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. . . 


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5econ& 1Ret>ise& EWtton 





t'OPFRiUHT, I»tt 


• •• • • # 

• • •• «• 

• • • • • • • 





Jackson Profetnor of Clinical Mrilichie 
in Harvard University 







This book is intended for students and, so far as I am aware, 
contains nothing original. I have written it because I have not 
been able to find any small work upon the subject which does not 
contain glaring errors. The correct books are too large ; the small 
l>ooks are out of date and repeat such well-worn myths as that the 
aortic second sound is normally louder than the pulmonic second, 
that aortic regurgitant murmurs are usually best heard in the second 
right interspace, that a hypertrophied left auricle can produce dul- 
ness and pulsation near the left sternal border, that systolic retrac- 
tion at the cardiac apex means adherent pericardium, that epigas- 
tric pulsation denotes hy]>ertrophy of the right ventricle, etc. 
Further, none of the smaller text-books contains any adequate 
account of muscle sounds, of pulmonary atelectasis, or of adherent 
pericardium. To record the well-known but often forgotten truth 
on such matters as these has seemed to me of importance in small 
books as well as in encyclopaedic treatises. 

The diagrams illustrating respiratory types are modifications of 
those used by Wylie and Sahli. 

I am indebted to Mr. Eliot Alden, of the Harvard Medical 
School, for his kind assistance in the preparation of the illustra- 
tions and to l)rs. E. H. Bradford and R. AY. Lovett for permission 
to use three cuts from their well-known work on orthopedic surgery. 

I am also indebted to the editor of the Archives of the Rontgen 
Ray for permission to use two radiographs from that journal. 



Introduction 1 

I. Methods of Examining the Thoracic Organs, .... 1 

II. Regional Anatomy of the Chest 2 



I. Size 5 

II. Shape 6 

(a) The Rachitic Chest 7 

(b) The Paralytic Chest, 8 

(c) The Barrel Chest, 9 

III. Deformities 12 

(a) Curvature of the Spine, 13 

(b) Flattening of One Side of the Chest 14 

(c) Prominence of One Side of the Chest, 14 

(d) Local Prominences, 15 

IV. Respiratory Movements, 16 

(a) Normal Respiration, 16 

(b) Anomalies of Expansion, 16 

1. Diminished Expansion, 17 

2. Increased Expansion, 18 

(c) Dyspnoea, 18 

V. The Respiratory Rhythm, 21 

(a) Asthmatic Breathing, 21 

(b) Cheyne-Stokes Breathing 21 



(e) Restrained Breathing 

(d) Shallow and Irregular Breathing, . 

(e) Stridulous Breathing 

VI. Diaphragmatic Movements (Litten's Phenomenon) 

VII. The Cardiac Movements, .... 

1. Normal Cardiac Impulse, 

2. Displacement of the Cardiac Impulse, 

3. Apex Retraction 

4. Epigastric Pulsation 

5. Uncovering of the Heart, 
Vlll. Aneurism and Other Causes ok Abnormal Pils 

the Chest Wall, 

IX. The Peripheral Vessels 

(a) Venous Phenomena, .... 

(b) Arterial Phenomena, .... 

(f) Capillary Phenomena 

X. The Skin and Mirrors Membranes, 

1. Cyanosis, 

2. (Edema 

3. Pallor 

4. Jaundice 

5. Scars and Eruptions, .... 
XI. Enlarged Glands. 


s OK 





I. Palpation, 42 

1. The Cardiac Impulse 42 

2. Thrills, 43 

3. Tactile Fremitus 44 

4. Friction, Pleural or Pericardial, 46 

5. Palpable Mies 47 

6. Tender Points, 48 

7. Abnormal Pulsations, 48 

8. Tumors 48 

9. Temperature and Quality of the Skin, 49 

II The Pulse 49 

1. The Kate, . . 51 

2. Rhythm, 51 




3. Compressibility, 52 

4. Size and Shape of Pulse Wave 52 

5. Tensiou 54 

6. Size and Position of Artery, 55 

7. Condition of Artery Walls, 56 

III. Aktekial Pressure and the Instruments for Measuring It, 57 

1. Gaertner's Tenoraeter 58 

2. The Itiva-Iiorci Instruineiit, 59 

3. The Instrument of Hill and Barnard 60 

4. The Oliver Instrument 61 



I. Technique. 64 

, . ( Mediate Percussion 64 

( Immediate Percussion, 64 

(b) Auscultatory Percussion. 71 

(r) Palpatory Percussion, 73 

II. Percussion-Resonance of the Normal Chest, . . . .73 

(a) Vesicular Resonance, 74 

(b) Dulness and Flatness 74 

(r) Tympanitic Resonance, 76 

(d) Cracked pot Resonance 80 

(f) Amphoric Resonance 81 

(/) The Lung Reflex 82 

III. Sense of Resistance, 82 


1. Mediate and Immediate Auscultation, . 

2. Selection of a Stethoscope, 

3. The Use of the Stethoscope, . 

A. Selective Attention and What to Disregard, 

B. Muscle Sounds, 

C. Other Sources of Error, .... 



Auscultation op the Lungs, 95 

I. Respiratory Types, 96 

(a) Vesicular Breathing 97 

(b) Tubular Breathing 99 

(r) Broncho- vesicular Breathing, 100 

(d) Emphysematous Breathing, 101 

(e) Asthmatic; Breathing, 101 

(/) Cog-wheel Breathing 102 

(g) Amphoric Breathing 102 

(A) Metamorphosing Breathing 102 

II. Differences between the Right and the Left Chest, . , . 103 

III. Pathological Modifications of Vesicular Breathing, . 103 

(a) Exaggerated Vesicular Breathing, .... 103 

(b) Diminished Vesicular Breathing 104 

IV. Bronchial Breathing in Disease, 100 

V. Broncho- vesicular Breathing in Disease, 100 

VI. Amphoric Breathing, 107 

VII. Rales, 107 

(a) Moist 107 

(b)Dry 108 

(c) Musical 110 

VIII. Cough. Effects on Respiratory Sounds, . . . Ill 

IX. Pleural Friction Ill 

X. Auscultation of the Voice Sound, . . : .113 

(a) The Whispered Voice 113 

(b) The Spoken Voice 114 

(e) Egophony 115 

XI. Phenomena Peculiar to Pncumo-hydrothorax, . . . .115 

(a) Succussion, 115 

(*) Metallic Tinkle, 110 

(c) The Lung Fistula Sound, 110 


1. The Valve Auras .117 

2. Normal Heart Sounds, 118 

3. Modifications in the Intensity of the Heart Sounds, . 120 



(a) Mitral First Sound 121 

1. Lengthening .121 

2. Shortening, 121 

3. Doubling 120 

(6) The Second Sounds at the Base of the Heart 122 

1. Physiological Variations, 122 

2. Pathological Variations 124 

(a) Accentuation of Pulmonic Second Sound, . . . 124 

(b) Weakening of Pulmonic Second Sound 125 

(e) Accentuation of the Aortic Second Sound, . . . 125 

(d) Weakening of the Aortic Second Sound 125 

(e) Accentuation of Both Second Sounds, .... 126 
(/) Summary, 126 

(e) Modifications in Rhythm of Cardiac Sounds and Doubling of Sec- 
ond Sounds, 127 

(d) Metallic Quality of the Heart Sounds 128 

(e) -Muffled" Heart Sounds 128 

4. Sounds Audible Over the Peripheral Vessels, .... 128 

(a) Arterial Sounds, 128 

(b) Venous Sounds, 129 


(Auscultation ok the Heart, Continued.) 

I. Terminology 130 

1. Mode of Production, 130 

2. Place of Murmurs in the Cardiac Cycle 132 

3. Point of Maximum Intensity, 133 

4. Area of Transmission, 134 

5. Intensity, Quality, and Length 136-139 

6. Relation to Heart Sounds, 139 

7. Effects of Respiration, Exertion, and Position, .... 139 

8. Metamorphosis of Murmurs, 140 

II. Functional Murmurs, 140 

III. Cardio-Rebpiratory Murmurs 143 

IV. Venous Murmurs, 144 

V. Arterial Murmurs, 144 








1. Valvular and Parietal Disk ask 145 

2. The Establishment and Failure ok Compensation, . . . 148 

3. Hypertrophy and Dilatation. 151 

4. Valvular Disease 156 

I. Mitral Regurgitation, 156 

(a) Pre-compeusatory Stage 158 

(ft) Stage of Compensation, 159 

(c) Stage of Failing Compensation 163 

(rf) Differential Diagnosis, 164 

II. Mitral Stenosis 166 

1. First Stage . .168 

2. Second Stage 170 

3. Third Stage 171 

4. Differential Diagnosis, 172 

III. Aortic Regurgitation 175 

1. Inspection 176 

(«) Arterial .Jerking 177 

(ft) Capillary Pulsation, 178 

2. Palpation 179 

3. Percussion 180 

4. Auscultation, 180 

5. Summary and Differential Diagnosis, 183 

6. Prognosis, 184 

7. Complications, 184 

IV. Aortic Stenosis 185 

1. («) The Murmur 186 

(ft) The Pulse 188 

(c) The Thrill 189 

(rf) Feeble Aortic Second Sound, 189 

2. Differential Diagnosis 189 

V. Tricuspid Regurgitation, 192 

1. (a) The Murmur, 193 



(b) Venous Pulsation, . 198 

(e) Cardiac Dilatation 194 

(d) Feeble Pulmonic Second Bound, 194 

2. Differential Diagnosis, 195 

VI. Tricuspid Stenosis 196 

VII. Pulmonary Regurgitation, 197 

VIII. Pulmonary Stenosis 198 

IX. Combined Valvular Lesions 199 

(a) Double Mitral Disease 200 

(ft) Aortic and Mitral Regurgitation, 201 

(f) Aortic Stenosis and Regurgitation, 202 


I. Parietal Disease ok the Heart 208 

1. Acute Myocarditis, 203 

2. Chronic Myocarditis 204 

3. Fatty Overgrowth 206 

4. Fatty Degeneration, 206 

II. Cardiac Neuroses, 207 

1. Tachycardia, 207 

2. Bradycardia 208- 

8. Arrhythmia, 209 

4. Palpitation, 210 

5. Congenital Heart Disease, 211 


I. Pericarditis, 214 

(a) Dry or Fibrinous, 214 

(b) Pericardial Effusion, 217 

1. The Area of Dulness, 218 

2. The Cardiac Impulse and the Pulse, "220 

3. Pressure Signs, 220 

(c) Adherent Pericardium, 222 

1. Retraction of Interspaces 222 

2. Limitation of Respiratory Movements, 228 



3. Absence of Cardiac Displacement with Change of Position, 223 

4. Hypertrophy and Dilatation not otherwise Explained, . . 323 

5. Capsular Cirrhosis of the Liver, 223 


1. Abnormal Pulsation 226 

2. Tumor, 226 

3. Thrill, 227 

4. Diastolic Shock 228 

5. Tracheal Tug 228 

6. Pressure Signs 229 

7. Percussion Dulness, 230 

8. Auscultation, 231 

(a) Murmurs, 231 

(b) Diastolic Shock Sound, 231 

9. Radioscopy, 233 

10. Summary, 233 

11. Diagnosis, . 234 





1. Tracheitis, 239 

2. Bronchitis 239 

(a) Physical Signs 239 

(6) Differential Diagnosis, 241 

8. Croupocs Pneumonia, 248 

(a) Inspection, 243 

(6) Palpation 244 

(c) Percussion 244 

((f) Auscultation, 245 




(e) Summary 248 

{/) Differential Diagnosis 248 

4. Broncho-Pneumonia 250 

5. pulmonary tubehcui.0818 i 251 

(a) Incipient Tuberculosis, 251 

(b) Moderately Advanced Cases, . 255 

(c) Advanced Phthisis 258 

(d) Anomalous Forms of Pulmonary Tuberculosis, .... 262 


(Diseases ok the Linos, Continued.) 

1. Emphysema 

(a) Small-Lunged Emphysema. 

(b) Large-Lunged Emphysema. 
(O Emphysema with Bronchitis and Asthma, 
(d ) Interstitial Emphysema, 
(r) Complementary Emphysema. 
(/) Acute Pulmonary Tympanites, 

2. Bkonchiai. Asthma, 

3. Syphilis of the Lung, 

4. Bronchiectasis, .... 

5. Cirrhosis ok the Li-no. 



I. Hydrothorax 272 

II. Pneumothorax 272 

III. Pneumohydrothorax and Pneumopyothorax, 274 

Differential Diagnosis of Pneumothorax and Pneumohydrothorax, . 276 

IV. Pleurisy, 278 

1. Dry Pleurisy 278 

2. Pleuritic Effusion 280 

(a) Percussion . . 281 

(b) Auscultation ... 287 

(e) Inspection and Palpation, 289 

3. Pleural Thickening, 291 



4 Encapsulated Pleural £ffusionB, 

5. Pulsating Pleurisy and Empyema Necessitatis, 

6. Differential Diagnosis of Pleural Effusions, . 





1. Abscess ami Gangrene of the Lung, . 298 

2. Cancer of the Lung 297 

8. Atelectasis 298 

4. (Edema and Hypostatic Congestion 299 


Appendix A. — Diseases ok tiik Mediastinum, 

1. Mediastinal Tumors, .... 

2. Mediastinals, 

3. Tuberculosis of Mediastinal Glands, . 
Appendix B.— Acvte Endocarditis, 
Appendix C— Examination ok Infant's Chests, 
Appendix D.— Radioscopy ok tjik Ciikst, 
Appendix E.— The Sphycmoohapii, 






L Methods o* Examining thk Thoracic Qbqakil 

To carry out a thorough examination of the chest we do five 
things: 1. We luok at it; tech ui cully (Tailed * l inspection. " 2, Wfl 
fed of it; teehnioally called "palpation." 3, We listen to the 

tnda produced by steiking ii ; technically called "percuflsion,.* 
4. We listen to the sounds produced within it by physiological or 
pathological processes} technically sailed "aa«enltetion.' J 5, We 

■ study pictures thrown on the fluoroscopic s eracna or on a photo- 
graphic plate by the Roentgen rays as they traverse the ehest; 
technically railed " radioscopy . ,+ 

I Measuring the dimensions oi the movements of the ohesl ("inett- 
suration '■) ii often mentioned as co-ordinate with the above meth- 
ods, but it yields very little information of practical value, and is 
:it present vi i v lit tin- useil 
The data obtained by examining the sputa, blood, and urine are 
frequently of gre&4 value in helping us to interpret the ajgna re- 
vealed by examination of the ehest, hut do not fall within the 
scope of this book. Accordingly, I shall confine myself in tin* 
first part of this book t<* a description of the methods of inspect- 
ing, palpating, percussing, and auscultating the ehest, with a brief 
account of the physical signs which we have learned to appreciate 
by the use of tlies«- methods | For radioscopy, see Appendix,) 



Without some knowledge of the regional anatomy of the chest 
no intelligent investigation of the condition of the thoracic organs 
can be carried on. Accordingly, I shall begin by recalling very 
briefly some of the most essential anatomical relations. 

II. Regional Anatomy of the Chest. 

It seems to me a mistake to divide the chest into arbitrary por- 
tions and to describe physical signs with reference to such division. 
The seat of any lesion can best be described 
by giving its relation to the clavicle, ster- 
num, or ribs on tin; front and sides of the 
chest, and to the scapuhe and ribs behind. 
Thus we may speak of rales as heard "above 
the left clavicle in front," "below the right 
scapula behind," "Ix-tween 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-axillary line " (see 
Fig. 1) ; or better, we may place the lesion 
by measuring the number of centimetres or 
inches from the median line of the sternum. 
In a similar way the place of the apex im- 
pulse 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. Measurements refer- 
ring to the nipple are entirely useless in 
women and not very reliable in men. It is 
better to measure as alx>ve. 

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 in- 
ternal organs which we desire to study, it Incomes unnecessary to 
memorize any technical terms or to learn the position of any arbi- 
trary lines and divisions such as are frequently forced upon the 

Fio. l.-Tne Mid- Axillary 


student, The only point* which it. is mivssary to memorize once 

for all ur« : 

1, The position of the heart, lungs, liver, and spleen with ref- 
erence to the bonei <»f the cshest. 

2, The position of certain points which i mght 
ns have a certain value in physical diagnosis* 1 mean (&) the 
lo-called " valve areas w of tin- heart, which do not correspond to 

the netiial position of tin- valves, tot realms to OS explained liter 

HitfijUun*. „„J 

UUrhl taffeta . 



— — J - 


* M " N. 

. :: frwftjim i>f the Ht-iLTl, l.tiitffh. Liver, sunt Sluiiuu li Tin- iti»i[itl Jim-* nurvspi -mi l*> tin* 

imUiiM.-MiI ibehing; (total?] ocMttiuioot Itne wpfonim itotaut; wfclte the poiM 

; .«! mil of Um hrwur ■*-■ Brace i* Insinrtte by light euiitimiou* n»es. Hsa 

ribs nrr* Qumbeiwl. 

OJt, and (/;) the pnenssinn outlines of tin- heart, liver, ajul spleen. 

These outlines do not correspond in size with the aetual dimensions 
of the organs within, yet there is a definite relation between the two 
which remains relatively constant, so that we eari infer \l 
tlie organ itself from the outlines which we determine by pereus- 
si an. The position of the organs themselves is shown in Pigs, % 
;:. and 4 t It will U- noticed in Fig, - that the lungs extend up 
the clavicles and overlap the Liver and the heart — facta of 
considerable importance in the physical examination of these or- 
gans, as will be later seen. It is also !*♦ fo> noticed how small 


a portion of the stomach is directly accessible to physical examina- 
tion, tin* larger part of it lying behind the ribs and covered by the 

^*- rpiwr i«hH. 

^j»I^»w«T lolie. 





m Liver 

FlO. 3.— Position of the Iieft Lung from the Fit;. 4. Position of the llight Lung from the 
Sides and of the Spleen. Side, and of the Liver. 

liver. The normal pancreas and kidneys arc practically inacces- 
sible to physical examination. 

The percussion outlines— corresponding to those portions of 
the heart, liver, and spleen which lie immediately beneath the 
chest walls — will be illustrated in the section on Percussion (s«*t; 
page 64). 




Mini may U> learned Uv a careful inspection of all parts of The 
but » tnl\- in ease the clothes an* wholly removed, A good 
agential, nitt this does not always mean s, rft^d light; for 
example, when examining the front of the chest it is often better 
tu have th** patient stand with his side to the window 00 fchal the 
light strikes obliquely across the cheat* accenting every depression 
and making every pulsation a moving shadow. In searching Eo* 

ortnal pulsations, this oblique light ih especially important. 

lu examining tin- thorax we look for tin following points: 

L The b; 

-, The general shape ami nutrition. 

;. Local defonnitiee or tumors. 

1. The respiratory movements oi tin* Hirst walls. 

Ti. The respiratory movements of t'" J diaphragm. 

<>. The normal cardiac 1 cements 

7. Abnormal pulsations (arterial, venoua, «>i capiOarj t. 

$. The peripheral vessels. 

9, The color ami condition «■** the skin and mucous membranes, 

10, The presence or absence nf glandular enlargement, 

1. S1/.1 c. 

Small chest* an seen in patientu who have been long in tu'd 
from whatever cause ; also in those who have suffered in infancy 
from rickets, adenoid growths in the oaso-pharynx, or a oombina- 
fcion n[ tin' two diseases. Abnormally large chests are seen chiefly 
in emphysema, *M course the ehests of healthy individuals vary 



a great deal in size at any gmai age, and I have been referring 
fche last sentences only to variations greater than those normally 

I r. Suapk* 

There ore marked diflWeuees in shape between tht? child's 
the adult's cheat in health. A child's trunk, as compared wit 


Fining ltr»iist. 

that of an adult, is far inure nearly cylindrical; thai is, the flute 
posterior diameter is nearly as great as the lateral. The adult % 
cheat is distinctly flattened from before backward, although indi- 
vidual variations in this reap&ftt ate considerable, as Woods Huto 
insun has shown. 

In childhood the coin in <sl pathological modifications are ill 



to adenoids or to rickets; fo mtddlis and later life to emphysema* 
phthisis, or old pleuritic disease. 

(«) The BachitU Cheat* 

The sternum generally projects {"pigeon breast "), hut in some 
eases, especially when rickets is combined with adenoid hyper- 
trophy, there may be a depression at the root of the sternum re- 
sulting in the condition known as "ftrnm-f brwat u ' (Figs. 5 ami 6). 

The sides of the cln compressed laterally ami slope in to meet 

the sternum as file sides of S ship slope down to meet the keel 
(jtectuji cariFwtitm) i Figs. *, 9 and 10). From the origin of the ensi- 
form cartilage a depression <>r groove is to be seen running down- 
ward and outward to the axilla and corresponding nearly to the 
attachment of the diaphragm. This is sometimes spoken of a* 
ih Harrison's groove " (Pigs. 1 1 and 1 If). The lotcrr tnnnjitt of the r#*& 

1 la some easts thifi oonditlco ujipearg to be congenita!. 


a great deal in size at any given a#\ ami 1 have been referring in 
the last sentences otilj t ■• rariatiorw grantor than those normally 


1L Su U 

There bi kl differences in shape between tin- child's anil 

the adult's chest in health. A child* 8 trunk, as compared with 

that of an adult, is far more nearly cylindrical; that is the>- 

jn isti rior diameter is nearly as great as the lateral. The adult's 

is distinctly flattened i'mm before backward, although indi- 

vidua] variations in this respect are n inside rable, as Womls Hutch- 

i Im shown. 

In ehildlmod the cottunofiesl pathological modifications ate dim 

mtrmyrmt t 

to adenoids or to ricketa; in middle and later lift- to rmphywra*, 
phthisis, or old pleuritic disease. 

(«) The Rtrkitit CAi*r. 

The sternum generally projects {* pigeon breast **), but 
fades, especially when rickets is cunibineii with adenoid hyper- 
trophy, there may he a depression at the root of thr >ni uuui tv- 
t ting in the condition known as M fiauui Arm*/ ■ • < Figs. 6 and 6) 

idea of the <■! ooipresaed taterall) and hIojxi in Lom*et 

the sternum as tin of a ship slo] k> tBtft the ke*J 

(pectus carina t ,9 and H>; P from the origin oj 

form cartilage a <\> n i*r groom U to Im seen running down- 

ward and outward to tin* ;ixj tdtaf nearly to the 

attachment of the diaphragm. Thi* U sometime* upokcn *ff a* 

rrUan** grmv" i Pigs, 1 1 and 12). - </<As 

1 ta aoaw cue* lid a condUliai appear* to W eoafHiJUi. 



in front often flare* out, owing to the enlargement of the liver and 
spleen below and the pull of the diaphragm above. Along thi 
of the choinlru-fostiil articulation there is to be Mt, and somt 

tin. 7. A,*'<|ijlP'tl tk*im*sMinii lit th»* Hi m it i if tht» Enstfonii tumi.ii:>* Tim patten! b- 

m*kKT <vf tevmif. who has n\\ lita lift* jtn'v^l iisniln^i tit* im-.--.~i bone the shoe nn wMrh 

hi* w- 

;i liiu- of feminencet nr swellings, to which the name oJ 
ehitis romryt* has been given (see Fig. 13). 

(6) Zfe •■ Paralytic t%omx, x 

Fig, 14 conveys a better idea of this form of cheat than any 
uVbi'riotion. The normal anteroposterior flattening is exaggerated 
BO that such persons are often apohi*o of an ^Jtat-chested." Tin* 
elaviclefi arr very prominent, owing to falling in of the t 


alMttre and below them; the shoulders we stooping, the seapuhe 
prominent, ba<3 the neck is generally long. The angle where the 
ribs meet at the enaifono cartilage, the -o-rwHed " costal an$U>" U in 
such cases \ i i v sharp. This type of el; been supposed 

to i^ characteristic of phthisis, but may be found in perao&s with 
perfectly healthy lungs. On the other hand, phthisis frequently 

m. 8, Pto 

exists in peteon* with rim-uiaHy shaped cheats or with abnormally 
to (Woods Hutchinson). (See Fig. 129, page 2S7.) 

< c) 77/ r ** Sam / t <ke*i, " 

Nuthtng is less like a barrel than the "barrel ©ft«rt. w Its 
striking characteristic is its greatly increased anteroposterior diam- 
eter, so that it approaches the form of the infant's chest, The 
costal angle is very obtuse* the ahouldera are high, and the neck 
is short The respiratory muvements of the barrel chest will lie 
spoken of later (see Figs. 15 and 16), 


X/ttritiott fj/thtt Chmt WqUm. 

Kmaciation is readily appreciated by inspection* The rib* are 

unusually prominent; tlip scanul;* 1 stand outj and the clavicles jiru- 

All MiU may be isfcn independently of any cthange in tin- 

shape "\ the chest such as wai described above under the title of 
Paraiyt&o Thorax, Tuberculosis of tin- apices of the lungs may 
ppodboe a marked falling in of th« tissue* above and below the 

eUviele independent ol any wnaoUtion of the ehest itself. 



fig. li- Pigeon 



The abnormalities just euinneraietl are sym met ileal and affect 

In ilc thorax. Under the head of 1 >** fortuities, I shall oou 


chiefly such abnormalities as atfVrt particular portions of tie- 
ami not the thorax as a whole. 

(m j Spinal Cnrvtttur*m unit Twinf** 

A good view of the patient's back brings out best the !• 
gives of lateral curvature, which are not at all infrequent in persons 

Fig. 11*— Karrtoofi** Qroovf. 

who are not awn re of them. Slight of deformity are beat 

seen by marking' with a skin-pencil the position of the spinous proc- 
esses (see I'u. 18). The, mure marked eases of lateral curvature, 
which are usually accompanied by a certain amount of twisting t 
nive rise !•» considerable displacement of the thoracic organs ami 
render unreliable the usual bony landmarks, with reference to 
which we judge of the position of the intra thoracic organs. By 
tmeh deformities the apex of the heart may be pushed up into the 



Pl«. ! wtve. 

fourth ipaee or i>m into Uhj axilla, ur purtioiia of the ittnga may 
mid iii;i«1i> atelectatic. 

I. The bulging on ih«* convex aide of tlie curv* way simulate 

an ii:n titisinal tumni". 

II. Putt's <li>f;is«' <>t tli«* WHUi shnulil 1»' looked lor as a part 

FIG. !*.— H*miiin»tif Itiu-htttr 1ti«Jir\ in i N<a of Swvimttwii. 


of the routine inspection i>f tb*' chest. It is sometimes bett' i 
than Aden. 

111. Abnormal rigidity of the spine, due to spondylitis di 
mans, is tn be recognized by watching the movements of the spinal 
column as the patient bends forward and back. Where the 
bite are lucked together, KB occurs in moderately advanced eases of 

this disease, the spine 
maintained rigidly 9tiff ? in- 
dependent of muscular sup* 
port, A similar stiffness of 
(he spine may also he seen 
in early Pott's disease. It 
is herr due mostly to mus- 
«idai spasm. 

\t>) Flattening of i> 
of the Chert, 

hi ehronic phthisis, irir- 
rhosis of the lung, or 1« 
standing pleuritic efhurion, 
marked falling in of one 
side of the chest is oil. 
l» j seen. This may be at*- 
parent in the upper and 
front portion, beneath the 
clavicle, or in the axilla, as 
in both situations {see Figs, 
14 itn.l 20). The shrinkage of the affected side is made mure ob- 
vious by contrast with the compensatory hypertrophy of the smiutl 
lung, which makes the sound Bide unusually full and prominent. 

1 ... II. The PurHlytii-Tik-'tu.v 

(e) Prominence of One Sida nfth$ <//• 

In pneumothorax or pleural effusions, and some times in malig- 
nant disease of the lung op pleura, there is a marked increase in the 
pise of the affected side of the chest. Very rarely emphysema 


may affect one lunp predominantly. In pneumothorax <n pleuritic 

tettiamam we usually see, in addition to the above enlargement, of the 
affected side, a smoothing out of 
the mtoeroostaZ depressions a© that 

the surface of that side is much 
more uniform than tin- other ride. 

t Bulging of the interspace* from 
great within tin* chesi 

rarely occurs* I have neret ^rn 

(</) LoGcd Prominenr. 
In nearly urn* -quartet- of 


healthy chests that part ">i 
thoracic wall which overlies. 
heart, i ailed "precordial 

is abnormally p» 
nent, The cause of this . 

■ tion is mueh disputed. A Bin 
prominence maybe brought abonl 
iu children, whose thoracic bones 
art viiy fltxil'lr (and occasionally 
in older patients), by the outward 
of an enlarged heart or 
of an effusion iu the pericardia] 
sac. The prominences due t«> 
spinal curvature have been al- 
ready mentioned. Lets common 
nausea of local prominence are: 

t* Aneurism of the arch of 
the aorta. 

2, Tumor of the cheat irall 
(lipoma, sarcoma, gumma) 01 of tlie lung, mediastinum, <>r of the 
thoracic glands pressing their way outward. 

. I mil AiUinm mi 18), 


X " * old i tuberotiloftifi) of a rib or of the stvnmra. 

4. Empyema perforating the chest wall, tin- so-called u empyema 


(«) X'liftfff/ Hvspirtttum. 

Daring normal respiration, one sees the ribs move outward and 
upward with inspiration, and downward and inward with expira- 
tion. I'nssibly one catches Borne 

li nt <»f the movements «»f tie 
diaphragm at tlie epigastrium 
In men, diap tie breath 

nig is more marked, while ii 
women breathing ie inonfely •» 
ilu "costal type "\ that is, i 
done bv the intercostal um- 
In certain diseases 
lion id tin 1 costal or o£ the 
phragiuatic type of breathing 
may be seen. In emphys 
for example, and in some 
nf as tit ma, the ribs move vorv 
little, and most of the work of 
ration is performed by tin 
diaphragm, whose, pull upon the 
tower ribs can sometimes he distinctly seen during inspiration 

i) ther hand, when the movements of the diaphragm aw impeded 

bv the presence nf 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, p. 19 ). 

(/') Anomalies *\f Bsepww/on* 

If we watch the patient while he takes a full breath, we may 
notice certain variations from the normal type of respiratory move 

■aft Bttiphymtiii 



We may see: (1) Diminished expansion of one side (as a 

« hole, or at the apex)* (3) [ncreased expansion of side. 

1 1 ) If diminished expansion <>f one sid<* fa due tc» pleuritic effusion, 

pneumothorax, or .solid tumor of the lung <>r pleura, the aJfccted 

s usually distended as well aa immobile, When, mi the other 

iTutv Tlirw We<?Jf8 
A lift t nrm-M<ni. 

hand, the lung is retracted <u' bound down fay atllu sinus, as in 
phthisis, old pleurisy, occlusion of the bronchus, or from the pres- 
suit* <ii an aneurism, we have immobility oombiued with a retraction 
of the affected side. In tuberculous disease at the apex of the 
, we may see one side or both sides fail to expand at tin* bop. 
in of the motion of one side of the idlest may also be due 


pain Of to pressure from lielow the diaphragm. An enlarged 1 
or spleen and tumors uf the hepatic OJ tplenie region may in this wai 
prevent the normal expansion uf one or the other side of the thoi 

Occasionally a hemiplegia or 
lateral paralysis "l the diapbrag 

i ^ ■ - ii ] t s in diminished movement 

one side of the choel , 

(2) In**tWt*(d f tJitlllSl'riU Of M||« 

side of tin' chest is observe ci princ 
pally us a compensator? or vioarv 
ovcrfunetioning of that side wh« 
tlio other side <d the chest is throw 
nut of use by a large pleui 
Hint), by pneumothorax, foi 
lug pleurisy with contraction, « 
cither cattnes. 

(r) />)/*/> 

This term is often used nttl 
loosely to include: (1) IntHeuh 
breathing whether rapid or slow, 
(L?) Unusually deep b] 
whether difti en It or not. (3) ! 
breath frig. 

Ti*ttr (hfXjtHtiii of <iijfifit!f fm 

itttj is al most always rapid ;i* metfc 
and dues not. differ at all from Kfa 
well-known phenomenon of being "out of breath w after a hard run 
or any violent exertion. Conceive these conditions as persi 
over hours <>i days, and we have the phenomenon known as dysj- 
mea. The breathing is not only thick but labored; that is, per 
formed with difficulty, and unusual muscles, not ordinarily called 
npini for respiration, come into play and are seen working abo v. 
the clavjelp and elsewhere. More or less distress is generally ex* 
pres s ed in the face, and there is of ten ;i hlueness of the lips 01 
dusky enloi- throughout the face, The commonest causes of riysp- 

Fic. 1».- La^ml ODTnfera B^r* Owp 
i in -tit hi. 



ncaa ue tin- rarioos forma of heart disease, pneumonia, large 
itic effusion, emphysema, asthma, ,md phthisis. 

Dyspnoea may ipeciallj I'taspmrr/'m, ns, for example, 

when a foreign body lodges in the larynx, 01 in ordinary "croup. M 
hi such cases we speak of rt inspiratory dip*pnmt 9 n distinguishing it 
torn tf ♦arp troto t y dytpnceu " such ;«* occurs in asthms and emphy- 
taenia. In tlit* latter condition tin 1 breath sedans to enter the chest 
readily | but the difficulty La to get it out again. Expiration in 
greatly prolonged ami often noi 

Combined types also occur in which 1m kt 1i respiratory acts an 

Abnormally deep ami full itwpitiitwit, without airy appearance of 
difficulty in tin* process, is sometimes seen near the fatal termina- 
i ion of cases <>i' diabetes, 
the so - Galled diabetif 

Simptti rapidity »f 
brmtkintj ahould be dts- 

aiahed from dyspnoea 

any type. In adults 
tin- normal rate of respi- 
ration i* ;il»*nt 22 per 
minute, [n children, u is 
ably quicker and 
more irregular. Jt ismri 
attempt here 

to « i nii pate all the 

causes which may lead to 
a quickening **f the respi- 
ration, Among the com* 
inintrr are muscular exei- 
emotional disturb- 
ance, disuses nf flu- ln-art rind lllltgs, and fluid 01 solid aCClUl 

ticins below the diaphragm, which push up that muscle ami • 

ih abnormally upon the thoracic ravity. Musi «»f tin* in- 
fectious fe also apt to be aucom|»aiiicd \<\ quickened breath- 

i h.. rjn. r«inrr»n-fl"h <•< i iit'*t, Emi«Ti-iuki, 


iiig, especially but not exeltuivdly when the fever is assoc 
;i disease of tin- heart* lung, pleura, of pericardium. 

Buekiitg-in of t.U»* interspaces in tie lower axillary regions 

below tlie clavicles dm 

.►en in ooiu 
with dyspiuea when* 
evei the lungs an* pn - 
vented by ^*]iw otm 
from properly expa»< 
in^ during inspii 
Negative pressure i 
tli us produced withi 
the chest) and the 
nioeplu'iie p re ssun 
without pnsht-s in t 
more elastic pa 
tin* thurax This 
iiomeiton is seen I 

lapse in- ,i 

a "Kirtioii <»r the h fcu 
<if a lung, Buch as in; 
occur in obstruction 
tin' glot&s (in whir 
(vase both si dew are 
equally retracted) <> 
from occlusion of 
in on eh ua In the h 

fcei* event, the snoking-iu "l tin- interspaces riuriug inspiration n 

mis only OH the affected Bide, 1 

1 Slight retraction of tlte lower interiipfiotiH in the uxilln during luaplratli 
la eftfiv seen in health, tn tlliwwe this plienoi'ieunn i* i^eHtly exaggBratsd. 

in. \M,- i^milnrnrfiir Rlehr sii'iv PMirnl KlTtijfcm. 



\ < HAXMKti in Mil RKHllltATHKY KlIVTHM. 

'. i \y nt-Stt'}.' s Brfftf h in if 

C) Asthmnff Hrmtkmy. 

i-thma the normal rhythm is reversed and the expiration 

becomes lunger, instead <<f shorter, than inspiration. Inspiration 

may be represented only by a short gasp, while expiration becomes 

u prolonged wheeze Lasting several times a* Kong as inspiration 

is usually rerj marked. En emphjmina we gel rary 

much the same type oi breathing sofai bni is concerned, 

but the dyspna tnd the auxiliary tuns- 

eles cif respiration are nol so apt to be celled into oae< In many 

I emphysema one sees the thorax move all as one piece, il m 

twing {o i senile fixation of the booesol (fee thorax from 

lificotton of the cartilaginous portions. Tn hereditary syphilis <>r 

|].lit]i!sis tin i may '"'''in- in youth or early middle age, 

An anomaly of respiratory rhythm in which short, recurrent 
paroxysms of dy&pnosa are preceded ami followed by periods in 
da inspiration occur* (apnoaa). If we represent the normal 
aton movement U\ an up-and-ilown line, as seen in Pig 22, 


HO, R— mvmn to a« I wnl amttWng-Rhyiliiii. 

heyue-Stokes type of breathing, would appear as in Pig 23 
The period <d apncca may last from one to ten seconds i then short, 
shallow respirations begin and increase rapidly, both in volume and 
in rate, until a maximum of marked dyspnoea is reached, when a 
di munition in the rate ami depth of the acl begins, and the pe 

tarns t.. Hi. apnosic state. The length of the whole 

may \«> from 30 to TO seconds, During the apnosic 

period the patient is apt to "Imp asleep for ;i few seconds and the 

pupils ma) become ncmtracteri. When the paroxysm *>f dyspnoea 


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 apmea. This type of breathing is most often seen in 
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 l)e physiological during sleep. As a 

i K.. 

< iH'yiu'-Stokw KcMpimtion. 

rule, it is a sign of grave prognostic significance, but patients have 
licen known to recowr eoinpletely after weeks or even months of 

( -heync-Stokes breathing. 

(<•) fusfi'tinrd or %i Catchg" llreathing. 

"When the patient lias a "stitch in the side," due to dry pleu- 
risy, intercostal neuralgia, or to other causes, the inspiration may 
1m* suddenly interrupted 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 which a full inspiration will cause. This 
type of restrained breathing is < ttcn seen in pleurisy and pneumo- 
nia, and in the latter disease expiration is often accompanied by 
a little moan or grunt of discomfort 

(V/) Shallow f/Hff irregular breathing is often seen in states of pro- 
foiuid 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. When death is imminent in any dis- 
ease, the respiration may become very irregular and gasping, and 
it is apt to be accompanied by a peculiar nodding movement of the 



bead, the chiu being thrown quickly upward during inspiration, and 
falling slowly during expiration. 1 have known hut one patient to 
recover after this tyj>e of breathing hail w\ 

After severe hemorrhage tin* breathing in ay be of a mghm§ tppt 
m well as very shallow. 

StridvltntM Breathing. 
A high-pitchedj crowing or harking sound is heard during inspi- 
ration when there is obstruction of the entrance of air at or pear 
the glottis. This type of breathing occurs in spasm or osd/ems of 
thfl glottis, "Group," laryngismus stridulus, and forms the * whoop ** 
m the paroxysms uf whooping-cough ■ Laryngeal or tracheal ob- 
struct ions dne to foreign bodies, or tumors within or pressure from 
without the air-tubes, may cause 9 similar typi* of respiration. It 
is in these cases especially that we see the ■mekiug-in of the inter- 
spaces mentioned above (see p. *2lh. 

VI, DtAFHBAOUATtG Moykmknts, 

Litten's Phenomenon. 
The normal movements of the diaphragm may be rendered vis- 
ible by the following procedure* suggested by Litton in 1892: The 
patient lies upon his bark with tin chest bared and tin- feet pointed 
directly toward a window. Cross lights must be altogether ex- 
cluded by darkening any other windows which the room ma3 T eon- 
tain' (see Fig. 24). The observe i stands at the patient's ride 
and asks him tc» take a full I math. As the ribs rise with the 
movement of inspiration, a short, narrow shadow moves down along 
the axilla from about the seventh to about the ninth or tenth rib. 
During the expiration the shadow rises again to the point from 
which it started, but is less easily seen. This phenomenon is to he 
seen on both sides of the cheat and sometimes in the epigastrium, 

'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 answer* very well. All other light must, of course, be ex- 


It is best seen in spare, muscular young persons of either sex, and 
is sever absent in health except in those who are very fat, or who 
cannot or will nut breathe ileeply. T itter ©audita* 

FlO- S4.~ Utton> DtopUrwgni Shadow. Pmjtw |*«mton <>l imtliiii mH 

jbsdow i> in^si ma nr'iii L 

fi\ steria anil in some very stupid persons who cannot bo made to 
understand what is meant by a full breath, Tn the observation <>f 
several thousand cases, I have never known it absent in h 
except under these conditions. 

In normal chests, the excursion of the shadow is about fcwi 
a half inches; with very forced breathing three and a half ui 

The ii nanism of this phenomenon is U-st understood by iu 

iug a eoronal section of the thorax as seen from the front or bade 
(see Fig. 25), At the «*nd < ft" expiration, Hie diaphragw 
flat against the thorax from its attachment up to about thi 
rib. During inspiration it "prrfo off*' as it descends and allows 
the edge of tin* lung to come down into the ebink between the ilia* 
phragni and thorax, This "peeling off" of tin- diaphragm and the 
descent of the lung during inspiration give rise t<» the moving 
shadow above described. 

By thus observing the excursion of the diaphragm we can obi 
.1 good deal uf information of clinical value. 



Iii pnetuuoniaof tin* tower h ►Iw, pleuritic effusion, extensive p]eu» 
ntir adheaiona, or in advanced eases of emphysema, fclte shadow is 
absent. This is explained by t)w FacM that in pneumonia; pleuritic 
effusion, and emphysema the diaphragm is held off from the client 
wall bo that its movements CHjmmunicate no shadow. 1 1 ■ pleuritic 
the movements of tin- diaphragm are prevented. In 
early phthisis I have generally found raton o$ the dia- 

plintgin diminished upon file affected aide, to a lot 

elaj u the affected luny and in part probably to pleuritic 

adhesions, < hi the other hand, fluid or solid tumors belov< the dia- 
phr&gm, unless very large, il<> not prevent the descent <>i thai mv 

i do tint abolish the diaphragm shadow, In oasee in which 
tin- diagnosis i» i t ■ doubt between fluid in the right pleura] cavity 

■ I an enlargement of the liver upward <«> a subdiaphragmatic afe- 
Mesa, the preservation oi the Lttten's phenomenon in thelattei two 
affections maj be oi alae in diagnosis. Very lart^c accumu- 

intis of ascitic fluid may -. itrain the diaphragmatic stove* 

nirtits thai mi shadow can be seen. Great muscular weal 
debility may greatlj diminish, hut nureh it «'v. j » prevent, fcheexcur- 

,if IT|»? f)iii|itiniJtTn ciilltlnf hninl l:.-x|)inilMIi /i, ttlltn; I 

i r1 rtirl i»r >■> pirniiim r /■ |**dtl(»n nf illnphiwni ill ftHdol H^pir»i i> n 

■ion of the shadow, In [mrRoiis who cannot In* made to liivutln* 
deeply enough bo bring it out, ;i hard cough will frequently render 

The use oi 'his method of examination tends, ta .1 certain ex- 
free as from the necessity of using t!i -, inasmuch as 


it furnishes us with the means of observing the diaphragmatic 
movements, on the 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 plainly as well. 

It also frees us to a considerable extent from the need of using 
the spirometer to determine the capacity of the lungs. 

l»y measuring the excursion of the phrenic shadow and taking 
account of the thoracic movement, we obtain a very fair idea of the 
respiratory capacity of the individual. 


(1) Th<> Xni'iHttt Cardiac Impulse. 

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 Mow the left nipple. This phe- 
nomenon is known as the cardiac impulse. 1 It is now generally 
admitted that the "apex impulse Tf 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, 1 think, been generally appreciated, will he discussed pres- 
ently. | The position of the inaxtmum impulse in adults is usually 
in the fifth intercostal 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 health 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. 2C>). 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 position. 

1 For a mure detailed description of the normal position of the cardiac 
impulse, see next page. 



heart is lifted wsh expiration by the rifle uf the dia- 

phragm and falls during inspiration, a gonesponi mge en l* 

observed in the. aj>ex Vat, whieh, in toned I 5, may shift ifl 

uiui'li as one interspace. Of the changes In tli#* position of the iw* 
pulse brought about In , 1 *ha1l speak in a later paragraph. 

VIQ, 36,— Showing amount of stiirtlnir "f UN fcpu fmjBTWl wimebJinp* uf Rwltkm, TtflMn* 
ner *1<»t mpiwenta Uie imttiw ot the impulse wben Uie pnttaut ltos no bin bark ; tbeotttrr 
lot oomspoad* I© Ibe potftii ii Dtf fee i$ft* with pulton! i»n Ml rffe. 

{f*) Beldtion of the maximum cardiac impulst to tAs opes of the 

—I mentioned above that the nuLxiimuu cardials impulse* is not 
due to the striking of the apex of the heart against the chest wall, 

the impact of a portion of the right ventricle. The praetn-a] 
importance of this fact is this: When we are trying to localize the 

f the heart in order to determine how far the organ extendi 
feu the left and downward, it will not do to he guided by tin* pofti 

28 /*// 1 'Sit 'A t DIA 1 7N0S IS OF h is R, i .s fiS OF THE CHI 

i.imi of the ttmximum impulse, for the ape? 

always I- i"- found three-fourths of an bach ot mare farther to tie 

left (stt 1 Fig, 1,'T). Tins ]ii;iy be jjn\nl 1 1\ |<i-irMissimi 

Kn.. *.':.— The Inn^r |h»t is thf MuMiimm C&nliitf lliirmlw. Tl 

i if tlit j iit'jirt, jl« oitijUni^ii iiy i^rt'iisHlou. The rllw niv munbpwd 

p. 58 i. Th<- true position of the earduu' apex thus determined 
responds usually not with the tiwjrimnnt impulse, but with the 1 pi 
farthest out and farthest down at which «»// n"j« awd /«# syn- 
chronous with the heart l>eat ™w he frit (for further diseussion 
this poia< ii below, p, 218). 

ft?) Besides the definite and loraliard impulse which has jtist 

been desurilied, it. is often possible to see Hint n < siderable section 

of the ohest wall in the precordial region is lifted a m m 

The phenomenon is the " Her?.* ■/*,<*<***" of tlie tiermans, with which 



i<< * Spits \ \ triable 

amount of"/.- fell orei any nonnaj 

ls.Mit wht'u it i* acting rapidly and Forcibly, aad in thin, nervous 

r^ or ui children even win ;n the heart is beating ipiieth It 
is more marked in cardiac neuroses of in cases in which the heart 

is liyj**rtrophied and in which there is mor less stiffening o 

rihs with loss tff their natural elasticity. At times it nun be 
impossible to localise any one point to which we can give the 
name oi apex impulse, and what we see is the rhythmical rue ami 
f ail oi the chest tm large as tin- palm of the hand or 


(#/) Ckaradrr of th* vttrdioc impulMc. —Palpation is considerably 
mote effective than inspection in giving us information as to the na- 
ture of tin* cardiac movements which give rise to the "apex b 
hut even inspection sometimes suffices t" show that the impulse has 
;i heaving OBAractei m is of the nature "fa short tap, ■ peristaltic 
. or a diffuse slap against the chest wall In some eases a dis- 
tnirt undulation can be seen passing from the apes region upward 

i th» j base of tin* heart; or less often m the opposite direction 

(2 I I>tspf't*;nttitt ttf thfi C'trtllttf littptittfe. 

To one familiat- with th*' position, extent), and character of the 
norma] cardiac impulse! any displacement «>t this impulse from its 
normal wit* 1 or any superadded pulsation in anothei pari oi the chest 
is apparent at a glance, I w ill consider first the con forma 

of dislocation of Hie ;i]» \ impulse 

(r#) Dispiftfcment uf th* tvfrtiiap itnjHtftt? *Jit*' to hypertrophy ctnd 
tlilvtittion qfthe htwrt* — By far the most common directions of dis- 
. i lent are toward tin- left axilla, or downward, As a rule, it 
is displaced in lioth these directions fit once. ! shall return to this 
subject more in derail under the heading Cardiac Hypertrophy, hut 
here ! may say thai enlargements of the let; ventricle tend espe- 
cially to displace the apex impulse downward, while enlargementa oi 
tin tight ventricle are more commonly associated with displacement 
of the impulse toward the axilla, 

\h) Next to hypertropin ami dilatation : fciie heart perhaps the 
commonest cause uf dislocation of the cardiac impulse is \m 



IVum below tin- diaphragm. When tlio diaphragm is raised i 
large accumulation of gas or fluid or by solid tumors of large m 
we inay see tin* apex beat in the fourth interspace ami often an i 
ox imnv inside the aipnle lim- + 

(f\ Of nearly equal frequency is displacement of the heal I 
fn pleuritic effk&ioti ax to pneumothorax. 

When a considerable amount of uir or fluid accumulates ii 
left pleura] cavity, the apex of the heart is displaced to the right 
so that it may 1m j concealed behind tlj** sternum or be visible beyond 
it to the right; in extreme eases it may be dislocated as far as 
right nipple. Kight pleuritic effusions liavc far less effect upon 
the positron of the cardiac impulse, but when a very large amount 
of fluid accumulates we may set 1 the impulse displaced considerably 
toward the left a villa 

i//( i have mentioned muses tending to push the heart, t- 
right, tn thr I* ft, or upward, Occasionally the heart is pushed 
iiotrntmni by an aneurismal tumor or a neoplasm of the medio 
num. In these eases there is usually mure 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, mid the diaphragm 
stands lower, and hence the apex beat may descend to the sixth in- 
terspace, or (more often) it may be lost to sight and touch hehiuti 
the bunch of convergent costal cartilages just to the left of 1 
ensifnrm. Very frequently in men past forty- rive the whole heart 
Rinks considerably, so that a marked systolic retraction (less often 
pulsation) is seen below the eusiform in the cpigastriiuu. 

(4) Displacement of the cardiac impulse resulting from WAw^.s- 
of the pericardium, or of the pleura* with subsequent contracts 
occurs in fibroid phthisis ami in some eases of long-standing disc, 
1 if the pleura. Through the effect of negative pressure the heart 
may be sucked int<» the space formerly occupied by a portion of T 
lung, when the latter has become contracted by disease. It seems 
likely, however, that hi the majority of eases adhesions between 
the pleura and pericardium [day a part in smh displacement. I-Sy 
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 



as well as to the right in such cases by the contraction which lakes 
place in the upper part of rhr rung. More rarely we ma\ sn- tin- 
heart drawn toward tin* left clavicle in fibroid phthisis of the left 

l/i Distort ii I the thorax due to spinal curvature or other 

causes may bring about a considerable displacement of the heart 
from its norma] position, 

ifj) Dt&trocardta and Situs Inversus, in rare oases a displace- 
ment of tin- apea impulse i<- the right of Th>. sternum may l>e due 
•ither to a transposition t*f all viscera [tin* liver being found upon 
the lefty the spleen upon tin* n^ttOto^ov to dextrocardia^ in which 
Hie heart alone is transposed while the other viscera retain their 

nal places (s.-i- Fig. i4o, p. 310). 

apex hnpulse is displaced by 
(«) Hypertrophy ami dilatation oi the hearl 
(A) Pressure from below the diaphragm. 

i. A it- or fluid in one pleura] cavity 3 especially the left. 

(</) Aneurism, mediastinal growths, and sagging of the aorta. 

(r) Fibroid phthisis. 

(/) Spinal curvature, 

(tj\ Transposition of the heart <»■ t>f all the viscera. 

(M) Apex Retraction. 

Before leaving the subject of the cardiac impulse it seems l>est 
to speak of those cast's in winch during systole we see s retmetion 
of one ur more interspaces at or near the point where the cardiac 
impulse normally appears. 

{«) In hv far the greater number of instance! snoti retraotioii is 
tine to negative pressure produced within the cheat by the vigorous. 
eon traction of a more or h'ss hypertrophied and dilated heart Jn 
them' lc retraction is usually to be seen in several iuter- 

Buch retraction is not at all uncommon and usually at- 

(6) Tn rarer cases several interspaces^ both in the precordial 


region and in the left lower axilla and back, may lie drawn in a* a 
result of adhesions between the i>ericardium and tin* eh est wall, 
such as form in cases of adherent |>ericaidiuin ami Hbrtms mcdias- 
tinitis (see Inflow, pages 2-2 and 303.) 

( I ) Kjtiytistrir Pulsation, 

In a euusidc-rable portion of healthy adults a pulsation or retrac- 
tion at the epigastrium synchronous with the systole of the heart is 
to lie seen from time to time. Such pulsation has often lieen treated 
as evidence of hypertrophy of the right ventricle of the heart, hut 
this I believe to be an error. It is not at all uncommon to find, 
post mortem, considerable hyj>ertrophy of the right ventricle in east's 
in which during life no epigastric pulsation has been visible, while, 
nu the other hand, the heart is frequently found normal at autopsy 
in cases in which during life there has lieen marked epigastric pul- 
sation. In some cases such pulsation is to be explained as the 
transmission of the heart's impulse through the liver, or as a lifting 
of that organ by the movements of the abdominal aorta. In other 
eases it is due to hathycurdiu ("low heart'' -a condition very com- 
mon in arteriosclerosis). 

(T\'\ Vtsitifr I'tifsittiwis tin,- fit t'n.nrrriiiif nf Portion* of the Heart 
Snriii'ilhf i'nrt'fil l'i/ tin' Luttifs. 

One of the commonest- causes of \ i.Mble pulsations in parts of 
the chest wln-re normally none i> to l>e seen is retract urn of the 
hi a if . 

ir/ 1 It is in chlorosis, perhaps, that we most frequently wr 
such pulsations. In that disease, as in other debilitated states, the 
In n us are often not adequately expanded owing to the siqierficiality 
of tin- respiration, and accordingly their margins do not cover as 
much of the surface of the heart as they do in Ileal thy adults. 
This results in rendering visible, in the second, third, or fourth left 
interspace near the sternum, pulsations transmitted from the conns 
arterioMis or from the right ventricle. Less commonly, similar pul- 
sations may be seen on the right side of the sternum. 

(ft) A rarer cause of retraction tit" the lungs is fibroid phthisis 
or chronic, interstitial pneumonia. In these diseases a very larvae 



f pulsation may be Been in the precordial region owing to the 
onooreriog of the heart by the retracted lung* even when the 

heart is not drawn out of its normal position. 

VI I L Am i ins m wo OTBMB CaVBVB 0» Atin'oi.-mai. Tunic An" 

Pi l>ATIO\\ 

So tar I hu n altogether of pulsations transmitted di- 

rectly to the thorax by the heart itself, but we hare also to bear b 

Fio. 8&— Poillfcra When Li ok in jr fur Slight ADMVtall Puis 


mind that a dilated aorta may transmit to the chest wall pulsations 
which it is exceedingly important for us to recognize and properly to 
inte rpr e t* No disease is easier to recognize than aneurism when the 
growth has perforated the chest wall and appears as a tumor exter- 
nally, l»ut it is much more important as well as much more difficult 
. e the disease while it is confined within the thorax. In 
such cases, the movi ■ 1 1 1 1 - 1 1 1 s t ran s i u i tted from the aorta to the chest 
wall may be so slight that only the keenest and most thorough in- 
spection controlled by palpation will detect them. When slight 
pulsations ar<^ searched for, the patient should be put in a position 


ahown in Fig. 28, and the observer should place himself so that liU 

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 
totally invisible ii the patient sits facing the light. 

I'ulsations due to aneurism are most apt to be seen in the fi] 
or second right interspace near the sternum, and not infrequently 
the clavicle and the adjacent parts may be seen in use slightly with 
every beat of the heart, but iu any part of the chest wall pulsa- 
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. 21*9). 

Ptiho t htfj Pint i'isy. 

In cases of purulent pleurisy in which the pus has worked 
way out betwen the ribs so that it is covered only by the skin 
subcutaneous tissues, a pulsation transmitted from the heart mai 
become visible, and the resemblance to the pulsation seen in aneu- 
rism may be confusing. Such pulsation is apt 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, Inspection of thk Pekiphbbal Vessels, 

In a work dealing with diseases of the heart and lungs it is 
possible to avoid reference to vascular phenomena apparent in 
neck or in the extremities, since such phenomena have a very duvet 
tearing upon the interpretation of the conditions obtaining within 
the chest. Inspection plays a very large part in the study of tht 
vascular phenomena. We should look for : 

(a) Venous phenomena. 

(A) Arterial phenomena. 

(<?) Capillary phenomena. 



(«) Inspection qftks. Veins, 

1. The condition of tin- wins of the neck is of considerable iin- 
poztaooe 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, ami 
in such cases they may be more or less distended during each ex pi- 
ration, especially if dyspnoea or cough is present. If the over- 
distended veins are completely emptied during deep inspiration 
and on both sides of the neck, we can usually infer that there is as 
over distention of the right side of the 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, but we may have also 

% A presystolic pulsation or ttmhtlation seen either in the ex- 
ternal jugular vein or in the blllbus jugularis between the two 
attachments of the stcniuinastoul 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. Systoik vsncus guUa&kn, such ai ooousa in one of the most 
serious valvular diseases of the heart— tricuspid regurgitation. ' 
Systolic venous pulsation 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 veu- 
hiele, the latter closely following the former. In any cast- in 
which a doubt arises whether a pulsation in the veins of the neck 
is due to tricuspid regurgitation, it is well to try the experiment of 
emptying the vein by stroking it from below upward. If it imme- 
diately tills from below , we may be practically certain that tricus- 
pid regurgitation is present. In the vast majority of cases of ve- 
nous pulsation due to other causes or occurring in healthy persons 

1 A pulsating carotid may transmit an up-and-down motion to the veins 
overlying U. In such cases, if the veins be emptied by "milking" them up- 

ward, they will not refill from below. 


a vein will not refill from below if emptied in the maimer above 

I. Rarely, superficial veins maj be Been to pulsate in other parts 
of the body, especially in sortie regurgitation, and occasionally 

large and tortuous veins may be seen pulsating upon the thoracic 

Fig. 39.-TortUi»uei Vritiw on rn 

intl Abdomen, (AuUh*t showed obtltenUlim of ttw 
i inferior.) 

or abdominal wall, representing an attempt at collateral cumulation, 
when one or the other vena cava is ruin pressed (Fig. 29), 

(6) Arterial Phenomena, 

L In thin ur nervous persons pulsations are not infrequently to 
be seen in the carotids independent of any abnormal condition of 
the heart. 

2. Very violent throbbing of the carotids, more noticeable than 



that seen in health, occurs hi many cases of aortic regurgitation 
and oecainozudly i n simple hypertrophy of the heart without any 
valvular oUneofl^. Wttttn the same causes, visible pulsation may 
OOgUf in the Buhelavian, axillary, brachial, and radial arteries, as 
well as in thr berial trunks of tlie lower extremity. 

I l;i Minn. -1 u blacksmith whose heart was considerably 

ged by hard work, bat without any valvular disease. Tulsa- 

Pig. 3&— Entwrgwl T-jriii-jMst Itradilai Aru-rUa (Arterfo-ectorordft). 

■a- as violent in all the- peripheral arteries which I have jusi 

3. In arterio-Bclerosia occurring in spare, elderly men, with or 
v. rfthout aortic regurgitation, one often notices a lateral excursion of 
the tortuous brachial arteries synchronous with every heart beat. 
An up-and-down pulsation may oocur»t the same time. Not infre- 
v tin- arteries which are stiffened by deposition of lime salts 
(see below, page 66) stand out visibly as enlarged, tortuous cords 
apon the temple and along tin* inner aide of the biceps muscle, 
m| 31) and occasionally the course of the radial artery 


may be traced over a considerable distance in the forearm. In rare 
eases inequalities produced in tin- arterial wall by deposition 
lime salts may be visible as well as palpable. 

(c) Cap Ufa rr/ FtU&a t fan . 

If a microscopic slide is placed against the mucous membrane of 
the lower lip so as partially to blanch its surface, one may see, with 

?I0. 31* -Enlarged and Tonmmn itrarhful Artery { Arterio-sr'teroats) 

each beat of the heart {in cases of aortic regurgitation and sometimes 
in other conditions), a delicate flushing of the blanched surfu<- 
ncath the glass slide. The same pulsation is sometimes to be ob- 
served under the finger nails, or may be still better brought out by 
drawing a pencil or other hard substance across the forehead so a* 
to cause a line of hypersemia, 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- 



ally in health in exophthalmic goitre and in conditions Ottociated 
with low tension in the peripheral arteries, as well as in any at 
inflammatory hyperemia (jumping toothache, throbbing felon, etc.). 

X. Inspection of the Skin and Minus M km branch. 

Light may t>e thrown upon the diagnosis of diseases of the chest 
by observing the color and condition of the cutaneous surfaces as 
well as of the mucous membranes. We should look for the follow- 
ing conditions: 

(1) Cyanosis. 

(3) (Kdema. 

(3) Pallor. 

(4) Janndice, 

(5) Sears and eruptions. 

(1) Oycmtmf. 

JKy cyanosis we mean a purplish or grayish -blue tint notifi- 
able especially in the face, in the lips, and under the nails. There 
are many degrees of cyanosis, from the slight purplish tinge of the 
lips, 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. When combined with pallor, one gets vari- 
ous ashy-gray tints , while the admixture of cyanosis and jaundice 
results in a color very difficult to describe, sometimes approaching 
a greenish hue. The commonest causes of cyanosis are : 

i ') Valvular or parietal disease of the heart. 

(#) Emphysema. 

(V) Asthma. 

(d) Pneumonia. 

(/) In some persons a certain degree of cyanosis of the lips 
pite perfect health, This is especially true of weather- 
beaten faces and those of the so-ealled "full-blooded" type. 


((;) Metliaemoglobinsemia, such as occurs after the excessive use 
of coal-tar analgesics (antifebrine, etc.). 

A rare but very striking type of cyanosis is that seen in cases 
of congenital heart disease, in which the lips may be indigo blue 
in color or almost black while yet no dyspnoea is present. 

(2) (Eth'imi. 

(Edema, or the accumulation of serous fluid in the subcutaneous 
spaces, is usually appreciated by palpation rather than by inspec- 
tion, but sometimes makes the face look very puffy, especially 
under the eyes This is not a common occurrence in diseases of 
the chest, in connection with which such oedema as takes place is 
usually to be found in the lower extremities and is appreciable 
rather by palpation than by inspection. If we are not familiar with 
a patient's face, Ave often do not perceive in it the changes of out- 
line due to oedema which a friend would notice at once. Clothing 
is apt to leave grooves and marks wherever it presses tightly upon 
the oedematous tissues, as around the waist or over the shoulders. 
In the legs, the presence of (edema may be suggested by an unnatu- 
rally smooth, glossy appearance of the skin Such impressions, 
however, may be false unless controlled by palpation, for simple 
obesity may produce very similar appearances. 

(.°») Pallor. 

Pallor suggests, though it does not in any way prove, anaemia, 
and anaemia 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 
conjunctivae, is much more apt to l>e a sign of real anaemia 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 



the conjunctivae, when the eecape o£ bile from the liver is hindered] 
is sometimes to be seen in connection with uncompensated heart 
rlifma iww when the liver is greatly distended by passive congestion 
Pneumonia is occasionally complicated by jaundice; but beyond 
this 1 know of no special oottBftOtioa between this symptom and 
diseases of the chest. 

(5) '«*. 

In eases of suspected syphilis of the lung or bronchi the pres- 
ence of scars and eruptions suggestive of syphilis may be useful in 

XI. Enlarged Gum-s 

Routine inspection of the chest may reveal the presence of en- 
larged glands in the neck or axilla', and may thereby give us a < lew 
to the nature of some intrathoviirie disease $ for example, the pres- 
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 possibility of pul- 
monary tubercukjsis or of an enlargement of the bronchial and me- 
diastinal glands. Again, malignant disease of the chest is some- 
times associated with the metastatic nodules over the clavicle, and 
a micToeoopio examination of them may thus reveal the natup 

intrathoracic disease to which they an seeimdary. Very large 

and matted masses of gin- '* elavietej whk(h have never 

• purated and have been painless and slow in their growth, sug- 

»t the presence of similar deposits in the mediaatuittm as a part 

the symptom complex known as "Hodgkin's disease." The 

presence of a goitre or enlargement of tin- thyroid gland may ac- 

it for a well-marked d\ 

hilis produces general glandular enlargement ; the post 
a] and the epitrochlear glands are often involved, but this is 
the case in many diseases other than syphilis. 



I Palpation. 

TiiKmost important points to be determined by palpation— that 
is, by laying the hand upon the surface of the chest— are: 

(1) The position and character of the apex /"■"/ of the heart, 

(2) The presence of a "thrill" (see below), 

(3) The vibrations of the spoken voice {"tortile fremitus ")• 

(4) The presence of pleuritic or pericardial friction. 

Other less important data furnished by palpation will be men* 
tioned later. 

(1) The Apex Brut. 

(a) In feeling for the apex impulse of the heart, one should 
first lay the palm of the hand lightly upon the chest just below the 
left nipple In this way we can appreciate a good deal about 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 regular or not, and in case it is irregular, whether the 
beats are unequal in force or whether some are skipped; further, 
one gets a more accurate idea than can be obtained through uwp 
tioii regarding the character of the cardiac movements. The power- 
ful heaving impulse suggesting a hypertrophied heart, the diffuse 
slap often felt in dilatation of the right ventricle, the sudden tap 
characteristic of mitral stenosis, the deliberate thrust occasionally 
met with in aortic stenosis, may be thus appreciated. 

{b} Alter this, it is best to lay the tips of two or three fingers 
over the point where the maximum impulse is to be seen* and fol- 
low it outward and downward until one arrives at the point farthest 
to the left and farthest down at which it is still possible to feel 



any up-and-down movement. This paint usually corresponds with 

apex of the heart, as determined by percassioci. if <&** *<* 
• ■/</ rn'/Zt i*//^ maximum earttiar tm put**, bat is often to be 
round at least an inch* farther to the left and downward (see at> 

Sometimes one can localize by palpation a cardiac impulse 
which is not visible ; on the other hand, in some cases we can see 
pulsations that we cannot feel. Both methods must lie used in 
every case. 

The results obtained by palpation and inspection of the apex 
region give us the most reliable data that we have regarding the 
siae of the heart. Percussion may be interfered with by the pres- 
ence of gas in the stomach, of fluid or adhesions in the pleural cav- 
ity, or by the ineptness of the observer, but it is almost always pos- 
sible with a little care to make out by a combination of palpation 
and inspection the positiou of the apex of the heart, When we 
can neither feel it nor see it, we may have to fall back upon auscul- 
tation, considering the apex of the heart to 1«< at or near the point 
at which the heart sounds are heard loudest. When endeavoring 
to find the apex of the heart, we must not forget that the position 

the patient influences considerably the relation of the heart to 
the chest walls If the patient is leaning toward the left or lying 
on the left side, the apex will swing out several centimetres toward 
ft axilla. 

(2) "Thrill*.* 

When feeling for the cardiac impulse with the palm of the 
hand, we are in a good position to notice the presence or absence 
iy important physical sign to which we give the name of 
" thrill n The feeling imparted to the fingers by the throat of 
a purring cat is very much like the palpable tt tftr&t n over the pre- 
cordia in certain diseases of the heart to be mentioned later. It u 
a vibration 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 space or elsewhere in the precordial region. This vibra- 
tion or thrill almost always occurs intermittently, i.e., only during 


■ portion of the cardiac cycle. When felt in the a])ex region* it 
usually occurs just before the cardiac impulse; this fact we ex] 
by railing it a "presystolic thrift"; hut occasionally we may feel a 
Htfstolw thrill at the apex — one, that is, which accompanies the car- 
diac impulse. The word thrill 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 thrill 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 t 
tional neuroses of the heart or In conditions of mental excitement 

As a rule we can appreciate B thrill nn.iv easily if we lay the 
fingerfl 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. Of the thrills felt over the base of 
the heart, more will be said in Chapter V1L 

(3) Vibmtlvnx Commttnitated to the Cheat Wall by the Voice 

lf 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 w while 
]ialm of the hand is laid flat upon the chest. The amount of I 
mitus to be obtained over a given part of the thorax varies, of course, 
according to the loudness of the winds spoken, and is influen 
;il mi 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 lit* re- 
peats them and to us.- approximately the same pitch of vi 

Other things 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 The amount of fremitus also varies widely in differ- 
ent parts of the healthy chest A glance at Fig 32 will help us to 
realize this The parts shaded darkest communicate to the fingers 



le most marked fremitus, while in the parts not shaded at all, Lit* 
no fremitus is felt Intermediate degrees of vibration are 
represented by intermeo!jate tints of shading From this diagram 
we See at ouee («) that the maximum of fremitus is to be obtained 
over the apex of the right lung in front, (ft) that it is greater in the 
upper part of the ehest, than in the Lower, and somewhat greater 
ronghout the right ernst. than in OOTTespondtTIg parts of the left. 

Vta. SL— DfMflbuttoti of Tactile FrwaKU*. 

hi* natural inequality of the turn fide* qfthe vhrst cannot he too 
>frtnttjhj innpharix&L 

Comparatively little fremitus is to be felt over the Beapulffl be 

bind, and still less in the precordial region in front. The outlines 

of the lungs can be quite accurately mapped out by means of the 

tactile fremitus in adults of low-pitched voice. In children, as has 

already mentioned, fremitus is usually very slight and may be 

entirely absent, and in many women it is too slight to be of any 

derable diagnostic value Again, some very fat persons and 

those with thick ehest walls transmit but little vibration to their 

walls when they speak. On the other hand, in emaciated 

patients or in those with thin-walled, flexible cheats, the amount 

of fremitus is relatively great. 


Bearing iii mind all these disparities — disparities both between 
persons of riiffeivnt age and different sex, and between the I 

aides of the chest in any 
person — we are in a position to 
appreciate the modifications to 
which disease gives rise ami 
which may be of great impor- 
tance in diagnosis, These vari- 
&tkmfl are: 

(a) Duninutioii or aba 
of fremitus. 

(ft) Increase or absence uf 

(a) If the lung is pu 
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. 

{ft) Solidification of the lung 
due to phthisis or pneumonia is 
the commonest cause of an -tw- 
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) Friction^ Pleural <>/• Pericardial* 

In many cases of inflammatory roughening of the pleural sur- 
faces ("dry pleurisy'-) a grating or rubbing of the 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 

-Sbawinjf Pol tit CI) nlWbk-ti Pleural 
F rit-t km la Most Often Heard. 



the other, whew the diaphragmatic pleura is in close apposition 
with the costal layer (see Fig. 33, p. 40)* 

Similarly, in roughening of the pericardial surfaces ("dry n or 
(i plastic " pericarditis) it is occasionally possible to feel a grating* 
m rubbing in the precordial region more or less synchronous with 
the heart's movements, Such friction is most often to be fell in 
the region of the fourth left costal cartilaj ig. 34). 

liable friction is of great value in diagnosis because it is a 
about which we can feel no doubt ; as such it frequently con- 

; -Showing Point IP) at Which Pericardial Friction ta Most Often H«ip*. 

tirms our judgment in cases in which the auscultatory signs an fefM 
Friction sounds heard with the stethoscope may be closely 
simulated by the rubbing of the stethoscope upon the skin, but pal- 
lable friction is simulated by nothing rlsi-, unless occasionally by 

(5) PalpaMe J?Zi!<>*. 

I >* ' asioually coarse, dry rales communicate a sensation to the 
placed upon the chest in the region beneath which the rales 
produced ; to the practised hand this sensation is quite differ- 
iKit from that produced by pleural friction, although the difference 
hard to describe. 


(6) Tender points upon the thorax. 

In intercostal neuralgia, dry pleurisy, necrosis of a rib, and 
sometimes in phthisis, one finds areas of marked tenderness in 
different parts of the chest. The position of the tender points in 
intercostal neuralgia generally corresponds with the point of exit 
of the intercostal nerves. These points are shown in Fig. 35. 

The tenderness in phthisis is most apt to be in the 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. :«. Showing Points of Exit of tbr Intercostal Nerves. 

cases pain is produced by very light pressure, but not by firm press- 
ure at the same point. 

(7) The presence of pulsations in parts of the chest where nor- 
mally there should be none is suggested by inspection and con- 
firmed by palpation. It is not necessary to repeat what was said 
above as to the commonest causes of such abnormal pulsations. 
When searching for slight, deep-seated pulsation (e.g. y from an 
aortic aneurism), it is well to use bimanual palpation, keeping one 
hand on the front of the chest and the other over a corresponding 
area in the back. 

(8) Fluctuation or elasticity in any tumor or projection from 



tflfl chest is a very important piece of information which palpation 
may give us. 

(9) The temperature and quality of the skin are often brought 
ti» our attention during palpation. After a little practice one < an 
usually judge the temperature within a degree or two simply from 
the feeling of the skin. Any roughness, dryness, or loss of elas- 
ticity of the skin (myxedema, diabetes, long-standing pyrexia, or 
asting disease) is easily appreciated as we pass the hand over the 
surface of the thorax or down the anus. The same manipulation 
often hrings to our attention In cases of alcoholism an unusually 
smooth and satiny quality of the cutaneous surface. 

II. The Pulse, 

Fifty years ago the study of the pulse furnished the physician 
ith most of the available evidence regarding the condition of the 
heart. At present this is not the case. With the increase of our 
knowledge of the direct physical examination 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 pulse 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 
\atniuing the heart and measuring the arterial pressure. 

Nevertheless, the radial pulse is still an important factor in diag- 
nosis, prognosis, and treatment, and will remain so, because itgives 
us quickly, succiuetlyj and in aim > - • i v rase a great deal of valu- 
able information which it would take more time and trouble to ob- 
tain in any other way. As W6 feel the pulse, we get at once a fact 
of central importance in the casej by the pulse the steps of our sub- 
sequent examination are guided. Ill emergencies or accidents the 
pulse gives us our bearings and tells us whether or not the patient's 
condition is one demanding immediate succor — e.g» f hypodermic 
stimulation — and whether the outlook is bright or dark, To gather 
this same information in any other way would involve losing valu- 
able time. 

Again, when one has to to see a large number of patients in a 


short time, as in visiting a hospital ward or on the crowded d 
private practice, the pulse is an invaluable short cut to some of 
most important data. 

Moreover, there are sonic important inferences which the 
and tut ft/ the pndrn enables us to make. They are not numerous, but 
their value may be great. Delay is one radial pulse when taken to 
connection with other signs may furnish decisive evidence of aneu- 
rism of the aortic arch; aortic stenosis is a lesion which cannot be 
diagnosed unless the pulse shows certain characteristic fe 
arterial degeneration may betray its presence chiefly in the periph- 
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 general condition of the eirculatio. 
all eases, it is essential that we should study it most carefully lioth 
in health and in disease. 

Bow to £M the Pulse. 

(a) We usually feel for the pulse in the radial artery tk 

this is the most suj^erfieial vessel which is readily available. I »■ ■- 
easioually, as when the wrists are swathed in surgical dressings or 
tM up in a straight- jacket, we make use of the temporal, facial, 
or carotid arteries. 

(b) Both radial s should always be felt at the same time. My 
making this a routine praetire many mistakes are avoided and any 
difference in the two pulses is appreciated. 

(c) The tips of three fingers (never the thumb) should be laid 
npon the artery, and the following points noted: 

1. The rate of the pulse. 

2. The rhythm of the pulse (regular or irregular). 

3. The amount of force necessary to obi iterate it [e&mpr 

4« The size and shape *>f the patev tmn\ 

5. The extent to which the artery collapses between beats 

6. The tixe trad petition of (hi a#Ur#. 


7, The condition of tin- artery wait** 

Each of these points will now l*> considered in detail 


1. The Rate of the Puter. 

In the adult male the pulse averages 72 to the minute, in the 
t» male 80. In children it is etmsidcrably more frequent. At birth 
it averages about 13(1, and until the third year it is usually above 
100. En some families as low pulse, W or leas, is hereditary ; on the 
other hand | it is nut very rate to observe a permanent pulse rate <>t 
100 or mora in a normal adult (see below, p. -07 ). Exercise at emo- 
tion quickens the pulse very markedly, and after food it is somewhat 

derated. Some account of the causes of ] pathological quicken- 
ing or Blowing of the pulse will i« found on pages -07 and 208, 


The pulse may be irregular in forc& t m rhythm, or (as most 
commonly happens) in both respects, \s a rule, irregularities in 
force are the more serious. Intermittenee or irregularity in rhythm 
alom\ means that the heart .skips one Of more beats at regular 0? 

pillar intervals. This may be a mere idiosyncrasy not associ- 
ated with any evidence of disease. 1 have known several instances 
in which a perfectly sound person lias been aware of such an irregu- 
larity throughout life — the heart dropping regularly every third or 
fourth beat. Surli rhythmical intermittenee in health is not un- 

When Wuts are dropped, not at fixed intervals, but Wretjuhehf, 
the pulse waves usually vary in force as well. This combination 
of irregular eardiae rhythm with variations in the streugth of the 
individual beata is very rarely seen in health and usually points to 
functional or structural disease of the heart. 

Special types of irregularity vvill be discussed Sate?. 

In general it may be said (V) that irregularity in the forre of 
the pulse beats is a sen mis sign, if overexertion and temporary 
tosic influences (tobacco, tea, etc, | run be ruled out; (h) that it is 
far more serious when occurring in connection with diseases of the 


aortic valve than in mitral disease; and (c) that it often occurs in 
connection with sclerosis of the coronary arteries and myocarditis 

3. Compressibility, or Systolic Arterial Pressure. 

There is no single datum concerning the pulse 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 
ringers rest as usual on the radial artery Then gradually increase 
the pressure made upon the vessel with the finger nearest the pa- 
tient's heart until the pulse wave is arrested and cannot be felt by 
the other lingers which rest loosely on the artery. The degree of 
for(»e 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 in/re), one comes to possess a fairly accurate mental 
standard or picture of the compressibility of the average pulse, and 
is then able to estimate in any given case whether it is more or le>s 
compressible than usual. 

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 Size, and Shape of the Pulse Wave. 

Of the use of the sphygmograph for representing pulse waves 
I shall speak later. The points discussed in this section are appre- 
ciable to the lingers. 

I. The size of the pulse wave — the height to which it lifts the 
ringer — depends on two factors : 

(rc) The force of the cardiac contractions (systolic arterial 

(/;) The tightness or looseness of the artery (tension, or diastolic 

If the arteries are contracted and small, the pulse wave corre- 


sponds ? while if they are large and relaxed, it needs only a moder- 
ate degree of power in the heart to prod ace a high pulse wave. If 
the tension remains constant the size of the pulse wave depends on 
force of the heart's contraction. If the heart power remains 
constant, the size of the pulse wave depends on the degree of \ 
(Hilar 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 cootratfioaa from the height of the 
pulse wave. 

II. The s ha jje of the pai* m also of importance. 

(n) It may have a very sharp summit, rising ami falling back 
again suddenly; this u knows as an Ul-mutain4d pulse, and may 
be due to a lack of sustained propulsive power iu the contracting 
heart muscle, to low vascular tension, or to a combination of the 
two causes. A weak heart with low arterial tension often prodi 
such a pulse wave— deceptively high and giving at first an impres- 
sion of power in the heart wall, but ill sustained and easily com* 
pressible. This is the "bounding pulse" of early infectious proc- 
esses. An exaggeration of this type of pulse is to be felt in aortic 
regurgitation (see Fig. 102). 

(hi) In sharp contrast with the above is the pulse wave which 
lifts the finger gradually and slowly, sustains it for a relatively 
long period, and then sinks gradually down again. Such a pulflQ 
with a M long plateau n instead of a sharp peak is to be felt most 
distinctly in aortic stenosis, less often in mitral stenosis and other 
itions (see Fig. 107). 

(e) The din-otic pulse wave la one in which the secondary wave, 
which the sphygmograph shows to be present in the normal puls»% 
is much exaggerated, so that a distinct "echo'' of the primary 
wave is felt after each beat. If the heart is acting rqpMK, tftua 
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- 
graph ic tracing as a part of the up-stroke of the primary wave 
This is known as the u ana€r&He pulse.* 

(</) The shape of the high'tenrion ptdsa tcace will be described 
in the next paragraph, 


5* Tetwtottf ft' I>itmtii?ir Arterial Pressure. 

The degree of contraction of the vascular muscles determines 
the size of the artery ami (to a great extent) the tension of the 
blood within it. But if the heart is acting feebly, there may be so 
little blood in the arteries that even when tightly contracted they 
do not subject the blood within them to any considerable degree of 
tension . To produce high tension, then, we need two factors: a 

W V 


N v 

Fro, 2fi- SphygTDojmi|thU' Tracing of Low Tension Pulse, 

certain degree of power in the heart muscle, and contracted arteries. 
To produce tow tension we need only relaxation of the arteries, and 
the heart may bis either strong or weak. 

The pvht qfUm tension collapses between beats, so that the ai- 
tery is less palpable than usual or cannot he felt at all. Normally, 

Fig, 07.— 8ptlyp™w™pb^l■ Tnw1n*r of Hlpfa Tension Pulse. 

the artery can just l>e made out 'between beats, and any consider* 
able lowering of arterial tension makes it altogether impalpable 
except during the period of the primary wave and of the dicrotic 
wave, which is often very well marked in pulses of low tension. 
The shape of the wave under these conditions has already been 
described (sec Fig. 30), 



JV niij], tenctp* i^ perceptible between beats as a f/*V 

fin*'/ wrrf w&tcA bom 6a retted fa* vee* thejlngar*, likeoueof the tril- 
lions rif | he wrist. It is also difficult to compress in most cases, but 
this may depend rather on the heart's power than 00 the degree 
-cular tension. A high-tension pulse is often indistinguishable 
in un one stiffened by arteriosclerosis {vide Utfw). The pulse wav»' 
is usually of moderate height or low, m M 1 falls away slowly with 
little or no die iva (see Fig. 37). 

6*, The Sbte and Position qfth$ Artery, 

I have often known errors to occur because a small artery is 
mistaken for a smBMpuhe wave* The size of the branches of the 
arterial tree varies a great deal in different individuals of the same 
weight and height, and if tin* radial is unusually small and a hur* 
; given 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 

I 0OHQltt46 (wrongly, perhaps) that the heart's Work is not being 
properly performed. The effort to obliterate *uch a pulse, how- 
eve i , itttr/f set us right by showing that despite the small size of the 
i (and consequently of the pulse wave) it takes as much foree 
as it imnnalh o obliterate it. lint in many eases we can 

determine the question satisfactorily often by using some instru- 
ment for measuring arterial pressure. Tims, a ntmtti puU» trttve (in 
a eongenitally small artery) may be distinguished from a weak 
From the contracted artery of high vascular tension we dis- 
tinguish the eongenitally smalt artery because the latter is uot to l»e 
rolled beneath the fingers, ami is not more than normally palpable 
between the pulse beats. 

Not infrequently the nurse reports in alarm that the patient has 
DO pulse, when in reality the pulse is excellent but the artery mis- 
placed SO as to be impalpable in the ordinary situation. It may be 
simply more deeply set than normal, so that the ringers cannot get 
at it, or it may run superficially over the end of the radius toward 
the "anatomical snutf box." Other anomalies are less common. 
As a rule, the other radial artery is normally placed and can he used 


as a standard, but occasionally both radials are anomalous and we 
may be compelled to use the temporal or facial instead. 

7. The Condition of the Artery Walls. 

Arterio-sclerosis is manifested in the peripheral arteries in the 
following forms : 

(a) Simple stiffening of the arteries without calcification. 

(b) Tortuosity of the arteries 

(c) Calcification. 

Simple stiffening without calcification is due to fibrous thicken- 
ing of the intima 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; hence 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 beading 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. The qualities 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 — unless 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 characteristics of the 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 the pulse in connection with 
the different diseases of the heart are described in the sections on 



those diseases. Mere it will suffice to ftmnierate some of the con- 
ditions in which vascular tension is usually increased or diminished. 

Low tension is produced by moderate exem.s*', by warmth (<\p,, 
a warm bath), by food. Among pathological conditions we may 
mention especially debilitated states, mental worry, and fov< i\ 

Hhjh teiiston is produced by fold (*.0. 9 cold bathing, malarial 
chills), and by constipation (in some cases). As a rule, the tension 
of the pulse increases with age and is hi^b after tin fiftieth yeaa 
p steria and migraine are often associated with increased vascular 
ision. Most frequent among pathological conditions as eaiws 
of high tension are ehrwii** nrphritU and arterio-*etnr*ori» with the 
various diseases in which arterio-sclerosis is a factor (gout, alcohol' 

i, lead poisoning, diabetes of fat old people, chronic bronchitis 
with emphysema). 

Among valvular heart lesions, aortic and mitral stenosis are 
especially apt to be associated HFtth increased vascular tensimi. 


Within the past few years a number of instruments have < 
into use, the object of which is to tell us with some approach to 
accuracy the lateral pressure in the peripheral ai'terie*. We have 
long attempted to estimate this pressure, by simple digital 
pression and palpation, and no doubt these methods in the hands of 
skilled observers will always have a held 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 yestenb\ , 
when one has felt many pulses 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 


amount of coin pre ssioo which lias 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 
;d tin- moment when its wall makes the widest exeurMon off oscilla- 

Instruments of the first type are said to measure tyttoliej 
IPV| and those of the second type to measure dia$U4i6 prttttttd, 
Under the first heading I shall describe the Riva-Rocci and Gai 
uer instruments. Under the second that of Oliver and that of Hill 
and Barnard. 

1. Gartner* $ Tonometer.— The end of a finger is made blood- 
less by rolling up over it a tight rubber ling. Over the blanched 
tinger tip one next applies a pneumatie ring, which can he inflated 
by means of a i libber bulb, while the tension within is meas* 
ii i ill 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 above what we expect in the case dealt 
with. (The tip of the finger all this time remains blanched.) 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 si/stu/ir \n-> 
are, that is, to the pressure during the systole of the left ventricle 
ur to the crest of the pulse wave. 

The advantages of the Gaertner instrument are its compactness 
aud 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 pressures in any of the dark -skinned races, aud that its 
readings are very much affected by vasomotor influences, such as 
nervousness or cold. If the fingers are cold it may be almost im- 
possible to make a satisfactory record with the instrument. Further, 
the spring manometer, like all instruments of this type, is very apt 



get out of order, and if the mercury manometer is employed the 

aent loses its only advantage, namely, its compacts 
2, Thr Rirtt- !;■.<■< t Instrument. — This instrument BOMUrtS esaen- 
tally of an inflatable rubber armlet, so arranged that it can be tilted 
closely around the upper arm, a mercury manometer of the ordinary 
pe, and an air-pump (see Fig, 38), The air forced from the 

MfKiffh-atkin «if Uih Riva-Rowl Instfiimettt. <B* pentrininii faun th< rnL 
versltyof INmnHvlvania MwliCAl Bulletin, i 

pump i* distributed into the rubber armlet ami into the man- 
ometer at the same time, and experiments have shown that tW 
actual pressure in the armlet is practically identical at any given 
time with that ill the manometer* To use the instrument we pump 
in air until the radial pulse stops, and at that instant note the 
leight of the mercury column, The reading thus obtained is 


taken to represent the systolic or maximum pressure in the brachial 

It is true that the air within the rubber ami let has to overcome 
not only the pressure within the radial artery, but the resistance of 
the artery wall and the elasticity of the soft parts around it. The 
former factor has been shown to represent a pressure of not more 
than 2 or 3 mm. Hg, provided the artery walls are norma]* If 
arterio-sclerosia is present, it has been estimated by von Basch that 
they may oppose a resistance equivalent to 5 or 6 mm. Hg, Tin- 
amount of error thus introduced, however, appears to l>e of no im- 
portance, since there are physiological variations of 6 aim, Hg or 
inure, occurring from moment to moment, and dependent on changes 
in the force of the heart beat and on the respiratory oscillation- 

The resistance of the soft parts around the artery is a factor of 
considerable importance, provided the compressing armlet is as 
narrow as many of those supplied with Riva*Rocei instruments. 
J hit if an armlet of about three and one-quarter inches width is 
used, according to the recommendation cf roil Recklinghausen and 
Stanton, we find that the pressure is practically the same in a given 
individual whether the armlet is applied round the upper arm f 
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 
upper arm or forearm, it seems safe to conclude that this factor may 
be neglected as a source of error in comparative measurements with 
arms of different sisses. 

Tin* instrument is a very simple and quick one to use, nei- 
very little practice and not more than a minute or a minute and a 
half for a single reading. The chief objection t<» it is its bulk and 

3, The Instrument of Btil and Barnard, — In essentials this in- 
strument is like the Riva*Rocd, except that all the connecting tubes 
are rigid, and that in place of the mercury manometer a very deli- 
cate aneroid instrument is employed to record the pressures within 
the armlet (see Fig, 39). The delicacy of this form of nianorae 
is so great that with rigid connections it is possible to register the 

oscillations of the artery wall and to estimate the amount of press- 
ure within the armlet at the time when the arterial oscillations on 
widest; in other words, when the arteries arc slackest. The work 
of Howell and Brush has demonstrated to my satisfaction that the 
pressure at the time of the maximum oscillation corresponds to the 
minimum or diastolic pressure within the arteries. 

The Hill and Barnard instrument, when in good order, seems to 

Tid. 3H.— H1I! k Biirtiurtl"* Sfihvgi uvUt. 

on the whole the best among those that an 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 the likelihood that 
lanometer will get out of order, a difficulty u> which all in- 
struments of this type are very prone. 

4. The Oiiter Instrument Thin 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 
opinion to the diastolic and not to the average or mean pressure. 
A small rubber capsule rilled 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 


cii.tnometer, where the oscillations and j »j ■ <led 

nun. Ug (see Fig. 40 ) + The instrument eompan 

simple one, imd if it wt re no1 constantly getting out of oniei\ 
be, I think j of considerable value, although it is a difficult iri^i 

Fi«. KK ^Oliver's IJ(t»im*Ipnaiiiuiti«<ti-r, 

m?tit to use. Its readings, however, soon become inaccurate ani 
iets« to correspond with the mercury column, 

Stanton (Univer$iitj of Penn. Med. Bu8. $ February, 1903) has 
succeeded in fitting a Riva-Itoeei instrument with rigid connecting 
tubes, so that with this single instrument he can record both maxi- 
mum and minimum pressures. The maximum or systolic pressure 
he records in the ordinary way* To get the minimum or diastolic 
-me he clamps off the tulie leading to the inflation bulb* and 
then lets out the air little by little until the mercury begins to oscil- 
late in the tube. The oscillations increase in extent up to a maxi- 
mum as tlte air is steadily let out, and thru ileereu&e again until 
they are lost. The reading for diastolic pressure is taken when tl 
mercury shows the greatest extent of oscillation in the tul»e. 



The I t h? of the Data Obtained by these lust nt uh uts. 

The subject is still in its infancy, but in a general way one may 
my that whenever it is important thai ire should know the strength 
of the heart beat or the tension of the peripheral arteries, these 
instruments are of value. Just which instrument is likely to come 
into permanent use I cannot venture to prophesy, but it seems to 
me likely that the charts of pulse rate will be supplemented bef< 
long by charts of blood pressure taken at regular intervals as a mat- 
ter of routine. Especially the investigation of diseases of the heart 
and kidney, diseases in which involvement of the suprarenal gland 
is suspected, intracranial hemorrhage or tumor and surgical shock, 
accurate record of blood pressure will be of value. Even the imper- 
fect instruments now in use are capable of yielding us most impor- 
tant information, if applied in comparative measurements upon the 
same patient at different times, so that all the elements of ermr arc 
constant. Thus in the study of drugs like alcohol, digitalis, 
strychnine, ether, chloroform, nitroglycerin, and others which are 
supposed either to raise or to lower blood pressure, these instru- 
ments have, I think, a great field before them. 



I. Technique. 

There is no other method of physical examination which needs 
so much practice as percussion, and none that is so seldom 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 per- 
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 
pitch — and form their judgments in percussing upon the quality or 
intensity of the note, and upon the sense of resistance. 

In this country practically all percussion is done with the fin- 
gers ; in Germany instruments are still used to a considerable ex- 

('/) Mediate and Immediate. Percussion. 

Percussion may be either "mediate" or " immediate, " the 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 



(ft) Methods. 

Mediate percussion (which is used ninety-nine hundredths of 
i© time) is performed as follows i 
The patient should either lie down or sit with bis back against 
iunie support* T!i- of tins is that for good percussion one 

Fig. <L— Pmltiou uf ihu* Huniis When P*TcussiiiM Hits Jliirht Ape*. 

is to press very firmly with the middle finger of the left hand 
ipon the surfaee of the cheat, so firmly that il the patient is sitting 
upon a stool without Buppm-t lor his back, it will need considerable 
exertion upon his part to avoid losing his balance. 


In percussing the front of the *-h« mportant to have 

patient sitting or ly in # i/i a siptitttetrtcal position- with* 

iiny twist or tilting to cue side. His head should point si 
forward and his muscU* must Or thoroughly relaxed* Many 
tients, when striped for examination, swell out their chests 

r«, 42. IVwill^D nf Uw Hands 

mg in.- Left Apr*. 

sit up with a military erectness. The muscular tension thus pro- 
duced modifies the percussion note and causes an embarrassing 
multitude of muscle sounds winch grpatly disturb auscultation. 

Having placed the patient in an easy and symmetrical position, 
uur percussion should proceed according to the following rules: 

(1) Always press as firmly as possible upon the surface of the 



with the second finger of the left hand 1 on the dorsum of 
which the blow is to he struck. Itaise the otfcei fingers of th** Left 
hand from the chest so :ls i tth its vibratuus, 

(2) Strike it quick, perpendicular, rebounding blow with the tip 
of the second finger 3 of the right hand upon the neoond linger of the 
left just behind the nail, imitating as f ar as possible with the right 
band the action of a piano-hammer. The quicker the percussing 

Fin. 43. -The Bight Way to Percuss-i. t„ From tke Wrist* 

finger gets away at<aiu after striking, the clearer will he tin- note 

Let all the blows struck in any one part of the chest be 
tin i form in force. 

1 Left-banded percusaors wili. of course, keep the right hand upon the 
d strike with the left, 

en percussing the right apex I prefer to strike upon the thumb (see 
41 and 42)41 it is almost impossible when standing directly in front 
.-f rlir patient to fit any of the fingers comfortably into the right supraclavicular 



(4) Strike from the wrist and ii-^t from 1 1 1 o »4bow (see Fi^ 
and 44). The wrist must be held perfectly Loot 

(5) Keep the percussing finger bent at a ritcht angle as in 


The force to be used in percussion depends upon the purpose 

FIG. W,— The Wn>ng Way to Pemis* ]. ... Vrm the Elbrtw, 

for which the percussion is used— that is, upon what organ we are 

lissiug- and also upon the thickness of the muscles cover 
that part of the chest. For example, it is necessary to pen 
very strongly when examining the back of a muscular man, where 
an inch or two of muscle intervenes between the finger on which 


re strike and the lung from which we desire to elicit a sound. 
Over tlif boot of tin and in the axilla* the muscular covering 

is much thinner* and hence a lighter blow suffices. In children or 
emaciated patients, or in any case in which the musrular devi-hip- 
ineiit is slight* percussinn should be as light as is sufficient to elicit a 
ir sound, llravy peretlflgion is s<.nntimes necessary hut always 
unsatisfactory, in that the sound which it elicits comes from a re la* 
tively large area of the chest and does not therefore give us infor- 


Fig, «*— Prc^r Podttao •■* iIj»- uk-nt humi imvmu I'-n mda± 

m about the condition of any sharply localized area. If a cai- 
uter, in tapping the wail to find the position of the studs, strikes 
oo hard, he will fail to find the beam, because the blow deli 
.rr the spot behind which the beam is situated is so forcible 

out the resonance oi the hollow pints around. It is the same 
with medical percussion. Heavy percussion is always inaccurate. 1 
It may be necessary where the muscles are very thick, but its value 

1 See also below, page 82, the lung relies. 


is then proportionately diminished. On the other band, it ta 
sible to strike bo lightly that no recognizable sound is elicited At 
all. The best percussion, therefore, is that which is just foi 
enough to elicit a clear sound without setting a large area of ohesl 
wall in vibration. 

The position of the patient above described applies to p<-; 
sion of the front* When we desire to percuss the back, it is nn- 


Pnytr J' 

ntletit During 1 Poiviisslon of Hip Biu-li, 

portaut to get the se&pnfee out of the way as far as possible, since 
we cannot get an accurate idea of sounds transmitted through them. 
To accomplish this, we put the patient in the position shown in 
Fig. 1(5, the arms grossed upon the chest and each hand upon the 
opposite shoulder. The patient should be made to bend forward; 
otherwise the left hand of the pereussor will be uncomfortably bent 
backward and his attention thereby distracted (sec Fig. 47). 

When the axilla* are to be percussed, the patient should put the 
hands upon the top of the head. 



(/>) Auscultatory I **• mission* 

If while percussing one auscuits at the same time, letting the 

chest piece of the stethoscope rest upon the chest, or getting the 

at or an assistant to hold it there, the sounds produced by 

i are greatly intensified, ami - in their volume, 

pft&fctj or quality are very readily appreciated. The blows must be 

Fifl, tt.-Wnmff Position fur pi..:-,/ thi< Jim-It. Tlie initial HbtiflM fn- Lm-iu f^nvanJ. 

very lightly struck, either upon the chest iteelf or upon the finger 
used as a pleximetei in the ordinary way. Some observers use a 
short stroking 01 scratching touch upon the chest itself without 
employing aoy'plexiineter. 

This method is used especially in attempting to map out the 
borders of the heart and in marking the outlines of the stomach. 
In the bands of skilled observers it often yields valuable results, 


but one source of error must be especially guarded against. The 
fine a/tt/iff which iwjwwtt**j when cyoprvuehiny on orpofi wh* 
den we desire tc nawk w*t t must neither approach the chest piece <*f 
the stethoscope nor recede from if, In o/tihvt words, the line along 
which we percuss must always describe a segment of a circle wL 
centre is the (lust piece of the stethoscope (see Fig. 48)# If we 
pi m cuss, as we ordinarily do, in straight lines toward or away from 
the border of an organ, our results are wholly unreliable singe 
every straight Line must bring the point percussed either closer to 

Percussion are. 

Chest-piece of 



ifl. -Auscultatory PereuaBJiwi, Showing Uie Are a\uag which sucb 


should l« 

the stethoscope o* farther from it, and the intensity and quality 
of the sounds conducted through the instrument tu our ears vary 
directly with its distance from the point percussed. 

It will be readily seen that the usefulness of auscultatory per' 
cussion is limited by this source of error, and that considerable 
practice is necessary before one can get the best results from tins 
method. Nevertheless it has, I believe, a place, though not a very 
important one, among serviceable methods of physical examination. 



(<?) 1'tffji'ftoirf Percussion* 

Bonn German observers gas i method of percussion in which 
attention is fixed directly 01 primarily on the amount of resistance 
offered by the tissues over which percussion is made. Even in or- 
dinary percussion the amount of resistance is always noted by 
;enced pereussoift, but the element in sound is usually the 
ni.tirs object of attention, Palpatm -sum is rather a series 

it pushes against various points un the chest wall, but some 

Norma) doiaum 
of ibe rtifbt apex. - 

Deep imnJliU 1 

\ supertii 
X-- dulni* 


Tntubc'i semilu- 
nar tympanitic- 


FiG, *&.-Fercuisffra Outlines Id th«* Normal Cne*L 

sound is elicited and probably enters into the rather complex judg- 
ment which follows. 

In this country palpatory percussion is but little employed. 

Percussion Resonance of the Kormax Chest. 

note obtained by percussing the normal chest varies a great. 
in different areas. In Fig. 49, tie' parts shaded darkest an- 
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 W elicited. 


(") The sound elicited in the latter areas is known as normal of 
ll vmieu$ar" resonance, and is due to the presence of a n 
amount of air in the vesicles of the lung underneath. If this »ix- 
containing* lung is replaced by a fluid or solid medium, as in pleu- 
ritic effusion or pneumonia, it is much more difficult fco elirit a 
sound, and such .sound as is produced is 
short, high pitched, and has a feeble carry- 
ing power when compared with the sound 
elicited from the normal lung. This 
short, feeble, high -pitched sound is 
known technically as a **r/j///** or 

Upper [i)Im>. 

,-' Lowit lot**. 

[ ^^ Splenkarua, 

"fiat** sound, flatness designating 
the extreme of the qualities that 
characterize dulness. Over the 
parts shaded dark in Fig. 40, we 
normally get a d\dl or flat tone* the darkest 
portions being flat and the others dull. 
The heavy shadow on the right corresponds 
to the position occupied by the liver, or 
rather by that part of it which is in frame* 
diate contact with the chest wall. The up- 
per portion of the liver is i d by the 
right lung (see Fig. 49), and hence at this 
pi j j ot we get a certain amount of : 
on percussion, although the tone is not so 
dear as that to be obtained higher up. Be- 
low the sixth rib we find true fiabMU ih-.u 
the sternum and for a few inches to the tight 
of this point* As we go toward the axilla, 
the line of lung resonance slopes down, aa is seen in Fig, 50. In 
the back resonance extends to the ninth or tenth ribs. 


BO I l H*iU"n or the LHt 
) ii iv in ItM Axilla* 

Nona ft I Jhrfl An 

(b) On the left side, the main dull area corresponds to the heart, 
which at this point approaches the chest wall, and over the por- 
tion shaded darkest is uncovered by the lung. The part here 



lightly shaded corresponds to that portion of the heart which is 

i tapped by the margin of the right and left lungs. 

Over the portion of the heart not overlapped by the lung (see 
7.'») tin' percussion note is nearly flat to light percus- 
sion, and very dull even when strongly percussed. This little 
quadrangular area is known as the u mtperfiekU cardiac apac*/' and 
tin* dulness corresponding to it is referred to as the n mtp$ffitiial n 

liae dulness, while the dulness corresponding to tin nut 1 up 
the heart itself beneath the overlapping lung margins is called the 
eardiac dulness. 

When the heart becomes enlarged, both of these areas, the deep 

and the superficial, are enlarged, the former corresponding to the 

d size uf 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 ej 

Accordingly, either the superficial or the deep dulness 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 mart out, hut 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 
pe reus sing 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 
tin' right and the upper borders, since here we have to perc 
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 deep 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 


an area of lung superficially that fine distinctions of note b 
impossible (see above, p. &9)* 

Good observers are to be found on each side of this quesi 
anil 1 have no doubt that either method works well in ski] 
hands. Personally I have found light percussion preferable, 

Whatever method we use we must percuss successive points 
along a line running at right angles to the border of the c«i 
Which we Wish to outline until a change of note is ]*ereeivt*d. 
Thus, if we wish to percuss out the upper border of the liver, we 
strike successive points along a line running parallel to the ster- 
num and ultout an inch to the riglit of it, J When a change of I 
is perceived, the point should be marked with a skin pencil ; then 
we percuss along a line parallel to the first on*.-, and perhaps 
inch farther out, and again mark with a dol the point at which the 
note first changes. A line connecting the points so marked aj 

the skin represents the border of the oi-nn to he outlined. 

If now we look at the upper part of the chest in Fig. 4^. we 
notice at once th:tt. the two sides are not. shaded alike: the I 
is distinctly tighter colored than the right. This is a very impor- 
tant point and one not sufficiently appreciated by students. The 

v of the normal right lung is distinctly less resonant than the 
apex of the left id a corresponding position. 

In percussing at the bottom of the left axilla, we come upon a 
small oval area of dulness corresponding to that outlined in Fig "u. 
This is the area of tpltnic dulness, so called, and corresponds to 
that portion of the spleen which is in contact with the chest wall* 
This dull area is to Ik> made out only in case the stomach and colon 
are not overdisteuded with air t When these organs are full of gas 
as is not infrequently the case, there is no area of splenic dulness 
ami the whole region gives forth, when percussed, a note of a qual- 
ity next to l>e described, namely, ** tympanitic.** 

(c) Tympanitic resonance is that obtained over a hollow bod} 
like the stomach when moderately distended with air J It is usu- 

■Or we may reverse tbe procedure; percuss first over the liver Mid then 
work (award the lung above until tbe note becomes more resonant. 

" Extreme distention here, as in a snare drum, is associated with ft dull 
percussion note, (see be low, p 274 > 



»f a higher pitch than the resonance to be obtained over the 
normal tang, ami may ba elicited by percussion lighter than that 

ded to bring wit the lung resonance. It differs also from the 
TOsiculAX <m pulmonary resonance in quality* m a way easy fed appj<- 
eiate but difficult to describe. Tympanitic resonance is usually to 
be heard when one percusses over the front of the left chest near 
tli»- ensiform cartilage and for a few inches to the left of this point 
an area corresponding with that of tin- stomach more or. less 
distended with air. This tympanitic area, known as u Travel 
m milunow spaaf*" varies agreat deal in size according to the contents 
of tin* stomach. It is bounded <m the right by the IWer flatness, 
above by the pulmonary resonance, on the hit by the splenic dul- 
HesSi and below by the resonance of the intestine, which is also 
tympanitic, although its pitch is different owing to the different 
nxe and shape of the intestine. 

(The right mx ilia shows normal lung resonance down to the 
point at which the liver flatness begins, as shown in fig* 4.) 

In the back t when the scapulae are drawn forward, as shown in 
Fig. 4<j, page 70 percussion elicits a clear vesicular resonance from top 
to bottom on each side, although the top of the right lung is always 
slightly less resonant than the top of the left, and sometimes the 
bottom of the nulif Lang is slightly less resonant than the corre- 
spending 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 fr«nt, <»n account id" the greater thickness of the 
back muscles. Yet in children or emaciated persons, or where the 
muscular development is slight, there may lie as much resonance 
behind as in front. 

Importance qf Percu$sing Symmetrical Points, — 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 symmetrical points, and not, for 
example, compare the resonance over the third rib in the right front 
with that over the third interspace on the left, since more resonance 
always be elicited over an interspace than over a rib. This 


comparison of symmetrical points, however, is interfered with by 
the presence of the heart on one side and the liver on the other, as 
well as by the fact that the apex of the right lung is normally tern 
resonant than that of the left A resonance which would be 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 m hot It plenml eavftiea, we 
have to make the best comparison we can between the Bound 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 on 
strikes, as well as upon the conditions obtaining within the 
A powerful blow over a diseased lung may bring out more reso- 
nanoe than a lighter blow over a normal lung. To strike witl< 
feet fairness and with equal force upon each side can be learned only 
by considerable practice. Furthermore, the distance from tl 
to each of the two points, the resonance of whirh we are compar- 
ing, must be the same— that is, we must stand squarely in front or 
squarely behind the patient, otherwise the note owning from the 
part farther from the ear will sound duller than Hint Doming from 
tliH nearer side 

The normal resouanee of the different parts of the chest can be 
considerably modified by the position of the patient, by deep breath* 
iug, by muscular exertion, 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 dulnese is extended in the same 
direction. Deep 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 

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 



proportionately enlarged. In old age, on the other hand, when the 
lungs have lost part of their elasticity anil sag down over thr heart 
and liver, the percussion dulness of these 01 . reduced. 

\diHons Modifying the Percussion Note tn Health, — The de- 
velopment of muscle or fat as well as the thickness of the chest 
-all will influence greatly the amount of resonance to be obtained 
)y percussion. Indeed, we see now and then an individual in no 
>art of whose chest can any clear percussion tone be elicited, In 
rontea, the amount of development of the breasts has also 
luence upon the percussion note In children » the note is geoer- 
ly clearer, and only the lightest perauuioa 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 emphysematous, a shade of tym- 
panitic quality is added to the normal vesicular resonance, The 
distention of the colon with gas may obliterate the liver dulness by 
rotating' that organ bo 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 
?ven in the left back. 

If a patient is examined while lying on the side the amount of 
resonance over the lung corresponding to th>« side on which he 
lies is usually less than that of tin? side which is uppermost, because 
rbtiH is mora 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 
flat, owing to the close juxtaposition 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 
rover ■ OOn&lderably larger portion of the liver 

PmvMJasi as a Moans t$f Ascertaining the MotmhUity of the Lang 
Borders. ^It is often of great importance to determine not merely 
the position of the resting lung but its power to expand freely. 
This can be ascertained by percussion in the following way: The 


lower harder of tin.' lung resonance, say in the axilla, is carefullj 
market! oat. Then percussion is made over a point joal 
Eavei <>! the resting lung ami at the same time the patient is directed 
to inspire deeply If the lung expands and its border moves 
th- 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 Hie 
axilla Litteif 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 importance, for an absence of 
such mobility ^ay indicate pleuritic adhesions, Its amount de- 
pends upon various conditions and varies much in different indi- 
vi duals, but complete absence of mobility is always pathological. 

(d) Crach^d-Pvt Resonance 

When percussing the chest of a crying child, ire aometi 
notice that, the sound elicited has a peculiar "chinking* 1 quality, 
like that produced by striking one coin with another, but more 
muffled. The Sound may l« J more closely imitated, and the mode 
of its production illustrated, by clasping the hands palm to pahu 
so as to enclose an air space which communicates with ihe outer air 
through a chink left open, and then striking the back of the under 
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 usually produced over a 
pulmonary 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 piece of the instrument just in 
front of his open mouth, leaving the auscultatory hands free for 
j h« r cussing. 



(**) Amphoric Resonant? 

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 be imitated by percussing the trachea or the cheek 
then moderately distended with air. 
The varieties of reaonanoe to be obtained by percussing the nor- 
al thorax are ; 
(1) Ptonrfor mmaneti to be obtained over normal lung tissue. 
( -i Tympttniti** rtsuutntw, to be obtained in Trail lie's semilunar 
(3) IMmfadsksd n»tma$te§ ot duine$i t such as is present over the 
-apuhe, and 

(4) Absence of resonance or ftntnr&s, such as is discovered when 

I percuss over the lowest ribs in the right front 
(.*) Cracked-pot resorttmwj sometimes obtainable over the chest 
of a crying child* 
(6) Amphoric n$mam^ obtainable over the trachea. 
Any of these sounds may denote disease if obtained in portions 
of the fthcflt where they are not normally found. Each hot it* 
/Jure, and heromrs pathofofjlvtil if/omul §i§meikef§, Tympanitic reso- 
nance is normal at the bottom of the left front and axilla, but not 
elsewhere. Dulness or flatness is normal over the areas corre- 
sponding to the heart, liver, and spleen, and over the scapulae, but 
not elsewhere unless the muscular covering of the chest is enor- 
mously thick. 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 means disease, usually pulmonary 
tvity or pneumothorax, if found elsewhere than over the trachea. 


(/) The Lung Reflex. 

It must also be remembered, when percussing, that in some eases 
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. Sense of Resistance. 

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 axilke and over those portions of the back not covered by 
the scapuhe, we feel in normal chests an elastic resistance when 
percussing which is in contrast with the dead, woodeny feeling 
which is communicated to the ringer when the air-containing lung 
is replaced by fluid or solid contents (pleuritic effusion, pneu- 
monia, phthisis, etc. ). In some physicians 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 distinct use in diagnosis. 



Auscultation may be practised by ] dacing one*s ear directly 
against the patient's chest (immediate auscultation) or with the 
help of a Btethoecope (m& imitation), 

Each method has its place. Immediate auscultation is said to 
advantages similar to fehoae of the low power of the jjhi- 
BOOpej in that it gives us a general idea of the condition of a nhi- 
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 have heard it said by E. G. Jane way and 
accomplished diagnosticians that the cmalded ear San perceive 
sounds conducted from the interi f the lung— aovtndfl quite inau- 
dible with any stethoscope— and that in this way deep seated areas 
oJ solidification maybe recognized. 

Immediate auscultation may be objected to 

(a) On grounds of delicacy (when examining persons of the 
opposite sex) . 

(A) On grounds of cleanliness {although the chest may be cov- 
ered with a towel so as to protect the auscultator to a certain 


(') Because we cannot conveniently reach the supraclavicular 
or the upper axillary regions in this way. 

(V) Because it is difficult 1«i localize the different valvular areas 
and the sites of eardiae murmurs if immediate auscultation is em- 

On account of t 1 ulijertimi the great majority of observ- 

w use the stethoscope t * ■ examine the heart. For the lungs, 

both methods are employed by most experienced auscultators. 


(Personally, I have never yet learned to hear anything with mj 
unaided ear which I could not hear better with a stethoscope, and 
the Bowles stethoscope seems to me to reach as large an area, and 
as deep as the unaided ear. Nevertheless the weight of competent 
opinion is against me ami greater exjHerienee will doubtless show 
me my mistake.) 

While learning the use of immediate auscultation it is best to 
close with the fingers the ear which is not in contact with the 
With practice one comes to disregard outer noises and does not 
need to stop the ear. 

Mkdiate Auscultation*, 

1, Stitrtian of a 3t§tk& 9 6op$ * 

(1) It is as rash for any one to select a stethoscope without first 
trying the tit of the ear pieces in his ears as it would be to buy i 
new hat without trying it on. What suits A* very well is quite im- 
possible for B. It is true that one can get used to almost . 
stethoscope as one can to almost any hat, but it is not necessary to 
do so. The ear pieces of the ordinary stethoscope are often too 
small and rarely too large. In case of doubt, therefore, it is better 
to err upon the side of getting a stethoscope with too large rather 
than too small ends. 

(-) The binaural stethoscope, which is now almost exclusively 
used in this country, maintains its position in the ears of the aus- 
cultator either through the pressure of a rubber strap stretched 
around the metal tubes leading to the ears, or by means of a steel 
spring connecting the tubes. Either variety is usually satisfactory, 
but I prefer a stethoscope made with a steel spring (see Fig. 51) 
because such a spring is far less likely to break or lose its elastic 
than a rubber strap. A rubber strap can always be added if this 
is desirable. It is important to pick out an instrument possessing 
a spring not strong enough to cause pain in the external meatus of 
the ear and yet strong enough to hold the ear pieces firmly in pl.t 
Persons with narrow heads need a much more powerful spring or 
than would l^e convenient for persons with wide heads. 



(3) The rubber tubing used to join the metallic tubes to the 
chest piece of the instrument should be as flexible as possible (see 
Fig, ol). Stiff tubing (see 
Fig. 52) makes it necessary 
I'm- tin- auseuitator to move 
his head and body Era 
place to place as the exam- 
ination uf 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 rawed, Stiff stetho- 
scopes are especially incon- 
venient when examining the 

(4) Jointed stethoscopes 
which fold up or take apart 
shonl d be scrupulously 
avoided. They are a delu- 
sion and a snare, apt to 
('unit' apart 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 stethoscopes made 
in one piece and possesses disadvantages which 
are peculiarly annoying. 

(5) The Chmt 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 very difficult to maintain in close apposition with thin 

Fin. flBL — Camtnin 
MftMMOpt with stiff 
Tubing and Rubber 

Fig. tt, — fttetb/Cttcope 
Fitted With Long 
Fleiible Tubes* Espe- 
cl*lij Cuffui Wfcen 
Examining Cblldivn. 


chests. To avoid this difficulty the chest piece is someti: 
of soft-rubber or its diameter still further reduced. 

^6) The Boohs Stethoscope* — (See Bigs. 83 and 54) W 
the last year there hits been introduced au instrument which* for 
moat purposes^ seems to me far superior to any other form of si 

scope with which I am acquainted. Its pe- 
culiarity is the chest piece, 
which consists 0l B very shal- 
low steel cup (se* Fig. 5B) 
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 when the 
latter is pressed against the 
cheat, and does not in any 
other way contribute bo the 
sounds which we hear with 
the instrument. Tins is 
proved by the Eaot that we 
can 1 1 ear as well even when 
the diaphragm is cr%eked 
a' ross in several directions. 
With this instrument al- 
most all sounds produced 
within the cl be heard 

Ife* BMW ^^muchmoredbtinrtlythunin 
**ii*j. Front view, -my other variety ut stetho- 
scope. Cftrdiac niuimurs 
which are inaudible with any other stetho- 
scope may be distinctly heard with this. Espe- 
cially is this true of low-pitehed murmurs 
due to aortic regurgitation. Yet it is useful for examination 
not merely of the heart, but of the lungs as well. For any 

Fiu. 54.— Ct*tn bl HMtl 
Bowles* SteLbosrope. 



who has difficulty in bearing tin? ordinary cardiac or respiratory 
sounds, or for one who is partially deaf, the 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 
til-' patient some discomfort and also tends to prevent the instru- 
*nt from slipping on the skin. The ft at chest piece makes tin* 
humeri t very useful in listening to the posterior portions of the 
lungs in eases of pneumonia in which the patient is too sick to be 
turned over or to sit up. Without moving the patient at all v 

Fi«t + K.-Ctae hew iM Btrntei" awewepupe. On tin* right the »ti&iiuw ruti Ltimiuijjifcitlng 
virh BkB ttr tatm. On Uir Uti Ui*? ilKipliruinu whW-h rover* thf cup, uatl the ring which 
bi.'Ms tl In pint*, 

work the chest piece In under the hark of the patient by pressing 
dnwn the bed-clothes, and in this way Bftft listen to any part of 
the chest without moving the patient. A further advant;> 
the instrument is that it enables us to gain an approximately ac- 
curate idea of the heart sounds without undressing the patient. Re- 
spiratory sounds cannot well be listened to through the clothes, 
as the nibbing Of the latter may .simulate rates, 

There are two purposes for which 1 have found the Howies 
•scope inferior to the ordinary stethoscope: 

(1) For listening over the apex of the lung for tine rales, e.*j. t in 
incipient phthisis* 

(2) For listening for mperjhiai sounds, such as a friction rub or 


a presystolic murmur, 1 When I desire to listen for fine rile & at 
an apex, for a friction rub, or for a presystolic murmur, I separate 
the cheat piece of the Howies stethoscope from the hard-rubber 
bell into which it is inserted, thereby converting the instrument 
into one of the ordinary form, With an extra hard- rubber bell 

attached, the instrument is 
no more bulky than an 
ordinary stethoscope, and 
far mure efficient, When 
used i'i ir listening to die 
respiration, the Bowie 
struinent gives us in forma- 
tion similar in some re- 
spect* to that obtained by 
the use of the free ear — 
that is, we are through it 
enabled to ascertain by lis- 
tening at one spot the ooa* 
ditinn of a much larger 
area of the chest than can 
in any other way be inves- 

Owing to the fact that 
both cardiac and respir 
sounds arc magnified I v fctu 
Bowles stethoscope, this 
instrument is especially 
adapted for use with stmn* 
sort of an attachment whereby several sets of ear pieces are 
joined by tubing to one chest piece that several persons may listen 
at once, Bowles' multiple stethoscope, fitted for six ami fur twelve 
observers, is seen in Figs oti and 57, and the method of its use in 

1 It has frequently been observed, when listening with die ordinary ttetba 
■cope, that a presystolic murmur can be better heard if only die very Hghl 
pressure is made with the steLhoseope. The fact that a thrill is communicated 
to the chest wall, and that that thrill Is connected with the audible murmur 
explains my calling tins murmur a superficial one, 

H'.. Ml 

Bowies' MuLUpli* KU-ihuset*]* for ^U £tu- 



Fig. 58, In the teaching of auscultation this instrument is of great 
value, saving as it does the time of the instructor and of the stu- 
dents and the strength of the patient. The sounds conducted 
through any one of the twelve tubes used in this instrument are 
as loud as those to 
be beard with a 
single instrument of 
the ordinary form, 
although far fainter 
than those to be 
heard with a single 
< thoscope. 

11 Tin Use nf the 

Having secured 
an instrument 
which tits the ears 
satisfactorily, the 
beginner may get a 
good ileal of prac- 
ti<*e by using it up- 
on himself, especi- 
ally upon his own 
1 >r Tl M "pf ^°' ^—Bowies' Multiple SteUioacope lor TwtflTe studeotfl. 

point to be learned is to disregard various irrelevant aoiimfo and to 

ritrate attention upon those which are relevant. Almost auy 

hears enough with a stethoscope, and most beginners hear too 

h. No great keeaness of hearing is required, for the sounds 

which we listen for are not, as a rule, difficult to hear if attention 

it concentrated upon them. 


A. Selective Attention and Wh*tt to Disregard. 

irdiugly, the art of using a stethoscope successfully depends 
the acquisition of two powers — 

A knowledge of what to disregard, (b) A selective atten- 


Hon or concentration upon those sounds which we know U> 

Among the sounds which we must learn to disregard aii 

(1) yoises produced ia the room or its immediate neighborhood, 
but not connected with the patient himself. It is, of course, easier 

Fju, 5&— BgwU-sT Multiple Suaboseop* jq Vm, Twelve tftudtnLs llsteuiciy ni yuiv 

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 dune in mor Jess noisy 

places, it is for the beginner a practial necessity to team to with- 
draw his attention from the various sounds which reach Iris ear 
from the street, from other parts of the building, or from the room 



in which he is working. This is at first no easy matter, but can 
be accomplished with practice, 

(2) When tin* power to disregard external noises has been ac- 
quired, a still further selection must be made among the sounds 
which com* to the ear through the tubes of the stethoscope. Noises 

• produced by frictiuu of the cheat piece of the stethoscope upon the 
skin are especially deceptive ami may closely simulate a pleural or 
peri card ial friction boumL It is well for the student to experiment 

■ upon t J l + • i il extent of wwh "skin rubs " by deliberately 

moving the chest piece of tin- stethoscope upon the skin ami listen- 
big to the sounds so produced, Mistakes can be avoided in the 
majority of cases by holding the chest piece of the stethoscope very 
firmly against the chest. This can be easily done when the patient 
is in the recumbent position, bttt when the patient is sitting up it 
may be necessary to preen so hard with the chesl place of the 
stethoscope ai to throw the patient oft* his balance unless he is in 

■ some way supported; aernn.lingly, 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 

I is pressed strongly against his chest. When listening 

to the back of the chest, the manoeuvre is reversed. If the skin 
in very dry, the ribs are very prominent, or the chest is thickly 
■■. ith heir, it may be impossible to prevent the occur- 
o4 adventitious sounds due to friction of the chest piece 
itj no matter how firmly the instrument is held. In 
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 
tnt where we desire to listen* should be moistened and any hair 
that may be present thoroughly wetted with a sponge, sn that it 
wiB lie Sat upon the chest. Otherwise the friction of the hair 
under the chest piece of the stethoscope may simulate crepitant 
closely as "skin rubs " simulate pleural friction. 
The friction of the ringers of the auscultator upon the chest 
or on some other part of the stethoscope frequently gives rise 
to s< minis closely resembling rales of one or another description. 
The nature of these sounds can be easily learned by intentionally 
ig the fingers upon the stethoscope. They are to be avoiled 


by grasping the instrument as firmly nlc, and by bouohi 

with as few tinkers us will suffice to hold it close against 

(4) Noises produced by a- shifting of the parts of the steiln'- 
scope upon each "tin r are especially frequent in stethoscopes made 
in si vera! pieces and jointed together A variety of snapping and 
cracking sounds, not at all unlike certain varieties of rales, may 
thus be produced, and if we are n<»t upon our guard, may lead to 
errors in diagnosis, Stethoscopes which have no hinges and which 
do not come apart are far less Likely t • v trouble us in this way. 

(5) When a rubber baud is used to press the ear pieces more* 
firmly into the ears, a very peculiar sound may be produced )• 
breathing of the auscultator as it strikes upon the rubber strap. It 
is a loud musical note, and may be confused with coarse, dry rales, 

When one has learned to recognize and to disregard the in 
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. Mu$ole Sound** 

Patients who hold themselves very erect while being exam- 
ined, or who for any reason contract the muscles of that portion of 
the chest over which we are listening, produce in these mufc< 
very peculiar and characteristic set of sounds. The contraction of 
any muscle in the body produces sounds similar in quality to those 
heard over the chest, but of less intensity. 

Those who have the faculty of contracting the tensor tympani 
muscle at will can at any time listen to a typical muscle sound. 
Or close both ears with the fingers and strongly contract the inus- 
seter muscle, with the teeth clenched, A high-pitched musrJe 
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 hear nothing but the breath sounds during expiration, 
while during inspiration the breath sound Is obscured by a series of 




are i 

short, dull, rumbling sounds, following each other at the rate of 
from five to ten in ft second. Occasionally the sound is like the 
puffing of the engine attaehed to a pile-driver, or like a stream of 
water falling upon a sheet of metal just slowly enough to he sepa- 
rated into drops and heard at a eon side rable distance. As already 
mentioned) we are especially apt to hear these nmsele sounds dur- 
ing forced inspiration, owine, to the contraction of voluntary mus- 
cles during that portion of the respiratory act. They are most 
often heard over the upper portion of the Hiest (over the pectorals 
in front and over the trapezius behind), but in some persons no 
of the sheet is free from them. It is a curious fact that we 

not always able tt> 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 1 ' rales are in reality due 
to muscular contractions. The adjectives u muffled " and " distant n 
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 

kling 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, hut have intended simply to call attention to the importance 
of studying them carefully. 

f. Other Sources qf Hfmr* 

Another source of confusion, which for beginners is very trouble- 
e, especially if they are using the ordinary form of stethoscope 
ith 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 hell is lifted 
from the skin at some point, or if one endeavors to listen over a 
yery uneven part of the chest on which the hell of the stethoscope 
cannot be made to rest closely, a roar of external noises reaches the 


ear through the chink left between the chest piece and the 
After a little practice one leant! blatantly to detect this 
of things and so to shift the position of the chest piece thai 
ual noises axe totally excluded ; but by the beginner, the pe 
babel of external noises which is heard whenever the stetho 
fails to fit closely against the chest is not easily re 
hence he tends to attribute same of these external sounds to di 
conditions within the cheat. 

Again, it is not until we have had considerable practice that 

Fig. ]Jfc-&ust)jo*»pe Held litem si 

FiO. tit). -Stethoscope Held Wrong SUe Up 

our sense of hearing comes instantly to tell us when something is 
wnmg about the stethoscope itself; when, foi example, one of the 
tubes is blocked, kinked, or disconnected, or when we are huM- 
:ie stethoscope upside down, so that the car pieces point 
downward instead of upward (see Figs, 09 and 60). If i 
when we have learned through long practice about how much we 
■ > ighl ,\t a given point in the normal chesr thsl we rec 

at once the fact that we are not hearing as much a* we should^ in 
case some one of the above accidents has happened. Many b 
ners do not listen long enough in any one place, but move the cheat 
pieee of the stethoscope about rapidly from point to point, as thej 
have seen experienced auacultators do ; but it is remarkable how 
much more one can hear at a given p imply persevering 


listening to beat after beat, or breath after breath. It is sometimes 
difficult to avoid the impression that the sounds themselves have 
grown loaders* ye eontiuue tu listen, especially if we are in any 
doubt as to what we hear. Therefore, if we hear indistinctly* it is 
important to keep on listening, ami to fix the attention suceessively 

■ ■aeh oi the different elements in the sounds under on m lii i- ration. 
In difficult cases we should v possible aid toward concen* 
tration of the attention, and where it is possible, all sources of dis~ 
traction should 1** eliminated. Tims, in any ease of doubt, 1 think 
it is important for the auscul*atjr to got himself into as comfort- 
able a position as he can, so that his attention is not distracted by 

'vu physical discomforts. Many auscultatory shut their eyes 
when listening in a difficult case so as to avoid the distraction of 
impressions coming through the sense of sight. It goes without 
mg that if quiet can be secured in the room where we are work- 

I. nd outside it as well, we shall be enabled to listen much more 
In the majority of eases ordinary quiet breathing is not forcible 
enough to bring out the sounds on which we depend for the diag- 
of the condition of the lungs. Deep or forced breathing is 
hat we need. 

La a rule, tin- patient must be taught how to breathe deeply, 

hich is best soocmplifihed by personally demonstrating the act of 

.. and then asking him to do toe same. Two difflcnl- 

ae encountered: 

(a) The patient may blow out his breath forcibly and with a 

since that is what he is used i i he takes a 

long breath under ordinary ci tnuuatawes ; or 

(h) It may be that lie cannot 06 madfi to lake * deep breath at 
all. The tirst of these mistakes alters the sounds tu be in sod with 

■ thoseo|M* in any pari of th< ahesl i>y disturbing both the 
rhythm and the pitch of the respiratory sounds In this way the 

be chad.' to sound tabular or asthmatic throughout a 

iouml chest. This difficulty can sometimes be overcome by demon- 

trating to the i >:tt ii-n t that what you desire is to have him take a 


full breath and then simply fc fit 00, but m)/ blow it forcibly out. 
In aonir cases the patient cannot be taught this, and we have to get 
on the best we can despite his mistakes. When he cannot be made 
to take a full breath at all, w T e can often accomplish the desired re* 
suit by getting him to cough. The breath just before and after a 
cough is often of the type we desire. The use of voluntary cough 
in order to bring out rales will be discussed later on. Another use- 
ful manoeuvre 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 whirh we desire. 

L Respiratory Types. 

In the normal chest two types of breathing are to be heard : 

(1) Tracheal, bronchial, or tubular breathing. 

(2) Vesicular breathing. 

Tracheal, bronchial f or tubular breathing is to be heard in normal 
cases if the stethoscope Is pressed against the trachea, and as a rule 

Fro. 61 -Situation of the TnwtKa and Primary Bronchi. 

it can also be heard over the situation of the primary bronchi, in 
front or behind (see Figs. 61 and 62). 

Venintftir hrmt king is to Ik* heard over the remaining portions 



lung— that is, in the front of the thorax except where the heart 
and the liver come against the chest wall, in the back except where 
the presence of the scapula? obscures it, and throughout both axilke. 

(1) Characteristics t*f Vtofadar Breathing, 

Vesicular breathing— that heard over the air vesicles or paren- 
chyma of the lung— has certain characteristics which 1 shall try bo 
inscribe in terms of intensity, duration, and pitch. 

Ftc. as. -Situation of tin* Traohea and Primary Bronchi, 

Of the quality of the sounds lieard over this portion of the lung 
is little can be said ; it soandfl something like the swish oi the 
wind in a grove of trees some distance off, and hence is sometimes 
spoken of as " breezy, M 

The intensity, duration, and pitch of the inspiration as compared 
with that of the expiration may be represented as in Fig, (.1.;. In 
tltis figure, as in all those to be used in description of respiratory 
sounds — 

(1) I represent tlie inspiration by an up-stroke and tin- expira- 
tion i>y a down-stroke (see the direction of the arrows in Fig 63), 
Tin- length of the up-stroke as compared with that of the 
Stroke correspond a t<> the length of inspiration compared with 



(3) The thickness of the up-stroke as compared with the down- 
stroke represents the intensity of tin- inspiration as compared with 
rlit- expiration. 

(4) The p'ttih of inspiration as compared with tliat .-t expi- 
ation is represented by the $harpne#g of the utujh which the up- 

Tia. *J. -Vesicular Bmth- 

Fro. **.- Distant Vesicular 

Fto- &. K\*tntrrw*l V«- 

stroke makes with the perpendicular as compared with that which 
the down-stroke makes with the perpendicular. The pitch *>/ » 
roo/mAy be thought of in this connection to remind ns of thfi n» rul- 
ing of these symbols. 

If now we look again sit Fig. if:; we see that when compared 
with expiration (the down-stroke), the inspiration is- — 

(a) More intense. 

(b) Longer. 

(r) Higher pitched* 

Our oamparisun is in variably made between inspiration and ex- 
piration, and not with any other sound as a standard. 

Now, this type of breathing (which , as t have said, is to be 
heard over every portion of the lung exeept thus*' portions imme* 
diately adjacent to the pr unary bronchi), is not heard every where 
with equal intensity. It is best heard below the clavicles in front, 
in the axilhe, and below the scapula 1 behind, bat uver the thin, 
lower edges of the lung, whether behind or at the sides, it is 
feebler, though still retaining its characteristic type as revealed in 
the inspiration and expiration in respect to intensity, duration, and 
pitch. To represent distant vesicular breathing graphically we 
nave only to draw its symbol on a smaller scale (see Fig. 04; t On 



other hand, when one tied the Lungs oi a pewon irhc has 

been exacting himself strongly* one heats the same type of n spira- 
HoS| bat un a target teaie, which may then be represented as in 

kS. This last symbol may also be used to rep re sent the respi- 
i Lit h mi which we hear over norma] hut thin-walled chests; for ex- 
ample, in children or in emaciated persons. It is sometimes known 
iggeiatrd" 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 increased 
and seem to be produced on a larger scale* Such breathing is sonii j - 
tlmeB spoken of as M rough n breathing, 

It is very important to distinguish at the outset between the 
d iffe r en t type* at breathing, one of which I have just described, and 
the different degree* of loudness with which any one type of breath- 
ing nniv be beard. 

TJ i Bronchial **? Tracheal Breathing in Health* 

Bronchial breathing may be symbolically represented as in Fig. 
Oti, in which tbe increased length of the down stroke corresponds 
to the increased duration of expiration , and the greater thick hcns 



Tin i iift.-Rn.whb1 Breath - 
Moderate Intensity. 

FIG- ti7* — Distant Br^nrfaiHl 

Flu, 6ft.— Verv Loud Hrun- 
i-blul BrratblQtf. 

of both lines corresponds to the greater intensity of both sounds, 
expiratory and inspiratory, while the sharp pitch of the "gable" on 
l^th sides of the perpendicular corresponds to the high pitch of 
both sounds, Expiration, it will be noticed, slightly exceeds inspi- 
• at imi both in intensity and pitch, and considerably exceeds it in 
duration, while as compared with vesicular breathing almost all the 


relations are reversed, Bronchial breathing has also a peculiar 
quality which can be better appreciated than described. 

In the healthy chest this type of breathing is to be heard ij 
listens over the trachea or primary bronchi (see above. Fig, jft), 
hut practically one hardly ever listens over the trachea and bronchi 
except by mistake, ami the importance of familiarizing one*s self 
with the type of respiration heard over these portions of the ehc 
is due to the fact that in certain diseases, especially in pneuinonii 
and phthisis, we may hear bronchial breathing over the petreneht 
of the lung where normally vesicular breathing should be heard. 

The student should familiarize himself with each of these typefl 
of breathing, the vesicular and the bronchial, concentrating 
tention as he listens first upon the inspiration and then upon the 
expiration, and comparing them with each other, first in dura! 
next in intensity, and lastly in pitch. To those who have not a 
musical ear, high-pitched sounds convey tin' general impression of 
being shrill, while low-pitched sounds sound hollow and empty, 
the distinction between intensity and pitch is one comparatively 
difficult to master. Distant bronchial breathing may be repre- 
sented in Fig, 67* and is to be heard over the back of the neck 
opposite the position of the trachea and bronchi. Fig, r,s repre- 
sents very loud bronchial breathing such as is sometimes heard 

(3) Broncho- Vesicular Breathing m Health* 

As indicated by its name, this type of breathing is intermediate 
between the two just described, hence the terms "mixed bfei 
ingj " or " atypical breathing " ( f< unbestimint "). Its characteristic* 
may be symbolized as in Fig, U9. In the normal chest one can be- 
come familiar with broncho -vesicular breathing, by exam inn 
apex of the right lung, or by listening over the trachea or one i »i th. 
primary bronchi^ and then moving the stethoscope half an inch at 
a time toward one of the nipples. In the course of this journey 
one passes over points at which the 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 



moving. Expiration is a tittle longer, iutenser, or higher pitched 
than in vesicular breathing, and inspiration a little shorter, feebler, 



Ft<k i».-Two Common Tnws of Brom-bo- 


Vesicular RretUriiir, 

A f 

TU^DIsliiiit Brosacbo-Veskular Bmuii- 

lower pitched; but since these characteristics are various!} 1 ' com- 
bined, there are many subvarieties of broncho-vesicular breathing. 
Fig. 70 represents two types of distant broncho -vesicular breath* 

(A) Emphysematous Bn-ttthhtg, 

A glance at Fig, 71 will call up the most important features of 
lis type of respiration. The inspiration is short and somewhat 
feeble, but not otherwise remarkable. The expiration is long, 
le, and low pitched. This type of breathing is the rale in 
riy persons, particularly those of the male sex* 

i 6) . isth m a t >> i Bn w t ft ht*j. 

Fig. 72 differs from emphysematous only in the greater intensity 
of the inspiration. In this type of breathing, however, both sounds 

Fig. 7) — Emphysematous Birthing. 


.- AsthinaUr Enjat&ing, * t *, #. 
S()ii«-nklnp (musical) ralea. 

ire usually obscured to a great extent by the presence of piping and 

squeaking rales (see below). 


(i\) Jtttt frt<ftttt? *>r k * CfHjtrhrtl " Br&Ukinff. 

As ;■ nth-, .inly tlu* inspiration ia interrupted, being transform red 
into a series of short, jerky puffs us shown in Fig. 73. Very rw 
the expiration is also divided into segments. When heard over the 

, cheat, cogwheel breathing is usually the result of ctejra 
uaaa } I'uiigne, or rhillim «a on the patients part. With the removal 
of these causes this ty [ »* * 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 


Fir., Ta,-Co|rwhfeL Hmdilng. 

Fin. T4 — Metamorphosing Braittiitiir. 

fatigue, nervonsneaHj or cold, it points to a local catarrh in the fine] 
bronchi such aa 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 sign iiieai ice- similar to that of rales or other signs of 
localized bronchitis (sec Indmv). 

(T) Amphoric w Cavernous Breathing (see below, p 107 i. 

(8) Metamorphosing Brwthing* 

Occasionally, while we are listening to an inspiration of normal 
pitchy intensity, and quality, a sudden metamorphosis occurs and the 
type of breathing changes from vesicular to bronchia] or amphoric 
(see Fig. 74^, or the intensity of the breath sounds may suddenly 
be increased without other change These metamorphoses are usu- 
ally owing to the fact that a plugged bronchus is suddenly opened 
by the force of the inspired air, so that the sounds conducted 
through it become audible. 



Pllh1.Kl\<l^ i'.IMVSI^N THE Twn SlIiH* OF THE ClIEST. 

Over the ajwx uf the right lung— that is, above the fight clavi- 
cle In '1 above the spine of the mgrala behtad— one hears 
ill the great majority of normal chests a distinctly broncho-vesicu- 
lar type of breathing. In a smaller number of cases this same 
t v ] m - ol breathing may be heard just below the right clavicle 
These facta oannot be too strongly insisted upon, since it is only 
fay bearing them in in nut that we can avoid the mistake of diagnos- 
ing a beginning consolidation of the right apes where Gone exists. 
Broaih Bounds whicA m tty normal war the nffhi apex would 
moan serious disease \f heard over similar portions of th*' left tuna. 
It will he remembered that the apex ol the right lung is also duller 
on percussion than the oomepoadlng portion of the left, and that 
the v.nee st muds and tactile fremitus are normally more intense on 
the right (see Fig, 32). 

Occasionally one finds at the base of the right lung posteriorly 
a slightly feebler or more broncho- vesicular type of breathing than 
in the corresponding portion ol the left lung. 

III. Pathological Modification* of Vehicular Breatimm, 

Having now distinguished tin* different types of breathing atui 
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) Ejroijf/t ft/ft rfttr lirwthittff ("Compensatory 91 Breathing). 

(a) It has already been mentioned that in children or in adults 
with very thin and flexible cheste the normal breath sounds are 
With relatively great, distinctness; also that after any exer- 
tion which leads to abnormally deep and forcible breathing a simi- 
tar increase in the in tensity of the respiratory sounds naturally 

($) The term "compensatory breathing!** or " vicarious " breath- 
ing, refers to vesicular breathing of an exaggerated type, such as is 
heard, for example, over the whole of one lung when the other lung 


is thrown out of use by the pressure of an accumulation of air or 
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 pleuritic effusion, or 
a contraction of the bones of that side of the chest such as occurs 
in spinal curvature. 

(2) Diminished Vmfotikw Ih-vuthing. 

The causes of a diminution in the intensity of the breath sounds 
without any change in their type mv. very numerous. I shall men* 
turn them in an order corresponding as nearly as possible to the 

I ive frequency of their occurrence, 

(a) Fluid, Air f or Solid in the Pleural Camty* — 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 ocuvs in inflammation of the pleura or by transudation (hydm- 
thorax). In such cases the layer of fluid intervening between the 
lung and the stethoscope of the auscultator causes retraction of the 
lung so that little or no vesicular mui-mur is produced in it, and 
hence done is transmitted to the ear of the auscultator. An ac- 
cumulation of air in the pleural cavity (pneiunothoraK) 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 sounds feeble or prevent their being heard because the 
vibrations of the thoracic sounding-board are thus deadened. Which - 
ever of these causes, fluid or air or solid, intervenes between the lung 
and the ear of the auscultator, the breath sounds are deadened or 
diminished without, as a rule, any modification of their type. The 
amount of such diminution depends roughly on the thickness of the 
layer of extraneous substance, 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 produce complete atelectasis 
of the lung or to deaden the vibrations of the chest wall* 



(b) B mph&mna of the tuny, by destroying its elasticity and re- 
ducing the extent of its movements, makes the breath sounds rela- 
tively feeble, but seldom, if ever, abolishes them altogether* 

(r) In bronchitis the breath sounds are usually considerably di- 
minished owing to the tilling up of the bronchi with secret inn. 
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- 
tort 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 hi listen- 
ing thntufjh ike rSUi i^> the breath sounds themselves, we usually 
notice that they are very feeble, especially over the lower two- 
thirds of the chest. (Edema of the iungm&y diminish the breath 
s« Hinds in a similar way. 

(*/) JPain in the tAortfigj 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 
, 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) Orr/tfMtntt of the H/t/wr 'trr /^/.wwynv, 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 from without, 
we get a unilateral en feel dement 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* 
men t of the breathing. 

It should be remembered, when estimating the intensity* 01 ':e 
breathing, that the sounds heard over the right lung are, as a rule, 
slightly more feeble than those heard over the left lung in the 
normal chest. 

km; fhi*sical diagnosis of diseases of the chest. 

IV. Kkonciual ob Tubular Breathing is* Di*kahe. 

{a) I haw already described the occurrence * *t bronchial breath- 
ing in parts of the normal chert, namely, over tin- trachea and pri- 
mal v bronchi. In lu-.inehial breathing may be heard clse- 
wlu'K- in the chest, ami usually points to solidification t>f that portion 
of lung from which it is conducted. It is heard most commonly in 
phihUU (set- below, p. 251 }. 

(i>) Croupous pneHMWiia is probably the next moat frequent 
cause of hronehial breathing, although by no means vwry ease of 
croupous pneumonia shows this sign. For a more detailed account 
of the conditions tinder which it does or does not occur in < nun 
pneumonia, see below, p, 245. Lobular pneumonia is rarely mani- 
fested hy tubular breathing. 

(?) In about one-third of the eases of pleuritic effusion distant 
bronchial breathing i* to be heard over the fluid On account of 
the feebleness of the breath sounds in such oases tiny at< often 
put down as absent, as we are bo accustomed to associate inter 
with the bronchia] type of breathing* One should be always nti 
the watch for any degree of intensity of bronchial breathing from 
the feeblest to the most distinct. 

(dj Rarer oau&ei 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. B&onoho-Yesii > LAii RuEATinsvf is* Drsi 

Respiration of this type 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 broneho-vesicular 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 eases 
of pleuritic effusion, one can usually hear broncho-vesicular breath- 


ing ov.q Th.- upper portion of the affected side, owing to (fa ntrac 
Hon of the lung at that point 

VI, Amphouic Ukkathiv*; [Amphora — AJae). 

pirations having a hollow, empty Bound like that produced 

hy blowing across the top of a bottle, air occasionally heard in dis- 

[lulniouary ca .;/. , in phthisis) OC in piHumnthorax, 

i*.r., under conditions in which tin- ail 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, futf thai qf&p&ration 

l&wrr then thtt of inspiration. The intensity and duration of the 

La varv, and the distinguishing mark is their quality which 

iiiblee that of a whispered a wkaJ* 


The term "i-Sles " is applied to sounds produced by the passage 
of air through bronchi which contain mucus or pus, or which are 
narrowed hy swelling of their walla. ' Rales are best classihVrl as 

(1 i Moist or babbling riles, including i") coarse, (/*j medium, 
and (<■) fine i 

! h v ..1 crackling rales (large, medium, or fine). 

Tli- this type are known as "'crepitant" or 

*euberepitant " rales, 

(3) Musical rales (high or low pitched). 

Eaih of these varieties will now be described more in detail. 

I I i Moist or Bubbling /tales. 

The nature of these is sufficiently indicated by their name. 
i largest bubbles are those produced in the trachea, 
and ordinarily known as the %t dmth rattle," Tracheal rales occur 

» Kales are of all auscultatory 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 a&atnst the skin or against the 
fingers of t] e observer. (See above, pa#e Wl.) 


IB any condition involving either profound unconsciousness or very 
tfivai weakness, so that the secretions which accumulate in the 
tni< a hca 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 stethoscojR 1 . In rutarrh of the larger 
bronchi large bubbling rales are occasionally to be 
heard. In phthisical cavities one sometimes lieara 
004*96, bubbling rales Ola reiy metallic and gurgling 
quality (see below, ]«. 268). The finer grades of moist 
rales correspond to the liner bronchi. 

In the majority of eases moist rales are most ruuu&r- 
ous during inspiration and especially during the latter 
part of this act. Their relation to respiration may 1*' 
represented graphically as in Fig, 7^. using large dots 
for coarse eflttfifl and small dots for line rales. Mm- 
rales can be symbolized by the letter 6* (squeaks). 

KitJ- ;.V-£f(>k>- 
slon of Floe 
HAlw at End 
of Inspiration. 

(2) Cratklinf EMm* 

These differ from the preceding variety merely by the ah&eilOB 
of any distinct bubbling quality, They aiv usually to be heard in 
cases of bronchitis in which the secretions are unusually tmwcuMM 
trti'l r lucid. They are especially apt to come at the end of inspira- 
tion, a large number being evolved in a vny short spare of time, BO 
that one often speaks of an "explogion of tine crackling rtles^at 
the end of inspiration. Crackling rales are to be heard in any on« 
of the conditions in which bubbling rales occur, but are inore fre- 
quent in tuberculosis than in simple bronchitis. 

Cn-jiitatd rates, which represent the finest sounds of this type, 
are very much like the noise which is heard when one takes a l*"k 
of hair between the thumb and first finger and rubs the hairs upon 
each other while liolding them close to the ear. A very large num- 
ber of minute crackling sounds is heard following each other in 
rapid succession. To the inexperience d ear they may seem to bin id 
into a continuous sound, but with practice the component parts may 



be distinguished. This type of rales is especially apt to occur dur- 
D alone, but nut reiy infrequently they are heard 
during expiration as well- From suberepitant rules they are dis- 
tinguished merely by their being still finer than the latter/ Sub- 
\int rales are often mixed with sounds of a somewhat coarser 
typ>\ while crepitant rales are usually all of a size. If the 
is covered with hair* sounds precisely like these fcwo varieties 
of rales maybe heard when the stethoscope is placed upon the hairy 
is. To avoid mistaking these sounds for rSles one must 
thoroughly wet or grease the liaii , 

Crepitant Rules in Atelectasis* 

Crepitant and suhetepitant rales are very often to be heard along 
the thin margins of the lungs at the base of the axilhe and in the 
bark, especially when a patient who is breathing superficially Gift 
begins to take deep breaths. In such cases* they usually disappear 
after Hie lew hot respiration^ and are then to be explained by the 
tearing apart of the slightly agglutinated surfaces of the liner bron- 

It is by n<< means invariably the case, however, that such sub- 
c re pi taut rales are merely transitory in their nr.nrrenee. In a large 
number of cases they persist despite deep breathing. The fre- 
queiicy of suberepitant rales, persistent or transitory, heard over 
the inferior margin of the normal lung at the bottom of the axilla, 
is shown by the following figures: Out of 35b' normal chests to 
which T have listened especially for these rales, 1 found 228, or 61 
j>er cent, which showed them on one or both sides. They are very 
rarely to to heard in persons under twenty years of age. After 
f.irty-rtve, OB the Other hand, it is unusual nnt to rind them. 
It i my experience they are considerably more frequent in the situa- 
1L*7 than in any other part of the itsng, but they 
s occasionally heard in the back or elsewhere. In view o£ 

1 A distinction wo* formerly drawn betweeu crepitant and aubcrepiunt 
riles, on the ground liint the latter w^re heard during both respirator}- sounds 
and the former only doting Inspiration, but this distinction cannot be main- 
tained and U gradual iy beinir given up. 


these facts, it seems to me that we must recognize that it is almost 
if nut quite physiological to find tin.- finer varieties of crackling 
rales at the base of the axilla* in persons over forty years uld. I 
have supposed these rales to be due to a partial atelectasis result- 
ing from disease in the thin lower margin of the lungs* Such por- 
tions of the Jung are ordinarily not expanded unless the respiration* 
are forced and deep. This explanation would agree with the obser- 
vations of A brains, to which I shall refer later (see below, p. 

(A) Crepitant or subcrepitant rales an also to he heard in a 
certain portion of eases of pneumonia, in the very earliest stages 
and when resolution is taking place ("crepitans redux"), More 
rarely tins type of rain may 1m? heard in connection with tubercu- 
losis, infarction, or oedema of the lung* 

In certain cases of dry pleurisy there occur fine crackling 
Bounds which oan scarcely be differentiated from subcrepitant rales. 
I shall return to the description of them in speaking el pleural 
friction (see below* p. 278). 

(3) Musical tin let* 

The passage of air through bronchial tubes narrowed by inthmi* 
matory swelling of their lining membrane (bronchitis), or by spas- 
modic contraction (asthma), gives rise not infrequently to a mul- 
titude of musical sounds. Such a stenosis occurring in relatively 
large bronchial tubes produces a drep-toued groaning sound, while 
narrowing of the finer tubes results \\\ piping ^ BQueakingj whfctHng 
noises of various qualities. ♦Such sounds are often known as n dry 
ru/ejt" in contradistinction to the "bubbling rnfes" above described, 
but as many non-musical crackling rales have also a very dry sound, 

ma to me best to apply the more distinctive term u m\ 
ntisi ? ' to all adventitious sounds of distinctly musical quality which 
are produced in the bronchi* Musical rales are of all adventitious 
sounds the easiest to recognize but also the most fugitive ami 
changeable, They appear now here, now there, shifting from min- 
ute to minute, and may totally disappear from the chest and reap- 
pear again within a very short time. This is to some extent true 
of all varieties of rales, but especially of the squeaking and groan- 
ing varieties. 



Musi ciil riles are heard, as b rule, more distinctly during expira- 
tion, especially when they occur in connection with asthma or ein- 
ua. In these diseases one may bear quite complicated chorda 
from tin* combinations uf ralen which vary in pitch. 

VII. Thi Effects *»k Couob. 

The lunaem-i- of coughing upon rales Is usually very marked. 

effect may he either to intensify them ami bring them out where 
tin v hive not previously l>een heard, or to cleat them away alto- 
gether. Other effects of coughing apor physical signs will be 
mentioned later on in the chapters on Pneumonia and Phthisis. 

VI II. PmwjRAii Friction. 

The surfaces of th* j healthy pleural cavity are lubricated with 
sufficient serum to imike them pass noiselessly over each other dur- 
ing the movements of respiration, Bat when the tissues become 
abnormally dry, as in Asiatic cholera, or when the serous surfaces 

roughened by the presence uf a fibrinous exudation, as in ordi- 
nary pleurisy, the nibbing of the two pleural surfaces against one 
another produces peculiar and very characteristic sounds known as 
u pleural frit&i&n sounds." The favorite seat of pleural friction 
sounds is at the bottom of the axilla, I.e., where the lung makes 
tie Widest excursion and where the costal and diaphragmatic pleura, 
are in close apposition (see Fig, 33). In some eases pleural frie* 
h nit soxuidi are to be heard altogether below the level of the lung. 
In others they may extend up several inches above its lower mar- 
gin, and occasionally it happens that friction maybe appreciated 
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 

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 palui of 
one himd over tie- ear and rubbing upon the back of this hand with 



tlie fingers of the other Pleural friction ia usually a catchy 
jerky, interrupted, irregular sound, and is apt to occur during in- 
spiration only, and particularly at the end of this act. It may, 
however, be heard with both respiratory acts, but rarely if ever 
occurs during expiration alone, The intensity and quality of the 
sounds vary a great ileal, so that they may be eumpared to y/v,tfV/« 
ruhititiffj r<i.:j>ui<j, And ormMng Bounds, They are sometime^ spoken 
of as u leathery J* As a rule, they seem very near to the ear, and arc 
sometimes startlingly loud. In many eases they cannot be heard 
after the patient lias taken a tew full breaths, probably becauae the 
roiitfh pleural surfaces ait 5 smoothed down temporarily by the frie 
tion which deep breathing produces* After a short rest, h*»v 
and a period of superficial breathing, pleural friction sounds 
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 had 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, edse 
rubbing sounds may thus be produced which perfectly simulat* 1 
pleural friction. In well-marked cases pleuritic friction can be 
fvH if the pabn of the hand is laid over the suspected area; occa- 
sionally the sound is so loud that it can be heard by the patient 
himself or by those around him. 

In doubtful cases, or when a friction sound appeal's to have 
disappeared, and when one wishes to bring it out again, there 
several manoeuvres suggested by A brains for obtaining this em* 

(a) Thr Arm Manoeuvre. 

The patient suspends respiration altogether, and the arm ii] 
the affected side is raised over the head by the patient himself or 
by the physician, as in performing Sylvester's method of artificial 
respiration . During this movement we listen over the suspected area . 
"By this manoeuvre the movement of the parietal against the vis- 
ceral pleura is opposite in direction to that occurring during the 



respiratory wt f and fur this reason the pleuritic sound may often 
be elicited after it has been exhausted in the ordinary act of breath- 


(b) The Decubital Manoeuvre. 

"Let the patient lie upon the affected side for a minute or two, 
then let him rise quickly and suspend respiration. Kow Listen over 
the affected area, at the same time directing the patient to take a 

Pleuritic friction sounds are distinguished from rales by their 
greater superficiality, by their jerky, interrupted character, by the 
foot that they are but little influenced by cough, and that they are 
increased by pressure* It hati already been mentioned, however, 
that there is one variety of Bounds which we have every reason to 
think originate in the pleura, which cannot be distinguished from 
certain varieties of crackling bronchial rales. Such Bound* Doom 
chiefly in connection with phthisical processes, in which both pleu- 
risy and bronchitis are almost iu variably present, and it is seldom 
of importance to distinguish the two* 

IX, Auscultation" of tup: Scokex or Whispered Voice Sorxus. 
The more important of these is: 

(a) Tin* WhUpered Foioe. 

The patient is directed to whisper "one, two, three," or 
* ninety-nine, 11 while the auscultator listens over differecnt portions 
of the chest to see tow] <■ the whispered syllables are trans- 

it In the great majority of normal chests the whispered 
is to be heard only over the trachea and primary bronchi in 
front and behind,' while over the remaining portion* of the lung 
little or no sound is to Ije heard. AVhcn, on the other hand, solidi*- 
« of the lung is present, the whispered voice may be dis- 
tinctly heard over portions of the lung relatively distant from the 
d bronchi; for example, over the lower lolies of the lung 
behind. The usefulness of the whispered voire in tbe search for 
small areas of solidification or for the exact boundaries of a solidi- 


Bed area is ve it great, especially when we desire to an atiOBl 

the pain and fatigue of taking deep breathe. Whispered voice 
sounds are practically equivalent to a forced expiration and can be 
obtained with very little exertion on the patient's part, The in- 
creased transmission of the whispered voice is. in my opinion, a 
more delicate best for solidification than tubular breathing. The 
hitter sign is present only when a considerable area of luui, r 
is solidified, while the increase of the whispered voire may be ob- 
tained over inneh smaller areas. Retraction of tin* lung above the 
level of a pleural effusion causes a moderate increase in the trans- 
mission ui the whispered voice, iuul at times this increased or bron- 
chial whisper is to be heard over tin- fin id its* If, probably by I 
mission from the compressed Long above. 

Where the lung is completely solidified the whispered words 
may be clearly distinguished over the affected area. In lesser de- 
gree* of solidification the syllables are more or less blurred, 

(&) The Sfrokm Vote** 

Tlie evidence given us by listening 6or the spoken voice in vari- 
ous parts of tin- chest is considerably less in value than that obtained 
through the whispered voice. As a rale* it corresponds with the 
tactile fremitus, being increased in intensity by the same causes 
which increase tactile fremitus, viz., solidification or condensation 
of the lung, and decreased by the same causes which decrease tac- 
tile fremitus — namely, 1 »> the presence of air or water in the pleu- 
ral cavity, by the thickening of the pleura itself, or by an ob- 
struction of the bronchus leading to the part over which a 
listening. In some cases the presence of solidification of the lung 
gives rise not merely to an increase in transmission of the spoken 
70006; but to B change in its quality ^ so that it sounds abnormally 
concentrated, nasal, and near to the listener's ear. The latter 
change may \»' heard over areas where tactile fremitus is not in- 
creased, and even where it is diminished. Where this ehai. 
the quality of the voice occurs, the actual words spoken can often 
be distinguished in a way not usually possible over either norma) 
or solidified lung. " Bronchophony, n or the distinct transmission 



audible words, and not merely uf diffuse, unrecognizable voice 
sounds, is considerably commoner in tin- aolidifi cation* due to pneu- 
monia than in those due to phthisis; it occurs in some cases of 
pneumothorax and pulmonary cavity. 

(c) Egvph&ny. 

A teQ&g tin- least important of the classical physical signs is a 
nasal or squeaky quality of the sounds which reach the observers 
ear when the patient speaks in a natural voice. To this peculiar 
quality of voice the name of "egophony " has been given. It is 
most frequently heard in eases of moderate-sized pleuritic effusion 
just about the level of the lower angle of the scapula and in the 
vicinity o! that point. Less often it is heard at the same level in 
front, It is very rarely heard in the upper portion of the Qa£fit 
and is by no means constant either in pleuritic effusion or in any 
other condition. A point at winch 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 
jlowtl. The presence of egophony is in no way distinctive of pleu- 
ritic effusions and may be heard occasionally over solidified lung. 

X. Phenomena Peculiar to PlfEUMOHTDBOTHOBAX and PNEU- 


(1) Succussi&n. 

v and then a patient consults a physician, complaining that 
he hears noises inside him as if water were being shaken about. 
One sncli patient expressed himself to me to the effect that he 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 theu shakes 
the whole patient strongly, one may hear loud splashing sounds 
known technically as u succutsioft." Such sounds are absolutely 
diagnostic of the presence of both air and fluid m the cavity over 
which they arc heard. Very frequently they may be detected by 
the physician when the patient is not aware of their presence. Oc- 

in; pm"srcAL diagnosis of diseases of the chest. 

caaiotuilly \ha splashing of the fluid within may be felt as well as 
heard* It U essential, of course, to distinguish suceussion due to 
the presence of air and fluid in the pleural cavity from similar 
sound s produced in the stomach, but this is not at all difficult in 
the majority of oaaet. It is a bare possibility that succussion 
sounds may lie due to the presence of air and fluid in the pericar- 
dial cavity. 

It is important to remember that suecuasion is never to be 
heard in simple pleuritic effusion or hydrothorax. The presenoe of 
air, as well as liquid, in the pleural cavity is absolutely essential to 
the production of succussion sounds. 1 

.', MeteUk Tfokk ot FaUing-Drop Sound. 

When listening over a pleural 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, and possibly to rales produced in the tissues around the 
cavity. It is stated that this physical sign may m rare cases be 
observed in larj^e-sized phthisical cavities as well as in pneumohy- 
drothorax ami pneumopyothorax. 

(3) The Littit r F*'*ttt?rr Sound. 

When a perforation of the lung occurs below the level of the 
fluid accumulated in the pleural cavity, bubbles of air may be 1 
out from the lung and up through the fluid with a sound reminding 
one of that made by children when blowing soap-bub I 

1 It i« well for the student to try for himself the following experiment, 
-winch I have found useful in impressing these fads upon the attention of 
classes in physical diagnosis: Fill an ordinary rubber hot- water bag U* the 
brim with water. Invert it ami squeeze out forcibly a certain amount <[>er- 
haps half) of the contents, by grasping the upper end of the hag and compi t.*}*- 
ing It, While the water is thus being forced out, screw in the nozzle of the 
hag, Nov shake the whole bag t 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 n and loud splashing will be easily heard. 

In* the routine 
in four places; 

(1) At the apex of the 
the nipple, the ■ mitral 



I- -TiiTB A mr t».™ 
of the 

Aortic an?*. *' 

no, ^.-Tbe Vain* An**. 

(2) In the second left intercostal spate near the sternum, the 
"jjulmoHu: area," 

(3) In the second right intercostal space near the sternum, the 
^ tu),'tw area," 

(4) At the bottom of the sternum near theensifunn cartilage, 
tilt.' H tricuspid area J* 

These points are represented in Fig, 7ii and are known us 


u valve areaM.* They tit* tmt correspond to the anatomical \*> 
of any one of the four valves, but experienee hits shown that sounds 
heard best at the apex can be proved (by post-mortem exami: 
Of otherwise) to be produced at the mitral orifice. Similarly sounds 
heard best in the second Left intercostal Bpaoe are proved to U* 
produced at the pulmonary orifice; those which are loudest at the 
seoond right intercostal space t<> be produced at the aortic orifiVe;' 
while those which are most distinct near the origin of the ensifonu 
cartilage are produced at, the tricuspid orifiee. 

IL TllK NOHMAL HkauT Khi \; 

A glance at Fig, 77. which represents the anatomical positions 
of the four valves above referred to, illustrates what I said above; 
namely, that the traditnui m-rus *U* nol correspond 

with the aiiatoinieul position uf the valves, It now we listen in 
the u mitral ttrrtt,-- that is, in tin- region of the apex impulse of the 
heart, keeping at the same time one ringer on some point at which 
the cardiac impulse is palpable, one hears with each outward thrust 
oi the heart a low, dull sound, and in the period between the heart 
beats a second sound, shorter and sharper in quality.* 

That which occurs with the cardiac impulse is known as the 
jirst sound ; that which occurs between each two beats of the heart 
is known as the te&mdd&tnd. The second sound is generally ad- 
mitted to be due to the closure of the semilunar valves The cause 
of the first sound has been a most fruitful souree of discussion, and 
no one explanation of it oan In- 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 — 

(a) The contraction of the heart muscle itself, 

(ft) The sudden tautening of the mitral curtains. 

Following the second sound there is a pause corresponding to 

1 For exceptions to this rule. **•<> below, pnge 183. 

'- 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 sec end sound, use one-half the length of the border 
instead of the whole. 



diastole of the heart. Normally tibia pause occupies a little 
more time than the Brat ami second sounds of fche heart taken to- 
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 "booming n in contrast with the 
^snapping" quality of the second .sound) but is also < oiisidcrahly 
more intense, so that it given us the uupo'ssion of being accented 
like the first syllable of a trochaic rhythm. After a little practice 
one grows mi accustomed to this rhythm that one is apt to n-]y upon 

_ A or Mi- rilve. 

I'tiiiiLiniii IfctaA, 



Fie. H.- AiuiMiilt'Al h mil km of the Cardliu.- Vulvas, 

appreciation at the rhythm alone for the identification of the 
Bjratolifl sound. This is, however, an unsafe practice 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 lighi or touch. We must either see or feel the cardiac impulse 
and assure ourselves that it is synchronous with the heart sound 
wlnrlj we take to be systolic." This point is of especial importance 
recognition and identification of cardiac murmurs, as will U* 
seen presently. 

bflB the cardiac impulse can be neither seen nor fell, the pulsation of 
die carotid will generally guide i\a. The radial pulse is not a safe guide. 


So far, I have been describing the normal heart sounds heard 
in the "mitral area," that is, at the apex of the heart. If now we 
listen over the pulmonary area (in the leecttid If ft intercostal 
space), we find that the rhythm of the heart sounds has changed 
and that here the stress seems to fall upon the "second ftonnd," 
i e , that corresponding to the LfeginnLng of diastole ; in other 
words, the first sound of the heart is here heard more feebly and 
the second sound more distinctly. The Bharp, snapping quality of 
the latter is here even more marked than at the apex, and deapite 
the feebleness of the first sound in this area we can usually recog- 
nize its relatively dull and prolonged quality 

Over the aortic arm (i.*., in the second right interspace* ilu 
rhythm is the same as in the pulmonary area, although the second 
sound may be either tiro&gor or weaker than the corresponding 
sound on the other side of the sten below, p, 113L>). 

Over the tricuspid area one hears sounds practically iudistin* 
guiflhfthlfl in tpiality and in rhythm from those heard at the apex. 

When the chest walls are thick and the cardiac sounds feeble, 
it may be difficult 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 so as to bring' the heart closer to the 
front of the chest. Such a position of the body also renders it 
easier to map out the outlines of the cardiac duiness by percnu 

In cardiac neuroses and during conditions of excitement oremo* 
thmal strain, the first sound at the ajM-'x is not only very loud but 
has ijften a curious metallic reverberation {"etiquette metnUiqiw") 
corresponding to the trembling, jarring cardiac impulse (often mis- 
taken for a thrill) which palpation reveals. 

III. Modifications is tub Intkx.hjtv of the Heart Souxns. 

It has almidy been mentioned that in young persons with thin, 
elastic chests, the heart sounds are heard with greater intensity 
than in older persons whose chest walls are thicker and stiffer. 
In obese, indolent adults it is sometimes difficult 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* 



eased conditions either of the heart sounds may be increased or 
diminished in intensity. I shall consider 

(1) The First Sound at the Apex {mmetimes Called the Mitral First 


(a) Increase in the length or intensity of the first sound at the 
apex of the heart occurs in any condition which causes the heart 
to act with unusual degree of force, such as bodily or mental 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 sometimes has a similar 
effect upon the sound, but less often than one would suppose* while 
dilatation of the left ventricle, contrary to what one would suppose* 
is not infrequently associated with a loud, forcible first sound at 
the apex. In mitral stenosis the first sound is usually very intense 
and is often ipoken of as a "thumping first sound " or as a "sharp 

(£) Shortening and weakening of the flist sound at the apex. 

In the course of continued fevers and especially in typhoid fever 
the granular degeneration which takes place in the heart muscle is 
manifested by a shortening and weakening of the first sound at the 
apex, so that the two heart sounds come to seem much more alike 
than usual. In the later stages of typhoid, the first sound may 
become almost inaudible. The sharp " valvular " quality, which 
one rmhrt s in the first apex sound under these conditions, has been 
attributed to the fact that weakening of the myocardium has caused 
a suppression of one of the two elements which gu to make up the 
first sound, namely, the muscular element, so that we hear only the 
short, sharp sound due to the tautening of the mil-nil curtains* 
Chronic myocarditis, or any other change in the heart wall which 
tends to enfeeble it, produces a weakening 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 pitch may 
lie due to fatty ov er growth of the heart, to emphysema or pericar- 
dial effusion in 0806 the heart is covered by the distended lung or 
by the accumulated fluid. Among valvular diseases of the heart 


the one most likely to 1m> associated with a diminution In intensity 
of the first apex sound is mitral regurgitation. 

(<*) Doubting of tlif first sound at the apex, 

It is not uncommon in healthy hearts to hear in the region of 
the apex impulse a doubling of tin* first pound so that it m 
suggested by pronouncing the syllables tt tojnipp M o* "tropp'.* In 
health this is especially apt to occur at the end of expiration In 
ie 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 j Modifications in the Second Sounds as Heard ol the Base qf the 


Physiological Variations* — The relative intensity of the pul- 
monic second Bound, when compared with the second Bound heard 
in the conventional aortic area, varies a great deal at different pe- 
riods of life. Attention was first called to this by Vierordt, 1 and 
it has oi hite years been recognized by the best authorities on dis- 
eaaee ol the heart) though the majority of currant text-books still 
repeat the mistaken statement that the aortic second sound is always 
louder than the pulmonic second in health. 

The work of Dr. Sarah U. Oeighton, done in myelinic 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 tweu- 
tieih year) the pulmonic second sound is louder in two-thirds of 
the cases. About half of 207 eases, between the ages of twenty and 
twenty-nine, showed an accentuation of the pulmonic second, while 
after the thirtieth year the number of cases showing such accentua- 
tion became smaller with each decade, until after the sixtieth \ 
we found an aooentuation of the aortic second in sixiy-sbt out of sixty 
eight cases examined. These facts are exhibited in tabular form in 

* Vierordt: "Die Messiing der Inteiisitfit der Henrtone" (TUblngen, 
188ij)* Sec alao Hochsiuger. "Die Auscultation dea k mi] lichen Herzens"; 
Gibson. " DiscaseK of the Heart" (1896) ; Kosetibaeh, "Disease* of the Heart" 
<li»0) ; Allbutt, "System of Medicine," 



Figa. 78 and 79 and appear to show that the relative intensity of 
the two sounds in the aortic and pulmonic arteries depends pri- 
marily upon the age of the individual, the pulmonic sound predomi- 
nating in youth and the aortic in old age, while in the period «d 
middle life there is relatively little discrepancy lietweeu the two. 





20-20! W-M : 40 -4* 

SO-.W flO-flfl 



■o % 










]v L- 

in k 


in V 


Fi(t. !*. -Showing U hi or Awentuftted Pului<mk' Second Bound In Bwh Decadt 

It is, therefore, far from true 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 otner. Pathological accentuation of the pulmonic sen. ml 
Bound must mean a greater loudness of this sound than should 
fa t x p e cte d at the apt of the patient in question^ and not eimply a 
greater intensity than that of the aortic second sound. The same 


observation obviously applies to accentuation of the aortic second 

Both the aortic and the pulmonic second sounds are sometimes 




Fig. TV.— Showing tbe Per Cent of Accentuated Aortic Second Sound In Each Decade. 

Based on 1,000 ease*. 

very intense during great emotional excitement or after muscular 
exertion, and sometimes without any obvious cause. 

Puth oloyicul J 'a nut ions. 

A. Accentuation of the Pulmonic Second Sound. 

Pathological accentuation of the second sound occurs especially 
in conditions involving a backing up of blood in the lungs, such as 
occurs in stenosis or insufficiency of the mitral valve, or in obstruc 


tive disease of the lungs (emphysema, bronchitis, phthisis, chronic 
interstitial pneumonia). Indirectly accentuation of the pulmonic 
second sound points to hypertrophy of the right ventricle, since 
without such hypertrophy the work of driving the blood through 
betmatod lung could not long be performed. If the right ven- 
tricle becomes weakened, the accentuation of the pulmonic second 
sound is no longer heard. 

It. Weaken* up af the Pulmonic Srtvnd Sound, 

Weakening of the pulmonic second sound is a very serious symp- 
tom, sometimes to be observed in cases of pneumonia or cardiac 
disease near the fatal termination. It is thus a very important 
indication for prognosis, and is to be watched for with the greatest 
attention in such cases. 

C, Aceeuiitatlon of the Aortic Sdoond Sound* 

I have already shown that the aortic second sound is louder 
than the corresponding sound in the pulmonary area in almost every 
individual over sixty years of age and in most of those over forty. 
A still greater intensity of the aortic second sound occurs — 

(m) In interstitial nephritis or any other condition which in* 

mi Arterial tension and so throws an increased amount of work 

upon the left ventricle. Indirectly, therefore, a pathologically loud 

sound points directly to increased tension in the peripheral 

nul indirectly to hypertrophy uf the left ventricle. 

(/*) A similar increase in the intensity of tin- aortic second 

aound occurs in aneurism or diffuse dilatation of the aortic arch. 

IK Jtituhmthm in the. Juttitnittf of the Aortic Second Sound. 

Whenevt i the amount of blood thrown into the aorta by the 
contraction of the left ventricle is diminished, as is the «•.<>• 

in mitral stenosis and to a lesser degree in mitral regurgita- 
tion, io second sound is weakened so that at the apex it 
may l>e inaudible. A similar effect is produced by any disease 
which weakens the walls of the left ventricle, such as fibrous myo- 


carditis, fatty degeneration , ami cloudy swelling. Relaxation of 
the peripheral arteries has the same effect. In conditions of col- 
lapse the aot^ic second sound may be almost or quite inaudible. 

In persons past middle life the second sounds are often louder 
in the third or fourth interspace than in the second, so that if we 
listen only in the seoond space we may gain the false impression I 
the second si muds are feeble, 

\< -iviiniatiiiii of both the seeond 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 a: and 

the aortic arch. XSudsx these conditions the second sound uiav 
sees and felt as well as heard. In a similar way, an apparent in- 
crease in the intensity of either one of the second sounds at the 
base of the heart may be produced by a retraction of one or the 
other lmiK- 

Summary. — (1) The mitral flrti mmnd is increased by h\ 
trophy or dilatation of the left ventricle, and among valvular dis- 

especially by mitral stenosis. It is weakened or reduj 
by parietal disease of the heart. Any <»f these changes may occur 
temporarily bom physiological causes, 

(2) The pulmonic t&wnd tonnd is usually more intense than 
the aortic in children and up to early adult life. Later the aortic 
second »0Uild predominates* Pathological accentuation of the see- 
ond pulmonic sound usually points to obstruction in the pulmonary 
circulation (mitral disease , emphysema, etc.). Weakening of the 
pulmonic secund means failure of the right ventricle and is serious, 

(3) The aortic second sun ad is increased pathologically by any 
cause which increases the work of the left ventricle (arteriosclero- 
sis, chronic nephritis). It is diminished when the- blood stream, 
thrown into the aorta by the left ventricle, is abnormally small 
(mitral disease, cardiac failure)* 

(4) Changes in the tricuspid sounds are rarely recognizable! 
while changes in the first aortic and pulmonic sounds have little 
practical significance. 


Modification* in the Rhythm nf the Cardiae Sounds* 


(1) Whenever aw walls « »l" the heart ate greatly weakened by 

example; in the taker weeks of a case of typhoid 
fever, the diastolic pause of the heart is shortened so that the car- 
diac sounds follow each othei almost as regularly as the ticking of 
a clock j hence the term "tick-tack heart." As this rhythm is not 
unlike that heard in the 1'ietal heart, tin- name of u tmbrpooardi* " 
is son" tm, , s applied to it. Tin* "tick-took " rhythm may be heard 
in any form of cardiac disease after compensation has failed, or in 
any condition le ailing to collapse, 

(2) A less common change of rhythm is that produced hy i 
shortening of the interval between the two heart sounds owing to 
an incompleteness of the contraction of tin* ventricle. This change 

• < ur In any disease of the heart when compensation fails. 
(M) ii<< "Gait /■ Mhythm m n Shortening of the diastolic pause 
together with doubling of one ur another of the cardiac sounds re- 
sults in uur hearing at the apex of tln j heart three sounds instead 
of two, which follow each other in a rhythm suggesting the hoof 

beats of a galloping lens.'. Sueh ;l rhythm may »weur temporarily in 

any heart which is excited en- overworked from my cause, but when 
permanent is usually a sign of grave cardiac ureaknete. The rhythms 

90 produced are usually anapa'stie, w w — * f w ^ — 9 $ w * \ or of 

this type : %-*• — ' v, ^ — ' *~> f w> — ' w, 

Doubling of the Second Souiuh at the Base *>/ the Heart, — At 
the end of a long inspiration this change may be observed in al- 
most any healthy person if one listens at the base of the heart It 

i ill letter brought out after muscular exertion or by holding the 
breath. In such cases it probably expresses the mm -synchronous 
closure of the aortic and pulmonic valves, owing to increased press- 
err in the pulmonary circulation. Similarly in diseased condi- 
tions, anything which increases the pressure either in the periph- 
eral arteries or in the pulmonary circulation, and thus throws 
in- leased work upon one or the other ventricle, will cause a doub- 
ling of the second sound as heard at the base <>t" the heart. 

In mitral stenosis a double diastolic sound is usually to be 


heard at the apex, and in the diagnosis of this disease this " double 
shock sound " during diastole may be an important piece of evi- 
dence, and may sometimes be felt as well as heard. The " double 
shock sound n uf 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 heart have also not been dwelt 
upon, since they have no special importance in diagnosis. 

MsktUic Heart Sound*. 

The preset*! t air in the immediate vicinity 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 us is not heard under any other conditions, 

M Muffihtf/ t %y M Prolongation)" or * l Unclearnesg " of the Heart v 

These terms are not infrequently met with in Literature, but 
their use should, I think, be discontinued. The facte to which 
tln'v refer should W explained either as faintness of the heart 
sounds, due to tin* causes above assigned, or as faint, short mur- 
murs. In their present usage such terma as u muffled " or ** \u\> 
heart sounds represent chiefly an unelearuess in the mind of the 
obser\ just what it is that he hears, and not any one recog- 

nized pathological condition in the heart. 

IV . SOVKM Arme.iK (Mil; THIS PeEIPHERAL Vksskls. 

(1) The nornial heart sounds are in adults audible over the 
carotids and ore* the subclavian arteries. In childhood and youth 
only the second heart sound is thus audible. 

i "_' i In about 7 per oenl of normal persons a systolic sound r 
be heard over the femoral artery. This sound is obviously m»t 



transmitted from the heart, and is usually explained as a result of 
the sudden systolic tautening of the arterial wall. 

In aortic regurgitation this 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 feinoral 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 Sounds. 

The violent closure of the venous valves in the jugular is some- 
times audible in cases of insufficiency of the tricuspid valve. The 
sound has no clinical importance, and is difficult to distinguish owing 
to the presence of the carotid first sound mentioned above . 



Cardiac Murmurs. 

( <t) Term in irftHjy. 

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 by any other term. The French word "aoufflr" 
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 that portion of the lung or pleura 
which overlies the heart are not considered "murmurs." 

(A) Morfr 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 the valve curtains, or by a stretching of the orifice into which 
the valves are inserted. 

Diseases of the valves themselves may lead to the production of 
murmurs : , \ 

(a) Wherf'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) . 



When the surfaces of the valves or of the parts immedi- 
ately adjacent are roughened m as to prevent the smooth flow of the 

b) I over them. 

{ft} When the OXlfice which the valves are meant to close is di- 
lated as a result of dilatation of the heart ( -h amber of which it forms 


I nigrum u> IUtintraift ti\r PriHjii^Unn of a rurdlar Murmur Through IlefjurirliiUion 
fr.s*Ti |bi aorta or in an AhPiulaiiial Baft I'M-- iimjw show* Um? direction of ttw M<wtf rur- 
tvnt and Hie i-uiied H»es the audlW*' blond <*di ()*•*. 

tin riitraiiri- nr exit The valves theinsel \ es cannot enlarge to 
keep pace with tin enlargement- of the orifice, and hence no longer 
■ttflea to reach across it* 

The presence of any one of these Lesions gives rise to eddies 
in the blood current and thereby to the abnormal sounds to which 
u" giro the name murmurs.' (See Figs, SO, s I and HI'). When 

«. ni.— Dimrram u> IlUmtmcv th«* ProdmiUuu «f a Canllar Murmur Through St«n<*ts of a 


valves fail to close and so allow the blood to pass back through 
them, we speak of the. lesion as regnrgUathm^ fo#tf£Ee£«tffi^ or iu- 
enm-prtener . if, for example, the aortic valves fail to close alter 
the left ventricle has thrown a column of blood into the aorta, 
soine of this blood regurgitates through these valves into the ven- 

' The method by which functional murniurBare produced will be discussed 
later. (See page Me } 


triple from which it has just been expelled, and we speak 
lesion as ^acrtic re{ptr$it<tH<m f if and of the murmur so produc 
an <t,ntt'i regurgitant murmur or a murmur of aortic regurgil 
A similar regurgitation from the loft ventricle into the h 
takes pl&CG in rase tin- mitral valve fails to close at the begi 
of systole. If, on tin- other hand, the mitral valve fail 
properly to admit tin- blood which should flow during diastole 
tin- Left auricle into the left ventricle, we speak of the gondii 
tnif ral ttmosii or antra? obstruction. A similar narrowing o 
aortic valves such as to hinder the egress of blood during tin- s 
of ill*' left ventricle is known as wortic stmosis or obstruction. 

rifl. «*,- ninffimm to Illustrate the Pn»diirtkin of Curdla** Munnura Thrnui?h Rtnifftwn 


volar lesions of the right side of the heart (tricuspid ami pulmonic 
valves) are comparatively rare, but arc produced ami named in p 
way similar to those just described. 

The facts most important to know about a murium* are: 

(1) Its place in the cardiac cycle, 

(2) Its point of maximum intensity. 

(3) The ana over which it can be heard. 

(4) The effects of exertion, respiration, or position upon it. 
Less important than the above are: 
(&) Its intensity. 

(0) Its quality. 

(t) Its length. 

(8) Its relation to the normal sounds of the heart. 

Each of these points will now be taken up in detail: 

(1) Time <>f Murmurs. —The first and most important thing to 
ascertain regarding a murmur is its relation to the normal cardiac 
cycle; that is, whether it occurs during systole or during diafftotej 
or in case it. does not rill the whole of one of those periods, in what 



of systole or diastole it occurs, Ft must be borne in mind that 

»r!i. period of systole is considered as lasting from the beginning of 
sound of the heart up to the occurrence of the second 
Bound | while diastole lasts from the beginning of the second sound 
until the beginning of the first Bound in the next cycle* Any mur- 
mur occurring with the first sound of the hearty or at the time when 

!i<i should t;i . or in anv part of the period inter- 

between Qui first Bound ami the second, is held to be tyttoUa. 

Munuuis ffhioh distinctly follow the first suit ml or do ttOl In-gin 

until the first sound is ended aw known as lot* tpttoHt murmurs. 
On the other hand, it seems beat] fbi ra be discs 

ire in detail later on, not t« i gjta tin name "i diasiolie to all 

murmurs which occur within the diastolic period as above defined. 

Mi innurs which occur during the last part of diastole and which 

I run Up to the first sound of the next cycle are usually known as 
ystolie n murmurs. All other murmurs occurring during dias- 
tole art' kr diastolic. 
The commonest of ftU the errors in the diagnosis of disease of 
the heart is to mistake systole for diastole, and thereby to misin- 
terpret the significant' of a murmur heard during those periods. 
This mistake would never happen it we were always careful to 
make sure, by mesne of sight or touch, jufil when ttte systole of 
the heart occurs. This may be done by keeping one finger upon 
the apex impulse of the heart Of upon the carotid artery while 
ening for murmurs, or, in case the apea impulse or the pulsar 
fciona of the carotid are bettei u felt, we can control by the 
the impressions gained by listening. It is never safe to trust 
mil appreciation of the cardiac rhythm to tell us which is the first 
heart sound and which the secoud. The proof of this statement 
.< n by the numberless mistakes made through disregarding it. 
dly untrustworthy 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, 

LooalUati&M of Murmurs. — To localize a murmur is to find 
its point of maximum intensity, and this is of the greatest impor- 
tance in diagnosis. Long experience has shown that murmurs 


heard loudest in tin* region of tin- apex beat (whether this is m Uw 
normal situation Of displaced); are in the vast majority of cases pre* 
dueed at the mitral valve. In about five per cent of tin* cases i 
murmurs may be best heard at. a point midway between tin 
of the normal cardiac impulse ami the rnsifonu cartihi 
rarely) an inch or two above this situation. 

Murmurs heard most loudly hi the second left intercostal 
are almost invariably produced at the pulmonic oritiee <-r just ab 
it in the conus arteriosus. 

Murmurs whose maximum intensity is nt. tin- root uf the fusi- 
form cartilage or within a radius of an inch and a .half from this 
point are usually produced at the tricuspid orifice, Murmurs pro- 
duced at the aortic orifice may Ik.* heard beat in the aortic area, but 
in a large proportion of eases are loudest mi the other side of the 
Sternum at or about the situation of the fourth left costal cartilage. 
Oi-uisionally they are boat heard at the apex of the heart or o 
the lower part of Hie sK-nnim (see below, Fig, 105). 

(3) Transmission of Murmurs. — If a murmur is audible nvr: 
eral valve areas, the questions naturally arise: "How are aw fa 
blow whether we are dealing with a single valve lesion Of 
several? Is this one murmur or two or three murmurs?** Obvi- 
ously the question can l>e asked only in ease the murmur which Wf 
find audible in various places occupies everywhere the same time 
in the cardiac cycle. It must, for example, be everywhere systolic 
or everywhere diastolic. \ systolic murmur at the apex cannot 
be supposed to point to the same lesion as a diastolic murmur, no 
matter where the latter is heard. Hut if we hear a systolic mur- 
mur in various parts of the chest, say over the aortic, mitral, 
tricuspid regions, how are we to know whether the sound is simple 
or compound, whether produced at one valve orifice or at several? 

This question is sometimes difficult to answer, and ii 
case skilled observers may differ in their verdict, but, as a rule, the 
difficulty may be overcome as follows : 

(1) Experience and post-mortem examination have shown th:tt 
the murmur produced by each of the valvular lesions has itw own 
characteristic area of propagation, over which it is heard with an in- 



■ v which regularly diminishes as we recede from a maximum 

eoireeponds with some oue of the valve areas just de- 

scribed. These areas of propagation are shown in Figs, 93, 94, l J7, 

nI 10-. Any murmur whose distribution dues not extern! beyond 

fchi sac iiivas, and which steadily and progressively diminishes 

in intensity as we move a way from the valve area over which it is 

st, may be assumed to be due to a single valve lesion md no 

-Hitful and TncutpM R«-irurfrlbitiiiti The intensity "f u»- ftyatollc murmur is leiust at 
the " wnlHt " of ibe slmiifd Ifn und lorfGunt us otic Hpprrwrjp* either end of It. 

mote. Provided but one valve is diseased* tliis OCHUae of procedure 
gives B&tifliactoty 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 
1 or apex region, and move the stethoscope one-half an inch 
a' a time toward one of the other valve areas, noting the intensity 
of any murmur we may hear at each of the different points pi 
• •ver. As we move toward the tricuspid area, we may gel an im- 
pression best expressed by Fig, 83. That is, a systolic murmur 
loudly at the apex may fade away as we move toward the 
enaifoniu until at the point j (Fig. H3) it is almost inaudible. Bat 
^o on in the same direction the murmur may begin to grow 


louder (and perhaps to change in pitch and quality as well* until a 
maximum is readied at the tricuspid area, beyond which the mur- 
mur again fades out. 

These facte justify us in sitxj>r<t'nnj that we are dealing with two 
murmurs, one produced at the tricuspid and one at the mitral ori- 
rice. The suspicion is more likely to be correct if then- has b 
a change in the pitch and quality of the murmur ad we n eared the 
tricuspid orifice, and may be cm tinned by the discovery of other 
evidences of a double lesion, Nv diagnosis %s satisfactory which 

to on the widens* »f murmurs alone. changes in the size of 
the heart's chambsw 02 in the pulmonary or peripheral rirculatii 
in the most Important facts in the case. Nevertheless the effort 
to ascertain and graphically to represent the intensity of cardiac 
murmurs as one listens along the line connecting the valve BJ 
has its value. An ''hour-glass" murmur, such as that represented 
in Fig. 83), generally means ttoo^valrte lesions. A similar ** hour- 
glass " maybe found to represent the auditory facts as we jn< 
from the mitral to the pulmonic or to the aortic areas (see Fig. 
y\) 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 quality " 
( Allbutt ) . This is especially true of aortic murmurs, which arc often 
heard well at the apex and at the aortic area, and faintly in the in- 
tervening space, probably owing to the interposition of the right 

In such cases we must fall hack upon the condition of the heart 
itself* as shown by inspection, palpation, and percussion, and upmi 
the Condition of the pulmonary and peripheral circulation, as 
shown in the other symptoms and signs of the eases (dropsy, cough, 

(4) Intensity of Mttnuurs.— Sometimes murmurs 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 arc rare and usually not 
serious, for the gravity of the lesion is not at all proportional to 


loudness of the murmur; indeed, other things being equal, 
Loud murmurs serious than faint ones, provided ire are sure 

., < ;u> i\> >aling with organic Lesions. (On the distinction between 
the Organic and fimeiinual murmurs, s«-e below, p. 141i.) 

A luud 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- 

M — Mitral Bpgurgi tattoo and Aortic StentteJu, The systolic murmur 1* loudest at the 1 1- 
tn?mUles of tbe staled area and falntert at It* " waki." 

duce as loud a sound as formerly. Tlie gradual disappearance of 

niur known to be due to a valvular lesion is, therefore, a very 

sign, and its reappearance revives hope. Patients are not 

infrequently admitted to a hospital 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, bx sueh a case, under the influence of rest and 

\g tonics, one may observe tin- development of a murmur as 

the 1 i^art wall regains its power, and the louder the murmur be* 

eomeslhe better the condition of the patient. On the other hand, 

when the existence of a valvular lesion has been definitely deter- 


mined] and jet the compensation remains perfectly good (foi < 
ph> in tin' endocarditis occurring in children in connection with 
chorea), an increase In the fondues* of the murmur may run paral- 
lel with the advance in the valvular lesion. 

In general rln- tnost important point about the intensity of a 
murmur is its inere&es uf decrease white wider observation, and not 
its loudness at any DUB tine i, 

i.'ii Qmlitn ti f Heart Murm&rs* —It has been already mentioned 
that the quality of a heart murmur is never anything lik 
sound whieh we ordinarily designate by tin* word "murmur." The 
GOmmoneat type Of In-art murmur has a blowing quality, whence the 
old name of "bullow* *aund, n The sound of the Letter "|" pep* 
longed in not unlike the quality of certain murmurs. Blowing 
murmur* may be IoTr*pitched like the sound of air passing through 
a targe tube, or high-pitched approaching the sound of a whistle. 
Tins lust, type B16rg6£ into that known itsif'tif murmur, iii 

which there is a definite musical sound whose piteh can i»' identi- 
Hasping or tearing soumls often characterise the louder 
varieties of murmurs. 

Finally, there is one type of sound which, though included 
under the genera] name murmur, differs entirely from any of the 
other sounds jus! described, This is the " presystolic rol^* 9 whieh 
has a rumhting or bhthbering quality or may remind one of a short 
drum-roll. This murmur is always presystolic in time and usually 
associated with obstruction at the mitral or tricuspid valve*. Xot 
in frequently some part of a cardiac murmur will have a musical 
quality while the test is simply blowing or rasping in character. 
Musical murmurs do not ifive us evidence either of an especially 
serious or especially mild tyjx* of disease. Their chief importance 
consists in the fact that they rarely exist without some valve 
lesion, 5 and are, therefore; of use in excluding the type of mur- 
mur known as "fimoHonat," 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 vahv orifice. 

' Rosenbach holds that Uwj may be produced by adhesive pericarditis. 



Murmurs may be areeufed at the beginning or the end; that 
may be of the Qiescendo ty]* 4 , growing louder toward the end, 
or of the dearesoesdo type with their maximum intensity at the 
aing. Almost all murmurs are of the latter type except those 
iated with initial or tricuspid obstruction. 

Lujth f.f Murm-urs. — Murmurs may occupy the whole 
tolt*, tin- whole of «li:tsto]e, or only a portion of ouc of 
, but no Doneluniorifl can be drawn as to the severity 
of the valve Lemon Cram the length of tin- murmur* A short mur- 
mur, «pecdatiy if diastolic, may 1m> of rety serious prognostic im- 

TUlations to the Kwmal Sounds of tin- Heart, — Cardiac mur- 
murs mayor may imt replace the normal In-art sounds. They may 
occur simultaneously with one or both sounds oi between the 
sounds. These facta haw a certain amount of significance in prop. 
nosia. Murmurs which entirely replacl cardiac sounds usually moan 

a severer disease of the affected valve than murmurs whieh aceom- 

, but do not replace, the normal heart sounds, Late systolic 
murmurs, which occur between the first and tin' seoond sound, are 
usually issooiated with s relatively slight degree of valvular dis- 
ease. Late diastolic imtrmurs, on the other hand, have n 
able significance. 
(8) Jfffi-rt* of I'ttsttifftt, JQxertis*) and B&pira&ionvf&ri Cardiac 
iiire. — Almost all cardial- murmurs are affected to a greater 
Of lass extent by the position which the patient assumes while he 
i mined. Systolic murmurs which are inaudible while the 
patient is in a sitting or standing position may he quite easily 
heard when the patient lies down. On the other hand, a pre- 
io roll which is easily heard when the patient is sitting up 
may entirely disappear when he lies down. Diastolic murmurs 
are relatively little affected by the position of the patient, but 
in the majority of cases are somewhat louder in the upright posi- 

The effects of cxereisr may perhaps be fitly mentioned here. 

Le murmurs may altogether disappear when the patient is at 

rest, and under such circumstances may be made easily audible by 


getting the patient to walk briskly up and down the room a : 
times. Such lesions are usually comparatively slight.' On 
other hand, murmurs which become more marked as a result of I 
are generally of the severest type (see above, p. 136). 

Organic murmurs are usually better heard at the end of exj 
rimi and become fainter during inspiration as tie- expanding I 
covers tin' heart. This is especially true of bb lueed at 

mitral valve, and is in marked contrast with the variations of func- 
tional murmurs which are heard chiefly or exclusively at the end of 

(9] Sudden Metanwrphwis <tf Murmurs. — In acute end* 
when vegetations are rapidly forming and changing their si 
upon the valves, munnurs may appear and disappear very sud- 
denly. This metamorphosing character of cardiac mnrmurs, when 
taken in cnnnt'i tiun with other physical signs, may be a very Ini- 
pnrtaut factor in the diagnosis of acute endocarditis. In a similar 
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. 

Not eveTy murmur whieh is to be heard over the heart points 
disease either in the valves or in the orifices of Hie heart. Perhaps 
&Q majority of all murmurs are thus unassoeiated with valvular 
disease, and to such the name of "accidental," "functional," or 
u Ineinie " murmurs has been given. The origin of these " functional M 
murmurs has given rise to an immense amount of controversy, and 
il cannot he said that any one explanation h uow generally a 
upon. To me the most plausible view is that which regards most 
of them as due either to a temporary or permanent dilatstii 
the conns arteriosus, or to pressure or suction exerted upon the 
overlapping lung margins by the cardiac contractions. Thi 
plains only the systolic functional munnurs, whieh make up ninety- 
nine per cent, of all functional murmurs. The diastolic functional 
murmurs, which undoubtedly occur, although with exceeding rarity, 
1 Fot exception to this see below, pagf 161, 



are probably < 1 1 Le* in most sounds produced in the veins of 

the iJ 1 : riinsmitt.1 'il feu the innominate or vena cava. 

CAorad wmtf flfwmwr*.— (1) Almost all func- 

tional murmurs are systolic, as has before been mentioned^ 

Tbe vast majority of them are heard beet over the pulmonic 
valve in the second left intercostal space. From tins point they 
are transmitted in all directions, and are frequently to be heard, al- 
though with Le« intensity, in the aortic and mitral areas. Occa- 
sionally they may have their maximum intensity in one uf the latter 

b luli-, tb< i y s,.ii and blowing in quality, though 

eice] they may be Loud and rough. 

h They are not associated with any evidence of enlargement 
of the heart noi with accentuation of the pulmonic second sound* 1 

They ar* 1 usually louder at the end of inspiration. 
Tb' v are usually heard over a wry limited area and not 
transmitted to the left, axilla ot to the back. 

Tiny ure 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. Res- 
piration, position, and exercise produce greater variations m them 
than in * " murmurs. 

(8) They are especially apt to be associated with r/jjcrww, 
although fche connection between ana-mia and functional heart nutr- 
ia by no means as close as. has often been supposed. The 
df ;iti;rTni;i, for example pernicious ftnmmJSj may not 
■rtinpanied by any murmur, while, on tlie other hand, typical 
fonctiona] murmurs are often heard in patients whose blood is nor- 
mal, and. even in full health. Vet in three eases of intense amentia 

I have beard tiUmtutu* murmurs loudest at the fourth left costal i-ar- 
aild leading to a diagnosis of aortic regurgitation. At au- 
thfl aitrt were in each case souud, and 1 am at a loss 

1 In chlotWig tRMiK-onrl pulmonic sound is often very loud (owing to the 
ion of the longs ami micuvei im; >f the coitus u-utiobubI and associated 
with a systolic murmur. 


to account For the murmurs. It should u<>i be forgotten that a 
real, though temporary, leakage through the mitral <>r tin 
valve may be associated with amsuita or debilitated condi 
owing to Weakening of the papillary muscles or nf the mitral 
sphinetei. In such cases we find not the signs of a functional 
murmur, us above described, 1 nit tl videuce of an organic vahv 

hereafter to !*■ described^ 

Tin' i list motions between organic aud functional heart murmurs 
may be summed up as follows i 

Organic murmur* may occupy any paj r. of the cardiac cycle J :\ 
s\stMlic, they are usually transmitted either into the axilla and 
back or into the great vessels of the neck; they are usually asso* 
ciated with evidences of cardiac enlargement and changes in the sec - 
pad sounds at the base of the heart, as well as with signs and symp- 
toms of stasis in other organs. < fcgante murmurs not infrequently 
have a muaica] or rasping quality, although tins is by no means al- 
ways the ease. They are rarely loudest in. the pulmonic area and 

ate relatively iminftueaoed by respiration, position, orexarcl 

Functional murmun are almost alwa -lie in time and 

usually heard with maximum intensity in the pulmonic area. They 
an- rarely transmitted beyond the precordial region and are usually 

Loudest at the eiirl of inspiration. They are not accompanied by 
evidences of cardiac enlargement <>r pathological aa ton <»f 

the second sounds at the base of the heart, nor by si,^ns of venous 
stasis or dropsy. They are very apt to be associated with amentia 
or with some special attack upon the resource* of the body | 
physical overstrain or fever), and to disappear when such fort* 
removed. They are usually soft in quality; never musical, The 
very rare diastolic functional murmur occurs exclusively, so far as 
1 am aware, in conditions of profound anmmia ; i»*, f when the hemo- 
globin is t ffBBty-flve per cent or less. It tan lie abolished by p 
ure upon the bulbils jugularis, and can )>e observed, if followed up 
into the neck, to pass over gradually into a continuous venous hum 
with a diastolic accent. 

Tabot ami Locke, Johns Hopkiiui Bulletin May. 1906 



f } ard%o- Re&pintfunj Murmurs, 

When a portion of the ftvr margin of the lung is fixed by ad- 
08 in a position overlapping the heart, tin* cardiac movements 
may rhythmically displace the air in such piece of lung so as to 
give rise to sounds which at times closely simulate cardiac mur- 
iini! -s. These mtiditiuns are ujost often to be found in the tongue- 
like projection of the left Lung, which normally overlaps the heart, 
but it is probably the ease thai oartUo-respiratoTy murmurs may l>e 
produced without any adhesion uf the lung to the pericardium 
under ennditioiis not at present understood, Such murmurs may 
be heard under the left cda\ icle oi below the angle of the left scap- 
ula, as well as near Hie apex of the heart, — less often in other parts 
id' the chest 

Cardiorespiratory murmurs may be either syskdie or diastolic, 
but the vast majority of east tystolie. The area over which 

they art* 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, especially at the end of that 
act, (This fact 1S a a important aid in distinguishing them 
tmi' earrlhuj murmurs, which are almost always fainter at the eiol 

of inspiration.) They are also greatly affected by cough or forced 
m or by holding the breath, whereas cardlae murmurs 

latmdy little changed thereby* Presanx i the outside 

of the thorai and it i thru vicinity may greatlj i lily their in- 
tensity or ipiality, while organic cardiac murmurs arc but little 
influenced by pressure. As a ride* they have the ipiality of nor- 
mal respiratory murmur, and sound like an inspiration interrupted 
ich diastole of the heart. 
In case the effect of the cardiac movements is exerted upon i{ 
piece of lung in which a catarrhal process is going 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 lie emptied or tilled under the inrluenee of the ear- 
diae movements, ('ardio- respiratory murmurs have no special diag- 

significanee, and are mentioned here only on account of the im- 


pintail ft* of not confusing them with true cardiac murmurs. Th**j 
n ere formerly thought to indicate phthisis, but such is not ih 

Mm, tuns of Venom Origin, 

I have already mentioned that the venous hum bo often I 
in the neok in oases of anaemia may 1>e transmitted to the region of 
■- ls<j of the heart ami heard there as ■ diastolic murmur owing 
to the acceleration of the venous current by the aspiration of the 
right ventricle during diastole. Such murmurs ;ii< rtty nn and 
may usually be obliterated by pressure upim the hull mis jugolaria, 
or even by the compression brought to bear upon the veins of He 
neck when the head is sharply toned to one side. They are 
better in the upright position and during inspiration. 


Arterial Murmurs. 

(1) Roughening of the arch of the aorta, due to chronic endo- 
carditis, is a frequent cause in elderly men of a systolic murmur 
heard best at the base of the heart ami transmitted into tie 
Of the neck. Such a murmur is sometimes accompanied by a pal 
pable thrill. From cardiac murmurs it is distinguished by the laek 
of any other evidence of cardiac disease and the presence of marked 
arteriosclerosis in the peripheral vessels (see further discussion 
under Aortic Stenosis, p. Tftfi, and under Aneurism, tv 228. 

(2) A narrowing of the lumen of the subclavian artery, du 
some abnormality in its course, may give rise to a systolic mur- 
mur heard close Uluw the clavicle iit its outer end. The mur- 
mur is greatly influenced by movements of the arm and especially 
by respiratory movements. During inspiration it is much loud 
and at the end of a forced expiration it may disappear altogether. 
Occasionally such murmurs are transmitted through the clavicle SO 

* he audible above it. 

(.3) Pressure exerted upon any of the superficial arteries (carot- 
id, femoral, etc. \ produces a systolic murmur (see below, p. L83). 
Diastolic arterial murmurs are peculiar to aortic regurgitation, 

(4) Over the anterior fontanelle in infants and over the gi 
Uterus systolic murmurs are to be heard which are probably arterial 
in origin. 






Clinically it is convenient to divide the ills which befall the 
heart into three classes : 

(J) Those which deform the cardial; valve* (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 lit**. The vegetations of acute 
andoearditis 1 do not usually produce any peculiar physical signs 
until they have bo far deformed or obatructed the valves as to pre- 
vent their opening or closing properly. 

The murmurs which arc often heard Ore* the heart in rases ,-t 
acute articular rheumatism cannot be considered as evidence uf 
vegetative endocarditis unless valvular deformities, and their re- 
sults in valvular obstruction or incompetency, ensue. The chordae 

tendinese may be raptured m Shortened, thickened, and welded to- 
gether into shapeless masses, but if these deformities do nut affect 
the action of the valves we have no means of recognizing them dur* 
life. Congenital malformations are practically unrecognizable 
as such. If they do not affect the valves, we cannot with ;uiy 0i -i - 
tainty make out what is wrong. 

For physical diagnosis, then, heart disease means either de- 


1 See Appendix. 


formed valves of* weakened walls* Whatever else mu 
are none tin." g ifler for il unless the autopsy enlightens us. 

In this chapter T shall confine myself r<> the discussion »»f vulvu- 
lar lesions and their results. 

Valvular lesions aiv of bwo fevpes: 

(a) Those whitih ■♦■ partial instruction of a valve oriBt 
Of prevent its opening fully (".vM/wfiV). 

fr'Ki. Ki,— T«e Base o| Oie umtntcted Heart Showing Sptalnwerk Action or the Muscular PftfN 
Surrounding the Mitral and Tricuspid Valves. Tne outer dotted line ta ilitf outline of fl» 
relaxed bean. The loner dotted circles ibow the sUse ut the mitral and tricuspid r*Iv« 
during diastole, a. Outline of the heart when relaxed ; h t outline of the re laied tricuspid 
valve; e, oullloe of the mltml orifice during UiaM"U\ (Afer Spaltchcilzj 

(b) Those which produce leakage through a valve orifice ( 
prevent its closing effectively (" regurgitation,** "in^^ffir,- 




msis results always from the stiffening, thickening, ami con- 
traction of a rolm 

Regurgitation, on the other baud* may be the result either of — 

Defoi in i t v of I v;ihe t or 
(A) Weakening of the heart muscle. 

The mitral and tricuspid orifices are closed not simply by the 
shutting of their valves, but also in part by the sphincter-like 

Mitral t-iTFtulns. 

Ft.,. M 

Tin* Mtttti Tain GfcNtt Showing tbe AtittW of ttw Papillary If uarit*. (xiU-r 

SOtioD of the circular fibres of the heart wall (see Fig. 85) ami the 
contraction of the papillary muscles i Fig, 86). 

In birds the tricuspid orifice has no valve and is closed wholly 
by the muscular sphincter of the heart wall. 

In conditions of the acute cardiac failure, such as may occur 
after ;i hard nm, the papillary muscles are in all probability relaxed, 
so that the valve-nape swing back into the auricle and permit regur- 
gitation of blood from the vertricle. 

14s physical diagnosis of diseases of the vhi 

Valvular incompetence, then, differs from valvular oh*tm 
in that the latter always involves deformity and stiffening of valves, 
while incompetence or leakage is often the result of deficient DO* 
eular action on the part of the heart wall. An <>shtru<*ted valve U 
almost always leaky as well, since the same deformities which pi 
\t j nt. a valve from opening usually prevent its closure; Intt thi* 
doe* nut work backward. A leaky valve is often not obstructs 
It is leaky Init not oshtructod if the valve curtain ltas been pract 
eally destroyed by endocarditis; or, again, it is leaky but no* 
structed if the leak represents muscular weakening of the nail 
sphincter or of the papillary muscles. Pure stenosis is very rare. 
Pun regurgitation is very common , 

When valves are so deformed that their orifice is both leaky 
obstructed, we have what is known as a ** combined " or " double 
valve lesion. 

Since valvular lesions are recognized largely by their re*utte t 
first upon the walls of the heart itself and then upon the other 
organs of the body, it seems best to give some account of these 
results before passing on to the description of the individual 
si otis in the heart itself. 

The results of valvular lesions are first conservative and 1 
destructive, The conservative results are known as: 

The establishment qf compensation through hypertrophy* 

The destructive or degenerative results are known as : 

The/aUuro of compensation through {•" without) dilatation* 

I shall consider, then, 

{«) The establishment and the failure of compensation. 

{it) Cardiac hypertrophy. 

(e) Cardiac dilatation, 



We may discriminate three periods in the progress of a ease of 
valvular heart disease : 



(1) The period before the establishment of compensation. 

(2) The period of compensation, 
j :-i rhe period of failing or ruptured compensation, 

(1) Cutiipenrntion Not Yet EtfablUktd. 

In mooi oasce of acute valvular endocarditjfl, whether of the 
relatively benign ox of the malignant type, there is a time when 
the Lesion in perfectly recognizable despite the fact that coinpensa- 

j hypertrophy has not yet occurred. Tn some cases this period 
may last fur months; the heart is not enlarged, there is uo accentu- 
ation of cither senond sound at the bast-, there is no venous stasis, 
and our diagnosis must rest solely upon the presence and character- 
istics ol tin' murmur. For example, i ri early cases of mitral regur- 
gitation due to chorea or rheumatism, the disease may be rceog- 
lii/.r-ti by the presence of a Loud musical murmur heard in tin- back 
as «reU as at xtn apes and in the axilla. In the curlier stages of 
aortic regurgitation occurring in young people as a complication oj 
rheumatic fever, there may be absolutely in* evidence of the valve 
lesion except &e characteristic diastolic murmur. In most text- 
books of physical diagnosis I think too little attention is given to 
stage of the disease. 

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 hyjjertrophy 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 circuit which it sup] dies with blood. What- 
ere* 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. 


X>>'\, any disease of tin* initial valve, whether «.>« 
leakage, results in engorgement of tin* lungs with blood* and he 
demands an increased mount • jf" work cm the part of the \ 
ventricle in order to force the blood through the overcrowded pul- 
monary vessels; lienor it. is in mitral disease that we Bnd tin- great- 
est compensatory hypertrophy of the right ventricle 

On the other hand, it is obvious that obstruction at the aortic 
valves of in the peripheral arteries (arteriosclerosis) demands an 
increase in power in the left ventricle, in order that, the requisite 
amount of blood may lie forced through arteries of reduced calibre, 
while if the aortic valve is so diseased that a part of the Wood 
thrown into the aorta by the left ventricle returns into that ven- 
tricle, its work is thereby greatly increased, since it has to oonta 
upon a larger volume of blood. 

In response to*these demands for increased work, the luuseulai 
wall of the left ventricle increases in thickness, and compensati^i 
thus established at the cost of an increased amount of work ■ »n the 
part of the heart. ' 

(3) FnUurv of L%>mpntmthm. 

Sonner or later in the vast majority of eases the heart, humli- 
eapped as it is by a leakage or obstruction of one or nnnv 
becomes unable to meet the demands ma tie upon it by the needs of 
the circulation. Failure of ruin pen sat ion is sometimes associated 
with dilatation of the heart and weakening of its walls, but in 
many cases no such change can be found to account i'ni its tan 
and we have to fall back upon changes in the nutrition of the 
In art wall or upon some hypothetical derangement of the ner- 
vous mechanism of the organ as an explanation. Whatever the 
cause may be, the result of raptured compensation is venous ftat 
that It, ledema or dropsy of various organs appears. If the 
left ventricle is especially weakened, dropsy appears first in the 
legs, on account of the influence of gravity, soon after in the geni- 

1 RniHjnbiich brings forward evidence to show thnt the arteries, the hinsos, 
«nd other organs actively assist in maintaining compensation. 



igs f Hver t and the serous cavities. Engorgement of the 
specially masked in canon of mitral disease with weakening 
of tlir right ventricle, and is manifested by dyspmca, eyas 
cou^h, ami hemoptysis. In many eases, however, dropsy is very 
irregularly anrl unaccountably distributed, and does not follow the 
just given. In pure aortic disease, uncomplicated by leakage 
>f the mitral valve, dropsy is a relatively late symptom, and dysp* 
and precordial pain (angina pectoris) are more prominent. 

1. Carrlittf Hypertrophy. 


Since cardiac hypertrophy or dilatation are not in themselves 

diseases, hut may OOOQr in any disease of the heart (valvular or 

tl), it seems best to %m some account of them and of the 

methods by which they may !»■ recognized, befoiv taking up sepa- 

Irately the different lesions with which they are associated 
Hypertrophy of the heart is usually (hie to the following causes : 
First (and must frequent) : Valvular disease of the heart itself, 
d: Obstruction of the How of blood through the arteries 
owing to increase of arterial resistance such as occurs in chronic 
nephritis and ait + TiN-i'lernsLH. Third: Obstruction to the circula- 
tion of tin* Mood through the lungs i emphysema, cirrhosis of the 
bung, fibroid phthisis). Fourth : Severe and prolonged muscular 
exertion (athlete's heart), 

In valvular disease the greatest degree of hypertrophy is to be 
seen usually in relatively young persons, and especially when the 
advHii' 8 of the lesion is not very rapid, 

1 1 ypei trophy of tlie heart in valvular disease ia also influenced 
by the amount of muscular work done by the patient, by the de- 
gree uf vascular tension t 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 predominantly affected. 


(1) Cardiac hypertrophy affecting especially the left ventriefa 
The apex impulse is usually lower than normal, often in 
tlu* sixth spaoQj occasionally in the seventh or eighth, 1 It is 
farther to the left than normal, but far less so than in oases to 
which tin- hypertrophy affects especially the right ventricle, The 
area <>f visible pulsation is usually in ere ased, and a considerable por- 
tion <>t tin* chest wall maybe seen to more with each s> I the 
heart, while frequently there -tolie retraction ol tile in1 
spaces to place of a systolic impulse. 

(A) Palpation confirms the results of inspection and shov, 
;ilsci that the apex impulse is unusually powerful. IV mission 
showa in many eases that the cardiac dulness is more intense and 
its area increased downward and to a leasei extent toward the left.' 

(c) If we listen in the region of the maximum cardiac impulse, 
wh generally hear an unusually long and tow-pitched first sound, 
which may <>r may not be of a greater intensity than normal, A 
very Inud first sound is much more characteristic of a cardiac neu- 
rosis 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 tin: &ortie area shows that the second sound at that point is 
Loud and ringing in character. Not infrequently the peripheral ar- 
teries (the Bubelavians, brachials, carotids, ra dials, and femorals) 
may l>e seen to pulsate with each systole of the heart, This sign is 
most frequently observed in eases of hypertrophy <»f the left 1 
tricle, which are due to aortic regurgitation, but is by no means 
peculiar to this disease and may l>e repeatedly observed when the 
cardiac liypcrtmphy i> due to nephritis or muscular work. I h 
frequently observed it in athletes, blacksmiths, and others whose 
muscular work is severe. 

The radial pulse wave has no constant characteristics, but de- 

1 This is dm* partly to a stretch ins; of (lie aorta, produced by the increased 

weight of the lie a it. 

Tost mortem hypertrophy of the left ventricle is often found despite the 
absence of the above signs iu life 



pen (Ik rather upon the cause which has produced the hypertrophy 
than upon the hypertrophy Itself. 

rtrdiae. Hypertrophy Affecting Especially tks Right Ventricle. 

h ia much mora difficult to be certain of Hie existenoe of en- 
largement of the right ventricle than of tin' Left, Practically we 
have but two reliable physical signs; 

IB the transverse diameter <rf the heart, 98 shows 
position of th« apex impulse ami by percussion ot* the 
borders of the heart j and 
($) Accentuation of the pulmonic second sound, which in 
palpable as well as audible. 

Tin- apex beat is displaced both to the left and downward, M 
'//v fti /A#» /f7>. in cases of long-standing mitral disease, the 
cardiac impulse may be felt in miil-axilla, several inches outside the 
nipple, and yt not lower down tnan the sixth LntercostsJ ipace- 
b a small percentage of cases (£«., when the ri^ht auricle ia en- 
gorged), an increased area of d illness to the light of the sternum 
ay be demonstrated. Accentuation of the pulmonic second sound 
is almost iuvariabl y present in hypertrophy of the right ventricle, 
though it is not peculiar to that condition. It may be beard, foi 
ample, in eases of pneumonia when no such hypertrophy is pros- 
t, but in the vast majority of cases of cardiac disease we may 
infer the presence and to some extent the amount of hypertrophy 
f the right ventricle from the presence of a greater or lessee ac- 
tuation of the pulmonic second sound. The radial pulse shown 
nothing characteristic of this type of hypertrophy* 

Epigastric pulsation gives us no evidence of the existence of 
hypertrophy of the right ventricle, despite contrary statement- in 
many text-books. Such pulsation is frequently to be seen in per- 
sons with normal hearts, and is frequently absent when the right 
entricle is obviously hypertrophied. It is perhaps most often due 
to an unusually low position of the whole heart, 




Dilatation 0* THS IIkakt, 

( 1 i A< utc Dilatation. - -Immediately after severe muscular exer~ 
l ion, B8j fax example, at the finish of a boat race, or of a two-mile 
run (especially in pereona not properly drained), an acute dilatation 
of the heart may OCCOr 3 and in debilitated or poorly nourished sub- 
jects such an acuta dilatation may be serious or even fatal in its 

( 2 ) Chrunic dilatation comes on gradually as a result of valvu- 

Viti. Iff, -Dlliiffd Hi'jm-L From \ . Zli.TllaJeri's AtlftS- 

lar disease or other cause, and gives rise to practically the samt 
physical signs as those <d 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: 

(a.) F*>t'Wt>niss and irregularity of the apex impulse and of the 
radial impulse, (b) enhtrtjimmt of the heart, as indicated by inspec- 
tion, palpation, and percussion, and (sometimes 1 ) ('■) murmurs indi- 
cative of stretching of one or another of the valvular orifices. 



Dilatation of tke Lrft Vmtriete, 

Inspection shows little that En not better brought oat by pelpa- 
ii. Palpation reveals a "flapping" cardiac impulse, or a vague 
shock displaced both downward and to the left and diffused over 
an i -normally large area of the cheat wall. Percussion verifies 
the position of t lie cardiac impulse acid sometimes shows an unuati* 
ally bltlnt or rounded outline at the apex of the heart, 

Auscultation, the first sound is usually rmj ahwt ami sJtarjt, 
but not foefoie unless it is accompanied by a murmur. In case the 
mitral orifice is bed a-^ to render the valve incompetent, or 

in case the muscles of the heart aw so Fatigued and weakened that 
they do not assist in dosing the initial m-iiicr, a systolic murmur is 
t** be beard at the apex of the heart, This murmur i* transmitted 

■.ilia and back, but does nut usually leplaOS the = first sound 

of the heart. The aortic second sound, as heard in the aortic area 
and a1 the apex, is feeble. 

Dilatation of the right ventricle of the heart ia manifested by an 
increase, in the area of cardiac dnlncss to the right of the sternum 
(corresponding to the position of the right auricle), by feebleness of 
the pulmonic second sound together with signs of congestion and 

engorgement of the longs, and often l>y a systolic murmur at the 
tricuspid valve; La., at or near the root Of tin- cnsifnrm cartils 

When this latter event occurs, one may have also systolic pulsation 
in the jugular veins and in the liver (see below, p. l'.» I U 

hi eases of acute dilatation, such as occur in infectious fevers 
or at the end of weil-oontested races, there is often to be heard a 
systolic murmur loudest in the pulmonary area and due very pos- 
sibly to a dilatation of the conns arteriosus. 

The diagnosis of dilatation of the heart seldom rests entirely 
upon physical signs referable to the heart itself* 111 acute cases 
our diagnosis is materially aided by a knowledge of the cause, 
which is often tolerably obvious. In chronic cases the Ijest evi- 
danee of dilatation is often that furnished by the venous stasis 
which results from it. 



The commonest and on the whole the least serious of valvular 
lesions is incompetency of the mitral, [1 remits hi most cases 
from the shortening, stiffening, and thickening of the valve pro- 
duoed by rheumatic endocarditis in early life. It is the lesion pn 
cut in most oases of chorea (see Figs. 88 and 89). 

Ttrnpofufif a&d curable mitr*tf rogvrgiiatum may result from 
weakening of the heart uiusele, which normally assists m rinsing 
the mitraj orifice through the sphincter-like rmiti aft ion of its cir- 
cular fibres. 

Great muscular fatigue, Mich as is produced by a hard boat 
race, may result in a temporary relaxation of the mitral sphincter 
or of the papdllarjr muscles sufficient to allow of genuine but tem- 
porary and cnrable regurgitation through tlie mitral orifice. In 
conditions of profound nervous debilil incut, or exhaustion, 

similar weakening of the cardiac muscles may allow of a teak 
through the mitral, which ceases with the removal of its cause. 
Stress lias l*ecn laid upon these points by Prince, and recently by 

Mitral insufficiency due to stretching of the ring into which the 
valve is inserted occurs not ^infrequently as a result of dilatation 
of the left ventricle, and is commonly known as rotatim inmqffie* 
of the mitral valve. The valve orifice can enlarge, the x'alve 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 result* of any form of mitral leakage occur in this order: 

1. DtiateHon or hypertrophy of the irft auricle, which has to 
reeeive 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 



as readily as it should ; h*nce the blood "hacks up M to the 
kings and thereby frigre*seti the work which the right ve&triclft 
must do in order tu force the blood through them. Thus result 
cedeuia of the lungs, ami 

i it;. b». 


Fm. SB. -Normal Heart during dyrtule* Mitral valve closed; blood flowing through Ife&Qptsj 
aortic valves ffito the aortu 

Flo. W. —Micnd Regurgitation. The heart Is Id syatule sad the arrow* straw tb» current flowing 
back In the left auricle as well as forward tutu the aorta, 


(3) Hypertrophy and dU<itat%&% <& the right ventriele, which in 
tani becomes or latex overcrowded bo that the tricuspid 
valve gives way and tricuspid leakage oocow. 

(4) The capacity for hypertrophy pOBses&ed by the right atu 
is soon exhausted, and wo get then — 

(♦V) General psatntj $taevt % which shows itself lirst b 
pulsation in tlio jugulars and in the liver and later in the ti 
drained by the portal and peripheral veins. Thfi :* in- 

creases the work of the left ventricle, and t — 

(6) Hfptrtropky ami dilatation tf the left ventricle. Hyper- 
trophy of the left ven trie] e is also produced by the increased work 
aty t<> maintain BOSOM vestige ot sphincter action at th»- leaky 
mitral orifice, as well as by the labor of contracting upon the extra 
quantity of blood delivered to it by Hie enlarged left aui > 

\i last the circle is complete. Every chamber in the heart is 
enlarged, overworked, ami failure is imminent. 

Returning now to the signs of mitral regurgitation. w« shall find 
it most convenient to consider first the type of regurgitation pro* 
dueed by rheumatism and resulting i" thickening, stiffening, and 
retraction of the valve. 

Physical Biases, 

(er) First Singe — Prior to the Establishment of ComfwriMtion. 

We have but one characteristic physical sign: 

A systolic murmur heard loudest at the apex of the heart, trans- 
mitted bo the back (Mow or inside the left scapula) and to the left 
axilla. The murmur is not infrequently musical in character, and 
when this is the case diagnosis is much easier. Systolic musical 
murmurs so transmitted do not .occur without Valvular Leakage, 
Knsenbach believes that adherent pericardium is capable of produc- 
ing such a murmur, but only, if I understand him rightly, in case 
there is a genuine mitral leakage due to the emban:t : brace 

of the pericardium which prevents the mitral orifice from closing. 

Functional w or **heemic M murmurs are rarely heard in the 
back, and very Finely, if ever, have a musical quality. 


Cases of mitral regurgitation are not very often seen at this 
stage, but in acute endocarditis after the fever and anaemia have 
subsided, or in chorea, such a murmur may exist for days or weeks 
before any accentuation of the pulmonic second sound or any en- 
largement of the heart appears. I have had the opportunity of 
verifying the diagnosis at autopsy in two such cases. 

(b) Second Staye — Compensation /established. 

As long as compensation remains perfect, the only evidence of 
regurgitation may be that obtained by auscultation, and I shall 
accordingly begin with this rather than in the traditional way with 
inspection, palpation, and percussion. 

The distinguishing auscultatory phenomena in cases of non- 
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 the angle of the left 
scapula (so far the signs are those of the first stage, above de- 

(b) A pathological accentuation of the pulmonic second sound. 
This is the minimum of evidence upon which it is justifiable to 

make the diagnosis of compensated mitral regurgitation. In the 
vast majority of cases, however, our diagnosis is confirmed by the 
following additional data : 

(r) Enlargement of the heart as shown by inspection, palpation, 
and percussion. 

The pidse in well-compensated cases shows no considerable 
abnormality. When compensation begins to fail, or sometimes 1 Mi- 
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 mitral disease than in 
that of any other valve ; it may continue for years and be compat- 
ible with very tolerable health. 


Returning now to the details of Ihe sketch just given, we will 

take up tirst 

(a) T/n* Mia-mur, — in children the murmur of mitral regui 
tion may be among the loudest of all murmurs to be heard in vai- 








Diagram to Kourv*.nt svhi.iU. MFtnil Murmur. The ht»vy llpea rrprtwnjl Dm zwrmaJ 
cardiac round* nnd tin* light ltn^ \ut- murmur, u-hii<h *n Uiis *mvh* due* tun rvulao «ie tlt>; 
sound and " topers " (iff rbarai'LprlKtf rally at the end, 

vular disease, but this dues nut oeoeaearify imply dial the lesion is 
a very severe one- A murmur which gr&Wi louder under observa- 
tion in a weJl-teompen sated valvular lesion may mean an advance of 
the disease, but if tin first seen after eompenaatioo his 

failed a faint, variable whiff in the mitral area inav mean t 
W m 'st type of lesion. As the patient improves under the influence 
- A i' st and cardiac tonics, such a niunnur nun grow very imn-h 
louder, or a muniiur previously inaudible may appeal* 
Tie- length of the murmur varies a great deal in d 
and is nut of any great practical inn It rarely end* 

abruptly, but usually "tails off 1 * at the end of systole (see Fig. 90 >- 
MuHcaJt murmurs ire heard inure often IS mitral regurgitation than 
in any other valve lesion, but the musical quality rarely lasts 
throughout the whole duration of the murmur, contrasting in this 
respect with musical murmurs produced at the aortic valve. The 




I H i ■ ■ 1 

Fin. i«.— Sftrtolir Mitral Murmur Replacing tpe First Brood ><r itn' Heart. 

first sound of the heart may or may not be replaced by the murmur 

(see Fig, 91), When the sound persists and is heard eithei 
or before the murmur, one can infer that the lesion is rela" 
slight in comparison with cases in which the first sound is wholly 

I MM -i'lai; LESiOm 

obliterated. Pmfatyttotic or lata Bystolic murmurs, which 

v heard in initial regurgitation, m said fro point to i rela- 
timely alight amount of rlinoarrfi in tin* valve («ee Fig. 90). Uns^u- 







► ns, ,t'.— Late Syaiollc Morraur. to* first a mod Is cli**r nwl an ttiiervnl intervene* between 

it «ml the utuimiir. 

bach claims that the late syitolfd murmur Is always due to organic 
tase of tin* valves and never oooan u i functional inurmur. 
When compensation fails, the imirinui- may altogether dtwppftag 

for a time, ami if the patient is then seen for the first time ami 
without rallying under tivntment, it may be impossible to 

F'wlrmnilH vhouJ 

kcu-'r^t here. 

to - Mltnl Rrguiyltutlon. 

Tttu murmur \s heard over I he shaded wv* u> well aa Id Hub 


make the diagnosis. The very worst cases, then, are those m which 
there is no murmur at all 

The murmur of mitral regurgitation is conducted in all directions, 
specially towurrl the axilfy and to the back (not around the 
i but direetlv). hi the latter situation it is usually loudef 


than it is in mid-axilla, and occasionally it, is heard as loudly in the 
back as an ywhere else. This is no doubt owing to the position of 
the left auricle (see Figs, 93 and 94). 

(b) After compensation is established and as long as it lasts an 
accentuation of the ijtuhnonie seetmrf xoimd is almost invariably to 
be made out, and may be bo marked that we can feel and see it, as 
well as hear it. Not infrequently one can also see and fet-l fUc 
pulsation of tin* rem us :irt*iiosus — nut the left auricle— in the m 
and third left interoortal sp*oe. ( Tt -nay be well to mention again 

Sjttollr murmur. 

Itfl. 1*4 . — Mitral Regurgitation. SI un m i r UhiutI . ■ ver the shaded ml 

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 sound, since this is true in the vast majority of eases 
in healthy individuals under thirty years of age, Pathological ac- 
centuation of the pulmonic second sound means a (/renter intensity 
of the sound than tee have a right to expect at tht age of the Individ- 
ual in question.) Occasionally the pulmonic second sound is redu- 
plicated, but as a rule this points to an accompanying stenosis of 
the mitral valve. At the apex the second sound (£*.* the trans* 
mitted aortic second) is not infrequently wanting altogether, owing 



relatively small amount of blood which ncoils upon the 
aortic "aives. 

(e) Enlargement »/ th* heart) and more especially of the right 
ventricle, ifl generally to be made out, and in the majority of MM 
this enlargement is manifested by displacement of the apex impulse 
both downward ami toward the left, but more especially to the 
left. Percussion mn firms the results of inspection and palpation 
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. 91). 

In children (in whom adhesive pericarditis often complicates 
the disease) a systolic thrill may not infrequently be felt at the 
apex, and the preeordia may be bulged, and even in adults such a 
systolic thrill is not so rare as some writers would have ns sup- 

(d) Thf puts*, 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 period is less common in pure 
mitral regurgitation than in cases complicated hy stenosis. 

(/-I Third Steffi —lutUimj Cevtpmsation. 

Wlieu compensation begins to fail, the pulse becomes weak and 
irregular, arid many heart beats fail to reach the wrist, but there 
is still nothing characteristic ,iln mt the pulse, winch di tiers in no 
respect from that of any ease of cardiac weakness of whatever 

it ) Evidence of venoits 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 
faii the patient begins to complain not only of palpitation and car- 
diac distress, but of dyspnoea, orthopnoea, and cough, and examina- 
tion reveals a greater or lesser degree of cyanosis with pulmu- 


nary <Bdema manifested by crackling rales at the base of the lungs 
posteriorly, ami possibly also by haemoptysis <►■ deuces of 

hydrothorax (see below, p. U72), If compensation is not re- 
lished* tin- ri^Lt ventricle dilates, the tricuspid becomes incompe- 
tent, the liver becomes enlarged and tender, dropsy becomes 
end, thy heart and pulse become more and more rapid and < 'regular, 
khe In-art murmur disappears and is replaced by a confusion of 
short valvular sounds, u gallop rhythm M or *d*l%rium eordi* t n often 
considerably obscured by tin* noisy, Labored breathing with numer- 
ous moist rales. In a patient seen for the first time in such a con- 
dition diagnosis may l>e impossible, yet mitral disease of some type 
illy \h> suspected, since murmurs produced at the aortic 
ralve are not so apt to disappear when compensation fails. The 
relative tricuspid insufficiency which often occurs is likely to maul- 
leal itself by an enlargement of the right auricle, soim-timi-s demon- 
strable by percussion and later by venous pulsation in the neck and 
in the liver. 

{d) Differential IH(jfjnQ9%** 

The murmur of mitral regurgitation may be confused with 

(1) Tricuspid regurgitation* 

(2) Functional murmurs. 

(3) Stenosis or roughening of the aortic valves, 
(1) The postmortem 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 reoogftin a tricuspid 
regurgitant murmur. Only #5 out of liD eases of tricuspid regurgi- 
tation found at autopsy were recognised during life. Alibutt*» 
iignres from Guy's Hospital are similar. In the majority of these 
eases, mitral regurgitation was the lesion on which attention was 
concentrated during the patient's life. This is all the more excus- 
able because 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 at™ a 
mitral regurgitant murmur, it may be impossible under such cir- 
DUmstanoea to distinguish it from the tricuspid murmur. Some- 



times the two arc of different pitch, but more often tricuspid regor< 
citation must be recognized mdirtctltf if at all, i.e., through the 
ftrido&oe given \*y venous puliation in the jugular veins ami hi the 
liver. Tricuspid murmurs arc not transmitted t<> tin* left axilla 
ami do not cans-' accentuation of the pulmonic seeo&d eoand, ul~ 
though they air compatible with auch accentuation. They are to 

KM distinguished from the murmurs of mitral regurgitation by their 
din* at of maximum intensity, possibly by a difference iu 

pitch, but most clearly by the concomitant phenomena of venoiiH 
pulsation above mentioned. 

(2) " Functional H 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 beat over the pulmonic valve or 
just inside or outside the apex beat (Potato). They are faint or 
inaudible at the end of aspiration, ami are more influenced by 

ition than organic murmurs are. In the upright position they 
often very faint. They ate rarely transmitted beyond the 
precorflia and are unaeeompunied by any evidences of enlargement 
of the lie art, by any pathological accentuation of the pulmonic 
second sound, 1 or any evidences of engorgement of the (nags, or 
general ran item, 

<.'pi Roughening or Qarrowiug of the aortic valves may produce 
fBtolic murmur with maximum Intensity in the ascend right m- 

r*3tal space, but this murmur is not infrequently heard all over 
the preeordia and <piite plainly at the apex, ao that it may simulate 
thfl murmur of mitral regurgitation. The nortie murmur may In- 
deed be beard more plainly at the apes llian at any other point tap 
ospi the ieoond right intercostal space, owing to the fact that the 
right ventricle, which occupies most of the precordial region be- 
tween Hm aortic and mitral areas, does QOt bud itself 'well to the 
propagation of certain types of cardiac murmurs. Under these 
circumstances "a loud, rough aortic murmur may be heard at the 

ft BlUBl be remembered that in chlorosis, a disease in which functional 
murmurs are especially prone to occur, the pulmonic second sound is often 
surprisingly toad, owing to A retraction of the left lung, which uncovers the 
root of the pulniouie artery. 


apex as a smooth murmur of a different tone " (Bfoadbeut 
a murmur is uot, however, likely to be conducted to the axilla or 
heard beneath the left scapula, nor to be accompanied by accentua- 
tion of the pulmonic second sound nor evidences of engorgement 
ot the lungs and general venous system. 

IL MiriiAi, Stenosis. 

Narrowing or obstruction of the mitral orifice is almost invari- 
ably the result of a chronic endocarditis which gradually glues to* 
getfaer the two flaps of the valve until only a funnel -shaped open- 
ing or a slit like a buttonhole is left (see Figs. 95 and SH$)« As we 
examine post mortem the tiny slit which may be all that is 1** t t of 
the mitral ortiice in a case of longstanding, it is difficult to ooa- 
eeive how sufficient blood to carry on the meeds of the circuJ 
could he 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 pun' mitral regurgitation. By some ttbeetrera the 
advent of stenosis is regarded as representing an attempt ai 
pensation for a reduction of the previous mitral leakage. Others 
consider that the stenosis simply increases tlie 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 in women, 

It is also curious that so many eases are associated with pul- 
monary tuberculosis. 

Physical Si*/ it*. 

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 valvular lesion of the heart. In the 
early stages of the disease the heart may appear to be entirely nor- 

1 Penwlek'a explanation, viz., that Lhe sedentary Life of women favors 
-W MUttftlve inflammation of the valve and it* curtains, resulting in 
>Htft, does not ae*m to me to be satisfactory. 



inal if the patient is at reft, md especially ^ MnuniDtd 01 the re- 
cumbent position, c-haractvi-istic signs being elicited only by exer- 
tion; or again a murmur which is easily audible with the patient 
in the upright position may disappear in the recumbent position ; 
of a murmur may be heard at one visit, at the next it may be im- 



Kit*, f«. 

FiG **.— Diagram to Represent the Position of the Valves In the Normal Heart during DiartoK 
tht* Open Mitral Allowing the Blood to Flow Down from the Left Auricle, the Aortic Clow* I. 

Wl(t. Ew.- Mitral Stanoiia— Period of Diastole. The Wood flowing from the toft auricle I* ob- 
itructed bj the thickened aud adherent mitral curtain*. 


possible tu elicit it by any manoeuvre, while at the third visit it may 
be easily heard again* These eharaeteristies explain to a certain 
extent the fact that differences of opinion so often an 
the diagnosis of mitral stenosis, aud that out of forty-eight i 
which this lesion was found at autopsy at the Massachusetts General 
Hospital, only twenty-three were recognized during life. No com- 
mon lesion (with the exception of tricuspid regurgitation) has been 
so frequently overlooked in our records. 

I shall follow ltroadljtfiit in dividing the symptoms into three 
stages, according to the extent to which the lesion has progressed. 


In the first stage inspection and palpation show that the apex 
beat is little if at all displaced, and percussion reveals no iurream 

fid, W, -Mitral BtMMfc 

in the an tt of cardiac dulfiess ; indeed, in rare cases the heart may 
bi smaller than usual. If one lays the hand lightly over the origin 
of the apex heat, one can generally feel the purring preaysttdtn thrill 
which is so characteristic of this disease, mure common indeed than 
in any other. This thrill is more marked in the second stage of 
the disease, but can generally be appreciated even in the first. Jt 
runs up to and ceases abruptly with the very sharp first sound, 



the sudden shock of whieh may be appreciated wen by palpation. 
I 'he thrill is 90roetiines palpable even when nc murmur can be 

I, and often tin* thrill is transmitted tc thr. axilla when the 
innnurn' is confined k> the apex region. On auscultation one 

i specially liter tie- patient has been exerting himself, mill 
particularly if he leans toward and to the left, :i ttari kwpitcked 
rnmbU ttr roil immediaislff pfti&ding the it/Hole and increasing 
in inte unity as it approaches the Hrst aouutl. At this stage of 
the disease the seen! id B0UJld oas still be heard at the apex. The 
first sound is wy sharply accented <»r snapping, and communi- 
cates a very decided shock to the ear when a rigid stethoscope 
is used. As anile, th» j murmur is finely confined to the region 
of the apex heat ami not. transmitted any r-onsidi»rablc distance in 
any direction. I hav^ situ cases in which it was to be beard only 








Hf,. H —The Murmur of Mitral Stenrals -Firs* SUpe* The p!n*?e of the murmur »ml its rTe*- 
r«Hflo riwnwiter ore indicated l>y the position of the light llwgjiut to-fore thtj Drat sound 
■ml by W»ir Increasing lenjrth. 

over an area the size of a half-dollar, 1 Very characteristic of mi* 
tral stenosis is a prolongation of the diastolic pause BO I rial the inter- 
val beween the second sound of one cycle and the first sound of the 
next is unduly long, Occasionally the diastolic sound is redupii* 
catod f M dunhli".shncksound*'— Sansumiai this stage of the disease, 
but this is much more frequent in the later j. liases of the lesion,' 

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. 

1 It may, however, be widely transmitted t. the left axilla ai d auui- le in 
tfae back or even over th : whole of the left chest, especially when the stenosis 
Is combined with regurgitation. 

f This is the opinion f moat obsei ■ ■ ■!■-. Sansora states that the "double- 
fibock sound" may precede ail other evidences of mi tral stenosis. 


J I. 

In the second stage the murmur and thrill are usually longer and 
may occupy th: whole of diastole, beginning with considerable in- 
tensity just after the reduplicated second sound, quickly diminish - 




11111 1 I 




PM. m— Type of Presystolic Murmur Often Heard In the Second Stage of Mltnl 
Bare Hit- murmur Ulls UK irftQii ol IllMfcHl. with a gradual Infr^ase ut Intensity 
pmarhes the Ilrat sound* No scornd snund 1m audible nf Un ipn, 

Log until it is barely audible, and thru again increasing with a 
steady crescendo up tu the tu-st Bound of tlie next cycle.' Th 
changes may be graphically represented as in Figs, 97 and 98. Dia- 
stole is now still more prolonged, so that the characteristic rhythm 
of this lesion is even more marked than in the earlier stages of the 
disease. In many eases at this stage no seoond sound is to be heard 
at all at the apex, although at the pulmonic orifice it is loud and 
almost invariably double, (This is jiie of the reasons for believing 
that the second sound which we usually hear at the apex is the 
transmitted aortic second sound. In mitral disease the aortic valves 


Ln ii M 

1 1 1 1 1 in 





Via> 100,— Type uf rrrsyBiollc Murmur Somi*Umc« Heard in tin- Swamd Mtfetit Mlirml B Xjuw I i 
There Ja n double crescendo. Tbe second bouh<] warn litpMflfel 

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 — 

1 Rarely on© finds a crescendo hi the middle of a long presystolic roll with 
* diminuendo && It approaches the first sound. 



sometimes as far as the mid -axillary line, and often descends to 
the sixth interspace. Occasionally the cardiac dulneaa is increased 
to the right of the sternum. 

The instability ami fleeting character of the murmur in the ear- 
lier stages of the disease are much less marked in this, the second 
itngri The first Bound at the ajtex still retains its sharp, thump- 
ing quality, and is often audible without tlie. murmur m the baek. 

The irregularity of the heart is genemJIy greater at this stage 
than in the earlier one. 


The third stage of the affection is marked by the disappearance 
of the character! stie murmur, and is generally synchronous with 
the development uf tricuspid re gu rotation. The right ventricle 
becomes dilated sometimes very markedly. Indeed, it may produce 
;i visible pulsating tumor below the left costal bonier and be mis- 
taken for cardiac? aneurism (Osier)* The snapping first sound and 
the "double-shock w BOUUd usually remain amliHe, l>nt the latter 
may be absent altogether. Diagnosis Ln 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, 
Iwth in force and rhythm. At times a presystolic thrill maybe 
felt even when no murmur is to be heard. 

The pulse shows nothing characteristic in many cases except 
that early and persistent irregularity which han been already al- 
luded to. In other cases the wave is low, long, easily compressnl, 
but quite perceptible between beats j but for the lack of sufficient 
power in the cardiac contractions the pulse would be one of high 

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 [ were a luxury rather than a necessity. 

Under the influence of digitalis the pulse is especially apt to 


nme the I*ltf* n/nttt! type in mitral stenosis. Every other beat is 
then so abortive that it fails to send a wave to the wrist, and the 
weak beat is succeeded by a pause. According to Broadbent the 
weak beat eomepoods to an alxjrtive contraction of the left 
triele accompanied by a normal contraction of the right ventricle, 

fiat for each two strong bents of the right side of the heart we 
have one strong and one weak beat of the left side of the heart. 

Mitral stenosis is in the great majority of cases combined vwth 
mitral regurgitation, arid it often happens that the agnn of regur- 
gitation are so ninth nmre prominent than those of stenosis that 
the latter escape observation altogether, QSpecislly in the third 
stage of the disease, when the typical presystolic roll has disap- 
peared. In such cases combined stenosis and regurgitation is to be 
distinguished from pure regurgitation by the sharpness of the t 
sound, which would W very unusual at this stage of a case of pure 
initial regurgitation. The presence of reduplicated second sound, a 
u double-shock sound w at lite outset of the prolonged diastolic pause, 
and of great irregularity in force and rhythm, is further suggestive 
of mitral stenosis. 

Mitral stenosis is apt to I" 1 associated witfc haemoptysis, with en- 
gorgement of the liver and ascites, anil especially with arterial em- 
bolism. No other valve lesion is so frequently found associated 
with embolism. The lungs are generally very voluminous, and 
may therefore mask an increase in area Of intensity of the cardiac 

liijQ'rr* ft f\*i I fh'ftrftt OS it. 

I have already discussed the difficulty of distinguishing a double 
lesion at the mitral valve from a simple mitral regurgitation « see 
above, p. 161), 

Other murmurs which may be mistaken for the murmur of mi- 
tral stenosis are; 

Of) The Austin Flint murmur. 

(?*) The murmur of tricuspid stenosis. 

(<) A rumbling murmur sometimes heard in children, after an 
attack ol pericarditis. 



I The Austin Flint murmur* 

In 1S02 Austin Flint studied two cases in winch daring life a 
typical presystolic roll was audible at the Apex of ike heart, yet in 
;viurli post mortem the mitral valve proved to 1m' perfectly normal, 
and the only lesion present was aortic insufficiency. This observation 
has since been verified by ( toler. Brain well, Gairdner, and other Com- 
pftteftt observers. At the Massachusetts General Hospital we have 
had seven such eases with SXltopsy, JTet, despite repeated confir- 
mation, Flint's observation baa remained fur neatly 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 moan 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 era be pro* 

daeed at the apex in eases of aortic regurgitation has \ n much 

debated. Some believe it is due to the impact of the sortie regur- 

int 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 mingling of the two currents of blood, that from 
the mitral and that from the aortic orifloe, is suttieient to prodnee 
the murmur. 

Hetweeu the H Austin Flint murmur " thus defined sad the mur- 
mur of true mitral stenosis, complicating aortic regurgitation, diag- 
nosis may be impossible, Tf there are no dilatation id the mitral 
orifice and uo regit imitation, cither from this cause or from deformi- 
ties of the mitral valve its^df, any evidence <>f engorgement of the 

pulmonary circuit (accentuation of tin- pulmonic i ml sound, 

Qsdema of the lungs, hemoptysis, and cough) speaks in favor of an 
actual narrowing of the mitral valve, while the absence of such 
signs and tbi presence of a predominating hypertrophy of the left 
ventricle tend tn convince us that the murmur is of the type di- 

bed by Austin Flint, i.e., that it ihies not point to any stcn- 
Deifl of the mitral valve. The sharp, snapping first sound and 
svstolic shock so characteristic of mitral stenosis are said to be 


modified or absent in connection with murmurs of the Austin Flint 


(b) Tricuspid obstruction, 

Luckily for us as diagnosticians, stenosis of the tricuspid vali 
is a very rare lesion* Like mitral stenosis it is manifested by a 
presystolic rolling murmur whose point of maximum intensit \ 
sometimes over the traditional tricuspid ami, 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 mitral 
stenosis is further increased by the fact that the two lesions fcfmosl 
invariably occur in conjunction . Hence Wfl have two presystolic 
murmurs, perhaps with slightly different point* of maximum inten- 
sity aad possibly with a difference in quality, but often quite 
distinguishable from each other. In the vast majority of ca 
therefore, tricuspid strict i^ tirsi recognized at the autopsy, and 
the dia^pioais is at. beart a vei v difficult one. 

(r) Bro&dbent, Koscnbach, and other* have noticed in children 
who have just passed through an attack of pericarditis a rumhliug 
murmur near the apex of the In-art, which suggests the murmur t>| 
mitral stenosis. It is distinguished from the latter, however, by the 
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 
are important, since their prognosis is much more favorable 
than that of mitral stenosis, 

Phear (Ltni<(t } 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- 
tation at autopsy; in 20 of these there was adherent pericardium 
at autopsy J in 9 nothing more than dilatation of the left ventrieh 
was found. In none of these cases was the snapping first sound, 
bo common in mitral stenosis, recorded during life. 

It should be remembered that patients suffering from mitral 
stenosis are very frequently unaware of any cardiac trouble, arul 
seek advice for anaemia, wasting, debility, gastric m puirooan 
complaints. This is less often true in other forms of valvular d 



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 previously. Such cases may present 
no signs of disease except the irregularity— yet may turn out to 
be mitral stenosis. 

1\\ Aortic ftseuBGiTATtox. 

Rheumatic endocarditis usually occurs in early life and most 
often attacks the mitral valve. Tin- commonest cause of aortic dis- 
ease on the other hand — arteriu-sclerosis — is a disease of late mid- 

lAfi&a/ {ftejji 

niu«u»|r in Af«fUr Ni-purfrJLutkin* TImj bknui is flowing back tbrougb tbe ptumpjr *nd 
Incompetent aortic valve*. 

die life, and attacks men much more often than women. When 
we think of aortic regurgitation, the picture that rises before us is 
usually thstt «>f a man past middle life and most often from the 
who live by rnanttal labor. Nevertheless cases occur at all 
ages and in both sexee^aud rlienmatic endocarditis does not spare 
rhe 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 ah crttnfa ff 
of the cusps (see Fig. 101), In rare cases an aortic casp may be 
ruptured as a result of violent muscular effort, and the signs and 


symptoms of regurgitation then appear suddenly, But as a mk 
the lesion mines on slowly and insidiously, and unless discovered 
accidentally or in the course of routine physical examination it may 
exist unnoticed for years. Dropsy and oyai relative ly late 

and rate, and the symptoms which Brat 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 i^rili» "*curs. If 

it doefl CXXmr, it is certainly exceedingly rare, as the aortic ihi£ ii 
tough and inelastic. 

Dilatation of tka aortic arch— practically diffuse aneurism— oc~ 
CUT9 <n ttlmmt rvery ease of aortic regurgitation, and produces sev- 
eral important physical signs. This complication is a very well- 
knowa one, but lias not, I think, been sufficiently insisted on in 
text-hooks of physical diagnosis. It forms part of that general 
enlargement of the arterial tree which is so characteristic of the 

Physical ftiytis* 

Inspection reveals more that is important in this disease than 
in any other valvular lesion. In extreme cases the patient's face 
or hand may blush visibly with every systole. Not iuftvpn-nth 
one can make the diagnosis across the room or in the street 1 > 
iug the violent throbbing of the carotids, which may be such as to 
shake the person 'a whole head and trunk, and even the bed on 
which he lies. No other lesion is so apt to cause a heaving of the 
whole chest and a bobbing of the head, and no other lesion so often 
causes a bulging of the precordia, for in no other lesion is the en* 
largemetit of the heart so great (cor bovinum or ox-heart). The 
throbbing of the dilated aorta can often be felt and sunn-times seen 
in the suprasternal notch or in the second right interspace. Not 
only the carotids but the subelavians, the brachials and radiate, 
the femoral and anterior tibial, and even the digital and dorsalis 
pedis arteries may visibly pulsate, and the characteristic jerking 
quality of the pulse may he seen as well as felt. This visible pul- 
sation in the peripheral arteries, while very characteristic of aortic 



regurgitation, is occasionally seen in cases of simple hypertrophy of 
the heart from hard muscular work (*.$*$ iu athletes). If the ar- 
teries are extensively calcified, their pulsation become much less 

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 increasing both their length 

Pubtutiuu ut the Jugulum* 

Pulsating or- 

Diastolic murmur. 

THsplimsd ranllat 

ML ]0fc— Aortic Regurgitation, Showing Position of the Diastolic Murmur and Areas of Ylalhte 


their diameter. Tlie visible arterial trunks become tortuous 
distended, while the arch of the aorta is diffusely dilated and 
Incomes practically an aneurism (see Fig. 102). With each heart 
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 downward 
and outward (but especially the former), corresponding to the hy- 
pertrophy and still more to the dilatation of the left ventricle, 


which is usually very great, aiul to the downward sagging of 
enlarged aorta. Dilatation is in this disease an essentially helpful 
and compensatory process. In a smalt proportion of the cases nn 
enlargement of the heart is to 1h» demonstrated. This was true of 
5 out of the last 67 cases which I have notes of, and geuer 
denotes an early and slight lesion. Not at all infrequently 
rinds a systolic retraction of the interspaces near the apex I 
instead of a systolic impulse. This is probably due to the neg;v 
pressure produced within the chest by the powerful contraction of 
an liypertrophied heart. In the suprasternal notch one often 1 
as well as sees a marked systolic pulsation transmitted from the ; 
of the dilated aorta, and sometimes mistaken for saccular aneur 

Arterial pulsation of the liver and spleen are rarely denim - 
strahle by a combination of sight and touch. 

( tynUary Pulsation, 

If one passes the end of a, pencil or other hard substance i 
or twice across the patient's forehead, and then watches the reM 
mark so produced, one can often see a systolic flashing of the hypcr- 
semic area w T ith each beat of the heart. This is by far the I 
method of eliciting this pheiumieuuii. It may also be seen ii a g 
slide is pressed against the mucous membrane of the lip so as j 
tially 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 inequality in the pressure made by the ob- 
server upon the glass slide or upon the nail. Very slight movemi 
of the observer's fingers, even such as are caused by his own ptj 
may give rise to changes simulating capillary pulsation. Capillary 
pulsation of normal tissues is not often seen in any condition other 
than aortic 1 regurgitation, yet occasionally one meets with it in 
diseases which produce very low tension of the pulse, such as 
phthisis or typhoid, anaemic and neurasthenic conditions, and I 
have twice seen it in perfectly healthy persons. In such cases the 
pulsation is usually less marked than in aortic regurgitation. 
Barely pulsation may be detected in the peripheral veins. 

1 Jumping toothache and throbbing felon are common examples of capil* 
lary pulsation in Inflamed areas. 




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 

is extreme, when it becomes wavy and diffuse. 

ular notch a systolic thrill is often to be felt. 
in the precordia is very rare. 

The pttUe ia important* usually characteristic 

In the supraclavic- 
A diastolic thrill 

The wave rises 



\ \\ \ 

J\ w 

v/ V V 

no. 1«»— SphygiuogTaphJe Tnulnff of the ** /%fc»tu* Crttr " In Aorti? Regurgitation. It* coU 
l&psiUK character la well shown. 

very suddenly and to an unusual height, then collapses completely 
and with great rapidity (pulsus ceier) (see Figs. 103, 104). 

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 emp- 
tying the artery* The quality of the pulse in aortic regurgitation 


la iliu* to the fact that a large volume of blood is suddenly aft 
i ihly thrown into tin- aorta by tin- li yportruphietl and dilate 
\f nt riflo, thus causing the characteristically sharp and sudd* 
Iq tin- peripheral arteries* The arteries then empty th»*ins< il 
tti'tt diree&tofu nt on^e, forward into the ftapillariea arid backward 
nii i» tin* heart through the incompetent aortic valves; lien 
sudden collapse in the pulse which, together with its sharp anil 
suddmi rise, are its important eharut-teriatioB, The arteries are 
larg« and often elongat to lie thrown into curves. 

Not infrequently one ea& demoustrate that the radial pulse is 
dd-iyed 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 ($ thartftyrti on wp 
pravt siffitf much more so than in any other valvular lesion. 


Percussion adds but little to tin* information obtained by inspec- 
tion and palpation, but verities the results of these methods of in* 
vestigation respecting the increased size of the heart, and especially 
of the left ventricle, whirh may reach enormous dimensions, espe- 
cially in cases occurring in young persons. The heart may be 
increased to more than/tun' t'tmt's ifs normal weight. 


In rare cases there may lie absolutely no murmur and the diag- 
nosis maybe impossible during life, though ir may U* snap 
by reason of the above-mentioned signs in the fieripherai arteries. 
But although the murmur is seldom entirely absent, it is often so 
faint as to be easily overlooked. This is especially true in ea^s 
4 M-rii i ring in elderly people, and when the patient has been for a 
considerable time at rest. The difficulty of recognizing certain 
eases of aortic regurgitation during life is shown by the fact that 
out of sixty -five cases of aortic regurgitation demonstrated at au- 
topsy in the Massachusetts General Hospital, only forty-four were 
recognized during life. 



In the majority of cases, however, the characteristic £fastolia 

mrmwr is easily heard if one listens in the right place, ami whan 

leard it l& the most distinctive and trustworthy of aU cardiac una" 

tntr*. It almost invariably points to aortic regurgitation and to 

nothing else. 

The murmur of aortic regurgitation, as has been already men- 
tioned, is dfastoNa in time. 1 Its maximttm intensity is untatfy nut 

F?G, ju> — Position of the Point of Maximum Intenriiy uf tin* Murmur of Anitlc Re*rurgltHtt>m, 
The *•** we most tblrlciy coDgrrgattrt wfoem lb* murmur ta QtaMft UewftL 

itt fhi> oonvmtional aortie area (second HgkL in&enpae*)} but <>n t/tn 
b ft side of the sternum about the level qf the fourth l*ft costal otutir 
tutf. In about one-tenth of the cases, ami especially when the 
aortic arc]] is iimrh dilated, the murmur is best heard in fehi 
entional aortic area. I ►coaaionally there are two points at which 
it may be loudly heard— one in the second right interspace and the 
other at or near the apex of the heart, while between these points 

1 Another murmur, systolic in lime, which almost always accompanies 
le diastolic murmur, ia usually due to roughening of tfce edges of the aortic 
Of to dilatation of the aortic arch. This murmur ^_o»t not be assumed 
mean aortic atenoala (aee below, p. 180), 


the murmur ia faint. This is probably due to the fact that the 
lefl veutriele, through which kibe murmur if oondrobedj approaches 
the surface of tin' chest cmly at the apex, while the intermediate space 
is occupied by the right ventricle, whir-h often fails readily to trans- 
mit murmurs produced at the aortic orifice. 1. [uentlythe 
murmur of aortic regurgitation is heard with maximum int 
at the second or third left mstal cartilage or in the region of the 
enaiforui cartilage (see Fig. KKi). 

From its seat of maximum intensity (Ha., usually from the 
fourth left costal cartilage) the murmur ia transmitted in all direc- 
tions, but not often beyuud the preeordia. In about one-third of 
tlits cases it is transmitted to the. left axilla or even to the hack. 
It is sometimes to be heard in the subclavian artery and the 
great vessels of the neck; in other cases two heart sounds am 





Fio. l(W t — Short Dlutollc Murmur Not Replacing the Second Sound. 

audible in the carotid, but no murmur. The murmur is usually 
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, 106). Late diastolic murmurs are rare. The mur- 
mur may or may not replace the second sound of the heart. Broad- 
bent believes that when it does not obliterate the second sound, 
the lesion ia usually less severe than when only the murmur is to 
be heard. Allbutt 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 effeet upon the 
murmur — less than upon murmurs produced at the mitral orifice. 



The first sound at the apex is generally loud and long. There 
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 tilling 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 uceas ion ally a diujstoUr 
mammtrm well (Puroziez's sign). This diastolic murmur in the 
peripheral arteries, obtained on pressure with the stethoscope, is 
practically never heard except in aortic regurgitat inn . It is thought 
by aome to be due to the regurgitant eairent in the great vessels 
which in very marked cases may extend as far as the femoral ar- 
toy. Dumziez's sign is a comparatively rare one, not present in 
most cases t«f aortic regurgitation, and usually disappears when 
compensation fails. 

Siinutttttif and Dtffftu'tttitt! DiaffnotU* 

A diastolic murmur heard with the maximum intensity about 
the fourth Irft costal cartilage (less often in the second right inter- 
space or at the apex) gives us almost complete assurance of the 
existence of aortic regurgitation. From pulmonary regurgitation, 
BD rxceedingly rare lesion, the disease* is distinguished by the pies- 
ence *of predominating hypertrophy of the left ventricle with a 
heaving apex impulse and by the following arterial phenomena : 

(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 143) are occasionally dias- 

Lic, but are very markedly influenced by position and by respira- 
>n, 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 
grare anaemia, may be obliterated by pressure over the bulbus jugu- 
laris. Such pressure has no effect upon the murmur of aortic regur- 


gitation, 1 hare recently reported (John* Hepkm* Bull, May, 
190.T) three cases of intense amentia associated with diastolic 
murs exactly like those of aortic regurgitation, but proved port 
mortem to be independent of any valvular lesion The ti 
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 ftgti 
often exceedingly faint, and should be listened for with tl- 
care and under the most favorable conditions. 

Bftimation qfth* Extent and Gravity oftke Lesion* 

The extent of the lesion is roughly proportional to — 
('/) The amount of hypertrophy of the left ventrirle. 

(0) The degree to which the pulse collapses during diai 
(provided the radial is not so much calcified as to mak 
impossible) . 

(>) The degree to which the murmur replaces the second en 
as heard over the right carotid artery (Broadbent). 

Irregularity of the pulse is a far more serious sign in thifl 
ease than in lesions of the mitral valve, and indicates the beginning 
of a serious failure of compensation. 

Another grave sign is a diminution in the intensity vi 


(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. 
100). Not infrequently this dilatation is the cause of . 
murmur to be heard over the region of tin- aortic arch and in the 
great vessels of the neck. 

(2) Bouffheninp of the Aortic Valve*. — In almost all cases of aortic 
regurgitation the valves are sufficiently roughened to produce a 

Lie 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 tin- 
diagnosis of aortic stenosis will be considered with the latter lesion. ) 



(3) The return of arterial blood through the aortic valve* into 
the left ventricle produces in time both hypertrophy and dilatation 
of this chamber, and results ultimately in a stretching of the mitral 
orifice which renders the mitral curtains incompetent. The result 

»is a "relative mitral insufficierin/," Le., oue 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 overdistension <»t' tin* 
left ventricle and often the accompanying angina, although at t ln j 
cost of engorging the lungs, 1 

(4 ) Th e A u$t la Ff in t Mu t*m. u r , — The maj ority of cases of a« • i ■ t i ■ ■ 
regurgitation are accompanied by a presystolic murmur at tin* apex, 
which may be due to a genuine mitral stenosis or may be produced 
in the manner suggested by Austin Flint, (For a fuller discussion 
of this murmur see above, p. I7^>. ) 

(5) Aortic stenotic frequently supervenes in fuses of aortic f&* 
gurgitation, and results in a more or less temporary improvement in 
the patient's condition. It has the effect of increasing the intensity 
of the diastolic murmur, since the regurgitating stream has t< i | 
through a smaller opening. 

The general visible arterial pulsation becomes much less marked 
if stenosis supervenes on regurgitation. 




Uncomplicated aortic stenosis is by far the rarest of the ralfu* 
lar lesions of the left side of the heart, as well as the most difficult 
to recognize. Out of two hundred and fifty-two autopsies made B.1 
tlie Massachusetts General Hospital in eases of valvular disi ;i- 
there was not one of uncomplicated aortic stenosis. Twenty-nim- 

ses occurred in combination with aortic regurgitation. During 
ife the diagnosis of aortic stenosis is frequently made, but often cm 

sufficient evidence — 1,6, f upon the evidence of a systolic murmur 
heard with maximum intensity in the second right intercostal spa«'i- 

1 This relative insufficiency of the mitral valve haa been termed ita 4I safety - 
vahe" action, but the safety is but temporary and dearly bought. 


and transmitted into the vessels of the neck. Such a murmur does 
indeed occur in aortic stenosis, but is by uo means peculiar to this 
^nmlition. Of the other diseases which produce a similar murmur 
more will be said under Differential Diagnosis. 

Tot 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 (vide infra)* 

(3) A palpable thrill (usually). 

(4) Absence or great enfeebleuient of the aortic second sound. 
Of these signs the characteristic pulM is probably the most im- 

-^fe& Jitr&/&rf 


YXCr. 107.— Aortic Stenosis. The heart is Lu syjtole and the blood column la abstracted by the 
imrrowtd aortic ring. The tultmi Is closed (as It should he). 

portant, and no diagnosis of aortic stenosis is possible without it. 
The heart may or may not be enlarged. 

Each of these points will now be described more in detail. 

(1) The Murmur,, 

(a) The vnarimum intensity of the 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. f 



in the third, fourth; or fifth right interspace, and occasionally it is 
heat heard to the left of the sternum in the second or third inter- 
costal space. (!) The time <>( the murmur ia laU wyrieU&$ that is, 
it follows the apex impulse at an appreciable interval, contrasting 
in this respect with the systolic murmur usually to be heard in 
mitral regurgitation, (r) The murmur is usually widely transmit* 
tedf often being audible over the whole chest and occasionally over 
the skull and the arterial trunks of the extremities (see Fig, 108), 
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 in the region uf tin- apex impulse, whither it is trans- 
mitted through the left ventricle. The same line of transmission 

Maximum Intensity 
of syntolin mtir- 
mar no' i tiirm. 

Fra. lift— Aortic 

The murmur in nudtble over tbe shaded area and sometimes over 
the whole chest. 

was mentioned above as characteristic of the murmur of aortic re- 
gurgitation in many eases. The murmur is also to be heard over 
the carotids and subclavian s, 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, especially in the recumbent position $ it is occasionally au- 
dible at some distance from the chest, and is often rough and 
vibrating, sometimes musical or croaking. Its length is unusually 


-teat, extending throughout the whole of systole, but to this rule 
there are occasional exceptions. The tirst sound in the aortic re- 
gion is altogether obliterated, as a rule, and the second souji 
either absent vr very feehle.' 

(S) Thv Pub*. 

Owing to the opposition snocmittered by the left ventricle in 
its attempt to force blood into the aorta, its contraetion is a] 
be prolonged ; hence tlie pulse wave Ha t gradually and late, ttnd j 
ft nut tj shttrhf. This is shown very well in sphygniographic trac: 
(see Fig, 10^). But further, the blood thrown into the anita by the 
left ventricle is prevented, by the narrowing of the aortie va! 
from striking upnn and expanding the arteries with its oidifi 
force; hence the pulse wave is not uuly slow to rise but ttimtft hi 

Fro. U»,— Sphyymojmipbte Trarliiff or the Puis* tn rnftmipltttiiei] Aortic Stennpia. Compare 
wUti the ti.innul palM WWe Hmi wltli liml of nr-r<u r»'»rur(rltiLtJf.ia <pU(ft* 174). 

height r contra* ting strongly with the powerful apex beat ( 4t pm 
parvu* "), Again, the delay in the emptying of the left ventricle, 
brought about by the obstruction at the aortic valves, the 

contractions of the heart relatively infre$ueai t and hence the pu 
is htftrquent (pulsus rarus) as well as small and slow to rise, The 
"pulsus rants, panms $ tardus" is, therefore, a most constant and 
important point in diagnosis, but unfortunately it is to lie felt 
in perfection only in the very rare eases in which aortic Bt&EUWUS 
mm uncomplicated. When stenosis is combined with regurgita- 
tion, as is almost always the case, the above-described qualities i-t 
the pulse are greatly modified as a result of the regurgitation. It 

1 "Occasionally, as noted by W, H. Dickinson, there is a musical murmur 
of preat intensity in the rt'jiiuii of the apex, probably due to a slight regurgito- 
lloo at high pressure through the tnitrul Ytlve-.**— 



is alau to Ix. 4 remembered that the pulttti of aortic sti-rmsia is by no 
means unalterable and does not exhibit its typical plateau at all 

A less characteristic, but decidedly frequentj variation in the 
pulse ware of aortic stenosis is the unaerotio curve. The slow, 
Long pulse with a long plateau at the summit is seen also in some 
mitral stenosis ami renal disease, and is not peculiar to 
ftort&e stenosu, but taken in connection with the other signs of the 
disease it has great value in dia 

(It) Th> ThrUL 

\n the majority of eases an intrust* 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, [t is a very important 
aid in the diagnosis of aortic M^nosis, but is by no means pathog- 
nomonic, since aneurism may produce a precisely similar vibration 
ie chest wall. 

The heart is slightly enlarged t» the left and downward as a 
rule, but the apex impulse is unusually indistinct, *" a well-defined 
id deliberate push of no great violence M (Broadbeat), Cone- 
mding to the protracted sustained systole the first sound at the 
apex is dull and long, but not very loud. 

Differential ZHagnima, 

A systolic murmur heard loudest in the second right intercostal 
■ i> by no means peculiar to aortic stenosis, bat may be due to 
any of the following eoiulilinns: 

(«) Roughening, stiffness, fenestration, or slight congenital mal- 
formation of tlir am tic valves. 

(b) Roughening or diffuse dilatation of the arch of the aorta, 

(<?) Aneurism of the aorta Of innominate artery, 

(4) Functional murmurs. 

1 ) Pulmonary stenu - 

(/) Open ductus arteriosus. 

($) Mitral regurgitation. 


(a and b) The great majority of such systolic murmurs at the 
base of the heart, first appearing after middle life, axe due to the 
causes mentioned above under <*, b, and c. In such cases it is usu- 
ally com bine d with accentuation and ringing quality of tin- softfte 
second sound owing to the arteriosclerosis and high arterial tension 
associated with the changes which produce the murmur. This 
furl tttufttttm rtf the trortic g§cond sttmtitl enables us, except in extraor- 
dinarily ran eases, 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 accompanies aortic 
regurgitation, is a frequent cause of a systolic murmur loudest fa 
the second right interspace, This may be recognized in certain 
rases by the characteristic area of duiuess on percussion and by its 
association with aortic regurgitation of long standing (see Fig. 102). 

Roughening of the intirna of the aorta (endaortiti*) is alwa\ 
be suspected in elderly patients with calcified and tortuous periph- 
eral arteries, and such a condition of the aorta doubtless favors the 
occurrence of a murmur, especially when accompanied by a slight 
degree of dilatation. The absence of a thrill and a long, slow 
pulse with a low maximum serves to distinguish such murmurs 
from those of aortic stenosis, 

(c) Aneurism of the ascending arch of the aorta or of the in- 
nominate artery may giYfl rise to every si^n of aortic stenosis except 
the characteristic pulse and the diminution of the aortic second 
sound. In aneurism we may have a well-marked tactile thrill and 
a loud systolic murmur transmitted into the neck, but there is 
usually some pulsation to be felt in the second right intercostal 
space and often some difference in the pulses or in the pupils, as 
well as a history of pain and symptoms of pressure upon the I 
ehea ami bronchi or recurrent laryngeal nerve, In aneurism the 
aortic second sound is usually loud and accompanied by a shock, 
and the pulse shows none of the characteristics of aortic steti< 

{'/) Functional murmurs, sometimes known as u hseniic,'* are 
occasionally best heard in the am tic area instead of in their usual 
situation (second left intercostal space). They occur especially in 
young, aneemic persons, are not accompanied by any cardiac en- 



largenient, by any palpable thrill, any diminution in the aortic 
second sound, or any distinctive abnormalities in the pulse. 

(e) Pulmonary stenosis, a rare lesion, is manifested by a sys- 
tolic murmur and by a thrill whose maximum intensity is usually 
on the left side of the sternum. In the rare eases in which this 
murmur is best heard in the aortic area it may be distinguished 
froaoo the murmur of aortic stenosis by the fact that it is not trans- 
mitted into the vessels of the neck, has no effect upon the aortic 
second sound, and is not accompanied by the characteristic changes 
in the pulse, 

(/) The murmur due to persistence 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 

(if) 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 differentia aortic stenosis may be distinguished 
from the other conditions which resemble it, provided it oc- 

implicated, but unfortunately this is very rare. As a rule, it 
occurs in connection with aortic regurgitation, and its characteristic 
signs are therefore obscured or greatly modified by the signs of the 
latter disease. We may suspect it in such cases (provided the mi- 
tral valve is sufficient) when we have, in addition to the signs of 
aortic regurgitation, a systolic murmur and palpable thrill in the 
aortic area transmitted into tfco great vessels, a modification of the 
Corrigan pulse in the direction of the "pitlmts tardu^ rants, par 

, n and less visible arterial pulsation than is to be expected in 
pure aortic regurgitation. 

Occasionally one can watch the development of an aortic steno- 
sis out of what was formerly a pure regurgitant lesion, the stenosis 
gradually modifying the characteristics of the previous condition. 
One must \»< -arciul, however, to exclude a relative mitral insuffi- 


, which, as has been alrpady mentioned al" »ry apt to 

supervene in eases o! aortic disease, owing to dilatation of tin* mi- 
tral uritiee, and which may modify tin* chars signs of aortic 
regurgitation very much as aortic stenosis does. 


Endocarditis affecting the tricuspid valve is rare in post-fuetal 
life; in the foetus it is not so uncommon. In cases of uleerutive 
4H- malignant endocarditis oeeuring in adult life, the tricuspid valve 
is occasionally involved, but the majority of cases of tricuspid i 
c;im' occur as a result of disease of the mitral valve and in the follow* 
ing manner: Hypertrophy erf tike right ventricle occurs as a rat 
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 regi i imitation, then, occurs in the latest stages of almost 
every ease of mitral disease and sometimes during the severer at- 
backs of failing compensation. 

Out of 408 autopsies at Guy's Hospital in which evidence of 
tricuspid regurgitation was found, 271, or two-thirds, resulted from 
mitral disease, 6'Sfrom myocardial degeneration, 55 from pulmonary 
disease (bronchitis, emphysema, cirrhosis of the lungj. Very few of 
these eases had been diagnosed during life, and in all of then 
valve was itself healthy but insufficient to close the dilated orifice. 

Gibson ami some other writers believe that temporary tricuspid 
regurgitation is the commonest of all valve lesions, and results from 
weakening 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 u *etfe&# valve** to relieve a temporary pulmonary eu- 
gorgemeafc. This "safety-valve" action, however, may be most 
disastrous in its consequences to the organism as a whole, despite 
the temporary relief which it affords to the overfilled lungs. The 
engorgement is simply transferred to the liver and thence to the 


abdominal organs and the lower extremities, so that as a rule the 
advent of tricuspid regurgitation lb recognised not as a relief nut. 

nous ami piohaUv fatal disaster. 

Physical Signs. 

(1) A systolic murmur is heard loudest at or near the fifth left 
(I cartilage, 

(2) Systolic venous pulsation in the jugulars and in the Hv. 
Engorgement of the right auricle producing an area of dul- 

beyond the right sterna] margin* 
[ntease cyanosis. 

( 1 i lit* Murmur,— The maximum intensity of the syetoliemur* 
liuir ui tricuspid regurgitation is usually near the junction of the fifth 
oi »ixth left costal cartilages with the sternum. Leube rinds the 
murmur a rib higher up, but it is generally agreed that the tricuspid 
a "i is a large one, so that the murmur may be heard anywhere 
I he lower part of the sternum or even to the right of it, Oa the 

other hand, there are some tricuspid murmurs which are best heard 
at a point midway between the apex impulse and the eusifonn carti- 
The murmur is not widely transmitted and is usually inaudi- 
ble in the haek; at tl ml of expiration its intensity is increased* 

In some eases ire 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. 1 have already explained (see p. 35) the distinc- 
tion between true Bpstolic 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 certai -. nl. If, on the other hand, it does 
not refill from 1>elow, the cause must be sought elsewhere, 


Pulsation in the liver must be distinguished from the " jogg 
motion which may be transmitted to it from the abdominal aorta er 
from the right ventricle. To eliminate these transmitted impulse! 
one must be able to gra.sp the liv«f bimanually, one hand in 
and one resting on the lower ribe behind. Bod to feel it distinctly ex- 
pand with every systole, or else to take its edge in the hand and 
to feel it enlarge m one's grasp with every beat of the heart. 


Systolic murmur, - 

Enlarn^d and 
siting liver. 

Fia. 1 hi.— TMriuptd Begurgltatli m. The murmur is beard belt over the eluded 

Pressure upon the liver often causes in distention and pulsa- 

tion of the external jugulars if tricuspid regurgitation is pre* 

(3) Enlargement of the heart, both to the right and to the left, 
as well as downward, can usually be demonstrated. In ran- rases 
a dilatation of the right auricle may be suggested by a percussion 
outline such as that shown in Fig, 110. 

The pulmonic second sound is usually not accented. The im- 
portance of this in differential diagnosis will be mentioned pi 
entry. If a progressive diminution in the intensity of the sound 
occurs under observation, the prognosis is very grav 

(4) Cyanosis is usually very great, and dyspncea and pulmonary 
cedema often make the patient's condition a desperate one, 



/hjfrrrntta I J>t*tffttt>!tiit, 

The statistics of rhe eases autopsied at the Massachusetts Gen* 
eral Hospital show that tricuspid regurgitation is less often recog- 
nized during life than any other valvular legion. The diagnosis 
was made ante mortem on only five out of twenty-nine i 
This is due to the following facta : 

(«) Tricuspid rejnirijiTatiuii may \»- present and yet ^i\<* rise to 
no physical signs which can be recognized during life* 

(A) Tricuspid regurgitation occurs moil frequently in connec- 
tion with mitral regurgitation; hence its aigni are frequently 
masked by those of the latter lesion. It is } there fori*, a matter of 
greal impo rt a nce aa well as of peal difficult fco distinguish tricus- 
pid regurgitation from 

| 1 | M it ml Rtguryttation, 

The difficulties ate obvious . The murmur of mitral regnrg 
tion has its maximuiu Intensity not mure than an inch or two from 
the point at which the tricuspid murmur is best heard* Both are 
systolic in time, They are, therefor©, to be diatinguiannd only — 

(a) In ease ire can demonstrate that there are two areas is 
which a systolic murmur is heard with relatively great intensity, 
with an intervening space over whieh the murmur is less clearly to 
be heard (see Fig. 111). 

(ft) Occasionally the two systolic murmurs are of different pitch 
Or of different quality, and may be thus distinguished. 

(p) Tricuspid murmurs are not transmitted into the left axilla 
and are rarely audible in the hack, and this fact is of value in case w« 
have to distinguish between uncomplicated tricuspid regurgitation 
and nneomplicated mitral regurgitation. Unfortunately these le- 
sions are terj apt to oeeuj simultaneously, so thai in practice our 
are generally directed toward distinguishing between a pure 
mitral regurgitation and one complicated by tricuspid regurgitation, 
- of doubt tin- phenomena of venous pulsation in the 
jugulars and in the liver are decisive if present, but their absence 
proves nothing. 


(<*) 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 
lutigs 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 leaking. 

('_') From " functional " systolic murmurs tricuspid insufficiency 
may generally be distinguished by the fact that its murmur is best 

Fig. 111.— Two Sv>toltr Murmurs < and Tricuspid) with a "" Vanishing Point ** between. 

heard in the neighborhood of the fusiform cartilage, and not in the 
second right intercohtal space where most functional murmurs have 
their seat of maximum intensity. Functional murmurs are unac- 
companied by venous pulsation, cardiac dilatation, or cyanosis. 

(.'!) Occasionally 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. 

Tki«tsi»ii> 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- 



rick was able to collect but lf>4 cases from tin- world's literature* 
Out of these l.*i4 cases, 1118, or 90 per sent, were combined with 
mitral stenosis, ami only V2 times has tricuspid stenosis been known 
to occur alone. 1 These observations account for the fact that tri- 
cuspid stenosis has hardly ever been recognized during life, since the 
murmur to which it gives list- is identical in time and quality and 
nearly identaeaJ in position with that of mitral stenosis. Narmw- 
ing of tin* tricuspid valve is to be diagnosed, therefore, only by the 
recognition of a presystolic murmur best beard in £be tricuspid ana 
and distinguisked either by its" pitch, quality, or position from the 
other presystolic murmur due to tin- mitral stenosis which is almost 
certain to aeoompany it. 

The hcai-t is usually enlarged, especially in its transverse direc- 
tion, but the enlargement is just, such as mitnil stenosis produces, 
arid does not aid our diagnosis at all. 

The diagnosis is still further complicated in many eases by the 
presence of an aortic stenosis in addition to a similar lesion at the 
tricuspid and mitral valves, so that it semis likely that in the future 
as in the past the lesion will l>e discovered first at autopsy. 


Organic disease of the pulmonary valve is excessively rare In 
post-frjatal life, but may occur as part, of an acute ulcerative or 
septic endocarditis. A temporary functional regurgitation through 
the pulmonary valvr may In- brought uUmt by any cause producing 
very high pretsure itt the pulmonary arterg* I have known 
medical students with perfectly healthy hearts wlin were able, by 
prolonged holding of the breathy to produce a short, high-pit' !m i 
diastolic nmrinnr best heard in the second and third left intercostal 
Spates and ceasing as soon as the breath wax let out. Of the OGCUT* 
ranoe of a murmur similarly produced under pathological condi- 
tions, especially in mitral stenosis, much has been written by 
Graham Shell, 

1 Out of 67 cases collected from the post-mortem records of Guy's Hos- 
pital, H"» t or \)7 per cent, were associsued with still mure extensive mitral 


From the diastolic murmur of run-tie regurgitation we may dis- 
tinguish the diastolic murmur of pulinonary incompetency by tiw 
fact that the Latter is beat heard over the pulmonary valve, m 
transmitted to the a]>ex of the heart it or to the great vessels, ami 
is never associated with a < Wri^aii pulse nor with capillary pulsa- 
t.ioii. ' The right ventricle, is hypertruphicd, the pulmonic second 
sound is sharply aeceuted and followed immediately by the murmur. 
Evidences of septic embolism of the lungs are i t » qu-iit 1 v praa 
and assist as in diagnosis. The regurgitation which may take 
place through the rigid cone of congenital puliuouarv 
not recognizable during life, 


Among the rare congenital lesions of the heart valves this 
probably the commonest. The heart, and particularly the ri 
ventricle, is usually much enlarged. There is a history «f cyanoflffl 
and dyspnoea since birth, Pulmonary tuberculosis complicates from 
nil. -iniirth tj one-third of all cases. A systolic thrill is USUs 
be felt in the second left intercostal space, and a loud systolic BWf 
inur is heard in the same area. The pulmonic second sound is weak. 

The region in which this murmur is best heard has been happily 
termed the "regitni qf rojnanee" on aceouut of the multiplicity of 
mysterious murmurs which have been beard there. The systolic 
murmur of pulmonary stenosis must be distinguished from 

(a) Functional murmurs due to aiuemia and debility or to severe 
muscular exertion, and possibly associated with a dilatation of the 
eon us arteriosus. 

(ft) Uncovering of the conus arteriosus through lack of expan- 
sion of the lung. 

(c) Aortic stenosis. 

(d) Mitral regurgitation. 

(e) Aneurism. 

(f) Roughening of the intima of the aortic arch. 

1 By registering the variations of pressure in the tracheal column of air 
Gerhard t dm shown graphically that a systolic pulsation of the pulmonary cap- 

illaries may occur in pulmonary regurgitation, 
tolic whiff may he heard all over the hinga. 

With the stethoscope a ays- 



(a and b) Functional murmurs, and those pmduced in the conus 
;. if ever accompanied by a thrill, are rarely so 
■ mm I ,is the murmur of pulmonary stenosis* anil are not associated 
itlt dyspnea, OJSIMXriSj and enlargement of the right ventricle. 

The murmur of aortic stenosis is usually Upon the right side 
of the sternum and ia transmitted to the neck, whereas the murmur 
of pulmonary stenosis is never so transmitted and is not associated 
with characteristic changes Ln the pulse (see above, p. 188), 

The murmur of mitral regur<jitfitie*\n occasionally loudest 
in the region of the pulmonary valvi-, bat differs from the murmur 
of pulnii diary stenosis m being* as a rule, transmitted to the back 
and axilla and associated with an accentuation of tin* pulmonary 
is. nind. 
(i) Atiturism may present a systolic murmur and thrill similar 
to tin ■*».! found in pulmonary stenosis, but may usually be distin- 
guished from the latter by the presence of the positive signs of aneur- 
ism, v\/.. — pulsation, and dulness in the region of the murmur, and 
signs of pressure on the trachea or on other structures iti the medi- 

i Roughening of the aortic arch occurs after middle life, 
while pulmonary stenosis is usually congenital. The murmur due 
to roughening may be transmitted into tin' carotids; that of pul- 
monary stenosis never. Enlargemaili of the right Ventricle is char- 
acteristic of pulmonary stenosis, but not of aortic roughening. 


>sentiai that the student should understand from the first 
that the number of murmurs audible in the preenrdia 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 
tjw heart; Bystolic and presystolic at the apex, yet no valve in- 
pncd except the aortic. In such a caee 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 n type. Hence in this 

200 FHYSn A f. niAO Ml \$2 ! ( F DISFASKS OF Tift: CBSST. 

ease the diastolic murmur alone of the four audible murmur 
to a valvular lesion* 

It is a good rule nut to multiply causes unie 
«>x plain as many signs a« possible under a single hyp h 

the above example the mitral leak might be due t«» an 
flit is, and there mljpaJ 1>e mitral stenosis and aortic 
but since we ean explain all the signs as results- 
— of one lesion (aortic regurgitation) it ie better <»> do so, jmd p 
mortem experience shows that our diagnosis ia more likely U 
right when it is made according to tins piineiple 

The most frequent combinations are: 

(1) Mitral regurgitation with mitral stenosis, 

(2) Aortic regurgitation with mitral regurgitation (with or with- 
out stenosis), 

(3) Aortic regurgitation with ao .with or without 
mitral disease. 

(1) J>ouhh Mitral ftijira&c* 

!■') It very frequently happens that the mitral valv<- is found 
to !><* both narrowed and incompetent at autopsy when onh 
these lesions bad been diagnosed during life. In fact mitral sfceno- 




Flo, 112,— Mitral Steiwwli and Iteffttnrttatfcift, abowtag retonoa of uiumiur to flrrt h«rt **>umi 

sis is almost never found at autopsy witr >ut an associated i 
ration, su that it is fairly safe to assume, whenever OM ma 
diagnosis of mitral stenosis, that mitral regurgitation is present as 
well, whether it is possible to hear any regurgitant murmur 01 
(see Rg. \\j )r 

(i) On the other hand, with a double mitral lesion one may 
have only the regurgitant 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 ehangeableness of the murmurs 
both in tvpe and position ia extraordinary. One often finds at one 



visit evidences of mitral stenosis and at another evidences of mitral 
regurgitation alone. Either murmur may disappear altogether tm 
a time and tea^pewwilwequt ntlv, This is peculiarly true of tin pre- 
systolic murmur, which is notoriously OIK <d the most Meeting and 
u i lei i tain of all physical si^ns. 

As a rule the same inflammatory dunged which produce mitral 
regurgitation in eur]y life result as they extend in narrowing the 
mitral valve, so that the signs of stenosis OOUae to predominate in 
later years. Coiueidenilv with tins narrowing oi the diseased valve 
a certain aim mi it of improvemeut in the patient' a eymptoma may 
take place, ami R o a euba eh regards the advent of Btenosifl in such :i 
ease as an attempt si rative ot compensatory change, tn 

many eases, however, Qo&ueh amelioration of the symptoms follows. 

(2) Aortic Ktgttrpittition with Mitral Dis&tse* 

Tin- si^ns of mitral disease occurring in eombinatiop with 
aortic regurgitation do not differ essentially from those of pure 

d Haled* -Y~~ 

Maximum lhu-n*iiv 

and dtlfltatk nmr- 
m u r, conducted 
up and down. 

Systulu murmur. 

Vio. 11:1,— Aortic and Mitral Reffunrltatmn. The shaded areas are ttm&e In wbteb tt»e murmurs 

are !• ■•ii'i^-r. 

mitral disease except that the enlargement of the heart is apt to 
he more general and correspond less exclusively to the right ven- 
tricle (see Figs. 1 13 and 114). The manifestations of the aortic lc- 


sion, on the other hand, are considerably modified by their associa- 
tion with the mitral disease. The Corrigan pulse is distinctly less 
sharp at the summit and rises and falls less abruptly. Capillary 

1st let 


BBllliLLLL-JtaB ■■«■ I 

»"■■ 1111111111111111. 

Fig. 114.— Showing Relation of Murmurs to Heart Sound 1c Regurgitation at the Aortic and 

Mitral Valves. 

pulse is less likely to be present, and the throbbing of the peripheral 
arteries is less ofteu visible. 

(3) Aortic IiftfurgitatioH with Aortic Stenosis. 

If the aortic valves are narrowed as well as incompetent, we 
iiud very much the same modification 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 pulsation 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 function. 

(4) The association of mitral disease with tricuspid insufficiency 
has been already described on p. 164. 



Takiktal Dibbaae t*r thk Hkakt 

Aw ff Mijtu ti rd it is , 

The myocardium is seriously, though not incurably, affected in 
all continued fevers, owing less to the fever itself than to the tox- 
fpniia associated with it. "Cloudy swelling," ot granular degener- 
ation of the muscle fibres, is produced l»v relatively mild infections, 
while a general septicjemis due to pyogenic organisms may produce 
extensive fatty defeneration of the heart within a few days. 

The physical nh/ttft are those "f cardiac weakna$*. 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 smiie eases its feebleness 
:s the second sounds seem accented by comparison. Soft blow- 
ing systolic murmurs may develop at the pulmonary orifice, less 
if ten at the apex or over the aortic, valve. 

The apex impulse becomes progressively feebler and more like 
a tap than a puslu Irregularity and incraaama 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 lie obtained 'luring life (although at autopsy it is not in- 
frequently found)/ but in acute artiouiar rheumatism an acute dila- 
tation of the heart appears to be a frequent complication, independ- 

1 Henchen** receat monograph on (hie subject, " Deber die «cuie Herzdila- 
totjnn bei acuten Infectionekrankbeiten," Jena. 18A9, does not seem to me 


ent of the existence of any valvular disease. Attention has bm 
especially called to this point by Lees antl Boynton < British M«L 
Jbur*, July 2, 1898) and by S. West. 

Influenza is also complicated not infrequently by acute cardiac 

Chrvtt it i Mtft H'tt rd it is ( '* * Wva ken cd Hea ri "). 

Fatty or fibroid changes in the heart wall occurring in chronic 
disease are usually the result at sclerosis of the coronary arteries 
and imperfect nutrition of the myocardium, but chronic toxaemias, 
like pernicious atwemia, may also produce a very high grade of fatty 
defeneration of the heart and especially of the papillary muscles. 

Whether fatty or fibroid changes predominate, the physical signs 
are the same. 

Physical Signs of Chronic* Myocarditis. 

Fur the recognition of these changes in the myocardium our 
present methods of physical examination are always unsatisfactory 
anil 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 degeneration 
of the heart muscle, although all the physical signs traditionally 
associated with this condition were present during life, 1 To a eon* 
siderabie 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. Symptoms 
of teurdiae we&knm 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, Chfcyne-Stokes breathing, or of syncope. 

Inspection and palpation may reveal nothing abnormal, or there 

1 A well-known Boston pathologist recently told me that he bad never 
known a case of myocarditis correctly diagnosed during Ufa 



may l>e an unusually diffuse, dapping cardiac impulse associated 
perhaps with a displacement of the apex heat to tin- lift and down* 
ward, Marked irregularity of the heart boat, IhiUi Dl fofoe and in 
rhythm, is sometimes demonstrable by these methods, and an in* 
emaai m the urea of cardiac dulness may be demonstrable in ease 
dilatation lias followed the weakening id the heart wall. AtucvUta- 
Hem may reveal nothing abnormal except that the aortic second 
sound 18 unusually sharp; in some cases feeble and rVffljgPttliW* &60f4 
souncfr are heard, although the first sound at the apex is not infro- 
oniently sharp. Reduplication of one 0? both sounds and disturb* 
■nee of rhythm, esj>eeially the "gallop rhythm," are not inln- 
It the ijjitial sphincter is dilated, or the papillary muscle* 
are weakened, a* not infrequently happens, wt- may have evidences of 
mitral regurgitation, a systolic murmur at the apex heard in the left 
axilla and back with accentuation of the pulmonic second sound. 


1. The histuj v and symptoms of the ease or the condition of 
other organs are often of more diagnostic value than is the physical 
examination of t|ie heart itself, whirl i may show nothing abnormal. 

2, Among the rather unreliable physical sighs, those most, often 
mentioned are i 

(a) Weakness and irregularity of the heart sounds. 
(P) Accentuation of the aortk second sound, 
(r) A diffuse slapping cardiac impulse, 

('/) Reduplication of some of tin- cardiac sounds (gallop 

(e) Evidences of cardiac dilatation. 

(/) Murmurs— especially the murmur of mitral insufficiency 
which often occurs as a result of dilatation of the valve orifices and 
weakening of the cardiac muscle. 

Dtfft \rmt it r I I)i> rtf it 09 1&. 

We have to distinguish myocarditis from— 
(a) rneoinplicatcd valvular lesions. 
(&} Cardiac neuroses. 


(a) It has been already pointed out that valvular lesions do not 
necessarily give rise to any murmurs when compensation has fa;. 
Under such circumstances one hears only irregular and weak heart 
sounds, as in myocarditis* The history of a long-standing val vu- 
lar trouble, a knowledge of the previous existence of antra 

age, method of onset, and symptoms of the rase may assist, us in 
tin' diagnosis. Cases of myocarditis an Sfiftfi likely to be anaocifttrd 
with, extensive dropsy than an- caaefl ««i valvular disease wlme com- 
pensation has been ruptured. 

(b) Weakness ami irregularity of the cardiac Bounds, wbm dm 
to nervous affection of the heart anil miaaaoeiated with parietal or 
valvular changes, is usually lcNaa marked attei slight exertion. The 
heart ■" rises to the occasion " if the weakness is a functional one. 
On the other hand, if fatty or fibroid change* are | igns 
and symptoms are much aggravated by any exertion. 

In some cases of myocarditis the pulse is excessively slow and 
shows no signs of weakness. This point will be referred to again 
in the chapter on Bradycardia. 

F*t t ttf t h-r tyro trth. 

An abnormally large accumulation of fat about the heart may 
U> inspected if, in a very obese person, eigne of cardiac embarrass- 
ment (dyspnoea, palpitation) are present, and if on examination we 
find that the heart sounds are feeble and distant but preserve 
normal difference from each other. When the heart wall is - 
coaly weakened i as in the later weeks of typhoid), the heart scaindi 
heroine more alike owing to the shortening of the first sound. 

In fatty overgrowth this is not the case. 

The diagnosis, however, cannot be positively made, \\ < 
pect it under the condition a above described, bill HO greater 
tainty can be attained. 

Fatty /' 

There are no physical signs by which fatty degeneration of the 

irt can be distinguished from other pathological changes which 

i< suit in weakening the heart walls. An extensive degree of fatty 



degeneration is often seen post mortem in cases of pernicious an&mia, 
although the heart sounds have been <dear> 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 Myocar- 
ditis (see p 803). 

I'AlM'lAi' NkI KOHKS. 

Tachycardia t Rapid EfwxrtJ. 

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 pulse rat* may vary a great deal in health. A classmate 
of mine at the Harvard Medical School had a pulse never slower 
than 1*0, yet his heart and other organs were entirely sound. Such 
eases are not TOty uncommon, especially in women, Temporarily 
the pulse rate may be greatly increased, not only by exercise and 
emotion, but by the intiuence of fever, of gastric disturbances, or of 
tie- menopause. Such a tachycardia Is not always of brief dnration 
The effects of a great mental shock may produce en acceleration of 
the pulse which persists for days or even weeks after the shock 

Among organic diseases associated with weakening of the pulse 

aumonest an? those of the heart itself. Next to them, oxoph- 

thalmie goitre, tumors or hemorrhage in the medulla, 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 

/ *> i roxysm *( I Tacft yea rdta . 

As indicated in the name, the attacks of this disease are apt to 
begin and to cease smMrtthf, They may last a few hours or several 
days. The pulse becomes frightfully rapid, often *300 per minute or 
more. Bristowe records a case with a pulse of 908 per minute. 


In tlip radial artery the pulse heat may lie impalpable The heart 
sounds are regular and clear, btil the diastolic pause is shortened 
the Hist Bound becomes Bhort and M valvular, ,§ resembling the sec- 
ond ("fie-foc heart 3 *). The paroxysm may be associated with 
aphasia and abnormal sensation* in tin- left arm. Occasionally the 
heart beoomea dilated, and a&dema td the lungs, albuminuria, and 

other nmiiifestatimis of stasis appear. As a rule, howev* KT, pan 
nial tachycardia can lie distinguished from the rapid heart-beat 
associated with cardiac dilatation by the tu-r thai the 1 lira 

perfectly regular. This same fiaftt a! la us iu excluding the 

cardiac neuroses due tu feobaocoj tea, ami other poisons, Pram 
tachycardia of Gr:n m tin affection now iu ci tioa 

differs by its paroxysmal ami intermittent character 

Brady* $fofr Heart i 

In many healthy adults the heart seldom beats orei 60 tfs 

I Among tin* causes which may produce for a si te an 
abnormally slow heart-beat are : 

(a) Exhaustion; for example, after fevers, after parturition, or 
severs muscular exertion, 

(b) Tojrtrmitt ; for example, jaundice, unemia, autu-intoxmations 
in dyspepsia 

i t In certain htfstrriftl and melaneholie states and in neurotic 
oh(Mpm 9 the pulse may be ex< dingly Blow Pain has also a ten- 
dency to retard the pulse, 

(ti) An increase qf intracranial preseure s ai in Q&eningitiSj cere- 
bral hemorrhage, depressed fracture of the skull Possibly in this 
category belong the cases of bradycardia sometimes seen in epilep- 
tiform or during syncopal attacks. Bradycardia from any one of 
these causes is apt to be of comparatively short duration. 

II Permanent bradycardia is most often associated with coro- 
nary sclerosis and myocarditis. Iu this disease the pulse may re- 
main below 40 for months or years, though strong and regular, yet 
the patient may be free from disagreeable symptoms of any kind. 
The rate of the heart-beat cannot always be estimated by counting 


the radial pulse. Hot infrequently many pulsations of the heart 
are not of sufficient Cores to transmit a wave to the radial artery, 
and the mistake should nrwr l» j made of diagnosing bradycardia 
simply by counting the radial poise. 


1 . Pht/8 iological Arrh yth m ia . —Arrhythmia, or irregularity in the 
I. moB 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. Auy psychical disturb- 
kir exertion may produce irregularity as well as a 
quickening of the heart-beat. Rarely the pulse may be 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 bi 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 jpu&s/ 1 which consists in a quickening of the 
pulse with diminution in volume during inspiration* 

If we leave on one side diseases of the heart itself, patko* 
^ogical arrhythmia is most frequently seen in persons who have used 
tofaaoeo or lea to Sloes*, or in dyspepsia. In these conditions it is 
often combined 1 with palpitation and becomes thereby very distress- 
ing to the patient. In connection with cardiac disease the follow- 
ing types of arrhythmia may Lie 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. 

(5) The Hyem&nal pulse is seen most frequently in cases of un- 
eompensated heart disease (particularly mitral stenosis) after the 
adininistratiou of digitalis. Every other beat is weak or abortive 

il'J FS 

L±?y';$z? . r z t r - e ^ g "^ 

:r rsx csest. 

-- - _-iJ-:--»-i 

-7 - c * — w 

*=?■:« :.i" 


% _ _^ ._ : :„ .I 

"- « - - -- _i - -A-* 

1-rZ.I .' "I^rS." Z.~« ~«i_" lT«i«...3 

Z r~-Z- i ~ :»--Z~J.Zrr 

■ T * TJ_L> ;v q I: ~ . r. 1 


' 1" -—-rCC. 



Auscultation of a palpitating heart shows nothing more than 
unusually loud and ringing heart sounds, but since palpitation is 
often \ with arrhythmia oJ one ot another type we must be 

'ful to exclude the palpitation symptomatic of acute dilatation 
the heart, such as may occur in debilitated persons after violent 
or unusual exertion. In this condition tin.- aiea <>l cardiac dulnees 
is increased ami dyspixeaupou slight exertion becomes marked. It 
goes without saying that in almost any case of organic disi-:. 
the heart palpitation may be a very marked and distressing svmp* 


From the time of birth it is noticed that the child is markedly 
and permanently eyanosed, hence the term "blue baby." Dyspnoea 
is often, though not always, present, and may interfere with suck- 
ing. The cyanosis ia practically sufficient in itself for the diag* 

Aiip genital diseases of the heart the commonest and the 

most important (because, it is less likely than any of the others to 

re immediately fatal) is: 

1. Ptiimatutrtf 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 pplmonary stenosis art 1 : 

A palpable systolic thrill most distinct in the pulmonary 

(£) A loud murmur (often rough or musical) heard beat in the 
same region, but usually transmitted to all parts of the eu»-st. 

(r) A weak or absent pulmonic second sound. 

(»/) An increased an*a**f cardiac dulneu oorresponding 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* 


though usually subject to pulmonary disorders (j me uno : 
berculosis) For a discussion of the differential diagnosis of thi* 
lesion, see above, p, 198. 

1*. Defects in the Ventrteular Septum. 

The loud syttoHc murmur produced by the rush of blood through 
ail opening lietween the ventricles is heard, fts a rule, over the whole 
precordia Its point of maximum intensity differs in different 
cases* but is hardly ever near the apex of the heart The most im- 
portant diagnostic point is the absence of a palpable thrill. With 
almost every other form of congenital heart disease in which a loud 
murmur is audible, there in a thrill as well Hypertrophy of both 
ventricles maybe present, but is seldom marked in uncomplicated 

(Pttfmn/ of tfis foramen ovale f if nnassociate-d with othei 
foots, does not usually produce any munaor or other signs by which 
it can be recognized during life, and causes no symptoms of any 
kind ) 

8. Persistence qftfae Duct its Arteriosus. 

The moat characteristic sign is a loud, vibratory systolic mur- 
mur with its intensity at the base of the heart and uncus* 
hypertrophy qf either ventricle* li complicated with stenosis at or 
close above the pulmonary valves, persistence of the ductus arte- 
riosus cannot be diagnosed, as the niurmur produced by it cannot 
with certainty be distinguished from that >f the pulmonary ste* 
nosis, and the presence of hypertrophy of the right ventricle de- 
prives us of the one relatively characteristic mark of a patent arte- 
rial duet 

It has been el aimed that a murmur persisting through systole 
and into diastole is diagnostic of an open arterial ductj but this 
supposition is not borne out by pctst-mortcm evidence. 

The signs produced by the other varieties of congenital heart 
disease, such as aortic stenosis and tricuspid or mitral lesions, do 
not differ materially from those characterizing those lesions in 



adults. Excluding these, we may summarize the signs of the othei 
lesions as follows : 

(a) Practically all cases of congenital heart 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. 

(b) If there is no thrill and no hypertrophy, the lesion is prob- 
ably a defect in the ventricular septum. 

(c) If there is a thrill but no hypertrophy, the lesion is probably 
a patent ductus arteriosus. 

(d) If there is a thrill and hypertrophy of the right ventricle, 
the lesion is probably pulmonic stenosis, especially if the pulmonic 
second sound is feeble. 



I. PfiJtticAKDma, 

Three forms are recognized clinically : 

(1) l'lastir. dry, or fibrinous perioarditia. 

IVuiiai (litis with effusion (serous or purulent ■'). 

(3) Pericardial adhesions oi adherent pericardium. 

Fibrinous pericarditis may be fully developed without giving 
rise to ui iv f»liysiral signs that ran be appreciated during lift?. In 
several cases of pneumonia in which I suspected that perioral 
might be present, I have listened most carefully for evidences of 
the disease and been unable to discover any; yet at autopsy it 
found fully developed — the typical shaggy heart. We ha^ 
reason b> believe, therefore, that pericarditis is frequently pre* 
but unrecognized, especially in pneumonia and in the rheumatic at- 
tacks of children. On the other hand, it may give rise to 
marked signs which are the result of— 

The rubbing of the roughened pericardial surfaces against 
one another when set in motion by the cardiac contractions* 

(h) The presence of fluid in the pericardial sac. 

(r) The interference with cardiac contractions brought about by 
obliteration of the pericardial sac together with the results of ad- 
hesions between the pericardium and the surrounding struct v. 

(1) Dry or Fibrinous Pekicakditis. 

The diagnosis rests upon a single physical sign — "pericardial 
frloti<m n — which is usually to be appreciated by auscultation alone, 
but may occasionally be felt as well. Characteristic pericardial 
friction is a rough, irregular, grating or shuffling sound which oc- 



curs irregularly and interruptedly during tlie larger part of each 
cardiac cycle. It is almost never accurately synchronous either 
with systole or diastole, but overlap* the cardiac sounds* and en- 
croaches upon the pauses in the heart cyele. It is seldom exactly 
the same in any two successive cardiac cycles and differs the ivby 
from sounds produced within the heart itself. Pericardial Motion 
seems very near to the ear and may often be increased by pressure 

_L„ Pelican Hal fj-Jctluu. 

FlO, llfi.— Sbowlnff Most Frequent Site of Audible PferJcardl*! FHc-ttoa. 

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. 115; 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 j 
but not infrequently it may be heard at the base of the heart or 
ovir the whole precordial region* The sounds are fainter if the 
I <ut it-lit lies on the right side, and sometimes intensified if, while 
sitting or standing, he leans forward and toward the left, so as to 
bring 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 


In rare eases the friction may occur only during systole or 
during diastole. In such eases the diagnosis b i»ericardial 

and intracardial sounds may be my difficult 

Differential Diagnosis. 

(«) PleurdrPtrioardial Friction. 

Fibrinous inflammation affecting that part of the pleura w 
overlaps the heart may give rise to sounds altogether indistingii: 
able from those of true pericardial friction when the inflamed pleu- 
ral surfaces are made to grate against one another by the in 
ments of the heart *Sueh sounds are sometimes < I in 

intensity during forced respiration and disappear at 1 ol 

expiration, while true pericardial friction is usually 1>est heard if 
the breath is held at the end of expiration. If a fl Kind 

heard in tin- pericardial region ceases altogether when the hreath 
is held, we may l>e sure that it is produced in the pleura and not 
in the pericardium, but in many eases tin.- diagnosis cannot be made 

(6) Intracardiac Murmurs* 

From murmurs due to valvular disease of the heart, pericardial 
friction can usually be distinguished by the fact that the south: 
which it gives rise do not accurately correspond either with syst 
or diastole, and do not occupy constantly any one portion of either 
of these periods. Cardiac murmurs are more regular, seem less 
superficial, and vary 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 ia 
usually recognized with comparatively little difficulty, but it is 
hard to make sure whether in addition we hear endocardial mur- 
murs as well. 



(2) Pericardial Effusion. 

Following the fibrinous exudation, which roughens the pericar- 
dial mirfaoe and produces the friction sounds just described, serum 
may arruniulaU' in the pericardial sac*. Its quantity may exceed 
but slightly the amount of fluid normally present in the pericar* 

flG* llrt— Pericardial Effusion, CardiohepatJe Angle obtuse. (From v, ZleraaaeD's Attafl,) 

dram, or may be 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. 


Jlvdropcricurdmiu denotes a dropsy of the p jui occur- 

ring by transudation as part of a general dropsy in cases of renal 
disease or cardial weakness. The physical sikms to which it grm 
rise do not differ from those of an inflammatory effi ,;id f ac- 

cordingly, all that is said of the latter in the following section may 
bd taken as equally an account of the signs of hydro pericardium. 

Hceuinjierieaidiuiji, off blood in the pericardial sac, due to 
or to ruptures of the heart, is usually so rapidly fatal that 
physical signs are recognisable. 

P/ttfsical Sign* 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 in the 
pericardial sac is shown chiefly in three ways : 

i 1 | By percussions which demonstrates an area of dnlness more 
or less characteristic (see below), 

(2) By auseuUettiim, winch may reveal an unexpected feebl* 
in the heart sounds when compared with the power shown in the 
radial pulse. 

By the signs and symptoms of pressure exerted by the peri- 
cardial effusion upon surrounding structuiee. 

Bulging of the preoordia is occasionally to be seen in children; 
in adults we sometimes observe a flattening of the interspace* just 
to the right of the sternum between the third and sixth i : 

(1) The Area of Percussion DufneAs.—Tke extent of the dull 
area depends not only on the size of the effusion and the position of 
the patient, but also on the ana unit of "give" in the pericardium 
and is the lungs as well as on the size of the lingula pulmonalis. 
Allowing for these uncertain factors, we may say; (a) One of the 
most characteristic points is the unusual' extension of the 
sion dnlness a considerable distance to the i beyond the car- 

diac impulse, (b) Next to this, it is important to notice a change 
in the angle made by the junction of the horizontal line correspond* 

1 In health the can! lac dulnesa extends about three- fourths of an inch be* 
yoinl the cardiac impulse, but in pericardial effusion the difference is greater. 



nig to the upper limit of hepatic dulness and the nearly perpendicu- 
lar line corresponding to the right border <»f the heart* In health 
■urdio-hepatic ; approximately a right angle; in pericar- 

dial effusion it is much more obtuse (see Fig. 117). Rotch has 
called attention to the 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 blunting 
of the cardb-hepatic angle), there seems to me to be nothing charac- 
teristic about the area of dubiess produced by pericardial effusion. 


i*»- Dulnev, 

Cardiac impulse. 

Llv.-r (hitraH. 

117.— Peivus»ion Duluessln Pericardial Effusion, wUU Tyiupimltk* Resonance Under the 

Left Clft\ h 

ie " pear-shaped " or triangnlar area of percussion dulness men- 
tioned by many writers has not been present in cases which have 
come under my observation. In large effusions percussion reso- 
nance may be diminished 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 dulness may be modified by change ia 

e patient's position. After marking out the area of percussion 


dulness with the patient in the upright position, let hini lie ttptt 
his right side. The right border of the an m of dulness wili 
times move considerably farther to the right. A dilated heart Ctt 
be made to shift in a similar way, bat bo ;i leaser extent. < - 
atively little change takes place if the patient lies on his let 
and no important information is elicited by placing him Hat on his 
back or by getting him to lean forward. 

Unfortunately, it is only with moderato-susad effuak' 
ring in a pericardial sac free from adhesions to the surroi 
parts that this shifting can be made out Large affusions may not 
shift appreciably, and less than loO e.c. of fluid probably eannot be 
recognized by this or by any other method. But with large effu- 
sions the lateral extension of the area of dulness may be so 
a,s to be almost distinctive in itself, i.e. t from the middle of the left 
axilla nearly to the right nipple, 

2 i Feebleness of the heart sounds and of the apex impulse is of 
diagnostic importance only 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 the 
diagnosis of pericardial effusion. 

Broncho- vesicular breathing with increased voice sounds may 
be heard over the tympanitic area below the left clavicle and 
sionally between the scapulae behind. This is a result of compres- 
sion of trie lung. 

(3) Pressure exerted by the pericardial exudation upon sur- 
rounding structures may give rise to dyspnoea, especially of a 
paroxysmal type, to dysphagia, to aphonia, and to an irn 
cough. The " paradoxical pulse," small and feeble during inspira- 
tion, is occasionally to be seen, but is by no means peculiar to tills 
condition and has no considerable diagnostic importance. 

(4) Inspection and palpation usually help us very little, but two 
points are occasionally demonstrable by these methods : 

(a) A smoothing out of the intercostal depression in the precor* 
dial region, especially near the right border of the sternum between 
the third and the sixth ribs. 

(b) A progressive diminution of the intensity of the apex im- 
pulse until it may be altogether lost. If this change occurs while 






patient is under observation, and especially if the apex impulse 
tappcar* 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 apex impulse becomes less visible 
the right- sided decubitus. 

Differential Diagnosis 

(\) Our chief difficulty is to distinguish the disease from hyper* 
trophy a&d dilatation of the heart In the latter, which often com- 
plicates acute articular rheumatism with or without plastic pericar- 
ditis tie apex impulse is often very indistinct to sight and touch 
as in pericardial effusion, Bat the area of dulness is less likely to 
extend beyond the apex impulse to the left or to modify the cardio- 
01 to shift when the patient lies on the right side* 
Pressure symptoms are absent, and there are no areas of broncho- 
hir breathing with tympanitic resonance under the left clavicle 
or in the axilla. Yet not infrequently these differentiae do not 
serve us. and the diagnosis £an he made only by puncture* 

(L't I have twice known cases of encapsulated empyema mistaken 
for pericardia] effusion. In one cane 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 until a rib had been removed and the region thoroughly 
xplored* It is not rare for pleuritic effusions to gather first 
in this situation, viz., just outside the apex impulse in the left 

Such effusions may gravitate very slowly to the bottom of the 
leural cavity or may become encapsulated and remain in their 
rigiual and very deceptive position. In such cases the signs of 
compression of the left king are similar to thoSB # produced by a 
pericardial effusion, and the results of punctures rfl&y be equivocal 
in the case just mentioned. If there is any dulness, even a very 
narrow zone! in the left axilla between the fifth and eighth ribs, 
though there be none in the back, the likelihood of pleurisy should 
be suggested. 

As between pleuritic and pericardial effusion the presence of a 


good pulse and the absence of marked dyspurea fav> nacr. 

In the two eases above referred to in which encapsulate 
was mistaken for pericarditis, the general condition of * 
struck me at the time as surprisingly good for p ruarditis. 

If both pleurisy and pericarditis are present, the are; 
cardial dubiess is not characteristic until the pleuritic fluid ha 
drawn off. The persistence of dulness in the eardio-hepatic &ngk 
and beyond the apex beat after a left pleurisy has been ei 
tapping, and after the heart has had Hen to return to its normal 
position, should make us suspect a pericardial effusion. 

Despite the utmost care and thoroughness in physical examina- 
tion, many cases of pericardial effusion go unrecognized, esp> 
in infants, in elderly persons, or when the lung borders are adher- 
ent to the pericardium or to the chest wall. 

In the rheumatic attacks of children, it should be remembered 
that pericarditis is even more common than endocarditis. 

Adherent Pericardium* 

In the majority of cases the diagnosis cannot be made during 
life, unless the pericardium is adherent, not only to the heart, but 
to the walls of the chest as well. When this combination of peri- 
carditis with chronic mediastinitis is present, the diagnosis may be 
suggested by 

(a) A systolic retraction of the chest wall in the region of the 
apex impulse, at the base of the left axilla and in the region of 
eleventh and twelfth ribs in the left back (Bxoadbent'fl sign). Such 
retraction is more marked during a deep inspiration. (It ab- 
be remembered that systolic retraction of the interspaces in 
vicinity of the apex is very commonly seen in cases of cardiac hy- 
pertrophy from any cause, owing to the negative pressure produced 
within the chest by the contraction of a powerful heart.) A quick 
rebound of the cardiac apex at the time of diastole (the diastolic 
afaook) is said to be characteristic of pericardial adhesions, but is 
often absent. 

(h) Collapse of the cervical veins during diastole has been no- 
turd by Friedreich, and the paradoxical pulse, above described, is 



said to be more marked in adherent pericardium than in any other 
known condition. Most recent writers, however, place no reliance 
upon it* 

(c) When the lungs are adherent to the pericardium os t-» the 
chest wall, as is not uncommonly the rase, the absence of the phrenic 
phenomenon (Litten's signs) and of any respiratory excursion of 
the pulmonary margins may be demonstrated. Since pericardial 
adhesions are most often due to tuberculosis, the discovery of tu- 
berculosis in the lung or elsewhere may be of aid in diagnosis. 

(d) 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 <>f meiliastino-periearditis. 
In health and in valvular or parietal disease of the heart, the apex 
beat will swing from one to two inches to the left when the patient 
lies on his left side, and the descant of the diaphragm during 
inspiration lowers the position of the cardiac impulse considerably. 

The presence of hypertrophy or dilatation affecting e 
cially the right side of the heart, and not accounted for by the 

itenee of any disease of the eiinliae valves, of the lung, or of 
kidney, should make us suspect pericardial and mediastinal 
adhesions. Such adhesions embarrass esj>e cially the right ven- 
tricle, liecause it is the right ventricle far more than the left which 
becomes attached to the chest wall. The left ventricle is more 
nearly fn 

(/) Since the space enclosed by the divergent costal cartilage 
just !>elow the etisiform is but loosely associated with tin- Ocn- 
tral tendon of the diaphragm, Broadbent looks especially at this 
point for evidence of mediastinal or pericardial adhesions, the 
effect of which is to arrest 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 mediast i 
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 such 
case adherent pericardium should be considered. Fi^s. 1 IS and 1U> 


show the appearance in eases of this kind in which the diagnosis 
\v;i* verified by autopsy. 

fia.m pig. lift. 

Figs. J in, | id. - Ad&Mvbt Pertmrdiuin, 

The diagnosis of adherent iwricartliuiii with chronic mediastini 
tis is suggested by 




(a) Systolic retraction of the lower intercostal spaces in the 
left axilla and in the left back, followed by a diastolic rebound. 

(b) The absence of any change in the position of the apex im- 
pulse with respiration or change of position. 

(c) The presence of hypertrophy and dilatation of the right 
ventricle without obvious cause. 

(d) 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 without any obvious cause. 




Aneurism of the Thokacic Aorta. 

For clinical purposes thoracic aneurisms may be divided into 
the diffuse aud 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 transverse aorta or diffuse 
dilatations of the whole aortic arch are more likely to extend within 
the chest without eroding the thoracic bones. Practically any 
aneurism which penetrates the thoracic bones may 1*3 inferred to 
b saccular, bul if do such penetration takes place, it maybe im- 
possible to make out whether the dilatation is diffuse or circum- 
scribed. I shall comsidei i 

I. The signs of tlie presence of aneurism. 

II. The evidences of its seat. 
Inspection and palpation give us most of the important informa- 
tion in the diagnosis of aneurism. The patient should be plat 

the position shown in Fig, 118, so that the light will strike obliquely 
across the surface of the chest, and the observer should be so p 
that his eyes are as nearly as possible at the level at that part uf 
the chest at which lie expect* to see pulsation. 

In the majority of oases of aneurism soin tnal jntUatwn 

may be made out cither to the ri^ht of the sternum in front 
Abnormal tne region of the left scapula behind. If the aneur- 
Puliation. ism is large, a considerable area of the chest wall may 
be lifted with each beat of the heart; with smaller growths the 
pulsating area may be small and sharply circumscribed. Not in- 
frequently an abnormal pulsation at the sternal notch or in the 



may be observed. Other causes of abnormal pulsations in 
the chest, such as dislocation or uncovering' of the heart, must of 
be excluded. Pulsations due to aneurism can sometimes 
distinctly seen to occur later than the apex impulse of the heart* 
Palpation controls the results of inspection, but at times a pui* 
Batioo may be seen better than felt ; at others may be felt better 
than seen, bimanual palpation — one hand uver the suspected area 
in front and one in a corresponding position behind— is useful. 
If the aneurism involves the ascending portion of the aortic 

I'm. \'A\— Piaillou Whan Looking Sliplit AiU'urbmul I^ijI.-.i :■ i.. 

arehj it i* likely sooner or later to erode the right margiu of the 
irmun and the adjacent parts id Um seeond <>r 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 almost always distinctly expansile in character, and 
differs 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 may 
be as hard M any variety of malignant new growth. Occasionally 


the thickness of the laniellated clot within it is so gtvat t 

pulsations an- transmittal to the suit u < . 

Whether Hie aneurism penetrates the cheat or not, it Is i 

possible to feel over it a tubntfirt'/ thrillj usual h 
tnfir in lame. Lfthe layer of laniellated clot in th*- 

sac is very thick, the thrill is less apt to be felt. 

More important in diagnosis is a diastolic nhoek or tap whi 

appreciated by laying the palm of the hand lightly over the &fi 


FIG, 1S1<— AneurlMtuU Tumor ( A). The umiw B pnuiia to a gummatous swelling 
alform atrtuagn. The radiographic appearand* or Ihte case at* inowii below IFU: 

area. This diastolic shock is due to the recoil of the blood in the di- 
lated aorta, and is one of the most important and chararti ristic signs 
Diastolic m aneurism. As the wall of the sac becomes WfeafcOTj 
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. 

ut special importance in aneurism of the transverse arch is the 
sign known as the tracheal tug, The arch of the aorta runs over 



the left, primary bronchus in such a way that when the aorta is 
dilated, the bronchus is pressed upon with each expansile pulsation 
Tracheal of tne artery. This systolic pressure transmitted to 
Tug, the trachea pmduees 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 behind hiin and gently presses the tips 
of the fingers uf both hands up under the lower border of the cri- 

no. I*.*. 

-Aneurinni Tumur performing the Sternum ut .1. At H there It u L-'mumat-ms 
(Bee below. Fig. 124, a nulkKgrapb uf Lb In vu&eK 

coid cartilage. In feeling thus for the tracheal tug as transmitted 
to the cricnid cartilage certain precautions must be observed: 

(a) One must distinguish the fcraehaal tug from a simple pulsa- 
tion tran mm it ted to the superficial tissues by the vessels under- 
neath. Such pulsation makes the tissues move ont and m rather 
than up and down. 

(!') A tracheal tug felt only during inspiration has no patho- 
logical significance and is frequently present in health. 

While preparing to try for the tracheal tug we may notice 
whether there is any dislocation of the trachea, as shown by the 


displacement of Adam's apple. Aphonia, stridor, cough, dysph;. 
and other symptom saw produced by pn i gullet and wind] 

Other signs oi iHHiirism, due to the pressure of the dilate 
upon the nerves nr vessels of the mediastinum, are: 

(1) Inequality of the pupils, 

(2) Inequality of the radial pulses. 

(3) (Edema and cyanosis of one arm 01 of QQ€ 5ld 
and head. 

(4) Pain in one arm from the pressuieot" an aiicnii 
the suMavmn artery upon the brachial plexus. 

(5) Clubbing of the ringers of one bund (rare). 

(6) Prominence of one eye (rare), 

(7) Flushing or sweating of one side of the face ( very ran 
Contraction or dilatation of the pupil is due to an irritatr 

panilytie allVction of the sympathetic nerves. This symptom is 
much commoner than the other effect of pressure upon the sympa- 
thetic nerves j namely, flushing or sweating of one side oi the : 

In comparing the pulses in the two radials we inuM in-ar in mind 
the possibility of a congenital difference between them, d 
difference either in the size of the arteries or in their position, and 
also that a tumor pressing on the subclavian may affect tin- pulse 
exactly as an aneurism. The pulse wave upon the affected aids 
(most often the left) may be either less in volume oi Later in I 
than the wave in the other radial artery, according as i: 
wave is actually delayed in the aneoriemal sac or merely diminish! d 
by it. In marked eases the pulse upon the affected side may be 
nearly or quite absent. On the other hand the inequalit] 
pulses may he so slight that the sphygmograph has to be employed 
to demonstrate differences in the shape of the wave not pcroi 
to the finders. 

Examination of the heart itself may show some disloc 
the organ to the left and downward, owing to the direct nres?-> 
of the aneurisnial sac, but no enlargement. 

If the aneurism is deep-seated, the results of percussion are 
negative. If, on the other hand, it be situated im mediately 



Death the sternum or close under the thoracic wall, an area of dul- 
ness, not present in the normal chest, may be mapped out. The 
outlines moot romuimily seen in .sueh eaftftS are shown in Fig. 123. 
D the aneurism involves the descending aorta, an area of dulness 
Uiaj be found in the region of the left scapula ur below it, and pul- 
sation may bo detected in the sunn- uir.i, 

III. AusQuUgtion* 

The signs revealed by auscultation axe not of much diagnostic 
value as a rule* In about one -half of the cases of sacculated aneu- 

Aneurismnl _ j_ 

Heart (lulnem, 

Yui. I^y, — Dlagran of Perrusslon [HjIdhm in Aortic Aueurlstcu 

rism there are no sounds or murmurs to 1h j beard over the tiunor. 
In other cases ;< systolic murmur, the audible counterpart of the 
vibratile thrill, may be heard over the area of pulsation, tumor, or 
dulness corresponding to the aneurismal sac. This systolic mur- 
mur maybe due to many causes other than aneurism, and has 00th* 
ing characteristic about it. A similar systolic sound is sometimes 
heard over the trachea (Di'imimond's sign) or in 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- 


pa hie diastolic shock, is generally to be heard in the aortic regie 
This diastolic sound, which is probably not produced by the a 
valves, is remarkably deep-toned and loud, and is, on the whole, the 
most important sign of aneurism revealed by auscultation. 

If a portion of either lung is directly pressed upon by the an- 
eurisinal sac, we may have the signs of condensation of the lung 
in the area pressed upon (slight dulness, broncho-vesicular breath- 
ing, and exaggerated voice sounds). If vm- of the primary bronchi 

From the from. 

From behind. 

FIG. 124- -Radiograph Of Case whose Ffcotnfrraph (B Reproduced a* Flgi. 118 and 111*. In Urn 
right-hand cut are shown the appearances seen from behind. The Left-hand cut, JU A* 
aneurhnra] sac ; S, heart displaced ; C, 1K«t ■ rj. >r in u^w) t 

is pressed upon, as occasionally happens, atelectasis of the c-m re- 
sponding Lung maybe manifested by the usual signs (duluess, ab- 
sence of tactile fremitus and of respiratory and vocal sounds). 

Si ii re aneurism is frequently associated with regurgitation 
the aortic valve, a diastolic murmur is not infrequently to 

If the aneurysmal sac is of very great size, the pulse wave 
the fentorals may be obliterated, as happened in a case descril 
by Osier* 

4, Diastolic ihcck may be felt. 

6. Pressure signs | uii.-ijiial pulses, pupils, hovn aim efO.)» 

7. Ditt/n-its Gn prrrUr.MMii Over tin 

B. Loadf t&w-pitched not d t&wuL 

9. Systolic murmur (leaal important of all). 

Am ujiiiiiaj 


Uie uicurism, 

Pio. i.Hi.-Exi^iKlvt" Aortta Aneurism Dhi EMgl 

10, Radioscopy may demonstrate a shadow higher uj> than that 
corre spoil ding to the heart and extending beyond that prodooed by 

the sternum, spinal ooltunu, and great vess> 

Diagnosis of the Seat of the Lesion* 

(a) Aneurism of the ascending arch generally approaches or 
penetrates the chest wall in the vicinity of the second rigki 
costfti tpaoe near the sternum Previous to perforating the thoracic 



etes, the growth of the aneurism may give rise to pain, pnlsa- 
tiuti, and dulness and thrill in this region. 

(h) AttturUm of the tranmtene arch or diffuse dilatation of the 
aorta, such as usually occurs in long-standing cases of aortic regur- 
gitation may not give rise to any visible pulsation of the chest 
wall, and, if drep-seated, need not produce any abnormal dulness 
on percussion, lu such oftQdfl an anrurism is to be recognized, if 
at all, by iiffl on the nerves or vessels of the medi- 

astinum (cough, aphonia, inequality of the pupils, tracheal tug, 

(f) An* BtrtfBt of the dtao&ndvng Q&rba gives rise usually to severe 
d persistent pain in tin* back, whico radiates along the intercos- 
tal nerves or downward. Other pressure symptoms are not marked, 
but in advanced eases an area of abnormal dulness and pulsation 
may be found in the region of the left scapula or below it. 

(<f) If the innominate artery or one of the carotids is involved, 
we usually fiud a pulsating lump in the region of one or the other 
elavii-u In-sternal joint or at the root of the neck, and the traoheq 
may be displaced to one Bide. It the Subclavian is involved or 
pressed upon, there may he pain and oedema in the corresponding 

jHfferm f la / Z>£ ifn pais, 

I Some writers draw a distinction between the diffuse dilata- 
tion of the aortic arch, which sooner or Inter complicates almost 
every case of incompetency of the aortic valves, and saccular aneu- 
rism of the transverse portion of the aorta. Clinically, such dis- 
tinction seems to be impossible, although if symptoms resembling 
those of aneurism gradually develop in a case of aortic regurgita- 
tion, ono may suspect that the dilatation of the aorta is merely 
part of the distention of the whole arterial tree, which aortic regur- 
um tends to prodm < . 
(¥i 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 


not produce characteristic changes in the pulse, and by the presence 
of some one of the symptoms above described, such as traH 
tug, pressure symptom s, abnormal area of percussion duln» 

(c) Simple dynamic 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. 

(d) Pulmonary tuberculosis or cancer of the oesophagus. \n 

mg as they may substernal pain, cough, and aphonia by piessun? 
upon mediastinal structures, have been mistaken for aneurism, 
from which, however, they may be distinguished by th- e of 

the positive signs above described, by the more rapid emaciation 
of the patient, and by the positive evidences of cancer or tubercu- 

(a) 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. I 
perfectly safe to insert a fine hollow needle in doubtful cases. No 
serious hemorrhage results if aneurism is present, and the diagi; 
and treatment may be greatly assisted. 

i f i Mediastinal tumors are sometimes almost indistinguishable 
from aneurism during life. They may produce a more intense and 
widespread dulness which is usually in the median line, whuV 
dulness of aneurism is oftener at one side. The pulsation trams: 
ted to a tumor by the heart has not the expansile character of am-u- 
rismal pulsation. Tumors are not associated with any diastolic 
shock, rarely with a tracheal tug* 

The course of most mediastinal tumors is pr< and at* 

tended by great cachexia, while the symptoms >.t aneurism are often 
more or less intermittent, and unless pain i i seven there is no such 
emaciation or anremia as is commonly seen with mediastinal tu- 
mors, Pressure symptoms maybe the same in both diseases, but 
are usually more marked with mediastinal growths, A metastatic 
nodule over the clavicle sometimes betrays the presence of a pri- 
mary focus within the chest. 



(g) Retraction of the right lung (fibroid phthisis), with or without 
displacement of the heart toward the diseased side, may uncover 
the heart so as to produce some of the signs of aneurism, i.e., pul- 
sation and dulness in the upper right intercostal spaces near the 
sternum, with a loud aortic second sound and sometimes a systolic 
murmur in the dull area. 

The history of the case and a careful examination of the lungs 
usually suffice to set us right. 

(h) Dilatation of the heart 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. 

PART lit 



I. Tracheitis. 

In connection with bronchitis or as a forerunner thereof, inflam- 
mation of Ml*- trachea is not uncommon. It gives rise to no char- 
tir- physical signs, but is to be suspected when the patient 
complains of oougk with pain over the upper portion of the sternum. 


Inflammation of the larger bronchial tubes is not often the 
cause of any definite physical signs, but with every paroxysm 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 radicate most accurately the situation of the large 
tubes when pointing out the position of pain produced by coughing. 

In the vast majority of cases of acute bronchitis the smaller 
bronchi are involved, and the swelling of their walls, with or with- 
out exudation, is manifested by the following physical signs: 1 

(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 of the 

1 Bronchitis may exist without rales, but cannot be diagnosed without 
them. Occasionally they are present only in the early morning. 


(2) M&ss, which art* squeaking or piping over bronchi width 

are narrowed without any considerable amount of exudation, m 
the tS9m in the 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. l#aw-j>ifcehed 
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 h< 
than the tiuer, crackling varii ty. The latter are produced in the 
smallest tubes, the former in the larger variety. 

Simple non-tuberculous bronchitis is almost invariably bilateral 
or symmetrical, and affects most often the Lower two-thirds of the 
lungs, leaving the apices relatively free. It is almost cod- 

fined to an apex. When rales are to be heard on one side of the 
eliest only, and when they jiersist in the same spot for days and 
weeks, tuberculosis is always to be suspected, especially if the 
rilles are localized at the summit of one or both lungs. It should 
never be forgotten that the tuWrele bacillus is capable of exciting 
a bronchitis indistinguishable from other varieties of bronchitis, 
except by its tendency to show itself at the apex of the lung and 
on one side only j most cases of pulmonary tuberculosis begin in 
this way. 

The only other variety of bronchitis which is often unilateral j* 
that due to the influenza bacillus. In the course of a ease of influ- 
enza, a unilateral localized bronchitis not infrequently occurs. < I 
a patch of lung, perhaps the size of the palm of the hand, tine, moist 
rales may persist for weeks, finally clearing up only after the pn- 
tient has resumed his ordinary occupation. Doubtless such local- 
ized patches of bronchitis arc often accompanied by foci of lobular 
pneumonia too small to be detected by our present methods of 
physical e x am in ation , 

Percussion dulness is absent in bronchitis except near the end 
of fatal cases, when the lung is stuffed 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 



negative results, of percussn m an ad growl ralue in excluding sol- 
idification oi fluid exudation. 

Occasionally percussion resonance may be illtflTWimiWfl owing to 
a alight temporary overdistention of the air vesicles from coughing. 

Inspection usually shows little or nothing of diagnostic impor 
tance in unite bronchitis. Long* stall ding cases, complicated U 
they almost invariably arc by emphysema, present changes in the 
shape of the thorax; but these are doe to the emphysema ratio i 
than to the bronchitis. In children aoute bronchitis sometimes 
invi lives so many of the smaller bronchi that dyspmea and use of 
accessory muscles of respiration are notable But this usual! v 
means atelectasis, broncho -pneumonia, or laryngeal spasm, in ailili- 
tion to the bronchitis. 

From violent coughing the jugulars may he distended, but no 
systolic pulsation occurs in them. 

Voice sounds and tactile fremitus are normal. 

/ J f'jf'rt | H Hal Ih'f</M itSiS . 

(St/rum a/tht ftotgraad bronchial asthma arc the only patholagi- 
cal processes (except hemorrhage into the lung substance) which 
give rise to signs like those of bronchitis. 

(1) In mdtmn of tht> Umffj or pulmonary apoplexy, one mux 
rind, as in simple bronchitis, a diminished vesicular breathing with 
crackling rales, but oidema of the lung is almost always best marked 
in the dependent portions; that is, in the posterior parts of the 
lung if the patient has been Lying upon the kirk, or in the lower 
lobes if he has been sitting up. The rales of trdeiiia are id ways 
moist, and are more uniform in size when compared to tho 
bronchitis. The recognition of a cause for the oedema, for ex- 
ample a non-compensated heart lesion, materially aids in the 

i*J) Bronchial asthwui or spasm of the finer bronchi produces dry 
squeaking and groaning sounds similar' to those heard iu the earlier 

] Id children examined during a crying-spell a cracked-pot sound en 
usually be elicited by percussion. This in in no way characteristic of biun- 
chiLisnnd .can of; en ht j Dbtalud in bemlthy infant*. 



stages ut many cases of bronchitis. But in bronchial astJaau 
rales are chiefly expiratory t and expiration "is prolonged ^n<J ml 
rified. Moreover, the inhalation of a lew drops of aniyl nitrite will 

temporarily dispel r;lli> due to bronchial 
spasm, while on the dry bron< 

it has no effect i A brains). 

(3) l>r<Mt'h'i'ffitttiiti<Mi*tt. Jn majj> 

cases of lobular or broncho- pneumonia 
physical signs are exclusively those <*f the 
coexisting bronchitis. In such cases tike 
diagnosis of bronchitis in not wn 
does not oorer tin* whole ground. I shall 

diaCUSfl farther under limiieho-piieuue 

the evidence which leads us 
that something i*ii »t «- tli i luti^ a 

i I > \£u*cli sound*. { 
circumstances (oold, nervou 
rambling n*>; dueed by muse 

tractions in the chest wall may simu- 
late rales so idosely that I miosis of 
bronchitis may l*e strongly suggested. 
The differentiation between rfilee and 
muscle sounds has already been discu- 
(see above, p. 92). 

(5) Atttlertatic orapitaiion. Crackling 

rales heard over the thin margins of the 

lungs at the base of the axilla or along 

the edgee of tin* manubrium i i due 

to atelectasis (see above). From bronchitis they are distinguj 

by their situation and by the lack of symptoms. They are best 

heard at the point shown in Fig, 125. 

Fig. 137,— Ttic Dots are PLim*«*I 
over the Art* wbwe Atelecta- 
tic Crepitation Is orumest 

Chronic Brenokii 

So far aa the bronchitis itself is concerned, there may bt* no 
difference in the physical signs between the acute ami chronic forms 



of the disease; but in the latter one almost invariably finds asso- 
ciated with the bronchitis itself 8 considerable degree of emphy- 
sema, of asthma, or of both conditions. Indeed, the foreground of 
the elinieal picture and the bulk of the physical sign are made up 
by the emphysema and asthma, rather than by the bronchitis itself. 
Accordingly, I shall not discuss rhmtiir bronchitis any further at 
this point, but will return to the subject in the chapter on Emphy- 


In its typical form croupous or fibrinous pneumonia produces 
solidification of one or more lobes* usually thr lower, the process 
being accurately bounded by the interlobular fissures. Although 
the physical signs of the earlier stages dirT. derably from 

those of the later ones, there seems to be no sufficient ground fur 
marking off stages of engorgement and of red and gray hepatiza- 
tion, for diniatUij these stages cannot be distinguished. 

The solidification may begin in the deeper parts of the lung 
( u cetitnt/ pnmt vm&n fa "), so that no physical signs are obtainable 
unless, later in the comae of the disease, the pr o e e w extends to the 
surface of the lung. 

Massive pneumonia, in which the bronchi as well as the air cells 
are plugged 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 

The frequency of endocarditis and perioarditai in connection 
with lobar pneumonia, especially with those of the left side, should 
be borne in mind. 

Physical Signs. 

(«) Inspection, — The aspect of the patient frequently suggests 

the diagnosis; the face is anxious, often flushed or slightly e-ya* 

nosed, the flush sometimes affecting most strikingly the side of the 

face corresponding to the lung affected.' Herpetic vesicles ("cold 

1 Perhapa because the patient Is apt to lie upon the affected side. 


mux's ") are often to l>c seen around the mouth or nose, Tli 
difikmlt breathing is at unci notifiable, and expiration i.s often ac- 
companied by a grunt. The use of the accessory muscles I 
ration and the dilatation ol the nostrils attract attention. 

The, torn lunation of marked dyspnoea with absence of droj 
met with more frequently in pneumonia than in any other disc 
Both sides of the chest usually move alik+', but OOCaaiomattj 
affected Bide shows deficient expansion especially in the later stage* 
of the disease, and the other side of the chest shows increased re- 
spiratory movements (compensatory). Rarely the pulsations of the 
heart may be transmitted to the chest wall through the affected lung. 

When pneumonia attacks a feeble old man, or follows injuries 
(surgical pneumonia), its onset may be insidious, and none of 
phenomena just described may be seen. 

(6) Poipaiwn. — In the groat majority oftmsestuvtile j>- 
wmfko&ty increased over the ifffected SfVOy 1 but in ease the bronchi 
are occluded by secretions or fibrinous exudate, fremitus may be di- 
minished or altogether absent. A few hard coughs will sometimes 
clear out the tubes and thus materially assist the diagnosis, i » 
sionally an increase in superficial temperature of the affected 
may be noticed by palpation, and rarely one feels a friction 
due to the fibrinous pleurisy which almost invariably aecompa 
the dise:t 

(r) Percussion. — Over the areu affected the pereueeion noti 
ally dull and mat/ f/e almost flat) except in the earliest and lab 
stages of the disease, in which it may have a tympanitic quality \ 
or without an element of slight dulness. More marked tvn . 
usually present over the unaffected lobes of the diseased lung < i 
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) Tn the pneumonias of children, and occasionally in adults* 
dulness mav be absent. 

1 By using the edge instead of the flut of the band the boundaries of soU 
id i lied lubes may often be very accurately marked out by means of the tactile 



( 2) When the lower lobe of the left Lung is affected, a distinctly 
tympanitic quality may bo transmitted to tin* consolidated area 
from a distended stomach m colon. 

(3) In rare eases, the percussion over the emisolidated area may 
l)e of a metallic quality, or produce lit*- "cracked -put ? - sound, 

(4) In central pneumonia there may I** no change in the percus- 
sion note* or it may be unusually full and deep so that the sound 
side seems dull by cninparisoiL 

A solidified lobe increases so much in size tliat the area of dul- 
ness Corresponding 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 dul&eat throughout nearly 
the whole back. 

The tight bade Is the most frequent Beat of pneumonic solidifioa- 
tions, but the ialness corresponding to it is often first noticeable in 
tin- posterior axillary line, A dnlness appreciable only in the front 
oi the chest ia almost sun- to oorreepoad to the upper lobe, while 
signs in the lower part of the right axilla correspond to the middle 
lobe. Many cases 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, Wintiieh says that, the minimum is a patch 5 cm. 
in diameter, 2 cm. deep, and superficially situated. 

Percussion often makes us aware of an increased resistance or 
diminished elasticity of the affected side, although the resistance is 
ddom as marked as in large pleural effusions, 

(ti) Auantittittoti.—lji the great majority of cases typical tubular 
breathing is to be heard over the affected aTea. Since a whisper 
is practically a forced expiration, this tttbitfttf quality is very well 

tgkt oat 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 
w hi speit 'd voice one may accurately mark out the boundaries of the 
consolidated area, and demonstrate in many eases that it coincides 
with the boundaries of one lobe of the lung. 

In the earliest stages of the disease the breathing may be bron* 


cho- vesicular ; more often it is feehU -or suppressed over the con* 
,olidated area, arid "crepitant rfilus," that is* very fi 
sounds, may be heard at the eud of inspiration, but these are much 
more cuiniuon in the stage of resolution 1 ("ere] it a: is i«>dux "), 

If BOine of the smaller bronchi are blo< 
quentfy the ease, respiration is absent or very feeble, and such 
eases are often mistaken for pleuritic effusion. In pneumonia of 
the upper lobe it is not rare for bronchial breathing to b 
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, tin- re nuty 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 

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 "egophtay"* 
occasionally to be heard. In the majority of rases, as has | 
already stated, the right lower lobe posteriorly is affected* so that 
the consolidated area is immediately in apposition with the spinal 
column. Under these circumstances, it is not ; c all iiiniummon 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. 12S>. 

The signs are usually less marked in the axilla and in the front 
of the lung, but in a minority jf cases, and especially when the 
upper lobes are affected, the signs are wholly in the front. When 
searching for evidences of consolidation in persons suspected to 
have pneumonia, one should never omit to examine the apices and 
very summit of the armpit, pressing the stethoscope 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- 

1 Crepitant rales are rarely heard in the pneumoniae of infancy and old 
age. They are not peculiar to pneumonia, but- occur in pulmonary oedema or 
hemorrhagic infarction— conditions easily distinguished from pneumonia. 



oseope is a great conveniens, owing bo Hu cas« with which its flat- 
tened extremity may be worked in between the patient and the bed- 
clothes without causing any discomfort. 

When rrsol titiofi begins, the signs may suddenly and completely 
disappear within a few hours. More frequently the bronrhijJ 
breathing is modified to broncho- vesicular, dulness and bronchi ■- 
phony become less marked, fine crackling rales (crepitans redux i 
or coarser moist bubbles appear, and the lung gradually returns to 
its normal condition within a period of three or four days. In the 

^- Tympany. 

Bronchial M-mitilng 
transmitted by 
column t*» 


Fio. IS* - Diagram of Btffna Id Ptwutnorilu, 

active stages of the disease the entire absence of rules is very eliar- 
acteristic. In ab<>ut 19 per ©ent. of the cases the solidification Of 
the lung persists after the fall of the temperature; indeed, it may 
be weeks or even months before it clears up, and yet the lung may 
be perfectly sound in the entL Ou the other hand, abscess or gan- 
grene may develop in the solidified lobe, or the latter may be trans- 
formed into a mass of tough fibrous tissue, and the adjacent portion 
of the chest may fall in (cirrhosis of the lung, chronic interstitial 

- Wandering pneumonia" is a term applied to cases in which 


fchfl consolidation disappears in one loU* *iiil v to reappear in another, 
or gfWMJg gradually fain lobe to Lobe. The physical signs in such 
dQ ni't ilihVr essentially from those air* 'ad \ bad. 

In a typical rase one finds (oftenest at the right bus..- U-hmd) 

1. Dulm-ss on i>ercussion. 

2. Increased taetile fremitus and voire soutv: 

I*. Tubular breathing and oooasioiitHy crepitant rales. 

These signs occurring in eoimeetion with fever, cough, rusty 
sputa, pain in the side, dyspnci'a, and herpes, are BufficJeat for the 

Bui many eases — same say the majority — are not I 
ftral aaen. The following are the commonest monmlifte : 

I re may be tympany instead of dulness, especially in 
children or when the solidification is at the left base. 

(A) The breathing may In* jWM? but vesienhir in character, or 
it may l*c absent, in ease bronchi are plugged; from the sait 

\r) Tactile fremitus may be diminished. 

A hard cough may clear out the bronchi and produce a sudden 
metamorphosis of the physical sipis with a return to the normal 

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 m 
out-of-the-way places, e.#., at the summit of the axilla, and the 
area of demonstrable physical signs may be no larger than a silver 

ir. ,V thorough examination of every inch of the chest is 
essential in doubtful cases. 

In the later stages of the disease crepitant or other tine rales 
often appear, and the signs of solidification suddenly or gradually 

TUffrrrntiaf Diagnosis. 

Pin mmuue scil iiliti eat ion is to be distinguished from 
ft) ricuritie effusion, 

I uberauloats ©tf the lung. 



(1) Fmin pleuritic effusion, pneumonia is bo I** distinguished 

iu the great majority of cast's Ijy differences in the onset, course, 
and general symptOBU of tin- disease. Ju pneumonia the patient is 
in more suddenly and violently attacked, tin- dyspnoea is much 
greater, cough ami pain are imuv distressing and mora frequent, 
mperatcne is higher, and tin- sputum often chiimct emtio. In 

pleuritic effusion tin- dulness is usually more intense than in pnen- 
uiuiiiii. Tactile fremitus and voice sounds an increased in pneu- 
iiEnhUL (exoepi when the bronchi are plugged); decreased or ubsent 
in pleuritic effusion. Bronchial breathing may be heard in both 
-es, but is usually feeble and distant when occurring in pleii- 
- < ii« i lond in pneumonia. If the affection be on the left side, 
the diagnosis IS much aided by the .presence of dislocation of the 
beart, which ia produced by pleuritic effusion and never tjy pneu- 
monia. In eases of pneumonia with occluded bronchi, one may 
have every sitpi of pleuritic effusion llntness, absent, breathing, 
POise and fremitus — and in such eases 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 full back upon the symptoms and upon such 
evidence as the blood count, herpes, sputum, etc. 

Tubeirulnsis of the lung causing as it may, a diffuse sol- 
idification of the organ, may be lmli-linguishable from pneumonia 
if we t:iki' aeooTHii onlv of the physical signs, but the two di> 

ii usually be distinguished without difficulty by the difference in 
their symptoms and course, and by the presence or absence of tuber* 
bacilli in the sputum. 

Inhalation- Pnktmoma. Asi-iication Pneumonia. 

When fooil orotbe? foreign substance* are drawn into the air 
passages, as may occur* tor example, during recovery from etlmi 
BJtrcoei&j a form of broncho-pneumonia may be set up, in whieh the 
solidified patches are not infrequently large enough bo \» k recognised 

bv the ordinary methods of physical examination. 

The lesions are usually bilateral and accompanied by a general 
bronchitis. Slight dulness and indistinct bronchial breathing can 


usually be made out over an irregular area in the backs of both 

signs are considerably less marked than in croupous pneu- 
monia, and the boundaries of the irregular patched «<f disease do 
not correspond to those of a lobe of the lung. 

It not rapidly fatal, the disease may be complicated by pulmo- 
nary gangrene or abscess and large quantities of fetid pus may be 
spit up. 


(Catarrhal *?r Lobular Pneumonia.) 

Multiple small areas of solidification scattered through both 
lungs, interspersed with areas of collapse, and usually associ 
with diffuse bronchitis, occur very frequently in children producing 
severe dyspnoea, cyanosis, cough, and somnolence, and running a 
v. i v 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, 

Tliis La the usual type of "lung fe\ f er 1- in infanta, although or- 
dinary lobar pneumonia is not rare in infancy and in childhood. 

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 ah* (vicarious emphysema) and render fcba physii 
signs very confusing and deceptive. 

Physical Signs. 

In the majority of cases there are no characteristic phy 
signs, and the diagnosis has to be made largely from the symptoms 
and course of the disease. The consolidated areas are usually 
small to give rise to any dulness on percussion, nr to any change in 
the breath sounds, voice sounds, or fremitus, so that auscultation 
shuws, as a rule, nothing more than patches of Hue rales occurring 
at the end of expiration. Localized tympanitic resonance is some* 



times present over the diseased area, making the sounder portions 
of the lungs seem dull by comparison. Occasionally , when many 
lobules have fused into 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 lie 
made, if at all, from the combination of the phytfoal signs of a 
ted bronchitis with the symptoms of pnmmtmm. "This pa- 
tient," we say, "has only the signs of bronchitis, but he is too 
sick. The cyanosis, dyspnoea, and fever are too marked. He is 
sicker than simple bronchitis will account for," 

Differentia I I ' fa gn as is* 

(</) Acntf jHihtmiutrtj ti(h<re*fh>sL>i may be indistinguishable from 
broncho-pneumonia by the physical signs atonr 'Die diagnosis 
must be made from the history and coins** of tin 1 disease OT from 
the presence of tubercle bacilli in the sputa, 

(ij) The ttJtfeapgJTS istelectasis of the lower lol>es vvliich iu;i 
company broncho-pneumonia gives rise to dulness and absence of 
respiratory and vocal sounds. Tims, the signs of pleuritic effusion 
are simulated, and in children tin* possibility of empyema should 
not be forgotten. As a rule, bronchu-pneunionia gives rise to much 
greater dyspnoea, and ts 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 pleuritic effusions, of course, such a change is impossible. 


(1) Incipient Tuberculosis. 

In the earlier stages of the disease there may be absolutely no 
recognizable physical signs, and the diagnosis ww\\ be established 
only by the positive result of a tuberculin injection or by the com- 
bination of debility with slight fever not otherwise to be accounted 


In suine cases the earliest evidence of the disease is h&moptysi*. 
When a patient consults a physirian on account of haemoptysis, it 
is frequently impossible to find any physical signs of disease in the 
lungs; not until weeks or mouths later do the characteristic changes 
recognizable by physical examination make their appearance. 

The very early hoarseness of the voice in tuberculous patients is 
"i great importance and often attracts our attention to the lungs 
Whetk the patient has said nothing about them. Definite physical 
signs in the lungs and tubercle bacilli in the sputa (artificially ob- 


Fro, 1»i -Diagram \a Sbow Position or Earliest m«m In Tuberculosi*. 

tained through the use of potassic iodide, se< asion 

ally be demonstrated before any cough has appeared. On the other 
hand, the patient may cough for weeks before anything abnormal 
van be discovered in the lungs. Occasionally tuberculosis begins 
with an ordinarily bilateral bronchitis, 1 have found tubercle ba- 
cilli in four such cases. More often the earliest physical signs 

i a t Fiue crackling rales at the apex of one lung, heard only 

1 Never percuss a patient within forty-eight hours after a hemorrhage, and 
never encourage cough or forced respiration in such ft one, There is danger 
of starting a fresh hemorrhage. 



with or after cough ami at the end of inspiration. [More rarely 
squeaks in;n be heard,] (See Fig. 129). 

(ft) A slight diminution in the excursion of the diaphragm on 
the affected side, as .shown by Litteif s diaphragm shadow. 

(c) Slight diminution in the intensity of the irsj.iratrnv mur- 
uiur, with or without interrupted inspiration ( M «O0*ifA#6l breath- 

(>/) In examining the apices of the lungs for evidence of early 
tuberculosis one should secure if possible perfect quia* in the room, 
and have the clothes entirely removed from the patient's <1m-m. 
The ordinary hard-rubber chest-piece is better than the chest-piece 
of the Bowles instrument when we wish to search the apices for 
fine rales, After Listening during quiet breathing over the apices 
above and below the clavicle in front, and above the spine of 
the scapula behind, t&fl patient should be directed to breathe out 
and then, at the end of expiration, to OOBgh. During the deep 
inspiration which is likely to precede 0* to follow such a OOttgfc tine 
should listen as ea re fully as possible at the apex of the lung, alum* 
and below the clavicle, concentrating attention especially upon tin* 
bet quarter of the inspiration, when rales are most apt to appear, 
Sometimes only one or two crackles may be heard with each inspi- 
ration, and not infrequently they will not lie heard at all unless t In- 
patient is made to cough, but even ft 9m$U rto, \f pertittmtj is 
important. In children who cannot ocmgii at will, one oan toGom- 
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 over the apex of the lung> 
one should never allow the patient to turn his head sharply in the 
uther direction, nch an attitude stretches the skin and mus- 

1 qd the side on which we are listening so as to produce annoy- 
ig muscle sounds or skin rubs. 

In cases in which one suspects that incipient tuberculosis is 

Kales heard only during the first few breath* and not found to persist on 
subsequent examinations, may be due to Ihe expansion of atelectatic lobules. 


present ami jet b which no positive evidence can be found, it is a 
good plan to give iodide of potassium igr. vii. three times u day) for 
;t few days. The effect of this drug is often to make rales more 
distinct^ and sometimes tu increase expectoration so that tubercle 
bacilli can be demonstrated when before none were to be obtain • 

<A) Tin* diminution in the excursion of the diaphragm upon the 
affected aide in oases of incipient phthisis Iras been much insisted 
upon by F 11 Williams and others who have interested themselves 
in the radioscopy of the chest, Lit ten'* diaphragm shadow g 
us a method of observing the same phenomenon without the need 
of a fluoroseope Even very slight tobeTeuloue changes in the lung 
are sufficient to diminish its elasticity and so to restrict its excur- 
sion and that <>t the diaphragm, Comparisons must always be 
made with the sound side in such cases, as individuals differ very 
mueh 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 diaphragm shadow, independ- 
ently of any active disease in the lung itself. 

Those who are expert in the use of the fluoruseopc believe that 
they can detect the presence 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 ur cog-wheel respiration, in which the inspiration 
i* made up of sharp, jerky puffs, signifies that the entrance of the 
aii into the alveoli is impeded, and sueh impediment is most likely 
to l»e due to tuberculosis when present over a considerable period 
iu a Localized area of pulmonary tissue. 

1 Any irritating vapor— fur example, creosote vapor — which produces vi o- 
h'ni cough and expectoration, may be used to expel bronchial secretions in 
doubtful cases. Tubercle bacilli may then be found in the sputum of pat tents 
who. without the irritating inhalation, have no cough and so no sputa. 

* See Appendix C. 



(2) Modi nttthj AdoMotd Cases 

So far I have been 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 apex of the lung, or of a slightly diminished pul- 
monary elasticity, whether due to pleuritic adhesions or to other 
causes. We have next to consider the signs in cases in which so- 
lidifi cation is present, though relatively slight in amount. This 
condition is comparatively easy to recognize when it occurs at the 

,- Complete 
_-"' Mitldiik-utluu. 


J— Rain. 

Fig. lak-Dtaffmm of SIrds la rhlbisfe. 

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 dulness on light percussion, 1 with increased resist- 

(6) Slight increase in the intensity of the spoken and whispered 
voice, and of the tactile fremitus (in many cases) 

l Other causes of dulness, such as asymmetry of the chest, pleural thicken- 
ing, and i u mors, must be excluded. Emphysema of the lobules surrounding 
the tuberculous patch may completely mask the dulness. 


Some ana of the nv rarietiea ucokt 

breathing (true bronchial breathing is a late sign), 

\.<i\ \\wuiv\n\\\\y loud transmiMion frf the heart sonnda, stpe: 

einlly under the clavicle. 

(«) Card io- respiratory murmurs (rt& p. 14**) are occasionally 
due to the pressure of a tuberculous lobule ujmjh tl 
artery. In eouuection with other signs they are nut altogethei 
valueless in diagnosis 

In ease there is also a certain amount lion in I 

ehi of the affected area or nlceralion around them, one often i 
lilies of a peculiar quality to which Skoda has gS76D tli** name of 
u <xm*Hmrtfiy rftlea,** Rales produced in Of very mar a solid, 
area are apt to have a very sharp, crackling (piality. their intensity 
being increased by the saint- acoustical conditions which mi'ieue 
the intensity «»t tin- voice sounds over the same area When such 
r§les are present at the apex of either lung, the diagm {bar 

culnsis is almost certain* but if, as not infrequently occurs, then 
;uc no rile* to be heard over the suspected area, our diagnosis is 
clear tWy in case the signs occur at the left apt 1 x Precisely th* 
same signs, if present at the right apex. Lean 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 I exm-th 

identical with those of a slight degree of solidification il 
these signs, and ouly these* are discovered at the right apex, 
cannot feel sure about the diagnosis until it in confirmed by the 
appearance of rales in the same area of the Left bide i whether ttJi 
Hie influence of iodide of potassium or spontaneously), 01 by the t 

if tubercle bacilli in the sputum. 1 
A sign characteristic of early tuberctdous changes in the lung and 

which t have frequently observed in the lower and r« 

sounder lobes <»f tuberculous lungs ia a raising of the pitch i 

w*, without any other change in tin- quality of the 
any other physical signs The import this sign in the diag- 

■niJ Th f fwrtlir * 1 dis P»rtiy between the two apic*a is leas marked in the supra- 
P n<ms fos ^ x behind than over the chmcle la front, and hence paihole.- 
vw jil the ;ip * x is more oftel| demonstrable behind than in tront. 



nosis of early feaberculoaifl of the lung's was insisted upon by the 
elder Flint in liis work 00 "The Respiratory Organs " (18bX>), and 
has more recently been mentioned by Norman Bridge, 

It niust never be forgotten that tuberculosis may take root in 

Fhj. i:;i.— Tins MEtaofl Jin* BaHdinciiitmi tit i mil Tiiin-ivli* niicfltl in the Sputa. He 

fj-i-K inrr-N-iiv wen, 

the most finely formed chests and in persons apparently in blooming 
health. The "phthisical chest " and the sallow, emaciated figure of 
the classical descriptions apply only to very advanced cases* Fig, 
131 represents a patient with moderately advanced signs of phthisis 
and abundant tubercle bacilli in the sputa. He feels perfectly 


well and is at work. On tin- other band, a patient with ray alight 
signs may l>e utterly prostrated by the tox:emia of the I 

(3) A<Ira, f r,<l I'lrfhUU. 

Characteristic of the more advanced stages ni tulwreulosi* in the 
lungs is the existence of large are its of solidified am! retracted li 
and, to :t teaser extent, the signs of cavity formation. The patients 
arc pale, emaciated, and feverish. The signs of solidification I 
already been enumerated in speaking of pneumonia. They are: 

L Marked dulness, or BTOO flatness,' with increased sense o( ir- 

% Great increase od roiea Bounds or of tactile fremitus. 

3. Tubular breathing, sonietimaa tau Unas feeble. 

4. As a rule, ooarse r&les, due to breaking down of t K- 
tissne, are also to be beard otot the solidified anas. Some?. 
these riles an produced within the pleuritic adhesions, which 
almost invariably present in such eases. If tlj* v disappear just 
after profuse expectoration, one may infer that they are produesd 
within the lung. 

Increase in the intensity of the spoken roioe, of the whifi] 
vitiee, or of tin tactile fremitus may he marked and yet no toil" 
breathing be audible. Each of these signs may exist and 1* of im- 
portance as signs of solidification without the others. Asa i 
it is ti*iie, they are associated ami Conn I very oharacfa ristic group, 
but there arc many exceptions to this i» 

The tendency of the spinal column to transmit I 
lung sounds produced in an area of solidification iramediul 
adjacent to it on the other side, has been already alluded bo 
the section on pneumonia, and what was then said holds goodoi 

ulcus solidification. Owing to this it is easy tu be misled 
diagnosing solidification at both apices when onh 

Since solidification is usually accompanied 1 tlOd in the 

affected lung in very advanced eases, the chest falls in to a gre.i 

J UntosB senile emphysema masks it. Fibroid phthisis itide iitfta) may 
•how no dulneae. Remember that gastric tympany may be transmitted to the 
J*a \xm% *n<i iiuutk dulnesa there. 



or less extent over the affected area, arid the respiratory exclusion 
is much diminished, as shown by Ordinary inspection and by tin- 
diminution or disappearance of feha Bxcuraion of the diaphragm 
shadow. The intensity of the tubular breathing depends on the 
canity of the solidified portions to the chest wall and bo the 
■ bronchi, as well aa on the presence or absence of pleui 

It is raw to find a whole lung solidified, The process, begin- 
ning at the apex OT jnat below, extends down aa far as the fourth 

llinBrtiiiil breath* 
ing. duh 

IiuTcosed. fremiti!*, 

Tncraiswl voice 


132,— To ILMh w of Sl(rti« ill Pulmonary Tu^nuhwls, 

rib in front, I.e., through the upper lobe, in a relatively short time, 
but below that point ita progress la comparatively slow and the 
lower lobes may be but little affected up to the time of death. On 

ktbc 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 ran- tote 
the disease to extend far in one lung without involving the Other. 
About the time that the tuberculous process invades the previ- 
ously sound lung it is apt to show itself at the apex of the lower lot*> 


of the lung first affected. Conaonating riles apj tear posteriori 
the line which the vertebral border of \\v scapula makes wh^u thr 
vn is raised OvW the shoulder. These points are i llnst t-at^il in 
Kg. 132, 

Cavity Ftifuffit' 

( ii vi ties of greater or lesser extent are formed in almost every 
case of advanced phthisis, but very seldom do they attain stick she 
as to be recognizable during life, [added* the diagnosis of cavity 
in phthisis plays a much Larger part in the text-books than it does 
in the pr:»i ti<v of medicine, since to be recognizable by y\ 
examination a cavity must not only lie of considerable size but iu 
walls must lie rigid and not subject to collapse,' it must comnnmi- 
eate directly with tin- bronchus and be situated near the surface ot 
the lung, and it must not be fillc<l up with secretions. Ir can 
ily 1»* 1 appreciated that it £■ but seldom that all these conditi 
present at oncej even then the diagnosis of cavity i* i difficult QDBj 
and I have often known skilled observers to be mistaken on tin* 

The signs upon which most reliance is usually placed are: 

(o) Amphoric or cavernous breathing. 

(A) "Cz&oked-pot resonance T ' on percussion. 
» < on rse, gurgling rales. 

(tt) Catwrncus or Amphoric Respiration*^ "When pre* 

type of breathing is almost pathognomonic of a cavity. Tf is also 
to be heard in pneumothorax, but the latter disease can usually 
be distinguished by the associated physical signs. Cave 
breathing differs from bronchial or tubular breathing m t- 
pitch is lower anil its quality hoUotff* The pitch of expiration 
is even lower than that of inspiration. Since a pulmonary eavity 
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. 

1 Yet not so rigid as to be uninfluenced by the entrance and exit of air. 



(h) Percussion sometimes enables us to demonstrate a circum- 
scribed area of tympanitic resonance sumnm marked dul- 
uess. More often fchs M craekfid-pot' J resonance can be elicited by 

I percussing over the suspected urea while the chest-piteo of the 
stethoscope is held dose to the patient's open mouth. 
Cracked-pot resonance is often absent over cavities; rarely 00- 
cuis in any other condition (*\*j. f in percussing the chest of a 

■ healthy, trying baby, and Occasionally oral solidified lung), 
(c) The voir*- sounds sometimes have a peculiar hollow quality 
(amphoric voice and whisper), 

(d) rough or the movements of respiration may bring out over 
the suspected area splashing or gurgling sounds, or occasionally 
a metallic tinkle. Flint has also observed a circumscribed bulging 
of an interspace dining cough. Bruce noted a high-pitched suck- 
ing sound during the inspiration following a hard cough ("rubber- 
ball sound "). 

Very important in the diagnosis of cavity is the wtermittenes of 
all above-mentioned - hich are present only when the cavity 

■ is comparatively empty, and disappear when it beOOHIM wholly 01 
ly tilled with secretions, For this reason, the signs are very 
apt to l>e absent in the early morning before the patient has expelled 
the accumulated secretions by coughing. 

^Wmt^ch noticed that the note obtained when percussing over 
a puln cavity may change, its pitch if the patient opens his 

mouth* Gerhimlt observed that the note obtained over a pulmo- 
nary eavitv changes if th€ patient shifts from an upright to a re- 
cumbent position Neither of these points, however, is of much 
importance in diagnosis. The same is true of metamorphosing 

I breathing (see above, p. 102). 
Tuberculous cavities differ from those produced by pulmonary 
abscess or gangrene in that the latter are usually situated in the 
lower two-thirds of the lung. Bronchiectasis, an exceedingly rare 
condition, cannot be distinguished by physical signs alone from a 
tuberculous cavity. 


This term applies to slow tuberculoid ->■> with relat; 

tittle ulceration and much fibrous thickening. 

In a considerable number of cases the physios] Blgn 
differ materially from those of (2u mting foi 

the disease, but occasional i I do* ohrxmk process at tlie 

■gifts of the lung resul* ol the pareruln 

the lung so that we have left a cluster of bronchi matted together 
by fibrous tissue, the percussion m be noticeably tympany 

lie; similar tympany may be dn* u> emphysema of the Lobulwi 
siiiTouuding the diseased portion. In such eaaea rales are usu- 
ally entirely absent; otherwise, the ■ ooi differ from those 
of ordinary phthisis, except that falling- in of the cheat walls over 
the retracted lung maybe more marked. Occasionally the heart 
may be drawn toward I »-ted lobes, $,y., upward and to rU 
right in right-sided phthisis at the apex. In two cases of tibroi 
disease at the left base, Flint found the heart beating near tl 
fovea angle of the left scapula. 

Phthisis tr it h Predominant Pleural Tkicktuituf, 

Tuberculosis in the lung is in certain eases overshadowed by the 
manifestations of the same disease in Hie pleura, so that the signs 
;ne ehiefly those of thkhrn^f pleura* To this subject 1 shall return 
in the section of Diseases on the Pleura (see below, p 278). 

Emphysematous Form ofPhtfi 

Tubercle bacilli are not very infrequently found in the sputa <<i 

:n which the history and physical signs point to chronic bron- 
chitis with emphysema. 1 have seen two such cases within a 
Dulnese is wholly masked by emphysema, tubular breathing 
;i!>« ut, and piping and babbling rales are scattered throughout |)ol 
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 ajw 
a ted with huge downy lungs and the *' barrel chest." Such cf 



cannot be identified as phthisis during life unless we make it an 
invariable rale to examine for tubercle bacilli the sputa of every 
in which sputa can be obtained, no matter what are the pky si- 
tu* i SlffttS. 

Phthisis with Anomalous Distribution ofths Lesions. 

Very rarely a tuberculous process may begin at the base of the 
lung When fche process seems to begin in this way, a healed foCUfl 
is often to be found at one apex surrounded by a shell of healthy 

Hw summit of the axilla should always be carefully examined, 
as tuberculous fool may be so situated as to produce signs only at 
that point. 

Another point often o\*erlooked in physical examination is the 
Iui<ffihi pulmonatis or tongue-like projection from the anterior mar- 
gin 1.1 f the left lung overlapping the heart. Tuberculosis is some- 
ti :ims found further advanced at this point than anywhere else. 

As a rule cases in winch signs 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 Pulmonary T ufarcvio &U. 

No one of the three forma in which acute phthisis occurs, viz,, 

(V) Acute tuberculous pneumonia, 

(b) Acute tuberculous bronchitis and peribronchitis, 

Acute miliary tuberculosis, involving the lungs, can be nr- 
Ogoked 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. 


I. £mi j hyj»kma. 

Fok clinical purposes, the great majority of cases of emphy- 
sema may be divided into two groups. 

Liryr-luntjtti emphyBPiiiBj usually associated with ohtofiifl 
bronchitis and asthma. 

(2) SmaU4mnffed f or senile, i mau 

Although the second of these forms is exceedingly coinnion, it 
is so inuch less likely than the tirst form to give rise to distressing 
symptoms that it is chiefly the large-lunged emphysema which is 
seen by the physician. In both conditions we have a dHatatiuo 
and finally a breaking down of the alveolar walls until the air spares 
are become relatively large and inelastic. In both forms, the elas- 
ticity of the lung is diminished; but in the large-lunged form we 

hi increase in the volume of the whole organ in addih 
the changes just mentioned. 

L" wt Emphysema, 

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 shoulder^ are 
high and stooping and the neck is short (see Fig. 133). The patient 
is often considerably cyanosed, and his breathing rapid and difficult. 
rattan is short and harsh; expiration prolonged and difficult. 
The ribs move but little, and, owing to the ossification of their car- 

l Formed by the junction of the manubrium with the second piece of the 


ages, are apt to rise and fall as if mack 1 in one piece (en r/ti- 
The working of the auxiliary DUMideB df n -pii-ation is not 
infrequently seen. The diaphragm shadow (Litteu's sign) begins 
excursion one or two ribs farther down than usual and moves a 
ueh shorter distance than in normal cases. 
Palpatio a shown a diniiiiutiuij in &0 tactile fremitus, through- 
out the affdeted portions j that is, usually throughout the whole of 
both lungs. Sometimes it is 
•in ri-ly to be perceived at all. 
Pti'ussitai yields very in- 
teresting information. The 
lisease manifests itself— 

I By hyper- resonance on 
percussion, with a shade of 
tympanitic quality in the note. 
(b) By the extension of the 
largins of the lung so that 
they encroach upon portions of 
the chest not ordinarily reso- 

The degree of hyper-resn- 
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 
eh est walls. The encroachment of the over- voluminous 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- 
Bfl higher than normally and the quality may be markedly tym- 
panitic, In the axillae and in the back the pulmonary resonance 
down one inch or more below its normal position, 








IffL- Harm OtMMl due to t Uroul* dkjd- 
I'hltto and Emphysema. 


AtttcuUatim shows in uncomplicated cases no very marked mod* 
ification of the inspiratory murmur, which, however f ma) be 
encd and enfeebled. The most striking change is a gn^t pr<>> 
tmd i ttf>elifrtnrttt of erpintHon s with a lowering of its 
(see 1%, 134). 

Tliis type uf bi> is like bronchial breathing in •►( 

Di l\ . that, in both of them expiration is made prolonged, 

hut • ■mphyseiuatoiis breathing is feeble and low* 
pitched, while bronchial breathing is inr 
and high-pitched, At tin the lunp 

the respiration is especially feeble and maybe 
ili« i replaced by crackling rftles. 
In "«mall*)janged empli have 

precisely the same physv . except that 

the boundaries <»f the rang are not extended, 
expiration is less prolonged and less difficult, 
and inspiration is normal. It does not tend 
to be complicated by In inu-1 litis Odd asthma; 
indeed the guialHuuged emphysema rarely gives rise to any symp- 
toms, and is discovered as a matter of routine physical exaniin 

FIO, lH-Dtagnm to 
I Hup irate Kmpbyse- 
matoiift Breathing 
Willi Nwtfral Explm- 
t<iry Rftlea. 

Hyper-resouaiicc on percussion. 

Feeble breathing with prolonged expiration. 

Diminished fremitus and voice sounds. 

Encroachment of the resonant lungs on the heart and liver 

dulness (in the large-lunged form). 

(«) Emphysema may be confounded with pnetumothwa*i mis 

both conditions hyper-resonance and feeble breathing are present. 
Hut emphysema is usually bilateral, encroaches upon but does uot 
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, wl 


meumothorax breathing is absent. 0* distant amphoric without 

(h) The signs of aneurism of the aorta pressing on the trachea 
n i'ii a primary bronchus are. sometimes overlooked because the fore- 
rand of the clinical picture is occupied by the signs of a coexist- 
ing bronchitis with emphysema. The cough and wheezing which 
the presence of the aneurism produces may then be accounted fur 
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 long borders. But the evidence of 

d mediastinal nerves and vessels (aphonia, unequal pulses 
n- pupils, etc), ami the presence of a diastolic shock mid tracheal 
tug are usually demonstrable 5 the flanker is that ire shall forget to 
took for them, 

it n Uncompensated mitral stenoois may produce dyspnoea and 
cyanosis and weak rapid heart action somewhat similar to that seen 
in emphysemaj and may not be associated with any rardiae. mur- 
mur, but the ilyspmea is not of the expiratory type, and the irregu- 
larity of the heart, with evidence of dropsy and general venous 

stasis, should make it evident that b thing more than simple atn 

phy^ema is present, 

»{rf) Tli'- uirrence of an emphysematous form of phthisis T 
have already mentioned in discussing the latter disease (see p. 2ol), 








Emf>hijsmi*t with Bronehuw 0? Afthma> 

In the gxtat majority Of eases, emphysema of the lungs is asso- 
ciated with chronic bronchitis and teij often with asthmatic parox- 
ysms, Sn.'h association is especially frequent in elderly men who 
have "had a winter ooilgh for many years and in whom arterio-sele- 
ia 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 pari 
the chest. When the asthmatic element predominates, dry rales 
are more noticeable, and occur clucHy or wholly during expiration, 
while inspiration is reduced to a short, quick gasp. 


Intcrst It ki I Bmp ht/at- m tt . 

In rare cases violent paroxysm* of coughing tnay 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 skin, 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 tra 
oiny wound, the air penetrating under the skin and producing a 

bj, crepitating swelling. 

M CompUmmtary BmpkpMma." 

When extra work is thrown upon one lung by loss of the func- 
tion of the other, as in pleuritic effusion — a considerable stretching 
of the overworked sound lung may take place. Tin- ell 
the lung is not diminished as in emphysema, but is greatly in- 
creased. Hence the term complementary emphysema should lie 
dropped and the term complementary ■ : . peusatory ) 

rrsorm u 00 su 1 tstltu tei I . 

Like emphysema, this condition leads to hyper-resonance m 
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 exaffperatad 
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 

AffuU Pulmonary Tfympat 

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 accounted for, he bell 
it* the same way. Like the shortening of the first ln-art sound, 
■avuu- pulmonary tympanites points to the weakening of muscle fibre 
which toxwmia is so apt to produce, Apparently the muscle fibres 
of the lung suffer like those of the heart, 



(Primary Spasm or this Bronchi). 

During a paroxysm of bronchial asthma 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 hypcr~r< sonant, the position of the dia- 
phragm low and its excrursiun much limited, and the cardiac and 
hepatic duiness obliterated by the resonance of the distended lungs. 
(In auscultation, practically no respiratory murmur is to \m heard 
despite the violent plunging of the cheat walls. AVr hear squeaks, 
groans, muscular rumbles, Bad 1 variety of strange sounds, but 
amid them all practically nothing is to be heard of the breath 
mnmds. "The asthmatic storm fixta 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. 

D i(ft> rential Dia g n «m*, 

(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 resembling that of primary bronchial 
asthma, but thorough examination should reveal other, evidence 
of mediastinal pressure, and the history of the case is very diftVi en t 
from that of asthma. 

\h\ Spasm of the glotti* produces a noisy dyspnoea, but the diffi- 
culty is with ht.yth'rrttfri, 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* 

i- •> The paroxysmal attacks of dyspnoea, which often occur in 

nic nephritis, myocarditis, and other diseases of the heart and 
dney, may be entirely indistinguishable from primary bronchial 
asthma but for the evidence of the underlying cardiac or renal dis* 






ease. As a rale, however, the element of spasm is much less 
marked ; the breathing is quick ami labored but not wheezing. 
ration is less prolonged, and the squeaking and groaning riles of 
asthma are not present. 


The diagnosis cannot be atads with certainty from the phy 
signs, and reata entirely rare oases in which it is made 

oil the history, the evidence of syphilis elsewhere in the body, ami 
the result of treatment. Moat cases are mistaken tor phthif 

Any ease supposed to be phthisis, but in which the examis 
of the sputa for tubercle bacilli is repeatedly negative, should lie 
given a coarse of syphilitic treatment. 

The physical signs, as in phthisis, are those of LocalL 
chitis or of soliilifh-atmn, but the lesions arc not ;i? the a; 
usually about the root of the lung or lower down. Cavities i 
formed. Stenosis of a bronchus may occur with resulting atelecta- 
sis of the corresponding lobules, 


This rare disease is still more rarely to be recognized during 
life. It is suggested by the history of raising within a few seconds 
tut minutes a large amount of (Vail sputa, a pint or more in marked 

BS< The physical signs may not be in any way distinctive, oi 
may be those of pulmonary cavity due to tnUn ulnsis. From the 

■ r bronchiectasis is to be distinguished in some cases by a 
knowledge of the previous history* Signs of cavity in phthisis are 
preceded and surrounded by signs of solidification in the same area, 
while in bronchiectasis this is not the case. Again, a bronchi* 
tic cavity is apt to occur, not at the apex, as in phthisis, but in Hie 
middle and lower thirds of the lung posteriorly. Aside from 
history and situation of the cavity and the presence or absence of 
solidification around it, we cannot tell from physical signs whether 
it be due to tuberculosis or to dilatation of a bronchus. In either 
ease we have the signs discussed on page 2G0 (cracked-pot reso- 


nance, amphoric breathing and voice sounds, coarse gurgling or 
splashing sounds on cough)— all these signs disappearing when the 
cavity becomes filled with secretions. 

The disease may cause marked retraction of the chest on the 
affected side, and neighboring organs may be drawn out of place. 

Cirrhosis of the Lung. 
(Chronic Interstitial Pneumonia.) 

As an end stage of unresolved 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 fibrous mass en- 
closing bronchi. 

The side of the chest corresponding to the affected lung Incomes 
shrunken and concave ; fremitus is increased, percussion resonance 
diminished or lost, respiration tubular with coarse rules. 

From tuberculosis the condition is to be distinguished solely by 
the history, the absence of bacilli in the sputa, and the comparative 
mildness of the constitutional symptoms. 

The right ventricle of the heart may become hypertrophied and 
later dilated with resulting tricuspid insufficiency. 



r of cardiac weakness due to valvular 
accumulation of serum may take plate 
physical signs are identical with 
(aee below, page 278) except that the 
always unilateral, while hydrothorax is usually bl- 
ip this rule occur, however, especially on the 
in which one pleural cavity ha titer- 

the results of ail earlier pleurisy. The 
by tapping in cases of hydrothorax is usually 
gravity and poorer in albumin tha 

The fluid shifts mote readily with change of position than u 
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 tew grains of potassium iodide by in out t 
produce a reaction for iodine in the fluid of hydrothorax and not iti 
pleuritic effusion. 

11 Pneumothorax. 

Pneumothorax, or the presence of air in the pleural cavity, may 
result from stabs or wounds of the chest wall, but is usually ■ 
plication of pulmonary tuberculosis which weaken* the lung until 
by a slight cough or even by the movements of ordinary respi 
the pulmonary pleura is ruptured and air from within the lung leaks 
into the pleural cavity. 

If the opening is of considerable size, and the air is not hindered 



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. 

I'/tt/stail St'/Hs. 

1. Itispeetwn.—Tke affected side may lag behind considerably in 
the movements of respiration. In very marked eases it is almost 
motion less and the interspaces are more or less obliterated. The 
diaphragm is much depressed and Litten's sign absent. In riglit- 
snlfd 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 tin* cardiac impulse 
may be lowered as well as displaced, owing to the descent of the 

2. Puljttztion. —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 eaniiut 
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. 134) 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* 
tinm The liver is greatly depressed in eases of right-sided pneumu 
thqr&x, and may be felt as low as the navel. 

3. Permission* — Loud tympanitic resonance is the rule through- 
out the affected side. Even a small amount of air is sufficient to ren- 
iIit 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. 



In no other disease do we get such clear, intense tymp 
resonance over the chest. 

The only exception to this rule ocbttTfl in ease3 in which the air 
within the chest is under great tension, making the cheat walls so 
taut that, like an over-stretched drum, they cannot vibrate prop- 
Under these conditions the percussion note becomes inuihV. 
times almost dull. 

Areas of dulness corresponding to the displaced org« 
or liver) may sometimes be percussed out, 

4. Auscultation. — Respiration and voice sounds are usual 
audible in the lower portions of the chest. At the top 
and rarely in the lower parts, a faint amphoric <»r metallic brcat 1 
may be heard, but as a rule the amphoric quality is brought 
much better by cough which is followed by a ringing aft* 
Or the air in the pleura may be set to vibrating and made to 
forth its characteristic! hollow, ringing sound if a piece of p 
(e.g., a coin) be placed on the back of the chest and struck with 
another coin, while we listen with the stethoscope over the fmi: 
the chest opposite the point where the ruin is. 

The clear ringing sound heard in this way is quite diiT 
from the dull chink obtainable over sound lung tissue. 

The "falling-drop sound'- or "metallic tinkle," and the fang 
fistula sound are occasionally audible (see above, p. 116)- 

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 effusion of fluid in the affected pleural cavity and we have then 
the signs of 


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 re.i 
appreciated if the observer puts his ear against the paJ 
and then shakes him briskly, Splashing sounds heard within 



est 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 tint patient may make it impossible to try succession, as in 

e acute cases with great shock it is dangerous to move him at all. 

Ito, 13!k— SeropneutnoLbornJu Nutetbehorizantal line at ttie surface of the fluid and Um» re- 
fnuU*) UiDff Ji»( above (tie loner timlf of Ihls Warn. Compare FSk. 14t {From v. Zlenimen'a 

The movements of breathing or roughing may bring out a " metal* 
*lio tinkle " (see above, p. 274). At Hie bane of the chest, over an 
area corresponding to the position of the fluid, an area of dnluess 
may he easily marked our, by percussion, and Ibis area shifts ptirp 
>sk*><U*t with change of position. The shifting dulness of pneu- 
moserothorax is strongly in contrast with the difficulty of obtaiu- 
lgany such shift in ordinary pleuritic effusion (see Fig. L3o> 


(The distinction between ^open pntutH&thortLXy" in n 
rent in the lung through which the air escaped in the pleura re* 
mains open, and u closed in which the rent has 

become obliterated — is one which cannot b 
eal signs alone It is often said that amphoric breathing 
cially an amphurir ling fcO 1 1 ■ *- voice and cough 

. •■■ - 

V v ii 1 1 ft r iit.-iJ 
ifxmiiriiT ami 

h^nlmwl .-cardiac 

titling. § r 


Km, l'" ; »iiu4baniJ with Dls|itar*<l Heart 

open pneumothorax, but post-mortem evidence does not 

out. Practically an open pneumothorax is one in which the 

amount of effused air increases, and closed pneumotl 

which the physical signs remain stationary ) 

Differential Diagnosis. 

The distinction between pneumothorax and emphysema has 
been discussed. 
When the air in the pleural sac is under such 
the percussion note is dull, the physics] signs may si: 
nth* effusion, but real flatness, such as characterizes effusion, has 
not, so far as 1 know, been recorded in pneumothorax, and the 
Ben Be of resistance on percussing is much greater over fluid than 
over air In case of doubt puncture is decisi 



\iui!i' pnriiutotliurax, coming on as it does with k syiu|ttoms 
ol collapse and graft shock, may be mistaken for angina pectoris, 
cardiac failure, embolism of the pulmonary artery, en acute pulmo- 
nary tympanites (tee above, \*. 262), 

Prom all fossa it can be distinguished by the pre9»noe «f am- 
phoric or metallic sounds, which are never to be obtained in the 
affections named. 

Flo. ]:t7. — niMptini4ni]iitJ< > HfraLu. Tht> « nil J I ri*- »f tht> ci]*plu<*'<l rliuplinurin vlalblp 1» 
left c3nvtrli It.iirl ilinptiu^ij lu rtlfhL at «.1<-rnijitl r O-'nmi v, /.iilll^MiU^ Alius.) 

(r) Hernia of the intestine through the diaphragm (see Fig, 137) 
at weakening ol the diaphragmatic muscular fibres, may allow 
the intestines to encroach upon the thoracic cavity and simulate 
pneumothorax very closely. The history and oouxse of the case, the 
abdominal pain, vomiting, and mdicanuria, generally suffice to dis- 
tinguish the condition. The peristalsis of the intestine may go on 
even in the thorax, and gurgling metallic Bounds corresponding to it 
and unlike anything produced in the thorax itself may be audible, 


The distinction between open and closed pneumothorax* towhvh 
T have already alluded, is far less important than the profteneeot 

absence of 

(a) Pulmonary tuberculosis 

(ft) Encapsulating adhesions in which the air is confined to a 
circumscribed area 

(a) The examination of the sputa and of the compressed lung 
may yield evidence regarding tuberculosis. On the sound side the 
compensatory hypertrophy covers up foci of dulness or rales so that 
it is difficult to make out much. 

(b) Encapsulated pneumothorax gives us practically all the signs 
of a phthisical cavity, from which it is distinguished by the fact 
that with a cavity the nutrition of the patient is almost always 
mueh vrorsa. 

Encapsulated pneumothorax needs no treatment. Hence the 
importance of distinguishing it from the non-encapsulated form of 
the disease, in which treatment is essential. 


Clinically, we deal with three types: 
(a) Dry or plastic pleur: 

(i>) Pleuritic effusion, serous or purulent. 
{<?) Pleural thickening. 

{«) Dry ob Plastic Pleurisy. 

Doubtless many cases run their. course without being recognized. 
The frequency with which pleuritic adhesions are found post mor- 
tal would seem to indicate this. " 

it is usually the characteristic stitch in the side which suggests 
physical examination. The pain and the physical signs resulting 
from the fibrinous exudation are usually situated at the bottom of 
the axilla where the diaphragmatic and costal layers of th** pleura 
are in close apposition. Doubtless the pleuritic inflammation is 
not by any means limited to this spot, but it is here that the few* 
layers of the pleura make the largest excursion while in apposi 
with each other. In the vast majority of cases, then, the physical 
signs are situated at the spot indicated in Fig. I 



Occasionally pleuritic friction is to bo heard in the precordial 
region, and after the absorption of B pleuritic effusion evidences 
of fibrinous exudatiou hi the upper parts of the Cheat 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, when 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 in the axilla?. Hiccup often ooeutfl and 
gives exquisite pain. 

Our diagnosis is based upon a single physical sign, ptmtritic 
fixation . The nature < if this sound and the 
manoeuvres for eliciting it have already 
been described (see above, p. 112), and I 
will here only recapitulate what was there 
gild. During the first few deep breaths 
one hears, while listening <»\n the painful 
area, a grating or robbing sound usually 
hat jerky and interrupted) moat 
marked :ii the latter part of inspiration, 
but often audible throughout the unfile 
respiratory sot. Alter a fen breaths it 
often disappears, but will visually reap- 
pear if the patient lies for a short time 
upcm the affected side, and then sits up 
and breathes deeply. In marked cases 
the iiibbing of the inflamed pleural sui- 
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 friction-rub barely audible* When 
heard at the summit of the chest, as in 
eases of incipient phthisis, pleural frie- 

Plii. T;w. -^gbowiDR the Point «l 
which Pleural Friction in moat 


tioti produces only a faint grazing sound, much more* tltli* , 
elusive than the sounds produced at the base of the chest. 

( 1 1 rationally the distinctive rubbing or grating sounds an more 
ox li'ss commingled with or replaced bf crackling sounds iridistin- 
guishable Cross the drier varieties of rales. It is now, 1 think, 
generally believed that such sounds may originate m the pleura as 
well as within the lung. The greatest rare should be taken to 
prevent an v sh if Hug or slipping of the stethoscope upon tfcfl sm: 
Of the chest, as by such means sounds exactly like those of pleural 
Eviction may be transmitted to the ear. In ease of doubt one 
should always wet or grease the skin so that the stethoscope I 
not slip. 

Mttsrfe 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 listening 
tor friction at the base of the left axilla, I have once ov twice been 
puzzled by some low-pitched rumbling sounds occurring at th€ end 
of inspiration, and due (as afterward 1) togas in the atom* 

ach which shifted its position with each descent of the diaphragm. 

In children friction sounds and pleuritic pain are much leu 
common than in adults, and the signs first recognisable are ii 
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 usnally absent of 
greatly diminished, owing to the restraint in the respiratory m> 
ments due to pain. Not infrequently pleuritic friction may be 
heard altogether below the level of the lung. 

(A) 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* 
animation. Since it is usually the results of percussion which firs* 
put us on the right track, I shall take up first 



1. A small effusion first shows as an area of dulness 

(<i ) J nst Ik low the angle of the scapula. 

(h) In the left axilla between the fifth and tin' eighth rib. 

(«) i >blitera4dng Traube's semilunar area of tympany; or 

(V) In the right front neai bbe angle made by the cardiac and 
hepatic Hoes of dulness (see Fig. 139). 

In the Tontine permission ol the chest, therefore, one should 
leave out these areas. A small effusion is most easily de* 

»d in children or in adults with thin cheat 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 


due to small 
pleural eff uflfoD.. 

Area of cardiac 
dul new. 

Fio. 139.— Small Pleural Effusion AmimuimiDj; Ma pHrt> near the Right Border of ttie 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 accumulation 


■■1 layer after layer of fibrinous exudate and its organization into 
fibrous plates, while very little fluid remains within. 

The amount of dulness depends also upon the thickness and elasti- 
city of the chest wall and the degree of collapse of the lung within. 

2. Large Effiiatou* — When the amount of fluid is large, th* 
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 tympnnitit note, 

Normal resonance 
and vesicular 

h foJeeaiid 
fremitus I n - 

ItelMM, DO bn-inh- 
or ftwninw. 

Zorn* of 


Exaggemfatf (com- 
Inff and rea«*. 


Wia* HQ. -Diagram to riluatrate Phyifcal SlgM In Mt*l*-ral^Si*ed Effuaioo In toe Left Pteui 

provided the bronchi remain open, as they almost always d<>. This 
tympany is high-pitched and sometimes astonishingly clear. I re- 
cently saw a case in which the note above the clavicle was almost 
indistinguishable with the eyes shut from that obtained in the i 
gastriura. Occasionally "cracked-pot" resonance may be obtai 
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 effusion is usual- 
ly renj marked, and the percussing finger feels a greatly incren 



resistance to its blows when compared with tin* elastic rebound <*f 
the sound side. 

3. Modemte Effttsiitmt. — Three tone* of lvsonam-p own often tie 
mapped out in the back: at the base d ulneas or flatness, above 
that a zone of mingled dulnefia and tympany, and at tli*? top normal 
resonance. The lowest zone corresponds bo the fluid, the middle 
zone to the condensed lung immediately above it, and the top zone 
to the relatively unaffected part (if the lung {ws Pig, 140). Not 
infrequently there is no middle zone but simply dttlne&S below and 
resonance above, as is usually tin/ ease in the axilla and front 

Fiii, 14J, Ltift neural EffWton. K«« lltJil i lit- snrfsiu- o! thu UuM l|0p8i mil want and up- 
ward from tilt* (i wen ah line. (Kn>m v. Zlemsaen'a AU&jO 

The position of the effusion depends only in part upon the in- 
fluence of gravity, ami is greatly influenced by capillarity and the 
degree of retraction of the lungs, Consequently the BurfttDe of 
the fluid is hardly ever horizontal except in very large aeeumuLa- 


ttons, With the patient in an upright position it usual 
a higher level in the axilla than in fchi - e Fig. 141V Near the 

spine and new the sternum (in right-sided effusions) the 
spending to the level <>f the fluid may rise sharply. 

The 3-00*9$ uf Ellis, as worked out so elaborately by Garland, 
varies still further the nmnvu line which conesponds to tt 

Trlnnjntt«r tp»r« 
liuJI liiidi 

it] umI 
t*r*-«i ■ 

Arnt >■: 



Fi.i. H*-\ TlivS-c nm of Ellis. 

face of the fluid (see Fig. 142). This curve can he obtained anly 
after the patient has. by cough and forced breathing, expanded the 
lung sm fully as possible* 

All these curves are to be found with thi^ 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 war* 
faee of the fluid, not being settled by gravity alone, is hardly • 

With change in the position of the patient the level of the fluid 
sometimes changes very slowly and irregularly s and sometini 
not change at all. If, for purposes of thorough examination, 
raise to a sitting posture a patient who has been for BOtne days or 
weeks in Vied, we should never begin the examination at otftoi 



may take Koine minutes fur tin- lun^s and the li nenmmo- 

data themselves to the new position. It is well also to get the 
patient, to fcOUgh and to take a numWr of full breaths before the 
examijiat! _run. 

To tot the mobility of the fluid with change of the pati< 
position, mark out the upper limit of fclie inluess in the back with 
the patient in the upright position. Then let tin* patient lie fam 
downward upon a coueh, and, after waiting a few minutes, percuss 
tin- previously dull area, It maybe found to have become resonant. 1 

Whoii the tliiid is ai isurU'd or removed by tapping, one would 
expert 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 gmaei We depend here far move npun 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, prreussiou is vn v useful during 
the sta^e of absorption. After percussing out the lower border of 
pulmonary resonance in the back, tin* patient is directed to take a 
bm£ 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 r*>n/ rarely. Dislocation of the 
heart is one of the most important of all the signs of pleural effu- 
eknij and is often the crucial point in differential diagnosis. It is 
v striking and at first surprising fact that a leffe-etded effusion 
displaces the heart far more than a right-sided effusion of the same 

' This test, however, is somewhat full acinus and of very little diagnostic 
value, since the lungs tend to swing up toward the back when the patient lies 
prone, even when nojfuid is present* and increase of resonance in the back with 
this change of position might, therefore, occur when the dutness was due to 
Chickened pleura and not to duid. 


size. Small or moderate ri d effusions often do not displace 

the heart at all. 

With left-sided effusions, unless wi \ small, ire find the area of 
cardiac dulness shifted toward the right and often projecting be* 
yond the right edge of the sternum (see Fig. 14 1 l (Inspection and 
palpation often give us even mure valuable information on this 
point. See below, £, 289.) We must be careful to distinguish such 
an area of dulness at the right sternal margin from that which may 
1>e produced in right-si' led effusions by the fluid itself (see abow 

As mentioned above, a right pleural effusion may very early 
show itself as an area of dulness along the right sternal margin. 
Light percussion will usually demonstrate that this dulness is con- 
tin nuns with a narrow strip of flatness at the base of the axil 
(ninth and tenth ribs). Such an effusion is late in creeping up the 
axilla, it appears first and disappears 1irsl along the right margin 
of the sternum. 

< >n the sound side the percussion resonance is often increased, 
owing to compensatory hypertrophy of the sound lung; the dia- 
phragm is pushed down and the borders of the heart or of the liver 
may be encroached upon. "When the hyper-resonance of the sound 
side is present, it should warn us to percuss lightly over the effu- 
sion, else we may bring out the resonance of the distended lung. 

S, t m m ** t-t/ of Percussion Signs* — (1) F 1 at oesa cor responding 
roughly to the position of the fluid. 

(2) Tympany above the Level of tin- fluid over the condensed 

(3) The level of the fluid is seldom quite horizontal. 

(4) Shifting of the fluid with change of position ifl rare, slow, 
and has little or no importance in diagnosis* 

Exceptions and Possible Errors. — (a) (Treat muscular pain and 
spasm may produce an area of dulness which simulates that uf 
pleural effusions, especially as the auscultatory signs may be equ ■ 
m isleadin g. A hypodermic of morphine will dispel the dulness 
along with the pain if it is due to muscular cramp, 

(b) If the lung on the affected side fails to retract (owing to 


emphysema or adhesions to the chest wall), the area of dulness and 
its intensity will be much diminished. 

(c) It must be remembered that dulness in Traube's space may 
be due to solidification of the lung, to sihu itt versus f 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. 

(*) The diagnosis between fluid and thickened pleura will be 
considered later. 


The auscultatory phenomena vary greatly in different cases, and 
in the same case at different times, because the essential condi- 
tions are subject to similar variations. H'hatrrrr aom rids are pro- 
duced in (he lantjs or hi (he hrvneht mat/ he heard over the fluid un* 
less toterftrod with by inflammatory thiekmifaff of the r^ful pleura. 
FUtid (ran *tf tits sounds well, but there may be no breath sounds pro- 
thioed and hence none audible over the fluid. Or tubular toundfl 
only may be produced because only the bronchi remain open,* the 
rest of the hmg being collapsed. 

Or again, if rales or friction sounds are produced in the lung, 
they, too, may be transmitted to the fluid and may (alas!) deter 
the timid u observer " from tapping. 

In about two-thirds of all large effusions no breathing at all is 
audible over the area of flatness on percussion. In the remaining 
third, and especially in children, tubular breathing, sometimes 
feeble, sometiim s very intense, is to be heard. 

In modi -rale effusions tl» ere arc 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 sounds correspond When breath sounds are absent, 
the voice sounds are likewise absent When the breathing is tubu- 


lar, the voice, and especially the whisper, is also tubular and inteii- 
sitied. That is, whtoMw tht bronchi are. open, the tw%§\ 

tr/if/ thp S&fljri traits thin, th*' bwtnthinfr IWftigj and whtSpGT wilt wrrr* 

tp&nd fa thn tracheal and bt&nehial sound*. Since children have es- 
pecially thin sheet uulK these bronchial sounds are especially fre- 
quent and intense in children." 

Near 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 twang, to which the term egophotiy is applied. 
This sign has no importance in diagnosis, since it is not constant, 
and not peculiar to fluid accumulations 

Kales are rarely produced in the retracted lung, and so are 
rarely to be heard over the fluid 

All these sounds may be diminished 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, may be very 
and very puzzling Bales may appear or disapiwar, breathing 
change in quality or intensity, and in the differential diagnosis of 
difficult eases the patient should always be made to cough and then 
breathe deeply before the examination is completed 

In very large effusions, when only the primary bronchi are 
open, there may be signs like those of pulmonary cavity at the site 
of the bronchi in front or behind (amphoric breathing, large metallic 
rftleSj etc ). Over the sound lung the breathing is exaggerated and 
extends unusually 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 left-sided effusions the apex sounds are ofb p 
loudest near the ensiform cartilage or beyond the right margin of 
the sternum. Eight-sided effusions have much In I upon the 

heart, but occasionally we find the heart sounds loudest at the left 
of the nipple or in the axilla 

Since many cases of pleural effusion are due to tuberculosis, we 

■RaceMi'g theory — that the whispered voice is conducted through serum 
but not through pus— is not borne out by facts. 



should never tjmft to search for evidences of this disease at the. 
apex of th** lung on the sound aide. «noe experience lias shown that 
phthisis fa more apt to begin here than on the side of the effusion. 

Sttmttttft'tf of AftsatlUttor*/ Sltjnn. 

(1) Tn moot eases voiee ami breath sounds are absent or very 
feeble over the area occupied by the fluid, 

(2) Tn a minority of the cases the breathing ami voice sounds 
may bo tubular and intensified, esq>eeially in children, 

(3) Over the condensed lung at the summit of the chest the 
ithitig 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 chest and the breath- 
ing is normal at the top of the chest. 

(4) Rales and friction sounds are rarely heard over fluid. 

(5) Ou the sound side the breathing is exaggerated. 

(6) The heart sounds may l»e absent at the apex and present in 
the left axilla or to the right of the sternum owing to dislocation 
Of rhe heart 

Inspection ttnd I **ff potion* 

The most important information given us by inspection and 
palpation relates to the 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 readies no higher than the sixth rib in the 
nipple line. The apex impulse is to be seen and felt to the right 
of the sternum, somewhere between the third and the seventh rib, 
when a large amount of fluid is present. With smaller effusions 
one may rind the apex l>eat lifting the sternum or close to its left 
border. The position of the heart may be confirmed by percussion. 

Tin' spleen is scarcely ever displaced. 

Right-sided effusions are Ear 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- 

<\ effusions often produce no dislocation of the heart whatever, 
The liver is often considerably pushed down by a ritjht-sidfd pleu- 


ritie effusion, and its edge may be palpable several inches below the 
costal margin. Its upper margin cannot be determined by per 
sion, as it merges into the flatness produced by the flui da- 

tiun above it. 

TitftUt: frem itus is almost invariably absent or greatly di 
ished OVBT the areas corresponding to the fluid j just above the l«v.-l 
<«i the fluid it is often increased. 

Ocea signally a slight fulness of the arl 
nized by inspection, and the interspaces may be less readily lis 
than upon the sound side* Bulging of the interspaces I have m 
ubserved. When the accumulation of fluid is large the respirat 
movements upon the affected side are somewhat diminished, 
shoulder is raised, and the spine curved toward the affected si 
The diaphragm is depressed, and Litten's sign therefore absent. 

There are no reliable means for clistin^iishm^ purulent from 
serous effusions. The whispered voire may be transmitted through 
either pus or serum. But we know that in children two- thirds 
all effusions are purulent, while in adults three -fourths of them ar* 

Physical Signs During Absorption of Pleural Effktfans. 

When the fluid begins to disappear, either spontaneously or as 
a result of treatment, the dulness very gradually disappears and 
the breath sounds, voice sounds, and fremitus reappear. In . 
the heart has been dislocated, its return to its normal position is 
often much slower than one would anticipate, aud indeed all tin- 
physical signs are disappointingly slow to clear up even after tap- 
ping. Pleural friction appears when the roughened pleural smii 
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 permanent thickening of the pleura;, con- 
siderable dulness often remains fur weeks after the fluid has 1> 

1 1 have purposely mode but little of the changes in the shape of the 
produced by pleuritic effusion**, as it has seemed to me that by far too modi 
stress has usually been laid upon such signs, 



{r) Pleural Thickening, 

In persons who have previously suffered from pleurisy with 
effusion, and in many who huve never to their knowledge had any 
such trouble, a considerable thickening of the pleunil membrane 
with adhesion of tin- OOttaJ and visceral layers may he mauife>t<-d 
by the following signs: 

(1) Dulness on percussion, sometimes slight, sometimes marked. 
_ Diminished vesicular respiration. 

(3) Diminished voiee sounds and tactile fremitus, 

(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 awl in the axilla. Occasionally a similar thickening may 
be demonstrated throughout the whole extent of the pleura, ami the 
lung failing to expand, the chest may fall in as a result of atmos- 
pheric pressure (see Fig. 120). 

The ribs approximate and may overlap! the spine becomes 
curved, the shoulder lowered, the scapula prominent, and the whole 
side shrunken. The heart may lie drawn over toward the air 

Jn the diagnosis of pleural thickening Bosen bach's "palpatory 
puncture" is some tin us our only resource. Under antiseptic po- 
tions a hollow needle is poshed between the ribs awl into the 
ral cavity. As the needle forces its way through the tough 
fibrous, or perhaps calcified, pleura, the degree and kind of p 
ance are very enlightening. Again, the amount of mobility of the 
point after the chest wall has Iteen 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 


Small accumulations of serum or pus may he walled off by ad- 
hesions so that the fluid does not gravitate to the lowest part of 
the pleural cavity or spread itself laterally as it would if free, 



Such localized effusions are moat apt to U» found in the lower axil 
lary regions or behind — sometimes between the base of thp lung and 
the diaphragm, and move rarely between the Lobes of one of the 
lungs or higher up I have fcwioa aeeii an encapsulated purulent 
effusion so close to the left margin *»f the heart that the diagnosis 
of pericardial effusion was made, 

The diagnosis of encapsulated pleural effusion is it difficult o 
and oftentimes cannot be made except by puncture. The ai| 
those of fluid in the pleura, but anomalously placed. Even 
ture may fail to clear up the difficulty, since the needle BUM 
entirely through the pouch of fluid and into some structure 
so that no fluid is obtained. 

Pulsating Pleurisy (Empyema Necessitatis}, 

Under conditions not altogether understood the movements 
transmitted by the heart to a pleural effusion {usually purulent 
may be visible externally as a cireuiuseriWd pulsating swelling ne 
the precordial region, or as a diffuse undulation of a considerable 
portion of the chest wall. Somatimee this pulsation is visible be 
cause the fluid has worked its way out through the tli 
and is covered only by the skin and subcutaneous tissues, but 
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 palpable thrill or dias- 
tolic shock and by the evidence of fluid in the pleura. 


Tlie following conditions are nut 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 may 



have present all the physieal signs of pleuritic effusion tacept 4U- 
,,,->,? qf the neighboring vrgw. The presence or abseiu-»> el 
such displacement, together with the history, symptoms, and course 
of the oaae, is therefore our mainstay iu distinguishing the two 

Prom ordinary croupous pnexuxumift (without occlusion of the 
bronchi) pleuritic effusion differs in that it produces a greater fie- 
gret' of dulness and a diminution of the spoken voice sounds and 
tactile fremitus. Bronchial breathing and bronchial whisper may 
he beard either over solid lung at over fluid accumulation, although 
the bronchial sounds are usually feeble mid 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. Iu pleuritic effusion we can sometimes determine that 
the line marking the upper limit of dulness shifts with change of 
the patient*! position, Tins ts, of course, impossible in pneumo- 
nia. A few hind emighs may open up an occluded bronchus and 
so clear up the diagnosis at once. In doubtful eases the patient 
should always lie 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 often followed by a purulent effusion, In children the lm h i i ■]> I 
are especially prone to become occluded even as a result of a simple 
bronchitis, and we must, then differentiate between atelectasis and 
effusion — in the main by the use of the criteria just described. 

(2) It is sometimes almost impossible to distinguish small fluid 
accumulations in the pleural cavity from pleural thickening with 
pulmonary atelectasis. In both conditions one finds dulness, dimi- 
nution of the voice sounds, respiration, and tactile fremitus, and 
absence of Lit ten's phenomenon, but the tactile fremitus is usually 
move 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 
sounds over the suspected area speaks strongly in favor of pleural 
thickening, but it is possible to hear friction sounds over fluid, 


probably because they are conducted from a point higher up in the 
chest at which no fluid ls present In doubtful cases the diagnosis 
can and should be cleared up by jrattrflfflfc 

(.*>) 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 bade dulness on percussion as high as 
niid-seapula, 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 hi the other case to 

Fro- M&- Are* of Dulneas in Solitary (tropical) Absc*«a of the Llrer, 

the liver which pushes up the lung together with the diaphragm. 
By physical signs alone I do not see how this diagnosis is possible, 
though Litten's sign may be of use, since the shadow is absent 
in empyema and sometimes present in mode rate -sized subdia- 
phragmatic accumulations. Some of the symptoms, such as chill*, 
sweating, and irregular fever, are common to both conditions. A 
careful consideration of the history and the associated signs and 
symptoms may help us to decide. 

Large solitary abscess of the liver, occurring as it almost in- 
variably does in the posterior portion of the right lobe, produ* 
area of flatness on percussion, which rises to a much higher level in 



the axilla and back than in front or near the sternum (see Fig. 143), 
and may be in this way distinguished from empyema; but when the 
liver contains many small abscesses, as in suppurative cholangitis, 
this peculiar line of dulness is not present. 

(d) Rare diseases, such as cancer or hydatid of the lung, may 
be mistaken for pleuritic effusion. The history of the case and the 
results of exploratory puncture usually clear up the difficulty. 




Abscess ajed Gaxquevz of nm Lcxo. 

I roxsiDER these two affect: because the pin 

signs, exclusive of the sputa, do not differ materially in the fcwn 
affections. In some cases then may S *•- uo physical signs at all. 
and the diagnosis is made ban tin- character of sputa and from a 
knowledge of the etiology and symptomatology of the ease. In 
other cases we find nothing more than a patch of coarse riiles <»r a 
small area of solidification, over which distant bronchia] breathingj 
with increased voice sound and fremitus, may 1** aj 
Rarely there may be slight dulitess on percussion, but as a rule the 
area is not sufficiently large or sufficiently su]>ertmial to produce 
this. One may find the signs of cavity (amphoric breathing, 
cracked-pot resonance, and gurgling rales), hut this is unusual. 

Gangrene of the lung is not a com in on disease. The diagi 
usually rests altogether upon the smell and appearance of tit* sputa. 
In fetid bronchitis one may have sputa of equal foulness, but the 
odor is different. The rinding of elastic tissue in the sputa proves 
the existence of something more than bronchitis. 

Pulmonary abscess, which, like gangrene, is a rare affection, \* 
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 thoee of empyema and 
should be easily recognized as such. The finding of W - 
is the crucial point in the diagnosis of intrapulmonary ahaee*** 

whether due to the tubercle bacillus or to other organisms. Tuber- 
culous absoe&s cavity > is usually near the summit of the lung, and 
"lint rariefikfl of abscess use Beat tin* base, but often then* an* 
no physical ngiu Uy which W€ can distinctly localize the process. 


Malignant Diheask 

'lit: hi -\»i, Plkika, oh Thkst Wai.i, 

Jn its earlier stages this affection it often mistaken Unr empy* 
ema ot serous effusion in the pleural cavity, and Ludeod the physi- 
cal si^us may Ik* in part due to an accumulation of fluid secondary 
to the malignant growth within the lung. The rapid emaciation 
of the patient ami the presence of a dark-brown bloody fluid in the 
pleural cavity, as determined by puncture, make us suspect malig- 
nant disease, but in sarcoma there la usually do emaciation until 

lalfi in the OOUrSe ol the disease. Tin- sjmht rarely contain fa*g- 
incuts of tissue whose structure ean be recognized as characteristic 

of malignant disease, Be< darj deposits in the supraclavieuiar 

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 grow tit within; occasionally it is not deformed 
at all. When the growth attacks only the lung tissue itself, leaving 
Ike bronchi and mediastinum free, we get signs like those of pleu- 
ral effusion (Eatn ess | absent breathing, voice sounds, and tactile 

If the disease begins in the bronchi, we may have a noisy d; 
tio^a from stenosis of a bronchus, and a weakening of the respiratory 
sounds normally to lie heard over the trachea in front has B6< 
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 place in a very irregular and confusing way. 

Signs and symptoms of pressure in the mediastinum due to 
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 arm. 


ATELEf I 'As is. 

(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), but are usu- 
ally too small to give rise to any characteristic physical ting 

(0) In must normal individuals a certain degree of atelc. 
of the margins of the lungs may be demonstrated in the following 
way: The position of the margins of the lungs in the axilke, in the 
back, or in the precordial region are marked out by percussion at 
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 Conner limits, 
owing to the distention of previously collapsed air vesicle©. 

If one auseuits the suspected areas during the deep breaths 
which arc used to dispel the atelectasis, very tine 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 Abrams has given the 
name of " atelectatic crepitation," are in my experience especially 
frequent at tin* base of either axilla. The same writer has not: 
an opacity to the arrays over such atelectatic areas* 

Forcible percussion may be sufficient to distend small are; 
collapsed lung, or at any rate to dispel the dulness previously p] 
ent (aee above, p. 82, the lung reflex). 

(c) When one of the large bronchi is compressed (as In an 
aneurism) or occluded by a foreign body, collapse of the eniie- 
sponding area of lung may be shown by diminished motion of the 
affected side, dubiess on percussion, and absence of breathing, voice 
sounds, and tactile fremitus. 

In new-born babies whose lungs do not fully expand at the time 
of birth, similar physical signs are present over the non -expanded 
lobes. The right lung is especially apt to be affected 

Li the differential diagnosis of extensive pulmonary collapse, 


the etiology, the suddenness of their onset, the absence of fever and 

emplacement of neighboring organs enable us to exclude pneu* 

I and pleuritic effusion. In distinguishing small areas of 

solidification from similar areas of atelectasis, Abrams finds the 

** lung-reflex " (see page 82) of value. Atelectatic areas expand 

if the skin overlying them la irritated* Solidified areas show no 


<Eiu :m \ ar THE L.UNo>, 

In cardiac or renal disease one can often demonstrate that the 
lungs have been invadrd by transuded serum as a part of the gen- 
eral dropsy- More rarely pulmonary fedema exists without much 
evidence of oedema in other organs or tissues. 

The only physical sign characteristic of this condition is the 
108 of Hue moist rfdes in the de| ten dent portions of the lungs; 
that is, throughout their posterior surfaces when the patient has 
been for some time in a recumbent position; or over the lower por- 
tions of the axdlse and the back if the patient has not taken to 

The rales are always bilateral m in leas the patient baa been lying 
for ;l long time on one side), and the individual hubbies appear to 
be all of the same size, or nearly >■», differing in this respect from 
ni be heard in bronchitis. No squeaking or groaning sounds 
are to be heard. The respiratory murmur is usually somewhat 
diminished in intensity. 

Ihilness on percussion and modification of voice sounds are not 
present, unless hydrothorax or hypostatic pneumonia complicate 
tin- oedema. 

HvrosTAi rr I'nkimhma. 

In long, debilitating illness, such as typhoid fever, the alveoli 
"f the dependent portions of the lungs may l)eeume so engorged 
with blood and alveolar cells as to I>e practically solidified. Under 
these conditions examination of the posterior portions of the lungs 
Bhowa usually: 

(a) Slight dulness on percussion teaching usually from the 


base to a point about one-third way up the scapula. At the very 
base the dulness is less marked and Incomes mixed with a shade of 

(b) Feeble or absent tactile fremitus. 

(c) Diminished or suppressed breathing and voice sounds. 

The right lung is apt to l>e 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- 

Rales of oedema 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 characterize 
croupous pneumonia are usually absent. 




I. Mediastinal Tumors. 

New growths of the mediastinal glands 1 usually manifest their 
presence by the following symptoms and signs : 

(1) Cachexia and substernal pain. 

(2) Evidence of pressure against : — 

(a) The gullet. 

(b) The windpipe or primary bronchi. 

(c) The large venous trunks. 

(d) Nerves which pass through the mediastinum. 

(e) The subclavian arteries. 
(/) The heart. 

(g) The ribs, clavicle, or sternum. 

(3) Secondary deposits in 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 inspiratory or expiratory, or both, and often 

1 Tuberculous glands uot being Mere included. 


of noisy strident type, may result from stenosis of the t 
primary bronchi. Owing to pressure oti one of the large 
tlir resonance and breath sounds and fremitus may be dimij; 
over the corresponding luiii?, in which finally abscess or gan . 
may develop, owing to the retention and decomposition ui the 
bronchial secretions, 

(r) If tlie pulmonary veins are pressed upon, a sysl tnnut 

may be audible in the left back, and congestion of the lungs may 

Pleasure on the innominate and subclavian veins produ 
nosis or oedema of the head, neck, shoulder, and arm, while tlie 
superficial veins of the cheat may become enlarged and prominent 
owing to an attempt at collateral circulation, especially if *ln 
cava superior is pressed upon. Fluid may accumulate in our or 
both pleural cavities if the vena azygoa m thoracic duct 
vol veil 

(rf) Aphonia or hoarseness points to pressure on the recurrent 
laryngeal nerve, and on laryngoseopie examination one vocal cord 
may be found in the cadaveric position. Inequality of the pupils, 
due to pressure on the sympathetic nerves* is not nncouunuii, 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 are symptoms of pressure mi the 

vagus (slowing or quickening of the heart) and on the pi 
nerve (hiccup, unilateral spasm, or paralysis of the diaphragm). 

(?) Weakening or delay in one radial pulse may be due to j 
are on the subclavian artery. 

(/) Occasionally the heart itself may he pushed out of place* 
(.7) Pressure of the new growth against the bones of lbs e$M 
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 their is tympanitic resonance In- 
stead of dulness over the affected area. The ribs Off sternum may 
be pushed forward, but this is not usually the case. Oecasionally 
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. 

Aneurism 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 
be surely diagnosed. The degree of anaemia and emaciation is usu- 
ally greater in malignant disease than in aneurism, but this is not 
always the case. The presence of secondary nodules in the neck or 
armpit speaks strongly in favor of new growth. 

Stenosis of a bronchus, due to syphilis and giving rise to dysp- 
noea, cough, stridor, pulmonary atelectasis, may be very difficult to 
distinguish from mediastinal growth, but the degree of aiiiemia and 
emaciation is usually less in syphilis, and the Iwneficial results of 
antisyphilitic treatment may render the diagnosis possible, espe- 
cially if there is evidence of syphilis elsewhere in the body or in 
the history of the case. 

Phthisis may be suggested by the weakness, emaciation, and 
persistent cough produced by mediastinal growths, but should be 
easily excluded by the examination of the lungs and sputa. 

II. Mediastinitis. 

The acute suppurative forms of this rare disease do not give rise 
to any characteristic physical signs in the chest. 

The evidences of chronic fibrous mediastinitis have been already 
sufficiently considered in connection with adhesive pericarditis. 


111. Tuberculosis of the Mediastinal G lands. 

Probably every ease of pulmonary tuberculosis is preceded or 
accompanied by tuberculosis of the bronchial lymph glands, and it 
numberless cases the tuberculous process never gets beyond then 
glands but is choked off there. In post-mortem examinations of 
children, no matter what the cause of death, it is exceptional not 
to find the bronchial glands tuberculous. 

Nevertheless the disease can but rarely be recognized during 
life. We may suspect it if, in a child showing tuberculous cervical 
glands or phthisis, we find evidence of pressure upon the right 
bronchus, increased tactile fremitus above the manubrium, lateral 
displacement of the trachea, or weakening of the pulse during in- 
spiration. If a bronchus is compressed, the resonance, tactile 
fremitus, and 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 primary 


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- 

Murmurs are often present but have usually 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 diastolic 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- 


to examine the heart previous to the onset uf the present 
i it is impossible to exclude a long-standing valvular lesion aa 

of the murmur, 

If murmurs eome and go from day to day, or suddenly increase 
intensity, we may suspect an aeote endocarditis, especially if a 
tusical murmur is pre eent or it' there be evidence of emboli 

Inspection, palpation, ami percttseioafl nwuily yield no signs at 
tportauce. There is no enlargement of the heart^no accentuation 
the second sounds, and no evidence of stasis. 



(1) Tactile fremitus and voice sounds can be investigated only 
case the child cries or Crows* The cry-suum 1 is in ten si tied ov»t 
solidified areas and may or may not be lost over fluid aecuinula- 

(2) Percussion must l>e very delicately performed if we are to 
void setting the whole chest in vibration with every stroke. It is 
est to strike wholly with the finger, keeping the hand (as well as 
the wrist and arm) unmoved. 

In listening to an infant- s lungs patience and concentration 
are essential. The child is apt to stop breathing when the exami- 
nation begins, and we have to wait patiently to catch the long-de- 
layed inspiration "on the wing," as it were, before the long expi- 
fcoiy 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-piece of the 
stethoscope with the ear-pieces are very convenient when examin- 
ing a wriggling child (see Fig. 51, p. So), as they make it possible 
to hold the chest-piece in position despite the constant movements 
.it the struggling sufferer. 

(5) It is advisable to examine first the back while the child is 
leid in the mother's arms with its back to the physician. 



($) Children almost always ory H made to lie down flat Ii 
we wish to bring ou1 the cry sound w order la test tin 

tactile fremitus, tins is n simple and humane method of prod 
it. If, on the other hand, peace is what we Blast desire, it 
t<> avoid putting the child in a recumbent positi 

(7) There is no type of breathing peculiar to children <»r in* 
Puerile breathing is simply vesicular breathing heard w«j 
distinctly on account of the thinness of the chest. It, in a health; 
ohildj the expiratory murmur is prolonged and bigh-pifa 
probably because the child blows out the breath : in tht* 

effort (so breathe deeply as it is told to do. A young infant 
does this, and its breathing is like that of adults except that life 
more rapid, more irregular, and better heard. 



Radioscopy gives assistance in the diagnosis of diseases of 
chest in two ways : 

L Through the use of the fluoroscopic screen. 

2. Through the use of radiographs. 

Those who are accustomed to tie nse of tin* flnoroacope gain 
far more information from it than from radiographs, but the i 
of the photographic plate is objective, permanent, and de 
airable, while the impressions gained from the Soorasoopa are more 
apt to W* modified by the personal equation, 

For the present, therefore ed both methods, 

I shall not attempt to discuss the advantages of the various 
forms of apparatus used for producing Roentgen rays in a 
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 
studying fractures. We need a "low " or "soft" tube which given 



rays of a relatively slight degree nt penetration. With high pene- 
tration rays the outlines of the solid organs are toss distinct because 
the rays tra heart and liver times! as easily as they do the 

tnngt. If the penetrating power is less, the rays are arrested by 
the solid organs, hut not by the lungs, and hence the outlines of the 
'former become visible. 

J. Thr Is* ,,/(/(,< FtH9r*8£6p6, 

1 It is advisable to remain in a dark room or to wear smoked 
glasses for a abort time before attempting to use the tluorosuope. 
This applies esjwcialiy to beginners. Skilled observers do not need 

h preparation of the retina, hut Mian: who complain attirst 

that they can "see absolutely nothing " when they apply the ftaoro- 
■eope to the chest. Bad their vision suddenly and permsnentlj iiu- 
prored after fifteen minutei in & dark room. Practice inerease* oar 
powers with the fluoroscopy as much as it doe* with the micro- 
scope, and it is unreasonable to expect bom the first all that 

an i 

2. The patient should be placed at least two feet from the tube, 
else there is likely to be distortion and magmiication of the shad- 
responding to the organs examined. The tube should l»e 

placed at such a height as to be opposite the most important objeet 
to be examined, and always in the median line. 

3. Patients may be examined either in the upright position — 
the tube about two reefc from the patient's back — the fluoroscope 
resting against the eh est — or in the recumbent position, supported 
on*a canvas cut with the tube underneath. I prefer the upright 
position. The patient's amis should always be extended forward 
SO as to get the seapule out of the way, 

4. To ei te the light upon a spot of special interest, we 
may use a metal plate with a rectangular opening about two by 
three inches near one end. When this 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 opening, but are intercepted 
by 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 shadows seen with 
the QuotyOfogpe, b pencil enclosed in a tube of brass is useful ; the 
brass jacket makes the pencil visible ami enables us to adji; 
paint to the outlines on the chest. An ordinary pencil ifl 
n-uted by the rays Completely, and it is hard t<» draw with a : 
which we cannot see. 

IL The X»rmul Fluoroscopic Picture (see Fig. 144), 

The lungs appear as the lightest part of the field owing to the 
large amount of air they contain j at thy end of full iaflpin 
they become still lighter. Against the light lung areas, tin 
lines of the ribs and of the vertebral eohui i the sternum I 

imposed) are clearly visible. Less clear, but usually qu. 
guishable, are the outlines of the heart and the upper border of the 
liver. A slight shadow (see Fig. 143) is often noticed just to the 
light and to the left of the heart in a position corresponding to the 
larger bronchi. The spleen is not usually to U< made out elearly, 
but the upper surf are of the diaphragm above it is generally risible. 
The eon tractions of the heart and the movements of the diupl 
are usually clear, and any restriction of the respiratory exr 
on one side can be noted, though the fluoroecope has no advantages 
over the inspection of Litten's diaphragm shadow (see p. 2:t) for 
this purpose, 

Abrams has noted that if the skin of the precordia is irritated 
by cold or pain, a reduction in tin sr/c of the heart occurs ("heart 
reflex M ) for a few seconds. 

]n children all these phenomena are - specially clear, owing to 
the thinness of their chest walls and we note at once how ninth 
more horizontal the child's heart is than the adult's (see Fig. 144). 

Ill The Fluoroscopy in I>f's>a#e t 

I shall mention first those diseases in which the fluoroscope fur- 
nishes us the most valuable information. 

1 . An*" ft r is m> — Sin all aneu ri sms o f the trans verse or descending 
aorta may sometimes be recognized by the x-rays when no other 



Chest Ol Heollhj Boy 
nine yean. 

Incipient Pbtblsif lit Rl^Ut Cheat of HealUij Adult, 



Advanced Phtbbli (cavity?). Advanced rbLblaL-r XlHnteruI PlrtbiHiii at Apices, 


Advanced Pbthi&ta- Advanced Pbtbigta. Pulmonary Empbyacnia. 

Fl fii 

Aortic AJieuriani, Aneurism of Left Auricle. Fibroid Pbt blsis of Right Lung, 

Heart drawn to tbe rtgbt. 

110, 144.— TweJre Radiographs of the Chest, as Seen from Behind (after WaliibamK 


method of physical examination yields satisfactory ovid 
abnormal shadow appears at one side of the stern uni (see F%. 
and may sometimes be seen to pulsate. In other eases the fluoro- 
soopio evidence is not the only evidence, but tends r<> entifima 

Flo, lift.- Rail MrrHph Of I Lie< cd Tnuatpcwllfcffl ofttw Viscorn. (Atu-r 

dispel suspicious aroused by the ordinary methods of examin 

Aneurism of the heart itself is recognizable, according to F, II. 

Williams, by the fluoroscopic examination. No other method of 

rxiiniiiiation gives us any evidence of such a lesion. 

2. Determination of the Outline* in P at i eaU with J£m- 

phyetmattnd} H Walls.— Emphysema spoils cardiac peitms- 



sion and interferes with inspection and palpation. But in fl 

work emphysema is a boon and a blessing, for it reodera ile- 
cardiac outlines more distinct t! ii. JItjuc, for determining 

The size and position of Hie heart in such nates, the jr-rays give 
genuine assistance, as thej also do when mapping out the heart in 
women with large breasts and tat chest walls, 

3, Central Pneumonia.— VfiUiaxns ami others have s&eoeeded 


I loin. 

Fto. l+fl,— Front View of TbornH*- ai -hm. The heart dlspinmt Uiiwnwird, 

in identifying foci of solidification beneath the surface of the lungs 
when no other physical signs could be obtained. It must be re- 
nabaiedj however, that congestion of the lung, (edema, atelec- 
iJtj and pleural thickening produce shadows similar to those of 
solidified 1 

■4, Tubemtl&sis. — It is still a matter of doubt whether tubercu- 
lous foci can be recognised by the fiuoroteopa before the disease has 


progressed sufficiently to produce localized rales, diminished bi 
sounds, or restriction of Littcn's phrenic phenomenon. 

Slight opacities have been noted in cases which later t 
to be tuberculosis, and which had not previously l«'t*n diagm 
but the shadows perceived h/y the fluoroftoope are capable of 
interpretations and correspond (as above said; to virions pathologi- 
cal conditions. Old quiescent foci may appear like advancing 

A neuroma I sao. 


NT— AnuurisDial Sac Radiographed fmm Behind 

sions and thus lead to serious errors. We do not want to h* 
patient off to Colorado or Davos on account of the shadow thrown 
by a long-healed lesion. Further, in some cases of rheum. 
anaemia, debility, and convalescent typhoid, appearan simi- 

lar to those of tuberculosis may be found (Williams). Hence the 
in tre pre tat ion of slight lung shadows in cases of suspected incipient 
phthisis is by no means easy. 


Advanced phthisis Tenders the lungs relatively opaque to the 
Roentgen rays except where extensive excavation has occurred; 
here we see a light area in a dark background (see Fig. 144) . 

No satisfactory radiographs of cases of incipient phthisis have 
so far been published, so far as 1 am aware. 

5. Pleuritic Effusions. — The displacement of the heart is some- 
times better shown by the s-rays than by ordinary methods of ex- 
amination, since the compensatory hypertrophy of the sound lung, 
which interferes with percussion and palpation of the heart, 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 Iks seen to 
move up and down with respiration. 

Small fluid accumulations flatten the normal curve of the upper 
surface of the diaphragm by filling up the chink between the inner 
surface of the chest in the axilla and the line of the diaphragm at 
that point. 

6. Emphysema. — The lungs l>econie unusually transparent and 
owing to the low pocition 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. 

Rati bxjrn phs. 

But little use has thus far Wen 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. 



This instrument 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 upon 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 
eliminating the personal equation when using it. The size and, to 
a certain extent, the shape 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 
applied with a pressure of three ounces to the wrist of A, and then 
with the same pressure to the wrist of B, the force exerted upon 
the artery may be quite different in the two cases owing to the dif- 
ferent shape of the wrist in the two individuals. 

Almost any type of tracing can be obtained from a normal pulse 
by varying the 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 
secondary waves unpalpable by the fingers, it has yet to be shown 
that it reveals anything of practical 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. 


Abrams, 82 

Abscess, pulmonary, 206 

Adenitis, 41 

Allbutt, 122, 182 

Amphoric breathing, 107 

Anatomy, regional, of the chest, 2 

Aneurism, 226 

a cause of abnormal pulsations, 

thoracic. 33, 226 
Aortic aneurism, 33, 226 

regurgitation, 175 

second sound, 125 

stenosis, 185 
Apex beat, 26, 42 

beat, see also Cardiac impulse 

retraction, 31 
Arrhythmia, 209 
Arterial movements, 36 

murmurs, 148 

pressure, instruments for measur- 
ing. 57 

sounds, 128 
Asthma, bronchial, 269 
Asthmatic breathing. 21 
Atelectasis, 298 

crepitant rales in, 109 
Auscultation, 83 

mediate and immediate, 84 

of the heart. 117 

of the lungs, 95 

sources of error, 93 

Barnard, 60 

Barrel chest, 9 

Bowles. 86 

Bradycardia, 208 

Bramwell, 178 

Breast, funnel, 7 
pigeon, 7 

Breathing, amphoric, 107 
asthmatic, 21, 101 
bronchial, 96, 99, 106 
broncho- vesicular, 100, 106 
catchy, 22 
cavernous. 107 
Cheyne-Stokes, 21 
cogwheel, 102 
compensatory, 103 
diminished vesicular, 104 
emphysematous, 101 
exaggerated vesicular, 103 
interrupted, 102 
irregular, 22 
metamorphosing, 102 
restrained, 22 
rough, 99 
shallow, 22 
stridulous, 23 
tracheal, 96, 99, 106 
tubular, 96, 99, 106 
vesicular, 96 
see also Respiration 

Bridge, Norman, 257 

Broadbent, 174, 223 



Bronchial asthma, 269 

dilatation, 270 
Bronchiectasis, 270 
Bronchitis, acute, 289 

chronic, 242 
Broncho-pneumonia, 250 
Brush, 61 

Cabot, 141 

Cancer of the lung, pleura, or chest 

wall. 297 
Capillary pulse, 88, 178 
Cardiac impulse, character of, 29 

impulse, displaced, 29 

impulse, normal, 26 

murmurs, 130 

movements, 26 

see also Heart 
Chest, barrel, 9 

deformities of, 12 

flat, 8 

in infants, physical examination 
of, 305 

rachitic, 7 

radioscopy of, 306 

wall, cancer of, 297 

walls, nutrition of, 10 

see also Thorax 
Cheyne-Stokes breathing, 21 
Cirrhosis of the lung, 271 
Compensation, establishment and fail- 
ure of, 148 
Cough, effects of, 111 
Creighton, Sarah R., 122 
Cyanosis, 39 

Deformities, 14 
Dextrocardia, 81 
Diaphragm, movements of, 23 
Dyspnoea, 18 

E<;oi*roxy. 115 

Ellis, 284 
Emphysema, 264 

complementary, 268 

interstitial, 268 

large-lunged, 264 

small lunged, 264 

with asthma, 267 

with bronchitis, 267 
Empyema necessitatis, 292 
Endocarditis, acute, 304 
Epigastric pulsation, 32 
Eruptions, 41 
Examining the thoracic organs, 

methods of, 1, 305 
Expansion, 16 

diminished, 17 

increased, 18 

Flint, Austin, 178, 257 
Fluoroscope, use of the. 807 
Fremitus, tactile, 44 
Friction, pericardial, 46 

pleural, 46 

sounds, pleural, 111 
Friedreich. 222 
Funnel breast, 7 

Gaertner's tonometer, 58 
Gairdner, 173 
Garland, 284 
Gibson, 122 
Glands, enlarged, 41 

Hae mo pericardium, 218 
Harrison 's groove, 7 
Heart, aortic regurgitation, 175 

aortic stenosis, 185 

arrhythmia, 209 

bradycardia, 208 

dilatation of, 154 

disease, congenital, 211 



Heart, diseases of, 145 

fatty degeneration of, 206 
fatty overgrowth of, 206 
hypertrophy of, 151 
mitral regurgitation, 156 
mitral stenosis, 166 
neuroses of, 207 
palpitation of, 210 
parietal disease of, 203 
pulmonary regurgitation, 197 
pulmonary stenosis, 108, 211 
rapid. 207 
situs inversus, 31 
slow, 208 

sounds, doubling of, 122, 127 
sounds, metallic, 128 
sounds, modifications of , 120 
sounds, muffled, 128 
sounds, normal, 118 ' 
sounds, pathological, 124 
sounds, rhythm of, 127 
sounds, shortening of, 121 
sounds, weakening of, 121 
tachycardia, 207 
tricuspid regurgitation, 192 
tricuspid stenosis, 196 
valvular lesions, combined, 199 
valvular lesions of, 145 
weakened, 204 
see also Cardiac 

Henchen, 203 

Hill and Barnard sphygmometer, 60 

Hochsinger, 122 

Howell, 61 

Hutchinson, Woods, 9 

Hydropericardium, 218 

Hydrothorax, 104, 272 

Inspection, 5 

Instruments for measuring arterial 
pressure, 57 

Jaundice, 40 

Litten's phenomenon, 28 

Locke, 141 

Lung, abscess of, 296 

cancer of, 297 

cirrhosis of, 271 

fistula sound, 116 

gangrene of, 296 

oedema of, 299 

reflex, 82 

syphilis of, 270 

tissue, collapse of, 298 
Lungs, diseases of, 239 

tuberculosis of, 251 

Mediastinal glands, tuberculosis of, 

Mediastiuitis, 303 
Mediastinum, diseases of, 301 

tumors of, 301 
Metallic tinkle, 116 
Methods of examining the thoracic 

organs, 1, 305 
Mitral regurgitation, 156 

stenosis, 166 
Movements, respiratory, 16 
Murmurs, arterial, 143 

cardiac, 130 

cardiorespiratory , 143 

functional or ha-mic, 140 

venous, 148 
Muscle sounds, 92 
Myocarditis, acute, 203 

chronic, 204 

(Edema, 40 

Oliver's hsemodynamometer, 61 

Osier, 171, 173, 210 

Pallor, 40 



Palpitation of the heart, 210 
Percussion, 64 

auscultatory, 71 

immediate, 64 

mediate, 64 

palpatory, 78 

resonance, 73 

resonance, amphoric, 81 

resonance, cracked- pot, 80 

resonance, dull, 74 

resonance, flat, 74 

resonance, tympanitic, 76 

resonance, vesicular, 74 

technique, 64 
Pericardial friction, 46 
Pericarditis, 214 

dry, 214 

fibrinous, 214 

with effusion, 217 
Pericardium, adherent, 222 

diseases of, 214 
Phear, 174 
Phthisis, fibroid. 262 
Pigeon breast, 7 
Pleura, cancer of. 297 
Pleural effusion, encapsulated, 291 

friction. 46 

friction sounds. 111 

thickening. 291 
Pleurisy, 278 

dry, 273 

plastic. 278 

pulsating. 84. 292 

with effusion. 280 
l*neumonia. aspiration. 249 

broncho , *ao 

catarrhal. 2»\0 

central. 248 

chronic interstitial. 271 

croupous. 248 

ribtinou*. 248 

Pneumonia, hypostatic, 299 

inhalation, 249 

lobular, 250 

massive, 248 

wandering, 247 
Pneumopyothorax, 274 
Pneumoserothorax, 274 
Pneumothorax, 104, 272 
Pressure, arterial r instruments for 

measuring, 57 
Pulmonary regurgitation, 197 

stenosis, 198, 211 

tympanites, acute, 268 
Pulsating pleurisy, 84 
Pulsation, capillary, 88 

epigastric, 82 

venous, 85 
Pulsations, abnormal, 48 

due to aneurism, etc., 83 

duo to retraction of the lung, 32 
Pulse, 49 

anacrotic, 53 

bounding, 53 

compressibility of, 52 

Corrigan, 179 

dicrotic, 58 

rate, 51 

rhythm, 51 

tension. 54 

water-hammer, 179 

wave, size and shape of, 5a 

Rachitis, effects on the thorax, 7 
Radioscopy of the chest, 806 
Rfiles, 107* 

bubbling, 107 

crackling. 108 

crepitant, 108 

moist. 107 

musical. 110 

palpable, 47 



Recklinghausen, von, 60 
Regurgitation, aortic, 175 

mi t nil, 136 

pulmonary. 107 

tricuspid, 192 
Resistance, sense of, 82 
Respiration, normal, 16 

types of. 96 

see also Breathing 
Respiratory movements, 16 
Rhythm, respiratory, changes in, 21 

Riva-Roeci sphygmometer, 59 
Rosary, rachitic, H 
Rosenbach. 122. 138, 150, 174 

Sansom. 169 
Scars, 41 
Skoda. 256 
Sphygmogmph, 314 
Sphygmometer, Hill and Barnard, 60 

Rivu-Koeci, 59 
Spinal curvatures and twists, 12 
Stan! on, 60, 62 
Steel, Graham, 197 
Stenosis, aortic, 185 

mitral, 166 

pulmonary, 198. 211 

tricuspid. 196 
Stethoscope, Bowles, 86 

choice of, 84 

use of, 89 
Succussion, 115 
Syphilis of the lung, 270 

Tachycardia, 207 
Tactile fremitus, 44 
Thoracic aneurism, 226 

organs, methods of examining 
the, 1, 305 
Thorax, paralytic, 8 

tender points upon, 48 
Thrills, 43 

Tonometer, Gaertner's, 58 
Tracheitis, 239 
Traube, 77 
Tricuspid regurgitation, 192 

stenosis, 196 
Tuberculosis of the mediastinal 
glands. 304 

pulmonary, 251 

pulmonary, advanced, 258 

pulmonary, incipient, 251 

pulmonary, moderately ad - 
vanced, 255 
Tympanites, acute pulmonary. 268 

Valve areas, 117 

Valvular lesions, combined, 199 

Vascular phenomena, 34 

Veins, inspection of, 35 

Venous sounds, 129 

Vierordt, 122 

Voice sounds, spoken, 114 

sounds, whispered, 118 

Williams, F. II.. 26, 254 

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To avoid fine, this book should be returned on 
or before the date last stamped below. 

L76 Cabot, R.C. 66422 
C116 Physical diagnosis of 
19Q5 diseases o£ the chest* 

N \MF