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 RC76.3 .C97 Percussion outlin 
 
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 ''UTLER AND GARLAND 
 
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 PERCUSSION OUTLINES. 
 
 BY 
 
 E. G. CUTLER, M. D. 
 
 ASSISTANT IS PATHOLOGICAL ANATOMY, HARVARD MEDICAL SCHOOL j VISITING PHTSICIAN 
 
 TO THE CARNEY HOSPITAL; PHYSICIAN TO OUT-PATIENTS, MASSACHUSETTS 
 
 GENERAL HOSPITAL; PATHOLOGIST TO THE CITY HOSPITAL, 
 
 G. M. GARLAXD, M. D. 
 
 ASSISTANT IN CLINICAL MEDICINE, HARVARD MEDICAL SCHOOL; PROFESSOR OF THORACIC! 
 
 DISEASES, UNIVERSITY OF VERMONT ; VISITING PHYSICIAN TO THE CARNEY 
 
 HOSPITAL; PHYSICIAN TO THE BOSTON DISPENSARY. 
 
 BOSTON: 
 HOUGHTON, MIFFLIN AND COMPANY, 
 
 11 BAST si:yknti;i:\tii BTBKBT, m:w voiuC 
 
 CIjc lUbcrs'tttc g)rtM, Cimbrrtrcjr. 
 
 1882. 
 
Copyright, 1882, 
 By E. G. CUTLER and G. M. GARLAND 
 
 The Riverside Press, Cambridge : 
 Stereotyped and Printed by II. 0. Houghton & Co 
 
PKEFACE. 
 
 This book is intended to teach students the ana- 
 tomical position of the thoracic and abdominal viscera 
 in the living subject, and to portray such boundaries of 
 those organs as are accessible to percussion. The al- 
 most daily necessity in every physician's practice for de- 
 termining the position and size of some concealed organ 
 will, we trust, prepare a cordial welcome for our book 
 from those who prefer well-defined knowledge to un- 
 certain guess-work. We have devoted our attention 
 mainly to the normal condition, and what we say re- 
 garding pathological phenomena is intended rather as a 
 guide to the proper methods for detecting abnormal 
 deviations than as a full description of the same. With 
 regard to the preparation of the book we will add that 
 it is essentially a condensed abstract of the German lit- 
 erature upon this subject, as contributed by Weil, Fer- 
 ber, Luschka, and Gerhardt. We have, however, re- 
 peatedly and carefully reviewed, in our own practice and 
 at the autopsy table, the points which we present, and 
 have convinced ourselves that they are correct. 
 
CONTENTS. 
 
 MM 
 
 CHAPTER L 
 Method in Pebcussion 1 
 
 CHAPTER n. 
 The Sxebndm, Diaphragm, and Pleuba 8 
 
 CHAPTER HI. 
 Thb Lungs 14 
 
 CHAPTER IV. 
 The Heabt and the Pebicabdidm 30 
 
 CHAPTER V. 
 The Liveb 41 
 
 CHAPTER VI. 
 The Spleen 46 
 
 CHAPTER VH. 
 The Stomach 54 
 
 CHAPTER VHL 
 The Kidneys 58 
 
 CHAPTER LX. 
 The Bladdeb .' . 60 
 
 CHAPTER X. 
 The Utbbus 62 
 
 CHAPTER XL 
 The Pebitonbum 04 
 
PERCUSSION OUTLINES. 
 
 CHAPTER I. 
 
 METHOD IN PERCUSSION. 
 
 TriE first essential to intelligent percussion is a cor- 
 rect method. Much has been written about pleximeters 
 of varied form and size — about hammers of different 
 weight and material, but the secret of successful per- 
 cussion lies in little details of method rather than in 
 the fibre of any instrument. According to our own 
 opinion the best pleximeter and hammer are the human 
 finger. It is always available. It is never forgotten or 
 lost. As a pleximeter it furnishes a wide scope in size, 
 from its tip to its entire palmar surface, and it need 
 never frighten the most timid child. It affords the best 
 and most instantaneous information regarding the re- 
 sistance of the parts percussed. The skillful use of the 
 fingers is somewhat more difficult to acquire than that 
 of a pleximeter and hammer, but any one who can per- 
 cuss well with the fingers can also do well with instru- 
 ments, although the reverse of this proposition is by no 
 means true. 
 
 It is a matter of choice whether one or more fingers 
 be used on each hand. We always employ the last 
 phalanx of the middle finger of the left hand as the 
 pleximeter, while the other fingers are raised from the 
 chest, so as not to interfere with the sound vibrations. 
 l 
 
2 PERCUSSION OUTLINES. 
 
 The rounded end of the middle finger of the right hand 
 forms our hammer, and we strike the pleximeter just 
 behind the nail in such a manner that the hammer nail 
 shall not touch the skin of the underlying finger — that 
 is, we strike with that fleshy part of the finger where the 
 distal surface curves into the palmar. 
 
 The pleximeter should be applied firmly with sufficient 
 pressure to prevent the slipping about of the soft parts 
 when the blow is given ; and this pressure should be 
 uniform for the two sides of the chest. What is of 
 still more importance, the percussion blows should be 
 given with uniform force, especially when comparing op- 
 posite sides of the chest. We have seen students un- 
 able to demonstrate the most striking differences of 
 percussion tones simply because they delivered their 
 blows with constantly varying force. The relative mer- 
 its of light and heavy percussion will be discussed later, 
 but whether light or heavy, the blows must be uni- 
 form. 
 
 Again, in comparing two sides of a chest, one should 
 always percuss symmetrical spots. If the pleximeter 
 finger be laid upon a rib on the one side, it should not be 
 transposed to an intercostal space On the other, but 
 should be placed on the symmetrical point of the com- 
 panion rib. 
 
 Taking into careful account the correct use of the 
 hands, attention should next be turned to the position 
 of the patient. If the subject of percussion be a man, 
 he should be exposed to the skin, due regard being paid 
 to the temperature of the room. Our rule is as fol- 
 lows : We tell a patient to strip to the waist and then 
 to put on his coat. This leaves the front of the body 
 bare and easily accessible. When we reach the axillary 
 region one arm can be slipped out of its sleeve, and 
 while the back is examined the coat can be put on in the 
 
METHOD IN PERCUSSION. 3 
 
 reversed position. A similar amount of exposure is not 
 usually advisable with women, but the judicious combi- 
 nation of a thin undershirt and a shawl, or an unstarched 
 dressing-sack alone, will allow ample scope for a skillful 
 percussor. The patient should be told to sit quietly and 
 naturally, with the chest muscles relaxed. Most men, 
 when stripped and approached for percussion, will throw 
 back their shoulders and protrude their chest as if on 
 dress parade. The muscular tension thus produced will 
 always modify the sounds from the organs beneath. 
 The two sides of the body should be held symmetrically, 
 and the face should be directed straight forward, in order 
 that the sounds of the apices may not be obscured by 
 tension of the overlying muscles. It is immaterial 
 whether the hands hang at the side or are placed on 
 top of the head. Hanging at the side, the arms are 
 out of the way, except during percussion of the axillary 
 regions. A slight withdrawal of the arm backward, how- 
 ever, will give access to the anterior part of the axillary 
 region, while a similar slight advance of the arm will 
 expose the posterior part of the same space. If one 
 hand is placed upon the head, which is on some accounts 
 the raosl convenient position during pei'cussion of the 
 lower border of the lung, it should be remembered that 
 such elevation of the arm carries the skin and ribs a 
 trifle upward, and an allowance must be made fortius 
 deflection in the subsequent record of the border ob- 
 tained. 
 
 Patients should not stand during percussion. They 
 should be allowed to sit on ;i stool or on a chair without 
 arms. If they are too weak to sit up and we are obliged 
 to pei'CU88 them in bed, we should be careful to note that 
 the body is straight, and that the shoulders are squarely 
 placed and not twisted out >A' symmetry by underlying 
 bolsters or pillows. Reference should also be made to 
 
4 PERCUSSION OUTLINES. 
 
 the fact that the position of the internal organs varies with 
 changes in the position of the body, a point which will 
 be treated of later under the head of the passive mo- 
 bility of the percussion boundaries. 
 
 Examination of the abdomen is best made with the 
 subject lying upon the back, with the head slightly raised 
 and the knees drawn up, so as to relax the abdominal 
 wall. To expose the spleen, the subject should lie upon 
 the right side, or half way between the right lateral and 
 the prone position. 
 
 Having thus discussed the preliminary stages of our 
 task, we will now describe the manner in which an inter- 
 nal organ may be outlined. It will be learned later that 
 only a small portion of all the anatomical borders are 
 accessible to percussion. Piorry, in the enthusiasm of a 
 new study, claimed that every organ of the body emits a 
 sound peculiar to, and distinctive of, itself. If this were 
 true, all the internal organs might be mapped out with an- 
 atomical nicety. Skoda was the first to vigorously attack 
 this idea. He maintained that aerated organs are resonant 
 by reason of the contained air. Those organs which con- 
 tain no air are simply non-resonant, and the sounds which 
 they emit when struck are indistinguishable from each 
 other. The question of percussion outlines resolves itself 
 into the tracing of boundaries between organs which are 
 very resonant, and those which are less resonant or pos- 
 sessed of a different quality of resonance, and those which 
 are non-resonant. Thus it is easy to trace the boundary 
 between the lung and the liver where they lie in appo- 
 sition, but impossible to distinguish the line of contact 
 between the heart and the liver. 
 
 In order to define any border which comes within the 
 province of our search we should percuss toward that 
 border from either side — and alternately from both sides 
 — in lines which are perpendicular to its known anatom- 
 
METHOD IN PERCUSSION. 5 
 
 ical course. Inasmuch as most of the percussion boun- 
 daries run transversely across the body, we have adopted 
 the following series of perpendicular lines, which should 
 be followed methodically and in succession: — 
 
 •Sternal line .... Along the border of the sternum. 
 
 Parasternal line . . Half way between the sternal and 
 mammillary lines. 
 
 Mammillary line . . Through the nipple on the male. On 
 the female this line should be drawn 
 perpendicularly downward from about 
 the middle of the clavicle. 
 
 Anterior axillary line Along the anterior border of axilla. 
 
 Axillary line . . . From the summit of the axilla down- 
 wan Is. 
 
 Posterior axillary line Along posterior border of axilla. 
 
 Scapula line . . . Through the apex of the scapula when 
 the arms are banging at the sides. 
 
 Vertebral line . . . Between the scapular and vertebral 
 column. 
 
 To illustrate the use of these lines, let us suppose that 
 tin' lower border <>f the right lung is the object of inves- 
 tigation. In such case one should begin on the sternal 
 line, and percuss downward until a point is reached 
 where the resonance of the lung ceases, and the flatness of 
 
 the liver begins. Having repeated the percussion often 
 
 enough to be sure of such change, this point should be 
 designated by a pencil mark on the skin. Then the 
 
 same steps should be repeated along the parasternal, 
 
 mammillary, and anterior axillary lines, and so on to the 
 
 vertebral line, the point of change of sound in each 
 
 case being marked. Then if these points I onnected 
 
 by a continuous line, one will have a sketch of the lower 
 
 border of the lung. It is always serviceable to percuss 
 
 toward the bord.-r sought, uol only from above down- 
 ward, but also from below upward, in which cafl ie 
 
6 PERCUSSION OUTLINES. 
 
 would mark the points where flatness changes to reso- 
 nance. 
 
 In outlining the heart one should percuss in the 
 sternal, parasternal, and mammillary lines, and even in 
 the anterior axillary and axillary lines. Under normal 
 conditions, the left border of the heart, as shown in 
 Plate IV., curves downward and runs parallel with the 
 mammillary line, hence, to define this border, it will be 
 necessary to approach it in oblique lines from the left 
 shoulder and left axillary region. 
 
 It is difficult to find a good pencil for marking the skin. 
 Ink spreads and dries slowly. Burnt cork is very good, 
 but inconvenient to carry, and an ordinary lead pencil is 
 too hard to make a mark on soft skin. Chalk and car- 
 bon work well for a time, but they rapidly absorb oil 
 from the skin, and cease to mark unless refreshed with 
 sand paper. We have found a very convenient marker 
 in the pencils which actresses use for staining their eye- 
 lids. These pencils are made, like ordinary cosmetics, 
 from grease stained with lamp-black or vermilion. They 
 are put up in little tin cases, with slides for pushing them 
 in and out, and can be carried about in the pocket. 
 They can be obtained at any perfumery store. 
 
 We must again emphasize the necessity of percussing 
 in straight lines, and of carefully completing one line 
 before beginning another. Students are very apt to 
 percuss across the chest in a zigzag direction or wander 
 about in circles. Such percussion teaches nothing, and 
 only serves to confuse the examiner. 
 
 A word in regard to the relative merits of light and 
 heavy percussion. Undoubtedly heavy percussion has 
 its place and serves a good purpose, especially over thick 
 muscles on the back, and in bringing out the dullness 
 of deep-seated consolidation. In outline percussion, 
 however, on the lateral and anterior aspects of the body, 
 
METHOD IX PERCUSSION. 7 
 
 light percussion alone should be employed. In crossing 
 the boundary between a resonant and a non-resonant 
 organ, if our blows are heavy, the resonance of the 
 former organ will be so transmitted over the latter that 
 the line of demarkation will apparently lie several cen- 
 timeters away from its actual position. We have found 
 that the best results are obtained with extremely light 
 percussion. The blow should never be given from the 
 elbow, but from the wrist or from the metacarpal joint 
 of the hammer finger. Where the chest is at all tender, 
 and especially in percussing children, we always keep the 
 hand quiet, and deliver our blows with the finger alone. 
 
 The burden of this book is the normal percussion 
 outlines of the body, and we devote but relatively small 
 space to pathological deviations. In presenting the sub- 
 ject thus, we have been actuated by the conviction that 
 perfect familiarity with the normal is the only true guide 
 to the abnormal. One who has a systematic method of 
 Bearching for the normal, and pursues that method rigor- 
 ously in every case, will, never fail to detect abnormal 
 deviations. 
 
CHAPTER II. 
 
 STERNUM. 
 
 The sternum consists of the manubrium, corpus sterni, 
 and the ensiform cartilage. It ordinarily lies in the me- 
 dian line, opposite the vertebral column. Congenital 
 and acquired deformities of either side of the chest will 
 of course alter its position. With pleuritic effusions the 
 sternum swings toward the affected side like a pendulum, 
 the lower end traveling four to five centimeters, while 
 the upper end moves only two centimeters. 
 
 The manubrium is normally quite resonant — the 
 sound is neither tympanitic nor vesicular, but has a qual- 
 ity of its own. It may be rendered dull by an over- 
 filling of the veins from valvular disease of the heart ; 
 by aneurism of the arch of the aorta ; by pericardial 
 effusion, and by pus gravitating from abscesses in the 
 neck. In the last-named case it is important to notice 
 that the dullness does not extend below the manubrium, 
 because the firm adhesion of the membranes of the ante- 
 rior mediastinum deflect the gravitating pus into the pos- 
 terior mediastinal space. 
 
 The resonance of the sternum is clearest and loudest be- 
 tween the second and fourth ribs. It is also clear between 
 the fourth and sixth ribs, although it here crosses 
 the heart, and is to a great extent in direct contact 
 with that organ. It would seem that the sternum is an 
 excellent conductor of sound from the neighboring lungs, 
 and thus conceals the flatness of the underlying heart. 
 
ANATOMY. 
 
 DIAPHRAGM. 
 
 Anatomy. 
 
 Viewed from above, the diaphragm presents a dome- 
 like projection into each side of the thorax, with a nearly 
 horizontal plane connecting the summits of the domes. 
 The upper surface is somewhat elliptical in shape, the 
 transverse diameter being the longest. The diaphragm 
 consists of two parts, a tendinous portion — pars phre- 
 nica — which forms the plane above, and a muscular 
 portion — pars costal is — which constitutes the sides of 
 the domes. The muscular portion has a long line of 
 attachment extending from the sternum along the bor 
 der of the ribs to the vertebral column. The sternal 
 segment rises chiefly from the apex of the ensiform car- 
 tilage, and is immediately lost in the tendinous layer. 
 The costal segment begins with one serration from the 
 seventh costal cartilage, and another from the outer por- 
 tion of the eighth cartilage. On the ninth rib the ser- 
 rations extend about a finger-breadth beyond the carti- 
 Iage, on to the costal bone. From here to the twelfth rib, 
 the muscle is attached to the osseous parts and the inter- 
 costal spaces. Its serrations also interdigitate with the 
 corresponding projections of the transverse abdominal 
 muscle. The vertebra] segment takes its origin from the 
 firsl tour lumbar vertebras. 
 
 Starting from this long line of attachment, the pars 
 COStalis rises directly upward, and lies in contact with the 
 chest wall for a distance which varies on different sides 
 of tin- chest and with different phases of respiration. On 
 reaching the lower border of the lung and the heart, it is 
 reflected beneath those organs and becomes the pars 
 phrenica. 
 
 The summit of the diaphragm changes with every 
 
10 PERCUSSION OUTLINES. 
 
 stage of respiration, but at the end of ordinary expiration 
 it coincides on the right side with a horizontal line drawn 
 through the sternal ends #f the fifth pair of ribs, and it is 
 a costal space lower on the left side. On the back it cor- 
 responds to the ninth dorsal vertebra. 
 
 Percussion of the Diaphragm. 
 
 The position of the diaphragm cannot be defined by- 
 means of any sound or modification of resonance peculiar 
 to itself. It is only by comparing its anatomical rela- 
 tions to other organs with the percussion boundaries of 
 those organs that we are able to form any opinion con- 
 cerning it. 
 
 The most important points to determine, are : — 
 
 1. The line of transition from the pars costalis to 
 the pars phrenica. This corresponds to the lower border 
 of the lung, and may therefore be deferred to the discus- 
 sion of that border. 
 
 2. The position of the dome. Gerhardt says it is idle 
 to try to define the arch of the dome, owing to its dis- 
 tance from the chest wall. Weil and Ferber think it 
 can be defined by strong percussion, but this is a difficult 
 task, and usually we can determine the probable height 
 of the diaphragm only by inference from the position of 
 other organs. When the dome of the diaphragm is de 
 pressed into the abdomen by a large pleuritic effusion, it 
 becomes readily accessible to percussion, and may often 
 be felt. 
 
 PLEUEA. 
 
 Anatomy. 
 
 The pleural membranes are divided into four parts, ac- 
 cording to the organs with which they are associated. 
 These parts are : — 
 
ANATOMY. 11 
 
 Pars pulmonis, which directly envelops the lung and 
 cannot be detached from the Bame. 
 
 Pars phreniea, which covers the diaphragm. 
 
 1'uj-x mediastinalis, which helps form the partition be- 
 tween the two halves of the chest. 
 
 Pars costalis, which lines the inner surface of the ribs, 
 intercostal spaces, and a portion of the sternum. 
 
 At the apex of the chest, behind the sternum and 
 along the vertebral column, the pars costalis is reflected 
 inward, to form the pars mediastinals, and these lines of 
 reflection constitute respectively the Buperior, anterior, 
 and posterior borders of the pleural cavity. The inferior 
 border of that cavity is formed by the reflection of the 
 costal into the diaphragmatic layer, or pars phrenica. 
 The most important of these borders, for percussion, are 
 the superior, anterior, and inferior. 
 
 The si(/>cri'>r ln,r<l< rs coincide accurately with the su- 
 perior binders of the lungs, and therefore require no sep- 
 arate notice at this point. See description of lungs, 
 page 14. 
 
 The anterior borders start on either side at the articu- 
 lation of the clavicles with tie- sternum, Plate; I., a b, c d. 
 They advance obliquely downward and inward, behind 
 the manubrium, until they reach the level of the inner 
 extremities of the second ribs, where they come into con- 
 tact with each other. Thence they proceed together 
 downward a little to tin' left of the median line, as far 
 as the fourth pair of ribs* when they separate. The 
 right border continues still downward, with a slight in- 
 clination to the right, until it meet-, the inferior bonier of 
 the right pleura, in the median line of the sternum, at the 
 Level of the sixth intercostal space. 
 
 The left anterior border bends Bomewhal sharply to 
 the left at the fourth rib, and crosses the cardiac area in 
 
 an irregularly diagonal direction until it reaches the 
 
12 PERCUSSION OUTLINES. 
 
 parasternal line in the sixth intercostal space. Here it 
 sweeps in an easy curve across the seventh costal cartil- 
 age, and is lost in the inferior border of the left pleura. 
 
 The inferior borders of the pleurae convex downward 
 on either side. The left one runs obliquely downward 
 and outward from the outer third of the sixth or sev- 
 enth costal cartilage to the bony portion of the twelfth 
 rib behind. Its termination is about on a level with a 
 horizontal line which halves the twelfth pair of ribs. 
 In its course it crosses the bony end of the eighth rib 
 in the mammillary line, and from there on it comes in 
 contact only with the bony portion of the ribs. It 
 reaches the tenth rib in the axillary line. The lowest 
 point of the pleural cavity is sometimes close to the 
 vertebral column and sometimes a little out from the 
 same. It maybe as far out as the scapular line in some 
 cases. 
 
 The right inferior border runs from the median line 
 of the sternum outward and downward along the sixth 
 costal cartilage or the sixth intercostal space to the outer 
 third of the seventh costal cartilage, whence it proceeds 
 in nearly the same manner as on the left side. It is 
 noticeable, however, that the pleural border on the 
 left side is a trifle lower than that on the right side, 
 which harmonizes with the fact that the left lung is 
 longer though smaller than the right one. 
 
 The posterior borders of the pleura? form perpendicu- 
 lar lines on either side of the. vertebral column. 
 
 Notice : 1. The inferior border of the pleura does 
 not reach so low as the line of attachment of the dia- 
 phragm, which runs along the costal arch from the ensi- 
 form cartilage to the outer extremity of the twelfth rib. 
 The diaphragm in this region is intimately attached to 
 the ribs and intercostal spaces. 
 
 2. A portion of the pericardium has no pleural cover- 
 
ANATOMY. 13 
 
 ing, owing to the oblique course of the anterior border of 
 the left pleura. This exposed region has a triangular 
 shape with its apex upward, and within this triangle the 
 pericardium lies in direct contact with the chest wall. 
 The portion of the pleura (pleura pericardiaca) which 
 does overlie the pericardium is intimately attached to the 
 latter. 
 
 3. The anterior borders of the pleurae touch each other 
 only between the second and fourth pair of ribs, and it 
 is here only that the posterior surface of the sternum is 
 wholly covered by pleura. 
 
 4. A triangular space behind the upper part of the 
 manubrium is free from pleural covering. Certain im- 
 portant organs lie behind this space. A needle thrust 
 through the manubrium at the angle formed by the 
 pleural layers would pierce the upper part of the peri- 
 cardium, which rises as high as the first pair of ribs. 
 Above the pericardium one would wound first the vena 
 innominata, and, back of that, the aorta. In childhood 
 this space also contains the large thymus gland. 
 
CHAPTER III. 
 
 LUNGS. 
 
 Anatomy. — The lungs present three surfaces and five 
 borders for consideration. The external or costal sur- 
 face is convex outward, corresponding to the concavity 
 of the chest Avail, and it is a sort of spherical triangle 
 with its apex above, and the lower pulmonary border for 
 the base. The inferior surface is also a spherical triangle 
 with its concavity looking down upon the diaphragm. 
 The median or mediastinal surface looks toward the cen- 
 tre of the body, and is pierced by the trachea and blood- 
 vessels which administer to the functions of the lungs. 
 
 Pulmonary Borders. — The superior border passes yoke- 
 like over the shoulder at three to five centimeters (two 
 to three finger-breadths) above the clavicle. Plate IV., 
 G, H. Anteriorly, it runs close to, and parallel with, the 
 posterior border of the sterno-cleido-mastoid muscle, until 
 it reaches the sterno-clavicular articulation, when it be- 
 comes the anterior border. On the back it is slightly 
 concave upward, and terminates at the level of the spi- 
 nous process of the seventh cervical vertebra. Plate 
 VII., A B. 
 
 The anterior border of the right lung corresponds accu- 
 rately to the anterior border of the right pleura, as given 
 on page 11, Plate I. 
 
 The anterior border of the left lung runs also parallel 
 with its pleura, as far as the inner extremity of the fourth 
 rib. Here it bends sharply to the left, and lies along the 
 
LUNGS. 
 
 15 
 
 fourth costal cartilage as far as the parasternal line. Then 
 descending slightly across the fourth "intercostal space, it 
 turns again toward the median line in a half-moon curve — 
 Incisura cardiaca — and approaches the sternum until it 
 reaches the sixth costal cartilage, when it again bends to the 
 left and is lost in the inferior border. This peculiar deflec- 
 tion of the border produces a tongue-like projection — 
 lingala pulmonis — which overlies the apex of the heart. 
 The inferior border of the left lung is, in front, a 
 little lower than that of the right lung. This difference 
 amounts to one and a half centimeters between the mam- 
 millary and parasternal lines, but no perceptible differ- 
 ence exists on the back. The following table shows the 
 relative positions of the inferior border on the two 
 sides. 
 
 1 rual aud mammillary 
 
 lines 
 Axillary line . 
 Bcapular line . 
 Vertebral line .... 
 
 Upper border of 6 c li 
 rib. 
 < tosses 7th rib. 
 
 tea loth rib. 
 •s 1 ltll lib. 
 
 Lower border 
 
 6th rib. 
 ( Irosses 7th rib. 
 < ru-sis loth rib. 
 ( Irosses 1 1th rib. 
 
 of 
 
 This tabic represents the position of the borders at the 
 end of normal expiration. The respiratory modifications 
 of the same will be noted later. 
 
 Tin: posterior borders run parallel with the vertebral 
 column. Little or no information can be obtained re- 
 garding them by percussion, except in cases of pleurisy, 
 when we find them shortened by the general contraction 
 of the lull 
 
 The antero-posterior borders, which bound the lower 
 
 part of the mediastinal surfaces, are inaccessible to per- 
 cussion. 
 
 Incisurce Interlvbtibircx. — Each lung is divided into 
 lobes by incisune, which extend from the surface to the 
 root of the lung, and are lined by reflections of the 
 
16 PERCUSSION OUTLINES. 
 
 visceral pleura. The right lung has three lobes, the left 
 lung two. 
 
 The main incisura begins on either side, behind, at the 
 level of the spinous process of the third dorsal vertebra. 
 This also coincides with the spines of the scapulae, when 
 the arms hang at the sides. 
 
 On the left side, the incisura runs obliquely downward 
 and forward, so as to cross the fourth rib in the axillary 
 line, and ends in the lower border of the lung on the sixth 
 rib in the mam miliary line. Plate II., E D. 
 
 On the right side the incisura divides into two 
 branches, about five to six centimeters above the apex 
 of the scapula. The upper branch runs forward, with 
 very slight descent, and ends in the anterior border of 
 the right lung at the fourth or fifth costal cartilage. In 
 the mammillary line it stands at the level of the third 
 rib. 
 
 The lower branch runs obliquely downward and for- 
 ward until it reaches the inferior border of the lung at the 
 sixth costal cartilage near the mammillary line. These 
 incisure cannot be defined by percussion, except in cases 
 of lobar infiltration of pneumonia. 
 
 Notice : 1. In the position of ordinary expiration, the 
 lower border of the lung on either side does not reach to 
 the bottom of the pleural cavity, but is elevated above the 
 same by a distance varying on different sides of the 
 chest. Plate II. During inspiration the lung descends 
 until, with the fullest breath, it occupies the entire cavity. 
 With the following expiration, the lower border glides 
 upward to resume its former position. The space which 
 is thus alternately occupied and abandoned by the lung 
 is called the complemented space (Gerhaudt), or the 
 sinus phrenico-costalis (Weil). As the lung deserts this 
 space, the diaphragmatic and costal layers of the pleura 
 are brought into contact, and thus the space becomes 
 temporarily obliterated. 
 
LUNGS. 
 
 17 
 
 The variations in the depth of this space on different 
 sides of the chest are shown in the following table 
 (Weil) : — 
 
 Parasternal line 
 Mammillary line 
 Axillary line 
 Scapular line 
 
 Vertebral line . 
 
 RIGHT 
 
 SIDE. 
 
 LEFT SIDE. 
 
 2+ ctm. 
 
 3 ctm. 
 
 6 
 
 " 
 
 6 " 
 
 10 
 
 " 
 
 10 " 
 
 4 to 5 
 
 « 
 
 4 to 5 " 
 
 4 to 5 
 
 " 
 
 4 to 5 " 
 
 These figures represent the condition of ordinary expi- 
 ration. With forced expiration they may be much in- 
 creased. 
 
 2. The anterior border of the left lung, in the cardiac 
 region, does not occupy the whole of the space allotted to 
 it. Plate L, Q. This excess of room, reserved for the 
 play of the pulmonary border, is called the sinus me- 
 diastino-costalis, and it will be seen later that the recog- 
 nition of its condition is very important, especially for 
 the diagnosis of emphysema. The widest portion of this 
 sinus is in the fourth intercostal space, where it is over 
 three centimeters. 
 
 3. The apex of the heart does not touch the chest wall, 
 but is separated from the same by the lingula pulmonis. 
 
 4. The lowest point of the lung is in the scapular line. 
 
 PERCUSSION OF THE LUNGS. 
 
 The only boundaries of the lungs which can be defined 
 bv percussion are the Buperioi and inferior borders, and 
 so much of the left anterior border as lies across the 
 cardiac area. 
 
 Superior Borders. — The apex of the lung rises above 
 the clavicle from three to five centimeters. The su- 
 perior bonier extends from the inner end of the clavi- 
 cle, at first upward along the posterior edge of the 
 sterno-cleido-mastoid muscle, and then over the shoulder 
 2 
 
18 PERCUSSION OUTLINES. 
 
 in a gentle sweep, to the spinous process of the seventh 
 cervical vertebra. Plate VII., A B. On the back, these 
 borders concave upward. 
 
 The distinction between the pulmonic resonance of 
 the apex and the tympanitic resonance of the trachea 
 in front can best be made out by light percussion, and 
 with the patient's mouth open. The importance of de- 
 termining these boundaries may be noticed in phthisis, 
 when one apex is often found considerably retracted. 
 Plate VII., o P. 
 
 Anterior Borders. — Owing to the peculiar resonance 
 of the sternum and to the fact that we cannot dis- 
 tinguish the sound of the right from that of the left 
 lung, it is impossible to outline those portions of the 
 anterior borders which underlie the sternum. Plate 
 IV. 
 
 In percussing down the left sternal line, we notice a 
 dull ins: of the resonance at the third rib. This dullness 
 is due to the underlying heart, and will be further men- 
 tioned in connection with that organ. On reaching the 
 fourth rib there is a sudden change from pulmonary 
 resonance to flatness, which indicates the transition from 
 lung to heart. The line of this transition extends a short 
 distance outward along the fourth rib, and then turns 
 perpendicularly downward across the fifth rib. At the 
 sixth rib it turns again to the left, and is lost in the 
 lower border. The line a to c, along the left edge of the 
 sternum, indicates the change from cardiac flatness to 
 sternal resonance. 
 
 Inferior Borders. — On the left side the inferior per- 
 cussion border lies as follows : — 
 
 Axillary line At the eighth rib. 
 
 Scapular line At the tenth rib. 
 
 Vertebral line At the eleventh rib. 
 
 The position of this border in the mammillary line is 
 
LUNGS. 19 
 
 often difficult to establish, owing to the great resonance 
 of the stomach beneath. Ordinarily, however, it is 
 
 placed at the sixth rib. 
 
 The inferior percussion border of the right lung stands 
 as follows : — 
 
 Median line At base of xiphoid cartilage. 
 
 Parasternal and mammillary 
 
 lines On sixth rib. Sometimes nearer 
 
 the upper edge ; sometimes 
 nearer the lower edge of the 
 rib. 
 
 Axillary line At the eighth rib. It may be 
 
 found as high as the seventh 
 intercostal space, or as low as 
 the eighth intercostal space. 
 
 Scapular line At tenth rib. 
 
 Vertebral line At eleventh rib. 
 
 The line, P Q, in Plate IV., represents the superior 
 border of the hepatic dullness, which will be described 
 elsewhere. 
 
 It will be remembered that these percussion bounda- 
 ries represent the normal expiratory position of the lung 
 in an adult. In extreme youth and in old age these 
 boundaries are differently situated. Plate IX. represents 
 the senile type, and Plate VIII. the infantile type. Thus 
 (e in children the pulmonary boundaries may be 
 found from one half to a whole interspace higher than in 
 an adult, while in old age they are the same distance 
 lower. 
 
 Moreover, during life the borders of the tangs are con- 
 tinually changing position with each act of respiration, 
 and with t'\<'\-\- change of the body. 
 
 Active mobility ol the lungs. — Concurrent with the acts 
 of breathing, the inferior borders of the Lungs arc alter- 
 nately descending and ascending, so that their percussion 
 
20 PERCUSSION OUTLINES. 
 
 Limits include a considerable space. The inspiratory de- 
 scent of the lower border is ordinarily : — 
 
 In the right parasternal line . . . 1£ to 2 centimeters. 
 In the right mammillary line . . . 2 to 3 centimeters. 
 
 In both axillary lines 3 to 4 centimeters. 
 
 In both scapular lines 2 centimeters. 
 
 (Weil.) 
 
 With forced expiration, these borders will be retracted 
 as far above their usual position, and even further than 
 they are lowered by the fullest inspiration. The amount 
 of excursion, therefore, between the position of fullest ex- 
 piration and that of fullest inspiration is : — 
 
 In the mammillary line 8^- centimeters. 
 
 In the axillary line 9^ centimeters. 
 
 In the scapular line 7^ centimeters. 
 
 That portion of the left anterior border which over- 
 lies the heart also undergoes active movements during 
 respiration. With inspiration this border is carried for- 
 ward into the sinus mediastino-costalis, so as to greatly 
 diminish the area of cardiac flatness. In some persons 
 the advance may be so great as to almost obliterate the 
 cardiac flatness. In a similar way, the area of flatness 
 is noticeably increased during full expiration. 
 
 Passive mobility of the lungs. — Gerhardt found that 
 the pneumono-hepatic border, when a man lies on his 
 back, is one to two centimeters lower than in the erect 
 posture. When one turns on to the right side, the in- 
 ferior border of the left lung descends by a distance equal 
 to a full inspiration. The same is true of the lower 
 right border, when one lies on the left side. These 
 changes of position are called the passive mobility of the 
 lungs, and it is important to bear them in mind when per- 
 cussing an invalid in bed. 
 
 The active and passive mobility of the lungs are usually 
 
LUNGS. 21 
 
 diminished or entirely absent in cases of emphysema and 
 pleurisy. In the former disease the lungs are perma- 
 nently enlarged and incapable of retraction, Avhile in 
 pleurisy the lungs may be either permanently retracted, 
 or so tied up by adhesions as to be held stationary. 
 
 Notice: The diagram of percussion boundaries, Plate 
 IV., does not portray any divisions between the lobes. 
 This is because the resonance of contiguous lobes cannot 
 be distinguished from each other under ordinary condi- 
 tions. In cases of pneumonia, where one lobe is solidi- 
 fied and its neighbor is not, the line of transition from 
 the dullness of the former to the resonance of the latter 
 will coincide with the anatomical sulcus. The careful 
 delineation of these lines will often :is>i>t in removing 
 doubts between pneumonia and pleurisy. 
 
 l'ATHOLOGY. 
 
 Pneumonia. — Pneumonia does not produce any 
 
 marked change in the gross outlines of the lungs. It 
 cause-, a diminution of the pulmonary resonance, how- 
 ever, which varies in intensity and extent according to 
 the amount and degree of infiltration, in catarrhal 
 pneumonia, the dull urea may be limited to a few lobules 
 only, but it is usually impossible to accurately define the 
 outline of such an urea, because the transition from dull- 
 i i io the resonance of neighboring lobules is very 
 
 gradual. 
 
 When an entire lobe is hepatized, as in croupous 
 
 pneumonia, the percussion line of demarkation between 
 the dull ami the companion resonant lobe corresponds 
 to the anatomical sulcus which separates them. It is 
 importanl to remember thai in some stages of pneumonia 
 — in the beginning of lobular pneumonia, and during tin; 
 resolving stage of croupous pneumonia — we may obtain 
 a tympanitic resonance over the parts which are relaxed 
 by disease. 
 
22 PERCUSSION OUTLINES. 
 
 Cavities. — Taken by themselves alone, and judged 
 by any or all of the signs which are peculiar to them- 
 selves, pulmonic cavities are very difficult of diagnosis. 
 It may be laid down as a safe rule, to start with, that 
 such cavities possess no pathognomonic percussion signs. 
 
 Several signs have been described, however, and more 
 or less importance has been attributed to them by differ- 
 ent writers ; and yet a careful analysis of the conditions 
 under which they may occur will reveal their fallibility 
 as indicators of cavities. These signs are : the cracked- 
 pot sound, tympanitic resonance, Wintrich's variable- 
 pitch, Gerhardt's variable-pitch, amphoric resonance. 
 
 The cracked-pot sound is obtained by listening at the 
 open mouth of the patient, while strong percussion is 
 made upon the chest. It resembles the chinking of 
 money, and may be imitated by clasping the hands loosely 
 together and striking the back of one of them upon the' 
 knee. This sound may be obtained from the chest, how- 
 ever, without the presence of a cavity, as with pleural ef- 
 fusion, pneumonia, pneumo-pericardium, and even upon 
 healthy persons. Thus, if we percuss the back of a 
 screaming infant, or of a thin woman, we may produce the 
 cracked-pot sound. 
 
 Tympanitic Resonance. — The best observers unite in 
 declaring that a cavity must be as large as a man's fist, 
 superficially situated, and surrounded by a certain amount 
 of indurated tissue, in order to give forth a tympanitic 
 note. But tympanitic resonance occurs more often with- 
 out cavities than with them, as with pleurisy and pneu- 
 monia. Weil thinks that not more than ten per cent, of 
 the cases of tympanitic resonance over the lungs are at- 
 tributable to pulmonic cavities. This sign, therefore, has 
 hut little value in itself. It has gained a new impor- 
 tance, however, by certain investigations made regarding 
 its pitch under various conditions. 
 
LUNGS. 
 
 23 
 
 Wintrich's Variable-pitch. — Wintrich observed that 
 when a cavity gave forth tympanitic resonance, the pitch 
 of tins resonance could be raised by opening the mouth of 
 the patient. In order to obtain this sign the cavity must 
 connect with a free bronchus. Sometimes the sign will 
 appear and then disappear, by reason of the plugging of 
 the bronchus with secretion. In such cases an effort at 
 coughing will clear the tube and restore the sign. A 
 similar change of pitch on opening and closing the mouth 
 may be noticed when percussing over relaxed pulmonary 
 tissue, and also with the so-called Williams' tracheal tone. 
 It follows, therefore, that other possibilities must be 
 eliminated before this sign can decisively indicate a 
 
 ea\ ity. 
 
 Gcrhardfs Variable-pitch. — Gerhardt noticed that a 
 cavity which is oval in shape and contains both fluid 
 
 Fi§f. 
 
 Fi$.2. 
 
 and air, as in Fig. 1, will give forth a tympanitic res- 
 onance which will vary in pitch with changes in the 
 position <>t" the patient. Suppose the Long diameter of 
 the cavity (<//<) to be in the Longitudinal axis of the 
 body, then the percussion note will have a higher pitch 
 
 when the patient stands, and a lower pitch when he lies 
 on his hack, because the column of air {a e), above the 
 
24 PERCUSSION OUTLINES. 
 
 fluid, is shorter in the former case (Fig. 1) than the 
 column (a 5) is in the latter (Fig. 2). 
 
 Amphoric Resonance. — This is a rare phenomenon with 
 cavities. In order for its production the cavity must 
 have a certain size ; its inner surface must be smooth, 
 and its walls must be of uniform consistency. Leich- 
 tenstein says that this phenomenon can often be detected 
 by listening to the chest, while a second person per- 
 cusses over the suspected cavity with a lead pencil upon 
 an ivory pleximeter. This method, he says, will often 
 reveal a cavity when all other tests have failed. 
 
 To sum up regarding the above signs, it may be said 
 that the cracked-pot sound and tympanitic resonance 
 have nothing characteristic of a cavity. The amphoric 
 resonance is more conclusive, and yet this sound may be 
 obtained over bronchi and trachea. 
 
 Wintrich's variable-pitch is very dubious. Gerhardt's 
 variable-pitch, when well marked, is perhaps the most 
 reliable of all. Weil says that in all cases where the 
 pitch was lower in the upright position, and higher on 
 lying down, he found a cavity present. In cases where 
 the pitch became higher on sitting up, he found a cavity 
 present in all but one instance. 
 
 Valuable evidence regarding the formation of a cavity 
 may be obtained under the following circumstances. 
 During a prolonged observation of a dull region on the 
 chest, if the resonance suddenly becomes clearer, or less 
 dull, with a tympanitic tinge, then we may suspect a 
 cavity, especially if the change in resonance is accompa- 
 nied by a sudden and profuse expectoration. 
 
 As to the size and exact form of a cavity, almost no 
 information can be obtained under any circumstances. 
 Thus, amphoric resonance, when present, is usually asso- 
 ciated with large cavities, but cases have occurred where 
 it appeared with a small cavity which connected freely 
 with a bronchus. 
 
EMPHYSEMA. 25 
 
 Emphysema. — In emphysema the entire chest as- 
 sumes permanently the position of inspiratory expansion, 
 which varies in degree according to the duration and 
 amount of the disease. 
 
 Pvlmonary Borders. — The inferior borders are the 
 ones chiefly affected. They may descend as low as the 
 seventh intercostal space, or the eighth rib in the mam- 
 millary line ; the tenth rib in the axillary line ; the 
 twelfth rib in the vertebral line. With moderate em- 
 physema the sinkage of the border will of course be 
 proportionally less. 
 
 The cardiac border is advanced so as to occupy the 
 cardio-mediastinal sinus. By this means the area of 
 cardiac flatness becomes diminished to a narrow zone at 
 the level of the sixth rib, or it may be entirely obliterated 
 in excessive cases. 
 
 It will be remembered that, in old age, the diaphragm, 
 heart, and inferior borders of the lungs always stand 
 at a lower level than in adult life. Hence, in diagnos- 
 ing emphysema, one should always compare the amount 
 of pulmonary expansion with the age of the patient. If 
 the lower border in a person over sixty- live years of age 
 reach no further than the seventh rib in the mam miliary 
 line, the condil ion is normal. 
 
 Another sign of emphysema is the diminution or ab- 
 sence of both the active and passive mobility of the infe- 
 rior borders of the lungs. We have seen cases where the 
 most energetic efforts at respiration, in various positions 
 
 of the hoily, failed to change the percussion borders. 
 
 The apices of the lungs are often raised to a higher 
 elevation — five to six centimeters — above the clavi- 
 cles, in which case the superior borders are correspond- 
 ingly higher. 
 
 Hepatic Boundaries. — The outlines of the liver are 
 considerably changed in emphysema. The pneumono* 
 
26 PERCUSSION OUTLINES. 
 
 hepatic border is always lower, and the apparent size of 
 the liver will then depend upon its relation to the ex- 
 panded lung. If the liver remains in its normal posi- 
 tion, or nearly so, then the area of hepatic flatness will 
 be necessarily diminished. On the other hand, if the 
 liver be simultaneously depressed by a descent of the dia- 
 phragm, then the area of flatness may remain normal in 
 size or even appear increased. 
 
 Pleurisy. — The changes produced by pleurisy in the 
 percussion boundaries of the lungs will vary according 
 to the character, seat, and extent of the affection. A 
 simple dry pleurisy with adhesions may leave the pul- 
 monary boundaries little affected, except as regards their 
 mobility. Thus firm adhesions may interfere with the 
 respiratory expansion, and also with the passive move- 
 ments which normally accompany changes of the position 
 of the body. Again, thick deposits of pleuritic mem- 
 branes will produce a general diminution of vesicular 
 resonance. 
 
 Pleurisy with Effusion. — With an encysted pleuritic 
 effusion, an area of dullness (or flatness, with a large 
 amount of fluid) will be found, which varies in shape and 
 position according to the size and situation of the exuda- 
 tion. No general law can be laid down for such cases, 
 and the dullness thus observed must be distinguished from 
 that which accompanies consolidation of the lung, by 
 such other evidence as can be obtained through auscul- 
 tation and palpation. 
 
 An accumulation of free fluid in the pleural cavity(pleu 
 ritic effusion, empyema, hydrothorax, kaematothorax,) 
 causes marked changes in the percussion outlines of the 
 pulmonary borders. As the fluid gradually forms, it 
 gathers at the bottom of the chest, and the lung begins 
 to contract in volume. Let it be said here, that a lung 
 which retains its integrity and elasticity cannot be pressed 
 
EMPHYSEMA. 27 
 
 upon, or compressed by, an encroaching effusion, until it 
 is completely collapsed, and the amount of fluid present. 
 is excessive. The lung simply contracts in volume, but 
 it still sustains the weight of the diaphragm plus that of 
 the fluid in the same manner that it previously sustained 
 the diaphragm alone. 
 
 Assoon as sufficient effusion has collected for detec- 
 tion by percussion — 200 cc. according to Seitz — we 
 obtain over the fluid a ilat sound, and varying degrees of 
 dullness over the collapsing lung above. The line of de- 
 markation between the flatness of the fluid and the dull 
 resonance of the lung is usually well marked. The 
 shape and position of this line, however, have been the 
 subject of much controversy. Most German writers fol- 
 low Wintrich in declaring that this line stands generally 
 highest behind in the neighborhood of the spinal column, 
 and thence, descends obliquely to the sternum. Some 
 allow that the line may sometimes be horizontal, but they 
 think that this shape is exceptional, and due to the posi- 
 tion maintained by the patient during the early stage 
 of the effusion. Thus, if the patient lie quietly in bed 
 during that stage, the fluid will assume a level corre- 
 sponding to that position. Subsequently, as the patient 
 arises and walks about, the fluid is prevented from re- 
 accommodation by adhesions, and hence the obliquity of 
 its surface. Among the French, Piorry and his followers 
 teach that an effusion ordinarily adjusts itself to a hori- 
 zontal level for all positions of the body. On the other 
 band, Damoiseau declined that the line in question is 
 never horizontal, but is more or less parabolic with its 
 summit in the axillary line, and its branches extending 
 down on either side to the sternum and vertebral column. 
 
 In our own experience, we have never seen a pleural 
 
 effusion (pneumo-hydrothorax excepted ) which presented 
 a horizontal line of demarcation, nor do we obtain a line 
 
28 PERCUSSION OUTLINES. 
 
 like that described by the Germans. On the contrary, 
 we find that the position assumed by an effusion is that 
 which was first described by Prof. Calvin Ellis, of Boston. 
 This observer discovered that with small and medium 
 effusions the line of flatness begins lowest behind at the 
 vertebral column. Thence it ascends obliquely across the 
 back, in a letter S curve, to the axillary region, where it 
 reaches its highest point. Then it advances to the ster- 
 num with a slight inclination downward. With large 
 effusions, which fill the chest to the second rib or higher, 
 this curve disappears, and the line becomes more nearly 
 horizontal, and more difficult to trace. As absorption 
 takes place, however, or the fluid is removed by aspira- 
 tion, the curve reappears and passes through retrograde 
 phases corresponding in shape to those of the earlier 
 stages. 
 
 It is sometimes difficult to trace the curve on the 
 back, owing to the great dullness of the lung immediately 
 above the effusion. This dullness is often due to a lack 
 of proper ventilation of the lower lobe, especially when 
 the patient is lying down, and therefore one should not 
 attempt to trace the line until the patient has taken 
 several deep breaths and thus thoroughly filled the lung. 
 In Fig. III. it will be seen that we have drawn a hori- 
 zontal line, A B, from the summit of the curve to the 
 vertebral column, and have thereby inclosed a rough, 
 triangular space, ABC. This space corresponds to 
 the lowest portion of the lung, and is especially liable to 
 be obscured by dullness. The lung lies here in contact 
 with the chest wall, but its resonance may be so dull 
 as to escape detection unless careful percussion is made 
 and the patient breathes deeply. We have termed this 
 space the dull triangle, and its recognition is of vital 
 importance. Heitler, in Vienna, has observed this same 
 triangular space of resonance, and has likened it to a 
 
PLEURISY. 
 
 29 
 
 monk's hood cut longitudinally through the centre and 
 hanging apex down. Rosenbach, of Breslau, has also 
 noticed that the resonance of this portion of the back in 
 pleurisy will often clear up on exercise or by breathing, 
 and such clearing up of the resonance of a dull back he 
 
 Fig 3. 
 
 baa made distinctive between pleurisy and pneumonia. 
 The Bame condition of things obtains in hydrothorax, but 
 
 in some cases the triangle may be still more dull, and re- 
 quire careful auscultation and percussion, owing to the 
 (edema of the limy; itself. 
 
CHAPTER IV. 
 
 HEART. 
 
 Anatomy. — The heart, inclosed in the pericardial sac, 
 lies in an oblique plane extending from the right side 
 above downward and forward toward the left side. It 
 is situated partly behind the sternum and partly behind 
 the right and left costal cartilages. Its highest point, 
 the upper border of the left auricle, corresponds to a line 
 connecting the lower borders of the sternal insertion of 
 the second pair of ribs. Its lowest point is at the middle 
 of the upper border of the sixth left costal cartilage. 
 The heart extends eight or nine centimeters to the left, 
 and four or five centimeters to the right, of the middle 
 line of the sternum. We distinguish in the heart in 
 relation to the chest wall, a right, a lower, and a left 
 border. The right border (Plate I., M N) is formed by 
 the right auricle, and runs in a line curving outward two 
 to three centimeters beyond the right edge of the ster- 
 num, from the middle of the second right intercostal 
 space to behind the sternal end of the fifth right costal 
 cartilage. 
 
 The lower border N O, is formed by the right ventricle, 
 and extends from the sternal end of the fifth right costal 
 cartilage in a slightly descending line to the fifth left in- 
 tercostal space, where it meets with the left border in the 
 mammillary line, or a trifle inside it. 
 
 The left border P o, runs in a convex curve from the 
 second left intercostal space downward and outward to 
 
HEART. 31 
 
 unite with the left end of the lower border at the apex of 
 the heart. 
 
 By far the greater portion of the heart is covered by 
 lung ; only a segment of the organ belonging exclu- 
 sively to the right ventricle lies directly against the 
 chest wall ; this segment is bounded below by the lower 
 edge of the heart, and on the right and left by the di- 
 verging anterior borders of the right and left lung. 
 The size and shape of this parietal portion of the heart 
 depends wholly on the course of the anterior edges of the 
 lungs, which have been fully described elsewhere. Dur- 
 ing quiet respiration it has a four-sided shape (Plate I.). 
 The right border is bounded by the front edge of the 
 right lung running near the left border of the sternum 
 from the level of the fourth to the sixth (or seventh) 
 costal cartilage; the upper border is bounded by that 
 part of the incisura cardiaca behind the fourth left costal 
 cartilage running outward to the fourth intercostal space : 
 the outer side is bounded by the more vertical portion of 
 the anterior border of the left lung, running in a convex 
 curve outward from the fourth intercostal space to the 
 sixth rib. The upper and outer borders unite with no 
 sharp line of division between them, and even in quiet 
 respiration exhibit manifold differences in their course. 
 This uncovered space is crossed diagonally by the left 
 pleura, in such a way that only in the lower portion does 
 the pericardium come in actual contact with the sternum. 
 
 I'ICItCUSSIOX. 
 The heart gives forth a Hat sound where it lies directly 
 against the chest wall. The boundaries of this region of 
 flatness above, to the right and left follow in general the 
 
 course of the anterior edges of the Lungs, and correspond 
 to those lines in which the transition from the clear ve- 
 sicular sound to the tint sound occurs. The lower border 
 
32 PERCUSSION OUTLINES. 
 
 of the heart cannot be defined by percussion, because 
 the flat sound of the heart is indistinguishable from that 
 of the left lobe of the liver. The lower border, therefore, 
 from the point where the liver meets it to the apex of the 
 heart, must be drawn arbitrarily, as described later. 
 
 We recognize an area of absolute flatness and one of 
 relative dullness in the percussion of the heart. It is 
 perhaps unnecessary to add that there are great diversities 
 of opinion in regard to the size and shape of this abso- 
 lute flatness, but we have generally found the following 
 dimensions to be most nearly correct. 
 
 In adults, the absolute cardiac flatness is an irregular 
 quadrangle (Plate IV., ABC D). The right border A C is 
 formed by the left edge of the sternum from the level of 
 the fourth to the sixth or seventh rib ; the upper border 
 A B runs behind the fourth costal cartilage outward and 
 downward, and meets with the left side of the quadrangle 
 at an obtuse angle ; the latter, B D, runs more vertically 
 downward to the sixth rib, where it meets with the lower 
 side of the quadrangle, C D, at an acute angle. While the 
 inner and lower sides have a tolerably constant length, 
 and, as a rule, measure five to six centimeters, the upper 
 and outer sides show manifold differences in their course 
 which it appears superfluous to mention in detail. We 
 need only say, that when the upper side deviates more 
 from a horizontal course, or the outer side becomes less 
 vertical in its direction, the region of absolute flatness 
 becomes smaller, and its form more triangular. The 
 right, the upper, and the left borders of this space are 
 readily obtained by gentle percussion. As the lower 
 border, in the greater part of its course, overlies the left 
 lobe of the liver, we can only obtain it by determining 
 the point on the right, where the cardiac and hepatic 
 flatness meet, and the position of the apex, and then join 
 these two by a straight line. It is only in rare instances 
 
HEART. 33 
 
 that the heart extends beyond the left lobe of the liver, 
 and in such cases the cardiac flatness is bounded by the 
 tympanitic sound of the stomach. 
 
 Notice : Comparison of the absolute cardiac flatness 
 and the portion of heart uncovered by lung shows a dif- 
 ference only in two places. (1.) The right border of the 
 cardiac flatness lies at the left edge of the sternum, the 
 front edge of the right lung on the other hand is half way 
 to the right of this line; the cause of this difference is 
 the oft mentioned vibration of the sternum. (2.) The 
 thin lingula pulmonis overlying the cardiac apex cannot 
 be mapped out. 
 
 The shape of the heart's flatness, described and fig- 
 ured in Plate IV"., A B C D, is normal for healthy people 
 from the middle of the second to the end of the sixth 
 decade. In childhood, and also in old age, the shape and 
 size of this area is somewhat different. In children, the 
 absolute flatness of the heart begins at the third rib, and 
 extends to the mammillary line (Plate VIII.), the apex 
 impulse being frequently met with in the fourth intercos- 
 tal space. The absolute cardiac flatness in children, there- 
 fore, is found to be relatively greater and .situated higher 
 up than in middle age. In old age, on the other hand, 
 the opposite condition is observed (Plate IX.). Here the 
 area of cardiac flatness is smaller, it does not begin till 
 t to tin; fifth rib. and it reaches outward to a less 
 extent ; its height and breadth amount to about four or 
 five centimeters. The cause of this diminution in the 
 size of the absolute flatness is the entrance of the border 
 of the left lung into the sinus-niediastino-costalis depend- 
 ent on senile emphysema, which may be regarded as a 
 normal senile condition. We need hardly call special at- 
 tention to the fact that these three types of cardiac llat- 
 giveil for childhood, adult life, and old age, are not 
 sharply defined, but rather gradually run into each other. 
 3 
 
34 PERCUSSION OUTLINES. 
 
 Active Mobility of the Absolute Cardiac Flatness. 
 
 The boundaries of absolute flatness are found in the 
 shape and extent described above, when the. person exam- 
 ined maintains the dorsal decubitus and breathes nat- 
 urally. These boundaries, however, suffer certain respi- 
 ratory displacements, and also certain displacements in 
 changes of the position of the body ; in other words, 
 they have a considerable active and passive mobility. 
 
 The upper border descends two to three centimeters, the 
 left border moves about as much to the right, and the 
 right border remains unchanged ; so that the absolute 
 cardiac flatness is diminished perhaps one third. With 
 the deepest possible inspiration, only a strip of flatness 
 the breadth of the finger can be discovered close to the 
 sternum, or it may be replaced by a clear pulmonary res- 
 onance at the left edge of the sternum. 
 
 The expiratory displacement of the borders averages 
 two centimeters outward and as much upward. 
 
 Passive Mobility. 
 
 When the individual examined changes from the 
 dorsal decubitus to the upright position, no displacement 
 of the cardiac boundaries follows. On the other hand, 
 when one is in the right lateral decubitus the same effect 
 is observed on the left and upper boundaries as in the 
 deepest possible inspiration ; and very frequently a re- 
 gion of flatness is found on the right of the sternum, 
 between it and the parasternal line, at the level of the 
 fifth or sixth rib, and even as high as the fourth intercos- 
 tal space. This right-sided absolute cardiac flatness is 
 separated from that on the left side by the clear sound 
 of the sternum ; and it may be enlarged by forced ex- 
 piration. The change from the dorsal to the left lateral 
 decubitus involves an excursion of the upper and left 
 
HEART. 35 
 
 borders in the same way : the left border, however, moves 
 somewhat further toward the left than in forced expira- 
 tion. 
 
 Relative Cardiac Dullness. 
 
 The size and shape of the relative dullness of the heart, 
 that is, where it is overlaid by lung, in most healthy in- 
 dividuals between the middle of the second and the end 
 of the sixth decade is represented by the line A I k, 
 Plate IV. 
 
 The right border of the figure is formed by the left 
 edge of the sternum from the level of the third to the 
 sixth intercostal space. 
 
 Above and toward the left the dullness is shut in by a 
 curved line, with its convexity directed outward, I k. 
 The upper more horizontal portion of this curve runs 
 through the third intercostal space, and over the fourth 
 rib obliquely outward and downward. The lower outer 
 portion of the curve runs in a nearly vertical line from the 
 fourth intercostal space to the sixth rib, just inside the 
 mammillary line. 
 
 Notice: 1. The percussion boundary corresponds to 
 the anatomical on the left only. All that portion of the 
 heart lying beneath the sternum and behind the left third 
 rib and second intercostal space cannot be brought out. 
 
 -. The boundary of the cardiac dullness above and to 
 tht; left is parallel to that of the cardiac flatness, and is 
 removed two to three centimeters from the same. 
 
 1 Mobility of the Relative Heart's Dullness. 
 
 The above boundaries suffer displacement just as do 
 those of the absolute flatness on deep inspiration and 
 changes of position ; and this is about the same in kilid 
 and extent as in the absolute flatness. They maintain 
 the same relation to each other, therefore, as in quiet 
 respiration or the dorsal decubitus. Two points deserve 
 to be mentioned, however. 
 
36 PERCUSSION OUTLINES. 
 
 First, In those cases where the absolute flatness quite 
 disappears on deep inspiration, there still remains on 
 the left edge of the sternum, from the level of the fourth 
 to the sixth rib, a region of relatively dull sound several 
 centimeters broad. 
 
 Second, When absolute flatness appears on the right 
 of the sternum in the right lateral decubitus, a zone of 
 dull resonance one or two centimeters in width may also 
 be found surrounding this flatness. (Weil.) 
 
 PATHOLOGY. 
 
 Diminution or disappearance of flatness in the cardiac 
 area is observed: 1. In congenital dexiocardia ; 2. In 
 left-sided pneumothorax with great expansion of the chest 
 and displacement of the neighboring organs ; 3. In ex- 
 tensive emphysema ; 4. In pneumo-pericardium. 
 
 In congenital dexiocardia, usually also in pneumo- 
 thorax of the left side, a cardiac flatness may be demon- 
 strated on the right side between the right edge of the 
 sternum and the right parasternal or mam miliary line 
 between the third or fourth and the sixth rib ; while in 
 great emphysema and pneumo-pericardium there is en- 
 tire absence of all cardiac flatness. In the extremest 
 degrees of emphysema there is everywhere above the 
 lower border of the lungs, even on the left side, a loud, 
 clear pulmonic sound. In less pronounced cases absolute 
 flatness may be absent, but a narrow zone of relative 
 dullness may be demonstrated along the left edge of the 
 sternum in the fifth and sixth intercostal space. In the 
 slightest degrees of emphysema, both relative and abso- 
 lute cardiac flatness can still be outlined, though they are 
 smaller and are situated lower down than in normal 
 conditions. 
 
 The diminution of the cardiac area of flatness in em- 
 physema is explained by the expansion of the lung into 
 
HEART. 37 
 
 the sinus mediastino-costalis. A disappearance of the 
 absolute cardiac flatness may occasionally be caused by 
 the transmission of resonance from the neighboring lung, 
 when the intercostal spaces are very narrow, and the cos- 
 tal cartilages are very elastic. 
 
 In the rare cases where free gas is present in the peri- 
 cardial sac, a clear tympanitic, almost metallic, sound is 
 obtained over the heart when the patient is lying on the 
 back. When the patient sits up or bends forward the 
 sound over the lower portion of the above tympanitic 
 region is dulled because the heart and any fluid pres- 
 ent in the pericardium sinks forward and downward. 
 
 Increase of the Cardiac Flatness. 
 
 In by far the greater number of cases, this is due to 
 hypertrophy and dilatation of the whole heart, or portions 
 of the same, or to the presence of fluid in the pericardium. 
 Again, when the heart is of normal size, and the pericar- 
 dium does not contain fluid, the cardiac dullness may 
 appear to be enlarged upward to the left, or toward the 
 right, or in fact in all directions, by reason of solidifica- 
 tion or retraction of the pulmonary borders. It is not 
 possible to distinguish by means of percussion alone which 
 part of the dullness belongs to the heart, and which to the 
 unaei.it. d lung (or fluid collected in the sinus mediastino- 
 costalis). 
 
 The form of cardiac dullness varies according as the 
 left oi- right ventricle is especially implicated in the dila- 
 tation and hypertrophy. 
 
 In hypertrophy of the left ventricle the boundaries of 
 both the absolute flatness and relative dullness are moved 
 chiefly to the hit and downward, more rarely upward, 
 while the right border remains at the left edge of the 
 sternum or near if. With a moderate increase of volume, 
 as from arterio -clm-osis, the absolute flatness may begin 
 
38 PERCUSSION OUTLINES. 
 
 at the third rib, and extend three or four centimeters 
 beyond the mammillary line at the fifth rib. While, for 
 example, in insufficience. of the aortal valves and conse- 
 quent high degree of hypertrophy and dilatation of the 
 left ventricle, the upper boundary may be normal, and 
 the left may reach into the anterior axillary line. 
 
 In dilatation and hypertrophy affecting chiefly the right 
 side of the heart, the upper borders of both absolute 
 flatness and relative dullness are normal, the left border 
 extends but slightly outward, and the right border either 
 remains at the left edge of the sternum, or, where the di- 
 latation is excessive, a new area of dullness on the right 
 is met with, divided from the normal area by the resonant 
 sternum. This may begin as high as the fourth costal 
 cartilage on the right edge of the sternum, and at the 
 level of the fifth and sixth costal cartilages extend one 
 and a half to two centimeters beyond it. 
 
 The displacements caused by respiratory movements 
 and changes of position with hypertrophy are more con- 
 siderable than in the normal condition. During a deep 
 inspiration the absolute cardiac flatness suffers a consider- 
 able decrease in extent toward the left, and in decubitus 
 on the right side, not only does the same phenomenon 
 occur, but in addition there is found absolute flatness on 
 the right of the sternum. Change from the prone to 
 the upright position of the body does not alter the boun- 
 daries. 
 
 With pleuritic effusion on the left side the heart is dis- 
 placed to the right, and with excessive accumulation of 
 fluid may be carried as far as the right axillary line. 
 
 With effusion on the right side the heart is carried to 
 the left, and may reach to the left axillary line. 
 
 With excessive distention of the abdomen, either by 
 ascites, tumors, or tympanites, the heart is pushed up- 
 ward. In a case of great ascites, confining the patient 
 
PERICARDIUM. 39 
 
 upon the left side, we found the cardiac impulse at the 
 third intercostal space in the left axillary line. The im- 
 pulse presented a peculiar intermittency, coinciding with 
 the respiratory movements, and was very strong during 
 expiration, while it disappeared with full inspiration. 
 
 The mobility of the cardiac boundaries may be lim- 
 ited by pericardial and pleural (sinus inediastino-costalis) 
 adhesions. 
 
 PERICARDIUM. 
 
 Anatomy. — The external or parietal layer of the peri- 
 cardium is the only one presenting any interest to us. 
 It corresponds neither in form nor volume with the inner 
 la er covering the heart, but is so much broader than 
 the latter, that even wdien the heart is moderately filled 
 with blood, it will still hold six ounces of water without 
 being extremely distended. (LuSCHKA.) The physio- 
 logical purpose of this arrangement is evident, and in 
 pathological conditions it affords room for the dilatation 
 and hypertrophy of the heart which are compensatory to 
 valvular lesions, emphysema, and so forth. The peri- 
 cardium reaches beyond the base of the heart up to the 
 middle of the first costal cartilage on the right side, and 
 on the left to the middle of the second costal cartilacre. 
 It extends below on the right to the mam miliary line in 
 the fifth intercostal space, and on the left to the sixth 
 rib at least in the mamniillary line. It is capable of some 
 distention beyond these points. 
 
 l'A THOLOGY. 
 
 Fluid in the pericardium collects in the lowermost part 
 first; and Iiotch, basing his conclusions on a series of 
 injections, claims that flatness in the fifth right inter- 
 costal Bpace, three centimeters from the edge of the 
 sternum, is diagnostic of this condition. The figure ob- 
 tained by percussion is triangular, with a broad base 
 below and a blunt apex above. 
 
40 PERCUSSION OUTLINES. 
 
 With moderate collections of fluid, the blunt apex of 
 the triangle is found in the third or second intercostal 
 space, near the left edge of the sternum. It runs from 
 here obliquely downward, and to the right as far as the 
 sixth rib in the sternal or parasternal line, and to the left 
 beyond the mammillary line. 
 
 If the fluid is very abundant, the apex may be situated 
 at the manubrium sterni, while the base reaches from the 
 right mammillary line at the level of the sixth intercos- 
 tal space, to the left axillary line at the height of the 
 seventh rib or even seventh intercostal space. The area 
 of absolute flatness is said to be greater in the erect than 
 in the prone position, and if this be true it forms a most 
 important point in the differentiation of pericardial ef- 
 fusion from enlarged heart. 
 
CHAPTER V. 
 
 LIVER. 
 
 Anatomy. — Three quarters of the liver lie in the right 
 half of the upper abdomen. This includes the lobus 
 dexter, lobus Spigelii, and generally the entire lobus 
 quadratus. The boundary between the right and left 
 lobes lies, in many cases, in the median line, but it may 
 be a finger-breadth to the right of the same. The left 
 lobe pushes in between the stomach and that portion of 
 the diaphragm upon which rests the heart. It extends 
 five to six centimeters to the left of the median line. 
 
 The upper border of the liver is a curved line corre- 
 sponding to the arch of the diaphragm. Its highest point 
 is in the right mammillary line, where it stands on a 
 level with the fifth pair of ribs in front, and with the 
 ninth dorsal vertebra behind. At the end of expiration 
 it is five centimeters higher than the pneti mono-hepatic 
 border. 
 
 The lower edge of the liver begins at the eleventh rib 
 in the vertebral line. It runs along this rib to the scap- 
 ular line, when it tarns obliquely upward and Forward, 
 and emerges from beneath the costal arch in the mani- 
 millary line, at the level of tin' tenth costal cartilage. 
 It then crosses the epigastrium, meeting tie' median line 
 of the body between the upper and middle thirds <>f the 
 distance; from the umbilicus to the apex of the xiphoid 
 cartilage. It, disappears behind the left costal arch be- 
 tween the hit mammillary and parasternal lines. 
 
42 PERCUSSION OUTLINES. 
 
 PERCUSSION. 
 
 The liver presents two percussion areas and three 
 borders for consideration — the first area is the portion 
 covered by lung ; and it gives a dull resonance on strong 
 percussion. The second area is the lower part of the 
 liver, which is not covered by lung, but lies in actual 
 contact with the chest wall. Here we obtain a flat sound 
 on percussion. 
 
 The superior border corresponds to the arch of the dia- 
 phragm, as previously remarked. Near the vertebral 
 column it is impossible to outline this border, owing to 
 the resonance of the intervening lung. On the sides and 
 in front it can usually be made out with sufficient ac- 
 curacy for practical purposes. (Plate IV., P Q.) With 
 a very thick lung, however, or with emphysema, it is im- 
 possible to detect it. That portion of the superior bor- 
 der which underlies the heart cannot be distinguished 
 because there is no difference between hepatic and car- 
 diac flatness. 
 
 The inferior border is more accessible, and can gene- 
 rally be made out by light percussion. It is indicated 
 by the transition from hepatic flatness to intestinal and 
 gastric resonance. When the intestines and stomach 
 are very resonant the percussion must be very light. 
 
 The pneumono -hepatic border separates the hepatic 
 flatness from the pulmonic resonance, and has already 
 been described. Irrespective of the actual size of the 
 liver, the area of hepatic flatness will depend upon the 
 position of this border, and therefore will diminish with 
 inspiration and emphysema, and be increased by expira- 
 tion or other shrinkage of the lung. 
 
 Gall Bladder. — The gall bladder ordinarily lies 
 beneath the liver, and is inaccessible to palpation or per- 
 cussion. Let the exit of bile be obstructed, however, 
 
LIVER. 43 
 
 and the gall bladder becomes distended by accumulated 
 secretion, and it will pi-oduce a well-defined tumor. In 
 such cases the tumor appears at the angle formed by the 
 junction between the lower border of the liver, as it 
 emerges from the costal arch, and the outer border of the 
 rectus abdominis muscle. The dull area is then usually 
 pear-shaped, and may be defined by the resonant intes- 
 tines about it. 
 
 PATHOLOGY. 
 
 Changes in the size of the liver are often very difficult 
 to determine by percussion, and even when variations in 
 the extent of hepatic flatness are detected it is still diffi- 
 cult to decide whether such variations are due to modifi- 
 cations of the liver itself or of the neighboring organs. 
 A diminution of the area of hepatic flatness may be pro- 
 duced by acute or chronic atrophj' of the liver. It may 
 also he due to the intrusion of coils of intestine between 
 the liver and abdominal wall. Tympanites, ascites, ova- 
 rian ami uterine tumors will produce the same result by 
 pushing the liver further up behind the lung. Emphy- 
 sematous enlargement of the lung, by lowering the pneu- 
 mono-hepatic border, will make the liver appear small. 
 An actual diminution of the liver can be diagnosed only 
 when, with decreased Hat area, we still find the pneumono- 
 bepatic border at normal height, ami we can exclude' all 
 conditions which produce elevation or twisting of the 
 organ. Tin- most difficult eases to decide are those where 
 a loop of intestine lies between the liver and the, chest 
 wall. Frerichs says that this condition may be surmised 
 when one <>!' the diameters of the liver is unusually small 
 as compared with the remaining diameters. 
 
 An enlargement of the area of hepatic flatness occurs 
 
 with hypertrophy of the organ Itself; also with any re- 
 traction of the lung which elevates the pneumono-hepatio 
 border. Displacements of the liver by pressure of tho- 
 
44 PERCUSSION OUTLINES. 
 
 racic tumors or pleuritic exudations cause an enlargement 
 of the flat area. In all such cases, therefore, it is ob- 
 vious that no diagnosis regarding the actual size of the 
 liver can be made until all associated conditions have been 
 carefully reviewed. 
 
 Weil gives the following valuable schedule of possible 
 complications, which cannot fail to be of service in de- 
 ciding many obscure cases. 
 
 1. The inferior border of the liver is in normal posi- 
 tion : — 
 
 (a) The pneumono-hepatic border is high : en- 
 largement of liver upward ; medium-sized pleu- 
 ritic effusion ; enlargement of liver with coin- 
 cident dislocation upward, as in hyperemia or 
 amyloid liver with ascites. 
 
 (6) The pneumono-hepatic border is low : emphy- 
 sema of moderate degree. In such a case the 
 height of the hepatic dull zone, above the 
 pneumono-hepatic line, is normal or increased. 
 
 2. The inferior border of the liver is too low. 
 
 (a) The pneumono-hepatic border is high : very 
 large hypertrophy or tumor of liver : large pleu- 
 ritic exudation. 
 
 (6) The pneumono-hepatic border is normal : hy- 
 pertrophy of liver ; anomalous position of the 
 same. 
 
 (c) The pneumono-hepatic border is low : exces- 
 sive emphysema ; pneumothorax. 
 
 3. The inferior border of the liver is too high. 
 
 (a) The pneumono-hepatic border is high : dislo- 
 cation upward. 
 
 (6) The pneumono-hepatic border is normal : atro- 
 phy of liver ; dislocation upward. 
 
LIVER 45 
 
 4. The hepatic flatness is entirely absent. 
 
 Oblique position of the liver, with ineteorismus and 
 ascites ; intervention of intestines ; formation 
 of free gas in the peritoneal cavity. 
 
 5. Transposition of the hepatic flatness to the opposite 
 side of the body in cases of congenital transposition of all 
 the internal viscera. 
 
CHAPTER VI. 
 
 THE SPLEEN. 
 
 Anatomy. — The spleen is situated in the left hypo- 
 chondrium, between the diaphragm, the left kidney, and 
 the posterior wall of the stomach. It extends from the 
 ninth to the eleventh rib, with its longest diameter di- 
 rected obliquely forward and downward, following the 
 course of these ribs. We distinguish an upper end 
 (Plate II.) distant two centimeters at least from the 
 body of the tenth dorsal vertebra, and an anterior end, 
 corresponding to the point lying nearest the middle line 
 of the body. When the spleen is oval in shape, besides 
 the upper and anterior ends, we may speak of two bor- 
 ders, an anterior and a posterior, which unite at G and 
 H. The anterior end is about in the axillary line, and 
 does not extend beyond the linea costo-articularis under 
 normal conditions. The anterior edge corresponds to the 
 course of the ninth rib ; in its upper portion it is covered 
 by lung, and only emerges from the pulmonary edge in 
 the posterior axillary line. In the angle made by the 
 lower border of the lung and the spleen, the stomach and 
 colon are located. The posterior edge follows the elev- 
 enth rib, and overlaps the left kidney a short distance 
 in its middle third. Where the posterior edge of the 
 spleen and the outer border of the kidney meet, the de- 
 scending colon is situated. When the shape of the spleen 
 is more rhomboidal, its front edge follows the course of 
 the ninth rib still farther forward than in the oval form, 
 
SPLEEN. 47 
 
 and the lower edge runs obliquely backward and down- 
 ward. 
 
 Notice : 1. About a third of the spleen (the upper 
 end, a part of the front and posterior borders) is covered 
 by lung. 
 
 2. The posterior border of the spleen lies in apposition 
 to the anterior border of the left kidney for about a third 
 of its course. 
 
 PERCUSSION. 
 
 We are unable to define by percussion that portion of 
 the spleen which is covered by lung. We can at most 
 obtain, in some cases, by strong percussion, a relatively 
 dull sound above the lower edge of the lung, extending 
 from the anterior axillary line to midway between the 
 posterior axillary and scapular lines, or to the scapular 
 line. The upper border of this ai'ea is parallel to the 
 pneumono-splenic border at a distance of two or three 
 centimeters. Between the scapular line and the vertebras 
 relative dullness for the spleen is no more demonstrable 
 than is the case with the liver on the other side. Be- 
 tween the anterior axillary line and the mammillary line, 
 as a rule, there is also no relative dullness above the edge 
 of the left lung. On gentle percussion the sound here is 
 as loud as it is higher up, and on stronger percussion it 
 usually becomes tympanitic, because the stomach, which 
 is full of air, is set in vibration underneath the lung. 
 The same condition frequently occurs also between the 
 posterior axillary and scapular lines, so that here like- 
 wise there is no relative dullness above the pneumono- 
 splenic boundary. 
 
48 PERCUSSION OUTLINES. 
 
 DETERMINATION OF THE BOUNDARIES OF THE 
 SPLEEN. 
 
 The best position for the patient to assume is decubi- 
 tus on the right side, diagonal decubitus (on the right 
 shoulder-blade and right hip), or standing erect. The 
 disadvautage of the first position is that the lower end 
 of the organ is often difficult to define, from the near 
 approach of the crest of the ileum to the lower ribs. 
 The disadvantage of the second position is that unless 
 the patient is near the edge of the bed, it is often im- 
 possible to define the posterior boundary. While the 
 chief disadvantage of the last position is the impossi- 
 bility at times of placing the patient erect. Where 
 great accuracy is sought, it is well to compare the bound- 
 aries found in the recumbent position with those obtained 
 while the patient is upright. If the spleen is percussed 
 in the upright position, we must in the first place deter- 
 mine the pneumono-splenic border, by percussing verti- 
 cally downward from above, in the vertebral, scapular, 
 posterior, middle, and anterior axillary lines. We thus 
 obtain the border B D (Plate V.), corresponding to the 
 lower edge of the left lung. Below the edge of the lung 
 we find, as far as the point E in the posterior (or middle) 
 axillary line, a dull sound ; further forward, a tympanitic 
 sound. If we percuss vertically downward in the axillary 
 region, we find, at I and K, the transition of the dull to 
 the loud tympanitic sound, and thus obtain the oval fig- 
 ure of dullness E K L. Posteriorly, the splenic dullness 
 becomes merged in that of the kidney and thick dorsal 
 muscles, and is difficult to outline. 
 
 The size of the organ is determined by the vertical 
 diameter of dullness in the axillary line, and by the dis- 
 tance of the anterior end of dullness from the costal arch. 
 To give the normal boundaries of splenic dullness in the 
 
SPLEEN. 49 
 
 upright position more exactly, the pneumono-splenic 
 angle, as a rule, is in the posterior axillary line; or be- 
 tween it and the middle axillary line, at the level of the 
 ninth rib ; more rarely of the ninth or eighth intercostal 
 space. The distance of the lower splenic border from the 
 upper one in the vertical line is five and a half to six and 
 a half, sometimes even seven, centimeters. The anterior 
 end of the spleen is behind the costo-articular line, or 
 at most, just reaches it ; or in other words is four to six 
 centimeters from the costal arch. In using the linea 
 costo-articular is as a defining point for the position of the 
 anterior border of the spleen, we must remember that, on 
 account of the varying length of the eleventh rib in dif- 
 ferent people, this line may be carried more toward the 
 front, sometimes more towards the back. 
 
 To define the splenic dullness we must employ some- 
 times gentle, sometimes strong percussion. Thus, while 
 the pneumono-splenic boundary between the axillary and 
 scapular lines, as a rule, is better obtained by medium 
 strong percussion, the definition from the tympanitic 
 sound of the stomach and colon, in cases where these or- 
 gans contain much gas, is better made by gentle percus- 
 sion, since by strong percussion the organs lying behind 
 the spleen are set in vibration, and their tympanitic 
 sound either causes the splenic dullness to appear too 
 small, or to disappear altogether. On the other hand, 
 the difference in sound is more distinct on strong per- 
 cussion when the stomach and colon have fluid or solid 
 contents. The sound is seldom perfectly fiat in the re- 
 gion where the spleen is accessible to percussion. There 
 is usually a tympanitic accessory sound which La espe- 
 cially distinct toward the edges of the organ. The boun- 
 daries of the spleen, therefore, as of the liver, are to be 
 placed where the tympanitic sound becomes clear and 
 loud ; or better, where the loud tympanitic sound of the 
 i 
 
50 PERCUSSION OUTLINES. 
 
 stomach and colon begins to be dulled, as we approach the 
 splenic region. 
 
 On change from the upright to the right lateral decu- 
 bitus, the pneumono-splenic border sinks two to four cen- 
 timeters, and the anterior extremity of the spleen ad- 
 vances to or beyond the linea costo-articularis. The dull 
 area of the spleen thus assumes a narrower and more 
 horizontal position. 
 
 Slight deviations from the conditions already given are 
 exceedingly common ; as, for instance, instead of the oval 
 figure described above as normal, we may obtain by our 
 percussion a figure distinctly triangular or rhomboidal ; 
 or, especially when the patient is in the upright posture, 
 the longest diameter may run more vertically. Still 
 these are all rather exceptions to the rule. Other varia- 
 tions from the conditions mentioned are caused by differ- 
 ences of age in the individual. Corresponding to the 
 lower position of the pneumono-splenic border, we always 
 find in advanced age the upper border of the splenic dull- 
 ness deeper, and the splenic dullness itself smaller than 
 in persons of middle age. It is of the greatest practical 
 importance to know all the conditions which render de- 
 termination of the splenic boundaries either difficult or 
 impossible. Cases are by no means rare in which, while 
 the lower border of the left lung has a normal position, 
 yet the splenic dullness cannot be demonstrated at all, 
 or it has a very circumscribed area. In such cases the 
 pulmonic sound suddenly changes to a loud tympanitic 
 one. The conditions which cause a diminution or disap- 
 pearance of the splenic dullness in perfectly healthy indi- 
 viduals are usually merely transitory, and depend on the 
 presence of a considerable volume of gas in the organs sur- 
 rounding the anterior and posterior edges of the spleen, 
 that is, in the stomach and colon. They are of less prac- 
 tical importance than a diffused dullness so frequently 
 
SPLEEN. 51 
 
 seen in health, extending far beyond the normal bounda- 
 ries, and they do not lead so often to a false diagnosis. 
 This diffused dullness in the region of the spleen is 
 readily explained. If the underlying colon and stomach 
 do not contain gas, but are filled with solid or liquid 
 substances, they give forth a sound which is indistin- 
 guishable from that of the spleen. The splenic dullness 
 then runs over into that of these organs, and therefore 
 appears enlarged. In such cases, an examination after 
 fasting for a time, or after a brisk cathartic, will show 
 that the splenic dullness may be normal after all. Again, 
 a very fat omentum may stretch to the left end of the 
 transverse colon, and displace it from the thoracic wall. 
 The shape of the dullness will often rouse suspicion that 
 we have something else before us; as, for example, when 
 the dullness is only five or six centimeters broad and 
 reaches to the costal arch, or when it has a breadth of 
 eleven centimeters and does not extend beyond the linea 
 costo-articularis. In cases where the shape of the dull- 
 ness is correct for that of the spleen, but differs only 
 in point of size, we may often arrive at the truth by 
 comparative percussion in different positions. The true 
 splenic tumor gives approximately the same relation to 
 the linea costo-articularis on repeated percussion, while 
 the boundaries of the apparent tumor are characterized 
 by their changeableness. 
 
 Passive Mobility. — The displacements to which the 
 splenic dullness is subject on change of position have 
 been already mentioned. There still remain the respira- 
 tory displacements, which are worthy of brief notice. 
 They have been hinted at above in speaking of the po- 
 sition of the diaphragm. With every inspiration the 
 splenic dullness is diminished in size and brought lower, 
 while the anterior end of the organ sometimes remains 
 undisturbed in its place and sometimes moves forward 
 
52 PERCUSSION OUTLINES. 
 
 and downward one or two centimeters. The descent of 
 the lower border depends on the descent of the whole 
 organ through contraction of the diaphragm ; the lower 
 border, after the deepest possible inspiration, is about one 
 centimeter lower, and the pneumono-splenic border about 
 three to four centimeters lower than before. If a deep 
 inspiration is made while in the right lateral decubitus, 
 the splenic dullness disappears completely, except in a 
 narrow line. In deep expiration the splenic dullness as- 
 cends and enlarges, because the lower border makes a 
 smaller excursion than the upper border. 
 
 PATHOLOGY. 
 
 The spleen may be either diminished or increased in 
 size, or it may be dislocated. 
 
 In mentioning the difficulties attending the determina- 
 tion of the splenic boundary, we called attention to the 
 fact that sometimes the splenic dullness was wholly ab- 
 sent. In certain diseases, emphysema, gas or fluid in the 
 peritoneal sac, we find it either much diminished or ab- 
 sent, for reasons sufficiently obvious. In wandering spleen 
 absence of dullness in the normal area may assume diag- 
 nostic importance, especially when a tumor situated else- 
 where in the abdomen can be replaced, and supply the 
 absent dullness. 
 
 Splenic Tumor. — The cautions mentioned above will 
 fully illustrate the care necessary in determining the ex- 
 istence of splenic enlargement. A diagnosis of such en- 
 largement, therefore, should not be made from one ex- 
 amination. Moderate enlargements of the organ are 
 shown by increase of the vertical diameter of the dull- 
 ness from five or six to nine or twelve centimeters ; also 
 by the advance of the anterior end to, or beyond, the 
 costal arch. At the same time the pneumono-splenic 
 border moves upward. The increase in the breadth of 
 
SPLEEN. 53 
 
 the dullness is caused by the descent of the lower and the 
 ascent of the upper border of the spleen. The lower 
 border may then reach in the right lateral decubitus as 
 far as the twelfth rib or even lower, the pneumono-splenic 
 border may stand in the middle axillary line at the 
 eighth rib, seventh intercostal space, or at the seventh 
 rib even. 
 
 The intensity of dullness in enlarged spleen is almost 
 without exception greater than that in the normal 
 spleen. 
 
 The dislocation resulting from fluid in the chest is for- 
 ward and downward, or the spleen may be made to as- 
 sume a more vertical position, and at the same time be 
 depressed. 
 
CHAPTER VII. 
 
 THE STOMACH. 
 
 Anatomy. — The stomach is so placed in the abdomen 
 that, no matter what changes of volume it undergoes, 
 about three quarters of it lie in the left hypochondrium 
 and one quarter in the epigastrium. Its longest diameter 
 runs obliquely from behind downward and forward to- 
 ward the right side ; the pyloric end curves slightly up- 
 ward, as a rule, in the median line, so that, on moderate 
 distention of the stomach the lowest point of the organ 
 falls in the middle of the space between the end of the 
 processus xiphoideus and the umbilicus. A horizontal 
 line from this point to the left border of the ribs runs 
 just below the junction of the greater curvature with the 
 costal arch. 
 
 The beginning of the stomach, the cardiac portion 
 (Plate I.), or, more correctly, the abdominal portion of 
 the oesophagus, is about on the level of the sternal edge 
 of the left sixth intercostal space, distant at least ten 
 centimeters from the anterior wall of the thorax. 
 
 The pyloric portion lies in the right half of the epigas- 
 trium, and, as a rule, barely reaches to the right costal 
 arch. 
 
 The small curvature hugs the lumbar vertebrae. 
 
 The great curvature is turned toward the lateral wall 
 of the left hypochondrium and the inner side of the an 
 terior abdominal wall. 
 
 The front, upper side, of the stomach, while in the left 
 
STOMACH. 55 
 
 hypochondrium, follows the concavity of the diaphragm, 
 the fundus occupying the highest point of the latter 
 (level of the fifth rib). This surface of the stomach is, 
 to a great extent, overlaid by the base of the left lung ; 
 while the portion located in the epigastrium is in part 
 separated from the anterior abdominal wall by the left 
 lobe of the liver. 
 
 The lower posterior surface of the stomach, which is in 
 part directed toward the dorsal wall of the abdomen, and 
 in part directed downward, at no place comes in direct 
 contact with the abdominal wall. Along the greater curv- 
 ature runs the transverse colon, ending in the region of 
 the fundus as the flexura coli sinistra. 
 
 Notice: 1. The whole posterior and lower side of the 
 stomach nowhere lies next the wall of the body. 
 
 2. The cardia, small curvature, a part of the front up- 
 per surface, are separated from the anterior abdominal 
 wall by the left lobe of the liver ; another part of the 
 front upper side and the great curvature are separated 
 from the wall of the thorax by lung. 
 
 3. Only a small portion of the anterior superior sur- 
 face lies directly against the abdominal wall. (Plate 
 
 I., W.) 
 
 PERCUSSION. 
 
 Percussion of the stomach presents certain difficulties 
 due to its varying size, according to the degree of dis- 
 tention with fluid, solid, and gas, and to the tension of the 
 abdominal wall. The sound given forth is, according to 
 these different conditions, dull, tympanitic, or metallic. 
 In addition, there is also the sound of the colon, which we 
 must distinguish from that of the stomach, and which, 
 with the changeable degree of distention, is often diffi- 
 cult. 
 
 In percussing the stomach, we assume the organ to be 
 partly filled. In the dorsal decubitus the solid and fluid 
 
56 PERCUSSION OUTLINES. 
 
 contents collect in the posterior portion of the stomach. 
 While the gaseous contents rise anteriorly, and with a 
 moderate degree of distention of the gastric wall, occa- 
 sion a tympanitic sound. The boundaries of this sound 
 are as follows, under the conditions given above. 
 
 1. Above and to the right the gastro-hepatic boundary. 
 (Plate I.) 
 
 2. Above and to the left the pneumono-gastric bound- 
 ary. 
 
 3. Below the lower boundary of the stomach, corre- 
 sponding to the greater curvature. 
 
 4. Between the gastro-hepatic and pneumono-gastric 
 boundaries, in cases where the left lobe of the liver is 
 overlaid toward the left by the absolute cardiac flatness, 
 is a gastro-cardiac boundary. 
 
 Of these boundaries the only actual one is the lower. 
 This is determined by a change from the tympanitic 
 sound of the stomach to one of a different pitch or clear- 
 ness, coming from the transverse colon ; and it is situated 
 midwav between the end of the processus xiphoideus and 
 the umbilicus, and runs thence in a tolerably horizontal 
 line to the left hypochondrium, and crosses the costal 
 arch about on a level with the ninth costal cartilage ; 
 thence following very nearly the course of the eighth rib, 
 it disappears behind the lower edge of the lung in the 
 middle axillary line. The lower border of the stomach 
 can be followed but a few centimeters to the right of the 
 median line, because it passes behind the lower edge of 
 the liver. The lower border varies from the above points 
 according to the greater or less degree of distention of 
 the stomach. The middle and right hand portions of 
 this boundary vary but little from the points given ; the 
 left, on the other hand, is capable of considerable varia- 
 tion. The less the degree of distention of the organ, the 
 more does it retract from the pneumono-splenic angle, till 
 
STOMACH. 57 
 
 it may meet the lung at the sixth rib even. In great 
 distention of the stomach, on the other hand, this entire 
 angle may be filled out. From the above facts, it is plain 
 that we must be content with defining that portion of the 
 stomach lying next the anterior thoracic and abdominal 
 wall. ' 
 
 PATHOLOGY. 
 
 Diminution of the gastric area of resonance may occur 
 from enlargement of the left lobe of the liver, from sple- 
 nic tumor, from an enlarged heart, or from emphysema of 
 the lung; the stomach in each instance remaining of 
 normal size, but being overlaid by the pathological 
 organs. 
 
 Increase of the gastric area of resonance, gastric dila- 
 tation is of greater importance. When the patient is 
 examined while lying on the back, the lower border cor- 
 responding to the greater curvature, is found to be lower 
 than normal, either at the umbilicus, below it, or, in ex- 
 treme cases, near the symphysis pubis. When the patient 
 is examined in the erect position, a dullness is obtained, 
 the lower border of which is somewhat lower than that 
 of the tympanitic resonance found in the horizontal po- 
 sition, and is due to the gravitation of the contents of 
 the stomach. 
 
CHAPTER VIII. 
 
 THE KIDNEYS. 
 
 Anatomy. — The kidneys lie on each side of the verte- 
 
 Dral column, close to the posterior abdominal wall, at the 
 
 level of the last dorsal and two or three upper lumbar 
 
 vertebrae. The right kidney is usually a little lower than 
 
 the left (Plate III.) The concave edge is toward the 
 
 spine, the convex edge is directed outward. The upper 
 
 end of the right kidney extends under the liver, so that 
 
 about a third of it is covered by the latter. The left 
 
 kidney touches the posterior lower border of the spleen, 
 
 as described above. Viewed from behind, the kidneys 
 
 are overlaid and about half covered by the eleventh and 
 
 twelfth ribs. The duodenum and ascending colon are in 
 
 front of the right kidney, and the descending colon is 
 
 in front of the left kidney. The colon encircles the 
 
 outer edge of each kidney. Behind, the kidneys lie on 
 
 a thick layer of muscle, the pillars of the diaphragm, 
 
 quadratus lumborum, transversus abdominis, sacro-spina- 
 
 lis, and latissimus dorsi. The lower end of the kidneys 
 
 is two to six centimeters above the crest of the ileum. 
 
 The outer edge extends ten centimeters from the median 
 
 line, so that the two outer edges are twenty centimeters 
 
 apart. 
 
 PERCUSSION. 
 
 *In the normal condition, the kidneys are not acces- 
 sible to percussion, owing to the thickness of the muscles 
 of the back, and to the resonance of the neighboring 
 
THE KIDNEYS. 59 
 
 intestines. The dullness obtained in the renal region, 
 and usually attributed to the kidneys (Plate VII., H I 
 and K l), has been found by Weil to be the same after 
 extirpation of one kidney ; and in a case of floating kid- 
 ney this dullness was the same both before and after 
 reposition of the organ. 
 
 Extreme cases of hydronephrosis and very large tumors 
 of the kidneys may produce a distinct flat area of their 
 own, 
 
CHAPTER IX. 
 
 THE BLADDEE. 
 
 Anatomy. — The bladder is situated in the pelvis, be- 
 hind the pubes. In the male, the rectum is directly 
 behind it ; and in the female, the uterus and vagina. 
 The shape and position of the bladder are greatly in- 
 fluenced by age, sex, and the degree of distention of the 
 organ. In infancy, the bladder is conical and projects 
 into the abdomen above the pubes. In the adult, when 
 empty, it is a triangular sac (three centimeters in diam- 
 eter usually) flattened from before backward, with its 
 apex reaching nearly as high as the upper border of the 
 symphysis pubis. When slightly distended, it has a 
 rounded form ; when greatly distended, it is oval. Its 
 longest diameter in the latter condition is vertical and 
 curved slightly forward. In the female, the bladder is 
 larger in the transverse than in the vertical diameter, and 
 is said to be more capacious than in the male. When 
 contracted, it has two lateral sinuses, which override 
 the vagina like saddle-bags. This fact, together with the 
 greater roominess of the female pelvis, permits a consid- 
 erable accumulation of urine in the bladder without any 
 appearance of the organ above the pubes. 
 
 The average capacity of the bladder, in health, is 500 
 cubic centimeters. 
 
 PERCUSSION. 
 
 The empty bladder in the adult cannot be reached by 
 percussion. How large a quantity of urine is requisite to 
 
THE BLADDER. 61 
 
 render the bladder accessible depends on the curve and 
 and thickness of the abdominal wall, and on the condition 
 of the neighboring intestine. The first effect of the col- 
 lection of urine within the bladder is to render the organ 
 spherical ; and it is not till a considerable quantity is 
 present, even in the most favorable subjects, that any- 
 thing like certainty can be attained on percussion. We 
 have found that an area of flatness extending ten centi- 
 meters above the pubes and nine centimeters in breadth, 
 coincided with six hundred and seventy cubic centimeters 
 of urine drawn immediately after the measurements were 
 made, in a man with emaciated and relaxed abdominal 
 wall. In another man, with a moderately prominent ab- 
 domen, four hundred cubic centimeters did not give any 
 evidence of its presence. 
 
CHAPTER X. 
 
 THE UTERUS. 
 
 In the unimpregnated condition, the uterus lies below 
 the brim of the pelvis. During pregnancy, after the 
 fourth month it begins to rise above the brim, and may 
 be outlined under favorable conditions. At the fifth 
 month, it stands half way between the symphysis pubis 
 and the umbilicus, in the median line. At the sixth 
 month it has reached the umbilicus. At the seventh 
 month it extends one third the distance between the 
 umbilicus and the processus xiphoideus. At the eighth 
 month, it is two thirds the distance between the above 
 points ; and at the ninth, it touches the lower end of the 
 processus xiphoideus. 
 
 Fig. 4. (Chadwick.) 
 
 LUNAR 
 
 MONTHS. 
 
 9th. 
 
THE UTERUS. 63 
 
 The resonance of the surrounding intestines often ob- 
 scures the percussion outlines of the impregnated uterus, 
 and more information can usually be obtained by palpation 
 than by percussion. 
 
CHAPTER XL 
 
 THE PERITONEUM. 
 
 Ascites. — The amount of fluid within the peritoneum 
 must be considerable to give evidence of its presence by 
 percussion. If it lies next the abdominal wall we obtain 
 dullness or flatness, according to its quantity. Free fluid 
 gravitates to the lowest part of the sac, so that the 
 boundaries of dullness or flatness vary with the position 
 of the patient. With moderate effusions, the lower bor- 
 der of the lungs, heart, and liver stand higher than normal. 
 The hepatic flatness appears to be decreased in size, be- 
 cause the intestines are displaced upward, and, where the 
 collection of fluid is large, the liver is tilted on its axis. The 
 splenic dullness is also found to be higher than normal and 
 smaller, unless the ascites depends on a condition which 
 gives rise to splenic tumor. When the patient is in the 
 supine position the upper border of flatness is crescent- 
 shaped, with the concavity directed upward. In the erect 
 posture it is horizontal. In the lateral decubitus the 
 flatness changes to the lower side, and is replaced in the 
 opposite flank by the clear resonance of the intestines. 
 When the amount of fluid is very great a flat sound is 
 obtained everywhere, except in the epigastrium, near the 
 processus xiphoideus, where it remains somewhat tym- 
 panitic. 
 
 The points of differentiation from Ovarian Tumor are 
 as follows : — 
 
 In Ascites, in the dorsal decubitus, the sound is tym- 
 
THE PERITONEUM. 65 
 
 panitic, in a curved line with the concavity upward, the 
 epigastrium being resonant and the flanks flat. Fur- 
 thermore, change of position gives modification of the 
 curve. 
 
 In Ovarian Tumor, the tympanitic resonance remains 
 longest in the flanks ; while, as a rule, the highest point 
 of flatness is in the middle line of the body, and change 
 of position, unless the tumor be small, gives rise to less 
 modification of the flatness. (Olshausex.) 
 
 The above distinctions are not absolute, since strong 
 percussion may bring out a deep-seated resonance in colon 
 or ccecum, or deep pressure may displace ascitic fluid. 
 
 In a patient with considerable ascites, we found that 
 in the dorsal decubitus, the line of flatness commenced at 
 the costal arch in the parasternal line on each side, and 
 swept round in a gentle curve to two and a half centime- 
 ters below the umbilicus. 
 
 GAS IN THE PERITONEUM. 
 
 If there is free gas in the peritoneum the sound has the 
 same pitch and distinctness throughout the whole abdo- 
 men ; this is, according to the degree of distention of the 
 abdomen, tympanitic, or metallic. 
 
 The hepatic flatness and splenic dullness may be absent 
 when the amount of gas is large, and there are no adhe- 
 sions of these organs to the abdominal wall. 
 
 In Meteorism similar results to the above may be ob- 
 tained by percussion, but usually the diffevenl clearness 
 and pitch of the sound in various parts of the abdomen 
 indicate that the gas is contained in coils of intestine of 
 different si/.e, and not in a single cavity. More impor- 
 tant data for distinguishing between these two condi- 
 tions, however, are obtained by other methods of inves- 
 tigation. 
 
 5 
 
Plate I. 
 
 Anatomical Borders — Anterior View. (Weil.) 
 
 A B, border of the right pleural nc. 
 
 C 0, border of the left pleural sac. 
 
 E P, edge of the right lung. 
 
 G H, edge of the left lung. 
 
 I, upper incinura Interlobular!* of the right lung. 
 
 K. lower inclsura interlobular™ of the right lung. 
 
 L, left incigura interlobular™. 
 
 M N, right border of the heart. 
 
 N O, lower border of the heart. 
 
 P O, left border of the heart. 
 
 Q, sinus TnediaatinocostallH, situated between the edge 
 of the pleura and incisure cardiaca of the anterior 
 border of the left lung. 
 
 R, highest point of the portion of liver coTered h\ 1 uim 
 
 S, lnwrr edge of the llTer. 
 
 T, cardiac portion of the stomach. 
 
 U. pyloric portion of the stomach. 
 
 V, -mall curvature of the stomach. 
 
 W, greater curvature of the stomach. 
 
Plate II. 
 
 Anatomical Borders on Left Side. (Weil.) 
 
 A 8 lower border of the left long. 
 A C, lower boundary of the pleura. 
 D E, tneisura Interlobnlaris. 
 F, edge of the left lobe of the Iirer. 
 
 H G, anterior and posterior ends of the spleen. 
 
 K, kidney. 
 
 N, stomach in moderate distention. 
 
Plate III. 
 
 x.*r 
 
 Anatomical Borders — Posterior View. (Weil.) 
 
 A, B, lower border* of the lung*. H, splevn. 
 
 C, 0, lower borders of the pleurtc. I, lower border of the ll»er. 
 
 E, F, inrisiirn- interlobulares. K, L, kidney*. 
 
 G, point where th« right inclsura divides into the sulc. interlob. dcxt. super, ami infer 
 
Plate IV. 
 
 Percussion Borders in Middle Age. (Wkil.) 
 
 ABCD, area of cardiac flatness. 
 A I K. area of cardiac dullness. 
 C E, lower border of right lung. 
 D F, lower border of left lung. 
 
 G, H, upper borders of lungs. 
 
 P Q, upper border of hepatic dullness 
 
 L M, lower border of hepatic flatness. 
 
 N O, lower border of stomach in moderate distention 
 
Plate V. 
 
 c^ 
 
 
 Percussion Borders on Left Side. (Weil.) 
 
 A B, lower border of hepatir flatneM. 
 C D, lower border of left lung. 
 
 E I L, splenic duilnew. 
 Q, lower border of stomach 
 
Plate VI. 
 
 ■ 
 
 -^K3--: 
 
 \ 
 
 % 
 
 . 
 
 Percussion Borders on Right Side. (Weil.) 
 
 A B, lower border of the right lung. C 0, lower border of hepatic Mitt lies* 
 
 E F, upper border of hepatic dullness 
 
Plate VII. 
 
 Percussion Borders ou the Back. (Wkil.) 
 
 A B, upper border of lungs H I, K L, outer borders of the so-railed renal dullness. 
 
 C 0, lower border of lungs. M N, lower borders of the lungs In deepest inspiration. 
 
 E H, lower border of spleen. O P, shrinkage of upper border nf lung in phthisis. 
 
 K F. lower border of hepatic flatness. 
 
Plate VIII. 
 
 Percussion Borders in Childhood. (WlXL.) 
 
 A B C D, cardiac flatm-PH. 
 I G H, cardiac dullness. 
 
 EC, FO, lower border* of the lungs 
 K, lower border of the liver. 
 
Plate IX. 
 
 /.-— iflfc^ 
 
 r> 
 
 
 
 Percussion Borders in Old Age. (Weil.) 
 
 A B C D, cardiac flatness. C E, F, lower borders of the lungs 
 
 G H, cardiac dullness. M L, lower border of hepatic flatness. 
 
 K, upper border of hepatic dullness.