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G. L. PEABODY 
 
 THE 
 
 PHYSICAL EXAMINATION 
 OF THE CHEST 
 
THE 
 
 PHYSICAL EXAMINATION 
 OF THE CHEST 
 
 IN HEALTH AND DISEASE 
 
 BY 
 
 REGINALD E. THOMPSON, M.D. Cantab. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS 
 
 SENIOR ASSISTANT PHYSICIAN AND PATHOLOGIST TO THE HOSPITAL FOR 
 
 CONSUMPTION AND DISEASES OF THE CHEST AT BROMPTON 
 
 WITH ILLUSTRATIONS ON WOOD 
 
 HENRY RENSHAW 
 
 356, STRAND, LONDON 
 
 1879 
 
3ALLANTYNE AND HANSON, EDINBURGH 
 CHANDOS STREET, LONDON 
 
PEEFACE. 
 
 In this Manual I have endeavoured to embody prevalent 
 doctrines with regard to the Physical Examination of the 
 Chest so far as they are in accordance with practical 
 experience, and to this end the works of many authorities 
 have been consulted, a list of which will be found at the 
 end of the book. 
 
 To the opinions of others I have added observations of 
 my own, the result of many years' experience in the Out- 
 patient and Pathological Departments of the Brompton 
 HosxDital, the number of patients that have come under 
 my care being over twenty-two thousand. 
 
 It would encumber these few pages too much were I to 
 quote, as I would fain do, aU the authors fi'om whom any 
 fact has been gleaned, but it is necessary to acknowledge 
 my indebtedness to the Works of "Walshe, which are 
 magistral in statement, accurate in detail, and full of 
 evidence of a delicate, musical appreciation, which quality 
 also characterises the observations of Flint, of New York, 
 from whom I have learnt much. 
 
VI PREFACE. 
 
 The illustrations tave been put on the wood with much 
 care by Messrs. Evans, from my own drawings, the 
 anatomical diagrams being based upon the works of Piro- 
 goff, Sibson, Weil, and Frorieps. To Messrs. Churchill 
 my thanks are due for leave to adapt two diagrams from 
 Braune's "Work. The illustration of Percussion is from 
 the friendly pencil of Mr. Henry Moore. 
 
 Although I have taken pains to insure completeness 
 and accuracy, errors will, of course, creep in, and I shall 
 be grateful for any suggestions and emendations which 
 will help to make this Manual trustworthy and useful. 
 
 South Kensington, 
 April, 1879. 
 
CONTENTS. 
 
 CHAP. ' PAGE 
 
 I. INTRODIJCTORY 1 
 
 II. THE TOPOGRAPHICAL ANATOilY OF THE CHEST . . 4 
 
 III. THE MOVEMENTS AND ACTION OF RESPIRATION . 22 
 
 IV. ON THE MODE OF CONDUCTING AN EXAMINATION . 26 
 V. INSPECTION , 28 
 
 VI. PALPATION 41 
 
 Vn. THE CLINICAL ACOUSTICS OF PERCUSSION ... 45 
 
 VIII. PERCUSSION 51 
 
 IX. PERCUSSION IN HEALTH 55 
 
 X. PERCUSSION IN DISEASE 63 
 
 XI. AUSCULTATION AND THE STETHOSCOPE .... 75 
 
 Xn. THE ACOUSTICS OF PULMONARY AUSCULTATION . 78 
 
 XIII. AUSCULTATION OF THE HEALTHY LUNGS .... 83 
 
 XIV. AUSCULTATION IN DISEASE OF THE LUNG ... 90 
 XV. PHYSICAL SIGNS OF PUMIONARY DISEASE . . . 112 
 
 XVI. CLINICAL ANATOMY OF THE HEART 194 
 
 XVII. THE SOUNDS OF THE HEAUT 199 
 
Vlii CONTENTS. 
 
 CHAP. PAGE 
 
 XVIII. THE ACOUSTICS OP BLOOD MURMURS 20S 
 
 XIX. INSPECTION, PALPATION, AND PERCUSSION IN 
 
 CARDIAC DISEASE 206 
 
 XX. SOUNDS OF THE HEART IN DISEASE 211 
 
 XXI. THE PHYSICAL SIGNS OP CARDIAC DISEASE . . , 223 
 
 XXII. CLINICAL ANATOMY OF THE AORTA 243 
 
 XXIII. DISEASES OP THE AORTA 246 
 
 XXIV. HISTORICAL SUMMARY 251 
 
 BIBLIOGRAPHY 254 
 
 INDEX . 255 
 
LIST OF SYNOPTICAL TABLES. 
 
 PAGE 
 
 1. Position of the Valves of tlie Heart ..... 20 
 
 2. Percussion Sounds in Health 61 
 
 3. Signs of Distended Lnng QQ 
 
 4. Percussion Sounds in Disease ....... 71 
 
 5. Eegional Significance of Dull Percussion ... 74 
 
 6. Respiratory Sounds 86 
 
 7. Sounds of Inspiration and Expiration .... 87 
 
 8. Increase and Diminution of Voice Sounds . . .88 
 
 9. Acute Tuberculosis and Emphysema 185 
 
 10. Sounds in Pulmonary Disease 191 
 
 11. Causes of Displaced Heart 208 
 
 12. Cardiac Murmurs 221 
 
LIST OF WOOD ENGEAVINGS. 
 
 FAGB 
 
 1. Front Yiew of the Chest 5 
 
 2. Back Yiew 7 
 
 3. Section showing Position of Organs (Pm'o^o^) . 14 
 
 4. Transverse Section {Braune) 16 
 
 5. Pigeon Breast 32 
 
 6. Alar Chest 3a 
 
 7. Flat Chest 34 
 
 8. Emphysematons Chest 35 
 
 9. Transverse Outlines of different Chests .... 39 
 
 10. Position of the Hands in Percussion 62 
 
 11. Front Yiew of Thoracic Organs 67 
 
 12. Side Yiew (Left) 6^ 
 
 13. Back Yiew 60 
 
 14. Miliary Tubercle 66 
 
 15. Stethoscope (Single) 76 
 
 16. Stethoscope (Double) 77 
 
 17. Brown Induration of Lung . 128 
 
xii LIST OF WOOD ENGRAVINGS. 
 
 FAas 
 
 18. Pigmented Fibroid Lung 149 
 
 19. Trabeculated Excavation of Lung 169 
 
 20. Transverse Section in Pyo - pneumotliorax 
 
 {Pirogoff) 174 
 
 21. Localised Tubercle 182 
 
 22. Enlarged Bronchial Glands 188 
 
 23. Position of Yalves of Heart (Braune) . . . .195 
 
 24. The Heart and its Valves 201 
 
 25. Transverse Section in Pericardial Effusion 
 
 {Pirogoff) 237 
 
 .26. The Arch of the Aorta 244 
 
THE 
 
 PHYSICAL SIGNS 
 
 OP 
 
 DISEASES OF THE CHEST. 
 
 CHAPTEE I. 
 
 rNTRODUCTOm EEMAEKS. 
 
 The piiyslcal examination of tlie chest is made by the 
 use of the three senses — sight, touch, and hearing — 
 applied by special methods to the investigation of the 
 condition of the chest and its contents. 
 
 The object of such examination is to ascertain the state 
 of the thoracic organs — the lungs, heart, vessels, and other 
 parts contained within the chest — so as to estimate the 
 state of health of the individual under examination and 
 the form of disease under which such a one may be 
 suffering. 
 
 The phenomena which are observed by the methods of 
 exploration used in an examination of the chest are called 
 Physical Signs, a term applied conventionally to signify 
 the indications of health and disease which are presented 
 to the senses of the examiner, and distinct from Symptoms, 
 which are chiefly derived from the answers of the 
 patient given to questions which have reference to the 
 history of the disease and the sensations caused by the 
 disease. 
 
2 INTRODUCTORY REMARKS. 
 
 Physical Slgrns are detected by tlie eye, hand, and ear 
 of tlie examiner. 
 
 Symptoms are mainly gathered from details given by 
 tbe patient. 
 
 Tbe following are the methods used in the physical 
 examination of the chest. 
 
 1. Inspection of the form and movements of the chest, 
 with Mensuration and graphic representation; consti- 
 tuting examination by the eye. 
 
 2. Palpation, or the application of touch. 
 
 3. Percussion, or the test by striking. 
 
 4. Auscultation (including succussion), or the test by 
 hearing. 
 
 The first of these methods appeals entirely to the eye ; 
 the second, and in some measure the third, concern the 
 sense of touch ; while the greater part of percussion and 
 auscultation entirely depend upon the sense of hearing. 
 
 For the nice appreciation of physical signs, which 
 require much training for their proper observation, con- 
 stant cultivation of eye, ear, and touch is necessary ; the 
 difficulty of the art is great, and the student must always 
 remember that the signs of disease are few compared with 
 the manifold conditions which give rise to them ; and it 
 cannot be too often urged that reliance can rarely be 
 placed on a single sign, but that the best results are to be 
 obtained by grouping together all the physical signs and 
 comparing them with the history and symptoms of the 
 case. 
 
 In many instances it is found that the physical signs 
 fall short of the amount of disease present, they may be 
 modified by some transient condition ; but the physician 
 would no more be warranted in dispensing with the 
 physical investigation of disease by all the means at his 
 disposal than in depending solely upon physical signs for 
 his opinion. Every method and appliance must be 
 resorted to, but each should be estimated at its due value, 
 and the student must neither be too sanguine as to the 
 possibility of forming a just estimate of all forms of 
 
INTRODUCTORY REMARKS. 3 
 
 disease by physical signs, nor cast down if lie makes 
 mistakes; but be may at the outset of bis labours be 
 warned that insidious and dangerous processes do not 
 always reveal themselves to the eye, hand, or ear, and to 
 av(jid even egregious blunders much assiduity and 
 caution are requisite. I have often observed that students, 
 who after qualifying themselves by laborious and careful 
 study for the practice of their profession, have applied 
 themselves to the perfecting of their knowledge in the 
 wards of a hospital set apart for pulmonary disease, 
 start with confidence in their powers of diagnosis, but 
 after some experience become disheartened from the 
 number of their failures. 
 
 Some comfort may, however, be assured to them, for 
 there is still a third stage to be reached, in which they 
 attain a knowledge of what the art can do. If they are 
 overwhelmed by failures they are in but a sorry plight 
 as regards the profession they have chosen ; but continued 
 perseverance will ultimately bring them to that more 
 satisfactory condition of knowing how far they can rely 
 upon signs. Careful students learn more from failures 
 than successes, and in these pages I shall endeavour to 
 keep in view the difficulties of the subject, as well as those 
 signs which lead to the triumphant detection of disease. 
 
 For the purpose of examination, the only instrument 
 required is a stethoscope — a full description of which is 
 given in another page : all others should be discarded, at 
 least until some proficiency has been obtained in the use 
 of the hands for percussion, and of the stethoscope. The 
 use of many instruments is never advantageous, and the 
 best kind of work is often done with the simplest tools. 
 
 b2 
 
CHAPTER IT. 
 
 THE TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 Before proceeding to examine the chest the student 
 ought to have an exact knowledge of the general 
 anatomy of the thorax and its organs, and especially of 
 the relative position of those organs with reference to 
 the surface of the chest, so as to be able to say what 
 organ or part of an organ underlies any particular point 
 to which attention is directed. 
 
 For this purpose it is convenient to map out the surface 
 of the chest into regions, and to each region are assigned 
 those parts which are comprised beneath it. 
 
 The following are the divisions generally used : — A 
 division into right and left is made by an imaginary 
 plane passing through the middle of the sternum and the 
 spine. 
 
 The Ri^ht Side contains — 
 
 The right lung, with its pleural covering, bronchial 
 
 tubes, nerves, and bloodvessels. 
 The right auricle and part of the right ventricle of 
 
 heart, the aortic and tricuspid valves. 
 The ascending aorta, the innominate artery, the right 
 
 subclavian, and the large veins of the right side. 
 Below the diaphragm on the right side are the 
 greater part of the liver and the gall-bladder, and 
 the right kidney. 
 The left Side contains — 
 
 The anterior mediastinum, the left lung and its 
 
 coverings, bronchial tubes, nerves, and vessels. 
 Part of the right ventricle, the left auricle and 
 ventricle, the pulmonary and mitral valves. 
 
ANTERIOH DIVISIONS. 5 
 
 The transverse and descending portions of tlie aorta. 
 The left common carotid, and the left subclavian. 
 The left recurrent nerve winding round the arch of 
 
 the aorta. 
 The left lobe of the liver, the stomach, spleen, 
 pancreas, and left kidney are situated below the 
 diaphragm on the left side. 
 The surface of the chest — front, back, and sides — is 
 mapped out by an artificial arrangement of imaginary ver- 
 tical and transverse lines, convenient for the purpose of 
 registering physical signs generally ; but for the exact loca- 
 tion of a certain sign it will be found preferable to measure 
 its position with reference to some anatomical part — the 
 middle of the sternum, the clavicle, or a rib ; and for this 
 a small three-inch rule, which can be easily carried in the 
 pocket, will be found very useful. The nipple is a good 
 landmark in men, but its position varies slightly in indi- 
 viduals and under conditions of disease : it cannot serve 
 for this purpose in women. 
 
 The anterior surface of the chest is thus divided : — 
 The Midsternal or mesosternal line is an imaginary 
 division passing down the centre of the sternum. On 
 either side of this, forming the right and left lateral 
 borders of the sternum, are the Parasternal lines. 
 
 The sternum is subdivided into an upper and lower 
 Sternal region, opposite the lower border of the third 
 rib. From the middle of the clavicle is drawn a vertical 
 line, which passes through the nipple on each side to 
 the lowest border of the ribs : this is the HJipple line. 
 Between these lines, right and left, lies the front part of 
 the chest, which is subdivided by transverse lines thus : — 
 The line of the clavicle. 
 
 A line level with the lower border of the third rib. 
 And another, level with the lower border of the 
 sixth rib. 
 The regions which are thus formed are — 
 Above the clavicle — Supra-clavicular. 
 The line of the clavicle — Clavicular. 
 
TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 Below the clavicle — Infra-clavicular. 
 
 Between tlie third and sixth rib — IVZammary. 
 Below the sixti rib — Infra-maiuznary. 
 The back is divided by the line of the spine and a line 
 falling vertically from the head of the scapnla. The sub- 
 divisions, which are very simple, are relative to the scapnla. 
 
 Tin. \. 
 
 Front Yiew of Chest. 
 That part of the back between the second and seventh 
 ribs which is covered by the blade-bone is called the 
 Scapular region, the part above being Supra-scapular. 
 That part which is uncovered, and hes between the two 
 shoulder-blades, is called the Interscapular regrion — 
 right and left. 
 
POSTERIOR DIVISIONS. 1 
 
 All tliat part whicli lies below the seventli rib is called 
 the infra-scapular region. 
 
 Fig. 2. 
 
 Back View. 
 
 Between the line of tbe scapnla bebind and tbe nipple 
 line in front lies tbe Axillary region — rigbt and left — 
 wbicb is subdivided into an upper and lower by tbe con- 
 tinuation of tbe transverse line just above tbe nipple. 
 
 Tbese divisions are not difficult, and are very easily 
 mastered by studying tbe accompanying illustrations. 
 Otber regions sometimes mentioned in descriptions of 
 thoracic disease are — 
 
 Tbe Prsecordial reg-ion, which overlies the heart, and 
 
8 TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 extends from the lower border of the second rib on either 
 side of the sternum in front to the sixth rib, and is 
 bounded on the right by a line a finger-breadth to the 
 right of the Right Parasternal line, and on the left by 
 a line a finger-breadth to the left of the left nipple line. 
 
 The epigrastric reg-ion, which is the central third of the 
 npper abdominal region. 
 
 The scrobicnlns cordis, or pit of the stomach, the depres- 
 sion in the upper part of the epigastrium below the 
 xiphoid cartilage. 
 
 The position of the internal organs and vessels in rela- 
 tion to the external topography of the chest may be 
 given as follows :— 
 
 The right and left lungs occupy the right and left cavi- 
 ties of the thorax, the heart being situated under the 
 sternum in the prsecordial region already described. 
 
 The supra- clavicular region contains the apex of the 
 lung, which rises one and a-half to two inches above the 
 clavicle. In the hollow above the clavicle, which is called 
 the supra-clavicular fossa, c^^se to the sterno-mastoid, 
 the pulsation of the subclavian artery may be felt and 
 here compressed. By deep pressure at the upper part of 
 the fossa the transverse process of the seventh cervical 
 vertebra may be reached. 
 
 • The clavicle overlies a portion of the upper lobe of the 
 lung on either side. 
 
 The right infra-clavicular region extends from the lower 
 border of the clavicle to the lower border of the third 
 rib, and overlies the chief portion of the upper lobe of 
 the right lung. 
 
 The right bronchus passes into the lung at the second 
 intercostal space. 
 
 The left infra-clavicular region overlies a part of the 
 upper lobe of the left lung. 
 
 The left bronchus passes into the left lung at the 
 second intercostal space, a little lower than the right. 
 Over this curves the arch of the aorta, just above the 
 second rib, close to the border of the sternum. 
 
POSITION OF ORGANS. 9 
 
 In the second interspace is situated the left auricle, 
 wliich is sometimes of considerable size in disease. 
 
 The right mammary region, between the third and 
 sixth ribs, overhes the middle lobe of the right lung. 
 
 The right auricle is situated beneath the second and 
 third interspace, close to the sternum. 
 
 The nipple in men is placed between the fourth and 
 fifth ribs, usually in the fourth intercostal space, but 
 sometimes in the fourth, sometimes in the fifth rib. 
 
 The left mammary region overlies a portion of the 
 upper lobe of the left lung and the greater part of the 
 heart — viz., the right and left ventricles. 
 
 The stomach extends to the fourth interspace. 
 
 The right infra-mammary region overlies the lower and 
 a portion of the inferior and middle lobe towards the 
 axilla. 
 
 The left infra-mammary region overlies a portion of the 
 left lobe of the liver and the stomach, with part of the 
 superior and inferior lobes of the lung. 
 
 In the right axillary region is the axillary portion of 
 the right lung, and part of the liver. 
 
 In the left axillary region is the left lung, chiefly the 
 inferior lobe, and the stomach. 
 
 BeMnd. — The lungs occupy all the region of the back, 
 the bronchi, right and left, being situated in the right 
 and left inter- scapular regions, between the fourth and 
 fifth dorsal spines. 
 
 But it must be remembered that the aorta arches over 
 the left bronchus, and passes down to the left of the spinal 
 column in the left inter- and infra-scapular regions. 
 
 In the right infra-scapular region is the liver, extending 
 to the level of the ninth rib ; and in the left infra-scapular 
 region is a small portion of the liver, the stomach, and 
 the spleen ; while below, on either side, is the region of the 
 kidneys. 
 
 It is so desirable to know the exact relation of different 
 parts, that the following account is given in alphabetical 
 order for ready reference : — 
 
10 TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 AORTA. — Arcli consists of an ascending, transverse, 
 and descending portion. 
 
 Ascending- portion (including the sinuses of Valsalva) 
 starts from the level of the aortic valves situated in mid- 
 sternum, on a level with the third cartilage in front, 
 with the top of the body of the sixth dorsal vertebra 
 behind. 
 
 It rises to a level with the lower margin of the second 
 right cartilage, and behind to the upper border of the 
 fifth dorsal vertebra. It has a length of two and a 
 quarter inches. At its root it is covered in front by the 
 appendix of the right auricle, and covers a little higher 
 up the right pulmonary artery. The main pulmonary 
 artery lies to its left, and the superior vena cava to its 
 right. 
 
 Transverse portion lies directly in front of the tra- 
 chea, the thoracic duct, and oesophagus ; is situated be- 
 hind the upper portion (manubrium) of the sternum, on 
 a level with the second cartilage. The upper margin 
 reaches the level of the ujoper border of this cartilage in 
 front, and the third dorsal spine behind. From this 
 border spring the innominate, the left carotid, and left 
 subclavian arteries, all close together. The lower concave 
 border arches over the left bronchus, being crossed in 
 front by the left phrenic nerve, the left recurrent laryngeal 
 nerve winding round it in a direction backwards and 
 upwards. 
 
 Descending portion turns downwards behind the left 
 bronchus near the fourth and fifth dorsal vertebree, finally 
 being fix:ed to the fifth and sixth vertebrae behind the root 
 of the left lung, the oesophagus being on the right side. 
 
 Descending thoracic aorta lies in front of the left half 
 of the spine from the sixth to the twefth dorsal vertebrae. 
 
 It passes into the abdomen between the crura of the 
 diaphragm downwards and slightly inclined to the right 
 side, lying in front of the body of the first lumbar 
 vertebra. 
 
 ARTERIES. — Innominate hes chiefly within the chest 
 
ARTERIES AND AURICLES. 11 
 
 behind the first bone of tbe sternum to tbe rigbt. At its 
 origin it lies in front of the trachea from a level with the 
 upper margin of the second cartilage, and it subdivides into 
 the right subclavian and right carotid just behind the 
 angular separation between the sternal and clavicular 
 ends of the sterno-mastoid muscle. 
 
 Iieft carotid springs from the transverse portion of 
 the arch of the aorta to the left of the innominate, and 
 passes upwards along the left of the trachea. 
 
 left subclavian springs from the left end of the 
 transverse part of the arch, and rises to a level with the 
 margin of the first left rib. 
 
 Pulmonary artery.— The main vessel springs from the 
 right ventricle of the heart behind the sternum, a little to 
 the left of the middle hue, on a level with the upper border 
 of the third left cartilage or the second interspace. 
 
 It lies in front of and above the aorta. It rises to the 
 under border of the arch of the aorta passing towards the 
 left, and at the lower border of the second rib in front (the 
 fourth dorsal spine behind) it divides into a right and left 
 branch which supply the luDg with blood for aeration. 
 
 The right pulmonary branch, the longer and larger of 
 the two, runs transversely behind the ascending aorta 
 into the root of the right lung, in front of the bronchus, 
 behind the veins (v, a, "b), the bronchus being above and 
 the veins below (b, a, v). 
 
 The left pulmonary branch passes in front of the 
 descending aorta, and enters the root of the left lung in 
 front of the bronchus and behind the veins (v, a, b), above 
 the bronchus and veins (a, b, v). 
 
 AURlcIiES. — The rigbt auricle occupies a space 
 behind the sternum between the lower border of the 
 second right cartilage and the lower border of the fourth, 
 from an inch beyond the right parasternal line to the 
 middle of the left half of the sternum. The apex of the 
 appendix is in the midsternal line at a level with the 
 upper border of the third cartilage. Into this auricle 
 open the venae cavse ; the superior vena cava pours into it 
 
12 TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 all tlie blood circulating above tbe diaphragm ; the inferior 
 vena cava, guarded at its mouth by the Eustachian valve, 
 returns all the blood from below the diaphragm. 
 
 The left auricle lies in front above the left ventricle, on 
 the left of the pulmonary artery beneath the second left 
 intercostal space, and extends from the lower margin of 
 the second left cartilage to the lower border of the third 
 cartilage ; behind it curves round and downwards, lying 
 between the fifth and the seventh dorsal spines. 
 
 Between the auricles is the auricular septum, which 
 before birth is perforated by the foramen ovale. Into the 
 posterior part of this auricle open the four pulmonary 
 veins, two right and two left. 
 
 Bronchial arteries supply the lungs with nutrient 
 blood. They spring from the aorta or from an intercostal 
 artery, and are from one to three in number ; they supply 
 blood to the bronchial glands, and tubes and coats of the 
 bloodvessels. Their capillaries ramify on the bronchial 
 mucous membrane, and much of their blood is returned 
 by the pulmonary veins to the left side of the heart. 
 
 BROXrCHUS. — The right, horizontal and short (one 
 inch), divides off from the trachea, and is distributed to the 
 root of the lung on a level with the fourth dorsal spine, 
 or betvf een the fourth and fifth dorsal bodies behind and in 
 front, opposite the second right cartilage. This tube is 
 higher in position than the right pulmonary artery and 
 vein. 
 
 The left, smaller and longer (two inches), ])asses obliquely 
 downwards into the left lung, beneath the arch of the 
 aorta, on a level with the fifth dorsal spine, one inch below 
 the right ; it crosses the oesophagus and descending aorta. 
 In front it is level with the lower border of the second left 
 cartilage. Thistube is lowerthan the left pulmonary artery . 
 
 THE DliLPHRAG-KS may be considered as tripartite, 
 having a right, middle, and left portion. 
 
 Tlie Rig^ht rises as high as the middle of the fourth 
 intercostal space a little below the nipple, the highest 
 point being to the left of the nipple line. In the axillary 
 
DIAPHRAGM AND HEART. 13 
 
 region it rises to tlie sixth and seventh ribs, behind it is 
 level with the eighth rib. 
 
 By its contraction it expands the right Inng and 
 depresses the liver and right kidney. 
 
 Tbe IVZiddle portion forms a flat surface, inclining from 
 the ninth or tenth vertebra, forwards and downwards to 
 the lower end of the sternnm. Upon it rests the heart, 
 which is lowered and lengthened by its depression. 
 
 In front it is attached to the seventh cartilage of each 
 side; between them a triangular gap is left behind the 
 xiphoid cartilage. 
 
 Tbe Iieft portion is narrower and lower than the right 
 at its summit by three-quarters of an inch, at its attach- 
 ment by a quarter of an inch. It does not rise above the 
 fifth rib, and is found at a level with the fifth intercostal 
 space, or the sixth rib; at the sternum, with the seventh 
 intercostal space in the axilla, and with the ninth rib 
 behind. The level varies in individuals. By its con- 
 traction it expands the left lung and lowers the stomach 
 spleen and left kidney. 
 
 With tranquil inspiration the diaphragm descends half 
 an inch ; in forced inspiration from one to two inches. The 
 diaphragm is supplied by the phrenic branches of the 
 foui-th and fifth cervical nerves and branches of the syn- 
 pathetic. 
 
 Relative Height of Eight akd Left Portion of Diaphragm. 
 
 Region. 
 
 Front. 
 
 Side. 
 
 Bach. 
 
 Right Portion. 
 Left Portion. 
 
 4th Intercostal. 
 
 6th Intercostal. 
 
 8th Intercostal. 
 
 5th Rib. 
 
 7th Rib. 
 
 9th Rib. 
 
 THE GAXiIi-BXiADDER is situated below the edge of 
 the right lobe of the liver, on the outside edge of the 
 right rectus muscle near the ninth cartilage. 
 
 HEART occupies the preecordial region, and lies 
 between the lower margin of the second rib and the upper 
 
14 TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 border of tlie sixth rib in front, and between tbe fourth 
 and eighth dorsal spines. 
 
 Fia. 3. 
 
 Section througli Sternum and Spine showing the position of Organs. 
 (Based on the sections of PirogoflP.) 
 
 The base from the origin of the arteries is indicated by 
 a line drawn through the sternum on a level with the 
 
KIDNEYS AND LIVER. 15 
 
 upper border of the third rib. The auricles extend above 
 this, and are sometimes very large. 
 
 The apex of the Heart is situated beneath the fifth 
 left intercostal space between the fifth and sixth left ribs 
 in front and behind, on a level with but much to the left 
 of the eighth dorsal spine. 
 
 The apex is generally one inch to the right of the left 
 nipple line ; one and a half inches below the left nipple ; 
 three and a half inches to left of middle sternal line. The 
 heart, on the right side, is in relation with the third, fourth, 
 and fifth right cartilages, and extends about an inch to 
 the right of the Right Parasternal Iiine ; on the left it 
 is in relation with the third, fourth, fifth and sixth left 
 cartilages, and extends to within rather less than an inch 
 of the left nipple line. 
 
 The auricles, ventricles, and valves are speciallydescribed 
 under their names. 
 
 A fuller description will be found on another page. 
 
 KIDirE'S'S. — These organs, right and left, are situated 
 below the diaphragm, their hilus being opposite the first 
 lumbar vertebra. Each kidney is about four inches long 
 and two or three broad. 
 
 The right lies between the eleventh and twelfth dorsal 
 spine and the line of the third lumbar spine. 
 
 The left is a Httle higher in position. 
 
 liIVER extends from the fourth intercostal space to the 
 eleventh right rib, the highest point being a little to the 
 inside and below the right nipple in front and behind from 
 the eighth to the eleventh or twelfth dorsal spine. It 
 comes into relation with the ribs behind, below the inferior 
 margin of the right lung at the tenth dorsal spine. 
 
 It has two main lobes, the right and the left, of which 
 the right is much the larger. 
 
 The lower edge of the Iiiver is sharp, and extends from 
 the lower border of the right margin of the thorax upwards 
 towards the apex of the heart, nearly to the left nipple 
 line. 
 
 Below the xiphoid cartilage its edge is from half an inch 
 
16 TOPOGKAPHICAL ANATOMY OP THE CHEST. 
 
 to two inclies towards the Timbilicns ; transverse diameter, 
 twelve mches ; thickest part, three and a half inches. 
 
 In the right axillary region it is covered by the six 
 lowest ribs. 
 
 The left lobe hides the lesser curvature of the stomach, 
 the pyloric and cardiac orifices. 
 
 ImTJNGS. — Right lung- is divided into three lobes. 
 irpper lobe extends from a point one and a half to two 
 inches above the clavicle, opposite the lower edge of the 
 seventh cervical spine to the upper margin of the fourth 
 right cartilage. 
 
 middle lobe, from the fourth right cartilage to the 
 fifth or sixth intercostal space. 
 
 Xiower lobe is bounded in the mammary region by the 
 sixth rib, in the axillary region by the eighth rib, and 
 behind it descends to a level with the tenth and eleventh 
 dorsal spines. 
 
 Fig. i: 
 
 STERNUM 
 
 L.AURICLE 
 PHRENIC. 
 
 R, VENTRICLE 
 
 R.AURICLE 
 FHRENIC 
 
 DESC< 
 
 Transverse Section showing portion of Heart and Lungs. (Braune.) 
 
 IiEFT IiUI7G. — Upper lobe extends from a point one 
 and a half to two inches above the clavicle, opposite the 
 lower part of the seventh cervical spine, to behind the 
 
LUNG AND MEDIASTINUM. 17 
 
 sixth left cartilage, and ascends upwards through, the 
 axillary region towards the base of the spine of the 
 scapula, and finally terminates opposite the third rib, 
 three inches below the apex of the lobe. 
 
 Below the fourth rib on the left side this lobe forms a 
 semilunar retraction, receding from the anterior surface of 
 the heart ; it carves round again towards the sternum 
 over the apex of the heart in a peculiar kind of tongue. 
 
 Inferior lobe extends from the sixth left cartilage 
 obliquely upwards and backwards to opposite the third 
 left rib at its junction with the vertebrae. The lower 
 margin of this lobe and the lung starts from behind the 
 sixth left cartilage in front, and extends obliquely down- 
 wards and backwards, crossing in succession the seventh, 
 eighth, ninth, tenth, and eleventh ribs. Behind, its lower 
 margin reaches a level with the eleventh dorsal spine. 
 
 Iiympliatics are superficial and deep. 
 
 The superficial or subpleural lymphatics form a network 
 beneath the pleura. 
 
 The deep lymphatics arise from the walls of the air-cells 
 and accompany the pulmonary artery and vein (perivas- 
 cular lymphatics), and others from the walls of the bronchi 
 accompanying the bronchial tubes (peribronchial lympha- 
 tics). All enter the bronchial glands at the root of the 
 lung. 
 
 ItXEDZASTINUIME. — Anterior is situated a little to 
 the left of the mid-sternal line, and is bounded by the 
 sternum in front and the loericardium behind. At its 
 upper third it encloses the remains of the thymus gland ; 
 in its middle the two lungs come close together, while at 
 the lower part the left lung recedes to leave the heart 
 uncovered. 
 
 Posterior lies between the posterior surface of the 
 pericardium in front and the spine behind. 
 
 It encloses the following parts : — 
 
 (Esophagus, Pneumogastric nerves, 
 
 Yena azygos, Descending aorta, 
 
 Thoracic duct. 
 
 Lb 
 
18 TOPOGEAPHICAL ANATOMY OF THE CHEST. 
 
 Ifferves whicli supply tlae lung come from bran clies of the 
 pneumogastric nerves, and tlie sympathetic from which the 
 anterior and posterior pulmonary plexuses are formed.' 
 
 XTipple in the fourth intercostal space, sometimes in the 
 fourth, sometimes in the fifth rib, about four to five inches 
 to the left of the mid-sternal line. 
 
 Its position varies, especially in disease. 
 
 <Esopliagrus, or gullet, leads from the pharynx to the 
 stomach, and lies between the fifth or sixth cervical ver- 
 tebra, and the ninth dorsal vertebra, where it merges into 
 the cardiac end of the stomach. Length, nine to ten inches. 
 
 In the neck it lies behind the trachea, the recurrent 
 laryngeal line lying between the two on each side ; in the 
 thorax it is fronted by the lower part of the trachea and 
 the left bronchus above, and by the posterior part of the 
 pericardial surface. 
 
 The aorta lies to the left, the vena azygos to the right; 
 the pneumogastric nerves being on either side. 
 
 Pulmonary vessels. — The functional supply of blood to 
 the lungs is through the pulmonary arteries, which sub- 
 divide (as they accompany the bronchial tubes) and ter- 
 minate in capillaries, which form a fine network on the 
 inuer surface of the air-sacs. They do not anastomose, 
 and the blood is returned by the pulmonary veins, which 
 also receive the greater portion of the blood supplied by 
 the bronchial arteries. 
 
 Scapula lies upon the back part of the thorax, between 
 the level of the second and seventh ribs. The spine of 
 the scapula in the usual upright position is nearly 
 horizontal and level with the clavicle. It is just over the 
 septum, between the upper and lower lobes. 
 
 The base of the spine is level with the third dorsal spine ; 
 the lower angle is level with the seventh or eighth dorsal 
 spine, and moves between the seventh and ninth ribs. 
 
 The two spines are 5| inches apart when at rest, 
 9 inches when stretched, 
 8| inches in the ordinary position 
 lor percussion. 
 
STOMACH. TRACHEA. VALVES. 19 
 
 Tlie lower angles are 6 inclies apart at rest, 
 
 13 inclies when stretclied, 
 
 * 10 inclies in tlie ordinary position 
 
 for percussion. 
 
 Spleen lies between tlie axillary lines on tlie left side, 
 beneath tlie ninth, tenth, and eleventh ribs. 
 
 Its upper edge is level with the ninth dorsal spine, 
 „ lower ,, „ eleventh dorsal spine. 
 
 Stoznacb varies much in size, sometimes contracted and 
 empty, sometimes full and distended. 
 
 Five-sixths of the viscus lies to the left of the mid- 
 sternal line ; one-sixth to the right. 
 
 The anterior surface is in relation with the anterior 
 abdominal wall, the diaphragm and the under- surface of 
 the hver, chiefly on the left side. 
 
 The posterior surface is in relation with the diaphragm, 
 pancreas, transverse duodenum, spleen, left suprarenal 
 capsule, and kidney. 
 
 The cardiac orifice is to be found at the seventh left 
 costal cartilage. 
 
 The pylorus lies generally three finger-breadths below 
 the ensiform cartilage, to the right of the middle line ; but 
 this varies very much at times, and I have seen it in the 
 pubic region. 
 
 Thoracic duct starts from the first lumbar vertebra, 
 and passing through the diaphragm to the right of the 
 aorta, ascends upwards behind the arch of the aorta and 
 to the left of the oesophagus, opening into the internal 
 jugular or subclavian vein on the left side. 
 
 Tracbea lies in the middle of the neck, and extends from 
 the level of the sixth cervical vertebra to the level of the 
 fourth or fifth dorsal vertebra behind, and the second rib 
 behind the manubrium of the sternum in front. It is four 
 to five inches long. On its right hes the innominate 
 artery, on its left the left common carotid ; while behind 
 it lies the oesophagus. 
 
 VAIiVES — Cardiac. — Aortic valves consist of three 
 semilunar or sigmoid valves, one of which is posterior and 
 
 c2 
 
20 TOPOGRAPHICAL ANATOMY OF THE CHEST. 
 
 two anterior. Perhaps tlie best method of naming them 
 is derived from their position as regards the inter-ventri- 
 cular septum : one being septal, the others anterior and 
 posterior respectively. They are situated behind and 
 below the pulmonary valves, and in front of the two 
 auriculo-ventricular openings. They lie behind the 
 sternum near the middle, and on a level with the lower 
 border of the third rib in front, and the body of the sixth 
 dorsal vertebra. 
 
 mitral extends from the third left cartilage, and lies 
 behind the left half of the sternum at this level, and 
 between the sixth and eighth dorsal spines behind. 
 
 Pulmonary may, like the aorta, be considered as having 
 septal, anterior and posterior segments ; lies in front of and 
 above the aortic valves, and to the left behind the left border 
 of the sternum, encroaching upon the second interspace. 
 
 Tricuspid lies behind the lower half of the sternum, 
 in front of and to the right of the mitral valve, from the 
 sternum close to the third left cartilage, to the fifth right 
 cartilage. 
 
 All these valves are so close together that they may be 
 all covered by a threepenny-piece (half- inch). While a 
 shirt button (quarter-inch) would include portions of all 
 but the tricuspid. 
 
 Valve. 
 
 Position. 
 
 Average Size 
 in Inches. 
 {Health.) 
 
 Extreme 
 
 Size. 
 {Disease) 
 
 Aortic. 
 
 Mid-sternum. 
 
 Lower border of third 
 
 cartilage. 
 
 31 
 
 4-0 
 
 Pulmonary. 
 
 Upper border of third left 
 
 cartilage, or 
 Second intercostal space. 
 
 3-5 
 
 4-8 
 
 Mitral. 
 
 Third left cartilage. 
 
 4-0 
 
 5-3 
 
 Tricuspid. 
 
 Between third left and 
 fifth right cartilage. 
 
 4-7 
 
 5-6 
 
VEINS. 21 
 
 VEIN'S — Pulmonary. — From eacb lung two proceed 
 fram the junction of branches arising from the pulmonary- 
 capillaries. In the root of the lung they are anterior to the 
 bronchus and artery, and finally terminate in the back of 
 the left auricle. They anastomose freely in the lung and 
 have no valves. 
 
 Cardiac spring from the coronary capillaries of the 
 heart and terminate in the coronary venous sinuses, which 
 open into the right auricle between the inferior vena cava 
 and the tricuspid valve. 
 
 Superior or descending vena cava receives the blood 
 from the head, neck, upper limbs, and walls of chest. 
 It opens into the right auricle at upper posterior part. 
 Just above the pericardium it receives the azygos 
 vein. 
 
 The azyg:os vein receives the blood from the back of the 
 chest. At the lower part of the chest it is divided into 
 a right and left vein, the right being connected with the 
 right lumbar vein, and the left with those of the left side. 
 This vein has valves and forms the continuity between 
 the superior and inferior system of veins. 
 
 Inferior or Ascending; vena cava carries the blood 
 from the lower limbs, the abdominal walls and organs. 
 It opens into the lower posterior part of the auricle, and 
 has no valves, except the Eustachian valve at its orifice. 
 
22 
 
 CHAPTER III. 
 
 THE MOVEMENTS A?fD ACTION OF RESPIRATION. 
 
 A SHORT account of the movements of tlie chest and the 
 alterations of the thoracic organs by the action of respi- 
 ration is necessary before proceeding to an inspection of 
 the chest. 
 
 The amount of breathing surface in the lungs is so far 
 above the ordinary requirements of the body that in 
 ordinary healthy breathing there is very little expansion 
 of the chest- walls ; the function of respiration being 
 carried od chiefly by the action of the diaphragm, even 
 this apparatus working easily and descending only half 
 an inch ; while the thoracic movements are not more than 
 one-twentieth of an inch ; sometimes in the robust, accord- 
 ing to Sibson, only one-thirtieth of an inch. 
 
 How is it then that the air is changedin the upper lobe 
 with so little expansion of its case ? The explanation 
 appears to me as follows ; and although it is advanced 
 simply as a theory, I must say that I know not other- 
 wise how to account for some of the phenomena that 
 occur in auscultation — as, for example, why the respiratory 
 murmur should be heard so loudly in some cases of cavity 
 when we know by inspection that there is no expansion of 
 the corresponding chest-wall. 
 
 A vacuum would be produced by the action of the 
 diaphragm but that the lung expands at its lower border 
 in correspondence with its action. This expansion can 
 only act directly on the descending bronchial tubes, but 
 air is drawn by this means along the main bronchus. 
 It will rise and fill the upper lobe if any air has passed 
 out of it. This withdrawal of air is, I believe, effected by 
 
ACTION OF THE DIAPHRAGM. 23 
 
 means of tlie primary current which is forced out of the 
 lower part of the lung by the action of the diaphragm ; 
 which current by its passage outwards in some measure 
 exhausts the air of the upper lobe, takins: a portion with 
 it, just as happens in the spray-producing instruments 
 by the action of the hand-ball. 
 
 The activity of the upper lobe is certainly less than 
 that of the lower lobe, and it is less altered in dimensions 
 by compression ; hence it follows that its function is not so 
 actively performed, the ventilation of this portion is not 
 so complete, the bronchial tubes are more open, and the 
 circulation is not so active. 
 
 In forced breathing the thorax is more active, while 
 the action of the diaphragm is also increased. The move- 
 ment begins with the diaphragm, and the chest gradually 
 expands from below upwards. Ransome made experi- 
 ments by fixing tapes of paper on the chest, and he found 
 that the order in which the tapes were torn was from 
 below upwards. 
 
 The lower rib is the first to rise and the last to descend. 
 Under these conditions the thoracic and abdominal walls 
 advance from one to two inches, and the girth of chest and 
 belly is increased two, three, or even four inches, the 
 diaphragm descending one or two inches. 
 
 The diaphragm by its action lengthens the lungs, 
 which are thus lowered about two inches. It lowers and 
 lengthens the heart about an inch and a half, and it 
 depresses the liver from two to three inches. During 
 deep inspiration the lower margin of the lung descends (to 
 quote Sibson) in front from the sixth to the seventh 
 cartilage, in the axilla from the seventh, eighth, and ninth 
 ribs to the eighth, ninth, and tenth ; behind, from the 
 tenth to the twelfth. 
 
 During the descent of the heart the lungs expand and 
 cover a great portion before exposed, the apex is lost 
 and the inspiration is felt at the xiphoid cartilage, and 
 the vessels descend with the heart just as the bronchi 
 descend with the trachea and the larnyx in company 
 
24 MOVEMENTS AND ACTION OF RESPIRATION. 
 
 with, the lungs. The stomach, spleen, and tidneys are 
 in like manner depressed, the pylorus being thrown down 
 two inches, and the kidney one inch. 
 
 In extreme inspiration the spine is fixed and the 
 action of all the upper muscles of the trunk is called 
 into play, and the clavicles and the shoulders are raised. 
 The sternum moves forward and upward, the lower 
 portion having the more motion. 
 
 The greatest movement of the ribs takes place in a line 
 half-way between the sternum and the chest, the fifth 
 rib having generally the greatest movement. 
 
 B/espiration is the same in cbildren of both, sexes up 
 to fourteen years of age, but after this the respiration in 
 women becomes less diaphragmatic and more thoracic, 
 and in adult females the thoracic movement is greater 
 than in men. This sexual difference of respiration has 
 a very marked effect in disease, and attention will be 
 drawn to some distinctions between the two sexes in 
 auscultation, and also in pathology. This difference is also 
 important in the examination of the patient; and whereas 
 it is necessary to examine the whole chest in a man, it is 
 sufficient in early cases of disease to examine only the upper 
 part of a woman's chest, front and back, and convenience 
 is really in accord with the requirements of the case. 
 
 The influence of respiration in disease has been greatly 
 overlooked, and its action as a morbid agent is only 
 recognised in the inhalation of irritative particles — smoke 
 carbon, fluff of wool, stone, clay, and iron; but its activity 
 in planting morbid secretions and blood has escaped 
 recognition. In a treatise on " Pulmonary Hgemorrhage" I 
 have endeavoured to show how blood becomes planted in 
 the lungs by the inspiratory force, and a full description 
 will be found in another page ; but a considerable patho- 
 logical experience convinces me that this is also true of 
 morbid secretions which are affected not only by the force 
 of inspiration, but equally with all other matter by the 
 force of gravity. 
 
 The result of this experience is to show that fluids 
 
INFLUENCE OF INSPIKATION. 25 
 
 slowly secreted in tlie lungs have a tendency to assume a 
 position in accordance with the laws of gravity, and seek 
 the most dependent parts, especially the hack; and matter, 
 fluid or soUd, which comes under the influence of inspira- 
 tion is planted in those regions in which the action of in- 
 spiration is not only first felt, but also chiefid/ felt, owing, 
 in the latter case, to expansion of the lung. 
 
26 
 
 CHAPTER lY. 
 
 ON THE MODE 01" CONDUCTING AN EXAMINATION. 
 
 When tlie student has thorouglily mastered tlie topo- 
 graphy of the chest and its movements in respiration, 
 he will be in a position to make a physical examination 
 of the chest, and a few remarks may be offered on the 
 proper method of conducting such an examination. 
 
 For the examination of men the body should be stripped 
 to the waist, the patient standing upright in front of the 
 examiner with his arms hanging down by the side. The 
 position which is most convenient will depend upon 
 the relative height of the examined and the examiner. 
 If the patient is tall it is difficult to examine the supra- 
 scapular region, and for this purpose a sitting posture 
 should be assumed, the patient reclining back when the 
 anterior surface of the chest is examined, and sitting 
 forward, with back slightly arched and arms hanging 
 down between the knees, for the examination of the 
 posterior surface. 
 
 If the upright position be assumed for the examination 
 of the posterior surface, which is generally by far the 
 most convenient posture, the patient should stand at ease 
 with the hands clasped, the arms hanging down in front, 
 the back slightly arched, the shoulders dropped, and the 
 head inclined downwards. 
 
 The object of this position is to insure the forward 
 movement of the shoulder-blades and a relaxed condition 
 of the shoulder muscles, which would, if contracted, inter- 
 pose a quantity of non-sonorous tissue between the lungs 
 of the patient and the ear of the examiner. 
 
 In the examination of women, exposure should be as far 
 
MODE OF EXAMINATION. 27 
 
 as possible avoided. From the peculiarities of respiration, 
 to which. I have already alluded, and from the conforma- 
 tion of the chest in women, the upper part of the chest is 
 the most important region for examination ; and sufficient 
 evidence is generally to be obtained as regards the anterior 
 surface of the chest by opening the dress in front without 
 any undue exposure. When the cardiac region has to 
 be examined the stays must be removed, and a thia under- 
 garment of linen only should cover the chest. For the 
 examination of the back, which should never be omitted, 
 the dress should be loosened and thrown upwards and 
 backwards from off the shoulders ; in this way there is no 
 difficulty in making a full examination of the back down 
 to the waist without offence to the most fastidious. 
 
 All flannel and thick tissues should be removed, as they 
 interfere and mask by their own rubbing and creaking 
 the proper sounds of the chest. 
 
 If the patient be examined in bed, a pillow should be 
 so arranged behind, close to the lower part of the trunk, 
 as to avoid any unnecessary exposure. The examiner 
 needs to observe the greatest delicacy in his treatment of 
 women ; let him be as tender as possible in the use of 
 percussion, let him avoid all roughness and harshness of 
 manner, making no more examination than is absolutely 
 necessary, exploring the chest rapidly but quietly, and he 
 will have little difficulty in securing the goodwill and 
 confidence of his patient, while he obtains all the evidence 
 which is requisite for the complete diagnosis of the case 
 under consideration. 
 
28 
 
 CHAPTER y. 
 
 INSPECTION. 
 
 The ocular examination of the chest is termed inspec- 
 tion, observation being made by the eye on the form, size, 
 condition, and movement of the chest. 
 
 A great deal of knowledge may be obtained by a glance, 
 if only the eye be properly trained, and it is a very good 
 exercise for the student to endeavour to find out simply 
 by inspection how close a diagnosis he can make on a case 
 of pulmonary disease. 
 
 The size and form of the chest should be first noted ; 
 the condition of the surface, the skin and the muscles, 
 the distance between the ribs, the symmetry of parts, 
 and the relative movements of respiration on both sides 
 and in various parts. The nicest appreciation of move^ 
 ments is often obtained by holding the head to one side, 
 and below the shoulder of the patient, and glancing up- 
 wards so as to obtain a view of the surface outline of the 
 chest against the light from the nipple below to the oppo- 
 site shoulder above. In this way, and especially by test- 
 ing both sides, a very accurate idea of the relative expan- 
 sion of different regions can be obtained more readily and 
 satisfactorily than can be done by the instruments of 
 precision invented for this purpose. 
 
 As an example of the advantages of inspection over 
 measurement, the following case may be given : — 
 
 A patient is suffering from an empyema, or collection of 
 pus in the left side, l^he right lung being extremely 
 expanded to make up forthe pressure on the left, measure- 
 ment shows that the size of the right side is seventeen 
 
EXTERNAL CONDITION. 29 
 
 inches and five-eigMlis, that of the left side being seven- 
 teen inches and three-eighths. 
 
 In this case measurement alone is neither a proof that 
 disease is present, inasmuch as the right side is usually 
 larger than the left, nor does it indicate on which side the 
 disease is present. 
 
 The eye at once on inspection detected a localised bulging 
 in the left infra-scapular region, and a view of the front 
 part of the chest showed that the right side was rounded, 
 while the left side was flattened — the expansion of the right 
 lung being due to a compensation for the empyema. 
 
 Measurement by instruments of all kinds is useful for 
 registering signs for future reference ; but for the pur- 
 poses of diagnosis the trained eye is a more delicate and 
 useful instrument, and of the greatest precision. 
 
 The following points should engage the attention of the 
 examiner : — 
 
 Tlie Condition of the Patient. 
 
 This may be soon gauged by practice, and an experi- 
 enced eye can form an opinion not only as to the state 
 of health of the patient, but in great measure as to the 
 general mode of life. 
 
 For robust health the chest should be full, and its lines 
 rounded : the bones should be well covered, no deep cavi- 
 ties below or above the clavicles, the skin soft and clear 
 and moist, the muscles plump and rounded. 
 
 Colour must be also observed as well as form. The 
 general hue of health is a rosy ruddy colour, which is 
 lost in disease. In aneemia the predominant colour is an 
 ivory-white ; the lips are pale. In chlorosis a slight 
 green tint is sometimes perceptible, and a deathly hue of 
 white is indicative of anemia perniciosa. 
 
 Diseases of the heart give indications of their presence ; 
 aortic regurgitation being shown by a peculiar straw 
 colour ; mitral regurgitation by purple lips and cheeks. 
 Liver disease is shown by a tint of jaundice ; while amy- 
 loid disease is often indicated by a peculiar patchy, pink and 
 yellow, appearance of the superficial capillaries of the skin. 
 
30 INSPECTION. 
 
 Fatty degeneration is suggested by tlie arcus senilis 
 of the pupil, and yellow patches on the conjunctiva 
 often indicate renal disease. 
 
 Syphilitic cachexia is marked generally by a peculiar 
 copper hue. 
 
 Malignant disease is also recognised by its dark tint 
 and peculiar aspect. 
 
 The mode of life may in some measure be ascertained. 
 If the skin is muddy and unhealthy, and the cheeks be 
 23atchy, the circulation not being vigorous, the surmise 
 may be hazarded that little exercise is taken, that the 
 patient keeps indoors, or is confined for long hours at 
 work. 
 
 Beer-drinking is detected by the condition of the veins, 
 which are full and distended, especially those of the ex- 
 tremities ; by the condition of the breath, which has a 
 peculiar sweet smell. 
 
 Spirit-drinking is shown by the harsh, dry condition of 
 the surface, and by the smell of alcohol in the breath. 
 
 The nose, it should be mentioned, can detect many 
 diseases — for example, diabetes, ozgena, uterine disease, 
 and even syphilis. 
 
 Form- of Cbest. — The typical form of the healthy well- 
 developed chest of an adult man needs little description. 
 It should be symmetrical, well covered, the muscles fuU 
 and round, the clavicles horizontal, the shoulders level, 
 and the bones but little visible. 
 
 For the full-developed form of chest, systematised 
 exercise of all the thoracic muscles is requisite, and in 
 practice . certain trades and occupations are found to 
 develop certain muscles on one side more than the other. 
 As a rule, the right side is larger than the left, unless the 
 individual is left-handed. 
 
 But peculiar forms of chest are compatible with health, 
 though not with strength. Eapid growth during youth 
 often results in malformations of the upper part of the 
 trank. A lad at school may grow at the rate of six or 
 eight inches in the year. This growth, if left to itself 
 
DEFORMED CHESTS. 31 
 
 without care and attention, monopolises the resources, 
 and the chest consequently expands very little — nay, may 
 actually diminish in girth, narrowed by tb.e elongation of 
 the rest of the body ; or from want of due nutrition the 
 body may be stunted. From some peculiar circumstance or 
 occupation it may grow to one side, or the shoulder may 
 droop, or the head may stoop. All these conditions do not 
 indicate disease, but simply imperfections of the body, 
 which demand attention. 
 
 Besides these imperfect conditions are others which are 
 due to disease — of which there are five notable varieties. 
 Of these, two are due to conditions of disease occurring 
 during early life, when the bones are soft and yielding. 
 
 Rickets, a disease of childhood, results in the production 
 of a pear-shaped chest with lateral incurvation, from the 
 inability of the softened and yielding ribs to resist the 
 pressure of the atmosphere when the diaphragm acts in 
 inspiration. This is called the rickety chest. 
 
 Pigreon toreast is the result of cough, catarrh, whooping- 
 cough and enlarged tonsils in childhood. The breast-bone 
 is unduly prominent, the ribs of the upper anterior part 
 of the chest are flattened, and the lower ribs are driven 
 inwards. 
 
 An illustration of this form of chest is given in the 
 accompanying woodcut ; and the transverse form of the 
 chest showing its triangular shape on page 39. 
 
 Deformities of the chest are also caused by spinal weak- 
 ness and curvature, the contour of the chest corresponding 
 to the curve of the spine. The shapes of the lungs within 
 the chest are modified accordingly, and very often subject 
 to emphysematous dilatations, from the excessive pressure 
 to which portions are subjected in order to fill up the 
 cavity of the thorax. 
 
 A transverse furrow which passes downwards from the 
 end of the sternum across the anterior surface of the chest 
 is due to imperfect expansion of the lungs during early 
 life. It is sometimes called Harrison's sulcus, inasmuch 
 as he proposed to make use of it with reference to the 
 
32 
 
 INSPECTION. 
 
 position of the liver ; but, as Gree remarks, it only indicates 
 wliat was the margin of the liver. 
 
 Fig. 5. 
 
 Pigeon Breast. 
 
 Besides these alterations of the chest, which are due to 
 childhood's diseases and arrested or too rapid growth, 
 there are certain forms which have been long recognised 
 as connected with phthisis. They have hence been called 
 phthinoid chests ; but it would be a grave error to suppose 
 that they are structural malformations which necessarily 
 precede or predispose to phthisis. There are certain forms 
 of narrow and long chests which represent hereditar}^ 
 weakness ; but deformities of the chest are the result 
 of the action of time — frequently the proof of previous 
 disease ; and the alar and flat chests, which have been 
 supposed to indicate a tendency to phthisis, are really 
 caused by it, and only by a very chronic form of this 
 disease. They may result from other conditions uncon- 
 nected with phthisis, the alar chest being produced by 
 atrophy of the muscles supporting the scapula and the 
 shoulder-joint ; flat chests may arise from the weakness 
 
ALAR CHEST. 
 
 33 
 
 or disease of early life. There is no form of chest which may 
 not be attacked by phthisis, and the indication of a predis- 
 position to phthisis is shown rather by the evidence of 
 structural delicacy than by malformations; and frequently 
 the subject of phthisis presents all the signs of symmetry 
 and even beauty of figure. 
 
 The Alar Cliest receives its name from the wing-like 
 prominence of the shoulder-blades as seen from the back. 
 
 Tig. 6. 
 
 Alar Chest. 
 
 It is due to dropping of the shoulders, the glenoid cavity 
 not being held in its proper position by the supporting 
 muscles, the trapezius and pectoral : the spine of the 
 scapula has an oblique direction downwards, the inferior 
 angle being tilted upwards and outwards. 
 
 D 
 
34 
 
 INSPECTION. 
 
 An iUustration of this form of chest is given ; it is taken 
 from a chronic case of phthisis of three years' duration, 
 with adhesion of the pleurae and a fibroid condition chiefly 
 of the left side. 
 
 This deformity may be simply due to feebleness of 
 muscle and wasting, or it may result from adhesive 
 pleurisy with contraction of the lung, the result of chronic 
 phthisis. 
 
 The flat cbest is either the result of previous alteration 
 of the chest, or it may be the result of atmospheric 
 pressure over a lung with a cavity. 
 
 The accompanying illustration is taken from a very 
 
 Fig. 7. 
 
 marked case of flattening, chiefly of the left side, both sides 
 being diseased. This was a case of arrested phthisis of 
 two and half years' duration and the heart was very much 
 pulled up towards the left shoulder. 
 
EMPHYSEMATOUS CHEST. 
 
 35 
 
 I have given on another page the transverse outline of 
 this chest. (See page 39.) 
 
 Another form of chest of a very marked character is the 
 circular, barrel-shaped chest of Emphysema, of which 
 an illustration is given. The transverse form of the chest 
 approaches very closely to a circle, the ribs being in a 
 position of extreme distension ; the manubrium sterni is 
 thrown far forward, and the supra-sternal fossa, or the 
 fonticulus gutturis, as it used to be called, is much 
 hollowed ; all the neck muscles are put on the stretch and 
 the sternum is curved, the xiphoid cartilage being pulled 
 in by the continued drag of the diaphragm and the pres- 
 sure of the atmosphere. 
 
 The spine and ribs corresponding to the lower part of 
 the thorax behind are often much curved. This is the 
 bulging chest of emphysema. 
 
 Fig. 8. 
 
 Emphysematous Chest. 
 
 It may be remarked that whereas the chest in emphy- 
 
 d2 
 
36 INSPECTION. 
 
 sema assumes a form of extreme expiration, in chronic 
 phthisis with pleuritic adhesions the chest takes the form 
 due to extreme inspiration. 
 
 The following brief summary of the changes which take 
 place in the form of the chest from disease may here be 
 given : — 
 
 They are either due to bulg-ingr or sbrinking- ; either of 
 these may be general or local, bilateral or unilateral. 
 
 Enlargrement of both sides is a common result of em- 
 physema : it occurs occasionally with pneumothorax, with 
 or without emphysema, the sound lung expanding to 
 perform the function of the opposite one, crippled by 
 disease, and in double pleurisy with effusion. 
 
 Enlargrement of one side is usually the result of 
 pleuritic effusion, from the presence of serous fluid, the 
 result of acute or chronic pleurisy ; of pus, or the presence 
 of blood in the pleura, a very rare event ; and of pneumo- 
 thorax, without compensatory expansion of the sound 
 lung. 
 
 It also arises from expansion of a sound lung consequent 
 upon the crippled condition of the opposite lung. This is 
 a very common result in arrested phthisis, in cirrhosis and 
 fibroid contraction of the lung with adhesive pleurisy. The 
 sound lung is sometimes so much expanded as to encroach 
 several inches beyond the mid-sternal line. 
 
 Unilateral bulging may also be found in cancer. 
 
 Contraction of both sides* — This condition occurs from 
 general adhesive pleurisy affecting both sides more or 
 less, with or without phthisis. It is rare to find double 
 pleurisy without phthisis, but such cases do occur, 
 according to my experience, as a result of drunkard's 
 dyscrasige, accompanied with or caused by cirrhosis or 
 granular kidneys. 
 
 The three constitutional dyscrasige which encourage 
 pleurisies are those associated with phthisis, drink, or 
 syphilis. 
 
 Contraction of one side. — This is the ordinary result 
 of all forms of pleurisy, with or without previous effusion. 
 
LOCAL ALTERATIONS OF CHEST. 37 
 
 It is the frequent concomitant of phthisis in all its forms. 
 When the adhesions are firmly attached to the diaphragm 
 the shoulder is pulled downwards, and the ribs slope 
 obliquely towards each other. 
 
 This condition also occurs as the consequence of 
 pulmonary collapse, especially in children. 
 
 ImOCAJ, AXiTERATXOKTS. — These alterations take the 
 form of bulg^ingrs caused by pressure from within out- 
 wards, or depressions due to pressure from without 
 inwards, from the force of the atmosphere. 
 
 Unocal bul^ingr occurs from collections of fluid — serous, 
 purulent, or bloody — ^from solid tumours, arising from 
 scrofula, aneurism, lymphadenoma, cancer, syphilis; and 
 from hypertrophy of the heart and the presence of fluid, 
 serous or purulent, in the pericardium. Enlargements 
 of the liver sometimes throw the lower ribs of the right 
 side forward. 
 
 Local swellings may be caused by collections of fluid in 
 cysts or abscesses in connection with some part of the 
 chest- waU ; sometimes, although rarely, in connection with 
 fistular sinuses through the thoracic pleura. They may 
 be also due to fatty cysts and to external cancer. 
 
 ImOcoI depression of the chest-wall results generally 
 from the absorption of fluid after an ordinary pleuritic 
 effusion, or as a result of the evacuation of pus from an 
 empyema, either naturally through the lung and bronchial 
 tube, an occasional termination, or artificially by tapping. 
 
 It is also a frequent result of a phthisical cavity : the 
 more chronic the progress and the greater the amount of 
 recovery the deeper will be the depression — propor- 
 tionately to the size of the cavity. Local retraction takes 
 place in a marked degree after profuse haemoptysis. This 
 is due to the contraction of the fibrin of blood which is 
 inhaled by the gasps of the patient into certain parts of 
 the lung. Local hollowing of the lower part of the sternum 
 is artificially produced by the pressure exercised in various 
 trades — as, for example, by shoemakers. 
 
 XlXeasurexaent of the Chest. — For all practical pur- 
 
38 INSPECTION'. 
 
 poses a double tape meastires the chest and the amount 
 of expansion on each side accurately enough. The two 
 tapes should be strongly connected behind, and the mark- 
 ing should be on the upper border of one and the lower 
 border of the other. The junction of the tapes should be 
 applied to the spine, and the tapes brought round in front 
 to the mid-sternal line. It is convenient to mark this 
 with ink or aniline pencil. 
 
 The stethometers which have been invented by the 
 legion, are vain for practical use, although some of them 
 have been found of great use for physiological experiments. 
 Callipers are convenient for measuring cross distances. 
 
 The girth of the chest in the robust adult man varies, 
 according to height and form, from thirty-three inches to 
 forty-one inches. 
 
 Maclaren, in his work on " Physical Education," gives 
 a table of averages for 100 boys of each age from ten to 
 eighteen. At ten years the average girth of chest was 
 found to be 25|- inches, with an additional inch for 
 each year afterwards up to fifteen, when the chest grows 
 larger ; at 
 
 16 being 32| inches, 
 
 17 „ 34i „ 
 
 18 ,, oo-j „ 
 
 He found the average of the first 100 names on the book 
 of the Oxford Gymnasium, all at or under nineteen years 
 of age, to be thirty -three inches. 
 
 Graphic representation of the chest is obtained by a 
 very simple instrument, the cyrtometer, of which the 
 cheapest form is that suggested by Dr. Gee — two pieces 
 of composition gas-pipe drawn out to the diameter of the 
 eighth of an inch, and united by india-rubber tubing. 
 
 The joint is applied to the spine, and the pipes are 
 accurately fitted round the chest. They are then removed 
 and laid on paper, when an exact tracing may be made, 
 giving the outline of a transverse section of the chest. The 
 chests of phthisical patients are sometimes very tender, 
 and the cyrtometer, when used for them, should be pliant. 
 
TRANSVERSE FORMS OF CHEST. 
 
 39 
 
 The transverse outline of a well-formed healthy adult 
 chest should be regular and symmetrical in form, the 
 right side of the chest usually a little larger (a quarter to 
 one inch) than the left side. In left-handed persons the 
 left is the larger side. In the regular male type of chest 
 the distance between the sternum and spine (antero-pos- 
 terior diameter) should fall short of the diameter between 
 the right and left sides (transverse diameter) by one- 
 fourth. 
 
 The proportion of the antero -posterior diameter will be 
 
 ri&. 9. 
 
 Transverse outlines of different forms of Chest, 
 three ; that of the transverse diameter will be four. 
 
 In 
 
40 INSPECTION. 
 
 the regular female type the proportion is as four to five. 
 Much attention has been paid to the use of this instru- 
 ment by Woillez in France, and by Dr. Gee in this country ; 
 and reference may be made to the works of these authors, 
 and also to a thesis by Dr. Norman Moore on its use in 
 detecting hypertrophy of the heart, for a full description 
 with figures. 
 
 The chief practical advantage of the cyrtometer is 
 obtained with reference to the diminution or increase of 
 pleuritic effusion, and in such cases its application is of 
 the greatest service in estimating the progress of the case. 
 
 All deviations from regularity of type should be care- 
 fully considered and accounted for, but as a rule it must 
 be stated that the cyrtometer indicates changes that 
 require time, and detects past conditions more readily 
 than recent alterations ; and I have been unable to con- 
 vince myself that it surpasses in precision and nicety a 
 well-trained eye, although it is very useful for the pur- 
 poses of registering present states for future reference. 
 Illustrations are given of the chief typical forms of trans- 
 verse sections of the chest in conditions of disease taken 
 from those chests of which drawings have already been 
 given. 
 
41 
 
 CHAPTER VI. 
 
 PALPATION. 
 
 Examination by totich is termed Palpation, and by it 
 certain phenomena are detected wbich appeal to tbe sense 
 of feeling but are bidden from tbe eye, and not revealed 
 always to tbe ear. 
 
 Tbe sense of toucb is valuable for tbe purposes of diag- 
 nosis, and in tbe following ways: — By tbe tactile per- 
 ception of — 
 
 1. Tbe quality of matter. 
 
 2. Vibrations of sound tbrougb various media. 
 • 3. Vibrations of friction. 
 
 4. Fluctuation of fluid. 
 
 5. Impulse and tbrills of tbe beart and vessels. 
 
 1. Tbe quality of matter, as regards its bardness, soft- 
 ness, and resistance, has attributes wbicb may be readily 
 leamt from toucb. 
 
 Tbe bealtby resilience of tbe lungs, especially as 
 gauged in tbe intercostal spaces by tbe tips of tbe 
 fingers, must be learnt by practice. 
 
 Any deviations from tbe normal condition as regards 
 smootbness of surface and solidity of matter are soon 
 detected. 
 
 ■ Glandular enlargements, common in scrofulous patients, 
 especially cbildren, and in lymphoma, are discovered by 
 pressing tbe thumbs or the ends of the fingers deep into 
 tbe supra-clavicular spaces : bardness and irregular 
 nodular swelHngs may be thus discovered, which give at 
 once a clue to the case, although their nature may be 
 Opeft to doubt. 
 
 Resistance is also felt by the finger when it is percussed 
 by the other hand, and this is a great advantage to be 
 derived from mediate percussion. 
 
42 PALPATION. 
 
 2. Yibrations of sounds caused by the voice of the 
 individual examined are transmitted to the palm of the 
 hand placed on the surface of the chest, and the intensity 
 of these vibrations is modified by circumstances. 
 
 This vibration, or vocal fremitus, does not correspond 
 with vocal resonance. The perception of tactile sensi- 
 bility not being so fine as that of hearing, voice sound 
 may be loud, but its fremitus imperceptible. In great 
 measure the fremitus is proportionate to the slowness of 
 vibrations, and the lower the note of the voice the greater 
 the fremitus. This is illustrated by a very simple experi- 
 ment. If the hand be placed upon the fiat sounding-board 
 of a pianoforte, and the keys be struck in succession from 
 the bass to the treble, it will be found that, although the 
 intensity of the sound may be the same, the fremitus is 
 diminished on going up the scale, and is entirely lost 
 with the treble notes. 
 
 Fremitus is more manifest over the right lung than 
 the left, chiefly in infra-clavicular, infra-scapular, and 
 inter-scapular regions ; very intense over the trachea ; 
 more marked when the patient is lying down, and in thin 
 persons. 
 
 It is much diminished in the region of the liver and 
 spleen ; absent in the superficial cardiac region, where the 
 heart is uncovered, and often absent in women, children, 
 and fat people. The voice of a bass or contralto is more 
 palpable than that of a tenor or soprano. 
 
 Yibrations may not be sufficiently rapid to produce a 
 musical sound, and fremitus may be felt when the sound 
 is inaudible. The vibrations of a string over a sounding- 
 box may be felt long after the sound from the string has 
 ceased to be audible, and the vibration of a big bell is 
 very perceptible after its sound has ceased. 
 
 The passage of vibrations from one medium to another 
 is attended with loss, the vibrations being reflected, and 
 thus the passage of fremitus from lung tissue through a 
 layer of fluid is much diminished. But this is by no 
 means universally the case. 
 
 A large collection of fluid may be present in the pleural 
 
PALPABLE VIBRATIONS. 43 
 
 cavity, and the fremitus may be intense. In proof of this 
 I would cite a case which has long been imprinted on my 
 memory. The physician, under whom the patient was, 
 considered the case from these physical signs to be one 
 of pneumonic consolidation. The patient died, and his 
 right side was found crammed with serous fluid. 
 
 The phenomena of fremitus in the presence of fluid have 
 received much attention, but the conditions which modify 
 vibrations are so complex that the point is not yet 
 decided ; and I would specially direct the attention of all 
 observers to the careful investigation of the subject. 
 
 I have not been able to substantiate the correctness 
 of the notion which supposes fremitus to depend upon the 
 character of the fluid, diminished fremitus being attri- 
 buted to pus. 
 
 The pressure of the lung, consolidated or compressed, 
 against the walls of the chest, conducts the vibrations 
 of the voice to the thorax, and fremitus is not often 
 completely annihilated, except in women or children. 
 
 Solidification of the lung intensifies vibration, but this 
 condition could not be established by this sign alone. 
 
 Aneurisms and tumours that come to the surface of the 
 chest annul fremitus, but it is increased if the lung be 
 compressed between the chest-wall and the tumour. 
 
 3. Yibrations due to friction may be felt in pleurisy, 
 pericarditis, peritonitis, and in loud rattling rhonchi. 
 These latter are very perceptible in children sufiering 
 from fluid in the tubes, the result of catarrh or teething, 
 and in the moribund, from feeble power of expectoration ; 
 and it is very necessary to bear in mind that as the infant 
 and child cannot expectorate, any secretion into the lungs 
 is apt to remain there for some time. 
 
 The vibrations from splash in pneumothorax may also 
 be felt, and in one remarkable case I remember to have 
 felt the splash more distinctly than it was indicated to the 
 ear by tinkle. 
 
 4. Fluctuations of fluid may be felt when such a 
 collection is tapped with one finger and the waves of 
 impulse are transmitted to the fingers of the other hand 
 
44 PALPATION. 
 
 placed at some little distance off in an intercostal 
 space. 
 
 Pulsations of vessels or of cardiac impulse are trans- 
 mitted through fluid, sometimes simulating aneurism. 
 This may occur in effusions into the pleura and pericar- 
 dium (serous or purulent). 
 
 6. Impulses and thrills of the heart and vessels are 
 very important signs in the detection of diseases of these 
 organs. 
 
 In all cases of thoracic disease, one of the first points 
 to engage the attention (after a full inspection) is the 
 position and character of the impulse of the heart. In 
 weak hearts this is sometimes felt and not seen. In ner- 
 vous excitement the impulse is rapid and sharp ; in 
 diseases of the heart, with hypertrophy, the impulse is 
 prolonged and heaving ; in dilatation, its area is generally 
 increased. 
 
 The impulse of the heart varies slightly with the posi- 
 tion assumed : in the supine it is diminished, by decubitus 
 on the right and left sides it inclines over to the same 
 side. Alteration of the position of the impulse, due to 
 dislocation of the heart, results from the presence of fluid 
 in the pleura, in the pericardium, from empyema, aneu- 
 rism, and mediastinal tumour, and very commonly from 
 adhesive pleurisy, with phthisis or fibroid pulmonary 
 disease. Local impulses not connected with the heart 
 itself may be due to aneurisms, or collections of fluid 
 and tumours near a pulsating vessel. 
 
 Tlirills, or vibrations resembling those produced by 
 the purring of a cat, and hence called " fremissement 
 Gataire," are caused by the rippling current of blood pass- 
 ing from a narrowed orifice into a dilated cavity; and hence 
 these vibrations are felt in roughened valves and dilated 
 ventricular and auricular cavities, and in cases of aneurism. 
 
 In the consideration of the indications afforded by pal- 
 pation as regards impulses and thrills, note should be 
 taken of the position, the extent of the impulse, its regu- 
 larity and occurrence with reference to the action of the 
 heart, and the presence or absence of thrill. 
 
45 
 
 CHAPTER YII. 
 
 THE CLINICAL ACOUSTICS OJF PEECUSSION. 
 
 HiTHEKTo the metlaods of examination nnder consideration 
 liave been concerned only with the eye and the touch, 
 needing no scientific knowledge to understand the laws to 
 which the observed phenomena are subject. But in 
 examination by the ear some knowledge of acoustics is 
 necessary before we can understand what sounds mean 
 and why they are altered. I have no intention of 
 entering upon an abstruse discussion of the laws of sound, 
 or I should probably find myself landed in some of those 
 difficulties and dilemmas which, those who have gone 
 before me have not altogether succeeded in escaping ; and 
 I shall only attempt a brief account of the characteristics 
 of sound and its modifications, with a few practical illus- 
 trations. 
 
 Sounds of all kinds are produced by a succession of 
 shocks received on the membrane of the ear, and trans- 
 lated by the auditory nerves to the brain, l^oises are due 
 to the jarring of such shocks hitting the tympanum in 
 irregular succession, a disagreeable and sometimes painful 
 impression being thereby produced ; just as the irregular 
 flickering of a dying lamp produces a disagreeable im- 
 pression on the sight. "When the shocks are regular and 
 sufficiently rapid in vibration a more pleasing effect 
 results, and this regularity constitutes the condition 
 necessary for musical sounds. 
 
 For present purposes, the verbal description of sound, 
 it is necessary to remember that sounds differ to indi- 
 vidual ears as colours do to individual eyes ; and, as many 
 persons are colour-blind, so many are deaf to musical 
 
46 CLINICAL ACOUSTICS OP PERCUSSION. 
 
 sounds ; and there is always great difl5.culty in conveying 
 a notion of a particular sound by words. In giving a de- 
 scription of a particular colour we liave to make a com- 
 parison with some well-known standard colour to which 
 similarity may be shown by carefully chosen epithets ; and 
 in a similar manner sounds must be described by simili- 
 tude with some well-known standard sounds. The com- 
 parison must be made with regard to certain attributes or 
 characters of sonnds, which may be here limited to 
 three : — 
 
 1. Intensity. 2. Pitcb, 3. Quality. 
 
 1. The intensity of a sound is readily appreciated and 
 indicated by epithets representing its degree of loudness 
 or softness ; a sound may be of great, moderate, or feeble 
 intensity, according as it is loud, moderately loud, or 
 soft. 
 
 2. Pitcli requires more deUcacy of appreciation, and in 
 some measure the refinement of a musical ear. Pitch is 
 proportionate to the number of vibrations by which a 
 sound is produced ; the greater the number of vibrations 
 in a certain time the higher the pitch, the fewer the vibra- 
 tions the lower the pitch. 
 
 Attention should be particularly directed to this attri- 
 bute of sound, as it is of the greatest value in diagnosis. 
 
 3. Quality indicates peculiar characteristics of sound 
 apart from pitch and intensity. The sounds of a violin 
 and a horn have different and pecuhar qualities of such a 
 kind as to enable an experienced ear to recognise at once 
 from which instrument such a sound has proceeded. The 
 description of quality is one of the greatest difficulty, and 
 we have to resort to well-known sounds of ordinary life 
 for comparisons, making use of such epithets as cooing, 
 bubbling, whistling, snoring, and the like. 
 
 Other characteristics of sound — namely, duration 
 and continuity, or interruption — indicate peculiarities in 
 the production of those sounds, to which future reference 
 will be made. 
 
PULMONARY RESONANCE. 47 
 
 The use of percussion in eliciting knowledge of the 
 solidity or hollowness of substances is known in ordinary 
 life from the custom of the carpenter when he wishes to 
 learn the position of a solid joint which will take a nail ; 
 he taps the wall with his hammer, and finds out by the 
 sound what he wants. 
 
 The resonance derived by percussion from matter is 
 dependent upon molecular structure, elasticity, density, 
 and the presence and contiguity of air ; the immediate 
 percussion of solid substances results in eliciting sounds 
 more or less resonant, according to their vibrating pro- 
 perties. 
 
 Lax tissue without air — as, for example, the liver, the 
 heart, the kidneys, and spleen — yield to percussion a non- 
 resonant sound which is termed " dull." Dulness of per- 
 cussion means absence of resonance. It is sometimes 
 called flatness. 
 
 Resonance, on the other hand, is elicited from vibrating 
 walls enclosing more or less air. This is the condition 
 which obtains in the chest, the walls of the chest which 
 encircle the air- containing organs (the lungs) vibrating 
 under percussion, and yielding a comparatively resonant 
 sound. 
 
 The sound elicited by percussion from the chest-walls, 
 with healthy lung beneath them, being the standard sound 
 of health, all other sounds, whether resonant or non- 
 resonant, are compared with this normal resonance ; 
 sounds that have more resonance are called hyper- 
 resonant ; those that have less, sub-resonant. 
 
 But even with a healthy state of lung, the sound 
 elicited by percussion varies under certain conditions of 
 the lung, and some explanation is demanded upon this 
 point. 
 
 The pulmonary resonance is derived from a number of 
 little sacs containing air, and the exact sound elicited 
 from them depends upon the tension of these sacs. A 
 drum, which is an air-containing instrument, with a top 
 and bottom formed of membrane, can have its note altered 
 
48 CLINICAL ACOUSTICS OF PERCUSSION. 
 
 at pleasure by tightening or loosening the membrane — 
 the tighter the parchment the higher the pitch. The 
 same result would follow putting the drum before the 
 fire and expanding the air. In the same manner, the air- 
 sacs of the lung, the more they are expanded the higher 
 the pitch of their note of percussion, the shorter their 
 vibrations, until all pitch is lost, and the note of percus- 
 sion becomes hard, wooden, and closely approximating to 
 
 dull. 
 
 A simple illustration of these points may be obtained 
 by filliping the cheek with the finger. With the mouth 
 open and the muscle relaxed, a dull flapping sound of 
 non-resonance is heard on percussion, to which, however, 
 a certain pitch may be given by stretching the muscle by 
 opening the jaws widely. "We have here an instance of 
 muscle when contracted giving a higher pitched sound 
 than when relaxed. The same result is obtained by 
 percussing the thigh when relaxed and when firmly 
 flexed. 
 
 If the mouth be closed and the cheeks inflated, a 
 distinct tone is produced as soon as a certain tension of 
 the muscle is thus obtained. This tone, which is termed 
 tympanitic, from its resemblance to the note of a drum, 
 can be altered in pitch by increasing the tension of infla- 
 tion. When the cheeks are pufi'ed out very tensely indeed 
 the note gives way to a dull, hard, wooden or mufl3.ed 
 sound, which closely resembles the non-resonant note of 
 liver or muscle. From these simple experiments it is 
 evident that, with elastic membranes (in order to obtain a 
 tone) a definite tension must first be obtained, the lax 
 membrane giving no distinct note. When this point is 
 arrived at, further tension raises the pitch of the note 
 until the vibrations fail to be appreciated by the ear, and 
 a mufl3.ed or non-resonant sound is then produced. 
 
 It is easy to show that this is true also of the percussion 
 note of the lungs. At the beginning of inspiration per- 
 cussion elicits a comparatively low-pitched sound. The 
 pitch of this is notably raised at the end of inspiration, 
 
AMPHORIC RESONANCE. 49 
 
 and still more so after a forced inspiration. Tlie student 
 should assure himself of the truth of these observations 
 by percussing the healthy chest in different degrees of 
 breathing. 
 
 The same rule holds good with regard to large 
 quantities of air beneath the ribs, as in pneumothorax. 
 The ribs may be regarded as so many vibrating rods 
 enclosing air. If free vibration be allowed — that is, if 
 the pressure of the air be not excessive — a marked 
 resonance of percussion is obtained, which, if it attain 
 to the dignity of tone, will be called tympanitic. If 
 the tension of the air be very great (and this occurs 
 in cases where the opening from the lung into the pleura 
 is small, indirect, and easily closed on expiration), then 
 the vibrations of the ribs may be so interfered with that 
 the tympanitic sound, which rises in pitch as the air- 
 pressure increases, becomes harder and more wooden, 
 and yields at length a non-resonant sound. I have 
 already observed that the ribs are to be considered as 
 the vibrating walls of an air-containing cavity. 'Now 
 the larger the space which is occupied by air within 
 the thorax the more nearly the chest approaches to the 
 condition of a barrel or wine-jar, and in such a condition 
 percussion gives rise to a reverberating or echoing sound 
 resembling that obtained from striking an empty cask — 
 hence called amphoric. 
 
 The ampboric sound is imitated by pursing the lips 
 and filliping the cheek, when a noise resemblino- fluid 
 pouring out of a wine-bottle is produced. The amphoric 
 sound is due to reverberation in a large hollow body with 
 a narrowed opening. If the sides of the resounding-box 
 are very rigid, if there be fluid present at the base of the 
 box, or if the cavity be struck by ringing metal — as, for 
 example, with a pliable metal hammer — a metallic clank 
 is superadded, which appears to be due to the addition of 
 a high-pitched overtone occurring at a very short interval 
 of time afterwards. 
 
 I have thus very briefly indicated some modifications 
 
50 CLINICAL ACOUSTICS OF PERCUSSION. 
 
 in the sounds of percussion whicli are teclinically 
 called — 
 
 Eesonant. Sub-resonant. 
 
 Hyper-resonant. MuflB.ed. 
 
 Tympanitic. Dull. 
 
 Ampiioric. 
 
 Metallic. 
 The first colunm indicates the terms applied to percus- 
 sion sounds in order of resonance ; the second, ia order 
 of dulness. 
 
 It remains to mention one sound of dubious import — 
 the cracked-pot sound, or hruit de pot fele. It is pro- 
 duced by a sharp and hard percussion, by which air is 
 driven out through a small opening, forming a little ex- 
 plosion, and it will be more fully explained in another 
 place, where its application to the detection of disease will 
 be discussed. 
 
51 
 
 CHAPTEE Yin. 
 
 PERCUSSION. 
 
 Percussion is the art of eliciting soimd by striking either 
 with the fingers or with instruments especially adapted 
 for the purpose, and enables the examiner to estimate 
 certain qualities, having special reference to resonance or 
 non-resonance, of the part stnick. 
 
 Percussion may be imxnediate when the striking fingers 
 or hammer are applied directly to the part examined, or 
 it may be mediate when something is interposed to receive 
 the force of the blow — the fingers of the other hand or a 
 small piece of wood or ivory. 
 
 ISTo other instruments are required for the purpose by 
 the ordinary observer but the fingers, and it is only for 
 the purposes of class demonstration that a pleximeter 
 should be used; the less show there is on the part of the 
 examiner, especially in the exhibition of instruments, the 
 more likely the patient is to undergo with equanimity 
 what is to most a sufficiently trying ordeal. Moreover, 
 the use of instruments prevents that appreciation of 
 resistance which is an important item of the knowledge 
 obtained from manual percussion. 
 
 Mode of Percussing-. — The art of percussing properly 
 is not easily attained, and demands considerable practice 
 before the skilled knack is acquired. It in some measure 
 resembles the art of pianoforte playing, and there are 
 few performers who can be said to have a really good 
 touch. 
 
 For the best manner of mediate percussion, one finger, 
 the forefinger of the left hand, should be placed with the 
 palmar surface on the chest at the part to be percussed, 
 
 e2 
 
52 
 
 PERCUSSION. 
 
 the other fingers being elevated clear of the chest snrface 
 (as in the accompanying illustration), and the blow should 
 be struck by the first three fingers of the right hand 
 closely held together without being touched by the thumb 
 
 Fig. 10. 
 
 Hands in Percussion. 
 
 and little finger. The fingers should be so bent (all the 
 phalangeal joints sharing in the bend) that the last joint 
 may strike vertically upon the finger of the left hand. 
 The blow must be given with the ends and not the pulps 
 of the fingers, and solely from the wrist, the forearm not 
 coming into play. The blow ought to be smart and 
 short, the percussing fingers being instantly removed ; 
 like the action of the pianist when playing an octave 
 passage staccato, or of a pianoforte hammer on its wire. 
 The proper art of percussion can only be acquired by 
 
MODE OF PEECUSSION. 53 
 
 long practice, and the miiscles of the wrist require to 
 be specially trained and strengthened for the purpose. 
 
 It is sometimes convenient in percussing a small spot 
 to use only the second or the third finger for delivering 
 the blow, and some percussers never use the first finger 
 at all. 
 
 Percussion may be made in two ways : with a slight 
 blow, thus eliciting vibration from the immediately 
 subjacent parts — this is termed superficial percussion ; 
 or with a strong heavy blow, eliciting sounds connected 
 with deeper-seated regions — this is called deep percussion. 
 
 The first study which should engage the attention of 
 the student is the standard sound of percussion, which 
 indicates a healthy and natural condition of the chest and 
 its organs ; and to this sound, upon which the practitioner 
 is so often called to express an opinion, much time may be 
 devoted with abundant profit. 
 
 For this purpose a healthy man should be selected, 
 of adult age, with not much muscular development — the 
 thinner the chest the better, as long as the man is in 
 a condition of health — and the percussion note of his 
 chest examined. 
 
 Percussion of a healthy chest yields a slightly different 
 note in different regions of the chest and in different 
 individuals, according to the external conditions of the 
 chest and some other circumstances ; and for the determi- 
 nation of a condition of health the best result is obtained 
 from comparing the sounds obtained in different regions 
 of the chest ; but it is of paramount importance that 
 some idea of the approximate note of health, and the 
 range of sound which is consonant with a condition of 
 health, should be retained in the memory. 
 
 Fortunately for the physical examiner, the concert pitch 
 of the lungs is seldom everywhere obliterated, and there is 
 generally some region where the true pulmonary resonance 
 can be obtained. 
 
 Those parts of the chest will of course yield the greatest 
 resonance in which there is the least quantity of material 
 
54 PERCUSSION. 
 
 interposed "between the fingers of tlie percussor and tlie 
 lung. 
 
 Tlie anterior part of tlie cliest yields a more resonant 
 sound tlian the posterior, partly because the muscles and 
 walls are not so thick, and partly because the front portion 
 of the lungs is the most expansile. 
 
 The standard pulmonary resonance may be obtained by 
 percussing the infra-clavicular region, between the clavicle 
 and the third rib, and the upper axillary regions. 
 
 There are two advantages incidentally belonging to the 
 first region as the source of the typical pulmonary sound, 
 to which all other percussion sounds are to be referred ; 
 one is, that this region is easily examined by simply loosing 
 the upper part of the patient's dress ; and the other is, that 
 this region is first affected in many forms of pulmonary 
 disease. 
 
 Besides the note elicited from percussing over pul- 
 monary tissue there is another normal or healthy reso- 
 nance, of a peculiar hollow hyper-resonant quahty, obtained 
 by percussing over the trachea and large tubes, hence the 
 name tracheal is applied to it. The regions which yield 
 this sound to percussion are given in the next chapter. 
 
55 
 
 CHAPTEE IX. 
 
 PERCUSSION IN HEALTH. 
 
 The percussion note of the tealtliy lung must be con- 
 sidered with, regard to those three qualities to which 
 attention has already been directed — viz. : 
 
 1. Intensity. 2. Pitcli. 3. Quality. 
 
 1. Its intensity will depend in some measure upon the 
 blow of percussion, and upon the thickness of the tissues 
 which overlie the ribs and intervene between the lungs 
 and the percussing fingers. 
 
 It is diminished by thick layers of muscle, of fat, and 
 by rigidity of the costal cartilages. 
 
 It is increased by expansion of the lung, by elasticity 
 of the cartilages, and absence of fat and muscle. 
 
 The average intensity must be described as moderately 
 loud. 
 
 2. Pitcb. — This must be considered as low in note, inas- 
 much as almost all others are higher. 
 
 3. Quality. — This can only be learnt by practice. It is 
 very peculiar and characteristic of elastic or spongy 
 tissue : hence it has received the epithet vesicular. 
 
 In describing healthy normal resonance, we may say 
 that the intensity of the sound varies according to 
 individual conditions, that the pitch is low and its quality 
 is vesicular. The exact appreciation of what is meant 
 by these words can only be obtained by clinical ex- 
 perience. 
 
 The student should devote some time to the percussion 
 of healthy chests, in order to acquaint himself with the 
 peculiar characters of the pulmonary resonance. 
 
 After this has been learnt, he may study the variations 
 
56 PERCUSSION IN HEALTH. 
 
 which are to be found in the different regions of the 
 thorax, consonant with a condition of health. 
 
 REGION'S OF THS AZTTERZOR SURFACE 
 OF CHEST. 
 
 Supra-clavicular. — ^Yesicnlar quality, marked above 
 the clavicles ; it becomes ti'acheal in quality near the 
 sternum, the result of percussing over the tube. 
 
 The height of the apex is an important object for 
 percussion, which in a condition of health extends a 
 distance of three finger-breadths above the clavicle; the 
 right being a little higher than the left, and in females 
 higher than in males. 
 
 Clavicular. — When percussion is made upon the bone 
 the note is altered, and becomes short and ringing. Near 
 the sternum it becomes tympanitic in resonance, because 
 of the proximity of the trachea ; near the humerus the 
 resonance is lost. 
 
 Infra-clavicular. — Vesicular resonance well marked, 
 particularly on percussing in the intercostal spaces. 
 'NesbY the sternum the trachea imparts its peculiar re- 
 sonance ; this is also evident between the second and 
 third ribs in the second intercostal space, under which 
 space the large bronchi lie, the left being a little lower 
 than the right. 
 
 niamznary. — Eesonance not so vesicular, on account of 
 the intervention of muscle. 
 
 There is a difference on the right and left sides. 
 
 The position of the Hver and heart must be studied, 
 inasmuch as these organs modify the percussion note. 
 
 Rigrbt side. — From the fourth rib to the sixth the 
 vesicular resonance is gradually diminished, becoming 
 more dull until at the sixth rib the dull note due to the 
 liver is obtained. 
 
 Between the third and fifth ribs, close to the sternum, 
 the position of the right auricle and ventricle of the 
 heart give a dull note. 
 
 Iicft side, — Eesonance diminished and dulled, from the 
 
ANTERIOE PERCUSSION. 
 
 57 
 
 presence of tlie right and left ventricles of tlie heart, 
 from the third rib to the fifth intercostal space. On the 
 outer portion of this region the stomach increases the 
 resonance of percussion, and a tympanitic note is elicited. 
 
 Fig. 11. 
 
 Front Thorax. 
 Inf^a-mammary. — In this region there is again a 
 difference on the two sides, owing to the positions of 
 organs. 
 
58 PERCUSSION IN HEALTH. 
 
 Rigrbt side. — Dull percussion, due to the subjacent 
 liver. 
 
 left side, — Inner half dull, owing to the presence of 
 the liver ; outer haK tympanitic, from the presence of the 
 stomach. 
 
 Sternal. — XTpper gives a hard short, but resonant note, 
 from the presence of the trachea, which underlies the 
 manubrium. 
 
 This is an important region for percussion in enlarge- 
 ment of the glands, and the presence of aneurism of the 
 transverse portion of the arch, and some mediastinal 
 tumours. 
 
 Xiower has a dull note, owing to the presence of the 
 heart. This extends from below the second rib to the 
 xiphoid cartilage. 
 
 AX-IImImAJLY, — upper of both sides very resonant, with 
 a good vesicular quality ; the lung lying close beneath the 
 ribs and being very expansile here. This is an important 
 region for percussion. 
 
 I^ower. — Ri^lit side yields a dull note from the pre- 
 sence of the liver, which is marked on a level with the 
 eighth rib. 
 
 lieft side. — Anterior portion generally tympanitic from 
 the presence of the stomach, the posterior portion being 
 dull from the position of the spleen between the ninth 
 and eleventh ribs. 
 
 POSTERIOR SURFACE, — Percussion should be made 
 over this surface of the chest with the patient's back 
 slightly bent, the head looking down and the hands 
 clasped in front : the muscles should be lax, the shoulders 
 brought forward and dropped. 
 
 Supra- scapular. — The presence of the trapezius inter- 
 feres with the vesicular quality of the percussion note. 
 
 Scapular. — The note is even duller, because of the 
 interposition of the shoulder-blade and its muscles. 
 
 Inter-scapular, — The note is more resonant, and be- 
 comes tracheal in quality half-way down between the 
 base of the scapular spine and the inferior angle, on 
 
POSTERIOR PERCUSSION". 
 
 59 
 
 acconnt of the position of the large bronchi which 
 bifurcate to the lungs (between the fourth and fifth dorsal 
 vertebrae). 
 
 Fig. 12. 
 
 Side View of Thorax (Left). 
 
 Ri^ht, — Tracheal resonance marked. 
 
 Keft. — The note is duller on account of the aorta, 
 which arches over the bronchus . 
 
 Infra-scapular — Rigbt side, — Eesonance intense and 
 vesicular as far as the eighth rib, where the liver dul- 
 ness is evident, becoming very marked at the tenth rib. 
 
60 
 
 PERCUSSION IN HEALTH. 
 
 Iicft side. — Tlie dulness due to the liver is only evident 
 near the spinal column on this side, and soon gives way 
 to tympanitic resonance due to the stomach. Near the 
 
 Fig. 13. 
 
 Back View of Thorax. 
 
 axilla the presence of the spleen is indicated by dulness 
 of percussion between the ninth and eleventh ribs. 
 
PERCUSSION SOUNDS. 
 
 61 
 
 Synopsis of Percussion Sounds in Health. 
 
 r Infra-clavicular .Eight and Left, 
 
 Clavietilar „ „ 
 
 / Eesonant -s Supra-clavicular 
 
 Upper Axillary 
 
 Vesicular 
 Sound 
 
 Sub-resonant. 
 
 I Inlra-scapular to eighth Rib. 
 
 'Mammary Right. 
 
 Supra-scapular ...Right and L'eft. 
 
 Scapular „ „ 
 
 Inter-scapular Left. 
 
 /"Mammary Left. 
 
 *-n" • ■ 1, ^ J Lower Axillary Right. 
 
 Kimimsned < ]nfra-scapular Right and Left, 
 
 Clnfra-mammar J Right. 
 
 [ Upper Sternal. 
 
 Tracheal Resonance \ Infra-clavicular near Sternum. 
 
 (.Inter-scapular Right. 
 
 f Lower Axillary Left, 
 
 t Infra-mammary Left. 
 
 Tympanitic Resonance 
 
 DuU. 
 
 /Infra-mammary .... } t>- ua t • 
 
 Lower Axillary j ^'S^^' ^^^^ ^iver. 
 
 I Infra-scapular j E^ght and part of 
 
 I ^ { Left, over Spleen . 
 
 Tbymus Gland. — It must "be pointed out that in child- 
 hood the thymus overlies the lungs in front, under the 
 upper part of the sternum, disappearing at puberty. It 
 reaches its maximum size at the end of the second year, 
 and measures two inches in length, and one and a half 
 inches in width. It extends a little above the sternal 
 notch, and descends as low as the fourth cartilage. 
 
 Alterations in tbe Percussion Note from Respiratory 
 IVXovements. 
 
 The amount of air taken into the lungs varies according 
 to the force of inspiration. In ordinary quiet respiration, 
 when the chief if not the only movement is effected by the 
 diaphragm, the amount of air is comparatively small, but 
 with a full inspiration, in. which action the muscles of the 
 thorax participate with the diaphragm in expanding the 
 chest-wall, the quantity of air is much increased, and the 
 air-sacs are fully dilated ; the cavity of the chest is also 
 increased in size. Eere there are two conditions which 
 alter the sound of the percussion note : the increased 
 
62 PERCUSSION IN HEALTH. 
 
 capacity of the chest gives to deep percussion a fuller, 
 more intense note ; but a less strong percussion will elicit, 
 especially at tlie end of inspiration and at tlie beginning 
 of expiration, a higlier pitched and a more muffled note. 
 The muffling of the note is due to the tension of the walls 
 of the air-sacs, and the same result may be obtained by 
 inflating a lung out of the body — a sheep's lung may be 
 readily obtained for the purpose — and inserting the 
 nozzle of a bellows into the bronchus : the more the lung 
 is inflated the more muffled the note of percussion be- 
 comes, and the higher the pitch. 
 
 The difference between the percussion notes in ordinary 
 and forced respiration is more marked on the right side 
 than on the left. 
 
 It is important that the student should make himself 
 acquainted with this difference, which involves a little 
 attention and some delicacy of ear : the peculiar muffled 
 note which occurs on percussing a distended lung is of 
 great importance in diagnosis, as will be shown in another 
 
 page. 
 
 Besides the variations in sound just mentioned are 
 others due to the alteration of place which the organs 
 below the diaphragm assume under the movements of the 
 diaphragm. 
 
 The liver moves down during inspiration, and returns 
 again to its first position during expiration. Under a 
 forced inspiration there is a movement downwards of an 
 inch and a half. 
 
 Forced expiration gives a rise of two and a half inches: 
 to five and a half inches, so that between the furthermost 
 limits is an interval of from four to seven inches. 
 
 Behind, the line of dulness is lowered from one to two 
 inches by deep inspiration. 
 
63 
 
 CHAPTEE X 
 
 PEECUSSION IN' DISEASE. 
 
 The normal sonnds of a healthy lung having been studied, 
 the student may turn his attention to the inves- 
 tigation of other sounds derived from percussion in 
 disease. The variations that occur in vesicular resonance, 
 putting aside for the present those in which dulness of 
 any degree participates, are chiefly noteworthy for altera- 
 tions in pitch, the pitch being always raised. Attention 
 has already been directed to the difference in pitch between 
 the pulmonary resonance from a lung before inspiration 
 and after deep forced inspiration, the pitch being invari- 
 ably higher. From what has been said in the chapter on 
 the Acoustics of Percussion it is evident that by subse- 
 quent degrees of distension the pitch becomes higher and 
 higher, until the vibrations are not appreciated by the 
 ear, and a tense muffled sound is elicited. 
 
 A high-pitched percussion note is obtained not only in 
 an artificial expansion, as in forced inspiration, but it is 
 also to be found in that condition in which one lung has 
 to do the work of the other which is crippled by disease, 
 the sound lung taking up what is termed compensatory 
 breatbingr. 
 
 For this puipose, not only are the air-sacs fully 
 expanded, giving rise to a high-pitched percussion note, 
 but the lung itself expands in volume to meet the call 
 which is made upon it. 
 
 It is necessary to percuss, therefore, across the mid- 
 sternal line, as one lung will sometimes encroach very 
 far — as much as four inches — across the line, and invade 
 the territory of its fellow lung. 
 
64 PERCUSSION IN DISEASE. 
 
 Tkis usually happens in greatest extent wlien tlie left 
 lung is diseased with phthisis or fibrosis, the heart being 
 drawn out of place and dislocated. 
 
 In such a case, although the pitch of the percussion 
 note is raised, the vesicular resonance is marked and its 
 intensity increased, on account of the increased size in 
 the resounding-box of the chest, to which some additional 
 effect is probably given by the expanded condition of the 
 bronchial tubes. 
 
 High-pitched resonance shows that there is a consider- 
 able strain on the portion of lung percussed — not a good 
 sign, inasmuch as it indicates an extent of disease else- 
 where. 
 
 But the distension of the lung may proceed further, 
 as in the case of complete or partial loss of elasticity, 
 leading to excessive dilatation of the air-sacs. This is 
 emphysema, and the true note of this emphysematous 
 distension when excessive is not the hyper-resonant note, 
 which is given in all books, but a decided muffled, non- 
 elastic, or hard sound, which I consider to be peculiarly 
 characteristic. This note can be obtained by superficial 
 percussion only, and is generally overlooked because the 
 examiner prefers to elicit the noisy resonance which an 
 emphysematous chest delivers when it is percussed with 
 a full blow. 
 
 The student is very apt to think that no one can mis- 
 take a case of emphysema, and instances of the disease 
 occur which can readily be detected at a glance ; but after 
 much experience of the errors of others, from my position 
 as pathologist, I must state positively that there is no 
 condition for which other diseases are more frequently 
 mistaken than emphysema ; and when students report a 
 fatal case as one of emphysema, I look to find acute 
 tuberculosis, a condition which resembles emphysema 
 very closely. 
 
 This brings me to the consideration of the percussion 
 note in tuberculosis. The invasion of a lung by an out- 
 crop of miliary tubercle necessitates extreme distension 
 
PERCUSSION SOUND OF TUBERCLE. 
 
 65 
 
 of the collateral tissue, and hence the external surface of 
 a tuberculous lung removed from the body has a similar 
 appearance to an emphysematous one, being pale, grey, and 
 much distended. Even when it is cut into the distension 
 of the air-sacs is very apparent, and the microscope shows 
 distinctly how much this condition prevails. In acute 
 
 Fig. 14. 
 
 Miliary Tubercle. 
 
 tuberculosis, therefore, percussion elicits a short high- 
 pitched muffled sound from the tense lung ; this is the 
 characteristic note of acute tuberculosis, especially in the 
 front of the chest. I shall have to refer to this point 
 again in discussing the physical signs of tubercle. 
 
 The amount of distension and the amount of tubercle arc 
 not always proportionate, inasmuch as the presence of 
 previous disease may render a small amount of tubercle 
 
66 
 
 PERCUSSION IN DISEASE. 
 
 fatal ; hence tlie note when tympanitic is sometimes reso- 
 nant, sometimes muffled. 
 
 The percussion note at the posterior surface of the 
 chest is often dull, the expansion of the lung being to the 
 front, and the tubercle especially conglomerated towards 
 the back, and the lung here condensed. 
 
 Variety in pitch requires great discrimination, and 
 although seemingly but a slight difference, it affords signi- 
 ficant indications of important processes. 
 
 There is no greater difficulty than the detection by 
 physical signs of tubercle, even in large quantity ; and in 
 the early stage of incipient infection the thermometer 
 must be used constantly if diagnosis is to depend upon 
 more than conjecture. 
 
 Synopsis of the Signs of Distended Lung. 
 
 Condition percussed. 
 
 Sound, 
 
 Pitch. 
 
 Extent. 
 
 Healthy Lung. 
 Before Inspiration. 
 
 Vesicular 
 Eesonance. 
 
 Low. 
 
 Normal. 
 
 Healthy Lung. 
 Forced Inspiration. 
 
 Vesicular 
 
 Resonance. 
 
 Loud. 
 
 Higher. 
 
 Increased 
 normal. 
 
 Lung distended. 
 
 Compensatory 
 
 Breathing. 
 
 Vesicular 
 
 Resonance, 
 
 Loud. 
 
 .Higher. 
 
 Abnormally 
 increased. 
 
 Emphysema. 
 
 Tympanitic Reson- 
 ance on deep 
 percussion. 
 Muffled on superficial 
 percussion. 
 
 High. 
 
 Increased. 
 
 Acute Tuberculosis. 
 
 Tympanitic Reson- 
 ance (in small 
 
 quantities). Muffled 
 (in great). Dull 
 percussion behind. 
 
 High. 
 
 Not increased 
 (generally). 
 
 The next modification of sound to be described is that 
 in which the vesicular resonance is diminished in various 
 
CAUSES OF DULL PERCUSSION. 67 
 
 degrees, or completely annulled ; this diminution or 
 absence of resonance constitutes dulness of percussion. 
 It may be slight, marked or absolute, tbe degree being 
 proportionate to the absence of air. 
 
 In dull percussion, resonance of tbe vesicular character 
 is more or less abolished and the pitch is raised. 
 
 Dulness is caused by various products of disease. 
 By fluids ^ In. the pleural sac — subpleural. 
 or I In the lung — intra-pulmonary. 
 solids i Outside the lung — extra-pulmonary. 
 
 Subpleural Fluids. — Accumulations of serum, pus, 
 and blood, as in hydrothorax, empyema, hsemothorax. 
 
 Subpleural Solids. — Blood coagulum, thickened pleura, 
 and foreign growths. 
 
 Zntra-pulmonary Fluids. — Serum, pus, and blood with 
 inflammatory fluid, exudates of all kinds, and hydatid 
 cysts. 
 
 Intra-pulmonary Solids. — Solid exudates into the 
 air-sacs — e.g., pneumonic, thickening of the lung tissue, 
 foreign growths invading the lung, blood fibrin inhaled 
 
 into the lung. 
 
 Extra-pulmonary. — Aneurisms of the aorta, malig- 
 nant and other growths, and enlargement of the 
 glands. 
 
 Dulness is also caused by absence of air from the air- 
 sacs, as in collapse and compression of the lung. 
 
 Collections of fluid in the pleural sac, not confined and 
 bound down to the chest-wall, are diagnosed by alterations 
 in the situation of the percussion-dulness by alterations 
 in the position of the patient. This is a most important 
 distinction which should never be neglected in percussing 
 regions which give a dull sound. Some change, how- 
 ever, takes place in the position of a lung simply from 
 gravity. 
 
 Ordinary pleuritic efi'usions are especially to be detected 
 in this manner, the lung, if not adherent to the side, float- 
 ing to the top of the fluid, and the fluid always tending 
 to gravitate towards the most dependent part. 
 
 r2 
 
68 PEECUSSION IN DISEASE. 
 
 The presence of fluid witMn the lungs gives a dull 
 sound on percussion only when the air is greatly dis- 
 placed; examples occurring in marked pulmonary con- 
 gestion and in pulmonary apoplexy. 
 
 Pulmonary cavities full of fluid, abscesses, and hydatid 
 sacs give dull notes. 
 
 Tubercle seldom gives dulness of percussion in front, 
 unless the lung be also affected with muck catarrhal 
 pneumonia, or unless it be in very large masses, as occurs 
 occasionally in old chronic cases in advanced years, or 
 with a fibroid condition of lung; then it is formed in 
 large broad bands, and yields a dull note ; dulness, 
 however, may be detected behind. 
 
 Thickened pleura seldom gives any marked dulness of 
 percussion, but I have seen cases in which the pleura has 
 been so thick as to give a percussion note of a very dull 
 character. 
 
 The third class of sounds elicited by percussion are 
 those which are remarkable for absence of vesicular 
 murmur, absence of dulness, and the presence of a 
 peculiar resonance> These are called, according to their 
 peculiar qualities — 
 
 1. Tubuiar. 2. Tympanitic. 3. Amp^box^CF 
 
 1, The tubular (tracheal) sound is elicited on per- 
 cussion over the trachea in the upper sternal, or near the 
 sternum in the infra^-clavieular region. It has a hallow 
 resounding quality, with ample vibrations, unlike the 
 short vibrati-on that characterises vesieuiar resonance. 
 
 It is heard in percussing region-s under which are solids:' 
 or fluids in elose contiguity with a bronchus or the 
 trachea, and as a rule is to be found in infra-clavicular,, 
 upper sternal, or infra -mammary regions in front, and 
 the inter- scapular behind. 
 
 It occurs in cases of consolidation, of collections of pus 
 overlying a bronclus, enlarged glands pressing upon the 
 trachea, and occasionally at the base of the lung when 
 dilatation of a bronchus is present, which is associated 
 sometimes with compression of the lung. It has also 
 
TYMPANITIC RESONANCE. 69 
 
 been noticed in deep-seated cavities containing air with 
 solid tissne intervening between it and the thoracic wall. 
 
 Simple dilatations of the tubes will give the same 
 note. 
 
 2. Tympanitic resonance derives its name from the 
 drum-like quality of its sound, which is generally clear, 
 prolonged, and of varying pitch, according to the tension 
 of the elastic walls which surround the cavity yielding 
 this sound. 
 
 In its typical form it is obtained by percussing a dis- 
 tended stomach, the note of which may be low if the 
 tension be not great ; or it may be high, and the vibrations 
 proportionately short, if the tension be very great. 
 
 It is found under the following conditions : — 
 
 1. In pneumothorax, from the collection of air in 
 
 the pleural cavity. 
 
 2. In cavities, the result of phthisis, situated im- 
 
 mediately beneath the chest-walls with little 
 tissue intervening. 
 
 3. The tympanitic resonance of the stomach or colon 
 
 may be transmitted generally over the left side. 
 I have known this mistaken for pneumothorax ; 
 the stomach being very much elevated by con- 
 traction of the left lung. 
 The sound elicited by percussing deeply over an emphy- 
 sematous chest may be called tympanitic, and it par- 
 takes of this quality from the increased size of the thorax, 
 from the increased quantity of air, and from dilatation of 
 the bronchi. 
 
 Superficial percussion, as I have already remarked, 
 elicits what is really the tense tympanitic sound, muffled 
 and quasi-dull in quality. The same hardness of sound 
 is characteristic of the highest note of the piano, which 
 has none of the resonant quality of the bass strings. 
 
 Tympanitic resonance is not uncommon in the upper 
 anterior region of the chest when the lower portion is 
 compressed by fluid, and it is sometimes present in pneu- 
 mjonia of the upper lobe during the stage of hepatisation. 
 
70 PERCUSSION IN DISEASE. 
 
 Upon tte causation of tkis there lias been nincli dis- 
 cussion. 
 
 Skoda, wlio was the first to draw attention to it, taught 
 that it was explained by the fact that the Inngs always 
 yield a tympanitic sonnd when the}^ are partially deprived 
 of air, appealing for snpport of this opinion to experi- 
 ments performed on the dead body; snch experiments 
 must, however, be always regarded snspectedly, inasmnch 
 as they cannot be assimilated to the manifold conditions 
 of life. 
 
 "WilHams beheved that the resonance had a tracheal 
 qnality, and attributed it to condensation of the Inng over 
 the large tubes, the sound being caused by their hyper- 
 resonant properties. This theory, which was also held 
 by Hudson, has been in great measure adopted by 
 "Walshe ; and as long as the resonance is confined to 
 the bronchial regions — that is, close to the sternum in the 
 second interspaces — this interpretation holds good. 
 
 The two conditions are not exactly, as the lawyers 
 would say, on all-fours. "When the sound is noticed in 
 apex pneumonia, it is generally, nieo judicio, towards the 
 end of the disease, when the patient and the lung are 
 recovering. Now, in pneumonia the lung is much 
 enlarged and swollen by the fibrinous exudate into the 
 alveoli, and not only is the lung much denser, but it is 
 also of greater bulk than natural, as shown by the in- 
 dentations of the ribs upon the surface. 
 
 If it happens that the upper lobe in its recovery, as 
 the exudation is absorbed, becomes expansile to air — the 
 chest-wall, however, being still thrown forward by the 
 bulky swelling of the non-absorbed portions of the 
 affected lung — the exjDanding tissue will have to meet the 
 surface of the chest from the pressure of the atmospheric 
 force ; the air-sacs will thus be over- distended and give 
 a percussion note of distension. This is the quality of 
 note which, to nay ear, is sometimes ehcited under such 
 circumstances. 
 
 The condition which also obtains in pleuritic effusion, 
 when the lower part of the lung is compressed by the 
 
REGIONAL DISTRIBUTION OP SOUNDS. 
 
 VI 
 
 fluid (the superior portion yielding a tympanitic resonance 
 to percussion), suggests a similar explanation for that 
 resonance which, as Walshe observes, " is an almost 
 unfailing attendant on pleuritic effusion." 
 
 The walls of the thorax being projected forward by the 
 bulging of the fluid outwards, the lung has to expand to 
 meet the walls, and hence the note of distension above. 
 
 Synopsis of Percussion Sounds. 
 
 Sound. 
 
 Significance. 
 
 ClEAK ok EESOIfANT. 
 
 Healthy Vesicular Eespiration. 
 
 Dun. 
 
 Increased density of Pulmonary Tissue. 
 Absence of air in the Air-sacs. 
 Morbid deposits iu the Air-sacs. 
 
 Tumouv, oV ,he Lung ( SglftoShs. 
 
 Pleural bifusions. 
 
 Aneurisms. 
 
 Very thick Pleura. 
 
 ( JSesonant. 
 Tympaititic \ 
 
 \Miiffied. 
 
 f Contiguity of Stomach and Intestine. 
 
 t Pneumothorax. 
 
 i Distended Stomach. Empiysema. 
 
 * ?"r ^^■feu'Zfhorai i Acu?e^r..etcul„si. 
 
 Amphobic. 
 
 Pneumothorax. 
 Phthisical Cavity with Air. 
 
 Cbacked Pot. 
 
 Cavity with Elastic-walls. 
 Bronchial consolidation with ditto. 
 
 3. Amphoric resonance has the addition of a musical 
 overtone or echo, resembling that produced by blowing 
 into an empty jar. 
 
 It is heard under two conditions — 
 
 1. Over a cavity, containing air (within the lungs), 
 
 opening into a bronchus. 
 
 2. Over a cavity containing air in the pleural cavity 
 
 (outside the lungs), opening through the lungs 
 
 into a bronchus. 
 This last condition may result from perforation of the 
 lung admitting air into the pleural sac, or from an 
 empyema burrowing its way through the lung and 
 
72 PERCUSSION IN DISEASE. 
 
 emptying itself into a bronclius, the pus being ejected by 
 the mouth and air taking its place. 
 
 It may also be heard in cases of pleuro -pneumonia, 
 especially when the walls of the chest are very elastic. 
 
 Cracked-pot sound (Laennec's hridt de pot fele) is very 
 similar to the chinking produced by striking the hands 
 (placed together loosely, palm to palm) upon the knee. 
 The sound is due to the sudden expulsion of air. 
 
 It is found in air-containing cavities with a free com- 
 munication with a bronch as, and when the mouth is open, 
 or when the chest is very yielding over a solid lung. 
 
 It has more interest as a sound than importance as a 
 sign. It should be remembered that it can only be pro- 
 duced generally once or twice at a time, and requires an 
 interval of rest before it can be reproduced. 
 
 The Reg-ional Distribution of Sounds. — However 
 practised an auscultator may be, he knows that, in addition 
 to his knowledge of sounds, he must be furnished with the 
 knowledge of the localities which certain forms of disease 
 principally affect, in order to give a probable interpretation 
 to sounds which may receive more than one explanation. 
 
 The regional distribution of sounds should especially 
 engage the attention of the student, the significance of 
 which will be best appreciated by a close attention to 
 pathology. Diseases, hke plants, have special habitats, 
 and the physician looks to find certain diseases planted 
 in certain districts. 
 
 There are some broad distinctions which may first be 
 insisted upon — 
 
 1. Diseases arising from stasis of the bloodvessels, 
 
 congestions of all forms have a tendency to gravi- 
 tate, and appear in the most dependent parts. 
 
 2. Pleuritic effusions are situated near the diaphragm, 
 
 in the lower half of the chest. 
 
 3. Diseases arising from irritation of the air-passages 
 
 affect the apex and the expansile parts of the 
 lung. This is also true with regard to the 
 inhalation of matter, whatever that matter be. 
 
REGIONAL DISTRIBUTION OF SOUNDS. 73 
 
 Vesicular resonance, detected passing across tlie mid- 
 sternal line from one side, and belonging to the lung of 
 that side, indicates a crippled condition of the opposite 
 lung. 
 
 Eesonance found in exaggerated degree in the axillary 
 regions and lower portions, with indications of phthisis 
 elsewhere, would raise a suspicion of tuberculosis — if 
 associated with aggravation of symptoms. 
 
 Dull percussion, in its various degrees affecting the 
 lower posterior borders of the lungs (especially the 
 right lung), suggests congestions, croupous pneumonia, or 
 pleuritic effusions. 
 
 When situated beneath and close to tlie lo'wer angle 
 of the scapula (especially on the right side), percussion 
 dulness indicates pulmonary apoplexy. 
 
 Over the upper lobe, in moderate degree, it suggests 
 catarrhal congestion, forms of phthisis, and hfBmorrhagic 
 inhalation ; in an absolute degree, the various pneu- 
 monias (croupous, catarrhal, scrofulous), and fibrosis of 
 the lung. 
 
 Over tbe middle portion of both lungs dulness indi- 
 cates brown induration, dependent uj)un mitral regurgi- 
 tation. 
 
 Empyemata are generally localised in the lower axillary 
 region of either side. 
 
 The dulness of enlarged glands and of mahgnant 
 growths is to be looked for in the upper sternal region, or 
 in the inter- scapular region close to the spine. 
 
 Dulness from aneurism is found in the upper sternal 
 region, often to the right side, sometimes to the left ; also 
 in the left inter-scapular and infra-scapular regions. 
 
 Tympanitic resonance, when found in the upper portion 
 of the chest, is due to cavity ; when found in the lower 
 part, it is due to air in the pleural sac. 
 
 These suggestions may be put into the following schema, 
 but it must *be understood that exceptions occur to the 
 rules here laid down, and several diseases are omitted, as 
 being infrequent, and detected better by other signs. 
 
74 PERCUSSION IN DISEASE. 
 
 Regional Significance of Dull Percussion. 
 
 
 ^igJit Side. 
 
 Sternum. 
 
 Left Side. 
 
 •S 
 §^ 
 
 •2 
 
 Supra- 
 clavicular. 
 
 Phthisis, advanced 
 
 Fibroid thickening. 
 
 Apex pneumonia. 
 
 Large glauds. 
 
 Aneurism 
 
 of Innominate Artery. 
 
 Scrofulous 
 glands. 
 Malignant 
 tumours. 
 Aneurism 
 of Arch of 
 Aorta. 
 
 Phthisis, advanced 
 Fibroid thickening. 
 
 Apex pneumonia. 
 Large glands. 
 Aneurism of 
 Left vessels. 
 
 Infra- 
 clavicular. 
 
 Phthisis (all stages). 
 
 Fibroid thickening. 
 
 Congestion. 
 
 ( Croupous. 
 Pneumonia J Catarrhal, 
 i Scrofulous. 
 Brown Induration. 
 
 Aneurism 
 of Ascending Aorta. 
 
 Aneurism 
 
 of 
 
 Arch. 
 
 Mnlignant 
 
 tumours. 
 
 Phthisis (all stages). 
 
 Fibroid thickening. 
 
 Congestion. 
 
 j Croupous. 
 Pneumonia \ Catarrhal. 
 [ Scrofulous. 
 Brown Induration- 
 Aneurism of 
 Descending part 
 of Arch. 
 
 Mammary. 
 
 Pneumonia. 
 
 Pericardial effusion. 
 
 Empyema. 
 
 Hydro thorax. 
 
 Pericardial 
 effusion. 
 
 Pneumonia. 
 
 Pericardial effusion. 
 
 Empyema. 
 
 Hydrothorax. 
 
 
 Supra- 
 scaxjular. 
 
 Fhtkisis, second stage 
 particularly. 
 Pneumonia, 
 Congestion. 
 
 Phthisis, second stage 
 
 particularly. 
 
 Pneumonia (not common). 
 
 Congestion. 
 
 •1 
 
 Scapular. 
 
 Phthisis (all stages) . 
 
 Fibroid disease. 
 
 Pneumonia. 
 
 Phthisis (all stages). 
 
 Fibroid disease. 
 
 Pneumonia. 
 
 •1 
 
 Inter-scapular. 
 
 Phthisis. 
 
 Tumours pressing on 
 
 Bronchus. 
 
 Aneurisms. 
 
 Large glands. 
 
 Phthisis. 
 
 Aneurism of Descending 
 
 Aorta. 
 
 Infra-scapular. 
 
 Pneumonia, croupous. 
 
 Pulmonary apoplexy. 
 
 Congestions. 
 
 Compressed lung. 
 
 Pleural effusions. 
 
 Pneumonia. 
 
 Congestions. 
 
 Compressed lung. 
 
 Aneurism of Descending 
 
 Aorta. 
 
 Pleural effusions. 
 
 ?5 
 
 "1 
 
 Upper. 
 
 Phthisis. 
 Fibroid Disease. 
 Inhaled blood. 
 
 Phthisis. 
 Fibroid disease. 
 Inhaled blood. 
 
 Lower. 
 
 Empyema. 
 Pleural effusions. 
 
 Empyema. 
 Pleural effusions. 
 
75 
 
 CHAPTER XI. 
 
 AUSCULTATION, AND THE STETHOSCOPE. 
 
 Auscultation is the term used to indicate the examina- 
 tion of the chest by the sense of hearing, the ear being 
 applied to the surface to listen for the sounds caused by 
 respiration, the action of the heart and the voice under 
 conditions of health and disease. 
 
 Auscultation may either be immediate, the ear being 
 applied directly to the surface of the body; or it is mediate, 
 some substance or instrument capable of transmitting 
 sound being interposed between the ear of the observer 
 and the chest of the individual examined. 
 
 The most convenient form of instrument is the single 
 stethoscope — a cylinder of pine-wood expanded at one 
 end — to be placed on the chest of the patient, and j&tted 
 above with a large circular flat expansion, the ear-piece 
 applied to the ear of the observer. 
 
 An illustration of a shape which is recommended for 
 ordinary use is given, with the size of the mouth- and ear- 
 piece. The whole length of the instrument should be 
 seven inches, the diameter of the cylinder five-eighths of 
 an inch; the ear-piece being about three inches in diameter, 
 and the mouth one and one-eighth of an inch. 
 
 The ear-piece should be slightly hollow, and adapted to 
 the ear. If carefully made with good pine, the stethoscope 
 can bear a good deal of use without breaking. If a tougher 
 instrument is required, it may be made of American birch. 
 
 The metal stethoscopes are extremely objectionable, and 
 should not be used, inasmuch as they impart a metallic 
 sound of their own to all vibrations transmitted through 
 them. 
 
76 
 
 AUSCULTATION, AND THE STETHOSCOPE. 
 
 The double stetlioscojDe, of wliicli an illustration is given, 
 is of great value, increasing the sounds heard over the 
 chest, and preventing any extraneous noises from reaching 
 the ears during auscultation. It also has the advantage 
 
 Fig. 15. 
 
 Stethoscope. — A, size of ear-piece D. B, size of mouth C. 
 
 of using both ears equally, and the patient can be examined 
 by it with greater ease. 
 
 This stethoscope can be furnished with one end or two. 
 With two mouth-pieces it can be used for comparison of 
 sounds in different regions, which is often advantageous 
 in determining the exact localities of cardiac sounds. 
 
 The first mediate instrument used by Laennec on the 
 occasion of the discovery of mediate auscultation (the 
 
STETHOSCOPES. 77 
 
 embryo, in fact, of tlie stethoscope) was a quire of paper 
 tightly rolled up into cylindrical form : the present shape 
 of the stethoscope resulted from modifications suggested 
 by Piorry upon the form of instrument devised by 
 
 f IG. 16. 
 
 Double Stethoscope. 
 
 Laennec. When the instrument is being used it must 
 be held lightly like a pen, placed quite flat upon the 
 surface, and closely applied with gentle pressure to the 
 part examined. 
 
78 
 
 CHAPTER XII. 
 
 THE ACOUSTICS OF PULMONAEY AUSCULTATION. 
 
 Before proceeding to describe the sounds to be heard and 
 listened for in auscultation, it may help to clear the 
 ground if I give some brief account of the influences 
 which modify these sounds. We are now considering 
 sounds caused by air in motion, passing through tubes, 
 and transmitted through various materials to the ear 
 placed outside the chest. 
 
 If the air contained in a tube be set in motion — as, for 
 example, by blowing across the mouth of such a tube, or 
 if it be driven along a tube — the agitation gives rise to 
 a series of vibrations producing peculiar sounds ; some- 
 times only a flutter or puff is audible, sometimes (if the 
 vibrations are sufficiently rapid and regular) musical 
 sounds are heard. 
 
 Sounds are caused by currents of air passing through 
 tubes, the air column being thrown into vibration. This 
 especially happens when the air is thrown against edges 
 and broken up ; in this manner giving rise to fluttering 
 noises similar to that produced in an organ-pipe by air 
 driven against the sharp edge at the mouth of the pipe. 
 The pipe takes up this flutter, and converts it by its own 
 resonance into a musical note. In the production of voice 
 sounds, the air is thrown against the vocal chords, and 
 into the resonant cavity of the mouth. In the production 
 of pulmonary sounds, air is drawn through the glottis 
 into the tubes, a pufi" or blowing sound being thus 
 produced. 
 
 Sound is very mach diminished in passing from one 
 kind of substance to another — it is, in fact, diffracted in the 
 
TRANSMISSION OF SOUND. 79 
 
 same maimer as light, and it is broken np wlien passed 
 from tlie vocal chords tkrongli healthy lung to the 
 snrface of the chest. If the stethoscope be placed in the 
 trachea the voice sounds will be heard clear and loud; 
 but let it be placed in the axillary region, and an indistinct 
 buzzing, from confused vibrations, can only be heard — 
 articulate sounds being lost. 
 
 This may happen in some measure from the closed 
 condition of portions of the lung, which is not fully and 
 rigidly expanded in health; but whatever be the true 
 interpretation, the fact is indubitable. 
 
 In conditions of disease, however, the voice sounds and 
 the blowing tubular sounds formed in the trachea are 
 transmitted with intensity ; and it appears that intensity 
 is retained by passage along rigid tubes, as well as by 
 conduction through solid matter. 
 
 The diScerence in the intensity of a sound transmitted 
 through india-rubber piping and a rigid cylinder is very 
 great. Biot found that he could hold conversations 
 through an iron pipe 3000 feet in length. This explanation 
 appears to me the best adapted to meet the phenomena 
 of transmitted voice sounds, which will receive further 
 consideration when Bronchophony is discussed. 
 
 Experiments made on lungs removed fi'om the body, 
 or on the dead body, even with the organs in situ, are 
 to my mind of no value; and some very valid objections 
 against conclusions derived from such experiments have 
 been concisely urged by Walshe. 
 
 Some experiments recorded in the Bevue Mensuelle for 
 1877, by M]M. Bondet and Chauveau, are worthy of con- 
 sideration in illustration of this subject. 
 
 The experiments were made on a mare affected with 
 inflammation of the left lung, which was consohdated. 
 Auscultation of this lung detected the presence of a 
 double blowing sound over the upper half ; and over the 
 trachea a double tubular sound, having the same character 
 as those heard over the lung, but of much greater intensity. 
 An incision was made in the trachea, but a little blood 
 
80 ACOUSTICS OF PULMONARY AUSCULTATION. 
 
 dribbled into tbe tubes from the wouud, giving rise to 
 coarse bubbling rattles, and an interval of time was allowed 
 to elapse until the sounds had returned to their previous 
 condition. When the wound was kept open inspiration 
 was no longer blowing, while expiration was still but only 
 slightly blowing. On one or two occasions the sounds 
 heard with such intensity over the consolidated lung were 
 temporarily completely suspended and annulled, evidently 
 by the presence of a plug of mucus in the tubes, as they 
 were restored after the animal had coughed the plug 
 away. 
 
 On the healthy side the vesicular murmur was normal 
 and distinct. 
 
 An india-rubber tube, with reed attached, was then 
 inserted into the trachea, and air was forced through the 
 reed. The noise was most distinctly heard, and it seemed 
 to be produced close to the ear listening over the con- 
 solidated portion of lung. The healthy tissue, on the 
 contrary, failed utterly to conduct the sound. 
 
 It is quite evident from these experiments that sounds 
 produced in the trachea or larnyx are not transmitted 
 along tubes surrounded with healthy lung tissue, but are 
 passed without loss along tubes surrounded by solid 
 matter. Bat it is also evident that the blowing sound in 
 the trachea was heard, although in diminished intensity, 
 over the solid lung ; and, moreover, that this was caused 
 partly by the passage of air through the glottis, inas- 
 much as it was lost when the air passed through the 
 wound in the trachea. 
 
 The abolition of the sounds from the presence of a plug 
 in the tubes appears to prove that the sound is trans- 
 mitted mainly by the air in the tubes. 
 
 These experiments are of a simple character, but they 
 throw light on many obscure points which deserve full 
 consideration. 
 
 A great deal of discussion has been raised with regard 
 to the cause of the vesicular pulmonary murmur, which I 
 shall not reproduce here, inasmuch as I believe the con- 
 
THE VESICULAR SOUND. 81 
 
 elusions of Barth and Eoger (which are supported by 
 their experiments) and those of Walshe are correct — 
 namely, that the sound is complex, that the true vesicular 
 sound is found in the air-sacs, but that some portion 
 of the pulmonary sound is transmitted from the bronchial 
 tubes. The conditions which appear to affect the trans- 
 mission of sounds from the trachea are very complicated ; 
 the condition of the tubes, the tension of the air-sacs, the 
 close approximation or adhesion of the surface of the 
 lung to the chest, and the presence of foreign matter in 
 the place of air, all have to be considered in this complex 
 problem. One lesson at least we may learn from all these 
 difficulties — that the interpretation of the significance of 
 any sound for the purpose of diagnosing the condition of 
 the thoracic organs can only be made after careful 
 deliberation with respect to all the signs and symjptoms 
 which may result from a full examination of the patient, 
 and reason must decide upon the varied phenomena 
 which are presented, not only to the ear but to all the 
 other senses. 
 
 Tubal sounds are modified by the presence of fluids 
 which give rise to bubbling sounds of more or less fluidity 
 or viscidity, according to the nature of the secretion. Often 
 vibrations are thus set up in the tubes which produce 
 sounds differing in pitch, according to the size of the tubes 
 in which they originate ; the large tubes sounding deep 
 snoring notes, the small tubes high-pitched, whistling, or 
 wheezing notes. 
 
 Sound is very much broken up and diminished by 
 having to pass from one medium to another ; a fact which 
 is illustrated by a simple experiment. Put a solution of 
 a carbonate (potash or soda) into a large glass, and ring 
 the glass by tapping it : the sound is free and clear. But 
 add a little acid to the watery solution, bubbles of carbonic 
 acid are given off, and if the glass be touched now it will 
 be found that the sound has gone, only coming back when 
 the effervescence ceases. 
 
 So also sound in passing from lung to fluid is much 
 
 G 
 
82 ACOUSTICS OF PULMONARY AUSCULTATION. 
 
 broken up, but it would be a mistake to suppose tbat 
 because little sound can be heard tbrougb pleuritic 
 effasions tbat fluid therefore does not conduct sound, 
 the fact being tbat tbe velocity of sound in water is more 
 tban four times its velocity in air. Tbe sounds of 
 respiration are not only diminisbcd by diffraction in 
 passing through another medium, but also, it must be 
 remembered, that the pressure of the fluid prevents the 
 expansion of the lung. The heart's sounds, it must be 
 mentioned, are heard in such cases. 
 
 The amphoric and metallic sounds that are heard in 
 some cases of disease are additional sounds (overtones) 
 added to the primary sound. If a jar or bottle be 
 blown into, a distinct additional sound is heard, as well 
 as a low note, which may be called the fundamental note ; 
 with the metallic sound the overtone is of a remarkably 
 ringing high-pitched character, and well imitated by 
 dropping a pin into a glass. 
 
83 
 
 CHAPTER XIII. 
 
 AUSCULTATION OF THE HEALTHY LUNGS. 
 
 The person nnder examination should assume tlie posi- 
 tion whicli has already been recommended as the best 
 suited for percussion of the chest ; the erect posture is 
 the easiest, but if it be more convenient for the patient to 
 be seated, the examiner should kneel on one knee by the 
 side, in order that his head may not be much bent. 
 Dress should be removed, so as to have at least the upper 
 part of the chest uncovered ; with men it is much better 
 to have the shirt taken off. Before entering upon a 
 description of the sounds of respiration, I must first warn 
 the student of certain fallacies to be avoided in the shape 
 of— 
 
 Extraneous Sounds. — Flannel, rough linen or cotton, 
 chest-protectors, and all manner of rustling stuffs should 
 be put out of the way, or crepitant and friction sounds, 
 entirely obscuring diagnosis, will assuredly be heard on 
 listening through the stethoscope. The hands should be 
 kept from the chest, as their rubbing becomes very 
 audible. The creaking made by stays renders it advisable 
 that these articles of dress should be taken off. 
 
 Sounds of Hair. — In some persons the presence of much 
 hair about the chest is a serious obstacle to free ausculta- 
 tion, and a rough skin, as, for example, ichthyosis, and the 
 like. 
 
 Muscular Ddurmur. — This sound is heard during the 
 contraction of muscle ; more superficial than the pulmo- 
 nary sound, low in pitch, and of a continuous rumbUng 
 quality ; it occurs where the muscles are thickest under 
 the humeral end of the clavicle, and above and below the 
 spine of the scapula. 
 
 g2 
 
84 AUSCULTATION OF HEALTHY LUNGS. 
 
 It is easy to solve any difficulty with regard to ttis 
 sound, by making tlie patient liold his breath and con- 
 tract the muscle under the stethoscope ; the muscular 
 murmur will then continue, the pulmonary sounds 
 being silent. 
 
 Professor Haughton has some interesting remarks on 
 this sound. Dr. WoUaston, who called attention to it in 
 1809, likened it to the rumbling of distant wheels. 
 
 Haughton found that it corresponded to DDD sHghtly 
 flattened, or two octaves below the ordinary bass D, cor- 
 responding to thirty-six vibrations in the second. 
 
 From a calculation made with regard to the vibrations 
 of wheels, their rumble corresponded to thirty-five vibra- 
 tions per second ; a calculation which curiously supports 
 WoUaston's description. 
 
 Eemarkable instances sometimes occur and the follow- 
 ing case is worthy of note : — It was observed in a man who 
 was largely employed in delivering circulars in London, 
 and from his insufficient food suffered much from muscu- 
 lar exhaustion and over-walking. The muscles were 
 ]Deculiariy irritable, and subject to fibrillations and twitch- 
 ings. The pulmonary sound was almost obscured by the 
 noise of the muscular murmur. 
 
 THE RESPZRilTOnV SOVNUS OF KEAl^TK. 
 
 The air is conducted from the mouth through the 
 glottis and trachea into the large bronchi. These tubes 
 subdivide rapidly and terminate in minute bronchioles, 
 which conduct the air to the spongy elastic air-sacs 
 situated round the thoracic walls. 
 
 The sounds which are heard in various regions during 
 the act of respiration are modified according to the parts 
 over which auscultation is directed ; and it is necessary 
 to distinguish three kinds — 
 
 1. Tracheal. 2. Bronchial. 3. Vesicular. 
 
 1. Tracheal. — This sound is heard by placing the 
 stethoscope over the trachea or larynx. 
 
 The (Quality of sound is that of a harsh rushing cur- 
 
BRONCHIAL AND VESICULAR SOUNDS- 85 
 
 rent to and fro (up and down) tlirongli a tube ; it CEin 
 be imitated by pursing the lips togetber and drawing 
 air in and expelling it ratber sharply. 
 
 This quality is termed tubular, and this sound gives 
 the characteristic indication of what is meant by this 
 term. 
 
 The pitch is high, and the intensity varies according to 
 the act of respiration, being loud in deep breathing. 
 There are differences with regard to the inspiratory and 
 expiratory sounds, which demand attention. 
 
 Inspiratory. — Quality, tubular; pitcb, high; in- 
 tensity, variable; duration, shorter than the inspi- 
 ratory act. 
 
 Expiratory. — Quality, the same ; pitch, higher ; 
 intensity, greater ; duration, often longer than the 
 insyjiratory. 
 
 There is a short interval which separates these sounds. 
 
 2. Bronchial. — This sound is a modified form of the 
 tracheal, than which it is less intense, not so whiffing in 
 quahty, nor so hollow ; it may be imitated by not closing 
 the lips so tightly as for the tracheal, the opening being 
 larger, and the sound resembling that of " whoo." As 
 compared with the pulmonary sound it is harsher, higher 
 pitched, and tubular. 
 
 This sound is heard on listening over the second 
 interspace close to the sternum, in front on either 
 side, and behind, in the middle of the inter-scapular 
 regions of either side between the fourth and fifth dorsal 
 vertebrae. 
 
 3. Vesicular IVZurmur. — This term, as being that used 
 byLaennec, I have kept to indicate the sound of respiration. 
 In its typical form it is best heard in the upper axillary 
 region, and also in the infra-clavicular, which is usually 
 the region appealed to for the sound of healthy breathing. 
 This m.urmur is peculiar to a condition of healthy elas- 
 ticity of the air- sacs : the sound is never simulated by 
 disease, and affords conclusive proof of a healthy con- 
 dition of the part from which the sound issues. It may 
 
86 
 
 AUSCULTATION OF HEALTHY LUNGS. 
 
 be studied witli advantage in cliildren, owing to its greater 
 intensity in early life. Its intensity varies with indivi- 
 duals; it is loud in cliildliood, feeble in old age, and 
 louder in women than in men. 
 
 Quality. — To this the term vesicular may be applied, 
 the character of the sound being soft and rustling, 
 Laennec compared it to the sound made by a bellows 
 without a valve ; a better comparison is the soft murmur 
 of a summer breeze through the leaves. 
 
 The difference between the sounds of inspiration and 
 expiration is very important, and must be carefully 
 studied and learnt. 
 
 Inspiratory sound begins with a soft distant whisper, in- 
 creasing with inspiration, and becoming rustling in quality 
 at the end of the act. It is heard from beginning to end 
 of the inspiratory act. 
 
 Pitch, low but higher than that of expiration. 
 
 Expiratory sound begins with the gentle rustle and 
 passes into a low-pitched breath or puff, which is neither 
 vesicular nor bronchial in quality. The sound goes away 
 from the ear, and is much shorter than that of inspira- 
 tion. 
 
 Pitcb, lower than that of inspiration. Intensity, less. 
 
 Synopsis of Respiratory Sounds. 
 
 Characters. 
 
 Inspiratory. 
 
 Expiratory, 
 
 Quality. 
 
 A soft breath, 
 ending in a rustle. 
 
 A rustle, ending 
 in a soft puff. 
 
 Pitch. 
 
 Higher. 
 
 Lower. 
 
 Intensity. 
 
 Greater. 
 
 Less. 
 
 Duration. 
 
 3, 
 
 1. 
 
 The tollowing are the regional peculiarities in the 
 respiratory sounds : — 
 
 Tracheal, heard at the upper sternum. 
 
VOCAL RESONANCE. 
 
 87 
 
 Broncblal, in front at the second intercostal space, 
 right and left, at the back between the fourth and 
 eighth dorsal vertebrae, more marked on the right side. 
 
 Vesicular, best heard in the upper axillary, infra- 
 clavicular, infra- scapular, and mammary regions. 
 
 There are some differences in the respiratory murmur 
 of the two sides. 
 
 Sound. 
 
 BigM side. 
 
 Left aide. 
 
 Inspiratory. 
 
 Less intense. 
 Less vesicular. 
 Higher in pitch. 
 
 More intense. 
 More vesicular. 
 Lower in pitch. 
 
 Expiratory. 
 
 Longer. 
 Higher in pitch. 
 
 Shorter. 
 Lower in pitch. 
 
 Vocal Resonance. — When the stethoscope is placed 
 above the sternal notch upon the trachea, and the person 
 examined speaks, the voice is transmitted with great and 
 even painful intensity, the sounds being concentrated into 
 the ear, the words being imperfectly articulated. At the 
 upper sternal region this resonance is diminished, and it 
 becomes weaker as the stethoscope is carried down the 
 bronchi. Over these parts the articulation of words 
 becomes very imperfect, the sound being diffused and no 
 longer appears to be concentrated directly into the ear, 
 but to come from a distance. This constitutes XTormal 
 Broncbopbony . 
 
 When much pulmonary tissue intervenes, and the 
 stethoscope is placed over regions where the vesicular 
 murmur is best heard, the articulation of words is ob- 
 literated, an indistinct buzzing solely is heard, the voice 
 sound scarcely reaching the ear at all. Yoice resonance 
 varies in individuals, and it is increased or diminished by 
 the foUowiug conditions : — 
 
88 AUSCULTATION OF HEALTHY LUNGS. 
 
 Increase. Diminution. 
 
 L««d I ^^^^_ ■ Feeble ) ^^-^^ 
 
 Low-pitclied ) High-pitcned ) 
 
 In men, In women. 
 
 In old people, In children. 
 
 In front, Betind. 
 
 Riglit side, Left side. 
 
 Clavicular 7 • Cardiac ) 
 
 V regions. ^ ^. > regions. 
 
 Inter-scapular J Hepatic i 
 
 "Wliisper. — Articulated speech, formed in the mouth 
 by the air of expiration (or inspiration) without the 
 intervention of voice sounds produced by the vocal chords, 
 constitutes whispering. 
 
 Yoice sounds can be formed by singing with the open 
 mouth without articulation. 
 
 Articulated sounds can be produced with laryngeal 
 or true voice sounds, by ordinary speech, or by vocalising 
 words (in songs), or 
 
 Articulated sounds can be produced without laryngeal 
 sounds, as by whispering. 
 
 The chief advantage of the whisper appears to lie in 
 the total absence of vocal fremitus, which interferes to a 
 great extent with the appreciation of transmitted sounds ; 
 moreover, sometimes the voice is transmitted with such 
 vibration and force as to be extremely painful to a deli- 
 cate ear. This sound must be conducted by the air in the 
 tubes ; from the trachea the whisper is conducted to the 
 ear as a high-pitched blowing sound, the words being 
 transmitted but not distinctly, while from the pulmonary 
 tissue it is conducted as a feeble, low-pitched blowing 
 sound (often it is inaudible), louder generally on the 
 right than the left, and of lower pitch on the right 
 side. 
 
 Fremitus, the palpable vibrations of sound, has already 
 been described in the chapter on Palpation. 
 
 Cougli> — In health the act of coughing is not accom- 
 panied by a shock of succussion, but gives rise to a hollow 
 sound, heard with the expiration over the trachea, and to 
 
USE or COUGH. 98 
 
 a short, dull, diffused sound heard over tlie pulmonary 
 tissue. 
 
 By the act of coughing air is forcibly expelled from the 
 lungs so as to induce free inspiration and expansion of 
 the air-sacs with the next breath, and by removing plugs 
 of mucus which obstruct the bronchial tubes ; or by 
 driving air into fluids, which otherwise remain quiescent 
 and silent, it may be made subservient to the purposes of 
 diagnosis. 
 
90 
 
 CHAPTER XIY. 
 
 AUSCrLTATION IN DISEA.SE OF THE LTJNG. 
 
 ncorbid sounds, caused by various conditions of disease 
 of the lungs, may be classified under three headings : — 
 
 1. Variations of vesicular sounds, 
 
 2. Alterations of respiratory sounds. 
 8. Adventitious, or ne-w sounds. 
 
 1. Under the first head may be described the pheno- 
 mena of those conditions which induce variations 
 (including total suppression) of the vesicular sounds, as 
 regarding 
 
 a. The intensity of the vesicular murmur. 
 h. The delivery or rhythm of respiration. 
 The intensity of the vesicular murmur may be — 
 Increased, Diminished, Suppressed. 
 Increased Vesicular Murmur (Exaggerated). — 
 This is due to functional activity of one lung or a por- 
 tion of lung from morbid diminution of function conse- 
 quent upon disease in another part. 
 It is sometimes termed 
 
 Puerile \ 
 
 Supplementary > Breathing. 
 Compensatory j 
 It foreshadows the substantial presence of disease in 
 some other region, and is more intense in proportion to 
 the vicinity of the disease. Its extent must be carefully 
 examined and tracked (if necessary) across the mid- 
 sternai line ; i£ the opposite lung be useless from phthisis, 
 fibrosis, or perforation, the sound lung may increase to a 
 very large extent. 
 
 :Qiminished Vesicular Murmur, — This may occur 
 
ALTERED VESICULAR SOUNDS. 91 
 
 simply from functional weakness, tlie resnlt of constitu- 
 tional debility or of some enfeebling disease ; it may be 
 due to disease extraneous to the lungs, as in paralysis, 
 peritonitis, ascites, and abdominal tumours of all kinds ; 
 to organic disease involving tbe respiratory apparatus, as 
 in obstructive disease of the larynx and bronchi, and 
 diseases of the lungs and pleura. 
 
 It may be persistent, as in prolonged and continued 
 organic diseases; or it may be intermittent, as in pleuro- 
 dynia, asthma, and temporary obstructions of the air- 
 passages. 
 
 The most common persistent diminution results from 
 pleural adbesion. 
 
 It must also be remembered that the chief part of the 
 inspiratory act being due to the contraction of the 
 diaphragm, anything which interferes with its full action 
 will diminish the vesicular murmur of inspiration in the 
 upper lobe. 
 
 Suppressed Vesicular XVIurmur. — This is complete 
 absence of sound — silence during respiration. It may 
 arise from complete obstruction of the air-passage, the 
 effusion of fluids into the pleural sac, or the presence of 
 air there. 
 
 It is also due to chronic conditions of fibrosis with 
 complete adhesion of the pleura. These silent conditions 
 must not be passed over as unimportant ; the absence of 
 sound is much more difficult to diagnose than its pre- 
 sence. 
 
 Alterations in Rliytbni, — The actual duration or the 
 relative proportion of inspiration and expiration may be 
 altered, and give rise to corresponding alterations of 
 sound. 
 
 Inspiration may be morbidly shortened, or it may be 
 deferred. 
 
 Shortened inspiration may be due to hampered 
 expansion of the lung, as from adhesion of the pleura, or 
 from incipient and painful pleurisy. 
 
 If the air-sacs are occupied, as, for example, in early 
 
92 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 stages of consolidation, the inspiratory act may continue 
 after tLe sound has ceased. 
 
 Deferred inspiration is an important sign in emphy- 
 sema. The respiratory act begins and continues before 
 the air- sacs respond to the expanding air. It also occurs 
 in distensiou of the lung from any cause, whether it be 
 compensatory or the result of tubercle. 
 
 Expiration may be morbidly shortened or prolonged. 
 
 Shortened expiration occurs as a result of distended 
 lung : the complete closure of the air-sacs is prevented in 
 consequence of the extra atmospheric pressure which 
 strains the particular regions distended. The dissemi- 
 nation of hard tubercle in certain air-sacs compels the 
 extra distension of others in the vicinity. 
 
 Prolonged expiration may be due to diminished elas- 
 ticity of the lung, and is a frequent sign of emphysema. 
 To such an extent may this be carried as to reverse the 
 ordinary proportions of inspiration and expiration. 
 
 Prolonged expiration has been by many considered as 
 evidence of phthisis and an indication of an early deposit 
 of tubercle, but as long as the pitch of the sound is normal 
 in character, no importance can be attached to this sign. 
 It must be remembered that the inspiratory sound may 
 be considerably prolonged, on the right side particularly, 
 and yet be quite consonant with a healthy state of lung. 
 As this is very generally believed to be an important sign, 
 I shall quote the opinions of Walsbe and Flint, with 
 whose conclusions I perfectly agree. 
 
 Walshe says* on this sign : " The signification of the 
 expiratory sound was in some degree mistaken by its re- 
 discoverer, Jackson; he exaggerated its specific importance 
 as a diagnostic sign of tubercle, and in this he has been 
 very generally followed. Many persons forget that what 
 may appear in a given individual as compared with 
 another, prolonged expiration, is really in him a natural 
 state." 
 
 Diseases of the Lungs and Heart, p. 100. 
 
SUPPRESSED EXPIRATION. 93 
 
 Flint says :* " A prolonged expiration at tlie snmmit 
 of the chest on the right side is sometimes incorrectly 
 considered to be evidence of phthisis. It is to be recol- 
 lected, in the first place, that prolongation of this sound 
 with a normal pitch and quality is never evidence of 
 solidification of lung, either from phthisis or any other 
 disease ; and, in the second place, even if the pitch be high 
 and the quality tubular, that it is not to be regarded as 
 abnormal, provided the inspiratory sound is unchanged 
 and other signs of disease are not present." 
 
 Vesicular resonance alone, which is simply prolonged, 
 must not be accepted as evidence of disease. 
 
 Suppressed expiration is only heard under one con- 
 dition of disease — an old contracting cavity. I have now 
 watched many cases, especially in young persons, in 
 whose lungs a cavity has formed and healed, and the only 
 sign revealed to the ear was a complete suppression of 
 the expiratory sound. In a number of cases this has been 
 observed on the left side ; in some cases the cavity has 
 been so small and the improvement so great that little 
 retraction was perceptible, but in other cases flattening 
 has taken place, together with some dislocation of the 
 heart upwards. 
 
 The explanation of this depends upon the contraction 
 of the tube communicating with the cavity, which will 
 admit air in free expansion, but soon shuts so as to 
 prevent at least any sound of expiration. The sign is by 
 no means infrequent (if the number of healed cavities be 
 taken into account), and is of great diagnostic value. 
 
 The inspiratory sound is usually in these cases high- 
 pitched but still vesicular, in consequence of the ex- 
 pansion of lung tissue in the vicinity of the cavity. 
 
 The evidence in proof of this statement is derived from 
 observations extending over some months, and even years, 
 during which time the cavity has been detected from its 
 origin to its contraction. In other cases the presence of 
 
 * On Auscultation, p. 110. 
 
94 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 the cavity has been substantiated by other physical 
 signs. 
 
 Eespiration may be hesitatingr in its delivery ; there 
 may be some interruption to free breathiag, instead of a 
 continuous delivery. This constitutes stammering, or 
 wavy respiration, i^ow, as long as this interruptedness 
 is not regular and uniform it is generally due to nervous 
 respiration, and is to be found in hysterical and hypochon- 
 driacal individuals, especially at a first examination. If 
 this be the cause, it passes off when the patient has become 
 more tranquil. 
 
 If respiration be short and jerky the interruption may 
 be caused by pain, and this condition is found in pleuro- 
 dynia and early pleurisy. 
 
 Marked jerking^ occurs when partial or long adhesions 
 have taken place, the continuous expansion of the lung 
 being thus prevented ; this may be found in progressing 
 adhesion of the pleura in the middle region, between 
 complete adhesion and incipient pleurisy. Under these 
 conditions, however, it coexists with other signs. 
 
 Cog-^ed respiration is a sign of more importance, and 
 I believe is found in the early stages of cancer when 
 obstruction of the bronchial tubes is produced by this 
 cause. In such a state of disease the cogging is very 
 slow, with long but regular intervals between ; it is most 
 marked during expiration. 
 
 It is also met with, as Walshe observes, in connection 
 with tubercle, and I have found this more especially at 
 the back of the lungs. This kind of cogging is very fine, 
 the intervals being small and frequent, and is probably 
 caused by agglutination of the tubes, in which a thick 
 glutinous exudation is often found from tubercle. It is 
 sometimes heard at the apices, but I have more often 
 met with it at the bases of the lungs. 
 
 2. The second class of sounds comprises those modifica- 
 tions in which the vesicular murmur is altered in quality 
 and pitch. 
 
 One of these is a dry papery quality of the vesicular 
 
ADVENTITIOUS SOUNDS- 95 
 
 munmir; an early indication, in my opinion, of 
 sypliilitic pulmonary disease. Many instances of this 
 have come under my observation, and it is a noteworthy 
 sign of the pulmonary disease which is found coexistent 
 solely with syphilitic cachexia ; I conclude therefore that 
 it is specific. In more advanced stages it is accompanied 
 with considerable harshness of sound, which is sharper 
 and more blowing in character. 
 
 This latter sound also belongs to peribronchial 
 thickening of all kinds when it is tubular in character, 
 and to thickened states of the pulmonary tissue when it 
 is high-pitched. 
 
 The last quality of sound is especially heard in cases of 
 profuse haemorrhage from the lungs, and I beheve it to 
 be due to the inspiration (insufflation) of blood into the 
 lungs, the blood corpuscles actually passing into the 
 alveolar tissue and stiffening it. 
 
 3. Adventitious sounds are those which have no 
 similarity to healthy sounds, and indicate in all instances 
 disease of some kind. 
 
 Although it is not desirable to refine overmuch in the 
 verbal description of sounds, it is necessary to separate 
 into distinct classes sounds which are capable generally 
 of some peculiar interpretation ; but the student must 
 distinctly understand that the object in view is a different 
 one from that of insinuating that a particular process has 
 throughout its progress one special soundpathognomonic of 
 that process solely. The varieties of sound are as different 
 as the shades of colour ; and, although broad distinctions 
 of a general kind may be put on paper, the difficulties of 
 defining a sound in practice and of forming a prognosis 
 from sounds are almost overwhelming ; and the marvel is, 
 not that errors should be committed, but that a just esti- 
 mate of the process and progress of a disease should so 
 often and with so much accuracy be made. 
 
 The classification which I shall adopt as best suited 
 for practical use is the following : — It will be found con- 
 venient to consider morbid sounds as arising from — 
 
96 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 a. Diseases of tbe alveoli. 
 
 Id. Diseases of tbe broncbial tubes. 
 
 c. Destructive diseases of tbe lung:. 
 
 d. Diseases of tbe pleura. 
 
 Some preliminary remarks are necessary as to the 
 terms used, as it has frequently happened in works on this 
 subject that one sound is expressed in different terms, 
 and consequently a good deal of confusion has arisen. 
 The terms used here shall be as far as possible those that 
 were introduced by Laennec, but they cannot always: 
 be used in exactly the same manner aud with the same 
 limitation ; besides which it is necessary to use additional 
 terms of EngHsh origin, sanctioned by the authority of 
 Enghsh writers. 
 
 The terms used by Laennec were the following : — 
 
 1. The rale crepitant humide, or crepitation. 
 
 2. The rale inuqueux-, or gargouillement. 
 
 3. The rale sonore sec, or ronflement. 
 
 4. The rale sibilant sec, or sifflement. 
 
 5. The rale crepitant sec a grosses hulles, or craquement. 
 
 The terms in general use in England have been the 
 word rale adopted from the French, signifying rattle ; 
 crepitation, signifying a crackle ; and rhonchus, adopted 
 from the Greek, signifying snoring. Unfortunately con- 
 fusion has arisen from the use of the last term rhonchus as 
 a substitute for rale, and the word has been used by Williams 
 and Walshe in this sense. The objection to this lies in the 
 fact that simple bubbling has no snoring quality about it^ 
 and I have used the term rhonchus solely to indicate the 
 snoring sound heard in diseased conditions of the large 
 bronchi. 
 
 The terms used here will be the following : — 
 
 Crepitation, a fine dry crackle. 
 
 Rale, the rattle of bubbles bursting. 
 
 Rboncbus. a snoring sound. 
 
 Sibilus, a whistle of varied pitch. 
 
 Gurgle, a hollow gurgling rattle. 
 
FINE CREPITATION. 97 
 
 Other words and adjectives will be used to indicate the 
 special quality of sounds in proportion to their approxi- 
 mation to any of the above terms, and it will be my 
 endeavour to keep the divisions distinct and simple, 
 rather than by over-refining to multiply differences and 
 increase confusion. 
 
 Rale was the term applied by Laennec to the sound 
 caused by the passage of air through liquids, the typical 
 rale being the load rattle of the dying; the air passing 
 through the secretions collected in the tubes and the 
 bases of the lungs owing to the strength of the patient 
 being no longer effective to expel them. 
 
 Adventitious vesicular sounds may be divided into the 
 following classes ; and they will be named mainly with 
 reference to their degree of moisture, although their 
 respective significance is very different : — 
 
 1. Fine crepitation. 3. Subcrepitant rale. 
 
 2. Crepitant rale. 4. Bubbling rale. 
 
 1. Fine crepitation indicates the crackle of a dry but 
 sticky surface, imitated very exactly by rubbing a lock of 
 hair close to the ear between the finger and thumb. 
 Laennec compared it to the crackhng of salt in the fire. 
 This sign is the most distinct and best defined of any 
 throughout the range of auscultation. 
 
 It may be described as composed of a multitude of 
 minute dry crackles, following closely and regularly one 
 upon the other during the act of inspiration solely. The 
 idea of bubbHng is not present to the mind when this sound 
 is heard, and indeed it is often dif&cult (except by the to- 
 and-fro nature of its production) to distinguish between 
 the fine crepitation of pneumonia and the fine friction of 
 the pleurisy which so often accompanies the former disease. 
 Flint has a very graphic description with reference to this 
 sound of pneumonia, which is worth quoting. He remarks 
 of it : "' A distinctive feature is the abrupt development of 
 the crepitant rale ; a shower of crackles, as it were, springs 
 up at the end of a forced inspiration." If I may venture on 
 a simile, I should say that it reminds me of the explosion 
 
 H 
 
98 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 of a maroon rocket bursting suddenly into a shower of 
 crackling and brilliant stars. 
 
 The similarity of the sonnd produced by rubbing hair 
 or squeezing a piece of spongy india-rubber suggests that 
 it is caused by the successive unfolding of surfaces 
 agglutinated together, and this theory accounts for the 
 limitation of the sound to inspiration. 
 
 This sign is characteristic of pneumonia of the croupous 
 form, but not of that form only, as it is sometimes heard 
 in catarrhal pneumonia, a disease which has a different 
 termination, duration, and prognosis. 
 
 I have watched cases of catarrhal pneumonia beginning 
 with this sign and rapidly going on to consolidation, 
 simulating very closely the croupous form of pneumonia 
 in physical signs, the aspect and subsequent condition of 
 the patient sufficiently indicating the nature of the disease, 
 which has been afterwards determined by actual inspection 
 in the dead-house. 
 
 The fine crepitation of croupous pneumonia is of short 
 duration, and is accompanied by symptoms indicating 
 great disturbance. Catarrhal pneumonia is more insidious 
 and prolonged ; other forms of pneumonia and congestion 
 sometimes simulate this sound very closely, but it will be 
 sufficient to mention the fact. 
 
 Reg^ional sigrnificance. — Croupous pneumonia attacks 
 lobes ; catarrhal pneumonia attacks lobules. In the first 
 case, large tracts of the base or the apex are involved ; in 
 the latter, the spots over which the sounds may be heard 
 are more limited, and not generally occupying the borders. 
 They are more central ; moreover, isolated patches some- 
 times occur with intervening lobules unscathed. 
 
 2. Crepitant rale. — This term is used as intermediate 
 between fine crepitation, which is of a dry, sticky character, 
 and the true rale, which has a bubbling quality. It is 
 synonymous with the moist crackling rhonchus of Walshe, 
 or the humid crepitation which is of classic use in the 
 Brompton Hospital. It will be seen that I have adopted 
 partially a term of Laennec's, but it is to be hoped that 
 
CREPITANT RALE. 99 
 
 no confusion will be thus created, as the term has a 
 distinct significance of its own, and intended to apply 
 solely to the peculiar class of signs which are heard in 
 initial stages of phthisis. 
 
 The crepitant rale is a crackle of larger size and more 
 viscid character than fine crepitation. It consists of a 
 series of few short, high-pitched, irregular crackles heard 
 during inspiration, and the interpretation which may be 
 put upon it is this : the unfolding of air-sacs full of viscid 
 secretion or exudation of a catarrhal type. It may be 
 found in the vicinity of nodular tubercle, but it is not due 
 to this form of tubercle simply, although it may be due 
 to that impairment of the alveolar wall which constitutes 
 a main feature of the tubercular process. 
 
 A full and excellent description of the nature of this 
 process in its various stages will be found in Dr. Grreen's 
 work on Pathology. 
 
 The condition of the alveolar tissue is estimated by 
 the high pitch of the sound induced by the amount of 
 thickening present, and by the blowing quality of the 
 expiratory sound. When these two signs are present the 
 limitation of the sound to inspiration is not necessary for 
 determining the character of the process ; and it may 
 with some confidence be asserted that a serious lesion of 
 the pulmonary tissue is taking place. The chance of 
 recovery will depend upon the constitutional power of 
 repair which belongs to the condition of the patient ; but, 
 as far as my judgment goes, it should be considered as a 
 structural ulceration, and not as the result of a general 
 infection. If the recuperative power is at a minimum, 
 the destruction will go on rapidly, and may lead to infec- 
 tion; either general, resulting in acute general tuber- 
 culosis ; or local, resulting in lobular tubercle. 
 
 Regional significance, — The regions which this sound 
 generally frequents are the infra-clavicular and the supra- 
 scapular ; and the latter region should always be examined, 
 inasmuch as the sound may be heard there when it is in- 
 audible in front. 
 
 h2 
 
100 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 To the same category must also be referred two otiier 
 sounds which have a similar significance, and are im- 
 perfect utterances of the moist crepitant rale. 
 
 These are the viscid crackle and the occasional 
 click. 
 
 The viscid crackle appears to belong to a more chronic 
 condition of exudation than the moist crepitant rale, and 
 it is heard when caseation is present, or when a chronic 
 fibroid condition of the lung tissue is softening. It is 
 usually a sign of some chronicity. 
 
 The occasional click, if solitary, is suspicious of lurking 
 mischief, or of recovery from previous disease ; but if this 
 sound be scattered and heard in various parts of the 
 chest, it is of very serious import. 
 
 This is almost the only sign which may be heard when 
 the chest is completely invaded by scrofulous pneumonia ; 
 and it afifords a good instance of the silent advance of a 
 very pernicious disease. 
 
 When scattered clicks are heard over the chest, it means 
 that the lobules are choked with exudate — either the 
 result of an extensive scrofulous pneumonia, or it may 
 be a rapid deposit of lobular tubercle in the midst of a 
 caseating catarrhal pneumonia. 
 
 All these signs — the crepitant rale, the viscid crackle, 
 and the occasional click — belong to similar processes, and 
 all come under the category of phthisis. Sometimes, in 
 whatever form they are subsequently revealed, they remain 
 silent until started by a cough-breath ; and it is therefore 
 very necessary to test the condition of the lungs by a cough 
 followed up by deep inspiration, or those ominous heralds 
 of future events may escape notice. 
 
 Exceptions to the Rule. — Viscid crackles and clicks do 
 occur as a result of chronic bronchitis ; but if innocent in 
 nature, they are only to be heard in one or two places, 
 over large tubes, or accompanied with tubal sounds, which 
 additional signs sufiiciently guarantee, in most instances, 
 their inactive character. At the same time, for accurate 
 diagnosis, the whole aspect of the case must be carefully 
 
SUBCEEPITANT KALE. 101 
 
 considered, especially whether the patient be losing flesh 
 or not. 
 
 These sounds also follow the clotting of blood in the 
 alveoli. In profuse haemorrhage blood passes into the 
 lungs (chiefly by insufflation) and gradually clots. This 
 is detected by the bubbling rales which follow a profuse 
 haemorrhage, and give way gradually to a viscid crackle ; 
 and finally an occasional click, as the blood coagulates and 
 hardens. 
 
 These sounds may be interpreted and estimated at their 
 proper significance, in accordance with the history of the 
 case, as regards the previous occurrence of haemoptysis ; 
 besides this, the peculiar localities in which blood is landed 
 by the inspiratory force help the diagnosis. 
 
 These localities are the upper lobe of the lung above 
 the root (generally beneath the first intercostal space, 
 close to the sternum), in the axillary region, in the fourth 
 or fifth intercostal space, and at the base of the lung in 
 the lower axillary region, or in the infra-mammary region. 
 
 3. The subcrepitant rale is a term used generally to 
 signify a fine bubbling sound heard with inspiration, and 
 frequently with expiration also ; the typical quality of 
 which is represented during the stage of resolution in 
 pneumonia. 
 
 The distinction here intended between this sound and 
 the bubbling rale is chiefly viscidity, a quality of great 
 importance, as indicating the probable character of the 
 exudation fluid. 
 
 As with the crepitant rale, modifications due to imper- 
 fect and incomplete formation of the sound are heard, the 
 full sound being sometimes only brought out by the 
 cougrb-breatli. 
 
 The subcrepitant rale is heard in congestion, local 
 pneumonia, brown induration, pulmonary apoplexy, in 
 purulent bronchitis, and from the presence of pus or blood 
 in the bronchioles and air-vesicles. 
 
 It is extremely difficult to decide upon the various 
 high-toned sounds which are comprehended under this 
 
102 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 term, and there are no defined limits between one class 
 of sounds and another. Distinctions of diagnosis will 
 depend npon the history of the case and the regional 
 habitat of the sonnd. 
 
 4. The bubbling: rale resembles the sonnd produced in 
 blowing soap-bubbles. These rales may be coarse or fine, 
 dependent upon the size of the bronchial tubes in which 
 the bubbles are formed. They accompany both inspiration 
 and expiration; in its typical form they are heard in 
 oedema of the lung, in congestion of the bronchioles, and 
 in capillary bronchitis. 
 
 These larger and moister sounds may also be heard 
 under conditions resembling those which I have described 
 as giving rise to the subcrepitant rale — namely, the pre- 
 sence of blood in the tubes and the liquid resulting from 
 the resolution of pneumonia. But the distinctive cha- 
 racter of this sound is typically heard in oedema arising 
 from, dropsy of the lungs. 
 
 In the mechanism of all these sounds the fine bron- 
 chioles probably participate ; but inasmuch as the sounds 
 have a vesicular and not a tubal quality, I have con- 
 sidered that the subject would be simplified by the pre- 
 sent arrangement. 
 
 In almost aU cases the significance of the rale may be 
 tested by the examination (microscopically or macro- 
 scopically) of the matter expectorated. 
 
 SOUNDS DUE TO DISEASES OF THE 
 BROXTCHZAIi TUBES. 
 
 Tubal sounds are those which are found in tubes, and 
 are distinct from the previous class already described, 
 inasmuch as they possess no vesicular quality, are con- 
 tinued during the act of inspiration and expiration — a 
 simple prolonged sound in contradistinction to the repe- 
 tition of bubbling sounds. They may be subdivided into 
 two classes : — 
 
 I. The wheezing vibratile sounds of various pitch, due 
 to vibrations -within resonating tubes. 
 
TUBULAR SOUNDS. 103 
 
 2. The so-called tubular or whiffing sounds trans- 
 mitted through rigid tubes. 
 
 1. The first set of sounds have received various names, 
 according to their quality and pitch ; it will be convenient 
 to term them — 
 
 Rhonclii, and it may be remarked that the pitch of a 
 note, the result of snoring, varies from a high squeak to 
 a deep bass ; and these rhonchi may be called sibilant 
 or sonorous, according as they are high or low pitched ; 
 and from the pitch a diagnosis may be made of the size 
 of the calibre of the tubes affected. These sounds de- 
 pend generally upon vibrating pellets of mucas within 
 the tubes, and, unless very abundant, they can be 
 silenced by cough. 
 
 2. Tubular sounds have a distinct significance of their 
 own ; both the sounds of respiration are of a blowing 
 character, similar to the normal bronchial sound of health, 
 and it has the quality which belongs to currents of air 
 passing through a tube. It is sometimes called blowing 
 respiration, or breathing. The characteristics of this 
 sound are the following : — 
 
 In pitch the inspiratory sound is high, and the expira- 
 tory sound is still higher ; and whereas the inspiratory 
 sound is a little shorter, the expiratory sound is con- 
 siderably prolonged. 
 
 The attention of the student must be particularly 
 directed to the high pitch of the expiratory sound, and to 
 the fact that it is much higher than the inspiratory sound. 
 Upon this point, which is due to Flint of New York, rests 
 the distinction between tubular and cavernous sounds. 
 
 Tubular or bronchial respiration is solidification of the 
 lung, caused either by exudation of a firm fibrinous 
 material into the air-cells, or by compression of air out 
 of the air-cells by an accumulation of fluid, or by the 
 presence of a tumour. 
 
 The usual explanation given of the soands here de- 
 scribed is conduction, but there are many difficulties in the 
 way of accepting this theory ; and it appears to me that 
 
104 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 a simple and probable explanation may be given by tbe 
 transmission of sonnd tbrough. rigid tubes. 
 
 Reg-ional significance. — Tubular breathing of large 
 extent, heard in the infra-clavicular and infra-scapular 
 regions, may be due to pneumonic consolidation, and this 
 is more probable if the axillary region also yield these 
 sounds ; but compression of the lung is generally met 
 with, at the base from fluid, and in the upper portion 
 from aneurism and tumour ; so that region is not a 
 satisfactory guide to diagnosis. If the sound be heard in 
 the inter- scapular region on either side, the pressure of 
 an aneurismal tumour should be suspected. 
 
 SOTTM-DS OF SSSTRITCTIOZr. 
 
 These sounds have peculiar characters and significance, 
 and they ought to have their proper place assigned to 
 them, neither in the vesicles nor in the tubes, but in 
 those portions of lung tissue which have become altered 
 and excavated by disease. The sounds are neither 
 vesicular nor tubular in quality ; they are of two kinds, 
 dependent upon the presence of air only, or of air and 
 fluid in the excavated part. 
 
 The fluid sound is a rale, and may be called the 
 gnrg-ling' rale ; the general quahty is a sharp repeated 
 crackling gurgle, with inspiration or expiration alone, or 
 with both together, the fluid being of a viscid character ; 
 it may be heard at any time during the progress of 
 inspiration, and is often started by the impulse of cough- 
 ing. It is heard only when hollow pouchings or sacs 
 have been formed (however small or large) during the 
 process of excavation. 
 
 If the tissue surrounding and forming the pouch be 
 hard and dense, and the cavity be small, the gurgle 
 becomes a sharp rattle, resembhng the rattling of peas in 
 a bag ; if, on the contrary, the cavity is large, not smaller 
 (I think from my observations) than a thumb-nail or nut, 
 then a distinct cavernous or hollow character modifies the 
 sound, and this modification forms the second kind of 
 sound resulting from destruction of the lung. 
 
CAVERNOUS SOUNDS. 105 
 
 Cavernous respiration is a hollow deep-toned blowing 
 sound produced in a cavity not smaller than a nut. 
 The pitch of the inspiratory sound varies with the size 
 of the cavity and the condition of the surrounding tissue, 
 being raised if the communicating bronchial tube is rigid 
 from thickened or consolidated tissue in its vicinity. 
 The inspiratory pitch is, however, lower than that of the 
 bronchial inspiratory sound. 
 
 The expiratory sound is lowered in pitch, and the dis- 
 tinction between bronchial and cavernous breathing is 
 dependent upon this difference of pitch in the expiratory 
 sound. 
 
 In bronchial or tubular breathing the pitch is high. 
 
 In cavernous breathing the pitch is low. 
 
 This sound is produced by the cavities of phthisis, 
 and it is seldom to be heard under other conditions. An 
 ampullatous or dilated bronchial tube, especially when 
 surrounded by thick tissue from compression, for example, 
 gives rise to a sound of this character, but the dilatation 
 must be very large to depress the pitch of the expiratory 
 sound. "Without denying the possibility of this, I must 
 say that I have not sabstantiated it yet as causing the 
 true cavernous sound. 
 
 Regrional Significance, — Solitary basic cavities are 
 extremely rare, and when this sound is heard over the 
 base of the lungs, or their lower part, it may be due to 
 gangrenous excavation, to abscess, or to the clearance of 
 an old pulmonary apoplectic patch. It must also be 
 mentioned that cavities may form from the clearance of 
 hsemorrhagic nodules, and their sites are usually the 
 upper lobe and the axillary regions of the lung. 
 
 Amphoric breathing is simply a modified condition of 
 the cavernous sound ; it resembles the sound caused by 
 blowing across the mouth of a bottle or flask ; the special 
 quality is due to the additional overtones produced by the 
 reverberation or echo of the original sound. The con- 
 ditions necessary for its production are — a large hollow 
 formed by more or less rigid walls, with a comparatively 
 
106 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 small opening leading to the bronchus ; it is characteristic 
 of a large body of air which is not removed entirely by 
 the act of expiration. (Flint.) 
 
 It is heard in large excavations with thin walls and 
 adhesions to the thorax, and is not uncommon in the 
 elastic chests of the young. 
 
 Reg-ional Sigrnificance. — When heard over the upper 
 part of the chest it indicates a large cavity, when heard 
 over the lower half it indicates perforation of the lung, 
 and communication with a large body of the air within 
 the pleural cavity, which constitutes pneumothorax. 
 
 metallic sounds (metallic tinkle) have a clear high- 
 toned metallic (silvery) quality, and resemble those pro- 
 duced on dropping a pin into a glass, or by pouring a few 
 drops of water from a height into a glass bottle contain- 
 ing a small quantity of water. It is due to the vibration 
 of a surface of water producing sounds in a resonating 
 cavity ; it is to be heard in some cases distinctly following 
 the primary sound, and results from secondary vibrations. 
 It may be produced by any agitation and movement when 
 the conditions of the chest are suitable for its production — 
 by breathing, voice, cough, or change of position ; it may 
 be heard in various regions, but its usual situation is 
 haK-way up the chest, on a level with the nipple. 
 
 As a rule, it must be considered as diagnostic of per- 
 foration of the lung, with air and fluid in the cavity of 
 the pleura, either from a cavity having burst through the 
 pleura, or from an empyema having burrowed its way 
 through the lung. 
 
 It is sometimes, though rarely, heard in pulmonary 
 cavity, and occasionally is simulated by the metalHc 
 tinkle of a distended stomach. 
 
 Splasbingr sound from succussion, or the jogging of a 
 patient with air and fluid in his chest, is one of the oldest 
 physical signs, and was known to Hippocrates. It re- 
 sembles the sound obtained from shaking a decanter half 
 full of water, or from rolling a cask nearly empty. It 
 can be heard sometimes at a considerable distance from 
 the patient, and by the patient himself. The best method 
 
PLEURAL SOUNDS. 107 
 
 of eliciting it is to shake the patient with the arm of the 
 observer round the body of the patient, the ear being 
 applied to the affected side behind. It is only heard in 
 pneumo-hydrothorax. 
 
 PIiEUBAI^ SOUITSS. 
 
 The three sounds just described are, strictly speaking, 
 pleural sounds, inasmuch as they are formed in the pleural 
 sac ; but as it was convenient not to break the thread of 
 continuity when the sounds due to destruction of the lung 
 were being described, they have been kept under that class. 
 
 The sounds caused by a diseased condition of the pleura 
 alone are few and simple, and may be all classed under 
 one head, that of — 
 
 Pleural Friction. — They consist of a series of super- 
 ficial, to-and-fro rubs, which may be imitated by putting 
 the stethoscope on the palm of the hand and rubbing the 
 back of that hand with the finger. 
 
 Adjectives may be added to express the exact quality of 
 the rub ; it may be simply a graze or creaking, or grating 
 in character. 
 
 When fully developed, the sound accompanies both acts 
 of the respiration : when imperfect, it may be only evident 
 occasionally, and with inspiration solely. Sometimes 
 it is so fine as to be easily mistaken for pneumonia, and 
 even when it is coarser it is often extremely difficult 
 to determine whether it is within or without the lung. 
 
 It indicates roughening of the pleural surfaces which in 
 health move freely without the slightest noise, and it 
 results from the fibrin of pleurisy (recent or old), from 
 cancer, and from tubercle of the pleura. 
 
 In empyema a more viscid rub, of a dull, crackling 
 quality may be heard, formed by the cohesion of pus to 
 the surfaces of the pleura. When heard, it is a very 
 characteristic sign. 
 
 VOCAXi BESON-AIUCX:. 
 
 Certain modifications of the voice are efiected by the 
 presence of disease, and it is necessary to make the patient 
 use his voice sometimes in various ways. Human beings 
 can speak (articulate), whisper (words without voice), sing 
 
108 AUSCCLTATIOX IX DISEASE OF THE LUXG. 
 
 and vocalise (words with, tlie singing voice), and all these 
 modes of using the organs concerned in the voice have 
 to be brought into play. The normal sound of the voice 
 through the pulmonary tissue has been described, and the 
 modifications it may undergo are the following : — 
 
 The intensity may be increased or diminished. 
 
 Increased vocal resonance is due to diminution of 
 air in the lungs, either from compression of the air- sacs or 
 thickening of the alveolar tissue, or the presence of solid 
 matter in the lumina of the air- sacs. But it also occurs 
 in some cases of emphysema and of pneumothorax. 
 
 It is heard in a variety of diseases, and indicates a 
 greater density of tissue than is natural, or a ready com- 
 munication between the air and the chest-wall. 
 
 Diminisbed vocal resonance, or suppression of voice, 
 occurs when fluid or air intervenes between the lung sur- 
 face and the chest-wall, when a collection of fluid (as in 
 abscess) is present within the lungs. In emphysema this 
 also occurs, but it should be noted that exactly the reverse 
 condition (as stated above) sometimes obtains, and emphy- 
 sema and pneumothorax may increase the intensity of the 
 voice. 
 
 Broncbopbony is the intense transmission of voice 
 sounds which occurs in solidification or compression of the 
 lung. It is not that articulate speech is transmitted in 
 perfection to the ear, but the voice sounds are concentrated 
 and high-pitched, accompanied often with a metallic clang 
 of high-toned character. Articulation may be only heard 
 as an indistinct buzz, and the voice may be much intensi- 
 fied ; and the definition of bronchophony must be the 
 intense transmission of the laryngeal voice. 
 
 It is heard in the consolidation stage of pneumonia, in 
 the compression of lung by fluid or by tumour ; and its 
 cause is probably due to moderate or incomplete rigidity 
 of the tubes. 
 
 Reg-ional Sig-nificance. — In the upper lobe it may be 
 due to pneumonic consolidation, or to the presence of 
 tumour, malignant or aneurismal. 
 
PECTOKILOQUY. 109 
 
 In tlie base it may be cansed by tbe pressure of fluid 
 (pus, serum, or blood) upon the lower part of tbe lung ; or, 
 if on tbe left side, from aneurism. 
 
 In tbe inter-scapular regions, if it be heard only close 
 to the spine, it is probably caused by enlarged glands or 
 aneurism. 
 
 The important part of bronchophony is not the non- 
 articulate nature of the sound transmitted, but the pitch 
 and intensity ; the pitch being high and the tone metallic. 
 
 Pectoriloquy must be defined as the transmission of 
 articulate sounds, with or without the laryngeal voice, in 
 all their distinctness to the ear; a sensation as if the 
 uttered speech of the patient passed immediately into the 
 ear of the examiner. 
 
 In order to assure oneself of this, it is necessary to 
 close the ear from all external sounds in order that the 
 speech of the patient may not be conveyed from outside ; 
 and if the single stethoscope is used, the free ear must be 
 stopped. 
 
 The difficulty, however, of stopping all outside sounds 
 makes the use of the whisper more valuable, and, more- 
 over, fremitus does not occur as with the full voice. 
 
 Pectoriloquy may result from the presence of a 
 moderate-sized cavity with smooth walls, with a direct 
 and somewhat large communication with a bronchus, or 
 from a sohdifled lung ; the mere transmission of articulate 
 speech is no arbiter between these two conditions, and 
 the only qualities that can be trusted is the pitch of the 
 voice. 
 
 If it be high-pitched, of a clanging character, with a 
 metallic silvery quality (like the tone of a silver corno- 
 pean), it is due to solidity; if, on the contrary, it be low- 
 pitched, hollow, and echoing in quahty, it is cavernous. 
 
 In this differentiation of pitch the whisper aids con- 
 siderably, in cavities being especially hollow in character. 
 Pectoriloquy is probably the result of transmission of 
 sound through large air- containing channels with rigid 
 walls. 
 
110 AUSCULTATION IN DISEASE OF THE LUNG. 
 
 2:g:opbony is the addition of a sound of tremulous or 
 bleating character to bronchophony. It receives its name 
 from its resemblance to the bleat of a goat, and can be 
 imitated by playing in schoolboy fashion on a comb 
 covered with a piece of thin moistened paper. 
 
 It may be elicited by vocahsation (articulate words 
 with the singing voice), and appears to depend upon the 
 free transmission of vibratmg sound along a rigid tube, 
 additional vibration being caused by moistened mem- 
 brane. 
 
 It used to be considered pathognomonic of flaid in the 
 pleura ; but it may be heard when the surfaces are only 
 slightly moistened, and in the lower part of a large cavity 
 kept moist with secretion. It certainly is diminished in 
 some cases by alteration in the position of the patient, 
 and this probably results from the separation of the lung 
 from the chest-wall by gravity. I observed this in a case 
 of empyema in the left inter- scapular region; the pus 
 had been evacuated through the lung, and no fluid was 
 obtained on introducing a fine trochar; the agophony, 
 which was marked over the left bronchus in the upright 
 position, disappeared when the patient was prone on his 
 belly. It is heard above the level of fluid when the 
 surface of the lung is only separated by a slight interval 
 from the chest-wall, and its usual habitat is in the inter- 
 scapular region of either side. It may, however, be heard 
 elsewhere, in the axillary region. It is a doubtful sign, 
 and indicates density of lung with some vibrating 
 moistened surface. 
 
 Cou^li sounds, sometimes called tussive signs, result 
 from making the patient cough. In every examination 
 this is a very necessary proceeding — necessary for the pur- 
 pose of dislodging any temporary obstruction from the 
 tubes, or of forcibly inflating the air-vesicles, and thus 
 separating the agglutinated surfaces or clearing the 
 lumina choked with exudation. 
 
 For this the patient should be instructed to cough, and 
 draw a deep breath immediately afterwards, and to this 
 
COUGH SOUNDS. 11 1 
 
 I have given tlie term Cougrb-breatb, wliicli sufficiently 
 indicates its meaning. 
 
 By this method of examination we often succeed in 
 detecting a crepitant rale of important significance, which 
 otherwise would remain obstinately silent. 
 
 In cases of large cavity the fluid often accumulates, 
 especially during the night, so as to block up the entrance 
 of the bronchus which supplies the air, and sometimes to 
 such an extent as completely to fill the cavity. Under 
 such conditions the only sign that may be at first pre- 
 sent is absence of murmur (silence) and dulness of per- 
 cussion ; but as soon as the cough forcibly aerates the 
 fluid, a crackle — sometimes an explosion of painful inten- 
 sity — is heard with great distinctness. 
 
 Trabeculae in large cavities often vibrate in a remark- 
 able manner with the impulse of the cough, and some- 
 times a distinct twang is thus produced. This sign is of 
 value, inasmuch as strings traversing a cavity cut up the 
 cavernous sound, and suppress it. 
 
 This twanging cough is also heard when the whole lung 
 is excavated and traversed by long trabeculae. 
 
 A brassy vibrating cough is heard in chronic inflam- 
 matory conditions of the mucous membrane, with a 
 relaxed condition of throat and vocal chords ; and in less 
 intensity, accompanied with a ringing high-pitched metallic 
 clang, it is heard in irritable stomach with gastric cough. 
 
 The sound of cough is sometimes, although not always, 
 transmitted through solids ; it is generally suppressed by 
 fluids. 
 
 There still remains one other sound to be mentioned — 
 the bell sound — which is elicited over a large air-contain- 
 ing cavity by striking together two coins placed upon one 
 side of the cavity while the ear is applied to the opposite 
 side ; this is sometimes of a very sonorous character. 
 
112 
 
 CHAPTBE XY. 
 
 PHYSICAL SIGNS OE DISEASES OF THE HESPIEATORT ORGANS. 
 
 Having now discussed tlie various signs which the physical 
 examination of the chest discovers in health and disease, 
 we may group them together in order to show how special 
 pathological conditions may be detected by their means. 
 
 The student is urged to omit no opportunity of making 
 himself fully acquainted with the macroscopical appear- 
 ances of pathological conditions ; and I would entreat him 
 to remember that he may never have such opportunities 
 of observation afforded to him after his student days are 
 over, when his time is taken up with daily visits to the 
 sick, and he has little leisure and no facilities for making 
 observations on the dead. Haud in hand, then, with 
 clinical study let pathology be conducted ; and, after some 
 knowledge of the elements of auscultation has been 
 acquired, it is always advisable to keep in the mind's eye 
 an imaginary picture of what would be found if the actual 
 condition of the parts examined was exposed to view. 
 
 All observations made at the bedside should be entered 
 in a book, and it is a very good plan to write out the whole 
 account in full at the end of the day. This is a method 
 well calculated to insure accuracy of description, and to 
 strengthen the memory of facts. 
 
 Forsitan hoec olim meminisse juvahii. 
 
 In the following description of diseases, with their appro- 
 priate signs, symptoms, and pathology, I shall in certain 
 measure adopt the alphabetical order, which favours a 
 simple arrangement : — 
 
 Asthma — Symptoms. — Spasmodic attacks of dyspnoea 
 of an aggravated form, occurring usually after midnight, 
 
ASTHMA — ATELECTASIS. 113 
 
 by which, the patient is compelled to resort to means for 
 regaining breath — sitting up, throwing open the windows, 
 forced expansion of the chest. The chest in spite of 
 efforts is stubbornly fixed, and noisy stridnlons breathing 
 is to be heard some distance from the patient. 
 
 The disease is especially hereditary; besides which 
 form is that produced by irritating vegetable matter — 
 hay asthma. It also occurs from heart disease. 
 
 Patbolog-y, — Inasmuch as asthma only ends fatally 
 when complicated with other pulmonary structural 
 changes which destroy the muscular contractility and 
 induce changes in the tubes, no description can be given 
 of the appearances due to asthma alone. 
 
 Sig:iis. — Inspection during the attack shows very 
 laboured movement of the thorax ; the sternum thrown 
 forward, the clavicles raised, and all the muscles on the 
 stretch — the exertions of the individual being directed 
 to the forcible expansion of the thorax; intercostal 
 spaces depressed from imperfect expansion of the lungs ; 
 supra- clavicular foss^ much deepened ; the epigastrium 
 sinking in. 
 
 Percussion note is not as clear as in health, and 
 generally the resonance is diminished. 
 
 Auscultation. — Absence of respiratory vesicular mur- 
 mur, the air not reaching the lobules; harsh hissing 
 sound (due to dryness and contraction of the tubes) of 
 peculiar character heard all over both sides of the chest. 
 Asthma is detected between the attacks by this dry 
 hissing sound — the dry sibilant rhonchus, with imper- 
 fect vesicular murmur. The character of the sound is 
 pathognomonic of the disease. 
 
 It should be remembered that undeveloped forms of 
 asthma are innumerable. Spasmodic and night coughs, 
 night dyspnoea, are usually traceable to hereditary 
 asthma. 
 
 ATEXiECTASZS, or imperfect expansion of the lung, 
 is the condition present during foetal life, and after birth 
 expansion may be incomplete, and the atelectasis con- 
 
 I 
 
114 SIGNS OF PULMONARY DISEASE. 
 
 genital, or it may result from some piilmonary disease, 
 causing obstruction of tlie air-passages. This was pointed 
 out first by Sir James (then Dr.) Alderson. 
 
 Symptoms are those due to impeded respiration, 
 dyspnoea, and lividity of surface ; the child refusing 
 food, peaking and pining, finally dying from apnoea or 
 convulsions. It is a sequela of acute bronchitis and of 
 measles, both lungs sometimes being afi'ected at their 
 bases. 
 
 Patliologry. — Dark purple patches of a wedge shape 
 are observed on the surface of the lung, collapsed and 
 depressed below the rest. They sink in water, having no 
 air, the vesicles being glued together, and not with the 
 granular surface of pneumonia, for which condition this 
 used to be mistaken. A thick viscid plug may be generally 
 detected in the supplying bronchus. 
 
 Sigrns are those due to condensed tissue. 
 
 Percussion over the part affected, dull. 
 
 Vocal resonance increased and bronchophonic. 
 
 iiuscultation shows absence of the vesicular murmur 
 and tubular breathing. 
 
 In the neighbourhood the lung is distended, and gives 
 rise to signs of emphysema. 
 
 ACUTE BRON'CHITIS — Symptoms.— Tightness of 
 the chest, a sense of constriction, as if a band was 
 tied round it, pain and soreness behind the sternum, 
 oppression and weight in breathing, dyspnoea, cough, 
 expectoration of clear frothy mucus, occasionally streaked 
 with blood if there be much vascular congestion. 
 
 Patbolo^y. — The initial stage is shown by congestion 
 of the vessels distributed beneath the basement membrane 
 of the bronchial tubes. This is followed, by oedema and 
 infiltration of serous fluid into the basement membrane, 
 which becomes thickened and swollen. Finally, desqua- 
 mation of the columnar epithelium takes place, followed 
 by secretion of catarrhal mucus from the surface of the 
 tubes and the mucous glands. 
 
 Physical Signs.— Inspection only conjectures the 
 
BRONCHITIS. 115 
 
 disease from the amount of cyanosis, or blueness of tlie 
 skin. The thoracic veins are sometimes enlarged if the 
 amount of disease be great. If severe, the thoracic move- 
 ments are fuller and more frequent. 
 
 Percussion gives no decided indication. 
 
 Auscultation elicits rhonchi, dry or moist, according 
 to the stage of the disease and the amount and quality of 
 the secretion. They are sonorous, low-pitched, snoring, 
 or cooing sounds, if the large tubes only are involved ; but 
 sibilant, whistling, high-pitched, if the small tubes are 
 concerned. 
 
 The points to which attention should be directed are — 
 the size of the tubes and the extent of lung involved ; the 
 viscidity or fluidity of the secretion, and its amount. 
 
 Capillary bToncbitis is of more serious import than 
 inflammation of the large tubes. It occurs often in child- 
 hood, and is detected by the bubbling rales, generally at 
 the posterior bases. 
 
 CKROXiTZC BROXJCHZTIS. — Symptoms are less urgent 
 and severe than those of the acute disease ; principally 
 cough, dyspnoea, tightness of chest, and more or less 
 viscid, sometimes purulent, sputa. 
 
 Patbologry. — Long-continued and repeated attacks of 
 inflammation lead to peribronchial thickening, irregular 
 or ampuUatous dilatation ; there is then considerable 
 hypertrophy of the muscular coats of the tubes, the 
 longitudinal flbres being especially well-marked ; emphy- 
 sema is sometimes present. 
 
 Physical Sig^ns, — Inspection gives no evidence unless 
 the dyspnoea is marked. Percussion may give a muffled 
 sound if there be any distension from emphysema, and 
 this will be detected by percussing hghtly ; if the tubes 
 be much dilated, a sound of greater intensity, almost 
 amphoric in quality, may be obtained. 
 
 Auscultation elicits harsh bronchial blowing sounds, 
 with dry or moist sonorous rhonchi, which become tubu- 
 lar if there be dilatation. 
 
 The voice sound varies very much, deficient and buzzing 
 
 i2 
 
116 SIGNS OF PULMONAKY DISEASE. 
 
 in some cases, bronchoplionic and pectoriloqnons in 
 others. 
 
 In these cases the heart must be carefully examined 
 for signs of pressure on the right side, pulsation in the 
 lower sternal region, the apex heat being obscured. 
 
 BROsrcHIECTASIS, or dilatation of the bronchi, 
 occurs as a result of chronic bronchitis and asthma, 
 where the tubal structure has suffered from atrophy of 
 the mucous coat and thichening of the fibrous layers. 
 It is produced by inhalation of u-ritating particles of 
 dust, fluff, wool, iron, clay, and stone ; and it gives rise 
 to forms of disease named according to the special trade 
 by which it is induced — as knife-grinder's rot, filer's 
 phthisis, &c. 
 
 Symptoms. — Much dyspnoea and expectoration, the 
 sputa being plentiful, opaque and purulent ; cyanosis is 
 usually present, the right ventricle of the heart being 
 eccentrically enlarged. 
 
 Patbolog-y. — The bronchial tubes are found much 
 thickened, irregularly pouched and dilated ; alveolar 
 walls thick, white and emphysematous. Sometimes the 
 upper lobe is in a condition of alveolar thickening, the 
 air-sacs irregularly dilated ; while in the lower parts may 
 be found old congestive patches of pigmented thick fibroid 
 tissue, indicative of partial lobular congestions and 
 haemorrhage. 
 
 Occasionally dilatation of the tubes is observed in com- 
 pressed portions of the lungs, in empyema or pleuritic 
 effusions. It happens especially in those chronic cases 
 where the fluid has been evacuated by natural or artificial 
 means. A compressed lung is very loth to expand, and 
 if the external pressure be removed the tubes will yield 
 to the internal force of the atmosphere, and it is common 
 to find this pouching near an empyema. 
 
 Si^ns. — Inspection observes depression of the inter- 
 costal spaces with fixity, and even retraction, of the walls 
 of the chest. 
 
 Percussion generally gives a dull or muffled note super- 
 
PLASTIC BEOXCHITIS. 117 
 
 ficially, wliicli may be more tympanitic with, a full 
 ■stroke. 
 
 Voice sounds, sometimes buzzing, sometimes bron- 
 ciioplionic, even pectoiiloquous. Fremitus increased. 
 
 Auscultation shows absence of true vesicular mur- 
 mur, the quaHty of sound being bronchial or tubular. 
 The pitch is high, in accordance with the thickness of the 
 alveolar tissue and the tension of the air- sacs. If the 
 dilatations be large, the tubular sound may be almost 
 cavernous ; but the pitch of the expiratory sound is not 
 low, although it may be very nearly of the same pitch as 
 the inspiratory sound. 
 
 A hollow blowing sound is produced in the case of 
 dilated bronchus from compression, and although there 
 is often great difficulty in determining this condition, the 
 pitch of the expiratory sound has not been, according to 
 my experience, lowered. Moreover, the position of the 
 -'J and at the base of the lung, with empyema or effusion, 
 would indicate the probable condition of the lung. If 
 this occurs on the left side, great resonance may be 
 superadded by the proximity of the stomach, which is 
 sometimes considerably dislocated upwards in such a case, 
 and may lead to a false diagnosis. 
 
 PZiASTZC BROliJCHZTZS is a peculiar and rare con- 
 dition. I have only observed it associated with scrofulous 
 phthisis ; the chief notable characteristic of the disease 
 is the expectoration of firm cheesy matter. 
 
 Patbology. — The tubes are distended and irregularly 
 pouched, chiefly near the periphery of the lung, and are 
 firmly stuffed with a hard curdy material which is formed 
 of cells and plastic matter, apparently derived from a 
 peculiar condition of the bronchial membrane. 
 
 Si^ns. — iSTone can be given of a sufficiently distinct 
 character to determine a diagnosis, but they are such as 
 arise from consolidation mthin the tubes and lobules — 
 .suppression of vesicular sounds, with dulness of per- 
 cussion. 
 
 The expectoration of the casts, according to "Walshe, 
 
118 SIGNS OF PULMONARY DISEASE. 
 
 is preceded some hours by dyspnoea and hacking 
 congh. 
 
 This condition must not he confounded with that in 
 which expectoration of fibrinous casts of the tubes takes 
 place subsequent to an attack of heemoptysis. It is true 
 that expectoration of such blood casts does not often 
 take place, inasmuch as the blood remains behind ; but it 
 is to be found in the lungs after death, if only the observer 
 knows what to look for and where to look for it. 
 
 The following case related by Graves in his " Clinical 
 Medicine" (vol. ii. p. 146) is worth quoting : — " A gentle- 
 man, who had been ill for some days before, was attacked 
 with hsemoptysis. For this he was bled, and in about 
 three hours afterwards he became collapsed, almost 
 asphyxiated, and struggling for life ; the right side of 
 the chest expanding and contracting energetically, the 
 left almost fixed and motionless. Dr. Stokes, who saw 
 him, immediately changed his position, and gave him a 
 gla,ss of wine, when he made one more effort, and violently 
 expectorated a coagulum consisting of fibrin, in some 
 parts nearly colourless, forming a complete solid mould 
 answering to the left bronchus, and its ramifications down 
 even to some of the minuter tubes. After this he rallied." 
 
 Flint, in his work on " Phthisis," records two cases of a 
 similar kind (p. 105). In one of these there was extreme 
 obstruction of the tubes, and death took place. The 
 other occurred in the person of a medical man, who 
 suffered from several successive attacks of haemoptysis. 
 On the third day after a copious attack he began to 
 expectorate bronchial casts, composed of fibrin and 
 shrunken blood globules. Before the expectoration the 
 patient had experienced some dyspnoea, but this passed 
 off, and he recovered his usual condition. 
 
 CIRRHOSIS OP THE loUXTG- was a term first given 
 by Corrigan, in 1838, to a peculiar one-sided sclerous 
 condition of the lung. 
 
 Symptoms are slow and insidious. The disease begins 
 with pleurisy or pleuropneumonia, and is characterised 
 
CIRRHOSIS AND CONGESTION. 119 
 
 by dyspnoea, dry cougli, and gradual emaciation. Oc- 
 casionally attacks of bronchial catarrh are present. 
 The history of the symptoms must be considered as yet 
 incomplete. 
 
 Pathologry. — The appearance of the Inng is peculiar 
 and distinct. One lung only is affected; it is much 
 dwindled and glued to the upper part of the axillary 
 region with firm thick adhesions. 
 
 In substance it is so hard and tough that it almost 
 creaks on section, and in appearance it is of a mottled 
 or streaky reddish grey. The bronchial tubes are much 
 thickened, and may be dilated into small cavities, besides 
 which there may be excavations. 
 
 Sigrns. — These are, in advanced conditions, unmistakable. 
 Inspection shows a flattened hollow chest over the part 
 afi'ected; the shoulders depressed; the ribs flattened; the 
 heart drawn up, and towards the diseased side ; the 
 opposite side expanding freely, the affected side fixed. 
 
 Percussion gives marked dulness over the diseased 
 lung, and high-pitched vesicular resonance over the 
 healthy one. I have known this extend four inches 
 beyond the mid- sternal line. 
 
 Palpation indicates the dislocation of the heart up- 
 wards, and towards the nipple ; the heart being uncovered 
 and evidently pulsating over a large area. Yocal fre- 
 mitus increased. 
 
 Auscultation gives absence of vesicular murmur; 
 tubular breathing, with or without loud bubbling rhonchi. 
 
 The illustration of the form of alar chest was taken 
 from a case of like kind, the disease being in the left 
 lung. Tricuspid murmur is heard in these cases. 
 
 COITGESTZOM' OF THE XiUDTG- occurs from stasis of 
 the pulmonary vessels, producing hyperaemia in the part 
 afi'ected. 
 
 Symptoms. — Difficulty of respiration, with more or less 
 dry cough ; or in advanced stages of the disease, sputa 
 streaked, or even abundantly mixed, with blood. 
 
 It is of common occurrence, and arises from failure of 
 
120 SIGNS OF PULMONARY DISEASE. 
 
 the heart to pump tlie blood throngli the lungs, due to 
 feebleness from age, fatty degeneration of -the heart, over- 
 growth of the body and arrest of cardiac development ; 
 from fevers, from cold, diseases of the heart, especially 
 those which affect the competency of the tricuspid valve ; 
 from purpura, scurvy, and haemophilia ; from cirrhosis of 
 the liver ; from copious beer-drinking, opium poisoning, 
 and from a general constitutional tendency to haemor- 
 rhage ; and from irritation. 
 
 Pathology.— Portions of the lung are seen of a dark 
 red or purple colour, gorged with bloody fluid, the tissue 
 sodden and swollen. The portion affected may contain no 
 air, and then it sinks in water ; or on section vast quanti- 
 ties of frothy, bloody serum pours from the cut surface, 
 sometimes in surprising quantity. The ordinary habitat 
 of this condition is the middle of the right lower lobe, 
 close under the angle of the scapula. 
 
 Physical Signs. — Inspection gives no indication, except 
 as far as the air does not enter the part affected, and that 
 portions of the ribs remain quiet and immovable. 
 
 Palpation gives some increase of vocal fremitus. 
 
 Percussion gives more or less dulness. 
 
 iiuscultation shows absence of respiratory miirmur un- 
 less there is healthy lung tissue over the patch of con- 
 gestion ; much crepitation, large and rather coarse, or the 
 signs of effusion into the air-sacs. Bronchial respiration 
 is heard only in those cases in which the vesicular mur- 
 mur and expansion of the air-sacs is obliterated by the 
 absence of air and the presence of bloody spumous fluid 
 in the air-sacs, and where at the same time the tubes are 
 not filled to any extent with secretion. 
 
 This is a most imj)ortant condition to diagnose, as in 
 old people, and in constitutions debilitated by excess or 
 broken down by previous disease, the consequences may 
 be rapidly fatal. 
 
 COMIPRESSIOIO' OP THS IiUlTG- results from pres- 
 sure either by fluid or solid tumour ; the air being more 
 or less expelled from the lung tissue. 
 
EMPHYSEMA. 121 
 
 Symptoms are those due to the condition of pressure, 
 and "will be described in their own place. 
 
 Patliolog:y. — The portion of lung subjected to pres- 
 sure is dense and tough; the air-sacs closely pressed 
 together. 
 
 Sig-ns are those of consolidation ; in all respects simu- 
 lating hepatisation. (See the remarks under the heading 
 Bronchiectasis.) 
 
 Compression prevents the formation of tubercle in the 
 portion of the lung affected. If the pressure be diminished, 
 expansion is generally induced in the tubes. 
 
 EMPHYSEMA — Symptoms. — This disease is charac- 
 terised by extreme dyspnoea of a continuous character. 
 
 The symptoms of disease arise from obstruction to the 
 respiration, and the patient presents the appearance of 
 one striving to increase, by all the means at disposal, the 
 capacity of the chest. The thorax is thrown forward ; the 
 alge nasi are dilated ; the muscles of the neck are stretched 
 to their utmost ; the complexion is muddy and of a 
 bluish-grey hue ; the extremities are cold, the pulse 
 feeble. 
 
 There are two kinds — the hypertrophous and the 
 atrophous. The atrophous form of emphysema is found in 
 the aged only, and is due to senile changes : the walls of 
 the air-sacs are destroyed without increase in the bulk of 
 the lungs. 
 
 The hypertrophous form is that which most commonly 
 occurs, and is notified by a barrel-shaped bulging of the 
 chest. The lungs are enlarged and press upon the heart, 
 which they cover in great measure, the apex being thrown 
 down to the right. 
 
 Patbology. — The emphysematous lungs are easily 
 recognised by their whitish-grey colour and their puffed- 
 out condition. The infundibulum is first expanded, and 
 the air-vesicles which communicate with it dilate so that 
 at length one large bulla or cavity is formed. 
 
 In atrophous emphysema the walls are much diminished, 
 the whole tissue sharing in the process of senile wasting ; 
 
122 SIGNS OF PULMONARY DISEASE. 
 
 the air-sacs comnmnicate and lose their divisions by form- 
 ing large chambers. 
 
 Senile atrophous emphysema is not a form of disease 
 which is often presented to observation. Hypertrophous 
 emphysema is far more common. 
 
 SigTis. — There is perhaps no disease of which the diag- 
 nosis is generally considered to be more easy than 
 emphysema. JSTevertheless, the opinions of authorities on 
 the physical signs vary more than with reference to any 
 other disease, and there are some diseases which are 
 frequently mistaken for emphysema. 
 
 Inspection. — The appearance of the patient indicates 
 persistent dyspnoea. Complexion muddy, and often blue 
 in tint ; eyes prominent, nostrils dilated ; muscles of neck, 
 especially the sterno-mastoid and the platysma myoides, 
 on the stretch ; the sternum, especially the upper part, 
 thrown forward and very convex in outline ; the clavicle 
 thrown forward; the supra-clavicular spaces depressed 
 and much incurved at every attempt to inspire, showing 
 the want of elastic expansion of the lungs, the intercostal 
 spaces depressed in inspiration, more especially the lower 
 ones, which fall in considerably. The pulsation of the 
 heart is seen beating below the xiphoid cartilage, which 
 is drawn in and forms a hollow, this being due to the 
 constant tension of the diaphragm, the whole chest being 
 rounded and in a condition of forced inspiration. 
 
 Palpation. — Pressure of the fingers in the intercostal 
 spaces gives a very inelastic sensation. 
 
 Yocal fremitus is diminished. 
 
 Percussion. — Deep, full percussion gives an intense 
 resonating note, which has been called hyper-resonant 
 invariably : this intensity of note is proportionate to the 
 dilatation of the bronchial tubes and the expansion of the 
 thorax. The note is slightly higher-pitched, as a rule, than 
 the normal vesicular resonance. 
 
 Superficial percussion, especially between the ribs in 
 the intercostal spaces, ehcits a tympanitic, muffled reso- 
 nance of very high pitch, which is an indication of the 
 amount of tension in the air- sacs. 
 
DRY CRACKLE OF EMPHYSEMA. 123 
 
 Special attention mnst be directed to this point, as it is 
 generally overlooked. The upper lobe is always more 
 affected with emphysema than the other lobes, and the 
 pitch of the note is higher in the affected parts than those 
 which are comparatively free from the disease ; and it is 
 only by carefully and Hghtly percussing over the regions 
 of the thorax that the distinction can be made. The 
 cardiac dulness is diminished and thrown down, because 
 of the displacement of the heart downwards and the over- 
 lapping of the distended lung. 
 
 Although emphysema in an exaggerated form can hardly 
 be mistaken, percussers invariably attack a chest diseased 
 in this manner, determined to elicit a noisy note which 
 they consider to be characteristic of the disease ; and I 
 must distinctly state that no disease is so carelessly 
 examined and so often mistaken as emphysema. 
 
 Vocal resonance may be buzzing or bronchophonic, 
 and fremitus may be diminished or increased. 
 
 Auscultation, — The sounds which are especially signi- 
 ficant of emphysema are deferred inspiration and prolonged 
 expiration : the first due to the higher expansion of the 
 lung, the second due to its impaired elasticity. Impaired 
 vesicular sound is also present. 
 
 The sounds are high-pitched, and the expiration is 
 even so much prolonged as to inverse the ratio between 
 the duration of inspiration and expiration. 
 
 There is a peculiar dry crackle heard in emphy- 
 sema which has attracted much attention, especially from 
 Laennec, who described it under the term "rale crepitant 
 sec a grosses huUes ou craq_uement" This sound, which 
 has a shuffling, up-and-down character, closely approxi- 
 mates to the pleuritic rub, and is very perceptible to the 
 touch. It occurs irregularly with the end of inspiration 
 and the beginning of expiration, and to my ear is very like 
 the sound caused by drawing a child's india-rubber 
 balloon over the palm of the hand. 
 
 If idiopathic emphysema is present, pleurisy is not 
 likely to be present also, inasmuch as the purely emphy- 
 sematous lung appears to be incapable of pleurisy : a 
 
124 SIGNS OF PULMONARY DISEASE. 
 
 peculiar cliaracteristic of tliis condition (post-mortem) 
 being the absence of adhesions. In pure emphysema then 
 pleurisy is likely to be absent, and this sound can hardly 
 be mistaken for anything else. 
 
 Additional signs of emphysema are the depression of 
 the diaphragm and liver — the heart displaced downwards ; 
 the right ventricle being brought to the front, while the 
 apex is thrown inwards, and pressure is evident on the 
 right side, from the presence of a tricuspid regurgitating 
 murmur. 
 
 The sounds of the heart are very much diminished by 
 the overlapping of an emphysematous lung. 
 
 Senile atrophous emphysema is diagnosed by the 
 weakened respiratory murmur, the impaired inspiration 
 and expiration, and by the high-pitched note of per- 
 cussion. 
 
 The student is especially cautioned against the hasty 
 diagnosis of this disease, which results from the facility 
 of diagnosis afforded in most cases by inspection. The 
 diseases which are likely to be mistaken for emphysema 
 are — ■ 
 
 Simple dilatation of the lung from hypertrophous 
 enlargement consequent upon extensive disease elsewhere 
 in the lungs. 
 
 Dilatation of the lun^y from acute tuberculosis, a con- 
 dition which is very seldom diagnosed, and which em- 
 physema closely resembles. 
 
 Pulmonary thrombosis and embolism, leading to dys- 
 pnoea and dilatation of the lung. 
 
 Pulmonary fibrosis, with contracted lung and dilated 
 tubes, and perhaps pneumothorax. 
 
 FIBROSIS, or fibroid disease, differs from cirrhosis of 
 the lung in not being confined to one lung, and it may 
 attack portions of the lung. 
 
 It appears to result from chronic pneumonia generally 
 of a congestive or catarrhal type. 
 
 Symptoms. — The chief indications of disease are 
 marked dyspnoea and cachexia, with occasionally abun- 
 
FIBROSIS OF LUNG. 125 
 
 dant expectoration, althougli that varies ^vith the degree 
 of bronchial catarrh present. 
 
 Patbolog7. — The Inng is rendered hard and almost 
 cartilaginous by the fibro-nucleated structure which in- 
 vades the whole of the pulmonary structure. The bron- 
 chial tubes stand out conspicuously, ringed with broad 
 white circles in the midst of iron-grey indurated lung 
 tissue, which was compared by Addison to Aberdeen 
 granite. The streaks of black pigment must be con- 
 sidered due to blood pigment, either in obstructed and 
 obliterated vessels, or in the peribronchial and perivas- 
 cular lymphatics. It is a condition which in scattered 
 patches, especially at the base of the lung, may be 
 attributed to old congestion or pneumonia ; but in the 
 apex form, where it occupies the upper lobe and the line 
 of demarcation between the pigmented old tissue and the 
 healthy, is very marked, it appears to me to be charac- 
 teristic of syphilis. 
 
 An illustration, on a very small scale, is given at page 
 128, intended to convey some notion of the iron-grey 
 indurated lung ; itwill be seen that I believe it to be 
 syphilitic. 
 
 Signs are those due to induration and contraction of 
 the part of lung affected. 
 
 Inspection will show flattening and fixity of the chest- 
 wall ; no expansion of that part. 
 
 Percussion gives a dull non-resonant note generally, 
 but if the tubes be much dilated the resonance may be 
 tracheal in quality, although high-pitched. I have known 
 this condition mistaken for emphysema, a proof of reso- 
 nance in the percussion note. 
 
 Palpation. — Yocal fremitus marked. 
 
 Auscultation. — Sometimes complete silence, especially 
 if the lung be extensively adherent, and the diaphragm be 
 drawn up. I have examined cases of this kind with the 
 shoulder drawn very much down and complete adhesion, 
 and absolutely no respiratory sound. If the base be free, 
 however, the diaphragmatic action induces a current in 
 
126 SIGNS OF PULMONARY DISEASE. 
 
 tlie upper lobe, to and fro, and tlien tubular respiration 
 is heard. 
 
 Yoice sounds, bronclioplionic or pectoriloquous. 
 
 Heart very mucli exposed ; its beat perceptible over 
 tliree interspaces ; sometimes a sliarp systolic murmur 
 may be teard at tlie base. 
 
 The opposite lung, if not affected, may show signs of 
 distension, by a high-pitched percussion note and puerile 
 respiration. 
 
 This condition of lung may break down, and be ex- 
 cavated under a condition of phthisis. When it begins 
 to liquefy it sometimes progresses very rapidly. The 
 sputa then assume a very characteristic green tint, owing 
 to the black pigment with which they are tinged. 
 
 GAlfGREsrE or TKX: ZaUliTG consists in the putre- 
 factive necrosis of lung tissue, and is consequent upon 
 pneumonia, poisoned blood, the pressure of tumours, 
 and organic cerebral disease. 
 
 Symptoms. — Chiefly constitutional, indicative of great 
 depression and prostration ; much dyspnoea, the breath- 
 ing being rapid and oppressed, and the expectoration of 
 purulent sputa of gangrenous odour being pathogno- 
 monic. It is, in fact, by this symptom alone that we are 
 sure gangrene is present. Sometimes the foetor is quite 
 overpowering. 
 
 Patbolo^y. — The disease may be general or circum- 
 scribed; it may be secondary to the pressure of an aneu- 
 rism or mass of cancer : the lung encroached upon being 
 horribly offensive, disintegrated, and shreddy; exuding 
 on section sanious fluid, or little patches may be seen 
 dark and soft in a similar condition. The supply of blood 
 must be totally cut off, and this obstruction may include 
 all the vessels supplying the part, 
 
 Si^ns afford no special indication of the disease. If it 
 be a result of pneumonia, the sounds of crepitating and 
 gurgling rales will be heard in the centre of the consoli- 
 dated mass of lung, or if the sphacelus be connected with 
 a bronchus there may be bubbling rales of large size 
 
HYDATIDS. 127 
 
 -with tubular respiration. Diagnosis depends upon the 
 odour of the breath and the sputa. 
 
 BVBATIBS of the lung are very rare in this country, 
 and in the majority of cases in which hydatids have been 
 expectorated, they have been seated in the right lobe of 
 the liver. 
 
 In Iceland it is an endemic disease, and some patients 
 with hydatids were brought to me when I was travelling 
 there. The diagnosis can only be made with certainty 
 when the cysts come to the surface, forming irregular 
 nodular swelHngs in the intercostal spaces, and the pre- 
 sence of hydatid membrane or booklets in the sputa is 
 established. 
 
 Symptoms, similar to phthisis, and characteristic of 
 destruction of lung tissue : pallor, emaciation, dysj-moea, 
 cough, pain in the affected side, shoulder and arm, decu- 
 bitus on the opposite side, bloody and purulent sputa 
 followed by the expectoration of portions of hydatids or 
 unbroken cysts, with night sweats and prostration. 
 
 Patbology. — Hydatids confined to the lung are rare, 
 but less rare in the liver ; in most cases they will there- 
 fore affect the right lung ; the cyst being situated in the 
 lung will press upon the external parts, the pulmonary 
 tissue being condensed and grey. 
 
 Signs. — Inspection shows the side affected to be more 
 or less fixed with unilateral bulging local, or in more 
 places than one, and obHteration of the intercostal 
 spaces. 
 
 Percussion note dull on the affected side, loud on the 
 opposite side. 
 
 Auscultation gives the signs of pressure ; absence of 
 respiratory murmur, tubular breathing, and after the 
 evacuation of the contents of the sacs, signs of cavity 
 and gurgling. 
 
 When the hydatids pass through the lung from the 
 liver, the general symptoms of liver disease are present, 
 and the sputa bile-tinted ; the signs then may be amphoric 
 and metallic. 
 
128 
 
 SIGNS OF PULMONARY DISEASE. 
 
 nrBURATZOir op the JmJTNG, commonly called 
 brown induration, arises from a varicose condition of the 
 pulmonary veins, consequent upon mitral regurgitation. 
 
 Symptoms are cliiefly due to tlie cardiac disease, to 
 wMch are superadded dyspnoea, cough, and the expec- 
 toration of bloody sputa. 
 
 Patbolog-y. — A peculiar dense tough condition of the 
 lungs is presented to view of a dark brick-red colour : the 
 condition is diffused over the lung, but according to my 
 observations radiates from the root as a centre ; on 
 close inspection I have found the middle portion of the 
 lung running across on a level with the root, chiefly 
 thickened. 
 
 EiG. 17. 
 
 Brown Induration of the Lung. 
 
 The microscopical appearance is peculiar ; the vessels 
 are seen in a swollen and tortuous condition, the alveolar 
 wall being also swollen; cells with blood pigment, and 
 blood occupy the lumina. As the condition is not re- 
 presented in most books, I have added here a drawing 
 from a preparation of my own. 
 
 Sigrns. — Inspection affords none of a distinctive cha- 
 
(EDEMA — PULMONAET APOPLEXY. 129 
 
 racter. Percussion gives marked dulness, and tlie region 
 over the second interspace is that which is most dnll. 
 
 Palpation, fremitus increased. 
 
 Auscultation shows density of tissue ; tubular blowing 
 respiration, absence of vesicular murmur, intf^nse high- 
 pitched bronchophony, and even pectoriloquy. I have 
 known this condition mistaken for cavity. 
 
 CEDSXVZA of the lungs takes place as the result of 
 general dropsy, chiefly from renal disease, but it is asso- 
 ciated also with passive congestions arising from bron- 
 chitis, cardiac disease, and adynamic conditions from 
 fever. 
 
 Symptoms are by no means distinctive, and only 
 suggest respiratory disturbance common with many other 
 forms of pulmonary disease. 
 
 Patbology is very characteristic ; the lung being 
 soaked in watery fluid without any colour, and the sacs 
 being completely infiltrated so as to be airless. The lung 
 is generally of a light grey colour, not crepitant, and 
 easily pitting (like an anasarcous leg) on pressure with 
 the end of the finger ; it sinks on being placed in water. 
 
 Signs. — The characteristic sign of this condition is the 
 fine bubbhng rale of a very liquid character, and some- 
 times resembling very closely the fine crepitation of pneu- 
 monia, but this bubbling rale is heard both during 
 inspiration and expiration ; it is also very regular and 
 rapidly repeated. Its usual situation is the posterior 
 bases of the lungs. 
 
 The palpation and percussion give variable sounds, 
 and are not distinctive of the condition. 
 
 PUZiIVIOia-ARV iiPOPIiEXV is the term applied to 
 extravasations of blood into the pulmonary tissue, with 
 laceration. 
 
 It commences as a congestion, the vessel giving way 
 from the vis a tergo, the intra- vascular pressure, the walls 
 being softened by disease. 
 
 Ssrmptoms. — The most important is haemoptysis, which 
 may occur in any quantity from mere streaks and specks 
 
130 SIGNS OF PULMONARY DISEASE. 
 
 to very large quantities. Dyspnoea, congli, a dull, heavy 
 pain, and discomfort on breathing, are general complaints 
 in this form of lung disease. It used to be attributed 
 solely to heart disease, but it may follow congestion from 
 cold, if the vessels be overloaded ; it is not uncommon 
 with cirrhosis and in beer-drinkers, and it may result from 
 stasis of the blood due to some derangement of the 
 circulation in debility of the heart. 
 
 It may occur without any blood being spat out. 
 
 Patbolo^y. — The appearances have been admirably 
 described by Laennec ; a patch of some size, resembling 
 damson cheese, is seen, the lung tissue being swoUen and 
 filled with dark, black clots of blood. In old j)atches of 
 some years' standing the patch becomes indurated and 
 pigmented, the blood either clearing out and leaving a 
 cavity, or losing its h^matin and becoming of a firm, 
 white fibrinous character. The position these patches 
 aft'ect is generally the middle of the right lower lobe, or 
 sometimes th^ corresponding part of the left lung. 
 
 Sig^ns. — Inspection shows imperfect expansion of the 
 part affected. 
 
 Percussion gives decided and circumscribed patches of 
 dulness. 
 
 Palpation perceives increased vocal fremitus, but this 
 is a variable sign, and is dependent upon the amount of 
 healthy tissue intervening between the patch and the 
 chest-wall. 
 
 Auscultation shows absence of breath sounds, with 
 occasional subcrepitant rales, increased by the cough- 
 breath or bubbling rales if the blood be very recently 
 effused and in some quantity. 
 
 PUXiMOITARV HSMORRHAGZ: occurs chiefiy from 
 the pulmonary arteries : the bronchial vessels cannot be 
 considered as giving rise to hasmorrhage, except in conges- 
 tion of the tubes and in the hsemorrhagic diathesis. To this 
 statement there are very rare exceptions — as, for example, 
 bronchial aneurism. Initial pulmonary hsemorrhage, ac- 
 cording to my opinion, generally arises from structural 
 
BLOOD-SPITTING AND ITS CONSEQUENCES. 131 
 
 weakness of vessels conseqnent upon a certain diathesis. 
 Initial bleeding sometimes occurs in very large quantities. 
 It is also found in beer-drinkers, tbe vessels being over- 
 loaded and softened. 
 
 Secondary bleeding, after pulmonary disease has been 
 establisbed, may occur from congestion, ulceration of 
 vessels, or strain upon weakened vessels. 
 
 Terminal bleeding occurring after tbe formation of a 
 cavit}^, and often proving fatal, is generally due to the 
 formation of a pulmonary aneurism ■^vT.tkin a cavity, or 
 pushing througb a bronchus, and to laceration of a vessel. 
 
 Symptoms. — The expectoration of blood. The colour of 
 blood in haemoptysis is generally of a bright red, and this 
 colour is observed when small pulmonary arteries have 
 given way ; but if a large branch of the artery is ruptured, 
 and the blood is delivered in large quantities, so as to 
 have Httle chance of aeration in transit, the blood ejected 
 is of a dark purple colour. Retained blood is always dark, 
 
 Patbolo^y. — In the hgemorrhagic diathesis the lungs 
 may be uniformly congested and in a highly-vascular 
 condition, but in most cases the bleeding is either traced 
 to»an obtruncated vessel by the action of excavation, or 
 to the formation of a pulmonary aneurism within a cavity 
 or bronchus. These vary in size, from a hemp-seed to a 
 Maltese orange. 
 
 Pulmonary apoplexy is another cause of hasmorrhage. 
 
 Sig^ns. — There are no signs which give indications of 
 approaching haemorrhage, nor of its occurrence at the 
 time. Cases have been reported in which pulsations and 
 murmurs of a peculiar kind were detected, due to pul- 
 monary aneurism, but such a case has never come under 
 my notice, and more evidence is required on this point. 
 
 Results of Haemorrbag-e. — These are extremely impor- 
 tant, and have been strangely overlooked. Blood ejected 
 in any quantity is Hkely during the act of passage to 
 induce dyspnoea; the next gasp, or simply the act of 
 breathing while the blood is flowing, lands a quantity of 
 the blood (which is welling up in the tubes) into the 
 
 k2 
 
132 SIGNS OF PULMONAKT DISEASE. 
 
 alveolar tissue. In cases of fatal bleeding patclies of 
 blood, as large as a tbnmb-nail, are found in tbe sound or 
 opposite lung. Tbese patclies occupy certain regions 
 under the special influence of inspiration ; tbe upper lobe 
 fii'st, and in. greatest quantity; tben tbe middle of the 
 base, or tbe anterior border of tbe lung ; and, lastly, the 
 axillary region, near the nipple. 
 
 Symptoms. — Dyspnoea and cough may result from 
 this, and if the invasion of the lung be very great, 
 emaciation follows. In many cases no result may be 
 observed, and patients may survive the event and die of 
 some other disease; or the nodules left from the blood 
 may soften under septic influences, clear out and form 
 cavities, and lead to all the symptoms and signs of ordi- 
 nary phthisis. 
 
 A condition of emphysema sometimes follows, from the 
 contraction of the nodules and compensatory expansion 
 of the lung in the vicinity. 
 
 Pathology-. — Hard, ivory-white fibrinous nodules are 
 found of different sizes, from a pea to a thumb-nail, in the 
 localities above mentioned ; these soften and liquefy, ulti- 
 mately leaving cavities which can be with difficulty, ^d 
 only sometimes, distinguished from ordinary phthisical 
 cavities. 
 
 Sig-ns. — These are to be considered from the aspect of 
 chronicity or the previous date of the bleeding. 
 
 If a patient applies soon after the attack, the pre- 
 sence of blood may be detected in the lung. This was 
 known to Laennec, who describes the sound with his 
 usual accuracy; but it must not be asserted that the 
 blood started from that place — it is simply there. 
 
 Percussion and palpation give no clue to its pre- 
 sence in this early stage. 
 
 Auscultation shows the presence of a fine bubbling 
 rale (or subcrepitant rale, if some little time has elapsed) 
 during inspiration and respiration, and the situation is 
 above the root of the lung (as Laennec knew), generally 
 close to the sternum under the clavicle. 
 
THROMBOSIS AND EMBOLISM. 133 
 
 If tlie quantity of blood is very profuse, tliese signs 
 may be found in the axillary region, near the nipple, or 
 near the anterior lower border. All these regions should 
 be invariably explored for their clues. 
 
 If some time has elapsed since the bleeding the moist 
 sounds disappear, gradually becoming more scanty and 
 viscid, until at length only a viscid chck is heard. This 
 is heard in very circumscribed patches, which is patho- 
 gnomonic of the condition. 
 
 Percussion then begins to give evidence, and small 
 patches of dulness can be made out. 
 
 Auscultation shows imperfect expansion of the patch, 
 the vesicular murmur being exaggerated in the vicinity, 
 the delivery being impeded, and jerky, free expansion 
 being stopped by the nodule. 
 
 Inspection then detects a shrinking in of the soft 
 parts and imperfect expansion of the lobe. 
 
 If the condition of the patient deteriorates, these 
 nodules soften, giving rise to characteristic hard crackling 
 rales, very high-pitched (like rattling peas), and eventually 
 the signs indicate that a cavity is being formed, high- 
 pitched gurgling rales being heard. 
 
 In this manner disease is produced which in all respects 
 closely simulates ordinary phthisis, and in advanced con- 
 ditions can with the greatest difficulty be determined 
 clinically or pathologically. 
 
 It remains to say that tubercle may result, although the 
 exact conditions necessary for its production are open to 
 doubt. 
 
 In many cases of profuse initial haemorrhage the 
 pulmonary signs are harsh, high-pitched, imperfect 
 vesicular murmur, which is due to the thickened con- 
 dition of the alveolar tissue consequent upon the pre- 
 sence of blood (fibrin and blood corpuscles), which may 
 be seen under the microscope within the walls, and by 
 which they are stiffened and thickened. 
 
 PUIiXVXOXrARV THROMBOSIS AXB SMBOI.ISIIX. 
 — For the purpose of auscultation these two conditions, 
 
134 SIGNS OF PULMONARY DISEASE. 
 
 whicli differ mainly in tlieir respective cansation, must 
 be considered as identical. They both produce plugging 
 of the vessels : a very large branch of the pulmonary 
 artery being sometimes occluded. 
 
 Symptoms. — More evidence is required on this subject, 
 but the principal symptoms are severe and sudden 
 dyspnoea ; turbulent actiou of the heart, from the exces- 
 sive sudden strain thrown upon it by the plugging of a 
 large vessel ; marked venous pulsation in the vessels of 
 the neck, in consequence of the yielding of the tricuspid 
 valve and the stoppage of the pulmonary current. The 
 dyspnoea is very severe and gasping, and may recur in 
 paroxysmal attacks, soon proving fatal. 
 
 Patbolo^y. — In both cases the vessels are plugged by 
 adherent or non-adherent clots. In embolism the plug, if 
 it obstructs the pulmonary arteries, is transferred from 
 the venous system generally of the lower part of the 
 abdomen, as in phlebitis of the lower extremities. 
 
 In thrombus the plug forms from neighbouring irrita- 
 tion, the presence of a large cavity with the vessel exposed 
 in close contiguity, or even the pouching of a collateral 
 purulent bronchus. 
 
 The wedge-shaped patches are usually due to embolism 
 of the bronchial arteries, from mitral or aortic fringing. 
 
 If the plugged artery (pulmonary) be large, the blood 
 supply is completely cut off from the corresponding 
 lobules, and a pale distended lung is the result ; or the 
 wedge-shaped mass and hgemorrhage result, if the vessel 
 be not large. 
 
 Sigrns require further clinical observations. A hyper- 
 resonant percussion note may be detected, and aus- 
 cultation will indicate absence of respiratory murmur 
 and the pressure upon the tricuspid valve; but the 
 symptoms must be looked to as more likely to indicate 
 the nature of the lesion than the signs. Yery little atten- 
 tion, it must be confessed, has hitherto been devoted to 
 this point ; the condition is, however, a rare one. 
 
 PXiSURAIi BISEASES. — Pleurisy may be acute or 
 
PLEUEISr. 135 
 
 ebronic, and may be a primary disease or occnr as a con- 
 sequence of some otlier disease. 
 
 Syzuptozus. — In acnte idiopatliic pleurisy one side 
 suffers, and tbe chief cliaracteristic symptom is tlie stitch. 
 in the side. This pain, which is generally described as a 
 sharp pain as if a knife was sticking in the side, is 
 increased by movement and respiration. It may or may 
 not be preceded by signs, which are seldom well-marked 
 unless pneumonia is present also. 
 
 A short, dry cough is present, with rapid breathing, 
 which is accelerated in consequence of the restrained 
 respiration resulting from the pain. 
 
 The pulse is frequent and hard: the urine much in 
 quantity and deep in colour. 
 
 Pathology. — There are four stages of pleuritic in- 
 flammation : — 
 
 1. Hyperffimia, or the dry stage, in which the vessels are 
 injected and the pleura becomes dry and opaque, losing 
 its elasticity and natural transparent apjjearance. 
 
 2. The stage of exudation, in which lymph is thrown 
 out on the surface of the membrane, which becomes dulled 
 and roughened. 
 
 3. The stage of effusion, in which a quantity of serum. 
 is poured out sometimes to a very large amount. 
 
 4. The stage of absorption followed by adhesion. 
 Physical Signs. — The movements of the pleura in a 
 
 condition of health are inaudible, but when the first stage of 
 inflammation (hyperaamia) alters the smoothness of surface 
 and causes pain during respiration, signs become manifest. 
 
 Zspection shows a marked diminution in the expansion 
 and elevation of the side affected. 
 
 Percussion is not altered. 
 
 Auscultation elicits a weak sujjerficial respiratory 
 sound, which is diminished in intensity according to the 
 pain of respiration, and which is jerky in rhythm. Some- 
 times an occasional graze is heard, which may be imitated 
 by putting the stethoscope in the palm of the hand and 
 rubbing the back with the end of the finger of the other 
 
136 SIGNS OF PULMONARY DISEASE. 
 
 hand. Sometimes two or three grazes are heard during 
 the respiratory act ; sometimes the sonnd is only to be 
 heard at the end of inspiration and the beginning of 
 expiration : they are quite superficial sounds and close 
 under the ear, and are sometimes increased by pressure, 
 especially in the intercostal spaces. 
 
 Second Stag'e of Exudation, — Inspection and percus- 
 sion, as in the first stage. 
 
 Palpation often detects the vibration due to the rubbing 
 of the two altered surfaces. 
 
 Yery rough sounds may now be heard with the stetho- 
 scope. Sometimes these sounds are recognised by the 
 patient. 
 
 Third Sta^e. — Effusion of fluid into the sac. 
 
 Inspection. — Bulging, to more or less extent in propor- 
 tion to the amount of effusion, is observed : the intercostal 
 spaces are obliterated and are level with the ribs, and they 
 sink in less with respiration than those on the other 
 side. 
 
 If the amount of fluid in the pleura be large there may 
 be displacement of the lung, the mediastina, the heart, 
 the diaphragm, and liver. 
 
 In effusion of the right side the liver may be depressed, 
 the right hypochondrium being prominent and the margin 
 of the liver lower than natural. It is necessary to 
 remember that the liver may be morbidly enlarged, a 
 condition which will interfere with the diagnosis of 
 effusion. If the effusion is very great the mediastina and 
 heart may be thrown over to the left. 
 
 In effusion of the left side the apex of the heart is 
 thrown over towards the right, and is lower than usual. 
 
 Measurement sometimes gives an increase of size for the 
 healthy side, but inspection will show whether the bulging 
 is local or general. 
 
 Palpation. — Yocal vibration is generally obstructed by 
 fluid, while above the fluid it is perceptible. 
 
 If the effusion be very great, the perception of fluctua- 
 tion may be transmitted by carefully percussing in an 
 
PLEURITIC EFFUSION AND ABSORPTION. 137 
 
 intercostal space witli one finger, a finger of the other 
 hand being placed some little way off. 
 
 The cardiac impulse is sometimes transmitted. 
 
 Percussion gives distinct evidence from diilness pro- 
 portionate in degree and extent to the quantity of fiuid 
 present. 
 
 Resonant tense percussion is found above the fluid. 
 This is explained at page 71. 
 
 Auscultation gives negative signs : no respiratory 
 murmur, and friction seldom is detected ; it occurs some- 
 times above the fluid if the layer be very thin. 
 
 Often at the upper part, at the upper limits of dulness, 
 aegophony may be heard. 
 
 If there is much compression of the lung, high-pitched 
 bronchial respiration (the expiratory pitch being very 
 high) is heard, and may be even heard through the layer 
 of fluid. 
 
 It is a mistake to suppose that sounds cannot be heard 
 through fluid : sounds are diminished by passing from one 
 medium to another, but not necessarily obliterated. 
 
 -^gophony is usually heard close to the angle of the 
 scapula, the lung being solidified or pressed to the back, 
 and when there is great compression of the lung from 
 very large efiusion loud bronchial breathing may be heard 
 all over the chest, although a mass of fluid be interposed 
 between the lung and the ear. 
 
 Over the sound lung the respiratory sound is loud and 
 puerile, and the sound of bronchial respiration may be 
 transmitted at the back for a distance sometimes of five 
 inches from the spine over the healthy lung. 
 
 Pourth Stag-e. — Absorption. 
 
 In the process of repair the fiuid becomes gradually 
 absorbed, and the parts tend to return to their original 
 positions. The distension of the side becomes less : this 
 may be estimated by careful measurement with the tape, 
 or, still better, by means of the cyrtometer. 
 
 As the fluid is absorbed the respiratory murmur 
 becomes more audible, and when the two surfaces meet 
 
138 SIGNS OF PULMONARY DISEASE. 
 
 tlie sound of retnrniiig friction is again heard for a short 
 time. 
 
 Even after the fluid has disai^peared, marked duhiess of 
 percussion may remain for some time, with increased 
 vocal resonance and bronchial respiration. 
 
 This is proportionate to the amount of pressure. 
 
 I must express my opinion, founded upon post-mortem 
 observation, that compressed lung, the result of effusion, 
 seldom returns completely to its normal condition, 
 inasmuch as adhesion takes place before the lung has 
 recovered. 
 
 The usual result of effusive pleurisy is adhesion, and 
 consequently impaired, if not completely annihilated, action 
 of the ribs to which the lung is adherent. 
 
 Absorption is noted just behind, near the spine, and in 
 front from the infra-clavicular region ; the last part to be 
 free being the lower axillary portion. 
 
 Damoiseau has noted that the line of the fluid forms 
 irregular curves, which become smaller and smaller as the 
 fluid retires, assuming a parabolic form. 
 
 Occasionally a peculiar ^***,^ curve is noticed which 
 appears to be dependent upon the lower line of the lung, 
 which is pressed upwards. 
 
 The ^""^v^ curve, which has received much attention, and 
 has been well described by Garland in America, appears 
 to be formed only when a dropsical effusion into the 
 pleura takes place ; it is rare, inasmuch as the lung 
 must not be bound down, or the curve will be altered. 
 The notion that the elasticity of the lung supports the 
 column of fluid is fallacious. 
 
 Decubitus in pleurisy has been much insisted upon by 
 writers as invariably on the affected side. This is very- 
 far from true, inasmuch as the side may be full of fluid, 
 and the patient may lie on the opposite (sound) side. 
 Decubitus appears to depend upon concomitant conditions 
 of disease ; in phthisis the patient invariably lies on the 
 sound side, and if pleurisy supervene the rule is still 
 observed, whatever be the amount of fluid effused. If 
 
EMPYEMA, 139 
 
 the amount be small and tlie plenrisy idiopathic, decnbitns 
 is on the affected side. 
 
 Blood in the pleura is of rare occurrence, except after 
 mechanical injury, or concurrent with, the presence of 
 malignant disease in the chest. I have seen a case of 
 simple bloody extravasation followed by coagulation and 
 the permanent presence of blood in the pleural cavity ; 
 the man dying two years after th.e extravasation of 
 blood from the results of a surgical operation for other 
 disease. 
 
 Pus within the pleura, or empyema, results from a con- 
 stitutional condition wbich modifies the exndation of a 
 pleurisy. It may be set up in children, debilitated by 
 previous disease or the subjects of the scrofulous dia- 
 thesis ; or it may occur from spinal abscess. In tbe adult 
 it follows pleurisies, a consequence of constitutional 
 dyscrasiae. 
 
 Symptoms are those general to chronic pleurisy, and 
 in addition to these are cbills and rigors, often repeated, 
 and pointing to the presence of pus ; pulse very rapid ; 
 tongue dry and brown ; hectic night-sweats, and more 
 constitutional disturbance than in serous effusions. The 
 thermometer must be frequently consulted in such cases. 
 
 Pathology. — Collections of pus within the pleura are 
 generally found in the lower part of the chest. They 
 have a tendency to burrow upwards in the axillary 
 region, or behind along the spine, and may eventnally 
 bore a passage through the lung, being evacuated by the 
 mouth, or a fistulous communication with the external 
 walls may be formed, the abscess bursting externally. 
 
 Sigrns. — Inspection often shows considerable bulging 
 of the affected side, with obliteration of the spaces ; but 
 this is caused by the pressure, and is not a distinctive 
 condition of empyema alone. Sometimes oedema of the 
 flank or surface may be observed, with, an erysipelatous 
 condition. These are certain indications of pus. 
 
 Palpation sometimes detects the frictional vibrations of 
 pus in the pleura due to its up-and-down movement. 
 
140 SIGNS OF PULMONARY DISEASE. 
 
 Yocal fremitiis is never (according to my experience) 
 completely absent, and sometimes qnite as intense as 
 that over tlie sound lung. I hesitate therefore at present 
 to accept the doctrine of Baccelli that absence of vocal 
 vibration and sonnd is distinctively pathognomonic of 
 pns. 
 
 Auscultation occasionally detects,. in early conditions 
 and in cases where the lung is not closely bound down 
 by a loculated or confined empyema, a very distinct and 
 superficial crepitant rattle, much louder and more fluid 
 than the simple pleuritic friction sound, but evidently 
 superficial, I believe this sound to be due to the separa- 
 tion of the pleural surfaces, temporarily agglutinated 
 by the presence of pus. 
 
 If there be much pressure and the lung be condensed 
 the breath sounds may be heard distant, but tubular, 
 through the fluid. 
 
 Aplgophn-ny is, I believe, rare in empyema, but I put these 
 observations forward with diffidence, inasmuch as more 
 evidence is required on this point. 
 
 When this condition is suggested, evidence should be 
 obtained by the introduction of the perforated needle. 
 
 When the collection of pus has burrowed and evacuated 
 its contents through the lung (which, according to my 
 experience, happens in the upper axillary region, close 
 under the axilla), the signs are those of pneumothorax, 
 limited in extent because of the adhesions round the 
 empyema. 
 
 There are then signs of air in the cavity, which are 
 described fully under the heading " Pneumothorax," to 
 which reference must be made. 
 
 The voice sounds then become pectoriloquous, articu- 
 late speech being intensely and distinctly transmitted 
 over the cavity ; the margin may be made out, not only 
 by percussion but the buzzing bronchophony (in- 
 distinct voice and speech) which can be readily heard all 
 round. 
 • The lower lobe of the lung may yield respiratory 
 
PNEUMONIA. 141 
 
 sounds, the upper being generally silent, only giving 
 gurgles on cough. 
 
 [Paracentesis is performed by introducing the trocar 
 into the chest. For this operation Laennec recommended 
 the fifth interspace in front of the digitation of the 
 serratus magnus ; but the advantage of selecting so high a 
 place for puncture is only due to the safety with which the 
 abdominal organs will escape accidental wounding. For 
 the purposes of evacuating an empyema, the lower the 
 perforation is the better adapted it is to clear out the 
 contents. Dr. R. D. Powell recommends the sixth or 
 seventh space, about the mid-axillary line, for serous 
 effusions. Bowditch operates between the ninth and 
 tenth, sometimes the tenth and eleventh, ribs behind, in a 
 line let fall from the lower angle of the scapula.] 
 
 Pneumothorax, as a condition resulting from phthisical 
 perforation of the lung, will be described after Phthisis. 
 
 CROUPOUS PlTEUlvloia-lA. — This disease has been 
 often described, and its symptoms, course, and physical 
 signs much studied, and are well known. 
 
 Symptoms. — Rigors, with much heat of skin, rapidity 
 of pulse ; oftentimes delirium ; sputa (scanty at first) 
 of a peculiar character, rusty and streaked with blood ; 
 the whole disease having a course of something under 
 three weeks, the acme of the disease being reached within 
 eight days, but the complete recovery depending upon the 
 amount of lung involved, the constitution of the patient, 
 and other considerations. 
 
 Pathology. — The conditions which are presented to 
 view in the post-mortem room are divided into stages. 
 
 First Stage (Hypersemia). — The vessels of the lobe 
 affected are found much enlarged and gorged with blood ; 
 the capillaries are seen to be very swollen and tortuous, 
 encroaching to a great extent upon the alveoli. 
 
 The affected portion of the lung is red, increased in 
 weight and density, and contains less air than it should do. 
 A cut section yields a viscid bloody liquid. 
 
 Physical Signs. — First Stage. — The earliest physical 
 
143 SIGNS OF PULMONAEY DISEASE. 
 
 sign that can be detected in pneumonia is a liarsli, high- 
 pitched, exaggerated breath, sound, not vesicular in cha- 
 racter, because the elastic condition of the air- vesicles is 
 lost. It is not often that one is called to cases until the 
 stage of exudation has set in, and the crepitant rale 
 pathognomonic of the disease is audible. 
 
 The crepitant rale has been often described, and no 
 better imitation can be given than the sound derived 
 from rubbing a lock of hair between the fingers. 
 
 It is a high-pitched, viscid, but not bubbling rale 
 (Laennec's rale crepitant) : it is the finest of all rales. 
 It is formed by the forcible separation of the glutinous 
 surfaces of the air-vesicles by the entrance of air during 
 inspiration. Vesicular breathing is diminished ; and the 
 tissue being made denser by the tortuous and turgid 
 capillaries, the respiratory sounds must be harsher, louder, 
 and higher-pitched than natural. 
 
 Inspection. — The thorax preserves its usual condition, 
 both as regards general form and as regards the inter- 
 costal spaces. Inasmuch as stitch from pleurisy often 
 accompanies pneumonia, the affected side is not used. 
 
 Palpation. — Yocal fremitus is increased ; the impulse 
 of the heart is stronger than normal. 
 
 Percussion. — The sound is more or less dull. 
 
 Second Stage (Red Hepatisation). — This is caused by 
 the consolidation of the pneumonic exudation : the in- 
 filtrated i^art of the lung being red and of liver-like con- 
 sistency. There is great increase of weight and solidity, 
 the air being completely drawn out; and a hepatised 
 portion of the lung sinks rapidly in water. On scraping 
 the surface of a cut section, plugs of exudation can be 
 scraped out, leaving the alveolar walls thickened. One 
 of the first things that strikes one on viewing a hepa- 
 tised lung from the body is the great weight and size of 
 the lung as compared with a healthy lung. It is also 
 ribbed on the surface. 
 
 Physical Sig-ns. — Inspection. Although in conse- 
 quence of the expanded state of the sound side it may be 
 
SOUNDS OF CONSOLIDATION. 143 
 
 difficult to detect any difference between the diseased and 
 sonnd side, in some cases the diseased side is enlarged, 
 and in joung people with elastic ribs, basic pnenmonia 
 may expand the part affected. This is also the opinion of 
 Walshe, Ziemssen, and Grisolle. 
 
 The expansion of the chest is lessened on the affected 
 side, increased on the sonnd side, and this is independent 
 of the pleuritic stitch. 
 
 Palpation. — ^Yocal fremitus is much increased in 
 intensity: the impulse of the heart is also frequently 
 transmitted to touch and ear as a tremulous vibration. 
 
 Percussion generally yields an absolutely dull note, 
 which may be confined to the lobar limits. 
 
 Sometimes the middle lobe is found distended and 
 enlarged, taking the functions of the diseased lower 
 lobe ; in this case resonant percussion will mark out the 
 position of the lobe. This distension of the lung, which 
 gives a clear but high-pitched note, enables us to contrast 
 in a very marked manner the note of solid lung and of 
 healthy distended lung. 
 
 But although dulness of percussion note must be 
 looked upon as generally characterising the stage of con- 
 solidation, it is necessary to point out that the density 
 may be so great that the sound elicited by percussion 
 may be drawn from the bronchial tubes, and a tubular or 
 even an amphoric note may be heard. 
 
 This statement is corroborated by Hudson, by whom it 
 was first observed, by Walshe, ]!Srienieyer, and Flint. 
 
 It has been observed on the right side as well as on the 
 left, and even the anterior base. It is possible that the 
 sound may be due in some cases to the consonance derived 
 from a distended stomach or colon, and this point recjuires 
 further observation. 
 
 Auscultation. — Bronchophony and tubular breathing 
 are the characteristic pathognomonic signs : bronchial 
 respiration, voice sound, and bronchophonic whisper are 
 heard in all their fulness in this stage. 
 
 The student must particularly study the pitch both of 
 
144 SIGNS OF PULMONARY DISEASE. 
 
 tte inspiratory and tlie expiratory sounds when a typical 
 case of pneumonic consolidation is under observation. 
 
 Broncliopliony and tlie sounds of solid material are 
 shown by the raising of the pitch and in tubular breath- 
 ing, the pitch of the expiratory sound is in a marked 
 manner much higher than that of the inspiratory sound. 
 
 This character distinguishes the soHd sound from the 
 hollow sound : the sound of cavity being characterised by 
 a lowering of the pitch of the expiratory murmur. 
 
 There is no greater stumbling-block in auscultation 
 than the distinction between solid and hollow sounds, 
 and long experience has convinced me that there is no 
 other means for distinguishing between them than this, 
 which we owe entirely to Austin Flint, of l^ew York. 
 
 The third stage of pneumonia must be considered from 
 two different views : either the disease progresses and the 
 patient goes from bad to worse, the anatomical condition 
 of the lung changing from the red hepatisation to the 
 grey, or suppurative form ; or, as more frequently happens, 
 the patient recovers, the disease retrogrades, and the red 
 hepatisation resolves, liquefies, and is absorbed. 
 
 Third Stage (Progressive Disease). — Grey (suppura- 
 tive) hepatisation. 
 
 Symptoms. — These, so far as they can be relied on to 
 indicate the unfavourable issue of the case, are very 
 subtle : the tongue, the pulse rate, and respiration must 
 be looked to and carefully watched. The pulse, as a rule, 
 is very frequent and small, occasionally dicrotous ; the 
 tongue becomes dry and baked, and the respiration hurried 
 and impeded. 
 
 Pathology. — The red solid look of the second stage 
 becomes mottled and flecked with grey; eventually all 
 the red colour disappears, and the lung becomes grey and 
 pulpy ; the alveolar contetits liquefy, and the walls of the 
 air-sacs ulcerate and break down. 
 
 Signs. — These are the same as those of the previous 
 stage; and we can only conjecture the progressive con- 
 dition from detecting localised patches, in which high- 
 
CROUPOUS AND CATARRHAL PNEUMONIA. 145 
 
 pitched rattling rale or bubbling rale are evident to the 
 ear ; but throughout there may be an absence of such 
 signs — almost absolute silence — dulness on percussion 
 being the only sign of disease- 
 Third Stage. — Resolution. — Disease retrogressive. 
 Symptoms are those of convalescence, the phenomena 
 of disease disappearing. 
 
 Pathology. — Absorption of the fibrinous exudation and 
 recovery of the alveolar tissue. 
 
 Signs. — Of these the most important is the redux 
 crepitation {cre^itatio redux), which is moister than the 
 fine crepitation of the initial stage, much less regular, 
 and at the beginning of the process scanty and few in 
 number. Like fine crepitation, they belong to inspiration ; 
 but as they become more fluid, and partake of the bubbling 
 character, they are continued on to the expiration. The 
 sign must be considered as, first, a crepitation due to the 
 unfolding of agglutinated sacs ; and, secondly, as a rale 
 when the exudation liquefies and pours into the bron- 
 chioles. Hence it is really intermediate between fine 
 crepitation and the subcrepitant rale. While this reso- 
 lution is proceeding the breathing becomes less tubular, 
 and gradually returns to its natural condition. 
 
 It is during this stage generally that Skoda's tympanitic 
 note may be detected by percussing over the upper lobe, 
 the lower lobe being consolidated — the explanation of 
 which I have already given, and briefiy is this : — The con- 
 solidated lung is increased in bulk very much when the 
 upper lobe resolves and the exudation is removed ; the 
 pressure of the atmosphere must force the surface of the 
 lung to meet the walls of the chest, which are thrown 
 forward ; hence the air-sacs are over-distended, and give a 
 hyper-resonant note (see page 70). 
 
 Catarrhal Pneumonia. — It is somewhat strange that 
 croupous pneumonia should have occupied so many 
 volumes, and that catarrhal pneumonia, a more insidious 
 and pernicious disease, should have absorbed so little 
 attention. It is a disease of not infrequent occurrence, 
 
 L 
 
146 SIGNS OP PULMONARY DISEASE. 
 
 the most frequent prodromal stage of phthisis ; whereas 
 croupous pneumonia is a very exceptional condition, either 
 as a complication or as an initial stage of phthisis. In all 
 books it is stated that catarrhal pneumonia is an extension 
 of bronchitis, but to this statement I must take objection, 
 if it be meant thereby that this form is simply a con- 
 tinuation downwards of disease travelling along the 
 bronchial tubes. 
 
 It is essentially a disease of irritation ; it arises from 
 
 the effect of irritating (often damp) air on the alveolar 
 
 walls, and that bronchitis often precedes only indicates 
 
 (to my mind) that the tubes really filter out noxious 
 
 ingredients from the air, and are defensive outworks 
 
 calculated to protect the alveoli. By the frequent 
 
 repetition of bronchial attacks the respiration becomes 
 
 more forced, and consequently eventually the irritating 
 
 particles affect the alveoli. I have watched catarrhal 
 
 pneumonia, commencing in a scrofulous patient with 
 
 all the acute symptoms of croupous pneumonia, passing 
 
 from the stage of fine crepitation through consolidation 
 
 in three weeks' time, terminating fatally after the space 
 
 of two months; the alveolar tissue being thickened 
 
 and invaded by cell-growth, and breaking down without 
 
 any sign of croupous exudation. 
 
 Symptoms may then closely simulate croupous pneu- 
 monia, but in the ordinary run of cases the disease is more 
 insidious, and follows previous attacks of catarrh and 
 bronchitis. The main symptoms are troublesome 
 cough, dyspnoea, and expectoration, with rapid pulse, 
 often an absence of febrile signs, but loss of flesh 
 and health are invariably present. 
 
 Pathology. — The process is one of irritation of the air 
 surface of lobules, and whereas croupous pneumonia is 
 lobar, catarrhal pneumonia is lobular ; indeed, it is some- 
 times seen (post-mortem) affecting lobules here and there ; 
 intervening lobules being untouched, and forming a marked 
 contrast by their grey appearance to the red colour of the 
 irritated lobules. 
 
CATARRHAL PNEUMONIA. 147 
 
 Hyperaemia is the initial condition followed by active 
 proliferation of the epithelium, the air- sacs being 
 filled more or less with the pinkish-white or light red 
 secretion. The condition may resolve, but it has a 
 marked tendency to progress, inasmuch as the lung that 
 gives way to such irritative disease is unable to throw it 
 off, and is very apt to succumb, probably from delicacy of 
 structure. If this takes place, then the alveolar walls 
 become invaded by the cellular growth, and ultimately 
 obstruction takes place, constituting the condition of 
 phthisis. 
 
 Si^ns. — In acute forms of the disease, especially when 
 several lobules are attacked, the signs may simulate very 
 closely the early stages of croupous pneumonia ; fine 
 crepitation, rather more liquid, not so high-pitched, less 
 ratthng, may be heard, but the more usual signs result 
 from a very insidious and chronic form. If, for example, 
 a patient comes for examination with a history of previous 
 colds and winter cough, we are very apt to find imperfect 
 expansion of the lung, deficient vesicular murmur, which 
 is impaired and more or less silent. On forced inspiration, 
 or after the cough-breath, we hear quite at the end of in- 
 spiration a little stick, almost a graze or rub, of ill- 
 defined character, and not amounting to a rale. This is an 
 extremely suspicious sign, and indicates retention of 
 catarrhal products. 
 
 If the disease progresses it may do so quite insidiously, 
 and at the next visit (if it be after two or three weeks' 
 interval) we may be surprised by hearing an explosion of 
 sounds after cough, or the sound may become more liquid 
 and lead up to the crepitant rale. 
 
 Inspection under such conditions shows imperfect 
 expansion. 
 
 Percussion detects some diminution of resonance. 
 
 In cases of previous disease, where the lower parts of 
 the same lung or the opposite lung become involved, 
 pec^-»liar patchy dulness may be detected, intervals of 
 distended lung being clearly made out. 
 
 l2 
 
148 SIGNS OF PULMONARY DISEASE. 
 
 Auscultation then may reveal no more than a few scanty 
 viscid clicks in the parts affected, with absence of respira- 
 tory murmur. 
 
 Prognosis in great measure depends upon the heredity 
 of the patient, the present condition of health, and the 
 amount of mischief. As far as signs are concerned, 
 fluidity is unfavourable, and the pitch of the sounds helps 
 towards forming a notion of the condition of the alveolar 
 tissue ; if there be much thickening, much consolidation, 
 the pitch is raised, and the sounds assume a rattling 
 quaUty. 
 
 If the disease retrogrades and the lung recovers, the 
 sounds die away and the vesicular murmur gradually 
 becomes restored, passing through a condition of im- 
 perfect elasticity, indicated by feeble vesicular murmur of 
 a pecuhar dry, and even harsh quality, in which the pitch 
 of the sound is slightly raised. 
 
 Pneumonia of this form is very apt to assume a special 
 character in accordance with the type of constitution 
 which it affects. In the young, cell-growth is a pecuhar 
 characteristic in all forms of disease and absence of 
 fluidity : the air- sacs become choked with cells, which are 
 very apt to give little indications of their presence to the 
 ear, and, moreover, they are not expectorated ; this is still 
 more marked in scrofalous types of constitution, of which 
 large cell-growth is a distinctive characteristic. These 
 prevent fluid sounds, and result rather in silence than 
 sound. On the other hand, in the adult, and especially 
 in broken-down constitutions, the exudations have a 
 tendency to become more fluid, and there is more sound 
 and more expectoration. It is impossible to do more 
 than indicate the varieties of signs under such altered 
 conditions ; they should, however, absorb much attention 
 on the part of the student. 
 
 Interstitial pneumonia is a condition of a very 
 chronic character, and, as a rule, is secondary to other 
 inflammatory processes affecting the alveolar tissue, the 
 l:ironchi, or the pleura. It includes a variety of diseases. 
 
SYPHILITIC PULMONARY DISEASE. 
 
 149 
 
 and the symptoms are fhose simply of anmilled respira- 
 tory function; dyspnoea, especially on exertion, and cough. 
 I have already described under the term fibroid disease 
 the symptoms and signs which are to be looked for in this 
 affection of the lung. I shall, in this place, only draw 
 attention to a peculiar form which is due to syphilis, and 
 which may be called sypbilitic pulmonary disease. To 
 a great extent this disease has escaped notice, but, after 
 the experience of ten years, I must say that I look upon 
 this as a specific lung disease, which is associated with 
 no other condition except chronic syphilitic cachexia, 
 and that it has distinct symptoms and signs of its own. 
 
 Fig. 18. 
 
 Pigmented Fibroid Lung. 
 
 Symptoms. — Marked dyspnoea, especially on exertion, 
 the patient being sometimes unable to walk except on the 
 level ; more or less cough of a ringing character, with or 
 
150 SIGNS OF PULMONARY DISEASE. 
 
 without expectoration, but generally there is much, 
 bronchorrhoea. As a rule, haemoptysis of no great 
 quantity is present from time to time. There is some- 
 times emaciation, but this is proportionate to the amount 
 of cachexia. It is invariably associated with the syphilitic 
 bronzing of shin and with tenderness on touch over the 
 clavicle or upper ribs. It is more common in women than 
 in men, and consequently primary symptoms are not 
 always to be made out : but tenderness of the scalp has 
 been, in my cases, seldom absent. 
 
 Patbolo^y. — Marked increase in the connective tissue 
 of the lung, which is most apparent in the inter-lobular 
 septa about the bronchial vessels and the tubes. It 
 results in the iron-grey induration, which may be found 
 also in other conditions, but is certainly associated with 
 syphilis in many cases. I append a sketch to indicate 
 the soHd condition which I believe may be ascribed to 
 syphilis. 
 
 Sig-ns. — Inspection gives no indication of the pulmo- 
 nary disease, but suggests the general cachexia fi'om the 
 bronzed skin. 
 
 Palpation, with rare exceptions, detects tenderness on 
 pressure, or on percussion over the bony parts of the 
 chest. 
 
 Percussion gives a more or less dull note. 
 
 Auscultation detects a peculiar, dry, papery rustling, 
 indicating thickening and want of elasticity in the air- 
 sacs. This sound is pitched high, and is generally 
 diffused over the infra- clavicular region. In marked 
 cases there is also a high-pitched, tubular, blowing sound, 
 derived from thickened bronchial tubes. I have now 
 examined a good many of these cases, which I consider 
 to be not rare ; about ten cases in the year come under 
 notice. I do not think that the signs resemble any other 
 form of pulmonary disease, and the condition to which this 
 syphilitic affection comes nearest is perhaps the early con- 
 dition of inflammation affecting the bronchial tubes. If 
 the condition of the two forms of disease be considered, 
 
SYPHILITIC PULMONARY DISEASE. 151 
 
 it will be seen that the two groups of signs are likely to 
 resemble each other, inasmuch as in the syphilitic disease 
 we have to deal with thickening of the connective tissue 
 of the alveolar and bronchial walls. 
 
 In support of these observations, I must first state that 
 they coincide with some made by Dr. Robinson, of the 
 Fusilier Guards, from an independent point of view. He 
 tabulated all the cases of syphilis which came under his 
 care (and the records are most carefully kept), and noted 
 the pulmonary symptoms and signs which followed. 
 I have sifted out a class of cases of pulmonary disease 
 which appear to me essentially distinct, and I find that 
 the signs are invariably associated with symptoms of 
 syphilis. Moreover, unless these cases are treated with 
 anti-syphilitic remedies they never improve. 
 
 The pathognomonic distinctions are these : — The absence 
 of moist sounds, for, although the patient often sufiers 
 from profuse bronchorrhoea, I have never yet detected 
 fluid sounds ; the general difi'used condition ; the absence 
 of the usual signs of phthisis, emaciation being present 
 only as a result of profound cachexia; the superficial 
 tenderness of the thorax, and the bronzed colouring of 
 the skin. 
 
 The condition remains unaltered for a considerable 
 time, and if treated by appropriate remedies the patient 
 soon improves, and the signs of induration disappear. 
 But if the patient suffers from reduced circumstances 
 (a condition not unusual in the class especially affected by 
 this form of pulmonary disease), the fibroid induration may 
 soften, liquefy rapidly, and give way to the usual con- 
 ditions of phthisis. Until this happens, life is sustained 
 with little else but the inconvenience of dyspnoea, aris- 
 ing from this affection; but if the lung is excavated, 
 the powers of life rapidly fail, and the patient dies 
 speedily. 
 
 It is then only under such circumstances that the 
 opportunity is afforded of examining the lungs after 
 death; and I believe it is only because of the carelessness 
 
152 SIGNS OF PULMONAKY DISEASE. 
 
 and want of interest witli wliicli cases of phthisis are 
 ordinarily inspected, that the condition has escaped 
 notice. The remaining tissue which snrronnds cavities 
 should be carefully inspected for indications of the primary 
 condition of the lung, and in these syphilitic cases fibroid 
 induration will be found to be present, 
 
 Xnfective pneumonia, or pythogenic pneumonia, is a 
 form of pulmonary disease arising from blood-poisoning, 
 from sewer gas and imperfect house-drains. 
 
 It has generally been presented to my notice in 
 labourers employed in the sewers, or engaged in night- 
 work, the emptying of cesspools, and the like. 
 
 That it is a distinctive disease I have no doubt, and 
 characterised by peculiar physical signs. 
 
 Symptoms indicate the condition which is closely 
 analogous to typhoid fever or septicemia ; rigors, some- 
 times repeated after an interval, heat of skin, rapidity of 
 pulse, brown furred tongue, pungent surface, great pros- 
 tration, and depression accompanied by emaciation, and 
 a peculiar sallow look characteristic of blood-poisoning, 
 have been observed. 
 
 I have now a case of this kind under my care, in 
 which the symptoms and course of the disease have been 
 very prolonged, lasting over some months, with repeated 
 remissions and exacerbations after intervals of about a 
 fortnight. 
 
 Pathologry. — I have not had an opportunity of examin- 
 ing such a case, but the conditions observed are reported 
 to be those of pneumonic congestion of a lobular (and not 
 lobar) character. 
 
 Auscultation elicits subcrepitant rales scanty and 
 scattered, sometimes at the base, sometimes at the apex; 
 they appear to be formed in the terminal or peripheral 
 lobules ; they are irregular, and occur during inspiration 
 and expiration, and have a peculiar viscid quality, sugges- 
 tive of hgemorrhage when the blood is thick. 
 
 The signs, I believe, are pathognomonic, and accompany 
 symptoms equally distinct. 
 
PHTHISIS. 153 
 
 PHTHISIS. — TMs disease has been kept until the 
 last, designedly placed out of its alphabetical order, inas- 
 much as it must not be looked upon as a single disease, 
 beginning invariably in the same way and continuing in 
 one uniform progress, but must rather be looked upon as 
 the terminus to which any pulmonary disease may con- 
 verge, the vortex in which all may end. Clinical ex- 
 perience shows that bronchitis, congestion of the lungs, 
 catarrhal pneumonia, pleurisy, fibroid disease, syphihtic 
 pulmonary disease, hsemorrhagic fibrin in the lungs, may 
 aU terminate in destruction of tissue resulting in excava- 
 tion and the formation of cavities. Secondary to the 
 cavities, in my opinion, comes the infection of tubercle, 
 which as a sequence of pulmonary disease is localised and 
 limited to alveoli, sometimes infecting the lungs generally, 
 as in acute tuberculosis. 
 
 Phthisis must then be defined as the disease in which 
 the tubercular infection plays an important part, and the 
 characteristic feature of which is the formation of cavities. 
 
 The predisposition to phthisis appears to be a special 
 structural delicacy which is inherited from the parent, 
 and which may be exhibited in various ways. It is not 
 necessary, for example, that all the lung structure should 
 be delicately constructed; it may be exhibited only in 
 parts, as in asthma, or mainly in the lymphatics and 
 glands, as in scrofula ; or it may be shown in a special 
 tendency to hgemorrhage without proneness to pulmonary 
 inflammation. 
 
 The old notion, which still finds many supporters, was 
 that phthisis began with the tubercular nodule, which, 
 grouping together, accumulated and broke down, resulting 
 in excavation; but the arguments that may be briefly 
 advanced against this theory are the foUo^dng : — 
 
 From pathology it can be shown that cavities form in 
 tissue which has undergone previous inflammatory pro- 
 cesses. Grey induration, pneumonic and syphihtic, may 
 terminate in excavation; haemorrhagic nodules soften, 
 and form cavities ; congestion of the upper lobe may 
 
154 SIGNS OF PULMONAEY DISEASE. 
 
 soften, liquefy, and form cavities. We can judge in many 
 cases how the cavity has been formed, and we know that 
 in the tubercular ]orocess the chief characteristic feature 
 is the obliteration of bloodvessels ; consequently softened 
 tubercular matter does not show signs of unaltered blood. 
 
 From clinical experience it can be shown that the most 
 frequent prodromal stage of phthisis is catarrh of severe 
 type, frequently repeated bronchial catarrh extending to 
 and involving the alveoli, or in more acute cases catarrhal 
 pneumonia. The evidence of the old theory has been in 
 great measure derived from physical signs supposed to 
 indicate the deposit of tubercle — that is to say, by signs of 
 consolidation, or of solid matter deposited in the upper 
 lobe. This evidence is by no means trustworthy as a 
 support of the theory, inasmuch as it can be shown that 
 early deposits of tubercle (crude tubercles) cannot be 
 detected, and do not give the signs attributed to them ; 
 nor can it with any probabiHty be suggested that a minute 
 nodule, or groups of nodules, when covered by a thick 
 layer of uninjured lung, can be detected. 
 
 If it be urged that all cell action of a destructive 
 character is to be considered tubercular, then in what 
 does the definition of tubercle consist ? This, indeed, 
 seems to be the phase of opinion which is gradually 
 gaining ground now — that tubercular processes may be 
 diffuse ; but to me the special feature of tubercular action 
 is not destruction, but chronic irritation of a very slow 
 character, in which the vessels are invaded, obstructed, 
 and gradually obliterated. Even the breaking down of 
 tubercular districts, which by all observers is allowed to 
 be due to so-ftalled necrotic processes, is not the charac- 
 teristic feature of tubercle, and is in very great probability 
 due to the same kind of septic changes which induces 
 destruction of non-tubercular tissue. I am extremely 
 unwilling to put forward any theories, but I cannot admit 
 the received notions regarding the nature of phthisis, and 
 I am bound to indicate the teachings of clinical experi- 
 ence, and put forward the facts which have been elicited 
 by many years' practice. 
 
PHTHISIS. 155 
 
 The initial or prodromal stage of phthisis must then 
 be considered as very variable. It may besrin with bron- 
 chitis, congestion, pleurisy, catarrh, or (most frequently 
 of all initial stages) it may begin with catarrhal pneu- 
 monia. It must not then be expected that the preliminary 
 stage will always be represented by dulness of percussion, 
 wavy breathing, increased vocal resonance, &c. All these 
 maybe present without phthisis, any and all of them may 
 be only the signs of previous inflammation and induration. 
 Such a condition indicates rather a quiescent, state, and 
 affords no evidence of any active process going on. 
 At the same time, such a condition may yield and soften 
 if the constitution of the patient be so enfeebled as to 
 encourage such destruction. 
 
 No one sign, or group of signs, can be relied upon to 
 indicate this first stage. They are variable, according to 
 the tissue which is first attacked ; if the bronchial tubes 
 be first affected, the signs due to such conditions will prove 
 the first stage, if phthisis follow ; and the same is true of 
 congestion with its respective signs, with pleurisy, and 
 any other form which alters the lung and so prepares it 
 for future destruction. 
 
 The preliminary condition necessary to prepare the 
 lung for phthisis is an unhealthy or morbid alteration of 
 the pulmonary (alveolar) tissue. When this has taken 
 taken place, from any cause whatever, the soil may be 
 said to be prepared for the seeds of phthisis. The sole 
 exception that need be made to the above general law is 
 the condition of emphysema, which is in many cases, but 
 not invariably, proof against the destruction of phthisis. 
 If previous attacks of disease, although successfully 
 resisted by the constitution of the patient, so far damage 
 the lung as to leave behind them marks or traces of their 
 action, that lung may, under certain conditions of health, 
 become the victim of phthisis, beginning first in the 
 affected locahties, and spreading to the rest of the lung. 
 
 If we examine a number of patients who have previously 
 suffered from pulmonary disease of an inflammatory type, 
 but were in a condition of health, we should find those 
 
156 SIGNS OF PULMONARY DISEASE. 
 
 signs wliicb. have been generally ascribed by writers to 
 the first stage of phthisis — signs which may be briefly 
 described as those of indurated or cicatricial tissue, with 
 impaired vesicular elasticity, and (in many) pleuritic 
 adhesions. These signs are notably dulness of percussion, 
 imperfect expansion of liing, high-pitched, slightly blowing 
 breathing, and imperfect delivery or wavy respiration. 
 
 The following Table, taken from Pollock's very careful 
 and accurate work on " The Elements of Prognosis in Con- 
 sumption," will illustrate this statement. It contains the 
 signs of eighty cases of incipient phthisis, observed with 
 special care, and it represents the relative frequency of 
 occurrence of the physical signs : — 
 
 Dulness of percussion observed in all the . . 80 
 Deficiency of respiratory murmur in . . .69 
 
 Bronchial voice 48 
 
 Rough inspiration 47 
 
 Expiration prolonged 47 
 
 Mobility of chest-wall lessened 41 
 
 Flattening of chest-walls 38 
 
 Tubular quality of respiration 32 
 
 Dry crepitation 17 
 
 Wavy inspiratory sound 15 
 
 According to the view of phthisis presented in these 
 pages the first stage of the phthisical process is that in 
 wbich destruction of tissue is threatened, if not actually 
 started, in the tissue ; but inasmuch as it is convenient to 
 keep the nomenclature and the divisions into stages which 
 have been sanctioned by long use, and, indeed, meet the 
 exigencies of the subject very well (I only object to the 
 interpretation of the signs), the subject will be considered 
 under its three stages, the signs being classified accord- 
 ingly. 
 
 The student must be forewarned that the signs of the 
 prodromal, or first, stage of phthisis are not uniform, but 
 that they vary according to the exact nature of the 
 previous disease, and according to the tissue (bronchial, 
 alveolar, or pleural) which has been injured. 
 
FIRST STAGE OP PHTHISIS. 157 
 
 1. First Stage. — This must then be declared Tariable, 
 and not one disease, and consequently no single group of 
 signs can be accepted as invariably preceding phthisis. 
 
 The chief pathological condition which excites suspicion 
 is the viscid nature of the secretion, accompanied by 
 thickening of tissue, indicative of (not a convalescence) 
 a morbid indolence in the repair of tissue and in the 
 removal of effete products. The distinctive features 
 leading to an unfavourable opinion depends upon consti- 
 tutional disturbance ; by signs alone it would be impossible 
 to determine from a single examination whether the vis- 
 cidity was due to a healthy drying-up of fluid secretions, 
 or a morbid stagnation and caseation; but if coupled with 
 this condition, we find a farther extension in the amount 
 of lung involved, increased di£B.culties in respiration and 
 cough, and the patient loses ground; the condition is 
 evidently full of danger. 
 
 It becomes, then, a task of great difficulty to determine, 
 for example, after repeated attacks of bronchitis in a 
 patient, whether the tissue of the lungs is yielding to the 
 disease or not. 
 
 When bronchitis is progressing unfavourably, such a 
 downward course is not indicated by increased secretion, 
 but rather by the presence of viscid clicks and crackles, 
 heard only occasionally and after a forcible cough-breath, 
 a httle air having detected some too quiescent collection 
 of material. 
 
 When phthisis follows attacks of bronchitis, the first 
 suspicious indications are — 
 
 Inspection, imperfect expansion of the upper lobe, due 
 to the unhealthy and inelastic condition of the tabes. 
 
 Auscultation indicates impaired vesicular murmur, 
 which is slightly harsh and dry, and a click, crackle, or 
 even subcrepitant rale after the cough-breath in one or 
 two places, deep-seated. 
 
 Catarrbal pneumonia is so frequently the preliminary 
 stage of phthisis that it must always be viewed as of 
 most serious import. Inasmuch as it may occur without 
 
158 SIGNS OF PULMONARY DISEASE. 
 
 jDroceeding to pMhisis, it lias to be considered as an 
 independent condition ; but if it occurs in patients debili- 
 tated by disease or by heredity of structural delicacy, the 
 physician knows that there will be no boundary line 
 between it and the commencement of phthisis, and will 
 form his prognosis accordingly. In a few instances, under 
 careful nursing, and perhaps from treatment, I have known 
 this condition end, not in destruction but induration, 
 and so the patient has recovered, even with phthisical 
 antecedents; but these cases are rare. The physical signs 
 have been already described under the heading Catari-hal 
 Pneumonia. 
 
 Inspection shows also in such a case, as in the previous, 
 imperfect expansion : the tissue is impaired, and offers 
 more resistance to the entry of air. If expansion of the 
 corresponding pai*t of the chest was forcibly induced, the 
 respiratory action would be fuller ; but the ventilation of 
 this lobe being due to a secondary current derived from the 
 action of the diaphragm, the force is not suiHcient to 
 overcome the resistance. 
 
 Auscultation indicates the presence of exudation into 
 the air-sacs by the very fine crepitant sound, moister than 
 the fine crepitation of pneumonia, not so moist as a rale, 
 although often inseparable in practice, which is heard 
 at the end of inspiration — that is to say, at the time of the 
 unfolding of the air-sacs. 
 
 This may progress onwards without a stage of demar- 
 cation to the second stage of phthisis, in which actual 
 alveolar destruction takes place ; or the secretion may 
 become more viscid, and the sounds of crei)itation may 
 dwindle down to a crackle or click, or even an almost 
 imperceptible stick (if I may be allowed the expression); all 
 these become of serious import if on forcible ventilation 
 of the parts afiected by the cough- breath the air-sacs are 
 detected in retaining secretion. Especially an unfavour- 
 able opinion must be suggested if the pitch of the sound 
 is high, as this is a decided indication of thickening of 
 tissue, and therefore (by conjecture) of alveolar invasion ; 
 
FIRST AND SECOND STAGES OF PHTHISIS. 159 
 
 n. most serious condition excellently described in Dr. 
 Green's work on " Pathology." 
 
 Wlien tlie preliminary stage is the relic of a pneumonic 
 process, to which is generally added adhesion (to more or 
 less extent) of the pleural surfaces, the signs will be those 
 of simple induration and adhesion. 
 
 Inspection, as before, shows imperfect expansion ; jGLsity 
 of the chest, if the adhesions are thick and firm. 
 
 Palpation will give want of resilience, hardness of 
 tissue, and more or less increase of vocal fremitus. 
 
 Auscultation indicates thickened tissue by absence of 
 vesicular murmur and blowing breathing, the pitch of 
 which is higher than natural. 
 
 The delivery of the sound may be jerky or impeded; 
 the expiratory sound may be prolonged. 
 
 If haemorrhage precedes the development of phthisis, 
 the condition which will be found indicates either a 
 diffused thickening of the alveolar tissue from inhaled 
 blood, or a localised patching with fibrinous nodules. 
 
 In the first case, a high-pitched, tense, harsh sound 
 will be heard (without any tubular respiration), not dis- 
 tinctive unless interpreted by the history; or, in the 
 second case, circumscribed patches of dulness, with im- 
 peded expansion of a jerking or hitching character ; high- 
 pitched and localised tubular respiration of a feeble kind, 
 with mcrease of voice sounds. 
 
 The sounds here indicated as occurring previous to the 
 establishment of phthisis are those which are usually 
 comprised in the descriptions given by most authors 
 regarding the first stage of the disease. I only difier in 
 attributing them to the results of previous conditions of 
 disease, and in objecting to receive such signs as proof of 
 the presence of tubercle. 
 
 With regard to the signs of the second and third stages 
 of phthisis and their interpretation there is no difference 
 of opinion. 
 
 2. The second stag-e is that of softening^, which is 
 characterised by the well-known sound which is accepted 
 
160 SIGNS OP PULMONARY DISEASE. 
 
 by all observers as tbe sound of incipient destruction ; 
 it is the crepitant rale. (Walshe, moist or humid 
 crackling.) 
 
 This sound I consider to be produced by liquid within 
 thickened alveolar tissue, which is the incipient condi- 
 tion of phthisis ; and is most usually found in advanced 
 conditions of catarrhal pneumonia. If it be considered 
 that catarrhal pneumonia is the acute form of that 
 disease of which tubercle is the chronic form, then it will 
 be correct to consider the crepitant rale as tubercular in 
 character ; but if it be stated that the crepitant rale is 
 always due to a softened mass or group of tubercular 
 nodules, this can be easily disproved by dissection. To 
 this point I have paid the greatest attention, carefully 
 examining the condition of the lungs : and, comparing 
 them with the careful notes of competent observers, 
 the most frequent pathological condition associated with 
 crepitant rale is advanced catarrhal pneumonia ; especially 
 that form which so often attacks the previously unaffected 
 portions of the lungs, and ushers in the fatal termination 
 of the disease. 
 
 But it is not only with catarrhal pneumonia that this 
 sound IS associated; it may be found in any condition in 
 which softening of indurated alveolar tissue is progressing : 
 in congestion, in advanced capillary bronchitis, spreading 
 downwards. In practice it may not always be dis- 
 tinguished, but in the majority of cases it is pathogno- 
 monic and distinct. 
 
 Second Stage. — Symptoms. — Emaciation and cough; 
 the expectoration of frothy but tenacious mucus with 
 puriform specks. In this stage the sputa should be care- 
 fully examined by the microscope for elastic tissue ; the 
 sputa being boiled with an equal bulk of caustic soda in 
 solution (twenty grains to the ounce), and the sediment 
 (after free solution) being examined. 
 
 Pathology. — The exudation products break down within 
 the alveolar walls, and liquefaction and complete dis- 
 integration takes place. The macroscopical appearance 
 
THIRD STAGE OF PHTHISIS. 161 
 
 are those of solution of the lung tissue, minute cavities 
 being in process of formation. 
 
 Sig:ns> — Inspection shows imperfect expansion ; if the 
 process is being established after much previous disease, 
 there may be actual flattening and depression below the 
 clavicle. 
 
 Palpation gives no distinct indication. 
 
 Percussion gives more or less dulness ; dependent upon 
 the amount of lung involved, and the chronicity of the 
 process. Eesilience of tissue diminished. 
 
 Auscultation detects the crepitant rale, which is more 
 audible after the cough-breath. Yocal resonance in- 
 creased ; indistinct buzzing bronchophony. 
 
 The special region for this sound is the supra- spinous 
 fossa, where it is even more frequently detected than in 
 the infra-clavicular region. The back regions should 
 never be omitted, inasmuch as all moist sounds love to 
 congregate there. 
 
 Third Stage. — Excavation of thelang, the continuation 
 and extension of the process of destruction, followed by 
 the evacuation of the contents, the result being the for- 
 mation of cavities of various forms and sizes. 
 
 This stage is characterised by the gurgling' rale, with 
 or without the cavernous sound, according to the size of 
 the cavity. If the cavity be large and completely empty 
 the cavernous sound only is heard, but this occurs only 
 when the disease is arrested and the cavity is not 
 secreting, or has been recently emptied. 
 
 The gvLTslins rale has a sharp rattling quality, of more 
 or less high pitch, according to the density of the sur- 
 rounding tissue ; it is due to air passing through a viscid 
 fluid (derived from the walls of the cavity) and consists 
 of a few bubbling rales of some size ; more audible and 
 sometimes only heard during or after cough. This sound 
 may be heard during inspiration or expiration, or during 
 both acts. It has more or less intensity, according to the 
 size of the cavity and the quantity of air the cavity con- 
 tains. It may be absent from the evacuation of the 
 
 M 
 
162 SIGNS OF PULMONARY DISEASE. 
 
 contents of the cavity by expectoration, and it may be 
 rendered indistinct and only andible after congb from the 
 accumulation of a large quantity of secretion, whicb 
 especially happens during the sleep of the phthisical 
 patient. 
 
 Diarrhoea and profuse sweating have a very marked 
 influence in diminishing the intra-pulmonary secretions ; 
 often no sounds at all are to be heard after a patient has 
 suffered much from purging. Very small cavities may 
 be detected by this sound— e.p^., rather less than half an 
 inch across. The only condition which is at all hkely 
 (and that very rarely) to give this sound is a dilated or 
 pouched bronchus, situated in the lower part of the 
 lung. 
 
 The cavernous sound is only produced in cavities of a 
 certain size ; the smallest which I have as yet detected 
 by its means was as big as a thumb-nail, three-quarters 
 of an inch across, the diagnosis being verified by post- 
 mortem esamination. The cavernous sound is a hollow 
 one, of which the special characteristic is the low pitch 
 of the expiratory sound. This distinguishes it at once 
 from the tubular sound, as I have already explained. 
 Moreover, this sound (in a cavity) appears to come back 
 towards the ear, while the expiratory sound of tubular 
 breathing recedes away fi*om the surface of the chest. 
 
 Symptoms. — All those usual in phthisis are found 
 aggravated and intensified ; emaciation, dyspnoea, cough, 
 with more or less expectoration, according to the progress 
 of the disease ; sputa punform, nummular, viscid, in 
 which fragments of vessels even and small bronchioles 
 may be visible under the microscope ; anorexia, fever, 
 night-sweats, and, if the secretion be excessive, dian'hoea, 
 especially if the patient is not extremely careful to reject 
 all the matter that comes into the mouth. 
 
 Patbolog-y. — Cavities vaiy in size; they start from small 
 beginnings, and may involve the whole of a lobe, which is 
 their usual extent, or they may even advance beyond and 
 include the divisions of the lobes and involve the whole 
 
SOUNDS OF CAVITY. 163 
 
 lung. It is not very rare to find tlie whole of one lung 
 converted into a simple bag, from whicli all tlie tissue 
 lias been ejected, leaving nothing but a thickened pleura 
 with remains of tissue at the edges. 
 
 Sigrns. — Inspection shows fixity of the chest-wall with 
 marked tiattening of the corresponding parts, the inter- 
 costal spaces being depressed. 
 
 Palpation gives no special indication. 
 
 Percussion gives a variable note, according to the 
 actual condition of the cavity and the amount of air or 
 secretion it contains. 
 
 With thick, dense walls, and a large amount of secretion 
 (the cavity being sometimes quite full, especially in the 
 morning) a dull note will be present. If, on the contrary, 
 the walls be thin, and there be much air and little fluid, 
 the note will be resonant, tympanitic, or amphoric. 
 
 The cracked-pot sound may also be elicited. 
 
 Auscultation gives the gurgling rale, the cavernous 
 sound ; sometimes bronchophony, often pectoriloquy ; and 
 the pectoriloquy, it must be added, has a cavernous 
 sound— it is hollow and low in pitch. 
 
 Yocal resonance is also increased in this case. 
 
 The above description applies to the generic form of 
 phthisis, which as a simple process of distinction may be 
 considered as one and indivisible ; but, as T have already 
 urged, the prodromal varieties converging towards 
 phthisis (in which all their primary features are engulfed) 
 are extremely numerous, having distinctive characters as 
 regards clinical history, symptoms, signs, and pathology. 
 If the primary features of these diseases are not known 
 and recognised, prognosis can be made on no firm basis ; 
 and if the phthisical proclivity is from the first over- 
 looked the ultimate restoraton of the health of the patient 
 is likely to be doubtful. I must therefore call attention, 
 first, to the varieties of cavity which belong to different 
 forms of phthisis ; and, secondly, to varieties of phthisis 
 which are of great clinical importance. 
 
 m2 
 
164 SIGNS OF PULMONARY DISEASE. 
 
 VARIOUS FORMS OF CAVITY. 
 
 All cavities may be considered from that point of view 
 in wliicli tlie condition of their secreting walls is con- 
 cerned. They may secrete profusely — a bad sign, as apt 
 to terminate rapidly; and this rule may be laid down 
 with regard to phthisis generally, that the rapidity of the 
 case is Kkely to be proportionate to the amount of the 
 secretion. The converse of this is, however, not true ; a 
 favourable result cannot be prognosed in all cases in 
 which the secretion is scanty. 
 
 Secreting- cavities are recognised by their gurgling 
 rales, especially after cough ; but if the secretion so accu- 
 mulate as to fill the sac, absolute silence may reign over the 
 cavity with dulness of percussion ; this may be especially 
 noticed in the morning after the accumulation during night. 
 
 Dry Cavity, — The fluid sounds diminish, and give 
 place to air sounds, cavernous respiration, cavernous 
 pectoriloquy, and tympanitic or amphoric percussion note. 
 The amphoric note especially characterises the elastic 
 walls of young persons. 
 
 Contracting- Cavity. — The fluid sounds are few, and the 
 air sounds are notable for a peculiar high-pitched whis- 
 pering quality, which is easily recognised when once 
 pointed out, and is quite characteristic of the condition. It 
 is extremely di£B.cult to convey any notion by words, but 
 it may be compared in some measure to the rustling of 
 stifi" silk. Other signs there are besides this and the 
 general improvement of the patient — e.g., the retraction of 
 the surface, the flattening of the chest-wall, and the 
 upraising of the heart. Pectoriloquy may give way to 
 bronchophony under this condition. 
 
 Healed Cavity. — This is by no means so rare a con- 
 dition as many believe ; it takes place most completely in 
 the young. The chest is flattened, the thorax immovable, 
 the shoulders may be depressed, the heart upraised and 
 displaced, and the expiratory sound may be completely 
 suppressed. Dull percussion will be found in some degree. 
 
FORMS OF CAVITY. 165 
 
 althougli there is occasionally an emphysematons dilata- 
 tion of tlie neighbouring parts, whicli will give tlie Idgh.- 
 pitched mnffled note. 
 
 Multilocular and trabeculated cavities are remark- 
 able for absence of sound : tbe cavernous sound may be 
 damped by the diaphragmatic partitions between the 
 cavities or the trabecnlas which run across them. Such 
 conditions are diagnosed only with great care. 
 
 It is well known that all hangings and curtains, and even 
 carpets, materially modify and obliterate the resounding 
 properties of a room, and the reverberation of echo has 
 been stopped by carrying a string from one end of the 
 room to the other. 
 
 Trabecule, which are long strings formed of vessels, 
 bronchial tubes, or interlobular tissue, play exactly the 
 same part in a cavity ; they damp sound, and obliterate 
 echoes. 
 
 They have the property of vibrating with cough, and 
 thus producing sound, I have heard intense twang pro- 
 duced by the vibration of trabeculse, and this sound is 
 very characteristic. 
 
 Isolated cavities, separated from the pi-incipal disease, 
 are frequently the result of the liquefaction of blood 
 residues, and may be recognised by their peripheral con- 
 traction and their pigmented walls. I have akeady 
 indicated the localities which they frequent. 
 
 CXiZN-ZCAXi FORIVIS OF PHTHISIS. 
 
 Acute, or ^allopin^ pbtbisis, was recognised and 
 described by Hippocrates. The symptoms given by him 
 are briefly these — fever, with rigors and constant sweats, 
 extremities cold, bowels deranged ; sputa small, dense, 
 concocted, and brought up rarely and with difficulty ; 
 fauces painful from first to last, having redness, with 
 inflammation ; the patient soon wastes and gets worse, 
 becoming delirious near death. It would be indeed 
 difficult to supersede this account, which is as accurate 
 as it is graphic. 
 
166 SIGNS OF PULMONAET DISEASE. 
 
 It occurs in early life, attacking young girls preferably, 
 and constitutions tainted by tbe heredity of pbtbisis. It 
 may run its course in twenty days (a rare occurrence) ; 
 more often it takes six to twelve weeks to complete its 
 work of destruction. 
 
 Symptoms are those due to an acute blood-poisoning, 
 concentrated particularly on the lungs. 
 
 The invasion of the disease is ushered in by 
 rigors, followed by continuous fever, and there may be 
 crops of sudamina; pain in the chest, dyspnoea of an 
 aggravated nature, cough, often paroxysmal and extremely 
 distressing, sputa scanty and viscid, gastric disturbances, 
 irritable fauces, and red tongue ; restlessness, wandering, 
 and delirium close the fatal scene. 
 
 Pathologry is of a very distinct kind, and is not to be 
 mistaken for any other condition. To give a concise idea 
 and definition of the macroscopical appearance, I would say 
 thaL the disease appears to belong to the type of catarrhal 
 pneumonia, attacking the lungs universally throughout, 
 starting from innumerable foci, spreading rapidly and de- 
 structively, and finally terminating in suppurative ulcera- 
 tion, forming a number of minute cavities in all parts of 
 the lung. 
 
 Signs are chiefly characterised by their universahty ; 
 ordinary phthisis is confined, for some time at least, to the 
 upper lobe of one side. Acute galloping phthisis starts 
 from many points, and the signs are scattered all over the 
 lung, but they are localised in spots or patches. Con- 
 solidation yields the first group of signs ; feeble breath, 
 of a high-pitched, ringing character, eventually becoming 
 tubular and metallic; dulness of percussion, insulated 
 spots of clicking, or the crepitant rale rapidly giving way 
 to metallic gurgling rattle, and increased consohdation 
 with bronchophony. The pleura is generally involved. 
 
 Such are the features of one of the most terrible and 
 acute forms of phthisis, which are pathognomonic of the 
 disease. 
 
 3taryiigreal pbthisis is another distinct form of disease 
 
LARYNGEAL AND SCROFULOUS PHTHISIS. 167 
 
 in wliicli the larynx is primarily affected, the kings being 
 often secondarily involved. It appears to me to begin 
 with an inflammatory affection of the larynx, vrhich is 
 followed by a rapid and general outcrop of tnbercles in 
 the larynx, pharynx, and even the tongue and the lungs. 
 
 Symptoms. — Catarrhal inflammation of the trachea and 
 larynx, accompanied by dryness of the throat and 
 hoarseness. On examining the throat it is found to be 
 red and swollen, of a dark hvid colour, and secreting a 
 nasty viscid fluid. The hoarseness progresses and 
 aphonia follows, with joain on deglutition and cough — 
 and marked tenderness on handUng the larynx; subse- 
 quently the development of tubercle becomes apparent, 
 and they can be seen in the fauces, and sometimes on the 
 tongue. The lungs give very little indications, at first, 
 of being involved, and the sputa throughout are scanty. 
 
 Patliolo^y. — The above conditions must be considered 
 as rare so far as it concerns the outcrop of tubercles, and 
 the pathology may be confined to rapid scrofulous ulcera- 
 tion. The disease generally attacks young persons ; 
 principally young men. 
 
 Signs are chiefly laryngeal, and the pulmonary signs 
 are very scanty, and, according to my experience of the 
 disease (examples are not very common), imperfect expan- 
 sion, harsh, dry, high-pitched respiratory sounds are the 
 chief signs. 
 
 Scrofulous forms of phthisis and pneumonia are 
 invariably characterised by large cell-growths, which form 
 plentifully and accumulate in the districts afiected by 
 inflammation. The marked characteristic symptoms of 
 true scrofula are the invasion by cell masses and the 
 absence of fluidity. Consequently the pathological 
 appearances are those of caseation and proliferation 
 rather than of softening and liquefaction. These condi- 
 tions are accompanied with the history or presence of 
 enlarged glands. 
 
 Sigms are characterised by the sounds of solidity rather 
 than of fluidity. 
 
168 SIGNS OF PULMONARY DISEASE. 
 
 In scrofulous pneumonia scattered clicks and dull 
 percussion may only be heard over lungs which are com- 
 pletely invaded in all parts by the scrofulous growths, and 
 the appearance of the patient only indicates the insidious 
 process which is undermining his life. 
 
 Trabecular Destruction of tbe Xiung-. — This variety 
 (to which I have given a name which will sufficiently 
 indicate what is intended) is another clinical variety of a 
 peculiar and destructive kind. I have seen several examples 
 of it, and invanably in persons of the lower orders, whose 
 constitutions have suddenly broken down under bad- 
 living, want, and the miseries of a poor and hopeless life ; 
 it has appeared especially to favour those who having, 
 during the period of active vital growth, given up their 
 bodies to all kind of excesses, by sudden immersion in the 
 depths of poverty are unable to supply the stimulants to 
 which they have long been habituated, or even to obtain 
 the support necessary for life. 
 
 Symptoms. — Dyspnoea cough, the expectoration of 
 abundant viscid, purulent, often very foetid sputa ; rapid 
 emaciation, night-sweats and prostration ; symptoms of 
 acute pleurisy, with pain on respiration. The disease 
 will run a rapid course in two or three months. 
 
 Pathologry. — The disease affects in a remarkable and 
 most complete manner the whole of one lung, and 
 generally it is the left which is rapidly cleared out, 
 leaving long cords of trabeculas, and a thickened ])leura as 
 the only remnants of what was once a lung. It attacks 
 patients not affected by heredity, and appeal's to be a 
 ]3neumonic process of an ulcerative type. I have given an 
 illustration of a case in which the whole of the left lung 
 was completely destroyed in three months. (See Fig. 19.) 
 
 Signs. — The incipient signs are in some cases referrable 
 to the bronchial tubes ; sub- crepitant rales scattered about, 
 eventually becoming more fluid, and developing into 
 bubbling or crackling rattles, very generally diffused. 
 
 In more advanced conditions we can hear no respiratory 
 murmur or there be a slisfht in-and-out sound of which 
 
TRABECULAR PHTHISIS. 169 
 
 tlie expiratory sound, such as it is, is lower in pitch. If 
 the trabeculse be many the cough may be twanging in 
 character, and with the action of the chest-walls, which is 
 very imperfect indeed, a rolling up-and-down, viscid 
 crackling sound caused, T believe, by the viscid secretions 
 moving over the surface of the sac. 
 Fig. 19. 
 
 Trabeculated Excavation of Lung. 
 
 Palpation gives an increase of vocal fremitus. 
 Percussion gives a dull tympanitic note, and broncho- 
 phony is present. 
 
 Although the signs are few and negative in kind, 
 
170 SIGNS OF PULMONARY DISEASE. 
 
 diagnosis may be made with certainty, and there is 
 no other condition that can be well mistaken for it. 
 
 illcoliolic intemperance has a very distinct effect 
 upon the condition, not only of the body generally, but 
 also specially of the lungs. 
 
 The beer-drinker (of either sex) who indulges in 
 copious potations pi)ttle-deep, adds a large quantity of 
 iluid to the vascular system of the body, increases the 
 intra-vascular pressure, and all the vessels become enlarged, 
 prominent, and swelled, especially those of the extremities. 
 The consequence is a general sloppy condition of all the 
 organs, hydropic degeneration (to use a more scientific 
 term) of all the tissues and vessels, and a tendency to 
 profuse haemorrhage, which is especially characteristic of 
 this intemperance, and in some cases imitates in all its 
 symptoms a condition of hsemophilia. 
 
 Patholog-y. — The lungs are found in a condition of 
 general vascular congestion and hyperaemia, and the 
 traces of previous haemorrhage are to be seen in old 
 caseous patches in the midst of pigmented and more or 
 less thickened lung tissue. When such lungs break 
 down the secretion is likely to be profuse and the 
 destruction rapid. 
 
 All the abdominal organs are found congested, enlarged, 
 softened, flabby, full of blood, the heart soft and much 
 enlarged, the liver fatty and congested, the kidneys 
 large and flabby with adherent capsules, and the spleen 
 large and diffluent. The sputa are, as a rule, in these cases 
 sanguinolent, and the tubercle that is subsequently 
 formed is invariably pigmented. 
 
 Spirit-drinking- has an opposite effect, and tends to 
 harden (or, if I may use the word, pickle) the lung and the 
 rest of the tissues. 
 
 The symptoms are those of a constitutional character, 
 and the effect is most marked on the nervous system — 
 tremulous fidgets, insomnia, and general excitement. 
 
 Patholog-y. — A hardened fibrotic condition of all the 
 tissues and organs is the result of spirit-drinking, and 
 
DISLOCATION OF HEAET. 171 
 
 the lung is inclnded in the list of altered organs. It 
 becomes hard and fibrotic; if cavities form they are 
 often no larger than a nut, and scattered around the peri- 
 phery ; between them the tissue is firm and hard and of a 
 fibroid character. 
 
 If tubercle result, it occurs in very close, compact, but 
 large masses, sometimes assuming the form of bands tra- 
 versing the lung. 
 
 Si^ns. — A hard, high-pitched, crackling rale is the 
 sound most frequently heard in and indicative of alco- 
 hoHc fibrosis, with hard, high-pitched, vacuous breath 
 sound. 
 
 [A caution is here necessary to those who, recognising 
 the source of the disease, think to check the further 
 progress of the malady by stopping the supply of liquor — 
 in other words, by turning off the tap. My experience 
 upon this point is that such cases very rapidly deteriorate. 
 If this is not done with great judgment, it would be better 
 for the patient to continue his vicious habits than to dis- 
 continue completely and suddenly all supply of spirits. 
 
 This is not my advice, however, with regard to beer- 
 drinking ; the immoderate imbibition of fluid should be 
 at once stopped and spirit substituted for beer.] 
 
 Bislocation of lieart or displacement as a result of 
 adhesive pleurisy and a contracting fibroid condition 
 of the lung, with or without cavity, is a very common 
 and important sign. 
 
 The heart is uncovered, the lung receding from its 
 surface and leaving it completely exposed, the beat being 
 perceptible over the praecordial region, in the second 
 interspace if the heart is drawn up, while the apex 
 assumes various positions in accordance with the 
 mechanical action (from the retraction of the left or the 
 right lung) which causes an alteration in its situation. 
 
 It may be drawn upwards and over to the left axillary 
 region, the apex beating in the side, or it may be drawn 
 Tip towards the right side ; the base in this case being as 
 high as the first interspace, and completely over to the 
 
172 SIGNS OF PULMONARY DISEASE. 
 
 right of the midsternal line, the apex beating near the 
 middle line under the sternnm in the lower sternal region. 
 Dislocation to the left is usually more marked than on 
 the right side, inasmuch as contracted conditions of the 
 lung are also more frequent on the left side. 
 
 Dislocation of cavities may be observed after some 
 lapse of time, the cavity having a tendency to slide with 
 the progressive retraction of the lung; so far as my 
 observation goes, cavities in the anterior of the lung move 
 towards the humerus, cavities in the posterior part of the 
 lung move towards the spine, the firmest and thickest 
 adhesion being situated here. 
 
 Advancing pbtbisis is marked by the extension of 
 sounds and the increase of their fluid quality ; as a rule, 
 the more abundant the secretion the more rapid the 
 destruction. 
 
 Arrested pbtbisis and its progress towards recovery is 
 marked by the absence of fluidity in the sounds, and their 
 gradual assumption of viscid, and subsequently dry, 
 qualities, together with the general improvement in the 
 patient's health and the diminution of expectoration. 
 The tissue hardens and the signs become harsh, rough, 
 and dry, assuming that whispering or rustling high- 
 pitched quality which I have already attempted to 
 indicate in the description of the sounds caused by a con- 
 tracting cavity. 
 
 The student must be advised that patients sufiering 
 from the last stage of phthisis present themselves for 
 examination when no signs can be detected; this often 
 follows diarrhoea or profuse sweating, and is, according 
 to my experience, more commonly the case with women 
 than men. 
 
 Decubitus in phthisis is usually on the sound side : 
 cough being increased by the accumulation of secretions 
 in the diseased lung if the patient lies on the afi'ected 
 side. 
 
 PXTEUIVIOTHORAX, or the presence of air in the 
 pleura, arises from perforating disease of the lung, or 
 
PNEUMOTHORAX. 173 
 
 traumatic injury causing a direct opening tlirougli the 
 chest-wall, or laceration of the lung from contusion and 
 fracture of the rib. 
 
 Perforation of the lung from disease takes place from 
 disease within the lung, destroying the pleura, this being 
 the usual condition of pneumothorax, or from an em- 
 pyema boring its way upwards into the lung, and esta- 
 blishing a communication with the air-passages. 
 
 The disease is generally accredited to tubercular action ; 
 but although it is a consequence of phthisis, perforation 
 is caused by the corrosive action of a purulent, almost 
 gangrenous, ichor, which burrows a way, sometimes by 
 very small channels, right through everything that comes 
 in its way, including the pleura, when it is not protected 
 by adhesion. 
 
 I fail to comprehend on what grounds this peculiar 
 action is ascribed to tubercle, the essential character of 
 tubercular action being chronic irritation and cell growth. 
 It is rather due to a pneumonic process of the suppu- 
 rative type, and the perforation may take place in caseous 
 patches which are suppurating, and in some cases have 
 a distinct circumscribed appearance, which suggests the 
 notion that they are really morbid matter planted in 
 parts of the lung by insufflation. A more mechanical 
 and less striking result is caused by the perforation of a 
 luDg from an empyema. It is to the first class of case 
 that acute and striking symptoms belong. 
 
 Symptoms. — Acute pain in the affected side, of a most 
 poignant and sudden character, accompanied with severe 
 dyspnoea and prostration. The patient is often conscious 
 that something has given way. Orthopnoea is the position 
 generally assumed at the moment, but a variety of pos- 
 tures may be tried, at one time the patient being supine 
 with the head raised, at another lying over towards the 
 sound side. 
 
 Palpitation is generally a marked symptom ; the pulse- 
 rate being greatly accelerated, and respiration also re- 
 markably hurried. Great anxiety is depicted on the coun- 
 
174 
 
 SIGNS OF PULMONARY DISEASE. 
 
 tenance, and the lips and face become livid, the voice being 
 reduced to a whisper, and the surface clammy. 
 
 As an exception to the rule, Walshe mentions a case 
 (and I could give a similar instance) of a man in the 
 third stage of phthisis, coming to him one day, with a 
 little more anxious face than usual, complaining of sKght 
 pain below the nipple of some hours' duration. He had 
 walked without difficulty more than a mile, although 
 the heart was pushed over into the left axilla ; the man 
 died in two weeks. 
 
 Fig. 20. 
 
 STERNUM 
 
 HEART 
 
 R.LUNr, 
 
 L.LUN 
 
 Transverse Section in Eight Pyo-pneumo thorax. (Pirogoff.) 
 
 Pathology. — On opening the chest more or less air 
 usually escapes ; this will depend upon the size and 
 patency of the opening from the lung into the pleura. 
 The lung is more or less collapsed. Perforation occurs in 
 the posterior axillary region, or in the mammary region, 
 in front below the third rib. I have seen as many as four 
 openings in the lung. Perforation is most frequent on 
 the left side. All the abdominal organs are gorged with 
 blood, which is forced upon them in consequence of the 
 pressure upon the vessels of the wounded lung. 
 
 Signs vary according to the size of the opening from 
 
PNEUMOTHORAX. 175 
 
 the lung to the pleura, and the free or impeded com- 
 munication between the air within, the pleura and the 
 large air-passages. 
 
 If the opening be small and easily closed, formed at 
 the termination of a small and tortuous sinus, air collects 
 within the pleura, and (expanding) causes much disten- 
 sion of the chest with pain. 
 
 Inspection in this case shows marked bulging of the 
 affected side with obliteration, and sometimes convexity 
 of the intercostal spaces. There is no movement of that 
 side of the thorax, the sound side heaving frequently 
 with laboured and hurried breathing. The heart is dis- 
 i3iaced towards the sound side, and away from the per- 
 forated lung, and the abdominal organs are thrown down- 
 wards by the pressure on the diaphragm. 
 
 Palpation detects little fremitus. 
 
 Percussion is high-pitched and tense, and if the inter- 
 nal pressure be very great, the vibrations may be so much 
 impeded that the note of percussion becomes muffled and 
 almost dull. 
 
 Auscultation gives negative signs when the air does 
 not enter freely; there may be no to-and-fro sound at all, 
 and all the sound audible may be the sound of the un- 
 affected lung transmitted over the compressed lung. 
 
 When the opening is free and patulous, then a different 
 group of sounds is heard. 
 
 Inspection. — The distension of the affected side may 
 not be great ; depression of the intercostals may actually 
 be observed with the inspiratory action of the thorax. 
 
 Palpation detects rather more fremitus. 
 
 Percussion gives a noisy, resonant, amphoric note. 
 
 Auscultation detects the sounds of loud to-and-fro 
 amphoric respiration which may have a metallic tone. 
 Vocal resonance may be intense and diffused and metallic 
 in quahty. 
 
 In the fistulous opening into the lung from an 
 empyema there is usually free communication, and for 
 two reasons— one is,that the opening is conical and large, 
 
176 SIGNS OF PULMONARY DISEASE. 
 
 not formed by tlie trickling downwards of a corrosive 
 fluid, but by tbe boring pressure upwards of a large body 
 of pus ; and the other is, that as the opening is situated 
 above the level of the root of the lung (the line of the 
 main bronchus) no expansion of the lung takes place to 
 close the opening. The rationale of this is very simple : 
 the empyema is mechanically forced upwards by the 
 pressure of the lower ribs and diaphragm, the locality of 
 least resistance, the direction in which the abscess is forced 
 to point being the upper part of the lung, hence the 
 empyema burrows upwards and bores into the lung 
 above. 
 
 In cases of pneumothorax from empyema the usual 
 signs of pneumothorax may be found, and pectoriloquy 
 also, the margin of the sac being thus exactly limited, 
 while over its boundaries buzzing bronchophony only can 
 be heard. 
 
 The bell sound is elicited over the air cavity of pneumo- 
 thorax by placing a half-crown on the walls of the chest 
 and striking it sharply with another coin, the ear being 
 placed against an opposite part of the chest. 
 
 There is one remarkable point with regard to perforation 
 and compression of lungs which deserves consideration. 
 
 Air can, I believe, pass across the mediastinum and 
 burst into the pleura. Wilks and Moxon relate two cases 
 of pneumothorax from tracheotomy, both lungs being 
 found contracted in the chest, and the cellular tissue in 
 the posterior mediastinum was filled with air, producing 
 large bubbles which had burst through the pleura into 
 the chest. 
 
 Some time ago a case of pneumothorax occurred, 
 proving fatal in an hour. When I examined the body 
 I found the left lung collapsed and compressed, and a 
 small perforation in the right lung, which was universally 
 adherent to the chest-wall. 
 
 Dr. Powell records a case of a kindred nature, in which 
 a sinus had opened from an old cavity through the 
 posterior mediastinum into the opposite pleural cavity. 
 
PNEUMOTHORAX. 177 
 
 Pneumotliorax is usually accompanied with fluid, and 
 tlien it strictly demands the term of hydro-pneumo- 
 tborax, or if the fluid be pus. pyo-pneumotliorax, the 
 
 latter term being especially applicable to an empyema, 
 which has formed a communication with the outside air 
 through the lung, and is not yet emptied. 
 
 When fluid and air are present together, then the suc- 
 cussion sound or splash may be heard. This only occurs 
 when the amount of fluid is not excessive ; if it be exces- 
 sive, the sounds due to air are lost and replaced by dul- 
 ness. 
 
 The splash of succussion has generally a ringing, 
 metallic, silvery quality, which also modifies the quality 
 of the voice and breath sounds. 
 
 The only sound that is likely to mislead is the metallic 
 sound of a distended stomach containing fluid, and this 
 point must be decided by percussing out the position 
 of the stomach. 
 
 In hydro-pneumothorax the patient assumes a variety 
 of postures and changes his attitude frequently, some- 
 times on the affected, sometimes on the sound side, rarely 
 assuming the upright position. 
 
 In one remarkable case that came under my notice, 
 adhesion to the diaphragm had taken place previous to 
 the perforation of the lung; consequently the sounds due 
 to the presence of air were almost annulled, and the sign 
 which indicated the condition was a metallic splash which 
 could be heard at the back, the fluid audibly running 
 along the posterior surface of the lung and descending 
 when the patient's position was suddenly changed. 
 
 na-FECTlVE PHTHISIS. — There is one other 
 variety of phthisis to which attention must be directed, 
 although observations on this are confessedly incomplete, 
 but many marked instances have come under notice of 
 such a kind as to compel belief in the infectivity (in some 
 form) of phthisis. For some time the peculiar symptoms 
 and signs of that form of pulmonary disease which 
 especially attacks wives who have devotedly nursed hus- 
 
 N 
 
178 SIGNS OF PULMONARY DISEASE. 
 
 bands who "have died from phthisis, have attracted my 
 notice, and the conclusion at which I have arrived is this — 
 that there is a peculiar constitutional condition caused by 
 the infection of phthisis simulating blood-poisoning 
 of a chronic kind, in which the general disturbance of the 
 system is out of all proportion to the amount of pulmonary 
 disease, which is not established until some months after- 
 wards : the condition is not a true phthisis, but rather a 
 chronic infective pneumonia. I have now in my note-book 
 details of fifteen cases, and they tend to show that this 
 condition is only caused by close communication with the 
 phthisical patient during the last months of life, and 
 the phenomena of infection are these: — 
 
 Symptoms. — Eapid emaciation, anorexia; depression, 
 with rigors repeated at intervals, profuse night-sweats, 
 diarrhoea, and often vomiting. Cough is established late 
 in the disease, and the sputa are frequently bloody. The 
 patient is soon very much emaciated, and of a sallow hue ; 
 skin clammy, pulse small and rapid. 
 
 Pathologry. — Hitherto only one case of the kind haa 
 been examined by me, but in this the appearances were 
 very pecuhar. The right lung had a cavity in the upper 
 lobe which had apparently formed from the breaking 
 down and evacuation of a congestive pneumonia, the 
 surrounding walls being soft and red, and the contents of 
 the cavity resembling the debris of congestion. One or 
 two groups of quite recent grey tubercle were found in 
 close connection with this cavity. The whole of the left 
 lung was studded throughout with little patches of lobular 
 congestion, some of which (of old standing) had caseated 
 and lost their colour. Microscopical examination showed 
 a congestive condition of the peripheral alveoli, and many of 
 the vessels were found plugged with small blocks of fibrin. 
 The connection between this condition and pyaemia was 
 shown by the presence of a recent empyema of small 
 size, and an erysipelatous phlebitis of both fore-arms. 
 
 So fully persuaded have I been as to the possibility of 
 3om.e form of infection, that guinea pigs were, at my 
 
INFECTIVE PHTHISIS. 179 
 
 siigg-estion, exposed to the emanations of a number of 
 phthisical patients. Out of eleven thus exposed in air- 
 flues leading from the wards (the air being drawn off by 
 a heating-apparatus) two died, one in eight, the other in 
 nine weeks after exposure, and they were found affected 
 with artificial tuberculosis of the lungs, liver, spleen, and 
 glands. They were examined by Dr. Klein, whose name 
 will be a sufficient guarantee for the accuracy of the 
 observations. The most remarkable point about the 
 infection is that it coincides in time with that necessary 
 for the production of tuberculosis by the injection of 
 tubercular matter. 
 
 These experiments are as yet incomplete, and only 
 tentative ; but they appear to lend colour to the theory 
 that the exhalations of a phthisical patient are poisonous. 
 
 Sigrns. — The next step is to show that the pulmonary 
 signs differ from those of ordinary phthisis, and they do 
 so in two points : one is, that the lung disease does not 
 account in any degree for the depressed and emaciated 
 condition of the patient; the other is, that signs are 
 frequently to be found on both sides. This is not in- 
 variably the case, but I have found it so in the majorit}'" 
 of the cases (15) that have come under my notice. 
 
 Inspection shows deficient expansion and imperfect 
 action. 
 
 Percussion gives a dull note. 
 
 Auscultation elicits the viscid sub-crepitant rale, dull 
 in sound and slow in formation, which is to be heard in 
 infective pneumonia, and is very much like the sounds 
 heard from hgemorrhage into the lung. These signs, when 
 put on paper, may seem to afford small grounds for 
 diagnosis, but when the whole phenomena of the case are 
 considered they appear to me to uphold the theory that 
 a form of blood-poisoning may result from the infection 
 of phthisis. If the lung disease be advanced excavations 
 may be present. 
 
 I think it right thus to call attention to this point, as 
 it may tend to induce those who nurse patients suffering 
 
 n2 
 
180 SIGNS OF PULMONARY DISEASE. 
 
 from plitliisis to adopt careful hygienic measures, notably 
 free ventilation, in order to shield themselves from harm. 
 
 TBICKEIVED "PJiEWRA. is a condition which fre- 
 quently occurs after chronic pulmonary disease of a fibroid 
 character. Adhesion first takes place as a consequence 
 of irritative diseases in the pulmonary tissue, and the 
 frequent concomitant of the phthisical process. The 
 agglutination of the pleural surfaces takes place without 
 efiusion, and is a gradual process, which creeps downwards 
 from the apex to the diaphragm. During the course of 
 the disease the lung, not being used so much as the sound 
 lung, adheres in the quiescent state — that is to say, more 
 or less in the condition of expiration. With the further 
 contraction of the lung, due to the fibroid action, the 
 adhesions are stretched, and as the traction is equal at 
 all points on the surface, the intercostal spaces are pulled 
 in and beneath the ribs, fatty tissue fills up the parts so 
 as to form marked ridges on the surface of the pleura, 
 and the thickness of the pleura is often great, some- 
 times as much as an inch. This adhesion of the pleura 
 and the active contraction of the fibroid lung are the 
 agents in the deformities which are so often observed in 
 the chests of phthisical patients. 
 
 Symptoms. — Dyspnoea, with occasional pain on exer- 
 tion. 
 
 Pattiologry. — Thickened, white, sclerous condition of 
 the pleura. 
 
 Sig:ns, — Inspection shows fixity of the thorax in pro- 
 portion to the extension of the adhesion. Tf the adhesion 
 has fixed the diaphragm, the shoulder is depressed, and the 
 body inclines to the side affected. The intercostal spaces 
 are much depressed. 
 
 Palpation indicates great hardness of the tissue. 
 
 Percussion will give a dull note on the surface with a 
 slight blow, and occasionally the dulness is very 
 marked. 
 
 Auscultation shows more or less diminution of breath 
 . sound. The characteristic sign of this condition I believe 
 
TUBERCLE, 181 
 
 to be marked transmission of tlie heart's sounds over the 
 area of adhesion, their intensity being sometimes loud. 
 
 In one case which was under my care, and subsequently 
 examined by Dr. Greenfield, the physical signs indicated 
 the presence of a circumscribed tumour in a peculiar 
 condition, the right infra-mammary region close to the 
 sternum. The post-mortem examination showed a large 
 circumscribed patch of very thick pleura in this position, 
 with fibroid lung beneath. 
 
 Cardiac sounds arising from pleural adhesion. 
 
 The adhesion of the pleura to the pericardial surface 
 causes traction upon and displacement of the heart. The 
 systoHc murmur which often follows this has been 
 already alluded to : it is audible generally over the pul- 
 monary vessel ; sometimes there is a double exocardial 
 crackle heard, which is probably due to the creaking of 
 the adherent parts, especially if a cavity be closely con- 
 tiguous to the heart, the heart sounds give rise to 
 creaking of a cavernous quality, sometimes of a very noisy 
 character, or the fiuid contents of the caArity are audibly 
 jogged by the heart's action. 
 
 The displacement of the heart from excessive accumula- 
 tion of fiuid within the pleura will, by the derangement of 
 the form of the vessels, give rise to murmur over the base 
 of the heart which disappears after tapping. 
 
 TUSERCKS. 
 
 Whether tubercle is the incipient cause of phthisis or 
 not, no one who has ever examined a phthisical lung will 
 deny that it is found as a recent formation before death . 
 Putting aside, then, the vexed question as to the com- 
 mencing process in phthisis, I must endeavour to point 
 out how the formation of tubercle is to be recognised by 
 physical signs. 
 
 Tubercle must be considered from two aspects : it may 
 be general, affecting both lungs, equally and uniformly 
 (or, indeed, the infection may be carried still further 
 throughout all the organs of the body), this must be 
 
182 
 
 SIGNS OF PULMONARY DISEASE. 
 
 termed general tubercular infection, or acute tubercu- 
 losis, or it may be local, affecting only limited portions of 
 the lung, in wbicli case it may be called localised 
 tuberculosis. 
 
 Buhl long ago pointed out that acute tuberculosis was 
 a general infection, derived from the absorption o/ 
 caseous matter ; the channels by which absorption is 
 effected being the lymphatic vessels. 
 
 Fig. 21. 
 
 Distension of Lung round Localised Scrofulous Tubercle, 
 Secondary to Phthisis. 
 
 Localised tuberculosis appears to me (from the con- 
 sideration of many pathological arguments which can be 
 brought to bear on the subject) due to the limited infec- 
 tion (not affecting the whole system) of parts of the lungs 
 
TUBERCULOSIS. 183 
 
 from the insufflation of septic matter into the lobules 
 along the bronchial tubes, or from aa eruption of tu- 
 bercles in the neighbourhood of an infecting region from 
 soakage into the tissue. 
 
 Tubercle, then, from my point of view, is invariably a 
 secondary product due to implantation, general or local, 
 of septic matter in tissue, capable of producing tubercle 
 by connective tissue growth. 
 
 Acute tuberculosis in its symptoms approximates 
 very closely to the conditions of typhoid fever, and is 
 sometimes only to be distinguished by very careful obser- 
 vation. 
 
 Symptoms are very subtle, and chiefly those which 
 point to blood-poisoning ; rigors, night-sweats, diarrhoea, 
 increased temperature, rapid pulse, great emaciation, and 
 notably a marked pallor and angemia of body. This is a 
 distinctive characteristic between the exanthematous 
 fevers and tuberculosis ; in the fevers we find flushing 
 and a general mottling of surface ; in tubercle infection, 
 paleness, and rapid emaciation. 
 
 Patbology. — The miliary eruption of tubercle has been 
 so often described that there is no need to enter into 
 microscopical details in this place. Two illustrations (one 
 of which will be found on page 65) are given to show the 
 distension of lung which takes place around tubercle. 
 The two drawings are taken from different specimens, the 
 one given here representing a nodule of localised tubercle 
 from a case of scrofulous phthisis, the other from a case 
 of acute tuberculosis : the actual process is difi'erentiu the 
 two cases, but the result is very similar. It must be 
 understood, however, that catarrhal pneumonia is a 
 condition which often precedes tubercle in localised form, 
 and also, but not so frequently, the acute form of general 
 infection. 
 
 The lungs in acute tuberculosis on removal from the 
 body are distended, and of a grey colour, and their con- 
 dition might easily be mistaken for that of emphysema. 
 An experienced obseiwer will, however, notice that the 
 
184 SIGNS OF PULMONARY DISEASE. 
 
 inflated grey appearance is universal and uniform, whereas 
 in emphysema portions of the lung are more affected 
 than others, and an irregular bullatous condition is 
 present. 
 
 Attention must also be called to the fact that the grey 
 distension of the tuberculised lung is always in the 
 anterior portions, while the posterior parts are com- 
 pressed and condensed, and the tubercle often closely 
 matted together. This is totally irrespective of the pre- 
 sence of catarrhal pneumonia or congestion, which will 
 induce gravitation of the fluid secretions to the back 
 part. 
 
 In most of the cases that I have examined I have found 
 this marked distinction of distended lung to the front, 
 and compressed lung to the back ; a condition which I 
 believe to be usually absent in emphysema. 
 
 On making section of the lung, we see minute isolated 
 nodules of tubercle scattered uniformly through the 
 lungs. I have been unable to detect any other peculiarity 
 in the localisation of miliary tubercle. 
 
 This condition may occur with or without pleurisy, and 
 in some cases pleurisy may take place during (T presume 
 in consequence of) the infection. 
 
 This appears to me so important a distinction between 
 this disease and emphysema (for which tuberculosis is too 
 often mistaken, but which is incapable of pleurisy) that I 
 referred to Dr. Goodhart, whose pathological experience 
 is very great. Out of thirty-seven cases of miliary 
 tubercle he found the symptoms of pleurisy in seven ; while 
 with regard to the disease in children he has formed 
 a decided opinion that the pleurse are very often adherent 
 by somewhat recent lymph — miliary tubercle in children 
 being more mixed up with cheesy products than in 
 adults. Although, then, pleurisy is not frequent in the 
 tuberculosis of adults, it is not absolutely precluded, as it 
 appears to be in idiopathic emphysema. 
 
 Sig:ns. — Inspection shows rapid breathing, generally 
 abdominal, chest not bulged, extreme emaciation, generally 
 
^ 
 
 TUBERCULOSIS. 185 
 
 depression of tlie intercostal spaces, and fixity of the ribs ; 
 skin very dry and rough. 
 
 Palpation gives no distinct indication, but the fremitus 
 is more distinct behind than before. 
 
 Percussion gives a high-pitcbed, tense, muffled note in 
 both superficial and deep percussions, and it sometimes 
 has a diminished resonance, approximating to dull. In 
 front, over all the anterior portion of the cbest, this 
 tense percussion note is most marked ; behind, the note 
 becomes actually hard and dull. 
 
 Auscultation. — Yocal resonance in front of a very 
 diffused, buzzing, indistinct cbaracter ; behind, high- 
 pitched bronchophony marked. Respiratory murmur 
 diminished and of a higb pitch ; inspiratory murmur 
 deferred ; expiratory shortened (this arises from tbe dis- 
 tension of the lung). Behind, indistinct tubular breath 
 sounds may be heard. 
 
 If to tbis condition be added congestion or catarrhal 
 
 neumonia, scattered clicks, crepitant sounds will be 
 heard; sometimes bubbling rales of a high-pitched, 
 rattling quality, which often mask the characteristic 
 signs. 
 
 The distinction between tuberculosis and emphysema, 
 and other diseases, is so difficult and nice that, although I 
 have already twice drawn attention to the point, it may be 
 convenient to give the chief characteristic features of the 
 two diseases in the following Synoptical Table : — 
 
 Actite Tuberculosis. 
 
 Emphysema. 
 
 In early Hfe. 
 
 Initial fever and rigors. 
 
 Diarrhoea often present. 
 
 Pallor. _ 
 
 Abdominal respiration. 
 
 Chest not enlarged. 
 
 Deep percussion muffled. 
 
 Marked dulness behind. 
 
 In advanced hfe. 
 
 No fever. 
 
 Diarrhoea not a symptom. 
 
 Cyanosis. 
 
 Thoracic respiration. 
 
 Chest bulged. 
 
 Deep percussion resonant. 
 
 Eesonance behind. 
 
186 SIGNS OF PULMONARY DISEASE. 
 
 Iiocalised tubercles occurring in lungs excavated by 
 phthisis are found in alveolar groups or clusters, and the 
 bronchioles leading to them are in a condition of marked 
 irritation. 
 
 Symptoms. — If they are forming in any quantity, as 
 they are apt to do when the secretion is excessive, or the 
 patient's strength so failing that the matter is not 
 ejected by expectoration, dyspnoea of an aggravated 
 form, with night-sweats, are observed, accompanied with 
 that paleness which is a marked peculiarity in the aspect 
 of the tubercular patient. 
 
 Patholog-y. — Alveolar groups of tubercle invariably 
 assume special localities, and are to be found in the 
 anterior and most expansile parts of the lungs ; adhesions 
 of the pleura discourage their formation, and the difference 
 in the amount in one lung, which is completely adherent, 
 and in the other when perfectly free is remarkable. 
 
 This form of tubercle, as a rule, avoids the back of the 
 lungs, especially when the lumina of the air-sacs are 
 already occupied by the secretions of congestion, and if an 
 acute outcrop is developed (in a case of one-sided cavity) 
 in a lung previously healthy, of which I have seen several 
 examples, the tubercle is chiefly deposited below the level 
 of the main horizontal bronchus. 
 
 In addition to these points (which appear to my mind 
 very suggestive) must be added the observation that 
 where the expectoration has been for some time back 
 tinged and mixed with blood continuously the groups of 
 tubercle are much pigmented. 
 
 Sigrns. — The chief indications are givenin the dyspnoea : 
 the respiratory murmur being feeble, with an occasional 
 scattered subcrepitant sound, or if the secretion be very 
 profuse, a plentiful crop of bubbling rales ; very likely to 
 be confounded with capillary bronchitis, and only to be 
 distinguished by the high-pitched, rattling quality which 
 belongs to the tubercular affection. 
 
 In chronic fibrosis of the lung with excavation occurring 
 in old spirit drinkers tubercle is sometimes found 
 
TUMOURS OF THE LUNGS. 187 
 
 deposited in a broad, glistening, homogeneous band affect- 
 ing the middle of the lung : this is of slow formation, and 
 pelds dull percussion, especially at the back, with absence 
 of respiratory murmur, and an indistinct bronchophony. 
 In all cases of localised tubercle, it is only by considering 
 all the phenomena that a diagnosis, which is not simply 
 conjectural, can be made. 
 
 TUMOURS. 
 
 Pulmonary tumours may be classified and considered 
 under three heads — glandular enlargements, malignant 
 growths, vascular tumours : these are practically those 
 which are presented to notice, but almost any kind of 
 growth occurring in the body may be repeated, usually as 
 a secondary condition in the lungs. The classification 
 above is not intended to be scientific, inasmuch as all 
 secondary growths in the lymphatics might be considered 
 as glandular enlargements ; but under this term it is 
 convenient to consider two forms of tumour which are 
 very similar, and in some cases extremely difficult to distin- 
 guish. They are Scrofulous Glands and Lymphadenoma. 
 
 Scrofulous grlands are very common, especially in child- 
 hood, but they may be seen in the adult, and associated 
 with scrofulous forms of phthisis. 
 
 Symptoms in children, dyspnoea and harsh, croupy, 
 dry cough, no expectoration, the cough being harsh and 
 ringing, and aggravated at night. 
 
 Fatliologry- — This condition is caused by enlarged 
 scrofulous glands embracing the trachea about its 
 bifurcation, and situated beneath the manubrium sterni. 
 
 Signs. — Inspectio'u shows the upper part of the sternum 
 thrown forward, if the enlargement is great and the case 
 chronic, as in the accompanying illustration. Palpation 
 detects nodular swellings and hardness in the supra- 
 clavicular foss£e. 
 
 Percussion gives marked dulness over the region. 
 Auscultation shows pressure on the trachea, a harsh 
 tracheal sound, intense behind, over the tubes. 
 
188 
 
 SIGNS OF PULMONARY DISEASE. 
 
 The second sound at the base of the heart is generally 
 accentuated with a sharp clack, the valves closing 
 under increased pressure, and there may be a systolic bruit 
 heard over the aortic or the pulmonary, or over both 
 valves. 
 
 I have given a drawing of the chest in a typical case, 
 because this condition, which is a very common one with 
 scrofulous children, is often overlooked. 
 
 Fig. 22. 
 
 Enlarged Bronchial Glands pressing forward the Upper Part 
 of the Sternum. 
 
 Kymphadenoma sometimes occurs as a general affection 
 of all the glands (Hodgkins' disease), or more locally it 
 may affect the glands of the neck or the mediastinum. 
 It is difficult to be sure of the exact condition : diagnosis 
 is helped by the extreme anaemia of the patient, who has 
 a sallow hue, and the glandular swellings are more 
 regular than in scrofula, and generally show first in the 
 supra-clavicular regions ; but this observation is made 
 with great reserve, as the clinical distinction between the 
 two is often impossible. When it occurs as a mediastinal 
 
MEDIASTINAL TUMOURS. 1S9 
 
 tumour it spreads into and encroaches upon the lung 
 tissue. 
 
 The growth is found to consist of reticular meshwork 
 containing lymphoid cells. 
 
 Mediastinal tumours of all kinds give similar symptoms 
 and signs ; of these, the following are the most charac- 
 teristic: — 
 
 Symptoms. — Dyspnoea of a very aggravated kind 
 recurring in spasmodic attacks ; more or less orthopnea, 
 sometimes very marked ; the patient being often obliged 
 to sit with the head down to relieve the trachea of the 
 tumour's weight ; dreading to go to bed, suifering from 
 wakeful and restless nights, cough with bloody sputa ; 
 and pain, and a sense of weight and constriction behind 
 the sternum- 
 
 Patbology. — Tumours of various kinds, embracing the 
 trachea and bronchi, and sometimes moulded firmly round 
 the large vessels of the heart. 
 
 Sigrns. — Inspection detects the prominence of the 
 sternum, the sternal and clavicular fossae being very 
 deep, the veins of the chest tortuous and enlarged ; local 
 bulging over the tumour ; stridulous or aphonic voice. 
 
 Palpation gives annulled vocal fremitus if the tumour 
 be next the chest-wall ; if it be covered by compressed 
 lung vocal fremitus may be increased. 
 
 Percussion gives distinct and circumscribed dulness ; 
 a very valuable sign. 
 
 Auscultation gives the signs of pressure on the tube ; 
 laryngeal stridor, and harsh, tubular, high-pitched re- 
 spiratory sound, or no breath sound if the pressure be 
 great. 
 
 Yocal resonance very indistinct from the tumour itself, 
 but intense bronchophony or pectoriloquy if compressed 
 lung cover it. 
 
 Cancer may assume two forms ; it may invade the 
 lung in isolated nodules, varying in size from a hemp- 
 seed to an orange, in which case it is generally secondary 
 to distant cancer, or it may originate in the bronchial 
 
190 SIGNS OF PULMONARY DISEASE. 
 
 glands and mediastinum, or more rarely attack the Inng 
 as a primary growth. 
 
 Symptoms. — Chiefly pain and emaciation; the dyspnoea 
 is not so constant, but will depend upon the amount of 
 invasion and the region infected; cough is usually 
 attended with bloody expectoration. 
 
 Signs. — Inspection. — Diminished respiratory action ; 
 flattened side, the axillary glands sometimes involved ; 
 malignant sallow hue of surface. 
 
 Palpation. — Yocal fremitus increased if the lung is 
 compressed ; annulled if expanded tissue intervene 
 between the chest-wall and the tumour. 
 
 Percussion gives a dull sound proportionate to the 
 extent of the growth. 
 
 iiuscultation detects tubular respiration, or if a 
 bronchus be compressed and obliterated by the growth 
 the respiratory sounds may be annulled and silent. 
 
 In the nodular form, and when the growths interfere 
 with the passage of the air, cogged respiration of a very 
 coarse and marked kind may be sometimes heard. 
 
 Yocal resonance may be diminished or intensely 
 increased. 
 
 Vascular tumours are considered in the next section, 
 under the heading " Aneurisms." 
 
 The evidence of the presence of such a tumour as far 
 as the pulmonary signs are concerned depend upon the 
 pressure produced upon the lung. If the main bronchus 
 be flattened, harsh tubular breathing will be heard ; if it 
 be occluded no breath sound will be heard over the tube, 
 and only an indistinct, stridulous, deferred, respiratory 
 murmur over the posterior base of the lung thus affected. 
 
SYNOPTICAL TABLES 
 
 OP 
 
 THE SOUXDS IX DISEASES OF THE 
 EESPIEATORY OEGAXS. 
 
192 
 
 SIGNS OF PULMONARY DISEASE. 
 
 Synopsis of Sounds in Disease of the Bespiratory Organs . 
 
 Morbid Yesiculab, Sounds. 
 
 Vesicular Murmur Altered. 
 
 Sound. 
 
 Significance. 
 
 Increased or exaggerated 
 
 Distended lung 
 
 Diminished 
 
 Teeble action 
 Adherent pleiira 
 
 Suppressed 
 
 Inspiratory sound short 
 
 Inspiration deferred 
 
 Expiratory sound short 
 Expiratory so\ind prolonged 
 
 Expiratory sound suppressed 
 Hesitating 
 
 Jerking 
 
 Obstruction of air-passages, 
 pleural fluid, or tumour 
 
 Hampered expansion 
 Adherent pleura. Pleurisy 
 
 Emphysema 
 
 Distended lung 
 
 Emphysema 
 Diminished elasticity 
 
 Contracted cavity 
 
 Hysteria 
 
 Adherent pleura 
 
 Cogged 
 
 Cancer. Tubercle 
 
 Harsh 
 
 Induration and thickening 
 Fibrosis. Syphilis. Hsemorrhagie 
 
 Adventitious Sounds. 
 
 Erne Crepitation 
 
 First stage of pneumonia 
 
 Crepitant rale 
 Viscid crackle 
 Occasional click 
 
 Early stage of phthisis 
 
 Subcrepitant rale 
 
 Congestion 
 Brown induration 
 Pulmonary apoplexy 
 
 Bubbling rale 
 
 Capillary bronchitis 
 (Edema of the lung 
 
 Morbid Bronchial Sounds. 
 
 Sonorous rhonchus 
 
 Large tube bronchitis 
 
 Sibilant rhonchus 
 
 Small tube bronchitis 
 
 SSLi}k-p-«- 
 
 Consolidation of lung 
 Compression from fluid, or tumour 
 
SYNOPTICAL TABLE OF SOUNDS. 
 
 Sounds of Destruction. 
 
 Friction 
 
 Metallic soimds 
 
 Splash 
 
 Eoughened pleura 
 
 Hydropneumothorax 
 
 Hydropneumotlioras 
 
 193 
 
 Sounds. 
 
 Significance, 
 
 Gurgling rale 
 
 Softened lung tissue 
 
 Cavernous respiration 
 
 Pulmonary cavity 
 
 Amphoric respiration 
 
 Pneumothorax 
 Pulmonary cavity 
 
 Pleural Sounds. 
 
 Morbid Yoice Sounds. 
 
 Increased vocal resonance 
 
 Dense pulmonary tissue 
 
 Diminished vocal resonance 
 
 Interposition of fluid, soUd, and air 
 between the chest-wall and lung. 
 
 Bronchophony 
 
 Solidification \ n -, 
 Compression j" ^ 
 and in other conditions 
 
 Pectoriloquy 
 
 Air-containing cavity 
 
 but also in other conditions 
 
 -S^gophony 
 
 Interposition of a vibrating sur- 
 face between a rigid tube and 
 the chest-wall 
 
 Metallic sounds 
 
 Hydropneumothorax 
 
 Morbid Cough Sounds. 
 
 Intense 
 
 Consolidation 
 Cavity 
 
 -r». . . 1 , Effusion into pleura 
 Dimmished Tumour near chest-waU • 
 
 Cavernous | Pulmonary cavity 
 
 MetalHc | Hydropneumothorax 
 
 Brassy 
 
 Bronchial irritation and pressure. 
 
194 
 
 THE PHYSICAL EXAMINATION OF 
 THE HEAET. 
 
 CHAPTER XYI. 
 
 CLINICAL ANATOMY OF THE HEART. 
 
 That portion of the external surface of the chest which 
 covers the heart is called the praecordial regrion; it 
 extends from the middle of the second intercostal space 
 to the lower border of the fifth intercostal space, 
 and is bounded on the right side by a vertical line 
 situated a finger's breadth to the right margin of the 
 sternum, and on the left by a vertical line a little within 
 the left nipple line. 
 
 The exact size and position of the heart varies in 
 individuals, but an average may be struck by comparing 
 a number of cases ; and the upper margin of the heart 
 may be placed, as above, in the middle of the second 
 interspace. The condition of the auricle varies with the 
 quantity of blood contained, and if distended they may 
 reach to the second rib. 
 
 Beneath the prsecordial region between the sternum 
 and the spine lies the heart. It has an irregular conical 
 shape, the base facing upwards, backwards, and towards 
 the right shoulder; the axis being directed downwards, 
 forwards, and towards the left. 
 
 The apex is situated in the fifth intercostal space, 
 between the fifth and sixth ribs, about midway between 
 the line of the left nipple and the left border of the 
 sternum ; three and a quarter inches to the left of the mid- 
 
EIGHT AURICLE AND VENTRICLE. 
 
 195 
 
 sternal line; two inches to the left of the left border of the 
 sternum ; one and a half inches below the left nipple ; one 
 inch to the right of the left nipple. 
 
 The heart has four chambers — two ventricles and two 
 auricles ; one ventricle and auricle on each side. 
 
 PULM.AR 
 
 L, AURICLE 
 PHREMIC 
 
 Fig. 23. 
 
 AORTA. 
 
 R. AURICLE 
 
 PHHENIC 
 
 Transverse Section of Thorax showing Position of Valves of the 
 Heart. (After Braune.) 
 
 Rigrht auricle lies in front of the right half of the left 
 auricle, above the right ventricle, behind the third right 
 cartilage — i.e., between the lower border of the second 
 right cartilage and the lower border of the fourth, ex- 
 tending into the right mammary region an inch (sometimes 
 more, sometimes less) beyond the right parasternal line. 
 It is, as a rule, covered by the right lung. 
 
 The tricuspid valve is situated between the auricle and 
 ventricle, between the third left and the fifth right 
 cartilage. 
 
 The riirht ventricle occupies the lower sternal region, 
 
 o2 
 
196 CLINICAL ANATOMY OF THE HEART. 
 
 extending from the third cartilage to the sixth, and trans- 
 versely from the right parasternal line to the junction of 
 cartilages and ribs, between the third and the fifth ribs on 
 the left side. 
 
 This portion of the heart forms the exposed front of the 
 heart, which is seen when the sternum is removed. The, 
 impulse of this ventricle is felt at the lower end of the 
 sternum ; and its axis is directed towards the pulmonary 
 artery in a verticle line. 
 
 The pulmonary valves are situated at the upper 
 border of the third left cartilage, close to the left border of 
 the sternum, which divides the line of the valves in 
 half. 
 
 The pulmonary artery ascends from the valves towards 
 the left side as far as the second left cartilage, where it 
 bifurcates. 
 
 The left auricle is situated at the posterior part of the 
 heart above the left ventricle, resting behind on the de- 
 scending aorta and oesophagus ; and covered in front by 
 the large vessels, and partly by the right auricle, it curves 
 round towards the left and forwards, and its auricular 
 appendix lies beneath the third left cartilage and cor- 
 responding interspace. 
 
 The mitral valve is situated between the left auricle 
 and ventricle ; behind, and to the left of the tricuspid ; 
 about level with the upper border of the third left carti- 
 lage, close to the left edge of the sternum; its lower 
 border being level with the fourth cartilage, just behind 
 the midsternal line. 
 
 The left ventricle lies below the left auricle, to the left 
 of the spine, extending towards the left, and forwards to 
 the apex situated in the fifth intercostal space ; it forms 
 the convex left portion of the heart, and extends from the 
 third to the fifth left interspace ; its furthest left border 
 reaching close to the left nipple line. 
 
 Its axis is horizontal, and its cavity, which is conical in 
 shape, is narrowest at its greatest distance from the 
 aorta. 
 
POSITION OP THE VALVES OF THE HEART. 197 
 
 Its apex is the apex of the heart, which beats at the 
 fifth interspace, where its impulse is felt. 
 
 The aortic valves are situated at the orifice of the 
 ventricle and the root of the aorta; below, and to the 
 right of the pulmonary valves ; behind the sternum, at 
 a place corresponding to the lower border of the third 
 cartilage. 
 
 A circle half an inch in diameter would include all the 
 valves, one of only quarter of an inch would include all 
 but the tricuspid. 
 
 The position of the heart and its valves having been 
 given in their relation to the anterior of the chest, their 
 position with regard to the back must be described. The 
 exact position varies in individuals very much, as will be 
 seen on comparing the results obtained in the frozen 
 sections of Pirogoff and Braune. 
 
 The following account may be taken as indicating the 
 average position of the heart and its valves : — The heart 
 lies between the fourth and eighth dorsal spines, the 
 top of the arch of the aorta being level with the third 
 dorsal spine, the top of the pulmonary artery on a level 
 with the fourth dorsal spine. The pulmonary valves are 
 opposite the fifth dorsal vertebra ; the aortic valves are oppo- 
 site the sixth dorsal vertebra ; the mitral valve is opposite 
 the sixth and seventh or eighth dorsal vertebra; the tricus- 
 pid valve between the sixth and eighth dorsal vertebra. 
 
 The superficial cardiac reg:ion is usually four-sided, 
 but sometimes triangular in shape ; is chiefly formed by 
 the right ventricle, which is exposed to view uncovered 
 by the lungs ; lies between the fourth cartilage to the 
 upper border of the sixth rib. It is bounded above and 
 at the sides by the right and left lungs, below by the 
 diaphragm. It measures vertically two inches, horizon- 
 tally two and a half inches. This uncovered space would 
 be contained within three lines forming a triangle ; the 
 midsternal line meeting one line drawn horizontally from 
 the apex, and another drawn upwards from the apex to 
 the level of the fourth cartilage. 
 
198 CLINICAL ANATOMY OF THE HEART. 
 
 The lungs from tlieir upper part descend together, and 
 meet to form a covering for the great vessels of the hearty 
 and they part generally on a level with the fourth carti- 
 lage; the left lung receding, and leaving the heart ex- 
 posed, by a double curve, at first convex, and then concave^ 
 when it curves forward again to form a very peculiar 
 tongue, which laps over the apex of the heart and passes 
 downwards, as will be seen by reference to the woodcut on 
 page 57. 
 
 They modify by their presence the dull note of per- 
 cussion, and consequently over all the praecordial surface, 
 excepting the region of superficial dulness, deep-seated 
 or diminished dulness is elicited by percussion over the 
 confines of the heart. 
 
199 
 
 CHAPTER XYII. 
 
 THE SOUNDS OF THE HEAET. 
 
 The heart moves smootUy and noiselessly in its peri- 
 cardial sac, and in a normal condition no sound is pro- 
 duced by this movement ; but when the ear is applied to 
 the prgecordial region of a healthy individual two sounds 
 are heard — one corresponding to the impiilse or systole, 
 which is called the systolic sound ; a second one which 
 follows this, and is called the diastolic sound. 
 
 Each of these sounds is followed by a short interval of 
 silence. 
 
 The two sounds differ in duration, intensity, pitch, and 
 quality. 
 
 The two silences differ in duration. 
 
 As regards the relative duration of the sounds and the 
 silences, if an entire period from the beginning of one 
 systolic to the beginning of another be divided into 10 
 parts — 
 
 4 will be occupied by the first sound (systolic). 
 
 1 by the following silence (post-systolic). 
 
 2 by the second sound (diastolic). 
 
 3 by the second silence (post-diastolic). 
 
 The sounds of the heart are chiefly due to the forcible 
 tension of the valves. 
 
 The first sound being caused by the closing of 
 the auriculo-ventricular valves, the tricuspid and the 
 mitral. 
 
 The second sound being caused by the falling to of the 
 sigmoid valves, aortic and pulmonary. 
 
 (For practical purposes these causes for the sounds of 
 
200 THE SOUNDS OF THE HEART. 
 
 the lieart are sufficient, but it may be well to state that 
 other causes help, viz. : — 
 
 ( The shock of the heart's apex on 
 ¥oY the first sound < the chest. 
 
 ( The bruit of muscular contraction.) 
 
 The sounds vary relatively at apex and base. 
 
 The first sound, as compared with the second at the 
 apex, is longer, louder, and lower in pitch; strongly 
 accentuated. 
 
 It is dull, accentuated, and booming in quality, sharply 
 defined at its beginning, not so much at the end. 
 
 The second sound is consequently at the same point 
 shorter, less loud, higher in pitch ; it has a sharp clacking 
 quality. 
 
 The sounds are slightly different when the ear is placed 
 over the base of the heart. 
 
 The first sound is not longer than the second ; it loses 
 its booming quality, and the accent is passed to the second, 
 which increases in intensity and ringing sound. 
 
 The auricular systole immediately precedes the impulse ; 
 in health this contraction gives no sound. 
 . The ventricular systole causes the impulse and the first 
 sound. 
 
 The arterial contraction, after the impulse of the heart, 
 causes the second sound by the pressure of the blood on 
 the closing sigmoid valves. 
 
 This is followed by a period of rest. 
 
 1st Sound.... I vrl*^,^!'''^ " [ Sl^^t Ventricular Contraction. 
 
 2nd Sound... j p^[^onar*'' I ^^^* Arterial Contraction. 
 
 o., < Tricuspid ... ) ^^^ ^Auricular Contraction 
 ^^1^^^^ 1 Mitral i ^P'^- i during the last part. 
 
 The impulse of the heart is sometimes difficult to deter- 
 mine in relation to the sounds. In health there is no 
 such difficulty, but it may be necessary to decide by other 
 means when the impulse takes place. If the apex beat 
 can be felt the sensation of the impulse will give a ready 
 
THE HEART AND ITS VALVES. 
 
 201 
 
 means for tlie recognition of tlie first sound, but if the 
 apex beat is from any cause indistinct, the finger must 
 feel for the pulse in the carotids, where it is synchronous 
 with the first sound, the radial pulse being perceptibly 
 postponed. 
 
 Fig. 24. 
 
 The Position of tlie Heart beneath the Sternum. The Bars indicate 
 the Position of the Valves. The Circles the Sites for Auscultation. 
 
 But it must be remembered that the heart has four 
 chambers which empty and refill, and it may be requisite 
 
202 THE SOUNDS OF THE HEAET. 
 
 to discover whether these chambers are acting properly. 
 This is to be done mainly by remembering that sounds 
 produced by a fluid in motion are transmitted in the 
 direction of the current. 
 
 The sound of the pulmonary valves is best heard at the 
 second left interspace. 
 
 The sound of the aortic valves at the second right 
 interspace. 
 
 The sound of the tricuspid along the left part of the 
 sternum from the fourth to the eighth ribs. 
 
 The mitral being best heard over a space (an inch in 
 diameter) at the apex beat. 
 
203 
 
 CHAPTER XVIII. 
 
 THE ACOUSTICS 01" BLOOD MUEMUES. 
 
 The modifications of sound resulting from the passage 
 of air through tubes of different calibre have been con- 
 sidered with reference to lung sounds, the production of 
 sounds in fluids also undergo modification which are 
 made use of in clinical medicine to detect alterations in 
 the heart and its vessels. 
 
 Formerly it used to be thought that the sounds heard 
 in heart disease during the circulation of the blood 
 resulted from the friction of the blood-current on the 
 walls of the heart or vessels through which the blood was 
 travelling. Laennec concluded that the abnormal sound 
 (which he likened to that produced by a pair of bellows 
 when in use), and caUed " bellows sound" (bruit de 
 soujfflet), was produced like the muscular murmur by 
 muscular contraction or spasm. 
 
 This theory was, however, challenged by Corrigan, who 
 substituted another, the gist of his observations being 
 found in the following quotation : — " When an artery is 
 pressed upon, a small stream rushes from a narrow 
 orifice into a larger one ; the rushing of the fluid is com- 
 bined with a trembling of the artery, and the sensation 
 to the sense of hearing is the bruit de soujfflet." 
 
 This is quite in accordance with the experiments of 
 Savart on the alterations in fluids as they pass through 
 small orifices. 
 
 If water be allowed to pour, for example, from the top 
 of a shower-bath, or from a cullender, the streams which 
 descend will be observed to be clear and continuous close 
 to the holes, while below they break into a succession of 
 drops, and this liquid vein, veine fluide, alternately swells 
 
204 THE ACOUSTICS OF BLOOD MURMURS. 
 
 and contracts in its course, like the bulgings of a vein, 
 ■ forming a vibrating column of water, which will produce 
 a musical sound if the drops be caught on a membrane. 
 The revolution of the fluid into drops begins to take place 
 soon after the fluid passes through the hole, becoming 
 more definite lower down until the drops become com- 
 pletely formed and separate. If under pressure these 
 drops succeed each other with sufficient rapidity a musi- 
 cal note may be heard. 
 
 This vibration of fluid passing through a narrow 
 orifice, which is similar to the vibration of air passing 
 through the mouth of an organ pipe, is the cause of sound 
 in fluids ; the subject has been of late years further in- 
 vestigated by Chauveau in some experiments on animals. 
 The artery of a horse was torn inside in several places, 
 and the vessel thus roughened to the current of blood, 
 but no hruit or sound was produced ; but when the vessel 
 was narrowed by a thread tied round it so as to make a 
 ■constriction in its course, the bellows murmur was heard 
 distinctly, and the vibrations caused in the current were 
 felt. It is easy enough to make a murmur of this kind 
 by pressing upon the jugular vein with the stethoscope, 
 and it is sometimes difficult in ordinary practice to avoid 
 making that very sound artificially, for which the observer 
 is searching, as indicative of disease. 
 
 The explanation of the sounds which are heard in 
 •anaemia, given by Chauveau, is very interesting and 
 simple; the quantity of blood circulating in anaemia 
 being reduced, the heart adapts itself to the required 
 condition and becomes also reduced in size; this was 
 shown in his experiments on horses, who were the subject 
 of anemia ; the cavities and orifices of the heart under 
 these circumstances became lessened in size, while the 
 large ai*teries maintained their normal size, being unable 
 to alter in consequence of the rigidity of their waUs ; hence 
 the blood passing out of diminished orifices into these 
 large vessels is broken up into a liquid vein, and sounds 
 ^re produced. 
 
THE .ETIOLOGY OF MUEMURS. 205 
 
 In a somewliat similar raanner the hmniiiing sound 
 produced in the veins, which the French have called the 
 hruit de diahle (from the resemblance to the noise of a toy 
 which bears the name), may be explained ; the size of the 
 jugular vein at the base of the neck (the position which 
 this murmur affects) is kept rigidly constant under all 
 circumstances in consequence of the adhesion of the 
 walls of the vessels at this part of the cervical fascia ; 
 when the calibre of the vein above is altered a murmur 
 is produced by the current passing into this rigid dilatation. 
 "With regard to musical murmurs in some cases it can be 
 shown that they depend upon the rapidity of the heart's 
 action ; a frequent murmur of a whistling character is one 
 heard in nervous and hysterical patients whose hearty 
 when they are being examined, is beating with a 
 surprising rapidity. This murmur abates considerably 
 when the patient becomes more tranquil. This is not, 
 however, the case with all musical murmurs, some 
 of which are persistent and so intense as to be audible 
 some distance from the patient and yet no organic disease 
 may be detected. Walshe, however, states that a musical 
 quality is sometimes given when prominent spicules of 
 a vibratile character project into the current. Rapidity 
 of the heart may be iised for bringing out the quality of a 
 murmur ; and if any doubt exists on such a question it is 
 useful to make the patient pace up and down the room 
 smartly for a short time. The rationale of musical 
 murmurs is a question not yet decided, nor can we at 
 present diagnose their causation. It is necessary 
 therefore to warn the student that cardiac disease is not 
 to be considered as proportionate to the intensity of the 
 murmur, and not seldom it is found that a most dan- 
 gerous cardiac disease is present which gives no audible 
 sound at all ; while one condition of the heart may give 
 rise to murmurs of varying quality, sometimes soft, at 
 another time loud and musical, so that in this department 
 of auscultation also the student must not be misled by 
 trusting solely to his ear. 
 
206 
 
 CHAPTER XIX. 
 
 INSPECTION, PALPATION, AND PERCUSSION IN HEAUT DISEASE. 
 
 In the physical examination of the heart, as in that of 
 the lungs, the first method to apply for the determination 
 of its condition is Inspection. 
 
 Attention is chiefly directed to the position of the apex, 
 which can generally be seen beating, but palpation 
 must aid the eyes to find the precise locality. As long as 
 the apex is beating beneath an intercostal sj)ace, eyes and 
 fingers are sufficient to establish its position ; but when it 
 is beating beneath the ribs or sternum, and the eyes 
 and the fingers cannot detect its whereabouts, the 
 stethoscope must be used and so moved about as to 
 discover by comparison of the relative intensity of the 
 sound at various points where the sound is loudest. 
 
 Pulsation must not be mistaken for the true apex beat, 
 as the apex may be forced from the surface of the chest, 
 and the pulsation of the right ventricle may (for example) 
 be visible. 
 
 The apex in health beats in the fifth intercostal space, 
 but it is driven out of place by various conditions of 
 disease. 
 
 The apex is lowered in enlargement of the heart, and 
 may be depressed down to the eighth rib. Walshe 
 mentions a case in which the apex was 3f inches to the 
 left of the nipple. 
 
 It is thrown down also by aortic aneurism and those 
 pulmonary diseases which force down the diaphragm : 
 these are emphysema, asthma, and chronic bronchitis, 
 pleuritic effusion, and (in some cases) mediastinal tumour. 
 
 The apex is raised by all abdominal diseases, tending 
 
LATERAL DISPLACEMENT OF HEART. 207 
 
 to force thediaplaragm upwards — e.g^., by ascites, distension 
 of the stomacli and abdominal tumours — the most frequent 
 cause of its elevation is the adhesion of the pleura and 
 the contraction of a fibroid or phthisical lung. 
 
 Pericardial effusion forces the apex of the heart upwards 
 so that it may beat as high as the fourth interspace. 
 
 Xiateral aisplacement of the apex takes place from 
 the diseased and towards the sound side in effusions 
 of all kinds and the admission of air into the pleural sac 
 from the presence of intrathoracic tumours from growth 
 and collections of matter or hydatid cysts in the liver ; 
 and from the sound towards the diseased side in con- 
 tracting lung the result of fibrosis or arrested phthisis. 
 In rare examples the displacement is congenital (conge- 
 nital transposition of the viscera). 
 
 The heart is thrown forward by tumours of the pos- 
 terior mediastinum, aneurism and cancer, and thrown 
 backward by tumours of the anterior mediastinum, cancer 
 and abscess, and by effusions into the pleura and peri- 
 cardium. 
 
 The apex changes its position according to the posture 
 assumed by the patient, but permanent displacement of 
 the heart may take place solely from decubitus on one 
 side. A most remarkable instance occurred lately under 
 my observation. 
 
 A woman who had suffered from sacro-iliac disease and 
 abscess of the left side for some months died after nineteen 
 months' illness. She had been compelled to lie always 
 upon the right side. After death the heart was found 
 lying over to the right side of the mesial line, the apex 
 being situated under the sternum, and the axis of the 
 heart being directed upwards towards the right shoulder. 
 The apex was on a level with the fifth interspace, and the 
 heart was not turned, the right ventricle being in its 
 proper place. There was no disease of the lungs further 
 than this, that the right lung was in a condition of slight 
 hypostatic engorgement. 
 
 The right lung weighed 18 ozs. ; te left, 9^ ozs . 
 
208 INSPECTION, PALPATION, AND PERCUSSION. 
 
 Synoptical Yieiv of Displaced Heart. 
 
 Apex Depressed 
 
 Emphysema 
 BroncMtis 
 
 Hypertrophy of Heart 
 Anemnsm 
 Pleuritic EflPusion 
 
 Apes Eaised 
 
 Diseases of Abdomen 
 Eibroid Phthisis 
 Pericardial Effusion 
 
 To the Left of Nipple 
 
 Fibroid Phthisis 
 
 Pleuritic Effusion ") r?.-, -n- ■u^.^-j 
 Pneumothorax j ^^^ *^^ ^'^^^ ^ide 
 Intrathoracic Timiours 
 
 To the Eight of Nipple 
 
 Eight Fibroid Disease 
 
 Left Empyema 
 
 Left Pleuritic Effusion 
 
 To the Eight of Sternum 
 
 Eight Fibroid Disease 
 
 Left Hydrothorax 
 
 Left Hydropneujnothorax. 
 
 Pulsation of tbe veins is a sign wMcli must attract 
 attention dnring inspection. 
 
 Plethora of the right auricle, preventing the free 
 return of blood to the heart, is indicated by waviness in 
 the jugular current. If the systolic impulse be distinct, 
 the tricuspid valve is incompetent. 
 
 Marked pulsation occurs in obstruction in the pulmonary 
 artery, notably in pulmonary thrombosis and embolism. 
 It occurs also as a result of old- standing emj^hysema 
 and mitral disease. 
 
 A plethoric condition of the veins is found in beer- 
 drinkers — from the copious imbibition of fluid; and this 
 condition is very conspicuous in the veins of the extremities. 
 
 Pulsation of the arteries is marked in atheroma, and 
 in regurgitation through the aortic valves. 
 
 Inspection must also appreciate any bulging or alte- 
 ration of the chest-wall. In early life this is caused some- 
 times in a very marked degree by cardiac hypertrophy, 
 the ribs being forced forward by the enlarged heart. 
 
DISPLACEMENT OP THE HEART. 209 
 
 Retraction of the skin over the apex beat after the 
 impulse of the heart has been delivered has been con- 
 sidered diagnostic of adherent pericardium, but this may 
 follow the pressure of the atmosphere acting from without 
 inwards, and cannot be depended upon as characteristic 
 solely of that disease. 
 
 It may be mentioned here that in displacement the 
 heart is often rotated in such a manner that when the 
 apex is pushed over to the right the left ventricle comes 
 forward, the right ventricle turning backwards, and when 
 it is pushed over to the left the right ventricle comes to 
 the front. 
 
 It is a common notion to look upon the movement of 
 the heart to the right side taking place, as if the heart 
 was pivoted above, and the apex moved to its allotted 
 place like the end of a pendulum ; but although this does 
 occur in extreme cases (of extensive effusion, for example), 
 yet the most usual form of dislocation is the movement 
 of the base upwards, the apex being situated under the 
 sternum, the push being exerted upwards towards the 
 right shoulder. 
 
 Palpation is used to estimate the impulse, ascertain 
 the position of the apex, and detect abnormal pulsations 
 and thrills. 
 
 The impulse is increased in functional excitement, in 
 angina pectoris, cardiac asthma, pericarditis, endocar- 
 ditis, hypertrophy of the heart, by sexual vice and alco- 
 holic intemperance, and in reaction after heemorrhage. 
 
 The impulse is weakened by debilitating influences, pro- 
 longed illness, fevers, dilatation of the heart, fatty 
 degeneration, and the deposit of fat about the heart, 
 effusion into the pericardium and emphysema. 
 
 Pulsation of an abnormal character may be due to some 
 other cause than the apex beat. It is frequently to be 
 seen in the epigastric region from dilatation of the right 
 ventricle, and is a common sign of emphysema. 
 
 Sometimes this form of pulsation is such as to induce 
 pulsation of the liver throughout the whole right hypo- 
 
210 IXSPECTION, PALPATION, AND PERCUSSION. 
 
 chondriac region ; a sign also visible in aneurism seated 
 beneath the liver. 
 
 Pulsation of a very extended nature may be often 
 observed wben tbe heart is uncovered by retraction of the 
 lung ; this is an ordinary result of phthisis with adherent 
 pleura, and occurs most frequently on the left side. 
 
 It is difficult in some cases to determine the exact 
 nature of the pulsation, and how it is caused, and whether 
 it be systolic or diastolic. 
 
 To solve this question a bristle carrying a piece of 
 paper (as suggested by Balfour) may be attached by a bit 
 of wax to the place, and its movements compared with 
 another placed over the apex. 
 
 Tbrills are caused by the palpable Aribrations of the 
 liquid vein or sonorous blood-current, or by the friction 
 of pericarditis. They have the same relation to blood 
 sounds that vocal fremitus bears to vocal resonance, in 
 being due to palpable vibration. 
 
 They are caused by the transmission of vibrations from 
 the blood-current to the containing walls, and, according 
 to Bergeon, are due to rough murmurs in a thin and 
 elastic tube. 
 
 As far as my observations go, they are usually present 
 when there is much dilatation with thinning of the walls 
 of the heart, and may be felt over the au.ricles as weU as 
 the ventricles. 
 
 Percussion is valuable for defining the size of the 
 heart or the presence of foreign matter in the pericardial 
 sac. 
 
 Hypertrojjhy of the heart is detected by the increased 
 area of dull percussion which extends chiefly in the 
 direction of the left axilla. 
 
 Pericardial effusion gives rise to an extended area of 
 dulness on both sides, and the region which must be 
 specially examined is the fifth right intersjDace. 
 
211 
 
 CHAPTEE XX. 
 
 SOUNDS OF THE HEAET EST DISEASE. 
 
 The sounds of tlie heart may by disease be increased or 
 diminished in intensity, altered in rhythm, or modified by 
 the presence of adventitious sounds, termed murmurs. 
 
 Increased intensity of sound is caused by increased 
 action of the ventricular walls, which may simply be 
 functional, the result of excitement, and is of frequent 
 occurrence in nervous and hysterical patients. When it 
 occurs with a bumping, irregular impulse of the heart it 
 suggests sexual intemperance and vice. It also occurs 
 from a dilated condition of the ventricles, with or without 
 hypertrophy. 
 
 In these forms of disease it is the first sound which is 
 specially intensified and accentuated. 
 
 Increased intensity of the second sound indicates 
 excessive arterial tension, which may be caused from 
 within the vessel by obstruction to the circulation, or it 
 may be due to pressure outside the vessel, as in tumours 
 embracing the vessel. This accentuation of the second 
 sound is found in children with scrofulous glands ; in 
 adults with aneurism, of which the sharp clacking sound 
 with which the valves close affords an early sign. 
 
 Biminisbed intensity of the sounds is caused by 
 weakening of the muscular walls of the heart from 
 adynamic diseases, fevers, cancer, and those diseases which 
 cause emaciation and atrophy generally. Fatty dege- 
 neration of the muscles, or the accumulation of fat 
 about the heart, are important causes of this modifica- 
 tion. 
 
 Distance of the heart sound, the sound being indis- 
 
 p2 
 
212 SOUNDS OP THE HEART IN DISEASE. 
 
 tinct and heard at some distance from tlae ear, is caused 
 by tlie interposition of fluid, as in pericardial and pleuritic 
 effusions, and by concentric hypertrophy of the ventri- 
 cular walls of the heart. 
 
 Zrreg-ularities of rhythm are evinced by reduplication . 
 of the sounds, or by intermittence. 
 
 Reduplication of the sounds is caused by the non- 
 synchronous action of the two sides which no longer 
 work in unison. 
 
 The first sound is doubled when the tricuspid valve is 
 closed behind time, and the second sound is doubled when 
 the aortic valves are shut before time. 
 
 Sounds are reduplicated at any age, and in health as 
 well as disease. 
 
 A very common cause of reduplicated apex sounds is a 
 distended stomach, which sometimes occasion inter- 
 mittence; the same condition is induced in many indivi- 
 duals at the time of an approaching thunder-storm. 
 
 Reduplication may be simply functional, or it may be 
 caused by organic disease, and indicates a non-syn- 
 chronous irregularity in the filling and emptying of the 
 cavities of the heart. 
 
 Znterxnittence in the sounds are due to two classes of 
 causes, one being extra-cardiac, and the other intra- 
 cardiac. 
 
 Under the first heading belong nervous conditions 
 from overwork and electrical states of the atmosphere, 
 especially during the approach of a thunder-storm, dis- 
 tension of the stomach, and dyspepsia, and gouty irri- 
 tation. 
 
 Under the second is included those severe forms of 
 mitral stenosis of which intermittence is a marked 
 symptom. 
 
 These two classes of conditions must be differentiated 
 by special attention to the character of the pulse, and the 
 general signs and symptoms of the case. 
 
 CARDIAC nxURMURS. — ^Adventitious sounds which 
 accompany the action of the heart, and are heard over 
 
CARDIAC MURMURS. 213 
 
 the praecordial region, are called cardiac murmurs ; they 
 are caused by some altered condition affecting the passage 
 of the blood, or by roughening of the pericardial surfaces. 
 
 In the first case they are endocardial. 
 
 In the second case they are exocardial. 
 
 Endocardial murmurs are the result of organic or 
 functional disease, and are due to — 
 
 Obstruction from disease. 
 
 Obstruction from imperfect valvular development. 
 
 Dilatation from pressure, morbid and mechanical. 
 
 Rupture of valves from injury. 
 
 Constitutional conditions causing heemic murmurs. 
 
 Exocardial murmurs are caused by disease affecting 
 the pericardium. 
 
 Endocardial Murmurs. — Obstruct'on generally arises 
 from endocarditis, frequently the result of rheumatism, 
 or more rarely of previous laceration of the valves ; in all 
 cases the growths which are formed on the surfaces of the 
 valves are largely fostered and increased by attrition with 
 the opposite parts of the valve and the blood-stream. 
 
 Obstruction from imperfect valvular mechanism may 
 be a congenital malformation, or as appears very probable 
 it may be due to an arrest in development, or to the 
 prevention of growth from structural peculiarity, whereby 
 the heart fails to meet the requirements of the growing 
 body. 
 
 In such a case the valve, or valves, which is quite 
 adequate for the vital requirements of childhood, becomes 
 quite incapable of conforming to the rapid development 
 of the whole frame, which sometimes takes place with 
 a surprising rapidity, and hence symptoms of cardiac 
 disease become developed during the early period of adult 
 life. 
 
 Dilatation of the heart's cavities, valves, or vessels 
 arises from excessive and prolonged strain — as, for example, 
 running, carrying weights, and those exercises which call 
 into play the muscles of the lower extremities. 
 
 Rupture of valves occurs usually from sudden exertions, 
 
214 SOUNDS OF THE HEART IN DISEASE. 
 
 lifting weights, and momentary strain of an extraordinary- 
 nature. 
 
 Hsemic murmurs are generally found in anaemia, in 
 fevers, and occasionally in endocardial irritation from 
 rheumatism. 
 
 Exocardial murmurs are caused by roughening of the 
 pericardium, the result of rheumatism, and other forms of 
 pericarditis, of cancer, and of tubercle. 
 
 The quality of cardiac murmurs may be expressed in 
 various terms — e.g., 
 
 Soft blowing bellows murmurs (bruit de souffiet). 
 E/Ough grating sawing sounds (bruit de rdjpe de scie). 
 Musical murmurs (bruit de soufflet musical). 
 
 Of these qualities, the first is common, the last rare. 
 
 The important characteristics to note in any particular 
 murmur are — 
 
 1. The time it occupies as regards the beat. 
 
 2. The site at which it is most intense. 
 
 3. The direction in which it i? transmitted. 
 
 1. As regards the period to which a murmur belongs, 
 all endocardial murmurs may be considered as included in 
 the three following : — 
 
 Systolic, formed during the ventricular systole. 
 Diastolic, „ „ „ „ diastole. 
 
 Presystolic, ,, „ „ auricular systole. 
 
 2. As regards the site at which they are heard with the 
 greatest intensity. 
 
 The area for aortic sounds is very extended, and a 
 murmur created at the valves may be heard more or 
 less distinctly over the sternum. The maximum inten- 
 sity is heard in the second right interspace, or over the 
 second right cartilage. It may be heard at the xiphoid 
 cartilage. 
 
 The area for mitral sounds is much more limited, and 
 confined to the position of the apex, from which it seldom 
 travels far. 
 
 The area for pulmonary sounds is a small space in the 
 second left interspace, close to the sternum. 
 
 The area for tricuspid sounds is above the xiphoid 
 
AORTIC SYSTOLIC MURMUR. 215 
 
 cartilage, and, according to mj experience, extends over 
 to the right side of the midsternal line. 
 
 3. As regards the direction in which the sound is trans- 
 mitted, that will be inflnenced in great measure by the 
 direction of the current, but the aortic marmur, whether 
 systolic or diastolic, is usually propagated along the aorta. 
 
 Exocardial murmurs are caused by the action of the 
 heart, and their position, as external to the heart, is the 
 chief point which demands diagnosis. 
 
 Murmurs due to disease of the aortic valves are simple 
 in cause and easily understood; they may therefore be 
 fitly considered first. 
 
 They are due to vegetations, contractions^ or rupture of 
 the aortic valves, and may be systolic or diastolic. 
 
 Aortic Systolic Murmur. — A direct onward murmur 
 produced by narrowing of the aortic orifice is formed 
 during the contraction of the left ventricle. 
 
 It is therefore systolic. 
 
 Site. — This murmur is heard with greatest intensity at 
 the base of the heart over the second right interspace or 
 the second right cartilage. 
 
 Transmission. — It may be traced upwards along the 
 course of the aoi"ta, and sometimes extends for a consider- 
 able distance from its origin. It may be heard in 
 the secondary arteries. 
 
 Causes. — In organic disease it arises from inflammatory 
 contraction and thickening of the aortic valves, from 
 rheumatism or following rupture of the valves, from con- 
 genital malformation, and from aneurismal dilatation 
 above the valves. 
 
 In functional disease it is heard when no permanent 
 alteration of the valves is present, as in ana3mia. 
 
 It may be heard in endocarditis during an early stage 
 of rheumatism. 
 
 This murmur must be looked upon less unfavourably 
 than aortic regurgitation. Aortic obstruction without 
 regurgitation is a rare form of heart disease ; and it must 
 be pointed out that hypertrophy of the ventricle takes 
 place in proportion to the obstruction. 
 
216 SOUNDS OF THE HEART IN DISEASE. 
 
 As a rule this murmur occurs in company witli that 
 of regurgitation, or with an alteration of the second 
 sound, which is either muffled, or feeble, or strongly 
 accentuated with the clack of a stiffened valve. If the 
 presence of aortic aneurism be suspected and the 
 amount of hypertrophy be great, prognosis must be made 
 with caution, and the murmur may be removed from the 
 category of least unfavourable to that of most dangerous. 
 
 The student must bear in mind that, notwithstanding 
 the general rule which may be applied to the aortic direct 
 or systolic murmur, isolated cases occur in which very 
 extensive disease of the aortic valves has been found after 
 death which has been indicated during life by only 
 a direct systolic murmur, and the disease has been 
 tolerated by the patient without ^proportionate symptoms 
 within a short time of death. Cases of this kind will be 
 found recorded by Graves, Stokes, and Peacock. 
 
 iLortic reg-urgitant xnurmur occurs with the second 
 sound of the heart, and is therefore diastolic. It is caused 
 by failure of the valves to stop the back current of the 
 blood, the valves being incompletely blood- tight. In 
 qualit}^ it varies, generally low in pitch and blowing, but 
 it may be loud, hissing, whistling, or musical, and it may 
 be accompanied with thrill. 
 
 Site is not uniform, its maximum intensity is usually 
 over the second right interspace, but it may be heard 
 over a large area, and may be even louder at the apes 
 than the base. 
 
 Transmission. — It has an extensive area through 
 which it is conducted, and it may be heard downwards 
 along the sternum as far as the xiphoid cartilage. It 
 may be heard all over the prgecordial surface or lost at a 
 short distance from the valves. 
 
 Causes. — It is due to permanent patency of the aortic 
 valves, from ossification or ulceration, from rupture, from 
 stretching of the aorta. 
 
 This murmur is a most important one and must be 
 looked upon as always dangerous. It is never functional. 
 
PULMONARY MURMUKS. 217 
 
 and therefore when heard organic alterations are always 
 present, and the liability to sudden death is very great. 
 
 Regurgitation induces dilatation of the heart. 
 
 The murmurs of the pulmonary valves are formed in. 
 the same way as those of the aortic, but they are 
 far less frequent and not so formidable. 
 
 Pulmonary systolic murmur is a direct onward 
 murmur and accompanies the systole. It is therefore a 
 systolic murmur. It is seldom rough or loud. 
 
 Site. — It is more superficial than the aortic murmur, 
 and is most intense at the second left interspace close to 
 the sternum on the left side. 
 
 Transmission. — It takes an upward direction to the 
 left towards the middle of the left clavicle. 
 
 Causes. — In consequence of the freedom from per- 
 manent injury which these valves enjoy in rheumatism 
 and their non-liability to rupture, the results of in- 
 flammatory disease are very rare. The chief causes of 
 this murmur are (if organic and permanent) of congenital 
 origin, the orifice being narrowed. 
 
 But the more frequent causes are inorganic or external. 
 Hsemic murmurs from aneemia and at the end of 
 an attack of rheumatism are common in this artery, and 
 murmurs from pressure or displacement. 
 
 It is common in children (it may be artificially produced 
 by the pressure of the stethoscope) as the result of the 
 pressure of an enlarged gland, and it is by no means 
 infrequent in cirrhosis of the lung with displacement 
 of the heart and contracting phthisis. 
 
 Pulmonary reg^urgitant murmur is extremely rare, 
 and its description need not be attempted. 
 
 One case of the kind was reported by Dr. Wilks, and 
 another has been published by Dr. Begbie. 
 
 A diastolic murmur, not aortic, has been heard at the 
 base of the heart and on the left side in cases of aortic 
 aneurism opening into the pulmonary artery. 
 
 The murmurs just described are sometimes termed 
 basic murmurs, because of their site of maximum intensity. 
 
218 SOUNDS OF THE HEART IN DISEASE. 
 
 We now come to another class, tlie apex mnrmnrs, whicli 
 are more difficult and complicated. 
 
 The student must bear in mind that the auriculo- 
 ventricular valves are closed in the systole of the ventricles, 
 and consequently that a murmur caused by the systolic 
 action of the ventricles drawing blood back through the 
 unclosed mitral or tricuspid valve is a regurgitant mur- 
 mur, although it is systolic. 
 
 mitral regurgitant or systolic murmur is one of the 
 most common murmurs, and is heard during the systole 
 of the ventricles ; it is therefore termed systolic, but, inas- 
 much as it is due to the backward current of the blood 
 through the mitral orifice, it is regurgitant. It is generally 
 soft and blowing in quality, but sometimes musical. 
 
 Site. — The apex of the heart is the situation of this 
 murmur. 
 
 Transmission. — The area of this murmur is sometimes 
 very limited, but it is to be heard conveyed along the ribs 
 to the lower angle of the left scapula. 
 
 Causes. — It is a frequent result of rheumatic endo- 
 carditis, and sometimes (rarely) of rupture, but this 
 murmur may occur without disease of the valve, and it 
 may result from the dilatation of the ventricular wall, 
 or from simple dilatation of the auriculo-ventricular 
 opening. 
 
 Tricuspid regurgitant or systolic murmur is formed 
 in the same way as the mitral regurgitant sound, by 
 the systolic action of the right ventricle forcing the 
 blood through the imperfectly-closed tricuspid valve. 
 
 Site, — This systolic murmur is heard over the xiphoid 
 (ensiform) cartilage and towards the right side. It is 
 seldom heard very high up. It is generally of a blowing 
 character. 
 
 Transmission. — It appears to me to be generally trans > 
 mitted towards the right side, and this especially occurs 
 if the right auricle and ventricle be out of place either from 
 distension or from dislocation. 
 
 Causes, — The principal cause is distension from intra- 
 
MITRAL PRESYSTOLIC MURMUR. 219 
 
 pulmonary pressure, and it is rare to examine fatal cases 
 of prolonged pulmonary disease without finding dilatation 
 of this valve. 
 
 It is found in emphysema, bronchitis, and cirrhosis of 
 the lung, and, according to my experience, is not an infre- 
 quent result of prolonged walking, lifting of weights, &c., 
 as induced by certain occupations. 
 
 IVIitral presystolic or direct murmur is caused by the 
 systolic auricular contraction during the passage of the 
 blood from the left auricle into the right ventricle. It 
 occurs just before the systole, and is never heard unless 
 stenosis or narrov\dng of the mitral valve is present. 
 
 It is often very harsh in quality, and accompanied by 
 thrill. 
 
 Its name, presystolic, was first applied by Gendrin in 
 1841. It precedes and runs up to the first sound of the 
 heart, but it is often difficult to time its exact period as 
 regards the heart beat ; it is necessary, then, to check 
 off the heart beat by putting the finger on the carotid 
 pulse, which occurs with the beat ; the radial being post- 
 poned or felt some time after. It is not a very rare mur- 
 mur, and is always of unfavourable import. 
 
 Site. — This murmur is very circumscribed in area of 
 extension, and is confined to the apex of the heart, not 
 travelling back to the left shoulder-blade as in the case of 
 mitral regurgitation. 
 
 Transmission. — The characteristic condition of this 
 murmur is its non-transmission, the area being very 
 limited. 
 
 Causes. — It is generally produced by rheumatic in- 
 flammation of the valve, leading to agglutination and 
 stiffness ; the result being usually what is known as a 
 button-hole mitral, a small opening in a membranous 
 valve, scarcely admitting the tip of the little finger. 
 
 Besides this there is another condition, the funnel- 
 shaped valve, which is long and contracted, but suggests, 
 not inflammation, but rather imperfect growth, dependent 
 upon congenital malformation. 
 
220 SOUNDS OF THE HEAET IN DISEASE. 
 
 The button-hole mitral is a very dangerous form of 
 heart disease, and the presystolic murmur always serious. 
 
 Tricuspid presystolic murmur has been heard, but it 
 is extremely rare in ordinary practice. 
 
 With regard to the frequency of murmurs, it may be 
 said that murmurs of the left side are common ; of the 
 right side, rare ; as regards single murmurs, the following 
 represents their order of occurrence — regurgitant murmur 
 of the mitral, aortic, and tricuspid, obstructive murmur 
 of the mitral and aortic. 
 
 The relative danger of the different murmurs can only 
 be estimated approximately, and they may be put in the 
 following order : — 
 
 Regurgitant murmurs on the left side are serious, and 
 may be followed by sudden death. 
 
 Obstructive murmur of the mitral valve is also very 
 serious ; of the aorta less dangerous. 
 
 The worst murmurs are no doubt the aortic regurgitant 
 and the mitral presystolic. 
 
 Pericardial Sounds. — The chief and most frequent 
 sounds caused by diseases of the pericardium are those of 
 friction, which are imitated by placing the stethoscope in 
 one hand and rubbing the back of that hand with the 
 finger of the other. 
 
 As a rule these sounds are superficial — that is, they 
 seem to be heard directly under the ear. 
 
 They may accompany the systole and diastole together 
 or singly. 
 
 Moderate pressure generally intensifies them ; strong 
 pressure prevents them. 
 
 They may also have their site altered by change in 
 the position of the patient; this is a very important 
 diagnostic point. The sound sometimes disappears when 
 the patient sits forwards, this probably depending upon 
 the intervention of fluid between the surfaces. 
 
 They are accompanied with fremitus, which can hardly 
 be mistaken for thrill. 
 
 These sounds vary much in intensity, and in slight 
 
CAEDIAC MURMURS. 
 
 221 
 
 degree may only be heard as a slight grazing ; in greater 
 degree they become creaMng, grating, and scratching. 
 
 These sounds are produced by pericarditis, fluid in the 
 pericardium, attrition from intense pressure, tubercle and 
 cancer of the pericardium, which conditions are rare, but 
 which certainly give rise to friction sounds. 
 
 Synopsis of Cakdiac MrRMUES. 
 
 Systolic MuTTnurs. 
 
 Site. 
 
 Transmission. 
 
 Cause. 
 
 Valves 
 Injtired. 
 
 2nd Eight 
 
 Interspace. 
 
 Base. 
 
 Along the Aorta 
 to the Eight. 
 
 Obstruction. 
 
 Aortic. 
 
 2nd Left 
 
 Interspace. 
 
 Base. 
 
 Towards the Left 
 Clayicle. 
 
 Obstruction. 
 
 Pulmonary. 
 
 Apex. 
 
 Left Axilla and 
 Scapula. 
 
 Eegurgitation. 
 
 Mitral. 
 
 LowerStemal 
 Eegion. 
 Apex. 
 
 Eight of Sternum. 
 
 Eegurgitation. 
 
 Tricuspid. 
 
 Diastolic Murmurs. 
 
 2nd Eight 
 
 Interspace. 
 
 Base. 
 
 Down the 
 Sternum. 
 
 Eegurgitation. 
 
 Aortic. 
 
 2nd Left 
 
 Interspace. 
 
 Base. 
 
 Downwards (?) 
 
 Eegurgitation. 
 
 PulmoTiary. 
 
 Fresystolie Murmurs. 
 
 Apex. 
 
 2^ot Transmitted. 
 
 Obstruction. 
 
 Mitral. 
 
 Pneumopericardium is a very rare condition, occurring 
 after perforation of the pericardium, and is recognised 
 
222 SOUNDS OF THE HEART IN DISEASE. 
 
 by a churning splash or gurgling sound with the heart's 
 action. Dr. Stokes describes the sound as a mixture of 
 various attrition murmurs, with a large crepitating and 
 " guggling" sound, while to all these phenomena was 
 a distinct metallic character. 
 
 It is an extremely rare condition. 
 
223 
 
 CHAPTER XXI. 
 
 THE PHYSICAL SIGNS OP CAEDIAC DISEASE. 
 
 Having now described the murmnrs which accompany 
 the heart's sounds from valvular and other diseases, I 
 shall proceed to group together the physical signs which 
 enable us to form a diagnosis on any special form of 
 disease presented to notice, and as in the case of pul- 
 monary signs, so here it will be convenient for reference 
 to adopt the alphabetical order, and conditions will be 
 included which are connected with or bear upon the 
 subject. 
 
 Anaemia. — This condition is easily recognised by in- 
 spection, the pale pearly- white skin not being mistakable, 
 this being the ordinary colour of simple anaemia. 
 
 Angemia perniciosa, however, is generally characterised 
 by a pale primrose colour, sometimes of a very sallow 
 hue. 
 
 Symptozns. — Debility with dyspnoea on exertion, and 
 a tendency to faint. 
 
 Patliolog-y. — Pallor of the organs is the only sign ; the 
 blood having a very scanty proportion of red corpuscles. 
 
 Sigrns. — The murmurs heard in anaemia are generally 
 soft, of a slight blowing quality, sometimes made very 
 harsh and whistling with exertion or excitement. 
 
 They are invariably systolic basic murmurs, and are 
 either heard in the aortic or in the pulmonary area. 
 
 They are accompanied by various murmurs in the 
 jugular veins, and have a tendency to alter. 
 
 The pulse gives no indication of disease. 
 
 Ang^ina pectoris is a disease capable of producing the 
 most acute anguish, terminating in sudden death. 
 
 Symptoms are derived entirely from the description of 
 
224 PHYSICAL SIGNS OF CAKDIAC DISEASE. 
 
 tlie patient; tlie cMef symptom being pain of a most 
 intolerable cbaracter, felt at tbe lower sternal region, with 
 pain referred to tbe middle of the arm and numbness. 
 To tliis is added a sense of impending deatb, due to op- 
 pression and a sense of suffocation, but it is not accom- 
 panied with difficult action of breathing. 
 
 Patbolo^y. — Yarious conditions are associated with 
 these symptoms, flabby dilatation, ossification and 
 rigidity of the coronary arteries, aneurism, and valvular 
 disease ; but, inasmuch as none of these are constantly 
 present, and they are found without angina, the condition 
 appears to be a neurosis (an anaemia it may be) of the 
 cardiac plexus. 
 
 In John Hunter's case the muscular tissue of the 
 heart was very pale, and the coronaiy arteries were con- 
 verted into long rigid tubes. 
 
 Si^ns. — There is no sign special to this disease, and 
 cases occur in which auscultation is quite at fault ; no 
 anomalous sign may be present; still disease may be 
 detected, and the physician must carefully examine for 
 feebleness of pulse, irregularity of action, and especially 
 to the percussion of the upper sternal region for the 
 detection of aneurism. Gairdner is of opinion that small 
 aneurisms very near the heart are more apt to induce 
 angina than larger tumours at a distance. 
 
 Aneurism of the heart is a localised sacculated pouch- 
 ing of a left cavity of the heart. The right cavities are 
 never affected in this manner. ISTo special symptoms 
 or signs can be attributed to them. In some of the cases 
 the condition was only detected after death, in others (22 
 out of 27) palpitation, tumultuous heart action, irregularity 
 of pulse are reported ; and the presence of valvular mur- 
 murs. The condition may occur at a very early age, this 
 beino- due to its connection with rheumatism ; it is usually 
 found as a ] ouch at the apex, varying in size from a nut 
 to a hen's egg, or even larger. Aneurisms of this kind 
 also are found involving tne left auricle and the aortic 
 and m.itral valves. 
 
AORTIC DISEASES. 225 
 
 Aortic Disease (Yalvular). — The diseases whicli affect 
 the aortic valves are known as obstruction and regurgita- 
 tion. 
 
 Aortic obstruction simply, without regurgitation, is 
 not very common, and may be present, even in excessive 
 extent, for a long period without inducing distress. This 
 has indeed occurred when the opening was not larger than 
 a pea. 
 
 Symptoms are due to insufficient filling of the systemic 
 arteries, but it may exist for some time without causing 
 constitutional disturbance, unless the other valves, notably 
 the mitral, give way under pressure. 
 
 Patliologry. — Inflammatory roughening of the valves 
 from rheumatism and chorea ; it also occurs from 
 congenital malformation, the valves being blended to- 
 gether to form a diaphragm or septum, perforated in the 
 middle. Hypertrophy of the left ventricle is an invariable 
 result of this form of disease. 
 
 Si§^ns. — A systolic murmur, heard with greatest inten- 
 sity at the second right interspace, and transmitted along 
 the course of the aorta. 
 
 If hypertrophy of the heart be present to any extent, 
 the apex beat may be thrown down, the impulse excessive, 
 and the sounds generally indistinct. 
 
 The pulse is small, and would be indicated by the 
 sphygmograph with a sloping upstroke and a round top. 
 
 Percussion must define the area of the heart, and dis- 
 cover any extension in size from hypertrophy. A systolic 
 thrill is often present. 
 
 The simple obstruction murmur is not common, and 
 comparatively with other cardiac murmurs deserves a 
 less unfavourable progno-is, but it is frequently associated 
 with the regurgitant murmur, a complication of very grave 
 anxiety. 
 
 The systolic murmur is often heard in cases of anaemia 
 and rheumatic endocarditis, in pericardial effusion and 
 aneurismal or altered conditions of the aorta above the 
 valves from displacement or pressure. 
 
 Q 
 
226 PHYSICAL SIGNS OF CARDFAC DISEASE. 
 
 The diagnosis of organic disease is materially aided by 
 the diagnosis of hypertrophy. 
 
 Aortic Regurgitation. — This is one of the most 
 dreaded diseases of the heart, inasmuch as it leads fre- 
 quently to sudden death. The general symptoms are 
 severe palpitation, induced b}^ the slightest exertion, or 
 by distension of the stomach, dyspnoea on exertion ; the 
 capillaries are evidently scantily filled, and the general 
 complexion is sallow and bloodless. Neuralgia and angina 
 are frequently associated with this disease, together with 
 sleeplessness and much agitation. Dropsy and cyanosis 
 are generally absent. 
 
 Pulse is sudden, abrupt, flipping, or jerking in quality, 
 the beat being immediately followed by a sudden collapse. 
 It has been called a water-hammer pulse ; the sphygmo- 
 graphic upstroke being very high, followed by a rapid fall, 
 the valves not being competent to support the column 
 of blood. 
 
 Pathologry* — It may result from rheumatic ulceration 
 of long standing, or more frequently from calcareous de- 
 generation, and from congenital malformation. In men 
 it is a condition following strain, rupture of one or more 
 of the valves not being uncommon. 
 
 Physical Signs. — A diastolic murmur at or below 
 the level of the aortic valves, heard along the lower part 
 of the sternum, sometimes most intense at the xiphoid 
 cartilage. It is transmitted above the valves to a con- 
 siderable distance. 
 
 This murmur is generally preceded by a systolic 
 murmur. If the diastolic murmur be inaudible in the 
 carotid arteries, it is accompanied by a systolic murmur, 
 heard best in the aortic area. This signifies much ob- 
 struction, less incompetence. 
 
 If, on the contrary, the diastolic murmur be audible in 
 the carotids, it is preceded by a loud systolic murmur 
 there, and this condition indicates much incompetence, 
 little obstruction. (Balfour.) 
 
ASYSTOLE — ATROPHY. 227 
 
 In advanced cases the beat is hypertropMed and dilated, 
 and the mitral valve incompetent. 
 
 The usual result of regurgitation is dilatation, to which 
 may also be added hypertrophy ; so that in this state of 
 the valves an enormous amount of blood is thrown at each 
 impulse into the arteries. Hence the visible pulsation of 
 the arteries of the neck and head, the vessels bounding up 
 under the skin ; the arteries are also lengthened by the 
 action, and hence the term " locomotive pulse." In the 
 brachial and radial arteries the pulse is much increased by 
 raising the arm, and the same effect is produced in the 
 lower arteries by the patient lying down. 
 
 The form of valvular disease is one of the most serious, 
 and is that from which sudden death occurs, and it has 
 been known to take place from the most trivial excite- 
 ment, even from speaking, eating, or walking. 
 
 Asystole is a term which was first suggCvSted by Beau 
 (asystoUe) to indicate the inability of the ventricle to 
 completely close and empty its contents into the aorta. 
 This may occur in cases of valvular disease, but dilata- 
 tion is its most frequent cause ; not only is the cavity 
 increased and the weight to be moved greater (from the 
 greater quantity of the blood received into the enlarged 
 cavity) but the muscle is thin, and less able to cope with 
 its task. 
 
 The physical signs of this impending condition are 
 diminished intensity of heart sound, hampered action, 
 accumulation in the right auricle, with a tricuspid 
 murmur and a feeble wavering pulse. 
 
 Atrophy of the heart is generally a result of wasting 
 disease, and may be found in emaciation after cancer, 
 and some forms of phthisis. As far as the pulmonary 
 disease is concerned, the heart is enlarged and increases 
 in size, but atrophy of the heart appears to be propor- 
 tionate to the emaciation. On looking over my notes of 
 178 fatal cases of phthisis and other chest diseases, I 
 find sixteen in which the heart weighed less than eight 
 ounces and a half, — all, with two exceptions, being 
 
 q2 
 
228 PHYSICAL SIGNS OF CARDIAC DISEASE. 
 
 associated with. pMhisis ; but ont of these sixteen, eleven 
 cases showed signs of amyloid, some of them to a very 
 great extent, the heart weighing from eight oimces and a 
 quarter to five ounces and three-quarters. In the other 
 cases of phthisis the heart weighed nine ounces or over. 
 
 Broncbial compression is sometimes caused by dila- 
 tation of the left auricle. Cases have been recorded 
 (first by King) in which the left bronchus was almost 
 obhterated by such pressui'e. 
 
 In a case reported by Friedreich, a loud humming 
 sound was heard with inspiration and expiration over the 
 whole left side of the chest. 
 
 Cliejme-Stokes respiration is a peculiar form of 
 dyspnoea, first described by Cheyne in 1818, and subse- 
 quently described by Stokes in the following terms : — 
 '•' It consists in the occurrence of a series of inspirations 
 increasing to a maximum, and then declining in force 
 and length until a state of apparent apncea is esta- 
 bhshed. In this condition a patient may remain for such 
 a length of time as to make his attendants believe that 
 he is dead, when a low inspiration, followed by one more 
 decided, marks the commencement of a new ascending 
 and then descending series of inspirations." This form 
 of breathing is found in fatty heart, valvular disease, 
 dilatation, and aortic atheroma. 
 
 Chorea is a disease closely associated with rheumatism, 
 and a frequent cause of inflammatory disease of the heart. 
 Out of 180 cases of acute rheumatism (recorded by 
 Sibson), twenty-one had chorea; fifteen of these had 
 pericarditis ; fourteen had endocarditis ; pericarditis and 
 endocarditis being together present in thirteen. 
 
 Bilatation of the heart is caused by the yielding of 
 weakened walls to excessive pressure, and arises fi-om 
 various debilitating influences, which weaken the muscu- 
 lar tissue of the heart — e.g., angemia, fevers, obesity from 
 pnlmonary obstruction — e.g., emphysema, cirrhosis, kc, 
 from valvular regurgitation, and from prolonged strain. 
 
 Symptoms. — Palpitation and liability to fainting; rapid 
 
DILATATION — EMBOLISM. 229 
 
 action of the heart from trivial emotions and excitement, 
 and hj distension of the stomach. Passive congestion of 
 all the parts supplied, which pour their blood into the 
 dilated cavity, leading to enlarged veins, cyanosis, and 
 dropsy. Congestion of the lungs inducing dyspnoea; 
 congestion of the liver, leading to jaundice and renal 
 congestion with albuminuria. Piles and diarrhoea are 
 frequent symptoms. 
 
 Fatholog-y. — All the heart's chambers (or only some) 
 may be dilated. It is generally accompanied with some 
 increase of the muscular wall. The walls are often 
 flabby, and the tissue pale. The orifices of the heart are 
 also distended. 
 
 Signs. — Percussion shows extended area of dulness, 
 and a circular form is assumed by the heart- The area 
 of dulness has been known to extend as high as the first, 
 as low as the seventh rib. 
 
 Impulse diffused over a large space and weaker than 
 normal ; occasionally causing undulations. Heart's 
 sounds are weakened; the first sound being short and 
 raised in pitch. 
 
 Fulse feeble and quick, especially under exertion. If 
 the amount of dilatation is excessive, and includes the 
 valves to any extent, soft blowing murmurs may be heard 
 and thrills localised according to the valve area. If the 
 tricuspid be much enlarged, which is common enough in 
 pulmonary obstruction, the jugulars become obstructed 
 and pulsate. 
 
 Embolism occurs from the removal of small pieces of 
 fibrin from a ragged or inflamed valve surface, the clot 
 passing away into the blood current and being impacted 
 in some vessel. 
 
 As regards the heart, this condition occurs from 
 disease of the mitral or aortic valves and the embolus 
 may pass into the lungs by the bronchial arteries and 
 into the brain by the cerebral arteries, giving rise in the 
 latter case to right hemiplegia with or without aphasia. 
 
 Patbologyc — Wedge-shaped blocks are formed in any 
 
230 PHYSICAL SIGNS OF CARDIAC DISEASE. 
 
 organ wliose blood-supply is tlms plugged. Wlien an 
 artery of the extremity is occluded gangrene foUows. 
 
 Fatty deg-eneration of tlie beart results from fatty 
 alteration of its muscular fibre. Tbe most frequent causes 
 of this disease are old age, alcoholism, gout, and wasting 
 diseases of all kinds. 
 
 Symptoms. — Syncope, vertigo, and dyspnoea are the 
 most common. As regards respiration it is in this form 
 of cardiac disease that the Cheyne-Stokes dyspnoea occurs- 
 
 Surface pale and sallow, disposition to melancholy, and 
 great indisposition to exertion of any kind. 
 
 Patbolog-y. — The muscular tissue of the heart is pale, 
 flabby, and soft, sometimes so friable and greasy that the 
 finger can go through it with very Httle pressure. Under 
 the microscope fat globules are seen in abundance filling 
 the muscular fibres. Sometimes the muscles are pale 
 and streaky, resembling the markings on a partridge's 
 breast. 
 
 Signs, — Percussion gives no indication. Impulse weak 
 and often indistinct, a feeble, very dull short first sound, 
 and a feeble but accentuated second sound are the chief 
 signs that indicate this important lesion. 
 
 Pulse very small, compressible, and feeble; often 
 irregular. 
 
 This is a dangerous condition, as it leads in many cases 
 to sudden death by syncope, or (rarely) by rupture of a 
 ventricle and oozing of the blood into the pericardium. 
 
 Foramen Ovale open is a condition leading to admix- 
 ture of the blood in the right and left sides of the heart. It 
 is a cause of cyanosis or morbus ceeruleus, but unless the 
 valve be permanently open this condition does not arise. 
 
 Symptoms. — Blueness of surface more or less marked, 
 the hue being of a mulberry colour, especially marked in 
 the extremities and Hps, and increased by cold. 
 
 Signs. — ^A double murmur, of a soft blowing quality, 
 loudest at the base of the heart, and heard half-way 
 down, but inaudible at the apex. The pulse gives no 
 indication. 
 
F(ETAL heart — GOUT — HYPERTROPHY. 231 
 
 Foetal Heart is rarely heard before the fifth month 
 It may be heard like the indistinct ticking of a watch ; 
 generally it is best heard between the fifth and sixth 
 month. The site over which it is heard is variable, 
 according to the position of the foetus, generally on the 
 left side, sometimes in the umbilical region, sometimes 
 in the right side. The number of pulsations ranges 
 from 120 to 180. 
 
 The placental murmur is variable in character, and 
 resembles the sounds produced by pressure on a large 
 vessel. It occurs first usually at the fourth month. It 
 has no special situation. 
 
 Gout leads to irregular and feeble action of the heart, 
 often of a spasmodic kind, associated with dyspepsia, 
 fatty degeneration of the heart, and disease of the liver 
 and kidneys. 
 
 Intermittence of heart's action, paroxysms of pain with 
 symptoms of angina and occasionally sudden death are 
 the result of the degenerative changes in the heart and 
 vessels from gout. 
 
 Irritable asthma and a peculiar form of bronchitis are 
 also caused by gout, and if the diathesis be not recognised 
 and the proper remedies exhibited the disease may persist 
 for some time. 
 
 Hypertropby of the heart is the result of healthy re- 
 action against stress of work, increased work demanding 
 increased growth. It results from valvular disease, espe- 
 cially aortic obstruction, from kidney disease as a result of 
 obstruction in the arterioles, consequent upon a diseased 
 state of their walls and in pulmonary obstruction. 
 
 Symptoms from hypertrophy alone are by no means 
 marked, and those generally given are derived from the 
 primary cause, or result from hypertrophy and dilatation 
 combined. 
 
 Patholog^y. — Great enlargement, thickening and hard- 
 ness of the muscular walls of the breast, so that a heart 
 may weigh twenty-four ounces. 
 
 In renal disease the hypertrophy is confined to the 
 
232 PHYSICAL SIGNS OF CAEDIAC DISEASE. 
 
 left ventricle, tlie right side sharing very little in the 
 increase. 
 
 Sigrns. — Inspection shows often a bulging of the 
 prgecordial wall, but chiefly in early life. Palpation detects 
 a very forcible and heaving action of the apex stroke due 
 to the fact that an extended area of ventricle delivers the 
 stroke, also with increased force. Percussion marks out 
 by dulness an increased area, sometimes as low as the 
 seventh left interspace. This area of dulness may be found 
 behind ; the heart, pressing upon the lung, preventing 
 resjDiration, and thus pleuritic effusion may be simulated. 
 
 The sounds of the heart are altered, the first sound 
 being dulled but prolonged, the second sound is generally 
 loud. Reduplication of the first sound is also met with 
 occasionally. 
 
 Pulse : full, hard, prolonged. 
 
 Bydropericardium, or dropsy of the pericardial sac, 
 occurs as a sequence of general dropsies, or is the result 
 of pressure upon the pericardial veins from aneurism or 
 tumour. 
 
 The symptoms are discomfort and a sense of weight in 
 the region of the heart, with dyspncea and feeble pulse. 
 The physical signs are those of effusion into the pericar- 
 dium described below. 
 
 Mitral diseases are regurgitant or obstructive, the 
 former arising from imperfect closing of the valve, the 
 latter from narrowing of the orifice. 
 
 mitral regurgritation may follow dilatation of the 
 orifice from extreme pressure, from prolonged exertion, or 
 it may be a result of endocarditis from rheumatism or 
 chorea. 
 
 Symptoms are those due to pulmonary obstruction : 
 dyspnoea in exertion being the most constant. Patients 
 suffering from this form of heart disease may, if careful, 
 enjoy fair health, but eventually dropsy, oedema of the 
 lungs, obstruction of the liver follow, with cyanosis and 
 general anasarca. 
 
 Patbologry, — Imperfect closing of the mitral valve, 
 
MITRAL REGURGITATION AND OBSTRUCTION. 23^ 
 
 wHch may be demonstrated after death hj the putting a 
 ligature round the aorta, cutting off the left apex, and 
 pouring a stream of water upon the ventricular surface 
 of the mitral valve. 
 
 Dilated hypertrophy is the common result of this con- 
 dition. 
 
 Sigrns. — Palpation, detects irregularity of rhythm and 
 impulse. Percussion shows extension of area in propor- 
 tion to the hypertrophy. 
 
 Auscultation detects a systolic niurmur at the apex. 
 It is not extended upwards towards the base, but may be 
 heard in the left axilla and at the angle of the left 
 scapula. 
 
 \Yith this sound is generally associated a marked inten- 
 sity of the pulmonary second sound, heard over the 
 second left interspace. 
 
 Pulse generally small, running, easily compressible, and 
 irregular. 
 
 Mitral regurgitation is a frequent result of rheumatism, 
 to which this form of heart disease is usually to be traced. 
 It is difficult to give an opinion with regard to the rela- 
 tive duration of life in such disease, but patients may 
 have a murmur indicating regurgitation, and show no 
 general symptoms for years, and I believe with care, time, 
 treatment, and rest, the murmur may diminish, and the 
 heart recover. 
 
 I have had cases under my care in which the murmur 
 was due to severe strain or prolonged exertion, and after 
 treatment with iron, and rest, the heart has recovered and 
 lost its murmur. 
 
 Mitral Obstruction. — This condition results in palpita- 
 tion and dyspnoea, the symptoms from pulmonary con- 
 gestion being marked, and oedema and dropsy being the 
 ordinary sequelae of this form of heart disease. 
 
 Symptoms. — The general appearance indicating 
 mitral obstruction is peculiar : a flushed hectic colour of 
 the cheeks, with or without cyanosis, and there is 
 frequent oedema, or general dropsy. 
 
234 PHYSICAL SIGNS 01 CARDIAC DISEASE. 
 
 The effect on tlie lungs is shown by congestion and 
 pulmonary apoplexies. 
 
 Pulse. — Small and running, weakened and irregular, 
 often intermittent. 
 
 Patholog^y. — This is the frequent result of rheumatism. 
 It may also be caused by endocarditis after laceration, 
 and it would seem to result from a congenital imperfec- 
 tion, the valve remaining of small size in spite of the 
 general growth of the body. 
 
 The worst form of mitral stenosis, or obstruction, is 
 that in which a button-hole opening, scarcely admitting 
 the tip of the little finger, is found in a membranous 
 diaphragm stretched across the valvular orifice. This is the 
 condition which gives rise to the presystolic murmur, and 
 is the most dangerous of mitral diseases, ranking nest to 
 aortic regurgitation in fatality. Another form is the 
 funnel-shaped opening, often of small size. 
 
 Besides this, vegetations may occur on the auricular 
 surface of valve, or on the free fiap on the ventricle. From 
 strain, one or two of the strings which hold the valve 
 down, give way, and may be found loose from their 
 attachment. 
 
 Piiysical Signs. — A murmur heard over the mitral area 
 at the apex, just preceding the systolic sound. This is 
 called the presystolic murmur. It follows the diastolic 
 sound, and runs up to the systolic. 
 
 The diagnosis is to be made sometimes only by placing 
 the finger on the carotid pulse. 
 
 It is often accompanied with a purring thrill or vibra- 
 tion, distinctly perceptible on placing the fingers over the 
 apex : and a heavy impulse or thump of the apex. 
 
 This murmur is, however, very apt to disappear, and the 
 student must not be deceived with regard to the presence 
 of mitral disease because there is no murmur. In the 
 worst conditions of the mitral, and when the heart is 
 most embarrassed, the murmur may be absent ; the apex 
 beat is very irregular, often thumping and intermittent, 
 the general condition, and especially the character of the 
 pulse, indicating great danger. 
 
MYOCARDITIS — MORBUS C-ffiRULEUS. 235 
 
 It is general to find in mitral stenosis pulsation on the 
 third interspace, due to tlie condition of tlie left anricle, 
 and a systolic murmnr is sometimes lieard in this region. 
 
 Myocarditis, inflammation of the muscular tissue of 
 the heart, a result of rheumatism as an extension of peri- 
 carditis, and of pygemia. 
 
 Symptoms. — Dyspnoea, debility of heart action, vomit- 
 ing, collapse, with delirium and coma. The average 
 duration (according to Friedreich) is four days, so that the 
 disease runs a very rapid course. 
 
 Pathology. — Muscular tissue of the heart is inflamed, 
 swollen, and softened. It becomes grey and yellowish, 
 breaking down under the formation of minute abscesses. 
 
 Signs are very indistinct : impulse of the heart weak, 
 and a systolic murmur has been noted; the first 
 sound of the heart being dull and feeble. Pulse frequent, 
 weak, and irregular. 
 
 The diagnosis depends upon the presence of acute 
 symptoms indicating sudden collapse of heart power. 
 
 Morbus Cseruleus, or the blue disease, is recognised on 
 inspection by the deep mulberry tint of the surface of the 
 patient. It is due to malformation of the heart or trans- 
 position of vessels, modifying the usual distribution of 
 arterial and venous blood. 
 
 Symptoms. — Purple discoloration of the skin, more 
 intense with palpation, dyspnoea, and, especially in cold 
 weather, bulbous fingers. Cough and bronchial congestion 
 are common. 
 
 Pathology. — Open foramen ovale; defective septum 
 between the ventricles ; pervious ductus arteriosus ; irre- 
 gular distribution of the aorta and pulmonary arteries ; 
 the aorta arising from the right ventricle, or from both 
 ventricles. 
 
 Signs, — In those cases which have come under my 
 
 observation I have detected a soft purring murmur below 
 
 the base. Walshe states that systolic basic thrill and 
 
 murmur are to be heard over the pulmonary area. 
 
 Pericardial Diseases. — Pericarditis is an inflammation 
 
236 PHYSICAL SIGNS OF CAKDIAC DISEASE. 
 
 of the pericardial sac associated with acute rhLeumatism, 
 jDysemia, and disease of the kidneys ; or it may be a resnlt 
 of the presence of aneurism or tumour. 
 
 Symptoms. — Pain is a characteristic symptom (occur- 
 ring in 70 per cent, of Sibson's cases), but it may be absent. 
 Tenderness is present, and pressure in the epigastrium 
 causes distress. 
 
 The usual position assumed by the patient, according 
 to my experience, is the supine (on the back), the sh.o alders 
 being low, but the head raised high, at an angle with the 
 line of the body, 
 
 Patbolog-y. — The ordinary and well-known signs of 
 inflammation of a serous membrane are observed : injec- 
 tion of the vessels on the surface ; fibrinous exudation 
 followed by eSusion of serous fluid into the sac. 
 
 Si^ns. — The preliminary sign of the onset of pericar- 
 ditis is exhibited in a state of excitement in the heart's 
 action, turbulent impulse, irregular rhythm, reduplication 
 of sounds and rapid pulse, accompanied by pain and 
 tenderness in some cases. 
 
 A friction murmur, which may be single and systolic or 
 double, may be the prelude to the friction-rubbing sound. 
 This sound is distinguished by being increased by pressure, 
 and is heard in the lower sternal region and the cor- 
 responding left side between the third and the fifth ribs. 
 
 The true friction rub (to-and-fro) is subsequently deve- 
 loped, sometimes in a very short time, lasting occasionally 
 for a short period, being then lost by effusion, although 
 this is not the rule. This rubbing sound is superficial, 
 harsh, and of a to-and-fro quality, with or without thrill. 
 As a rule the friction sound is at first limited to the 
 position and surface of the right ventricle ; but as the 
 disease progresses it extends to the left side, and the 
 friction sound is heard over the apex. It may also extend 
 to the large vessels, and be heard under the manubrium 
 sterni, and over the right auricle. Thrill, when felt, is 
 generally present in the second left interspace, or over 
 the apex. 
 
PEEICARDIAL EFFUSION. 
 
 237 
 
 Effusion into the pericardium is detected chiefly by 
 percussion. Tlie fluid effused finds its level under tlie 
 force of gravity, and falls to the lower portion of the sac ; 
 as it increases it depresses this portion, and forces the 
 heart upwards, the sac being gradually enlarged on either 
 side, before and behind, pushing the diaphragm and the 
 abdominal organ downwards and the lungs on one side. 
 The accompanying diagram, from one of Pirogoff's frozen 
 sections, will show what takes place. 
 
 Fig. 23. 
 STER MUM 
 
 FLUID IN 
 PERICARD. 
 
 HEART 
 
 R.LUNCi 
 
 Transverse Section in a case of Pericardial Effusion. (Pirogoff.) ' 
 
 The effusion increasing, the lower part of the sac extends 
 on either side, and the whole form of the pericardium is 
 pear-shaped, the stalk end being above ; and the area of 
 dulness extends across the front part of the chest from 
 the sixth right cartilage to the sixth left, and the 
 fifth right interspace should be examined carefully and 
 frequently where pericarditis is suspected. The heart is 
 thrown to the top of the fluid, and is sometimes raised 
 very high, the impulse being felt as high as the second 
 interspace, the apex reaching the fourth rib. 
 
238 PHYSICAL SIGNS OF CARDIAC DISEASE. 
 
 The usual course is about eight or ten days from the 
 beginning to the end of the effusion. 
 
 As the fluid is absorbed the heart regains its normal posi- 
 tion, and the rub of pericarditis, usually on the return of the 
 sound, grating and harsh, is again heard over the surface. 
 
 When the effusion is great the area of dulness may 
 extend over the anterior surface of the chest, from the 
 clavicle to the ninth right and left cartilages. (Sibson.) 
 
 Pericardial adbesion, to a limited extent, cannot be 
 detected; but if the adhesions are extensive, as, for example, 
 when they completely envelop the whole surface of the 
 heart, the following signs may be looked for : — 
 
 Sigrns. — Retraction of the intercostal spaces over the 
 heart, followed by a diastolic shock or back-stroke. Area 
 dulness not diminished, and especially no alteration in 
 this sign, nor in the impulse when the patient assumes 
 a different position. The action and impulse are some- 
 times feeble, and generally tumultuous, hampered and 
 irregular, and in some cases violent action has been 
 observed over all the front part of the chest. 
 
 These are signs which have been noticed in cases of 
 adherent pericardium, but the condition is difficult to 
 diagnose. 
 
 Pneumopericardium. — The presence of air in the peri- 
 cardium is recognised by a churning or gurgling splash, 
 and has been noticed in perforation of the pericardium 
 from artificial puncture (paracentesis pericardii), accidental 
 puncture of the oesophagus from a juggler's knife, trau- 
 matic injury, fistulous opening from hepatic abscess, com- 
 munication with a pulmonary cavity and cancerous 
 ulceration. 
 
 The condition is extremely rare, but the signs are always 
 described as peculiar and striking. 
 
 Tubercle and cancerous nodules may affect the peri- 
 cardium secondary to a general infection, and give rise 
 to rough friction sounds. Cancer, according to my expe- 
 rience, may give rise to extremely rough to-and-fro sounds. 
 
 Pulmonary obstruction gives rise to systolic 
 
PYEMIA — RHEUMATISM — EUPTURE. 239 
 
 imirmur, and this murmur is heard not infrequently from 
 pressure or traction upon the artery ; it is frequent with 
 adherent pleura and cirrhosis of the lung or contracting 
 phthisis, and is not uncommon in children from enlarged 
 glands pressing upon the artery. It also occurs from 
 congenital malformation. 
 
 Sig-n. — A systolic murmur over the second left inter- 
 space, transmitted upwards towards the middle of the 
 left clavicle in the direction of the vessel. 
 
 Pulmonary re^urg-itation is a very rare disease. 
 One case has been reported by Dr. Wilks; in this a 
 double bruit was heard, more distinct on the left side ; 
 the pulse of aortic regurgitation being absent. 
 
 Pyaemia may cause pericarditis and endocarditis ; 
 and abscess of the septum has been found in rare cases. 
 
 Rbeumatism is one of the most frequent causes of 
 heart disease, endocardial and exocardial, in this country, 
 but it is necessary to point out that rheumatism is absent 
 in many cases, and inflammatory agglutinations of the 
 valves may follow other diseases. From my own esperi- 
 ence, I believe that diseases from injury are numerous, 
 more so than is the general opinion. 
 
 Pericarditis occurs in about twenty per cent, of cases of 
 acute rheumatism ; coming on with the onset of the 
 disease, and generally at the end of the first week; but it 
 may be postponed until three weeks, or even more. 
 Effusion progresses for three days after the mitral 
 symptoms, and in eight days afterwards declines, giving 
 altogether twelve days for the stage of effusion. These 
 data are taken from Sibson's elaborate paper in "Reynold's 
 System of Medicine." As regards the frequency with 
 which the valves are attacked, the same observer gives 
 the following data: — In 107 cases of endocarditis (out of a 
 grand total of 325 cases of acute rheumatism) fifty-seven 
 had mitral murmur, thirteen had tricuspid murmur, ten 
 aortic, and nine mitral and aortic combined. 
 
 Rupture of the lieart is a consequence of fatty 
 disease, especially partial or localised, so as to produce 
 
240 PHYSICAL SIGNS OF CARDIAC DISEASE. 
 
 weakening of limited areas. It occurs in old age, gene- 
 rally above sixty ; and the rupture has been induced by 
 slight exertion, even by straining at stool. 
 
 Symptoms. — Intense and sudden pain in the praecordial 
 region, with collapse and faintness, followed by very 
 speedy death. Yomiting is an occasional symptom, and 
 also diarrhoea. Patients have lived forty-eight hours 
 after the rupture, and even as long as a week. 
 
 Pathology. — The pericardium is found full of clot, and 
 a rent is seen on the surface of the heart, generally 
 single, but sometimes more than one ; most frequently 
 on the anterior wall not far from the apex. The left 
 ventricle is usually the part ruptured, but the right 
 auricle and right ventricle may suffer. 
 
 Sigrns. — Death is so sudden that examination during 
 life can seldom be made. Extended area of percussion 
 dulness, and the absence of palpable impulse are the chief 
 signs. 
 
 Rupture of valves is due to overstrain from excessive 
 muscular action. 
 
 Strain upon the heart is induced in three ways. It 
 may result from sudden momentary exertion, as the 
 lifting of weights, jumping, or the like, in which the 
 upper muscles of the thorax are called into play ; or from 
 prolonged continued action of the lower muscles of the 
 trunk, as in walking and running; or from the com- 
 bined action of all the trunk muscles, as in walking or 
 running with heavy loads. 
 
 In the first case, the valves of the heart may give 
 way and rupture from their attachment ; the aortic valves 
 being most frequently torn ; the mitral valve suffering 
 next in frequency, and the tricuspid the least often. 
 
 The symptoms are severe and sudden, and the patient 
 is generally aware of something having given way ; pain 
 at the heart is generally severe, extending to the spine 
 and shoulders ; syncope is the chief symptom when the 
 aortic valves are torn, suffocation and oppression, in 
 rupture of the mitral valve ; hemoptysis may occur soon 
 after the injury. 
 
TRICUSPID MURMURS. 241 
 
 Sig-ns. — A loud double murmur, with occasionally a 
 flapping sound over the area of the valves affected. 
 
 Prolonged exertion of walking or lifting may lead to 
 strain upon the cavities of the heart, producing dilatation 
 of a very marked character of all or only of some. 
 
 Two fatal cases of the kind have come under my 
 observation, the symptoms of which were very peculiar, 
 the pain being referred to the lower part of the body, the 
 patients being collapsed, cold, and with blue extremities. 
 Blood- spitting was present to some extent. 
 
 In these cases the signs were due to dilatation, and soft 
 double purring murmurs with thrills were heard over the 
 heart's area, which were transmitted along the aorta, 
 into the axilla, and to the right of the sternum. Cases of 
 a similar kind have come under examination, occurring 
 especially in hammermen or men engaged in foundry 
 work ; the right side of the heart in these cases being 
 extremely prone to dilatation. With complete rest and 
 tonic treatment the heart recovers and the murmurs go. 
 
 Aneurism is another condition which results from 
 exertion, to be described in the next chapter. 
 
 Tricuspid I^uriuurs are those due to obstruction or re- 
 gurgitation — the result of endocarditis, or more frequently 
 of dilatation from pressure. The area of murmur is at 
 the lower sternal region and towards the right. 
 
 Tricuspid Reg^urgitant or Systolic murmur is by 
 no means rare, and is a sequela of pulmonary pressure, 
 whether it be from disease of the lungs or from regurgi- 
 tant disease of the mitral valve. Among diseases of 
 the lung, emphysema, chronic bronchitis, cirrhosis, and 
 fibroid disease of the lung may be considered as special 
 causes of this murmur. Thrombosis and embolism also 
 produce great strain upon the valve, with marked venous 
 regurgitation. 
 
 Tricuspid Cbstruction from stenosis of the valve is a 
 rare disease. Dr. Hayden has recorded a case in which a 
 presystolic murmur was heard in the fourth intercostal 
 space close to the left side of the sternum. 
 
 E 
 
242 PHYSICAL SIGNS OF CARDIAC DISEASE. 
 
 Dilatation and obstruction of this valve produces 
 great stasis of the venous system, throwing a large 
 quantity of blood on to the abdominal organs, a condition 
 likely to lead to dropsy. 
 
 Venous Enlargrement must raise a suspicion of thoracic 
 tumour, especially when local. In women the condition 
 accompanies lactation. 
 
 Venous lium {bruit de diahle) is a continuous murmur, 
 not unlike the noise proceeding from a shell placed 
 to the ear, heard generally in the jugulars under con- 
 ditions of ancemia, but extending also to other veins, 
 for example, the femoral. Their mode of formation has 
 been explained already, and care must be taken not 
 to produce murmurs artificially by the pressure of the 
 stethoscope. 
 
 They vary in quality and intensity, according to the 
 action of the heart. 
 
 Venous Pulsation indicates regurgitation through the 
 tricuspid or pressure from tumour and aneurism. It 
 occurs in most marked form when the obstruction to the 
 pulmonary circulation is great, and is a characteristic 
 sign of thrombosis and embolism. 
 
243 
 
 PHYSICAL SIGXS OF DISEASES OF 
 THE AOETA. 
 
 CHAPTEE XXII. 
 
 CLmiCAL AlfATOMY OF THE AORTA. 
 
 The aorta, tlie great vessel of the systemic circulation, 
 rises from the base of the heart in continuation with the 
 conus arteriosus of the left ventricle, its orifice being 
 guarded by three sigmoid valves. Opposite to each flap 
 the root of the aorta bulges outward, the three dilatations 
 being known as the sinuses of Valsalva. The pulmonary 
 artery is at first in front of the aorta, but afterwards it 
 passes to its left side. In its course upwards the aorta 
 bends over to the left side, forming the arch of the aorta, 
 which is divided into three portions, — the ascending, 
 transverse, and descending parts of the arch. 
 
 The trachea, oesophagus, and thoracic duct, lie behind it : 
 while it arches over the left bronchus and the pulmonary 
 artery : the left recurrent laryngeal nerve doubles round 
 its under surface, passing behind it to form a loop. 
 
 The upper convex portion of the arch gives rise to the 
 innominate, left carotid, and left subclavian arteries. It 
 first touches the spine between the fourth and fifth dorsal 
 vertebra : it then descends along the left side of the spinal 
 column, passing through the opening of the diaphragm. 
 The thoracic duet, the greater vena azygos, and the 
 oesophagus (at first) are to the right side, but the oeso- 
 phagus crosses over to the left in front, and is on the left 
 side just above the diaphragm. 
 
 k2 
 
244 CLINICAL ANATOMY OF THE AORTA. 
 
 The topograpliical anatomy of the aorta has already 
 been given at page 10 : but some acconnt of the abnormal 
 conditions which are fi-equently found affecting the 
 position and distribution of the arch and the secondary 
 arteries, is important with reference to the diagnosis of 
 anenrism. 
 
 Fig. 26. 
 
 R.SECUR.LABITNCN. 
 
 R. VAC US 
 
 U.RECUR.N, 
 
 L .VAC US 
 
 U.SDBCL.A^ 
 
 The Arch of the Aorta with yeighboui'ino: Parts. 
 
 The arch may vary in size and position : it may reach 
 as high as the top of the sternum, or may arch very low 
 down, and be much reduced in size. 
 
 Lately, I examined a remarkable instance of the latter 
 condition with diminished circulation of the left side. 
 The patient had suffered from laryngitis and enlarged 
 
VARIATIONS OF THE AORTA. 245 
 
 gland: and the signs, consequently, closely simulated 
 those of aneurism. 
 
 The aorta and the pulmonary artery may be transposed 
 at their origin, so that the aorta circulates venous blood : 
 an occasional cause of morbus cseruleus; or there may be 
 intercommunication between the two, or both may be 
 blended together in one stem. 
 
 The variations regarding the vessels springing from the 
 arch are very numerous : for example, there may be one, 
 or as many as six. 
 
 A common variety is the junction of the two left 
 arteries into one, so that a right and left innominate are 
 given off. 
 
 When four vessels are given off the commonest addition 
 is due to the interposition of a left vertebral artery : the 
 condition in which there are two pairs, right and left, of 
 carotid and subclavian vessels, is rare. 
 
246 
 
 CHAPTEE XXIII. 
 
 DISEASES OE THE AOHTA. 
 
 The diseases to which, the aorta is liable are those result- 
 ing frora arteritis of an acute or chronic nature. These 
 are, thickening of the walls, a condition to which the term 
 endo-arteritis deformans has been given, and a degenera- 
 tion commencing in the inner coat of the artery termed 
 atheroma, leading to ossification. It is with the latter 
 condition that we are at present concerned, as the cause 
 of those saccular expansions communicating with an 
 artery, which are called aneurisms. They may be con- 
 sidered under two forms : as dilatations of limited portions 
 of the vessel, the fusiform or cylindrical aneurism, or as 
 sacculated pouches, given off from one side of the vessel, to 
 which the name saccular aneurism is given. 
 
 Mechanical strain is no doubt the chief cause of these 
 sacs : women are very rarely the subjects of aneurism, 
 men are very liable, especially those who are subjected to 
 great exertion and labour in their trades and occupations : 
 and aneurisms occur at the period of life at which men are 
 most active in exertion, and in frames of body which are 
 remarkable for a robust and muscular development ; and 
 when a man in the prime of life, of vigorous strength and 
 robust build, presents himself for examination with a 
 history of cardiac and pulmonary symptoms, suspicion of 
 aneurism should be at once present to the mind of the 
 examiner. 
 
 Symptoms. — These are often very obscure, and depend 
 chiefly upon the amount of pressure upon the adjacent 
 organs and nerves. 
 
 The most frequent indications of pressure are derived 
 
SYMPTOMS OF ANEURISM. 247 
 
 from the presence of dyspnoea, sometimes very severe, 
 often spasmodic. Palpitation on exertion, inability to 
 walk far without a feeling of being ready to drop, point 
 to distress in the circulation. 
 
 Pain in the chest is felt over the aneurism, or in the 
 neck and arms, in the sternum, and sometimes in the 
 spine. 
 
 ]Laryngreal Symptoms are extremely important and 
 distinct. A high-pitched raucous clanging cough and 
 voice are characteristic of pressure, and often present in 
 aneurism ; but it must be pointed out that a very small 
 tumour from the under-surface of the arch (where the 
 recurrent nerve hooks round it) is sufficient to cause the 
 symptom, and laryngeal stridor and spasmodic dyspnoea 
 of a severe nature may be present without other signs, 
 indicating aneurism, Gairdner relates an instructive 
 case in which such a condition arose from a small 
 aneurism of the innominate pressing on the right re- 
 current nerve. Complete aphonia may be present. 
 
 .fiLstlimatic attacks of breathing may occur without 
 laryngeal complications, from pressure on the left bron- 
 chus. 
 
 Haemoptysis is not uncommon, although it generally 
 occurs in specks and streaks, and may be overlooked. If 
 in large quantities, the blood may come from direct com- 
 munication of the sac with the air passages, and death 
 may be preceded by copious gushes of blood from the 
 mouth. 
 
 Byspbagia occurs from the pressure of the tumour on 
 the oesophagus. 
 
 Alteration of the pupil, consisting in contraction of 
 the pupil of the affected side, and immobility under altered 
 conditions of light have been observed in many cases. 
 Dilatation occurs in rare cases. 
 
 Ortbopnoea is the position generally assumed by the 
 patient, the exact attitude maintained being that which 
 will enable the force of gravity to aid in the removal of 
 pressure from the parts principally affected. 
 
248 DISEASES OF THE AORTA. 
 
 Gairdner lias ably summarised the symptoms in 
 aneurism, and the following is a, precis of his remarks : — 
 
 1. When angina pectoris is present, the aneurism is 
 probably situated in the ascending portion, near the 
 cardiac plexus. 
 
 2. When laryngeal symptoms are present, the right or 
 left recurrent nerve is involved from a sac in the innomi- 
 nate, or on the posterior and inferior part of the arch. 
 
 3. Bronchial asthma and orthopnoea indicate pressure 
 of the pulmonary plexus of nerves from the descending 
 part of the arch. 
 
 4. Alterations of the pupil are due to pressure upon 
 the sympathetic from the upper and back part of the 
 arch, or its branches. 
 
 5. Dysphagia is a result of pressure on the oesophagus 
 or the pneumogastric nerve. 
 
 Sigrns. — Inspection detects local bulging and protru- 
 sion of the manubrium, the sternal fossa being deep and 
 well marked. 
 
 The positions of bulging are the right infraclavicular 
 region close to the sternum, the left infraclavicular and 
 mammary regions, the upper sternal and the infraclavi- 
 cular region, on both sides ; sometimes the bulging 
 (when the sac has made its way through the chest wall) 
 is enormous. 
 
 Palpation detects pulsation, a very important sign of 
 vascular tumour ; a little behind the apex beat, the im- 
 pulse of which is occasionally intense, with a heaving or 
 pushing character, and a hard solid feel if there be much 
 coagulum in the sac. 
 
 Tbrill may be transmitted to the touch, due to the 
 rippling current of blood in the sac. It is more common 
 in fusiform dilatations than in sacculated aneurisms, 
 sometimes it is only found in the most prominent part of 
 the tumour, and it may be present at one time and dis- 
 appear at another. 
 
 Percussion gives the earliest indication of arterial 
 enlargement, and the region in which this is detected 
 
SIGNS OP ANEURISM. 249 
 
 depends upon the locality of tlie aneurism, and the 
 part should be carefully examined by cross percns- 
 sion, that is, by placing the finger of the left hand 
 parallel to the sternum, and percussing from the right 
 nipple-line to the left side ; a circumscribed patch of 
 percussion will be found at the second right interspace if 
 the aueurism is situated in the ascending arth, or in 
 the first if it should be in the innominate artery. 
 
 If the aneurism is situated under the sternum, the 
 percussion note is more difficult to distinguish. 
 
 If it is in the descending part of the arch the left inter- 
 scapular region should be carefully searched, and especially 
 the part opposite the fourth dorsal vertebra. 
 
 Sometimes the dulness is found lower down, between 
 the eighth and tenth dorsal vertebraB. 
 
 Percussion occg^sionally fails to establish the presence 
 of aneurism. 
 
 Auscultation. — When the ear is applied over the seat 
 of aneurism the result may be to show — 
 
 1. That there are no sounds at all. 
 
 The sac maybe silent, a condition which is by no means 
 uncommon, especially in sacculated aneurisms in the form 
 of blind pouches, given off from different parts of the arch. 
 
 2, That there is a double sound, 
 
 a double murmur, 
 
 a systolic murmur with diastolic sound, 
 a diastolic murmur with systolic sound. 
 These sounds are due to aneurism uncomplicated with 
 disease of the aortic valve. 
 
 As far as I know there is no practical point to be 
 obtained from these diff'erent sounds, which vary from 
 posture and other considerations. 
 
 As a rule I would say that noisy double sounds with 
 free expansile pulsation are due to dilatation without 
 coagulum. 
 
 Pulsations with thudding impulse and sounds only, or 
 no sounds at all, are due to sacculated aneurisms fiUed 
 with coagulum. 
 
250 DISEASES OP THE AORTA. 
 
 The exact location of an aneurism must be made by a 
 careful consideration of tlie parts affected, by the position 
 of the aneurism, and the careful investigation of the 
 several pulses. 
 
 The secondary condition of the heart, resulting from 
 aneurism, forms an important point in the group of 
 physical signs. In early conditions, when pressure upon 
 the aortic valves is marked, the second sound over the 
 valves may be very accentuated, sharp and clacking ; 
 but this is not an invariable rule, and in some advanced 
 cases the heart sounds are very indistinct and deadened. 
 
 The impulse of the heart must be accurately noted and 
 the position of the apex ascertained. It is often displaced 
 from hypertrophy, and sometimes in an extraordinary 
 manner from pressure of the tumour encroaching upon 
 and pushing down the base of the heart. 
 
 Pulse may be diminished or obliterated in a special 
 vessel, or its beat postponed. Careful search should be 
 made for inequality, by testing the corresponding arteries 
 on each side with the hands. Diminution in the pulse 
 of one side indicates pressure or weakening of the current 
 from dilatation. The student must be cautioned that 
 congenital peculiarities sometimes traverse this sign. 
 
 Pulmonary sig^ns must be looked for especially over 
 the large bronchi in the interscapular regions. Signs of 
 pressure are often present, and are either stridulous 
 breathing and bronchial respiration, or abolition of the 
 respiratory marmur except at the base of the lung. 
 
 The frequency in which aneurisms occur may be given 
 in the following order, derived from Sibson's figures : — 
 
 Ascending. 
 
 Transverse. 
 
 Ascending and transverse. 
 
 Sinuses of Yalsalva. 
 
 Descending. 
 
251 
 
 CHAPTER XXiy. 
 
 HISTORICAL SUMMARY. 
 
 I CA]SfNOT conclude tliese pages witliout giving a short 
 sketcli of the history of physical signs ; how far they date 
 back, and to whom they are due : one's memory should 
 always have a place for those observers who have 
 established one fact which enables ns to detect the presence 
 of disease. 
 
 The earliest sign for the detection of thoracic disease, 
 known centuries ago to Hippocrates, was probably the 
 splash of succussion ; and the use of percussion for the 
 diagnosis of fluid in the belly was known in his time. 
 
 It was not until rather more than a century ago, that 
 the art of percussion was amplified and practised by 
 Auenbrugger, who published his results in 1761. 
 
 It is due, however, to Corvisart that the discoveries of 
 Auenbrugger, who had met with most undeserved 
 neglect by his contemporaries, were brought to light, and 
 the art was practised especially with regard to heart 
 diseases. Corvisart, as Laennec, his pupil, distinctly 
 states, never applied his ear immediately to the chest, 
 although he was aware that the beating of the heart could 
 be heard by holding the ear near the chest. To continue 
 Laennec's account, Bayle was the first to listen directly 
 to the chest. 
 
 It was not until 1816, that mediate auscultation was 
 discovered by Laennec. 
 
 He was consulted by a yoiing woman apparently suffer- 
 ing from disease of the heart. Her age and sex rendered 
 immediate auscultation inadvisable. Laennec, remember- 
 ing that sounds could be heard transmitted through wood, 
 
252 HISTORICAL SUMMARY. 
 
 conceived the idea of making use of this property of solids 
 in the case. He took a roll of paper and applied one end 
 to the prgecordial region, on the other end he placed his 
 ear, and he was not more surprised than gratified to hear 
 the beating of the heart more clearly and distinctly than 
 by immediate auscultation. 
 
 For the next three years he employed himself in 
 elaborating this discovery by observation at the Hopital 
 ISTecker, and in 1819 he published his work on mediate 
 auscultation. 
 
 To him we owe most of our knowledge of physical signs, 
 and his observations have well stood the test of time. 
 
 Since his time additional observations have been made. 
 
 Piorry, in 1826, who elaborated the doctrine of percussion, 
 supposed that each organ and substance had a special 
 sound. He invented the pleximeter, and modified the form 
 of the stethoscope. 
 
 In 1839, Skoda published his work on percussion and 
 auscultation, and established a scientific basis for the 
 interpretation of percussion notes. 
 
 To him is particularly due the discovery of the tym- 
 panitic note, which is often found above the fluid of an 
 effusion, and hence is sometimes called Skoda's tympanitic 
 note : his interpretation of the sound is open to challenge. 
 
 Among English observers and writers on this subject, 
 Williams comes first, publishing his work on diseases of the 
 lungs in 1828. After him came Walshe, whose book is a 
 perfect library of facts, noted with the greatest accuracy, 
 supported by pathological evidence, and detected with a 
 nice musical ear. 
 
 Flint, of ISTew York, devoted much attention to the con- 
 ditions of sound involving an alteration of pitch, and to 
 him are due the distinctive characters of solid and hollow 
 sounds, which are cHnically of the greatest value and 
 importance. 
 
 To France must be attributed, not only the name given 
 to the presystolic murmur by Gendrin in 1841 , but the con- 
 dition which it indicates, as first described by Fauvel. 
 
HOOKERS VISION OF THE STETHOSCOPE. 253 
 
 In recent times, much has been done for the advance- 
 ment of auscnitation, especially with regard to the dis- 
 tinctive signs of cardiac disease, by Peacock in England, 
 Stokes in Ireland, and Gairdner and Balfour in Scot- 
 land. 
 
 There are still obscure points to clear up, and fresh 
 observations required with regard to the interpretation 
 of sounds, which may exercise the attention and thought 
 of all. 
 
 It would be difficult to find a more apposite conclusion 
 to this brief account of the revelations of the stethoscope 
 than that prophetic view of the employment of sound for 
 the indication of the working of the animal frame, which 
 is contained in the following quaint but striking words 
 (which have been often quoted before) from the writings 
 of Hooke, in the beginning of the last century. 
 
 " Who knows but that it may be possible to discover 
 the motions of the internal parts of bodies by the sound 
 they make; that one may discover the works performed 
 in the several offices and shops of a man's body, and 
 thereby discover what instrument or engine is out of 
 order, what works are going on at several times, and lie 
 still at others, and the like. I could proceed further, but 
 methinks I can hardly forbear to blush when I consider 
 how the most part of men will look upon this, but yet again 
 I have this encouragement not to think all these things 
 utterly impossible, though never so much derided by the 
 generality of men, and never so seemingly mad, foolish, and 
 fantastic, that as the thinking them impossible cannot 
 much improve my knowledge, so the believing them 
 possible may perhaps be an occasion of taking notice of 
 such things as another would pass by without regard as 
 useless." 
 
254 
 
 BIBLIOGEAPHY. 
 
 Alison. Physical Examination of the Chest. 
 
 Andeal. Clinique Medicale. 
 
 AuENBKUGGEE. Invontum Novum. 
 
 Balfouk. Diseases of the Heart. 
 
 Baeth et Rogee. Traite Pratique de 1' Auscultation. 
 
 CoEvisART. Maladies du Cceur. 
 
 Da Costa. Medical Diagnosis. 
 
 Flint on Percussion and Auscultation. 
 
 Gaiednee. Clinical Medicine. 
 
 Gee. Auscultation and Percussion. 
 
 Geeen. Pathological Anatomy. 
 
 Helmholtz on Sound. 
 
 Heeschell's Articles on Sound. 
 
 Hughes on Auscultation. 
 
 Laennec. Traite de 1' Auscultation Mediate. 
 
 NiEMEYEE. Lectures on Medicine. 
 
 Peacock on Valvular Diseases of the Heart. 
 
 PiEOGOPF. Sectional Anatomy. 
 
 Pollock. Elements of Prognosis in Consumption. 
 
 Powell on Consumption. 
 
 Eeynolds. System of Medicine. 
 
 SiBSON. Medical Anatomy. 
 
 Skoda. Abhandlung iiber Percussion. 
 
 Stokes on Diseases of the Heart and Aorta. 
 
 Tuener's Introduction to Anatomy. 
 
 Tyndall on Sound. 
 
 Walshe. Diseases of the Lung and Heart. 
 
 Weil. Handbuch der Topographischen Percussion. 
 
 WiLKS and Moxon. Pathological Anatomy. 
 
 Williams on Diseases of the Lungs and Pleura. 
 
255 
 
 I1nDEX= 
 
 ABOLITION of sound, 80 
 Acoustics of auscultation, 78 
 „ blood murmurs, 203 
 
 „ percussion, 45 
 
 Action of diaphragm, 23 
 „ respiration, 24 
 Acute bronchitis, 115 
 „ tuberculosis, 1S2 
 „ „ and emphysema 
 
 compared, 185 
 Adherent pericardium, 238 
 
 pleura, 91, 138, ISO 
 Adventitious sounds, 95 
 Alar chest, 33 
 
 Alcoholism and phthisis, 170 
 Altered percussion note, 61 
 „ pupils in aneurism, 247 
 „ respii-atory rhythm, 91 
 Amphoric sounds, 49, 82, 115 
 Anaemia, 223 
 Aneurism of aorta, 246 
 
 „ „ frequency of, 250 
 
 „ „ signs of, 248 
 
 of heart, 224 
 Aorta, position of, 10, 243 
 
 „ variations in, 245 
 Aortic diseases, 246 
 „ obstruction, 225 
 „ regurgitant murmur, 216 
 „ regurgitation, 226 
 „ systolic murmur, 215 
 „ valves, 19, 197 
 „ „ diseases of, 214, 225 
 Apex of heart, 15, 194 
 „ „ displaced, 206 
 
 „ „ lowered, 206 
 
 „ „ raised, 206 
 
 „ „ retracted, 209 
 
 Arch of aorta, 10, 244 
 Area of aortic sounds, 214 
 „ mitral sounds, 214 
 „ pulmonary sounds, 214 
 „ tricuspid sounds, 213 
 Arteries, position of main, 10 
 Ascending part of arch of aorta, 10, 
 
 244 
 Asthma, 113 
 
 Asthma and aneurism, 247 
 Asystole, 227 
 Atelectasis, 114 
 Atrophous emphysema, 121 
 Atrophy of heart, 227 
 Attributes of sound, 46 
 Auricles, left, 11 
 
 right, 11 
 Axillary region, 7 
 Azygos vein, 21 
 
 BACK, 9 
 Base of heart, 14 
 Basic murmurs, 216, 217 
 Beau's asystole, 227 
 Bell sound, 111 
 
 Bilateral enlargement of chest, 36 
 Bowditch's operation in Paracentesis, 
 
 141 
 Bronchial arteries, 12 
 
 „ compression, 190, 228 
 „ sounds, 85 
 Bronchiectasis, 116 
 Bronchitis, acute, 114 
 „ chronic, 115 
 
 „ plastic, 117 
 
 Bronchus, left, 12 
 
 right, 12 
 Bronchophony, 108 
 Brown induration of lung, 127 
 Bruit de diable, 205 
 „ pot-fele, 50 
 „ rape, 214 
 „ scie, 214 
 „ soufflet, 203, 214 
 „ „ musical, 214 
 
 Bubbling rales, 102 
 Bulging of chest, 36 
 
 „ „ from large heart, 20S 
 
 CANCER of lung, 189 
 „ pericardium, 238 
 
 Cardiac murmurs, 212 
 „ orifices, 20 
 „ sounds in health, 199 
 „ „ pleurisy, 181 
 
 veins, 21 
 
256 
 
 INDEX. 
 
 Catarrhal pneumonia, 145 
 
 „ „ and phthisis, 157 
 
 Causes of displaced heart, 208 
 Cavernous respiration, 105 
 
 „ sounds, 161 
 Cavities, 164 
 
 „ contracting, 164 
 
 „ dislocated, 172 
 
 „ dry, 164 
 healed, 164 
 
 „ isolated, 165 
 
 5, multiloculai*, 165 
 
 „ secreting, 164 
 
 „ trabecular, 165, 169 
 Chauveau's experiments on heart 
 
 sounds, 204 
 Chauveau's experiments on lung 
 
 sounds, 79 
 Chest, anterior, 5 
 „ back view of, 7 
 „ divisions of, 5 
 Cheyne-Stokes respiration, 228 
 Chorea, 2-28 
 
 Chronic bronchitis, 115 
 Cirrhosis of lung, 118 
 Clavicle, 8 
 Clavicular region, 6 
 Clinical anatomy of aorta, 243 
 
 „ „ heart, 199 
 
 „ ,j lungs, 16 
 
 Cogged respiration, 94 
 Colour, observation of, 29 
 Compensatory breathing, 63, 90 
 Compressed bronchus, 117, 228 
 
 lung, 120 
 Condition of patient, 29 
 Congestion of lung, 119 
 Contraction of chest, 36 
 Contracted cavity, 164 
 Corrigan's cirrhosis of lung, 118 
 
 „ theory of heart's sounds, 203 
 
 Cough-breath, 111 
 
 „ sounds, 110 
 Cracked-pot sound, 50 
 Crackle of emphysema, 123 
 
 viscid, 100 
 Crepitant rales, 99 
 Crepitation, fine, 97 
 Croupous pneumonia, 141 
 Cyrtometer, 30 
 
 DECUBITUS in phthisis, 138, 172 
 „ in pleurisy, 138 
 
 „ pneumothorax, 173 
 Deep percussion, 53 
 Deferred inspiration, 92 
 Descending aorta, 10 
 Diaphragm, 12 
 Diaphragmatic action, 23 
 Dilatation of heart, 228 
 Diminished heart sound, 211 
 
 „ vesicular murmur, 90 
 
 „ voice sound, 88 
 
 Diseases of aorta, 246 
 
 „ heart, 223 
 
 „ lungs, 112 
 
 ,, pericardium, 235 
 
 „ pleura, 134 
 
 Dislocation of cavities, 172 
 
 „ heart, 171, 203 
 
 Distant heart sounds, 211 
 Divisions of chest, 5 
 Dropsy of the lung, 128 
 Dulness of percussion, 67 
 Dyspiiagia, 247 
 
 EFFUSION" into the pericardium, 
 237 
 Effusion into the pleura, 136 
 Embolism, 133, 229 
 Emphysema, 121 
 Emphysematous chest, 35 
 
 „ percussion, 64 
 
 „ respiration, 123 
 
 Emphysema and tubercle, compared, 
 
 66, 124, 185 
 Empyema, 139 
 Endocardial murmurs, 213 
 Endocarditis, rheumatic, 239 
 Enlargement of chest, 36 
 
 of heart, 231 
 Epigastric region, 8 
 Exaggerated vesicular murmur, 9) 
 Exocardial murmurs, 213 
 Experiments of Bondet and Chauveau, 
 
 79 
 Experiments of Chauveau, 204 
 Extraneous sounds, 83 
 
 FATTY heart, 230 
 Fibrinous casts, 117 
 Fibrosis of lung, 124 
 Fine crepitation, 96, 98 
 First stage of phthisis, 157 
 Flat chest, 34 
 Fluctuation of iiuid, 43 
 Foetal heart, 231 
 Foramen ovale open, 230 
 Forced breathing, 23 
 „ inspiration, 48 
 Forms of chest, 30 
 Frequency of aneurism, 250 
 
 „ rheumatic endocarditis, 
 
 239 
 Fremissement cataire, 44 
 Fremitus in health, 42 
 „ in disease, 43 
 Friction, pleural, 1U7 
 
 „ pericardial, 220, 236, 238 
 
 GAIRDNER on aneurism, 248 
 Gall bladder, position of, 13 
 Gangrene of lung, 126 
 Gee's cyrtometer, 38 
 Girth of chest, 38 
 Gouty heart, 231 
 
INDEX, 
 
 25; 
 
 Graphic representation, 3S 
 Gargling rale, 102, 161 
 
 „ ,, in pneumoperieardiura, 
 
 222 
 
 H^MIC murmurs, 214 
 Haemoptysis in aneurism, 247 
 Haemorrhage, pulmonary, 130 
 „ results of, 131 
 
 „ signs of, 131 
 
 Harrison's sulcus, 31 
 Harsh respiration, 95 
 Haughton's caleuiatious in muscular 
 
 murmur, 84 
 Heart, anatomy of, 13, 14, 15, 19, 20 , 
 
 194 
 Heart, aneurism of, 223 
 
 „ apex, position of, 15 
 
 „ displaced, 208 
 
 „ in hypertrophy, 232 
 
 „ pericardial effusion, 237 
 
 „ asystole of, 227 
 
 „ atrophy of, 227 
 
 „ dilatation of, 228 
 
 „ fatty, 230 
 
 „ foetal, 231 
 
 „ gouty, 231 
 
 „ hypertrophy of, 231 
 
 „ inflammation of, 235 
 
 „ palpitation of, 228 
 
 „ rheumatic affections of, 239 
 
 „ rupture of, 239 
 
 „ sounds of, in health, 199 
 
 „ „ „ in disease, 211 
 
 ,, strain of, 240 
 Hesitating respiration, 94 
 Historical summary, 257 
 Hooke's vision of the stethoscope, 253 
 Hydatids of the lung, 126 
 Hydropericardium, 232 
 Hydro-pneumothorax, 177 
 Hyper-resonant percussion, 47 
 Hypertrophous emphysema, 121 
 Hypertrophy of heart, 231 
 Hysterical breathing, 96 
 
 IMMEDIATE auscultation, 75 
 „ percussion, 51 
 
 Impulse of heart, 44, 200 
 
 „ „ increased, 209 
 
 „ „ weakened, 209 
 
 Increased intensity of heart sound, 211 
 „ vesicular murmur, 90 
 „ vocal resonance, 88, 108 
 
 Induration of lung, 127 
 
 Infective phthisis, 177 
 „ pneumonia, 152 
 
 Influence of respiration in disease, 24 
 
 Infra-clavicular region, 6 — 8 
 
 Infra-mammary region, 5 
 „ scapular region, 6 
 
 Innominate artery, 10 
 
 Inspection, 28 
 
 Inspu'atory murmur, 85, 86 
 Intensity defined, 46 
 
 „ of percussion, 55 
 Intermittent heart sound, 212 
 Interscapular region, 6 
 Interstitial pneumonia, 148 
 Irregularity of heart's rhythm, 212 
 
 JERKING respiration, 94 
 Jogging or saccussion sounds, 103 
 
 KIDNEYS, 15 
 King on compressed bronchus, 
 228 
 
 LAENNEC'S discovery of ausculta- 
 tion, 251 
 Laennec's sounds of the lungs, 96 
 
 „ theory of heart sounds, 203 
 Laryngeal symptoms in aneurism, 247 
 Left auricle, 196 
 „ bronchus, 12 
 ,, carotid artery, 244 
 „ diaphragm, side of, 13 
 „ lung, 16 
 „ side, contents of, 4 
 „ ventricle, 196 
 Lines dividing chest, 6 
 „ midsternal, 6 
 „ parasternal, 6 
 Liquid vein, 203 
 Liver, position of, 15 
 Lobes of left lung, 16 
 
 „ „ right, 13 
 Local bulgings of chest, 37 
 „ depressions, 67 
 „ tubercle, 182, 186 
 Lungs, anatomy of, 16 
 „ cirrhosis of, 118 
 „ compression of, 120 
 „ congestion, 119 
 „ consohdation, 141, 143 
 „ diseases of, 132 
 „ fibrosis, 124 
 „ gangrene, 126 
 „ hydatids of, 127 
 „ induration of, 128 
 „ oedema of, 129 
 „ syphilitic disease of, 149 
 „ tumours of, 187 
 Lymphadenoma, 188 
 Lymphatics of lungs, 17 
 
 MAMMARY region, 6 
 Measurements of chest, 37 
 Mediastinum, 17 
 Mediastinal tumours, 187 
 Mediate auscultation, 75 
 
 „ percussion, 51 
 Mesosternal line, 6 
 Metallic sounds in auscultation, 106 
 
 „ „ percussion, 82 
 
 Mitral valve, anatomy of, 20, 196 
 
 S 
 
258 
 
 INDEX. 
 
 Mitral valve, diseases of, 232 
 
 „ murmurs, 218, 219 
 
 „ obstruction, 233 
 
 „ presystolic murmur, 219 
 
 „ regurgitation, 232 
 Mode of conducting an examination, 26 
 
 „ percussing, 51 
 Morbid sounds, 90 
 Morbus cieruleus, 235 
 Muffled resonance, 64 
 Movements of respiration, 22 
 Murmurs of the heart, 211 
 Muscular murmurs, 83 
 Musical murmurs, 105 
 
 „ sounds, 45 
 Myocarditis, 235 
 
 TVTIPPLE line, 6 
 
 1>| „ position of, 18 
 
 Normal bronchophony, 87 
 
 „ percussion resonance, 55 
 „ vesicular murmur, 84 
 „ voice sounds, 87 
 
 OBJECT of physical examination, 1 
 Occasional click, 100 
 (Edema of lung, 128, 129 
 (Egophony, 110 
 (Esophagus, position of, 18 
 
 „ aneurismal pressure of, 248 
 
 Orthopnoea in aneurism, 247 
 
 PALPATION, 41 
 of heart, 209 
 Paracentesis thoracis, 141 
 Parasternal lines, 6 
 Pectoriloquy, 109 
 Percussion, 51 
 
 „ acoustics of, 45 
 
 „ deep, 53 
 
 „ dulness of, 47, 74 
 
 „ in disease, 63 
 
 „ flatness of, 47 / 
 
 health, 53 
 
 „ hypertrophy of heart, 210 
 
 „ immediate, 51 
 
 „ mediate, 51 
 
 „ mode of, 52 
 
 „ regional, 58 
 
 „ „ signilicance of, 
 
 74 
 
 „ sounds of, 71 
 
 „ sub-resonant, 47 
 Pericardial diseases, 235 
 
 „ effusion, 237 
 
 „ ,, percussion in, 210 
 
 „ presence of air in, 238 
 
 „ „ pus in, 237 
 
 „ sounds in disease, 220 
 Phthinoid chests, 32 
 Phthisis, 153 
 
 „ first stages, 157 
 „ second stage, 159^ 
 
 Phthisis, third stage, 161 
 „ acute, 165 
 „ advancing, 172 
 „ alcoholism and, 170 
 „ arrested, 172 
 „ clinical forms of, 165 
 „ galloping, 165 
 „ infective, 177 
 „ laryngeal, 166 
 J, scrofulous, 167 
 „ trabecular, 168 
 Physical examination, 1 
 
 „ „ of heart, 194; 
 
 „ signs, 1 
 
 Pigeon breast, 31 
 
 Pit of stomach, 8 
 
 Pitch defined, 46 
 
 „ of percussion, 55 
 Placental murmur, 231 
 Plastic bronchitis, 117 
 Pleural friction, 107 
 „ sounds, 107 
 Pleurisy, 134 
 Pleuritic adhesion, 137 
 
 „ effusion, 135, 136, 137 
 „ thickening, 180 
 Pneumonia, catarrhal, 145, 157 
 „ croupous, 141 
 
 „ „ first stage, 141 
 
 „ „ second stage.. 
 
 142 
 „ „ third stage, 144 
 
 „ infective, 152 
 „ interstitial, 148 
 Pneumopericardium, 221, 238 
 Pneumothorax, 172 
 Position of valves, 20, 195, 197 
 Prsecordial region, 7, 194 
 Prolonged expiration, 93 
 Puerile breathing, 90 
 Pulmonary apoplexy, 120 
 „ ai'teries, 11 
 „ compression, 120 
 „ congestion, 119 
 
 „ hsemorrhage, 130 
 
 ,, obstruction, 238 
 
 J, regurgitation, 239 
 „ regurgitant murmur, 217" 
 „ resonance, 47 
 „ systolic murmur, 217 
 „ valves, 20, 196 
 „ veins, 21 
 „ vessels, 18 
 Pulsating fluids, 44 
 Pulsation abnormal, 209 
 „ of arteries, 208 
 „ heart, 206 
 
 „ liver, 209 
 
 „ veins 208 
 
 Pupils altered, 247 
 Pus in the pleura, 139 
 
 5, „ pericardium, 237 
 Pyaemia, 239 
 
INDEX. 
 
 259' 
 
 Pylorus, 19 
 Pyo-pneumothorax, 177 
 
 QUALITY of matter, 41 
 „ percussion, 55 
 
 „ sound, 46 
 
 RALE, bubbling, 102 
 „ cavernous, 104 
 „ crepitant, 98, 160 
 „ crepitant humide, 96 
 „ crepitant sec, 96, 123 
 „ defined, 96 
 „ dry crackJin?, 123 
 „ gurgling, 104, 161 
 „ Laennec's, 96, 97 
 „ muqueux, 96 
 „ mucous, 100, 101 
 „ sibilant sec, 103 
 „ sonore sec, 103 
 „ snbcrepitant, 101 
 „ tabular view of, 192 
 „ viscid, 100, 140, 169 
 Eeduplieation of heart sounds, 2] 2 
 Eegions of the chest, 6 
 Regional distribution of sounds, 72 
 „ significance of amphoric 
 
 breathing, 106 
 „ „ bronchophony, 
 
 108 
 „ „ cavernous re- 
 
 spiration, 105 
 „ „ dull percus- 
 
 sion, 74 
 Resonance of percussion, causation of, 
 47 
 „ J, in di&erent 
 
 regions, 61 
 „ „ in health, 56 
 
 „ „ trachseal, 61 
 
 „ „ tympanitic. 
 
 61 
 Eespiration, movements of, 22 
 
 „ 5, in childi'en, 24 
 
 „ „ of men, 24 
 
 „ „ of women, 24 
 
 „ productive of disease, 25 
 Eespiratory sounds in health, 84 
 
 „ „ „ synopsis 
 
 of, S6 
 „ „ pulmonary dis- 
 
 ease, 91 
 Eesnlts of haemorrhage, 131 
 Ehonchus defined, 26 
 „ sibilant, 103 
 
 „ sonorous, 103 
 
 Eheumatism, its effects, 239 
 Eickety chest, 81 
 Eight auricle, 195 
 „ axillary region, 7 
 „ bronchus, 8, 12 
 „ clavicular region, 8 
 „ infira-clavicular region, S 
 
 Eight infra-mammary region, 9 
 „ infra-scapular region, 9 
 „ interscapular region, 9 
 „ lung, 16 
 „ mammary region, 9 
 „ scapular region, 9 
 „ side of chest, 4 
 „ „ diaphragm, 13 
 
 „ supra-elavicular region, 8 
 „ „ scapular region, 6 
 „ ventricle, 195 
 
 Eotation of heart, 209 
 
 Eupture of heart, 239 
 
 valves, 213, 240 
 
 SAVAET'S experiments on fluids^ 
 203 
 Scrobiculus cordis, 8 
 Scroftdous glands, 187 
 „ "phthisis, 167 
 „ pneumonia, sounds of, 100. 
 
 Second stage of phthisis, 159 
 „ „ pleurisy, 136 
 
 „ „ pneumonia, 142 
 
 Shortened expiration, 92 
 „ inspiration, 91 
 
 Sibilant rhonchi, 103 
 Silences of heart, 199 
 Silent respiratory murmur, 91, 162 
 Sites of valvular sounds, 202 
 Skoda, 70, 252 
 Sonorous rhonchi, 113 
 Sounds abolished or annulled, 80, 165. 
 „ causation of, 7S 
 „ of destruction, 114 
 „ diminished, 7S 
 „ extraneous, 83 
 „ of hair, 83 
 „ of heart, 199 
 „ intensified, 79 
 ,, production of, 45 
 „ percussion in disease, 63 
 „ „ health, 55 
 
 „ production of, 45 
 „ of tubercle, 65 
 Splashing sounds, 106, 177 
 Spleen, position o^ 19 
 Stethometers, 33 
 Stethoscopes, double, 77 
 
 „ single, 76 
 
 Stomach, 19 
 Strain of heart, 240 
 Snbcrepitant rale, lul 
 Subresonant percussion, 47 
 SuccussioD, 106 
 Superficial percussion, 53 
 Supplementary breathing, 90 
 Suppressed expu-ation, 93 
 
 „ vesicular murmui*, 91 
 
 Supra- clavicular fossa, 8 
 „ „ region, 6, 8 
 
 ,, scapular region, 6 
 Symptoms defined, 1 
 
2(50 
 
 INDEX. 
 
 Synopsis of sounds, 61, 66, 86, 192, 221 
 Synoptical tables, see Tables 
 Syphilitic pulmonary disease, 149 
 
 TABLES synoptical. 
 Adventitious sounds, 192 
 Broncbial sounds, 192 
 Cardiac murmurs, 221 
 Cough sounds, 193 
 Diaphragm, position of, 13 
 Diastolic murmurs, 221 
 Distended lung, signs of, 66 
 Inspiratory and respiratory 
 
 sounds, 87 
 Murmurs of heart, 221 
 Percussion sounds in disease, 71 
 „ „ health, 61 
 
 Pleural sounds, 193 
 Presystolic murmur, 221 
 Pulmonary sounds in disease, 192 
 Eegional significance, 74 
 Respiratory sounds, 86 
 Systolic murmurs, 221 
 Tubercle and emphysema, 185 
 Valves, position of, 20 
 
 „ size of, 20 
 Valvular murmurs, 221 
 Vocal resonance, 88 
 Voice sounds, 193 
 Terms used by Laenuec, 96 
 Thickened pleura, 180 
 Third stage of phthisis, 161 
 Thoracic duct, 19 
 ThrHls, 44, 210 
 Thrombosis, 133 
 Thymus gland, 61 
 Tinkle, 106 
 
 Topography of chest, 4 
 Trabeculse, 111 
 Trabecular phthisis, 168 
 Trachea, 19 
 
 „ bifurcation of, 19, 243 
 Tracheal sound, 84 
 Transverse outlines of chest, 39 
 „ portion of arch, 10 
 „ section of chest, 16 
 „ „ heart, 195 
 
 „ J J in pericardial effu- 
 
 sion, 237 
 „ „ in pyo-pneumo- 
 
 thorax, 174 
 Tricuspid obstruction, 241 
 
 „ presystolic murmur, 220 
 „ regurgitation, 218, 241 
 „ systolic murmur, 218 
 „ valve, position of, 20 
 Tubal sounds, 102 
 Tubercle, 181 
 
 „ and emphysema, 185 
 „ percussion in, 66, 185 
 „ sounds of, 185, 186 
 Tubular breathing, 104 
 
 Tubular percussion, 64 
 
 „ sounds, 103 
 Tumours of lung, 187 
 Tympanitic resonance, 69 
 
 „ „ muffled, 64, 71 
 
 UNILATERAL contraction of chest, 
 36 
 „ enlargement, 36 
 
 VALVES, diseases of, 214 
 „ position of, front, 19 
 „ „ back, 197 
 
 „ rupture of, 240 
 Valvular murmurs, 221 
 
 „ sites of, 214, 221 
 „ sounds, 200 
 „ „ sites of, 202 
 
 Variations of aorta, 274 
 Vascular tumours, 190 
 Veine fluide, 203 
 Veins, pulmonary, 12, 21 
 Vena cava, ascending, 21 
 
 „ descending, 21 
 Venous enlargement, 242 
 „ hum, 242 
 ,, pulsation, 242 
 Vesicular murmur causation, 81 
 „ „ description, 85 
 
 „ „ regional peculiari- 
 
 ties, 86 
 „ „ synopsis of, 86 
 
 „ „ diminished, 90 
 
 „ „ exaggerated, 90 
 
 „ „ suppressed, 91 
 
 Vessels of heart, 21 
 „ lung, 18 
 Vibrations of sound, 41 
 
 „ „ from friction, 43 
 
 Vibrations palpable, 43 
 Viscid crackle, 100 
 Vocal fremitus, 42 
 „ resonance, 87 
 „ „ diminished, 88, 107 
 
 „ „ increased, 88, 108 
 
 „ „ in disease, 107 
 
 WALSHE'S opinions, 70, 71 
 „ „ on musical 
 
 murmurs, 
 105 
 Whisper, 88 
 
 Wilks on air in the pleura, 176 
 Williams on tracheal resonance, 70 
 
 XIPHOID cartilage in emphysema, 
 35 
 „ „ aortic murmur, 
 
 at, 216 
 
 TTELLOW hue of surface, 29, 223 
 
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