Class _3-(lX£ Book Plfc^ Goipghtij" COPYRIGHT DEPOSm NOTES ON PHYSICAL DIAGNOSIS BY JOHN METCALFE POLK, A.B., M.D. LA TE Instructor in Medicine, Cornell University Medical College and Adjunct Assistant Physician, Bellevue Hospital EDITED BY C. N. B. CAMAC. A.B., M.D. ^ NEW YORK CORNELL UNIVERSITY MEDICAL COLLEGE 1905 LiERARYot >aA)GRtSS iwo Oopiei rtweiveu AUG 26 iyU6 /. QU>^S <:X AAC. MW COPY a. Copyright, 1905, by DR. WILLIAM M. POLK Press of J. J. Little & Co. Aster Place, New York The publication of this work is undertaken not merely as a memorial to its lamented Author, but because of its intrinsic merit in elucidating a subject which presents problems of exceptional difficulty to students of medicine. Yet one who was long and closely associated with Dr. Polk throughout his stu- dent and hospital days, as well as in his later field of usefulness as an instructor, may be permitted to add a word of tribute. His relations with his fellow- students, his teachers and his patients alike, were marked by a courtesy and unusual charm of man- ner, which, with his enthusiasm for scientific work and scholarly attainments, fitted him in special de- gree for professional successes, had he been longer spared to achieve them. The work has been brought fully to date by the editorial revision of Dr. Camac, and has received the unqualified approval of all the instructors in the de- partment which it covers. W. Oilman Thompson. INTRODUCTION In the spring of 1903, Dr. John Metcalfe Polk and I talked over the advisability of getting to- gether notes for the third year class in the Cornell University Medical College, on Physical Diagnosis,, which subject we, together w^ith Dr. Montgomery H. Sicard, had been appointed to teach during the ensuing winter. We met several times and com- pared our notes, Dr. Polk's being largely transla- tions from Sahli, while mine were taken chiefly from British and American authorities. The work was engaging and instructive, and I re- call with advantage the questions which were raised and which we endeavored to answer in the post- mortem room. I cannot let this opportunity pass without urging upon instructors the cultivation of this free discussion of doubtful signs, and the study of the normal post-mortem appearance while such questions are fresh in the mind. The benefit and life which it gave to our teaching was a subject of frequent remark between us. With these associations it was with peculiar inter- est that I received the manuscript of these notes from Dr. Wm. M. Polk and with affectionate regard for his son I set about placing in enduring form this one of the many evidences of that thoroughness which characterized all the undertakings of our col- IXTRODUCTIOX league, whose gentle and considerate ways were all too soon taken from among us. While Sahli is the authority for many of the state- ments made, the notes are by no means a mere trans- lation. With the exception of a few final revisions, changes of sequence of various subjects, the notes are exclusively the work of Dr. Polk. W^here ad- ditions have been made they are indicated as foot- notes. I am indebted to Dr. Walter L. Niles for re-read- ing the proof. C. N. B. Camac. CONTENTS PAGE I. GENERAL EXAMINATION 9 Inspection 9 Mensuration 12 Percussion 12 Palpation . . . 16 Auscultation 18 Of breath sounds 18 Rales 21 Of voice sounds 22 II. DETAIL CONSIDERATION OF METHODS OF PHYSICAL EXAMINATION . . 25 The Thorax 25 Inspection, normal Thorax 25 " abnormal Thorax . . . . 25 - Respiration, normal 29 " abnormal; dyspnoea . . .32 Lungs and Pleurae 41 Palpation 41 Percussion 43 Comparative Percussion 52 Auscultation 57 Heart, Pericardium and Vascular Sys- tem 70 Inspection and Palpation 70 Percussion 75 Auscultation 80 Pulse and Arterial Wall 100 III. DIFFERENTIAL DIAGNOSIS .... 108 IV. DISEASES OF PLEURA AND LUNGS .121 It is hardly an exaggeration to say that [honest work is never thrown away. If we do not find the imaginary treasure, at any rate we enrich the vineyard. John Lubbock. GENERAL EXAMINATION The application of Physical Diagnosis is furthered by an outline plan which is comprehensive enough to cover the topographical peculiarities and variations of the field, whether they be on the surface or beneath; and specific enough to indicate to the examiner any one of its methods he may need in the solution of his problem. Such an out- line, however, should be sufficiently concise to be readily held in memory. Attention, therefore, is first asked to the following con- densed statement of subject and matter which is to be elaborated as we progress in our course. (See page 25.) INSPECTION: Position of Patient: Standing, Sitting, Lying. The body and the extremities must be straight and the muscles relaxed. Light : Direct, Oblique. Condition of Abdomen : Normal, Relaxed, Distended, Generally, Locally. Bony Deformities : Fractured Clavicles, etc., lo NOTES ON PHYSICAL DIAGNOSIS Spinal Curvatures, Deformed Pelvis, Shortened Leg. Bony Landmarks: Supra Sternal Notch, Clavicles, First Interspace, Junction of Second Rib with Sternum, Base of Xyphoid Cartilage, Seventh Rib at Sternum, Eleventh and Twelfth Ribs, Seventh Cervical Spine, Fourth and Twelfth Dorsal Spines. Surface Markings : Mid-sternal Line, Sternal Line, Parasternal Line, Mammary Line, Anterior-axillary Line, Mid-axillary Line, Posterior-axillary Line, Scapular Line, Spinal or Mid-dorsal Line. Outline of the Lungs : One inch above inner third of clavicle anteriorly, Eleventh cervical spine posteriorly. Right Lung: Sternal 6th rib, Mammary 6th rib, Mid-axillary 8th rib. Scapular loth rib, Spinal nth rib, Left Lung: Sternal 4th rib, Parasternal 5-6th rib. Mammary 6th rib, Mid-axillary 8th rib, GENERAL EXAMINATION ii Scapula loth rib, Spine nth rib. Division of Lobes : Left: Begins at 4th Dorsal Spine, Mid-axillary 5th rib, Parasternal 6th rib. • Right : Begins at 4th Dorsal Spine, Divides at middle of Axilla, Upper goes to Sternal line at 4th rib. Lower to Mammary line and 6th rib. Tracheal Bifurcation is opposite the 4th dorsal spine posteriorly and the 3d costal cartilage anteriorly. Size and Shape of Thorax : Normal, Phthisical, Emphysematous J ^, '. ) Chronic, Rachitic, Harrison's Groove, Pigeon Breast, Costo- Sternal Groove, Kypho-Scoliotic, Congenital, Funnel Shaped, Acquired (Boat shaped). BULGINGS : Diminished Expansion, )...,, , ^ , -r, ^ . . V L nilateral or Local. Retractions. j Types of Respiration : i Costal, Normal -l Costo-Abdominal, ( Abdominal, Pathological. Diaphragmatic Excursion : Litten's Sign, 12 NOTES ON PHYSICAL DIAGNOSIS Unilateral Diminution, Absence of Movement, Inspiratory Abdominal Insinking. Dyspnoea : Catchy, Accelerated, Superficial, Slow, Deep, Inspiratory Dyspnoea, Expiratory Dyspnoea, Irregular, Cheyne-Stokes. Abnormal Movements of the Thorax : Emphysematous, lack of lateral expansion, Normal insinking of lower interspaces, Abnormal sinking of ribs and interspaces. MENSURATION : Circumference, Semicircumference. Cyrtometry : Diameters. Shape of chest at various levels. PERCUSSION : Methods: Immediate; Finger, Fingers. Mediate: Fingers, Instrumental, Auscultatory Percussion: Stethoscope on organ, percuss or scratch toward stetho- scope. Stethoscope as centre, percussion in circle. Coin clink in pneumothorax. Tactile Percussion: GENERAL EXAMINATION 13 Attributes of Percussion : Vesicular. ( Flat or hard, ^ ^1 Tympanitic. Duration J J^^^' ) Short. Intensity | ^^^^^ Pitch i fS"^' [ Low. Five Types of Percussion Note Obtained over Thorax : Flat or Hard, Dull, Vesicular or Resonant (Normal), Hyperresonant or Vesiculo^tympanitic, Tympanitic. Attributes of the Five Types : Flat : Quality Hard, Duration Short, Intensity Diminished, Pitch High. Dull : QuaHty Hard Vesicular, Duration Decreased, Intensity Slightly Diminished, Pitch Higher than Normal. Vesicular : Quality Vesicular, Duration Long, Intensity Loud, Pitch Low. Hyperresonant : Quality Vesiculo-Tympanitic, Duration .... Long or Short, ' Intensity .... Loud, Pitch Low or High. 14 NOTES ON PHYSICAL DIAGNOSIS Tympany : Quality Musical, Duration Short or Long, Intensity Decreased or Loud, Pitch High or Low. Rules for Percussion : Position of patient ; perfectly upright or flat, muscles relaxed. Compare corresponding points on both sides of chest. Comparison should be made in same stages of res- piration. Finger should be applied with equal firmness and in the same parallel on both sides. Strike with equal force on both sides. Have listening ear at the same distance from points percussed. Conditions Influencing the Percussion Note in the Normal : Position of patient, Muscular contractions, Bony structures. Muscle, fat, oedema, Thoracic and spinal deformities. Structure of organs within the thorax and abdomen, Respiratory phases. Variation in the Percussion Note of the Normal Thorax : Above and below the clavicles pure vesicular; right higher pitched than left, Over the pectorals the note is slightly dull depend- ing on the thickness of the muscle or gland, Sternum, to third rib vesiculo-tympanitic due to trachea, 3d to 4th rib vesicular, 4th to 6th rib dulness of heart. GENERAL EXAMINATION 15 Sternal Lines : Right : 3d and 4th ribs, relative dulness of heart, 5th rib, relative dulness of liver, 6th rib, liver flatness. Left : 3d interspace, relative heart dulness, 4th to 6th interspace, cardiac flatness, 6th interspace, liver flatness extending to the left as far as the parasternal line. Right ^lammary Line: 5th interspace, relative liver dulness, 6th interspace, flatness of liver. Mid-axillary Lines : Left: Good resonance and note increasing in fifll- ness as one descends, due to stomach, till splenic dul- ness is reached at about the 9th rib and extends to the nth rib. Right: Good resonance till relative dulness of liver is reached at 8th rib, flatness at 9th rib. Posteriorly (Scapular Line) : Note high pitched above due to the muscles and bones; on the right, relative liver dulness at 9th, ab- solute at loth; on left, flatness of muscles at loth or tympany of stomach or colon. Pulmonary Excursions : The lung moves normally in respiration about an inch; on deep respiration about 2f to 3 inches. Other Abnormal Percussion Notes and Signs: Amphoric resonance: this is similar to striking the cheek when the mouth is filled with air. Is heard over cavities. Cracked Pot: is similar to striking the closed hands on the knee; is a stenotic murmur due to air being driven from a cavity through a narrow opening. Ob- i6 NOTES ON PHYSICAL DIAGNOSIS tained in the normal chest by percussing thin walled elastic thorax while the patient speaks, or in children when crying. Obtained over cavities under the following condi- tions : The cavity must be over 6 mm. in diameter. It must be superficially situated. Must have elastic walls and open into a bronchus. Wintrich's change of note : On percussion over a cavity a higher pitched tympany is obtained when the patient's mouth is open than when it is closed. This observation must be made under the same phase of respiration. Gerhardt's change of note: is found in oval cavities half filled with fluid. Percussion over the short diam- eter gives a lower note than over the long. This should be made with the patient in several positions. Biermer's change of note in pneumothorax : There is a higher pitched note in the lying position than in the standing, the cavity being enlarged in the latter position by the descent of the diaphragm. Williams' tracheal note (tympany) : obtained over consolidations near large bronchi or over the aj>ex in complete compression of the lung in pleurisy. Friedrich's sign: a high pitched note over a cavity on inspiration and a low pitched one on expiration. This is also obtained over the normal lung. PALPATION: The position of the patient should be the same as in percussion. Examine for areas and points of tenderness, as Over pleurisy. Over seat of intercostal neuralgia. Over praecordium in heart disease (not con- stant), and GENERAL EXAMINATION i? For resistance and fluctuations. For variations and degrees of local expansion. For tactile or vocal fremitus. Fremitus : A vibration produced in the larynx is transmitted down the columns of air in the bronchi to the lung tissue and thence to the chest wall and hand. Note. — The terms Vocal and Tactile, as applied to fremitus, refer to the sensation conveyed to the liand (tactile) by the vibration of the voice (vocal). (See also note on page 41.) — Editor. Rules: Compare corresponding points on each side of the chest. Apply both hands. Apply one hand. Conditions Varying the Fremitus in the Normal Chest : Fremitus is more marked in : The adult than the child. Men than women. Thin people than in fat or muscular. Deep voiced than in high. Strong people than in weak or sick. Conditions of the larynx. The words selected, 99 being better than 66. Diminishes in intensity the further one goes from the large bronchi ; is most marked : Over the upper part of the sternum. Between the scapulae at the fourth cervical ver- tebra. Over apices. The vocal fremitus is more marked over the right apex both anteriorly and posteriorly and in the right axilla than on the left side. Three theories for this difference : 1 8 NOTES ON PHYSICAL DIAGNOSIS The right bronchus is given off higher up and at more of a right angle and is larger than the left. The liver may influence the fremitus. The right thorax is larger by one-half an inch than the left. Tussile fremitus : is a vibration felt on coughing. Rhonchial fremitus : is a vibration produced by moist rales. Friction fremitus : is a vibration produced by pleuri- tic or pericardial rales or rubs. AUSCULTATION : Mediate with stethoscope. This is to be used only when locating fine superficial rales. Distant tubular breathing cannot be heard with the stethoscope. Ear. With or without sounding cloth. Rules : The position of the patient is the same as for per- cussion. The position of the examiner should be comfortable and the head not too low. Auscultate with normal rate and depth of respira- tion. Auscultate with forced respiration. Auscultate after the patient has coughed, and dur- ing cough. Always listen at the patient's mouth to catch the character of the sound there produced. Breath Sounds or Respiratory Murmurs: Inspiration is a muscular act. Expiration is (largely) a passive elastic retraction of the thoracic walls and lungs. Any condition altering this elasticity causes mus- cular effort in expiration. GENERAL EXAMINATION 19 The duration of the inspiratory act is physiologically shorter than that of the expiratory. Note. — On listening over the normal chest, however, inspiration is audible for a longer period than is expiration. — Editor. The normal respiratory murmur is produced in the larynx. The vibration passes down the column of air and the bronchial wall and is diffused through the al- veolar spaces and the soft lung tissue to the chest wall where the auscultating ear appreciates the murmur as a soft rustling sound. The normal inspiratory murmur is heard throughout the inspiratory phase. Then follows a slight pause. Then the expiratory murmur which may vary in dura- tion from one-half the length of the inspiration to none at all. Causes : Inspiration is a muscular act ; expiration partially muscular but largely passive. The current of air on inspiration is passing toward the auscultator, and away from him on expiration. The Attributes of Respiration : Rhythm, Intensity, Pitch, Duration, Quality. Alteration in the Rhythm : Interrupted, Prolongation of pauses, Expiration prolonged. Alterations in Intensity: Absent breathing, Decreased, Increased or exaggerated. 20 NOTES OX PHYSICAL DIAGNOSIS Alterations in Quality: Harsh or rude, Broncho-vesicular : Inspiratory, Expiratory, Mixed. Puerile, Bronchial or tubular, Cavernous, Amphoric. All of the latter except the puerile are accompanied by a prolongation of expiration and are increased in intensity (may be decreased). Puerile breathing has the broncho-vesicular quality, but is normal in rhythm. The Variations in the Breath Sounds in the Nor- mal Chest : The normal vesicular murmur is heard under the left clavicle and below the angles of the scapulae. (a) Women louder under clavicle (costal breath- ing). (b) Men louder under scapulae (diaphragmatic breathing). Harsh prolonged expiration under the right clavicle and at the posterior right apex. (See causes of variai- tion in fremitus, page 17.) Bronchial, upper part of sternum. Harsh, at fourth dorsal due to bifurcation of trachea. All these signs vary in different persons. The Pathology and Physics of the Alterations in THE Breath Sounds : Absence of the murmur is due to : Lack of expansion of lung, Obstruction of a bronchus. GENERAL EXAMINATION 21 Separation of the lung from the thorax. Diminished murmur is due to : Rigid hmg from inflammation, Diminished expansion from adhesions, Dilatation of air sacks in emphysema. Harsh or rude breath sounds are due to : Bronchitis, Early infiltrations. Broncho-vesicular sounds are due to : Areas of consolidation mixed with normal lung tissue. Bronchial: Hig^h pitched ") ^^ ,. ,^ ,. Dependmp; upon the ex- Medmm V ^ ^ , ^, ^ ... ^. ^ ( tent of the consolidation. Cavernous ) „ . . , , . V Cavities. Amphoric i Rales : Note. — These are never heard over the normal lung except at the lower axillae and under the clavicles of shallow breathers. In such indi- viduals a shower of crepitant rales is heard at the end of the first or second deep inspiration and then they are not again heard. The differ- ential feature between these normal rales and those due to pathological causes is that the latter are constant. — Editor. Pleuritic Friction Rales: are heard during inspira- tion and expiration close to the ear and are not changed by coughing. Moist : Crepitant. Crepitant Rales : are heard usually in showers at the end of inspiration but may come at any time during inspiration and expiration, are produced in the alveoli, and are heard in all early exudative inflammations of the alveoli, in atelectasis and pleurisy. They are the finest and most clear cut and crackling rale that is heard. They decrease in number after a time but do 2 2 NOTES ON PHYSICAL DIAGNOSIS not change their character or location after deep breathing and coughing. Fine Mucous or Bronchial Subcrepitant Rales: are produced by mucus in the finest bronchioles, are moist in character, distant from the ear and change in char- acter, number and position on coughing. Medium and Large Mucoiis Rales: are produced by mucus in bronchi of various sizes. Mucous Gurgles: large and small; are heard over cavities. Dry: New leather rub. Dry subcrepitant. Sibilant Rale: is a whistle due to stenosis of the small bronchi. Sonorous Rale: is a musical vibration in the large tubes due to stenosis. Mucous Click: is a clicking sound not disturbed by coughing. SuccussiON : Is a splashing sound obtained by shaking the pa- tient's thorax from side to side. Is heard in large cav- ities and in pneumothorax with fluid. The Effect of Cough ox Rales : It brings them out when absent without it. It intensifies existing rales. It obliterates rales by clearing the bronchi of mucus. Auscultation of Voice: Follow^s the same general laws as vocal fremitus and is increased or diminished over the normal chest as is fremitus. The sound heard is that produced in the larynx and GENERAL EXAMINATION 23 is transmitted by the air in the air passages and by the lung tissue and thoracic wall to the listening ear. The word itself, as a rule, cannot be recognized. Over larynx: Laryngophony. Over upper sternum : Bronchophony. Over lung substance : Normal vocal resonance. This last has none of the characteristics of an artic- ulated word. Vocal resonance may be : Absent, Decreased, Normal, Increased or exaggerated, Changed in character or quality. Under the latter we have : Bronchophony, which approaches an articulation, is higher pitched and more intense than the normal vocal resonance, having a peculiar vibratory quality. Is heard in early infiltrations before tubular breathing is to be heard. Pectoriloquy : is a clear transmission of the voice, the spoken word being heard distinctly. It differs from bronchophony in that it is a transmission of speech while the first is a transmission of sound only. Is heard over consolidations and cavities. Aegophony: is a resonance of a tremulous, nasal character (similar to the bleating of a goat) ; it is rarely heard and is not characteristic. It is heard at the angle of the scapulae in slight pleural accumulations with compression of the lung. Note. — Remembering that pho7ios means sound and loqiior means speech, the significance of these terms will be appreciated. Thus we have bronchophony meaning bronchial sound — words not distinguishable, and pectoriloquy meaning chest speech, words clearly heard. These terms were originally employed by Laennec, the great French Clinician %nd inventor of the Stethoscope. — Editor. 24 NOTES ON PHYSICAL DIAGNOSIS Cavernous- voice: is a hollow deep tone. Amphoric voice: is a resonance of a hollow metallic character with a musical quality. It is heard over large cavities and in pneumothorax. Whispered voice: It may be employed in place of the respiratory sound in those too weak to take a deep breath. Normally it is heard over the upper part of the chest near the large bronchi. Note. — In thin-chested individuals a modified whispered voice may be heard all over the chest. — Edito)-. Exaggerated bronchial whisper. Whispered bronchophony. Whispered pectoriloquy. Cavernous whisper. Amphoric whisper. These names apply to the same variations in the character and quality of the whisper as is heard in the case of the voice. The variations are found under the same pathological conditions as those of the voice, but when obtained are more pathognomonic of the condi- tions. The metallic tinkle : Is a sound similar to water being dropped into a metallic vessel. Is heard during the respiratory phases over large cavities and in pneumo- thorax. The resonance of cough: Bronchial Cough, Cavernous Cough, Amphoric Cough. Note. — Metallic laryngeal cough, ringing or brassy in character.— Editor. DETAIL CONSIDERATION OF METH- ODS OF PHYSICAL EXAMINATION THE THORAX i The Normal Thorax. Inspection: Epigastric or costal angle should be about a right angle; convexity of the ribs should be gradual and uniform, with no angles of prom- inence; lower interspaces should be apparent, the upper ones should not be apparent ; antero posterior diameters should be less than the transverse; the horizontal measurements should increase slightly from above downwards. Sternum: Straight, and without prominences or depressions, except a shght prominence at the junc- tion of the manubrium with the gladiolus, which marks sternal position of the second rib. Scapula:: Should lie flat and not sink too low; foss9e should not be too deep. The Abnormal Thorax. Emphysematous, Acute: In fhe acute stages there is a retraction of the lower and bulging of the upper portion of chest, with a consequent diminished tho- racic capacity. Chronic: The thorax is enlarged; 25 26 NOTES ON PHYSICAL DIAGNOSIS abnormally bulging, antero posterior diameter equal or greater than transverse; epigastric or costal angle is obtuse; spine curved. If the emphysema is diffuse, or confined to the lower parts of lungs, the chest assumes the position of normal inspiration. If the emphysema is old or of long standing, there is much cough and the upper part of the thorax is dilated, the lower part being contracted. In general emphy- sema the thorax assumes the shape which constitutes the true " Barrel Shaped Chest.'' The Paralytic or Phthisical: A flat, long, narrow thorax ; ribs in front and behind are abnormally slant- ing; the epigastric or costal angle acute, intercostal spaces broad, fossae deep, due to the relaxation and weakness of the muscles ; the shoulders droop and the scapulae flare out widely. This thorax is seen also in weak people, and is a predisposing cause to tuberculosis, with which disease it is usually asso- ciated. The Rachitic Types: Transversely constricted. In this type the Harrison's grooves are seen. These begin at the xyphoid cartilage, and pass to the mid- axillary line. These are seen in children and are pro- duced by the obstruction to the entrance of air as by adenoids, etc. The result is that the upper part of the chest is expanded by the muscular effort, the middle part forced in by atmospheric pressure and the costal borders are flared out widely by the distended abdo- men. Pigeon Breast: A groove runs from above down- wards on either side of the sternum, and the antero- posterior diameter is increased with a narrowing of METHODS OF PHYSICAL EXAMINATION 27 the lateral diameters. The " Rosary " may be present. All these rachitic forms may be combined, and as the child advances in years the deformity may dimin- ish or entirely disappear. The Boat Shaped Breast: This is a marked depres- sion of the upper portion of the chest, and is due to an atrophy of the pectoral muscles. It is an apparent malformation only of the bony structures, as there is no actual variation in bone formation. Note. — This type is rare and is usually confused with the follow- ing. — Editor. The Funnel Breast (the congenital or true) : In this the sternum wholly from above downwards takes a slant inwards. In this form of chest the organs may be compressed, giving the same results as in scoHo- kyphosis. Acquired or false. In this only the lower portion of the sternum near the xyphoid alone sinks in. There is no interference with the chest activity. This depression, like that of the Harrison's Grooves, is due to the pull of the diaphragm, but at its sternal attachment, and indicates un- usual efforts at inspiration such as would be exercised by a child over- coming chronic obstruction in the air passages, as adenoids or hyper- trophied post-nasal mucosa. In early childhood the bony structures yield and a tendency to funnel breast would prompt the clinician to examine the throat and posterior nares. — Editor. The Kypho-scoliotic : Variations in the shape of the chest during hfe : Cylindrical at birth. Oval after the first year. Norma] of adult. Oval in old age. 28 NOTES ON PHYSICAL DIAGNOSIS The Asymmetrical Thorax: An enlargement of one- half of the thorax is due to disease; as in pleural exudates, pneumo-thorax and pulmonary infiltra- tions; in these the enlarged side is broader than the uninvolved, the mammae and shoulder plates are further from the median line and the shoulder is higher. In cases of large exudates the spine is curved towards the involved side in order that the body may maintain its equilibrium. Large Spleen, Large Liver, Local Tiiinors of the Ab- domen may bulge the lower portions of the thorax, especially when prevented from sinking by adhesions. Meteorism and Ascites; the lower portion of thorax may be markedly bulged by accumulations of fluid or gas, the costal borders flare outward, greatly increas- ing the lower diameters of the thorax. This is espe- cially to be borne in mind with reference to the action of the diaphragm. Local bulging due to Tumors, Aneurysms, Enlarged Heart, Local Pleural Accumnlations: It must be re- membered that anything that diminishes the negative pressure in the pleural sac or increases the volume of the lung itself will cause that side to bulge; in other words the intra-thoracic pressure is brought closer to that of the atmosphere. Contracting processes of the lung or pleura or com- binations of the two, or where a pleural exudate has been absorbed and the lungs have been unable to ex- pand to their normal volume, the thoracic walls sink in to meet the lungs. In unilateral contractions of thorax the breadth is narrow, shoulder sinks, mammae and scapulae are METHODS OF PHYSICAL EXAMINATION 29 nearer the middle line, and the spine is concave toward diseased side. Depression of one fossa or diminished bulging on coughing is very suspicious of tubercular involve- ment. In making unilateral measurements of chests, take the median Hue from the pubcs to the chin, as the sternum is displaced markedly in all these condi- tions ; inspection and palpation will reveal more than all the measuring one can do. Inter-costal Bulging in Pleurisy with Effusion: The ribs in inspiration in their ascent may simulate a re- traction of the interspaces. Retraction of the lower interspaces on forced inspiration in thin individuals must not be mistaken for a sign of adherent pleura. Note. — Bulging of the interspaces is an extremely rare sign of pleural effusion. — Editor. In inspiration the shape of the chest and curve of the spine is most essential ; also the conditions of the abdomen, and any superficial examination of the abdomen for tumors, organs, gas, etc., is absolutely necessary for a comprehensive examination of the chest. Respiration. In the normal newborn is 44 to the minute, at 5 years of age 26 to the minute, in the adult 16-24 to the minute. There is one respiration to four pulse beats. Respiration increases on changing from the standing to the prone position, diminishes in sleep, is increased by exercise ; after a full meal by pressure on the diaphragm, by skin excitations (cold bath, etc.), by psychical influences; during digestion. 30 NOTES ON PHYSICAL DIAGNOSIS by smoking, drinking, etc.; by temperature as seen in fever, and also by artificial heat. Forms of Respiration, Normal: Costal in women, costo-abdominal in men, costal (chiefly) in children. Pathological: limitation of excursion of diaphragm, as by paralysis of diaphragm, in emphysema, by pain, by muscular degeneration, by infections and anemias, by progressive muscular atrophy, by multiple neuri- tis, in the feeble by inflammatory conditions, such as pleurisy, pericarditis, subphrenic abscess, etc., the latter being produced partly by the pain and partly by the paresis, and partly by the inflammatory and circulatory disturbances. Diaphragmatic excursion is also limited by a pendulous abdomen, gravid uterus, large liver and spleen, gas, ascites, tumors, in all of which conditions costal breathing may actually or relatively be increased. Limitations of Costal Breathing: Calcification of ribs, of the costal cartilages, of the costal ligaments, of attachment of the spinal vertebrae, as in arthritis deformans, fractures of the ribs, degenerations and paralysis of the intercostal muscles. Litten's Sign, or the Diaphragmatic Phenomenon: In certain patients, by no means all, a shadowy line can be seen, by proper light, to descend on inspiration for from one to two or even three interspaces (de- pending on the depth of the inspiration) in the an- terior axillary line and to rise on expiration. It is caused by the diaphragm peeling from the ribs, the lung being slightly delayed in entering the comple- mental space; therefore, between diaphragm and edge of lung there is a line of diminished pressure al- METHODS OF PHYSICAL EXAMINATION 31 most tending toward a vacuum, which causes a sUght sinking in of the soft parts of the thorax. It is not seen in very stout people or in oedematous conditions, pleural exudates, emphysema, adherent lung, pneu- monia, pneumothorax, paralysis of the diaphragm. Note. — If absent on one side while present on the other it is con- sidered as one of the early signs of tubercular involvement of the lung on that side on which it is absent. — Editor. If present it indicates that the diaphragm lies on the thoracic wall, and that it is movable and non-adherent. The sign is said to be present in subphrenic abscess and absent in empysema ; the accuracy of this state- ment is doubtful. The sign may be confused with the expiratory shadow produced by a sinking of the ribs and by the inspiratory sinking of the lower ribs, due to the positive abdominal pressure being substi- tuted for a negative thoracic pressure. In this latter case the wave is seen both in inspiration and expira- tion, whereas Litten's sign is more especially an in- spiratory phenomenon. Asymmetrical Breathing: Pathological inspiratory sinking of thorax, diminished or absent respiratory movements, can be seen in the distended as well as in the contracted thoracic half. Stenosis of Bronchus, Infiltrations, scar tissue, adhesions, hypertrophied heart, pericarditis (on left side only), pleural adhe- sions, pneumothorax, pain, are all factors. Peri-pneumonic insinking of the thorax is seen in broncho-pneumonia and atelectasis. This is due to the great intrathoracic pressure produced by the dia- phragm descending and the solidified lung failing to fill the complemental space, also by the direct pull of 32 NOTES ON PHYSICAL DIAGNOSIS the diaphragm on the lower ribs. This is especially observable in children with broncho-pneumonia. In the same way the epigastrium and jugular fossae are drawn inwards. Abnormal Rhythm and Frequency in Respiration: Changes in frequency are due to dyspnoea (increased demand for air), as seen in exercise, deficient ven- tilation, etc. From nervous affections, as hysteria, psychoses, cerebral pressure, uraemia and diabetic coma. The rhythm is also disturbed in severe infec- tions, by increased body temperature, in the death agony, and by cardiac and respiratory diseases. The characteristic of the respiration in meningitis is the regularity or irregularity of the pauses, which are of unequal duration. This is not Cheyne-Stokes breathing. Cheyne-Stokes breathing has a long pause, followed by quick breaths, increased in length to a maximum, then gradually declining again to the pause. Cheyne-Stokes breathing is seen in affections of the brain, in respiratory and circulatory diseases, in arterio sclerosis, and in uraemia especially. During the pauses in this type of breathing there are marked changes in the pulse frequency, in the pupils and blood pressure, none of which, however, is con- stant. During the period of deepest breathing the patient may be cyanotic, the cyanosis increasing to the pause. An attack of Cheyne-Stokes breathing may come on during sleep. In cardiac and nephritic cases it may be present for months before the patient realizes he has any disease. Morphine increases and aggravates the condition. The cause of Cheyne- Stokes respiration is an increased excitability of the METHODS OF PHYSICAL EXAMIXATION 2>3 respiratory centre, due to poor aeration of the blood. The blood becomes saturated with COo, which stimu- lates the respiratory centre, causing increased breath- ing till this saturation is slightly offset by oxygen. When this takes place breathing diminishes and the pause ensues. Dyspnoea: Objective. Increase in frequency, in- crease in depth (faster than normal, slower than nor- mal, or normal). Subjective. Increased, normal, de- creased, both in frequency and depth. In true dyspnoea the two go together with or without C3^ano- sis; there may be all variations of the rhythm. A patient may not complain of shortness of breath, but present a subjective dyspnoea in the objective sign of deep sighs. Obstructive dyspnoea with cyanosis may, from the CO2, so anesthetize the patient that the dyspnoea is uncomplained of. With praecordial dis- tress subjective dyspnoea is very marked, but there is an absence of objective dyspnoea. Marked objective dyspnoea may be present without cyanosis if the in- creased effort is sufficient to aerate the blood. Under this condition there is no subjective dyspnoea, and ob- jective dyspnoea and cyanosis are the two important factors. In considering the respiration, both the fre- quency and the depth of the respiratory movements must be observed. Forms of Dyspnoea: i. Pain necessitates the taking of short, rapid respirations, in order that the excur- sion of lung may be as small as possible. This is purely objective, and may be considered as a func- tional obstruction, the patient being compelled to breathe more frequently in order to make up for the 3 34 NOTES ON PHYSICAL DIAGNOSIS lack of depth. Causes : Affections of the intercostal muscles, rheumatism, trichinosis, fracture of the ribs, diseased conditions of the lung or pleura, peritonitis with abdominal pain. 2. Diminution of functional surface of lung, or mechanical limitations of lung movements. In this form, as a rule, respiration is in- creased both in depth and in frequency. There being- no objective symptoms and no cyanosis, as the in- crease is sufficient to compensate, but as soon as extra work is required, then subjective dyspnoea and cyano- sis ensue, which is particularly characteristic of early emphysema and brown induration, due to cardiac dis- eases. In pleurisy or pneumo-thorax, where one side of the lung is rendered entirely functionless, the number of respirations may be normal, but the lung excursions greater; this is caused by disease of the lung tissue, exudates in the thorax, tumors, air, dim- inished space in the pleural cavity, kypho-scohosis, upward pressure of diaphragm, diminished movement of lung, miliary tuberculosis, brown induration, em- physemia, indurated pneumonia, adherent pleura, paralysis and cramps of the respiratory muscles, dyspnoea following circulatory disturbances, and non- compensating cardiac lesions. The essential feature of all these conditions is the stasis. By the slowing of the circulation of the blood and the accumulation of the blood in the veins the venous blood loses its oxygen, and takes up more CO2, the respiratory centre thereby being excited and causing an increase in the number and depth of the respirations. The capillaries of the alveoli of the lung are not decreased but increased by the distended blood vessels, the lung METHODS OF PHYSICAL EXAMINATION 35 being stiffer, however, and therefore less elastic. It is also enlarged and approaches the inspiratory posi- tion, causing diminution in the excursions by the lung. In brown induration there is an increased production of connective tissue, which adds both stiffness and increased size to the lung. Sudden accumulations of blood in the lung, in either acute or chronic condi- tions (exercise, cardiac weakness), produces attacks of what is called cardiac asthma. In mitral disease, even with compensation, cyanosis may be present without any subjective or objective dyspnoea, due to the accumulation of blood above referred to. Bron- chial catarrh is present in all forms of mitral disease and it aggravates greatly the attacks of dyspnoea and the general cyanosis. Stenosis of the Upper Air Passages: From this cause the respiratory activity is increased in energy, duration and frequency. By the increased duration the air can be better drawn over obstructions, and to compensate for this slowing of the respirations the in- spirations must be deeper. As the stenosis increases the celerity increases to a certain point, death en- suing from the failure of the shallow, quick breathing to overcome the obstruction. Causes: Large tonsils, retro-pharyngeal abscess, true or false croup, spasm or oedema of the glottis, paralysis of the vocal cord adductors, stenosis of the larynx and trachea, and a foreign body compressing the trachea. If steno- sis of one of the chief bronchi exists, the breathing will be slow and deep as long as the stenosis is over- come. If the stenosis is complete, the whole work will then be thrown on the patent lung, in which case 36 NOTES ON PHYSICAL DIAGNOSIS the rapid breathing will be greatly increased. When the stenosis is high in the respiratory passage and of severe grade the lungs will not be completely filled with air, which will cause an increased negative pres- sure in the thorax, as shown by the sinking in of the lower lateral ribs, epigastrium and supra clavicular fossae. This sinking of ribs is increased by the dia- phragm being unable to descend, it being so high up in the thorax. Dyspnoea in Bronchitis: Due to the swelling of the mucous membrane and an accumulation of the secre- tions in the smaller bronchi. When few bronchi are involved, the remaining patent ones compensate. There is no subjective, and only slight objective dysp- noea, but when many small bronchi are closed there is objective as well as subjective dyspnoea. When middle-sized bronchi are almost closed, deep, forced respiration, slower than nomal, can overcome the stenosis, which is the type of respiration seen in fibrin- ous bronchitis. In contrast to this, there are cases in which the respiration is increased, but not in pro- portion to the degree of stenosis. This may be asso- ciated with subjective dyspnoea and cyanosis, but if there is no expiratory stridor and prolonged expira- tion, stenosis below the tracheal bifurcation would be indicated. In these cases the respiratory effort is not sufficient to overcome the stenosis, and the pressure of the expiratory muscles upon the air passages in- creases the stenosis. There are many transitional forms of this expiratory dyspnoea due to the relation of the dyspnoea to the expiratory strength. METHODS OF PHYSICAL EXAMINATION 37 Dyspnoea in Asthma and Emphysema: Bronchial Asthma, hke the latter, is a stenosis of the finer bron- chi. It is a question whether the stenosis leads to a slowing of the respiration through the smaller open- ings or if it causes accelerated respiration. Emphysema: Due to fixed inspiratory position of lung, diminished excursion, diminished alveolar sur- face, diminished capillary surface and circulatory dis- turbances. In pure uncomplicated emphysema {i.e., no enlargement or bronchitis) the dyspnoea is of a superficial character, increased by slight exertion. As nearly all cases of emphysema are accompanied by diffuse bronchitis, usually of the dry character, the tendency is to a slowing and deepening of the respira- tion on account of the bronchial stenosis, the stiff- ness and increase of volume of lung. The degree of alveolar destruction varies so with the bronchial con- dition that the demand of the organism may cause any sort of breathing. In the majority of cases the subjective is more marked than the objective dyspnoea. Urcemic Dyspnoea: Uraemic asthma with slow, long breathing is not due to the uraemic condition, but to the cardio-bronchial or pulmonary oedema. In this condition any form of dyspnoea may be present. Febrile Dyspnoea: Artificial heat increases respira- tion. Fever may do the same. Toxins may stimulate the respiratory centre. The character of respiration may vary vastly in different diseases. Ancemic Dyspnoea: Due to the diminished oxygen carrying power of the blood. In order to compensate 38 NOTES ON PHYSICAL DIAGNOSIS for this deficiency the inspired air must remain a longer time in contact with the blood. In pernicious anaemia, therefore, the characteristic respiration is not only increased in frequenc}^, but also in depth. This form of dyspnoea is seen also in diabetic coma, due to the fact that the blood does not take up oxyg-en readily. Mixed Breathing: In rapid respiration the relative duration of inspiration to expiration is as the normal. In deep breathing the relation is changed and one or the other is prolonged. Accessory Muscles of Inspiration: In forced expira- tion the abdominal muscles are used, while in inspira- tory dyspnoea they come into play in hastening ex- piration for the next inspiration. Dyspnoea and Cyanosis: Dyspnoea tends to lessen cyanosis. If cyanosis is present with dyspnoea the lat- ter prevents the CO2 accumulation from becoming too great. However, the organism is being supplied with blood of poor quality and therefore suffers; in chronic cyanosis the patient after a time adapts him- self to the condition and suffers no subjective dyspnoea. This may be due to : the anesthetic action of the COo; the more sudden the onset of the cause of dyspnoea, the greater the objective and subjective symptoms; the more gradual the onset, the less the symptoms. Voice: Hoarseness due to tumors, to disease or injury of the vocal chords, to paralysis, to weakness, such as is seen in cachectic or feeble patients; to phthisis, in which the hoarseness may be due to the lo- cal phthisical process. Hoarseness with inspiratory METHODS OF PHYSICAL EXAMINATION 39 dyspnoea points to stenosis of the larynx; hysterical aphonia is never preceded by hoarseness. Note. — Hoarseness amounting- not infrequently to aphonia may ac- company pleurisy or aneurysm of the aortic arch. In the latter the hoarseness is due to pressure on the recurrent laryngeal nerve. — Editor. Nasal Voice: Closed form. From stenosis of nasal cavities due to polypi, suppuration, hypertro- phic rhinitis. Open form : Cleft palate ; syphilitic destruction of palate. Loss of Voice (aphonia) comes from an inability of the chords to vibrate or approximate. Voice is modified by sex, age, strength, dyspnoea, local disease. In heart disease, when the patient is im- proving, the voice is stronger ; when the condition be- comes graver, the voice is weaker. Cough: In considering weakness or loss of voice recall the distribution of the vagus sensory nerve. The portions of the trachea most sensitive to irritation are the inter-arytenoid mucous membrane and that at the bifurcation of the trachea. The trachea is next in sensibility and the bronchi next. Stimulation of the lung parenchyma produces no cough. Stimulation of the visceral pleura produces a cough, while stimu- lation of that of the parietal pleura will not. Rare Cases : Stimulation of the pharynx, base of the tongue, and oesophagus. Cold feet will in some in- stances cause cough, and drafts on different portions of the body are also in some cases influences produc- tive of cough. There is no true stomach cough. It comes from the pharynx or larynx, or perhaps some irritation in the 4^ NOTES OX PHYSICAL DIAGXOSIS nasal cavities. The most likely explanation of stom- ach cough proper is that by inflammation or de- rangement of the gastric mucous membrane the vomiting centre in the bulb transmits a stimulation through the respiratory centre. This has never been proven or demonstrated. Nervous Cough: Is extremely rare. Usually some small inflamr.iatory area of the respiratory tract ex- ists. Paroxysmal Cough. ?.5 seen in ^^'hooping Cough, or from foreign bodies, profuse secretions, bronchiecta- sis and cavities. The inspiratory whoop in whooping cough is due to a spasm of the glottis caused by the traumatism it receives. This whoop is rarely, if ever, heard in other conditions. From violent irritation of the cough centre the stimulus is spread to other por- tions of the fourth ^•ent^icle. especially to the vomit- ing centre. Venous Stasis du: t: Cough: Patients" statements as to cough must be duly weighed, as those with marked phthisis may complain of no cough or ex- pectoration. In such cases the secretions are not in- frequently swallowed. Disfc}ision by Coughing: Mostly in upper part of chest, upper ribs, supra-clavicular foss?e. especially as seen late in emphysema, in beginning phthisis, Avhen there is distension o^ only one supra-clavicular fossa by coughing. Such c?.ses should be regarded with XOTE. — Elongated u^•^lla, irritation of fauces and of the auditory canal and rvTnpanum are causes of cough. — Editar. METHODS OF PHYSICAL EXAMINATION 4i LUNGS AND PLEURA. Palpation. The chest is palpated (felt) in order to detect re- sistance, fluctuations, abnormal impulses and frem- itus. Fluctuations are obtained only in the superficial lesions of the chest walls; it is impossible by this sign to demonstrate fluid within the chest. Pvdsations: Visible and palpable pulsations are due to tumors, aneurysms, etc. These, however, can best be appreciated with the ear. Pulsation of the lung tissue may rarely be felt in marked mitral regur- gitation and in pulmonary insufficiency; pulsation of a pleural exudate as transmitted from the heart im- pulse is rare, as in this condition the soft tissues are under tension. In emphysema, where the tissues, due to inflammation, have lost their tension, the sign is less frequently obtained. If tension of exudate is high, it is non-obtainable. The most favorable condition in which to obtain the sign is when the tension of the fluid within the thorax is the same as the atmospheric pressure and when the soft parts have lost their tone. Vocal Fremitus or Tactile Fremitus: Produced by Note. — Some confusion has arisen from the terms vocal and tactile fremitus. Vocal tactile fremitus is the vibration {fi-emitus fremare, to murmur) of the air in the respiratory passage produced by the voice (vocal) and transmitted through the chest and felt by the hand touching (tactile) the chest. In speaking, therefore, of vocal fremitus, no reference (by most authors) is made to what is heard. The voice vibrations as heard are spoken of as pectorophony and subdivided into bronchophony, pec- toriloquy, and segophony, see note, p. 17. — Editor. 42 NOTES ON PHYSICAL DIAGNOSIS the vibrations of the air passing the larynx; trans- mitted through the air in the bronchi to periphery of lung through the chest wall to the hand. It is best felt where the chest wall is thin, as in the supra-clavicular region anteriorly. It diminishes from this point downward. As a rule it is more in- tense at the right apex than at the left. However, many cases are seen in which the condition is the op- posite. The theoretical explanation of this greater intensity at the right apex is that the right bronchus is shorter and larger and is higher than the left. The route of the right lung is supposed to be more di- rectly in communication with the thoracic wall, as heart and vessels are interposed on the left side. Pos- teriorly on the right side vocal fremitus is more dis- tinct. Here again the condition varies greatly. Causes Altering the Intensity: Is diminished by thick muscles, fat, loss of elasticity of the thoracic walls, loss of elasticity of the lung as in emphysema, conditions separating the lung from the chest wall as in pleurisy, plastic or effusive, tu- mors, air, etc. Feeble vibrations of the larynx, as from high or weak voice, such as occurs in women or in feeble pa- tients, the phonetic character of the word selected, the conditions preventing the air from reaching the lung, as in stenosis of the bronchus. It is increased in thin walled thoraces, consolida- tion of the lungs, etc. ; also in infiltrations of the lung and in large bronchial cavities. The increased fremitus accompanies bronchial breathing and voice, but this rule at tim.es undergoes METHODS OF PHYSICAL EXAMINATION 43 a marked modification. In large exudations of fluid or in pneumothorax with a compression of the Kmg, one gets below the edge of the fluid bronchial voice and breathing with no fremitus. In infiltrations a bronchus may be closed by secretions or by the pressure of tumors, in which case there will be neither voice nor fremitus. In exudation with compression of the lung one may get such a marked fremitus that the whole tho- racic wall is thrown into vibration. In this condition the fremitus, which is very intense, is below the level of the fluid. Bronchial voice and breathing may also be present over the same area. This fremitus, bronchial voice and breathing, may be very intense if adhesions over a markedly compressed lung exist. Vocal fremitus is best obtained by light palpation with the ulnar side of the hand, never forgetting to compare both sides of the thorax. Percussion. Percussion is either immediate or mediate, ob- tained with plexor and pleximeter. The essential conditions in percussion are. first: apply the pleximeter closely; second: compare both sides of the chest; tJiird: strike with equal force on both sides; fourth: vary the strength of the stroke according to the thinness of the chest and the depth of the organ to be percussed; fifth: stand in front of the patient. There are three vibrations produced: Those of the pleximeter, Those of the chest wall, 44 NOTES ON PHYSICAL DIAGNOSIS Those of the air in the lung. The first is httle marked, the second most marked in those with thick chest walls from muscle or fat. Stethoscopic percussion or scratching. Respiratory percussion. Deep inspiration yields a fuller and higher pitched sound. Deep expiration is the opposite. Attributes of percussion sounds : The Quality of the note depends upon the com- position of the instrument producing it. For exam- ple, the violin note differs in quality from that of a piano. Over the normal chest we have three quahties of note : (i) the vesicular resonance, resonant note due to the vibration of air in the vesicles ; (2) dull; (3) tym- panitic in altered organs. The first is best obtained at the left infra-clavicular fossa. It varies with, first the thickness of the chest wall; second, intervention of bone; third, adjacent viscera; fourth, the force of the percussion. Intensity means loudness, is increased in (i) thin- ness of the chest wall ; (2) force of the percussion. Duration means the length of the sound and varies inversely with the pitch. The higher the pitch, the shorter the duration. Pitch: High, intermediate, low. The higher the tension of a cavity be, the more numerous will the vibrations be, and the higher the pitch will be, but the shorter the amplitude of the vibrations and the less will the intensity be. In the normal lung the air vesicles are under little tension and the resonance is of a low pitch. If the lungs are distended, we get a high pitch with a tym- METHODS OF PHYSICAL EXAMINATION 45 panitic quality, the vesiculo-tympanitic resonance of Flint. This is heard in distended lungs in acute com- pensatory emphysema. Tympanitic sounds vary in pitch, increasing in- versely with the size of the cavity and directly with the degree of tension. For example, the stomach usually gives a lower pitch than the intestine, but a markedly distended stomach gives a higher pitch note. In great distension the tympany may be lost. Diilness and Flatness are high pitched. Beginning infiltration gives a higher pitched note than normal. Below the right clavicle one gets over the normal lung a higher pitch than below the left. The causes are, first: the root of the lung is higher; second: the muscles of the right side are greater; third: the pres- ence of the liver. Didness is absence of resonance or air. Denotes presence of a fluid or solid. It differs from flatness in degree : Slight, moderate, or marked. Topographical Percussion Ride: In differentiating dull from resonant percussion, use light percussion. This keeps the deeper and lateral areas from being set in vibration. The point always to be kept in mind is that light percussion means more light application of the pleximeter than lightness of stroke; deep percussion does not mean violent blow, but merely a moderate blow, with a distinct pressure of the ap- plied finger. By too violent a stroke or too hard pressure of the applied finger, a greater area of thorax tissue, etc., is thrown into vibration and a false result is obtained. The old idea that dull areas were found nearby tympanitic portions has been disproved by 46 NOTES ON PHYSICAL DIAGNOSIS this method. This rule has to be altered in oedema- tous, fatty or muscular people, especially in regard to light percussion. Deep percussion never gives abso- lute dulness, but relative. Light percussion gives ab- solute and also relative. The normal body differs from, the cadaver in that in the latter the tissues have lost their elasticity and the organs have changed their position. Flatness is a term used to denote absolute loss of resonance. Tactile Percussion: Is an increased sense of resist- ance to the finger. This is a valuable differential quality. Tympany is a sound produced by percussing over a cavity filled with air whose walls are neither too tense nor too yielding. Variations in the normal chest : Above Clavicles: The best vesicular resonance is obtained from above the middle of the clavicles; at the inner end of the clavicle the note becom^es tym- panitic, due to the trachea ; at the outer end the note is dull. Over Clavicles: At the middle of the clavicles a resonant note is given; at the outer end a dull note, and at the inner end the note is high pitched. (The osteal note.) Belozi' Clavicles (Infra-Clavicular) : On the left side the normal resonant note is obtained, while on the right side the note is higher pitched, shorter in dura- tion and less clear. This is not always the case. Right Sternal Line: The thickness of the muscles varies the note on both sides. Between the third and METHODS OF PHYSICAL EXAMINATION 47 the fifth rib, one gets the relative duhiess of the heart, absolute dulness of the liver at the sixth rib, and relative dulness at the fifth. RicrJit Mammary: At the fifth rib the note is raised o in pitch and diminished in intensity, due to the rela- tive dulness of the liver; at the sixth the note is flat. Left Sterml Line: At the third interspace there is the relative dulness of the heart ; at the fourth rib ab- solute dulness, which extends to the sixth rib. Note. — Below the sixth rib stomach tympany is given (semilunar space of Traube see also page 66) — Editor. Sternum: In the sternal notch the tympany of the trachea is given. From upper sternum to the third rib one gets a resonance bordering on tympany, due to the trachea. From the third to the fourth rib one gets the pure lung note. From the fourth to the sixth rib one gets slightly diminished resonance, due to the heart, although the lung lies under the ster- num. This is more marked at the left edge of the sternum. At the sixth rib one gets liver dulness or flatness. The Axillary Spaces: There is good resonance on both sides in the mid-axiflary line; on the right side, at the eighth rib, one gets relative and at the ninth rib absolute liver dulness. On the left, at the ninth rib, the spleen is reached and extends to the eleventh rib. The spleen extends backwards on the tenth rib as axis for two or three inches, and is lost in the muscles of the back. The stomach, where it lies behind the lung, gives a clearer note to the lung than does the liver in a corresponding situation on the left. 48 XOTES ON PHYSICAL DIAGNOSIS Posteriorly: The position of the patient greatly in- fluences the character of the note obtained. Supra and Infra-spinoiis Fossa: The resonance is diminished on account of the bones and muscles, but comparison of the two sides can be better carried out in this situation than in front. Inter-scapular Region: Better resonance is obtained in this region than in the supra and infra-spinous fossse, but not so good as in infra-scapular region. At the upper portion the tympany of the trachea may influence the note. Infra-scapular Region: The note here more nearly approaches that of the normal as obtained in the left infra-clavicular. RigJit Scapular Line: The relative dulness of the liver is found at the ninth rib ; the absolute at the tenth. Left Scapular Line: The resonance extends to the tenth rib. It ma}^ be influenced by the tympany of the stomach or colon, or the dulness due to the pos- terior portion of the spleen. For the same reasons the resonance on the right side may be slightly higher pitched and of less intensity, due to a greater muscu- lar development. Remember the lungs move an inch or more on deep inspiration and expiration. Kidneys: The left is higher than the right. The dulness of the kidneys cannot be differentiated from that of the liver and the spleen, nor the dulness of inner borders of the kidneys from that of the spine. The anterior border is three to four inches from the median line and is limited by the tympany of the METHODS OF PHYSICAL EXAMINATION 49 colon on the left and of the stomach and colon on the right. Lower borders can be defined by the line of tym- pany of the colon just above the crest of the ileum. Abnormal Sounds: Vesiculo-tympanitic (Skoda's or Flint's) resonance. The quality of this note is composed of a vesicular and a tympanitic element. The pitch is higher in proportion as the tympanitic element predominates over the vesicular and the in- tensity is increased. It is due to a relaxation of the lung tissue. There may be either one of two forms of relaxation. Mediate relaxation, as relaxation of lung in pleu- risy, pneumothorax, lobar pneumonia (second stage). In pleurisy with a small amount of fluid Skodaic re- sonance is obtained just above the fluid, due to the relaxation of the lung. Immediate relaxation, as relaxation of lung in em- physema, acute over-distension of the air vesicles, asthma, effusion of fluid into alveoli without complete consolidation, as in pneumonia (first and third stage), oedema, portions of lung near consolidated areas, early phthisis (disseminated form), gangrene and abscess of lung. Pure Tympanitic Resonance: Is found normally over the larynx, trachea and the left infra-axillary area, due to the stomach."^ The larger the volume of air the lower the pitch ; the smaller the transverse open- ing to the cavity the higher the pitch. * These are all normal cavities containing more or less air, and the signs obtained over them may be taken as expressive of the signs of air- containing cavities in general. The variations of voice sounds may be also tested over these areas. — Editor. 4 so NOTES ON PHYSICAL DIAGNOSIS Wintriclis Sign: One gets a higher pitched note when mouth is open than when closed, while per- cussing over a cavity. If change of note is not ob- tained lying down, but is on sitting up, it shows that in the first position the opening to the cavity is ob- structed. For illustration percuss over the thyroid. This latter will, of course, not present any difference in the note on changing from the sitting to the lying position. GcrJiardfs Change of Note: One gets a higher pitch in percussing over the long axis and a low pitch over the short axis of the cavity. Tympany is found in pneumothorax if tension in cavity is not too great. Biermers Change of Note: When patient stands, the diaphragm is depressed and the cavity is enlarged and one gets a lower pitch than when the patient lies down. Williams' Tracheal Resonance: Is produced by per- cussing over consolidated lung near a large bronchus. The note obtained in this condition approaches the tympanitic in character. This note is also heard over the compressed lung above large pleural effusions. Amphoric Resonance: Is a note of an echoing char- acter. Siiccussion Splasli: Is the splashing of fluid heard on shaking the chest of a patient with hydropneumo- thorax ; is produced by fluid in a cavity with air. The metallic sound is dependent on the tension in the cavity, and is heard over a pulmonary cavity, pyo- pneumothorax, stomach, cavities at base of lung, etc. The Cracked Pot Note: Is a modified tympanitic METHODS OF PHYSICAL EXAMINATION 5^ sound caused by the expulsion of air from a cavity through a small hole. The cavity must be super- ficially situated. The mouth of the patient must be kept open and the blow must be short and forcible. It is sometimes heard in pneumothorax with opening into the lung. The Metallic Percussion Note: When a coin is placed upon the chest of a patient suffering from pneumo- thorax and lightly tapped with another coin a clear hell-like sound is heard if the ear is placed at the same time against that portion of the chest opposite to that on which the coin is. The physical requirements for obtaining this note are that the space or cavity be of sufficient size, the walls smooth and the tension of the air within the cavity not too great. This sign is ob- tained at certain areas only, and if present may dis- appear after the removal of fluid in pneumothorax, or appears, if absent originally. This is due to the variation of tension within the cavity. The position of the patient may bring this tone out, or change its character. This is due to changes in the diameters of the air spaces, as a result of the moving fluid. In the sitting posture, with the fluid pushing down the diaphragm, the tone is deep. In the prone position, it changes to one of a higher pitch. Always percuss the same point on changing the position. Air in the prsecordium gives tympany or a metallic tone, chang- ing with change of position of patient. Lung cavities rarely give metallic tones, as they do not fulfil the re- quirements. (See footnote.) As a rule, they are not large enough, their walls are too thick and irregular. 52 NOTES ON PHYSICAL DIAGNOSIS and they lie too deep. A diaphragmatic hernia may give a metalUc tone. Note. — Percussion : Normal vesicular note is that obtained over the normal lung; dulness or flatness is that obtained on percussing thigh. There are many transitions between these two. The more air a body contains, other conditions being equal, such as tension, etc., the louder the sound. The deeper the layer of air-containing tissue, or the thicker the air-containing parts of an organ, the louder the note. jNIany conditions modify the above. The tympanitic note has a musical character as distinguished from the normal resonance, i.e., the vibra- tions are clear and distinct. Organs which are subject to no tension give no tympany ; as the tension increases the pitch rises till the point is reached where tension is so high that the note becomes flat. There is no adequate physical explanation of this phenomenon. Tympany de- pends on the size of the space, the tension of the tissue, the consistency, etc., and the tension of the air within the space. It is difficult to distin- guish where normal resonance leaves off and tympany begins. One gets combinations of dulness with tympany; for example, dull, high tympany; dull, low tympany, etc. A metallic or musical note heard especially at the latter part of the sound is due to the association of the sounds and is caused by the walls of the cavity being smooth and thin and the cavity either being without any opening or having a small opening. The space, in order to produce this note, must be less than six centimeters in diameter. It is difficult to produce and is best heard by percussing with a hard object and auscultating at the same time. It may be heard over the stomach and colon, also in the space between the lung and pleura. — Editor. Comparative Percussion. Normal lung resonance is diminished by fat, mus- cles, the mammary glands, the scapulae, dense or hollow organs in the neighborhood; where there is marked convexity of the chest, the normal resonance is lost, as a convex surface vibrates less readily than a flat. This is especially seen in kypho-scoliosis. Dulness comes from the interposition of solid ma- terial between the normal lung tissues and the thorax wall, as exudations, thickened pleura, tumors, con- METHODS OF PHYSICAL EXAMINATION 53 gestions, consolidations, infiltrations, atelectasis, etc. Closure of a bronchus with the absorption of air and the exudation of fluid. This last may be small or large, deep or superficial. In mediary infiltrations, early stage of capillary broncho pneumonia, diffuse tumor metastases, etc., one may have relative dulness, normal or hyper- resonant tone. Pleuritic Dulness: As a rule the line of dulness in pleuritic exudates is obtained from behind, down- wards and forwards. This is caused by the elastic retraction of the lung upwards and backwards. In hydro-thorax, in the early stage, the case is the same, but later, as the fluid increases, the line is circu- lar about thorax and changes more or less readily on change of position of patient. In pleurisy, the case is different, as there are adhesions and the line keeps its position of obliquity, while the exudate gradually moves in the direction of least resistance. In case of pleurisy, where the line is horizontal, there must be some resistance to the retraction of the lung, such as adhesions, infiltrations, etc. The dulness of pleuritic exudate is absolute. In lung infiltration of the most intense degree, the bron- chi contain air to a greater or less degree and give slight resonance. Displacement of the heart and liver is more characteristic for exudates than infiltrations. In left-sided exudations the half-moon space (Traube semi-lunar space, see p. 47) is dull, even when the lung is in its normal position, and is the best and most posi- tive sign of early or slight exudate. It fails only when the complementar}^ space is obliterated by old or fresh 54 NOTES ON PHYSICAL DIAGNOSIS pleuritic adhesions. In very excessive exudates, the diaphragm can be pushed down to the edge of the ribs, or even below, and unless covered by the gut, may give dulness to the ribs or below ribs. In some cases the exudate moves readily with change of posi- tion of patient. This is more frequently met with in the serous than in the purulent. In some cases the fluid goes about among the adhesions, and in such cases in the sitting posture the posterior dulness is lower and less intense, while the anterior becomes more intense, but not so high. In slight exudates the fluid ma}^ spread thinly over the lung, and if this takes place slowly the dulness diminishes after the patient has been standing or sitting for some time. In the beginning of exuda- tions the lung above gives a normal note. As the ex- udate increases, the tension of the lung is diminished, and the note obtained over the lung area is hyper- resonant (Skoda's resonance). As soon as the ex- udate compresses the lung, dulness appears, but never to the same degree as that obtained over fluid. In this last instance one can at times obtain tracheal tympany. After absorption a thickened pleura can give almost as flat a note as fluid. It must be borne in mind that people can have a chronic fluid exudate and appear perfectly well, having no subjective symp- toms. Care must be taken not to diagnose such cases as thickened pleura. Also dulness gives no true idea of the extent of the pleurisy, as adhesions to the chest wall ma}^ divert the fluid upward and along the spine and into the mediastinum. The height of the dulness must always be judged by the intensity of the note ; relative dulness in this respect indicates nothing, as METHODS OF PHYSICAL EXAMINATION 55 fibrine deposits, atelectatic lungs, etc., may be a source of error. Increase of voice and fremitus ob- tained over compressed lung at the upper edge of the fluid is of the greatest value in determining the extent of the exudations. HydrotJwrax: The fluid moves rapidly, as a rule, with changes in position. This is denied by some and Sahli says that the change is slow. In distended ab- domen, hydro-thorax may be undemonstrable as the diaphragm in this condition being pushed up may ob- scure the signs of thoracic fluid. In the upright position, if the abdominal walls are weak, the dia- phragm is pulled down, and slight fluid accumulation becomes more marked. In large transudates, by put- ting the patient on his side, signs of fluid may be ob- tained along the spine. If fluid and air are combined, changing the position of the patient readily changes the position of the fluid. In slight exudates if the diaphragm is pushed down and the fluid is not, in the upright position, demon- strable by the above signs, then by bending the pa- tient forward an area of flatness can be obtained. If the patient w4th pleural exudate lies on his side, the area of flatness changes to one along the spine. If adhesions are present none of these statements hold good. Hmnotliorax: It must be remembered that until the blood coagulates, which requires some time, the signs of hsemothorax are identical with those of hydrothorax. Later, because of coagiflation and in- flammation with adhesions, the exudate cannot move with change of position of patient. S6 NOTES ON PHYSICAL DIAGNOSIS Consolidation of the Lung: Is never so dull as fluid, is not so sharply defined, and is more or less pro- gressive in the opposite direction of gravity. Usually a hyper-resonant note is obtainable, nearby to infiltration. Broncho-Pneumonic areas are usually found below and behind, on the edges of the lung, in front and at the sides, or at the column along the spine. Tu'bercular infiltration at the apex, or along the antero-inferior edges of the lung. In- farcts are usually posterior and low down. Tumors of the lung or pleura give intense dulness, more so than infiltration, as there is no air contained in the tumor mass. Tumors of the mediastinum give dul- ness above the heart area ; if pleural exudate, or thick- ened pleura is also present, it is practically impossible to make a diagnosis by the physical signs. Dulness of cavities is due either to fluid within the cavities, to thickened walls, or to infiltrations about the cavity area. After free expectoration, the dulness may be replaced by tympany or resonance. Atelectasis : Due to an obstruction of the large or small bronchi. Absorption of air from the alveolar spaces and its replacement with exudate. Gives the same signs as broncho-pneumonia. A very large heart, by compressing the lung, may give signs of consolidation at the base of left pleural cavity. A dull note may persist, after absorption of a pleural ex- udate, due to deposit on pleura and lung. Abnormal Hyper-Resonance or Tympanitic Tone: (i) Emphysema gives an abnormally loud and deep tympanitic tone. (2) Relaxation of the lung tissues due to changes in the inter-thoracic pressure from METHODS OF PHYSICAL EXAMINATION SI tumors, exudate and enlarged heart. Below tuber- cular infiltrations or just above pleural exudates and in pneumonic conditions also this note is ob- tained. In the early stages of infiltration one gets hyper-resonance or even tympany over the involved area. Early oedema and atelectasis also give this hyper-resonance, due to the relaxation of the lung tissue. Pneumothorax, as a rule, gives an abnor- mally loud tympanitic note, especially if air is under moderate pressure. If the pressure of the air on the chest is the same as that of the atmosphere one gets distinct tympany. In cavities with large thin walls surrounded by slight infiltration, one gets the true tympany. Very small and numerous cavities or deep lying large ones may give the normal tone. Dia- phragmatic hernia gives a note which is the same as that obtained over the intestine. Tympany from oesophageal diverticulum is very rare. Auscultation. Normal Breath Sounds: Inspiration is always heard; expiration may be inaudible or heard at the begin- ning of the expiratory act, its duration in this in- stance being equal to about one-third to one-fifth that of inspiration. This normal vesicular murmur not only proves that air is in the lung, but that it is circu- lating. Theories: (i) is produced by the friction in the air against the smaller bronchi and infundibula; (2) is produced in the larynx and transmitted through the air within the bronchi. In opposition to this theory is the following : The absence of the murmur in bronchial stenosis. The 58 NOTES ON PHYSICAL DIAGNOSIS increase of the murmur in overaction of local parts of the lung. Diminished breathing over adhesions, where lung mobility is restricted. In stenosis of the larynx a loud noise is heard at the larynx, and practi- cally no murmur over the lung. According to Sahli, the normal pulmonary vesicu- lar murmur is produced by the contractions of the heart, independent of the respiratory movement. With infiltrated lungs there may be a vesicular without any laryngeal murmur. Whether this is due to the friction of the air in the small tubes SahH does not state. He believes that the stretching of the elastic alveolar walls, one after the other, produces a vibration, and that this is the cause of the murmur. He compares this to the murmur produced by the ex- pansion of a dry sponge. Physiological Bronchial Breathing: Is of a high pitched blowing character. Expiration is louder than inspiration and longer in duration. Is caused by the larynx, the laryngeal chords being closer together in expiration than in inspiration, thus causing a higher pitched note. Expiration is a longer process physio- logically than inspiration, thus accounting for the du- ration. This physiological laryngo-tracheal murmur varies in different individuals. It differs from the pathological in that it is always accompanied by a vesicular murmur and is best heard over the sternum between the scapulce and at times at the right apex. It is increased when vesicular breathing is weak or absent. Decreased Vesicular Breathing: Varies with the depth of the breath and the area auscultated. For ex- METHODS OF PHYSICAL EXAMINATION 59 ample, at the apex and edge of the lung. The lung structure being thin at these points a weaker mur- mur is heard than over the thicker parts of the lung. Increased Vesicular Murmur: In thin chest wall, and in children. Children have a louder murmur, mixed with a little bronchial quality; the so-called puerile breathing. Increase in Pitch: Is heard in catarrh of the finer bronchi. This favors the theory of Laennec, that the vesicular murmur is produced by friction in the sm.aller bronchi. Increased intensity of vesicular murmur is also heard in all conditions of relaxed lung tissue, beginning pneumonias, in the neighbor- hood of infiltrations and near conditions diminishing the cavity space of the chest, as small multiple infil- trations, tuberculosis at the apex, while over the adjoining normal portion of the lung the murmur is faint as the lung is here thin. It is diminished in all conditions of diminished or decreased ex- pansion of the lung. Weakness or absence of fJie vesicular murmur: (i) Stenosis of the larynx or trachea, stenosis of the bronchi, capillary bronchitis. (2) Obstruction to the lung expansion, pleuritic adhe- sions, multiple infiltration, causing a stifi^ness of the lung tissue, tubercular infiltrations with dulness where bronchi are closed, and due to inflammatory infiltra- tion of the walls. (Seen very often.) Pleuritic eft'u- sions, where one side or a portion of the chest wall does not move. Pain acts similarly. In emphysema, where the lungs are so large that there is little ex- pansion. Bronchitis plays a secondary role in this respect, but aids in diminishing the intensity and in 6o NOTES ON PHYSICAL DIAGNOSIS changing the quahty of the murmur. Separation of the lung from the chest wah, as in thickened pleurre, air, exudates and tumors. Prolonged Expiration: Is a frequent, but not a con- stant accompaniment to harsh vesicular murmur. Is seen in bronchitis, where there is some slight stenosis, due to the catarrh. It takes longer for the air to pass the narrow opening, and therefore greater force is required for its expulsion. This condition can be either local or general. Emphysema or asthma or both generally exist when this sign is present. AVhen local it is a suspicious sign of tuberculosis. Rough Vesicular Breathing: Must not be confused with increase in intensity of murmur. The latter is a very pure, intense, smooth sound, while the rough breathing is much more indistinct and lacking in character. This is also a sign of bronchial catarrh and verges on the sound produced by distant mucous rales. It can sometimes be separated from the vesicu- lar murmur. It is produced in the bronchi by tena- cious secretions. Cog Wheel BrcatJiiug: AA^hen heard over one or both lungs it is due either to aneurysms, certain forms of pleurisy, or fatigue of the respiratory mus- cles. When local it is due to bronchitis, with a valve- like obstruction of the air, or to diminished expansile power of the lung, as in local pleuris}^ It must be distinguished from the normal vesicular murmur in- terrupted by other pathological or adventitious sounds. This condition is hard to distinguish from the so-called indefinite and rough breathing. METHODS OF PHYSICAL EXAMINATION 6i BroncJiial Breathing: Is heard over parts of the lung where no physiological bronchial breathing is to be heard. It is due to infiltrations, compressions, cavi- ties and fusiforml}^ dilated bronchi. There are two theories: (i) That solid lung conducts laryngo-tra- cheal murmur better than the air vesicles. This is not tenable, as, when bronchi are closed by secretions, etc., one hears no breathing over the involved area. Transmitted brcncJiial breathing may be due to (i) Bron- chial breathing in one part of the lung, increasing the laryngo-tracheal murmur over the whole thorax. (2) Air passing a bronchus leading to a consolidated area acts in the same way as when one blows over the top of a bottle. Bronchial breathing due to compres- sion is heard so long as bronchi are open. The ex- tent of the compression can be gauged by the type of bronchial breathing. Closure of a bronchus with the absorption of air in the lung tissue gives no bronchial breathing. A cav- ity or dilated bronchus produces a louder sound, as the vibration is local. This is aided by conditions of infiltration about the lesion. Deep breathing and coughing by displacing the secretions vary the char- acter of the bronchial breathing. Bronchial breath- ing can vary in quality and pitch as the vowels a, e, i, 0, II. Amphoric Breathing ^ is of a deep bronchial charac- ter, with a metallic tone. As a rule a cavity must be larger than six centimeters to obtain this type of breath sound. The deep bronchial breathing can * Amphora, a jar. This breathing is like the sound produced by blowing- over the mouth of a jar. — Editor. 62 NOTES ON PHYSICAL DIAGNOSIS ■ readily be mistaken for amphoric. Amphoric breath- ing is said to be metalhc when the metallic tone ex- ceeds the deeper ground tone. Sometimes over an infiltrated lung one gets amphoric breathing. The cause is unknown. Over the base of the lung in pneu- monia one may get the metallic tone of bronchial breathing, due to a distended stomach or colon. The position of the mouth in deep breathing can produce amphoric or cavernous breathing over areas of nor- mal bronchial breathing. This can be distinguished from pathological conditions by varying the position of the patient's mouth. Metamorphosed Breathing: Either begins as vesicu- lar and changes to broncho vesicular, or begins as bronchial and is lost in vesicular. Bronchial breath- ing may also change its pitch, and bronchial may change to amphoric breathing. These changes all take place in one phase of respiration, as inspiration or expiration alone. It is supposed to be due to an irregular filling of the cavities with air or to a lack of expansibility in the infiltrated lung. Indefiiiite breathing is always faint. It is not loud enough to give a character. Is heard in pleural effu- sions. The vesicular murmur may be overshadowed by the murmurs transmitted from other portions or local rales. In a word, it is a murmur with no definite character. Mixed or Broncho-Vesicidar: Inspiration vesicular, expiration bronchial. Inspiration broncho-vesicular, expiration bronchial. Both the vesicular and bron- chial breathing are not produced in the same part of METHODS OF PHYSICAL EXAMINATION 63 the lung. The one or the other is transmitted, as in sHght irregular infiltrations, near consolidations, near compressions, and near cavities. The vesicular ele- ment has transmitted through it a bronchial element. Rales. ^ Mucous Rales are moist or dry, according to the character of the secretion. Are due to a vi- bration of the mucus in the bronchi. Can be heard in other parts of the chest than where produced, but it is easy to locate their place of origin. Coughing and deep breathing alter them, and it is a very good plan to examine suspected tuberculosis cases before they rise in the morning and before the}" have coughed or taken deep breath. Moist Rales: Large and small. Can be produced artificially by blowing with varying strength through tubes of varying size containing fiuids of different consistency. These are produced by air passing through a fluid, such as the secretions of the bronchi. They are produced by the air setting in vibration lay- * Rales are an evidence of an inflammatory process of the pleura or air passages — they are never heard over the normal lung. By taking note of the character of the sounds heard the stage of in- flammation may in a general way be determined. A " cold in the head " may be taken as an example of the stages in the formation of the exu- date in the respiratory passage. The slight exudate at the beginning to the thick purulent discharge later will, when moved by the respired air, yield sounds diff'ering with the amount and character of the exudate. By observing also the location at which these sounds are heard, and whether they are changed in character by coughing and deep respira- tion and whether heard with inspiration, expiration, or both, the por- tion of the lung involved together with the stage of inflammation can be ascertained. The only occasion when rales may be said to be present normally is when heard at the apices or lower axill?e on the first or second deep inspiration after quiet breathing. These occur at the end oi deep in- spiration and unless pathological are not constant. — Editor. 64 NOTES ON PHYSICAL DIAGNOSIS ers of mucus on the bronchial walls. Large rales in- dicate involvement of large tubes, with much mucus. Small rales the opposite. These rales are heard both in inspiration and expiration, but better in inspiration, as the inspiratory movement is quicker and more vio- lent. Smaller rales are more numerous, as the smaller bronchi are greater in number. When fine rales are heard constantly in a localized position, one can say with certainty, without other signs, that tuberculosis, broncho pneumonia, infarct or bronchiectasis is present. When widely spread, they are of less im- portance. Large mucous rales, Avhere no large bron- chus is, indicates enlarged bronchi or cavity. At the apex it usually means cavities. At the base, when associated with broncho-vesicular breathing, it indi- cates bronchiectasis. It must be kept in mind that these large rales can be widely transmitted. This is true also of local infiltrations. In haemorrhage or oedema the rales are fine, the inspiration and expira- tion being of the same character, the so-called con- tinuous rales. The moist rale is one associated with acute, severe diseases of the lung, and when located at an apex means a rapid process. The usual bron- chial secretion is tenacious, and produces the so- called dry rale. The moist is associated with marked exudation. The Dry Rale differs from the moist in that it is not so regularly continuous, but is single and irregu- lar, and may have a musical or whistling character. They are produced by the tearing or stretching of mucus and differ from the moist in that after the first vibration they are not able to regain their former po- METHODS OF PHYSICAL EXAMINATION 65 sition before the next respiratory acts. They do not therefore occur with every respiratory act, but only with every second, third or fourth act. In inlikra- tions of the lung, the tissues themselves may pro- duce this crackle. Musical Rales may be produced by (i) Tenacious mucus or membrane. (2) Swollen mucous membrane and deposits of secretions producing a stenosis of the smaller bronchi. (3) Compressed bronchi close to- gether. These have the same significance as the moist, and as a rule can be palpated on the chest walls, as rhonchi. Are usually widely transmitted (Sahli). Crepitant Indux and Crepitant Redux: Heard in all beginning lung inflammations or infiltrations from any cause whatsoever. Are produced by the swollen alveolar walls being pulled apart, the fluid exudate playing a secondary role. They can be produced in the lung of the cadaver. They are also heard at the base of the lung of those that breathe superficially. In the latter case they soon disappear after two or three deep breaths. They are also 'heard on inspira- tion. When heard on expiration, they are due to air being pumped into a portion of the lung which on inspiration was insufihciently inflated, as heard in adhesions, near infiltrations, and especially in pneu- monia. Cardio-Pneumonic Rales * produced by the systole of the heart: These can vary from vesicular breathing to cavernous and simulate any form of rale. It is * If of a murmurous character, are called cardio respiratory mtirnnirs. — Editor. 5 66 NOTES ON PHYSICAL DIAGNOSIS thought by some that diastole can produce a murmur, but this is uncertain. Pleural Sounds: Are produced by roughness or dryness of the pleural surfaces. The further one goes from the hilus, that is, towards the more mobile por- tion, the better one hears these sounds. When heard at the apex, it is due more to centrifical distension of the lung than to displacement of the lung tissue as a whole. The sound, according to roughness, can be heard on inspiration and expiration, or both. It is best represented by laying one hand on the ear and rubbing the back of the same with the finger of the other. The murmur may be like any of the rales in the chest. Friction Rub, so-called nezu leather rub: The chief characteristic of this sound is that it is not continuous throughout the respiratory phase, but occurs with pauses between. It is of a dry, creaking quality, and differs from the moist, mucous rale in that it is heard close to the ear and is not influenced by coughing. In some cases it can be increased by pressure on the chest and is even at times palpable. The friction rub dift'ers from the crepitant rales in that the former is heard both in inspiration and expiration. At times it is impossible to distinguish whether a sub-crepitant rale is produced on the pleura or on the lung tissue. External Perieardial Pleural Rales are synchronus with the heart beat and independent of the respira- tion, save that they are usually intensified on deep inspiration. Pleuritic rales are heard at the begin- ning and end of pleural inflammation before the formation of and just after the absorption of the ex- METHODS OF PHYSICAL EXAMINATION 67 udate. \Mien present at tiie upper border of the fluid, they are due either to a dry pleurisy above the incapsulating adhesions of the fluid, or else to an atelectatic lung, but when heard below the level of the fluid, they are due to adhesions at this point or are transmitted through the chest wall from above. The reappearance of rales below the line of dulness shows beginning absorption of fluid, the dulness re- maining above on account of thickening of the pleura. Transmitted pleural rales are not palpable. The rales of interstitial emphysema are similar to the fine mu- cous or crepitant rales, but with a metallic quality. J^oicc Sounds. BronclwpJwny: Is heard over the lung normally where the large bronchi are situated. Normal bronchial breathing and bronchophony are heard over the same areas. It diminishes as one descends on the lung. Its presence indicates con- solidation or cavity formation. It may be increased and have a metallic tone, and in some people it is louder than in others, especially at the right apex. Pectoriloquy is not necessarily a sign of cavity, as it is also heard over consolidations. Where the area of infiltration is small, w^hispered voice, however, can be demonstrated when all other signs fail. Mistakes in Auscultating: Hair on the chest may simulate crepitant rales. If they interfere moisten them with oil or water. The tone produced by mus- cular contraction simulates rough breathing or rales, especially at apex. In shivering from cold, the muscle tone is produced before the tremor can be seen or felt. On auscultating above the clavicles with stethoscope, 68 NOTES ON PHYSICAL DIAGNOSIS especially in those using accessory muscles, an irregu- lar murmur is produced in the sterno-cleido-mastoid muscle, similating rough breathing or crepitant rales ; fat, especially that of the mammary gland, may also similate these sounds. Friction of the stethoscope on the skin, against the clothes or the rustling of the clothes themselves may be a source of error. The lung area in children and in the senile is usually enlarged. The Active and Passive Mobility of the Lung: The lung moves on deep inspiration and expiration eight cm., practically three fingers. The absolute dulness of the heart will disappear in thin people or in those with strong abdominal walls. The liver-lung line is lower on the dorsal position than in the upright position. In those with a pendulous abdomen, the liver not being supported by the abdominal muscles, is lower in the upright position than in the dorsal. Changing from the dorsal to the lateral position, the lung moves downward three to four centimeters. This normal mobility of the lung is diminished in emphysema, fibrous conditions and infiltrations of the lung tissue with adhesions, all forms of oedema and congestion. It is suspended entirely by adherent pleura, by adhesions of the complementary spaces. In demonstrating the mobility of the lung ordinary respiration must not be used, nor, on the other hand, should forced respiration alone be employed, as this latter tends to inflate the lower edges of the lungs and thus gives pulmonary resonance at an abnormally loAv point. Forced inspiration and moderately forced METHODS OF PHYSICAL EXAMIXATIOM 69 expiration should be employed. Use light percussion, as by deep percussion a larger portion of thorax is set in vibration and the lung resonance thus transmitted downward. Ahnonnal Positions of the Lung: In emphysema, the apices are higher. The heart is covered, and the lower limits are deeper. Sometimes in fat people and in those with strong abdominal muscles, this lowering of the lung border cannot be demonstrated, but over the heart the enlargement is evident. Local emphysema from various causes gives local changes, such as is obtained in true emphysema. In mitral disease, asthmatic attacks or capillary bronchia tis, the lungs are enlarged and decreased in elasticity, as is shown by their diminished excursion. Enterop- tosis and congenital floating tenth rib give a low posi- tion of the lung. The lung area is diminished by ab- dominal accumulations, and all those conditions which tend to displace the diaphragm upwards. Pericardial accumulations and hypertroph}^ of the heart displace the lung to the side. If this last is great enough to perceptibly diminish the negative pressure in the thorax, the lower border of the lung retracts and we get all those signs of atelectasis. Conditions in the Lung Itself Causing Contractions: Tubercular pleuritic thickening, etc., preventing lung from retaining its normal position. Retraction of the Apex in Tuberculosis : The size and shape of the thorax altering the tension of the lung tissue and irregularities in the outline may lead to a false diagnosis. 70 NOTES ON PHYSICAL DIAGNOSIS HEART. Inspection and Palpation. Use the flat of the hand to determine the general character of the cardiac impulse, then the finger, to locate the apex beat. TJw Normal Apex Beat: The apex is located in one or two intercostal spaces. Towards the base, in the mid-clavicular, a post diastolic sinking is som.etimes seen. The first corresponds with the outer area of the heart dulness; but if the heart is covered with the lung, the apex that is seen is within the true limit of the cardiac dulness. Its position in health is the fifth interspace, in the fourth in children, in the sixth in the old. In a healthy adult it has a variation of an interspace upward or downward ; in very small chil- dren it may be outside of the mid-clavicular line. The size varies, but it is usually two centimeters square. As a rule the apex has a thin tongue of lung inter- posed between it and the thoracic wall. At times -it may lie behind a rib, when no impulse w^ill be visible on the chest wall. In enormous right heart enlarge- ments the apex is made up of right ventricle. The apex varies greatly, due to the thickness of the tho- racic walls, to fat, muscle, oedema, etc. An absence of impulse is not necessarily an index of disease. With normal respiration, the apex does not move, nor is its distinctness influenced. When an indiv- idual lies on the right side, the apex may disap- pear, due to the lung moving over and covering it. Lying on the left side intensifies the impulse. The METHODS OF PHYSICAL EXAMINATION 7^ movements of the heart itself must be taken into con- sideration. In bending the patient forward the apex lies closer to the thoracic wall and appears stronger. In deep expiration, the lungs retract, and unless the patient strains violently, the apex will disappear, as the deep expiration without muscular effort dimin- ishes the flow of blood to the left heart, thereby diminishing the intensit}' of the apex beat. Neuroses and muscular action increase the force and breadth of the apex. Keep in mind that the normal apex beat comes before the blood has left the ventricle. Note. — Students should cultivate the habit of looking not only for " the apex beat," but for Impulses — determine how many there are, their location, and the maximum of these. Normally there is usually only one such impulse. When there is more than one in the normal heart, the maximum is that of the apex. In the diseased heart or vessels the max- imum is by no means always the apex. " Point of maximum impulse " should therefore be spoken of in preference to "' apex beat." — Editor. Pathological Apex: The apex is displaced by an enlarged heart, either from dilatation or hypertrophy. Dilatation of the right ventricle displaces the apex outward and on account of the slant of the diaphragm downward. In atrophy, the apex may be displaced inward. This is rare. In very large right hearts, where the apex is produced by the right ventricle, there is a displacement outward, and as a rule down- w^ard, but as the enlargement is mostly over the dome of the diaphragm, the apex is not displaced down- ward as much as is seen in dilatation of the left heart. Displacements of the Heart due to Pathological Con- ditions outside of the heart : Situs inversus : The apex is in the same position as the left, but situated on the right side. 72 NOTES ON PHYSICAL DIAGNOSIS Eniphyscma: The apex is lower and is placed in- ward on account of the low diaphragm. Right Pleural Exudate: The apex is displaced up- ward and to the left, due to the diminished negative pressure. Compensatory emphysema must be re- membered as a factor in this displacement. Left Pleural Exudate: The apex is lost or displaced to the right. Diminished intra-thoracic pressure from any cause, ascent of the diaphragm from this cause also, or from increased abdominal pressure, are conditions which all tend to displace the apex upward. Increase in the Force and Size of the Apex: Increase in force and size within certain limits is normal. This increase occurs in febrile conditions, Basedow's dis- ease, from tobacco, alcohol, and other toxic agents; after exercise and in nervous palpitation. Dilated heart may give the impression of an increase in force of the apex beat, although signs of cardiac failure are present. This is due to the lung having been displaced and the heart lying close to the thorax. The apex impulse occurs during the closure time. The strength of the heart being used up during the closure period, less strength is left for the output of the blood; for this reason the closure time is prolonged, the heart being close to the thorax for a longer time than normally, and giving the appearance of a strong impulse. This is frequently met with in failing com- pensation. On the other hand, when the heart is strong, the closure time is very short, as the heart readily overcomes the pressure in the vessels. It is in METHODS OF PHYSICAL EXAMINATION 73 contact with the thoracic walls, sinking back during the propulsion period. Such cases give a very quick, sharp apex beat. These are seen at times in aortic regurgitation, where the characteristic heaving im- pulse is absent. It also occurs not infrequently in mitral stenosis. A distinct, strong apex beat is met with in any condition which causes the lungs to re- tract. The slow, heaving apex beat is characterized by slow heart action, an impulse limited in ex- tent and very forcible. This is due to the pro- longed closure period and to the marked resistance in the arteries, etc. The characteristic feature is the slow, powerful impulse at the apex area. An ex- cessive filling of the ventricle would give the same conditions approximately as aortic regurgitation. A vibration felt at the apex and simulating a thrill may occur with a violent, quick heart action, and is felt in nervous palpitation and powerfully acting hearts. Weakening of the Heart Apex: The apex may be absent when marked emphysema exists ; also with pericarditis, left pleural exudate, left pneumothorax, ard w^ith tumors or air in the anterior mediastinum. GEdema of the thoracic wall, excessive deposit of fat or a muscular thoracic wall may also be a cause of a weak cardiac impulse. The absence of an apex beat in pericardial effusion is of value only if the apex beat Avas noted before the attack. The apex impulse may be present with pericardial exudate, if adhesions bind the heart to the thorax, or if the exudate sinks to the side and leaves the heart free. In excessive heart weakness the apex disappears, due to the lack of 74 NOTES ON PHYSICAL DIAGNOSIS power to produce the closure period, as a very weak heart may produce a marked apex impulse. The apex impulse, however, is often normally weak or absent. On this account the sign is an uncertain one. The pulse and other signs and symptoms are of greater value. When a distinct apex is found within the limit of absolute cardiac flatness, it suggests pericardial exudate. This phenomenon is also seen in mitral regurgitation, in which the heart has no true closure time, the apex beat being visible only when a certain degree of intra-ventricular pressure is reached. Systolic Sinking: Normally a retraction of the apex with systole which has no definite explanation is sometimes seen. Sahli thinks that these are cases of absent apex beat, and what is seen is that part of the heart inside and above the apex which normally retracts with systole. Systolic sinking is said to be due also to adherent pericarditis. It is caused only by adhesions of the heart, pericardium or lung to the thorax. This is a rare pathological finding. Hyper- trophy, dilatation and pericarditis may change the form of the heart contraction so that the apex is di- verted backwards, thus exerting a negative pressure on the thorax and allowing the atmosphere to press the interspaces inward. This is frequently seen in aortic regurgitation. Many cases of adherent peri- carditis never have this retraction of the apex. It is an unreliable sign. Occasionally a retraction of the lower portion of the sternum and interspaces occurs with a large heart and associated emphysema. The exact explanation of this is not clear, but it is cer- tainly not due to adhesions. METHODS OF PHYSICAL EXAMINATIOX 75 Percussion. Absolute dulness indicates the edge of the lung, but not the size of the heart. Emphysema or pleural adhesions mask the true outline. A large heart and pericardial exudates displace the lung. whereas in emphysema, etc., the lung edge may be in a normal position or even cover an enlarged heart. Relative dulness when obtainable gives more accurate information, but must always be taken in conjunction with the superficial. Deep percussion begins at the lower border of the left third rib, and curves downward and outward to apex. To the right some authors give left para sternal Hue, but in mos: cases it goes to the right as far as the upper edge of the fourth rib at its sternal attachment. Over the sternum the lung gives a resonant note throughout and therefore renders percussion here uncertain. In old people, due to senile emphysema, the dull area is sm.all. In children, due to the thin edge of the lung, it is large. The shape of the thorax alters the relative position of the cardiac dulness, as a broad thorax does not give so large an area of dulness as a long narrow^ one. A narrow or displaced sternum may give the impression of a right heart enlargement. The centre of the clavicle, although the most reliable landmark for the mid-clavicular line, is not always reliable in localizing the heart, as the clavicle may not be sym- metrical in length, and even be longer or shorter, as compared to the breadth of the thorax. These varia- tions occur in narrow-shouldered, broad-chested indi- 7f> NOTES OX PHYSICAL DIAGXOSIS viduals. In all such cases take the total breadth of the heart dulness at the third or fourth interspaces. Active and Passive Mobility of the Heart : In deep inspiration the area of superficial and deep dulness is diminished; the first ma}^ even be obliterated, while during deep expiration the areas are increased. With the patient in a recumbent position the heart is capable of lateral motion, especially to the right, which corresponds to the motion of the individual from side to side. Where absolute dulness can be ob- tained to the right of the sternum, with loss of flatness on the left, in the sitting position the dulness is slightly intensified. If the patient bends forward it is still more increased. This is due to the heart push- ing the lung to one side. Lateral inclination of the patient will falsify these results. Absence of Dulness: In emphysema, pneumo- thorax, pneumopericardium, and in heart atrophy, the dulness is too small to be appreciated. In high grade emphysema, the diaphragm is displaced down- ward, and therefore the heart is low. Pneumothorax also displaces the heart. Pericardial emphysema gives a metallic percussion note, and other ausculta- tory signs. If stomach tympany confuses the cardiac outline, bend the patient forward and use light per- cussion. Enlarged Heart due to a Retraction of the Lung: As from atelectasis, infiltrations, fibrosis, in the shallow breathing of weak people in whom the lungs retract; and in conditions diminishing the intrathoracic nega- tive pressure which act in the same way as pressure on diaphragm, etc. Infiltrations of the lung about METHODS OF PHYSICAL EXAMINATION 77 the heart may stimulate cardiac enlargement. In en- largement of the heart the superficial and deep areas of dulness are not parallel. In extreme cases with very large hearts, there may be no demonstrable car- diac enlargement. Where the lungs are entirely pushed to one side, there is no deep dulness. \Mien compression of the lung exists, percussion does not indicate correctly the size of the heart. When percussion indicates an enlargement of the heart greater than one to two cm., dilatation is pres- ent, as the greatest hypertrophy without dilatation never exceeds one centimeter. Other signs show a pure hypertrophy better than the percussion, as, for example, a heaving apex, high tension pulse, accentuated aortic second sound, etc. One is tempted to say on obtaining dulness at the right of the sternum that the right heart is enlarged, or when the left cardiac area is by percussion mark- edly enlarged, that the left ventricle is enlarged. This is wrong, as a left or right heart enlargement can give an increased area of dulness upw^ards. This is due to the oblique position of the organ. An en- larged left ventricle can push the whole heart to the right. A right heart enlargement may be entirely to the left. Both cavities may be equally enlarged and the heart give a simple right or left heart enlarge- ment, all being due to the fact that a dilated cardiac cavity can lead secondarily to a displacement of the whole organ. The position of the enlarged heart is influenced by the condition of the contents of the mediastinum, by bony formation, the height or slant of the diaphragm, the attachment of the pericardium 78 NOTES ON PHYSICAL DIAGNOSIS and great vessels and by pulmonary conditions. The right heart is difficult to percuss. It is covered by the sternum. Enlargement of the right ventri- cle tends to displace the heart to the left on account of the slant of the diaphragm. This is often seen in mitral disease with no enlargement of the heart to the right, but with an apex markedly displaced to the left. Enlargement upward, if conforming to the car- diac outline, is due to an enlargement of the right or left ventricle. If an absolute dulness is found near the base of the heart and close to the sternum, it may be due to an enlarged auricle, especially the left, or to the great vessels. In some cases, the dilated portion of the heart may push the lung absolutely to the side and give a pure flat note. This can be seen in markedly enlarged left auricles with a small ventricle, as in mitral stenosis. At times one can get a small process to the right of the sternum, due to an enlarged right auricle. Fluid in tlic Pericardium: The absolute (deep) and relative (superficial) areas of dulness are parallel, ex- cept in large exudates, in which there is absolute dul- ness only. As the specific gravity of the fluid is lighter than the heart, it rises and the heart sinks. In the recumbent position the fluid rises and gives a broad area. In the semi-recumbent position, there is a broad area of flatness above the normal cardiac area, due to the fluid rising above the great vessels and displacing the lung. The cardio-hepatic angle is 90 degrees in the normal individual. In pericarditis, with effusion, it is an obtuse angle. In the erect position the lower diameter of flatness is broader METHODS OF PHYSICAL EXAMINATION 79 from side to side than from above downward, as com- pared with the dorsal position. Care must be taken not to mistake an enlarged heart, that sinks on the diaphragm, due to its weight. Also in standing there is more blood in the peripheral circulation and the auricles are not so completely filled as in the lying- position. When pericardial adhesions exist, these rules do not hold. CEdema of the anterior media- stinum must not be mistaken for pericarditis with effusion. Displacement of the Heart: The heart is attached by the great vessels to the mediastinum above and lies in the pericardial sac attached to the diaphragm below. The organ floats in the thoracic cavity, and anything disturbing the equilibrium, such as changes of pressure above or below the diaphragm, or in the right or left pleural cavities, displaces the medi- astinum and thus changes the position of the heart. Displacements of the diaphragm do not occur acutely, as the fixation of the central tendon to the mediastinum is too strong. After a time this attach- ment yields and the central tendon descends. This is seen in mediastinal tumors, pleural exudates and emphysema. Upward displacements occur very acutely and are due to increased abdominal pressure, as from gas, ascites, tumors, etc. The displacement of the heart to the right or left is due to changes in the negative pressure of the two pleural cavities and exudate on one side diminishes the negative pressure, and there is displacement of the heart to the oppo- site side, due to an increased negative pressure of its pleural cavity. An enlarged left heart can diminish so XOTES ON PHYSICAL DIAGXOSIS the negative pressure in the left pleural cavity and thereb}' displace the heart to the right. Anything increasing the negative pressure on one side can draw on the heart, as is seen after pleurisies with dimin- ished volume of the lung, contracted pleura, fibroid phthisis, interstitial pneumonia, etc. In acute pleurisy with effusion,, the heart is displaced to the opposite side. After absorption, the heart is displaced to the diseased side, and after a time returns to its normal position if not bound by adhesion. Deformities of the thorax can displace the heart in any direction. Dextro-cardia must never be forgotten. In these dis- placements of the heart, the organ undergoes a pen- dulous movement. Auscultation. Auscultation of Heart Sounds: The Heart Tone is a misleading term, as it rarely yields a definite tone. Heart Sound is a better term. A s^-stolic and diastolic sound is spoken of. These sounds are compound. There are five systolic sounds: The mitral valve, tricuspid valve, beginning of the aortic and pulmonary, and the muscular sound. There are two diastolic sounds : The aortic and the pulmon- ary valve. The muscle sound must always be kept in mind. The heart muscle is not subject to tetanic con- traction as are the other muscles of the body. The heart muscle contracts suddenly with a correspond- ingly sudden vibration. As for the sounds produced in the big vessels at systole, these are not appreciated, as the first sound of the heart comes before the blood METHODS OF PHYSICAL EXAMINATION 8i gets into the vessels, and therefore before they vi- brate. The individual tones are difficult to distin- guish from one another, but as a general rule all im- purities of the first tone heard over the ventricle may be considered to emanate from the muscle. Anatomical Location of the Valves: The valves are anatomically too close together to differentiate the source of the sounds by auscultation when listening over this anatomical area. Clinical Location of the Valves: From clinical and post mortem observation classical points at which the valves' sounds are best heard have been determined. Determination of Systole and Diastole: At the base the second sound is usually louder than the first; at tlie apex, the first sound is usually louder than the second. The systolic interval is shorter than the dias- tolic. The sounds, however, may be identical at the places mentioned and the intervals may be of the same duration. This method is therefore not always to be relied upon. Palpating and observing the apex impulse unless absent is a good method. Palpation and observation of the carotids is relia- ble unless the heart is very rapid. The radial pulse occurs 22-100 of a second after the apex impulse, and is therefore uncertain, but unless the heart is rapid is for practical purposes reliable. The best guide is the accentuation of the sounds and the duration of the pauses. The Force of the Heart Tones: Factors outside of the heart itself which diminish the force, as fat, muscle. 82 NOTES ON PHYSICAL DIAGNOSIS oedema of the thoracic wall, large breasts, pericardial and pleural effusions, emphysema, pneumothorax and any displacement of the heart as a whole. Heart tones are increased by thin chest wall, contraction of the lung, diminished negative pressure in the thorax as in kyphosis, high diaphragm, retractions of the lung, consolidations of the lung about or over the heart, displacements of the heart, pneumopericarditis, lung- cavities about the heart, pneumothorax and a dis- tended stomach. In these latter cases there is a metallic quality to the tones. Conditions zcifJiin the lieah itself: naturally strong heart, hypertrophy in compensation of organic diseases, varying quanti- ties of blood 'in the ventricles. Factors TchicJi -n'eaken the force of the heart: failing heart, as in collapse; lost compensation and valvular lesions. We may assume that the sounds in the right and left heart are heard on the chest wall with the same intensity, as the left ventricle is behind the right heart and the aorta is behind the sternum. The aortic second sound is intensified in high arterial tension and arterial sclerosis. The pulmonic second sound is increased in mitral disease, a feeble left ventricle and in pulmonary conditions. \Mien compensation fails, the sounds are weak or absent. In hypertrophy the first sound is not necessarily increased, as this is more dependent upon the rapidity than upon the amount of the con- traction. When we have a low tension in the arteries we get a loud sound as the heart contracts with vio- lence ; with high tension the sound is weak, due to the slow^ contraction ; also a complete filling of the ventri- cle causes the valves to be put on a slight tension be- METHODS OF PHYSICAL EXAMINATION 83 fore systole, which lessens the mtensity of the first sound. This is heard in mitral regurgitation and in prolonged diastole. Changes in the valves produce diminution in the intensity of the heart sounds, but this is not always the case, as, for instance, increase in the intensity of the heart sounds may be heard in diseases of the aortic valve. Absence of the sounds suggests organic disease, but is not diagnostic. In mitral regurgitation, there is no left heart sound, as the closure period is absent. There is more blood in the ventricle, therefore a slower contraction, and the aorta is not put in vibration as less blood flows into it. The aortic sound may be weak, because there is less tension in the vessels and also more blood comes from the auricle, thus more nearly equalizing the tension in the ventricle and aorta. Insufficiency of the mitral and tricuspid valves occasionally leads to a total absence of the first sound. The diminution of the right or left heart sound gives some idea of the extent of the insufficiency, provided compensation is complete, as this will cause weakness of the sound. The Quality of the Heart Sounds: Varies greatly in the normal heart. May be sharp and ringing, low and dull, or rough. Pathologically: A loud ringing second aortic is heard in atheroma ; a ringing first in aortic dilatation and aneurism, nervous palpitation, and in hypertrophy. Impureness or roughness of the first sound may be due to poor closure of a nor- mal valve, to a stiiT valve, or to sHght insufficiency; is also heard in chronic myocarditis.'^' * Roughened aorta from atheroma is an important and common factor producing a systolic murmur or roughening at the aortic area. — Editor. §4 XOTES ON PHYSICAL DIAGNOSIS Increase in Number of Sounds: The sounds are nor- mal in character, but the events in the cardiac cycle do not occur with the normal synchronism or extra sounds are added. ^ Divided or split sounds are those in which there is a double sound heard, with a very slight interval. Double or re-duplicated sounds are those in which a more pronounced inter- val occurs. The re-duplication of a sound may be due to nervous disturbances or variations in pressure. Re-duplication of the second sound is thought to be due to high tension, closure of one valve (that un- der the highest pressure) before the other. Sahli denies this and says it is due to a difference of pres- sure within the arteries and ventricles, that is, when the pressure in the ventricles is very low, closure of the arterial valves occurs more rapidly. Sometimes, in normal breathing, during inspiration, the blood does not flow into the left ventricle as rapidty as into the right ; therefore the pressure in the right ventri- cle is low and the aortic valve closes before the pul- monic. This is normal re-duplication. The same oc- curs in mitral stenosis for a similar reason; the aortic valves close first. In mitral regurgitation the case is different, as the increased quantity of blood thrown into the ventricle equalizes the pressure between the aorta and the left heart; therefore the aortic closes * It must be remembered that the two normal heart sounds are com- posed of many sounds. The occu?rence of but two sounds depends upon the perfect synchronism of all the events going to make up these sounds. Anything which disturbs this sequence will delay one or the other of the factors producing the sounds, and the belated event will be evidenced by an additional sound. These extra sounds are verj^ important clinical evidences of disturbed cardiac mechanism and should be carefull\' stud- ied bv the clinician. — Editor. METHODS OF PHYSICAL EXAMiyATIOX 85 slower and the pulmonic faster, or first. In support of this theory he states that the second sound does not come with the actual closure of the semi-lunar valves, but is due to tension in the arteries after these valves are closed. In utilizing this re-dtipHcation of the second sound for diagnosis, it must be constant and not restricted to any phase of respiration. Re- duplication of the first sound is heard over the vessels, and is due to some difference in the tension of the valves. This can be brought about in conditions where the tension being high in the arteries the closure period is longer, therefore a normal but de- layed sound is produced. The second portion of the re-duplication, being due to the tension in the large vessels, is heard at the base of the heart more dis- tinctly than normally. Physiologically this can be produced by slow, deep breathing, as this act raises the arterial pressure. Triple RhytJini: In mitral stenosis this rhythm is heard at the apex. The murmur may or may not be present. It is produced in the mitral opening, as it is best heard at the mitral area. It is due to the con- tracted valve forming a diaphragm, against which blood is thrown by the large hypertrophied auricle. It must not be confused with reduplicated second sounds. The rhythm is different, as is also the loca- tion. Gallop Rhythin : Three sounds are heard over the whole of the heart. At the apex the middle sound is accentuated; at the base the last. This differs from that just described in that it is heard over the w'hole heart area. It is caused bv the sudden relaxation of 86 NOTES OX PHYSICAL DIAGXOSIS the ventricular wall, the blood being thrown into the ventricle at the auricular contraction. To recapitulate, then, we have the following: Re- duplication of the first tone is heard at the base, due to the unequal tension in the ventricle and vessels ; doubling of the first tone is heard at the apex in mitral stenosis; doubling of the first tone is due to the diastolic tension, and heard over the whole heart. Doubling of the second tone is due to alterations be- tween the great vessels and the respective ventricles. Auscultation of the Heart Murmurs : The name tone applies better to murmurs, as they are more often of a musical tone than the heart sound itself. The sounds in the heart and vessels are produced by a single vibration transmitted to a substance. Mur- murs are a number of such vibrations. A tone can be compared to a blow on a drum, a murmur to that of a sound produced by blowing through a tube. Alurmurs can be endocardial or pericardial, or acci- dental and pneumo-pericardial. Alurmurs heard by patients themselves or at a distance are usually musi- cal. Two factors enter into the production of mur- murs : the force and rapidity of the stream and the changes in the calibre of the valve chamber or vessel through which the stream is flowing. Valvular Murmurs: Murmurs are produced by the blood passing from the normal heart calibre through a narrow opening. The blood may flow in the normal direction, but through a narrower calibre, as in sten- osis. The blood may flow in an opposite direction to that of normal, the valve not closing sufficiently. In- sufficiency takes place by a shortening of the valve in METHODS OF PHYSICAL EXAMINATION 87 its long diameter, by holes or tumors, by excrescences or thickenings preventing close opposition of the op- posed surfaces. Relative insufficiency takes place by an enlargement of the ventricular cavity, displacing the papillary muscles, and thus preventing the valves from closing, also by too strong a diastoHc filling of the ventricle, either through a too great supply of blood from the veins, as in non-compensating heart, or from blood being left behind, as in failing heart. Functional insufficiency of the auricular openings is seen in nervous disturbances and in improper inerva- tion of the papillary muscles. Relative insufficiency of the vascular openings may be due to dilatation of the ring from high pressure or diseases of the arterial wall. Never forget that the murmurs are dependent for their production upon the celerity of the blood stream. Their lack of production is especially seen in mitral stenosis and in aortic insufficiency, with mitral and tricuspid regurgitation, the tension being too low in the arteries to produce a murmur. The quality of the murmur has no clinical value, as it is dependent more upon the shape than the degree of the opening. Loud murmurs are heard with medium sized openings ; small or large openings cause weaker murmurs. This is of no value, as there is no unit by which to compare loud and soft murmurs. In feeble heart action the murmurs may be weak or absent, and only by exercising the patient or awaiting com- pensation can the murmur be heard. In listening to the heart in the standing or lying position, the murmurs vary greatly, due to changes in the blood pressure. In mitral stenosis in the dorsal position 88 NOTES ON PHYSICAL DIAGNOSIS at times no murmur can be heard. This is in some cases true also of aortic insufficiency. In this latter condition, if the patient assume the erect position, gravity increases the celerity of the blood and so emphasizes the murmur. In aortic stenosis the mur- mur in the upright position may disappear entirely. Accidental or relative murmurs usually have a softer character than the organic. However, this does not apply to all cases, as some accidental murmurs are very rough and loud, while organic murmurs may be of a very soft character. Note. — These variations in quality and intensity of murmurs, with changes of position, are more usually associated with functional than with organic murmurs. — Editor. Localization of Murmurs'. Classical points for the valves : Apex for mitral, lower portion of sternum for tricuspid, right and left second interspaces for aortic and pulmonary. Murmurs are produced on both sides of the lesion, and the side with the wildest cavity produces the loudest vibration. The nearness of the lesion to the surface and the condition of the organs under and overlying same are factors influ- encing the location of maximum intensity of mur- murs. The column of blood is not only a conductor of sound, but as the sound is produced on one or the other side of the opening through which the blood tlows, this causes some murmurs to be loud and others soft. Sounds travel better with the current of the blood than against it.* Systolic murmurs pro- * Time of AlMrmtirs. The pulse at the wrist, the vessels of the neck and the apex beat must always be observed in determining the time of the murmur. This is essential, as even practised ears cannot in many instances determine the time of the sounds on listening alone. — Editor. METHODS OF PHYSICAL EXAMINATION 89 dnced by aortic stenosis are transmitted to the neck and are heard best over the second interspace. At times this murmur may be heard over the ventricle or even at the apex. This is due to the fact that the murmur is produced in the ventricle and not in the aorta." Diastolic aortic munnurs are heard best over the third left rib, over the ventricle or apex. This is due to the fact that the murmur is produced in the ventri- cle, the blood flows towards the apex and that the aortic valve, at the second right interspace, is deeply situated. In exceptional cases the murmur is heard in the vessels of the neck alone. Systolic munnurs of the mitral valve are heard best at the apex, where the first sound is produced. The left ventricle comes to the surface at this point alone. The murmur is louder in the large cavity of the ven- tricle than that of the auricle, although the blood flows away from the apex. When the auricle is mark- edly dilated, one can hear the diastolic murmur over the second left interspace. This is due to the wide cavity of the auricle, the direction of the blood stream, and displaced lung. A markedly dilated ven- tricle by displacing the lung can approach the chest wall, and the murmur be heard best over the third left interspace. Diastolic mitral murmurs are heard best at the apex and are very local, because the blood flows towards the apex. The ventricle is the larger cavity, and the * Remember that in speaking of a murmur as being " heard at'' cer- tain points, the locality referred to always means the area of " niaxiiniim intensity " of the loudness of the murmur. — Editor. 90 NOTES OX PHYSICAL DIAGNOSIS the apex lies against the thoracic wall. In very large right hearts in mitral stenosis the left ventricle can be covered by the right and the murmur may be ab- sent. True diastolic murmurs coming at the begin- ning of diastole are found in cases of very large auri- cle with small ventricle. The murmurs are heard over the auricles. Systolic friatspid munnurs are best heard at the lower part of the sternum and at the right of the same, as the right ventricle and auricle lie closest to the thoracic wall at this point. This is more distinct the greater the dilatation of the auricle and ventricle. Diastolic tricuspid inunniirs are heard best over the .same point. Systolic pulmonary munnurs are heard best over the pulmonary area and over the whole of the right ventricle. This murmur is heard under the left clavicle and distinctly behind, and is not heard in the vessels of the neck. Diastolic pulmonic murmurs are heard over the lower part of the sternum on account of the direc- tion of the blood flow and the size of the ventricle. They are never heard in the vessels of the neck. The above rules apply only when the heart is not essentially changed in size and position. The heart sounds associated with murmurs are produced in the heart wall, in the big vessels and from the normal valves. The intensity of the murmur is dependent on the celerity of the blood stream. Therefore, most murmurs diminish in intensity as agents acting upon the blood stream, the heart muscle, for example, fail. Only in the auriculo-ventricular stenosis is this rule METHODS OF PHYSICAL EXAMINATION 91 reversed, as in the auricular contraction the celerity of the blood is increased toward the end of the pause. This is the only characteristic murmur, and even in rapidly beating hearts the phase of the heart cycle may be determined by this murmur. Exceptions to the Presystolic Mitral Murmur: At times it is a true diastolic murmur heard at the be- ginning of diastole and best heard over the base of the heart. The next form of this murmur is when we have a true diastolic dying away and then followed by a presystolic. This is brought about by the dam- ming back process and the added auricular contrac- tion. This is seen in moderate lesions. The next is the true short presystolic murmur heard only at the apex in advanced stenosis, when the blood flows through the opening so slowly in the beginning of diastole that there is no murmur produced till the auricle contracts. When the auricle is unable to con- tract, as in the most marked forms of this lesion, there is no murmur heard at all.* A prediastolic murmur heard just before the second sound as a rule means a slight mitral or tricuspid insufficiency, as it comes at the period when the pressure in the ventricles is high and is produced by a slight giving way of the ring or papillary muscles. It is also favored by the fact that the auricle is completely dilated at this period by the sHght leak and gives a larger cavity for the * Two-thirds of the auricular contraction is passive (non-muscular), one-third is active (muscular), this last one-third is what is spoken of as "Auricular Systole," It is during this last one-third that a presystolic murmur is produced by the effort of the heart muscle to force the blood out of the auricle through the stenosed (narrowed) mitral orifice. — 92 NOTES ON PHYSICAL DIAGNOSIS production of the murmur. This must not be con- fused with pauses between the closure time, first sound, and the systoHc murmur in aortic and pul- monary stenosis. This is so very short that there should be no cause for confusion. Double Lesions: Systolic murmurs heard at the apex and over the aorta : The murmurs may be of a different character and strength at the two places. This is a dangerous criterion, as the transmission may alter the character and strength greatly, as a loud mitral or a weak aortic may have exactly oppo- site significance. At both points the murmur may be of equal quality and strength. By moving the stethoscope from one point to another these varia- tions in the intensity of the murmur may be detected. This is only valuable when the difference in dura- tion, intensities of the sounds, character and phase of the murmur are noted. There are many condi- tions modifying the murmur, as the right ventricle, lung, etc. Keep in mind that the classical points for the auscultation of murmurs do not hold good on changes in the size and position of the heart and surrounding organs. The murmur alone is not suffi- cient to diagnose a heart lesion, as will be repeatedly proven at the autopsy table. Accidental Murmurs: The relative murmurs are the same as the organic, as far as the physical signs go, and therefore must be classed with the organic till excluded by treatment, rest, etc. Haemic is a misleading term for certain functional niunnurs, as a great majority of these murmurs have nothing to do with the condition of the blood. Ac- METHODS OF PHYSICAL EXAMINATION 93 cidental murmurs are mostly systolic and are heard usually over the apex and the pulmonary area. As these often have the same character as the organic, they may be considered as being produced by the blood stream, and following the same laws. It is strange that the normal heart produces no murmurs, and that these adventitious sounds are limited to pathological conditions. Marked variations in the calibre of the heart cavities fit exactly to the laws that we apply to the production of murmurs. This may be explained by the fact that there is no suitable relation between the variations in calibre and the celerity of the flow of the blood. It has been defin- itely proven that the blood can flow out of the nor- mal heart 16^2 times faster than it ordinarily does, and that the ventricles are more distended during diastole in the slow beating heart. All these points go to make up conditions favoring the theory of the production of murmurs. The conditions, however, are not the same in the diastolic accidental murmurs, as there is nothing to vary the force of the contrac- tion, the quantity of the blood, and the configuration of the heart. This latter is well seen in mitral steno- sis with the frequent absence of the murmur, as the low arterial blood pressure favors quick ventricular contraction. Sahli, however, thinks that the blood pressure has little influence. Fever and weakness favor low blood pressure and quick ventricular con- traction. In anaemia the diminished cohesion of the blood favors the production of murmurs, as it has been shown that the blood flows faster in anaemic people than in normal. The venous hum is by some 94 NOTES OX PHYSICAL DIAGNOSIS explained in this way. The systoHc murmurs produced by roughness in the aorta or endocardium, due to atheroma, are of course not to be classed among functional or accidental murmurs. The pulmonary artery, rarely, if ever, becomes atheromatous. Ac- cidental murmurs may be systolic respiratory mur- murs. Diastolic accidental murmurs are heard over the aorta and are confused with true insufficiency. The point of differentiation is that the diastolic functional murmur increases in intensity as one passes to the vessels of the neck. A diastolic murmur heard all over the cardiac area is usually due to marked anaemia, and is found where the haemoglobin is very low, 15 to 25 per cent.* Some murmurs are un- explainable and may be associated with any lesion. In making a diagnosis, use every means to exclude a true lesion, then take up the conditions causing accidental murmurs ; even then a positive opinion cannot be formed. Don't forget that in anaemia rela- tive murmurs are frequent, also in atheromatous con- ditions of the aorta murmurs are frequently heard over the aorta and apex. Diastolic accidental mur- murs are only heard in severe anaemias, and are al- ways accompanied by systolic murmurs and venous hums. The character of the murmurs means nothing, as accidental murmurs may be very loud and the or- ganic very faint. Prediastolic murmurs are never ac- * Research has definitely proven that the blood condition cannot be, even within v^^ide limits, determined from a functional murmur. The murmur is frequently marked when the blood is normal, and vice versa. The blood and heart should always be thoroughly studied quite inde- pendently of one another. — Editor. METHODS OF PHYSICAL EXAMINATION 95 cidental. The influence of respiration on organic and accidental murmurs is marked. This is due to the covering of the heart with the lung or variations in the blood stream due to respiration. In inspiration the lung covers the heart, and the murmurs are fainter; in expiration the reverse is the case. The flow of blood in and out of the right heart is favored by inspiration. By quick inspiration the vessels in the lungs are dilated and the blood is held back from the left ventricle. In slow, deep breathing this hap- pens only at the first part of inspiration. Pericardial Miinnurs: Are all those heard syn- chronously with the heart action, but produced out- side of the heart cavities. Pericardial rubbing. Pleuro-pericardial rubbing. Precordial emphysema. Pericardial splashing. Pericardial rubbing is due to inflammation, depos- its, tuberculosis, tumors, or abnormal dryness of the pericardial surfaces. The murmur may be loud and rough or soft, the latter easily being confused with an endocardial murmur. Also rough endocardial mur- murs may be mistaken for pericardial friction rtib. The endocardial murmurs are more closely associated with the heart sound, though this is by no means con- stant. The pericardial murmurs come at any time, between the heart sounds, overlapping same, or may be a continuous murmur, without relation to the heart sounds. The beginning of the pericardial murmur comes before the first sound, and is due to the fact that the outer wall of the heart during the 96 NOTES ON PHYSICAL DIAGNOSIS first part of the propulsion time moves before the full ventricular contraction begins. Murmurs may come in the middle of systole and diastole with dis- tinct pauses between the sounds. They may begin in the middle of systole and terminate in the middle of diastole. They may be continuous, increasing in intensity at the middle of systole and diastole. As the murmur is produced on the anterior portion of the heart, it is best heard when the lung is thin or absent. If pericarditis is of the adhesive variety, or if fluid is present, the murmur may come and go as conditions allow. Even when fluid is present, the murmur can be heard at the base where the surfaces are close to- gether, or at the apex where the weight of the heart brings the surfaces in contact. By bending the pa- tient, forward pericardial murmurs are increased, whereas endocardial murmurs are changed by the recumbent or erect positions. In deep inspiration the lung presses on the pericardium and increases the murmur. The respiratory phase in varying the filling of the right and left ventricles influences the murmur. Val- salva's experiment of deep inspiration with the reten- tion of the breath and straining, as at stool, keeps the blood from the thorax and the heart. Under these conditions the endocardial murmurs decrease in intensity. The pericardial by pressure of the lung increase. This is a dangerous procedure. Pleiiro-pericardial Murmurs between the Heart and the Costal Pleura or the Heart and the Lung Pleura: Pericardial murmurs are heard where the heart lies bare, as near the sternum ; extra pericardial near the outer edge of the true cardiac flatness. METHODS OF PHYSICAL EXAMINATION 97 In pericardial emphysema with air in the anterior mediastinum, there is absence of the heart duhiess and a feebleness of the heart sounds, and with each contraction of the heart, crepitant rales of a metallic quality are produced. The pericardial splash with a metallic sound is heard synchronous with the heart sounds, and must be differentiated with that produced by the stomach and pneumothorax. This can be done by exclusion and by percussing the heart, wdth changes in position of patient. The heart sounds may themselves have a metallic quality. Auscultation of the Vessels: Aside from those trans- mitted from the heart, the vessels are, by the same laws, capable of producing sounds and murmurs. Auscultation of Arteries: Listen over the carotids, the subclavian, and above and below the clavicle, over the radials, the crural and the abdominal aorta. On auscultating over the carotid or the subclavian, a sys- tolic and a diastolic sound can be heard from the heart. The brachial, the crural and the abdominal aorta may give a systolic sound. The smaller ar- teries give no sound. By pressing the stethoscope on a vessel a systolic murmur is heard. If the vessel is obliterated a systolic pressure sound is produced. In children from three months to six years old, a systolic murmur is heard over the fontanelles and head. This is physiological, and is principally pro- duced in the carotids. As the heart sounds both nor- mally and pathologically are transmitted into the carotids and subclavians, an absence of the second sound suggests aortic insufficiency. In pulsus celer from fever or aortic insuf^ficiency, a tone is heard in 7 98 NOTES ON PHYSICAL DIAGNOSIS all the arteries, small and large. In marked aortic insufficiency, a double sound can be heard, due to the relaxation of the arteries. This is at times also heard in chlorosis, pregnancy and lead poisoning. In aortic insufficiency, by placing the stethoscope on one of the large arteries, one or two sounds are heard. Subclavicular Murmurs: By auscultation of the subclavian artery with the arm hanging by the side, in cases of tubercular disease of the apex with adhe- sions, a murmur can be heard, increased on deep in- spiration and sometimes on expiration. Care must be used that the inspiratory act does not increase the pressure of the stethoscope on the arteries. This has little value, as it is heard in normal individuals with varying position of the arm. Over the carotids can be heard murmurs analogous to that heard in anaemia, but differing from the venous murmur. This can be heard over the aorta and the carotids and can even be palpated. Over the facial vessels of those with Basedow's disease a systolic murmur can some- times be heard. Auscultation of the Veins: Normally the blood flows through the veins without any murmur or tone. In exceptional cases there is a slight hum. In tri- cuspid regurgitation by tension on the veins and closure of the valves in the bulb, a loud systolic tone can be heard, distinguishable from the carotid in that it precedes it. Tlic Humming Murmurs: One hears a continuous murmur with a systole and sometimes with diastole over the vessels of the neck, which is increased in intensity during inspiration. ^v ^^ METHODS OF PHYSICAL EXAMINATION 99 The point to auscultate is the attachment of the sterno-mastoid muscle to the thorax. It is heard best on the right side, as the flow of blood is more direct to the heart. In the upright position the flow of the blood is ac- celerated in the veins from the head, so that one hears this murmur better in the erect position. In the dorsal position the murmur is usually lost. By turning the head to the left or by slight pressure of the stethoscope the murmur is increased. As the flow in the veins is continuous, the murmur that is heard is usually constant. These interrupted murmurs may be confused with the cardiac, arterial, or respiratory sounds. Only by noting the point of maximum intensity and the variations in character in the different positions of the patient can the diagnosis be made. The Cause: It is not due to a collapse of the veins, as this does not take place where the murmur is heard. The following theories have been advanced: (i) the increase of celerity with which the blood flows in anaemic conditions; (2) the passage of the blood from the veins into the bulb ; (3) a diminished co- hesion of the blood. When heard in normal indi- viduals, it may be due to some anatomical anomaly, or to variations in the celerity of the blood flow. In the standing position, the sucking action of the res- piration increases the velocity of the blood flow and gives all the conditions for the production of mur- murs at the bulb. Turning the head to the left may cause some constriction of the veins by the sterno- mastoid or omohyoid muscles. Systole increases the lOo NOTES ON PHYSICAL DIAGNOSIS murmur, as in the venous pulse at this time the curve is an ascending one. The increase during diastole is more complicated. It may be due to a vibration in the walls of the veins caused by the normal ascent of the negative pulse wave. The same murmur can be heard over the crural veins at times and also over a vascular goitre or tumor. Sahli thinks that they are of value if marked. In Basedow's disease, the hum heard over the veins may be transmitted from the goitre. Note. — Cardio-Respiratory Mtirmur : This is not produced in the heart or vessels, but is due to the forcing out of the air from the air cells of the lung by the heart with each contraction squeezing the lung against the thoracic wall over the proecordiam. The murmur has a " puffing" quality, is loudest on inspiration and disappears on expiration. The Uterine Bruit: Loud systolic murmur similar to that heard over a vascular goitre is heard normally over the gravid uterus, and, like the former, is due to the tortuous and numerous blood vessels. Mediastinal adhesions may produce both friction rubs and sounds resembling murmurs. The mediastinum as the seat of enlarged glands, tumors and inflammation must not be forgotten. This important space is receiving more attention clinically of late. General Classif cation of JMnrmurs : Organic — Actual cardiac lesion; diseases of valves, etc. Functional — No cardiac lesion, anaemia; cachexia, etc. Mechanical — No lesions, cardiac or otherwise; cardio-respiratorv. Accidental — Adhesions pulling upon the heart or blood vessels; Subclavian (systolic) — Editor. The Pulse. The character of the pulse is an indication of the heart strength, the blood pressure, and the condition of the peripheral arteries; valvular lesions, fever and certain cardiac neuroses also have certain pulse char- acteristics. METHODS OF PHYSICAL EXAMIXATIOX lOi Tlic Methods: Finger, sphygmograph, sphygmom- eter, inspection and auscultation. Palpate the radial artery over the styloid process of the radius between the tendons of the supinator longus and the radialus internus. Keep in mind that this is not a constant position. Always compare both radials as to size, as they vary greatly in normal individuals. Use the larger of the two for diagnosis. TJic Arterial J Fall: Try to roll the artery under the finger, note hardness and resistance as the con- dition of the arterial wall influences the pulse \vave markedly and must be first determined. In the high grades of arterial thickenings the vessels are tortuous. This is a normal condition for the temporals, but they are not nonnally z'isiblc. Deposits of chalk in the vessel wall may be felt. A high grade of local arterio- sclerosis of the aorta, of the vessels of the kidneys or of the cerebral vessels may exist without change in the peripheral arteries. In these cases a hard pulse is usually found and some changes in the urine. In counting the pulse beats, if irregular, count one min- ute and repeat, taking the highest count. The pulse varies physiologically. Psychical influences, espe- cially in nervous people, cause marked variation in pulse rate. The pulse rate rises during motion and change of position of body after which it soon falls. This is true also during and after the passage of urine and faeces. After exhaustion the pulse remains high for some time. Rate: In the recumbent position 66, in the sit- ting 71, in the standing 81. The taking of food in- creases the pulse rate, especially after a heavy meal. I02 NOTES ON PHYSICAL DIAGNOSIS when this mcrease may persist for some hours. Daily variations are due to food or starvation, in the latter the variations being probably caused by changes in the bodily temperature. TJie Influence of the Blood Pressure: When the blood pressure is high the pulse is slow, when low the pulse is accelerated. In the recumbent position the blood pressure is higher than in the erect. In- spiration and coughing increase, expiration decreases the blood pressure. Variations as to Age: In the foetus 133 to 144; in the first year 123 to 143; ten to fifteen years 76 to 91 ; twenty to sixty years 69 to 83. After the age of sixty, it progressively decreases. Women have from seven to eight beats more than men of the same age and size. Tall people have a lower pulse rate than short people. When the pulse is not felt with an apex beat, it may be due to a hemi-systole. The fever and the pulse curve run about parallel. Each degree of temperature equals about eight pulse beats. A hig-h pulse rate and a low fever means a grave prognosis, as it indicates a disturbance of the cardiac or vasomotor apparatus. A high temperature w^ith a low pulse rate is seen in patients with cerebral pressure, diseases of the myocardium, tuberculous disease. A high pulse with a low temperature is seen in collapse. In typhoid fever the pulse is low in com- parison with the fever. This is a point against miliary tuberculosis and sepsis. In pulmonary tuberculosis and in children the pulse rate is very high, in com- parison with the temperature. Diseases of the heart, lost compensation, endo- and pericarditis, Basedow's METHODS OF PHYSICAL EXAMINATION 103 disease, nervous tachycardia, pressure on the heart, all cause a high pulse rate. Pain may increase or de- crease the pulse rate. Certain drugs increase, others decrease, the rate and pressure. This influence of drugs must be taken into account, in interpreting the pulse. Psychological influences must be consid- ered in palpitation and subjective dyspnoea. Lozv pulse rate: Normal in some people; as low as 20 in fatty heart ; slightly slowed in aortic insufficiency and cachexia; after the crisis in fever and during conval- escence ; in pain and shock, and jaundice. During the onset of the jaundice the pulse is slow; later, by the heart adapting itself or due to elimination of bile acids by other channels, the pulse becomes normal. In all these cases there is a marked tendency to an increase in the pulse rate from slight causes. The Relation of pulse, temperature, and respiration. 72 98! 18 Respiration to pulse, i to 4. Temperature to pulse, 1° to 10 beats. —Editor. drawing off of fluid from the chest or abdomen slows the pulse. A physiologically irregular pulse is rare, but is very frequent as a transitional condition and is associated with conditions which influence the rate. Marked disturbance suggests an organic disturbance of the heart. Usually an arrhythmic pulse is accom- panied by irregularity in force. In speaking of the size of the pulse, the degree of distension of the arterial wall is meant. A celer pulse is a sudden rise and fall of the pulse wave, as seen in aortic insufficiency and in all conditions lowering the arterial tension. Tardus is a slow wave as in aortic stenosis. There are many I04 XOTES ON PHYSICAL DIAGXOSIS combinations of these two. The word celer should be applied to the water hammer pulse, as tliere are many forms of sudden rise with slow descent which may be considered as true pulsus tardus. In feeble hearts the celer pulse disappears. Tension: As a rule, with the celer pulse the blood pressure is below normal; conversely, a small pulse can be easily obliterated and yet the blood pressure be very high. Try to determine the tension between the systoles. A high tension pulse must not be confused with thick arterial walls. In fever the blood pressure during the systole is high, during diastole it is low. A dicrotic pulse is seen in all conditions of low tension, and is best appreciated by Hght palpa- tion. With sloAv, deep respiration the pressure in- creases, and the size of the pulse decreases during inspiration; during expiration the opposite obtains. Capillary Pulse: Pressing lightly on the patient's finger nail or drawing one's finger nail across the patient's forehead shows a pulsating blush at the junction of the red and white areas. This is capillary pulse. It is not seen in healthy individuals. With low arterial tension and in the celer pulse, as in Base- dow's disease, fever, chlorosis, etc., the capillary pulse may be seen, but this is by no means always true. It is also seen in aortic insufficiency in the compensating stage and in areas of inflammation. It is caused by anything which facilitates the flow of blood in the capillaries or retards the outward flow from the same. The normal pulse wave is lost in the arterioles or else recoils. TJie Effect of Respiration on the Veins: In inspira- METHODS OF PHYSICAL EXAMINATION 105 tion they collapse, in expiration they fill. This is seen not in normal but in forced breathing. If venous congestion is present this phenomenon is seen with the normal respiration. When the patient coughs dilatation of the cervical veins is distinctly seen, and in conditions of chronic violent coughing a perma- nent venous dilatation may result. Dilatation of the veins by inspiration is seen in chronic mediastinitis, due to the pull of the lung on the vessels ; also where some pressure is exerted on the vessels, as in peri- carditis with effusion, pleural effusions and media- stinal tumors. This latter may inhibit the movement of the thoracic contents, and thus be a factor influ- encing the flow of blood in the veins. Venous Pulse: Can be distinguished from the arte- rial by its large, flat, undulating movement, in con- trast to the sudden impulse of that of the artery. It has little force or tension. By compressing above it disappears. By pressing below it is increased. This last does not apply if the pulse is positive (i.e., due to tricuspid regurgitation with true cardiac impulse). The normal negative pulse is not seen in those with indistinct jugular veins, and is intensified in those with slight disturbances of the circulation. In posi- tive venous pulsation, compression of the vessel causes the pulse to disappear above the point of com- pression. In negative venous pulsation the pulse dim- inishes or disappears below the point of compression. \Mien negative pulse persists below the point of com- pression, it is due to a large vessel emptying into the jugular below this point. If pulsation is marked above the point of compression the pulsation is due io6 NOTES ON PHYSICAL DIAGNOSIS to a transmission from the arteries or to an arterio- venous communication. The valves of the jugular vein do not retard the negative pulse, as it is a wave and not a regurgitation. Venous collapse occurs with the first part of systole and is due to the dilatation of the auricle, and the sucking action of the systole of the heart. The dila- tation of the veins is due to four factors, one working against three. This one against the three is the suck- ing action of the dilated ventricle. The three factors which favor dilatation of the veins are (i) the increased thoracic pressure of the dilated heart ; (2) the closure time before systole; (3) the auricular contraction. The cause of the wave in the middle of the ascending Hmb of the venous curve is due to the stopping of the blood as the auricle is filled and starts to contract. This causes a sudden stop of the blood flow into the auricle and causes the wave. In comparing the nega- tive venous pulse with the positive, never judge by the apex beat, as the apex impulse occurs with the closure time, and therefore with the height of the negative venous pulse wave, and would lead to the diagnosis of a positive venous pulse. For comparison always observe the carotids at the same level. Note. — The cervical veins are under normal conditions insufficient — that is, a back pressure may cause pulsation of the jugular without any valvular lesions existing. This is the condition in Stokes-Adams disease, where a double auricular systole may be noted to every ventricular sys- tole (Erlanger's Experiments). — Editor, The Positive Venous Pulse: Is synchronous with the carotid pulse. The ascending wave begins be- fore the carotid and has an undulation in its middle. The early start is due to the fact that it begins at the METHODS OF PHYSICAL EXAMINATION 107 closure time and the undulations are produced by the same factors as produce those of the negative pulse. Liz\cr Pulsations : Seen and felt to the right of the median line; is an expansile pulsation, and is to be distinguished from the transmitted aortic pulsation seen and felt in the epigastrium. This expansile pul- sation is seen in the liver, in tricuspid regurgitation. The Positive Centripetal or Penetrating Pulse: Is found in conditions of low arterial tension with marked celer pulse. Is usually associated with the capillary pulse, but it may be absent, as the capilla- ries are too small to show the pulsation, and it may not make its appearance until it is passed on to the smaller veins. This pulsation disappears when pres- sure is applied between the heart and the periphery. It is very rare. Diastolic Venous Collapse: Is due to adhesions of the heart with the thoracic wall and so during sys- tole, the negative intra-thoracic pressure being mark- edly diminished, there is a swelling of the veins. At the beginning of diastole there is a marked sudden collapse. This may be confused with the positive venous pulse, but on pressure upon the veins it disap- pears below the point of pressure. Combinations of the positive and negative pulse are impossible of diagnosis. DIFFERENTIAL DIAGNOSIS Pulmonary Diseases : Diseases of the Nose, Pharynx and Larynx. Stenosis of the Larynx. Trachea. Bronchi. Bronchitis: Acute, Capillary, Chronic, Dry, Fibrinous, Bronchorrhoea, Putrid. Bronchiectasis. Asthma, Bronchial. Asthma, Cardiac. Broncho Pneumonia (Lobular). Lobar Pneumonia. Cirrhotic or Interstitial Pneumonia. Pneumokoniosis. Emphysema: Acute, Compensatory, Interstitial, Atrophic. Cardiac or Brown Induration: Oedema: Inflammatory Stasis. Hypostatic Pneumonia. Atelectasis : Infarction. Abscesses: Primary, Embolic. Gangrene. io8 DIFFERENTIAL DIAGNOSIS 109 Tumors : Primary, Metastatic. Parasites : Echinococcus, Actinomycosis. Mediastinal : Abscess, Tumors. Tuberculosis : Miliary, Pneumonic, Ulcerative, Fibroid, Pleurisy: Acute, Local, - Acute, Chronic, Broncho, Lobar. Encapsulated, ) Diaphragmatic. f Dry, Serous, P , , Serofibrinous, ' Purulent, Hsemorrhagic, Chylous. thickened Chronic, Fibrinous, Serofibrinous, . , Fibroid, ( P^^"-"^- Serous, Purulent. Hydrothorax. Haemothorax. Pneumothorax. Hydro or Pyopneumothorax. Cysts: Echinococcus. Inspection : Conditions in zMch a bulging of one side of the thorax is seen: Note. — As a clinical fact, bulging, except from bony deformity and tumors, is rarely seen. — Editor. Lobar Pneumonia. Pneumothorax. no XOTES ON PHYSICAL DIAGNOSIS Pleural effusions and conditions diminishing the negative pressure. Compensatory Emphysema. Spinal Qirvatures. Tumors : Thoracic and Abdominal. Conditions causing a refraction of one-half or a part of the thorax: Pulmonary Fibrosis. Tuberculosis, chronic. Cirrhosis. Chronic Pleuritic Thickening, after absorption of old pleural effusions, with poor pulmonary expansion. Spinal Curvatures. Conditions causing a decreased expansion of part or half of the thorax: Pain : Pleurisy, Fractured Rib, Neuritis. Pulmonary Infiltrations: Pneumonic, Tubercular, Fibroid, etc. Pleural Adhesions. All the conditions causing bulgings and retractions. Bronchial Stenosis. Tumors. Dyspncea : Inspiratory: Stenosis of the upper air passages, pharynx, larynx. Stenosis of the Trachea. Stenosis of one of the large Bronchi. Expiratory : Emphysema, Capillary Bronchitis, Asthma, Fibrous Bronchitis. DIFFERENTIAL DIAGNOSIS m Palpation : Fremitus is normal in Bronchitis : All varieties save capillary. Bronchiectasis (save over large cavities). Asthma: Bronchial. Pleurisy, Acute Dry. Brown Induration. Miliary Tuberculosis. Fremitus and voice sounds change correspondingly. Fremitus is normal in diseases of the upper respira- tory passages. Increased in: All conditions of Pulmonary Infiltrations, bronchi being open. Pneumonic, Tubercular, Fibroid, Atelectatic, Infarctions, Abscesses. Gangrenous, Tumors, Cystic. All cavities with thick walls. Bronchiectatic (General Bronchial Dilatation), Tuberculous, Gangrenous, Discharged Abscesses (resulting adhesions). Diminished or Absent in: All conditions of alveolar dilatation: Emphysemas, Capillary Bronchitis, Asthma. Conditions where the bronchi are closed: Tracheal and Bronchial Stenosis, Capillary Bronchitis, Fibrinous Bronchitis. 112 NOTES ON PHYSICAL DIAGNOSIS All conditions separating the lung from the chest wall, as Air : Pneumothorax. Fluid: Pleural Effusions and Exudates, Hydrothorax, Hsemothorax, Pyothorax. Thickened Pleura : Chronic Fibrinous Pleurisy, Tumors, Cysts. Percussion : Conditions in zi'hich a Normal percussion note is ob- tained : Diseases of the upper air passages. Tracheal and Bronchial Stenosis. All forms of Bronchitis save Capillary. Bronchiectasis save over cavity. Asthma, Bronchial. Asthma, Cardiac. Brown Induration. Early Oedema. Miliary Tuberculosis. Acute Dry Pleurisy. Conditions in which Hyperresonance (vesiculo tym- panitic resonance of Flinty or Skoda' s resonance) is obtained: Dilated Alveoli. Emphysema: Acute, Chronic, Compensatory, Interstitial. Capillarv Bronchitis, 1 * , -r^. ^ ^ , ^ y Acute Distensions. Asthma. DIFFERENTIAL DIAGNOSIS 113 Conditions producing a relaxation of the lung tissue, as early inflammatory congestion, seen in: Early tuberculous infiltration, Oedema, Hypostasis, Pneumonia first and third stage. Relaxation of the lung tissue due to nearby in- filtrations : Tuberculous Infiltration. Bronchopneumonia. Lobar Pneumonia. Infarct. Abcesses. Tumors. Atelectasis from Pressure: Ascent of Diaphragm. Pleural Effusions and Accumulations. Pleural and Mediastinal Tumors. Pericardial Effusions and Enlarged Heart. The upper part of Lobar Pneumonic Infiltra- tion. Pneumothorax : Local, General. Cavities. Conditions in zvhich Dulness is obtained: All conditions of thickened pleura. All conditions of alveolar infiltration or partial con- solidation. Early Lobar Pneum.onia. Late Stage of Lobar Pneumonia. •' Broncho Pneumonia. Tuberculous Infiltration. Infarction (Small Multiple). Small Abscess. 8 114 NOTES ON PHYSICAL DIAGNOSIS Gangrene. Pulmonary Fibrosis. Metastatic Tumors. Pulmonary Oedema. Atelectasis. Hypostatic Pneumonia. Small Cavities and Consolidation. Slight Pleural Effusion. Enlarged Heart. ] p f * i Pericardial Accumulations. [ Conditions in zvhich a Flat Note is obtained: Complete Consolidation of Lung Tissue as in: Lobar Pneumonia. Tuberculous Consolidation. Pulmonary Fibrosis. Atelectasis (Marked). Hypostatic Pneumonia (Marked). Tumors. Abscess. ) ^ c 1-1 Before discharge. Gangrene. Infarct (Large). Cysts. Mediastinal Tumors. Cavities Filled with Fluid. Pleural Accumulations of Fluid as in: Pleural Effusion (Large), Local, General. Hydrothorax. Haemothorax. Pyothorax. Pyopneumothorax. Tumors and Cysts (Large). Pneumothorax when air is under great tension. DIFFERENTIAL DIAGNOSIS nS Conditions in ziliicJi a true Tympanitic Note is ob- tained: Caznties of the lung superficially situated and under a certain tension : Tuberculous, Bronchiectatic, Gangrene, ) ^^^^^^ Discharge. Abscess, j ^ Local Pneumothorax, Diaphragmatic Hernia, Interstitial Emphysema. Auscultation of the Voice : Conditions in which Vocal Fremitus {the vibration produced \by the voice and appreciated by the ear listening over the chest) is absent: Pleural Exudates and Transudates : Local, General. Pneumothorax : Local, General, Thickened Pleura (Marked), Tumors of the Pleura, Obstructed Bronchus, Mediastinal Tumors, etc. Conditions in which Vocal Fremitus is decreased: Emphysema, Asthma, Capillary Bronchitis, Fibrinous Bronchitis, Brown Induration, Pneumokoniosis, Thick Pleura. Conditions in which Vocal Fremitus is found to be normal: Bronchitis, Dry Pleurisy, ii6 NOTES ON PHYSICAL DIAGNOSIS Miliary Tuberculosis, Very Early Tuberculous Bronchitis, All deep seated consolidations, Early Oedema, Small Scattered Areas of Consolidation (Broncho- pneumonia ) , Early Infiltration. Conditions in zvhich Vocal Fremitus is increased: All conditions of Pulmonary Consolidation, as : Broncho-pneumonia. Lobar Pneumonia, Tuberculous Pneumonia, Fibroid Pneumonia, Hypostatic Pneumonia, Atelectasis, Infarct, Gangrene, Abscess, Tumors and Cysts. All Cavities as : Tuberculous, Bronchiectatic, Abscess, Gangrene. The voice sounds are absent, decreased or normal under the same conditions as vocal fremitus. They are increased in: All early congestions and infiltrations of the Lung Tissue as in : Early Tuberculosis, Early Lobar Pneumonia. Deep Seated Consolidations as in: Central Pneumonia. DIFFERENTIAL DIAGNOSIS 117 Scattered Areas of Consolidation as in : Broncho-pneumonia, Tubercular Broncho-pneumonia, Ad^ultiple Infarcts, Multiple Abscesses, Metastatic Tumors. All Pulmonary Consolidations as in: Lobar Pneumonia, Fibroid Pneumonia, Gangrene, Abscess, Tumors, Cysts, etc. Cavities (All Varieties) : Auscultation of the Breath Sounds : Changes in Rhythm: Interrupted : Nervous Patients, Pain, Early Infiltration, Pleurisy (Dry). Prolongation of Pause between inspiration and ex- piration : Inspiration is short as in: Pulmonary Consolidation. Expiration is delayed as in : Lost elastic Retraction as in emphysema. Expiration is prolonged in : Bronchitis, • Early Infiltration, Partial Stenosis of the Bronchioles, Asthma, Emphysema, Consolidations, Cavities. ri8 NOTES ON PHYSICAL DIAGNOSIS Alterations in the Intensity oj the Breath Sounds : Absent: Pleural Exudates and Transudates, Markedly Thickened Pleura, Pneumothorax, Tumors of the Pleura. Mediastinal Growths. Decreased: Emphysema, Asthma, Brown Induration, Thickened Pleura. Very Early Infiltrations as : Pneumonic, Tuberculous. Miliary Tuberculosis. Increased: Bronchitis, Bronchial Stenosis, Fibrinous Bronchitis, Infiltrations. Alterations in Quality : Harsh or Rude: Emphysema, Bronchitis, Early Infiltrations, Bronchial Stenosis, Miliary Tuberculosis. Broncho-vesicular (small consolidations) : Broncho-pneumonia, Tuberculous Infiltrations, Multiple Abscesses and Infarcts, Small Cavities. Bronchial or Tuhulous (all consolidations) : Lobar Pneumonia, DIFFERENTIAL DIAGNOSIS 119 Tuberculous Pneumonia, Fibroid Pneumonia, Abscesses, Gangrene, Hypostatic Pneumonia, Atelectasis, Cavities (at times). N. B. — Tubular Breathing is characterized by having a higher pitched expiration than inspiration. In Cavernous Breathing the expiration is of the same pitch as the inspiration, or lower. Cavernous Breathing: Large Cavities. Amphoric with a Metallic Quality: Cavities. Rales. Pleuritic and Friction Rales: Dry Pleurisy, Above the fluid in pleural effusions, Pneumonia. Crepitant Rales: All early infiltrations and exudations into the al- veoli. The absorption stage in Lobar Pneumonia, Atelectasis, Miliary Tuberculosis. Siihcrepitant Rales: Capillary Bronchitis, 'Dry Pleurisy (?) Early infiltrations. Miicotis Rales: All forms of Bronchitis save the dry and fibrinous., Small Cavities. I20 NOTES ON PHYSICAL DIAGNOSIS Mucous Gurgles: Cavities (all varieties that have fluid in them), Hydropneumothorax with fistulse below the fluid, Large Bronchi. Sibilant Rales: Asthma, Capillary Bronchitis, Emphysema, Fibrinous Bronchitis, Dry Bronchitis. Sonorous Rales: Bronchitis, Cavities. DISEASES OF THE PLEURA AND LUNGS Diseases of the Pleura. Pleurisy: When pleurisy without effusion exists the symptoms complained of by the patient, such as pain, fever, etc., help more in judging this variety of pleurisy than do the physical signs. Dry Pleurisy. Inspection: The patient lies on the back or on the affected side. The excursion of the thorax on the involved side is less than on the sound side. If pleural surfaces are very rough, the friction rub can be appreciated by palpation. Percussion gives a normal note over the involved area, but produces pain. The excursion of the edge of the lung is de- creased, due to restricted movement of the affected side or to adhesion of pleural surfaces. Auscultation: A sharp rale heard on inspiration and expiration, sounds close to ear placed directly on the chest, and is increased by pressure and deep breathing; at times this friction may be heard with the stethoscope."^ The murmurs differ from dry mucous rales in that they do not alter in character, position, intensity or number on coughing. However, the pleurisy may be combined with some catarrhal condition, in which * It is a most important point that early pleurisy may be entirely missed by using the stethoscope and not the ear directly upon the chest. — Editor. 12 2 NOTES ON PHYSICAL DIAGNOSIS case the number, etc., may diminish, but location never. They differ from crepitant rales in that the latter are sharper, not so prolonged, and come at the end of the inspiratory act. Both pleuritic and crepitant rales become weaker after some time of deep breathing, but after a rest they return. The points characteristic of pleuritic friction are that they vary in quality as inspiration proceeds, are usually circumscribed, and extend into expiration. In rare cases all means fail in making a proper in- terpretation of sounds, so diagnosis must be with- held. If pleurisy is near the heart, the friction comes not only with the respiration, but also with the cardiac movements. It usually increases with deep inspira- tion. In miliary tuberculosis, with tubercles on the pleura, although no true pleurisy is present, a fric- tion sound is produced that is practically the same as that in dry pleurisy. All other symptoms may fail, such as cough, pain, etc., so that in this condition the friction rale is the essential point. Pleurisy with Eifusion. Inspection: The patient lies on the involved side or back, so that he can have the full use of the normal lung. The diseased half of the thorax is decreased in its excursion, the lower part first, and later, with the increase of the exudate, the upper part. The involved side is larger than the one not involved. The heart is displaced towards the sound side. The abdominal organs are displaced downward from sinking of diaphragm, as is shown DISEASES OF THE PLEURA AND LUNGS 123 by palpable liver and spleen. These latter organs must be palpated directly as they move but little on inspiration. The diaphragm assumes more or less the inspiratory position. Pulsations of exudate are found mostly on the left side, with overacting large heart and with the relaxa- tion of the costal muscles due to inflammation as in empyema. This may be local empyema, or aneurysm. Percussion is the most reliable. The note is flat, and there is an increased resistance to the finger. The upper line of dulness may be oblique, higher pos- teriorly than anteriorly, or the reverse, or even higher in axillary line than in front or behind. Adhesions, position of the patient during the accumulation, or excess of inflammatory lymph between pleural sur- faces above the line of the fluid, or compression of the lung may cause these variations. The fluid changes its level when the patient changes his posi- tion, but this takes place slowly, due to the adhesion of pleural surfaces about the fluid, w^hich, if very firm, prevents entirely this change of level. Above the level of the fluid the lung gives a tympanitic, deeper note, due to its relaxation. At times cracked pot tone is obtained when the lung is compressed and the bronchi stenosed. Below the clavicle, in marked compressions, Williams' tracheal note is obtained. Exudates of 300 c. c. and less give no dulness. Shghtly larger ones give dulness on Hght percussion. This is best demonstrated by percussing all over one side of the chest from the axilla dow^n, with the pa- tient in the upright position, then allowing patient to lie on his side supported on his elbow. Palpation: 124 NOTES ON PHYSICAL DIAGNOSIS Fremitus is absent over fluid, or weakened above fluid. It is increased, if the compressed lung lies close to the chest. When present below the level of the fluid it may be due to adhesions, or to markedly compressed lung above, being close to chest wall and then setting the whole chest wall in vibration on that side. Auscultation over fluid of moderate quantity gives diminished murmur, or no murmur at all. If the lung above is merely relaxed and not compressed, murmur is absent. If compressed, marked tubular breathing is heard over lung and weak tubular breathing over fluid. The voice is increased over compressed lung, di- minished over fluid, or present for the same reasons as given for presence of fremitus. In moderate exudates posteriorly near scapulae, aegophon}^ may be heard, due to waves of voice sound passing to the smaller bronchi that lie close together, thus interrupting the vibrations. This may be heard over the chest of healthy children, and at times over infiltrated lung. Note. — yEgophony (goat bleating sound), a broken series of sounds. Only the higher notes in the sound wave reach the ear; the lower ones are inaudible, due to certain physiological and pathological conditions. — Editor. At the line of fluid a friction murmur can be heard. This is rare and must not be confused with crepitant rales of compressed lung. Other signs have little value, as they are found in other diseases. The pulse is small as diastole of the heart is dimin- DISEASES OF THE PLEURA AND LUNGS 125 ished by tendency to positive pressure in tiiorax, lessened sucking action on veins, and a retarded cir- culation through the lungs. The arteries on this account are not well filled, and CO2 accordingly rais- ing the blood pressure, and causing the blood to flow slowly through the capillaries. Cyanosis and dyspnoea vary with the extent of the fluid, etc. Differential Diagnosis:- If no dulness be present and typical rales are heard, the diagnosis of dry pleurisy may be made. At times rales are absent though dry pleurisy exist. In this case, if pain be present, which is increased on local pressure and made worse by deep breathing, sneezing and coughing, a probable diagno- sis can be made. Muscular rheumatism must not be overlooked, as all the above manipulations increase pain in this con- dition. By pinching the muscle, the pain is materially increased in rheumatism, while faradization decreases it. Periostitis and caries of the ribs may give local manifestations and be also associated with pleurisy. Intercostal neuralgia at times cannot be dift'eren- tiated, as the pleurisy may involve the nerves and give rise to an associated neuritis with characteristic ten- der points. As a rule, pleurisy is not so local, and the pain is more apt to be increased on deep breathing. The application of the anode of a constant current does not diminish the pain. As the pain of pleurisy may be referred to the terminations of the intercostal nerves in the epigastrium, this may simulate gastral- gia, gastric ulcer, gall stones, or peritonitis. The di- agnosis of pleurisy without hearing the friction rales 126 NOTES ON PHYSICAL DIAGNOSIS should be made with the greatest caution. To dis- tinguish pleural exudate from pulmonary consolida- tion, is at times difficult, as in the first condition the voice fremitus and tubular breathing may be present and even be increased, while in consolidation, when the bronchi are stopped, all these signs may fail. The chief points of difference, aside from the cause of the disease, are the following : Pneumonia : Pleural Exudate : PercKsstoji. The dulness is never absolute The dulness is absolute and in- and diminishes from above down. creases from above down. Voice So tends. Bronchial voice or breathing is These are less over the flattest present and is loudest over the area and segophony is present, dullest area, ^gophony is absent, and is brought out by coughing. J^a/es. Crepitant rales are heard over Are not heard well over the flat the dullest area. area, but over upper edge of same. Displaceme7it. Displacement of other organs is Is more or less marked accord- slight, ing to the extent of the exudate. The diagnosis of cavities, from sacculated empy- ema may be difficult, as both give the same physical signs and puncture results in pus. After the expec- toration of large quantities of pus from cavity the signs change. Mediastinal tumors are diflicult to diagnose. They usually give irregular outlines on percussion, and are located in the upper part of the chest. They cause special symptoms and give dull " processes " to the normal side, etc. In this con- dition no fluid may be obtained on aspiration from the pleura as the needle goes through soft inflamma- DISEASES OF THE PLEURA AND LUNGS 127 tory lymph and is plugged, or the needle is not long- enough or of large enough calibre. Flakes of fibrin may plug the needle, or the exudate may be so thick, that it does not flow well, or the needle may get lodged in adhesions of the lung tissue. Aneurysm and Pulsating Local Pleurisy: The latter are usually situated low down, and are increased by deep expiration. The absence of murmur, pressure symptoms, change in the pulse and distal vessel mur- murs will serve to differentiate pulsating pleurisy from aneurysm. Peripleuritic abscesses have in com- mon with pleurisy the same physical signs, save that there are no signs of compressed lung, friction sounds or displaced organs. Note. — Pulsating pleurisy is rare and is practically always due to pus formation. — Editor. Subphrenic Abscess: The edge of the lung moves. When the trocar is introduced the inspirations ac- celerate the flow, while expiration retards it, which is opposite to the condition found in pleural exudate. Enlarged Liver or Spleen: The displacement is usu- ally downward. Hccmothorax: History of the injury, aneurysm or gangrene and symptoms of exsanguination. The only way to definitely determine this is by puncture, which must be repeated several times if blood is obtained, as the needle may enter a vessel in the pleura or lung and pure blood be withdrawn. ' If blood-tinged fluid is withdrawn, as occurs in hsemorrhagic diathesis, tu- berculosis or cancer, this does not indicate hsemo- thorax in the true sense, as the fluid is blood, mixed with serum. 128 NOTES ON PHYSICAL DIAGNOSIS Hydrothorax: The fluid in this condition is much more readily movable, and is usually associated with heart, kidney or liver disease or with cachexia. The other signs are the same as for any fluid in the pleural cavity. Having demonstrated the presence of the exudate, it is now necessary to find out its character, whether serous, purulent, bloody or decomposed. The general symptoms, history and course of the case are, as a rule, reliable indices. The puncture is the only sure means, and in the case of pus several must be made if fluid is not obtained with the first punc- ture. When pus is suspected, the puncture must be made low down, as the cellular elements sink and leave the upper fluid only turbid. Bacteria in the so- called idiopathic variety of pleurisy are undoubtedly of tuberculous origin; pneumococci, staphylococci, streptococci and tubercle bacilli have been found on the pleura without suppuration. Later, however, these favorable conditions may develop and pus ap- pear. Pleurisy in rare cases may be associated with rheumatism, and the typhoid bacillus has been found in some cases. Their mode of entrance into the pleura is not known. The cause of pleurisy must now be determined. AVe have primary and secondary pleurisy, the first being more apparent than actual. Rheumatic pleuris}^ (Fielder) in which the pleurisy is the first manifestation, the joint affections, endo- carditis, etc., following it. Some cases of apparent primary pleurisy with a sudden onset, high fever, herpes, etc., may be classed as secondary to a focal lobar pneumonia. Blows on the chest cause an area of decreased resistance and a field for in- DISEASES OF THE PLEURA AND LUNGS 129 fection. Cold acts in the same way by reducing the resistance. 7/ie great majority of primary pleurisies, if not all, are due to the tubercle bacillus from small tuberculous nodes at the apex extend- ing to the pleura, or to bursting of small tuberculous brojichial glands. At times the onset simulates a latent tuberculous affection. The following facts go to prove the above : Pleurisy in those with hereditary taint; history of former tuberculous disease in some part of the body; tuberculous glands, etc., found post mortem ; tuberculosis developing later in life ; tuber- culosis produced in animals by inoculation. Secondary pleurisy is usually due to extension from the neighboring structure, as the lung, thoracic wall, spine, neck, abdominal viscera, heart or mediastinum. A second class is that form introduced by the blood, either by diminished resistance from nephritis, gout, sepsis, syphilis, chronic diseases in the chest, as aneu- rysm, tumors, etc. Pneinnothorax : May come on suddenly with dysp- noea and cyanosis, or there may be no such manifes- tations, the condition coming on with no distress. Unilateral pneumothorax is one of the easiest condi- tions of the thorax to diagnose. The diseased side is enlarged. The intercostal spaces bulge* and neigh- boring organs are displaced to the opposite side. The patient lies on the diseased side and breathes rapidly, and the fremitus and voice are weak or absent. The percussion note varies with the ten- sion of the air in the cavity, the presence or ab- sence of fistulae and fluid. Above the flu'' a nor- * See note, page 29. I30 NOTES ON PHYSICAL DIAGNOSIS mal note is obtained or hyperresonance. (Skodaic resonance or Flint vesiculo-tympanitic note.) If the air is under tension, a tympanitic or metallic tone can be obtained, the latter best by auscul- tating with the ear, and striking a pleximeter with a hard substance. If fistulae be present, the cracked pot note and the change of note on opening and closing the mouth are obtainable (Wintrich's note). These latter two signs are best demonstrated in those cases where a large cavity has ruptured and connects with a large bronchus. The change of note on respiration is present, i.e., a higher and fuller note on deep inspiration than expiration. A satisfactory explanation has not been given for this. Biermer's sign, where the tone is deep on standing, high on ly- ing down, is present, and this change of note is par- ticularly noticeable when a metallic tone is present. This is due to the fluid pushing down the diaphragm in the sitting position and thus enlarging the cavity. Auscultation gives the most pregnant results for diagnosis. The breath sounds (tubular breathing due to the compressed lung), voice and mucous rales have a metallic quahty. When the fluid drops from the lung or thoracic wall, striking the surface of the fluid, the " falling drop " (metallic tinkle) sound is heard. In rare cases the heart sounds have a metallic tone. Succussion is an absolutely diagnostic sign of pneumothorax or large cavities in the chest. "^ Differential Diagnosis: A marked left-sided con- tracting fibrosis of the lung may draw the diaphragm and stomach well up into the thorax, giving over the * See page 50. DISEASES OF THE PLEURA AND LUNGS 131 lower portion of the thorax absence of breath sounds, tympanitic percussion and succussion. In these cases the affected side is not enlarged, but rather con- tracted, and the succussion comes with gastric as well as with respiratory motion; on washing out the stom- ach the succussion disappears. Diaphragmatic hernia, where the stomach and co- lon pass into the thorax, gives the signs of pneumo- thorax. Here the metallic notes are more dependent on the peristaltic movements than on the respira- tory and by washing out the stomach the succussion is lost. A pyopneumothorax hypophrenicus is an accu- mulation of gas and pus between the liver and the diaphragm on the right side, due to the rupture of some intestinal viscus. A similar condition can occur on the left side from the perforation of a gastric ulcer. Previous gastric or duodenal ulcers, typhoid, peri- tonitis, appendicitis, abscess of the liver and spleen, peri-nephritic abscess, tuberculous cavities at the base of the lung and trauma are some of the eti- ologic factors which, according to Leyden, are aids in the diagnosis of this condition. The signs are marked downward displacement of the liver, with slight displacement of the heart and lung edge, and an absence of bulging interspaces. The presence of vesicular breathing to the edge of the dulness or tympany. On puncture the needle is depressed on inspiration, and the fluid is under greater tension than on expiration, due to the movements of the diaphragm. Sacculated pneumothorax, as compared to a large 13 2 NOTES ON PHYSICAL DIAGNOSIS cavity, is rare, so cavity should first be considered by the chnician. All the symptoms of general pneumo- thorax fail over the sacculated area save succussion, and this latter is almost never heard in cavities. Fremitus and voice sign and changes of note on open- ing and closing the mouth, sinking of the interspaces, together with change of the signs after expectoration, suggest cavity. All the other signs of cavity may be present in local pneumothorax, especially if there be an opening in the lung. There is nothing significant in the location of a cavity, as pneumothorax may be at the apex, due to some small tuberculous cavity rupturing, and cavities, the result of gangrene and abscess, etc., may be found at the base. TJie Diagnosis of Special Forms of Pnciiinothorax: Having demonstrated that pneumothorax is present, the next step is to determine its kind. This is im- portant for the therapy and prognosis. We have to distinguish between : Closed. Fistulous (i.e., the air entering and passing out of the cavity on inspiration and expiration). Valve fistula: {i.e., the air entering on inspiration, but not passing out on expiration). Change of note on opening and closing the mouth points toward the closed variety. Large gurgles (if the opening is below the line of the fluid) and the ex- pectoration of serous pus on the patient assuming certain positions point towards the fistulous variety. This last, however, may be absent when most ex- pected. According to Weil, the displacement of the heart and diaphragm in open pneumothorax is pres- DISEASES OF THE PLEURA AND LUNGS i33 ent, but not to so great an extent as in the closed va- riety. This displacement in the open variety is due to the lost negative pressure on the affected side. Testing the gas pressure by the trochar and mano- meter shows a higher pressure in the closed than in the open variety. According to Ewald, CO2 below 5 per cent, points towards the open form, above 10 per cent, to the closed. This last is neither prac- tical nor reliable. If an opening in the thorax exist, one can tell if there is a hole in the lung by asking the patient to take a deep breath while closing the ex- ternal w^ound with the finger, and on removal of the latter there should be, if a fistula in the lung be pres- ent, no inrush of air. In the closed form the displace- ment of the organs is greater, and the affected side is greatly enlarged. A distinct fistulous murmur is ab- sent, though metallic rales and breath sounds may come from the retracted lung. The change of note on percussion in changing the position of the patient is present, but the change on opening and closing the mouth is absent. With an increase in the tension of the gas the fremitus is greatly diminished. Ventile pneumothorax is a valve-like fistula that allows air to enter but not to leave a cavity. Here the signs soon change to the closed form, with a greatly distended thorax, that is increased by the exudations of fluid. Absence of expectoration of the exudates is to be expected. The Etiological Diagnosis: Nine-tenths of the cases are due to pulmonary tuberculosis, with a small cav- ity rupturing before adhesions have formed. Other causes of cavity lead to it, such as bronchiectasis. 134 NOTES ON PHYSICAL DIAGNOSIS gangrene, cavity, foreign bodies lodged in the lung, bursting of emphysematous alveoli on straining. Rupture of the intestines or stomach from ulceration may cause pneumothorax, although here it is apt to produce a hypophrenic pyopneumothorax. Lastly, according to Levy, a gas producing bacterium in the pleural exudate may produce pneumothorax. Note. — It must never be forgotten that an inexpert use of the aspirator in removing fluid from the plural cavity may produce pneumo- thorax. This is a serious and unpardonable accident. — Editor. Neoplasms of the Pleura. Primary are diagnosed with great dii^culty. Aside from the general manifestations of cancer or sar- coma, the signs may be those of pleural effusions, thick pleura, or mediastinal tumor. The puncture reveals a bloody or dark fluid with altered cells, blood, fat, and perhaps pieces of tumor either stuck to the needle or floating in the exudate. If the costal pleura is involved, a long needle is needed as short ones give negative results. The affected side may bulge or re- tract, as the case may be. The diagnosis must be made on the cachexia, metastases, glandular swell- ings, and perhaps the growth of the tumor externally. EcHiNococcus OF Pleura. This gives signs of pleural exudate with a displace- ment of the organs, etc., and no fever. The diagnosis is made by puncture, the aspirated fluid being free from albumin and containing hooks and bladders. DISEASES OF THE PLEURA AND LUNGS 13 5 If the cysts suppurate the hooks alone differentiate the condition from empyema. Diseases of the Trachea. Local diseases of the trachea are rare when not combined with diseases of the larynx on the one hand, or of the bronchi on the other. The organ can best be investigated with the laryngoscope. Diseases of Bronchi and Lungs. Bronchial Stenosis: Is usually an easy diagnosis to make if the larger bronchi are involved. Dyspnoea is the most marked characteristic symptom, and the degree of the same is dependent on the rapidity of the onset of the stenosis. The pic- ture differs according to the position of the stenosis, whether the lesion is above or below the bifurcation. The stenosis of the finer bronchi is not included under this head, as the symptoms are dift'erent, as seen in capillary bronchitis and asthma. The symptoms are dyspnoea, cyanosis and those of irrita- tion of the vasomotor centers by CO2. The pulse is slow and full, and the tension is high and shows on the sphygmographic tracing marked variations of the respiratory blood pressure. In some cases a distinct pulsus inspiratorius intermittens can be seen. The prolonged phases of the difficult breathing retard the venous flow and diminish the respiratory acceleration of the blood in the pulmonar}^ vessels, thus leading to venous congestion, dilatation of the right heart, swelling of the liver and a decrease in the quantity of 136 NOTES ON PHYSICAL DIAGNOSIS urine. The type of respiration is that of inspira- tory dyspnoea, the auxihary muscles of respiration standing out distinctly. The number of respira- tions is decreased as air enters the lung slowly, and the expiratory stimuli are delayed in reaching the brain center. As there is a decreased quantity of air inflating the lung, the movements of their borders are distinctly Hmited. With the increase of the negative pressure within the thorax on inspiration there is a marked sinking of the supraclavicular fossae, the free edges of the ribs and the epigastrium. The above symptoms indicate that there is an obstruction of the air passages that causes difficulty in inspiration. On percussion one finds no change of note over both lungs. This throws out all those conditions causing dyspnoea from obliteration of alveoli by infiltration, transudation, exudation of the lung tissue, or destruc- tion of lung tissue by gangrene, abscess, tumors, com- pression of the lung as from pleural exudates, trans- udates, tumors, and air. By the auscultation signs cardiac dyspnoea can be excluded. The vesicular breathing is markedly di- minished and also the voice and fremitus. These facts, taken in conjunction with a normal percussion note, are characteristic. Besides these a whistling or rasp- ing stenotic murmur can be heard even some dis- tance from the chest. Now that the diagnosis has been made of stenosis of the upper air passages, we must determine where it is situated and what the cause is. Laryngeal Stenosis: The head is thrown back and the thyroid cartilage moves up and down with inspira- DISEASES OF THE PLEURA AND LUNGS i37 tion and expiration. A loud stenotic murmur is heard over the larynx. Laryngoscopic examination reveals a lesion such as croup, oedema, a foreign body, etc. Do not forget that a bronchial stenosis may be associated with this condition. Tracheal or Bronchial Stenosis: The head is stretched forward and the thyroid cartilage moves little. Nega- tive result on laryngoscopic examination. Due to the lack of sufficient air passing to the lung, the in- spiratory retractions are more or less marked. The symptoms vary accordingly as the stenosis is above or below the bifurcation. Where one large bronchus is stenosed, the corresponding half of the thorax does not expand, while the other half has excessive ex- pansion and the lungs become overinflated. The diaphragm is pushed down and the lung edges are lower than normal and nearby organs are covered. On the diseased side the percussion is resonant. Fre- mitus, voice and the respiratory murmur are de- creased, and a stenotic murmur can be heard and felt. Weakness of voice or the presence or absence of voice indicates little. Having located the lesion, now de- termine its cause. Conditions External to the Bronchi: Struma is the most frequent cause and especially the post-sternal variety. Tumors of the oesophagus com.e next. Never introduce a sound in attempting to diagnose this con- dition, as when one gets tracheal stenosis there is apt to be some oesophageal stenosis and the results are misleading and the procedure is attended with great danger to the patient. Aneurysm comes next, and can usually be diagnosed. Aneurysm may cause 138 NOTES ON PHYSICAL DIAGNOSIS not only tracheal but also bronchial stenosis. Medi- astinal and lung tumors have produced the con- dition as also enlarged bronchial glands, especially when tuberculosis of the lung is present. Peri- cardial exudates and enlarged left auricle have been known to cause bronchial stenosis. Caries and ab- scess of the spine are also causative factors. Condi- tions zvithin the bronchi. In bronchitis fibrinosa, as a rule, one gets an expectoration of casts, etc. Inflam- matory thickening of the bronchial wall in bronchitis is rare, and is probably diagnosed by exclusion only. Tumors of the bronchial wall are considered in the same hght as the last named. A diagnosis of carci- noma of the walls is made where there is bloody ex~ pectoration, no fever, unaccountable cachexia and a swelling of the glands in the neck and axilla. Acute oedema after inhalation of steam or flame. Syphilitic stenosis is usually at or near the bifurcation, and one has bloody sHmy sputum and other signs of syphilis. Ulcers of the larynx. After a tracheotom.y the forma- tion of granulation tissue in the small trachea of a child may also lead to stenosis. In foreign bodies the history helps, and the fact that changes of position alter the symptoms. Do not forget that a body can pass to the bronchi and cause no symptoms at the time, but may later, wath an inflammatory reaction at the point of lodgment set up a stenosis. Hysterical stenosis is due to a spasm of the tracheal or bronchial muscles. Catarrhal Bronchitis: The swelling of the bronchial mucous membrane and the secretions from the same give signs that may be palpated and auscultated. DISEASES OF THE PLEURA AND LUNGS i39 There is no change of percussion note in uncompli- cated cases. The larger the bronchi involved, the less the signs and symptoms and the smaller the more marked. Catarrh of the large tubes gives cough together with palpable and audible rales of large size, which latter depend for their size and quality on the quantity and character of the secretion. As the other smaller bronchi are affected, one gets fine mucous rales. The size, character, etc., is dependent on their location and the character of the secretion. The respiratory murmur is changed, in that it is harsher and expiration is prolonged. This is due to the stenosis of the medium-sized bronchi through swelling, secretions and perhaps spasm. On the plugging of a bronchus the voice, fremitus and mur- mur may be absent, but all may return after cough- ing. Sudden attacks of slight dyspnoea may be due to the latter. When stenosis of the bronchi exists expiratory effort and coughing cause retardation of the venous emptying, to which is added the slight de- crease in the excursion of the lung. This all tends to dilate the right heart, swell the liver, diminish the urine and produce cyanosis. However, these symp- toms are slight and never so great as in emphysema. We get emphysema and peribronchial induration of the lung in all cases of chronic bronchitis. Chronic bronchitis differs from the acute only in the history, sequels and a tendency to involve the finer bronchi. The etiological factors are inhalations, gas, intoxica- tion, infection, alcohol, etc. Constitutional diseases, as nephritis and congestion (cardiac). Putrid Bronchitis: Is a rare disease. The general I40 XOTES OX PHYSICAL DIAGXOSIS signs are those of chronic bronchitis with a foul spu- tum. This sputum differs in no way from that of bronchiectasis, and at times it is impossible to dis- tinguish the conditions from one another. Only signs of cavity and the characteristic periodic expec- toration of large quantities of sputum serve to dis- tinguish bronchiectasis. Gangrene of the Lung: Unless elastic fibres be found, the diagnosis is difficult, and only when cavity signs appear can a conclusion be drawn. Local em- ph3'sema may give the same kind of sputum and dif- ferential diagnosis from the last two diseases is especially difficult. Only by change of sign on ex- pectoration and the distinct purulent character of the sputum is the diagnosis possible. In all these condi- tions the history and the other symptoms must be resorted to. Capillary Bronchitis: Is chiefly found in children, and is characterized by dyspnoea due to the occlu- sion of the finer bronchi, is not at all relieved by coughing, and is attended by slight expectoration. With the difficult breathing, venous stasis, COo poi- soning, etc., appear. Aside from the cyanosis, etc., the most striking feature is the sinking in of the epi- gastrium and the hypochondrium, due to the difficulty with which the air enters the alveoli on inspiration. The upper smaller bronchi, not being so much in- volved and the air passing through them readily, the violent inspiratory act distends the alveoli in this part of the lung. Due to the plugging of many fine bronchi, the voice is decreased. There is no change of the percussion note, unless atelectasis or pneu- DISEASES OF THE PLEURA AND LUNGS 141 monia is present. In atelectasis, by placing the pa- tient on the side opposite to the dulness after cough- ing and deep breathing, the dulness passes away. In early bronchopneumonia there are no signs, save the increase of fever and the constitutional symptoms. Only later do signs of infiltration become distinct. Miliary Tuberculosis: The signs and the picture may be the same, however the location of the rales at the apex, rather than at the base, the history, severity of the constitutional symptoms and large spleen, and the choroidal tuberculosis, all point to the latter dis- ease. The physical signs are auscultatory. The breathing is vesicular, but with prolonged, harsh ex- piration. Below and behind fine mucous rales are heard differing from the crepitant in that they come both in inspiration and in expiration and that they are variable with coughing, breathing, etc., and have no constant character. The cough is marked at first, but in weak children or in old people it may be absent. The expectoration is absent or very slight. When it is coughed up and put in water, the mucous from the large tubes floats on top and from these fine strings come down which examined under the microscope show^ a central fibre with a corkscrew arrangement of material about it. The whole thing is made up of mucus (Hoffmann) due to the mucus being com- pressed in the fine tubes by coughing. The spiral ar- rangement may be due to twists in the tubes. These are not characteristic at all, as they are found in bron- chitis fibrinosa, asthma, and in lung infiltrations. Fibrinous Bronchitis: The diagnosis is made on get- ting casts that are made up of fibrin in layers with 142 NOTES ON PHYSICAL DIAGNOSIS cells in them and some blood. When they form m large branches they give signs of bronchial stenosis and occlusion which is relieved on expectoration of the casts and returns with the formation of new ones. Etiological factors help little. It is found in diph- theria, pneumonia, scarlet fever, and in tuberculosis. It is supposed to be a staphylococcus infection of the bronchi. Bronchiectasis : The characteristic symptom is the periodic expectoration of large quantities of sputum, while between times there is little or no cough or ex- pectoration. This is due to the diseased enlarged bronchial wall having little excitability. It is only when the secretion overflows or by position of patient flows on the normal mucous membrane, that a stimu- lus is given and an attack of coughing induced which lasts till the cavity is emptied. The sputum contains elastic and fibrous tissue and pus cells. Blood cells, "hsematoidin and Charcot crystals may also be found. The sputum, when allowed to stand in a glass, sepa- rates into three layers and contains pyogenic organ- isms. It is a septic condition, hence the fever. The sign of cavity may or may not be present. The presence of the signs depends upon whether the cavity is full or not. If the cavity is near to the surface and surrounded by a thick wall, the changes from the signs of consolidation to those of cavity after expectoration are very characteris- tic. Constant large mucous rales located at one spot near the edges or the base of the lungs are strong evidence in favor of bronchiectasis (Sahli). In the area of large cavities, the excursion of the lung is de- DISEASES OF THE PLEURA AND LUNGS i43 creased and the chest may be sunken. As the bron- chiectatic cavities are met with in tuberculosis, the faihire of finding tubercle bacilli in the sputum after many examinations and the other symptoms point to bronchiectasis. If the cavities are at the apex the ex- pectoration is not so periodic, and the elastic fibres are in the sputum in great numbers, and the diagno- sis of tuberculosis should be made. Don't forget that bronchial cavities are met with at the apex. Hyper- trophy of the right heart, etc., helps little, as this is often seen in tuberculosis. It is almost impossible to make a dift"erential diagnosis from a sacculated empyema that has ruptured into a bronchus. All the physical signs are alike, and the periodic expectora- tion of material is the same. The presence of large numbers of haematoidin and cholesterin crystals points towards empyema, as these form after the process has lain dormant for some time. The history of the sudden expectoration of pus helps, and if it breaks through the chest wall, even then the diagnosis is not certain, as cavities in the lung may do the same. In gangrene of the lung the process is quicker, the spu- tum has a peculiar odor, and the elastic fibres retain their alveolar structure. More difficult and almost impossible is a diagnosis from putrid chronic bron- chitis with a diffuse uniform enlargement of the tubes. Complications, as joint affections, brain abscesses; etc., are hard to ascribe to the lung condition, but must be kept in mind. Brain abscess following bron- chiectasis is very frequent, especially where the bron- chial glands suppurate. Aside from the sHght blood- streaked expectoration, profuse hemorrhage may oc- 144 NOTES ON PHYSICAL DIAGNOSIS cur, and in this connection tuberculosis must be kept in mind. Bronchial Asthma : Only zvJien tJie astJinia is due to nervous conditions, and there is no pathological change in tJie body, aside from the nervous system, is the condition considered one of true bronchial asthma. The symptoms are simple. The attacks of expiratory dyspnoea with utilization of the expiratory muscles and the slowing of respiration, together with signs of stasis and cyanosis. With the stenosis of the finer bronchi there is an acute distension of the lungs, espe- pecially of the upper portion. This can be shown by the deep position of the lung edges, and the oblitera- tion of the cardiac flatness. The excursions of the lung are diminished, and on percussion a box tone note is obtained over the whole of the thorax. On auscultation the vesicular breathing is decreased in intensity, but is harsh in quality with a prolongation of expiration, all being due to the fact that little air circulates in the lung, and what does, has to pass the stenosed bronchi, and is under higher pressure dur- ing expiration than normally. Whistling, sibilant and sonorous rales are heard. Few mucous rales are heard. The above applies only to the attack. To- ward the close of the attack there are many mucous rales of all sizes, etc. This is due to an acute con- gestion of the mucous membrane of the bronchi from some vasomotor disturbance (Stoerk). During the attack the pulse is small and of a high tension (CO2 poison). The heart tones are faint from the cover- ing of the lung, etc. The differential diagnosis: The expiratory dyspnoea throws out all those conditions DISEASES OF THE PLEURA AND LUNGS i45 causing inspiratory dyspnoea, as stenosis of the larynx, trachea, and the larger bronchi. Emphysema and chronic bronchitis have expiratory dyspnoea. In the two last-named conditions there is a distinct patho- logical change present which gives signs between at- tacks. Asthma being a pure neurosis, gives no signs between the attacks, the lungs being normal. How- ever, at times there are acute asthmatic attacks in these conditions that can be ascribed to no increase in the secretion or swelHng of the mucous membrane. In these conditions we have to deal with a spasm of the bronchioles brought on by some reflex condition, as gastric irritation, cold air on the back, accumula- tion of Curschmann's spirals or Charcot's crystals supposed to cause spasm of the smaller air passages. The spirals and crystals are found also in other con- ditions, but not in such numbers as in asthma. They are numerous during the attack of asthma, but in ex- ceptional cases may be absent. That they have noth- ing to do with the attack is shown by the fact that they may be found in great number in the sputum of asthmatics between the attacks. Schmidt found small fibrous plugs in asthmatic sputum that differed from the spirals in that they are made up of fibrin and not of mucus. Spasm of the glottis gives in- spiratory dyspnoea, moving of the larynx, no acute distension of the lung, sinking of the epigastrium on inspiration and an attack of short character, while the asthmatic attack lasts two or three hours at least. Cramp of the diaphragm is inspiratory, and all the inspiratory muscles are involved. The abdomen is protruded, and after a few seconds there is a forced 146 NOTES ON PHYSICAL DIAGNOSIS inspiration, and the attack passes off. Etiological diagnosis : If the lungs are free between the attacks, then all conditions (emphysema, chronic bronchitis) can be excluded as causes. The upper air passages must be examined for polypi, etc. If nothing is found here, the abdominal organs must be examined, as worms, diseases of the uterus, stomach, etc., may pro- duce asthmatic attacks. Asthmatic attacks come in some women during menstruation. All those things that cause cardiac asthma must be thrown out, as lead poisoning, distended stomach, nephritis. Per- sonal idiosyncrasy to odors must be ruled out. Le- sions of the vagus nerve, as pressure from lymph glands or struma in the neck, etc., chronic diseases as malaria, arthritis, anaemia and infectious diseases must be considered. Atelectasis: Where air is not in the alveoli, and the walls lie against each other, there is a decrease of the functionating space and dyspnoea and cyanosis result. The edges of the lung are normal, and the retraction is made up by a compensating emphysema. If an area more than five centimeters is involved, a dull note may, by light percussion, be obtained which is at times hyperresonant. If the compression is com- plete there is bronchial voice and breathing. The crepitant rales over the area are characteristic, and show that the part can expand. With a deep nega- tive pressure in the thorax, there is decreased ex- pansion of the chest, also of the lung. Blood is not pumped into the right heart, and the decreased move- ment of the lung does not draw it from the right ventricle. The left auricle does not dilate, and so one DISEASES OF THE PEEURA AND LUNGS i47 gets a venous and pulmonary congestion and low arterial pressure. Dilatation of the right heart is dis- tinctly made out as the lung edges are retracted. The diagnosis is made by noting the cause of the atelectasis, and by the absence of general symptoms which accompany other pulmonary affections. Etio- logical diagnosis: Exclusion of that variety found in the new born due to a lack of power to expand the lungs or to plugging of the bronchus with mucus or meconium. Atelectasis is secondary to other condi- tions, such as those which decrease the negative pressure in the thorax or compress the lungs, such as enlarged heart, aneurysm, tumors of the medi- astinum and pleura, exudates of air or fluid in the thorax, spinal curvatures, pressure upward of dia- phragm, from enlarged liver, spleen, ascites, gas, tu- mors, etc. The condition may arise from decreased expansions of the lung in very weak people or those lying on one side for a long time, also in capillary bronchitis of children and in typhoid, where the bronchi are plugged with mucus. Never make the diagnosis of atelectasis unless you have a cause. Pleural exudates have no increase in voice or fre- mitus. Pneumonia is more lasting and constant, and gives a bloody sputum and fever. By changing the position of the patient and having him breathe deeply the signs of consolidation change to normal if atelec- tasis is present. Local atelectasis must be diagnosed with care. Only when conditions for the production of atelectasis are present and continued crepitant rales are heard should the diagnosis be made. Hypostasis: As in atelectasis the mechanical role 148 NOTES ON PHYSICAL DIAGNOSIS plays a large part in this condition. The lowest point of the lung is the seat of the lesion, but the position of the patient greatly influences the location of the stasis. Besides the collapse of the lung, we have an exudation of serum and blood cells due to the weak- ness of the heart, associated with superficial breath- ing. The conditions that favor the last are weakness from age, infectious diseases, especially typhoid and cachexia. All those conditions that decrease the size of the lungs, thus slowing the blood flow through the same, favor this condition, as ascites, meteorism, tu- mors, shallow breathing and large liver. The latter produces right-sided atelectasis. Usually, however, it is on both sides. The symptoms are dyspnoea, small pulse, dilated right heart, venous congestion and cyanosis (symptoms which go with many conditions, but in this condition are important). The early physi- cal signs, i.e., before all the air is out of the lung, are hyperresonance or dulness, feeble breath sounds and rales. Later when the air is all out the signs are those of complete consolidation. If the process goes on to inflammation, of a catarrhal or loose fibrinous pneumonic type, fever develops (if not already pres- ent from the original disease), and there is blood in the sputum. The last may be due to a bronchitis causing hypostasis. If the sputum is frothy and se- rous there may be many moist rales at the base to- gether with oedema. Hemorrhagic infarct is usually unilateral, and not so extensive, and there is marked heart weakness or a cardiac lesion present. Emphysema : Chronic lasting dilatation of the alve- olar wall with loss of elasticity and rupture of the DISEASES OF THE PLEURA AND LUNGS i49 same, with fatty degeneration and obliteration of the capillaries and increase in the size of the lung and dis- placement and covering of organs by the same. Ex- piration is due to the faUing and sinking of the thorax by its weight and elasticity and the elastic traction of the lungs. In emphysema this is changed, and w^e have an expiratory effort or expiratory dyspnoea. In- spiration suffers first, as the lungs do not go to full expiration, and as the act is delayed, the reflex stimu- lus to the inspiratory centre is delayed. The chest, lungs, etc., are in the inspiratory position, and the ribs, cartilages and ligaments get stiiT and bony. In emphysema the lung is larger than normal, and oxygen in greater quantity is required to keep this residual air in a proper condition. Dyspnoea there- fore results. The above all cause a forcible inspiration by means of the accessory muscles. The diaphragm being flattened, does not rise on expiration or sink on inspiration, and is greatly hindered in its function. The abdominal type of respiration is lost, and one gets pure costal breathing. In this forced expiration in or- der to push up the diaphragm and to pull down the thorax, the spine is bent forward and may become fixed in that position. The vital capacity is reduced to I, GOO cc. and under. The frequency of respiration is increased, and one gets asthmatic attacks if there is constriction of the bronchi. In coughing the lungs go in the direction of least resistance over the heart and through the opening over the clavicles, which bulge. Physical Findings: The chest may be normal in shape, in the early stages, and if there is no cough, or I50 NOTES ON PHYSICAL DIAGNOSIS if the disease sets in after anchylosis of the cartilages, ligaments, etc., has taken place, the chest may be broad transversely, but more frequently antero-pos- teriorly. Due to the forced expiration and cough, the lower part is constricted and the upper part bulged, as the air is forced up to that part, it being more yielding than the lower. Fremitus may be nor- mal if the thorax is not too stiff and bronchitis is not present. Percussion: A hyperresonant note due to the re- laxed lung tissue is obtained. The edges of the lung are lower than normal, even extending to the first or second lumbar vertebra. The lung moves lit- tle on deep inspiration. The liver is depressed, the spleen likewise. (May be enlarged from congestion.) The spleen is not palpable, as it is not depressed by the immovable diaphragm. The upper dulness is lower than normal. Auscultation: The breathing sounds are less in- tense, expiration is prolonged, and, if bronchitis is present, harsh breathing and mucous rales are heard. Circulatory Disturbances: These are not the least important. B}^ the decreased elasticity of the lung and the diminished excursion of the thorax and lung, there is less elastic pull on the left auricle, and the blood is not drawn out of the lung capillaries in in- spiration. On expiration there is less negative press- ure in the thorax, so that the blood does not flow from the lung into the auricle, which is compressed. Numbers of capillaries in the lung are destroyed or narrowed, and the lung does not expand enough to draw blood from the right ventricle, so that there DISEASES OF THE PLEURA AND LUNGS 151 is not only hypertrophy of the ventricle from the first cause, but also dilatation from the second. As the lungs do not move and expiration is prolonged and forced, the blood is not only not drawn into the tho- rax as normally, but is retarded greatly by expira- tion, which latter condition is ag'g^ravated by the coughing. So we have a retardation of the blood flow through the systemic veins, a high blood pressure in the pulmonary arteries, and a low one in the pul- monary veins. The systolic emptying of the left ventricle is aided by the normal expiration, and re- tarded by forced expiration. All these go to decrease the flow of blood into the aorta, and thus lessen the blood pressure. It is at times impossible to demon- strate a right heart enlargement, as the heart is not only covered by the lung, but by the low position of the diaphragm, the base of the heart is displaced downward and backward, and the apex outward. The apex cannot be seen or felt, and percussion gives a smaller heart flatness than normal. If one gets a normal-sized area of flatness in emphysema, a large heart is suggested. Marked epigastric pulsation can be felt and seen due to the low position of the dia- phragm, and a hypertrophied right ventricle. A sys- tolic retraction of the epigastrium can be seen due to atmospheric pressure. The auscultatory signs of the heart vary usually, in that the first sound at the apex is faint due to the covering of the lung. It may be reduplicated or sharp from myocarditis. The sec- ond pulmonic sound is accentuated, but may be nor- mal due to the lung covering. The aortic is weak or absent. Murmurs are usually heard which are acci- 152 NOTES ON PHYSICAL DIAGNOSIS dental. If relative tricuspid insufficiency is present, one gets a venous pulse, etc. Signs of venous stasis, cyanosis, and oedema follow. The bronchitis grows worse with the weakness of the heart, as the bron- chial veins are congested. Cough and expectoration increase, and if blood be present in the latter, tuber- culosis and emboli are to be thought of. Differential Diagnosis: The form of thorax, char- acter of breathing, revelations of percussion, such as character of note, size of lungs, diminished excursion and absence of heart flatness, together with an en- larged right heart and signs of blood stasis with an accentuated pulmonic second sound, together with a displaced liver and spleen, are all characteristic features. Acute distension of the alveoli in asthmatic and capillary bronchitic conditions may be difficult to detect, where no history is obtainable. The lungs in these conditions are never greatly en- larged, and as soon as the acute symptoms subside return to their normal size and mobility. Pneu- mothorax has in common only the feeble voice and fremitus and the loud percussion note. All the other symptoms are different. \A'ith pulmo excessi- vus, where the lungs are very large, one gets the same percussion note as in emphysema, and enlargement of the lung with absence of heart flatness. However, the lung edge has normal excursion, and there is no weakness of voice, fremitus and breath sound, and the pulmonic second sound is not accentuated, or the right heart enlarged. Brown Induration : In mitral disease and idiopathic hypertrophy with left heart failure, the diagnosis is far from easy. In em- DISEASES OF THE PLEURA AND LUNGS i53 physema the characteristic form of the chest may be absent and marked signs of venous congestion with heart murmurs be present, while in heart dis- ease, the lungs may be enlarged and the bronchi- tis may be marked. Hydrothorax may be present and interferes with the marking out of the lungs, and hydropericardium may be mistaken for a large heart. The change of position of patient does not indicate hydrothorax, as the fluid may not change, due to adhesions, and the lung may from com- pression be unable to inflate. Heart disease and emphysema in some cases are associated. Tubercu- losis and emphysema are not infrequent. Early stages of emphysema are hard to diagnose, but with the slight increase in the size of the lung with the distinct decrease in mobility and the other symptoms a probable diagnosis can be made. Vicarious Emphysema is where the air does not enter one portion of the lung, the normal portion be- ing distended, not only by inspiration, but by expira- tion, coughing and straining. It is seen in pleural ex- udates, fibrosis, scoliosis, and in lung retractions after pleurisy. The diagnosis is based on the etiological factor. The sound lung is larger than normal and extends over on to the diseased side. If a part of the lung is fibrous, the normal part can distend so that the edges of the diseased lung are normal in size. Senile Emphysema is an atrophy of the alveolar wall with no distension. The lungs are not enlarged and the edges are movable. The heart is not cov- ered. The sides of the chest are flattened. Dyspnoea 154 NOTES ON PHYSICAL DIAGNOSIS is present, due to the decrease in the alveolar surface and the destruction of the capillaries. Therefore there is venous stasis. The heart is not enlargfed to the right as this organ takes part in the general atrophy. There is nothing common between the two conditions, save the dyspnoea and cyanosis. Interlobular Emphysema has more pathological than clinical interest, due to the marked coughing and straining. Siihpleiiral and mediastinal Emphysema is air in the skin of the neck, back and chest wall. Replacement of the heart flatness with a sonorous note that is distinguishable from pneumopericardium in that it does not vary on changes of position. This is due to the air in the anterior mediastinum. One gets crepitant rales with the heart movements and ab- sence of cardiac pulsation. There is resonance to the edges of the ribs with an absence of breath sounds. Attacks of suffocation and distension of the veins in the neck occur. CEdema of the Lungs may usually be readily diag- nosed. In extreme cases the lung may be so com- pletely infiltrated with serum that one gets all the signs of consolidation, but this is very rare. Usually there is no change in the percussion note from the normal, unless the interalveolar tissue is infiltrated with serum, when we get a hyperresonant note. By auscultation many very moist rales are heard of varying sizes but always having a fluid character. The sputum is usually copious, foam-like and tinged with blood, especially in pneumonias, where it is brown in color, coming as it does from the deeper DISEASES OF THE PLEURA AND LUNGS i55 parts of the lung. The above makes the diagnosis sure, unless the condition is very small and local, or if in those unable to expectorate. In this case the tracheal rattle or the retained sputum masks the finer auscultatory signs. To find out the cause of the oedema is the chief point in the diagnosis, as the oedema is but a result of some other condition. There are two forms of oedema, the inflammatory and the passive congestive. In the first, there is an inflammation of the alveolar wall, intense enough to cause extravasation of serum, but not of cells. This condition is seen outside of the areas of true con- solidation in pneumonia. Is also seen where the whole lung is involved without any true cellular in- filtration. This may be due to the fact that the pa- tient dies at an early period of exudation, when the serum has come out, but the cells have not started to infiltrate. According to Sahli, the inflammatory character of the oedema is to be met with more fre- quently than is thought. The signs in this form are those of oedema with some signs of true inflamma- tion scattered about or of a primary true pneumonia. The passive congestive form has been worked out by Welch and Cohnheim. Paresis of the left ventricle may occur, which causes a backing of the blood into the lungs, while the right ventricle keeps up its con- tractions. The cause is still the same, but in these cases the heart may have been doing more work than normally during the patient's life, such as we see in interstitial nephritis or arteriosclerosis. When this excessive function fails a damming back of the blood immediatelv occurs, and a continuance of the 156 NOTES ON PHYSICAL DIAGNOSIS right heart action with oedema. Lack of oxygen has the effect of inhibiting the function of the left heart as compared with the right. The reason that this condition does not happen more often in vakailar disease of the heart is that the right heart fails as well as the left and there is no high tension in the pulmonary vessels. In resistance to the pulmonary circulation, the right heart overcomes this and the left heart throws the proper amount of blood into the arteries. In these cases not the left but the right heart fails, and oedema results. Spasm of the heart as in angina pectoris can produce c^edema in the same way, as the spasm involves the left heart more than the right (Grossmann). The essential conditions for the production of oedema of this sort is the failure of the left heart to throw out the proper amount of blood into the arteries, together with the strong contraction of the right ventricle. Lobar pneumonia is usually an easy diagnosis when signs of infiltration are prominent. It is only when the infiltration is local or small in extent that the diagnosis is difficult. The most important symp- tom is the rust-colored sputum, and only in ex- tremely rare cases does the expectoration fail. The sputum is tough, sticking to the cup, trans- parent; blood is mixed with it and the color is yellow or brown red. When put in water branched coagulse of the finer bronchi may be seen, later when resolu- tion sets in the sputum is yellow and in delayed crisis green with abundance of pus cells. With in- flammatory oedema it is foamy and prune colored. With gangrene, it has the characteristic odor. Mi- DISEASES OF THE PLEURA AND LUNGS i57 croscopically it is made up of altered red cells, mucous bodies and white cells, epithelium and micro- organisms. Friedlander's bacillus is met with only exceptionally. Fraenkel's is by far the commoner organism in pneumonia. The bacteria are most viru- lent when taken from the lung at the time of great- est inflammatory reaction. In the cases of marked toxemia it has been found in the blood. Fraenkel's bacillus can migrate to other organs than the lung in pneumonia. It is also found in other organs in other diseases than pneumonia. The streptococcus, usually of the broncho-pneumonic type, can cause a lobar pneumonia. In this type of pneumonia the resolution is markedly delayed. There are numbers of mixed infections. When the sputum is typical, there can be no doubt as to the diagnosis, though all physical signs fail. However, the signs usually ap- pear early, and often on the first day. AMien the signs are indistinct, the consolidation being very small and central, the area can be discovered only by a slight increase of voice or dulness as compared with the corresponding sound side. The voice change is the earliest, as the diminished breath sounds described by some are not constant. Usu- ally this first change in voice is heard directly in the axilla or over the scapula. Percussion in the stage of engorgement and resolution gives hyperreson- ance. Over the consolidation one gets dulness, but never so intense as that obtained over fluid. Usually this is sharply limited to the area involved. The cracked-pot note has been obtained and if the apex is consolidated Williams' tracheal note. 158 NOTES ON PHYSICAL DIAGNOSIS with the change on opening and closing the mouth, can be demonstrated. When the lower left lobe is involved, one gets the tympany of the stomach, but the half moon space is never obliterated as in pleural exudate, the solid lung not passing into the comple- mental space. Inspection gives increased breathing and expansion of the sound side. There is dimin- ished expansion on the involved side early if pleurisy is present.^ The involved half of the chest is larger than the other, but never so great as that seen in pleural exudate. Palpaticn gives increased fremitus, if consolidation is present and lies close to the chest wall. It is not obtained in very large infiltration where the chest is too distended to vibrate; also if the large bronchi are plugged with mucus. Auscultation gives bronchial voice over the con- solidation and aegophony if the consolidation is very great and the bronchi are compressed, the vibration passing through the compressed and filled bronchi irregularly. Crepitant rales are heard at the early stage till consolidation sets in. They come at the end of inspiration and are rarely if ever heard on expiration. In the latter case, pleuritic rales and fine bronchial rales must not be overlooked. Mu- cous rales in the bronchi of the consolidated area may have a "metallic timbre." The general symptoms are ushered in by a marked chill, sometimes several slight chills, rarely no chills, save in old people. Pain in the side if pleurisy is present,"^ pain in the abdomen and along the attach- * Primary pleurisy is rarely complicated with pneumonia. Pneu- monia practically never occurs without pleurisy. — Editor. DISEASES OF THE PLEURA AXD LUXGS i S9 ments of the diaphragm. In this latter case no physical signs are present at all. Breathing is rapid and rises above the pulse rate showing that it is not due to the temperature alone. It is always above 30 and can go as high as 100. (Gerhardt.) The temperature rises to or above 104 degrees Fahr. very quickly. It may fall on the first or second day, but this is very rare ; usually it lasts a week. Just before the crisis, one may have a fall of temperature ( pseudo crisis) followed by a rise, or the temperature may rise very high with no pseudo crisis before the fall. After the fall there may be a subnormal temperature for awhile. The intermittent height of fever in pneu- monia is seen when new areas are suddenly involved or the disease is complicaetd with malaria. Old people often have no fever. The pulse is usually full, strong and fast and with cardiac failure becomes more accelerated and irregu- lar. Heart weakness and collapse is seen after the crisis. Cough is superficial and restrained, i.e., short cough raises little but sounds very loose. In old people it may be absent. The face at first shows the flush of fever, followed by cyanosis and herpes labialis, which is very fre- quent. Jaundice is a frequent symptom, and all cases with this color of the skin and high fever should have the lungs examined for pneumonia. The spleen is enlarged but is hard to palpate, es- pecially if the left side is involved, as the diaphragm does not descend. Percussion is very untrustworthy. The enlargement of the spleen is greater after the crisis, and this may be due to its function of accu- i6o NOTES ON PHYSICAL DIAGNOSIS mulation of waste material. This post critical swell- ing is greater the earlier the crisis. The urine shows changes due to the fever, but al- buminous urine is more constant than in any other infectious disease and at times the degeneration of the kidneys passes on to an acute nephritis with marked albuminuria, blood cells and kidney epithe- lium, which nephritis may last for months after the acute disease. During the height of the fever there is an increase in the albumpse due to the destruc- tion of the nuclei of the leucocytes and a decrease in the chlorides, which latter reappear as soon as the inflammatory symptoms have subsided. The ex- cretion of urates is increased throughout but especi- ally at the time of the crisis. This latter may have some relation to the diaphoresis that takes place at the time and the destruction of the nuclei. There is a distinct increase in the urea during resolution and for one or two days the urine may be alkaline (Pick). Albuminuria may be due to cardiac weak- ness. The blood shows an acute leucocytosis more than in any other disease. The destruction of the red cells varies with the intensity of the inflammation. Pneumococci may be found in the blood. As a rule the diagnosis is easy. Those cases in which the signs are late in appearing, and expectora- tion is absent, or an associated condition is present, as delirium tremens, are less readily diagnosed. In old people, cough, high fever and chill may be ab- sent, but usually the physical signs are distinctive. The abortive form (Kiihn) in epidemics with all DISEASES OF THE PLEURA AND LUNGS i6i symptoms of pneumonia and no signs and of short duration may occur. These sometimes have purely cerebral symptoms. They should be diagnosed as pneumonia only with caution and after every cause has been excluded and an epidemic is present. Differential Diagnosis: In pneumonia, the true signs of consolidation are distinct and the dulness is less intense than in pleurisy with effusion. In the latter the signs of consolidation are greatest above the fluid and diminish as one passes into the dullest area below. With a pneumonia of the upper part of the lower lobe and with some oedema or infiltration below, one gets the same signs as in pleurisy with effusion, save that the rales are heard below, whereas in pleurisy with effusion they are at the upper part of the dulness. The termination of the two condi- tions is distinctive. Infarct may begin with a chill and fever. In this case the signs are the same; the sputum is more intimately mixed with blood and there is a cause present. The fever is not t3^pical, if present at all. CEdema is difficult to differentiate, especially the inflammatory variety, besides, the two conditions frequently exist side by side. The onset, exciting cause, heart action and the foamy sputum, together with the diffuseness and bilateral distribu- tion, point to oedema. A true serous pneimionia oc- curs which is discussed under oedema. Tuberculosis of the rapidly advancing pneumonic variety simulates the acute pneumonia. The sputum is not the same and the tubercle bacilli are present, and the his- tory aids one. However, an acute pneumonia added to a tuberculous process ma}^ mask the latter, and i62 NOTES ON PHYSICAL DIAGNOSIS only after studying the cause of the disease is a diagnosis possible. Catarrhal Pneumonia: The diagnosis is made on the symptoms, cause and history, rather than on the physical signs, save that the negative results of the latter, together with the symptoms, etc., re- ferrable to an acute pulmonary condition are of value. The disease is caused by the extension of a bronchitis (either direct or by aspiration) to the alveoh, the diplococcus of Fraenkel usually being the excitant. Atelectasis plays an important part in that it prepares the way for the extension. Chil- dren with their small bronchi (which readily become plugged), delicate mucous membranes and suscep- tible alveoH, taken together with their inability to expectorate, are prone to the disease. In the old, the conditions are not the same, but here there is not only lack of power to expectorate, but also a diminished excitability of the bronchial mucous membrane with an absence of cough stimulation. Also these people have an atrophic mucous mem- brane with a loss of the ciliated epithelium which normally sweep the secretions out of the small bronchi. All these factors favor infective material passing to the alveoli and producing pneumonia. (N.B. — x\trophy of the muscle tissue of the bronchial wall may here be a factor). Aspiration pneumonia, and infectious bronchial catarrh are the most fre- quent causes, such as accompany influenza, measles, whooping cough, diphtheria, scarlet and typhoid. Differential Diagnosis: Croupous pneumonia has a sudden onset, usually unilateral and local; is not apt DISEASES OF THE PLEURA AND LUXGS 163 to be preceded by an infectious bronchitis and comes in active adults. The sputum is often absent in bronchopneumonia, but when present is usually puru- lent. Exceptions to these are frequent. ^^'ith absence of signs save fine mucous rales, broncho-pneumonia is impossible to differentiate from acute miliary tuberculosis. The location of the signs at an apex and the finding of the bacilli may help, but both conditions are more often absent. Choroid tuberculosis points toward general tubercu- lous infection. Atelectasis : The signs change or dis- appear on alteration of the patients' position and there usually is no fever. Interstitial Pneumonia: Usually follows a chronic inflammatory process or is the result of a reparative process following acute inflammation or destruction of lung tissue. It is seen after chronic bronchitis, pleurisy of gangrenous or caseous processes after lobar or catarrhal pneumonia, and where the alveolar wall is thickened. As a sequence to syphilis and to the inhalation of coal, stone or iron dust, etc. In making a diagnosis the aetiology must be taken into account. The signs vary with the extent of the pro- cess. On inspection one sees a retraction and immobil- ity of a part or whole of one side of the thorax. The ribs lie close together, the spine is curved to- ward the diseased side, the shoulder is lower, and the scapula, although closer to the spine, flares out- ward. The respiratory movements are decreased and the involved half has a smaller measurement than the sound. The capacity of the lungs is de- 1 64 NOTES ON PHYSICAL DIAGNOSIS creased. In contractions of the left lung, the apex of the heart is displaced to the left and upward, due to the negative pressure or traction. The pulsation in the cardiac area is greater, as the lung is retracted. Just outside of the pulmonic area a systolic pulsa- tion can be seen and felt at times; also a diastolic shock of the pulmonic second sound, which is ac- centuated in this condition. In the rig*ht sided con- tractions the picture is different. The heart is dis- placed to the right and by vicarious emphysema of the left lung the heart flatness is absent. The dis- placed abdominal organs and the movements of the lateral halves of the diaphragm must be observed. Percussion: If the lesion is at the upper part of the lung, the apex is lower than normal and the signs of phthisical or bronchiectatic cavities may be pres- ent. If the lesion involves the lower part of the lung, the lower border is higher than normal, carry- ing with it in its upward retraction the diaphragm and the abdominal organs, unless the pleura is ad- herent or there is a marked decrease in the expansion of that side of the thorax. By vicarious emphysema (the middle lobes being the seat of the lesion) the edge of the lung may be as low as normal, but have decreased excursion. The uninvolved lung may be so emphysematous that it reaches over into the in- volved half of the thorax, and if movable this linear movement on the anterior edge can be demonstrated by percussion. This is especially noticeable in left sided contractions. Auscultation: One gets bronchial voice and fre- mitus, bronchial breathing and ringing rales. If cav- DISEASES OF THE PLEURA AND LUNGS 165 ities be present, all the characteristic signs are ob- tained. Over other parts of the lung one gets signs of emphysema. The sputum may contain the exciting dust par- ticles. If bronchiectatic cavities be present, the char- acteristic periodic expectoration and the signs are present. Blood is usually absent. When present, tuberculosis should be suspected. Circulatory dis- turbances are due to the destruction of the lung tis- sue, and the decreased expansion of the lung with consequent right heart dilatation and venous conges- tion. Chronic Pulmonary Phthisis: This is a destructive disease of the lung with progressive characteristics, as apical catarrh, tuberculous granulations, tubercu- lous peri-bronchitis, cheesy bronchopneumonia, and finally cavity formation. All these pathological changes may be traced clinically in their develop- ment. The presence of the tubercle bacillus indicates the chronicity or subacuteness of the process. The Diagnostic Value of the Tubercle Bacillus: In most of the cases it is easy to find. In early stages or in the fibroid stage, they may be absent or only found after twenty or thirty examinations. The num- ber has no relation whatever as to the extent of the process. Physical signs can alone tell this, and also give an idea where and in what stage the process is. It must be remembered that tubercle bacilli may be in the sputum of a patient with tuberculosis of the nose, etc. An absolute diagnosis cannot be made unless the bacilli are found. The smegma bacillus (decolorized with alcoholic methylene blue) 1 66 NOTES ON PHYSICAL DIAGNOSIS and the lepra bacillus (not transmissible to animals) are morphologically and in their staining qualities similar — the latter is identical in these respects to the tubercle bacillus. The mixed infections, such as streptococci, staphylococci and diplococci add greatly to the symptoms and the gravity of the prognosis. The use of tuberculin causing an active reaction of the tuberculous process locally with general manifes- tations, also is a dangerous practice."^ It is by no means sure, as many tuberculous processes give no reaction whatever. Diagnosis of tlie First Stage: The disease is intro- duced in conditions of weakness, anaemia, diabetes, poor nourishment either from poor food or blood or from gastroenteritis. Follows inflammatory diseases of the bronchi or lung tissue, but rarel;y, if ever, fol- lows lobar pneumonia. The apex of the lung is the most frequent site of the lesion, and this is due (ac- cording to Hanan) to the act of coughing, which drives the infection up into the apex or back from the bronchi, t The first sign is rales, indicating a local catarrh at the apex. All other signs may be absent. One usually has slight dulness, also above the clav- icle, and the bacilli may be found in the sputum. In percussion of the apex, the difference in note of the two sides should not be taken into account, as this difference is frequently met with in normal individ- uals, and especially in emphysema. Only distinct * At Saranac Dr. Trudeau uses this method for diagnostic pur- poses and reports no ill results. It should not be employed, however, by those unfam'liar with the method and proper usage. — Editor. \ That it is an area of respiratory inactivity is another explanation. — Editor. DISEASES OF THE PLEURA AXD LUXGS 167 changes in the note with marked differences in the height of the apex above the clavicle, together with auscultatory changes should be recognized. The breathing is diminished. These may be cogwheel or prolonged expiration, with a sharp or rough vesicular murmur. Undetermined breath sounds together with fine mucous or medium-sized mucous or crepitant rales may be present. Hemorrhage precedes the tuberculous lesion only in those cases where it is induced by trauma, the blow causing the hemor- rhage, and the blood acting as a culture medium for other bacteria which set up an inflammation, thus predisposing this part of the lung to tuberculous in- fection. This is extremely rare. Usually the hemor- rhage comes from a small process in the smallest bronchi, where the wall is involved. The hemor- rhage occurs in people apparently normal, and is fol- lowed by a rapid increase of the signs. This increase, in the extent of the process after the hemorrhage, is particularly noticeable when the process has extended to small cavity formations, and the contents of the same mixed with blood is aspirated into great areas of the lung. This is followed by a difluse acute pro- cess with death in two or three weeks (Baeumler). Such hemorrhages follow straining, and the signs at first are crepitant rales, high fever and a tympanitic note. This differs from miliary tuberculosis in that the course is more rapid, blood and tubercle bacilli are found in the sputum and signs of consolidation set in early. AA'ith all the above symptoms fever is present. It is rarely absent in tuberculosis. A high fever indicates a rapid process or an extension, com- plication, etc. 1 68 NOTES ON PHYSICAL DIAGNOSIS The diagnosis is supported by .the family history, weakness, etc., the shape of the chest, the poor con- dition and the weak muscles, the presence of tuber- cular glands, bones, joints, or anal fistulse. Combinations of Tuberculosis and Pleurisy: Fre- quently the pulmonary tuberculous process is intro- duced by pleurisy. The pleurisy is really a manifesta- tion of the tuberculous process in the lung, which later develops rapidly after the pleurisy is cured, or during the acute stage. Frequently a patient who has a latent tuberculous process becomes ill through the addition of pleurisy, and the process is discovered. Pleurisy that is primary usually involves the sound side, and the coughing, etc., together with the run- down condition of the patient, predisposed to the in- fection of the good lung. The tubercle bacilli in the sputum may be found in cases that give no physical signs. Diagnosis of tlie Second Stage: ■ This is character- ized by peribronchitis and cheesy pneumonia. This stage is usually combined with that of the third stage. At times the patient dies before softening of or dis- charge from the area, and the lung gives a picture of true broncho-pneumonia. A ver}^ rapid process with cavity formation is met with and is called pJitJiisis Uorida. At times every change can be found in the same lung, even to fibrous formations. Percussion gives marked dulness from the apex downward together with bronchial voice and fremi- tus, mucous rales and bronchial breathing. Usually these signs are most marked at the apex and decrease DISEASES OF THE PLEURA AXD LUXGS 169 as one descends. In those cases of gelatinous cheesy broncho-pneumonia (of A. Fraenkel and Troje) the material is aspirated into the lower part of the lung. In these cases one gets signs most distinct at the bases AA'ith remittent fever, prostration, green or bloody sputum with very few tubercle bacilli. If the connective tissue process predominates, we then get retraction or diminshed expansion over the involved area, the lowering of one shoulder and all the other signs of interstitial pneumonia. Other symptoms referable to the lung are systolic murmurs over the subclavians due to narrowing of the vessel produced by the shrunken apex, paralysis of the right recurrent laryngeal nerve from the same cause and the eye changes due to involvement of the third cervical ganglion. The left laryngeal nerve is involved when the bronchial glands are enlarged. Pleuritic rubs are heard very often and may be followed by an effusion. The skin may show pityriasis or lichen, and there may be cyanosis, right heart complications, night sweats, etc. The fever is variable, and follows no constant rule. Some cases have no fever, while others have a constant high temperature. The heart is usually not enlarged, as it adapts itself to the decreased amount of blood in the system, besides, no hypertrophy is apt to set in on account of the lowered vitality of the organ- ism. Xow and then cases are met with which show distinct right heart dilatation and hypertrophy, with accentuation of the pulmonic second sound. In marked fibrous conditions the heart is displaced and congestion of organs may be shown by enlarged liver and spleen. These latter organs can enlarge of them- lyo NOTES ON PHYSICAL DIAGNOSIS selves (as fatty liver and hypoplastic spleen). The urine is decreased from the congestion and changes within the kidneys. The sputum in the third stage is profuse, muco-purulent with alveolar cells and bac- teria of all kinds together with the tubercle bacilli. If a gelatinous pneumonia be present, one gets a greenish sputum or a sputum similar to that of lobar pneumonia. Diagnosis of the Third Stage: This stage is charac- terized by softening of the consolidated areas and their exudate leaving cavities. The sputum be- comes tough and heavy (sinking in water) and not frothy. This is due to the fact that it lies in the cavi- ties and becomes concentrated and then is expelled direct, with no chance of mixing with air. It contains many elastic fibres. Blood in the sputum may appear in streaks or in large quantity. This may be due to the process involving the blood vessels in the lung or to rupture of an aneurysm. Death may follow a profuse hemorrhage from a large cavity. Bacteria and tubercle bacilli are found in great numbers. Aside from the general symptoms and the above, the physical signs give definite data if the cavity is acces- sible, i.e., not deep-seated or hidden by consolidations. Percussion: Tympany at the apex above or below the clavicle indicates cavity. The cavity must not he smaller tJian a zcalniit, lie close to the thorax or be sep- arated from it by consolidated tissue, and the walls must be in a condition to vibrate to give this sign. The distinctness of the tympany is dependent on the quantity of air within the cavity, z.e., there must not be too much secretion. In large cavities Wintrich's sign DISEASES OF THE PLEURA AND LUNGS 171 can be obtained, i.e., a high note results on percuss- ing over the cavity with the mouth open, and a low one with the mouth closed, Avhile the patient stops breathing. Gerhardt's sign is also present, z.r., change of note in placing the patient on the back from the upright position. The so-called interrupted Wint- rich's sign is that which can be obtained in the upright position and not in the dorsal or vice versa. All these percussion phenomena can be obtained in other con- ditions of the lung. To be mentioned is Friedrich's sign, i.e., a slight change of note on inspiration and expiration. Leube states that when the above phe- nomena are definitely obtained they indicate cavities. If Wintrich's sign is absent, Rumfe's inspiratory change of note may be obtained, i.e., after two or three deep respirations, a final inspiration is taken and the mouth and nose of the patient closed. Then opening the mouth and protruding the tongue gives a change of note. The cracked-pot note is often obtained in normal people with thin chest walls while they speak. It is obtained over cavities which lie close to the chest wall and communicate with a bronchus. A metallic overtone lasting longer than the dull ground tone is obtained over large cavities with smooth, uniformly thickened walls which are in a condition to refiect the sound wave. This can only be heard at times by auscultating when one percusses with a hard substance. The opening to the bronchus must not be too large, and by opening the mouth the sound can be heard more distinctly. It is ob- tained frequently in pneumothorax. Auscultation: With the above conditions present, 172 NOTES ON PHYSICAL DIAGNOSIS a metallic tone is added to the breath sound (amphoric breathing). The voice may be amphoric and mucous rales have a metalHc character. Falling drop or me- tallic tinkle due to mucous rales may be obtained. Pneumothorax can give all the signs of cavity, espe- cially if local. Usually in cavity the intercostal spaces are sunken and the fremitus and voice are increased. In local pneumothorax the opposite is true. Cracked- pot and other percussion signs are not so frequently met with in the latter condition. Pneumothorax is not often mistaken for cavity, as succussion rarely if ever occurs in cavity. Other symptoms as weak- ness and emaciation are increased. However, there are exceptions, as well nourished patients may have marked changes in the lung. The urine, aside from tuberculosis of the kidneys, etc., shows changes of degeneration or nephritis. The presence of the diazo reaction indicates a rapidly progressive process, and is a bad prognostic sign. Acute miliary tuberculosis may appear at any time. Note. — Tubercle bacilli from the lung of miliary tuberculosis are often not found, and this failure to find the organisms constitutes one of the most confusing negative findings in a disease which is frequently- confounded with typhoid fever and sepsis— i5"(-/zV^r. EMBOLUS OF THE PULMONARY ARTERY. HEMORRHAGIC INFARCT. Their origin is thrombi on the tricuspid valv€ from endocarditis or more often from thrombi formed in a dilated and weakened right auricle or ventricle as a consequence of obstructive pulmonar}^ DISEASES OF THE PLEURA AND LUNGS i73 conditions, as emphysema, etc., or to mitral disease. It also results from left heart failure or even from right heart failure in myocardial degeneration. Un- less an origin can be found for the embolus, the diagnosis should be made with care. The closure of one of the large pulmonary branches or the pul- monary artery itself, leads to sudden death. The blood cannot pass to the left heart, so the arterial supply is cut off. The right heart cannot empty it- self, and therefore dilates, causing venous conges- tion. There is loss of consciousness, marked dysp- noea, and collapse. A paralysis of the heart may lead to the same symptoms and cases have been di- agnosed which at autopsy showed no signs of em- bolus. Dyspnoea is dependent on the size of the ves- sel obstructed and usually does not last long, as the organism soon accommodates itself to the condition. A chill is always present and fever if the embolus is infected in which case a pleurisy is set up and can even lead to abscess formation. The physical signs are those of brondio-pneumonia, located in the lower part of the lungs or along the spine. The sputum is usually bloody and other conditions, such as tuber- culosis, fibrinous bronchitis, purpura, and tumor of the lung must be excluded. In very rare cases, where the embolus has not completely closed the artery, a systolic thrill can be felt and a murmur heard over the area of embolism. Unless the etio- logical factor can be found, the diagnosis should not be made. There are some conditions, such as anas- tomosis of the pulmonary and bronchial vessels, where the embolus causes no infarct. If the emboli 174 NOTES ON PHYSICAL DIAGNOSIS are infected, numbers of small metastatic abscesses are formed which produce no physical signs. If the embolus is large, a pulmonary abscess may form. The diagnosis must not be made till the etiological factor is discovered. Pulmonary Abscess. Usually follows septic emboli, alcohoHc lobar- pneumonia, inhalation broncho-pneumonia. It may also follow any pulmonary inflammation and is a frequent sequel of influenza pneumonia. The etio- logical factor is of the greatest importance and only when the symptoms are distinct can the diagnosis be made with ease. The sputum is usually made up of pure pus. After standing in a glass, the upper layer is clear, or turbid, and is composed of serous material, while the lower is made up of pus cells, elastic fibres in alveolar arrangement, fat cells and cholesterin and hsemotoidin crystals, besides bacteria of all kinds. After the discharge of the abscess the typical signs of cavity are present, which gradually disappear if the process heals. The case usually runs a septic temperature with chills. The differential diagnosis is to be made between the above condition, local empyema with rupture into the lung, tuberculous bronchiectatic cav- erns and pulmonary gangrene. The local empyema, whether from spinal, mediastinal or subphrenic ab- scesses, can be diagnosed by the fact that at no time of the disease can pulmonary tissue and structure be found in the sputum. In addition the local mani- festations of these conditions may aid. The phthisi- ■ DISEASES OF THE PLEURA AND LUNGS iJS cal cavity does not furnish the same quantity of elas- tic fibres as- the abscess and the sputum is not so purulent or abundant. Tubercle bacilli are found in the sputum of all such cavities. The etiological fac- tors and history aid in the diagnosis. Tuberculous conditions may be present elsewhere. The site does not help, as abscess may form at the apex and a tuberculous cavity may occur in the lower lobes. More difficult is the diagnosis of bronchiectatic cavities. However, the sputum here is of a putrid odor, not so purulent, and contains few, if any, elas- tic fibres, and never an alveolar arrangement. In pulmonary gangrene, the elastic fibres are absent, due to their being digested by some peptic ferment. Only in gangrene following abscess are they found. The foul odor, dirty color, the Ditrich's plugs, lep- tothrix, coloring blue with iodine, and the cause of the disease, all are distinctive of the process. Pulmonary Gangrene. The diagnosis is easy, as the symptoms are char- acteristic. The sputum has a penetrative, sweetish, foul odor, which is most marked at the time of ex- pectoration. Long standing specimens lose their odor. The sputum is made up of the following: It is a thin fluid of a dirty green gray or brown color with more or less altered blood mixed with it. On standing, it separates, according to Traube, into three layers: the upper the foam, the middle clear, and the lower the sediment, made up of fat, fatty acid crystals, debris and fibres that show the arrange- ment of the alveoh. Elastic fibres are absent, due 176 NOTES ON PHYSICAL DIAGNOSIS to the action of a ferment that destroys them (Filehne). If found it means that part of the lung tissue which has not undergone gangrene has been torn off. The smell of the breath is more apt to mis- lead one as there are so many conditions giving a foul breath. Other things are the bacterial fungus of Ditrich, the leptothrix of Leyden and Jaffe, the micrococcus of Hirschler and Terny; these have all been described as the specific cause of the gangrene. The chemical examination of the sputum shows fatty acids, ammonias, phenol, indol, skatol, etc. The general symptoms are those of fever, loss of strength and gastroenteric disturbances. Only the physical signs together with the sputum give an idea of the condition present. The physical signs are those of consolidation, soon followed (in a day or two) by signs of cavity. In the diffuse type the signs are more those of a rap- idly advancing infiltration, while in the local the cavity formation and the signs of such predominate. The differential diagnosis from putrid bronchitis and bronchiectasis may be difficult so long as the lung structure is absent from the sputum of gangrene. The physical signs are not so local or distinctive in the first two named conditions, besides it must be kept in mind that these conditions may cause gan- grene at any time. Only by observing the case and taking into consideration the etiological factors of gangrene such as pneumonia, septic or decomposed emboli, diabetes, etc., can a diagnosis be made. Note. — The odor of the sputum in BroncJdectasis (multiple abscesses), Abscess and Gafigrene is a striking characteristic. In DISEASES OF THE PLEURA AND LUNGS i77 bronchiectasis tlie offensiveness is so great that the sufferer is a source of annoyance to himself as well as to those in the same room and some- times in a large ward. It is among the rare conditions in which the patient is conscious of an odor produced in his own body. As an example of the opposite of this may be mentioned the offensive breath, often causing great embarrassment to the sufferer, from post-nasal catarrh and defective teeth dui not noticeable to the patient himself . — Editor. Pulmonary Syphilis. Only a probable diagnosis can be made in the cases of undoubted syphilis that have a contracting process of the lung tissue with dyspnoea and signs of bron- chial stenosis due to gumma formation and diffuse interstitial pulmonitis. The absence of the tubercle bacilH and the arrest of the process on antisyphilitic treatment aid the diagnosis. Tumors of the Lung. The small mediary tumors are impossible to diag- nose. Primary cancer of the lung, if of miliary infil- tration variety, gives few signs. The large local ones give signs of consolidation. The diagnosis is to be made on obtaining tumor masses in the sputum or after puncture. Echinococcus cysts give signs of consolidation, and are to be diagnosed only after finding booklets in the sputum or after puncture. A cyst of the liver may extend to the lung. ^Actinomycosis of the lung may cause fibrinous con- solidation or cavities. The diagnosis is to be made on obtaining the organism in the sputum or the pleu- ral fluid. (James Israel.) Note i. — Rupture of an amoebic abscess from the liver into the lung gives prune-juice colored sputum which contains the amoeba^ There are 12 1 78 NOTES ON PHYSICAL DIAGNOSIS not pulmonary signs but a history of dysentery, and the amoeba in the sputum is conclusive evidence. — Editor, Note 2. — Enlarged bronchial and peri-bronchial glands (mediasti- num) from tuberculosis and other infections together with tumors of the mediastinum constitute one of the most obscure conditions in the thorax. Tuberculosis especially may have its chief seat here and yet yield pul- monary symptoms, as haemoptysis, expectoration and cough without any signs. The sputum too may or may not contain tubercle bacilli. — Editor. AUG 25 1905.