HOW TO EXAMINE THE CHEST HOW TO EXAMINE THE CHEST A PKAOTICAL GUIDE FOR THE USE OE STUDENTS BY SAMUEL WEST, M.D. Oxon., F.R.C.P. ASSISTANT PHYSICIAN AND MEDICAL TUTOR TO ST. BARTHOLOMEW'S HOSPITAL; SENIOE PHYSICIAN TO THE ROYAL FREE HOSPITAL? CONSULTING PHYSICIAN TO THE NEW HOSPITAL FOR WOMEN; LATE PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE CHEST, VICTORIA PARK LONDON J. & A. CHURCHILL 11, NEW BURLINGTON STUEET 1890 mo flC UJ CO PEEEACE TO THE SECOND EDITION. I HAVE taken advantage of a new edition to recast a few paragraphs wIlicIi I thouglit might be more concisely or clearly expressed, to make several verbal alterations, and to introduce two or three new figures. In all these changes I have steadily borne in mind the original object with which the book was written, and I have not departed from its elementary character nor added to its size. SAMUEL WEST. 15 WiMPOLE Street, Cavendish Squaee, W. October 18th, 1890. PEEPAOE TO THE FIRST EDITION. In the following pages I have not aimed at writing an exhaustive treatise on auscultation and percussion, but merely an introduction to the examination of the chest by these and other methods. Each section is virtually based on lectures delivered by me at St. Bartholomew's Hospital, during the course of the demonstrations, which it has been my duty, as medical tutor, to give to the students during the last few years, by way of preparation for clinical workin the medical wards. I have therefore avoided all discussion of theory, and have adopted in the text, without argument, that theory in each case which ajopears to me on the whole to furnish the best explana- tion of the facts. I have endeavoured throughout to keep clearly Vlll PEEPACE TO THE FIRST EDITION. in view the wants of beginners^ and to write a simple and concise account of tlie main facts of prominent importance_, describing what seems to me the best method of observing these facts^ and showing the use which may be made of them for the purpose of diagnosis. I am much indebted to Dr. Andrew and Dr. Bristowe for their friendly criticism and advice, which I take this opportunity of gratefully ac- knowledging. SAMUEL WEST. ' 15 WiMPOLE Steeet, Cayendish Sqtjaee, W. March, 1883. CONTEJS'TS. INTRODUCTORY CHAPTER. The Thorax The Parts of the Thorax The Contents of the Thorax The Position of the Patient The Methods of Examination SECTION I.— THE LUNGS. 1. Inspection. a. The Shape of the Chest Its Measurement Named Varieties of Thorax Changes of Shape due to Disease Deformities . The Condition of the Superficial Veins 5. The Movements of the Chest on Respira tion The Types of Respiration The Amount of Air respired Alterations in the Respiratory Movements The Number of Respirations Synopsis 2. Palpation. How to Count the Ribs . The Shape and Movements of the Chest Abnormal Sensations The Vocal Vibrations Sense of Resistance Synopsis I PAGE 1 1 3 3 5 9 10 12 18 19 19 20 20 21 22 23 26 27 27 28 28 29 30 X CONTENTS. SECTION I.— THE LUNGS (continued). 3. Peecussion. pa&e 31 34 35 37 39 43 43 45 47 47 49 53 56 59 Method of Percussion Resonance and Dulness . The Size of the Lungs Boundaries of the Lungs . The Surface-Markings of the Liver Do. of the Spleen Do. of the Stomach Do. of the Lungs Alterations in the Boundaries of the Lungs Symmetrical Unsymmetrical Varieties of Percussion Sound Want of Symmetry on Percussion . Synopsis 4. AtrscrLTATiON. Of Stethoscopes . . .60 Vocal Resonance and its Varieties . . 65 The Sounds of Breathing and their Varieties 70 Use of the Facts ascertained in Diagnosis . 78 Other Pulmonary and Pleural Sounds . 83 Synopsis . . . .91 Conclusion . . . .92 Suggestions for the Construction of Diagrams . 93 General Synopsis of the Examination of the Lungs 95 SECTION II.— THE HEART. 1. Inspection. The Shape of the Prsecordial Region . 100 The Movements in the Prsecordial Region : Apex Beat : Its Normal Position . . 101 Normal Peculiarities . . 102 Displacement . . . 102 Its Character . . .103 Changes in Disease , . 104 CONTENTS. XI SECTION II.— THE HEART (continued), page Pulsation in Abnormal Places . . 104 Synopsis .... 106 2. Palpation. How to Fix the Apex . . . 107 Abnormal Sensations . . . 107 Synopsis , , . . 109 3. Peectission. The Size of the Heart and the Cardiac Dulness 110 Alterations in the Cardiac Dulness . . 114 Synopsis . . . .118 4. Auscultation. The Sounds of the Heart . .121 Reduplication . . . . 124 Murmurs . . . .125 Their Classification . . . 126 How to Time them . . . 127 Subdivision of . . . 129 Their Cause . . . 134 Their Place . . .135 The Position of the Valves . . 137 The Axes of the Heart . . .139 The Diagnosis of Valvular Disease . . 143 Inorganic Murmurs — Endocardial . . 147 Exocardial . .151 Murmurs Audible in other Parts of the Thorax 153 Synopsis .... 156 General Synopsis of the Examination of the Heart . . . . .157 SECTION III.— THE PULSE. Its Cause .... 161 The Pulse Rate . . .161 The Aeteey. Its Course . . . .163 Its Coats . . . .163 Its Tension . . . . .164 Xll CONTENTS. SECTION III.— THE PULSE (continued). The Pfise Wave. PAGE The Sphygmograph . 166 The Ehythm of the Pulse . 172 Want of Symmetry . 175 Synopsis . 177 SECTION IV.— THE MEDIASTINUM. Displacement of the Mediastinum . . 181 The Parts of the Mediastinum . 183 Diseases of the Mediastinum . 183 Their Diagnosis . 186 Synopsis . 192 LIST OF ILLUSTRATIONS. PAGE 1. The front of the thorax . . .4 2. The back of the thorax . . .5 Cyrtometer tracings : 3. of the healthy chest . . 10 4. of an emphysematous chest . 13 5. of a rickety chest . .15 6. of a pigeon-breast . . 16 7. of an alar or pterygoid chest . 16 8. of an unsymmetrical chest . 19 9. tracing of Cheyne-Stokes' breathing 25 10. Diagram showing position of the thoracic and abdo- minal organs, with their surface-markings . 36 11. Diagram showing the boundaries of the lungs in health . . . . .42 12. in emphysema . . .46 13. in senile emphysema . . .48 14. in compensatory hypertrophy . . 50 15. in pneumothorax . » .52 16. in pleuritic effusion . . .54 Figure of : 17. ^— the single stethoscope . . .62 18. — — - the binaural and differential stethoscope . 63 19. Diagram showing the position of the bronchi behind 72 20. Diagram showing the real size of the heart, and the size of the absolute cardiac dulness . . Ill XIV LIST OF ILLUSTEATIONS. PAGE Alterations in the cardiac dulness : 21. in aortic disease . . . 115 22. in mitral disease . . . 116 23. in pericardial effusion . . . 117 24. Diagram of the heart's action . . . 120 25. Diagram of a systolic murmur . . . 128 26. Diagram of a short prsesystolic murmur . . 130 27. Diagram of a long prsesystolic murmur . . 130 28. Diagram of a short postsystolic murmur . .131 29. Diagram of a long postsystolic murmur . . 131 30. Diagram of a double murmur, systolic and postsystolic 132 31. Diagram of a double murmur, prsesystolic and systolic 132 32. Diagram of a mid- diastolic murmur . . 133 33. Diagram of the position of the different parts of the heart, and of the places at which to examine the orifices and the axes of the heart . . 136 34. Diagram of the hand on the chest to represent the heart ..... 138 35. Diagram of the area of cardiac dulness in a case of mitral stenosis . . . . 145 36. Diagram of the murmurs and of the heart-sounds in the same case .... 146 Pulse tracings : 37. diagrammatic .... 167 38. 39, 40, and 41. normal and abnormal . 169 42. of mitral incompetence . . . 172 43. of the pulsus paradoxus . . . 174 HOW TO EXAMINE THE CHEST. INTRODUCTORY CHAPTER. THE THOEAX. The Chest or Tliorax is a box, tlie sides of wliicli are formed by the spine, tlie ribs and intercostal muscles, and the sternnm. Above, it is closed by muscles and membrane, between which the vessels and other structures pass into, or out of, the cavity of the chest. Below, it is completely closed by the diaphragm, which is attached, posteriorly to the spine, ante- riorly to the sternum, and all round to the free margin of the ribs, or, as it is called, the Costal Arch. The Parts of the Thorax. Externally, the thorax is mapped out into certain regions {figs. 1 and 2), named according to the anatomy of the part : 1 2 HOW TO EXAMINE THE CHEST. In the middle line, the Sternal, divided into the Upper, Middle and Lower Sternal, with the Episternal above : On either side of the sternum, the Parasternal : Further outwards, the Clavicular, the Supraclavicular and Infraclavicular, the Mammary and Inframammary : Laterally, the Axillary, upper and lower : Posteriorly, the Supraspinous and Infraspinous, the Infrascapular and the Interscapular. These terms are useful as indicating roughly the particular region under examination, but when greater accuracy is required, the locality should be fixed by reference to the parts of the bony framework, such as the ribs, sternum, &c. Measurements are often taken from the nipple as a fixed point, or from a vertical line passing through the nipple, and called the Nipple line ; but from the varying position which the nipple occupies in different persons, especially in women, such measurements are not satisfactory. The^line which is usually described as the nipple line is a vertical drawn from the middle point of the clavicle downwards. This cuts the edge of the costal arch, usually at the tip of the THE THOEAX. 6 eiglitli ribj and in ordinary cases passes through the nipple. The Contents of the Thorax. The thorax contains the Lungs on either side, and between them the Heart and the other struc- tures in the Mediastinum. Closely related as all these organs are to one another, it is impossible to limit our examination absolutely to one or other of them ; but for convenience we may divide our subject in this way, making reference, in our description of one organ, to the others, only so far as may be necessary for clearness. Position of the Patient. When the chest is being examined, it should, if possible, be completely bare. To examine the front of the chest, the patient should stand, or sit, straight up, with the arms hanging down, or, if lying down, should be flat upon the back, with the arms by the side and the legs straight. To examine the back of the chest, the patient should sit or stand with the arms folded, the shoulders rounded, and the head bent forward, so as to make the back as broad and round as possible, and to widen the interscapular spaces. 4 HOW TO EXAMINE THE CHEST, Fig. 1. Diagram of the front of the thorax and abdomen. The vertical lines are the nipple lines. The figures refer to the'named regions. 1. The supraclavicular. 2. The clavicular. 3. The infraclavicular. 4. The mammary. 5. The inf ramammary. 6. The hypochondriac. 7. The episternal. 8, 9, 10. The upper, middle, and lower sternal. 11. The epigastric. 12. The umbilical. 13. The hypogastric. 14. The lumbar. 15. The iliac. THE THOEAX. Fl&. 2. Diagram of the back of the thorax. The letters refer to the named regions. A. The supraspinous. B. The iufraspinous. C. The infrascapular. D, E. The interscapular. The Methods of Examination. In our examination of tlie chest we use tlie senses of sights touclij and hearings and we arrange our observations accordingly, under the three heads of : 1. Inspection, i.e. what we can see. 2. Palpation, i. e. what we can feel. 3. Percussion and Auscultation, i. e. what we can hear. These methods are applicable to all parts of 6 HOW TO EXAMINE THE CHEST. the body, thougli not in an equal degree, but they are of cliief importance in tlie examination of tlie chest. Any other methods which may be available in certain cases will be referred to and described as occasion arises to make use of them. It is desirable, so far as possible, to represent in a graphic form all the information we obtain. Ways of doing this will be suggested as oppor- tunity offers. We shall commence with the systematic exa- mination of the lungs, then proceed to the examination of the heart, and lastly, to that of the rest of the mediastinum. Our observations will be arranged in order under the heads of Inspection, Palpation, Percus- sion, Auscultation. SECTION I. THE LUNGS. THE EXAMINATION OF THE LUNGS. INSPECTION. When we inspect^ or look at^ a chest we have two sets of facts to observe : 1st. Those, which we can observe as well in a dead as in a living person, relating to the Shape or Form of the chest : 2nd. Those, which are only seen during life, viz. the Movements of the chest during respira- tion. I omit, for the present at any rate, all those phenomena not associated with the shape or movements of the chest, such as dilated veins, &c., as not immediately connected with the exa- mination of the lungs. THE SHAPE OF THE CHEST. This admits of great variation, even within the limits of health, so that there is no fixed normal or physiological type. 10 HOW TO EXAMINE THE CHEST. Average Measurements of Healthy Chests. The healthy adult thorax {fig. 3) is wider than it is deep, that is, it measures more transversely than from front to back. In a fully-developed man the average measurements are transversely Fig. 3. Healthy chest. Cyrtometer tracing reduced. 9 to 10 inches, and antero-posteriorly 6 to 7 inches. In women these measurements are about 1 inch less. These are of course only rough averages, and vary much in different individuals. In quite jOMngchildrentlnetwo diameters are nearly equal, so that the shape becomes almost circular. THE LUNGS. mSPECTION. 11 The apparatus required for measuring tlie chest consists of : 1 . A measuring tape. 2. A pair of callipers. 3. A cyrtometer. The Cyrtometer is an apparatus by means of which a life-size tracing may be obtained of the shape of the chest. There are many forms of cyrtometer, but the most convenient_, and that in ordinary use, is made of two pieces of composition gas-piping, each about eighteen inches long, and joined together by a hinge or piece of gutta-percha tubing. The method of using this apparatus is as follows : The patient^s chest being bare, a mark is made at the base of the xiphoid cartilage in front, and another posteriorly upon the spine, on the same horizontal level. With a pair of callipers, the measurement is taken between these two points, and two marks made upon a sheet of paper, corresponding with the points of the callipers, ^' spine ^' being written opposite one, and " ster- num '^ opposite the other. The '^ cyrtometer ^^ is then taken, the hinge placed upon the mark upon the spine, and the soft piping bent round the ribs, until the two arms meet at the mark in front. A little careful 12 HOW TO EXAMINE THE CHEST. moulding causes tlie piping to take the form of tte chest. A mark is now made upon the piping in frontj to indicate the spots upon the two arms corresponding with the mid die line of the sternum. The cyrtometer is then held by the hinge, and the two arms allowed to fall off the chest by their own weight, care being taken that they are not twisted in any way as they are removed. The whole apparatus is now laid upon the sheet of paper, so that the hinge corresponds with the spine mark, and the marks upon the cyrtometer in front, with the sternum marks. A pencil is carried round the inside of the arms, and an exact tracing of the shape of the chest is thus obtained. Lastly, the words " Right " and " Left " are written on the corresponding sides, and the tracing is complete.* Named Varieties of Thorax. The different forms of chest are for the most part described by ordinary terms, such as long or short, broad or narrow, deep or shallow, and all of these various forms may be quite consistent with health. * By means of a very simple apparatus, such as the pan- tograph, a cheap form of which may be purchased now for one shilling, these large tracings may be quickly reduced to a convenient size for the note-book. THE LUNGS. INSPECTION. 13 Certain marked deviations from the normal form havOj however, received special names. These are : 1. The Barrel-shaped chest. 2. The Rickety chest. 3. The Pigeon-breast. 4. The Alar chest. The Barrel-shaped Chest is, as its name implies, like a barrel {jig. 4). It is almost Pia. 4. Barrel-shaped chest. Cyrtometer tracing from a case of emphysema reduced. This is very like the tracing obtained from an infant's chest, which is also nearly circular in shape. circular in section. Its transverse and antero- posterior diameters are almost the same. The sternum is bowed forwards, and the spine often 14 HOW TO EXAMINE THE CHEST. backwards, so that, in profile, the outline is usually distinctly bi-convex. This form is always associated with a patho- logical change in the lungs, to which the name emphysema is given. The other peculiar forms of chest are not necessarily associated with any change in the lungs. They are due to causes which were at work when the chest was developing in child- hood, at a time when the ribs were soft and yielding, and are evidence rather of past than of present disease, although in all these cases it commonly happens that the lungs are weak, and become subsequently affected. The Rickety Chest gives a tracing such as is shown i'n.fig. 5. The longitudinal furrow at the sides of the sternum corresponds with what was in childhood the ossifying end of the ribs. Most rickety children suffer much from bronchitis, and the bronchi in children become easily plugged. When this is so, the air cannot enter freely into the air vesicles, and on inspiration the chest walls are driven in by atmospheric pressure. The softest parts yield most. These are, of course, the ossifying ends of the ribs and cartilages, which are, moreover, in rickets especially soft and yielding. If this condition lasts for any length of time, it may become permanent and give rise to the rickety form found in adults. THE LUNGS. INSPECTION. 15 In rickety cliildren a deep transverse furrow running across botli sides of tlie cliest below the nipples^ about on a level with the fifth space^ is often seen. This is called Harrison's furrow. When well niarked_, its causes are the same as that of the rickety chest. It is most evident on the right side, and corresponds with the upper border of the liver in childhood. It may be traced, though often indistinctly, in most healthy Fm. 5. Rickety chest. The diagram shows a slight want of sym- metry, as is not uncommon in these cases. adults, but when excessive, is usually evidence of past lung affection. In the Pigeon-breast {fig. 6) the sternum is protruded, and the ribs straightened out at the angles and at their junctions with the cartilages. In external appearance it resembles, as the name implies, the carinate or keel-shaped breast of a pigeon. 16 HOW TO EXAMINE THE CHEST. ri&. 6. The Pigeon-breast. Here also is slight want of symmetry. ri&. 7. The Alar or Pterygoid Chest. This is a good instance of a tracing of a flat chest. THE LUNGS. INSPECTION. 17 This is merely a variety of the rickety chesty and is due to the same causes. In the Alar Chest or Pterygoid Chest (jig, 1), the upper parts of the chest_, viz. the sternum and neighbouring ribs_, are flattened and sunken. The shoulders in consequence fall forward^ and thus throw the posterior and lower borders of the scapulae off from the ribs_, so that they are tilted outwards and project like rudimentary wings (alae)^ whence the name. With this peculiar deformity^ the muscles con- nected with the upper part of the thorax are usually imperfectly developed or atrophied^ and in consequence^ this has been also called the Paralytic form of thorax. This, like the other forms, though presumptive of disease of the lungs, is not necessarily asso- ciated with it. The healthy chest is as nearly as possible symmetrical in all its parts. Any want of sym- metry, even though it be but slight, is most important evidence of disease, either past or present."^ * The right side of the chest usually measures about half an inch more in circumference than the left ; probably in con- nection with the greater development of the muscles on the right side in right-handed persons, but this does not give any appearance of asymmetry to the eye. 2 18 HOW TO EXAMINE THE CHEST. Changes of Shape due to Disease. In disease tlie changes of shape may be of two kinds. There may b( 1st. Increase in size, or as it is usually called, Bulging ; 2nd. Decrease in size, or Contraction. These changes may affect both sides, i. e. be bilateral, or only one side, i. e. be unilateral ; and in either case they may involve either the whole of the side, or only part of it. Even where the change is bilateral, it is rarely absolutely symmetrical. Symmetrical bilateral increase in size is only met with in the barrel-shaped chest of emphysema. Symmetrical bilateral decrease in size occurs only in the opposite condition, in which both lungs are uniformly shrunken, and more rarely also in the paralytic, alar, and other forms of chest described above. With these exceptions, changes in shape are always unsymmetrical, and it is therefore for a Want of Symmetry, i. e. for a difference between the corresponding parts of the two sides of the chest, that we chiefly look as evidence of disease {fig- 8)- When there is such a want of symmetry it is sometimes difficult to say whether this want is due to a bulging of one side, or to a shrinking of THE LUNGS. INSPECTION. 19 the other. Further examination only can deter- mine this question. Fig. 8. An extreme instance of want of symmetry. The tracing was taken from a child in whom the left side was contracted after an empyema. Deformities. In certain trades, for instance, among car- penters, weavers, and shoemakers, a depression is often found at the bottom of the sternum, some- times of considerable depth. This is usually due to pressure during work (as by the last, auger, or weavers^ beam), though the deformity is occasionally congenital. The Gondition of the Superficial Veins. Except where patients are very thin, the veins are rarely visible in health beneath the skin. 20 HOW TO EXAMINE THE CHEST. In disease they are often dilated and frequently unsymmetrically so. When this occurs^ the direction in which the blood is travelling should be determined. This is done by placing two fingers upon the most prominent vein, and then drawing them apart along the vein in order to press the blood out. By raising first one finger and then the other^ it will be clear from which direction the vein fills most easily. This will be then the direction in which the blood is travelling."^ THE MOVEMENTS OF THE CHEST ON RESPIRATION. These are alternately movements of expansion and contraction^, i. e. inspiratory and expiratory. On ins]3iration the chest expands in all directions. The sternum moves forward^ the ribs rise,, the intercostal spaces widen, and the diaphragm descends. These movements are freest in the lower parts of the chest. They are partly thoracic and partly diaphragmatic. In women the ribs ntove most, and the respi- ration is called Thoracic or Costal. In men and in young children the diaphragm ^ Enlarged subcutaneous veins over the mammse and upper part of the chest are usual in women who are suckling, or who have had children. This is, of course, physiological. THE LUNGS. INSPECTION. 21 moves most, and tlie respiration is called Dia- phragmatic or Abdominal. A change of type from costal to abdominal or vice versa is often an evidence of disease. The Measurements of the chest vary within wide limits. The average circumference of a healthy man^s chest at the level of the nipple is after expiration about 32 inches, and after in- spiration about 35^ inches, giving thus a differ- ence on the average of each respiration of 3 1 inches, or about one twelfth. On forced respiration the difference can sometimes be made much greater. These measurements in women are somewhat less. The Amount of Air, which is taken in and out, will depend upon the amount of the respiratory movement of the chest and upon its size. In ordinary breathing it is calculated that in a healthy man on the average about 30 cubic inches are drawn in at each inspiration, and the same quantity emitted at each expiration. About 100 cubic inches more may be squeezed out on forced expiration, and about the same amount more taken in on forced inspiration. Making the total maximum quantity of air which can be inspired or expired about 230 cubic inches. Instruments have been devised for measuring 22 HOW TO EXAMESTE THE CHEST. the Vital Capacity of the chest,, i.e. the total amount of air, which can be taken in^ or forced out, by the deepest possible respiration. They are known as Spirometers, but hitherto they have not been found to be of much use in diagnosis. Alterations in the Respiratory Movements. When the respiratory movements are increased in range above the normal, we speak of them as Exaggerated ; when decreased below the normal we speak of them as Impaired or Deficient. When the movements are deficient, less air will enter the lungs than is necessary, and the patient will suffer from shortness of breath, or as it is called Dyspnoea (difficulty of breathing) . Dyspnoea may be the result of deficient respi- ratory movements under two opposite conditions, for the lung's may be prevented either from expanding, or from contracting, so much as they should. In the former case the condition is spoken of as Defective Inspiration or Deficient Expansion, and the dyspnoea is called Inspiratory ; the latter, as Deficient Expiration, and the dys- pnoea is called Expiratory. When the patient cannot lie down on account of the difficulty in breathing, the term used is not dyspnoea, but Orthopnoea, i. e. dyspnoea which THE LUNGS. INSPECTION. 23 obliges the patient to sit up {orihos, upright) to get breath. When from any cause there is obstruction to the entrance of air, the deficient expansion of the lungs will make itself manifest in the softer parts, of the thorax, i. e. in the intercostal and supra- clavicular spaces, and they will sink in somewhat during inspiration. This is called Inspiratory Eecession. When the obstruction is considerable, not only the soft parts, but also the ribs, especially the lower ones, yield, and are sucked in during inspi- ration. In its most extreme form, this is met with in children suffering from croup, and where the obstruction is of long standing, or oft repeated, as has been stated already, it is the cause of certain deformities, which may be permanent (p. 14). The exactly opposite condition to inspiratory recession of the intercostal and supraclavicular spaces, viz. Expiratory Bulging, is common in cases in which the elasticity of the lungs is reduced, and the expiration obstructed. It is most marked during a fit of coughing, in patients suffering from extreme emphysema. The Number of Respirations is about 14 to 18 in the minute, and bears to the pulse, on the aver- age, the relation of 1 to 4. On quiet respiration, the movements occur at 24 HOW TO EXAMINE THE CHEST. regular intervals^ tliougli they are largely influ- enced by emotion and excitement^ both as regards number and regularity. Except in children and in cases of hysteria^ the number^ even in disease, rarely- exceeds 40 to 50. As a general rule the more rapid the respirations^ the more shallow they are. The movements of respiration, in healthy per- sons at rest, follow one another at regular intervals, the rhythm being maintained by the action of the nerve centres in the medulla oblongata. The movements are to a very great extent under voluntary control, and may therefore be made to vary much by the action of the will, as in speaking, singing, &c.j but irregularity is often independent of the will, and is due then to inter- ference with the action of the respiratory centre^ usually in response to reflex irritation from some other part. Thus, mental emotion may lead to laughing, crying, sobbing, &c., irritation in the lungs or stomach to coughing, hiccough, &c. Of all forms of irregular respiration the most peculiar is that known by the name of Cheyne- Stokes' Breathing."^ In this form the respiration at times ceases for some seconds, and then recommences, the move- * Dr. Cheyne first observed it and Dr. Stokes subsequently more minutely described it. THE LUNGS. INSPECTION. 25 ments being at first small and rapid^ becoming gradually deeper^ and often at the same time slower, until the maximum expansion of the chest is reached, when they decrease in the same manner^ until again for a time the movements cease {fig. 9). Fig. 9. A semi- diagrammatic tracing of Cheyne-Stokes' Breathing. The upstrokes represent inspiration, the dovvnstrokes expiration. The more or less horizontal line indicates the pause in respi- ration, which sometimes lasts for as much as three quarters of a minute. In all these cases the movements still remain symmetrical. They are altered in their general rhythm, but not in symmetry. When the move- ments are unsymmetrical, there is some local dis- ease, past or present, to account for it. Inspection of the chest presents but few diffi- culties, if it be remembered that, with the excep- tions to which reference has been made, what we have to look for is not a departure from some ideal normal type to be carried in the memory, but simply a want of symmetry, or similarity. 26 HOW TO EXAMmE THE CHEST. between tlie two sides of tliat particular chest whicli we are examining. When this want of symmetry exists, there must be some condition of disease, past or pre- sent, to account for it. SYNOPSIS. On Inspection then we note — I. The Shape of the Chest : Barrel. Rickety. Pigeon. Alar. Paralytic. Shoemakers', Weavers', Carpenters'. Harrison's Furrow. Defects of Symmetry. II. The Movements of the Chest : their number, their regularity, their type, costal or diaphragmatic, if impaired, or exaggerated. Defects of Symmetry. T. f Inspiratory. Dyspncea^^ ^ "^ L Expiratory. Orthopncea. THE LUNGS. PALPATION. 27 PALPATION. The first thing to be done on palpation is to Count the Ribs, and_, simple as this seems to be^ mistakes are often made. It will be easily and correctly done, if it be remembered, that the first rib, which we can get comfortably between two fingers, is the second. It is easier to count the spaces than the ribs, and we know, that the rib corresponding to the space lies above the space. Our landmarks, as we shall see, are all deter- mined with relation to the ribs and spaces. THE SHAPE AND MOVEMENTS. Nearly all that can be seen can be also felt, but sometimes, in case of difficulty, the hand may help the eye. This is especially the case with the movements of the chest. For this purpose, the hands must be placed symmetrically upon corresponding parts. At the apices, the thumbs should be placed together upon the sternum, and the fingers allowed to rest beneath the clavicles, or, in children, the thumbs may be placed in con- 28 HOW TO EXAMINE THE CHEST. tact upon tlie spine_, and the fingers bent over the shoulder^ so as to rest upon the upper part of the chest in front. In either of these ways very slight differences in the amount of move- ment upon the two sides may be detected. The Widening of the Intercostal Spaces on in- spiration may be easily observed^ by placing the hands upon the lower parts of the chest or in the axillae and spreading the fingers so that they lie in the intercostal spaces. "We are able in this way to determine : 1. If the spaces be narrower or wider on one side than on the other ; 2. If they be retracted or unduly prominent; 3. If the expansion or widening on inspiration be sufficient in amount^ and equal on the two sides. Abnormal Sensations. Occasionally the grating of Pleuritic Friction (^. v.)j the wheezing of Rhonchus and Sibilus (^. v.)y or the crackling of Crepitation {q.v.), may be felt. YOCAL VIBEATIONS. If, while the hand is placed upon the chest, the patient be made to speak, the vibrations of the voice will be felt by the hand. They are called Vocal Vibrations. They may be also heard, if the THE LUNGS. PALPATION. 29 ear be placed upon the cliestj as we sliall see under '''Auscultation/^ and then they are spoken of as Vocal Resonance. There is no real difference between tliem except one of terms. We feel vocal vibrations^ and we listen to vocal resonance. As the ear is more sensitive than the hand^ so we can occasionally hear the vocal resonance^ when we cannot feel the vocal vibrations. This is especially the case in women and children_, in whom the vibrations of the voice are not intense. The louder the voice_, the deeper or more bass the tone, and the thinner the patient, the more easily will the vibrations be felt. The other con- ditions, which alter the vocal vibrations, will be discussed laterunderthe head of ^^ Auscultation,^' when we speak of vocal resonance. For the present it is sufficient to say, that the same want of symmetry in the physical signs, which we look for on inspection, is to be searched for also on palpation. It is this want of sym- metry, which is of the chief practical importance. Se7ise of Resistance. If the intercostal spaces be lightly tapped with the tips of the fingers over the upper part of the chest, a sensation of elasticity or springiness will be obtained. If, however, the same thing be done, where a solid organ lies beneath the chest walls. 30 HOW TO EXAMINE THE CHEST. as over tlie liver^ the sense of elasticity will be lost^ and, in its place,, tlie fingers will experience a feeling of resistance. The same thing happens, if the lang becomes solid, or if it be separated from the chest walls by changes in the pleura. To this feeling the name Sense of Resistance is given. It is, how- ever, of no great practical importance, except when combined with percussion (palpatory per- cussion). When, in disease, there is a large collection of pus in the pleura [Empyema) Fluctuation may sometimes be elicited in the usual way ; but except when the empyema is pointing, i. e. when the pus is close beneath the skin, fluctuation is extremely rare. SYNOPSIS. On Palpation, then, we proceed to count the ribs, and next to observe : 1 . The Shape and Movements of the Chest. 2. The Vocal Vibrations. 3. The Sense of Resistance. 4. Abnormal Sensations, when present, such as friction, crepitation, rhonchus, sibilus, or pos- sibly fluctuation. THE LUNGS. PEECUIOSSN. 31 PERCUSSION. By Percussion is meant the metliod of striking the walls of the bodj^ so as to cause them to yield a sound. We must consider^ then^ 1st, the best way of producing sound by percussion, and 2ndly, the kinds of sounds, which may be produced, and what meaning and value may be attached to them. Percussion may be direct (immediate), when we percuss upon the skin directly, or indirect (me- diate), when we percuss upon something placed upon the skin. In the examination of the Chest Direct Per- cussion is not employed now except upon the sternum, the clavicles and the spine of the scapula, where, from the absence of much cover- ing, the sound produced is not interfered with. For Indirect Percussion we require : 1st, some- thing to strike with, and 2ndly, something to strike upon. Apparatus of various kinds has been devised for this purpose : — 1 . Hammers, or, as they have been called, Plessors, of various sizes, shapes, and substances, to strike with. 2ndly. Flat Plates (Plessimeters), of metal, wood, or ivory, to strike upon. 32 HOW TO EXAMINE THE CHEST. These forms of apparatus have been almost entirely abandoned_, and in their place we are in the habit of using the fingers on one hand^ as our plessor^ to percuss with_, and one of the fingers of the other hand^ as our plessimeter^ to percuss upon. In this way we combine; with percussion, those sensations described in the previous chapter under the head of " Sense of Kesistance.^^ This method of percussion has been called Palpatory Percussion. The tip or pad of one finger, say the middle, is the head of the hammer, the rest of the hand, the handle. The blow should be light, but firm, produced by a free action of the wrist, as in playing octaves upon the piano. The art is not easy to acquire, but can be well practised by placing the whole forearm, from the elbow to the fingers, flat upon a table and then percussing, the forearm being firmly pressed down with the other hand, to keep it fixed, and to prevent the wrist being raised from the table. The hammer of a piano forms the best illustra- tion of the kind of movement we require. When a note is struck upon the key-board, the hammer is driven sharply against the wire, but does not remain more than an instant upon it, quickly recoiling and leaving the wire free to vibrate. THE LUNGS. PEECUSSION. 33 This is wliat the hand should do. The finger should deliver a short, sharp stroke, and imme- diately return from contact with the chest. It will require much practice to get this proper movement. Sometimes^ instead of the tip of one finger, the tips of two or three are employed. This has no special advantage, except^ that as the head of the hammer is broader, a greater surface is thrown into vibration, and therefore the sound is some- what louder ; but, if more fingers than one be used^ care must be taken that the pads of the fingers are all upoji the same level,, so that they may all strike the chest at the same time. This, again^ can be practised best upon the table, by pressing first the tips of the fingers firmly down to get them level, then raising them, fixed in that position, and proceeding to percuss. In choosing a finger to percuss upon, one should be selected which is not bandy^ so that it may lie perfectly flat. It matters little which is chosen. For convenience^ it is generally either the index or the little finger. The object we have in view in percussing the chest is to throw into vibration the parts beneath the walls of the thorax. "We must, therefore, avoid as much as possible all interference with these vibrations from the walls themselves. This we do by placing the fingers upon which we per- 3 34 HOW TO EXAMINE THE CHEST. CUSS perfectly flat upon the chesty and exercising slight pressure^ so as to condense the tissues immediately beneath. If the finger be placed loosely _, instead of firmly, upon the skin_, and still more if it be not in all parts quite in contact^ the percussion note will be impaired. In order that there may be as little of the walls as possible for the vibrations to pass through before reaching the organs beneath, we must per- cuss straight upon the surface, that is, perpendi- cularly to the walls and not in a slanting direc- tion. To sum up — 1st. Our hands form our only apparatus. 2nd. The finger percussed upon must be placed flat, and pressed firmly upon the chest. 3rd. The blow must be from the wrist, light, short, firm, and delivered at right angles to the chest-walls at the part percussed. Grood percussion is difficult to acquire, but is worth all the time and trouble spent upon it. Resonance and Dulness. When we percuss upon the walls of a cavity containing air, for instance over a drum, we obtain a hollow or, as it is called, a resonant sound. When we percuss upon a solid mass, like the thick part of the thigh, the hollow sound is not THE LUNGS. PEECUSSION. OO produced, and the sound wliicli is produced is called non-resonant or dull. Many varieties of resonance and non-resonance are described, but it is sufficient for us at pre- sent to recognise the difference between sounds which are resonant^ and those which are non- resonant. Over the lungs the note is resonant^ because the lungs contain air. Over a solid organ^ such as the liver^ the note is non-resonant or dull. The Size of the Lungs. We are now in a position to apply these facts practically. How large are the Lungs ? This is naturally the first question of importance^ and percussion alone enables us to answer it. For the lungs are in direct relation with solid organs, and, where these are, the note, which over the lungs has been resonant, will become non-resonant or dull. If we mark upon the skin of the chest the places where this occurs, we obtain certain lines. These are called Surface-Markings, or Medical Landmarks. These landmarks indicate certain relations in which the organs stand to the outer parts of the body. They must not be confounded with the ana- tomical boundaries, sizes, and shapes, of these dif- ferent organs, with which they only approximately 36 HOW TO EXAMINE THE CHEST. Fig. 10. Diagram showing the position of the great organs of the thorax and abdomen with their surface-markings. L, Liver. ST, Storaach. s, Spleen. K, Kidney, c, Colon. The Lungs are left unshaded. Their upper and anterior boundaries only are shown by a line of thick dots. The Heart is represented of its anatomical size, and upon it in black is indicated the size of tbe absolute cardiac duLness. The Hepatic dulness is represented in black. The line of small dots above ■on the right side, shows tlie position of the upper part of the liver, and there- fore of the vault of the diaphragm deep within the thorax. Just outside the right nipple Une, at the edge of the ribs, the little excrescence marks the position of the Gall-iladder. The Stomach is indicated partly by dotted and partly by continuous line. The area of stomach resonance lies between the dotted line ou the left side and the margin of the.fiostal arch. The anteriof^arts of the Spleen and Kidney are indicated in black. THE LUNGS. PEECUSSION. 37 correspond. For example^ tlie surface-markiDgs of tlie heart inclose a space (the cardiac area)^ which is small compared with the real size of the heart [jig. 10), but it is of the greatest importance- for the reason that^ so long as the organs in immediate relation with the heart are normal^ the space varies in size and shape in direct corre- spondence with any change in the heart itself. The medical landmarks and anatomical boun- daries are therefore not the same things and though closely related must not be confused one with the other. The Boundaries of the Lungs. The lungs are in close contact with the ribs along their whole length from the sternum to the spine. The ribs are^ therefore, the natural External Boundaries. The apex of each lung rises as a blunt cone into the neck as far as an inch and a half above the clavicle. The curved line, which corresponds with the apex and sides of this cone, can be easily percussed out, and gives the Upper Boundary. The edges of the lungs approximate anteriorly beneath the manubrium sterni, and come in con- tact, at a point corresponding with the junction of the second costal cartilage with the sternum ; they remain in close approximation doM^n as far 38 HOW TO EXAMINE THE CHEST. as tlie level of tlie fourth costal cartilage. From this point the anterior margin of the right lung continues onward down to the bottom of the sternum_, sloping slightly away to the right side, while that of the left bends sharply away to the left side^ to a point about two inches and a half from the bottom of the sternum. This leaves a roughly triangular space between the two lungs in which part of the pericardium is uncovered. It corresponds roughly speaking with the area of cardiac dulness [q-v.]. The Middle Boundary cannot be determined by percussion for the following reason : The sternum is a solid bone^ which lies for some distance in close relation with the lungs. When, then, it is percussed — even in a part, where only solid structures lie beneath^ as under the upper part of the manubrium, or under the lower part over the heart — the vibrations are transmitted to those parts of it which lie over the lungs^ and so to the lungs themselves, and, in consequence, the note in any part of the sternum will be resonant. The Lower boundary is of course the diaphragm, but this is too thin to define by percussion, so that we can determine its position only by means of the organs in relation with it ; these are, the liver, the stomach, and the spleen. Two of these organs, the liver and the spleen, are solid bodies, and will give, therefore, a non-resonant sound. THE LUNGS. PEECUSSION. 39 The stomacli contains air, and will, therefore, yield a resonant sound. Percussion will enable us, then, to determine where these organs are, and in this way where the diaphragm is. On the right side the termi- nation o£ the lungs will be marked by a line of non-resonance, or dulness, corresponding with the liver, and on the left side by a line of altered resonance corresponding with the stomach, and by a line of dulness corresponding with the spleen. Before, then, we can determine how large the lungs are, we require to know what the upper boundaries of the liver, stomach, and spleen are in health, I.e. the surface-markings corresponding with these organs."^ The Surface-Marhmgs of the Liver. If a piece of string be taken and one end of it be placed upon the apex of the heart, ^. e. in the fifth left intercostal space, one inch inside the nipple line, and the rest be carried almost hori- zontally, but with a slight inclination downwards, round the right side of the chest to the spine, this will represent the surface-marking usually described as the Upper Boundary of the Liver. * In ordinary respiration the lungs do not quite come up to the edge of the pleura; the small space left is called the com- plemental space. 40 HOW TO EXAMINE THE CHEST. It will correspond, in the right nipple line^ with the upper border of the sixth rib^ and^ as the ribs are curved downwards^ it will cut the eighth, ninth, and tenth ribs as it passes backwards. This line is the same whether the patient be standing erect or lying' upon the back. It marks the limit of absolute dulness, but since the liver rises anatomically above this line deeper in the chest, forcible percussion will give a note of impaired or defective resonance, often as much as an inch higher in the nipple line. This is the normal position during ordinary respiration, when the chest is moderately dis- tended with air, and the breathing quiet. It may be about an inch higher on forced expiration, or an inch lower on forced inspiration. While speaking of the liver it will be conve- nient to complete the description of the hepatic area. The greater part of the right lobe of the liver is concealed under cover of the ribs on the right side, and part also of the left lobe is beneath the ribs on the left side {fig. 10). In the epigas- trium part of the right lobe and part of the left are exposed, with the notch, which usually lies almost in the middle line, about half way between the umbilicus and the junction of the sternum with the xiphoid cartilage. THE LUNGS. PEECUSSION. 41 The liver passes under cover of the ribs on the right side just in the nipple line. This corre- sponds usually with the tip of the eighth costal cartilage. The Lower Boundary of the liver^ then, on the right side is continuous posteriorly with the edges of the costal arch, and comes out from under the ribs in the right nipple line. It then extends across the abdomen in a double curve, inter- rupted by the notch, to the apex of the heart (/^. 10). As the lower part of the liver in front lies in close relation with the stomach and transverse colon, the transmitted resonance makes it gene- rally very difficult to ascertain exactly by per- cussion the lower border of the liver, which is usually more easily fixed by palpation. The liver is most conveniently measured in the nipple line. In this line the Upper Boundary should be at the level of the upper border of the sixth rib, and the Lower should cut the margin of the costal arch. Just outside this part {i.e. at the tip of the ninth rib) is the position of the gall-bladder. The vertical measurement of the hepatic dul- ness in the nipple line is, in the adult man, on the average four inches. 42 HOW TO EXAMINE THE CHEST. Fia. 11. Diagram showing the normal boundaries of the lungs. THE LUNGS. PEECUSSION. 43 The Surface- Markings of the Spleen. The Splenic Area is roughly oval in shape^ and dull on percussion. It extends along the tenth rib as its long axis^ from the posterior axillary- line, forwards and downwards, for about two inches and a half. Its transverse diameter reaches above to the ninth rib, and below to the eleventh rib. This area cannot, however, always be dis- tinctly made out in adults. It is more easily determined in children. This is due probably to the fact that the ribs in children are softer and less rigid, and do not therefore transmit the resonance so readily from the adjacent lungs. The Surface- Markings of the Stomach. The area of Stomach Resonance (Traube's zone) extends from the apex of the heart {i. e. the edge of the left lobe of the liver) to the tip of the tenth rib. It is semicircular in shape, the diameter being formed by the costal arch, and measuring about six inches in length. Its depth is about three inches. The stomach extends, of course, much farther than this, across the epigastrium, beneath the margin of the liver {fig' 10), and, like the 44 HOW TO EXAMINE THE CHEST. coloiij whicli lies in immediate relation with it beloWj will give a resonant sound there^ but it is only the limited area described above, which, in the examination of the chest, is spoken of as the area of stomach resonance. The boundaries of the stomach and spleen are not so constant, or so easy to determine, as those of the liver, but they are also not of so much importance, for the liver reaches so far to the left side, that its boundaries, taken in conjunction with the cardiac dulness, are enough to fix, with sufficient accuracy for ordinary purposes, the size of the left liing. We have now ascertained the position of the diaphragm, and we know, that all that is above this should be occupied by lung, except in the mediastinum, where the heart and great vessels lie. In health we need consider nothing but the heart, for the rest of the mediastinum gives, as the lungs do, a resonant note on percussion. The Area of Cardiac Dulness is roughly tri- angular in shape, and corresponds approximately with the space exposed by the left lung as it recedes from the right. It is represented on the diagram (2. 'v.)j and will be found fully described later. THE LUNGS. PERCUSSION. 45 The Surface-Markings of the Lungs. Tliese are as follows : The Upper. A curved line, the apex of whicli reaches one inch and a half above the clavicle. The Anterior. {a) On the Right Side^ the middle line of the sternum, from the level of the second costal carti- lage to the base of the xiphoid cartilage. (h) On the Left Side, the middle line of the sternum, from the level of the second to the level of the fourth costal cartilage, and thence to the apex of the heart. The lower. (a) On the Right Side, the upper border of the liver. (b) On the Left Side, a line drawn from the apex of the heart along the upper border of the stomach resonance and the splenic dulness. The Posterior. 1. A Vertical Line drawn on each side one inch from the dorsal spine. 2. A Horizontal Line drawn outwards on each side from the eleventh dorsal spine. This, on the right side, is continuous with the upper boundary of the liver 46 HOW TO EXAMINE THE CHEST. Fig. 12. Diagram showing in dark line the actual houndaries of the lungs in a well-marked ease of emphysema, and in dotted line the normal houndaries. THE LUNGS. PEKCFSSION. 47 ALTERATIONS OF BOUNDARIES. In disease tlie lungs rarely remain of their normal size. They are either larger or smaller than they ought to be. These changes^ though often evident on inspection and palpation_, are most distinctly indicated by alterations in the boundary lines. The diaphragm is freer to move than any part of the thoracic walls^ and alterations in its posi- tion are often among the earliest evidences of changes in the lungs. This can be recognised only by percussion. Hence the importance of determining as early as possible in our examina- tion of the chest the position which the dia- phragm occupies. Symmetrical Changes. Where the lungs are Symmetrically Enlarged,, as in the disease called emphysema^ there may or may not be visible enlargement of the thorax, but there will always be displacement of the diaphragm. The diaphragm will stand lower than it ought, often a whole interspace too low. The cardiac area will also be smaller than it should be ; for the lungs, as they enlarge, cover up that part of the prgecordium which, in the ordinary condition, is exposed. 48 HOW TO EXAMINE THE CHEST. Diagram showing the boundaries of the lungs in a case of bilateral contraction of the lungs (senile emphysema). The white dotted line shows the normal boundaries. THE LUNGS. PEECUSSION. 49 ' The percussion signs, then, of emphysema show displacement downwards of the diaphragm, and diminution in size, or absence of the cardiac dulness. Where the lungs are Symmetrically Contracted, as often happens in old age (senile emphysema), the diaphragm will stand at a higher level than normal. It may be a whole intercostal space too high, and, in like manner, the prsecordium will be more uncovered than usual, and the area of cardiac dulness larger than normal. Unsymmetrical Changes. If the changes be limited to one side, the diaphragm on that side will be displaced. If the lung on that side be larger, the diaphragm will stand lower ; if smaller, it will stand higher. Where a part of one lung is contracted, as after pleurisy, or where a large cavity has formed in it, the opposite lung, if it has remained healthy, often undergoes compensatory enlarge- ment. This has received the name of Compen- satory Hypertrophy.* As the one lung is much smaller, and the other much larger than it ought to be, we shall have evidence of a great * This is also spoken of as compensatory emphysema, but, as there is probably no true emphysema, this term is misleading, and should not be used. 4 60 HOW TO EXAMINE THE CHEST. Fia. 14. Diagram' showing the displacement of the boundaries in a case of contraction of the left lung, with compensatory hyper- trophy of the right. THE LUNGS. PEECUSSION. 51 dislocation of tlie boundaries as is sliown in A similar extreme dislocation of boundaries is seen in cases where one pleural cavity is greatly distended with, air^ as in pneumothorax [jig. 15), or with fluid, as in pleuritic effusion (fig. 16) » In these latter cases, not only is the diaphragm pushed down as far as it can go, so as to become sometimes even concave instead of convex above and to project below the ribs, but the lateral boundaries are also dislocated far over towards the unaffected side. This we determine by an extension beyond the sternum, in the one case {pneumothorax) of the area of resonance, and in the other [pleuritic effusion) of the area of dulness. In those cases of pneumothorax, however, in which there is free communication between the air inside the pleura and that outside the body, either by a large opening through the chest- walls or through the lung, and where, consequently, there is no distension of the pleura, i. e. no pres- sure in the pleura, there is still considerable dislocation of boundaries. This is due to the elasticity of the lungs, the lungs on each side contracting, and that on the sound side dragging over towards itself the mediastinum and the organs in it. 52 HOW TO EXAMINE THE CHEST. Fig. 15. Diagram showing the displacement in a case of pneumo- thorax of the left side. THE LUNGS. PEECUSSION. 53 VARIETIES OF PERCUSSION SOUND. Hitherto we have considered percussion onlya^ the means of determining the size of the lungs, we must now consider how it enables us to deter- mine the conditions in which the lungs are. Wherever the lungs are^ the percussion note should be resonant. The amount of resonance varies within wide limits, even in health/ in different individuals. These variations depend in great part upon the amount of skin, fat, and muscle which covers the ribs, i. e. upon the thick- ness of the walls of the thorax, and is therefore less in fat than in thin people. Even in a perfectly healthy chest the resonance varies in different parts, being greatest in the axilla where there is least to interfere with the percussion sound. But, making allowance for all this, the reso- nance may be greater or less than it ought to be. In emphysema, where the vesicles of the lungs are dilated and their walls thinned, where, there- fore, there is relatively more air and less solid in the lung, the note becomes deeper, more hollow- sounding, more drum-like. This is called Tym- panitic Resonance, and resembles the note which may be normally obtained on percussing over the stomach. A variety of tympanitic percussion is not un- 54 HOW TO EXAMINE THE CHEST. Fig. 16. Diagram showing the displacements produced by a large effusion into the right pleural cavity. The black area represents the absolute dulness of the fluid. The heart is displaced so that the apex is outside the left nipple line. The liver is depressed and twisted, so that the notch is nearly under the margin of the left costal arch, instead of being in the middle line. The white line indicates the probable position of the upper border of the liver on the right side, and of the edge of the I'ight pleura on the left side. THE LUNGS. PEECUSSION. " 55 common in cases, where air-containing lung tis- sue intervenes between the chest- walls and some non-resonant substance more deeply seated, as, for instance, a deep-seated pneumonia, or a tumour, or even fluid effusion in the pleura. It is probably due to the relaxation of the lung tissue, i.e, the loss of its normal tension and tone above the parts diseased. A similar hyper-resonance is not rare in acute fevers, and has probably the same causation and explanation as that loss of tension and tone in the intestines, which gives rise, under similar conditions, to tympanites. For the opposite condition, in which there is less air and more solid relatively in the lung, there is no distinctive name, but the percussion resonance is spoken of as Impaired or Deficient. Many other varieties of resonance have been described and various names given to them, but they are not really required in actual practice. For ordinary purposes the following four terms are all that are necessary : 1st. Tympanitic. 2nd. Normal. 3rd. Impaired."^ 4th. Dull. * Boxy is a term often used. The term conveys much what the sound of percussion suggests. It is as though we were per- cussing an air-containing chamber with dense and rigid walls 56 HOW TO EXAMINE THE CHEST. One other naraed variety of abnormal percus- sion sounds must be referred to^ viz. tbe Cracked- pot Sound (bruit de pot fele). This is a jarring or jangling sound, like tbat produced when a cracked china bowl is struck. It is not uncommon in cases of phthisis over superficial cavities in the lung, and it is best elicited by forcible, sharp percussion, the patient having the mouth wide open and breathing quietly. It is not constant in phthisis, nor is it by itself any sign of disease of the lungs, for it is not rare in children with healthy chests, and maybe sometimes produced in adults, where air-containing lung tissue lies between the chest- walls and some solid mass, either a patch of pneumonic consolidation, a tumour, or occasion- ally even an enlarged heart. It is supposed to be due to the sudden forcing out by percussion of a stream of air from a por- tion of the lung into the bronchial tubes, and can be imitated fairly well by clenching the palms of the hands loosely together, and striking them sharply upon the knee. Want of Symmetry on Percussion. Fortunately, it is not for the most part an increase or a decrease in tone, as compared with like a box, and it corresponds frequently with such a condition, pathologically. THE LUNGS. PEECUSSION. 57 an ideal typical standard^ wliicli we have to recognise, but, as on inspection and palpation, so also on percussion, it is for a want of symmetry, ^. e. for a difference between corresponding parts on tlie two sides, that we look as evidence of disease. If, in corresponding parts of the chest, the percussion resonance is not also symme- trical, but there is a difference between the two sides, it is certain that some change has occurred in the parts beneath. The only place in health in which want of symmetry is observed, with the exception of the cardiac area, to which reference has been already made, is at the apex. At the right apex the lung is thicker, stumpier, and is more en- croached upon by the large vessels than on the left side. Consequently, there is often a slight impairment of percussion here, as well as also, on palpation, and auscultation, a slight increase in the amount of the vibrations of the voice and of the breath sounds. The difference is, however, slight, and yet the same amount of difference against the left side would be evidence of disease. It is necessary to refer to this, although it is not likely to create difficulty under ordinary circumstances. Wherever the percussion note is unsymmetrical, there is, with the previously mentioned excep- tions, some change in the condition of the 58 HOW TO EXAMINE THE CHEST. part beneatlij namely^ in the lungs or in tlie pleura. Under '^ Auscultation ^^ we shall learn how to determine whicli of these it is due to. For the present it is sufficient to note that by means of percussion we can establish two sets of most important facts about the lungs. 1. Their size and their relation to adjacent organs. 2. In most cases their condition, whether healthy or not. THE LUNGS. PEECUSSION. 59 SYNOPSIS. On percussing a cliest^ it is most important to proceed systematically. 1st. We must determine the actual boundaries of tlie lungs, mark tliem carefully, and compare them with those, which, we know, ought to be found in health. 2nd. "We must percuss the corresponding parts of the chest in order, from above downwards, comparing one side with the other : 1. The supraclavicular I. In front, <; regions ; 2. The clavicular re- gions ; 3. The subclavicular re- gions ; 4. The mammary and infra-mammary re- gions ; II. Laterally, 5. The axillary regions ; 6. The suprascapular re- gions ; 7. The infrascapular re- gions. 8. The interscapular spaces. If these be all symmetrical, the lungs and pleura are probably healthy. If not, we shall then proceed to ascertain what is wrong by further examination. III. Posteriorly, < 60 HOW TO EXAMINE THE CHEST. AUSCULTATION. Under tMs head we place all facts which we can ascertain by placing the ear upon the chesty and listening to the sounds produced. These are of two kinds. 1. The sounds produced by breathing. 2. The sounds produced by the voice. Apparatus. For the purposes of auscultation apparatus is not generally necessary^ though it is convenient. Stethoscopes {stethos, the chest ; skopeiuj to examine) have been devised of all kinds^ some solidj some hollow, and made of metal^ wood, ivory, or other substances, of various sizes and shapes. Habit will accustom us to all, and, except for convenience, we might do without any. The stethoscopes in use at present are of two kinds, the single, for one ear, and the double, for both ears — the binaural. It is best to commence with the single stetho- scope. The single stethoscope consists of a cylinder. THE LUNGS. AUSCULTATION. 61 usually of some tough or light wood, six or eight inches in length, with a broad flat end on which to place the ear, and a narrow end to be placed upon the chest. It is usually perforated by a hole running from end to end {fig, 17). In choosing a stethoscope the chief points are these : — The broad part should be of such a size and shape that the ear may rest comfortably upon it. The small end should not be more than about three quarters of an inch in diameter. It should have broad, flat, and rounded edges, so that it may not pinch or cut the skin when it is placed upon it. Let us suppose that we are going to examine the chest with the left ear. The stethoscope is taken in the right hand near its small end, and placed upon the part we wish to examine in such a way that it is everywhere in close contact with the skin, care being taken that nothing is touching the stethoscope or moving upon the walls of the chest. The chest, if possible, should be bare. The left hand is laid upon the shoulder or back of the patient, and the left ear placed upon the ear-piece of the stethoscope. The right hand may then be taken away, and the stethoscope will be supported between the ear and the chest. The hand upon the shoulder will keep the patient steady, and will prevent the exercising 62 HOW TO EXAMINE THE CHEST. of more pressure upon tlie stethoscope with the head than is necessary to keep it in its place. In examining a patient it is most important not to be in an uncomfortable position^ other- wise the patient will be probably uncomfortable also. Fig. 17. The single stethoscope. Binaural stethoscopes are now much used [fig. 18). They are convenient,, especially for the examination of patients in bed/but they are not the best to begin with^ as it is difficult at first to distinguish the sounds produced in the stetho- THE LUNGS. AUSCULTATION. 63 scope; from those produced in tlie lung, and they have this practical disadvantage, that the chest- piece must be placed directly upon the skin, for Fm. 18. Binaural stethoscopes. even a covering of thin gauze is sufficient to inter- fere greatly with the transmission of the sounds. The differential stethoscope, in which there are two chest-pieces with separate tubes, is not much employed at present, and has, I think, no special 64 HOW TO EXAMINE THE CHEST. advantage except sometimes for tlie examination of tlie heart. The simplest instrument is the best to begin witb^ and we shall use the single stethoscope such as is shown in fig. 17. Every stethoscope has its own intrinsic noises^ which have to be got accustomed to. This is especially the case with the binaural. A good auscultator should be equally at home in examin- ing with either the single or double stethoscope as well as with the naked ear, for each method has its own advantages and conveniences. THE AUSCULTATION OF THE VOICE. We will deal with the voice sounds first, because they are less difficult to explain. Vocal Resonance. The vibrations of the voice are produced in the larynx and mouth ; the musical note at the vocal cords, the words in the mouth and pharynx. The vibrations are propagated thence in all direc- tions — outwards through the mouth, and back- wards along the trachea and bronchial tubes. It is well to select some simple sound for the patient THE LUNGS. AUSCULTATION. 65 to produce^ and to use the same always, sucli as the long vowel ^'ah!'^ or the words '^ninety- nine/^ When the stethoscope is placed over the larynx^ and the patient speaks, we hear the voice-sounds with an intensity which is almost painful. If the stethoscope be placed lower down upon the trachea, we hear them less loudly, and over the alveoli of the lung, though still audible, they are much diminished in intensity, have lost their clearness and sharpness, and have become hum- ming or muffled. To the vibrations of the voice which we hear the name Vocal Resonance is given, to distinguish them from the vibrations which we feel, and which are called vocal vibrations. Yocal vibra- tions we feel [Palpation) . Yocal resonance we listen to [Auscultation). Varieties of Vocal Resonance. The vocal resonance over the vesicles of the lung receive the name of pulmonary, muffled, or^ better, Vesicular resonance. Over the larynx it is called Laryngeal, and over the trachea Tracheal_^ while that which is intermediate between tracheal and vesicular is called Bronchial, and bears also the name Bronchophony (phone, voice) . 5.. 6Q HOW TO EXAMINE THE CHEST. These terms are purely conventional and do not admit of accurate definition. The classification is anatomical,, and as the trachea, for example, passes into the bronchi on one side and the larynx on the other, so do the varieties of tracheal resonance pass insensibly into bronchial or laryngeal. By laryngeal, tracheal, bronchial, and vesicular resonance, therefore, is meant resonance of such a kind as is heard in health over these parts re- spectively of the respiratory tract, and, when these terms are used in reference to disease, it is not meant, that we have necessarily an entirely new sound such as is never heard in health, but that sounds, which in health ought only to be heard in particular places, are in disease heard somewhere else, where they ought not to be heard= The sounds of disease are for the most part not so much abnormal sounds, as normal sounds heard in abnormal places. Fortunately it is not the name we give to these sounds, but the fact itself, which is im- portant for the purposes of diagnosis. If, where we should only hear vesicular reson-" ance, we do not hear it, but some other kind of resonance, whatever name we call it by, we know the lung to be in an abnormal condition. The vibrations of the voice are carried, not by the walls of the tubes, but by the air within them. TEE LUNGS. AUSCULTATION. ^1 This is proved by the fact thatj when the column of air is broken by either a foreign body stick- ing in a bronchus or by the tubes beiug filled with mucus^ the vocal resonance is lost in the corresponding part. Eveiy time the tubes divide the vibrations are in part dispersed and lost^ and where the tubes finally split up into the numerous vesicles of the lungs, this dispersion becomes so great that but little of the original vibrations is left to pass on to the walls of the chest. How much the alveolar tissue of the lung is capable of diminishing sound is clearly demon- strated in the case of emphysema, where the enlarged lung comes forward and covers up the heart, muffling the heart-sounds* to such an extent as to make them almost inaudible. Hardly anything can muffle sound better than a pillow, though the actual amount of solid sub- stance it contains is small. The conditions are much the same in the lungs, viz. relatively large air spaces separated from each other by thin, irregular septa (the feathers) . The amount of vocal resonance differs much in different individuals. This depends in chief measure : * It is not uncommon under these circumstances for a dia- gnosis to be made of a weak heart, though the cause of the weak heart-sounds lies not in the heart, but in the lungs. 68 HOW TO EXAMINE THE CHEST. 1st. Upon the loudness of the A^oice, i. e. the amount of sound produced : 2nd. Upon tlie depth of the voice^ for the deeper the voice is, the coarser are the vibrations; hence in women and children the vibrations of the voice are more difficult to hear (as they are also to feel) than in men : 3rd. Upon the thickness of the walls of the chest. Thus the vibrations are often absent in very fat people,, or where the subcutaneous tissue is oedematous. When the vocal resonance is listened to over a portion of consolidated lung, the vibrations are sometimes carried with unusual distinctness along the stethoscope into the ear, so that not only the vibrations of the voice, but even the words, are very distinctly audible. This is called Pectori- loquy or Direct Vocal Resonance. It is a variety of bronchophony. In bronchophony there is an increase in the transmission of the voice or vocal sounds. In pectoriloquy of the speech or articu- late sounds. When the lungs are consolidated, or where there are large cavities in them, the Heart- Sounds, like the vocal vibrations, are often carried with unusual loudness to the ear, and we speak of them as unduly audible. THE LUNGS. AUSCULTATION. 69 In cliildren The Cry is as useful as tlie voice in adultSj and tlie same changes in resonance occur in it. Often^ instead of speaking out loudly^ the patient is made to whisper. The Whisper-Sounds undergo changes similar to those of the vocal sounds. They may be diminished or increased. Thus^ we speak of Bronchial Whisper or Whisper- ing Bronchophony, of Whispering Pectoriloquy, and of Cavernous or Amphoric Whisper. It has been stated that whisper-sounds provide an easy means of distinguishing between an effusion of pus and an effusion of serum into the pleural cavity, the whisper-sound being distinct when the effusion is serous, and absent when it is purulent. This is not correct. When the stethoscope is placed over a part of the chest where the lung is solid, and the observer speaks, the resonance of his own voice is some- times loudly heard in the ear which rests upon the stethoscope. This has been called Auto- phony {AutoSj own ; phone, voice) . Its exact physical causes are not understood, but it is, so far as is known, only met with over consolidated lung. It remains to speak only of one other term often used, viz. JEgophony. This is a peculiar tremu- lousness, which is added to the vocal vibrations. 70 HOW TO EXAMINE THE CHEST. and wliicli lias been compared to the bleating of a goatj whence the name was taken. It is heard in cases of moderate pleuritic effusion at the upper level of the fluid, and usually only poste- riorly at the inferior angle of the scapula. Occa- sionally a somewhat similar tremulousness is heard just above pneumonic consolidation at the base of the lung. ^gophony is supposed to be due to the irre- gular conduction of vocal vibrations through lung tissue which is irregularly compressed and collapsed, as it lies just above the fluid, ^go- phony is not very common, and when met with is of little practical importance. THE SOUNDS OF BREATHINa. What has been said of the sounds of the voice is true also to a great extent of the sounds of breathing". If the stethoscope be placed upon the larynx and the patient breathe in and out, sounds will be heard both on inspiration and on expiration. These sounds are produced in great measure like the sounds of the voice by vibrations set up in and round the glottis, and like them they travel in all directions, outwards through the mouth and inwards towards the lungs, and as they THE LUNGS. AUSCULTATION. 71 travel backwards tliey are progressively dimin- islied in intensity^ until over the vesicles but little of tliem is heard. Now^ if we compare the breathing over the larynx with that over the vesicles^ for instance^, at the base of the lung behind^ we shall notice- that not only is there a difference in loudness^ but that there is also an alteration in character. At the Larynx the breathing- sounds are clear, harsh_, and double ; inspiration and expiration are both loud, and equal in loudness and dura- tion. Over the Vesicles the sound is feebler and has lost its clear character. It has become, like the voice-sounds, muffled, and instead of two sounds one only is audible. Expiration is absent, or if not entirely absent, is only to be heard faintly and with difficulty. As in the case of the voice-sounds so with the breathing-sounds a classification can be made into Laryngeal, Tracheal, Bronchial, Vesicular, and we mean by these terms, when we are speaking of disease, that the respiratory sounds audible over the seat of disease resemble the sounds heard in health either over the larynx^, trachea, or bronchi, as the case may be. If we are in doubt what name to give to a particular kind of breathing we should com- pare it with that heard over the different parts 72 HOW TO EXAMINE THE CHEST. Fig. 19. ^hows the position of the trachea and bronchi behind. The circles mark the spots where bronchial breathing is often lieard in a healthy chest. THE LUNGS. AUSCULTATION. 73 of the respiratory tract, and name it accord- ingly. The larynx and trachea are superficial and can be easily reached by the stethoscope. The bronchi are deeply placed, but bronchial breath- ing may be heard normally sometimes in front upon the first piece of the sternum, and behind either upon the second dorsal spine or right and left of the spine an inch or two lower in the interscapular spaces (fig. 19). Vesicular breathing is soft and muffled in character, and consists almost entirely of an inspiratory sound, expiration being either quite inaudible, or very faint. The sound is probably made up of two parts. 1. The sound which is conducted along the bronchi and smaller tubes and modified by having to pass through the vesicles. 2. A sound produced in the vesicles by the air as it passes into them from the small air- tubes. Whatever explanation is given of its produc- tion, the sound itself is characteristic. What it is, however, cannot be taught by description. It must be learnt by observation. Vesicular breathing is, as has been said, marked off from all other kinds by the absence or faintness of the expiratory sound. 74 HOW TO EXAMINE THE CHEST. In laryngeal, tracheal, and bronchial breath- ing expiration is as loud and long as inspiration, but in each the sounds have in addition certain peculiar characters. Thus, in laryngeal breath- ing it is as if the mouth was in the position to pronounce the diphthong " Slu/' in tracheal the vowel ^^ ah/^ and in bronchial the guttural '' ch.^^ . Bronchial breathing is the most important of all the pathological terms. In it expiration is as loud and as long as inspiration, and both have ajeculiar, harsh, grating noise, which is quite characteristic. No description can convey any idea of what it is like ; the sound must be heard to be realized, and once heard will not be easily forgotten. Between bronchial breathing and vesicular breathing come various forms of abnormal respiration in which expiration is audible, but in which it is not as long or as loud as inspira- tion, or if so has not, at any rate, the character- istic harshness. A name is required for these varieties of respiration, which while not vesicular are at the same time not bronchial, but no name is at present generally adopted. They might be termed tubular to indicate that it is the kind of respiration we might suppose would be heard over the tubules if we could reach them. Un- THE LUNGS. AUSCULTATION. 75 fortunately, tubular has been used by some writers as a general term, to embrace all kinds of abnormal breathing, and by others to indicate the same thing as bronchial. Bronchiolar would be in some respects a better term, but it is not likely to be adopted. Undefined hreathing'^ was once suggested, but has fallen out of use. In the absence of any generally accepted term to indicate these intermediate forms of respiration, no choice is left but to describe what is heard in plain language, and to say that expiration has such or such a relation in respect of length and loudness, to inspiration, and that one or both have such or such a character. This may be lengthy, but it is not ambiguous. Much of the confusion in the terminology of auscultation is due to the use of the term bronchial by different writers in different senses. By most teachers and authors bronchial breath- ing is used to signify a particular kind of abnormal breathing which is very characteristic, and in this strict sense it should, in my opinion, be always and only used. By others, unfortu- nately, it is used as a general term to mean any form whatever of breathing which is not normal. The double use of the term is of course most perplexing, but by bearing it in mind much con- fusion will be avoided. * Unbestimmtes Athmen. 76 HOW TO EXAMINE THE CHEST. What has been said of tlie vocal resonance applies with equal force to the breath-sounds^ viz. that none of these technical terms are neces- sary^ they are only convenient ; and that it is not the term employed^ but the fact indicated by the term that is of importance. Moreover^ the terms used are incapable of exact definition or description^ for as the trachea passes into the bronchi^ the bronchi into the tubules, and the tubules into the vesicles, so will the breathing- sounds indicated by these terms merge gradually into one another, and it will be impossible to agree upon the exact point at which the line must be drawn in each case between them. What is meant when these terms are applied to disease is that over some part of the lung where, for example, vesicular breathing ought to be heard, it is no longer heard, but some other kind of breathing ; and the particular term used to describe it is taken as indicating roughly the amount and kind of change which, in our opinion, the lung has undergone. Cavernous and amphoric breathing are not audible anywhere in health. They approximate in character to the laryngeal sound, hut have jn addition a greater hollowness, and, in the case of amphoric breathing, certain superadded semi- musical (consonant) sounds, such as those heard THE LUNGS. AUSCULTATION. 77 on breatliing into a jug (amphora), from wMcli the name is taken. , Stridor is a peculiar variety of laryngeal or tracheal breathing. It is pathognomonic of narrowing or constriction of some part of these tubes. It is a loud, harsh, see-saw^ double grating sound, audible at a distance from the patient, and associated usually with dyspnoea. The cough in these cases is also usually stridor- ous, or as it is sometimes called brassy or metallic. The constriction is most commonly produced by the direct pressure upon the trachea of an aneu- rysm or tumour, but it may have its seat in the larynx in consequence of local changes there, as in croup in children, or in stenosis or tumour in the adult. Sometimes the breathing-sounds over the vesicles are normal, so far as their character goes, i. e. they are vesicular, but their rhythm is altered. They have become jerky, interrupted (Saccadee), wavy. The cause of such an alteration of rhythm varies. It may be due to irregular action of the muscles, either in consequence of some change or defect in the muscle itself, or, as is more common, in consequence of irregular nervous action ; hence it is very common in nervous or hysterical 78 HOW TO EXAMINE THE CHEST. patients. Or its cause may lie in tlie lung itself, and be due to imperfect and irregular expansion of tlie lung-tissue ; lience it is often met witli in tlie early stages of consolidation of the lung. Sucli alterations in tlie rliytlim of respiration are usually unsym metrical and are to be dis- tinguislied from those symmetrical abnormalities wMcli are due to irregular respiratory movements of central origin like sobbings sighing, coughing, or Cheyne-Stokes breathing (^. v.). Energetic breathing increases the loudness of inspiration and makes expiration also audible over the vesicles. The respiration thus altered has been named Puerile Breathing because it is so commonly heard in children, even where the chest is perfectly healthy. In the adult it is better called complementary breathing, being often heard, when a portion of the lungs is diseased, over the unaffected parts. USE OF THESE FACTS IN DIAGNOSIS. Let us now inquire what use we can make of these facts for the purpose of diagnosis. The sounds produced at the larynx, whether by the voice or by breathing, are transmitted, as THE LUNGS. AUSCULTATION. 79 we have said, almost entirely by the air column in the trachea, bronchi, and smaller tubes to the vesicles of the lungs. They then cross the two layers of the pleura to reach the chest- walls, and through these are conducted to the ear. Along their whole course they are progres- sively diminished; 1st. Every time that the air-tubes divide, and especially by their terminal expansion into the vesicles ; 2ndly. As the vibrations pass from the vesicles to the pleura and chest-walls, and thence along the stethoscope to the ear. We may regard all these parts, viz. the air- vesicles, the pleura, and the chest-walls as so many obstructions placed in the way of the vibrations. Any alteration in these parts will change the transmission of the vibrations. It may make them more easily or less easily heard, and we shall speak then of the voice- or breathing- sounds. 1. As Increased, i.e. more intense than normal. 2. As Diminished, '\i. e. less intense than 3. As entirely absent, J normal. And lastly, as Modified (e.g. in segophony). If, for instance, the walls be very thick, as in fat persons, or where the subcutaneous tissue is oedematous, a greater obstruction will be offered to the vibrations, and they will be diminished. 80 HOW TO EXAMINE THE CHEST. If we lay outside the walls of the chest several folds of cloth, we place a fresh obstruction in the way of the vibrations, and they are therefore diminished. If we take a water-cushion and lay it upon the chest, the vibrations then cease to be audible, and become completely absent. The effect would be the same, if we could place the water-cushion inside the chest-walls^ i. e. in the pleural cavity. In many forms of disease of the pleura this is exactly the condition which is produced. An effusion of fluid takes place into the pleural sac. and we have our water-bag inside the chest. In other cases the pleura itself becomes much thickened, but in both conditions alike a fresh obstruction is offered to the passage of vibra- tions, and they will be either much diminished or completely absent. On the other hand^ we have learnt that it is the breaking up of the air-tubes into the vesicles of the lung which muffles most the vibrations in health, for they have to pass through a most heterogeneous body formed of numerous irre- gular air chambers separated by thin septa, like a feather pillow. Suppose now, that this very heterogeneous body were made homogeneous by the substitu- tion for the air in the vesicles of some solid substance, we should do away at once with what -THE LUNGS. AUSCULTATION. 81 we know to be one of the cliief obstructions to tlie passage of vibrations. The other parts then remaining the same, the vibrations would reach the chest-walls increased in intensity. This we find to be the case,, and we have therefore an easy means of diagnosing between diseases of the two great structures belonging to the lung, viz. the lung itself and its pleural sac, for we have, in affections of the pleura one obstruction more, and therefore diminished pas- sage of vibration, and in solidified lung ono obstruction less, and therefore increased trans- mission of vibrations. All that has been just said applies equally to the vocal resonance, the vocal vibrations, and the breathing-sounds. If, then, we find in any part of the chest that the vocal vibrations, the vocal resonance, and the breathing-sounds are increased, we may con- clude that this is due to the lung in that part having become consolidated. If, on the other hand, we find the vocal vibrations, vocal reson- ance, and the breathing- sounds diminished, we may infer that the pleura is affected. In both cases alike percussion will be either much im- paired or absolutely dull, because there is either but little air-confcaining lung- tissue or none at all in that part. '":"'"^'~'*' "~ Given then a part of the lung in which the 6 82 HOW TO EXAMINE THE CHEST. percussion is impaired or dull, we are enabled by palpation and auscultation to determine, whether this dulness be due to an affection of the lang or of the pleura according to the following table ; Table for the diagnosis between Diseases of the Pleura and Disease of the Lung. Disease of the Pleura {e.g. fluid effusion). Percussion dull. Disease of the Lung {e.g. pneumonic consolidation). Percussion dull. Vocal vibrations "j diminished Vocal resonance V or Breathing-sounds J absent. Vocal vibrations Vocal resonance >• increased. Breathing-sounds } As has been already stated the vibrations travel chiefly by the air in the tubes. If, then, by any chance the tubes become plugged, so that the continuity of the column of air is broken, the transmission of the vibrations will be prevented. This happens occasionally in pneumonic consoli- dation where there is excessive bronchial secre- tion, and makes the diagnosis difficult ; but the course of the case will remove all doubt, for, as the secretion is removed, the ordinary signs of consolidation will appear. There are, on the other hand, some cases of pleuritic effusion, especially in children, in which the voice- and breath-sounds, instead of being absent, are increased, and may be even bron- chial. The reason of this is not known. The THE LUNGS. AUSCULTATION. 83 fact should be remembered^ but difficulty in diagnosis is rarely caused by it. NEW SOUNDS, We have liitberto spoken of sounds, tbe ana- logues of most of wMcli may be beard normally in bealtb. We now come to the class of sounds which are heard only in disease. These fall into two groups, 1. Those produced in the lungs, Pulmonary. 2. Those produced in the pleura, Pleural. To the pulmonary sounds the name Rales was given by Laennec, who divided them into crepi- tant, mucous, and sonoro-sibilant ; the two first are more commonly called Crepitation, and the latter Rhonchus and Sibilus. These are the terms which we shall employ. Crepitation. Crepitation is produced by the bursting of air- bubbles in fluid, and it is spoken of as Large, Medium, or Small, according to the supposed size of the bubbles which produce it, the larger bub- bles giving rise to the louder sound. Excellent crepitation is heard after washingthe hands in warm water, as the little soap-bubbles. 84 HOW TO EXAMINE THE CHEST. whicli form the lather^ burst. This explanation has caused crepitation to be often spoken of as Moist sounds, in contra-distinction to Bhoncbus and Sibilus, which are called Dry sounds. One form of crepitation hasprobably a different explanation from that given above. This is called Fine Hair Crepitation^ because it sounds like the crackling of the hair of the head or whisker when rubbed between the fingers over the ear. It is probably due to the crackling produced by the separation of the walls of the vesicles from each other by inspiration_, when^ as the result of collapse or pressure, they have been in partial contact. Crepitation similar in character^ though prob- ably not produced in the same way_, is also heard occasionally over emphysematous lungs. The noisy bubbling sounds^ which are heard in the trachea of dying people, and to which the name of " The Death Rattle '' is given^ are pro- duced, like the ordinary forms of crepitation, by the bubbling of air, as it passes through the mucus which has collected in the trachea. Rhoiichus and Sihilus. Rhonchus and Sibilus are sounds often musical in char act er_, produced by vibrations set up in THE LUNGS. AUSCULTATION. 85 the air_, as it passes througli tlie broncliial tubes, tlie mucous membrane of wliicli lias been altered or roughened by inflammation or secretion. Rhonchus is produced in the large tubes and is deeper in tone. It is often described as snor- ing, cooing, or grating, according to tlie special characters of the sound. Sibilus is produced in the small tubes, and is wheezing and more hissing in character. One great peculiarity of rhonchus and sibilus is the rapid way in which they alter or occasionally temporarily disappear, as the mucus which has caused them is dislodged. A fit of coughing will often alter the character of the rhonchus and sibilus, as well as also the places where they are heard. Coughing affects also crepitation, occasionally remoying it, when we may infer that it was pro- duced by a temporary accumulation of mucus in a small bronchus, or as is usual rendering it more evident, and sometimes producing it, where in ordinary respiration it is not audible. In every case, where it is at all likely that crepitation may be produced, the patient should be made to cough while the chest is being listened to, and then, either during the cough or, as is more com- mon, during the deep inspiration which follows it, crepitation may be heard. 86 HOW TO EXAMINE THE CHEST. Pleural Friction. The surfaces of the healthy pleura are smooth, and move upon each other during respiration without producing any sound. When the sur- faces are no longer smooth, but are roughened by disease, the rubbing of the two rough surfaces produces a sound, to which the name of Friction is given. The character of pleural friction differs much in different cases. Sometimes it resembles the creaking of a piece of dry leather when it is folded. This is called Dry-Leather Creaking'. At other times it is distinctly rubbing in character. At other times the sound is hardly a rubbing sound so much as a minute crackling, audible usually at the end of inspiration. This it is often very difficult to distinguish by the sound alone from the fine small crepitation produced in the lung. Characters of the Friction- Sound. Friction, being produced in the pleura near to the walls of the chest, will sound " close under the ear ;'^ as the lungs move to and fro, it will be '^ double/' being due to the roughening of the pleura, it will be heard only where the roughen- THE LUNGS. AUSCULTATION. 87 ing exists, and may therefore be very " limited in extent ''; and being produced by the move- ments of the lungs during respiration, it may '^ cease ivhen the breath is held." Where the pleura is roughened immediately over the pericardium, the movements of the heart may be sufficient to produce the rubbing. This is called Pleuro-Pericardial Friction. When as sometimes happens this is not modified by breathing, it will be difficult to distinguish it from the friction-sound, produced by a similar roughening of the pericardium (c/. pericardial friction). In inflammation of the pleura, so soon as the part becomes roughened, a friction-sound is pro- duced. Soon the two layers are separated by an exudation of fluid, and the sound then dis- appears. When the inflammation subsides, and the fluid is reabsorbed, the two layers come once more into contact, and the friction-sound is heard again. This is called Redux Friction, i. e. friction which has come back. The same may occur with crepitation in some cases, and then it is spoken of in like manner as Redux Crepita- tion. When from some cause air gets into the pleural cavity, the case becomes one of Pneumo- thorax (air in the thorax). The lung then 88 HOW TO EXAMINE THE CHEST. collapses away from tlie cliest-walls back to- wards tlie spine round its root_, i. e. the bronclius and great vessels. As in tlie case of an effusion of fluid, the lung is separated a long distance from the walls of the chest, though by air instead of fluid, and the voice- and breathing- sounds have to pass through a large air-contain- ing chamber, before they reach the ribs. In most cases this has the same effect, as if the ■effusion were not air bufc fluid, and the vocal vibrations, the vocal resonance, and breathing- sounds are either much diminished or absent. It might, however, have been expected, that the air cavity would act like a sounding box, so that the sounds produced in the bronchi would be transmitted to the cavity and be thereby increased in loudness, and being at the same time altered by consonance become more or less distinctly amphoric. In some cases this does actually happen, so that we have two groups of cases of pneumothorax. In the one the voice- and breath-sounds are diminished or absent, and in the other are amphoric in character. Not only may the breathing- and voice-sounds become amphoric under these circumstances, but also crepitation. It has then received the name of Metallic Crepitation. Metallic Tinkling has a different explanation. It is caused by drops of fluid falling from the THE LUNGS. AUSCULTATION. 89 walls of a cavity into fluid Lelow {gutta cadens), giving rise to tlie same sound as drops of water often do, wlien falling in a well or grotto. Wlien_, over a pneumothorax, a coin is laid upon tlie chest-wallsj and tapped lightly with another, while the ear is placed upon the chest, the sound is often heard like the tapping of a metal bell or a porcelain dish. To this has been given the name of Bell-Sound {bruit d'airain) . It may be audible over any sufl&ciently large cavity. It is most common, though not constant, in pneu- mothorax, and in some of these cases ordinary percussion may be similarly metallic. When air has been for some time in the pleura, it is generally associated with an effusion of fluid, which is sometimes pus and sometimes serum. The names of Pyopneumothorax {air and pus in the pleura), and Hydropneumothorax (serous fluid and air iji the pleura) are then given to these conditions respectively. This mixture of fluid and air in a large cavity gives rise to a new physical sign, which can only be met with under these conditions {air and fluid), and which is therefore said to be " patho- gnomonic.^^ This is Succussion, a splashing sound, heard when the patient is suddenly shaken, while the ear is resting upon the chest. 90 HOW TO EXAMINE THE CHEST. thougli it may sometimes be heard at a distance from the patient. Succussion may also be produced in tbe stomacbj a fact wbicb must be borne in mind in diagnosing pneumothorax of the left side^ though it can rarely cause any real difficulty. Theoretically all these sounds, amphoric and succussion, may be produced quite as well in a large cavity in the lung as in pneumothorax, although the cases are in practice rare, in which confusion would arise. When, however, the opening into the lung is wide, the physical con- ditions are almost identical, and the diagnosis becomes very difficult by auscultation alone. THE LUNGS. AUSCULTATION. 91 - SYNOPSIS. On auscultating tlie chest we must proceed systematically. We must listen : 1. To tlie Voice-Sounds, and determine whether they are symmetrical_, i. e. whether they are equal on the two sides ; if there be a difference we must note it, and ascertain whether it be an increase on one side, or a diminution on the other. 2. To the Breathing- Sounds, and ascertain if they be symmetrical or not; we must listen, first for the Inspiratory Sound, and next for the Expiratory Sound; if expiration be audible, we must note its length, duration, and intensity in comparison with inspiration, and may express the changes by the use of such terms as bronchial, tracheal, &c. 3. We must listen for Superadded Sounds, such as are never audible in a healthy chest, for Crepi- tation, Friction, or for sounds characteristic of large cavities, such as Amphoric or Cavernous Sounds, Metallic Echo and Tinkling, the Bell- Sound, Succussion. 92 HOW TO EXAMINE THE CHEST. CONCLUSION. The detection of tlie early stages of disease of tlie lungs is often very difficulty and would be impossible without careful attention to minute details. The normal variations in the physical signs of tlie chest are so wide^ and the transition between health and disease so gradual_, tliat no sharp line of demarcation can be drawn between them. It is upon a want of symmetry in these physical signs that we chiefly rely. Most diseases of the lungs are unsymmetrical, either only one side is attacked_, or if both, sides are attacked_, they are rarely affected to the same degree. So that the physical signs can hardly ever be symmetrical^ and whether we inspect, palpate, percuss, or auscult, in all cases alike, it is for this want of symmetry that we are on the watch. In one place only (with the exception of the cardiac area) is there normally any want of sym- metry. This is at the apex. On the right side, for the reasons already mentioned, percussion is hardly so resonant, while the vocal vibrations, the vocal resonance and breathing-sounds are slightly more intense than on the left side. The THE LUNGS. AUSCULTATION. 93 difference is only slight^, but tlie same difference against the left side instead of the right would be evidence of disease. Lastly, a diagnosis should never be based upon a single physical sign. An abnormality in one respect alone may be physiological. In disease of the lungs there will certainly be a concurrence of several physical signs, which separately might be worth little, but which taken together make the diagnosis certain. It is desirable, so far as possible, to represent all the facts observed in a diagramniatic form. Dulness may be represented by shading (or colouring) the corresponding parts of a diagram of the chest. Vertical lines may be used to indi- cate that the dulness is due to solid lung, hori- zontal that it is due to fluid. Crepitation may be represented by dots or small circles according to the size (large, medium, or small). Cavities by irregular areas, described in the shaded parts. Pleuritic Friction by zigzag lines. Other physical signs by initial letters. Fl. = Flattening. Mts. = Movements. Y. V. = Yocal vibrations. Y. R. = Yocal resonance. 94 HOW TO EXAMINE THE CHEST, B-h. = Rlioiiclius. Sb. = Sibilus. Pect. = Pectoriloquy, ^g. = ^gopliony. I. = Inspiration. B, = Expiration. Bi. = Respiration. R. V. = Vesicular. ->. R. t. = Tubular. R. br. = Broncliial. ^Respiration. R. tr, = Tracbeal. R. c. = Cavernous. IorE. + . = Prolonged inspiration or expi- ration. I or E — . = Deficient ,, ,, I = E. = Inspiration as long as expiration. I < E, = J, shorter than „ I > E. = J J longer than j. THE LUNGS. AUSCULTATION. 95 SYNOPSIS OF THE EXAMINYTION OF THE LTJNOS. In the accompanying table I have given the chief subdivisions of the examination of the luogs; the details are given in the text^ and are summa- rised at the end of each chapter. InsjpGction. The chest at rest. Its shape. The chest in motion. The movements of respi- ration. Paljpation, The vocal vibrations. The sense of resistance. Abnormal sensations (friction^ &c.). Percussion. The normal boundaries of the lungs. The resonance of the various parts of the chest. Auscultation, The vocal resonance. The breathing-sounds. Superadded Sounds. SECTION II. THE HEAET, THE EXAMINATION OF THE HEART. The examination of tlie liearfc is conducted upoin the same system as tliat of the lungs. We consider : First — What we can see (Inspection). Secondly — What we can feel (Palpation). And lastly — What we can hear (Percussion. and Auscultation). 100 HOW TO EXAMINE THE CHEST. mSPECTIOK Tliat part of the thorax whicli is over the heart is called the Praecordium or the prascordial region. On Inspection we consider First — its shape ; Secondly — the movements visible there. THE SHAPE. In healthy there is nothing in the shape of the praecordium to indicate the position of the heart, and even in many forms of disease there is no perceptible change in it. Where, however, the heart is very large, espe- cially in young people, the praecordium may be unduly prominent, and it is then said to be Bulging. THE MOVEMENTS. When the heart is healthy, the only movement visible under ordinary circumstances is that of THE HEART. INSPECTION. 101 the apex. In the full-grown adult this movement is seen in the fifth intercostal space, one inch inside_, and usually about one inch and a half below the left nipple. Measurements, however, taken with the nipple- as a fixed point are unsatisfactory, because the nipple is not always found in exactly the sam& place. For this reason it is better to take instead of the nipple The Nipple Line. This is a line drawn from the middle point of the clavicle ver- tically downwards. It passes often through the nipple. Position of the Ajpex. The Apex then is seen in the fifth intercostal space, one inch inside the nipple line on the left side. In health, it is identical with the true ana- tomical apex of the heart, but in disease this is often not the case, and the impulse which we see frequently corresponds with a part of the left ventricle some distance from the anatomical apex. When we speak therefore " clinically " of the apex, we agree to mean that point on the left hand side of the chest farthest outwards a nd downwards, at which the movement of the heart can be seen or felt. This is often two or three inches from the normal place. 102 HOW TO EXAMINE THE CHEST. No7'mal Peculiarities of the Apex. In cliildreiij the apex is often normally slightly "higher and farther out than in adults, and may fceat in the fourth interspace or under the nipple. In adults, when lying over on the left side the apex is often seen in the nipple line. Hence in fixing the apex, the patient must either stand erect, or, if lying down, must lie straight upon the back. The contraction of the abdominal muscles on standing up counteracts the tendency of the heart to fall, so that the apex is not displaced. The same occurs in the case of the liver, the upper border of which is if anything, a little higher when a person is standing up, than when he is lying down. Respiration makes no perceptible difference in the position of the apex. Displacement of the Apex. When the apex is not in its normal place, it is said to be Displaced. Even a very slight displacement may be of great importance, for there is hardly any disease of the heart or pericardium, in which the apex preserves its normal position. Thus, in disease of the mitral valve, and in all THE HEART. INSPECTION. 103 cases of enlargement of tlie riglit side of tlie hearty tlie apex is displaced outwards {i. e. to the left side) but it still usually remains in tlie fifth, space. In disease of the aortic valves^ and in all cases of enlargement of the left ventricle, the apex is displaced not only outwards but also downwards, and is often found in the sixth or even the seventh space. In pericarditis what seems to be the apex beat is often raised so as to be seen in the fourth space. This is especially the case in children. Where the heart itself is displaced, the apex will of course be displaced also. In some rare cases all the organs are placed upon the wrong side, e.g. the heart on the right and the liver on the left. This is spoken of as Transposition of Viscera. It is a very rare con- dition. The Character of the A'pex Beat. In health this is a simple slight bulging, due to the contraction of the ventricles, affecting a circle of about half an inch in diameter, such as we might expect to produce by tapping with one finger on the inside of the intercostal space. In disease the apex beat is frequently altered in character. When it is visible over a much larger area 104 HOW TO EXAMINE THE CHEST. than normal^ it is described as Extended Cardiac Impulse. When it is not distinctly localised, it is spoken of as Diflfased Impulse. When it is not a simple bulging, but has a wave-like movement, it is called Undulatory Impulse. When the intercostal space corresponding with the apex is drawn in, instead of bulging, each time the heart contracts, this alteration is des- cribed as Systolic Recession of the apex. SystoHc recession is also occasionally seen in the second, third, or fourth spaces, but only when the patient is very thin, and is then com- monly associated with some contraction of the upper part of the left lung. Occasionally an impulse is seen at the apex, not only when the heart contracts, but also when it commences to dilate. This is called ^^ Diastolic Impulse " (or the back stroke of Hope). Pulsation in Abnormal Places. In disease impulse synchronous with the move- ments of the heart is often seen at other parts of the chest beside the apex ; 1. Below the xiphoid cartilage in the epigas- trium j this is called Epigastric Pulsation : ^ * Pulsation is occasionally observed in the hepatic region THE HEART. INSPECTION. 105 2. In the second intercostal space, right and left of the sternum, in relation with the aorta on the right side, and with the pulmonary artery on the left j this commonly occurs in cases in which the lungs are contracted at the apices : 3. Occasionally on the right side in the fourth or fifth, intercostal spaces, even as far as the right nipple j this is due to displacement of the heart, but it is not the apex which beats here, for it is not a part of the left ventricle, but of the right ; 4. Under the manubrium sterni ; this is gener- ally due to disease of the great vessels (aneurysm): 5. In the vessels of the neck, either in the arteries {arterial pulsation) , or in the veins {venous pulsation) . Arterial Pulsation is systolic, and due to the very forcible projection of blood into the vessels. Venous Pulsation is usually systolic, but may be also diastolic. When the beating of the heart is very forcible, the whole praecordium is often lifted by it. This is known as General Heaving. below the lower ribs on the right side. This usually is asso- ciated with heart disease, and is called Hepatic Pulsation, 106 HOW TO EXAMINE TEE CHEST. SYNOPSIS. On inspection tlien we look for 1st. Changes in the Shape of the Prsecordium. Bulging ; 2nd. Changes in the Movements, I. At the Apex, {a) Change in the position of the apex beat_, (6) Change in its character. Increased, Extended, Diffuse, Undulatory, Diastolic impulse. Systolic recession : II. In other Places, Greneral heaving, Epigastric pulsation. Pulsation over the aorta or pul- monary artery. Pulsation in other parts of thorax, (Aneurysmal) . Pulsation in sides of neck, (a) Venous. (b) Arterial. Pulsation in the hepatic region. THE HEART. PALPATION. 107 PALPATION. As in tlie case of tlie examination of tlie lungs, speaking generally, all that can be seen can be also felt, both as regards the shape of the prse- cordium and the movements of the heart. The movements are often more easily recog- nised by the hand than by the eye, and the position of the apex is always finally fixed by palpation. To Fix the Apex, This should be done with the tip of one finger, the object being to find out the exact point farthest outwards and downwards at which the heart can be felt beating. Abnormal Sensations. Next the whole hand should be placed upon the prsecordium, first below and then above, in order to detect either undue movement in this region, or abnormal sensations such as do not occur when the heart is healthy. The most peculiar of these abnormal sensations 108 HOW TO EXAMINE THE CHEST. are described as Thrills. They are due to coarse vibrations, set up by eddy-like currents in the bloody in consequence usually of some obstruction to the course of its current. Thrills may be systolic or diastolic, i. e. may occur when the ventricle is contracting or dilating. Of all thrills the most striking occurs at the apex, and has been aptly compared to the sensa- tion felt when the hand is placed upon the back of a cat purring, and from this it has received the name of Purring Tremor or Fremissement Cataire. This form of thrill occurs immediately before the contraction of the ventricle, and is there- fore called prsesystolic. Thrills are also sometimes felt in the second or third intercostal spaces on the right or left side. They are most common on the right side, and are connected with affections of the aortic valves. Occasionally the vibrations occur at such regular intervals as to produce a musical note. To this reference will be made again under auscultation. When the two layers of the pericardium are roughened, the rubbing of the two surfaces together may be easily heard, but it is some- times also felt. It is called Pericardial Friction or Friction Rub. Thrills, as well as also friction, are sometimes THE HEART. PALPATION. 109 felt under tlie manubrium sterni. In these cases they are due usually to aneurysm of tlie arcli of tlie aorta. In the neck, thrills may be felt both in the arteries and veins. In the arteries, they are usually propagated from some point below, generally from the aortic valves. In the veins, they are commonest in cases of extreme ansemia, e. g. chlorosis. When the valves of the pulmonary artery close forcibly in thin people, their closure may be fre- quently felt by the hand as a sharp flap or shock in the second left intercostal space. This is often to be seen, as well as to be felt, and has already been referred to under Inspection. It has received the name of Valve Shock. SYNOPSIS. Palpation enables us to confirm most of the facts recognised on inspection, and further to ascertain the occurrence 1. Of Thrills, {a) Systolic, (6) Diastolic, (c) Presystolic ; 2. Of Valve Shock; 8. Of Friction. 110 HOW TO EXAMINE THE CHEST. PEECUSSION. The Size of the Heart. How Large is the Heart ? As witli the lungs^ so with the hearty this is naturally the first important qiiestion_, and it can only be answered by means of percussion. It has been already stated_, that part of the heart is uncovered by the left lung, and that this part lies just above the diaphragm to the left of the middle line of the sternum (fig. 20). If we percuss this part we obtain a non-resonant sounds for the reason that there is no air-containing lung beneath. The Cardiac Area is^ roughly speaking, a tri- angular space. To describe a triangle three points are required, and these three points are : 1. The apex, which is to be found in the fifth intercostal space one inch inside the left nipple line j 2. The junction of the fourth left costal car- tilage with the sternum ; 3. The bottom of the sternum at its junction with the xiphoid cartilage. THE HEART. PEECUSSION. Ml Fig. 20. Diagram showing the real size of the heart, and the size of the absolute cardiac dulness. 1, 2, 3, are the three points described in the text. 112 HOW TO EXAMINE THE CHEST. The area of cardiac dulness may be then described by drawing 1. One line (the Upper Boundary) slightly curved outwards from the apex to the junction of the fourth costal cartilage with the sternum on the left side ; 2. A second (the Lower Boundary) from the apex to the base of the xiphoid cartilage ; this is nearly horizontal ; 3. A third (the Right Boundary) from the base of the xiphoid cartilage vertically upwards along the left border of the sternum to the fourth costal cartilage. Within this area the percussion-sound will be dullj or^ if not absolutely dull_, will be much im- paired. This area is called the area of Absolute — or Superficial — Cardiac Dulness. It does not, of course, represent the real size of the heart, which we know occupies a much larger space in the thorax {fig. 20). If we percuss forcibly outside the upper boundary, we obtain a note, which, though more resonant than within the area described, is still less resonant than the note in other parts of the chest, for by forcible per- cussion we throw into vibration the deeper parts of the chest, and these are, of course, less resonant where the heart is, than where there is nothing but lung-tissue. This increased area of impaired resonance is called the Deep — or Rela- THE HEAET. PEECUSSION. IIB tive — Cardiac Dulness. Et extends about three quarters of an incli beyond tlie upper border of tlie area of absolute dulness along the fourth ribj and curves down to fuse with it at the apex {fig. 20). The Lower Boundary cannot be determined by percussion^ for the heart lies here upon the diaphragm, and the diaphragm upon the liver^ and both the heart and the liver give a dull note to percussion. This boundary may be, however,, accurately represented by drawing a horizontal line from the apex of the heart to the base of the xiphoid cartilage. Tbis line is in direct continuation with the upper border of the area of hepatic dulness described previously. The right border of the heart cannot be shown by percussion to extend beyond the left edge of the sternum, and for this reason. The sternum is a solid body, lying above and to the right side immediately upon, the lungs. When it is per- cussed we obtain vibrations, not only from the parts immediately beneath, but also by conduc- tion from the lungs in relation with it at a distance from the part percussed, and the sound is then resonant, even on parts of the sternum under which no lung lies. When from any cause, as for instance by enlargement of the right side of the heart, the lung is pushed away from the sternum, the 8 114 HOW TO EXAMINE THE CHEST. resonance over it will become impaired^ or even absolutely dull. If tbe lungs and tbe pleura are normal, any increase in tbe size of tbe beart is attended by a correlative increase in tbe size of tbe cardiac dulness, but, if tbe lungs and pleura be not bealtby, a difficulty may arise in one of three ways. 1. If tbe lungs be too large, as in empbysema, tbey will encroacb upon tbe cardiac area, and cover up tbe beart, eitber wbolly or in part, and tbe cardiac dulness will then be eitber wbolly absent, or be mucb reduced in size [fig. 12). 2. If tbe lungs be contracted, as tbey dften are in cbronic affections, more of tbe beart will be exposed, and tbe cardiac dulness will be propor- tionately increased {fig. 13). 3. Lastly, if tbe lungs be consolidated, or tbe pleura be diseased, in tbose parts wbicb are in immediate relation witb tbe beart, we sball obtain on percussion a dull note, as over tbe beart itself, and our means of determining tbe beart^s dulness will be lost. Alterations in the Cardiac Dulness. Diseases of tbe beart, in almost every case except atropby, — and tbis cannot be clinically demonstrated — are attended by increase in THE HEART. PEECUSSION. 115 Fig. 21. Diagram showing the shape of the absolute cardiac dulness in aortic disease (enlargement of the left ventricle). Apex displaced downwards and outwards. The white dotted line shows the normal area of absolute cardiac dulness. 116 HOW TO EXAMINE THE CHEST. Fig. 22. © Diagram showing the shape of the absolute cardiac dulness in mitral disease (enlargement of the left auricle and of the right side of the heart). Apex displaced outwards and not downwards. Great in- crease of dulness to the right. The white dotted line shows the normal area of absolute cardiac dulness. THE HEART. PERCUSSION. 117 Fig. 23. Diagram showing the shape of the absolute cardiac dulness in a case of large pericardial effusion. The white dotted line indicates the normal area of absolute cardiac dulness. 118 HOW TO EXAMINE THE CHEST. size^ and therefore by increase in tlie size of tlie cardiac dulness. This is easily determined unless the lungs and pleura be also affected. When the cardiac dulness is increased^ its shape varies much^ according to the kind of disease with which the heart is affected. The shape may remain triangular and be simply enlarged. This is the rule in all cases of hyper- trophy of the left ventricle, of which aortic disease may be taken as the type {fig. 21). Or, it may cease to be triangular, and become either irregularly quadrilateral, as in mitral disease {fig. 22), or roughly globular, as in cases of great general enlargement or of pericarditis (fig.n). Lastly, the cardiac dulness will be displaced when the heart is displaced, or be altered in size and shape in consequence of deformities in the thorax. SYNOPSIS. By percussion, then, 1. We determine the size of the cardiac dulness, And 2. Ascertain any alterations in its size, shape, or position. THE HEART. AUSGDLTATION. 119 AUSCULTATION. When the ear is placed upon the cardiac region of a healthy man, the two sounds of thte heart become audible. They differ somewhat in character, and have been compared to the twa syllables 'Mub" and ^^dup/' the first being longer and heavier (lub), the second shorter and sharper (dup). The heart, we know, is in constant movement, either contracting or dilating, and this is true of the auricles as well as the ventricles, but, inas- much as it is the contraction of the ventricles which is the most important, we agree, when the terms contraction and dilatation are used, to refer to what the ventricles are doing, unless we dis- tinctly specify some other part. The ventricle then is continually moving, never absolutely at rest, but always either contracting or dilating. Directly contraction ends, dilatation begins, and vice versa. We may represent the hearths action diagram- matically in the form of a circle {fig. 24), once round the circle representing one complete cycle of the heart's action. 120 HOW TO EXAMINE THE CHEST. The movements of the heart are associatedwith the two sounds already referred to. These may be represented upon the diagram by shaded spaces cutting the circle^ the first much thicker ±hau the second, to indicate its greater length. Diagrammatic representation of the heart's action. S = the systolic period. D = the diastolic period. l = the first sound of the heart. 11 = the second sound of the heart. 111 = the prsesystolic, or auricular systolic, period. We have, then, in investigating the hearths action to consider, first the two sounds of the heart, and secondly the two intervals by which these sounds are separated. These intervals in health are periods of silence. It will be observed in the diagram, that the shaded spaces divide the circle into unequal parts, the shorter bearing to the longer roughly the relation of two to three, that is to say, the shorter is two-fifths of the whole circle, and the THE HEART. AUSCULTATION. 121 longer three-fiftlis. This is approximately tlie relation, wliicli has been found by measurement to exist, between the length of the period of con- traction and of the period of dilatation. To the shorter of these periods, the period of contraction, the name Systole is given, and to the longer, the period of dilatation^ the name Diastole. Systole and diastole are therefore periods of time, and, though they stand in a certain relation to the sounds of the heart, are to be carefully distin- guished from them. We have therefore, when listening to the heart, to observe, first the two heart- sounds, and secondly the two periods of silence. The Sounds of the Heart. The chief cause of the second sound of the heart is the closure of the semilunar valves in the aorta and in the pulmonary artery. The first sound is more complex, and although it is due in part to the closure of the auriculo- ventricular valves, other factors appear to be necessary for its normal production, such as a healthy condition of the muscular tissue of the heart and of the blood. As the result of observation of the heart-sounds in disease, it is probable that, even for the second sound, the simple theory of its production by the 122 HOW TO EXAMINE THE CHEST. closiDg of valves does not by itself afford a suffi- cient explanation in all cases. The valves_, liowever_, play so mucli tlie most important part in tlie production of tlie sounds of tlie lieart_, that it will not be necessary in this place to consider the other possible causes^ but we may assume for our present purpose_, that the heart-sounds are due in all cases alike to the closure of valves. The first sound is long, rather dragging, and well represented by the syllable ^^ lub." This is indicated upon the diagram by a broad shaded space. The second sound is flapping in character, shorter, and sharper, and is well represented by the syllable " dup." It is indicated upon the diagram by a narrow shaded space. We have no means at present of measuring the length of the heart-sounds. Tlie figure given is diagrammatic^ and indicates their duration only approximately. The first sound of the heart is produced, when the ventricle begins to contract, and marks there- fore the commencement of the period of systole. The second sound is produced, when the ventricle begins to dilate, and marks therefore the com- mencement of the period of diastole. Systole therefore extends from the commencement of the first sound up to the second; diastole from the second up to the first. THE HEART. AUSCULTATION. 123 The first sound is sometimes spoken of as tlie systolic sound^ and tlie second as the diastolic sound. These terms are confusing and should not be used. The characters of the sounds in health are sufii- ciently distinct^ so that there is little risk of mistaking them, but this is not so in disease, and it becomes necessary to have some means of determining, which sound it is that we hear, or if, as occurs in many cases, the sounds be absent, to determine when the heart is contracting, and when it is dilating, i. e. " To time the Heart.^^ This is easily done by means of the pulse. The pulse beat is due to the sudden driving of blood into the vessels by the contraction of the left ventricle. Near the heart the pulse beat and the systole of the ventricle are practi- cally synchronous, but at a distance from the heart this is not so, for the wave is delayed in reaching a distant vessel, as for instance the radial at the wrist, and in disease this retarda- tion is often considerable. Some vessel must therefore be selected as near as possible to the heart. The most suitable for the purpose is the carotid. This will be conveniently reached by grasping the side of the neck with one hand, the fingers being behind, and by pressing the thumb down in 124 HOW TO EXAMINE THE CHEST. front between the sterno-mastoid muscle and tlie larynx or trachea. The carotid will then be felt pulsating beneath the thumb. The pulse wave in the carotid is a long one^ and lasts as long as the period of contraction. Reduplication and Accentuation of Sounds. The heart is a complex organ formed of many parts. It might be supposed, then, that we should get many sounds instead of only two, and yet in health the two sides of the heart act in such per- fect harmony together, that they produce only one first sound and only one second sound. This is by no means so in disease, for, when this accurate adjustment is disturbed, the two sides cease to act synchronously together, and the sounds become double, or as they are called Reduplicated. Instead of a clear ^'^lub-dup, lub-dup,^^ we hear as it were ^^ lur-rub-dur-rup, lur-rub-dur-rup." This has also been called Cantering [Bruit de Galop) . Either sound may be reduplicated, though it is more commonly the second. Sometimes, where the want of harmony is not so marked as this, the relative loudness of the sounds on the two sides of the heart may be altered. These louder sounds are called Accen- tuated. THE HEART, AUSCULTATION. 125 Murmurs. We have stated_, that in a healthy heart we hear two sounds onlj^ and that thej are separated by two periods of silence. In disease we often hear during these periods of silence a fresh sounds and this we agree to call a murmur. A Murmur may be defined to be a sounds pro- duced by the movements of the heart, occurring in those intervals, during which in health no sound is audible. Murmurs must not be confounded with heart- sounds, nor must they be spoken of as simply replacing the heart-sounds. They may, it is true, replace the heart-sounds, but then they always do something more, and the two things are essen- tially distinct. Murmurs may be heard, when both the sounds are present, or when one of the sounds is absent, or even both of them, and lastly, the heart-sounds may be modified, or even absent, without any murmur at all. The terms, employed to describe the characters of murmurs, are those in ordinary use, such as soft, blowing J loud, faint, harsh, grating, rasping, 8fc. Some are musical in character, and are then spoken of as musical murmurs. Commonly deep in tone, but occasionally high pitched, such murmurs will be described as cooing, piping, 126 HOW TO EXAMINE THE CHEST. lohistling, &c., according to tlie kind of musical sound produced. They frequently change their tone and character, and occasionally the musical part may even for a time disappear. These variations depend upon varying conditions of the circulation. The vibrations, which produce these musical murmurs, are often also easily felt, and give rise to some of the more striking forms of thrills. Heart murmurs, even when distinctly musical, are not often heard by the patient, however loud they may appear to the person auscultating. Classification of Muvinurs. Cardiac murmurs are divided into two groups, according as they are produced inside, or outside the heart, and they are named accordingly Endo- cardial and Exocardial. The exocardial murmurs will be discussed later. Of the endocardial murmurs there are two classes, I. Those which depend upon some pathological change in the heart, and which are therefore called Organic ; II. Those, in which no such change exists, and which are therefore called Inorganic. Murmurs may also be classified according to the movements of the heart. THE HEAET. AUSCULTATION. 127 The heart is always either contracting or dila- ting, and murmurs_, therefore, fall naturally into two groups, I. Those which occur during the period of contraction (systole) ; these are called Systolic murmurs; II. Those which occur during the period of dilatation (diastole) ; these are called Diastolic murmurs. Sow to Time Murmurs. We are able, as we have seen, to determine, by feeling the pulse, the time at which the left ventricle contracts. If, then, we place the ear upon the chest and the thumb or the finger upon the carotid, and hear a murmur, we know, should the murmur come at the same time as the pulse beat, that it occurs when the ventricle is contracting, and that it, therefore, is a systolic murmur. On the other hand, should the murmur not come at the same time as the pulse beat, we know that it is produced when the ventricle is not contracting, but dilating, i. e. during diastole, and that the murmur is therefore diastolic. We may indicate the murmurs which we hear upon the diagrams, by shading lightly (or in a different colour) the spaces left between the darker shadings, which represent the heart- 128 HOW TO EXAMINE THE CHEST. sounds^ varying tlie deptli of shading witL. tlie intensity of the murmur. Tiius Jig. 25, repre- sents a systolic murmur. The shading runs directly into that corresponding with the first sound. This indicates, that the murmur in this case was continuous with the first sound, and could not be separated from it. The shading is darkest towards the first sound, and becomes lighter towards the end of systole. This indicates, that Fia. 25. Diagram of a systolic murmur with botli heart-souuds audible. The gradually decreasing intensity of the murmur is indi- cated by lighter shading. the murmur was loudest at the commencement, and that it gradually became fainter towards the end, of systole. In a similar way most varieties of murmurs may be diagrammatically represented. THE HEART. AUSCULTATION. 129 Subdivision of Endocardial Murmurs. Systole is a mucli shorter period of time than diastole^ and we do not find it possible to sub- divide tlie class of Systolic Murmurs. We con- tent ourselves with speaking of them as Long and Short. Diastole has a longer period and^ moreover, when change occurs in the rate of beating of the hearty it is at the expense of the diastole that this chiefly takes place. Diastolic Murmurs are easily subdivided into groups^ according as they occur at the commence- ment, in the middle, or at the end of the diastolic period, and have been named accordingly early, middle, and late diastolic murmurs. The murmur at the end of Diastole, late Dias- tolic, gradually increases in intensity up to the first sound, and is terminated abruptly by it ; it comes immediately before the systole, or, if we have one finger upon the carotid, immediately before the pulse beat there. It is, therefore, usually called a Praesystolic murmur (before the systole) {fig. 26). It is frequently associated with the peculiar purring thrill previously de- scribed. A prassystolic murmur may be long or short. The short occupies aboat the last third of dias- tole, and is the same as the late diastolic {fig. 26) . 9 130 HOW TO EXAMINE THE CHEST. The long occupies tlie last two-thirds of diastole, and is equivalent to the mid plus the late dias- tolic [fig, 27). Fig. 26. Diagram of a short prsesystolic murraur (auricular systolic — late diastolic). At tlie apex the first sound is longer than normal, and the second sound is absent. The murmur increases in intensity up to the first sound, and is abruptly terminated by it. Fig. 27. Diagram of a long prsesystolic murmur (late + mid- diastolic). Now, what is happening in tlie heart at the time at which this murmur is produced ? We know that immediately before the ven- tricle contracts, the auricle contracts, so as to THE HEART. AUSCULTATION. 131 ensure the complete filling of the ventricle with, blood. But this is just the time at which the murmur is heard. It has for this reason also received the name of Auricular Systolic^ by which Fig. 28. Diagram of a sliort postsystolic murmur (early diastolic), immediately following and continuous with the second sound, which is still audible. Fig. 29. Diagram of an ordinary diastolic murmur (long postsystolic or early + mid-diastolic). The second sound is lost in the murmur. is meant_, that it is due to the contraction of the auricle. It is better^ however^ to use the more common term_, and call it Prsesystolic. 132 HOW TO EXAMINE THE CHEST. Diastolic murmurs heard at the commencement of Diastole may be spoken of as Long or Short. The very short murmur of this kind^ which occurs immediately after the pulse beat^ or if the second sound be present, immediately after the Fig. 30. Diagram of a double murmur (systolic and long postsvs- tolic). Both sounds are lost in the murmurs. Fig. 31. Diagi'am of a double murmur (prsesystolic and systolic). The first sound is audible and the second absent. second sound, has received the name of Post- systolic {after the systole) {jig. 28). The most common kind is usually described as THE HEAET. AUSCULTATION. 133 Diastolic^ or^ in order to distinguisli it from tlie praesystolic murmur^ Ordinary Diastolic. ThiSj liowever_, often leads to confusion and seems to imply, tliat a prassystolic murmur is not diastolic, as it clearly is. It would be better, I think, to speak of all those murmurs which, occur at the commencement of diastole as Postsystolic, and subdivide them into Long and Short, the long answering to what is usually called the ordinary diastolic, the short to what is more commonly called the postsystolic. The mid-diastolic murmur, i. e. the murmur which is heard only in the middle portion of the diastolic period and has a distinct interval before and after separating it from the heart- FiG. 32. Diagram of mid-diastolic murmur. sound {fig. 32), is the rarest of all the murmurs. It is I believe met with only under the same con- ditions, as give rise to the prgesystolic murmur. 134 HOW TO EXAMINE THE CHEST. The murmurs may be tabulated tbus Murmurs < Systolic {^^'°^^- pearly 1 = short |p„^^^y^^„,,^_ Diastolic <{ middle:: = Mid-diastolic. > =long "1^ Prsesystolic or l^late J = short J Auricular systolic. The Cause of Endocardial Murmurs. Murmurs in the heart (or vessels) are due to eddies set up in the blood. These will be pro- duced_, whenever a current of fluid has to pass through a narrow aperture into a larger space^ the eddies thus set up generating a sound. It might be supposed_, with such an explanation, that murmurs would be constantly produced, even in a healthy heart, inasmuch as the blood has to pass through the narrow valvular orifices into the larger cavities of the ventricles or vessels, but, so long as the normal relation exists between the size of the orifices and that of the cavities or vessels, we know that murmurs are not heard ; so soon, however, as this normal relation is dis- turbed, murmurs are likely to arise. Theoretically they may depend upon changes of two kinds : first, dilatation of the cavities into which the blood is passing, the orifices being unaltered; or, secondly, alteration in the condition THE HEART. AUSCULTATION. 135 of these orifices^ the cavities remaining normal. These conditions are usually associated. We meet with both kinds of murmurs clinically, but inas- much as it is most common to find, when endo- cardial murmurs have been heard^ that the orifices a re altered, we will for the present con- fine our attention to those murmurs which are due to valvular lesions, and consider the means we have of determining at which orifice of the heart the disease exists. ENDOOAEDIAL MUEMURS DUE TO VALVULAR DISEASE, The Place of Murmurs. Murmurs ^re transmitted in the direction in which the blood is passing at the time of their production. Let us take an instance. If a murmur is produced at the aortic orifice at the time when the blood is being driven through it by the contraction of the ventricle, the murmur will be carried along the aorta upwards, and will be heard some distance above the valves. In the same way, if the murmur is produced when the heart is dilating, the valves being incompetent, and allowing a stream of blood to pass back through them into the ventricle, the murmurs 136 HOW TO EXAMINE THE CHEST. ¥ia. 33. Diagram of the heart, showing the anatomical position of the valves, the axes of the aorta and pulmonary artery, and the places where to put the stethoscope when examining the dif- ferent orifices of the heart. The dark lines A, P, M, te, indicate the actual position of the aortic, pulmonary, mitral, and tricuspid valves respectively ; The thin lines the axes of the aortic and pulmonary orifices; The circles, the places upon which to put the stethoscope, when examining the corresponding orifices. THE HEART. AUSCULTATION. 137 will be heard below the valves, that is to say, on the ventricular side of them. Murmurs have, therefore, been spoken of as Onward and Back- ward murmurs, that is, murmurs which are pro- pagated onwards, in the direction of the normal current, or backwards, contrary to the normal current. This fact is of the greatest importance, because it gives us the means of fixing with certainty the place at which a given murmur is produced. We require to know first the normal position of the valves of the heart. The Position of the Valves, Anatomically they lie very close together, as is shown in the diagram [fig. 33), so that if the mouth of a stethoscope were placed at the junc- tion of the third left costal cartilage with the sternum at its upper border, it would cover the middle points of three out of the four valves, the one not covered being the tricuspid. At this point, then, it would be impossible to separate the murmurs with certainty, for the pul- monary valve lies immediately above the aortic, and the mitral behind and a little to the left of them both. If the left hand be loosely clenched, and placed upon the chest, so that the knuckles of the middle 138 HOW TO EXAMINE THE CHEST. Fig. 34. Diagram of the left hand placed upon the chest to repi'esent the size of the heart and the position of its various parts. Dotted lines indicate the size of the heart (j%. 20) and of the absolute cardiac dulness. For description see text. THE HEART. AUSCULTATION. 139 phalaDges of the fingers rest upon the sternum^ we shall obtain a rough estimate of the size of the heart and of the relative position of its dif- ferent parts in that individual, as the diagram shows {fig- 34). The row of knuckles indicates the line of the tricuspid valve, and what is seen of the fingers towards the right represents the right auricle. A line, drawn from the knuckle of the first finger to the carpal end of the ulna, divides the back of the hand into two unequal parts ; the larger and lower represents the anterior surface of the right ventricle, the upper and smaller that of the left ventricle, while the line itself corresponds with the septum. The knuckle of the thumb marks the position of the left auricle. If the thumb be now straightened, it will indicate the direction which the aorta takes in the first part of its course; and if a pencil be grasped by the hand, as in the diagram, it will cross the thumb, and lie in a similar position, directed towards the opposite side, and will represent the direction which the pulmonary artery takes in the first part of its course. The Axes of the Heart. We may draw two lines, one in the direction of the thumb and the other of the pencil, and these we may speak of as the Axes, or lines of direction. 140 HOW TO EXAMINE THE CHEST. of the aorta and of tlie pulmonary artery re- spectively. Now, it is along tliese axes, onwards or back- wards, as the case may be, that murmurs pro- duced at these orifices will be propagated. By observing, then, the direction in which a murmur travels, we are enabled to say with accu- racy at which orifice the murmur is produced. We may define the Axis of the Aorta to be a line drawn from the apex of the heart to the right sterno-clayicular articulation, and the Axis of the Pulmonary Artery to be a line drawn from the middle of the xiphoid cartilage to the left ste rno- clavicular articulation [fig. 33). These lines it will be observed, cross the end of the second costal cartilage close to the sternum, and if we place the stethoscope upon them in the second intercostal space, right or left of the sternum, we have placed it upon points respec- tively nearest to one of the valves, and at the same time farthest from the other. We say, there- fore, that in order to examine the condition of the aortic valves, we place the stethoscope, in the posi- tion indicated (a) in the diagram, in the second right intercostal space, and of the pulmonary valves (p) in the second left intercostal space. We will now consider more particularly the aortic murmurs. THE HEART. AUSCULTATION. 141 Systolic aortic murmurs, tliat is to say, mur- murs whicli are produced at the aortic orifice, when the blood is being driven out of the left ventricle, will travel in the axis of the aorta upwards towards the right sterno-clavicular joint, and will be heard above the valves here or even further in the course of the large arteries. Dia- stolic aortic murmurs, on the other hand, which are produced by the blood passing back again into the ventricle, will be propagated in exactly the opposite directiou, that is to say, towards the apex of the heart. They are often trans- mitted with great intensity along the whole length of the sternum, even as far as the xiphoid cartilage. Where these murmurs are very faint, they are often not intense enough to reach the apex, and may then be heard at a point in the axis of the aorta short of the apex, the commonest place being on the level of the fourth left costal cartilage. Sometimes it is only in this place that these murmurs are audible. /. What has been said of the aorta is true, mutatis mutandis , also of the pulmonary artery. In the case of the mitral valve the difl&culties are greater. The line of direction or Axis of the Mitral orifice may be roughly taken to be a line drawn from the apex of the heart to the left 142 HOW TO EXAMINE THE CHEST. interscapular space posterioi^ly_, on a level witli the sixth, dorsal vertebra. If a long skewer were taken, and thrust into the chest at the apex of the heart_, and brought out at the point men- tioned behind, it would represent the axis of the mitral orifice, and give therefore the line of direction, which the blood follows in passing from the left auricle into the left ventricle. If, then, a murmur is produced at the orifice when the ventricle is contracting, it would be caused by a stream of blood passing backwards from the left ventricle into the left auricle in a direction contrary to the normal current of blood. We should expect, therefore^ the ven- tricle being in front and the auricle behind, to hear such murmurs posteriorly in the left inter- scapular space. If, however, the murmur is produced when the ventricle is dilating, it would be caused by a stream of blood passing in the opposite direc- tion, that is, in the same direction as the normal blood current, and we should expect not to hear it behind. Now this is just what occurs. Both kinds of murmurs are audible at the apex, but the systolic only behind. The mitral valve, however, lies so deep down, that the points along the axis, which we can reach, nearest to the valve itself are the apex of THE HEAET. AUSCULTATION. 143 the heart in fronts where the left ventricle be- comes superficial, and the left interscapular space behind ; and these are the spots we choose to listen at, when we wish to examine the condition of the mitral valve. The fourth valve, the Tricuspid, lies superficial. Murmurs produced at this orifice we hear best immediately over the valve, that is, along the lower part of the sternum. IThe places, then, at which we listen for . murmurs at the different orifices are 1. The aortic, in the second right inte^^costal space close to the sternum ; 2. The pulmonary, in the second left inter- costal space close to the sternum ; 3. The mitral, at the apex of the heart; 4. The tricuspid, at the bottom of the sternum. But it is not sufficient to note the presence only of a murmur at these places. We must also carefully trace the direction in which it is propagated, and determine especially the spot at which it is heard loudest, i. e. its place of maximum intensity. The Diagnosis of Valvular Diseases. Now, at each of these places we have to consider, as has already been stated, first, the 144 HOW TO EXAMINE THE CHEST. two sounds of tlie heart, and, secondly, any inurmurs wMcli are heard between them, and we may therefore construct for each of these spaces a diagram similar to that already described. The heart being thus a complex organ, all the various parts of which stand in such close rela- tion in action to each other^ we should expect to find, that it would be almost impossible to meet with any change in one part, which was not associated with correlative changes in other parts. Hence the rule to examine each and every part of the heart, and to note carefully every one of the changes there detected, before venturing to make a diagnosis of any disease. We have therefore four places to listen at, and at each of these places we have two sounds and two intervals to consider. The sounds may be both present, or one or both absent. They may be accentuated or reduplicated. If murmurs be present, we have then to deter- mine to which of the intervals they belong, i. e. whether they be systolic or diastolic ; and if dias- tolic in which part of the diastole they occur. Examination of the heart, then, is a compli- cated undertaking, and must be conducted sys- tematically, if a correct diagnosis is to be made. It is well to represent, so far as possible,, all THE HEAET. AUSCULTATION. 145 the information we can obtain in a diagram matio form. Fia. 35. Complete diagram of a case of mitral stenosis. The black area shows the size and shape of the absolute cardiac dulness. A. Valve shock. B. Epigastric pulsation. C. Venous pulsation. Veins dilated. Dotted circle indicates the area within which the murmur is heard and a prajsystolic thrill felt. X. Shows the point of maximum intensity. For the purpose of illustration a simple and well-marked case of mitral stenosis lias been 10 146 HOW TO EXAMINE THE CHEST. selected^ tliat disease wliicli gives rise to tlie prae- systolic murmur already frequently referred to. Fia. 36. A is the representation of what is heard in the second rightj p in the second left intercostal space, and M at the apex. The pulmonary sounds are louder than the aortic. This is indicated by darker shading, and the second sound is redupli- cated. At the apex the first sound is prolonged and loud, the second sound is absent, and there is a long prsesystolic murmur. SucL. diagrams are mucli easier to read tlian long verbal descriptionSj and the construction of them tends to clearness of conception. THE HEAET. AUSCULTATION. 147 ENDOCARDIAL MURMURS NOT DUE TO VALVULAR DISEASE. We are now in a position to consider some of the other kinds of murmurs audible in the car- diac region. The remaining organic endocardial murmurs are due for the most part to roughenings or little outgrowths (vegetations) from some part of the Inner walls of the heart, and occasionally to local pouchings [aneurysms) of the heart walls. These conditions are all of them rare, and are sometimes impossible to diagnose. The points upon which chief stress would be laid, are the evidences of some organic heart disease, but without the physical signs which indicate any of the ordinary forms of valvular lesion. 148 HOW TO EXAMINE THE CHEST, INOEGANIO MURMURS. The Inorganic Murmurs, i. e. those not asso- ciated with gross pathological change in the hearty form a large and important class. They are rarely lond, harsh^ murmurs^ but for the most part soft and blowings and are nearly always systolic. They may be heard in almost any part of the cardiac area^ but they are not propagated^ as a rule^ along the various axes, as organic murmurs are, and they vary much in different individuals, and even in the same individual at different times. Their varying character, and their usual disap- pearance in the course of time, are points of dia- gnostic importance, but they are frequently very difficult to distinguish from some of the murmurs due to organic lesions. The commonest form of inorganic murmur is heard in the second left intercostal space near the sternum and a little below this place. It is called a Pulmonary Systolic murmur. A similar systolic murmur is often heard lower down in the third space just within the left nipple line ; this is possibly produced in the left auricle : or again, between the left nipple and THE HEART. AUSCULTATION. 149 the apex of tlie hearty and this is probably pro- duced in the left ventricle : and lastly over the right ventricle in the region of the Tricuspid valve. All these murmurs, as has been already stated, are systolic. So far as we know at present, dias- tolic inorganic murmurs do not occur in the car- diac region. The causes of these murmurs are not yet quite established. From the fact that they are very commonly found in conditions of great anaemia, they have been attributed to an altered condition of the blood, and have been called Anaemic, Hsemic, or Blood Murmurs. As the condition of the blood is only one of the factors in their causation, and inasmuch as there is also in most of these cases dilatation of the heart, it seems probable, that many of these murmurs are due to this cause, and they are now often called Dilatation Murmurs. Such murmurs have for a long time been referred by many writers to regurgitation through the auriculo-ventricular orifices, although it is diflBcult to understand, if this be the true explana- tion, why anaemic murmurs on the left side of the heart are not, like the ordinary regurgitant mitral murmurs, audible behind. When dilatation is extreme, the auriculo- ventricular orifices certainly become permanently stretched, and too wide for the valves to close 150 HOW TO EXAMINE THE CHEST. them completely. In this way regurgitation of the blood will occur_, and a loud murmur be pro- ducedj which may be impossible to diagnose from the murmur due to regurgitation from organic disease of the valves. Such regurgitation from stretching may occur on both sides of the hearty but it is commoner on the right side, and is the ordinary cause of systolic tricuspid murmurs. .THE HEAET. AUSCULTATION. 151 EXOCARDIAL MURMURS. Of the exocardial murmurs the most important is that^ wMcli is due to the rubbing together of the two layers of an inflamed pericardium. The healthy pericardium is smooth, and the movements of the heart within produce no sound. So soon^ however, as the pericardium becomes roughened, as it does in pericarditis, a sound is produced. This has received the name of Pericardial Friction. It is rough J rubbing , grating in character, nearly always double {to and fro) . It appears superficialj i, e. close beneath the ear. It is usually not audible over a wide area, i. e. it is localised or limited in extent. It does not bear the same strict relation to the heart-sounds^ and is not propagated in the way that endocardial murmurs are. It frequently alters with the posi- tion of the patient, a phenomenon not so fre- quently observed with other murmurs. In most cases pericardial friction is easy to diagnose from the character of the sound alone^ but in doubtful cases the correct diagnosis will be made by observing the relation of the mur- 152 HOW TO EXAMINE THE CHEST. mur to tlie intervals of tlie hearty tlie effects of position^ and tlie direction of propagation. Tlie chief difficulty will arise, wlien tlie pleura is inflamed over the pericardium_, from the fact that the movements of the heart may then cause a friction sound by rubbing the two layers of the roughened pleura together. Such friction is called Pleuro-pericardial, its seat being not in the pericardium, but in the pleura over the peri- cardium. Pleuro-pericardial friction is often altered by deep respiration, the lung being forced between the two layers of roughened pleura and separa- ting them, so that the friction may disappear for the time, to return again on expiration. This does not always happen, and in some cases re- spiration has no effect upon the sound. The difficulties of diagnosis will then be very great. Murmurs are occasionally heard over the prge- cordium, which have their seat not in the heart, but in the lung. They are probably produced by air being suddenly driven out by the move- ments of the heart from a portion of the lung in immediate relation with it, with force sufficient to produce a distinct blowing sound. Such murmurs are rare. THE HEART. AUSCULTATION. 153 MUEMURS AUDIBLE IN OTHER PAETS OF THE THORAX. Aneurysms or dilatations of the aorta, or occa- sionally the pressure of a mediastinal tumour upon the large vessels, may give rise to mur- murs, audible under the first piece of the sternum, or to one side of it. They are generally systolic, though some- times double, and are not easy to diagnose from murmurs due to disease of the aortic valves. In children a continuous murmur is sometimes heard in this place, when the head is thrown back, produced, it is stated, in the veins, by the pressure of large lymphatic glands in the medias- tinum. Beneath the clavicle, a systolic murmur is frequently heard, the Subclavian Murmur. Its seat is in the subclavian artery, though its causes vary in different cases. It is sometimes due to compression of the artery by the muscles or by the stethoscope, and is then altered, or made to disappear, by changing the position of the arms or the pressure of the stethoscope. In other cases it occurs in connection with phthisis, and has been then referred to pinching of the arteries by 154 HOW TO EXAMINE THE CHEST. adhesions at the apex of the lung. Lastly^ it may be due to aneurysmal dilatation of the artery. A similar murmur, associated with vascular dilatation_, is common in cases of exophthalmic goitre over the thyroid gland, and is sometimes heard over other large vessels. _ Murmurs are frequently heard, also, in the Vessels of the Neck, both in the arteries and the veins. The commonest place for them is at the root of the neck, just above the clavicles. In the Arteries, the murmur is systolic, and occurs in cases of ansemia. Such angemic arterial murmurs are often difficult to diagnose from the murmurs propagated upwards along the vessels in cases of disease of the aortic valves. Venous Murmurs are sometimes heard in healthy people but are commonest in that form of extreme anaemia, which is called chlorosis. When in such a patient the stethoscope is placed above the clavicle over the origin of the sterno-mastoid muscle, a continuous blowing or rushing sound is heard, often mingled with hum- ming, semi-musical sounds, which have been compared with the buzzing of a fly. This is the Bruit du Diable or Nonnen-Gerausch. It is loudest usually on the right side. It is in- creased by pressure, although pressure alone is THE HEART. AUSCULTATION. 155 not sufficient to produce it^ and may destroy it. It increases in intensity with whatever increases tlie rapidity of circulation through the veins. Hence it is loudest in the erect position^ during the dias- tole of the heartj and during inspiration. The seat of the murmur is in the veins^ for compression of the vessel with the finger above stops the murmur^ with a pressure too small to have any effect upon the artery. Various explanations have been given of the murmur. It has been attributed to the peculiar condition of the blood (spanaemia)^ but as it is not heard in all cases of anaemia, ifc is more satis- factory to refer it_, as also those similar murmurs in the hearty to a condition of dilatation of the vein. The ansemia produces from malnutrition a relaxed condition of the muscular tissue, the relaxed vessel dilates, wherever it can. Where, however, it passes through dense fascia, as at the root of the neck, this dilatation is prevented, and we have in this way a dilatation produced above and below, with an apparent constriction in the middle, the exact physical conditions requisite for a murmur. 156 HOW TO EXAMINE THE CHEST. SYNOPSIS. On Auscultation then we have to investigate, 1 . The Sounds of the heart : 2. The Intervals between them : 3. If Murmurs be present in the Cardiac Region ; 1 . Whether they are systolic^ or diastolic, and if diastolic^ to which part of the diastole they belong; 2. Their place of maximum intensity ; 3. The direction in which they are propa- gated ; 4. Any special peculiarities they may present : 4. Murmurs elsewhere ; 1. Under the Manubrium Sterni ; 2. In the vessels of the neck, 1 . Arteries ; 2. Veins; 3. Beneath the clavicle. THE HEAET. AUSCULTATION. 157 SYNOPSIS 0¥ THE EXAMINATION OF THE HEART. Inspection. 1. The Shape of the prsecordial region. 2. The Movements, a, the apex beat. hj impulse elsewhere. Palpation. 1. The position of The Apex. 2. Impulse elsewhere. 3. Thrills, Valve-shock, Friction. Percussion. The Cardiac Dulness, its size, shape, and position. Auscultation. 1. The Sounds of the heart. 2. Murmurs. 3. Friction. 4. Murmurs elsewhere in thorax or neck. SECTION III. THE PULSE. THE EXAMINATION OF THE PULSE. When tlie left ventricle contracts^ the blood, wliicli is driven into the aorta distends it and travels along the arteries in the form of a wave. It is this wave of distension, which is felt, when the finger is placed upon the artery, and which is spoken of as the pulse. The Pulse may be examined in any superficial artery, but the Radial at the wrist is usually selected, because it is easily accessible, lying, as it does, close under the skin, and upon a solid backing of bone. In health, every contraction of the heart produces a beat at the wrist, and we therefore commence the examination of the pulse by count- ing the Number of Beats in the minute. This is called the Pulse Rate. The Pulse Rate varies much in different individ- uals according to age, sex, temperament, &c., and also in the same individual under different 11 162 HOW TO EXAMINE THE CHEST. coiiditions_, e.g. rest;, exercise^ emotion^ &c.j but tlie average in a healtliy young man at rest is aboQt 70^ and in a woman about 80. In young cbildren it is more rapid^ and readies 90 or 100_, while in infants it is about 120 (c/. Table). PULSE EATE AT DIFFERENT AGES. (From Carpenter's 'Physiology.') Beats per minute, 140—150 130—140 115—130 In the foetus in utero Newly-l3orn infant During 1st year „ 2nd year „ 3rd year From 7th to 14th year „ 14th to 21st year „ 21st to 60th year Old age 100—115 90—100 80—90 .75—80 70—75 75—80 In disease, especially in children, the number may rise to 140 or 150, and even higher. The beats are then often so rapid, that they appear to run into one another, and cannot be counted, and tbe pulse is called Running. The number rarely falls below 50, although cases are recorded, in which it did not exceed 40 or occa- sionally 30, and even less. The character of the wave will of course be much affected, not only by the force with which the heart contracts, and the amount of blood driven into the vessels, but also by the condition of the vessels themselves. . THE PULSE. 163 - These different factors must be clearly dis- tinguished in making an examination of the pulse, and; before considering the characters of the pulse wave, we require to know all that we can ascertain about the condition of the artery itself,, and the amount of blood which it contains. The Course of the Artery. A healthy radial artery runs a straight course down the forearm, but in disease and old age it is often much twisted, or, as it is called, Tortuous. The only superficial artery which is normally tortuous is the temporal, and this only slightly. The Coats of the Artery. To estimate the thickness of the walls of an artery the tip of one finger, usually the index, is placed upon it, and pressed down so as to flatten it against the bone, and then moved slowly over it from side to side. In a healthy young person, the coats are thin and smooth, and flatten out underpressure, so as to lie like a piece of folded tape, and to be hardly detectable under the finger. With increasing age, they normally become somewhat thicker, and are, therefore, more easily felt in the middle-aged than in young persons. In disease and old age, the Thickening is often 164 HOW TO EXAMINE THE CHEST. SO considerable^ tliat the artery seems like a piece of thick straw^ or even in extreme cases like a small pipe stem, and may be made to roll from side to side distinctly under the finger. This thickening is usually due to a disease of the inner coats called atheroma^ which sometimes affects the whole coat Uniformly _, at other times only parts of it, occurring then in Patches, which can often be distinctly felt. In other cases, as in granular kidney, the thickening is due to a Hypertrophy of the mus- cular coat of the artery, and is therefore uniform and general. Apart from pathological change, the coats will appear to be thicker or thinner, according as the vessel is contracted or dilated. What the normal relation is between the thickness of the coats of an artery and its calibre, can only be learnt by experience, but in all cases alike, so long as the walls are of normal thickness, the vessel can be flattened out by pressure so as to be not more distinctly felt than a piece of folded tape would be. The Tension of the Artery, The ease with which an artery with healthy -coats can be compressed gives us a measure of the Tension in the vessel. Easily compressible, incompressible, soft, and THE PULSE. 165 hardj are terms often used in descriptions of the pulse, but they lead to confusion, for they may apply to different conditions. Thus, for example,. a cannon ball and a football are both hard and not easily compressible, but for different reasons.. In the one case the walls are rigid, and in the other the walls are tense. In describing the- pulse it is most important to bear in mind this distinction. The blood in an artery is under pressure and tends, therefore, to dilate the vessel. This tendency is resisted by the muscular and elastic- tissues in its coats, and the balance of these two- opposing forces constitutes the tone of the vesseL Alterations in tension are in most cases due to alterations in the muscular resistance, and thus the tension is taken as the index of the muscular condition of the vessel — increased tension being regarded as indicating increased muscular resist- ance, and diminished tension diminished mus- cular resistance. Increased tension is, therefore,, usually associated with a contracted vessel, and diminished tension with a dilated vessel. When^ as sometimes happens, the converse is met with, viz. high tension with a dilated vessel, or low tension with a contracted vessel, the cause is to- be sought elsewhere than in the muscular coat of the vessel, and will be found either in the heart or in the capillaries. 166 HOW TO EXAMINE THE CHEST. Alterations in tension will affect not only tlie calibre of the vessel^ but also tlie size and character of the pulse wave. Thus high tension usually goes with a low wave and low tension with a high wave. The Pulse Wave. To examine the pulse wave^ one finger^ say the indeX; is placed upon the artery with just suffi- cient pressure to feel the vessel when no wave is passing. When it passes, the finger will be jerked up, kept up for a short time, and then allowed to fall, and we shall be able to form an estimate of the force, size, speed, and form of the wave. By means of the Sphygmograph all these various facts may be recorded in a graphic form, the pulse or sphygmographic tracing {Jig. 37) ; but it is well to premise that no instrument can take the place of the finger. More can be learnt by the careful and intelligent examination of the pulse by the finger than by any sphygmographic tracing. In the diagram a white line indicates what is probably the real curve, and it differs in many respects from the sphygmographic tracing, which is represented by a dotted line. These differences are due chiefly to defects in the instrument, the lever being jerked up too THE PULSE. 167 Fig. 37. The white line indicates the true curve of the pulse, the dotted line the sphygmographic tracing. I and II show the times at which the 1st and 2nd sounds of the heart occur. The systole lasts therefore from i to ii, and the diastole from ii to i. The wave, which is felt distinctly by the finger, corresponds in length with the line ^, q. The single wave m is split up by the sphygmograph into the two waves a and e, and the second single wave ce into the two waves and e. The diagram is taken, with modifications, from Dr. Galabin's Thesis for M.D. Cantab., 1873. 168 HOW TO EXAMINE THE CHEST. higli and then falling too low^ and in this way giving a double wave where there ought only to be one. The sensation conveyed to the fingers repre- sents more nearly the real curve. This^ we see rises sharply^ then subsides slowly for some distance^ until it is interrupted by another slight rise^ after which it finally falls more rapidly down to the level from which it started. The only part which we feel distinctly is the top of the wave between m and (E in the diagram^ and it is in this part that the most characteristic changes occur. The whole pulse wave extends of course from I to i^ that is^ from one beat to the next. A long wave would then be the same thing as a slow pulse. When we speak of a long wave in this sense_, it will be better to call it a rapid or slow pulse^ because we really refer to its frequency^ and this will be discussed later^ and because long and short are more commonly used in reference to the top or head of the wave (corresponding with the line p, q) than to its total length. The parts of the wave to examine most attentively are the upstroke or rise^ and the top or head. The Upstroke may be abrupt (fig. 41) or gradual (fig. 42), high {fig. 41) or low {fig. 39). THE PULSE. Fm. 38. Normal pulse tracing. 169 Fig. 39. Tracing of a pulse of increased tension from a case of gran- ular kidney (square top). - Fig. 40. Tracing of a dicrotic pulse. Fig. 41. Pulse tracing from a case of Aortic Incompetence. Water- hammer pulse. (Sudden rise and sudden fall.) 170 HOW TO EXAMINE THE CHEST. The Top of the Wave {p to q) represents tlie maximum distension in the vessel. If the tension be well sustained {figs. 38 and 39)^ the subsidence will be gradual ; if ill sustained_, it will be abrupt (/?.41). Where the subsidence is gradual^ the wave will appear long, and seem to pass slowly under the finger, and where it is abrupt, it will appear short, and seem to pass rapidly under the finger. This is what is meant generally by a Long and Short Wave. When the tension is very low, the second wave, or ^^ recoil wave ^^ as it has been termed ((e), is often well marked, and may even be as large and as distinct as the primary wave. The pulse is then felt as a double beat, and is called Dicrotic {twice heating) {fig. 40). In some other rarer cases, instead of two dis- tinct} waves, several smaller ones are felt, and the pulse is called Thrilling. These thrills may in some conditions of the artery be produced by pressure, and on this account it is important to feel the pulse only with one finger, lest by a little unequal pressure vibra- tions maybe set up, and the pulse made artificially thrilling. One of the most peculiar forms, and at the same time one of the most important clinically. THE PULSE. 171 is known as tlie Waterhammer Pulse {fig. 41). This is pathognomic of incompetence of the aortic valves. It is characterised by a very high upstroke and by very short duration. It has a short sudden wave^ and conveys to the finger the sensation of a sharp forcible jerk^ the artery seeming to empty itself and collapse, almost immediately after the beat has been felt. The high upstroke is caused by the great force with which the blood is driven into the arteries^ for the leffc ventricle is hypertrophied. The short duration or sudden collapse is due to the fact that the aortic valves do not close^ so that the blood flows back from the aorta into the ventricles, and the tension in the arteries is not maintained. The position of the arm makes a great differ- ence in the distinctness with which the characters of this pulse are felt at the wrist. If the arm hang down, the force of gravity tends to keep the artery fairly full, but, if the hand be raised above the head, it helps to empty it, and the peculiarity becomes more marked. , This pulse is also known by other names : 1. Corrigan^s Fidse, from Dr. Corrigan who described it ; 2. The Locomotor Pulse, from the peculiar way, in which the impulse seems to travel down the 172 HOW TO EXAMINE THE CHEST. arnij wheD it is so exposed that the whole length of the artery is visible ; And 3. The Pulse of Unfilled Arteries, because they so quickly empty themselves. If the stetho- scope be placed over a large artery^ like the brachial or femoral^ in such a case^ a heavy thud is often heard, synchronous with the pulse. Possibly this may have given origin to the name waterhammer. Rhythm of the Pulse. In the healthy pulse the waves are equal in size, and follow each other at equal intervals of time. When this is not so, the pulse is called Irregular, and it may be irregular (1) in Force, i.e. in the size of its waves, (2) in Frequency, i.e. in time, or (3) as is most common both in force and frequency (Jig- 42). Fig. 42. Pulse tracing from a case of Mitral Incompetence. Pulse irregular in force and frequency. Irregularity of the pulse is usually due to irregular contraction of the heart, as the result either of muscular weakness or of impaired nerve control. THE PULSE. 173 Any nervous excitement may make botli lieart and pulse irregular for the time. And in some acute diseases of tlie brain and upper part of tlie spinal cord tlie rhythm of the pulse is often of diagnostic importance. In these cases the beats both of heart and pulse follow one another appar- ently with regularity, but the frequency varies much from time to time even to the extent of 10 or 15 beats in consecutive minutes. As a matter of routine then the pulse should be counted two or three times at short inter- vals. Muscular weakness of the heart often shows itself in the pulse by irregularity of force, i.e. in the size of the waves ; but this is usually associ- ated also with irregularity in time. In such cases any slight extra work thrown upon the heart, even, for example, the effort of standing up, may increase the difference between the number of beats at the heart and at the wrist. When this weakness is great, some of the beats may fail to reach the wrist and the pulse is then called ** Intermittent " and in extreme cases, the pulse may be entirely absent at the wrist, the heart not having power to drive a single wave so far. Although in most cases irregularity of the pulse is due to irregularity of heart action. 174 HOW TO EXAMINE THE CHEST. tliere are cases in which the pulse is markedly irregular, while the heart continues to beat regu- larly. This irregularity is generally synchronous with the respiratory movement s_, and in this way regular oscillations in the pulse tracings are pro- duced. In health this is not detected except by deli- cate apparatus in the large vessels near the heart, but, where the circulation is feeble, it may be observed at the wrist in an irregularity, not only of force but also of time, synchronous with the inspiratory movements of the chest. In the most extreme form, this gives rise to the Pulsus Paradoxus {fi,cj. 43), or Pulsus cum Fig. 43. Pulsus Paradoxus. Pulsus cum luspiratione intermittens. Taken from a case of Purulent Pericarditis. The pulse is very dicrotic, the second wave being almost as large as the first. The horizontal line indicates the remissions due to inspiration, and lasting for two or three heart beats. Inspiratione intermittens. The pulse beat then disappears entirely during inspiration, and often hardly a trace of vibration can be detected even THE PULSE. 175 upon an enlarged sphyg-mograpliic tracing. In the most typical form tlie heart remains perfectly regular, both in force, as judged by the loud- ness of the heart-sounds, and in time. The typical pulsus paradoxus is very rare. Its causes vary. In some few cases, the heart seems to be in such an extreme condition of muscular feebleness, that it is unable to overcome even the very slight increase of work, which inspira- tion throws upon it. In most cases, however, the pulsus paradoxus is found to be caused by adhesions or bands, which surround the larg'e vessels either in the medias- tinum or within the pericardium, in such a way that, when the chest expands on inspiration, they are tightened, the vessels compressed or pinched, and the pulse wave stopped. Want of Symmetry. The pulses in the two wrists in health are exactly symmetrical, both in time and force, the only allowance, that may have possibly to be made, is for an anatomical difference in the size of the vessel, but this does not often present any practical difficulty. In disease of various kinds, the artery of one side may be twisted, pressed upon, stretched, or 176 HOW TO EXAMINE THE CHEST. displaced in sucli a way as to obstruct tlie circu- lation through it^ and thus a Want of Symmetry will be produced. Usually this shows itself in an alteration in the Character of the Wave on the affected side, which may be recognised by the finger and de-^ monstrated by a sphygmographic tracing, but besides this the wave is often Retarded, so that it reaches the wrist on the affected side at a per- ceptibly later time. These, like all other defects of symmetry, are of very great practical importance in the dia- gnosis of disease. THE PULSE. 177 SYNOPSIS OF THE EXAMINATION OF THE PULSE. I. The Artery. , 1. Its course, straight^ tortuous. 2. Its coats J - !^-^^ * fa. Uniformly. 1 tnickenedi , t i. i, ^ \^b. In patches. II. The Calibre of the Vessel, i. e. the size of the column of blood it contains, in relation to the size of the vessel. III. The Tension, whether increased or dimin- ished. IV. The Pulse wave. 1. Its frequency, ^. e. the number of beats in the minute. rirregular ( ^^ ^^^^^^ 2 . Its rhythm -l ^orm frequency . (^Intermittent. 3. The wave. 1. Its rise, high or low. 2. Itshead/1^^? ^^' ^^^^*^ Lrapid or slow. 3. Its character (dicrotic, thrilling, waterham- mer, &c.). 4. Its symmetry, in time and force. 12 SECTION IV. THE MEDIASTINUM, THE EXAMINATION OF THE MEDIASTINUM. The Mediastimim is the irregular space^ extend- ing from tlie first rib to tlie diaphragm, and lying between tbe sternum in front, the spine behind, and the lungs on either side. Part of this space is occupied by the heart, the rest contains the large arteries and veins con- nected with the heart, the trachea and the roots of the lungs, the oesophagus, and thoracic duct, with numerous nerves, small vessels, and glands. Displacement of the Mediastinum. All these structures are intimately connected together, and form a mass which is firmly fixed below by its attachment to the diaphragm, and posteriorly and above by its attachment to the spinal column, so that vertical displacement is hardly possible. With the sternum, however, the connections are loose, so that Lateral Displace- ment may occur by a kind of rotation, as a door 182 HOW TO EXAMINE THE CHEST. swings upon its hinge^ tlie hinge in this case being the aorta^ where it is fixed to the spine. The mediastinum remains in the middle line in health. Not because it is "fixed" there^ but because of tho equal balancing of the forces, which tend to displace it on either side. The chief of these is the elasticity of the lungs. If air be admitted freely into one pleural cavity, the lung on that side collapses, and the elasticity of the other lung, being unopposed, comes into play. This lung also contracts, and in doing so pulls over the mediastinum. If one pleural cavity be greatly distended by air or fluid, the mediastinum may be pushed over by the pressure and be still further displaced {figs. 15 and 16). On the other hand, if one pleural cavity be contracted, as with the fibroid thickening, which often occurs after chronic pleurisy, the medias- tinum will be pulled over, just as the ribs on that side are pulled in (fig. 14) . The Physical Signs of Displacement of the Medi- astinum en masse are : 1. Those of displacement of the heart (q.v.) ; 2. Those of displacement of the anterior boun- daries of the lungs {q. v.). These have been already discussed, and need not be further referred to here. THE MEDIASTINUM. 183 The parts of the Mediastinum. The Heart, although strictly included in the mediastinum_, has been already described in a separate chapter. The Rest of the Mediastinum is not so easily accessible. The places where it is examined are : 1. In front, beneath the upper part of the sternum ; 2. Behind, on either side of the dorsal vertebrae in the interscapular spaces. Diseases of the Mediastinum. In front, the mediastinal region extends from the episternal notch down the sternum to the level of the fourth costal cartilage. In health this part is only slightly prominent, moves slightly with respiration, is resonant to percussion, and beneath it, tracheal or bronchial breathing and resonance are not infrequently audible. Apart from affections of the lungs and pleura, which may modify the physical signs here, the diseases of this part are chiefly two, each attended by the formation 0^ a Tumour, viz. Aneurysm and New Growth. In either case the lungs are pushed aside by a 184 HOW TO EXAMINE THE CHEST. Fi&. 44. Diagram of a Mediastinal Tumour. The shaded area heneath the manubrium and upper ribs indicates the area of impaired percussion resonance. The edges of the lungs are retracted, or pushed aside by the mass beneath. THE MEDIASTINUM. 185 mass, and their place beneatli the sternum is taken by the non-resonant tumour (jig. 44). The percussion, therefore, is impaired or dull, and the physical signs of consolidation are present as in the lungs, viz. increased vocal vibration, in- creased vocal resonance, and increased breathing- sounds. In addition there may be present in some cases Bulging, Pulsation, Thrills, or Friction, and occasionally also Vascular Murmurs. Posteriorly, in the interscapular spaces, the same two diseases are met with, and may give rise to the same physical signs. In this region, however, impairment of percussion is much more difficult to make out, because of the thick muscular covering to the ribs, the percussion note here being normally deficient in tone, but of course symmetrical. Want of symmetry is what we look for, and this is often very distinct, so far as vocal vibrations, vocal resonance, and breathing-sounds are concerned, although the other physical signs which are occasionally present in front, viz. bulging, pulsation, thrills, friction and murmurs, are but rarely obtained behind. Where the tumour is large, not only the lungs but also the heart and diaphragm may be pushed out of place, and we shall then have, in addition_, the ordinary physical signs of displacement of these organs. 186 HOW TO EXAMINE THE CHEST. The Diagnosis of Diseases of the Mediastinum. The diagnosis of mediastinal affections^ by means of tlie physical signs alone^ is often very difficulty especially when the disease is not exten- sive, and is deeply seated, and it is then rather upon the secondary symptoms, to which the disease gives rise, than upon the physical signs^ that the diagnosis depends. These Secondary Symptoms are for the most part due to mechanical interference, by pressure, with the function of the various organs in the thorax. What these symptoms may be, depends upon the part pressed upon, and varies according to the seat of the disease, and, to determine this, an intimate knowledge of the relationship of the different parts in the mediastinum is essential. These are given in detail in any good work on anatomy. It will be sufficient for our present purpose to group the various symptoms together with reference to their cause, and to indicate in this way the use, which may be made of them for diagnosis. I. Pressure upon the Vessels will lead to inter- ference with the circulation through them. When the Veins are compressed, the part of THE MEDIASTINUM. 187 the vessel on the side away from the heart will be distended, and an attempt will be made to establish the circulation through collateral chan- nels. This will give rise then, first, to Distension of the Large Veins above the seat of pressure, as is especially common in the lower part of the neck, or on the shoulders ; secondly, to abnormal Dilatation of the Subcutaneous Veins usually over the front of the chest ;"^ and lastly, to oedema of those parts supplied by the obstructed veins. In both cases the distension is usually unsyni- metrical. It is important to determine in all these cases the direction in whicli the blood is travelling in the dilated vessels, in the way described at p. 20. The circulation through, the Arteries may be interfered with, either as the result of direct pressure upon them,- or in consequence of the vessels being so twisted or stretched at their origin, that their mouths are obstructed. In either case the Pulse, carotid or radial, will become unsymmetrical. There will be a differ- ence either in force or in time, that is to say, one pulse will be either Smaller than the other, or will reach the wrist later than the other, i. e. be ^eiarded. * The physiological dilatation of the mammary veins re- ferred to at p. 20 must not be confounded with this patho- loofical dilatation. 188 HOW TO EXAMINE THE CBEST. Pressure upon either arteries or veins may pro- duce a Murmur J audible of course near tlie seat of pressure. In the arteries it is usually SystoUcj and in the veins often Continuous. II. Pressure upon the Respiratory Tract will lead to interference with respiration^ and give rise to Dyspnoea, Stridor, or Gough, all of which are frequently Paroxysmal. Dyspnoea may be due to pressure upon the trachea or bronchus, or directly upon the lung itself, and similarly cough may be the result of irritation of any of these parts. Stridor, whether in breathing, speaking, or coughing, on the other hand, is always evidence of pressure upon the trachea or bronchi, if there be not a local affection of the larynx to account for it, as can easily be determined by laryngo- scopic examination. Where the pressure is upon the trachea, the air will have difficulty in entering both lungs equally, but where it is upon the bronchus or lung of one side, the obstruction is unilateral, and, therefore, we shall find a want of symmetry in the physical signs ; the vocal vibrations and the vocal resonance may be weaker than on the unaffected side, and the respiratory murmur may be feebler or often altered in character, expira- tion especially becoming prolonged and occasion- ally wheezing. THE MEDIASTINUM. 189 The place to examine for these altered physical signs is as far away as possible from the root of the lungs^ where, as a rule, the obstruction exists; and the most convenient part to select is low down at the base of the lungs posteriorly, i. e. in the infrascapular region. In such cases as these a slight want of sym- metry may be of great importance. III. The symptoms of Pressure upon the Nerves vary with the nerve affected, and with the amount of pressure, slight pressure producing the results of irritation, and considerable pres- sure those of paralysis. The nerves are the Pneumogastric, the Phrenic, the Sympathetic, and the Intercostal. 1. Of these, the most important is the Pneumo- gastric, distributed as it is to the larynx, lungs, and heart. The Recurrent Laryngeal Branch on the left side, where it winds round the arch of the aorta, is especially exposed, and is therefore often affected. Irritation of this branch, as also of the pulmo- nary branches of the pneumogastric, commonly produces attacks of Spasmodic Dyspnoea, which are sometimes fatal. Paralysis, on the other hand, often leads to affection of the voice, in consequence of paralysis of the muscles which move the vocal cords. 190 HOW TO EXAMINE THE CHEST. The effect upon tlie heart is usually to produce Irregularity J Palpitation, and Paroxysmal PaiUy and occasionally attacks of Syncope which may prove fatal. 2. Pressure upon the Intercostal Nerves gives rise to Pains, referred usually to their peripheral distribution on the side or front of the thorax_, or occasionally following the course of the intercosto- humeral nerve^ down the inner side of the arm as far as the elbow. 3. The Phrenic Nerves usually escape, or at all events the diaphragm rarely gives evidence of any affection, when only one phrenic is in- volved. 4. The Sympathetic Nerves enter largely with the spinal nerves into the various plexuses in the thorax, and cannot be separated in their action from the spinal nerves already referred to, unless certain alterations in the rate of beating of the heart be attributed to their influence. lY. Pressure upon the Thoracic Duct produces no symptoms, by which it can be diagnosed, although theoretically it might be the cause of anaemia and malnutrition. V. Lastly, Pressure upon the (Esophagus causes ByspJiagia, i.e. difficulty in swallowing either solids or liquids, and occasionally, where the obstruction is considerable, it may lead to Regur- gitant Vomiting. THE MEDIASTINUM. 191 It is the combination and association of these various symptoms^ wliicli make it possible to determine in a given case tlie locality of a tumour in tlie thorax. All that the physical signs enable us to estab- lish in many cases is the presence of a tumour in some part of the mediastinum. Its nature^ whether aneurysm or new growth^ has often to be decided rather by the general or constitutional condition^ than by the physical signs. In young or old people, the probabilities are in favour of new growth ; especially if the cachexia, usual with malignant disease, be present. On the other hand, in middle-aged persons , especially in men,, the probabilities are in favour of aneurysm. This diagnosis would be confirmed by evidence of vascular change in other parts, as for example by thickened arteries, or by the history of causes likely to produce vascular degeneration, such as laborious work, drink, and syphilis. In the majority of cases, however, the diagno- sis does not present any great difficulties. 192 HOW TO EXAMINE THE CHEST. SYNOPSIS. In making the diagnosis of a mediastinal tumour, we liave to consider 1. The evidence of a mass in the mediastinum, as given (a) By the physical signs ; (6) By the pressure symptoms ; 2. The facts pointing to the nature of the mass ; {a) Special physical signs ; (6) The age, history, and constitutional condition of the patient. INDEX. A. PAGE Abdominal respiration . 21 Absolute cardiac dulness . 112 Accentuation of the heart- sounds . . . 125 >3Egophony . . .70 Air, amount of, on respira- tion . . . .21 Alar chest, the . , .17 Amount of air on respira- tion . . . .21 Amphoric breathing . . 76 — whisper . . .69 Anaemic murmurs . . 149 Aneurysm, thoracic . . 183 Aortic disease, alteration - of cardiac dulness in . 118 — murmurs . . .141 Apex of the heart, the . 101 — displacements of the . 102 Arch, the costal . . 1 Area, the cardiac . .110 — the splenic . . .43 — of stomach resonance . 43 Arterial murmurs in neck . 154 — pulsation . . . 104 Arteries, calibre of . . 164 PAGE Arteries, changes in coats of — pulse of unfilled . — tortuous Asymmetry of thorax disease of the lungs Auricular systolic murmurs 131 Auscultation . . 5, 60 — of the breathing sounds 64 . 163 . 172 . 163 in 18,25 —r of the heart . . 119 — of the voice . . 64 Autophony . 69 Axillary region, the . . 2 Axis of aorta . 140 — of heart . 139 — of mitral orifice . . 141 — of pulmonary orifice . 140 B. Backward murmurs . . 137 Bad breathing (dyspnoea) . 22 Barrel- shaped chest, the . 13 Bell sound, the . . . 89 Bladder, position of the gall- . .... 41 13 194 INDEX. PAGE Blood-current, in dilated superficial veins, direc- tion of . . .20 Blood murmurs . . 149 Boundaries of the lungs . 37 — displacement and dislo- cation of . . .51 — of the liver . . .41 Breathing, alteration of, in disease . . .79 — Cheyne- Stokes' . . 24 — sounds . . . .70 — varieties of . . .71 Bronchial breathing . . 171 — resonance . . .65 — whisper . . .69 Bronchophony . . .65 — whispering . . .69 Bruit d'airain . . .89 — de pot fele . . .56 — du diable . . . 154 Bulging, expiratory . . 23 — of chest in disease of lungs . . . .18 — of the priBcordium . 100 C. Callipers . . . .11 Cantering action of the heart. . . .124 Capacity of the chest, the vital . . . .22 Cardiac dulness, the altera- tions in . . .114 PAGE Cardiac dulness, the area of absolute . . 112 the area of relative . 112 — impulse . . . 104 Carinate chest . . .15 Carpenter's chest . . 19 Cataire, fremissement . 108 Cavernous breathing . . 74 — whisper . . . 69 Chest, the .... 1 — alar . . . .17 — barrel-shaped . . 13 — change of shape of, in disease . . .18 — measurements of . .10 — paralytic . . .17 — pigeon-breast . . 15 — position of patient on examining the . .3 — pterygoid . . .17 — rickety . . . .14 — varieties of . . .12 — variations in shape of . 9 Cheyne-Stokes' breathing . 24 Clavicular region, the . 2 Compensatory hypertrophy, or emphysema . . 49 Complemental space . . 39 Consolidation of lung, the diagnosis of . .80 Contents of the thorax, the 3 Contraction of chest in dis- ease of the lungs . 18 — of lungs . . .49 Corrigan's pulse . .171 INDEX. 195 PAGE Costal arch, the . . 1 — respiration . . .26 Count the ribs, how to . 27 Cracked-pot sound . . 56 Crepitation . . .83 — fine hair . . .84 — metallic . . .88 — redux . . . .87 — to be felt ... 28 Croup, chest in . 12, 23 Crying, resonance of . 69 Cyrtometer . . .11 D. Death rattle, the . . 84 Deep cardiac dulness, the area of . . . 112 Defective inspiration . 22 Deficient expansion . . 22 — expiration . . .22 — resonance on percussion 57 — respiratory movement . 22 Deformities of chest . . 19 Diagram of heart-sounds . Ill Diaphragmatic respiration 20 Diastole . . . .127 Diastolic impulse . . 104 — murmurs . . .127 Dicrotic pulse . . . 170 Difficulty in breathing . 22 Diffused cardiac impulse . 104 Dilatation murmurs . . 149 — of superficial veins . 20 Direct percussion . . 31 PAGE Direct vocal resonance . 68 Direction of blood- current in superficial veins . 20 Displacement of boundaries of the heart . . 98 — of the lungs . . .49 — of the mediastinum . 181 Dry sounds . . .84 Dulness, percussion . . 34 Dyspnoea, expiratory . . 22 — inspiratory . . .22 E. Early diastolic murmur . 131 EfEusion, boundaries of lungs in pleuritic . 57 Emphysema, compensatory 49 — expiratory bulging in . 23 — physical signs of . .49 — senile . . . .49 — shape of chest in . . 13 Endocardial murmurs . 126 Enlargement of the lungs . 47 Epigastric pulsation . . 104 Episternal region, the . 2 Exaggerated resonance . 55 — respiratory movements . 22 Examination, methods of . 3 Exocardial murmurs . 126, 151 Expansion, deficient . . 22 Expiration, deficient . . 22 Expiratory bulging . . 23 — dyspnoea . . .22 Extended cardiac impulse . 104 196 INDEX. F. PAGE Fine hair crepitation . . 84 Fluctuation . . .20 Fluid in pleura, diagnosis of 82 Forms of chest ... 9 Fremissement cafcaire . 108 Friction felt on palpation . 28 — pericardial . . 108, 151 — pleuritic . . .86 — pleuro-pericardial 87, 152 — redux . . . .87 Furrow, Harrison's . .15 G. Gall-bladder, position of . 41 General heaving of prsecor- dium .... 105 H. Hsemic murmurs 149 Hammers for percussion . 31 Harrison's furrow- 15 Heart, the 97 — apex of . 101 — auscultation of 119 — axes of. 139 — cantering action of 124 — diagnosis of valvular diseases of . 143 — displacement of . 98 — how to time . 123 — impulse of . 104 — inspection of 99 — m^urmurs (videravLrravirs) 125 PAGE Heart, palpation of the . 107 — percussion of the . .110 — valves, position of . 137 Heart-sounds, the . . 120 — accentuation of the . 124 — reduplication of the . 124 — unduly audible in dis- ease of lungs . . 68 Heaving of prsecordium, general . . . 105 Hepatic pulsation . . 105 Hydropneumothorax . 89- Hyper-resonance . . 55 Hypertrophy, compensatory 49 I. Immediate percussion . 31 Impaired resonance on per- cussion . . .55 — respiratory movements . 22 Impulse, diastolic . . 104 — of the heart . . . 104 Increased resonance on per- cussion . . .56 Indirect percussion . . 31 Infraclavicular region, the 2 Inframammary region, the 2 Inf rascapular region . . 2 Infraspinous region, the . 2 Inorganic murmurs . . 148 Inspection of the heart . 99 Inspiration, defective . 22 Inspiratory dyspnoea . . 22 INDEX. 197 PAGE Inspiratory recession . . 23 Intercostal spaces, bulging of . . . .23 — contraction of . .28 — recession of . . .23 — widening of . . .28 Intermittent pulse . . 173 Interrupted breathing . 77 Interscapular region, the . 2 Irregular pulse . . .172 — respiration , . .24 J. Jerky breathing . . 77 L. Landmarks, medical (see Surface-markings) . 35 Laryngeal breathing . . 71 • — resonance . . .65 Late diastolic murmur . 180 Line, the nipple . . 2 Liver, surface-markings of 39 Locomotor pulse, the . 171 Lungs, auscultation of the 60 — boundaries of the . . 37 — consolidation of the . 81 — contraction of the . 49 — diagnosis between dis- ease of the pleura and of the ... 82 — enlargement of the . 47 — inspection of the . . 9 PAG-E LungSj palpation of the . 27 — percussion of the . . 31 — size of the . . .35 M. Mammary region, the . 2 Markings, surface . . 35 Measurements of chests . 10 — varying with respiration 21 Mediastinum . . . 181 — boundaries of . . 181 — diagnosis of diseases of . 186 — diseases of . . .183 — dislocation of . . 181 — parts of . . . 183 — places to examine . . 183 — synopsis of examination of ... . 190 Mediate percussion . . 31 Medical landmarks . . 35 Metallic crepitation . . 88 — tinkling . . .88 Methods of examination . 3 Mid-diastolic murmur . 131 Mitral disease, alteration of cardiac dulness in .118 — murmurs ■. . . 142 — stenosis, case of . . 145 Moist sounds . . .84 Movements of respiration, alterations in . . 22 — how to examine, by palpation . . .27 — of chest in respiration . 20 198 INDEX. PAGE Movements of the prse- cordium . . . 100 Murmurs, anaemic, hsemic, blood . . . .149 — aortic .... 141 — auricular systolic . . 131 — backward . . . 137 — cause of endocardial . 134 — classification of . . 126 — definition of. . .125 — diastolic . . . 129 — dilatation . . . 149 — endocardial and exo- cardial . . .126 — endocardial, not due to valvular disease . .147 — exocardial . . . 151 — heart . . . .125 — how to time . . . 127 — inorganic, characters of 148 — in vessels of neck . .154 — mitral .... 142 — musical . . . 126 '■ — onward .... 137 — organic and inorganic . 126 — place of . . . 135 — postsystolic . . .132 — prsesystolic . . . 129 — pulmonary systolic . 148 — subclavian . . . 153 — systolic and diastolic . 127 — table of . . . 134 — tricuspid . . 143, 149 — venous . . . 154 Musical heart murmurs . 126 N.. Nipple line, the Nonnen-gerausch Number of respirations O. Onward murmurs Orthopncea P. PAGE . 2 . 154 . 23 137 22 Palpation . . 5 — of heart . 169 — of lungs . 27 Palpatory percussion . 32 Pantograph . 12 Paradox pulse, the . . 174 Paralytic chest, the . . 17 Parasternal region, th e . 2 Pectoriloquy . 68 — whispering . . 69 Percussion 5 — apparatus for . 91 — boxy . . 55 — deficient . 55 — definition of . . 31 — direct (immediate' ) . 31 — dull . . 55 — exaggerated . . 53 — impaired . 55 — indirect (mediate) . 31 — method of . . 32 — normal . . 55 — of the heart . . 110 INDEX. 199 PAGE Percussion of lungs . . 31 — palpatory . . .32 — sounds, varieties of . 51 Pericardial effusion, altera- tion of cardiac dulness in . . . . 118 — ^friction . . 108, 151 cliaracters of . . 151 Pigeon-breast, the . . 15 Plessimeters . . .31 Plessor . . . .31 Pleura, diagnosis between diseases of lung and of . . . .82 Pleuritic effusion . . 51 diagnosis of . .82 — friction . . .86 felt on palpation . 28 Pleuro-pericardial friction 67, 152 Pneumothorax, ausculta- tion in . . .87 — boundaries of lungs in . 51 Position of patient for exa- mination of the chest . 3 Postsystolic murmurs . 132 Prsecordium, the . . 98 — bulging of . . .98 — the movements of. .98 — the shape of . . .98 Prsesystolic murmurs . 129 Pterygoid chest, the . . 17 Puerile breathing . . 78 Pulmonary systolic mur- murs .... 148 Pulsation, arterial — epigastric — hepatic. — venous . Pulse, the . — Corrigan's . PAGE . 104 . 104 . 105 . 105 . 161 . 171 — cum inspiratione in- termittens . . .174 — dicrotic . . . 170 — hard, soft, &c. . . 164 — incompressible . . 164 — intermittent . . . 173 — irregular . . .172 — locomotor . . .171 — of unfilled arteries . 172 — paradox . . . 174 — relation to respiration . 23 — retardation of . .176 — rhythm of . . . 172 — synopsis of the . .175 — tension 160 — thrilling . . .170 — want of symmetry . 175 — waterhammer . . 171 Pulse rate, the . . . 161 conditions affecting the . . . . 162 Pulse wave, the . . . 166 Purring tremor . . . 108 Pyopneumothorax . . 89 R. Rales Rate of respiration Rattle, the death 83 23 84 200 INDEX. PAGE Recession, inspiratory . 23 — of apex beat systolic . 104 Reduplication of the heart- sounds . . . 124 Redux crepitation . .87 — friction . . .87 Regions of chest . . 2 Relative cardiac dulness • 112 Resistance, sense of . .29 Resonance, percussion . 34 — area of stomach . .43 — deficient . . .55 — dull .... 55 — impaired . . .55 — normal . . . .55 — tympanitic . . .53 — varieties of . . . 53 — vocal, varieties of . .65 Respiration, amount of air on 21 — Cheyne-Stokes' . . 24 — costal or thoracic . . 20 — diaphragmatic or abdo- minal . . .21 — effect of emotion on . 24 — interrupted . . .77 — irregular . . .24 — jerking. . . .77 — movements of . .20 — Saccadee . . .77 — variations in movements of 22 — voluntary control over . 24 — wavy . . . .77 Respirations, effect of ex- citement and disease ,upon number of . .23 PAGE Respirations, number of . 23 — relation to pulse . . 23 Respiratory movements, how to examine (pal- pation) . . .27 in men, women, and children . . .20 Rhonchus . . . ,83 — felt . . . . 28 Ribs, how to count the . 27 Rickety chest, the . .14 S. Senile emphysema . . 49 Sense of resistance . . 29 Shape of the healthy thorax 10 — varieties of . . .12 Shoemakers' chest . . 19 Short breath (dyspnoea) . 22 Sibilus . . . .83 — felt . . . .28 Solidification of lung, dia- gnosis of . . .81 Sound, cracked-pot . . 56 — the bell . . .89 — the splashing . . 89 Sounds, dry and moist . 84 — of breathing . . .70 — of the heart, the (see Heart-sounds) . . 120 whisper . . .69 Space, complemental . . 39 INDEX. 201 PAGE PAGE Spaces, bulging of inter- Synopsis of auscultation oJ costal. 23 heart . . . . 156 — contraction of intercostal 28 — of auscultation of lungs , 91 — widening of intercostal . 28 — of general examination Sphygmograph, the . 166 of heart 157 Spirometer, the 22 of lungs . 95 Splashing sound 89 of the mediastinum 190 Splenic ai'ea 43 of the pulse . 177 Sternal region, the 2 — of inspection of heart 106 Stethoscopes 60 of lungs . 26 — binaural 63 — of palpation of heart 109 — single . 62 of lungs 30 Stokes' breathing, Cheyne- 24 — of percussion of heart 118 Stomach resonance, the area of 43 of lungs 50 — size of . 43 Systole 121 Stridor, stridorous breath- — murmurs 127 ing . 171 — pulmonary . . 148 Subclavian murmurs . 153 — recession of apex beat . 104 Succussion 89 Superficial cardiac dulness. the area of . 112 T. — veins, dilatation of 19 Supraclavicular region, the 2 Tension pulse . 162 Supraspinous region, the . 2 Thoracic aneurysm . 183 Surface markings 35 — respiration . 20 — liver .... 39 — tumour 183 — lungs .... 45 Thorax, the 1 — spleen .... 43 — changes in shape of, in — stomach 43 disease 18 Symmetrical contraction of — contents of the 3 lungs .... 49 — measurements of . 10 — enlargement of lungs . 47 — parts of the . 1 Symmetry in shape of — varieties of . 12 thorax, want of, evi- Thrilling pulse . 170 dence of disease , 18 Thrills 108 14 202 INDEX. Time the heart, to Tinkling, metallic Tracheal breathing . — resonance Tracing, cyrtometer, chest . — sphygmographic . Transposition of viscera Traube's zone . Ti'emor, purring Tricuspid murmurs . Tumour, mediastinal . Tympanitic resonance, percussion . Types of respiration . U. PAGE . 123 . 88 . 71 . 65 of or 11 167 103 43 108 149 182 53 26 Undulatory cardiac impulse 104 V. Valve shock . . .109 Valves of heart, position of 137 Valvular disease, diagnosis of . . . .143 Varieties of chests . . 12 Veins, dilatation of . .20 Venous murmurs in neck . 154 — pulsation . . . 105 Vesicular breathing . . 73 PAQ-E Vesicular resonance . . 65 Vibrations of voice in women and children . 29 Vibrations, want of sym- metry in . . .29 — vocal . . . .28 Viscera, transposition of . 103 Vital capacity of the chest 21 Vocal resonance . 29, 64 varieties of . .65 — vibrations . . .28 Voice, auscultation of the . 64 W. 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By Alfred Cooper, F.E.C.S., Senior Surgeon to St. Mark's Hospital for Fistula; and F. Swinford Edwards, F.E.C.S., Senior Assistant Surgeon to St. Mark's Hospital. Second Edition, with Illustrations. 8vo, 12s. Diseases of the Rectum and Anus. By Harrison Cripps, F.E.C.S., Assistant Surgeon to St. Bartholomew's Hospital, etc. Second Edition. 8vo, with 13 Lithographic Plates and numerous Wood Engra-vnngs, 12s. 6d. By the same Author. Cancer of the Rectum. Especially considered with regard to its Surgical Treatment. Jacksonian Prize Essay. Third Edition. 8vo, with 13 Plates and several Wood Engravings, 6s. The Diagnosis and Treatment of Diseases of the Eectum. By William Allingham, F.E.C.S., Surgeon to St. Mark's Hospital for Fistula. Fifth Edition, By Herbert Wm. Allingham, F.E.C.S., Surgeon to the Great Northern Central Hospital, Demonstrator of Anatomy at St. George's Hospital. Svo, with 53 Engravings, 10s. 6d. 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By Frederick Treves, F.E.C.S., Surgeon to the London Hospital ; and Hugo Lang, B.A. Crown Svo, half-Persian calf, 12s. 11, NEW BURLINGTON STREET. 2i J. 8^ A. ChurehilVs Recent Works. Chemistry, Inorganic and Organic. With Ex- periments. By Charles L. Bloxam. Eighth Edition, by John Millar Thomson, Professor of Chemistry in King's College, London, and Arthur G. Bloxam, Head of the Chemistry Department, the Goldsmiths' Institute, New Cross. 8vo, with 281 Engravings, 18s. 6d. By the same Author. Laboratory Teaching ; or, Progressive Exer- cises in Practical Chemistry. Sixth Edition, by Arthur G. Bloxam. Crown 8vo, with 80 Engravings, 6s. 6d. Watts' Manual of Chemistry, Theoretical and Practical. Edited by William A. Tilden, D.Sc, F.R.S., Professor of Chemistry Normal School of Science, South Kensington. Second Edition. Inorganic Chemistry. Crown 8vo, 8s. 6d. Organic Chemistry. Crown 8vo, iOs. Practical Chemistry, and Qualitative Analysis. By Frank Clowes, D.Sc. 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Sixth Edition. 8vo, with 102 Engravings, 17s. 6d. 11, n:EW BURLINGTON STREET. 26 J. ^ A. ChurchiWs Recent Works. Chemical Technology : or, Chemistry in its Applications to Arts and Manufactures. Edited by Charles E. Groves, F.E.S., and William Thorp, B.Sc. Vol. I. — Fuel and its Applications. By E.J. Mills, D.Sc, F.R.S., and F. J. Rowan, C.B. Royal 8vo, with 606 Engravings, 30s. Vol. II.— Lighting, Fats and Oils, by W. Y. Dent. Stearine Industry, by J. McArthur. Candle Manu- facture, by L. Field and F. A. Field. The Petroleum Industry and Lamps, by Boverton Redwood. Miners' Safety Lamps, by B. Redwood and D. A. Louis. Royal 8vo, with 358 Engravings and Map, 20s. Cooley's Cyclopaedia of Practical Receipts, and Collateral Information in the Arts, Manufactures, Professions, and Trades : including Medicine, Pharmacy, Hygiene, and Domestic Economy. Seventh Edition, by W. North, M.A. Camb., F.C.S. 2 Vols., Roy. 8vo, with 371 Engravings, 42s. Chemical Technology : a Manual. 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Eevised and Enlarged, with the Co-operation of S. Arloing, Director of the Lyons Veterinary School, and Edited by George Fleming, C.B,, LL.D., F.E.C.V.S., late Principal Veteri- nary Surgeon of the British Army. Second English Edition. Svo with 5S5 Engravings, 31s. 6d. 11, NEW BURLINGTON STREET. 28 Index to J. & A. Churchill's Catalogue. Abercrombie's Medical Jurispru- dence, 3 Adams' (W.) Clubfoot, 18 Contractions of the Fingers, etc., 18 Curvature of the Spine, 18 Allen's Chemistry of Urine, 22 Commercial Organic Analy- sis, 26 Allingham's (W.) Diseases of the Eectum, 24 Armatage's Veterinary Pocket Ee- membrancer, 28 Auld's Bronchial Affections, 1.3 Barnes' (E.) Obstetric Operations, 6 Diseases of Women, 6 Beale (L. S.) on Liver, 12 Microscope in Medicine, 12 Shght Ailments, 12 Urinary and Eenal Derange- ments, 22 Beale (P. T. B.) on Elementary Biology, 3 Beasley's Book of Prescriptions, 8 Druggists' General Eeceipt Book, 8 Pocket Formulary, 8 Bellamy's Surgical Anatomy, 2 Bentley and Trimen's Medicinal Plants, 9 Bentley's Systematic Botany, 9 Berkart's Bronchial Asthma, 13 Bernard on Stammering, 14 Bernay's Notes on Analytical Chem- istry, 26 Bigg's Short Manual of Orthopaedy, 18 Bloxam's Chemistry, 25 Laboratory Teaching, 25 Bousfield's Photo-Micrography, 28 Bowlby's Injuries and Diseases of Nerves, 17 Surgical Pathology and Morbid Anatomy, 17 Bowman and Bloxam's Practical Chemistry, 25 Brodhurst's Anchylosis, 17 Curvatures of Spine, 17 TalipesEquino-Varus,17 Bryant's Practice of Surgery, 16 Tension, Inflammation of Bone, Injuries, etc., 16 Buist's Vaccinia and Variola, 13 Burckhardt and Fenwick's Atlas of Electric Cystoscopy, 22 Burdett's Hospitals and Asylums of the World, 4 Butlin's Malignant Disease of the Larynx, 21 Operative Surgery of Malig- nant Disease, 21 Sarcoma and Carcinoma, 21 Buzzard's Diseases of the Nervous System, 14 Peripheral Neuritis, 14 Simulation of Hysteria, 14 Cameron's Oils, Eesins, and Var- nishes, 27 Soaps and Candles, 27 Carpenter and Dallinger on the Mi- croscope, 28 Carpenter's Human Physiology, 3 Charteris on Health Eesorts, 15 Practice of Medicine, 11 Chauveau's Comparative Anatomy, 28 Chevers' Diseases of India, 10 Churchill's Face and Foot Deformi- ties, 18 Clarke's Eyestrain, 19 Clouston's Lectures on Mental Diseases, 4 Clowes and Coleman's Quantitative Analysis, 25 Clowes and Coleman's E'ementary Qualitative Analysis, 25 Clowes' Practical Chemistry, 25 Cooley's Cyclopaedia of Practical Eeceipts, 27 Cooper's Syphilis, 23 Cooper and Edwards' Diseases of the Eectum, 24 Cripps' (H .) Cancer of the Eectum, 2 1 Diseases of the Eectum and Anus, 24 Cripps' (E.A.) Galenic Pharmacy, 8 Cullingworth's Manual of Nursing, 7 Monthly Nurses, 7 Dalby's Diseases and Injuries of th Ear, 20 Short Contributions, 20 Day on Diseases of Children, 7 on Headaches, 15 Domville's Manual for Nurses, 7 Doran's Gj^uEecological Operations 6 Druitt's Surgeon's Vade-Mecum, 17 Duncan (A.) on Prevention of Dis- eases in Tropics, 10 [ Continued on next page 11, NEW BURLINGTON STREET, Index to J. & A. Chubchtlx's CxTAJjOaxTK— continued. Duncan (J. M.) on Diseases of Wo- men, 5 Ellis's (E.) Diseases of Children, 7 Ellis's (T. S.) Human Foot, 17 Ewart's Bronchi and Pulmonary- Blood Vessels, 11 Fagge's Principles and Practice of Medicine, 10 Fayrer's Climate and Fevers of India, 10 Natural History, etc., of Cholera, 10 Fenwick (E. H.), Electric Illumina- tion of Bladder, 22 Symptoms of Urinary Dis- eases, 22 Fenwick's (S.) Medical Diagnosis, 12 Obscure Diseases of the Abdomen, 12 Outlines of Medical Treat- ment, 12 The Saliva as a Test, 12 Fink's Operating for Cataract, 19 Flower's Diagrams of the Nerves, 2 Fowler's Dictionary of Practical Medicine, 11 Fox's (C. B.) Examinations of Water, Air, and Food, 3 Fox's (T.) Atlas of Skin Diseases, 21 Fox (Wilson), Atlas of Pathological Anatomy of the Lungs, 11 Treatise on Diseases of the Lungs, 11 Frankland and Japp's Inorganic Chemistry, 26 Fraser's Operations on the Brain, 16 Fresenius' Qualitative Analysis, 25 Quantitative Analysis, 25 Galabin's Diseases of Women, 6 Manual of Midwifery, 5 Grardner's Bleaching, Dyeing, and Calico Printing, 27 Brewing, Distilling, and Wine Manufacture, 27 Gimlette's Myxcedema, 12 Godlee's Atlas of Human Anatomy,l Goodhart's Diseases of Children, 7 Gowers' Diagnosis of Brain Disease, 13 Manual of Diseases of Ner- vous System, 13 Medical Ophthalmoscopy, 13 Gowers' Syphilis and the Nervous System, 13 Granville on Gout, 14 Green's Manual of Botany, 9 Groves and Thorp's Chemical Tech- nology, 27 Guy's Hospital Eeports, 11 Habershon's Diseases of the Abdo- men, 15 Haig's Uric Acid, 12 Harley on Diseases of the Liver, 14 Harris's (V. D.) Diseases of Chest, 11 Harrison's Urinary Organs, 23 Hartridge's Eefraction of the Eye, 19 Ophthalmoscope, 19 Hawthorne's Galenical Prepara- tions, 8 Heath's Certain Diseases of the Jaws, 16 Clinical Lectures on Sur- gical Subjects, 16 — ■ Injuries and Diseases of the Jaws, 16 Minor Surgery and Ban- daging, 16 Operative Surgery, 16 Practical Anatomy, 1 Surgical Diagnosis, 16 Notes on Gyngecological Hellier's Nursing, 6 Higgens' Ophthalmic Out-patient Practice, 19 Hillis' Leprosy in British Guiana, 20 Hirschfeld's Atlas of Central Ner- vous System, 2 Holden's Human Osteology, 1 Landmarks, 1 Hooper'sPhysicians' Vade Meeum,10 Hovell's Diseases of the Ear, 20 Howden's Index Pathologicus, 2 Hutchinson's Clinical Surgery, 17 Hyde's Diseases of the Skin, 21 Hyslop's Mental Physiology, 5 Jacobson's Male Organs, 22 Operations of Surgery, 17 Johnson's Asphyxia, 12 Medical Lectures and Es- says, 12 Journal of Mental Science, 5 Keyes' Genito-Urinary Organs and Syphilis, 23 Kohlrausch's Physical Measure ments, 28 Lancereaux's Atlas of Pathological Anatomy, 2 Lane's Rheumatic Diseases, 14 Langdon-Down's Mental Affections of Childhood, 5 IContinued on next page. 11, NEW BURLINGTON STREET. Index to J. & A. Churchill's C at ai.ogvk— continued. Lee's Microtomists' Vade-Mecum, 28 Lescher's Eecent Materia Meclica, 9 Lewis (Bevan) on the Human Brain, 3 Liebreich's Atlas of Ophthalmo- scopy, 19 Maedonald's (J. D.) Examination of Water and Air, 3 MacMunn's Clinical Chemistry of Urine, 22 Macnamara's Diseases and Refrac- tion of the Eye, 18 Diseases of Bones and Joints, 16 McNeill's Isolation Hospitals, 4 Malcolm's Physiology of Death, 6 Mapother's Papers on Dermatology, 21 Martin's Ambulance Lectures, 15 Maxwell's Terminologia Medica Polyglotta, 24 Mayne's Medical Vocabulary, 24 Mercier's Lunacy Law, 5 Microscopical Journal, 27 Mills and Rowan's Fuel and its Applications, 27 Moore's (N.) Pathological Anatomy of Diseases, 2 Moore's (Sir W. J.) Diseases of India, 10 Family Medicine, etc., for India, 10 Tropical Climates, 10 Morris's Human Anatomy, 1 MouUin's (Mansell) Surgery, 16 Nettleship's Diseases of the Eye, 18 Ogle on Puncturing the Abdomen, 15 Oliver's Abdominal Tumours, 6 Diseases of Women, 6 Ophthalmic (Royal London)Hospital Reports, 18 Ophthalmological Society's Trans- actions, 18 Ormerod's Diseases of the Nervous System, 13 Owen's (I.) Materia Medica, 7 Owen's (J.) Diseases of Women, 6 Parkes' (B.A.) Practical Hygiene, 4 Parkes' (L. C.) Elements of Health, 4 Pavy's Carbohydrates, 12 Pereira's Selecta h Prescriptis, 8 Phillips' Materia Medica and Thera- peutics, 8 Pitt-Lewis's Insane and the Law, 4 Pollock's Histology of the Eye and Byehds, 19 Proctors Practical Pharmacy, 8 Purcell on Cancer, 22 Pye-Smith's Diseases of the Skin, 21 Quinby's Notes on Dental Practice, 20 Ramsay's Elementary Systematic Chemistry, 26 Inorganic Chemistry, 26 Reynold's Diseases of Women, 6 Richardson's Mechanical Dentistry, 20 Roberts' (D. Lloyd), Practice of Mid- wifery, 5 Robinson's (Tom) Eczema, 21 Illustrations of Skin Dis- eases, 21 Syphilis, 21 Ross's Aphasia, 14 Diseases of the Nervous Sys- tem, 14 Royle and Harley's Materia Medica, 9 St. Thomas's Hospital Reports, 11 Sansom's Valvular Disease of the Heart, 13 Savage's Female Pelvic Organs, 5 Schetelig's Homburg-Spa, 15 Schweinltz on Diseases of the Eye, 19 Shaw's Diseases of the Eye, 19 Short Dictionary of Medical Terms, 24 Silk's Manual of Nitrous Oxide, 20 Smith's (E.) Clinical Studies, 7 Diseases in Children, 7 Wasting Diseases of Infants and Children, 7 Smith's (J. Greig) Abdominal Sur- gery, 6 Smith's (Priestley) Glaucoma, 19 Snow's Cancers and the Cancer Process, 21 Palliative Treatment of Can- cer, 21 Reappearance of Cancer, 21 Squire's (P.) Companion to the Pharmacopoeia, 8 London Hospitals Phar- macopoeias, 8 Methods and Formulse, 27 Starling's Elements of Human Phy- siology, 3 Stevenson and Murphy's Hygiene, 4 Stille and Maisch's National Dis- pensatory, 9 {Continued on next page. 11. NEW BURLINGTON STREET. Index to J. & A. Churchill's C at xj.ogv'k— continued. Stocken's Dental Materia Medica and Therapeutics, 20 Sutton's (F.) Volumetric Analysis, 26 Sutton's (H. G.) Lectures on Patho- logy, 2 Sutton's (J. B.) General Pathology, 2 Swain's Surgical Emergencies, 15 Swayne's Obstetric Aphorisms, 5 Taj^lor's (A, S.) Medical Jurispru- dence, 3 Taylor's (F.) Practice of Medicine, 10 Taylor's (J. C.) Canary Islands, 15 Thin's Cancerous Affections of the Skin, 22 Pathology and Treatment of Ringworm, 22 Thomas's Diseases of "Women, 6 Thompson's (Sir H.) Calculous Dis- eases, 23 Diseases of the Prostate, 23 Diseases of the Urinary Organs, 23 Introduction to Cata- logue, 23 Lithotomy and Litho- trity, 23 Stricture of the Ure- thra, 23 Suprapubic Operation, 23 Surgery of the Urinary Organs, 23 Tumours of the Bladder, 23 Thome's Diseases of the Heart, 11 Tirard's Prescriber's Pharmacopoeia, 9 Tomes' (C. S.) Dental Anatomy, 20 Tomes' (J. & C. S.) Dental Surgery, 20 Tommasi - Crudeli's Climate of Rome, 12 Tooth's Spinal Cord, 14 Treves and Lang's German-English Dictionary, 24 Tuke's Dictionary of Psychological Medicine, 5 Influence of the Mind upon the Body, 4 Tuson's Veterinary Pharmacopoeia, 28 Valentin and Hodgkinson's Qualita- tive Analysis, 26 Vintras on the Mineral Waters, etc. of France, 15 Wagner's Chemical Technology, 27 Walsham's Surgery : its Theory and Practice,15 Waring's Indian Bazaar Medicines, 9 Practical Therapeutics, 9 Watts' Manual of Chemistry, 25 West's (S.) How to Examine the Chest, 11 Westminster Hospital Reports, 11 White's (Hale) Materia Medica, Pharmacy, etc., 7 Wilks' Diseases of the Nervous Sys- tem, 13 Williams' Veterinary Medicine, 28 Surgery, 28 Wilson's (Sir E.) Anatomist's Vade- Mecum, 1 Wilson's (G.) Handbook of Hygiene, 4 Wolfe's Diseases and Injuries of the Eye, 18 Wynter and Wethered's Practical Pathology, 2 Year Book of Pharmacy, 9 Yeo's(G. F.) Manual of Physiology, 3 JV.B. — J. S)- A. CMirchiU's larger Catalogue of about 600 icorks on Anatomy, Physiology, Hygiene, Midwifery, Materia Medica, Medicine, Surgery, Chemistry, Botany, etc. etc., with a complete Index to their Subjects, for easy reference, will be foricarded post free on application. America.—/, i.^- A. Churchill being in constant communication icith variou publishing houses in America are able to conduct negotiations favourable to Enalish Authors. LONDON : 11, NEW BURLINGTON STREET.