College of ^f)piitian^ anh ^urgeontf 
 
 ©r. Maltet J@. Barnes; 
 
THE 
 
 PHYSICAL SIGNS OF CARDIAC DISEASE 
 
Ipvicc 3/e 
 
 The Physical Signs of Pulmonary 
 Disease. 
 
 For the Use of Clinical Students. 
 
 BY 
 
 GRAHAM 8TEELL, M.D., F.R.C.R, 
 
 Physician to the MancJiester Royal Infirmary. 
 
 Manchester: J. E. CORNISH, 16, St. Ann's Square. 
 
THE 
 
 PHYSICAL SIGNS 
 
 CARDIAC DISEASE 
 
 GRAHAM STEELL, M.D. Edin. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON ; PHYSICIAN TO THE 
 
 MANCHESTEK ROYAL INFIRMARY ; AND LECTURER IN CLINICAL 
 
 MEDICINE, OWENS COLLEGE. 
 
 For the Use of Clinical Students 
 
 Second BC)ttion 
 
 MANCHESTER : J. E. CORNISH 
 1891 
 

TO THE 
 
 STUDENTS OF THE MANCHESTER ROYAL INFIRMARY 
 
 FOR WHOM IT WAS WRITTEN 
 
 I DEDICATE 
 
 THIS LITTLE WORK. 
 
CONTENTS. 
 
 
 PAGB 
 
 Anatomical Considerations, 
 
 1 
 
 Introductory Remarks, 
 
 8 
 
 Inspection, ..... 
 
 10 
 
 Palpation, . . . . • 
 
 19 
 
 Percussion, ..... 
 
 26 
 
 Auscultation, ..... 
 
 37 
 
 Appendix, 
 
 66 
 
ANATOMICAL CONSIDERATIONS. 
 
 There are certain essential points in the anatomy of the heart 
 Avhich it is important for the chnical student to bear in mind. 
 What may be termed " applied " anatomy will alone be con- 
 sidered here. 
 
 As to the Position of the Hea7't and Great Arteries in the Chest. 
 — The heart may be regarded as an irregular cone in shape, and 
 its longitudinal axis from base to apex runs from above down- 
 wards from right to left, and from behind forwards, in tlie 
 cavity of the chest. The base is on a level with the fourth, 
 fifth, sixth, seventh, and eighth dorsal vertebrae. The apex 
 points in the direction indicated, and is practically in contact 
 with the chest-wall (a small portion of the border of the left 
 lung intervening over the very extremity) in the fifth inter- 
 costal space, about two inches to the left of the left border of 
 the sternum. Much the larger portion of the heart is made 
 up of the ventricles, the right being anterior, the left posterior 
 and coming to the front only at the left border and at the apex. 
 When the heart is regarded from the front, in sitii, the left 
 auricle is concealed from view, with the exception of its 
 apjDcndix, which appears above the left or superior cardiac 
 border to the left of the pulmonary artery. The right auricle, 
 covered by lung, is close to the anterioi* wall of the chest, and 
 its position is of considerable importance to the physician, as 
 will be afterwards shown. Taking the heart as a whole, two 
 
 B 
 
ANATOMICAL CONSIDERATIONS. 
 
 thirds lie to the left of the median line of the body ; one third 
 lies to the right. 
 
 Ilg. I. (from Walshe) shows the general position of the heart in the thorax. The area 
 of "superficial cardiac dulness," i.e., the portion of cardiac surface uncovered by 
 lung, is also represented. 
 
 We have described the heart as a cone, and the heart proper 
 is of this form ; but, superimposed upon it, we have the smaller 
 globular mass formed by the great arteries {vide Fig. I.) 
 
 A glance at Figure II. will show the very oblique direction 
 of the tricuspid orifice. In accordance with this direction of the 
 orifice the blood current from the right auricle into the right 
 ventricle is almost horizontal, while the current of blood from 
 
ANATOMICAL CONSIDERATIONS. 6 
 
 the ventricle into the pulmonary artery passes upwards, and to 
 the left nearly at a right angle with it. It is possible that the 
 latter fact bears some relation to the production of the epigas- 
 tric impulse to be afterwards described. It will be evident how 
 enlargement of the right auricle from over-distension becomes 
 appreciable by percussion as an increase of the cardiac dulness 
 to the right of the sternum. Of all the cavities of the heart, it 
 is most liable to temporary over-distension, and its enlargement 
 is an index of the degree of obstruction suffered by the circu- 
 lation in cardiac and pulmonary diseases. The thin walls of 
 the auricles are in marked contrast with the thick w^alls of the 
 ventricles. 
 
 Fig. II. (modified from Sibson) is a diagrammatic representation of the circulation in 
 the right side of the heart. 
 
 Let us now examine a transverse section of the heart through 
 the auricles, and note the arrangement of the four orifices 
 (vide Fig. III.). The separation of the pulmonary valves from 
 the corresponding auriculo-ventricular set, is somewhat surprising 
 at first sight ; but a moment's consideration will tell us that this 
 is due to the conus arteriosus (infundibulum) of the right ven- 
 tricle, which passes in front of the aortic orifice. We shall find 
 
4 ANATOMICAL CONSIDERATIONS. 
 
 later that aortic regurgitation muriuurs are very well heard over 
 the stenium, especially in its middle and lowest thirds ; and the 
 relation of pjirts which we have just described probably explain* 
 the phenomenon. During the diastole, the pulmonary valves 
 being competent, there is no current of blood in the in- 
 fundibulum, and it is the portion of the right ventricle in 
 closest relation with the sternum : an aortic regurgitation 
 murmur will thus be readily transmitted to the surface 
 tlu'ough the infundibulum, and once having reached the sternum 
 it will be readily conducted along the bone. 
 
 Fig. III. (from Heatli's "Practical Anatomy") sliows tlie relative position of the 
 different cardiac orifices. It will be evident why aortic regurgitation murmurs are so 
 well heard over the sternum, as they liave only to pass through the infundibulum 
 of tlie right ventricle, where, during the diastole, there is no movement of blood. 
 Having once reached the sternum, such murmurs are well carried along the bone. 
 
 The arrangement of the cusps of the arterial valves — two 
 anterior and one posterior in tlie pulmonary artery, two 
 posterior and one anterior in the aorta — is worthy of note. 
 The orifices of the coronary arteries open from behind the 
 
ANATOMICAL CONSIDERATIONS. 5 
 
 interior and left posterior aortic cusps. Immediately behind the 
 two posterior cusps of the aorta is situated the large anterior 
 flap of the mitral valve, which is embraced by the sliort 
 semilunar posterior flap of the same. The close proximity of 
 the two sets of valves should be borne in mind. 
 
 It is to be noticed that the currents of blood to and from 
 the left ventricle are almost parallel in the long axis of that 
 ■cavity, thus differing from the like currents in the right side 
 of the heart, which, as we have seen, are nearly at right angles. 
 The fact, no doubt, bears relation to the "apex-beat" of the heart. 
 
 The arterial valves act in a simply mechanical manner. It 
 is otherwise in the case of the auriculo-ventricular valve- 
 a,pparatus, for in them the valves are dependent for their perfect 
 function on vital contraction of muscle. The orifice which they 
 have to close must be diminished in size by muscle contraction 
 before they can come efficiently into play ; moreover, they nnist 
 be maintained in action by the same means. " Muscle-failure " 
 of the heart (vv'hatever its cause) may, then, render perfectly 
 sound auriculo-ventricular valves incompetent. In clinical 
 medicine the importance of this fact is very great. 
 
 "Auscultator}^ Landmarks" now require careful consideration. 
 Numerous observers have made painstaking investigations into 
 this subject ; and it would seem to result from their labours 
 that there are variations from the usual position in many 
 individuals, allowance for which has to be made. The position 
 ■of the apex and chambers of the heart has already been briefly 
 indicated. It remains for us to determine on the Surface, the 
 points corresponding respectively to the position of the different 
 valvular orifices, as far as in us lies, although, for the following- 
 reason, this is a matter of trifling importance : — "A superficial 
 4irea of half an inch will include a portion of all four sets of 
 valves, in situ ; an area of about quarter of an inch, a portion 
 
ANATOMICAL CONSIDERATIONS. 
 
 of all except the tricuspid." * We shall not err much in 
 stating that the left anterior cusp of the pulmonary valves lies 
 
 Fig, IV'. represents the normal position of the different cardiac orifices, along with the 
 areas employed for the pun^ose of isolating murmurs generated at these oriftces 
 respectively. 1, The pulmonary orifice (the two anterior cusps are represented) 
 I., the pulmonary area (over the valves themselves) ; 2, the aortic orifice (the single 
 anterior cusp is represented); II , the aortic area: 3, tlie mitral orifice; III, the 
 mitral area : 4, the tricuspid orifice ; IV., the tricuspid area. The arrows show the 
 direction of transmission of murmurs as described in the text. The arrow pointing 
 downwards and to the left, representing the transmission of aortic regurgitation 
 murmurs, would be better placed lower, say below the tliird cartilages. 
 
 beliiij<l tlie extremity of the third costal cartilage at its upper 
 
 ''■ Walshe, "Diseases of the Heart," p. G. 
 
ANATOMICAL CONSIDERATIONS. 7 
 
 border, the right anterior cusp lying under cover of the sternum . 
 Shghtly lower down, to the right of, and deeper in the chest 
 than the pulmonary valves, lies the single anterior cusp of the 
 aortic valves. A line drawn across the sternum from tlie 
 extremity of the third left cartilage in a nearly horizontal 
 direction will represent the mitral orifice. A line drawn from 
 the third left interspace across the sternum, and sloping 
 downwards nearly to the fifth right cartilage, will represent the 
 tricuspid orifice (vide Fig. IV.) 
 
 These considerations for ever dismiss any hope that might 
 have been entertained as to a knowledge of the position of the 
 valvular orifices in relation with the chest-wall enabling us by 
 placing our stethoscope over a certain orifice to determine the 
 production of a murmur at it. The principle upon which we 
 are to base our method of ascertaining the orifice, at which 
 a murmur is generated, must be other than this. 
 
 A glance at Fig. I. will show the crossing of the two great 
 arteries, the pulmonary passing to the left, the aorta to the 
 right ; the fonner reaching the lower border of the second left 
 costal cartilage, the latter the upper border of the second right 
 costal cartilage close to the sternum. As regards proximity to 
 the surface, the pulmonary artery is nearer the surface, opposite 
 the third cartilage than at the level of the second cartilage, 
 owing to this vessel passing backwards in its upward course, 
 while the aorta approaches the surface most closely at the 
 junction of the second right costal cartilage with the sternum. 
 When we place our stethoscope over the sternal end of the 
 second right costal catilage, we place it over what is termed the 
 "aortic area," where we exjDcct to isolate murmurs generated at 
 the aortic orifice. The second right costal cartilage has been 
 named the " aortic cartilage." When we place our stethoscope, 
 again, over the junction of the third left costal cartilage with 
 
8 INTRODUCTORY REMARKS. 
 
 the sternum, we cover the "puhnonary area," where we listen 
 for soimds generated at the pulmonary orifice. Dr. Walshe has 
 named the second left costal cartilage "the pulmonary cartilage," 
 but the same author admits the point here contended for.* The 
 left ventricle approaches the surface at the apex of the heart, 
 and we listen for mitral murmurs there. We have still to fix 
 an area for the tricuspid orifice, over which murmurs generated 
 at that orifice, have their maximum intensity. This has been 
 given as " immediately above or at the ensiform cartilage,"! 
 again as " over the right ventricle, where it is uncovered by the 
 lung, i.e., at the lower part of the sternum, and over the whole 
 space between this and the apex." ^ Both these areas are open 
 to an objection, which will be afterwards explained in the section 
 on aortic murmurs, in which place the peculiarities of conduction 
 possessed by certaui aortic regurgitation murmurs will be 
 pointed out. 
 
 The normal pericardium, closely surrounding the heart, calls 
 for no mention here, while the results of effusion will be best 
 considered when we come to "percussion," and then also the 
 relations of the lungs will receive attention. 
 
 * Vide Walshe, " Diseases of the Heart," p. 6. par 17, and p. 98, par. 112. 
 t Walshe, "Diseases of the Heart," p. 95, par. 110. 
 J Gairdner, "Clinical Medicine," p. 586. 
 
 INTRODUCTORY REMARKS. 
 
 In the investigation of cardiac diseases we employ four 
 " physical methods of diagnosis," namely. Inspection^ Palpation, 
 Percussion, and Auscultation. Mensuration may be admitted as 
 
INTRODUCTORY REMARKS. V 
 
 iSi fifth. Each method rightly applied yields its own special 
 information, and no clinical examination of the circulatory 
 apparatus can be considered complete, which omits to make use 
 of the data afforded by any one of them. If we regard our 
 diagnosis as a standpoint which we take up and have to defend, 
 we may also regard the facts ascertained by each of these 
 methods as lines of defence with which to accomplish our 
 object. Every line, however, is defective at some part, and if 
 standing alone, would offer a passage to the attack of an 
 assailant. The greatest amount of security, therefore, for our 
 diagnosis will depend upon our having availed ourselves of the 
 help of all the defensive power at our command, i.e., of the 
 facts afforded us by all four physical methods of diagnosis. Of 
 course symptomatology must not be neglected, but here we 
 have to do only Avith physical signs. 
 
 Fig. V| 
 
INSPECTION. 
 
 It is taken for granted that we have the patient stripped before 
 us, and usually in the recumbent position. The various points 
 to be attended to in Inspection may be arranged according to the 
 following table : — 
 
 A. 
 
 1. Bulging of the whole cardiac region. 
 
 2. Bulging of the intercostal spaces in the cardiac region. 
 
 B. — Impulses of the Ventricles. 
 
 1. The apex-beat or impulse of the left ventricle. 
 
 a. Extrinsic displacements of the apex-beat (due to 
 pericardial or peritoneal effusions, shrinking of the 
 upper portion of the left lung, &c.) 
 
 h. Intrinsic displacements of the apex-beat from en- 
 largement of the left ventricle. 
 
 2. Epigastric impulse or impulse of the right ventricle. 
 
 C. — Cardiac visible impulse other than that of the ventricles. 
 
 1. Pulsation over dilated left auricle (?). 
 
 2. Pulsation over dilated right auricle (?). 
 
 3. Pulsation over cardiac surface, which does not correspond 
 to the impulses of the ventricles nor to the situation of the- 
 auricles. 
 
 D. — Displaced cardiac impulse (i.e., when the whole organ is 
 displaced as from pleuritic effusion, shrinking of the left lung, &c.) 
 
INSPECTION. 1 1 
 
 E. — Vascular Pulsation, 
 
 1. Aneurism of aorta, &c. 
 
 2. Venous pulsation at root of neck. 
 
 3. Abnormal pulsation of carotids, &c. 
 
 4. Capillary pulsation. 
 
 F. 
 
 Systolic depression (1) of intercostal spaces over cardiac sur- 
 face, and (2) of ribs, sternum and space between xiphoid carti- 
 lage and ribs. 
 
 A. 
 
 1. Bulging of whole Cardiac Region. — This occurs in great 
 and generally chronic pericardial effusion. It is common in 
 the cardiac enlargement following valvular disease, often accom- 
 panied by pericardial adhesion, in early life. Sometimes it 
 exists, apparently, as a congenital peculiarity, or as a consequence 
 of rickets. (Edema of the integuments, limited to the cardiac 
 region, may occur in pericardial effusion of some standing. 
 
 2. Bulging of Intercostal Spaces in Cardiac Begion. — This can 
 only result from pericardial eflfusion of inflammatory origin. 
 
 B. 
 
 , 1. The situation of the normal apex-beat has been already 
 indicated. Its area is small — about one square inch. When 
 the left ventricle is enlarged, but still retains its natural fonn, 
 the apex-beat becomes more extensive, and more or less altered 
 in position. 
 
 a. Alterations of Apex-Beat from Extrinsic Causes. — xVmong the 
 extrinsic causes of displacement of the apex-beat are accumula- 
 tions of fluid in the pericardium and peritoneum. It is evident 
 that ascites will also tend to tilt up the apex of the heart, causing 
 the organ to lie more horizontally, but it will at the same time 
 elevate the whole organ. Pericardial effusion, as a cause of 
 
12 IXSPECTIOX. 
 
 altered situation of the apex-beat, is of greater interest. Wlien 
 fluid accumulates in the pericardium the walls of the sac yield. 
 This they do more readily when inflamed, and we have reason 
 to believe that it is the upper portion of the sac which gives 
 way first, so that the fluid distends the sac upwards {vide 
 Fig VII. p. 31). Whatever be the explanation of its occurrence, 
 elevation of the apex-beat is a reliable and valuable sign in 
 pericardial efiusion. For the full value to be attached to the 
 sign, the position of the apex-beat previous to the effusion 
 must have been known. Shrinking of the upper portion of the 
 left lung, as in chronic phthisis, frequently raises the apex-beat, 
 causing the heart to lie more horizontally, or elevating the 
 whole organ. 
 
 h. Displacement of the Apex-Beat from Intrinsic Causes. — 
 Enlargement of the left ventricle displaces the ajDCx-beat down- 
 wards and to the left (vide Fig. VI.). Enlargement of the right 
 ventricle eventually tends to throw it to the left, but in this 
 case the true apex-beat is apt to disappear, a more or less 
 diffused undulatory movement between the sternum and what 
 represents the apex, accompanied by epigastric pulsation, indi- 
 cating the cardiac action. In health, if the breath be held, 
 the apex-beat will disappear, epigastric pulsation becoming de- 
 veloped. I'his results from engorgement of the cavity of the 
 nght ventricle. In dilatation of the left ventricle in excess of 
 liypertrophy, the true apex-beat is often replaced by a diffused 
 pulsation, and the downward displacement of the apex is less 
 than in cases in which the ventricle, although enlarged, retains 
 it« shape. 
 
 2. Epigastric or Impulse of the Right Ventricle. — Epigastric 
 pulsation, whicii, we have seen, may occur physiologically, is a 
 common pheiHjmenon in all diseases in which the pulmonary 
 circulation is embarrassed. In such cases the liver is frequently 
 
INSPECTION. 1 3 
 
 enlarged from passive congestion, tending to render such pulsa- 
 tion more visible ; while in emphysema the depressed diaphragm 
 is a further factor in its production. Functional palpitation of 
 the abdominal aorta, and the pulsation of an abdominial aneurism, 
 can hardly be confounded Avith the epigastric pulsation, which 
 we are now considering, and need only be mentioned. The 
 rare phenomenon of pulsation of the whole liver, produced by 
 great tricuspid regurgitation, must be borne in mind. 
 
 In thus dwelling upon the preceding areas of cardiac impulse,, 
 it must not be supposed that we mean that they constitute the 
 only seats of visible cardiac movement. They certainly are 
 however, the important areas of cardiac impulse. 
 
 C. — Cardiac Visible Pulsation other than the Ventricular 
 
 Impulses. 
 
 1. Pulsation of Dilated Left Auricular Appendix (f) — Occa- 
 sionally, it is said, in cases of mitral stenosis the appendix of the 
 left auricle becomes so much enlarged as to cause visible pulsation 
 above the third cartilage to the left of the sternum, which is 
 further stated to be systolic in time, and to be due to a 
 regurgitant ciuTent from the left ventricle through incompetent 
 mitral valves. In our experience systolic pulsation above the 
 third rib, close to the sternum, is due to a dilated infundibulum 
 of the right ventricle.* 
 
 2. Pulsa tio7i of Dilated Right Auricle (?) — Pulsation to the right 
 of the sternum, auricular in origin, is a rare phenomenon, and 
 occurs only in cases of extreme enlargement of the right side 
 of the heart. The right aiu'icle, which in the majority of cases 
 alone passes to the right of the sternum, usually suffers dilata- 
 tion in excess of hypertrophy ; and, where it is shown by 
 
 *In a case under my care the enlargement of this portion of the right ventricle was 
 so great as to give rise to extension of the cardiac dulness in the upward direction, 
 simulating the dulness of pericardial effusion. 
 
14 INSPECTIOX. 
 
 percussion to be much enlarged and even to have pushed aside 
 the superimposed lung, no pulsation may be visible. When 
 pulsation is visible over the right auricle it is probably pro- 
 duced by the mechanism described above with reference to the 
 left auricle, and is therefore systolic and not presystolic. 
 
 When there is sufficient enlargement of the right auricle to 
 be detected by percussion there is probably always a condition 
 of systole catalecticj or imperfect systole of the auricle. 
 
 3. Pulsation over the Cardiac Surface, which Pulsation does not 
 correspond to the impulse of the ventricles nor to the situation of 
 the auricles. — As already indicated, when the right chambers of 
 the heart are enlarged, pulsation may become visible to the 
 left of the sternum in the second intercostal space, the pulsa- 
 tion corresponding to the situation of an enlarged infundibulum 
 of the right ventricle. In cases of intra-thoracic tumour in the 
 posterior mediastinum, in which the heart is pushed forwards 
 from behind, the cardiac impulse is observed in an area 
 almost coextensive with that of the whole organ, and the usual 
 impulses of the right and left ventricles escape recognition in 
 the diffuse general impulse. The heart during its diastole 
 accommodates its shape to surrounding parts, but during 
 systole it asserts the circular outline presented by its ventricles 
 in a state of contraction, hence the forward impulse, when the 
 posterior mediastinum is encroached upon by tumour. 
 
 D. 
 
 By displaced cardiac pulsation is meant pulsation of the 
 heart, away from the normal cardiac region, vjith absence of 
 jndsation in the normal area, not merely pulsation due to 
 extension of the nonnally situated heart beyond its legitimate 
 limits. Displacement of the heart is most commonly observed 
 in left pleuritic effusion, in which case it may lie quite to the 
 
INSPECTION. 15 
 
 right of the sternum. Retraction of lung substance may draw 
 the heart to the right or left, but generally upwards, inasmuch 
 as it is the upper portions of the lungs which chiefly undergo 
 phthisical contraction. Ascites, ovarian cystic disease, and 
 tympanitic distension of the bowels, push up the whole heart, 
 besides causing it to lie more horizontally. Hydatids growing 
 from the upper surface of the Hver likewise displace the heart. 
 Aneurisms of the arch of the aorta may again depress the 
 heart, while mediastinal growths may push it aside according 
 to the direction of their development. 
 
 E. 
 
 1. A pulsating area above the third rib, the pulsation being 
 systolic in rhythm, and the apex-beat of the heart not having 
 undergone elevation, is probably vascular in origin, but if close 
 to the sternum it may be due to a dilated infundibulum of the 
 right ventricle, or possibly to a dilated left auricle. If the 
 pulsation be over a wide area and heaving, {vide *' Palpation"), 
 it is aneurismal. In certain deformed chests, even though the 
 deformity be not extreme, an abnormal position of the arch of 
 the aorta may closely simulate an aneurism. In contraction or 
 collapse of the left lung, a deceptive appearance of aneurism 
 may be given, from exposure of the pulmonary artery, frequently 
 in such cases dilated. Aneurisms of the arch of the aorta 
 generally become visible above the third rib, to the right or left 
 of the sternum, or in the middle line, this bone having been 
 corroded by pressure. Great care should be taken to have the 
 patient in a good light and to observe the chest from different 
 points of view. It is especially important to look along the 
 surface of the suspected area. 
 
 2. Venous Pulsation at Root of Neck. — This is an important 
 feature of cardiac disease. It is almost necessarily accompanied 
 
1 6 INSPECTIOX. 
 
 by abnoiinal fulness of the veins. The right side is usually 
 the more, it may be only, aftected. We must remember that 
 respiration exerts a powerful influence on the return of blood to 
 the thorax. Thus, during an expiratory effort, we see the veins 
 of the neck swell up ; while, during a deep inspiration, the 
 circulation in them is accelerated, and they collapse. In cases 
 of adherent pericardiimi, sudden collapse of the veins during the 
 caixliac diastole has been observed. This was supposed by 
 Friedreich to be due to stretching of the intra-thoracic veins by 
 the heart adherent to the diaphragm and chest-wall, during its 
 systole, and subsequent recoil during the diastole. Venous 
 pulsation is auricular-systolic or ventricular-systoHc, or both, 
 but the foi-mer is of less magnitude and importance. 
 The tracing of a jugular pulse affords evidence of an 
 auiicular contraction-wave preceding the ventricular-wave. 
 Distension of the veins, if habitual, as in cases of emphysema 
 and cardiac disease, must render the valves of these vessels in- 
 competent ; and it is probable that the phenomenon which we 
 are considering is never developed in perfection without the 
 occiuTcnce of this defect. Much care is necessary on the part 
 of the begimier to distinguish true venous from conununicated 
 arterial pulsation. The finger should be pressed lightly upon 
 the external jugular at the root of the neck ; if the pulsation 
 continue, it is evidently arterial. Moreover, in the case of 
 the venous pulse, by pressing a finger of the other hand 
 upwards and emptying the vein from below, on removing the 
 finger from the root of the neck, the blood will be seen to 
 rush up according to the degree of incompetence of the valves 
 of the veins and tricuspid orifice. When well marked, jugular 
 pulsation may be regarded as a clear indication of incompetence 
 of the tricuspid valves ; but it must be remembered that 
 tricuspid incompetence may exist without this sign, if the 
 
INSPECTION. 17 
 
 venous valves remain competent. This is most likely to occur 
 where there is only temporary engorgement of the right cardiac 
 cavities. On the other hand, a slight degree of pulsation may 
 arise simply from the percussion of the tricuspid closure, reacting 
 on the blood column in over-full veins. 
 
 3. Abnormal visibleness of arterial pulsation accompanies 
 one cardiac valvular lesion as a peculiar feature. This valvular 
 lesion is aortic regurgitation. Mere exaggerated visibleness 
 hardly adequately expresses the peculiar jerk which character- 
 ises the pulse in the affection named. As this subject, however, 
 will again, require our careful attention, we may be brief here. 
 There is one peculiarity of aortic regurgitation which is best 
 appreciated by inspection — namely, a locomotion of the vessels 
 forwards, and, if they be tortuous, in somewhat veiTaicular 
 fashion. In all cases in which the left ventricle is enlarged, 
 carotid pulsation tends to become unduly visible ; so also in 
 cases without cardiac enlargement, whenever the circulation is 
 excited temporarily by emotions, &c., or permanently, as in 
 Graves' disease. Morbid changes (atheromatous) in the arteries 
 themselves likewise simulate in some respects the pulse of aortic 
 reflux ; but with the precaution to fix our attention on the 
 larger trunks, the sign under consideration is of great diagnostic 
 value. 
 
 4. Another phenomenon, which, when well marked, is almost 
 characteristic of aortic reflux, is the so-called " capillary pulsa- 
 tion." By laibbing the finger nail over the skin, say of the 
 forehead, a red mark is produced, and after a few seconds, if this 
 be carefully watched (it is often most evident some little distance 
 off), a distinct wave of deepening and paling in colour is observ- 
 able over the surface of the artificial erythema, while its edge 
 extends and recedes. 
 
18 INSPECTION. 
 
 F. 
 
 1. Systolic Depression of the Intercostal Spaces in the Free- 
 cordial Begi-on. — This is not uncommon in the fourth space (and 
 even third) above the apex-beat, when the heart is enlarged, or 
 at all events comes into more extensive contact with the chest- 
 wall. There is in such cases still an apex-beat. 
 
 2. Systolic Depression of the Eibs^ Sternum, and Space between 
 Xiphoid Cartilage and. Fibs, accomiyanied by absence of the Apex- 
 Beat — This indicates universal pericardial adhesion, the prse- 
 cordial pleural layers being likewise united, but it is a rare 
 phenomenon. Most cases of simple pericardial adhesion cannot 
 be recognised by physical signs, although the condition Is one of 
 great importance in cardiac pathology, inasmuch as it exerts 
 an injurious influence on the heart-muscle. 
 
PALPATION. 
 
 Signs which may be ascertained by palpation : — 
 
 A. — Cardiac Impulse. 
 
 1. Situation and extent of apex-beat. 
 
 2. Strength of apex-beat. 
 
 3. Strength of epigastric impulse. 
 
 4. Closure of semilunar valves with undue force perceptible 
 to hand. 
 
 5. Diastolic backstroke. 
 
 J3. — Vibrations perceived by means of the hand 
 applied over Cardiac Region. 
 
 I" Presystolic. 
 
 1. Thrills ^ Systolic. 
 
 ( Diastolic. 
 
 2. Friction fremitus. 
 
 C. — Thrills, &c., perceived by means of the hand placed 
 over Pulsating Areas other than that of the Heart. 
 
 1. Aneurisms. 
 
 2. Dilatation of aorta, or normal aorta unduly in contact 
 with chest-wall. 
 
 In the use of palpation as a method of cardiac examination, 
 it is important that the whole hand should be placed flat upon 
 the surface, and this is especially necessary when the apex-beat 
 has to be sought for. 
 
20 PATTATIOX. 
 
 A. 
 
 If the apex-beat be invisible, its position must be ascertained, 
 if possible, by palpation. The normal situation of the apex- 
 beat has already been defined, and some of the changes it 
 undergoes in disease indicated. When inspection and palpation 
 alike fail to reveal the presence of an apex-beat in the recum- 
 bent posture, the patient should be asked to sit up, inclining 
 forwards (not inclining to the left side, if "\ve would determine 
 the position of the apex). The absence of the apex-beat becomes 
 an important item in the data for a diagnosis, due allowance 
 being made for unusually thick chest-walls, emphysema, the 
 apex beating under a rib, &c., and care expended on the in- 
 vestigation is not lost, though the object of our search be not 
 found. 
 
 While any discussion as to the mode of j^i'oduction of the 
 physiological apex-beat would be out of place here, the fact of 
 the apex-beat being the expression of the contraction of the left 
 ventricle must be emphasized. When this chamber undergoes 
 enlargement, the apex-beat is necessarily altered in situation, 
 and it becomes more extensive. The presence of a true well- 
 defined apex-heat implies the retention, in greater or less 
 degree, by the ventricle, of its normal pointed form. When the 
 chamber becomes dilated and rounded, the true apex-heat is lost, 
 and only a diffuse impulse remains to represent the systole of the 
 ventricle, or there may be no impulse perceptible, although the 
 ventricle is enlarged. Tlie vigour of the heart-muscle and the 
 degree of effort, with which the left ventricle accomplishes its 
 contraction, are elements which exert a great influence on the 
 production of the apex-beat. In severe fever, for instance, the 
 apex-beat may be watched failing day by day until it is 
 entirely lost. In Bright's disease, with cardiac hypertrophy 
 well maintained, the apex-beat is slow and heaving, while in 
 
PALPATION. 21 
 
 palpitation of nervous origin the apex-beat is quick and 
 slapping. Certain valve lesions are accompanied commonly by 
 peculiarities of the apex-beat. Thus aoi-tic incompetence is 
 generally accompanied by a vigorous apex-beat so long as the 
 heart-muscle remains healthy. There is some reason to believe 
 that the apex-beat may fail in great aortic obstruction, although 
 the left ventricle is hypertrophied and its muscle sound. Many 
 cases of mitral stenosis are accompanied by a well-marked 
 apex-beat, which corresponds with the sharp abrupt first sound, 
 that is characteristic of the lesion. In this case it may be 
 supposed that the ventricle begins to contract before it has 
 been distended to the full amount — before, in fact, the current 
 from the auricle has ceased. 
 
 The impulse of the right ventricle is altogether different from 
 the apex-beat, and seems to be delivered by the broadside of 
 the ventricle. In this relation the position of the pulmonary 
 artery with regard to the right ventricle may be borne in 
 mind. Epigastric impulse is, at best, only an indirect impulse, 
 conveyed through the liver, and it is always diffuse and ill- 
 defined. The apex-beat and the epigastric impulse generally 
 vary inversely — when the one is pronounced the other is defec- 
 tive or absent. Thus, when there is much enlargement of the 
 right side of the heai-t, the left ventricle is pushed back by 
 the enlarged chamber, and in long-standing cases the right 
 ventricle reaches the apex of the heart. In certain eases of 
 aortic regurgitation, again, the left ventricle for long is alile to 
 €ope with the difficulty, so that the embarrassment of the 
 circulation does not pass backwards through the lungs to the 
 right side of the heart. Such cases have a very exaggerated 
 and displaced apex-beat, but little or no epigastric impidso, 
 while engorged liver and dropsy are conspicuous by their 
 absence. 
 
22 PALPATIOX 
 
 It is seldom that both impulses — those of the left and right 
 ventricles — are well marked at the same time.* In severe fever 
 (as Typhus) while the apex-beat fails, epigastric impulse is 
 established and increases, as the result of the obstiiiction in 
 the pulmonary circulation, invariably more or less jDresent under 
 the circumstances, and of the retention of vigour in greater 
 degree and for a longer period by the right ventricle in com- 
 parison with the left ventricle. When the left ventricle becomes 
 dilated and rounded, its systole is invariably imperfect — systole 
 caialectic — and whether there be or be not mitral regurgitation, 
 the right side of the heart becomes involved in the ob&truction 
 suffered by the circulation. Thus we have two causes at work 
 in obliterating the apex-beat and establishing or exaggerating 
 epigastric impulse. While the apex-beat is a noiTiial phenomenon, 
 epigastric impulse is generally, though by no means always,, 
 abnormal. 
 
 1. The Situation of the Apex-heat. — When the left ventricle 
 is enlarged and retains its pyramidal form the apex-beat is 
 displaced downwards and towards the left. Its extent, too, 
 normally about a square inch, is increased in greater or less 
 degree. 
 
 In pericardial effusion the apex-beat is elevated. Other cir- 
 cumstances influencing the position of the apex-beat, have been 
 already referred to under " Inspection." 
 
 2. The strength of the impulse is a matter of nnich im- 
 portance both in cardiac and general diseases. Of the former, 
 fatty metamorphosis and the compensatory hypertrophy of 
 aortic- valvular disease ofier good examples. Of the latter, the 
 weakening of the heart in typhus, so admirably described by 
 
 * Some time ago a patient was admitted into the Mancliester Infirmary under my 
 care, witli typical em])hyHema of the lungs. Hut in addition to epigastric impulse, he 
 presented a very well-<lefined vigorous apex-beat : on careful consultation, a faint 
 blowing diastolic murmur of aortic incompetence was heard, which fully explained the 
 condition of tlic apex-beat. • 
 
PALPATION. 23 
 
 Stokes, and the hypertrophy consequent on Bright's disease, 
 furnish ilkistrations. In all these cases, it is the left ventricle 
 which is first and chiefly afffected, and consequently it is the 
 apex-beat, which undergoes alteration. Pericardial efifusion 
 diminishes the force of the apex-beat. 
 
 3. Eingastric Pulsation. — This phenomenon is better per- 
 ceived by " Inspection," but in cases in which there is great 
 enlargement and hyjDcrtrophy of the right ventricle, a distinct 
 heaving is felt over the lower part of the sternum and in the 
 epigastrium.. 
 
 4. The Closure of the Pulmonary Semilunar Valves is frequently 
 perceptible as a shock to the hand placed on the surface of the 
 chest over the appropriate area, in cases in which there is 
 obstruction to the pulmonary circulation from any cause. It 
 will be rendered more distinct in proportion as the pulmonary 
 artery is exposed by retraction of the lung. The pulmonary 
 orifice, it will be remembered, is situated near the surface of the 
 chest. A similar phenomenon may be perceived over the aorta 
 in cases of dilatation of the vessel with high arterial tension. 
 
 5. Diastolic Back-Stroke. — This is only rarely met with as a 
 sign of adherent pericardium with cardiac enlargement. My 
 experience of the phenomenon would lead me to regard it as 
 resulting from the rebound of the dilating heart after the systolic 
 depression already noted under " Inspection " (F. 2). 
 
 £. — Vibrations perceived by means of the hand applied 
 over the Cardiac Region. 
 
 These naturally fall into two classes — endocardial and 
 exocardial. 
 
 1. Endocardial Thrills. — Thrills are produced at or rather 
 beyoi^d the cardiac orifices by the veines jluides which give rise 
 
24 PALPATION. 
 
 to the con-esponding murmurs. A thrill is most common where 
 there is obstruction to the blood-current at a rigid and contracted 
 orifice, as in aortic and mitral stenosis. 
 
 The aortic obstructive thrill is systolic, the mitral obstructive 
 thrill is presystolic or diastolic in rhythm. In case of dilatation 
 of the aorta, a systolic thrill may be perceptible over the vessel, 
 although there is no actual constriction of the orifice. The 
 presystolic thrill of mitral constriction, which accompanies the 
 systole of the auricle, is limited to the apex, and possesses the 
 peculiar feature of increasing in intensity up to the apex-beat, 
 which at once cuts it short. The diastolic thrill of the same 
 lesion accompanies the expansion of the left ventricle, and dimi- 
 nishes in intensity towards its end. It also is an apex thrill. 
 When they co-exist, as they often do, these two thrills can be 
 easily distinguished. Sometimes mitral regurgitation is accom- 
 panied by systolic thrill at the apex, but this is comparatively 
 rare. Aortic regurgitation is more frequently attended by 
 diastolic thrill, felt at the apex of the heart, to which it may be 
 limited. The incompetence of the valves is usually considerable 
 in cases of the kind. In certain rare cases of very free aortic 
 regurgitation, to be referred to later, a short indistinct thrill, 
 apparently of presystolic rhythm, may be perceptible at the 
 apex, and simulate, in some degree, the auricular-systolic 
 thrill of mitral stenosis. 
 
 2. Friction FremitttSj due to exudation on the pericardial 
 surfaces, need be here only mentioned, as the subject of friction 
 is fully considered in the section on Auscultation. 
 
 C. — Thrills, dr., perceived hy means of the hand applied over 
 Pulsating Areas other than that of the Hearty viz., Aneurisms. 
 
 1. When an impulse, other tlian that of the heart, yet 
 
PALPATION, 25 
 
 synchronous with its systole, is at least as forcible as the 
 ■cardiac pulsation, very reliable evidence is afforded of the 
 presence of an aneurism. The murmurs audible over aneurisms 
 are sometimes represented in palpation by thrills. Again, as 
 already indicated, when the semilunar valves are closed with 
 abnormal force, as is always the case in aortic aneurism, a 
 distinct thud may be felt by the hand placed over the tiunour. 
 2. When the aorta is dilated and in exaggerated contact with 
 the chest-wall from any cause, a thrill may be perceptible over 
 the area of contact. Such thrills accompany murmui'S, and 
 their causes will be considered under "Auscultation." 
 
PERCUSSION. 
 
 I. — "Superficial" Dulness indicates the extent of cardiac surface 
 in direct contact with chest-wall. 
 
 II. — " Deep " Dulness indicates approximately the absolute 
 size of the heart. 
 
 In front the heart being surrounded, except infcriorly, by 
 air-containing lung, we are enabled to estimate its size or the 
 amount of pericardial effusion, by means of percussion, inasmuch 
 as the heart or distended pericardium, yields no resonance over 
 that portion of the chest-wall with which it is in contact, and 
 modifies the resonance of the lung beyond that area by 
 rendering the layer of resonant tissue superficial to the heart 
 less thick. 
 
 Percussion determines for us the size of the heart or pericardial 
 sac distended with fluid, also the area in which aneurismal 
 tumours come into contact with the chest- wall. In health 
 the large vessels cannot be recognised by percussion. If they 
 could they would form a more or less circular dull area, super- 
 imposed upon the cardiac dulness proper, i.e.^ above the level 
 oi the third rib {vide Fig. I.). 
 
 There arc two methods of ascertaining the size of the heart 
 by percussion. One is to determine what is called "the superficifd 
 cardiac dulness." This really means mapping out the area in 
 which the heart comes into contact with the chest-wall. The 
 anterior border of the left lung se^^arates from the anterior border 
 
PERCUSSION. 27 
 
 of its fellow at the fourth rib, and passes outwards and downwards 
 to about the union of the fifth rib with its cartilage ; it then 
 extends downwards and inwards along the sixth left cartilage, 
 thus leaving a rudely triangular space in which the heart (chiefly 
 the right ventricle) comes into contact with the thoracic wall 
 {vide Fig. I.). If this space fonncd a regular triangle, the 
 superior or external side would measure three inches, the internal 
 side corresponding to the middle line, two inches, and the inferior 
 two and a half inches, but it is only approximately of trian- 
 gular form. Except at the right side, where .sternal resonance 
 modifies the percussion note, this dulness is easily defined l)y 
 light percussion. The peculiar resonance of the sternum in- 
 terferes to some extent with our deteniiination of the right 
 border of cardiac dulness, unless the right auricle is engorged, 
 and the dulness extends to the right of the bone. But it is 
 often possible to detect a decided difference in the percussion 
 sound of the right and left halves of the sternum at the le^•el 
 of the heart. The information acquired by this mode of 
 percussing the heart, though alone relied upon by many 
 physicians, is open to the objection that it does not tell us the 
 absolute size of the heart, but only the size of the cardiac sur- 
 face which is in contact with the chest-wall. 
 
 The other method of estimating the size of the heart by 
 percussion depends upon the modification which the organ 
 j)roduces on the resonance of the lung overlying it : it determines 
 approximately the actual size of the heart. In performing 
 percussion according to this method, we have, as it were, to 
 jjercuss through a certain depth of lung-tiss\ie. A few experi- 
 ments in the post-7nortem room will make abundantly plain the 
 fact, that a thin layer of lung tissue gives a "less full" or 
 ;." more empty " note than a thick layer. In percussing from 
 Avell beyond the cardiac region towards the triangular area of 
 
28 PERCUSSIOX. 
 
 supei*ficial cardiac dulness, the gradual transition from the full 
 pulmonary note elicited beyond the heart, to the complete 
 emptiness or dulness of the percussion note in the triangle 
 referred to, in proportion as the heart encroaches on the lung 
 space, will be easily appreciated. Until the heart comes into 
 immediate contact with the chest-wall, the lung will yield its 
 clear and resonant note, though one becoming more and more 
 " empty." By practice the power of determining sufficiently 
 for all clinical purposes the line at which the heart begins to 
 modify the pulmonary note is soon acquired. 
 
 In cases of "large-lunged emphysema," thick masses of 
 emphysematous lung-tissue spread over the heart, so as to 
 render this method of percussion useless. But, in this case, 
 the other or superficial method is of no greater value, as the 
 voluminous left lung encroaches upon the triangle. 
 
 With regard to the deep method, percussion in two directions 
 is sufficient for ordinary purposes. These are, in a line drawn 
 vertically downwards one inch to the left of the left border of 
 the sternum, and in a line drawn transversely along the fourth 
 rib, or in the male, through the nipple {vide Fig. VI.). The 
 normal limits are as follows : — Dulness commences at the third 
 rib and terminates at the sixth rib, but this latter limit cannot 
 be ascertained satisfactorily, owing to the junction of cardiac 
 and liepatic dulness. Percussing from left to right, dulness 
 should commence just within the nipple line, and should not 
 transgress the right border of the sternum. Though in health 
 the right auricle reaches to half an inch to the right of the right 
 border of the sternum, it lies beneath the comparatively thick 
 border of the right lung, and cannot be distinguished by percus- 
 sion. It is to be noted, however, that there is often some slight 
 diminution of resonance for barely a finger's breadth along the 
 right sternal margin at the level of the right auricle, in cases in 
 
PERCUSSION. 
 
 29 
 
 which there does not seem to be, from other evidence, any 
 enlargement of the auricle. This may be due to approxima- 
 
 Fig. VI. represents the method of percussion described in the text. The clear space 
 indicates the normal anatomical area of the heart, the asterisks marking the spots 
 where percussion, in the directions indicated, first detects the influence of the under- 
 lying solid organ upon the lung resonance (as mentioned in the text, in health 
 dulness is hardly ever detectable to the right of the sternum). The dots represent 
 the boundaries of abnormal dulness : — Extension upwards, indicating pericardial 
 effusion. Extension to the right, indicating enlargement of the right auricle. 
 Extension to the left, indicating enlargement of the left ventricle. The normal 
 position of the apex-beat is represented by an asterisk. The depressed apex-beat by 
 a dot. The inferior extremity of vertical dulness is unsatisfactory. Valuable 
 information as to the lower limit of the heart may be obtained from taking into 
 considei^ation the upper border of the liver dulness to the right of the sternum. 
 
-30 PERCUSSION. 
 
 tion of the cartilages of the ribs as they join the sternum. By 
 •inspection and palpation we are able in the great majority of 
 cases to deteiTiiine the position of the apex-beat, and by means 
 of it we are enabled, with the limits of vertical and transverse 
 percussion just described at our disposal, to make a rough 
 outline sketch of the cardiac organ in the following way (vide 
 Fig. VI.) : — A curved or semi-lunar line is to be drawn from the 
 apex-beat to the upper extremity of the vertical dulness in the 
 parasternal line {i.e., one inch to the left of the left border of the 
 sternum), which line should pass through the left extremity of 
 the transvei'se dulness. Again, a similar curved line is to 
 be drawn from the apex-beat to the right extremity of the 
 transverse dulness. Lastly, the two lines drawn from the 
 apex are to be joined by a third curved line. In this way a 
 rough outline of the heart is obtained. Measurements can be 
 made, taking the middle line of the sternum as the fixed point 
 for those in a transverse direction to the right and left, and the 
 cartilages of the ribs as the fixed points for longitudinal mea- 
 surements. The upper border of hepatic dulness to the right 
 of the sternum should always be determined. The indications 
 afforded by abnomiities in the cardiac dulness are briefly as 
 follows, percussion being made in the manner described : — 
 
 ( 1 . ) Increase upwards = pericardial effusion (rarely enlargement 
 of the infundibulum of the right ventricle, possibly en- 
 largement (jf the appendix of the left auricle). 
 
 (2.) Increase to the right = enlargement of the right auricle. 
 
 (3.) Increase to the left = dilatation of the left ventricle. (But 
 great enlargement of the right ventricle ultimately leads to the 
 same result).* 
 
 • In caHes in which emphysema seems to be the primary mischief , it is no uncommon 
 thing to find both riglit and left ventricles of the heart enlarged. It seems more likely, 
 in these cases, that there is a degenerative tendency vi^hich has manifested itself in the 
 heart as well as in the lungs tiian that the dilatation of tlie left ventricle is sequential 
 to that of the right. 
 
PERCUSSION. 
 
 31 
 
 As already mentioned, increase upwards is the chief character- 
 istic of the dulness of pericardial effusion, but a hardly less 
 marked feature is the form assumed by the dull area {vide Fig. 
 VII.). Only when the case is chronic does the distended peri- 
 cardium assume a more globular form. 
 
 When the apex of the heart is found beating considerably 
 within the dull area, almost conclusive evidence of pericardial 
 
 fSibson). 
 
 Fig. VII. — In this figure the effect of effusion into the pericardial sac is shown. The 
 cardiac (1) dulness will increase upwards, and the dull area assume more or less the 
 shape indicated here anatomically, being broadest inferiorly. 
 
 effusion is afforded, the lungs being, of course, resonant in the 
 neighbouring regions. In simple dropsy of the pericardium, the 
 pyramidal shape assumed by the dulness is less marked. 
 
32 
 
 PERCUSSIOX. 
 
 The detemiination of the size of the heart or of a distended 
 pericardium, by percussion, may be interfered with by pleuritic 
 effusion, or consolidation of the neighbouring portions of lung, 
 but these usually present no difficulty in diagnosis, as charac- 
 teristic pulmonary physical signs are pronounced. Tnily 
 disheartening, however, to the beginner, are the results of what 
 Dr. Walshe has well called "horizontal conduction." For 
 instance, in a case of cardiac disease with enlargement of the 
 organ, the heart is seen pulsating OA^er a wide area, yet over the 
 
 Fig. VIII. 
 
 very pulsating area a tympanitic note is elicited on percussion 
 • — a distended stomach lying beyond, being the cause of the 
 anomaly. This is an example of the importance of the rule 
 never to trust to one physical sign. Even in these circum- 
 stances the liglitest possible percussion will generally yield 
 dulncss over the part of the clicst-wall in contact with the 
 heart. 
 
PERCUSSION. 33 
 
 For purposes of practical diagnosis, the essential points to be 
 ascertained are the following : — (1) The size of the right auricle, 
 (2) the. size of the left ventricle, and (3) the presence or absence 
 of pericardial effusion. This may be done by a few veiy simple 
 manipulations. 
 
 Percuss downwards an inch or more, if necessaiy, to the right 
 of the sternum until the liver dulness (the lung-margin) is 
 reached. ]\Iark the spot with a copying-ink pencil. Then 
 percuss towards the sternum not less than an inch above the 
 level marked, and note the spot at which the modification (if 
 any) of the lung sound, due to the auricle beneath, becomes 
 appreciable. When absolute dulness to the right of the sternum 
 is detected in this way, it signifies a very great degree of 
 distension of the auricle, which has displaced the lung margin. 
 Such distension, no doubt, implies imperfect systole — systole 
 catalectic — on the part of the auricle. It is a good habit to 
 compare the percussion sound to the right of the sternum above 
 and below the third cartilage, when any modification of the 
 lung-sound has been noticed at the latter level. 
 
 We next turn our attention to the left of the sternum and 
 endeavour to determine the size of the left ventricle. Inspection 
 and palpation having preceded percussion, the situation of the 
 apex-beat will probably be known. If so, let us mark the spot, 
 noting the intercostal space in which it is situated. This spot 
 will correspond pretty closely to the level of liver dulness 
 already marked on the right side, or it may be a little lower. 
 Let us next percuss from the anterior border of the axilla, or, if 
 necessary, further outwards, towards the heart, choosing the 
 level of the apex-beat if that has been determined by inspection 
 or palpation, or if not, the level corresponding to rather less 
 than an inch above the liver dulness, to the right of the steniiun. 
 Whether the situation of the apex-beat has or has not been 
 
 D 
 
34 PERCUSSION. 
 
 revealed by inspection or palpation, the cai'diac dulness reached 
 at the level indicated will represent the apex of the heart 
 closely enough for all practical purposes, and the apex is the 
 part of the heart which extends furthest to the left. Outwards 
 {i.e., to the left) and downwards are the directions in which the 
 apex of the heart is displaced, when the left ventricle is enlarged, 
 and it fortunately happens that when the downward displace- 
 ment is most pronounced, the apex-beat is usually easily 
 discerned — the ventricle retaining more or less its normal 
 fonn instead of becoming rounded — so that any error that 
 might arise from our getting above the apex is prevented. It 
 is to 1 >Q remembered in relation to this method of determining 
 the size of the left ventricle, that approaching the apex of the 
 heart we very soon reach "superficial" dulness (vide p. 1). 
 
 The upper boundary of the heart-dulness is determined by 
 percussion in a vertical direction, an inch to the left of the 
 sternum. Nonnally, as already stated, there should be no 
 modification of lung-resonance due to the heart above the third 
 left cartilage. 
 
 The results of percussion of the heart in a given case may be 
 shortly noted in the following way : — The left cartilage to 
 which the cardiac dulness (in the sense of lung resonance 
 modified by the heart) reaches, is recorded in Roman numerals 
 III. or II , as the case may be, while the extension of dulness 
 to the right and left respectively from the middle line is noted 
 
 in Arabic figures placed below. Thus, o _ ^ was noted in a 
 case of aortic regurgitation, in the last stage of the disease, and 
 implied enormous enlargement of the left ventricle and great 
 distension of the right auricle, with absence of pericardial 
 effusion. In this disease, enlargement of the right side of the 
 
 heart may be long delayed. Tlie figures tiJ a were noted in 
 
PERCUSSION. 35 
 
 a case of mitral stenosis and indicated some distension of the 
 right auricle, slight enlargement of the left ventricle, and 
 absence of pericardial effusion. 
 
 Good practical rules for guidance are, that normally (1) there 
 should be no dulness to the right of the sternum, and that 
 (2) the cardiac dulness to the left of the sternum should not 
 -extend beyond a line drawn vertically downwards from the 
 nipple, and that. (3) modification of resonance due to the heart 
 should not be encountered above the third cartilage, when per- 
 cussion is made in a vertical direction an inch to the left of the 
 sternum. 
 
 When it is remembered that the heart is a contractile organ, 
 -constantly undergoing changes in size and shape, the utility of 
 attempting very accurate measurements of it by percussion, 
 may well be doubted. On the other hand, however, it is certain 
 that an approximate estimation of the size of the heart can be 
 made by means of jDcrcussion, and of all the physical signs 
 afforded by the heart there is none of greater — perhaps of so great 
 — value as that which indicates enlargement of the organ as a 
 •whole or in part. The size of the right auricle enables us to 
 gauge the obstruction in the pulmonary circulation and more or 
 less in the general circulation. When there is enlargement of 
 the right auricle, confirmatory evidence of such obstniction 
 will not be wanting — dyspnaea, enlarged tender liver, dropsy, 
 •ifec. Enlargement of the left ventricle depends, for the 
 most part, upon dilatation of its cavity — an unmixed evil, 
 unlike hypertrophy of its walls. As a matter of clinical and 
 pathological experience it will be found that valve-lesions 
 which tend to induce excess of pressure within the chamber 
 during diastole are most potent in the production of dilatation. 
 Aortic regurgitation offers the best example of this fact. In 
 pure aortic obstruction it may be doubted, if dilatation of the 
 
36 PERCUSSION. 
 
 left ventricle ever supervenes, before the ventricle has assumed 
 from failing power, the condition, which we have called systole 
 r.atalectic. 
 
 In this relation it may be permitted to quote from a recent 
 work of Drs. Roy and Adami on " Heart Beat and Pulse Wave," 
 as follows : — "One of the effects of rise of pressure in the 
 systemic arteries is to diminish the extent to which the fibres 
 of the heai*t-wall are shortened during systole .... The effect 
 of the diminished shortening is, as we have shown, to increase 
 the quantity of residual blood which is left in the ventricle at 
 the end of systole. This increase in the residual blood does 
 not, however, under noi-mal conditions, lead to a diminution of 
 the amount of blood expelled by the heart in a given time, 
 seeing that it is compensated for by an increased expansion 
 during diastole." 
 
AUSCULTATION. 
 
 A. (a.) The normal heart sounds. 
 (6.) Modifications of these. 
 
 1. Intrinsic (accentuation, reduphcation, weakening, ifec.) 
 
 2. Extrinsic (effects of pericardial effusion, obesity, (to.) 
 £. New or adventitious sounds. 
 
 I. Endocardial Murmurs 
 
 .(«.) Valvular, i.e., formed at / 
 or beyond the auriculo-ven- 
 tricularor arterial orifices from 
 structural changes in the valves 
 -or orifices, or from the auriculo- 
 "ventricular valves being ren- 
 dered incompetent by muscle- 
 failure, or froQi alteration in 
 the relation of the size of an 
 .arterial orifice to that of the 
 adjoining vessel. 
 
 b. Amemic murmurs, tfec. 
 
 (a) Obstruction < "^ ■, j_. 
 ^ \ relative. 
 
 (/3) Regurgitation. 
 
 1. From disease 
 valves. 
 
 of 
 
 2. From muscle-failure 
 (auriculo-ventri- 
 cular valves). 
 
 \ 
 
 Murmurs their 
 
 ) 
 
 II. Exocardial Murmurs or Friction 
 
 In health. 
 
 In disease. 
 
 1. Arterial. 
 .2. Venous. 
 
 3. From dilatation of 
 orifice (arterial 
 valves). 
 
 Ehytlim. 
 
 ^laximum intensity. 
 Direction of transmission. 
 
 Pericardial. 
 Pleural (of cardiac 
 rhythm). 
 Vascular Sounds. 
 
 3. Aneurism al. 
 
38 AUSCUI.TATIOX. 
 
 ■ A. (a.) The cause of the normal "sounds " of the heart is a 
 subject which cannot be altogether omitted, inasmuch as the 
 inferences to be drawn from the abnormal sounds heard in 
 disease will to some extent depend upon the mechanism 
 assigned to each. For practical purposes the " valvular " 
 theory, which regaixls the sudden closure of the valves as the 
 main element in the production of the " sounds," is satisfactory 
 enough. For practical pui'poses it is necessary, however, that 
 the auscultator should bear in mind various factors w^hich exert 
 an influence upon the heart sounds in one wa}' or another^ 
 without his necessarily believing in a " muscle-contraction " 
 sound. 
 
 We must recognize a "muscle contraction" factor in the 
 production of the first " sound " as heard at the aj^ex. With 
 regaixl to it, rapidity of contraction would seem to pla}' an 
 important part; possibly there may be an "arterial wall" 
 element in the "sounds" as heard at the base of the heart over 
 the groat ai-teries. The fact that a systolic sound closely 
 simulating a " sound " of the heart can be heard in the 
 femoral artery in cases of aortic regurgitation, in which the 
 " sounds," being replaced by murmurs are inaudible over the 
 heart itself, is matter of common observation. Moreover 
 Traulje showed that in certain cases of extreme aortic regurgi- 
 tation actually two " sounds " may be heard over the femoral 
 arteiy, although the mode of production of the latter has not 
 as yet been explained. 
 
 In clinical descriptions, " sounds " in the technical sense must 
 be carefully distinguished from "murmurs." In the cases re- 
 ferred to Traube drew attention to this distinction, as the very 
 rare phenomenon obsei'ved by him had been confused with the 
 conuiion sign of a double murmur, in aortic regurgitation. A 
 "sound," resembles a nomial cardiac "sound," Lubl)orDuj); 
 
AUSCULTATION. 39 
 
 murmurs, on the other hand, are more or less prolonged and 
 blowing. Pericardial Friction should not be called a murmur, 
 and gives to the ear an idea of the mode of its production, 
 hardly to be mistaken. 
 
 The condition of the valves seems, in the absence of 
 munnurs, to have some influence on the cardiac "sounds." 
 For instance, in cases of great aortic stenosis from rigid 
 valves having only a slit between them, neither second "sound" 
 nor diastolic murmur may be audible. It has been supposed 
 by some, that the common funnel-shaped deformity of the valves 
 in mitral stenosis is a factor in the production of the 
 characteristically accentuated first sound of tlie lesion. The 
 first "sound" of the heart corresponds to the commencement of 
 the contraction or systole of the ventricles and to the closure 
 of the mitral and tricuspid valves, the second "sound" to the 
 commencement of expansion or diastole of the ventricles, and 
 of the recoil of the great arteries, and to the closure of the 
 arterial valves. How much "sucking" force may be exercised 
 by active expansion of the ventricles it is difficult to estimate ; 
 but there are reasons for believing that such force may con- 
 tribute materially to the production of certain murmurs (mitral 
 diastolic). We must remember that the "sounds" are not 
 co-extensive in time with the systole or diastole of the ventricles, 
 inasmuch as a mitral regurgitation murmur is frequently 
 heard along with the first " sound " a7id following it, showing 
 that the contraction is going on after the "sound" has terminated, 
 while a diastolic murmur is often heard following the second 
 sound. 
 
 The right and left sides of the heart each produce two 
 "sounds," ; and although we hear in health only two "sounds," 
 the occurrence of non-coincidence in time of the two pairs of 
 " sounds " might be conjectured under morbid conditions {vide 
 
40 AUSCULTATION. 
 
 Reduplication of " Sounds "). These and other points will call 
 for further notice as the various abnormities met with in 
 disease are considered in detail.* 
 
 (6.) Modifications of the Heart Sounds. 
 
 1. Intrinsic Modifications — Accentuation. — This character is 
 commonly observed in the second sound. As the name indicates, 
 by accentuation is meant an intensification of the sound, owing, 
 apparently, to the closure of the valves taking place with 
 abnormal force. In all valvular diseases of the heart accentua- 
 tion of the second sound over the pulmonary artery is the rule, 
 and, indeed, must occur whenever there exists hindrance to the 
 pulmonary circulation. Regurgitation through the tricuspid 
 orifice will, of course, tend to diminish the sign. In cases of 
 Bright's disease, in which there is high arterial tension, the same 
 character is given to the aortic second sound, and most markedly 
 when there is dilatation of the aorta. In cases of thoracic 
 aneurism, in wliich the diagnosis is difficult, accentuation of the 
 second sound over the aorta may prove a useful indication. The 
 first sound is said to be accentuated, when it is short, abrupt, 
 and "thumping," i.e., accompanied by a distinct shock. The 
 loud abrupt first sound of mitral stenosis may be explained by 
 the existence of difficulty in filling the left ventricle, due to the 
 lesion, so that the ventricle contracts before it is fully distended, 
 and, therefore, has a light burden, so to speak, while its nutrition 
 is unimparcd. The rapidity of contraction has probably nmcli 
 to do with this character of the sound. In hypertrophy of the left 
 ventricle an opposite character is assumed by the first sound ; 
 
 ^ In the preceding remarks the word aoiinds, meaning the normal cardiac sounds 
 or sounds of the same character, has been distinguislied by inverted commas. This 
 will not be done in the rest of the work, as the significance of the term in its technical 
 sense has been exjtlained, and no doubt is likely to arise as to the sense in which 
 the word is to be taken, the general or teclinical. 
 
AUSCULTATION. 41 
 
 iit becomes dull and toneless. For an explanation we must have 
 regard to the cause of hypertroph}^ : it is, shortly, increased 
 work calling forth effort. Every contraction of the ventricle 
 qinder these circumstances implies abnormal resistance overcome. 
 In certain cases of dilatation of the heart, on the other hand, 
 the first sound is short and peculiarly clear. A fair degree of 
 ^nutrition of the ventricular walls seems necessary for the produc- 
 tion of an accentuated first sound. In fevers the modifications 
 undergone by the heart sounds are of peculiar interest, and 
 were admirably described by Dr. Stokes. The first change is 
 •shortening of the first sound, so that it comes to resemble the 
 second sound. This stage is accompanied by low arterial tension, 
 while the ventricular walls have not yet suffered in nutrition to 
 .an extreme degree. In most cases, no further change takes 
 place, the sounds remaining like those of the foetus in utero. 
 In typhus fever most commonly, but occasionally in other fevers, 
 a further stage is reached, the first sound losing in tone and 
 finally becoming inaudible. This last condition, however, is 
 extremely rare, as the changes referred to take place on the left 
 •or systemic side of the heart chiefly, and the first sound of the 
 Tight ventricle remains after that of the left has ceased. 
 
 Reduplication of the sounds is a common modification. Either 
 ■sound may be the subject of it. A probable explanation has 
 -already been suggested, when the naturally duplicate mechan- 
 ism of the cardiac sounds was referred to. Such explanation 
 is not, however, entirely satisfactory — does not seem to meet 
 all cases. In mitral stenosis reduplication of the second sound, 
 heard over and below the pulmonary area — often at the apex — 
 is common. When it occurs the usually accompanying accen- 
 tuation of the pulmonary second sound is less easily recognized. 
 Supposing the two diastolic sounds to be produced on the left 
 ^nd right sides of the heart respectively, it would seem that 
 
42 AUSCUI.TATIOX. 
 
 the former is the aortic, the latter the pulmonar}' second sound 
 (vide Note, page 52). Phonetically a double second sound may be 
 represented by the syllables ta-ta, thus with the first sound 
 Lubh'-ta-ta. In Bright's disease reduplication of the first sound 
 at the apex and over the ventricles is a very frequent sign. 
 The ordinary reduplicated first sound may be represented 
 phonetically by the syllables "turrup;" while the second sound 
 is represented in the usual Avay by "dup" — turrujy dup. A 
 peculiar form of reduplication is known by the French name 
 hruit de galop. No verbal description of it would be likely 
 to succeed in giving the reader an idea of it, but the sound is 
 very characteristic of a dilated heart, and is well worth careful 
 clinical study. 
 
 In cases of mitral stenosis, the second sound is often 
 characteristically absent at the apex of the heart. Owing to 
 this absence of the second sound a variety of presystolic 
 murmur, followed by an accentuated first sound, is very readih^ 
 mistaken by beginners for a systolic murmur followed by the 
 second sound. 
 
 (2) Extrinsic. — Tlic heart sounds, as heard over the surface 
 of the chest, may be modified, not from any change in the 
 manner of their production, but by interference with their due 
 conduction to the ear. Hydro-pericardium is an instance of this, 
 in which the feebleness of the sounds is in marked contrast 
 with the increased area of dulncss. Another significant sign in 
 sucli cases is hearing the sounds more distinctly at the upper 
 part of the sternum, than over tlie centre of the pra3Cordial 
 region. Of course the heart's action is interfered with in 
 these cases and the sounds may be intrinsically altered and 
 weakened as well. A thick chest-wall necessarily renders the 
 s(junds less audible. The transmission of the heart sounds^ 
 ])eyond the prajcordial region which depends upon morbid 
 
AUSCULTATION. 43^ 
 
 alterations in the lungs, is a question properly belonging to the 
 subject of pulmonary diagnosis. 
 
 B. New or Adventitious Sounds. 
 
 T. Endocardial Murmurs. — Cardiac murmurs are abnormal,, 
 more or less blowing sounds accompanying or replacing the 
 ordinary cardiac sounds, and having a definite relation to 
 physiological action, contraction or expansion, taking jjlacc in 
 the chambers of the heart. They vary in loudness and in 
 quality as Avell as in pitch, but all are prolonged and wanting 
 in the characteristics of a heart sound in the technical 
 acceptation of that term. 
 
 For practical pui'poses murmurs may be divided into twO' 
 classes — {a) Valvular, and (6) so-called Haemic. In the former, 
 which will chiefly engage our attention, there is some structural 
 alteration present at or immediately beyond the cardiac orifice 
 concerned, most commonly in the valves themselves, or there 
 is defect in the muscular complement of the valve apparatus in 
 the case of the auriculo-ventricular valves. 
 
 Structural change may give rise to two kinds of murmurs 
 — (a) Obstruction or direct, and (/3) Regurgitation murmurs. 
 (a) Obstruction murmurs may again be divided into two classes 
 — (1) Cases in which the orifice is contracted by local disease, 
 or in which there is some projection from the valves or arterial 
 walls calculated to obstruct the blood-current in greater or 
 less degree. A very loud murmur may be produced In- 
 a trifling obstruction of this kind. Such murmurs iorm. the 
 absolute obstruction class. (2) Cases of relative obstruction, by 
 which term we express the condition present, for instance, in the 
 aorta, when the channel of the vessel is dilated while the 
 orifice retains its normal size, or at any rate is not enlarged 
 proportionately to the channel beyond. Under such circum- 
 
44 AUSCULTATIOX. 
 
 stances '' fluid veins " are formed as the blood current spreads 
 out after its passage through the orifice, and these are the 
 cause of the niumiurs audible over the chest-wall. 
 
 (/3) Regurgitation murmurs may be di^ided into three 
 •classes, according to the mechanism of the incompetence on 
 which they depend. (1) Murmurs produced by incompetence 
 ■depending upon disease of the valves themselves. (2) Murmurs 
 produced by incompetence of the auriculo-ventricular valves 
 ■depending on muscle-failure. The auriculo-ventricular orifices 
 have to be prepared by muscle-contraction for the action of the 
 valves, which again are maintained in action by muscle 
 contraction. Moreover, in dilated ventricles the altered 
 relations of the musculi papillares to the curtains have to be 
 taken into account. (3) Murmurs produced at or beyond 
 ;arterial orifices by incompetence of the valves, the result of 
 •dilatation of the orifice consequent upon the dilatation of the 
 adjoining channel of the vessel. Owing to the increased area 
 which the valves have to cover, they, though in themselves 
 healthy, are rendered incompetent. 
 
 Endocarditis (generally rheumatic) is the chief cause of 
 deformity of the valves themselves, and this being (except in 
 intra-uterine life) almost confined to the left side of the heart, 
 we liave to do with murmurs of the first-class almost alone 
 •on that side. A large class of aortic murmurs arise from 
 incompetence of the valves depending on atheromatous changes 
 in the vessel, cither as the result of chronic changes in the 
 valves, or of dilatation of the vessel and enlargement of its 
 •orifice. Lastly there is tlie "muscle- failure" class of mitral 
 and tricuspid regurgitation murmurs. The last two classes of 
 Timrmurs are met with in the degenerative period of life, or 
 under certain special circumstances in earlier life, and bear no 
 relation to rheumatism. The injurious effect exerted upon the 
 
AUSCULTATION. 45 
 
 heart-muscle by an adherent pericardium must be borne in 
 mind. How complicated is the subject of the etiology 
 of valve lesions may be inferred from the statement of the 
 fact, that aortic incompetence may depend on half-a-dozen 
 pathological processes. 1. Rheumatic endocarditis. 2. Ulcera- 
 tive or septic endocarditis. 3. Chronic sub-inflammatory 
 changes, accompanied by thickening and subsequent shrinking 
 of the valves, the result of habitual excessive strain upon 
 the valves. 4. Atheromatous changes affecting the valves. 
 5. Atheromatous changes leading to dilatation of the aorta, 
 and finally of its orifice, so as to render the healthy valves 
 incompetent. 6. Rupture of a valve (though presumably not 
 a sound one). The pathological diagnosis of a heart-case 
 cannot be made by physical signs alone, and must, therefore, 
 be alluded to as little as possible in a work which deals only 
 with these. 
 
 In the case of every murmur heard over the prsecordial region, 
 three points have to be determined : — 
 
 1. Rhythm. 
 
 2. Position of maximum intensity. 
 
 3. Direction of transmission. 
 
 1 . In every case the rhythm of a murmur should be determined 
 by keeping the finger on some artery near the heart, as the 
 carotid or subclavian, while listening. 
 
 A murmur may be presystolic (i.e., auricular systolic), 
 systolic (ventricular systolic), or diastolic (ventricular diastolic). 
 The following diagram will illustrate the relation of these 
 different murmurs to the heart sounds : — 
 
46 
 
 AUSCULTATION. 
 
 Sound 
 1 
 
 ■•8L.= PRESYSTO 
 
 Lie. Id.s: 
 
 SYSTOLIC. C.= DIASTOLIC . 
 
 Fig. IX. represents the different rhythms of murmurs as described in the text. 
 "Witli regard to diastolic murmurs of mitral origin, when there is also a presystolic 
 murmur present it is evident that it merely depends upon the duration of these 
 murmurs, whether there be or not a pause between them. 
 
 The systolic murmur is represented as running off from the 
 first sound, and when the murmur is due to mitral or tricuspid 
 regurgitation, nature bears out the truth of this representation, 
 if any portion of the first sound remain audible. 
 
 Again, in the case of the diastolic murmur of aortic incompet- 
 ence, it often happens that the murmur is preceded by the second 
 sound, which, of course, is coincident with the commencement 
 of the expansion or the end of the contraction, of the ventricle, 
 while the murmur is coincident with the continuance of the 
 expansion of the ventricle. It is quite common to hear sound 
 and murmur together in the lesser degrees of aortic incom- 
 petence. Murmurs of aortic incompetence possess, generally, 
 a diminuendo character, that is, they grow fainter from their 
 commencement, as the backward flow may be supposed to 
 become less rapid and forcible, owing to the fuller expansion of 
 the ventricle, and the recovery of the elastic aorta from its 
 distension. Presystolic murmurs, on the other hand, increase in 
 intensity towards the first sound, with which they abruptly 
 close. A tricuspid presystolic murmur is very rare. Constric- 
 tion of both orifices — mitral and tricuspid — is, however, not 
 
AUSCULTATION. 47 
 
 very rare, but the degree of constriction of the mitral orifice is 
 usually much greater than that of the tricuspid orifice. 
 
 We. shall now consider in detail the murmurs which experi- 
 ence has shown to occur in disease. 
 
 The Presystolic or Auricular-systolic Murmur is a murmur 
 .generated at the auriculo-ventricular orifice, corresponding in 
 time to the physiological action of contraction of the auricle. 
 The ventricle, already near repletion, on receiving the blood 
 ottiore or less forcibly propelled into it by the auricle, at once 
 ■contracts, so that there is no pause, and the presystolic murmur 
 runs into the first sound, which is always present in these 
 cases. It seems very likely that the flow from the auricle has 
 not ceased at the time when the ventricle contracts and puts 
 ^n end to the murmur. (By palpation, it will be remembered, 
 the thrill accompanying the presystolic murmur is felt to run 
 up to the apex-beat, with which it abruptly closes.) This 
 murmur increases in intensity up to the first sound, as repre- 
 sented in Fig. IX. ; the fact may be explained by the increased 
 power acquired by the auricle as its cavity becomes lessened. 
 However explained, this growing in intensity of the murmur up 
 to the first sound is characteristic. When it possesses all the 
 attributes just described, we receive certain information from 
 the presystolic murmur that mitral or tricuspid stenosis exists. 
 Unfortunately, it is often absent, either temporarily, although, 
 of course, the stenosis remains unchanged, or permanently. The 
 disappearance of the murmur may be of no good omen. It may 
 be due to failure of the contractile vigour of the auricle, but the 
 ■capricious coming and going of the murmur frequently observed, 
 perhaps scarcely bears out this explanation. 
 
 The presystolic murmur, followed by the accentuated first 
 sound of the lesion, may be represented phonetically by the 
 syllable " trnip." It will be remembered that a double first 
 
48 AUSCULTATIOX. 
 
 sonnd is represented by " turnip." It is sometimes difficult to 
 distinguish the presystolic murmur and first sound from a double 
 first sound, but in the latter case there is no crescendo character 
 as in the former. A difficult}" with regard to the diagnostic 
 value of the presystolic murmur is occasioned by the fact, first 
 pointed out by the late Prof. Austen Flint, that in certain 
 exceptional cases of free aortic reflux, so close a simulation of a 
 presystolic murmur imperfectly developed may be heard as to 
 deceive even a practised ear. The clinical rule is, that in the 
 presence of free aortic regurgitation, and especially when this 
 arises from aortic disease and not from rheumatic endocarditis, 
 great caution must be exercised in the diagnosis of mitral 
 stenosis. 
 
 Systolic Murmurs. — In our consideration of the presystolic 
 munnur, matters were rendered comparatively simple, inasmuch 
 as the production of the murmur could take j^lace only at the 
 auriculo-ventricular orifices and have but one mechanism. 
 In the case of systolic murmurs a certain amount of complexity 
 must be encountered, as such murmurs can be generated at 
 either arterial or auriculo-ventricular orifices, and in each case 
 their mechanism is diffi3rent. Generated at an arterial orifice,, 
 the systolic is an obstruction murmur indicating absolute or 
 relative stenosis of the orifice. Arising at an auriculo- 
 ventricular orifice, it is a murmur of regurgitation produced by 
 incompetence of the mitral or tricuspid valves allowing a 
 leakage backwards into the auricle during the systole against 
 the general blood-cun-ent. In both cases the murmur coincides 
 in time with the contraction of the ventricles. In quality it 
 varies, being not unfrequently harsh, when due to absolute 
 stenosis and a rough and rigid condition of the aortic valves, 
 and generally soft and blowing when due to incompetence of 
 the auriculo-ventricular valves. In cases of great aortic 
 
AUSCULTAl'IOX. 49 
 
 Stenosis, when calcareous valves form a diaphragm across the 
 orifice with only a central slit, this murmur is often peculiarly 
 loud, harsh, and prolonged, while the aortic second sound may 
 be inaudible. Lastly, over a dilated left auricle, it is said that 
 a murmur purely systolic in rhythm is sometimes audible about 
 an inch or an inch and a half to the left of the sternum above 
 the third rib, alleged to be caused by a regurgitated current 
 from the ventricle. This explanation of the murmur heard in 
 the region indicated is very doubtful. 
 
 Several points of interest with regard to murmurs of systolic 
 rhythm will call for consideration in the section on the 
 "Transmission of Murmurs." Here we shall only mention the 
 presence, in greater or less integrity, of the first sound in some 
 cases, while in others the murmur entirely replaces the sound. 
 A systolic apex-murmur, not propagated to the back, frequently 
 accompanies mitral stenosis, and is no doubt due to some 
 regurgitation through the deformed orifice. In such cases the 
 first sound is usually present to some extent at the apex, and 
 at the back, indeed behind the mid-axillary line, as a rule takes 
 the place of the murmur. In muscle-failure of the left 
 ventricle, without disease of the valves themselves, an apex 
 murmur is generally not carried to the back. It is often 
 observed in the course of acute rheumatism that a recently 
 developed apex-murmur is accompanied b}^ the first sound at 
 the apex, and is not at first carried to the back, although the 
 first sound ma}^ ultimately be lost and the murmur become 
 audible at the back. 
 
 Diastolic Murmurs. — Like the systolic, the diastolic is a 
 murmur owning a diiferent mechanism according as it is pro- 
 duced at the aortic or mitral orifices. In the former case it is a 
 murmur of regurgitation, in the latter a murmur of obstruction. 
 As the significance of a systolic murmur is so far exactly tlie 
 
 £ 
 
50 
 
 AUSCULTATION. 
 
 reverse (i.e., produced by blood currents flowing in opposite 
 directions), according as it is apical or basic in origin, so also 
 the significance of the diastolic murmur at base and apex is 
 reversed (vide Fig. X.). The diastolic murmur due to aortic 
 
 AT APEX. 
 
 Fig. X.— The arrows represent the direction of the current generating systolic and 
 diastolic murmurs, according as these are formed at the base or apex of the heart. 
 Thus a systolic murmur at the base is of obstruction mechanism, at the apex of 
 regurgitation mechanism. A diastolic murmur at the base, again, is of regurgitation 
 at the apex of obstruction mechanism. The long vertical lines represent the first 
 sound, the short the second sound, as in the preceding figure. 
 
 incompetence is much the more common, and, as a rule, it is 
 preceded by a systolic mumiur, or at all events, a murmurish 
 first sound, seldom by a perfectly healthy first sound. Fre- 
 quently the second sound is audible as well as the murmur, 
 indicating a less degree of damage to the valve. This occurs 
 most remarkably where there is dilatation of the first part of 
 the aorta, and we have a " relative " obstruction mumiur, 
 systolic in time, succeeded by an accentuated second sound, 
 immediately followed by a blowing murmur. The aortic 
 diastolic murmur, as a rule, is soft and blowing, but in some 
 cases it is harsh* and one variety is characterised by being 
 accompanied by a thrill at the apex of the heart, where the 
 murmur is specially loud. It is a notorious fact, that under 
 certain temporary conditions, the aortic diastolic murmur may, 
 
 * Aortic diaHtoHc murmurs not very rarely furnish examples of more or less musical 
 murmurs, occasionally audible at some distance from tlie patient's body. 
 
AUSCULTATION. 51 
 
 for a time, disappear, although the valves are incompetent as 
 over, as evidenced by the vascular phenomena of the disease. 
 It may be here mentioned that a faint aortic diastolic mui*mur 
 is the last murmur which the student of auscultation learns to 
 recognise, and even after considerable practice, he will be apt 
 to miss the finer varieties of the murmur. 
 
 In rare cases a very short murmur precedes an accentuated 
 second sound over the aorta. Dr. Walshe has represented the 
 combination of sound and murmur by the word PHWE...TT. 
 The sign may be regarded as indicative of a dilated aorta. The 
 murmur is short, and,, in comparison with the sound which 
 follows it, insignificant. 
 
 The diastolic mitral* murmur differs materially from the pre- 
 systolic murmur already described, not only in rhythm, but in 
 •quality. The difference in rhythm will be readily appreciated 
 by reference to Fig. IX. The diastolic murmur does not in- 
 crease in intensity as the presystolic, but on the contrary 
 diminishes. It is commonly harsh, and often accompanied by 
 thrill, as already noted under palpation. This thrill is quite 
 distinct from the presystolic thrill, as already described. Both 
 murmurs are brought about by the same conditions, namely, a 
 narrowed auriculo - ventricular orifice, yet each possesses a 
 mechanism of its own. In the case of the true presystolic 
 murmur we have seen that the contraction of the auricle is 
 the physiological action of the heart associated with the 
 murmur. In the case of the mitral diastolic murmur we have to 
 do with the active (?) expansion of the ventricle pZws the blood- 
 
 * Dr. Balfour states that a diastolic murmur due to mitral stenosis may be audible, 
 and have its maximum intensity in the pulmonary area. This murmur is soft and 
 blowing, unlike the apex true diastolic murmur of mitral stenosis, and is probably 
 produced in the pulmonary artery and infundibulumof the riglit ventricle as a murmur 
 of high pressure, the pulmonary artery being dilated, and its valves permitting of a 
 certain amoimt of regurgitation. This murmur is not usually constant, at least when 
 first developed. (VUI. Med. Chronidc, Dec, 1888, "The murmur of high pressure in 
 the pulmonary artery.") 
 
52 AUSCULTATION. 
 
 •pressure in the lungs. We can readily imagine expansion of 
 the ventricles taking place with greater force at the com- 
 mencement of the diastole, rendering the current of blood 
 through the auriculo-ventricular orifices more rapid and forcible 
 at the outset, and gradually diminishing in intensity as the 
 cavities are filled. The pressure of blood in the auricle will 
 at the same time diminish. We may expect the murmur to 
 represent the blood current audibly. A presystolic and a 
 diastolic muimur frequently co-exist, when, if there be no 
 pause between them, the diastolic murmur becomes augmented, 
 as the flow of blood through the orifice is reinforced by auricular 
 contraction. If the diastolic murmur exist alone, auricular 
 contraction is in abeyance, as far as murmur-production is 
 concerned.''' 
 
 2. The maximum intensity of Murmurs. — The impossibility of 
 distinguishing the orifice at which a murmur is produced by 
 hearing it most loudly over the anatomical position of the orifice 
 in question, has already been stated and explained. The four 
 artificial areas, which are named respectively after each set of 
 valves, and the reasons for their selection having been already 
 considered, it will suffice here to recapitulate their situations. 
 
 The aortic area — over the junction of the second right costal 
 cartilage with the sternum. 
 
 The pulmonary area — over the junction of the third left 
 costal cartilage with the sternum. 
 
 The mitral area — over the apex-beat. 
 
 The tricuspid area — over the lower end of the sternum and 
 portion of right ventricle not covered by lung. 
 
 It does not follow that every endocardial murmur must have 
 
 its maximum intensity over one of these areas. For instance, 
 
 * When a reduplicated second sound is heard along with the diastolic murmur, the 
 latter portion of the double sound seems heard "through" the murmur as if this: 
 followed the former portion. 
 
AUSCULTATION. 53 
 
 an aortic regurgitation murmur is not unfrequently audible only 
 over and to the left of the lower part of the sternum, or in the 
 pulmonary area, or at the apex. In fact, a triangle may be 
 sketched out with one side corresponding to the right border 
 of the sternum up to the 2nd cartilage, the other side consist- 
 ing of a line drawn from the same cartilage to the apex of the 
 heart, and the base of a line drawn from the apex to the end of 
 the sternum, in any part of which triangle an aortic regurgitation 
 murmur may have its maximum intensity or be alone audible ; 
 the wliole area must, therefore, be explored in a suspected case. 
 The characters of the sounds or murmurs at each of the named 
 areas must, however, always be carefully investigated and com- 
 pared with the sounds and murmurs heard elsewhere, while the 
 laws of the propagation of murmurs, to be immediately con- 
 sidered, will materially aid in arriving at a correct diagnosis. 
 Friction rubbing is usually heard best where the heaii) lies most 
 superficially, and, therefore, in the triangular space which we 
 have described as formed by the indentation in the anterior 
 border of the left lung, but it is, as a rule, developed earliest at 
 the base of the heart. The consideration of the maximum 
 intensity of murmurs is inseparably connected with the subject 
 treated of in the next paragraph — viz., the transmission of 
 murmurs — and will receive in that place further comment. 
 Apart from the isolation of individual murmurs, the position of 
 maximum intensity of the heart-sounds as a whole may be of 
 fs'ome importance, as in hydro-pericardium, where the elevation 
 of the area of maximum intensity is significant. All displace- 
 ments of the heart will alter the position of the maximmn 
 intensity of the heart sounds in a corresponding direction. The 
 ■eflfect of aneurisms or aneurismal dilatation of the arch of the 
 aorta in intensifying markedly the aortic second sound over 
 their seat afibrds valuable diagnostic indication. Consolidation 
 
54: .AUSCULTATION. 
 
 of either pulmouaiy apex may render the cardiac sounds almost as 
 loud there as over the heart itself ; but this, and similar pheno- 
 mena, belong rather to the subject of pulmonary diagnosis, with 
 ■which we are not at present concerned. 
 
 3. Transmission of Murmurs. — Much of our success in cardiaa 
 diagnosis will depend upon a coiTect appreciation of this property 
 of muiTuurs. As has just been stated, the influence of the 
 respiratory organs in conveying the cardiac sounds beyond the 
 heart's own area is great, but here we presuppose the paren- 
 chyma of the lungs healthy.* As a general rule, murmurs are 
 carried in the direction of the blood-current producing them. 
 
 The normal directions of propagation of the dift'erent 
 munnurs are as follows : — 
 
 1. Aortic obstruction muimurs — carried upwards in the 
 coui-se of the large vessels. 
 
 2. Aortic regurgitation murmurs — carried downwards along 
 and to the left of stenium, often from the level of the third 
 cartilage ; sometimes reach the apex and may be little heard 
 elsewhere. 
 
 3. Mitral regurgitation murmurs — carried towards the left 
 axilla, and backwards to the vertebral groove. 
 
 4. Mitral obstruction muimurs — best heard at the apex, 
 little propagated beyond. 
 
 5. A tricuspid munnur — rarely extends much beyond its 
 own area, but inclines to the right. 
 
 The amount of first sound accompanying a mitral regurgita- 
 tion murmur when both are present is liable to vary. A more 
 im[>ortaut point, perhaps, is the change wliich the murmur is 
 found to undergo on carrying the stethoscope to the left and 
 backwards. Should such a murmur ha gradually lost and 
 
 * The heart sounds, especially the second sound, are usually in liealth louder under 
 
 the riiOd than the left clavicle. {Vid. McdImI, Lcciun-H awl Y'y'.swys, hy Dr. deorge 
 Johnson, p. 4»i5.) This is no doubt the result of the position of tiie aorta. 
 
AUSCULTATION. 55 
 
 become replaced by a first sound, say at the mid-axillary line 
 and posteriorly to it, a fair presumption may be made that 
 there 'is either regurgitation through a constricted orifice, or 
 regurgitation from incompetence of healthy valves-curtains as 
 the result of muscle-failure. This rule is not absolute, and the 
 occurrence of a mitral murmur not conducted to the back as a 
 sign of endocarditis in the course of acute rheumatism has 
 already been noted. Moreover, in some cases of mitral stenosis 
 a systolic murmur at the apex is audible at the back. In the 
 presence of rheumatism or chorea, or of a history of either of 
 these, the presumption should always be that any murmur 
 audible over the heart depends on endocarditic changes. 
 
 In concluding the subject of endocardial murmurs it is 
 necessary to call attention to a murmur which may be called a 
 " respiratory-systolic " murmur, and which appears not to be 
 produced in the heart at all, but in the superjacent lung by 
 compression. This murmur is usually met with about the apex 
 of the heart, and is therefore liable to be confused with a mitral 
 regurgitation murmur. Its nature will be recognised by the 
 influence exerted upon it by the respiratory act, during some 
 part of which it usually quite disappears. Variation of an apex 
 systolic murmur with respiration does not by any means exclude 
 its being a mitral regurgitation murmur. Regm'gitation is 
 possibly freeer during inspiration. 
 
 The sounds remaining pure over the area corresponding to 
 the portion of the heart uncovered by lung is an important 
 point in the diagnosis of the "respiratory systolic " murmur. 
 
 (6.) Anoemic Murmurs, <ix. — The consideration of these mur- 
 murs occupies a large portion of the space devoted to vascular 
 murmurs ; but here passing reference must be made to similar 
 murmurs heard over the prsecordial region. Systolic in time, 
 seldom harsh, and never permanently so, they are loudest, and 
 
56 AUSCULTATION. 
 
 not uncommonly heard only over the pulmonary area. They 
 may appear, however, at the aortic area, and ultimately at the 
 mitral and tricuspid areas, although in all probability in the 
 last two cases, the heart-muscle badly nourished by virtue of 
 the anaemia, has permitted the valves to become incompetent.* 
 The chief characteristic of hsemic murmurs is their seat of 
 maximum intensity over the pulmonary area (where murmurs 
 the result of structural changes are rare), and their being 
 commonly accompanied by venous hum in the neck. A great 
 deal evidently has yet to be learnt with regard to the murmurs 
 of anaemia not only as to their mechanism, but also with regard 
 to the blood conditions which induce them. Patients may 
 suffer from severe degrees of anaemia without developing 
 murmurs, while others develop marked murmurs when suffer- 
 ing from only slight degrees of anaemia. 
 
 Mention may be made, in this place, of murmurs due to 
 coagulation of the blood in the chambers of the heart or in the 
 large vessels. They are generally systolic and loudest at the 
 base — i.e., arterial obstruction murmurs. Cases, however, have 
 been recorded where presystolic and aortic diastolic murmurs 
 have been produced by coagulation : in the latter case, however, 
 it is doubtful if ulceration of the valves had not caused both 
 thrombus and incompetence. Common as is the phenomenon 
 of ante-mortem clotting in the heart and large vessels apart from 
 any local disease, judged by post-mortem room experience, it is 
 very seldom that a murmur is detected during life. No doubt, 
 in the majority of cases, a murmur, even if produced, would be 
 
 * The 80-called haemic murmur at the pulmonary area lias indeed been supposed 
 always to be the result of dilatation of the left cavities (mitral regurgitation mechanism), 
 and really to be formed in an enlarged left auricle and not in the pulmonary artery. 
 It is said to Ijave iis maximum intensity further to the left than a murmur really 
 generated in the pulmonary artery would have. I am not prepared to assent to this 
 tlieory. If the ordinary murmur of anwrnia over the pulmonary area is so explained, 
 the like murmur over the aorta, often almost as loud, remains unexplained. 
 
AUSCULTATION. 57 
 
 obscured by the pulmonary rales which in great abundance so 
 often precede death. 
 
 II. ^Pericardial Frictio7i. — We have preferred to consider the 
 audible phenomena due to pericardial inflammation apart from 
 -endocardial murmurs. The opposed surfaces (visceral and 
 parietal) of the pericardium having lost their normal smoothness 
 ^nd lubrication, the movements of the heart must necessarily be 
 productive of attrition sound, and, inasmuch as the movements 
 of the heart are divisible into systolic and diastolic, so likewise 
 will the rubbing sound produced by these movements be 
 divided. If this friction sound be imperfectly developed, it 
 will probably be deficient in its diastolic portion, the movement 
 of the heart taking place during the diastole being less forcible, 
 and therefore less likely to generate attrition noise. A friction 
 rub may then exist during the systole only, and occur during 
 but a part of this action, while a diastolic friction sound is 
 probably never met with alone. We have already seen that 
 the first and second sounds are not co-extensive in time with 
 the systole and diastole of the heart, contraction and expansion 
 following (and in the case of auricular contraction, preceding) 
 the sounds, so the period of rest enjoyed by the heart must be 
 exceedingly short, unless we consider the act (?) of expansion as 
 rest. From the above considerations we might expect that 
 friction noise would have no definite relation to the heart's 
 sounds, but would extend beyond them, so to speak, and, 
 although divided, be almost continuous. At whatever period 
 there is cardiac movement, at that period also there may be 
 pericardial friction noise. This is always accompanied by a 
 sensation of rubbing, difficult to describe, but readily appreciated 
 ^t the bedside. Except where the pericardium is covered by 
 lung, friction noise gives to the ear a marked character of being 
 produced superficially. Where, however, the lung overlaps, it 
 
58 ADSCULT-^TION. 
 
 iijay be purely systolic in rhythm, and, from lacking the ordi- 
 nary character of superficialness, closely simulate an endocardial 
 murmur. From anatomical considerations it might be expected 
 that friction would be most audible over the right ventricle, 
 where it comes into contact with the chest- wall. This accords- 
 with the usual situation of the maximum intensity of friction 
 sounds, viz., over the lower half of the sternum and to the left 
 of that region. But Dr. Walshe's statement is well worthy of 
 quotation — " "When the entire cardiac surface is the seat of fric- 
 tion murmur, the maximum amount of noise exists, according tO' 
 some authors, about the nipple ; to others, behind the sternum. 
 / am satisfied no rule of the hind can he established.''^ Friction is 
 usually well marked, and occurs early at the base of the heart. 
 One great character of friction sound is its non-transmission 
 m the directions already indicated in the case of endocardial 
 miu-murs, or, indeed, much beyond the anatomical limits of the 
 pericardium in any direction. Of course allowance must be 
 made for extreme loudness of the sound. It has been pointed 
 out that attrition sounds do not correspond in time with the 
 cardiac sounds. Another character is their comparative 
 uniformity of intensity from commencement to close. Thus^ 
 they do not extend up to or run off from the sounds as endo- 
 cardial murmurs do. In fact they are independent of the 
 cardiac sounds. Occasionally, however, there seem to be 
 "interruptions" of the sounds giving a more or less divided 
 character, it may be to both systolic and diastolic portions. 
 The last, but not least important, peculiarity of friction sounds 
 is their susceptibility to modification by pressure with the 
 stethoscope ; probably this character affords an absolutely 
 diagnostic sign of pericarditis, when a previously single attrition 
 sound is followed by a diastolic sound on making pressure 
 with the stethoscope. It may be well to mention, in conclusion, 
 
AUSCULTATION. 59* 
 
 that the diastolic or second portion of the to-and-fro sound, 
 which constitutes pericardial friction, has been observed to be 
 double, and Dr. George Johnson has observed a presystolic or 
 auricular-systolic friction, giving rise to triple rhythm.* Changes 
 going on in the pericardial surfaces alter from time to time 
 the quality and situation of maximum intensity of attrition 
 sound. Pericardial effusion is in marked contrast with pleuritic 
 effusion in regard to the power of annulling friction sound, very 
 large pericarditic effusions not unfrequently failing to produce 
 this result. Still less likely is effusion to aunul friction sound 
 when enlargement of the heart co-exists. The elevation of the 
 apex-beat of the heart in pericarditic effusion has already been 
 noticed, and its influence on the cardiac audible phenomena 
 must not be lost sight of. The vigour of the cardiac contrac- 
 tion exerts much influence upon the production of pericarditic 
 friction noise. In purulent pericarditis there may be no trace 
 of friction sound, for the absence of which the softness of the 
 exudation may partly account, but the chief cause is the 
 greatly depressed vigour of the heart muscle. Of the many 
 varieties of friction sound, extending from a faint graze to a. 
 coarse grating sound, no description has been offered, owing to 
 the impossibility of conveying to the mind of those whO' 
 have not heard for themselves, a correct idea of the sound 
 described. 
 
 Sometimes pleuritic friction may be of cardiac rhythm, that 
 is, be produced in the neighbourhood of and by the movements 
 of the heart, but a very little care will obviate any risk of 
 mistaking pleuritic for pericarditic friction. 
 
 Vascular Sounds. 
 1. Arterial. — We have ah-eady endeavoured to make clear 
 
 * " Medical Lectures and Essays." Chap. XXXVI. 
 
60 wlUSCULTATIOX. 
 
 the distinction which is drawn between sounds and murmurs in 
 the technical sense of these words. In the case of arterial 
 auscultatory signs, use will still be made of the same terms 
 with the same signification. Many writers speak of the systole 
 and diastole of the heart and of the arteries separately, the 
 systole of the heart of course corresponding to the diastole of 
 the arteries, and the systole of the arteries to the diastole of 
 the heart. This leads almost necessarily to confusion, and here 
 we shall speak of systole and diastole with reference to the 
 heart only. 
 
 The arteries commonly examined with the stethoscope, are 
 the carotid, subclavian, and femoral arteries, not because they 
 possess peculiarities, but for purposes of convenience. 
 
 The carotid and subclavian vessels being near the heart, it is 
 not surprising that in them we should hear sounds resembling 
 the cardiac sounds, and probably the same transmitted — 
 certainly so as regards the second sound. In the femoral 
 artery an approach to a sound in the form of a thud, systolic 
 in rhythm, is alone audible. This sound is evidently produced 
 in the arterial wall. We have as yet spoken of the auscultatory 
 signs heard over a large artery when pressure is carefully 
 avoided, and the stethoscope laid Hghtly over the vessel 
 examined. The sound referred to, corresponding with the 
 systole of the heart, whether occurring in the carotid, sub- 
 clavian or femoral, in the great majority of instances is at once 
 transformed into a murmur on pressure being made with the 
 stethoscope. The facility with which this change is produced 
 varies much, and in some cases the artery seems to resist the 
 strongest pressure without there being alteration to a murmur. 
 The second sound in the carotids and subclavians remains 
 unchanged, although the first sound be changed into a murmur. 
 
 In morbid conditions we may hear either sounds or murmurs 
 
AUSCULTATION. 61 
 
 produced in the arteries. We have referred to the systolic 
 sound audible in health over the femoral artery — a dull thud 
 lather than a sound. In certain abnormal conditions this thud 
 comes to resemble a cardiac sound much more closely. This 
 phenomenon is not pathognomonic of any one condition, unless 
 it be an abnormally great and sudden change from the state of 
 relaxation to one of tension, i.e., varying blood pressure. Hence 
 it is in cases of aortic regurgitation that we meet with the best 
 examples of this sound. In rare cases of extreme defect of the 
 aortic valves there is sometimes heard in addition a second 
 sound. The occurrence of this phenomenon gives us certain 
 proof that the sounds we hear over arteries can be produced 
 locally, for in the cases we refer to there exist no cardiac 
 sounds to be transmitted, if transmission to the femoral artery 
 were possible. 
 
 The potency of an anaemic condition in the production of 
 murmurs and in the augmentation of those produced by other 
 causes has been already noticed. Anaemic murmurs are probably 
 all systolic in rhythm, although it is alleged that a diastolic 
 anaemic murmur may exist. *" Haemic muimurs, as a rule, are 
 soft and blowing, although by pressure their character may 
 be altered. The most important haemic murmur is the venous^ 
 and while considering it, we shall have to refer again to the 
 arterial. By means of pressure, we have seen, a systolic mur- 
 mur can generally be developed over any large artery in health ; 
 hence it is natural to suppose that from various morbid condi- 
 tions pressure will occasionally be exerted on arterial trunks, 
 and murmurs be thus produced. 
 
 Sir Dominic Corrigan long ago showed that murmurs were 
 produced, not at the point of constriction, but on the distal side 
 
 * I have on one oi- two occasions examined cases which seemed to support the 
 allegation. The subject of diastolic murmur in anaemia is referred to in Dr. Stephea 
 Mackenzie's Lettsomian Lecturc)>, 1S91. 
 
'62 . AUSCULTATION. 
 
 beyond. We have already dwelt upon the importance of 
 " relative obstruction" in treating of the murmurs of the heart. 
 
 On pressiu'e being made over the large arteries in free aortic 
 regurgitation, a double murmur, systolic and diastolic, is found 
 to be the rule, but the diastolic portion is usually very much 
 shorter and less loud, while a certain degree of pressure is 
 required to develop it. No doubt, as heard over the carotid 
 and subclavian arteries, these murmurs may be transmitted 
 from the aortic orifice and its immediate neighbourhood. Direct 
 murmurs formed at the aortic orifice are, in accordance with the 
 common rule, carried onwards in the course of the circulation 
 with much greater facility than regurgtation murmurs. The 
 double murmur heard in the femoral must, however, be generated 
 locally. By pressure on the vessel we produce obstruction to 
 two cun-ents, the one flowing onwards, much the more powerful, 
 the other flowing backwards and feeble, corresponding with the 
 regurgitant flow backwards through the valves. In each case, 
 " fluid veins " are generated, audible as murmurs. 
 
 A uscultation of the Veins. 
 
 Venous. — In ansemic subjects over the internal jugular veins at 
 the root of the neck, and especially on the right side, the venous 
 cun-ent becomes soniferous. Murmur is produced, and the mur- 
 mur differs from all the murmurs which we have considered in 
 being continuous. The quality and intensity of the sound varies 
 much, not only in different cases but in the same case, by applica- 
 tion of varying degrees of pressure, and according to the rapidity 
 of the bloodcurrent returning to the heart. Among the agencies 
 tending to accelerate the blood-current in the jugulars may be 
 mentioned inspiration, the diastole of the heart, and the upright 
 posture. Inasmuch as these act independently of one anot her the 
 intensity of the murmur is constantly liable to slight variations, 
 
AUSCULTATION. 63 
 
 irrespective of any change in the amount of pressure exerted. 
 In quality the murmur may be soft and blowing, humming or 
 musical, or it may consist of an almost roaring noise. Apart 
 from the intrinsic variation in intensity, of which we have men- 
 tioned some of the causes, the murmur seems regularly intensi- 
 fied in many cases during the systole of the heart. When this 
 is the case it will usually be found that we are dealing not with 
 a venous murmur alone, but also with the arterial murmur 
 already described. To an unpractised ear this combination bears 
 * some resemblance to a double murmur. The arterial murmur, 
 drowning the venous for the time, represents the systolic portion, 
 while the venous murmur, inaudible from the loudness of the 
 arterial murmur during the systole, alone represents the diastolic 
 portion of the double murmur. 
 
 In the above sentences we have described the venous murmur 
 as occurring at the root of the neck in an anaemic subject. 
 Naturally we have taken as our example the phenomenon where 
 best developed ; but other veins, as the subclavian, femoral, 
 superior longitudinal sinus, tfec, manifest similar murmur. 
 Moreover, chlorosis or anaemia is not necessary for a slight 
 - development of the sign. Nay, it is met with, usually feebly 
 marked however, in cases in which little or no departure from 
 health can be detected. On the other hand all forms of 
 anaemia do not induce the murmurs usually associated with the 
 condition. 
 
 3. Auscultation of Aneurismal Sacs. — Either sounds or 
 murmurs, or sounds and murmurs together, may be audible 
 over aneurismal sacs. So many variations and different com- 
 binations are found to exist that Dr. Walshe enumerated no 
 fewer than ten varieties which he had himself heard, adding 
 that " the list probably might be increased from the experience 
 of others." With regard to murmurs or sounds audible over 
 
64 AUSCULTATION. 
 
 aneurisms of the arch of the aorta, the questions, of course, will 
 always arise : to what extent are the sounds or murmurs, 
 generated at the aortic orifice ? to what extent m the sac itself ? 
 To commence with the simplest type, we may hear over the 
 pulsating area exceedingly loud sounds, the second invariably 
 possessing more or less of the characteristic feature we have 
 called accentuation. That the aortic valves should be closed 
 with exaggerated force is only what we might expect. The 
 existence of two sounds, resembling (apparently being) the 
 heart sounds, and at least of as great intensity, away from the 
 region of the heart itself, is a sign strongly presumptive of 
 aneurism ; and, when heard over an area pulsating with at 
 least as great force as the heart, the presumption of aneurism 
 rises almost to certainty. In considering the propagation of 
 murmurs, the influence of the conducting power of the lungs 
 has already been mentioned. Here it is only referred to, lest 
 error may arise from abnormal loudness of the heart sounds 
 over a consolidated apex. The distinctness of the first sound, 
 however, in aneurisms varies much, there being frequently 
 present only a dull thud. Sometimes there is only a systolic 
 jog or push, which is felt rather than heard. The second sound 
 also may be deficient in distinctness, though still conveying the 
 impression of accentuation. In aneurism of the arch it is the 
 systolic sound which commonly fails. The next combination 
 we have to refer to is a systolic murmur, followed by the 
 accentuated second sound so often mentioned. Thirdly, there 
 may be a double murmur. In the case of aneurisms of the 
 arch of the aorta, of course in the great majority if not in all, 
 when double murmur exists, the aortic valves are incompetent, 
 and it has been supposed that both murmurs are transmitted 
 from the heart. It is probably by no means always so, and 
 it is not imlikely that murmurs may be produced about the 
 
AUSCULTATION. 65 
 
 mouth of saccular aneurisms. The systolic is usually the louder 
 and harsher of the two murmurs, although the diastolic may be 
 the more prolonged. Another feature often presented by the 
 double murmur heard over aneurismal sacs is its continuity — 
 the systolic and diastolic portions being practically continuous. 
 These remarks sufficiently indicate the auscultatory signs which 
 may be expected to be found over aneurisms of the arch, and 
 aneurisms in this situation can alone be considered in a descrip- 
 tion of the " Physical Signs of Cardiac Disease." 
 
APPENDIX, 
 
 THE PULSE. 
 
 For purposes of convenience we usually place our finger on 
 the radial artery at the wrist to ascertain the rate of the heart 
 beats, and from this universal custom we have come to 
 speak of the pulse, meaning the pulsation felt in the radial 
 artery. Each beat of the pulse corresponds with a cardiac 
 systole, but they are not quite synchronous. As we pass from 
 the centre to the periphery, a perceptible interval becomes 
 apparent between the cardiac and vascular beats. In certain 
 morbid conditions this interval becomes more evident, and in 
 aortic reflux the interval is very pronounced, so much so, as in 
 some cases to render the pulse almost synchronous with the 
 succeeding ventricular contraction, instead of with its own. 
 It is a good precaution to feel both radial pulses in investigating 
 vascular disease. Absence or diminution of the radial pulse 
 on one side is an important sign of aneurism. In many cases, 
 however, it depends on irregular distribution of the arteries 
 merely, and sometimes upon obstruction due to endarteritis. 
 Both subclavian and carotid pulses have been known to be 
 obliterated by chronic endarteritis at the origin of the vessels. 
 In every case absence or diminution of a radial pulse is a sign 
 calling for further investigation. 
 
 The j)ulse may be considered under the following heads : — 
 
APPENDIX — THE PULSE. 67 
 
 Derangements or Variations of the Pulse. 
 
 -4.-^ With reference to the Pulse, considered as a series of 
 
 Beats or Impulses. 
 
 B. — With reference to the Pulse, considered as a Single Beat. 
 
 C. — With reference to the condition of the Arterial Walls. 
 
 A. includes irregularity in respect to either 
 
 ^ *^ ^ '^' > or both together. 
 (6.) Equality, J 
 
 B. includes the following variations : — 
 
 1. Large and small.- 5. Dicrotism, &c. 
 
 2. Full and empty. 6. Thrills. 
 
 3. Compressible and incom- 7. Corrigan's, or the water- 
 
 pressible. 
 4. Quick and slow. 
 
 hammer pulse. 
 
 A, 
 
 (a.) Frequency of the Pulse Beat. — Pulse-rate, though of com- 
 paratively minor importance in cardiac diagnosis, cannot be 
 altogether passed over without comment. In the majority of 
 cases of valvular disease of the heart the pulse is rendered more 
 frequent. This effect is commonly observed in mitral disease, 
 while one form of aortic disease is characterised by the opposite 
 tendency (aortic obstruction). Fatty degeneration of the heart 
 sometimes reduces the pulse much below the normal frequency. 
 Of an infrequent pulse each individual beat may be quick and 
 of short duration, or, on the other hand, slow and laboured. 
 The point is of some clinical importance, and should always be 
 noted in a report. The normal standard is from 60 to 70 per 
 minute, but many individuals present variations from this 
 standard, some having a pulse as infrequent as 30, othei*s as 
 
68 APPENDIX — THE PULSE. 
 
 -frequent as 80 and more. In the condition known as "tachy- 
 cardia " the pulse becomes extremely frequent — 200 per minute 
 for instance. When it is remembered that the pulse-rate forms 
 a feature in all the specific fevers, and is not without diagnostic 
 . and prognostic value in most other diseases, the multifarious 
 bearings of its study will be apparent ; but here we have to do 
 with pulse-rate only in its relation to the diagnosis of diseases of 
 the heart. 
 
 (6). Equality. — In health one beat is as another. In disease 
 this may no longer be the case, and some beats may be full and 
 strong, while others are hardly perceptible, and some heart-beats 
 may even be imperceptible in the pulse. The arrangement of 
 the dissimilar beats varies indefinitely. 
 
 Irregularity of the Pulse. — This common feature of the pulse 
 in cardiac disease may be considered as composed of two 
 elements, one having relation to the pulse frequency, the other 
 to the pulse equality. The well-known occurrence of inter- 
 mission may be regarded as a defect in frequency. It is, in a 
 large majority of cases, a pause in the rhythmic contractions 
 of the heart ; but it may be due to inequality carried to excess — 
 i.e., the ventricular contraction being so feeble as not to be 
 represented in the radial artery. Distinct pauses may be 
 followed by a scries of rapid beats, or there may be no pause 
 yet the pulse vary in frequency and force at different moments. 
 A strong beat commonly follows a pause, {vide Fig. 15) and then 
 a series of weaker beats may immediately ensue. Irregularity 
 of tlie pulse is a feature of cardiac disease, easily recognised 
 and of much importance, although it is not necessarily the 
 expression of valve disease. When, indeed, it is associated 
 with the last, it probably depends more upon the state of 
 imtrition and innervation of the heart substance than upon 
 any special fonn of valve defect, although it is usually regarded 
 
APPENDIX THE PULSE. 69 
 
 as characteristic of mitral disease. Irregularity is by no means 
 uncommon in the absence of all organic diseases of the heart, 
 as in dyspepsia, functional derangement of the liver, the specific 
 fevers, &c. Sometimes a succession of irregular beats recurs in 
 ^ cycle, fonning a sort of order in disorder. A not uncommonly 
 observed phenomenon under the physiological action of digitalis, 
 •especially in cases of mitral stenosis, is an apparently very slow 
 pulse, which is found on further investigation to be accompanied 
 by a normal frequency of the cardiac contractions ; when the 
 latter are more closely studied in relation with the pulse, they 
 .are found to occur in pairs, one of each pair alone producing a 
 pulse beat in the radial artery {vide Fig, 16). Although most 
 -common in cases of mitral stenosis, this peculiarity of the 
 pulse is met with in other diseases. It has been observed, for 
 instance, in a case of aortic regurgitation under the influence 
 of digitalis. In mitral stenosis it may occur independently of 
 the action of the digitalis. 
 
 The forms under which irregularity may be met with are 
 exceedingly numerous, and no advantage would accrue from an 
 attempt to enumerate them. 
 
 The '■^Pulsus Paradoxus.'' — This pulse is characterised by be- 
 ■coming ver}^ feeble during inspiration. It has been stated to 
 be characteristic of certain cases of " chronic mediastinitis " 
 .associated with adherent pericardium. 
 
 B, 
 
 The characters of the individual beat of the pidse have of 
 late, perhaps, ceased to be the object of interest which they 
 were to the older physicians. The invention of the sphvgmo- 
 graph is the chief cause of this, in the same way that the 
 invention of the clinical thermometer may be charged with tlie 
 decline of attention directed to-day to pulse frequency in the 
 
70 APPENDIX — THE PULSE. 
 
 specific fevers and febrile diseases generally. The comparative- 
 disuse of these simple methods of diagnosis and prognosis has- 
 undoubtedly been carried too far. 
 
 The Individiial Pulse Beat, — Under this head we enumerate 
 a few of the leading varieties of pulses. 
 
 1. Small and Large. — The meaning to be attached to these 
 terms is apparent, and clinically the distinctive character of 
 each is easily recognised. In mitral disease the pulse is usually 
 small. In dilatation of the left ventricle with hypertrophy it 
 is, as a rule, large. There can be little doubt that when the 
 walls of the ventricle have become degenerated and the cavity 
 has become rounded in shape, the systole is often habitually 
 incomplete. It must be remembered that, normally, the supra 
 papillary space of the left ventricle contains blood at the end of 
 the systole. The smallness or largeness of the pulse does not,, 
 however, depend solely upon the condition of the left ventricle. 
 For instance, general exposure to cold will render a normal 
 pulse small by contracting the muscular coat of the vessels, 
 while warmth tends to produce an opposite effect. 
 
 2. Ftdl and empty. — By an empty pulse we mean one that 
 gives us, on palpation, the sensation of being but partially 
 filled, or, in other words, that the vessel is capable of holding 
 more than is supplied to it. The full pulse, on the other hand,, 
 is the direct counterpart of this, for in it the blood seems 
 supplied to repletion. 
 
 3. Compressible and Incompressible. — At the bedside it 
 will be found that pulses vary much as regards the amount 
 of pressure necessary to cause their obliteration. The pulse 
 which resists pressure is " incompressible," the pulse readily 
 obliterated " compressible." The degree of compressibility is 
 an important sign, and is always worthy of attention. In the 
 days of bleeding much attention used to be directed to this. 
 
APPENDIX — THE PULSE. 71 
 
 character, and the incompressible pulse, perhaps wisely, formed 
 an indication for the lancet. The incompressible pulse is /)ar 
 excellence the pulse of "high tension." In a good example of a 
 high tension pulse the radial artery is felt like a solid cord, 
 and when the finger is placed lightly on it no pulsation may 
 be perceptible in it. Pressure with the finger not only elicits 
 the pulsation but shows the high degree to which the vessel 
 may be compressed without the pulsation being obliterated. 
 The expression " full between the beats " is often applied to 
 the high tension pulse. High tension is associated with peri- 
 pheral resistance, but requires a vigorous left ventricle for its 
 maintenance. 
 
 4. Quick and Slow. — These characters are most manifest in 
 the infrequent pulse, of which we may have two varieties. One 
 is characterised by a rapid impulse of short duration, the other 
 by a prolonged impulse. The conditions of peripheral resistance 
 and of the contraction of the left ventricle no doubt are the 
 chief factors in the production of these varieties. When the 
 pulse is interfered with by the interposition of an aneurism 
 between it and the heart the pulse is prolonged ; there is delay 
 of the beat but not of its beginning " but of the period of 
 maximum pressure." (Fig. 13.) 
 
 5. Dicrotism. — Sometimes there is a double beat corre- 
 sponding to a single cardiac contraction, the second beat being 
 very much less perceptible. This is the dicrotic pulse, and one 
 usually believed to be associated with low tension. Drs. Roy 
 and Adami deny this. {Vid. Practitioner, 1890, p. 134.) It is 
 commonly met with in enteric fever and other febrile states. 
 (Figs. 3, 4, 5.) 
 
 6. The pulse in some morbid states is accompanied by thrill. 
 This happens occasionally in cases of aortic regurgitation, with 
 dilated ventricle and unfilled arteries. 
 
4 2 APPENDIX THE PULSE. 
 
 7. Corrigan^s Pulse, or the Pulse of Aortic Rejlux. — This pulse 
 possesses a very special character, and bears the name of the 
 physician who first described it — Sir Dominic Cori'igan. It is 
 known also under the names of the " water-hammer pulse," 
 " the pulse of unfilled arteries," &c. As already mentioned, 
 this pulse possesses an extreme degree of visibleness. It is 
 characterised by a sudden filling of the artery followed 
 immediately by an equally sudden emptying, and this 
 peculiarity becomes exaggerated on raising the arm to a right 
 angle with the recumbent trunk. In cases of aortic regurgita- 
 tion, especially the variety depending on endocarditis, the pulse 
 in the peripheral arteries is frequently delayed, it may be to 
 such a degree that the pulse becomes almost synchronous, not 
 with its own systole, but with the one succeeding. 
 
 c. 
 
 Endo-arteritis. — Having ascertained the characters of the 
 pulse proper, there remains to be investigated still another 
 point, namely, the state of the arterial walls. This is readily 
 ascertained by obliterating the pulse by firm pressure, and 
 rolling the forcibly-emptied vessel against the bone, when, if 
 the coats be thickened and atheromatous, we are able at 
 once to recognise the condition. In some cases the vessel 
 becomes almost moniliform, from irregular thickening and 
 calcareous deposit in its coats. 
 
 For further particulars regarding the pulse the reader is 
 referred to the series of sphygmograms which follows. 
 
APPEXDIX — THE PULSE. 
 
 73 
 
 iFiG. I. — (The late Dr. Mahomed.) Shows a method of gauging tension. The tracing will 
 Serve to illustrate the principal features of a pulse curve. There is the "upstroke," 
 then a depression forming with the upper portion of the "upstroke" the "percussion 
 wave." An elevation, the " tidal wave," succeeds. This wave terminates with the 
 "aortic notch" (B) which indicates the end of systole and the beginning of diastole. 
 The elevation immediately following this notch is the "dicrotic wave." A line 
 drawn through the lower extremities of the series of "upstrokes" is called the 
 "respiratory line." The tracing represents a pulse of considerable tension, and it 
 will be noticed that the "tidal wave" rises above the dotted line drawn from the 
 summit of the "upstroke " to the " aortic notch." The " aortic notch," again, is at a 
 considerable height above the " respiratory line." The old and best known nomen- 
 clature is retained here. Drs. Roy and Adami, in their paper already referred to, 
 propose to name the " percussion wave" the "papillary wave"and the "tidal wave" 
 the "outflow-remainder wave." Their observations, further, seem to throw some 
 doubt upon the suitableness of the terms "high " and "low tension," in common use, 
 as applied to tracings presenting the characteristic features, which are illustrated in 
 the following tracings. 
 
 Fig. 2.— (Mahomed.) Showing high tension, 
 case there was no albumen in the urine. 
 
 In this 
 
 IiG. 3.— (Mahomed.) Low 
 tension and dicrotic pulse. 
 I'he aortic notch ap- 
 proaches the respiratory 
 line. 
 
 Fig. 4. — (Mahomed.) Fully dicrotic pulse. 
 The aortic notch^reaches the respira- 
 tory line. 
 
 F'G. 5.— (Mahomed.) H>-perdicrotic pulse. 
 The aortic notch falls below the res- 
 piratory line. 
 
 Fir,. 6.— (Mahomed.) Tracing showing 
 l)ronoiinccd tidnl and dicrotic waxes. 
 
APPENDIX — THE PULSE. 
 
 Fig. 7. — (Mahomed.) Tracing of pulse in aortic legurgitation due to 
 endocarditic disease. 
 
 Fig. 3.— (Mahomed.) Pulse ia case of aortic regurgitation, due to aortitis deformans. 
 
 Fig. 9. — (Mahomed.) Tracing of pulse in 
 aortic obstruction. 
 
 FiG. TO. — Tracing of pulse in aortic ob- 
 struction showing another type. (From 
 Reynolds' "System of Medicine," VoL 
 IV., p. 659.) 
 
 Fig. II.— Pulse in mitral stenosis. The tracing shows a well-marked tidal wave and the 
 occasional occurrence of abortive beats. 
 
APPENDIX THE PULSE. 
 
 75 
 
 [Fig. 12, — (Mahomed.) Pulse of cardiac dilatation, with mitral regurgitation. There is no 
 tidal wave. The upstokes vary in length. 
 
 Fig. 
 
 Fig. 
 
 14. 
 
 Figs. 13 and 14 (Mahomed) represent the right and left radial pulses respectivelj- in a. 
 case of aneurism of the right axiliary artery. The former is extremely aneurismal ia 
 character. 
 
 Fig. 15. — Tacing of pulse showing a " missed " beat with succeeding uiiusuallj; full beat. 
 The tracing was taken from a case of great dilatation of the left ventricle. The 
 systole was no doubt habitually imperfect. As a consequence of the missed l)eat and 
 the accumulation of blood in the chamber, the left ventricle seenui to have been 
 roused to a supreme effort. 
 
APPEXDIX THE TULSE. 
 
 Fjg. i6. — Bigeminal pulse. If the abortive heart-l)eat is imperceptible in the pulse the 
 latter seems only to be unusually slow. 
 
 Fig. 17. — fMahomed.) Pulse of atheromatous arteries. 
 
 20th. Oct., 1887. 
 
 Fig. 18. 
 
 25ih Oct. 
 
 Fig. 19. 
 
 1st Nov. 
 
 Fig. 20. 
 
 4th Nov. 
 
 Fig. 21. 
 
APPENDIX — THE PUL3E. 
 
 77 
 
 19th Nov. 
 
 Fig. 
 
 6th Dec. 
 
 Fig. 24. 
 
 Figs. 18—24 represent pulse tracings taken in a case of "heart-failure " occurring during the- 
 course of chronic Bright's disease. The patient made a good recovery from his " licart- 
 failure." The tracings shows a progressive increase of pulse-tension. (Case reported in 
 Medical Chronicle y Jan., 1888.) 
 
 Fig. 
 
 Fig. 26. 
 
 Figs. 25 and 26. — Pulse tracings from a case of " heart-failure." 
 
 Fig. 26 represents the pulse after recovery. (Case reported in Lancet, Aug. 14th, 1886.) 
 
 Fig. 27. 
 
 Fig. 28. 
 
 Figs. 27 and 28.— Pulse tracings from a ca^e of "cardiac-failure." 
 
 Fig. 28 represents the pulse after recovery. (Case reported ill Lancet, Sept. loth, iSS?,) 
 
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 The physical signs of cardiao. 
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