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 FOUNDED BY^ 
 
 ROSWELL P. FLOWER 
 
 for the use of the 
 N. Y. STATE VETERINARY COLLEGE 
 
 1897 
 
Cornell University 
 Library 
 
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 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
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 http://www.archive.org/details/cu31924000230809 
 
PLATE I. 
 
 Radiograiili of Bronchial Tree (ehlld). Broachi filled with Shot No. 10. 
 Diameter, .038 in. 
 
PHYSICAL DIAGNOSIS 
 
 DISEASES OF THE THORAOIO AND 
 ABDOMINAL ORGANS. 
 
 A. Manual for Students and Physicians. 
 
 EGBERT LEFETEE, M.D. 
 
 PEOFESSOR OF CLINICAL MEDICIKE AND ASSOCIATE PROFESSOR OF THERA- 
 PEUTICS IN THE UNIVERSITY AND BELLBVUB HOSPITAL MEDICAL COLLEGE ; 
 ATTENDING PHYSICIAN TO BELLEVUE AND ST. LUKE'S HOSPITALS; 
 CONSULTING PHYSICIAN TO BETH-ISRAEL HOSPITAL; MEMBER OF 
 THE NEW YORK ACADEMY OF MEDICINE, ETC. 
 
 Illustrated with 74 Engravings and 12 Monochrome 
 Plates 
 
 LEA BROTHERS & CO. 
 
 PHILADELPHIA AND NEW YORK 
 
 1902 
 
 -T 
 
Entered according to the Act of Congress in the year 1902, by 
 
 LEA BEOTHEES & CO. 
 In the Office of the Librarian of Congress. All rights reserved. 
 
TO MY FORMER STUDENTS, 
 
 WHOSE INSISTENT 
 
 ••WHY?" 
 
 FURNISHED THE INCENTIVE 
 
 FOR THIS WORK. 
 
PREFACE 
 
 The great number of works on Physical Diagnosis 
 deterred me for a long time from writing another, and 
 it was only at the urgent request of a number of my 
 former students that I undertook to put in permanent 
 form the methods that I have used for a number of years 
 in teaching. 
 
 Especial emphasis has been laid on the altered 
 anatomy of the organs under examination, and its rela- 
 tion to the physical signs. The respiratory and cardiac 
 sounds, their production and their modifications, both 
 normal and pathological, have been discussed more fully 
 than in most books of like scope, as experience has shown 
 that unless the student clearly understands how these 
 sounds are produced the tendency is to regard each 
 variation from the normal as pathognomonic of special 
 disease, rather than dependent on changes in structure 
 or function which may be present in conditions not 
 necessarily pathologic. 
 
 In this way only can diagnostic values be estimated, 
 and the range and limitations of Physical Diagnosis be 
 understood. 
 
 Physical Diagnosis is now taught at an early period in 
 the curricula of the medical schools, and this circum- 
 stance has made it necessary to give a brief account of 
 the morbid changes in different organs, and of their 
 secondary effects, both immediate and remote. 
 
 (v) 
 
VI PREFACE. 
 
 In the preparation of this book I have gleaned freely 
 from other works on Physical Diagnosis, and from 
 articles in the medical journals. 
 
 I am indebted to Prof. C. G. Coakley and to my 
 associate, Dr. S. A. Brown, for many valuable sugges- 
 tions; to Dr. Henry J. Prentiss, director of practical 
 anatomy, for the chapter on Eegional Anatomy, the 
 production of many of the illustrations and the prepara- 
 tion of the material for the radiographs of the bronchi ; 
 to Mr. Eugene W. Caldwell, director of the Edward N. 
 Gibbs Memorial X-Eay Laboratory, for the radiographs 
 and for suggestions in chapter on Examination with X 
 Pay ; and to Dr. Titus M. Coan for valuable assistance 
 while the work was going through the press. 
 
 E. Lb F. 
 
 52 West Fifty-sixth St., New Yobk. 
 September, 1902. 
 
OONTEI^TS. 
 
 PART I. 
 ANATOMICAL. 
 
 CHAPTER I. 
 REGio]srAL Anatomy lY-36 
 
 PAET II. 
 THE RESPIRATORY SYSTEM. 
 
 CHAPTER 11. 
 Inspection 37-57 
 
 CHAPTER HI. 
 Palpation 58-68 
 
 CHAPTER IV. 
 Percussion 69-95 
 
 CHAPTER V. 
 Auscultation 96-122 
 
 CHAPTER VI. 
 
 Auscultation (Continued) 123-140 
 
 CHAPTER VII. 
 
 Diagnosis of Diseases of Respibatort 
 
 Tract . 141-220 
 
 PART III. 
 THE CIRCULATORY SYSTEM. 
 
 CHAPTER VIII. 
 Inspection 221-232 
 
 (vii) 
 
vill CONTENTS. 
 
 CHAPTER IX. 
 Palpation 233-256 
 
 CHAPTER X. 
 Pbecussion 257-265 
 
 CHAPTER XI. 
 
 Auscultation 266-301 
 
 CHAPTER XII. 
 Diagnosis of Diseases of the Heart 302-351 
 
 (3HAPTER XIII. 
 Diagnosis of Diseases of the Pericaedium^ 352-364 
 
 CHAPTER XIV. 
 Diagnosis of Diseases of the Blood-vessels^ 365-374 
 
 PAET IT. 
 THE ABDOMINAL 0EGAN8. 
 
 CHAPTER XV. 
 Inspection 375-381 
 
 CHAPTER XVI. 
 Palpation 382-410 
 
 CHAPTER XVII. 
 Percussion 411-421 
 
 CHAPTER XVIII. 
 Auscultation 422-424 
 
 PART V. 
 Examination with X Ray 425-432 
 
PHYSICAL DIAGNOSIS. 
 
 PART I. 
 ANATOMICAL. 
 
 CHAP TEE I. 
 
 REGIONAL ANATOMY. 
 
 The following anatomical facts will serve as an aid 
 to the location of thoracic and abdominal viscera. 
 
 The trunk is divided by the diaphragm, or midriff, 
 into two great cavities, the thorax and abdomen. 
 
 The diaphragm is a muscular, tendinous structure, 
 attached by its circumference to the ensiform cartilage, 
 six or seven lower costal cartilages, the external and 
 internal arched ligaments, and upper two or three 
 lumbar vertebra3 by two crura. It is inserted into a 
 central trif oil tendon, and points convexly upward ; 
 therefore increasing the vertical diameter of the 
 abdomen at the expense of that of the thorax. In 
 moderate expiration this convexity reaches to the level 
 of the fourth intercostal space on the right, and to the 
 fifth on the left. This gives a general landmark for 
 the base of the lungs and. heart apex above, the upper 
 limits of the liver and stomach below. 
 
 2 
 
18 ANATOMICAL. 
 
 The limits of the thorax extend from the origin of 
 the diajahragm to the apices of the lungs, at the level of 
 the first dorsal vertebra behind, or one-half to one inch 
 above the clavicles, but deeply placed behind the sterno- 
 cleido-mastoid muscles and scalenus anticus muscles. 
 
 THE SUPERFICIAL LIMITS OF THE ABDOMEN. 
 
 Above they are formed by the attachments of the 
 diaphragm to the costal arches, etc. ; below by the pubic 
 bones, Poupart's ligaments and iliac crests. 
 
 TRUE LIMITS OF THE ABDOMEN. 
 
 The true limit above is the vault of the diaphragm ; 
 that below is the floor of the pelvis, i. e., levatores ani, 
 etc. 
 
 THORAX. 
 
 The thorax is a conical-shaped structiire, whose walls 
 are : sternum and costal cartilages, anteriorly ; ribs, 
 laterally and posteriorly, and the twelve dorsal vertebrse 
 in the posterior median line. Its floor is the dia- 
 phragm; its apex, is determined by the apices of the 
 kings, which are limited by the scalenus anticus muscles, 
 beneath which the lungs project into the neck. The 
 cavity is flattened from before backward, and above is 
 reniform in shape on cross section, due to the marked 
 anterior projection of the bodies of the dorsal vertebra^. 
 
 The sternal wall is obliquely placed, being nearer the 
 posterior thoracic wall at its upper than lower limit. 
 
 It begins at the episternal notch, opposite the second 
 dorsal vertebra, and terminates at the ensif orm cartilage, 
 opposite the ninth dorsal vertebra. 
 
 The vertebral wall begins at the first dorsal vertebra 
 and ends at the twelfth ; therefore the thoracic cavity is 
 longer behind than in front, sloping downward and 
 backward. 
 
KEGIONAL ANATOMY. 19 
 
 Surface Markings of Thorax. 
 
 Anteriorly, Median Line. — Above is the cpisternal 
 notch or jugular fossa, located between the sternal heads 
 of the sterno-cleido-mastoid muscles and above the first 
 piece of the sternum. Passing down, we come to the 
 sternal groove or furrow. Its floor is the sternum, sub- 
 cutaneously placed, its lateral boundaries the sternal 
 origins of the great pectoral muscles. Running the 
 finger down this furrow, it comes to a marked ridge, the 
 sternal angle, or angle of Ludovici. It is formed by the 
 union of the first and second pieces of the sternum, and 
 is opposite the articulation of the second costal cartilages 
 — a valuable landmark in the counting of ribs. At the 
 inferior extremity of the second piece of the sternum 
 or gladiolus is located the infrasternal fossa (epigastric 
 fossa or scrobiculus cordis). It is well marked, 
 because of the prominent sternal articulations of the 
 seventh costal cartilages and depression of the third 
 l^iece of the sternum (ensiform or xiphoid cartilage). 
 
 Laterally. — Passing from the first piece of the sternum 
 almost horizontally outward and backward are the two 
 clavicles, which overlie the first ribs. At the junction 
 of the convex inner two-thirds with the concave flat 
 outer one-third of the clavicles are felt the coracoid 
 processes, projecting forward one-half to three-quarters 
 of an inch from beneath the clavicles. Directly external 
 to the coracoid processes we come to the upper extremi- 
 ties of the humeri, their lesser tuberosity and bicipital 
 ridge being directly imder the finger. 
 
 Above the clavicles are the supraclavicular fossa?, 
 into which the apices of the lungs project, but deeply 
 placed beneath the sterno-cleido-mastoid and scalenus 
 anticus muscles. Normally, these fosste are shallow. 
 
 Below the clavicles are the faintly marked infra- 
 claviciilar fosste. Below the second ribs are the second 
 intercostal spaces ; the right being called the aortic inter- 
 space, the left the pulmonic. 
 
20 ANAT03IICAL. 
 
 The nipples in the male and young females are 
 usually found in the fourth intercostal spaces, about 
 four inches from the median line. 
 
 Passing downward and outward from the junction of 
 the gladiolus and ensiform cartilages are the deviations 
 of the cartilages of the seventh, eighth, ninth and tenth 
 ribs, forming the subcostal angle, which is more acute 
 in the case of a long, narrow thorax. Kimning the 
 finger down either side of this angle, we discover that 
 the eighth costal cartilage is firmly attached to the 
 seventh, while the ninth and tenth are freely movable, 
 having a loose fibrous attachment to the cartilage above, 
 instead of articular facets. The eleventh and twelfth 
 ribs are felt below and behind the tenth. 
 
 With the arms raised, the hands resting on the head, 
 the axillary regions are exposed. The anterior and 
 posterior borders of which, when continued vertically 
 downward, form the anterior and posterior axillary 
 lines; the vertical line midway placed is the mid- 
 axillary line. It is in this region that the lungs are 
 nearest the examiner. 
 
 Posteriorly. — In the median line is the vertebral fur- 
 row, at the bottom of which can be felt the vertebral 
 spines. This furrow is more marked in the cervical 
 and lumbar regions than in the dorsal and sacral regions. 
 
 Though the seventh cervical vertebra is called the 
 vertebra j)rominens, the first dorsal spine is more promi- 
 nent, projecting posteriorly perhaps one-fourth of an 
 inch further than the seventh cervical spine. Laterally, 
 we come to the scapulse, located between the second and 
 seventh dorsal vertebra-, thus simplfying the location of 
 the_ ribs posteriorly. The spines of the scapuljc meet 
 their vertebral borders usually opposite the fourth 
 dorsal vertebra. 
 
 The vertebral borders of the scapula are located about 
 one and one-half to two inches from the median line but 
 deviating slightly towards the inferior angles. 'The 
 interspace is called the infrascapula region. The region 
 
BEGWNAL A NA TOM Y. 
 
 21 
 
 aliove each scapula spine is called the snprascapiila 
 region; below, the infrascapula region. 
 
 Contents of Thorax. 
 
 Trachea, two bronchi, two Inngs, two ])lenra, heart, 
 
 Fia. 1, 
 
 BroMclii (fhikl) lilleil witli shot, No. 10. Diameter, .0:iH inch. Lateinl vieAV. 
 
 with its pericardinm, great vessels, ocsojihagns and 
 thoracic dnct. 
 
 Trachea. — Fonr to four and oneduilf inclies in length. 
 Kuns slightly obliqnely from above downward and 
 
22 
 
 ANATOMICAL. 
 
 backward a little to the right of the median line. It 
 begins at the cricoid cartilage of the larynx opposite the 
 sixth cervical vertebra and terminates at its bifurcation 
 into two bronchi opposite the fourth dorsal vertebra, or 
 in the plane passing horizontally from the junction of 
 
 Fig. 2. 
 
 Bronchi (adult) filled with shot, No. 4. Diameter, .110 inch. 
 
 maubrium and gladiolus to the body of the fourth dorsal 
 vertebra. (Plate II, and Fig. 1.) 
 
 Bronchi. Eight and Left. — Two to two and one- 
 half inches long from the bifurcation to where they 
 
o 
 
R Ed ION A L ANATOMY. 23 
 
 break up into bronchia at the hilum of each hmg. Each 
 enters its respective hilum, the most posterior of the 
 structures forming the lung root, i. e., two pulmonary 
 veins, one pulmonary artery and one bronchus. They 
 are in a plane anterior to the descending aorta, oeso- 
 phagus, thoracic duct, etc. 
 
 Right Bronchus. — Usually it has a greater lumen than 
 the left, and is practically a continuation of the trachea, 
 owing to the obliquity of the left bronchus. Aboiit one- 
 half an inch from the bifurcation the right bronchus 
 gives off a large branch, which passes to and supplies 
 the upper lobe of the right lung, terminating above in 
 apical branches. It crosses above the right pulmonary 
 artery, and is therefore eparterial. 
 
 All other branches of both bronchi are hyparterial. 
 
 The right bronchus, considerably diminished in size, 
 passes to the hilum, and continues in the lung substance 
 downward and backward, to terminate in the angle 
 between the diaphragm and posterior parietes. It gives 
 off four sets of branches (antero-lateral and postero- 
 lateral), alternately placed. The first antero-lateral 
 branch supplies the middle lobe ; the rest, the lower lobe. 
 
 Left Bronchus. — The left bronchus passes more 
 obliquely to the hilum of the left lung, and, entering the 
 lung substance, terminates in the postero-inferior angle. 
 
 It gives off no branches until entering the hmg, and 
 then gives off four sets — fotir ventro-lateral and four 
 dorso-lateral — alternately placed. Its first ventro- 
 lateral branch differs from that of the right bronchiis, 
 because it gives off a large ascending branch, which sup- 
 plies the upper part of the left lobe to its apex. It is 
 therefore the homalogue of the eparterial branch of the 
 right lung. The continuation of the first ventro-lateral 
 branch supplies the rest of the left upper lobe. 
 
 The remaining ventro-lateral and dorso-lateral 
 branches supply the lower lobe. 
 
 Referring to the X-ray picture of the bronchial tree, 
 it is evident that more volume of sound passes down the 
 
24 ANATOMICAL. 
 
 right bronchus, because it has a greater lumen and is 
 almost a continuation of the trachea. 
 
 The eparterial branch of the right bronchus arises 
 just below the bifurcation, and, entering directly the 
 right upper lobe, distributes its branches to the apex, 
 passing through less lung substance than is the case 
 with the ascending branch to the left apex. Therefore 
 sound will be less modified on reaching the right apex 
 than the left. 
 
 As breath sounds arise in the larynx, and are modified 
 by the decrease in the lumen of the air-passages and 
 surrounding tissue, we will expect to find in the right 
 apex persistence of the tubular quality of the breath 
 sounds. Such is the case, broncho-vesicular breathing 
 being a normal condition on that side. 
 
 Increased vocal fremitus in the right iipper lobe 
 normally is also explained by the above anatomical facts. 
 
 Because the right bronchus is almost vertical, it is 
 located in the right infrascapula region, and explains 
 why frequently broncho-vesicular breathing is heard in 
 that location. 
 
 Lungs. Right and Left. — Irregularly, pyramidal 
 in shape. Each present an apex directed upward and 
 placed deeply in the neck imder the scaleni muscles; 
 below, the base, deeply concave, resting on the dome of 
 the diaphragm; an external surface markedly convex, 
 fitting into the concavity of the ribs; an internal sur- 
 face, concave to permit the lodgment of the heart and 
 great vessels ; an anterior border, sharply defined, over- 
 lapping the heart and great vessels ; a posterior border, 
 blunt, fitting into the concavity of the ribs between the 
 posterior angles and the bodies of the first ten dorsal 
 vertebras. 
 
 Each hmg is divided into two great lobes by an 
 oblique fissure, which is practically constant. It beo-ins 
 posteriorly about three inches IdoIow the apex, and 
 passes obliquely downward and forward on the external 
 surface to the junction of the anterior border with the 
 
liJLU-lUl\JlL, A1\A1VMY. 25 
 
 base. They reach inward ahnost to the hihim of each 
 lung. 
 
 We see, therefore, that the upper primary lobe of 
 each lung consists of the apex, anterior border and sur- 
 face, while the lower primary lobe consists of the poste- 
 rior border, posterior surface and base. The upper 
 lobe of the right lung is usually subdivided into two 
 unequal lobes by a secondary fissure running from the 
 anterior border obliquely downward and outward to the 
 great oblique fissure, thus cutting off a small triangular 
 lobe from the anterior sxirface. The anterior border of 
 the right lung passes nearly vertically downward till it 
 reaches its base. The anterior border of the left lung 
 leaves the vertical nearer its base than apex, and passes 
 obliquely downward and outward to reach the sharp 
 edge of the base, thus uncovering a small triangular 
 area of the heart. 
 
 Surface Markings of Trachea, Bronchi and Lungs. — The 
 trachea begins lat the cricoid cartilage opposite the sixth 
 cervical vertebra, and terminates deeply opposite the 
 junction of the manubrium and gladiolus in front; 
 fourth dorsal vertebra behind, or junction of the root of 
 the spine of the scapula with its vertebral border when 
 the scapula; are normally placed. 
 
 The brpnchi enter the hilum of each lung about 
 opposite the fifth dorsal vertebra. 
 
 Lungs. — The apex of each lung reaches into the sujira- 
 clavicula fossa one to one and one-half inches above the 
 clavicle, usually between the two heads of origin of the 
 sterno-cleido mastoid. 
 
 Anje'eiok Boedees. Right Lung. — Its anterior 
 border .ajiproaches the median line opposite the second 
 costd-Stepual articulation, and continues downward in 
 the median line to opposite the sixth costo-sternal articu- 
 lation, where it meets the thin margin of the base. This 
 margin leaves the median line, passes backward with a 
 gentle convexity, pointing downward, and finally joins 
 the posterior border at the tenth dorsal vertebra. In 
 the mid-axillary line it usually crosses the eighth rib. 
 
26 
 
 yi NATO MICA L. 
 
 Antebioe Boeder of Left Lung. — Readies the 
 median line opposite the second costo-sternal articula- 
 tion; continues downward in the median line to opposite 
 the fourth costo-sternal articulation. At this point it 
 leaves the median line and passes downward and out- 
 ward towards the apex of the heart, located in the fifth 
 
 Fro. 3. 
 
 ReUition of huij^s, pleura, lu'art and liver to u^diy tlioriix. 
 
 intercostal space, three and one-half inches to the left 
 of the median line ; and it continues to the sixth costal 
 cartilage, where it reaches the thin hasal margin. The 
 latter then passes liackward to the tenth dorsal vertehra, 
 crossing the eighth rib in the niid-axillary line. 
 
 Fissures. Eight Obeique. — Begins at fourth dor- 
 sal vertehra, and passes downward and outward to the 
 junction of the anterior border and base on the right 
 seventh costal cartilage nearer its sternal articulation. 
 
nF.GIONAL ANATOMY. 27 
 
 Left Oblique. — Begins at third dorsal vertebra and 
 passes downward and forward to near the junction of 
 the anterior margin and base, somewhere on sixth costal 
 cartilage, external to the apex of heart. Therefore a 
 
 Fig. 4. 
 
 Relation of lungs, pleura, spleen and kidneys to bony thorax. 
 
 smaller area of the left lower lobe presents anteriorly 
 than the right lower lobe. 
 
 Lessee ITissuee oe Eight Lung. — It leaves the 
 median line opposite the fourth costo-stei*nal articula- 
 tion, and passes downward and outward to meet the 
 great oblique fissure in the mid-axillary line at about the 
 sixth rib. (Figs. 3 and 4.) 
 
28 ANATOMICAL. 
 
 PLEUEA. 
 
 There are two distinct pleural sacs ; one for each lung. 
 They have no relation with each other except at the 
 junction of the anterior margins of the lungs, when they 
 slightly overlap. 
 
 Each pleural sac is divided into two portions, a 
 visceral and parietal. The visceral pleura is in intimate 
 relation with the lung wall, passing into the fissures. 
 The parietal pleura is in intimate relation with the 
 thoracic walls, pericardium, sides of great vessels, 
 oesophagus, etc., as it leaves the under surface of the 
 sternum to be reflected over these last structures in pass- 
 ing to the posterior parietes. 
 
 The parietal pleura becomes continuous with the 
 visceral pleura at the root of the lungs and downward 
 to the diaphragm, thiis forming a double fold of pleura 
 running from the root to the diaphragm, and called the 
 lateral ligament of the lung. The parietal pleura leaves 
 the base of the lungs and projects into the costo-phrenic 
 sinus, reaching to the twelfth dorsal vertebra posteriorly. 
 
 Surface Markings of Pleura. 
 
 The surface markings of the pleura is that of the 
 parietal pleura. 
 
 The right pleura begins at the apex of the right lung, 
 one to one and one-half inches above clavicle. It reaches 
 the median line opposite the second costo-sternal articii- 
 lation, and continues vertically downward to the 
 seventh costo-sternal articulation. It then crosses the 
 seventh, eighth, ninth ribs, the tenth rib in the mid 
 axillary line, and reaches the twelfth dorsal vertebra 
 posteriorly. 
 
 The left pleura begins at the apex, one to one and one- 
 half inches above the clavicle; approaches the median 
 line opposite the second costo-sternal articulation, and 
 continues in the median line to opposite the fourth costo- 
 sternal articulation. It then deviates, skirting the 
 
^i21,\Ji^U^y .IJU .'Ll\ 
 
 :ai03IY. 29 
 
 border of the sternum about one-balf to oue inch from 
 its left edge. It then has much the same course as the 
 right. This deviation permits paracentesis pericardii 
 without involvement of the pleura. 
 
 HEART. 
 
 The heart is a pyramidal-shaped organ of about the 
 size of a man's fist. In the male it is five inches in the 
 long diameter, three and one-half inches laterally and 
 two and one-half inches antero-posteriorly. 
 
 It presents an apex, base, anterior and posterior sur- 
 faces, thin right border, due to the thin wall of the right 
 ventricle, and blunt left border, due to the thick wall of 
 the left ventricle. 
 
 It is obliquely placed, its base looking upward, some- 
 what backward and to the right; its apex downward, 
 somewhat forward and to the left. It is anchored by 
 its great vessels, which spring from the base, and rests 
 by its posterior surface on the diaphragm. 
 
 The heart cavity is divided into foiir compartments : 
 right and left ventricle, occupying the apical portion of 
 the heart, and the right and' left auricles, occupying the 
 basilar portion. 
 
 The ventricles are asymmetrically placed, owing to the 
 intraventricular sejatuni passing from the base obliquely 
 downward to the thin right border one-half to three- 
 fourths of an inch from the apex. 
 
 The right ventricle consequentlv presents anteriorly, 
 with its apex at the right thin border, nearer tlie 
 sternum; while the left ventricle presents posteriorly, 
 excepting its apex, which occupies the true heart apex, 
 and therefore is farther removed from the sternum than 
 the right ventricular apex. 
 
 The right ventricle presents an atrium and infundi- 
 bulum, or conns arteriosus ; the latter leading into the 
 pulmonary artery. The left ventricle presents an 
 atrium and aortic vestibule, the latter lying between the 
 right mitral flap and ventricular septum. It is behind 
 the infundibuluni of the right ventricle. 
 
30 ANATOMICAL. 
 
 Each auricle presents an atrium and appendix. The 
 right auricle and appendix present anteriorly behind the 
 sternum, and reaching to the right of its right border 
 from the third to the sixth costal cartilaees. 
 
 The left auricle presents posteriorly, its auricular 
 appendix only presenting anteriorly behind the third 
 rib about one and one-half inches to the left of the 
 sternum. 
 
 The anterior auriculo-ventricular sulcis is placed 
 obliquely behind the sternum, reaching from the left 
 third costo-sternal articulation to the right sixth costo- 
 sternal articulation. As the cardiac valves lie in the 
 ventricular base, ^e see how their surface markings 
 practically lie in this line. 
 
 The arch of the aorta begins at the base of the left 
 ventricle, behind the infundibulum of the right ventri- 
 cle, and beneath the inferior angle of the left third costo- 
 sternal articulation ; it passes upward and towards the 
 right one and one-half to two inches. At the upper 
 angle of the second right costo-sternal articulation it 
 sweeps backward toward the left side of the fourth 
 dorsal vertebra to become the descending aorta. 
 
 The pulmonary artery begins at the infundibulum of 
 the right ventricle, behind the left border of the 
 sternum, opposite the second interspace, and passes 
 upwards, backward and to the left, where it bifurcates 
 under the aortic arch into the right and left pulmonary 
 branches. 
 
 Surface Markings of Heart. 
 
 Take a point on the lower border of the second costal 
 cartilage, one inch from the left border of the sternum, 
 and draw a line to the iipper border of the third costal 
 cartilage one-half inch to the right of the sternum. 
 From this last point draw a line to the right seventh 
 costo-sternal articulation, with a moderate convexity, 
 pointing to the right. 
 
I JJ ^l J.* 
 
 :nT)Mr. 31 
 
 The apex is located in the fifth intercostal space, 
 three and one-half inches to the left of the median line. 
 Connect the left end of the base line with the apex, and 
 the right seventh costo-sternal point with the apex, and 
 we map out the entire area of the heart. 
 
 To differentiate this area, connect a point behind the 
 left third costo-sternal articulation with a point on the 
 right sixth costo-sternal articulation. This plots out 
 the auriculo-ventricular sulcis. The heart area to the 
 right of this line represents the position of the right 
 auricle, the tip of its appendix being on this line 
 opposite the third costal cartilage. The line running 
 from the seventh right costo-sternal articulation to the 
 apex of the heart represents the thin right border of the 
 right ventricle. The left auricle is placed posteriorly, 
 but its apex presents anteriorly at a point on the left 
 convex line leading from the base to the apex, where it 
 crosses the third costal cartilage about one and one- 
 quarter inches from sternum. The continuation of this 
 line represents the blunt left border of the left ventricle. 
 
 The Location of the Valves. Pulmonary Valve. — 
 It is beneath the upper angle of third left costo-sternal 
 articulation. The valvular sound follows the course of 
 the pulmonary artery to the pulmonary or left second 
 interspace. 
 
 Acetic Valve. — Lower angle of third left costo- 
 sternal articulation, just behind left edge of sternum. 
 Its valvular sound follows the course of the aorta to the 
 aortic or right second interspace. 
 
 MiTEAL Valve. — Behind the sternum, opposite 
 fourth costo-sternal articulation. Its valvular sounds 
 are carried to the apex of the left ventricle, or true apex 
 of the heart. 
 
 Teicuspid Valve. — In median line of sternum, 
 opposite fourth intercostal space. Its valvular sounds 
 are carried to the apex of the right ventricle, or just to 
 the left of the ensiform cartilage. 
 
 We observe that the valves are located nearly in the 
 
32 ANATOMICAL. 
 
 plane of the auriculo-ventricular sulcis, the auriculo- 
 ventricular valves being located a little to the left of 
 this surface marking, ov/ing to the obliquity of heart ; 
 the apex pointing more anteriorly, the base more 
 posteriorly. 
 
 Superficial and Deep Areas of Cardiac Dullness. — The 
 superficial area of cardiac dullness is that portion of 
 the heart uncovered by the lungs. It is triangular in 
 area. The apex is above where the anterior borders of 
 the two lungs separate in the median line opposite the 
 fourth costo-sternal articulation. The right border of 
 this triangle is the anterior border of the right hmg, and 
 therefore passes vertically downward in the median line. 
 The left border is that of the left lung, and runs from 
 the median line opposite the fourth costo-sternal articu- 
 lation to the apex of the heart. There is no inferior 
 boundary, as the cardiac dullness fuses with the liver 
 dullness. The deep area of cardiac dullness is the rest 
 of the heart outline. 
 
 PERICARDIUM. 
 
 A pyramidal-shaped serous sac, inclosing the heart, 
 and the aorta and pulmonary artery for one and one-half 
 inches of their course and the superior vena cava ; but 
 only partially enfolding the inferior vena cava. 
 
 Its apex is directed iipward, where the pericardium 
 continues as a tubular prolongation on the great vessels. 
 Its base rests on the diaphragm, blending with central 
 tendon and extending over the left muscular portion. 
 It is composed of two portions, an outer fibrous coat and 
 an inner serous coat, the latter lining the fibrous coat 
 and reflected downward on the great vessels to enfold 
 the heart. 
 
 The pericardium is attached to the sternum in front, 
 and is in intimate relation with the parietal pleura, 
 which is reflected upon it. It is covered by lung and 
 pleura anteriorly, except for a small triangular area, 
 where the left visceral pleura leaves the median line at 
 
REGIONAL ANATOMY. 33 
 
 the fourth costo-sternal articulation to be deflected to the 
 left about two fingers' width from the left border of the 
 sternum. 
 
 ABDOMEN. 
 
 The abdomen is divided into three zones — epigastric, 
 mesogastric and hypogastric — by two horizontal planes. 
 The upper one runs antero-posteriorly at the lower 
 limits of the tenth ribs, while the inferior one passes 
 between the anterior superior spines of the ilia. These 
 three zones are subdivided by two vertical planes ere'cted 
 from the mid-Poupart points. The subdivisions are: 
 right and left hypochondriac regions, which project 
 behind the costal cartilages into the vault of the dia- 
 phragm, and the epigastric region, triangular in shape, 
 within the subcostal angle. The right and left lumbar 
 and umbilical region, and, lastly, the right and left iliac 
 or inguinal regions and the hypogastric or pubic regions. 
 
 Liver. — The liver occupies the right hypochondriac 
 region, part of the epigastric and the left hypochondriac 
 as far as the mammary line. 
 
 Its upper limits fit into the vault of the diaphragm, 
 i. e., fourth intercostal space on the right and fifth on 
 the left. Its sharp anterior border passes obliquely 
 from the right hypochondriac region and below to the 
 left hypochondriac region and above, crossing the right 
 costal border between the ninth and tenth costal carti- 
 lage and the left costal border under the eighth costal 
 cartilage. 
 
 The fundus of the gall bladder, when distended, pre- 
 sents under the right costal border where the lateral 
 border of the right rectus abdominis crosses, or at the 
 right ninth costal cartilage. 
 
 Stomach. — The stomach, when moderately distended, 
 presents a cardiac or cesophageal entrance; a cavity 
 divided into a fundus, projecting into the left dome 
 of the diaphragm; a body reaching do-nmward to 
 the plane separating the epigastric from the mesogastric 
 3 
 
31 ANATOMICAL. 
 
 zone and an antrum pyloris, which is located to the right 
 of the median line. It finally opens by the pyloric 
 opening into the first part of the duodenum. 
 
 It occupies, therefore, the left hypochondriac region 
 and a portion of the epigastric. The cardia and pyloris 
 are deeply placed. The anterior surface rests against 
 the anterior parieties. The stomach is in close relation 
 with the liver superiorly, with the pancreas posteriorly ; 
 the left kidney and spleen to the left and posteriorly; 
 the transverse mesocolon below. 
 
 The surface markings of the stomach are : 
 
 Cardia. — Left seventh costo-sternal articulation. 
 
 Fundus. — Eeaches to fifth left intercostal space. 
 
 Greater curvature reaches to line connecting tips of 
 ninth or tenth ribs. 
 
 Pylorus. — Just to right of median line, three and one- 
 half to four and one-half inches below lower end of 
 gladiolus. 
 
 When moderately distended, a triangular area of the 
 stomach is pal]Table in front. Its right boundary is the 
 free border of the liver, passing from under the right 
 ninth costal cartilage to the left eighth costal cartilage. 
 The left border is the left costal border from the eighth 
 to the tenth. Its lower limit is the greater curvature, 
 on a line crossing between the ninth or tenth ribs. 
 
 Spleen. — The spleen is in close relation to the 
 stomach, being attached to its body by the gastro-splenic 
 omentum. The spleen lies in the left hypochondriac 
 region, but posteriorly placed. It extends between the 
 ninth and eleventh ribs, its long axis running parallel to 
 the left tenth rib. Its posterior limit reaches to within 
 one and one-half to two inches of the vertebra, while its 
 anterior limit extends to about the mid-axillary line. 
 
 The spleen lies in the hollow of the diaphragm its 
 upper third having the lung interposed between it 'and 
 the parieties ; its middle third separated from the parie- 
 ties by the costo-phrenic sinus, a space below the luno' 
 between the diaphragm and thoracic wall. Its lower 
 
REGIONAL ANATOMY. rf5 
 
 third is in contact with the left kidney and tail of 
 pancreas. We thus see that it is practically impossible 
 to palpate the spleen under normal circumstances. 
 
 Kidneys. Eight and Left. — ^Retroperitoneal placed 
 obliquely downward and outward on the posterior wall 
 of the abdomen. The left is more superiorly placed, 
 resting on the eleventh and twelfth ribs, and extending 
 to within two and one-half to three inches from the iliac 
 crest. 
 
 The right extends* from the upper border of the 
 twelfth rib to within about two inches from the crest of 
 the ilium. The lateral borders of the two kidneys 
 extends beyond the lateral limits of the erector spina) 
 muscles. 
 
PAET II. 
 THE RESPIRATOEY SYSTEM. 
 
 PI AFTER II. 
 
 INSPECTION. 
 
 By inspection is understood the act of viewing the 
 patient so as to learn all that may be observed by the 
 sense of sight. Inspection is one of the most important 
 methods of physical diagnosis, and all systematic exami- 
 nations should begin with it ; and while it is not final, it 
 is valuable in determining certain essential facts that are 
 further differentiated by the other methods of physical 
 diagnosis. 
 
 The technique of inspection is as follows: 
 
 (1) The patient should be stripped of clothing as far 
 as possible. In children and in the male adult all 
 clothing should be removed from the chest except that 
 which may be necessary to avoid chilling of the sur- 
 face; in the female, delicacy may demand that the 
 patient be thinly covered, but wherever it is required 
 the examiner should not hesitate to demand that the siir- 
 face be bare, if only a part at a time, so that correct 
 observations may be made. Where for any reason it is 
 impossible to bare the chest thoroughly, miich of the 
 observation that would ordinarily be made by inspection 
 must be made by palpation. 
 
 (2) Inspection may be made with the patient either 
 standing, sitting or in the recumbent posture, according 
 to the circumstances of the case. 
 
i> THE EESPIEA TOE Y ,S YSTEM. 
 
 When the patient is able, the standing or sitting 
 posture is preferable, inasmuch as it is easier for the 
 observer, and the movements of the chest are not inter- 
 fered with. The patient should assiune a natural or 
 customary posture. TJsiially as soon as inspection is 
 commenced they try to assume a "correct" j)osture. 
 
 (3) It is necessary that the light fall equally on both 
 sides, as the value of inspection is in the comparison of 
 one portion of the chest with the corresponding portion 
 of the opposite side. The observer generally stands 
 directly opposite the patient, so as to have both sides 
 within the range of vision. Where it is necessary to 
 determine slight variations in the upper portion of the 
 thorax, it can often be best done by the observer stand- 
 ing behind the patient and looking over the shoulder 
 and downward along the clavicle and upper ribs. This 
 will show the slightest degree of depression in these 
 areas. 
 
 NORMAL CHEST. 
 
 The size of the normal chest varies within Avide 
 limits, and also with the age and sex of the individual. 
 In determining whether or not its variations are within 
 the normal limits, it is necessary to consider the general 
 physique of the patient, as the size of the thorax should 
 bear a definite relation to height and weight. 
 
 It is extremely difficult to describe a perfectly normal 
 chest. The thorax should be well developed, although 
 it is only one in four persons that have perfectly and 
 symmetrically-developed chests. The neck should bear 
 certain definite relations to the bony thorax, and 
 according to the general physique of the patient, the 
 neck will be long or short and its relations will vary 
 according to the development of the upper portions of 
 the body. 
 
 _ The direction of the clavicles varies with the indi- 
 vidual. In the broad, square-shoiildered individual they 
 lie almost in a horizontal plane, while in those with 
 sloping shoulders the outer border tends to slope down- 
 
INSPECTION. 39 
 
 wards and backwards to meet the tip of tlie shoulder 
 blade. Above the clavicle there is, normally, a slight 
 depression, called the supraclavicular depression. The 
 depth of this depression varies in individual cases, and 
 whether or not it is normal can only be judged by com- 
 paring it with the general contour of the chest. Increase 
 in the depth of the depression above the clavicle occurs 
 in those conditions which cause diminution of the size 
 of the apex of the lung, interfering with its normal dis- 
 tension when the thorax is enlarged in respiration. 
 These conditions may affect the entire lung, causing 
 general contraction of the chest, as in general pulmonary 
 fibrosis, etc., or may affect the apex only of one or both 
 lungs. While a number of diseases may cause this local 
 condition, the most important is pulmonary tuberculosis. 
 
 The sternum normally is carried forward and down- 
 ward from its junction ^ith the clavicle. At the junc- 
 tion of the upper and middle portion of the body the 
 so-called angle of Louis is formed. This varies in 
 individual cases, and is increased in certain diseases of 
 the respiratory tract. 
 
 The ribs curve forward and meet the sternum so as 
 to give a gradually increasing depth to the chest from 
 above downwards. There is also a gradual increase in 
 the angle with which they join the sternum from above 
 downwards. At the epigastric notch the angle is well 
 marked, and its acuteness varies with the general con- 
 tour of the chest. 
 
 The intercostal spaces are of a definite width, accord- 
 ing to the shape of the thorax. They shoiild be slightly 
 depressed, and in a well-developed thorax are visible 
 only in the lower portions. 
 
 Posteriorly, the scapula lies flat upon the ribs, and 
 the spine is, normally, slightly curved toward the right 
 side. 
 
 The physiological departures from the perfect chest 
 have been variously described as long and short, broad 
 and narrow, deep and hollow. All these variations, 
 
40 THE BESPIRA TORY SYHTEII. 
 
 though quite consistent w'ith health, may give the 
 student great difficulty in determining Avhether or not 
 thev are within the range of normal. 
 
 As the development of the chest varies greatly in dif- 
 ferent individuals, many chests are seemingly indicative 
 of some intrathoracic diseases which depend upon non- 
 development of the bony thorax and of the lungs during 
 the maturing period of life. 
 
 How can it be determined if the shape, form and size 
 of the chest is within the range of normal for the indi- 
 vidual under observation ? 
 
 This can be done only by taking into consideration 
 not only the thorax, but the entire bony skeleton as well, 
 and determining if the thorax harmonizes with it. The 
 social status of the individtial, the general physique, 
 occupation, etc., must be fully considered. Faultv 
 habits of posture may cause slight asymmetry of the 
 bony thorax without in any way influencing the function 
 of the contained organs. The observer must not form 
 the inference that each departure from the ideal thorax 
 is pathological, but must note the variations from the 
 normal, and by the other methods of physical diagnosis 
 determine if there is any change in the location, struct- 
 ure or function of the underlying thoracic organs. 
 
 Deviations from the normal chest have been classified 
 as follows : 
 
 PATHOLOGICAL CHESTS. 
 (1) The Barrel-shaped, or Emphysematous Chest. — In 
 
 this form there is an increase in all of the diameters of 
 the chest, especially marked in the antero-posterior. 
 The chest assumes a type more nearly approaching that 
 seen in the infant. (Fig. 5.) The position is one of 
 full, forcible inspiration. The clavicle and sternum 
 are carried upward and forward by the action of the 
 auxiliary muscles of inspiration ; the neck is shortened ; 
 the infraclavicular spaces may be deeper than normal^ 
 shallower, or may be even projecting. The scapulse arc 
 
INSPECTION. 
 
 4-1 
 
 thrown upwards, outwards and forwards, and project 
 from the rounded thorax. The normal antero-posterior 
 curvature of the spine is increased. 
 
 Bilateral or uniform enlargement is most frequently 
 caused by pulmonary emphysema (large lung) ; it occurs 
 also during attacks of asthma (temporary emphysema), 
 bilateral pleurisy with effusion, hydro-thorax and 
 cancer (rare). 
 
 (2) The Phthisical, Paralytic, Alar, or Pterygoid Chest. 
 — In this type there is an abnormal flattening of the 
 
 Fig. 5. 
 
 Bilateral enlargement of emphysema. 
 Outer line — a circle drawn to show how nearly the emphysematous 
 
 approaches the circular shape. 
 Dotted line = natural adult chest. 
 Inner line = emphysematous chest. 
 
 Actual measurement in ceidimetrrs 
 Circumference = natural, 89.0 emphysematous, 87.75 
 
 Transverse = " 29.6 " 27.25 
 
 Antero-posterior = " 22.25 " 25.4 (Dk. Gee.) 
 
 sternum and ribs, so that the antero-posterior diameter 
 of the chest is diminished and there is a slight increase 
 in the lateral diameter. (Fig. 6.) 
 
 The depression of the ribs and of the sternum carries 
 
42 
 
 THE BESPIRArOBY SYSTEM. 
 
 the sternal end of the clavicle downwards, lengthening 
 the neck and causing the chin to project farther forward 
 than normal over the anterior plane of the thorax, giving 
 a characteristic apjjearance to the individual. 
 
 The angle of the jjlane of the clavicle with the scapula3 
 and sternum alters the dejiressions above the clavicles, 
 increasing their depth. The intercostal spaces are 
 deejDoned; the shoulder blades are depressed and stand 
 out from the ribs, giving the winged ajjpearance (alar, 
 or pterygoid). 
 
 The movements on quiet breathing may be nearly 
 normal in frequency and extent, but on exertion or 
 
 Fig. 6. 
 
 ISc 
 
 The flat or phthisical chest, short antero-posterior, long transverse 
 diameter. (Gee.) 
 
 forced breathing expansion is less than normal, and 
 the movements become more rapid. 
 
 This type may be simulated in marked emaciation by 
 diminution in the soft parts which normally give the 
 rounded contour to the upper portion of the chest. Lack 
 of niuscular development, or changes in the muscles of 
 respiration, such as occur from long recumbence in bed 
 cause slight depressions of the bony thorax, due to feeble 
 inspiratory efforts. Symmetrical depressions of the 
 thorax in the above conditions are easily differentiated 
 from those dependent upon pathological intrathoracic 
 
INSPECTION. 43 
 
 conditions by noting that the normal contour of the bony 
 thorax is preserved, although there may be a slight 
 flattening of the chest. 
 
 The pathological conditions which tend to produce the 
 phthisical type of chest are thickening of the intercostal 
 pleura, which interferes with the elevation of the ribs, 
 and widening of the intercostal spaces during inspira- 
 tion ; thickening of the pulmonary pleura preventing the 
 
 Fig. 7. 
 
 Transverse section of a rachitic chest at level of sixth thoracic vertebrte. 
 Circumference, 32)^ inches; right half, 1Q% inches; expansion, 2 inches. 
 
 normal expansion of the lung; changes in the lung 
 which diminish its elasticity, as tubercular induration, 
 fibrosis, etc., and the closure of the bronchi, which pre- 
 vents the entrance of air into the lung. 
 
 (3) The Rachitic Types. — In the simplest form there 
 is a flattening laterally of the chest, especially in the 
 lower segment; while in the upper portion the sternum 
 is carried forward and the ribs are more or less straight- 
 
44 
 
 THE RESPIRATORY SYSTEM. 
 
 eiK'd, so that the antero-posterior diameter of the chest 
 is increased above, while the lateral diameter is dimm- 
 ished below. (Fig. 7.) From this simple type the 
 diameters greatly increase up to the so-called pigeon- 
 breasted" type. (Fig. 8.) In this form the sternum 
 is pushed forward; "the ribs are straightened out at 
 their angle and at their junction with the cartilages," 
 so that a section of the chest is nearly triangular and the 
 whole contour resembles that of the breast of a pigeon. 
 Kachitic chests also frequently show nodular enlarge- 
 ments at the junction of the bony ribs with the carti- 
 lages, which have been named the rachitic rosary. 
 
 Fig. 8. 
 
 Circumference =42.75 centinietres. 
 
 Rickety chest. Dotted line indicates the shape of chest in an infant about 
 
 the same age. (Gee.) 
 
 (Fig. 9.) The depressions and peculiarities of the 
 rachitic chest are due to intercurrent attacks of bron- 
 chitis, involving the smaller tubes and causing interfer- 
 ence with the entrance of air into the alveoli, and the 
 production of a partial vacuum during inspiration. The 
 effect of atmospheric pressure and the action of the 
 diaphragm is to depress the soft and yielding thorax. 
 
 Frequently, near the junction of the fifth rib with 
 the sternum, and running obliquely across the chest, 
 there is a well-marked depression or groove, which has 
 been named the Harrison furrow. The occurrence of 
 
46 
 
 THE BESPIBATOBY SYl^TEM. 
 
 Harrison's furrow and the deformities that occur _m the 
 lower portion of the chest as a result of the action o± 
 the diaphragm are closely related to that phenomenon 
 known as Litten's sign, which will be later described. 
 
 In the departures from normal above mentioned 
 there is a certain want of symmetry between the two 
 sides, but, as the changes are bilateral, they are gener- 
 ally classified as symmetrical deformities. 
 
 Fig. 10. 
 
 31-7S- 
 
 . — ^r- 
 
 ..--30 
 
 •■/ff-s 
 
 Unilateral enlargement of chest (right side) artificially produced by injecting 
 air into the right pleural cavity. Unbroken line : outline before injection. 
 Broken line : outline after moderate distension. Dotted line: outline after 
 extreme disten.sion. Figures at bottom of vertical line indicate the antero- 
 posterior diameter ; along horizontal line, transvei'se semi-diameter; remain- 
 ing figures, right and left semi-circumference. (Gee.) 
 
 The chest also presents unilateral or asymmetrical 
 enlargement and retraction, which may affect an entire 
 side or a j^ortion only. The unilatoral deformities may 
 be dependent upon spinal curvatures, congenital and 
 occujiation deformities, swelling or ccdema of soft parts, 
 or to intrathoracic changes. 
 
 Unilateral Enlargements. — Unilateral enlargements are 
 most readily seen when the patient is viewed from 
 
INSPECTION. 47 
 
 the front. On the affected side the clavicle is higher; 
 the supraclavicular space may be deeper or shallower, 
 according to the cause. The maminse may be displaced 
 outwards, with widening of the intercostal spaces, which 
 may be shallow or bulging, according to the condition 
 present. From behind the spine is curved toward the 
 enlarged side, and the scapula is carried outwards. 
 Movement on the affected side may be increased, dimin- 
 ished or absent. (Fig. 10.) The intrathoracic causes 
 of unilateral enlargement may be due to 
 
 (1) Compensating emphysema. In this condition 
 the lung of the enlarged side is performing more work 
 than normal, and is receiving not only its own quota of 
 air, but also that which should be received by the 
 opposite side. When diie to this cavise, the increased 
 action of the muscles of inspiration are plainly visible, 
 and the intercostal spaces are deepened with each 
 inspiration; the action of the diaphragm is increased, 
 and movements on the larger side are exaggerated. 
 
 (2) General unilateral enlargement of the chest may 
 be due to filling of the pleural cavity with air (pneumo- 
 thorax), fluid (pleurisy with effusion), pus (empyema), 
 dropsical effusions (hydrothorax) or solid tissue. 
 
 In enlargements due to diseases of the pleura, not 
 only is the size of the chest enlarged, btit the depressions 
 of the intercostal spaces are diminished, obliterated, or, 
 in extreme cases, may be bulging. There is also marked 
 depression of the diaphragm and protrusion in the epi- 
 gastric region ; and the movements of the affected side 
 are diminished or absent. 
 
 (3) Unilateral enlargement of the thorax may be 
 induced by a lobar pneumonia affecting an entire lung. 
 
 Care must be taken, when there is marked asymmetry 
 of the thorax, in determining the relative changes that 
 have taken place in the two sides, whether or not the 
 enlargement of one side is absolute and abnormal, or, 
 on the contrary, whether it appears te be longer than 
 normal because of unilateral diminution of the opposite 
 side. 
 
48 
 
 THE BE8PIRAT0BY SYSTEII. 
 
 Unilateral Diminution in Size.— In this condition tlie 
 affected side is smaller in all dimensions. (Fig. 11.) 
 The ribs are closer together ; the intercostal spaces are 
 narrowed, and may even be obliterated, or the ribs, m 
 extreme cases, may overlap each other, especially m the 
 lower portion. The ribs are more oblique than nor- 
 mally, giving that side of the chest a longer and 
 narrower appearance. The mamma is nearer the median 
 
 Fig. 11. 
 
 Unilateral retraction of chest, consequent upon cirrhosis of left lung, in a 
 girl of fourteen years. The figures indicate antero-posterior and transverse 
 diameters and semi-circumferences of right and left half of chest. (Gee.) 
 
 line ; the top of the shoulder is lower than its fellow on 
 the opposite side; the scapula is thrown nearer to the 
 spinal column, and the spinal column is curved, the 
 convexity looking towards the opposite side. The 
 movements of the affected side are diminished, re- 
 stricted, or may even be absent. The supraclavicular 
 fossa is deeper than normal. 
 
 Unilateral diminution in size may be due to (1) 
 primary arrest of development, as occurs in infantile 
 
INSPECTION. 49 
 
 hemiplegia, etc., when the asymmetry is not limited to 
 the thorax alone, but generally extended over the entire 
 lateral half of the body ; and the affected side, although 
 smaller than the opposite, preserves its normal physio- 
 logical features. 
 
 Unilateral diminution in size also occurs when there 
 is atrophy or loss of function of the muscles of normal 
 inspiration. In this condition retraction of the side 
 could only occur when the condition had lasted for a 
 long time, and the unopposed traction or negative press- 
 ure of the lung had been sufficient to cause a gradual 
 depression of the ribs. 
 
 (2) Diseases of the PLEUEiE. — Marked retraction 
 of the thorax occurs in diseases of the pleuras, especially 
 after absorption of the fluid in pleurisy with effusion, 
 when changes occur in the lung or in the pleura; which 
 prevent the kmg thoroughly filling the thorax, as pul- 
 monary collapse and fibrosis and chronic thickening of 
 the pleura, adhesions of the two siirfaces of the pleura. 
 
 (3) Changes in the Lungs. — These include changes 
 in the lung which cause a diminution in its size, as 
 chronic interstitial pneumonia (fibrosis, cirrhosis of the 
 lung), tuberculosis, interference with the entrance of 
 air into the lung through narrowing or occlusion of the 
 lumen of the bronchi of entire lung. 
 
 LOCAL BULGINGS. 
 
 The asymmetry of the chest may be due to changes 
 that affect a limited portion of the chest only. 
 
 Limited enlargements may be due to (1) changes that 
 occur in the soft parts, as swellings or tumors, lipomas, 
 malignant growths, etc. 
 
 (2) Diseases involving the bony thorax itself, as peri- 
 ostitis or exostosis, fractures of the bony thorax, or from 
 localized deformities due to spinal curvature, distortion 
 of the ribs, with enlargement of one side, the front of 
 4 
 
50 THE RE8PIEA TORY SYSTEM. 
 
 which is compensated for by a corresponding increase 
 of the opposite side behind. 
 
 (3) A bulging of a limited portion of the chest wall 
 may be produced by a localized or encapsulated collec- 
 tion of fluid or air within the pleural cavity. The 
 amount of deformity that such a collection may produce 
 is directly dependent upon the conditions of the bony 
 thorax, being most marked in early childhood, when the 
 chest wall is soft and yielding, very slight effect or none 
 being produced on the rigid chest wall of adult life. 
 
 (4) Bulging of the thorax over the prsecordial space 
 may occur as a result of cardiac enlargement, or of 
 pericarditis with effusion. The amount of bulging will 
 depend upon the condition of the chest wall, the same as 
 was mentioned above. Dilatation of the large vessels 
 may also cause local bulgings, which may be attended 
 with visible pulsation. Local bulging of the bony 
 thorax in aneurism does not occur until the pressure of 
 the dilating vessel has been sufficient to cause a soften- 
 ing of the overlying bones. 
 
 (5) Enlargements of the lower zone of the thorax 
 may be caused on the right side by enlargement of the 
 liver, and on the left side by enlargement of the spleen. 
 
 (6) General enlargement of both sides of the lower 
 portion of the thorax below the fifth rib may be pro- 
 duced by anything that increases the intra-abdominal 
 pressure, as meteorism, ascites, abdominal tumors reach- 
 ing the diaphragm, etc. 
 
 LOCAL DEPRESSIONS OR RETRACTIONS 
 OF THE CHEST. 
 
 These may be produced (1) by diseased conditions of • 
 the soft parts, as local wasting in the muscles of a part. 
 If there is_ paralysis of the muscle, so that its action 
 upon the ribs is interfered with, the constant negative 
 pressure that is exerted by the lung may be sufficient to 
 cause a slight depression or retraction over the affected 
 
INSPECTION. 51 
 
 area. (2) Disease of the bony structures, as rachitis. 
 (3) Changes in pleura, as thickening, adhesions. (4) 
 It may be dependent upon a disease of pulmonary tissue, 
 as tuberculosis, fibroid induration and other pathological 
 conditions which render it less distensible. 
 
 It is necessary at this point to have a clear idea of the 
 factors that produce localized depressions in diseases of 
 the lung and pleura. In normal inspiratioUj when the 
 thorax enlarges as a result of muscular action, the dis- 
 tensible lung readily fills the cavity. When, on the 
 other hand, a change occurs within the thorax, affecting 
 the pleura or the pulmonary tissue, either as a result of 
 tubercular infiltration or fibroid induration, on inspira- 
 tion the a,ffected portion of the lung does not readily 
 enlarge, and as a result there is a tendency to produce a 
 vacuum at the point affected. In the early stages a 
 compensatory dilatation of the surrounding alveoli may 
 make up for this lack of distensibility of the lung, but, 
 on account of the gradually-developing muscular weak- 
 ness and constant action of the atmospheric pressure 
 over the affected part, there is produced the character- 
 istic depression or retraction of localized intrathoracic 
 diseases. 
 
 In diseases of the pleura, characterized by adhesions 
 and obliterations of the sac after the absorption of the 
 fluid in pleufisy with effusion, with atelectasis of the 
 lung, and in resection of the rib, these factors may 
 caiise a retraction of the entire side. 
 
 RESPIRATORY MOVEMENTS. 
 
 In addition to changes that occur in the form and 
 size of the chest, the movements of respiration are to be 
 noted. Difficulty may be experienced in getting patients 
 to breathe properly. Under examination they are apt to 
 breathe abnormally, and in certain nervous individuals, 
 if they are conscious of observation, it is impossible to 
 get a true idea of the respiratory movement. These 
 
52 THE EE8PIBAT0BY SYSTEM. 
 
 individuals should be observed without attracting atten- 
 tion to your purpose. 
 
 ISTormally, the movements of the two sides are equal 
 and simultaneous. With each inspiration the upper 
 portion of the chest is well filled out ; there is a. move- 
 ment upward and outward of the ribs; an increase in 
 the vertical, transverse and antero-posterior diameter 
 of the thorax ; depressions of the intercostal spaces are 
 increased, and there is a protrusion of the abdomen in 
 the epigastrium, due to the descent of the diaphragm. 
 With expiration the movements take place in the reverse 
 order. 
 
 The movements of inspiration are active, depending 
 upon the action of the muscles on the bony thorax, 
 increasing the size of the thoracic cavity with the pas- 
 sive distension of the lung. In expiration the move- 
 ments are caused by the elasticity of the overdistended 
 lung, aided by the elastic tension of the entire thorax 
 and the weight of the chest. 
 
 Three types of respiration are recognized as physio- 
 logical : 
 
 (1) The costal, or superior costal, which is seen 
 chiefly in women. In this type the movements of the 
 upper portion of the chest are most marked ; there is 
 little expansion of the lower segment of the thorax, and 
 the protrusion of the abdomen is slight. In this type the 
 sternum as a whole is elevated. Elevation of the 
 sternum occurs both in quiet and deep breathing in 
 women, but in man only in deep breathing. 
 
 (2) The inferior costal in which the most marked 
 movement occurs in the lower six ribs,' and the dia- 
 phragmatic phenomena are more markedly noticed. 
 This is the type of breathing normal for an adult male. 
 
 (3) The diaphragmatic or abdominal breathing which is 
 chiefly present in children. 
 
 ■ In determining whether the movements of respiration 
 are normal, tliorefore, it is necessary to take into account 
 the sex i^nd age of the patient. 
 
INSPECTION. t)Z 
 
 Costal breathing may be abnormally increased (1) 
 when the movements of the lower segment of the thorax 
 or diaphragm are interfered with by oedema or inflam- 
 mation of the lower lobes of the lungs, preventing their 
 expansion, in which case the exaggerated costal breathing 
 is compensatory.' (2) Pleurisy with effusion, involving 
 both pleural sacs. (3) Diseases of the bony thorax, as 
 Pott's disease, or painful affections which interfere with 
 the movement of the ribs on both sides. 
 
 (4) Painful affections of the soft parts, although they 
 rarely affect both sides. (5) Paralysis of diaphragm, 
 due to bulbar paralysis, neuritis of the phrenic nerve 
 in multiple neuritis, hysterical neuroses. When the dia- 
 phragm does not act there is absence of protrusion of 
 the epigastric region, with inspiration, and it may be 
 replaced by depression, which is especially noticeable 
 in hysterical paralysis and diaphragmatic pleurisy. 
 (6) Diseases below the diaphragm, with pain on move- 
 ment of the abdominal organs, as peritonitis, general or 
 local. (7) Increased abdominal pressure from ascites, 
 tympanites or tumors, which mechanically prevent the 
 descent of the diaphragm. 
 
 The inferior costal and diaphragmatie breathing may 
 be increased by any condition that prevents or inter- 
 feres with the normal costal breathing, as consolidation 
 of the upper lobes of the lung from any cause, painful 
 affections involving the pleurae, intercostal nerves, or 
 bony thorax. It is especially diagnostic if it replaces 
 normal costal breathing in the female adult, except in 
 old age. in proportion as there is a lack of expansion 
 of the bony thorax and the movement of the ribs is 
 interfered with, there is a corresponding action of the 
 diaphragm and diaphragmatic, or abdominal breathing. 
 In old age the bony thorax becomes more rigid, and 
 increased abdominal breathing is present in the female 
 as well as in the male. 
 
 The movements may be increased unilaterally when- 
 ever there is interference with the respiratory function 
 
54 THE RESPIRATOBY SYSTEM. 
 
 of the opposite side. This condition is compensatory, 
 the increased action of the unaffected side making 
 up as far as possible for the absence of function o± the 
 other. . 
 
 Increased Respiratory Movements. — The movements o± 
 respiration are increased in extent and number m con- 
 ditions of dyspnoea, which may be due to (1) diseases 
 of the lungs, which diminish their vital capacity, as 
 bronchitis with exudation, consolidations of the lung 
 from various causes, diseases of the plfiurse. (2) 
 Cardiac diseases, in which there is imperfect aeration of 
 the blood from deficient circulation. (3) Diseases of 
 the blood, in which its power to take up oxygen is 
 diminished (anaamia). (4) Nervous diseases, in which 
 there is no defect in oxygenation, but rather an increased 
 irritability of the respiratory centers. (5) In those dis- 
 eases in which there is an increase in the elimination of 
 CO2, as seen in fevers, etc. 
 
 Distinction is made between exaggerated breathing, 
 or increased motion, in which the ordinary muscles of 
 respiration only are involved, and labored breathing, 
 where the extraordinary muscles of respiration are 
 called into play. 
 
 Diminished respiratory movement may be bilateral, 
 unilateral or local, and may occur as a result of (1) dis- 
 eases of the muscles of respiration, (2) painful condi- 
 tion of soft spots, (3) diseases of the bony thorax, (4) 
 diseased conditions of the pleurae or (5) in diseased con- 
 ditions of the lung, either general or local. 
 
 Bilateral diminution, or absence of motion, occurs 
 when there is disease of the bony thorax, especially 
 Pott's disease, preventing a normal movement of the 
 ribs. Also in diseases involving the intercostal nerves 
 and muscles. It is present, with enlargement of the 
 thorax, when both pleural cavities contain air or fluid; 
 when the elasticity of the lung is diminished, as in 
 emphysema; after absorption of fluid in pleurisy or 
 empyema; with thickening and adhesion of the pleura 
 
INSPECTION. r>5 
 
 in diseases of the hings which prevent or interfere with 
 this expansion. 
 
 Whenever there is difficulty or interference with the 
 entrance of air in the lung, through narrowing or occlu- 
 sion of the iipper air-passages or bronchi, as a result of 
 forced inspiratory effort, there is a marked depression 
 of the lower portion of the thorax, due to the partial 
 vacuum that is prodiiced. IvTot only is motion inter- 
 fered with, but the number of respirations is diminished. 
 
 Unilateral and local diminution of motion varies in 
 degree from slight lagging to entire absence of motion, 
 and may be due to loss of muscular power; to painful 
 conditions of the muscles (inflammation, neuralgia) ; 
 of the bony thorax (periostitis, fracture of ribs, etc.) : 
 to diseased conditions of the pleurae (acute pleurisy, 
 painful and catchy breathing), or increased thickness 
 and adhesions preventing movement of ribs and expan- 
 sion of lung.' These conditions are associated with 
 unilateral and local retraction. When the pleura con- 
 tains air and fluid, loss of motion is associated with 
 increase in size. 
 
 LITTEN'S PHENOMENON. 
 
 In addition to the protrusion of the epigastrium, 
 Litten has called attention to the effect that descent of 
 the diaphragm has on the lower portion of the chest. 
 If a person who is not too fat is so placed that lying on 
 his back the light fall upon the chest from the direction 
 of the feet only, the observer, standing at the side, 
 notices a narrow shadow moving downward when a full, 
 deep breath is taken. This shadow is due to expansion 
 of lower ribs, caused by the slow separation, by the 
 descent of the diaphragm, of the two surfaces of the 
 pleura over the so-called complemental spaces and the 
 gradual extension of the lower border of the lungs, with 
 filling out of the intercostal spaces. 
 
 The phenomenon is modified or absent in all condi- 
 
56 THE RE8PIRA TORY SYSTEM. 
 
 tions that (a) change the normal relation of the 
 two surfaces of the pleura in the complemental space, 
 viz., effusion into the pleural cavity, pneumonia of the 
 base of the lung, pulmonary emphysema ; (h) or inter- 
 fere with the descent of the diaphragm, as adhesions of 
 the two surfaces of the pleura ; or (c) prevents the lung 
 from distending as iibroid induration and tubercular 
 infiltration, especially of the apex. 
 
 Litten's phenomenon is often of value in diagnosing 
 slight pleuritic effusions from enlargements of the liver 
 and spleen, as subdiaphragmatic conditions do not inter- 
 fere with the descent of the diaphragm, unless attended 
 with pain or greatly increased intra-abdominal pressure. 
 
 ALTERATIONS IN FREQUENCY. 
 
 Eapidity of respiration varies normally with age. 
 Under one year of age it is 44 per minute; one to five 
 years, 26 ; five to twenty years, 20, and after twenty 
 years of age the average rapidity is 18. Physiologi- 
 cally, it is influenced by posture, exercise, digestion and 
 by mental influence. In diseases of the respiratory 
 tract the rate is increased in proportion to the inter- 
 ference with the aerating function of the lungs. The 
 rate in diseases of the lung is never decreased, except 
 laryngeal or tracheal stenosis and asthma. 
 
 Diminution in the rate of respiration is otherwise 
 dependent upon some influence acting on the nervous 
 system, and especially on the respiratory center. 
 
 ALTERATION IN RHYTHM. 
 
 JSTormally, the movements of breathing are in perfect 
 rhythm, each respiratory act being of equal length and 
 depth and following each other without any appreciable 
 pause. The movement of inspiration is slightly shorter 
 than that of expiration, the ratio being as 5 to 6. As 
 age advances this ratio becomes slightly greater, due to 
 
INSPECTION. 57 
 
 the impaired elasticity of the lung, so that in the aged a 
 ratio of 5 to 8 is not unusual. 
 
 In asthma and emphysema the rhythm is disturbed in 
 proportion to the expiratory difficulty, so that the move- 
 ment of inspiration may be short, spasmodic or jerky, 
 while expiration is slow, prolonged and incomplete. 
 
 When obstruction of the tipper air-passages (intra- 
 laryngeal or intratracheal growths, false membranes, 
 etc.) produce inspiratory dyspnoea, then the inspiratory 
 movements are prolonged and the breathing is slow. 
 
 The rhythm is also disturbed when the respiratory 
 movements cause pain (intercostal neuralgia, pleuro- 
 dynia, pleurisy, etc.), and, as the pain is most intense 
 at the time of greatest motion, the inspiration is short, 
 shallow and catching and expiration slow and feeble. 
 
 A peculiar disturbance of rhythm has received the 
 name of "Cheyne-Stokes" breathing. The movements 
 are unequal ^and arhythmical, but follow a fixed cycle. 
 One or two shallow respirations are followed by four or 
 five that progressively increase in frequency, depth and 
 noise until the acme is reached, and then gradually sub- 
 side in inverse order. This is followed by a longer or 
 shorter respiratory rest or "pause" (apncea), which is 
 followed by another attack of disturbed breathing. 
 
 This type of breathing occurs in severe types of 
 cerebral, cardiac and renal diseases and narcotic poison, 
 and is generally an unfavorable symptom. 
 
CHAPTER III. 
 
 PALPATION. 
 
 By palpation we obtain information by the sense 
 of touch, or tactile sense, and it is usually the second 
 step in the examination of the respiratory and circula- 
 tory organs. 
 
 While it confirms all that has been learned by inspec- 
 tion, it is in many respects more definite and exact, and 
 increases the evidence that has already been obtained 
 by the eye, for it determines the presence or absence of 
 certain vibratory phenomena 'and allovps of difPerential 
 diagnosis between conditions that produce similar 
 changes in the shape of the thorax. 
 
 As inspection furnishes results of a general character, 
 so also does palpation, and, on account of the ease with 
 which it is performed, we often Substitute it for inspec- 
 tion where that is impossible on account of the posture 
 of the patient to view the chest. 
 
 The results obtained by palpation depend upon the 
 sensitiveness of the observer's sense of touch (tactis 
 eruditus), and whether or not the chest is examined in 
 a methodical and systematic manner. 
 
 Every part of the thorax should be examined, and 
 those who claim that palpation is of minor importance 
 are either deficient in the sense of touch or employ it 
 in a haphazard manner without attention to details. 
 
 In performing palpation the surface should be bare, 
 so the hand can be applied directly to the skin. It 
 IS not necessary to expose the thorax to view, as the hand 
 can be slipped imder a loose covering. At times it may 
 be necessary, on account of a feeling of delicacy on the 
 
PALPATION. 59 
 
 part of the patient, to have a thin covering, as gauze, 
 between the surface and the liand, but even this inter- 
 feres with the examination to a certain extent. The 
 hands of the examiner should be warm, so as not to be 
 unpleasant to the patient. 
 
 Attention should be paid to the position of the 
 patient, and the examiner should always bear in mind 
 that want of symmetry is a matter of greatest iiupor- 
 tance, so that the two sides should be compared region 
 by region, as each portion of the chest gives its own 
 evidence. 
 
 By jaalpation of the thorax, with reference to the 
 respiratory organs, knowledge is gained of the follow- 
 
 (1) SIZE, SHAPE AND SYMMETRY OF THE THOEAX. 
 
 Palpation gives very little information on these points 
 beyond what can be gained by inspection, and in most 
 cases it is not as accurate in regard to symmetry. When 
 inspection is impossible, on account of not being able 
 to expose the chest, we gain a fairly accurate knowledge 
 by palpation. 
 
 One important fact noted by palpation is the loca- 
 tion of the different ribs. Remember that the second 
 rib is the one below the clavicle, that can be taken 
 between the fingers; it corresponds with the ridge on 
 the sternum. 
 
 (2) RESPIRATORY MOVEMENTS. 
 
 As its object is to test if the movements of the two 
 sides are simultaneous and equal, it is necessary that 
 the hands be placed over corresponding regions of the 
 chest for comparison. 
 
 As the time, extent and rhythm of the respiratory 
 movements are to be examined, also whether the widen- 
 ing of the intercostal spaces occurs equally on both sides, 
 the hands must be so placed as to note these points. 
 
60 THE RESPIRATORY SYSTEM. 
 
 To palpate the anterior surface of the chest, the 
 examiner stands behind the patient and places the hands 
 over the chest so that the fingers are parallel with the 
 ribs, resting in the intercostal spaces. By these means 
 a better perception of motion and of time is obtained. 
 To palpate the posterior surface, the position is reversed. 
 
 The antero-posterior movement of the chest is 
 noted by placing one hand over the sternum in front, 
 and the other posteriorly over the spine. 
 
 The movement of the clavicle and upper ribs is 
 observed by placing the hand over the shoulder, the 
 fingers resting on the anterior portion of the chest, and 
 the thumb behind on either side of the spine. 
 
 The examiner should remember that the respiratory 
 movements are influenced by age and sex, as already 
 explained under "Inspection." 
 
 Slight inequality of motion between the two sides, as 
 shown by a slight lagging of one side, when present in 
 the slightest degree, is detected by the expert palpator, 
 and is of diagnostic importance. 
 
 Under "Inspection" attention was called to Litten's 
 phenomenon. The action of the diaphragm that pro- 
 duces it can be felt as well as seen, and gives us impor- 
 tant evidence of any change in the movement of the 
 diaphragm. 
 
 Palpation is almost as sensitive as the fluoroscope in 
 detecting slight changes in diaphragmatic movement. 
 
 (3) VIBRATORY PHENOMENA. 
 
 Vocal fremitus, also called tactile and tussive fremi- 
 tus, are the vibrations that are felt by the hand on the 
 surface of the chest when the air contained in the lungs 
 is thrown into vibrations sufficiently strong to be trans- 
 mitted to the thorax and recognized by the sense of 
 touch. The vibrations of ordinary respiration are too 
 feeble to be appreciated by the hand, while they are 
 
PALPATION. 61 
 
 recognized by the ear and termed normal vesicular 
 murmurs, or breath sounds. 
 
 In order to obtain vibrations sufficiently powerful, 
 the voice is used. The movements of the vocal cords 
 set up corresponding vibrations in the air contained in 
 the lungs, which are transmitted through the thorax 
 and appreciated by the hand on the surface of the chest. 
 Vibrations set up by the voice are not of equal 
 strength for all persons, varying according to the voice, 
 sex and age of the individual. The wave length in man 
 is from 8 to 12 feet; in women, 4 to 6 feet, while in the 
 child the wave length is so short and the vibrations so 
 rapid as to render vocal fremitus indistinct. 
 
 As the character of the vibrations produced by the 
 voice modify the vocal fremitus that is obtained, it is 
 necessary that the vocal vibrations be as equal and as 
 uniform as possible. For this reason the patient is 
 usually instructed to count 1, 2, 3 or use some phrase, 
 as 99 or 44. Any monotone may be employed to set up 
 the vibrations. 
 
 It must be borne in mind that each individual will 
 have his own vocal fremitus, which will have a direct 
 relation to the character of his voice. Voices that are 
 low pitched and heavy, as in man, give a correspond- 
 ingly strong vocal fremitus; while, on the other hand, 
 the thin, weak or high-pitched voice, as in woman, being 
 an octave above that in man, gives a correspondingly 
 weak vocal fremitus, which in some cases may be so 
 faint as not to be detected by touch. 
 
 The vibrations produced in the larynx do not reach 
 all portions of the surface of the chest with equal 
 intensity. We note that it is stronger over the right 
 lung than over the left ; that it is more marked over the 
 right apex than over the left. 
 
 The reason for this difference in intensityis explained 
 by the anatomical arrangement of the primary bronchi 
 on the two sides and their relation to the trachea. The 
 bronchus going to the right lung is more nearly a con- 
 
62 
 
 THE RESPIRATORY SYSTEM. 
 
 tinuation of the trachea, has a greater lumen, and, in 
 addition, leaves tlio trachea at a less acute angle, so that 
 the vihrations that are set up in the larynx reach the 
 entire right lung with greater force, on account of the 
 larger column of air contained in the bronchi. 
 
 Fig. 12. 
 
 The situation of the bronchial tree emphasizes the fact tliat vocal fremitus 
 is obtained more distinctly over the right than the left lung, greater in the 
 upper than the lower thorax. 
 
 Vocal fremitus over the apices of the t\vo lungs differ, 
 being more intense on the right side.. 
 . ^I"^". physiological increase of ^-ocal fremitus on the 
 right side often misleads the observer, as its intensity 
 may suggest a pathological condition of the lung 
 
 llie cause of this marked increase of vocal fremitus 
 oyer the apex of the right lung is due to the fact tha 
 the bronchus supplyii^g the upper lobe is given off from 
 
PALPATION. 63 
 
 the primary bronchus close to the trachea, and the vibra- 
 tions conveyed to the upper lobe of the right lung are 
 correspondingly stronger. Whether or not this increase 
 is pathological can only be determined by considering 
 other signs in connection vs^ith it. 
 
 The nearer the bronchi approach to the surface of the 
 lung, and the larger their lumen, the more distinct will 
 the vibrations be felt. For this reason the vibrations 
 are stronger over the upper portion of the thorax, 
 between the scapula behind, especially on the right side, 
 and at the junction of the second intercostal spaces on 
 the right side and the third on the left. (Fig. 12.) 
 
 The further the surface of the chest is removed from 
 the larynx and trachea, the smaller the bronchi that sup- 
 ply the portion of the lung immediately underlying it, 
 the greater the proportion of pulmonary tissue to the 
 bronchi, the weaker will be the vibrations that are con- 
 veyed from the larynx to the surface of the chest, and 
 consequently the vocal fremitus that is felt over the 
 lower portion of the thorax and nearest the extremities 
 of the lung is much weaker than over the large bronchi. 
 
 In addition to the influence of the pulmonary struct- 
 ure, the vocal fremitus is modified by the condition of 
 the chest wall ; and, according to the law that vibrations 
 are lost in passing through media of different densities, 
 and especially when passing from a media of a lesser to 
 one of a greater density, vocal fremitus will be weak 
 over those portions of the chest where a large amoimt of 
 tissue intervenes between the hand and the pulmonary 
 structure. 
 
 This is especially marked over the mammae in women, 
 over the scapula behind and is uniformly modified over 
 the chest when the soft parts are greatly increased in 
 thickness. 
 
 It is very necessary that the examiner shoiild bear in 
 mind the normal variations of vocal fremitus that occurs 
 over different regions of the chest, and that he thor- 
 oughly familiarizes himself with tU^ir relative intensity. 
 
6 i THE RESPIRATORY SYSTEM. 
 
 In examining for vocal fremitus the whole hand is 
 placed lightly npon the chest, so as to get a relative idea 
 of the vibrations over the point that is examined, it 
 will make a difference whether the fingers are placed m 
 the intercostal spaces, as in testing for the respiratory 
 movement, or on the ribs and bony thorax. 
 
 When the fingers are placed between the ribs, then 
 the vocal fremitus that is felt is , transmitted from the 
 pulmonary tissue directly through the thin covering of 
 the intercostal spaces, while if the hand is placed upon 
 the ribs, or, as is usually done, across the ribs and 
 intercostal spaces, then the vibrations that are felt are 
 not those that are conveyed to the surface by the portion 
 of the lung immediately under the hand, but are all the 
 vibrations that have been brought to the surface and 
 have been taken up by the bony thorax, which acts as a 
 sounding board. 
 
 In order to examine for vocal fremitus in a limited 
 area, it is best to place the tips of the fingers only upon 
 the chest in the intercostal spaces while the patient is 
 speaking. In this way slight local variations may be 
 readily detected. 
 
 When the hand is placed over the shoulders, the 
 thumb resting behind and the tips of the fingers beneath 
 the clavicle, we obtain an idea of the relative intensity 
 of the vocal fremitus that is produced in the entire 
 upper portion of the thorax. 
 
 Vocal fremitus may be increased, diminished or 
 absent. 
 
 Vocal Fremitus Increased. — ^As was seen above, under 
 Normal Variations in Vocal Fremitus, the vibrations 
 that are made in the larynx are modified by the con- 
 ducting power of the lung, and are normally weakened 
 as they pass from the larger to the small bronchi, and 
 from these to the alveoli. 
 
 As the "spongy" condition of pulmonary tissue inter- 
 feres with the transmission of vibration, so, on the other 
 hand, any condition which renders the lung more homo- 
 
PALPATION. 65 
 
 geneous gives an increased power of conduction, and 
 consequently increases vocal fremitus. 
 
 Increased vocal fremitus is obtained in all pulmonary 
 consolidations, such as those of pneumonia, tubercular 
 infiltration, infarction or fibroid thickening of the lung ; 
 and the amount of vocal- fremitus is directly dependent 
 upon the changed anatomy of the lung and its increased 
 power of conduction. 
 
 As the vibrations that are brought to the surface are 
 transmitted through the columns of air contained in the 
 lung and the pulmonary structures, the tension of the 
 lung tissue will modify the transmission of these vibra- 
 tions. 
 
 Increase of tension increases the ease with which the 
 vibrations are carried from one portion of the lung to 
 the other, and also increases the rapidity of the vibra- 
 tions themselves. 
 
 Increase of tension is present in pulmonary conges- 
 tion, causing a slight increase in vocal fremitus. 
 
 In children, in addition to the high-pitched voice, 
 with its attendant rapid vibrations, the tense pulmonary 
 tissue causes the vibrations to become so rapid as to be 
 indistinct. 
 
 Increased vocal fremitus is felt over cavities in the 
 lung, as the vibrations from the larynx, trachea and 
 bronchi are transmitted direct through the large air- 
 containing spaces to the surface of the chest. 
 
 Diminished or Absent Vocal Fremitus. Changes Dub 
 TO THE Bronchi. — As the vibrations are conveyed 
 chiefly through the columns of air in the bronchi to the 
 surface of the lung, anything that diminishes the lumen 
 of the tube would interfere with the transmission of the 
 vibrations from the larynx in direct proportion to the 
 diminution in size. If it is occluded, aerial vibrations 
 are arrested, and there is an absence of vocal fremitus 
 over the area supplied by the occluded bronchus. 
 
 Vocal fremitus may be diminished through narrow- 
 ing of the lumen of the tube in bronchitis and asthma, 
 5 
 
6 6 THE RESPIUA TOR Y SYSTEM. 
 
 and may be entirely interfered with in plugging of the 
 bronchi, as occurs in fibrinous bronchitis, in pneumonia, 
 or by the growth of tubercle nodules ; and also by occlu- 
 sion of the tube by pressure, as in aneurism. 
 
 Changes Due to Pulmonary Tissue. — Just as 
 tense pulmonary tissue by vibrating in unison with the 
 air in the bronchial tubes increases the amount of vocal 
 fremitus, so all conditions which render the lung tissue 
 less tense interfere with the transmission of vibrations 
 to the surface by smothering or absorbing the vibrations 
 conveyed to it. This is especially noticeable with loss 
 of elasticity and negative pressure in emphysema, while, 
 on the other hand, it does not occur in compensatory 
 emphysema, where the tension of the pulmonary tissue 
 is increased, as in this condition the vocal fremitus may 
 be normal, the increase of tension in the pulmonary tis- 
 sue counterbalancing the increased sponginess from 
 dilation of the alveoli. 
 
 Influence of the Pleura. — Ordinarily the normal 
 pleura, on account of its extreme thinness, has no influ- 
 ence on vocal fremitus. When, however, the pleura is 
 thickened, or it contains effusion of any kind, it inter- 
 feres markedly with the transmission of the vibrations 
 from the lungs, according to the law that vibrations are 
 lost when they pass from a rarer to a denser medium, 
 and the amount lost, ranging from a slight diminution 
 in intensity to total absence, will be in direct proportion 
 to the amount of thickening or fluid that is contained 
 within the pleural cavity. 
 
 The conditions of the pleura which interfere with the 
 transmission of vibrations are: (1) Pleuritic thicken- 
 ing, which may be due either to primary pleurisy or be 
 dependent upon tubercular inflltration: (2) Exuda- 
 tions upon the surface of the pleura, as occurs in acute 
 pleurisy with plastic exudation: (3) Effusion into the 
 pleura, whether serous, sero-fibrinous or purulent. The 
 specific gravity of the fluid does not alter to an apprecia- 
 ble degree the transmission of vocal fremitus. (4) 
 
PALPATIO^. 67 
 
 When the pleural cavity contains air, as in pneumo- 
 thorax, the vocal fremitus is interfered with, because 
 the relaxed lung is a poor conductor of vibration. 
 
 Influence of the Ohbst Wall. — Increase in the 
 thickness of the soft parts will diminish vocal fremitus^ 
 according to the law that vibrations are lost in passing 
 from a rare to a dense medium, but not to the same 
 degree as a corresponding thickness of the pleura. 
 
 The reason for this is that when the pleura is thick- 
 ened the vibrations are smothered or suppressed before 
 they can be conveyed to the bony thorax, which acts as 
 a sounding board and overcomes to a certain degree the 
 inertia of soft (thickened) tissues of the chest wall. 
 
 This diminution will occur especially if the source 
 of vocal fremitus, namely, the voice, is of such a nature 
 as to give normally a feeble vocal fremitus. 
 
 Ehonchi and Palpable Rales. — In addition to the vibra- 
 tions that are produced by the voice, the air passing 
 through the liquid secretion in the bronchi is frequently 
 thrown into vibrations sufficiently strong to be conveyed 
 to the chest wall as fremitus. On account of being 
 made in the bronchi, they have been named bronchial 
 rhonchi, or palpable rales. 
 
 They occur chiefly with inspiration, and are most 
 frequently felt in children; and are usually associated 
 with noisy or asthmatic breathing, but the ordinary 
 sibilant or sonorous rales of asthma are so high-pitched 
 and the vibrations are so rapid that they are not detected 
 by sense of touch. 
 
 Friction Fremitus. — Ordinarily the surface of the se- 
 rous membranes glide over each other without friction. 
 When, however, there is a marked roughening of the 
 two surfaces, then their movement may be attended 
 with vibrations sufficiently intense to be felt on the 
 surface. 
 
 Friction fremitus is most commonly felt at the point 
 of greatest motion of the serous membranes, normally 
 in the axillary space over the fifth and sixth ribs. 
 
6 8 THE BE8PIRA TOR Y SYSTEM. 
 
 Splashing or Succussion Fremitus. —When air and fluid 
 are contained in the pleural cavity, and rarely in large 
 cavities in the lung lying close under the pleura, on 
 coughing or violent shaking of the chest the motion of 
 the fluid contents may be sufficient to be felt on the sur- 
 face. 
 
 Pain. — In addition to the vibratory phenomena, it is 
 possible to determine by palpation whether or not pain 
 is present. 
 
 Pain on palpation may be due to a sensitive condition 
 of the chest wall itself, as is seen in the tender spots of 
 Valleux, in inflammatory conditions of the muscular 
 tissu? and in diseased conditions of the bony thorax, as 
 periostitis, etc. 
 
 An important variety of pain elicited by palpation is 
 interpleural, In order to test for this it is necessary 
 that tfie pressure be made so forcibly as to interfere with 
 local expansion of the chest and bring the two surfaces 
 of the pleura into close contact. The sign is valuable 
 in tubercular involvement of the pleura over the apex. 
 It is obtained by standing behind the patient, bringing 
 the hands over the shoulder, as in testing f oj* voeal 
 fremitus, and making firm pressure with tips of the 
 fingers in the infrascapulat fossa. 
 
 ' Frequently it is possible to obtain this slight sign 
 when no pleuritic raleS can be detected by auscultation. 
 
 The test for pain, and especially interpleural pain, 
 should be left till the last, as, if it is performed earlier 
 in palpation, it is apt to disturb the rhythm and move- 
 ment of the thorax, a:nd so lead to false impressions. 
 
 Fluctuation. — By palpation we also determine the 
 consistency and elasticity of tumors and enlargements 
 of the chest that have been noted on inspection. 
 
CHAPTEK IV. 
 
 PERCUSSION. 
 
 Percussion in physical diagnosis is the act of strik- 
 ing the body in order to elicit sound by setting up 
 vibrations. 
 
 If the tissues that are percussed are solid, as the 
 thigh, the sound produced will be dull, and is described 
 as toneless, flat or dead. If, on the other hand, it con- 
 tains air or gas, as the thorax or abdomen, it gives out a 
 sound that has resonance or tone aiid the elements of 
 sound — (1) quality or timbre, (2) intensity or volume, 
 (3) pitch, (4) duration or length — ^will be present and 
 easily recognized by the ear. 
 
 It is necessary to consider the elements of sound in 
 detail, so as to appreciate their value in the percussion 
 of the thorax. 
 
 The quality or timbre of a sound is "that character- 
 istic by vs^hich the sound produced frorri some particular 
 source, as from an instrument or voice, may be dis- 
 tinguished from sounds from other sources, instruments 
 or voices." 
 
 It is physically dependent upon the form of the vibra- 
 tions by vi^hich the sound is produced, and although the 
 pitch, intensity and duration may alter, the quality still 
 indicates the source of the sound. 
 
 The quality of the sound produced by percussion over 
 lung tissue is called pulmonary or vesicular resonance. 
 
 The intensity or volume of sound depends upon the 
 amplitude or extent of the vibrations. It varies directly 
 as their square, and is further modified by the force of 
 the blow. 
 
70 THE RESPIRATORY SYSTEM. 
 
 The intensity is influenced in pulmonary percussion 
 by the amount of the air-containing tissue that is set in 
 motion. It is also modified by the surrounding tissues, 
 whether or not they are easily thrown into vibration 
 when struck, and so impart motion readily to the con- 
 tained air. Therefore, in the percussion of the thorax 
 the intensity of resonance is influenced by the condition 
 of the chest walls, bony thorax and pulmonary tissue. 
 
 The influence of the force of the blow and the amount 
 of air contained and the nature of the covering is 
 readily illustrated in the drum. While the quality of 
 the sound does not change, the intensity or volume is 
 directly in proportion to the force of the blow upon the 
 drum head. 
 
 The pitch depends upon the rapidity and length of 
 the vibrations. The shorter and more rapid the vibra- 
 tions, the higher the pitch. This is well illustrated in 
 the fiddle string or drum head. The pitch becomes 
 higher when the tension of the vibrating medium is 
 increased, and is lowered by relaxing it. 
 
 The pitch is the most difficult part of a sound to 
 appreciate, because the ear do'es not note slight varia- 
 tions in pitch as readily as changes in quality, intensity 
 or duration, and it is only by training the ear that the 
 finer changes are recognized. 
 
 Beginners are. confused by the fact that high pitch is 
 most frequently associated with dullness, and therefore 
 it seems impossible to distinguish between a high-pitched 
 note which is dull or characterless, as over-consolidated 
 lung, and a resonant, clear note that is also high 
 pitched, as occurs over distended lung • tissue with 
 increased tension. 
 
 Within certain limits, pitch varies in the lung accord- 
 ing to the tension of the tissues, but, as this is slight, it 
 can only be considered in connection with the other ele- 
 ments of sound. 
 
 The pitch of the percussion note over normal luno- 
 tissue is low, varying within narrow limits in different 
 individuals. 
 
PEBCUSSION. 71 
 
 As pitch depends not only upon the rapidity and 
 length of the vibrations of the air in the pulmonary 
 tissue, but also upon the facility with which the vibra- 
 tions pass through the tissues, the different notes Ave 
 obtain in percussion of the thorax are modified by the 
 soft parts of the chest, the bony thorax and the patho- 
 logic conditions in the jsleura and pulmonary tissue. 
 
 From a diagnostic standpoint, variation in pitch is 
 the most important of all changes that occur in the per- 
 cussion sound, as it shows the physical condition of the 
 part percussed. 
 
 The duration of sound depends upon the length of the 
 
 Fig. 13. 
 
 Flatness. 
 
 
 
 \Dull 
 
 \ 
 
 tone. 
 
 
 \ 
 
 v^Trael 
 
 \ 
 
 eal or tubular tone. 
 
 
 
 
 \ 
 
 Resonant tone. 
 
 
 
 ^xTympanitic tone 
 
 Volume and duration. 
 Diag:rainniatie sketch of the relations of the character of tone. The perpen- 
 dicular line represents the pitch. The transverse line the 
 volume and duration. 
 
 waves and their persistence, and varies directly with 
 the pitch and intensity. 
 
 The elements of sound have a definite relationship to 
 each other. (Fig. 13.) Sounds that have the highest 
 pitch have the least intensity and minimum duration 
 and resonance. Such a soimd is described as flat or 
 airless. 
 
 As the pitch becomes lower the intensity increases, 
 duration lengthens, quality of resonance becomes more 
 marked and the sound is described as dull, resonant or 
 tympanitic, according to the pitch. 
 
72 THE BESPIBATOBY SYSTEM. 
 
 JSTormal pvilmonary resonance has a quality character- 
 istic enough to be easily recognized, although impossible 
 to describe, low pitch, grea-t intensity and duration. 
 
 It is this combination of the elements of sound that 
 is described by the "clearness" of the note. 
 
 As these elements vary, the various pathological 
 types are produced. 
 
 METHODS OF PERCUSSION. 
 
 In order to elicit soimds from the air-containing 
 spaces of the lungs by percussion, vibrations are set up 
 in the chest in a number of different ways : 
 
 (1) Immediate, or Direct Percussion. — This was first 
 used by Auenbrugger, in 1Y61. In this method the 
 blow is struck directly upon the chest wall, generally 
 over the bony structures. The sound produced is 
 chiefly that made by striking the bony thorax, and its 
 value is to show the ease with which the thorax itself is 
 thrown into vibration. Light immediate percussion 
 over the clavicle is especially sensitive in showing slight 
 differences in resonance at the apex of the lung in begin- 
 ning tuberculosis when no change can be detected by 
 mediate percussion. 
 
 (2) Mediate, or Indirect Percussion. — In this method 
 the blow is struck not directly upon the thorax, but upon 
 some interposed medium, which is called the pleximeter. 
 In this country a finger of the left hand, either the index 
 or the second, is generally used as the pleximeter, but 
 some examiners use in its place pleximeters made of 
 various substances, as ivory, wood or other material that 
 has a certain amount of elasticity. 
 
 Tt is important that the student become familiar with 
 a single method. If he is constantly siibstituting for 
 the finger the ivory or wood pleximeter, he does not 
 become proficient in any one method, and is confused by 
 the sounds elicited. Ordinarily one of the hardest 
 things for the student to ignore in percussion is the 
 
PERCUSSION. ' 73 
 
 sound produced by striking the pleximeter, which, in 
 instruments made of ivory, etc., is especially marked, 
 and is one of the chief objections to their use. 
 
 The finger, on the contrary, has a structure homo- 
 genous with that of the thorax, and does not add a new 
 quality to the percussion note. After a certain amount 
 of practice, this sound is ig-nored, and only that which 
 is elicited from the deeper portion of the thorax noted. 
 As a pleximeter, the fingers give a wider range in size 
 and shape, and readily adapt themselves to the surface 
 of the thorax. 
 
 It is a matter of choice which finger of the left hand 
 is selected for this purpose, as all have been advised, 
 but whichever is selected, that one should always be 
 used. The other fingers and the hand should be raised 
 from the chest so as not to dampen the vibrations. The 
 finger used should be applied firmly enough to hold the 
 soft parts in place and to leave no space between the 
 finger and the soft parts, as this will give an impure or 
 "cracked-pot" sound. 
 
 In addition to the above advantages, the finger also 
 allows the examiner to note the resistance of the tissue 
 percussed and any lack of vibration, so that in percussing 
 the chest one frequently feels more than he hears. 
 
 Accurate comparative percussion requires that the 
 finger be applied to corresponding spots on the two 
 sides. If percussion on one side is over the rib or inter- 
 space, it should be made over the same tissues on the 
 opposite side, and the same amount of pressure should 
 be used. 
 
 To obtain the purest pulmonai-y resonance, the finger 
 should not be placed upon the bony thorax, but in the 
 interspace. The reason for this will be considered 
 later. 
 
 That with which the blow is struck is called the 
 plessor. For this purpose may be used the finger or 
 fingers of the right hand, or a small hammer of ivory, 
 wood or some other elastic substance. Many hammers 
 
74 
 
 THE RESPIEATOEY SYSTEM. 
 
 have been advised, and the virtues of each one has been 
 extolled by the inventor, but all are inferior to the finger, 
 although proficiency in finger percussion is harder to 
 attain, and demands no little practice. Ordinarily the 
 failure to appreciate the value of percussion as a means 
 of diagnosis is due to imperfect technique. The fingers 
 are bent in a crooked and imeasy position; the whole 
 arm is then moved, and the blow is struck from the 
 elbow. This blow is necessarily a heavy one, and, on 
 account of the infrequency with which it is struck and 
 
 Fio. 14. 
 
 Showing position of fingers in percussion. 
 
 the length of time that the percussing finger rests upon 
 the pleximeter, suitable vibrations are not set up in the 
 chest wall. 
 
 To get the clearest sounds, it is necessarv that the 
 fingers be bent from the second joint, so that the tips of 
 the fingers are even, and they must strike squarely and 
 quite vertically upon the pleximeter. The blow should 
 be struck entirely from the wrist, and should be a short 
 sharp tap, the percussing finger or fingers resting but a 
 
PEBCmSION. 
 
 ib 
 
 short time upon the finger struck. TFig. 1-1.) Light 
 percussion can be performed by a motion of the finger 
 only. Care should be taken by the beginner that the 
 nail of the hammer finger does not strike directly upon 
 the underlying finger. The blow should be struck with 
 the rounded end of the finger, just as it curves to meet 
 the palmar surface. 
 
 A good way of obtaining the wrist motion is by plac- 
 ing the entire arm flat upon the leaf of a table and strik- 
 ing it from the wrist from forty to eighty times a 
 
 Fig. 15. 
 
 minute. (Figs. 15 and 16.) The resonant table leaf 
 readily shows by the sound any variation in the force or 
 frequency of the blow. It is well also for the student to 
 stand close to a wall, facing it, and, applying the arm 
 to the wall, perform the same motions, so as to accustom 
 himself to percussing in different positions. 
 
 The rapidity with which the blow is struck has a 
 marked influence iipon the amount of sound produced. 
 In certain cases single blows, with long intervals 
 between, are used for the purpose of determining the 
 
76 
 
 THE RESPIRATORY SYSTEM. 
 
 ease with which the thorax is thrown into vibration. 
 When they are struck with medium rapidity (but not 
 less than forty to the minute), the vibrations reach the 
 deeper portion of the lung with equal strength and a 
 clear note is obtained. When the blows are struck too 
 rapidly, there is an accumulation, so to speak, of vibra- 
 tions, and there occurs an interference of the sound 
 waves. 
 
 The force of the blow should be the same over corre- 
 sponding portions of the two sides. 
 
 Fig. 16. 
 
 A correct position for the patient is almost as impor- 
 tant as the technique of the operator. The surface 
 should be bare, but if this is undesirable, then the 
 covering should be as thin and soft as possible. Males 
 do not object to being stripped to the waist for examina- 
 tion, but in the female, and especially the young, it is 
 best to have the surface protected by a soft, thin dress, 
 sack or shawl. 
 
 Whether standing, sitting or l.ying, the patient shoiild 
 assume a perfectly easy and natural position, with the 
 muscles relaxed and the positions of the two sides 
 
PERCUSSION. 7 1 
 
 symmetrical. While the standing posture is the most 
 convenient for the examiner, it is best to examine 
 patients who are weak in either the sitting or lying 
 position, as the pressure of the finger on the chest is apt 
 to cause them to sway, or, to prevent this, they brace 
 themselves, and so cause uneven tension of the muscles 
 of the two sides. In examining patients in bed, care 
 should be taken that the body is straight and the shoul- 
 ders not unevenly placed. 
 
 It should be remembered that when the patient is in 
 bed and surrounded by pillows, the character of the per- 
 cussion sound will be somewhat changed, being slightly 
 muffled ; also that the percussion outline of the organs is 
 modified by their "passive mobility." 
 
 When percussing the front of the thorax, the patient's 
 arms should hang easily at the side, and the head should 
 be held straight in the median line. The patient, in 
 order to avoid breathing in the examiner's face, fre- 
 quently turns the face sharply to one side, rendering 
 percussion above the clavicle difficult, and the result- 
 ing tension of the muscles changes the soimd of the 
 two sides. To percuss the axillary space, the arm 
 should be moved slightly backward, or raised at a right 
 angle to the body, with the hand resting on the head, so 
 as to relieve the tension of the muscles. 
 
 When percussing the .back, as the heavy muscles and 
 scapula interfere with the pulmonary tissue underneath, 
 the shoulder blades are carried forward toward the 
 axillary space by folding the arms across the chest, with 
 the tips of the fingers resting on opposite shoulders. 
 Or, when sitting, the arms may hang loosely between 
 the knees, allowing the shoulders to drop forward as 
 much as possible. These positions uncover a large por- 
 tion of the thorax, and the line of the scapula corre- 
 sponds to the lower border of the upper lobe and inter- 
 lobular septiim. 
 
T8 THE BESPIRATOKr HYSTEM. 
 
 CONDITIONS MODIFYING PERCUSSION SOUND. 
 
 As the object of percussion is to elicit sound from the 
 deeper portion of the thoracic cavity, it is necessary to 
 consider the influences that the different structures have 
 upon the vibrations that are set up. 
 
 (1) Influence of the Soft Parts. — The ease v?ith which 
 the soft parts are thrown into vibration depends largely 
 upon their structure. Muscular tissue, on account of 
 its tension, is easily influenced, so that, with the bony 
 thorax chiefly covered with muscle, vibrations are 
 readily conveyed to the deeper portions of the chest. 
 On that part of the thorax where the muscle tissue is 
 heavy, blows that would be suflicient to set up vibrations 
 in the air-containing spaces below the thinly-covered 
 portion are absorbed by the heavy muscle, and no sound 
 is heard. 
 
 Adipose tissue, on account of its lack of elasticity, is 
 thrown into vibration with difliculty, while cedematous 
 tissue is the most difiicult of all to influence by ordinary 
 percussion. The effect that the soft parts have upon 
 vibration is clearly shown in Fig. 17. 
 
 In order to overcome this interference of the soft 
 parts with the transmission of vibration, it is necessary 
 that the percussion be more forcible, as shown in Fig. 
 17. 
 
 It is thus easily perceived that percussion of the same 
 strength will not elicit the same soimd over all portions 
 of the chest, irrespective of the condition of the lung 
 itself. Where muscle or adipose tissue is thinnest a 
 fairly good pulmonary resonance may be obtained with 
 light percussion, while, on the other hand, where the 
 muscle or fat is thick, as over the mammae and the heavy 
 muscles of the back, very forcible percussion is neces- 
 sary, and the sound obtained is the dull, high-pitched 
 note of the solid structures with little pulmonary 
 resonance. 
 
 The student must be on his guard to differentiate 
 
PERCUSSION. 
 
 79 
 
 between dull, high-pitclied notes that are obtained by 
 percussion over the thick soft parts from the dullness 
 that is due to intrathoracic changes. 
 
 (2) The Influence of the Bony Thorax. — Bony tissue, 
 
 Fig. 17. 
 
 1 2 and 3 represent the difference ot result of percussion notes of equal 
 strength, but with different body thielcnesses. 3 and 4 show how by increasing 
 the force of the blow lung resonance is obtained. 
 
8 THE BESFIBA TOR Y SYSTEM. 
 
 when thinly covered, gives a peculiar note of its own 
 when struck. The bony thorax is easily thrown into 
 vibration, and if the blow be struck upon a rib the vibra- 
 tions that are set up are not only transmitted to the 
 viscera underneath, but are conveyed along the ribs to 
 the sternum and other bony portions of the thorax. 
 
 The readiness with which the bony thorax takes up 
 vibrations must also be considered in the force of the 
 blow. If the blow is very forcible, the whole of one 
 side of the thorax may be thrown into vibration, and 
 then, instead of obtaining sound from the portion 
 immediately underneath the part struck, vibrations are 
 obtained from the whole of the thorax, the sternum act- 
 ing as a sounding board. Forcible percussion over the 
 clavicle, on account of the conveyance of the vibrations 
 to the sternum and through it to the general thorax, is 
 used merely to indicate the condition of one side of the 
 chest as compared with the other, and is of little value 
 as indicating the condition of the tissue immediately 
 underneath it. A marked consolidation of one lung, or 
 a collection of fluid in the pleural cavity, makes the 
 percussion of the clavicle on the affected side much 
 duller. 
 
 Percussion over the sternum is resonant, with a 
 peculiar bony note. The sternum acts as a sounding 
 board, and is influenced to a slight extent only by the 
 normal underlying tissue. When the normal resonance 
 of the sternum is diminished and a dull sound is 
 obtained, it shows that these vibrations are interfered 
 with by intrathoracic conditions, that replace the ante- 
 rior edges of the lung, solid growths in the mediastinum, 
 by fluid accumulations in pericardium, or by aneurysmal 
 dilatation of the aorta. 
 
 The ease with which the bony thorax is thrown into 
 vibration varies at different periods of life. 
 
 In the child, on account of the flexibility of the ribs 
 vibrations are easily conveyed to the underlying lung, 
 and a clear, well-defined pulmonary resonance is 
 
PERCUSSION. 81 
 
 obtained, scarcely modified by the sound given off by the 
 bony thorax. Percussion in children should, therefore, 
 be light, otherwise diffuse vibrations are set up and reso- 
 nance is obtained from a large extent of lung tissue. 
 
 As the bones of the thorax become more rigid, espe- 
 cially in old age, the bony sound becomes more marked, 
 and there is a raising of pitch, so that it is described as 
 a boardy or wooden note. 
 
 (3) Influence of the Pleura. — The normal pleura has 
 practically no effect on the vibrations produced by per- 
 cussion, but pathological changes which cause thickening 
 influence them in a marked degree. 
 
 On account of the close relation that the pleura bears 
 to the ribs, a very slight thickening is sufficient to inter- 
 fere with the vibrations that are set up by percussion of 
 the overlying structures. This is detected not only in 
 the sound elicited, but in a peculiar "hard feeling" 
 imparted to the fingers. The ordinary springy condi- 
 tion is changed to one of increased resistance, and 
 varies in degree according to the characters of the 
 changes in the pleura. 
 
 When the thickening is caused by new tissue homo- 
 geneous with the pleura, then its influence is slight. 
 If, however, a thick layer of plastic exudation covers the 
 surface, then the dullness will be in direct proportion to 
 its thickness. 
 
 A collection of fluid within the sac renders the note 
 flat, the feeling being similar to that noticed when the 
 thigh is struck. 
 
 In order to determine whether or not the variation in 
 the resonance is due to pleuritic thickening or to changes 
 in the pulmonary tissiie, the effect of percussion of dif- 
 ferent degrees of force must be used. 
 
 Light percussion will be markedly influenced by 
 slight pleuritic thickening, while in very forcible per- 
 cussion the vibrations are so strong as not to be inter- 
 fered with to any appreciable extent. This is shown 
 in Figs. 18 and 19. 
 6 
 
82 THE BESPIBATORY SYSTEM. 
 
 (4) Influence of the Pulmonary Tissue. — ^The resonance 
 that is obtained from the thorax is dne to the lung being 
 an air-containing organ, and the elements of sound 
 depend largely upon the condition of the tissues of the 
 lung itself and the amount of air contained. 
 
 1 and 2 show effect of weak percussion over pleu™. 3 and 4 show effect of 
 strong percussion over pleurse. 
 
PERCUSSION. 83 
 
 ^ The walls of the alveoli, on account of their marked 
 distension and the tension, are easily thrown into vibra- 
 tion, giving a sound with a characteristic quality, low 
 pitched, of great intensity and duration — the normal 
 pulmonary sound or resonance. 
 
 (a) Change in Tension. — Increase in tension of the 
 pulmonary tissue causes an exaggeration of the normal 
 resonance. The two conditions in which this occurs are 
 in acute compensatory emphysema of the lung before 
 the duration of the distension has allowed of permanent 
 dilatation, and in children where there is marked 
 elasticity of the alveoli walls and relative overdistension 
 of the lu.ng. 
 
 The slight change in the tension of the lung that 
 occurs at the end of full inspiration and expiration 
 causes a slight variation in the resonance. It is most 
 marked at the borders of the lung. 
 
 Decrease in the tension of the pulmonary tissue gives 
 a tympanitic quality to the sound. The change in ten- 
 sion may involve both lungs, and be due to pathological 
 changes in the pulmonary tissue, decreasing its elas- 
 ticity, as in emphysema. 
 
 The tension of the lung is also lowered by marked 
 upward displacement of the diaphragm, as it occurs in 
 increased intra-abdominal pressure from ascites, tumors, 
 etc. The tension of the lung is also relaxed by any 
 accumulation of fluid in the pleural sacs. In old age 
 not only is the pulmonary elasticity diminished, with a 
 lowering of tension, but the rigidity of the thoracic wall 
 causes the percussion note to have a peculiar tympanitic 
 quality. 
 
 The changes in tension may be local, as occurs over 
 the affected area during the first and third stages of 
 croupous pneiimonia and in the unaffected portions of 
 the lung on the same side during the second stage, due 
 to enlargement of affected portion. This is most 
 marked when the entire lower lobe is involved. When 
 the pleural cavity is sufficiently filled with fluid to 
 
84 THE BESPIBATOBY SYSTEM. 
 
 allow of relaxation of the lung, the same condition 
 occurs. The peculiar tympanitic resonance over the 
 relaxed portion of the lung in the second stage of pneu- 
 monia, and in pleurisy with effusion, has been named 
 Skoda's resonance. 
 
 One of the earliest signs of tubercular infiltration of 
 a portion of the lung, especially when it affects the apex, 
 is the slight tympanitic quality of the percussion note. 
 
 The influence of diminution in the pulmonary tension 
 upon the percussion note of the thorax demands further 
 consideration. 
 
 In the normal chest, when the blow is struck upon the 
 bony thorax, the negative pressure or suction action of 
 the lungs causes a movement inward of the ribs, while 
 at the same time it prevents a corresponding free out- 
 ward rebound. This has the effect of dampening the 
 vibrations of the bony thorax. The sound obtained is 
 that of the pulmonary tissue, modified to but a slight 
 extent by the peculiar sound of the bony thorax. 
 
 With diminished elasticity of the lung and decrease 
 in the negative pressure, when, the bony thorax is per- 
 cu^ssed its movements are not infiuenced to the same 
 degree by the lung, and the percussion note contains a 
 larger proportion of the bony quality and pitch; while 
 at the same time the pitch of the pulmonary resonance 
 is lower, and the sound obtained is described as slightly 
 high pitched, wooden or boardy. 
 
 In percvissing the thorax in diseases in which a 
 lowering of the tension occurs, the examiner must 
 exclude the bony quality of the sound and heightening 
 of the pitch that occurs. 
 
 (b) Change in Amount of Pulmonary Tissue. — 
 Increase in the amount of pulmonary tissue in any por- 
 tion of the lung, whether or not it diminishes the air- 
 containing space, produces a change in resonance. 
 This change is described as dullness, and is character- 
 ized by heightening of the pitch and a peculiar harden- 
 ing of the quality, with diminished intensity and 
 
PERCUSSION. 85 
 
 duration. If the size of the air-containing spaces be 
 decreased at the same time that the solid structures of 
 the lung are increased, the diminiition of resonance 
 would be in direct proportion to the changes. When 
 the tension of the tissue is higher than normal, the pitch 
 will be markedly raised; while, on the other hand, if 
 there is marked relaxation, the dullness Avill be attended 
 with a lowering of the pitch and will have a tympanitic 
 quality. 
 
 Increase in the tissue of the lung relative to the air- 
 containing spaces occurs with fibrosis, where the normal 
 structures are increased either as a result of germ infec- 
 tion, especially by the tubercle bacilli, or of mechanical 
 irritation, as in the conditions classified under janeumo- 
 coniosis. 
 
 (c) Changes in the Aie-Containing Spaces. — 
 Increase in the size of the air-containing spaces and the 
 amount of air contained in the hmg causes a marked 
 augmentation of the resonance produced by percussion, 
 and the quality of the sound will depend upon the 
 physical condition of the pulmonary tissue. With the 
 enlargement of the air spaces, if the tension of the pul- 
 monary tissue is increased, as occurs in compensatory 
 emphysema and in acute asthma, the pitch is slightly 
 raised and the soimd is abnormally clear. When, on 
 the other hand, the pulmonary tissue is relaxed, as in 
 large lung and in the senile form of emphysema, the 
 pitch is lowered and of a tympanitic character, giving 
 the typical emphysematous or "band-box" percussion 
 note. 
 
 When destruction of a portion of the lung tissue 
 occurs, forming large air-containing spaces or cavities, 
 the percussion sound will depend upon their situation, 
 size, form, condition of the walls and the surrounding 
 tissue, and whether or not it is open or closed and the 
 amount of fluid contained. 
 
 Cavities lying close to the surface, and especially at 
 the apex, and opening more or less directly into a 
 
8 6 THE BE8PIRA TOR Y SYSTEM. 
 
 medium-sized bronclius, give the most marked sound, 
 and those the size of a walnut can be detected by per- 
 cussion. When situated deeper in the lung, and sur- 
 rounded by fairly normal lung tissue, only a faint 
 tympanitic quality may be noted. When covered by 
 thickened lung tissue, or by thickened pleura, the sound 
 becomes dull and at the same time slightly tympanitic. 
 This has been variously described as boardy tympanitic, 
 dull tympanitic, etc. The influence of the overlying 
 tissue may be so great that no cavity sound can be 
 obtained. (Fig. 20.) 
 
 When the walls of the cavity are rigid, the pitch of 
 the sound changes. In those with lax walls the sound is 
 described as cavernous. The quality is tympanitic ; the 
 pitch is low, with intensity and duration proportionate. 
 In those with tense, rigid walls it is described as 
 amphoric, with a more marked resonance and higher 
 pitch. These variations in sound are comparative; 
 the cavernous merges into the amphoric, and numerous 
 subdivisions have been made, as caverno-amphoric, etc. 
 
 When the bronchus leading to a cavity is closed, the 
 tympanitic sound is less marked, and the sound is duller 
 and high pitched. 
 
 Certain peculiar changes have been detected over 
 cavities : 
 
 Winteich's Change of Sound^ ok Foecibi.!: 
 Pitch.- — In cavities opening into a large bronchus, and 
 situated near the surface of the lung, a change of pitch 
 is noted when percussion is made with the mouth open 
 or shut. When the mouth is wide open, it is high 
 pitched, and more tympanitic than when the mouth is 
 closed. Frequently cavities that give no distinguishing 
 feature when the mouth is closed are easily detected 
 when the mouth is open. 
 
 Geehaedt's Change of Sounu. — At times the 
 pitch and intensity of the tympanitic sound over a 
 cavity changes with the posture of the patient. Various 
 explanations have been given of this phenomenon but 
 
PERCUSSION. 87 
 
 it is probably due to alterations in size and form of the 
 cavity, its relation to the chest wall and the connecting 
 bronchus. The sign is not often detected, but when 
 present is diagnostic of a cavity. 
 
 Feiedeicii's Kespieatoey Change of Sound. — 
 This is noted when percussion is made during forcible 
 inspiration and expiration, and is dependent upon the 
 changes that occur in the size of the cavity and the 
 tension of its walls. 
 
 The Ceacked-Pot Sound. — This is a peculiar 
 "clinking" sound heard when forcible percussion is 
 made over a cavity connecting directly with bronchiis 
 during expiration with the mouth open, and is most 
 easily obtained when the cavity is situated in the upper 
 portion of the lung and the chest walls are flexible. This 
 sound can be imitated by loosely clasping the hands 
 with palmar surfaces slightly touching and forcibly 
 striking the back of one hand on the knee, thus forcing 
 the air through the narrow chink formed. This sound, 
 while most frequently found in cavity formation, may 
 be produced by forcible percussion in the normal lung 
 when the thorax is very elastic, as in children. 
 
 Decrease in Size. — As the pulmonary resonance is 
 due to the air contained in the lung, diminution in the 
 amount will be attended by a corresponding decrease of 
 resonance. If the displacement of the air is complete, 
 then percussion of that portion of the lung will be 
 similar to that obtained over any solid, airless tissue, as 
 the thigh or liver, and the sound will be designated as 
 flat. 
 
 It is necessary that a clear distinction be made 
 between dullness and flatness. As long as any reso- 
 nance can be detected, the term dullness must be used 
 with some qualifying word denoting its degree. Flat- 
 ness means that the sound is absolutely devoid of any 
 resonance. 
 
 It is rare for pulmonary consolidation to give a per- 
 
8S 
 
 THE RESPIUATORY SYSTEBL 
 
 foc'tlj flat note, as there is usually enough air in the 
 
 bronchi of tlie affected ])ortion to give slight resonance. 
 
 Liquid effusions and solid groAvths in the pleural 
 
 Fig. 19. 
 
 T^ormal 
 
 Dulness 
 
 Flatness 
 
 mat 
 
 Impaired 
 
 Normal 
 
 Changes in percussion note. 
 
 cavity, on tlic other haiul, are frequently large enouo-h 
 to give a perfectly flat sound. ° 
 
PERCUSSION. 
 
 89 
 
 The percussion note obtained when the lung has been 
 rendered more or less airless or solid depends upon the 
 seat of the consolidation. If the consolidated area is 
 
 Fig. 20. 
 
 Deep Seated Consolidation 
 masked by 
 Emphysematous Lung 
 
 Localized Emphysema 
 
 Compensatory 
 
 to 
 
 Consolidation 
 
 (Dulness) 
 
 Dulness with 
 Tympanitic quality 
 
 close to the surface, immediately underneath the pleura, 
 its influence upon the resonance would be marked, and 
 
90 THE BESPIBATOBY SYSTEM. 
 
 it can be best detected by ligbt ratber than by heavy 
 percussion. If, on the other hand, it is situated deeper 
 in the lung, and separated from the pleura and bony 
 thorax by a zone of air-containing lung, then, in direct 
 proportion to its depth, will it influence the resonance 
 obtained, and more forcible percussion is needed. This 
 can be best understood by referring to Figs. 19 and 20. 
 
 (5) Influence of Heart and Liver. — The resonance 
 of the lung is impaired by the solid structures (heart 
 and liver) that are covered to a greater or less extent 
 by pulmonary tissue. The extent and degree of the 
 dullness will depend upon the size and mobility of the 
 lung on the one hand and that of the solid organs on the 
 other. 
 
 The dullness that is detected over these organs, which 
 gradually increases in degree until it merges into the 
 perfectly flat sound of the organ itself, is known as rela- 
 tive cardiac and liver dullness. The influence of these 
 organs upon the resonance and force of the blow neces- 
 sary to elicit this relative dullness is indicated by Figs. 
 21 and 22. 
 
 The normal boundaries of these areas and the diag- 
 nostic significance of changes in extent are discussed 
 under "Percussion," Parts III and IV. 
 
 INDIVIDUAL AND REGIONAL VARIATIONS OF 
 PERCUSSION SOUND. 
 
 From what has been said about influence of the dif- 
 ferent structures upon the percussion note, it is readily 
 appreciated that no standard can be set. Each 
 patient will have an individual variation within the 
 range of normal, as the soft parts are thick or thin, the 
 bony thorax flexible or rigid, the lungs large or small, 
 with high or low tension, and, in addition, the sound 
 will vary according to the portion of the thorax per- 
 cussed. 
 
 As the value of percussion lies in the comparison of 
 
PERCUSSION. 
 
 91 
 
 the note obtained over corresponding spots on the two 
 sides, it is necessary to keep in mind the normal varia- 
 tions that occur over these spots. 
 
 The percussion note over the right hmg, from the 
 apex to the second interspace in the axiUary line, is 
 slightly higher in pitch, and duller than on the left side. 
 This is due to the bronchi on the right side being rcla- 
 
 FlG. 21. 
 
 Absolvite anil ivl.ative heart and liver dullness, also regional variation 
 in tliorax. 
 
 tively larger and nearer the surface. The change in 
 percussion corresponds to the increase in vocal fremitus 
 over the same area. 
 
 The percussion note on the right side from the fourth 
 interspace is modified by the relative liver dullness, 
 while on the left side, beginning at the third interspace, 
 close to the sternum, and corresponding to the site of 
 
92 
 
 THE EESPIEATORY SYSTEM. 
 
 tlie lieart, the cai-diac flatness and relative dullness is 
 present. These variations are noted in Fig. 21. 
 
 PERCUSSION OUTLINES OF THE LUNG. 
 
 Percnssion gives valuable information concerning the 
 size and mohility of the lung, and no examination is 
 complete unless the percussion OTitline of the borders of 
 
 Fig. 22. 
 
 Peroussioil outline of the limg {anterioi;. 
 
 the lung during inspiration and expiration is deter- 
 mined. 
 
 The only boimdaries or borders that can be definitely 
 mapped out by percussion are a superior and inferior, 
 and that portion of the anterior that is uncovered by the 
 sternum and overlies the heart. At the end of quiet 
 
PERCUSSION. 
 
 93 
 
 inspiration tlie superior liorder of the lung readies two 
 or tliree ceutinieters above the ehivicle, occupying the 
 supraclavicuhir space. 
 
 With full inspiration, the superior border is carried 
 a finger to a tiiiger and a lialf liigher, and the s])ace is 
 filled out in all directions; while the percussion note is 
 clearer and fuller from the increased tension of the 
 
 Fig. 2:?. 
 
 Perourtsion outline of the lun}^ (posterior). 
 
 pulmonary tissue and enlargement of the air S2)aces. 
 The su])erior border does not rise as high when there is 
 ])leuritic thickening and adhesions. In emphysema the 
 superior border is higher than normal with expiration, 
 but there is not a corresponding increase in size during 
 inspiration, and the note has a tympanitic quality, with 
 but slight change at the end of full inspiration. The 
 
94 THE BE8PIBAT0RY SYSTEM. 
 
 inferior borders on the two sides are slightly different. 
 On the right side, starting from the base of the xiphoid 
 cartilage, it ciirves obliquely downward and outward 
 across the sixth rib in the axillary line, the tenth rib in 
 the scapular line, and meets the vertebral column at the 
 junction of the eleventh rib. 
 
 On the left side, the inferior border can only be 
 determined in the axillary line, as the presence of the 
 stomach renders its detection in the mammary line 
 difficult. (Figs. 22 and 23.) 
 
 AUSCULTATORY PERCUSSION (Stethoscopic Percussion) 
 
 In this method the chest piece of the stethoscope is 
 placed upon the chest over the organ that is under 
 examination; mediate and immediate percussion is 
 made from a distance toward the point where the stetho- 
 scope rests, and the variations in the sound are noted. 
 When the percussion is made directly over the organ, a 
 marked increase in the intensity of the vibrations is 
 both heard and felt. 
 
 Within certain limitations, it is a valuable method of 
 examination, allowing of a differentiation between con- 
 ditions giving the same sound, as between the flatness of 
 the heart and liver where the two organs are contiguous ; 
 between right-side pleurisy with effusion, pulmonary 
 consolidation and liver flatness. 
 
 In order to be of use, the chest piece of the stethoscope 
 should be small and rest wholly over the organ under 
 examination. A special part to replace the ordinary 
 chest piece should be used, so as to allow of its being 
 placed between the ribs, thus avoiding the vibrations 
 readily conveyed by the bony thorax. The percussion 
 should be light, and, as the value is comparative, the 
 points percussed should be equally distant from the tip 
 of the stethoscope. 
 
 Another method which I have found very sensitive, 
 and which avoids the vibrations of the bony thorax, is 
 
PERCUSSION. 05 
 
 to listen to the percussion note with the chest piece of 
 the stethoscope not touching the surface, but held just 
 above and close to the point of percussion. In mapping 
 
 Fig. 24. 
 
 Auscultatory percussion. 
 
 out the relative dullness of the heart and liver, it is 
 more definite than vrhen chest piece rests on the bony 
 thorax. (Fig. 24.) 
 
CHAP TEE V. 
 
 AUSCULTATION. 
 
 Auscultation of the lungs is the act of listening at 
 the surface for the sounds made within the thorax dur- 
 ing the act of breathing, and may be performed in two 
 ways : Immediate, in which the ear is placed directly 
 upon the chest which is protected by a thin covering. 
 Mediate, in which one of the different forms of stetho- 
 scope is used. 
 
 Each method has its advocates, and both are useful. 
 The advantages of immediate aiiscultation are that (a) 
 there are no modifications of sound occurring through 
 the use of instruments ; (b) the ear appreciates bolter 
 the slight changes in the normal elements of the sound ; 
 (c) the ear notes the movements of the thorax, which 
 occur at the time the sound is heard; (d) there is less 
 exposure of the surface. 
 
 The advantages of the use of the stethoscope, or 
 mediate auscultation, are : (a) It is easier to examine 
 certain portions of the chest more or less inaccessible to 
 the ear, as the supraclavicular fossa; (b) it limits the 
 sphere of examination to the small area covered by the 
 chest piece of the stethoscope; (c) delicacy often dic- 
 tates its use over certain portions of the body, as the 
 breasts ; (d) the examiner avoids infection and contami- 
 nation by parasites. 
 
 The disadvantages are that certain elements of sound 
 are modified or distorted by the resonance of the instru- 
 ment used, and many extraneous sounds are also intro- 
 duced, as rubbing or scratching frictions sounds made 
 by the rubbing of the stethoscope on the surface, and 
 muscle sounds or creakings are intensified. Children 
 
avscuLtation. 97 
 
 are often frightened by use of an instrnment. Where 
 a person is very thin, it is impossible to have the stetho- 
 scope fit closely to the surface, and so to exclude the 
 sounds present in the room. 
 
 Students should be thoroughly familiar with the 
 sounds obtained by the direct method, and should use 
 the indirect for certain special purposes only. 
 
 To auscultate satisfactorily, attention should be given 
 to the position of the patient. Both sides of the chest 
 should have opportunity to move with equal freedom. 
 The patient should breathe naturally, and care should be 
 taken that inspiration and expiration are not noisy. It 
 is imj)ossible for many persons to breathe naturally 
 when their attention is called to the act. Usually the 
 inspiration is taken quickly and forcibly; the breath is 
 held for an appreciable time, and then either forced out 
 rapidly or allowed to escape so slowly that no sound is 
 heard. In nervous patients fairly natural breathing 
 may be obtained after coughing, or by having the patient 
 first talk for a certain time. All constricting clothing, 
 as stays, etc., should be removed, so that the chest may 
 be as nearly normal as possible. As the value of 
 auscultation is comparative, symmetrical points on the 
 two sides should be examined and the differences noted. 
 
 PHYSIOLOGY OF NORMAL BREATH SOUNDS. 
 
 It is necessary to have a clear understanding of the 
 manner in which the normal respiratory murmurs, or 
 breath sounds, are produced in order to appreciate and 
 correctly interpret the variations that are heard over the 
 different portions of the lung in health and the altera- 
 tions that occur in disease. 
 
 As the name implies, the breath sounds depend upon 
 the respiratory movement, and necessarily occur only 
 during inspiration and expiration. The modifications 
 of these sounds heard over the different portions of the 
 chest may be divided into two grquj)?: ^^^ 
 7 
 
9 8 THE BE8PIRA TOB Y SYSTEM. 
 
 (A) Those which depend upon the variations in the 
 normal sounds. These variations are limited to (a) 
 quality or character, (h) intensity, (c) pitch, (d) dura- 
 tion, (e) rhythm, (f) the relative length of expiration 
 and inspiration to each other. 
 
 (B) To the production of new or adventitious sounds 
 or rales, which may be dry or moist, friction, etc. See 
 page 112. 
 
 During inspiration enlargement of the thoracic cavity 
 occurs in all directions, causing (a) movement of air in 
 the respiratory tract; (h) change in the tension of the 
 tissues forming the walls of the bronchi, bronchioles and 
 alveoli. 
 
 In quiet breathing 30 cubic inches of tidal air are 
 drawn into the respiratory tract during inspiration and 
 forced out during expiration, and, as the estimated 
 capacity of the larynx, trachea and bronchi is 10 cubic 
 inches, and that of the alveoli after quiet expiration is 
 150 cubic inches, it is evident that the tidal air is car- 
 ried even into the alveoli, and that there is aerial move- 
 ment throughout the entire respiratory tract. Passing 
 to and fro through the glottis, the tidal air is thrown 
 into vibrations that are intense enough to be audible. 
 
 Laryngeal Breath Sounds. — The sound produced at the 
 glottis is known as the laryngeal breath sound, and has 
 the following characteristics: It is heard with both 
 inspiration and expiration, but with a distinct break or 
 pause between them, as the inspiratory sound is not 
 audible during the latter part of the act. 
 
 The sounds produced during inspiration and expira- 
 tion are nearly equal in length, that of expiration being 
 slightly longer. The sound is harsh and blowing, the 
 quality being tubular ; the pitch is high, that of expira- 
 tion being harsher and higher pitched than that of 
 inspiration. 
 
 When the mouth is closed and the breathing is 
 through the nose, the sound produced is more intense. 
 
AUSCULTATION. 99 
 
 harsher and higher pitched, as the vibrations made at 
 the glottis are reinforced by those produced in the 
 pharynx. The laryngeal sound may be imitated by 
 placing the tongue in the position to pronounce "h" or 
 "ch" and brea:thing deeply and regularly. 
 
 The intensity and character of the laryngeal sounds 
 depend (a) upon the force and rapidity with which the 
 tidal air rushes through the glottis ; (h) the size of the 
 glottis ; (c) the position of the vocal cords ; (d) the con- 
 dition of the tissues of the larynx. Thus the sounds 
 vary to a certain extent in each individual. As the 
 vibrations made at the glottis are the basis of all sounds 
 normally heard over the lung, the laryngeal breath 
 sounds serve as a standard in each case by which an 
 estimate of what should be the normal intensity of the 
 respiratory sotmds heard over the other portions of the 
 chest. 
 
 The vibrations made at the glottis are conducted 
 through the respiratory tract simultaneously by two 
 channels: (1) Aerial, i. e., vibrations of columns of 
 air contained in the bronchi, bronchioles arid alveoli; 
 (2) the tissues of the walls of the bronchi, bronchioles 
 and alveoli. 
 
 Aerial Conduction. — The laryngeal sound is conducted 
 by the aerial vibrations through the trachea to its bifur- 
 cation into the primary bronchi almost unchanged, 
 except for a slight toning down of the harshness. The 
 laryngeal, or tracheal, sound represents the highest type 
 of tubular or bronchial breathing, and is normally heard 
 over the larynx and trachea; at times over the upper 
 portion of the sternum in front and over the vertebral 
 column as far as the fifth dorsal vertebra behind. It- 
 is heard over other regions of the chest only when patho- 
 logical changes have occurred in the respiratory tract, 
 that permit its conduction from its normal site to otbcT 
 areas. 
 
 At the bifurcation of the trachea, the column of mov- 
 ing arid vibrating air is divided into two uneven parts, 
 
100 THE BE8PIBAT0BY SYSTEM. 
 
 the larger passing to the right bronchus, the smaller to 
 the left. With this division certain changes occur, 
 which influence the aerial vibrations that have been 
 carried down from above. 
 
 (1) The united capacity of the two bronchi being 
 greater than that of the trachea, the force of the current 
 of tidal air is less. 
 
 (2) Eeflection, or reverberation of the laryngeal 
 vibration, which causes confusion of the sound. 
 
 (3) The impinging of the column of air on the angle 
 of bifurcation adds new vibrations and a new quality 
 of sound to that received from above. 
 
 Tissue Conduction. — The vibrations transmitted 
 through the walls of the trachea and bronchi convey the 
 laryngeal sound unchanged in quality, and but slightly 
 weakened. 
 
 The effect of these two series of vibrations is to so 
 modify the sound in the primary bronchi that it can be 
 distinguished as a type, i. e., bronchial breathing. 
 
 Bronchial breathing differs from the laryngeal sound 
 as follows : The tubular quality is slightly diminished, 
 and is less sharp, the change being most marked on 
 inspiration. The pitch is not as high, and there is a 
 corresponding loss in intensity and harshness. Inspira- 
 tion and expiration are nearly equal in duration, 
 expiration alone being slightly shortened, and the pause, 
 while present, is not so marked. 
 
 As the tidal air descends along the bronchial tract, at 
 each division of the column similar changes occur, as 
 at the bifurcation of the trachea. 
 
 The MoDiFicATioisrs of the Aeeial Vibrations that 
 occur in the different divisions of the bronchi are as 
 follows: (1) The increased capacity of the branching 
 tubes (a) reduces the force of the current in the tidal 
 air and (i) causes diffusion of the vibration. These 
 two factors lead to a loss of intensity in the sound 
 produced. 
 
 (2) The refraction or reverberation occurring in the 
 
AUSCULTATION. 101 
 
 broachi causes the tubular laryugeal sound to become 
 confused in character, the harsher tones being especially 
 modified, while the more musical elements persist. 
 This makes the pitch of the sound lower than tha;t 
 which is heard above the large bronchi and larynx. 
 
 Obliteration or change in the harsher qualities has 
 been variously explained, but the mere fact of their 
 loudness or harshness causes their reverberation to occur 
 more easily, and therefore the primary vibrations are 
 interfered with by the secondary vibrations of reverbera- 
 tion. 
 
 (3) At each bifurcation of the bronchi the moving 
 column of tidal air has sufficient force to set up new 
 vibrations, which, being added to those received from 
 above, modify the quality of the sounds ; and although 
 the sound remains tubular, it has a softer blowing 
 character. 
 
 The Modifications of Vibeatiobts theotjgh Tis- 
 sue Conduction. — The walls of the large and medium- 
 sized and cartilaginous bronchi are good conductors of 
 vibration. The change that occurs as the vibrations 
 are carried through the tissues of the different branches 
 of the bronchial tree is chiefly loss of intensity, but the 
 bronchial character persists. On account of the rigidity 
 of the bronchi, tissue vibrations are influenced but 
 slightly by the aerial vibrations within them. 
 
 As a result of these two classes of vibrations, aerial 
 and tissue, the sounds heard over all portions of the 
 bronchial tract will be more or less characteristic. The 
 pause between the inspiratory and expiratory sounds in 
 the larynx is well marked. This pause becomes less 
 and less marked the farther down the respiratory tract 
 the examination is made. This is due to the more 
 continuous movement of air during inspiration and 
 expiration in the lower divisions of the bronchi. Above 
 there is merely the tidal air going in and out; below 
 there is the more continuous movement of not only the 
 tidal air, but also the columns of residual air. During 
 
102 THE RESPIRATORY SYSTEM. 
 
 the latter portion of inspiration the air passes through 
 the glottis without setting up audible vibrations, while, 
 on the other hand, on account of the position of the 
 vocal cords during expiration, audible vibrations are 
 produced throughout the entire act. Lower down in 
 the bronchi the added vibrations cause a continuous 
 sound, increasing in intensity, to be made throughout 
 inspiration. While, on the other hand, in expiration 
 the current becomes progressively feebler. 
 
 In the larynx and large bronchi the tubular quality 
 of the sound is equal during inspiration and expiration. 
 Over each successive lower division of the bronchi the 
 inspiratory sounds lose their pure bronchial character, 
 while the expiratory sound retains it to a greater degree. 
 This difference in the amount of tubular element is due 
 to the fact that in inspiration new vibrations are added 
 at each division of the bronchi, which modify the 
 tubular quality. During expiration, on the other hand, 
 no new sounds are added. 
 
 If it were possible to apply the ear or the stethoscope 
 to the different subdivisions of the bronchial tree, each 
 would give its own peculiar type, having a characteristic 
 quality, pitch, intensity and duration. (Fig. 25.) 
 
 Certain pathological conditions allow these varying 
 degrees of bronchial breathing to be heard at the sur- 
 face, and according to the character of the sound heard 
 the nature and extent of the anatomical changes in the 
 lung are determined. 
 
 Chawges in the Broitchioles and Alveoli. — 
 From what has already been said of conduction of the 
 glottic vibrations by the air contained in the trachea and 
 bronchi, and by the walls of the tubes, and the modifica- 
 tions that occur in the sound in different portions of the 
 bronchial tract, it is easy to understand that still greater 
 modifications will take place in the bronchioles and 
 alveoli. As long as the divisions of the bronchial tubes 
 contain cartilage and muscular tissue, the vibrations 
 transmitted through the homogeneous tissue preserve in 
 
.1 USCUL TA TION. 103 
 
 a large measure the tubular quality of the laryngeal 
 sound, and are not easily modified by the aerial vibra- 
 tions. 
 
 "Below the diameter of 1-24 inch (1 mm.) the bron- 
 chial tubes have neither cartilages, mucous glands nor 
 any continuous muscular coat ; circular and longitudinal 
 elastic fibres replace the musciilar coat." (Powell.) 
 
 This change in the structure of the bronchi has a 
 marked influence on the conduction of the laryngeal 
 sounds onward towards the surface, which has been so 
 marked a feature of the vibrations transmitted by the 
 tissues. As the structure of the bronchioles and alveoli 
 becomes less and less homogeneous with that of the 
 larger bronchi, the vibrations received from above are 
 not conveyed so easily. The loss of the tissue vibration 
 causes a dampening of the tubular or bronchial quality 
 of the sound. As the structures of the bronchial tubes 
 and alveoli becomes more membranous and tense, they 
 are influenced to a greater degree by the aerial vibra- 
 tions. 
 
 The rapid breaking up of the smaller bronchi into 
 bronchioles causes a still more marked change in the 
 aerial vibrations received from above. They are dif- 
 fused, reflected again and again ; the sound is confused ; 
 the harsh tubular and blowing character is lost; the 
 softer, more continuous and rustling (musical) quality 
 alone remaining. 
 
 There has been much discussion whether the move- 
 ment of the tidal air in the bronchioles and its passage 
 into the alveoli is sufficient to produce audible vibra- 
 tions, and whether the sound heard at the surface of the 
 lung during inspiration is due entirely to the vibrations 
 made at the glottis, changed by transmission through the 
 lung, or is in part composed of vibrations made at the 
 junction of the bronchioles with their infundibuli. 
 Some claim that the sound heard at the surface during 
 inspiration is made in the alveoli. 
 
 After quiet expiration, the capacity of the alveoli is 
 
104 THE RESPIRATORY SYSTEM. 
 
 estimated at 150 cubic inches; the amount of tidal 
 air in quiet breathing is 30 cubic inches, which in forced 
 inspiration and expiration may reach 200 cubic inches 
 in man and 150 cubic inches in the female. _ There is 
 no question that it is possible for the tidal air to pass 
 from the narrow bronchioles into their relatively wide 
 infundibuli, and to produce vibrations which, if not 
 audible in themselves, would intensify in some respects 
 and modify in others the vibrations, already present, 
 which had their origin at the glottis. 
 
 The aerial vibrations, and especially those in the 
 alveoli, play an important part in the production of 
 the inspiratory sound heard at the surface. They 
 explain why the vesicular element is present to a greater 
 or less extent as long as tidal air reaches the alveoli, 
 even though changes in the stroma of the lung may 
 allow bronchial sound to be heard through tissue con- 
 duction, and why inspiration does not have as tubular a 
 quality as expiration. In inspiration through the 
 enlargement of the thoracic cavity the tissues of the 
 alveoli and bronchioles are rendered more tense, have 
 greater power of conduction, and are more easily thro"mi 
 into vibrations, so that there is a corresponding increase 
 in the intensity of the sound up to the end of the act. 
 
 Normal Respiratory Murmur. 
 
 Over the surface of the lung the breath sounds (the 
 respiratory murmur) have the following characteristics 
 or elements during inspiration: 
 
 The quality is variously described as breezy, rustling, 
 sighing, slightly shuffling or vesicular, corresponding to 
 the sound produced by regular and natural breathing 
 when the lips are placed in a position to pronounce "!F" 
 or "V." The pitch is low ; the intensity increases to the 
 end, and is heard throughout the act (duration). The 
 rhythm^ is regular. The sounds of inspiration and 
 expiration occur at regular intervals. 
 
AUSCULTATION. 105 
 
 All these elements of the respiratory murmur will 
 vary normally within Avide limits in different indi- 
 viduals, but will always have a definite relation to the 
 intensity of the sounds heard over the larynx and 
 trachea, as has already been noted. 
 
 The expiratory portion of the respiratory murmur 
 immediately follows that of inspiration, and differs in 
 the following respects: The quality is harder, the 
 breezy vesicular element being replaced by a slight 
 blowing sound; the pitch is higher;^ the intensity is 
 less, being loudest at the beginning and rapidly fading 
 out, so that its duration is only one-half to one-third 
 that of inspiration. 
 
 It is necessary to explain why these differences occur 
 in expiration in order to understand the occurrence of 
 pathological changes. 
 
 It has already been noted that inspiration is a 
 muscular act which continues until the thorax is fully 
 expanded. The laryngeal sound is made at the glottis, 
 and is conducted downwards by (1) the current of tidal 
 air which is towards the surface of the chest, and (2) 
 by the tissues in the bronchi, bronchioles and alveoli, the 
 tension of which increases to the end of the act. In 
 addition to the vibrations made at the glottis, other 
 vibrations are added at different parts of the tract, and 
 especially at the opening of the bronchioles into their 
 ' infundibuli. All of these factors cause the inspiratory 
 part of the murmur to have its peculiar quality and 
 pitch ; to increase in intensity to the end, and to be heard 
 throughout the act. 
 
 Expiration, on the other hand, is normally a passive 
 act, which depends upon the elasticity of the thorax and 
 the pulmonary tissue and the contraction of the muscle 
 fibres present in the bronchi. This force is greatest at 
 the beginning. The sound in the larynx is made at the 
 level of the vocal cords, and the direction of the tidal air 
 
 ' Many authors state that the pitch of expiration is lower than that of 
 inspiration. ' 
 
106 THE EESPIRATOEY SYSTEM. 
 
 is upwards and away from the surface of the chest. 
 The direction of the expiratory current of air inter- 
 feres with aerial conduction of the sound downwards. 
 As the tidal air is forced out of the alveoli into the 
 tubes, no new vibrations are made in the bronchioles or 
 tubes. 
 
 The sound that is heard at the surface in expiration 
 is chiefly that conveyed by the tissues of the respiratory 
 tract, so that the quality lacks the vesicular element and 
 is somewhat blowing and hard, and its pitch is higher 
 than inspiration sound. As the tidal air is forced out 
 of the lung the tension becomes less, losing the power to 
 conduct, so that the intensity is most marked at the 
 beginning, rapidly diminishing ; and the sound is heard 
 only during a short part of the time, or may be entirely 
 wanting, especially where the expiratory laryngeal 
 sound is naturally very soft or the expiratory force 
 weak. 
 
 The fact that during expiration the vibrations are 
 chiefly conducted by the tissues explains the tendency 
 of the blowing or bronchial element to be so much more 
 pronounced during this portion of the murmur. 
 
 KsGIOIfAL VaeIATIONS OP THE BeEATH SoUI^TDS. 
 
 The breath sounds vary in intensity, duration, quality, 
 pitch and in the relative lengths of the sounds heard 
 during inspiration and expiration over different por- 
 tions of the lung. 
 
 It is necessary to have a thorough knowledge of the 
 normal variations in order to recognize the alterations 
 that occur in morbid conditions, because a type of 
 breathing that is normal for one region would be patho- 
 logical if heard in another. 
 
 It has already been shown that over the larynx, 
 trachea and primary bronchi the tubular sound is heard 
 unmodified, and constitutes the laryngeal, tracheal and 
 bronchial types of breathing. 
 
 Over the interscapular space, opposite the spine of the 
 scapula, the sound is neither pure bronchial nor entirely 
 
AUSCULTATION. 107 
 
 vesicular in quality and pitch, but is of an inter- 
 mediate character. The tubular sound is modified, so 
 that inspiration has a soft, blowing, but somewhat bron- 
 chial, character, and the pitch is not as high as over the 
 trachea. The expiratory sound is separated from the 
 inspiratory by a shorter pause, and corresponds to the 
 inspiration sound in quality and pitch, but its duration 
 is not as long as over the trachea. The tubular element 
 is more marked on right side than the left, on account of 
 the relation of the trachea and bronchi to spine and ribs. 
 (Plate II.) 
 
 In front of the chest on the right side, at the junction 
 of the second rib with its costal cartilage, the respiratory 
 murmur differs from that heard on the left side in the 
 corresponding region. While vesicular in character, 
 there is a slight blowing element added, and its intensity 
 and pitch are slightly raised. Over the right apex of 
 the lung the same difference is present in a more limited 
 degree, due to the origin of the bronchus supplying the 
 upper lobe of the right lung. 
 
 The reason for the normal regional differences of 
 vesicular murmur is the relative nearness of the large 
 bronchi to the chest wall, so that, although these are 
 covered by lung tissue, the elements of the bronchial 
 sound are present in the respiratory murmur in a 
 greater degree than elesewhere. 
 
 Types of Respiratory Sound. — Various classifications 
 have been made of the different types of breath sounds 
 heard in health and in disease. 
 
 Some authors use as a basis of their nomenclature the 
 diseases of which the sounds are diagnostic!; others 
 employ terms descriptive of the pathological changes. 
 The one that is most commonly used, andl also the most 
 satisfactory, is that which considers the elements of the 
 sounds and groups the types according to the changes 
 that occur in intensity, rhythm, duration, quality, pitch 
 and the relative length of inspiratory to" the expiratory 
 sound. 
 
108 THE BE8PIBA TOR T SYSTEM. 
 
 Changes in Intensity. (1) Increased, Exagger- 
 ated, Compensatory, Vicarious, Puerile Breathing. — 
 The chief change from the normal is in the intensity of 
 the breath sounds. Inspiration has the vesicular ele- 
 ment accentuated. Expiration is slightly longer than 
 normal, and of a soft, blowing character. It occurs 
 whenever the breathing is very deep and active, as in 
 forced voluntary breathing; also in dyspnoea and over 
 portions of the lung, which by increased activity are 
 compensating for imperfect action in another part. 
 
 Puerile breathing, which is the normal breathing of 
 children under twelve years of age, differs from exag- 
 gerated breathing, in that both inspiration and expira- 
 tion are abnormally loud and sharp, and expiration is 
 nearly as intense and long as inspiration. It is some- 
 what blowing in character, and may have a slight 
 bronchial quality. 
 
 (2) Diminished, Feeble, Senile, Emphysematous 
 Breathing. — The sounds are faint, and heard only for a 
 short time, and expiration may be inaudible. The 
 diminished intensity may be due to shallow breathing, 
 imperfect muscular action caused by weakness, pain in 
 the muscles, nerves or pleura; rigidity of the bony 
 thorax; thickness of the soft parts of the thorax and 
 thickenings of, or exudations and effusions into, the 
 pleural sac; interference with the movement of air 
 through the bronchi ; weak glottic sound, dependent 
 upon normal or pathological conditions of the larynx. 
 
 The breath sounds that occur when the elasticity of 
 the lung is impaired, as in emphysema and old age, 
 differ from ' simple diminished breath sounds, in that 
 the inspiratory is short and weak, and the expiratory 
 sound is relatively stronger and longer. 
 
 (S) Absent or Suppressed Breathing. — The breath 
 sounds are not heard. This is due to changes that 
 render conduction to the surface impossible. It is most 
 marked in effusions of serum, pus or blood into the 
 pleural sacs; in closed pneumo-thorax with pulmonary 
 
A USCUL TA TION. 109 
 
 collapse; over cavities filled with fluid; with occluded 
 bronchus, and occasionally when there is great thick- 
 ness of the chest wall associated with feeble breathing. 
 
 Alteeations in Rhythm. — Interrupted, jerky, 
 wavy, cog-wheel hreathing. Instead of the inspiratory 
 breath sound being even and continuous, with a gradual 
 increase in intensity, it is broken and puffy. The 
 expiratory sound may also be uneven. 
 
 This may be due to irregular muscular action, as in 
 nervous patients and in painful conditions of the thorax 
 and pleura, or to interference with the passage of air 
 through the bronchi, as occurs in early tubercular 
 infiltration of the apices, 'Svhen the air enters different 
 lobules at different times." 
 
 Over the heart and large blood-vessels a peculiar, 
 jerky, puffing sound may be heard, due to the cardiac 
 systole forcing from the alveoli. 
 
 Alterations in Duration. — The significance of 
 change in duration of breath sounds depends upon (a) 
 whether the normal relation is preserved between the 
 sounds of inspiration and expiration ; (h) whether it is 
 associated with adventitious sounds, and (c) whether 
 there is any alteration in pitch and quality. 
 
 The inspiratory and expiratory sounds, while preserv- 
 ing their normal relations, may be lengthened or short- 
 ened by all conditions which have been mentioned as 
 producing increased or diminished breath sounds. 
 
 Prolonged Expiratory Breath Bound. — This occurs 
 under various conditions. 
 
 (1) When the expiratory sound is prolonged, but is 
 low pitched and faintly blowing in quality, it depends 
 upon diminished elasticity of the lungs, and is asso- 
 ciated with decrease in the length of inspiratory sound, 
 with a slight pause between inspiration and expiration. 
 Loss of elasticity occurs in old age and in emphysema. 
 This type of breathing has therefore been designated as 
 "em pliy somatous. ' ' 
 
 (2) The expiratory sound may be prolonged, and 
 
110 
 
 THE RESPIRATORY SVSTESL 
 
 Fig. 25. 
 
AUSCULTATION. Ill 
 
 accompanied by moist or dry rales, due to narrowing 
 of the tubes by secretion or by spasm of the muscular 
 tissue, as occurs in asthma, bronchitis and the early 
 stage of pulmonary tuberculosis. 
 
 (3) A prolonged expiratory sound may be associated 
 with a higher pitch and a blowing quality, due to 
 changes in the lung which increase its power of con- 
 ducting to the surface the sound which is normally 
 present in the bronchi throughout the entire expiratory 
 act. This may be due to increase in or induration of 
 the normal structure of the lung, as in the early stages 
 of tubercular infiltration, interstitial pneumonia or 
 fibroid thickening. 
 
 This type of breathing is normally present over the 
 apex of the right kmg. 
 
 A prolonged expiration sound, associated with slight 
 increase of the tubular quality and heightening of the 
 pitch, marks the faintest alteration in the elements of 
 the respiratory sounds in the transition from the normal 
 vesicular murmur to the different degrees of bronchial 
 breathing. 
 
 Alterations in Quaxity and Pitch. — The changes 
 that occur in the quality or character of the breath 
 sounds depend upon the addition of the bronchial and 
 tubular and decrease of the vesicular elements. The 
 extent to which this may occur varies. Based on the 
 proportion of the vesicular and bronchial quality 
 present, various subdivisions of bronchial breathing 
 have been made : 
 
 (1) Broncho-vesicular, indeterminate, subtuhular, 
 hinted or indistinct bronchial breathing. _ Sharp breath- 
 ing with bronchial quality in expiration; transition 
 breathing; rude respiration; harsh breathing. 
 
 As the names indicate, the distinguishing feature oi 
 this type is the presence of both vesicular and bronchial 
 quality. This depends upon the changes in the lung, 
 which allow the bronchial soimd to be heard at the sur- 
 face. These changes may be due to tubercular infiltra- 
 
112 THE RESPIRA TOR Y SYSTEM. 
 
 tion, croupous pneumouia, or fibroid induration from 
 any cause. It is normally present in the interscapular 
 region. 
 
 The term "broncho-vesicular" is by some extended to 
 all cases of bronchial breathing which do not have the 
 well-marked tracheal quality, while others limit it to 
 that type where a faint bronchial qiiality is added to 
 the vesicular breathing. 
 
 The terms "rude" and "harsh" have been used by 
 some authors to describe certain grades of broncho- 
 vesicular breathing, but should be discarded, as they 
 are misleading, having been employed by others as 
 synonyms for exaggerated breathing. 
 
 (2) Pure bronchial breathing is characterized by 
 absence of the vesicular quality. Both the inspiratory 
 and expiratory sound are high pitched and tubular; 
 that of expiration the more markedly so. 
 
 (S) High-pitched, blowing^ tubular and tracheal 
 breath sounds merely have reference to the intensity and 
 extent of the bronchial elements. 
 
 (i) Cavernous and amphoric breathing are modifi- 
 cations of the bronchial type. The former is low 
 pitched and hollow; the latter is high pitched and 
 metallic. 
 
 (B) ADVENTITIOUS SOUNDS. 
 
 Tn addition to the breath sounds present in the chest, 
 there may be heard certain abnormal or adventitious 
 sounds, which depend entirely upon pathological 
 changes in the bronchi, alveoli and pleura. 
 
 Adventitious sounds are divided into three classes: 
 
 Dry Rales, Moist Rales and Friction Sounds. 
 
 (1) Dry Rales, or rhonchi, ai'e musical sounds, pro- 
 duced by vibrations set up in those bronchial tubes 
 whose lumen has been markedly narrowed by tenacious 
 
AUSCULTAriON. 
 
 113 
 
 exudates, contraction of the musciilar coats or pressure 
 of tumors. These changes are of such a nature as to 
 practically convert the bronchial tubes into wind instru- 
 ments. 
 
 Fig. 26. 
 
 These sounds or rales may vary in quality, pitch, 
 intensity and duration, according to the size of the 
 tubes involved. 
 
114 THE BESPIBA TOR Y SYSTEM. 
 
 They are usually divided into two classes, sonorous 
 and sibilant. 
 
 SoKTOEOus KALES are snoring, low-pitched, loud 
 sounds, which may be heard during both inspiration and 
 expiration, or may be limited to one part only of the 
 respiratory act, according to the nature of the cause. 
 They may be heard in connection with the vesicular 
 murmur, or may entirely obliterate it. 
 
 Stridor is a type of sonorous rale in which the vibra- 
 tions are very coarse, and the sound produced hoarse 
 and low pitched. It occurs in diseases of the larynx, 
 trachea and main bronchi. The vibrations producing 
 stridor and sonorous rales may be strong enough to 
 produce tactile fremitus, as described in palpation. 
 
 When the narrowing in the trachea and large bronchi 
 is not sufficient to produce a musical sound, but is still 
 sufficient to increase the tubular quality normally 
 present, it will influence the respiratory murmur by 
 adding a bronchial element, as will be described later. 
 
 Sibilant kales are whistling, piping, squeaking, 
 humming, hissing sounds, which are markedly musical, 
 shrill and high pitched. The quality and the pitch will 
 depend upon the size of the tube, the degree of contrac- 
 tion, the force of the current of air, the conditions of the 
 pulmonary tissue and the conduction of the sound to 
 the surface. 
 
 These rales are permanent or transient, according to 
 the nature of the cause. AVhen the narrowing of the 
 tube is due to pressure of a tumor or to a growth within 
 the bronchus, the rales will be permanent. When, on 
 the other hand, the sound is caused by secretions in the 
 tubes or spasm of the muscular fibers, they are variable 
 and inconstant, disai^pearing from one spot and appear- 
 ing in another. 
 
 They also change in character. At one time they 
 may be hissing, shrill or whistling, and again sonorous, 
 as tubes of a different size are involved. Coughing 
 deep inspiration or the inhalation of chloroform or ether 
 
AUSCULTATION. 115 
 
 will modify those of a transient nature, according to 
 the cause. 
 
 While usually there is little difficulty in determining 
 what rales belong to the dry type, in the finer, less 
 musical sibilant ones it is often a matter of opinion how 
 they are to be classified. 
 
 (2) Small, Medium and Large Moist Rales. — Moist 
 KALES, as the name indicates, are due to the vibrations 
 produced by the movement "of air through fluid (mucus, 
 serum, blood or pus) in the air-containing spaces of the 
 lung. 
 
 Certain characteristics of the rales depend upon the 
 nature of the fluid. When it is thin and watery, the 
 rales will have a moist, bubbling sound; when it is 
 thick, in addition to the moist sound, there will be an 
 element of sharpness or stickiness, as the bubbles burst 
 with an explosive noise. 
 
 The quality and pitch of moist rales are modified by 
 the condition of the surrounding lung. When the lung 
 is normal, the sound of the rale loses its sharpness in 
 transmission, the moist character only remaining. But 
 in consolidated areas the rale has a certain ringing 
 character, due to the supposed resonating efl^ect of the 
 consolidated structures and their increased conducting 
 power. 
 
 The variations that occiir in the characters of moist 
 rales liaA^e led writers and teachers to adopt various 
 classifications and to designate their Subdivisions by 
 names which they considered more or less descriptive 
 of the sound, or of the pathological condition that ren- 
 dered their occurrence possible. 
 
 [Jn fortunately, different authors do not use the same 
 descriptive terms in the same sense, so the "crepitant" 
 rale includes not only the finest crackling sound, but 
 also those of larger size, which are by others classified 
 as "subcrepitant," or "small mucus." 
 
 This want of agreement in classification and nomen- 
 clature has led to great confusion, and it is particularly 
 
116 TEE BESPIBATOBY SYSTEM. 
 
 perplexing to tlie student, as it conveys the inipression 
 that there is a diversity of opinion as to the diagnostic 
 significance of these adventitiotis sounds. 
 
 It is almost hopeless to arrange a classification that 
 will include all the terms used. 
 
 Fortunately, the tendency is more and more to avoid 
 a specific descriptive term, and to describe the sound in 
 terms of quality, pitch, duration and intensity. 
 
 Ceepitations, oe "CebpItant Kales." — These are 
 the minutest of the moist rales, and have been by some 
 writers described as belonging to the dry type. ^ They 
 have a fine, somewhat dry, crackling sound, similar to 
 that produced by slowly and firmly rubbing a lock of 
 hair between the finger and thumb close to the ear. At 
 times they liave a sharpness that resembles the sounds 
 produced by the crackling of salt thrown upon the fire, 
 or the sound gives an impression of stickiness, as when 
 the moistened thumb and finger, having been pressed 
 together, are separated close to the ear. 
 
 Their pitch is high, and they convey the impression 
 of being produced near the surface. They occur in 
 showers or explosions, and are of uniform size. 
 
 They are persistent at the spot first heard, not being 
 removed by coughing; and are usually restricted to 
 inspiration, although they may at times be heard 
 momentarily just at the beginning of expiration. Some 
 authors state that they may be heard only during expira- 
 tion. Formerly it was claimed that one of the dis- 
 tinguishing features of the crepitant rale was that it 
 occurred only during inspiration, and that any rale 
 having the same general characteristics, but occurring 
 during expiration, could not be a crepitant rale. 
 
 There are differences of opinion as to the place and 
 mode of production and diagnostic significance of the 
 crepitant rale. Some claim that they are intrapul- 
 monary, being produced in the ultimate bronchioles and 
 alveoli, and due to the separation of the walls of the 
 alveoli, which were more or less firmly agglutinated by 
 
AUSCULTATION. 117 
 
 tenacious secretions. Others claim they are caused by 
 the bursting of fine bubbles, formed by the forcing out, 
 during inspiration, of the secretions from the bron- 
 chioles into their infundibuli. Others believe that they 
 are extrapulmonary, and are made in the pleura, being, 
 in fact, the finest of friction sounds. 
 
 The facts that seem to uphold the latter theory are 
 their remaining at the spot where first heard, not being 
 influenced by coughing; that they are usually heard 
 only with inspiration, but may occur with expiration; 
 and that a forcible pressure by the ear or stethoscope 
 upon the chest wall during expiration will often cause 
 them to be heard with expiration, when before they were 
 only detected with inspiration. While production of the 
 crepitant rales in the bronchioles and alveoli is possible, 
 their pleural origin is more probnble. 
 
 These rales have a special importance, as they have 
 been considered diagnostic of the first stage of croupous 
 pneunmnia, occurring even before changes in the res- 
 piratory murmur. In this disease they have also been 
 called the "rale indux," and confusion has occurred by 
 considering them also the "rale redux." 
 
 They occur also over the seat of catarrhal pneumonia, 
 caseous tiibercular pneumonia, infarctions, oedema of 
 the hmg and atelectasis. 
 
 Dry crepitations are frequently heard at the base of 
 the lung in persons who have been long confined to the 
 recumbent posture, and in those in whom there has been 
 superficial breatliing. They are most apt to be heard 
 after the fortieth year, and disappear after two or three 
 full breaths have been taken. These rales are caused 
 by the action of lung that has been for some time in 
 the quiescent state. 
 
 Classification of Moist Rales. — The most rational di- 
 vision of the moist rales is, according to their size, into 
 small, medium and large rales. 
 
 Appreciation of the size of a rale is important, as it 
 indicates (a) the size of the bronchus in which the 
 
118 THE BESPJSA TOR Y SYSTEM. 
 
 sound is made ; (h) it is diagnostic of the extent of the 
 disease, and whether or not further pathological changes 
 have occurred heyond the mere presence of more or less 
 fluid secretion in the t\ibes. 
 
 The size of the rale should always be considered in 
 conjunction with its intensity and nearness to the ear. 
 The larger the rale, the larger sliould be the space in 
 which it is made, and consequently it should give the 
 impression of being more or less distant from the 
 surface. 
 
 If, on the other hand, there is heard over a region 
 where the bronchi are normally small, as at the apex or 
 base, fairly large-sized rales, but at the same time 
 appearing to be close to the surface, it indicates that 
 there has occurred dilatation of the bronchi (bron- 
 chiectasis), or destruction of pulmonary tissue, and the 
 formation of cavities of greater or less extent. 
 
 The small moist rale, in addition to its size, differs 
 from crepitations or the "crepitant rale" in the follow- 
 ing: (a) The liquid character is more marked. 
 (h) While heard chiefly with inspiration, it is also 
 present during the first part of expiration, and may 
 persist throughout, (c) It is influenced by coughing, 
 at times disappearing when the bronchi are clear of 
 their fluid contents ; at other times appearing when the 
 secretion is forced from the alveoli into the bronchi. 
 
 The designation by some authors of these relatively 
 large moist rales as "crepitant" has led to much con- 
 fusion. 
 
 The small moist rales are divided into two groups, 
 according to the quality of their sound. 
 
 While both groups of the small moist rales are due to 
 the presence of fluid secretion in the air-containing 
 spaces, the difference in the quality of sound is 
 dependent upon the condition of the pulmonary tissue, 
 its influence on the conduction of the rale sound to the 
 surface, and on its power to modify. 
 
 (1) When the pulmonary tissue is normal, the moist 
 
A USOULTA TION. 119 
 
 sonnd made in the bronchi is modiiied, as is the bron- 
 c'liial sound that is normally present at the site where 
 the rales are made, and they are heard at the surface as 
 soft liquid or bubbling sounds. 
 
 Authors have used the terms "bubbling," "liquid," 
 "mucous," "submucous," "non-ringing," "non-consonat- 
 ing" ("klanglos") to describe the sound. 
 
 (2) When there are present changes which increase 
 the power of condi^ction by the tissues, or produce a 
 resonating effect, as occurs in increased tension (chil- 
 dren), or in pulmonary consolidation due to increase of 
 tissue, or the filling of the air spaces by solid exudate 
 (pneumonia, tuberculosis, etc.), the rales will be hoard 
 at the surface Avith increased sharpness. They will 
 liave a higher pitch and a crackling, explosive or ring- 
 ing quality. 
 
 Hence the names "dry," "crackling," "crepitating 
 moist rale," "humid crackling," "explosive moist rale," 
 "subcrepitant," "ringing," "consonating" ("klingend"), 
 given to describe this character of sound. 
 
 Rales in group 2 are usually associated with percus- 
 sion, palpation and auscultatory signs that indicate the 
 pathological conditions. 
 
 When this type of rale is not attended by these con- 
 firmatory signs, the quality is due to the tenacious 
 character of the secretions. 
 
 Tlio medium and large-sized rales are also divided 
 into two groups, and present the same general characters 
 as the small, but are larger-sized and are heard during 
 expiration to the same extent as during inspiration. 
 
 The largest of the moist rales have received several 
 names to denote their association with certain patho- 
 logical conditions. 
 
 Gurgles are produced in cavities partially filled 
 with fluid, where the bronchus enters below the level of 
 the fluid. They may be present during inspiration and 
 expiration, or may be induced only by coughing. They 
 are large, liquid, bubbling sounds, with a peculiar hoi- 
 
120 THE EE8P1BA TOR Y 8YSTE3I. 
 
 low ringing quality, which, distinguishes them from 
 other moist rales of the same size. 
 
 Mucous CLICKS are sounds which may be imitated by 
 whispering the word "click." They generally occur 
 singly, and are short, snappy, sticky sounds, heard only 
 during inspiration. Their mode of production is still 
 in doubt, but they are generally associated with soften- 
 ing of tubercular deposits. This term is gradually 
 falling into disuse, as these rales are not considered to 
 have the diagnostic significance which was formerly 
 given them. 
 
 Metallic tinkle is a single loud, high-pitched 
 sound, with a marked echo quality, and is produced in 
 large cavities with thin, tense walls. The peculiar echo 
 quality of the sound is due to reflection or reverberation 
 in the cavity. While heard with greatest distinctness 
 in pyopneumothorax, it may occur over a large pul- 
 monary cavity, when it is called "amphoric echo." 
 
 SucGussiON sound is a splashing sound that occurs 
 when the pleural cavity contains air and fluid. 
 
 This sign may be induced by giving the patient a 
 quick, short shake, or by coughing. While the sign is 
 present in pneumo-hydro- and pneumo-pyothorax, it 
 may occur in cavities of the lung when of large size and 
 filled with fluid. 
 
 (3) Friction Sounds. — In normal conditions the move- 
 ment of the two surfaces of the pleura on each other is 
 unattended with any sound, but in diseased conditions 
 rales of various kinds may be produced. 
 
 (a) Buy Frictions or Crepitations. — When the 
 surface becomes abnormally dry, the to and fro move- 
 ments are attended with a dry rubbing sound, similar to 
 that produced when the dry surfaces of the hands are 
 passed lightly over each other, or it may be like the 
 crepitations described above under moist rales. 
 
 Dryness of the pleura occurs during the first stage of 
 its acute inflammation and when a large amount of fluid 
 has been lost from the body, as in excessive diarrhoea of 
 the choleraic type. 
 
AUSCULTATION. 
 
 121 
 
 (i) Moist Ceepitations. — When tlie pleiirse are 
 covered with a tenacious secretion which glues the two 
 surfaces together, their separation is accompanied by 
 sticky, moist, crackling, crepitating rales. This type 
 frequently replaces the dry rales, as the plastic exuda- 
 tion is poured out after the first stage of inflammation. 
 
 (c) EuBBiNG^ Rasping^ Grating^ Geazing^ Creak- 
 ing^ Leathery Sounds. — These occur when the 
 surfaces of the pleura are roughened by exudation, by 
 inflammatory changes or joined together by bands of 
 adhesions. These rales may be felt by the patient, or 
 detected by the hand or ear as fremitus. 
 
 As the pleural rales depend upon the movement of the 
 thorax, they will be heard with the greatest intensity 
 over the lower segment of the thorax at the end of 
 inspiration and at the beginning of expiration, as the 
 play of the pleura is greatest during these portions of 
 the respiratory act. 
 
 When due to a sticky exudation, deep breathing fre- 
 quently causes the rides to disappear. They can be 
 heard again after quiet breathing and when pressure is 
 made on the chest wall so as to increase the friction. 
 
 Differentiation of Pleural from Bronchial 
 Rales. 
 
 In certain cases it is impossible, by the quality or size 
 of the rale, to separate the pleuritic from the bronchial 
 rales. 
 
 Pleural. 
 
 Localized. 
 
 Generally unilateral. 
 
 Frequentl}^ accompanied h y 
 pain. 
 
 They give the iniiiression of 
 being produced close to the ear. 
 
 Bronchial. 
 
 Not generally localized, hut if 
 so, they are associated with signs 
 of bronchitis, or consolidation. 
 
 Very apt to be bilateral. 
 
 Generally no pain. 
 
 They seem more .or less distant 
 from the surface. 
 
122 
 
 THE BESPJBATOBY SYSTEM. 
 
 Usually increased by coughing 
 or deep breathing. 
 
 They are localized at the point 
 where first heard. 
 
 Their intensity may be in- 
 creased by pressure upon the sur- 
 face. 
 
 Occur in showers or bunches, 
 and all of uniform size. 
 
 Frequently disappear after 
 coughing or deep breathing. 
 
 The location chaises frequently 
 as the result of coughing. 
 
 Unmodified by such pressure. 
 
 Various sizes may be heard at 
 the same time. 
 
 It must be borne in mind that pleuritic and bronchial 
 rales may be present at the same time. 
 
 (4) Indeterminate, or Indefinite Rales. — In addition to 
 the dry, moist and friction rales, another class has been 
 recognized under the title of "indeterminate" or "indefi- 
 nite" rales. They are crepitating, crumpling, crack- 
 ling sounds, moist or dry, heard over various portions 
 of the thorax during inspiration, expiration, or both. 
 The origin and mode of production of their sound are 
 doubtful. 
 
 They include the muscle sounds and the so-called 
 emphysematous crackle. Some authors include in this 
 class all rales that cannot be definitely determined as 
 bronchial or pleuritic in origin. 
 
CHAPTER Vl. 
 
 AUSCULTATION (Continued) 
 
 (A) CONDITIONS MODIFYING AERIAL VIBRATIONS 
 
 AND CONDUCTION OF SOUND BY THE 
 
 COLUMN OF AIR. 
 
 Movement of Tidal Air. 
 
 As the respiratory sounds depend primarily upon the 
 movement of air through the glottis and bronchial tract, 
 they will be influenced by the amount of tidal air, the 
 force of the current, and the rapidity of its movement. 
 These factors will influence chiefly the vesicular quality 
 of inspiratory sound and the intensity and duration of 
 both respiratory sounds. 
 
 When the breathing is deep, and at the same time 
 moi'e rapid than normal, the inspiratory sound is 
 sharper in quality and more intense, while the expira- 
 tory has a more blowing quality, and its intensity is 
 accentuated. When the muscles of expiration aid the 
 normal elasticity of the kings, the duration of the 
 expiratory sound may nearly equal that of the inspira- 
 tory. When this type of breathing is general, it is 
 called exaggerated breathing. 
 
 When the respiratory function of one lung is inter- 
 fered with from any cause, as pneumonia, pleurisy with 
 effusion, etc., and the unaffected lung is doing more 
 work in consequence, the breathing over the unaffected 
 side is called compensatory breathing. 
 
 Exaggerated or compensatory breath sounds may be 
 
124 THE RESPIEATOBY SYSTEM. 
 
 limited to one lobe, as when pneumonia affects tlie other. 
 They may be limited to a portion of a lobe. This occurs 
 (a) when a bronchus is plugged, or (h) when some of 
 the lobules are filled with inflammatory exudate. In 
 such cases the unaffected lobules on this division of the 
 bronchial tree accommodate not only their own normal 
 quantity of tidal air, but also that which should go to the 
 affected part ; and not only is the current stronger, but 
 there is overdistension of the alveoli, increased tension 
 and resultant change in the vesicular murmur. 
 
 Localized exaggerated breathing in any portion of the 
 lung always indicates compensatory action, and is there- 
 fore an important diagnostic sign. 
 
 Conditions which diminish the amount of tidal air, 
 w^eaken its force, or slow the current, will cause a 
 diminution of the breath sounds heard at the surface. 
 
 These conditions may be due to changes (a) in the 
 bronchial tract, as in certain stages of bronchitis ; (h) in 
 the parenchyma of the lung, as in emphysema; (c) in 
 the pleura, as adhesions or fluid; (d) in the bony 
 thorax, as increased rigidity; (e) in the soft parts, as 
 feeble muscular action. 
 
 In some individuals the normal vesicular murmur is 
 so faint during quiet breathing that it can scarcely be 
 appreciated. This may be due to the manner of breath- 
 ing or to anatomical conditions of the larynx. In such 
 cases it is necessary for the patient to take deep breaths 
 in order to obtain the breath sounds. 
 
 Influence of the Larynx. 
 
 As has already been noted (page 99), the normal 
 vesicular murmur will vary within wide limits, but will 
 always have a definite relation to the character and 
 intensity of the sound heard over the glottis, which 
 forms the basis of all breath sounds present in the 
 lung; so that as each voice has its own individual 
 quality by which it is recognized, so also will the char- 
 
A USCUL TA TJON. 125 
 
 aeter of the respiratory sounds differ. Therefore, when 
 the question arises whether or not the hreath sounds are 
 within the range of normal, the laryngeal sound should 
 always be taken as a guide. 
 
 Morbid conditions of the larynx will modify the 
 breath sounds in either inspiration or expiration, or in 
 both. 
 
 As has been shown, the inspiratory portion of the 
 vesicular murmtir is composed not only of sounds made 
 in the larynx, but also of those made in other portions 
 of the bronchial tract and at the alveoli, while the 
 expiratory portion depends entirely on the conduction 
 to the surface of the sound made at the larynx. There- 
 fore, any changes made in the character or intensity of 
 the glottic soimd will be most marked in the expiratory 
 murmur. 
 
 The laryngeal sounds may be increased by anything 
 which narrows the opening or changes the relation of the 
 parts. The change in the breath sounds produced may 
 l)e limited to one or both portions of the respiratory act. 
 Narrowing of the glottis, depending upon malignant or 
 non-malignant growth, tuberculosis and syphilis, may 
 cause greater or less change in the quality of the sound, 
 so that the respiratory murmur heard at the surface of 
 the chest will have a peculiar harsh, blowing quality. 
 Paralysis of the vocal cords diminishes the size of the 
 lumen of the glottis and produces change in the quality 
 of the sound, but it is not as marked as in morbid 
 growths ; and while the quality of the sound is changed, 
 it lacks the harshness. Inflammatory thickening and 
 exudations (oedema glottidis) produce the same changes 
 as new growths. Croup (laryngeal diphtheria) and 
 spasmodic conditions of the larynx produce a form of 
 stridor, which, on account of its musical quality, may 
 mask the vesicular element of the breath sounds so that 
 the only sound heard over the surface of the chest will 
 be more or less bronchial in type. It must be especially 
 remembered that the introduction into the larynx of 
 
126 THE UESPIRATOBY SYSTEM. 
 
 intubation tubes, or the presence of a tracbeotomy tube, 
 may cause the breath sound heard over the lung to be 
 distinctly tubular. This frequently causes the diag- 
 nosis to be made of secondary pneumonia, and a corre- 
 sponding gloomy prognosis in cases of diphtheria in 
 young children. 
 
 It will be diminished by conditions which will hold 
 apart the vocal cords. 
 
 Especial care must be taken in judging of the pul- 
 monary condition by auscultatory signs when disease of 
 the larynx, which causes a diminiition of the glottic 
 sound, is present, as the effect of changes in the 
 laryngeal sound may be so marked as to prevent bron- 
 chial breathing being produced in well-marked consoli- 
 dation of the lungs. 
 
 Influence of the Bronchi. 
 
 The condition of the bronchial tubes may modify the 
 respiratory sounds in their normal elements, or add new 
 sounds, as adventitious sounds of rales. 
 
 When the lumen of the tubes is narrowed, either by 
 congestion, as in acute bronchitis, by growths within or 
 by pressure from without, the intensity of the miirmur 
 over that portion of the lung which they supply with air 
 may be increased or diminished, according as the 
 amount and movement of tidal air is influenced. When 
 the narrowing causes no diminution in the amount of 
 air passing to the lung beyond, then, on account of the 
 narrowing, the movement of the air through the nar- 
 rowed portion will be more rapid and forcible. 
 Inspiration will be harsher in character, while expira- 
 tion will be more blowing, higher pitched and of longer 
 duration. 
 
 If, on the other hand, changes in the bronchi inter- 
 fere with the movement of air, so that it reaches the 
 bronchioles reduced in amount and force, inspiration 
 will be feeble, the vesicular element especially weak, and 
 expiration perhaps inaudible. 
 
AUSCULTATION. 127 
 
 Diminution in the intensity of the respiratory 
 murmur is most marked when the smaller bronchi are 
 involved. These changes in intensity may be bilateral 
 or limited to one lung or a portion of one lung, accord- 
 ing to the morbid processes. 
 
 The abnormal or adventitious sounds present in dis- 
 eases of the bronchi are the dry and moist rales, accord- 
 ing to the changes in the bronchi and nature of their 
 contents. 
 
 Dry Rales. — When the lumen of a bronchus is so 
 abruptly narrowed, either by contraction of the muscular 
 fibres or by thick, tenaciovis secretion, as to produce con- 
 ditions like those of a wind instrument, as the tidal 
 air passes over the obstruction into the relatively wider 
 lumen beyond, vibrations are set up and a sound pro- 
 duced as in the larynx at the glottis. 
 
 The character of the sound will depend upon the 
 degree of narrowing, the size of the tube and the force 
 of the current, and the adventitious sound will be added 
 to or modify that made at the glottis. 
 
 When the narrowing is relatively slight, the sound 
 produced will be of a harsh, blowing, non-musical 
 character, similar to that made normally at the larynx. 
 At the surface it will have a well-marked bronchial 
 character, most marked with expiration, and almost 
 identical with that heard when the lung is consolidated, 
 from which it is differentiated by the signs noted by 
 percussion and palpation. This sound may occur in 
 bronchitis, asthma and pulmonary tuberculosis. In the 
 latter disease it may be associated with more or less 
 consolidation. 
 
 When the narrowing is more marked, the sound will 
 have a more musical quality, being a type of stridor 
 already described. 
 
 When the constriction is in a tube of the second or 
 third division, it produces a deep-toned, low-pitched, 
 musical sound (sonorous rale). 
 
 When in the smaller tubes, the sound is shriller, 
 higher pitched, whistling (hissing or sibilant rale). 
 
128 THE EE8PIEAT0BY SYSTEM. 
 
 The division into sonorous and sibilant rales is an 
 arbitrary one, and one type merges into another, accord- 
 ing to the size of the tube and nature of the obstruction. 
 
 The dry rales are not permanent, being evanescent, 
 appearing and disappearing; now being heard at one 
 place, then over another area. 
 
 The effect of these rales on the normal respiratory 
 murmur varies according to their number and intensity, 
 and whether or not the constriction is so marked as to 
 interfere with the movement of tidal air and prevent 
 the production of the normal vesicular element. 
 
 The persistence of the vesicular sound is an important 
 diagnostic sign, indicating the degree of obstruction. 
 Students frequently fail to aiipreciate the vesicular 
 murmur even when present, as the sibilant and sonorous 
 sounds are so striking as to engross the attention. 
 
 The special significance of these rales being heard in 
 inspiration or expiration, or limited to one or the other, 
 will be considered under the diseases. 
 
 Moist Rales. — When the bronchi are more or less filled 
 with fluid, there will be present the different varieties 
 of moist rales that have already been described (page 
 115). 
 
 The conditions that produce dry and moist rales may 
 affect the entire bronchial tract, as in general bronchitis, 
 or may be limited to one limg or to a portion of a lobe. 
 The wide or limited distribution of the adventitious 
 sounds is of important diagnostic value. 
 
 The Effect of Plugging of a Bronclnis. — Complete 
 closure of a bronchus by compression from without, as 
 by an enlarged gland or aneurism, by the plugging 
 with secretions or plastic exudation, as in bronchitis and 
 pneumonia, or by a growth within the tube, as in tuber- 
 culosis, produces marked diminution or complete 
 absence of the breath sounds, according to the site of the 
 obstruction. It influences the production of sound by 
 the tidal air and the transmission by the tissues. Vibra- 
 tions that are present in the column of air are arrested 
 
AUSCULTATION. 129 
 
 at the point of occlusion, and as there is no movement 
 of air beyond that point, no sound is made at the junc- 
 tion of the alveoli with the infundibuli, and conse- 
 quently the vesicular quality of the respiratory murmur 
 is wanting. 
 
 Important changes occur in the area that is supplied 
 by the occluded bronchus. The air beyond the obstruc- 
 tion is rapidly absorbed, and when the plug acts as a 
 ball valve the air may be forced out during expiration, 
 but not replaced during inspiration. Removal of air 
 causes relaxation af the lung, and more or less complete 
 atelectasis. As will be shown later, this loss of tension 
 causes the tissue to be a poor conductor of vibrations, 
 and the expiratory portion will be especially feeble or 
 absent. 
 
 When a large bronchus is occluded, no sound will bs 
 heard over the portion supplied, so that even bronchial 
 breathing may be absent in complete consolidation of the 
 lung, as in croupous pneumonia. If a small branch 
 only is involved, then feeble breath sounds may be heard 
 over the affected area, and, the surrounding portion of 
 the lung being overdistended, exaggerated or compen- 
 satory breathing is present. (Fig- 25.) 
 
 (B) CONDITIONS MODIFYING TISSUE VIBRATION 
 
 AND THE CONDUCTION OF SOUND 
 
 BY THE TISSUES. 
 
 The Influence of Tension. — The elasticity of the tissues 
 of the respiratory tract and their degree of tension has 
 an important effect not only on the intensity, but also 
 on the quality and pitch of the breath sounds. 
 
 When the elasticity and tension are increased, the 
 tissues are more easily influenced by the aerial vibra- 
 tions present in the bronchi and air spaces. The 
 vibrations are shorter; the tissues become better con- 
 ductors of sound ; the inspiratory sound is consequently 
 more intense, has a sharper vesicular quality and the 
 9 
 
130 THE RESPIRATORY SYSTEM. 
 
 pitch will be slightly raised. The expiratory sound is 
 louder, more intense, is longer, has a more marked blow- 
 ing quality, often with a suspicion of a bronchial ele- 
 ment. Age has an important effect on the elasticity and 
 tension of the respiratory apparatus. In the child not 
 only is the resiliency of the tissues greater, but up to 
 twelve years of age the relatively more rapid develop- 
 ment of the thorax than the lung causes the tension to 
 be much greater than in the adult, and is one of the fac- 
 tors that ca^^ses the respiratory sounds in children to be 
 distinctive enough to be called "puerile breathing" and 
 stand out as a type. 
 
 Exaggerated or compensatory breathing is due to 
 increased tension, as well as to changes in the volume 
 and force of the tidal air. 
 
 With advancing years, and when pathological changes 
 occur, as in emphysema, there is a loss of elasticity; 
 and, although the lung may be distended beyond the 
 normal, there is a lowered tension, and the respiratory 
 sounds are feeble and lower pitched; insj)iration is 
 shorter, while expiration is prolonged. 
 
 Influence of the Increase of Tissue in the Walls of the 
 Bronchi and Alveoli on the Eespiratory Sounds. — When 
 considering the production of normal vesicular murmur, 
 it was stated that the thin, membranous structure 
 of the walls of the bronchioles and alveoli was chiefly 
 influenced by the vibrations of the air contained in 
 them ; also that this tissue was a poor conductor of the 
 vibrations brought to it from above through the more 
 solid tissues of the walls of the bronchi, and that these 
 facts accounted for the absence of the bronchial or 
 tubular sound in the normal respiratory murmur. 
 
 When the normally light membranous structure of 
 the periphery of the lung is changed into denser con- 
 nective tissue, as occurs in interstitial or fibroid changes 
 in the interlobular septa (in interstitial pneumonia 
 fibroid phthisis and certain types of pulmonary tuber- 
 culosis), the new tissue, being more homogeneous with 
 
AUSCULTATION. 131 
 
 the walls of the larger bronchi, will conduct the bron- 
 chial sound from the deeper portion of the lung direct 
 to the surface. The change may be so slight as only to 
 give a slightly prolonged expiration. The ear may 
 detect two types of breathing in varying proportions — 
 the normal vesicular murmur and an added bronchial 
 element, most marked in expiration. This mixed 
 breathing is called broncho-vesicular. The proportion 
 and character of the tubular quality will depend upon 
 (a) the amount of new tissue; (h) the extent of its 
 penetration into the lung and the size of the bronchial 
 tubes reached. 
 
 Broncho-vesicular breathing varies from the faintest 
 tinge of the bronchial sound to that in which the tubular 
 sound predominates, and the vesicular element can only 
 be faintly detected. (Fig. 25.) 
 
 When the air in the alveoli is replaced by coagulated 
 exudate or tissue, as occurs in pneumonia, hemorrhagic 
 infarction and tubercular infiltration, then during 
 inspiration the vesicular quality is absent, because there 
 is interference with the amount and force of tidal air, 
 and the aerial vibrations are unable to modify the tissue 
 vibrations present. The consolidated lung, being a 
 good conductor, allows the bronchial sound present in 
 the deeper portion of the lung to be heard. 
 
 When the consolidation is very slight, the sound from 
 both the normal and consolidated lung is brought to the 
 ear, so that the only change noted may be limited to a 
 prolongation of expiration, with a slight raising of the 
 pitch, i. e., the faintest type of broncho-vesicular breath- 
 ing. 
 
 If the consolidation reaches only to the small bronchi, 
 then the breathing, while bronchial, is of a soft, blowing 
 quality; the pitch is raised; the intensity corresponds 
 to the pitch, and the expiratory sound is prolonged, 
 more tubular and higher pitched than the inspiratory, 
 and a short pause is noticed between inspiration and 
 expiration. 
 
132 THE BESPIBATORY SYSTEM. 
 
 When a medium-sized tube is involved, the quality 
 will be more bronchial; the pitch will be higher; the 
 intensity greater; the expiratory sound will be higher 
 pitched and longer than the inspiratory, and will have 
 a more markedly tubular character. This is usually 
 described as bronchial breathing. 
 
 When an entire lobe is involved, then the sound heard 
 is that conveyed from the large bronchi. It has all of 
 the characteristics of that heard normally over the 
 trachea, and is called pure bronchial, tubular or tracheal 
 breathing. 
 
 The auscultatory signs heard at the surface in con- 
 solidation of the lung, whether due to fibrosis of the 
 stroma or filling of the air spaces, are not always as 
 typical as has just been described. 
 
 When the consolidated portion reaches the surface, 
 and is immediately beneath the ear, then the breathing 
 will be typical of the pathological changes, but when it 
 is deeper and is covered by lung that is normal, or in a 
 state of compensatory distension, the bronchial element 
 may be entirely masked by the normal or exaggerated 
 breath sound of the overlying portion of the lung, or it 
 may be faintly detected, especially in expiration, where 
 the first part has a fairly normal quality, but the latter 
 part is prolonged, high pitched, more blowing and 
 bronchial. (Fig. 25.) 
 
 This type of breathing, according to the intensity of 
 the bronchial sound, as has been described as "broncho- 
 vesicular breathing," "prolonged, high-pitched expira- 
 tion" or one of the types of the so-called "metamorphos- 
 ing breathing." 
 
 The influence of changes occurring in the pleura on 
 the bronchial breathing of consolidation will be con- 
 sidered later. 
 
 Influence of the Increase in the Size of the Air-Containing 
 Spaces (cavity formation and bronchiectasis) — The destruc- 
 tion of lung tissue and the formation of cavities, which 
 are at least partly empty and connect freely with a 
 
A USOULTA TION. 133 
 
 bronchus, cause a modification of the bronchial breath- 
 ing, which is called cavernous or amphoric, according to 
 the dimensions of the cavity, the condition of the tissue 
 forming its walls and the size of the bronchus opening 
 into it. 
 
 Much confusion will be avoided if it be remembered 
 that tubular, cavernous and amphoric are all types of 
 bronchial breathing ; that they vary in degree, and often 
 approach each other in character. While they have a 
 general resemblance, the differentiation is made by the 
 quality and pitch of the sound. 
 
 The bronchial sound that is brought to the cavity is 
 resonated, as when one blows over the mouth of a bottle. 
 When the walls of the cavity are flaccid and of low ten- 
 sion, a peculiar hollow sound is produced, which is 
 called cavernous. The inspiratory portion is soft, 
 blowing, hollow, but less tubular, and lower pitched 
 than the tracheal sound. The expiratory is more blow- 
 ing, wavy or puffy; the pitch is lower than that of the 
 inspiratory, which distinguishes it from bronchial 
 breathing, in which the pitch of expiratory is higher 
 than that of the inspiratory sound. 
 
 The sound heard over the trachea, behind, serves as a 
 standard for bronchial breathing with which to compare 
 doubtful cavernous breathing. 
 
 When the walls of a cavity are rigid and tense, as 
 when composed of dense, fibrous tissue, when sur- 
 rounded by consolidated lung, or when bound to the 
 chest wall by firm pleuritic adhesions, the sound pro- 
 duced is amphoric. 
 
 It is a hollow, blowing sound, similar to the cavern- 
 ous, but has a harsh, metallic or slight echo quality. 
 The tubular element is more marked, but less than in 
 bronchial breathing, and the expiratory sound has a 
 lower pitch than that of inspiration. 
 
 The terms cavernous and amphoric, used to designate 
 the breath sound, heard over cavities, are sometimes 
 uncertain in their application, owing to the individual 
 
134 THE BESPIBA TOB Y SYSTEM. 
 
 interpretation of the sound heard. This is due to the 
 fact that the walls of cavities vary in tension. A type 
 of breath sound is frequently heard which has the quali- 
 ties of the cavernous and amphoric breathing in vari- 
 ous degrees, and may be called caverno-amphorie or 
 amphoro-cavernic, as either type predominates. 
 
 When the cavity is filled with fluid or the bronchus 
 leading to it is occluded, cavernous or amphoric breath- 
 ing may be absent, either temporarily or permanently. 
 
 When a bronchus opens freely into the pleural cavity 
 filled with air, a peculiar, intense type of amphoric 
 breathing is heard. This has been called the "lung 
 fistula sound." 
 
 (C) CONDITIONS MODIFYING VOCAL RESONANCE. 
 
 The difference in the sounds heard over the chest 
 when a person breathes, whispers or speaks depends upon 
 the character of the vibrations made at the glottis. 
 
 Whispered Voice or Whispered Resonance. 
 
 In order to intensify the sound made at the larynx, 
 the patient may be instructed to breathe noisily, or, 
 what is better still, to whisper with different degrees 
 of loudness. The whispered voice, in addition to being 
 more intense than the breath sound, gives the articu- 
 late elements of speech — the consonants. The clearness 
 with which they are heard over the different regions of 
 the chest indicates the extent and degree of the changes 
 that have occurred in the power of the lung to conduct 
 sound to the surface. 
 
 The whispered voice is heard with expiration, and 
 when patients are too weak to take deep breaths we can 
 increase the intensity of the sound heard on expiration 
 without exhausting the patient by having him whisper. 
 
 ISTormally, the whispered words are conveyed to the 
 ear as soft, diffuse, indistinct sounds. Over those por- 
 
AUSCULTATION. 135 
 
 tions of the lung where tracheal, laryngeal and bronchial 
 breathing normally exist, the whispered words are heard 
 with greater distinctness, and the. words will be recog- 
 nized more or less completely. 
 
 Conduction of the whispered voice will be increased 
 or diminished in the same manner and under like condi- 
 tions as the breath sounds. It is especially valuable to 
 determine the presence of a slight amount of consolida- 
 tion, when the whispered words will be brought to the 
 ear with increased distinctness. 
 
 As consolidation increases in extent and involves the 
 larger tubes, the whispered words become more and 
 more distinct, until it is possible not only to recognize 
 the whispered words or ntimbers (whisper-bron- 
 chophony), but also to detect the articulate parts of 
 speech, as the consonants (whisper-pectoriloquy). 
 
 The Spoken Voice or Vocal Resonance. 
 
 The vibrations of the spoken voice are so powerful 
 as to influence the entire amount of air within the 
 bronchi and alveoli, so that they are not only heard at 
 the periphery as normal resonance, but are also felt as 
 fremitus. The open bronchi, with their tense, elastic 
 walls, act as speaking tubes, and the sound made at the 
 glottis is modified in its conduction to the surface, as 
 follows: (1) By reflection, reverberation or echo 
 within the tubes, so that confusion of the sound occurs. 
 (2) By diffusion in the ramifications of the bronchi 
 and alveoli, so that it is weakened or less intense. 
 
 In the larynx and trachea little change occurs in the 
 sound, except that the consonants are not heard as 
 distinctly, but the intensity of the sound seems to be 
 slightly greater than at the mouth. 
 
 In the larger bronchi, as heard over the sternum and 
 parasternal portion of the infraclavicular space in front, 
 and upper portion of the interscapular space behind, the 
 sound is more indistinct, the words are blurred, but still 
 
136 THE EESPIBA TOR Y SYSTEM. 
 
 distinguishable, and the pitch of the sound is slightly 
 higher than in the trachea. 
 
 This sound is called "normal bronchophony," and 
 may be heard over other regions of the chest when con- 
 solidation of the lung tissue transmits it unmodified to 
 the surface. 
 
 With each division of the bronchi the soimd is still 
 further reflected, confused and weakened, as were the 
 breath sounds, until at the surface of the lung the 
 articulate parts of speech are absent; the words are not 
 distinguishable, and it becomes an indistinct humming, 
 buzzing sound, normal vocal resonance. 
 
 Normal vocal resonance will vary in individuals, 
 according to the character of the voice, as has been 
 mentioned under "Palpation." 
 
 It will be influenced by the same changes in the 
 bronchi and alveoli that modify breath sounds and the 
 fremitus of palpation. 
 
 Vocal resonance may be absent, feeble or exaggerated. 
 Just as in proportion to the pulmonary consolidation, 
 the expiratory part of the respiratory murmur varies 
 in intensity, pitch and quality, from the faintest 
 suspicion of bronchial sound up to pure bronchial 
 breathing, so vocal resonance varies in the clearness 
 with which the articulate sounds are heard from a 
 slight increase of normal resonance up to bronchophony, 
 where the words are heard more or less distinctly, but 
 confused and associated with vibrations of the chest 
 wall. 
 
 Pectoeiloqut, as its name implies, sounds as if the 
 patient was speaking directly through the chest, or as if 
 we were listening directly over the larynx through a 
 solid medium, as a block of wood. It is an exaggerated 
 form of bronchophony. Its characteristic feature is the 
 remarkable distinctness with which the consonants of 
 the spoken words are heard. It is best detected with 
 the whispered voice, as there is less confusion from 
 reverberation. 
 
AUSCULTATION. 137 
 
 Pectoriloquy is heard over consolidated lung that is 
 in a high state of tension, and that extends to the large 
 bronchi. 
 
 Over pulmonary cavities two kinds of spoken and 
 whispered resonance are heard : (a) cavernous and (h) 
 amphoric. 
 
 Caveenous resonance is produced in cavities with 
 thin, lax walls. It is a type of bronchophony. The 
 sound is hollow, low pitched, and has a puffing, blowing 
 character. With the spoken voice, the words are con- 
 fused, having a slight echo qiiality. With the whispered 
 voice, the words are more distinct, but not articulate. 
 
 Amphoeig eesonance occurs in cavities with tense 
 walls, and is usually associated with amphoric breath- 
 ing. The sound is a type of pectoriloquy, in that it is 
 distinctly articulate, with a hollow, ringing, well-marked 
 echo quality and high pitch. 
 
 ^GOPHONy is a form of vocal resonance that occurs 
 in certain stages of effusion in the pleural sac. The 
 voice is not as intense as in bronchophony, but is high 
 pitched,- tremulous, with a marked nasal sound, so that 
 it has been compared to the bleating of the goat ; but it 
 is more like the voice of a person with a cleft palate. 
 It is not associated with increased vocal fremitus. The 
 condition of the lung allowing its production will be 
 considered under "Pleurisy with Effusion." 
 
 Auscultation of the Cough. 
 
 The sound produced by coughing is frequently util- 
 ized in diagnosis, but it is not as reliable as- vocal reso- 
 nance. In the normal lung it is heard at the surface as 
 an indistinct, sharp soimd, accompanied by sudden move- 
 ment of the chest wall, due to the action of the expira- 
 tory muscles. In varying degrees of pulmonary 
 consolidation and in cavities it has been named bron- 
 chophonic, cavernous and amphoric cough, having the 
 
138 THE BESPIBATOBY SYSTEM. 
 
 same features as vocal resonance under similar condi- 
 tions. 
 
 On account of the forcible expulsive power of cough, 
 a larger amount of air than usual is driven out of the 
 lung, and the succeeding inspiration is correspondingly 
 increased in volume. This allows slight changes in the 
 bronchi and pulmonary tissue to be detected by the 
 character of the vesicular murmur. "A post-tussive 
 suction soimd" or "India rubber-ball sound" is frequently 
 heard with the inspiration immediately after the cough 
 when cavities with soft, yielding walls are present. It 
 is a sucking, semi-sonorous, low-pitched sound, usually 
 accompanied by a few mucous clicks or medium-sized 
 moist rales. It is a very important and reliable sign of 
 cavity formation. 
 
 Coughing has a marked effect on moist rales. When 
 the fluid contents of the tube are dislodged, it may cause 
 them to disappear entirely, or to change small rales to 
 those of larger size. When the secretion is in small 
 cavities, with more or less occlusion of the bronchial 
 tubes leading to them, no rales may be detected diiring 
 quiet, or even forcible, breathing, but are heard after 
 coughing. 
 
 The Bell Souktd^ Bell Tympawy^ ok Coiisr Reso- 
 WAiYCE. — In pneumothorax, or when a large cavity is 
 present in the lung close to the surface, if percussion is 
 made on the anterior portion of the chest with two 
 coins while the auscultator listens behind, there is heard 
 over the affected area a distinct ringing bell- or anvil- 
 like sound. In order that this air-containing space may 
 act as a resonator, it is necessary that it be of a certain 
 size, with tense walls. 
 
 Veiled Pupe. — This is a short, high-pitched, puffing 
 sound, which is added to the inspiratory murmur toward 
 the end of inspiration. It has been considered diag- 
 nostic of small sacculated bronchiectatic cavities. 
 
AUSCULTATION. 139 
 
 (D) INFLUENCES OF CHANGES IN THE PLEURA 
 ON THE BREATH SOUNDS. 
 
 The normal pleura, being very thin and almost homo- 
 geneous with the tissue of the walls of the alveoli, does 
 not affect the transmission of the respiratory sounds. 
 When the pleura is thinly covered with a sticky secre- 
 tion, different varieties of friction sounds are heard, 
 which may mask the pulmonary sound. 
 
 When the pleural changes cause pain on breathing, 
 movement of the affected side is restricted, and there is 
 a correspionding decrease in the intensity of the vesicular 
 murmur. Generally all increase in the thickness of the 
 pleura, whether from plastic exudation or interstitial 
 changes, interferes with the transmission of vibrations 
 to the surface, and influences the intensity of the breatli 
 sounds. 
 
 "The motion of sound, like all other motion, is 
 enfeebled by its transmission from a light body to a 
 heavy one" (Tyndall), so that the vibrations in the 
 thin membranou:s walls of the alveoli are transformed 
 into vibrations in the thickened pleura, with loss in 
 their- intensity which is proportionate to the change in 
 the homogeneity or density of the pleura. 
 
 Changes in the pleura, especially the pulmonary por- 
 tion, which render it less elastic or distensible, curtail 
 the normal inspiratory enlargement of the lung, and 
 thus decrease the amount and force of tidal air and 
 enfeeble the breath sounds. This effect is especially 
 marked over the apices and lower borders of the lungs. 
 
 Collections of fluid, air or the formation of new 
 growths in the pleural sac separate more or less widely 
 the two surfaces of the pleura, and allow the lungs to 
 retract. This produces loss of tension in the pulmonary 
 tissue and weakens the vibrations at the surface of the 
 lung, so that the breath sounds are heard very feebly 
 or not at all. 
 
 The occurrence of bronchial breathing and segophony 
 
140 TBE BESPIBA TOB Y SYSTEM. 
 
 at the upper level of the fluid effusions will be explained 
 under "Pleurisy with Effusion." 
 
 Adhesions between the two surfaces of the pleura 
 may cause marked decrease in the breath sounds by 
 preventing normal moveinents and limiting expansion. 
 
 When pleural adhesions keep the pulmonary tissue 
 tense, or are associated with increase of pulmonary tis- 
 sue, as occurs in interstitial pneumonia and the fibroid 
 type of phthisis, they may form homogeneous bands of 
 connection between the ribs and the bronchi, and so 
 permit the breath sounds to be heard where ordinarily 
 they are absent. 
 
 (E) INFLUENCE OF THE THORACIC WALL 
 ON BREATH SOUNDS. 
 
 The bony thorax acts as a sounding board for the 
 vibrations conveyed to it, and influences the intensity 
 of the breath sounds according to its elasticity. At the 
 same time, by its rigidity, it affects the movement of the 
 ribs and modifies the amount of tidal air and the inten- 
 sity and duration of the vesicular murmur. 
 
 The inspiratory portion of respiration being a 
 muscular act, its intensity, duration and rhythm are 
 easily modified by changes affecting the muscles. 
 
 The rhythm may become irregular, jerky or inter- 
 rupted through the imperfect or irregular contraction of 
 the ordinary muscles of inspiration. It may be due to 
 nervousness of the patient, disease of the nervous sys- 
 tem or of the muscles themselves, or to pain either in the 
 chest wall or in the pleura. 
 
 Expiratory movement, although normally a passive 
 act, may be altered by the muscles of expiration in the 
 same manner as inspiration. 
 
 The thickness of the soft parts will also affect the 
 clearness with which the respiratory sounds are heard, 
 in a manner similar to its effect on vocal fremitus. (See 
 "Palpation.") 
 
CHAP TEE VI I. 
 
 DIAGNOSIS OF DISEASES OF EESPIRATOEY TEACT. 
 
 BRONCHITIS. 
 
 Bronchitis is an inflammation of the different tis- 
 sues of the bronchial tubes. It may be acute or chronic. 
 It may involve a limited portion only, as the large tubes, 
 or the entire bronchial tract. Primary acute bronchitis 
 usually affects the bronchi of both lungs to a nearly 
 equal extent. Accompanying or pre-existent disease of 
 the lung causes the bronchitis to be limited to a portion 
 of one lung only, or to be much more intense on one side 
 than on the other. 
 
 Acute Bronchitis. 
 
 The physical signs present in acute bronchitis depend 
 on: (1) The size of the bronchial tubes involved. 
 (2) The nature and extent of the changes in the mucous 
 membrane. (3) The character, amount and distribu- 
 tion of the secretion or exudation present in the bronchi. 
 (4) The influence of changes in the mucous membrane, 
 and the presence of secretion on the movement of air in 
 the bronchi. 
 
 As the lumen bronchial tube has a most important 
 bearing on the intensity of the physical signs and the 
 gravity of the disease, it furnishes a basis for classifica- 
 tion of the varieties of bronchitis. Acute bronchitis 
 may be divided into : 
 
 A. Bronchitis of the Larger Tubes. This includes 
 
 involvement of the trachea and the larger cartilaginous 
 
142 THE BE8PIBAT0BY SYSTEM. 
 
 tubes, whose diameter is so great that the tumefaction 
 of the mucous membrane and the presence of more or 
 less fluid secretion or inflammatory exudation, does not 
 cause marked obstruction or interference with the 
 movement of air. 
 
 B. Bronchitis of the Middle-Sized Tubes. — ^An inflam- 
 mation of the medium-sized and smaller cartilaginous 
 tubes, whose lumen is narrowed to a greater or less 
 extent, with a more or less interference with the move- 
 ment of air and a corresponding production of physical 
 signs. Synonyms. — Simple bronchitis, acute bronchial 
 catarrh. 
 
 C. Bronchitis of the Smaller Tubes. — An inflammation 
 of the smallest cartilaginous and non-cartilaginous 
 tubes down to the lobular bronchioles, and character- 
 ized by marked obstruction of the bronchi and imperfect 
 ventilation of the lung. Synonyms. — Acute capillary 
 bronchitis, acute suffocative catarrh. 
 
 D. Bronchitis of the Smallest Tubes, including lobular 
 bronchi, and extending into the intralobular bronchioles 
 and air-passages, with tendency to lobular consolidation. 
 This is characterized by extreme interference with pas- 
 sage of tidal air to and from the alveoli, with imperfect 
 oxygenation of the blood. Synonyms. — Capillary 
 bronchitis of infancy and old age; capillary bronchitis 
 with broncho-pneumonia; peripneumonia nothia. 
 
 Physical Signs. — As the classification of bronchitis 
 given above is largely arbitrary, and as we rarely find 
 the disease limited to the different divisions of the 
 bronchi, so also the physical signs that are present in 
 one variety of bronchitis merge more or less into those 
 of the other varieties. It is best to compare the physical 
 signs of the different varieties. 
 
 Inspection. — A. Bronchitis of the Larger Tubes. — 
 As there is neither change in the pulmonary tissue nor 
 interference with the movement of air tiirouffh the 
 bronchi, there is no alteration in the shape and size of 
 the thorax. The respiratory movements may be slightly 
 
DISEASES OF BE8PIBAT0RY TRACT. 143 
 
 increased, both in frequency and depth, but the two 
 sides move symmetrically, and expansion is full and 
 free. 
 
 B. Bronchitis of the Middle-sized Tubes. — In mild 
 cases no change is noted in the size or form of the 
 thorax, and the respiratory movements are but slightly 
 increased in force and frequency. In severe cases, in 
 proportion to the narrowing of the lumen of the bronchi 
 by inflammatory swelling or secretion and interference 
 with the free movement of air, the respiratory move- 
 ments are more rapid and labored, expansion being 
 restricted when tubes of smaller calibre become involved 
 and the above signs become increased in intensity. 
 
 C. Bronchitis of Smaller Tubes. — There is a marked 
 movement of the upper portion of the chest, with violent 
 action of the accessory inspiratory muscles; the expan- 
 sion of the chest is chiefly confined to upper portion; 
 there is loss of expansion in lower portions of the chest, 
 and diaphragmatic action is restricted. As the case 
 becomes more severe, and the interference with the 
 movement of air through the small bronchi becomes 
 more marked, two types of dyspnoea may develop. 
 
 (1) Inspiratory Dyspnoea. In this form the greatest 
 interference is with air passing into the alveoli; the 
 action of the accessory muscles of inspiration is espe- 
 cially great, causing marked elevation of the upper por- 
 tion of the chest, while the partial vacuum that is pro- 
 duced in the lower portion of the lung causes depression 
 of the intercostal spaces, loss of expansion of the lower 
 portion of the thorax, and, in infants and young chil- 
 dren, yielding of the chest walls, depression of the lower 
 ribs and retraction of the abdomen. 
 
 (2) Expiratory Dyspnoea. In this form entrance of 
 air into the alveoli is fairly free, and the chief difficulty 
 is with the tidal air passing out of the alveoli, due to 
 plugging of the small bronchi with secretion or to 
 spasm of the bronchi themselves. This gradual over-' 
 filling of the alveoli (acute emphysema) causes enlarge- 
 
144 THE RESPIRATORY SYSTEM. 
 
 ment of the thorax; the movements of inspiration are 
 short and followed by a pause, while those of expiration 
 are prolonged and labored. During expiration the 
 accessory muscles are brought into play, and there is 
 bulging of the intercostal spaces and supraclavicular 
 fossa. 
 
 D. Bronchitis Involving the Lobular Bronchioles and 
 Alveoli. — The cyanosis is more marked ; the respirations 
 are rapid ; from thirty to forty, and may reach sixty, or 
 even more, per minute. The dyspnoea is chiefly inspira- 
 tory, with deep depression of the supraclavicular fossa 
 and intercostal spaces, and, as the bases of the lungs are 
 chiefly involved in children, there is marked drawing in 
 of the lower ribs, ensiform cartilage and epigastrium. 
 
 Palpation. — A. Bronchitis of Large Tubes. — Sur- 
 face temperature slightly raised ; respiratory movements 
 normal (free, rhythmical and symmetrical) ; vocal 
 fremitus normal, except when larynx is also involved, 
 when it is reduced in direct ratio to the huskiness of 
 the voice. 
 
 B. Bronchitis of Middle-sized Tubes. — In mild cases 
 the respiratory movements ^nd vocal fremitus are 
 within range of normal. In severe cases, with marked 
 congestion and tumefaction of the mucous membrane 
 and thick, tenacious secretion, the movements are 
 slightly more rapid and somewhat labored, vocal reso- 
 nance is diminished, and when large bronchi are 
 plugged, there is restricted motion over portion of 
 lungs supplied by occluded tubes and absence of vocal 
 fremitus. Khonchal fremitus is sometimes present. 
 
 0. Bronchitis of Smaller Tubes. — In mild cases vocal 
 fremitus may be normal or slightly diminished. In 
 severe cases, in proportion to the obstruction, the move- ' 
 ments will be rapid and labored, and vocal fremitus 
 feeble or even absent. In children, and sometimes in 
 adults with thin, elastic chest walls, rhonchal fremitus 
 is present. 
 
 p. Bronchitis Involving Smallest Bronchioles and 
 
DISEASES OF RESPIRATORY TRACT. 145 
 
 Alveoli. — Vocal fremitus is diminislied, or even absent, 
 when obstruction is extreme. When inflammation has 
 extended to the alveoli, causing consolidations of lung 
 (broncho-pneumonia) close to the costal surface, vocal 
 fremitus may be increased. 
 
 Percussion. — A. Bronchitis of the Large Tubes. — 
 As there is no change in the structure or tension of the 
 pulmonary tissue or size of the air-containing spaces, 
 percussion soimd will be normal in quality, intensity, 
 pitch and duration. 
 
 B. Bronchitis of the Middle-sized Tubes. — Percus- 
 sion sound is normal imless one of the tubes is pltigged. 
 If the portion of lung supplied by occluded bronchus 
 is in contact with costal surface, the percussion sound 
 will have a slight tympanitic quality. If the surround- 
 ing portion of the lung that is in state of compensatory 
 emphysema is reached by percussion, the sound will be 
 hyper-resonant. 
 
 0. Bronchitis of Smaller Tubes. — In mild cases 
 slight dullness in percussion may be present over lower 
 portion of lung. In severe cases over portion of chest 
 which is in a state of more or less compensatory 
 emphysema, there is a varying degree of hyper-reso- 
 nance, while over the lower portion, when there is 
 inspiratory dyspnoea, imperfect expansion, collection 
 of secretion in bronchioles and alveoli, with partial 
 collapse of the lung; there is dullness, with slight 
 tampanitic quality. When the dyspnoea is expiratory, 
 with distension of the alveoli, there is hyper-resonance. 
 
 D. Bronchitis Involving Bronchioles and Alveoli. — 
 Over areas of secondary bronchial pneumonia, if near 
 the surface and of sufficient size, the percussion is dull 
 in proportion to the extent of consolidation. As sur- 
 rounding vesicles are frequently in a state of collapse, 
 the note may be dull, with tympanitic quality. When 
 the consolidated area is small and overlapped by dis- 
 tended emphysematous lobules, the percussion note may 
 be normal or hyper-resonant. 
 10 
 
146 THE RESPIBATOBY SYSTEM. 
 
 Auscultation. — A. Bronchitis of Large Tubes. — In 
 mild cases there is no change in normal breath sounds. 
 In the more severe types of the disease, during the dry- 
 stage, the normal ttibukr sound heard over the trachea 
 and large bronchi has a harsher quality, due to the 
 slight narrovsring of the tubes. When secretion is 
 present, if tenacious, it may produce local narrowing, 
 causing coarse, sonorous rales. If the secretion is more 
 liquid, a few large moist or mucous rales, which are 
 easily removed by coughing, may be present. In the 
 adult marked auscultatory signs are the exception; in 
 children they are present more frequently. Vocal 
 resonance is unchanged. 
 
 B. Bronchitis of Medium-sized Tubes. — In mild 
 cases the breath sounds over the lung are normal, except 
 that during the dry stage the quality is slightly harsher 
 and the expiratory part of the sound is longer, but 
 unchanged in quality and pitch. When the amount of 
 fluid present in the tubes is fairly abundant, large and 
 medium-size liquid, bubbling rales are heard during 
 both inspiration and expiration. In more severe cases, 
 when the lumen of the bronchi is narrowed by the con- 
 gested and swollen mucous membrane during the dry 
 stage, the respiratory mtirmur is less intense than nor- 
 mal during inspiration, while in expiration it is pro- 
 longed and has a faintly sonorous quality, which may 
 be mistaken for a type of bronchial breathing. From 
 this it is differentiated by being heard over both lungs 
 and by the absence of the associated signs of consolida- 
 tion, dullness and increased vocal fremitus. When the 
 fluid is abundant and tenacious, sonorous and sibilant 
 rales and rhonchi are present. These adventitious 
 sounds may mask the respiratory murmur ; they are apt 
 to be inconstant, are easily changed in character by 
 coughing and deep breathing, and are heard over both 
 lungs with equal intensity. When the secretion is more 
 liquid, dry rales are less prominent, and heard chiefly 
 over the upper portion of the lung, while large and 
 
DISEASES OF EESPIEATOBY TRACT. liY 
 
 medium-sized liquid, bubbling rales predominate. They 
 are most abundant at the base, as the secretion tends to 
 gravitate to the most dependent portion of the lung, 
 especially in children and feeble adults. As the 
 smaller tubes become involved, either by extension of the 
 inflammation or by gravitation of the secretions into 
 them, the dry rales become more sibilant and the moist 
 rales finer and more crepitating. Vocal resonance is 
 normal or slightly diminished. 
 
 G. Bronchitis of the Smaller Tubes. — The respiratory 
 murmur may show very little change during the dry 
 stage ; the intensity of inspiratory sound is diminished, 
 the quality being somewhat harsher and dry, the pitch 
 unchanged. The expiratory sound is more intense 
 than that of inspiration ; the sound is prolonged, and 
 may have a harsher, blowing quality. When liquid is 
 present, sibilant rales and smaller mucous rales accom- 
 pany both sounds. In direct proportion to the severity 
 of the case, the respiratory sounds are diminished in 
 intensity, and may be obscured and replaced by hissing, 
 sibilant rales and small liquid rales and crepitations. 
 As the secretion accumulates in the bronchi, it tends to 
 gravitate to the lower part of the lung, so that over this 
 portion the small, bubbling and crepitating rales will be 
 most marked, while over the upper portion of the lung 
 the moist rales will be coarser and the sibilant rales 
 more abundant. 
 
 D. Bronchitis Involving the Lobular Bronchioles and 
 Alveoli. — Extension of inflammation into the lobular 
 bronchioles and alveoli (broncho-pneumonia) is shown 
 by the more or less intense bronchial quality of the 
 breath sounds, especially marked during expiration; 
 the rales heard over the areas of bronchial breathing are 
 finer, more ringing or crepitating than those heard in 
 simple bronchitis, and are most abundant just at the end 
 of inspiration. Vocal resonance is increased over areas 
 of consolidation. 
 
 DiflFerential Diagnosis. — The diagnostic features of the 
 different varieties of acute bronchitis are: (1) There 
 
148 THE BESPIBATOBY SYSTEM. 
 
 is a bilateral distribution of all the physical signs. (2) 
 In proportion to the severity of the disease, the smaller 
 bronchi become involved, giving more marked physical 
 signs over the lower portion of the chest. (3) The 
 physical signs detected are those due to changes in the 
 bronchial tubes only, i. e., the presence of rales of vary- 
 ing size and interference with the movement of tidal air. 
 
 The diseases with which acute bronchitis is most 
 liable to be confounded are : 
 
 Broncho-Pneumonia (Acute Catarrhal Pneumonia). — In 
 both diseases the signs are bilateral, most intense at 
 the base of the lung, and there are numerous rales. But 
 in broncho-pneumonia there is not the same uniformity 
 of distribution. Broncho-pneumonia gives, over the 
 area of consolidation, increased vocal fremitus. Uncom- 
 plicated acute bronchitis, diminished vocal fremitus. 
 Broncho-pneumonia, dullness of varying degree, accord: 
 ing to amount of lung involved. Bronchitis, but slight 
 change in resonance. Broncho-pneumonia, bronchial or 
 tubular quality of the breath sounds, which is absent in 
 bronchitis. 
 
 Acute Diffuse Pulmonary Tuberculosis. — The physical 
 signs in this disease are bilateral, and at the beginning 
 are almost identical with those of capillary bronchitis 
 with small areas of broncho-pneumonia, but the general 
 constitutional symptoms are graver. As the disease 
 advances, the physical signs become more distinctive. 
 
 Inspectioit. — Tuberculosis: Respirations are more 
 rapid ; cyanosis out of proportion to dyspnoea ; restricted 
 motion over the entire chest. Retraction of the thorax 
 most marked over upper portion of limg, and more 
 marked at one apex than the other. Bronchitis: 
 Retraction most marked over the lower lobes ; generally 
 increased fullness of tipper portion of the chest in pro- 
 portion to the retraction at base. 
 
 Palpatiow. — Tuberculosis : Vocal fremitus may at 
 first be diminished; later increased with extension of 
 consolidation. Simple bronchitis: Vocal fremitus 
 normal or slightly diminished. 
 
DISEASES OF RESPIRATORY TRACT. 149 
 
 Peecussiojst. — Tuberculosis: Eesonance early im- 
 paired, with slight dullness, due to change in the alveoli, 
 and early pleuritic involvement. Dullness is most 
 marked over the upper portion of the chest; there is 
 increased sense of resistance over the part involved. 
 Bronchitis : Percussion normal or hyper-resonant. 
 
 Auscultation. — The differential diagnosis rests 
 chiefly on the course of the disease and the distribution 
 of the rales. While in acute bronchitis, with the 
 dyspnoea and cyanosis, there is a corresponding number 
 of dry and moist rales, most marked at the base, in 
 tuberculosis the number of moist rales is comparatively 
 few, and they are as ntimerous, or even more so, at the 
 apex as at the base ; also there is generally an uneven dis- 
 tribution of the rales on the two sides. Later there is a 
 tendency for the signs of consolidation to become more 
 marked over different areas of the lung, and. to be fol- 
 lowed by signs of diffuse softening and cavity formation. 
 Frequently it is possible to find in some portion of the 
 lung, especially at the apex, an old focus, with its char- 
 acteristic physical signs of long-standing consolidation. 
 
 Pulmonary CEdema. — The differential diagnosis of 
 bronchitis from pulmonary oedema rests chiefly on the 
 order of occurrence of moist rales. In acute bronchitis 
 the larger tubes are primarily involved, and the rales 
 first detected are those of large size. With the extension 
 of the disease into smaller bronchi, rales of correspond- 
 ing size are also present, and are heard over the entire 
 lung. In pulmonary oedema fiuid collects in the alveoli, 
 and fine crepitating rales are first heard over the lower 
 borders and base of the lung. The larger rales are only 
 present when the oedema is extensive. 
 
 Chronic Bronchitis. 
 
 The physical signs of chronic bronchitis, when only 
 the mucotis membrane is involved, are similar to those 
 of the acute variety. Long continuance of the cough 
 
1 5 THE BESFIBA TOR Y SYSTEM. 
 
 interferes with the function of the lung, and repeated 
 attacks of acute or subacute bronchitis develop secondary 
 changes in the bronchi, alveoli and pulmonary tissue. 
 These changes determine the different types of chronic 
 bronchitis and cause its symptoms and physical signs 
 to be more or less characteristic of the secondary 
 changes, (a) bronchiectasis, (b) asthma or spasmodic 
 bronchitis, (c) emphysema, (d) fibroid or interstitial 
 pneumonia. 
 
 Types or Varieties of Chronic Bronchitis. — ^A. Simple 
 chronic catarrh of the large tubes (winter cough) ; 
 characterized by cough and slight expectoration, with 
 tendency to intercurrent attacks of acute bronchitis. 
 The structures of the lung are but slightly changed from 
 the normal. 
 
 B. Dry catarrh ; characterized by very little secretion 
 from the mucous membrane, by constant or persistent 
 cough, scanty or difEcult expectoration, presence of 
 dyspnoea. The constant and violent attacks of coughing 
 early induce emphysematous change, and acute attacks 
 of bronchitis may cause it to assume temporarily the 
 physical signs of the spasmodic type. The physical 
 signs are those of acute bronchitis during the dry stage. 
 
 C. Bronchitis with abundant secretion. Under 
 this may be included (1) bronchorrhcea, of which two 
 types are recognized, (a) cases in which the secretion is 
 thin, watery, slightly tenacious, resembling the white 
 of an unboiled egg. Severe paroxysmal attacks of 
 coughing and dyspncea occur in the morning, and may 
 last for one or two hours, after which the chest is clear ; 
 or they may be repeated at longer or shorter intervals, 
 followed by complete relief. From the character of the 
 symptoms and expectoration, the names "mucoid asthma" 
 and "bronchorrhcea serosa" have been given, (b) Cases 
 with sero-purulent or muco-purulent expectoration, 
 attended with almost constant coughing and frequent 
 attacks of paroxysmal dyspnoea. These attacks rapidly 
 induce structural changes in the lung of the emphysema- 
 
DISEASES OP RESPIRATOBY TRACT. 151 
 
 tous, bronchiectatic and fibroid types. (2) Fetid bron- 
 chitis. In this the secretions have undergone decompo- 
 sition, and may occur in bronchi that have not been 
 dilated, but is most frequently dependent upon dilata- 
 tion of the bronchi and long retention of secretion. 
 (3) Plastic bronchitis, in which the secretion is 
 coagulated in the bronchi, occluding them by fibrous 
 plugs. A still further subdivision of the types of 
 chronic bronchitis has been made upon the secondary 
 changes in tlie lung, as: D. Bronchitis with spasm 
 of the bronchi, spasmodic or asthmatic bronchitis. E. 
 Bronchitis with distension of the alveoli, emphysema- 
 tous bronchitis. F. Bronchitis with marked fibroid 
 or interstitial changes. 
 
 Physical Signs. Inspection. — A. There is no change 
 in the size, shape or movements of the chest. B. 
 Thorax early assumes emphysematous type. Move- 
 ments at first are exaggerated, and are more frequent. 
 Later, expansion interfered with. Expiratory dyspnoea. 
 C. In simple serous bronchorrhcea the respiratory move- 
 ments are similar to those of acute bronchitis ; in 
 chronic purulent catarrh and simple putrid bronchitis, 
 in the early stages, there is no change in the size or 
 movements of the thorax. Later it assumes the 
 emphysematous or fibroid type. Plastic bronchitis: 
 extreme dyspnoea. Loss of expansion on inspiration 
 especially marked over base of lung when localized to 
 small portion of bronchial tract or limited motion over 
 affected area. D. Thorax gradually assumes more or 
 less the condition found in emphysema ; the movements 
 of the chest are similar to those present during the 
 attack of spasmodic asthma. E. Chest emphysema- 
 tous in all respects. F. General retraction of the chest ; 
 loss of exDansion. 
 
 Palpation. — A. Negative. B. ISTegative or vocal 
 fremitus may be slightly diminished. C. Bronchor- 
 rhoea ; feeble vocal fremitus ; rhonchi felt during acute 
 paroxysmal attack. Plastic bronchitis; loss of vocal 
 
1 5 2 THE RESPIMA TOE Y SYSTEM. 
 
 fremitus over occluded tubes. D. Vocal fremitus fee- 
 ble; rhonchi frequently present. E. Vocal fremitus 
 feeble or absent. F. Increase of vocal fremitus espe- 
 cially marked over regions of large bronchi. 
 
 Pekcussion. — Percussion note is unchanged in the 
 milder types. When the lung has undergone emphy- 
 sematous changes the note is hyper-resonant. Fibroid 
 arid cirrhotic changes give more or less dullness, with 
 woodeny quality. 
 
 Auscultation. — A. Signs indefinite. Few large 
 moist rales may be detected, especially if secretion is 
 present. Over the large bronchi, the breath sounds may 
 be slightly roughened in character. B. Dry catarrh ; 
 respiratory murmur may be unchanged. C. In (1) 
 bronchorrhcea during the attack, large and small liquid 
 rales and sibilant and sonorous rales may be present. 
 Breath sounds obscured by loud noise of rales. After 
 expulsion of mucus, the respiratory murmiir may be 
 normal. (2) In fetid bronchitis the rales are more or 
 less constant. Breath sounds are feeble. (3) In plastic 
 bronchitis over that portion of the lung supplied by 
 occluded bronchus, there will be absence of all breath 
 sounds. D. In spasmodic bronchitis, as the name 
 implies, associated with the moist rales are the breatli 
 sounds and dry rales that characterize an acute 
 asthmatic attack. E. In emphysematous bronchitis 
 the breath sounds are feeble, especially the inspiratory 
 sounds, the expiratory portion being prolonged, low 
 pitched and usually attended with rales. F. In 
 chronic bronchitis with fibroid change the inspiratory 
 soimd is feeble, but the expiratory portion is prolonged, 
 high pitched and has a faint tubular character. 
 
 Differential Diagnosis. — Chronic bronchitis is separated 
 from the acute forms by the history of the attack and 
 the presence of secondary changes in the lung. The 
 various types of chronic bronchitis may be associated 
 with pulmonary tuberculosis. 
 
DISEASES OF BESPIBATOBY TRACT. 153 
 
 BRONCHIECTASIS. 
 
 Bronchiectasis is a distinct dilatation of tlie bronchial 
 tubes. It may be limited to a portion of one lobe only, 
 or may involve to a greater or less extent the bronchi of 
 one or both lungs. Bronchiectasis is never a primary 
 disease, but is secondary to some pathological change in 
 the walls of the bronchi which alters or destroys their 
 elasticity. The dilating force may be (a) increased 
 pressure within the ttibe caused by coughing; (b) trac- 
 tion on the walls, causing permanent enlargement of 
 their calibre. This traction may be diie to contraction 
 of bands of fibrous tissue in the interlobular septa, 
 especially when they are stretched from the bronchi out- 
 ward to the pleura. The dilatation of the bronchi may 
 be sacciilated or cylindrical. 
 
 The diseases with which bronchiectasis may be asso- 
 ciated as a complication are broncho-pneumonia, capil- 
 lary bronchitis with atalectasis, chronic bronchitis 
 affecting tlie large and medium-sized tubes, emphysema, 
 obstruction of the tubes from pressure from without, 
 interstitial change in the lung, as occurs in chronic 
 interstitial pneumonia (cirrhosis of the lung), in fibroid 
 phthisis, and in pleurisy with retraction. 
 
 Physical Signs. — The physical signs of bronchiec- 
 tasis depend (1) upon the disease with which it is 
 associated; (2) the nature of the dilatation, whether 
 cylindrical or fusiform; (3) whether the air passes 
 through the dilatation to structures beyond; (4) the 
 localization and distribution of the dilatations ;^ (5) the 
 proximity of the dilatation to the surface of the chest ; 
 (6) the size of the tubes involved; (7) the condition of 
 the cavity, whether full or empty. 
 
 Inspection. — The chest conformation of bron- 
 chiectasis is not typical. The shape and size of the 
 
 ' One lung, S2 pei- cent.; both lungs, 48 per cent. Of the unilateral cases the 
 uppei' lobe was Involved in 21 per cent.; middle lobe, 3 per cent.; lower lobe, 
 32 per cent., and the entire lung, 42 per cent. (Fowleb.) 
 
154 THE BESFIBATOBY STSTEM. 
 
 thorax are determined by that of the disease to which it 
 is secondary or with which it is associated. Three types 
 occur — the emphysematous, the retracted and the com- 
 bination of both, where retraction in one portion of 
 the chest is compensated for by emphysematous expan- 
 sion, at other portions. In the emphysematous type 
 the upper portion of the chest, especially the supra- and 
 infraclavicular spaces, are markedly distended, while the 
 lower portion shows more or less retraction. Motion 
 over the affected area is restricted according to the type 
 of the disease and the condition of the surrounding 
 lung. In mild cases, and when the disease is localized, 
 motion may be but slightly impaired. When general 
 or due to obstruction of the bronchi, the affected side 
 will be more or less retracted. 
 
 Palpation. — Vocal fremitus varies with the condi- 
 tion of the lung surrounding the bronchiectatic dilata- 
 tion. When involvement of the bronchi is associated 
 with emphysematous dilatation of the surrounding tis- 
 sue, vocal fremitus is normal . or diminished. Vocal 
 fremitus is absent in occlusion of the bronchi or filling 
 of the cavities with secretion, and also Avhen marked 
 pleural thickening has occurred. It is increased when 
 the lung is fibrous and the bronchial tubes are patent 
 beyond the dilatation. 
 
 Peecdssion.^ — Percussion note varies with the extent 
 of the lesion, the condition of the surrounding lung, the 
 nearness of the dilatation to the surface and the quantity 
 of secretion in the cavities. As many of these factors 
 are subject to frequent change, variation in the degree 
 of resonance is an important diagnostic sign. Wheii 
 dilatation of the bronchi is slight, and it is surroimded 
 by normal lung, the percussion sound may be normal. 
 When marked emphysematous dilatation with relaxa- 
 tion of the lung occurs, the soimd will be hyper-resonant, 
 with a somewhat tympanitic quality added, due to tlie 
 dilatation of the bronchi. When the dilatation of the 
 bronchus is large, and near enough to the surface to be 
 
DISEASES OF RESPIRATOBY TRACT. 155 
 
 influenced by the percussion, the sound will be tympa- 
 nitic or amphoric, according to the size. There will be 
 change in the note according as the mouth is open or 
 shut. When dilatation is surrounded by indurated 
 hmg, the note is dull, high pitched, with peculiar 
 tympanitic "boxy" or "boardy" quality. One of the 
 distinctive features of the percussion sounds of bron- 
 chiectasis is the localization of the change to the middle 
 or lower third of the chest, especially over the back. 
 
 AuscuLTATioisr. — The most important sign is the 
 blowing, hollow, but not tubular, sound when the dilata- 
 tion is cylindrical, and a cavernous sound when the 
 dilatation is sacculated. Both the inspiratory and 
 expiratory breath sounds are interrupted and wavy, the 
 blowing or cavernous quality being most marked just at 
 the end of inspiration (veiled puff). Moist rales are 
 present according to the amount and distribution of 
 secretion in the bronchi and cavity. When the dilata- 
 tions are cylindrical, the rales will have the character- 
 istics of those heard in simple bronchitis of large and 
 medium-sized tubes. But the size of the rales is larger 
 than would he found if the tubes in that region were of 
 normal calibre. In sacculated dilation the rales are 
 larger, more gurgling, with an occasional Croaking, 
 sonorous rale. When the dilatation is surroimded by 
 fibrous lung; the rales have a ringing? or metallic quality. 
 The occurrence of acute general bronchitis will change 
 the character of the physical signs present over the 
 cavity according as the bronchi are narrowed by inflam- 
 matory swelling or cavity filled with liquid secretion. 
 With the subsidence of acute bronchitis, instead of the 
 breath sounds returning to normal, the characteristic 
 sounds of dilatation are heard. Vocal resonance over 
 the cavity and whispered cavernous or amphoric breath 
 sounds may be heard, according to the size and condition 
 of the cavity and the surrounding lung. 
 
 Differential Diagnosis. — Bronchiectasis must be differ- 
 entiated from other diseases of the lung in which cavity 
 
156 TEE BESPIMA TOE Y SYSTEM. 
 
 formation occurs. The character of the physical signs 
 heard over the site of dilatation in bronchiectasis is not 
 pathognomonic, and a diagnosis of the nature of the 
 cavity can only be reached by exclusion. 
 
 Pulmonary Tuberculosis. — ^Pulmonary tuberculosis is 
 the most frequent cause of the cavities found in the 
 lung. 
 
 LocATioiir. — ISTon-tubercular, solitary bronchiectatic 
 cavities rarely involve the apices. It is most common 
 at the base, but may involve the middle or lower third 
 of the lung. Tuberculosis is especially likely to involve 
 one or both apices primarily, extending to the middle 
 and lower portions. In bronchiectasis the changes in 
 the portion of the lung involved are more or less 
 uniform. In phthisis limited portions of the lung may 
 show the different stages of the diseases. 
 
 Inspectiojst. — In bronchiectasis the retraction is most 
 marked over the lower portion of chest ; the upper por- 
 tion may be normal or show in supra- and infraclavicu- 
 lar spaces emphysematous dilatation. In tuberculosis 
 the retraction is most marked in the upper portion of 
 the lung; the supra- and infraclavicular spaces are 
 depressed. In bronchiectasis the patient is fairly Avell 
 nourished, and there is more or less duskiness of the 
 skin, congestion of the mucous membrane, fullness about 
 the lips and nose and the jugulars are distended. The 
 tuberculous patient is emaciated, the mucous membrane 
 and skin pale and anfemic and there is no distension 
 of jugulars. In bronchiectasis the heart is displaced 
 horizontally towards the diseased side ; epigastric pulsa- 
 tions are present. In tuberculosis the heart is displaced 
 upwards and obliquely, and without epigastric pulsation 
 except when it involves the base of the lung secondary 
 to changes in the pleura. 
 
 PALPATioisr. — In bronchiectasis vocal fremitus may 
 be diminished, except when marked fibroid induration 
 is the cause of the dilated bronchi. In tuberculosis vocal 
 fremitus is generally increased in proportion to the 
 amount of consolidated lung tissue around the cavity. 
 
DISEASES OF BESPIBATOBY TRACT. 15 Y 
 
 Peecussion. — Broncliiectasis : The supraclavicular 
 region is rarely dull ; its note is generally hyper-resonant 
 or emphysematous. Dullness most frequently present 
 over lower portion of chest. Tuberculosis: Dullness 
 at the apex, becoming more intense as consolidation 
 advances. Cavernous, amphoric or cracked-pot percus- 
 sion always follows a first stage of dullness. 
 
 Auscultation. — Bronchiectasis : The blowing, hol- 
 low sound of cylindrical dilatation and the cavernous 
 tubular sound of the sacculated form are unattended by 
 any signs of pulmonary consolidation. Normal breath- 
 ing sounds may be heard between the areas of cavern- 
 ous breathing. In tuberculosis the sound is cavernous 
 or amphoric. Bronchial breathing is heard over sur- 
 rounding lung. In bronchiectasis the signs indicate 
 that the cavities are of uniform size. In phthisis the 
 cavities are rarely uniform. In bronchiectasis the size 
 of the cavities remains stationary. In phthisis the 
 cavities gradually enlarge, with associated signs of 
 softening. 
 
 General Bronchitis and Fetid Bronchorrhoea. — Bronchiec- 
 tasis is distinguished from general bronchitis by absence 
 of fetor ; from simple fetid bronchitis or bronchorrhoea 
 the differential diagnosis is often extremely difficult. 
 
 The following signs are most important: Hollow, 
 blowing or cavernous or amphoric breath sounds, accord- 
 ing to the type of cavity. In general bronchitis vesic- 
 ular murmur is present, but diminished or feeble; 
 cavernous breathing not present. Size of rales has an 
 important significance. In bronchiectasis over cavity 
 there are large moist rales, mucous clicks and gurgles ; 
 they are larger than could occur if the lumen of bronchi 
 in that region was normal. In chronic bronchitis the 
 size of the rale corresponds to the normal size of the 
 tube. 
 
 Gangrene and Pulmonary Abscesses. — In pulmonary 
 gangrene and pulmonary abscess there may be one or 
 more cavities. When single, they generally follow some 
 
158 THE EESPIRA TOS Y SYSTEM. 
 
 inflammatory condition of the lung or adjacent viscera. 
 The signs of cavity formation are limited to a small 
 portion of the lung, and are more likely to be close to the 
 surface. The patient is acutely ill. Kespirations are 
 rapid and motion markedly interfered with over affected 
 area. Pulse is rapid, feeble and dicrotic. Before the 
 stage of excavation there is dullness on percussion ; vocal 
 fremitus is increased; there is bronchial breathing. 
 With the production of the cavity, the hollow, blowing, 
 cavemovis or amphoric quality of breath sounds will be 
 associated with the signs of more or less complete con- 
 solidation. When the cavities are multiple, they are 
 nearer to the surface of the lung than in bronchiectasis ; 
 there is early involvement of the pleura over affected 
 area. 
 
 In bronchiectasis the patient is usually well nour- 
 ished, and does not give the impression of being acutely 
 sick. Changes in respiratory movement are most 
 marked over lower third of lung. 
 
 Microscopical Examination. — Presence of elastic 
 fibres in the sputum is diagnostic of the destructive 
 process of gangrene and abscess. They are absent in 
 simple bronchiectasis. 
 
 Localized Empyema Opening into a Bronchus. — Local- 
 ized empyema opening into a bronchus, with localized 
 pyo-pneumo-thorax, may simulate a bronchiectatic 
 cavity, and is differentiated by the following: The 
 enlargement of the chest is localized at' the site of the 
 lesion. The percussion note is tympanitic when cavity 
 is empty. If it contains fluid, there will be zone of 
 flatness, which changes with the position of the patient. 
 Lung fistula sound is present rather than the hollow, 
 blowing or cavernous sound of bronchiectasis. 
 
 ACUTE CONGESTION OF THE LUNG. 
 
 Active hyperajmia of the lung may be general or local. 
 It depends on (a) cardiac overaction due to muscular 
 
DISEASES OF BESFIBATOBY TRACT. 159 
 
 exertion, cardiac stimulants, nervous or emotional 
 causes; (h) irritation of the respiratory tract due to 
 inhalation of steam, extremely cold air or other irri- 
 tants ; (c) determination of blood to the lungs by chill- 
 ing of the surface of the body or during the chill of 
 acute diseases, especially malaria ; (d) it occurs during 
 onset of all inflammatory diseases of the lung. 
 
 Physical Signs. — The physical signs will vary accord- 
 ing to the degree of congestion. The distension of the 
 blood-vessels is especially marked in the alveolar walls, 
 causing the pulmonary tissue to be increased in amount 
 and less elastic, with corresponding diminution in the 
 amount of tidal and residual air. 
 
 Inspectioi^. — Dyspncea, with respiration more rapid 
 than normal. 
 
 Palpation. — Vocal fremitus unaltered or slightly 
 increased. 
 
 Pekgussion. — Resonance slightly impaired; pitch 
 somewhat raised ; change in percussion note not suffi- 
 cient to give well-marked dullness. 
 
 AuscuLTATioiT. — The respiratory murmur has less 
 of the vesicular quality than normal; inspiration is 
 harsher and slightly higher pitched ; expiration is pro- 
 longed, higher pitched than inspiration, Avith a blowing- 
 quality. When localized, the above changes in the 
 physical signs are more noticeable by comparison with 
 the surrounding normal lung. 
 
 PASSIVE CONGESTION OF THE LUNG. 
 
 Passive hypersemia of the lung is caused by interfer- 
 ence with pulmonary circulation, due to (a) organic 
 lesions at the valvular orifices or to pressure of inter- 
 thoracic tumors ; (h) to insufficiency of cardiac power, 
 dependent upon myocardial disease or secondary to 
 adynamic conditions, as typhoid fever, ana?mia,^ etc. 
 Feebleness of respiratory movements favors stasis at 
 the borders of the lung, while gravity causes the circula- 
 
160 THE RE8PIBA TOB Y SYSTEM. 
 
 tion to be weakest in the most dependent portions (hypo- 
 static congestion), which varies with the posture of the 
 patient. 
 
 Long continuance of passive congestion causes exuda- 
 tion of serum into the interstitial tissue (hypostatic 
 pneumonia), into the alveoli, infundibula and bronchi 
 (pulmonary cedema), and red-blood cells and connective 
 tissue elements into the stroma of lung (brown indura- 
 tion). 
 
 Physical Signs. Inspection. — Dyspnoea; respiratory 
 movements most marked over upper portion of chest ; 
 loss of motion over base of lungs ; slight cyanosis, espe- 
 cially during sleep and on exertion. Patient gradually 
 assumes the sitting posture. 
 
 Palpation. — Vocal fremitus normal over upper por- 
 tion of lung; diminished along edge of lung and over 
 base in simple, passive congestion. When secondary' 
 changes (induration) occur, vocal fremitus is increased. 
 
 Pekcussion. — Upper portion of chest normal or 
 hyper-resonant ; over base, slight dullness, most marked 
 over right side below angle of scapula. Secondary 
 changes in the lung causes the dullness to be replaced by 
 flatness. 
 
 Auscultation. — Over upper portion of chest, the 
 breath sounds may be normal; or with inspiration 
 harsher and expiration blowing and prolonged. Over 
 the lower portion of the chest, the vesicular murmur is 
 feeble or absent. When induration occurs, the breath 
 sounds have a bronchial quality. Eales are present in 
 oedema. 
 
 In the early stage the physical signs are bilateral; 
 later they become more intense, according to the posture 
 of the patient, over certain portions of the lung. 
 
 PULMONARY CEDEMA. 
 
 Pulmonary oedema is never a primary condition, but 
 always secondary to (a) acute inflammation of the lung. 
 
DISEASES OF EESPIBATOllY TRACT. 161 
 
 (h) passive congestion, (c) or is part of a general 
 oedema. The oedema will be local or general, according 
 to the cause, and its distribution will be influenced by 
 the same factors that were mentioned xmder passive 
 congestion. 
 
 Physical Signs. Iwspectiobt. — The changes in size, 
 shape and motion will depend upon the condition to 
 which the oedema is secondary. Eilling of the alveoli 
 at the most dependent portion causes loss of motion, 
 with compensation elsewhere. 
 
 Palpation. — Vocal fremitus is diminished or absent 
 over the lower portion of the chest. Rhonchi may be 
 detected when fluid is present in the larger tubes. 
 
 Percussion. — Dullness in the early stage over the 
 base of the lung. As the air spaces become flUed with 
 fluid, dullness becomes more intense, and may be 
 replaced by flatness. The line of dullness gradually 
 extends upward with increased severity of the condi- 
 tion. 
 
 Auscultation. — The distinctive physical sign of 
 pulmonary oedema is the presence of fine, crepitating, 
 moist rales. In mild cases these are heard over the 
 most dependent portions and along the borders, while 
 over the rest of the lungs the breath sounds may be 
 normal. As the oedema becomes more intense and 
 involves the bronchi, rales of larger size and more 
 bubbling are also heard. 
 
 LOBULAR PNEUMONIA. 
 
 Synonyms. — Broncho-pneumonia, disseminated ca- 
 tarrhal pneumonia, pulmonary catarrh. 
 
 Lobular pneumonia is characterized by a filling of the 
 alveoli by inflammatory products, which differ from 
 those of lobar pneumonia in containing less of the fibrin 
 factors of the blood and more of the elements drawn 
 from the lining membrane of the alveoli and bronchi. 
 
 The pathological changes of lobular pneumonia may 
 11 
 
162 THE RESPIRATORY SYSTEM. 
 
 be due to a variety of causes : (a) Capillary bronchitis, 
 (h) acute pulmonary catarrh of whooping cough and 
 other infectious diseases ; (c) passive or hypostatic con- 
 gestion, (d) pulmonary infarction, (e) diffused tuber- 
 cular infection. (See Pulmonary Tuberculosis.) 
 
 The distribution of the areas affected by catarrhal 
 pneumonia will vary according to the nature of the 
 cause; the type is determined by the phvsical signs. 
 The affected lobules may be widely and fairly evenly 
 scattered through both lungs, and separated by normal, 
 emphysematous or collapsed lobules, giving (A) the dis- 
 seminated type of lobular pneumonia. Usually a 
 number of adjacent lobules are involved, and produce 
 well-marked patches of consolidation in different por- 
 tions of the lung. (B) The confluent type is due to the 
 coalescence of these patches, causing one or more lobes 
 to be almost completely consolidated, producing a condi- 
 tion which gives physical signs almost identical with 
 those of lobar or croupous pneumonia. 
 
 Physical Signs. A. Disseminated Lobular Pneumonia. 
 ■ — The physical signs of this form have been described 
 under D. Acute Bronchitis. 
 
 B. Confluent Lobular Pneumonia. — The physical signs 
 differ from those of the disseminated type, as follows : 
 
 Inspection. — Dyspncea is more markedly obstructive 
 during inspiration. As both lungs are not equally 
 involved, deficient expansion, is more marked over one 
 side of the thorax. When due to passive or hypostatic 
 congestion, loss of motion is most marked over the base 
 or dependent portions. 
 
 PALPATiON.^Vocal fremitus may be increased when 
 the areas of consolidation are close to the surface. When 
 they are separated from the surface by emphysematous 
 lung or surrounded by collapsed lobules, vocal fremitus 
 may be normal or diminished. 
 
 Percussion. — In the early stage percussion may be 
 normal. When surrounded by collapsed lung, the per- 
 cussion note is dull, but of a tympanitic quality. With 
 
DISEASES OF RESPIRATORY TRACT. 163 
 
 increase in consolidation, the resonance is diminished, 
 the note becomining dull and high pitched. 
 
 Auscultation. — The change in the breath sound will 
 vary with the amount of pulmonary consolidation and 
 its relation to the surface of the chest. When the con- 
 solidated area is deep seated or surrounded by normal, 
 emphysematous or collapsed lung, the bronchial quality 
 will not be heard, or it will be faintly detected only at 
 the end of expiration (see Fig. 24). The nearer the 
 pneumonic patch approaches the surface, the more dis- 
 tinctly will the bronchial breathing be heard. The 
 rales heard over the consolidated part differ from those 
 heard in bronchitis, in being more uniform in size ; their 
 number is fairly constant, and the quality is clearer, 
 higher pitched and more definitely ringing, resembling 
 the crepitant and subcrepitant rales of lobar pneumonia. 
 
 Differential Diagnosis. Pulmonary Collapse (Atalectasis.) 
 — ^Pulmonary collapse and lobular consolidation are 
 both common in extensive bronchitis of the smaller 
 tubes, and are usually associated. The physical signs 
 will vary according as one or the other condition is 
 predominant. 
 
 IsrsPECTiON. — In both conditions motion is restricted, 
 especially over the lower portion of the chest. 
 
 Palpatioist. — In consolidation vocal fremitus is nor- 
 mal or slightly increased. In pulmonary collapse vocal 
 fremitus is diminished or absent. 
 
 Pebcussion. — In pulmonary consolidation the per- 
 cussion note is dull. In pulmonary collapse there is 
 diminished resonance, with tympanitic quality. 
 
 Auscultation. — In consolidation the breath sounds 
 are more or less bronchial in character. In pulmonary 
 collapse the breath sounds are feeble or absent. Vocal 
 resonance, in consolidation increased ; in collapse, feeble 
 or muifled. 
 
 Acute Disseminated Tuberculosis. — Differential diag- 
 nosis between acute disseminated tuberculosis with soft- 
 ening and disseminated lobar pneumonia is extremely 
 
] 64 THE RESPIBATOBY SYSTEM. 
 
 difficult. Physical signs may be identical, the location 
 of the two conditions being frequently the only dis- 
 tinctive point. Tuberculosis affects especially the 
 apices, while lobular pneumonia involves the lower 
 lobes, especially the base. 
 
 Acute miliary tuberculosis without softening is dif- 
 ferentiated from broncho-pneumonia in that it involves 
 the apex, and rales are not common. 
 
 Broncho-pneumonia involves the base, and is attended 
 with rales. 
 
 Lobar Pneumonia. — Lobular pneumonia may be so 
 extensive as to consolidate more or less completely an 
 entire lobe. Lobular pneumonia, even when more or 
 less lobar in character, does not present the uniform 
 consolidation that occurs in lobar pneumonia, nor is it 
 limited to one lobe or to one lung. In the second stage 
 of lobar pneumonia over the affected portion of the lung 
 the breath sounds are usually clear and unattended with 
 rales. 
 
 LOBAR PNEUMONIA. 
 
 In lobar or croupous pneumonia the alveoli and 
 smaller bronchi are filled with an exudate composed of 
 coagulated fibrin and cellular elements. During the 
 course of the disease the pathological changes that occur 
 pass through three definite stages. 
 
 1, Stage of Engorgement. — The lungs are intensely 
 congested, especially in the affected lobe, whose dis- 
 tended blood-vessels interfere with its expansion and 
 elasticity; the pulmonary tension is altered, and there 
 is slight enlargement of the lobe. There is more or 
 less liquid secretion in the alveoli and bronchioles, and 
 also oedema of the subpleural and pleural tissues. There 
 may also be a layer of plastic material on the free sur- 
 face of the pleura. This stage may last from a few 
 hours to three or four days. 
 
 2. Stage of Red Hepatization, or Consolidation. — In this 
 stage there is distension of the alveoli and bronchioles 
 
DISEASES OF RESPIRATORY TRACT. 165 
 
 with serum, leucocytes and red-blood corpuscles. The 
 serum coagulates and holds in its meshes of fibrilated 
 fibrin the corpuscular elements. The consolidated por- 
 tion is airless and "in a state of immovable expansion 
 more densely solidified than it could be by any artificial 
 injection with coagulable fluid." (Powell.) 
 
 The pleura over the consolidated portion is covered 
 with a layer of the same coagulated exudate. In addi- 
 tion, the pleural sac may contain fluid serum, which may 
 be clear, txirbid, blood-stained or purulent. Complete 
 consolidation of the affected lobe may occur in a few 
 hours, or, beginning in a circumscribed portion, it may 
 be days before it extends throughout the entire lobe ; or 
 it may remain limited to a portion of the lobe oidv. 
 This stage lasts usually from five to seven days, termi- 
 nating with the crisis. 
 
 3. State of G-ray Hepatization, or Besolution. — The 
 changes that take place during the stages of engorgement 
 and consolidation are fairly constant and rapid. Those 
 that occur during the third stage may be variable. At 
 the beginning of the stage of gray hepatization the biilk 
 of the lung is greater than in that of red hepatization, 
 but it is less firm. The solid coagulum in the alveoli 
 undergoes liquefaction ; air again enters the alveoli, pass- 
 ing through the liquid exudate, giving rise to large moist 
 rales that are named rale redux. The third stage of 
 pneumonia may terminate in (a) resolution. The con- 
 tents of the alveoli are removed by absorption and 
 expectoration; the lung regains its resiliency and 
 returns to normal condition. In the majority of cases 
 perfect resolution and recovery occurs. 
 
 (h) Purulent Infiltration and Abscess of the Lung. — ■ 
 In this condition the coagulated fibrin liquifies, but, 
 instead of fatty degeneration and absorption of the cor- 
 puscular elements, a suppurative inflammatory process 
 contimies ; there is destruction of the lung tissue and the 
 formation of cavities of varying sizes. 
 
 (c) Gangrene results from failure of nutritive circu- 
 
166 THE BESPIBA TOE Y SYSTEM. 
 
 lation, either through, thrombosis of the large vessels or 
 capillary stasis. 
 
 (d) Unresolved or Chronic Pneumonia. — ^In this con- 
 dition the changes that ordinarily occur with the crisis 
 are absent. There is a proliferation of new cells in the 
 tissues of the lung and also in the alveoli. These organ- 
 izes into new tissue, and there is a gradual development 
 of fibrous tissue in the alveoli. 
 
 Physical Signs. — The physical signs of pneumonia have 
 been divided into three stages, corresponding to the 
 pathological changes in the lung. It must be constantly 
 borne in mind that these pathological divisions are 
 largely arbitrary, and that as the transition of one stage 
 into the other may be rapid or gradual, so the physical 
 signs of one stage merge into those of the succeeding 
 stage. 
 
 Inspbotion.^ — First Stage. Patient lies on the 
 affected side; circumscribed flush (pneumonic spot) 
 over one or both malar bones; repiration rapid, 25 to 
 40, panting in character, especially during expiration. 
 Motion on affected side slightly restricted. When the 
 pleura is not involved, the movements of the two sides 
 may be equal. When pain (pleurisy) is present, 
 motion is less on the affected side than on the opposite ; 
 inspiration is either catching or restrained ; expiration is 
 slow. Movements of the opposite side are exaggerated. 
 
 Second Stage. Face dusky; marked movements of 
 the nares ; breathing rapid and panting. Slight enlarge- 
 ment of the affected side of the chest. Motion on the 
 affected side diminished, with compensatory movement 
 on the opposite side. Breathing will be costal or 
 abdominal, according as the upper or lower lobes 
 are involved. Involvement of the diaphragm (dia- 
 phragmatic pleurisy) causes absence of abdominal 
 breathing. 
 
 Third Stage. With the absorption of the exudate, 
 movements of the affected side gradually return to 
 normal. 
 
DISEASES OF RESPIEATOBr TBACT. 167 
 
 Palpation. — First Stage. During the early stage 
 of engorgement vocal fremitus is normal or slightly 
 diminished. As consolidation, occurs, it gradually 
 increases in intensity. 
 
 Second Stage. When consolidation of the lung is 
 complete, vocal fremitus is greatly increased. In cen- 
 tral pneumonia vocal fremitus may be but slightly 
 increased. It is diminished in marked thickening of 
 the pleura, and absent when effusion occurs in the 
 pleural sac, and also when the large bronchi leading 
 to consolidated portion is blocked. Friction fremitus 
 may be felt over the affected part in the earlier stages of 
 consolidation, while movement of the lung is still 
 possible. 
 
 Third Stage. There is gradual diminution of vocal 
 fremitus with return to the normal. During the early 
 stage of resolution, blocking of the bronchus is most 
 likely to occur, with a temporary absence of vocal 
 fremitus. After paroxysms of coughing vocal fremitus 
 may retiirn. Absence of vocal fremitus after the 
 removal of exudate from the alveoli is due to exudation 
 on the pleura or filling of the pleural sac. 
 
 Pbegtjssion. — First Stage. Percussion note at first 
 may show no change. As congestion increases, the 
 intensity diminishes; it is shorter in duration, higher 
 pitched and resonant, but with a slight tympanitic 
 quality. The dullness of consolidation is most apt to 
 appear first just beneath the angle of the scapula and 
 to develop towards the axillary line. As air in the 
 alveoli is replaced by the solid exudate, the note becomes 
 duller, higher pitched and less resonant, until complete 
 consolidation. 
 
 Second Stage. The percussion note is dull and high 
 pitched, but even in complete consolidation resonance is 
 present in a very slight degree. The sound is flat if 
 pneumonia is complicated by extensive pleuritic 
 changes. 
 
 When consolidation of the lobe is not complete, the 
 
168 THE KESPIEATOBY SYSTEM. 
 
 air-containing, but relaxed, lobules scattered through the 
 consolidated portion cause the percussion note to have 
 a dull, tympanitic or tubular quality. When the pneu- 
 monia is central and air-containing lung is interposed 
 between the chest wall and the consolidated portion, the 
 character of the percussion note will depend upon the 
 condition of the interposed lung, (a) When the lung is 
 in a state of compensatory emphysema and tension is 
 increased, the percussion note gives increased resonance. 
 (h) When the lung is relaxed, the percussion note is 
 dull, with tympanitic or cavernous quality. Percussion 
 dullness is especially apt to be absent in children and in 
 old persons, due to the elasticity of the chest Avail in 
 children and the emphysematous condition of the lung, 
 associated with rigid thorax, in the aged. 
 
 The normal boundaries of the lobes are changed,' so 
 that when the lower lobe is involved the dullness extends 
 higher than the normal outline, and may be detected 
 almost to the upper portion of the scapula. When the 
 upper lobe is involved, the dullness is most marked 
 anteriorly. Enlargement of the consolidated portion 
 allows of relaxation of the unaffected portions of the 
 lung on the same side, over which a peculiar tympanitic 
 resonance is obtained — Skoda's resonance. Percussion 
 over the opposite lung shows exaggerated percussion 
 note, due to compensatory emphysema. 
 
 Third Stage. As the removal of the exudate con- 
 tinues and the alveoli again contain air, the percussion 
 sound becomes more resonant. The pulmonary tissue 
 does not at once regain its normal elasticity, and fre- 
 quently with the return of resonance the sound has a 
 more or less tympanitic quality and is low pitched, on 
 account of the relaxation of the lung. Dullness may 
 be continued after resolution is well advanced, owing to 
 the presence of pleural exudate. Flatness over the base 
 of the lung occurs in cases of unabsorbed effusion in the 
 pleura or the occurrence of empysema. It was noted 
 above that lobar pneumonia in children is frequently 
 
DISEASES OF BESPIEATOBY TRACT. 169 
 
 unattended with marked dullness. The presence of 
 well-marked dullness, with increased resistance over the 
 lower portion of the lung, is usually due to the occur- 
 rence of acute empyemia during the course of a pneu- 
 monia. 
 
 Auscultation. — First Stage. In the earliest stage 
 of engorgement the breath sounds are weaker than 
 normal over the affected portion. Over adjacent por- 
 tions the breath sounds are slightly exaggerated ; later, 
 as the engorgement increases, the breath sounds become 
 harsher, especially marked during expiration. As the 
 exudation fills the alveoli, the inspiratory portion of the 
 breath sound loses its vesicular element, has a faint 
 blowing quality, and the pitch becomes higher. The 
 expiratory portion is at first slightly prolonged, higher 
 pitched, with a distinct bronchial character. As the 
 consolidation becomes more marked, there is a gradual 
 disappearance of the normal vesicular murmur and an 
 increase in the intensity of the bronchial breathing. 
 
 The crepitant rales (rale indux), which has been 
 considered by some authors as characteristic of this 
 stage of pneumonia, may be present before percussion 
 dullness or the occurrence of the bronchial type of 
 breathing. The crepitant rale is not always present. 
 It may be absent (a) when the consolidation is central 
 and there is no pleural involvement ; (}>) when complete 
 consolidation occurs very rapidly; (c) in secondary 
 pneumonia. When pneumonia is superadded to acute 
 bronchitis, large and small moist rales may be present 
 and mask the crepitant rale and the early changes in the 
 breath sounds. The crepitant rale, when present, is of 
 important diagnostic significance. 
 
 Second Stage. Bronchial breathing during tlie 
 second stage is present in proportion to the degree of 
 consolidation. As the alveoli becomes filled, the breath- 
 ing passes from a stage of high-pitched, prolonged 
 expiration, broncho-vesicular, to pure tubular and 
 laryngeal breathing. The bronchial, tubular and 
 
170 THE RESPIRATORY SYSTEM. 
 
 tracheal breathing that is present in pneumonia differs 
 from that heard over the bronchi, trachea and larynx in 
 the normal lung. It is higher pitched; expiration is 
 more prolonged, and the tubular element has a peculiar, 
 distinct, "audible" quality, which is a striking feature 
 of the sound. Although it may not be very loud, this 
 quality of the sound is easily detected when present. 
 This distinctive quality of the breath sound in pneu- 
 monia is due to the resonating influence of the dense 
 consolidated lung on the vibrations brought to it by the 
 walls of the bronchi. In central pneumonia the inter- 
 posed unconsolidated lung causes the breath sounds to 
 have a combined distinct bronchial breathing, associated 
 with normal vesicular murmur. The bronchial element 
 in these cases is especially marked during expiration. 
 When the amount of consolidation is slight and situated 
 deep in the lung, the bronchial sound may not be 
 detected as such, but a high-pitched, blowing sound 
 may be heard after the expiratory sound of the normal 
 lung has ceased. In cases of central pneumonia, 
 increased vocal resonance (bronchophony) may be the 
 only sign present. Plugging of a large bronchus causes 
 the bronchial breathing to be absent. This is especially 
 apt to occur in the massive type of pneumonia. Thick 
 exudation upon the pleura or effusions into the pleural 
 cavity gives a weakening or absence of the bronchial 
 sounds. Effusions into the pleural cavity, especially 
 where they occur before the stage of complete con- 
 solidation, give a type of breathing that is similar to 
 cavernous breathing. In pneumonia affecting the 
 upper lobes of the lung, feebleness or absence of bron- 
 chial breathing may occur Avithout blocking of the 
 bronchus or the interference of thick pleural exudate. 
 Over the unaffected portion of the same side, the respira- 
 tory sounds may be feeble or exaggerated, according as 
 the lung is relaxed or is in a state of compensatory 
 emphysema. Over the opposite lung the breath sounds 
 are exaggerated. Frequently bronchial breath sounds 
 
DISEASES OF RESPIRATORY TRACT. 171 
 
 may be transmitted to the opposite side, suggesting the 
 occurrence of double pneumonia. Vocal resonance is 
 increased in intensity in proportion to the degree of 
 consolidation, and corresponds to the various changes 
 that occur in the bronchial breathing. Pectoriloquy 
 is present in complete consolidation. In central pneu- 
 monia, when uninvolved overlying lung masks the 
 physical signs, increase in vocal resonance may be the 
 only diagnostic symptom present; it should always be 
 sought for in doubtful cases, especially in the aged. 
 
 Third Stage. The earliest indication of change in 
 the consolidated lung is that the peculiar, clear, "audi- 
 ble" character of the bronchial breathing of the 
 second stage is lost. The breath sounds become bron- 
 chial, and their vibratory quality gradually disappears. 
 With these changes in the bronchial sounds, air again 
 enters the bronchioles and alveoli, and medium-sized 
 rales (rale redux) are heard with inspiration and 
 expiration. As the alveoli become free of the exudate, 
 the moist rales diminish in number and finally dis- 
 appear. The vesicular quality returns as the bronchial 
 is lost. 
 
 As the lung does not at once regain its normal 
 elasticity, the expiratory sound may for a variable time 
 be slightly prolonged and low pitched. In chronic 
 unresolved pneumonia the signs of the secondary stage 
 persist for a long time, and are gradually replaced by 
 those of chronic interstitial pneumonia. When the 
 pneumonic area undergoes purulent infiltration, the 
 rale redux is associated with or displaced by larger 
 liquid rales ; the bronchial element of sound persists, 
 and later, with the destruction of lung tissue, cavernous 
 breath sounds are present. 
 
 Vocal Resonance. — ^With the beginning of the third 
 stage, pectoriloquy of the second stage is replaced by 
 bronchophony, which gradually diminishes in intensity 
 until it becomes exaggerated resonance. With the com- 
 pletion of resolution, the voice sounds return to the 
 normal. 
 
172 THE RESPJBATOBY SYSTEM. 
 
 Differential Diagnosis. Acute Pulmonary Congestion — 
 
 During the early part of the first stage of pneumonia 
 the harsh respiratory murmur over the lung is due to 
 acute congestion of the entire respiratory tract. As the 
 localization of the congestion occurs in the lobe that is 
 to be affected, there will be a gradual increase in the 
 harshness of the respiratory murmur in comparison 
 with the rest of the lung. 
 
 Pleurisy with Effusion. — During the stages of consoli- 
 dation and resolution, pneumonia may be confounded 
 with effusion into the pleural cavity. It is especially 
 important that these two conditions be differentiated, 
 on account of the frequency with which empyema fol- 
 lows pneumonia, especially in children. 
 
 Inspection. — In pneumonia the size of the chest is 
 only slightly increased; the intercostal spaces persist, 
 not being flattened or bulged ; motion of the affected 
 side is limited ; of the opposite, slightly increased. In 
 effusion into the pleura the enlargement of the affected 
 side is marked; there is flattening or bulging of the 
 intercostal spaces. The motion over lower portion of 
 the chest is absent. Position of the heart: In pneu- 
 monia the apex beat is in a normal position. In 
 effusions the heart is displaced. Location of the apex 
 beat of the heart is one of the most important signs in 
 separating the two conditions. 
 
 Palpation. — In pneumonia the vocal fremitus is 
 . markedly increased, except when the bronchus is 
 plugged. In effusion vocal fremitus is absent, and is 
 only detected when adhesions are present. In pneu- 
 monia the diaphragm is not displaced downwards, and 
 there is no change in the position of the abdominal 
 organs. In effusion there is marked displacement of 
 the diaphragm; the liver or spleen are palpable below 
 the free border of the ribs. 
 
 Pbecussion. — In pneumonia the note is dull, but 
 still resonant; it is not flat. In effusion, note flat or 
 toneless. In pneumonia the area of percussion dullness 
 
DISEASES OF BE8PIRAT0BY TBACT. ITS 
 
 follows the anatomical division of the lung. In effusion 
 it follows a curved line, being highest in the axilla. 
 Skoda's resonance may be present in both conditions. 
 
 Auscultation. — In pneumonia the breath sounds 
 over area of dullness are bronchial or tubular in char- 
 acter. The sound gives the impression of being pro- 
 duced close to the surface. In effusion the breath 
 sounds are absent over the lower portion of flatness; 
 may be present at the upper level of the fluid, and differ 
 from those of pneumonia in lacking clearness and being 
 more or less distant from the surface. In pneumonia 
 during the stage of resolution, rales are present. In 
 effusion, liquid rales are not detected ; friction rales may 
 occasionally be heard. 
 
 Vocal Resonance. — In pneumonia, bronchophony or 
 pectoriloquy is present. In effusion over lower por- 
 tion of thorax, the voice sounds distant from the ear. 
 Over the upper portion of the fluid pectoriloquy of a 
 peculiar nasal character is heard (a^gophony). 
 
 Hemorrhagic Infarction. — In hemorrhagic infarction 
 the consolidation of the lung is due to the presence in 
 the alveoli of the affected area of coagulated blood, so 
 that the physical condition of that portion of the lung 
 involved by hemorrhagic infarction is identical with 
 that of a localized lobar pneumonia. Differential diag- 
 nosis is based on the position and distribution of the 
 consolidation and the presence of valvular disease of the 
 heart. In pneumonia the entire lobe is usually 
 involved. Hemorrhagic infarction is localized, and is 
 generally most apt to occur at the lower portion of a 
 lobe and along its border. In pneumonia, unless com- 
 plicated by organic cardiac disease, there are no adventi- 
 tious heart sounds. Hemorrhagic infarction is generally 
 associated with the physical signs of valvular lesion of 
 the heart. The dyspnoea in pneumonia is panting ; the 
 patient lies upon the affected side or more or less 'flat 
 upon the back. In hemorrhagic infarction the patient 
 assumes the position of orthopnoea during the early por- 
 tion of the attack. 
 
174 THE nESPmATOBY SYSTEM. 
 
 Collapse of the Lung. — When this condition occurs in 
 children, or when it affects the entire lobe, differential 
 diagnosis may be very difficult. On inspection, in 
 pneumonia, there is slight enlargement of the side. In 
 collapse, retraction of the side occurs. In pneumonia 
 there is increased vocal fremitus. In collapse, fremitus 
 is diminished or absent. 
 
 In pneumonia there is dullness on percussion. In 
 collapse the resonance is slightly impaired and asso- 
 ciated with marked tympanitic quality. 
 
 In pneumonia there is well-defined bronchial breath- 
 ing. In collapse the breath sounds are feeble; may 
 have slight bronchial character, but are indistinct and 
 distant from the ear. Pneumonia, during first and 
 third stages adventitious sounds present. Collapse, 
 these signs may be absent. 
 
 CHRONIC INTERSTITIAL PNEUMONIA. 
 
 Synonyms. — Cirrhosis of the lung. Fibroid phthisis. 
 
 The distinctive pathological change in this type of 
 pulmonary disease is the increase in the fibrous struct- 
 ures of the lung. This overgrowth of connective tissue 
 may be limited to the peribronchial tissue of the larger 
 or medium-sized tubes. It may affect the interlobular 
 septa, extending into the interlobular wall. In other 
 cases it primarily involves the walls of the alveoli 
 themselves, while in others it starts in the subpleural 
 and pleural tissues and gradually extends inwards. It 
 is rare to find fibroid induration limited to the different 
 tracts above mentioned, although it may have its origin 
 in one or the other of them. 
 
 The effect of increase of fibrous tissue is (a) to 
 increase the solid structures of the lung, (h) Accord- 
 ing to the law of fibrous tissue, contraction takes place. 
 (c) The induration of the tissue and the thickening of 
 the walls of the alveoli interfere with the elasticity of 
 the lung, and causes more or less impairment of the piil- 
 monary function, (d) Following the. contraction, there 
 
DISEASES OF RESPIBA TCB V TRACT. 175 
 
 IS more or less atrophy of the alveolar walls, resulting 
 in emphysematous dilatation, or disappearance of the 
 walls, and coalescence of adjacent alveoli. Bronchiec- 
 tasis of varying degree is also present. 
 
 Three types of pulmonary fibrosis can be recognized 
 by physical signs: (1) The massive or lobar type; 
 (2) the broncho-pneumonic type; (3) the disseminated 
 reticular or diffuse form. The type of the disease 
 corresponds more or less closely to the etiological factors. 
 
 (1) Lobar pneumonia and the confluent type of 
 broncho-pneumonia with collapse are often the origin 
 of the massive or Ljbar type. Pleurisy with effusion, 
 in which there has been extensive changes in the pul- 
 monary subpleural tissue and long retention of fluid in 
 the sac, causing more or less pulmonary collapse, is 
 frequently followed by a lobar type, in which the 
 primary changes are at the surface of the lung, crippling 
 its respiratory function, and followed by retention of 
 secretion within the alveoli, secondary broncho-pneu- 
 monia, and subsequent diffuse fibrosis. The occlusion 
 of a large bronchus by foreign bodies or by pressure;, 
 as of aneurism, causes the tissue beyond the obstruc- 
 tion to collapse more or less. There is retention of 
 inflammatory exudates, and the subseqiient development 
 of fibroid tissue. 
 
 (2) The broncho-pneumonic type may be induced by 
 those conditions which cause diffuse capillary bronchitis 
 or broncho-pneumonia. The broncho-pneumonic type, 
 when localized at the apices, is especially prone to occur 
 as a part of the pathology of pulmonary tuberculosis, 
 and is to a large extent a conservative process. It may 
 occur either at the beginning of the disease, may follow 
 on acute secondary inflammation or may be cicatricial 
 when there has been cavity formation. 
 
 (3) The disseminated type is generally dependent 
 upon chronic bronchial irritation which may follow 
 simple bronchitis, or may be due to the mechanical 
 irritation in the so-called dust disease, or pneumono- 
 
176 THE BESPIRATOBY SYSTEM. 
 
 koniosis. Two forms of diffuse fibrosis are recognized 
 by physical signs: 1. The emphysematous form, in 
 which the fibroid tissue of the peribronchial and inter- 
 lobular portions of the lung are especially involved and 
 there is associated dilatation of the alveoli. 2. The 
 contracted form, in which the alveolar walls and the 
 su.bpleural tissue are especially involved. In this there 
 is marked loss of the expansile tissue of the lung. 
 
 Physical Signs. Inspection.- — In the localized fibro- 
 sis of the lobar and broncho-pneumonic types there is 
 marked retraction of the chest over the seat of the 
 disease, the extent being in proportion to the amount 
 of lung tissue involved. Ketraction of the lung causes 
 a flattening of the chest wall, raising of the diaphragm 
 and displacement of the mediastinum and heart toward 
 the affected side. Change in the position of the ribs 
 causes depression of the shoulder and curvature of the 
 spine. The respiratory movements over the affected 
 area are restricted in proportion to the extent of the 
 disease. The opposite side will be in a state of com- 
 pensatory emphysema and functional activity. 
 
 Diffuse Type. — In the emphysematous form the 
 shape and size of the chest and the respiratory move- 
 ments will correspond to those described under Large 
 Lung Emphysema (see Emphysema). In the con- 
 tracted form the shape of the chest is more or less 
 analogous to the small lung or senile form of emphy- 
 sema. There is contraction of the lower portion of the 
 thorax; the intercostal spaces are narrowed; the ribs 
 may overlap. Expansion of the lung is deficient; the 
 diaphragm is carried upward, and the supraclavicular 
 and suprasternal spaces are deepened. It is rare for 
 this condition to be uniform or equally marked on 
 both sides. In tuberculosis one entire lung may be 
 involved, while in the other it may be limited to the 
 apex. When secondary to mechanical bronchitis, the 
 changes are more uniform. 
 
 Palpation. — Vocal fremitus is variable, and gives 
 
DISEASES OF BESPIBATOEY TRACT. 17Y 
 
 important information as to the nature of the change in 
 the lung and the extent of the involvement. In the 
 massive or lobar type there will be increase in vocal 
 fremitus. In the broncho-pneumonic type the change 
 in vocal fremitus will correspond to the extent of the 
 disease and its nearness to the surface of tlie lung. 
 The vocal fremitus may be feeble or absent when there 
 is obstruction of the bronchi leading to the affected area, 
 and when there is marked thickening of the pleiira. In 
 the diffuse type vocal freniitiis is markedly diminished 
 in the emphysematous form. In the contracted form it 
 may be increased, but usually, on account of its associa- 
 tion with pleural thickening, it is feeble or absent. Tlie 
 localization of the disease also causes variations in the 
 intensity of the vocal fremitus. Fibrosis of the apex is 
 usually attended with increased vocal fremitus, Avhile 
 when the' base is involved the vocal fremitus is dimin- 
 ished or absent. 
 
 Peecussiokt. — Increase of the solid structure of the 
 hmg causes dullness of the percussion note. Loss of 
 tension of the lung and diminution in the size of the 
 alveoli causes the dullness to have a peculiar wooden 
 and tympanitic quality. Thickening of the pleura 
 causes a more marked dullness, with increased sense of 
 resistance. In the emphysematous form the increase 
 in the size of the alveoli causes the percussion note to 
 be hyper-resonant. 
 
 Auscultation. — In the lobar type the breath soimds 
 are bronchial in character and more or less weakened, 
 but differ from those present in true lobar pneumonia 
 in being less intense and having a somewhat soft, blow- 
 ino- quality. Bronchophony is also present, but is weak 
 and distant. 
 
 In the broncho-pneumonic type, if the area involved 
 is close to the surface of the lung, bronchial or broncho- 
 vesicular breathing will be present. Wlien situated 
 deeper in the lung and covered by distended alveoli, 
 bronchial breathing may be absent, and the respiratory 
 12 
 
ITS THE RE8PIRA TOR Y SYSTEM. 
 
 murmur will be feeble. When rales are present over 
 the affected areas, they will have a sharp, metallic 
 quality. In the disseminated type one of the character- 
 istic features is the feebleness or absence of the vesicular 
 element of the inspiratory sound, associated with feeble, 
 prolonged and slightly bronchial expiratory sound. 
 Pleural changes cause both the vesicular and bronchial 
 elements of the breath sounds to be weakened or 
 obliterated. 
 
 Differential Diagnosis. — The differentiation of the 
 fibrosis that occurs in tuberculosis from that of non- 
 tubercular diseases of the chest is frequently impossible. 
 Fibrosis always occurs in certain forms of tubercular 
 infection of the lung, and has no distinctive features. 
 The condition known as coal miners' phthisis, fibroid 
 phthisis, etc., is frequently due to the combination of 
 dust irritation and tubercular infection. Frequently 
 the fibroid changes in the lung are so marked as to 
 become the most important factor, while the tubercular 
 changes are subsidiary. 
 
 EMPHYSEMA. 
 
 Pulmonary vesicular emphysema is an overdistension 
 of the air-vesicles, and may be acute or chronic. The 
 varieties of emphysema are: (1) Compensatory or 
 vicarious. This may be limited to a few lobules, to a 
 lobe or involve one lung only. This type of emphysema 
 occurs when distension of a portion of the pulmonary 
 tract is compensatory for deficient expansion in other 
 portions of the lung. 
 
 (2) General vesicular emphysema. In this variety, 
 associated with dilatation of the air-vesicles, are struct- 
 ural changes in the walls of the alveoli which diminish 
 their resiliency and lead to atrophy. Two types of 
 general emphysema are recognizc^l ; (a) Chronic, large 
 lung or hypertrophic emphysema, and (h) small lung, 
 atrophic or senile emphysema. 
 
DISEASES OF RESPIRATOEY TRACT. ITO 
 
 (3) Interlobular or interstitial emphysema, with 
 infiltration of air into the piilmonary stroma. 
 
 In general, chronic, large-lung emphysema the most 
 marked change, in addition to increased dilatation of 
 the alveoli, is a loss of elasticity of the alveolar walls, 
 which influences the respiratory function. As has 
 been mentioned before, while the pulmonary tissue is 
 passive during inspiration, merely dilating with 
 enlargement of the thorax, during expiration it is active, 
 and plays a most important part in contracting the 
 chest. Perfect respiration requires that the chest be 
 contracted as well as expanded. The power of the 
 lung to contract is due to (a) elasticity of the alveoli; 
 (h) contraction of the muscular tissue of the bronchial 
 tract. 
 
 In proportion as the normal elasticity of the pul- 
 monary tissiie is impaired in emphysema, the following 
 conditions are induced: (a) Faulty expiratory con- 
 traction leads to gradual overdistension of the lungs, 
 increase in the amount of residxial air and diminution 
 in the amount of tidal air. The chest wall, unacted 
 upon by the elasticity of the lung, assumes at first the 
 position of full inspiratory expansion. As the ventila- 
 tion of the lung is imperfect, dyspnoea is easily induced 
 on exertion, and the accessory inspiratory muscles are 
 called into play to increase still further the capacity of 
 the chest. The upper portion of the bony thorax is 
 carried upward; the sternum is carried forward; ribs 
 rotated outwards; the intercostal spaces widen; antero- 
 posterior diameter of the chest increases. "Enlarge- 
 ment of the chest to the limit of thoracic resiliency 
 occurs." (Powell.) Enlargement of the lung dis- 
 places the heart towards the median line, and the dia- 
 phragm is depressed, together with the abdominal 
 
 organs. 
 
 (h) Circulatory changes. The circulatory system is 
 affected in two ways: (1) Normally the elasticity of 
 the lung causes a negative pressure within the thorax, 
 
180 THE BE8PIBA TOR Y SYSTEM. 
 
 which, during inspiration, equals Y to 9 mm. of mercury. 
 "The elastic fibres of the lung are upon the stretch and 
 are pulling upon the ribs, intercostal spaces, upon the 
 diaphragm and upon the heart and great vessels. The 
 elastic pull of the lung . . . assists the diastolic 
 expansion of the ventricles . . . and acts upon 
 the vena cava within the chest and generates within 
 them, as well as within the right auricle, a force of suc- 
 tion. This suction from within the chest extends to the 
 great veins just without it in the neck."^ 
 
 As the elasticity of the pulmonary tissue becomes im- 
 paired, the suction force of the lung decreases ; there is 
 a corresponding imperfect dilatation of the right auricle 
 and emptying of the great veins. This interferes with 
 the return circulation, which early shows itself in dis- 
 tension of the jugular veins and a tendency to general 
 venous stasis.^ (2) The dilatation of the alveolar 
 walls, with the subsequent atrophy, causes obstruction 
 to the pulmonary circulation through narrowing the 
 capillaries, by stretching and by obliteration. The 
 effect of this circulatory obstruction is to raise the press- 
 ure in the pulmonary artery, which is early indicated by 
 accentuation of the pulmonic second sound. To over- 
 come the increased tension in the pulmonary artery, the 
 right heart hypertrophies ; sooner or later the hyper- 
 trophy fails to keep pace with the progressive obstruc- 
 tion of the pulmonary circulation and the increased 
 work. The right ventricle is unable to empty itself; 
 dilatation of the cavity occurs, with incompetency of the 
 tricuspid valve, and regurgitation in the right auricle. 
 When tricuspid regurgitation occurs, the imperfect 
 venous return, due to diminished negative pressure, is 
 acutely increased. Pulsations occur in the jiigular 
 vein; there is passive congestion of all the abdominal 
 viscera, with enlargement of the liver and spleen, the 
 occurrence of ascites and general anasarca. 
 
 * American Text-Book of Physiology, Vol, I, p. 95. 
 
 ^ In compensatory emphysema the decrease in negative pressure is not 
 present. In the senile tyjje it is not a marked featiu-e of the disease. 
 
DISEASES OF BESPIBA TOB \ ' TBA CT. 181 
 
 Physical Signs. — The physical signs of emphysema 
 vary with the degree of pulmonary distension and loss 
 of elasticity. They are modified by intercurrent attacks 
 of acute bronchitis,, spasm of the bronchi (asthma) and 
 the secondary changes in the circulatory system. 
 
 Inspection. Large-Lung Emphysema. — The patient 
 presents a more or less characteristic appearance. The 
 chest is enlarged in all directions, especially in the 
 antero-posterior diameter. The dorsal curve of the 
 spine is exaggerated. The sternum is carried forward ; 
 the ribs are rotated outward and are more horizontal; 
 the upper intercostal spaces are widened, and the lower 
 portion of the chest is seemingly contracted in com- 
 parison with the upper portion, but there is an increase 
 in the transverse diameter. These changes in the bony 
 thorax give the barrel-shaped chest of emphysema. 
 Mensuration shoAvs enlargement of the thorax is in 
 all directions, especially marked in antero-posterior 
 diameter. 
 
 The movements of the thorax are altered ; ins]uration 
 is short, jerky, with very slight expansion from first to 
 fourth ribs. The muscles of the neck are hypertrophied 
 and prominent, the upper portion of the chest being 
 pulled upwards by the accessory nmscles of inspiration. 
 With inspiration the suprasternal, supraclavicular and 
 upper intercostal spaces are deepened. The lower por- 
 tion of the chest is depressed during inspiration by the 
 action of the diaphragm, and breathing is chiefly 
 abdominal. 
 
 Expiration is tardy, slow and prolonged, with forcible 
 contraction of the abdominal muscles. During expira- 
 tion the intercostal spaces may be even with, or project 
 beyond, the level of the ribs. Cardiac impulse is not 
 seen in the normal site, but is displaced downward and 
 inward. Epigastric pulsation is marked. The jugular 
 veins are prominent and, in tricuspid regurgitation, 
 
 pulsating. 
 
 Small-Lung Emphysema.— The patient has the 
 wasted, shrunken appearance of old age. The thorax is 
 
1 S 2 THE BESPIBA TOR Y SYSTEM. 
 
 contracted, the shoulders are rounded, but the clavicles, 
 ribs and sternum are depressed; the intercostal spaces 
 are narrowed below the fourth rib. The lower ribs are 
 very oblique, and the edges may be in contact. The 
 movements of respiration are shallow; the thorax is 
 more rigid than in the large-lung type. During inspira- 
 tion there is deepening of the supraclaviciilar fossa and 
 intercostal spaces. The diaphragm is not depressed, 
 but its descent is limited. Cardiac impiilse is not dis- 
 placed downward and toward the median line, as in the 
 large-lung type, but may be slightly elevated and carried 
 further to the left. Epigastric pulsation and distension 
 of the jugular veins are absent. 
 
 C ompensato7'y Etaphysema. — ^When compensatory 
 emphysema involves the entire lung, the enlargement of 
 the side is attended with movements of increased func- 
 tion, i. e., increased expansion during inspiration, while 
 in expiration the contraction of the thorax is energetic 
 and prolonged. The cardiac position varies with the 
 cause of the emphysema and the side involved. 
 
 Emphysema limited to a lobe or part of a lobe will 
 affect the size, shape and movement of the thorax, 
 according to the cause. When emphysematous dilata- 
 tion occurs in jDortions of the lung surrounding areas of 
 consolidation or induration, it may prevent the 
 deformity that is usually associated with the primary 
 condition. 
 
 Palpatioit. Large-Lung Emphysema. — Vocal frem- 
 itus varies in proportion to the rarefaction of the lung 
 and the diminution of pulmonary tension. It may be 
 normal in mild cases, diminished or absent in well- 
 marked. Cardiac impulse felt in the epigastric region 
 is diffuse ; the force depends entirely upon the degree 
 of hypertrophy of the right ventricle. The liver may 
 be felt below the free border of the ribs ; the edges are 
 firm, smooth and rounded in proportion to the conges- 
 tion from distvirbed venous return in the vena cava. 
 The spleen may be enlarged and palpable, secondary to 
 
DISEASES OF RESPIBATOBY TliAC'T. 183 
 
 hepatic congestion. When emphysema is associated 
 with bronchitis or spasm of the bronchi, rhonchi may be 
 felt. 
 
 Small-Lung ■Emphysema. — Vocal fremitus is but 
 slightly changed, and may show slight increase in 
 intensity, especially over the areas of large bronchi. 
 
 Compensatory Emphysema. — Increased tension of 
 the lung causes the normal vocal fremitus to be slightly 
 increased. 
 
 Percussion-. — Large-Lung Emphysema. — Rarefac- 
 tion of pulmonary tissue and increased amount of air 
 contained in the thorax causes the percussion note to be 
 hyper-resonant ; the low tension of the pulmonary tissue 
 lowers the pitch. The condition of the chest wall (page 
 84) permits the bony quality to be added to that of the 
 pulmonary tissue, so that the quality is changed. 
 According as these different elements enter into the per- 
 cussion sound, it has been described as vesico-tympanitic, 
 band-box, boardy, woodeny, etc. The character of the 
 sound does not show variation during inspiration and 
 expiration. The borders of the lung are extended, and 
 resonance may be obtained as low as the twelfth rib 
 behind. The normal areas of hepatic and cardiac dull- 
 ness are diminished or al)sent. 
 
 Small-Liuig Etnpliysema. — The percussion nole is 
 hyper-resonant, but the pitch is not lowered; the quality 
 is clearer and more tympanitic than in the large lung 
 type. The areas of cardiac dullness are not diminished, 
 but may be increased by retraction of the pulmonary 
 borders. Tleisatic dullness is slightly higher than nor- 
 mal. The rigid chest wall gives an increased sense of 
 resistance. 
 
 Compensatory Emphysema. — In acute cases all the 
 elements of normal percussion sounds are exaggerated. 
 The note is hyper-resonant, clear and slightly higher in 
 pitch. 
 
 In long-standing cases, secondary changes in the lung 
 may cause loss of tension and the percussion sound of 
 
1 8 4 THE BESPIBA WB Y S YSTEM. 
 
 the large-limg emphysema. In chronic localized emphy- 
 sema the percussion note varies according to the condi- 
 tions with which it is associated. 
 
 Auscultation. — Large-Lung Emphysema. — ^Dviring 
 inspiration the vesicular murmur is short, feeble, or 
 may be inaudible, being replaced "by a low-pitched, 
 rumbling sound of muscular contraction." (Fowler.) 
 During expiration the breath sound is prolonged, and 
 continues with nearly equal intensity to the end of the 
 act. In direct proportion to the severity of the disease, 
 the ratio of the length of inspiration to expiration is 
 altered. Expiration becomes longer than inspiration, 
 sometimes reversing the normal ratio, being four times 
 as long as inspiration. The pitch is low, and the quality 
 slightly blowing. When emphysema is associated with 
 bronchitis and spasm of the bronchi, various-sized dry 
 and moist rales are heard (spasmodic emphysema). 
 
 When emphysematous blebs have formed beneath the 
 pleura, fine crackles are heard with inspiration and 
 expiration, or both (fine crackling crepitations, emphy- 
 sematous gurglings). With the failing right heart, 
 fine, moist, crepitating rales, due to pulmonary oedema, 
 are heard over the base of the lungs. 
 
 Cardiac sounds are not heard over the normal area, 
 and vary according as hypertrophy or dilatation is most 
 marked. Over the normal apex of the heart the first 
 sound is low pitched and prolonged in hypertrophy, 
 short and sharp when dilatation and cardiac weakness 
 occur. Over the base the cardiac sounds are heard at a 
 lower level than normal, and there is accentuation of 
 the second soimds to the left of the sternum, due to 
 increased tension of the pulmonary artery. A systolic 
 murmur is frequently present over the displaced apex. 
 At first this may be present only after exertion, or dur- 
 ing transient attacks of intercurrent bronchitis. Later 
 it may be permanent, with all the associated signs of 
 tricuspid regurgitation. Cardio-respiratory murmurs 
 are at times present over the normal area of cardiac 
 dullness. 
 
DISEASES OF BESPIHATOBY TRACT. 185 
 
 Small-Lung Emphysema. — The deviations from nor- 
 mal are not as marked as in the large lung. The 
 inspiratory sound is nearly normal in length, but feeble. 
 The expiratory sound is prolonged, but rarely exceeds 
 the length of inspiration ; is harsher, and its pitch is not 
 as low. 
 
 Compensatory Emphysema. — Breath sounds are 
 exaggerated. They retain their normal characteristics, 
 but are pure in type. 
 
 Diflferential Diagnosis. — The distinctive signs of large- 
 lung emphysema are bilateral enlargement of the chest, 
 with increase in the antero-posterior diameter and 
 founded contour (barrel-shaped chest) ; Avideniiig of the 
 intercostal spaces; restricted inspiratory movement, 
 with prolonged and labored expiration ; displacement of 
 the apex beat and epigastric pulsation. 
 
 Feeble vocal fremitus, associated with hyper-resonant 
 and low-pitched percussion note. 
 
 The inspiratory portion of the breath sounds is short, 
 feeble or absent, while the expiratory portion is pro- 
 longed, low pitched and relatively more intense. 
 
 Pneumo-thorax. — Enlargement of the thorax is not 
 symmetrical, but more marked over the affected side. 
 The intercostal spaces of the affected side are obliter- 
 ated. Movements of the two sides are unequal. There 
 is absence of motion on the affected side, with active 
 movement of the opposite. The heart is displaced 
 toward the xmaffected side. The percussion note is 
 hyper-resonant, but of tympanitic quality, the normal 
 vesicular quality being absent. Coin test shows a 
 peculiar metallic quality of sound. Vocal fremitus is 
 absent. Vesicular murmur is absent. Amphoric 
 breathing is present on inspiration and expiration when 
 the opening to bronchus is patent. Lung fistula sound 
 at times detected. 
 
 Hydro-pneumo-thorax. — Below level of fluid there is 
 flatness on percussion. On shaking the jjationt succus- 
 sion sou.nds may be detected, with metallic tinkles. 
 
1st) THE BESPIBA TOM Y SYSTEM. 
 
 Cardiac Dyspnoea. — In acute febrile diseases and in 
 anffimia, physical signs similar to those obtained in a 
 mild degree of emphysema are frequently present, espe- 
 cially the hyper-resonant, low-pitched percussion note. 
 This is differentiated from true emphysema m that the 
 respiratory sounds retain their normal relation to each 
 other. 
 
 ASTHMA. 
 
 Asthma is a disease characterized by attacks of 
 intense dyspnoea of a paroxysmal type, occurring more 
 or less suddenly. 
 
 Attacks of asthmaic dyspncea may be due to acute 
 narrowing of the lumen of the bronchial tubes by (a) 
 spasm of the muscles of the bronchi (idiopathic or true 
 asthma), (h) vaso-motor dilatation of the blood-vessels 
 or inflammatory swelling of the mucous membrane 
 (secondary asthma). 
 
 Between the attacks in the primary type the respira- 
 tory tract may be normal. In the second type it shows 
 the change of the primary condition. 
 
 Condition of Lungs During Asthmatic Attack. 
 — In proportion to the intensity of the attack, there is 
 increase in the amount of residual air and a correspond- 
 ing decrease in the quantity of tidal air, with resultant 
 overdistension of the alveoli. The chief factor in caus- 
 ing interference with the normal movement of the air 
 during inspiration and expiration is the spasmodic con- 
 traction of the muscular tissue present in the bronchial 
 tubes. Muscle fibres have been demonstrated in the 
 bronchial tract as far as the infundibula. The muscle 
 fibres of the bronchi are passive during inspiration, but 
 during expiration their contraction is an important fac- 
 tor in forcing the air out of the lung and in the produc- 
 tion of normal expiratory breath sounds. 
 
 During an asthmatic attack the normal rhythmical 
 action of the bronchial muscles is disturbed. With 
 
DISEASES OF BESFIRATOBY TRACT. 187 
 
 expiration the contractions are excessive, narrowing the 
 lumen of all the tubes, and even closing entirely the 
 smaller ones, especially the non-cartilaginous. With the 
 following inspiration active contraction of the muscle 
 ceases, but more or less spasm remains, so that 
 there is persistent interference with the movement of air 
 in the lung; but it is not so great as during expiration. 
 In mild attacks the inspiratory obstruction may not be 
 present. With each respiratory act more air is taken 
 in than is expelled, until the thorax is distended to the 
 utmost; there is imperfect ventilation of the lung and 
 deficient oxygenation of the blood, with attending 
 symptoms of dyspncea. The effect of an asthmatic 
 attack is overdistension of the hmg, causing depression 
 of the diaphragm, enlargement of the thoracic cavity in 
 all directions ; the heart is displaced downward and 
 toward the median line. 
 
 Contraction of the bronchi and overdistension of the 
 alveoli cause diminution of the normal negative inter- 
 thoracic pressure du.ring inspiration, and may give rise 
 to positive pressure during both inspiration and expira- 
 tion, which in turn causes interference with pulmonary 
 circulation, overdistension of the right ventricle, and 
 interference with venous return circulation. 
 
 With the subsidence of an attack, the pulmonary con- 
 dition may return to normal. Ee]3eated and long- 
 continued attacks of asthma gradually produces 
 permanent dilatation of the air-vesicles and secondary 
 emphysema. 
 
 Physical Signs. Inspection. — (a) During attack: 
 The face may be pale or slightly cyanotic; the patient 
 generally sits up in the position to give greatest leverage 
 to auxiliary muscles of respiration; the shoulders are 
 elevated ; the chest assumes the barrel shape of emphy- 
 sema. With inspiration, the muscles of the neck, espe- 
 cially the sterno-cleido-mastoid, are prominent,^ and 
 cause the movements of the cliest to be short and jerky, 
 lifting the thorax en masse, but with very little expan- 
 
188 THE BESFIMA TOB Y SYSTEM. 
 
 sion. Interference with the free entrance of air into 
 the alveoli causes depression of the soft parts, so that 
 the suprasternal, supraclavicular and intercostal spaces 
 are deepened. The diaphragm is forced to the lowest 
 point possible, the lower portion of the thorax and 
 sternum are depressed, and the epigastric region becomes 
 more prominent. Expiration follows inspiration with- 
 out a pause, and is prolonged, labored, but feeble. 
 Movement of thorax is very slight, and due to the action 
 of the auxiliary muscles of expiration, which, forcing 
 the bony thorax against the inflated lung, cause bulging 
 of the intercostal spaces and supraclavicular fossa?. 
 Respirations are not increased in frequency, and may be 
 less than normal. Jugulars are distended, and the apex 
 beat is displaced downward and to the right, with 
 marked epigastric pulsation. 
 
 (h) Between the attacks: the condition of the lungs 
 may be normal. When asthma has produced permanent 
 dilatation of the air-vesicle, the shape and movement of 
 the thorax are those of emphysema. 
 
 Palpation. — (a) During attack: vocal fremitus 
 never increased ; may be diminished or absent. Over a 
 given area it varies from time to time, according to the 
 degree of contraction of bronchi leading to the part. 
 Ehonchi may be felt. The cardiac impulse is displaced 
 downward to the right, and is diffused ; pulse is small 
 and intermittent, especially during inspiration (pulsus 
 paradoxus), (b) Between the attacks: vocal fremitus 
 is normal or diminished, as in emphysema. 
 
 Peegussion. — (a) During attack: percussion sound 
 hyper-resonant. During early stage of the disease, 
 with increased tension in the lung, the sound is slightly 
 higher pitched, but clear. After repeated attacks, the 
 diminished elasticity of the lung causes the pitch to be 
 altered (lower) and the quality to be tympanitic or 
 boardy (see Emphysema). Enlargement of the lung 
 causes cardiac and hepatic areas of dullness to dis- 
 appear. The borders of lungs are extended, and show 
 
DISEASES OP RE8PIRA TOR Y TRA CT. 189 
 
 no variation between inspiration and expiration, (b) 
 Between the attacks: resonance may be normal or more 
 or less emphysematotis. 
 
 Auscultation. — (a) During attaclcs: inspiratory 
 vesicular murmur may be heard from time to time. 
 When present, it is of normal quality, but weak, short 
 and jerky. Usually it is absent or obscured by sibilant 
 or sonorous rales. 
 
 During expiration respiratory murmur is usually 
 absent, being replaced by prolonged dry rales of sonor- 
 ous, sibilant, cooing or whistling type. The rales are 
 constantly changing in intensity and character over a 
 given area, at times disappearing, either with return of 
 normal vesicular murmur or absence of all sound. 
 With subsidence of the attack, large and small-sized 
 moist rales are present, due to secretion in the bronchi. 
 
 When asthmatic attacks occur during the course of 
 acute or chronic broncliitis, the dry and moist rales are 
 both present. Vocal resonance is normal or somewhat 
 diminished ; cardiac sounds during attack are masked 
 by dry rales in the hmg. 
 
 (h) Between the attachn: respiratory sound may 
 return to the normal, or a few wheezing rales may be 
 present for some time after dyspnosa has disappeared. 
 After severe attacks, fine, bubbling, moist rales, with 
 feeble respiratory murmur, may be heard for some 
 hours or days over the base of the lung and along the 
 borders. In chronic cases, emphysematous breathing is 
 present between the attacks. 
 
 Differential Diagnosis. Cardiac Dyspnoea. — Subjects of 
 valvular and myocardial disease of the heart may suffer 
 from intercurrent attacks of spasmodic dyspnoea. It 
 has the following physical signs which differentiate it 
 from asthma: 
 
 IisrsPECTioisr. — The breathing is sighing or panting in 
 character; the rate is increased; the movements of 
 inspiration and expirati(m are of nearly equal length. 
 Expiration lacks the characteristic prolongation of 
 
190 THE BE8PIEA TOR Y SYSTEM. 
 
 asthma. The chest lacks the typical distension of 
 asthma. In asthma breathing is spasmodic, with in- 
 spiration short ; expiration, prolonged and labored. The 
 rate of respiration not increased. 
 
 Peecussion. — In cardiac dyspncea the note over the 
 upper portion of the chest is normal. Over low^er por- 
 tion of the chest, especially at the base, posteriorly, dull- 
 ness is more or less marked, in proportion to the amount 
 of pulmonary cedema and passive congestion. 
 
 In asthma the note is hyper-resonarit over all portions 
 of the chest, especially at the base. 
 
 Auscultation. — In cardiac dyspnoea during inspira- 
 tion, vesicular murmur is present over upper portion of 
 lung ; over base it may be feeble or absent, according to 
 the amount of pulmonary congestion and oedema. 
 
 The relative length of inspiration and expiration is 
 but slightly altered. Hales, both dry and moist, may be 
 present, but dry rales are not as varied and are more 
 constant than in asthma ; while moist rales are relatively 
 more abundant, especially over the base. In chronic 
 passive congestion (cardiac pneumonia) the breath 
 sounds may have a bronchial quality. When dyspnoea 
 is due to valvular disease, the physical signs of the lesion 
 are usually present. At times the distinguishing signs 
 in the lung may be intense enough to mask the cardiac 
 murmurs. 
 
 In asthma dry rales are the most prominent. When 
 detected, breath sound is normal, never bronchial. 
 
 Laryngeal and Tracheal Stenosis. Inspection. — 
 Dyspnoea is insjiiratory with increased movement of 
 the larynx. Size of the chest is diminished; the dia- 
 phragm is elevated; there is marked retraction of the 
 suprasternal, supraclavicular and intercostal spaces. 
 Inspiratory portion of resjairation is prolonged and 
 labored. Expiratory movement is shorter than normal. 
 In asthma the dyspnoea is chiefly expiratory; the chest 
 is enlarged; the diaphragm is depressed. 
 
DISEASES OF BESPIBATORY TRACT. 191 
 
 Percussion. — In stenosis the percussion note has 
 diminished resonance. In asthma it is hyper-resonant. 
 Auscultation. — In stenosis, vesicular murmur over 
 the lung is diminished or feeble ; the stridor, due to the 
 narrowing of the larynx, frequently cause bronchial 
 type of breathing to be heard over both lungs. The 
 changes in the respiratory sounds are constant. In 
 asthma, dry rales of varying size are heard over a given 
 area, constantly changing in character. 
 
 Aneurism of the Aorta. — Compression by the aneuris- 
 mal sac of the trachea and left bronchus may simulate 
 very closely an asthmatic attack. The physical signs 
 are not bilateral. The intensity of the signs will 
 depend on the degree of narrowing. When the bronchus 
 is only slightly narrowed, the respiratory sound heard 
 over the lung beyond the point of constriction may have 
 a slightly tubular or a marked sonorous quality. Entire 
 occlusion of the bronchus causes absence of breath soimd 
 over portion of lung supplied by the tube. Dullness 
 over the sternum and tracheal tugging, brassy cough, 
 and heaving impulse are generally sufficient for diag- 
 nosis. 
 
 Hysterical Breathing.— rParoxysmal and labored breath- 
 ing, similar to that of asthma, occurs during hysterical 
 attacks. Expansion of the chest, due to voluntary 
 action of the muscles of inspiration, and voluntary inter- 
 ference with expiration, may be identical with that of 
 asthma. The rate of the breathing is generally 
 increased. 
 
 On auscultation the dry rales, with prolonged expira- 
 tion are not present. 
 
 PULMONARY TUBERCULOSIS. 
 
 Synonyms. — Phthisis, consumption. 
 
 Pulmonary tuberculosis is a disease of the lungs, due 
 to the presence of the tubercle bacilli, with the produc- 
 tion of tubercular nodules. 
 
 The distribution of the tubercles may be localized or 
 
192 THE RESPIRA TOB Y SYSTEM. 
 
 diffuse. The primary effect is the same in both pases, 
 varying merely in degree. When localized, its point of 
 selection is usually the apex, although certain factors 
 may determine its primary location in other portions of 
 the lung. When more widely distributed, it may 
 involve an entire lobe or lung, or may be disseminated 
 throughout the entire bronchial tract. 
 
 Effect Upon the Lung. — Immediate lodgment of the 
 tubercle bacilli usually occurs in the terminal bron- 
 chioles. With the production of the tubercular nodule, 
 the bronchiole becomes occluded, and the alveoltis 
 supplied by the bronchiole becomes the seat of an inflam- 
 matory process, with the production of broncho-pneu- 
 monia. The peribronchial tissiie is also involved. 
 Extension to neighboring lobules occurs through the 
 lymph spaces and vessels into the interstitial tissue, and 
 also through the bronchi. On account of the relation 
 of the lymphatics of the interlobular tissue to the pleura, 
 there is early involvement of the subpleural tissue, with 
 secondary involvement of the pleural sac, which may, 
 however, not be of a tubercular nature. 
 
 Secondary Changes. — Dependent upon tubercular in- 
 fection, three varieties of pathological changes occur: 
 (1) Congestion, inflammation and oedema of the tissues 
 adjacent to the tubercular nodule, producing more or 
 less complete consolidation of the alveoli, with inflam- 
 matory products (catarrhal, broncho-pnemnonia). (2) 
 Necrosis (caseation, liquefaction, softening) of the 
 infected area. (3) Growth of connective tissue (fibro- 
 sis). These three processes occur together, and are 
 present in varying degrees. As one or another pre- 
 dominates in an individual case, the rapidity of its 
 course and the type of the disease is determined. 
 
 Two forms of pulmonary tuberculosis occur: A. 
 Acute. J3. Chronic. These can be still further sub- 
 divided into types, according to (a) distribution of the 
 infection; (h) the character of the changes in the 
 infected area. 
 
DISEASES OF EESPIRA TOR Y TRA CT. 1 9 3 
 
 A. Acute Pulmonary Tuberculosis. 
 
 Three types may be recognized clinically : (1) Acute 
 miliary, tuberculosis, pulmonary type. In this form of 
 the disease the tubercle bacilli are widely distributed 
 throughout the lung. The eruption of tubercles is very 
 rapid, and the inflammatory changes in the alveoli and 
 adjacent bronchi are very marked. These early changes 
 in the lung are almost identical with those that occur in 
 acute _ capillary bronchitis with involvement of the 
 alveoli. The necrosis and liquefaction occur almost at 
 once, while there is almost e<miplete absence of con- 
 nective tissue increase. 
 
 (2) Broncho-pneumonic type. In this form the 
 eruption of tubercular nodules is at first localized in the 
 apex of one or both of the upper lobes, or tubercular 
 foci may be scattered throughout the lung. The areas 
 involved in the tubercular process are the seat of an 
 intense catarrhal inflammation, and caseation, with 
 liquefaction and cavity formation, occurs very rapidly ; 
 so that the lung passes in a short time through the stages 
 of infection, tuberculization, infiltration (broncho- 
 pneumonia), and softening, with the production of a 
 number of small cavities. The tubercular masses may 
 coalesce, forming a confluent broncho-pneumonia. 
 
 (3) Lobar type. Occasionally the amount of tissue 
 involved by a confluent area of tubercular broncho-pneu- 
 monia may be so great as to involve nearly an entire 
 lobe, giving consolidation as extensive as is found in 
 acute croupous pneumonia. 
 
 On account of the rapidity of the changes and the 
 nature of the physical signs, various names have been 
 given to this form of acute pulmonary tuberculosis, as 
 acute phthisis, acute pneumonic phthisis, tubercular 
 pneumonic phthisis, caseous tubercular imeumonia, 
 broncho-pneumonic phthisis, acute catarrhal iDlithisis, 
 epithelial phthisis, florid phthisis, galloping consump- 
 tion. 
 13 
 
1 9 i THE BESPIBA TOR Y SYSTEM. 
 
 Physical Signs. — In the acute miliary type the earliest 
 changes may be those of general bronchitis, grackially 
 increasing in intensity with the occurrence of broncho- 
 pneumonia. In the early stage of acute miliary tuber- 
 culosis, the signs are identical with those described 
 under Capillary Bronchitis with involvement of the 
 bronchioles and alveoli (page l-ii), the dyspnoea, how- 
 ever, is more marked and persistent. Where the dis- 
 ease is localized, the following signs may be present : 
 
 Inspection. — In the broncho-pneumonic type, in the 
 early stage, there is no change in the shape of the chest. 
 With occlusion of a large number of bronchi and pul- 
 monary collapse, there is depression of the thorax over 
 the affected area, with loss of motion. With the occur- 
 rence of liquefaction (softening) and the formation of 
 cavities, the depression may become less marked, and 
 motion may return. 
 
 In the lobar type there may be loss of motion over a 
 wider area, while more complete consolidation of the 
 lung causes absence of thoracic depression. 
 
 Palpation. — In the broncho-pneumonic type vocal 
 fremitus may be normal when the disease is deep seated, 
 and feeble when there is marked pulmonary collapse. 
 When the consolidation is close to the surface, vocal 
 fremitus is slightly increased. 
 
 In the lobar type vocal fremitus may be as intense 
 as in true croupous pneumonia. 
 
 Percussion. — In the early stage the percussion note 
 may be normal. Over the portion of lung affected by 
 obstruction of the bronchi, the percussion note is dull, 
 with slight tympanitic quality. Later there is gradual 
 increase of dullness, according to the degree of consoli- 
 dation. When pleural changes are present, dullness 
 may almost reach the degree of flatness. With cavity 
 formation, the dullness is replaced by cavernous or 
 amphoric percussion resonance. 
 
 Auscui/rATioN. — The earliest signs over the affected 
 area are those of diffuse bronchitis, with sibilant and 
 
DISEASES OF RESPIRATORY TRACT. 195 
 
 sonorous rales and moist rales of a liquid, bubbling 
 character. The breath sounds may be weak in occlu- 
 sion of the bronchioles and pulmonary collapse. As the 
 collapsed lung becomes consolidated by inflammatory 
 products, the breath sounds become bronchial in char- 
 acter, but_ rarely tubular. The liquid, bubbling rales 
 of bronchitis are replaced by sharp, crepitating rales 
 and by pleuritic friction soimds. As softening occurs, 
 the small rales are re])laced by coarser ones, and the 
 bronchial breathing loses its sharpness and has a hollow, 
 blowing quality ; it rarely becomes markedly cavernous 
 or amphoric. The slower the course of the disease, the 
 greater the tendency for the areas of consolidation to 
 coalesce, with a corresponding increase in the intensity 
 of the bronchial quality of the breath sounds. As the 
 different tubercular areas do not undergo the changes of 
 consolidation, softening and cavity fonnation with the 
 same degree of rapidity, -the physical signs of all stages 
 of the disease will be found in different portions of the 
 lung. In the localized broncho-pneumonic and lobar 
 types, the disease may at any stage lose its acute char- 
 acter and pass into the subacute or chronic form. 
 
 Differential Diagnosis. Simple Broncho-Pneumonia. 
 — As stated above, the early physical signs are identical 
 in the tubercular and non-tubercular forms. As the dis- 
 ease advances to the stage of softening, slight differences 
 may be noted. In the simple, non-tubercular pneumonia 
 resolution occurs at a uniform rate over the affected 
 areas, with a gradual return to the normal condition. 
 In the tubercular type, with softening and destruction 
 of the lung tissue, rales become larger than those com- 
 mon in bronchi of normal size. The bronchial character 
 of the breath sounds is gradually replaced by soft, blow- 
 ing, pufEng breath sounds, especially marked on expira- 
 tion. In the lobar pneumonic form the physical signs 
 may be for a time identical with those of croiiijous 
 pneumonia, but later certain changes develop in the 
 consolidated lung which differ. The vocal fremitus 
 
196 THE BESPIBA TOB Y SYSTEM. 
 
 over the consolidated area, while it may be as intense as 
 that found in the second stage of croupous pneumonia, 
 is not uniform over all portions of the lobe involved. 
 During the period of softening, vocal fremitus does not 
 diminish to the same degree in the tuberculous cases. 
 On auscultation, fine crepitating rales of the first stage 
 of croupous pneumonia may be present, but they are not 
 as fine nor as sharp, and do not occur in well-defined 
 showers. They do not disappear with the occurrence of 
 bronchial breathing, as in croupous pneumonia, but per- 
 sist until replaced by the coarser rales of softening. 
 With the beginning of softening, the rales of tubercular 
 pneumonia may be identical with those of resolving 
 croupous pneumonia (rales redux), but they tend to 
 become larger, and are later replaced by mucous clicks 
 and gurgles. In croupous pneumonia the rales are 
 uniform in size, and become fewer as resolution occurs. 
 
 The bronchial breathing of tubercular pneumonia 
 does not disappear with the signs of softening, but, 
 while it may for a time be more or less masked by rales, 
 it reajDpears over scattered areas and has a hollow, 
 cavernous or amphoric quality. In croupous pneu- 
 monia the bronchial quality of the breath sounds 
 gradually fades out as resolution proceeds. 
 
 While the above physical signs may aid in differen- 
 tiating tubercular from non-tubercular lobar pneumonia, 
 tlie most important data are obtained by the tempera- 
 ture, duration and covirse of the disease, and micro- 
 scopical examination of the sputum. In tubercular 
 pneumonia the physical signs of softening are not asso- 
 ciated with the phenomenon of crisis and lowered range 
 of temperature. The cxjiectoration of tubercular pneu- 
 monia is apt to be grayish-green (Traube), differing 
 markedly from the tenacious, blood-stained (brick dust) 
 sputum of croupous pneumonia. 
 
DISEASES OF BESPIUA TOR Y TEA CT. 1 9 'i 
 
 (B) Chronic Pulmonary Tuberculosis. 
 
 In the svibaeute and chronic forms of pnh-nonary 
 tuberculosis, following local infection by the tubercle 
 bacilli, pathological changes occur which are of the 
 same general nature as those of the acute form, but 
 differ in the degree of severity and in their course. 
 
 In these forms the disease is more distinctly localized. 
 With the development of the tubercular nodules, there 
 may be congestion, inflammation and oedema of the 
 affected lobules, giving the pathological changes and 
 physical signs of localized acute bronchitis or acute 
 pneumonia, as was described in the acute forms. These 
 acute conditions subside, and the disease runs a milder, 
 more subacute or chronic course. In the large majority 
 of cases the incipient stage is more insidious, and with 
 the local infection there is little or none of the acute 
 inflammatory change, but a progressive increase of the 
 connective tissue (fibrosis), which extends outward 
 from the site of infection along the interlobular septa 
 to the surface of the lung, and early involves the 
 pleural and subpleural surfaces, causing thickening and 
 adhesion. The bronchi in the affected area are nar- 
 rowed or occluded, with subsequent pulmonary collapse. 
 The fibrosis and changes in the bronchi and alveoli 
 cause imperfect expansion of that portion of the lung 
 an'd retraction of the tissues of the thorax over it, unless 
 the functionless portion is compensated for by the 
 adjacent overlying lobules. During the early or 
 incipient stage, all degrees and extent of these patho- 
 logical changes may be present at different times in the 
 same case. Their relative preponderance determines 
 the type of the disease and influence its course. The 
 physical signs present will be those of localized bron- 
 chitis, catarrhal pneumonia, fibrosis and pleurisy. The 
 more marked the fibrosis, the more latent and chronic 
 the course. 
 
198 THE BESPIRA TOR Y SYSTEM. 
 
 The disease may be arrested in this stage by encapsu- 
 lation of the tubercular area by a dense fibrous envelope. 
 Usually (second stage) there is extension of the tuber- 
 culous infiltration to adjacent portions of the same lobe, 
 as described below. This extension is along fairly 
 definite lines, and is usually associated with more or less 
 consolidation, due to connective tissue increase. With 
 the extension of the disease there is corresponding 
 involvement of the pleura, which may be acute, sub- 
 acute, adhesive or pleurisy with effusion. The con- 
 solidation is never as complete as in croupous pneu- 
 monia. 
 
 Sooner or later, in the majority of cases, necrosis 
 (third stage) of the tubercular areas occurs, followed 
 by liquefaction and softening, with the formation of 
 cavities of varying sizes. These later changes may first 
 show themselves in the jsrimary focus, or, when fibrosis 
 has been more marked, condensation may occiir without 
 cavity formation; while breaking down occurs in those 
 portions secondarily affected. This tendency of chronic 
 pulmonary tuberculosis to necrose and form cavities has 
 given it the name of chronic ulcerative tuberculosis. 
 Necrosis and softening occur especially in those cases 
 in which the inflammatory changes (broncho-pneu- 
 monia) have been most marked. Where fibrosis has 
 predominated, the disease may present the changes that 
 were desci?ibed under chronic interstitial pneumonia 
 (page 1Y4). Of equal importance v/ith the pathological 
 changes and physical signs is the distribution of the 
 primary foci and the manner of extension of the disease 
 throughout the pulmonary system. 
 
 "Tubercular disease, in its onward progress through 
 the lung, in the majority of cases follows a distinct 
 route, from which it is only turned aside by the intro- 
 duction of some disturbing factor." ("Localization of 
 Lesions of Phthisis," Fowler. ) 
 
 Site and Progress of Pulmonary Tuberculosis. — 
 The most common point of primary infection is at 
 
DISEASES OP UESPlRATORY TRACT. 199 
 
 the apex of the upper lobe of the lune;, 1 to 11/^ inches 
 below the summit. This may be either on the anterior 
 or posterior border. Anteriorly, this point corresponds 
 to the supraclavicular and the infraclavicular space 
 opposite the middle of the clavicle, posteriorly to the 
 supraspinous fossa. From this point of oriein, the dis- 
 ease tends to involve the upper lobe, following alon.'r the 
 anterior border. Yet not infrequently the primary 
 localization is on the oiiter portion of the upper lobe, 
 corresponding to the first or second interspaces, just 
 below the outer third of the clavicle — a localization 
 less favorable for arrest or cure than the first. After 
 involvement of one upper lobe, the secondary tubercular 
 deposit may appear at the apex of the opposite lung, 
 but generally there is early involvement of the upper 
 portion of the lower lobe on the same side, at a point 
 which corresponds to the midscapular space opposite 
 the fifth dorsal spine. When the physical sig-ns over 
 the apices of the lung are doubtful, the presence^ of 
 change in the breath sounds or the occurrence of rales 
 over this position is of great diagnostic value, as it 
 almost invariably indicates that the signs at the apex 
 are due to tubercular changes. The base of the lower 
 lobe is rarely primarily affected, so that if the respira- 
 tory sounds over the apices are normal much caution 
 must be exercised in pronouncing the changes that occur 
 at the lower portion of the lower lobes tubercular. 
 Secondary foci in the upper portion of the lower lobe 
 occur soon after primary infection of the upper lobe on 
 the same side, generally extending backwards along the 
 posterior surface of the lung and along the line of inter- 
 lobular septa. The interlobular septa and the area o± 
 usual extension correspond to the lower border of the 
 scapular when the arm is raised above the level of tiie 
 clavicle, and the hand carried well over the shoulderof 
 the opposite side until the finger tips rest upon the spine 
 of the scapula. Extension downward generally occurs 
 by the development of separate foci, and not by gradual 
 
200 THE RESPIRA TOR Y SYSTEM. 
 
 extension from the upper portion of the lobe. Primary- 
 basic tuberculosis is extremely rare. In estimating the 
 probability of basic lesions being tubular in origin, the 
 following points must be considered : 
 
 1. If the physical signs of the disease in the lower 
 lobe are continuous from apex to base, it is probably 
 tuberculosis. 
 
 2. If the base is affected, but the upper part of the 
 lower lobe is free from all change, the basic lesion is 
 probably (a) non-tubercular ; it may be collapse follow- 
 ing bronchiectasis, catarrhal pneumonia, pneumonia or 
 pleurisy, (h) "If tubular, it is secondary to some con- 
 dition which has diminished the normal resisting power 
 of the base, i. c, pleurisy followed by partial collapse, 
 for example ; but the presumption is strongly in favor of 
 non-tubercular lesion." (Fowler.) 
 
 The apex of the opposite lung is generally involved 
 after the lower lobe on the primarily affected side. The 
 lesion has usually the same site as in the lobe primarilv 
 affected, bvit may be close to the interlobular septum, 
 corresponding on the chest wall to the upper part of the 
 axilla. The middle lobe of the right lung is rarely the 
 seat of the primary lesion. It is generally affected 
 rather late by extension from the upper lobe on the same 
 side, and may escape entirely. 
 
 Physical Signs. — The physical signs present in stib- 
 acute and chronic pulmonary tuberculosis during the 
 different stages vary with the nature of the pathological 
 changes, at one time approaching those of the acute 
 type, to again become less acute, closely simulating 
 those of chronic bronchitis, chronic interstitial pneu- 
 monia or chronic pleurisy. One of the most distinctive 
 features of the physical signs of chronic pulmonary 
 tuberculosis is their localization for a longer or shorter 
 time, especially at the apex, and their gradual extension 
 throughout the lung. This fact allows of division of 
 the signs into those diagnostic of three stages of the dis- 
 ease: (1) The early or incipient stage; (2) the stage 
 
DISEASES OF RESPIBATORY TRACT. 201 
 
 of extension and consolidation, and (3) the stage of 
 softening and excavation. These stages cannot be 
 defined with positive sharpness, but they are useful to 
 indicate the nature of the preponderating pathological 
 changes ; and the same case may shovsr all stages present 
 in different portions of the lung, or even in one lobe. 
 
 Inspection. Early or Incipient Stage. — The thorax 
 over the affected area may show no change in size or 
 shape, or early there may be depression of the bony 
 thorax. Flattening of the upper portion of the thorax 
 is suggestive of tuberculosis, especially when the flatten- 
 ing is limited to one apex. Frequently it can only be 
 noted when the patient is lying flat, or when looking 
 down over the shoulder. 
 
 When fibrosis and pulmonary collapse are the pre- 
 dominating pathological changes, the deformity of the 
 thorax is marked. There is deepening of the supra- 
 and infraclavicular spaces, and retraction of the first 
 and second ribs, and the clavicle becomes somewhat 
 prominent. With these changes in the bony thorax, 
 the expansion over the affected area is markedly dimin- 
 ished, while that of the opposite side is increased. 
 Pleural involvement with pain gives still further 
 diminution of motion. Changes in the bony thorax 
 may be entirely absent when dilatation of the air-vesicles 
 (compensatory emphysema) occurs aroimd the affected 
 
 area. 
 
 Second Stage.— As the disease advances, the signs 
 noted by inspection are influenced by the amount of 
 fibrous induration present. When this is slight, the 
 chest may show very little deformity, although motion 
 of the thorax may be markedly diminished. \Vhen 
 fibrous thickening of the lung is marked, there is local- 
 ized flattening of tiie chest and marked loss of expansion. 
 Extension of the disease to the upper portion of the 
 lower lobe causes the scapula on the affected sule to 
 'become more prominent, while at the same time there 
 may be curvature of the spine. 
 
202 THE RE8PIBAT0BY SYSTEM. 
 
 Third Stage. — With the occurrence of softening when 
 the pneumonic changes have heen the most marked feat- 
 ure, with a slight amount of fibrosis, the deformity of 
 the previous stage may be lessened, virhile at the same 
 time expansion over the affected area becomes freer. 
 Frequently, when the apex of one lung is in the third 
 stage, with early secondary involvement of the opposite 
 side, the expansion will be freer on the side first 
 affected. 
 
 In some cases marked softening with cavity forma- 
 tion does not occur, being replaced by interstitial 
 changes in the affected area. In these cases there is 
 marked contraction of the chest, producing curvature of 
 the spine. When situated in the upper portion, there 
 is depression of the shoulder, with projection of the 
 scapula. The intercostal spaces are depressed, and the 
 ribs may overlap each other; expansion is diminished 
 or absent. When the upper lobe of the left side is 
 affected, the apex beat of the heart is displaced upward 
 and slightly outward, and may be seen in the third left 
 interspace, or even higher. When the lower lobe of the 
 left side is involved, the apex beat may be seen in the left 
 axilla. Fibrosis of the right upper lobe causes the 
 heart to be displaced toward the right, the apex beat 
 frequently being invisible, because it is under the 
 sternum. Contraction of the right lower lobe causes 
 the apex beat to be seen at times beyond the right border 
 of the sternum. 
 
 Palpation Early or Incipient Stage. — It must be 
 borne in mind that vocal fremitus beneath the right 
 clavicle is greater than that on ihc left, and serves aF- a 
 standard for comparison. If vocal fremitus is equally 
 well marked on both sides, it indicates that there is 
 either diminution on the right side or increase on the 
 left. 
 
 In the early stage vocal fremitus may be normal, 
 increased or diminished over the affected area. It is 
 normal when the lesion is deep seated and covered with 
 
DISEA SE8 OF IIE8PIRA TOE Y TEA CT. 203 
 
 normal lung; increased when there is inflammatory 
 change or marked fibroid thickening; diminished when 
 pnlmonary collapse or pleuritic thickening is marked. 
 Change in vocal fremitus in tuberculosis is to be taken 
 in connection with the other physical signs. Palpation 
 IS frequently more accurate than inspection in showing 
 slight change in the expansion over the apices. 
 
 Second Stage. — With extension of the disease beyond 
 the primary foci, vocal fremitus may show the same 
 variations _ as noted during the first stage. Usually 
 extension is accompanied by well-marked inflammatory 
 changes in that portion of the lung that is secondarily 
 affected, and there is a corresponding increase in vocal 
 fremitus. Involvement of the upper portion of the 
 lower lobe causes increased vocal fremitus over tlie 
 interscapular space. Further extension over the lower 
 lobe causes increased vocal fremitus in parts which are 
 not contiguous. Involvement of the opposite side of 
 the upper lobe may show the same changes as those that 
 occur in the primary foci. 
 
 Third Stage. — Vocal fremitus may be increased with 
 the beginning of softening, due to the occurrence of 
 acute exacerbations, which frequently accompany this 
 change. When cavities are formed, vocal fremitus 
 becomes less marked. When fibroid changes jiredomi- 
 nate in the later stages, it may be increased. Thicken- 
 ing of the pleura freqiiently causes diminution of vocal 
 fremitus. 
 
 Peecussiokt. First Stage. — The percussion note 
 may be unchanged, but the earliest departure from 
 normal is usually a slight rise of pitch, with diminution 
 of resonance. Percussion of the apex is most important. 
 Percussion should be uniform and not too forcible, and 
 the tissues of the thorax should be lax. The height to 
 which the apex of the king rises above the clavicle dur- 
 ing inspiration and expiration should be determined, as 
 diminished expansion on one or both sides is frequently 
 the earliest symptom. Posteriorly, dullness on percus- 
 
204 THE BESPIBATOBY SYSTEM. 
 
 sion, with marked heightening of the pitch, may Be 
 noticed in the supraspinous region. Thickening of the 
 pleura causes the note to be dull and higher pitched, 
 with increased sense of resistance. 
 
 Second Stage. — As consolidation extends, dullness 
 will be detected along the edge of the sternum, and 
 extending toward the axillary line. Careful percussion 
 should be made at the apex and in the axilla in all eases. 
 Involvement of the upper portion of the lower lobe 
 causes marked dullness in the interscapular space. 
 When one apex is affected, careful examination for 
 change in pulmonary resonance should be made fre- 
 quently over the opposite apex. 
 
 Third Stage. — Softening in the affected area may 
 early cause a slight return of resonance, with tympanitic 
 quality over the area where the percussion was dull and 
 high pitched during the stage of consolidation. With 
 destruction of lung tissue and the formation of a cavity, 
 the percussion note becomes cavernous or amphoric, 
 according to the condition of the walls of the cavity. 
 Marked pleuritic thickening with fibroid change causes 
 the note to become dull, with a well-marked boardy or 
 wooden quality. 
 
 AuscuLTATioKT. Early or Incipient Stage. — Usually 
 the earliest signs are the occurrence at the apex of fine, 
 moist rales or crepitations, which are noticed during 
 inspiration. These may be detected only after cough- 
 ing, and may be limited to one or two rales. An impor- 
 tant feature of these rales is their persistence at the 
 point where first heard. Dry rales over one apex at 
 times precede even moist crepitations, and are associated 
 with feeble inspiratory breath sounds. These auscul- 
 tatory signs generally antedate the early signs noted by 
 inspection, palpation and percussion. 
 
 The respiratory murmur may be affected in various 
 ways during the inciinent stage. It may be (a) feeble, 
 wavy or jerky in inspiration or expiration, or in both. 
 This change is generally associated with occlusion of 
 
DISEASES OF EESPIKATOBY TRACT. 205 
 
 the bronchioles and collapse of the air-vesicles, (h) 
 Wavy inspiration, with prolonged, :)ioh-pitchcd, slightly 
 blowing expiration. This occurs Avhen there is more 
 marked increase in fibrous tissue, (c) The inspiratory 
 breath sounds are harsher, higher pitched, with slightly 
 tubular quality, while the expiratory is prolonged so 
 that its length equals or exceeds that of inspiration ; its 
 pitch is higher and its quality blowing or tubular when 
 the inflammatory changes are most marked (broncho- 
 pneumonia). 
 
 It is necessary to call attention again to the normal 
 breath sounds that may occur over the right a]X'x. 
 Normally, these are slightly harsher than on the left 
 side, and in certain anatomical arrangements the 
 bronchi themselves may have a well-marked tubular 
 quality. The relative intensity of the breath sounds on 
 the two sides has the same diagnostic importance as the 
 vocal fremitus. 
 
 Second Stage. — As the disease advances, the auscul- 
 tatory signs change, according to (1) tlie extent of 
 consolidation, giving the more intense type of bronchial 
 breathing; (2) whether or not there is accompanying 
 bronchitis when dry and moist rales are present; (3) 
 fibrosis and induration, causing marked increase in the 
 length of expiration ; the bronchial element is not 
 as marked, but is higher pitched than in the broncho- 
 pneumonic type. (4) Thickening of the pleura causes 
 various types of friction rales to be heard, with diminu- 
 tion or absence of the breath sounds. (5) Compensa- 
 tory distension of the lobules surrounding the affected 
 area sufficient to cause the signs of consolidation to be 
 masked by those of compensatory emphysema. 
 
 Secondary involvement of the upper portion of the 
 lower lobe is shown by fine rales and pleuritic crepita- 
 tions, with tubular breathing in the interscapular space 
 and over the hilus of the lung. The character of the 
 breathing heard at this point is peculiar, on account of 
 the relation of the upper portion of the lower lobe to the 
 primary bronchi. 
 
20G TEE BE8PIBAT0BY SYSTEM. 
 
 Third Stage. — The occurrence of moist rales and 
 their change in size when bronchitis has been a promi- 
 nent symjotom are the first evidence of softening. At 
 first these rales have, in addition to their liquid quality, 
 one of sharpness, dependent upon the consolidated con- 
 dition of the lung in which they are made. But the 
 conversion of the consolidated area into a cavity causes 
 the breath sounds of the second stage to be changed in 
 character. The pitch is lower, and the well-marked 
 tubular quality is rejolaced by one of more hollow char- 
 acter, cavernous or amphoric. If the cavities are dry, 
 no rales may be present. If they contain fluid rales of 
 large size, gurgles will be present. 
 
 Vocal resonance over the area of softening changes 
 in intensity, the broncophony and pectoriloquy of the 
 stage of consolidation being replaced by amphoric or 
 cavernous voice sounds. The stage of softening is 
 rarely uniform throughout different portions of the 
 lung, except in the more acute forms of the disease. 
 
 ACTINOMYCOSIS. 
 
 Infection of the lung by the ray fungus occurs gener- 
 ally secondary to that of the mouth or other portions of 
 the respiratory tract. Occasionally it may oiccur 
 primarily in the lung. Clinically, two stages are recog- 
 nized. 
 
 First Stage. — This is characterized by gradu^al involve- 
 ment of the lung and pleura. During this stage the 
 physical signs are those of tuberculosis of the lung or 
 emphysema, according as the pulmonary or pleural 
 element is predominant. Usually the primary focus is 
 at the base of the lung. 
 
 Inspection. — Restricted motion over the lower por- 
 tion of the affected side. With extensive involvement 
 of the lung or pleura, there is increased bulging. 
 
 Palpation. — As there is more or less occlusion of the 
 bronchi in the affected area, vocal fremitus is dimin- 
 
DISEASES OF RESPIRATORY TRACT. 207 
 
 ished. Extension to the pleura is attended with absence 
 of vocal fremitus. 
 
 Percussion. — Flatness, with increased sense of 
 resistance. 
 
 Auscultation. — Feeble or absent respiratory mur- 
 mur and pleuritic frictions. 
 
 Second Stage. Inspection. — This is characterized 
 by extension of the growth to the chest wall, aud the 
 involvement of the various structures. There is absence 
 of motion over the affected area. The intercostal spaces 
 are filled. Infiltration of the soft parts causes localized 
 inflammatory signs. With necrosis of affected tissue, 
 there is discharge of characteristic pus. 
 
 Palpation. — Over the intercostal tissue there is a 
 sense of hardness in the interspaces and a brawny, 
 osdematous condition of the soft 2)arts externally. With 
 breaking down, before free opening occurs, fluctuation 
 may be detected. 
 
 Percussion. — Before the opening occurs on the sur- 
 face of the chest, the signs may be that of localized 
 empyema. The percussion outline does not follow that 
 of effusion into the free pleural cavity, although it may 
 be identical with that of localized empyema. The 
 diagnosis can frequently only be made by puncture and 
 microscopical examination of the fluid obtained. 
 
 SYPHILIS OF THE LUNG. 
 
 Syphilitic lesions of the lung may occur as (1) 
 gumma, (2) broncho-pneumonia, (3) interstitial pneu- 
 monia (syphilitic phthisis), (4) involvement of the 
 bronchial glands and lymphatics. Destructive disease 
 of the lung due to syphilis is very rare. 
 
 The physical signs that accompany the different 
 changes in the lung are closely allied to those dependent 
 upon tubercular infection, and are not distinctive. 
 Diagnosis depends largely upon the distribution of the 
 foci and the subsequent course. 
 
208 
 
 THE BESPIBATOBY SYSTEM. 
 
 Tubercular Disease. 
 
 Pulmonary tuberculosis pri- 
 marily involves the aijcx, and its 
 extension tliroughout the lung 
 follows a definite line. 
 
 Coincident with the extension 
 of the disease, softening and cav- 
 ity formation occur. 
 
 When cavities occur they tend 
 to enlarge with concurrent signs 
 of softening and consolidation. 
 
 Fibrosis in pxilmonary tiibercu- 
 losis is usually attended with 
 secondary changes of consolida- 
 tion and softening. 
 
 Stenosis of the bronchi rare. 
 
 Syphilitic Disease. 
 
 Syphilis usually affects the 
 hilus and central portion of the 
 lung. 
 
 With extension softening and 
 destruction of lung tissue rarely 
 occur. 
 
 Cavities, when present are of 
 the bronchiectatic type, and are 
 attended with the signs described 
 under bronchiectasis. 
 
 Fibrosis excessive, distribution 
 through the lung follows the line 
 of lymphatics in the interlobular 
 spaces. 
 
 Stenosis of bronchi and larynx 
 commonly associated with change 
 in the glandular structures at the 
 hilus. 
 
 In many cases the differential diagnosis can be based 
 only on repeated examinations of the sputum and the 
 absence of tubercle bacilli, especially when signs of 
 softening and bronchitis are present. 
 
 MALIGNANT DISEASE OF THE LUNG. 
 
 Primary involvement of the lung is rare. It is 
 usually dependent upon extension from the mediastinal 
 and adjacent structures or metastasis from distant por- 
 tions of the body. It is especially liable to occur after 
 operation on the mammary gland. 
 
 Physical Signs. —These are variable, according to the 
 site of the disease and whether the pleura is involved. 
 
 Inspection. — When deep seated or localized, inspec- 
 tion may be negative. With occlusion of a bronchus, 
 localized retraction of the chest may be present. Exten- 
 sion to the pleura causes marked local bulging. When 
 
DISEASES OF RESPIBATOBY TliACT. 209 
 
 the entire pleural sac is involved, there is excessive 
 enlargement of the affected side, exceeding that of 
 effusions into the pleural cavity. 
 
 Palpation. — Vocal fremitus is increased unless the 
 growth occludes a bronchus or involves the pleural 
 cavity, when it is diminished. The cardiac impulse 
 may be displaced, and pulsations may be transnutted 
 through the new growth to abnormal areas. 
 
 Percussion. — Change in the ])orcussion note varies 
 according to the situation of the growth and the char- 
 acter of the surrounding tissue. 
 
 Auscultation. — The sounds are those of consolida- 
 tion, pulmonary collapse or thickening of the pleural 
 sac. When extension to the lung is secondary to 
 mediastinal involvement, pressure symptoms arc 
 present. 
 
 PLEURISY. 
 
 Pleurisy is an inflammation of the serous membrane, 
 characterized by an exudation upon the free surface of 
 the pleura, which may be fibrinous, serous, sero-fibriii- 
 ous, sero-purulent, purulent or hemorrhagic. All 
 these varieties of exudation may occur at different 
 stages of the same case of pleurisy. The inflannnation 
 may not be attended with an exudation upon the free 
 surface, but characterized by a fibrous thickening. 
 Inflammations of the jileura may be acute or chronic, 
 general or localized, primary or secondary. JSTumerous 
 classifications or subdivisions of pleurisy have been 
 made. For physical diagnosis three forms are suffi- 
 cient, depending upon the character and amount of the 
 exudation and the changes produced in the jjleura: 
 (1) Dry pleurisy "with fibrinous exudate; ('2) pleurisy 
 with effusion, and (3) chronic pleurisy with adhesions. 
 
 (1) Dry Pleurisy. — Before the exudation appears the 
 pleural surface undergoes certain changes, which may 
 give quite distinctive physical signs. The normal 
 
 14 
 
210 TBE RESPIBA TOR Y SYSTEM. 
 
 moist condition of the pleural surface is lacking. The 
 surfaces becomes dry; there is loss of lining endothe- 
 lium, with more or less roughening of the pleural sac. 
 When exudation takes place, the pleural surfaces are 
 more or less thickly coated with fibrinous material, 
 which, while allowing a certain amount of movement 
 between the two pleural surfaces, causes thickening of 
 the pleural sac and the occurrence of physical signs. 
 
 (2) Pleurisy with Eflfusion. — This form includes sero- 
 fibrinous pleurisy, subacute pleurisy, chronic pleurisy 
 with eflfusion, empyema. The nature of the fluid does 
 not modify the physical signs. The physical signs that 
 are present with effusion into the pleiiral cavity are 
 dependent upon the presence of the fluid and the effects 
 that it produces upon the lung, heart, position of the 
 diaphragm and abdominal viscera and in the thoracic 
 walls. Normally the pleural surfaces are in apposition 
 throughout. They are kept together by atmospheric 
 pressure, although the elasticity of the lung on the one 
 side and that of the thorax on the other produces a con- 
 stant traction on the two pleural surfaces, which tends 
 to separate them. When fluid or air is present in the 
 pleural cavity, certain changes occur: (a) The two 
 surfaces of the pleura are separated ; (h) the distension 
 of the pleural sac diminishes the space to be filled by the 
 lung ; (c) the elasticity of the lung causes it to retract 
 and to exert traction or lifting power on the fluid. 
 Until a certain point is reached, the fluid exercises no 
 compressing action on the lung, which retracts before 
 the fluid until its elasticity is satisfied. After this point 
 has been reached, the fiuid causes compression of the 
 lung. _ (d)^ With the filling in of the pleura there is loss 
 of tension in the pulmonary tissue, producing change in 
 the percussion note, (e) The chest walls, relieved from 
 the pulling action of the lung, assume the position of 
 elastic equilibrium, changing the contour of that side 
 of the thorax. The diaphragm, unacted upon by the 
 lung, does not rise as high in the thorax; later on the 
 
DISEASES OF RESPIRATORY TRACT. 211 
 
 weight of the fluid causes it to descend still lower. 
 (f) The opposite lung is also influenced by the change 
 in the interthoracic pressure, and tends to contract and 
 draw the heart and mediastinum towards the unaffected 
 side. Gradually, with the accumulation of fluid, 
 the normal interthoracic negative pressure diminishes 
 to zero, and later may be replaced by positive pressure. 
 As long as a negative pressure is present in the chest, 
 it exercises an action upon the fluid. As the fluid 
 increases the negative pressure becomes less marked, 
 and later the weight of the liquid itself exerts a positive 
 pressiire, causing bulging of the intercostal spaces, com- 
 pression of the lung, depression of the diaphragm, dis- 
 placement of the heart and interference with return 
 circulation. As the negative pressure depends upon 
 the elasticity of the lung, the occurrence of signs indi- 
 cating change from negative to positive pressure is an 
 index of the elasticity of the lung when taken in con- 
 nection with amount of expansion. 
 
 (3) Chronic Pleurisy with Adhesion.— In chronic 
 pleurisy with adhesion, more or less fluid may be 
 jiresent, but usually the most marked pathological 
 change is fibrous thickening of the pleura with 
 adhesions, binding together the two surfaces of the sac. 
 The effect of thickening of the pleura is to interfere 
 with expansion of the lung and to prevent free move- 
 ment of the thorax. When these changes are localized, 
 their effects are limited to the area involved, causing 
 many of the thoracic deformities and interference with 
 respiratory movements noted imder "Inspection" and 
 "Palpation." Thickening of the pleura, with imperfect 
 expansion of the pulmonary tissue, causes change in the 
 percussion note. As explained under "Auscultation," 
 imperfect expansion of the lung causes diminution or 
 absence of the normal breath sounds. Localized 
 adhesive pleurisy occurs early in pulmonary tubercu- 
 losis, and modifies the physical signs of that condition. 
 
 Physical Signs. Inspection. 1. Dry Pleurisy. — 
 
212 THE RESPIBATOBY SYSTEM. 
 
 When pain is present, the patient leans to the affected 
 side, or lies on that side to prevent motion. Expansion 
 is restricted, and motion is short and jerky. Movement 
 over opposite lung is exaggerated. 
 
 2. Pleurisy with Effusion. — ^When effusion, either 
 fibrinous or serous, is sufficient to separate the two sur- 
 faces, with absence of pain, motion over the affected side 
 may be freer. With the occurrence of liquid effusion, 
 there is slight enlargement of the lower portion of the 
 thorax. As effusion increases, the contour of the side 
 becomes more rounded, with widening of the intercostal 
 spaces. With complete filling of the pleural sac, the side 
 is enlarged in all directions. The spine is slightly 
 curved toward the affected side; the intercostal spaces 
 are obliterated, and the chest appears smooth. Motion 
 becomes progressively less until, with full distension, it 
 is absent. When positive pressure occurs within the 
 pleural sac, there is bulging of the intercostal spaces, 
 and pulsations may be present. The opposite side is in 
 a state of compensatory emphysema, and the respiratory 
 movements are exaggerated. Cardiac displacement 
 occurs early unless prevented by adhesions or conditions 
 causing fixation of the mediastinum. With absorption 
 of the fluid or with its withdrawal, the chest returns 
 gradually to its normal contour, with increase of the 
 respiratory movements. 
 
 3. Pleurisy with Adhesion. — The occurrence of 
 pleural thickening or adhesions causes movement to be 
 restricted, followed by retraction of chest walls on the 
 affected side if pulmonary expansion is prevented. 
 These changes are especially marked over the base of the 
 lung. 
 
 Palpation. 1. Dry Pleurisy. — Vocal fremitus may 
 be normal. When the fibrinous exudate is thick, vocal 
 fremitus may be diminished or absent. Slight friction 
 fremitus may be detected. 
 
 2. Pleurisy with Effusion. — ^With the occurrence of 
 effusion, there is gradual loss of vocal fremitus, occur- 
 
DISEASES OF RESPIRATORY TRACT. 21;' 
 
 ring first in the lower portion of the pleural sac 
 posteriorly, and gradually advancing upward as the sac 
 becomes filled. When the fluid has reached a certain 
 amount, vocal fremitus is usually increased at the upper 
 level. Vocal fremitus over the upper lobe of the lung 
 may be normal. With extensive effusion, relaxation 
 of the lung causes absence of vocal fremitus over the 
 upper lobe also. Compression of the lung causes 
 increased vocal fremitus posteriorly along the spine. 
 Vocal fremitus may be detected over the site of the 
 fluid when adhesions bind the lung to the chest wall 
 and prevent its retraction. The degree of cardiac dis- 
 placement may be estimated more definitely by palpa- 
 tion than by inspection. Displacement of the liver 
 below the free border of the ribs occurs when the effusion 
 is large, or when retraction of the lung or loss of 
 elasticity cause the fluid to act upon the diaphragm 
 early. 
 
 3. Pleurisy with Adhesion. — Pleuritic thickening, 
 besides interfering with respiratory movements, causes 
 diminution of vocal fremitus; and these, when asso- 
 ciated with fibrous induration of the lung, may caiise 
 increased vocal fremitus. 
 
 Percussion. 1. Dry Pleurisy. — With a slight 
 fibrinous layer, there is little or no change in resonance. 
 If exudation is very abundant, there is loss of resonance, 
 with increased sense of resistance. 
 
 £. Pleurisy with Effusion. — ^With the occurrence of 
 effusion, the earliest indications are shown by flatness 
 at the base of the lung posteriorly. Slight effusion 
 causes the area of flatness to be widest along the spine, 
 sloping in a gentle curve toward the axilla. With 
 increase of fluid, the line of dullness extends beyond 
 the axilla to the mammary line. When the fluid is 
 STifficient to reach the angle of the scapula, the percus- 
 sion outline shows a more or less curved line, which has 
 been called the "curved line of Ellis." 
 
 The fluid rises highest in the axilla, and on the 
 
214 THE BESPIBA TOR Y SYSTEM. 
 
 anterior border of the chest the line curves slightly 
 downward toward the sternum, while posteriorly the 
 line descends more abruptly to the spine. Percussion 
 of the affected side at this stage shows three zones: 
 (1) Flatness over the fluid ; (2) posteriorly, dullness over 
 
 Fig. 27. 
 
 Lines 1, 2, 3, curve of small effusion. 
 
 " 4, 5, 0, 7, curved line of Ellis (letter of S). 
 Dotted line from summit of curve to spine, ujippr limit of dull triangle. 
 
 the triangular space, bounded above by a line drawn 
 horizontally from the apex of the line of flatness in the 
 axilla. Above the horizontal line pulmonary resonance 
 of low pitch, with faint tympanitic quality, may be 
 detected. (3) On the anterior portion of the chest 
 
DISEASES OF RESPIRATORY TRACT. 
 
 215 
 
 between the horizontal line and the line of flatness, per- 
 cussion gives a peculiar tympanitic quality — Skoda's 
 resonance. (Figs. 27 and 28.) * 
 
 As the fluid increases in amount and the elasticity of 
 the lung is satisfied, the fluid assumes a more horizontal 
 line, and at last, when negative pressure has been 
 replaced by positive (which generally occurs when the 
 
 Fig. 28. 
 
 Dotted line slio'wing xaosition of heart, according to iiinount of effusion. 
 
 fluid reaches the level of the third rib), the lung is com- 
 pressed by the fluid, and a small area of tympanitic 
 percussion may be detected anteriorly under the clavi- 
 cles, close to the sternimi, and in the supraspinous fossa 
 behind. 
 
 As the curved outline of the fluid depends upon the 
 elasticity of the lung, a more nearly horizontal line. 
 
216 THE RESPIBA TOR Y SYSTEM. 
 
 with a small amount of effusion, shows that there is loss 
 of pulmonary elasticity or that the lung is prevented 
 from retraction by adhesions, or that there is consolida- 
 tion (probably tubercular) at the apex. The position of 
 the line of fluid does not change readily with change in 
 posture of the patient. When the patient has long 
 occupied the recumbent posture, the line of Ellis is more 
 or less displaced by the fluid gravitating toward the most 
 dependent portion. 
 
 3. Pleurisy with Adhesion. — Fibrous thickening of 
 the pleura with adhesions causes the percussion note to 
 be impaired over the lower portion of the lung, and is 
 usually associated with retraction of the bony thorax. 
 
 Auscultation. 1. Dry Pleurisy. — The respiratory 
 murmur is jerky and partly suppressed; inspiration is 
 shortened, with expiration prolonged, slow and feeble. 
 During the early stage the dry, rubbing friction sounds, 
 similar to the sound made when two rough surfaces of 
 paper are rubbed together, or when the hand is rubbed 
 over the ear, are heard. With the occurrence of plastic 
 exudation, the character of the friction sounds change. 
 They become stickier, are superficial, and later may 
 have a fine, grazing character. They are most abun- 
 dant at the end of inspiration and the beginning of 
 expiration. They may be absent in quiet breathing, and 
 only be detected at the end of a deep inspiration. When 
 the pleurisy of the left side involves the portion over- 
 lying the prsscordia, friction rales may be heard 
 synchronously with the heart sounds. 
 
 2. Pleurisy with Effusion. — The auscultatory signs 
 are variable. The signs typical of effusion of small 
 amount are slight diminution or absence of breath 
 sounds at base of lung and distant voice soiinds. As the 
 fluid increases in amount, there is absence of breath 
 sounds over the lower portion of the thorax correspond- 
 ing to the line of percussion flatness. At the level of 
 the fluid vesicular murmur may be faintly heard, asso- 
 ciated with bronchial breathing of a peculiar blowing 
 
DISEASES OF RESPIRATORY TRACT. 217 
 
 wavy character. The voice sounds arc also of a wavy, 
 nasal character (ffigophony). At the upper portion of 
 the thorax, over the apex of the lung, vesicular murmur 
 may be normal or slightly exaggerated. In large 
 effusions at the upper level, bronchial breathing becomes 
 more intense, and bronchophony and pectoriloquy are 
 present. 
 
 Occasionally tubular or bronchial breathing, broncho- 
 phony and pectoriloquy are heard over the fluid, simu- 
 lating the auscultatory signs heard in pneumonia. 
 These signs are especially apt to occur in children ; also 
 when bands of adhesion prevent the lung from retract- 
 ing as the fluid accumulates, so that it is compressed 
 posteriorly along the spine. The sound is conducted bv 
 the tense bands of adhesion through the fluid to the 
 bony thorax. Small consolidation of the lower lobes of 
 the lung may also cause bronchial breathing to be 
 present below the level of the fluid. 
 
 In addition to displacement of the heart, a soft, sys- 
 tolic murmur is detected over the precordial space when 
 the effiision is sufiiciently large to cause pressure upon 
 the mediastinum or slight distortion of the large vessels. 
 With disappearance of the fluid, the breath sounds 
 return, and pleuritic frictions are heard above the level 
 of the fluid. 
 
 3. Pleurisy with Adhesion. — ^Pleuritic thickening 
 with adhesion causes absence or diminution of the 
 breath sounds, with friction fremitus of a rough, rasp- 
 ing or creaking character. Intercurrent attacks of 
 acute pleurisy may reinduce the signs of fibrinous 
 exudation and of effusion. 
 
 Diflferential Diagnosis. Pleurodynia. — Inspection and 
 palpation may be identical. Percussion shows no 
 change in resonance. On auscultation there are present 
 feeble breath sounds, diie to loss of expansion of the 
 thorax, but unattended with friction rales. 
 
 Hydatid of the Pleura. — This may begin at the base 
 of the lung, but rarely gives a line of dullness so 
 
218 TEE EESPIBA TOR Y SYSTEM. 
 
 symmetrical as that of pleurisy with effusion. Usually 
 tiie area of percussion flatness is more nearly circular, 
 with resonance on either side, Avhich may have a more 
 or less tympanitic quality. Displacement of the heart 
 and ahdominal viscera does not occur unless the cyst is 
 large. Over the cyst localized bulging of the chest wall 
 is very marked. The differential diagnosis by physical 
 signs between encapsulated pleurisy and hydatid cyst 
 is almost impossible. 
 
 Pneumonia. (See page 172. ) 
 
 Sub-Diaphragmatic Abscess. Inspection. — Change in 
 the size and contour of the chest is most marked over the 
 free ribs extending to the hypochondrium. 
 
 Palpation. — Absence of vocal fremitus over lower 
 portion of thorax, associated with rigidity of hypochon- 
 driac region and marked depression of liver. 
 
 Pi<:egussion. — Upper line of flatness is high in axilla, 
 but does not conform to that of pleurisy with effusion at 
 the same level. Absence of dull area behind. Skoda's 
 resonance may be detected anteriorly. Displacement of 
 the heart does not occur. Slight displacement upward 
 of the diaphragm. The apex of the diaphragm is 
 higlier than normal. On examination with the X ray 
 the difference between subdiaphragmatic and supra- 
 diaphragmatic conditions is well marked. 
 
 HYDROTHORAX. 
 
 This condition differs from pleurisy with effusion in 
 that it is not inflammatory, but due to simple dropsi- 
 cal effusion into the pleural cavity. When limited to 
 one side, the physical signs are identical with those of 
 the inflammatory type. Usually both sides are involved, 
 and the following physical signs are present : 
 
 Inspection. — Slight motion on both sides. Slight 
 enlargement over lower portion of thorax. 
 
 Palpation. — Vocal fremitus is most marked poste- 
 riorly. Heart is displaced upward. 
 
DISEASES OF RESPIRATORY TRACT. 219 
 
 Percttssion. — Flatness over lower portion of thorax. 
 Line of flatness does not follow markedly the curve 
 noted under unilateral affections. Above the level of 
 the fluid Skoda's resonance is early present, with hyper- 
 resonance at the apex. 
 
 Auscultation. — Absence of breath sounds at the 
 base, below the level of the fluid. Bronchial breathinc; 
 at the upper level. Fine, moist rales are heard in the 
 rest of the lungs if pulmonary oedema is present. 
 
 PNEUMOTHORAX. HYDRO-PNEUMOTHORAX. 
 
 Diie to the presence of air or air and fluid in the 
 pleural cavity. 
 
 Physical Signs. Inspection. — Enlargement inore 
 marked than in pleurisy with effusion. Loss of motion 
 complete. 
 
 Palpation. — Absence of vocal fremitus. In hydro- 
 or pyo-pneumothorax succussion fremitus (splashing 
 sounds) is present when the patient is shaken or on 
 violent coughing. 
 
 Percussion. — Pneumothorax ; increased resonance 
 over affected side. When fluid and air are isrcsent in 
 the pleural cavity, two zones of resonance are detected — 
 flatness below the level of the fluid, and increased reso- 
 nance with a tympanitic quality above it. The line of 
 flatness is horizontal. When the anterior portion of the 
 chest is percussed with two coins while the observer 
 listens behind, a peculiar ringing, metallic sound is 
 heard (coin test). 
 
 Auscultation. — In pneumothorax there may be 
 absence of all respiratory sounds over the affected side. 
 When an opening exists between the bronchial tract and 
 pleural cavity, a peculiar, intense, amphoric breathing 
 is heard (lung fistula sound). When fluid and air are 
 both contained in the pleural cavity, by shaking the 
 patient, or after coughing, succussion sounds are pro- 
 
220 THE EESPIBA TOE Y SYSTEM. 
 
 duced. The falling of drops of secretion from the 
 upper portion of the cavity into the fluid below gives a 
 peculiar echo-like sound (metallic tinkles). 
 
PAET III. 
 THE CIRCULATOEY SYSTEM. 
 
 CHAPTER VIII. 
 
 INSPECTION. 
 
 Inspection of the circulatory system embraces not 
 only the heart,- but also all of those phenomena which 
 depend upon cardiac action. It includes the contour of 
 the prascordial area, the visible cardiac movements as 
 shown by the apex beat, the pulsations of the arterial 
 and venous systems, respiratory movements (dyspncea), 
 color of the skin and mucous membrane, and oedema of 
 the cellular tissue. 
 
 For examination, the patient's clothing should be 
 removed, so that a free view of the anterior portion at 
 least of the chest, may be obtained. The patient should 
 be examined in both direct and oblique light, and in the 
 standing and recumbent postures. The examiner 
 should view the surface from directly in front and after- 
 wards obliquely, so as to note all cardiac movements. 
 
 The circulatory movements may be seen more 
 clearly by placing over the seat of motion a piece of 
 adhesive plaster through which a pin has been stuck, 
 and applying to this pin a piece of cotton or lint as a 
 flag. Or small cones of paper or bits of cotton wool 
 may be stuck to the chest wall with mucilage or oint- 
 ment. The object of this is to increase the area of 
 
222 THE CIECULATOBY SYSTEM. 
 
 motion as seen at the extremity of the pin or paper cone, 
 and to determine whether or not the movement is 
 expansile. This latter condition is hest seen by plac- 
 ing over the area a piece of rubber plaster with a slit 
 cut through it ; this will show increase in size by widen- 
 ing of the opening. 
 
 Data obtained by inspection must be verified and cor- 
 rected by the knowledge obtained by the other methods 
 of examination. 
 
 Normally, that portion of the thorax which is Imown 
 as the prsecordia shows a slight flattening surrounded by 
 a slight elevation of the ribs. 
 
 In the fifth intercostal space, 2% to 3 inches to the 
 left of the sternum, at a point where a line drawn 2 
 inches from the left edge of the sternum and 1 inch 
 inside the nipple line bisects the space, is seen a local- 
 ized, rhythmical impulse occupying an area of about 
 1 inch square. 
 
 THE APEX BEAT. 
 
 This is due to the impact of the heart near the 
 anatomical apex on the chest wall. It does not mark, 
 as is commonly supposed, the true anatomical apex, but 
 that part which strikes the chest wall is distant from 
 the true apex about three-quarters of an inch. 
 
 The cardiac impulse is due to change in form of the 
 heart during systole, the vertical diameter being length- 
 ened, with a corresponding shortening of the transverse. 
 
 The site of the apex beat varies normally within cer- 
 tain limits. In the child it is higher, being found in the 
 fourth interspace, and farther from the mediastinum. 
 In old age it is lower down, being in the sixth inter- 
 space, nearer the median line. In persons Avith short, 
 broad thoraces it is found slightly above the fifth inter- 
 space, while in those in whom the thorax is narrow it 
 may be found underneath the sixth rib. and even at the 
 upper border of the sixth interspace. The site of the 
 
INSPECTION. 223 
 
 apex beat also varies with the position of the patient. 
 When lying on the left side, it is carried to the left as 
 far as the midclavicular line, and even further; when 
 the patient is lying on the right side, it is carried inward 
 toward the sternum, but its mobility is not as much 
 as when the patient is lying on the left side. The 
 respiratory act also causes a slight change in the loca- 
 tion of the apex beat. In quiet respirations it is but 
 little changed. In forced inspiration it is carried down- 
 ward and toward the median line, while in forced 
 expiration it is displaced upward and slightly to the left. 
 
 Changes in the Praecordia. — The bony thorax over the 
 cardiac area may bulge from the third to the seventh rib, 
 and from the sternum to the left nipple ; or the projec- 
 tion may extend from nipple to nipple. The bulging 
 and distortion of the praecordial area may be caused by 
 conditions not associated with cardiac or circulatory dis- 
 eases: (a) Swelling of the cellular tissue, due to 
 inflammatory exudation or to localized deposits of 
 adipose tissue; (b) changes in the bony thorax de- 
 pendent upon rickets ; (c) a bulging anteriorly, with a 
 compensating posterior curve from spinal curvature. 
 
 Local bulgings over the prsecordium may be caused 
 by cardiac changes, although they are not marked unless 
 the cardiac disease occurred in early life, when the 
 flexibility of the bones permitted easy distortion. 
 (a) Cardiac hypertrophy and dilatation do not pro- 
 duce marked change in the prsecordial area unless it has 
 occurred early in life, when it may produce a distinct 
 forward bulging of the sternum and ribs, especially of 
 the left side. Congenital cardiac disease produces the 
 most marked distortion of the thorax. The amount of 
 deformity in the case of chronic hypertrophy with dila- 
 tation is important in estimating the time of life at 
 which the cardiac disease occurred, (b) Pericarditis 
 causes the contour of the prsecordium to be rounded, the 
 normal slight flatness being absent. The interspaces 
 are wider than normal, being even with the surface of 
 
224 THE CIRCULATORY SYSTEM. 
 
 the ribs orlbulging, according to the amount of exuda- 
 tion into the pericardial sac. The amount of bulging 
 that is present in the case of pericarditis with effusion 
 depends upon the flexibility of the bony thorax; it is 
 marked in childhood, and scarcely noticeable or absent 
 when ossification of the ribs has taken place. 
 
 Aneurism at different portions of the thoracic artery 
 may produce local bulgings, as will be described later. 
 
 Permanent retraction of the bony thorax does not 
 occur as the result of cardiac disease unless associated 
 with other changes in the thoracic viscera. 
 
 Conditions Modifying the Location, Extent and Character 
 of the Apex Beat. — As has already been stated, the 
 visible apex beat merely marks the point at which some 
 portion of the heart near the anatomical apex strikes 
 the chest wall. The portion of the heart which gives 
 the impulse is generally the right ventricle, about three- 
 quarters of an inch from the true apex. The point of 
 contact of the heart may vary within wide limits, due to 
 changes in the relation of the heart to the chest wall, so 
 that the visible apex beat is changed from the normal in 
 location, extent and character. 
 
 Influence of the Soft Parts. — The apex beat is much 
 more noticeable and the exact point of contact more 
 distinct in thin persons, especially those with flexible 
 thoraces. In persons where the prajcordia is thickly 
 covered with adipose tissue the area of impulse will be 
 slightly increased, while the point of the apex beat will 
 be less distinct. This is especially marked in cases 
 where the mamma is full and tense, the cardiac impulse 
 being conveyed to the entire breast and the apex beat 
 being masked. Where the mamma is large and flaccid, 
 the apex beat may be entirely absent. 
 
 Influence of the Bony Thorax. — The elasticity and 
 mobility of the ribs influence largely the character of 
 the apex beat. In children, where there is marked 
 de]n'ession of the thorax during expiration, the apex 
 beat is distinct and more extensive. In old age the 
 
INSPECTION. 225 
 
 rigidity of the thorax and secondary changes in the hmg 
 cause the apex to become indistinct or absent. Narrow 
 intercostal spaces may render the apex beat invisible, 
 the heart striking the chest immediately under the rib. 
 In very broad thoraces the apex beat is higher, being 
 underneath the fifth rib, or even in the fourth interspace. 
 In long, narrow thoraces the apex beat is lower, being 
 displaced downward and slightly outward. The flat, 
 rachitic or paralytic thorax, with narrow antero-poste- 
 rior diameter at the lower portion of the prEecordium, 
 brings the apex beat further to the left in the fifth inter- 
 space. The pigeon-shaped thorax, with increase in the 
 antero-posterior diameter, causes the apex beat to be 
 nearer the median line and somewhat indistinct, except 
 where the depression beyond the bulging causes the true 
 apex to strike the chest wall. 
 
 When the ribs over the cardiac region are displaced 
 by primary disease of the lungs, the apex beat is dis- 
 placed to the right or left and upwards or downward, 
 according to the pulmonary condition. 
 
 Influence of Diseases of the Pleura. — Filling of the 
 pleural sac with air or fluid causes displacement of the 
 heart to the opposite side and alters its relation to the 
 chest wall, unless the movement of the heart is prevented 
 by adhesions. 
 
 Effusions into the right pleural sac cause the heart to 
 be displaced to the left and upward, the apex beat being 
 seen in the mid-axillary line. The base of the heart is 
 also displaced, but not to the same degree as the apex. 
 
 Effusions into the left pleural sac move the heart 
 toward the right, so that, according to the amount of 
 fluid present, the apex beat may be felt at any point 
 between the normal site and the right mammillary line. 
 As was noted under "Pleurisy with Effusion" (page 
 215), displacement of the heart is one of the most char- 
 acteristic signs of this condition. Occasionally the 
 cardiac impulse is transmitted to the fluid, giving the 
 physical signs of pulsating empyema. 
 15 
 
2i!(l THE rlECULATORY HYSTEM. 
 
 Adhesions of the pleural surface and contractions 
 draw the heart toward the affected side, with displace- 
 ment of the apex beat. This will be fully explained 
 later on. 
 
 Influence of Changes in the Lung. — Quiet breathing- 
 produces no change in the apex beat. FiiU, deep in- 
 spiration causes the inflated lung to cover the heart to a 
 greater detirec, thus lessening the extent and force of 
 
 to* 
 
 the ajiex beat, and may cause it to disai)pcar entirely. 
 Frequently it is sufficient to displace it downward, so 
 that it is seen an interspace lower. 
 
 Permanent increase in size of the lungs, as in general 
 emphysema, causes marked change in the relation of the 
 heart to the bony thorax. As a result of the increase in 
 size of the lungs and loss of tension, as was explained 
 under ''Emphysema," there is elevation of the ribs and 
 depression of the diaphragm, which also depresses the 
 heart, the apex beat being carried inward and down- 
 ward. When increase in size of the lung is associated 
 with obstruction of the circulation, the hypertrophy and 
 dilatation of the right ventricle increase the 2:)ulsation 
 in area and extent, and carry it still lower, giving 
 epigastric pulsation. 
 
 Unilateral emphysema causes the heart to be dis- 
 placed similarly to the manner seen in pleurisy. Com- 
 pensatory emphysema in the right lung carries the apex 
 beat to the left and higher. Enii:]iysema of the left 
 lung causes it to be lower, and rarely disj^laces it beyond 
 the left sternal line. 
 
 Shrinkage of the lung as a result of pleurisy, or due 
 to interstitial change in the pulmonary tissue (as in 
 interstitial pneumonia and fibroid phthisis), draws the 
 hearft.oward the diseased side. When the changes are 
 limited to the lower border of the left lung, that portion 
 of the henrt which is normally covered by pulmonary 
 tissue may be brought intu <lirect contact with the chest 
 wall ; the visible apex beat will be increased in area and 
 carried horizontally to the left, and a gTeater portion of 
 
INSPECTION. 227 
 
 the heart, including the true apex, strikes the chest wall. 
 When the change is more oxlcnsivo, the heart may be 
 drawn upward and outward, the apex beat being seen in 
 the mid-axillary line. When the right lung is affected, 
 the heart is drawn to the right side and upward' 
 involvement of tlie upper portion of the lung mav 
 cause visible pulsations -of the pulmonary artery^ in the 
 second left interspace, or it may be so extensive 'tli at the 
 phases of cardiac movement, systole, diastole and the 
 pre-systolic contraction of the auricle may he seen over 
 the entire pra>cordial space, giving the impression of a 
 peristaltic wave. 
 
 Influence 6f Changes in the Pericardium. — Effusion into 
 the pericardium causes change in the site and area of 
 the apex beat, according to the character and amount of 
 exudation. In small effusions the apex beat may be 
 seen over a wider area, especially toward the epigas- 
 trium. When the pericardium is filled to a greater 
 degree, the visible apex beat is carried upward into the 
 fourth interspace or higlier, due to a portion of the heart 
 higher up striking the chest wall, and not to an upward 
 displacement of tlie true a])ex. When the pericardium 
 is fully distended with fluid, the apex beat may be 
 absent. 
 
 Adhesions of the pericardium to the pleura or medias- 
 tinum may cause retraction of the chest wall over tlie 
 apex (Broadbent's sign). Eetraction of the chest wall 
 over the pra-cordial area is one of the diagnostic signs of 
 adhesions of the pericardium when it produces marked 
 visible recession of the costal cartilages, ribs and 
 sternum, and is associated with signs of cardiac hyper- 
 trophy greater than the amount of cardiac valvular dis- 
 ease would produce, and where there is also evidence 
 of a co-existing pleurisy or exo-cardial disease. 
 
 Retraction of the chest wall over the apex also occurs 
 with adlierent pericardium, secondary to pulmonary 
 tuberculosis. 
 
 Influence of Changes in the Heart. — The site, extent 
 
228 TEE CIRCULATORY SYSTEM. 
 
 and character of the apex beat corresponds, within cer- 
 tain limits, to the extent of the cardiac changes. 
 Powerful action of the heart, due to physical exertion 
 or mental excitement, as in Grave's disease, in poisoning 
 and in fevfir, causes the apex heat to be more noticeable 
 and broader by causing a larger area of the chest wall 
 to be affected. 
 
 In a similar manner, simple hypertrophy of the left 
 ventricle causes the apex beat to be carried to the left 
 and very slightly downward. Increase in the size and 
 force of the left ventricle causes a portion of the heart 
 closer to the true apex to strike the chest wall, and the 
 beat is strong, distinct and defined. When the left 
 ventricle is both dilated and hypertrophied, the apex 
 beat is carried doAvnward and to the left, being seen in 
 the eighth interspace or lower. The impulse is in pro- 
 portion to the amount of hypertrophy; the apex beat 
 will be correspondingly strong, a large area of the chest 
 wall will be influenced and the impiilse, though wide, 
 will be well defined. 
 
 When dilatation is the most marked feature, the apex 
 beat will be weak and diffused. 
 
 Eight-sided cardiac hypertrophy causes the visible 
 pulsation to appear between the ensiform cartilage and 
 the normal position of the apex beat in the fifth inter- 
 space. The apex beat may be carried slightly to the 
 left, but rarely goes beyond the left mammary line. 
 When the hypertrophy of the right ventricle is extensive 
 and associated with dilatation, pulsation may be seen in 
 the third, fourth, fifth, sixth and even seventh inter- 
 space near the termination of the cartilages on the left 
 side of the sternum, or in the epigastrium, along the 
 free border of the ribs on the left side. 
 
 When dilatation of the right ventricle is extensive, 
 with slight hypertrophy, the area of pulsation is more 
 extended, and the character of the impulse is more 
 diffused. 
 
 Dilatation of the right, auricle may cause pulsation 
 
INSPECTION. 229 
 
 to be seen in the fifth right interspace along the 
 sternum. Pulsation of the conus arteriosus and hyper- 
 trophy and dilatation of the right ventricle may produce 
 pulsations in the second and third interspaces on the left 
 side. 
 
 Cardiac weakness from any cause, as myocarditis, 
 fatty heart, degenerations, etc., causes the apex beat to 
 be less noticeable or entirely absent. 
 
 In congenital transpositions of the organs the apex 
 beat is found to the right side of the fifth interspace, 
 and has the characteristics of that noted in the normal 
 heart. 
 
 Influence of Changes in the Mediastinum. — Aneurism of 
 that portion of the aorta contained in the mediastinum, 
 abscesses, new growths and enlarged glands displace the 
 ajDex beat downward and to the left. Fibrinous medias- 
 tinitis with contraction may bind the heart down and 
 cause retraction of the pra3cordial area during systole. 
 
 Influence of Abdominal Changes. — Pressure from below 
 the diajjhragm, due to ascites, meteorism, tumors or 
 anything that increases the contents or the abdominal 
 pressure forces up the diaphragm, causing the heart 
 to be displaced upward and the apex beat to be seen in 
 the fourth interspace to the left. 
 
 Displacement of the diaphragm vlownward, as occurs 
 in ptosis of the abdominal organs, etc., carries the apex 
 downward, and the impulse is seen in the epigastric 
 region only. 
 
 IMPULSES DUE TO CHANGES IN BLOOD-VESSELS. 
 
 Aneurism of the thoracic aorta may produce visible 
 pulsations in different portions of the thorax. When it 
 involves the ascending portion, the pulsation is seen to 
 the right of the sternum. When the transverse portion 
 is involved, the impulse may be conveyed to the sternum 
 itself and upward, and be seen also in the episternal 
 notch. Aneurism of the descending aorta, when 
 
230 THE CTRCULATOBY fiYSTEBL 
 
 developing forward, shows the impulse to the left of the 
 sternum. 
 
 Arterial Pulsations. — Xormally, the only pulsation that 
 is seen in the arteries is a slight movement in the caro- 
 tids just ahoA'e the clavicles. 
 
 Conditions Causing Visible Pulsations in the Arteries. 
 (1) Cardiac Causes. — AVhen cardiac action is sudden 
 and forcible, as occurs in exercise and under mental 
 excitement, the blood is forced into the aorta and larger 
 blu( id-vessels with sufficient force t" cause a marked 
 visible pulsation. 
 
 (3) Yaticnlar Causes. — "When the blood is forced 
 from the heart into the blood-\'esselri that are only par- 
 tially filled, instead of the nornud pulse wave lieing 
 transmitted through the blood-x-essels, there is a direct 
 pro]uilsion of the blood wave through the aovt;i into the 
 blood-vessels themselves. This C(iu<lition of the blootl- 
 vessels occurs (a) whenever there is a rapid enqitying of 
 the larger blood-vessels into the capillaries and veins, as 
 (iccnrs in vaso-motor loss of control, in Gra\'e's disease, 
 chlorosis and ana'uiia ; (h) when t]ie aorta, during 
 diastole, empties itself into the enlarged ventricle 
 (aortic regnrgitation), and with the following systole 
 there is a sudden forcing of a larne amount of blood into 
 the partially em])ty and collapsed aorta and its branches. 
 In aortic regnrgitation the visible systolic pulsation mav 
 be seen over the entire body. Arterial pulsation is also 
 seen Avhen the blood-vessels have been converted from 
 elastic, distensible tubes into rigid ones. Xormally, 
 with each systoli' there is dilatation of the aorta, and 
 during diastok' the elasticity of the large vessels forces 
 the blood onward. When the a(U'ta is converted into a 
 rigid tube, with each systole the heart impulse is con- 
 veyed to the entire arterial tract, producing visible 
 movement in the blood-vesscds. 
 
 Capillary Pulse. — Occasionally in aortic regurgitation 
 systolic, rhythmical pulsations are seen in the cajiil- 
 liiries; with loss of cardiac power these pulsations dis- 
 
IXSI'ECTION. 231 
 
 ajipear. Capillary pulse may bo ol),servf(l by friction of 
 the surface, producing dilatation of tlie superficial 
 blood-vessels by placing a slide on the uiucons mem- 
 brane of the lips and with slight pressure causing the 
 capillaries alone to be seen. 
 
 Venous Pulsation. — Slight pulsations may be seen in 
 the neck during health, but ai-e most marked i)i the 
 sid)jects of chlorosis and ana-mia. In ordttr to see them, 
 the patient should be recumbent, the head thrown 
 slightly backward and the light should fall across the 
 riiot of the neck obliquely. The physician should view 
 the neck at a slightly higher level. 
 
 The noriiid.l Venous pulsations are usually a gradual, 
 general dilation of the l)lood-vessel. "The wave is 
 longer, broader and less sudden in its oscillation than 
 that seen in the artery. It is more influenced by 
 posture, being greatest when the patient is lying flat. It 
 is presystolic, ocemrring before that of the carotid; the 
 collapse of the vein corresjionds to the ajiex boat." 
 
 In chlorosis and aniemia this presystolic venous pulsa- 
 tion may be markedly increased. The ahnonnal 
 pulsations seen in the veins art; systolic in time. They 
 are most marked in the veins of the right side, and are 
 best looked for in the external jugulars just above the 
 clavicle, outside of the border of the sterno-cleido- 
 nnistoid muscle, as at this point the vein is unaccom- 
 panied by the artery. 
 
 It is necessary to determine whether or not the sys- 
 tolic pulsation in the vein is due to the impulse con- 
 veyed to the vein from a distance. (1) If slight, slow- 
 pressure over the vein at the lowi'st point stops the pulsa- 
 tion, it shows that it is a true venous pulsation. Such a 
 light pressTire would not influence pulsations transmitted 
 from the artery. (2) By drawing the finger upward 
 along the course of the vein, and keeping it at the iipper 
 level, the vein will fill from below and the pulsation M'ill 
 be systolic. Sudden emptying of the vein during 
 diastole is said to be a sign of adherent pericardium, 
 but this is a doubtful sign. 
 
232 THE CIKCULAWBY SYSTEM. 
 
 Pulsation in the peripheral veins may be due (a) to 
 aortic regurgitation; (h) certain etages of fever, and 
 is made more visible by putting a thin layer of sealing 
 wax over the vein. 
 
 Cardiac Dyspnoea. — Cardiac dyspnoea differs from pul- 
 monary dyspnoea in the following respects : ( 1 ) While 
 the patient is at rest the respiratory movements are 
 normal, but the slightest exertion induces an intense 
 feeling of oppression and dyspnoea. (2) Examination 
 of the lung shows no interference with the entrance and 
 exit of air; respiratory movements are increased in 
 force, frequency and extent without the other evidences 
 of interference in the respiratory tract. (3) The 
 dyspnoea is out of all proportion to the lesion that may 
 have been induced secondarily in the lung by the cardiac 
 disease. 
 
 Types of Caediag Dyspstcea. — (1) Dyspnoea on 
 exertion, (2) paroxysmal dyspnoga, occurring when at 
 rest, especially when the patient wakes out of sleep, due 
 to sudden raising of the blood pressiire; (3) chronic 
 dyspnoea or orthopncea, (-4) rhythmical dyspnoea 
 (Cheyne-Stokes respiration). 
 
 Dropsy. — ffidema due to cardiac disease appears first 
 over the dorsum of the feet and at ankles and skin over 
 the lower portion of the tibia. As interference with the 
 circulation becomes more marked, the dropsy ascends 
 from below upward, involving the thighs, abdomen and 
 finally becomes general (anasarca), when the serous 
 cavities become involved. 
 
 CEdema due to renal causes appears first in the face, 
 and soon becomes general. In auEPmia the dropsy first 
 develops in the more dependent parts of the body, and 
 in this respect resembles that of cardiac disease. 
 
CHAP TEE IX. 
 
 PALPATION. 
 
 Palpation not only corroborates the data obtained by 
 inspection, bnt also corrects it, and gives additional and 
 more exact information concerning the changes in the 
 prEecordia and their causes. It enlarges the knowledge 
 of cardiac movements by detecting pulsations too feeble 
 to be noticed by the eye, and shows not only the position 
 of the apex beat, but also its extent, force, character and 
 rhythm. 
 
 While inspection gives us the point at Avhich some 
 portion of the heart strikes the chest Avall, by palpation 
 we are able to fix the position of the anatomical apex, 
 and it is thus possible to determine the true size of the 
 heart. 
 
 It is especially valuable to determine whether pulsa^ 
 tions are systolic, diastolic, irregular or intermittent, 
 and to detect other vibratory phenomena, as fremitus 
 and thrills. 
 
 In order to obtain the most satisfactory results from 
 palpation, it is necessary that the patient assiime an easy 
 position, whether it be standing, sitting or reclining. 
 When feasible, the patient should be examined in more 
 than one position, as posture has a marked influence on 
 the position and force of the cardiac impulse. The 
 observer should place his hand lightly over the lower 
 portion of the prsecordia and note the general character 
 of the sensation conveyed to it. Then, by the tips of the 
 fingers, the exact location of the maximum apex beat 
 may be determined. Frequently, when the pulsations 
 are indistinct or diffuse, it is difficult to locate exactly 
 
234 TEE CIBCULATOBY SYSTEM. 
 
 the point of maximum intensity of tlie apex beat. In 
 such cases it is best to apply the tips of the fingers to 
 the thorax beyond the point of visible pulsation, and, 
 moving them along the interspaces, locate the point at 
 which the elevating impulse is felt most distinctly. 
 
 Palpation enlarges the knowledge obtained by insjiec- 
 tion of increase in size of the jiracordia by determining 
 whether or not the enlargement is due to oadema, inflam- 
 matory swelling, or new growths of the soft parts. In 
 regard to the bony thorax, it determines the degree to 
 which it is influenced by each cardiac beat. 
 
 The cardiac movement is felt by the hand placed over 
 the prfficordia in the region of the apex, in an adult witli 
 fairly thin chest walls, as a diffused throb, which at tlie 
 fifth intercostal sjDace ends with a distinct elevating 
 impulse. The pulsation felt is synchronous ^yith the 
 visible apex beat and the carotid pulsation, and slightly 
 precedes the radial pulse. In thin persons with flexible 
 chest walls, a distinct, sharp jerk or shock may bo felt 
 at the base of the heart when the flat of the hand is 
 applied. With the finger tips it can be localized in the 
 third or fourth interspaces, close to the sternum. It is 
 diastolic in time, due to the closiire of the a(jrtic and 
 pulmonary valves (valve shock). In its most ]XTfect 
 manifestation, cardiac impulse is felt as a distinct 
 movement or peristaltic wave passing from apex to base. 
 
 The apex beat varies normally in its point of maxi- 
 mum intensity, force and extent, as has already been 
 described under "Inspection." 
 
 Conditions Modifying the Apex Beat. — The influence of 
 posture on the position of the heart is much move notice- 
 able by palpation than by inspection, and must always 
 be taken into account. When the patient is standing, 
 bending forward causes the cardiac impulse to become 
 more distinct and sustained; In many cases the apex 
 beat can only be located with the iiatient in this position. 
 When in the semi-recumbent position or lying flat u]ion 
 the back, the heart recedes from the chest wall, and the 
 
PALPATION. 2,60 
 
 impulse becomes correspondingly weak and indistinct. 
 When lying on the left side, the heart is displaced 
 toward the same side, and is felt about midway between 
 its normal position and the anterior axillary line; and 
 the apex impulse is not so marked, being covered to a 
 greater extent by lung tissue. When lying on the right 
 side, the heart is carried toward the right, and the apex 
 beat is felt nearer to the sterniun, or it may be under the 
 sternum, and the impulse will be faint or entirely 
 absent. When the heart is carried under the sternum, 
 the beat may be sometimes felt as a diffused, weak epi- 
 gastric impulse. 
 
 The position of the apex beat varies with age, as has 
 already been explained. During the first two years of 
 life it is visible in the fourth interspace, but palpation 
 shows that the true apex is near or to the left of the 
 nipple line. From the second until the sixth year it 
 gradually assumes a position nearer to the median line 
 and lowei', until after the sixth year it is found in the 
 fifth interspace. In childhood the force of the beat is 
 relatively greater, on account of the flexibility of the 
 ribs and the condition of the lungs. In old age the 
 heart is displaced downward and toward the median 
 line, and the apex beat is stronger on account of senile 
 hypertrophy. 
 
 Influence of the Soit Parts. — Marked increase in the 
 thickness of the thoracic wall has but a slight effect upon 
 the palpable apex beat ; by firm pressure we are able to 
 render the tissues in such a condition as to readily 
 convey the impulse. 
 
 Influence of the Bony Thorax. — In young subjects, with 
 thin, elastic ribs, the cardiac impulse is sufficient to 
 be felt as a lift or elevating sensation, not only in the 
 intercostal s]iaces, but also over the ribs, the point of 
 maximum intensity of the apex beat being much more 
 distinct and less diifused than in the adult. Where the 
 bony structures are rigid, the cardiac impulse influences 
 the bony thorax but slightly, and the apex beat is only 
 
236 THE CIROULATOBY SYSTEM. 
 
 felt in the intercostal spaces ; in other portions of the 
 thorax it is more the sensation of a jar. 
 
 Influence of Changes in the Pleura. — Eilling of the 
 pleural sac with air or fluid, in addition to displacing 
 the apex beat, changes the character of the impulse. 
 The relation of the heart to the chest wall being changed, 
 the impulse is feebler and more diffused. Occasionally 
 pulsations from the heart are conveyed to the fluid in 
 the pleural cavity and transmitted over the entire 
 thorax. This is more likely to occur when the fluid is 
 piirulent (pulsating empyema). 
 
 Contraction of the left pleura causes the heart to 
 be uncovered, and a larger area to be brought in con- 
 tact with the chest wall. The apex beat is not only 
 carried to the left, but it is also more visible and of a 
 wider extent. When the same change occurs in the 
 right pleura, the impulse may be felt to the right of the 
 sternum. When the pleural surfaces are covered with 
 thick, tenacious exudate, as in acute pleurisy, cardiac 
 movement may cause friction fremitus to be felt with 
 each beat, or only when the cardiac systole coincides 
 Avith full inspiration or expiration. It is sometimes 
 difiicult to determine whether the fremitus which is felt 
 is produced in the pleura or in the pericardium. If 
 produced in the pleura, it does not occur if the patient 
 holds his breath. The exception to this rule occurs 
 when adhesions have taken place between the peri- 
 cardium and the pleural surfaces. 
 
 Influence of Changes in the Lung Tissue. — The efl'ect of 
 lung changes upon the position of the apex beat has 
 already been noted. Retraction of the left lung causes 
 the apex beat to become more extensive ; retraction of 
 the right lung may cause displacement of the apex beat, 
 with a more diffused and weaker impulse. 
 
 General emphysema, in addition to changing the 
 position of the heart and apex beat, is also apt to induce 
 changes in the heart itself, causing the apex beat to 
 become more feeble and diffused. In unilateral emphy- 
 
PALPATION. 237 
 
 sema the apex beat is not only displaced bv the enlarged 
 lung, but, as this condition is usually associated with a 
 corresponding diminution of the other lung, there is apt 
 to be some change in the heart itself which modifies the 
 character of the apex beat. 
 
 Influence of Changes in the Pericardium. — Effusions 
 into the pericardium cause not only elevation of the 
 visible apex, but the intervention between the heart and 
 the chest wall of a layer of fluid causes the beat to 
 become less distinct, and at the same time somewhat 
 diffused. As the effusion increases in amount, the pul- 
 sation felt over the lower portion of the prascordia is a 
 peculiar, wave-like sensation, while over the site of the 
 visible apex beat there is felt a weak, elevating impulse. 
 In extreme effusion the only impiilse noticed may be a 
 diffuse sensation of fluctuation. When the pericardium 
 is covered by thick, tenacious (plastic) exudate, a 
 friction fremitus may be felt over the entire prsecordia, 
 but most frequently it is limited to that portion of the 
 pericardium that is not covered by lung tissue, and which 
 corresponds to the area of absolute dullness on percus- 
 sion. It may be detected by light pressure over the 
 prtecordia, and can be intensified by causing the patient 
 to lean forward and making firm pressure in the inter- 
 spaces. The fremitus occurs rhythmically with the 
 cardiac action. 
 
 Influence of Cardiac Changes. — As the palpable impulse 
 is due to the impact of the heart on the chest wall, it will 
 vary according to the muscular power and size of the 
 heart. In the normal heart it is increased by those 
 causes which produce overaction, as nervous excitement, 
 pyrexia, toxic agents, exertion and irritability of the 
 heart muscle, due to a beginning inflammation of the 
 pericardium or endocardium. These factors will 
 merely cause increase in the force of the apex beat, 
 without change in its location. Hypertrophy of the 
 heart modifies the character of the apex beat according 
 to which portion of the organ is affected. Hypertrophy 
 
238 THE CIECULATORY SYSTEM. 
 
 of the left ventricle causes the pulsation to be strong, 
 prolonged and heaving or thrusting in character. The 
 apex beat is well defined, and the lifting impulse, while 
 marked, is not sudden. When hypertrophy and dilata- 
 tion of the left ventricle are associated, not only is the 
 apex beat carried downward and to the left, being fre- 
 quently felt in the mid-axillary line, but the impact may 
 be powerful enough to influence the entire left chest, and 
 is felt as a lifting, heaving motion. 
 
 When dilatation of the left ventricle is tlie most 
 prominent feature, there being relative muscular weak- 
 ness, although hypertrophy is present, the impulse is 
 weak and abrupt, and the apex beat is ill-defined and 
 diffused. The lifting sensation of the normal apex 
 beat is wanting in simple dilatation of muscular weak- 
 ness or degeneration. 
 
 As normally the apex beat is due to some portion of 
 the right ventricle striking the chest wall, in ]iy])er- 
 trophy of the right ventricle this area is increased and 
 carried toward the median line, and the sensation felt 
 by the hand is of a diffused lifting character, which is 
 visibly transmitted to the epigastrium and the lower 
 portion of the sternum. When dilatation and hyper- 
 trophy are associated, the impulse becomes more dif- 
 fused. In marked dilatation with muscular weakness, 
 the impulse is of a wave-like, indistinct character, and 
 may be felt to the right of the sternum. 
 
 Palpable Vibrations, or Thrills. 
 
 jSTormally, the blood passes through the cardiac orifice 
 without being thrown into vibration, but when the 
 smooth surfaces of these orifices are roughened or nar- 
 rowed, Avhen the valves become insuffipient to close them, 
 or when the blood is reduced in specific gravity, vibra- 
 tions may be produced in the blood stream of suflicient 
 intensity to be conveyed to the surface and to be detected 
 by the hand as thrill, which has been compared to that 
 
PALPATION. 239 
 
 felt over the back of a purring cat (fremissement cataire, 
 Katzcnschniirrcn) . 
 
 As the thrills always depend on the movement of 
 l)l()(i(l through a cardiac orifice, it is necessary to deter- 
 mine (a) their location, (b) their area of diffusion and 
 (c) their relation to the period of the cardiac cycle 
 (time or rhythm), as they may be systolic, diastolic or 
 prc-systolic. 
 
 Over the a]icx of the heart, the thrills may be due to 
 mitral obstruction, mitral rcj;'urgitation, rarely to aortic 
 ol)strnction and regurgitation. 
 
 Thrills due to mitral obstruction are usually well 
 defined and have a jDeculiar vibratory character, so that 
 the term "p\irring thrill" has been given them. The 
 ])(iint of maximum intensity is somewhat above and to 
 the inner side of the apex. The area of diffusion is 
 usually limited to that of the apex beat, although at 
 times it may be carried beyond. They are felt just 
 before the lifting impulse of the a]iex, by which they are 
 usually terminated. As they occur during that portion 
 of the diastole which immediately precedes the systole, 
 they arc said to be ijre-systolic. 
 
 Thrills felt in mitral regurgitation are usually of a 
 snft, indistinct character, felt chiefly over the area of 
 the maximum apex beat and occurring at the time of the 
 lifting impulse. 
 
 Thrills at the apex, due to aortic obstruction or 
 regurgitation, are usually faint in character, and their 
 intensity increases as the hand passes upward over the 
 pnecordia toward the base of the heart. 
 
 Thrills felt o-\'er the upper portion of the chest may 
 be produced at the aortic or the pulmonic orifices. While 
 pulmonic obstruction and regurgitation may be attended 
 with vibrations sufficiently powerful to be felt at the 
 surface as thrills, they are so extremely rare that they 
 may practically be left out of consideration. 
 
 Thrills produced by aortic obstruction have their 
 point of maximum intensity at the second intercostal 
 
240 THE CIMCULATOSY SYSTEM. 
 
 cartilage on the right side. They are transmitted 
 upward, and occur synchronously with the apex beat 
 and the carotid pulsation. The character of the thrill 
 has nothing distinctive. 
 
 Thrills occurring with aortic regurgitation have the 
 point of maximum intensity at the second right costal 
 cartilage or slightly below, and may be transmitted to 
 the sternum or be felt over the entire precordial area. 
 
 Palpation of the Blood- Vessels. — The heart, in connec- 
 tion with the arterial and venous systems, constitutes the 
 circulatory apparatus, and palpation of the heart would 
 be incomplete and misleading for diagnosis if both 
 arterial and venous systems were not included. 
 
 Palpation of the Aorta. — ISTormally, the aorta is 
 beyond the reach of the examining finger, except in a 
 few cases where deep pressure behind the sternum in 
 the episternal notch detects a faint pulsation. Tn 
 enlargement of the calibre of the aorta, as occurs in 
 diffuse dilatation of the blood-vessel, secondary to 
 valvular disease of the heart, or dependent upon 
 atheroma, or in aneurism, the aorta may be palpable 
 not only above the clavicle and sternum, but also in the 
 first and second intercostal spaces on either side of the 
 sternum. 
 
 In dilatation of the transverse portion of the aorta, 
 the pulsation of the blood-vessel may be transmitted to 
 the upper portion of the sternum, and may be also 
 accompanied by a thrill which is synchronous with the 
 heart action. 
 
 Aneurism of the ascending and transverse portions of 
 the aorta may communicate imlsations to the trachea 
 and larynx, giving the tracheal tug. In order to obtain 
 this sign, the patient is placed in the erect position, 
 standing or sitting, the mouth closed and the chin ele- 
 vated to its fullest extent. The examiner grasps the 
 cricoid cartilage between the thumb and finger, and 
 makes gentle upward pressure. 
 
 On account of the tendency of the innominate and 
 
PALPATION. 241 
 
 carotid arteries to transmit a pulsation to the trachea, 
 Evart has advised that the examination be made in the 
 following manner: "The observer stands behind the 
 seated patient, whose head is thrown back and supported 
 against the observer's chest. The tips of both index 
 fingers are then inserted under the lower edge of the 
 cricoid cartilage, which is gently raised by them," when 
 a very distinct and unmistakable traction downward is 
 felt with each systole of the heart. In extreme aortic 
 regurgitation slight pulsation may be felt in the trachea, 
 but it lacks the peculiar dragging, tugging sensation. 
 
 Tracheal tugging is only present when "the aneurism 
 is so situated that it presses from above downward upon 
 the bronchi near their bifurcation, or upon that portion 
 of the trachea just above it." As an aneurism, to give 
 such a pressure, must be given off from the posterior and 
 inferior portions of the transverse division of the aorta, 
 tracheal tugging is an early manifestation. 
 
 THE PULSE. 
 
 When an artery is palpated to obtain the pulse, a 
 portion is usually selected where the vessel can be com- 
 pressed between the examining finger and a firm point, 
 as a bony eminence. The tem^^oral, facial or radial 
 arteries may be selected as meeting this requirement. 
 On account of the readiness of access, and also from the 
 fact that its condition is not readily disturbed by dis- 
 ease of the structures which it supplies, the radial vessel 
 is preferred. 
 
 In order to readily appreciate all the elements of the 
 pulse, it is necessary that a certain amount of the vessel 
 be under observation. This is attained by the classical 
 method of placing the tips of three fingers on the radial 
 artery, the most sensitive and most highly educated 
 index finger nearest the heart, while the thumb supports 
 the Avrist at the back. Another is "that the patient's 
 hand and forearm is supported by the examiner's left 
 16 
 
242 THE CIRCULATORY SYSTEM. 
 
 hand, while the fore finger of the right hand is applied 
 longitudinally over the artery. In this way the vessel is 
 felt over a considerable length of its course by one finger 
 of the observer, and varying degrees of pressure can be 
 applied to it, while the skin can be pushed up and the 
 size of the artery and the character of the arterial coats 
 can be determined." (Sanson.) 
 
 The sensation that is felt when an artery is palpated 
 is due to the momentary increase in arterial pressure 
 that occurs when the left ventricle emj)ties itself into the 
 aorta. The Y>vlse wave distends the vessel that has been 
 partially empty during diastole, and whose lumen is 
 still further narrowed by the examining finger. "The 
 pulse then indicates simply the degree of duration of the 
 increased pressure in the arterial system caused by the 
 ventricular systole." (Broadbent.) 
 
 It is necessary to bear in mind that three factors are 
 concerned in the production of the pulse : ( 1 ) Cardiac 
 action, which determines (a) frequency (fast or slow), 
 (h) force (strong or weak), ('c) rhythm (regular, 
 irregular or intermittent). 
 
 (2) The elasticity of the blood-vessel, upon which 
 depends the degree of compressibility of the pulse (hard 
 or firm, compressible or incompressible). 
 
 (3) Eesistance in the arterioles and capillaries, which 
 determines the readiness with which the larger blood- 
 vessels are emptied during the period of diastole and 
 regulates (a) the size of the pulse ; whether the excur- 
 sion of the artery compressed by the finger is wide or 
 narrow, when the pulse is spoken of as large or small ; 
 ,(hj the duration of the time that the wave is perceptible 
 to the touch, so that the pulse is long or short ; (c) ten- 
 sion or the degree of distension of the blood-vessels 
 present throughout the cardiac diastole, and especially 
 near its end. 
 
 Size, duration and tension are usually associated in 
 a definite manner. Low resistance in the artery and 
 capillaries give the pulse of large size, short duration and 
 
PALPATION. 243 
 
 low tension, while great interference causes the pulse to 
 be small, long and of high tension. 
 
 These three factors are more or less correlated and 
 react on each other, and each exerts its own peculiar 
 influence on the pulse, both in health and disease. 
 
 The Normal Pulse. — The normal pulse for the healthy 
 adult male beats 72 times per minute (frequency) ; the 
 strength of each distending impulse is the same (force), 
 and the beats follow each other at regular intervals 
 (rhythm). The lumen of the artery is readily obliter- 
 ated by the examining finger nearest the heai't, and the 
 pulse wave is sto])ped at the point of pressure, beyond 
 which, distally, the artery cannot be detected as a sepa- 
 rate structure. The pulse wave is felt as a dilating force 
 
 Fig. 29. 
 
 Sphygmograijhic tracing- of normal j^ulse. 
 
 a, 6, percussion up-strolce; a, 6, c, percussion wave; c, </, p, tidal wave; e, /, 17, 
 
 dicrotic wave ; <J, e, /, aortic notch ; /, g, diastolic period, 
 
 of some volume (size), which does not raise the finger 
 to the full height at once, but takes a definite time to 
 reach its acme and declines in the same manner (dura- 
 tion) ; and between the pulsations the artery is felt 
 under the finger, and can be compressed with greater or 
 less ease according to its degree of distension (tension). 
 It is necessary to distinguish between the incompressi- 
 bility of a blood-vessel due to condition of its Avails and 
 the amount of pressure necessary to overcome the dis- 
 tension of the vessel due to the blood pressure (tension). 
 When the pulsations in the artery are obliterated with 
 difiiculty, if the incompressibility is due to increased 
 thickness of the arterial coats, the artery will be felt 
 beyond the point of compression as a more or less rigid 
 
244 THE CIBCULATOBY SYSTEM. 
 
 cord; while if the incompressibility is due to high 
 arterial tension, it will be impossible to detect the artery 
 beyond the compressing finger. 
 
 While the above are the average characteristics, each 
 pulse may present individual peculiarities in the three 
 factors spoken of. Both radial arteries should be 
 examined, and when differences are detected it is neces- 
 sary to determine whether they are due to anomaly in 
 the size or distribution of the arteries, or are dependent 
 upon pathological changes, as aneurysms, plugging of 
 the blood-vessel, etc. 
 
 I. Conditions Modifying the Cardiac Elements of the Pulse. 
 (a). Frequency. — ^While the average pulse rate is 72 
 per minute, there are certain normal variations. 
 Usually the pulse of females is slightly quicker — 80 per 
 minute — and it has been claimed that in tall people the 
 pulse is slower. At birth the pulse is 120 to 140, and 
 gradually diminishes in frequency until at six years of 
 age it is 100, and at puberty 80 or less. In old age the 
 pulse becomes slower, but in extreme age its frequency 
 is increased. There is also a diurnal variation in the 
 pulse rate, corresponding to the body temperature, it 
 being more frequent in the afternoon and evening and 
 after eating, slower during sleep and during the early 
 morning hours. While a pulse of 60 may be normal 
 for one adult and 100 for another, usually a pulse 
 of over 90 per minute is morbid. 
 
 Increase in Frequency. — The rate of the pulse may 
 be increased by the following: (a) Muscular exertion. 
 
 (b) Mental and emotional excitement; the degree of 
 increase will vary with the individual, according to the 
 irritability of the nervous system (temperament). 
 
 (c) Keflex irritation from other organs, especially the 
 aljdominal and pelvic viscera, (d) Diseases of the 
 nervous system, especially those involving the nervous 
 lueclianism of the heart through the pneumogastric, 
 sympathetic nerves or the cardiac ganglia, (e) Fever. 
 As a rule, for each degree of temperature above the 
 
PALPATIO!f. 245 
 
 Sphygmographic Tracings of the Pulse. 
 
 Fig. 30. 
 
 JWVJV/ 
 
 Right radial artery. Left radial artery. 
 
 Aneurysm of arch of aoi-ta. 
 
 Fie. 31. 
 
 Slow liulse (CO) (acromeg-lia). 
 
 Fig. 3S. 
 
 Small, thready, rapid pulse (98) (chill of malaria fever). 
 
 Fig. 33. 
 
 High-teijsion pylse (chronic nephritis). 
 
 Fig. 34. 
 
 Low-tension diciotic pulse (pneumonia, eight hours before death). 
 
 Fig. 3.5. 
 
 Low-tension pulse, feeble eordiac action (typhoid fever, third week). 
 
246 
 
 THE CIBCULATORY SYSTEM. 
 
 normal there is an increase of eight or ten heats. Cer- 
 tain diseases do not conform to this rule ; thus in typhoid 
 fever the pulse is generally slow in proportion to the 
 temperature, and is of diagnostic value in differentiat- 
 ing this disease from tuberculosis and septic conditions. 
 When, in typhoid fever, the pulse rate correspoilds 
 
 Fig. 36. 
 
 Rapid (100) low-tension, dicrotic, on admission. 
 
 Fig. 37. 
 
 Twelve hours later (80), free stimulation, slower 
 
 Fig. 38. 
 
 Six hours after crisis (86). Four days later, no stimulation. 
 Pneumonia, showing v.iriation in pulse. 
 
 to the temperature range, it indicates a grave con- 
 dition. In scarlet fever, with the very beginning of 
 the throat symptoms, the pulse ranges from 120 to 
 160, and this is of .great aid in differentiating scarla- 
 tinal sore throat from that due to other causes, as 
 diphtheria, simple follicular tonsillitis, etc. In fevers 
 
PALPATION. 2i7 
 
 due to septic infection, tlie pulse is accelerated out of 
 proportion to the range of temperature, and in the 
 puerperium a rapid pulse, with slight elevation of 
 temperature, is a suspicious sign. ' (f) Anaemia and 
 debility, (g) Respiratory diseases. In nearly all of 
 the acute inflammatory diseases of the respiratory tract 
 the pulse rate is increased. Normally, the ratio 
 between pulse and respiration is 4 : 1. This ratio is 
 disturbed in respiratory diseases, such as pneumonia, 
 when the ratio becomes 3 : 1, or even 2 : 1 ; or equal. In 
 febrile conditions due to pulmonary disease, this sign is 
 found of value when the usual physical signs are absent. 
 (h) Cardiac conditions. The pulse may be accelerated 
 in all valvular diseases, although as long as compensa- 
 tion is perfect the increase may be very slight. When 
 there is muscular insufficiency, the rate is markedly 
 increased, especially i^jion exertion. 
 
 Acceleration of the pulse is a prominent symptom 
 of neuroses of the heart. In Grave's disease the pulse 
 fanges from 100 to 120 ; in paroxysmal tachycardia it 
 may reach 160 or 200, but does not remain permanently 
 at this point, although it may be constantly above the 
 normal. In irritable heart (paroxysmal hurry) it is 
 also increased. 
 
 Rheumatoid arthritis, before marked deformity of 
 the joints, frequently has a pulse, as an early symptom, 
 of 110 or 120. 
 
 The rate of the pulse bears a definite relation to the 
 amount of tension in the blood-vessels, and should 
 always be considered in this relation. 
 
 Diminution in Frequency. — As mentioned before, the 
 pulse may be habitually slow as an individual pecu- 
 liarity. Usually a pulse under 60 is considered morbid, 
 while a pulse of 40 is usually of grave significance. 
 
 The pulse may be slowed by (a) reflex nervous irrita- 
 tion, (h) ISTervous diseases, especially those which 
 cause increase in the intercranial pressure, as tumors, 
 hemorrhage and meningeal effusion. It is also slowed 
 
248 THE CIRCULATORY SYSTEM. 
 
 in certain cases of mania, melancholia and general 
 paralysis of the insane, and in injury to the cervical 
 portion of the spinal cord. A slow pulse in epilepsy is 
 always a grave symptom. In myxcedema the pulse is 
 constantly slow, (c) Convalescence from fevers, (d) 
 Toxaemias, especially bile, urea and certain acute dis- 
 eases, (e) Increase in arterial tension, (f) Cardiac 
 disease. A slow pulse is a grave symptom when it 
 occurs in cardiac disease, and was formerly supposed to 
 be pathognomonic of fatty degeneration of the heart, 
 but is not usually present except when the degenerative 
 change is due to atheroma of the coronary arteries. 
 
 The pulse is not always a true guide to the frequency 
 of the heart, as a form of slow pulse occurs in which 
 only every other beat of the heart is felt at the wrist. 
 The examination of the heart shows that the beat whicli 
 is not felt as a pulse in the artery is feeble and incom- 
 plete. This type of slow pulse is most frequently 
 present in mitral stenosis. This form of infrequency 
 often alternates with a form of irregularity called 
 "pulsus bigeminus," as will be explained later. 
 
 (h) FoEGE. — The force of the pulse wave is 
 dependent on the energy with which the blood is forced 
 by the ventricle into the aorta. It bears a certain rela- 
 tion to the force of the apex beat, so far as it (the apex 
 beat) depends upon the muscular strength of the left 
 ventricle. This rule holds good as long as the ventricle 
 propels into the aorta the normal amount of blood in 
 the normal time, as the fullness of the arterial system 
 during the entire cardiac cycle is an important element 
 in the strength of the pulse. 
 
 Increase in Force. — The force of the pulse wave is 
 increased (a) when the cardiac action is more vigorous 
 than normal, as occurs in exercise, in mental and 
 emotional excitement, and in cardiac neuroses, as 
 Grave's disease, (h) When the cardiac muscular power 
 is increased above the normal, due to change in the 
 muscle, as occurs in simple hypertrophy of the left ven- 
 
PALPATION. 249 
 
 tricle. When, in addition to hypertrophy of the muscle 
 wall, the cavity of the left ventricle is enlarged (dilata- 
 tion), not only is the force of the blood wave augmented, 
 but it has greater volume. 
 
 Diminution of Force. — The pulse wave may be de- 
 creased in strength (a) when the contraction of the 
 cardiac muscle is less forcible on account of general 
 muscular weakness, as in debility, or due to lack of 
 nerve tension, as in neurasthenia, etc. (b) When there 
 is true muscular weakness, as occurs in cardiac degenera- 
 tion, which may be primary or secondary to valvular 
 disease of the heart, (c) When the amount of blood 
 that is forced into the aorta is decreased through imper- 
 fect emptying of the heart from cardiac weakness, from 
 imperfect filling of the left ventricle, and general reduc- 
 tion in the amount of blood, as in hemorrhage. 
 
 Irregularity in Force. — In health the individual beats 
 have the same volume. Under certain conditions there 
 is inequality of force, some of the beats being fuller than 
 others. This form of irregularity is present most fre- 
 quently in mitral regurgitation, when dilatation and 
 weakness of the left ventricle occur ; it may be made 
 more pronounced by raising the arms above the head, 
 increasing the action of gravity. Its presence should 
 always direct attention to the condition of the cardiac 
 muscle. When irregularity in force is due to muscular 
 insufficiency, slight exertion is often sufficient to induce 
 also irregularity in rhythm. 
 
 (c) Ki-iYTi-iM. — The normal rhythm of the heart may 
 be disturbed in two ways : (a) A beat is dropped at 
 more or less regular intervals, giving the intermittent 
 type of pulse, (b) The beat occurs at irregular inter- 
 vals, giving the true irregular or arrhythmical pulse. 
 
 Intermittent Pulse. — Intermittent pulse has the char- 
 acteristic that, with tha exception of the missing beat, 
 the pulse is regular. The intermission may occur 
 according to rule; that is, after a definite number of 
 beats, as when the fifth, seventh, eleventh or twenty-first 
 
250 TEE CIMCULATOBY SYSTEM. 
 
 beat is lost ; or it may follow no rule. Examination of 
 the heart may show a corresponding omission of the 
 cardiac systole (pulsus deficiens), or that there is a 
 cardiac systole, but too weak to be felt at the radial 
 artery (pulse intermittens). 
 
 When the intermittent pulse is habitual, the inter- 
 mission is apt to be according to rule. This form is of 
 little clinical significance, being often a constitutional 
 peculiarity ; or it may be caused by the use of tea, coffee, 
 tobacco, etc. It must be borne in mind that the inter- 
 mission usually disappears during pyrexia from any 
 cause, and returns with the normal temperature. "When 
 it returns during the height of the temperature, it is an 
 tmfavorable sign. 
 
 In degeneration of the myocardium and in valvular 
 diseases the pulse may be intermittent while the patient 
 is at rest, but on exertion the intermission is replaced by 
 true irregularity, with shortness of breath and other 
 signs of cardiac insufiiciency. When the intermission 
 is due to some disturbance of innervation, on exertion 
 such change does not occur, or the rhythm may become 
 perfectly regular. Broadbent clainas that an intermit- 
 tent pulse is not a contraindication to the administration 
 of ana3sthetics (chloroform), but that the condition of 
 the pulse should be watched during the early stage of 
 narcosis. Generally the intermission disappears, but if 
 from the first the pulse becomes weah and irregular, the 
 administration of the anassthetic should cease. The 
 same rule applies to ether and nitrous oxide. 
 
 Irregular Pulse. — Irregular pulse has the character- 
 istic that the beats follow each other at irregular 
 intervals, and are also irregular in force. The tend- 
 ency to irregularity varies at different periods of life. 
 During infancy the pulse is easily disturbed in all its 
 cardiac elements, especially its rhythm. The same 
 tendency to arrhythmia is noted in extreme old age. 
 Irregularity of the pulse may be a normal condition in 
 individuals when it is constant. 
 
PALPATION. 251 
 
 The causes of irregularity may be : (a) Reflex irri- 
 tation from abdominal or pelvic viscera, especially when 
 they are associated with flatulency and displacement 
 
 Fig. 39. 
 
 Pulse irregular in rhythm and force (myocarditis with dilatation). 
 Fig. 40. 
 
 Mitral regm-gitation. 
 
 Fig. 41. 
 
 Aortic obstruction. 
 
 Fig. 42. 
 
 Aoi'tic regurgitation. 
 
 Fig. 43. 
 
 Mitral stenosis. 
 
 upward of the diaphragm, (h) Disturbances of the 
 nervous system by shock, grief, continued worry, 
 neurasthenia, anaemia, debility, etc. (c) Diseases of 
 
252 THE CIRCULATORY SYSTEM. 
 
 the brain and meninges, (d) Toxaemia, due to alcoliol, 
 tea, coffee, tobacco, digitalis, belladonna, etc., or that of 
 the infections, diseases, especially the early stages. The 
 irregularity that occurs later in acute disease may be 
 due to the toxajmia or to degenerative changes in the 
 cardiac muscle, (e) Cardiac diseases. • In valvular 
 disease marked .irregularity does not occur during stage 
 of compensation, but is one of the early signs of muscu- 
 lar insufSciency. In mitral stenosis it is a common, but 
 not grave, symptom. In all forms of myocarditis it is 
 an important prognostic sign. 
 
 II. Conditions TModifying the Elasticity, of the Arteries. 
 — ^The sensation ' conveyed to the linger by the normal 
 artery has been described, and attention called to the 
 necessity of discriminating between the degree of com- 
 pressibility due to changes in the coat of the artery and 
 that due to increased blood pressure. When the coats of 
 tlie arteries are thickened and rendered inelastic by 
 increase of fibrous tissue, the pulse wave will be obliter- 
 ated with difficulty, and beyond the point of compression 
 distally the artery will be easily detected as a more or 
 less rigid cord. As the tube becomes more inelastic, it 
 becomes longer and tortuous, and each pulse wave is felt, 
 not as a beat, but as a worm-like movement. Calc'are- 
 ous deposits may be detected as isolated plates, and 
 "may feel like a striiig of beads under the finger." 
 
 III. Conditions Modifying Resistance in Arteries and 
 Capillaries. — The amount of arterial and capillary resist- 
 ance determines the size, intensity and diiration of the 
 normal pulse, and any change in the degree of resistance 
 influences all of these elements. 
 
 DiMiNDTioisro]? Eesistance.— When the resistance 
 is reduced below normal, there is a relatively greater 
 increase in the distension of the artery with each ven- 
 tricular systole. The pulse wave passes more rapidly 
 under the finger, and between the beats the artery is but 
 slightly distended with blood, and is almost obliterated 
 by light pressure of the examining finger ; and the pulse 
 
PALPATION. 253 
 
 felt at the wrist has the following characteristics : The 
 pulse wave dilates suddenly the flattened artery, giving 
 the sensation of a large-sized pulse ; it does not gradually 
 reach its acme, but seems to reach the finger full size. 
 The beat is sharp, passes qtiickly under the finger (short 
 duration) and the artery remains distended but for a 
 very short time (tension rapidly falls). This type of 
 pulse is spoken of as "large, short, low-tension pulse." 
 
 In the normal pulse the examining finger can scarcely 
 detect dicrotism, which is caused by the elastic recoil of 
 the artery on tlie closure of the aortic valves, although it 
 is very perceptible in the sphygmograph tracing. (Fig- 
 39.) 
 
 When the resistance in the arteries is very low, this 
 wave becomes quite apparent to the finger, and the pulse 
 is spoken of as dicrotic. In low tension the force and 
 frequency of the heart determines the type of pulse. 
 When the heart is beating rapidly and forcibly, the 
 arteries are kept well filled, the pulse wave is felt 
 as a large, sharp, well-sustained beat, and the piilse is 
 called "full and bounding," and is easily obliterated. 
 Dicrotism, while present, is not noticed, on account of 
 the size of the primary pulse wave. As the force of the 
 heart diminishes, the pulse becomes less full, and is 
 sharper and shorter and more easily obliterated by light 
 pressure on the artery, and the dicrotic wave becomes 
 more pronounced. This type of pulse is spoken of as 
 the "gaseous pulse." When the heart power becomes 
 insufficient to empty the left ventricle, the pulse is 
 weak and characterless — "small, running pulse" (page 
 245). 
 
 Causes of Low Tension. — (a) Low tension may be 
 a constitutional peculiarity in some individuals and 
 families, when it may be associated with increased fre- 
 qviencyin some cases and obesity and weak cardiac action 
 in others (diminution in ca])illary resistance). (h) 
 Temporary low tension is caused by warmth, as weather, 
 baths, hot* drink and food, (c) It may be dependent 
 
254 THE CIBCULATOBY SYSTEM. 
 
 upon nervous causes, as mental or nervous exhaustion 
 from whatever cause, (d) Debility due to malnutri- 
 tion or secondary to chronic disease. (e) Pyrexia 
 generally causes a full, bounding pulse, usually in 
 proportion to its degree. Later the pulse may become 
 weak, quick and dicrotic, on account of the effect 
 of the high temperature on the cardiac muscle or the 
 influence of the toxines on the heart itself, or on the 
 nervous system, (f) Cardiac diseases. As the press- 
 ure in the arterial system depends upon the amoimt of 
 blood that is forced into it, as well as the resistance to 
 the passage of the blood through the arterioles and 
 capillaries, the tension will be lowered whenever the 
 heart is luiable to empty itself, due to valvular disease 
 or to muscular weakness. In aortic insufficiency the 
 collapsing or water-hammer pulse is diie to the sud- 
 den fall in the blood pressure caused by the free regurgi- 
 tation of blood into the ventricle. The peculiarities of 
 this pulse will be described under aortic regurgitation. 
 Increase of Resistance. — In normal conditions there 
 is a certain correlation between the force and frequency 
 of the heart and the outflow from the arterioles, and a 
 normal mean blood pressure is maintained. The normal 
 blood pressure varies at different periods of the cardiac 
 cycle. With cardiac systole, the pressure is raised to 
 the maximum, and the artery is felt as a tense, distended 
 tube. During diastole, as the pressure gradually sub- 
 sides, the tube becomes lax, and can no longer be felt. 
 When resistance to the outflow of blood is increased, the 
 tension is increased, the pressure in the blood-vessels 
 does not subside ; and the artery remains filled, so that it 
 is detected not only with the beat, but in the interval. 
 The sensation conveyed to the finger by the pulse wave 
 also is changed. The examining finger not causing so 
 marked a flattening of the artery, there is less motion 
 felt, and the pulse wave slowly reaches its height to 
 slowly decline. As the size of the artery is not much 
 altered between the pulse waves by light pressure, the 
 
PALPATION. 255 
 
 pulse is small, and the wave gradually distends the ves- 
 sel and is felt for a relatively long period, and the artery 
 remaining perceptible in the interval. 
 
 As in low tension, so in increased resistance the type 
 of the pulse will vary with the force and frequency of 
 the heart and the condition of the large blood-vessels. 
 When the muscular power of the heart is sufficient to 
 overcome the resistance in the blood-vessels, and the 
 muscular coats of the aorta oppose the increased cardiac 
 action, the tension in the arteries will be sustained 
 almost uniformly during the interval, and the pulse will 
 be correspondingly small, long and of high tension. 
 
 When the heart fails, the pulse becomes irregular and 
 arterial pressure is lowered. When, on the other hand, 
 the aorta and large vessels yield to the blood pressure 
 and become dilated, the pulse becomes larger and the 
 duration is shorter, although the arteries remain over- 
 filled during diastole. 
 
 Causes of High Tension. — (a) Temporary high-ten- 
 sion pulse may be caused by increase in the amount of 
 blood, as occurs for a short time after meals or after tak- 
 ing large quantities of water, and is persistent when the 
 elimination of the fluid by the skin and kidneys is inter- 
 fered with, producing permanent overdistension of the 
 blood-vessels, (b) It may be also temporarily increased 
 by frequent and powerful overaction of the heart, as 
 occurs ill mental or emotional excitement and in the 
 early stage of physical exertion. Or (c) it may be due 
 to temporary increased resistance in the blood-vessels, as 
 occurs from external cold, congestive chill, or hysteria. 
 
 Permanent high tension may be caused by all those 
 factors which cause increased resistance in the capil- 
 laries, (a) as drugs, ergot and the digitalis group; (b) 
 toxiumia, as occurs in gout, rheumatism, lead poisoning 
 and in renal disease; (c) changes in the walls of the 
 capillaries which interfere with permeability, as 
 atheroma and arterio -capillary fibrosis. These changes 
 may be primary or secondary. 
 
CI-IAPTEE X. 
 
 PERCUSSION. 
 
 By percussion of the cardiac region it is possible 
 (a) to determine the size of the heart in certain dimen- 
 sions only; (h) its relation to other thoracic and 
 abdominal organs ; (c) changes in the outline of certain 
 portions. 
 
 Percussion of the prsecordia gives two areas: (1) 
 The area in which the clear pulmonary resonance 
 becomes more and more impaired by the presence 
 of the airless structure of the heart ; that is, the area of 
 relative cardiac dullness. (2) The area in which no 
 pulmonary resonance can be detected, the area of abso- 
 lute cardiac dullness or cardiac flatness. The percus- 
 sion outline of these two areas is most difficult to 
 determine. Many claim that they have no value, or, at 
 least, only a limited value in the diagnosis of cardiac 
 diseases. 
 
 The amount of information obtained by percussion 
 over the prjccordia depends upon the technique and the 
 acuteness of the examiner, and whether or not the 
 examination is conducted methodically and for a definite 
 purpose. 
 
 Methods of Examination. — In percussing for relative 
 dullness, it is most important that the line should be 
 determined at which the normal pulmonary resonance 
 is impaired by the underlying heart. 
 
 Percussion is begun over the thorax at some distance 
 from the anatomical borders of the heart. The finger is 
 placed across the ribs parallel with the sternum, and 
 forcible percussion is made, the finger being moved 
 
PEKCOSSlONk 257 
 
 inward toward the cardiac area till slight change in 
 the percussion note is detected. This point is marked 
 on the thorax, and the same area is again percussed with 
 blows varying in strength, with the finger both in the 
 vertical position and also parallel to the ribs lying in the 
 interspaces, until the positive point of cardiac diillness 
 is determined. This method is carried on at different 
 levels, until the outermost area of cardiac dullness is 
 outlined. 
 
 After this has been determined, the examiner then 
 proceeds to outline the point at which the pulmonary 
 resonance ceases and the heart, in contact with the chest 
 wall, causes a perfectly flat note. It is necessary that 
 the percussion blows vary in force as we proceed from 
 the outer line of cardiac dullness, where the layer of 
 lung is relatively thick, toward that of cardiac flatness. 
 
 The Area of Cardiac Dullness. — In the normal adult the 
 outer area at which cardiac dullness is detected is as 
 follows : On the right side no change is noted above the 
 third rib, except occasionally a slight loss of resonance 
 due to the underlying aorta. Although the right auricle 
 projects beyond the sternum opposite the third costal 
 articulation, it is impossible to accurately map out the 
 border which extends beyond the sternum, as the tliick- 
 ness of the pulmonary tissue is so great that percussion, 
 sufficiently strong to penetrate to the underlying heart, 
 will set up lateral vibrations also, which, being conveyed 
 to the sternum, give a resonant note. The most that 
 can be detected on the right side by skillful percussion 
 and a trained ear is a slight change in resonance, extend- 
 ing from the fourth rib to the area of liver dullness. 
 
 On the left side, that portion of the heart that lies 
 above the third rib cannot be detected by percussion, on 
 account of the thickness of the pulmonary tissue and its 
 close proximity to tlie sternum. At the lower level of 
 the third rib, close to the sternum, the deep cardiac 
 dullness is detected. The line of dullness extends in 
 a curved line across the third intercostal space to 
 17 
 
258 THE CIBCULAfOMY SYSTEM. 
 
 the middle of the fourth rib, 31/2 to 4 inches from 
 the mid-sternum and just inside the nipple line. Erom 
 this point it runs almost vertically downward to the 
 sixth rib, just inside the nipple line. When the heart 
 and structures contained within the mediastinum are 
 normal, they do not influence to any appreciable degree 
 the resonance of the sternum. (Fig- 22.) 
 
 The Area of Cardiac Flatness. — That portion of the 
 heart that lies in direct contact with the chest walls gives 
 a perfectly flat sound on percussion, and corresponds 
 in outline to the anterior margin of the left lung. The 
 resonance of the sternum prevents that portion of the 
 heart that lies between the anterior edge of the riglit 
 lung and the left edge of the sternvim being detected by 
 percussion. The thin lingula pulmonalis that covers 
 the apex of the lung does not modify the flat percussion 
 note. (Fig. 21.) 
 
 The normal area of cardiac flatness is somewhat 
 quadrangular in shape. The right border extends along 
 the left edge of the sternum, from the upper edge of 
 the fourth rib and along the border of the sixth rib, 
 where it merges into the hepatic flatness. 
 
 The upper borders run diagonally across the fourth 
 rib for about two inches, and then vertically downward 
 to the sixth rib. Accurate mapping oiit of the borders 
 of cardiac dullness and flatness being very difiicult, some 
 authors have recommended that the area of cardiac flat- 
 ness be estimated in two directions only. 
 
 (1) The vertical line. Perciission is made along the 
 para-sternal line, one inch to the left of the sternum, 
 and the following varieties of resonance are noted on 
 percussion over the normal heart: (a) From the 
 clavicle to the upper border of the third rib full pul- 
 monary resonance is detected, (h) From the third rib 
 there is a gradual diminution of resonance and a height- 
 ening of pitch (cardiac dullness), until at the upper 
 border of the fourth rib there is absolute loss of reso- 
 nance (cardiac flatness), (c) From the upper border 
 
PERCUSSION. 259 
 
 of the foiirth rib the sound is flat, and merges, below the 
 sixth rib, into that of the liver. Over this normal flat 
 area very forcible percussion may detect a deep-seated, 
 tympanitic resonance when distension of the stomach or 
 intestines is present. 
 
 (2) Transverse line. Percussion is made along a 
 line which corresponds to the upper edge of the fourth 
 rib on the left side. The sound is flat for 2 to 21^ 
 inches from the edge of the sternum, when it merges 
 gradually into dullness, which terminates just inside the 
 nipple line. 
 
 Numerous modifications of the ordinary method of 
 percussion by the finger have been devised in order to 
 increase the ability to outline the heart. The most 
 important are: (a) Auscultatory percussion (page 
 94) and (b) plessimetric percussion or Sanson's method. 
 Instead of the finger, a pleximeter of vtilcanite is used. 
 This pleximeter consists of two thin, flat, oblong plates, 
 one 1x1/2 inch, the other % x % inch, joined in the 
 middle by a central square column li^ inches high. It 
 is closely held to the chest wall by the index and middle 
 fingers of the left hand, placed on either side of the 
 vertical column. "The observer commences by apply- 
 ing the pleximeter with its long diameter parallel to the 
 sternum, about midway between the axilla and the right 
 sternal border, percussion being made upon the summit 
 of the column by one or two fingers of the right hand, 
 the strokes from the wrist being sharp and decisive, 
 though not necessarily forcible. This procedure in the 
 normal conditions elicits the normal thoracic vibrations. 
 The pleximeter is then approached nearer and nearer — 
 always in parallel lines — ^to the sternum, until the line 
 is reached where the vibrations are sensibly modified. 
 By slightly inclining the pleximeter so that the vibra- 
 tions come from its left edge, there is practically a line 
 of surface without noticeable breadth. The point at 
 which the resonance is modified is marked. By repeat- 
 ing the process just described at higher and lower levels 
 
260 TSE CIBCULATORY SYSTEM. 
 
 and uniting the marks, the observer delineates the area 
 on the right side of the outer border of the heart dull- 
 ness. In like manner, by percussing from above down- 
 ward, with the long diameter horizontal instead of 
 vertical, the upper limit of the liver, as indicated by an 
 area of modified vibrations, is arrived at." 
 
 In percussing on the left side of the chest, the observer 
 begins at the left of the second rib, 2 or 3 inches to the 
 left of the sternal border, and approaches to the right 
 until the line of modified vibration is arrived at, which 
 will be nearly parallel with that obtained on the right 
 side. 
 
 Percussion is made at different levels, as on the right 
 side, until the heart is outlined. 
 
 By this method not only is the outer border of the 
 heart noted by the ear, but also detected by difference 
 in vibrations, as felt by the finger resting on the lower 
 plate. A certain amount of experience is needed in 
 order to obtain the best results by this method. 
 
 Conditions Modifying the Normal Areas of Cardiac Flat- 
 ness and Dullness. — Both areas may be proportionately 
 increased or diminished, or the dimensions of one may 
 be altered at the expense of the other. 
 
 JSToEMAL Vaeiatiows. — The size and location of the 
 percussion areas are influenced (a) by the age of the 
 individual; (h) by the posture of the patient; (c) by 
 the condition of the lungs according to forcible inspira- 
 tion and expiration; (d) by the position of the heart 
 due to elevation or depression of the diaphragm. 
 
 In children the heart is relatively larger than in 
 adults, and lies higher in the thorax, while the greater 
 elasticity of the lungs and flexibility of the bony thorax 
 causes a much larger portion of the heart to be un- 
 covered by lung tissue and in closer contact with the 
 chest wall. In children, during full inspiration,, the 
 area of cardiac dullness is relatively increased, while 
 that of flatness is diminished ; and the reverse condition 
 obtains during shallow breathing and full expiration. 
 
PERCUSSION. 261. 
 
 The elasticity of the sternum and costal cartilages per- 
 mits dullness to be detected at the right border of the 
 sternum. The upper border of cardiac dullness reaches 
 the middle of the second intercostal space in the para- 
 sternal line, and the outer left border to the nipple line 
 at the third interspace. At the lower border of the 
 fourth rib it extends a quarter to a half inch beyond the 
 nipple line. The shape of the area of cardiac dullness 
 is somewhat semicircular, with the convexity upward. 
 The area of absolute flatness in children is also increased 
 in extent and raised by the width of an interspace. The 
 right border is close to the left sternal margin; the 
 upper line is in the third interspace, and extends almost 
 straight across to the upper border of the third rib, close 
 to the mammary line. The left border is usually just 
 within this line, and extends to the lower edge of the 
 fifth rib. 
 
 It is necessary to bear in mind the variations in the 
 cardiac percussion area that occur in children, as they 
 have an important bearing on the diagnosis of effusions 
 into the pericardium. 
 
 In old age the areas are smaller and lower in position. 
 In the left para-sternal line, the upper limit of dullness 
 is about the lower border of the fourth rib, and of flat- 
 ness about the middle of the fifth rib. The left border 
 is also nearer the median line. 
 
 The position of the patient alters in a slight degree 
 the percussion areas. They are the same whether the 
 patient is lying on the back or in the upright position. 
 When lying on the right side, the area of flatness to the 
 left of the sternum diminishes or disappears entirely. 
 A smaller area of flatness may be detected just to the 
 right edge of the sternum, in the third interspace. 
 When lying on the left side, the area of flatness is 
 increased, the left border being carried nearly to the 
 mammary line. 
 
 Influence of the Soft Parts. — The effect of the soft parts 
 on the resonance from the thorax has already been con- 
 
262 THE CmaULATOBY SYSTEM. 
 
 siderecl. When the thorax is thickly covered, it is 
 impossible to accurately outline the area of cardiac flat- 
 ness, that obtained by light percussion being generally 
 carried too far to the left. 
 
 Influence of the Bony Thorax. — The elasticity of the 
 bony thorax also exerts an influence on the percussion 
 areas. As before explained, the highly elastic thorax' 
 of the child will give a much more accurate outline of 
 the heart than the rigid and more resonant thorax of the 
 adult. 
 
 Influence of the Lung and Pleura. — A.S the area of 
 cardiac flatness corresponds to that portion of the heart 
 that is uncovered by lung tissues and the area of rela- 
 tive dullness to the part covered by a thin layer, 
 both areas will be increased or diminished by changes 
 occurring in the lung or pleura. The normal varia- 
 tions in size occur, as has already been mentioned, 
 during the ordinary acts of respiration. Enlargement 
 of the lung, as occurs in general emphysema, causes a 
 smaller part of the heart to be in contact with the chest 
 wall, increases the thickness of the layer of lung cover- 
 ing the heart, and displaces the heart downward 
 and toward the median line. These changes cause the 
 area of cardiac flatness to be diminished or absent. As 
 emphysema is usually attended with hypertrophy and 
 dilatation of the right side of the heart, the areas of 
 percussion dullness and flatness do not correspond to the 
 size of the heart, so that a normal area of cardiac flat- 
 ness, occurring with other physical signs of emphysema, 
 is always indicative of a marked right-sided cardiac 
 hypertrophy and dilatation. In compensatory emphy- 
 sema of the left lung, both cardiac dullness and flatness 
 to the left of the sternum may be diminished or absent. 
 When the heart is displaced to the right, an area of 
 varying dullness may be detected to the right of the 
 sternum. In compensatory emphysema of the right 
 side, pulmonary resonance extends to the left of the 
 sternum, and the right border of cardiac flatness is 
 moved further from the left sternal margin. 
 
PERCUSSION. 2G3 
 
 The area of cardiac flatness may be enlarged in 
 all directions by retraction or consolidation of the 
 anterior border of the lung, or thickening of the pleura. 
 Eetraction of the anterior border of the left lung, by 
 uncovering the heart, increases the area of flatness at 
 the expense of that of dullness, the shape of the area of 
 flatness corresponding to changes in the lung and 
 secondary displacement of the heart. 
 
 When the anterior border of the right lung is 
 retracted, cardiac dtiUness may be detected to the right 
 of the sternum. When the heart is displaced to the 
 right, the degree of dullness will depend upon the extent 
 to which the heart is in close contact with the chest wall. 
 
 Increase in the area of flatness over the prtecordia 
 may be due to changes in the pleura or to consolidation 
 of that portion of the lung overlying and surrounding 
 the heart. 
 
 It is impossible by percussion alone to determine 
 where cardiac flatness ceases and that due to pulmonary 
 or pleural change begins. 
 
 Effusion into either pleural investment may cause 
 some enlargement of the cardiac area of flatness. 
 
 Influence of Changes in the Pericardium. — Changes in the 
 pericardium increases the area of flatness either by 
 causing hypertrophy of the heart (adhesive pericarditis) 
 or distension of the sac (effusion). Fluid in the peri- 
 cardiiim, collecting in the most dependent portion of 
 the sac, causes (a) increase in the transverse diameter 
 of flatness and marked dullness to the right of the 
 sternum, beginning in the fifth interspace on the right 
 side. On the left side the flatness extends upward and 
 toward the nipple line. As the fluid increases in 
 amount the shape of the area of flatness over the praecor- 
 dia becomes more triangular, with a broad base below 
 and blunt apex above. The amount of fluid determines 
 the size and shape of the triangle, and causes the area of 
 deep-seated dullness to be replaced by flatness, sur- 
 rounded by a zone of tympanitic pulmonary resonance. 
 
264 THE CIRCULATORY SYSTEM. 
 
 Tke resonance over the sternum is also changed when 
 the fluid in the pericardium exerts pressure on it. 
 Pneumo-pericardium causes the cardiac flatness to be 
 re]5laced by a low-pitched tympanitic resonance. 
 
 Influence of Cardiac Changes. — Increase in the size of 
 the heart, whether due to hypertrophy or dilatation, or 
 both, increases the area of cardiac dullness to a much 
 greater degree than that of absolute flatness, which, as 
 before shown, is generally increased by causes external 
 tx) the heart. 
 
 The size and shape of the increase in cardiac dullness, 
 or flatness due to cardiac hypertrophy and dilatation, 
 vary according as the right or left side is affected. 
 Hypertrophy of the left ventricle causes the left border 
 of both dullness and flatness to be moved to the left and 
 slightly downward. The upper border remains fairly 
 constant, while the right border is unchanged. The 
 area of dullness over the apex is pointed. When dilata- 
 tion and hypertrophy are associated, the area of flatness 
 is more quadrangular ; the transverse diameter at 
 the level of the fourth rib is increased by extension 
 toward the left, and the outline over the apex is rounded. 
 In extreme dilatation and hypertrophy of the left heart, 
 as occurs in insufficiency of the aortic valves, the left 
 bordef of flatness may reach the anterior axillary line, 
 and dullness the mid-axillary line. 
 
 In hypertrophy or dilatation of the right side, when 
 the ventricle alone is involved, the upper border of flat- 
 ness at the level of the fourth rib shows no marked 
 increase. The lower left border is carried slightly out- 
 ward, and the right border remains at the left margin 
 of the sternum. 
 
 When dilatation and hypertrophy affect both ventricle 
 and auricle, the dullness may be detected beyond the 
 right border of the sternum as high as the fourth costal 
 cartilage. Dilatation and hypertrophy of the right heart 
 may cause slight change in the sternal resonance, but 
 not to the same degree as pericardial effusion, aneurism, 
 ox mediastinal tumors, 
 
PERCUSSION. 265 
 
 Percussion of the Aorta. — The great vessels normally 
 give very slight and hardly perceptible dullness in the 
 second interspaces. When any dullness is detected, it is 
 most marked on the right side and is rounded in outline. 
 Increase of this area is generally due to aneurismal 
 dilatation of the aorta, although mediastinal new 
 growths can cause it. 
 
CHAP TEE XL 
 
 AUSCULTATION. 
 
 Auscui^TATiON of the heart furnishes information 
 concerning the normal cardiac sounds, their relative (a) 
 rhythm, (b) character or quality, (c) points at which 
 they are most distinctly heard (maximum intensity), 
 (d) areas over vs'hich they are audible (areas of dif- 
 fusion), (e) variations and modifications, both normal 
 and abnormal; (f) abnormal or adventitious sounds 
 (murmurs, frictions), etc., and the degree to which they 
 replace the normal cardiac sounds. 
 
 Auscultation should always follow inspection, palpa- 
 tion and percussion, as the data obtained by these 
 methods are differentiated and enlarged by those 
 detected by auscultation, while at the same time they 
 correct and define variations in the normal sounds and 
 the significance of adventitious sounds. 
 
 Methods of Examination. — Both the mediate and the 
 immediate methods of auscultation are employed, each 
 having its proper field. 
 
 By mediate auscultation, with the ear applied directly 
 to the chest, the observer hears not only the sotmds of 
 the heart, but he also notes the impulse and other tactile 
 sensations, and is thus able to gauge more accurately 
 the period of the cardiac cycle at which both normal and 
 abnormal sounds occur. 
 
 Immediate auscultation, employing a stethoscope, in 
 addition to the advantages noted under Auscultation of 
 the Lung, is especially valuable in the examination 
 of the heart, as it (a) limits the sound heard to that 
 portion of the chest wall covered by the thoracic end 
 
AUSCULTATION. 267 
 
 of the Stethoscope. This is very important, as the 
 cardiac orifices are situated close to each other, and 
 it is necessary to determine where both normal and 
 adventitious sounds are heard with the greatest inten- 
 sity; while with the ear alone we are apt to include 
 more than one valve area in the scope of the examina- 
 tion, (i) It cuts off external sounds, (c) It intensi- 
 fies some of the sounds produced in the heart, especiallv 
 those due to valve action and murmurs. 
 
 In selecting a stethoscope, the following points should 
 he observed : 
 
 The binaural forms are mostly used. The advan- 
 tages of the rigid ones over those made with flexible 
 tubes are increased power of conduction and convey- 
 ance of cardiac impulse, as well as sound. The dis- 
 advantages are a certain resonating effect, which 
 increases the intensity and may change the character of 
 the higher-pitched valve sounds and murmurs. In 
 order that the stethoscope be a good conductor of sound, 
 whether rigid or made of flexible (rubber) parts, the 
 interior should be absolutely smooth. The thoracic end 
 of the stethoscope should be small, so as to fit closely to 
 tjje surface of the chest and also limit the field of exami- 
 nation to a small area. The ear pieces should fit the ear 
 without producing pain or discomfort. Usually too 
 small ear pieces are selected, which penetrate too deeply 
 into the canal. The ear pieces should merely close up 
 the wider portion of the orifice. The spring holding 
 the ear pieces in place should not be too stiff, and where 
 the instrument has to be used for long periods of time 
 each day a form of stethoscope should be used in which 
 the pressure of the spring can be regulated. 
 
 The examination should be made methodically, and 
 those portions of the heart should be first examined 
 where the cardiac sounds are most distinct, both as to 
 intensity and their relation to the ventricular systole. 
 
 Normal Cardiac . Sounds. — ^Two sounds are produced by 
 cardiac action, each having a definite relation to the 
 
268 THE CIBCVLATOBY SYSTEM. 
 
 phase of cardiac cycle and differing in time, character, 
 position of maximiim intensity and area of diffusion. 
 
 First Bound. — The first sound of the heart corre- 
 sponds to the ventricular systole, closure of the mitral 
 and tricuspid valves and opening of the aortic and pul- 
 monary valves, with forcing of the blood stream from 
 the right and left ventricular cavities into the pul- 
 monary artery and aorta. The first sound of the heart 
 is a prolonged, low-pitched, dull sound, which has some 
 resemblance to the soiind made in the pronunciation of 
 the syllable "lubb." 
 
 The cause of the first sound of the heart is still a 
 matter of dispute. Numerous theories have been 
 advanced, but no , one of them has been universally 
 adopted. The consensus of opinion is that the first 
 sound of the heart is composed of two elements: (a) 
 The muscular element, due to the contraction of the 
 cardiac muscle and its impact on the chest wall, giving 
 the prolonged, dull, low-pitched quality. (h) The 
 valve element, due to the closure of the mitral and tri- 
 cuspid valves and stretching of the chordge tendineaa and 
 papillary muscle, causes the short, sharp and high- 
 pitched quality. As will be explained under Modifica- 
 tions of Normal Sounds, the first sound will vary accord- 
 ing as one or the other of these elements predominates. 
 
 The first sound of the heart is heard most distinctly 
 at the region of the apex. At this point both muscular 
 and valve elements are present. The muscular element 
 predominates, because at the time it is heard the rigidly- 
 contracting apex of the heart strikes the chest wall and 
 is momentarily held in contact with it, conveying the 
 vibrations to the thorax. 
 
 Second Sound. — The second sound of the heart corre- 
 sponds to the closure of the aortic and pulmonary valves. 
 It is shorter, sharper and higher pitched than the first 
 sound of the heart, being somewhat similar to the sound 
 produced by the pronunciation of the. syllable "dubb." 
 It is composed of one element only, the valve sound, 
 
AUSCULTATION. 
 
 2G9 
 
 snapping, and may be "very 
 
 whic]i is short, tense and „..„,.^..,g, ,.^^ ,,,„j ^^ vcxj 
 closely imitated by stretching with more or less sudden- 
 ness a piece of cloth or a moistened membrane." 
 (Sanson.) 
 
 The second sound of the heart, being composed 
 entirely of the sounds made by the closure of the aortic 
 and pulmonary valves, is heard most distinctly over the 
 base of the heart. 
 
 Fig. 44." 
 
 Diagi'ammatie representation of the movements and sounds of the heart. 
 (After Sharpey.) This diagram shows merely the general relations of the 
 several events, and does not represent exact measurements. 
 
 In a heart beating seventy-two times a minute, Foster estimates each 
 entire cardiac cycle as occupying about 0.8 sec, of which 0.3 sec. represents the 
 duration of the systole of the ventricle, 0.4 sec. the diastole of both auricle and 
 ventricle, or the " passive interval," and 0.1 sec. the systole of the auricle. 
 
 Only one "pause" is marked here — sometimes called the "long pause; " 
 some writers describe a " short pause " also — indicated in the diagram by the 
 small space between the first and the second sound. 
 
 Valve Areas. — Listening over certain portions of the 
 chest, the first and second sounds are heard with vary- 
 ing intensity and clearness, and it is possible to appre- 
 ciate the sounds made at the different valves. The 
 areas at which the valve sounds are best heard are called 
 
2^70 
 
 THE CIECULA TOBY SYSTEM. 
 
 valve areas, and are named according to the valve 
 virhence the sound proceeds — aortic area, pulmonary 
 area, tricuspid area and mitral area. The areas do not 
 correspond to the anatomical situation of the valves, but 
 to points on the surface of the chest, to which the vibra- 
 tions made at the valves are conducted with the greatest 
 intensity. (Fig. 45.) 
 
 Fig. 45. 
 
 From above downwards, shelving: the anatomical positions of the pulmonic, 
 aoi-tic, mitr.'il and tricuspid valves. The arrow-heads show their respective 
 sites of audibility. Shaded portion shows pai-t of left heart projecting; beyond 
 the rig:ht heart. 
 
 The Mitral Area. — The valvular element of the first 
 sound, heard at the fifth intercostal space, is that pro- 
 duced by the mitral valve. The location of the 
 mitral area does not correspond with the anatomical site 
 of this valve, which is situated behind the'left half of the 
 sternum, opposite the insertion of the third left costal 
 
A USCULTA TION. 2T1 
 
 cartilage. The conduction of the vibrations made at 
 the mitral valve to the apex is through the tense chorda^ 
 tendineai and papillary muscle, and the ventricular wall. 
 
 The Tricuspid Area. — The sound made at the tri- 
 cuspid valve is heard over the lower end of the sternimi. 
 ('(induction of the sound from seat of production to the 
 lower end of the sternum is due to conveyance by the 
 chorda3 tendinea; and papillary muscle on the right side 
 to that portion of the right ventricular wall which is in 
 close contact with the lower left edge of the sternum. 
 
 The Aortic Area is in the second right intercostal 
 space, close to the sternum, and the second right cartilage 
 has been called the "aortic cartilage." The aortic valve 
 is situated lower than this area, being behind the left 
 half of the sternum to the left of the right third inter- 
 space. The vibrations made at the aortic orifice are 
 conveyed to the aortic area through the tense walls of the 
 aorta, which at this point come closely in contact with 
 the chest wall. 
 
 The Pulmonic Area is at the second left intercostal 
 space, close to the sternum, and corresponds more nearly 
 than do the other areas to the anatomical site of the 
 valve, which is slightly lower under the third intercostal 
 cartilage, extending slightly into the second interspace. 
 
 Modifications of the Cardiac Sounds. The cardiac 
 
 sounds may be modified (a) in intensity, which may be 
 increased or diminished, and (h) in rhythm, which con- 
 cerns the duration of the pause which separates the 
 sounds. 
 
 (a) Changes in Intensity. — This may involve both 
 sounds in nearly equal proportions, or it may affect only 
 one sound. Normally, tlie intensity of the first and 
 second sounds of the heart bear a definite relation to 
 each other. The intensity of the sounds may be rela- 
 tively increased or diminished without indicating any 
 pathological change in the heart, as the intensity is 
 largely dependent upon the degree of endocardial and 
 blood pressure. The increase or diminution affecting 
 
272 THE CmCULATORY SYSTEM. 
 
 both sounds should always be considered in connection 
 with the tension and compressibility of the pulse. 
 
 The cardiac sounds vary normally within certain 
 limits. In the young the first sound is shorter, higher 
 pitched and more ringing in character, with a greater 
 prominence of the valvular element than in the adult ; 
 while the second sound, heard over the pulmonic area, 
 is louder than the aortic. After middle life the first 
 sound is duller, more prolonged and lower pitched, the 
 mitral and tricuspid elements being relatively less 
 prominent, while the aortic sound becomes more accen- 
 tuated and is louder than that heard in the pulmonic 
 area. 
 
 In adult life the first sound varies greatly. "In thin, 
 nervous people the first sound is high pitched, short and 
 more ringing in character. In the robust and vigorous 
 it is low pitched, prolonged and rumbling, while in the 
 fat and indolent it is indistinct and short." 
 
 The cardiac sounds are modified (1) by those condi- 
 tions which increase or diminish the conduction of the 
 sounds to the surface, as (a) thickness or thinness of the 
 soft parts, (h) condition of the bony thorax, (c) changes 
 in the lung and pleura, (d) changes in the pericardium ; 
 (2) by changes in the circulatory system. 
 
 Incebasb ts Intensity. — Both sounds of the heart 
 are increased in intensity (a) when the thorax is thinly 
 covered by soft parts ; (h) when the bony thorax is 
 flexible and readily thrown into vibration; (c) when, 
 through changes in the pleura or lungs, the heart is 
 uncovered to a greater extent than normal; (d) when 
 the pulmonary tissue that normally covers the heart is 
 rendered more homogeneous by consolidation and the 
 cardiac sounds are conveyed to the surface with a 
 peculiar distinctness, the valvular element being espe- 
 cially prominent. Cavities with tense walls and 
 pneumo-thorax also cause increased conduction of the 
 normal heart sounds. (e) Adherent pericardium 
 causes increase in the cardiac sdiinds, due both to 
 
AUSCULTATION. 273 
 
 increase of power of conduction and to secondary 
 changes induced in the heart muscle. 
 _ Increase in intensity may be due to conditions of the 
 circulatory system. 
 
 First Sound.-— The intensity of the first sound may be 
 increased both in the muscular and valvular elements or 
 only in one. In cardiac overaction, and associated with 
 low tension in the blood-vessels, as occurs in fevers, 
 physical exertion, mental and emotional excitement and 
 in Grave's disease, the first sound is high pitched and 
 short, and the valve element is most marked. When 
 cardiac hypertrophy is present (compensating), and 
 when cardiac overaction is associated with high tension 
 in the blood-vessels, the muscular element predominates 
 and the sound is dull, prolonged and booming. When 
 cardiac hypertrophy ceases to be compensating, the first 
 sound, although more intense than normal, becomes 
 short, sharp and "flapping," the valvular element being 
 most pronounced. 
 
 Second Sound. — Increase in intensity of the second 
 sound of the heart may be due to the accentuation of 
 both aortic and pulmonic sounds, or it may be limited 
 to one sound. 
 
 Accentuation of the Aortic Sound. — Accentuation of 
 the aortic sound is usually dependent upon increased 
 pressure within the aorta, which causes the valves to 
 close with greater tension and suddenness than nor- 
 mally. The increased pressure within the aorta may be 
 transient, as when due to increased cardiac action or to 
 obstruction to the flow of blood from the arteries and 
 capillaries, as spasm from chilling of the surface, nerv- 
 ous shocks, etc. ; or it may be permanent, as occurs in 
 cardiac hypertrophy with dilatation and in arterial 
 sclerosis, kidney disease, etc. The aortic second sound 
 is usually accentuated in pregnancy, because of the 
 marked increase in blood mass. Accentuation of the 
 aortic second sound is usually associated with a corre- 
 sponding increase in the intensity of the first sound. 
 18 
 
2Y4 THE CIRCULATORY SYSTEM. 
 
 This relation is frequently disturbed by tbe muscular 
 power of the heart becoming insufficient, when the 
 second sound becomes accentuated and the first sound 
 grows progressively weaker and feebler. , This associa- 
 tion is always a grave symptom. 
 
 As the aortic sound is normally weaker than the pul- 
 monic sound until middle adult life, the intensity of 
 these two sounds must be compared in order to detect 
 changes in the normal relative intensity. After middle 
 adult life, normally, the aortic sound approaches more 
 nearly that of the pulmonic, and the latter becomes more 
 intense. 
 
 Accentuation of the Pulmonic Sound. — The sound 
 over the pulmonic area is accentuated by conditions 
 which raise the blood pressure in the pulmonary artery, 
 as acute and chronic congestion of the lungs, acute 
 inflammatory diseases, anajmia, and obstructive diseases 
 of the lungs (emphysema, fibroid induration). As will 
 be shown later, increased tension in the pulmonary 
 artery is associated with corresponding hypertrophy of 
 the right ventricle. Wlien endo-ventricular pressure in 
 the right ventricle is raised above a certain point, insuffi- 
 ciency of the tricuspid valve occurs (safety-valve 
 action), and there ensues a corresponding diminution 
 in the accentuation of the pulmonic sound. 
 
 Diminution in Intensity. — The cardiac sounds are 
 diminished in intensity by (1) those conditions which 
 interfere with conduction to the surface, as (a) when 
 the thorax is thickly covered with adipose tissue; (h) 
 when the bony thorax is rigid; (c) when the heart is 
 separated from the chest wall by distended lung tissue 
 (emphysema) or displaced by effusions into the pleural 
 cavity; (d) by effusions into the pericardium and 
 pneumo-pericardium. In these conditions the character 
 of the sounds is muffled (2) by changes in the heart 
 itself. 
 
 First Sound. — The intensity of the first sound of the 
 heart is diminished by all conditions of muscular feeble- 
 
AUSCULTATION. 275 
 
 ness, both relative, as when hypertrojihy is no longer 
 compensating, and absolute, as degenerations of the 
 cardiac muscle. The sound in these conditions is short, 
 sharp, and the booming character is lacking and replaced 
 by a peculiar "flapping" quality, dependent upon the 
 valve element. 
 
 The Second Sound. — The aortic sound is diniiuished 
 in intensity by (1) conditions which cause low blood 
 pressure, decrease in the aortic recoil, and due to 
 (a) feeble heart action ; (b) imperfect or slow filling of 
 the aorta, as occurs in aortic stenosis, mitral stenosis 
 and mitral regurgitation; (c) loss of blood mass from 
 hemorrhage, diarrhoea, etc., (d) or increased rapidity of 
 flow from the arteries and capillaries. (2) Changes in 
 the valves themselves, diminishing their elasticity, as 
 in endocarditis. 
 
 The pulmonic sound varies within much nari'ower 
 limits than does the aortic, as the pressure within the 
 pulmonary artery is more uniform. Marked diminu- 
 tion in the pulmonic second sound is generally indicative 
 of failure of the right ventricle. 
 
 Changes ijst Kiiytiim. — The rhythm of the heart 
 may be disturbed by alterations in (1) the relative time 
 of the pause. When the heart beat is increased in fre- 
 qu:ency, in proportion to the rate of the heart, there is a 
 corresponding shortening of the pause between the 
 second and first sounds of the heart (diastole), but this 
 is never sufiiciently marked to disturb the normal 
 rhythm. 
 
 (3) In emhryo-cardia, in which the two sounds follow 
 each other at equal intervals, giving the peculiar tick- 
 tack character of the fojtal heart. This condition is 
 generally indicative of profound muscular weakness, 
 and occurs in the terminal stage of cardiac disease and 
 impending cardiac failure in typhoid and other acute 
 diseases. It is an especially grave symptom in typhoid 
 and in Grave's disease. 
 
 (3) Canter or Gallop Rhythm. — In this condition 
 
276 THE CJRCOLATOBY SYSTEM. 
 
 three sounds of the heart are noted. The three sounds 
 may be equally -distinct, or the added sound may be of a 
 different character and may occur at any period of the 
 cardiac cycle. The rhythm is similar to that of the 
 footfalls of a galloping horse, hence the name, "gallop 
 rhythm," or "bruit de galop." 
 
 (J^) Beduplication of Sounds. — Both the first and 
 second sound luay be reduplicated or doubled. A 
 slight degree of reduplication of the second soiind is 
 physiological, and can be induced by holding the breath. 
 In this condition the temporary heightening of the 
 pressure in the pulmonary artery causes tardy closure 
 of the pulmonic valves. Doubling of the first sound 
 may also occur, but is usually more apparent than real. 
 To account for the reduplication of the sounds, many 
 theories have been advanced. As the reduplication 
 seems to concern chiefly the valvular elements of the 
 sounds, it is evidently due to the fact that the time of 
 the maximum intensity of the soimds made at the dif- 
 ferent valves on one side of the heart does not corre- 
 spond to that of their fellows on the other side of the 
 heart, being separated by an appreciable interval. 
 
 Abnormal or Adventitious Sounds. Murmurs. — The 
 abnormal or adventitious sounds heard over the pra^,cor- 
 dia may be produced (1) within the heart (endocar- 
 dial), or (2) in the pericardium, lung or pleura 
 (exocardial). 
 
 Endocardial Murmurs. — Endocardial niurmurs are due 
 to vibrations made at the valve orifices by the movement 
 of the blood through them. Normally, the blood passes 
 the valvular orifices without any sound being produced 
 except the normal first and second sounds. This noise- 
 less passage of the blood demands (1) normal anatomi- 
 cal conditions at the 0]3cnings, as far as smoothness of 
 surface, relation of the size of the opening, both relative 
 and absolute, to the part beyond, and perfect closure of 
 the opening by the valves during the normal period. 
 (2) A certain specific gravity of the blood, and (3) a 
 
AUSCULTATION. 277 
 
 definite rapidity and force of the current. Disturbance 
 of any one of tliese factors may be sufficient to break up 
 the moving column of blood into "fluid veins" whose 
 vibrations are rapid enough to produce a sound or 
 murmur when transmitted to the surface of the body. 
 
 Classification of the Murmurs. — Murmurs are classified 
 as (1) organic or valvular, (2) inorganic or non- 
 valvular. 
 
 Oegawig oe Valvular Muemues. — Fluid veins are 
 made whenever the blood is forced through a narrow 
 portion of the circulatory tract into a part that is larger. 
 In the normal heart the relative sizes of the opening and 
 cavities of the heart and aorta are such that fluid veins 
 are not formed under usual conditions. 
 
 The necessary physical condition for the production 
 of fluid veins may be produced by anatomical changes 
 at the valve orifices which (a) interfere with the pas- 
 sage of blood in normal direction through the opening, 
 as narrowing of opening or roughing of the surface 
 (obstruction or stenosis) ; (h) which allow of abnormal 
 or backward flow (regurgitation), due to imperfect 
 closure of opening, from change in valves (absolute 
 insufiiciency), or to dilatation of opening (relative 
 insufficiency). (c) At the aortic and pulmonary 
 orifices, increase in the size of the vessel may so change 
 the relation between the size of the opening and the 
 cavity beyond as to favor the production of fluid veins. 
 
 Inoeganio oe ISTokt-Valvulae Muemues. — These 
 may occur with normal cavities, oriflces, and are diie 
 to (a) changes in the blood, lowering its specific gravity. 
 This allows the fluid veins to be more readily formed in • 
 both normal and pathological conditions of the valves 
 and orifices, and also in the great vessels. The specific 
 gravity of the blood is lowered in anaemia, hydrajmia, 
 and the murmurs are known as ancemic or hcemic. 
 
 (h) Increase in rapidity and force of the current of 
 blood. It is possible for the action of the heart to be 
 so energetic and rapid as to produce vibrations 
 
278 THE CIBCULATOBY SYSTEM. 
 
 (inorganic murmurs) at the different orifices when they 
 are normal in size and structure and the specific gravity 
 of the blood is unchanged. The murmurs are known 
 as functional or dynamic. 
 
 A certain amount of force is also necessary to produce 
 murmurs in pathological conditions of the heart. 
 
 In every case of endocardial murmur one or more of 
 the above factors are present in varying degrees, and 
 each has an influence in producing certain characteristic 
 features of the murmur. 
 
 Characteristics of Murmurs. — The recognition of an 
 endocardial murmur and the determination of its origin 
 and pathological significance depend upon its (1). 
 quality, (2) intensity, (3) time or rhythm, (4) point of 
 maximum intensity, (5) area of diffusion, (6) duration, 
 (T) permanency and influence of exertion and posture. 
 
 Quality of the Murmur. — Endocardial murmurs 
 vary widely in relation to their quality, and it is some- 
 times difiicult to determine whether or not a slight varia- 
 tion from the normal sound is due to the presence of a 
 miirmur. All murmurs have in a greater or less degree 
 a liquid character. In addition to this, they may have a 
 peculiar rushing or harsh, blowing sound, which may be 
 imitated by the voice in pronouncing the syllables uf, 
 uv, lis, usli, uzj or they may have a soft, blowing sound, 
 as represented by the syllables with vowel sounds of oo, 
 u, ah, auj or, again, they may have a rougher, more 
 vibrant character, as in uur, orr, an: At times the 
 vibrations may have a musical sound. 
 
 The quality of the sound does not determine whether 
 the murmur is organic or inorganic, although hjcmic 
 murmurs as a rule are of the soft, blowing character. 
 
 The quality of the murmur may change from time to 
 time in the individual case, depending upon the changes 
 in size and structure of the orifice and valves, tlie rela- 
 tive size and condition of the space into which the blood 
 is forced, the varying force of the cardiac action, and the 
 presence or absence of anssmia. 
 
AUSCULTATION. 279 
 
 Intensity op Muiimurs.— Tho intensity or loudness 
 of ^ endocardial murmurs shows great variability in 
 lesions involving the different orifices or in the same 
 orifice at different times. 
 
 The intensity of a murmur depends upon (a) the 
 force of the blood current, (h) the size and shape of the 
 orifice at which the murmur is made and the state of the 
 cavity into which the vibrating blood is thrown, and 
 (c) the condition of the blood. 
 
 Systolic murmurs, the force being supplied by the 
 ventricular contraction, are usually louder, other things 
 being equal, than diastolic murmurs, whose force is due 
 to the elastic recoil of the aorta and pulmonary artery. 
 In pre-systolic murmurs the force is supplied by the 
 auricle. 
 
 The varying degrees of intensity are of important 
 diagnostic and prognostic value, as diminution in the 
 intensity is frequently the first sign of failing cardiac 
 power. On the contrary, gradual increase in the inten- 
 sity of the murmur may indicate gradual restoratiou of 
 compensation. 
 
 The size and shape of tlic orifice influences the 
 intensity of the murmur according to the character of 
 the vibrations produced. The narrower the orifice in 
 proportion to the size of the cavity beyond, the more 
 intense is the murmur as a rule. 
 
 The intensity of the murmur is also influenced by 
 the character of the circulating blood. When the 
 specific gravity is reduced by diminution of the cor- 
 puscular elements or by the decrease in proteids 
 (hydrasmia), the murmurs are louder and their quality 
 is changed. As the specific gravity blood becomes more 
 nearly normal, the loudness of the murmurs decreases. 
 
 Thie intensity of the murmurs made at the different 
 orifices of the heart varies considerably with the posture 
 of the patient. Of murmurs made at the mitral and tri- 
 cuspid orifices, the obstructive murmurs are loudest 
 when the patient is sitting or standing, and become 
 
280 TEE CIRCULATORY SYSTEM. 
 
 feebler or disappear when he is lying down. Regurgi- 
 tant murmurs at these orifices, on the other hand, are 
 most distinct when the patient is lying flat on the back, 
 and become more indistinct as he resumes the upright 
 posture. Munnurs made at the aortic and pulmonary 
 valves are not influenced to the same extent by posture. 
 Aortic regurgitation is loudest when the patient is in the 
 recimibent position, and is still further increased if one 
 or both arms are raised above the head. Systolic 
 anaemic murmurs heard over the base of the heart are 
 loudest when in the recumbent position, and their 
 . intensity is also increased at the end of expiration and 
 just at the beginning of inspiration. 
 
 Time or Rhythm. — As endocardial murmurs may be 
 produced at any part of the cardiac cycle, the most 
 important characteristic is its relation to the normal 
 cardiac sounds. As the ventricular systole is the most 
 prominent phase of the cardiac cycle, being marked by 
 the visible apex beat, the carotid pulse and the first 
 sound of the heart, murmurs are timed by it. Mur- 
 murs are described as systolic and diastolic. On 
 account of the relative length of the diastolic pause, 
 those murmurs that are only heard during that portion 
 of diastole that immediately precedes the occurrence of 
 the first sound have been named pre-systolic murmurs. 
 
 Systolic murmurs may be (1) obstructive, as when 
 produced by blood flowing in a normal direction through 
 valves that should be open at this period of the cardiac 
 cycle — that is, the aortic and pulmonic valves — or (2) 
 regurgitant, as when the blood is forced back through 
 valves that should be closed, namely, the mitral and 
 tricuspid valves. 
 
 DiASYSTOi.ic MURMURS are (1) regurgitant, being 
 due to leakage at either the aortic or j^ulmonary valves, 
 which should normally be closed at the completion of 
 systole and occurrence of the second sound. 
 
 (2) Pre-systolic murmurs are obstructive, being 
 produced at the mitral and tricuspid valves during the 
 
AUSCULTATION. 
 
 281 
 
 aiiricular systole, which immediately precedes the ven- 
 tricular systole and the occurrence of the first sound. 
 _ As the time at which the' murmur occurs and its rela- 
 tion to the normal sound is most important for diagnosis, 
 it is necessary that it be correctly determined. Ordi- 
 narily the first sound of the heart is the more easily 
 detected than the second sound, and is used to time the 
 murmur by auscultation. But whenever it is masked 
 by the occurrence of a systolic murmur, the time of the 
 different phases of the cardiac cycle should be deter- 
 mined by listening over the valve areas, where second 
 
 Fig. 46. 
 
 1st aouna and Hmmd. 
 
 ■■Illl^ 
 
 Systolic murmur, following first sound. 
 1st Sound 2nd Sound 
 
 Systolic murmur, aecompauying fir.^t souuil. 
 1st Sotmd 2nd Sound 
 
 Systolic murmur, replacing first soTmrl. 
 
 soimds are heard with greatest distinctness. With these 
 facts well impressed, the time of the abnormal sound can 
 be fixed most readily. 
 
 The differential stethoscope is frequently an aid in 
 determining the time of a murmur, as it allows of com- 
 parison, through the two chest pieces placed at different 
 po-rtions of the chest, of the murmur with the first or 
 second sound heard at an area unintluenced by it. 
 
 Murmurs may accompany or take the place of the nor- 
 mal heart sounds, and their duration is also measured by 
 their relation to the normal cardiac periods. As the 
 
282 
 
 THE CIRCULATORY SYSTEM. 
 
 first sound of the heart is made up of both muscular and 
 valvular elements, systolic murmurs will influence one 
 or the other of these elements by accompanying it or 
 replacing it, according to the changes that have occurred 
 at the orifice and the effect of these lesions on the ven- 
 tricular wall and cavity. (Fig. 4G.) Diastolic mur- 
 murs may accomjjany, take the place of, or follow the 
 second sound; and the presence or absence of the 
 valvular sound, and whether or not the murmur follows 
 it, determine to a certain extent the condition of the 
 orifice of the valves themselves. (Fig. 47.) 
 
 Fig. 47. 
 
 1st Sound iSnd Sound 
 
 1st Sound 
 
 Uiastolie murmur, following second sound. 
 1st Sound gnd Sound Jst Sound 
 
 Ijate diastolic muimur. 
 1st Sound Snd Sound 1st Sound 
 
 Pre-systolic mm-murs. 
 
 Point of Maximum Intensity and Area of Dif- 
 fusion. — The point at which a murmur is most dis- 
 tinctly heard determines the orifice at which it is made. 
 
 The points of maximum intensity of the endocardial 
 murmurs do not correspond to the anatomical site of the 
 valves nor entirely to the valve areas. The conduction 
 of murmurs to their points of maximum intensity is 
 dependent (a) on the direction of the blood current 
 which produces the murmur, and (b) on the readiness 
 with which certain portions of the heart, by reason of 
 
AUSCULTATION. 
 
 283 
 
 their anatomical relations, transmit the vibrations made 
 at the point of obstruction or regurgitation to the sur- 
 face. Trom the point of maximum intensity, the mur- 
 mur is transmitted in different directions (area of 
 diffusion). The extent and direction of the transmis- 
 sion are variable, chiefly according to (a) the strength 
 and character of the vibration producing the murmur ; 
 
 Fig. 48. 
 
 Mitral pre-systolic murmur. pJ* Apex of heart. 
 
 (h) the method of primary conduction to the surface, 
 whether mainly by blood current or solid structures 
 (heart, lung, etc.), and (c) to the diffusion over the 
 chest from the point of maximum mtensity by the bony 
 thorax and soft parts. It is necessary to consider the 
 point of the maximum intensity and area of diitusion 
 of the murmurs made at the different orifices. 
 
284 
 
 THE CIRCULATORY SYSTEM. 
 
 Murmurs Made at the Mitral Orifice. Mitral Pjke- 
 SYSTOLic MuBMUES. — The point of maximum intensity 
 is slightly to the right of the apex of the heart (left 
 ventricle), whether it is in the normal position or dis- 
 placed, and its area of diffusion is, as a rule, very 
 slightly beyond the region of the apex. (Fig. 48.) 
 The localization of a murmur at the region of the apex 
 of the left ventricle is due (a) to the direction of the 
 vibrating blood current, which is concentrated at the 
 
 Fig. 49. 
 
 Mitral obstruction. Large arrow direction of current of blood. 
 
 apex by the valves of the narrowed orifice, (h) The 
 flaccid condition of the overlying right ventricle pre- 
 vents the transmission of the vibrations to the surface 
 in that direction, (c) The left ventricle being also in a 
 state of relaxation and at its greatest distance from the 
 chest wall, the vibrations, conducted to the surface 
 through the overlying lung, influence a very small area 
 of chest. (Fig. 49.) 
 
AUSCULTATION. 
 
 i85 
 
 A wider area of diffusion of the pre-systolic mitral 
 murmur is generally due either to unusually close rela- 
 tion of the apex of the left ventricle to the chest wall, or 
 to increased po-wer of conduction on the part of the tis- 
 sues surrounding the apex of the heart, or to the 
 character of the vibrations. 
 
 The pre-systolic munnur heard at the apex is gener- 
 ally due to obstruction at the mitral orifice, although 
 
 Fig. 50. 
 
 Mitral systolic. 
 
 murmurs with this rhythm and localization without 
 mitral obstruction have been heard in aortic regurgita- 
 tion (Flint murmur), in aortic obstruction and with 
 adherent pericardium. 
 
 MiTEAL Systolic Muemubs.— The point of maxi- 
 mum intensity is at or close to the apex. The area of 
 diffusion extends also around this point, and to the lett 
 
286 
 
 THE CIBCULATOBY SYSTEM. 
 
 beyond the praacordia into the axillary region. (Fig. 
 50.) The murmur is also heard in the back, the point 
 of maximum intensity being in the left interscapular 
 space, a little above the angle of the scapula, opposite 
 the spines of the fifth and sixth dorsal vertebrae. (Fig. 
 
 Fig. 51. 
 
 Mitral systolic. 
 
 51.) The area of diffusion is usually limited to the 
 left scapiilar and interscapular regions. 
 
 The murmur made at the mitral valve (situated 
 behind the left half of the sternum at the level of the 
 fourth interspace) reaches the surface in front over the 
 
AUSCULTATION. 
 
 287 
 
 apex of the heart and behind in the scapiilar region bv 
 two different lines of conduction. (Fig. 52.) Conduc- 
 tion to the apex is mainly by the tissues of the left ven- 
 tricle, which at the time of the first sound of the heart 
 are m a state of extreme tension. The vibrations made 
 by the regurgitant stream are transmitted (a) by the 
 leaflets of the mitral valve through the tense chorda? 
 tendinese and papillary muscle to "the apex of the left 
 
 Fig. 52. 
 
 Mitral regurgitation. Large arrow shows direction of current of blood. 
 Small arrows shoAV conduction of vibration to the apex by chordse tendineae 
 and papillary muscles. 
 
 ventricle, (h) The apex of the left ventricle at this 
 time is in direct contact with the chest wall, to which it 
 transmits the vibrations of the murmur, (c) From the 
 point of contact (the point of maximum intensity) the 
 vibrations are conveyed along the ribs in all directions 
 (diffusion). Over the pra3cordia they are deadened by 
 the right ventricle, so that their diffusion to the right 
 
2S8 
 
 THE CIRCULATOBY SYSTEM. 
 
 and upwards is limited. The vibrations are conveyed 
 by the ribs to the axillary region. The murmur is 
 heard over wider area when the left ventricle is much 
 hypertrophied, and the a|)ex is displaced downward and 
 to the left, and is in contact with the chest wall to a 
 greater extent. 
 
 Conduction of the mitral regurgitant murmur to the 
 scapular region is from the left auricle, which is thrown 
 
 Fig. 53. 
 
 Aoi-tic obstruction. 
 
 into vibration by the stream of regurgitant blood. 
 From the auricle the vibrations are transmitted through 
 the overlying tissues to the surface. The mitral 
 regurgitant murmur heard in the back corresponds more 
 nearly to the anatomical site of the valve. 
 
 _ Mitral systolic murmurs may occur in mitral insuffi- 
 ciency, due to acute or chronic endocarditis, causing 
 
AVSCVLTATION. 
 
 289 
 
 deformity of the leaflets, dilatation of the left ventricle, 
 or to dilatation of the left ventricle enlarging the mitral 
 orifice and causing relative insufficiency of the leaflets 
 to close the opening. 
 
 Murmurs Made at the Aortic Orifice. Systoi.ic Mau- 
 MURS. — The point of maximum intensity as a general 
 rule is situated over the manubrium sterni, and not at 
 the second right cartilage (aortic area). The area of 
 
 Fig. 54. 
 
 Aortic regurgitation. 
 
 diffusion is upward into the carotids, and laterally along 
 the clavicles and over the subclavian arteries. Conduc- 
 tion is by the current of blood in aorta to the point of 
 maximum intensity. The vibrations are transmitted 
 through the walla of the aorta to the manubrium sterni 
 and clavicles. (Fig. 53.) _ 
 
 Systolic murmurs in the aortic region may be caused 
 19 
 
200 
 
 THE CIBCVLATORY SYSTEM. 
 
 by conditions that lead to the production of vibrations 
 at the valve orifice itself or in the aorta just beyond. 
 At the orifice: (1) Narrowing of the lumen of the 
 opening by changes in the valves (stenosis). (2) 
 Eoughening of the surfaces by vegetations, calcareous 
 deposits without diminution in the size of the orifice 
 (non-stenotic). In the aorta : (1) Roughening of the 
 inner walls of the aorta. (2) Dilatation of the aorta. 
 
 Fjg. 55. 
 
 Aortic regurgitation. Arrows show lines of conduction of vibrations. 
 
 Inorganic causes: (1) Functional or dynamic, due to 
 increase of cardiac force, as in cardiac overaction caused 
 by mental or emotional excitement, physical exertion. 
 Grave's disease. (2) Plfemic or ana?mie. 
 
 Murmurs due to anfomia are heard in the aortic area 
 or over the sternum, but are transmitted into the vessels 
 of the neck with increasing intensity. 
 
AUSCULTATION. 
 
 291 
 
 _ Aortic Diastolic Murmurs. —The point of maximum 
 intensity is not, as usually described, at the second 
 right intercostal cartilage, but over the sternum and at 
 the left edge, opposite the third interspace or fourth 
 costal cartilage. The area of diffusion is downward 
 along the sternum, and also to the apex of the left 
 ventricle. (Fig. 54.) Conduction of the aortic 
 regurgitant murmur to the sternum at the point of 
 
 Fig. 56. 
 
 Tricuspid obstruction. 
 
 maximum intensity is due to the intimate relation of 
 the aortic cusps with the auriculo-ventricular septum of 
 the right side of the heart. The vibrations made by the 
 regurgitant stream are transmitted from the aortic 
 valves through the right auriculo-ventricular septum to 
 that portion of the sternum that is in closest contact with 
 it, viz. : from the third left interspace to the sixth rib on 
 
292 
 
 THE CIECULATOBY SYSTEM. 
 
 the right side. Conduction of the murmur to the apex 
 of the left ventricle is by the regurgitant stream. (Fig. 
 55.) The character of the murmur heard at the apex 
 may differ greatly from that present over the sternum. 
 Variations in the location of the point of maximum 
 intensity and area of diffusion are dependent upon the 
 cause and the nature of the secondary changes in the 
 heart and aorta (see Aortic Eegurgitation). 
 
 Fig. 57. 
 
 Tricuspid regurgitant. 
 
 Eegurgitation at the aortic orifice may depend upon 
 (a) absolute insufficiency of the valves, due to vegeta- 
 tions, loss of substance, thickening and distortion of the 
 valves, congenital malformation (rare) ; (h) upon rupt- 
 ure of the valves; (c) upon relative insufficiency, as 
 when the valves are normal, but insufficient to close the 
 orifice on account of dilatation of the aortic ring. 
 
AUSCULTATION. 
 
 293 
 
 Murmurs Made at the Tricuspid Valve. — Tricuspid 
 murmurs are usually most distinct over the lower por- 
 tion of the sternum and along the lower left costal 
 cartilages. 
 
 Tricuspid Pee-systolic Muemues. — The point of 
 maximum intensity is over the lower portion of the 
 sternum, at the upper edge of the ensiform cartilage, 
 and the area of diffusion corresponds with the area of 
 superficial cardiac dullness. (Fig. 56.) Conduction 
 
 Fig. 58. 
 
 Pulmonic systolic— stenotic. 
 
 to the surface of the vibrations made at the tricuspid 
 valve is from that portion of the right ventricle which is 
 in direct contact with the sternum. 
 
 The tricuspid pre-systolic murmur is extrciiiely rare, 
 and, when detected, is diagnostic of obstruction at the 
 orifice, either congenital or acquired. 
 
294 
 
 THE CIRCULATORY SY8TE3I. 
 
 Teicdspid Systolic Muemues. — The point of maxi- 
 mum intensity is at the base of the ensiform cartilage, 
 and the area of diffusion from the point of maximum 
 intensity is upward and to the right, not above the third 
 rib, and to the left toward the apex of the heart. (Fig- 
 57.) Conduction of the murmur in these two direc- 
 tions is by the regurgitant stream, and by transmission 
 
 Fig. 59. 
 
 Pulmonic systolic anseniie murmur. 
 
 through chorda; tendinea; to apex, the same as in mitral 
 regurgitation. 
 
 Vibrations made at the valve are carried by the 
 regurgitant current of blood upward into the auricle 
 over which the murmur is heard. The vibrations are 
 transmitted to the right ventricular wall by the attach- 
 ment of the valve and by the tense chorda tendineaj and 
 
AUSCULTATION. 295 
 
 papillary muscle. The point of maximum inteusity 
 and the area of diffusion vary according to the degree of 
 hypertrophy and dilatation. At times the murmur 
 corresponds in location to the mitral area. It is rarely 
 heard beyond the praBcordia, and is not carried into the 
 axilla nor heard behind in the scapular region. 
 
 Kegurgitation at the tricuspid orifice results from 
 
 Fig. 60. 
 
 Ansemia, pulmonic systolic. 
 
 insufficiency due to (a) the effects of acute and chronic 
 endocarditis, to vegetations, to induration or distortion 
 of the valves, and to shortening of the chorda; tendineffi ; 
 (b) from dilatation of the right ventricle and tricuspid 
 ring, with relative insufficiency. The dilatation may 
 be permanent or transient (safety-valve action). (See 
 Kegurgitation at Tricuspid Orifice.) 
 
296 
 
 THE CIRCULATORY 8YSTE3I. 
 
 Murmurs at the Pulmonary Orifice. Pulmonic Sts- 
 Touc MuKMUES. — The point of maximum intensity is 
 at the left intercostal space, close to the sternum. The 
 area of diffusion may be circu^mscribed around the point 
 of maximum intensity, or may extend upward along the 
 course of the pulmonary artery and laterally to the left. 
 (Fig. 58.) 
 
 The occurrence of a systolic murmur at the pulmonic 
 area is extremely common, and may be due (a) to 
 
 Fig. 61. 
 
 Pulmonic diastolic. 
 
 organic changes in the valves, producing obstruction 
 (rare), or (b) to narrowing of the lumen of the pul- 
 monary artery by changes in the surrounding structures 
 or torsion from displacement of the heart; (c) to 
 anannia, either alone or associated with dilatation of the 
 
AUSCULTATION. 297 
 
 artery (most commonly). In anaemic murmurs the 
 jroint of maximum intensity and area of difEusion is 
 more variable than in those dependent on stenosis at 
 orifice. (Figs. 59 and GO.) 
 
 Pulmonic Diastolic Muemues. — This murmur is 
 very rare. The point of maximum intensity is over the 
 pulmonic valve area. The area of diffusion is alonjr the 
 left edge of the sternum. It may occur (a) from con- 
 genital malformation or ulcerative endocarditis ; (h) 
 from relative insufficiency caused by dilatation of the 
 pulmonary artery or orifice. (Fig- 61.) 
 
 Exocardial Murmurs. A. Arteeial Muemues. — The 
 presence over the aorta of the normal cardiac sounds, 
 and of murmurs made at the aortic orifice and in aorta, 
 has already been mentioned, and will be still further 
 considered under diseases of the aorta. 
 
 When the stethoscope is lightly applied to the carotid 
 and subclavian arteries, the normal first and second 
 cardiac sounds may be faintly heard; the first sound 
 weak and low pitched, the second sound louder, higher 
 pitched, and snapping, corresponding to its character 
 at the aortic cartilage. Over the arteries that are 
 further removed from the heart, as the brachial, crural, 
 femoral, etc., no sound is normally heard uidess the 
 p-essure of the stethoscope is stifficiently hard to com- 
 press the artery when there is heard a systolic mur- 
 mur ("pressure murmur"), whose intensity corresponds 
 to the degree of narrowing, and which may have a 
 musical quality. 
 
 Murmurs heard over the arteries may be produced 
 (a) at the cardiac orifice or aorta, and conducted into 
 them, or (h) in the blood-vessels at the point where 
 heard. 
 
 Systolic muemues made in the arteries may be due 
 (a) to roughening of the inner coat ; (b) to narrowing of 
 the lumen, which, may be caused by changes in the Avail 
 of the artery, as calcareous plates, or due to pressure 
 from surrounding structures, as lymph nodes, etc. ; 
 
298 THE CIRCULATORY SYSTEM. 
 
 (c) to dilatation of the vessel from fevers, acute local 
 inflammation, chronic dilatation and vaso-motor condi- 
 tions, causing paresis of the vessel itself at certain 
 points; (d) to anseniia. Two or more of these causes 
 may be combined in any given case. The association of 
 localized vaso-motor dilatation with anaamia is particu- 
 larly common. 
 
 Over the subclavian arteries a short, blowing, systolic 
 nmrnmr ("whiff") is normally heard when the chest is 
 fully expanded. This murmur may become constant 
 and harsher if the artery is contracted or a sharp bend 
 produced by retraction of the apex of the lung or 
 pleural adhesions. This subclavian murmur is fre- 
 quently mistaken for an aneurismal murmur. 
 
 Diastolic mdrmues may be heard in the arteries in 
 cases of extensive aortic regurgitation. In rare cases a 
 double murmur has beeii heard in the femoral artery in 
 pregnancy without aortic regurgitation. The statement 
 has been made that it also occurs in lead poisoning and 
 in mitral stenosis. 
 
 B. Venous Muemues. — A murmur or humming 
 sound may be heard over the great vessels above the 
 clavicles behind the sterno-cleido-mastoid muscle in 
 about fifty per cent, of young persons, the frequency 
 diminishing with age. The occvirrence of a murmur at 
 this site is due to the sharp bend forward in the internal 
 jugular vein and its relation to the omohyoid muscle 
 (Hamernyk). This murmur is continuous, and varies 
 in intensity. It is loudest during and immediately 
 after auricular diastole, during inspiration and when 
 the patient is sitting or standing, as at this time the 
 current in the veins is strongest. It becomes very faint 
 or disappears entirely when the patient is recumbent. 
 It is loudest on the right side of the neck, and is 
 increased by slightly turning the head to the left. 
 
 In anaemic conditions this physiqlogical murmur 
 becomes constant, intensified, and in quality more 
 musical. It may also be induced by slight pressure 
 
 w 
 
AUSCULTATION. 29!) 
 
 over the veins in other regions of the body. The 
 ansemic venous hum (bruit du diable) is differentiated 
 from the arterial murmur by being continuous, and the 
 intensity not varying with systole of the heart. When 
 communication occurs between the artery and the vein 
 (arterial varix), a systolic murmur is heard over the 
 area involved. 
 
 Sounds Made in the Pericardium. — ISTormally, the ser- 
 ous surfaces covering the heart move noiselessly. When 
 the surfaces are roughened audible vibrations are made, 
 and the sound is recognized as pericardial by (a) its 
 character, (h) its time, (c) its localization and trans- 
 mission, (d) modifications that occur by posture and 
 pressure. 
 
 The character of the pericardial friction sounds may 
 simulate very closely the endocardial murmurs, but 
 usually they are of a rubbing, scratching, rasping or 
 scraping quality. Friction sound, although dependent 
 upon cardiac action, may not coincide in rhythm with 
 the different phases of the cardiac cycle, extending as a 
 single sound beyond the period of systole or diastole. 
 It may occiir as a to-and-fro (double) sound, due to the 
 motion of both ventricular systole and diastole, or it 
 may even have a triple rhythm, due to auricular systole, 
 as well as the ventricular action. 
 
 The friction sound may present variations in rhythm 
 and quality over different portions of the pracordium, 
 and those having a murmurish quality may lead to 
 the diagnosis of endocardial murmur. 
 
 Pericardial friction sound is limited to the prrecordial 
 space, although rarely heard over the entire pericardium, 
 even in general inflammation of the sac. It may be 
 heard over that portion of the pericardium that is 
 reflected over the base of the aorta, and be detected as 
 high as the second interspace and as far as the left 
 nipple. The point of maximum intensity is iisually 
 over the base of the heart, in the third and fourth inter- 
 spaces. 
 
300 THE CIRCULATORY SYSTEM. 
 
 The important diagnostic feature of pericardial 
 sounds is that they give the impression of being made 
 close to the surface, and that their intensity and char- 
 acter may be modified by posture. When the body is 
 thrown forward so that the heart is in closer contact 
 with the anterior portion of the pericardium, the 
 sounds become more distinctly frictional in character, 
 which lessens as the patient resumes the upright posi- 
 tion, and may be absent when he is recumbent. Firm 
 pressure with the ear or stethoscope over the prajcordia 
 also increases the intensity of the sound. 
 
 Pericardial friction sounds vary in character and 
 location from time to time, according to the nature of 
 the changes in the sac. 
 
 Pleuro-Pericardial Friction Sounds. — Pleuro-pericardial 
 friction sounds may be heard over that portion of the 
 pleura that overlaps the heart. This sound is most fre- 
 quently heard in the fourth and fifth intercostal spaces. 
 The quality and rhythm of this friction sound may 
 correspond with that made in the pericardium, but the 
 rhythm is disturbed by the respiratory movements, dis- 
 appearing with full inspiration and recurring with 
 expiration. 
 
 Cardio-Pulmonary Sounds. — A blowing sound, as of a 
 muLrmur, may be produced by cardiac action in the layer 
 of lung that is interposed between the heart and the 
 chest wall. It is due to the impact of the heart forcing 
 air out of the alveoli with suff^icient force to produce a 
 localized respiratory murmur or puff (cardio-respiratory 
 murmur). It is heard most frequently over the apex of 
 the heart and along the left border of relative cardiac 
 dullness, and is not transmitted in the area of cardiac 
 murmurs heard in the same locality. While caused by 
 cardiac action, the murmur is not always synchronous 
 with the cardiac sounds ; it may be heard during systole 
 and for a short time after the occurrence of the second 
 sound. The intensity of the nmrmur is variable, and is 
 affected chiefly by the respiratory movements, and also 
 
AUSCULTATION. 301. 
 
 by the posture of the patient. It may be loudest either 
 during inspiration or expiration, or may be present only 
 when the lungs are fully inflated and the breath is held. 
 At times, instead of being heard with each heart beat, it 
 is only detected with each fourth beat, its rhythm being 
 determined by the respiratory cycle. 
 
 Its intensity may be increased by firm pressure with 
 the ear of stethoscope over the prsecordia. 
 
 When the air-vesicles and bronchioles contain secre- 
 tion, the cardiac respiratory murmur may be attended 
 with fine crackling or moist rales. 
 
CHAPTEK XII. 
 
 DIAGNOSIS OP DISEASES OF THE HEAKT. 
 VALVULAE LESIONS. 
 
 REGURGITATION AT THE MITRAL ORIFICE. 
 
 Eeguegitation at this orifice is the most frequent of 
 all valvular lesions, and at the same time that most 
 compatible with good physical health. 
 
 Normally, competency at the mitral valve is dependent 
 upon (a) perfect coaptation of the valve leaflets; (h) 
 control over the position of the valve leaflets through the 
 chordas tendineas by the papillary muscle ; (c) contrac- 
 tion of the muscle of the ventricle, vphich reduces the 
 area of the auriculo-ventricular opening to one-half the 
 size that it has during ventricular diastole, and also 
 changes the shape from a circular to a somewhat oval 
 form. 
 
 Incompetency may be due to disturbance in manner 
 or time of one or more of these co-ordinating factors. 
 Coaptation of the mitral leaflets may be interfered with 
 (1) by swelling or vegetations (acute or subacute endo- 
 carditis), (2) by loss of substance (ulcerative endocar- 
 ditis), (3) by thickening, shriveling or distortion, or 
 binding together in a manner to prevent closure. (4) 
 The flbrous ring to which the valve is attached may be so 
 thickened as to interfere with the action of the valves. 
 (5) The chorda3 tendineas may be stretched, thickened or 
 distorted. (6) The papillary muscles may fail to exert 
 the right amount of traction at the right time on the 
 
DISEASES OF TTTE HEART. 303 
 
 chordffi tendinese from weakness of the muscles or 
 change (dilatation) of the ventricular cavity. (7) The 
 size of the auriculo-ventricular orifice may not be suffi- 
 ciently contracted at the time of systole, on account of 
 fibrous thickening of the ring at the base of the valves, 
 flabbiness of the cardiac muscle or dilatation of the left 
 ventricle. In this latter condition the valves, though 
 normal, are insufficient to close the opening (relative 
 valvular insufficiency). 
 
 Insufficiency at the mitral orifice, due to dilatation of 
 the ventricular cavity, is a frequent secondary lesion in 
 primary aortic stenosis or regurgitation. Imperfect 
 ventricular contraction and dilatation of the ventricular 
 cavity may be caused by anaemia, and by acute or chronic 
 wasting diseases when associated with physical exertion 
 or high blood pressure in the aorta. 
 
 Effects of Mitral Regurgitation. — The effects of mitral 
 regurgitation are both immediate and remote, and vary 
 in degree according to tlie amount of blood that is 
 regurgitated into the auricle, the force of the current, 
 and the extent to which tlie disturbance of function at 
 the mitral orifice is compensated for. The changes 
 induced by this lesion can be divided into three stages, 
 according as (1) they are limited to the left auricle and 
 ventricle ; (2) as they extend beyond the left auricle and 
 involve the pulmonary circulation and right ventricle; 
 (3) when failure of compensation by the right ventricle 
 occurs, with regurgitation at the tricuspid valve and 
 interference with venous circulation. 
 
 FiEST Stage. Compensation by Left Aueicle and 
 Venteiclb. — The earliest effect of regurgitation is to 
 dilate the auricle, which receives the blood from two 
 sources: (1) Normal, the flow from the pulmonary 
 vein ; (2) abnormal, flow from the left ventricle through 
 the mitral valve. 
 
 The increased amount of blood received into the 
 auricle during diastole increases its work during systole, 
 and liypertrophy occurs ; and, as the dilated and hyper- 
 
304 TEE CIBCULATOEY SYSTEM. 
 
 trophied auricle throws more blood than normally into 
 the ventricle during its diastole, the ventricle also 
 dilates and meets the increased demands upon it by 
 hypertrophy. In this stage the compensation is through 
 the dilatation and hypertrophy that occurs simultane- 
 ously in both left auricle and ventricle. If the amount 
 of regurgitant blood is not large, there is no interference 
 with pulmonary circulation ; neither is the blood forced 
 back into the pulmonary veins during auricular systole, 
 as the openings of the veins are closed, as in the normal 
 condition, by muscular contraction, and consequently 
 the effects of regurgitation are limited to the left auricle? 
 and ventricle. 
 
 Second Stage. Compensation by Right Ven- 
 tricular Hypertrophy. — ^When the amount of 
 regurgitant blood is large and the force of the current 
 strong enough, dilatation of the left auricle occurs 
 beyond the power of compensation. The auricle is 
 quickly filled by the blood from the ventricle, and, as the 
 pressure in the pulmonary veins is normally low, the 
 flow of blood from the lung is interfered with, and con- 
 gestion occurs. This congestion causes interference 
 with the flow of blood through the capillaries and raises 
 the blood pressure in the pulmonary artery, which in 
 turn causes the pulmonary valves to close with greater 
 tension, and induces hypertrophy of the right ventricle 
 as its work is increased, having to empty itself against 
 the raised pressure in the pulmonary artery. The 
 hypertrophy of the right ventricle compensates for the 
 lesion at the mitral orifice, and increases in degree up to 
 a point which depends upon the nutrition of the heart 
 muscle and the strength of the tricuspid valves. 
 
 Third Stage. Failure of Right Ventricular 
 Compensation. — When pressure in the pulmonary 
 artery becomes raised to a certain point, compensation 
 by the right ventricle may fail in two ways: (1) The 
 tricuspid valve may yield to the high endocardial press- 
 ure (safety valve action), (2) or the muscular power of 
 
DISEASES OF THE HEART. 305 
 
 the right ventricle heing insufficient to overcome the 
 pressure in the pulmonary artery, the ventricle only par- 
 tially empties itself during systole. At the next 
 auricular systole it is overdistended by the blood 
 received in addition from the right auricle. The dila- 
 tation of the right ventricular wall increases the 
 auriculo-ventricular opening, vfhich becomes too large to 
 be closed by the tricuspid valves (relative insufficiency). 
 Incompetency at the tricuspid orifice relieves the work 
 of the right ventricle, but causes interference with ve- 
 nous circulation, resulting in passive congestion of the 
 abdominal organs, and later, effusion into the serous 
 sacs and cellular tissue. 
 
 Physical Signs. Inspection. — The signs noted on 
 inspection correspond to the effects produced by the 
 lesion uix)n the heart and to the secondary changes in 
 the lungs and in the pulmonary, venous and arterial cir- 
 culations. The severity of the lesion is estimated by the 
 extent of these changes. 
 
 First Stage. — ^When the amount of regurgitation is 
 slight, inspection may be negative, or dilatation and 
 hypertrophy of the left ventricle may cause the visible 
 apex beat to be displaced slightly downward and to the 
 left. When mitral regurgitation occurs early in life, 
 the apex may be carried to the left nearly as far as the 
 anterior axillary line, and there may be bulging of the 
 prajcordia. 
 
 Second Stage. — ^According to the degree of right- 
 side cardiac hypertrophy, the area of the apex beat is 
 increased. It is seen further to the left, and also over 
 the lower portion of the prascordia toward the median 
 line and in the epigastrium. In marked dilatation and 
 hypertrophy of the left auricle, pulsations may be 
 present at the second left interspace, dependent upon the 
 systole of the auricle. This auriculo-ventricular sys- 
 tole may impart a wave-like motion, from above down- 
 ward, to the pr£ecordia. 
 
 Third Stage. — When compensation, through hyper- 
 20 
 
306 THE CIBCULATOBY SYSTEM. 
 
 trophy of the right ventricle, fails, and dilatation 
 results, a diffused cardiac impulse is present over the 
 entire lovirer portion of the left side of the thorax, and 
 also in the epigastrium. In extreme dilatation of the 
 right ventricle, pulsations may be seen from the third 
 to the sixth interspaces near the sternum on the left 
 side, and in the epigastrium along the border of the ribs. 
 
 Tricuspid regurgitation and dilatation of the right 
 auricle may cause pulsations to be seen in the fifth right 
 interspace along the sternum, and systolic pulsations in 
 the veins of the neck. 
 
 Involvement of the lungs is shown by cyanosis, 
 dyspncEa (orthopna3a) ; venous stasis by enlargement of 
 the abdomen (ascites), changed respiratory movements 
 (hydrothorax) and oedema of the extremities. 
 
 Palpatiojst. — The character of the cardiac action 
 detected by palpation corresponds with that noted by 
 inspection. 
 
 First Stage. — ^When dilatation of the left ventricle is 
 slight, the apex beat, in addition to being displaced to 
 the left and slightly downward, is strong, and the point 
 of contact is well defined. In proportion to the dilata- 
 tion and hypertrophy, the strength of the impulse is in- 
 creased and heaving in character, while the area becomes 
 enlarged. No thrill will be felt unless mitral regurgita- 
 tion is associated with stenosis. 
 
 Second Stage. — The impulse over the lower portion of 
 the prsecordia is forcible, and the area is diffused, but 
 not so well defined. 
 
 Third Stage. — ^With failure of right-side compensat- 
 ing hypertrophy, the impulse becomes more diffused. 
 When dilatation predominates, it has a Avave-like, indis- 
 tinct character, and may be detected to the right of the 
 sternum and in the epigastrium. 
 
 The pulse in the first stage shows no alteration. In 
 the second stage it may become very irregular. Witli" 
 failure of the right heart (third stage), the arteries may 
 be improperly filled, and the pulse becomes small and 
 irregular in force and frequency. 
 
DISEASES OF THE HEART. 307 
 
 When incompetency of the tricuspid valve occurs, 
 the liver will be found enlarged and extending below the 
 free border of the ribs. In extreme cases it will be 
 pulsating. Examination of the abdomen will show 
 ascites, and effusion into the pleural cavities will cause 
 enlargement of the lower portion of the thorax, with 
 loss of respiratory movements. 
 
 PEEcrrssioN. First Stage. — Percussion shows but 
 slight increase in the area of cardiac dullness. In 
 hypertrophy and dilatation of the left ventricle alone, 
 the outline of dullness over the apex is pointed. 
 
 Second Stage. — With hypertrophy of the right ven- 
 tricle, the area of cardiac dullness is increased to the 
 left at the level of the fourth rib, and the outline at the 
 apex becomes rounded. 
 
 Third Stage. — With dilatation of the right ventricle 
 and tricuspid regurgitation, there is increase in the 
 upper border of flatness at the level of the fourth rib, 
 and dullness may be detected to the right of the sternum 
 at this point. Over the lower portion of the sternum 
 there may be diminution of the sternal resonance; at 
 the apex dullness extends to the left and downward. 
 
 Pulmonary Resonance. — In the first and second stages 
 the pulmonary resonance is not impaired. In the third 
 stage, cedema of the base of the lungs may cause a 
 diminished resonance. In the later stages, with effusion 
 into the pleural cavity (hydrothorax), flatness is present 
 over the lower portion of the chest. The percussion 
 area of the liver is also increased. 
 
 Auscultation. — The distinctive sign of regurgita- 
 tion at the mitral orifice is a murmur which occurs with 
 the ventricular systole, accom]mnios, replaces or fol- 
 lows the first sound of the heart (Figs. 50 and 51), hav- 
 ing its point of maximum intensity at or near the apex, 
 and is diffused in all directions, especially to the left, 
 to the axillary line or beyond. Posteriorly, it may be 
 heard in the left interscapular space, just below spine of 
 scapula. 
 
 The quality of the murmur is variable. It may be 
 
308 TEE CIBCULATOBY SYSTEM. 
 
 harsh, high pitched and whistling in character, or soft, 
 low pitched and blowing. Some claim that it always 
 has a more or less musical quality. It also changes 
 from time to time, and is influenced by posture, being 
 most marked when the patient is in the recumbent 
 position. 
 
 The quality and intensity of the murmur do not indi- 
 cate the extent nor character of the lesion, which are 
 estimated by the effect upon the heart and changes in the 
 normal cardiac sounds, and in the circulatory system. 
 
 First Stage. — In slight regurgitation a murmur may 
 not be present, but the first sound of the heart at the 
 apex may be prolonged, due to change in the valvular 
 element (impure first sound). When a murmxir accom- 
 panies the first sound which retains its valvular element, 
 the amount of regurgitation is small. The distinguish- 
 ing sign of this stage is the absence of accentuation of 
 the second sound of the heart in the pulmonic area, with 
 a normal intensity of the aortic sound ; also the absence 
 of right-side ventricular hypertrophy. 
 
 Second Stage. — On the other hand, accentuation of 
 the pulmonic second sound is a characteristic sign of 
 compensation of the mitral lesion by hypertrophy of the 
 right ventricle. It has been claimed that the diagnosis 
 of mitral regurgitation cannot be made unless this 
 accentuation of the pulmonic second sound is present. 
 
 In estimating the extent of the lesion by the accentua- 
 tion of the pulmonic second sound and its relation to the 
 aortic, the age of the patient should always be taken into 
 consideration; also whether increased tension in the 
 pulmonary artery is due to obstructive pulmonary dis- 
 ease (see page '274). 
 
 When right-side ventricular hypertrophy compensates 
 for the lesion at the mitral valve, the murmur retains a 
 fairly definite quality, intensity and duration; also 
 auscultation of the lungs does not show evidences of 
 pulmonary ajdema, although the breath sounds may be 
 harsher than normal. 
 
DISEASES OF THE HEART. " 309 
 
 Third Stage. — ^With failure of compensation, the 
 murmur at the apex becomes less intense. Its trans- 
 mission to the left is less marked, while the occurrence 
 of tricuspid regurgitation causes the murmur to be 
 heard over a wider area to the right, it often being 
 impossible to separate these two -murmurs; at the same 
 time the pulmonic second sound diminishes in intensity. 
 The mitral murmur in some cases may entirely dis- 
 appear, the tricuspid murmur only being heard. In 
 proportion to the failure of compensation, the physical 
 signs of pulmonary oedema and effusion into the pleural 
 cavities occur. 
 
 Diagnosis of the Pathological Condition. — The nature of 
 the lesion at the mitral orifice cannot be determined by 
 the physical signs alone, although these may be in a 
 measure distinctive. When incompetency is due to a 
 recent endocarditis, there is veiy little change in the 
 size of the heart, and the murmur is of a soft, blowing 
 quality. When the valves are distorted, thickened, or 
 perfect coaptation prevented by contraction of the 
 chordaj tendineffi, due to a previous endocarditis, the 
 effect upon the left and right heart is more marked, and 
 the murmur has a harsh, rough and more musical 
 quality. 
 
 According to the degree of interference with the 
 valves, the murmur replaces the valvular clement of the 
 first sound at the apex. 
 
 Incompetency due to dilatation of the left ventricle 
 (relative valvular insufficiency) rarely gives a loud, 
 high-pitched murmur. When this condition is secondary 
 to disease of tlie aortic orifice, or changes in the arterial 
 system, the mitral murmur is much less intense than 
 those at the aortic orifice. Age is an important factor 
 in determining the nature of the lesion. Under forty 
 years of age, uncomplicated mitral regurgitation^ is 
 generally due to a previous endocarditis. Occurring 
 after forty-five years of age, it is generally due to 
 secondary dilatation, and is associated with the history 
 
no 
 
 THE CIRCULATORY SYSTEM. 
 
 and physical signs of the primary lesion at aortic orifice 
 or in arteries (arterio-sclerosis). 
 
 Functional and Hcemic Murmurs in the Mitral Area. 
 — Murmurs with the first sound at the apex, that occur 
 in anaemia or severe febrile diseases, are generally soft, 
 blowing in quality, and are not associated with 
 secondary changes in the heart or pulmonary circulation. 
 (Fig. 62.) The apex beat is not displaced ; the force is 
 weak, not lifting; the second sound over the pulmonic 
 
 Fio. 62. 
 
 Anseniia — systolic murmur in mitral area. 
 
 area is not accentuated, although there may be a soft, 
 blowing murmu.r (Fig. 63), and the tension of the 
 radial pulse is unaffected. 
 
 Murmurs of this character may occur during acute 
 febrile diseases, especially rheumatism, and be due to 
 acute endocarditis affecting the mitral valve, or to tem- 
 
DISEASES OP TEE HEART. 
 
 311 
 
 porary insufficiency resulting from cardiac mnscnlar 
 weakness (myocarditis). It is impossible to determine 
 whether these mnrmni-s are organic or functional at first 
 examination, and their natnrc can only be decided by 
 noting the changes that occur in the murmur and the 
 effect on the heart and circulation. 
 
 Aortic stenosis may be attended l)y a murmur that is 
 heard at the apex, with a quality different from that 
 
 F(G. 63. 
 
 Ansemia, systolic murmur in mitral and pulmonary areas. 
 
 present at the base of the heart, and simulating the 
 murmur of mitral regurgitation. This murmur is not 
 transmitted to the axilla nor associated with accentua- 
 tion of the pulmonic second sound. 
 
 Diflferential Diagnosis. — Exo-cardial murmurs may 
 simulate those of mitral regurgitation. Pericardial 
 
312 THE CIBCULATOBY SYSTEM. 
 
 friction sound may be localized at the apex, and be 
 synchronous with the first sound of the heart. It is 
 differentiated from the endocardial murmur by changes 
 in the intensity and character caused by pressure and 
 position, and it is not transmitted beyond the apex beat 
 nor heard behind in the interscapular space. 
 
 Pleuritic friction sounds generally have more or less 
 of the friction quality, and are influenced also by press- 
 ure and position, and their rhythm is more dependent 
 apon respiratory than cardiac action. 
 
 Gardio-res'piratory rnurmurs are also influenced by 
 the respiratory movements, being intensified during 
 inspiration, and generally inaudible at the end of exjjira- 
 tion. The point of maximum intensity does not corre- 
 spond to the apex of the ventricle, but is somewhat 
 removed from it. The murmur does not replace the 
 first sound of the heart nor change its valvular character. 
 It is also influenced by the position of the patient, being 
 most marked in the recumbent position, although this 
 is not an invariable rule. 
 
 STENOSIS AT THE MITRAL ORIFICE. 
 
 Obstruction at the mitral orifice may occur as an 
 isolated lesion, but it is usually associated with regurgi- 
 tation. 
 
 Normally, with ventricular diastole the mitral orifice 
 enlarges to twice the size that it has during systole, and 
 the relaxation of the papillary muscles allows free open- 
 ing of the leaflets. The flow of blood through the 
 opening is due to three forces that are operative at 
 different periods of the ventricular diastole: (1) The 
 aspirating or suction force of the dilating ventricle. 
 This force is most marked during the first period of 
 ventricular diastole, and gradually decreases as the 
 ventricle becomes distended. (2) Pressure of blood in 
 the auricle and pulmonary veins. This is most marked 
 also at the beginning of diastole. (3) Auricular sys- 
 
JDISEA8ES OF TEE HEAHT. 31?> 
 
 tole, which completes the emptying of the auricle, and 
 occurs just before the first sound of the heart. 
 
 Narrowing of the mitral orifice may be due to changes 
 that involve the auriculo-ventricular ring, interfering 
 with the normal enlargement of the opening during 
 diastole, or they may involve the leaflets or the ehordr,^ 
 tendinese. Those changes are generally secondary to 
 endocarditis. 
 
 The earliest change of endocarditis is usually the pro- 
 duction of vegetations on the auricular surface of the 
 valve, which, while causing no obstruction, render the 
 surface rough and allow of the production of a murmur. 
 Secondary thickening of the leaflets and the chorda' 
 tendinese prevent free motion of the valves, causing them 
 to project into the centre of the ventricle, and, while the 
 obstruction is slight, fluid veins are foi-med. Attach- 
 ment of the edges of the leaflets may occur, converting 
 tlic valve into a funnel, and producing more or less inter- 
 ference with the flow of blood. This condition is 
 especially liable to occur in children. More marked 
 adhesion and retraction of the valves may occur, so that 
 the opening becomes a mere split. 
 
 Effects of Mitral Obstruction. — The changes that occur 
 as the result of mitral stenosis are comparatively slow, 
 and the effects produced upon the circulatory system can 
 be divided into three stages. 
 
 First Stage. — The immediate effect of obstruction at 
 the mitral orifice is to increase the -work of the left 
 auricle, which is met by a compensating liyjiertropliy. 
 
 When the obstruction to the flow of blood is slight, 
 the effect may not extend beyond a simple hypertrophy 
 of the left auricle, which is suificient to force the normal 
 amoimt of blood into the ventricle and to prevent any 
 interference with the pulmonary circulation. 
 
 Second Stage. — When the obstruction is niore 
 marked, the effect may extend beyond the left auricle 
 and involve tlie pulmonary circulation and the right 
 heart. Interference with the pulmonary circulation 
 
314 THE CIBCULATOBY SYSTEM. 
 
 may occur in two ways, according as tlie liypertrophy of 
 the left auricle is sufficient or insufficient to compensate 
 for the obstruction. (1) Hypertrophy of the left auricle 
 may be siifficient to close the openings of the pulmonary 
 veins and to empty itself at the time of auricular systole, 
 and yet pressure in the pulmonary circulation may be 
 above normal. This occurs when the obstruction at the 
 mitral orifice is so marked that the aspirating force of 
 the heart and the pressure in the pulmonary veins are 
 insufficient to empty the pulmonary circulation during 
 the early portion of diastole. This increases pressure 
 in tlie pulmonary veins, arteries and capillaries, causing 
 secondary hypertrophy of the right ventricle, with 
 accentuation of the pulmonic second sound. Dilatation 
 of the left auricle is not present during this period of the 
 second stage, and only occurs when the power becomes 
 insufficient to overcome obstruction. 
 
 (2) When the hypertrophy of the left auricle is 
 unable to overcome the obstruction, dilatation occurs, 
 and with auricular systole the blood is forced from the 
 auricle, not only through the obstruction, but also into 
 the pulmonary veins, and marked congestion of the lung 
 ensues. As was explained under "Mitral Eegurgita- 
 tion," this interference with pulmonary circulation is 
 compensated for by hypertrophy of the right heart. 
 
 During this stage the left ventricle may be norm.al, 
 or, on account of imperfect distension of its cavity dur- 
 ing diastole, this cavity may be reduced in size. 
 
 Third Stage. — Failure of right ventricular compensa- 
 tion occurs in mitral obstruction under the same condi- 
 tions and with the same effects as has already been 
 noted under "Mitral Eegurgitation." 
 
 Physical Signs. Iwspegtioit. — The changes noted by 
 inspection correspond to change in the position of the 
 apex beat and the condition of the circulation. 
 
 In the first stage, there being no increase in the size 
 of the ventricles, the apex beat is in the normal position. 
 In children the pulsation of the auricle may be noted in 
 the second and third left interspaces. 
 
DISJSASES OF THE HEART. 
 
 !15 
 
 In the second star/e, especially during the early period, 
 the apex beat is displaced upward and to the left, even 
 beyond the nipj)le line. (Fig. 04.) With dilatation of 
 the right ventricle there is increase in the area of visible 
 apex beat and extension tovsrard the median line. When 
 the disease occurs in early life, there may be slight 
 enlargement of the prax-ordia. 
 
 In the third stage the apex beat is diffiipcd and indis- 
 tinct. Interference with the pulmonary circulation 
 
 Fig. 64. 
 
 Displacement of apex upward and to the left in mitral stenosis. 
 
 causes marked cyanosis of the membranes and a dusky 
 appearance of the skin. Interference with return 
 circulation causes the veins of the neck to become 
 prominent, and pulsations are noted when tricuspid 
 regurgitation is present. 
 
 Palpation. First Stage. — The apex beat may be 
 normal or slightly decreased in force. Over the apex 
 beat a thrill may be felt. The characteristic feature of 
 
316 TEE CIRCULATORY SYSTEM. 
 
 the thrill is its sudden termination at the moment that 
 the apex beat is felt. The duration of the thrill and its 
 length will depend upon the degree of obstruction and 
 the force of the current during different periods of 
 ventricular diastole. 
 
 The pulse may be normal or show slight emptiness of 
 the artery. 
 
 Second Stage. — Hypertrophy of the right ventricle 
 causes the apex beat to be more diffused. Over the left 
 intercostal spaces the closure of the pulmonary valves 
 may be felt as a shock. The thrill is more marked. 
 The pulse may be normal and regular when patient is 
 quiet, becoming irregular on exertion. 
 
 Third Stage. — ^With failure of right-side compensa- 
 tion, the apex beat becomes more diffused and wave-like, 
 the thrill weaker or absent, or, if present, is felt but for 
 a short time before the apex beat. The pulse is small, 
 irregular, and the arteries are imperfectly filled. 
 
 When failure of compensation has occurred gradually, 
 with long-continued interference ^£r& the venous circu- 
 lation, increased pressure in the arterifej. due to obstruc- 
 tion to capillary circulation, may cause hypertrophy of 
 the left ventricle, so that the apex beat \ will be more 
 marked than during the earlier stage^***^ 
 
 Percussiow. First Stage. — Tltearea of percussion 
 dullness is normal. During the second and third stages 
 it corresponds to the anatomical enlargement of the 
 heart (see Mitral Regurgitation). 
 
 Auscultation. — The diagnostic sign of obstruction 
 at the mitral orifice is the presence of a marked vibra- 
 tory murmur, which begins an appreciable time after 
 the second sound and increases in intensity until ter- 
 minated abruptly by the accentuated first sound (pre- 
 systolic) ; the point of maximum intensity is at the apex, 
 around which it is diffused. 
 
 The above are cliaracteristics of the typical murmur 
 of mitral obstruction, but it is subject to variations in 
 quality, duration and intensity, dependent upon the 
 
DISEASES OF THE HEART. 317 
 
 degree and character of the obstruction and the force 
 of the current of blood through the opening. 
 
 The murmur has been described as rough, rumbling, 
 rolling, churning, grinding, blubbering, and may be 
 simulated by pronouncing the syllables "rrb," "rrt." 
 
 The most distinctive feature is the short, sharp sound 
 that terminates the murmur, which always persists, 
 even though the other phases of the murmur are absent. 
 It may be the only sign present of mitral obstruction, 
 as the murmur is not constant. 
 
 The production of a murmur demands that the blood 
 pass through the contracted orifice with a definite 
 amount of force. As the rapidity of the passage of the 
 blood through the heart varies from time to time, accord- 
 ing to the rate of cardiac action, the murmur may be 
 absent at one time and present at another. Variations 
 in the force of the current also cause a rise and fall in 
 the intensity of the murmur. 
 
 The duration of the murmur and its relation to the 
 first and second sounds of the heart also vary. When 
 the murmiir is heard only for a brief period, just before 
 the first sound, it is distinctly pre-systolic. The dura- 
 tion may be longer, however, so that it occupies the 
 major portion of diastole, or in some cases it may be 
 heard with greatest intensity almost immediately after 
 the occurrence of the second soimd; but this murmur 
 can never occur with or replace the second sound of the 
 heart. (Fig. 47.) 
 
 The presence of a murmur during the different por- 
 tions of diastole depends upon the nature of the force. 
 When the force necessary to produce the murmur is due 
 to auricular systole, the murmur is heard just before 
 the first sound. When the constriction is marked and 
 the force is supplied by the aspirating action of the 
 left ventricle and the tension that exists at the time in 
 the auricle and pulmonary veins, the munnur will occur 
 earlier in diastole. 
 
 First Stage. — The murmur is harsh in proportion to 
 
318 
 
 THE CIBCVLATOBY SYSTEM. 
 
 the constriction and the auricular hypertrophy, markedly 
 pre-systolic, and terminated with the accentuated first 
 soimd of the heart, which is clear. In slight stenosis 
 the accentuated first sound may only be present, or 
 the murmur may be temporarily absent when the patient 
 is in bed and the cardiac action is quiet. 
 
 Second Stage. — The murmur is harsh, occurs earlier 
 in the diastole, with marked pre-systolic increase in inten- 
 sity. The pulmonic second sound is accentuated, and 
 there is a tendency to reduplication of the second soimd 
 over the base of the heart and absence of the second 
 sound at the apex. Change in the second sound at the 
 base or apex is due to increased pressure in the pul- 
 monary artery, with diminished tension in the aorta. 
 
 During this stage, when the power of the left auricle 
 is failing, two points of intensity may be noted (double 
 crescendo) ; one mid-diastolic, and the other pre-systolic, 
 depending upon the varying force of the blood current. 
 (Fig. 65.) Auscultation of the lung during the early 
 
 Fig. 65. 
 
 Double crescendo. Mitral obstructive niurniur. 
 
 portion of this type shows a slight harshness of the 
 respiratory murmur. Long-continued high tension in 
 the pulmonary circulation later produces signs of cardiac 
 pneumonia — brown induration. 
 
 Third Stage. — In proportion to the feebleness of the 
 left auricular systole and lowering of the pressure in 
 the jDulmonary circulation, due to failure of right heart 
 compensation, the murmur loses its characteristic rough- 
 ness or disappears. Accentuation of the second sound 
 is absent. The first sound becomes short, sharp and. 
 sudden over the tricuspid area ; the soft systolic murmiir 
 of tricuspid regurgitation may be detected. Over the 
 
DISEASES OF THE HEART. 319 
 
 lungs, failure of the right heart is shown hy the physical 
 signs of pulmonary oedema and effusion into the serous 
 cavities, as noted under "Mitral Kegurgitation." 
 
 Differential Diagnosis. — Murmurs that may he mis- 
 taken for that of mitral stenosis are (1) those whose 
 points of maximum intensity are at the apex — ^mitral 
 regurgitation, tricuspid regurgitation — and (2) those 
 that occur during diastole — aortic regurgitation (Flint 
 murmur), tricuspid stenosis, pericardial (friction) 
 murmurs. 
 
 Mitral EEOUEGiTATioisr. — The murmur of mitral 
 stenosis increases in intensity up to the occurrence of 
 the first sound of the heart ; that of mitral regurgitation 
 begins with the first sound, and gradually diminishes in 
 intensity. 
 
 The murmur of mitral stenosis is localized at the site 
 of the visible apex beat ; that of mitral regurgitation is 
 transmitted beyond the prascordia toward the axilla, and 
 is heard also behind. 
 
 Mitral regurgitation and mitral stenosis are fre- 
 quently associated. Under these circumstances, when 
 both murmurs are present, a harsh, rough murmur is 
 heard, culminating with the sharp first sound, which is 
 immediately followed by a softer, blowing murmur, 
 which is transmitted toward the axilla. 
 
 Tricuspid Eegukgitation. — The murmur of tri- 
 cuspid regurgitation may be heard with the point of 
 maximum intensity just within the apex beat. When 
 not secondary to mitral stenosis, its time, its area of 
 diffusion and the secondary effects upon the venous cir- 
 culation are the distinctive features. When associated 
 with mitral stenosis, it follows the first sound of the 
 heart, and is soft, blowing in character. Tricuspid 
 regurgitation is determined more by the changes in the 
 venous circulation than by the presence of the murmur. 
 
 Aortic KEGUEOiTATioisr. — The murmur of mitral 
 stenosis may occupy most of the diastolic period. It 
 usually begins an appreciable time after the occurrence 
 
320 THE CIBCULATOBY SYSTEM. 
 
 of the second sound, and can never accompany or replace 
 it. The murmur of aortic regurgitation, on the other 
 hand, accompanies, replaces or follows immediately 
 after the aortic sounds. 
 
 The murmur of mitral stenosis is suddenly termi- 
 nated with the occurrence of the first sound. _ That of 
 aortic regurgitation is most marked at the beginning of 
 diastole, and usually fades out before the occurrence of 
 the first sound. • 
 
 "Flint" Muemue. — This may occur as a marked pre- 
 systolic increase of the diastolic murmur, or may occur 
 as a separate sound in aortic regurgitation. 
 
 Teicuspid Stenosis. — The time of these two mur- 
 murs are identical. Their points of maximum intensity 
 may be slightly separated, but usually they are the same. 
 The murmurs are also similar in quality and duration 
 during the diastolic period. The differentiation is 
 extremely difficult, and is made only when the two 
 murmurs vary in point of maximum intensity and in 
 quality. 
 
 Peeicaedial Feigtion Sounds. — Pericardial fric- 
 tion sounds, especially when due to adherent pericar- 
 dium, may simulate the murmur of mitral stenosis, but 
 the sound does not terminate with the apex beat, being 
 carried slightly into the systolic period. 
 
 OBSTRUCTION AT THE AORTIC ORIFICE. 
 AORTIC STENOSIS. 
 
 Obstruction to the flow of blood through the aortic 
 orifice, due to diminution of its calibre, is a rare con- 
 dition, but signs somewhat similar to those produced by 
 narrowing of the orifice are present when the orifice 
 remains of the same diameter as in liealth. 
 
 True obstruction, or stenosis, at the aortic orifice may 
 be caused by (1) contraction of the fibrous ring; (2) 
 rigidity of the cusps of the valves; (3) adhesions of the 
 borders of the valves, and (-1) masses of vegetations. 
 
DISEASES OF THE HEART. 321 
 
 Non-obstructive conditions producing a murmur at 
 the aortic orifice may be (1) roughening of the surface 
 of the valves by vegetations, calcareous deposits; (2) 
 changes in the size of the aorta (relative obstruction), 
 and (3) changes in the specific gravity of the blood 
 (hsemic or functional murmur). 
 
 Eflfect of Stenosis. — The effects of obstruction at the 
 aortic orifice may be divided into three stages, according 
 as they are limited to (1) the left ventricle, (2) extend 
 beyond the mitral valve and involve the pulmonary cir- 
 culation and right ventricle, (3) when they extend 
 beyond the tricuspid valve and involve the venous 
 circulation. 
 
 First Stage. — As the lesions that produce obstruction, 
 whether due to endocarditis or secondary changes in the 
 aorta, progress slowly, there is a corresponding gradual 
 increase in the work of the left ventricle, which is met 
 by compensating hypertrophy without any correspond- 
 ing degree of dilatation. Dilatation does not occur 
 until the left ventricle fails to empty its cavity at each 
 systole. This failure may be temporary, as when the 
 cardiac rate is suddenly increased. Compensation by 
 increased hypertrophy may again occur, but the dilata- 
 tion of the cavity remains. 
 
 The effect of the stenosis is limited to the left ven- 
 tricle for a variable period until repeated, or extensive 
 dilatation of the left ventricular cavity causes imperfect 
 action of the papillary muscles and enlargement also 
 of the auriculo-ventricular ring and relative insuffi- 
 ciency of the mitral valves. The effect upon the arterial 
 system is marked, producing a characteristic pulse. 
 
 Second Stage. — When regurgitation at the mitral 
 orifice occurs the work of the left ventricle is tem- 
 porarily relieved, and there is immediate interference 
 with the pulmonary circulation, increased tension in the 
 pulmonary artery and compensating hypertrophy of the 
 rio-ht ventricle. For subsequent changes in this stage, 
 and those that occur during the third stage, with failure 
 21 
 
322 THE CIRCULATORY SYSTEM. 
 
 of compensation by the right ventricle (see Mitral 
 Regurgitation, page 304). 
 
 In conditions which give a similar murmur, but are 
 non-obstructive, the primary effect on the left ventricle 
 and the subsequent changes in the heart are absent. An 
 exception to this is where atheroma or loss of elasticity 
 of the aorta has preceded the dilatation of the aorta, 
 when there is hypertrophy of the left ventricle. In this 
 condition dilatation of the aorta may occur, instead of 
 regtirgitation, at the mitral orifice. 
 
 Physical Signs. Inspection. — The position and 
 extent of the apex beat correspond to the changes in the 
 size of the heart. 
 
 First Stage. — ^When there is hypertrophy only of the 
 left ventricle, the apex beat may be in the normal posi- 
 tion, or, at most, carried slightly to the left, and is well 
 defined. When hypertrophy and dilatation are asso- 
 ciated, it is displaced to the left and downward, and the 
 area is more diffused. 
 
 Second Stage. — The apex beat is seen further to the 
 left, and also over the lower portion of the prrecordia. 
 Visible pulsations may be present in the third, fourth 
 and fifth interspaces (left), and there may be precor- 
 dial bulging. 
 
 Third Stage. — Dilatation of the right ventricle, ve- 
 nous engorgement, and tricuspid regnirgitation give a 
 diffused, wavy pulsation, with enlargement and pulsa- 
 tions of the veins in the neck. 
 
 Palpation. First Stage. — Palpation gives impor- 
 tant information concerning not only the condition of 
 the heart, but also the degree of stenosis and the nature 
 of the structural changes. The apex beat is character- 
 istic. It lacks the sudden, sharp tap of the normal 
 heart, and the impulse is slow, labored and sustained, 
 terminating with a short, sharp recoil that may give the 
 sensation of a slight tap. 
 
 When dilatation is added to hypertrophy, the labored 
 and forcing action of the heart is increased, but it does 
 
DISEASES OF THE HEART. 323 
 
 not have the lifting, heaving impulse of hypertrophy 
 and dilatation due to other causes. Over the base of the 
 heart an intense thrill may be felt ; the point of maxi- 
 mum intensity is usually in the aortic area, but it may 
 be detected also at the apex. 
 
 The intensity of the thrill does not indicate the 
 degree or nature of the lesion, although it occurs most 
 frequently when the obstruction is due to fibrous or 
 atheromatous thickening of the aortic ring or cusps. 
 The intensity of the thrill is more directly connected 
 with the force of the current. 
 
 The pulse is of great importance in aortic stenosis. 
 Its character, when taken in connection with the changes 
 in the heart, determines the extent of the lesions that 
 cause the systolic murmur at the aortic orifice. 
 
 In proportion to the degree of obstruction is the vari- 
 ance between the slow, labored, but forcible, apex beat 
 and the small pulse wave. 
 
 l^ormally, with ventricular systole the blood is 
 rapidly forced into the aorta, which is distended, giving 
 to the radial artery the characteristic pulse Avave. In 
 proportion to the obstruction the blood is slowly forced 
 into the aorta during the entire period of systole, so that 
 there does not occur the siidden distension of the aorta, 
 and the pulse wave lacks the sharp rise and continues 
 longer. 
 
 JSTon-obstructive conditions, producing aortic systolic 
 murmurs, do not give this type of pulse. 
 
 The characteristics of the pulse in aortic stenosis are 
 well seen in the sphygmograjahic tracings (Fig. 41). 
 
 The effect of exertion on the pulse is important in 
 determining the power of the hyjoertrophied left ven- 
 tricle to compensate for the lesion. When exertion 
 increases the frequency and force of the pulse, then 
 compensation is perfect, be the obstruction small or 
 great. If it causes a long, even and regular jDulse while 
 the patient is quiet, to become shorter, small and 
 irregular in force and rhythm, then the compensation is 
 
324 THE CIBCULATOBY SYSTEM. 
 
 sufficient when the heart is beating slowly, but is inade- 
 quate to empty the ventricle when the rate is increased. 
 
 Second Stage. — ^When regurgitation at the mitral 
 orifice occurs, the cardiac impulse is less labored, but 
 shorter and more diffused. The thrill over the base of 
 the heart becomes less intense or may disappear, and the 
 pulse becomes shorter and smaller and is not disturbed 
 to the same extent by exertion. 
 
 Third Stage. — The impulse becomes indistinct and 
 wavy, the thrill is absent and the pulse is small and 
 thready. 
 
 Percussion. — Changes in the areas of cardiac flat- 
 ness and relative dullness correspond to the changes in 
 the size of the right and left ventricles. During the 
 stage of simple hypertrophy of the left ventricle, no 
 change in the percussion can be detected. With the 
 occurrence of dilatation, the area of deep dullness is 
 enlarged to the left and downward. 
 
 Auscui-TATiow. — The characteristic sign of aortic 
 stenosis is a systolic murmur, occurring Avith the first 
 sound of the heart at the base,^ with the point of maxi- 
 mum intensity in the second right intercostal space and 
 transmitted upward and laterally. A marked feature 
 of systolic murmurs made at the aortic orifice is their 
 transmission into the great arteries. (Fig. 53.) The 
 murmur varies in quality, duration, point of maximum 
 intensity and area of diffusion, according to the char- 
 acter and extent of the lesion and the secondary changes 
 in the heart. 
 
 First Stage. — When the obstruction is slight and due 
 to vegetations or recent endocarditis, the murmur is soft, 
 and occupies but a portion of the systolic period. The 
 point of maximum intensity is at the second right inter- 
 costal space, and the area of diffusion is but sliglitly 
 beyond it. The aortic second sound is only slightlv 
 diminished. 
 
 1 If the iTiiinnur is timed )iy tlie apex beat or tlie first sound at the apex, it 
 may seem to occur sllg-litly after the beginning: of systole. 
 
DISEASES OF THE HEART. 325 
 
 When fibrous or atheromatous changes have stifl'ened 
 the valves and the aortic ring, the murmur replaces the 
 first sound at the base, and is harsh and sawing in char- 
 acter, especially if thrill be present. It may persist 
 during the entire systolic period. The second sound is 
 muffled or impure ; the point of maximum intensity is at 
 or above the second right costal cartilage, and the mur- 
 mur is hoard over the upper portion of the sternum, 
 laterally along the ribs and clavicles, and may be heard 
 in the interscapular space behind. 
 
 When dilatation of the left ventricle occurs, the point 
 of maximum intensity is at the left edge of the sternum, 
 at the jimction of the third and fourth costal cartilages. 
 A systolic murmur may also be heard at the apex, which 
 may be due to conduction of the murmur made at the 
 base through the ventricular wall, but usually caused by 
 slight regurgitation at the mitral orifice. When due to 
 mitral regurgitation, at first the miirmnr may be only 
 present after exertion or other causes that increase the 
 cardiac rate. 
 
 Second Stage. — The murmur at the base loses its 
 harshness. Its area of diffusion is less, and the murmur 
 at the apex becomes more marked ; it is associated with 
 accentuation of the pulmonic second sound and with 
 other signs of pulmonic congestion, and later with 
 those of the third stage — ^venous congestion and tri- 
 cuspid regurgitation (see Mitral Eegurgitation). 
 
 Diagnosis of the Pathological Condition. — The diagnosis 
 of aortic stenosis from other conditions, causing a sys- 
 tolic murmur over the aortic area, is made by the 
 association with the murmur (a) the signs of primary 
 cardiac hypertrophy of the left ventricle, (h) the 
 presence of a thrill, (c) the characteristic contrast 
 between the force of the apex beat and the size of the 
 pulse. 
 
 Aortic obstruction rarely continues as an isolated 
 lesion for any length of time, being usually associated 
 with regurgitation. In uncomplicated stenosis the 
 
326 THE CIRCULATOBY SYSTEM. 
 
 aortic second sound is impure, miiffled and lacks trie 
 normal tense, valvular element. When regurgitation 
 occurs, the aortic sound becomes very feeble, or is 
 replaced by the murmur. 
 
 Eoughening of the surface of the valves gives a soft 
 systolic murmur, which is localized around a point of 
 maximum intensity at the second left intercostal space ; 
 the aortic second sound is clear, and there is no change 
 in the position and force of the apex beat or in the pulse. 
 These sounds are identical with the early stage of acute 
 endocarditis at the aortic valve, that may ultimately 
 produce true obstruction. 
 
 Dilatation of the aorta, altering the correlation 
 between the size of the aortic orifice and the cavity 
 beyond, frequently causes a murmur. The early 
 changes due to atheroma diminish the elasticity of the 
 aorta, converting it into a rigid tube, increasing the 
 work of the heart, and causing hypertrophy of the left 
 ventricle. If the aortic surfaces are also roughened, r 
 harsh murmur will be present, the aortic second sound 
 will be accentuated, and there will be more marked 
 distension and pulsation of the vessels of the neck as a 
 result of the loss of distensibility in the aorta. The 
 pulse wave will be more sudden, and correspond in 
 size and force to the apex beat. When dilatation 
 occurs, the murmur becomes softer than that of simple 
 aortic stenosis, the second sound is accentuated, the apex 
 beat has the prolonged, labored character, and the pulse 
 is sudden and short. In dilatation and relaxation of the 
 aorta, due to neuro-cardiac conditions (Grave's disease, 
 hysteria, etc.), the murmur is soft, bloAving in quality, 
 and heard over the vessels of the neck ; the cardiac action 
 is rapid ; the first sound of the heart is short and sharp ; 
 the second sound is clear ; the pulse full and compressi- 
 ble, and there are pulsations in the vessels of the neck. 
 
 Diflferential Diagnosis. Aweukism. — Aneurism of the 
 ascending aorta may give a systolic murmur and thrill 
 similar to those in aortic stenosis, but the second sound 
 
DISEASES OF THE HEART. 327 
 
 is increased in intensity, and may be felt as diastolic 
 valve shock. There is diminution of the resonance over 
 the upper portion of the sternum, and there is generally 
 present pulsation over the upper jjortion of the sternum, 
 and pressure symptoms involvins; the bronchi and 
 nerves. The pulse does not show the characteristics of 
 aortic stenosis. 
 
 HiEMic MUEMUES having their point of maximum 
 intensity at the second right intercostal space are heard 
 also in the second left intercostal space, the usual site of 
 maximum intensity. They are soft, blowing murmurs, 
 and are not associated with signs of cardiac hyper- 
 trophy. The pulse is short, soft and compressible. 
 The skin and mucous membranes have the characteris- 
 tic appearance of anaBmia. 
 
 Pulmonary obstruction has a systolic murmur, 
 with its point of maximum intensity to the left of the 
 sternum, but the murmiir is not transmitted into the 
 vessels of the neck. The aortic second sound and pulse 
 are unchanged. 
 
 Patent ductus aeteeiosus gives a systolic mur- 
 mur, Avith the point of maximum intensity in the second 
 left intercostal sjmce. The murmur begins somewhat 
 after the first sound (late systolic), and contimies 
 usually after the second sound. It may be heard over 
 the entire upper portion of the chest, but is "never car- 
 ried into the vessels of the neck or arms." 
 
 REGURGITATION AT THE AORTIC ORIFICE. 
 
 Regurgitation at the aortic orifice is always dependent 
 upon structural changes in the valves guarding it, or on 
 dilatation of the fibrous ring. Perfect closure at this 
 orifice is dependent upon normal elasticity of the semi- 
 lunar valves, whose free edges are forced together by 
 the pressure of the blood in the aorta at the time of 
 diastole. 
 
328 THE CIRGULATOBY SYSTEM. 
 
 Eegurgitation may be caused by (1) vegetations on 
 the free surface of the valves, preventing perfect coapta- 
 tion; (2) loss of tissue due to ulcerative endocarditis; 
 (3) the cusps may be thickened, shrunl^en or deformed 
 by sclerotic processes, due to chronic endocarditis or 
 secondary to changes in the aorta. 
 
 The sclerotic processes that ])r(iduce thickening and 
 distortion of the cusps, or changes in the aorta, are slow, 
 but progressive, so that there is a tendency for the 
 insufficiency of the valve to gradually increase. 
 
 (4) Dilatation of the aorta may be so marked as to 
 involve the fibrous ring and produce enlargement of the 
 aortic orifice, rendering it too wide to be closed by the 
 cusps^^ (relative valvular insufficiency). 
 
 (5) Kupture of the aortic cusps may be caused by 
 violent muscular exercise. It is doubtful whether 
 rupture of a cusp can occur from this cause unless it has 
 been previously diseased. 
 
 Effects of Regurgitation at the Aortic Orifice. — The 
 effects of regurgitation at the aortic orifice can be 
 divided into three stages, according as they are limited 
 (1) to the left ventricle and arterial system; (2) as they 
 extend beyond the mitral valve and involve the pul- 
 monary circulation and right ventricle, and (3) as they 
 extend beyond the tricuspid valve and cause interference 
 with the general venous system. 
 
 First Stage. — The immediate effect is exerted during 
 diastole on the left ventricle and arterial circulation. 
 On the ventricle the effect of the regurgitant stream is 
 to produce dilatation. The dilating force is due (a) to 
 the pressure of the regurgitant current from the aorta, 
 and (b) to that in the auricle and pulmonary veins, 
 reinforced by auricular systole. The blood is driven 
 into the ventricle by the elastic recoil of the aorta, and is 
 aspirated also into the ventricle during the early portion 
 of diastole by the expanding cavity. When the ventricle 
 
 ' Dilatation of the fibrous ring sufficient to cause incompetency of the valve 
 has been denied, but its occurrence mvist be admitted. 
 
DISEASES OF THE HEART. 329 
 
 is filled, tlie pressure in the aorta continues to act on tlie 
 left ventricle tlirougli the incompetent valve, according 
 to Pascal's law, and cause still further dilatation. The 
 rapid filling of the ventricle from the aorta removes one 
 of the normal forces that aids the flow of blood from the 
 auricle (see Mitral Obstruction, page 312), so that with 
 auricular systole a larger amount of blood is forced into 
 the already overfilled ventricle. 
 
 On the aorta an equally marked effect is produced 
 during diastole, according to the extent of the regurgita- 
 tion. There is a sudden diminution of the blood press- 
 ure, which is felt throughout the entire arterial system. 
 
 The primary effects produced during diastole are fol- 
 lowed by secondary changes in the ventricle and orta 
 during systole. Tlie increased amount of blood in the 
 ventricle augments the work of the heart during systole, 
 which is met by a compensating hypertrophy. The 
 greater capacity of the ventricle causes a larger amount 
 of blood than normal to be driven into the aorta, and the 
 hypertrophied muscle propels it with greater force. 
 These two factors cause increase in the normal blood 
 pressure and overdistension of the aorta and great ves- 
 sels during systole, which is followed by almost as 
 sudden a fall of blood pressure during diastole, due to 
 aspiration into the ventricle. 
 
 The effect of the sudden forcing of an increased 
 amount of blood into the arteries causes them to become 
 not only dilated, but also elongated and tortuous. This 
 effect upon the arteries may extend to the veins and 
 capillaries. 
 
 The dilatation of the ventricle during diastole, and 
 the hypertrophy of the ventricle and dilatation of the 
 aorta during systole must be considered as correlated 
 effects of aortic regurgitation. In uncomplicated 
 regurgitation they bear a definite relation to each other. 
 As the dilating force is constantly acting on the ven- 
 tricle, there may be frequent attacks of dilatation, fol- 
 lowed by recompensation, before insufficiency at mitral 
 
330 THE CIRCULATORY SYSTEM. 
 
 valve occurs. Under these circumstances the left ven- 
 tricle may attain enormous proportions (cor bovinum). 
 
 When obstruction is associated virith regurgitation, 
 the sequence of effects is disturbed. Hypertrophy of 
 the left ventricle is most marked, while dilatation of 
 the aorta is less, due to the slowness with which the 
 enlarged ventricle empties itself through the constricted 
 opening. 
 
 Second Stage. — ^When the mitral valve becomes 
 incompetent through dilatation of the ventricle or 
 changes in the cusps of the valves, there is marked 
 interference with pulmonary circulation and the func- 
 tions of the right heart, causing the consecutive changes, 
 as described in Mitral Regurgitation (page 303). 
 
 Incompetency of the mitral valve secondary to aortic 
 regurgitation must not be considered as an unfavorable 
 complication. Generally it is a conservative process, 
 relieving the stress on the right ventricle. When com- 
 pensating hypertrophy does not keep pace vrith dilata- 
 tion through imperfect nutrition, or is ruptured by 
 intercurrent causes, as physical exertion, disease, etc., 
 the constantly acting dilating force tends to overpower 
 the contracting power of the ventricle, and death from 
 asystole occurs unless regurgitation through the mitral 
 orifice takes place, relieving the left ventricle both dur- 
 ing diastole and systole. 
 
 Compensation for the aortic regurgitation by hyper- 
 trophy of the right ventricle may exist for a long time. 
 When it fails (third stage), it is due to the same cause 
 that induces it in lesions at the mitral orifice. 
 
 Physical Signs. Inspectiost. — Inspection of the pra;- 
 cordia and arteries gives important information, and is 
 frequently sufficient for diagnosis. 
 
 First Stage. — When the regurgitation has produced 
 but a small amount of dilatation and hypertrophy, the 
 apex beat is but slightly displaced, and is localized. As 
 the size and power of the heart increase, the apex is car- 
 ried further downward and outward, and the visible 
 
DISEASES OF THE HEART. 331 
 
 impulse becomes more marked, witli a diffused heaving 
 of the chest and bulging of the prajcordia. In some 
 cases the diminution of the size of the enlarged heart 
 during systole and the increased negative pressure are 
 sufficient to cause retraction of the chest wall over the 
 region of the apex beat, instead of the usual lifting 
 impulse. 
 
 Pulsations of the aorta, carotids, subclavians, brachials 
 and more peripheral arteries are present in proportion 
 to the extent of the lesion. The blood-vessels also stand 
 out more prominently, and when they are markedly 
 tortuous the pulsations in the more superficial ones have 
 a peculiar vermicular appearance. Pulsation in the 
 vessels may be strong enough to produce movement of 
 the extremities, or even of the head. In well-marked 
 cases capillary pulsation may be present. 
 
 Second Stage. — The apex beat becomes more diffused, 
 and is carried further to the left and downward. The 
 pulsation in the vessels of the neck are not as marked. 
 
 Third Stage. — The heaving left impulse is replaced 
 by a diffuse apex beat, extending to the epigastrium. 
 Systolic pulsations are seen in the jugulars. 
 
 Palpation. — Palpation of the prsecordia shows the 
 apex beat to be changed in position and character, 
 according to the relative degree of dilatation and hyper- 
 trophy of the left ventricle, and subsequently of the 
 right ventricle. 
 
 First Stage. — In hypertrophy with slight dilatation 
 (eccentric hypertrophy), the apex beat is displaced 
 slightly to the left. The force is increased. In well- 
 marked hypertrophy and dilatation the systolic impulse 
 is lifting and heaving in character, and may jar the 
 entire thorax and give a well-marked thrust if the ribs 
 are elastic. Diastolic recoil may be detected, especially 
 in cases where there is systolic retraction of the chest 
 wall. When dilatation exceeds hypertrophy, the apex 
 beat is diffused and lacks force. Diastolic thrill may be 
 felt over the base of the heart or diffused over the entire 
 
332 
 
 THE CIRCULATORY SYSTEM. 
 
 prsecordia. The pulse of aortic regurgitation is the most 
 diagnostic of all the valvular diseases, and is also impor- 
 tant in estimating the degree of the lesion. The char- 
 acteristic feature of the pulse depends on the sudden 
 emptying and collapse of the artery during diastole, 
 followed by an equally sudden overfilling during systole, 
 so that the highest and lowest points of tension follow 
 
 Fig. 66. 
 
 Double iioi'tic murmur and mitral regurgitation. Second stage. Dotted lines 
 show fluoroscopic outline of the heart. 
 
 each other very rapidly. The sphygmographic tracings 
 (Fig. 42) show this. The passage of the pulse wave 
 xmder the finger causes a sensation as of a series of hard 
 particles passing, and the pulse is described as shotty or 
 water-hammer (Corrigan's pulse). Elevating the arm 
 intensifies this characteristic by favoring, through 
 gravity, the emptying of the artery during diastole. 
 
DISEASES OP THE HEART. 333 
 
 The pulse is regular as long as liypertropliy compen- 
 sates for the regurgitation. When it becomes unequal 
 to this task, irregularity, both in rhythm and force, 
 occurs. When the regurgitant stream is small, the 
 water-hammer character of the pulse is not marked. It 
 becomes progressively more prominent with increase in 
 dilatation of the left ventricle, and it is also exaggerated 
 when regurgitation is associated with aniemia or any 
 condition favoring low resistance in the arteries and 
 capillaries. Obstruction at the aortic orifice by inter- 
 fering with the sudden emptying of the ventricle causes 
 the pulse to be smaller and longer. 
 
 Second Stage. — ^With regurgitation at the mitral valve 
 and hypertrophy of the right ventricle, the apex of the 
 left ventricle is displaced from the chest wall. The 
 impulse is carried downward, and also toward the 
 median line, and may be felt in the epigastrium. 
 
 When regurgitation at the mitral valve takes place, 
 the pulse becomes smaller ; with the iliird stage failure 
 of compensation, feeble and irregular. 
 
 Third Stage. — Failure of compensation and dilata- 
 tion of the right ventricle cause a feeble, wavy, diffused 
 impulse, which is also irregular in force and rhythm. 
 
 PEECtrssiON-. — The increase in the area of percussion 
 dullness corresponds to the changes in the size and shape 
 of the heart. First Stage. — ^When dilatation is slight 
 and hypertrophy well marked, the area of dullness over 
 the apex is sharply triangular, and extends downward 
 and outward. Increase in dilatation causes the apex 
 area to become rounded and extend further toward the 
 left. There is no change along the left border of the 
 sternum imtil, second stage, right ventricular hyper- 
 trophy occurs. Third Stage. — Dilatation of the right 
 ventricle may cause dullness to be detected to the right 
 of the sternum. Dilatation of the aorta may cause 
 increased dullness at the level of the second interspace 
 to the right of the sternum. 
 
 Auscultation. — The murmur distinctive of regurgi- 
 
334 THE CIBCULATORY SYSTEM. 
 
 tation at the aortic orifice is diastolic, with the point of 
 maximum intensity over the sternum or at the left edge 
 opposite the third interspace and fourth costal cartilage, 
 transmitted down the sternum to the ensiform cartilage, 
 and at times to the apex. It is also heard over the aorta 
 and arteries. (Fig- 54.) 
 
 The murmur varies in quality and loudness, point of 
 maximum intensity, area of diffusion, and duration, 
 according to the character and extent of the lesion at the 
 aortic orifice and the secondary changes in the aorta and 
 heart. 
 
 The quality and loudness of the miirmur are 
 dependent upon the natiire of the opening through which 
 the blood regurgitates (whether large or small, rough or 
 smooth), and the force of the blood current determined 
 by the blood pressure in the aorta. 
 
 First Stage. — The murmur may be soft, blowing in 
 character, and scarcely audible. When the regurgitant 
 stream is forced through a narrow, rough opening with 
 great force, the murmur is harsh, grating, sawing and 
 audible at times some distance from the patient, ^^''hen 
 the opening is large, the murmiir is more gushing, and 
 rapidly diminishes in loudness. When a murmur that 
 has been loud becomes weaker and shorter, it indicates 
 low pressure in the aorta, due to failure of cardiac 
 power or decrease of resistance in capillaries. 
 
 The duration of the murmur and its relation to the 
 normal cardiac sounds are important data in determin- 
 ing the nature and extent of the lesion. The longer the 
 murmur persists during diastole, retaining the san\e 
 degree of loudness, the smaller is the amoimt of blood 
 that regurgitates through the valves and the slighter the 
 effect on blood pressure in the aorta. Murmurs whicli 
 are heard for a short time only during the early portion 
 of diastole, and rajndly diminish in loudness, indicate 
 free regurgitation. 
 
 The murmur may accompany, follow or take the place 
 of the aortic second sound, according to the condition of 
 
DISEASES OF THE HEART. 335 
 
 the valves. When the incompetency is dvie to vegeta- 
 tions or deformities limited to one cusp, or when all 
 the cusps are involved, but their elasticity is not 
 destroyed, the aortic second sound may persist, and the 
 murmiir will accompany or follow it. In such cases the 
 regurgitation is generally small, although free regurgi- 
 tation may occur with persistence of the second sound. 
 
 When incompetency of the cusps is secondary to 
 arterial disease or dilatation of the aorta, an accentuated 
 aortic second sound may persist with the murmur. 
 When the second sound is 'absent or the murmur replaces 
 it, regurgitation is usually free, and not associated with 
 stenosis. 
 
 The point of maximum intensity and the area of dif- 
 fusion vary greatly. The murmur may be heard 
 lou.dest in the aortic area, over the sternum, opposite the 
 third interspace, at the ensiform cartilage, and at the 
 apex, or it may be almost equally intense over the 
 entire prascordia. 
 
 The point of maximum intensity is at the aortic area, 
 and associated with persistence of the aortic second 
 sound when regurgitation is secondary to thickening or 
 atheroma of the aorta. 
 
 Free regurgitation, with very little diastolic tension 
 of the aortic cusps, causes the murmur to be heard 
 loudest over the right ventricle at the ensiform cartilage 
 (conduction through the ventricular septum) and at the 
 apex (conduction by the regurgitant stream). 
 
 Frequently the quality of the diastolic murmur heard 
 at the apex differs from that over the sternum. The dif- 
 ference is due to the routes by which the vibrations made 
 at the valve reach the surface ; over the apex by the 
 regurgitant stream giving a soft, blowing sound; over 
 the sternum by the dense tissue giving a harsher, 
 higher-pitched sound. (Fig. 55.) 
 
 Over the carotids and distal arteries, diastolic mur- 
 mur is detected in proportion to the freedom of regurgi- 
 tation. (Duroziez.) 
 
336 THE CmCULA TOE Y SYSTEM. 
 
 A diastolic imirmiir is heard in addition to the nor- 
 mal systolic murmur (pressure murmur) when the 
 stethoscope is firmly pressed on the artery. It never 
 occurs except in free aortic regurgitation, and is 
 dependent upon a strong reflux current toward the 
 heart. In slight regurgitation it is absent. 
 
 In addition to the diastolic murmur, a systolic mur- 
 mur is usually heard in the aortic area and over the 
 arteries in well-marked cases of aortic regurgitation. 
 The systolic murmur may be due to true obstruction 
 or to dilatation of the aorta (relative obstruction), which 
 occurs in a greater or less degree in aortic regurgitation. 
 
 When true obstruction and regurgitation are com- 
 bined at the aortic orifice, the systolic murmur is harsh, 
 and carried into the vessels of the neck with diminished 
 intensity; but, in proportion to the obstruction, the 
 carotid pulsations are less marked, and the pulse does 
 not have the jerking, water-hammer character. 
 
 When the systolic murmur is due to dilatation of the 
 aorta, without diminution in the size of the aortic 
 orifice, it is soft, blowing at the base of the heart, and 
 holds its intensity over the vessels, or may become 
 louder; it is attended with marked pulsation in the 
 carotids and the characteristic palse. The diastolic 
 murmur is relatively more intense than the systolic, and 
 is especially intense over the carotids and distal arteries. 
 The first sound of the heart is booming, and the pul- 
 monic second sound is not accentuated. 
 
 Second Stage. — When incompetency occtirs suddenly 
 at the mitral valve, due to muscular weakness, the 
 diastolic murmur at the base becomes less intense ; the 
 systolic murmur at the base becomes softer, and is not 
 transmitted so far into the vessels of the neck. Over 
 the apex another systolic murmur is heard, due to mitral 
 regurgitation. It has all of the characteristics of that 
 condition, and is associated with accentuation of the 
 pulmonic second sound. After mitral regurgitation has 
 occurred, with terajwrary relief of the left ventricle 
 
DISEASES OF THE HEART. 337 
 
 recompensation may occur, with persistence of the mitral 
 murmur. Increased power of the heart is shown by the 
 returning harshness and loudness of both diastolic and 
 systolic murmurs over the base of the heart. 
 
 _ Third Stage. — ^With failure of compensation by the 
 right ventricle, the murmurs become indistinct or 
 absent; there is a diminution of the pulmonic second 
 sound, and the tricuspid regurgitant murmur and the 
 physical signs of pulmonary congestion and cedema, 
 already noted, supervene. 
 
 OBSTRUCTION AT THE PULMONARY ORIFICE OR IN 
 THE PULMONARY ARTERY. 
 
 Obstruction of the pulmonary orifice occurring after 
 birth, is one of the rarest of lesions, although as a 
 congenital condition it is relatively frequent in propor- 
 tion to the other cardiac defects, and is often associated 
 with patent foramen ovale or other malformations of 
 the heart. Although true obstruction is a most imcom- 
 mon lesion, the diagnosis of obstruction at the pul- 
 monary orifice is freqiiently made, as a number of 
 conditions cause over the pulmonary valve area a systolic 
 murmur whose points of maximum intensity and areas 
 of diffusion are identical with those of stenosis. 
 
 True obstruction at the pulmonary orifice may be 
 due to changes in the cusps, as the presence of vegeta- 
 tions, thicikening and adhesion of their borders, that 
 produce a funnel-shaped opening; or the fibrous ring 
 may be contracted. 
 
 The pulmonary artery may be narrowed just beyond 
 the orifice by endarteritis. Pressure along the course 
 of the pulmonary artery by pleuritic adhesions and 
 mediastinal tumors (aneurisms, enlarged glands, malig- 
 nant growths, etc. ) may cause all the effects of obstruc- 
 tion at pulmonary orifice. 
 
 TvTon-obstructive conditions causing a murmur over 
 22 
 
338 
 
 THE CIRCULATORY SYSTEM. 
 
 the pulmonic area are (1) aiifemic conditions, especially 
 chlorosis; (2) neuro-cardiac diseases, as Grave's dis- 
 ease and allied disorders; (3) altered relation of the 
 heart to the chest wall, due to displacement and uncover- 
 ing of the heart by retraction of the overlying lung, 
 pleuritic changes, etc. 
 
 Effect of Obstruction at the Pulmonary Orifice. — Inter- 
 ference with the flow of blood causes the right ventricle 
 
 Fig. 67. 
 
 Pulmonary stenosis, tricuspid, regurgitation, pulsating- liver. 
 
 to become hypertrophied. If the obstruction is slio-ht 
 no further effect may be produced. If the endocardial 
 pressure is much increased during systole, regurgitation 
 at the tricuspid valve occurs, causing both dilatation and 
 
DISEASES OF THE HEART. 339 
 
 hypertrophy of the right ventricle, interference with the 
 general venous return and passive congestion of the 
 abdominal organs, with oedema and effusion into the 
 serous cavities. Clubbing of the fingers and toes, with 
 enlargement and arching of the nails, occur in long- 
 continued interference with return circulation. 
 
 Physical Signs. Inspection. — Cyanosis is almost 
 always present. If the obstruction is congenital, it is 
 most marked (blue baby). When the obstruction occurs 
 in early childhood or later in life, cyanosis may only be 
 noticed on exertion. Over the prsecordia no change may 
 be present unless there is dilatation and hypertrophy of 
 the right ventricle, when the apex beat is carried down- 
 ward, and is also seen in the epigastrium. With 
 secondary tricuspid regurgitation, distension of the veins 
 of the neck, and later pulsation in them, may be 
 detected. The respiratory movements are increased, 
 dyspnoea occurring on slight exertion. 
 
 Palpation. — Over the base of the heart there is felt 
 a distinct systolic thrill, with the point of maximum 
 intensity at the left edge of the sternum opposite the 
 second and third interspaces, which may be diffused 
 over a wider area. The apex beat is most marked over 
 the site of the right ventricle. The pulse is not affected 
 until failure of the right heart, with tricuspid insuffi- 
 ciency. 
 
 Peecussion. — The area of cardiac flatness is slightly 
 enlarged. When the dilatation of the right heart is 
 marked, it may be detected to the right of the sternum. 
 
 Auscultation. — The diagnostic sign is a harsh, 
 superficial, systolic murmur, with the point of maxi- 
 mum intensity at the junction of the second rib with the 
 sternum. It may be widely diffused over the upper 
 portion of the chest, but is nevei- heard in the great ves- 
 sels of the neck. The second pulmonic sound is indis- 
 tinct, or may be absent. The duration of the murmur 
 is long, beginning sharply with systole and continuing 
 almost to the second sound. The murmur is changed 
 
840 THE CIRCULATORY SYSTEM. 
 
 but slightly by the posture of the patient. Holding the 
 breath causes it to become momentarily more intense, 
 and then weaker. Forced inspiration intensifies it ; 
 forced expiration weakens or annihilates it. (Fig. 58.) 
 
 Non-Obstructive Murmurs in the Pulmonic Area. — These 
 have the same time (systolic) and point of maximum 
 intensity as the obstruction. 
 
 The anwmic murmurs are soft and blowing ; they are 
 rarely musical or harsh. They are markedly influenced 
 by position, being weaker in the upright and louder in 
 the recumbent postures. They are infliienced in the 
 same manner as are the structural murmurs by respira- 
 tion. They are associated with arterial murmurs in the 
 carotids and subclavians, or with a venous hum. The 
 patient is pale. On exertion a ruddy color may occur, 
 but no cyanosis. There is no change in the size of the 
 right heart, and they are not accompanied by thrill. 
 Frequently in women (for the first three days) after 
 child birth a murmur may be heard over the pulmonic 
 area. It is apt to have a scratching, crepitant-like 
 quality. (Figs. 59-60.) 
 
 In the neuro-cardiac diseases the characteristics of 
 the murmur are the same as those due to the anaemic. 
 The cardiac action is increased, and there is marked 
 pulsation in the vessels of the neck. 
 
 Altered Relation of the Heart to the Chest Wall— 
 Displacement of the heart by effusion into the pleural 
 cavity frequently causes a murmu.r to be heard over the 
 pulmonic area, which disappears on withdrawal of all 
 or part of the fluid. Uncovering of the pulmonary 
 artery by retraction of the lung also disturbs its relation, 
 and causes a soft, blowing murmur to be present. 
 These two conditions are associated with change in the 
 pulmonary signs. Pleuritic adhesion, and retraction of 
 the lung due to pleuritic or pulmonary changes, may 
 cause slight narrowing of the pulmonary artery, as well 
 as displacement. The murmur will be associated with 
 depression of the thorax, with change in vocal fremitus, 
 
DISEASES OF THE HEART. 34-1 
 
 increased area of dullness opposite the fourth rib and 
 signs of pulmonary and pleural changes. 
 
 Differential Diagnosis. Systolic Mwmurs. — Aortic sys- 
 tolic murmurs usually have the point of maximiim 
 intensity to the right of the sternum, or may be localized 
 in the pulmonary space. They are heard in the vessels 
 of the neck. In aortic obstruction the pulse is small, 
 and the cardiac change is limited during the earlier 
 stages to hypertrophy of the left ventricle. 
 
 Aneurismal Murmurs. — Aneurism may produce a 
 systolic murmur and thrill in the pulmonic area, but it 
 will be attended with pulsations and increased dullness 
 over the upper part of the sternum and pressure 
 symptoms. 
 
 Patent Ductus Arteriosus. — The particular feature 
 of the murmur of patent ductus arteriosus is its point of 
 maximum intensity, which is further to the left of the 
 sternum, and also it continues beyond the second sound. 
 It is frequently associated with pulmonic obstruction as 
 a congenital condition. 
 
 REGURQITATION AT THE PULMONIC ORIFICE. 
 
 Pulmonic regurgitation due to structural changes at 
 the orifice is an extremely rare condition. When present, 
 it is either congenial and associated with pulmonic 
 obstruction; or, if acquired after birth, is due to 
 ulcerative endocarditis or secondary to dilatation of the 
 pulmonary artery. In the acquired form the cusps of 
 the artery show pathological conditions analogous to 
 those described under aortic regurgitation. 
 
 Functional or physiological incompetency of the pul- 
 monary valves may occur as a result of dilatation of the 
 pulmonary artery, due to high blood pressure secondary 
 to mitral disease, or changes in the lung interfering with 
 the pulmonary circulation, as emphysema, fibrosis, etc. 
 Physiological incompetency may take place under exces- 
 sive functional activity of the respiratory organs, as in 
 
342 THE CIECULATOBY SYSTEM. 
 
 contests of speed, endurance, etc. When it occurs under 
 these conditions, it protects the integrity of the pul- 
 monary circulation. The physical signs of this type of 
 regurgitation are slight, and usually masked by the 
 rapidity of the cardiac action and exaggerated breath 
 sounds. 
 
 The Effect of Regurgitation at the Pulmonic Orifice.— 
 The effect is to cause primary dilatation, with coinci- 
 dent hypertrophy of the right ventricle, and later tri- 
 cuspid regurgitation, with its accompanying phenomena. 
 
 Physical Signs. Inspection. — The apex beat is car- 
 ried to the left. Pulsations may be seen in the epigas- 
 trium and in extreme dilatation of the heart to the right 
 of the sternum. Distension of and pulsations in the 
 veins of the neck occur with tricuspid regurgitation. 
 
 Palpation. — The apex beat is diffuse, and most 
 marked over the right ventricle and close to the sternum 
 and in the epigastrium. Over the base of the heart a 
 diastolic thrill may be felt. Cardiac dullness is 
 increased, and may be detected beyond the right edge 
 of the sternum over the site of the pulsation. 
 
 Auscultation. — A diastolic murmur is heard with 
 the point of maximum intensitv in the second left inter- 
 costal space, with the area of diffusion downward along 
 the sternum and to the apex of the right ventricle. The 
 murmur may be harsh, rasping and superficial, espe- 
 cially when associated with pulmonary obstruction, or 
 soft and blowing when due to dilatation of the pul- 
 monary artery. (Fig. 61.) 
 
 Differential Diagnosis. — ^Pulmonic regurgitation is 
 easily distinguished from aortic regurgitation when the 
 two murmurs have their usual point of maximum inten- 
 sity and area of diffusion. However, they may coincide 
 in these respects. In pulmonic regurgitation the signs 
 of hypertrophy and dilatation are limited to the right 
 side of the heart; in aortic regurgitation the left ven- 
 tricle is chiefly involved. In pulmonic regurgitation 
 dyspnoea and cyanosis, with clubbing of the fingers are 
 
DISEASES OF THE HEART. 343 
 
 marked, also p^ilsations are noted in the veins. In 
 aortic regurgitation the pulsations in the carotids and 
 character of the piilse are distinctive. In pulmonic 
 regurgitation a murmur is not heard in the vessels of 
 the neck; in aortic regurgitation a double murmur is 
 heard in the vessels of the neck and over the arteries. 
 
 OBSTRUCTION AT THE TRICUSPID ORIFICE. 
 
 Obstruction at the tricuspid orifice is one of the 
 rarest cardiac lesions. Most of the cases are not recog- 
 nized during life. Of the recorded cases, nearly 80 per 
 cent, occurred in women. 
 
 The obstruction is usually duo to adhesions of the free 
 margins of the leaflets, converting the valve into a 
 funnel-shajied structure, or reducing the opening to a 
 mere slit. 
 
 Effect of Tricuspid Obstruction. — The effect varies 
 according to the degree of obstniction, and may be 
 limited to the right auricle or extend beyond to the 
 venous circulation. When the stenosis is slight, hyper- 
 trophy of the right auricle is frequently sufficient 
 to overcome the obstruction to the flow of blood through 
 the orifice. When the power of the auricle is insufli- 
 •cient, interference with the return circulation occurs, 
 causing congestion of the abdominal organs and effusion 
 into the serous cavities. 
 
 Physical Signs.— The physical signs present in tri- 
 cuspid obstruction vary greatly. In some of the 
 reported cases they were well marked, and in others 
 indistinct. As in mitral obstruction, the murmur may 
 be present ^t one time and absent at another. 
 
 Inspection. — ^When the obstruction is slight and is 
 compensated for by the right auricle, no change is noted. 
 Interference with venous circulation is shown by dis- 
 tension of the superficial veins, especially of the neck. 
 When pulsations occur, they are synchronous with the 
 
344 THE CIBCULATOBY SYSTEM. 
 
 aiiricukr systole. There is also some duskiness of the 
 skin and oedema. Effusion into the pleural cavity may 
 cause change in the position of the apex beat. 
 
 Palpation. — At times a thrill is felt. Its maximum 
 intensity may be over the valve along the left border of 
 the sternum, or at the apex of the right ventricle in the 
 fifth interspace. It may occur in both locations at the 
 same time vs^ith nearly equal intensity, or its maximum 
 intensity may alternate, being first in one place, then in 
 another. The radial pulse shows no change, except in 
 marked obstruction, when it is rapid, irregular, small 
 and compressible. Cardiac impulse may be normal or 
 in marked obstruction, feeble and irregular. 
 
 Percussion. — Very little change is produced, except 
 that dilatation of the right auricle may increase the 
 transverse area of percussion flatness at the level of the 
 fourth rib. 
 
 Auscultation. — The diagnostic sign of tricuspid 
 obstruction is a pre-systolic murmur, with the point of 
 maximum intensity over the lower portion of the 
 sternum at the upper edge of the ensiform cartilage. 
 Its area of diffusion corresponds to the area of super- 
 ficial cardiac dullness. The murmur may occupy the 
 entire diastole, with accentuation just before the systolic 
 impulse. (Fig. 56.) 
 
 Differential Diagnosis. — The distinctive features of tri- 
 cuspid obstruction are absence of ventricular hyper- 
 trophy, marked venous turgescence, the presence of a 
 thrill and a pre-systolic murmur limited to the area 
 occupied by the right ventricle. On account of its 
 frequent occurrence with mitral obstruction, it is 
 masked by the signs of that lesion. 
 
 Miteal Obsteuction. — Mitral obstructign has also 
 a pre-systolic murmur, and inspection shows right ven- 
 tricular hypertrophy, and, when venous overfilling is 
 present, also hypertrophy and dilatation of the right 
 ventricle. 
 
 The thrill is more vibratory in quality, and is located 
 
DISEASES OF THE HEABT. 345 
 
 at the apex, but its termination by ventricular systole is 
 more definite. The murmur, although it may be heard 
 diiring the major part of the diastole, has a pre-systolic 
 accentuation more marked, and the mvirmur terminatea 
 with the short, intensified first sound. The maxim^im 
 intensity is at the apex, but it is not diffused widely, 
 and is never heard along the left border of the sterniun 
 or over the ensiform cartilage (tricuspid area). 
 
 The pulmonic second sound is accentuated in mitral 
 obstruction, and indistinct in tricuspid obstruction. 
 
 REGURaiTATION AT THE TRICUSPID ORIFICE. 
 
 Kegurgitation at the tricuspid orifice occurs under 
 two separate conditions. (1) It may be due (a) to 
 vegetations on the leaflets, preventing perfect coaptation, 
 
 (b) to thickening, shrinkage or deformity of the leaflets, 
 
 (c) to induration and shortening of the chordre tendinesB 
 and papillary muscles. These structural changes are 
 usually due to endocarditis and pericarditis which are 
 likely to involve other valves besides, and are relatively 
 rare at the tricuspid valve alone. 
 
 (2) Incompetency at the tricuspid orifice is most 
 frequently dependent on dilatation of the- right ven- 
 tricular cavity and the auriculo-ventricular ring, which 
 becomes too large to be closed by the valves. _ Kelative 
 valvular insufiiciency occurs much more readily at the 
 tricuspid valve than at the mitral. There is abundant 
 proof that there exists a safety valve action at the tri- 
 cuspid orifice, and that slight temporary regurgitation 
 occurs whenever the pressure in the pu.lmonary artery 
 reaches a certain height. Under normal conditions, 
 the functional or physiological regurgitation that occurs 
 under extreme exercise or exertion is temporary, dis- 
 appearing with the return of the blood pressure to 
 normal. When tricuspid incompetency frona dilatation 
 of the right ventricle is secondary to persistent high 
 
346 THE CIBCVLA TOB Y SYSTEM. 
 
 pressure in the pulmonary artery or obstruction at the 
 puhnonary orifice, it is permanent, and represents 
 another broken link in the chain of cardiac compensa- 
 tion. 
 
 The cause of high blood pressure in the pulmonary 
 artery may be obstructive disease in the lungs (emphy- 
 sema and fibroid changes) or lesion at the mitral orifice, 
 either primary or secondary (see Mitral Kegurgitation 
 and Obstruction). When the relative insufficiency is 
 due to transient increase of pressure in the pulmonary 
 artery (as in acute bronchitis, overexertion, etc.), or to 
 temporary disturbance of cardiac nutrition (pyrexia, 
 toxines, anaemia, etc.), the dilatation may become less 
 and the valves again become competent to close the 
 orifice with the disappearance of the disturbing factors. 
 
 Effect of Tricuspid Regurgitation. — The immediate effect 
 is upon the right auricle, which may become dilated to 
 an enormous extent. The secondary hypertrophy is 
 never very miarked, and is always inadequate to com- 
 pensate for the lesion. The great veins become dilated, 
 the inferior vena cava more so than the superior. The 
 valves protecting the veins at the root of the neck 
 become incompetent. Venous stasis causes general 
 oedema. One of the earliest effects of tricuspid regurgi- 
 tation is enlargement of the liver and the occurrence 
 of ascites and hydrothorax. 
 
 Physical Signs. Inspection. — As an isolated lesion, 
 the apex beat is displaced inward toward the median 
 line, and may be beneath the sternum or in the epigas- 
 trium. Impulses due to auricular systole may be seen 
 in the third and fourth interspaces to the right of the 
 sternum. When secondary to left-side cardiac disease, 
 the apex is displaced downward and outward, and also is 
 seen in the epigastric region. When secondary to 
 emphysema, distension of the lung causes the epigastric 
 pulsation to be specially prominent. Cyanosis is 
 usually present. In long-continued interference with 
 return circulation clubbing of the fingers occurs. 
 
DISEASES OF THE HEART. 347 
 
 Systolic venous pulsations are jDresent in the jugulars, 
 most markedon the right side. In marked cases pulsa- 
 tion of the liver may be seen. The respiratory move- 
 ments are increased unless hydrothorax occurs, when 
 there vs^ill be loss of motion over the lower portion of 
 the thorax. 
 
 Palpation. — Cardiac enlargement corresponds to 
 that noted by inspection. When tricuspid regurgitation 
 is a primary disease, the epigastric pulsations are weak 
 and undulatory. When secondary to cardiac or pul- 
 monary changes, the pulsations are more forcible and 
 heaving. When the ear is placed over the tricuspid 
 area, a characteristic wavy impulse is detected in addi- 
 tion to the murmur. Hepatic pulsations are one of the 
 diagnostic signs, and must be differentiated from 
 impulse transmitted to the liver from the aorta or the 
 enlarged right ventricle. Pressure on the liver in tri- 
 cuspid regurgitation increases jugular pulsations. 
 
 Percussion. — The cardiac area is enlarged to the 
 right. Dullness may be detected beyond the right bor- 
 der of the sternum at the kn-el of the fourth rib. 
 
 Auscultation. — The murmur of tricuspid regurgi- 
 tation is systolic, soft, blowing, with the point of maxi- 
 mum intensity along the sternum at the junction of the 
 fifth and sixth costal cartilages. The area of diffusion 
 corresponds to the extent of the pra^cordia. It does not 
 extend above the third rib nor beyond the apex. The 
 intensity of the murmur is increased during expiration, 
 and is diminished or absent during inspiration. The 
 second sound varies. When tricuspid regurgitation is 
 primary, it is weak and indistinct. When secondary to 
 increased pressure in the pulmonary artery, the second 
 sound is accentuated. (Fig. 57.) 
 
 Differential Diagnosis. — The distinctive features of tri- 
 cuspid regurgitation are extension of the cardiac area to 
 the right, systolic pulsations in the veins and liver, and a 
 soft, blowing, systolic murmur, with the point of maxi- 
 mum intensity over the site of the tricuspid valve and 
 
348 THE CIEOULATOBY SYSTEM. 
 
 heard over the prsecordia. It is to be differentiated 
 from other lesions characterized by a systolic murnmr. 
 
 Mitral Regurgitation. — In mitral regurgitation the 
 murmur is heard with the point of the maximum 
 intensity at the apex, and it is carried beyond the 
 prsecordia to the left into the axilla, and that it is heard 
 behind. The thrill is vibratory and distinctly pre- 
 systolic. The apex is displaced to the left and down- 
 ward. 
 
 Aortic Stenosis. — The systolic murmur is heard above 
 the third rib, and is carried up into the vessels of the 
 neck. It is also associated with characteristic pulse. 
 
 Pulmonic Obstruction. — In pulmonic obstruction the 
 point of maximum intensity and the area of diffusion 
 are diagnostic. (Fig. 58.) 
 
 DISEASES OF THE MYOCARDIUM. 
 
 Hypertrophy and Dilatation. 
 
 Hypertrophy of the cardiac muscle may occur in two 
 forms ^ — (1) simple hypertrophy, (2) hypertrophy with 
 dilatation of the cavity, or eccentric hypertrophy. It 
 may be limited to the walls of a single cavity, or may 
 be general. Cardiac dilatation is also divided into two 
 forms^ — (1) simple dilatation, in which there is increase 
 in the size of the cavity, with thinning of the wall ; (2) 
 dilatation with hypertrophy, in which, with enlarged 
 size of the cavity, there is increase in the relative thick- 
 ness of the heart wall. In both eccentric hypertrophy, 
 and dilatation with hypertrophy we have increase in the 
 size of the cavity, with increase in thickness of the heart 
 muscle. The distinction between these two conditions 
 depends upon the relative efHeiency of the cardiac mus- 
 
 ' Concentric hypertrophy characterized by increase in thiclcness in the 
 walls of the cavity with diminution of its size is rarely recognized during life. 
 
 " Atrophic dilatation has been described dependent on wasting of the 
 cardiac muscle coincident with increase in size of the cavity. 
 
DISEASES OF THE HEART. 349 
 
 cular power to the dilatation. When the working power 
 of the heart is increased beyond what is needed to over- 
 come the cause and effect of the dilatation, it is classified 
 as eccentric hypertrophy. When, on the other hand, dila- 
 tation is predominant, and the increased muscular tissue 
 barely compensates for the dilatation, it is classified as 
 dilatation with hypertrophy. 
 
 Physical Signs. — Cardiac dilatation and hypertrophy 
 are generally secondary conditions. 
 
 The physical signs present in the different forms are 
 fully described. under "Inspection," "Palpation," "Per- 
 cussion"^ and "Auscultation," also under the diagnosis 
 of the different valvular diseases. 
 
 Acute Myocarditis. 
 
 This may exist in two forms, (1) as an acute 
 degeneration of the muscle tissue of the heart dependent 
 apon infectious fevers (cloudy swelling, parenchyma- 
 tous myocarditis) ; (2) as an infiammatory affection of 
 the interstitial tissue of the heart, which may also be 
 due to infectious diseases, or may be secondary to acute 
 inflammations of the pericardium or endocardium. 
 
 Localized or suppurative myocarditis may result from 
 infection from micro-organisms, secondary to suppura- 
 tions in distant portions of the body or due to extension 
 from infectious endocarditis. 
 
 Physical Signs. — The physical signs present are those 
 indicative of defective muscular power, with varying 
 degrees of dilatation. The earliest change noted is fee- 
 bleness of the cardiac impulse, both to inspection and 
 palpation. Auscultation shows gradual diminution in 
 the muscular element of the first sound, with accentua- 
 iiion of the aortic and pulmonic second sounds. When 
 dilatation occurs, the murmurs of mitral and tricuspid 
 regurgitation may be present. 
 
350 THE CIRCULATORY SYSTEM. 
 
 Chronic Myocarditis. 
 
 Chronic changes in the myocardium may be due to 
 (1) fatty degeneration of the muscle tissue; (2) fibroid 
 degeneration (fibroid or interstitial myocarditis) ; (3) 
 fatty overgrowth (fatty infiltration or cor adiposum). 
 
 Physical Signs. — The physical signs in disease of the 
 myocardium are those of weak heart, "weak in muscle 
 power and weak in its resistance to blood pressure;" 
 signs of hypertrophy and dilatation are usually present 
 in varying degree, according to the cause of the condi- 
 tion. 
 
 Inspection. — The apex beat of the heart may be in 
 the normal position, or displaced; when the changes in 
 the myocardium are secondary to sclerosis or atheroma 
 in the blood-vessels, the apex beat will be displaced out- 
 ward and to the left in proportion to the hypertrophy 
 and dilatation. With insufiiciency of cardiac power, the 
 patient shows disturbances of the superficial circulation 
 and slight blueness of the extremities. Atheroma of the 
 blood-vessels is shown by prominence of the temporal 
 and other arteries. In fatty overgrowth there is asso- 
 ciated obesity. 
 
 Palpation. — The location of the impulse depends 
 upon the presence of hypertrophy and dilatation. In 
 fatty degeneration the impulse is feeble and diffused. 
 When associated with hypertrophy, especially of the 
 fibroid type, the impulse, while heaving, lacks the lifting 
 force proportionate to the size of the heart. The pulse is 
 weak in comparison to the seeming effort of the heart. 
 When cardiac power is insufficient, arrhythmia occurs, 
 which may be constant or induced by slight exertion. 
 
 Peecussion. — The dimensions of the heart are in- 
 creased with hypertrophy and dilatation in all direc- 
 tions. When dilatation is predominant, percussion 
 dullness extends above the third interspace and to the 
 nipple line or beyond it. In fatty overgrowth the per- 
 cussion area of the heart is increased. Frequently it is 
 
DISEASES OF THE HEART. 351 
 
 impossible to map out the heart on account of the thick- 
 ness of the superficial tissue. 
 
 AuscitltatiojST. — The characteristic sign is a short, 
 feeble first sound at the apex, with a relatively louder 
 second sound over the aorta. The pulmonic second 
 sound is not increased in intensity. Usxially there is 
 reduplication of the first sound. With the occurrence 
 of dilatation and valvular incompetency, soft, blowing 
 murmurs are heard in the mitral and tricuspid areas. 
 
 Diagnosis of myocarditis rests upon the above physi- 
 cal signs, associated with other evidence of insufficiency 
 of muscular power, as dyspncea, oppression in the chest, 
 or anginal pain on exertion and after meals, syncope 
 with cardiac irregularity. 
 
CHAPTER XIII. 
 
 DIAGNOSIS OF THE DISEASES OF THE PERICAEDIUM. 
 
 The smooth surfaces of tlie pericardium, lubricated 
 by the normal secretion of the serous membrane, glide 
 over each other during the cardiac and respiratory 
 movements without producing any vibrations which can 
 be detected by palpation or heard as a friction sound. 
 The amount of secretion contained in the pericardial 
 sac in health varies within very narrow limits, and is 
 never present, in such quantity as to be detected by 
 physical examination. Pericardial diseases produce 
 distinctive physical signs, according as the normally 
 smooth surfaces are altered so as to produce vibrations 
 which may be felt or heard, or the sac is distended by 
 fluid. 
 
 Pericarditis. 
 
 According to the nature of the changes in the peri- 
 cardial sac, three forms of pericarditis can be recognized 
 by physical signs, irrespective of their aetiology. The 
 morbid conditions of each form may exist separately or 
 may be combined in varying degrees, and due to widely 
 differing causes. As a number of non-inflammatory 
 conditions of the pericardium may produce changes 
 similar to those due to the inflammation, and as the 
 physical signs depend upon the altered state of the sac, 
 they will be described with the different forms of peri- 
 carditis. 
 
 (1) Dry, Plastic or Fibrinous Pericarditis. — In this form 
 the surfaces may be abnormally dry from diminished 
 
DISEASES OF THE PEBICAEDIUM. 353 
 
 secretion, dependent tipon loss of blood or fluid from the 
 body, or changes in the serous membrane during the 
 early stage of inflammation. Later during the inflam- 
 matory attack the surfaces may be covered with thick, 
 tenacious exudate (fibrinoxis or plastic). The surfaces 
 may also be roughened by fibrous, tubercular or malig- 
 nant growths. The physical signs will vary according 
 to the nature of the change. 
 
 (2) Effusion into the Pericardium, Pericarditis with Effusicn. 
 — The fluid poured into the sac may be sero-'fibrinous, 
 serous, purulent or hemorrhagic. Serous effusion, 
 small in amount, may coincide with a flbrinous exudate 
 which coagulates on the surfaces, while the more liquid 
 element gravitates to the bottom of the sac (sero-fibrin- 
 ous pericarditis). The liquid element (serum) of the 
 inflammatory exudate may be excessive and rapidly fill 
 the pericardial sac without the occurrence of the dry, 
 or plastic stage. Serous effusion into the pericardium 
 occurs as part of a general dropsy and interference with 
 the return circulation (hydro-pericardium), and is 
 unattended with any inflammatory changes. It usually 
 accompanies effusion into other serous sacs. 
 
 Purulent effusion may occur primarily, as in septic 
 disease, or be due to secondary changes in sero-fibrinous 
 or serous inflammatory pericarditis. Hemorrhagic 
 effusion (hsemo-pericardium) may be inflammatory or 
 be dependent upon new growths, blood condition 
 (scurvy, purpura), rupture of the heart or of a cardiac 
 aneurism. 
 
 The physical signs present in effusion are in propor- 
 tion to the amount of fluid and the effect of the enlarged 
 pericardium upon the heart and surrounding organs. 
 The nature of the fluid does not modify the physical 
 
 signs. 
 
 (3) Pericardial Adhesion. Adherent Pericardium. — This 
 is usually secondary to inflammatory diseases of the 
 pericardium. It may be limited to a few bands loosely 
 stretched between the two surfaces and not interfering 
 
 23 
 
354 THE CIBCULATOBY SYSTEM. 
 
 with the cardiac action ; or the two surfaces may be 
 closely united, or the sac may be completely obliterated, 
 in which case the movements of the heart will be entirely 
 or in part restricted and secondary hypertrophy or dila- 
 tation with hypertrophy will occur. 
 
 Physical Signs. — As the three forms of pericarditis 
 may be variously combined, or follow each other during 
 the course of an attack of pericarditis, they will be con- 
 sidered together. 
 
 Inspection. Dry, Plastic or Fibrinous Form. — 
 There is no change in the contour of the prsecordia. 
 The apex beat is in the normal position, the impulse 
 more forcible, due to cardiac irritability. When asso- 
 ciated with myocarditis, the impulse is weaker and more 
 diffused. 
 
 Second Form. Effusion into the Pericardium. — 
 Change in the prajcordia will be in proportion to the 
 quantity of fluid and the elasticity of the chest walls. 
 The effects on the shape and size of the thorax will be 
 most noticed in thin persons and in children, and may bo 
 masked in stout persons. The apex beat is seen at a 
 higher point on the chest wall, according to the amount 
 of fluid present. This is not due to elevation of the 
 anatomical apex, but to the changed relation of the 
 anterior portion of the heart to the chest Avail, so that a 
 point nearer the base of the heart strikes the chest wall 
 and gives the visible and palpable apex beat, (a) Small 
 effusions may produce no change in the prtecordia. The 
 apex beat is displaced inward and slightly elevated, (h) 
 In medium-sized effusions the intercostal spaces along 
 the left side of the sternum, from the tliird to the sixth, 
 are filled out, and may be slightly bulging. The thorax 
 over the a]iex is slightly enlarged, (c) In large effusions 
 the bulging over tlic praicordia is marked, and the lower 
 end of the sternum is pushed out ; the epigastric region 
 is more prominent, the costal cartilages and ribs are 
 elevated, and the intercostal spaces on both sides of the 
 sternum are wider, the normal depressions being absent. 
 
DISEASES OF THE PERICARDIUM. 355 
 
 The changes in the lower portion of the chest are due to 
 diminished negative pressure within the thorax and 
 depression of the diaphragm and liver by the weight of 
 the fluid. The visible impulse is usually seen above the 
 fourth rib. In extreme distension pericardial bulging 
 may extend as far as the second rib. 
 
 Enlargement of the pericardial sac causes reduction 
 of the negative pressure within the chest, and allows of 
 the elevation of the bony thorax and changed relation 
 between the ribs individually, and especially between 
 the first rib and the clavicle. Ewart has called atten- 
 tion to the changed relation between the clavicle and the 
 first rib (first rib sign) as important in diagnosis of 
 effusion of considerable amount. The left clavicle is 
 raised to a higher level, so that the upper edge of the 
 first rib on the left side can be felt as far as its sternal 
 attachment. When the amount of fluid is sufficient to 
 produce a positive pressure, instead of the normal nega- 
 tive pressure in the pericardium, cyanosis occurs, also 
 pulsations in the veins of the neck, due to auricular 
 contraction. 
 
 The effect of posture on the apex beat in effusion is 
 the opposite of what occurs in other conditions, causing 
 an elevation of the apex beat. When the patient is on 
 the right side, the apex beat becomes lower and more 
 distinct; in other conditions it is higher, weaker or 
 absent. 
 
 Adherent Pericardium. — Flattening of the chest over 
 the lower portion of the prsccordia usually occurs. 
 Occasionally there is bulging, due to hypertrophy and 
 dilatation of the heart. Systolic retraction of the chest 
 wall may be limited to the apex and the intercostal 
 spaces to the left of the sternum, or to the left half of the 
 epigastrium. The respiratory movements are altered 
 when extensive pericardial changes are present. With 
 inspiration there is loss of expansion over the lower 
 portion of the left chest below the horizontal nipple line, 
 and drawing in of the end of the sternum. Protrusion 
 
356 THE CIBCULATOBY SYSTEM. 
 
 of the abdomen, and frequently ascites, may occur. The 
 apex beat is displaced outward and downward or ele- 
 vated as high as the fourth rib, according asthe heart 
 is hypertrophied or dilated or fixed by adhesions m an 
 abnormal position. The apex beat does not vary with 
 change in the posture of the patient. The diastolic 
 rebound of the heart may be visible. Diastolic collapse 
 of the veins is occasionally seen. 
 
 Palpatioit. Dry, Plastic or Fibrinous Pericarditis. 
 — The cardiac impulse may be increased. Friction 
 fremitus is felt over different portions of the prsecordia 
 in a small proportion of cases ; it is most readily detected 
 by making moderate pressure in the intercostal spaces 
 with the finger tips. The rhythm of the fremitus 
 generally corresponds with the systole, but may extend 
 into the diastolic period or be confined to it. It does 
 not have a well-defined or stable point of maximum 
 intensity, but varies in different cases and in the same 
 case at different times, although it is more frequent and 
 persistent over the base of the heart. The area over 
 which it is felt is usually the circumscribed point of 
 maximum intensity; occasionally it is felt over the 
 entire prsecordia, and may be perceptible in widely 
 separated spots. The fremitus gives the sensation of 
 being superficial and produced by the rubbing together 
 of dry, rough or sticky surfaces. In acute cases the 
 friction fremitus is present for a short time only, and 
 varies from day to day in situation, extent and char- 
 acter. 
 
 Effusion into the Pericardium. — Friction freniitus, 
 usually absent over the lower portion of the praecordia, 
 may be detected above the fourth rib and over the site 
 of the great vessels. Cardiac impulse is felt at a higher 
 level, and is more diffused according to the amount of 
 diffusion. Fluctuation over the praecordia may be 
 present when the amount of fluid is sufficient to c^ive 
 positive pressure in the pericardium. Diminution in 
 the amount of fluid causes the cardiac impulse to be felt 
 
DISEASES OF THE PERICARDIUM. 357 
 
 at a lower point, and to become more defined. Eemoval 
 of the fluid is frequently attended with reappearance of 
 friction fremitus. 
 
 Adherent Pericardium. — In addition to the abnormal 
 movements of the chest wall noted in inspection, the 
 cardiac impulse frequently gives the sensation of being 
 abnormally close to the chest wall. According to the 
 situation and extent of the adhesions and the secondary 
 changes in the heart (hypertrophy or dilatation), the 
 impulse will be displaced to various portions of the 
 prsecordia, and will be strong, diffused or of a more 
 undulating character. When adhesions unite the heart 
 with the chest wall, diastolic shock is a marked symptom. 
 
 PEECtrssioN'. Dry, Plastic or Fibrinous Pericarditis. 
 — No change in the area of superficial flatness or rela- 
 tive dullness is detected unless myocarditis with dilata- 
 tion is present. The extreme edge of cardiac dullness 
 corresponds closely to the apex beat. 
 
 Effusion into the Pericardium. — The most distinctive 
 sign of pericardial effusion is change in the extent and 
 outline of the area, of cardiac flatness and dullness and 
 their relation to each other. These changes can be 
 detected by careful and systematic percussion when but 
 a small quantity of fluid is present. The area of flatness 
 increases, while that of relative dullness diminishes. 
 As the pericardium increases in size, change in the 
 interthoracic pressure (negative pressure) allows that 
 portion of the lungs which normally covers the peri- 
 cardium to retract, so that there is not the gradual 
 change from normal pulmonary resonance to cardiac 
 flatness. In extreme distension of the pericardium, the 
 change in the intrathoracic pressure may be suflicient to 
 cause diminution of function in different portions of the 
 lungs, with characteristic pulmonary resonance. A 
 small effusion causes change in the percussion area, 
 most marked at the level of the fifth rib. (a) To the 
 left the flatness extends to the site of the normal apex 
 beat or slightly beyond. The area of relative dullness 
 
358 THE CIRCULATORY SYSTEM. 
 
 in this region is decreased, (h) At the right of the 
 sternum dullness is detected in the fifth intercostal 
 space (cardio-hepatic triangle), and the cardio-hepatic 
 triangle becomes more obtuse (Rotch's sign). As the 
 fluid increases in amount, the area of flatness extends 
 in all directions, especially laterally, at the lower level 
 of the pericardium. With the increase in extent, the 
 contour of the pericardial flatness also changes, 
 becoming more pyramidal, with the two sides meeting 
 the base at nearly equal angles. More marked distension 
 causes the lower segment of the pericardium to be more 
 globular and the upper portion more cylindrical, so that 
 the typical pear-shaped outline obtains. Sternal reso- 
 nance is altered by the effusion. As the sac becomes 
 filled, the resonance becomes impaired, and is later 
 replaced by flatness. The change in loss of resonance 
 occurs from below tipward, in contradistinction to that 
 occurring in aneurism of the aorta. The percussion 
 note over the lung is changed according to the amount 
 of fluid present. As the fluid increases, the enlarged 
 pericardium allows retraction in the overlapping lung 
 and diminution of tension, so that the normal pul- 
 monary resonance is replaced by a tympanitic quality 
 (Skoda's resonance), which in large effusion may be 
 present over the apex of the lung on the left side. 
 
 "Whenever fluid is effused into the pericardium, 'the 
 normal resonance is modified at the left posterior base 
 in the most definite way. A patch of marked flatness is 
 found at the left inner base, extending from the spine 
 for a varying distance outward, usually not quite so far 
 as the scapular line, and ceasing abruptly with the 
 vertical boundary. Above, its extension is also variable, 
 according to the size of the effusion. Commonly it does 
 not extend higher than the level of the ninth or tenth 
 rib, and here, again, its horizontal boundary is abrupt. 
 Its shape is that of a square, and is quite unlike that of 
 any dullness arising from pleuritic effusion." (Ewart.) 
 
 Over the liver, the upper limit of both dullness and 
 
DISEASES OF THE PERICARDIUM. 359 
 
 flatness is lowered; the lower edge of the liver is below 
 the free border of the ribs in proportion to the depres- 
 sion o± the diaphragm. 
 
 Adherent Pericardium. —Chmges in thickness of the 
 pericardium do not afi'ect the percussion area. Any 
 alteration m size or shape is due to the presence of 
 hypertrophy or dilatation of the heart. 
 
 AusciTT.TATiON. Dry, Plastic or Fibrinous Perlcar- 
 dttis.~The diagnostic sign of this form is the friction 
 sound. The quality of the friction sound varies 
 according to the condition of the pericardial surfaces. 
 It may be soft and murmurish, simulating the endocar- 
 dial murmur; soft, dry, grazing or brushing, as when 
 the dry finger tips or pieces of silk are gently rubbed 
 together close to the ear; sticky; or harsh, creaking or 
 grating, as when new leather 'is bent. In addition to 
 the friction quality, the sensation of being superficial is 
 a distinctive feature. The rhythm of the friction 
 sound, while dependent upon cardiac movement, is not 
 accurately limited to the periods of the normal cardiac 
 sounds, but by extending beyond them it gives a double 
 or to-and-fro rhythm, which is characteristic of peri- 
 cardial friction. The point of maximum intensity is 
 not stable, and the sound is not conducted beyond tlie 
 prascordia except in rare cases, when the conduction is 
 due to change in the surrounding lung tissue. 
 
 The friction sound may be heard over any portion of 
 the prascordia, but its most persistent site is over the 
 base of the heart, opposite the third and fourth ribs on 
 the left side. The intensity of the sound is influenced 
 by (a) pressure, (b) position, and (c) respiratory move- 
 ments in a rather characteristic way. (a) Pressure 
 over the pra3cordia causes the friction sound to be heard, 
 or, when present, to become more intense and audible 
 over a wider area and for a longer period of time; it 
 also increases the to-and-fro character, and emphasizes 
 its want of synchronism with the normal cardiac sounds. 
 (h) Posture. Bending the body forward, so that the 
 
360 THE CIRCULATORY SYSTEM. 
 
 heart conies in contact witli the anterior portion of 
 the pericardium, affects the friction sound in the same 
 manner ■ as pressure. It intensifies the sound, and 
 increases the area over which it is heard, (c) Kespira- 
 tory movements. The intensity, quality and extent of 
 the friction sounds change during inspiration and 
 expiration. In some cases the increase in these feat- 
 ures occurs during inspiration, and at others during 
 expiration. The significant fact is that the sound is 
 altered to a marked degree during either inspiration or 
 expiration. Variability from day to day in the site, 
 rhythm, intensity and quality is a distinctive feature of 
 pericardial friction sounds. 
 
 Elusion into the Pericardium. — As fiuid accumu- 
 lates, there is disappearance of the friction sound, as 
 there was of friction fremitus, over the lower portion of 
 the pericardium except when separation of the anterior 
 surface of the heart from the pericardium is prevented 
 by adhesions. At the base, and especially where the 
 pericardium is reflected along the great vessels, the 
 friction sounds may persist during the entire course. 
 The cardiac sounds over the site of the normal apex are 
 weak or inaudible, and are more distinctly heard toward 
 the base of the heart over the sight of the visible 
 impulse. The pulmonic second sound may be increased. 
 
 The respiratory sounds are also modified. The 
 respiratory murmur and vocal fremitus along the nor- 
 mal site of the anterior border of the lung, especially on 
 the left, are feeble or absent. Bronchial breathing and 
 segophony may be heard in large effusions below the 
 right nipple and behind at the angle of the left scapula. 
 
 If the patient lies with face downward, or leans for- 
 ward on the knee and elbow, the dullness and bronchial 
 breathing in the back disappear. With absorption of 
 the fluid, the friction sound may return, and there will 
 be early disappearance of the respiratory signs. 
 
 Cardiac sounds are heard in the normal site and with 
 
DISEASES OF THE PEBIGAEDimr. 361 
 
 normal intensity Avhen myocardial changes have 
 occurred. 
 
 Adherent Pericardium. — The auscultatory signs are 
 not distinctive, and depend on the condition of the sur- 
 faces and the degree of change pi'oduced in the heart 
 and at the valvular orifices. A rough pericardial fric- 
 tion sound may be heard over different portions of the 
 prsecordia, especially the base. The cardiac sounds 
 may vary greatly. The first sound may have the 
 valvular quality accentuated or may be doubled; the 
 second sound may be reduplicated and accentuated. 
 Both sounds may be heard abnormally clear behind. 
 Endocardial murmurs, due to dilatation of the cavities 
 may be present. 
 
 Differential Diagnosis. — The distinctive features of 
 acute, dry, fibrinous pericarditis are friction fremitus 
 and friction sound of marked superficial, rubbing 
 quality, vs^ith no fixed point of maximum intensity. The 
 sound does not coincide with the areas of the normal 
 valve sounds nor vs^ith the areas of endocardial mur- 
 murs, and it is not transmitted bej^ond the prascordia. 
 Its rhythm is not accurately synchronous with the 
 periods of the cardiac sounds, but lias a double, to-and- 
 fro character. The intensity of the sound varies during 
 the respiratory movements, and is increased by pressure 
 over the prsecordia, and is loudest when the patient is 
 erect or bending forward. There is no evidence of 
 cardiac enlargement. 
 
 Acute Endocar-ditis and Chronic Valvular Disease. — 
 The thrill present in endocardial diseases is localized at 
 the apex (mitral obstruction) or at the base (aortic 
 stenosis or regurgitation). It has a definite relation to 
 the rhythm of the cardiac sounds, and does not give the 
 impression of being superficial. The endocardial mur- 
 murs have a definite area of maximum intensity and 
 area of diffusion. Murmurs made at certain valves are 
 heard beyond the prsecordia. The intensity of the 
 murmur is not altered by pressure. Systolic murmurs 
 
362 THE CmCULATOBY SYSTEM. 
 
 are loudest in the recumbent postiire and fainter in the 
 erect. In chronic valvular disease, hypertrophy and 
 dilatation of the heart are present. 
 
 Pleuritic Friction and Pleuro-pericardial Friction 
 Sounds. — Friction sounds made in the pleura by the 
 movement of the heart may simulate those of pericar- 
 ditis. They are distinguished by the effect of respira- 
 tion on the intensity and quality of I he sound. On deep 
 inspiration, the sound is intensified. When the patient 
 takes a full breath and holds it, the sound disappears. 
 
 Effusion into the Pericaedium. — The distinctive 
 features of effusion into the pericardium are that the 
 visible cardiac impulse is raised; the lower portion of 
 the prascordia is fuller than normal; the intercostal 
 spaces are wider and smoothed out, or even bulging, 
 according to the extent of the effusion, and pulsations 
 may be noted above the fourth rib. The percussion 
 area of cardiac flatness is increased, and extends to the 
 left beyond the normal site of the apex beat. To the 
 right there is at first dullness in the fifth interspace, 
 with gradual extension to the right of the sternum ; the 
 area of relative deep-seated cardiac dullness is dimin- 
 ished, with a sharp line of demarcation between pul- 
 monary resonance and cardiac flatness. The outline of 
 the cardiac flatness becomes more pyramidal or pear- 
 like. The sternal resonance is impaired from below 
 upward in proportion to the distension of the peri- 
 cardium. On auscultation, the cardiac sounds are 
 feeble or absent over the apex, but are heard more 
 clearly toward the base. Friction sounds over the base 
 of the heart may be sometimes detected. Over the lung, 
 the normal vocal fremitus and respiratory murmur are 
 absent over the normal position of the anterior border. 
 In extensive effusion areas of bronchial breathing are 
 found in the right intermammary region in front, and at 
 the angle of the left scapula behind. 
 
 Dilatation and Hypertrophy of the Heart. — The 
 visible, palpable apex beat is carried downward and to 
 
DISEASES OF THE PEBICABDIUM. 363 
 
 the left. Left ventricular hypertrophy causes forcible 
 apex beat; in right ventricular hypertrophy the apex 
 beat is diffused, and is seen and felt also in the epigas- 
 trium. When dilatation predominates, the impulse is 
 feeble and diffused, but felt at the lower portion of the 
 prascordia and in the epigastrium. 
 
 Dullness does not extend beyond the apex beat to the 
 left, nor flatness beyond the right of the sternum. The 
 normal sternal resonance is but slightly impaired. 
 There is relative greater increase in the area of dullness 
 over that of flatness. 
 
 The cardiac soimds are heard distinctly at the apex. 
 When hypertrophy and dilatation are due to valvular 
 lesions, the characteristic murmurs are present. 
 
 Effusion into the Left Pleura. — In this condition dis- 
 placement of the heart to the right gives elevation of the 
 impulse and dullness or flatness to the right of the 
 sternum. But the flatness on the left side extends 
 beyond the prtecordia, and has its highest point in the 
 axillary line, and is noted behind. Bronchial breath- 
 ing, when present, is above the level of the fluid, but not 
 at the angle of the scapula. 
 
 Adherent Pericardium. — The characteristic feat- 
 ures of adherent pericardium are flatness of the chest 
 over the lower portion of the prascordia, with systolic 
 retraction over the apex or other portions of the prseeor- 
 dia, according to the seat of adhesion, associated with 
 diastolic rebound, and at times diastolic collapse of the 
 veins. Rough, creaking pericardial friction sounds 
 may be present. 
 
 There are no pathognomonic signs of this condition, 
 and diagnosis rests on the relation of the physical signs 
 to each other. 
 
 Cardiac Hypertrophy and Dilatation. — Systolic 
 retraction over the apex may be present in massive 
 cardiac hypertrophy with adhesions between the peri- 
 cardial sacs. It is distinguished from adherent peri- 
 
364 THE CIRCULATORY SYSTEM. 
 
 carditis by the history of the case, and the presence of 
 valvular lesions causing the hypertrophy. 
 
 Pneumopericardium. 
 
 Gas in the pericardium may be due to the decomposi- 
 tion of the fluid contents or to perforation of the peri- 
 cardium, which may be traumatic or may be due to 
 ulceration from air-containing spaces. 
 
 Physical Signs. Inspegtiow. — Distension of the peri- 
 cardium causes bulging over the pra?cordia. The apex 
 beat is weak or absent, and is most marked when the 
 patient bends forward. 
 
 Palpation. — Emphysematous crepitations may be 
 present. Succussion splash may be felt with movement 
 of the heart when air and fluid are present. 
 
 Percussion. — The percussion sounds are most dis- 
 tinctive. Over the pericardium there is a tympanitic 
 percussion note, frequently with a ringing, metallic 
 quality. Cracked-pot resonance may be present on 
 forcible percussion when there is free opening. The 
 percussion note over the prsecordia varies with the 
 posture of the patient. In the recumbent posture the 
 entire prsecordia is resonant. When the patient stoops 
 forward, bringing the heart against the chest wall, a 
 small zone of dullness may be detected. When fluid and 
 air are in the pericardium, flatness may be present over 
 the lower portion of the pericardium and tympanitic 
 resonance above. The line of flatness changes with the 
 position of the patient. 
 
 Auscultation. — The character of the sounds vary 
 according to the presence of air alone or of air and fluid 
 in the pericardium. With air alone, or if there is but 
 little fluid, the heart sounds have a loud, ringing, metallic 
 quality. When the cardiac action produces movement 
 of the fluid, metallic splashing or churning (water 
 wheel) sounds are present. Endocardial murmurs 
 when present, are intensified by reverberation in the 
 pericardium. 
 
CHAPTEK XIV. 
 
 DIAGNOSIS OF DISEASES OF THE BLOOD-VESSELS. 
 
 ANEUEISM OF THE AORTA. 
 
 Dilatation of the aorta occurs in two forms: (1) 
 Fusiform or cylindrical. In this form, at the seat of 
 the dilatation, there is increase of the lumen of the 
 artery in all directions without the occurrence of pouch- 
 ing at any point, and unattended by the formation of 
 any tumor or by pressure symptoms, even when the other 
 physical signs of dilatation are very marked. To this 
 form belong those general dilatations of the aorta and 
 of the arteries given off from the arch, which may be due 
 to changes primarily in the blood-vessels (aortitis, 
 atheroma, etc.) or secondary to regurgitation at the 
 aortic orifice. This form persists for a long time in a 
 stationary condition, and beyond pulsation over the 
 course of the artery, and the thrill and the murmur due 
 to the enlarged lumen of the tube gives rise to no 
 secondary symptoms. 
 
 Acute dilatation of the blood-vessel frequently occurs 
 in inflammatory conditions of the aorta. It may dis- 
 appear under rest and treatment, or may remain as a 
 permanent dilatation. 
 
 (2) Sacciform or circumscribed form. This is due 
 to dilatation involving a part only of the circumference 
 of the wall of the artery, with the formation of a circum- 
 scribed tumor whose cavity is connected with the lumen 
 of the artery by an opening of varying size, but the 
 
366 
 
 THE cmCULATOBY SYSTEM. 
 
 diameter of the opening is smaller than that of the 
 aneurismal sac. 
 
 The aneurismal tumor, filled with coagulated or fluid 
 blood, produces physical signs and symptoms which are 
 in part due to the tumor itself and in part dependent 
 upon its pressure upon the bony thorax, the heart, 
 oesophagus, trachea, bronchi, lungs and mediastinal 
 structures. The signs and symptoms of aneurism vary 
 according to the size and situation of the tumor and the 
 direction of its pressure. 
 
 Table of Peessueb Signs in Aneueism. (Sanson.) 
 
 ( Local pain. 
 Pressure of the bony thorax causes -j Local oedema (pulsation). 
 
 (. Absorption of tissue. 
 
 Pressure on nerve causes . 
 
 Pressure on blood-vessel causes 
 
 Pressure on air tubes causes 
 
 Pressure on lung causes . . 
 Pressure on oosophagus causes 
 
 (Unequal pupils, pa- 
 ralysis of vocal 
 cords. Hemiple- 
 gia or paraplegia. 
 
 . Asthmatic dyspnoea. 
 
 Inequality of pulses. 
 
 {Local oedemas. 
 Enlarged col- 
 lateral veins. 
 
 Tracheal signs 
 
 Bronchial signs- 
 
 Paroxysmal 
 
 dyspnoea. 
 Brassy cough. 
 Bilateral 
 
 stridor. 
 
 'Also paroxys- 
 mal dyspnoea 
 and cough. 
 Unilateral 
 
 stridor. 
 I Filling or con- 
 solidation of 
 L lung behind. 
 
 ■{ Consolidation and displacement. 
 \ Dysphagia. 
 
DISEASES OF THE BLOOD-VESSELS. 36Y 
 
 Physical Signs. Inspection. 1. Ascending Portion 
 of the Arch. — Bulging of the thorax and pulsating 
 tumor are present to the right of the sternum in the 
 second and third intercostal spaces, except when the 
 aneurism projects upward and inward from the lesser 
 curvature. The apex beat of the heart may be in the 
 normal position or be displaced downward. Pressure 
 upon the superior vena cava causes distension of the 
 superficial veins of the chest and localized cyanosis or 
 oedema of the right side of the face or of the upper 
 extremities. Pressure upon the sympathetic nerve 
 causes contraction of the right pupil. Pressure upon 
 the right or left bronchus causes diminished expansion 
 of the corresponding side of the chest. 
 
 2. Transverse Portion of the Aorta. — Bulging of the 
 upper portion of the sternum, with diffuse pulsation 
 most marked in the epigastric notch and in the arteries 
 of the neck. Pulsating tumor is present when erosion of 
 the ribs or sternum occurs. (Figs. G8 and 69.) Trachea 
 displaced backward or laterally. Apex beat is gener- 
 ally in normal position. Pressure upon left bronchus 
 causes restricted motion of the left side. Pressure on 
 the sympathetic nerve causes_ contraction of the pupil on 
 the affected side. 
 
 3. Descending Portion of the Arch and Upper Por- 
 tion of the Descending Aorta. — When the sac develops 
 on the anterior surface, there is bulging of the inter- 
 costal spaces to the left of the sternum. The apex beat 
 is displaced to the right, and two areas of pulsation are 
 seen. When it develops on the posterior surface, there 
 is absorption of the ribs and vertebra?, with pulsations in 
 the interscapular space. 
 
 4. Descending Aorta, Inferior Position. — Enlarge- 
 ment of the lower portion of the chest, displacement of 
 the heart upward and to the right, diffuse pulsations in 
 the epigastrium and toward the left. Loss of respira- 
 tory motion over the lower ribs. 
 
 5. Abdominal Aorta. — Pulsating tumor in the 
 
368 
 
 THE CIRCULATORY SYSTEM. 
 
 abdomen, frequently causing pulsations also over the 
 hepatic area. 
 
 Palpation. — By palpation the dilating or expansile 
 impulse is felt over the aneurism, and associated with a 
 well-marked diastolic shock, due to recoil of the blood 
 upon the aortic valves. In a certain number of cases 
 a well-marked thrill may also be detected. The force 
 
 Fig. 68. 
 
 Aneurism of aorta, bulging of sternum and pulsating tumor. 
 
 of the aneurismal pulsation should nearly equal that 
 of the heart at the apex (Balfour). The location of the 
 apex beat and the occurrence of confirmatory signs will 
 vary according to the site oi the tumor. 
 
 1. Ascending Portion of the Arch. — ^Aneurism of 
 this portion of the aorta is attended by a well-marked 
 
DISEASES OF THE BLOOD-VESSELS. 
 
 3G9 
 
 dilating impulse, accompanied with thrill, followed by 
 diastolic shock. The apex beat is displaced downward 
 and to the left, and usually increased in force. 
 
 When the aneurism involves the innominate artery, 
 the right radial pulse is usually smaller and slightly 
 delayed. 
 
 2. Transverse Portion of the Arch. — Over the sternal 
 region the impulse is usually heaving in character. 
 
 Fig. 69. 
 
 Aneurism of aorta, bulging of sternum and pulsating tumor. 
 
 unless absorption and perforation have occurred. 
 Fingers introduced into the episternal notch may detect 
 the dilatation of the aorta, expansile pulsation and thrill. 
 The radial pulse generally shows marked difference in 
 character. Tracheal tugging is almost diagnostic of 
 aneurism of this portion of the aorta. Pressure upon 
 the oesophagus causes dysphagia. 
 24 
 
3Y0 THE CIRCULATORY SYSTEM. 
 
 3. Descending Portion of the Arch and Upper Por- 
 tion of the Descending Aorta.—When the aneurism 
 develops forward, the apex beat is displaced toward the 
 right, and may he found to the right of the sternum; 
 while to the left of the sternum the aneurismal pulsation 
 may he detected in the region of the normal apex. The 
 aneurismal pulsation is slightly later than that of the 
 apex. When it develops posteriorly, the apex may he 
 displaced to the right or left, according to the direction 
 of the tumor. Impu.lse may he felt in the interscapular 
 space. 
 
 Ji.. Descending Aorta, Inferior Portion. — The apex 
 is elevated. There is diffuse pulsation over the lower 
 portion of the thorax. 
 
 5. Abdominal Aorta. — As the artery can be grasped 
 through the abdominal wall, the dilating character of the 
 pulsation is easily detected. 
 
 Peecussion. — There is diminished resonance or flat- 
 ness over the site of the tumor. At times percussion 
 detects the presence of aneurism Avhen inspection and 
 palpation are negative. When the sac projects close to 
 the surface, its size may be definitely determined. 
 
 1. Ascending Portion of the Arch. — Aneurism pro- 
 jecting forward and to the right gives well-marked 
 dullness in the second and third interspaces. 
 
 2. Transverse Portion of the Arch. — ^Aneurism 
 pressing upon the sternum causes dullness over the 
 •ipper portion of the sternum, with increased sense of 
 resistance. When developing posteriorly or backward, 
 increased dullness in the interscapular region may be 
 detected. 
 
 3. Descending Portion of the Arch and Upper Por- 
 tion of the Descending Aorta. — ^Displacement of the 
 heart causes percussion dullness over an abnormal site. 
 Unless the anevirism projects close to the surface, it 
 may he undetected by percussion. Posteriorly, increase 
 in the percussion dullness may be made out in the left 
 
DISEASES OF THE BLOOD-VESSELS 371 
 
 i. Descending Aorta, Inferior Poriion.—Tho normal 
 pracordia flatness or dullness are extended to the left 
 and over the lower portion of the thorax. 
 
 5. Abdominal A orfo.— Dullness over site of tumor 
 Auscultation.— The signs detected by auscultation 
 are not as distinctive as those noted by inspection, palpa- 
 tion and percussion. Frequently over the aneurism 
 the hrst and second sounds of the heart are heard with 
 abnormal clearness, and are at times the only sims 
 detected. One or both of the cardiac sounds may be 
 replaced by a murmur or bruit, which varies widely in 
 quality. A systolic bruit is most frequently present, 
 and may be made in (a) the aneurismal sac, and gener- 
 ally disappears when the contents become solid by 
 coagulation ; (b) in the dilated artery ; (r) in a portion 
 of the aorta partially compressed by the tumor. A 
 systolic murmur may be heard over the pracordia 
 (Drummond's sign), or detected when the chest piece 
 of the stethoscope is introduced into the mouth and the 
 lips closed on it (Sanson's sign). Corresponding to the 
 diastolic shock felt on palpation, an intense, low-pitched, 
 second sound may bo heard over the aorta. When 
 heard beliind in the interscapular space, it is especially 
 significant of dilatation of the aorta. A diastolic mur- 
 mur is heard Avlien iuconipetencv (jf the aortic valve is 
 present, and replaces the diastolic shock and sound. 
 The respiratory sounds Avill be altered according to the 
 site of the aneurism aiul the ])ressure on the trachea and 
 bronchi, or dis])laceraent of the lung. 
 
 1. Ascending Aorta. — Usually, the s^-stolic and 
 diastolic cardiac sounds arc either intensified or replaced 
 by murmurs. The most frequent combination is a well- 
 marked systolic bnilf, and a short, sharp diastolic shock 
 or sound heard over the second intercostal space to the 
 right of the sternum and behind in the interscapular 
 region.*' Pressure on the right or left bronchus gives 
 
372 THE CIBCULA TORY SYSTEM. 
 
 rlionchi, tubular breathing (pressure type) and feeble 
 vesicular murmur over the corresponding side of the 
 chest. 
 
 2. Transverse Portion of the Arch. — Cardiac sounds 
 and murmurs are similar to those hoard when the ascend- 
 ing portion is involved. Pressure on the trachea causes 
 harsh stridor to replace the normal respiratory sounds 
 over both lungs. Pressure limited to the left bronchus 
 gives tubular breathing at point of pressure and feeble 
 vesicular murmur over the left side of the thorax. 
 
 S. Descending Portion of the Arch and Upper Por- 
 tion of Descending Aorta. — Usually distinctive changes 
 in the cardiac sounds and murmurs are not present, and 
 the diagnosis is made from evidences of pressure on the 
 left bronchus and lung and from the displacement of the 
 heart. Narrowing of the left bronchus causes stridor 
 and diminished breathing below the affected portion. 
 Occlusion of the bronchus and collapse of the lung are 
 attended with absence of respiratory murmur and feeble 
 vocal resonance. 
 
 J^. The Descending Aorta, Inferior Portion. — The 
 auscultatory signs are very slight. Pressure of the 
 tumor does not produce stridor, but may cause over the 
 lower portion of the chest, occupied by compressed lung, 
 bronchial breathing and increased vocal fremitus. 
 
 5. Abdominal Aorta. — Usually over the site of the 
 pulsation a well-marked systolic bruit is present. The 
 systolic murmur over the aorta is not pathognomonic of 
 aneurism, as it may occur when the aorta is relaxed, or 
 displaced by anterior curvature of the spine, or slightly 
 narrowed by the pressure of the stethoscope. 
 
 Diflferential Diagnosis. — ^The distinctive signs of 
 thoracic aneurism are the presence of visible pulsations, 
 with or without bulging of the chest wall, and tumor. 
 Over the tumor, when present, the pulsations are expan- 
 sile, and frequently accompanied by systolic thrill and 
 diastolic shock. The force of the pulsation felt should 
 nearly equal that felt over the apex beat. The apex 
 
DISEASES OF THE BLOOD-VESSELS. 373 
 
 beat and area of cardiac dullness may be normal or dis- 
 placed. Over the site of the aneurism, when it reaches 
 the surface, there may be flatness, surrounded by an 
 area of relative dullness. When deep seated, diminu- 
 tion of resonance only over that portion of the chest may 
 be noted. Auscultation may reveal increased cardiac 
 sounds, with diastolic shock or bruits replacing the 
 normal sounds. In addition to the above, pressure 
 signs will be present, varying in character according to 
 the location of the aneurism. 
 
 Mediastinal Tumoes. — Mediastinal tumors have 
 many physical signs in common with thoracic aneurism, 
 especially those referable to pressure. The chief dis- 
 tinguishing points are that mediastinal tumors, while 
 producing bulging of the chest, are not attended with 
 erosion of the bony thorax. The pulsations, when pres- 
 ent, are not expansile, but convey the impression of a 
 non-expansile force being transmitted. Over the site 
 of pulsation, thrill and diastolic shock are not present. 
 Pressure upon the large interthoracic veins produces 
 more marked superficial venous disturbance. 
 
 Glands in the clavicular and interclavicular and 
 axillary regions are involved when the tumor is 
 malignant. Over the site of bulging there is increased 
 firmness of the bony thorax to pressure. 
 
 The superficial area of flatness is very much greater 
 than that over which pulsations are felt. Dimiimtipn of 
 sternal resonance is especialy marked. Over the site of 
 dullness, increased resistance and loss of normal thoracic 
 elasticity are noticeable. _ t • ^• 
 
 Over the site of dullness and pulsation, distinctive 
 cardio-vascular sounds are absent. Over the lung, 
 pressure symptoms are more marked and uniform, and 
 apt to be attended by secondary structural changes, due 
 to extension of the growth from the mediastinal. 
 
374 THE CIBCULATOEY SYSTEM. 
 
 AETERIO SCLEROSIS OR ARTERIO-CAPILLARY 
 FIBROSIS. 
 
 This condition causes increased peripheral resistance, 
 with heightened arterial tension. 
 
 The effects of arterio-sclerosis can be divided into 
 three stages. First stage — In proportion to the inter- 
 ference with the flow of blood through the capillaries and 
 arteries, there is a corresponding hypertrophy of the left 
 ventricle, which compensates for the lesion as long as the 
 left ventricle is able to empty its contents into the aorta. 
 The second stage or failure of compensation. — ^When 
 the muscular power of the heart is insufficient to over- 
 come the resistance in the aorta, dilatation of the ven- 
 tricle occurs, with insufficiency of the mitral valves 
 (mitral regurgitation), and the subsequent changes in 
 the pulmonary circulation, and compensating hyper- 
 trophy of the right heart. Subsequently (third stage) 
 failure of the right ventricle to overcome interference 
 with the pulmonary circulation may induce dilatation 
 of the right ventricle, tricuspid regurgitation and inter- 
 ference with venous return. 
 
 Physical Signs. — The cardiac changes of arterio- 
 sclerosis are identical with those that occur when tho 
 interference is due to obstruction at the aortic orifice. 
 In arterio-sclerosis the obstruction is simply transferred 
 from the area of the aortic valves to a more distant point 
 in the arterial system. (See Aortic Stenosis, page 320.) 
 
 The superficial blood-vessels are lengthened, promi- 
 nent and tortuous, and the pulsations are visible. On 
 palpation the artery is hard and incompressible, and 
 even when the pulsations are obliterated can be felt 
 beyond the point of compression as a hard, roimded cord. 
 On auscultation, the aortic second sound differs from 
 that of aortic stenosis, in that it is accentuated and ring- 
 ing in quality. With faihire of compensation at the 
 left ventricle or regurgitation at the mitrkl orifice, the 
 aortic second sound becomes indistinct. 
 
PART I\^. 
 THE ABDOMINAL ORGAI<rS. 
 
 CHAP TEE XV. 
 INSPECTION. 
 
 Inspection of the abdomen includes consideration of 
 the shape and size of the abdomen, the changes in the 
 sicin, the condition of the blood-vessels, both arterial and 
 venous, and the movements, both respiratory and visceral. 
 The examination should be made with the patient in 
 both the erect and recumbent pfi.stures when possible, 
 although usually it is made in the recumbent position 
 only. In the standing posture the shape of the abdomen 
 and the support given the abdominal viscera by the 
 parieties are most clearly seen, and in enteroptosis this 
 method of examination is especially valuable. Exami- 
 nation in the recumbent posture demands that the body 
 shall be exposed from just below the mammary glands 
 as far as the pubes, so as to compare the lower portion 
 of the thorax with the abdomen. The patient should 
 lie perfectly straight on the back, the head and trunk 
 slightly elevated, so as to relax the abdominal muscles. 
 The abdomen should be well illuminated, and the 
 examiner should view it from all sides, so as to note any 
 inequalities of surface and shadoA^■s caused by move- 
 ments. 
 
 The Normal Abdomen. — The contour of the abdomen 
 
376 THE ABDOMINAL OEGANS. 
 
 should bear a definite relation to that of the thorax and 
 general physique of the patient. In children and in the 
 adult male past middle life the abdomen is relatively 
 larger and rounder, especially in the upper and middle 
 zones. In males during early adult life there is gener- 
 ally a depression in the epigastric region. In females, 
 independent of the effects of tight lacing, there is 
 more or less of a depression in the lower portion of the 
 thorax and hypochondriac regions, with a lengthening of 
 the waist line and a corresponding broadening of the 
 lower portion of the abdomen. When compression of 
 the thorax by corsets has occurred, this natural condition 
 is made more marked. In those who have borne chil- 
 dren, the lower portion of the abdomen is larger and the 
 walls are flaccid. 
 
 Examination of the Parietes. — The skin may show cer- 
 tain discolorations (jaundice, pigmentation of Addison's 
 disease and that secondary to pregnancy) or strife, the 
 result of overdistension (pregnancy, ascites, obesity). 
 It may be tense, dependent upon distension of the 
 abdomen, or lax, secondary to overdistension from preg- 
 nancy, ascites, tumors, and in wasting diseases. 
 
 The blood-vessels may be more prominent than nor- 
 mal, especially the veins, when the superficial ones are 
 enlarged on account of compensatory changes due to 
 obstruction of return circulation, either portal or 
 general. 
 
 The movements of the abdomen are {a) respiratory. 
 These in the adult male and in children are especially 
 marked. With inspiration the abdomen becomes promi- 
 nent, especially in the upper zone. In females this is 
 less marked, on account of the breathing being largely 
 costal. With deep respiration the movements are more 
 pronounced in both sexes. Increased respiratory move- 
 ment occurs in diseases that interfere with expansion of 
 the upper portion of the thorax. Diminished respira- 
 tory movement occurs in all painful affections below the 
 diaphragm, either involving the abdominal muscles or 
 
INSPECTION. 377 
 
 the peritoneum, general or local, and especially that por- 
 tion covering the organs that are influenced by the 
 descent of the diaphragm. 
 
 (h) Visceral. — Peristalsis of the normal stomach is 
 not noticed except when the abdominal walls are thin 
 and relaxed. These movements may be noted when the 
 stomach is distended and the peristalsis become 
 exaggerated, especially when there is stenosis at the 
 pylorus, with secondary hypertrophy of the walls. 
 
 The movements of the stomach are seen as distinct 
 waves, passing from left to right across the epigastric 
 region to the costal margin on the right side. When 
 more pronounced, they may cause protuberances or 
 bosses of the abdominal walls, which pass slowly in the 
 same direction. The latter conditions occur when the 
 stomach is markedly dilated, and may at times be seen 
 over a large portion of the abdomen. 
 
 Movements of the small intestine may normally be 
 seen when the abdominal walls are thin and lax. Those 
 of the large intestine are seen only in pathological con- 
 ditions, dependent upon neuroses or stenosis, with over- 
 distension of the gut above the site of obstruction. 
 Those of the small intestine are vermicular, and are 
 seen especially in the umbilical region. Those of the 
 large intestine are especialy marked in the lumbar and 
 epigastric regions, and the direction of the motion is 
 contrary to that of the stomach, being from right to left. 
 
 Enlargement of the Abdomen. — Enlargement of the 
 abdomen may be (A) symmetrical, (B) localized. 
 Symmetrical enlargement of the abdomen may be due 
 to (1) increase of the abdominal walls (fat, cedema, 
 etc.). (2) Distension of the peritoneal cavity by air 
 (rare) or fluid (ascites). (3) Distension of the intes- 
 tine with gas (meteorism). (4) Massive tumor filling 
 the abdominal cavity (uterus : pregnancy, fibroids ; 
 ovaries : distended bladder, etc. Although these condi- 
 tions may cause uniform enlargement of the abdomen, 
 certain peculiarities noted by inspection are aids in 
 
378 
 
 THE ABDOMINAL ORGANS. 
 
 differential diagnosis. Enlargement due to increase in 
 the abdominal walls is associated with general obesity. 
 The walls in the recumbent posture are more or less 
 widened, and lack the dome-shaped appearance. In 
 ascites the fluid collects in the most dependent portion of 
 the abdomen, which enlarges laterally, and its shape 
 changes as the patient is tiirned on the side or sits up. 
 
 Fig. 70. 
 
 Fig. 71. 
 
 Ascites due to cirrhosis of liver. 
 
 (Figs. 70 and 71.) In accumulations of gas in the 
 intestine, the abdomen is distended in all directions 
 uniformly, and there is no change in shape with altered 
 posture of the patient. In tumors the enlargement is 
 not entire symmetrical. 
 
 Local Abdominal Enlargement or Bulging. — Inspec- 
 
INSPECTION. 379 
 
 tion is very important in detecting local enlargements or 
 bulgings. The abdomen should ho viewed from all 
 directions, in order to detect the shadows caused liy 
 unevenness of its surface. Local enlargements of the 
 abdomen may be caused by enlargement of structures 
 normally situated in that region or tumors springing 
 from them, or the region may be invaded by organs dis- 
 placed from adjacent areas. 
 
 Epigastric Kegion. (1) Abdominal Walls. — Local 
 contractions of the recti (phantom tumor) ; abeess of 
 abdominal walls, lipomas. 
 
 (2) Peritoneum. — Localized effusions into the lesser 
 peritoneal cavity, tumors of the omentum. 
 
 (3.) Siomach. — Distension from food or gas, or 
 dilatation, with or without stenosis; tumors of that 
 portion of the stomach that is parietal (cancer, etc.). 
 
 (Jf.) Pancreas. — Cysts, cancer. 
 
 (5) Aoria. — Aneurism of the aorta or its branches. 
 
 (6) Liver. — Enlargements of the liver, displacement 
 of the left lobe of the liver downwards, abscess, hydatid, 
 gumma, cancer, etc. 
 
 (7) Large Intestine. — Distension of transverse colon, 
 tumor of colon. 
 
 Umbilical Region. — Many of the conditions that were 
 noted in the epigastrium may extend to this region also. 
 
 (1) Abdominal TFa^L— Umbilical hernia, abscess, 
 
 lipoma. 
 
 (2) Peritoneum. — Encysted effusion into the peri- 
 toneal cavity, tumors of the omentum. 
 
 (3) /Siomac/i.— Dilatation, tumors of the pylorus. 
 (I^) Aorte.— Pulsations of aorta due to aneurism or 
 
 anterior curvature of the spine. 
 
 (5) Enlarged Mesenteric or Retro-perdoneal Mands. 
 — Tubercular, cancerous, etc. 
 
 (6) Intestine.— Cancer of the intestine, especially the 
 
 large intestine. • 4. • j 
 
 (7) Movable liver j spleen, Vidneys may project into 
 
 this region. 
 
380 THE ABDOMINAL ORGANS. 
 
 Hypogastric Region. — ^Distensions may be caused other- 
 wise than by changes in the abdominal wall and peri- 
 toneum ; they are dependent chiefly upon distended blad- 
 der and enlarged uterus (pregnancy, tumors). 
 
 Upper Eight Lateral Region. — In the lateral region 
 (including the hypochondrium and upper portion of the 
 lumbar region to the level of the umbilicus) enlarge- 
 ments due to changes in the abdominal walls and perito- 
 neiim are rare. 
 
 (1) Liver. — ^Enlargements of liver (fatty liver, 
 abscess, congestion, syphilis, hypertrophic cirrhosis, 
 amyloid, displacement of the liver downward, leukajmia, 
 hydatid, carcinoma). 
 
 (2) -Gall Bladder. — Distended gall bladder, gall 
 stones, hydrops and cancer. 
 
 (3) Ascending Colon. — Impaction of faeces, cancer. 
 (Jf) Kidney. — Hydronephrosis, pyonephrosis, ha3mo- 
 
 nephrosis, sarcoma, perinephritic abscess, cancer of 
 suprarenals. 
 
 Upper Lett Lateral Region. — (1) Stomach. — Dilated, 
 distended, carcinoma of fundus. 
 
 (2) Spleen. — Enlargements (congestion, primary or 
 secondary, to obstructive disease of liver; leukaemia, 
 pseudo-leukasmia, malaria, movable or displaced spleen, 
 abscess, carcinoma, hydatid. 
 
 (3) Intestine. — Impaction of faeces in splenic flexure 
 of colon. Enlargements of kidney. 
 
 Lower Right Lateral Region. — (From the level of the 
 umbilicus to the brim of the pelvis.) 
 
 (1) Abdominal Wall. — Hernia, abscess of abdominal 
 wall and psoas abscess burrowing forward. 
 
 (2) Peritoneum. — Localized tumor secondary to dis- 
 ease of appendix or intestine. 
 
 (3) Intestine. — Tumors of appendix, impacted faeces, 
 typhlitis, perityphlitis, intussception, cancer of caecum, 
 or of ascending colon. 
 
 (J^) Kidney. — Displaced kidney. 
 
 (5) Ovaries and Tubes. — Ovarian tumors, cysts of 
 
JNSrECTIOX. 381 
 
 the broad ligament, pelvic abscess, tubal or extra-uterine 
 pregnancy. 
 
 Lower Lert Lateral Region. — Distension of the sigmoid 
 ilexure of the colon due to impaction of fseces, new 
 growths in rectum, in addition to the same conditions 
 may occur on the right side. 
 
 Decrease in Size. — The abdomen may be decreased in 
 size, due to contraction of the abdominal muscles, as 
 occurs in the early stage of peritonitis and secondary to 
 cerebral disturbance, especially basUar meningitis. In 
 stenosis of the oesophagus or cardiac portion of the 
 stomach, the empty condition of the stomach and intes- 
 tines, with the emaciation, causes the abdomen to have a 
 lax, shrunken appearance. 
 
 Illumination of the Stomach. — ^The outline of the stom- 
 ach may be seen by the use of Einhorn's gastro-diaphane. 
 For this purpose the stomach is first washed out, and 
 then filled with clear water, into which an electric bulb 
 attached to a flexible wire is introduced. 
 
CHAPTER XV I. 
 
 PALPATION. 
 
 Method of Examination. — For satisfactory palpation 
 of the abdomen, it is necessary for the patient to be in 
 the recumbent posture, and the regions of the abdomen 
 should be accessible from all sides. The head and 
 shoulders should be elevated so as to relax the abdominal 
 muscles, and the patient must be instructed to be as limp 
 as possible, and not try to aid the examination by 
 any voluntary motion. As the object of the examina- 
 tion is to reach the abdominal organs, relaxation of the 
 abdomen is a necessity. Very little is gained by having 
 the patient draw up the legs, as there is a tendency to 
 hold the abdominal muscles rigid in order to support 
 them. When the patient is very nervous or apprehcTi- 
 sive of the examination, it may be necessary to divert 
 the attention by asking (piestions and seemingly to 
 examine the tongue with the eye, while with the hands 
 we are palpating the abdomen. The hands of the 
 examiner shoiild be warm, to avoid causing reflex con- 
 traction of the abdominal muscles. 
 
 At the beginning of the exaudnation the ])alms of the 
 hands should be placed lightly upon the abdomen and 
 passed over it in all directions, so as to get a general 
 idea of the condition of the walls, the degree of resist- 
 ance. 
 
 Patients Avho are very ticklish arc frequently more 
 disturbed by a light touch than by more forcible palpa- 
 tion. The amount of pressure should be gradually 
 increased, in order to determine whether any part 
 of the abdomen is sensitive, as shown by pain and 
 
PALPATION. 383 
 
 local muscular contraction. Whenever such areas are 
 present, their examination should be left till the last. 
 
 In general enlargement of the abdomen it is necessary 
 to determine its resistance (gas, fluid or solid). 
 When local enlargements are detected, we deterniine 
 (1) their relation to the surface, (2) whether they are 
 fixed or movable, the extent and direction of their 
 mobility, and whether they move Avith respiration; (3) 
 their shape and size, nature of their surface ; (4) their 
 relation to structures normally found in that region and 
 to adjacent organs ; (5) the presence of frictions, thrills, 
 and pulsations ; (6) whether they are sensitive or not. 
 
 In order to gain more definite knowledge, it is often 
 necessary after examination in the recumbent posture 
 to put the patient in the hitc-ral or in the knee-chest 
 position. 
 
 Abdominal Walls. — The condition of the abdominal 
 walls affects the information obtained by palpation 
 regarding the abdominal viscera. 
 
 When the walls are thin and relaxed, they offer very 
 little obstacle to palpation. Tension of the walls, due 
 to muscular contraction, prevents satisfactory palpation, 
 so that an anaesthetic may be required. Localized con- 
 tractions, especially of the recti, due to ticklishness, pain 
 or tenderness, frequently simulate tumors of the wall 
 or underlying structures. 
 
 Increase in thickness of the abdominal walls from 
 fat renders palpation very difficult. 
 
 Local enlargements and tumors of the abdominal wall 
 may be due to (a) muscular contractions, (h) fatty 
 tumors (lipomas), (c) abscess, (d) hernia. _ All these 
 tumors give the impression of being superficial. They 
 can be grasped by the hand, and their mobility is limited 
 to that of the walls ; while tumors situated within the 
 cavity do not have their mobility limited to the walls 
 unless they adhere to the parietal peritoneum. 
 
 Tumors due to muscular contraction vary m shape 
 and size. ContractJon of the recti causes a well-defined 
 
384 THE ABDOMINAL ORGANS. 
 
 oblong mass, with the long axis corresponding to that of 
 the muscles, while those of the oblique muscles are ill- 
 defined. The characteristic feature of muscular tumors 
 is their variable consistency ; at one time they are hard 
 and resistant, and as the muscle relaxes they become 
 softer, smoother and finally disappear (phantom tumor). 
 They may be painful when due to rheumatism or 
 neuralgia, or attended with irritation of the parietal 
 peritoneum. 
 
 Lipomas are soft, yielding masses Avith fairly well- 
 defined borders, and with greater or less mobility under 
 the skin. Their firmness is increased when the surface 
 over them is chilled by ether spray or the application 
 of salt and ice. They are painless, and when grasped 
 firmly and forced to the surface the skin over them 
 shows depressions, indicative of the lobulated structure 
 of the tumor. 
 
 Abscesses are usually tense and elastic or fluctuating ; 
 they are well defined unless surrounded by (Edematous 
 tissue, which gives a boggy feel and pits on pressure. 
 Acute abscesses are red and painful, with local elevation 
 of temperature. 
 
 Hernias. The us^lal site of the hernial tumor is at 
 the natural openings in the abdominal walls and the 
 umbilicus, although they -may occur at any part of the 
 abdominal parietes. The mass gives an air-cushion 
 feel, and becomes more tense as the intra-abdominal 
 pressure is raised by deep breathing, coughing or con- 
 traction of the abdominal muscles. They are not 
 usually tender, and firm pressure may reduce the mass 
 with sensation of gurgling. After reduction, the open- 
 ing in the abdominal wall can be felt. Percussion over 
 the mass gives a tvmpanitic note. 
 
 Separation of the recti muscles leads to projection of 
 the abdominal wall. The tumor is soft, yielding, with 
 air-cushion feel and tympanitic note. 
 
 Peritoneum. — Normally, the peritoneum presents no 
 palpable phenomena. Acute general inflammation 
 
PALPATION. 3S5 
 
 causes the abdomen to become extremely tender and 
 resistant, on account of muscular contraction. Later 
 paralysis of the intestine causes tympanites to be 
 marked. Respiratory movements are diminished or 
 absent. 
 
 General peritonitis may be simulated by painful 
 affections of the abdominal walls (rheumatism, neural- 
 gia, lead colic, etc.) and tympanites, due to intestinal 
 disease, or to hysterical conditions. In painful affec- 
 tions of the abdominal wall, respirations are not dis- 
 turbed to the same degree as in peritonitis. Pain ia 
 more paroxysmal, and the constitutional symptoms are 
 less severe. In hysterical conditions the physical signs 
 may be identical. The diagnosis is made by considera- 
 tion of all symptoms, especially others of an hysterical 
 nature. 
 
 Acute localized peritonitis is usually secondary to dis- 
 ease of organs covered by the serous membrane, and will 
 be considered with each organ. 
 
 Diffuse thickening of the peritoneum secondary to 
 acute or tubercular involvement gives an increased sense 
 of resistance, and a more or less boggy feel. In local 
 thickenings and ill-defined indurations there are felt 
 nodular masses, more or less movable, simulating 
 enlarged glands. They are frequently associated with 
 thickening and retraction of the omentum (q. v.). 
 
 Fx.uiD m THE Peeitoneai. Cavity, Ascites. — Pluid 
 causes a change in the normal feel of the abdomen, 
 and abnormal sensations. The fluid collects in the 
 most dependent portion of the sac, according to the 
 posture of the patient; and as it increases the intes- 
 tines are displaced, floating on its surface unless pre- 
 vented by peritoneal adhesions or short mesentery. 
 Over the fluid the normal air-cushion feel of the 
 abdomen is replaced by increased resistance, _ as it the 
 wall were thickened. This is especially noticeable m 
 the flanks with the patient in the recumbent posture. 
 Above the fluid the distension of the abdomen causes the 
 25 
 
38G THE ABDOMINAL ORGANS. 
 
 walls to be tense, otherwise the feel is normal. With 
 change in posture of the patient, there is corresponding 
 shifting of the fluid and intestines. 
 
 Fluctuation. — ^When the palm of the hand is placed 
 on one side of the abdomen near the level of the fluid, 
 while oh the opposite side a sharp percussion tap is made 
 with the other hand, a wave-like motion in the fluid is 
 felt as a distinct impulse, most distinct near the leVel of 
 the fluid wheii the fluid is under tension and able to move 
 freely. Under such conditions a light tap is sufficient 
 tb produce the phenomenon. When the abdominal wall 
 is thick and the amount of fluid scanty, or if it is pre- 
 vented from, moving freely, the stroke must be stronger,' 
 and the impulse is feeble. It is often difficult to deter- 
 mine whether the impiilse felt has been transmitted by 
 the fluid or by the abdominal wall. Transmission by 
 the abdominal wall can be arrested if an assistant presses 
 firmly with the ulnar edge of the hand in the median 
 line. When the amount of fluid is small, fluctuation 
 may be best detected by placing the patient on the side 
 and placing a hand over the flank behind, between the 
 l6wer ribs and the crest of the ilium, and tapping over 
 the front of the abdomen. Fluctuation may be absent 
 when the abdomen is over distended and tension is very 
 high, or when adhesion of the intestines or a short mesen- 
 tery prevents the usual motion of the fluid. 
 
 The abdomen in ascites is usually painless, unless the 
 condition is secondary to peritonitis or complicated by 
 it. Palpation of solid organs and tumors is prevented 
 when the amount of fluid is large. By dipping (i. e., 
 launching sharply with the tips of the fingers) over the 
 organs sought for, the fluid is displaced, and the surface 
 or edge of the solid organs can be felt. 
 
 Fluid in the peritoneal cavity may be due (a) to 
 inflammation of the peritoneum, simple, tubercular or 
 cancerous; (h) interference -with portal circulation' 
 (obstructive disease of the liver (q. v.), thrombosis of 
 the portal vein, pressure on the portal vein from 
 
PALPATION. 387 
 
 abdominal tumors, etc.); (c) interference with the 
 general return circulation secondary to pulmonary and 
 cardiac disease ; (d) as a part of general dropsy (kidney 
 disease, ana?mic condition). 
 
 The differential diagnosis of the cause is made by the 
 physical signs. of the primary lesion. Frequently the 
 condition of the liver can only be determined after 
 tapping. 
 ^ A localized collection of fluid may occur in any -por- 
 tion of the peritoneal sac. It is most common in the 
 lesser peritoneal cavity, where it forms a tense, globular, 
 cyst-like tumor in the epigastric region, not movable, 
 and over which distinct fluctuation cannot be obtai'ned. 
 It is generally painless. At times it may transmit from 
 the aorta pulsations which are not expansile. 
 
 Air in the peritoneal cavity, due to perforative peri- 
 tonitis, gives marked distension of the abdomen, with 
 increased tension of its walls. The diamosis from 
 tympanites is made by percussion and auscultation. 
 
 The Omentum is not palpable unless thickened by in- 
 flammation or new growths. Deposits of fat in the 
 omentum (peritoneal lipoma) give a thickened, elastic 
 feel to the abdomen, with the impression of fluctuation. 
 Thickening of the omentum may occur from chronic or 
 tubercular peritonitis, and gives the sensation of 
 increased superficial resistance over the upper zone of 
 the abdomen, without any free border being detected. 
 There may be tenderness in the acute and subacute 
 stages, when more chronic there is no pain. The mass 
 is not movable with respiration. Retraction of the 
 thickened omentum may form a distinct tumor in the 
 upper portion of the abdomen. The tumor may be felt 
 as a transverse ridge with a distinct border below, which 
 may simulate an enlarged left lobe of the liver, or it may 
 be an irregular or ball-like mass. Cancer nodules may 
 be diffused over the omentum, or new growths may form 
 irregular masses similar to those in the stomach and 
 liver. Tumors of the omentum do not move with 
 
388 THE ABDOMINAL ORGANS. 
 
 respiration unless attached to the edge of the liver, in 
 which case differential diagnosis is very difficult. They 
 are differentiated from primary malignant growths of 
 the stomach by being fixed, and more prominent when 
 the stomach is full or inflated. 
 
 Hydatid cysts of the omentum are rare. When 
 unilocular, they give a sensation of superficial, globular 
 tumors, and the hydatid thrill may be present. Multi- 
 locular cysts, when small, may simiilate the early stage 
 of cancerous infiltration. 
 
 Stomach. — Normally, the stomach cannot be detected 
 by palpation, as only a small portion of the anterior sur- 
 face and greater curvature is in contact with the 
 abdominal wall. In extreme emaciation, during con- 
 traction of the stomach, there is slight resistance. 
 Normally, in most persons the upper portion of the 
 epigastrium is more sensitive to pressure than the rest 
 of the abdomen. Increased tenderness over the gastric 
 region occurs in acute and chronic catarrhal inflamma- 
 tion of the stomach ; in malignant disease, in ulcer (cir- 
 cumscribed area) and whenever the peritoneal covering 
 of the stomach is involved secondary to gastric disease. 
 
 In dilated or displaced stomach the boundaries can- 
 not be determined by palpation. The swelling noted 
 by inspection gives a soft, yielding feel, except during 
 contraction, when the sensation varies according to the 
 cause of the dilatation. In atonic dilatation there is 
 slight increase of resistance, and an even, wave-like 
 motion from left to right can be detected. When dilata- 
 tion is due to obstruction at the pyloris (cancer, ulcer, 
 stenosis from adhesion, or displacement) there is hyper- 
 trophy of the muscular coat, and the contractions of the 
 stomach causes hard masses and irregular protuberances 
 to be felt as the peristaltic wave passes across the 
 abdomen. Over the region of the pyloris the con- 
 traction is harder and longer, and almost always 
 accompanied with sensations of gurgling or escape of 
 gas. When the stomach relaxes a tumor may be felt. 
 
PALPATION. 389 
 
 It is only exceptionally that the normal pylorus can be 
 lelt as a tumor. Splashing and succussion sounds 
 (clapotage) can be obtained in a dilated stomach when 
 It contains both gas and fluid. They are obtained by 
 placing the tips of the fingers over the stomach and 
 shaking it with quick movements, or by bimanual palpa- 
 tion, one hand beneath the ribs behind and the other 
 over the stomach in front. They are diagnostic of dila- 
 tation only vjrhen taken in connection with other signs, 
 as they can be obtained in the normal stomach, and in 
 the colon when the contents are liquid. 
 
 TuMOES OF THE Stomach. — Tumors of the stomach 
 can only be felt when situated in that portion which is 
 in contact, normally or abnormally, with the abdominal 
 walls. They may be due (1) to contracted stomach, 
 (2) diffuse infiltration of the walls, with cancer; (3) 
 local thickenings of different portions of the stomach 
 wall by inflammatory products or new growths. 
 
 The entire stomach may be so contracted as to form a 
 tumor (a) in stenosis of the cesophagus or cardia, (h) by 
 the prolonged use of concentrated diet, (c) by fibrous 
 thickening of the stomach, with or without cancerous 
 infiltration. In these conditions the stomach is usually a 
 rigid mass, felt as a transverse ridge in the region of the 
 normal stomach, and giving the same sensation as a 
 thickened omentum. It is movable, and changes its 
 position with deep breathing. 
 
 Diffuse infiltration of the stomach wall may be later 
 associated with contraction of the stomach and forma- 
 tion of a tumor, as mentioned above, or the lumen of the 
 viscus may be increased. In the latter condition the 
 stomach is felt as a large, ill-defined mass, which, dur- 
 ing contraction, becomes harder and has tlie more defi- 
 nite contour of the stomach. It may occupy the normal 
 gastric position, but is usually displaced downward, and 
 the pylorus is felt somewhat to the left of the median 
 line. 
 
 TuMOES oi" THE Pyloeic Eegion. — Thcsc may be 
 
390 THE ABDOMINAL ORGANS. 
 
 due (1) to primary changes at the pylorus, as already 
 mentioned, or to extension of cancerous growths from 
 neighboring organs to this region. 
 
 The characteristic features of primary tumor of the 
 pylorus are (a) their location ; usually they are detected 
 to the right of the median line, between the umbilicus 
 and the ensiform cartilage. When stenosis is marked, 
 dilatation and displacement of the stomach cause the 
 tumor to be felt in the region of or below the umbilicus 
 and to the left of the median line. (h) Mobility. 
 When felt in the epigastric region, the tumor is movable 
 in all directions, but more freely downward and to the 
 left. When the pylorus is displaced below the 
 umbilicus, the mobility is not so great, (c) The tumors 
 vary in size, and are usually actually larger than palpa- 
 tion would indicate, (d) Their consistency is hard; 
 during peristalsis they become harder, and their contoui- 
 more defined, (e) The detection of gurgling or escape 
 of gas is an important diagnostic sign, especially when 
 it occurs during peristalsis. 
 
 Tumors of the pylorus, du^e to extension from neigh- 
 boring organs, lack the characteristic mobility, and are 
 usually associated with the physical signs of the 
 primary growth. 
 
 Pancreas. — The normal pancreas is not palpable, 
 although claim has been made that in extremely thin 
 persons and in those with enteroptosis it can be dis- 
 tinctly felt. In diseased conditions the gland can only 
 be detected when it is enlarged to a considerable degree. 
 In acute or chronic pancreatitis it is not palpable, but 
 in the epigastric region tenderness on firm pressure 
 may be present with increased sense of resistance. 
 
 Pancreatic enlargements are mostly due to cancer 
 and cysts. Tumors due to tubercle, gumma, lymphoma 
 and sarcoma are rare, and when present give most of the 
 physical signs of cancer. 
 
 Cancer of the Panceeas. — As this usually begins 
 at the head of the gland, a tumor is felt in the epigas- 
 
PALPATIOX. UDl 
 
 trium, midway Ix-tween the xiphoid cartilage and tlio 
 umbihcus, and a little to the right of the median 
 Ime, close to the edge of the liver. Its form may he 
 round or oblong, hut the outline cannot be well 
 dehned. Its position is not influenced by respiratory 
 movements. When it can be easily felt, it is generally 
 fixed, or only slightly movable. Non-expansile pulsa- 
 tions may be felt, due to its relation to the aorta. Com- 
 pression by the tumor of the portal vein causes ascites ; 
 that of the vena cava causes cedema of the lower extremi- 
 ties. The presence of a tumor in the region of the 
 pancreas is not sufficient for diag-nosis of cancer of that 
 organ, as similar tumors may be caused by cancer of 
 the pylorus, duodenum, colon, or liver. The associated 
 signs of cancer of the pancreas are (1) early, intense 
 and persistent jaundice; (2) dilatation of the'gall blad- 
 der, (3) enlargement of the liver, (4) fatty stools. 
 
 Differential Diagnosis. — It is differentiated from tu- 
 mor of the pylorus by being deeper seated and not mov- 
 able, and that the stomach is not dilated and hypertro- 
 phied. When the growth extends to the duodenum, 
 stomach changes may be jaresent. Tumors due to cancer 
 of the lower edge of the liver, in the region of the pan- 
 creas, move with respiration, and their relation to the 
 edge of the liver can usually be determined. In primary 
 cancer of the gall bladder the distended gall bladder is 
 harder, while the liver is not enlarged. Enlargement of 
 the retroperitoneal glands from any cause may give a 
 tumor similar, as far as palpation is concerned, to can- 
 cer of the pancreas. 
 
 Cysts of the Panceeas. — ^When small, the tumor 
 is felt to the left of the median line, toward the costal 
 cartilage. It is globular, smooth, resistant and inelastic, 
 and when deep seated gives a sensation of hardness. It 
 is uninfluenced by respiratory movements, and on firm 
 pressure may be slightly movable, both vertically and 
 laterally. As the cyst enlarges, it is more in the median 
 line, and displaces the stomach upward (rarely down- 
 
392 THE ABDOMINAL ORG Am. 
 
 ward). The transverse colon either overlies it or is 
 pushed downward. It may attain to such a size as to 
 fill the entire abdominal cavity, with compression of the- 
 bile ducts (jaundice), of the portal veins (ascites) and 
 of the vena cava (oedema of the lower extremities). 
 Pulsations over the tumor are frequently very pro- 
 nounced, and, although they are transmitted from the 
 aorta, may give a slight expansile sensation, and on 
 auscultation often a bruit. Examination of the patient 
 on the hands and knees removes these features, sug- 
 gestive of abdominal aneurism. 
 
 Differential Diagnosis. — Cysts of the pancreas cannot 
 by physical signs be differentiated from effusion or 
 hemorrhage into the lesser cavity of the peritoneum. 
 Hydatid cysts of the liver, spleen or peritoneum may 
 closely resemble cysts of the pancreas. They are some- 
 what more movable and elastic, and frequently give 
 fluctuation or hydatid thrill. Aspiration and examina- 
 tion of the fluid chemically, showing it to be non- 
 albuminous, and microscopical evidence of booklets 
 determines their nature. Ovarian cyst may give similar 
 signs on external palpation. Vaginal (bimanual) 
 examination, however, shows its relation to the pelvic 
 organs. 
 
 In hydronephrosis the most prominent portion of the 
 abdomen is usually situated to the right or left of the 
 median line. The lower portion of the tumor extends to 
 the brim of the pelvis. It is oblong, and the colon 
 usually crosses its long axis toward its inner side and 
 not transversely, as in pancreatic cysts. 
 
 Liver. — ^Normally, with abdominal walls of ordinary 
 thickness, the liver cannot be felt at the lower border 
 of the ribs, except where the left lobe crosses the epi- 
 gastrium. In persons with very lax walls, and espe- 
 cially in women who have borne children, the liver may 
 be felt in the right mammary line at or a little below the 
 free border of the ribs. In children the relatively large 
 size of the liver renders it more palpable. 
 
PALPATION. 393 
 
 In palpation of the liver attention is paid to the fol- 
 lowing: (1) Position of the lower margin and the 
 degree to which it extends below the free border of the 
 ribs, and in the epigastric region. (2) Its consistency. 
 (3) The condition of its surface, whether even or tin- 
 even. (4) Its edge, whether sharp, rounded or irregu- 
 lar. (5) Presence of pain or tenderness. (6) To what 
 extent the change in the liver has involved other 
 abdominal organs, especially the occurrence of jaundice, 
 ascites and enlargement of the spleen. The diagnosis 
 of the nature of the changes occurring in the liver 
 depends largely upon the relative preponderance of 
 these physical signs. 
 
 The edge of the liver may be felt below its normal 
 area, on account (A) of displacement without increased 
 size; (B) of enlargement of the liver, either uniform or 
 irregular. 
 
 (A) Displacement of the liver may be due (1) to 
 interthoracic conditions which depress the diaphragm, 
 and with it the liver, as enlargement of the lungs from 
 emphysema, asthma, pneumonia and tumors of the lung. 
 Effusion into the right pleural cavity, pneumothorax, 
 mediastinal growths, pericardial effusions, cardiac 
 hypertrophy and dilatation, also effusions into the left 
 pleural cavity, may cause localized displacement of the 
 left lobe without any marked change in position of the 
 right. (2) Sub-diaphragmatic conditions, as collections 
 of fluid or pus between the diaphragm and liver. (3) 
 Prolapsus of the liver from tight lacing, enteroptosis 
 and deformities dependent upon rickets and spina] 
 caries. 
 
 The degree of displacement will depend upon the 
 causal factors ; the shape, size, consistency and condition 
 of edge and surface are usually normal unless enlarge- 
 ment of the liver is a complication. In prolapsus of the 
 liver, in addition to the ordinary respiratory movements, 
 there is an independent mobility, due to the loose attach- 
 ment of the organ. 
 
ddi THE ABDOMINAL ORGANS. 
 
 Differential diagnosis between displacement of the 
 liver without enlargement and trvie enlargement of the 
 viscus is made by the percussion outline. 
 
 (B") I. Uniform Enlargements of the liver may be 
 due (1) to circulatory changes Avhich may be active, as 
 occur in hot climates and in acute inflammatory condi- 
 tions, and those dependent upon infectious diseases 
 (malaria, typhoid and scarlet fevers, measles, yellow 
 fever, small-pox, etc.) ; passive congestion dependent 
 upon interference with circulation in the hepatic vein, 
 due to cardiac or obstructive pulmonary diseases or 
 ]>ressure on tlic vena cava. (2) Blood diseases. 
 Leukaemia, Hodgkin's disease, and pernicious anajmia. 
 (3) Degenerations of the liver (fatty liver, amyloid 
 liver, hypertrophic cirrhosis, diffuse syphilitic hepa- 
 titis.). (4) Obstructive disease of the bile ducts (jaun- 
 dice), either primary or secondary. 
 
 II. Irregular Enlargements or Tumors or the 
 LiVEu, due to cancer, hydatid and abcess, also 
 syphilitic liver. These conditions may produce uniform 
 enlargements. At times irregular enlargement of the 
 liver may be due to prolongation of the lower portion of 
 the organ and from the effects of pressure of tight lacing. 
 
 (1) Congestions of the liver. In simple, active 
 hyperaemia of the liver the enlargement is slight. The 
 lower border is felt just below the free edge of the ribs 
 and slightly lower than normal in the epigastric region. 
 The consistency is slightly increased, the surface is 
 smooth and the edge well defined. In acute infectious 
 diseases, especially typhoid fever in the early stage, the 
 enlargement is identical with that of simple congestion, 
 later changes in the liver cause it to become larger, 
 softer, and the lower margin cannot be so readily 
 felt. In other infectious diseases the liver shows vary- 
 ing degrees of enlargement and consistency, but the 
 normal shape remains. Tenderness is present when- 
 ever the peritoneal covering is stretclied or inflamed. 
 
 In passive congestion of the liver the enlargement is 
 
PALPATION. 395 
 
 in proportion to the anionnt of interference witli the 
 circulation. Secondary changes cause the organ to 
 become harder; the surface is smooth, the ed.oes sharp 
 and well defined. With secondary interference witli 
 the portal circulation, ascites occur. Jaundice occurs in 
 secondary intestinal catarrh. Chronic congestion of the 
 liver may also he due to malarial infection and residence 
 in the tropics. 
 
 (2)^ In leuksemia, Hodgkin's disease, pernicious 
 anieniia and diabetes the enlargement of the liver is 
 uniform, and varies with the severity of the disease. 
 In leukaemia and Hodgkin's disease it is relatively less 
 marked than the enlargement of the spleen and' lym- 
 phatic glands. Tlie normal outline of the organ is 
 retained; it is harder than normal, and the edges are 
 usually sharp and well defined; the surface is smooth. 
 
 (3) In fatty liver the organ is uniformly enlarged 
 and of normal shape. The enlargement may be very 
 marked, and the lower edge reach almost to the crest of 
 the ilium and below the umbilicus. The feel is soft and 
 elastic ; the surface is smooth, the edges round and well 
 defined, and the outline can be easily made out by slight 
 pressure. It is not tender to pressure, and is not 
 attended with interference with portal circulation or 
 enlarged spleen. 
 
 Hypertrophic cirrhosis has many of the features of 
 fatty liver. Its enlargement may be great, and it is 
 harder than normal; the su.rface is smooth, and the 
 edges sharper and well defined. With contraction of 
 the connective tissue, there is diminution in size ; the 
 liver becomes harder, the surface and edges irregular, 
 but the nodules are small, assuming gradually the 
 features of cirrhosis with enlargement. The organ is 
 not tender to pressure unless associated with peri- 
 hepatitis. 
 
 In amyloid liver the enlargement is marked, but the 
 liver has a hard, resistant feel, and the surface is smooth, 
 with sharp, well-defined edges ; sometimes, however, they 
 
396 THE ABDOMINAL ORGANS. 
 
 may be rounded. The edge of tlie liver cannot be 
 moulded by firm pressure. Pain and tenderness are 
 absent. Ascites occurs in the later stages. 
 
 In diffuse syphilitic hepatitis the liver is larger and 
 firmer than normal; the surface is smooth; the edges 
 are sharp and well defined, similar in many respects to 
 the condition noted in amyloid liver. 
 
 Syphilis of the liver may cause the organ to be 
 nodular when gummata are formed, and when contrac- 
 tion of the fibrous tissue causes depressed areas with 
 intervening nodules or bosses of hypertrophied liver tis- 
 sue. The enlargement may be marked, extending nearly 
 to the umbilicus. The consistency of the nodular masses 
 varies according to the amount of connective tissue 
 present. Gummata, when close to the surface, are more 
 resistant than normal liver tissue. The enlargement of 
 the liver is not rapid, and the nodules increase in size 
 slowly. 
 
 Cancer of the liver may cause enlargement to a vary- 
 ing degree. Though it is usually massive, it may 
 involve certain portions of the organ to a greater extent 
 than others ; but the enlargements may be fairly uni- 
 form. The consistency is not uniform, the cancerous 
 masses being harder than other portions. The surface 
 is irregular, and the irregularities may be felt as bosses 
 or nodules of varying sizes. Frequently at the apex of 
 a nodule a depression (umbilication) can be felt, and 
 this is diagnostic of malignancy. These tumors may, 
 however, be soft or semi-fluctuating. The edges are 
 usually irregular, due to the projection of cancerous 
 grovrths and to contraction of the liver substance. There 
 is more or less tenderness on pressure over the prominent 
 areas when the new growth involves the peritoneal coat. 
 Ascites and jaundice occur in 50 per cent, of all cases. 
 
 Abscess may develop in different portions of the 
 liver, and cause irregular enlargement upward into 
 the thorax or downward below the free border of 
 the ribs and in the epigastric region, or outward through 
 
PALPATION. 397 
 
 the thoracic walls. When central, it may cause a more 
 or less uniform enlargement of the organ. When it 
 develops upward, the liver is displaced downward, but 
 has the normal outline and characteristics. When the 
 tumor develops from the lower portion of the liver, it is 
 more or less globular ; its surface is smooth, and fluctua- 
 tions may be detected when the abscess is close to the 
 surface. Pain and tenderness are variable. 
 _ Hydatid cysts of the liver may cause enlargement 
 similar in many respects to that of abscess. When the 
 cyst is situated on the lower border of the organ, the 
 mass is globular, soft and fluctuating, and at times the 
 hydatid thrill may be detected. They are painless 
 unless attended with localized peritonitis. 
 
 (4) Obstructive disease of the bile ducts, primary 
 and secondary, causes hepatic enlargement. The 
 enlargement is usually slight, the consistency but little 
 firmer than normal, the surface smooth and the edges 
 well defined. Interference with portal circulation and 
 enlargement of the spleen occur according to the nature 
 of the cause (see Gall Bladder). 
 
 Differential Diagnosis. — Differentiation by palpation 
 of the uniform enlargements of the liver from each 
 other and from displacements through thoracic or sub- 
 diaphragmatic conditions has been described in consider- 
 ing the different diseased conditions of the organs, and 
 will be further discussed under percussion and ausculta- 
 tion. 
 
 The irregular enlargements may be simulated by 
 other tumors occurring in organs adjacent to the liver. 
 The most prominent of these are accumulations of 
 fa3ces about the hepatic flexure of the colon (see Intes- 
 tine), cancer of stomach (see Stomach), right renal 
 enlargement (see Kidney), puckered or indurated 
 omentum (see Omentum), and tumors of the abdominal 
 wall. Usually the differentiation is made not only by 
 the signs obtained from palpation, but from those 
 obtained by percussidn and auscultation, together with 
 
398 THE ABDOMINAL ORGANS. 
 
 the secondary effects of these tumors upon organs with 
 which they are connected. 
 
 The most important features of tumors of the liver 
 are their motility, their parietal situation and their 
 well-defined relation to the edges of the liver, jaundice 
 and ascites. Cancerous growths that involve the liver 
 and neighboring organs late in the disease have no dis- 
 tinctive features by which the origin of the growth can 
 be determined, and the differential diagnosis is made 
 from the history and the secondary effects. 
 
 Gall Bladder. — ^When it is empty, the gall bladder can- 
 not be felt, but when moderately distended it may be 
 detected as an ill-defined mass at the edge of the right 
 ninth costal cartilage, close to the outer edge of the 
 rectus muscle, which corresponds to that point at the 
 free border of the ribs where a line drawn from the 
 right acromian process to the umbilicus crosses it. 
 
 Palpable enlargements of the gall bladder are due (1) 
 to distension by (a) bile, (b) mucus (hydrops), (c) 
 pus (empyemia) and (d) to gall stones which may be 
 caused by inflammatory conditions or stenosis or obstruc- 
 tion in the cystic or common ducts. (2) To new 
 growths, malignant and benign. 
 
 Enlargements of the gall bladder, from whatever' 
 cause, have certain features in common. The size 
 varies greatly from a scarcely palpable tumor to one 
 of large size; usually, however, it is not larger than a 
 good-sized pear. The degree of enlargement of the 
 same tumor may vary from time to time. The tumor is 
 smooth, rounded and gourd-like, the large end being the 
 most dependent. When the tumor becomes very large, 
 the lower portion becomes more globular in relation to 
 the neck, which is thin. When the distension is due to 
 gall stones, the tumor may have a nodular feel. 
 
 The tumor has a double mobility,^ moving with the 
 Jiver with respiration, and also being more or less 
 freely movable in all directions about its point of attach- 
 iiipnt to the liver, the range of motion being one of the 
 
TABLE FOE DIAGNOSIS OF DISEASES OF THE LIVER— LEU BE. 
 
 SIZE OF MVEU. 
 
 Diminished. 
 
 Simple atrophy. 
 
 Atrophic nutmeg; 
 liver. 
 
 Atrophic cirrhosis. 
 
 Syphilitic liver 
 (atrophic form. 
 rare ) . 
 
 Acute yellow atro- 
 phy. 
 
 Liver al).scess. 
 DiaVietes liver. 
 Congestion. 
 
 Jaundice, ol>- 
 
 strnctive. 
 
 Fatty liver. 
 
 Pa.ssive h y pe r- 
 emia. 
 
 Syphilitie liver. 
 
 Leukaemia. 
 
 Hypertrophic cir- 
 rhosis. 
 
 Amyloiil. 
 
 Carcinoma. 
 Echinot'occu.s. 
 
 :)NSI.STENrV OK LIVER. 
 
 Soft to 
 Kluctiiatinti;. 
 
 Fatty liver. 
 
 Abscess. 
 
 Kehinoooccns 
 imilocularis. 
 
 Firm, a little 
 
 harder than 
 
 normal. 
 
 Simple 
 phy. 
 
 Jaundice. 
 rrypera*mia, 
 
 tro- Ens'oi'Ji'ed. 
 Cirrhosis. 
 Syphilitic livei'. 
 
 Ech i n (n-occiis 
 multilocidaris 
 (beeominj'soft). 
 
 Amyloid. 
 
 Carcinoma. 
 
 Hyiiertro])liit' cir- 
 ri losi.s 
 
 Smooth to Sharp. 
 
 Fatty liver, elas- 
 tic, thrill. 
 
 Jaundice, oh- 
 
 strnctive. 
 
 Hypertrophic cir- 
 rli OS i s (sonif- 
 times slij-htly 
 rounded). 
 
 Echinococcus. 
 
 Simple at)*ophy. 
 
 EDGE OK J.IVEK. 
 
 Thick, 
 Rounded. 
 
 Fatt> liver. 
 Congestion. 
 Aniyioid. 
 
 Cirrhosis (rarely 
 palpable). 
 
 Al)scess. 
 
 Carcinoma. 
 
 Syphilitic liver. 
 
 Tubercle bat'illi. 
 
 SURFACE OF LIVEH. 
 
 Cong'estion. 
 
 Fatty liver. 
 
 J a un d i e f , ob- 
 structive. 
 
 Elephantiasis. 
 
 Amyloid. 
 
 IjcukiT'mia. 
 
 Diabetes liver. 
 
 Acute y e 1 I u w 
 atropliy, 
 
 Cirrhosis. 
 Abscess. 
 Syphilitic liver, 
 Carcinoma. 
 Echinoroccus. 
 
 JAtTNOICE. 
 
 Absent. 
 
 Rare. 
 
 Frefiuent. 
 
 Amyloid. 
 
 (Only when the 
 
 Abscess. 
 
 Fatty liver. 
 
 biliary pas- 
 
 sages are di- 
 
 Congestion. 
 
 Adhesive p^-le- 
 phlebitis. 
 
 rectly involved 
 in the diseased 
 processes). 
 
 Cirrho.sis. 
 Carcinoma. 
 
 
 Echinococcus. 
 
 Echinococcus 
 
 muUilocularis 
 
 
 Syphilitic liver. 
 
 Elephantiasis 
 
 Jaundice, ob- 
 structive. 
 
 Absent. 
 
 Present. 
 Carcinoma. 
 
 Pain Present. 
 
 Fatty liver. 
 
 Echinococcus 
 
 Elephantiasis 
 
 Syphilis with 
 
 multilocularis. 
 
 Jaundice, ob- 
 structive. 
 
 contraction. 
 Echinococcus 
 
 Acute yell o w 
 atrophy. 
 
 Echinococcus 
 
 multilocularis. 
 
 Carcinoma. 
 
 unilocularis. 
 
 Cin-hosis. 
 
 Syphilitic liver. 
 
 Absce-ss. 
 
 Adhesive py le- 
 phlebitis. 
 
 Amyloid. 
 
 Congestion {con- 
 stant in the late 
 stages). 
 
 Abscess. 
 
 EXLAKGEMENT OF THE SPLEEN. 
 
 Absent. 
 
 Carcinoma. 
 Fatty liver. 
 
 Echinococcus unilocularis (rarely from stasis in the 
 portal system). 
 
 Congestion. 
 
 Syphilitic liver. 
 
 Cirrhosis (atrophic). 
 
 Echinococcus multilocularis. 
 
 Hypertrophic cirrhosis. 
 
 Amyloid. 
 
 (Also in acute yellow atrophy and abscess due to the 
 general systemic infection.) 
 
 Note.— In general, the diseases are so arranged in the columns that the individual symptom of each diseafje increases in frequency or intensity as the column is read 
 
 downward. 
 
PALPATION. 399 
 
 diagnostic featiires of the tumor. Generally it can be 
 carried up and caused to disappear beneath tlie liver, 
 and can also be carried to the median line; but it is 
 impossible to displace it downward toward the pelvis. 
 
 Its relations to the liver are well defined ; a sulcus can 
 be usually detected between the enlarged gall bladder 
 and the liver. Fluctuation cannot be detected, as the 
 tumor is usually too tense. The tenderness varies. 
 When due to obstruction from gall stones, pressure over 
 the tumor may cause colicky pains. 
 
 Malignant growths of the gall bladder are usually 
 hard and more or less irregular. The size in this con- 
 dition is not so great as in distension by its contents. 
 
 Enlargement of the gall bladder may be associated 
 with enlarged liver when obstruction of the common bile 
 duct occurs from any cause, and jaundice will then be a 
 marked and persistent symptom. AVhen the obstruc- 
 tion occurs in the cystic duct, j aim dice, if present, is 
 transient, and not intense. 
 
 Differential Diagnosis. — Tumors of the gall bladder 
 may be confounded with prolongations of the lower edge 
 of the liver, with hydatids of the liver, with movable 
 kidneys, tumors of the intestine and tumor of the 
 pylorus of the stomach. 
 
 (1) Abnormal prolongations of the lower border of 
 the liver do not have free mobility, and their outline is 
 usually continuous with the smooth, convex surface of 
 the liver. Their size is permanent. 
 
 (2) Hydatid tumor attached by a pedicle may simu- 
 late an elongated gall bladder. It is more distinctly 
 fluctuating, and frequently hydatid thrill can be 
 detected. It is painless, and, while it is movable, has 
 not the same range of mobility as has the gall bladder, 
 and it is displaced more slowly. 
 
 (3) Movable or floating kidney has many features m 
 common with enlarged' gall bladder. Both tumors are 
 rounded and smooth, but that of the gall bladder is 
 gourd-shaped, the narrow portion projecting toward tlie 
 
400 THE ABDOMINAL ORGANS. 
 
 fissure of the liver, the enlarged lower end lying toward 
 a point just below the umbilicus. The kidney retains 
 its normal shape. The feel of the two is also some- 
 what different. The gall bladder is usually firmer, and 
 when filled with calculi may show an irregular outline. 
 The gall bladder gives the impression of being super- 
 ficial, and it is constantly felt when pressure is made 
 over the front of the abdomen. Movable kidney, on the 
 other hand, is variable in its situation, and it is not 
 always detected in the same position by anterior palpa- 
 tion. The two tumors differ in range of mobility. The 
 gall bladder is influenced by respiration, and the kidney, 
 when situated close to organs that move synchronously 
 with the diaphragm, may also have a similar motion. 
 The gall bladder moves around a fixed point, and can be 
 pushed upward to either side and backward, but not 
 dovsmward into the pelvis; and when displaced behind 
 the liver towards the normal kidney-position it tends to 
 return to its own normal position in front of the 
 abdomen. The kidney moves readily to different loca- 
 tions in the abdomen. It may be carried to the median 
 line and beyond or downward into the pelvis, and 
 upward and backward into the normal position, where it 
 tends to remain until displaced by pressure over the loin 
 or by posture. It slips underneath the examining fin- 
 gers like a "greasy mass." 
 
 When the large intestine is inflated, the gall bladder 
 is pushed up and becomes more prominent. The mov- 
 able kidney disappears behind the intestine, and cannot 
 be felt. 
 
 Tumors of the pyloric region of the stomach, while 
 movable, do not have the same range of motion, being 
 displaced farther to the left beyond the median line, 
 with a more restricted mobility to the right. Associated 
 conditions are usually sufficient for diagnosis. 
 
 Spleen. — The spleen is deeply situated underneath the 
 bony thorax posteriorly, and is normally not palpable, 
 except when the abdominal walls are thin and lax and 
 
PALPATION. 401 
 
 the spleen is slightly movable, and can be pushed for- 
 ward so as to be brought close to the costal margin in the 
 hypochondrium. Frequently, when the spleen is abnor- 
 mally movable, turning the patient on the right side 
 causes it to have an anterior position, and to be felt 
 as a movable tumor. Deformity of the thorax, espe- 
 cially when involving the spine, may cause the normal 
 spleen to be palpable. 
 
 Movable or wandering spleen gives, in addition to the 
 tumor that is felt at the free margin of the ribs, a 
 diminished sense of resistance on palpation over the 
 normal area, and a more tympanitic percussion note. 
 
 EwLAEGEMENTS OF THE Splbeh". — Conditions that 
 increase the spleen in size cause it to develop anteriorly, 
 and to be felt under the free border of the ribs. The 
 enlargements may be uniform or irregular. 
 
 Uniform enlargement occurs (a) in infectious and 
 febrile diseases. In many of these the enlargement is 
 so slight as to be scarcely palpable. In typhoid fever, 
 scarlet fever, small-pox, it is generally palpable, accord- 
 ing to the severity of the disease. In erysipelas, sepsis 
 and pyaemia, also in acute tuberculosis, the enlargement 
 of the spleen may be sufficient to bring its free edge 
 beyond the border of the ribs, (h) In interference with 
 the portal circulation from primary disease of the liver 
 (q. v.), or to cardiac or respiratory disease, (c) In 
 chronic hypertrophy, due to amyloid disease, leukaemia, 
 Hodgkin's disease, splenic anasmia, chronic malarial 
 infection (ague cake), and occasionally in syphilis and 
 tuberculosis. _ _ j --i 
 
 The irregular enlargements occur chiefly in hydatids, 
 
 cancer and abscess. 
 
 The characteristics of splenic tumor are : (1) They 
 
 are superficial, and are not separated from the abdomi- 
 nal walls by any of the abdominal contents. The upper 
 portion disappears under the free border of the ribs, 
 and cannot be defined. (2) They move with respira- 
 tion, and have also a slight independent range of motion 
 26 
 
402 THE ABDOMINAL ORGANS. 
 
 upward and backward on firm pressure. They have 
 passive mobility toward the median line and down- 
 ward when the patient is turned on the right side and 
 put in the knee-chest position. (3) The tumor in 
 uniform enlargements retains the normal splenic con- 
 tour, and when it extends any distance beyond the free 
 border of the ribs the notch can be easily detected. (4) 
 The surface of the tumor is smooth. (5) The consist- 
 ency varies. In acute enlargements, due to infectious 
 and septic diseases, it is soft and yielding; in the more 
 chronic enlargements it is hard and resistant. In the 
 irregular enlargements of cancer, hard, nodular bosses 
 may be felt on the surface. In hydatid cyst, when the 
 tumor can be readily palpated, it is tense, elastic and 
 rounded; fluctuation, however, can rarely be detected, 
 but hydatid thrill may be obtained. 
 
 (6) The edge of the spleen is usually well defined, 
 and, with the notch, is one of the diagnostic features. 
 
 When the consistency of the spleen is soft, the edge is 
 not so distinct as in some chronic enlargements, espe- 
 cially malarial. 
 
 The size of the spleen varies in dijBFerent enlarge- 
 ments. In the chronic enlargements of leukajmia, 
 Hodgkin's disease and malaria the size is greatest. The 
 spleen is rarely painful, except when the peritoneal 
 covering is involved, as occurs in acute inflammation, 
 infarction, syphilis and abcess. Posteriorly, the 
 splenic enlargement does not extend to the median line, 
 so that forcible palpation below the ribs in the flank 
 may enable us to distinguish the edge between the edge 
 of the tumor and the erector spinse muscles. 
 
 Differential Diagnosis. — The acute enlargements of 
 the spleen cannot be difl^erentiated by palpation. When 
 dependent upon engorgement, due to obstructed portal 
 circulation, the enlargement is usually associated with 
 changes in the liver and heart, and there is more or less 
 ascites. 
 
 Of the chronic enlargements, amyloid enlargement is 
 
PALPATION. 403 
 
 rarely great. It is usually associated with similar 
 changes m the liver and kidney, due to prolonged sup- 
 puration. In leukssmia the splenic enlargement is 
 marked, and is attended with anajmia and changes in the 
 superficial glands and liver. In Hodgkin's disease the 
 splenic enlargement is relatively marked, as is also the 
 enlargement of the lymph glands. In ague cake the 
 enlargement closely resembles in size and consistency 
 that of splenic leukemia, and the differential diagnosis 
 is made on the blood examination. 
 
 Enlargement of the spleen in anagmia (splenic 
 anaemia) occurs chiefly in children, and is not attended 
 with blood changes of leukasmia or malarial infection. 
 
 Splenic enlargement may be confounded with other 
 tumors appearing in the left upper portion of the 
 abdomen, the most important of which are fecal accumu- 
 lations in the descending colon and sigmoid flexure. 
 Fnecal masses are distinguished by the absence of 
 respiratory and passive motion, the rounded contour, 
 absence of the notch and sharp edge, the peculiar feel, 
 and the efl^ect of treatment (purgatives). 
 
 Cancer of the stomach, especially of the greater 
 curvature, and the cardia may give an ill-defined tumor 
 under the free border of the ribs. When the tumor 
 becomes palpable in the epigastrium or below the ribs, 
 the hard feel, associated with gastric symptoms, readily 
 distinguish it. 
 
 The differential diagnosis between tumors of the left 
 kidney and spleen will be considered below. 
 
 Kidneys. — The normal kidney cannot be detected by 
 palpation, except in children and in persons who are 
 thin and have very lax abdominal walls, when the lower 
 edge can be felt on bimanual palpation just underneath 
 the free border of the ribs, at the end of a deep inspira- 
 tion. The kidneys may be palpable when they are 
 abnormally movable or wandering, or enlarged. 
 
 Movable kidneys are those which have a range of 
 motion downward toward the pelvis, and which do 
 
404 THE ABDOMINAL ORGANS. 
 
 not extend laterally into other portions of the abdomen. 
 In this condition, when the patient is standing and 
 leaning forward, or at the end of deep inspiration 
 when in the semi-recumbent posture, the kidney may 
 be felt to glide under the hand into the pelvis, so 
 that the upper border can be felt. On change of posi- 
 tion or pressure from below, the kidney slips back into 
 its normal position. The cause of movable kidney may 
 be enteroptosis or emaciation in a person who has once 
 been very stout. It is especially liable to occur in 
 women who have borne children and with overstretched 
 abdominal walls. Anterior curvatiire of the spine, 
 involving the lower dorsal and lumbar vertebrae, fre- 
 quently displaces the kidney forward, so that it is both 
 seen and felt in the anterior portion of the abdomen. 
 
 Wandering kidneys have a wider excursion, and may 
 occupy any part of the abdomen, moving from place to 
 place with ease, according to the posture of the patient 
 and the direction of pressure. The kidney shape is 
 retained, which enables one to recognize the organ ; the 
 borders are rounded, and the hilus is frequently palpa- 
 ble. On firm pressure pain of a sickening character is 
 elicited, frequently radiating down toward the bladder. 
 
 Enxaegements of the Kidney. — Enlargements 
 of the kidney are due to (1) malignant disease (sarcoma 
 and carcinoma), (2) cystic degeneration, (3) hydatid, 
 (4) hydro- and pyo-nephrosis, and (5) perinephritie 
 abscess. 
 
 Kenal tumors are extremely difficult to diagnose, and 
 are frequently confounded with those of other organs. 
 Their most characteristic feature is their relation to 
 the surface. When they reach the anterior portion 
 of the abdomen, their most prominent part is at the 
 umbilicus or just above it. They occupy the space 
 between the crest of the ilium and the costal margin. 
 Posteriorly, they fill the entire space between the lower 
 border of the ribs and the pelvis, causing a smoothing 
 out of the hollow of the loin, but rarely any prominence. 
 
PALPATION. 405 
 
 Forcible palpation in this area gives a uniform resist- 
 ance, extending to the spine. The mobility of the 
 tumors is but slightly influenced by respiration, although 
 when they are large and in contact with the diaphragm, 
 a slight respiratory mobility may be detected, but it is 
 never as marked as in tumors of the liver and spleen. 
 The statements that kidney tumors are totally uninflu- 
 enced by respiration frequently lead to error in 
 diagnosis. 
 
 The size of the tumors varies greatly, and also that of 
 the same tumor from time to time. Tumors due to 
 sarcoma, cystic degeneration and perinephritic abscess 
 are stable in size, and may reach great dimensions, 
 especially sarcoma in young subjects, almost filling the 
 entire abdominal cavity. They rarely cause projec- 
 tion of the lower ribs or fill the pelvis. Those due to 
 hydro- and pyo-nephrosis are more variable in size, 
 according to the degree of distension. 
 
 The uniform enlargements preserve to a marked 
 degree the kidney shape. Perinephritic abscesses, on 
 the other hand, may be somewhat globular. 
 
 The consistency of the tumor varies, being hard and 
 dense in malignant disease and elastic in other forms, 
 varying with the degree of tension. 
 
 Fluctuation can rarely be detected. The relation of 
 enlargement of the kidney to other structures is some- 
 what characteristic. The large intestine usually over- 
 lies the tumor, and can be detected by palpation and 
 percussion. (Fig- 74.) The small intestine may also 
 be between it and the abdominal wall. In exceptional 
 cases the tumor may displace the colon downward and 
 toward the median line on the right side, or carry the 
 descending portion of the colon toward the median line 
 so as not to be covered with it. This relation of the 
 large and small intestines to the tumor overlying it dis- 
 tinguishes it from splenic tumors (Fig. 73), which are 
 always parietal and never have the gut between them and 
 the abdominal wall, and, on the other hand, liver tumor, 
 
406 THE ABDOMINAL ORGANS. 
 
 which is usually parietal, but may occasionally have the 
 small intestine between the abdominal wall and itself 
 when the enlargement is irregular and is associated with 
 ascites. 
 
 Ireegulae Enlaegements. — Irregular enlargement 
 of the kidney by malignant disease or abscess may cause 
 the tumor to lose its reniform shape, making it abnor- 
 mally prominent in one direction ; and may also change 
 the normal relation to the intestine. 
 
 Differential Diagnosis. — Kenal tumors are differen- 
 tiated from splenic tumors by the rounded contour and 
 the absence of the sharp, well-defined edge and notch; 
 also by the presence of intestine over the tumor (per- 
 cussion). The renal tumors are less movable. The 
 renal tumors, if they passed beneath the ribs, leave a 
 palpable sulcus, due to their rounded border. Splenic 
 tumors are in close contact with the anterior surface. 
 Posteriorly, renal tumors occupy the entire space 
 between the free border of ribs and crest of ilium, and 
 the resistance is uniform. In splenic tumors an unoccu- 
 pied area can be detected in the flank, which is also 
 resonant on percussion. 
 
 Hepatic tumors are also parietal at the costal margin, 
 and the free edge of the tumor, with the sharp, well- 
 defined margin, is transverse to the abdomen, following 
 the normal slant of the liver. AVhen renal tumors 
 develop upward, so as to be in contact with the liver, a 
 sulcus can usually be detected between the rounded edge 
 of the tumor and the sharp, displaced edge of the liver. 
 
 Ovarian tumors are parietal, and are surrounded with 
 intestines, giving resonance on percussion. They grow 
 upward from the pelvis, and reach the surface just 
 below the umbilicus, while renal tumors generally 
 develop from behind -forward, and first reach the 
 abdominal wall at or a little above the umbilicus. 
 
 The massive ovarian tumors generally become cen- 
 trally situated, while renal tumors remain unilateral. 
 Ovarian tumors cause displacement of the uterus up- 
 
PALPATIO^ 407 
 
 ward or downward. Renal tumors rarely involve the 
 
 JJC-i V IS. 
 
 Intestines -The different portions of the intestine 
 cannot be distinguished from each other by palpation. 
 Ihe small intestine normally is not palpable. It is 
 possible to feel certain portions of the large intestine 
 when the abdominal walls are thin and relaxed. The 
 sigmoid flexure of the colon can most frequently be 
 detected, and occasionally the head of the cfficum^ and 
 ascending colon. The transverse portion cannot be 
 made out. The appendix is only at times palpable, 
 although the statement is frequently made that it is 
 possible to feel it both by surface and bimanual palpa- 
 tion, one finger being in the rectum or vagina. Dif- 
 ferent portions of the intestinal canal may become 
 palpable when distended with gas or the walls become 
 thickened through muscular contraction or inflammatory 
 products or new growths, or when the canal becomes 
 filled with semi-fluid or solid contents. In simple disten- 
 sion of the intestines, with relaxation of the intestinal 
 walls, the entire abdomen has an air-cushion feel. When 
 the distension is the result of chronic obstruction in any 
 portion of the tract, the hypertrophied intestine may be 
 more or less distinctly felt during peristalsis. 
 
 Localized inflammatory thickening of the intestinal 
 wall may occur at any point. It is rarely palpable in 
 the small intestine, as it is usually associated with nar- 
 rowing of the part and distension of the intestine 
 immediately adjacent. 
 
 Thickening of the csecum, appendix and ascending 
 colon causes a tumor to be felt in the right iliac region. 
 The appendix may be detected as a hard, cord-like mass, 
 more or less freely movable under the finger. When 
 acutely inflamed and associated with peritoneal involve- 
 ment and rigidity of the muscles, the appendix cannot 
 be distinguished as such, but an ill-defined tumefaction 
 or a distinct tumor occupies the appendicular region, 
 with a marked tenderness at a point midway between the 
 
408 THE ABDOMINAL OEGANS. 
 
 anterior superior spine and the iimbilicus (McBurney's 
 point) . 
 
 Involvement of the csBcum, with extension of inflam- 
 mation to surrounding parts (typhlitis), causes a 
 similar tumor to he felt. Abscess formation (peri- 
 typhlitic abscess) in this region, due to inflammation of 
 either appendix or cascum, gives a less resistant tumor, 
 with a sensation of deep-seated fluctuation. 
 
 Cancer of the head of the csecum and iliocsecal valve, 
 producing stenosis, causes a tumor that is hard, resistant, 
 and, unless the neoplasm has extended to surrounding 
 structures, nodular and movable. 
 
 The tTimor of intussusception in this region is smooth, 
 uniform, and not tender on pressure. It is also asso- 
 ciated with distension of the intestine, and may not be 
 palpable. Tympanites is marked. 
 
 Faecal impactions, occurring in the ascending colon, 
 give an oblong tumor with a rounded contour, which 
 may extend from the middle of Poupart's ligament to 
 the imder surface of the liver. The surface may be 
 smooth, but it is usually more or less irregular or 
 lumpy, and on firm pressure an indentation may be 
 caused. When the pressure is removed, the walls sepa- 
 rate slowly from the mass, giving a sensation of sticki- 
 ness (adhesive sympton). When the fa-cal mass io 
 hard, these, symptoms may be absent, and the feel may 
 closely simulate' that of a cancerous tumor. 
 
 Next tq the appendicular region, the most frequent 
 site of tuikdrs' is the left iliac region. The most com- 
 mon tumors here are inflammatory thickening of the 
 intestine secondary to diseases causing ulceration. 
 Inflammatory thickening of the sigmoid flexure fre- 
 quently causes it to be felt as a hard, well-defined, rope- 
 like mass. Fsecal impaction and malignant disease in 
 this region have the same features as elsewhere. 
 
 In examining the intestinal tract by palpation, in 
 addition to tumors, sensitive and painful areas must be 
 noted. The different portions of the canal vary greatly 
 
PALPATION. 409 
 
 in their sensitiveness to palpation. It is most sensitive 
 in the region of the cascum, and epigastrimn midway 
 between the ensiform cartilage and umbilicus. The 
 entire canal may become sensitive in acute intestinal 
 irritation, whether inflammatory or not. Local inilam- 
 mation of the intestine causes increase in sensitiveness, 
 and when the peritoneum is involved there is localized 
 pain, with increased rigidity of the overlying muscles. 
 
 Differential Diagnosis. — In addition to the tumors 
 already noted, the ilac regions may be invaded by tumors 
 from the pelvic organs, as ovarian tumors, cysts, espe- 
 cially of the broad ligaments, pelvic abscess, extra- 
 uterine pregnancy, or by hernias and abscess burrow- 
 ing along the psoas muscles. These are differentiated 
 usually by vaginal examination. 
 
 Pelvic Organs. — Tumors may arise from the uterus 
 and adnexa. Tumors of the uterus may be due to 
 pregnancy, fibro-myomata or fibroids. In pregnancy 
 the tumor is ovoid, smooth, freely movable laterally, and 
 in proportion as it extends above the pelvic brim the 
 diagnostic signs of contractions and foetal movements are 
 detected. Distension of the uterus from retained men- 
 strual flow and from growths may give the contractile 
 symptoms of pregnancy. 
 
 Fibroid tumors of the uterus may simulate pregnancy, 
 as far as size, shape and mobility are concerned, but 
 they lack the contractile sign. When they involve only 
 one portion of the uterine wall they give an irregular 
 
 tumor. 
 
 Ovarian tumors are usually felt in the iliac regions, 
 and as they increase in size assume more the medial 
 position. They are usually cystic, and have a round, 
 smooth, elastic feel. Fluctuation can at times be 
 detected. Examination per vaginam shows their rela- 
 tion to the broad ligaments and uterus. They are_ difler- 
 entiated from ascites and renal tumors by percussion. 
 
 Parovarian cysts have many features of ovarian cysts 
 As they are usually thin-walled, fluctuation is a marked 
 symptom. 
 
410 THE ABDOMINAL ORGANS- 
 
 Distended bladder may give a tumor occupying tlie 
 lower portion or the entire abdominal cavity. Its shape, 
 smoothness and elasticity cause it to simulate ovarian 
 tumors, ascites, pregnancy and pancreatic cysts. The 
 possibility that a large abdominal tumor occupying the 
 median position may be a distended bladder should 
 always be borne in mind, and the viscus should be 
 examined by catheter before excluding this condition. 
 
CHAPTEK XVII. 
 
 PERCUSSION. 
 
 By percussion it is possible to outline the borders of 
 the solid organs of the abdomen, and by the relative 
 degree of dullness or flatness to determine their relation 
 to the air-containing (resonant) organs of the thoracic 
 and abdominal cavities. 
 
 When two solid organs are in contact, as the left lobe 
 of the liver and heart, it is impossible to define their 
 borders by simple percussion, although at times ausculta- 
 tory percussion aids in doing this by showing slight dif- 
 ferences in the percussion note. The borders of the 
 stomach, large and small intestine, can be determined 
 only approximately, as will be explained later. 
 
 For percussion the posture of the patient is the same 
 as described under Palpation. The fingers should 
 always be used both as hammer and plexiraeter. The 
 strength of the percussion stroke should be regulated 
 according to the nature of the organ percussed, whether 
 solid or hollow, and its relation to the surface and to 
 organs and tumors giving a different note. The per- 
 cussion note is still further modified by the nature of 
 the parietes, as the abdominal cavity is inclosed in part 
 by the bony thorax and in part by the abdominal walls, 
 varying in thickness and tension. As there is marked 
 normal regional variation, it is necessary to be thor- 
 oughly familiar with the percussion sounds present in 
 the usual anatomical divisions of the abdomen. 
 
 Left Hsrpochondrium. — This region includes that por- 
 tion of the abdominal cavity lying beneath the ribs on 
 the left side of the body. The vault of the diaphragm 
 
412 THE ABDOMINAL ORGANS. 
 
 rises as high as the level of the fifth rib. The upper 
 portion of this area is occupied by the thoracic viscera 
 ■ — heart and lungs, and by the abdominal organs — 
 left lobe of the liver, stomach and spleen — and the per- 
 cussion sound varies accordingly. Over that portion 
 where the heart and liver are parietal the note is flat. 
 Just below the area of flatness, toward the edge of the 
 costal arch, the thin left lobe of the liver gives a super- 
 ficial dullness on light percussion, while on forcible 
 percussion a tympanitic quality can be obtained from 
 the underlying stomach. To the left of the area of 
 cardiac and liver flatness the lung is parietal from the 
 fifth to the lower border of the sixth rib, and the sound 
 is that of pulmonary resonance, with added tympanitic 
 quality from the stomach. The proportion of the two 
 sounds varies with the force of the percussion and the 
 condition of the stomach and lung, pulmonary resonance 
 increasing when the lung is overdistended, as in full 
 inspiration or emphysematous dilatation; diminishing 
 with retraction of the lung from any cause, and becom- 
 ing flat when the complemental space of the pleura is 
 filled by effusion. Distension of the stomach or dis- 
 placement upward of this organ by increased abdominal 
 pressure causes a relatively higher position of the dia- 
 phragm and corresponding increase in stomach reso- 
 nance. ^ 
 
 PIalp-Moow Space (Traube). — This embraces all 
 that portion of the lower thorax below a concentric line 
 starting from the cardio-hepatic fiatness in the sixth 
 interspace, and extending downward to the anterior 
 axillary line or mid-axillary line, which corresponds 
 approximately to the lower border of the lung. In this 
 space the stomach is parietal, and the note is high 
 pitched and tympanitic, with a peculiar metallic, echo- 
 like quality (stomach tympany). 
 
 The percussion note over this space may be altered by 
 a number of conditions. (1) The upper boundary may 
 be invaded by pulmonary resonance, due to increase in 
 
PERCUSSION. 413 
 
 Size of the lung, with depression of the diaphragm. 
 (2) Tt may ho flat from depression of the diaphragm by 
 pleurisy with effusion. (3) The normal stomach 
 tympany may he replaced by flatness, due to the filling 
 of the organ with food or liquid. (4) Enlargement 
 anteriorly of the left lobe of the liver from any cause 
 may give an area of flatness or dullness. (5) Toward 
 the axillary line in the region of the ninth to the eleventh 
 rib enlargement of the spleen may give dullness or 
 flatness. (6) Distension of the colon may give ch tinge 
 in the tympanitic sound. 
 
 The Splenic Area. — This area is to the left of the 
 half -moon space, and limits it in that direction. Although 
 the spleen is contained in the abdominal cavity, with its 
 long axis parallel to the tenth rib, and occupying the 
 space between the ninth and the tenth ribs from the 
 mid-axillary line in front to within 1% to 2 inches of 
 the vertebral column behind, under normal conditions 
 but a small portion of its anterior border approaches the 
 surface. On account of its respiratory and passive 
 mobility, its position and corresponding effect on the 
 percussion note will vary according to the posture of 
 the patient. When lying on the back, it is displaced 
 posteriorly; when lying on the right side, it is laore 
 anterior, but further removed from the surface. In the 
 erect posture its position is more nearly horizontal, and 
 slightly lower. It is impossible to accurately outline 
 the normal spleen by percussion, surroimded and in part 
 overlapped as it is by air-containing structures. The 
 dullness obtained is only relative to the pulmonary 
 resonance above and stomach tympany anteriorly, intes- 
 tinal tympany below and flatness of lumbar muscles and 
 kidney posteriorly. 
 
 To determine the splenic area dullness, the percvission 
 blow must vary according to the nature and condition of 
 the overlying structures. Over the portion covered by the 
 lung, beginning beyond the normal area, the percussion 
 is first made toward the spleen with fairly strong blows 
 
414 TSE ABDOMINAL ORGANS. 
 
 until slight deep-seated relative dullness is detected. 
 From this point the percussion proceeds with gi'adually 
 diminishing force. From the gastric and intestinal 
 borders only light percussion is used. In the normal 
 condition of the lung, with stomach and intestine empty 
 and not distended with gas, a small area of splenic dull- 
 ness may be detected in the mid-axillary line or between 
 it and the post-axillary line and between the lower edge 
 of the ninth and upper edge of the eleventh ribs. Beyond 
 this area the splenic dullness becomes progressively 
 masked by increased pulmonary resonance as percussion 
 proceeds toward the posterior border. 
 
 The size and position of the area of splenic dullness 
 varies with the respiratory movements, being larger at 
 the end of expiration and smaller or disappearing dur- 
 ing inspiration. On account of the relation of the 
 spleen to surrounding organs, the normal area of splenic 
 dullness may be replaced (a) by increased resonance; 
 (b) increased dullness or flatness. Increased resonance 
 over the splenic area may be due to depression of the 
 lower border of the left lung, dependent upon emphy- 
 sema or to distension of the stomach and intestines, large 
 and small, with gas (tympanites). Diffused dullness 
 in the splenic area may be caused by consolidation of the 
 lung overlapping the spleen, left pleural effusion or 
 pleural thickening ; fluid distending the stomach, or fiU- 
 ing of the transverse portion or splenic flexure of the 
 colon with faeces; also by general ascites. Absolute 
 increase in splenic dullness occurs in all enlargements of 
 the spleen, and when that organ becomes more parietal. 
 On account of the effect of surrounding organs upon 
 splenic dullness, the diagnosis of enlargement of the 
 spleen should not be made by percussion alone, but the 
 results should be corroborated by palpation. 
 
 Right Hypochondrium. — In the right hypochondriimi 
 all of that portion of the abdominal cavity that is 
 covered anteriorly by the thorax is occupied by the liver, 
 the upper border of which rises as high in the mammary 
 
PFAUVSSION. 
 
 415 
 
 Jhk^ as the. fifth rih, corn.spm.iing tu the dome of the 
 
 Pereu.ssiuu over the liver gives two an-as. TIio first 
 correspomls ^vith t],at pertiou win..], is separafd fnnu 
 the thoraeie wall by the lung— tiie area ef relative ,lull- 
 ness; and the second, that portion where the liver is 
 parietal — the area of liver fiatness. 
 
 Fig. 
 
 Absolute and relative heart and liver dullness, also ret^ional variation 
 in thorax. 
 
 The pneumo-hepatic border ef the liver corresponds 
 to a line that separates the relative lie])atic dullness 
 from hepatic flatness. The position of this liorder and 
 the area of hepatic flatness will vary according to the 
 condition of the right lung, the border being lower and 
 the area of hepatic flatness smaller with full inspiration 
 and ill einphysema, and the border being elevated with 
 
416 THE ABDOMINAL ORGANS. 
 
 increase in the area of flatness in expiration and diminu- 
 tion of the size of the lung. The relative liver dullness 
 cannot be detected over the entire upper portion of the 
 liver, as the pulmonary tissue is too thick for the liver 
 to be reached by the percussion vibration. (Fig. 72.) 
 
 The point at which the influence of the underlying 
 liver upon pulmonary percussion will be detected Avill 
 depend markedly upon the force of the percussion blow, 
 which will also influence the determination of the 
 pneumo-hepatic border. Proceeding from above down- 
 ward, the percussion blows should be progressively 
 lighter as the lower border of the lung is approached, 
 where only the lightest stroke should be employed. 
 
 The pneumo-hepatic border should be determined by 
 percussion from the area of relative dullness to absolute 
 flatness, and also beginning over the flat area by per- 
 cussing toward the area of relative dullness until faint 
 resonance is detected. Normally the pneumo-hepatic 
 border extends from the base of the ensiform cartilage 
 in the median line to the upper border of the sixth rib 
 in the mammary line, and to the eighth rib of the mid- 
 axillary line. Well-marked liver dullness extends one 
 or more interspaces higher, gradually shading off into 
 pure pulmonary resonance. 
 
 The area of absolute flatness on the anterior portion 
 of the chest extends from the pneumono-hepatic border 
 to the free border of the ribs. Over the lower portion 
 the thinness of the liver permits percussion vibration to 
 reach the underlying air-containing organs, and gives 
 a slight tympanitic quality to the note. 
 
 CowDiTioifS Modifying the Aeea of Flatness 
 OvEE THE LivEE. — The area of liver flatness may be 
 enlarged upward by : 1. Changes in the thoracic organs 
 due to (a) consolidation of that portion of the lung over- 
 lying the liver, (h) Ketraction of the lung, causing 
 greater portion of the liver to become parietal, (c) 
 Effusion into the right pleural cavity or thickening of 
 the pleura. 2. Displacement of the liver upward from 
 
PERCUSSION. 4-lY 
 
 any cause. In this condition the lower edge of the liver 
 is also raised above the normal limit. 3. Absolute en- 
 largement of the liver, which may be uniform or irreg- 
 ular, corresponding to the conditions noted under Pal- 
 pation. In these conditions the enlargement of the liver 
 upward is not so great as downward, except when 
 secondary changes produce increase in the intra-abdomi- 
 nal pressure and displacement upward of the liver and 
 diaphragm. 
 
 In irregular enlargements or tumors, the outline 
 corresponds to the location of the tumors. 
 
 Extension of the area of flatness downward may be 
 due to displacement from thoracic disease, causing 
 descent of the diaphragm and liver. In this condition 
 the liver may be forced down below the free edge of the 
 ribs, and the area of absolute dullness is only relatively 
 increased, the pneumono-hepatic border being also 
 depressed. Absolute enlargement of the liver, uniform 
 or irregular, causes the area of flatness to extend accord- 
 ing to the change occurring in the liver. 
 
 Solid tumors or fluid extending to the liver cause the 
 flatness to extend beyond the normal liver area. 
 
 Decrease in the area of hepatic flatness may be 
 apparent or absolute. It is seemingly diminished 
 whenever the area of normal flatness is encroached upon 
 by distension of the lung above or by the stomach or 
 intestine below. The greatest diminution in the size of 
 the liver occurs in cirrhosis and in acute yellow atrophy. 
 
 The True Abdomen. — Percussion of all the anterior 
 portion of the abdomen not inclosed by the thorax gives 
 a tympanitic note, due to the underlying air-containing 
 organs. In the epigastrium the stomach is overlapped 
 by the left lobe of the liver, which is too thin to prevent 
 the percussion vibration reaching the stomach. On 
 light percussion, slight dullness due to the liver may be 
 
 The percussion note obtained over the stomach, large 
 and small intestines, is tympanitic in quality, and varies 
 
 27 
 
418 ri-TE ABDOMINAL ORGANS. 
 
 slightly in pitch over the different segments, according to 
 the amount of air contained and the tension of the walls ; 
 but it is difficult to determine accurately the outline of 
 the stomach and large and small intestines, on account 
 of their varying size and degree of distension. 
 
 To determine the lov^^er border of the stomach, it is 
 examined when filled with fluid or artificially distended 
 with air. When the patient is in the recumbent posture, 
 the fluid gravitates to the most dependent portion; the 
 note obtained over the viscus on percussion is tympa- 
 nitic, and its lower limit is separated from the adjacent 
 large intestine by a difference in pitch. The patient 
 then assuming the upright position, the fluid — the 
 amount of which may be increased by drinking water — 
 causes the lower segment, which was previously tym- 
 panitic, to become flat on percussion. 
 
 Distension of the stomach by forcing air through a 
 stomach tube, or by the production of carbon dioxide by 
 having the patient drink separately a solution of tartaric 
 acid (3ss) and one of bicarbonate of soda (3ss), causes 
 the note to become markedly tympanitic and ringing. 
 When it is not safe to cause forcible distension of the 
 stomach, the large intestine may be distended by forcing 
 gas from a Davidson syringe into the rectum, and so 
 causing a difference in the pitch of the distended colon 
 from that of the more relaxed stomach. 
 
 CoiroiTioNs MoDiFYiiTG Abdomiwal Kesonance. 
 Thickened Abdominal Walls. — Increased thickness 
 of the abdominal walls, especially when due to fat, and 
 also accumulations of fat in the omentum (omental 
 lipoma), cause a slight diminution of resonance over the 
 entire abdomen, which, however, is not sufficient to 
 obliterate the tympanitic resonance of the stomach and 
 intestines, but which masks the normal outline of the 
 solid organs and renders the detection of tumors difficult, 
 especially when they are small and not entirely parietal. 
 
 Fluid in the Abdominal Cavity^ Ascites. — A 
 small amount of fluid does not modify the percussion 
 
PERCUSSION. 419 
 
 note over the abdomen, as the fluid gravitates to the most 
 dependent portion, according to the posture. When 
 sufficient in amount to rise above the symphysis in the 
 erect position and above the heavy muscles of the flank 
 in the recumbent posture, it gives a flat note where it is 
 parietal, and, as the intestines are floated on the surface 
 of the liquid, a tympanitic note is found above its level, 
 which is always horizontal. 
 
 As the fluid moves freely in the abdominal cavity, the 
 line of flatness and the area of tympany change with 
 alteration of posture. As the fluid gives a flat note, like 
 that of solid organs, it is always necessary to change the 
 position of the patient in determining whether or not 
 the extension of dullness beyond the normal limits is due 
 to effusion into the abdominal cavity or to absolute 
 increase in size of the solid organs. 
 
 When the abdominal cavity is extensively distended 
 with fluid, or when the fluid is encapsulated, free move- 
 ment may not occur. Although usually the intestines 
 float above the fluid, adhesions or short 'mesentery may 
 bind them down so as to prevent this. 
 
 The relation of the area of tympanitic resonance to 
 that of flatness is important in differential diagnosis of 
 flatness due to ascites from abdominal tumors. In 
 ascites, with the patient in the recumbent posture, the 
 area of tympantic resonance occupies the centre of the 
 abdomen around the umbilicus, changing position with 
 that of the patient, and always resuming the uppermost 
 position; while in solid tumors which are parietal the 
 dullness . occupies the most prominent portion of the 
 abdomen, and is surrounded by tympanitic resonance, 
 which does not change with altered posture. 
 
 Abdominal Tumoes. — ^Abdominal tumors cause 
 diminution in resonance according as they are parietal. 
 
 Tumors of the stomach and intestine are rarely large 
 enough to give well-marked flatness, although when 
 associated with thickened peritoneum there may be a 
 slight diminution of resonance. 
 
420 
 
 THE ABDOiTIKAL 0J1GAN8. 
 
 Fiucal aceumiilatioiis in tlie large intestine may be 
 detected by percussion, as they are usually parietal. 
 They may easily be detected when they occupy the 
 
 Fig. 73. 
 
 Fig. 74. 
 
 Flatness 
 
 Tumor of spleen. 
 -Kesoiiance between po.sterior margin 
 and lumbar niuseles. 
 
 Tumor of left kidney. 
 
 caecum, the ascending colon or the sigmoid flexure. 
 When situated in the hepatic or splenic flexures, they 
 increase the areas of dullness of liver or spleen. 
 
PERCUSSION. 421 
 
 Enlargements of the liver and spleen, when they 
 extend beyond the ribs into the abdominal cavity, give 
 well-marked areas of flatness, sharply defined by the 
 surrounding intestines. The enlarged organs are parietal, 
 but it is only in exceptional conditions that a portion of 
 the intestine intervenes between it and the abdominal 
 wall. Tumors springing from the under surface of the 
 liver, as hydatids, or irregular enlargements, as cancer, 
 may have intestine in front. 
 
 Posteriorly the liver dullness does not extend to the 
 spine, but well-marked splenic dullness may extend to 
 the spine in the upper portion, while lower down there 
 is an area of resonance between the tumor anteriorly 
 and the edge of the lumbar muscles posteriorly. (Fig. 
 73.) 
 
 Tumors of the kidney are not parietal throughout, 
 and the area of flatness is usually divided by the colon 
 in front of it. Posteriorly the flatness extends to the 
 spine throughout. (Fig. 74.) 
 
 In tumors of the pelvic organs the dullness extends 
 upward from the pubic arch, and is surrounded by 
 intestinal resonance in the flank and above. Dullness 
 over the tumors may be diminished by distension of tho 
 , intestine with gas (meteor ism) or by air in the peri- 
 toneal cavity (perforative peritonitis). 
 
 When dullness in the flank is present, not extending 
 also to the central zone of the abdomen, with resonance 
 between the dullness and the central portion of the 
 abdomen and the pelvic brim, the tumor is not of pelvic 
 origin, but is from the deeper tissues (pancreas, retro- 
 peritoneal glands, etc.). 
 
CHAPTEK XVIII. 
 
 AUSCULTATION. 
 
 Auscultation of the abdominal organs gives very 
 little aid in differential diagnosis, and is limited to (a) 
 splashing sounds made in hollow organs containing both 
 air and fluid ; (b) gurgling, churning or cooing sounds, 
 due to passage of fluid through the intestinal canal; 
 (c) friction sounds, produced by the roughened peri- 
 toneum over solid or hollow organs which move with 
 respiration ; (d) vascular or haemic sounds. 
 
 (a) Splashing sounds (succussion) may be heard over 
 the stomach and large intestines when they are agitated 
 with short, sharp blows with the tips of the fingers. 
 
 In the stomach this occurs when the viscus contains 
 both air and fluid and is to a certain degree relaxed. It 
 was formerly considered diagnostic of gastroectasis, but 
 can occur without any pathological condition of the 
 stomach being present. Its chief value as a sign of 
 enlarged stomach is in finding it persistently below the 
 normal limit of the stomach. 
 
 Over the csecum, on account of the liquid character of 
 its contents, succussion sounds may also be produced. 
 When found beyond the head of the caecum, especially in 
 the transverse portion of the colon, it indicates an abnor- 
 mally liquid state of the fsecal mass in these locations. 
 In the small intestine succussion cannot be induced. 
 
 (b) Gurgling or churning sounds are heard over the 
 stomach and intestines, due to the passage of liquida 
 from the narrowed portions into the wider areas beyond. 
 Over the cardia, normally, a hissing murmur is heard 
 soon after swallowing liquids. In obstruction at the 
 
AUSCULTATION. 423 
 
 cardia from any cause, the normal deglutition sound 
 niay be replaced by a gurgling or rushing sound occur- 
 ring at a relatively later period, and due to the forcing 
 of the contents of the cesophag-us through the obstruction. 
 
 Over the small and large intestines, normally, cooing, 
 gurgling sounds are heard. When the intestines are 
 distended with gas and the peristaltic activity is 
 increased, this may become loud enough to be heard at 
 some distance from the patient. 
 
 In tympanites with lessened peristalsis, as occurs in 
 paralysis of the intestines, and in peritonitis, absence of 
 this normal sound in proportion to the distension is of 
 diagnostic importance. 
 
 Over the ileo-csecal valve, gurgling can frequently be 
 heard on firm pressure. This has been frequently cited 
 as one of the symptoms of typhoid fever, but it is not 
 pathognomonic of this disease, as it occurs whenever the 
 contents of the small intestine are more liquid than 
 normal and when there is slight distension of the ileum 
 with gas. 
 
 (c) Friction sounds are heard whenever the peritoneal 
 coats are covered with inflammatory exudate and there 
 is free movement between the surfaces. This is most 
 marked in perihepatitis and perisplenitis, provided the 
 normal respiratory mobility of the liver and spleen is 
 not interfered with. It is rarely heard over hollow 
 organs, although in acute localized inflammation of the 
 stomach it may be present. The quality of the sound 
 will vary according to the character of the exudation. 
 In fibrinous exudation it occurs as fine, crackling rales. 
 When adhesions are present, creaking, crumpling fric- 
 tion sounds may be heard. 
 
 (d) Vascular or hsemic murmurs may be heard over 
 different portions of the abdomen. Solid tumors and 
 growths pressing on the aorta or large blood-vessels may 
 cause sufiicient narrowing to induce a murmur, which 
 is conveyed by the tumor to the surface, and is heard as 
 a bruit, synchronous with the first sound of the heart, 
 
424 THE ABDOMINAL 0BGAN8. 
 
 or it may be a little delayed. Aneurismal dilatation of 
 the aorta or abdominal vessels may cause a similar mur- 
 mur to be heard. They are differentiated from pressure 
 murmurs by the presence of expansile pulsations. 
 
 Over the liver a systolic murmur may be heard, due 
 to the conveyance of tricuspid regurgitant murmur, 
 
 In tumors of the uterus, arterial sounds may be 
 present. In pregnancy, in addition to the uterine 
 souffle, there is heard the foetal heart beat. Hsemic 
 sounds, simulating the uterine souffle, may also be heard 
 in extra-uterine pregnancy and in vascular tumors of 
 the uterus, but the foetal heart sound is not heard.. 
 
PAET Y. 
 EXAMINATION^ WITH X RAY. 
 
 For making X-ray examination of the body, it is 
 necessary to have apparatus of great power, and also 
 means for adjusting tHe quality of the ray emitted by 
 the tiibe, which may be accomplished either by inserting 
 a series of spark caps in the circuit connecting the tube 
 or by adjusting the vacuum of the tube. There are on 
 the market a number of tubes provided with vacuum 
 regulating devices, all of which depend for their action 
 upon the liberation of a little gas from some salt which 
 is contained in a small chamber connected with the tube. 
 
 The exciting apparatus maybe either a static machine, 
 an ordinary induction coil, or a coil of high frequency 
 type. If an induction coil is used, it should be capable 
 of delivering heavy sparks, 10 or 15 inches long, and 
 should be provided with means for giving very rapid 
 interruptions of the primary circuit. The turbine mer- 
 cury interrupters and the liquid or electrolytic interrup- 
 tions are available for this purpose. The induction 
 coil has the advantage that it occupies a comparatively 
 small space, and its action is not affected by the weather. 
 If the static machine is used, it should be of a rather 
 large size, having, for example, 10 to 16 revolving plates 
 of about 30 inches diameter. The static machine gives 
 a very steady excitation of the Crookes tube, and is 
 therefore very satisfactory for fluoroscopic examina- 
 tions. It is, however, more or less susceptible to 
 changes in weather conditions. 
 
426 EXA^IINATJON WITH X BAY. 
 
 Qn account of the constant movements of respiration, 
 the fluoroscope examination of the thoracic viscera is 
 perhaps more satisfactory than the radiograph. Much 
 valuable information may be obtained by observing the 
 movements of the parts, as, for example, the excursions 
 of the diaphragm, the pulsations of the heart or of 
 aneurism, the change of level of fluid in the pleural 
 cavity, due to change of position of the subject, etc. 
 The facility with which these examinations can be made 
 and the accuracy of their findings will vary with dif- 
 ferent subjects. Obviously, a small, thin subject will 
 give a more satisfactory fluoroscopic picture than a large, 
 muscular one. At first it may seem that by increasing 
 the intensity and penetrating pov^er of the rays we could 
 examine a large subject as well as a small one, but this 
 is not the case. It is easy enough to produce X rays 
 of sufficient intensity to penetrate any human body, but 
 in order to make a satisfactory fluoroscopic examination 
 or radiograph it is necessary that these rays be inter- 
 cepted to varying extents by the different structures 
 under examination, so that they will cast shadows of 
 diseriminable density. A thick layer of muscular or 
 adipose tissue, although it may transmit the ray, to a 
 certain extent confuses the shadow of substances of less 
 capacity which lie beneath it; hence it is impossible to 
 differentiate the tissues under examination by increas- 
 ing the power of the X rays. 
 
 Fluoroscopic examinations should be made in a dark- 
 ened room. It will be found that it takes the average 
 eye from five to fifteen minutes to adjust itself so as to 
 use the fluoroscope to the best advantage. All clothing 
 should be removed from the patient, and the examina- 
 tions can be conveniently made with the patient in a sit: 
 ting position, with the arms resting over the head, so as 
 to draw the scapulae away from the median line. It is 
 well to have two fluoroscopes^a large one, which will 
 show the entire region, and a small one, with which 
 small parts may be examined and the light from a large 
 
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PLATE VIT. 
 
 Radiograph of Diffuse Tuberculosis of the Left Lung. 
 (Fihrold chauges very maried). 
 
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EXAMINATION WITH X RAY. 427 
 
 area excluded. Sometimes it will be convenient to 
 examine the patient in a recumbent position. In this 
 case It is well to place the subject on a stretcher, placing 
 the tube underneath and the fluoroscope above. The 
 canvas of the stretcher offers very little obstruction to 
 the X ray. A protective screen 'of thin aluminum is 
 sometimes interposed between the X-ray tube and the 
 subject under examination, to prevent any burning by 
 the rays. This screen offers very little obstruction to 
 the X ray, and therefore interferes very little with the 
 examination. 
 
 For the reasons pointed out above, the radiograph of 
 the thorax will usually not be so satisfactory as the 
 fluoroscopic examination, though it may be valuable as a 
 permanent record. The apparatus required for making 
 the radiographs will be practically the same as those 
 described for fluoroscopic examinations, with the addi- 
 tion of necessary plates, etc. 
 
 Observation by means of the X ray of the thorax and 
 abdomen presents many points of interest to the 
 clinician. A thorough knowledge of the normal appear- 
 ance of the different parts of the body under the X ray 
 is absolutely necessary for the proper use of the fluoro- 
 scope, and for correct interpretation of the skiagraphs 
 as a means of diagnosis, otherwise false interpreta- 
 tion will be made. The use of the X ray in medicine 
 should be accompanied by the use of other methods of 
 diagnosis, and should never be relied upon alone. 
 
 For the beginner, the subject to be examined should 
 be carefully selected. A young person, preferably an 
 adult male about twenty years old, and not too fleshy, is 
 the best. It should be constantly borne in mind that 
 each subject will present a picture that has certain 
 individual peculiarities, according to the thickness of 
 the soft parts, the bony structures and antero-posterior 
 diameter of the chest. The fluoroscope has many advan- 
 tages over the skiagraph for a beginner, as the outlines 
 are more distinct, and it is possible, by varying the 
 
428 EXA3IINATI0.N WITH X RAY. 
 
 intensity of the light, to oUain a better view of the 
 thoracic and abdominal organs and to determine their 
 
 The Normal Picture. — As in other methods of diagno- 
 sis, the examination should be systematically conducted. 
 At first a general inspection of the thorax from above 
 downward is made. The picture upon the screen shows 
 in the median line corresponding to the sternum, spinal 
 column and mediastinal spaces, a dark shadow at the 
 level of the third rib, which widens out into a more or 
 less spherical figure, corresponding to the ventricles, and 
 resting on the dome of the diaphragm, which appears as 
 a dark line. On either side of this central shadow ap- 
 pears a light field, corresponding to the pulmonary tis- 
 sue, which should present a thin, foggy, uniform shadow, 
 varying during the phases of the respiratory act, being 
 lighter on full inspiration and darker at the end of 
 expiration, according to the rarefaction of the lung. 
 Traversing the light area of pulmonary tissue, the ribs 
 are noted, their prominence varying with the intensity 
 of the light used. Beyond the thorax, the bony 
 structures and soft parts are readily distinguishable. 
 (Plates III and IV.) 
 
 In addition to the outline of the organs above men- 
 tioned, the extent of their motion should also be noted. 
 Ventricular contraction is well defined, also slight pul- 
 sation of the aorta can be seen. The line of the dia- 
 phragm varies with the respiratory act, descending with 
 inspiration, when the complemental spaces of the pleura 
 become distinguishable as a transparent area. The 
 movements of the diaphragm should be uniform, both 
 sides acting simultaneously and to the same extent. 
 With the descent of the diaphragm and rarefaction of 
 the lung, the cardiac position changes and the outline 
 becomes more distinct. 
 
 The Effect of Changes in the Lung on the Fluoroscopic 
 Picture. — These may cause the shadows to be more 
 intense and darker when the density of the lung is 
 
EXAMINATION WITS X BAY. 429 
 
 cliarigod by increase in the normal structure or by fill- 
 iiig of the alveolar spaces ; or the opposite when rarefac- 
 tion of the lung occurs from increased size of the 
 alveolar spaces, or when there is destruction of tissue 
 with cavity formation. They may also cause change in 
 the movements of the diaphragm and in the position of 
 the heart and mediastinal structures. 
 
 Conditions Causing Dark Areas. — Tuberculosis. It 
 should be borne in mind that the right apex is not so 
 markedly transparent as the left. This corresponds to 
 the normal- variation noted under palpation, percussion 
 and auscultation. The amount of darkening will corre- 
 spond to the degree of change. (Plates V and VI.) 
 
 As in other methods of examination, the fluoroscoijic 
 picture of the two sides is comparative, and should 
 always be judged on this basis. When the tubercular 
 area is central and surrounded by emphysematous lung, 
 the shadow of the affected portion is more pronounced. 
 
 In the incipient cases a slight denseness in the shadow 
 will be observed in one apex when carefully considered 
 in comparison with clearness of the normal shadow, and 
 with the apex on the other side. As the pathological 
 process extends until consolidation or cavity results, the 
 shadow will progressively become deeper and larger 
 until the change on the two sides is very marked. The 
 fibroid changes are evident by the absence of the normal 
 foggy shadow and by a more dense shadow over the areas 
 involved. (Plate VII..) This condition is often 
 noticeable in the lower portion of the chest, secondary to 
 the diaphragmatic involvement. Eetraction and thiel<:- 
 ening of the pleura give a darker shadow, and marked 
 loss of motion over the affected area. (Plate VIII.) 
 
 Pneumonic consolidation. In lobular pneumonia 
 the dark areas correspond to the site of the lesion, and 
 have the same general appearance as those of tubercular 
 infiltration. Croupous pneumonia gives a well-defined 
 shadow, corresponding to the degree of consolidation 
 and the division of the lobes. Kadioscopy aids greatly 
 
430 EXAMINATION WITH X BAY. 
 
 in differentiating pneumonia from primary or compli- 
 cating effusion, showing the relation of the lung to the 
 diaphragm. In pneumonia, on full inspiration, the 
 descent of the diaphragm shows a light line between the 
 lung and the moving shadow of the diaphragm. When 
 effusion occurs, primary or secondary, this line is not 
 seen. Pleural effusions cause a uniform dark shadow. 
 The character of the fluid does not influence this shadow. 
 In addition to the shadow caused' by the fluid, it is 
 possible to determine the line that the fluid assumes in 
 the chest and the amount of displacement of the thoracic 
 viscera. 
 
 Calcareous deposits in the lung or flbroid thickening 
 also cause slight shadows. The bronchi may give an 
 ill-defined shadow on either side of the median dark 
 space, and must always be considered. Enlargements 
 of the glands cause shadows to appear. 
 
 Conditions Causing Lighter Shadows. — The lung 
 transmits light more readily in emphysema, and 
 there is less change of shadow during respiration. 
 The movements of the diaphragm are not as great; 
 the heart appears unusually clear, and also assumes the 
 typical position. In pneumo- and hydro-pneumothorax 
 the shadow is less marked over that portion of the pleura 
 which contain air (Plate IX), while when fluid is pres- 
 ent a dark shadow is seen below its level. The upper 
 level assumes a horizontal line, in contradistinction to 
 the curved line seen in simple effusion. In hydro- 
 pneumothorax the splashing of the fluid is plainly seen 
 on shaking the patient, and also the change of level on 
 his changing position. The pulmonary shadow is pres- 
 ent above the level of the fluid, and is slightly deeper in 
 density, owing to the compression. In pneumothorax 
 the lack of motion of the diaphragm during inspiration 
 is the most striking feature. The displacement of the 
 heart and the relatively denser shadow of the opposite 
 lung are diagnostic. Cavity formation also gives a well- 
 marked light area. When the walls of the cavity con- 
 
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EXAMINATION WITH X HAY. 431 
 
 tain calcareous deposit, or tlie cavity is surrounded by 
 consolidated lung, a shadow may replace the light area. 
 
 Examination of the Circulatory System. — For satisfac- 
 tory examination of the borders of the heart, the lung 
 and pleura must be clear. ISTormally a dark shadow is 
 caused by the ventricles, while the right auricle causes 
 a faint shadow to be seen just to the right, and on the 
 left a fainter shadow is caused by the left auricle. The 
 rarefaction of the lung causes these shadows produced 
 by the auricles to become clearer, so that they are more 
 pronounced at the end of full inspiration than in expira- 
 tion, and also in emphysematous dilatation than in nor- 
 mal lung. Dilatation of the cavities or distension by 
 blood causes a correspondingly darker shadow. As has 
 been mentioned, the intensity of the shadows will vary 
 according to the amount of light used. The pulsations 
 of the heart and aorta may be seen, especially during 
 inspiration. 
 
 The exact cardiac outline can be mapped out on the 
 chest by means of an indelible pencil; the lower end 
 encircled in the metal cylinder. After carefully outlin- 
 ing the heart and locating the apex, the tracing can be 
 made direct from the chest wall. The tracing should 
 include the nipple and one or two bony parts of the 
 chest. This chart can be filed and retained as a perma- 
 nent record. (See Fig. 66.) 
 
 Cardiac Diseases. — The fluoroscope, in selected cardiac 
 cases, will materially assist in determining the cardiac 
 area, shape and relation to the surrounding viscera. In 
 the following diseases important points will be enumer- 
 ated in detail : u • j • • 
 
 Peeicaeditis with Effusion. — The fluid m peri- 
 carditis changes the shape of the cardiac shadow, giving 
 the broad base below; the pulsating apex is less 
 visible A point of great value in this condition can 
 be noted on deep inspiration ; as the diaphragm descends 
 the pericardium can be seen to pull away from the 
 cardiac mass, and is distinguished by the slight change 
 
432 EXAMINATION WITH X BAY. 
 
 in density between the pericardial fluid and the cardiac 
 wall. 
 
 Adhesive Pbeicabditis. — The displacements due to 
 retraction are visible, and also those which occur when 
 the pericardium is displaced by fibroid changes in the 
 lung. 
 
 Hypeetbophy and Dilatation. — Changes in size 
 and in. the shape of the cardiac shadow can be,, by means 
 of the scheme outlined above, readily observed and 
 recorded accurately for future observation. (Plate X. ) 
 
 MiTEAL Stenosis.-^— The change in. the shape of the 
 heart in this condition is very noticeable. The axis of 
 the shadow is changed ; the apex is carried upward and- 
 to the left, aiid the long diameter is almost parallel with 
 the diaphragm.. 
 
 Aneueism. — The localization of aneurism at the 
 base of the heart, or involving the arch of the aorta, is 
 probably one of the most important results of fluoro- 
 scopic work. The bulging of the vascular wall can be 
 noted accurately, and its relation to the base of the heart 
 or great vessels plainly demonstrated. (Plates XI and 
 XII.) 
 
 The Radiograph in Cardiac Diseases.^ — The radiograph 
 in cardiac diseases has been of much less assistance than 
 the fluoroscope, ^yet, where, available, it places in _oue 
 hands an absolute picture of. the conditions under con- 
 sideration. In many subjects a radiograph can be 
 obtained which will determine the outline and position 
 of the heart, location and size of the aneurisms of dif- 
 ferent portions of the aorta. 
 
PLATE XII. 
 
 oaiadiograph of Aneurism of Ascending Portion of Thoracic Aorta. 
 
INDEX. 
 
 Abdomen, auscultation of, 422 
 decrease in size of, 381 
 enlargements of, 377 
 causes of, 377 
 
 local, 379 
 epigastric region, 379 
 hypogastric region, 380 
 lateral region, upper left, 380 
 right, 380 
 lower left, 381 
 right, 380 
 umbilical region, 379 
 inspection of parities, 376 
 movements of, 376 
 respiratory, 376 
 visceral, 377 
 percussion of, 411 
 regional anatomy of, 33 
 superficial limits of, 18 
 true limits of, 18 
 
 percussion of, 416 
 tumors of, percussion over, 420 
 Abdominal walls, palpation of, 
 383 
 tension of, 383 
 tumors of, 383 
 Abscess of liver, 396 
 
 of spleen, 402 
 Actinomycosis, 206 
 
 condition of lung in, 206 
 physical signs of, 206 
 stages of, 206 
 Adherent pericardium, 353 
 cardiac sounds in, 361 
 differential diagnosis of, 363 
 friction sounds in, 361 
 retractiou of chest wall in, 
 355 
 Adventitious sounds, 112 
 
 iEgophony, 137 
 
 in pericarditis with effusion, 
 360 
 Alar chest, 41 
 Amphoric breathing, 112 
 
 resonance, 137 
 AuEEmia, arterial pulsations in, 
 230 
 pernicious, liver in, 395 
 venous pulsation in, 231 
 Anaemic murmurs, 277 
 
 in pulmonic area, 340 
 Aneurism of aorta, 365 
 
 apex beat in, 367, 369, 370 
 bruit in, 371 
 
 bulging of chest wall in, 367 
 cardiac sounds in, 371 
 diastolic murmur in, 371 
 differential diagnosis of, 372 
 differentiated from aortic 
 stenosis, 326 
 from asthma, 191 
 Drummond's sign in, 371 
 dysphagia in, 369 
 fluoroscopic examination of, 
 
 432 
 forms of, 365 
 palpation, 240 
 physical signs of, 367 
 pressure signs in, 366 
 pulsating tumor in, 367 
 pulse in, 369 
 Sanson's sign in, 371 
 superficial veins in, 367 
 thrill in, 368 
 tracheal tugging in, 369 
 traction of pupil in, 367 
 of thoracic aorta, 229 
 Aneurismal murmurs differen- 
 tiated from pulmonary obstruc- 
 tion, 341 
 
i34 
 
 INDEX. 
 
 Angle of Ludovici, 19 
 Aorta, aneurism of, 365 
 
 apex beat in, 367,. 369, 370 
 bruit in, 371 
 
 bulging of chest wall in, 367 
 cardiac sounds in, 371 
 diastolic murmur iu, 371 
 differential diagnosis of, 372 
 differentiated from asthma, 
 
 191 
 Drummond's sign in, 371 
 dysphagia in, 369 
 physical signs of, 367 
 pressure signs in, 366 
 pulse in, 369 
 Sanson's sign in, 371 
 superficial veins in, 367 
 thrill in, 368 
 tracheal tugging in, 369 
 traction of pupil in, 367 
 arch of, 30 
 percussion of, 265 
 thoracic, aneurism of, 229 
 Aortic diastolic murmurs, 291 
 interspace, 19 
 
 pulmonic, 19 
 regurgitation, arterial pulsa- 
 tions in, 230 
 capillary pulse in, 230 
 causes of, 328 
 differentiated from mitral 
 
 stenosis, 319 
 effects of, 328 
 
 location of apex beat in, 330 
 murmurs in, 333 
 physical signs of, 330 
 pulsation of blood-vessels in, 
 
 331. 
 pulse in, 332 
 
 water hammer, 332 
 sound, accentuation of, 273 
 stenosis, 330 
 area of cardiac flatness in, 
 
 324 
 causes of, 320 
 diagnosis of pathological 
 
 condition in, 325 
 differential diagnosis of, 326 
 differentiated from tricuspid 
 
 regurgitation, 348 
 effects of, 321 
 location of apex beat in, 322 
 
 Aortic stenosis, murmur of, 324 
 physical signs of, 322 
 pulse in, 323 
 thrill in, 323 
 systolic murmurs, 289 
 
 differentiated from pul- 
 monary obstruction, 341 
 valve, 31 
 Apex beat, cause of, 222 
 
 conditions modifying charac- 
 ter of, 224 
 extent of, 224 
 location of. 224 
 influence of abdominal 
 changes on, 229 
 bony thorax on, 224 
 in children, 224 
 in old age, 224 
 changes in heart on, 227 
 in lung on, 236 
 in mediastinum on, 229 
 in pericardium on, 227 
 of soft parts on, 224 
 of diseases of pleura on, 225 
 location of, 222 
 in aneurism of aorta, 367 
 
 369, 370 
 in aortic regurgitation, 330 
 in aortic stenosis, 322 
 in mitral regurgitation, 
 
 305 
 in mitral stenosis, 314 
 in myocarditis, 350 
 in pericarditis with ef- 
 fusion, 354 
 in pneumo-perlcardium, 
 
 364 
 in tricuspid regurgitation, 
 346 
 palpation of, 234 
 
 Influence of bony thorax 
 on, 235 
 of cardiac changes on, 
 
 237 
 of changes in lung tissue 
 on, 236 
 in pericardium, 237 
 in pleura on, 236 
 of posture on, 234 
 of soft parts on, 235 
 in pulmonary regurgitation, 
 342 
 
INDEX. 
 
 435 
 
 Appendicitis, 407 
 Appendix, palpation of, 407 
 Arterial murmurs, 297 
 pulsations, 230 
 in anaemia, 230 
 in aortic regurgitation, 230 
 in chlorosis, 230 
 conditions causing, 230 
 cardiac, 230 
 vascular, 230 
 in Grave's disease, 230 
 in rigid blood-vessels, 230 
 Arterio-capillary fibrosis. See 
 
 Arterio-solerosis. 
 Arterio-sclerosis, 374 
 cardiac changes of, 374 
 cardiac sounds in, 374 
 murmurs in, 374 
 physical signs of, 374 
 stages of, 374 
 
 superficial blood-vessels in, 374 
 Artery, pulmonary, 30 
 Ascites, 385, 418 
 abdomen in, 386 
 causes of, 386 
 
 differential diagnosis of, 387 
 fluctuation in, 386 
 Asthma, 41, 186 
 causes of, 186 
 condition of lungs between 
 
 attacks, 187 
 condition of lungs during 
 
 attacks, 186 
 differential diagnosis of, 189 
 physical signs of, 187 
 Atelactasis, 163 
 Ausculatory percussion, 94 
 Auscultation of abdomen, 422 
 sounds heard in, 422 
 of abdominal organs, 422 
 of the circulatory system, 266 
 of cough, 137 
 of the heart, 266 
 of lung, 96 
 methods of, 96, 266 
 
 technique of, 97 
 of thorax, 96 
 use of stethoscope in, 266 
 of uterus, 424 
 Axillary region, 20 
 
 B 
 
 Baeeel-shaped chest, 40 
 Bell sound, 138 
 tympany, 138 
 Bladder, distended, 410 
 Blood-vessels, impulse due to 
 changes in, 229 
 palpation of, 240 
 pulsation of, in aortic regurgi- 
 tation, 331 
 rigid, arterial pulsations in, 230 
 superficial, in arterio-sclerosis, 
 374 
 Brain, diseases of, irregular pulse 
 
 due to, 252 
 Breath sounds, alteration in 
 duration of, 109 
 in quality and pitch of, 111 
 in rhythm in, 109 
 amphoric, characteristic of, 
 
 133 
 blowing, 112 
 
 causes of prolonged expira- 
 tory, 109 
 cavernous, characteristic of, 
 
 133 
 changes in intensity of, 108 
 character of, 99 
 conditions modifying con- 
 duction of, by columns of 
 air, 123 
 conduction of, by air, 99 
 
 by tissue, 100 
 difference between inspira- 
 tory and expiratory, 105 
 dry rales in, 127 
 effects of changes in bronchi- 
 oles and alveoli on, 102 
 of consolidation on, 131 
 of plugging of bronchus 
 on, 128 
 exaggerated or compensa- 
 tory, 123 
 high-pitched, 112 
 influence of bronchi on, 126 
 of changes in pleura on, 139 
 of increase in size of air 
 
 spaces on, 132 
 of increase of tissue in the 
 walls of bronchi and 
 alveoli on, 130 
 
436 
 
 INDEX. 
 
 Breath sounds, influence o£ 
 larynx on, 124 
 of movement of tidal air 
 
 on, 123 
 of tension on, 129 
 of thoracic walls on, 140 
 intensity of, 99 
 laryngeal, 98 
 
 modification of, in different 
 divisions of bronchi, 100 
 through tissue conduction, 
 101 
 moist r&les in, 128 
 normal, elements of, 104 
 
 physiology of, 97 
 regional variations of, 106 
 tracheal 112 
 tubular, 112 
 types r.f, 107 
 Broadbent's sign, 227 
 Bronchi, influence of, on breath 
 sound, 126 
 position of, 22 
 Bronchial breathing in pericar- 
 ditis, with efiusion, 360 
 pure, 112 
 Bronchiectasis, 153 
 causes of, 153 
 
 differential diagnosis of, 155 
 differentiated from ietid bron- 
 chorrboea, 157 
 from gangrene, 157 
 from general bronchitis, 157 
 from localized empyema 
 opening into a bronchus, 
 158 
 from pulmonary abscesses, 
 
 157 
 from pulmonary tuberculosis, 
 156 
 physical signs of, 153 
 Bronchitis, 141 
 acute, 141 
 
 differential diagnosis of, 147 
 differentiated from acute 
 diffuse pulmonary tuber- 
 culosis, 148 
 from broncho-pneumonia, 
 
 148 
 from chronic osderaa, 149 
 physical signs of, 142 
 chronic, 149 
 
 Bronchitis, chronic, differential 
 diagnosis of, 152 
 physical signs of, 151 
 varieties of, 150 
 classification of, 141 
 of the larger tubes, 141 
 of the middle sized tubes, 142 
 of the smaller tubes, 142 
 of the smallest tubes, 142 
 Bronchophony, 135 
 Broncho-pneumonia, 161 
 
 differentiated from acute 
 
 bronchitis, 148 
 phthisis. See pulmonary 
 tuberculosis, acute 
 Broncho-vesicular breathing. 111 
 Bronchus, left, branches of, 23 
 plugging of, effect on breath 
 
 sounds, 128 
 right, branches of, 23 
 Bruit in aneurism of aorta, 371 
 
 Cancek of intestines, 408 
 of liver, 396 
 of pancreas, 390 
 .Capillary pulse in aortic regurgi- 
 tation, 230 
 Cardia, 34 
 Cardiac dilatation, 348 
 
 differentiated from adherent 
 
 pericardium, 363 
 irregular pulse due to, 252 
 dropsy. See Cardiac (Edema 
 dullness, areas of, influence of 
 bony thorax on, 262 
 of cardiac changes on, 
 
 264 
 of changes in pericar- 
 dium on, 263 
 of lung on, 262 
 of pleura on, 262 
 soft parts on, 261 
 normal, conditions modi- 
 fying, 260 
 outline of, 257 
 in mitral regurgitation, 
 307 
 in consolidation of lung, 263 
 in dilatation of heart, 264 
 of left ventricle, 264 
 
index:. 
 
 •±37 
 
 Cardiac dullness in emphysema, 
 262 
 in hypertrophy of heart, 264 
 in hypertrophy of ventricle, 
 
 264 
 in pericarditis, 263 
 in pericarditis with effusion, 
 
 356 
 in retraction of left lung, 263 
 superficial and deep areas of, 
 
 32 
 in thickening of pleura, 263 
 dyspnoea, characteristics of, 232 
 differentiated from asthma, 
 189 
 from emphysema, 186 
 types of, 232 
 flatness, area of, in aortic 
 stenosis, 324 
 influence of bony thorax 
 on. 262 
 areas of, influence of cardiac 
 changes on, 264 
 of lung on, 262 
 of changes in pericar- 
 dium on, 263 
 of pleura on, 262 
 of soft parts on, 261 
 in mitral regurgitation, 
 
 307 
 normal conditions modi- 
 fying, 260 
 outline of, 258 
 
 method of determining, 
 258 
 in consolidation of lung, 263 
 in dilatation of heart, 264 
 
 of left ventricle, 264 
 in emphysema, 262 
 in hypertrophy of heart, 264 
 
 of left ventricle, 264 
 in pericarditis, 263 
 
 with effusion, 356 
 in retraction of left lung, 263 
 in thickening of pleura, 263 
 hypertrophy, 348 
 differentiated from adherent 
 pericardium, 363 
 impulse in myocarditis, 350 
 murmurs, 276 
 
 oedema, differentiated from 
 renal, 232 
 
 Cardiac sounds in aneurism of 
 aorta, 371 
 in arterio-sclerosis, 374 
 
 changes in rhythm of, 
 275 
 in embryocardia, 275 
 in cantor or gallop 
 rhythm, 275 
 in reduplication of 
 sounds, 276 
 intensity of, changes in, 271 
 diminution of, 274 
 first sound, 274 
 second sound, 275 
 increase of, 272 
 first sound, 273 
 second sound, 273 
 modifications of, 271 
 in myocarditis, 351 
 normal, characteristics of, 
 
 267 
 in pericarditis with effusion, 
 
 360 
 in pneumo-pericardium, 364 
 weakness, irregularity of pulse 
 in, 249 
 Cardio-pulmonary sounds, 300 
 Cardio-respiratory murmurs, dif- 
 ferentiated from mitral regur- 
 gitation, 312 
 Cartilage, eiisiform, 19 
 
 xiphoid, 19 
 Catarrh, pulmonary, 161 
 Catarrhal pneumonia, dissemi- 
 nated, 161 
 Cavernous breathing, 112 
 
 resonance, 137 
 Chest, alar, 41 
 barrel-shaped, 40 
 bilateral enlargement of, 41 
 emphysematous, 40 
 normal, description of, 38 
 physiological departures 
 from, 39 
 paralytic, 41 
 pathological, 40 
 local bulgings of, 49 
 depressions or retractions 
 of, 50 
 phthisical, 41 
 pigeon breasted, 44 
 pterygoid, 41 
 
438 
 
 INDEX. 
 
 Chest, rachitic types of, 43 
 
 unilateral diminution in size 
 of, 48 
 enlargements of, causes of, 
 46 
 Cheyne-Stokes breathing, 57 
 Chlorosis, arterial pulsations in, 
 230 
 venous pulsation in, 231 
 Circulatory system, auscultation 
 of, 266 
 fluoroscopic examination of, 
 
 431 
 palpation of, 233 
 percussion of, 256 
 Circumscribed aneurism of aorta, 
 
 365 
 Cirrhosis of lung, 174 
 Cog-wheel breathing, 109 
 Coin resonance, 138 
 Congestion of lung, 138 
 Consumption. See Pulmonary 
 
 Tuberculosis 
 Corrigan's pulse, 332 
 Cough, auscultation of, 137 
 Crepitations, 116 
 dry, 120 
 moist, 121 
 Cyanosis in obstruction of pul- 
 monary artery, 339 
 Cylindrical aneurism of aorta, 
 
 365 
 Cysts of pancreas, 391 
 
 Depressions, local, of chest, 
 
 causes of, 50 
 Diaphragm, 17 
 
 Diastolic murmurs, rhythm of, 
 280 
 
 Dilatation, cardiac, 348 
 
 physical signs of, 349 
 Drummond's sign in aneurism of 
 aorta, 371 
 
 Dry pericarditis, 352 
 Dynamic murmurs, 278 
 Dysphagia in aneurism of aorta, 
 
 369 
 Dyspnoea, expiratory, 143 
 
 inspiratory, 143 
 
 Ellis, curved line of, 213 
 
 Emphysema, 178 
 cardiac dullness in, 262 
 flatness in, 262 
 condition of lung in, 179 
 differential diagnosis of, 185 
 differentiated from cardiac dys- 
 pnoea, 186 
 from hydro-pneumo thorax, 
 
 185 
 from pneumo-thorax, 185 
 effects of, 179 
 physical signs of, 180 
 pulmonary, 41 
 types of, 178 
 varieties of, 178 
 
 Emphysematous chest, 40 
 
 Endocardial murmurs. See Mur- 
 murs, Cardiac 
 
 Endocarditis, acute,diff'erentiated 
 from pericarditis, 361 
 
 Ensiform cartilage, 19 
 
 Epigastric fossa, 19 
 
 Exoeardial murmurs, 297 
 
 F^CAL impaction, 408 
 Fibrinous pericarditis, 352 
 Fibroid phthisis, 174 
 Flint murmur, dilferentiated 
 
 from mitral stenosis, 320 
 Florid phthisis. See Pulmonary 
 
 Tuberculosis, Acute 
 Fluoroscopic examinations, 425. 
 See also X ray 
 of adhesive pericarditis, 432 
 of aneurism, 432 
 of circulatory system, 431 
 of hypertrophy and dilata- 
 tion of the heart, 432 
 of mitral stenosis, 432 
 of pericarditis with effusion, 
 431 
 picture, conditions causingdark 
 areas in, 429 
 effect of calcareous deposits 
 on, 430 
 changes in lung on, 428 
 fibroid changes on, 429 
 
INDEX. 
 
 439 
 
 Fluoroscopic picture of normal 
 thorax, 428 
 
 pleural effusion in, 430 
 Fremitus friction, 67 
 splashing or succussion, 68 
 vocal, causes of, 60. See also 
 
 Vocal Fremitus 
 Friction, fremitus, 67 
 
 in pericarditis, 356 
 sounds, 120 
 
 creaking, 121 
 
 dry, 120 
 
 grating 121 
 
 grazing, 121 
 
 leathery, 121 
 
 moist, 121 
 
 in pericarditis, 359 
 
 pleuro-perieardial, 300 
 
 rasping, 121 
 
 rubbing, 121 
 Functional murmurs, 278 
 Fundus, 34 
 Fusiform aneurism of aorta, 365 
 
 Gall bladder, enlargements of, 
 398 
 causes of, 398 
 characteristics of, 398 
 palpation of, 398 
 tumors of, 398 
 differential diagnosis of, 
 399 
 Galloping consumption. See 
 Pulmonary Tuberculosis, Acute 
 Gaseous pulse, 253 
 Gerhardt's change of sound in 
 
 percussion, 86 
 Grave's disease, arterial pulsa- 
 tions in, 230 
 Gurgles, 119 
 
 H 
 
 H^Mic murmurs. See Anasmic 
 Murmurs, differentiated from 
 aortic stenosis, 327 
 
 Half-moon space, 412 
 
 Harrison furrow, 44 
 
 Harsh breathing. 111 
 
 Heart, apex of, 29 
 auricles of, 30 
 auscultation of, 266 
 cavities of, 29 
 
 dilatation of, differentiated 
 from pericarditis with ef- 
 fusion, 362 
 diseases of, diagnosis of, 301 
 effect of pleurisy on, 210 
 hypertrophy of, differentiated 
 from pericarditis with ef- 
 fusion, 362 
 influence of changes in, on 
 apex beat, 227 
 on percussion sound, 90 
 palpation of, 233 
 percussion of, 256 
 reginal anatomy of, 29 
 surface markings of, 30 
 Hemorrhagic infarction differen- 
 tiated from lobar pneu- 
 monia, 173 
 pericarditis, 353 
 Hinted or indistinct bronchial 
 
 breathing, 111 
 Hodgkin's disease, liver in, 395 
 
 s^een in, 402 
 Hydatid cysts of liver, 397 
 
 of pleura, 217 
 Hydro-pneumo-thorax, 219 
 differentiated from emphysema, 
 
 185 
 physical signs of, 219 
 Hydro-thorax, 41, 218 
 physical signs of, 218 
 Hypertrophic cirrhosis, liver in, 
 
 395 
 Hypertrophy cardiac, 348 
 physical signs oi, 349 
 Hypochondrium, left, percussion 
 of, 411 
 right, percussion of, 414 
 Hysterical breathing, differen- 
 tiated from asthma, 191 
 
 I 
 
 INDBTERMINATE breathing. 111 
 Infarction of spleen, 402 
 Infraclavicular fossse, 19 
 Infrascapula region, 20 
 
440 
 
 INDEX. 
 
 Inspection of abdominal organs, 
 375 
 tecliniqae of, 375 
 of the circulatory system, 221 
 of the heart, 221 
 
 technique of, 221 
 of lungs, 37 
 of thorax, 37 
 technique of, 37 
 Interlobular emphysema, 178 
 Interrupted breathing, 109 
 Interstitial emphysema, 178 
 Intestines, cancer of, 408 
 intussusception of, 408 
 palpation of, 407 
 tumors of, 407 
 
 percussion over, 420 
 Intussusception of intestines, 408 
 
 Jebky breathing, 109 
 
 K 
 
 Kidneys, enlargements of, 404 
 
 movable, 403 
 
 palpation of, 403 • 
 
 regional anatomy of, 35 
 
 tumors of, 404 
 differential diagnosis of, 406 
 differentiated by percussion 
 from those of spleen, 420 
 percussion over, 4^0 
 
 vcandering, 404 
 
 Labyngeal breath sounds, 98 
 
 stenosis, differentiated from 
 asthma, 190 
 Larynx, influence of, on breath 
 
 sounds, 124 
 Leukaemia, liver in, 395 
 
 spleen in, 402 
 Li tten's phenomenon, 55 
 Liver, abscess of, 396 
 
 cancer of, 396 
 
 congestion of, 394 
 
 degeneration of, 395 
 
 displacement of, 393 
 causes of, 393 
 
 enlargements of, differential 
 diagnosis of, 397 
 
 Liver, enlargements of, irregular, 
 394 
 percussion over, 420 
 uniform, 394 
 fatty, 395 
 
 flatness of, conditions modify- 
 ing, 416 
 in Hodgkin's disease, 395 
 hydatid cysts of, 397 
 in hypertrophic cirrhosis, 395 
 influence of, on percussion 
 
 sound, 90 
 in leukaemia, 395 
 obstructive disease of, 397 
 palpation of, 392 
 
 facts to be noted on, 393 
 percussion of, 415 
 in pernicious anaemia, 375 
 pulsation of, in tricuspid 
 
 regurgitation, 3^7 
 regional anatomy of, 33 
 syphilis of, 396 
 tumors of, 394 
 Lobular pneumonia, 161 
 Ludovioi, angle of, 19 
 Lung, acute congestion of, 158 
 causes of, 158 
 physical signs of, 159 
 anatomy of, 24 
 auscultation of, 96 
 borders of, 25 
 cirrhosis of, 174 
 collapse of, differentiated from 
 
 lobar pneumonia, 174 
 consolidation of, cardiac dull- 
 ness in, 263 
 flatness in, 263 
 effect of pleurisy on, 210 
 fissures of, 26 
 influence of changes in, on 
 
 apex beat, 226 
 inspection of, 37 
 lobes of, 24 
 
 malignant disease of. 208 
 physical signs of, 208 
 palpation of, 58 
 possive congestion of, 159 
 causes of, 159 
 physical signs of, 160 
 percussion of, 69 
 outlines of, 92 
 syphilis of, 207 
 
INDEX. 
 
 441 
 
 M 
 
 McBueney's poiut, 408 
 Malaria, spleen in, 402 
 Mediastinal tumors,differentiated 
 
 from aneurism of aorta, 373 
 Mediastinum, influence of 
 
 changes in on apex beat, 229 
 Meninges, disease of, irregular 
 
 pulse due to, 252 
 Metallic tinkle, 120, 220 
 Mitral obstruction, differentiated 
 from tricuspid obstruction, 
 344 
 orifice, regurgitation at, 302 
 presystolic murmurs, 284 
 regurgitation, accentuation of 
 pulmonic second sound in, 
 308 
 area of cardiac dullness in, 
 307 
 flatness in, 307 
 diagnosis of pathological 
 
 condition in, 309 
 differential diagnosis of, 311 
 differentiated from mitral 
 stenosis, 319 
 from tricuspid regurgita- 
 tion, 348 
 effects of, 303 
 
 irregularity of pulse in, 249 
 location of apex beat in, 305 
 murmur of, 307 
 physical signs of, 305 
 pulse in, 306 
 stages of, 303 
 thrill in, 306 
 stenosis, 312 
 causes of, 312 
 
 differential diagnosis of, 319 
 effects of, 313 
 fluoroscopic examination of, 
 
 432 
 irregular pulse due to, 252 
 location of apex beat in, 314 
 murmur of, 316 
 physical signs of, 314 
 pulse in, 316 
 thrill in 315 
 systolic murmurs, 285 
 valve, 31 
 Movable kidneys, 403 
 
 Mucous clicks, 120 
 Murmurs, aortic diastolic, 291 
 causes of, 292 
 in aortic regurgitation, 333 
 Murmur of aortic stenosis, 324 
 systolic, 289 
 causes of, 289 
 arterial, 297 
 
 causes of, 297 
 in arterio-sclerosis, 374 
 cardiac, 276 
 
 area of diffusion of, 282, 284 
 causes of, 276 
 characteristics of, 278 
 classification of, 277 
 
 inorganic or non-valvular, 
 
 277 
 organic or valvular, 277 
 conduction of vibrations to 
 surface, 283-285, 289, 291, 
 294 
 intensity of, 279 
 
 changes in, 279 
 point of maximum intensity 
 
 of, 282, 284 
 quality of, 278 
 rhythm of, 280 
 time of, method of determin- 
 ing, 281 
 diastolic, in aneurism of aorta, 
 
 371 
 diasystolic, rhythm of, 280 
 exooardial, 297 
 mitral presystolic, 284 
 
 causes of, 285 
 of mitral regurgitation, 307 
 stenosis, 316 
 systolic, 285 
 causes of, 288 
 in myocarditis, 351 
 in obstruction of pulmonary 
 
 artery, 339 
 presystolic, rhythm of, 280 
 of pulmonary regurgitation, 
 
 342 
 in pulmonic area, 340 
 diastolic, 297 
 
 causes of, 297 
 systolic, 296 
 causes of, 296 
 systolic, 297 
 rhythm of, 280 
 
442 
 
 INDEX. 
 
 Murmur, in tricuspid obstruc- 
 tion, 344 
 presystolic, 293 
 causes of, 293 
 regurgitation, 347 
 systolic, 294 
 causes of, 295 
 venous, 298 
 causes of, 298 
 Myocarditis, acute, 349 
 forms of, 349 
 physical signs of, 349 
 chronic, 350 
 apex beat in, 350 
 cardiac impulse in, 350 
 
 sounds in, 351 
 forms of, 350 
 murmur in, 351 
 physical signs of, 350 
 irregular pulse due to, 252 
 Myocardium, disease of, 348 
 
 N 
 
 Neevous system, disturbances 
 of, irregular pulse due to, 
 251 
 
 Obsteuctive disease of liver, 
 
 397 
 Qidema, of lungs. See Pulmo- 
 nary Oiedema. 
 pulmonary, chronic, difEeren- 
 tiated from acute bronchitis, 
 149 
 Omentum, palpation of, 387 
 tumors of, characteristics of, 
 387 
 differential diagnosis of, 387 
 Ovaries, tumors of, 409 
 
 Palpation of abdominal 
 organs, 382 
 method of, 382 
 of aorta, 240 
 of appendix 407 
 of blood-vessels, 240 
 of the circulatory system, 233 
 for fluctuation, 68 
 of friction fremitus In, 67 
 of gall-bladder, 398 
 
 Palpation of heart, 233 
 of intestines, 407 
 of kidneys, 403 
 of liver, 392 
 of lung, 58 
 method of counting ribs in, 
 
 59 
 of omentum, 387 
 for pain, 68 
 of pancreas, 390 
 of pelvic organs, 409 
 of peritoneum, 384 
 respiratory movements in, 59 
 of rhonchi and palpable rale'*, 
 
 67 
 of splashing or suocussion 
 
 fremitus, 68 
 of spleen, 400 
 of stomach, 388 
 technique of, 58, 233 
 of thorax, 58 
 value of, 58, 233 
 vibratory phenomena in, 60 
 Pancreas, cancer of, 390 
 
 differential diagnosis of, 
 391 
 cysts of, 391 
 
 differential diagnosis of, 
 392 
 palpation of, 390 
 tumors of, 390 
 Paralytic chest, 41 
 Patent ductus anteriosus differ- 
 entiated from aortic 
 stenosis, 327 
 from pulmonary ob- 
 struction, 341 
 Pectoriloquy, 136 
 Pelvic organs, palpation of, 409 
 
 tumors of, 409 
 Percussion over, 420 
 Percussion of abdomen, 411 
 of abdominal organs, 411 
 ausculatory, 94 
 of the circulating system, 256 
 fluid in abdominal cavity in, 
 
 418 
 of the heart, 256 
 of left hypochondrium, 411 
 of liver, 415 
 of lung, 69 
 methods of, 72, 256 
 
INDEX. 
 
 443 
 
 Percussion, methods of, imme- 
 diate or direct, 72 
 
 mediate or indirect, 72 
 
 technique of, 73 
 outlines of lung, 92 
 over abdominal tumors, 420 
 over enlargements of liver, 420 
 
 of spleen, 420 
 over fsecal accumulations, 420 
 over tumors of intestines, 420 
 
 of kidney, 420 
 
 of pelvic organs, 420 
 
 of stomach, 420 
 of the praecordia, 256 
 
 areas of, 256 
 in pneumo-pericardium, 364 
 of right hypochondrium, 414 
 sound, conditions modifying, 
 
 cracked-pot sound in, 87 
 duration of, 71 
 elements of, 69 
 Friedrich's respiratory 
 
 change of sound, 87 
 Gerhardt's change of sound 
 
 in, 86 
 individual and regional 
 
 variations of, 90 
 influence of the bony thorax 
 on, 80 
 of change in air spaces 
 on, 85 
 
 in amount of pulmo- 
 nary tissue on, 84 
 of tension on, 83 
 of heart on, 90 
 of liver on, 90 
 of the pieura on, 81 
 of pulmonary consolida- 
 tion on, 87 
 tissue on, 82 
 of the soft parts on, 78 
 intensity of, 69 
 modified by site of consoli- 
 dation, 89 
 pitch of, 70 
 quality of, 69 
 Wintrich's change of sound 
 
 in, 86 
 of splenic area, 413 
 stethoscopic, 94 
 of stomach, 417 
 
 Percussion of thorax, 69 
 
 of true abdomen, 417 
 Pericardial friction sound dif- 
 ferentiated from mi- 
 tral regurgitation, 
 312 
 from mitral stenosis, 
 320 
 Pericarditis, 352 
 
 adhesive, fluoroscopic exami- 
 nation of, 432 
 cardiac dullness in, 263 
 
 flatness in, 263 
 differential diagnosis of, 361 
 dry, 352 
 
 friction fremitus in, 356 
 sound in, 359 
 fibrinous, 352 
 
 friction fremitus in, 356 
 sound in, 359 
 forms of, 352 
 hemorrhagic, 353 
 physical signs of, 354 
 plastic, 352 
 
 friction fremitus in, 356, 
 357 
 sound in, 359 
 purulent, 353 
 sero-fibrinous, 353 
 with adhesions, 353 
 with effusion, 353 
 
 segophony in, 360 
 bronchial breathing in, 
 
 360 
 cardiac dullness in, 357 
 flatness in, 357 
 impulse in, 356 
 sounds in, 360 
 difi'erential diagnosis of, 
 
 362 
 fluoroscopic examination 
 
 of, 431 
 location of apex beat in, 
 
 354 
 pulmonary resonance in, 
 
 358 
 respiratory sounds in, 
 
 360 
 Skoda's resonance in, 358 
 Pericardium, diseases of, diag- 
 nosis of, 352 
 
444 
 
 INDEX. 
 
 Pericardium, influence of changes 
 in, on apex beat, 927 
 regional anatomy of, 32 
 sounds made in, 299 
 characteristics of, 299 
 diagnostic features of, 300 
 Peritoneum, palpation of, 384 
 Peritonitis, general, abdominal 
 
 walls in, 385 
 Peri-typhlitic abscess, 408 
 Phthisical chest, 41 
 
 causes of deformity, 43 
 Phthisis. See Pulmonary Tuber- 
 culosis, 
 acute. See Pulmonary Tuber- 
 culosis, Acute, 
 catarrhal. See Pulmonary 
 Tuberculosis, Acute, 
 fibroid, 174 
 
 pneumonic. See Pulmon- 
 ary Tuberculosis, Acute. 
 tubercular pneumonic. See 
 Pulmonary Ttiberculosis, 
 Acute. 
 Pigeon-breasted chest, 44 
 Plastic pericarditis, 352 
 Pleura, anatomy of, 28 
 hydatid of, 217 
 influence of change in on 
 apex beat, 236 
 in on breath sounds, 
 139 
 of diseases of, on apex beat, 
 225 
 on percussion sounds, SI 
 left, effusions into, differ- 
 entiated from pericarditis 
 with effusion, 363 
 surface markings of. 28 
 thickening of, cardiac dull- 
 ness in, 263 
 flatness in, 263 
 Pleurisy, 20» 
 
 condition of sac in, 209 
 differential diagnosis of, 
 
 217 
 physical signs of, 211 
 effect of, on heart, 210 
 
 on lung, 210 
 forms of, 209 
 with adhesion, 211 
 
 physical signs of, 212 
 
 Pleurisy, with effusion, 41 
 
 condition of sac in, 210 
 differentiated from lobar 
 
 pneumonia, 172 
 physical signs of, 212 
 Pleuritic friction differentiated 
 from pericarditis, 362 
 sounds, differentiated from 
 mitral regurgitation, 312 
 Pleurodynia, 217 
 Pleuro-pericardial friction, dif- 
 ferentiated from pericar- 
 ditis. 362 
 friction sounds, 300 
 Pneumonia, chronic interstitial, 
 174 
 causes of, 175 
 condition of lungs in, 174 
 diflferentiail diagnosis of, 
 
 178 
 physical signs of, 176 
 types of, 175 
 differentiated from pleurisv, 
 
 218 
 lobar, 164 
 
 condition of lungs in, 164 
 differential diagnosis of, 
 
 172 
 differentiated from acuta 
 pulmonary congestion, 
 172 
 from collapse of lung, 
 
 174 
 from hemorrhagic infarc- 
 tion, 173 
 from pleurisy with effu- 
 sion, 172 
 physical signs of, 166 
 stages of, 164 
 
 engorgement, 164 
 gray hepatization or 
 
 resolution, 165 
 red hepatization or 
 consolidation, 164 
 terminations of, 165 
 lobular, 161 
 causes of, 162 
 condition of lung in, 161 
 confluent, 162 
 
 differential diagnosis of, 
 163 
 
INDEX. 
 
 445 
 
 Pneumonia, lobular, diSerenti- 
 ated from aciite dis- 
 seminated tuberculosis, 
 163 
 from lobar pneumonia, 
 
 164 
 from pulmonary collapse, 
 163 
 disseminated, 162 
 physical signs of, 162 
 varieties of, 162 
 Pneumo-pericardium, 364 
 apex beat in, 364 
 cardiac sounds in, 364 
 percussion in, 364 
 physical signs, of, 364 
 water-wheel sounds in, 364 
 Pneumothorax, 219 
 
 differentiated from emphy- 
 sema, 185 
 physical signs of, 219 
 Praecordia, inspection of, 223 
 bulging of, causes of, 25ia 
 percussion of, 256 
 Pre-systolic murmurs, rhythm 
 
 of, 280 
 Pterygoid chest, 41 
 Puerile breathing, 130 
 Pulmonary artery, 30 
 obstruction of 337 
 causes of, 337 
 cyanosis in, 339 
 differential diagnosis of, 
 
 341 
 effects of, 338 
 murmurs in, 339 
 physical signs in, 339 
 thrill in, 339 
 catarrh, 161 
 congestion differentiated from 
 
 lobar pneumonia, 172 
 emphysema, 41 
 obstruction differentiated 
 
 from aortic stenosis, 327 
 oedema, 160 
 causes of, 160 
 physical signs of, 161 
 regurgitation, 341 
 apex beat in, 342 
 causes of. 341 
 differential diagnosis of, 
 342 
 
 Pulmonary regurgitation, effects 
 of," 342 
 murmur of, 342 
 physical signs of, 342 
 resonance in pericarditis, 358 
 tissue, influence of, on percus- 
 sion sounds, 82 
 tuberculosis, acute, 193 
 
 difl'erential diagnosis of, 
 
 195 
 physical signs of, 194 
 types of, 193 
 causes of, 191 
 chronic, 197 
 
 condition of lung in, 197 
 physical signs of, 200 
 stages of, 200 ' 
 effect of, on lung, 192 
 forms of, 192 
 secondary changes of, 192 
 site and progress of, 198 
 valve, 31 
 Pulmonic diastolic murmurs, 297 
 obstruction differentiated 
 
 from triscuspid regurgita- 
 tion, 348 
 sound, accentuation of, 274 
 systolic murmurs, 296 
 Pulse, 241 
 
 in aneurism of aorta, 309 
 in aortic regurgitation, 332 
 
 stenosis, 323 
 in conditions of, modifying 
 elasticity of arter- 
 •ies, 252 
 resistance in arteries 
 and capillaries, 252 
 dicrotism of, 253 
 elements of, 242 
 examination of, 241 
 force of, 248 
 
 diminution of, causes of, 
 
 249 
 increase, in, causes of, 248 
 irregularity in, 249 
 frequency of, 244 
 intermittent, causes of, 250 
 
 characteristics of, 249 
 irregular, causes of, 251 
 characteristics of, 250 
 due to reflex irritation, 251 
 in mitral regurgitation, 306 
 
446 
 
 INDEX. 
 
 Pulse in mitral stenosis, 316 
 normal, 243 
 rapid, causes of, 244 
 slow, causes of, 247 
 tension of, high, causes of, 
 255 
 low, causes of, 253 
 in tricuspid obstruction, 344 
 
 Pupil, contraction of, in aneur- 
 ism of aorta, 367 
 
 Purulent pericarditis, 353 
 
 Pylorus, 34 
 
 Rachitic chest, causes of, 44 
 
 rosary", 44 
 Radiograph in cardiac diseases, 
 
 432 
 Rales, crepitant, 116 
 
 diagnostic significance of, 
 
 116 
 mode of production of, 116 
 dry, 127 
 
 cause of, 112 
 differentiation of pleural 
 from bronchial, 121 
 of small moist from crepi- 
 tant, 118 
 friction, 120 
 dry, 120 
 moist, 121 
 indeterminate or indefinite, 
 
 122 
 moist, 128 
 
 characteristics of, 115 
 classification of, 117 
 importance of size of, 117 
 large, 115 
 medium, 115 
 quality of sound of, 118 
 small, 115 
 sibilant, 114 
 sonorous, 114 
 stridor, 114 
 Regional anatomy, 17 
 Regurgitation at aortic orifice, 
 327 
 at mitral orifice, 302 
 causes of, 302 
 at pulmonic orifice, 341 
 Respiratory movements, 51 
 
 Respiratory movements, abnor- 
 mal, alteration in fre- 
 quency in, 56 
 diminished, causes of, 54 
 increased, causes of, 54 
 costal breathing in, 
 
 causes of, 53 
 inferior costal dia- 
 phragmatic breath- 
 ing in, causes of, 53 
 inferior costal in adult 
 
 male, 52 
 normal, 52 
 
 alteration in frequency 
 in, 56 
 in rhythm in, 56 
 costal in women, 52 
 diaphragmatic abdomi- 
 nal in children, 52 
 murmurs. See Breath Sounds, 
 rhythm of, in adult, 57 
 in aged, 57 
 alteration in, 56 
 sounds in pericarditis with 
 effusion, 360 
 types of, 107 
 Rhonchi and palpable rales, 
 
 palpation of, 67 
 Rotch's sign, 358 
 Rude respiration. 111 
 
 Sacciform aneurism of aorta, 
 
 365 
 Sanson's signs in aneurism of 
 
 aorta, 371 
 Scrobieulus cordis, 19 
 Sero-fibrinous pericarditis, 353 
 Skoda's resonance, 215, 358 
 Splashing fremitus, 68 
 Spleen, abscess of, 402 
 
 enlargements of, 401 
 causes of, 401 
 percussion over, 401 
 
 in Hodgkin's disease, 402 
 
 infarction of, 402 
 
 in leukaemia, 402 
 
 in malaria, 402 
 
 palpation of, 400 
 
 percussion of, 413 
 
 regional anatomy of, 34 
 
 syphilis of, 402 
 
INDEX. 
 
 447 
 
 Spleen, tumors of, characteris- 
 tics of, 401 
 dift'erential diagnosis of, 
 402 
 Stenosis at mitral orifice, 312 
 Stethoscope, use of, in auscul- 
 tation; 266 
 Stethoscopic percussion, 94 
 Stomach, dilated, 388 
 displaced, 388 
 palpation of, 388 
 percussion of, 417 
 regional anatomy of, 33 
 surface markings of, 34 
 tenderness over, 388 
 tumors of, 389 
 
 characteristic features of, 
 
 390 
 percussion over, 420 
 Sub-diaphragmatic abscess, dif- 
 ferentiated from pleurisj', 
 218 
 Subtubular breathing. 111 
 Suecussion fremitus, 68 
 
 sound, 120 
 Supraclavicular fossae, 19 
 Syphilis of liver, 396 
 of lung, 207 
 
 differential diagnoss of, 
 
 208 
 varieties of, 207 
 of spleen, 402 
 Systolic murmurs, rhythm of, 
 280 
 
 Thoeacio aorta, aneurism of, 
 229 
 
 walls, influence of on breath 
 sound, 140 
 Thorax, anatomy of, 18 
 
 auscultation of, 96 
 
 bony, influence of, on percus- 
 sion sounds, 80 
 
 contents of, 21 
 
 inspection of, 37 
 
 palpation of, 58 
 
 percussion of, 69 
 
 subcostal angle of, 20 
 
 surface markings of, 19 
 Thrill in aneurism of aorta, 368 
 
 in aortic stenosis, 323 
 
 Thrill in mitral regurgitation, 
 306 
 stenosis, 315 
 in obstruction of pulmonary 
 
 artery, 339 
 in tricuspid obstruction, 344 
 Thrills, 238 
 causes of, 238 
 character of, 239 
 Trachea, position of, 21 
 Tracheal stenosis, differentiated 
 from asthma, 190 
 tugging, 240 
 
 in aneurism of aorta, 309 
 method of examining for, 
 240 
 Transition breathing. 111 
 Tricuspid obstruction, 343 
 
 dift'erential diagnosis of, 
 
 344 
 effects of, 343 
 murmur in, 344 
 physical signs of, 343 
 pxilse in, 344 
 thrill in, 344 
 veins in, 343 
 pre-systolic murmurs, 293 
 regurgitation, 345 
 causes of, 345 
 dift'erential diagnosis of, 347 
 differentiated from mitral 
 
 stenosis, 319 
 elfect of, 346 
 location of apex beat in, 
 
 346 
 murmurs in, 347 
 physical signs of, 346 
 pulsation of liver in, 347 
 stenosis dift'erentiated froiu 
 
 mitral stenosis, 320 
 systolic murmurs, 294 
 valve, 31 
 Tubercular pneumonic phthisis. 
 8ee Pulmonary Tuberculosis, 
 Acute. 
 Tuberculosis, acute diff'use pul- 
 monary, differentiated from 
 acute bronchitis, 148 
 pulmonary, differentiated 
 
 from bronchiectasis, 150 
 Tumors of abdominal walls, 
 palpation of, 383 
 
448 
 
 INDEX. 
 
 Tumors of kidneys, palpation 
 of, 404 
 of liver, palpation of, 394 
 mediastinal, differentiated 
 from aneurism of aorta, 
 373 
 of omentum, palpation of, 387 
 of ovaries, 409 
 
 of spleen, differential diag- 
 nosis of, 402 
 palpation of, 401 
 of stolnach, palpation of, 389 
 of uterus, 409 
 Typhlitis, 408 
 
 U 
 
 Ulcerative tuberculosis, 
 chronic. See Pulmonary Tu- 
 berculosis, Chronic. 
 Unilateral diminution in size of 
 chest, 48 
 enlargements of chest, causes 
 of, 46 
 Uterus, auscultation of, 424 
 tumors of, 409 
 
 Valve areas, 269 
 aortic, 271 
 mitral, 270 
 pulmonic, 271 
 tricuspid, 271 
 
 Valves, regional anatomy of, 31 
 
 Valvular disease, chronic, dif- 
 ferentiated from pericar- 
 ditis, 361 
 lesions, 301 
 
 Veiled puff, 138 
 
 Veins, superficial, in aneurism 
 of aorta, 367 
 in tricuspid obstruction, 343 
 
 Venous murmurs, 298 
 pulsation, 231 
 abnormal, 231 
 in ansemia, 231 
 in chlorosis, 231 
 normal, 231 
 
 Ventricle, left, 29 
 
 right, 29 
 Vocal fremitus, causes of, 60 
 in child, 61 
 
 diminished, by clianges in 
 bronchi, 65 
 in the chest wall, 67 
 in pleura, 66 
 in pulmonary tissue, 
 66 
 increase of, cause of, 64 
 in children, 65 
 by pulmonary consolida- 
 tions, 65 
 by tension of pulmonary 
 
 tissue, 65 
 over cavities, 65 
 in man, 61 
 
 modified by chest wall, 63 
 normal variation in, 61 
 over the apices, 62 
 physiological increase of on 
 
 right side, 62 
 regional variations in, 61 
 
 causes of, 61 
 technique oif, 61, 64 
 in ^A'oman, 61 
 resonance, characteristics of, 
 134 
 conditions modifying, 134 
 whispered voice or whis- 
 pered resonance, 134 
 
 W 
 
 Wandering kidneys, 404 
 Water-hammer pulse, 333 
 Water-wheel sound in pneumo- 
 pericardium, 364 
 Wavy breathing, 109 
 Wintrich's change of sound in 
 percussion, 86 
 
 Xiphoid cartilage, 19 
 X-ray examinations, 425 
 
 apparatus for, 425 
 
 value of, 427 
 
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6 Lea Beothkbs & Co., Philadelphia and New Yoek. 
 
 CliOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL 
 DISEASES. New (5th) edition. In one octavo volume of 750 pages, 
 vrith 19 colored plates. Cloth, $4.25, net. 
 
 ^m-YoiSOTA's Abitract of Za/ws of U. S. on Custody of Insane, octavo, 
 $1.50, is sold in conjunction with Clouston on Mental Diseases for 
 $5.00, net, for the two works. 
 
 CLOWES (PRANK). AN ELEMENTARY TREATISE ON PRACTI- 
 CAL CHEMISTRY AND QUALITATIVE INORGANIC ANALY- 
 SIS. From the fourth English edition. In one handsome 12mo. 
 volume of 387 pages, with 55 engravings. Cloth, $2.50. 
 
 COAKIiEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT- 
 MENT OF DISEASES OF THE NOSE, THROAT, NASO- 
 PHARYNX AND TRACHEA. Second edition. In one 12mo . 
 volume of 556 pages, with 103 engravings and 4 colored plates. Cloth, 
 ■ 2.75. net. 
 
 The work is a convenient and in- 
 expensive guide to the entire field of 
 diseases of the nose and throat, which 
 
 may be recommended as a complete 
 and trustworthy summary of the 
 subject. — Medical News. 
 
 COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. 
 of 829 pages, with 339 engravings. Cloth, $5.50; leather, $6.50. 
 
 COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY 
 AND PATHOLOGY. "With Notes and Additions to adapt it to Amer- 
 ican Practice. By Thos. C. Stellwagen, M.A., M.D., D.D.S. In one 
 handsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25. 
 
 COLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL 
 DIAGNOSIS. In one handsome 12mo. volume of about 350 pages, 
 with many illustrations. Shortly. Lea's Series of Pocket Text-books, 
 edited by Been B. Gallaudet, M. D. See page 17. 
 
 COLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET 
 TEXT-BOOK OF PHYSIOLOGY. 12mo. of 316 pages, with 153 
 illustrations. Cloth, $1.50; ilexible red leather, $2.00, ««<. Lea's 
 Series of Pocket Text-books, edited by Been B. Gallaudet, M. D. 
 See page 17. 
 
 practitioner with the advances in 
 this Bubject.^TAe Physician and 
 Surgeon. 
 
 Well written and up to date. It 
 
 is a manual admirably adapted to 
 
 teach the beginner the essentials of 
 
 physiology, and to acquaint the 
 
 OONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- 
 EASES OF CHILDREN. Sixth edition, revised and enlarged. In 
 one large 8vo. volume of 719 pages. Cloth, $5.25 ; leather, $6.25. 
 
 CORNEL (V.). SYPHILIS : ITS MORBID ANATOMY, DIAGNO- 
 SIS AND TREATMENT. Translated, with Notes and Additions, by 
 J. Henet C. Simes, M.D. and J. William White, M. D. In one 
 8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. 
 
 CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES 
 OF WOMEN. In one handsome 12mo. volume of 368 pages, with 
 107 illustrations. Cloth, $1.50, net; flexible leather, $2.00, net. 
 Lea's Series of Pocket Text-books, edited by Been B. Gallaudet, 
 M. D. See page 17. 
 This is, like all the other manuals I book for practitioners. — St. Louis 
 
 in this series, a most excellent guide I Medical and Surgical Journal. 
 
 or students and a handy reference ' 
 
Lea Beothebs & Co., Philadelphia and New York. 
 
 ^^'^^S^^^^*'^^ ^-1 ON MINERAL WATERS OF TPIE 
 UNITEb STATES. Octavo, 575 pages. Cloth, $3.50, net. 
 
 In such a book as this the medical 
 profession will find a wonderful ally ; 
 it is remarkably complete in every 
 detail, giving the results of analyses 
 
 of every water of any known medici- 
 nal properties. — The Louisville 
 Monthly Journal. 
 
 CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR- 
 MACOLOGY. Second edition. In one handsome octavo volume 
 of 881 pages, with 464 illustrations. Cloth, .$4.50, net. 
 
 CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 
 Second edition. Handsome Svo., 732 pp., with 47 illus.Cloth, $3.75, net. 
 
 The best exposition of our knowl 
 edge of pharmacology which has yet 
 been given to the medical public. 
 We can cordially recommend it to 
 all our readers who are desirous of 
 
 acquainting themselves with the very 
 latest knowledge on this very im- 
 portant subject. — The Montreal Med- 
 ical Jowrnal. 
 
 DAJLTON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. 
 Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, 
 $5 ; leather, $6. 
 
 DOCTRINES OF THE CIRCULATION OF THE BLOOD. In 
 
 one handsome 12mo. volume of 293 pages. Cloth, $2. 
 
 DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of 
 Gynecology. For the use of Students and Practitioners. Fourth 
 edition. In one handsome 12mo. volume of 402 pages, with 154 
 illustrations. Cloth, $1.75, net. 
 
 knowing, and presents these princi- 
 ples in a clear, concise and thorough 
 manner. The book can be highly 
 commended. — The Medical Age. 
 
 Dr. Davenport has the happy 
 faculty of selecting just those points 
 in gynecological therapeutics and 
 surgery "which the student and junior 
 practitioner most stand in need of 
 
 DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 
 
 STUDENTS AND PRACTITIONERS. In one very handsome 
 
 octavo volume of 546 pages, with 217 engravings and 30 full-page 
 
 plates in colors and monochrome. Cloth, $5 ; leather, $6. 
 
 From a practical standpoint the j thoroughly scientific and brilliant 
 
 work is all that could be desired. A | treatise on obstetrics. —ifed. News. 
 
 DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second 
 edition. In one 12mo. volume of 287 pages. Cloth, $1.75. 
 
 DB IiA BEOHE'S GEOLOGICAL OBSERVER. In one large octavo 
 volume of 700 pages, with 300 engravings. Cloth, $4. 
 
 DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- 
 TEM OF SURGERY. In contributions by American Authors. 
 Complete work in four very handsome octavo volumes, containing 
 3652 pages, with 1585 engravings and 45 full-page plates in colors 
 and monochrome. Per volume, cloth, $6.00; leather, $7.00; half 
 Morocco, gilt back and top, $8.50. For sale by subscription only. 
 Full prospectus free on application to the publishers. 
 No work in English can be con- I American Journal of the Medical 
 
 sidered as the rival of this.— TAe I Science*. 
 
 DERCUM (FRANCIS X.). A MANUAL OF MENTAL DIS- 
 EASES. Octavo, about 350 pages with many engravings. Shortly. 
 
8 Lea Beothkes & Co., Philadelphia and New York. 
 
 DERCUM (FRANCIS X.,) EDITOR. A TEXT-BOOK ON 
 NERVOUS DISEASES. By American Authors. In one handsome 
 octavo volume of 1054 pages, with 341 engravings and 7 colored 
 plates. Cloth, $6.00 ; leather, $7.00. Net. 
 
 The best text-book in any lan- 
 guage. — The Medical Fortnightly. 
 
 The inost thoroughly up-to-date 
 treatise that we have on this subject. 
 — American Journal of Insanity. 
 
 DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 
 
 Their Classification, History, Symptoms, Pathology and Treatment. 
 Very handsome octavo, 240 pages, 46 engravings, and 9 full-page 
 plates in colors. Limited edition, de luxe binding, $4, net. 
 
 DRAPER (JOHN C). MEDICAL PHYSICS. A Text-book for Stu- 
 dents and Practitioners of Medicine. In one handsome octavo volume 
 of 734 pages, with 376 engravings. Cloth, $4. 
 
 DRUITT (ROBERT). THE PRINCIPLES AND PEACTICE OF 
 MODERN SURGERY. A new American, from the twelfth London 
 edition, edited by Stanley Boyd, F. R. C. S. In one large octavo 
 volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. 
 
 DUANE (ALEXANDER). A DICTIONARY OF MEDICINE AND 
 THE ALLIED SCIENCES. Comprising the Pronunciation, Deriva- 
 tion and Full Explanation of Medical, Dental, Pharmaceutical and 
 Veterinary Terms. Together with much Collateral Descriptive Mat- 
 ter, Numerous Tables, ete. Third edition. Square octavo of 652 
 pages, with 8 colored plates, with thumb index. Cloth, $3.00, net ; 
 limp leather, $4.00, net. 
 
 DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF 
 GYNECOLOGY. Second edition. Handsome octavo of 717 pages, 
 with 453 illustrations in black and colors, and 8 colored plates. Cloth, 
 "1.00, net; leather, $6.00, net; half Morocco, $6.5,0, net. 
 
 tice of modem gynecology. — Inter- 
 national Medical Magazine, 
 
 The book can be safely recom 
 
 mended as a complete and reliable 
 
 exposition of the principles and prac- 
 
 DUNGIilSON (ROBUEY). A DICTIONARY OF MEDICAL SCI- 
 ENCE. Containing a full explanation of the various subjects and 
 terms of Anatomy, Physiolo^j Medical Chemistry, Pharmacy, Phar- 
 macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
 gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
 ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry etc., etc. 
 By RoBLEY Dtjnglison, M. D., LL. D., late Professor of Institutes 
 of Medicine in the Jefferson Medical College of Philadelphia. Edited 
 by Richard J. Ddnglison, A. M., M. D. Twenty-second edition, thor- 
 oughly revised and greatly enlarged and improved, with the Pronuncia- 
 tion, Accentuation and Derivation of the Terms. With Appendix. 
 In one magnificent imperial octavo volume of 1350 pages, with thumb 
 index. Cloth, $7.00, Net; leather, $8.00, Net. This edition contains 
 portrait of Dr. Dunglison. 
 The most satisfactory and authori- scarcely be measured. — Med. Record 
 
 tative guide tothe derivation, defiui- Pronunciation is indicated by the 
 
 tion and pronunciation of medical phonetic system. The definitions are 
 
 te.Tms.~TheChwrlotteMed.Jowrnal. unusually clear and concise. The 
 Covering the entire field of medi- book is wholly satisfactory.— Cm- 
 
 eine, surgery and the collateral versity Medical Magazine. 
 
 sciences, its range of usefulness can 
 
Lea Beothbbs & Co., Philadelphia and New York. 9 
 
 DtJNCAJV (J. MATTHEWS). CLINICAL LECTURES ON THE 
 DISEASES OF WOMEN. Delivered in St. BaHholomew's Hospital. 
 In one octavo volume of 175 pages. Cloth, $1.50. 
 
 DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
 TOLOGY. Octavo, 450 pages.with 363 illustrations. Cloth, $3.25, net. 
 The best one-volume text or refer- I of published in America. — Virginia 
 enoe book on histology that we know ' Medical Semi-Monthly. 
 
 NORMAL HISTOLOGY. Second edition. Octavo, 319 pages. 
 
 with 244 illustrations. Cloth, $2.50, net 
 
 BCKLEY (WILLIAM T.). A GUIDE TO DISSECTION OF THE 
 HUMAN BODY. Octavo, about 450 pages, richly illustrated in 
 black and colors. In Press. 
 
 REGIONAL ANATOMY OF THE HEAD AND NECK FOR 
 
 STUDENTS AND PRACTITIONERS. Octavo, 240 pages, with 
 36 engravings and 20 plates in black and colors. Cloth, $2.50, net. 
 
 EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
 MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
 leather, $4.50. 
 
 BDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
 Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
 with 148 engravings. Cloth, $3 ; leather, $4. 
 
 EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
 TATION. Second edition. In one 12mo. volume of 427 pages, 
 with 77 illustrations. Cloth, net, $2.25. 
 
 It is written in plain language, 
 and, while primarily designed for 
 physicians, it can be studied with 
 profit by any one of ordinary intel- 
 
 ligence. The writer has adapted it 
 to American conditions, and his 
 suggestions are, above all, practical. 
 — The NewYork Medical Journal. 
 
 BLiIjIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. 
 Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, 
 $4.25 ; leather, $5.25. 
 
 BMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
 TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 
 150 original engravings. Cloth, $5 ; leather, $6. 
 
 ERICHSEN (JOHN E.). -THE SCIENCE AND ART OF SUR- 
 GERY. Eighth edition. In two large octavo volumes contaimng 
 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. 
 
 ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See^mm'con 
 Text-Books of Dentistry, page 2. 
 
 F-VANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 
 In one handsome 12mo. volume of 409 pages, with 148 illustrations 
 Cloth $1 75 Net- limp leather, $2.25, net. Lea's Series of Pocket 
 Text-book's, edited by Been B. Gallaudbt, M.D. See p 17. 
 
 EWING (JAMES) ON THE BLOOD AND ITS DISEASES. Hand- 
 some octavo, 423 pages, 28 engravings, 14 colored plates. Cloth, 
 net, $3.50. 
 
10 Lka Bbothees & Co., Philadelphia and New Yobk. 
 
 FABQTJHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 
 Fourth American from fourth English edition, revised by Fkank 
 Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 
 
 FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
 EAE. Fourth edition. In one octavo volume of 391 pages, with 73 
 engravings and 21 colored plates. Cloth, $3.75. 
 
 FINDIiEY (PALMER D.). A TREATISE ON GYNECOLOGI- 
 CAL DIAGNOSIS. Octavo, about 600 pages. Amply illustrated. 
 Shortly. 
 
 PLEVX (AUSTIN). A TREATISE ON THE PRINCIPLES AND 
 PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 
 by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 
 pages, with engravings. Cloth, $5.00 ; leather, $6.00. 
 
 The work has well earned its lead- 
 ing place in medical literature. — 
 Medical Record. 
 
 The best of American text-books 
 on Practice. — Amer.Medico-Sv/rgical 
 Bulletin. 
 
 — A MANUAL OF AUSCULTATION AND PERCUSSION ; of 
 the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
 Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
 In one handsome 12mo. volume of 274 pages, with 12 engravings. 
 
 — A PRACTICAL TREATISE ON THE DIAGNOSIS AND 
 TREATMENT OF DISEASES OF THE HEART. Second edition 
 enlarged. In one octavo volume of 550 pages. Cloth, $4. 
 
 ON PHTHISIS: ITS MORBID ANATOMY ETIOLOGY, ETC. 
 
 A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
 Cloth, $3.50. 
 
 FOIiSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
 ON CUSTODY 9F THE INSANE. In one 8vo. vol. of 108 pages. 
 Cloth, $1.50. With Clouiton on Mental Diseases (new edition, see 
 page 6) $5.00, net, for the two works. 
 
 FORMTJIiARY, POCKET, see page 32. 
 
 FOSTER (MIOHAELi). A TEXT-BOOK OF PHYSIOLOGY. Sixth 
 and revised American from the sixth English edition. In one large 
 octavo volume of 923 pp., with 257 iUus. Cloth, $4.50 ; leather, $5.50. 
 
 Unquestionably the best book that 
 can be placed in the student's hands, 
 and as a work of reference for the 
 busy physician it can scarcely be 
 excelled. — ThePhila. Polyclinic. 
 
 This single volume contains all 
 that will be necessary in a college 
 course, and all that the physician 
 will need as well. — Dominion Med. 
 Monthly. 
 
 FOTHERGHili (J. MILNER). THE PRACTITIONER'S HAND- 
 BOOK OF TREATMENT. Third edition. In one handsome octavo 
 volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 
 
 FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
 ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
 bodying Watts' Physical and Inorganic Chemiatry. In one royal 
 12mo. Volume of 1061 pages, with 168 engravings, and 1 colored 
 plate. Cloth, $2.75 ; leather, $3.25. 
 
Lea Brothbes & Co., Philadelphia and New Yoek. 11 
 
 PRANKJLANp (E.) AND JAPP (F. R.). INORGANIC CHEMISTRY, 
 in one handsome octavo volume of 677 pages, with 51 engravings and 
 2 plates. Cloth, $3.75 ; leather, $4.75. s s 
 
 ^^^3^ i^^r^^^^- DISORDERS OF THE SEXUAL OR- 
 UAJN b IN THE MALE. In one very handsome octavo volume of 
 jiS pages, with 25 eiigravings and 8 full-page plates. Cloth, $2. 
 
 pathology and rational treatment to 
 many cases of sexual disturbance 
 whose treatment has been too often 
 fruitless for good. — Annala of 
 
 It is an interesting work, and one 
 which is timely and needed.— Medi- 
 cal Fortnightly. 
 
 The book is valuable and instruc- 
 tive and brings views of sound 
 
 ^^^^^^^"^'"^ (BERN B.). A POCKET TEXT-BOOK ON SUR- 
 GERY. In one handsome 12mo. volume of about 400 pages, with many 
 illustrations. Shortly. Lea's Series of Pocket Text-books, edited by 
 Been B. Gallatidet, M. D. See page 17. 
 
 GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A 
 Multum in Parvo. In one square octavo volume of 845 pages, with 
 159 engravings. Cloth, $3.75. 
 
 GAYLORD (HARVEY R.) and ASCHOFF (LUDWIG). THE 
 
 PRINCIPLES OF PATHOLOGICAL HISTOLOGY. With an in- 
 troductory note by William H. Welch, M. D. In one very hand- 
 some quarto volume of 354 pages, with 81 engravings in the text and 
 40 full-page plates. Cloth, $7.50, nei. 
 GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
 By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
 imp. octavo volume of 915 pages, with 950 illustrations in black and 
 colors. Cloth, $6.50; flexible waterproof, $7; leather, $7.50, net; 
 half Morocco, $8.00, net. 
 
 The illustrations far outnumber 
 and exceed in size and in profusion 
 of colors those in any previous work ; 
 and they can well claim to be the 
 most successful series of anatomical 
 pictures in the world. — J'Ae Ameri- 
 can Practitioner and News. 
 
 The chief merit in the book will 
 
 be found, in the descriptive text, 
 which is accurate, concise, and gives 
 the essentials of descriptive anatomy 
 with less waste of words and better 
 emphasis of important points than 
 any similar text-book with which 
 we are familiar. — The Boston Medi- 
 cal and Surgical Journal, 
 
 GIBBES (HENBAGE). PRACTICAL PATHOLOGY AND MORBID 
 HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. 
 
 GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGI- 
 CAL. New fifteenth edition thoroughly revised. In one imperial 
 octavo volume of 1249 pages, with 780 large and elaborate engrav- 
 ings. Price with illustrations in colors, cloth, $6-25, net; leather, 
 $7.25, net. Price, with illustrations in black, cloth, $5.50 ; leather, 
 $6.50, net. 
 
 This is the best 
 upon Anatomy 
 
 single volume 
 
 the English 
 
 University Medical Mag- 
 
 language. 
 azine. 
 
 Holds first place in the esteem of 
 both teachers and students. — The 
 Brooklyn Medical Journal. 
 
 The most largely used anatomical 
 text-book published in the English 
 language. — Annals of Swrgery. 
 
 Gray's Anatomy affords the student 
 more satisfaction than any other 
 treatise with which we are familiar. 
 — Buffalo Med. Journal. 
 
12 Lea Brothkes & Co., Phii^adelphia and New Yokk. 
 
 GRAYSON (CHARLiBS P.). DISEASES OF THE THROAT, 
 NOSE, AND ASSOCIATED AFFECTIONS OF THE EAR. In 
 one handsome octavo volume of about 500 pages, with 129 engravings 
 and 8 plates in colors and monochrome. In Press. 
 
 GOULlD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
 vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 
 
 OREEN (T. HENRY). PATHOLOGY AND MORBID ANATOMY 
 Ninth edition. In one handsome octavo volume of 577 pages, with 
 339 engravings and 4 colored plates. Cloth, $3.25, net. 
 
 The work is an essential to the 
 practitioner — whether as surgeon or 
 physician. It is the best of up-to- 
 date text-books. — Virginia Medical 
 
 A work that is the text-book of 
 probably four-fifths of all the stu- 
 dents of pathology in the United 
 States and Great Britain. — The 
 American Practitioner and News. 
 
 Monthly. 
 
 GREENE ("WnililAM H.). A MANUAL OF MEDICAL CHEM- 
 ISTRY. For the Use of Students. Based upon Bov^man's Medical 
 Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 
 
 GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
 EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
 BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
 Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. 
 
 GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN 
 DISEASES. In one handsome 12mo. volume of 350 pages, with 
 many illustrations. Shortly. Lea's Series of Pocket Text-books, edited 
 by Bern B. Gallatjdet, M. D. 
 
 HABERSHON (S. O.).. ON THE DISEASES OF THE ABDOMEN 
 Second Americaij from the third English edition. In one octavo vol- 
 ume of 554 pages, with 11 engravings. Cloth, $3.50. 
 
 HALIi (WINFIELiD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo 
 of 672 pages, with 343 engravings, and 6 full page colored plates. 
 Cloth, $4,00 ; leather, $5.00, net. 
 
 Truly a scientific treatment of the 
 subject. The clearness with which 
 physiological facts are demonstrated 
 makes it of special value to the 
 medical student. The science of 
 physiology is one, the importance 
 
 of which needs to be more strongly 
 impressed upon students A book 
 which makes this so easily possible 
 is to be highly commended. — West- 
 em Medical Seview. 
 
 HAMUjTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
 DESCRIPTION AND TREATMENT. Second and revised edition. 
 In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 
 
 HARDAWAY (W. A.). MANUAL OF SKIN DISEASES. Second 
 edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
 2 plates. Cloth, $2.25, net. 
 
 The best of all the small books to 
 recommend to students and practi- 
 tioners. Probably no one of our 
 dermatologists has had a wider every- 
 
 day clinical experience. His great 
 strength is in diagnosis, descriptions 
 of lesions and especially in treat- 
 ment. — Indiana Medical Journal. 
 
Lea Brothers & Co., Philadelphia and New Yoek. 13 
 
 HARE (HOBABT AMOBY). PRACTICAL DIAGNOSIS. THE 
 USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. Fourth 
 edition. In one octavo volume of 623 pages, with 205 engravings 
 and 14 full-page colored plates. Cloth, $5.00, wet; half Morocco, 
 $6.50, net. 
 
 It is unique in many respects, and 
 the author has introduced radical 
 changes which will be welcomed by 
 all. Anyone who reads this book 
 will become a more acute observer, 
 will pay more attention to the simple 
 yet indicative signs of disease, and 
 
 he will become a better diagnosti- 
 cian. This is a companion to Prac- 
 tical Tlierapeutics, by the same 
 author, and it is difficult to conceive 
 of any two works of greater practical 
 utility. — Medical Seview. 
 
 HARE (HOBART AMORX). A TEXT-BOOK OF PEACTICAL 
 
 THERAPEUTICS, with Special Reference to the Application of Reme- 
 dial Measures to Disease and their Employment upon a Rational 
 Basis. With articles on various subjects by well-known specialists. 
 Ninth and revised edition. In one octavo volume of 851 pages, 
 with 105 engravings and 4 colored plates. Cloth, $4.00, net; leather, 
 $5.00, net; half Morocco, $5.50, net. 
 
 Its classificktions are inimitable, 
 and the readiness with which any- 
 thing can be found is the most won- 
 derful achievement of the art of in- 
 dexing. This edition takes in all 
 the latest discovered remedies. — 
 The St. Louis Clinique. 
 
 The great value of the work lies 
 in the fact that precise indications 
 for administration are given. A 
 complete index of diseases and 
 remedies makes it an easy reference 
 work. It has been arranged so that 
 
 it can be readily used in connection 
 with Hare's Practical Diagnosis. 
 For the needs of the student and 
 general practitioner it has no equal. 
 — Medical Sentinel. 
 
 The best planned therapeutic work 
 of the century. — American Prac- 
 titioner and News. 
 
 It is a book precisely adapted to 
 the needs of the busy practitioner, 
 who can rely upon finding exactly 
 what he needs. — The National Med- 
 ical Remew. 
 
 HARE'S SYSTEM OF PRACTICAL THERAPEUTICS. In a series 
 of contributions by eminent practitioners. Second edition. In three 
 large octavo volumes containing 2593 pages, with 457 engravings 
 and 26 full-page plates. Price per volume, cloth, $5.00; leather, 
 $6.00 ; half morocco, $7.00. Full prospectus free on application. 
 For sale by subscription only. 
 
 The Hare's System of ten years 
 ago will hardly be recognized in 
 this new edition, so complete are the 
 changes, so extended the disserta- 
 tion and so complete the re-dress. 
 The additions alone are sufficient to 
 make a new volume. The choice of 
 eubiects is wide and the names of 
 the authors are a sufficient guaran- 
 tee of the character of the mode of 
 treatment. The dominant feature 
 of the work, one that the well- 
 
 known editor constantly presents, is 
 the everyday workability of treat- 
 ments advocated. Here are no 
 lengthy theoretical dissertations 
 largely padded by quotations from 
 European authors, but concise, prac- 
 tical rules that can be made to fit 
 present-day needs. What, why 
 and HOW are the questions with ref- 
 erence to the use of drugs that the 
 authors answer — particularly the 
 HOW. — Medical Newt. 
 
14 Lba Bkothbbs,& Co., Philadelphia and New Yoek. 
 
 HARE (HOBAJRT AMORY) ON THE MEDICAL COMPLICA- 
 TIONS AND SEQUELiE OF TYPHOID FEVER. Octavo, 276 
 pages, 21 engravings and two fuU-page plates. Cloth, $2.40, net. 
 
 read with great profit. — Cleveland 
 Journal of MedAdne. 
 
 A very valuable production. One 
 of the very best products of Dr. 
 Hare and one that every man can 
 
 HARRINGTON (CHARLES). PEACTICAL HYGIENE. Hand- 
 some octavo, 721 pages, 105 engravings, 12 plates. N*t, $4.25. 
 
 HARTSHORNE (HENRY). ESSENTIALS OF THE PEINCIPLES 
 AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
 volume, 669 pages, with 144 engravings. Cloth, $2.75. 
 
 A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 
 
 12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 
 
 ■ A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 
 
 Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
 tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. 
 
 HAYDEN (JAMBS R.). A POCKET TEXT-BOOK OF VENER- 
 EAL DISEASES. Third edition. In one 12mo. volume of 304 
 pages, with 66 engravings. Cloth, $1.75, net. Flexible leather, 
 $2.25, net. 
 
 It is practical, concise, definite 
 and of sufficient fulness to be satis- 
 factory. — Chicago Clinical Review. 
 
 It is well written, up to date, and 
 will be found very useful. — Inter- 
 national Medical Magazine. 
 
 HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND 
 NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
 tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
 Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
 of 414 pages,with 113 engravings. Cloth, $3. 
 
 HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 
 one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
 Student's Series of Manuals, page 27. 
 
 HERMANN (li.). EXPERIMENTAL PHARMACOLOGY. A Hand- 
 book of the Methods for Determining the Physiological Actions of 
 Drugs. Translated by Robert Meade Smith, M.D. Inonel2mo. 
 volume of 199 pages, with 32 engravings. Cloth, $1.50. 
 
 HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 
 one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
 colored plates. Cloth, $2.50. 
 
 We commend the book not only to 
 the undergraduate, but also to the 
 physician who desires a ready means 
 of refreshing his knowledge of diag- 
 nosis in the exigencies of professional 
 life. — Memphis Medical Monthly. 
 
 Excellently arranged, practical, 
 concise, up-to-date, and eminently 
 well fitted for the use of the prac- 
 titioner as well as of the student. — 
 Chicago Med. Recorder. 
 
Lea Beothkbs & Co., Philadelphia and New Yobk. 15 
 
 HERTER (C. A.). LECTURES GN CHEMICAL PATHOLOGY. 
 In one 12mo., volume of 454 pages. Cloth, $1.75, net. 
 
 Hllili (BERKELEY). SYPHILIS "AND LOCAL CONTAGIOUS 
 DISORD EKS. In one 8vo. volume of 479 pages. Cloth, $3.25. 
 
 HILIilER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
 Second edition. In one royal 12mo. volume of 353 pages, with two 
 plates. Cloth, $2.25. 
 
 HtRST (BARTON C.) AND PEERSOti (GEORGE A.). HUMAN 
 MONSTROSITIES. Magnificent folio, containing 220 pages of t«xt 
 and illustrated with 123 engravings and 39 large photographic plates 
 from nature. In four parts, price each, $5. 
 
 HOBIjYN (RICHARD D.). A DICTIONARY OF THE TERMS 
 USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
 Thirteenth edition. In one 12mo. volume of 845 pages. Cloth, 
 $3.00, net. 
 
 HODGE (HUGH Ij.). ON DISEASES PECULIAR TO "WOMEN, 
 INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
 revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 
 
 HOFFMANN (FREDERICK) AND POTVIER (FREDERICK B.). 
 A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
 Examination of Medicinal Chemicals and their Preparations. Third 
 edition, entirely rewritten and much enlarged. In one handsome octavo 
 volume of 621 pages, with 179 engravings. Cloth, $4.25. 
 
 HOIiMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
 ciples and Practice. Fifth edition. Edited by T. Pickemng Pick, 
 F.R.C.S. In one handsome octavo volume of 1008 pages, with 428 en- 
 gravings. Cloth, $6 ; leather, $7. 
 
 A SYSTEM OF SURGERY. With notes and additions by various 
 
 American authors. Edited by John H. Packard, M. D. In three 
 very handsome Svo. volumes containing 3137 double-columned pages, 
 with 979 engravings and 13 lithographic plates. Per volume, doth, $6 ; 
 le»ther, $7 ; half Russia, $7.60. For tale by nubicription only. 
 
 HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one 
 octavo volume of 308 pages. Cloth, $2.50. 
 
 HUNTINGTON (GEORGE S.). A TREATISE ON ABDOMINAL 
 ANATOMY. Quarto, with 250 pages of text and 300 full-page 
 plates, Shortly. 
 
16 IiHA Bbothkbs & Co., Philadelphia and New York. 
 
 HYDE (JAMES NEVINS) AND MONTGOMERY (F. H.) A 
 PEACTICAL TREATISE ON DISEASES OF THE SKIN. Sixth 
 edition, thoroughly revised. Octavo, 832 pages, with 107 engrav- 
 ings and 27 full-page plates, 9 of which are colored. Cloth, $4.50, net; 
 leather, $5.50, «e<; half Morocco, $6.00, net. 
 
 This edition has been carefully re- 
 vised, and every real advance has 
 been recognized. The work answers 
 the needs of the general practitioner, 
 the specialist, and the student. — The 
 Ohio Med. Jour. 
 
 A treatise of exceptional merit 
 characterized by conscipntious caie 
 and scientific accuracy. — Buffalo 
 Med. Jowmal. - 
 
 A complete exposition of our 
 knowledge of cutaneous medicine as 
 it exists to-day. The teaching in- 
 
 culcated throughout is sound as well 
 as practical. — The American Jour- 
 nal of the Medical Sciences. 
 
 It is the best one-volume work 
 that we know. — Virginia Medical 
 Semi-Monthly. 
 
 A full and thoroughly modern 
 text-book on dermatology. — The 
 Pittsburg Medical Jieview. 
 
 The most practical handbook on 
 dermatology with which we are ac- 
 quainted. — Chicago Medical Re- 
 corder. 
 
 JACKSON (GEORGE THOMAS). THE READY-KEFERENCE 
 HANDBOOK OF DISEASES OF THE SKIN. Fourth edition. 
 In one 12mo. volume of 617 pages, with 82 illustrations and 3 colored 
 plates. Cloth, $2.75, net. 
 
 As a student's manual, it may be 
 considered beyond criticism. The 
 book is singularly full. — St. Louis 
 Medical and Surgical Journal. 
 
 Without doubt forms one of the 
 best guides for the beginner in der- 
 matology that is to be found in the 
 English language. — Medicine. 
 
 JAMIESON (W. ALlLAN). DISEASES OF THE SKIN. Third 
 edition. In one octavo volume of 656 pages, with 1 engraving and 9 
 double-page chromo-lithographic plates. Cloth, $6. 
 
 JEWETT (CHARIiES). ESSENTIALS OF OBSTETRICS. Second 
 edition. In one 12mo. volume of 385 pages, with 80 engravings and 
 5 colored plates. Cloth, $2.25. 
 
 An exceedingly useful manual for 
 student and practitioner. The au- 
 thor has succeeded unusually well 
 in condensing the text and in arrang- 
 
 ing it in attractive and easily tangi- 
 ble form. The book is well illus- 
 trated throughout. — Nashville Jour, 
 of Medicine and Surgery. 
 
 — THE PRACTICE OF OBSTETRICS. Second edition. By Am- 
 erican Authors. One large octavo volume of 775 pages, with 445 
 engravings in black and colors, and 35 full-page colored plates. 
 Cloth, $5.00, net; leather, $6.00, net; half Morocco, $6.50, met. 
 
 A clear and practical treatise upon 
 obstetrics by well-known teachers of 
 the subject. A special feature of 
 this work would seem to be the 
 excellent illustrations with which 
 
 the book abounds. The work is 
 sure to be popular with medical 
 students, as well as being of extreme 
 value to the practitioner. — The 
 Medical Age. 
 
Lea Bbothkks & Co., Philadelphia and New Yobk. 17 
 
 "^^^^^J^T^"^ HANDBOOK OF OPHTHALMIC SCIENCE 
 AiNjj fHAi^lUjiL,. Second edition. In one octavo volume of 649 
 pages, with 201 engravinss, 17 ohromo-lithographic plates, test-types of 
 Jaeger and Snellen, and Holmgren's Color-BIindjoess Test. Cloth. 
 $5.50 ; leather, $6.50. 
 
 KING (A. F. A.). A MANUAL OF OBSTETRICS. Eighth edition. 
 In one 12mo. volume of 612 pages, with 264 iUustrations. Cloth, 
 $2.50, net. 
 
 From first to finish it is thoroughly I of nearly every fact of importance, 
 practical, concise in expression, well —Virginia Med. Semi-Monthly. 
 Illustrated, and includes a statement ' 
 
 KIRK (EDWARD C). OPERATIVE DENTISTRY. Second 
 edition. Handsome octavo of 857 pages, with 897 illustrations. See 
 American Text-Boolca of Dentittry, page 2. 
 We have only the highest praise tempted. We can heartily reoom- 
 
 for this valuable work. It is replete mend it to the profession.— TAo 
 
 in every particular, and surpasses Ohio Dental Journal. 
 
 anything of the kind heretofore at- 
 
 KTiEIN (E.). ELEMENTS OF HISTOLOGY. Fifth edition. In 
 one 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, 
 net. See Student's Series of Manuals, page 27. 
 It is the most complete and con- I This work deservedly occupies a 
 
 cise work of the kind that has yet first place as a text-book on his- 
 
 emanated from the press. — TheMed- tology. — Canuddan Practitioner. 
 
 ical Age. I 
 
 KOPLIK (HENRY). THE DISEASES OF INFANCY AND 
 CHILDHOOD. Octavo, about 700 pages with 168 engravings. In 
 press. • 
 
 LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 
 handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 
 
 LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
 BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
 octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 
 
 LEA'S SERIES OF POCKET TEXT-BOOKS, edited bjr Bern 
 B. GALLAtTDBT, M. D. Covering the entire field of Medicine in a 
 series of 16 very handsome 12mo. volumes of 350-450 pages each, 
 profusely illustrated. Compendious, clear, trustworthy and modern. 
 The following volumes constitute the series. 
 
 Collins and Rockwell's Physiology. Mabtin and Rockwell's Chem- 
 istry and Physics. Nichols and Vale's Histology and Pathology. 
 ScHLEip's Materia Medica, Therapeutics, Medical Latin, etc. Mals- 
 BAEY'S Practice of Medicine. Collins' Diagnosis. Potts' Nervous 
 and Mental Diseases. Gallaudet's Surgery. Gkindon's Der- 
 matology. Ballengek and Wippeen's Diseases of the Eye, Ear, 
 Throat and Nose. Evans' Obstetrics. Ceockbtt's Gynecology. 
 TUTTLB's Diseases of Children. Rockwell's Anatomy. Zapffe's 
 Bacteriology. 
 
 For separate notices see under various authors' names. 
 
 liEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
 AND INDULGENCES IN THE LATIN CHURCH. In three 
 octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 
 
18 Lea Beothbbs & Co., Philadelphia and Nbw Tobk. 
 
 liEA (HENRY C). CHAPTERS FROM THE RELIGIOUS HIS- 
 TORY OF SPAIN; CENSORSHIP OF THE PRESS; MYSTICS 
 AND ILLUMINATI OF THE ENDEMONIADAS ; EL SANTO 
 Nl5fO DE LA GUARDIA. 12mo., 522 pages. Cloth, $2.50. 
 
 —THE MORISCOS OF SPAIN, THEIR CONVERSION AND 
 
 EXPULSION. In one royal 12ino. volume of 425 pages. Cloth, 
 $2;25, net. 
 
 SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 
 
 OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
 TORTURE. Fourth edition, thoroughly revised. In one hand- 
 some royal 12mo. volume of 629 pages. Cloth, $2.75. 
 
 STUDIES IN CHURCH HISTORY. The Rise of the Temporal 
 
 Power — Benefit of Clergy — Excommunication. New edition. In one 
 handsome 12mo. volume of 605 pages. Cloth, $2.50. 
 
 AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 
 
 IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
 some octavo volume of 685 pages. Cloth, $4.50. 
 
 LEA'S SERIES OF MEDICAL EPITOMES. Covering the en- 
 tire field of medicine and surgery in twenty convenient volumes of 
 about 250 pages each, amply illustrated and written by prominent 
 teaohers and specialists. Compendious, authoritative and modern. 
 Following each chapter is a series of questions which will be found 
 convenient in quizzing. The series is constituted as follows : 
 
 1, Hale's Anatomy. 2, Guenther's Phyjiology. 3, McGlannon's Chemis- 
 try and Physics. 4, ICiepe's Materia Medica and Therapeutics. 5. 
 Dayton's Practice of Medicine. 6, Hollis's Physical Diagnosis. 7, 
 Arneill's Clinical Diagnosis and Urinalysis. 8, Nagle's Nervous and 
 Mental Diseases. 9, Wathen's Histology. 10, Stenhouse's Pathology. 
 11, Archinard's BaeteriMogy. 12, Magee and Johnson's Surgery. 13, 
 Veasey's Ophthalmology. 14, Brown and Ferguson's Ear, Nose and 
 Throat. 15, Schmidt's Genito-Urinary and Venereal Diseases. 16, 
 Sehalek's Dermatology. 17, Pedersen's Gynecology. 18, Manton's 
 Obstetrics. 19, Tuley's Pediatrics. 20, Dwight's Jurisprudence and 
 Toxicology. 
 
 LE FEVRE (EGBERT). A TEXT-BOOK OF PHYSICAL DIAG- 
 NOSIS. In one 12mo. volume of about 350 pages, amply illustrated. 
 In press. 
 
 liONG (ELI H.). A MANUAL OF DENTAL MATERIA MEDICA 
 AND THERAPEUTICS. 12mo, about 350 pages with many en- 
 gravings. Shortly. 
 
 liOOMIS (ALFRED L.) AND THOMPSON (W. OILMAN 
 EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 
 Contributions by Various American Authors. In four octavo vol- 
 umes of about 900 pages each, fully illustrated in black and colors 
 Per volume, cloth, $5 ; leather, $6 ; half Morocco, $7. For tale by 
 subscription only. Full prospectus free on application to the Pub- 
 lishers. 
 
 LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 
 very handsome octavo volume of 925 pages, with 170 engravines. 
 Cloth, $4.75 ; leather, $5.75. s e 
 
Lea Beothkks & Co., Philadelphia and New Yokk. 19 
 
 liYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
 volume of 362 pages. Cloth, $2.25. 
 
 MAISOH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
 MEDICA. Seventh edition, thoroughly revised by H. C. C. Maisch, 
 Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, -with 
 285 engravings. Cloth, $2.50, net. 
 
 Used as text-hook in every college I The best handbook upon phar- 
 of pharmacy in the United States macognosy of any published in this 
 and recommended in medical col- country. — Boston Med. & Sur. Jour. 
 leges. — American Therapist. \ 
 
 MAliSBARY (GEORGE E.). A POCKET TEXT-BOOK OF 
 
 THEORY AND PRACTICE OF MEDICINE. In one handsome 
 
 12mo. volume of 405 pages, with 45 illustrations. Cloth, $1.75, net; 
 
 flexible red leather, $2.25, net. Lea's Series of Pocket Text-books, 
 
 edited by Bbkn B. GALLAtTDET, M. D. See page 17. 
 
 Will readily commend itself to 1 recent advances in medicine with 
 
 students and busy practitioners, the best of that which is old. — 
 
 bringing forward as it does the most ' Medical Review of Beviews. 
 
 MANUALS. See Student's Quiz Series, page 27, Student's Series of 
 Marmals, page 27, Series of Clinical Manuals, page 25, and Series of 
 Medical Epitomes, page 18. 
 
 MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12rao. 
 
 volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
 
 See Se/ries of Clinical Manuals, page 25. 
 MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 
 
 In one 12mo. volume of about 400 pp., fally illustrated. Preparing. 
 
 MARTIN (WALTON) AND ROCKWELL, (WM. H). A POCKET 
 TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- 
 some 12mo. volume of 366 pages, with 137 illustrations. Cloth, $1.50, 
 net; limp leather, $2.00, net. Lea's Series of Pocket Text-Books, 
 edited by Bbbn B. Gallatidbt, M. D. See page 17. 
 The work accurately reflects both I ter is excellent.-TAe Medical and 
 
 sciences in their present develop- Surgical monitor. 
 
 ment. The arrangement of the mat- 
 
 MAY (C H.). MANUAL OF THE DISEASES OF WOMEN. For 
 the use of Students and Practitioners. Second edition, revised by L. 
 S. Rait, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
 ings. Cloth, $1.75. 
 
 MEDICAL NEWS POCKET FORMULARY, see page 32. 
 
20 
 
 Lea Bbothebs & Co., Philadelphia and New Yobk. 
 
 MITOHEIjL (S. WEIR). CLINICAL LESSONS ON NERVOUS 
 DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
 and 2 colored plates. Cloth, $2.50. 
 
 The book treats of hysteria, recur- 
 rent melancholia., disorders of sleep, 
 choreic movements, false sensations 
 of cold, ataxia, hemiplegic pain, 
 treatment of sciatica, erythromelal- 
 gia, reflex ooularneuroais, hysteric 
 
 contractions, rotary movements m 
 the feeble minded, etc. Few can 
 speak with more authority than the 
 author. — The Journal of the Ameri- 
 can Medical Atiodation. 
 
 MITOHELIj (JOHN K.). REMOTE CONSEQUENCES OF 
 INJURIES OF NERVES AND THEIR TREATMENT. In 
 one handsome 12mo. volume of 239 pages, with 12 illustrations. 
 Cloth, $1.75. 
 
 MORRIS (MAIiCOIiM). DISEASES OF THE SKIN. Second 
 edition. In one 12mo. volume of 601 pages, with 10 ehromo-Iitho- 
 graphic plates and 26 engravings. Cloth, $3.25, net. 
 
 The work is essentially clinical 
 and practical in its scope and is 
 characterized throughout by clear- 
 ness and simplicity of style and 
 
 strong common sense. It is alike 
 suitable for the student, physician 
 and specialist. — Buffalo Medical 
 Journal. 
 
 MXrUiER (J.). PRINCIPLES OF PHYSICS AND METEOR- 
 OLOGY. In one large 8vo. vol. of 623 pages, with 638 cuts. 
 Cloth, $4.50. 
 
 MT7SSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 
 DIAGNOSIS, for Students and Physicians. Fourth edition, thor- 
 oughly revised. In one octavo volume of 1104 pages, with 250 en- 
 gravings and 49 full-page colored plates. Cloth, $6.00, net; leather, 
 $7.00, net; half Morocco, $7.50, net. 
 
 We have no work of equal value 
 in English. — Vriiverrity Medical 
 
 The best of its kind, invaluable to 
 the student, general practitioner and 
 teacher. — Montreal medical Journal. 
 
 NATIONAIi DISPENSATORY. See S»««, JSfawcA <fe Owpori, p. 27. 
 
 NATIONAIi FORMULARY. See StUU, Maitch <& Catpari'g National 
 Diapematory, page 27. 
 
 NATIONAIi MEDICAL DICTIONARY. See SilUngi, page 4. 
 
Lea Beothbbs & Co., Philadelphia and New Yoek. 21 
 
 NETTLiESHIP (B.). 
 
 thoroughly reyised. 
 engravings, and 5 
 blindneaa test. Cloth, $2.25, net. 
 
 By far the best student's text-book 
 on the subject of ophthalmology. — 
 Tlie Climcal Review. 
 
 This work for compactness, practi- 
 cality and clearness has no superior 
 in the English language. — Journal 
 of Medicine and Science. 
 
 DISEASES OF THE EYE. Sixth edition, 
 
 In one 12mo. volume of 662 pages, with 192 
 
 colored plates, test-types, formulae and oolor- 
 
 The present edition is the result 
 of revision both in England and 
 America, and therefore contains the 
 latest and best ophthalmological 
 ideas of both continents. — The Phy- 
 sician and Surgeon. 
 
 NICHOLS (JOHN B.) AND VALiE (F. P.). A POCKET TEXT- 
 BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 
 12mo. volume of 452 pages, with 213 illustrations. Cloth, $1.75, net : 
 flexible red leather, $2.25, net. 
 
 Lea's Series of Pocket Text-books, edited by Been B. Gallaudet, 
 M. D. See page 17. 
 
 Systematically arranged, and in 
 the highest degree, interesting. 
 Thoroughly up to date. The book 
 is an exceptionally good one. We 
 
 can safely and conscientiously rec- 
 ommend it to both students and 
 practitioners. — Tlie St. Louis Medi- 
 cal and Surgical Journal. 
 
 NOKRIS (WM. F.) AND OIjIVER (CHAS. A.). TEXT-BOOK OF 
 OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
 engravings and 5 colored plates. Cloth, $5 ; leather, $6. 
 
 It is practical in its teachings. 
 We unreservedly endorse it as the 
 best, the safest and the most compre- 
 hensive volume upon the subject that 
 
 has ever been offered to the Amer- 
 ican medical public. — Annals o] 
 Ophthalmology and Otology. 
 
 OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 
 In one 12mo. volume of 625 pages, with 85 engravings and 4 colored 
 plates. Cloth, $2. See Series of Clinical Mamuala, page 25. 
 
 PARK (ROSWEIili). A TREATISE ON SURGERY BY AMERI- 
 CAN AUTHORS. Third edition. In one royal octavo volume 
 of 1408 pages, with 692 engravings and 64 full-page plates. Cloth, 
 $7.00, net ; leather, $8.00, net. 
 
 The work is fresh, clear and practi- 
 cal, covering the ground thoroughly 
 yet briefly, and well arranged for 
 rapid reference, so that it will be of 
 special value to the student and busy 
 practitioner. The pathology is 
 broad, clear and soientifio, whfle the 
 ■uggestions upon treatment are 
 
 clear-cut, thoroughly modern and 
 admirably resourceful. — Johns Hop- 
 kint Hospital Bulletin. 
 
 The latest and best work written 
 upon the science and art of surgery. 
 Oolwmbus Medical Journal. 
 
 It is thoroughly practical and yet 
 thoroughly scientific. — Med. News. 
 
22 Lba Beothkbs & Co., Philadelphia and New Yoek. 
 
 PARK (WILIjIAM H.). BACTERIOLOGY IN MEDICINE AND 
 SUEGERY. 12mo., 688 pages, with 87 illustrations in black and 
 colors, and 2 plates. Cloth, $3.00 net. 
 
 This book fills a very distinct 
 gap. None of the text-books in our 
 language take up the subject of bac- 
 teriology so thoroughly and so 
 soundly as does this from the point 
 
 of view of the hygienist and public 
 health officer. The work is correct 
 and very well up to date. — The Mon- 
 treal Medical Journal. 
 
 PARRY (JOHN 8.). EXTRA-UTERINE PREGNANCY, ITS 
 CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
 MENT. In one octavo volume of 272 pages. Cloth, $2.50. 
 
 PARVIN (THEOPHUiUS). THE SCIENCE AND ART OF OB- 
 STETRICS. Third edition. In one handsome octavo volume of 
 677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
 leather, $5.25. 
 
 Parvin's work is practical, con- 
 cise and comprehensive. We com- 
 mend it as first of its class in the 
 
 English language. — Medical Fort- 
 nightly. 
 
 PEPPER'S SYSTEM OF MEDICINE. Seepages. 
 
 PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 
 Series of Manuals, page 27. 
 
 SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 
 
 with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 
 
 PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 
 In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
 See Series of Clinical Manuals, page 25. 
 
 PLiAYFAlR (W. S.). A TREATISE ON THE SCIENCE AND 
 PRACTICE OF MIDWIFERY. Seventh American from the ninth 
 English edition. In one octavo volume of 700 pages, with 207 
 engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. 
 
 An epitome of the science and 
 practice of midwifery, which em- 
 bodies all recent advances. — The 
 Medical Fortnightly. 
 
 This work must occupy a fore- 
 most place in obstetric medicine as 
 
 a safe guide to both student and 
 obstetrician. It holds a place among 
 the ablest English-speaking authori- 
 ties on the obstetric art. — Buffalo 
 Medical and Surgical Journal. 
 
 — THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
 TION AND HYSTERIA. In one 12mo. volume of 97 pages 
 Cloth, $1. 
 
Lea Bbotbebs & Co., Philadelphia and Mbw xobk. as 
 
 POCKET FORMULARY, see page 32. 
 
 POCKET TEXT-BOOKS, see page 18. 
 
 POIilTZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
 EAR AND ADJACENT ORGANS. Third American from the 
 Fourth German edition. In one octavo volume of 748 pages, with 
 330 original engravings. Preparing. 
 
 POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS 
 AND MENTAL DISEASES. In one handsome 12mo. volume of 
 445 pages, with 88 engravings. Cloth, $1.75, net; limp leather, $2.25, 
 net. Lea's Series of Pocket Text-books, edited by Been B. Gali.au- 
 DBT, M. D. See page 17. 
 
 of the numerous discoveries in every 
 branch of neurology is clearly pre- 
 sented. The book is a reliable guide. 
 — The Medical Bulletin. 
 
 ■ A TEXT BOOK ON MEDICAL AND SURGICAL ELECTRI- 
 
 Dr. Potts has succeeded in de- 
 picting the main facts in a manner 
 that will be appreciated by students 
 and general practitioners. The gist 
 
 CITY. Octavo, about 350 pages, amply illustrated. Shortly. 
 
 POSEY (W. C.) AND WRIGHT (JONATHAN). A TREATISE 
 ON THE EYE, NOSE, THROAT AND EAR. Octavo, about 1100 
 pages, richly illustrated in black and colors. In press. 
 
 PROGRESSIVE MEDICINE, see page 32. 
 
 PURDY (CHARLES W.). BBIGHT'S DISEASE AND ALLIED 
 AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
 pages, with 18 engravings. Cloth, $2. 
 
 PYE-SMITH (PHIIilP H.). DISEASES OF THE SKIN. In one 
 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2, 
 
 QUIZ SERIES. See Student's Quiz Series, page 27. 
 
 RAIiPE (CHARLES H.). CLINICAL CHEMISTRY. In one 
 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
 Student's Series of Manuals, page 27. 
 
 REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- 
 ISTRY. Fifth edition, thoroughly revised. In one 12mo. vol- 
 ume of 326 pages. Cloth,.$2. 
 
 A clear and concise explanation 
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 — X^ew Orleans Med. and Surg. Jmur. 
 
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 CINE. In one octavo volume of 729 pages. Cloth, $4; leather, $5. 
 
 ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 
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 838 pages with 473 engravings and 8 plates. Cloth, $4.25, net; leather, 
 $5.25, net. 
 
 satisfactory or valuable single vol- 
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 A clear, concise, comprehensive 
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 ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON 
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 DEPOSITS. Fourth American from the fourth London edition. In 
 one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 
 
 ROCKWELL, (W. H., Jr.). A POCKET TEXT-BOOK OF AN- 
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 SOHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
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 Sixth edition. In one handsome octavo volume of 426 pages, 
 with 463 illustrations. Cloth, $3.00, net. 
 
 Nowhere else will the same very 
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 lish \a.ng\ia.g%.— The Boston Med. and 
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 A COURSE OF PRACTICAL HISTOLOGY. Second edition. 
 
 In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 
 
 SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS 
 
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 tains in a concise, definite, and as- and Therapeutics.— TAe National 
 
 similable form the essential knowl- Medical Review. 
 
 •dije required in the most complete 
 
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 SCHMAUS (HAN'S.) AND EWING (JAMES). PATHOLOGY 
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 SENN (NICHOIjAS). SUEQICAL BACTERIOLOGY. Second edi- 
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 one octavo volume of 608 pages, with 139 engravings and 19 full-page 
 colored plates. Cloth, $3.75, net. 
 This book thoroughly deserves its 
 
 In all respects entirely up to date. 
 — MecUcal Mtcord. 
 
 The chapter on examination oi 
 the urine is the most complete and 
 advanced that we know of in the 
 English language. — Canadian Prac- 
 titioner. 
 
 success. It is a very complete, authen^ 
 tic and useful manual of the micro- 
 scopical and chemical methods 
 which are employed in diagnosis. 
 Very excellent colored plates illus- 
 trate this work. — JYew York Medical 
 Journal. 
 
 SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
 and Laboratory Work for Beginners in Chemistry. A Text-book 
 specially adapted for Students of Pharmacy and Medicine. Seventh 
 edition. In one 8vo. volume of 613 pages, with 64 engravings and 8 
 plates showing colors of 64 tests, and a spectra plate. Cloth, $3.00, net. 
 
 It is difficult to see how a better 
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 chemistry than is contained between 
 
 the covfers of this book. — The North- 
 western Lancet. 
 
 Its statements are all clear and its 
 teachings are practical. — Virginia 
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 SliADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
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 SMITH (EDWARD). CONSUMPTION; ITS EAKLY AND KEME- 
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 SMITH (J. LEWIS). A TKEATISE ON THE DISEASES OF IN- 
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 and rewritten and much enlarged. In one large 8vo. volume of 983 
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 The most complete and satisfac- 
 tory text-book with which we are 
 acquainted. — American Gynecologi- 
 cal and Obstetrical Jov/mal. 
 
 A safe guide for students and phy- 
 sicians. — The Am. Jour, of Obstetrics. 
 
 For years the leading text-book on 
 children's diseases in America. — 
 Chicago Medical Secorder. 
 
 SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
 oughly revised edition. In one octavo volume of 892 pages, with 
 1005 engravings. Cloth, $4 ; leather, $5. 
 
 One of the most satisfactory works 
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 published. The book is a compen- 
 
 dium for the modern surgeon. — Bos- 
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 Every practitioner of medicine 
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 study it, and we are sure he ^ill 
 
 never regret it. — St. Lowis Medical 
 and Surgical Jov/rnal. 
 
 A clear and lucid summary of 
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 — The Therapeutic Gazette. 
 
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 Medicines, including those recognized in the latest Pharmacopoeias of 
 the United States, Great Britain and Germany, with numerous refer- 
 ences to the French Codex. Fifth edition, revised and enlarged 
 including the U. S. Pharmacopoeia, Seventh Decennial Revision. 
 With Supplement containing the National Formulary. In one 
 magnificent imperial octavo volume of about 2025 pages, with 
 320 engravings. Cloth, $7.26; leather, $8. With ready reference 
 Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 
 
Lea Bbothkes & Co., Philadelphia and New Yoek. 27 
 
 STIM80N (liEWIS A.). A MANUAL OF OPERATIVE SURGERY. 
 Fourth edition. In one royal 12mo. volume of 581 pages, with 293 
 engravings. Cloth, $3.00, net. 
 
 A useful and practical guide for The book is worth the price for the 
 all students and practitioners. — Am. illustrations alone. — Ohio Medical 
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 DISLOCATIONS. Third edition. In one handsome octavo vol- 
 ume of 842 pages, with 336 engravings and 32 plates. Cloth, $5.00, 
 net; leather, $6.00, net; half Morocco, $6.50, net. 
 
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 engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50. 
 
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 we would say, get Taylor first, and 
 then add as means and inclination 
 enable you. — American Practitioner 
 and News. 
 
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 TAYliOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
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 The author has presented to the 
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 tific work aa yet published on sexual 
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 Medical Newt. 
 
 —A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES 
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 802 pages. Cloth, $3.75. 
 
 THOMAS (T. GATLLARD) AND MTJNDE'(PAtJIi F.). A PRAC- 
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 Cloth, $5 ; leather, $6. 
 
 The best practical treatise on the 
 subject in the English language. 
 It will be of especial value to the 
 general practitioner as well as to the 
 specialist. The illustrations are very 
 satisfactory. Many of them are new 
 and are particularly clear and attrac- 
 tive. — Boston Med . and Sur. Jowr. 
 
 This work, which has already gone 
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 been translated into French, Ger- 
 man, Spanish and Italian, is the 
 most practical and at the same time 
 the most complete treatise upon the 
 subject. — TKt Archives of Oynecol- 
 ogy, Obstetrics and Pediatrics. 
 
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 octavo volume of 1012 pages, with 79 engravings. Cloth, $5.00, 
 net; leather, $6.00, net; half Morocco, $6.50, net. 
 
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 TIRARD (NESTOR). MEDICAL TREATMENT OF DISEASES 
 AND SYMPTOMS. Handsome octavo volume of 627 pages. Cloth, 
 $4.00, net. 
 
 this is a work destined to become 
 popular, and we take great pleasure 
 in commending it in the highest 
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 This work will rapidly come into 
 favor with students and practition- 
 ers. It deals comprehensively with 
 therapeutical medications and pre- 
 sents a great number of well-selected 
 formulas of every day use. Certainly 
 
 TODD (ROBERT BENTLiEY). CLINICAL LECTURES ON CER- 
 TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 
 
 TREVES (FREDERICat). OPERATIVE SURGERY. In two 
 8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 
 
 A SYSTEM OF SURGERY. In Contributions by Twenty-five 
 
 English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
 with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
 487 engravings and 2 colored plates. Complete work, cloth, $16.00. 
 
 TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. 
 New edition. In one 12mo. volume of 600 pages, with 61 engravings. 
 Cloth, $2.00, net. See Student's Series of Manuals, page 27. 
 
30 IfBA Bkothbiis & Co., Philadelphia and New Yoek. 
 
 TTJTTIjE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES 
 OF CHILDREN. In one handsome 12mo. volume of 374 pages, 
 with 5 plates. Cloth, $1.50, net ; flexible red leather, $2.00, net. Lea's 
 Series of Pocket Text-books, edited by Been B. Gallaudbt, M. D. 
 See p. 17. 
 
 It is a good work — the author hav- 
 ing condensed most of the leading 
 points in connection with diseases 
 
 of infancy and childhood into short 
 and readable chapters. — Virginia 
 Medical Semir Monthly. 
 
 VAUGHAN (VICTOR O.) AND NOVY (FREDERICK G.). 
 CELLULAR TOXINS, or the Chemical Factors in the Causation of 
 Disease. New (4th) edition. In one 12mo. volume of 480 pages. Cloth, 
 $3.00, net. 
 
 The work has been brought down 
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 The most exhaustive and most re- 
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 American Jomr. of the Med. Sciences. 
 
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 With thumb-letter index for quick use, 25 cents extra. Special rates 
 to advance-paying subscribers to The MEDICAL News or The 
 American Joitenal op the Medical Sciences, or both. See p. 32. 
 
 WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
 PRACTICE OF PHYSIC. A new American from the fifth and 
 enlarged English edition, with additions by H. Habtshoene, M. D. 
 In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 
 
 WEST (CHARLiES). LECTURES ON THE DISEASES PECULIAR 
 TO WOMEN. Third American-from the third English edition. In 
 one octavo volume of 543 pages. Cloth, $3.75 ; leather^ $4.75. 
 
 ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 
 
 CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth $1. 
 
 WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
 ING. Fifth edition. In one 12mo. volume of 640 pages with 
 509 engravings, many of which are photographic. $3.00, mli!. ' 
 The part devoted to bandaging is 
 
 perhaps the best exposition of the 
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 can be highly commended to the 
 student, the practitioner and the 
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 WeU written, conveniently ar- 
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 covers the field so fully as to render 
 it a valuable text-book, as well as a 
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 WHITMAN'S (ROYAL,). ORTHOPEDIC SURGERY. One octavo 
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 The descriptions of symptoms are 
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 date in every sense. — The Charlotte 
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 We doubt whether any book on work of Dr. Yeo's. The value of 
 
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 widespread usefulness than has this —Neto York Medical Jowrnal. 
 much-quoted and much-consulted 
 
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 volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 
 
 In studying the different chapters, surgical specialty and every page 
 
 one is impressed with the thorough- abounds with evidences of prac- 
 
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 are numerous— the book thoroughly modern work upon this gromng de- 
 
 praotical— JSfedicaZ News. partment of surgery.— TAe Chicago 
 
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 ZAPFFE (F. C). A POCKET TEXT-BOOK OF BACTERIOLOGY. 
 Handsome 12mo. of about 350 pages, amply illustrated. Preparing. 
 
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