ineomjietent, we
find very much the same moditication of the physical signs charac-
teristic of aortic regurgitation as is produced by the advent of a
mitral lesion ; that is to say, the throbbing in the peripheral ar-
teries is less violent, the characteristics of the radial pulse are less
marked, and the capillary i^ulsation is not always to be obtained
at all. Indeed, this blunting of all the typical manifestations of
aortic regurgitation may give us material aid in the diagnosis of
aortic stenosis, provided always that the mitral valve is still per-
forming its fimction. '
(4) The association of mitral disease with tricuspid insufficiency
has been already described on p. 218.
' Some astonisliing exccptious to this rule liave been menfioneil on pages
2-10 fuul 343.
CHAPTER XI.
PAEIETAL DISEASE.— CARDIAC NEUROSES.— CONGENl
TAL MALFORMATIONS OF THE HEART.
Parietal Disease of the Heart.
Acute Mi/ocardltis.
The myocardium is seriously, though not incurably, affected in
all continued fevers, owing less to the fever itself than to the tox-
aemia associated with it. "Cloudy swelling," or granular degener-
ation of the muscle fibres, is produced by relatively mild infections,
while a general septicaemia due to pyogenic organisms may produce
extensive futty degeneration of the heart within a few days.
The 2^^'!/sic(il sir/ns are those of cardiac -weakness. The most
significant change is in the quality of the first sound at the apex
of the heart, which becomes gradually shorter until its quality is
like that of the second sounds, while in some cases its feebleness
makes tbe second sounds seem accented by comparison. Soft blow-
ing systolic murmurs may develop at the itulmonary orifice, less
often at the apex or over the aortic valve.
The apex impulse becomes progressively feebler and more like
a tap than a push. Irregidarity and increasing rapidity are omi-
nous signs which may be appreciated in the radial pulse, but still
.better by auscultation of the heart itself. In most of the acute in-
fections evidence of dilatation of the weakened cardiac chambers is
rarely to be obtained during life (although at autopsy it is irot in-
frequently found),' but in acute articular rlieuinatistn an acute dila-
tation of the heart appears to be a frequent complication, independ-
' Henchen's recent monograph on this subject, " Ueber die acute Herzdila-
tation bei acuten Infectionskrankheiten," Jena, 1899, does not seem to me
convincing.
17
258 PHYSICAL DIAGNOSIS.
ent of tlie existence of anj' valvular disease. Attention has been
especially called to this [loint by Lees and lioynton (Bn'fisli j}fed.
Jour., July 1', IS'JS) and by S. \Vest.
IxFLUExzA is also complicated not infrei^uently bj- acute cardiac
dilatation.
Wt'ul^cni'il lIi'Kii ( " C/iniiiif JJi/ncKnh'tis '^ ).
Fattj' or fibroid changes in the heart wall occuriug in rhronic
disease may result from coronary sclerosis and imperfect nutrition
of the myocardium, but in many cases no lesions are fninid post
mortem in the heart, the heart weakening as a result of long-con-
tinued overwork against an increased arterial resistance (nephritis,
arterio-sclerosis).
Whetlier definite myocardial changes are present or not, the
signs are the same.
I'll //.•ilea/ Sii/iif: nf D'l'iilcciicd lli'urt.
For the sure recognition of changes in the myocardium our
present methods of physical examination are always unsatisfactory
and often wholly inadequate. Extensive degenerations of the
heart wall are not infrequently found at autopsy when there has
been no reason to suspect them during life. On the other hand,
the autopsy often fails to substantiate a diagnosis of degeneratior,
of the heart nruscle, although all the physical signs traditionally
associated with this condition were present durhig life.' To a con-
siderable extent, therefore, our diagnosis of myocarditis must de-
pend upon the history and symptoms of the case ; physical exami-
nation can sometimes supplement these, sometimes not. Sj-mptoms
of cardiac weakness developing in a man past middle life, especially
in a patient who shows evidences of arterio-sclerosis or high ar-
terial tension, or who has suffered from the effects of alcohol and
syphilis, suggest parietal disease of the heart, fatty or fibroid.
The probability is increased if there have been attacks of angina
pectoris, Cheyne-Stokes breathing, or of syncope.
Inspection and palpation may reveal nothing abnormal, or there
' A well-known Boston pathologist receiUly told me that he had nevet
known a case of myocarditis correctly diagnosed during life.
PARIETAL DISEASE. 259
may be an unusually diffiTse, slapping cardiac impulse associated
perhaps with, a displacement of the apex beat to the left and down-
ward. Marked irregularity of the heart l)eat, both in force and in
rhythm, is sometimes demonstrable by these methods, and an in-
crease in the area of cardiac dulness may be demonstrable in case
dilatation has followed the weakening of the heart wall. Ausculta-
tion may reveal nothing abnormal except that the aortic second
sound is unusually sharp ; in some cases feehle and in-e(/ular heart
sounds are heard, although the first sound at the apex is not infre-
quently sharp. Blood pressure is often much increased. The
sounds may be reduplicated and " gallop rhythm " is not infrequent.
If the mitral sphincter is dilated, or the papillary muscles are weak-
ened, as not infrequently ha})pens, we may have evidences of mitral
regurgitation, a systolic murnnxr at the apexheaid in the left axilla
and back with accentuation of tlie puhnonic second sound.
Siimmari/.
1. The history and symptoms of the case or the condition of
other organs are often of more diagnostic value than is the physical
examination of the lieart itself, wliich may show nothing abnormal.
2. Among the rather unreliable physical signs, those most often
mentioned are :
{«) Weakness and irregularity of the heart sounds.
(h) Increased blood pressure.
(c) A diffuse slapping cardiac impulse.
(d) Eeduplication of some of the cardiac sounds (gallop
rhythm) .
(e) Evidences of cardiac dilatation.
(/) Murmurs — especially the murmur of mitral insufficiency
which often occurs as a result of dilatation of the valve oritices and
weakening of the cardiac nuiscle.
Dljferentiiil Z>lii//nosis.
We have to distinguish the weakened heart from —
((•() Uncomplicated valvular lesions.
[/i) Cardiac neuroses.
260 PHYSIrAL PlAOyOSlS.
(ii) It has been already pointed out tliat valvulai' lesions do
not neeessai'ily give rise to anv nuivnmrs when compensation has
failrd. Under sueh cireuuistances one hears only irregular and weak
heart sounds, as in niynr-arditis. The history of a long-standing
\alvnlar troulile, a knowledge of the pre\-iims history of the case,
the age, method of onset, and the high bhiod pressure maj' assist us
in the diagnosis. Cases of weakened heart are less often associated
with extensive dropsy than are eases of valvular disease whose coni-
piensatiou has been ru[)tured.
(/') Weakness and irregularity of the cardiac sounds, when due
to nervous affection of tlie heart and unassociated with parietal or
valvular changes, is usually less marked after slight exertion. The
heart "rises to tlie occasion" if the weakness is a func'tional one.
On the other Iiand, if any serious weakening is present, the signs
and symi)roms are much aggravated by any exertion.
In some cases of myocarditis the pulse is excessively slo'^v and
shows no signs of weakness. Tliis point will be referred to again
in the chapter on Bradycardia.
Fattij Ovi rgroirth.
An abnormally large accumulation of fat about the heart may
be suspected if, in a very obese pierson, signs of cardiac embarrass-
ment (dyspircea, palpitation) are present, and if on examination we
find that the heart sounds are feeble and distant but preserve the
normal difference from each other. When the heart wall is seri-
ously weakened ('as in the later weeks of tyjihoid), the heart sounds
become more alike owing to the shortening of the first sound.
In fatty O'^'ergrowth this is not the case.
The diagnosis, however, cannot be positively made. "We sus-
pect it under the conditions above described, but no greater cer-
tainty can be attained.
Fattij Di'i/riicriitioti.
There are no pihysical signs by which fatty degeneration of the
heart can be distinguished frcun other pathological changes which
result in weakening the heart walls. An exteirsi\'e degree of fatty
CARDIAC NEUROSES. 261
degeneration is often seen post mortem in cases of pernioious anffimia,
altliougli tlie lieavt sounds liave been clear, regular, ami in all re-
spects normal during life. The little we know of the physical
signs common to fatty degeneration and to other forms of parietal
disease of the heart has been included in the section on Weakened
Heart (see ]>. 257).
Oak.diao Neuroses.
T/tc/i//c(H'dla (E.((p'ul ITeiirt).
Simple quickening of the pulse rate, or tachycardia, which may
pass altogether unnoticed by the patient himself, is to be distin-
guished from palpitation, in which the heart beats, whether rapid
or not, force themselves upon the patient's attention.
The prrlse rate may vary a great deal in health. A classmate
of mine at the Harvard Medical School had a pulse rarely slower
than 100, yet his heart and other organs were entirely sound. Such
cases are not very uncommon, especially in women. Temporarily
the pulse rate may be greatly increased, not only by exercise and
emotion, but by the influence of fever, of gastric disturbances, or of
the menopause. Such a tachycardia is not always of brief duration
The effects of a great mental shock may produce an acceleration of
the pulse which persists for days or even weeks after the shock
Among organic diseases associated with weakening of the pulse
the commonest are those of the heart itself. Next to them, exoj)!!-
thalmic goitre, tumors or hemorrhage in the iireduUa, and obscure
diseases of the female organs of generation, are the most frequent
causes of tachycardia.
The only form of tachycardia which is worthy to be considered
as a more or less independent malady is
Faroxysmal Tachycardia.
As indicated in the name, the attacks of this disease are apt to
begin and to cease suddenhj. They may last a few hours or several
days. The pulse becomes frightfully rapid, often 200 jier miniite oi
more. Bristowe records a case with a pulse of 308 per minute
262 PHYSICAL DIAGXOSIS.
Ill the radial artery the pulse beat may be impalpable. The heart
soumls are regular ami clear, Init the diastolic pause is shortened and
the first sound becomes short and "' valvulai'," resembling the sec-
ond (" tic-tiic Iii'di-t''). The parox^vsm may be associated with
aphasia and abnormal sensations in the left arm. Occasionallj- the
heart becomes dilated, and cederaa of tlie lungs, albuminuria, and
other nianifestations of stasis ap^iear. Usually, however, the par-
oxysm has no serious results. It can be distinguished from the
tachycardia of cardiac dilatation by tlie fact tlurt the lieart renuiins
perfectly regular. This same fact also assists ns in excluding the
cardiac neuroses due to tobacco, tea, and otlicr poisons. From the
tachycardia of Graves' disease tlie affection )u_i\v in consideration
differs liy its paroxysmal and intermittent character.
Brodi/ciinliii fSfoic Heart).
In many healthy adults the lieart seldom beats over 60 times a
minute .
I. Among the causes wliich maj- produce for a short time an
abnormality slow heart-beat are :
((/) Exliuustion: for example, after fevers, after parturition, or
severe muscular exertion.
(l>) Toxwmia ; for example, jaundice, uramia, auto-intoxieations
in dj'spepsia.
(c) In certain liijsterical and melancholic states aird in neurotic
chUdren, the pulse may be exceedingly slow Pain has also a ten-
dency to retard the pulse.
(rf) An ino'case of intracranial pressure, as in meningitis, cere-
bral hemorrhage,, depressed fracture of the skull. I'ossibly in this
category belong the cases of bradycardia sometimes seen in ejnlep-
tiform or during syncopal attacks. Bradycardia from any one of
these causes is apt to be of comparatively short duration.
II. Stokes-Adams' disease (due to a lesion of the bundle of
His) refers especially to a i)aroxysmal bradycardia witli syncope,
yet the ]iulse may remain below 40 for months, tiiougli slnnig and
regular, and the jiatient may be free from symptoms of any kind.
The rate of the heart-beat cannot be estiuuated by counting the ra-
CARDIAC NEUROSES. 263
dial pulse. Careful study of tlie jugular motions, especially with a
polygraph, usually shows that souu> auricular beats do not reach
the ventricle (heart blockj so that there are 2 or 3 beats in the
jugular for every 1 in the radial.
Arrhi/th/iiia.
1. Phi/siolof/ical Afrlnjtii milt . — Arrhythmia, or irregrilarity in the
force or rhythm of the heart-beat, is to a certain extent physiologi-
cal. The heart normally beats a little faster and a little more strongly
during inspiration than during expiration. Any psychical distuib-
ance or muscular exertion may produce irregularity as well as a
quickenmg of the heart-beat. Rarely the jjulse may l^e irregular
throughout life in perfectly healthy persons. This irregularity is
usually of rhythm alone; every second or third beat may be regu-
larly omitted without the individual knowing anything about it or
feeling any disagreeable symptoms connected with it. More rarely
the heart's beats may be permanently irregular in force as well as
rhythm despite the absence of any discoverable disease.
In children the pulse is especially apt to be irregular, and dur-
ing sleep some children show that modification of rhythm known
as the "paradoxical jjuisc," which consists iri a cj^uiekenmg of the
pulse with diminution ui volume during inspiration.
(2) If we leave on one side diseases of the heart itself, i^atho-
''o(/ical arrJu/thmia is most frequently seen in persons who have used
i^'bacco or tea to excess, or ur dyspepsia. In these conditions it is
often combined with palpitatioir and becomes thereby very distress-
ing to the patient. In connection with cardiac disease the follow-
ing types of arrhythmia may be distinguished :
(a) Paradoxical Pulse. — Any cause which leads to weakening
of the heart's action may occasionally be associated with paradoxical
pulse. Fibrous pericarditis has been supposed to be frequently
associated with this type of arrhythmia, but if so it is by no means
its only cause.
(li) The bigeminal pulse is seen most frequently in cases of un-
compensated heart disease (particularly mitral stenosis) after the
administration of digitalis. Every other beat is weak or abortive
264 PHYSICAL DIAOyOSTS.
aiid is succeeiled by an umisually long paiTse. Sometimes eYt'r\
tliinl beat is of the abortive type, or an unusually long interval
may divide the heart-beats into groups of three i^" tfirn'iiiiinil
(<:) Hiiiliri/orairUa, or the " tic-tac heart," represents a shorten-
ing of the diastolic jiause and of the first sound of the heart so that
it resembles the second sound, as in the IVvtal heart. Any case of
uncompensated heart disease, ■whether valvular or parietal, may be
associated Avith this disturbance of rhythm.
((/) The gallop rlnjtluii.
Owing to a reduplication of one of the heart sounds (usually
the second), "n'c .may have three sounds instead of two witli each
beat of the heart, the sounds possessing a rhythm which reuunds us
of the hoof -beats of a galloping horse (see p. 181). This rhythm is
heard especially in the failing heart of mterstitial ne])hritis or cor-
onary sclerosis.
(p) Dcliiuiiiii cordis is a term used to express any great irregir-
laxity and rapidity of the heart-beats wliich cannot be reduced to
a single tjiJe or rhj-thm. It is seen in the gravest stages of uncom-
pensated heart disease.
Palplti(tio)i.
Best defined as an " irreguhrr or forcible heart action j>crcc/ifil'lc
to the Individual." The essential point is that the individual
becomes conscious of each beat of his heart, whether or no the heart
action is in an}' way abnormal.
(a) In irritable conditions of the nervous system, such as occur
at puberty, at climacteri(^, or in lunirasthenic persons, palpitation
may be very distressing. Temporary disturbances, such as fright,
may produce a similar and more or less lasting effect.
(li) The effect of high altitudes, or of even a moderate eleva-
tion (1,500 feet) is sufHci(>nt to produce in many healthy persons a
quickening and strengthening of the heart's action, so that sleep
may be prevented. After a fe\\- nights this condition usually
passes off, provided the heart is sound.
((■) Abuse of tobacco and tea have a similar effect.
CONGENITAL HEART DISEASE. 265
Auscultation of a palpitating heart shows nothing more than
unusually loud and ringing heart sounds, but since palpitation is
often associated with arrhythmia of one or another type we must be
careful to exclude the ^palpitation symptomatic of acute dilatation
of the heart, such as may occur in debilitated persons after violent
or unusual exertion. In this condition the area of cardiac dulness
is increased and dyspncea upon slight exertion becomes marked. It
goes without saying that m almost any case of organic disease of
the heart palpitation may be a very marked and distressing symp-
tom.
CONGENITAL HEAET DISEASE.
From tlie time of birth it is noticed in some cases that the child
is nurrkedly cyanosed, hence the term "blue baby." Dyspnoea is
often, though not always, present, and may interfere with suclviug.
I'lie cyanosis, if present, is practically sufficient in itself for the
diagnosis.
Among congenital diseases of the heart the commonest and the
most important (because it is less likely than any of the others to
prove immediately fatal) is :
1. Pulmonary Stenosis.
This lesion is usually the result of foetal endocarditis, and is
often associated with malformations and defects, such as patency
of the foramen ovale and persistence of the ductus arteriosus. The
physical signs of pulmonary stenosis are :
(rt) A palpable systolic thrill most distinct in the pulmonary
area.
{h) A loud systolic murmur (often rough or musical) heard best
in the same region, but transmitted to all parts of the chest.
((?) A weak or absent pulmonic second sound.
(d) An increased area of cardiac dulness corresponduig to the
right ventricle.
Unlike most other varieties of congenital heart disease, pulmo-
nary stenosis is compatible with life for many years, and "blue
babies " with this lesion may grow up and enjoy good health, al-
266 PHYSICAL DIAGNOSIS.
though usnally subject to pulmonaiy disorders (pneiunonia or tu-
berculosis) For a discussion of the differential diagnosis of this
lesion, see above, p. 252.
2. Defects ill the Tentrindar Septum.
The loud si/stuHc murmur produced by the rush of blood through
an opening between the yentricles is heard, as a rule, over the whole
precordia. Its point of niaxiniuni uitensity differs in diti'erent
cases, but is hardly ever near the apex of the heart. The most im-
portant diagnostic jioint is the ahsence of a palpable thrill. "With
almost every other form of congenital heart disease in which a loud
murmur is audible, there is a thrill as well Hypertrophy of both
ventricles may be jjresent, but is seldom marked in uncomplicated
cases.
(Pafetici/ of tJie foramen ovale, if unassociated with other de-
fects, does not usually produce any murmur or other signs by which
it can be recognized during life, and causes no symptoms of any
kmd.)
3. Persistence of the Ductus Arteriosus.
The most characteristic sign is a loud, vibratory systolic mur-
mur with its mtensity at the base of the heart and unassociated with
hypertroijhy of either ventvicle. If complicated with stenosis at or
close above the pulmonary valves, persistence of the ductus arte-
riosus cannot be diagnosed, as the murmur produced by it cannot
with certainty be distinguished fi'oni that if the pulmonary ste-
nosis, and the presence of hjq^ertrophy of the right ventricle de-
prives us of the one relati^'ely characteristic mark of a patent arte-
rial duct.
Gil)son considers that a murmur persisting through systole and
into diastole is diagnostic of an ojieu arterial duct, but this sup-
position is not borne out in all cases by post-mortem evidence.
The signs produced by tlie otlier varii'ties of congenital lieart
disease, such as aortic stenosis and tvicusiiid or mitral lesions, do
not differ materially from those cliaructerizing those lesions in
CONGENITAL HEART DISEASE.
2fi7
adults. Excluding these, we may summarize the signs of the othei
lesions as follows :
(a) Practically all cases of congenital lieart disease, which pro-
duce any physical signs beyond cyanosis and dyspnoea, manifest
themselves by a loud systolic murmur heard all over the precordia
and often throughout the chest. Its maximum intensity is usually
at or near the base of the heart.
(U) If there is no tJirlU and no lii/pertroplnj, the lesion is prob-
ably a defect in the ventricular septum.
(e) If there is a tJirill hut no hypertyoi)]nj, the lesion is probably
a patent ductus arteriosus.
((/) If there is a ilirlll and hijpertrojjlnj of the right ventricle,
the lesion is probably pulmonic stenosis, especially if the pulmonic
second sound is feeble.
CHAPTER XII.
DISEASES OF THE PEKICAEDIUM.
I. Peeicakditis.
Three forms are recognized clinically :
(1) Plastic, dry, or fibrinous pericarditis.
(2) Pericarditis with effusion (serous or purulent).
(3) Pericardial adhesions or atUierent pericardium
Fibruious pericarditis maj' be fully developed without giraig
rise to any physical signs that can be appreciated during life. In
several cases of pneumonia in which I suspected that pericarditis
might be present, I liave listened most carefully for evidences of
the disease and been unable to discover anj- ; j-et at autopsy it was
found fully developed — the typical shaggy heart. "SVe have every
reason to believe, tlierefore, that pericarditis is frequently present
but unrecognized, especialh' in pneumonia and in the rheunnitic at-
tacks of children. On the other hand, it may give rise to very
marked signs which are the result of —
(a) The rubbing of the roughened pericardial surfaces against
one another when set in motion l\v the cardiac contractions.
(/)) The presence of fluid in the pericardial sac.
(c) The interference with cardiac contractions brought about by
obliteration of the pericardial sac together -with tlie results of ad-
hesions between the pericardium and the surrounding structures.
(1) Dry or Ftbrixous Pericarditis.
The diagnosis rests upon a single physical sign — "pericardial
friction " — which is usually to be appreciated hj auscultation alone,
but may occasionally lie felt as well. Characteristic pericardial
friction is a rough, irregular, grating or shuffling sound which oc-
DISEASES OF THE PERICARDIUM.
269
curs irregularly and interruptedly during the larger part of eacli
cardiac cycle. It is almost uever accurately synchronous either
with systole or diastole, but ocei'lups the cardiac sounds, and en-
croaches upon the pauses ui the heart cycle. It is seldom exactly
the same in any two successive cardiac cycles and differs thereby
from sounds produced within the heart itself. Pericardial friction
seems very near to the ear and may often be increased by pressure
Pericardial friction.
Fig. 147. — Showing Most Frequent Site of Audible Pericardial Friction.
with the stethoscope ; it is not materially influenced by the respi-
ratory movements.
It is best heard in the majority of cases in the position shown
in Fig. 147 ; that is, over that portion of the heart which lies near-
est to the chest wall and is not covered by the margins of the lungs ;
but not infrequently it may Ije heard at the base of the heart or
over the whole precordial region. The sounds are famter if the
patient lies on the right side, and sometimes intensified if, while
sitting or standing, he leans forward and toward the left, so as to
briirg the heart into closer apposition with the chest wall.
Pericardial friction sounds often change rapidly from hour
to hour, and may disappear and reappear in the course of a
day.
'270 PHYSICAL DIAGyOSIS.
In rare cases tJie frietiou may occiir only during systole or only
during diastole. In sucli eases the diagnosis between pericardial
and iutraeardial soiuids may be very difficult.
DiFFEKEXTIAL DIAGNOSIS.
((/) Plciiro-Perirardidl Friction.
Fibrinous inflammation affecting tliat part of the pleura wliich
overlaps tlie heart may give rise to sounds altogether indistinguisli-
able from those of true pericardial friction when the inflamed pleu-
ral surfaces are made to grate against one anotlier by tlie move-
ments of the heart. Such sounds are sometimes increased in
intensity during forced respiration and disajipear at the end of
expiration, while true pericardial friction is usually best heard if
the breath is held at the end of expiration. If a friction sound
heard in the pericardial region ceases altogether when the breatli
is held, we may be sure that it is produced in tlie pleura and not
in the pericardium, but in many cases the diagnosis cannot be made
correctly.
(?') Intracardiac Murmurs.
From murmurs due to valvular disease of the heart, pericardial
friction can usually be distinguished by the fact that the sounds to
which it gives rise do not accurately correspond either with systole
or diastole, and do not occupjr constantly any one portion of either
of these periods. Cardiac murmurs are more regular, seem less
superficial, and varv less with position and from hour to hour.
Pressure with the stethoscope does not increase so considerably the
intensity of intracardiac murmurs. When endocarditis and peri-
carditis occur simultaneously, it may be very difficult to distinguish
the two sets of sounds thus produced. The pericardial friction is
usually recognized with comiiaratively little difficult}', but it is
luird to make sure whether iu addition we hear endocardial mur-
murs as well.
DISEASES OF THE PERICARDIUM.
271
(2) Peeicaedial Effusion.
Following the fibrinous exudation, which roughens the |>eri(:'av-
dial surface and i^roduces the friction sounds just described, serum
may accumulate in the pericardial sac. Its quantity may exceed
but slightly the amount of fluid normally present in the periear-
Fig. 148.— Pericardial Effusion, C'ardio-liepatic Angle obtuse. (From v. Ziemssen's Atlas.)
dium, or may Ids so great as to embarrass the cardiac movements
and finally to arrest them altogether. In chronic (usually tubercu-
lous) cases, the pericardium may become stretched so as to hold a
quart or more without seriously interfering with, the heart's action,
while a much smaller quantity, if effused so rapidly that the peri-
cardium has no time to accommodate itself by stretching, will prove
rapidly fatal.
272 PHYSICAL DIAGNOSIS.
Hj'droperioardium denotes a drops}' of tlie pericardium oceur-
riug liy traiisrrdation as ])art of a general dropsy in eases of renal
disease or cardial ■\vealciiess. The pliysical sigiis to which it gives
rise do not differ from those of an inflammatory effusion, and, ac-
cordingly, all that is said of the latter in the following section may
be taken as equally an account of the signs of hydropericardium.
Hinemopericardium, or blood in tlie pericardial sac, due to stabs
or to ruptures of the heart, is usually so rapidly fatal that no
physical signs are recognizable.
PJi>/s!caI Siffiis of Pericardial Effusion.
In most cases a pericardial friction rub has been observed prior
to the time of the fluid accumulation. The presence of fluid m the
pericardial sac is shown chiefly in three ways :
(1) By iiercussion, which demonstrates an area of dulness more
or less characteristic (see below).
(2) By ausculfafioii, wliich may reveal an unexpected feebleness
in the heart sounds when compared with the power sliown in tlie
radial pulse.
(3) By the signs and symptoms oi jjressiirr exerted by the peri-
cardial effusion upon surroimding structures.
Bulging of the precordia is occasionally to be seen in childi'en;
in adidts we sometimes observe a flattening of the interspaces just
to the riglit of tlie sternum between tlie tlurd and sixtli ribs.
(T) TJie Area of Pereiission Pit/iiess. — The extent of the dull
area depends not only on the size of tlie effusion and the position of
the patient, Ijut also on the amount of "give " in the pericardium
and iu the lungs as well as on the size of the lingula pulmonalis.
Allowing for these uncertain factors, wc may say : {")<>neof the
most chai'acteristio points is the unusual ' extension of the percus-
sion dulness a considerable distance to the left of the maxiiiiaiu
cardiac impulse. (/') Next to this, it is important to notice a change
in the angle made by the junction of the horizontal line correspond-
> In liealtli tlic cardiac dulness extends uboiit '(- (if an ineli lieyimd I lie niaxi-
Jimn) cardiac impulse, Ind, in pericardial elVusimi the dilVerenee is greater.
DISEASES OF THE PERICARDIUM.
273
iiig to the upper limit of hepatic duluess and the nearly perpendicu-
lar line corresponding to the right border of the heart. In health
this cardio-hepatic angle is approximately a right angle; in pericar-
dial effusion it is nuu-h more obtuse (see Fig. 149). llotcli has
called attention to tlie importance of dulness in the fifth right inter-
costal space as a sign of pericardial effusion, but a similar dulness
may be produced by enlargement of the liver.
Except for the two points mentioned above (the unusual exten-
sion of the dulness to the left of the cardiac impulse and the bluuting
of the cardio-hepatic angle), there seems to me to be nothing charac-
teristic about the area of dulness produced by pericardial effusion.
Tympany,
Dulness,
Cardiac impulse.
Liver dulness.
Fig. 149.— Percussion Dulness in Pericardial Effusion, with Tympanitic Resonance Under the
Lett Clavicle.
The "pear-shaped" or triangular area of percussion dulness uien-
tioned by many writers has not been present in cases which have
come under my observation. In large effusions percussion reso-
nance may be dimmislied in the left back, and under the left clav-
icle the percussion note may be tympanitic from relaxation of the
lung. Traube's semilunar space may be obliterated, but this occurs
also in pleuritic effusions.
In some cases the area of duhress may be modified by change in
the patient's position. After marking out the area of percussion
L8
274 PHYSICAL DIAGXOSIS.
iluluess with the patient iu the upright position, let him lie upon
his right side. The right border of the area of dulness vill some-
times move consideraljly farther to the right. A dilated lieart can
be made to shift iu a similar "way, hut to a lesser extent. Compar-
atively little change takes place if the patient lies on his left side,
and no important information is elicited hy placing him flat on his
back or by getting him to lean for^vard.
Unfortunately, it is only ^vith moderate-sized effusions occur-
ring ur a pericardial sac free from adhesions to the' surrounding
parts that this shifting can lie made out. Large effusions may not
shift appreciably, and less than l.'iO c.c. of fluid probably cannot be
recognized by this or by any otlier method. But 'with large effu-
sions the lateral extension of the areii, of dulness may be so great
as to be almost distinctive in itself, i.e., from the middle of the left
axilla nearly to the right nippile.
(2) Feebleness of the heart sounds and of the apex impulse is of
diagnostic importance onl}- when it gradually takes the place of the
normal phenomena as one watches the heart from day to day.
Under these conditions they have some confirmatory value in tlie
diagnosis of pericardial effusion.
Tubular breathing v.'ith increased voice sounds and tactile frem-
itus can often bo heard near the angle of the left scajmla. Tins is
a result of compression of the lung, but is often jnistaken for
pneumonia.
(3) Pressure exerted b}' the pericardial exudation upon sur-
rounding structures may give rise to dj'spnrea, especiallj- of a
paroxysmal tj'pe, to dysphagia, to aphonia, and to an irritating
cough. The "paradoxical pulse," small and feeble dirring inspira-
tion, is occasionally to be seen, but is bj- no means peculiar to this
condition and has no considerable diagnostic importance.
(4) Inspection, and palpation usually help us very little, brrt two
points are occasionally demonstrable by these methods :
(a) A smoothing out of the intercostal depression in the p^recor-
dial region, especially near the right border of the sterniuu between
the third and the sixth ribs.
Qj) A progressi^'c diminution of the intensity of the apex im-
pulse until it uuxy be altogether lost. If this cbange occurs while
DISEASES OF THE FERICARDIIUI 275
the patient is aiider observation, and especially if the apex impulse
reajypears or becomes more distinct when the patient lies on the
right side, it is of considerable diagnostic value. In conditions
other than pericardial effusion, the aj^ex impulse becomes less visible
in the right-sided decubitus.
Dijfefcnthil Did gnosis.
(1) Our chief difficulty is to distinguish the disease from hyper-
trophy and dilatation of the heart. In the latter, which often com-
plicates acute articular rheumatism with or without plastic pericar-
ditis, the apex im]:)ulse is often very indistinct to sight and touch
as in pericardial effusion. But the area of dulness is less likely to
extend beyond the apex impulse to the left or to modify the cardio-
hepatic angle, or to shift when tlie patient lies on the right side.
Pressure symptoms are absent, and there are no areas of broncho-
vesicu.lar breathing with tympanitic resonance under the left clavicle
or in the track. Yet not infrecprently these differentiae do not serve
us, and the diagnosis can be luade only by ])uueture.
(2) I have twice known cases of interlobar empyema mistaken
for pericardial effusion. In one case a needle introduced in the
fifth intercostal space below the nipple drew pus from what turned
out later to be a localized purulent pleurisy, but the diagnosis was
not made uirtil a rib had been removed and the region thoroughly
explored. It is not rare for pleuritic effusions to gather first
in this situation, viz., just outside the apex impulse in the left
axilla.
Such effusions may gravitate very slowly to the bottom of the
pleural cavity or may become encapsulated and remaui in their
original and very decejitive position. In such cases the signs of
compression of the left lung are similar to those produced by a
pericardial effusion, and the results of punctures may be equivocal
as in the case just mentioned. If there is any dulness, even a very
uarrow zone, in the left axilla between the fifth and eighth riljs,
though there be none in the l^ack, the likelihood of empyema should
be suggested.
As between iileuritic and pericardial effusion thn presence of a
276 PHYSICAL DIAGNOSIS.
good pulse and the fdisence of marked dyspuoaa favors the former.
Ill the two cases above referred to in whioh interlobar empyema was
mistaken for pericarditis, tlie general condition of the patient struck
me at the time as surprisingly good for pericarditis.
If both pleurisy and jjericarditis are present, the area of peri-
cardial dulness is not characteristic until the pleuritic fluid has been
drawn off. The persistence of dulness in the cardio-liepatic angle
and beyond the apex beat after a left pleurisy has been emptied by
tapping, and after the heart has had time to return to its normal
position, should make us suspect a jiericardial effusion.
Despite the utmost care and thoroughness in physical examina-
tion, many cases of pericardial effusion go unrecognized, especially
in infants, in elderly jiersons, or when the lung borders are adher-
ent to the pericardium or to the chest wall.
In the rhennratic attacks of children, it should be remembered
tXidii liericarditis is I'Vi'jt. morn common tJian cndocurditis.
AdJi event Pericardium.
In the majority of cases the diagnosis cannot be made during
life, unless the pericardium is adherent, not only to the heart, bat
zo the walls of the chest as well. When this combination of peri-
carditis with chronic mediastinitis is present, the diagnosis may be
suggested Ijy
(a) A systolic retraction of the chest wall in the region of the
apex impulse, at the base of the left axilla and ui the region of the
eleventh and twelfth ribs in the left back (Broadbent's sign). Such
retraction is more marked during a deep inspiration. (It should
be remembered that systolic retraction of the uiterspaces in the
vicinity of the apex is very commonly seen in cases of cardiac hy-
pertrophy from any cause, owing to the negative pressure produced
withui the chest by the contraction of a powerful heart.) A quick
rebound of the cardiac apex at the time of diastole (the diastolic
shock) is said to be characteristic of pericardial adhesions, but is
often absent.
(Jj) Collapse of the cervical veins during diastole has been no-
ticed by Friedreich, and the paradoxical pulse, above described, is
DISEASES OF THE PERICARDIUM. 'All
said to be more marked in adlierent pericardium than in any (ithi-r
known condition. Most recent writers, however, place no reliance
upon it.
((') When the lungs are adherent to the pericardium or to the
chest wall, as is not uncommonly the case, the absence of the phrenic
phenomenon (Litten's signs) and of any respiratory excursion of
the pulmonary margins may be demonstrated. 8ince pericardial
adhesions are most often due to tuberculosis, the discovery of tu-
berculosis in the lung or elsewhere may be of aid in diagnosis.
(fZ) Broadbent considers that the absence of any shift in the
position of the apex beat, with respiration or change of patient's
position, is an important point in favor of mediastino-pericarditis.
In health and in vahoilar or piarietal disease of the heart, the apex
beat will swing from one to two inches to the left wlien the patient
lies on his left side, and the descent of the diaphragm during full
inspiration lowers the position of the cardiac impulse considerably.
(e) The presence of hypertrox^hy or dilatation affecting espe-
cially the right side of the heart, and not accounted for by the
existence of any disease of the cardiac valves, of the lung, or of
the kidney, should make us suspect pericardial and mediastinal
adhesions. Such adhesions embarrass especially the right ven-
tricle, because it is the right ventricle far more than the left which
becomes attached to the chest wall. The left ventricle is more
nearly free.
(/) Since the space enclosed by the divergent costal cartilage
just below the ensiform is but loosely associated with the cen-
tral tendon of the diaphragm, Broadbent looks especially at this
point for evidence of mediastinal or pericardial adhesions, the
effect of which is to ari'cst completely the slight respiratory move-
ments of this part of the abdominal wall.
(^) Adherent pericardium, occurring as a part of a widespread
chain of fibrous processes involving the pleura, the mediastinum,
and the peritoneum, may give rise in young persons to a train of
symptoms and signs suggesting cirrhosis of the liver. Ascites
collects, the liver is enlarged, yet there are no signs in the heart,
kidneys, or blood sufficient to explain the condition. In any
suoli case adlierent pericardium should be consulered. Fig. 150
278
PHYSICAL DIAOXOSIS.
ahow the a}ipearaiiee in cases of this kind in which tlie diagnosis
was verified hy autopsy.
Fir,. 150.— .\i-lherent Pericanlium, Ascites.
i^ininiiari/.
The diagnosis of adlierent iieiicai-dimu with chronic mediastini
tis is suggested by
DISEASES OF THE PERICARDIUM. 279
(a) Sj^stolio retvactioii of llie lower intercostal spaces in the left
axilla and in the left back, followed by a diastolic rebound.
(Ii) Tiie absence of any change in the position of the apex im-
pulse with respiration or change of pwsition.
((■) The presence of hypertrophy and dilatation of one or both
ventricles "without obvious cause.
((/) The absence of any respiratory excursion of the lung bor-
ders near the heart and of the abdominal wall at the costal angle.
(e) The presence of signs like those of hepatic cirrhosis in a
young person and withorrt any obvious cause.
CHAPTER XIII.
THORACIC ANEURISM.
Aneurism of the Thoracic Aorta.
For clinical purposes thoracic aneurisms may be diTided into
the diffuse and the saccular. Saccular aneurisms of the ascending
or descending portion of the arch of the aorta are apt to penetrate
the chest "wall, "while aneurism of the trans\'erse aorta or diffuse
dilatations of the "^^'hole aortic arch are more likely to extend "within
the chest without eroding the thoracic bones. Practically any
aneurism which penetrates the thoracic bones may lie inferred to
be saccular, but if no such penetration takes place, it may be im-
possible to make out whether the dilatation is diffuse or circum-
scribed. I shall consider :
I. The signs of the presence of aneurism.
II. The evidences of its seat.
Inspection wiA pulpfttion give us most of the important informa-
tion m the diagnosis of aneurism. The patient should be placed in
the position sho"n'n ui Fig. 151, so that the light vill strike obliquely
across the surface of tlie chest, and the observer should be so placed
that his eyes are as nearly as possible at the level at that piart of
the chest at "^vhich he expectt to see pulsation.
In the majority of cases of aneurism some abnormal pulsation
may be made out either to the right of the sternum in front or in
Abnormal the region of the left scapula behind. If the anenr-
Pulsation. ism is large, a considerable area of the cliest -wall may
be lifted -with each beat of the heart; "with smaller growths the
pulsating area may be small and sliarply circumscribed. Not in-
frequently an abnormal pulsation at the sternal notch or in the
THORACIC ANEURISM.
281
neck may be observed. Other causes of abnormal pulsations in
the chest, such as dislocation or uncovering of the heart, must of
course be excluded. Pulsations due to aneurism can sometimes
be distinctly seen to occur later than the apex impulse of the heart.
Palpation controls tlie results of inspection, but at times a pul-
sation may be seen better tlian felt ; at others may be felt better
than seen. Bimanual palpation — one hand over the suspected area
in front and one in a corresponding position behinil —is useful.
If the aneurism involves the ascending portion of the aortic
I'lii. 151.— Pusition When Loukiiig lor Slight Aueurismal Pulsation.
Tumor.
arch, it is likely sooner or later to erode the right margin of the
sternum and the adjacent parts of the second or third costal car-
tilages and appear externally as a round swelling in
which a systolic pulsation is to be seen and felt. This
pulsation is in some cases distinctly expansile in character, and
ilift'ers in this respect from the up-and-down motion which may
be communicated to a tumor of the chest wall by the beating of a
normal aorta. The tumor is usually firm, rarely soft, and nia}^ be
as hard as any variety of malignant new growtli. Occasionally
•2s-2
rHYsfCAL DIAGXOSIS.
the tliickucss cif the himelhited ehit ^vitlliIl it is sn yi-eat that no
pulsations are trausniitteil to tlie surtuce.
^Yhetllel■ the aneurism penetr!lT.es the diest or not, it is often
possible to feel over it a r'ih)-(itiii<i tlirill, usually siis-
Thrill .1 > J J
tolit: in tinu^. If the layer of lamellated clot in the
sao is very thiek, the thrill is less apt to be felt.
j\Iore innHirtant in diagnosis is a didsfalic tilioelc or tap whicli is
appreciated b}- laying the palm of the hand lightly over the affected
Fig. 153.— Ani'uiisuial Tumor (_i). Thf arrow B points to a gummatous swelling: neartheeu-
siform cartilage. The radiogi-apblc appearances of this case are shown below (Fig. 1.55).
area. This diastolic shock is due to the recoil of the blood in the di-
lated aorta, and is one of the most impHn'taut and characteristic signs
Diastolic "^ aneurism. As the wall of the sac becomes weaker,
Shock, the intensity of this shock diminishes. This diastolic
shock may be appreciated over the trachea also, and is thought by
some to have even more significance 'when felt in this situation.
Of sjiecial importance in aneurism of the transverse arch is the
sign known as the tracheal tug. The arch of the aorta runs over
THORACIC ANEURISM.
283
the left primaiy bronchus in snch a way that when the aorta is
dilated, the lirouchus is pressed upon with each expansile pulsation
Tracheal of the artery. This systolic pressure transmitted to
Tug. the tracliea produces a distinct downward tug upon it
with each systole of the heart. The tug is best felt by making the
patient throw back his head so as to put the trachea upon a stretch.
The physician then stands behuid him and gently presses the tips
of the lingers of both hands up under the lower border of the cri-
FIG. 153.— Aneurism Tumor Perforatinfj; the Sternum at A. At B there is a gummatous mass.
(See below. Fig. 155, a radiograph of this case).
coid cartilage. In feeling thus for the tracheal tug as transmitted
to the cricoid cartilage certain precautions must be observed :
(a) One must distinguish the tracheal tug from a simple pulsa-
tion transmitted to the superficial tissues by the vessels under-
neath. Such i^ulsation makes the tissues move ottt and in rather
than up and down.
(5) A tracheal tug felt only during inspiration has no patho-
logical significance and is frequently present in health.
T^Tiile preparmg to try for the tracheal tug we may notice
whether there is any dislocation of the trachea, as shown by the
284 PHYSICAL DIAONOSIS.
displacement of Adam's apple. Aphonia, stridor, cough, dysphagia,
and other symptoms are produced by pressure on gullet and windpipe.
Other signs of aneurism, due to the pressure of the dilated aorta
upon the nerves or vessels of the mediastinum, are :
(1) Inequality of the pupils.
(2) Inequality of the radial pulses.
(3) Qlldema and cyanosis of one arm or of one side of the neck
and head.
(4) Pain in one arm from the pressure of an aneurism involving
the subclavian artery upon the brachial plexus.
(5) Clubbing of the fingers of one hand (rare).
(6) Prominence of one eye (rare).
(7) Flushing or sweating of one side of the face (very rare).
Contraotioii or dilatation of tlie pupil is due to a paralytic or
irritative affection of the sympathetic nerves. This symptom is
much commoner than the other effect of pressure upon the sympa-
thetic nerves; namely, flushing or sweating of one side of the face.
In comparing the pulses in the two radials we must bear in mind
the possibility of a congenital difference between them, due to a
difference either in the size of the arteries or in their position, and
also that a tumor pressing on the subclavian may affect the pulse
exactly as an aneurism. The pulse wave upon the affected side
(most often the left) may be either less in volume or later in time
than the wave in the other radial artery, accordmg as the pulse
wave is actually delayed in the aneurismal sac or merely diminished
by it. In marked cases the pulse upon the affected side may be
nearly or quite absent. On the other hand the inequality of the
pulses may be so slight that the sphygmograph has to be employed
to demonstrate differences in the shape of the wave not perceptible
to the fingers.
Examination of the heart itself may show some dislocation of
the organ to the left and downward, owing to the direct nressure
of the aneurismal sac, but no enlargement.
II. Percussion.
If the aneurism is deep-seated, the resu.lts of percussion- are
uegative. If, on the other hand, it be situated immediately be-
THORACIC ANEURISM. 'iob
neath. the sternum or close under the thoracic wall, an area of dul-
ness, not present in the normal chest, may be mapped out. The
oatlines most commonly seen in such cases are shown in Fig. 154.
^^^len the aneurism involves the descending aorta, an area of dulness
may be found m the region of the left scajjula or below it, and pul
sation may be detected in the same area.
III. Auscultation.
The signs revealed by auscultation are not of much diagnostic
(ralue as a rule. In about one-half of the cases of sacculated aueu-
Aneurismal
dulness. '
■ Heart dulness.
Liver dulness.-
Fig. 154.— Diagram of Percussion Dulness in Aortic Aneurism.
rism there are no sounds or murmurs to be heard over the tumor.
In other cases a systolic murmur, the audible counterpart of the
vibratile thrill, may be heard over the area of pulsation, tumor, or
dulness corres|)onding to the aneurismal sac. This systolic mur-
mur maybe due to many causes other than aneurism, and has noth-
ing characteristic about it. A similar systolic sound is sometimes
heard over the trachea (Drummond's sign) or ui the mouth, if the
patient closes his lips around the pectoral extremity of the steth-
oscope (Sansom's sign).
A loud, low-pitched diastolic sound, corresponding to the pal-
286
PHYSICAL DIAGXOSIS.
pable diastolic slioek, is generally to be heard in the aortic, region
Tlus diastolic soiuid, which is probably not produced hj the aortic
valves, is remarkably deep-toned and loud, and is, on the whole, the
most imp>ortant sign cd' aneurism revealed by auscultation.
If a portion of either lung is directly jiressed upon bj- the au-
eurismal sac, "we may haw the signs of condensation of the lung
in the area pressed upi^m (^slight duluess, broncho-vesicular breath-
nig, and exaggerated voice soimds). If one of the primary bronchi
From behiuil.
Ftg, ];V). — Railinurnph of Citse wlioso PlintOErraph is 'Roprodnoed as Fi.irs. I5"J and 1 'lo. In the
rifilit-liaiid cut are shewn tlie appearances seen from behind. The left-hand out, A, A.
aneiu-isnial sa*-; 7J, heart displaced ; C, liver (not in focus).
is oressed upon, as occasionally happens, atelectasis of the corre-
sponding lung may be manifested by the usual signs (dulness, ab-
sence of tactile fremitus and of respiratory and vocal sounds).
Since aneurism is frequently associated with regurgitation at
the aortic valve, a diastolic murmur is not infrequently to be
heard.
If the aneurisnml sac is of veiy great size, the ]nilse Avave iu
the fcmorals may lie oliliterated, as happened in a case described
by Osier.
THORACIC ANEURISM.
IT. Radioscopij.
287
With the fluoroseope and through photography one can often
make out a shadow correspondrng to the position of the aneurism.
Fig. 1.56.— Aortic Aneurism. {From v. Ziemssen'.s Atlas.)
The position of the shadow is best explained by reference to Figs,
155, ]5G. and 157.
Sumviary.
The most important signs of aneurism are :
1. Ahnor n I al pulsation — visible or palpable
2. Tumor over which a
3. TJirill and a
288 PHYSICAL DIAGNOSIS.
4. Diastolic sIiocJc may be felt.
6. Traclieal tnij.
6. Pressure signs (unequal jjulses, pupils, hoarseness, pain, etc )
7. Dulness on percussion over the suspected area.
8. Loud, lou'-jjitcJied aortic second sound.
9. Systolic ntuvmtir ("least important of all).
Fig. 1.57.— Aneurism nf the .\orta. (Curschman.)
10. Radio.HCopii may demonstrate a shadow higher up than that
corresponding to the heart and extending beyond that produced by
the sternum, spinal column, and great vessels.
Dlaijnosis of the Scat of tlie Lesion.
(a) Aneurism of tlie ascending arc/i, generally approaehes or
penetrates the chest wall hi the vicinity of the second right inter-
costal space near the sternum. Previous to jjerforatiug the thoracic
THORACIC ANEURISM. 289
parietes, the growtli of the aneurism may give rise to pain, pulsa-
tion, and dulness and thrill iu this region.
{b) Arietmsm of f/ie trauKverne ari'li or diffuse dilatation of the
aorta, which is the most eoinmon of all types of aortic aneurism,
may not give rise to any visible pulsation of tlie chest wall, and, if
deepi-seated, need not produce any al)normal dulness on percussion.
In such cases an aneurisnr is to be recognized, if at all, by evidences
of ijres.sure on the nerves or vessels of the mediastinum (cough,
aphonia, inequality of the pupils, tracheal tug, etc.).
(c) Aneurism of the descend in f/ r/orta gives rise usually to severe
and persistent pain in the back, wliich radiates along the intercos-
tal nerves or downward. Other jn-essure symptoms are not marked,
but in advanced cases an area of abnormal dulness and pulsation
may be found in the region of the left scapula or l)elo\v it.
(d) If the hmominnte artery or one of the carotids is involved,
we usually find a pulsating lump in the region of one or the other
claviculo-sternal joint or at the root of the neck, and the trachea
may be displaced to one side. This form, however, is distinctly
rare. The violent throbbing and dilated ('arotid of aortic leakage
is often mistaken for it.
Differential Diagnosis.
(a) It is important to distinguish the diffuse dilatation of the
aortic arch, which sooner or later complicates almost every case of
incompetency of the aortic valves, from saccular aneurism of the
transverse aorta. Dulness and pulsation, perhaps with systolic mui'-
mur and thrill in the second and third right interspaces near tlie
sternum, occur in many cases of aortic regurgitation, but though
the aorta is dilated, its coats are not ruptured and it never breaks.
The absence of jrressure signs (pain, ajdionia, etc.) distinguishes it
from true aneurism.
(S) Aneurism is not infrequently mistaken for aortic stenosis, in
which a systolic murmur and thrill, similar to those occurring in
aneurism, are to be heard over the region of the aortic arch. From
aortic stenosis aneurism is distinguished by the fact that it does
19
290 PHYSICAL DIAGNOSIS.
not produce cliaiacteristie changes in tlie jinlse, and by tlie presence
of some one of the symptoms above described, sucli as tracheal
tug, pressure sj'uiptoms, abnormal area of percussion dulness, etc.
((■) Simple dyuamic throbbing of a normal aortic arch similar
to that which occurs in the abdominal aorta may lift the chest wall
so as to simulate aneurism. The other positive symptoms and
signs of aneurism are, however, absent.
((/) Pulmonary tuberculosis or cancer of the oesophagus, produc-
ing as they may suljsternal pain, cough, and aphonia by pressure
upon mediastinal structures, have been mistaken for aneurism,
from which, however, they may be distmg-uished by the absence of
the positi^'e signs above described, by the more rapid eirraciation
of the patient, and by the positive evidences of cancer or tubercu-
losis.
(e) Empyema necessitatis may produce a pulsating tumor like
that of aneurism and the area of dulness may be similar, but there
is no diastolic shock, no tactile thrill or murmur, and the history
of the case is usually very different from that of aneurism. It is
perfectly safe to insert a fine hollow needle in doubtful cases. No
serious hemorrhage results if aneurism is present, and the diagnosis
and treatment may be greatly assisted.
(/) Mediastinal tumors are sometimes almost indistinguishable
from aneirrism during life. They may ]n-odnce a more intense and
widespread dulness which is usually in the median line, while the
dulness of aneurism is oftener at one side. The pulsation transmit-
ted to a tumor by the heart has not the exjiansile character of aneu-
rismal pulsation. Tumors are not associated with any diastolic
shock, rarely with a tracheal tug.
The course of most mediastinal tumors is progressive and at-
tended by great cachexia, while the symptoms . r aneurism are often
more or less intermittent, and unless j>aiu i ; sever' there is no such
emaciation or antemia as is commonly seen with mediastin.d tu-
mors. Pressure symptoms may be the sanre in both diseases, but
are usually more marked with mediastinal growths. A metastatic
nodule over the clavicle sometimes betrays the jn-esence of a pri-
mary focus within the chest.
THORACIC ANEURISM. 291
(g) Retraction of the rhjld Ixiruj (fibroid phthisis), with or without
displacement of the heart toward the diseased side, may uncover
the heart so as to joroduce some of the signs of aneurism, i.e., jjul-
sation and dulness in the upper riglrt intercostal spaces near the
sternum, witli a loud aortic second sound and sometimes a- systolic
murmur iii the dull area,.
The history of tlie case and a careful examination of the lungs
usually suffice to set us right.
(A) Dilatation of tlte lieart may be so extreme that pulsation
and percussion dulness appear in the characteristic aneurismal area
to the right of the sternum, especially if there is solidification of
the left lung. But the pulse is in such cases much weaker and
more irregular than is to be expected in uncomplicated cases of aortic
aneurism, and the history of the case is usually decisive.
By the same marks we can distinguish the pulsations of a
dilated lieart, which sometimes appear in the left hypochondrium.
CHAPTER XIV.
DISEASES OF THE LUNGS.
BEONCHITIS, PNEUMONIA, TUBERCULOSIS.
I. TKAClIEniS.
In connection with bronchitis or as a forerunner thereof, inflam-
mation of the trachea is not uuconinion. It gives rise to no cliar-
acteristic physical signs, but is to be suspected when tlie patient
complains of cowjh with pain over the uppev portion of the sternum
Beos^chitis.
Inflammation of the larger bronchial tubes is not often the
cause of any definite physical signs, but with every piaroxysm of
coughing the patient may feel pain in an area corresponding ex-
actly to the anatomical position of the primary bronchi. I have
seen patients indicate most accurately the situation of the large
tubes when pointing out tire position of pain produced by coughing.
In the vast majority of cases of aviite hroiiclilfis the smaller
bronchi are involved, and the swelling of their walls, with or with-
out exudation, is manifested by the following physical signs : '
(1) Diminution in the intensity of vesicular breathing over the
area affected (rarely in the earliest stages the breath sounds are
exaggerated and harsh, especially in the upper portions cf the
chest).
I Bronchitis may exist without rales, but caiuiot be diagnosed without
them. Occasionally they are present only in the early morning.
BRONCHITIS. PNEUMONIA, TUBERCULOSIS. 293
(2) Bales, which are squeaking or piping over bronchi which
are narrowed witliout any considerable amount of exudation, as is
tlie case in tlie earliest stages of many cases, and bubbling, crack-
ling, or clicking in later stages, when watery or viscid exudation is
present in the tubes. The calibre of the bronchi affected can be
estimated from the coarseness or fineness of the rales. Low-pitched
groaning sounds point to a stenosis of a relatively large bronchus,
while squeaking and whistling sounds are usually produced in the
smaller tubes. Large, bubbling rales are much less often heard
than the finer, crackling variety. The latter are produced in the
smallest tubes, the former in the larger variety.
Simple non-tuberculous bionchitis is almost invariably hllateral
or symmetrical, and affects most often the lower two-thirds of the
lungs, leaving the apices relatively free. It is almost never con-
fined to an apex. \Vlien rales are to be heard on one side of the
chest only, and when they jjei'sist in the same spot for days and
weeks, tuberculosis is always to be suspected, especially if the
rales are localized at the summit of one or both lungs. It should
never be forgotten that the tubercle bacillus is capable of excituig
a bronchitis indistmguishable froin other varieties of bronchitis,
except by its tendency to show itself at the apex of the lung and
on one side only ; most cases of pulmonary tuberculosis begin in
this way
The onl}' other variety of bronchitis which is often unilateral is
that due to the influenza bacillus. In the course of a case of influ-
enza, a unilateral localized bronchitis not infrequently occurs. Over
a patch of lung, perhaps the size of the palm of the hand, fine, moist
rales may persist for weeks, finally clearmg up only after the pa-
tient has resumed his ordinary occupation. Doubtless such local-
ized patches of bronchitis are often accompanied by foci of lobular
pneumonia too small to be detected by our present methods of
physical examination.
Percussion dulness is absent in bronchitis except near the end
of fatal cases, when the lung is stiiffed with mucus and pus, or
when atelectasis has occurred owing to extensive plugging of the
larger bronchi. These events are rarely seen, and in general the
294 PHYSICAL DIAGNOSIS .
negative results of percussion are of great ^-alue iu exelndiiig sol-
idification or fluid exudation.
Occasionally percussion resonance may be increased owing to
a slight temporary overdistention of the air vesicles from coughing.'
Inspection usually shows little or nothing of diagnostic impor-
tance in acute bronchitis. Long-standing cases, complicated as
they almost invariably are by emphysema, present changes in. the
shape of the thorax ; but these are due to the emphysema rather
than to the bronchitis. In children acute bronchitis sometimes
involves so many of the smaller bronchi that dyspnoea and use of
accessory muscles of respiration are notable. But this usually
means atelectasis, broncho-pneumonia, or laryngeal spasm, in addi-
tion to the bronchitis.
From violent coughing the jugulars may be distended, but no
systolic pulsation occurs in them.
Voice sounds and tactile fremitus are normal.
Differential Diar/nosls.
(Edema oftlie lung and bronchial asthma are the only pathologi-
cal processes (except hemorrhage into the lung substance) which
give rise to sigus like those of bronchitis.
(1) In fr-dema of tlie luiif/, or in pulmonary apoplexj-, one may
find, as in simple bronchitis, a diminished vesicular breathing with
crackling rales, luitcedema of the lung is almost always best marked
in the dependent portions; tliat is, iu the posterior parts of tlie
lung if tlie patient has been lying upon the back, or in tlio lower
lobes if he has been sitting up. The rales of oedenur are mostly
bubbles, and are more uniform in size when compared to those of
bronchitis. The recognition of a cause for the t^denia, for ex-
ample a non-compensated heart lesion, materially aids in the
diagnosis.
(2) Broneliidl (iKtIinxi or spasm of the finer bronchi produces dry
squeaking and groaning sounds similar to those heard in the earlier
'In cliililreii (.■.xaniiocil dmiii!;' a crying sprll ;i cr;u'k('<l-)Hit sniuul can
uRually be elicited by percnssion. This is in no way eliaracteristic of bron-
cliitis and can often be obtained iu healtliy infants.
BRONCHITIS, PNEUMONIA, TUBERCULOSIS.
295
stages of many cases of liroucliitis. But in In-oncliial asthma the
rules are chiefly ex/iirafari/, and expiration is prolonged and inten-
sified. jNforeover, the inhalation of a few drops of amyl nitrite will
temporarily dispel rales due to bronchial
spasm, while on the rales of dry bronchitis
it has no effect (Abrams).
(3) IlroncJio-^menvtonia. In many
cases of lobular or broncho-pneumonia the
physical signs are exclrrsively those of the
coexisting bronchitis. In such cases the
diagnosis of bronchitis is not wrong, but
does not cover the whole ground. I shall
discuss further under broncho-i^neumonia
the evidence which leads us to suspect
that somethuig more than bronchitis is
present.
(4) Muscle sounds. Under certain
circumstances (cold, nervousness), the
rumbling noises produced by muscular
contractions in the chest wall may simu-
late rales so closely tliat the diagnosis of
bronchitis may be strongly suggested.
The differentiation between rales and
muscle sounds has already been discussed
(see above, j>. 146).
(6) Atelectatic crejntation. Crackling
rales heard over the thin margins of the
lungs at the base of the axilla or along
the edges of the manubrium are often due
to atelectasis (see above). From bronchitis they are distinguished
by their situation and by the lack of symptoms. They are best
heard at the point shown in Fig. 158.
Fig. 158.— The Dots are Placecl
over the Area where Atelecta-
tic Crepitation is Oftenest
?Ieard.
CJironiG Bronchitis.
So far as the bronchitis itself is concerned, there may be no
difference in the physical signs between the acute and chronic forms
206 I'lIYSlCAL DIAONOSTS.
of (lie disrasi" ; Imt, in llie lath'v one almost invavialily tiiuls associ-
ated Avitli the lii-oncliilis itself a consideralile ileyvee of enipliyseiua,
of astliiiia, anil of lnoneliieetasis. Imleed, the foregvound of the
cliiiieal |iictnn' and the hulk of the jdiysieal sij;iis are made n]i by
these three diseases, rathin'than hy llie hronehitis itself. A(M'ord-
ingly, 1 shall not disruss elirinnc lironelnlis an\' further at this
])oint, lint will return to the snbjeet in the chapters on I'hnpliysenia
and on r>roiieliieetasis.
OKOlTrOUS rNKATMONl A.
Ill its typical form croupous or fibrinous ])iieumoiiia produces
solidification of one or more lobes, usually the lower, the process
being accurately bounded by the interlobular fissures. Although
the pihysical signs of the earlier stages differ considerably from
those of the later ones, there seems to be no sufficient ground for
marking off stages of engorgement and of red and gray hejiati/.a-
tion, for c/iiiirn//// these stages cannot be distinguished.
The S(di(lification may begin in the deeper parts of the lung
(''' centra/ jiiiriiiii(}iii(i^'), so that no jihysical signs are obtamable
unless, later in the course of the diseas(>, the ])rocess extends to the
surface of the lung.
Ifagsive pnc/niiniiia, in which the bronchi as well as the air cells
are ])lugged with fibrin and leucocytes, is a relatively rare form of
the disease, but possesses great clinical importance on account of the
marked resemblance between its physical signs and those of pleural
effusion.
The frequency of endocarditis and pericarditis in connection
with lobar pneumonia, especially with those of the left side, should
be borne in mind.
Plii/sicol S!i/iis.
(ii) liis/ifi'fiii/i. — The aspect of the patient frequently suggests
the diagnosis; the face is anxious, often flushed or slightly cya-
nosed, the flush s(nuetimi>s affecting most strikingly the side of the
face corresponding to the lung att'ected.' Herjictic vesicles ("cold
' Perhaps because the patient is apt to He upon the affected side.
BRONCHITIS. PNEUMONIA, TUBERCULOSIS. 297
sores ") are often to be seen around the nioutli or nose. The rapid,
difftcnlt breathuig is at once uoticable, and expiration is often ac-
companied by a grunt. The use of the accessory muscles of respi-
ration and the dilatation of the nostrils attract attention.
The combination of marked dyspnoea with absence of dropsy is
met with more frequently in pneumonia than in any other disease.
Both sides of the chest usually move alike, but occasionally the
affected side shows deficient expansion especially ui the later stages
of the disease, and the other side of the chest shows mcreased re-
spiratory movements (compensatory). Earely the pulsations of the
heart may be transmitted to the chest wall through the affected lung.
^\lien pneumonia attacks a feeble old man, or follows injuries
(surgical pneumonia), its onset may be msidious, and none of the
phenomena just described may be seen.
(li) Paljjution. — In the great majority of cases tactile fremitus is
markedbj increased over the affected area,' but in case the bronchi
are occluded by secretions or fibrinous exudate, fremitus may be di-
mmished or altogether absent. A few hard coughs will sometimes
clear out the tubes and tlius materially assist the diagnosis. Occa-
sionally an increase in superficial temperature of the affected side
may be noticed by palpation, and rarely one feels a friction rub
due to the fibrinous pleurisy which almost uivariably accompanies
the disease.
(c) Percussion. — Overtlie area affected tiie -percussion note isgener-
ally dull and may he almost flat, except m the earliest and latest
stages of the disease, in which it may have a tympanitic quality with
or without an element of slight dulness. . More marked tympany is
usually present over the unaffected lobes of the diseased lung (that
is, over the upper lobes in the great majority of cases.)
The conditions just described represent the great majority of
cases, but the following exceptions occur :
(1) In the pneumonias of children, and occasionally in adults,
dulness may be absent.
' By using the edge instead of tiie flat of tlie hand the boundaries of sol-
idified lobes may often be very accurately marked out by means of the tactile
fremitus.
298 PHYSICAL DIAGNOSIS.
(2) When the lower lobe of the left lung is affected, a distinctly
tymj^anitic quality may be transmitted to the consolidated area
from a distended stomach or colon.
(3) In rare cases, the percussion over the consolidated area may
be of a metallic quality, u- produce the " cracked-pot " sound.
(4) In central pneumonia there may be no change in the percus-
sion note, or it may be unusually full and deep so that the sound
side seems dull by comparison.
A solidified lobe increases so much ui size that the area of dul-
ness correspondmg to it often seems incredibly large. Thus, al-
though the lower lobe reaches in health not more than half-way up
the scapula, when solidified it produces dulness throughout nearly
the whole back.
The right base is the most frequent seat of pneumonic solidifiea-
tions, but the dulness corresponding to it is often first noticeable in
the posterior axillary line. A dulness appreciable only in the front
of the chest is almost sure to correspond to the upper lobe, while
signs in the lower part of the right axilla correspond to the middle
lobe. Many eases of central pneumonia first appear at the surface
in one or the other axilla.
As regards the amount of solidification needed to produce per-
cussion dulness, Wintrich says that the minimum is a patch 5 cm.
in diameter, 2 cm. deep, and superficially situ.ated.
Percussion often makes us aware of an mcreased resistance or
diminished elasticity of the affected side, although the resistance is
seldom as marked as in large pleural effusions.
(d) Auscultation. — In the great majority of cases typical tubular
breathing is to be heard over the affected area. Since a whisper
is practically a forced expiration, this tubular qualiti/ is very well
brought out if the patient is made to whisper "one, two, three,"
or any other succession of syllables, and by this method the fatigue
and pain of deep breathing may be saved. By this use of the
whispered voice one may accurately mark out the boundaries of the
consolidated area, and demonstrate in many cases that it coincides
with the boundaries of one lobe of the lung.
In the earliest stages of the disease the breathing may be bron-
BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 299
cho-vesicular ; more often it is feeble or sujapressed over the con-
solidated area, and "crepitant rales," that is, very fine crackling
sounds, may be heard at the end of inspiration, but these are much
more common ni the stage of resolution' ("crepitans redux ").
If some of the smaller bronchi are blocked, as is not infre-
quently the case, respiration is absent or very feeble, and such
cases are often mistaken for pleuritic effusion. In pneumonia of
the upper lobe it is not rare for bronchial breathing to be absent
even without plugging of the bronchi.
In cases of "central pneumonia," that is, when the area of
solidification is in the interior of the organ, there may be no
change in the breath sounds, or a bronchial element may be faintly
audible on auscultation with the unaided ear, and only by this
method.
The intensity of the spoken or whispered voice is greatly in-
creased over the area of consolidation, and sometimes the words
can be distinguished. The nasal twang known as " egoj^hony " is
occasionally to be heard. In the majority of cases, as has been
already stated, the right lower lobe p)Osteriorly is affected, so that
the consolidated area is immediately in apposition with the spmal
column. Under these circumstances, it is not • ', all uncommon to
hear bronchial breathing transmitted from the consolidated lobe
to a narrow zone close along the spinal column on the sound side.
Such a zone is often mistaken for consolidation (see Fig. 159).
The signs are usually less marked in the axilla and in the front
of the lung, but in a minority of cases, and especially when the
upper lobes are affected, the signs are wholly m the front. When
searchmg for evidences of consolidation in persons suspected to
have pneumonia, one should never omit to examine the apices and
very summit of the armpit, iDressing the stethoscojDC up behind the
anterior fold of the axilla.
In examining the posterior lobes, when the patient is too weak
to sit up and is loath even to turn upon the side, the Bowles steth-
' Crepitant rales are rarely heard in the pneumonias of infancy and ola
age. They are not peculiar to pneumonia, but occur in pulmonary cedema or
hemorrhagic infarction— conditions easily distinguished from pneumonia.
300
PHYSICAL DIAGXOSIS.
oscope is a great eonvenience, owing to tlie ease with wliieli its flat-
tened extremity may be "worked in between tlie patient and tlie bed-
clothes without causuig an}' discomfort.
When i-egii/iif!o>i begins, the signs may suddenly and completely
disappear within a few hours. More frequently the bronchial
breathing is modified to broncho-vesicular, dulness and broncho-
phony become less marked, fine crackling rales (crepitans redux)
or coarser moist bubbles appear, and the Iraig gradually returns to
its normal condition within a period of three or four daj'S. In the
^- Tympany.
Bronchial breathine:
transmittetl by .
spinal column to
sound lung.
Solidillcution.
Fig. L59.- Diagram of Signs in Pneumonia.
active stages of the disease the entire absence of rales is very char-
acteristic. In about 19 per cent, of the cases the solidification of
the lung persists after the fall of the temperature ; uideed, it may
be weeks or even mouths before it clears up, and yet the lung may
be perfectly somid m the end. On the other hand, abscess or gan-
grene or fibrosis may develop in the solidified lobe. Commonest
and most important, however, is the post-jniriniioiiic einj>i/i'iiiii
(basal ov interlobar) which is often mistaken for delayed resolu-
tion. The latter is rare; empj^ema, common (see below, p. 349).
" Wanderhi'j pneitmoniii- " is a term applied to cases in which
BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 301
the consolidation disappears in one lobe only to reappear in another,
or spreads gradually from lobe to lobe. The physical signs in such
cases do not diifer essentially from those already described.
Sunima7'i/.
In a typical case one finds (oftenest at the right base behind)
1. Dulness on percussion.
2. Increased tactile fremitus and voice sounds.
3. Tubular breathing and occasionally crepitant rales.
These signs occurring in connection with fever, cough, rusty
sputa, pain in the side, dysjonoea, and herpes, are sufficient for the
diagnosis.
But many cases — some say the majority — are not typical when
first seen. The following are the commonest anomalies :
(a) There may be tympany instead of dulness, especially in
children or when the solidification is at the left base.
(J) The breathing may be feehle but vesicular in character, or
it niay be absent, ui case bronchi are plugged ; from the same cause
(c) Tactile fremitus may be diminished.
A hard cough may clear out the bronchi and produce a sudden
metamorphosis of the physical signs with a return to the normal
type.
In these atypical cases, we have to fall back upon the symp-
toms, the history, the blood, and sputa for help in the diagnosis.
Deep-seated pneumonic processes may appear at the surface in
out-of-the-way places, e.g., at the summit of the axilla, and the
area of demonstrable physical signs may be no larger than a silver
dollar. A thorough examination of every inch of the chest is
therefore essential in doubtful cases.
In the later stages of the disease crepitant or other fine rales
often appear, and the signs of solidification suddenly or gradually
disappear.
Differential Diagnosis.
Pneumonic solidification is to be distinguished from
(1) Pleuritic effusion, serous or purulent.
(2) Tuberculosis of the lung.
B02 PHYSICAL DIAGKOSIS.
(1) Fi'om })leui-itic effusion, |ineumoiiia is to be distinguished
in tlie great majority of cases liy differences in the onset, course,
and general symptoms of tlie disease. In pneumonia the patient is
far more suddenly and violently attacked, the dyspnoea is much
greater, cough and pain are more distressing and more frequent,
the temperature is higher, and the sputum often characteristic. In
pleuritic effusion the dulness is usually more intense than in pneu-
monia. Tactile fremitus and voice sounds are increased in pneu-
monia (except when the bronchi are plugged) ; decreased or absent
in pleuritic effusion. Bronchial breathing may be heard in both
diseases, but is usually feeble and distant when occurring in pleu-
risy, and loud in pneumonia. If the affection lie on the left side,
the diagnosis is much aided by the presence of dislocation of the
heart, "whicli is produced by pleuritic effusion and never bj^ pneu-
monia. In cases of pneumonia with occluded bronchi, one may
have every sign of pleuritic effusion — flatness, absent breathing,
voice and fremitus — and in such cases the absence of any disloca-
tion of the heart, provided the disease is upon the left side, is very
important. If a similar condition of things occurs upon the right
side, one may have to fall back upon the S3'mptoms and upon such
evidence as the blood count, herpes, sputum, etc.
(2) Tuberculosis of the lung causmg, as it may, a diffuse sol-
idification of the organ, may be indistinguishable from pneumonia
if we talve account only of the physical signs, but the two diseases
can usually be distinguished without difficulty by the difference in
their symptoms and course, and by the presence or absence of tuber-
cle bacilli in the sputum.
Inhalation Pxeubionia. Aspiration' Pneumonia.
When food or other foreign substances are drawn into the air
passages, as may occur, for example, during recovery from ether
narcosis, a form of broncho-pneumonia may be set up, in which the
solidified patches are not infrequently large enough to be recognized
by the ordinary methods of physical examination.
The lesions are usually bilateral and accompanied by a general
bxonchitis. Slight dulness and indistinct bronchial breathing can
BROSCniTIS. Pi\EUMOXlA. TUBERCULOSIS. 303
usually be made out over an irregular area in the backs of both
lungs.
The signs are considerably less marked than in croupous pneu-
monia, and the boundaries of the irregular patches of disease do
not correspond to those of a lobe of the lung.
If not rapidly fatal, the disease may be complicated by pulmo-
nary gangrene or abscess and large quantities of fetid pus may be
spit up.
Broncho-Pneumonia.
(Catarrhal or Lobular Pneumonia.)
Multiple small areas of solidification scattered through both
lungs, interspersed with areas of collapse, and usually associated
with diffuse bronchitis, occur very frequently in children producing
severe dyspnoea, cyanosis, cough, and somnolence, and running a
very fatal course.
The solidified lobules may fuse so as to form considerable areas
of hepatized lung, or there may be no lesion larger than a pea.
This is the usual type of " lung fever "' in infants, although or-
dinary lobar pneumonia is fully as common in older cliildren.
The widespread atelectasis of the lower lobes which is associated
with the disease in most cases owing to the plugging of the bronchi
with tenacious secretions, is probably as serious in its effects as the
pneumonic foci themselves.
The anterior and upper parts of the lungs often become dis-
tended with air (vicarious emphysema) and render the physical
signs very confusing and deceptive.
Pliyskal Signs.
In the majority of cases there are no characteristic physical
signs, and the diagnosis has to be made largely from the symptoms
and course of the disease. The consolidated areas are usually too
small to give rise to any dulness on percussion, or to any change in
the breath sounds, voice sounds, or fremitus, so that auscultation
shows, as a rule, nothing more than patches of fine rales occurring
at the end of expiration. Localized tympanitic resonance is some-
304 PHYSICAL DIAGNOSIS.
times present over the diseased area, malcing the sounder portions
of the huigs seem dull by comparison. Occasionally, wliP.n many
lobules have fused uito a single mass of larger area, the ordinary
signs of consolidation may be obtained, although they are apt to
disappear within twenty-four or forty-eight hours and appear in
another situation. As above said, the diagnosis is usually to be
made, if at all, from the combination of the pln/sknl signs of a
localized bronchitis irit/i flie si/iiij>fo)iis of pneumonia. "This pa-
tient," we say, "has only the signs of bronchitis, but he is too
sick. The cyanosis, dyspncea, and fe^-er are too marked. He is
sicker than, simple bronchitis will account for."
Differential Diar/nosis. "^
(«) Acute pulmonarij tuberculosis may be indistinguishable from
broncho-pneumonia by the physical signs alone. The diagnosis
must be made from the history and course of the disease or from
the presence of tubercle bacilli in the sputa.
(b) The extensive atelectasis of the lower lobes which may ac-
company broncho-pneumonia gives rise to dulness and absence of
respiratory and vocal sounds. Thus, the signs oi pleuritic effusion
are simulated, and in children the possibility of empyema should
not be forgotten. As a rule, broncho-pneumonia gives rise to much
greater dyspnoea, and is associated with a more extensive bronchitis,
than usually coexist with pleural effusion. The atelectatic lobules
may be expanded by coughing or by the cutaneous stimulus of cold
water, and thus resonance and breath sounds may suddenly return.
With jileuritic effusions, of course, such a change is impossible.
TUBERCULOSIS OF THE LUNGS.
(1) Incipient Tuberculosis.
In the earlier stages of the disease there may be absolutely no
recognizable physical signs, and the diagnosis may be established
only by the positive result of a tulierculin injection or by the com-
bination of debilitij with slight fever not otherwise to be aecountfd
for.
BRONCHITIS, PNEUMONIA, TUBERCULOSIS,
W.5
In some cases the earliest evidence of tlie disease is hcBtiioptysis.'
When a patient consults a physician on account of haemoptysis, it
is frequently impossible to find any physical signs of disease in the
lungs ; not luitil weeks or months later do the characteristic changes
recognizable by physical examination make their appearance.
The very earlij lioarseiiess of the voice in tuberculous patients is
of great importance and often attracts our attention to the lungs
when the patient has said nothing about them. Definite physical
signs in the lungs and tubercle bacilli in the sputa (artificially ob-
FiG. 160.— Diagram to Show Position of Earliest Signs in Tuberculosis.
tained through the use of potassic iodide, see below) may occasion-
ally be demonstrated before any cough has appeared. ()\\ the other
hand, the patient may cough for weeks before anything abnormal
can be discovered in the lungs. Occasionally tuberculosis begins
with an orduiarily bilateral bronchitis. I have found tubercle ba-
cilli in four such cases. More often the earliest physical signs
are :
(ft) Fine crackling rales at the apex of one lung, heard only
' Never percuss a patient within forty-eight hours after a liemorrhage, and
never encourage cougli or forced respiration in such a one. Tliere is dangei
of starting a fresh hemorrhage.
20
306 PHYSICAL DIAGNOSIS.
with or after cough and at the end of inspiration. [INIore I'arelj
squeaks may be heard.] (See Fig. 160).
(l>) A slight diniuiution in the excursion of tlie diaphragm on
the affeetetl siile, as sliown bjr Litten's diapliragni sliadow.
(c) Slight dimmution in the intensity of the resjiiratory mur-
mur, with or without interrupted inspiration (^''cog-wheel hveatli-
ing ").
((() In examining the apices of the lungs for evidence of early
tubercidosis one should secure if jJossible perfect quiet in the room,
and have the clothes entirelj^ reiuoved from the patient's chest.
The ordinary hard-rubber chest-piece is better than the chest-piece
of the Bowles instrument, and both the chest and the skin should
be wetted. After listening during quiet breathing over the apices
above and below the clavicle in front, and above the spiine of
the scapula behind, the patient should be directed to breathe out
and then, at the end of expiiration, to cough. During the dee]>
inspiration which is likely to precede or to follow such a cough one
should listen as carefully as possible at the apex of the lung, above
and below the clavicle, concentrating attention especially ujion the
last quarter of the inspiration, when rales are most ap)t to appear.
Sometimes only one or two crackles may be heard with each insjii-
ration, and not infrequently they will not be heard at all unless the
patient is made to cough, but even a shir/le ra/r, if jjersistent,^ is
important. In children who cannot cough at will, one can accom-
plish nearly the same result by making them count as long as pos-
sible with one breath and then listening to the immediately suc-
ceeding inspiration. When listening ox-er the apex of the lung,
one should never allow the patient to turn his head sharjdy in the
other direction, since such an attitude stretches the skin and mus-
cles on the side on which we are listening so as to produce annoy-
ing muscle sounds or skin rubs.
In cases in which one suspects that inciiiient tuberculosis is
' Rales heard only duviiip; the first few breaths and not found to persist oo
subsequent examinations, may be due to tlie exjian.sion of atelectatic lobules
BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 307
present and yet in which no positive evidence can be found, it is a
good plan to give iodide of potassium (gr. vii. three times a day) for
a few days. Tlie effect of this drug is often to make rales more
distinct, and sometimes to increase exjjectoration so that tubercle
bacilli can be demonstrated wlien before none were to be obtained.'
(li) The diminution in the excursion of the diaphragm upon the
affected side in cases of incipient phthisis has been much insisted
upon by F. H. Williams and others who liave interested themselves
in the radioscopy of the chest. Litten's diaphragm shadow gives
us a method of observing the same phenomenon without the need
of a fluoroscope. Even very slight tuberculous changes in the lung
are sufficient to diminish its elasticity and so to restrict its excur-
sion and that of the diaphragm. Comparisons must always be
made with the sound side in such cases, as individuals differ very
much in the extent with which they are capable of depressing the
diaphragm. It must be remembered that pleuritic adhesions, due
to a previous inflammation of the pleura, may diminish or alto-
gether abolish the excursion of the diai)hragm shadow, independ-
ently of any active disease in the lung itself.
Those who are expert in the use of the fluoroscope believe that
they can detect the |n'esence of tuberculosis in the lung by radi-
oscopy at a period at which no other method of physical examina-
tion shows anything abnormal. I shall return to the consideration
of this point in the section on Radioscopy.'
Interrupted or corj-wlieel respiration, in which the inspiration
comes in high-pitched jerky puff's, signifies that the entrance of tke
air into the alveoli is impeded, and such impediment is most likely
to be due to tuberculosis when present over a considerable period
in a localized area of pulmonary tissue.
' Any irritating vapor — for example, creosote vapor — which prodnces vio-
lent cough and expectoration, may be used to expel bronchial secretions in
doubtful cases. Tubercle bacilli may then be found in the sputum of patients
who, without the irritating inhalation, have no cough and so no sputa.
'' See Appendix C.
308
PHYSICAL DIAGNOSIS.
(2) Moderate/)/ Advaneed Cases
So far T liave beeu speaking of the detection of tuberculosis at
a stage prior to the production of any considerable amount of solid-
ification The signs considered have been those of bronchitis
localized at the ajiex of the lung, or of a slightly diuiuiished pul-
monary elasticity, ^^■hetller due to pdeuritic adhesions or to other
causes. We have next to consider the signs iu cases in which so-
lidification is present, though relatively slight in amount This
condition is comparatively easy to recognize when it occurs at the
Rales. -_
-Rales.
Fig. 161.— Diagram of Slprns in Phthisis.
left apex, but more difficult in case only the right apex is diseased
Partial solidification of a small area of lung tissue at the left apex
gives rise to
(a) Slight duluess ou light percussion,' with increased resist-
ance.
[li) Slight increase in the intensitj' of the spoken and whispered
voice, and of the tactile fremitus (m many cases)
1 Other causes of duluess, such as asymmetry of the chest, pleural thickeu-
iug, and tumors, luust be excluded. Emphysema of the lohules siuTounding
the tuberculous patch may completely mask the dulness.
BRONCHITIS. PNEUMONIA, TUBERCULOSIS. 309
(e) Some one of the numerous varieties of bronelio-vesiculai
breathing (true bronchial breathing is a late sign).
(rf) Abnormally loud transmission of the heart sounds, espe-
cially under the clavicle.
(p) Cardio-respiratory murmurs (ride p. 197 are occasionally
due to the pressure of a tuberculous lobule upon the subclavian
artery. In connection with other signs they are not altogether
valueless in diagnosis
In case there is also a certain amount of secretion in the bron-
chi of the affected area or ulceration around them, one often hears
rales of a peculiar quality to which Skoda has given the name of
" conso7iatinff mles." Rales produced in or very near a solidified
area are apt to have a very sharp, crackling equality, their intensity
being uicreased by the same acoustical conditions which increase
the intensity of the voice sounds over the same area When such
rales are present at the a}>ex of either lung, the diagnosis of tuljer-
culosis is almost certain, but if, as not infrequently occurs, there
are no rales to be heard over the suspected area, our diagnosis is
clear 07ili/ in case the signs occur at the left apex. Precisely the
same signs, if present at the right apex, leave us in doubt regard-
ing the diagnosis, for the reason that, as has been explained above,
we find at the apex of the right lung in health signs almost exactly
identical with those of a slight degree of solidification. Hence, if
these signs, and only these, are discovered at the right apex, we
cannot feel sure about the diagnosis until it is confirmed by the
appearance of rales, the presence of fever, loss of weiglit, a jiositive
tuberculin reaction (ocular, cutaneous, or subcutaneous), or by the
finding of tubercle bacilli in the sputum.'
A sign characteristic of early tuberculous clianges in the lung
and one whicli I have frequently observed in the lower and relatively
sounder lobes of tuberculous lungs is a raising of the pitch of inspi-
ration,'without any otlier change in the quality of the breathing or
any other pliysieal signs. The importance of this sign in the diag-
' The natural disparity between the two apices is less marked in the supra-
spinous fossa behind than over the clavicle in front, and hence pathological
dulness at the apex is more often demonstrable beljind than in front.
-' " Sharp breathing " (Turban).
310 PHYSJf'AL DIAGNOSIS.
nosis of early tuberculosis of the lungs was insisted upon by the
elder Flint iu his work on "The liespiratory Organs" (ISGO), and
has more recently been mentioned b}' Norman Bridge.
It must never be forgotten that tuberculosis may take root iu
Fig. 162. —This Patipnt has Sulldidcation at both Apices and Tuliercle Baollll In the Sputa. He
feels perfeetlv well.
the most finely formed chests and in persons ajiparently in blooming
health. The "phthisical chest " and the sallow, enuiciated figure of
the classical descriptions apply only to very advanced cases. Fig.
162 represents a patient with nK)deratel3' advanced signs of phthisis
and abundant tubercle bacilli iu the sputa. He feels perfectly
BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 311
well and is at work. On tlie other hand, a jjatient with very slight
signs may be utterly prostrated by the toxseniia of the disease.
(3) Advanced Plitlikh.
Characteristic of the more advanced stages of tuberculosis in the
lungs is the existence of large areas of solidified and retracted lung,
and, to a lesser extent, the signs of cavity formation. The patients
are pale, emaciated, and feverish. The signs of solidification have
already been enumerated in speaking of pneumonia. They are :
1. Marked dulness, or even flatness,' with increased sense of re-
sistance.
2. Great increase of voice sounds or of tactile fremitus.
3. Tubular breathing, sometimes loud, sometimes feeble.
4. As a rule, coarse rales, due to breaking down of the caseous
tissue, are also to be heard over the solidified areas. Sometimes
these rales are j^rodueed within the xdeuritic adhesions, which are
almost invariably present in such cases. If they disappear just
after profuse expectoration, one may infer that they are j^roduced
within the lung.
Increase in the intensity of the spoken voice, of the whispered
voice, or of the tactile fremitus may be marked and yet no tubular
breathing be audible. Each of these signs may exist and be of im-
portance as signs of solidification without the others. As a rule,
it is true, they are associated and form a very characteristic group,
but there are many exceptions to this rule.
The tendency of the spinal column to transmit to the sound
lung sounds produced in an area of solidification immediately
adjacent to it on the other side, has been already alluded to in
the section on pneumonia, and what was then said holds good of tu-
berculous solidification. Owing to this it is easy to be misled into
diagzrosing solidification at both apices when only one is affected.
Since solidification is usually accompanied by retraction in the
affected lung in very advanced cases, the chest falls in to a greater
' Unless senile emphysema masks it. Fibroid plithisis (vide infra) may
siiow no dulness. Remember that gastric tympany may be transmitted to the
left lung and mask dulness there.
312
PHYSICAL DIAGXOSIS.
or less extent over the affected area, and the respiratory excursion
is luueh diminished, as shown by ordinary inspection and by the
diminution or disappearance of tlie excursion of the diaphragm
shadow. The intensity of the tubuhir breathing depends on tlie
proximity of the solidified portions to the chest wall and to the
large bronchi, as well as on the presence or absence of pleuritic,
thickening.
It is rare to tiud a whole lung solidihed. The pirocess, begin-
ning at the apex or just below, extends down as far as the fourth
Bronchinl breath-
ing, dulaess.
Increased fremitus
Increased voice
sounds.
Hales.
Fig. li>^.— To Illustrate Progress of Siiins in Pulmonary Tuberculosis.
rib m front, i.r., through the upper lobe, in a relatively short time,
but below that point its progress is comparatively slow and the
lower lobes may be but little affected up to the time of death. On
the relatively sound side the exaggerated (compensatory) resonance
may mask the dulness of a beginning solidification there, which
sooner or later is almost sure to occur. It is exceedingly rare for
the disease to extend far in one lung without involving the other.
About the time that the tuberculous process invades the jyevi-
ously sound lung it is apt to show itself at the apex of the lower lobe
BRONCHITIS, PNEUMONIA, TVBER' VT.OSTS. 31?!
of the lung first affected. Consonating rales appear posteriorly along
the line which the vertebra] border of the scapula makes when the
arm is raised over the shoulder. These points are illustrated in
Fig. 163.
Cavity Formation.
Cavities of greater or lesser extent are formed in almost every
case of advanced phthisis, but very seldom do they attain such size
as to be recognizable during life. Indeed, the diagnosis of cavity
ui phthisis plays a much larger part in the text-books than it does
in the practice of medicine, since to be recognizable by physical
examination a cavity must not only be of considerable size but its
walls must be rigid and not subject to collapse,' it must communi-
cate directly with the bronchus and be situated near the surface of
the lung, and it must not be filled up with secretions. It can read-
ily be appreciated that it is but seldom that all these conditions are
present at once; even then the diagnosis of cavity is a difficult one,
and I have often known skilled observers to be mistaken on this
point.
The signs upon which most reliance is usually placed are:
(a) Amphoric or cavernous breathing.
(b) " Cracked-pot resonance " on percussion.
(c) Coarse, gurgling rales.
(a) Cavernous or Amphoric BesjArat ion.— When jDresent, this
type of breathing is ahnost pathognomonic of a cavity. It is also
to be heard in pneumothorax, but the latter disease can usually
be distinguished by the associated pdiysical signs. Cavernous
breathing differs from bronchial or tubular breathing in that its
pitch is lower and its quality holloiv. The pitch of expiration
is even lower than that of inspiration. Since a pulmonary cavity
is almost always surrounded by a layer of solidified lung tissue, we
usually hear around the area occupied by the cavity a ring of bron-
chial breathing with which we can compare the quality of the cav-
ernous sounds.
> Yet not so rigid as to be uninfluenced by the entrance and exit of air.
314 PHYSICAL DTAGXOSIS.
(h) Peieussioii sometimes enables its to deiuoiistrate a circum-
scribed area of tympanitic resonance surrounded by marked dul-
ness. ISIore often tlie "cracked-pot" resonance can be elicited by
percussing over tlie susi)eeted area while the cliest-piece of the
stethoscope is held close to the patient's open moutli.
Cracked-pot resonance is often absent over cavities ; rarely oc-
curs ill any other condition {i'-;/., in percusshig the chest of a
healthy, erijiiuj baby, and occasionally over soliditied lung).
(r) The ^'oice sounds sometimes have a peculiar hollow cpiality
(amphoric voice and whisi)er),
{cl) Cough or the movements of respiration may bring out over
the suspected area splasliing or gurgling sounds, or occasionally
a metallic tinkle. Flint has also observed a circumscribed bulging
of an interspace during cough. I-truce noted a high-pitched suck-
ing sound during the inspiration following a hard cough ("rubber-
ball sound '').
Very iin]iortaiit in the diagnosis of cavity is the intenuittence of
all above-mentioned signs, wliich are present only when the cavity
is comparatively empt}^, and disappear when it becomes wholly or
mostly filled with secretions. For tliis reason, the signs are very
apt to be absent in the early morning before the patient has expelled
the accumulated secretions bjr coughing.
Wintrich noticed that the note obtained when percussing over
a pulmonary cavity may change its pitch if the patient opens his
mouth. Gerhardt observed that the note obtained over a pulmo-
nary cavity changes if the patient shifts from an u]>right to a re-
cumbent iiosition. Neither of these points, liowever, is of much
importance in diagnosis. The same is true of metamorphosing
breathing (see above, p. IHfi).
Tuberculous cavities differ from tliose produced hj pulmonary
abscess or gangrene in that the latter are usually situated in the
lower two-thirds of the hmg. Kroncliiectasis, if considerable in
extent, cannot be distinguished by })hysical signs alone from a
T.uberculous cavity.
BRONCHITIS. PNKUMONIA. TUBERCULOSIS. 315
FUirokl Pldhtsk.
This term applies to slow tuberculous jji-ocesses with relatively
little ulceration and much tibrons thickening.
In a considerable number of cases the physical signs do not
differ materially from those of the ordinary ulcerating forms of
the disease, but occasionally when a slow chronic process at the
a})ex of the lung results in the falling-away of the parenchyma of
the lung so that we have left a cluster of bronchi matted together
by fibrous tissue, the percussion note may be noticeably tympani-
tic; similar tympany may be due to emphysema of the lobules
surrounding the diseased portion. In such cases rales are usu-
ally entirely absent ; otherwise, the signs do not differ from those
of ordinary phthisis, except that falling-in of the chest walls over
the retracted lung may be more marked. Occasionally the heart
maybe drawn toward the affected lobes, e.g., upward and to the
right in right-sided jihthisis at the apex. In two cases of fibroid
disease at the left base, Flint found the heart beating near the
lower angle of the left scapula.
Plitlikis vitli Predoniinant Pleural Thickening.
Tuberculosis in the lung is in certain cases overshadowed by the
manifestations of the same disease in the pleura, so that the signs
are chiefly those of fJiichened pleura. To this subject I shall return
in the section of Diseases on the Pleura (see below, j). 331).
TSwpliysematous Form of PI/tIti.sis.
Tubercle bacilli are not very infrequently found m the sputa of
cases in which the history and physical signs point to chronic bron-
chitis with emphysema. I have seen two such cases within a year
Dulness is wholly masked by emphysema, tubular breathing is
aljsent, and piping and babbling rales are scattered throughout both
lungs. The emphysema may be of the senile or small-lunged type,
as in one of my recent cases (with autopsy), or it may be associ-
ated with huge downy lungs and the "barrel chest." Such cases
316 PHYSICAL DIAGNOSIS.
cannot be identified as phthisis during life unless we make it an
invariable vule to examine for tubercle bacilli the sputa of every
case in which sputa can be obtained, no matter what are the phyil-
cal signs.
Phthisis with Anomalous Distribution of the Lesions.
Very rarely a tuberculous i:)rocess may begin at the base of the
lung When the process seems to begin in this way, a healed focus
is often to be found at one apex surrounded by a shell of healthy
lung.
The summit of the axilla should always be carefully examined,
as tuberculous foci may be so situated as to produce signs only at
that point.
Another point often overlooked in physical examination is the
lingnla pulnionaUs or tongue-like projection from the anterior mar-
gin of the left lung overlapping the heart. Tuberculosis is some-
times found further advanced at this point than anywhere else.
As a rule cases in which sigirs like those of phthisis are found
at the base of the lung turn out to be either empyema, or abscess,
or unresolved pneumonia (cirrhosis of the lung).
Acute Txdvionary Tuberculosis.
No one of the three forms in which acute phthisis occurs, viz.,
(a) Acute tuberculous pneumonia,
(6) Acute tuberculous bronchitis and jieribronchitis,
(c) Acute miliary tuberculosis, involvmg the lungs, can be rec-
ognized by physical examination of the chest. The first form is
almost invariably mistaken for ordinary croupous pneumonia, until
the examination of the sputa establishes the correct diagnosis. In
the other two forms of the disease, the physical signs are simpiy
those of general bronchitis.
CHAPTER XV.
EMPHYSEMA, ASTHMA, PULMONAEY SYPHILIS, ETC.
I. Emphysema.
Foe clinical purposes, the great Biajority of cases of empliy-
sema may be divided into two groups.
(1) Larfje-lunged empliyseina, usually associated with chronic
bronchitis and asthma.
(2) Sinall-liinged, or senile, emphysema.
Although the second of these forms is exceedingly common, it
is so much less likely than the first form to give rise to distressing
symptoms that it is chiefly the large-lunged emphysema whicli is
seen by the physician. In both conditions we have a dilatation
and finally a breaking down of the alveolar walls until the air spaces
are become relatively large and inelastic. In both forms, the elas-
ticity of the lung is diminished ; but in the large-luirged form we
have an increase in the volume of the whole organ in addition to
the changes just mentioned.
Large-Lunged EmpTiysema.
The diagnosis can usually be made by inspection alone. In
typical cases the antero-posterior diameter of the chest is greatly
increased, the in-spaces are widened, and the costal angle is blunted,
while the angle of Ludwig' becomes prominent. The shoulders are
high and stooping and the neck is short (see Fig. 164). The patient
is often considerably cyanosed, and his breathing rapid and diificult.
Inspiration is short and harsh ; expiration prolonged and difficult.
The ribs move but little, and, owing to the ossification of their car-
1 Formed by the junction of the manubrium with the second piece of the
sternum.
318
PHYSICAL DIAGNOSIS.
tilages, are apt to rise and fall as if made in one piece {en cui-
rasse). The working of the auxiliary muscles of respiration is not
infrequently seen. The diaphragm shadow (Litten's sign) begins
its excursion one or two ribs farther down than usual and moves a
much shorter distance than in normal cases.
Pitlpaiion shows a diminution in the tactile fremitus, through-
out the affected portions; that is, usually throughout the whole of
both lungs. Sometimes it is
scarcely to be perceived at all.
JPerciission j'ields very in-
teresting information. The
disease manifests itself —
(a) By hyper-resonance on
percussion, with a shade of
tympanitic quality in the note.
(?/) By the extension of the
margins of the lung so that
they encroach upon portioirs of
the chest not ordinarily reso-
nant.
The degree of hyper-reso-
nance depends not only upon
the degree of emphysema but
upon the thickness of the chest
■walls. The note is most resonant and has most of the tympanitic
quality when the disease occurs in old persons with relatively thin
chest walls. The encroachment of the over-vohrminous lungs upon
the liver and heart is demonstrated by the lowering of the line of
liver flatness from its ordinary position at the sixth rib to a point
one or two interspaces farther down or even to the costal margin,
while the area of cardiac dulness may be altogether obliterated,
the lungs completely closing over the surface of the heart. At the
apices of the lungs resonance may be obtained one or two centi-
metres higher than normally and the quality may be markedly tjan-
panitic. In the axillaj and in the back the jiulmonary resonance
extends down one inch or more below its normal position.
164.-B;irrel Cbest due to Chronic IJiuu-
chitis and Empliysema.
EMPHYSEMA. ASTHMA, PULMONARY SYPHILIS, ETC. 319
AusciiltatioH shows in uncomplicated cases no very marked mod-
ification of tlie inspiratory murmur, which, however, may be short-
ened and enfeebled. The most striking change is a great ijrolonga-
tion a7id enfeehlement of expiration, with a lowering of its pitch
(see Fig. 165).
This type of breathing is like bronchial breathing in one re-
spect ; namely, that in both of them expiration is made prolonged,
but emphysematou.s breathing is feeble and low-
pitched, while bronchial breathing is intense
and high-pitched. At the bases of the lungs
i the respiration is especially feeble and may be
\ altogether replaced by crackling rales.
: ■ ■ In " small-lunged emphysema " we have
' precisely the same physical signs, except that
Fig. 165.— Diatrram to ,, -, , . j- . i i ^ ^ t i
niustrate Emphyse- ^"-^ boundaries of the lung are not extended,
matous Breathing expiration is less prolonged and less difficulty
with Musical Expira- , . . . . \ t- , ,
tory Eaies. and inspiration is normal. It does not tend
to be complicated by bronchitis and asthma;
mdeed the small-lunged emphysema rarely gives rise to any symp-
toms, and is discovered as a matter of routine physical examination.
Siimmari/.
1. Hyper-resonance on percussion.
2. Feeble breathmg with prolonged expiration.
3. Diminished fremitus and voice sounds.
4. Encroachment of the resonant lungs on the heart and livei
dulness (in the large-lunged form).
Differential Diagnosis.
(«.) SmphgsemaiasLj be confounded with ^meumothorax, since in
both conditions hyper-resonance and feeble breathing are present.
But enipjhyseina is usually bilateral, encroaches upon but does not
displace neighboring organs, and is not often associated with hydro-
thorax. Emphysema, if extensive, is usually associated with
chronic bronchitis and so with squeaking or bubbling- rales, while in
320 PHYSICAL DIAGNOSIS.
pneirmothorax breathing is absent or distant amphoric without
rales.
(6) The signs of aiieiirisin of the aorta pressing on the trachea
or on a primary bronchus are sometimes overlooked because the fore-
ground of the clinical picture is occupied by the signs of a coexist-
ing bronchitis with emphysema. The cough and wheezuig which
the presence of the aneurism produces may then be accounted for
as part of the long-standing bronchitis, and the dulness and thrill
over the upper sternum to which the aneurism naturally gives rise
may be masked by extension of lung borders. But the e\ddence of
pressure on mediastinal nerves and vessels (aphonia, unequal pulses
or pupils, etc.), and the presence of a diastolic shock and tracheal
tug are usually demonstrable ; the danger is that we shall forget to
look for them.
(c) Uncompensated mitral stenosis may produce dyspnoea and
cyanosis and weak rapid heart action somewhat similar to that seen
in emphysema, and may not be associated with any cardiac mur-
mur, but the dyspnoea is not of the expiratory type, and the irregu-
larity of the heart, with e\adence of dropsy and general venous
stasis, should make it eindent that something more than simple em
physema is present.
(d) The occurrence of an emphysematous form of ^jhthisis I
have already mentioned in discussing the latter disease (see p. 304).
Emphysenia loitli Bronchitis or Asthma.
In the great majority of cases, emphysema of the lungs is asso-
ciated with chronic bronchitis, bronchiectasis, and asthmatic parox-
ysms. Such association is especially frequent in elderlj' men who
have had a winter cough for many years and in whom arterio-scle-
rosis is more or less well marked. In such cases the prolonged and
feeble expiration is usually accompanied by squeaking and groaning
sounds, or by moist rales of various sizes and in various parts of
the chest. "WHien the asthmatic element predominates, dry rales
are more noticeable, and occur chiefly or wholly during expiration,
(vhile mspiration is reduced to a short, quick gasp.
EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 321
Interstitial Emjjh ijsema.
In rare cases violent paroxysms of coughing may rupture the
walls of the alveoli so as to allow the passage of air into the inter-
stitial tissue of the lung, from whence it may work through and
manifest itself under the skm, giving rise to a peculiar crackling
sensation on palpation, and to a similar sound on auscultation.
More frequently the trouble arises in connection with a tracheot-
omy wound, the air penetrating under the skin and producing a
downy, crepitating swelling.
" CcDiipIementary Ei)iphijsema."
When extra work is thrown upon one lung l)y loss of the func-
tion of the other, as in pleuritic effusion — a considerable stretching
of the overworked sound lung may take place. The elasticity of
the lung is not diminished as in emphysema, but is greatly in-
creased. Hence the term complementary emphysema should be
dropped and the term complementary (or compensatory) hijiwr-
resonance substituted.
Like emphysema, this condition leads to hyjier-resonance on per-
cussion and to encroachment of the pulmonary margins upon the
neighboring organs (as shown by a reduction in the area of dulness
corresponding to them), but the respiratory murmur is exaggerated
and has none of the characteristics of emphysematous breathing.
A word may here be added regarding the condition described
by West under the name of
Acute Puhnonarg Tympanites.
In fevers and other acute debilitating conditions West has ob-
served that the lungs may become hyper-resonant and somewhat
tympanitic on percussion, owing, he believes, to a loss of pulmo-
nary elasticity. The tympanitic note, often observable around the
solidified tissue in pneumonia, is to be accoimted for, he believes,
in the same way. Like the shortenuig of the first heart sound,
acute pulmonary tympanites points to the weakening of muscle fibre
which toxfemia is so apt to produce. Apparently the muscle fibres
of the lung suffer like those of the heart.
21
322 PHYSICAL DIAGNOSIS.
BRONCHIAL ASTHMA.
(Peimaet Spasm of the Bronchi).
During a paroxysm of bronchial astlima our attention is at-
tracted even at a distance by the loud, wheezing, prolonged expira-
tion preceded by an abortive gasping inspiration. The breathing
is labored, much quickened in rate, and cyanosis is very marked.
The chest is distended and hyper-resonant, the position of the dia-
phragm low and its excursion much limited, and the cardiac and
hepatic dulness obliterated by the resonance of the distended lungs.
On auscultation, practically no respiratory murmur is to be heard
despite the violent plunging of the chest walls. "We hear squeaks,
groans, muscular runiljles, and a variety of strange sounds, but
amid them all practically nothing is to l)e heard of the breath
sounds. "The asthmatic storm flits about the chest, now here now
there," the rales appearing and disappearing.
At the extreme base of the lungs there may be dulness due to
atelectasis of the thin pulmonary margins.
Dijferent'uil Diagnosis.
(a) Mechanical irritation of the bronchi, as by the pressure of
an aneurism or enlarged gland, may set up a spasm of the neigh-
boring bronchioles much resemljling that of primary bronchial
asthma, but thorough examination should reveal other evidence
of mediastinal pressure, and the history of the case is very different
from that of asthma.
(h) Spasm of the glottis produces a noisy dyspncea, but the diffi-
culty is with insjnration, instead of with expiration, and the crow-
ing or barking sound is not like the long wheeze of asthma. No
rales are to be heard, and the signs in the lungs are those of col-
lapse instead of the distention characteristic of asthma.
(c) The paroxysmal attacks of dyspnoea, which often occur in
chronic nephritis, myocarditis, and other diseases of the heart and kid-
ney, may be entirely indistinguisliaV>le from primarj' broncliial asth-
ma but for the evidence of the underlying cardiac or renal disease.
EMPHYSEMA. ASTHMA, PULMONARY SYPHILIS, ETC, 323
(d) Acute dyspnoea in young infants is sometimes due to en-
larged thymus {thymic asthma). The diagnosis rests on the elimi-
nation of all other causes for sudden dyspnoea and the presence
(sometimes) of increased substernal dulness.
SYPHILIS OF THE LUNG.
The diagnosis cannot be made with certainty from the physical
signs, and rests entirely (m the rare cases in which it is made at all)
on the history, the evidence of syphilis elsewhere in the body, and
the result of treatment. jNIost cases are mistaken for phthisis.
Any case supposed to be phtliisis, but in which the examination
of the sputa for tubercle bacilli is repeatedly negative, should be
given a course of syphilitic treatment.
The physical signs, as in phthisis, are those of localized bron-
chitis or of solidification, but the lesions are not at the apex but
usually about the root of the lung or lower down. Cavities are not
formed. Stenosis of a bronchus may occur with resulting atelecta-
sis of the corresponding lobules.
Bkoxchietasis (Bronchial Dilatation).
(a) The commonest tj'pe is that associated with chronic bron-
chitis and recurrent attacks of winter cough. Innumerable small
bronchioles become dilated and the resulting cavity infected — usu-
ally— with influenza bacilli (\^'iii. II. Smith). The signs are sim-
ply those of a chronic bronchitis with or without emphysema and
asthmatic seizures.
(5) When the disease is further advanced and the cavities are
larger, a sudden change in the patient' s position (or especially hanging
head downward over the side of the bed) may cause him to raise
large amounts of sputa (half a pint or more) within a few minutes.
This sputum is not usually foul and rarely contains blood or elastic
fibres. Even at this stage there may be no physical signs of local-
ized cavities — but only those of the associated bronchitis.
(e) In a small number of cases signs of cavity (see above, p.
313) may be made out.
324 PHYSrCAL DIAGXOSIS.
From pulmonary abscess the disease may usually be distiuguislietl
by the history, the sputa, and the I'aet that loeal signs of cavity
surrouniled liy solulitieatiou and bronchitis can usually be demon-
strated in abscess.
The disease may cause marked retraction of the chest ou the
affected side, and neighhoriug organs may be drawn out of place.
ClEKHOSIS OF THE LuXG.
(Chronic Interstitial rneiimonia.)
As an end stage of unresohed croupous pneumonia, or as a
result of chronic irritation from mineral or vegetable dust, a shrink-
age of a part or the whole of the lung may occur, which progresses
until the pulmonary tissue is transformed into a tibroirs mass en-
closing bronchi.
The side of the chest correspondmg to the affected lung becomes
shrunken and concave; fremitus is increased, percussion resonance
diminislied or lost, respiration tubular with coarse rales.
From tuberculosis the condition is to be distinguished solely by
the history, the absence of bacilli iu the sjiuta, and the comparative
mildness of the constitutional symptoms.
The right ventricle of the heart may become hypertrophied and
later dilated with resulting tricuspid insuificieucy.
EXAMINATION OF srUTA.
I. On'ifin. — Frobably the majority of all sputa, excejiting to-
liacco juice, come from the intanplniri/ii.r, and are /iiiirki-(U not
coughed up. It is rarely of value to examine such sputa, although
influenza bacilli, diphtheria bacilli, pneumococci, and other bacteria
may be f(>nnd.
What we want iu most cases is sputa coughed up fronr the pri-
mary bronchi or lower down, and the patient should be accordingly
instructed. Early morning cough is most likely to bring up sputa
from the bronchi
Young children do not raise sputum, but when it is important
to obtain it we nuiy insert the forefinger (covered with a bit of cot-
ton) into the pharynx, so as to excite a spasm of coughing. The
EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 325
sputum is deposited on the cotton before the child lias time to swal-
low it, and may then be withdrawn and examined.
II. Quantit//. -If the amount expectorated is large (i.e., one-
half a pint or more iu twenty-four hours ), we may be dealing with :
1. Pulmonary cedema (watery, sometimes pink and frothy).
2. Advanced phthisis (muco-purident).
3. Empyema ruptured into a bronchus (pure pus).
4. Abscess of the lung (foul smelling).
5. Bronchiectasis (large amount within a few mniutes on change
of i^osition).
III. Odor. — Unless retained in a lung cavity (abscess, gan-
grene) sputum is rarely ill-smelling. In gangrene of the lung the
breath as well as the sputum is horribly oifensive, and the odor soon
fills the room and the house.
IV. Gross Appeariuices. — (a) Bloody sjnifum (hsemoptysis)
means pure or riearlij ^jitre blood in considerable qua.ntity, a tea-
spoonful or more, -not mere streaks of blood iu muco-purulent spu-
tum, which usually comes from an irritated throat.
Haemoptysis thus defined is seen chiefly in the following condi-
tions, arranged in the order of frequency :
1. Phthisis.
2. Pulmonary congestion with infarction (mitral disease).
3. Pneumonia.
4. After epistaxis.
5. Abscess or gangrene of the lung.
6. Without known cause ("vicarious menstruation," etc.).
Rare causes are new growths of the lung, parasites ( Distomum
Westermanni), aortic aneurism rupturing into an air tube, ulcer of
the trachea or bronchi.
The cause of hEemoptysis can usually be made out by a thor-
ough examination of the chest and a study of the other symptoms in
the case. In phthisis there are often no physical signs in the lungs
at the period when the bleeding occurs or for some weeks after it.
Blood coughed up can usually be distinguished from blood vomited
{hcematemesis) by careful questioning and by examining the blood.
Blood coughed up often contains bubbles of air and is alkaline in
i3ii6 PHYSICAL DIAGNOSIS.
reaction, while blood from the stomach is usually mixed with food,
not frothy, and perhaps acid in reaction.
(b) Fneumonic Sputum. — The color is most characteristic; it is
either
(1) Tawny-j-ellow or fawn-colored ("rusty"), or
(2) Orange-juice colored {not orange, but pale straw colored).
These colors, associated with (jrudt tenacity, so that the sputum
clings to the lips and does not fall from an inverted sputum-cup,
are almost pathognomonic of pneumonia — though pneumonia often
occurs without any sucli sputa.
(c) Serous s^jutum, profuse and watery, is characteristic of pul-
monary oedema.
(d) alack or ffrai/s/iutui/i is due to carbon, dust, or tobacco smoke
inhaled.
(e) Purejjus — not nuico-jiurulent — is oftenest seen in influenza,
occasionally in empj'ema breaking through tlie lung.
(/) Muco-purulent sputum occurs in manj' diseases and is char-
acteristic of none.
IV. Microscopic E.ra m ination . — Ninetj'-nine-one-hundredths of
all examinations are for the tubercle bacillus. Of the many useful
methods of staining for this organism the following seems to me
the best :
1. Pick out with forceps the most purulent portion of tlie
sputa and smear it thiiilij over a cover glass. All particles thick
enough to be opaque should be removed from the cover glass be-
fore staining.
2. Dry the preparation Itcld in tlic fingers over a Bunsen or al-
cohol flame. Then fix it in Cornet's forceps and pass it three times
through the flame, sputum side down.
o. Flood it with carbolic fuchsin,' and steam it — do not boil it
— over the flame for about thirty seconds. Be sure to use enougli
stain so that it does not drj' on the cover glass.
4. Wash in water and decolorize for twenty seconds in tweuty-
per-cent H.^SO^.
' Carbolic-acid crvstals, 5 gm. ; fuclisiu (saturated alcoholic solution), 10
gm. ; water, 100 gm.
EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 327
5. Wash in water and then in ninety-five-per-cent alcohol for
thirty seconds or nntil the color ceases to come out.
6. Wash in water and cover with Loffler's methylene blue ' for
about tliirty seconds.
7. Wash in water, dry on blotting paper, and mount in Canada
balsam.
The whole process need not take more than five minutes, and
it is absolutely essential that every physician should be familiar
with it.
The bacilli are stained red, everything else blue. They should
be looked for only with an immersion lens (one-twelfth-inch), a
wide-open diaphragm, and a good white light. In the vast major-
ity of cases the bacilli are found, if at all, within a few minutes
and in almost every field. Occasionally one has to search longer,
but it is better to search one well-stained preparation thoroughly
than to spend the time in preparing and examining several.
The presence of red-stained haeilli in specimens of sputa so pre-
pared is practically pathognomonic of tuberculosis. Other acid-
resisting bacilli occur in the urine, but almost never in the lung.
The ahsi'iiee of tidierele bacilli after at least six examinations of
satisfactory specimens ° obtained several days apart makes it very
unlikely that phthisis is jjresent. One or two negative examina-
tions are of no significance.
Pneumoroeric and Infaenza Bacilli. — For both these organisms
Oram's stain is on the whole the best. This is performed as fol-
lows :
1. Prepare a smear as above directed.
2. Cover it with aniline-oil-gentian-violet solution' (freshly
made each week) and heat to steaming point.
' Saturated alcoholic solution of methylene blue, 30 c.c. ; aqueous solution
of KOII (1 in 10,000), 100 c.c.
' A satisfactory specimen is one prepared without any slips in technique
from purulent spula obtained by coughing and not by hawking.
^Saturated alcoholic solution jif gentian violet, 13 c.c; aniline water, 84
c.c. ; aniline water is the clear filtrate from the mixture of aniline, 5 parts,
with water, 25 parts.
328
PHYSICAL DIAGNOSIS.
S. Wash in water and cover witli TKl solution ' for thirty sec-
onds.
4. Wash in ninety-Hve-per-cent ah'ohol until tlie bhie color
ceases to come out.
5. Counterstain with ]>ismarck brown for thirty seconds.
6. Wash ill water and mount in Canada balsam.
The pneumococcns with t1iis stain comes out blue-black and
its morpholog}' is well shown (see Fig. IdCi). The presence of a
Kid. llill.— Piu'uiiini-orci ill SpiiUiiii. l\V. II. Siiiilli.) ((.'nini'.s sUiiii.)
few pneuniococci free in the sputum is not of importance. When
the organisms are verjr abundant, and especially' when many of
them are contained within leucocytes, a pneumococi'us infection is
strongly suggested, though it may be a imeuiuococcus bronchitis
without pneuiminia. In the earlies* stages of an infection fewer
' lodiiic, 1 gill. ; iHitussiuin iddidc, 2 gm ; wiitur, 300 c.c.
EMPHYSEMA. ASTHMA. PULMONARY SYPHILIS, ETC. 329
organisms are found within leucocytes than is the case later. Ob-
viously one can learn only by practice what is meant by "few" or
'' many " ort^anisms.
The ■iiifiiciizd bacillus is tlie smallest organism to be found in
the sputum. lu specimens stained by Gram's method (as above
given ) the influenza bacilli come out as nmmte,fiiinf/i/ l/roini-stained
points, contrasting with the intense, blue-black of i^neumococci and
other organisms. Only wlien present in large numbers both inside
and outside tlie leucocytes of the sputa are they diagnostic of active
influenzal infection, since the organism is a common inhabitant of
the upper air passages.
Althougli other organisms — actinomyces, micrococcus catarrhalis,
streptococcus, bacillus mucosus eapsulatus — are sometimes found in
sputa, their importance does not justify an account of them here.
liidicdtioiiif for Sputum E.ramlnntion. — Any cough with sputa
lasting more tliau a week calls for an examination of sputa. In
doubtful cases of influenza or pneumonia, and in any case in which
tuberculosis is suspected, an examination is imperative.
When the symptoms or physical signs suggest tuberculosis but
no sputa can be obtained, it is well to stimulate the bronchial secre-
tions with 10 gr. of potassium iodide after meals for a week. A
way of getting sputa from young children lias already been de-
scribed (page 324).
CHAPTER XVI.
DISEASES AFFECTIXG THE PLEURAL CAVITY.
I. Hydkothorax.
In cases of nepliritis or of cardiac -w^eakness due to vahiilai
heart disease a considerable aecuiimlation of seriim may take place
in both pleural cavities. The physical signs are identical "with
those of pleuritic effusion (see below, jiage 336) except that the
latter is almost always unilateral, while hj'drothorax is usually bi-
lateral. Exce]itions to this rule occur, however, especially on the
right side or in cases in which one pleural cavity has been obliter-
ated by iibrous adliesions, the results of an earlier pleurisy. The
iluid obtained by tapping in cases of hydrothorax is usually con-
siderably lower in specific gravity and poorer in albumin than that
exuded iu pleuritic inflammati(m.
The fluid shifts more I'eadily with change of position than is the
case with many pleuritic effusions, owing to the absence of adhe-
sions in hydrothorax.
Friction sounds, of course, do not occur, as the pleural surfaces
are not inflamed. A few grains of jiotassium iodide by mouth soon
piroduce a reaction for iodine in the fluid of hydrothorax and not in
pleuritic effusion.
II PNEUMOTH0K.A.X.
Pneumothorax, or the presence of air in the pleural cavity, may
result from stabs or wounds of the chest wall, but is usually a com-
plication of pulmonary tuberculosis which weakens the lung until
by a slight cough or even by the movements of ordinary respiration
tlie iiulmonary pleura is ruptured and air from witliin the lung lealis
into the pleural cavity.
If the opening is of considerable size, and the air is not liindered
DISEASES AFFECTINO THE PLEURAL CAVITY. 331
or encapsulated by adhesions, great and sudden dyspnoea with pain
and profound " shock " may result. More commonly the air enters
the pleural cavity gradually, the other lung has time to hyper-
trophy, and the heart and other organs become gradually accus-
tomed to their new situations.
Physical Signs.
1. Inspection. — The affected side may lag behind considerably in
the movements of respiration. In very marked cases it is almost
motionless and the interspaces are more or less obliterated. The
diaphragm is much depressed and Litten's sign absent. In right-
sided pneumothorax, which is relatively rare, the liver is depressed
and the edge can be felt below the ribs.
The heart is displaced as by pleuritic effusion, but usually to a
less extent. With left-sided pneumothorax the cardiac impulse
may be lowered as well as displaced, owing to the descent of the
diaphragm.
2. Palpation. — Fremitus is absent over the lower portions of the
chest corresponding to the effused air. At the summit of the chest
over the retracted lung, fremitus may be normal or increased. In
rare cases when the lung is adherent to the chest wall and cannot
retract, fremitus is preserved.
The positions of the heart and liver are among the most impor-
tant points determined by palpation. Not infrequently no cardiac
impulse is to be obtained. Sometimes it may be felt to the right
of the sternum (see Fig. 167) or in the left axilla, but not infre-
quently it is so fixed by pleuropericardial adhesions that it is drawn
upward toward the retracted lung or remains near its normal situa-
tion. The liver is greatly depressed in cases of right-sided pneumo-
thorax, and may be felt as low as the navel.
3. Percussion. — Loud tympanitic resonance is the rule through-
out the affected side. Even a small amount of air is sufficient to ren-
der the whole side tympanitic and often to obscure the dulness which
the frequently associated pleural effusion would naturally produce.
Indeed, it is the rule that small effusions are wholly masked by the
adjacent tympany.
332 PHYSICAL DIAOXOSIS.
In no other disease do we get such clear, intense tympanitic
resonance over the chest.
The only exception to this rule occurs in cases m which the air
within the chest is under great tension, making the chest walls so
taut that, like an over-stretched drum, they cannot vihrate properly.
Lender these conditions the percussion note becomes muffled, at
times almost dull.
Areas of dulness corresponding to the displaced organs (heart
or liver) may sometimes be percussed out.
4. Atiscultafion. — Eespiration and voice sounds are usually in-
audible in the lower portions of the chest. At the top of the chest,
and rarely in the lower parts, a faint amphoric or metallic breathing
maj^ be heard, but as a nile the amphoric quality is brought out
much better by cough which is followed l\v a ringing after-echo.
Or the air in the pleura may be set to vibrating and made to give
forth its characteristic, holh:A\', ringiug sound if a piece of metal
(e.r/., a coin) be placed on the back of the chest and struck with
another coin, wliile "\ve listen with the stethoscope over the front of
the chest opposite the point where the coin is.
The clear ringing sound heard in this way is quite different
from the dull chink obtainable over sound lung tissue.
The "falling-drop sound" or "metallic tinkle," and the lung
fistula sound are occasionally audible (see above, p. 170).
On the sound side the breath sounds are exaggerated. At the
top of the affected side over the collapsed lung the breathing is
bronchial and rales are occasionally heard.
In the great majority of cases pneumothorax is complicated by
an eifusion of tluid in the affected pleural ca\'ity and we have then
the signs of
III. Pnf.umoserotiiorax or Pxeumopyothokax
"When both fluid and air are contained in the pleural cavity, the
patient may himself be able to hear the splashing sounds which
the movements of his own body produce. These are more readily
appreciated if the i)l)S('i-\'cr ])uts his ear against the patient's chest
and then shakes him briskly. Splashing sounds heard within the
DISEASES AFFECTING THE PLEURAL CAVITY.
33.3
chest are absolutely pathognomonic and point only to the combina-
tion of fluid and air within the pleural cavity. One must distin-
guish them, however, from similar sounds produced in the stomach.
By observing the position of maximum intensity of the sounds, this
distinction may be easily made. Unfortunately the critical condi-
tion of the patient may make it impossible to try succussion, as in
the acute cases with great shock it is dangerous to move him at all.
Fig. 167.— PneumoscTOthorax Seen from Behind. Nute the horizontal line at the surface of the
nuld and the retracted lung just above the inner halt of this line. Compare Fig. 173.
(From V. Ziemssen's Atlas.)
The movements of breathing or coughing may bring out a " metal-
lic tinkle " (see above, p. .''i.SS). At the base of the chest, over an
area corresponding to the position of the fluid, an area of dulness
may be easily marked out by percussion, and this area shifts very
markedly with change of position. Tlie shifting dulness of pneu-
moserothorax is strongly in contrast with tlie difficulty of obtain-
ing any such shift in ordinary pleuritic effusion (see Fig. 1 68).
334
PHYSICAL DIAGNOSIS.
(The distinction between "ojti'ii pnciiiiiotJioni.r,'' in wliich the
rent in the Inng through which the air escaped in the pleura re-
mains open, and " clost'd jnieiimotliora.r,'' in which the rent has
become obliterated — is one wliich cannot be established by physi-
cal signs alone. It is often said that amphoric breathing, and espe-
cially an amphoric ring to the voice and cough sounds, denote an
Liver. — — — —
Tympany,
breathing
and voii'e
absent or
faint
amphoric.
[ Dulne.ss,
shiftine
Fluid= { wi(h
I'lianse ot
position.
Fig. 168.-Lctt. Pni'imiosorotliorax \yith Displaced Heart.
open pneumothorax, but post-mortem evidence does not hear this
out, I'ractically an open pneumothorax is one in which the
amount of effused air increases, and closed pneumothorax is one in
which the physical signs remam stationary )
Differential Diagnosis
The distinction between jmeumothorax and emphysema has al-
ready been discussed.
(a) When the air in the jdeural sac is under such tension that
the percussion note is dull, the physical signs may simulate pleu-
ritic effusion, but real flatness, sucli as cliaracterizes effusion, has
not, so far as I kno^v, been rect)rded in pneumothorax, and the
sense of resistance on percussing is much greater over fluid than
over air. In case of doubt puncture is decisive.
DISEASES AFFECTING THE PLEURAL CAVITY.
335
(I)) Acute iJiieumothorax, coming on as it does with symptoms
of collapse and great shock, may be mistaken for angina jjectoris,
cardiac failure, embolism of the pulmonary artery, or acute pulmo-
nary tympanites (see above, p. 315).
From all these it can be distinguished by the presence of am-
phoric or metallic sounds, which are never to be obtained in the
other affections named.
Fio. 169.— Diaplirasmalic, Hei'nia. The outline of the displaf-ed diapliratrm visible helow the
left clavicle. Heart displaced to rijrht of sternuin, (From v. Zienisseu's Atlas.)
(c) Hernia of the intestine through the diaphragm (see Fig. 169)
or great weakening of the diaphragmatic muscular filn-es, may allow
the intestines to encroach upon the thoracic cavity and simulate
pneumothorax very closely. The history and course of the case, the
abdominal pain, vomiting, and indicanuria, generally suffice to dis-
tinguish the condition. The peristalsis of the intestine may go on
even in the thorax, and gurgling metallic sounds corresponding to it
and unlike anything produced in the thorax itself may be audible.
n36 PHYSICAL DIAGNOSIS.
The distinction between open and closed jmeumothorax, to which
I have already alluded, is far less important tliaii the presence or
absence of
(a) Pulmonary tuberculosis
(b) Encapsulating adhesions in which the air is confined to a
circumscribed area
(n) The exam.ination of the sputa and of the compressed lung
may yield e\'idence regarding tuberculosis. On the sound side the
compensatory hy]>crtrophy covers up foci of dulness or rales so that
it is dithcult to make out much.
(b) Encapsulated pneumothorax gives us jiractically all the signs
of a phthisical ca\'ity, from which it is distinguished liy the fact
that with a cavit}' the nutrition of the patient is almost alwaj's
much worse.
Encapsulated pneumothorax needs no treatment. Hence the
importance of distinguishing it from the non-encapsulated form of
the disease, iu which treatment is essential.
I'LEUEISY.
Clinically, we tleal with three types :
(a) Pry or plastic pleurisy.
(b) Pleuritic effusion, serous or purulent.
(c) Pleural thickening.
((() Dry or Plastic Pleurisy.
Doubtless many cases run their course without being recognized.
The frequency with which pleuritic atUiesions are foiuul post mor-
tem would seem to indicate this.
It is usually the characteristic stitch in the side which suggests
physical examination. The pain and the physical signs resulthig
from the tibrinous exiulation are usnalh' situated at the bottom of
the axilla where the diaphragnuitic and costal layers of tlie pleura
are in close apposition. Doubtless the pleuritic inlianuuation is
not by any means limited to tliis spot, l)ut it is here that the two
layers of the pleura make the largest excursion while in apposition
with each other. In the vast majority of cases, then, the physical
signs are situated at the spot indicated in Fig. 170.
DISEASES AFEECTING THE PLEURAL CAVITY.
337
Occasionally pleuritic friction is to be heard in the precordial
region, and after the absorption of a i^leuritic effusion evidences
of fibrinous exudation in the upper parts of the chest are sometimes
demonstrable. Most rarely of all, evidence of plastic pleurisy may
be found at the apex of the lung in connection with early phthisis.
In diaphragmatic pleurisy, wlien the fibrinous exudation is espe-
cially marked upon the diaphragmatic pleura, friction sounds may
be heard over the region of the attachment of the diaphragm in
front and behind as well as iu the axillte. Hiccup often occurs and
gives exquisite pain.
Our diagnosis is based upon a single physical sign, xjleuritk
friction. The nature of this sound and the
manoeuvres for eliciting it have already
been described (see above, p. 166), and I
will here only recapitulate what was there
said. During the first few deep breaths
one hears, while listenkig over the painful
area, a grating or rubbing sound usually
somewhat jerky and internrpted, most
marked at the latter part of inspiration,
but often audible throughout the whole
respiratory act. After a few breaths it
often disappears, but will usually reap-
pear if the patient lies for a short time
upon the affected side, and then sits up
and breathes deeply. In marked cases
the rubbing of the inflamed pleural sur-
faces may be felt as well as heard, and it
is not very rare for the patient to be able
to feel and hear it himself. Pleuritic fric-
tion may be present and loud without
giving rise to any pain. On the other
hand, the pain may be intense, and yet
the frictio]i-rub barely audible. When
heard at the summit of the chest, as in
cases of iucipient phthisis, pleural fric-
Wm. 170.— Showing the Point at
which Pleural Friction is most
Often Heard.
22
338 PHYSICAL DIAGNOSIS.
tion produces only a faint grazing soiuul, iiiurli more delicate and
elusive tlian the sounds produced at the base of the chest.
Occasionally the distinctive rubbing or grating sounds are more
or less commingled with or replaced by crackling sounds indistin-
guishable from the drier ^■arieties of rales. It is now, I think,
generally believed that such sounds may originate in the pleura as
well as within the lung. The greatest care should be taken to
prevent any shifting or slipping of the stethoscope upon the surface
of the chest, as by such means sounds exactly lilte those of jdeural
friction may be transmitted to the ear. In case of doubt one
should always wet or grease the skin so that the stethoscope can-
not slip.
Muscle sounds are sometimes taken for pleural friction, but they
are bilateral, usually low-pitched, sound less superficial than pleu-
ral friction, and are not increased by pressure. "When listenmg
for friction at the base of the left axilla, I have once or twice been
piirzzled by some low-pitched rumbling soiuuls occurring at the end
of inspiration, and due (as afterward a^jpeared) to gas in the stom-
ach which shifted its position with each descent of the diaphragm.
In children friction sounds and pleuritic pain are much less
common than in adults, and the signs first recognizalile are those
of effusion. In adults the presence of a very thick layer of fat
may make it difficult or impossible to feel or hear pleural friction.
The breath sounds over the affected area are usually absent oi
greatly diminished, owing to the restraint in the respiratory move-
ments due to pain. Not infrequently pleuritic friction may be
heard altogether below the level of the lung.
(li) Pleuritic Effusion.
Many cases are latent, and the patients consult the physician on
account of slight cough, weakness, or gastric trouble, so that the
effusion is first discovered in the course of routine physical ex-
amination. Since it is usually the results of percussion which first
put us on the right track, I shall take up first
DISEASES AFFECTING THE PLEURAL CAVITY.
339
Permission.
1. A small effusion first shows as an area of dulness
(a) Just below the angle of the scapula.
(b) In the left axilla between the fifth and the eighth rib.
(c) Obliterating Traube's semilunar area of tympany ; or
(ci) In the right front near the angle made by the cardiac and
hepatic lines of dulness (see Fig. 171).
In the routine percussion of the chest, therefore, one should
never leave out these areas. A small effusion is most easily de-
tected in children or in adults with thin chest walls, provided our
percussion is not too heavy. An effusion amounting to a pint
should always be recognizable, and smaller amounts have frequently
been diagnosed and proved by puncture.
The amount of a pleuritic effusion is roughly proportional to
the area of dulness on percussion, but not accurately. It is very
common to find on puncture an amount of fluid much greater than
irea of dulnesa
due to small --c-f-"
pleural effusion.
Area of cardiac
dulness.
Fio. 171.— Small Pleural Effusion Accumulating (In part) near the Rigbt Border of the Heart.
could have been suspected from the percussion outlines ; on the other
hand, the dulness may be extensive and intense on account of great
inflammatory thickening of the costal pleura, by the accmnulatioD
340
PHYSICAL DIAGXOSIS.
of layer aftri- layer of fibi-inous exudate and its organization into
fibrous plates, "n-hile very little fluid remains -witliin.
The amount of duluess depends also upon the thickness and elasti-
city of the chest wall and the degree of collapse of the lirng within.
2. Lo.nji.' Effiigioiis. — "When the amount of fluid is large, the dul-
ness may extend throughout the whole of one side of the chest with
the exception of a small area above the clavicle or over the primary
bronchus in front. This area gives a high-pitched ti/ni/Hiiiitic note,
Nomial reyniiance
and V e ,s i 0 11 1 a r
bivatbinir.
Tympany, voice and
fremitus i u -
creased.
Flatness, no breath-
ini?. Voice sounds,
or fremitus.
Zone of condensed
luutr above the
fluid.
Exag-gerated (com-
peVKitory ) breatli-
ing and reso-
nance.
no. 1T2.-Dia£rram to Illustrate Fbysical Signs in JloderiUe-Sizeii EfTusiou iu the Left Pleura.
provided the bronchi remain open, as they almost always do. This
tympany is high-pitched and sometiuies astonishingly clear. I re-
cently saw a case in which the ntite tibove the clavicle was almost
iiulistiuguisliable with the e3"es shut from that obtained in the epi-
gastrium. Occasionally '' cracked-pot " resonance may be obtained
in the tympanitic area.
The pitch changes if the patient opens and closes his mouth
while we percuss (^"Williams' tracheal tone'').
The dulness over the lower portions of a large eii'usiou is usual-
ly veri/ marked, aird the percussing finger feels a greatly increased
DISEASES AFFECTING THE PLEURAL CAVITY.
341
resistance to its blows when compared with the elastic rebonnd of
the sound side.
o. i\Io(h'i-(tfe l^j^'utiioiis. — Three zones of resonance can often be
mapped out in the back : at the base dulness or flatness, above
that a zone of mingled dulness and tympany, and at the top normal
resonance. The lowest zone corresponds to the fluid, the middle
zone to the condensed lung immediately above it, and the to]) zone
to the relatively unaffected jiart of tlie lung (see Fig. 172). Not
infrcipiently tliere is no middle zone biit sinqdy dulness below and
resonance above, as is usually the case iu the axilla and front
Fic. 173. Left I'k'llrul ElTiisu.ii Noii' llmt Ihe siirfiii'i- iif lln- lliiid .sl..i«'S oiiUvaiil anil up-
ward from tUe iiH'iiian line. (Frum v. Zieiiisseu\s Atlas.)
The jiosition of the eifusiou depends only in part npou the in-
fluence oi gravity, and is greatly influenced by capillarity and the
degree of retraction of the lungs Consequently the surface of
the fluid is hardly e\'er horizontal except in ver}- large accumula-
342
PHYSICAL DIAQNOSIS.
tions. With the patient in an upright position it usually reaches
a higher level in the axilla than in the back (see Fig. 173). Near the
spine and near the sternum (in right-sided effusions) the line corre-
sponding to the level of the fluid may rise sharply.
The S-curve of Ellis, as worked out so elaborately by Garland,
varies still further the uneven line which corresponds to the sur-
Triangulur space
dull until patient
has cou{:rhed and
breathed deeply.
Area of dulness
bounded above by
the S-curve ol
Ellis.
Fia. 174.-The S-Curve of Ellis.
face of the fluid (see Fig. 174). This curve can be obtained only
after the patient has, by cough and forced breathing, expanded the
lung as fully as possible.
All these curves are to be found with the patient in the upright
position. None of them has any considerable diagnostic impor-
tance, and the chief point to be remembered is that the upper sur-
face of the fluid, not being settled by gravity alone, is hardly ever
horizontal.
With change in the position of the patient the level of the flaid
sometimes changes very slowly and irregularly, and sometimes does
not change at all. If, for purposes of thorough examination, we
raise to a sittiug posture a patient who has been for some days or
weeks in bed, we should never begin the examination at once, since
DISEASES AFFECTINO THE PLEURAL CAVITY. 343
it may take some minutes for the lungs and the fluid to accommo
date themselves to the new position. It is well also to get the
patient to cough and to take a number of full breaths before the
examination is begun.
To test the mobility of the fluid with change of the patient's
position, mark out the upper limit of the duluess in the back with
the patient in the upright position. Then let the patient lie face
downward upon a couch, and, after waiting a few mmutes, percuss
the previously dull area. It may be found to have become resonant.'
When the fluid is absorbed or removed by tapping, one would
expect an immediate return of the percussion resonance. But in
fact the resonance returns very slowly and is wholly unreliable as
a test of the amount of absorption which has occurred. Thickened
pleura and atelectatic lung may abolish resonance long after the
fluid is all gone. We depend here far more upon the evidence ob-
tained by auscultation and palpation and on the general condition
of the patient.
To determine the returning elasticity of the lung and the degree
of movability of its lower border, percussion is very useful during
the stage of absorption. After percussing out the lower border of
pulmonary resonance in the back, the patient is directed to take a
long breath and hold it. If the lung expands, the area of percus-
sion resonance will increase downward.
Percussion aids us in determining whether neighboring organs
are displaced by the pressure of the accumulated fluid. The liver
is often pushed down, the spleen verij rarely. Dislocation of the
heart is one of the most important of all the signs of pleural effu-
sion, and is often the crucial point in differential diagnosis. It is
a very striking and at first surprising fact that a left-sided effusion
displaces the heart far more than a right-sided effusion of the same
' This test, however, is somewhat fallacious and of very little diagnostic
value, since the lungs tend to swing up toward the back when the patient lies
prone, even when no fluid is present, and increase of resonance in the back with
this change of position might, therefore, occur when the dulness was due to
thickened pleui-a and not to fluid.
344 PHYSICAL DIAGXOSIS.
Bize. Small or moderate liglit-sided effusions often do not displace
the heart at all.
"With left-sided effusions, unless very small, we find the area of
cardiac duluess shifted toward tlie right and often projecting be-
yond the right edge of tlie sternum (^see Fig. IT.S). (Inspection and
palpation often give us even juore valuahlc Information on this
point. See below, p. 347.) We must be careful to distinguish such
an area of duluess at the right sternal margin from that which may
be produced in right-sided effusions by the fluid itself (see above).
As mentioned above, a right pleural effusion may very early
show itself as an area ot duluess along the right sternal margin.
Light percussion will usually demonstrate that this duluess is con-
tinuous with a narrow strip of flatness at the base of the axilla
(ninth and tenth ribsV Such an effusion is late in creeping up the
axilla. It appears first and disa]ipears first along the right margin
of the sternum.
On the sound side the ]iercussion resonance is often iiu'-reased,
owing to compeusatory hypertroiihy of the S(_)nnd lung; the dia-
phragm is pushed down and the borders of the heart or of the liver
may be eueroached ujion. "When the hyper-resonauce of the souiul
side is present, it should warn us to jiercuss lightly over the etfu-
sion, else we may bring out the resonance of the distended lung.
Siriiniii'iri/ of J'irri/.isinii. Si;/ii.'i. — (1) Flatness corresponding
roughly to the positioii of tlie fluid.
(2) Tympany above the level of the fl\iid o^■er the condensed
lirng.
(3) The le^'el of the fluid is seldom quite horizontal.
(4) Shifting of the fluid with change of position is rare, slow,
and has little or no importance in diagnosis.
E.rrejifioiis and I'oxsiJilf Errors. — {a') (xreat muscular pain and
spasm may produce an area of ilubiess which simulates that of
pleural effusions, especially as the auscultatory signs umy be equally
misleading. A hypodermic of morphine will dispel the duluess
along wdtli the pain if it is due to muscular cramp.
(6) If the lung on the affected side fails to retract (owmg to
DISEASES AFFECTING THE PLEURAL CAVITY. 345
emphysema or adhesions to the chest wall), the area of dulness and
its intensity will be much diminished.
(<■) It must be remembered that dulness in Traube's space may
be due to solidification of the lung, to situs inversus, to tumors, or to
overfilling of the stomach and intestine with food, as well as to
pleural effusion; also that the size of the tympanitic space varies
greatly in health.
(rf) Rarely percussion may be tympanitic over an effusion at
the left base owing to distention of the stomach or colon.
(e) The diagnosis between fluid and thickened pleura will be
considered later.
Aiismiltation.
The auscultatory phenomena vary greatly in different cases, and
in the same case at diffeient times, because the essential condi-
tions are subject to similar variations Wliatever sounds are pro-
duced in the lungs or in the bronehi maij be heard oner the fluid un-
less interfered with hy inflanimatory thieheninrj of the costal -pleura.
Fluid transmits sounds well, but there maybe no breath sounds pro-
duced and hence none audible over the fluid Or tubular sounds
only may be produced because only the bronchi remain open, the
rest of the lung being collapsed.
Or again, if rales or friction sounds are joroduced in the lung,
they, too, may be transmitted to the fluid and may (alas!) deter
the timid " observer " from tappmg.
In about two-thirds of all large effusions 7io breathing at all is
audible over the area of flatness on percussion. In the remaming
third, and especially in children, tubular breathing, sometimes
feeble, sometimes very intense, is to be heard
In moderate effusions there are often three zones in the back.
At the bottom we hear nothing, in the middle zone distant bron-
chial or broncho-vesicular breathing, while at the summit of the
chest the breathing is normal
The voice soimds correspond ^^1len breath sounds are absent,
the voice sounds are likewise absent When the breathing is tubu-
346 PHYSICAL DIAGXOSIS.
lar, the voice, and espt-cially the whit^per, is also tubidar ami iDten
silied. That is, ichcneccr the bronchi are open, the lung retraeted,
and the chest walls thin, the hreathing, roiee, and lehisper irill eorre-
Sjjond to the trarheal and hronehial goiinds. Since children have es-
pecially thin chest walls, these bronchial sonnds are especially fre-
quent and intense in chilcb-en.'
^ear the angle of the scapula and in a corresponding position
in front, the sound of the spoken voice may have a peculiar high-
pitched, nasal t'waug, to which the term egophony is a]i]>lied.
This sign has no importance in diagnosis, since it is not constant,
and not peculiar to fluid accunnilations
Eales are rarely produced in the retracted lung, and so are
rarely to be heard over the fluid.
All these sonnds may be dimmished or abolished if the costal
pleura is greatly thickened
The influence of cough upon the lung, and so upon the sounds
produced in it and transmitted through the fluid, nuiy be very great
and very puzzling Eales may appear or disappear, breathing
change in quality or intensity, and in the dift'erenti;rl diagnosis of
ditflcult cases the patient should always be made to cough and then
breathe deeply before the examination is completed.
In very large eflarsions, when only the primary bronchi are
open, there nuiy be signs like those of pulmonary cavity at the site
of the bronchi in front or behind (amphoric breathing, large metallic
rales, etc.). Over the sound lung the breathing is exaggerated and
extends miusuallv far down in the back and axilla, owing to hyper-
trophy of the lung.
The heart sounds may be absent at the apex owing to disloca-
tion of the heart. In hd't-sided eft'usions the apex sounds are often
loudest near tlie ensiforn> cartilage or beyond the right margin of
tlie sternum Eiglit-sidrd effusions liave mucli less eft'ect njion tlie
heart, but occasionally we find the lu'art sounds louih'st at tlie left
of the nipple or in the axilla
Since many cases of phnual effusion are due to tuberculosis, we
'Bacelh's theory — that the whispered voice is coudiicted through serum
but uot through pus — is not horue out by facts.
DISEASES AFFECTINQ THE PLEURAL CAVITY. 347
should never omit to seareli for evidences of this disease at the
apex of the king on tlie sniiiid side, since experience has shown that
phthisis is more apt to begin here than on the side of the effusion.
Sumviari/ of Aiiscultatori/ Siijns.
(1) In most cases voice and breath sounds are absent or very
feeble over the area occupied by the fluid.
(2) In a minority of the cases the breathing and voice sounds
may be tubular and intensified, especially hi children.
(3) Over the condensed lung at the siimmit of the chest the
breatliing is bronchial or broncho-vesicular, according to the degree
of condensation. If the amount of fluid is small, the layer of con-
densed lung occupies the middle zone of the eliest and the breath-
ing is normal at the top of the chest.
(4) Kales and friction sounds are rarely heard over fluid.
(5) On the sound side the breathing is exaggerated.
(6) The heart sounds may be absent at the apex and present in
the left axilla or to the right of the sternum owing to dislocation
of the heart.
Iiisj)('ctio)i and Palpation.
The most important information given us by inspection and
palpation relates to tlie displacement of various organs by the pres-
sure of the accumulated fluid. In left-sided pleuritic effusions the
heart is usually displaced considerably toward the right, even when
the level of the fluid reaches no higher than the sixth rib in the
nipple line. The impulse is then to he seen and felt to tlie riglit
of the sternum, somewhere between the third aiul the seventh rib,
when a large amount of fluid is present. With smaller effusions
one may find the apex beat lifting the sternum or close to its left
border. The position of the heart may be confirmed by percussion.
The spleen is scarcely ever displaced.
Right-sided effusions are far less likely to displace the heart, and
it is only when a large amount of fluid is present that the apex of
the heart is pushed outward beyond the nipple. Moderate right-
sided effusions often produce no dislocation of the heart whatever.
The liver is often considerably puslied down by a right-sided pleu-
348 PHYSICAL DIAONOIIS.
I'itic effusion, and its edge may be palpable several inches below the
costal margin. Its iqiper margin cannot be determined by percus-
sion, as it merges into tlie flatness jirodnced by the fluid accumula-
tion above it.
Iiictilf fri'iiiifiis is almost invariably absent or greatly dimin-
islied over the areas corresponding to the fluid; just above the level
of the fluid it is often increased.
Occasionally a slight fulness of the affected side may be recog-
nized by inspection, and the interspaces may be less readily visible
than upon the sound side. Bulging of the interspaces I liave never
observed. When the accumulation of fluid is large the respiratory
movements upon the affected side are somewhat diminished,' the
shoulder is raised, and the spine curved toward the affected side.
The diaphragm is depressed, and Litten's sign therefore absent.
There are no relialjle means for distinguishing purulent from
serous effusions. The wliispered voice may be transmitted through
either pus or serum. But we know that in children two-thirds of
all effusions are jiurulent, while in adults three-fourths of them are
serous.
Pln/slriil >SV;/«« Diiriiuj .Mignrpt'ion of J'/ciiriil Jiffiisiinis.
"When the fluid begins to disappear, either s}>outaneously or as
a result of treatment, the dulness very gradually disappears and
the breath sounds, ^'oice sounds, and fremitus reappear. In case
the heart has been dislocated, its leturn to its normal iiosition is
often much slower than one w(ju]d anticipate, and indeed all the
physical signs are disappointingly slow to (dear up even after tap-
ping. Pleural friction appears when the roughened pleural surfaces,
which have been held apart by the fluid, are allowed by the disap-
pearance of the latter to come into apposition again. Owing to pul-
monary atelectasis and ])ermanent thickening of the i)leura, con-
siderable dulness often remains for weeks after tlie fluid lias been
absorbed.
' I liave purpo.sely made but little of the chanses in the shape of the chest
produced by pleuritic effusiou.s, as it lias seemed to me that by far too much
stress has usually beeu laid upon such signs.
DISEASES AFFECTING THE PLEURAL CAVITY.
B49
Intvrlohur Empyeina.
In recent j^eavs the frequency and imjjortance of empyema lim-
ited to an interlobar tissure has become impressed upon many clin-
icians. I have seen both the post-pneumonic and the tuberculous
types. In most of the cases so far reported the pus has been de-
monstrated in the tissure which runs along the vertebral border of
CoTiipressed area.-^ of
hiiiff, t^howiiif; in-
tense t u b u 1 a r
breathing anil
whisper with dul-
ness.
Flatness.
Diniiiiisheil or absent
breathini;.
l>iniinishc<l (ir al)scnt
Fig. 1T4a.— Signs in Interlobar Empyema.
the scapula when that bone is pulled as far forward as possible by
crossing the arms in front (see Fig. 174a).
This is a region seldom carefully examined.
In the strip here indicated one finds flatness on percussion with
(usually) diminished fremitus, and feeble or absent breath-sounds.
X-ray examination may bring out in sharp relief a shadow corre-
sponding to this area and sharply contrasted with the relatively
normal lung al)ove and below it.
The exploring needle often fails to tind the pus, but the search
should not be given up (if the physical signs are clear) until a rib
has been excised and the region thoroughly explored under complete
anaesthesia.
^i.'ill PHYSICAL DIACXOSIS.
{(■) Tleukal Thickening.
In persons vrho have previously suffered from pleurisy with
effusion, and in many who have never to their knowledge had any
sueh trouble, a considerable thieki'uiug of the pleural membrane
with adiiesiou of the costal and visceral layers may be manifested
by the following signs:
(1) Jlulness on percussion, sometimes sliglit, sometimes marked.
(-) I'imiiiislu'd \esicular respiration.
(o) ^'oice sounds and tactile fremitus diminished or increased.
(4) Absence of Litten's phenomenon and diminution in the
normal respiratory excursion of the chest.
These signs are most apt to be found at the base of the lung
behind and in the axilla. Occasionally a similar thickening may
be demonstrated throughout the whole extent of the pleura, and the
lung failing to exi)and, the chest may fall in as a result of atmos-
pheric pressure (see Fig. 61).
The ribs approximate and may overlap, the spine becomes
curved, the shoulder lowered, the scapula in-ominent, and the whole
side shrunken. The heart may be drawn over toward the affected
side.
In the diagnosis of pleural thickening Eoseubach's "palpatory
puncture " is sometimes our only resource. Under antiseptic pre-
cautions a hollow needle is pushed between the ribs and into the
pleural cavity. As the needle forces its way thr<wgli the tough
fibrous, or perhaps calcified, pleura, the degr(>e and kind of resist-
ance are very enlightening. Again, the amount of mobility of the
point after the chest wall has been pierced tells us whether the
needle is free in a cavity, entangled in a nest of adhesions, or fixed
in a solid "carnified" lung. There is no danger if the needle is
sterile.
ENCArSULATED Plkuuai, Ekfusion.
Small accumulations of scrum or jnis may be walled off by ad-
hesions so that the fluid docs not gravitate to tho lowest part of
the pleural cavity or spread itself laterally as it would if free
DISEASES AFFECTING THE PLEURAL CAVITY. ;i51
Such localized effusions are most apt to be found in the lower axil-
lary regions or behind — sometimes between the base of the lung and
the diaphragm, and more often between the lobes of one of the
lungs or higher up, I have twice seen an encapsulated purulent
effusion so close to the left margin of the heart that the diagnosis
of pericardial effusion was made.
The diagnosis of encapsulated pleural effusion is a difficult one
and oftentimes cannot be made except by prmcture. The signs are
those of fluid in the pleura, but anomalously placed. Even punc-
ture may fail to clear up the difficulty, since the needle may pass
entirely througli the pouch of fluid and into some structure behind
so that no fluid is obtained.
Pulsating Pleukisv.
Under conditions not altogether understood the movements
transmitted by the heart to a pleural effusion (usually purulent)
may be visible externally as a circumscribed pulsating swelling near
the precordial region, or as a diffuse undulation of a considerable
portion of the chest wall. Sometimes this pulsation is visible be-
cause the fluid has worked its way out through the thoracic wall
and is covered only by the skin and subcutaneous tissues, but occa-
sionally pulsation in a pleural effusion becomes visible, although no
such perforation of the chest wall has occurred.
The condition is a rare one, and is of importance only because it
may be mistaken for an aneurism, from which, however, it should
be readily distinguished by the absence of a jialpable thrill or dias-
tolic shock and by the evidence of fluid in the pleura.
Differential Diagnosis of Pleukitio Effusion.
The following conditions are not infrequently mistaken for
pleuritic effusion :
(1) Croupous pneumonia with occlusion of the bronchi.
(2) Pleural thickening, with pulmonary atelectasis.
(3) Subdiaphragmatic abscess or abscess of the liver.
In croupous pneumonia with plugging of the bronchi one maj
352 PHYSICAL DIAGXOSIS.
have present all the pliysieal signs of pleuritic effusion iwci'pt dis-
pl<tcement of ihe nc'Kjlihorinij organs. The presence or absence of
such disijlacemeut, together ^rith the history, sj^mptoms, and course
of the case, is therefore our mainstay in distinguishing the two
diseases.
Froui orJiiiiirii croupous pueuuiouia (without occlusion of the
bronchi) pleuritic effusion differs in that it produces a greater de-
gree of duluess and a diminution of the spoken voice soimds and
ta<!tile fremitus. Bronchial breathing and bronchial "whisper may
be heard either over solid lung or o\-er fluid accumulation, although
the bronchial sounds are usually feeble and distant in the latter
condition. The displacement of the neighboring organs is of im-
portance here as in all diagnoses in which pleuritic effusion is a
possibility. In pleuritic effusion we can sometimes determine that
the line marking the upper limit of dulness shifts with change of
the patient's position. This is, of course, impossible in pnemuo-
nia. A few hard coughs may open up an occluded bronchus and
so clear up the diagnosis at once. In doubtful cases the patient
should always be made to cough and breathe deeply before the
examination is finished.
It should always be remembered that one may have both pneu-
monia and pleuritic effusion at the same time, and that pneumonia
is oftert followed by a purulent effusion. In childi-en the bronchi
are especially prone to become occluded even as a result of a simple
bronchitis, and we must their differentiate between atelectasis and
eiiusion — in the main by the use of the criteria just described.
(2) It is sometimes almost impossible to distinguish small fluid
accunrulations in the pleural ca-^-ity from pleural thickening with
pulmonary atelectasis. In both conditions one fiirds dulness, dimi-
nution of the voice sounds, respiration, and tactile fremitus, and
absence of Litten's phenomenon, but the tactile fremitus is usually
more diminished when fluid is present than in simple pleural thick-
ening and atelectasis. An area of dulness which shifts with change
of position points to pleuritic effusion. The presence of friction
soimds over the suspected area speaks strongly in favor of pleural
thickening, but it is possible to hear friction sounds over fluid,
DISEASES AFFECTING THE PLEURAL CAVITY.
.353
probably because they are conducted from a point higher up in the
chest at which no fluid is present. In doubtful cases the diagnosis
can and should be cleared up by imncture.
(3) In two cases I have known enlargement of the liver due to
multiple abscesses to be mistaken for empyema. In both condi-
tions, one finds in the right back dulness on percussion as high as
mid-scapula, with absence of voice sounds, breath sounds, and
fremitus. These conditions are due in one case to the presence of
fluid between the lung and the chest wall, and in the other case to
Fio. 175.— Area ot Dulness in Solitary (tropical) Abscess of the Liver.
the liver which pushes up the lung together with the diaphragm.
Without the fluoroscope or a good radiograph this diagnosis may be
impossible. With the fluoroscope it should be possible to see that
the dome of the diaphragm caps the shadow and moves down witli
it during inspiration. Some of the sj-mptoms, such as chills, sweat-
ing, and irregular fever, are common to both conditions. A careful
consideration of the history and the associated signs and symptouis
may help us to decide.
Large solitary abscess of the liver, occurring as it almost in-
variably does in the posterior portions of the right lobe, produces an
area of flatness on percussion, which rises to a much higher level in
23
354
PHYSICAL DIAGXOSIS.
the axilla and back than in front or near the sternum (see Fig. ITS),
and may be in this vraj distinguished from empj-ema; but when the
liver contains man}- small abscesses, as in suppurative cholangitis,
this peculiar line of duluess is not present.
((:I) Eare diseases, such as cancer or hj'datid of the lung, may
be mistaken for pleuritic effusion. Tlie history of the case and the
results of exploratory pimcture usually clear up the dilticulty.
Examination of E:riir]ati\<^ and Transudates.
Onl}- such methods as can be carried out without a thermostat
will be here described. Hence the examination of diphtlierui
swabs, blood cultures, and pus are excluded. We have left the
Fig. 17fi.— LTmphocytosis in Pleural Fluid. Prim.iry tuberoulous pleurisy. (X T50 diameters.)
(Mussrrave. 1
fluids obtained by tapping the pleura, the peritoneum, and the spinal
cord. The first is the most important.
r)/.sK.i8/-,vs AFFKCTixa nn: flkikal cAVirr. ooo
r!rin-<!l Fluids. — A tiuid witlulrawn from tho pleura by punet-
uro may bo a iuooha\ui\\l transudate ^hydvotlioiaxV may be evi-
dence of tuberculous }'!t-iirisi/ ypviuiaiy or associated with phthisis \
or. rarely, an exudate of septie ov eaueerous oiigiu.
To mvestiLjate thi'se thuds we note ;
1. (^e.'ev. Bloody tUiids suggest eaueer, but oeeasionally oeeur
in pneumonia and tubereulosis.
-. ir,'i_7';.'.' l">vo[>sieal thud is ceiuu-ally l>,\\^u- l.Olo in speeitie
Fill. 1".— lVlyniK-lo;ii^ Slid l;iiv>' I v-.;>pV,.v>i<s :n l".ti:ral Fhii.l fn^vA a Ca^k^ of Tniumaiic
Aouto ln(*-Iioas rU'iiris.) . i\ 7,V> diauu-UTS.i iMussravoO
gravity. Exudates ai-e usually in the vicinity of 1.0.0. An ordi-
uavv speeitie-gravity bulb is used.
;>. The Ct-iis <\T'ih(' Si-dinunt ^^eytodiaguosisV
Technique of C!/toJta;/iH>si.<. — 1. Fouv tluid into tubes of a cen-
trifuge and eontrifufivlize five minutes.
■J. l"'our oft" the supernatanr fluid and stir up the sediment with
' The amouiu of :\lbumin usu:Uly ruusparalloi with ihowoicht of the fluid.
556
PHYSICAL DIAGNOSIS.
a platinum loop, so as to suspend the sediment in the few remain-
ing drops.
3. Spread a drop of the mixture on a dean cover glass with the
platinum loop and let the smear dry without heating it.
i. Stain like a blood film (see below, page 471) with the follow-
FiG. 1T8.— Pleural Fluid in Hydrothorax Iiue to cardiac lii^ea^^e. Enilntlielial plaques and cells.
(X 750 diameters.) tMusgrave.)
ing mixture:' Wright's modification of Ijcishman's stain, ."> parts;
pure methyl alcohol, 1 part.
6. After staining, wash ver;/ gently, using a droi'per (else the
whole film ma}' be pushed off), and dr}' in tlu\p'nr/ers over a lUiu-
sen or alcoholic flame. Do not blot the preparation.
6. IMount in Canada balsam and examine with an oil-immersion
lens.
Interj^retation of Sesi/Its. — (a) In tiibcrcnloiis pleiirisi/, bjmpho-
' y\igge.sted by Musgravc: Boston Med. and Surg. Jouru., vol. cli., p. 319, 1904.
DISEASES AFFECTING THE PLEURAL CAVITY. 357
cijfes make up from seventy to ninety-nine per cent — usually over
ninety per cent — of all the cells found in the sraeari(see Fig. 176).
(/i) In septic cases due to the streptococcus, staphylococcus, or
pneumocoecus the majority of the cells are polynucleur leucocytes
(see Fig. 177).
(c) In transudations (dropsical) the predominating cell is a large
mononuclear type, apparently endothelial in origin and often occur-
ring in sheets or "plaques" (see Fig. 178).
Exceptions occasionally occur, but in the main these rules are
sufficiently exact to be of value in diagnosis when taken in connec-
tion with all the facts in the case.
In peritoneal Ji aid i\].% \\ii<i of cytodiagnosis has not as yet fur-
nished information of any considerable diagnostic value.
In cerebrospinal fluid obtained by lumbar puncture the predom-
inance of lymphocytes is not so often associated with tuberculosis as
it is in the jjleura, but usually means chronic cerebrospinal irrita-
tion such as is produced by dementia paralytica and tabes. An
excess of polynuclear cells is usually due to acute meningitis, —
epidemic or sporadic.
'This rule, howevtr, does not work lioth ways. Tuberculosis produces
lymphocytosis, but so do other chronic irritations. The lymphocytosis is a
mark of chrouicity and only suggests tuberculosis, but there are no other com-
mon causes for chronic pleural irritation.
CHAPTER XVII.
ABSCESS, GANGRENE, AND CANCER OF THE LUNG,
PULMONARY ATELECTASIS, (EDEMA, AND HYPO-
STATIC CONGESTION.
Abscess and Gangrene of the Lung.
I CONSIDER these two affections together because the physical
signs, exclusive of the sputa, do not differ materially in the two
affections. In some cases there may be no physical signs at all,
and the diagnosis is made from the character of sputa and from a
knowledge of the etiology and symptomatology of the case. In
other cases we find nothing more than a patch of coarse rales or a
small area of solidification, over which distant bronchial breathing,
with increased voice sound and fremitus, may be appreciated.
Rarely there may be slight dulness on percussion, but as a rule the
area is not sufficiently large or sufficiently superficial to produce
this. One may find the signs of cavity (amphoric breathing,
cracked-pot resonance, and gurgling rales), but this is unusual.
Gangrene of the lung is not a common disease. The diagnosis
usually rests altogether upon the smell and appearance of the sputa.
In fetid bronchitis one may have sputa of equal foulness, but the
odor is different. The finding of elastic tissue in the sputa proves
the existence of something more than bronchitis.
Pulmonary abscess, which, like gangrene, is a rare affection, is
often simulated by the breaking of an empyema into the lung and
the emptying of the pus through a bronchus. Large quantities of
pus are expectorated in such a condition, and abscess of the lung is
suggested, but the other physical signs are those of empyema and
should be easily recognized as such. The fLJidmg oi elastic fibres
is the crucial point in the diagnosis of intrapulmonary abscess.
360
PHYSICAL DIAGNOSIS.
whether due to the tubercle bacillus or to other organisms. Tuber-
culous abscess (cavity) is usually near the summit of the lung, and
other varieties of abscess are near the base, but often there are
no physical signs by which we can distinctly localize the process.
Malignant Disease of the Lung, Pleura, ob Chest Wall.
In its earlier stages this affection is often mistaken for empy-
ema or serous effusion in the pleural cavity, and indeed the physi-
cal signs may be due wholly to an acciiiiiiilatiou of fluid secondary
to tlie malignant growth within the lung. The rapid emaciation
of the patient and the rapid reaccumulation of a dark-brown bloody
fluid in the pleural cavity, after puncture, make us suspect malig-
nant disease, but in sarcoma there is usually no emaciation until
late in the course of the disease. The sputa rarely contain frag-
ments of tissue whose structure can be recognized as characteristic of
malignant disease. Secondarj- deposits in the supraclavicular glands
may suggest the diagnosis.
The thorax is usually somewhat asymmetrical. The affected
side may be either contracted or distended according to the nature
of the malignant growtli within; occasionally it is not deformed
at all. When the growth attacks only the lung tissue itself, leaving
the bronchi and mediastinum free, we get signs like those of pleu-
ral effusion (flatness, absent breathing, voice sounds, and tactile
fremitus).
If the disease begins in the bronchi, we may have a noisy dysp-
noea from stenosis of a bronchus, and a weakening of the respiratory
sounds normally to be heard over the trachea in front has several
times been noted. Percussion dulness, if present, is usually over
the upper portions of the chest, and may disappear and reappear
or skip from place to i^lace in a very irregular and confusing way.
Signs and symptoms of pressure in the mediastinum due to sec-
ondary involvement of the peribronchial glands may be present and
may simulate aneurism, or the growth may press directly upon the
brachial plexus, producing pain in the shoulder and arm.
ATELECTASIS. 361
Atelectasis.
(a) Areas of atelectasis or collapse of pulmonary tissue are
often present in connection with various pathological processes in
the lung (such as tuberculosis or lobular pneumonia), Ijut are usu-
ally too small to give rise to any characteristic physical signs;
nevertheless
(b) In most normal individuals a certain degree of atelectasis
of the margins of the lungs may be demonstrated in the following
way : The position of the margins of the lungs in the axillae, in the
back, or in the precordial region are marked out by percussion at the
end of expiration. The patient is then directed to take ten full
breaths, and the pulmonary outlines at the end of expiration are
then percussed out a second time. The pulmonary resonance will
now be found to extend nearly an inch beyond its former limits,
owing to the distention of i)reviously collapsed air vesicles.
If one auscults the suspected areas during the deep breaths
which are used to dispel the atelectasis, very fine rales are often
to be heard at the end of expiration, disappearing after a few
breaths in most cases, but sometimes audible as long as we choose
to listen to them. These sounds, to which Abranis has given the
name of "atelectatic crepitation," are in my experience especially
frequent at the base of either axilla. The same writer has noticed
an opacity to the a;-rays over such atelectatic areas.
Forcible percussion may be sufficient to distend small areas of
collapsed lung, or at any rate to dispel the dulness previously pres-
ent (see above, p. 136, the hing reflex).
(c) When one of the large bronchi is compressed (as by an
aneurism) or occluded by a foreign body, collapse of the corre-
sponding area of lung may be shown by diminished motion of the
affected side, dulness on percussion, and absence of breathing, voice
sounds, and tactile fremitus.
In new-born babies whose lungs do not fully expand at the tune
of birth, similar physical signs are present over the non-expanded
lobes. The right lung is especially apt to be affected
In the differential diagnosis of extensive pulmonary collapse,
362 PHYSICAL DIAONOSIS.
the etiology, the suddenness of the onset, the absence of fever and
of displacement of neighboring organs enable us to exclude pneu-
monia and pleuritic effusion. In distinguishing small areas of
solidification from similar areas of atelectasis, Abrams finds the
" lung-reflex " (see page 136) of value. Atelectatic areas expand
if the skin overlying them is irritated. Solidified areas show no
change.
(Edema of the Lungs.
In cardiac or renal disease one can often demonstrate that the
lungs have been invaded by transuded serum as a part of the gen-
eral dropsy. More rarely pulmonary oedema exists without much
evidence of oedema in other organs or tissues.
The only physical sign characteristic of this condition is the
presence of numerous rales in the dei^endent portions of the lungs;
that is, throughout their posterior surfaces when the patient has
been for some time hi a recumbent position ; or over the lower por-
tions of the axillae and the back if the patient has not taken to
his bed.
The rales are alway-s bilateral (unless the patient has been lying
for a long time on one side), and the individual bubbles appear to
be all of the same size, or nearly so, differing in this respect from
those to be heard in bronchitis. Squeaking or groaning sounds are
less often heard. The respiratory murmur is usually somewhat di-
minished in intensity.
Dulness on percussion and modification of voice sounds are not
present, unless hydrothorax or hyjiostatic pneumonia complicate
the oedema.
Hypostatic Pneumonia.
In long, debilitating illness, such as tyi^hoid fever, the alveoli
of the dependent portions of the lungs may become so engorged
with blood and alveolar cells as to be practically solidified. Under
these conditions examination of the posterior portions of the lungs
shows usually :
(a) Slight dulness on percussion reaching usually from the
HYPOSTATIC CONOESTION. 363
base to a point about one-third way up the scapula. At the very
base the dulness is less marked and becomes mixed with a shade of
tympany.
(i) Feeble or absent tactile fremitus.
(c) Dim.uiished or suppressed breathing and voice sounds.
The right lung is apt to be more extensively affected than
the left.
Occasionally the breathing is tubular and the voice sounds are in-
creased, making the physical signs identical with those of croupous
pneumonia, but as a rule the bronchi are as much engorged as the
alveoli to which they lead, and hence no breath sounds are pro-
duced.
Rales of cedema or of bronchitis may be present in the adjacent
parts of the lungs. The fact that the dulness is less marked at the
base of the lung than higher up helps to distinguish the condition
from hydrothorax.
The diagnosis is usually easy, owing to the presence of the un-
derlying disease. Fever, pain, and cough such as chai-acterize
croupous pneumonia are usually absent.
CHAPTER XYIII.
THE ABDOMEN IN GENERAL, THE BELLY WALLS,
PERITONEUM, OMENTUM, AND MESENTERY.
EXAMIXATIOX OF THE AbDOMEX IX GeXEEAL.
OuK methods are crude and inexact conijiared to those applica-
ble to the chest. Auscultation is of practically no use. Inspec-
tion is hel[)ful in but few cases. ]'alpation, our mainstay, is often
rendered almost impossible by thickness, muscular spasm, or ticklish-
ness of the abdominal walls. Percussion is of great value in some
cases, but j-ields no useful results in the majority.
Techii iijiic. — The knack of abdominal examination, and especially
that part of it whereby the skilled diagnostician gets his most val-
ued information, is difficult even to demonstrate and almost impos-
sible to describe. Hence the account of it in this and other books
is very brief when compared with the space allotted to the methods
of examining the chest.'
The table or bed on which the patient lies during most abdomi-
nal examinations (excluding g3'na3cological work) should be at least
three feet In'ijJi, narrow, and Jinn. jMost beds are too lon% too
wide, and too soft ; but, on the other hand, the piatient must not be
made uncomfortable by the hardness or coldness of the surface on
which he lies. A comfortable pillow should be provided.
' I have heard a physician in a leading American city say tliat when pal-
pation of the spleen in typlioid fever was lirst introduced, tliere was but one
physician in tlie city wlio had the knarli, and that Ins colk^agucs were very
sceptical about the possibility of acconi|ilishing the feat at all. I have seen a
similar uncertainty regarding tlie palpation uf the normal but slightly dis-
placed right kidney.
THE ABDOMEN IN GENERAL. 365
Inspection. — We need a tangential light, such as accentuates
by shadows every uiievenness of the svirface. If the patient is ex-
amined in the ordinary dorsal decubitus, the liglit from any single
window, except one oveiiiead, is satisfactory. If one inspects the
abdomen with the patient upright, he should stand with his side to
the light, not facing it. By inspection we seek information on:
(a) The general contour of the abdomen.
(b) The surface of the belly walls, especially the skin and the
navel.
(c) Respiratory movements, their limitation or absence.
(d) Peristaltic movements (gastric or intestinal in origin).
(e) The presence of local pronunence or (rarely) depression.
Insjjection oftJie Bellij Wall. — 1. The surface of tliehelly wall is
often searclied most carefully for the rosu spots of typhoid fever,
which are hyperajniic, very slightly elevated spots, about the diam-
eter of a large pin head (2-4 mm.). They disappear on pressure.
Pimples are usually larger, better defined at the edges, and more
highly colored, contrasting with the very pale red of most rose
spots. Tliey are by no means confined to the belly and may be
found exclusively on the back. Having been at tlie outset some-
what sceptical of their value in diagnosis, I have become thoroughly
convinced by greater experience and more careful examination.
The spots are present in about three-fourths of all cases, and, while
they. also may occur in any disease when tlie blood contains bacteria
{e.g., sepsis), they are commonest in typhoid.
2. Distended and tortuous veins on the abdomen are seen in dis-
eases obstructing the portal circulation (rarely in cirrliotic liver) or
the inferior cava (see Fig. 60).
.3. Strife, or linear markings on the skin of the abdomen, follow
any long-standing trouble that stretches the skin — pregnancy, obes-
ity, tumors, etc. They are red when first produced, but later
turn white (lineoi alhicantes).
4. Scars of old wounds or operations may be of great diagnostic
value in comatose or delirious cases.
5. Projection or levellijig of the normal depression at the navel
is evidence of distention within the belly.
ob6 PHYSICAL PIAGXOSIS.
i?('*/)i'm^_)ry movements of the belly walls are limited or cease in
painful diseases within the peritoneum (^peritonitis, lead colic) or
when the diaphragm is pushed up by a large tumor, ascites, or mete-
orism.
T'ti-istoltir ir'tfi's creeping along beneath the belly walls are
seen with chronic stenosis and obstruction at the pylorus or at some
point in the colon and occasionally iu thin but healthy persons.
Hfrni'i and local and general prominences will be discussed iu
connection with abdominal tumors Qxige olO).
Palpatiox.' — With the patient on the back upon a suitable bed
or table," the head on a comfortable pillow, and the abdomen ex
posed, run the palm of the hand (warm) lightly over the whole sur-
face, to accustom the muscles to its presence. Then try whether
better relaxation of the belly walls is obtained when the patient's
knees are drawn up. Some patients relax better in this position ;
others when the legs are extended.
If the muscles of the abdomen remain contracted and stiff even
when the patient is comfortable and has become accustomed to the
presence of the physician's hand, we may try to induce relaxation:
(n) By getting the patient to take a series of deep breaths.
(/)) By diverting his attention through conversation or other-
wise.
If these means fail and it is important that we should thoroughly
investigate the abdomen, we have left two further ways of produc-
ing relaxation, viz. :
i^c') By putting the patient into a warm bath.
((f) By anesthesia (ether or chloroform).
The movements of the physician's hand should never be sudden
or rough. He should avoid digging into the skin with his nails or
pressing strongly on a small spot with the tinger-tips. If any spot
' Special methods of palpating a diseased kidney, spleou. or liver are de-
scribed in the sections on those organs,
* It is essential that the physician as well as the patient should he comfort-
able during an abdominal examination, else his attention is not whoUj' on his
work. Hence the importance of a high, narrow bed, or table, so that the
physician need not stretch or stoop to reach the patient.
THE ABDOMEN IN GENERAL. 367
be suspected to be tender, that should be palpated last, after going
over the rest of the abdomen. If it is necessary to make deep
pressure at any point, it is best to lay the fingers of the left hand
loosely over the spot and then exert pressure upon them with the
fingers of the right hand. The passive hand is more sensitive. To
reach a deep spot, put the hands in this position over it, ask the
patient to take a long breath, and, as the belly falls in expiration,
follow it down with the hands. Then hold what you have gained,
and with the next full expiration you may be able to get in still
deeper, until after a series of deej) breaths the desired spot is
reached. Naturally this cannot be done if there is much tender-
ness, but pure nervous spasm may sometimes be overcome in this
way.
To make use of the relaxation secured by a hot batli, we need
an unusually long tub, so that the patient can lie almost flat when
his knees are sVujhtli/ drawn up. If he is doubled up with his
knees and head in close proximity, nothing can be accomplished.
The patient gets into the tub with the water comfortably warm, and
its temperature is then raised to between 110° and 120° F. by pour-
ing in very hot water. The greatest relaxation is usually attained
after about ten minutes' immersion.
This method is far less inconvenient than etherization and is
especially valuable when the recti are well developed and form
rounded, tumor-like masses as soon as ordinary palpation is at-
tempted. If we suspect that a tumor-like mass may be one of the
bellies of the rectus, it is well to grasp the mass with the hand and
then ask the patient to raise his head. The mass will harden sud-
denly if it is the rectus.
What call he Felt Beneath the Normal Abdominal Walls.
No part of the normal intestine, including the appendix, can,
in my opinion, be felt through the abdominal walls. The same is
true of the stomach, spleen, left kidney, pancreas,' bladder, and
' Leube believes that in very tliin subjects the head of the pancreas may
occasionally be felt.
36S PTn'S[(\{L niAaxnsis.
pelvic organs. All that -we can make out in most normal cases
is:
1. The abdominal aorta.
2. The spinal column, near and above the umbilicus.
o. Fart of the liver (occusioualh', if the costal angle is sharp and
the belly walls are thin and lax).
4. The tip of the right kidney i^in many young persons).
5. Gurgling and splashing in the stomach or colon.
The aorta is too deep to be felt at all in some persons, but, on
the other hand, it is astonishing liow close under the belly wall it is
in others, ('.r.,iu those whose dorsal spine projects sliarpl}' for-
ward. Tn such persons the aorta may be almost taken in the hand,
and its course, calibre, and motions are so startliugly evident that
it is often mistakenly sujiposed to be the seat of an aneurism (see
above, page -SO), especially as a systolic murmur and thrill can be
appreciated over it if a little pressure is exerted, so as to produce
an artificial stenosis.
Behind and beside the aorta we can sometimes feel the bodies of
the vertebra?, and on them trace the division of the aorta into the
common iliacs.
The liver cannot be felt at all in the great majority of normal
persons, but occasionally the costal angle is so sharp that a small
portion of the organ is palpable in the epigastric region.
Bimanually (see below, page 417) the tip of the normal right
kidney may often be caught between the hands at the end of a
long inspiration, especially in young, thin people with lax belly
walls.
If the stomach or colon contains fluids, the paljiating hand often
elicits sounds corresponding to the movement of these fluids. Their
only importance in diagnosis will be mentioned on page 378.
The ilio-psoas muscle can occasionally be felt deep in the iliac
region.
Very deceptive often are muscular bundles in the external
obli(pie, which seem distinguishable as sausage-shaped tumors, and
doubtless give rise to some of the legends about feeling the nor-
mal appendix.
THE ABDOMEN IN GENERAL.
369
Palpahle Lesion of the Ih'Hy Walls.
The occurrence of lesions, to lie recognized niainl}- b}' inspection
and percussion, lias been discussed (page 365). Besides these we
search for :
1. Hernia-, epigastric or vmliilieal (see Fig. 179). The diagnosis
rests on tlie i>resence of an impulse on coughing, with or witliout a
reducible tumor. Omental hernias do not bulge with cough.
2. Separation of the Ilecti. — When tlie patient, lying on the
back, lifts his head and shoulders, a longitudinal wedge bulges out
Fig. 179. — Epiirastric Hernia.
along the median line of the belly from the gastric to the suprapu-
bic region.
3. Abscess of the abdominal walls usually represents a stitch ab-
scess or the external vent of pus burrowing from the ap)pendix, the
pelvis, or the prevesical sp)ace. But in about one-third of the
cases no such cause can be found. An infected hsematoma due to
trauma or without known cause explains some cases, and occasion-
ally tuberculosis or actinomycosis ocoirs. Tlie latter conditions
are recognized by the microscopic examination of the pus and of the
abscess wall.
4. Sarcoma of the belly wall is rather rare, and can be recog-
nized with certainty only by microscopic examination; without this
I have known it to be confused with lipoma and with tuberculoiii.
24
370 PHYSICAL DIAGNOSIS.
5. TJiirkciihuj nr injlamination at the nai-el occurs in some cases
of cancerous or tuberculous peritonitis. The diagnosis rests on the
further evidence of cancer or tuberculosis within the peritoneal cav-
ity and on the microscopic examination of a piece excised for the
purpose.
Palpation of the Spleen (see page 413).
Palpation of the Liver (see page 388).
Palpation of the Kidney (see page 417).
Studij of AbdiDHUKiI Tumors.
One should notice ; Size, contour, roiiiiistciirt/, ntotiUifij irith press-
tire and with respirafinu, tenderness, j^n/satioii, peritonea/ crepitus,
adherence to the skin or to the abdominal wall, relationsliip to any
abdominal organ (also dulness or resonance on percussion, see below,
page 372).
Most of these points need no comment. To ascertain whether
the tumor involves the skin, one lifts up a fold of skin crossuig the
mass. If the skin dimples markedly over the tumor, i.e., fails to
rise at that point while on all sides of the mass it can easily be
picked up, the skin is adherent. Tumors in the abdominal wall
can usually be gathered up along with the latter when we grasp a
large fold with both liands.
To determine the relationship of a tumor with the liver or spleen
we note :
(«) \Miether a groove or interval can be made out, by palpation
or percussion, between the mass and either of those organs.
(?)) Whether its respiratory mobility is as great as theirs.
(e) Whether there are other facts in the case suggestive of he-
patic or splenic disease (jaundice, ascites, leuktemic blood).
(d) The effect of inflation of the colon (see below). Tumors
connected with the spleen are forced forward and do not become
resonant when the colon is inflated.
To determine the degree of respirator)/ niobilitij, hold the fingers
of one hand in contact with the lower edge of the mass and allow
them to descend with it while the patient takes a full breath. To
THE ABDOMEN IN GENERAL. 371
make sure that an actual descent occurs, one must sight the mass
(and the hand) against some motionless object in the room beyond,
else one may be deceived by the movement of the abdominal walls
over the tumor, while tlie tumor itself remains motionless or nearly
so. Tumors connected with the liver or spleen move about two
inches witli a forced inspiration. Kidney tumors move less, seldom
as much as an inch. Pancreatic and retroperitoneal tumors have
scarcely any mobility. Those connected with the intestine vary
considerably in respiratory mobility, according to the presence and
degree of adherence to other parts, but their excursion is rarely an
inch.
Peritoneal crtqjitns is a grating, rubbing sensation experienced
on light palpation, and due — supposedly — to the presence of a
plastic, peritoneal exudate similar to that which produces the
friction sounds in pericarditis. Over an enlarged spleen {e.g., in
leukaemia) peritoneal crepitus may be due to local perisplenitis, and
in perigastritis, perihepatitis, and perienteritis similar crepitus
occurs.
Dlpinng refers to a sudden displacement of the abdominal wall
and whatever lies close beneath it, by a swift poke of the finger
tips, which may succeed thereby in touching a solid organ or tumor
which gentle, gradual palpation misses. Thus one may reach and
mark out an enlarged liver through a layer of ascites which would
prevent ordinary j^alpation.
Percussion. — Abdominal percussion is less valuable than tho-
racic. A lighter blow is used, and the distinction between dulness
and tympany is easy. It is of value chiefly to determine the j^res-
ence of fluid free in the peritoneal cavity, and to ascertain whether
a tumor is due to or covered by gaseous distention.
(ft) Free fluid (ascites, peritonitis, hsemoperitoneum, ruptured
cyst) gravitates to the flanks and suprapubic region, while the hi-
testines float up and occupy the epigastric and umbilical space.
Hence there is dulness in the flanks and over the pubes, with reso-
nance in the epigastric and umbilical regions. But the crucial and
ever-necessary test is the shifting of this area of dulness whew the
patient turns on his side ; then the uppermost flank should become
■■"- PHYSICAL DIAGNOSIS.
resoiiaut aiul tlie lower lialf of the belly — iiicliuliiig part of tlie
umbilical i-egiou — dull. Without this test the mere marking out of
(lull areas iu the flanks is not conclusive e\i(.lence of free fluid there.
Still less reliable is the ■'fluctuation wave," which can be trans-
mitted as an impulse jialpable to the hand laid flat on one flank,
bj' sharply snapping the otlier flank. Similar imptilses can be trans-
mitted through the fat of the liell}' wall, despite all efforts to check
them by pressure upon the hitter.
(/') Percussion is our iinal test in the diagnostic procedure that
begins with Intintioii of tlic cnlnii. Air is fm-ced into the rectum
with an ordinary' Davidson syringe, and, as the cidon becomes
prominent and hyperresonant, we note whether its tympany covers
up the tumor-nu^ss under investigation or whether the mass lies an-
terior to and remains dull over the inflated colon. Kidney tumors
lie behind the inflated colon ; splenic tumors reuuiin dull in front
of it.
Aiisculfafori/ j'lercii.'^.^iiDi. for identification or demarkation of ab-
dominal tumors and organs, has never been successful in my hands
nor in those of most of the observers in whose results I have confi-
dence. Hence I omit further descripitiou of it.
Percussion of the stoinocjt und sji/ccn (see below, pages o80 and
412).
Percussion of Tr<7iihr's seiniliiniir ii/)nj-ic(nific sjiace (the small
area bounded on the right by the splenic and on the left by the he-
patic dulness, above by the free edge of the left lung, and below by
the lower edge of the ribs) is, in my experience, of very little value
in diagnosis. This tymiianitic area is obliterated in many pleuritic
effusions (not in all), but many other causes (full stomach or gut,
obese omentum) may produce similar dulness.
DiSEASKS OF THE PERITONEI
1. Peritonitis — local or general.
2. Ascites.
3. Cancer and tuberculosis.
THE ABDOMEN IN GENERAL. 373
/. Peritonitis.
1. Local jierifonitis gives evidence of its presence by (a) pain,
(h) tenderness, (c) muscular spasm, ((/) tumor, and ( e) constitu-
tional manifestations.
The pdiii may be at first diffuse, later localizing itself at the site
of the lesion ; or it may be felt first wliere the peritonitis begins and
spread with the lesion if the general peritoneal cavity become in-
volved. The character and intensity of the pain vary greatly.
Tenderness is the important sign in diagnosis, and helps us to
exclude the various colics and other causes of pain which are often
relieved by pressure.
Local musculi(r spasm of the belly muscles to guard the tender
lesion beneath is of great value in jiointing our attention to the spot
affected, tliougii the muscles may be so rigid as to prevent palpa-
tion through them. \_Pso(is spasm is described in the section on
appendicitis, see page 402.]
The tumor is apt to consist of intestine or other organs matted
together by adhesions about the site of tlie process.
The constitutional manifestations are those of infection, viz.,
fever, leucocytosis, anorexia, constipation, often albuminuria and
albumosuria.
The commonest causes of local peritonitis are :
1. Appendicitis.
2. Pus tube.
3. Gall-bladder inflammation.
Less common is cancer or ulcer of the stomach or intestine.
2. General Peritonitis. — The belly may be generally swollen and
tympanitic or retraciecl and hard. General tend crii ess is the most
important sign. In advanced o&ses free f^i id in tJie flanks may be
demonstrated, as explained on page 371. Faeces and even gas cease
to move, as the intestines are paralyzed. Vomiting is the rule, and
soon becomes very foul (stercoraceous). There is fever, with a
rapid and very weak pulse. The mind is clear, alert. The facial
expression is not peculiar and may be normal. If there is persis-
374
PHYSICAL DIAGXOSIS.
teut vomiting the faeies of that condition aiijiears, viz., a drawn,
pinched, anxious loolv, witli dark circles under tlie eves. The nau-
sea and the rapid loss of fluid liy vomiting account for these ap-
pearances.
The leucocyte count is generally elevated, but in the most,
virulent cases remains normal or sub-
normal.
//. Jsrites.
Tlie commonest causes are :
(1) Portal stasis, usually from cir-
rhosis of the liver.
[-) DrojiS}', from cardiac, pericar-
dial, or renal disease.
(3) Tul)erculous peritonitis.
(4) Anffimia.
(5) Cancer of the peritoneum.
(<i) Solid ovarian tumors.
The methods of diagnosis of ascites
have been explained above. The diag-
nosis of its cause depends on tlie his-
tory, the results of puncture, and the
general physical examination. The contour of the belly is often
that pictured in Fig. ISO.
///. Cancer and TuhcfCiiIosls offjir Pri-itoiieu»l.
In connection with cancer or tulierculosis of some abdominal or
pelvic organ, the disease may become spread throughout the perito-
neum with deposits in the omentum and mesenter}-. The signs
are : 1. Tumor masses scattered here and there, sometimes at the
navel. 2. Ascites. 3. Enurciation and anaemia.
The diagnosis of cancer depends on the recognition of multiple,
hard, nodular tumors in the abdomen of a patient known to have
cancer of some al)dominal organ.
Somewhat similar masses, usually due to loops of intestine
ISO.— Characteristic Shape of
Belly in Ascites.
THE ABDOMEN IN GENERAL. 375
matted together by adhesions, may be felt in tuhemdotis peritonitis,
but here they are larger, fewer, and not so hard. Cancer appears
in late life, tuberculous peritonitis usually in early life. The ema-
ciation and anaemia are less marked in tuberculosis, aud fever is
more marked. The history or present evidence of tuberculosis else-
where— lung, pleura, glands, pelvis, testis- — favors the diagnosis of
tuberculous peritonitis. Cytodiagnosis and the tuberculin test may
be of value in diagnosis.
The Mesentery.
1. Enlarged glands — tuberculous, cancerous, or as part of
Hodgkin's disease — can occasionally be felt in very thin patients.
Their recognition as glands would depend on more obvious evidence
of their cause in other parts of the body.
2. Mesenteric thrombosis produces all the signs of intestinal ob-
struction (see below, page 403), from which it can rarely if ever be
distinguished without operation or autopsy.
CHAPTHli XIX.
THE STO>rA('H, LIVER, AXO I'AXCKEAS.
Thk Stumach.
The best metlioJs of examining the stdinnch are :
1. Inspection and iialpation of the eiMgastruun and the neigh-
boring portions of the alulonien.
'2 Estimation of tlie si/e anil position of the organ after dis-
tending it with air or watei.
3. Examination of the stomach contents : ((f) fasting ; (/'Rafter
a test meal.
By combining the results of these three methods of examination
Avitli the results of our general examination of the body — enutcia-
tion, anaemia, etc. — and with the data obtained by a careful history,
we obtain all the information about the stomach which it is possible
for us to make use of at the piresent time.
1. Ii!sj^ci:fii)ii niiiJ PaljiaticDi oftlir J\pii/iu<friii»i.
t^ii) Tri>(Iri-ii(:<.<s. — The noruud stonmcli cannot be seen or felt,
nor can anything certain be learned in regard to it by percussion or
auscultation. Tenderness in tlie epigastrium is so common that we
can attach no significance to it unless it is extreme and sharply lo-
calized in a small area. Extreme localized tenderness is of a cer-
tain amount of value in connection with the diagnosis of gastric
ulcer, but is by no means jiathognoiuonii" of it. In a small propor-
tion of cases cutaneous tenderness in the back (lower dorsal or
up[)er luudiar region) can be elu'itcd in cases of gastric uh'cr.
THE STOMACH, LIVER, AND PANCREAS.
377
(b) A tumor in the epigastrium (see Fig. 181) is of far greater
importance tlian any other local evidence. If it occurs in an emaci-
ated and anaemic person past middle life, is hard and nodular, and
docs not disappear after catharsis, it is almost invariably due to
cancer of the stomach. In a young person such a tumor may be
due to a mass of adhesions about a gastric ulcer. Tumors of the
pancreas much less often reach the surface in this region ; tumors
of the liver are generally larger, and their connection with this or-
Fia. 181.— Epigastric Tumor in Gastric Cancer.
gan can generally be demonstrated by percussion, palpation, and
by their greater respiratory mobility when compared with gastric
cancer.
Epigastric hernia usually shows an impulse on (;oughing, is soft
and dough}' iu feel, and presents none of the other symptoms and
signs of gastric cancer.
Tubercular deposits iu the omentum are almost always associ-
ated with ascites, fever, and other evidences of tuberculosis either
in the examination of other organs or in the history.
(/■) J'isil)Ie gastric peristalsis means stenosis of the p3dorus (can-
cer, cicatrix, adhesions, simple thickening, or muscular spasm).
The contraction wave passes from left to right across the epigas-
trium, and is seen by means of the shadow cast by a tangential
light with the patient in a recumbent position. If the peristalsis
37S
PHYSICAL DIAOXOSIS.
stops it can sometimes be reexcited by briskly snapping the epigas-
tric region witli tlie finger.
(</) Tlie nonuid sjj/iish sound can usually be heard if sudden,
quick pressure is made in the epigastrium within three hours after
a meal. If splashing can be elicited more than three hours after a
meal, and espieeially if it is
present before breakfast, it is
evidence of gastric stasis and
usuall}^ of dilatation.
(<') Hi/pogastric liulijing due
to dilated stomaeli is occasion-
ally seen in cases of marked
dilatation when the patient
stands up, and is examined in
profile (see Fig. 182).
Fig. 183.-
-Outline of Abdomen in Dilatation of
tlie Stoiuacti.
2. EstiiiKitlon of tlie Size, Posi-
tion, Secretonj <tnd Motor
Poirer of the StomaeJi.
Whenever we cannot arrive
at a satisfactory diagnosis by
means of the above methods of
external examination w h e n
taken in connection with the
historj' and the general condi-
tion of nutrition, we must undertake a more direct investigation of
the organ, which begins with (o) the jiassm/i' of tlie sfoiinie/i tube.
The standard red rubber tube generally in use in this country
comes in two sizes. Personallj- I prefer the larger, with a lateral
as well as a terminal opening at tlie lower end, although the smaller
size produces somewhat less discomfort. The patient should be
covered by a rubber sheet and the clothing removed from his abdo-
men. So p)repared, he sluiuld sit in a straight-backed, wooden
chair, with a good-sized foot-tub between his feet and a towel in
THE STOMACH, LIVER, AND PANCREAS. 379
bis hand ready to wipe away the profuse secretions of the mouth
and pharynx. He shoukl then be warned that the process of pass-
ing a tube, although entirely free from danger, is very disagreeable,
both on account of tlie nausea which it produces and because it
often seems to the patient as if he were choking and could not get
his breath. This, in fact, is not the case, and if the jjatient will
persist in drawing long, deejj breaths tliroughout the process of
passing a tube, the worst of it is over in twenty seconds.
The tube is moistened witli water and pushed straight down
through the pharynx without any attempt to direct it, beyond keep-
ing the median line. There is no danger of entering the trachea
and no use in trying to avoid it. On its way down the tube is ar-
rested now and then by muscular spasm of the oesophagus, but after
a few seconds tlie spasm relaxes and allows us to imah the tube on
until the twenty-two-inch mark reaches the teeth. The lower end
of the tube is then in the stomach,' and we are ready to extract the
gastric contents (in case a test meal has been jireviously given), to
wash out the organ, or to distend it with air or water.
(I)) Extracting the Gastric Contents. — One hour after a test
meal " the tube is passed and the patient is then asked to lean for-
ward, press with his hands upon his stomach, and strain down as
if he were going to have a movement of the bowels. In most cases
this suffices to force the gastric contents out througli the tube and
into a basin, which is held ready. If the gastric contents cannot
be extracted either iu this way by having the patient lie down or by
moving the tube in the pharynx so as to excite nausea, we should
make sure first that the eye of the tube is not plugged. This may
be ascertained by disconnecting the funnel ajid blowing through the
tube, which usually suffices to discliarge any obstacle from the e3'e
of the tube. If still the gastric contents do not flow out, we may
use suction by connecting a Politzer air-bag with the end of the
tube in place of the funnel.
' Unless there is gastric dilatation or gastroptosis; then the tube must be
pushed In several Inches farther, the distance depending on the position of the
lower gastric border, as determined in previous examinations.
' A slice of bread and a glass and a halt of water is a good test meal.
3S0 PHYSICAL DIAGXOSIS.
For the analysis of the contents so obtained, see below, page
379.
(c) I>isti'>idi/iij the Sfoiiinc/i. — ^^'e may use either air or water.
The first is more comfortable, the second rather more accurate. To
distend the stomach tcit/i dir, disconnect the funnel and attach a
Davidson sj'ringe. Then have the patient — still with the tube in
his stomach — lie down upon a lied with the abdomen exposed, and
pump air rapidhj in with the Davidson syringe. The rapid entrance
of air causes a reflex closure of the jiylorus and allows irs to distend
the stomach. ^Yhile an assistant ]iumps in the air, we inspect and
percuss the epigastric region, «'liicli soon begins to bulge out and
assume on percussion a t3'm}ianitic note differing clearly in pitch
and qualitj' from that obtained in other portions of the abdomen.
After a certain amount of air has been pumped in, the lower border
of the stomach ( as sliown by percussion") ceases to descend, and
about this time tlie patient begins either to complain of pain or to
belcli up wind around the tube, showing tliat the organ is fully dis-
tended. We then mark upon the abdominal wall the position of the
lower border of the stomach, and if possible of the upper, which
can usually be obtained by percussion.
Posith'Di oft/ic Js'nniiiil Sti'iDididi. — The lower border of the nor-
mal stomach after air distention rarely descends below the level of
the umbilicus; hence any stonmch whose lower border descends
lower than this should be considered dilated, provided that the
upper border is approximately in the normal situation. If the up-
per border is lowered as much as the fundus, we are probably deal-
ing witli a case of [/nntrojifusis or dropping of the whole organ.
To dlf:tt'iHl the stomach ii-it/i ir<itci\ we simply pour it in
through the funnel until the i>atient coniidains of decided discom-
f(n't and fulness. AVe then note the amount poured in, let the fun-
nel emjit}- into,'^. large foot-tub on the floor, allow the water to si}>hon
out, and measure the amount so olitained. The normal stomach
will hold about l,r)0(!) c.c. (or three pints). Anything over this
amount is pathological. A ditficulty of the method of distention
by water is that it is sometimes im})Ossible to get out of the stom-
ach all of the water that we have put into it, whereas with disten-
THE STOMACH, LIVER, AND PANCREAS. 381
tioa with air there is no difficulty in forcing out the air through
and around the tube by pressure ou the epigastrium.
(d) Washing the Stomach {Lavage). — Though not of much use
in diagnosis, this procedure may be briefly mentioned here. After
introducing the tube as above described, about a pint of water is
poured in through the funnel, and, just before the water disappears in
the vortex of the funnel, the latter is rapidly lowered so as to empty
by siphonage into a vessel on the floor. This ])rocess is repeated
until food and mucus cease to come out and the water runs clear.
To remove the tube at the end of any of the procedures just de-
scribed, we have only to pinch it tightly just outside of the pa-
tient's teeth and pull it rapidly out.
3. Examination of Gastric C(mtents.
1. The contents of the fasting stomach are best obtained by pass-
ing the tube before breakfast, and should consist of no more than a
few cubic centimetres of clear fluid containing free hydrochloric acid.
If any food is i^resent, gastric stasis is proven. If morj than 60
c.c. of fluid without food are present, hypersecretion is indicated.
2. Gastric Contents after a, Test Meal. — The best test meal is
that of Ewald, and consists of a slice of bread (or its equivalent in
crackers or cereal) with a glass and a half of water. After this
meal not more than 100 c.c. should be found in tlie stomach at the
end of an hour. Occasionally the stomach has emptied itself even
within the hour, and we have then to reduce the period.
After extracting the gastric contents as above described and
noting the quantity, we should investigate also their color, odor,
and general ajjpearance. (a) Small streaks of blood are of no con-
sequence. Considerable quantities of blood (fresh) suggest ulcer.
Small quantities of dark-brown substance resembling blood should
be investigated by the guaiac test. If this is positive, gastric can-
cer is suggested.
The giiaiac test is best performed as follows : Cliip off the oxi-
dized outer shell of a lump of gum guaiac and prepare a fi'esh tinc-
ture hj shaking a few chips of the inner non-oxidized guaiac with a
few cubic centimetres of alcohol. Add about 10 drops of this tine-
382 PHYSICAL DIAGNOSIS.
ture aud 2 c.c. of hydrogen peroxide to an ethereal sohition of the
gastric contents prepared by extracting 10 c.c. of gastric contents
with 2 c.c. of ghicial acetic acid and 15 c.c. of ether (shake 5 niin-
ntes). On aihling the guaiac to the ethereal solution of gastric
contents a h/xe culur indicates the prmence of lilood.
(6) For acetic and butyric acids we test merely by our sense of
smell. Whenever stasis or fermentation has occurred, we are apt
to get a characteristic odor of these acids mingled with that of yeast.
(c) The general appearance of the contents tells us little that is
important. In cases of marked dilatation they often separate into
three layers — tlie upper frothy, the middle a thin, turbid liquid,
and the lower a flocculent sediment of partially digested food.
Mucus is not of any considerable clinical significance unless it
is so abundant that the whole stomacli contents will slide in one
lump from one beaker to another.
When absolutely no digestion has taken place, as in the rare
cases of achylia gastrica, the contents consist simply of unaltered
bread and water.
Chemical Tests of Gastric Contents.
1. Dip a jjiece of blue litmus in the contents ; if no reddening
occurs, no further tests need be made.
2. If the contents are acid to litmus, test with Gunzhurg' s re-
agent (phloroglucin, 2 gm. ; vanillin, 1 gni. ; alcohol, 30 gm.), by
mixing two drops of it with an equal amount of gastric contents (un-
tiltered) upon a white porcelain plate or dish, and evaporating slowly
over a flame.' If free HCl is present, a bright rose pink appears.
In the absence of free HCl, the color is a dirty yellowish-brown.
If this test is positive, we need make no further tests except the
following :
Quantitative Estimation of Free HCl and of Total Acidity.
To 10 c.c. of unfiltered gastric contents add four drops (about)
of Topfer's reagent (dimethyl-amido-azo-benzol : 0.5 per cent alco-
' The same test may be performed on a glass slide which is subsequently
put upon a piece of white paper to bring out the color.
THE STOMACH, LIVER, AND PANCREAS. 383
holic solution) in a beaker; a carmine-red color results. Fill a
graduated burette with decinormal NaOH solution, and let it run
out into the beaker, a few drops at a time, until the carmine-red
color disappears. While titrating stir the mixture constantly with
a glass rod. Note the number of cubic centimetres of NaOH that
have run out.'
To estimate the quantity of free HCl, multiply the number of
cubic centimetres of NaOH used in the titration by 0.0365; the
result is the percentage of free HCl. Normal free HCl varies from
0.07 to 0.2 per cent, or from 2 to 6 c.c. of decinormal NaOH for 10
CO. of gastric contents.
The estimation of combined HCl and of the acid salts is seldom
of importance.
Total acidity is determined by adding to the same beaker of
contents in which the free HCl has just been neutralized two or
three drops of a one-per-cent solution (alcoholic) of phenolphthalein,
and continuing the titration with the NaOH solution (and constant
stirring) until a permaneiit red color appears. By mutiplying the
number of cubic centimetres of NaOH used from the beginning of
the first titration up to the point when the red color reappears by
0.0365, we obtain a figure i presenting the percentage of total acid-
ity. The normal range of total acidity is from 0.15 to 0.3 per cent,
and we usually find that we have used from 4 to 8 c.c. of the NaOH
solution in the process of neutralizing 10 c.c. of gastric contents.
Lactic acid is to be tested for only when HCl is absent. The
test must be made at once, since lactic acid soon develops in stom-
ach contents which are kept in a warm place. To perform the test,
we dilute a solution of FeCl (strong aqueous) with water until a
faint yellow color barely remains. Then fill the concavities of two
test tubes with this solution, using one for comparison. If, on
' An ordinary medicine-dropper may be substituted for the burette if we
get an apotliecary to mark with a file upon it the point to which a (previously
measured) cubic centimetre of water rises when sucked into the dropper.
The half-centimetre point can be similarly marked. Decinormal NaOH solu-
tion is then sucked into the dropper and expelled, one-half centimetre at a
time, into the beaker containing the Topfer's reagent and gastric contents.
3S4 PHYSICAL DIAGNOSIS.
adding ;i few drops of stomach contents to the other, a considerable
iiiteiisilication of the yellow color occurs, lactic acid is almost cer-
tainly present. A negative test rules out lactic acid.
The sediment need not be examined. It is true that sarcinte and
various bacteria (Boas-Oppler bacillus and others) are often found
in cases of gastric stasis, but they add little if anything to the other
evidence of stasis more easily obtained — i.e., the symptoms men-
tioned on page 386, tlie presence of splashing more than four hours
after a meal, the evidence of dilatation or gastroptosis as given
above, and the finding of organic acids.
4. Incidence and Dingnosis nf Gastric Diseases.
In the Avards of the Massachusetts General Hospital the number
of cases apjjarently of gastric disease treated between 1870 and 1905
was as follows :
Cancer 403
Ulcer 536
Dilatation 170
Dyspepsia' 1,003
Total 2,111
The data at our disposal are as follows:
1. The history.
2. The local and external examination of the epigastric region.
3. The estimation of the size and motor power of the stomach.
4. The examination of the gastric contents.
(a) Jn advanced cancer of the stomac]i\fe liave pain, emaciation,
anaemia, symptoms of fermentation (see page 386), often dilatation
and motor insufhciency due to pyloric stenosis, absence of HCl in
the gastric contents (often), and in many eases the presence of
digested blood ("coffee grounds") in the gastric contents and occult
Ijloud (guaiac) in the f;eces. But witlioutthe ]iresenee of an epigas-
tric tumor all these facts are insufficient for diagnosis. Even the
'/.('., cases of painful digestion including anoiiialies of motion, sensation,
secretion, " t;astritis " and "gastric catarrh," but without evidence of ulcer,
cancer, or dilatation.
THE STOMACH, LIVER, AND PANCREAS. 385
tumor itself jiiay deceive us, as the adhesions around a gastric ulcer
may present a simiUu- mass to the palpating hand.
The age of the patient is of great importance, especially if dur-
ing the earlier decades of life he has been totally free from gastric
symptoms. Ani/ tijpe of dtjspepsia, anij sort of genuine gastric
trouble,^ occurring in a person over forty who has never had any
such trouble before, is strorigly suggestive of cancer.
(b) Gastric ulcer gives us usually the symptoms of hyperacid-
ity (next paragraph), perhaps a demonstrable excess of HCl in the
gastric contents and a more or less characteristic history ; but with-
out the occurrence of hemorrhage with the vomiting of bright blood
and "perhaps tarry stools (melaena), diagnosis is never certain.
Since gastric ulcer often leads to cicatricial stenosis at or near the
pylorus, its symptoms are frequently complicated by those of gas-
tric dilatation and stasis.
(c) Hyperacidity (or, more strictly, hyperchlorhydria) gives us
usually painful digestion, with a good appetite and a clean tongue.
Pain may come soon after a meal, and in such cases it is apt to be
excited especially by eating meat, but it is oftener felt when the
stomach is quite empty — e.g., in the night or before a meal. It is
prone to occur in chlorotic or neurotic persons or during periods of
special stress and worry. It frequently leads to gastric ulcer.
(rf) Hypoacidity (hypochlorhydria) is not a disease, but a
symptom occurring temporarily or for a longer period in connection
with various stomach troubles (dilatation, "catarrh," nervous dys-
pepsia), as well as in many conditions entailing general debility
with stomach symptoms. Hypoacidity is often associated with
stasis and fermentation. It is recognized, of course, by the chem-
ical tests described above.
(e) Gast7-ic dilatation, when considerable, is almost always sec-
ondary to pyloric obstruction (due to cancer, cicatrix, or adhesions).
Symptoms suggesting it are the vomiting at one time of a large
quantity — a quart or more — of stomach contents, often containing
fragments of food eaten more than eight hours [)reviously. Sucli
' We must be careful to exclude angina pectoris as well as gall stones and
their effects.
25
3S6 PHYSICAL DJAGyOSIS.
attacks of vomiting occur usually not after every meal, but at
longer intervals. It is to be positively diagnosed bj- passing a tube
and distending the stomach with air or water.
(/') Giistric stasis occurs with more or less constanc}* in almost
everj^ disease of the stomach and in many general constitutional
diseases ( tuberculosis, aufemia, general debility). It constitutes
what is usuallj' referred to by patients as "indigestion," "dyspep-
sia," or "sour stomach." Fennetitatioii of stomach coiitfiittt too
long retained is the essential point. This results in a sen.se of
weight and pressure in the epigastrium, eructations of gas and of
sour or burning fluids, loss of ajtpetite, nausea, and vomiting. The
tongue is geiierally furred and the bowels are constipated. Head-
ache, vertigo, and depression of spirits often accompany it.
The Liver.
The Massachusetts General Hospital records ( ISTO-IOO.")) show
the following figures bearing on the incidence of diseases of the
liver :
Passive congestion <<' 1,288
Portal cirrhosis 234
Biliary cirrliosis (Hanoi's) 0
Cancer of tlie liver 184
Sarcoma of tlie liver 3
Abscess of tlie liver ~\\
Leulismic iutiltration 46
Pseudolenkainhc iutiltration 10
Amyloid iutiltratiim. 9
Patty infihration 6
Hydatid cyst 8
Sypliilis 8
" Simple cyst " 6
Actinomycosis 3
Acute 3'ellow atrophy 2
Tuberculosis 1
Total 1,858
THE STOMACH, LIVER, AND PANCREAS. 387
Diseases of the Gall Bladder and Bile Ducts.
Cholelithiasis 457
Aeiite cholecystitis 110
Catarrhal jaundice .' 125
Cholangitis 9
Total 701
The evidences of liver disease may be either local or general.
Local siffns include : («) Pain and tenderness in the hepatic re-
gion. (?;) Enlargement of the organ, symmetrical or irregular, (c)
Atrophy of the organ.
The <je7ieral signs which assist in the diagnosis of liver disease
are: (a) Portal obstruction. (/;) Jaundice, including changes in
the color of the skin, mucous membranes, and excretions, (c) Loss
of flesh and strength, (d) Evidences of infection (fever, leucocy-
tosis, chills, sweats, anorexia), (e) Cerebral symptoms (headache,
vomiting, depression, delirium, convulsions, coma).
The various attempts to test the liver functions by chemical
examination of urine and faeces have not as yet been successful ;
hence all diagnoses of liver disease must be built up of the above
eight grottps of data.
(a) Hepatic Pain.
This forms little or no part of many cases of liver disease, since
it occurs only xvhen the capsule is stretched or its nerves are involved
ill a 2^erihepatitis. Many cases of hepatic abscess, for example, run
their course without pain or become painful only when the pus bur-
rows to the surface and stretches the capsule. Besides this capsule
plain in liver disease, we have shoulder pain referred to the region of
the right scapula, less often to other parts of the back. Capsule pain
is most noticeable in cancer of the liver; shoulder pain in abscess.
Tenderness is present in the same cases which are painful, i.e.,
those in which there is perihepatitis or stretching of the capsule
by rapidly increasing tension from within. The latter condition is
commonest in passive congestion, but is not characteristic of an^
single disease.
388 PHYSICAL DIAQiXOSIS.
{h) Enlargement of the Lirer.
Tumors behind the liver, pushing it forward and down, are of-
ten overlooked, because tliey bring the liver so prominently into the
foreground and fasten our attention on what is mistaken for an en-
largement of the organ. Wherever the cause of a supposed enlarge-
ment of the liver is not obvious, retroperitoneal sarcoma or some
other deep-seated tumor should be suspected.
I have already alluded to the possibility of mistaking the en-
larged liver for empyema, and vice versa (see above, page 354).
We are sure of an increase in the size of the liver only when we
can feel its edge below the ribs and can determine bj' percussion
that its upper border is not depressed." To feel the edge of the
liver, hook the fingers of both hands around the margin of the right
ribs and ask the patient to take a deep breath. At the height of
inspiration an edge may be felt to descend against the lingers and
to push its way beneath them. Unless an edge, either sharp or
rounded, is felt, one cannot be sure of hepatic enlargement, for per-
cussion of tlie lower edge of the liver is notoriously unreliable
Dulness below the costal margin is frequentlj- found in cases with-
out hepatic enlargement, and should never be relied on unless the
liver can be felt.
The long, smooth edge of the liver descending one to two
inches with full inspiration is rarelj' mistaken for anything else,
but if the edge is irregular and the surface nodular (see below)
it may be hard to distinguish liver from stomach or possibly
kidney.
If ascites is present, the presence and dimensions of an enlarged
liver beneath the fluid can sometimes be made out by dipping (see
above, page 371). If this is impossible, the ascites may be tapped,
after which it is usually easy to feel any enlargement that is pres-
ent, as the belly walls are very flaccid.
' A normal liver may be pushed dowu by air, water, or solid tumors in the
lung and pleura, so as to be palpable below the ribs; but the evidence of a
cause and the low position of the upper border usually make diagnosis easy.
THE STOMACH, LIVER, AND PANCREAS. 389
The causes of liepatic enlargement (in adults'), arranged ap-
proximately in the order of frequency, are :
1. Passive congestion (later stages of uncompensated heart dis-
ease).
2. Obstructive jaundice (from any cause).
3. Cirrhosis.
4. Fatty liver, including "infiltration " and "degeneration."
5. Malignant disease.
6. Syphilis of the liver (congenital or acquired).
7. Abscess of the liver.
8. Leukaemia and pseudoleukaemia.
9. Cholangitis.
10. Amyloid.
11. Hydatid cysts.
The laryest livers are found in malignant disease, biliary cir-
rhosis, and abscess.
In -passive congestion the liver is very tender, and the presence of
uncompensated heart disease '' usually makes the diagnosis easy.
The surface of the organ is smooth and firm.
In cirrhosis a distinction must be drawn between (a) latent or
compensated cases, wholly without symptoms, and (J) uncompten-
sated cases, in which diagnosis depends on the chronic enlargement
without any considerable increase under observation, associated
with evidence of portal or hiliary obstruction [or both) and without
much pain or irregularity of the liver. Eighty per cent of the two
hundred and thirty-four cases recorded at the Massachusetts Gen-
eral Hospital showed enlargement, and only twelve per cent sliowed
pain (cf. Malignant Disease, below).
The fatty liver is soft and smooth in feel. The presence of
phthisis or alcoholism makes us suspect this diagnosis, which de-
pends largely on excluding other causes of enlargement.
Malignant disease of the liver (cancer or sarcoma) is usually sec-
' In infants, rickets, antemia, and gastro-intestinal disturbances often produce
hepatic enlargement, tlioiigli tlie splenic enlargement is usually nuicli greater.
(The infant's liver is normal!)' | inch below the ribs in the nipple line.)
^Either primary or resulting fioru chronic bronchitis and emphysema.
390 PHYSICAL DIAGNOSIS.
oiidaiy to neu' growth elsewhere. The liver tjroics 7-apiclh/ under
obseri'afio/i, is usually ^)(n'»/«/ (SO per cent of 168 JNIassachusetts
Hospital cases) and nodiihir. Jaundice and irregular fever are
present in over one-half of the cases (54 and 62 per cent respec-
tively), and the loss of flesh and strength is marked.
Ohsfnicfire /(uindiri' (due to Stone, stricture, catarrh, or tumor
of the bile ducts, or to anj' other cause) often produces an enlarged
liver. Diagnosis depends on the evidence of a cause for the ob-
struction and the absence of hepatic nodules, pain, or a rapid in-
crease ill the size of the organ.
Si/2>/ii/itii' llrrr may be distinguishable from cirrhosis or from
malignant disease only by the therapeutic test. The history or
present evidences of alcoholism or of s^-philis are important factors
in diagnosis, but, since syphilis may simulate the nodular liver of
malignant disease or the general enlargement and portal stasis of
cirrhosis. It Is essi'/ifiid to r/ive ((iifisi/p/iilitic trcatniott in all doubtful
cast's of lirer disease.
Absi'ess of the lirer produces enlargement, pain, fever, leucocy-
tosis, and chills in t3'pical cases, but any of these sj-mptoms may
be absent and diagnosis is often difficult. The presence of a possi-
ble cause (amojbic dysenterj^, appendicitis) is important evidence.
The etilari/euient is more apt to be ujurard and to the right than in
other liver diseases, since the pus usually starts in the right lobe
and burrows upward. Hence many cases are mistaken for empyema
(see above, page 354). Should fluctuation appear e.xternally the
diagnosis is usually obvious, but in many cases this does not oc-
cur.
Soft new growths and syphilis may be almost indistinguishable
from aliscess bj' local signs, but jaundice is much commoner in ma-
lignant disease and the liver of syphilis is often irregnilar. The
history is of value.
Sniipiiratire cholaii(/ifis ov jii/li'jihlebifis gives us practically the
same sj-mptoms as abscess, but the spleen is enlarged in about one-
third of the cases.
Amyloid lirer is recognized b}' the presence of an appropriate
caiise (chronic suppuration or S3']diilis) and the evidence of amyloid
THE STOMACH, LIVER, AND PANCREAS. .391
in other organs (enlarged spleen, albuminuria, diarrhoea). The
liver is smooth, not inegular as in hepatic syphilis.
The leukcrmic lirer is recognized by blood examination ; the
pseudo-leukgemic liver by the normal blood and the histological
examination of the glandular enlargements 'wlach always accom-
pany it.
Hi/dittid cyst is rarely to be diagnosed by physical signs. The
history of a residence in Australia, Iceland, certain parts of Ger-
many, or of the British Isles is important evidence, since the
disease has never been known to originate in North America. Phj'si-
cal examination may enable us to make out that the hepatic enlarge-
ment is due to a cystic tumor, tense and elastic, with notable
absence of constitutional disturbances (Rolleston).
(e) Atrophy of the Liver.
Diminution in the size of the liver can hardly ever be demon-
strated satisfactorily during life, since we must rely upon percus-
sion for our evidence, and percussion of the upper and of the lower
border of the liver may be rendered difficult by distention of the
lung (emphysema) or of the colon. Atrophy occu.rs in a small pro-
j)ortion of the cases of hepatic cirrhosis and in acute yellow atrophy,
but is rarely recogiuzed in either condition. The rapidly fatal
course of the latter disease with jaundice and a " typhoidal state"
contrasts with the prolonged portal stasis characteristic of cirrhosis.
(f?) Tortal Oh struct i 071 .
A characteristic group of signs manifest the presence of an ob-
stacle to the flow of blood through the portal system. This group
includes :
1. Haematemesis and dyspepsia.
2. Ascites' (see page 374).
3. Splenic enlargement.'
' Ascites and splenic enlargement are not purely mechanical phenomens
ToxfEmia and sometimes cbronic peritonitis or cardiac failure contribute.
392 PHYSICAL DIAGNOSIS.
4. Collateral dilatation of veins about the navel and elsewhere.
Hcematfmi-fn'g is usually dne to rupture of ililated (esophageal
veins, oecasionall_y to gastritis.
Sph'iiir eiihin/iiiii-nf. is more marked in the rare eases assoeiated
with chronic jaundice {hiliari/ cirr/iosis ) and without ascites.
The <'(^^';t' of portal obstruction is: 1. Cirrhosis, in ninety-hve
per cent of the cases. The remaining Hve per cent is made np
of: 2. Obliterations of the portal vein, usually by thrombosis or
tumors.
((') Jtiinnlic)'.
The i/elliiir sfniiiimj of sclera, skin, and mucous membranes,
with or without changes in the color of the urine and f;i;ces, is
known as jaundice. I have classed it as a general rather than a
local sign of liver disease, because it may occur from toxa'uiia and
independent of any lesion of the liver; for instance, in septie;emia,
malaria, yellow fever, and pernicious an;pmia. It is true, never-
theless, that all jaundice is due ultimatelj' to obstruction in the
path of the bile stream. In the toxremic eases tlie obstruction is
due to inflammation of some of the .'oinil! diicfs within the liver. In
the cases dne to stone or cancer the obstruction is in the lanji'v bile
ducts, usually the common duct.
Causes of Jdinidiee. — The four types most often seen are:
1. Jaundice of the new-born (occurs in from thirty to eighty per
cent of all children).
2. Catarrh of the bile ducts ("catarrhal jaundice "),
o. Gall stones, especially in the common duct.
4. Cancer (pancreas, glands, liver, or bile ducts).
Less common are the cases due to :
5. Cirrhosis of the liver.
6. Sj'philis of the liver.
7. Infectious disease or toxa?mia.
Rare causes are :
8 Acute yellow atrophy, with or without phosphorus ]ioisoning,
9. Weil's disease and other types of infectious jaundice.
10. Congenital obliteration of the bile ducts.
THE STOMACH, LIVER, AND PANCREAS. 393
The ri'sii/fs of Jaundice upon the body are chiefly the following:
(«) Slow pulse (often below 60). (/<) Itching of the skin, (c)
Mental itepression. (</) Hemorrhagic tendency (which renders
operation dangerous).
In mild eases there is no bile in the urine; in severe cases it is
almost alwaj'S present. Tlie stools are t/rai/ or clay-colored when
the obstruction is in the larger bile ducts outside the liver, but in
the toxiiemie forms of jaundice abundance of bile passes into the
intestine and the stools are of normal color.
Diagnosis of the cause of jaundice depends on the following con-
siderations :
1. If it occurs daring the first four days of life without any
other symptom and passes off within a few weeks, we call it simple
jaundice of tlie neu-horn .
2. If tlie attack is preceded by gastro-intestinal disturbances,
usually in a young person, if pain and liepatic enlargement are
slight or absent, and if the jaundice passes off within six weeks, we
term it " cafai-rhal Jaundice" (though the pathology of this and of
the preceding condition is unknown).
3. If there have been attacks of biliary colic (see below, page
393), intermittent fever with intervals of good health, and no con-
siderable or progressive enlargement of the liver or gall bladder,
stone ill the common duct is probably the diagnosis.
4. Cancer of the pancreas, duodenal pa]>illa, bile ducts, or of
the glands at the hilus of the liv-er, produces enlargement of the
gall bladder, pain, and a jaundice of tihe intensest type known.
Loss of flesh and strength is rapid. Cancer of the liver itself gives
a rapidly enlarging, nodular liver with steady pain, and, in flfty
per cent of cases, jaundice.
5. Ill ovdina.1 J jn I rf a! cirrJiosis the jaundice is less intense and
permanent, portal stasis is usually evident, and there is generally
a moderate enlargement of tlie liver.
6. Enlargement of the liver with jaundice lasting for years in
young people is called biHari/ cirrhosis.
7. Hepatic si/philis produces jaundice in a small percentage of
cases, and under these conditions is so apt to be mistaken for cancer
394 PHYSICAL DIAGNOSIS.
that I think all cases supposed to be cancer in or near the liver
should be given a course of antisyphilitic treatuieut. Other lesions
or syuiptouis of syphilis will naturallj' influence us.
8. Tiie jaundice secondary to septicfeuiia, yellow fever, malaria,
and pernicious ana?niia is usually slight and rarelj' shows in the
urine or bleaches the stools. The evidence irf the an;\eniia or of an
infection uuikes evident the nature of the jaundice.
9. Acute j-ellow atrophy cannot be deteruiincd without autopsj'.
Its chief svmptouis are given in its name.
10. Weil's disease is the term applied to some or all of the
groups of infections of unknown origin which are accompanied by
jaundice. From catarrhal jaundice it is to be distinguished during
life only by convincing evidence of general infection.
Congenital obliteration of the biliarj' ducts is suggested by the
occurrence of congenital, intense, and pernninent jaundice with
hemorrhage and enlargement of the liver and spleen.
(/■) Loss of Flrslt and Sfr,-iii/fh
in cases pu-esenting other signs of liver disease is connnonest in
uncompensated cirrhosis and in malignant disease, but may occur in
gall-stone disease, syphilis, or abscess. I have known a pliysician
greatly alarmed at his own rapid emaciation, though his symptoms
(jaundice ami colic) pointed to stone in tlie common duct and opera-
tion proved this diagnosis correct.
((/) y/it' liifriiioii (J roup o/ Si/iii jifoiiis.
These symptoms — viz., fever, chills, sweats, lencoc_ytosis, dis-
turbances of digestion ami sleep — are oftenest seen in : 1. Cholan-
gitis. 2. Hepatic abscess.' o. "Ball-valve" or " floating " stone
in the common duct. In the last disease jaundice is usuall}- pres-
ent ; in the others usually absent. In cancer of the liver fever and
leucocytosis are often present, but the other signs of infection are
rarely seen.
' With or wiUicuit pylcplilcbitis.
THE STOMACH, LIVER, AND PANCREAS. 395
(h) The Cerebral Symptoms of Liver Disease.
These vary from simple depression and apathy to delirium, con-
vulsions, and coma. Severe symptoms are oftenest seen at the end
of uncompensated cirrhotic cases ; eighty-two ])er cent of our fatal
cases showed during the last days of life sympitoms indistinguishable
from those of uraemia.
The Gall Bladder and Bile Ducts.
(a) Biliary eolie, and (5) enlarged gall Madder, with or without
tenderness and pain, are the data on which (with tlie evidence of
local or general infection, cachexia, intestinal obstruction, and jaun-
dice) our knowledge of gall-bladder disease is built up.
Differential Diagnosis of Biliary Colic.
Biliary colic, due to impaction of a gall stone in the cystic or
common duct, is a sudden, agonizing pain in the gastric or hepatic
region, radiating thence in all directions, with fever, chills, and
vomiting. In most cases the attack lasts from three to twelve hours
(Rolleston) unless relicTed by morphine. The pains may be of any
degree of severity, and are often accompanied by tenderness over
the hepatic region. The liver or gall bladder is seldom paljjable.
Jaundice precedes or follows the attack in about one-lialf of the
cases.
Eenal colic differs in that it usually starts over the kidney (in
the back) and radiates down the ureter, while the urine is apt to be
bloody but free from bile.
Floating kidney may produce pains which cannot in themselves
be distinguished from biliary colic. The palpation of the floating
kidnej' may be all that makes us suspect that organ to be the cause
of suffering.
Peptic ulcer (gastric or duodenal) produces sharp, paroxysmal
pain, but this usually follows a meal, can be relieved by alkalies,
and produces no fever, chill, or sweat. Hyperchlorhydria may
:i96 PHYSICAL DIAGyOSIS.
produce similar pain at uight (the eoimuonest time for biliary colic),
but is relieved by food or alkali.
Lea(/ colic is almost always associated with lead dots iu the
gums and stippling of the red corpuscles (see pages 24 and 472).
The history of work as a painter or plumber and the absence of ten-
derness assist the diagnosis.
Enlarged Gall Blnildei:
AM. enlarged gall bladder cannot be felt miless it is stretched
tight by its contents; a very tense gall bladder may be palpable
without much enlargement. Probably most enlarged gall bladders
are not tense, and so cannot be made out without operation. When
palpable the organ presents as a smooth, rounded, pear-shaped tu-
mor at the margin of the ribs in the nipple line.
The causes of enlargement are :
(a) Stone in the ci/sfic duct, at the neck of the gall bladder.
(In) Cancer of the pancreas ox other tumor obstructing the com-
mon duct from without.'
(c) Cholecystitis.
In the first of these jaundice is rarely present (ten to fifteen per
cent — Eiedel '), and colic with or without palpable tumor is our
guide to diagnosis.
In cancerous obstruction there is intense and perm;uient jaun-
dice.
In choleci/stifis there is usually no jaundice, but all the signs of
local and general infection — jtain, tenderness, leneoci/tosls, and fever
— are present. In acute cases the symptoms, however, may be
indistinguishable from those of appendicitis, since the pain may
be referred to the navel or even to the appendix region. Many
mistakes of diagnosis between appendicitis and acute cholecystitis
occur, and must occur until our present diagnostic resources are
increased.
' Courvoisier lias shown that if the common duct is obstructed by a gal'
stone the gall blailder is very rarely enlarged.
'^Riedel: Berlin, kliu. Wocli., 1901, No. 3.
THE STOMACH, LIVER, AND PANCREAS. 397
Results of CholecT/stitis.
(a) Adhesions about the gall bladder may involve the duodenum
or pylorus, and produce kinking and consequent dilatation of the
stomach and chronic dyspepsia.
(/)) Intestinal obstruction (see below, page 403) is occasionally
produced by the ulceration of a large gall stone from tlie gall blad-
der into the intestine, usually tlie small intestine or duodenum.
The Panckeas.
Diseases of the pancreas can very rarely be diagnosed by our
present methods. If greatly enlarged (tumor, cyst, liemorrhage)
it may become palpable as a deep epigasti-ic tumor, but we are
rarely able to differentiate such tumors from tliose of the retro-
peritoneal structures.
Indirect and uncertain information is afforded by the presence
in the urine of sugar or fat-splitting ferments ' and in the stools by
the appearance of an abnormal amount of muscle fibre or of fat not
otherwise to be accounted for {i.e., in the absence of jaundice, diar-
rhoea, tuberculous peritonitis, or large meals of fat).
Cancer of the pancreas may sometimes be suspected on account
of its pressure effects. Intense and permanent jaundice with en-
larged (perhaps palpable) gall bladder and liver may be due to the
pressure of cancer in the head of the pancreas upon the common
bile duct. Ascites and swelled legs may be produced by compres-
sion of the inferior vena cava. But the diagnosis can rarely be more
than a suspicion, for cancer of the duodenal papilla or retropeii-
toneal sarcoma may produce similar pressure effects. Should these
pressure effects coincide with a glycosuria and the presence of a deep-
' The suspected urine is neutralized with potassium hydro.xide and one
portion of it boiled to destroy any ferment that may be present. To this and
to the unboiled portion ethyl butyrate is added. In twenty-four hours an acid
reaction may appear in the unboiled specimen if it contains a ferment, while
the other specimen shows no considerable changein reaction.
398 PHYSICAL DIAGNOSIS.
seated, almost immovable tiimor, the suggestion of pancreatic disease
becomes more plausible.
Acute jjancreatic disea.'^e, hemorrhagic or suppurative, is not rec-
ognizable until it is seen at an operation undertaken for the relief
of some grave, acute lesion of the upper abdomen. Perforated gas-
tric ulci'r and intestinal obstruction may give identical symptoms,
viz., sudden, intense, epigastric pain and tenderness, with vomiting
and collapse. One or two daj's later a tender epigastric tumor may
app)ear, but this presents no characteristic peculiarities.
Pancreatic ci/st presents a very slow-growing, possibly elastic,
deep-seated epigastric tumor, which usually jiroduces little in tlie
way of pressure effects, and may be associated witli glycosuria and
fatty stools.
Bronxed Plabefes. — The association of diabetes Avitli bronzing of
the skin and enlargement of the liver is stronglj^ suggestive of
chronic fibrous pancreatitis.
In any doubtful case the possibility of piancreatic disease is
increased: («) If improvement follows the administration of pan-
creatic preparation ; (A) if glycosuria follows the administration of
100 gm. of glucose (alimentary glj^cosuria).
Incidence of Pancreatic Disease.
The following table is from the Massachusetts General Hospital
records (1870-1905) :
Cases.
Cancer of the pancreas 35
Acute pancreatitis 13
Chronic pancreatitis 10
Cyst of the pancreas 3
Total 81
CHAPTER XX.
THE INTESTINE, SPLEEN, KIDNEY.
The Intestines.
Incidence of Intestinal Disease (excluding diarrhcEa and constipa-
tion) at the Massachusetts General Hospital, 1870-1905.
1. Appendicitis 3,314
2. /Vcute obstruction 143
3. Cancer (above tlie rectum) 155
4. Dilated colon . 6
5. Tuberculosis 8
6. Fiscal impaction (above the rectum) 3
Total 3,621
Data, for Diagnosis.
The data on -which are based all our conclusions regarding intes-
tinal disease are obtained from the following sources:
1. Paul (colicky or steady) and tenderness, tenesmus.
2. Gaseous distention and the noises and sensations produced by
gas.
3. Diarrhoea or constipation.
4. Muscular rigidity of the belly wall protecting an intestinal
lesion.
5. Tumor, palpable or visible, and believed to be connected
with the intestines (together with the effect of catharsis on such
tumor).
6. Visible or palpable jyeristalsis (see page 366).
7. Digital or visual examination of the rectum (see page 443).
8. Exaniination of the intestinal contents, ffecjal and other (see
page 404).
9. Inflation of the colon through the rectum, (see page 372).
10. Indicanuria — rarely of value.
400 PHYSICAL DIAGNOSIS.
11. Constitiitioiiiil miuiifestati(i/is, such as fevers, vomiting,
leucoeytosis, emaciation.
Some of these data need further comment.
latest i nil I I'liin. — Many pains associated with intestinal disease
(appendicitis, cancer) are due in fact to irritation of the peritoneum.
Which of the numerous pains referred to the bellj' should be
interpreted as infi'sfimi/ in origin? Those esiieoially which (a)
shift rapidly from place to place ; (//) aecompanj' the noises and
sensations of tlie passage of gas and f:eoes through tlie intestine;
((■) accompany diarrhcea or constipation.
Tenderness is usually a symptom of peritoneal rather than intes-
tinal irritation. With true intestinal pain (ro/lc) there is often
relief hij pressure — the precise opposite of tenderness. Yet so
close is the association of intestine and peritoneum tluat in appen-
dicitis, intestinal ulceration, tumors, and even in simjile gaseous
distention of the gut, there is often local or general tenderness.
When extreme and associated with constitutional manifestations
— fever, leucoeytosis, collapse — it always suggests peritonitis.
When there are no constitutional manifestions, a piurely local pain
or tenderness lias little diagnosfie value.
Tenesmus. — The desire to pass another stool as soon as one has
been evacuated, together with local burning and straining, means
always reetnl irritation (inflammation, ulcer). It is one of the most
definite and reliable symptoms known.
Gaseous distention of the intestine is proved by an increase of the
7iorma^ tympanitic note over part or all of the belly, together with
a in'omiiienee of the overlying belly wall. It is chiefly and most
frequently the colon tlmt produces distention.
The siff7iificanee uf distention is vague and depends largely on
the associated data. In acute (/astro-intestinal "catarrh" the
diarrhoea and absence of severe constitutional manifestations make
us put little stress on the associated distention. In typhoid fever
distention results frdui atony of the intestinal walls and is " to some
extent a measures of the intensity of the local lesions '' (Osier). In
intestinal obstruction distention may be extreme if the stoppage is
low down (in the colon), less marked if the lesion is high up. In
starvation, children (if ten get very large bellies, owing to muscular
THE INTESTINE. SPLEEN. KIDNEY. 401
atony of the gut and the resulting gaseous accumulation. But in
no ease is the distention of itself of much diagnostic value. The
associated symptoms give it significance.
Diai-rha'tt, the passage of more and looser stools than is normal
for the individual, is, like distention, a result of many causes both
within and outside the intestine.
The most important are :
j ((() liuliijcstion (acute and chronic).
1. Intestinal disease. \ f\ Ulceration (some cases only V
j (f) Infectious diseases (cholera, dysentery, typhoid i
[(rf) Intestinal parasites.
{((if) Nervous causes (emotion, Basedow's disease,
etc ^
(h) General infections (.sepsis),
(f) Cachectic states (anaemias, nepliritis, etc.).
By a search for these causes, as well as by the use of the data
obtained by examination of the stools, we arrive at an understand-
ing of the diagnostic significance of diarrhoea.
Aside from diarrhoea, constipation, and dysentery, which produce
no pliysical signs beyond those described — distention, borborygmi,
pain, tenderness, tenesmus, and constitutional manifestations —
there are but thre« important diseases of the intestines :
I. Appendicitis.
II. Intestinal obstruction.
III. Cancer of the bowel.
1. A/jjyendicitis.
1. The local signs are pain, tenderness, muscular spasm, and
tumor.
2. The general or constitutional signs are fever, chill, rapid
pulse, vomiting, constipation, frequency or cessation of micturition,
and leucocytosis.
(«) The jyi'n may be at first general, later localizing itself in the
right iliac fossa, less often near the navel, the gall bladder, or in
any other part of the belly.
(J) The tenderness is more important in diagnosis; indeed, with-
out tenderness diagnosis is rarely possible. It is usually greatest
26
402 PHYSICAL DIAGNOSIS.
near a point half-way from the anterior iliac spine to the navel.
Occasionally a tender point in the pelvis may be reached by rectal
examination, but this is not a reliable sign.
(c) Miiscnlar spasm over the appendix region is present in most
cases, and, while it renders accurate pjalpation impossible, it is in
itself so characteristic of the disease that we do not regret it.
r'.<:rias spasm occurs in a minority of cases. The patient leans
his liudy forward and toward the right in walking, or, if recum-
bent, draws up the right thigh to relax the spasm.
(fZ) Tumor — about the size and shaj^e of a lemon, ill-defined and
tender — is felt in the right iliac fossa in many cases. It nray l)y
considerably larger and better defined if abscess has existed for sev-
eral days, or it may be smaller and more sausage-shaped.
(e) The constitutional signs may or may not be marked, accord-
ing to the duration of the process, its virulence, and the degree of
infection of the peritoneal cavity. The fever is usually moderate,
under 102.2° F., with corresponding elevation of the pulse. Vom-
iting comes at the outset if at all, and is usually over by the second
day. A leucocyte count which rises or remains elevated (above
16,000) accompanies the active and advancing stages of the disease.
In cases that are very mild or tightly walled in by adhesions, and
in cases with virulent general peritonitis, the leucocytes may be
normal or subnormal.
Diagnosis can hope only to establish the existence of a local
inflammatory process in the abdomen; acute cholecystitis and acute
pus tube may present signs indistinguishable from those of appen-
dicitis, though the site of tenderness often sets us right. Non-
inflammatory p)rocesses, such as biliary and renal colic, floating
kidney, and acute gastro-iutestinal upsets, can usually be excluded,
since they do not show so much local tenderness, fever, and leuco-
cytosis.
In those who are familiar with the symptoms of appendicitis, a
vivid imagination may conjure up a set of sensations that are diffi-
cult for the physician to distinguish from those of the actual dis-
ease. Even tenderness may be simulated, but, by distracting the
patient's attention while we palpate, we may be able to press hard
over tlie appendix without eliciting complaint. The absence of leu-
THE INTESTINE, SPLEEN. KIDNEY. 403
cocytosis, the age and sex of the patient, also help us to exclude
appendicitis.
//. Intestinal Obstruction.
(a) Acute Obstruction. — A person may have had no faecal discharge
for a week or even considerably longer and yet present all the evi-
dences of good health. It is only when vomitimj, severe paroxysms
of pain, and distention of the belly ensue that we suspect obstruc-
tion. In the acute cases tumor is noted in only about fifteen per cent.
In the chronic cases, usually due to stricture or cancer, a faecal
tumor can often be felt and diarrhoea may alternate with constipation.
By physical signs alone I do not believe that general peritonitis
and acvite intestinal obstruction can always be distinguished. Fever
is not distinctive of general peritonitis, for it occurred in eighty-four
out of one hundred and twenty-two cases of acute obstruction in the
Massachusetts Hospital records, and in forty-three of these cases
free fluid in the peritoneal cavity was demonstrated as well. Ster-
coraceous vomiting may occur in general peritonitis; it was absent
in three-fourths of the Massachusetts Hospital cases of obstruction.
Weak, rapid pulse, cold extremities, and a drawn, anxious face are
common to both diseases. Tenderness is more general and more
marked in general peritonitis than in simple obstruction, yet some
tenderness was complained of in fifty-six out of the one hundred and
twenty-two cases of obstruction just cited.
On the whole, the differential diagnosis of these two diseases
seems to depend far more on the history and the etiology than on
physical signs.
(b) Chronic Obstruction. — Here the diagnosis is simpler. There
is usually a history of increasing constipation sometimes interrupted
by occasional attacks of diarrhoea. ' Tumor is palpable in fifty-eight
per cent of cases. Visible jjeristalsis was recorded in seventeen per
cent of the Massachusetts Hospital cases. Distention is gradual and
late. Cachexia is frequently present. Cancer of the colon, usually
at the sigmoid or caecum, is the commonest cause. Stricture, ex-
cept cancerous stricture, is rare.
' The latter combination occurred in six per cent of the Massachusetts Hos-
pital cases.
404 PHYSICAL DIAGX^OSIS.
('■) Acute (Jhsfriiction hi/ o Chronic Lesion. — Cancer of the sigmoid
often exists for montlis almost latent, or produces onlj- moderate
constipation, so that the patient considers himself well. Such can-
cers piresent an annular growth, hardly bigger than a signet-ring,
practically an annular stricture.
This stricture ma}' be suddenly " .</;»^ cloicn'' during an acute
gastro-intestinal attack, and we are then confronted with all the
signs of acute obstruction. Only the seat of the lesion, the age of
the patient, and jiossibly the appearance of peristaltic waves can
lead us aright in our diagnosis of the cause of obstruction.
JII. Cancer oftJic Boicel.
The signs are usually tliose of chronic intestinal obstruction (see
last section) with a well-detined tumor. Occasionallj' the tumor
may not piroduce much obstruction, and we have sinipdy piain and a
tumor which we iind by examination is not attached to the liver,
spleen, kidney, or stomach, and usually about the size of a hen's
egg. If faeces have accumulated behind such a tumor, we may feel
larger masses. In my experience pialpiable tumors due to ftecal im-
paction alone, without organic stricture or cancer, are very rare, ex-
cept in the rectum or lower sigmoid ; if found above this region they
are almost invariably dependent on stricture or cancer of the bowel.
Examination of Intestinal Contents.
1. Weight. — With the average diet of the adult " Anglo-Saxon,"
the weight of the daily stool is from 100 to 250 gm. (about 25 to
70 gm. dry), but Chittenden has shown that with a low proteid diet
of 2,000-2,750 calories value, the weight of the stool may be less
than half this amount.'
2. Color. — («.) White or light yellow — milk diet, bread and
milk diet.
(b) Black — blood, bismuth or iron (medicinal), blackberries,
huckleberries, red wine.
' "Physiological Ecouomy ia Nutrition," 1904, p. 42.
THE INTESTINE, SPLEEN, KIDNEY. 405
(c) Green; some normal infants' stools after standing ; fermented
infant's stool if green when passed; green vegetablf-s, calomel.
(d) Gray — absence of bile (jaundice), sometimes after cocoa or
chocolate.
(e) Bloody red — if in small amount and fresh, usually due to
hemorrhoids; in large amounts it may also be due to hemorrhoids
or to any of the causes of intestinal ulceration (typhoid, cancer,
dysentery, etc.).
3. Odu)\ — In adults of no great significance. In infants foul
stools suggest albuminoid decomposition, and strongly sour stools
suggest acid fermentation.
4. Abnormal In<jredients. — (a) Undigested food in small quan-
tities is present in normal stools, but when digestion is faulty larger
quantities easily recognized by the naked eye may occur. Pieces
of meat, flakes of casein (especially in typhoid patients overfed
with milk), fragments of starchy food, and lumps of fat (steator-
rhcea) may be seen.
The natural inference from the presence of these substances is
that the gastro-intestinal tract is not at present dealing with them
satisfactorily. Fatty stools are present in jaundice, tuberculosis,
or amyloid of the intestine, and even in simple catarrh. Thougli
often associated with pancreatic disease, fatty stools are by no means
characteristic of it.
(h) Mucus. — Small shreds of mucus adherent to faeces are of
no importance and cause much unnecessary worry among anxious
mothers. Larger amounts, if intimately mixed with the stool, point
to catarrh of the small intestine; if mucus thickly coats or makes
up the bulk of the stool, the trouble is in the colon. Tlie latter is
by far the commonest condition. Anything from a very mild to a
severe catarrhal condition is accompanied by mucus.
(c) Fresh Blood. — Piles are by far the commonest cause of
bloody stools, and the amount of blood may be trifling or may be
large enough to produce in time a severe anaemia.
Enteritis (the mild follicular or the severe ulcerative form)
often produces bloody stools. The associated symptoms, diar-
rhoea, mucus, and pain, together with the etiology (dietetic error,
^06 PHYSICAL DIAONOSIS.
typhoid fever, amceba eoli"), must determine the nature of the en-
teritis.
In ca/iccf of the rectum or sigmoid (rarelj- higlier up in the
bowel), small quantities of blood, fresh or altered, are almost
always passed sooner or later. The infrequent, offensive, and pain-
ful stools and the results of digital examination usually reveal the
source of the blood.
In intiiSf:uscej>tion the association of bloody stools with the sad-
den appearance of a painful abdomiual tumor (usuallj- in the ca;cal
region), vomiting, and severe constitutional manifestations suggest
the diagnosis.
In hemorrhagic diseases (purpura, seurvj-, acute leukfemia) blood
may come from the intestine as well as from the other mucous mem-
branes. Other rare causes for blood in stools are a ruptured aneur-
ism, tlirombosed mesenteric artery, rectal syphilis, or fissure.
{(T) Altered blood (tarry stools, melffina) follows the pouring out
of blood — a pint or more — in the upper gastro-intestinal tract, and
occurs in hepatic cirrhosis, gastric or duodenal ulcer, after severe
nose-bleed, and occasionally from other causes. Oeeult Mood, rec-
ognizable by the gu.aiac test, often occurs in cancer or ulcer of the
stonmch, and forms an important link in the chain of evidence on
•which the diagnosis of those diseases is based.
[e) Ftis is not of great diagnostic value. Large amounts mean
the breaking of an abscess (appendix, pus tube) into the rectum.
Small amounts occur in ulcers or even from catarrh.
(f) Shreds of tissue point to ulceration.
('/) Gall Stones. — In suspicious cases break up the fa?ces in a
sieve with plenty of water. The peculiar, facetted shape of most
gall stoues is easily recognized.
Jiitestinal Parasites.
Bacteria. — Only the tubercle bacillus can be recognized without
culture methods, which do not fall within the scope of this book.
For the identification of tubercle bacilli the following method is
to be recommended: "Dilute the stool with ten volumes of water,
mix thoroughly, and let it stand in a wide-mouthed bottle for
CABOT PHYSICAL DIAGNOSIS.
PLATE I.
Fi(i. 1.— Trii'boinonas hominis. (Lpiickart.)
Fig. 2. ' Rulaulidiuin coli. iLeu'kait i Magnifled ;ii)(iiit IM) diameters.
Fig. .i.— Lamhiia inti'stinalis. (Lniirkart.)
THE INTESTINE, SPLEEN. KIDNEY.
407
twenty-four hours. The narrow layer between tlie thin supernatant
liquid and the solid sediment contains the bacilli. Remove this
with a pipette, spread it on a cover slip, evaporate slowly to dry-
ness, and proceed as with sputum " (" Harvard Outlines of Medical
Diagnosis," 1904, p. 29).
Animal P<irasites.
The most important are :
I. Serious.
Ama'bu cnli,
Ht)ok-\vonii
j (a) Unoinaria nmericana.
( (A) Ancli3'lostonia duodenale.
II. Relatively
mild.
3. Tape-worms: the beef -worm (Taenia saginata) is verj^
common; the pork-worm (T.Tnia solium) is rare;
the niiiiiatiiie taiie-wonii (Ttenia nana) and tiie
lish-worm (Dibotlii-iocepiialiis lutus ') are fairly
common. Several other forms occur in foreign
countries.
4. Strougy loides intestiualis.
5. Balantidium coli. 0
6. Billiarzia luematobium.
III. Usually
7. Ascaris Inmbrieoides (round-worm).
8. O.xyuris vermicularis (thread-worm; pin-worm).
I , "i 9- Tiichiuris trichiura (whip-worm).
naimiess. | jq Trichomonas intestinalis.
l_ 11. Lamblia intestinalis.
Tape-worms, round-worms, pin-worms, and the strongyloides
are to be recognized in their adult form (see Figs. 183, 184, 185,
186, 187). They are usually noticed by the patients themselves
and brought to the physician for examination. If the worm has the
look of a common earth-worm, but a length of live to nine inches,
it is safe to call it the " round-worm " (Ascaris lumbricoides); if the
wnriu is about one-half an inch long and as thick as a pin, it is in
all probability a "pin-worm " (Oxyuris vermicularis).
The Am/r'ha coli is to be searched for in fresh stools passed into
a warm vessel. • A bit of mucus from such stools is put upon a
warmed slide with a drop of water, covered with a cover glass, and
examined at once with a high-power dry lens. It is recognized by
1 Fish tape-worms may produce a severe anaemia, but in probably the
great majority of all cases they do not do so.
40S
PHYSICAL DIAGyOSIS.
tlie presence of distinct amaiioid movementg} When dead it assumes
a round shape, but one should not attempt a positive diagnosis un-
less live amoeboid parasites are present.
The other parasites are ideutihed, as a rule, by the iinding of
their eggs in the stools. The technique of this operation is de-
scribed below, as exemplified in the searcli for the egg of unciiia-
ria — at present the egg most important for Americans to recognize.
Eggs of piarasites catch the eye
in the examination of stools, first of
all, by the clean-cut, mnfhematical
symmetry of tlieir oval, when com-
FiG. 183.— a, Head of Tienia sagin.ita, Tiiueh magnlfled ; h, uterine winal of same. About
twenty brauobes on eacb side.
pared with the irregular, shapeless masses wliicli usually appear
in slide and cover preparations fi'om the fieces.
Secondly, the size of parasitic eggs is greater than tliat of most
of the ol)jects seen in the f;eces; and, tltirdly, they are for tlie most
part dark brown, stained witli hila (the iincinaria is an exception).
The differences between individual species will lie described
later. In Plates II. and III. tlie most important eggs are pictured
and catalogued.
'Sec Apjiendix F.
CABOT-PHYSICAL DIAGNOSIS.
PLATE II.
I»ist()lii;i hiiski,
Ascaris liiiiiliricdiitc
:r, ^.....-^■m^
■"^-$.r^
.-'-'
r:^%
■-< T'
.. ■ ■, ,
■J
: <',<>.> O ■,
•a
rticiiiaria uiiirric
Aiiclivloshniia duudeiiale.
Truliuris trichiura.
Diliii[ii)incc|)lialns
iatiis.
Titnia snlimn.
?:(;(, S (IF INTESTINAL PARASITES.
All an^ niafinitlpd 2'>0 rlifimeters.
Ta-uia saKiuala.
THE INTESTINE, SPLEEN, KIDNEY.
409
The UnciiKirlii nmericana or its European equivalent (^Ancliylos-
toviii diiodi/iiii/c) is recognized most easily by tlie iilentitication of its
eggs in the stools. These eggs are characteristic (see Plate II.),
and " tlie only thing liable to be confounded with them is the ovum
of Ascaiis lumbricoides stripped of its heavy, bile-stained outer
shell (see Plate II.); but this has a
double contour and contains a shapeless
mass of granular matter not differen-
tiated" (as most uncinaria eggs are)
"into clear segments."' The greater
Fig. 184. — a, Head of Taenia solium (noVe crown of books) ; J>, uterine canal In two segments,
(inly five t^ seven branches on each side.
size of the American hook-worm's egg compared to that of the
European worm is sliown in Plate II. "Free embryos are rarely
if ever found in intestine. Wlieii free (worm-like) embryos are
seen in the stools, they are generally those of the ytrongyloides in-
testinalis " (see Fig. 187).
' All the r^uotations in this section are from the "Report of tlie Commis-
sion for the Study and Treatment of Auasmia iu Porlo Kico," by Ashford,
King, and Igaravidez (December l.st, 1904), a study of 5,490 cases.
41(1
PHYSICAL DIAGNOSIS.
The ova of uncinaria catch the eye in a rapid examination,
first, because they are "not (jeneraUij hile-stained , hut clear, whereas
those of the commonly associated intestinal parasites are of a yel-
low to deep amber or brown color."
They are distributed quite evenly
throughout the entire faecal mass;
hence, in searching for them, the
following method is advisable :
Tfcliiiique of JWicroscoji'w Exami-
nation.— " A bit of fseees the size of a
match head is removed with a tooth-
pick and placed on a glass slide.
Upon this is placed a cover glass
and pressed down so as to give a clear
Fig. 185. — Taenia naiui IDwarf Tapp-worra). a, Honklct; h. bead, ^n'eatly enlarged; f, whole
wurni, luaj^uifled about 10 times.
centre to the specimen. Do not add water. Examine with a one-
third to two-thirds objective, a No. 4 ocular, and a partially closed
diaphragm. If too much light is admitted the delicate ovum will
be passed over."
THE INTESTINE, SPLEEN, KIDNEY.
411
The following interesting table (from the studies of Asliford,
King, and Igaravidez in Porto Rico) sliows, roughly, the relative
frequency (in a tropical climate) of the common intestinal parasites
Fig. 186. — Segments of the Dibotbrlocephalus latus (Fish Tape-worm). Note the rosette-
shaped uterine marJtinfr.
recognizable by their eggs. In the examination of the stools of
5,490 cases of uncinariasis they found as well:
Ascaris lumbricoides in 1,408 (many others seen but not noted).
Trichuris trichiura in 326 (many others seen but not noted).
Strongyloidesintestinalisin. . 36 (the embryo worms, not eggs).
Bilharziahfematobium in.. . . 21 (frequentl_v no careful search
was made for this egg).
Balantidium coli In 14
Oxyuris vermlcularis in 3
Amoeba coli in 3
Tienia saginata in 3
TiEnia solium in 3
Ascaris lumbricoides has usually a thick, wavy (" mammillated ")
shell; but this is not always seen, and in its absence the egg is dis-
tinguishable from Uncinaria americana chiefly by tlie absence of
the segmentation usually seen in the egg of the latter (see Plate
II., b).
Trichuris trichiura (also called Tricocephalus dispar) has a thick
shell, very dark-stained, and apparently pointed and perforated at
412
PHYSICAL DIAGNOSIS.
eacli end, instead of curving evenly over as tlie uncinaria egg does
(see Plate II., c).
lilUiarzia eggs are not at all uncommon iu the fajces, though
more often described in the urine, in con-
nection with hffimaturia. The terminal
spine at one end is their most character-
istic feature (see Plate II., d).
The other eggs are briefly described in
the explanatory text accompanying Plate
II.
The Spleen.
Dlsciise.': of the apleen (abscess, malig-
nant disease) are almost never recognized
during life. It is for evidence of splenic
enlargement as a factor in the diagnosis of
diseases originating elsewhere that we in-
vestigate the splenic region as part of the
routhie of abdominal examinations.
iSjiIinic cilia n/emoit is detected chiefly by
palpation. Percussion plays a minor role
in the determination of the organ's size,
and should never be relied on in the absence
of palpable evidence. Palpation is easy,
provided the organ is enlarged sufficiently
to project beyond the ribs without forced
respiiration, but much piractice is needed
when the enlargement is slight, as in, for
example, most cases of typhoid fever.
Palpation of the Spleen.
The co-operative action of both hands
is as essential as in vaginal examination, and
each hand must do the right thing at the right
Fig. 187.— Strongyloldes ster-
coralis. Mag^nillfd about ~5()
diameters. (After TLayer.)
CABOT-PHYSICAL DIAGNOSIS.
PLATE III,
Heterupbyes
lietir-rophyes.
h till itnliiiiin
Aiichylostoini
daiiden;ilp.
Billi 11 /n Diploirnnopuius BiJharzia
2TanUi^^.
A.t)( alls ( ),\yuri,s
Jutiibni nidpq \-('niik'iiU)ris,
!)a3iiiatobiuni. replialiis hitiis.
Para.CTnniinus Taenia nana
westermani.
Distoiiu
fi^lineiiiii
Dictoca-^liiiii
lanceolatuMi
SUr.imylnjd.
stpr-rora
DRAWINGS OF EG(ifl OF IXTESTINAT. PAIIASITES.
All are niacfnifled 9M). (Aftnr Lnoss).
THE INTESTINE, SPLEEN, KIDNEY.
413
moment. The patient should be on his back, his liead comfortably
supported and his knees drawn up. The left hand, placed over the
normal situation of the spleen, («) draws the whole splenic region
downward and inward toward the expectant hnger-tips of the riglit
hand; (i) at the same time the left hand should slide the skin and
Fig. 188.— Position of the Hands In Palpation of the Sploou.
subcutaneous tissues over the ribs and toward the right hand (see
Fig. 188), so as to leave a loose fold of skin along the margin of the
ribs and give the palpating fingers a slack rather than a taut cover-
ing to feel through.
The right hand lies on the abdominal wall just below the margin
of the ribs, and the fingers should point straight up the path down
which the spleen is to move, i.e., obliquely toward the left hypo-
chondrium. With the hands in this position ask the jjatient to
draw a full breath. Keep the hands still and do not e.xpect to feel
anything until near the end of inspiration. Then draw the hands
slightly toward each other and dip in a little with the right finger-
tips, so that if the spleen issues from beneath the ribs its «dge will
meet the finger-tips for an instant and spring over them as they
rise from diving into the soft tissues (see Fig. 188).
Some physicians have the patient lie on the right side, and
414 PHYSICAL DIAGNOSIS.
standing behind liiiu, hook theiv fingers over the ribs in the left
hyiioehondriuni. In this way we may be aiih' to feel the spleen at
the end of a long insjiiration, but I liave sehloni found this position
as useful as that described above.
A hard, fibrous spleen (malaria.) is mucli easier to feel than a
soft one (typhoid).
I'crriission D/'f/ir Sjilee?!.
Only when tlie edge of the spleen has been felt is it worth while
to try to define its upper border by i)ereussion. Normally there is
dulness in the niidaxillarj' line from the nintli to tlie eleventh ribs,
corresiionding to that part of the spleen that is most superficial.
Its lower aiul posterior borders cannot be defined; its anterior edge
is approximatel}^ in the midaxillary line (see Fig. 38). If this
small area of dulness is enlarged upward and forward, and if the
edge has been felt below the ribs, it is probable that tlie increased
area of dulness corresponds to an enlargement of the organ.
Causes of Sjjh'/iic Enlargcmei^t.
Slight enlargement of the spleen can often be detected in :
1 . Rickets and other debilitating conditions of childhood with oi
without aiuBmia.
2. Malaria.
?,. Tj'phoid fever.
In other acute infections slight enlargement can usually be
nade out post mortem, but not during life.
Marked enlargement (chronic) occurs in:
1. Chronic malaria — 8 per cent of my series.
2. Heiiatic cirrhosis — .30 per cent of my series.
.". " Splenic anpemia " — 4 per cent of my series.
4. Leuksemia (of any type") — 35 per cent of my series.
5. Hodgkin's disease — 6 jier cent of my series.
0. Amyloid — 1 ]>er cent of my series.
7. Witliout known cause (" primary " or " idiopathic " spleno-
megaly)— 12 per cent of my cases.
Rare causes are abscess, tuberculosis, malignant disease, penii-
THE INTESTINE, SPLEEN, KIDNEY. 415
cious aiuiemia, polyeytliteinia, hydatid, sy]ihilis, and LeiHlmian-
Donovau disease. Together these make 4 per cent of my series.
Differences Between a Large Spleen and Timwvs (of the kidney or
other organs). — A large spleen is easily recognized after a little
practice. As it enlarges it Iteeps its slutpe and advances obliquely
across the belly toward the navel or (in marked cases) beyond it.
It is always hard and .i/iiooth of surface, although the edge near-
est the epigastrium shows one or more natelies which are very char-
acteristic. The edge is sharp, never rounded, and the whole organ
is very .fuparficial, being covered only by the belly walls, so that if
we inflate the colon (by forcing air into the rectum with a Davidson
syringe), it jjasses hehiiul the spjleen and does not obliterate its dul-
nesB.
Tumors of the kidney fill out the flank, and an impulse can be
transmitted to the lumbar region by bimanual palpation. They
have no sharp edge or notches, are often irregular of surface, and
not so superficial. The inflated colon passes in front of a tumor of
the kidney and obliterates the dulness due to it.
All these differences hold for any other tumors likely to be con-
fused with an enlarged spleen.
Differential Diagnosis of the Various Causes of Splenic
Enlargement.
In children, splenic enlargement without fever or leukaemic blood
changes is to be classed as a manifestation of general debility. It
has no special connection with any type of anaemia, though anaemia
is often seen with it.
In typhoid the fever and the Widal reaction are generally siifir-
cient to make clear the cause of the splenic enlargement; in active
malaria the blood parasites are always demonstrable, and in chronic
cases the history and the locality are significant.
Hepatic cirrhosis (a.nd Banti's disease) should show evidences of
portal stasis (ascites, jaundice, haematemesis).
Splenic ancemia means simply an aiiEemia of unknown origin
associated with an enlarged spleen.
Leuhannic enlargement of the spleen is easily recognized by the
characteristic blood picture.
416 PHYSICAL DIAGNOSIS.
Jlodgldn's disease shows glanilular enlargements in the neck,
axillffi, and groins, with normal blood. Histological examination
of au excised gland is necessary for diagnosis.
Amyloid can be suspected (never positively diagnosed) as the
cause of an enlarged spleen, if there is a history of syphilis or
chronic suppuration (hip abscess, phthisis, etc.X
Diseases of the Kidxey.
Incidence of lienol Zfisease (Massachusetts General Ilosjiital, 1870-
1905).
Acute nephritis 200
Chronic glomcrulo-uephritis 417
Chronic interstitial neplu'itis 350 '
Amyloid nephritis 9
Floating kidney 337
Stone in the kidney ' 145
Malignant disease 43
Tuberculous kidney 41
Pyouepbrosis and abscess 54 ^
Perinepbritic abscess 35
Kydrouepbrosis 19
Cystic kidneys 10
Total 1,449
We get evidence of diseases of the kidney in four ways :
1. By external examination of the region of tlie kidnej'.
2. By examination of the urine.
3,. By cystoscopy and the ureteral catheter.
4. By study of the constitutional symptoms — fever, leueocyto-
sis, aiuemia, uriiemia, dropsj% cardiac hypertrophy.
Local exam illation acquaints us with the presence of tenderness
and tumor.
{a) Tenderness is present usually in abscess of the kidnej^ (tu-
berculous or non-tuberculous) and in perinepbritic abscess, less
often in connection with nephrolithiasis, occasionallj' in hydrone-
' Seven hundred and seventy-live other cases of " uepluitis " not further
speciried.
^Including acute ba'niatogenovis cases.
THE INTESTINE, SPLEEN, KIDNEY. 417
phrosis and malignant disease. A floating kidney may have an
exquisite and peculiar sensitiveness to pressure, which differs from
ordinary tenderness.
(5) Tumor in the kidney region may occur in abscess in or
around tlie.kidney (including tuberculosis of the kidney and pyo-
nephrosis), malir/nant disease, hydro7iephrosis, and cystic kidney.
The latter members of this list afford examples of the largest tu-
mors associated with the kidney.
Characteristics Common to Most Tumors of the Kidney.
Renal tumors are best felt bimanually, one hand in the hypo-
chondrium and the other in the region of tlie kidney behind, with
the patient in the recumbent position. In this way the tumor may
often be grasped and an impulse transmitted from hand to hand.
It is usually round and smooth, often very hard, less often fluctu-
ating. It descends slightly with inspiration. If the colon Is in-
flated by forcing air into the rectum with a Davidson syringe, res-
onance appears in front of the tumor; this serves to distinguish it
from tumors of the spleen which are pushed forward by the inflated
colon as it passes behind them. Tumors of the kidney never pre-
sent a thin and sharp edge, like that of the spleen. Occasionally
they are irregular and nodulated — a condition almost never found
in the spleen.
(«) Malignant disease of the kidney, sarcoma, or hypernephroma,
is much commoner in children than in adults, and makes up the great
bulk of the large abdominal tumors occurring in childhood. The
characteristics of the tumor are those already described, except tliat
in advanced stages the tumor pushes forward from its position in
the loin until it may reach the umbilicus or even fill the abdomen.
Kodular irregularities can usually be felt. There may be haematu-
ria, emaciation, and auEeniia, sometimes leucocytosis. Metastases
— especially bone metastases — are often the tirst evidence of the
disease.
(p) Hydronephrosis and cystic kidney may be indistinguishable
from each other unless the hydronephrosis is intermittent and dis-
appears with a great gush of urine, or unless the cystic kidney is bi-
lateral— as, indeed, is usually the case. In both diseases a smooth,
27
418
PHYSICAL DIAGXOSIS.
roiuul tumor forms in the loin and hj-pocliomlrium, usually without
much constitutional disturbance aud very fretj^uentlj' with a urine
like that of chronic interstitial neiihvitis (see below) (see Fig. 189).
Tain and tenderness are slight. Tlie tumor uiaj' be astonishingly
hard and often gives no sign of fluctuation. With cystic kidne}- it
nurjr be coarsely lobulated. Like other tumors of tlie kidney it de-
scends sliglitly on inspiratiou. C3'stic kidneys are often congenital,
but usually produ(H> no svinptonis until they have attained a consid-
erable size, and hence are often t)vcrloiiked or discovered accident-
all}'. lu hydronejihrosis the diagnosis may be assisted lij^ etiological
liiuts, such as an abnormal degree
of mobility of tlie kidney on tlie
alfected side, a Iiistov)' of renal
colic ^\•illl or without hiematuria,
or a prostatic obstruction.
((■) I'iriiicji/irlf/c (ihf:ci:<s usually
works its ^vay to the surface in the
back, between the crest of the ilium
and the twelfth rib. This was the
situation of tlie external tumor in
12.") out of o5 eases recorded at the
Massachusetts General Hospital.
A tender swelling appears at the
point just described, sometimes
wilh redness and heat, and almost
alwaj-s with fever, chills, leuco-
cytosis, and some enunciation. Tlie
urine niay show nothing abnormal
or nmy show tin' evidence of cys-
titis, of concomitant nephritis, or,
rarel)', of an abscess within the kidne^y itself. I'erinephritic ab-
scess often i-eumius latent f(u- weeks or n\ouths, and the anmunt of
pus accumulated may be a ipuirt or more.
( (I ) ^llisccss affile Jcidiici/, including tuberculous, suppurating kid-
neys and pyonephrosis, usually produces a suu)oth, round tumor in
the h3-pocliondriuui and loin. It has the characteristics common to
most renal tumors (_see last page), but is usually distinguishable by :
Fig. ISO.— Left Hydruneplirusis.
THE INTESTINE, SPLEEN, KIDNEY. 419
1. The etiology (r-ystitis, stone in tlie kidney, tuberculosis, pj'se-
mia). In acute cases, however, there is often no discoverable cause.
2. The pi'esence of renal pyuria (see below, page 423).
3. The presence of fever, leucocytosis, and the usual constitu-
tional signs of an infectious process.
(e) Floating Kidney ; Dlsidaced and Movable Kidney. — The tip
of the right kidney is palpable in most thin persons with loose belly
w^alls. If the whole organ is palpable but not movable, we speak
of it as displaced. If the range of mobility is relatively great we
call \t floating ; if relatively slight we call it movable. With biman-
ual palpation (as described above) we exert pressure just at the end
of a deep inspiration and maintain it. During expiration something
smooth and round may then be felt to slip U[)ward between our
hands toward the ribs. If the kidney " hides " behind the ribs,
have the patient sit up, cough, and breathe deeply; then repeat the
bimanual jialpation as lie lies on his back. Very movable or float-
ing kidneys may be found far from their normal home, and are then
recognized by : 1. Their size, sliape, and slippery feel. 2. The
sickening pain produced by pressure. 3. The ])ossibility of replac-
ing them.
Renal Colic and Other Renal Pain.
Typical rennl colic \'a paroxysmal, like all colics; that is, an at-
tack begins suddenly, ends suddenly, and lasts but a few hours or
less. The pain usually begins in the back, over the kidney, and
follows the course of the ureter to the groin. During an attack the
testicle on the affected side may be tender and drawn up tightly by
contraction of the cremaster.
When associated with hsematuria or i)yuria, with or without sud-
den stoppage of water during an attack and without any general or
constitutional symptoms between attacks, renal colic is strongly sug-
gestive of stone in the ])('lvis of the kidney; but similar attacks may
occur with other surgical diseases of the kidney, with tuberculosis,
with kinking of the ureter, and very often without any cause dis-
coverable at operation.
From biliary colic it may be distinguished by the (a) different
27
i-0 PHYSICAL DIAGyOSIS.
situation of the pain, {/>) by the presence of blood or pus in the
urine, and (^c) tlie absence of jaundice in this or a former attack.
Froui I^ictl'g i'fifiit: (severe colicky pain occurring in connection
witli floating kidney'), renal colic is distinguished by the absence of
abnormal mobility of the kidney and by the situation and course of
the pain.
Iir i/itrsfinal rnl'ti- the jiain shifts its ]iositiou frequently and is
associated witli noises produced by wind in the bowels, or with diar-
rluea or constipation.
Be/Ill/ 2>'i ill, ii'if coll,', occurs in almost any disease of the kidney
except neplivitis. and is characterized b3' its situation over the ana-
tomical seat of the kidney and b_y the lack of any connection with
)nuscular movements (lumbago'), with spinal movements (^hypertro-
phic arthritis), or with the sacro-iliac joint.
I have now described what seems to me most important in tlie
lociil e.rterniil examination for kidney disease, and have mentioned,
along with the different lesions producing tumor, the geneial con-
stitutional manifestations which are of assistance in diagnosis.
Aside from the local and the constifntioiuil evidence of renal disease,
we have only the evidence afforded bj- the urine, to which I now
pass on.
Examination of tlie I'riiic.
The urine as passed per urethram is a resultant and reflects the
influence of many different organs and surfaces. Thus disturb-
ances of metabolism, such as diabetes, intoxications (lead, arsenic),
diseases of the heart, liver, and intestine, febrile I'onditions. infec-
tive or malignant disease of any ]iart of tlie urinary tract (^kidney,
ureter, bladder, or urethra), as well as the different tyjies of ne-
phritis, all affect the urine, though hardly any of them produce
piathognomonic clianges in it. In this section 1 shall consider tlie
urine as a piece of evidence in the diagnosis of kidney disease, and
only in contrast with this will its characteristics in extrarenal
troubles be mentioned briefly.
The most essential features of the urine in the diagnosis of kid-
ney disease arc :
1. The amount passed in twentj-four liours, measuring sepa-
THE INTESTINE, SPLEEN, KIDNEY. 421
rately the portions passed at night (8 p.m. to 8 a.m.) and in the
daytime (8 a.i\i. to 8 p.m.).
2. The specific gravity.
3. The loolvs (optical properties).
4. Tlie reaction to litmus.
Much less important than these are the microscopic and chemi-
cal examinations (albumin, casts, etc.).
The Amount and Welglit of tlie Urine.
The twenty-four-hour amount concerns us chiefly in diabetes and
the different types of nephritis.
Foli/urla occurs in health after the ingestion of large quantities
of water, and sometimes in conditions of nervous strain. In dis-
ease it characterizes both forms of diabetes, cirrhotic kidney (pri-
mary, secondary, or arterio-sclerotic), and is seen during the con-
vaJescence from acute nephritis and from various infectious diseases.
In diabetes of either form several quarts or even gallons may be
passed. lu cirrhotic kidney the increase of urine occurs very largely
at night, so that the amount may be double that passed in the day-
time, just reversing the conditions of health.
Olifjuria or scanty urine occurs in health when the amount of
water ingested is small or when water is passed out of the body
abundantly through the skin or by the bowels (diarrhoea). In dis-
ease oliguria or absolute suppression of urine (^anuria) occurs at the
beginning of cwute nephritis and as a result of occlusion of one or
both ureters by stone or malignant disease.'^ Remarkable examples
of anuria also occur in hysteria. Infectious fevers and cachectic
states often diminish the secretion of tlie urine by one-half or more.
The specif c gra.vity is usually low with polyuria and high with
oliguria, but in diabetes mellitus the presence of the sugar gives us
jjolyuria with high specific gravity.
Total Urinary Solids. — By multiplying the last two figures of
the specific gravity by the number of ounces of urine passed in
' It is a remarkable but well-attested fact that wben one ureter is suddenly
blocked both kidneys may stop secreting for the time. Yet when one kid-
ney is gradually destroyed as in tuberculosis, the other hypertrophies so as
to assume the function of both.
422 PHYSICAL DIAGNOSIS.
twenty-four hours nnd the product hy 1.1, wo get a tigiire represent
ing the total uriuary solids in grains, with accurac}' suttteient foi
clinical diagnosis. Thus if 30 ounces of urine are passed in L'J
hours and the gravity is 1.020, then 20 \ 30 x 1.1 = titiO grains.
The signiticance of this figure will be discussed later (see page 428).
Optical Properties.
Color. — Dilute urines (polyuria) are generally pale, and concen-
trated urines (oliguria) high in color. A dark or brownish tint in
the urine is generally produced by bile, by lilood pigment, or as a
result of certain drugs — carbolic acid, coal-tar preparations, and
salol. If the color is due to bile, a briglit canary yellow appears in
the foam after shaking up a little of the urine in a test tube. No
other tests for bile are necessary. Urines darkened by blood pig-
ment show abundant blood corpuscles in the sediment;' when the
color is due to drugs we can usuallj' learn this fact from the his-
tory.
TurhiiJitij in alkaline urine is usually due to the jiresence of bac-
teria. In acid urine it is produced in a great majority of eases by
amorphous urates, and disappears on heating the urine, while the
turbidity due to bacteria is unaffected by heat. Xormal urine may
be turbid and alkaline, owing to the presence of insoluble carbo-
nates and phosphates, bat clears on the addition of acetic acid.
Hence turbidity, not removed bj- heat or acetic acid, is almost
always due to bacteria, i.e., to cj'stitis, pyelonepluitis, or both.
Slireih seen floating in the urine are presumpti\e evidence of
urethritis, and practically always of gonorrlura.
The (jross sediment as seen by tlu' naked ej'c amounts in health
to nothing more than a slight cloud, which settles in the lower part
of the vessel containing the urine. Tliis cloud is somewhat denser
in women than in men, owing to the presence of vagiiuil detritus.
When the gross sediment amo\uits to anything more than this, it is
almost invariably made up of (<() jitis, {/i) hlooil, or ( c) urates.
The latter are dissolved on heating. Pus has usuallv its ordinary
yellow color and general apiiearance. lUood maj- be somewhat
' Exci-'pt in Slime eases of iuviiiDglnbinuiia.
THE INTESTINE, SPLEEN, KIDNEY. 423
lighter or somewhat thirkev tliau under ordinary conditions, but is
usually recognized without difficulty.
SiGNiFicANcio OK THESE SEDIMENTS. — A urdfij, Sediment means
nothing ]uore tiiaii a concentrated urine standing in a cold room.
In the winter-time patients often bring us, in great alarm, a bottle
of milky or fawn-colored and turlnd urine, which is not in any way
abnormal. The urates have been precipitated over night by tlie low
temperature of the bedroom.
Pyurit, or gross pus in the urine, is oftenest seen in cystitis
and less often in pyelonephritis and renal suppurations. The pus
occurring in gonorrhceal urethritis is usually much less in quantity
than that coming from tlie bladder or kidney, and can be distin-
guished by the local signs of gonorrhcea. Leucorrhosal pus can be
excluded by withdrawing the urine by catheter. The rupture into
the urinary passages of an abscess from the prostate or any part of
the pelvis may produce a profuse but transient p)yuria.
After excluding gonorrhcea, leucorrhcea, and abscess, which can
usually be done with the help of a good history and a catheter, we
have left ci/sfitis and renal suppurations, whicli it is verj' important
and sometimes difficult to differentiate. In both we have the fre-
quent and painful passage of small quantities of a urine which is in
no way remarkable except in containing large amounts of pus and
bacteria. Cystoscopy is often essential.
In many cases the differentiation may be accomplished as fol-
lows : Have the patient save for twenty-four hours the urine voided
at each passage in <i separate bottle (all of tlie bottles Ijeing of uni-
form size), and mark ea(th bottle with the hour at which it was
tilled. Then arrange the specimens in a row, beginning with that
passed earliest and ending with that passed last. Now if the case
is one of cystitis without involvement of the kidney, tlie amount of
pus that settles is jiractically the same in each bottle (allowing for
differences in the amount of urine in the different bottles). But if
the pus conies from the kidney, it is almost always discharged in-
termittently, and hence some of the bottles will be almost free from
sediment, while in a group of the others the amount of pus increases
as we pass along the line, reaches a maximum in one or two bottles,
and decreases again in those representing the later acts of micturition.
424 PHYSICAL DIAGNOSIS.
Pus from the bladder is generally alkaline, although in tubercu-
losis it may be acid; pus from the kidney is generally acid. When
both organs are involved, as is frequently the case, we have a mixt-
ure of the characteristics of both types of pyuria, and cystoscopic
examination with or without catheterization of the ureters is usually
necessarj'.
In renal pl/nria we often have local signs in the renal region
(tumor and tenderness ), a history of renal colic, and decided con-
stitutional symptoms.
In vesical pi/uria we have vesical pain, often tenesmus, no renal
pain or tumor, and usually slighter constitutional symptoms. The
amount of squamous epithelium (see below) is sometimes larger in
cystitis than in renal suppurations, but no reliable inferences can be
drawn from the size or shape of the cells.
To determine whether jms from the bladder or the kidney is tu-
berculous or non-tuberculous in origin, we usually inject the sedi-
ment into a guinea-pig, which develops tuberculosis or not accord-
ing to the nature of the pus injected. This method is much more
reliable than the bacteriological examination of the sediment, for
besides the tubercle bacillus other bacilli which retain fuchsin and
resist decolorizatiou by strong mineral acid and by alcohol occasion-
ally occur in the urine.
Hcrmaturia. — In searching for the source of the blood we must
be sure to exclude the female genital organs. IMenstrual blood and
uterine bleeding from various other causes often contaminate the
urine, and must be excluded by using a catheter.
The causes of true hematuria, arranged approximately in the
order of frer|iiencj', are:
1. ICarly cystitis.
'J 8tone in the kidney (less often vesical stone).
3. Acute nephritis and acute hemorrhage in chronic nephritis.
4. Tumors of the kidney or bladder.
5. Tuberculosis of the kidney or bladder.
Less common causes are: floating kidney, hydronephrosis and
cystic kidneys, aninml jiarasites in the urinarj' ]iassages, poisons
(turpentine, carbolic acid, eantharides), hemorrhagic diseases
THE INTESTINE, SPLEEN, KIDNEY. 425
(purpura, scurvy, leukasmia), trauma and renal infarction. In
nearly half of all cases no tunise can be found.
In cystitis there are bladder symptoms — pain, tenesmus, fre-
quent and painful micturition. The blood is mixed with pus and
epithelium, and is especially abundant in the urine passed near the
end of the act of micturition. If the bladder is irrigated it is hard
to get the wash-water clear.
In renal stone tliere are no bladder symptoms to speak of, the
blood is pure and thoroughly mixed with the urine, and if the blad-
der is washed out tlie final wash-water is clear. There is often
renal colic (see p. 419) and sometimes the passage of stones or
gravel by urethra.
In acute nejjhritis the blood is rarely fresh, generally dark choc-
olate in color. The twenty-four-hour amount of urine is small,
and albumin and casts (see below) are abundant. General oedema
is common. Local symptoms in the kidney or bladder are absent.
In renal tumor and especially in renal tuberculosis^ a have often
pyuria and the local and constitutional evidences above described
(page 418), with m.arked and early bladder symptoms (even when the
bladder is not diseased J.
Tumors of the bladder need cystoscopy for diagnosis.
In the diagnosis of the rarer forms of ha;maturia we rely chiefly
on the history (trauma, poisons ingested) and on the evidences
afforded by cystoscopy and general physical examination.
Chemical Examination of the Urine.
1. The Iteaction of the Urine.
The reaction of normal urine is acid to litmus, except tempora-
rily after large meals. Its acidity becomes excessive in fevers or
occasionally without any known cause.
Alkaline urine has generally an ammoniacal odor and suggests
cystitis. As a result of decomposition and bacterial fermentation all
urine becomes alkaline (ammoniacal) on standing exposed to air.'
'Simultaneously a dark-brown color rarely appears: (dkaptonuria, a fact
426 PHYSICAL DIAGNOSIS.
Occasionally we find urine alkaline from fixed alkali and without
known cause.
The value of the litmus test is chiefly &s jji'lma-facie m'idence of
stasis in the bladder and cystitis. Occasionally tuberculous cystitis
and the first stages of any variety of cystitis are associated with
acid urine, but in most cases lasting o\'er a week animoniacal fer-
mentation and alkalinity appear.
//. Albuminuria and the Texts; for It.
Serum alhumin is the only variety of clinical importance, and
for this but two tests are necessary: (1) Nitric-acid test; (2) test
by boiling.
The nitric-acid test is best performed in a small wineglass.
After filling this half full of urine, insert a small glass funnel to
the bottom of the urine and gently pour in concentrated nitric acid.
If albumin is present, a white ring forms at the junction of the acid
with the urine, either immediately or in the course of ten minutes.
If carefully performed this test is delicate enough for all clinical
purposes, but since some of the albumoses give a similar precipitate,
the boiling test should be used as a control whenever a positive re-
action is obtained with nitric acid. None of the other rings, ob-
servable above or below but not at the junction of the acid with the
urine, is of any clinical importance.
Tlie Boiliii;/ Test. — To half a test tube full of urine add three or
four drops of dilute acetic acid, and boil the uppei' three-quarter
inch of the urine. If albumin is present a white cloud a^ipears. P
albumose is present a white cloud appears on heating, disappears on
boiling, and reappears on cooling. In jjerforming this test the ad-
dition of acetic acid as above described is absolutely necessary to
prevent error.
For the detection of albumin no other tests are needed. For its
approximate quantitative estimation, Esbach's method is the best.
JSsbach's Method. — A special tube (see Fig. 190) is employed.
at present of no clinical significance except that such urines redvicc Fehhng''.j
solution and may be mistakenly supposed to contain sugar.
THE INTESTINE, SPLEEN, KIDNEY.
427
Urine is poured in up to the mark "U," and then Esbach's reagent '
up to the mark "E." The tube is then corked, inverted about half
a dozen times, and set aside for twenty-four hours. A precipitate
falls and tlie amount per mille is then read off on
the scale etched upon the tube. If the urine is not
acid it must be made so with dilute acetic acid, and
unless its specific gravity is already very low it should
be diluted once or twice with water so as to bring
the gravity below 1.008. After such a dilution we
must, of course, multiply the result obtained by a
figure corresponding to the dilution. The method
is not accurate, but is probably accurate enough for
practical purposes.
III. Significance of Albuininuria.
It is important to realize that albuminuria very
often occurs without nephritis and that nephritis oc-
casionally occurs without albuminuria. Among the
more important types not due to kidney disease are
the following: (1) Febrile albuminuria; (2) albumi-
nuria from renal stasia; (3) albuminuria due to pus,
blood, bile, or sugar in the urine; (4) toxic albuminuria.
Besides these, there are a good many cases of
albuminuria occurring in diseases of the blood, after
violent exertion, after epileptic attacks, aud without
any known cause. Many of the latter group occur
only in the daytime when the patient is in an upright
position, and are absent as long as the patient lies
down (^orthostatic albuminuria); others occur inter-
mittently and sometimes at regular intervals (cyclic
albuminuria).
Exclude fever, circulatory disturbance, anaemia, poisons — such
as cantharides, turpentine, carbolic acid, and arsenic and deposits
' Esbach's reagent: Picric acid, 10 gm,; citric acid, 20 gm, ; distilled water,
1,000 c.c.
Fig. 1S)0. — Es-
bach's Albu-
menometer.
42S PHYSICAL DIAGNOSIS.
of blood or pus in the urine, before deciding that a case of albumi-
nuria is due to nei)hritis. To exclude the cyclic and orthostatic
varieties is more difficult, and some authorities believe that tliese
represent true neiiliritis in a more or less latent stage. In general,
however, it is a good rule not to attribute albuminuria to nepliritis
unless there is other and more convincing evidence in the physical
characteristics of the urine and in tlie other organs of the patient.
If tlie 24-hour amount and the gravity are approximately normal,
and if there is no tedema, no increased blood pressure, no cardiac
liyjiertrophy, no uriemic manifestations, and nothing alarming in tlu^
sediment of the mine, ^ve shoukl not ihagni}se nephritis. I sliall
discuss this point further in the section on the examination of the
sediment (see page 431). It will be noted that praiiicul/i/ all tlie
types of allniminiirid not due to nepJirk'is are- tra/isieiit, wliile, with
the exception of certain stages of chronic interstitial nephritis, the
albuminuria of nephritis is as permanent as the nephritis itself.
IJ\ Glucofiiria and Its Slgnijiemiee.
For glucose in the urine we need but one qualitative and one
quantitative test, viz., Fehling's test and the fermentation test.
1. FehUnffs Test. — Mix in a test tube equal parts of a standard
solution of copper sulphate ' and a standard solution of alkaline tar-
tartes,'' and add to this mixture an equal amount of urine. Mix
and heat nearly to boiling. The amount of error entailed by boil-
ing is slight and unimportant, but the only advantage of boiling is
a slight saving of time. If sugar is present a yellow or reddish-
yellow precipitate occurs, either at once or (if the amount of sugar
is very small) after the urine has cooled. Fehling's solution may
also be used for (juantitative estimation of sugar, but it is more
convenient to use :
' Made liy dissolving 34.04 gm. pure CnS04 in water and tlicn adding
enougli water to make 500 c.c.
-Made by dissolving 173 gni. Kocbelle salts and GO gm, sodic hydrate eaoli
in 300 c.c. of water, mixing the two solutions, and adding water to make
500 c.c.
THE INTESTINE. SPLEEN, KIDNEY. 429
2. The Fermentation Test. — Take the specific gravity of the
urine as carefully as possible. Pour six or eight ounces of urine
into a wide-mouthed vessel and crumb into it half a cake of fresh
Fleischmanu's yeast. Set the flask aside in a warm place, and after
twenty-four hours test the supernatant fluid with Fehling's solution
as above; if sugar is still present fermentation must be allowed to
go on twenty-four hours longer. As soon as a negative reaction to
Fehling's luis been secured (whether in twenty-four or forty-eight
hours), the specific gravity of the filtered urine is again taken, i It
will be fouiul lower than before the fermentation, and for every
degree of S])ecific gravity lost we may reckon that 0.23 per cent of
sugar has been fermented out of the urine. Thus if the reading
was 1.040 before fermentation and 1.020 afterward, we multiply
the difference between these readings, 20, by 0.23, giving 4.6 p)er
cent — the percentage of sugar.
Felding' s test should be ajjplied to every urme exarnmed ; it takes
but a minute or two. When it shows a yellow or red precipitate, the
fermentation test should also he tried ; and if both tests are jjositive
tve shall run but a negligible risk in saying that glucose is present.
From the result of the fermentation test and the twenty-four-hour
amount of urine, we can estimate the daily output of sugar through
the urine.
Permanent glucosuria means diabetes mellitus. Transitory glu-
cosuria may be due to a great manj' causes, among which are : (1)
Diseases of the liver; (2) diseases of the brain, organic or func-
tional, especially the latter ; (3) infectious fevers ; (4) poisons, es-
pecially narcotics (alcohol, chloral, morphine) ; (5) pregnancy; (G)
exophthalmic goitre.
Experimental ("alimentary") glucosuria can be produced in
many of these same diseases by giving the patient 100 gm. of glu-
cose in solution.
The differential diagnosis of the cause of glucosuria depends on
the recognition of one of the above conditions.
' The room temperature must be approximate!}' the same as at the time
of the previous reading.
130 PHYSICAL DIAGNOSIS.
V. The Acetone. Bodies.
Acetone, Diacetic and Beta-Oxybutyric Acids.
1. Test for Acetone. — To about one-sixth of a test tube of urine
add a crystal of sodium nitroprusside, and then ISTaOH to strong
alkalinity. Shake and add to the foam a few drops of glacial acetic
acid. A purple color shoirs acetone.
2. Test for Diacetic Acid. — A Burgundy red color when a strong
aqueous solution of ferric chloride is added to fresh urine {not pre-
viously boiled) in a test tube. If this reaction is well marked beta-
oxybutyric acid is probably also present, but "we possess no clinical
test for the latter substance.
Sic/nip'eance of tJie Acetone Bodies. — Diminishe<l utilization of
carbohydrate food by the body is usually the cause of the appear-
ance of these bodies in the urine. This may occur: (*() Because suf-
ficient carbohydrates are not eaten (starvation, rectal alimentation,
fevers, etc.). {h) I>ecause they are not cdisorhed (vomiting, diar-
rhoea, etc.). (c) Because they are not assimilated (diabetes).
VI. Other Chemical Tests.
The information to be derived from testing for indiean, for the
amounts of urea, uric acid, chlorides, phosphates, and sulpliates,
does not seem to me sufficient to justify the time spent. The same
is true of the diazo reaction.
Simon's lucid arguments for tlie value of the indiean test have
not been borne out by my experience with it in diagnostic puzzles.
The tests for urea and uric acid are of value only when we possess
a knowledge of all the factors governing their excretion, knowledge
which in clinical work we almost never have. Diminution or ab-
sence of the urinary chlorides in pneumonia is not constant, and
occurs in many other infections (typhoid, scarlet fever, etc.). The
diazo reaction is nearly constant in typhoid, but is occasionally
found in so many other febrile and cachectic states that most clini-
THE INTESTINE, SPLEEN, KIDNEY. 431
cians have ceased to rely on it. Its value in the prognosis of
phthisis is slight. I believe that the general abandonment of the
tests for the sulphates and phosphates will soon be followed by the
abandonment of the tests for urea, uric acid, indican, and the chlo-
rides. The use of these tests gives the wppearaiice of accuracy and
scientific method in diagnosis — the appearance, hut not the reality.
VII. Microscopic ISxamination of ZTrinarij Sediments.
Methods.— A. centrifuge is convenient, but not necessary. The
sediment should be allowed to settle in a conical glass (see Fig.
191), whence a drop of it can be transferred to a slide by means of
a pointed glass pipette. Close the upper end of this
with the forefinger and introduce the pointed end into
the densest portion of the sediment; next very slightly
relax the pressure of the forefinger until urine and
sediment flow into the lower one-half or three-fourths
inch of the pipette. Then resume firm pressure with
the forefinger, withdraw the pipette, wipe the outside
of it dry, put its point upon a microscopic slide, and fig. 191.— con-
again sliahtli/ relax the pressure of the forefinger so "■"' ^^'^^ '"''
° -^ '' ^ , . ° Urinary Sedi-
as to let a small drop of urine and sediment run out ments.
upon the slide. Cover this drop with a seven-eighths
inch cover glass, and examine it with a Leitz objective No. 5 or
Zeiss DD.
The arrangement of the light is most important. The iris dia-
phragm should be closed until one can just distinguish the outlines
of the cells and other objects in the field. If more light is ad-
mitted the pure hyaline casts will be invisible.
Results. — The objects of chief importance in the sediment are :
(a) Casts; (b) cells; (c) crystals; (rf) animal i^arasites or their
eggs.
1. Casts. — Casts, or moulds of the renal tubules, may be homo-
geneous and transparent (hyaline. Fig. 192, 1) or may have attached
to this matrix a variety of graiiules, cells, crystals, or fat drops.
According to the variety of passengers carried down from the kid-
PHYSICAL DIAO^'OSIS.
Fin. 192.- Casta. J, Hyaline oasts: - and .'. hyaline oasts
with cells and blood adherent; 4, "eylindroids."
uey on the casts, we call tliem tjraiiular, hrown-granular, cc/lti/ar,
hlood, fatfi/, or cri/sta/-
/iniriii;/ casts (see Fig.
1".)L', l' and S, and Fig.
J9.S, 1, •^, S, and 4).
Dense ov !i ir/h/i/ n-
fracfi/v rasts, oolcirless
or straw colored, are
occasionally seen, and
are often given a va-
riety of names quite
unjustified by any
knowledge of their
composition (('.;/.,
" wax}'," ' " fibrinous,"
etc.).
From strands of
mucus, foreign bodies, and other sources of error, true casts nmy
be distinguished by the fol-
lowing traits :
(a) Their side.s are par-
allel.
(b) One end is rounded;
sometimes both ends.
Med corpuscles mid oflicr
cells upon casts are to be rec-
ognized— the former by the
size, shape, and, if fresh, by
their color Qiale straw ) ; the
latter by the presence of a
nucleus.
Fdt drops are spherical
Fig. 193.— Casts. 1, Tllood-oasts; J, fatty casts; S,
' Some dense, refriit:tile casts granular easts ; 4, cellular oasts,
give the amyloid reliction, but
this does not indicate ainyhiid kidneys and has no known elinieal signifi
cance.
THE INTESTINE, SPLEEN. KIDNEY. 433
and very highly refractile, so that they seem to have a black line
at their periphery.
Ci-i/stals can be recognized by their angles. They are of no im-
portance.
Other bodies on casts are called gramdes.
SifiNiFiCANCE OF Casts. — Casts may occur in health (unless we
choose to class muscular fatigue as disease) as well as under any of
the conditions giving rise to albuminuria (see J)age 427). They are
usually more numerous in nephritis than in most other conditions.
Any type of cast may occur in any type of nephritis, but
C'flhihir,^ blood, and hrow7i^gramdar casts are most often found
in acute nephritis.
Fattij, liifjhlij refractinf/, or dense casts most often predominate
in chronic (jlonieridar nephritis ("diffuse" or "parenchymatous"
nephritis).
Hyaline and granular casts may occur in any type of nephritis
and in many other conditions (fatigue, renal stasis, etc.). In the
urine of persons over fifty years of age the presence of a few hya-
line and granular casts has no known clinical significance, and may
probably be considered physiological.
Periods occur in the course of many cases of chronic interstitial
nephritis when no casts can be found. If any occur they are usually
of the hyaline and fine granular types.
2. Free Cells in Urinary Sediment. A. Becognition. — The pres-
ence of macroscopic pus or blood already alluded to may be veri-
fied by the microscope.
(a) Fresli red cells, lately freed from the blood-vessels, preserve
their straw-yellow color. Their presence points to the recent effu-
sion of blood, probably from the bladder, urethra, or renal pelvis.
Q)) Abnormal blood, decolorized and shadowy red discs, can be
recognized wii;h practice by their size and shape. We may infer
that they have remained some time in the urine and have probably
come from the kidney.
' "Cellular " is a better term than "epithelial," since we have no marks for
recognizing renal epithelium or for distinguishing a renal cell from a lym-
phocyte.
28
434
PHYSICAL DIAGNOSIS.
Cf^■if
0
f9
/^
l-"i(!. 104.— Sp(Tiiia1<"'Zi
0
',
(r) Pus is easily recognized as a rule by the presence of the
familiar polymorphous nucleus in luost of the cells. Should (Umht
arise, a droii of dilute aceti(^ acid allowed to run
under the cover glass Avill sharpen the outlines
of the nuclei and facilitate their recognition.
(d) Spermatozoa (see Fig. 194) are often seen
in the urine after coitus or nocturnal emissions.
They are of no importance, excejit that when
appearing in the urine of females they nuiy afford
valuable medico-legal evidence. They are easily
recognized by their size and shajie.
(c) Other varieties of cells need not be differ-
entiated, sinci' almost anv of tlie varieties usually described (si/iic-
moiis, sjiinJlc-shiijii-il, finuhiti:, etc.) may come from any part of the
urinary tract. luiinl clU are not recognizable by our present
methods of examination.
Any of the urinary cells
may contain fat droiis, but these
have no special diagnostic sig-
nificance.
B. Intcrprcfdfioii. — The
signihcance of large quantities
of blood or of pus in the urine
has already been discussed
(page 423). When recognizable
<iii/i/ by the microscope they
have no diagnostic value.
The [u'esence of large num-
bers of cells not coming from
the blood-vessels (squamous,
spindle-shaped, etc.) is usually
associated with cystitis, pro-
vided the acndental admixture
of vaginal detritus is excluded. Pyelitis and renal sujjpurations
may fill the sediment with similar cells, and oulj' by other methods
of examination (i'ystoseo]iy, ureteral catheterization) and by tak-
FiG. 19.").— Crystals cif Triple Ptiosphat
and Aramoniiiiii Urate (suuiU
spines).
THE INTESTINE. SPLEEN, KIDNEY.
435
p:'
V> ,.« 0
Q'*,® ®
* ^5!.?,*
x^f
"^>*
«>
Cc
.0
iiig account of all the facts in the case can the differentiation be
made.
3. Crxjstuh in Urinari/ Sediments (see Figs. 195, 196, and 197).
^ — The varieties oftenest seen
.^^c-^^^f^ are: {<i) Triple phosphate
(ammoniacal urine, cystitis) ;
(b) ammonium urate ; (c)
uric acid; (rf) calcic oxal-
ate.
All of these varieties are
colorless except the uric-acid
crystals, wliich are usually
light or dark yellow or yel-
lowish-brown.
None of these have much
significance in diagnosis.
The first two merely confirm
the evidence of urinary de-
composition (usually from
cystitis) afforded by the re-
action, turbidity, and odor of the urine.
Uric-acid crystals, if present in great numbers in the urine when
passed, suggest the search for
macroscop)ic masses (gravel)
and for other evidence of renal
stone, but as a rule they are of
no importance.
The same may be said of
calcium oxalate. Oxaluria is
one of the most persistent bug-
bears of the medical profes-
sion, but it is utterly harmless
except in the rare cases in which
it accompanies macroscopic
gravel and jjoints to renal stone.
4. Animal ^Mrasites or their eggs are occasionally found in the.
Fig. 196.— Crystals of Uric Acid (whetstone-shaped)
with Calcic Oxalate (small octahedral) and Amor-
phous Urates.
Fig. 197.— Calcic Oxalate Crystals.
4:i6
rHYSICAL DIAGXOSIS.
mine, with ov witliout luvinatuvia ami eviJoiice ot cystitis i^see Figs.
198 aiul 109 V
CJL-?
Fir. 1»*.— Vinosr:"' Ia-Is in t'rino. (UiUiiiL's.^ n, rrolnuii'd liooks nf ih;iU' ; /■. toi>-sliii|n'i1
lins also iR'eu found lu the urine.
iSiini Ilia ri/ ofllir Criihiri/ Pirfiiri's .l/o.s';" Usffiil in ./''idijiidsis.
Aside from poli/iiria, iilltiuv'hi , lufiiidf uriti, ami /ii/iiria, wliich
have already been disiuissed, (ho iimst imiiovtant. conditions in
which the \ninc iiives valuabh' diai^nostic evidence are:
THE INTESTINE, SPLEEN, KIDNEY.
437
1. Cystitis. — Urine passed frequently, painfully, and in small
amounts. Turbid, ammoniacal, and offensive (after the earliest
stages). Much pus and many other cells are found in the sedi-
d'\r' ®- / ®
Fig. 199.— Bllharzia Eggs in the Urine, with Blood, Calcic Oxalate, and a Hyaline Cast. (O'Neil.)
ment, with bacteria, triple phosphate crystals, and amorphous
debris.
2. Ai'iite. NepJiritis (or acute exacerbations in chronic cases). —
Scanty, heavy, highly albuminous urine, often bloody and contain-
ing in the sediment iii.iicJi hlood and many cells, free or on casts.
Other varieties of casts occur, but are not characteristic. In con-
valescence the urine becomes abundant and of light weight, and
the other abnormalities gradually disappear.
3. Chronic Glomerular Nephritis ("parenchymatous"). — The
urine is rather scanty, pale, and of light weight (1.012-1.018,) with
a large amount of albumin and, in the sediment, much fat — free.
43S PHYSICAL DIAGNOSIS.
in cells, and on casts. Also found, but not characteristic, are all
the other varieties of casts. If death does not ensue within eigh-
teen months, the urine is apt to assume the characteristics of the :
4. Contracted kidney (primary, secondary, or arterio-sclerotic),
with polyuria (often several quarts; urine especially abundant at
night), low specific gravity (1.010 or less). Traces of albumin and
a few hyaline and granular casts occur steadily or intermittently.
5. Pyelitis and acute heematogenous renal suppiirations are dis-
eases much more commonly recognized since 1904 than pi'eviously.
The presence of bacteria (usually colon bacilli) and pus without many
cells of other types in acid urine should always lead to bacteriologi-
cal and cystoscopic examinations. The presence of pain, tenderness,
or tumor in the region of the kidney (usually the rigid kidney) and
the occurrence of fever and leucocytosis support the diagnosis, espe-
cially in children and in women near parturition. To distinguish
]>ure 23yelit in from pyelitis com]Aica.tmg a renal infection is at present
very difficult.
CHAPTER XXI.
THE BLADDER, RECTUM, AND GEKITAL ORGANS.
Thk Bladder.
Incidence of lUadder Disease.
(Massachusetts General Hospital, 1870-1905.)
C'3'Stitis 839 cases.
Stone ,538 "
Cancer 57 "
Papilloma 20 "
Tuberculosis 43 "
Data.
Distention, tiimov, tlie urine, and the results obtained by cystos-
eopy, by catlieterization, by rectnl and vtiijinaJ e:ruminiitiii7i, by tlte
x-ray, and by soundinrj for stone furnish most of our direct evidence
in bladder disease. Pain in the bladder or near the end of the penis,
and frequent, painful micturition with vesical tenesmus or strain-
ing, are common symptoms in various lesions of the organ, and
direct our attention to it, though they do not indicate the nature of
the trouble.
/. Distention, oftlie Bladder.
In both sexes, distention is often wliolly unknown to the patient,
and may be accompanied by frecpieiit acts of urination, especially
in prostatic obstruction. A distended bladder is readily recognized
by palpation as a smooth, round, firm, symmetrical tunu:)r in the
median line, above the pubes. The tunioi- is dull on jjerciission,Sind
in slight degrees of distention this dtilne.'is ahone the jndies may be
the only physical sign obtainable. In well-marked cases, which are
most common in males, the distended bladder may reach to the
navel or even above it, and the beginner is usually astonished at its
440
jl'IIYSICAL DIAGNOSIS.
dimensions and its firm, resistant surface (see Fig. 200). Diagnosis
rests on tlie infrequeucy of other tumors of tliis region in men and
on the result of catheterization or suprapubic aspiration. In females
a histor}' of failure to pass iirine almost invariably nwkes the diag-
nosis obvious, though occasionally after operations disteutiou of tlie
bladder and dribbling of uriue nmy go together in 'women, as they
so fret^ueutl}' do in men.
The commonest causes of distended bladder are :
(1) Prostatic hypertroplij-, aloue or combined with
(2) Old strictures of the urethra.
Less common are :
(o ) Spasm of the urethra in gouorrhcea.
(4) Acute prostatitis.
(5) Paralysis of the bladder, from disease or injury, after opera-
tion, and in fevers.
(6) Tumor or stone near the neck of tlie bladder.
The diagnosis of the cause of distention rests on the history', the
result of attempts at catheteriza-
tion, the rectal examination, the
condition of the urine, and the phy-
sical signs in other parts of the
body. A long history of frequent
micturition, especially at night, in
an old man, an obvious enlarge-
ment of the prostate felt by rectum,
and the passage of ammoniacal
urine suggest j/rostatic o/istni(ilo)i.
Tlie information obtained during
the passage of a catheter usually
clinches the diagnosis.
..iciitc i-ftciitiiiii, with no j>revious
history of frequent micturition ov foul-smelling urine in a young or
middle-aged man, who has had gonoriha'a and may or may not
have noticed a diminution in the size of the stream of urine piassed,
suggests a vrethral sfricfiirc. The (vatheter decides.
Spasvi of the inrtJira. may occur in acute gonorrhoea, and pro-
-Dtstendert Bladder UeiKhing
Above the Navel.
THE BLADDER, RECTUM, AND GENITAL ORGANS. 441
duces a retention which may often be overcome liy hot poultices and
enemata. The liistory and the effects of treatment suggest the
cause of the retention.
Acute 2J)'ostatitis, as a cause of retention following gonorrhoea,
is suggested by pain and tenderness in the perineum, painful defe-
cation, fever, perhaps chills, and a hot, tender prostate felt by rec-
tum. Abscess may form and discharge by urethra or rectum.
Paralysis of the hladder, as a cause of retention, is usually obvi-
ous f]'om the history and from the evidence of disease of the spinal
cord, or of operation and semicomatose states (as in fevers and
shock).
Tumors of the Madder are suggested by intermittent hsematuria
with vesical irritation, and confirmed by cystoscopic examination.
II. The Urine as Evidence of Bladder Disease.
This has been described above (page 437). Cystitis, acute or
chronic, usually gives characteristic evidence of itself in the urine,
and suggests thereby the possibility of gonorrhoea, of vesical stone,
of prostatic or other obstruction to the outflow, and of vesical tu-
berculosis. When a urine like that of chronic interstitial nephritis
occurs with chronic prostatic obstruction, the relief of the obstruc-
tion is necessary if we are to prevent progressive development of
cirrhotic kidney from back pressure.
Frequent micturition is much commoner and less significant in
women than in men. All sorts of " nervousness " and emotional
strain pjroduce this symptom in women, independent of any demon-
strable source of irritation in the urinary tract. Aside from these
conditions the symptom is oftenest met with in :
(a) Cystitis, with characteristic changes in the urine.
(S) Prostatic obstruction, with evidence of retention.
(c) Gonorrhcea, with evidence of this disease.
(rf) Paralysis of tlie hladder (see above).
(e) Overconcentration of the urine (estimated by the color and
specific gravity).
III. Stone in the Bladder. — Pain near the end of the penis, espe-
442 PHYSICAL DIAGNOSIS.
cially at the end of mieturition and aggravated by jolting or active
motion, frequent urination, especially in the daytime, sudden inter-
ruption of the stream of urine, and luematuria at the end of micturi-
tion, are the most frequent symptoms of stone, especially if they
occur in boys. In old men stone may be wholly without character-
istic symptoms, and at any age the symptoms can never do more
than suggest the possibility of stone and the advisability of searcli-
ing for it systematically with a proper sound.
IV. Tuberculosis of the Bladder. — Cystoscopy and the recogni-
tion of tubercle bacilli by animal inoculation are the only reliable
means of diagnosis. A chronic cystitis in a young or middle-aged
person, especially witli an acid urine, is suggestive.
The Eectum.
It is not and sliould not be a part of routine physical examina-
tion to examine the rectum. The commonest conditions which call
for such investigation are :
(«) Hemorrhage at stool.
(6) The protrusion after defecation of something which is not
easily returned ("piles ").
(o) Painful defecation or pain in the region of the rectum at
other times.
(f?) The presence of an ulcer or sinus near the rectum.
(e') Habitual constipation, not explained by lesions elsewhere.
(/) Intestinal obstruction.
(g) All subacute diarrliceas of elderly persons (cancer).
(/;) Susi)ected appendicitis, ju'ostatitis, prostatic tumor or ob-
struction, or diseases of tlie seminal vesicles.
(/) Pelvic symptoms in women with tiglit hymen.
The diseases of tlie rectum whicli we are esi)ecially on the look-
out for are: (1) Hemorrlioids ; (2) fissure of the anus; (3) ischio-
rectal abscess; (4) fistula in ano ; (5) cancer of the rectum. Less
common are: (6) pruritus ani; (7) jn-olapse of the rectum; (8)
ulceration or stricture of thi' rectum.
THE BLADDER, RECTUM, AND GENITAL ORGANS. 443
Methods.
For most examinations tlie finger suifices. It should be covered
by a tliin, rubber finger-cot, greased with vaseline, and should be
introduced slowly and gently while the i^atient strains down as dur-
ing defecation.
Tlie examining finger should note the presence of abnormal
]>rominenees or resistance (piles, tumors) in any part of the rectum,
of tender spots (ulcer, abscess), and strictures. The shape and size
of the prostate gland, its consistence, and the presence or absence
of tenderness in it are of importance. The normal seminal vesicles
can be felt if distended. If they are hard and nodular, tuberculosis
should be suspected.
High up on the right side the finger niay touch a tender spot if
an inflamed appendix is near the pelvic biim.
In women the uterus, especially if retroverted, may be easily
felt, and most of the other details of pelvic examination (see below,
page 449) can be more or less clearly made out.
For higher and more thorough examination a cylindrical specu-
lum and a head mirror should be used, with the patient in the
knee-cliest position.
Hemorrhoids. — The diagnosis of external hemorrhoids, which
can easily be brouglit outside the anus, is made at a glance. Inter-
nal hemorrhoids are best seen witlr a rectal speculum, and niaj' re-
semble the external or may consist of " bright red, spongy, granular
tumors, rarely larger than a ten-cent pnece, and situated high up in
the rectum " (ncevoid piles) .
Fissure of the amis is often connected with a small ulcer and
with cedematous folds, which resemble an external pile but are
mucli nioi-e tender. Oti separating these folds the fissure comes into
siglit. It produces severe p)ain during and after defecation.
Ischio-reotal abscess presents near the anus the ordinary signs of
abscess with pain radiating through the pelvis, but may open either
within or outside the rectum and results in
Fistula in ano, a sinus beside the rectum, opening in-
444 PHYSICAL DIAGNOSIS.
ternally, externally, or in both directions. It jnay be very tortuous
and need examination with S})eculuui and probe. Tuberculosis is
always to lie suspected in such hstulse.
Cancer of the rectwni is suggested by the occurrence of recta?
pain during defecation, with blood in the stools and alternating
diarrhoea and constipation, usually with some pallor and emacia-
tion, in persons past middle life. Owing to neglect of a thorough
examination many cases are at first mistaken for piles.
The examining finger reaches a hard, ulcerating mass high up,
as a rule, in the rectum. It may be easier to reach if the patient
stands or squats and strains down during examination.
From tuberculous or benign stricture with or without ulceration,
and from benign villous growths, it may be impossible to distin-
guish cancer without histological examination of an excised piece.
Tumors of the pirostate are felt on the anterior wall of tlie rec-
tum and ptractically never idcerate.
The Male Genitals.
Eoutine examination of the male genitals includes investigation
of the penis for the presence of :
(«) Urethral discharge and its consequences.
(&) Chancre.
(c) Chancroid
(d) Balanitis.
(e) Phimosis or paraphimosis.
(/) Periurethi'al abscess.
{(j) Malformations,
(/t) Cancer.
In the testes and scrotum we look for :
(a) Epididymitis (gonorrhojal or tuberculous).
(U) Orchitis (traumatic, syphilitic, tuberculous, after mumps and
other infections).
(c) Tumors of the testis (cancer or sarcoma),
(f/) Hydrocele and hsematocele.
(e) Varicocele.
THE BLADDER, RECTUM, AND GENITAL OROANS. 445
(/) Scrotal hernia.
(g) Absence of one or both testes.
TJie P 67118.
Urethral dhcharge, if not obvious, may often be brought to light
by " stripping" the urethra forward from the prostatic region to the
meatus. If Gram's stain brings out an intracellular, decolorizing
diplococous in the exudate, there is no reasonable doubt of the 2)res-
ence of gonorrhoea.
CJumcre (" hard sore "), the primary syphilitic lesion, is a super-
ficial, painless, indolent ulcer with an liulurated Ixise and a scanty
serous discharge. It is usually round or oval and sharply demarked
fi'om the surrounding tissue by elevated edges. It is rarely multi-
ple. Painless, hard, non-suppurating buboes accompany it. The
glans and the inner surface of the prepuce are the commonest sites.
Chancroid (" soft sore ") is like any other painful, superficial
ulcer without induration, irregular in shape, often multiple, and
with abundant discharge. A single, painful bubo accompanies it in
about one-third of all cases.
Balanitis (inflammation of the surface of the glans penis), usu-
ally gonorrhoeal, has the ordinary signs of inflammation; it often
spreads to the inner surface of the prepuce.
Phimosis is a contraction of the oriflce of the prepuce, so that it
cannot be retracted to uncover the glans. May be hereditary or
the result of gonorrhoea.
In 2}araphimosis the prepuce is caught behind the glans penis so
that it cannot be brought forward. Great oedema of the neighbor-
ing parts usually results.
Peri-nrethral abscess, usually a complication of gonorrhoea, ap-
pears as a small, tender swelling on the under surface of the ure-
thra.
Malformations are chiefly hypospadias or congenital deficiency of
some portion of the lower wall of the urethra, and epispadias (rare),
a similar deficiency- in the upper wall. A short, downward curved
penis is often associated with hyposjiadias.
446 PHYSICAL DIAGNOSIS.
Cancer of the penis attacks tlie foreskin or the glans, and lias
the usual characteristics of ei)itlielioma elsewhere.
Tlie Testes and, Scrotum.
Acute epididi/mitis, usually a complication of gonorrha^a, appews
as a hot and tender swelling liehind the testis, often jireceded hy
tenderness along the spermatic cord. Acute hydrocele may accom-
pany it.
Chronic epididi/niifis, usually ttihercidous, is painless and insid-
ious in onset, and produces a hard, irregular enlargement low down
behind one or liotli testes, to which, however, the })rocess is apt
soon to spread. Caseation and involvement of the skin later ])ro-
duce a suppurating sinus, which is often the first thing to bring the
patient to a ])hysician.
Acute orchitis is often due to a blow, to gonorrhoea, or to mumps.
The testis is symmetricall}' swollen and tender, biit suppuration
rarely follows.
CJironic ore/iiti.i, often st/philitic, is slow, painless, and may be
accidentally discovered as a slightly irregular induration of tlie
testes with little if any increase in size. Ulceration and fistnhe are
rare in the sjqdiilitic form, common in the tuberculous.
Cancer of the testis may ai)pear at any age. It is soft, almost
fluctuating, and grows very rapidly, soon involving and ]ierforat-
ing tlie skin, so as to produce an offensive, fungous, granulating
outgrowth which easily bleeds. The inguinal glands are involved.
Sarcoma of the testis, eoiumonest at puberty, produces a painless,
uniform enlargement, and may reach great size. It may resemble
hydrocele or hfematocele and be mistaken for the latter, especially
for an old effusion in a tliickened sac (see below).
Diagnosis depends on rajiid growth, the entire absence of trans-
lucency, the tendency to adhere to the skin and to present uneipial
resistance in different portions (Jacobson). Incision should be
made in all doubtful cases.
Ilijdrocde, an accumulation of serous fluid in the tunica vagi-
nalis, may depend on trauma or on an acute epididymitis or orchi
THE BLADDER, RECTUM, AND GENITAL ORGANS. 447
tis, but is usually chronic and of unknown cause. It may be con-
genital and communicate with the peritoneal cavity or form part of
a general dropsy in heart or kidney disease.
Examination shows a smooth, tense, fluctuating tumor, without
impulse on cough, usually without pain, tenderness, or any sign of
inflammation, and, above all, translucent if examined with a hydro-
scope tube or in a dark room with a candle.
If the fluid is opaque or bloody, or if the tunica is thickened,
there may be no translucency and diagnosis may be impossible
without puncture. The testis lies hehind the effusion and near its
lower end.
Hirmatocele usually follows injury and produces a heavy, opaque,
non-fluctuating tumor, which may closely resemble sarcoma unless
the history and evidence of trauma are clear. Incision or jjuncture
should decide.
Varicocele, an enlargement of the veins about the spermatic cord
and vas deferens, is easily recognized as a mass of tortuous vessels,
genei'iilly in tlie left side It often complicates hypernephroma.
Scrotal hernia is usually reducible, tympanitic on percussion,
and gives an impulse on coughing. If it consists largely of omen-
tum it will be dull on percussion. The history of the case and the
progression of the tumor from above downward usually make its
origin clear.
Absence of one or loth testes from the scrotum should direct our
search upward to the inguinal canal, since a retained testis may be
the seat of troublesome inflammation or of malignant disease. (For
examination of the seminal vesicles, see the Rectum, page 44.3.)
The Female Genitals.
Methods.
Inspection of the external genitals is easy if the parts are prop-
erly exposed by a satisfactory position and a good light. Intravag-
inal inspection needs a speculum (Sims' or bivalve) and usually an
assistant to hold it.
448 PHYSICAL DIAGNOSIS.
Palpation should always be bimanual, the left forefinger in the
vagina (or in the rectum if the hymen is narrow), the right hand
above the symphysis pubis. The proper co-operation of the hands
is hard to describe and depends on practice. The pressure of the
external hand lieljis to bring the pelvic organs within reach of the
examining finger in the vagina. Unless the organs can be thus
grasped or balanced between, the outer and inner hands, no satisfac-
tory examination is possible. Tenderness may prevent this or ren-
der an anaesthetic necessary, but gentleness and the avoidance of
any sudden or rapid motions do much to facilitate the examination.
The left hand, in making its way into the upper parts of the vagi-
nal vault, should press only on the perineum, avoiding the region
of the clitoris. It is astonishing how much pressure can be borne
without pain, jirovided it is exerted gradually and upon the peri-
neum only. Many examiners find it advantageous to rest the left
foot upon a stool, with the left elbow on the knee.
Lesions.
I. In the EXTEKNAL GENITALS One looks for some of the same
lesions already described on page 444, viz., chancre, chancroid, local
inflammations, and tumors. Only the commonest and most impor-
tant lesions will be mentioned here.
(rt.) In young children a suppurating vuIvo-nag'mUis, usually
gonorrhceal, but non-venereal, is easily recognized by the abundant
purulent discharge.
(S) Local eczema, often red and angry, is commonly the result
of the irritation of diabetic urine.
(c) Varicose veins and oedema of the vulva are common in preg-
nancy and occasionally result from large pelvic tumors.
((f) Ruptured perineum, with more or less protrusion of the vag-
inal walls, carrying with it the bladder (cystocele) or rectum (recto-
cele), is readily recognized if the normal anatomy of the parts is
familiar.
(e) The hymen may be imperforate with retention of menstrual
THE BLADDER, RECTUM. AND GENITAL ORGANS. 449
fluid, or tender, irritated remains of it after rupture may cause pain
and need removal.
(/) Urethral caruncle (a small vascular papilloma at the en-
trance of the urethra) is a bright red excrescence, usually the size
of a split pea or smaller. It may cause no symptoms or may pro-
duce irritation, especially during micturition.
(ff) Small abscesses of the glands within or around the urethra
may cause p)ain iu coitus or during micturition.
II. The Uterus. — Only the commonest lesions will be dealt
with here, viz. :
1. Laceration and "erosion" of the cervix.
2. Malpositions of the organ.
3. Endometritis.
4. Cancer of the uterus.
5. Fibro-niyoma of the uterus.
1. (a) Lacerations of the' cervix following childbirth are very
common and frequently produce no symptoms. They are readily
recognized by inspection and palpation, and are often combined
with :
(Ij) " JSrosions," an ulcerated, raw surface at and around the os
uteri, with or without the formation of small cj'sts. At times the
OS assumes a warty, irregular appearance, sxTggesting cancer, from
which it can be distinguished only by histological examination of an
excised piece.
2. (rt) Malpositions (backward or forward) may involve the
whole organ (ante- or retroversion) or represent a bending of the
organ upon itself (ante- or retroflexion). These lesions may be va-
riously combined and frequently exist without producing any symp-
toms. Indeed, it is doubtful whether there is any single "normal"
position for the uterus. Its position is recognized by bimanual pal-
pation, which should also determine whether the uterus is freely
movable or whether it is bound in place by adhesions, such as are
very often found with backward displacements.
{h) Prolapse oftJie uterus toward the vaginal outlet is often a
result of pelvic lacerations unrepaired. When the uterus is outside
the vaginal outlet, we call the condition 2Jrociclentia.
29
450 PHYSICAL DIAGNOSIS.
(c) Lateral disj>Iace)ni'iit of the uterus by pressure of tumors or
traction by old adhesions is less common.
3. Endoini'trltls may [iresent no definite physical signs except a
muco-purulent discharge (leucorrhcea, "whites") and jterhaps un-
duly frequent, profuse, or prolonged menstruation. The slightest
touch of a uterine sound may jiroduce bleeding. It often accom-
panies disturbances of digestion and neurasthenic conditions, prob-
ably as part of a general prostration rather than as its cause.
4. Cancer af t/ie iifcri/.'i usually attacks the cervix, and in marked
cases is easily recognized by sight and touch as a " cauliflower "-
like, //^((^((fi'rtr/ //(((ft'.s on the cervix. In its early stages it maybe
confounded with "erosions " and intiammator}- conditions, and only
microscopic examination can satisfactorily determine its nature.
Prafuse hemorrluKje, especially in a woman about the period of the
menopause, ami the offensive odor of the (l!.sehar</e suggest the diag-
nosis. The vaginal wall is soon involved in the growth, and irrita-
bility or obstruction in bladder or rectum may result.
5. Filiro-iin/oiiia of the uterus is by far the commonest tumor of
that organ. It produces hemorrhages at or between the menstrual
pieriods, and anjemia results. Otherwise its effects are those of
pressure on the bladder ami rectum, or on neighboring nerves cu-
vessels (pain, cedema).
Bimanual palpation determines, first of all, the fact that the
growth is connected and moves with the uterus. This determined
and cancer excluded by the absence of any involvement of the cer-
vi.x: or of the vaginal wall, the chief difficulty may be in distin-
guishing the growth from a pregnant uterus. Usually its irregular
shape, the persistence of menses, and the lapse of time settle the
question.
Lengthening of the uterine canal is an important contirnuatory
sign of fibromyoma, but sounds should never be passed to determine
this fact unless pregnancy can be definitely excluded.
III. Fallopian^ Tuhf.s. — Salpingitis (acute or chronic) and
tubal pregnancy are the most im[ioitant diseases of the tubes.
(o) SaljiuKjilis is usually gonorrluBal, occasionally tuberculous,
sometimes of unknown origin. A painful, tender swelling or indu-
THE BLADDER. RECTUM, AND GENITAL ORGANS. 451
ration in the region of the tube, with or without fever, chill, or
leucocytosis, constitutes the evidence for diagnosis. From pelvic
peritonitis of the tubal region diagnosis is impossible.
From tubal pregnancy diagnosis may be very difficult, and sus-
picions are rarely aroused until rupture occurs (^vide infra). If the
signs and symptoms of pregnancy are absent and tenderness is
marked, the condition is usually called salpingitis ; but even then
mistakes often occur, as the menses may persist in tubal pregnancy
and the foetal tumor may be tender. Only when pregnancy can
absolutely be excluded is diagnosis sure.
(6) Tubal pregnancy, as just ex])lained, is rarely to be diag-
nosed until the growth of the foetus ruj^tures the tube — an event
which usually occurs between the tlnrd and the twelfth week of
pregnancy.' Sudden pelvic pain with tenderness, vomiting, and
evidence of internal hemorrliage (I.e., pallor, faulting, weak, rapid
pulse, thirst, air hunger) suggest the diagnosis, especially if a tumor
in the tubal region can be detected bimanuall}'.
IV. OvAEiES. — K ^irohipsed ovary is often felt during a vaginal
examination, being recogni/.ed by its size, shape, and relation to the
uterus.
Ovaritis, enlargement, and tenderness of one or both ovaries is
usually part of tubal disease and not sharply to be distinguished
from it before operation . In othei' cases it is associated with cyst for-
mation, and the cysts may be palpated bimanually. Abscess of the
ovary is not commonly diagnosed, bu.t is met with in operations for
pus tubes.
(Jvariaii Tumors.
(a) Small Tumors. — In their earlier stages these growths pro-
duce symptoms only when complications arise, i.e., suppuration or
twisting of the pedicle. Small, supjmratincj cysts give practically
' If disturlianccs of menstruation, morDing nausea, clianges in the breasts,
and cyanosis of the vagina are combined with an extra-uterine tumor and an
unusually slight uterine enlargement, the diagnosis of tubal gestation may be
suspected prior to rupture.
452
PHYSICAL DIAONOSIS.
the same signs as those of a pus tube, and are recognized only at
operation or autopsy.
Tirkti'd pedicle gives rise to symptoms and signs often indistin-
guishable from those of intestinal obstruction. Onl}- tlie recogni-
tion of the tumor as ovarian can suggest that the acute symptoms
may be due to twisting of its pedicle.
(/') Large nraricrn tiniiors have been confused in my experience
with pregnancy, fibroid of the uterus, ascites, and tuberculous peri-
FHi. -111. — Huge Ovariau Cyst.
tonitis. From tliese we maj' usually distinguish an ovarian tumor
by its history, its origin from one side of tlie belly, by the sliaiie
of the belly, the area of percussion dulness, and the pelvic examui-
ation .
By the historj^ we should attempt to exclude disease of the
heart, kidney, and liver, and tuberculosis of any organ, should in-
quire into the position of the tumor in the earlier stages of its
growth, and estal)lish the presence or absence of the ordinarj^ signs
of pregnancy and of viterine hemorrhages such as occur with fibroids.
In ascites or tuberculotis peritonitis the flanks often bulge (see
Fig. 180, page 374 ), whereas in ovarian disease the bulging is central
and greatest just below the navel (see Fig. 201").
THE BLADDER. RECTUM, AND GENITAL ORGANS. 45:^
If by the liistory or by palpation and percussion we can deter-
mine that the tumor is fluctuant and springs from one side of the
abdomen, it is in all probability ovarian. High psoas abscess
sometimes presents identical signs, but is associated with evidence
of spinal tuberculosis (see below, p. 491). Moderate ascites or tu-
berculous peritonitis leaves au oval, resonant area about the navel,
which is absent with large ovarian tumors ; but if the amount of
free fluid is large, percussion and palpation may give results iden-
tical with those found in ovarian disease.
Vaginal examination may exclude fibroid by showing that the
uterus is not directly connected with the tumor and by demonstrating
with a uterine sound that the uterine canal is not elongated.
Solid tumors of the ovary, carcinoma, sarcoma, or fibroma are
rarely recognizable before operation and are often mistaken for pe-
dunculated uterine fibroids. They are apt to be associated with
ascites.
CHAPTER XXII.
THE LEGS AND FEET.
The Legs.
/. Hq,.
The examination of the hip will be discussed later (see page
491).
//. Groin.
In the groin we look for evidences of:
1. Enlarged or inflamed lymphatic glands and scars of ])revious
inflammation.
2. Hei-nia and hydrocele of the cord.
?i. Psoas abscess.
Less common are :
4. Retained testis.
5. Filarial lymphatic varix.
1. Ingubiul Glands. — Two sets of inguinal glands are distiii
guished — one ai-ranged along the lower half of I'oupart's ligameni ;
the other lower down, around the saphenous opening.
(^f) "^'lif " l'ou[iait"s group" are acutely enlarged in lesions of
the genitals ("bubo" of gonorrhoea,' syphilis, chancroid) and peri-
neum; chronically enlargeil in malignant disease of the penis, uterus
(late), and other genitalia.
(A) Tlie sai)henous group is enlarged in response to lesions of the
thigh, leg, and foot (cuts, wounds, ulcers, eczenui, etc.).
' The bubo of gdiiorrhd'n often sii|ipiniitrs; lliat of sypliilis rarely. Hence
a scar in the inguinal region suggests an old gonorrlia'u.
THE LEGS AND FEET.
455
(c) Either or both groups may be enlarged in leukaemia, Hodg-
kiu's disease (see above, page 30), infectious arthritis, and various
obscure fevers. In many cases no cause for enlargement can be foiuul.
2. Hernia is diagnosed by the presence of a soft, resonant, fluc-
tuating, usually reducible tumor with an impulse on coughing.
Hydrocelii of tJie cord gives
also an impulse on cough-
ing, but usually shows a
distinct limit above. On
pulling the cord the swell-
ing moves too.
3. Psoas abscess (see
Fig. 202) presents the ordi-
nary signs of pus and is
associated with vertebral
tuberculosis (dorsal or lum-
bar) .
4. Retained testis
should be suspected when-
ever an inguinal tumor is
present and only one tes-
tis is found in the scrotum.
5. Filarial hjvijjhan-
giectasis is generally mis-
taken for hernia and oper-
ated on as such, although it gives no impulse on coughing and can-
not be completely reduced. The history of residence in the tropics
should always suggest an examination of the blood (at night) for
tilarise.
III. The Thigh.
The records of the Massachusetts General Hospital show that
(1) epiphysitis and osteomyelitis (septic or tuberculous) are almost
ten times as common as any other serious lesion of the thigh, except
fracture. The cases are to be divided into acute septic eases and
chronic, usually tuberculous, cases.
Fig. 202.— Psoas Abscess.
(Bradford and Lovett.)
4o() PHYSICAL DIAGNOSIS.
Tlie acute septic cases begin witli severe pain, tenderness, fever,
chill, and leucocytosis. Later an induration and tinally fluctuation
appear, and the abscess, if not incised, will break externally. Gen-
eral, sometimes fatal, septicemia may talce place.
The chronic tuberculous cases tirst consult the physician, as a
rule, for .•;iini.-<, which proves when explored to lead to dead bone,
as do most of the sinuses from septic cases.
The diagnosis of the acute cases depends chiefly on excluding
arthritis of any type. Careful examination with testing of joint
motions will usually demonstrate that the j^ain and tenderness are
in the bone and not in the joint. Tlie leucocyte count is but
slightly elevated in most cases of arthritis, but is decidedly high,
20,000 or more, in most cases of acute osteomyelitis. The same is
true of tlie temperature. jMonarticular arthritis — tlie only variety
likely to be considered in such a diagnosis — is rare in j'outli, when
most cases of acute osteomyelitis and epijdiysitis occur.
Whether the disease starts in the sliaft of the lioiie or in the
epiphysis is to be determined by the seat of pain and tenderness.
Tuberculous cases can be recognized only by tlie histological ex-
amination. Old cases may be suspected by the presence of a scar,
but
(2) 3IiiItij)Ir wliite scars should always suggest, tliough they are
far from proving, sj'philis, for rJironic ulcer above the knee is often
due to gumma.
Tumors of the TJitgJi.
(1) Siireoma of the fcm}ir is the commonest and largest tumor
of the thigh. Among one hundred and thirty-three tumors of the
thigh recorded at the Massachusetts General Hospital, sixty-six
^\'evii sarcoma. A hard, spindle-shaped growth encircles the femur;
the lower end is the commonest site, but any part of the bone may
be attected (see Fig. 20.3).
(2) Osteoma, or exostosis, occurred eleven times in the one hun-
dred and thirty-three cases just mentioned. It is much smaller and
of slower growth. The last trait usually serves to distinguish it
from sarcoma. -V-ray should decide.
THE LEGS AND FEET.
457
(3) Metastatic cancel' of tlie upper half of the femur may occur
after cancer of the breast, but rarely gives rise to symptoms uuless
spontaneous fracture occurs — an event which always shoulcl suggest
cancer. Epithelioma of
the thigh is not very rare
(twelve cases in the one
hundred and thirty-three
above referred to). Its
traits are those of epi-
thelionui elsewhere.
Tubercahisis of the
knee may simulate sar-
coma of the lower end of
the femur, but sarcoma
grows more rapidly.
The tuberculin test or an
exploratory incision may
be necessary to decide the
diagnosis.
(4) Psoas abscess or
hip-Joint abscess (see Fig. 202) may burrow down so as to point on
the thigh. The evidence of disease in the hip or vertebi'as is usu-
ally sufficient to make clear the diagnosis.
Fig. 1^03.— Sarcoma of the Femur.
Miscellaneoiis Lesions ofilic Tliigh.
(1) Phlebitis with thrombosis of a vein, usually the saphenous,
is a common cause for swollen thigh (and leg) with pain and tender-
ness, especially over the inflamed vein, where a cordy induration can
often be felt. Typhoid fever and the puerperal state are the usual
causes. Diagnosis depends on tlie presence of these signs and causes
and the absence of any other demoustralde cause for inflammation.
(2) Meralgia imrKstJietiea means the presence of a patch of an-
sesthesia, paresthesia, or hyperesthesia (tenderness), with or with-
out pain, on the anterior and upper surface of one or both thighs
(the area of the external cutaneous nerve).
45S
PHYSICAL DIAONOSIS.
(o) Fiii/i't's i/isi'iisr (osteitis defoiinaus) presents usually its
most luarked lesions in the legs and head, though most of the other
bones are also affected. In the leg the most cliaracteristic lesions
are forward bowing of the femur
and tibia with out\vanl rotation
of the whole limb (see Fig. 204).
The .r-ray shows nrarked thick-
ening of some areas, with thin-
ning of others.
(4) Intermittent Claudication,
and " (_'ranips." — Insufficient cir-
culation through the arteries of
the legs uuiy give rise to sudden
"giving way" of one or both
during running or walking, the
power returning after a short
rest. lu patients at rest the
frequent recurrence of jiainful
cramps iir the muscles may be
the oidy manifestation of the
disease.
Obliteration of the dorsalis
[)pdis ((H' larger arteries) b}- ar-
teriosclerosis is often found, but
there is reason to believe that
local anaemia, due to vasomotor
disturbances or other causes,
nraj' produce similar cramps
(e.g., those seen in football [ilayers during a hard run and in
pregimnt women).
Far<ili/ses.
mans). Note tln^
bowin<r of le^y iiml
r;L-..' (Osteitis Di'f.ir-
iiilward and forwiiid
;ins, (Robin.)
leg, occurring in children, is usually due
in ailnlts it usually forms part of a lieini-
pleijid or is of /ii/.sf erica/ origin. Keiirifi.i, ilue to alcohol, lead,
arsenic, or diphtheria, may alTect one leg predominantly, but both
(1) Puridii^i.'i of i>n(
to iintcriar jio/innn/i'/ifin
THE LEGS AND FEET. 459
are usually involved. Cerebral innnitple(j't(iii, due to cortical lesions
of the leg aiea, are rare. Chorea may l)e associated with a limp,
half-paralyzed couditiou iu one leg, usually with some involvement
of the arm on the same side, and the characteristic motions (see
above, page 44) make the diagnosis clear.
The differential iliagnosis of the other varieties of monoplegia is
usually easily made with the aid of a careful history and a thorough
examination of the other parts of the body.
(2) Complete j}aralys'is of hoth l,-ijs (paraplegia) is commonest
in diffuse or transverse myelitis {e.(j., in spinal tuberculosis or me-
tastatic cancer with pressure on the cord), in multiple sclerosis,
spastic paraplegia (hereditary or acquired), and in late tabes. Hys-
teria also may produce a spastic paraplegia, though monojilegia is
commoner in this disease.
(3) Partial parali/sts of both, legs is oftenest due to neuritis,
resulting from the causes mentioned above. The extensors of
the foot are especially affected and toe-drop results, so that in
walking " the entire foot is slapped upon the ground like a flail "
(Osier).
Differential Diagnosis. — (a) In diffuse or transrerse myelitis,
whether or not the trouble be due to pressure, there are increased
reflexes, anajsthesia, usually loss of control of the sphincters (in-
voluntary urine and faces), and often bed-sores.
(b) In spastic paraplegia of any type the legs are stiff and the
reflexes increased, but sensation and the sphincters are normal and
there is no atrophy or bed-sore formation.
(c) In multiple sclerosis there are usually no disturbances of sen-
sation or of the sphincters, and the paralysis is associated with nys-
tagmus, intention tremor, and slow, staccato speech.
((^) Tales dorsalis shows ataxia, but no paralysis until late in its
course. The paralytic stage is preceded by a long period character-
ized by lightning pains, bladder symptoms, Argyll-Robertson pupil
(see page 15), and loss of knee-jerks.
(e) Tli/steria may take on almost any type of paralysis and may
deceive the very elect, but as a rule the other evidences of hysteria
guide the diagnosis.
460
PlDSJi 'AL hlAdNO.Sl.S.
/r. T/ir Kit,;-.
((() Tubpvoulosis, atrophic, liypcrti-ophic, ami iiifef'tious artliii-
tis, and trauiiuUic. sj'uovitis are the coiumoiit'st ilisea.scs, hut will be
(lescriiied witli other dis-
eases of tlie joints (see
])age 48Gj.
(/<) ][ () II s e ni a i d's
knee, is a bursitis of tlie
prepatellar bursa (see
Fig. 'Mt>). Fluctuation,
with or without heat
a 11 d tenderness, and
limited i,o the pre})atel-
lar spaee, is diaL;iiostic.
((■) J) o w -lugs and
knock-knee are so easy
of diagnosis that I shall
simpler mention them
here.
V. 'Jlic Lnirri- Lc<i.
1. Viiriro.si' /■ (■ / /( .S-,
with their results (e(^ze-
]na and nicer), are the
commonest lesions of
the lower leg. The
soft, twisted, pui'plisli
emiiu'uces are easily
recognized. I/nnliii'.^s in
Fig. 205.— PreputcllarliursiUs ("nuuscauuid'a Kucu"). ^nrh a vein usiuilly
means tlivomliosis. It
should be remend)(u'<'d that jiregnancy and jielvic tumors nuiy pro-
duce vai'icoso veins in the legs.
2. Chronic ulcere of ilu; luivcr laj, especially those iu front, are
THE LEGS AND FEET. 461
usually due to varicose veins aud the resulting malnutrition of the
tissues. They leave a hnnvii near after healing. Syphilitic ulcers
usually leave a white scar ; they may occur in the same situation,
but are more comniou above the knee or on the calf.
3. Syphil'dic periostitis is common on the shaft of the tibia, and
gives rise io pain (worse at night) with tenderness and some swell-
ing. Later honii xodes are sometimes formed, similar t(j those
alreadj' pictured on the frontal bone.
4. Osteom)/elitis (acute septic or chronic tubercular) often starts
on the head of the tibia, witli intense pain, tenderness, fever, and
leucocytosis (if acute or septic) ; there results a general septic;emia
or a local sinus leading to dead bone.
5. Snrco}na not infrequently attacks the upper end of the tibia
or fibula, producing lesions similar to those described in the femur.
6. CEdema of the Irr/s^ is oftenest due to:
(a) Uncompensated heart lesions, primary or secondary from
lung disease.
(/y) iSfephritis.
( r) Anaemia.
(("/) Xeuritis (alcoholic, beri-beri, etc.).
(e) Varicose veins.
(/) Obesity, Hat-foot, and other causes of deficient local circu-
lation.
In some cases no cause can be found (" angioneurotic " cedema,
"essential" and "hereditary" ledema). Diagnosis of tlie cause of
(edema depends on tlie history and the examination of the rest of
tlie body.
In one leg cedema nuiy be due to thronihosis of a vein (see page
457), to pressure of tumors in tlie 2)eh'is (pregnane^', etc")., to liemi-
plegia, or to ■iiiflanimntion.
7. Teiidrriiess in tlie loirer h'ljs frequently accompanies cedema
from any cause. It may also be due to neuritis or tvichiniasis, and,
of course, to any local inflammation.
' It is notable tliat cedema is usually greatest lu the front of the leg and in
the back of the thigh.
4R2
PHYSICAL DIAGNOSIS.
The Feet.
1. Tlie varieties of chih-fn,it axe: («) Kijuinux, \:\\e heel drawn
up. (/i) Tunis, tlie ankle beat outward, (r) Vafi/ns, the ankle
bent inward and the foot outward. (</) Cnh-inirus, the foot turned
outward and upward.
The affection, wliicli is usually congenital, occasionally tlie result
of contractures after ]iaralysis, presents no difficulties in diagnosis.
Fi(i. au6.- Flat-foot. CBradlord and Lovett.)
2. Fl(if-f(ii)t is a breaking down or weakening of the normal arcli
of tlie foot, so tliat the print of the sole loses more or less of the
normal concavity in the inner side (see Figs. 206, 207, and 208).
There are usually pain and tenderness near the attachment of tlie
ligaments ami often higher up on the leg.
THE LEGS AND FEET.
463
3. Tenosi/nov'dh of tlie Achilles tendon often proiluces pain in
the tendon, increased liy use and sometimes associated with palpa-
ble creaking or crepitus over it.
4. Enlanjed (^rachitic) ep'qjliyses are seen at tlie lower end of the
Fig. 207.— Flat-foot. Print of tlie sole. (Bradford and LOTett.)
tibia and fibula just above the ankle-joint in about forty per cent of
rachitic cases. The other signs of rickets in tlie child make diagno-
sis easy.
5. Tuberculosis is especially apt to attack the ankle bones in
young persons. It is recognized by the usual evidences of joint
tuberculosis (see below, page 494).
6. Epithelioma of the ankle has the characteristics of ©iiitheli-
oma elsewhere.
464 PHYSICAL DIAGNOSIS.
7. ErythromeliiUjio , or red neiualgia of the extremities, is com-
monest ill the feet. The toes (or fingers) are red, liot, tender, and
painful in (Eajnaiul's disease the digits are cold and painless or
aneesthetic ). The attaclis are aggravated by heat and not (like
those of Raynaud's disease) by cold. Such attacks are probably
Fig. 208.— Print of tbe Soles of Normal Feet. (Bradford and Lovett.)
akin to the condition of "lint feet" often seen in arteriosclerosis and
myocarditis. Tlie patient kicks off the Ited clothes from his feet at
night on account of the burning sensations in them. Other evi-
dence of insufficient arterial blood supply (''.,'/., clubbing, intermit-
tent claudication, cramps, gangrene) may coexist.
THE LEGS AND FEET. - 465
The Toes.
Many of the lesions already mentioned in the fingers are found
also in the toes {e.g., atrophic and hypertrophic arthritis, acromegaly,
pulmonary osteoarthropathy, tuberculous or syphilitic dactylitis,
tremors, spasms, and choreiform movements). Other lesions, such
as ingrowing toe-nail, bunion, hallux valgus, policeman's heel, are
too purely local to deserve description here. Excluding these we
have left :
1. Goat, which is especially prone to attack the metatarso-pha-
langeal joint of the great toe, producing all the classical signs of
inflammation.
2. Gangrene is usually the result of arteriosclerosis with or
without diabetes mellitus, but may result (as in the fingers) from
arterial spasm or local asphyxia (Raynaud's disease).
3. Perforating Ulcer. — In diabetes and sometimes in tabes a
trophic or nutritional ulcer may develop in the toe or tarsus as a
result of nerve influences similar to those which j) reduce Charcot's
joint or herpes zoster in the diseases just mentioned. It is called
" perforat'mcj ulcer " because of its stubborn progression despite a
plan of treatment that checks ordinary infectious abscesses. Actual
perforation is not often seen.
4. " Tender toes " after typhoid fever result from an infectious
neuritis.
6. " llortoii's disease" (metatarsalgia) means pain in the tarsus
at a small spot near the distal end of one of the three outer toes,
always associated with compression of the foot by tight boots and
probably due to pinching of the external plantar nerves between the
metatarsal bones. It is relieved by proper shoes.
30
CHAPTER XXITI.
THE l!LO(^l).
ExAMIXAM'KlN' nv 'I'll 10 I'lLdllD.
The essentials nF blood exainiiiatioii as a part oL' plij'sical diag-
nosis are as follows :
I. ll(i'/i/(ii//(i/tin /rut ('l'aJl(ivist) in all eases.
II. Study ot a s/iiiiir</ hliinil Jil HI. in most eases.
III. Total Inifiiciitc i-iiinit ('l'honia-Z(MSs) in many eases.
IV. Count t)l' ;■('(/ i-(>r/)i/sr/cs ii ml W'hliil raictiiiii in a few eases
V^. Coagulation time, rarely.
I will now give a brief a,e(/ount t)l' each of these motlunls and of
the interpretation of the data obtained b}' them.
/. Ild-iiiotihihln.
(«) The Tallqvist seale <^onsists of ten strips of red-tinted ])aper
coiTe.spomling to the. tint of a iilter paper of standard (piality when
saturated with blood eontaiuing ten per cent, twenty j>er cent, thirty
per cent, et(^, liaimoglobin up to one hundred jier <'.ent. To per-
form the test we ])unef;Ure the lobe of the ear with a gliner's needle
{not with sewing needle), saturate a strip of the filter paper whieh
is bound up with the scale, in the blood of the ]iatient to be exam-
ined, and (M)nipar(! the tint of this st-rip with tlie diirerent standard
tints in the S(^ale. Always saturate at least half a S(pnu'e in(^h of
filter ])aper with blood and allow it to dry until the gloss has dis-
apt)eared. J)o not hlot it, and do not delay in making the com-
parison after the humid gloss has disa])peared. Stand with the
light beliilid yo\i <ir at oni' side of yon ; use dayliglit always.
THE BLOOD.
4(i7
The test is not accurate within ten degrees, but a de!j;ivr of ac-
curacy greater tlian tliis is very raiely re(]uired for any purpose of
diagnosis, prognosis, or treatment. In rare cases, when a more
accurate reading is needed, we may use the instrument of Gowers
as modified by Saldi.
{h) Salili's instrument see (Fig. 209) must be ol)taiiied from one
of the firms recommended by liim,' else the standard solution is
likely to be inaccurate in col-
or. To use the instrument
we first put a few drops of
water '' into the em[)ty tube
(Fig. 209, />•), then sack up
blood with the pipette (Fig.
209, C), until the mark 1 is
reached. Wipe the ponit of
the pipette and immediately
blow ou.t the blood into the
water at the bottom of the
tube (2)*). Suck this mixture
of blood and water back into
the pipette and blow it out
again twice to cleanse the pipette. Next add water from the
dropper (/)), a few droi)s at a time, until the tint of the nuxture
of the blood and water is the same as that of the standard solu-
tion, when both are looked at witli transmitted liglit. After
each addition of water close the end of the tube with the thumb
and invert it twice, then sc'rape the thumb on tlie edge of the tube
so as to rub off any moisture deposited there during the process of
inversion. As the tint of the mixture of blood and water ap-
proaches that of the standard solution, add the water two drops
at a time, and close the eyes for a few seconds between each two
attempts at reading. When the colors in the two tubes seem to be
I Holt/, (ir lUiclii of Berne.
'' The description here given follows Gowers.
S;xhli — " Jilll tlic empty tiilie to the mark 10 witli deciuornnil HCI .solu-
tion," and Mow the lilood into tliis — llien dilute willi water a.s above.
Fig. 2(19,— (io\ver.s' na'iuutrlobnionieter. LI, DI-
lutlnRtube; (', pipeU«; D, dropper.
468 PHYSICAL DIAGNOSIS.
identical, read off the figure corresponding with tlie meniscus of the
coluniu of fluid in the tube. The resulting figure represents the
percentage of hajmoglobiu.
(r) Tlie Color Index. — The data to be obtained by these instru-
ments stand for the amount of the coloring matter in a given unit
of blood when conqjared with the amount in a similar unit of nor-
mal blood. When the hcemoglobin percentage is low, ancemiais al-
ways present, and the degree of anaemia is measured by the amount
of reduction ia the haemoglobin per cent. But the percentage of
haemoglobin is not a measure of the number of corpuscles present in
a given unit of blood, for if the cor})uscles are large and contain each
of tlienr a relatively large amount of haemoglobin, tliey may be con-
siderably diminished in number and yet furnish a nornurl bulk of
haemoglobin, as tested by either of the instruments described. Thus
in pernicious auEemia the corpuscles are often so large that they
contain nearly one-third as much again as a normal cori)UScle, so
that even though their number is considerably dinrinished they may
carry a normal amount of liEemoglobin. This condition is known
as a."liigh color index.'" On the other hand, the number of red
corjmscles may be normal, yet each corpuscle so deficient in lisemo-
globiu that the ha?moglobin in a given quantity of blood is as low
as forty or fifty per cent. This state of things is often found in
chlorosis or in any form of secondary anaemia (see below, piage 477\
When the diminution in the number of red corpuscles is greater
than the diminution of hcemoglobin, we say that the color index is
high, meanuig that each corpuscle carries more haemoglobin than
normal. Thus if we have a red count of two millions and a half of
red cells, and each cell contained the normal amount of haemoglobin,
the haemoglobin percentage would be fiftj', representing a reduction
in haemoglobin proportional to the reduction in the red cells; but if
with the same count we had a haemoglobin piercentage of seventy-
five, this would mean that each corpuscle contained half as niiu'h
again as compared with the )u«moglobin in normal red cells. Here
we should say that the color index is 1.5. Five million red cells
and one hundred per cent of luemoglobiu give a color index of 1 ; so
do four million red cells with eighty per cent of lu^moglobin, three
THE BLOOD.
4()
iiiilliou and sixt^' per et'iit, two luilliou and t'ort-j- per rent, and so
on. An example of low coloi- index would be four million red etdls
with forty jier eent luemoglobin, representing- a eolor index of 0.5;
or three million red cells with tliirtj' per (^ent luBnioglobin, repre-
senting again a color index of 0.5.
The diagnostie signilieanee of the color index is bi-ietlj^ this:
Any diminution in luemoghihin means ana'uiia, but a. diminution in
hemoglobin with a high color index suggests, though it does not
prove, pernicious anaMuia, while a low color index points to chloro-
sis or secondary aiueuiia of any type. Noruud color index, despite
an;eniia, is most often found immediately after hemorrhage.
II. Stuih/ of the ,Sf((iiinI lUn,,,! Film.
To recognize the y'/v'.sT;/f(' ami the <lrr/rfc of anaemia one needs
only the Inriiioijlobin tc.^t, but to determine the l.lnd of ana?uiia, to
study the leucocytes, or to search for parasites we need the stained
blood lilm. Two processes are now to be described:
1. I'reparing the tilni.
13. St;nning.
1. H/(ii>i/ p'/ i/i.': may be spread on slides or on cover glasses. The
first method is the easier; the second gives better })reparations. To
prei)are blood films on slides,
dip two slides in water ami
rub them clean with a towel
or handkerchief; put a drop
of blood near one end of
one sliile, jnit the other slide
against the drop, and rest
it evenly upon the first, as
shown in Fig. 210. Next
draw the upper slide along
horizontally, so as to spread
the drop over the whole
surface of the lower slide. The process ma_y then be repieated, re-
versing the slides and using as a '' spreader " the one on which the
. -J/^oJ-
Fig. 210.— Methoii of Spiviulins Blood Fllnis.
470
PHYSICAL DIAGNOSIS.
film lias already been iirepareil. This method is so simple that one
can usually succeed with it at the first attempt, but the corpuscles
are not sjiread quite so evenly as iu cover-glass ]ireparations and it
is somewliat more ditticult to get a perfect stain.
The coner-ffhiss matliod requires a much greater degree of clean-
liness and manual dexterity than the slide method. Cover glasses
must be washed in water and then thoroughJij polished with a silk
(not cotton or linen) handkerchief. The success of the whole proc-
ess depends upon the thoroughness of the polishing. Every part
of tlie glass must be thoroughly gone over, taking care not to omit
the corners. This is rather tedious and often drives us to use
slides, which can be much more quickly
prepared. With cover glasses we }uust
remove not only all dirt ami grease, but
also every speck of dust or lint which may
settle upon them. The use of silk as a
polisher reduces this difficulty to a mini-
mum.
Having prepared the cover glasses in
this way, the next point is to keep them
both clean and dry during the process of
spreading the blood. We must always
hold tliem as iu Fig. 211, and never touch any part of their sur-
faces with the fingers. Any one whose fingers tend to get moist
must handle the cover glasses with forceps, but most of us will al-
ways use our fingers, despite the warnings of our Teutonic brethren.
Holding a cover glass as in Fig. 211, touch the centre of it with the
tip of a drop of blood as it issues from a puncture, taking care
not to touch the skin of the ear itself; then drop this cover glass
(l)lood side downward) upon a second cover glass in such a posi-
tion that tlieir corners do not match. If the covers are quite clean
and free from dust, the blood drop will at once spread so as to
cover the whole surf ace of the glasses. Tlie instant it stops spread-
ing, take hold of the upper cover glass h}' one corner and slide it
rapidly off without lifting it or tilting it at all. T'his needs some
practice, and some men never learn it ; hence the use of slides.
Fig. 211.— Proper Method of
Hotdinff a Cover (llass.
THE BLOOD. 471
Eilms so prepared will keep for a long time without deteriorat-
ing, especially if the air is excluded.
'2. iStiiiniiii/. — The introduction of the Komanowsky method of
staining (Nocht's, Ziemann's, Jenner's, Leishman's, Wright's) ena-
bles us to dispense with all other blood stains and greatly shortens
the time of the ])rocess. Wright's stain is identical with Leish-
man's except in the method of preparation, which Wright has consid-
erably siiiiplitied, and as either of these mixtures can be obtained
ready made of any of the larger dealers in ])hysicians' supplies, I
shall nut describe the method of making it. Eeliable stains can
always lie obtained from the Massachusetts General Hospital in Bos-
ton. An ounce bottle will stain hundreds of specimens.
To stain a cover-glass film, grasp it with Cornet's forceps, rest
the forceps on the sink so that the film side is upward and is ap-
proximately horizontal. Draw a little of Wright's or Leishman's
stain into a clean medicine-dropper and squeeze out upon the film
enough to flood its surface.
(«) Allow the stain to act for one minute; during this time the
niethylic alcohol contained in it fixes the film upon the cover glass.
(Zi) Next add distilled water fi-om a clean medicine-dropper until
a greenish metallic lustre appears like a scum upon the surface of
the stain. Usually about six or eight drops of water are needed if
we are using a seven-eighths-inch cover glass. The stain, so di
luted with water, should remain upon the cover glass about two
minutes. The exact time does not matter.
(c) Next Avash off the stain with water cautiously and let the film
remain in clean water for about a minute more or until it takes on
a light p)iuk color. Dry gently with blotting paper and mount in
Canada balsam.
This whole process can be completed inside of five minutes, and
I know of no other staining method at once so rapid, so reliable,
and so widely api)licable. It brings out all tlie minutiae of the red
corpuscles, leucocytes, and blood parasites, and for clinical work no
other stain is needed.
Appearance of Films so Stained. — 1. The normal red corpvs-
cles appear as round discs with pale centres. Their color depends
A7-2
PHYSICAL DIAGXOSIS.
upon the length of time that we eontiuue the washint;; with clear
water after the staining mixture lias been poured off, and varies
from brown through pink to golden yellow.
(ii) Poiki/ori/fdsis means the appearance in the blood of red cells
variously deformed, sausage slia[)ed, battledore sliaped, oblong,
[lear shaped, etc. It is always assoidatcd with (ilinnrDKiHties in the
size of the cori)uscles, so tliat dwarf forms and giant forms appear.
(b) PolyeliroiiKisid (or jio/i/cJiroJiidfophilia) refers to abnormal
staining reactions in the red corpuscles, wliereby isolated individ-
uals take on a brownish or purplish tint, sharply contrasted with
the pink or yeilow of the corpuscles around. If this brownish or
purplish tint occurs in all the corpuscles, it has no pathological sig-
nificance, but merely means that the staining has been incorrectly
performed.
((■) " Stijypliuf/" refers to fine, dark-blue dots scattered over the
pink surface of a red corpuscle, as if a charge of fine shot had been
fired into it.
All the abnormalities just described are to be found in aii}' of
the types of severe anaemia,
whether ]iriniary or secondary,
but stippling may also be found
ifitho}it aiiii'iiiia in some cases
of leaiJ i>iii<:i»)inij, and is there-
fore useful as a confirmatoiy
sign in cases of this disease.
Nucleated red corpusch's are
divided into two main varieties :
(1) noniiobhists, which are of
the size of normal corpuscles ;
and (!') luegaJobhists, which are
larger tlian normal corpuscles
(see Fig. 2113). The nucleus
of the normoblast is generally
small and deeply stained, navy
blue. In the megaloblast the nucleus may have the same charac-
teristics or may be much larger and paler, with a distinct iutrauu-
no. 212.— NucU'iited Red Cells, ni, ni, Megalo-
blasts ; H, normoblast ; s, stippled cell.
THE BLOOD.
47;-!
clear network. Tlie protoplasm of both varieties is often discol-
ored, murky, gray, or even blue, and s<)]iietimes stippled, so that
by begiiniers the cell may be mistaken for a leucocyte. The mis-
take may be avoided, however, after some experience. In the pro-
toplasm of inicleated cells
there are often concentric
rings like tlie layers in an
oyster shell, and their outline
is usually more irregular than
that of any leucoctye. Fur-
ther points of differentiation
must be learned by practice.
2. Leucocytes. — In normal
blood four main varieties may
be distinguished :
(a) Polynuclears or poly-
morphonuclear neutrophiles.
(J)) Lymphocytes (large
and small).
(c) Eosinophiles.
{d) Mast cells.
(a) Polij7iuclears. — The
deeply stained, markedly con-
torted nucleus assumes a great
variety of shapes in different
cells, and is surrounded by a
pinkish protoplasm studded
with sjjots or granules just
large enough to be distin-
guished under the oil immer-
sion and slightly deeper in
tint than the
around them.
make up about two - thirds
(^sixty to seventy per cent) of
all the leucocytes ^iresent in the blood (see Fig. 213, a).
^'
protoplasm fig. 21.3.- a, Leucocytosls (40,000) ; sixteen polymi-
.. clears in a fleld. 6, Lympbatic leukaemia, jj,
J-Iiese cells polynuclear; »i, megalo blast ; f, eosinophlle.
Twenty-one lymphocytes in this fleld.
474 PHYSICAL DIAGNOSIS.
(Ji) Li/iiijilini-i/trs. — Tlie smallest variety is about the size of a
red cell, and consists of a round nucleus stained deep blue and sui-
roLuuled by a very narrow rim of pale, bluisli-green protoplasm.
In the larger forms the nucleus occupies much less siiace relatively,
is often less deeply stained, and may be indented. Tlie latter vari-
ety is sometimes burdened with the useless name of " transitional
cell," a term which in my opinion should be given up, since all
lymphocytes are transitional. In the protoi)lasm of the larger vari-
<;ties of lympliocyte one often sees a spirinkling of tine pink gran-
ales. ¥ioni fii-eufi/-ti CI' to thirti/'fire jjf'r CKut (or about one-third)
Df all leucoc3'tes belong to the lymphocyte group — classing all sizes
together (see Fig. 213, /<).
(c) Eosiiioplitlcs. — The nualeus is irregularly contorted and at-
tracts very little notice, owing to tlie very brilliant jiink color and
relatively large size of the granules in which it is immersed. The
outline of the cell is more irregular than that of any other leuco-
cyte, and its granules often become broken away and scattered in
the technique of spreading the blood. The eosino])hiles make up
approximately one -per cent of the leucocj'tes of iiormal blood.
(rf) Hast Cells. — Tlie shape of the nucleus can rarely be made
out, and the main characteristic of the cell is the presence of large
dark granules, stained blue or plum color, sometimes almost black,
and arranged most thickly about tlie margin of tlie cell. Mast
cells are very scanty in normal blood and make up not more than
one-half of one pcv cent of the leucocytes.
Other varieties of leucocytes which appear in the blood only in
disease will be mentioned later.
3. Blood Plates.— In the normal blood film, stained as directed
above, one finds, l)eside the red corpuscles and the different varie-
ties of leucocytes, a varying number of bodies, usually aliout one-
third the diameter of a red corpuscle, irregularly oval in shape,
staining dark red or blue and tending to cohere in bunches. Occa-
sionally larger forms occur, and in these a vague network and some
hints of a nucleus may be traced.
The significance of these bodies is unknown and they have at
present no importance in medicine, although they not infrequently
THE BLOOD.
lead to mistakes, because, when lying on top of a red corpuscle,
they bear a slight reseinlilance to a malarial piarasite.
III. Civnitiii'j till' iriiifi' Ciifjiiisrles.
The instrument used all over the world at tlie present da}' is the
pipette of Thoma-Zeiss, in whicli the blood is diluted either ten or
twenty times. The diluting solution is one-half of one per cent
glacial acetic acid in water. This diluting solution often accumu-
lates spores and be-
comes cloudy. As soon
as this happens a fresh
bottle should be pre-
pared. After a rather
deep puncture blood is
sucked up to the mark
pioint .5 on the pipette,
wliich is tiien immersed
in the diluting solution
and suction exerted un-
til tlie mixture is drawn
up to the point marked
11. This gives a dilu-
tion of one to twenty.
By drawing blood up
to the point marked 1,
instead of to the point
marked .5, we obtain a dilution of one to ten. After this the ends
of the p)ipette can be closed with a rubber band, and the blood, so
shut in, can be kept or transported without loss or change.
When we are ready to make the count, the rubber band is re-
moved and the pipette rolled in the lingers rapidly back and forth
for about one minute, to mix up the contents of the bulb thoroughly
and evenly. ISText blow out three drops, in order to get rid of the
pure diluting solution which is in the shank of the pipette. Then
put upon the circular disc of the counting chamber a drop of the
-Indicating an Order in wiiicli the Squares may
be Counted.
476 " PHYSICAL DIAGNOSIS.
mixtui-e fioiii the l>ull) of the piiiette. This drop must be of sucli a
size tliat wlien the cover glass (see J^'ig. 215 Ji ) is let down upon it '
the droji will cover at least nine-tenths (jf the circular disc and not
s[)ill into the moat around it. The size of this dj'ojj can only be
learned by practice. After about five minutes the leucocytes will
have settled upon the ruled sjiace which occupies the centre of the
floor of the counting chamber, and the count can then be begun,
using preferaljly a No. 5 objective of Leitz or a DD of Zeiss. The
whole ruled space should be counted, and after a little practice tliis
takes not more than hve minutes. I usually begin my count in the
left upper corner of the ruled space and proceed in the direction in-
"i^^"^*
Fig. 215.— Thoma-Zeiss CountinR Slide. A, Ruled disc : B, cover-elass ; C. iiinat.
dicated by the serpentine arrow in Fig. 214. In normal blood onfi
finds from thirty to tifty leucocytes in the whole ruled space. The
number of leucocytes per cubic milliinetre is ol)tained by multiply-
ing this figure by 200. Tlius if the number of leucocytes counted
is 36, the number in a culjic millimetre of blood is 35 x 200 = 7,000.
If great accuracy is needed, a second count with a fresh drop should
be made and the average of the two taken ; but in ordinary clinical
work tliis does not seem to me necessary, for the amount of error,
although considerable, is not such as to affect our diagnostic infer-
ences.
IV. Cnmitini) flie Tied C'orjnisrles.
Perliaps once in every twenty-five or hfty cases that one sees it
is well to know the number of red corpuscles. They can then be
counted with the Thoma-Zeiss pipette which is made for the pur-
|iose, and so arranged tliat the blood may be diluted one to two huu-
' T(i avoid iiir liuliblrs lower, tlie cover gluss with aid of a. needle as in
iiiouDting microscopic specimens. This must be done as quickly as possible
after the drop has been adjusted ou the counting disc.
THE BLOOD. 477
dred. The technique is exactly that described in the last section,
except that we need less blood and use a different diluting solution.
1 am accustomed to use a mixture suggested by Goweis, made up
as follows :
Sodium sulphate gr. cxii.
Dilute ucetic acid 3 i.
WattT § iv.
Blood is stu-ked up to the mark 0.5 and then Gowers' solution
to the mark 101. After the drop has been adjusted in the counting
chamber and the corpurscles have settled upon the ruled space, we
usually count a field of twenty-five small squares at each of the
four corners of the whole ruled space. The figure so obtained is
multiplied by 8,000. The result is the number of corpuscles per
cubic millimetre.
IXTERPKETATIOX ClF THK EksULTS SO OBTAINED.
1. iSi-'coiiildj't/ .{)iiinii'nt .
The liEemoglobin is usually redueed more than the count of red
corpuscles, giving a loir color imhw. In mild cases the hsemoglobhi
may fall as low as forty per cent before the i-ed corpuscles sliow any
considerable diminution. In severe cases the red cells fall to .'ijOOO,-
000, 2,000,000, and occasionally even to 1,000,000 or below it;
but the luemoglobin i>eually suffers even more severelj-.
The leucocytes may be iiornml, increased, or diminished, de-
pending on the cause of the anaemia. Thus in an;¥mia due to
chronic suppurative hip-disease the leucocytes are often increased to
20,000 or 30,000, while in malarial anajmia the leucocytes are often
subnormal. There are no characteristic changes in the differential
count, which varies with the underlying disease.
The changes seen in the stained blood film are briefly: Poikilo-
cytosis, abnormal staining of the red corpuscles, and the jireseuce
of nuclei either in normal-sized corpuscles (normoblasts) or in giant
corpuscles (megaloblasts). The degree of poikilocytosis and abnor-
mal staining reaction is ])roportional to the severity of the anaemia.
In mild cases we find only normoblasts, and those only after a long
478 PHYSICAL DIAGNOSIS.
search ; in severe cases we may find megaloblasts as well, but almost
invariably these cells are fewer tlian the normoblasts.
The commonest causes for secondary or symptomatic anaemia
ai-e as follows :
(n) Hemorrhage — gastric, hemorrlioidal, traumatic, puerperal,
etc.
(7/) Malaria, more rarely sepsis or other infections.
(<•) Malignant disease.
((?) C'hronic suppurations.
(e) Chronic glomerulo-nephritis.
(/) Cirrhosis of the liver.
(ff) Poisons, especially lead.
(/() Chronic dysentery.
(() Intestinal parasites.
It is important to remember that insufficient food or even star-
vation does not produce auEemia, and so far as we know no form of
bad hygiene has any notable effect upon the blood. Persons may
grow very pale under bad hygienic conditions, but their blood is
usually not affected unless one of the diseased conditions men-
tioned above is present.
2. Chlorosis.
The blood is practically identical with that just described,
though the color index is sometimes lower, poikilocytosis less-
marked, and nucleated red cells fewer. The pallor of the centres
of the cells (" achromia") is often very marked. The leucocytes are
generally normal and the differential count practically so, although
the percentage of polynuclear cells is often low with a corresponding
relative increase of lymphocytes.
8. Peniicions Ancemia.
The numlDer of red cells is usually below 2,000,000 when the
case is first seen. The color index is high and the leucocyte count
subnormal. The stained specimen shows very marked deformities
THE BLOOD. 479
and abnormal staining reactions in tlie red cells, with a tendency to
the predominance of large forms. Many of tlie latter contain nn-
clei (" megaloblasts '■), and a smaller number of normal-sized cells
also contain nuclei ("normoblasts").
The polynuclears are relatively diminished, witli a correspond-
ing relative increase in the lymphocytes.
In the remissions which form so important a featnre of the
course of periucious anpemia, the lilood is generally transformed
until it is almost or cpiite normal. In the subsequent fall it may
take on all the features of secondary ana?mia or chlorosis, and lead
to unavoidable errors in diagnosis and prognosis. Fortunately cases
are rarelj' seen for the first time at tliis (non-characteristic) stage.
IXTERPRETATIOX OF THE RESULTS OF THE LeUCOCYTE CoUXT AND
DiffeflExtial Couxt.
By combining the facts obtained by the total white count and
the differential count, we can estimate the inimlier of each variety
of leucocyte contained in a cubic millimetre of blood. Thus with
10,000 white corpuscles, 70 per cent of which are polj-nuclear (as
seen in the stained film), we have 7,000 ]iol3'naclear cells per cubic
millimetre, which may be considered the upper normal limit. Any
number greater than this should be considered as a leucoci/t'isis. In
a similar waj' we can say that any number greater than .3,.')00 is above
the normal limit for lympliocytes and constitutes a lijiiipliocijtosis,
while eosinopltiUa is present whenever the number of eosinophiles is
more than 400 per cubic millimetre. It is much better to use these
absolute numbers than to rely upon jiercentages. If we say, for
example, tlmt o per cent of eosinoiihiles is within normal limits, « e
shall make an error now and then in cases of myelogenous leukae-
mia, in which, with a total count of ijOO, 000 leucocytes, o ])er cent of
eosinophiles would amount to a total of 1.5,000 jier cubic millimetre,
or nearly thirty times the normal number. Errors are also common
in the opposite direction. For example, in typhoid, with a total
leucocyte count of 3,000, the lymphocytes nray reach 60 per cent
and j-et be well witlnn tlie normal limits, foi- (iO jier cent of o,000 is
4S() PHYSICAL DIAONOSIS.
onljr 1,800. Ill this case the apparent lymphocytosis is due to an
absohtti', decrease in ])olynuclear cells.
For the reasons here given it seems to me best to use the follow-
ing deKuitions :
1. Leucocytosis is an increase iu the jiolynuclear cells beyond
the normal— 7,000.
2. Lymphocytosis is an increase of lymphocytes beyond the nor-
mal upper limit — .S,500.
3. Eosinophilia is an increase of eosinophiles beyond tlie normal
upper limit — ."iOO iier cubic millimetre.
Oeeiirrenee of Li:ueociit(ish.
Leucocj'tosis, like fever, occurs in a great variety of conditions,
of which the foUownig are the most important:
1. In iiifccfiiiii.i dinedges — exeejit typhoid, malaria, uncomplicated
tuberculosis, measles, small])ox (prior to the pustular stage),
mumps, (-iei'inan measles, and influenza.
2. In a variety of fo.rcriiiic eniKllfiini.'i, such as urajuiia, hepatic
toxfemia, diabetic eonui, rickets, and poisoning by illuminating gas.
3. In a minority of cases of iiin/ii/iiitiif ilisr(it:e, especially sar-
coma.
4. After violent muscular c.vcHion, including parturition, and
after cold baths or massage.
There is in all probability no constant leucocytosis iu pregnancy
or during digestion.
Leucocytosis is most often of value iu the differential diagnosis
between typhoid fever or malaria on the one hand, and pyogenic
infections (meningitis, appendicitis, sepsis, pneumonia) on the otlier.
A leui^ocyte-chart is often of value in judging whether a local sup-
purative proctess, such as appendicitis, is advancing or receding, or
whether pus-pocketing has taken place. ]'>y a leucocyte-chart is
meant a series of letieocyte counts at short intervals — twelve,
twenty-four, or forty-eight luiurs. ll'/ieii fal-eii in coiuiccfion. leith
the otlier dill Icnl ihifa, a leucocyte chart is often of the greatest
value, especially in following the course of any disease ; to a less
THE BLOOD. 4S1
extent in diagnosis. In internal medicine leucocyte counts are
especially useful in febrile conditions, in the great majority of which
they assist tlie diagnosis.
Certain exceptions to the rules above given must be remem-
bered :
1. Quiescent, thickly encapsulated collections of pus, in which
the bacteria have died or lost their virulence, usually 'p^'odnce no
leucocytosis. In this group come some of the abscesses of the liver
or about the kidney, and a few cases of appendicitis.
2. Tlie most virulent and overwhelming infections are apt not
to be accompanied hij leucocytosis. Thus, for example, the most
virulent cases of j^iie^mionia, diphtheria, or general peritonitis
often run their course without leucocytosis.
Lymp hocytosis .
Only in two diseases does well-marked lymphocytosis occur: 1.
Lymphatic leukaemia. 2. Whooping-cough and its complications
(many cases).
Occasionally lymphocytosis occurs in rickets, hereditary syphi-
lis, and anything that produces debility in children. Lymphocyto-
sis is of value chiefly in the differentiation of lymphatic leukaemia
from other causes of glandular enlargement.
Eosinopihilia.
The eosinopliiles are increased chiefly in :
1. Bronchial asthma.
2. Chronic skin diseases.
.3. Diseases due to animal parasites (trichiniasis, uncinariasis,
filariasis, hydatid disease, Bilharzia disease, trypanosomiasis, and
with most of the intestinal worms k
4. Myelogenous leukaemia.
Tliere seems to be also some vague connection between eosin-
ophilia and diseases of the female genital tract (except cancer and
tibromyoma of the uterus).
31
4,Si
PHYSICAL DIAGNOSIS.
LF.iiK,i':i\riA.
Two fiiniis aro ilistiuij'uisliod, tliougli the distinction is chiefly a
clinical one : ((0 IM^yeloid nnd {/>) l3fniplioid.
1. jMijeloid Leakwiiiiii.
The lencocytcs are usually aljout 250,000 per cubic millimetre
when the case is first seen, but often run much higher, and some-
times lower. There is no an-
gemia in the earliest stages;
later moderate secondary aii-
Eemia develops.
The differential count shows
an extraordinary varirfi/ of
ti/pes, including many not seen
in normal blood (see Fig. 216).
The ijiajoritij of the leucocytes
are jioli/nuclcarv, but many of
these are atj-pical in size or in
the shape of their nucleus.
From 20 to 40 per cent of the
leucocytes are inyelocijfrs (or
mononuclear neutrophiles), the
" infantile " form of the poly-
nuclear cell. LiimpJionjtes are
absolutely normal or increased, but their percentage is low, on ac-
count of the greater increase of the other forms. Eosinoj^hUes are
absolutely much increased, though the percentage is not much above
normal. Mast rcl/g are more numerous tliau in any other disease
(1 to 12 ])er cent, out of an enormous total increase). Nori/iohlasfs
are usually very numerous; megaloblasts scanty.
Under the influence of intercurrent infections or after a-ray
treatment the blood may return to nornud.
Fig. 3iti.— Myukigvuuas Leuka?iiii;i. tn. Myelo-
cytes; p, polynuclear; b, mastcell: n, normo-
blast.
THE BLOOD. 4S;i
2. Li/iii/>hoid Leiikaniiiii.
The total increase of leucocytes is usually much less than in the
other type of leukaemia — 40,000 or 80,000 — or less in average cases.
The differential count shows an overwhelming proportion of lymph-
ocytes—90 to 99.9 per cent as a rule. In the acute forms of the
disease the large lymphocytes predominate; in chronic cases the
small forms.
The blood-film is mo7iotonous in contrast with the wonderful
variety seeu in myelogenous leukcCmia (see Fig. 213, b).
r. The Widal Eeaction.
(ff) Technique. Among the numerous agglutinative reactions
between the serum of a given disease and the micro-organism pro-
ducing that disease, only one has yet attained wide use in clinical
medicine, viz., tlie so-called Widal reaction in typhoid fever.
There are many waj^s of performing this reaction, but in my
opinion the following is the best:
Measure out in two small test tubes ten drops and fifty drops
respectively of a highly motile twelve- to twenty-four-hour bouillon
culture of typ)hoid bacilli, in which the bacilli have no tendency to
adhere spontaneously to each other. Carry these tubes and a mi-
croscope to the bedside, puncture the patient's ear as usual, and
draw a little blood into a medicine-dropper of the same size as that
used in measuring out the typhoid culture. Expel one drop of
blood into each of the tubes containing typhoid culture, and exam-
ine a drop of each mixture between a slide and cover glass with a
high-power dry lens. If within fifteen minutes clumping has
taken place in the 1 : 10 mixture, or if within one hour clumping
has taken place in the 1:50 mixture, the reaction may be consid-
ered positive. By clumping I mean an agglutination of the bacilli
into large groups and the complete or nearly complete cessation of
motility.
If it is inconvenient to carry the culture and the microscope to
the bedside, ten or twenty drops of blood may be milked out of the
ear and collected in a test tube (a three-inch test tube of small call-
4S4 PHYSICAL DIAGNOSIS.
bi'e is best). After clotting lias taken j)laee, it the edges ol' tlie (dot
are sejiarated from the glass with a needle or a wire, a few drops of
serum will exude, and this serum can Ix; mixed with the boiullon
culture in the manner already described.
Less reliable, in my opinion, is the use of blood dried upon glass
or glazed paper in large drops and subsecpieiitly dissolved in the cult-
ure itself.
(A) .Interpretation. A positive reaction occurs at some period in
the course of ninety-live per cent of all cases of typhoid fever, but
the proi)ortion of cases in wlii(di the reaction occurs early enough to
be of diagnostic value varies greatly in dilferent e[iidemics. In
most ei)idemics about two-thirds of the cases show a jiositive \Vidal
reaction by the time the patient is sick enough to consult a ]iliysi-
cian. The reaction maybe absent one day and jireseut on the next,
and varies greatly in intensity in different cases and at dilferent
times with the same case.
11. liliiiiil /'iiril.^ife.^.
1. The MuUt.riid I'm-a^Ue (see Mates IV. and V.).
In films stained as abovc^ directed the niahuial |iarasite ap])eai's
blue against the pink background of the corpuscle. A crimson-
stained dot should appear in some ])ortion oC the blue-stained or-
ganism; the ])rotoplasm of the veil corpustde around it is often
studde<l with jiiuk dots.
TJic stained specimen is preferable to the fresh blooil in thi^
searcli for malarial pxirasites, for the young, ring-sliapi'(l, oi' "hya-
line" forms often escape notice altogetlier in ficsh speeiiuens.
T('r//r/». organisms are distinguished friuu the a'slivo-autumnal
variety by the following tests:
((f) Tertian parasites nuike the corpus(de conlaining them larger
than its uninfected neighbors.
(/') Segmenting forms nev<'r occur i}i the jieriplu'ral blood of a-s-
tivo-antumiud fevers.
{(•') '^ Creaeen.t.'i" (see I'late V.) lu'vcu' <iccur except in lestivo-
autumnal fevers.
CABOT- PHYSICAL DIAGNOSIS.
PLATE IV.
Fk;. 1.— Vmiui^ TtTtiiiu Panisi(<'s. (StiiiiicW wiiU 'Wri^'Lil'y uiudiUraciuii nf
Leishiiiarrs slain. i
Fuj. ::?. — Mature Tertian Parasites, (Eosiu and inetliylnnH IduH.)
FiH. :!.— SpK''nientiii{,^ Tertian Paratiites. (Eosin and metliylene blue.)
THE BLOOD.
4sri
2. The Tri/pdnosonta.
In Central Africa (ami jin'smiiably in other tropical countries)
the blood or gland juice of many persons contains the organism
shown in Fig. 217, whicli lias long heen known as a parasite of the
blood of horses and of many of tlie lower animals. Human try-
FiG. 217.— Tryimiiiwoiii:!, in nuiiiau Blood. (By perinissiuii of Dr. J. Everett Iiutton and the
London Lancet.)
panosomiasis — a clironic, debilitating malady — becomes "sleejiiiig
sickness" when the tryptanosoma enters the cerebrospinal canal.
3. Fil'ii'lasis.
In the blood of many inhabitants of tropical countries there is
found (with or withoiit symptoms) the parasite shown in Fig. 218.
The species most often found is present in the periplieral blood only
486 PHYSICAL DIAGNOSIS.
at night; hence the blood shimld lie exaiiiiiied aftei- 8 p.m. A fresh
Fid. 3;8.— The Filaria Sanguinis Hominis. The head, curled up, Is seen to the right of the cut,
the tail at the left. Instantaneous photomicrograph. Fourhundred diameters magniOcation.
drop is spread between slide and cover and examined with a low-
power lens (No. 5 objective Leitz).
/K-
d-
iH
"\
■-■/-
n
c
---^
***■
M
•
"■■m
Fig. 319.— Pratt's ■Miiilillcalion or Ilu^ IJnHljc-l'Jiissell rdaffuldiiictiT. 7.', llnit^s rlngsoldured to
glass si ido ; fi, cover glass ; a blood drop on the under sidi' of this, wlien in place on the brass
ring, Is close to the point of the hollow inetiil needle whkii forms the extremity of the infla-
tion tube, C.
CABOT PHYSICAL DIAGNOSIS.
PLATE V.
Fio. 1.— 'r\;o A'duii^'- j;stiv<.)-;iiitLimnaI Parasites. ("Wri^^hr's nindiiicatiou of
Leishman's stain.)
Fid. 2.— jEstivo-auturrinal Parasites. Ring body at tlie left ; crescent at tlie riKtit.
Stained like Fig. 1.
Fk;. :!.— Ovoid in ^stivo-
auMittinal Malaria.
Fig. 4.— Crescent in ^stivo-autumnal Malaria.
THE BLOOD. 487
T//. h'stlllKlfinll. (if ( 'iKKJIlhlttUlh TlllW.
The r!i-<i(lie-i;usst'll iust ruiiK-Mit, us luoditied by Pratt ' (see Fig.
219), is tlie one wiiich I lia\e used luost. To use the instrument,
we put a di'op of water on tlie slide, iuside the metal ring (A').
Smear this ring witli vaseline. Tut a drop of blood o]i the under
side of the cover glass and press the latter down into the vaseline,
so tliatthe blood droj) eonics in the middle of the metal ring. Then
watidi it willi a low power of the micidscopt'; at intervals of one
nniiute a current of air is lironght inio (contact with the drop by
means of a rubber tube and bull), ('. As snon as coagulation has
taken place, the impact of tins current of air ceases to make the
corpustdes fly ahead and iimdnccs a radial current.
Normally, coagulation (iccurs under these conditions in from
three to eight minutes; anything outside these limits is to be con-
sidered pathological. All readings must be made at a single
temperature.
The estimation of coagulation time seems to be of some value to
surgeons in rehition to the question of operation in cases of hem-
orrhagic tendency (purpura, jaundice, and various liver diseases).
> Pratt: JouvDid ot Medical Ucscurcli, November, 1903. Tl)e instrument
costs 75 cents.
CHAPTER XXIV.
THE JOINTS.
EXAMINATKINS OF THK JoiNTS.
A. DJcfliods II ltd Data.
I. By inspection and pulpation we detect:
1. Pain, tenderness, and heat in, near, or at a distance from tlie
joi]it.
2. Enlargement :
(ff) Hard, probably bony.
(1>) Boggy, probably infiltration or thickenini; of eapsnle and
periarticular structures.
((■) Flnctuating, probal)ly fluid in tlic joint.
3. Irregularities in contour :
(ff) Osteophytes or "lipping" (attached to the bone),
(i) Gouty tophi (not attached to the bone).
(e) Constriction-line opposite the articulation,
(f/) Protrusion of joint-pockets in large effusions, filling out of
natural depressions.
4. Limitation of motion :
(ff) Duo to ])ain and elfusion.
(i) Due to nnis(uilar spasm.
((') Due to thickening or adhesions in the capsular and periartic-
ular structures.
((/) Due to obstruction by bony outgrowths or gouty toplii
(p) Due to ankylosis.
5. Excess of motion (subluxation).
THE JOINTS. 489
6. Crepitus and creaking.
7. Pree bodies in the joint.
8. Tropliic lesions over or near a joint (cold, sweaty, mottled,
cyanosed, white, or glossy skin, muscular atrophy).
9. Sinus formation, the sinus leading to necrosed bone, to goutj^
tophi, or abscess in or near the joint.
10. Distortion and malposition, due to contractures in tlie mus-
cles near the joint, to necrosis, to exudation, or to suliluxation.
11. Telescoping of the joint with shortening (limb, toe, linger,
or trunk).
II. By radiosco2jy we investigate :
1. Bony outgrowths, their shape, extent, and position.
2. ISTecroses and atrophies of bone, their extent and position.
3. The structure of the bones in and near the joints.
4. The presence of lesions in the articular cartilages.
5. Free joint bodies, their presence and position.
III. Indirectly w^e may gain valuable information about the
joints by noting:
1. General constitutional symptoms, their presence or absence.
These include fever, chills, leucocytosis, glandular enlargement,
albuminuria, and emaciation.
2. Tuberculin reaction, its presence or absence.
3. Disease of other organs, their presence or absence, i.e., syph-
ilis, tubercarlosis, tabes, and other chronic spinal-cord lesions, en-
docarditis, hceuiophilia, various acute infections (gonorrhoea, influ-
enza, scarlatina, septicaemia), and skin lesions (psoriasis, purpura,
hives).
4. The course of the disease and the results of treatment.
B. Technique of Joint Examination.
(a) Enlargement is generally unmistakable, but when there is
much muscular atrophy between the joints the latter may seem en-
larged by contrast, when in fact they are not.
(Zi) Fluctuation is obtained in most joints, as in any part of the
body, by pressing a finger on each of two slightly separated spots
4!»0 PHYSICAL DIAGNOSIS.
in the suspected area, and eiiileavuving to tvaiisniit tluough the iu-
tevveuing space an inipuLse fi-nni one finger to the other. Fat or
niusele will also transmit an impulse, but less ]iei-feetly than fluid.
Tn tlie knee we test for " floating of tln^, jiatella " over an effusion
by surrounding the joint with the hands, whi(di are presseil slightly
toward each other to limit the escape of fluid in either ilirection,
and then sinJiJciil 1/ making (piick pi'essurc on the patella with one
finger. If we feel or hear t-lie patella knock against the bone below
and rebound as we release the pressure, fluid in abnormal quantity
is present.
(r) In-ct/iiliirifii.'i (if ('(iiifiiiir are easily recognized, ]n-ovided the
normal contour is familiar.
(fZ) B(i)iy oiitgraivths may be obvious (as in Heberden's nodes),
but if within the joint they niay be recognized only by the sudden
arrest of (in oflterictse fi-ee Jidiit nidtion at a certain point. In many
cases radioscopy is necessary.
(e) Goiifji tophi are identified positively by transferring a minute
piece to a glass slide, teasing it iii a drop of water, covering with
a cover glass, ami examining with a high-power dry lens and a
partly closed diaphragm. The sodium l)iurate crystals are charac-
teristic.
Fluid or semi-fluid exudates in joints may fill up and smooth out
the natural depressions ajound the joint, or, if the exudate is large,
maj' bulge the joint pockets; in the knee-joint four eminences may
take the place of the natural depressions, two above and two below
the patella.
(y) Limitations of motion due to muscular spasm are seen with
especial frequency in tuberculous joint disease, but may occur in
almost any form of joint trouble, particularly in the larger joints.
(1) Hip-joint, two forms oi spasm are important; (1) That
which is due to iri-itation of the psoas alone i/isoas sjmsm); (2) that
in which aJl the inus<-/es nu)ving the joint are more or less con-
trai^ted.
Tn iiu]-e jisoas sjiasin the thigh is usually sonu^what flexed on the
trunk, though this nmy be concealed by forward bending of the lat-
ter. Very slight degrees of i)Soas spasm may be appreciable only
THE JOINTS. 491
when, with the patient lying on his face, we attempt hyperexten-
sion (see Fig. 220).
The otlier motions of tlie hip — rotation, adduction, abduction,
and flexion — are not impeded.
General spasm of tiie hip muscles is tested with the patient on
the back upon a table ov bed (a child may be tested on its mother's
1
■
|, i
m^^
^^^
/ 1
^^ "T^
,
"""^
-^,i
■ ^,^.
.----->?-i^
Fic. 22U.— TesUQK Ibf'Psoas Spasm. (Bradford aud Lovett.)
lap) and the leg flexed to a right angle, botli at the knee and at the
hip. Using the sound leg as a standard of comparison, we may
then draw the knee awaj^ frojn the middle line (abduction), toward
and past the middle line (adduction), and toward tlie patient's
chest (flexion). Rotation is tested by holding the knee still and
moving the foot away from the median line of the body or toward
and across it
(2) Spinal column. Muscular spasm of the muscles guarding
motion in tlie vertebral joints can be tested by watching the body
attitude (a stiff, "military" carriage in most cases), and by efforts
to bend the spine forward, backward, and to tlie sides.
In most cases we can make out limitation of these motions by
asking the patient to stand with knees and hips stiff and then bend
his trunk (of course, naked) as far as he can in each of the four
directions. If we are familiar with the average range of motility
492
PHYSICAL DIAGNOSIS.
in each direction and at the ilii't'erent ages, tliis test is usuallj' easy
and rapid. Backward bending is the least satisfactory, and in
doulitful cases the patient should Ije on liis face, wliile the ])hysi-
cian, standing above luni, lifts the whole body l)y the feet (see Fig.
-'I'l).
(.">) In the joints of the shoulder, knee, elbow, wrist, ankle,
toes, and hngers, there is usually no ditticulty m testing for muscu-
lar spasm, and no special directions are needed.
2\> ilisfi iKjiii^li III u.'^ciihir .tj>iisi)i. fi-<iiii hiiiiij oiitijrfiirth 'A^ a cause of
limited joint motion, we should notice that bonj- outgrowths (''.y.,
Yu;. ;2J1.— Uisidily !■£ Siiiue lu Pott's Dis'
in the hip) allow perfeetl}- free luotion up to a certain point; then
motion is arrested suddenly', completel}', ami without great pain.
Muscular spasm, on the contrary, checks motion a little fronr the
outset, the resistance and jiain f/r((r/»(///// increasing until our efforts
are arrested at some point, vaguely determined by our strength and
liard-heartedness and by the patient's ability to bear the pain.
Motions limited l)y capsular thickening and adhesions are not,
as a rule, so painful after the first liiuberiug-up process is over.
There is no sudden arrest after a space of free mobility, but motion
THE JOINTS. 493
is limited from the first and usually in all directions, though the
muscles around the joint are not rigid. The possibility of more or
less limbering-out after active exercise (or passive motion) distin-
guishes this type of limitation.
In true ankylosis, there is no motility whatever.
(</) Excessive motion in a joint is recognized simply by contrast
with the linuts furnished us by our knowledge of anatomy and of
the physiology of joint motion at different ages. \Yhen the Ijoiie
and cartilage appear normal or are not grossly injured, we call the
excessive motility of the joint a subluxation , but excessive motility
may also be due (as in Charcot's joint) to destruction of bone and
other essentials of the joint.
(/() To detect crepitus and creaking we simply rest one hand on
the suspected joint, and with the other put it through its normal
motions, while the patient remains passive.
(t) 'M.ost free joint bodies are not palpable externally, and are rec-
ognized only by their sjunptoms, by the a;-ray, and by operation.
(,/) Shortening of a. lintb as evidence of joint lesions is tested by
careful measurements. The vast majority of such measurements
are nuide with reference to the hip-joint. The tip of each anterior
superior iliac spine is marked with a skin-pencil, and likewise the
tip of each inner malleolus. Then, with tlie patient lying at fidl
length on a flat table, the distance fi'om anterior superior spine to
inner malleolus is measured with a tape on each side.
The method of obtaining the other data tabulated on page 488
needs no explanation, except the- radioscopic technique — a subject
which I am not competent to discuss.
C. Joint Diseases.
I shall use the classification proposed by Goldthwaite and divide
joint diseases as follows :
1. Infectious arthritis : («) Tuberculosis. (//) Other infections.
2. Atrophic arthritis : (a) Primary. {Ij) Secondary to organic
nerve lesions (Charcot's joint).
494 PHYSICAL DIAGNOSIS.
'■'>. Hypertrophic arthritis.
4. Gouty arthritis.
5. Haemophilic arthritis.
Under inf actions artJtritis are included all varieties of articular
" rheuniatisiu " ami the joint troubles symptomatic of gonorrhoea, of
streptococcus infections (including scarlet fever), influenza, syphi-
lis, typhoid, and other fevers. As tuberculosis is an infection we
must include it in this group, altliough the disease begins usually
as an osteitis and involves the joint secondarily l)y extension.
I. Tuherculous ArtJiritis. — The characteristics of joint tubercu-.
losis are :
(a) Sloiv progri-ax, with gradual enlargement and disabling of tlie
joint.
(/() Muscular s/xtmii, especially in disease of the hip or vertebrae.
(r) Evidences of low-yrade inflammation (moderate heat, swell-
ing, pain, and tenderness).
(t(f) Abscess and sinus flonuation.
(e) Alaljyositions {e.g., shortening of one leg in hip-joint disease,
angular backward projection in spinal disease, subluxations in the
knee-joint).
(/") Bone necrosis, as shown by .r-ra}'.
The order of frequency in the different joints is as follows :
spine, liip, knee, wrist, shoulder (tuberculous dactylitis is described
on page 50).
In tlie deep-seated liip-joint, diagnosis has to depend largely on
sliorteni II g and on the presence of limitation of all tlie hip motions
by muscular sjiasni (see above, page 491), unless the disease is of
long standing and manifests itself by ahscesses burrowing to the
surface. Usually these abscesses point in the upper anterior thigh,
but they may open behind the great troclmnter, below the gluteus
maximus, or at any point in the vicinity of the liip.
Besides muscular spasm, sliortening, and abscess formation, we
get some aid from tlie general and vague joint symptoms present in
this as in many other joint lesions. Sucli are enlargement (felt as
thickening about tlie great trochanter), muscular atropliy, pain, ten-
derness, and crepitus.
THE JOINTS. 495
In spinal tiiherrii/iini.'i [I'ott'a disease^ the distortion of the bones
with tonuation of a kiuiclile in the back is often obvious and prac-
tically diagnostic. In other cases we dejiend on muscnlar spasm or
abscess forniation. The muscular spasm gives a stiff back and ofteii
psoas contraction (see below). The abscess is peculiar, in that it
usually works along in the sheath of the psoas and pohits in the
groin below Poupart's ligament (see Fig. 202); less often it appears
in the back or in the gluteal region, and rarely it may invade almost
any part of the body (lung, gullet, gut, peritoneum, rectum, hip-
joint, etc.).
Psoas sjiasm, which is common both in hip and spinal tubercu-
losis, is by no means jjeculiar to these diseases, and it is worth re-
membering that it nnay be due to various other lesions, such as :
(a) Hypertrophic arthritis of the spine.
(S) A]ii)endix abscess.
(f) Perinephritio abscess.
In the peripheral joints (shoulder, elbow, wrist, finger, knee,
ankle) the diagnosis of tuberculosis rests on the chronic enlarge-
ment and disal)ility, with abscess and sinus formation.
Hysterical or acute traumatic lesions (with or without neurosis)
may present symptoms ami signs identical with those of tubercu-
losis. Decision is aided most by : (a) The lapse of time and the ef-
fects of treatment, (b) a:-Ray examination, (c) The predominance
in functional and traumatic cases of pain and tenderness rather than
muscular S})asm or malposition.
II. Acvfe Infectious Arthritis. — All varieties are distinguished
from the otlier t3q)es of arthritis by : (a) Tlie absence of any marked
bone lesions^ in most cases. (J/) The tendency to recoy<!r?/ in the great
majority of cases.
The milder forms, whose cause is unknown, we have hitherto
designated as " I'heumafism." The others are distinguished as
gonorrhoeal, pneumococcie, syphilitic, influenzal, dysenteric, etc.,
according to the organism jjroducing them.
Between this group and those known as "rheumatism," there is
' E.xceptioiiiilly, virulent iufcctions (especially those due to imeumocucci ov
streptococci) may do«troy cartilage aud bone and end in true bony anl^ylosis.
49(i
PHYSICAL DIAC7yOSIS.
r
"1
«
JUM
Fiu. »:-':;.- .i-U;iy, sliouliiir ll;uids ill Atro|iliu' Ai'lliritis.
THE JOINTS.
497
no clear pathologic distinction. JVIild infection with i^yogenic cocci
may leave a sound joint, thongh the general tendency is to crippling
through tibrous adhesions. On the other hand, arthritis of "rheu-
matic" {i.e., of unknown) origin may end in suppuration, crijipliug
tlie joint with adhesions, though in most cases it leaves a sound
joint.
All the members of the infectious group of joint lesions present
tlie locitl nlfjiis iif iii^flu III iiKitiiiii and the ronatiiiitiniKil. sir/iis of infec-
a b
Fig. ;S3.— a, Charccit's Joint with Loose P.odlps ; /), Pulmonary Osteo-arthropatby.
tloii. All may be complicated by endocarditis, but in those of un-
known origin (" rheumatic ") this complication is especially com-
mon. Tliere is no bony liypertropliy, bone destruction,' sinus
formation, or marked irregularities of contour. A general enlarge-
ment (more or less spindle sha^ied, owing to periarticular thick-
ening and muscular atrophy) is the rule. The joint motions are
' See note on page 495.
32
49S
PHYSICAL DIAGNOSIS.
limited chiefly hy pain and effusion; muscular spasm is not prom-
inent.
One or man}- large or small joints may be affected in anj' of the
varieties of infectious arthritis, tliough the gonorrluval virus is apt
wBm, WMfclliilBiil''" I ' •
Fifi. 224.— Atrophic Arthritis. Early stage.
to lodge in few joints (oftenest the knee or ankle) and the " rheti-
matic " virus in many joints, while the typhoid poison lias a predi-
lection for the spine.
III. Afrnji/tir Aiiliritis. — Two t3'pcs must be recognized: («) A
monarticnlar form, secondary usually to tabes or syringomyelia
(''Charcot's joint," " neuropathic joint''), and tither diseases of tlie
spinal cord. (A) A ]>olyarticiilar jirimary form ("rheumatoid ar-
thritis").
In both, the distingiiisliiiig characteristic is atroph}' and destruc-
tion of cartilage, bon(>, and joint meiubraiies — a ])rocess which in
the early stages can be identified only by the .r-ray (see Fig. 222).
THE JOINTS.
499
Later the disintegration of the joint is usually evident, and is fol-
lowed by distortions, contractures, and ankylosis.
(a) The inowirtu-iiliii' form is generally easy to recognize on ac-
count of its rapid, painless course, with semifluctuant swelling,
secondary to a well-marked cord lesion, such as locomotor ataxia.
A large joint is almost always affected, oltenest the knee, less often
the hip, slioulder, or elbow.
The joint shows abnormal
mobility and the bones can
often be felt to grate (see Fig.
22.3).
(/() The 2)riii!ari/ polijiirtir-
ulur form usually begins in
the fingers, and is very apt to
occur sijm mi'1rli-(tlhi, i.e., in
corresponding joints of botli
hands at the same time (see
Fig. 224). The joints are en-
larged, boggjf, spiudle shaped
(owing to tlie rapid atropliy
of the interossei), often abnor-
mally wliite, api)arentl3' fluct-
uant, and sliow trophic skin
lesions (glossj' skin, sweat-
ing, mottling) (see Fig. 225).
The terminal finger-joints are
rarely swollen. Late in the
course of the disease a ring of constriction often marks the line of
articulation (see Fig. 226). Tain is not severe until motion is at-
tempted or unless the joint is jarred and stirred up \>y some trau-
matism.
The changes progress slowly and attack new and larger joints,
moving centrally froju the ])erii)her3'. At any stage tlie process
may become arrested, l)ut usually not until onJeijIosis or covtractures
have occurred in one or many joints. Some of the "ossified ]nen "
of dime mxiseums are in tlie ankylosed stage of this teriibh^ malady.
Fig.
:i5.--AtropIiu- Artlii'iti.s. ((iuldthwaite.)
500
PITYSICAL ryJAONOSTS.
I'lt'xiou of lingers wit.li li)ii('rox1.i'nsiiiii of t.lii' Icnninal jniiils ;nul
(It'HectJim id ilic \ilnav siili^ :ivc (■(iiiiiiuni lU'lnriiiitiii'S.
V\ . //i//n'r/ni/)/i !<■ Art li lil is.- I!(iii\- ciilai'LjciiH'iil. ;inil <isi.('()]iliy1.in
.S|iiirs ui'O the distiiif-i'iiisliiiiL;' Iratiire. Tlic new ixiui' is Driciii'sl {\v-
jiosited roinul tlit^ imIi^-cs of tin' ai'l.iciiliii- carlalaLi'i', fdriiiinL; an irrcL;-
ular fungoid ring (" nng Ininc " in lioiscsj uv "lip" iirav l,lu! joiiit.
V\v.. :-'a;. AU-upliir Arllirilis. I,iilc' sUiki^ Willi .■luisli iciiiin liiiu iil lln' jcliil I
Uliilillliwiillr.)
Tlii^ at.ta(dnnents (if the ligamcnl,s (cy. , 1 lie anii-rinr laicral liga-
ment of tlie Rjiiiio or tlio cotyloiil Jiganicnt in flu'. liiii-jninl- ) rnniisU
another favorite site for tlio bony (l('|iosits.
{ii) In the tenniiial linger- joinl s {" llrhfnicii's iim/rf:") tlie
process may remain I'or years willioiil, exlending to any otluM'
articulation anil ^vitllllllt |)roiliiciiig any iliseomrcui; ( l<'igs. TiO and
{/) ) Tlie disi'ase may lie limited to tlie lii |i- joint ( " iiiorliiis coxa'
senilis ") or to any (itlier siiigl(5 joint, iirodnring piiri'h' meidianieal
disturbances by limitatrion of motion. 'I'liere is no eonsideralilc
muscular spasm, and motion is quite I'ree np to a certain point, at
THE JOINTS.
50]
which it is suddenly "locked " by the interfei-ence of the bony out-
growths. The situation, size, and shape of tliese outgrowths can be
shown, as a rule, b}- the .r-ray alone. Vain and swelling are
slight or absent, unless tianuiatisiir (^internal or external^ stirs
-Hyperti'oiiliic Artbritis with Heberdeu's Nock's.
up the joint and produces a synovitis. The chief complaint is of
stiffness.
(e) Several jouits may be affected, and there may result much
pain because nerves pass through or over the new-formed bone and
are compressed by it. This form is most often seen in the spine
(" spondylitis deformans," " osteoarthritis "), where a jjortion of the
front and side of the vertebral column is "plastered over" with
new-formed bone (see Fig. 228), which later invades the interverte-
.")! I.
PHYSICAL DIAOyOSIS.
bral eartilatje aiul piinluces ankylosis (_see Vi'j.. --!•)• I'itliev a stvaii;lit
'■ raiurod " s^iine vv a I'tn-ward cuv\'('i,l sjiiiu'.
new- 1 i
fuciued > — I
l-ume \
Flu. XI'S.— llyiHTlmiililr ArlUrilis uf S|iilic. IGoldtliwuik'.)
THE JOINTS. 5()M
111 tlie early stages tlie disease is recognized by :
(^/) Nerve j/aiii, running round tlie body or ihjwii the legs,' as
the iuteroostal and spinal nerves are pressed on.
(li) Limitut'uin of Jifofinn. The process is usually unilateral,
wholly or |iredoiiuiiantly ; lience the ]iatieiit can usually bend much
Fig. 339.— Hypertrophic Arthritis (Spiue) ol Spice with Ankylosis. (Goldthwaite.)
better to one side (see Figs. 2.';0 and 231) than to the other. Mo-
tion is also more or less limited in other directions, but forward
bending is fairly well performed as a rule, in sharp contrast with
" lumbago," which renders forward bending and tlie subsequent re-
covery almost impossible.
(c) Couffliin// or sneezing often gives great pain, probably because
the costo-vertebral joints are involved in the new growth; if anky-
losis of these joints occurs later, the respiratory movements of the
chest are interfered with.
V. Goutij Jrthritis. — The deposits of urate of sodium in the
soft structures around the joint are, like those in the ear (see
' Maiij' ueiinilgias and sciaticas arc due to this disease.
ri()4
PHYSICAL DIAGNOSIS.
Fig. 230.— StLOWing Normal Flexibility of Spine. «joliltli\vaite.)
Fit:. ;S1.— Hypertrophic Arthritis ol Spine. Motion to left limited. (GokUliwaite.)
TBE JOINTS.
505
Fig. 232), close beneath tlie skin or perforate it, and hence are
recognizable (as above exjilaiiied) by microscoiiic examination.
They somewhat resemlile the nodes of hypertrojiljio artliritis,
but are not attached to the bone and can be moved abont in the soft
structures over it. a'-Eay
examination shows that
there is often considerable
destruction of bone in tlie
\Meinity of tlie to)ihi (see
Figs. ■S.V.i and 234).
YI. ILi-niopJtilif .li-
FiG. 2 )~.— Gouty Toptius in tlie
Ear.
Fig. 2:33. - Ciuuty .VrUintls. (dolcltlnvaite.)
thi-itis. — A chronic stiffening and enlargement of the joint, re-
sembling in many resiiects the joint of liyiiertropliic arthritis,
but often accompanied by the formation of fibrous adhesions, en-
sues in some cases of haemophilia, presumably as a result of fre-
quent heniorrhages and serous oozings in the joint. The diagnosis
depends on the evidence of lijemophilia, the youth of the patient,
and the absence of infection as a causative factor.
50(1
PHYSICAL DIAGNOSIS.
Kelativk Fkkquency of the Yakious Joint Lksions.' — The
following table was jirepared li_y ]>r. Vic.keiy - from the records of
Fl(i. Z'A. .i-!'Luy ol Hand in Coiily Artliiitis. ((.uldUiwaite.)
the Alassaohusetts General liospital (1893-1903) :
Inf(.'rlious HI llirilis -:
873
I Acme rhcmiialic arthritis 591
] Subacute rlieuiiiatio arthritis 193
GiiiKirrlKi-al artlii-itis 8G
I Typlioid artlirilis (sjiiiie') 3
Ilypertropliic and atrophic arllnitis 43
Gout 9
' Chronic villous artlu'itis ("dry joint ") is a imrcly local process and there
fore receives no further mention here.
'^Boston Med. and Surg. Jour., November 17th, 1904.
CHAPTER XXV.
THE NEEVOUS SYSTEM.
Examination of the Nekvoiis System.
The outlines of neurological diagnosis depend on knowledge of:
I. Disturbances of motion.
II. Disturbances of sensation.
III. Disturbances of reflexes (including sphincteric and sexual
reflexes).
lA". Disturbances of electrical excitability.
V. Disturbances of speech and handwriting.
\I. Disturbances of nutrition (" trojihic ").
Yll. Psyclii(! disordei'S.
I shall attempt no topical diagnosis of nerve lesions, no diag-
nosis, that is, depending on memorizing the brain areas, cord lev-
els, or skin-and-musde ai'cas corresponding to particular nerve
lesions. The general practitioner for whom this book is intended
will not attempt to carry such points in his head, but will refer to
specialists or special text-books when the case confronts hiui. The
general methods most often employed are all that I attempt to de-
scribe.
/. iJisordfirs of Motion.
1. Gaits.
2. Paralyses.
3. Spasms and tremors.
4. Ataxia.
1. Gaits. —The most important gaits are:
(a) The sii'istic.
(b) The ataxic.
508 PHYSICAL DIAGNOSIS.
{(■) Tlie L;'ait of /m I'n/i/sis lUjitaiiH.
((/) The tnc-di-iij) (j<iit.
(<•) The </iiif <if SI III plr iri'ii L'lirss.
With t.lic xjidtttic ijii'il t.lieri' is ligidity of tlie legs, making it
(lifflcnlt to lift the feet; hence the patient scuffs along, usually with
bent knees and as if his feet were fastened to the ground.'
Tlie iitii.i-ic ijii'it is difficult to descvilie. Tiie patient is not nius-
culavly weak, but does not know wliere liis feet are or where the
ground is; lience lu:> flounders and tlii'ows liis feet about irregularly.
Tlie (jii'it <if iHiriil i/sis iiijitinis is an exaggeration of the old man's
gait, such as we often see on tlu! stage. The whole l)ody is bent
forward and rigid (see Fig. 2'.'>rt), ami, if progress is accelerated by
a push given from behind, the iiatient may be unable to stop himself.
In the toe-drop (jolt the foot is raised liigh and slapped down
upon the ground with a flail-like motion.
2. F<iriili/sis or Porrsia. — No <lid.ailed account can be given here
of the method of testing iiulividual muscles for loss or impairment
of power. In general, a knowledge of the origins and attachments
of mus{des enables us to work out for ourselves a series of tests
that will bring any desired group into contraction. It is convenient
to class jiaralyses according to tlu^ir origin as follows:
{o) Unt iji jilt nil I/sis : iv^wnXXy h,iiinipli'.(jiii. (arm and leg on same
side, with or without the face).
(/;) Coril i>ii rnli/sh : usually pordjilnjio (both legs, rarely l)oth
arms) or iiioiiojilrij'in- (on(! extremity).
(r) Cm II ml nvrrf ptirolijxia : usually our or ninrr. vijr iiii/sr/rs.
(il) I'vriiilii'rol. iivrri; p(i i-iil i/sis : special muscle f/rou/is, oftenest
the extensors of the wrist or foot, the shoulder muscles, ami those
suppli('(l by t.lie facial nerve.
(r) //i/slrririil pii riili/.^is : no strict aiuitomieal distribution, of-
tenest monojilegia (one e.xti'emity).
Teripheral lU'rve paralyses are especially apt to be accompanied
by setisory symptoms, electrical changes, and wasting. Bi'ain paral-
' The r/'oxs-kyr/eil rjiiit is a spastic guit in wliicli tlic adiluctors of the tliiglis
are so contracted tliat tlie feet tend to be crossed. Tliis gait is oftenest seen
in the congenital spastic 'paralyses.
THE XERVOUS SYSTEM.
509
yses have relatively few sensorv .•^vinptonis [ siimetimes pai'a?stlie-
sia>. see below. ]>age o\-) aiul velatively slight wasting. Mental
ehanges, eonia. or eonviilsions often jireeede or follow them. Cord
Fu:. "-^i-'i.- .vui[iul^- etiar.t>ter!:>[ir of r;iral>>is Airitans. (Cursehiiiann.i
paralyses may or may not show these assoeiations. but are often
aceoni[ianied by disorders of the bhulder and reetnm.
3. Sji''S'i)i. Tri-iiinr, II ltd FiliriJ'iirii Tiritclthnj. — (a) Spasm means
involuntary museular eontraetion. The familiar "eramp " is a good
exami'le of the type of spasm known as t"iiii: sji'isrn . In eontrast
with tliis is the fhniii' sj''is»i. in which flexors and extensors con-
tract alternateh' to ju-oduee a motion like that of our forearm wlien
510 PHYSTOAL DIAGNOSIS.
we sliakc up a fluid in a Irst tube, cir like the ankle elonns (see
below).
Spasms may be general or lucal, /'.''., involve few or many inns-
eles. In strye.hnine pdisoning tlie wliole body may be ilirown into
- vig'uhty Of I/, ■iii'ni/ toil ii- s/iiisiN. At tlie beginning of an epilejitic
seizure the body stilfens oid. (toiiie spasm"), then beeonu'S "con-
vulsed " {;/('iirni/ (■/iiiilf s/iii.siii). Liicii/ /ii///c spasm is exemplilied in
the ordinary "<■;■(( //(^)." 'I'lie spasti(^ gait, aliove described, is an-
other coniniou example ot tonic spasm limited mainly to one group
of muscles. ^Phe /•niifnict iirc^ whicli so often affect tlie soinnl mus-
cles in a j)artiallv paraly/cd limb (sec above, page 5(t.Sj arc also ex-
amples of hinil ftniir s/msiiis.
At/icfiisis, a special variety of local toinc s|iasm, lias been de-
scribed on page 45.
Liicdl i-liiiiic s|>asni is not coniuum. It may lie due to irritation
of a small portion of tln^ cerebral cortex by various lesions (".Tack-
soniau epilei)sy "), and sometimes precedes or alternates with the
general spasms of (n-iliuary epilejisy. It also occurs in 113'steria.
Artiti(ually a nn)uieutary or ]ii(ilongcd clonic spasm of tlie foot
muscles is often ]n'oduoed in testing f(U' the mil-lr rloiius (see below,
page 515).
(/)) Ti'i'inof may be detined as a rlniiic s/irisiii nf sliort c.rfiirshiii.
Its I'.auses and varieties liave already been discussed (see jiage 43).
((■) F'lhr'illiirij tirifcliiiKjs means the brief rejieated contraction of
small bundles of muscle til)res. It is seen in jiaticnts wlio are cold
or n(M'vous, in many debilitated and neui-a.sthenic eoinlitions, and
often in muscles affected by proi/rrnsirf vn/sni/nr iifnip/ii/.
((/) Choreic, and cJnirclforiii nmvenu'nts have already been de-
scribed ( page 44).
4. Afdxiti. — Inco-ordination of tlu' various muscles wliich nor-
mally act together to prodiu-t^ a well-directed movement is called
ataxia. All young infants exhibit ataxia in their nuire or less un-
successful gi-a,sping movcMucnts. Alcolioli(; intoxication often pro-
duces typical aiaxia, and it is also excmpliricd in \]\o. i/nif af fnlic.t
(hir.iiili.f. There is wo lack of muscnbir coiitra,ction — often too niucli
— but it is disorderly and ill-directed.
THE NERVOUS SYSTEM. 511
Deficieiic)/ in tJic j^owcf tn hulance. in standing or walking is per-
hajis the commonest tj'pe of ataxia, and may be due not only to the
causes just mentioned, but also to cerebellar disease and ear dis-
ease. In these types there is often a tendency to stagger in one
particular direction, e.(j., to the right, and the ataxia is associated
with vertigo and with other evidences of brain tumor or of ear dis-
ease.
In tabes dorsalis and otlier diseases we test the power to bal-
ance by asking the patient to bring his feet together (toe to toe and
heel to heel) and to close his eyes. If he is unable to preserve his
balance his failure is known as ^^ linmherifs. ^i(jn."
11. Disorders of Sensdtion.
The following are the most important types:
1. An<vsf]ii'.'<i<i (or insensibility to pain, to touch, to heat and
cold, and to muscle sensation).
2. Hi/pcru'.'ithp.'iia (or or('rsi'ii.'<itirciir.-<s).
3. I'lfnr.^f/ii'.-iiii (abnormal, false, or disordered sensation).
4. Fiiiii.
5. Di.'ioriler.i of sjii'fial fii'ii.^r.
These disturbances may all be seen in different stages or types
of lesions of the spinal cord or peripheral nerves. They are less
common in biain lesions.
1. Tests of aiia'.stlic.tia are time-consuming and difficult, because
we depend iov our data on the patient's intelligent answer to the
cpiestion, "Do you feel that?" As a rule, we cover the patient's
eyes and then touch the suspected parts — first liglitly, then more
strongl}' — questioning him to see if he feels the touch, can judge
the nature of the touching object (finger, pencil, pin), and tell
where he is touched. A ]>in-prick is oftenest used to test ]iain
sense, and test tubes filled, one \v'ith hot, one with cold water, are
convenient for trying the temperature sense. Finall}', we try
whether the patient can recognize familiar oljjects placed in his
hand and can tell the position in which you may i)ut his arms or
legs. Failure to make these discriminations is known as astereog-
512 PHYSICAL DIAG.XOSIS.
itosi.^, and occurs oftenest in brain lesions affecting the temporal
lolx's.
J)issoci(itiriii of gi'iisdfloii — the preservation, for example, of
sensations of touch with loss of those of jiaiii and temperature —
occurs oftenest in s}-ring'i)m3'elia.
Delai/i'd si'iisution and ]nistakes regarding the jioint touched in
testing are commonest in tabes dorsalis, which disease i)resents a
great variety of sensory disorders not here catalogued.
Tlie distril)ution of anaesthesia depends, like the distriliution of
paralysis, on the lesion. /fciiiiiniirsfl/ixiii is seen oftenest in /ii/sfr-
riii ami ofijait'K- hi-niii Irsiniis. Cord lesions, such as trmisri'i-fif iiii/r-
/itis (ir r'niqirrssioii <if flir cord, usually produce an.'Bsthesia in tlie
area suiipried hy the spinal nerves below the lesion, ri'i-iiihvnil
iiriTf /I'sidiis may produce aiiEesthesia of the skin areas supplied by
the nerve in (piestion.
Areas of /ii/fttcrica/ (uirc^tliesia (with liypersesthesia and pares-
thesia) usually do not correspond to the distribution of any set of
nerves or centres, and are distinguished bj' this fact.
2. lliipertt'^tlieain is most often recognized as hypercesthesia for
pain (tenderness) ov in the special senses (sensitiveness to liglit or
noise). It is coiumonest in peripheral nerve lesions and in hyste-
ria. The tests are the same as those for an;>3stliesia.
3. Pitrcfstlirsit is commonest in the form of tlie familiar prick-
ling and tingling felt when one's arm or leg has "gone to slee])."
Sensations as of crawling insects are not uncommon ; the " liot feet "
of many elderl}' persons (with arteriosclerosis) and the "liurning
hands" of many washerwomen are other familiar examples.
Locdl jiiinrstlicsiji, is not uncommon in lesions of the cerebral
cortex, and constitutes the preliminary "(iiira" witli wliieli many
attacks of e})ilepsy are ushered in. Well-developed fu/x's (/nrsn/is
shows many curious or distressing varieties of parajsthesia, as do
many otlier varieties of peripheral neuritis.
///. li,'tfej-cs.
We may distinguish :
1. Pupil ri'fexc's.
THE NERVOUS SYSTEM. 513
2. Deej) reflexes (tendon reflexes).
3. Superficial reflexes (skin reflexes).
4. Sjiliincteric reflexes.
5. Sexual reflexes.
1. Pujjil reflexes have been described on page 16.
2. Tendon Reflexes. — Among the most important of these is the
knee-jerk (quadriceps tendon); less important are the ankle-jerk.
(Acliilles tendon) and ankle clonus, the wrist, elbow, and jaw re-
flexes.
To test the knee-jerk many methods are used; the following
seems to me the best : The patient sits with his knees flexed at a
blunt angle. The physician lays his left hand on the front of the
thigh and strikes the tendon of the quadriceps, just below the pa-
tella, with the linger tips of the right hand or with a rubber ham-
mer. The left hand feels the sudden contraction of the quadriceps
whether the foot jerks or not. If no contraction is obtained we
should try what is known as " reenforcement of the knee-jerk."
The essence of this is concentration of the patient's attention on
a voluntary muscular contraction in another part of the body. We
may accomplish this by asking the patient to hook the fingers of
his hands together, and at a given signal to give a quick pull upon
them and then let go. The physician gives the signal (often
the word "now") and strikes the patella tendon at the same mo-
ment.
The knee-jerk is often wanting or feeble in young infants. It
varies a great deal in persons of different temperament; in high-
strung or oversensitive persons and in the Jewish race very lively
knee-jerks are often seen without disease.
Absence of knee-jerk is oftenest found in:
(a) Peripheral neuritis (alcoholic, diphtheritic, lead, etc.).
(b) Tabes dorsalis.
(c) Anterior poliomyelitis (on the paralyzed side).
(d) In the deepest coma from any cause.
(e) In complete severing of the spinal cord.
Given a case without knee-jerks:
33
514 PHYSICAL DIAGNOSIS.
N'curifis is suggested by the histoiy and etiology, by the pres-
ence of marked sensory symptoms (pain, tenderness), and the ab-
sence of symptoms pointing to the brain or (toid.
In fd/ifs the Argyll-Robertson pupil, tlie disturbance of tlie
sphincters and sexual power, the "lightning pains" here and there,
the presence of Romberg's symptom (see page 511), and later the
ataxic gait are important confirmatory signs.
Anterior l)oHomijditis presents a flaccid jiaralysis, usuallj^ of one
extremity, coming on suddenly in a young child and wholly with-
out sensory symptoms.
Comatose patients, if the coma is due to cerebral hemorrhage
and is not of the profoundest type, often show increased knee-jerks
on the paral3'zed side; but in very profound unconsciousness all
reflexes are lost.
Part'uil destruction of the cord often increases the reflexes, but
total division usually abolislies them.
Increased knee-jerk is found in : ^-
(a) Cerebral paralyses (infantile, apoplectic, dementia paralytica,
etc.).
(/') Spastic paraplegia and the amyotrophic forms of lateral
sclerosis.
(r) Many cord lesions, localized above the lumbar enlargement
(transverse or pressure myelitis).
((/) In the earliest stages of peripheral neuritis.
((?) Multiple sclerosis.
(/) Some forms of chronic arthritis.
DiFFEKEXTiAr. DIAGNOSIS of cascs witli increased knee-jerks:
Cerehral /larali/ses usually manifest their place of origin by the
presence of psychic symptoms (coma, idiocy, dementia) and by
convulsions. The i)aralysis is usually hemiplegic and involves no
wasting beyond the afrojdii/ of disuse.
Sjia.itic parap/ei/ia is rv^adily recognized bj' the gait (see page
r)()S) and the absence of marked sensory or sphincteric symptoms.
Its pathology is n<it known. if marked wasting of the nuiscles
occurs it is termed " min/ofroii/iie lateral sclerosis."
THE NERrOVS SYSTE3L 515
Transverse or diffuse cord lesions above the lumbar enlargement
produce usually anaesthesia below the level of the lesion and almost
invariably relaxation of the sphincters.
The earliest staijes of pci-ipliei-al neuritis are usually recogniza-
ble, despite a lively knee-jerk, by the predominant sensory symp-
toms and the etiology.
Multiple sclerosis presents, in typical cases, intention tremor
(see above, page 44), nystagmus (page 16), and staccato speech.
In atypical cases diagnosis is difficult and cases are often mistaken
for hysteria.
Almost any chronic joint disease, except tuberculosis, may be
associated with increased reflexes. Diagnosis depends on the ab-
sence of other causes for the increase.
Other Deep Reflexes. — The Achilles reflex is best obtained by
having the patient kneel on the seat of a well-padded chair, with
his feet unsupported, while we strike the Achilles tendon. The
significance of its absence or increase is practically the same as that
just given for the knee-jerk, but, since it represents a slightly lower
position in the sjjinal cord, it may be affected earlier than the knee-
jerk in any cord disease which begins at the bottom of the cord and
travels up. Thus in tabes I have known the Achilles reflex absent
when the knee-jerk still persisted.
Ankle clonus occurs in spastic eoiiditious of the legs or in any
disease which increases the other leg reflexes. It is obtained by
supporting the patient's leg in a state of such relaxation as can be
obtained, then suddenly and quickly forcing the foot up as far as it
will go toward the shin, and holding it in this position. A clonic
spasm results, which in fi-ue anlde clonus persists as long as we
choose to hold the foot iu tliis position. Spurious clonus is obtained
when only a few contractions occur, the muscle then relaxing. This
spurious clonus can often be obtained in neurasthenic and hysterical
states, and has not the significance of true clonus.
Kernitf s sign is a reflex contraction of the liam-string muscles,
obtained by flexing the tliigh on the trunk at a right angle (as in
the ordinary sitting position) and then attempting to extend the
51fi PHYSICAL DIAGNOSIS.
lower leg. Its motion is arrested about half way between the right
angle and full extension.
This reflex is of some value in the diagnosis of meningitis, though
allowance must be made for the stiffness of old age. The sign is by
no means pathognomonic, but is of some confirmatory value.
The deep reflexes of the arms (wrist, biceps, and triceps tendon)
are obtained by snapping these tendons sharply with the finger.
Decrease in these reflexes we cannot perceive, since they are onlt/
obtainahle wJien increased. They are increased in practically the
same diseases which increase the leg reflexes, and also in some
chronic joint troubles.
The, jaw-jerk is obtained by asking tlie patient to let the lower
jaw drop fully, placing a finger on the chin and percussing that finger
as in percussion of the cliest.
3. Superficial Rejie-xes. — A "ticklish" person is one whose su-
perficial reflexes ("skin and muscles) are very lively. Among path-
ological reflexes of this type :
(rf) The litdilnsld reflex is the most important. It is a modifica-
tion or reverse of the normal plantar reflex, which crumples up the
toes toward the sole of the foot if the sltin of the foot is tickled.
To obtain the Babinski reflex, bare the patient's foot and draw
the blunt end of a pencil along the inner side of the sole from heel
to toe with moderate pressure. If tlie great toe cocks up toward
the shin, Babinski's reflex is present. Sometimes several other toes
spread laterally and follow the great toe.
The reflex is obtained on the paralyzed side in hemiplegia and
other lesions involving the motor tract.
(]>) The cremasteric reflex draws the testis tight vrp against the
body (as after a cold bath) when the skin and muscles on the
inner side of the thigh are gathered up and firmly grasped in the
hand.
(c^) The ahdominal and epigastrii' ^^ iic^\e reflexes " are excited
by lightly and quickly stroking the skin of these parts with a pen-
cil point or something of the sort.
The presence of cremasteric, abdominal, and epigastric reflexes
indicates that the portion of the spinal cord in which they are rep-
THE NERVOUS SYSTEM. 517
resented (upper lumbar and lower dorsal regions) is functionally
sound. The absence of these reflexes, however, signifies nothing,
for in many healthy persons they cannot be excited.
(fZ) The reflex of winl-'mfj excited by the ordinary stimuli signi-
fies the approximately normal conductivity of the fifth and seventh
nerves (trigeminal and facial).
4. Sphincteric Reflexes. — The sphincters of tlie bladder and rec-
tum are kept closed in tlie normal adult by reflex contraction ex-
cited by the presence of urine and faeces. If there is no aware-
ness of faeces at the anus or of urine at the neck of the bladder,
owing to destruction of tlie conducting nerves or spinal nerve-cen-
tres, involuntary urination and defecation occur.
This is the case in transverse, diffuse, or compression myelitis
above the segment (fourth and fifth sacral) where the centres for
bladder and rectum are rei)resented; ' also in tabes dorsalis, dementia
paralytica, ami less often in otlier chronic sjunal diseases. Periph-
eral neuritis and brain lesions rarely affect the sphincters.
In deep coma from any cause (epilepsy, cerebral liemorrliage)
the sphincters may be relaxed, owing to the abolition of sensation.
5. Sexual Power. — Sexual power may be regarded as a reflex in
the presence of a particular stimulus, and is diminislied or lost in
chronic cord diseases involving the first and second sacral segments
(lumbar enlargement) or the nerves leading to them, e.g., in tabes,
some cases of myelitis and dementia paralytica, etc. Temporary
increase of power may precede the diminution.
IV. Electrical Reactions.
In health a sharp contraction occurs if a faradic current is ap-
plied to a nerve or over a muscle, and a similar contraction can be
obtained with the galvanic current just when the circuit is closed
or broken, but not when the current is passing.
In contrast with these conditions is tlie reaction of degeneration.
' It must be remembered that these nerves ariae from the cord at the level
of the first lumbar vertebra, thougli they do not iss^ie f-om the spinal column
till the fourth and fifth sacral foramina are reached.
:)1S PHYSICAL DIAGXOSIS.
When tills is present we obtain no mnseiilar twitching with the
faradlc ciinent anil none over the nerve with the galvanic; but
irit/i tJir i/iilran!c orer the iinisvle a s/oir, irnnn-Uke contrficfion oc-
curs, and the response to the positive ]jole is as good as to the neg-
ative, or better, whereas normally there is far better response to
the negative. This is the rnnijilete reaction of degeneration; in
p<trtiiil reactions of degeneration all tlie nornuil reactions nuiy be
present, but diminished in intensity.
Reaction of degeneration occurs l]i all diseases affecting the an-
terior motor horns of the cord or their prolongations downward in
the peripheral nerves ; for example, in anterior poliomyelitis, pro-
gressive muscular atrophy, transverse or pressure myelitis, and all
severe forms of peripheral neuritis. I)i brain lesions this reaction
rarely occurs.
In 2^1'of/iiosit: a reaction of degeneration persisting after six to
twelve weeks is unfavorable for recovery of the use of the muscles
in which it occurs. If reaction of degeneration is absent or partial
froiii the start, prognosis is for relatively speedy recovery, weeks
rather than months.
V. Speech and Hfnuhcritlng.
Aphasia, the loss of the power to speak or understand speech,
despite normal hearing and muscular powers, occurs in lesions af-
fecting the third left frontal and first left temporal convolutions
of the brain.'
The lesions producing aphasia may be permanent anatomical
changes following hemorrhage or tumor, or they jnay be transitory,
us in urfemia and migraine.
The power to write or read letters is lost ((/(/raphia) when the
angular and supraniargiual convolutu)ns are destroj'ed.
Deijeiierdt'tou. of the liaiidicritiini, as compared with the standard
of former years, is often a helpful bit of evidence in the diagnosis
of dement/jf, piini/i/fieii, but may occur temporarily in various fatigue
states.
' In some left-baudcd jiersous the centres are on llie right side of the brain.
THE NERVOUS SYSTE3L 51 fl
VI. Tro^jJiic or Vasoiiwfor Disorders.
Tro2}Jiie lesions of the joints, muscles (atroijhy ), skin, and nails
have already been exemplitied (pages 499 and 52). They blend with
and are by some explained as the results of vascular changes (vaso-
motor). Herpes hdnulls ("'cold sore") and herpes zoster ("shin-
gles") certainly seem to give every evidence of being due to nerve
nutritive disorders and not to vascular changes. The acute bedsores
which form in myelitis, the " anf/ioneurotie" local sa-eUmcjs which
appear liere and there in certain persons, and the local syncope or
asphyxia which sometimes lead to Raynaud's form of gangrene,
seem to need both nei-ve and vessel changes to explain them.
In brain lesions these trophic and vasomotor changes are much
rarer than in disease of the cord and peripheral iierves.
VII. The Examination of Psychic Functions.
The diagnosis of the mental factors of disease forms an impor-
tant part of the study not only of neurology, but of all diseases
wherever situated; but as it cannot be called physical diagnosis, it
falls outside the scope of this book, except in so far as loss of con-
sciousness, coma, may be considered under this heading.
Coma.
The causes of coma are identical with the causes of convulsions.
Every disease which causes the one may cause the other; hence all
that is here said on the diagnosis of coma applies equally well to
the diagnosis of convulsions. Either or both may result from :
1. Apoplexy (including cerebral hemorrhage, embolism, and
thrombosis).
2. Uraemia and hepatic toxaemia.
3. Diabetes. i
4. Cerebral concussion (stun).
5. Cerebral compression.
520 PHYSICAL DIAGNOSIS.
(). Syncope (fainting).
7. Opium.
8. Aleoliol.
9. Hysteria.
10. Epilepsy.
11. Gas poisoning.
12. Sunstroke.
Ajioplcxij is the probable diagnosis when an elderly person who
has shown no previous signs of ill-health beeonies suddenly and
deeply comatose within a few seconds or minutes. If liemiplegia is
present (with or without aphasia) and if we can exclude the other
causes above mentioned, the i)robability of ajioplexy is increased.
To determine hemiplegia in a comatose patient, try the following
tests :
((() Lift the arm and then the leg, first on one side and then on
the other, and let go. The supported member fails more limply on
the paralyzed side.
(li) Pinch or prick the limbs alternately. The sound limb may
be moved, while tlie other remains motionless. Pressure over the
supraorbital notch may bring out a similar difference in the response
of the two sides.
((■) Try the knee-jerks. On the paralyzed side the jerk maj' be
increased.
{d) Try Itabinski's reaction. It may be present on the para-
lyzed side or on both sides.
Uirrmia. — The diagnosis between apoplexy and uraemia is some-
times impossible, since urtemia may produce hemiplegia and the
urine in the two conditions (as obtained l)y catheter ) nurj' lie identi-
cal. Usually, however, tlie urtemic patient has previously shown
obvious signs of nephritis — aulenia, headache and vomiting, long-
standing oliguria, or polj'\ir)a witli albuminuria. Convulsions more
often pre(«de or follow the coma of ununiia than that of apoplexy.
Retinal hemorrhages or albuminuric retinitis, if recognized by oph-
thalmoscopic examination, ])oint strongly to unemia.
The hepatic toxaemia in whic^h many cases of cirrhosis die is dis-
tinguishable from uraimia only if the previous history of the case is
THE NERVOZTS SYSTEM. " 521
kuowu to us and the signs of liver disease (ascites, jaundice, caput
Medusaj) are evident.
Diabetic coma is usually recognized with ease, because the evi-
dences of advancing diabetes lead gradually up to it. The emacia-
tion of the patient, the sweetish odor of the breath, the presence of
sugar, and especially the evidences of acetone and diacetio acid in
the catheter-urine, are the essential factors in diagnosis. Dysp-
noea ("air hunger '') precedes thecoma in about one-third of the
cases.
Concussion (or stun) after a blow usually clears up in a few
minutes and so presents no difficulty in diagnosis. If the coma
lasts on for hours or days (as it sometimes does) the suispicion
arises that we are dealing with
Compression. For this the evidences are : Focal symptoms,
convulsions, slowing of the pulse, and signs of depressed fracture.
To determine the latter fact may be impossible without trephining,
since the inner table of the skull may be broken, while the outer is
intact. The focal signs to be looked for are paralyses (ocular or
peripheral).
Syncope (or fainting) is usually over in a few minutes and so
betrays its nature, but it must not be forgotten that a slight convul-
sion may occur just as the patient comes out of coma. No suspi-
cions of epilepsy need be aroused thereby, but if there have previ-
ously been signs of hysteria we may be in doubt whether the
fainting fit is not of hysterical origin. Tlie history of the case, the
circumstances at the onset of the attack, and the presence or ab-
sence of hysterical behavior during it usually guide us aright.
Opium p>oisoning produces a coma from which the patient can
usually be more or less aroused. Contracted pupils and slow respi-
ration are the most characteristic signs. A laudanum bottle or a
subcutaneous syringe found near the patient often assist the diag-
nosis.
Alcoholic coma is rarely complete. The patient can be aroused.
The circumstances under which he is found, the odor of alcohol on
the breath, the absence of paralysis, fever, small jnipils, or urinary
abnormalities are the main supports in diagnosis. There is no char-
522 PEYSICAL DIAGNOSIS.
actevistii! pulse and the jmpils show no constant changes, though in
many cases they are dilated.
Hi/atfrii'iil (■(Hint usually occurs in young women who have pre-
viousl}' sliown signs of liysteria. In falling they never hurt them-
selves. The eyelids are contracted, often tremulous, and when
forcibly palled open often expose eyeballs rolled up so that tlie
whites alone are seen. The luinds are ai)t to make grasping motions,
and there are irregular, semipurposive movements of various parts
of the body. A startling word may arouse the patient, but anaes-
thesia to pain (o\'er one-half or all the body) is often complete.
Postepileptic eoiKd, is usually recognized with ease, because of
the convulsions which precede it and which are usually known to
have occurred at intervals before. The S(!ars of previous falls may
be found on the head.
G((s jioigoniiif/ rarely presents any diagnostic ditticnlties, because
the circumstances under which the patient is found make clear the
cause of his condition. An odor of gas nmy hang about his breath
for some hours.
Sunstroke is recognized by the state of the weather and the pres-
ence of a very liigh temperature (lOfi", 110°, 115° F., or even
more). There is no otlier characteristi(! sign. Tliis condition is to
be distinguished from Jieat e.r/idiistioii, in which there is no fever and
no coma.
A.PPEND1CES.
APPENDIX A.
DISEASES OF THE MEDIASTESTCTM
I. Mediastinal Tumors.
New growths of the mediastinal glands' usually manifest theii
presence by the foUowuig symptoms and signs :
(1) Cachexia and substernal pain.
(2) Evidence of pressure agaiast : —
(a) The gullet.
(b) The windpipe or primary bronchi.
(c) The large venous trunks.
{d) JVerves which pass through the mediastinum.
(e) The subclavian arteries.
(/) The heart.
(g) The ribs, clavicle, or sternum.
(3) Secondary deposits ia the cervical or axillary glands.
(a) By pressure on the gullet swallowing may be rendered diffi-
cult or impossible (dysphagia) .
(b ) By pressure on the windpipe may be produced displacement
of the latter to one side, or fixation so that it cannot be moved in
any direction. The larynx may be drawn down into a noticeably
low position, and the laryngoscope may demonstrate that the tra-
cheal wall is bulged inward by the pressure of the new growth
upon it.
Dyspnoea, either insf)iratory or expiratory, or both, and often
' Tuberculous glands not being here included.
524
PHYSICAL DIAGNOSIS.
of noisy strident type, may result from stenosis of the trachea oi
primary bronchi. Owing to pressure on one of the large bronchi,
the resonance and breath sounds and fremitus may be diminished
over the corresponding lung, in which finally abscess or gangrene
BMH^^I
H
BSH
B
B -i^b^SI^H
1 '^'^-'^flHI^HH
1 ^^^spm
Fig. 236.— Sarcoma o£ Mediastinum and Cervical Gland. Vena cava superior obstructed.
may develop, owing to the retention and decomposition of the
bronchial secretions.
(c) If the pulmonary veins are pressed upon, a systolic murmur
may be audible in the left back, and congestion of the lungs may
ensue.
Pressure on the innominate and subclavian veins produces cya-
nosis or CEdema of the head, neck, shoulder, and arm, while the
superficial veins of the chest may become enlarged and prominent
owing to an attempt at collateral circulation, especially if the vena
cava superior is pressed upon. Fluid may accumulate in one or
DISEASES OF THE MEDIASTINUM 525
both pleural cavities if the vena azygos or thoracic duct is in-
volved (see Fig. 236).
yd) Aphonia or hoarseness points to pressure on the recurrent
laryngeal nerve, and on laryngoscopic examination one vocal coid
may be found in the cadaveric position. Inequality of the pupils,
due to pressure on the sympathetic nerves, is not uncommon, and
severe pain along the distribution of the intercostals or running
down the arm indicates that the spinal ganglia or brachial plexus
are pressed upon. Much rarer ai'e symptoms of pressure on the
vagus (slowing or quickening of the heart) and on the phrenic
nerve (hiccup, unilateral spasm, or paralysis of the diaphragm).
(e) Weakening or delay in one radial pulse may be due to press-
are on the subclavian artery.
(/) Occasionally the heart itself may be jjushed out of place.
(jf) Pressure of the new growth against the bones of the chest
may give rise to an area of percussion dulness under or near the
manubrium, which, however, is not likely to show itself until late
in the course of the disease when the new growth has reached a
considerable size. In many eases there is tympanitic resonance in-
stead of dulness over the affected area. The ribs or clavicle may
be pushed forward, but this is not usually the case. Occasionally
the new growth, if very vascular, may pulsate like an aneurism or
transmit the pulsations of the heart to the chest wall, and a systo-
lic murmur may be heard over the pulsating area, so that the resem-
blance to aneurism is increased.
Differential Diagnosis.
Mediastinal tumors may be mistaken for
(1) Aneurism of the aortic arch.
(2) Syphilitic stenosis of a bronchus.
(3) Phthisis.
Anerirlsm may be confounded with mediastinal new growths
even by the most competent observers. Tactile thrill, diastolic
shock, and tracheal tugging, if present, should suggest aneurism.
If these signs are absent, aneurism may still be present but cannot
rvjti PHYSICAL DIAOXOSIS.
be surely diaguoseil. The (ley:i'ee of aiueinia and eiuaeiation is usu-
ally greater in malii^iianti disease tliau in aneurism, but this is not
always the ease. The preseuee of seeondary uodules in tlui iieek or
armpit sjieaks strongly in t'ax'or of new growth.
Stenosis of a bronchus, duo to syphilis and giving vise to dys])-
naM, cough, stridor, pulumnary atelectasis, may be very ditheult to
distinguisli from mediastinal growth, but the degree of ana'niia, and
emaciation is usually less in syphilis, and the beuelieial results of
antisyphilitie treatnuuit may render the diagnosis jiossible, es])e-
cially if there is evidence of syphilis elsewhere in the body or in
the histcuy of the ease.
Phthisis uury be suggested by the weakness, enniciation, and
persistent cough produced by nuHliastinal growths, but should be
easily excluded by the examination of the Inngs and S]nita.
II. IMediastinitis.
The acute suppurative forms of this rare disease do not give rise
to any charaeteristie ]ihysica.l signs in the chest.
The e\'idences of chronic tibrons mediastinitis have been already
sufficiently I'.onsidered in connection « ith adlu>sive pericarditis.
III. Tuberculosis ok tiik ^AIkoi astixal (.tlanus.
Probably every case of indiiuinary tuberculosis is preceded oi'
accompanied by tuberculosis of the bronchial lymph ghuuls, and in
nunilierless eases the tuberculous process lu'ver gets beyond these
glands but is choked off there. In post-mortem examinations of
children, no matter what the cause of deidli, it is exci'ptional not
to find the bronchial glands tuberculous.
Nevertheless the disease can but rarely be recogni/.ed during
life. We may suspect it if, in a. child slmwing tuberculous cervical
glands or phthisis, avc lind evidence of pressure njion the right
bronchus, increased tactile fremitus above the nurnubrinui, lateral
displacement of the trachea, ov weakening of the jiulse during in-
spiration. If a bronchus is compi'cssed, tlie resonance, tactile
ACUTE ENDOCARDITIS. 527
fremitus, ami breath sounds are diminished over the correspond-
ing lung. Wiederhofer lays stress upon an increase in the inten-
sity of the expiratory murmur over the situation of the left j)rimary
bronchus.
APPENDIX B.
ACUTE KND0CARDITI8.
Whether the disease be of the benign or of the malignant (sep-
tic) type, the results of physical examination of the heart are usu-
ally very equivocal. We may guess that endocarditis is present
owing to the presence of a cause (rheumatism), of a fever not oth-
erwise explained, of a rapid irregular pulse of low tension, but the
physical signs over the heart will not usually assist our guess ma-
terially.
Murmurs are often present but have usuallj^ the characteristics
of "functional" murmurs (.systolic, limited, soft, without accentu-
ation of the pulmonic second sound or cardiac enlargement). If
we can observe the advent of a diustolw murmur in such a case, we
may fairly attribute it to a fresh endocarditis of the aortic (very
rarely of the pulmonic) valve, but if we have not had the oppor-
tunity to examine the heart previous to the onset of the present
attack it is impossible to exclude a long-standing valvular lesion as
the cause of the murinur.
If murmurs come and go from day to day, or suddenly increase
in intensity, we may suspect an acute endocarditis, especially if a
musical murmur is present or if there be evidence of embolism.
Inspection, palpation, and percussion usually yield no signs of
importance. There is no enlargement of the heart, no accentuation
of the second sounds, and no evidence of stasis.
rvJS PHYSJCAI. DTAi^yOSIS.
APPENDIX C.
PHYSICAL EXAMINATION OF THE CHEST IN INFANTS.
(1) Tactile fremitus and voice sounds can lie investigated only
in case the cliild cries or crows. Tlie cry-sotuul is intensified over
solidified areas and may or may not bo lost over fluid accumula-
tions.
{'2) Percussion must be verj- delicately performed if wo are to
avoid setting the whole chest in vibration with e\'ery stroke. It is
best to strike wholly with the finger, keeping the lunul (as well as
the wrist and arm) luimoved.
(o) In listening to an infant's lungs patience and concentration
are essential. The child is apt to stop breathing when the exami-
nation begins, ami we have to wait patiently to catch the long-de-
layed inspiration "on the wing," as it were, before the long expi-
ratory wail begins. The inspiration, when it does come, is unusu-
ally intense owing to the thinness of the chest in infancy.
(4) Long flexible rubber tubes connecting the chest-])iece of the
stethoscope with the ear-])ieces are very convenient when examin-
ing a wriggling child (see Fig. 8.'>, p. 1 17"), as tliey make it ]iossible
to hold the chest-]>iece in jiosition despite the constant movements
of the struggling sufferer.
(5) It is advisable to examine first the back while the child is
held in the mother's arms with its back to the physici;ui.
(6) Children almost always cry if made to lie down flat. If
we wish to bring out the cry soiuul in order to test the vocid and
tactile fremitus, this is a simple and luunane nu'tliod of jn-oducing
it. If, on the other hand, peace is what we most desire, it is best
to avoid putting the child in a recumbent positiiui.
(7) There is no type of breatluug jieculiar ft) children or in-
fants. I'uerile breathing is simply vesicular breatluug heard very
distinctly on account of the thinness of f.he chest. If, in a healthy
child, the expiratory murmur is prolonged and high-pitched, this is
probably because the child blows cmt the breath forcibly in the
effort to breathe deeply as it is t(dd to do. A young infant never
RADIOSCOPY OF THE CHEST. 529
does this, and its breathing is like that of adults except that it is
more rapid, more irregular, and better heard
APPENDIX D.
RADIOSCOPY OF THE CHEST.
Radioscopy gives assistance in the diagnosis of diseases of the
chest in two ways :
1. Through the use of the fluoroscopic screen.
2. Through the use of radiographs.
Those who are accustomed to the use of the fluoroscope gain
far more information from it than from radiographs, but the record
of the photographic plate is objective, permanent, and demon-
strable, 'while the impressions gained from the fluoroscop)e are more
apt to be modified by the personal equation.
For the piresent, therefore, we need both methods.
I shall not attempt to discuss the advantages of the ^'arious
forms of apparatus used for producing Roentgen rays in a Crookes
tube ; the subject would carry me beyond my depth as well as be-
yond the limits of this book ; but whatever form of instrument is
used, the vacuum in the tube should be less perfect when we desire
to use it for the chest than when searching for foreign bodies or
studyuig fractures. We need a "low " or " soft " tube which gives
rays of a relatively slight degree of penetration. With high pene-
tration rays the outlines of the solid organs are less distinct because
the rays traverse the heart and liver almost as easily as they do the
lungs. If the penetrating power is less, the rays are arrested by
the solid organs, but not by the lungs, and hence the outlines of the
former become visible.
I. The Us& of the Fluoroscope.
1. It is advisable to remain in a dark room or to wear smoked
glasses for a short time before attempting to use the fluoroscope.
This applies especially to beginners. Skilled observers do not need
34
530 PHYSICAL DiAoy'osrs.
such i)reparatioii of tlie ictiiia, Imt many novices who i-oniplain at- lirst
that tliey can "scu absolutely nothing " when they ap])ly tlie fluoro-
scope to the ehest, tind their vision suddenly and permanently ini-
prored after fiftet'n minutes in a dark room. Praetieo inereasea our
powers with tlie fluorosco])e as niueh as it does with the micro-
scope, and it is unreasonable to expect to see from the first all that
an expert sees.
2. The patient should be placed at least four feel from the tube,
else there is likely to be distortion and magnification of the shad-
ows corresponding to tlie organs examined. The tube sliould be
placed at such a lieight as to be opposite the most important object
to be examined, and always in the median line.
3. Patients niay be examined either in the upnight position —
the tube about two feet from the patient's back — tlie fiuoroscope
resting against the chest — or in the recumbent position, supported
on a canvas cot with the tube underneath. I jirefer the u])right
position. The patient's arms should alwa-ys be extendiul forward
so as to get the scapuhe out of the way.
4. To concentrate the light ujion a spot of special interest, we
may use a metal jilate with a rectangular opening about two by
three inches near one end. AVhen tliis plate is held between the
tube and the patient, so that the opening is opposite^ the spot to
be examined, the rays pass through the ojiening, but are iutercejited
hj the metal around it. The hand which holds this plate should
be protected from the action of the rays.
5. To mark on the chest the outlines of the sliadows seen with
the fiuoroscope, a pencil enclosed in a tube oi. brass is useful; the
brass jacket makes the pencil visible and enables us to adjust its
point to the outlines' on the chest. An ordhiary pencil is pene-
trated by the rays completely, and it is hard to draw with a pencil
which we cannot see.
77. 77ir JS'oniKi/ F/iim-osru/iir r'niurc (see Kmiitispiece).
Tlie lungs ap}iear as the lightest part of t-he fiidd owing to the
large amount of air they eonlain ; at tlu^ end of full inspiration,
they become still lighter. Against the light lung areas, the out-
RADIOSCOPY OF THE CHEST. 531
lines of the ribs and of the vertebral column (with the sternum super-
miposed) are clearly visible. Less clear, but usually quite distin-
guishable, are the outlines of the heart and the upper border of the
liver. A slight shadow (see Fig. 174) is often noticed just to the
right and to the left of the heart in a position corresponding to the
larger bronchi. The spleen is not usually to be made out clearly,
but the upper surface of the diaphragm above it is generally visible.
The contractions of the heart and the movements of the diaphragm
are usually clear, and any restriction of the respiratory excursion
on one side can be noted, though the fluoroscope has no advantages
over the inspection of Litten's diaphragm shadow (see p. 76) for
this purpose.
Abrams has noted that if the skin of the precordia is irritated
by cold or pain, a reduction in the size of the heart occurs ("heart
reflex ") for a few seconds.
In children all these phenomena are especially clear, owing to
the thinaess of their chest walls and we note at once how much
more horizontal the child's heart is than the adult's.
HI. Tlie Fluoroscope in D'tsease.
I shall mention first those diseases in which the fluoroscope fur-
nishes us the most valuable information.
1. Aneurism. — Small aneurisms of the transverse or descending
aorta may sometimes be recognized by the a;-rays when no other
method of physical examination yields satisfactory evidence. An
abnormal shadow appears at one side of the sternum (see Fig. 237)
and may sometiaies be seen to pulsate. In other cases the fluoro-
scopic evidence is not the only evidence, but tends to confirm or
dispel suspicions aroused by the ordinaiy methods of examination.
Aneurism of the heart itself is recognizable, according to F. H.
Williams, by the fluoroscopic examination. No other method of
examination gives us any evidence of such a lesion.
2. Determination of the Cardiac Outlines in Patients with Em-
pliysema and Fat Chest Walls. — Emphysema spoils cardiac percus-
sion and interferes with inspection and palpation. But in fluoro-
632
PHYSICAL DIAGNOSIS.
I'lU. :37.— Uiicllot'iuiiti of TboEuili; Aueurlsm,
RADIOSCOPY OF THE CHEST. 533
scopic work emphysema is a boon and a blessing, for it renders the
cardiac outlines more distinct than usual. Hence, for determining
the size and position of the heart in such cases, the x-rays give
iwfit-i^/w -■■".■ r~ -^^M^^^^^^^^^m
B^^HHHHHBHHI
KH^"'
hi
H|
iS^H^M^ ""^i^l^^l
^1
^^^^^K^'fi^*
^m
^^^^H
^^Kk
m
■
H
11
^^^1
^^H
F^s
^1
1^
Ld
Fig. 238. — Right-sided Pneiimottiorax seea from Behind. The collapsed right lung is seen
against the spinal column and surrounded by an unnaturally bright area corresponding to
the empty thoracic cavity. The shadow of the heart appears vaguely on the left side of the
spine.
genuine assistance, as they also do when mapping out the heart in
women with large breasts and fat chest walls.
3. Central Pneumonia. — Williams and others have succeeded
in identifj'ing foci of solidification beneath the surface of the lungs
when no other physical signs could be obtained. It must be re-
534
PHYSICAL DIAGNOSIS.
lueiulieied, lioue\ev, that- congestion of tlif lung, anlema, atelee
tasis, and pleural tliickening produce shadows siunlar to those of
solidified Inng.
4. Ti(hi'ri-iil,ixis. — It is still a matter of doubt whether tiilicreii-
lous foci can be recognized by the tiuorost'.ope before the disease has
progressed suliicieutly to produce localized rales, diminished breath
sounds, ox restriction of Litten's phrenic jihenomenon.
Slight opacities ha\e been noted in cases which later turned out
F](i. Ml.— Aueuiismal Sur. lliulinKraplieil fii>ni lieliiml.
to be tuberculosis, and wliieh had not previously been diagnosed,
but tlie shadows jierccived by the fluoroscoiie are capable of many
interpretations and correspond (as above said) t.o various patholog-
ical conditions. Old (juiescent foci may appear like advancing le-
sions and thus lead to serious errors. We do not want to hurrv a
patient off to Colorado or Davos on account of the shadow thrown
BADIOSCOPy OF THE CHEST.
5:^.5
by a long-healed lesion. Further, in some cases of rheumatism,
antemia, debility, and (■(invnlesccnt tj'phoid, appearances very simi-
lar to those of tuberculosis may be found (Williams). Hence the
interpretation of slight lung slmdows in cases of suspected incii^ient
phthisis is by no means easy.
Advanced phthisis renders tlie lungs relatively opaque to the
Fig. 2i0.— Aneurisnial sac Radiographed from in Front.
Roentgen rays except where extensive excavation has occurred ;
here we see a light area in a dark background.
No satisfactory radiographs of cases of iucipient phthisis have
so far been published, so far as I am aware.
5. Pleuritic affusions. — The displacement of the heart is some-
times better shown by the .r-rays than by ordinary methods of ex-
amination, since the compensatory hypertrophy of the sound lung,
53G PHYSICAL DIAGNOSIS.
wliicli interferes witli pereussioii and palijation of tlie lieart, renders
radioscopy easier.
The fluid exudate intercepts the rays perceptibly, and when the
movements of the diaphragm are not abolished on the affected side,
the line corresponding to the surface of the fluid can be seen to
6. Emphi/senKi. — The lungs become unusually transparent and
owmg to the low poeition of the diaphragm the heart descends and
assumes a very vertical position ("ptosis of the heart"); these
points are very clearly seen with the fluoroscope.
Radioyraphs.
But little use has thus far been made of radiographs in study-
ing diseases of the chest. The movements of the heart, of the
chest walls, and of the diaphragm render all the outlines indistinct.
For aneurisms, especially those containing a thick layer of clot, and
for intrathoracic tumors, radiographs may be very useful, and
bronchial lymph glands are sometimes rendered visible.
APPENDIX E.
THE SPHYGMOGRAPH.
This instrmnent consists of a system of levers by means of which
the pulsations of the radial artery are transferred to a needle whose
oscillations can be graphically recorded u.pon a piece of smoked pa-
per. It is a very fascinating little toy, but in its present form is
almost devoid of practical usefulness owing to the impossibility of
elimuiating the personal equation when using it. The size and, to
a certain extent, the shajje of the wave traced upon the smoked
paper can be influenced at will by the amount of pressure with
which the instrument is applied to the wrist. If an instrument is
move up and dowTi with respiration. During inspiration the heart
moves toward the side on wliicli the exudate is. (Greene.)
Small fluid accumulations flatten the nornual curve of the upper
surface of the diaphragm by filling up tlie chink between the chest
wall and the diaphragm.
THE SI'IIYdMOOHAPH. 537
ajiiilied ^s-ith a pressure of three uiiuees to the wrist of A, aud then
with the same i)ressure to the wrist of B, the foiee exerted upon
the artery may he quite different in the two cases owing to the dif-
ferent sliape of the wrist in the two indi\-iduals.
Almost any tyjie of tracing can be ohtained from a normal pulse
bj' varying tlie pressure.
This objection is fatal to the use of the sphygmograph as an in-
strument of precision, and although it is capable of recording tiny
Paravertebral
Triangle
Fig. 211.— Areas of Dulness in Pleural Effusion.
secondary waves unijalpable by the fingers, it has yet to be shown
that it reveals anything of pjractical diagnostic value which is not
appreciated by skilled fingers. For these reasons I have given no
account of the instrument in the body of this work. The poly-
graphic simultaneous records of the venous and arterial (or cardiac)
movements so extensively studied by "Mackensie, Wenkeback, Cush-
n}' , and others, are not referred to either in this section or elsewhere
in this book because I liave not yet liad enough experience with
their use to have any personal opinion as to their diagnostic or prog-
nostic value.
J'lnSlCAL DIAdMiSlS.
ATPKXDIX F.
THE PAHAVEUTEBHAI> THIANlUILAK AREA OF DULNESS IN
I'LEl'RAI. KKFl'SION.
Ivovaiiji -was tlio lii'st to iioiiil- out, this sii^'ii, thoiigli it is ttsually
iniscalled " < ! rnfi-ii'n .sii/ii." Ovvv the spinal cohumi and on the
sound side of tlie ehest theie ajiiiears in niost pleui'al ettusions an
avea of duhiess such as is shown in Kig. 241. This is due, jire-
suniahly, to tlie disphieenienr. of tlie mediastinal (issues. If the
patient lies on the diseased side tlie triangular dulness disaiii)eai's
(as a ruh') from the other side (Ewart's "eru(ual test").
Subdiaphragmatie ahseess or tumor may ]iroduce a similar area
of dulness.
Opinions differ as t<i the importance of the ]iaravertel)ral tri-
angle in excluding soliditieation and solid tumors. So far, 1 have
not found it of niucli value.
INDEX.
Abd(_)men, contour of, 365
ilistendeJ and tortuo\is veins of,
365
inspection of, 364
marking of, 365
methods of examination, 364
organs palpable in, 368
jialpation and percussion of,
364
palpation, methods of, 366
projection or levelling of navel,
365
respiratory movements of, 366
rose spots on, .365
tumors of, 370
tumors of, diagnosis from tumors
of wall, 370
tumors of, observation of, 370
tumors of, respiratory mobility
in, 370
timiors of, with ascites, 370
tumors of, with jaundice, 370
tumors of, -with leukaemio blood,
370
AI)dominal reflexes, 516
wall, abscess of, 369
wall, actinomycosis of, 369
wall, infected luiematoma of, 369
wall, sarcoma of, 369
wall, tuberculosis of, 369
Abscess, alveolar, 25
cervical, in Pott's disease. 31
cold, 55, 69
in tuberculous arthritis, 494
iscliio-rectal, 443
of abdominal wall, 369
of appendix, psoas spasm in, 405
of brain, optic neuritis in, 16
of glands near urethra, 449
of liip-joint, 457
of liver, 3.54-390
of lung, l^reath in, 21
of tonsil, 28
perinepliritic, 54, 418
perinephritic, psoas spasm in,
495
peri-uretliral, 445
psoas, 55, 455-457
diagnosis from actinomyco-
sis, 55
pulmonary, 359
retropharyngeal, 28
tuberculous, 55
Acetone breath, 21
Achilles reflex, test for, 515
tendon, tenosyno\'itis, 463
Achromia of red cells, in chlorosis,
478
Achylia gastrica, stomach contents
in, 3S2
539
.540
INDEX.
Acid urine, 4'J5
AciiP, eruptions on forehead in, 9
nose in, 17
Acromegalia, 8, 9, 40
chin in, 10
face in, 8, 9
family likeness in, 9
feet in, 47
hands in, 47
nose in, 10, 17
prominent cheek bones in, 10
ridges above eyes in, 10
"whopper-jaw" in, 10
Actinomyces of belly-wall, 369
Actinomycosis of neck, 34
Acute dyspnceic conditions, depressed
fontanels in, 7
endocarditis, 527
fevers, loss of hair in, 7
Addison's disease, buccal patches in,
26
Adenitis, 29, 94, 95, 523
Adenoids, 10
and thoracic deformity, 60
breathing in, 11
face in, 10, 11
mouth in, 10, 18
nose in, 17
snoring in, 11
tonsils in, 28
Adherent pericardium, 276
Agrapliia, 518
Albuminuria, Esbach's test for, 426
in local peritonitis, 373
in peritonitis, 373
significance of, 427
test for, 426
with nephritis, 428
without nephritis, 427
Alcoholism, ataxia in, 510
breath in, 21
Alcoholism, coma in, .521
tlistribution of fat in, 12
exaggerated pharyngeal reflex in,
29
face in, 12
nose in, 12, 17
paralysis in, 36, 458
shaking of head in, 13
tongue in, 22
tremor of hands in, 44
vomiting in, 29
mth fatty Uver, 389
Alkaline urine, 425
Alopecia areata, patchy baldness in,
7
Amoeba coli, 407
coli, in fsEces, 407
Amphoric breathing, 161, 313, .322
Amyloid disease, spleen in, 414-416
liver, 390
Amyotropliic lateral sclerosis, 514
Anaemia, ascites in, 374
blood in, 472
diagnosis of, 14
in cancer of peritoneum, 374
in cancer of stomach, 384
in tuberculosis of peritoneum,
.374
cedema of eyehds in, 14
of nails, 52
pernicious, blood in, 478
retinal haemorrhage in, 16
secondary, blood in, 477
secondary, cavises of, 478
AniEsthesia, hysterical, 512
in neuritis, 36
tests of, 511
Anatomy of chest, 56
Aneurism, 54, 2,80-291
abdominal, 368
abnormal pulsation in, 86, 87j 280
INDEX.
541
Aneurism, auscultation in, 285
cliagnosis of, 288, 289
diastolic shock in, 282
diffuse, 280, 289
distinguished from aortic steno-
sis, 289
distinguished from diffuse dilata-
tion of the arch, wthout rup-
ture of coats, 289
distinguished from empyema ne-
cessitatis, 290
distinguished from mediastinal
tumors, 290
emaciation in, 2
percussion signs in, 284
pressure symptoms in, 284
radioscopy in, 287, 528
thoracic, 280, 291
thrill in, 282
tracheal tug in, 283
tumor in, 281
Avith contracted pupil, 15
Angioneurotic local swelUngs, 519
cedema of Up, 19, 20
cedema, symptoms of, 14
Ankle clonus, test for, 515
epithelioma of, 463
jerk, test for, 515
tuberculosis of, 463
Ankylosis, following atrophic arthri-
tis, 499
Anorexia in local peritonitis, 373
nervosa, malnutrition in, 2
Anterior pohomyelitis, acute paralysis
in, 36
poliomyeUtis, knee - jerk in,
514
poliomyelitis, reaction of degen-
eration in, 518
Anus, fissure of, 443
fistula of, 443
Aorta, aneurism of, pointing in l)ack,
54
normally palpable, 368
Aortic aneurism, 86, 280
disease, 229, 246
obstruction, see Stenosis
pulsation (dynamic), 86
regurgitation, 229-239
regurgitation, complication of,
238
regurgitation, diagnosis of, 237
regurgitation, murmurs in, 235
regurgitation, pulse in, 232, 233
regurgitation, signs, 230
regurgitation, sounds in, 236,
237
roughening, 238
second sound, 179
stenosis, 239-246
stenosis, diagnosis of, 243-245
stenosis, murmurs in, 240
stenosis, pulse in, 242
stenosis, signs in, 240-246
stenosis, thrill, 243
Apex beat, see Cardiac Impnlse
cardiac, see Heart
retraction, 84
Aphasia, 518
Apncea, in Cheyne-Stokes breathing,
74
Apoplexy, 75
coma in, 520
distinguished from ursemia, 520
Appendicitis, cause of peritonitis, 373
diagnosis of, 402
local and constitutional signs in,
401, 402
muscular spasm in, 402
psoas spasm in, 495
simulated, 402
tumor in, 402
.542
IXDEX.
Appendix in pal|i;ition. 3liS
Arcus senilis. 10
senilis in arteriosclerosis, l(i
senilis in old age. Ui
ArgA-ll- Robert son pupil. 15
Arm. .'i5
contractures of. 37
Arms, deep reflexes of. 516
fatty tumors of. 3S
gouty deposits in. 38
in Paget 's disease. 40
in rickets. 41)
cvi lema of. 3S
o?dema of. iu Hodgkin's disease.
3S
a?dema of. in inflammation. 38
o?dema of. in nephritis. 38
cedema of. in sarcoma of limg. 3
cedema of. in sarcoma of medias-
tinum, 3S
cedema of. in tlu-ombosis. 38
cedema of. with tumors. 38
paralysis of. 35
sarcoma of hone of. 38. 39
sypihilitic nodes in bone of. 38
tuberculosis of bone of, 38, 40
tuljerculous lesions of, 39
wasting of, 37
Arrhythmia. 263
Arsenic pioisoning. neuritis in. 458
poisoning Avitli conjunctivitis. 14
Arterial movements. 89
murmiu's. 198
pressure. 111-117
pressnre. diastolic, 108, 116
pressure, methods of meastu'ing,
111
jiressurc, systolic. 106, 114
|)ulsations, 89
sclerosis, 90
sotmds, 182
Arterial tension, 108. 109, 111
"alls, calcification of. 110
Arteries, auscultation of. 237
calcification of. 1 10
diseases of. 1 10. 2S0
inspection of. 89
murmurs in. 198. 237
pvisition of, 109
size of, 109
stiffening of, 110
tuberosity of, 90
Arteriosclerosis, arcus senihs, 16
gangrene of toe in. 465
hot feet in, 464
panpsthesia in, 512
Arthritis, acute infectious, distin-
guished from other types, 495
acute infectious, endocarditis in,
497
acute infectious, results of. 497
acute infectiovis, signs in. 497
atropliic. 47-.50, 496, 498, 499
atropihic, changes in wrist, 47
atrophic, flipper-lumd in. 46. 47
atrophic. Morvan's disease in. 50
distinguished from acute osteo-
myelitis, 456
dysenteric, 495
gonorrhoeal, 495
gouty, 503
hicniophihc, diagnosis of, 505
hypertrophic, features of, 500
hypertrophic, Ileberden's nodes
in, 47-50
hypertrophic, of sacro-iliae .joint.
53
hypertrophic, psoas spasm in.
495
hypertrophic, with kyphosis, 54
infectio\is, 494
infectious, inguinal glands in, 455
INDEX.
543
Arthritis, influenzal, 495
imeumococcic, 495
syphilitic, 495
tuberculous, 494
Ascaris lumbricoides, 407-411
Ascites, 372-374
Aspliyxia, local, in Raynaud's dis-
ease, 49
Astereognosis, 511
Asthma, 322
bronchial, 322
bronchial, blood in, 481
diagnosis of, 322
Asthmatic l)reathing, 74, 322
Ataxia, causes of, 374
forms of, 510
respiratory movements of belly
in, 306
Romberg's sign in, 511
Atelectasis, 66, 73, 163, 361
crepitant rales in, 163
Athetosis, 45, 510
Atrophic ai'thritis, ankylosed stage in,
499
arthritis, deformities in, 500
arthritis, monarticular form, 499
arthritis, polyarticular form,
symmetrical involvement of
joints in, 499
arthritis, primary polyarticular
form, 499
arthritis, types of, 496, 498, 499
arthritis, x-ray of hand in, 496
diseases of -wrist-joint, 40
Atrophy following fracture or dislo-
cation, 37
in hysteria, 37
muscular, claw-hand in, 46
of disuse, 37
progressive muscular, fibriUai-y
twitching in, 510
Atrophy, progressive muscular,
wasting of arm in, 37
trophic, 37
Auscultation, 137, 198. (See also
Breathing ami Murmurs.
Rdlea. Heart .sounds.)
mediate vs. immediate, 137, 138
of heart, 171, 198
of lungs, 149-170
of muscle sounds, 146
sources of error in, 146-149
technii|ue of, 14.3-146
Babinkski's reaction, in paralysis,
520
reflex, test for, 516
Back, 53, 66
aneuiism pointing in, 54
dermoid cyst of, 55
epithelioma of, 55
in lumbago, 53
lipomata of, 55
perinephritic abscess of, 54
spina bifida of, 55
stiffness of, 53
tumors of, 54
Bacteria in faeces, method of exami-
nation for, 406
Balanitis, 445
Balantidium coli, 407
Baklness, hereditary, 7
in trigeminal neuralgia, 7
patchy, in alopecia areata, 7
patchy, in skin disease, 7
Barrel chest, 64, 318
Baths, cold, leucocytosis in, 480
Belly, in cretinism, 10
in general peritonitis, 37
wall, hernia in, 369
wall, lesions of, 369
Biceps, rupture of, 38
544
INDEX.
Bile in blood. 14
in urine, 14
Bile-ducts, 395
Bilharzia disease, blood in, 481
ha?matobiuni, 407-412
Biliary colic, 41!)
colic, differential diagnosis of, 395
obstruction, 14
Bladder data, 439
diseases of, urine in, 441
distention of, 439
distention of, causes of, 44(1
paralysis of, retention of m-ine in,
441
statistics on, 439
stone of, 441
tuberculosis of, 442
tumors of, retention of urine in,
441
tumors of, urine in, 425
Blindness, dilatation of pupil in, 15
Blood, appearance when stained, 471
coagulation time in, 487
color index of, 468
counting red corpuscles, method
of, 476
counting white corpuscles, meth-
od of, 475
cover-glass preparation of, 470
eosinophiha in, 480
examination of, 466
examination of stained, 469
hajmoglobin tests, 466-468
in chlorosis, 478
in faeces, 405-406
in lymphatic leuktcmia, 481
in pernicious ana'inia, 478
in secondary anirmia, 477
interpretation of result of leu-
cocyte count and differential
count, 479
Blood, in vomitus in gastric cancer,
384
in whooping-cough, 481
leucocytes in, 473
leucocytosis in, 480
lymphocytosis in, 480
normoblasts disting\iished from
megaloblasts in, 472
nucleated red cells in, 472
parasites in, 484
percentages of white cells in, 473
platelets in, 474
poikilocytosis, 472-477
polychromasia, 472-477
preparation of film, spreatling,
469
pressure, see Pressure
staining of, 469
stains used, 471
stippled red cells in, 472
test for, 381
Widal reaction. 483
Bodj', as a whole, 1
fluid in, 1
weight of, 1
Bone, destruction of, in atrophic
arthritis, 498
Bones in acromegalia, 10
Bony nodes of forehead, 8
Bow-legs, 4(iO
Bradycardia, 262
Brain, abscess of, optic neuritis in, 16
diseases of, transient glucosuria
in, 429
lesions of, hemiana\sthesia in, 512
par.alysis of, 508
paralysis of, mental changes in,
509
tumors of, optic ne\n-itis in, 10
Branchial cyst, 33, 34
fistulie, congenital, 34
INDEX.
545
Breast, funnel, 62
pigeon, 62, 65 (see also Chest)
Breath, acetone, 21
foul, 21
in alcoholism, 21
in foul teeth and gums, 21
in gastric fermentation, 21
in poisoning by illuminating gas
22
in starvation, 21
in stomatitis, 21
in syphilis, 21
in typhoid fever, 21
in uraemia, 21
Breathing, amphoric, 161
asthmatic, 69, 74, 155
bronchial, 153, 160
bronchovesicular, 160
catchy, 75
cavernous, 161
Cheyne-Stokes, 74
Cheyne-kStokes, causes of, 75
cogwheel, 156
compensatory, 157
costal, 69
diaphragmatic, 69
difficult, 71
diminished, 71
emphysematous, 155
exaggerated vesicular, 153, 157
grunting, 75
interrupted, 156
irregular, 75
metamorphosing, 156
normal, 69. 72
puerile, 153
rapid, 71. 72
restrained, 75
rough, 153
shallow, 75
sighing, 76
35
Breathing, stertorous, 75
stridulous, 74, 76
tracheal, 153, 1.54, 160
tubular, 153, 160
types of, 74
vesicular, 151
(see also Respiration)
Brodie Russell coagulometer, 486
Bronchi, dilatation of (see Bronchiec-
tasis)
diseases of, 292, 296, 322-324
stenosis of, 525
Bronchial asthma, 294, 320, 322
breathing (see Breathing)
Bronchiectasis, 323
Bronchitis, 292
acute, 292
chronic, 40, 47, 295, 320
diagnosis, 294
Bronchophony, 168
Bronchopneumonia, 303
Bronchovesicular, 160 (see Breathing)
Buccal cavity, 25
cavity, gangrene of, 26
ca\'ity, in Addison's disease, 26
cavity, pigmentations in, 26
Bulging of interspaces, 68
of one chest, 68
Bursitis of prepatellar bursa, 460
"Cachexia" of old age, 2
Calcaneus, 462
Calculus, biUary, 393
Cancer, gastric, 2
gastric, advanced, symptoms,
384
gastric, malnutrition in, 2
gastric, statistics of. 384
gastric, tumor in, 377
gastric, with absence of hydro-
chloric acid, 384
/
546
INDEX.
Cancer, metastatic, of thigh, 457
metastatic, with pressure on
cord, paraplegia in, 459
obstruction of gall-duct in, 396
of chest wall, .360
of intestines, signs and symptoms
of, 404
of liver, 389
of lung, 67, 360
of pancreas, jaundice in, 396-397
of penis, 446
of peritoneum, 372-374
of peritoneum, ansemia in, 374
of peritoneum, ascites in, 374
of peritoneum, diagnosis of, 374
of peritoneum, emaciation in, 374
of peritoneum, signs of, 374
of peritoneum, tumors in, 374
of pleura, 355-360
of rectum, 444
of sigmoid, 404
of testis, 446
of thyroid gland, 32
of tongue, 22
of uterus, 450
with enlarged cervical glands,
30
Canker of tongue, 22
Capillary pulse, 52, 91, 232
Cardiac disease, ascites in, 374 (see
also Heart)
disease, diuresis in, 1
disease, dropsy in, 1
disease, sweating in, 1
disease, weight in, 1
hypertrophy (see Hypertrophy)
impulse, character of, 79
impulse, displacement of, 66, 79,
203, 205, 208, 210, 231, 243,
277, 334, 343
impulse, normal, 79
Cardiac murmurs, 184-198 (sec
Murmurs)
moveraent,s, 203, 257, 261-265
neuroses, 261-265
neurosis, arrhythmia in, 263
neurosis, bradycardia in, 262
.neurosis, palpitation in, 264
neurosis, tachycardia in, 261
outlines, 57,205-208, 531
sounds, 172
Caries of vertebrae, abscess in, 28
Carphologia, 43
Cartilage, destruction of, in atrophic
arthritis, 498
Casts in urine, 431
Cavernous breathing, 313
Cavity, pulmonary, 313
Cervical rib, an accessory, 34
Chancre of lip, 19
Chancroids, inguinal glands in, 454
Charcot's joint, atrophic arthritis in,
498
joint, motility in, 493
Cheek bones in acromegalia. 10
Chest, anatomy of, 56
auscultation of, 137—170
barrel-shaped , 64
deficient expansion, 70
deformities, 60, 64, 66
examination of, 60, 361
examination of, in infanc.v, 528
expansion, anomalies of, 69
expansion, diminished, 70
expansion, "en cuirasse," 74
expansion, increased, 71
flattening of, 66
fluctuation in, 352
fluoroscopic, 529
in adenoid disease, 60
inspection of, 60
landmarks of, 56, 66
IXDEX.
547
Chest, local depression, 61, 62
local prominences. 67
movements of, 69-76
palpation of, 96-10.3
phthisical, 63, 67, 304-316
prominence, local, 68
prominence of one side, 67
racliitic, 60. 62. 63
radioscopy of. 352
retraction of. 73
shape of. 61-66
size of. 60
surface of. 91-96
tenderness in, 102
wall, cancer of, 360
wall, nutrition of. 6.5. 93
Che^Tle-.Stokes breathing. 75
Chickenpox. tliroat in. 27
Chilliness, diagnosis from chill, 4
Chills, 3. 4
after infusion of salt solution. 4
after or during labor, 3
after passage of catheter, 3
determination of etiologj'. 4
diagnosis from chilliness, 4
of acute infections, 3
of malaria, 3
of ''nervous" states- 3
of sepsis, 3
Chin in acromegaUa, 10
Chlorosis, blood in, 478
Cholangitis, suppurative. 390
s^Tnptoms in. 394
Cholecystitis, cause of peritonitis, 373
results of, 397
signs of, 396
Chorea. 13
leg in, 459
post-hemiplegic, 45
spasm in. 13
.Svdenham's. of hands, 44
Choreiform movements. 510
Circulation, portal, obstruction of,
365
Cirrhosis of liver. 389
of Hver. abdominal veins in,
365
of liver, spleen in, 414—415
of liver, toxsemia in, distin-
guished from uraemia, 520
of lung, 83. 315. .324
Claudication, intermittent, 458
Clavicles, prominence of, 63, 65
Claw-hand. 46
in chronic poliomyelitis. 46
in paralysis of interossei and
lumbricales. 46
in progressive muscular atrophy,
46
in si.Tingomyelia. 46
Cleft palate. ^20 '
Club-foot, varieties of. 462
Cog-wheel breathing. 156
Cold sore. IS. 19. 519
tremor of hands in, 43
Colic, biliary. 419
in gaU-stone impaction, 395
in plunibism, 396
intestinal. 420
renal, 39.5-419
Collapsed states, depressed fontanels
in. 7
Colon, fluid in. palpation of, 368
inflation of, in chagnosis of ab-
dominal tumors, 370-372
Coma, 519
causes of. 519
determination of hemiplegia in.
520
dilatation of pupil in, 15
knee-jerk in, 514
sphincteric reflexes in. 517
.'US _ INDIiX.
(.'omperisat-ion, oardino, cslalilislinu'ril, ( 'raniiiin, T)
and raihiiT cil'. 'JO'i 1311;") si/.c and shapr, .-)
('oniprcssiiin, cdnia in, syni|p((>in.s in, Crcrnasha-ii' ri'lli'x, Mli
TiLM Cri'iiilns in numail icaiiar a(i-ii|)liiu
cil' liniKS, (iCi arlhiilis, l!M.)
(.'oncaissiiin, conia in, .'"il! I in |iia'if,'asl ril is, .'(T I
Con^rnit.al licarl. disease, LMi,') in periliepal il is, 'M \
s[)astie ]tar:ily,sis, gail in, nO.S in peiaspienitis, 'M \
(.'onp'stiiin, liy|)(i.sla(ic, i!(>'J in pciilDin'l is, 'M\
Cunjnnclivitis, II piailnneal, ^(71
(lislinKuisliod I'nmi irilis. II ( 'rel inisni, Id
fron; (i\'ei'do,se of aisenie, I I dei'cir-ined lefj;s in, III
fntni ()\'e?'(]nse of iodide of pot- delayed closnre ol lonl.anels in, 11
ash, I I faco in. Id
with hay-fever, II lips in, LS Lid
with inllnenza, II innnlli in, l,S 'JO
with measles, II pot-heily in. Id
with yellow h'ver, I I teeth in. 'JO
Con.sciousness, loss of. Til'.! tonf^ne in, 2 1
Constipation in local ptaitoiut is. (Vonp. 711
i!7.'{ ( 'in\'at ni-e of spine, (id, 7d, 71
tongue in, '2'2 ('\;ni()sis, \Y1. Liil.')
('nntaf^ioii, p.sychie. choreiforni ni(j\'e- of nails, .''I'J
nientsin, IT) Cyst, liranehi.il. :i:!. :i I
( 'ontract nres follii\\iii^ .aliopliie ;ir- dermoid, of hack, Ti.')
thrilis, l'.)!l of ovary. I.M l.'i'J
liemiplefjie, hand in, Hi Cystitis, symptoms in. ILT)
of .arm, 'M nrine in. I'J.i. hw. I \ I
of the intca'ossei .and hnnliiie.ales, with freipiiail nnel uril ion, 111
ela.w-haiid in. Hi Cysloeele. I I.S
('ord, compression of. ana'st hesi.a in, < 'ysloscopw I I'J
.'')I2 Cyto-di.af;nosis. :i."i.") li.'i.S
lesions of, kni'e-jia'ks in, al.'"} of pleural effusion, li.-ili
]iaralysis, .adS tcchniipii' ol'. '.'<'<y'i
p.ai-alysis of. disord(a's of hladdia-
■and rectum in, ad'.) IlKnn.i'rv. lihrill.ary twitchinu; in. ;"ild
( 'orn<<a, Hi splecai in. I I .~i
Costal anfjle. til Deformities, eonf,naiit al, of lie.irl, '_'().'')
CoukIi, Kiri, :id(; ,,f chest, ki iw
Craiii]!, sp.'ism in. .^)ll) of hands. Id
('ranial-n<a'vi' par.alysis, .MLS J )i'f^(ai(a'at ion, reaction of. .^ I 7
INDEX.
549
Dementia puralytica, degenenitinn of
handwriting in, 518
paralytica, reaction (if |>upil in,
15
paralytica, sexual power in, 517
paralytica, sphincteric reflexes
in, 517
paralytica, tongue in, 22
Dermatitis, resulting from pediculi, 8
Dextrocardia, 84
Dialietes, acetonaemia in, -i'-iO
lireath in, 21
bronzed, 398
coma in, signs in, 521
dyspnoea in, 72
malnutrition in, 2
niellitus, 429
mellitus, gangrene of toe in, 465
optic neuritis in, IG
retinal hemorrhage in, 16
ulcer of toe in, 465
Diaphragm, 69
movements of, 69, 74, 76
paralysis of, 71
Diarrhoea, causes of, 401
(.lepressed fontanels in, 6
malnutrition in chronic, 2
Diastolic murmur (see Murmur)
•shock, 282
Dibothriocephalus latus, 407-411
Diet! s crisis 420
Digestion, painful, with hyperaci(Hty,
385
Dilatation cardiac, 205, 208, 291
Diphtheria, larynx in, 26
neuritis due to, 458
tonsils in, 26
with enlarged glanils, 30
with nasal discharge, 17
Displacement of cardiac impulse, 82
(see also Cardiac}
Distention, flatulent, 400
Distentions following atropine ar-
thritis, 499
Drop,sy, evident, 1
in cardiac disease, 1
in renal disease, 1
increase of weight in, 1
latent, 1
Ductus arteriosus, persi.stence of,
266
Dulness on percussion, 130
Dupuytren's contraction, 51
Dysentery, arthritis in, 495
chronic, anfemia in, 478
Dyspepsia, malnutrition in chronic, 2
.statistics of, 384
Dyspnoea, 71, 74, 523 (see also Breath-
ing)
■ causes of, 72
nose in, 17
mouth in, 18
varieties of, 72
Dystrophy, muscular, lordosis in, 54
Ear, gouty tophi of, 505
Egophony, 169, 299, 346
Electrical reactions, 517
Emaciation, 2, 374-394
Emphysema, 60, 67, 317-322
atrophic (or small-lunged), 317
barrel chest in, 60, 67, 318
breath sounds in, 319
complementary, 321
complications of, 320
diagnosis of, 319
interstitial, 321
large-lunged, 317
neck in, 29
percussion signs in, 318
radioscopy in, 535
senile, 317
550
INDEX.
Emphysema, subcutaneous, 321 (.see
Interstitial)
with asthma, 320
with bronchitis, 320
with kyphosis, 54
with tuberculosis, 315
Empyema, 346, 352-353, 354
necessitatis. 69, 290, 352
witli liypcrtrophic osteoarthri-
tis, 40, 47
Endocarditis, acute, 213, 251, 527
chronic, 213-258
in acute infectious arthritis, 497
Endometritis, 450
Eosinopliile cells in blood, 473
Eosinophilia, 4S1
Epididymitis, 446
Epigastric pain, 376
pulsations, 85, 276
reflexes, 516
retraction, 84
tumor, 377-384
Epigastrium, hernia in, 377
inspection and palpation of, 376
tumor of, 377
Epilepsy, local pariesthesia in, 512
scars on forehead in, 8
spasms in, 510
Epiphyses, enlarged, in rickets, 463
Epiphysitis, acute septic, 455
acute septic, diagnosis from ar-
thritis, 486
chronic tuberculous, 456
Epispadias, 445
Epithelioma of ankle, 463
of back, 55
of hip, 19
of nose, 17
of thigh, 4.57
Epulis, 25
Equinus, 462
Eruptions on forehead, 8, 9
Erysipelas, oedema of eyelids in, 14
symptoms of, 14
Erythromelalgia, 464
Ewald's test meal, 381
Exophthalmic goitre, 11, 12, 31
goitre, glucosiu'ia in, 429
Exostosis of thigh, 456
Eyelashes in plithisis, 12
Eyelids, dro|)ping of, 16
oedema of, 13, 14
Eyes, 13, 14
in Graves' disease, 11, 12
in hydrocephalus, 5
in jaundice, 14
in mviscle paralysis, 508
in phthi,sis, 12
Face, 5, 9
after vomiting, 12
in acromegalia, 8, 9
in adenoids, 10, 11
in alcoholi.sm, 12
in chronic diffu.se nephritis, 12
in cretinism, 10
in exophthalmic goitre, 11, 12
in general peritonitis, 12, 374
in Graves' disease, 11, 12
in heart disease, 12
in intestinal obstruction, 12
in leprosy, 11, 12
in myxci'dema, 10
in nephritis, 12
in paralysis agitans, 11
movements of, 13
oeilematous, 12
spasms of, 13
Fallopian tubes, 450
Faradic reaction in disease. 518
Fat, distribution of, in alcoholisni.
12
INDEX.
551
Fatigue, degeneration of handwriting
in, 518
Fatty metamorphosis of heart, 260
Febrile disease, bulging fontanels in, 6
Feces, abnormal ingredients in, 405
bacteria in. method of examina-
tion for, 406
blood in, 405-406
color of, 404
examination of, 404
gall-stones in, 406
microscopic examination of, tech-
nique, 410
mucus in, 405
odor of, 405
parasites in, eggs, diagnosis of,
408-409
parasites in, types of, 406
pus in, 406
tissue shreds in, 406
weight of, 404
Feet, hot, in myocarditis, in arterio-
sclerosis, 464
in acromegalia, 47
Fermentation in cancer of stomach,
384
Fever, continued, 3
crisis in, 3
determination of, 3
dilatation of pupils in, 15
emaciation in, 2
in atropinism, 3
infectious, 3
infectious, glucosuria in, 429
in inflammations, 3
in nervous excitement, 3
in pneumonia, 3
in "septic" conditions, 3
in sunstroke, 3
intermittent, 3
in toxic states, 3
Fever, in tuberculosis, 3
in typhoid, 3
lysis in, 3
nosebleed in, 17
peritonitis, 373
tremor of hands in, 43
types of, 3
Fibrillary twitching, 510
Filariasis, blood in, 481
parasites in, 485-486
Fingers, clubbed, 47-49
in heart disease, 47-49
in lung disease, 47-49
in pleural disease, 47-49
Fistula, branchial, congenital, 34
Fixation of costo-vertebral joints, 74
Flat-foot, 462-463
Flattening of one chest, 66
Flipper-hand in atrophic arthritis,
46, 47
Fluid, free, in abdomen, tests for, 371
free, in ascites, 371
free, in haemoperitoneum, 371
free, in peritonitis, 371
free, in ruptured cyst, 371
Fluoroscope, use of, 529
Flush in phthisis, 12
Follicular tonsillitis, 27
Fontanels, 6
bulging of, 6
delayed closure of, 6
depression of, 6
time of closing of, 6
Forehead, 8
bony nodes of, 8, 9
eruptions of, 8, 9
eruptions of, differential diagno-
sis in, 9
scars of, 8
Fremitus, tactile, 98
tactile, in emphysema, 320
552
IXDEX.
Freinitus, tactile, in pletiial tliickon-
ing. ijl
tactile, in pleuritic etfiision, oTiO
tactile, in pnetniuinia. '297
tactile, in pnemnothorax. o^il
tactile, in pulmonary tuberculo-
sis. 30S. 311
vocal. 167-l(i9 (see also Vocal)
Friction, pericardial. 100. 'J(iS
peritoneal. 371
pleural. 100, Iti.i. 337
Frontal bone syphilis. S. 9
Fttnne4 breast. 62
Gait, ataxic, oOS
in paralysis agitans. SOS
in toe-drop. 508
spastic. 50S
Gall-bladder. 395
adhesions about. 397
and hile-ducts. statistics on. .387
enlarged. :i97
enlargement of. 3i90
enlargement of. causes. 396
Gall-duct, common, ol.istruction of. by
stones. 39-i
stones. 396
Gall-ducts. 395
Gall-stone in intestinal obstruction.
397
Gall-stones, 393
in feces. 406
Galvanic reaction in disease. 518
Ganglion. 41
Gangrene, causes of. 465
local, in Raynaud's disease. 49
of buccal cavity. 126
of lung. 3.59
of lung, breath in. -1
Raynaud's form of. 519
toe in. 465
Gas, poisLtniug \^y . coma in, 522
Gastric cancel , tiniior in, diagnosis of.
•3/ (
contents, tests of. 382
dilatation. 385
dilatation, malnutrition in. 2
diseases, incidence anil iliagnosis
of. 384
fermentation, breath in. 22
fermentation, tongue in. 22
hemorrhage, with ulcer. 385
peristalsis, 377
peristalsis in adhesions of py-
lorus, 377
fieristalsis in cancer of pylorus.
377
peristalsis in cicatrix of pylorus.
377
peristalsis in muscular spasm of
pylorus. 377
peristalsis in simple thickening
of jiylorus. 377
stasis in disease. 386
stasis, subjective symptoms in.
:i86
ulcer. 385
ulcer, malnutrition in. 2
ulcer, tongue in. 22
ulcer, vomitus with bright blood
in. 385
General peritonitis, face in, 12
Genitals, female, 447
female, diseases of. blood in, 481
fenvale. inspection of. 448
female, lesions of, 448
female, methods of examination.
447
female, palpation of, 448
male. 444
German measles, glands in, 30
Glands (.see also Adcnilix)
INDIiX.
553
Glaiiils, cervical, 30
cervical, in malignant disease, 80
cervical, in tuberculosis, 30
enlarged, in mesentery, 375
in cankers, 30
in caries of the teeth, 30
in diphtheria, 30
in German measles, 30
in Hodgkin's disease, 30
in lymphatic leukaemia, 30
in the exanthemata, 30
in tonsillitis, 30
inguinal, enlarged when, 4.54
of neck in syphilis, 30
Glottis, obstruction of, 73, 76
Glucosuria and its significance, 42.8
experimental, 429
transient, 429
Goitre, simple, 31, 32
with exophthalmus, 11, 12, 31
Gonorrhcea, arthritis in, 49.5
balanitis in, 445
distended bladder in spasm of
urethra in, 440
inguinal glands in, 454
orchitis in, 446
with epididymitis, 446
with frequent micturition, 441
Gout, arthritis in, .503
toe in, 465
tophi, diagnosis of, .505
tophi in tendon in, 40
tophi in, test for, 490
Gouty arthritis, 503-505
arthritis, destruction of bone in,
505
arthritis, x-ray of hand in, .506
Graves' disease, 11, 12, 31
disease, eyes in, 11, 12
disease, face in, 11, 12
disease, hands in, 42
Graves' disea.se, tremor of hands in,
44
Groin, 454
glands in, 454
hernia of, 455
hydrocele of cord in, 455
psoas abscess in, 455
Gumlioil, 25
Gums, 24
hemorrhage of, 25
in debilitated states, 25
in lead-poisoning, 24
in poisoning by mercury, 25
in poisoning by potassic iodifle,
25
in scurvy, 25
lead line in, 24
.sordes of, 25
.spongy, 25
suppuration of, 25
Giinzburg's reagent, 382
I].EMADYN.\MOMETEK, Oliver's, 116
H;emateme.sis, in portal obstruction,
392
Hitmatocele, 447
Htematoma, infected, of belly-wall,
369
Haematuria, causes of, 424
Hiemin test, .381
Hajmoglobin, tests for, 466-468
Ha^mopericardiuni, 272
Hsemophilia. no.sebleed in, 17
Ha?mophiUc arthritis, .505
Hemorrhage, pulmonary, 305
Hair, 7
general loss of, 7
in acute fevers, 7
in myxcedema, 8, 10
in phthisis, 12
in syphilis, 7
5.54
IN DUX.
Ilair, nits in, S
normal loss of. 7
jiediculi in, S
rubbins off of licail in rickets, 7
Hand in acronief^alia, 47
Hands, clioreiforni incnonients of, 44
deformities of, 4(i
evidence of occupation, 41
examination of, 42
in atrophic arthritis, 46, 47
in chronic poliomyelitis, 46
in contractm'cs following hemi-
plegia, 46
in Graves' disease, 42
in niyxoedema, 46-48
in paralysis of median or ulnar
nerves, 46
in progressive nniscular atroi)liy,
46
in syringomyelia, 46
moisture of, 42
movements of, 42
professional spasm of, 44
spasms of, 44
tem|>erature of, 42
tremor of, 4!i
tremor of, causes, 43
tremor of, in alcoholism, 44
tremor of, in cold, 43
tremor of, in fever, 4'.i
tremor of, in Graves' di.sease, 44
tremor of, in hy.steria, 44
tremor of, in multiple sclerosis,
44
tremor of. in nervousness, 43
tremor of, in old age, 43
tremor of, in j)aralysis agitans,
44
tremor of, in loxa-mia, 43
tremor of, lest for, 43
Handwriting, degener.ation of, .^>!.^
Hang-nails. 62
Hare-lip, 20
Harri.son's groove, 62
Hay fever with conjunctivitis, 14
Head. .'")
abnormalities of. .'>
In hydrocephalus. [■>
in idiocy. 5
in rickets, 6
movements of, 13
open areas, .5
shaking of. 13
shaking of. in alcoholics, 1.3
shaking of. iii mor})hinisin. }'A
shaking of. in j)oisoning liy to-
bacco. 13
,shaking of. in t(]xic conditions, 13
sweating of, 7
Heart, 171-267
action of. 2113. 2r.7. 261-26.5
apex. |iosition. 97
apex, impulse. 7!). S2. 96
apex, retraction. ,S4
area, changes in. i:;2
area, in pericarditis. 272
area, normal, 129
arrhythmia of, 263
auscultation of, 171
bradycardia, 262
congenital malformations of, 26.')
dilatation of, 2I1S 210, 231
di.scases of, 199-267
enlargement of (sec //.v/xc/ro/i/i//)
examination of, 171-199
fatty mctamorphcsis, 260
hypertrophy of. 203, 20;i-20S,
210, 231. 243, 277
hypertrophy, causes of, 20.5
impulse, 79, S2
imjnilse, absence of, 274
im|)uls(>, dis|)laccuient of, N2
i
INDEX.
555
Heart, impulse, modification of, 06
in aortic regurgitation, 229-2.'i9
in aortic stenosis, 239-246
in mitral regurgitation, 210-220
in mitral stenosis, 220-229
in myocarditis (acute), 257
in neurosis of (chronic), 258
in pericarditis, 268, 274, 276
in pleural adhesions, 83, 3-51
in pleural effusion, 343
in pneimiothorax, 331
in pulmonary regurgitation, 251
in pulmonary stenosis, 252, 265
mspection of, 79-86
irregular action of, 263 (see also
Arrhythmia)
lips in disease of, 18
murmurs, 184-199 (see also
Murmurs)
outlines of, 128
palpation of^ 96
palpitation of, 264 (see also
A rrhythmia )
parietal diseases of, 257-261
percussion of, 129
rapidity of (see Tachycardia)
situs inversus, 345
slow (see Bradycardia)
sounds, abnormalities of, 172
sounds, accentuation of, 178, 179
soimds, character of, 172
sounds, doubling of, 176, 181
sounds, intensification of, 175,
178-179
sounds, metallic, 174, 182
sounds, modifications of, 174
sounds, muffling of, 182
sounds, normal, 172
sounds, position of, 171
sounds, qualities of, 173
sounds, reduplication of, 176, 181
Heart sounds, rhythm of, 181
sounds, shortening of, 209
sounds, weakening of, 175, 179
tachycardia, 261
temperature, 3
tricuspid regurgitation, 246
tricuspid stenosis, 250
uncompensated, 3
valves, position of, 171
valvular lesions, combined, 253
valvular lesions of, 199
weakness, 258
(See also Cardiac)
Heberden's nodes, 47, 50, 500
Hemiansesthesia, 512
Hemiplegia, 508
athetosis in, 45
atrophy of disuse in , 37
changes of nails in, 52
determination of, in comatose
state, 520
paralysis of leg in, 458
tongue in, 22
Hemiplegic hand, following contrac-
tures, 46
Hemorrhage, anaemia in, 478
bulging fontanels in, 6
in retina, 16
tendency of, in jaundice, 393
Hemorrhoids, 443
Hepatic abscess, symptoms in, 394
Hernia, epigastric, 369, 377
of groin, 455
of scrotum, 447
umbilical, 369
Herpes labiahs, 18, 19, 519
tongue with, 22
zoster, 519
Herpetic stomatitis, 19
Hip-joint, hypertrophic arthritis of,
500
i6
IXDEX.
Hip-joint, liiuilalion of iiiolioii in,
-194
HoilnKin's disease, glands in, oO, o7.")
di,sease, inguinal glands in, 4.k')
disease, redema of arm in, 38
disease, spleen in, 414-410
Housemaid's knee, diagnosis of, 460
Hydafid disease, blood in, 481
Hydrocele. 440
Hydrocephalus. 5
bulging of fontanels in. 6
delayed closure of fontanels in. (1
Hydrochloric acid, absence of, in can-
cer of stomach. 384
Hydronephrosis. 417
Hydropericardivuii , 272
Hydrothorax. 330
Hymen, imperforate. 448
Hyperacidity, gastric. 385
painful digestion in. 385
Hyper;i?sthesia. tests of, .^12
Hyperchlorhydria (see IIiiiKmciilil;/).
pain in, 305
Hyi-iertropihic arthritis, features of,
500
arthritis, hip-joint in, 500
arthritis, kyphosis in, 54
arthritis, limitation of motion in,
503-,')04
arthritis, nerve pain in, 503
arthritis, psoas spasm in, 495
arthritis, signs in, ,500
arthritis, spine in, ."lOI. ."i02, .503,
504
Hypertrophy, cardiac. 203. 205, 208.
210. 231. 233. 277
of lung. 07
Hypoacidity, .stomach trouble, .385
Hypochlorhydria (sec Hypoacidity)
Hypospadias, 445
Ilyjiostatic congestion. 302
Hysteria, ana-slhcsia in. 512
atrophy in. 37
choreiform movements in. 45
coma in. 521
hemiana^sthesia in, 512
hypera^sthesia in. 512
paralysis in, 30, 458, 508
ptosis in, 10
spasm in, 13
tremor of hands in. 44
Idiocy, mouth in. 18
Im|)ul.se. cardiac (see Canliac)
Incidence of diseases of the bladder,
439
of diseases of the intestine. 399
of di-seases of the kidney. 410
of diseases of the li\er. 3.S0
of diseases of the pancreas. 398
of diseases of the stomach. 384
Indicanuria, 399
Infancy, examination of chest in. 522
jaundice in. 15
Infantile atrophy, inaliuitrition in, 2
Infections, acute, arthritis in, 495
acute, chills in, 3
arthritis in, 494
crippled joints in. 497
fever in, 3
leucocytosis in, 480
Inflammation, oedema of arm in, 38
Influenza, arthritis in, 495
with conjunctivitis, 14
with nasal discharge. 17
Insomnia, 2
emaciation duo to, 2
in painful disea.ses, 2
Inspection of normal thoracic |iu!
sations, 82-87
of apex beat, 79
of cardiac movements. 79
INDEX.
557
Inspection of detormities of chest, G2
of peripheral vessels, 87
of respirator}' movements, 69
of skin and mucous membranes,
92
of thorax, 60, 96
Intestinal colic, 420
contents, examination of, 404
obstruction, acute and chronic,
403
obstruction, by gall-stone, 397
obstruction, causes of, 403, 404
obstruction, chronic, \'isible peri-
stalsis in. 403
obstruction, face in, 12
obstruction, physical signs in, 403
obstruction, symptoms in, 403
parasites, 406
tenderness, 400
tenesmus, 400
Intestines, cancer of, signs and symp-
toms of, 404
disea.ses of, constitutional mani-
festations, 400
diseases of, data for diagnosis,
399
diseases of, statistics on, 399
gaseous distention in, and its sig-
nificance, 400
pain, 400
parasites in, eggs, diagnosis of,
408-409
Iritis, with regular outline of pupil,
1.5
Ischio-rectal abscess, 443
Jack.sonian epilepsy, 44
epilepsy, spasms of hand, causes
of, 44
Jaundice, 14, 93, .392
catarrhal, 393
Jaundice, causes of, 14, 392
congenital, .394
diagnosis of cause, 393
in acute yellow atrophy, 394
in biliaiy cirrhosis, 393
in cancerous obstruction of gall-
duct, 396, 397
in cholelithiasis, 393
in new-ljom, 393
in portal cirrhosis, 393
in syphilis, 393
in toxtemia, 392
in urine, 393
in Weil's disease, 394
itching in, 14
malignant, 393
mental depression in, 14
of eye, distinguished from suli-
conjunctival fat, 14
of malaria. 15
of mucous membrane. 14
of new-born, 15
of pernicious anaemia, 15
of sepsis, 15
of ,skin, 14
results of, on body, 393
secondary, in septicuemia, 394
slow pulse in, 14
stools in, .393
with bile in urine, 14
with bile-stained sweat, 14
with catarrh of bile-ducts, 14
with hepatic cirrhosis, 15
with obstruction by stone, 15
with syphilis, 1.5
with toxiemia, 1.5
with tumors obstructing bile-
ducts, 15
Jaw in acromegalia, 10
Jaw-jerk, test for, 516
Joints, ankylosis of, 493
558
INDEX.
Joints, arthritis of, 494
arthritis of, order of frequency
in, 494
bony outgrowths, 490
capsular thickening and atlhe-
sions of, motion in, 492
chronic diseases of, knee-jerks in,
515
creaking in, 493
crepitus in, 493
diseases of, 493
diseases of, general spasm in,
490-491
diseases of, psoas-spasm in, 490
diseases of, shortening of limb in,
493
diseases of, symptoms of, 489
enlargement of, 489
examination of, 488
excessive motion in, 493
exudates in, 490
fluctuation in, 489
free bodies in, 493
hip, hypertrophic arthritis of,
.500
in atrophic arthritis, 499
in hiemophilic arthritis, .505
in rheumatoid arthritis, 499
inspection of, 488
irregul-rities of contour, 490
lesions of, relative frequency in,
506
lesions of, statistics on, 506
limitations of motion, tests of,
491
muscular spasm, tests for, 491
palpation of, 488
radioscopy, 489
sacro-iliac, hypertrophic arthritis
of, 53
.sacro-iliac, tuberculosis of, 53
Joints, spindle, in atrophic arthritis,
47
symmetrical invoh'ement of, in
arthritis, 499
to distinguish muscular spasm
from bony outgrowth, 492
Keratitis, syphilitic, 16
Kemig's sign, test for, 515
Kidney, 416
abscess of, 418
abscess of, etiology, 419
abscess of, signs of, 419
contracted, urine in, 438
cyst of, 417, 418
cyst of, distinguisheil from hy-
dronephrosis, 418
diseases of, 417
diseases of, evidence of, 416
diseases of, pain in, 420
diseases of, urine in, 420, 425,
428
floating, 419
floating, pain in, 395
floating, tenderness in. 417
malignant disease of, 417
movable, 419
palpation of, 368, 417
statistics on, 416
tumors, characteristics of, 417
tumors of, 417
tumors of, method of examina-
tion. 417
tumors of. urine hi, 425
Knee, 460
housemaid's, diagnosis of, 460
tuberculosis of, distinguished
from sarcoma, 457
Knee-jerk, absence of, 513
Knee-jerks, increased, differential di-
agno.sis in, 514
INDEX.
559
Knee-jerks, in paralysis, 520
test for, 513
Knocii-knee. 460
Koplik's spots in measles, 25
Kyphosis, 54
in emphysema, 54
in hypertrophic arthritis, 54
in Paget's disease, 54
in Pott's disease, 54
in rickets, 54
Lajiblia intestinalis, 407
Lavage, of stomach, method, 379
Lead-colic, pain in, 396
Lead-Une, 24
Lead-poisoning, paralysis in, 36, 37
respirator}' movements of belly
in, 366
Legs, bowed, 460
chronic ulcers of, 460
in cretinism, 10
in hysteria, 459
in multiple sclerosis, 459
in spastic paraplegia, 459
in tabes dorsalis, 459
cedema of, causes of, 461
osteomyelitis in, 461
parah'sis of, causes, 458
paralysis of, differential diagno-
sis in, 459
sarcoma of, 461
tenderness of, in neuritis, 461
tenderness of, in trichiniasis, 461
varicose veins of, 460
Leprcsv. H
face in, 11
hand in, .50
skin in, 11
Leucocyte-count in general peritoni-
tis, 374
Leucocytosis, diagnostic value of. 4.S0
Leucocytosis. in appendicitis, 402
in local peritonitis, 373
in osteomyelitis, acute, 456
occurrence of, 4.S0
LeukiEmia. inguinal glands in, 455
liver in, 391
lymphatic, blood in, 481-483
myelogenous, blood in, 481-482
myelogen(jus, x-ray in, 482
nosebleed in. 17
.spleen in, 414—415 '
tonsils in, 28
Leukoplakia Iniccalis, 23
Line;r albicantes, 363
Lipoma of arm, 38
Lipomata of back. 55
Lips. 18
angioneurotic oedema of, 19, 20
cancer of, glands in, 30
chancre of, 19
color of, 18
epithelioma of, 19
in cretinism, 1.8-20
in heart disease, 18
in lung disea.ses, 18
in methaemoglobinfemia. 18
in myxoedema. 20
in poisoning by acetanilid. 18
in poisoning by coal-tar anti-
pyretics, 18
Litmus-test. 426
Litten's sign, 76, 78. .306
Liver, abscess of, distinguished from
.syphilis or malignant disease,
390
abscess of, .symptoms in, 390
acute yellow atrophy of, 391
amyloid, disease of, 390
atrophy of, 391
cancer of. 389
cancer of, diagnosis of, 390
560
IXDEX.
Liver, cancer of, emaciation in, 390
cirrhosis of, i!S9
cirrhosis of, aluloniinal 'veins in,
:«'.5
cirrhosis of, amcniia in, 478
cirrhosis of, atrophic. 391
cirrliosis of, emaciation in, 2
cirrliosis of, latent, 3S9
cirrhosis of, portal obstruction in,
3S9
cirrhosis of, uncompensated. 389
congestiiMi of, 3,S9
diseases of, :->,S7
diseases of, cerebral symptoms
in, 39.")
diseases of, .signs in, 387
enlargement, 388
enlargement, causes of, 389
enlargement, condition.s with
which confounded, 388
enlargement, diagnosis of, 388
enlargement, in obstructive jaun-
dice, 390
fatty, 389
growth of, in cancer. 390
hydatid disease of, 391
in leuka-mia, 391
malignant disease of, symptoms
in, 39-1
pain and tenderness in, 387
palpable normally. 368
portal obstruction in, 391
.statistics on, 3Sli
sypliilis of, 390
syphilis of, distinguished from
cirrho.sis or malignant di.sease,
390
tumors of. 377
Locomotor ataxia, atrophic arthritis
hi, 499
Lonlo.sis, ,54
Lordosis in muscular dystrophy. 54
in tuberculosis, 54
with abtlominal tumors, 54
with pregnancy, 54
Lumbago, 53
Lung, ab.scess of, 21, 3,')9
acute miliary tuberculosis of, 316
adventitious ,sounds (see Rdtcs)
anatomy of. 57
atelectasis of, S2, 163, 304. 361
auscultation of. 149-165
cancer of, 67, 3tiO
chronic interstitial jinctimonia,
83, 315, 324
cirrhosis of, 324
collapse of (see Atclcitasis)
congestion of (see U^ilcma)
consolidation of (.see Solidifica-
ti<in)
disea.ses of, 292-329
diseases of, fingeis in. 47. 49
diseases of. lips in. 18
emphysema of. 317-321
fibroid di.sea.se of. 83. 315. 324
fistula sound. 170
gangrene of. 21. 3,59
hypertroiihy of. 67. 321
malignant disea.sc of. 67. 3(i0
miliary tuberculosis of. 316
oedema of. 362
palpation of. 98
perciLssion of. 131-131)
phthisis. 304-316
pneumonia. 296. 302. 303, 362
position of, 58
radiosco|iy of, 534
rales in disease of, 161, 306
reflex, 136
llontgen ray examination of, 57,
359
sarcoma of, 30, 38, 360
INDEX.
561
Lung, solidification of, 298, 311, 323
sputa in diseases of, 324
syphilis of, 323
tuberculosis of, 304-316
Lupus erj'thematosus, nose in, 17
Lymphangiectasis, filarial, 4.55
Lymphatic leukiemia, blood in, 481
glands in, 30
Lymphocyte cells, in blood, 473
cells, in pleural fluid, 355
Lymphocytosis, 481
in debility, 481
Malaria, aneemia in, 478
chills in, 3
jaundice of, 394
parasites in, 484
spleen in, 414
mth jaundice. 15
Malignant disease, anseniia in. 478
Malnutrition, 2
emaciation in, 2
in anorexia nervosa. 2
in chronic diarrhcea, 2
in chronic dyspepsia, 2
in diabetes, 2
in gastric cancer, 2
in gastric dilatation, 2
in gastric ulcer, 2
in infantile atrophies. 2
in oesophageal stricture. 2
Massage, leucocytosis in, 480
Mast cells, in blood, 473
Measles, conjunctivitis in. 14
Koplik's spots in, 25
oedema of face in, 10, 14
Mediastinal glands, tubercidosis of,
526
pressure, signs, 284, 523
tumors, .38, 290
Mediastinitis, 276, 278. 526
36
Mediastinum, diseases of, 523-527
Megaloblasts. 472. 477, 479
Mela^na, 385
Meningitis, bulging fontanels in, 6
strabismus in, 16
tuberculous, optic neuritis in, 16
Mensuration, 56
Mental symptoms in myxoedema, 10
Meralgia parajsthetica, 457
Mesenteric thrombosis, 375
Mesenterjf, enlarged glands of. 373
Metallic tinkle, 170, 232
Metatarsalgia, 465
Meteorism, respiratory mo^-ements of
belly in, 366
MethfemoglobinEemia, lips in, 18
test of. 18
Microcephalia, 5
Migraine, aphasia in, 518
Mind, depression of, in jaundice, 393
in general peritonitis, 373
Mitral disease, 210. 229 (see also
Heart)
regurgitation, 210
stenosis, 220
Monoplegia, 508
leg in, 459
Morbus coxEe senilis, 500
Morton's disease, 465
Morvan's disea.se, .50
Motion, disorders of, 507
Mouth, canker-sores of, 19
fissures in. 18
herpes of, 18, 19
in adenoids, 10-18
in cretinism. 18-20
in dyspncea, 18
in idiocy, 18
mucotis patches in, 18-25
syphilitic ulcers of. 18
Movements, respiratory, 69
562
INDEX.
Mucous luenibrnue in javuidicc, 14
Mucus in feces. 405
Multiple sclerosis, intestinal trouior
of. 44
sclerosis, knee-jerks in, 515
sclerosis, nystagunis in, 16, 44
sclerosis, paraplef;ia in, 459
sclerosis, speech in, 44
sclerosis, tremor in, 44
sclerosis, with spastic gait, 44
Mumps, 30
"accidental," 194
orchitis in. 446
Murmurs, arterial, 198
at apex, 212
at xiphoid, ISS
cardiac, 1S4-19S
cardio-respiratory, 197
conduction of, 188
diagnostic interpretation of, 190,
249
diastolic, 187. 234-236
diastolic, in aniemia, 196
diastolic, in aneurism, 286
diastolic, in aortic area, 286
diastolic, in aortic regurgitation,
234
diastolic, in ensiform cartilage,
234
diastolic, in mitral area, 235
diastolic, in mitral stenosis, 224
diastolic, in pulmonary area, 251
diastolic, in pulmonary regurgi-
tation, 251
disappearance of. 191, 225
effects of exercise on, 193
effects of position on , 193
effects of respiration on, 193
from pressure, 198
finictional, 194, 195, 196, 244
h;pmic (see Functional)
Murmurs in aortic aneurism, 285
in aortic area, 235, 239, 240-246
in aortic regurgitation, 235
in aortic roughening. 219, 238,
244
in aortic .steno.sis, 240
in back, 212
in mitral area. 212, 21S, 222,
226
in mitral regurgitation, 212. 21S
in mitral stenosis, 222-225
in neck, 196. 198
in pulmonary area, 196, 251 , 252
in pulmonary regurgitation. 251
in pulmonary stenosis. 252
in relative insulhciency. 239. 244
in tricuspid area, 188. 247
in tricuspid regurgitation. 247
in tricuspid stenosis. 247
length of, 193
maximvmi intensity of. 190
metamorphosis of, 194
musical, 192
of an;eniia, 196. 244
of Flint. 227. 239
organic, 190, 196
position of. 187
prcsy.stolic. 187
production of, 184
quality of, 192
significance of, 190
systolic, at apex, 212
systolic, at base, 240
systolic, in tricuspid area, 18S,
247
systolic, over arteries, 198
terminology of, 184
time of, 186
transmission of, 188
vascular, 198
venous, 198
INDEX.
563
Muscle, ilio-psoas, when palpable, 368
sounds, 146, 295
Muscular dystrophy, lordosis in, 54
Mydriasis, causes of, 15
Myelitis, acute, bedsores in, 519
sexual power in, 517
transverse or diffuse, paraplegia
in, 459
Myocarditis, acute, 257
chronic interstitial, 258
diagnosis of, 2,59
hot feet in, 464
in acute rheumatism, 257
physical signs in, 258
Myoma of uterus, 4,50
Myxoedema, 10
changes of nails in, 52
diagnosis by palpation, 10
diy skin in, 10
face in, 10
hand in, 46-48
increase of weight in, 1
infantile form, 10
infiltration with mucin in, 1
lips in, 20
loss of hair in, 8, 10
mental dulness in, 10
nose in. 17
onset of symptoms in, 10
pufEness of face in, 10
subnormal temperature in, 10
temperature in, 3
tongue in, 24
Nail.?, 52
capillary pulse, 52
changes, in chronic skin diseases,
52
changes, in hemiplegia, 52
changes, in myxoedema, 52
changes, in neuritis, 52
Nails, changes, in pulmonary osteoar-
thropathy, 47-49
changes, in syringomyelia, 52
disturbed nutrition of, 52
grooved, after acute disease, 52
in anaemia, 52
in cyanosis, 52
incurvation of, 47, 49, 52
indolent sores around, 52
Navel, inflammation or thickening of,
369
Neck, 29
abscess of, 29-31
actinomycosis of, 34
disea,ses of, 29-35
in emphysema, 29
in paralysis agitans, 11
in phthisis, 29
length of, 64
pulsations in, 33, 34
scars of, 29-31
Necrosis, anesthetic, in leprosy, 50
of bone, in tuberculous arthritis,
494
Nephritis, acute, urine in, 437
chronic diffuse, face in, 12
chronic glomerulo-, anaemia in,
478
diagnosis of, 1'4
face in, 12
glomerular, chronic, urine in,
437
glomerular, polyuria in, 438
cedema of arm in, 38
oedema of eyelids in, 14
optic neuritis in, 16
parenchymatous, 437
retinal hemorrhage in, 16
symptoms, 425
temperature in, 3
urine in, 425
564
INDEX.
Nephrolithiasis, symptoms in, 42.')
urine in, 425
Nervousness, tremor of lianils in, 4:i
Nervous system , M7
Neuralgia, Tri
red, of extremities, 4(14
Neurasthenia, fibrillary twitchings in,
510
knee-jerk in, 51H
with ptosis, 10
Neuritis, anaesthesia in, 36
atrophy of arm in, :i7
changes of nail in, 52
due to pressure, 35
hysterical, paralysis in, 36
multiple, paralysis in, 37
obstetrical, paralysis in, 36
optic, 16
pain in, .36
panipsthesia in, 36
(laralysis of leg in, 458
postdiphtheritic, 29
pressure, paralysis in, 35
pressure, test for, 36
tenderness of leg in, 461
toxic, paralysi.siin, 36
with partial paralysis of l)oth
legs, 4.59
New-born, jauntlice in, 3!i3
Nodes, bony, in syjihiiis, on leg, 161
Heberden's, 47-.50
in hypertrophic arthritis, .5()t)
OJi forehead, 9
syphilitic, 9-3S
Noma, 26
Normoblasts in blooil, 472, 477, 479
Nose, 17
epithelioma of, 17
falling of bridge in, 17
hemorrhage of nuicous mem-
brane in, 17
Nose, in acne rosacivi. 17
in acromegalia, 10, 17
in adenoids, 17
in alcoholism, 12, 17
in dyspnoea, 17
in hipus erytlieniatosus, 17
in myxcx'dema, 17
local diseases of, 17
significance of dried blood in, 17
size and sliajie, 17
tuberculosis of, 17
Nosebleed , 1 7
in fever, 17
in htemophilia, 17
in leuk;T?mia, 17
in purpura, 17
in trauma, 17
Nutrition of chest , 65
Nystagnuis, 10-44
nuiltipic sclerosis with, 16
Ohrsitv, 1
Olistruction, laryngeal, 7()
Ocular motions, 10
(Edema, 93, 217
angioneurotic, 461
diagnosis of cause, 3S
in ani^mia, 461
in deficient local ciieul;ition, 401
in flat-foot, 4()1
in hemiplegia. 401
in inflanunation, 401
in nephritis, 401
in neuritis, 461
in obesity, 461
in pressure, 461
in thrombosis, 401
in uncompensated heart lesions,
401
in varicose veins, 461
of arm in mediastinal di.sease, 523
INDEX.
565
CEdema of eyelids, 13, 14
of lungs, 294, 362
CEsophagus, .stricture of, 2
Oliguria. 421
Omentum, tubercular deposits in, 377
Opium-poisoning, coma in. 521
shaking of head in, 13
Optic atrophy, 16
atrophy, as result of optic neuri-
tis, 16
neuritis, 16
Orchitis, 446
Osteitis deformans, 6, 458
deformans, bony thickening in, 6
Osteoarthritis, 501
Osteo-arthropathy, pulmonary, hy-
pertrophic, 40-43, 47
Osteoma of thigh, 456
Osteomyelitis, acute, leucocytosis in,
456
acute septic, 455
acute septic, diagnosis from ar-
thritis, 456
chronic tuberculous, 456
tibia in, 461
Ovarian disease, diagnosis of, 4.52, 453
Ovaries, 451
abscess of, 451
cyst of, 451-452
cyst of, with twisted pedicle, 452
tumors of, 452
Ovaritis, 451
Oxaluria, 435
Oxyuris vermieularis, 407
Paget's disease, 6, 458
disease, arm in, 40
disease, bony thickening in, 6
disease, enlargement of skull in, 6
disease, with kyphosis, 54
Pain, in cancer of stomach, 384
Pain, in intestinal diseases, 400
in kidney disease, 420
in liver disease, 387
in local peritonitis, 373
in lumbago, 53
in obstetrical neuritis, .36
in osteomyelitis, 461
in pressure neuritis. 35
in syphilitic nodes of humerus, 38
in toxic neuritis. .36
Palate, paralysis of, absence or di-
minished reflex in, 29
soft, adhesions, 29
soft, perforation of, 29
Pallor, 93
in phthisis, 12
Palpation, 96-103
and dipping, 371
and friction, pleural or pericar-
dial, 100
in aneurism, 280-282 '
in myxcBdema, 10
of abdomen, methods of, 366
of apex-beat, 96
of normal abdomen, 368
of rales, 101
of the pulse, 103-111
of thrills, 97
of voice vibrations, 98
(see also Fremitus)
Palpitation, 264
Pancreas, 397
cancer of, diagnosis of, 397
cancer of, jaundice of, 396, 397
cyst of, 398
diseases of, 397
diseases of, aids in diagnosis of,
398
diseases of, diabetes in, 398
diseases of, diagnosis of, 397
diseases of, stools in, 397
rm
INDEX.
r:iiu'icns, iliseases of, uiiiii' in, .'i!)7
statistics Mil, ittIS
tunioi' ol', 'A7 !>-'A':)7
tumor of, {^all-bladder in, ili)7
I'aiicroalilis, acute, 398
Pariesthcsia, 512
in neuritis, 36
Paralyses, cerebral, knee-jerk in, 514
Paralysis, 508
afiitans, 11-13
ai;ilan.s, face in, 11
afj;itans, gait in, 508
agitans, hands in, 13
agitans, rigidity of neck in, 11
agitans, tremor of hands in, -44
btdbar, 29
congenital, choreiform move-
ments in, 45
in acute anterior poliomyelitis,
36
in anterior ].)olioniyeliti.s, 458
in chorea, 459
in diseases of s])inal cord, 37
in hemiplegia, 458
in hysteria, 36, 458, 4.59, .508
in lead-poi,soning. 36, 37
in multiple neuritis, 37
in midtiple sclerosis, 459
in neuritis, 458
in obstetrical neiuitis, 36
in pres.stire neuritis, 36
in tabes, 4.59
in toxic neuritis, 30, 37
in transverse myelitis, 4.59
in trarmiatic neurosis, 36
infantile cerebral, athetosis in, 45
of brain, .508
of cord, 508
of cranial nerve, 508
of interossei and lumbricalcs,
claw-hand in. 46
Paralysis of intesliues, in general
p(.'ritinHlis, 373
of leg, 458
of meilian oi' ulnar nerves, claw-
hand in, 16
of palate, test for, 29
of ])eripheral nerve, 508
serratus, sGipula in, 55
with contraction of pupil, 15
Paralytic thorax, 63
Paraphimosis, 445
Paraplegia,, 457, 508
spastic, 4,59
Parasites, animal, diseases due to,
blood in. 481
in feces, 406
in the blood, 484
intestinal, ana-mia in, 478
intestinal, eggs of, 40.S-409
Paresis, 508
Paronychia , 52
Parotid gland, cancer of, 30
gland, enlargement of, 30 ,
Parttu'ition, leucoeyto.sis in, 4,'-0
Passive congestion, in liver enlarge-
ment, 389
Patella, floating of. test for, 4<)0
Pectus carinatmu, 62
Pediculi in hair, 8
Penis, 445
cancer of, 446
chancre of, 445
chancroid of. 445
dischai'ge from, 44.5
intlanuuation of glands of, 445
nialfcu'mations of, 435
Peptic \ilcer, pain in, 395
Percussion, ausodtatory, 125
force of. 122
innnediate, 1 18
mediate, 119-136
INDEX.
567
Percussion of abdomen, 371
of lung borders. 133
outlines of thoracic organs, 58,
128
palpatory, 136
resonance, 127
resonance, amphoric, 135
resonance, cracked-pot, 134
resonance, dull, 128
resonance, flat, 128
resonance, tympanitic, 130
resonance, vesicular, 128
technique of, 118
Pericardial friction (see Pericarditis)
Pericarditis, acute plastic, 268
diagnosis of, 270, 275
dry. 268
fibrinous, 268
friction, diagnosis of, 270
friction in, 268
with effusion, 271
with effusion, diagnosis of, 275
Pericardium, adherent, 276
diseases of, 268-280
Perinephritic abscess, 54, 418
abscess, psoas spasm in, 495
Perineum, ruptured, 448
Periostitis, 461
Peripheral nerve lesions, aneesthesia
in, 512
nerve lesions, hyperfesthesia in,
512
nerve paralysis, 508
neuritis, knee-jerk in, 514, 515
I'eristalsis, visible, gastric. 377
■visible, in intestinal obstruction,
403
Peritoneum, cancer of, antemia in,
374
cancer of, ascites in, 374
cancer of. emaciation in. 374
Peritoneum, cancer of, signs in,
374
cancer of, tumors in, 374
diseases of, 372
tuberculosis of, anaemia in, 374
tuberculosis of, ascites in, 374
tuberculosis of, emaciation in,
374
tuberculosis of, signs in, 374
Peritonitis, 372
causes of, 373
general, 373
general, facial expression in, 374
general, fever. in, 373
general, intestinal paralysis in,
373
general, leucocyte count in, 374
general, mind in, 373
general, pulse in, 373
general, swollen belly in, 373
general, tenderness in. 373
general, vomiting in, 373
local, albuminuria in, 373
local, anorexia in, 373
local, constipation in, 373
local, fever in, 373
local, leucocytosis in, 373
local, muscular spasm in, 373
local, pain in, 373
local, symptoms in, 373
local, tenderness in, 373
local, tumor in, 373
respiratory movements of belly
in, 366
with thickening or inflammation
of navel , 369
Peri-urethral abscess, 445
Pernicious anjemia, blood in, 478
ansemia, jaundice of, 394
angemia, remissions in, 479
anemia, with jaundice, 15
568
INDEX.
Pharyngitis, general redness in, 2(i
of smokers, L'i)
Pharynx, 20
abscess of, 28
in diphtheria, 26
in pharyngitis, 26
in sciirlet fever, 26
methoil of examination, 26
Phimosis, 445
Phlebitis, 457
Photophobia, 15
Phthisis, 11, 304-316
acute, 316
advanced, 311
chronic. 308-316
dilatation of pupils in, 15
eyelashes in, 12
eyes in, 12
fibroid, 66
flush in, 12
hair in, 12
incipient, 304
neck in , 29
pallor in, 12
pupils in, 12
skin in, 11
thoracic deformity in, 64
with fatty liver, 389
(sec also Tuberculosis)
Pigmentations in buccal cavity, 26
" Pink-eye," 14
Pin-worm, in faices, 407
Platelets in blood, 474
Pleura, cancer of, 355-360
diseases of, 330-358
Pleural adhesions, 78
cancer or hydatid of lung,
355
effusion, 70, 76, 338-3,50
effusion, diagnosis from pleural
thickening, 353
Pleural effusion, diagnosis from pneu-
monia, 362
eff'usion, diagnosis from sub-
diaphragmatic effusions, 354
effusion, encapsulated, 350
effusion, signs during absorption
of, 350
exudate, cells in, 356
friction, 100, 165, 337
friction, distinction from muscle
soimds, 338
friction, distinction from pericar-
dial friction, 270
friction, distinction from rales,
338
friction, means of eliciting. 166,
167
thickening, 3.50, 353
Pleurisy, 330-350
clubbed fingers with, 47, 49
iliaphragmatic, 337
dry, 336
egophony in, 169
heart in, 343, 344
pain in, 336
plastic, 336
pulsating, 87, 352
radioscopy of, 535
restrained breathing in, 75
tuberculous, 356. 357
Plumbisni, blood in, 472
gums in, 24
paralysis in, 36, 37, 4,58
Pneumococcus infection, arthritis in,
495
Pneumonia, 296-304
aspiration, 302
broncho-, 303
catarrhal, 303
central, 296, 531
chronic interstitial, 324
IXDEX.
569
Pneumonia, crepitant rales in, 299
croupous (or lobar), 290
croupous, blood in, 4SU
croupous, diagnosis from pleur-
isy, 302
croupous, diagnosis of, 301
croupous, egophony in, 299
croupous, signs in, 296
croupous, sputa in, 326, 328
hypostatic, 362
inhalation, 302
lobular, 303
massive, 296
migratory, 300
resolution of, .300
tuberculous, 302, 304
Pneumopyothorax, 332
Pneumoserothorax, 3.32
Pneumothorax, 67, 70. 330
Poikilocytosis in blood smears, 472,
477
Poisoning by gas, coma in, .522
by illuminating gas, breath in,
22
by mercury, gums in, 2.5
by potassic iodide, gums in, 2.5
lead, lead-line in, 24
opivmi, coma in, 521
Poisons, ansemia in, 478
glucosuria in, 429
Poliomyelitis, anterior, 458
atrophy in, 37
chronic, claw-hand in, 46
Polychromasia in blood smears, 472,
477
Polynuclear cells in blood. 473
Polyuria, 421
Portal obstruction, causes of, 392
obstruction, signs of, 391
stasis, ascites in, 374
Postepileptic coma, 322
Pott's disease, 66
disease, cervical, symptoms of,
33
disease, cer\ical, with abscess, 31
disease, diagnosis of, 495
disease, vertebrae in, 33
disease, with kyphosis. 54
Pregnancy, choreiform movements in,
45'
glucosuria in, 429
lordosis in, 54
spasm in, 13
tubal, 451
Pressure, arterial, 111-117
arterial, methods of measuring,
111
diastolic, 108, 116
media.stinal, 523
systolic, 106, 114
Presystolic murmur (see Murmur)
Primary polyarticular atrophic ar-
thritis, diagnosis of, 499
Procidentia, 449
Progressive muscular atrophy, fibril-
lary tmtchings in, 510
muscular atrophy, reaction of de-
generation in, 518
Prominence, local, 68
of chest, 68
Prostate, hypertrophy of, distended
bladder in, 440-441
Prostatitis, acute, retention of urine
in, 441
Pseudo-leukfemia, tonsils in, 28
P.soas abscess, 455-457
spasm in disease, 495
Psychic fvmctions, examinations of,
519
Ptosis, 16
in hysteria, 16
in neurasthenia, 16
ilt
0
INDEX.
I'insis ill .sy|illilis, l()
I'uliiioiiary ilisrn.sc, 292-32!) (see
Liiiifl)
hemoriiia,!;"e, 'M)!i
cviU'iua, 2!)-l, :'.{V2
osteoartl\ropathy, -11—13, 47
regui'gitatiou, 251
stenosis. 2r>2
syphilis, 323
tympanites, 321
Pulmonic area. 171, 178, 196, 251, 252
seeonit soinul , 1 7S
Pulsatin.i; pleui-isy, ,S7
Pulsation, almoinial. 82-87, 280
capillarj-, 91, 232
epigastric. S.")
venous, 88, 247
venous, in tricuspid disease, 247
visible, 85
Pulse, 103-117
anacrotic, 107
bounding, 107
capillary, 52, 232
coiuprcssihility of, Ult) (see also
Arterial firtssitrc)
Corrigan's, 233
dicrotic. 107
frequency of, 105, 261
in aneurism, 104
in aortic regurgitation, 233
in aortic .stenosis, 104, 242
in peritonitis, 373
irreguliirity of, 105, 263
method of feeling, 104
rate, 105
rhythm or regul.'irily. 105
slow. 262. 393 (see Iirn,liir,ir,li„)
tension, 108
value of, 103
venous, 88
volume, 106
I'ulse, water-hanunei', 233
wave, size and shape of, 106
(sec alsi) ,1 rhriiil trulls)
(see also ArUrlal prcxsiire)
Pupil. 15
Argyll- Robert son, 15
contraction of, 15
dilatation of, 15
irregularity of, 15
Pupils, in phthisis, 12
reflexes 15, 5bl
tests of reflexes of. 15
with sluggish reaction, 15
Purpura, nosebleetl in, 17
Pus in fa>ces, 406
tube. 450
lube, cause of peritonitis, 373
Pylephlebitis. 3i)0
Pyloric stenosis, in cancer of stomach.
384
Pylorus, stenosis of, gastric peristalsis
in, 377
stenosis of. ]ieristalsis in. 366
Pyonephrosis, 418
Pyorrhcpa alveola ris, 25
Pyuria, 423. 424
CjuiNSV sore throat, 28
1! M'uriis, effects on chest, 60-63
e]iiphyses in, 40
head in, 6
teeth in, 20
(.see also l\'ifkrls)
Radio.scopy, 79, 287, 529-536
Hales, 161-165
bubbhng, 161
cousonating, iU I
cracklmg, 162
cre))itant. 163, 299
(.liagnosis of, 167
INDEX.
571
R:"iles, ■dry," 162
■ moist," 161
musical, 164
palpable, 101
\arieties of, 161
Raynaud's disease, 49, 464
disease, gangrene in, 49, 465
disease, syncope in, 49, 519
Reaction of degeneration, 517
Recti, separations of, 369
Rectum, abscess of, 443
cancer of, 444
fissure of, 443
fistula of, 443
hemorrhoids of, 443
methods of examination, 443
symptoms which suggest exami-
nation, 442
Reflex, lung, 136
Reflexes, 512-513
deep, 515
exaggerated pharyngeal, 29
in bulbar paralysis, 29
in postdiphtheritic neuritis, 29
of pupil, 513
superficial, 516
Regurgitation, aortic, 234
mitral, 212, 218
pulmonary, 251
tricuspid, 188, 247
Penal calculus, 419
calculus, symptoms, 425
calculus, urine in, 425
cohc, 395, 419
disease, ascites in, 374
disease, diuresis in, 1
disease, sweating in, 1
disease, weight in, 1
Resistance, sense of, 136
Resonance (see Percussion resonance)
Respiration (see Breathing)
Respiratory mo\'ements, 69-71
sounds, 151-161 (see Breathing)
rhythm, 74
Restriction of thoracic movements, 70
Retina, 16
hemorrhage of, 16
hemorrhage of, in anicmia, 16
hemorrliage of, in dialietes, 16
hemorrhage of, in nephritis, 16
Retraction of thorax, 70, 73
causes of, 76
causes, lung, 291, 317
Retrocele, 448
Rheumatoid arthritis, 495, 498
Rickets, arm in, 40
delayed closure of fontanels in, 6
epiphyses in, 40, 463
head in, 6
rubbing off of hair of head in, 7
spleen in, 414
sweating of head in, 7
teeth in, 20
with kyphosis, 54
Romberg's sign, 511
Rosary, rachitic, 63
Rose spots, diagnosis of, .365
Round-worm in fseces, 407
Sahli's test for hcemoglobin, 467
Salpingitis, 450
Sarcoma of arm, 38, 39
of belly wall, .369
of femur, 456-457
of leg, 461
of lung, cedema of arm in, 38
of mediastinum, oedema of arm
in, .38
of scapula, 55
of testis, 446
of thyroid gland, 32
of tonsil, 27
572
INDEX.
Swipula, iingel-winj;, r).")
])romiiient, G')
sarcoma of, 55
Skii' from syphilitic ulcers on leg,
461
Scarlet fever, pharynx in, 20
fe\-er, tonsils in, '26, 27, 28
Scars of foreheail, S
significance of, 31
Scoliosis, with twisting of spine, 54
Scrotum, 446
hernia of, 447
hydrocele of, 446
Scurvy, giuns in, 25
Senility, tremor of hands in, 43
Sensation, delayed, 512
disorilers of, 511
dissociation, 512
Sepsis with jaundice, 15
SepticaMnia with jaimdice, 394
Serratus paralysis, scapula in, 55
Sexual power, 517
Shock, diastolic, 284
Sigmoid, c^mcer of, 404
Skin, diseases of, chronic, lilooil in,
481
in jaundice, 14
in leprosy, 11
in myxoedenia, 10
in phthisis, 11
itching of, in jaundice, 393
lesions of, trophic, in atrophic ar-
thritis, 499
Skull, enlargement of, 6
Sleep, loss of, 2
Smallpox, eruptions on forehead in, 9
throat in, 27
Snuffles, syphilitic, 17
Sordes, 25
Sounds, cariliac, 171-179 (see also
Heart)
Sounds in lung fistvda, 170
respiratory, 151-161 (see also
Brcalkinij)
Spade-hand, 46
Spasm, muscular, 373, 490-492, 494
psoas, 495
tonic, 509-510
Spasms, clonic, 509-510
hands in, 44, 45, 46
of face, 13
Spastic paraplegia, knee-jerk in, 512
Speech, loss of, 518
Sphincteric reflexes, 517
Sphygmograph, 535
Sphygmometer, 111 (see Bhiinl press-
ure)
Spina bifida, 55
Spinal cord, pressure on, ]iara])legia
in, 459
cord, severing of, knee-jerk in,
514
curvature, 54, 66, 70
curvature, scapula in, 55
Spine, chronic diseases of, sphincteric
reflexes in, 517
in hypertrophic arthritis, 501,
502, 503, 504
normal flexibility of, 504
tuberculosis of, 495
Spleen, diseases of, .59, 412
enlarged, distinguished from
other tumors, 415
enlargement of, 412, 414, 415
palpation of, 412-414
jiercussion of, 414
in portal obstruction, 392
Splenic anaemia, 414, 415
Spondylitis deformans, 501
Sputa, appearance of, 324
examination of, 324-329
odor of, 325
INDEX.
573
Sputa, origin of, 324
staining of, 326
Squint, 16
Starvation, breath in, 21
Statistics on bladder, 439
on gall-bladder and liile-ducts,
387
on diseases of liver, 399
on joint lesions, 506
on kidney, 416
on liver disease, 386
on pancreatic disease, 378
on thigli disease, 455
on thigh tumors, 456
Stenosis, aortic, 239
mitral, 220
of a bronchus, 73, 286, 323
pulmonary, 252
tricuspid, 250
Stethoscope, choice of, 138
use of, 143
varieties of, 138
Stomach, 376
cancer of, .384, 385
cancer of, glands in, 30
cancer of, statistics, 384
cancer of, vomitus in, 385
contents, acetic acid in, 382
contents, acidity of, 381
contents, blood in, 381
contents, blood in, tests for, 381
contents, chemical tests of, 382
contents, color of, 381
contents, determination of total
acidity of, 382
contents, free hytlrochloric acid
in, tests for, 382
contents, general appearance,
381
contents, in achylia gastrica, 382
contents, in fermentation, 382
Stomach, contents, in stasis, 310
contents, inspection of, 382
contents, lactic acid in, 383
contents, lactic acid in, test for,
383
contents, method of obtaining,
381
contents, mucus in, 382
contents, nitric acid in, 382
contents, normal quantity ef , 381
contents, odor of, 381
contents, sediment in, 384
contents, significance of organic
acids in, .384
contents, total acidity, 383
dilatation of, 378
dilatation of, causes and symp-
toms, 385
dilatation of, diagnosis, 386
dilatation of, statistics of, 384
diseases of, incidence and diagno-
sis of, 384
distention of, methods, 380
estimation of size and po.sition,
.378, 380
fluid in, palpation of, 368
hj'peracidity in, 385
hypoacidity in, 385
hypogastric bulging of, 378
inspection and palpation, 376
methods of examination, 376
normal splash sound in, 378
passing of tubes, .378
secreting and motor power of,
378
test meal for examination of, 379,
.381
tumor in cancer of, 377
ulcer of, statistics of, 384
vi.sible peristalsis in, 377
washing of, method, 381
574
IXDEX.
Stomatitis, breath in, 21
gangrenous, 26
Stools in gastric ulcer, 3S5
in jaundice, 14, 39o
in pancreatic disease, 397
Strabismus, 16
Stridor, respiratory, 523
Strongyloides intestinalis, 407, 412
Strycluiine poisoning, spasm in, 510
Subsultus tendininn, 43
Succussion, 169, 332
Sugar, 42.S (see Gtuvosuria)
Sunstroke, coma in, 522
fe\er in. 3
Suppurations, clironic, anaemia in,
478
Sweat, in jaundice, 14
Syncope. 521
local, in Raynaud's disease, 49
Syphilis, arthritis in, 495
breath in, 21
chancre of penis in, 445
congenital, teeth in, 20, 21
coryza in, 17
dactylitis in,4S-50
eruptions on forehead in, 9
glands of neck in, 30
hereditaiy, delayed closiu-e of
fontanels in , 6
inguinal glands in, 454
jaundice in, 393
keratitis in, 16
loss of hair in, 7
mucous patches in, lS-25
nodes on luunerus in, 38
no.se in, 17
of frontal bone, 7
of li\cr, 390
of huig, 325
of tongue, 23
orchitis in, 446
Syphilis, palate in, 29
periostitis in, 461
periostitis, scars on forehead re-
sulting from. 8
ptosis in. 16
sores about nails in. 52
strabisnuis in, 16
tonsils in, 27
Syringomyelia, changes of nails in,
claw- hand in, 46
felons in, 50
Morton's disease in, 50
with atrophic arthritis, 498
Systolic murmiu' (see ^fllrlllul■)
T.vBES dorsalis, ataxia in, 510
dorsahs, knee-jerk in, 514
dorsiilis, opitic neuritis in, 16
dors:Uis, para^sthesia in, 512
dorsiilis, paraplegia in, 459
dorsalis, reaction of pvipil in, 15
dors;ilis, Rouilierg's sign in, 511
dors;\lis, sexual power in, 517
dorsalis, spliincteric reflexes in,
517
ulcer of toe in, 4(i5
with atropine arthritis, 49,8
with contraction of pupil, 15
Tachycardia, 261
Tactile fremitus. 98, 297, 308, 318, 350
TaMiia .s;iginata, 407, 408
solium, 407, 409
nana, 407, 410
Tallqvist's test for lupmoglobin, 46t)
Tape- worm in fa'ces, 407, 411
Teeth, 20
grinding of, 21
in congenital sypliilis, 20
in cretinism, 20
in rickets, '20
INDEX.
Teeth, time of appearance, 20
Temperature, 2
in myxcedema, 3, 10
in nephritis, 3
in osteomyelitis, acute, 456
in pathological conditions, 3
in uncompensated heart disease,
3
malingering in, 2
significance of, 2
subnormal, 3
Tenderness in general peritonitis, 373
in intestinal diseases, 400
Li peritonitis, 373
Tenosynovitis, 41
of Achilles tendon, 463
Tension of pulse, 108
Testes, 446
absence of one or both, 447
cancer of, 446
hsematocele of, 447
retained, 455
sarcoma of, 446
Tetany, spasms in, 46
Thigh, 455
cancer, metastatic, 4.57
cramps in, causes of, 458
diseases of, statistics on, 455, 456
intermittent claudication of, 458
meralgia, paraesthesia of, 457
miscellaneous lesions of, 457
osteoma of, 456
sarcoma of, 456
significance of scars on, 456
tumors of, statistics, 456
Thoma-Zeiss blood counter, 475
Thoracic aneurism (see Aneurism)
deformities, 62-68
disease, 199-363
disease, methods of diagnosis in,
56-198
Thorax, paralytic, 63
tender points on, 102
Thrill, 97
in aortic aneurism, 2S2
in aortic .stenosis, 243
in congenital heart lesions, 265,
266
in mitral regurgitation, 217
in mitral steno.sis, 222
in pulmonary stenosis, 252
Throat, in chickenpox, 27
in diphtheria, 26
in smallpox, 27
in pharyngitis, 26
in scarlet fever, 26, 27, 28
methods of examination, 26
with streptococcus infection, 27
Thrombosis, cedema of arm in, 38
of mesentery, .375
of vein, 460
Thrush, 27
Thyroid gland, atrophy of, 31
gland, malignancy of, 32
Tis.sues, accumulation of fluid in, 1
Tobacco, shaking of head in, 13
Toe-drop gait, 508
Toes, 465
le.sions of, 465
tender, after typhoid fever, 465
Tongue, 22
cancer of, 23
cancer of, glands in, 30
canker of, 22
coating of, 22
cyanosis of, 22
dry brown, 22
fis.sures of, 23
geographic, 23
herpes of. 22
hypertrophy of, 24
in alcoholism, 22
576
INDEX.
Tongue, iii cretinism, 10, 24
in dementia paralytica, 22
in facial paralysis, 22
in gastric fermentation, 22
in hyperacidity or gastric ulcer,
22
in myxoedema, 24
ill typhoidal states, 22
in weakness, 22
--' indentation of, 22
, jaundice in, 22
leukoplakia buccalis, 23
syphilis of, 23
tremor of, 22
tuberculosis of, 23
ulcers of, 23
Tonometer, Gaertner's, 112
Tonsil, abscess of, 28
Tonsillitis, acute, 28
follicular, 28
with enlarged glands, 30
Tonsils, 26
enlargement of, 28
general redness of, 26
in adenoids, 28
in diphtheria, 26, 27
in leukaemia or pseudo-leukfemia,
28
in pharyngitis, 26
in scarlet fever, 26, 27, 28
malignant disease of, 27
membrane on, 27
method of examination, 26
sarcoma of, glands in, 30
syphilitic ulcerations of. 27
tuberculous ulcerations of, 27
yellowish- white spots on, 27
Ttipfer's reagent, .382
Tophi, gouty, diagnosis of, 50.5
in gout, test for, 490
Tort'collis, congenital, 32
Torticollis with spasm, 32
Toxeemias, fever in, 3
in hepatic cirrhosis. 2
in tuberculosis, 2
in typhoid, 2
leucocytosis in, 478
tremor of hands in, 43
with jaundice, 15
Toxaemias, emaciation in, 2
Tracheal tug, 283
Tracheitis, 292
Transverse myelitis, ana?sthesia in,
512
Traube's semilunar tympanitic space,
percussion of. 371
Trauma, nosebleed in, 17
scars on forehead resulting from,
8
Traumatic neuro.ses, paralysis in, 36
Tremor, 510
Tremors of hand, 43
of hands in alcoholism, 44
of hands in cold, 43
of hamls in fever. 43
of hands in Graves' disease, 44
of hands in hysteria, 44
of hands in multiple sclerosis, 44
of hands in nervousness, 43
of hands in old age, 43
of hands in paralj'sis agitans, 44
of hands in toxa-mia, 43
of tongue, 22
Trichiniasis. blood in. 481
cedema of eyelids 'u, 14
tenderness of leg in. 461
symptoms of, 14
Trichiuris trichiura, 407, 411
Trichomonas intestinalis. 407
Tricuspid disease. 188. 247-251
regui'gitation. 24G
stenosis, 2.50
INDEX.
577
Trigeminal neuralgia, baldness in, 7
Trophic disorders, .519
disturbances, 48
Trypanosomiasis, blood in, 481
parasite in, 48.5
'I'ulierculosis, arthritis in, 494
dactylitis in, 48-.50
emaciation in, 2
epididymitis in, 446
in ankle bones, 463
of belly wall, 369
of lione of arm, 38-40
of cervical glands, 30
of hip, lordosis in, 54
of knee, distinguished from sar-
coma., 457
of mediastinal glands, 526
of nose, 17
of omentum, 377
of peritonenra, 372, 374
of peritoneum, anipmia in, 374
of peritoneum, emaciation in, 374
of peritoneum, signs in, 374
of sacro-iliac joint, 53
of spine, 495
of spine, lordosis in, 54
of the lungs, 304-316, 534
of the lungs, acute, 316
of the lungs, advanced, 311
of the lungs, cavity formation in,
313
of the lungs, chronic, 308-316
of the lungs, cough in, 305, 306
01 the limgs, diagnosis of, 304-
316
of the lungs, emaciation in, 310
of the 1 ings, fever in, 304
of the lungs, hemorrhage in, 305
of the langs, hoarseness in, 305
of the lungs, Litten's signs in,
307
37
Tulierculosis of the lungs, physical
signs in, 304, 316
of the lungs, rales in, 306
of the lungs, tuberculin in, 304
of the lungs, with emphysema,
315
of tongue, 23
of wrist joint, 40
orchitis in, 446
sores about nails in, 52
spinal paraplegia in, 459
ton.sils in, 27
vertebral, abscess in, 55
Tul)ereulous peritonitis, ascites in,
374
Tug, tracheal. 283
Tumors, 'AS
abdominal, 78, 370
abdominal, lordosis in, 54
abilominal, respiratory mo\'e-
nients of belly in, 3(55
aneurismal, 281
congenital, of back, 55
in cancer of peritoneum, 374
in cancer of stomach, 377
in epigastrium, 377, 384
in local peritonitis, 373, 374
mediastinal, 290
cedema of arm in, 38
of back, 54
of liver, 377
of pancreas, 377
of spine, 66
Tympanites, ]iulmonaiy, 321
Typhoid fever, breath in, 21
fever, nosebleed in, 17
fever, rose spots in, 365
fever, spleen in, 414, 415
fever, tender toes after, 465
fever, toxaemia in, 2
fever, Widal reaction in, 483
o , .s
/.VD/:.Y.
I LiKi; in tuberculous lUunylitis. id
of leg. 4li(.l
of stoin:icli. statistics of. :iS4
of tongue. 2:i
perforating, of toe. 4ti.i
Uncinaria aniericana. 4tl7. 409
eggs of. 410
Uncinariasis, blooil in. 4S1
Uraemia, aphasia in. olS
breath in. 21
distinguished from apoplexy. ,)L!0
Urate of soditini in gouty deposits.
.30:^
I'rethra. abscess of. 445
caruncle of. 449
discharge from. 44.3
jrlands. abscess of. 449
stricture of. distended bladder
in. 440
I'rine. acetone in. 4:!0
aciUe retention of. 440
albmnin in. 427. 42S
albumin in. Esliach's test. 420
allnunin in. significance of. 427.
42.S
albumin in. tests for. 420
amount. 419
animal parasites in. 4.'-!o. 4:^0.
4:^7
bile in. :i9:-!
blood in. 424. A.VA
casts in. 4i-!l-4.'^:->
chemical examination of. 42.i
color of, 422
crystals in -iediment. 4:i.'i
di;icetic acid in. 4:^0
diazo reaction. 4:!0
eggs of Hilharzia haanaloliiuin
in. 412
glucose in, 428
glucose. Feliliiig's t»st Inr. 42s
Uruie. glucose, fermentation test
for, 429
in bladder disease. 441
in cystitis. 423
in diseases of pancreas. 397
in jaundice. 14
in kitlney disease. 420. 42.3. 42S
in renal suppm-ation. 423
optical properties of. 422
overcoiicentration of. 441
pus in. 423. 434
pus in. diagnosis of origin. 42,'i.
424
reaction of. 42o
retention of. in acute prostatitis.
441
sediment of. 421
sediment of free cells in. 433
sciliment of. microscopic exami-
nation of. 431
sediments, signiticance of. 423
slireds in. 422
significance of free cells in, 434
specific gra\ ity of. 421
siiermatozoa in. 434
total solids in. 421
tiu'bidity of. 422
lu-ate sediment in. 423
Uterus. 449
cancer of, 4,30
endometritis. 4.30
erosions of cervix. 449
fibro-myoma if. 4,30
lacerations of cer\ ix. 449
malpositions of, 449
prolapse of, 449
Uvula. 2,S
Vvi.oi s, 4ti2
\alve areas. 171
Valvtilar heart lesions. 2Ut-2,3G
INDEX.
579
Valvular lesions, oombined, 25.3
Varicocele, 447
Varus, 402
Vascular phenomena, 87, 92
phenomena in aortic regurgita-
tion, 230-2154
sounds, 182, 183
tension, 108
Vasomotor disease, 519
Veins, abdominal, 365
inspection of, 88, 247
pulsations in (see Pulsnti'on)
sounds in, 183
thrombosis of, 4fiO
varicose, 460
Ventricle, dilatation of, 209
hypertrophy of, 206-208
Ventricular .septum, defects of, 266
Vertebrse, cer^■ical, dislocation of,
32
deviations of, 33
deviations of, due to haliit or oc-
cupation, 33
deviations of, due to intracranial
diisease, 33
deviations of, in astigmatism, 33
when palpable, .368
\'cjcal fremitus, 167-169
fremitus, in i)leuri,sy with effu-
sion, 345, ■■','>()
fremif\is, in pneumonia, 298, 299
fremitus, in pneumothorax, 332
fremitus, in pulmonary tubercu-
losis, 308, 311
fremitus, .spoken, 16.S
fremitus, whispered, 167, 298,
350
Voice sounds (see Vocal fremitus)
Vomiting, in ga.stric cancer, 384
in gastric ulcer, 385
in general peritonitis, 373
Vomiting, in intestinal obstruction,
403
Vomitus, •' coffee-groiuid," .3.X4
Vuh'a, eczema of, 448
(edema of, 448
varico.se veins, 448
Vulvo- vaginitis, 448
Wa.stiN(; liiseases, depressed font.a-
nels ill, 7
Weeping sinew, 41
Weight, gain in, 1
in infectious fe"\'ers, 2
in in.somnia, 2
in malnutrition. 2
in myxnedema, 1
in old age, 2
in toxa'inic slates, 2
iucrea.sed after wasting iliseases, 1
increa.sed in drop.sy, 1
loss ...f. 2
physiological changes in, 2
Weil's di.sease, .jaundice in, .394
Whooping-cough, blood in, 481
oedema of eyeliils in, 14
AMdal reaction in tj-phoiil. 483i
\\'inking reflex, 517
Wrist , enlargement of bones in pulmo-
nary osteoarthnjpatliy. 42, 43.
47
in atrophic aithritis, 47
Wrist-drop in lead-poisoning, 36
Wry-neck, 32
X-UAY in diagnosis of Pott's di.sea.se,
495
in hypertrophic arthritis, 501
in joint examination, 489, 490-
493, 494
YeTjLow fever, with conjunctivitis. 14
fe\'er, jaundice of, 394
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