COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX64116816 
 RC76 .C81 1 896 Essentials of physic 
 
 M^, 
 
 <^^ 
 
 ESSENTIALS 
 
 OF 
 
 HYSICAL DIAGNOSIS 
 
 THORAX. 
 
 CORWiN. 
 
 ■^i'^'m 
 

 Columbia Winti^tviitv ^^^& 
 in tfje Cttp of Jgetu gorb 
 
 COLLEGE OF PHYSICIANS 
 AND SURGEONS 
 
 Reference Library 
 
 Given by 
 
ESSENTIALS 
 
 PHYSICAL DIAGNOSIS 
 
 OF THE 
 
 THORAX. 
 
 BY 
 
 ARTHUR M. CORWIN, AM, M. D, 
 
 Demonstratob of Physical Diagnosis in Rush Medical College; 
 
 Attending Physician to the Centbal Free Dispensary, 
 
 Department of Rhinology, Laryngology, 
 
 AND Diseases of the Chest. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 PHILADELPHIA : 
 W. B. SAUNDERS, 
 
 925 Walnut Street. 
 1896. 
 
Copyright, 1896, 
 By W. B. SAUNDERf 
 
 ELECTROTYPED BY PRESS OF 
 
 WESTOOTT 8i THOMSON, PHILAOA. W, B. SAUNDERS. PHILADA. 
 
PREFACE TO THE SECOND EDITION. 
 
 The first edition of this book, published under the title 
 " Outline of Physical Diagnosis of the Thorax," was chiefly 
 intended to meet the immediate wants of my classes. From 
 its rapid distribution it has seemed to have reached a wider 
 field. The present edition under the new title, as published 
 by Mr. Saunders, is a revision of the original text, with an 
 added section setting forth the signs found in each disease 
 of the chest. 
 
 In the preparation of this synopsis I have availed myself 
 of the works of the best writers upon Diagnosis, General 
 Medicine, Physiology, and Anatomy, from which I have 
 endeavored to cull the essentials of the subject in hand. 
 
 To Drs. Wm. R. Parkes and John Edwin Ehodes I desire 
 to express my thanks for their valued services rendered in 
 the reading of the proof. 
 
 A. M. C. 
 
PREFACE TO THE FIRST EDITION. 
 
 The following outline aims to present in systematic form 
 the gist of the science of physical diagnosis as applied to the 
 thorax. 
 
 In this form it is hoped that the salient points of the sub- 
 ject may be the more readily grasped by those who are all 
 too busy, while in medical college, to seek them out of ex- 
 tensive treatises and to arrange them for proper assimilation. 
 
 It is designed to meet the immediate demands of the 
 student, and to be a further guide to a more elaborate study 
 of the theme as set forth in existing literature, and as fur- 
 nished in the clinical material of public and private practice. 
 
 While the intention has been to confine the subject to the 
 thorax, reference has been made to some of the abdominal 
 organs, and to various phenomena of the circulatory system 
 outside of the chest, where these have seemed to be specially 
 related to the chest cavity and its organs. 
 
 I am indebted to Drs. John M. Dodson, James B. Her- 
 rick, John Edwin Rhodes, and George H. Weaver for sug- 
 gestions in the correction of proof. 
 
 A. M. C. 
 
Fig. 1.— Corwin's Double Binaural Stethoscope. 
 
Fig. 2.— Corwin's Multiplex Stethoscope. 
 
Fig. 3.— Folded Single Stethoscope. 
 
THE 
 
 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
THE 
 
 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Definition. — Physical Diagnosis is the science and art of 
 objective examination of the body as practised upon its 
 surface. 
 
 The science of physical diagnosis deals with the character, 
 causes, and significance of physical signs, and the methods 
 of eliciting them. Signs are objective features, as distin- 
 guished from symptoms, which are purely subjective. 
 
 The art of physical diagnosis is the practical applica- 
 tion of the science. Its aim is, therefore, to distinguish ob- 
 jectively between health and disease, and between various 
 diseases. 
 
 Introductory Note. — Objective examination, though deal- 
 ing in a broad way with the entire body, finds its most profit- 
 able application to the thorax, which is therefore the field of 
 its operation as considered in the following synopsis. The 
 four divisions of the subject are (1) Topography of the Chest ; 
 (2) Landmarks of the Chest ; (3) Methods of Physical Diag- 
 nosis ; (4) Physical Signs common in and peculiar to each 
 Disease of the Chest. 
 
 17 
 
18 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 TOPOGRAPHY OF THE CHEST. 
 
 The topography of the chest deals with the regions, their 
 boundaries and their contents. 
 
 Fig. 4.— Anterior surface of the chest. 
 
 ANTERIOE EEGIONS. 
 
 SUPRA-CLAVICULAR regions. 
 Boundaries : 
 
 ABOVE, the line drawn from the junction of the ex- 
 ternal with the middle third of the clavicle to a point 
 at the inner margin of the sterno-mastoid muscle, on 
 a level with the upper ring of the trachea. 
 BELOW, \)l\q superior border of the inner two-thirds 
 
 of the clavicle. 
 IWTERNALLY, the anterior border of tlie sterno- 
 cleido-mastoid muscle. 
 Contents : the apices of the lungs ; parts of the sub- 
 
TOrOUHArUY OF THE VlUuST. 19 
 
 clavian and carotid arteries ; and the sulx.'lavian and 
 jugular veins, on either side. 
 
 CLAVICULAR regions. 
 
 Boundaries : the margins of the inner two-thirds of the 
 
 clavicle. 
 Contents : 
 
 BIGHT SIDE, the apex of the lung. 
 EXTERNALLY, the subclavian artery. 
 INTERNALLY, the innominate artery and recurrent 
 laryngeal nerve. 
 LEFT SIDE, the apex of the lung. 
 
 EXTERNALLY, parts of the subclavian vessels. 
 INTERNALLY, parts of the subclavian and carotid 
 vessels. 
 
 INFRA-CLAVICULAR regions. 
 Boundaries : 
 
 ABOVE, the lower border of the clavicle. 
 
 BELOW, the lower border of the third rib. 
 
 INTEBNALLY, the border of the sternum. 
 
 EXTEBNALLY, a line let fall from the junction of 
 the middle with the outer third of the clavicle, and 
 passing down an inch to the outer side of the nipple 
 (some authorities give the mammillary line). 
 Contents : 
 
 EITHEB SIDE, lung tissue. 
 
 BIGHT SIDE, a part of the aorta, descending vena 
 cava, and right bronchus. 
 
 LEFT SIDE, the pulmonary artery and left bronchus, 
 the base of the heart and great vessels. 
 
 MAMMARY regions. 
 Boundaries : 
 
 ABOVE, the lower border of the third rib. 
 BELOW, the lower border of the sixth rib. 
 INTEBNALLY, the margin of the sternum. 
 EXTEBNALLY, a line let fall from the junction of 
 
20 PHYSICAL DIAGNOSIS OF THE CHEST, 
 
 the middle with the outer third of the clavicle, passing 
 an inch to the outer side of the nipple. 
 Contents : 
 
 MIGHT SIDE, the lung, right lobe of the liver, right 
 auricle, right ventricle, and diaphragm. 
 
 LEFT SIDE, the lung and heart. 
 
 INFRA-MAMMARY regions. n^ 
 
 Boundaries : 
 
 ABOVE, the lower border of the sixth rib. 
 BELOW, the lower border of the false ribs and car- 
 tilages (the costal arch). 
 INTERNALLY, the costal arch. 
 
 EXTERNALLY, a line let fall from the junction of 
 the middle with the outer third of the clavicle. 
 Contents : 
 
 BIGHT SIDE, the lung on deep inspiration, the right 
 
 lobe of the liver. 
 LEFT SIDE, the lung and the left lobe of the liver. 
 
 SUPRA-STERNAL region. 
 Boundaries: 
 
 ABOVE, a line on a level with the first ring of the 
 
 trachea. 
 BELOW, the inter-clavicular notch. 
 LATERALLY, the anterior borders of the sterno- 
 cleido-mastoid muscles. 
 Contents : the trachea, thyroid gland, vessels, and oesoph- 
 agus. 
 
 SUPERIOR STERNAL region. 
 Boundaries : 
 
 ABOVE, the inter-clavicular notch. 
 BELOW, a line on a level Avith the third costal car- 
 tilages. 
 LATERALLY, the margins of the sternum. 
 Contents : the lung below the level of the second costal 
 
TorooBArnr of the chkst. 21 
 
 cartilage, the descending vena cava, aorta, [)MliiH)iiai-v 
 artery, and bifun^ation of the traclica. 
 
 INFERIOR-STERNAL region inclndes the sternnm below 
 the level of the third costal cartilages. 
 Contents : a part of the right auricle and the origins of 
 the pulmonary artery and aorta ; a small part of the 
 left lung ; a part of the right ventricle, right lung and 
 liver, and a part of the attachment of the pericardium 
 to the diaphragm. 
 
 LATERAL REGIONS. 
 
 AXILLARY regions. 
 Boundaries : 
 
 ABOVE, the axilla. 
 
 BELOW, a line on a level with the lower border of the 
 
 mammary region. 
 AWTEBIOBLY, a vertical line let fall from the junc- 
 tion of the middle with the outer third of the clavicle. 
 JPOSTEBIOBLY, the anterior or axillary border of 
 the scapula. 
 Contents : lung-tissue, and the main bronchi deeply 
 placed. 
 
 INFRA-AXILLARY regions. 
 Boundaries : 
 
 ABOVE, the axillary region. 
 BELOW, the margins of the false ribs. 
 AJVTEBIOBLY, the external boundary of the infra- 
 mammary region. 
 POSTEBIOBLY, a line let fall from the inferior 
 angle of the scapula (scapular line). 
 Contents : 
 
 EITHER SIDE, lung- tissue. 
 
 BIGHT SIDE, the right lobe of the liver. 
 
 LEFT SIDE, the spleen and part of the stomach. 
 
22 
 
 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Fig. 5.— Posterior surface of the chest. 
 
 POSTERIOR REGIONS. 
 SUPRA-SCAPULAR regions. 
 
 Boundaries, those of the supra-spinous fossse. 
 Contents : the apices of the lungs. 
 
 SCAPULAR regions. 
 
 Boundaries, those of the infra-spinous fossse. 
 Contents : lung-tissue. 
 
 INTER-SCAPULAR region. 
 Boundaries : 
 
 EXTERNALLY, the posterior borders of the scapulae. 
 The region extends from the level of the second to 
 that of the seventh dorsal vertebra. 
 Contents : 
 
 BIGHT SIDEf the lung, bronchial glands^ and main 
 bronchus. 
 
LANDMARKS OF TlIK CHEST. 23 
 
 LKt'T SE Die, the lung, glands, main In-oiicluis, aorta, 
 thoracic duct, and (lesopliagus. 
 
 INFRA-SCAPULAR regions. 
 Boundaries : 
 
 ABOVE, inter-scapular and scapular regions. 
 BELOW, the margins of the false ribs. 
 POSTEIilORLY, the spines of the dorsal vertebrae, 
 
 below the seventh. 
 ANTERTOliLY, the scapular line. 
 Contents : 
 
 BIGHT SIDE, the liver, lung, and upper end of the 
 
 kidney. 
 LEFT SIDE, the lung and a part of the spleen, kid- 
 ney, and intestines. 
 
 LANDMARKS OF THE CHEST. 
 
 The landmarks inclnde the various points, lines, and 
 measurements to which reference may be made in showing 
 the relation of the deep organs to the surface. 
 
 LINES OF EEFERENCE. 
 VERTICAL lines of reference. 
 
 Meso-sternal line, the mid-line of the sternum. 
 
 Sternal lines, right and left, corresponding to the lateral 
 margins of the sternum. 
 
 Mammillary (not mammary) hues, right and left, passing 
 vertically through the nipples. 
 
 Para-sternal lines, right and left, passing vertically mid- 
 way between the mammillary and sternal lines on the 
 respective sides. 
 
 Anterior Axillary lines, right and left, passing vertically 
 through the points at which the pectorales majores leave 
 the chest, the arms being at right angles to the body. 
 
 Posterior Axillary lines, right and left, passing vertically 
 
24 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 througli the points at which the latissiinus dorsi leave 
 
 the chest, tlie arms being at right angles to the body. 
 Mid-axillary lines, right and left, midway between the 
 
 anterior and posterior axillary lines. 
 Scapular lines, right and left, passing vertically through 
 
 the inferior angles of the scapulae. 
 Vertebral line, passing through the spines of the vertebrae. 
 
 HORIZONTAL line of reference. 
 Horizontal Nipple Line. 
 
 OBLIQUE line of reference. 
 
 Linea-costo-articularis, drawn from the left sterno- 
 clavicular articulation to the free end of the left 
 eleventh rib. 
 
 LANDMARKS OF THE LUNGS. 
 
 OUTLINE of the lungs. 
 
 Outline of the Right Lung. 
 
 THE AJPEX extends an inch and a half above the first 
 rib, and is apt to be a little lower than the apex of 
 the left lung. 
 
 THE ANTERIOH BOJRHER lies in the meso-sternal 
 line from the level of the second to the level of the 
 sixth costal cartilage. 
 
 THE INFERIOR BORDER in adults lies as follows, 
 in the average position ; on deep inspiration it is de- 
 pressed an inch and a half lower ; in children it is 
 from a half to a full interspace higher ; in the aged 
 it is often as much lower : 
 IN THE MAMMILLARY LINE at the sixth rib. 
 IN THE MID- AXILLARY LINE at the eighth rib. 
 IN THE SCAPULAR LINE at the tenth rib. 
 Outline of the Left L^ung. 
 
 THE APEX extends one inch and a half to two inches 
 above the first rib. 
 
LANDMARKS OF THE CHEST. 25 
 
 TUB ANTElilOR BORDEli lies in the meso-sternal 
 
 line IVoni the level of the seeond to the level of the 
 
 fourth costal cartilage. 
 THE INFERIOR BORDER lies (in the average 
 position), 
 
 IN THE MESO-STERNAL LINE, at the fourth costal 
 cartilage. 
 
 IN THE PARA-STERNAL LINE, at the fifth rib. 
 
 IN THE MAMMILLARY LINE, at the sixth rib. 
 
 IN THE MID- AXILLARY LINE, at the eighth rib. 
 
 IN THE SCAPULAR LINE, at the tenth rib. 
 The inferior border of the left lung reaches half to 
 
 three-quarters of an inch lower than the right in the 
 
 mid-axillary and scapular lines. 
 
 FISSURES of the lungs. 
 
 Fissures of the Right Lung. 
 THE LONG FISSURE. 
 
 ITS POSITION : it separates the lower from the mid- 
 dle and upper lobes. 
 ITS DIRECTION is from above and behind, obliquely 
 
 downward and forward. 
 ITS RELATION to the chest is about as follows : 
 Near the Vertebral Column it is three inches 
 below the apex of the lung (near the inner end 
 of the spine of the scapula). 
 In the Mid-axillary Line it is about the level of 
 
 the fourth rib. 
 ^Tiist within the Mamniillary Line it cuts the 
 lower margin of the lung at the sixth rib. 
 THE SHORT OR LESSER FISSURE. 
 
 ITS POSITION : it separates the upper from the mid- 
 dle lobe. 
 ITS DIRECTION is obliquely dow^nward and forward 
 from a point near the anterior border of the scapula, 
 where it joins the long fissure. 
 
26 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 ITS RELATION to the cLest-wall is about as follows : 
 It lies at lirst nearly under the third rib^ but crosses 
 the third intercostal space about the mammillary 
 line, and cuts the anterior border of the lung about 
 the junction of the fourth costal cartilage with the 
 sternum. 
 Fissure of the Left Lung. 
 
 THE LONG FISS THE (the left lung has but one fissure). 
 ITS POSITION : it separates the upper from the lower 
 
 lobe. 
 ITS DIRECTION is from above and behind, obliquely 
 
 downward and forward. 
 ITS RELATION to the chest-wall is as follows (in the 
 average position) : 
 Near the Vertebral Column it is about three 
 
 inches below the apex of the lung. 
 In the 3Ii(l-axillary Line it is about the level of 
 
 the fourth rib. 
 In the 3Iainmillarf/ Line it cuts the lower mar- 
 gin of the lung at the sixth rib. 
 
 LOBES of the lungs. 
 Anteriorly : 
 
 OJSr THE MIGHT SIDE, 
 
 THE UPPER LOBE lies above the third intercostal 
 
 space. 
 THE MIDDLE LOBE lies below the third interspace, 
 
 reaching to the lower margin of the lung. 
 THE LOWER LOBE is practically absent anteriorly. 
 ON THE LEFT SIDE, 
 THE UPPER LOBE reaches from the apex to the 
 
 lower margin of the lung. 
 THE LOWER LOBE is practically absent anteriorly. 
 Laterally : 
 
 ON THE BIGHT SIDE, 
 
 THE MIDDLE LOBE is present above the fourth rib. 
 
LANDMARKS OF Till': (UKST. 27 
 
 THE LOWER LOBE rcjuilios fVoiii tlic fourth ril> to 
 the lower margin of the hiii^-. 
 
 ON Till: LEFT Sim:, 
 
 THE UPPER LOBE lies above the fourth rib. 
 THE LOWER LOBE reaches from the fourtli rib to 
 the h)wer margin of the hmg. 
 Posteriorly : 
 
 OX BOTH STDKS, 
 THE UPPER LOBE practically lies above the spine 
 
 of the scapula. 
 THE LOWER LOBE reaches from the spine of the 
 scapula to the lower margin of the lung. 
 
 THE TRACHEA. 
 Dimensions. 
 
 LENGTH, four and one-half inches. 
 CALIBRE, three-fourths to one inch. 
 
 A A 
 
 Median Line 
 
 Fig. 6— Showing divergence of main bronchi. 
 
 Bifurcation, under the middle of the sternum about the 
 level of the second costal cartilage, at the level of the 
 third dorsal vertebra. The septum or line of divergence 
 between the two bronchi is to the left of the median 
 line, thus influencing the direction of foreign bodies 
 which enter the trachea. 
 
28 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 THE PRIMARY BRONCHI. 
 Direction. 
 
 THE RIGHT bronchus is nearly horizontal. 
 
 THE LEFT bronchus is oblique. 
 Position. 
 
 THE BIGHT lies under the second rib. 
 
 THE LEFT lies under the second intercostal space. 
 Length. \ 
 
 THE MIGHT is about one inch long. 
 
 THE LEFT is nearly two inches long. 
 Calibre. 
 
 THE MIGHT bronchus is larger than the left. 
 
 Fig. 7.— Relations of the heart (Holden). 
 LANDMARKS OF THE HEART. 
 OUTLINE of the heart. ^ 
 
 The Base nearly corresponds in level with the superior 
 margin of the third rib. 
 
LANDMARKS OF THE CHEST. 2ii 
 
 The Apex lies under the fifth intercostal space, 
 
 TIFO INCHES BELOW the nipple (in the male) and 
 HALF AN INCH TO THE RIGHT of the left mam- 
 millary line. 
 
 The Right Margin corresponds with a line beginning on 
 the third costal cartilage half an inch to the right of 
 the right sternal line, curving slightly to the right and 
 downward to the end of the sternum. 
 
 The Left Margin corresponds with a line Ijeginning on 
 the third costal cartilage an inch to the left of the left 
 sternal line, curving to the left and downward to the 
 apex beat, but not including the nipple. 
 
 The Lower Margin corresponds nearly with a line join- 
 ing the apex and the end of the sternum. 
 
 RELATION of the heart to the lung in front. 
 
 It is Covered by the lung (Gardiac dulness) from the 
 upper margin of the third to the lower margin of the 
 fourth rib, and below the fourth rib between the para- 
 sternal line and the left margin of the heart. 
 
 It is Uncovered by the lung {cardiac flatness) in the tri- 
 angular or irregularly quadrilateral area bounded on 
 the right by the meso-sternal line, on the left and above 
 by a line drawn from the fourth costal cartilage to a 
 point a little to the right of the apex beat. 
 
 VALVES of the heart. 
 Position (Gray). 
 
 semilunah valves. 
 
 THE PULMONIC valve lies behind the left sternal 
 line at the level of the third costal cartilage. 
 
 THE AORTIC valve lies close to the left sternal line, 
 behind the third intercostal space. 
 
 auriculo-ventricular valves. 
 
 THE TRICUSPID valve lies behind the meso-sternal 
 line about the level of the fourth costal cartilage. 
 
30 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 THE BICUSPID or mitral valve lies about one inch 
 to the left of the sternum behind the third inter- 
 costal space. 
 
 LANDMAEKS OF THE AOKTA. 
 
 The aorta is most superficial in the right second intercostal 
 space at the edge of the sternum. The arch of the aorta 
 lies an inch below the inter-clavicular notch. 
 
 LANDMAEKS OF THE INNOMINATE AETEEY. 
 Its course may be traced by an oblique line drawn from 
 the mid-sternal line at the level of the second costal cartilage 
 to the right sterno-clavicular articulation. 
 
 LANDMAEKS OF THE LIVEE. 
 
 RIGHT LOBE of the liver. 
 Its Upper Margin lies, 
 
 IJ^ THE 3IAM3IILIjARY LINE, at the fourth in- 
 tercostal space. 
 IN THE MID-AXILLABY LINE, at the sixth rib. 
 IN THE SCAPULAR LINE, at the eighth rib. 
 Its Lower Margin lies half an inch beloAV the costal arch, 
 
 in the average healthy adult male. 
 Relation of the liver to the lung. 
 
 IT IS COVERED by lung {hepatic dulness), 
 
 IIM THE MAMMILLARY LINE, from the fourth inter- 
 space to the sixth rib. 
 IN THE MID- AXILLARY LINE, from the sixth to the 
 
 eighth rib. 
 IN THE SCAPULAR LINE, from the eighth to the 
 tenth rib (the lower margin of the lung may be 
 depressed an inch and a half on deep inspiration). 
 IT IS UNCOVEREn by lung {hepatic flatness) from 
 these points (sixth, eighth, and tenth ribs) down- 
 ward. 
 
LANDMARKS OF THE CHEST. 31 
 
 LEFT LOBE of the liver. 
 
 Its Upper Margin lies under and against the diaphragm, 
 adjoining the heart. 
 
 Its Lower Margin (in the median line) lies about mid- 
 way between the end of" the appendix sterni and the 
 umbilieus. 
 
 Its Left Margin reaehes nearly to the left manunillary 
 line. 
 
 LANDMAKKS OF THE SPLEEX. 
 THE SPLEEN IS COMPLETELY SHELTERED Ixnealli 
 the ribs, and cannot be felt in health except in rare cases. 
 THE OUTLINE of the spleen. 
 
 Its Upper Margin lies under the ninth rib. 
 Its Lower Margin lies under the eleventh ril). 
 Its Anterior Extremity nearly reaches the linea costo- 
 articularis, drawn from the free end of the eleventh rib 
 to the left sterno-clavicular articulation. 
 Its Posterior Extremity approaches within two-thirds 
 of an inch of the body of the tenth dorsal vertebra. 
 
 THE DIRECTION is obliquely backward and upward, the 
 long axis corresponding nearly with the direction of the 
 tenth rib. 
 
 THE RELATION of the spleen to the lung. 
 
 It is Covered by lung in its posterior and upper third, 
 which lies in the infra-scapular region. 
 
 It is Uncovered by lung in its anterior and lower two- 
 thirds, which lie chiefly in the infra-axillary region. 
 
 LANDMARKS OF THE VEKTEBR^. 
 
 THE SEVENTH CERVICAL VERTEBRA, vertebra 
 prominens, is readily made out. 
 
 THE TWELFTH DORSAL VERTEBRA may be located 
 by reference to the twelfth rib, which may be felt when 
 the lumbar muscles are relaxed ; in muscular subjects it 
 
32 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 may be located by following the lower margin of the 
 trapezius muscle. 
 
 ALL THE SPINES are located by slight friction with the 
 finger, reddening the skin over their tips. 
 
 SLIGHT CURVATURE of the vertebral column to the 
 right or left exists in right- or left-handed persons. 
 
 LANDMAEKS OF THE EIBS. 
 
 THE SECOND RIB is on a level with the prominence (angle 
 of Lewis), more or less marked in all persons, at the junc- 
 tion of the first and second pieces of the sternum. 
 
 THE SEVENTH RIB lies at the inferior angle of the scap- 
 ula when the arms hang at the sides. 
 
 THE FIFTH RIB is just covered by the convex lower bor- 
 der of the pectoral is major. 
 
 THE THIRD COSTO-STERNAL JUNCTION is on a 
 
 level with the body of the sixth dorsal vertebra. 
 
 THE HORIZONTAL NIPPLE LINE cuts the sixth inter- 
 costal spaces in the mid-axillary lines. 
 
 THE ELEVENTH AND TWELFTH RIBS can always be 
 felt when the abdominal wall is relaxed. 
 
 THE INFERIOR END OF THE STERNUM is on a level 
 with the tenth dorsal vertebra. 
 
 LANDMAEKS OF THE SCAPULA. 
 
 The scapula lies over the ribs from the second to the 
 seventh. The inner end of the spine of the scapula is 
 nearly on a level with the third dorsal vertebra, main 
 bronchus, and beginning' of the pulmonary fissures behind. 
 
METHODS OF PHYSICAL DIAGNOSIS. ',V^ 
 
 METHODS OF PHYSICAL DIAGNOSIS. 
 
 The methods of physical examination are inspection, pal- 
 pation, mensuration, percussion, auscultation, and succussion. 
 
 INSPECTION. 
 Inspection reveals color, nutrition, size, form, posture, and 
 movements. 
 
 COLOR may be due to pigmentation, or vascularization, or 
 both. 
 Color dependent upon pigmentation may be 
 NOR3IAL, 
 
 LOCAL, as in the areola? about the nipples, color of 
 
 the eyes and hair. 
 GENERAL, as in the Negro, Malayan, Indian, bru- 
 nette, and blonde. 
 ABNORMAL. 
 
 LOCAL, moles, lentigo, chloasma, the seat of scars, 
 
 leucoderma. 
 GENERAL, icterus, argyria, Addison's disease. 
 Color dependent upon vascularization. 
 
 XOB3IAL^ erythema, ruddy complexion or the opposite. 
 ABNORMAL. 
 LOCAL. 
 
 Arterial, congestion, eruptions, etc. 
 Venous, ecchymosis, enlarged superficial veins and 
 capillaries. 
 GENERAL. 
 
 Arterial, congestion, or its opposite, pallor, chloro- 
 sis, anaemia. 
 Venous, cyanosis, morbus cseruleus. 
 Color dependent upon both vascularization and pigmenta- 
 tion is observed in various cachexise, malignant disease, 
 disease of the liver, etc. 
 NUTRITION is manifested by the degree of fatty deposits 
 or nuiscular development, as well as by the color. 
 
34 
 
 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 SIZE of the chest. 
 
 Normal size of the chest. 
 
 CIBCUMFEBENCE of the chest at the level of the 
 nipples in man, just above the mammse in women. 
 AVERAGE circumference thirty-four inches in men, 
 
 thirty-two in women. 
 USUAL E XT R E M ES, twenty-eight to forty-four inches. 
 
 Chest-measurement as related to Height and Weight. 
 
 Height. 
 
 Chest 
 
 Standard 
 
 20 per cent. 
 
 45 per cent. 
 
 
 Weight. 
 
 under weight. 
 
 over weight. 
 
 5 feet 
 
 33J 
 
 115 
 
 92 
 
 167 ' 
 
 5 " 1 in. . . . 
 
 34 
 
 120 
 
 96 
 
 174 
 
 5 " 2 " . . . 
 
 35 
 
 125 
 
 100 
 
 1811 
 
 5 " 3 " . . . 
 
 36 
 
 130 
 
 104 
 
 188* 
 
 5 '' 4 " . . . 
 
 36J 
 
 135 
 
 108 
 
 195 
 
 5 " 5 " . . . 
 
 37 
 
 ]40 
 
 112 
 
 203 
 
 5 " 6 « . . . 
 
 37i 
 
 143 
 
 1]4 
 
 207 
 
 5 " 7 " . . . 
 
 38 
 
 145 
 
 116 
 
 210 
 
 5 " 8 " . . . 
 
 38i 
 
 148 
 
 119J 
 
 215 
 
 5 " 9 " . . . 
 
 39 
 
 155 
 
 124 
 
 224^ 
 
 5 " 10 " . . . 
 
 m 
 
 160 
 
 128 
 
 232 
 
 5 " 11 " . . . 
 
 m 
 
 165 
 
 132 
 
 239 
 
 6 " 
 
 41 
 
 170 
 
 136 
 
 246 
 
 RESPIRATORY EXPANSION, two to seven inches. 
 Average of the chest, two inches and a half. 
 Usual Extremes, two to four inches. 
 SE3II-CinCV3IFEIiENCE laterally. 
 
 THE RIGHT SIDE is usually half an inch larger than 
 the left in right-handed persons. 
 Abnormal size in 
 
 CIRCU3IFEnENCE ; this may be disproportionately 
 SMALL compared with the vertical diameter of the 
 chest, when it is generally associated with flatness 
 or hollowness of the upper anterior part of the 
 chest, wing-like projection of the scapulae, an acute 
 costal angle, and deficient respiratory expansion. 
 The circumference is apt to be disproportionately 
 
METHODS OF PHYSICAL DIAGNOSIS. Zh 
 
 LARGE in marked emphysema. 
 SEMI-€lIiCUMFERENCE ; either side of the chest 
 may be 
 SMALL compared with the other, as a result of fibroid 
 contractions of the lung on that side, following 
 pleurisy, pneumonia or collapse. It may be 
 LARGE as compared with the other, in case of exten- 
 sive pleuritic effusion or pneumothorax. 
 FORM of the chest. 
 
 Normally the chest is a nearly symmetrical, truncated, 
 conical pyramid, flattened slightly in its antero-posterior 
 diameter. 
 Abnormal forms of the chest. 
 ASYMMETRIC AIj forms. 
 
 LOCAL BULGINGS may be due to irregularities of the 
 * Chest-wall ; tumors or swellings such as sarcoma, 
 
 abscess, periostitis, or deformities of the bony 
 framework. 
 Pressure from within, due to the 
 Thoracic Organs. 
 Circulatory organs. 
 
 Enlargement of the heart in children. 
 Hydro- or pneumo-pericardium, aneurysm. 
 Lungs and Mediastinum. 
 Tumors or sw^ellings. 
 
 Pleuritic accumulation of gas, fluid, or solids, 
 e. g, pneumothorax, serothorax, tumors. 
 Abdominal Organs. 
 
 Enlargement of abdominal organs. 
 Abnormal accumulation of gas, fluid, or solids, 
 encroaching upon the thorax. 
 LOCAL DEPRESSIONS, as the retraction of the supra- 
 and infra-clavicular regions from contraction of the 
 apex of the lungs in phthisis ; or the retraction of 
 the chest in any region following fibroid induration 
 of the lung. 
 
36 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 RELATIVELY SYMMETRICAL forms of the ab- 
 normal chest. 
 
 THE PIGEON BREAST deformity of the chest occurs 
 chiefly in childhood^ and is characterized by lateral 
 constriction of the thorax, with straightening of 
 the true ribs and prominence of the lower end of 
 tlie sternum ; this is a result of rhachitis. 
 
 THE RHACHITIC CHEST is de^veloped in early life ; it 
 is characterized by lateral retraction of the thoracic 
 walls, the anterior surface being broader than in 
 the pigeon breast, and the sternum less prominent ; 
 the costo-chondral junctions are thickened, pre- 
 senting a series of bead-like eminences known as 
 the rhachitlc rosary, 
 
 THE ALAR CHEST is characterized by ving-Iihe pro- 
 jections of the scapulae, usually associated witli a^ 
 narrow chest, sloping shoulders, and an acute costal 
 angle. It is commonly significant of constitutional 
 weakness, which favors the development of pul- 
 monary phthisis. 
 
 THE EMPHYSEMATOUS OR BARREL-SHAPED 
 CHEST is characterized by roundness of contour, 
 the antero-posterior diameter being lengthened, the 
 transverse diameter shortened, and the upper end 
 of the sternum prominent ; the intercostal spaces 
 are wide and full, the shoulders are thrown for- 
 ward, the scapulae separated, and the whole pos- 
 ture stooping. 
 
 FUNNEL BREAST, characterized by sinking in of the 
 lower end of the sternum, is a congenital deformity 
 sometimes observed in several branches of the same 
 family ; it may be so marked as to interfere seriously 
 with respiration. Shoemakers^ breast is an acquired 
 deformity of similar form, and is caused by the 
 pressure of tools against the lower part of the 
 sternum. 
 
METHODS OF PHYSICAL DIAGNOSIS 37 
 
 HARRISON'S GROOVE is a horizontal line of depres- 
 sion along the false ribs, corresponding to the in- 
 sertion of the diaphragm ; it is sometimes observed 
 in conditions of chronic inspiratory dyspnoea neces- 
 sitating powerful action of the diaphragm, especially 
 in rhachitic children. 
 
 SPINAL curvatures; the chest may be asymmet- 
 rical or symmetrical, deviations being either antero- 
 posterior or lateral, or both. These may be due 
 either to defective development of the bodies of the 
 vertebrae or to caries. 
 
 POSTURE. The position of the body as a whole or in its 
 parts is significant as an aid to diagnosis. 
 Voluntary posture, as ordered by the examiner. 
 NATURAL postures. 
 
 FIXED position, upright, standing, sitting, recumbent. 
 CHANGE from the upright posture to recumbency 
 may reveal movable organs, fluids or gases, or 
 evidence of pain. 
 UJVNA TUBAL or specially-arranged postures to facil- 
 itate examinations — genu-pectoral, left lateral semi- 
 prone, etc. 
 Involuntary posture, as assumed by the patient as a re- 
 sult of disease. 
 r OS TUBE OF THE BODY AS A WHOLE. 
 
 DROOPING, relaxed, or reclining posture as indicat- 
 ing lassitude, debility, helplessness. 
 FORWARD, BACKWARD, OR LATERAL inclination 
 more or less fixed, as a result of 
 Brolonf/ed Habit, or from occupation. 
 PartUd Desfruction ftf the Bony Suirport (Pott's 
 
 disease, etc.). 
 Muscular Contraction from 
 
 Infj.ammation of the soft parts, and 
 Abxormal Prp:ssures from tumors or enlarged 
 
38 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 organs — viz. forward inclination to relieve the 
 backward pressure of an aneurysm or other 
 tumor against the trachea, marked flexion of 
 the body in peritonitis, colic, etc. 
 Lesions of the Central or Peripheral Nervous 
 System may produce opisthotonos or over-exten- 
 sion of the vertebral column from tonic contrac- 
 tion of the posterior, cervical, dorsal, and lumbar 
 muscles, with associated extension of the thighs 
 and extension of the legs in tetanus, spinal menin- 
 gitis, hysteroid convulsions. 
 RECUMBENCY UPON OR INCLINATION TOWARD 
 THE AFFECTED SIDE is common in the first stage 
 of pleurisy. 
 INABILITY TO LIE ON THE AFFECTED SIDE in 
 many cases of pleurisy with effusion, and in case 
 of superficial inflammations, or in some cases of 
 cardiac disease. 
 INABILITY TO LIE DOWN AT ALL in certain cardiac 
 and pulmonary diseases interfering with respira- 
 tion — viz. asthma. 
 POSTURE OF THE BODY IN ITS PARTS. 
 FIXED POSITION of the limbs in any position in 
 
 catalepsy. 
 LIMBS RELAXED or parts of the body drawn to the 
 
 opposite side in unilateral paralysis. 
 LIMBSOR HEAD DRAWN INTO DISTORTED POSI- 
 TIONS by muscular or fibroid contractions. 
 POSITION OF A LIMB involuntarily corresponds 
 to that giving least pain in disease of the 
 joints. 
 FACIAL EXPRESSION is closely related to posture, 
 and depends largely upon the influence of the in- 
 tellect, feeling, and will. 
 
 Intellectual, expression of intelligence or imbe- 
 cility, etc. 
 
METHODS OF PHYSICAL DIAGNOSIS. 39 
 
 Er¥iotional, expression of pain, anxiety, fear, grief, 
 
 anger, joy, etc. 
 7 olitlonal. 
 
 Voluntary control in the change of expression. 
 Involuntary distortion of features as seen in 
 paralysis and contraction. 
 
 MOVEMENTS. 
 
 General nuiscular movements are of interest as being 
 normally or abnormally present or absent, as in paralysis 
 and chorea, or as eliciting pain. 
 GAIT is peculiar in various diseases of the central or 
 
 peripheral organs. 
 CONVULSIONS OR TRE3IOBS may be present. 
 COUGHING, SNEEZING, SNORING, SIGHING, 
 YA WNING, AND HICCO UGH, while visible signs 
 as well as symptoms often of disease, are better classed 
 with subjective features. Cough as a sign is referred 
 to under Auscultation. 
 Respiratory movements. 
 
 NOR3IAL breathing is termed eupncea. The two sides 
 of the chest should expand equally, and the upper 
 part of the chest should be Vv'ell filled with each 
 inspiration. There is a slight falling in of the inter- 
 costal spaces during inspiration, and a corresponding 
 shallowness of these during expiration. 
 THE RHYTHM or ratio of the inspiratory to the ex- 
 piratory aet is as six to seven (Gibson), there being 
 no pause between them. 
 THE TYPES of respiration include costal or superior 
 costal breathing as observed in women, inferior 
 costal breathing as usually observed in men, ab- 
 dominal or diaphr<t(prw.tic breathing as seen in 
 children. 
 THE RAPIDITY of normal respiration varies accord- 
 ing to 
 

 U 
 
 per 
 
 minute, 
 
 years 
 
 26 
 
 
 iC 
 
 u 
 
 20 
 
 
 ii 
 
 ve" 
 
 18 
 
 
 u 
 
 Y " 
 
 16 
 
 
 a 
 
 '^ 
 
 18 
 
 
 a 
 
 40 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Intrinsic Conditions, 
 
 Age. 
 
 Under one year, 
 One to five 
 Five to twenty 
 Twenty to twenty-five ^^ 
 Twenty-five to thirty 
 Thirty to fifty 
 Physical 
 
 State, posture. 
 
 Activity, general muscular, digestion, etc. 
 Mental 
 
 State, temperament. 
 Activity, emotional, volitional. 
 Extrinsic Conditions, 
 
 Rarity of the Atmosphere, elevation, etc. 
 Excessive Heat acting on body-temperature. 
 ABNORMAL breathing regards the 
 FORM of the chest during respiration. 
 
 Edcjiansion of the chest in abnormal breathing. 
 Diminished expansion may be unilateral or bi- 
 lateral {vide tlie conditions and causes of feeble 
 respiration). 
 Bulging" of the intercostal spaces during expira- 
 tion is observed in emphysema. 
 detraction of the soft parts of the chest, xiphoid 
 process, and false ribs in inspiration occurs in 
 croup, paralysis of the vocal cords, and other 
 conditions involving obstruction of the upper 
 air-passages. 
 RAPIDITY OF ABNORMAL RESPIRATION. 
 
 Ahnornially Mapid respiration is termed hy- 
 
 j^erpnoea. This is observed in most conditions 
 
 causing dyspnoea (vide), notably in the following : 
 
 In Fever, especially in nervous persons, and in 
 
 children. 
 
METHODS OF PHYSICAL DIAGNOSIS 41 
 
 In all Conditions Causing Painful Breathing-, 
 
 such a8 diseases of the pleura, dia})hragm, aud 
 
 peritoneum, fracture of the ribs, pleurodynia. 
 
 In Diseases Narrowing the Bronchial Tubes : 
 
 asthma, bronchitis. 
 In Conditions Lessening the Aerating and Cir- 
 culatory Areas of the Lungs. 
 Pulmonary Disease: emphysema, cedema, 
 
 pneumonia, etc. 
 Pleuritic Affections : air, fluids, or solid 
 tumors in the pleural cavity pressing on the 
 lungs. 
 Abdominal Affections : tumors, swellings, 
 or effusion, or gas. 
 In Disease of the Heart affecting the pulmonary 
 
 circuit. 
 In some Diseases of the Nervous System. 
 Abnormalli/ Slow liespiration might well be 
 termed hypopncea. This is observed in the 
 course of Cheyne-Stokes respiration, and some- 
 times in diseases of the brain and meninges; in 
 acute infectious diseases with marked mental 
 dulness; in stenosis of the upper air-passages, 
 due to intra-tracheal tumors, foreign bodies, in- 
 flammation, compressions from without, and 
 paralysis of the abductors of the vocal cords. 
 S'tispefided Hespiratiofi is termed ajpncea, which is 
 due to want of a proper stimulus to respiration, 
 owing to saturation of the blood with oxygen 
 and the presence of a deficient amount of car- 
 bonic-acid gas ; it is observed in the course of 
 Cheyne-Stokes respiration. It seems to be the 
 condition of the foetus in utero. 
 Asphyxia literally means absence of the pulse — 
 i. e, the almost pulseless condition of suspended 
 vitality resulting from lack of oxygen in the 
 
42 PHYSICAL I) f A GNOSIS OF THE CHEST. 
 
 blood or its saturation with COg. The stages of 
 asphyxia (Landois) are 
 Hyperpnoea, lasting about one minute. 
 Convulsions, lasting about one minute. 
 Exhaustion, lasting about three minutes, during 
 which the heart continues to beat, but feebly. 
 When the heart ceases to beat recovery is im- 
 possible. '' 
 VARIATION IN THE RHYTHM OF RESPIRATION. 
 An increase in the number or depth of respirations, 
 or both, is the chief characteristic of dyspnoea or 
 difficult breathing. 
 Dyspticea. 
 
 Varieties of Dyspncea. 
 
 Inspiratory dyspnoea : dyspnoea may be 
 purely inspiratory, or it may be associated 
 with difficult expiration in varying degree ; 
 it is the result of obstruction to the ingress 
 of air into the lung, and is observed in 
 croup, compression of the trachea, and 
 paralysis of the diaphragm, etc. 
 Expiratory dyspnoea, pure, or associated 
 with difficult inspiration, is due to obstruc- 
 tion to the exit of air from the lung, as is 
 typically observed in asthma and emphy- 
 sema. 
 Mixed expiratory and inspiratory dyspnoea is 
 most frequent ; it is observed in many dis- 
 eases of the lungs and heart, and in fever. 
 Exaggerated dyspnoea, or orthopnoea, re- 
 quiring the sitting or standing posture and 
 the use of the extra muscles of respiration, 
 is observed in acute asthma and in advanced 
 cardiac disease, etc. 
 Cheyne-Stokes Respiration is character- 
 ized by a number of shallow respirations 
 
METHODS OF PHYSICAL DIAGNOSIS 43 
 
 which become deeper and more dyspnoeic to 
 a given point at whieli there may be a groan, 
 and then grow more superficial till they ap- 
 ])arently cease ; after a pause (apnoea) the 
 series is repeated, the whole cycle occupying 
 from thirty-five seconds to a minute, the 
 number of respirations usually being about 
 thirty. During the pause the pupils are 
 contracted and inunobile to light, and con- 
 sciousness is usually lost. In some cases 
 consciousness returns with deep breathing, 
 and the pupils dilate and react to light. 
 This is normal in animals during hiberna- 
 tion ; abnormal in man, due to cerebral or 
 medullary disease (meningitis, hemorrhage, 
 tumors), uraemia, certain affections of the 
 heart, and to opium-poisoning. 
 Causes of DyspncBa, 
 
 Respiratory causes of Dyspncea may de- 
 pend upon 
 Insufficient quantity of air supplied to the 
 lungs, owing to — 
 
 1. Imperfect respiratory movements, due 
 
 to— 
 (a) Paralysis, lesions of the central or 
 
 peripheral nervous system. 
 (6) Pain, as in inflammation of the 
 
 pleura and peritoneum, pleurodynia, 
 
 intercostal neuralgia, trichinosis of 
 
 the diaphragm, etc. 
 (c) Muvscular weakness. 
 {d) Yielding walls of the chest due to 
 
 rickets and fractures. 
 (e) Loss of elasticity of the chest- wall : 
 
 myositis ossificans, scleroderma. 
 
 2. Loss of elasticity of the lungs from 
 
44 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 emphysema^ pleuritic adhesion, pro- 
 longed compression. 
 
 3. Lessened capacity of the chest, due 
 
 to— 
 
 (a) Bony malformations. 
 
 (b) Pressure from thoracic or. abdom- 
 inal effusion or tumors. 
 
 4. Lessened lumen of the air-passages : 
 
 (a) Extra-mural causes : cicatricial con- 
 tractions, pressure of tumors, etc. 
 
 (b) Intra-mural causes : thickening of 
 the walls of the air-passages, mus- 
 cular spasm, as in bronchitis, asthma, 
 and laryngismus stridulus. 
 
 {(') Inter-mural : foreign bodies, secre- 
 tions, and false membranes within 
 the air-passages. 
 
 5. Diminished surface for circulation and 
 
 interchange of gases in the huig, 
 owdng to — 
 
 (a) Inflammation of the lungs : pneu- 
 monia, fibrosis, tuberculosis. 
 
 (6) Collapse or compression of the lung 
 from pressure of air, fluid, or solids : 
 tumors, pleuritic efl'usion, pneumo- 
 thorax. 
 
 (c) Destruction of the alveolar capil- 
 lary network, as in emphysema. 
 
 Modified quaJity of the. air which is inhcded. 
 
 1. Insuflicient density due to heat, high 
 altitude, decreased atmospheric pres- 
 sure. 
 
 2. Del^eterious adulterations : noxious 
 gases, etc. 
 
 3. Insuflicient oxygen. 
 CiRCULATOEY CAUSES OF Dyspncea include 
 
METHODS OF PHYSICAL DIAGNOSIS. 45 
 
 Diminished quantity of blood aerated ^ owing 
 to— 
 
 1. Oligsemia, after acute lieinorrliage. 
 
 2. Pulmonary ischseniia, from 
 
 (a) T7.S' a f route, due to 
 PuliiKJiiary disease : emphysema, 
 
 fibrosis, compression, etc. 
 Arterial disease. 
 
 Extra-mural : compression, liga- 
 tion. 
 
 Intra-mural : inflammation of the 
 arterial coats. 
 
 Inter-mural : eml)olism. 
 
 (b) Vis a tergo may be diminished 
 
 owing to 
 Cardiac inefficiency from 
 Valvular disease. 
 Compression of the heart by peri- 
 cardiac or pleuritic effusion. 
 Muscular weakness of the heart 
 from atrophy, myocarditis, de- 
 generation, etc. 
 Modified quality of the blood. 
 
 1. Super-heated blood acts on the re- 
 spiratory centre, heat-dyspnoea. 
 
 2. Deteriorated blood : pernicious anae- 
 mia, fevers, poisons. 
 
 Circulatory Movements. 
 
 VASCULAR MOVEMENTS, 
 VENOUS movements (pulsations). 
 Normal Venons Movefiients, 
 
 Jugular Presystolic pulsation (slight) is rarely 
 visible in health (Vierordt). 
 Abnormal Venous Movent en fs. 
 
 Jugular Systolic pulsation occurs in tricuspid 
 regurgitation. 
 
46 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Hepatic venous systolic pulsation is sometimes 
 visible in marked tricuspid regurgitation. 
 ARTERIAL movements (pulsation). 
 Normal Arterial Movements. 
 
 Carotid pulsation is frequently visible under the 
 angle of the jaw, varying with the degree of 
 adiposity and the force and excitation of the 
 heart. 
 Aortic pulsation is exceptionally visible in the 
 supra-sternal region (high position of the 
 arch). 
 Abnormal Arterial Pulsation, 
 
 Carotid pulsation, when marked, may signify 
 hypertrophy of the left ventricle, insufficiency 
 of the aortic valve, arterial sclerosis (aortic), 
 or aneurysm. 
 .Aortic pulsation 
 
 In the neck is sometimes due to insufficiency 
 of the aortic valve, to aneurysm, or to hy- 
 pertrophy of the left ventricle. 
 In the eight second intercostal space 
 pulsation is always abnormal, and is usually 
 significant of one of the conditions just 
 mentioned. 
 Pulmonary arterial pulsation appears to the left 
 of the sternum in aneurysm of this artery. 
 Pulsation of this artery may sometimes be 
 seen in fibrosis of the lung. 
 Capillary pulsation (Quincke) may be seen in 
 Marked hypertrophy of the left ven- 
 tricle, but more often in marked aortic 
 INSUFFICIENCY. The pulsation is observed 
 in the bed of the finger-nails, at the fundus 
 of the eye, in the mucous membrane of the 
 lip under pressure of a glass slide, and also 
 in the line of erythema caused by drawing 
 
METHODS OF PHYSICAL DIAGNOSIS. 47 
 
 the finger-nail with some force over the ])a- 
 tient's surface. 
 CARDIAC MOVEMENT (pulsation). 
 APEX BEAT of the heart. 
 
 Cause of the apex beat : The lieart changes in 
 form, sliortening and thickening, in systole, and 
 at the same time changes in position, revolving 
 on its axis, the apex being projected forward. 
 VisibiUff/ of the apex beat. 
 Normally the visibility varies with tlie 
 
 Shape of the chest and the width of the 
 
 intercostal spaces ; 
 Thickness of the chest-wale from the 
 presence of fat, muscle, and mammary 
 gland ; 
 Posture of the body, the apex being less 
 
 visible in recumbency ; 
 Force of the heart's action, as dependent 
 upon its innate power and its excitation. 
 Abnormally the visibility of the apex beat varies 
 greatly. 
 Very marked pulsation is usually observed 
 
 in hypertrophy ; 
 Slight or absent pulsation is observed in 
 Conditio us of cardiac iveakness from 
 
 1. General debility, or 
 
 2. Local weakness of the heart\s muscle, 
 dependent upon cardiac atrophy ; cardiac 
 degeneration, fatty, fibroid, or amyloid ; 
 or cardiac dilatation. 
 
 Interposition of air between the heart and 
 chest-vmll : emphysema, pneumothorax, 
 pneumo-pericardium ; ^w/V? ; pleuritic or 
 pericardiac effusion ; solids : tumors, 
 fibrinous deposit. 
 
 Thicket liny of the chest-vmll : excessive fat, 
 
48 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 scleroderma^ oedema, emphysema of the 
 chest-wall. 
 Blsplaeement of the heart , as by traction 
 from behind by fibroid contraction. 
 Locution of the apex beat. 
 
 Normal Location of the Apex Beat. 
 
 In the adult male it is in the fifth inter- 
 costal space, two inches below and one inch 
 inside the nipple line. 
 Variations from the position in the healthy 
 adult male accord with 
 Age : in children under ten years the apex 
 beat is usually in the fourth intercostal 
 space inside or outside the left mammillary 
 line ; in old age it is apt to be lower down, 
 sometimes in the sixth intercostal space. 
 Respiration. Deep inspiration may carry it 
 
 down to the sixth interspace. 
 Posture on the 
 
 1. Left side, may carry it to the left of 
 the nipple line. 
 
 2, Right side, to the right of the usual 
 position. 
 
 Physical exertion or emotion. The apex beat 
 
 may become stronger or broader, or may 
 
 be carried to the left when the individual 
 
 is greatly excited. 
 
 Abnormal Location of the Apex Beat ; it may 
 
 be displaced. 
 Upward. 
 
 Pushed up by deformity of the chest- wall ; 
 pericardiac effusion (here it is apparently 
 so) ; abdominal tympanitis, tumors, and 
 ascites ; paralysis of the diaphragm. 
 
 Pulled upward by fibroid contraction of the 
 upper lobe of the left lung. 
 
METHODS OF PHYSICAL DIAGNOSIS. 49 
 
 Upward and to the left. 
 
 Fashed upward and to the left by hyper- 
 trophy of the left lobe of the liver or by 
 abdominal tumors. 
 Pulled by fibroid contractions of the left 
 lung. 
 Downward and to the left. 
 
 Pushed downward and to the left by de- 
 formity of the chest-wall ; large aneurysm 
 of the arch of the aorta ; mediastinal tu- 
 mors ; riglit pleuritic effusion or pneumo- 
 thorax ; hypertrophy of the left ventricle 
 (strong apex beat); dilatation of the left 
 ventricle (weak apex beat). 
 Pulled downward and to the left V)y fibroid 
 contractions of the pleura and lung. 
 To the right. 
 
 Pushed to the riglit Ijy deformity of the chest- 
 wall, emphysema of the lungs, leftpleuritic 
 effusion, or pneumothorax. 
 Pulled to the right by fibroid contractions 
 of the right lung, or held by pleuritic 
 adhesion. 
 Located on the right side in transposition of 
 the thoracic organs (a rare condition). 
 PRECORDIAL PULSATION is observed together with 
 the apex beat, 
 In Valvular Disease frequently ; in cardiac irrita- 
 bility, especially in thin or young persons ; in 
 adhesive pleurisy with mediastinal pericarditis, 
 here there is usually a systolic drawing in of 
 several intercostal spaces. 
 Til Infiltration, of tJie Jjiing lying in front of the 
 
 heart. 
 In Empyema Pulsans, v/hich may occur when 
 pus in the pleural cavity lies in front of the 
 
50 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 heart, the cardiac movements being communi- 
 cated to the fluid. It is probably favored by 
 paresis of the intercostal muscles, high tension 
 in the fluid and a powerful heart. 
 EPIGASTRIC PULSATION. 
 
 Hypertr'02}hy of the Itight Ventricle, especially 
 if accompanied by pulmonary emphysema, fre- 
 quently causes a systolic pulsation or trembling 
 of the epigastrium. 
 
 Fulsation of the Normal Heart may be trans- 
 mitted to the epigastrium through an hyper- 
 trophied left lobe of the liver. 
 
 Pulsation of tlie Normal Aorta may be seen in 
 the epigastrium in thin persons, especially when 
 the stomach is empty. 
 
 Pulsation of an Abdominal Arieiirysm of the 
 aorta may be visible in the epigastrium. 
 
 Venous Hepatic Pulsation^ observed in the epi- 
 gastrium, may occur in marked tricuspid in- 
 sufficiency (rare). 
 
 PALPATION. 
 
 Palpation is the method of physical examination by the 
 sense of touch, and it confirms much of what has been ob- 
 tained by inspection ; it reveals 
 
 SIZE, SHAPE, contour, roughness, etc. 
 CONSISTENCE, fluctuation, 
 
 MOISTURE AND HEAT; and elicits 
 
 PAIN. 
 Area. 
 
 LOCALIZED, as in intercostal neuralgia (Yalleix's 
 
 three tender points). 
 GENEMAL sensitiveness, hypersesthesia. 
 
METHODS OF PHYSICAL DIAGNOSIS. 51 
 
 Depth. 
 
 SUPERFICIAL. 
 
 SKIN, inflammation. 
 M use LE , pleurodynia. 
 
 FRACTURE OF RIBS (crepitus, tenderness, disloca- 
 tion). 
 DEEB-SEA TED, 
 PLEURA. 
 
 MOVEMENTS. 
 Muscular. 
 Respiratory. 
 Circulatory. 
 
 CARDIAC MOVEMENTS, apex beat, precordial pul- 
 sation, etc. {vide under inspection). 
 EXTENT. 
 Localized, 
 Diffused. 
 CHARACTER. 
 Intensity. 
 Rhythm, 
 VENOUS MOVEMENTS. 
 ARTERIAL MOVEMENTS upon palpation, 
 AORTIC dilating pulsation of aneurysm, etc. 
 CAROTID pulse. 
 RADIAL pulse. 
 
 Factors in the Production of the Pulse, 
 Force of the Heart's Beat. 
 Elasticity of the Large Vessels. 
 Resistance at the Valvular Orifices of the 
 
 heart. 
 Resistance in the Arterioles and capillaries. 
 Volume of the Blood. 
 Characteristics of the Pulse, as regards 
 Quality of the pulse. 
 
 Degree of tension of the pulse. 
 
52 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Increased or high tension makes the incom- 
 pressible or hard pulse. Tension is 
 increased during inspiration, being 
 highest : 
 
 1. At the beginning of expiration, except 
 in pulsus paradoxicus. 
 
 2. By accelerated action of the heart. 
 
 3. By stimulation of the vaso constrictors, 
 as by the action of cold, electricity, and 
 certain drugs. 
 
 4. By diminished outfloAv of blood at the 
 periphery. 
 
 5. By disease of the vessel walls : athero- 
 ma, sclerosis, old age ; drugs — e. g. 
 lead-poisoning. 
 
 6. By compression of the large arterial 
 trunks, ligation, or pressure. 
 
 7. By impeded venous flow, as in preg- 
 nancy, constipation, chronic bronchitis, 
 emphysema, nephritis, etc. 
 
 Decreased or low tension makes the com- 
 pressible or soft pulse ; tension is de- 
 creased during expiration, being lowest : 
 
 1. At the beginning of inspiration, ex- 
 cept in pulsus paradoxicus. 
 
 2. After a hemorrhage. 
 
 3. By stoppage of the heart. 
 
 4. In elevated parts of the body. 
 
 5. By stimulation of the vaso dilators, 
 action of drugs. 
 
 Degree of fulness of the artery or volume 
 of the pulse. 
 Increased volume of the pulse makes the 
 large or full pulse. This is seen in car- 
 diac liypertrophy, plethora, early stage of 
 chronic nephritis. 
 
METHODS OF PHYSICAL DIAGNOSIS. 53 
 
 Decrea.s('({ vohiiiw of the pulse makes the 
 small empty pulse as seen in general 
 weakness from wasting disease, cardiae 
 weakness, cardiac valvular lesions, aortic 
 stenosis, mitral stenosis, or marked in- 
 sufficiency without compensation. 
 Alternate increase and decrease of the volume 
 of the pulse is observed in aortic insuf- 
 ficiency, giving the collapsing or icater- 
 hammer pulse of Corrigan. 
 Force of each pulse-wave depends chiefly upon 
 the energy of tlie cardiac systole, and also 
 upon the amount of vascular tone. 
 Increased force of each pulse-wave, making 
 the strong pulse, occurs with increased car- 
 diac energy and vascular tone. 
 Decreased Force of each pulse-wave, making 
 the weak pulse, is the result of cardiac debility. 
 Duration of each pulse-w^ave depends upon the 
 dilatation of the artery by the blood-current, 
 and its contraction during the passage of 
 the blood into the capillaries. 
 Prolonged duration of each pulse-wave, 
 giving the slow or sluggish pulse, occurs in 
 all diseases producing contraction of the 
 smaller arteries, as nephritis, artero-sclerosis, 
 angina pectoris. 
 Shortened duration of each pulse-wave, 
 giving the active, quick pulse, is present in 
 all diseases and conditions giving relaxed 
 arteries, as in febrile affections and in aortic 
 regurgitation. 
 Rhythm of the Pulse. 
 Varieties of rhythm. 
 
 Irregular pulse, as respects time, rate, and 
 volume. 
 
54 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 1. Irregular in time: varying length of 
 successive intervals between beats, 
 either rhythmical or arhythmical. Ir- 
 regularity in rate may be manifested by 
 change in rapidity from fast to slow or 
 vice versa. 
 
 2. Irregular in volume : varying strength 
 or fullness of successive beats. 
 
 (a) Pulsus bigeminus : beats occurring 
 in pairs^ with intervals between each 
 pair, the second beat of each pair 
 being weaker than the first. 
 
 (6) Dicrotic pulse : characterized by a 
 double beat — i. e., a large beat fol- 
 lowed by a small after-beat, occurring 
 with each cardiac systole ; it is a weak 
 pulse of low tension. It is obtained 
 in fever patients and in some condi- 
 tions of great exhaustion. 
 
 (c) Pulsus trigeminus : groups of three 
 beats, the groups being separated by 
 intervals. 
 
 (d) Intermittent pulse : here a beat is 
 dropped out or is abortive, cardiac 
 systole not being strong enough to 
 send through the arteries a wave of 
 sufficient size to be felt at the wrist. 
 
 (e) Pulsus paradoxicus : normally the 
 tension of the pulse is increased 
 during inspiration, but in pulsus 
 paradoxicus it is decreased during 
 inspiration, the pulse being very 
 small or even absent at that time. 
 It depends upon diminished lumen 
 of the aorta, and notably occurs in 
 mediastinal pericarditis, concretii 
 
METHODS OF PHYSICAL DIAGNOSIS. Of) 
 
 perici'irdii, and witli lar^c pleuritic 
 effusion. 
 (/) Irrognlarity or incoordination of 
 the two radial pulses is sometimes 
 observed in aortic aneurysm or 
 aneurysm of the puhiionarv artery. 
 Causes of broken rhythm of the pulse. 
 General causes of broken rhythm. 
 
 1. Nervous 1 
 
 o i-r 1 , .action 01 druii-s or disease. 
 
 2. Circulatory J ^ 
 
 Local causes of broken rhythm. 
 
 1. Reflex, dyspepsia, etc. 
 
 2. Circulatory, diminished blood pressure 
 in the arteries, as in anaemia. 
 
 3. Cardiac weakness from 
 
 (a) Degeneration, atrophy, etc. 
 (6) Mechanical interference with its 
 action ; 
 Acting within the cardiac apparatus, 
 due to valvular disease, pericardiac 
 effusion. 
 Acting from outside the heart : pleu- 
 ritic effusion, distended stomach, 
 hepatic enlargement, tumors, de- 
 formities of the chest. 
 Frequency of the Pulse, rate or number of 
 beats. 
 The average pulse rate in healthy adult 
 males is seventy -one beats ; in females, 
 eighty per minute ; the pulse is relatively 
 more rapid also in infancy, in small persons, 
 in the upright position, in high altitudes, in 
 late periods of the day, after meals, during 
 emotional excitement, intellectual exercise, 
 or muscular exertion. 
 The slow pulse, bradycardia, is character- 
 
66 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 ized by a rate of sixty beats or less per 
 minute ; it has been observed as low as 
 fifteen beats. It is 
 No7"mal in 
 
 1. Certain persons, habitually, apparently 
 inherited. 
 
 2. Women immediately after child-birth. 
 
 3. Old age. ^ 
 Abnormal. 
 
 1. Symptomatic in 
 
 (a) General diseases and conditions at- 
 tended by great exhaustion, e.g. con- 
 valescence from acute fevers, typhoid, 
 diphtheria, pneumonia, and in dia- 
 betes and anaemia. 
 
 (6) Digestive tract : aggravated dys- 
 pepsia, gastric ulcer, cancer of the 
 oesophagus. 
 
 (c) Urinary tract : uraemia. 
 
 (d) Cardiac coronary sclerosis, myocar- 
 dial degeneration, fatty, fibroid, etc., 
 aortic stenosis. 
 
 (e) Nervous system. 
 
 Central diseases with gross lesions, 
 as in early stage of meningitis, 
 apoplexy, tumors of the cerebrum, 
 injuries to the cervical cord. 
 
 Peripheral, pressure upon the vagus 
 by tumors, etc. 
 
 Neuroses, so-called idiopathic disease 
 of the nervous system — epilepsy, 
 hysteria in certain cases, mania, 
 
 .general paresis, following fright. 
 
 Toxic: tea, coffee, lead, uric acid 
 (uraemia), bile (jaundice). 
 The rapid pulse, tachycardia, is character- 
 
METHODS OF PHYSICAL DIAGNOSIS. 57 
 
 izcd hy a rate of eighty-five beats or more 
 per minute ; it lias ])e('ii observed as 
 liigli as two luni(h'e(l and fifty beats in 
 adults. 
 Normally, the pulse is rapid in certain healthy 
 adults habitually, and in certain indi- 
 viduals who are able voluntarily to in- 
 crease the rate of the heart ; in women at 
 gestation : and in children as foUows : 
 Infants, 130 to 150. 
 
 One year old, 120 to 130. 
 Two years old, 105. 
 Three years old, 100. 
 Five years old, 90 to 94. 
 
 Variations from emotions and phys- 
 ical exercise, etc., vide the average 
 pulse. 
 Ahnormally rapid pulse may be 
 1. Symptomatic, arising from 
 
 {a) Undue irritation of the nervous 
 system, as related to 
 Age : young rapidly-growing weak 
 
 persons. 
 Sex : women usually at establishment 
 of menstruation and the meno- 
 pause, especially when anaemic and 
 chlorotic. 
 Habits: venereal excess, masturba- 
 tion. 
 Toxic : tobacco, alcohol, tea, coffee. 
 Fatigue : physical or mental. 
 Fever. 
 {b) Lesions of the cardiac nervous 
 mechanism. 
 Central : bulbar disease impairing 
 the function of the vagus, tumors 
 
58 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 or swell ingSj softening in the 
 
 medulla or cord, hemorrhage. 
 Peripheral : tumors or swellings 
 
 pressing upon the vagus, neuritis. 
 Neuroses. 
 
 Exophthalmic goitre. 
 
 Epilepsy, hysteria, irritable heart 
 of soldiers. 
 
 Neurasthenia. 
 2. Keflex. 
 
 (a) Circulatory : lesions of the heart or 
 vessels. 
 
 (b) Respiratory : nasal growths and 
 hypertrophies, pharyngeal and laryn- 
 geal disorders. 
 
 (c) Gastro-intestinal : dyspepsia, intes- 
 tinal Avorms in children. 
 
 (d) Genito-urinary : ovarian and uter- 
 ine disease, nephritis, phimosis. 
 
 Fremitus is a trembling felt by the hand on examination. 
 It has been termed fremissement cataire from its like- 
 ness to the vibration felt upon the back of a purring 
 cat. 
 
 CIRCULATORY FREMITUS or thrill is due to 
 vibrations originating within the heart or great ves- 
 sels, and it includes : 
 
 ANEURYSMAL or VASCULAR FREMITUS, sometimes 
 felt over large superficial aneurysms, and occa- 
 sionally over the carotids in valvular disease of 
 the heart, and over the jugular veins in tricuspid 
 insufficiency ; also, 
 ENDOCARDIAL or CARDIAC FREMITUS, not infre- 
 quently obtained, upon palpation of the praecordia, 
 in certain valvular lesions. 
 
 Causes of Cardiac Freniitiis : like certain cardiac 
 murmurs it may be due to the whirling of the 
 
METHODS OF PHYSICAL DIAGNOSIS 59 
 
 blood-stream against a i-oiiglicucd siirfacc or past 
 a constriction. 
 Freqiieni'ff of i'm-diac Fremitus, 
 
 It generally occurs with loud cardiac murmurs, 
 but comparatively few nuirmurs are accom- 
 panied by a thrill. 
 It is most common with mitral obstruction 
 
 (presystolic) and aortic obstruction (systolic). 
 It is more rare with aortic regurgitation (dias- 
 tolic), mitral regurgitation (systolic). 
 It is very rare with lesions of the right heart. 
 Locatioti of CardUic Frentitus, 
 
 It is g-enerally felt best when the murmur is 
 heard loudest — e. g., just above the apex in 
 mitral obstruction ; in the aortic area in aortic 
 obstruction and atheroma ; over the jugulars 
 in case of constriction of these vessels from 
 pressure, as in enlargement of the thyroid gland ; 
 over the carotids (systolic) in aortic regurgita- 
 tion from the sudden filling of the relatively 
 empty vessels. 
 Intensity of Cardiac Freniitus, . 
 
 It is apt to be, like Murmurs, increased by ex- 
 ertion. 
 It may disappear in cardiac weakness, and re- 
 turn with reviving strength or upon excitement. 
 FRICTION FREMITUS is a rubbing or grating sen- 
 sation felt by the hand in palpation over a part where 
 two roughened, inflamed, serous surfaces are moving 
 upon each other, as in the first stage of pleurisy, oc- 
 casionally in pericarditis, and rarely in peritonitis. 
 HHOJSTCHAL, bronchial, or rale FREMITUS 
 is caused by the passage of air through fluid in the 
 trachea and larger bronchi during respiration ; the 
 vibrations produced are sometimes so marked as to 
 be felt by the hand upon palpation. 
 
60 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 CAVERNOUS FREMITUS : this may sometimes be 
 felt over superficial cavities in the lung^ owing to the 
 vibration of fluid Avithin them. 
 
 VOCAL FREMITUS f variously termed voice frem- 
 itus, vocal vibration or pectoral fremitus, is a trem- 
 bling felt by the hand when placed upon the chest of 
 a person who is speaking aloud (tussive or cough 
 fremitus is of the same nature). 
 INTENSITY OF VOCAL FREMITUS. 
 Increased or marked vocal fremitus. 
 Normal, is found with 
 
 Low PITCHED VOICES, 
 
 Strong voices ; near to the 
 
 Larynx ; over the 
 
 Teachea and 
 
 Great bronchi ; it is more marked over the 
 
 Eight apex of the lung than over the left, 
 
 owing to the size and direction of the right 
 
 bronchus ; it is more marked over 
 Thin chests from the absence of muscle or 
 
 fat. 
 Abnormal, increased vocal fremitus is found : 
 Over consolidation of the parenchyma of 
 
 the lung, when the bronchial tubes, of large 
 
 and medium size, are patulous, as obtains in 
 
 phthisis and pneumonia ; 
 Over compressed or collapsed lung above 
 
 the level of the effusion ; 
 Over a cavity near the surface, with dense 
 
 walls and a free opening into a large 
 
 bronchus. 
 Diminished or Suppressed vocal fremitus. 
 Normal, vocal fremitus is weak or absent with 
 High pitched voices ; 
 Weak voices; 
 Women, over lower half of chest ; 
 
METHODS OF PHYSICAL DLAONOSIS. 61 
 
 Children, over tlie wliole chest ; and at a 
 
 Distance from the larynx and large 
 bronchi ; over 
 
 Thick chest- walls from excess of fat, mus- 
 cle, or mammary gland. 
 Abnormal, diminished vocal fremitus is due to 
 
 Interposition of 
 
 Fluid, as in hydrothorax, pleurisy with effu- 
 sion, etc. ; 
 Aivy as in emphysema, pneumothorax ; 
 Solids, as in adherent and markedly thick- 
 ened pleura, large solid tumor. 
 
 Obstruction of the large bronchial 
 TUBES from the presence of a foreign body, 
 or compression by a tumor or stricture. 
 
 MENSURATION. 
 
 Measurement determines size and the symmetry or asym- 
 metry of the chest ; in the latter case it is instituted from the 
 •middle point behind to the middle point in front. 
 
 PERCUSSION. 
 
 Percussion is the art of eliciting sounds by striking the 
 body. 
 
 METHODS of percussion. 
 
 Immediate, striking directly upon the part; this method 
 
 is of comparatively little use. 
 Mediate, striking upon an intermediate object held against 
 
 the part. 
 
 INSTRUMENTS, in mediate percussion (varieties). 
 Hammer, plexor or plessor. 
 
 Pi ex i meter, or plessimeter, the medium upon which the 
 hammer strikes. 
 
62 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 THE NATURAL and most useful instruments are the 
 middle or index fingers of one hand^ serving as plexor^ 
 and one or more fingers of the other hand, as pleximeter. 
 
 ARTIFICIALLY, they may be made of hard rubber, 
 Avood, etc. 
 
 RULES FOR PERCUSSION. 
 
 The Patient. ^ 
 
 THE SURFACE should be bare of clothing. 
 THE LI3IBS symmetrical, the same position being 
 maintained in the examination of the two sides. 
 TO EXAMINE THE FRONT of the chest the arms 
 
 should be at the sides. 
 TO EXAMINE THE BACK the arms should be folded 
 
 in front. 
 TO EXAMINE THE SIDES the arms should be folded 
 above the head. 
 POSITION OF THE BODY. 
 
 EASE OF POSITION, to avoid discomfort and to in- 
 sure like muscular tension on the two sides. 
 POSTURE : the erect, recumbent, or sitting posture^ 
 or all these may be required, as in determining 
 change of position of solid organs or of the level 
 of fluids ; recumbency must be maintained if there 
 is danger of heart failure. 
 The Examiner should maintain a position symmetrical 
 with regard to the patient, the ear being at the same 
 relative distance from the points percussed. 
 The Instruments (their use). 
 
 THE PLEXIMETER should be applied 
 
 WITH FIRMNESS, to avoid a cushion of air beneath 
 it ; the firmness of pressure should be uniform at 
 all points of percussion. 
 PARALLEL TO THE RIBS, upon or between them. 
 OVER SYMMETRICAL POSITIONS on the two sides 
 of the chest for comparison. 
 
METHODS OF PHYSICAL DIAGNOSIS. 63 
 
 THE FLEXOR and its use : 
 
 THE STROKE should ))e made WITH THE ENDS OF 
 THE FINGERS rather than witli their pulps. 
 
 THE STROKE SHOULD BE MADE PERPENDICU- 
 LARLY to the surfaee. 
 
 THE STROKE should be REBOUNDING, in using tlie 
 hand the motion should be from the wrist. 
 
 THE STROKES should be MODERATELY RAPID in 
 succession. 
 
 THE STROKE should be made with MODERATE 
 FORCE, never causing pain, but more forcible for 
 sounding deep-seated organs than for superficial. 
 
 THE TWO SIDES SHOULD BE PERCUSSED IN 
 LIKE STAGES OF RESPIRATION, preferably at 
 the end of expiration. 
 
 PERCUSSION SOUNDS. 
 
 The Elements of Sound in percussion. 
 
 Q UALITYf the characteristic property or chief attribute 
 which distinguishes one sound from another — e. g. 
 full, empty, shallow, clear, soft, hard, toneless, dead, 
 ^^ thigh sound. '^ 
 INTENSITY, the quantity or loudness, largely govern- 
 ing the distance at which a sound can be heard ; 
 varying w^ith 
 THE FORCE OF THE BLOW. 
 THE VOLUME OFAIR under the part. 
 THETHINNESS AND ELASTICITY OF THE CHEST- 
 WALL. 
 nuitATION, the length of time a sound can be 
 
 heard. 
 PITCHf the degree of elevation in the musical scale. 
 ITS RELATION to duration and intensity, the lower 
 the pitch the longer the duration, and the greater 
 the intensity, and per contra. 
 THE FACTORS IN ITS PRODUCTION. 
 
64 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 The Larger the Car Hies (containing gas) in the 
 
 part, the lower the pitch, and per contra. 
 The Ch'eater the Tension of the Inclosing Wall, 
 
 the higher the pitch, and per contra. 
 Proocimity of Solid Bodies elevates the pitch. 
 The Larger the Ojiening in a cavity, the higher 
 the pitch. 
 The Varieties of Percussion Sbunds. 
 
 JVOB3IAL BULMONABY OB VESICULAB 
 BESONANCE or lung sound. 
 LOCATION, over those parts of the healthy lung 
 which do not overlap the heart, liver, or spleen, 
 and which are not covered by the scapulae {vide the 
 landmarks). The resonance obtained over the lung 
 w^hich overlaps these organs, while normal vesicular, 
 is relatively less resonant, and hence properly 
 termed dulness. Resonance is less intense and 
 higher in pitch over the right apex than over the left. 
 CAUSE of the normal vesicular resonance ; it is prob- 
 ably due to the combined vibration of the walls of 
 the chest, alveoli, and bronchi and the air con- 
 tained within them, the resonance of the deeper 
 parts being modified by the thickness of the fleshy 
 parts and by the elasticity of the bony elements. 
 CHARACTER of normal vesicular resonance. 
 Quality, soft, clear, full, resonant, vesicular. 
 Pitch, low. 
 Intensity, great. 
 Duration, long. 
 VARIATIONS IN CHARACTER. 
 In the Same Individual , 
 
 In a Griven Location vesicular resonance varies 
 
 with the degree of respiratory expansion. 
 In Different Locations it varies according to 
 the size or amount of lung under the part and, 
 the thickness of the chest- wall. 
 
METHODS OF PHYSICAL DIAGNOSIS 65 
 
 III Different Indirlduals it varies according to 
 the same factors. 
 EXAGGERATED rULMONARY MESONANCE, 
 
 LOCATION. 
 
 Norniul, over both lungs in children. 
 Abnomial, 
 
 Over both Lung-s in marked anaemia, in em- 
 physema (the resonance present in this disease 
 has also been termed by Flint vesiculo-tym- 
 panitic). 
 Over One Lung" when the other is partially or 
 wholly crippled by consolidation, compres- 
 sion, etc. 
 Over Sound Parts of a crippled lung. 
 CAUSE, the lung is over-distended with air, either 
 functionally, or from organic trouble as in em- 
 physema. 
 CHARACTER : this is like that of vesicular resonance, 
 except for increase of intensity and duration and 
 slightly lower pitch. 
 VARIATIONS IN CHARACTER accord with the 
 amount of air in the part, within reasonable limits. 
 BOWE RESONANCE. 
 
 LOCATION, over the sternum and clavicle, and to a 
 
 slight extent over the ribs. 
 CHARACTER. 
 
 Quality, non-tympanitic, resonant, ringing. 
 Pitch, higher than that of vesicular resonance. 
 Intensity, less than that of vesicular resonance. 
 Duration, shorter than that of vesicular resonance. 
 DULNESS, diminished resonance. It includes vesic- 
 ular and tympanitic dulness. 
 LOCATION. 
 
 Normal Vesicular Dulness is obtained where the 
 lung overlaps the heart, liver, and spleen and 
 underlies the scapulae. Normal tympanitic dul- 
 
PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 ness is found over the lower part of the liver, 
 heartj and spleen when the stomach and colon 
 are distended with gas. 
 Abnormal Vesicular Dulness is obtained over 
 Thickening' of the Chest-wall from oedema, 
 
 tumor, or inflammatory swelling. 
 Interposition, between the lung and chest-wall, 
 of solids or fluids; a moderately thick layer 
 of inflammatory lymph on the pleural surface ; 
 a moderate amount of pleuritic effusion, in- 
 flammatory or non-inflammatory ; extra-pul- 
 monary tumors of small size. 
 Consolidation of the Lung", moderate in amount: 
 pneumonia, tuberculosis, syphilis, new growths, 
 oedema, pulmonary hemorrhage, collapse of 
 lung. 
 CAUSE, less air or relatively more solids beneath the 
 
 part than in normal lung. 
 CHARACTER. 
 
 Quality, harder, emptier, less clear, less vesicular 
 
 than normal pulmonary vesicular resonance. 
 Pitch, higher. 
 Intensity, less. 
 Duration, shorter. 
 VARIATIONS, in character in different individuals 
 and in different localities, accord Avith the relative 
 amount of air or solids, approaching the character 
 of pure pulmonary resonance on the one hand and 
 flatness upon the other. 
 FLATNESS. 
 LOCATION. 
 
 Normal, over those organs or parts containing no 
 air, hence over that portion of the heart, liver, 
 spleen, and kidneys uncovered by lung. 
 Abnormal, over the chest when there is an exag- 
 geration of any of those morbid conditions which 
 
METHODS OF PHYSICAL DIAGNOSIS. 67 
 
 in a slight degree produce dulness : pleurisy with 
 effusion, emphysema, hydro-thorax, etc. 
 CAUSE, entire absence of air or gas in and for some 
 distance beneath the organ under the part percussed. 
 CHARACTER. 
 
 Qualitij, hard, empty, muffled, non-resonant, the 
 
 ^^ thigh sound." 
 Pitchf very high, highest of all percussion notes. 
 Duration, very short. 
 NO VARIATIONS OF ITS CHARACTER, as such, 
 occur ; it may be modified by tympanitic resonance, 
 where hollow gas-containiilg organs like the stom- 
 ach or colon underlie a solid organ like the liver ; 
 it is then termed tympanitic dulness, really a modi- 
 fication of tympany. 
 TYMPANITIC RESONANCE or tympany. 
 LOCATION. 
 
 Normal, where the stomach or colon, distended 
 with gas, underlies the infra-mammary, infra- 
 axillary, and infra-scapular regions, and some- 
 times over the lower part of the mammary and 
 inferior sternal regions ; also over the trachea. 
 Ahnomial. 
 
 Over a part of the chest when Gas is present 
 
 in the Pleural Sac, pneumo-thorax. 
 Over a Pulmonary Air-containing Cavity of 
 
 large size, phthisis, abscess. 
 Complete Solidification of a Part of the upper 
 lobe of the lung, tympany being obtained from 
 the trachea beneath ('' tracheal tone " of Wil- 
 liams), second stage of pneumonia, phthisis. 
 Bronchiectasis with surrounding solidification, 
 
 interstitial pneumonia. 
 Conduction of Stomach Resonance high up 
 on the left side, when the lower lobe of the 
 left lung is solidified. 
 
68 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 CAUSE, percussion over a hollow gas-containing or- 
 gan or cavity, the walls of which are more or less 
 thin and tense. 
 CHARACTER. 
 
 Qualittj, non-vesicular, resonant, ringing, but 
 
 harder than vesicular resonance. 
 Pitchy higher than vesicular resonance, variable. 
 Intensitij and duration variable. 
 VARIETIES OF TYMPANY. 
 
 Closed Ti/mjMiny is the sound obtained by percus- 
 sion over a cavity filled with gas, and not com- 
 municating - freely by an opening with the ex- 
 ternal air — e. g., the stomach and colon. It is 
 obtained also in some cases of pneumothorax. 
 O^jen Tympany includes amphoric and cracked- 
 metal resonance. 
 Amphoric Resonance is obtained over a cavity 
 with a large opening, as in percussion of the 
 cheeks Avith the mouth open. 
 Location . 
 
 Normal over the trachea, and sometimes 
 over the upper part of the chest in chil- 
 dren. 
 Abnormal^ abscess or tubercular cavity com- 
 municating with a large bronchus. 
 Cause, percussion over a moderate sized gas- 
 containing cavity with rigid, non-collapsing 
 walls and free communication by a large 
 opening ; tlie examiner's ear or the mouth 
 of the stethoscope should be near the 
 patient's open mouth. 
 Character, its quality is tympanitic but pe- 
 culiarly ringing and hollow like the sound 
 produced by blowing across the mouth of a 
 bottle ; its pitch is higher than vesicular res- 
 onance, but varies with the size of the cavity 
 
METHODS OF PHYSICAL DIAGNOSIS. 69 
 
 and of the opening, and the condition of the 
 adjacent lung. Its intensity and duration 
 are variable. 
 Change in the Character of am])horic 
 resonance. 
 Wintrich\s change of aound only occurs over 
 a cavity which freely communicates with 
 a bronchus ; a louder, more amphoric, and 
 higher-pitched note is produced over a 
 cavity when the mouth is open, especially 
 with the tongue protruding. The note 
 wdth the mouth closed may be dull but 
 slightly tympanitic. 
 Williams'' tracheal tone, or change of sounds 
 so called, is the tympanitic note obtained 
 by percussion over the trachea, its change 
 in character being similar to that in Wint- 
 rich's change of sound. 
 Interrupted Wintrich\s change of sound (Ger- 
 hardt, Moritz). This differs from the 
 former in that the change is marked in 
 some positions of the body, in others in- 
 distinct or absent owing to the closure of 
 the opening by the secretions wdthin the 
 cavity. 
 Gerhardfs change of sound. A tympanitic 
 sound, whether open or closed, may change 
 in pitch with change in posture. This 
 may be due to the change in the tension 
 of the chest-wall and that of the cavity, 
 and to the change in location of fluids 
 within the cavity. 
 Friedreich's J or the respiratory change of 
 sound. A tympanitic note over the lung, 
 or over a cavity within it, is higher in 
 pitch at the end of deep inspiration than 
 
70 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 in expiration, due probably to the higher 
 tension. 
 Cracked-metal Resonance is a form of open 
 tympany, and may be imitated by striking 
 upon the knee with the hands loosely clasped 
 palm to palm. 
 Location and Cause. 
 Normal. \ 
 
 1. If the chest be covered with much 
 hair, under percussion. 
 
 2. If the pleximeter be loosely applied. 
 
 3. Sometimes it is obtained over the upper 
 part of the chest of children, especially 
 when crying. 
 
 4. Sometimes in adults when singing a 
 prolonged note. 
 
 Abnormal. 
 
 1. Over some air-containing pulmonary 
 cavities communicating with a bronchus 
 by a small opening ; percussion should 
 be firm, and during expiration, the 
 patient's mouth being open. 
 
 2. Occasionally in pleurisy, over the lung 
 above the effusion ; sometimes in the 
 engorgement stage of pneumonia. 
 
 3. When an opening exists through the 
 chest-wall into the pleural sac. 
 
 AUSCULTATION. 
 
 METHODS of auscultation. 
 Immediate or direct. 
 Mediate or indirect. 
 
 INSTRUMENTS of mediate auscultation, the stethoscope. 
 Varieties. 
 
 UNIA UBALf hollow and solid. 
 
METHODS OF PHY SIC AL DIAGNOSIS 71 
 
 BIN AUR A h,Km^\i^^y Camman's, Dennison's, Alli- 
 son's differential, Corwin's multiplex. 
 Objections to the stethoscope. 
 
 IT HAS A SrECIAL RING or roaring sound like a 
 
 shell. 
 OFTEN rOORLY MADE, 
 FRIGHTENS CHILDREN. 
 NOT ALWAYS AT HAND. 
 Advantages of the stethoscope. 
 
 SHUTS OUT OUTSIDE SOUNDS. 
 CONCENTRATES and circumscribes sounds. 
 INTENSIFIES sounds. 
 
 CERTAIN PARTS OF THE CHEST ARE INAC- 
 CESSIBLE to the unaided ear. 
 IT IS SOMETIMES INDELICATE to apply the 
 
 ear directly to the chest. 
 IT IS SOMETIMES UNFLEASANT and may be 
 DANGEROUS to apply the ear to the chest. 
 RULES for auscultation. 
 
 The Patient should have regard to 
 
 SY3IMETRY, immobility, and ease of position. 
 THE CHEST SHO ULD BE BARE for mediate aus- 
 cultation, and should have a single layer of thin soft 
 covering for immediate auscultation. 
 Tine Examiner should have 
 
 THE HEAD on a plane higher than the body to pre- 
 vent congestion of the auditory apparatus ; 
 THE A TTENTION concentrated upon one sound or 
 set of sounds at a time. 
 The Instruments. 
 
 THE EAR-FIECE should fit the external meatus ac- 
 curately and point in the same direction as the canal, 
 downward and forward. 
 THE TUBES should be, in lumen, the size of the ex- 
 ternal auditory canal ; it is of no advantage to have 
 them larger. 
 
72 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 THE L AUGER CHEST-JPIECE should not exceed 
 one and one-fourth inch in diameter at the distal end. 
 It is designed for the lung sounds. 
 
 THE SMALLER CHEST-PTECE is especially de- 
 signed for the sounds of the heart and vessels. But 
 it answers very well for auscultation of the lungs. 
 
 THE ENTIRE LENGTH of the instrument from ear- 
 piece to chest-piece should not exceed about twenty-two 
 inches {vide cut of simple compact stethoscope which 
 the author has found a most satisfactory combination). 
 The Act of auscultation. 
 
 THE R003I should be quiet. 
 
 THE EAR OF THE STETHOSCOPE should be 
 firmly applied to the chest. 
 
 THERE SHOULH BE NO FRICTION between 
 parts of the instrument ; between the chest and the 
 instrument ; between the hand and the instrument ; 
 between the hand and the chest ; between the hand 
 and the clothing ; between the chest and the clothing. 
 
 CORRESPONDING PARTS OF THE CHEST 
 should be compared, and in like stages of respiration. 
 
 THE ENTIRE CHEST should be examined. 
 
 SOUNDS HEARD upon auscultation. 
 The Elements of sound. 
 QUALITY, ^ 
 PITCH, I . 
 
 DURATION I percussion sounds. 
 
 INTENSITY, J 
 
 RHYTHM is the relation of sounds to each other, as 
 that of inspiration to expiration, or the relation of the 
 first and second sounds of the heart. 
 Varieties of Sounds upon auscultation. 
 PULMONARY sounds. 
 
 RESPIRATORY sounds vary in kind, intensity, and 
 rhythm. 
 
METHODS OF PHYSICAL DIAGNOSIS. 73 
 
 Kinds or Veirieties of liespiratoi'y Si>i(nd. 
 
 Normal Vesicular Breathing (persons should 
 breathe more forcibly than usual, but with 
 the same rhythm). 
 Locality : it is heard over the i)arenchyma 
 of the lung away from the main bronchi ; 
 best in the infra-scapular regions. 
 Cause of the vesicular sound (opinic>n varies). 
 It may he produced at the glott'iH, and mod- 
 ified by conduction through the spongy 
 tissue of the lung. 
 It may be due to the entrance of air into the 
 
 alveoli during dilatation. 
 It may he due to the vihration of the lung 
 substance from increased tension in in- 
 spiration and the reverse in expira- 
 tion. 
 Character. 
 
 Inspiratory sound. 
 
 Quality, breezy, rustling, soft, vesicular. 
 Pitch, low compared with that of laryn- 
 geal breathing. 
 Intensity, variable. 
 
 Duration, coincident with the inspiratory 
 act. 
 Expiratory sound. 
 
 Quality, like the inspiratory but less vesic- 
 ular. 
 Pitch, lower than that of tlie inspiratory 
 
 sound. 
 Intensity, variable ; the sound may not 
 
 be appreciable but is generally so. 
 Duration, much shorter than the expira- 
 tory act. 
 Rhythm : the ratio of the inspiratory to 
 the expiratory sound is about three 
 
74 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 to one^ there being a sliglit interval 
 between them. 
 Variation in character largely depends upon 
 the nearness of the point of auscultation 
 to the large bronchi. 
 Bronchial Breathing*. 
 Locality and Cause. 
 
 Normal, heard over the trachea. 
 Abnormal (as a sign of disease), heard over 
 consolidated lung, the main bronchi lead- 
 ing to which are patulous, consolidated 
 lung being a better medium of conduction 
 of the sound from the larynx. It is heard 
 in pneumonia and phthisis. 
 Character, it is substantially like that of 
 tracheal breathing, though slightly less in- 
 tense. 
 Laryngeal and Tracheal Breathing" differ from 
 each other but little. 
 Locality, heard over the larynx and trachea. 
 Character. 
 
 Inspiratory sound. 
 
 Quality, tubular, blowing, but changing 
 in harshness with the force of the act. 
 Pitch, higher than that of the inspiratory 
 sound of normal vesicular breathing, 
 and varying in pitch with the force of 
 the act. 
 Intensity, great but variable. 
 Duration, a little shorter than the inspira- 
 tory act. 
 Expiratory sound. 
 
 Quality, very similar to that of inspiration. 
 Pitch, higher than that of inspiration. 
 Intensity, greater than that of vesicular 
 breathing. 
 
METHODS OF PHYSICAL DIAGSOSIS. 1-) 
 
 Duration, longer than that of the expira- 
 tory sound of vesicular breathing. 
 Rhythm : the expiratory sound is as long 
 as the inspiratory, and a short interval 
 exists between them. 
 Cavernous Breathing-. 
 
 Locality (it is an abnormal sound) heard 
 
 over some pulmonary cavities. 
 Cause, empty pulmonary cavity with easily 
 collapsing and expanding walls in ex])ira- 
 tion and inspiration. 
 Character. 
 
 Inspiratory sound. 
 
 Quality, soft, blowing, or puffing, but 
 
 neither vesicular nor tubular. 
 Pitch, low. 
 
 Intensity, variable, but usually slight. 
 Duration, variable. 
 Expiratory sound. 
 
 Quality, like that of the inspiratory sound. 
 Pitch, lower than that of the inspiratory 
 
 sound. 
 Intensity, variable, but usually slight. 
 Rhythm : the expiratory sound is about 
 the same length as the inspiratory. 
 Broncho-cavernous Breathing*. 
 
 Locality and Cause, cavity surrounded by 
 solidified lung, as is found sometimes in the 
 late stage of tuberculosis, abscess, or gan- 
 grene. 
 Character, both cavernous and bronchial 
 
 elements are heard together. 
 Varieties, metamorphosing breathing ; here 
 the inspiratory sound is bronchial at first, 
 but suddenly becomes cavernous. 
 Vesiculo-cavernous. 
 
76 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Locality and Cause, cavity covered by more 
 
 or less healthy lung. 
 Character, as indicated by its name. 
 Amphoric Breathing. 
 
 Locality, over a large cavity with relatively 
 rigid walls and with a large opening, as may 
 be obtained in tuberculosis and occasionally 
 in pneumothorax. ^ 
 Cause, the peculiar vibration of air in its 
 passage in and out of, or across the mouth 
 of a flask-like cavity. 
 Character. 
 
 Inspiratory sound most distinct. 
 
 Quality, musical, hollow, metallic, harder 
 
 than that of cavernous breathing. 
 Pitch of expiratory sound lower than that 
 
 of bronchial breathing. 
 Intensity, usually greater than that of 
 
 cavernous breathing. 
 Rhythm : amphoric breathing is usually 
 heard best in inspiration. 
 Intensity of Hespiratory Sotitids. 
 
 Bxag-g-erated, Supplementary, or Puerile 
 Breathing. 
 Locality. 
 
 Normal in childhood, the chest-walls being 
 
 thin and elastic. 
 
 Abnormal, over one lung when the other is 
 
 crippled by consolidation, obstruction, 
 
 etc. ; over healthy parts of a crippled lung. 
 
 Cause, the lung is performing more than its 
 
 usual function. 
 Cpiaracter, like that of normal vesicular 
 breathing,' except of greater intensity; both 
 inspiratory and expiratory sounds are louder 
 and longer than usual. 
 
METHODS OF PHYSICAL DIAGNOSIS. 11 
 
 Feeble Respiration. 
 
 LOCA LIT Y. 
 
 Normal. 
 
 Ov'er thick chest-walls, as in muscular or 
 fat persons ; over the female mammae 
 and over the scapulae. 
 
 At a distance from the large bronchi, over 
 the lower part of the chest, especially 
 in women. 
 
 In superficial breathing. 
 
 The vesicular murmur is normally less 
 intense on the right than on the left 
 side. 
 Abnormal from 
 
 Imperfect transmission, due to oedema or 
 vswelling of the chest-walls ; air, fluid, 
 or inflammatory lymph in the pleural 
 sac. 
 
 Loss of elasticity of the lung, emphysema. 
 
 Partial blocking of the air-cells with blood 
 or serum, as in pulmonary oedema. 
 
 Consolidation of lung with filling up of 
 the bronchi. 
 
 Obstruction of the larynx, trachea, or 
 bronchi from a collection of pus, mucus, 
 blood, or fibrin ; foreign body ; thick- 
 ening of the mucous membrane ; pres- 
 sure of tumors. 
 
 Constriction of the tubes from muscular 
 contraction, asthma, bronchiolitis. 
 
 Deficient action of the respiratory muscles. 
 Mechanical obstruction, as in tympany, 
 
 ascites, abdominal tumors. 
 Pain, as in pleurisy, peritonitis, pleuro- 
 dynia, neuralgia. 
 Paralysis of the diaphragm. 
 
78 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Suppressed Respiratory Sound ; entire absence 
 of respiratory sounds. 
 Locality and Cause, an exaggeration of the 
 conditions which produce feeble respiration : 
 pneumo-thorax, hydro-thorax, occlusion of 
 the larger air-passages. 
 Mhythni of Respiratory Sounds. 
 
 Interrupted, Jerking, Wavy or Cog-Wheel 
 Respiration. 
 Locality. 
 
 Normal, in nervous persons, agitated by ex- 
 amination ; here it is apt to be heard more 
 or less over the whole chest, but it may 
 be localized ; sometimes it is heard in 
 healthy persons from no apparent cause. 
 Abnormal, it may accompany : 
 
 Pain, as in pleurisy, pleurodynia, inter- 
 costal neuralgia ; it is generally heard 
 over the whole chest. 
 Phthisis, here it may be an early sign, 
 localized over the affected apex. 
 Cause of cog-wheel breathing : in some cases 
 (pain and nervousness) it may be due to the 
 irregular and undecided manner of respira- 
 tion, in others (phthisis) it is probably caused 
 by the break or delays in the passage of air 
 through the affected bronchioles. 
 Character : either the inspiratory or expira- 
 tory sound, or both, may be broken into 
 several parts, or may be characterized by 
 successive variations in intensity ; usually 
 it is most marked in inspiration. 
 Interval between Inspiration and Expiration 
 may be more or less prolonged. 
 In emphyse]\ia, owing to a deferred expira- 
 tory soiuid. 
 
METHODS OF PHYSICAL DIAGNOSIS 79 
 
 In consolidation of the lung owing to short- 
 ening of the inspiratory sound. 
 Shortened Inspiratory Sound. 
 
 Locality (where and w hen licard) and Cause. 
 In emphysema it is due to the beginning of 
 the respiratory aet before the beginning 
 of the sound. 
 In consolidation (bronchial breathing) it is 
 due to the ending of the inspiratory sound 
 before the ending of the inspiratory act. 
 Chakacter. 
 
 When due to emphysema. 
 Quality, vesicular. 
 Pitch, comparatively low. 
 When due to consolidation. 
 Quality, tubular. 
 Pitch, high. 
 Prolonged Expiratory Sound. 
 Locality. 
 
 Normal, over the right apex ; sometimes pro- 
 longed expiratory sound over the left apex 
 in slightly less degree ; over the larynx, 
 trachea, and bronchi (vide the landmarks). 
 Abnormal, over consolidated lung; over a 
 cavity ; over emphysematous lung ; in 
 asthma ; in case of certain valve-like ob- 
 stacles in the air-passages. 
 Cause : difficult and prolonged exit of air 
 from the lungs — e. g., in emphysema, owing 
 to loss of elasticity of the lung ; in asthma, 
 owing to spasm of the bronchial muscles. 
 Character. 
 
 When due to solidification of the lung. 
 Quality, tubular. 
 Pitch, high. 
 When due to a cavity. 
 
80 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Quality, blowing, cavernous or amphoric. 
 Pitch, low. 
 When due to emphysema. 
 Quality, vesicular. 
 Pitch, low. 
 When due to asthma. 
 Both quality and pitch are obscured by 
 dry rales. 
 VOCAL SOUNDS. 
 
 Eletne^its of Sound: these are like those consid- 
 ered in respiration and percussion, though not 
 all of them are so significant in the consideration 
 of vocal sound. 
 Varieties of Vocal Sound, 
 Normal (Vesicular) Vocal Resonance. 
 Locality, it is heard 
 
 Over the lung at a distance fi^om the trachea 
 
 and bronchi while the person is speaking. 
 
 In adult males it is generally heard over the 
 
 entire lung. 
 In ivomen and ehildren it is heard over the 
 upper part of the chest, and but indis- 
 tinctly over the lower part. 
 Cause : it is due to the transmission of the 
 voice through the parenchyma of the lung 
 and the chest- wall. 
 Character. 
 
 Quality^ diffused, muffled, buzzing, seeming 
 to come from the deep parts of the lung 
 (articulation not transmitted). 
 Pitch, varies with the pitch of the voice. 
 Intensity, greater over the right apex than 
 over the left, especially in the infra-clav- 
 icular Region. 
 Variations from the normal are chiefly in 
 intensity. 
 
METHODS OF PHYSICAL DIAGNOSIS. 81 
 
 Diminished vocal resonance. 
 
 Locality and cause : it is the result largely 
 of those conditions ^vhich cause feeble 
 respiratory sounds. 
 Exaggerated vocal resonance. 
 
 Locality : it is heard over moderately con- 
 solidated lung ; pneumonia, phthisis, etc. 
 Cause, consolidated lung is a better me- 
 dium for transmitting sound from the 
 larynx than is ordinary lung tissue. 
 Character : it differs from normal vocal 
 resonance simply in being more intense, 
 seeming to come from a point not far 
 distant from the surface. It is usually 
 associated with broncho- vesicular respi- 
 ration. 
 Bronchophony or Bronchial Voice. 
 Locality. 
 
 Normal, heard over the main bronchi. 
 Abnormal, heard. 
 
 Over consolidated lung as in the second 
 stage of pneumonia, phthisis ; above the 
 level of the fluid in pleuritic effusion. 
 Over a vomica with firm walls (some- 
 times), surrounded by consolidation. 
 Cause, consolidated lung a better medium of 
 
 transmission. 
 Character. It is more concentrated than nor- 
 mal vocal resonance and exaggerated vocal 
 resonance, seeming to come from a point 
 near the ear, immediately under the steth- 
 oscope (no distinct articulation). It is usually 
 associated with bronchial breathing, though 
 not necessarily, li^ pitch varies, and its in- 
 tensity also, though usually increased above 
 that of normal resonance. 
 
82 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Varieties of Bronchophony. 
 jEgopho7iy (goat voice). 
 
 Locality^ over consolidated lung, covered 
 by a thin layer of fluid in the pleural 
 cavity, as in pleuro-pneumonia with 
 slight pleuritic effusion. 
 Character, it is like that of bronchophony, 
 except that it i$ of less intensity and 
 has a tremulous sound, seeming to come 
 from a considerable depth. 
 Pectoriloquy (speaking through the chest). 
 Locality and cause. It is heard 
 
 1. Over consolidated lung, phthisis, 
 
 pneumonia. 
 (a) Quality, clanging, metallic. 
 {h) Pitch, high. 
 
 2. Over a cavity with smooth walls and 
 
 a large opening, abscess, bron- 
 chiectasis, etc. 
 (a) Quality, soft. 
 (6) Pitch, low. 
 Character, it is like that of bronchophony 
 with the addition of distinct articula- 
 tion in the transmitted voice. 
 Amphoric Voice. 
 
 Locality, over pneumo-thorax or pulmonary 
 
 cavity Avith a free opening. 
 Character. 
 
 Quality, hollow, musical. 
 Pitch and Intensity, variable. It is fre- 
 quently associated with amphoric respira- 
 tion and resonance. 
 WHISPERING SOUNDS. 
 
 Normal Whispering Mesonance. 
 Exaggerated Whispering Mesonance, 
 WJiispering Bronchophony, 
 
METHODS OF PHYSICAL DIAGNOSIS. 83 
 
 Cavernous Whisper. 
 Whispering Pectoi'iloquy. 
 Awtphoric Whisper, 
 
 These whispering sounds correspond largely in 
 locality, cause and character to the vocal sounds, 
 the sound of phonation being substituted by that 
 of aspiration. 
 TUSSIVE OR COUGH SOUNDS. Cough though a 
 symptom is a sign of importance. 
 Definition, A deep inspiration is followed by 
 closure of the glottis, contraction of the mus- 
 cles of expiration, rise of tension within the 
 pulmonary air-passages, and sudden opening of 
 the glottis with violent explosive escape of the 
 compressed air and fibration of the vocal cords. 
 delation to Auscultation, Much the same laAVS 
 govern the sounds produced by coughing as 
 apply to vocal sounds in auscultation of the 
 chest. 
 
 Coug-h may Remove Temporary Obstacles 
 from the air-passages, thereby changing or 
 destroying sounds. 
 It Necessitates Subsequent Deep Inspiration 
 with consequent distention of the air- vesicles. 
 Varieties of Cough. It is dry or moist according 
 to the amount and character of the accompany- 
 ing secretion. 
 
 Laryngeal Cough, hacking, often spasmodic, 
 and due to laryngitis, local irritation^ or to 
 reflex nervous trouble. 
 Bronchial Coug-h, dry or tight, quick, harsh, 
 and brassy. Tjoose, more or less rattling, 
 owing to secretion within the tubes. It is 
 frequently accompanied by pain along the 
 attachments of the diaphragm, and more or 
 less soreness under the sternum. Bronchitis. 
 
84 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Cavernous Cough has a hollow quality, and is 
 usually intense and accompanied by gurgling 
 sounds. 
 Amphoric Cough is ringing, with the peculiar 
 resonance heard in blowing across the neck of 
 a bottle. 
 
 The terms cavernous and amphoric cough 
 refer to sounds he^rd upon auscultation 
 in certain cases where cavities open into 
 large bronchi. 
 Causes of Cough. It may be 
 Voluntary, or may be 
 Involuntary, due to stimulation of the 
 
 Nerve centre in the floor of the fourth ven- 
 tricle. 
 Eeflex. 
 
 Nerve-trunhs, 
 
 Vagus or superior laryngeal nerves. 
 Peripheral. 
 
 Direct stimulation of the mucous mem- 
 brane of the air-passages by irritat- 
 ing particles, cold air, etc. Espe- 
 cially the surface of the 
 Soft palate and pharynx. The 
 Larynx is the most sensitive part of the 
 
 air-passages. 
 Trachea and bronchi : the most sensi- 
 tive part is at the bifurcation of the 
 trachea. 
 Indirect stimulation. 
 
 Irritation of the pleura (the costal layer) 
 
 as in pleurisy. 
 Irritation of the auditory meatus. 
 Decayed teeth. 
 Irritation of the post nares. 
 Irritation of the skin by cold draughts. 
 
METHODS OF PHYSICAL DIAGNOSIS 85 
 
 Derangement of the domach possibly a 
 ciiuse of (tough. 
 ADVENTITIOUS SOUNDS. 
 
 Moist Rales. 
 
 Large, coarse, or mucous rales. 
 
 Locality^ where produced : large and middle- 
 sized tubes ; " death rattle " heard in the 
 trachea. 
 Cause, air bubbling through fluid, whether 
 
 mucus, blood, or pus. 
 Character. 
 
 Quality, bubbling, moist. 
 Pitch, usually low but variable. 
 Intensity, variable. 
 
 Duration, they may be removed by cough- 
 ing or deep inspiration. 
 Rhythm, they may accompany inspiration, 
 expiration, or both. 
 Condition, acute and chronic bronchitis, pro- 
 fuse pulmonary hemorrhage, etc. 
 Small, fine, mucous, or subcrepitant rAles. 
 Locality, small tubes. 
 Cause, air bubbling through fluid. 
 Character. 
 Quality, moist, fine, bubbling, or crack- 
 ling or sticky (mixed in size). 
 Pitch, varying with size of tube and con- 
 dition of surrounding lung. 
 Intensity, variable. 
 Duration, they may be removed by deep 
 
 inspiration or cough. 
 Rhythm, they may accompany either or 
 both acts of respiration. 
 Condition, capillary bronchitis, third stage 
 of tuberculosis, lobular pneumonia, pul- 
 
86 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 monary congestion and oedema, severe 
 hemorrhage, chronic bronchitis, etc. 
 Dry Rales. 
 
 Sonorous Rales. 
 Locality, large tubes. 
 
 Cause, narrowing of the lumen of the 
 bronchi, from viscid mucus adhering to 
 their wall ; swelling of the mucous mem- 
 brane ; spasm of the annular bronchial 
 muscles ; fibroid contractions ; pressure 
 upon the bronchi by an aneurysm or other 
 tumors or swellings. 
 Character. 
 
 Quality, snoring. 
 Pitch, low. 
 
 Intensity, variable, usually very loud. 
 Duration, they are usually not removable 
 by cough or deep inspiration, except 
 when due to viscid mucus. 
 Rhythm, they may accompany either or 
 both acts of respiration. 
 Conditions, asthma, bronchitis, and other 
 more rare conditions causing narrowing 
 of the tubes. 
 Sibilant RIles. 
 Locality, small tubes. 
 Cause, same as that of sonorous rales. 
 Character. 
 Quality, whistling, hissing, creaking. 
 Pitch, high. 
 
 Intensity, less than sonorous, but variable. 
 Duration, they may be removed by cough 
 
 or deep inspiration. 
 Rhythm', they may accompany either or 
 both acts of respiration. 
 Conditions, asthma and bronchitis. 
 
METHODS OP PIIYStCAL DIAGNOSIS. 87 
 
 Crepitant Kales. 
 
 Locality^ they are produced in the ultimate 
 
 air-vesicles. 
 Cause (probably), sudden separation of the 
 walls of collapsed air-vesicles, adhering 
 more or less, from the presence of fibrinous 
 exudate upon their surfaces. 
 Charader. 
 Quality, like the crackling of salt thrown 
 upon the fire, dry, very fine, numerous, 
 and uniform in size, as compared with 
 subcrepitant rales, Avhich are coarser, 
 bubbling, moist, fewer in number, and 
 of different sizes. 
 Pitch, high. 
 Intensity, variable. 
 
 Duration, they are not disturbed by cough. 
 Rhythm, they are never heard in expira- 
 tion, always in inspiration, usually at 
 its end. 
 Condition, typically in the first stage of 
 lobar pneumonia, sometimes in incipient 
 tuberculosis at the apex of a lung ; rarely 
 in pulmonary hemorrhage and oedema. 
 They may frequently be found at the 
 lower part of the posterior aspect of the 
 chest for a few deep inspirations in feeble 
 persons who have been in the recumbent 
 posture for some time. 
 Indeterminate Rales. 
 Crumpling sounds. 
 Locality. 
 
 Normal, sometimes heard at the end of 
 a forced inspiration, usually bilateral. 
 Abnormal, they are sometimes heard in 
 emphysema. 
 
88 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Cause, none known definitely. 
 Character, something like the sound of 
 parchment when wrinkled, and occur- 
 ring at the end of forced inspiration. 
 Condition, emphysema. 
 Friction Sounds, 
 
 Locality, over inflamed pleura or pericardium, 
 
 rarely over the peritoneum. 
 Cause, rubbing together of two serous surfaces, 
 roughened by exudate, or dry from diminished 
 secretion. 
 Character. 
 
 Quality, rasping, grating, grazing, creaking, 
 simulated by rubbing the hand upon the 
 chest during auscultation. They are few in 
 number compared with rales, and are irreg- 
 ular in occurrence. 
 Duration, they are not removable by cough 
 
 or deep inspiration. 
 Rhythm, usually they are most prominent at 
 the end of inspiration or beginning of ex- 
 piration. 
 Condition, pleurisy and pericarditis in the first 
 stage ; rarely in peritonitis over the spleen or 
 liver. 
 Unclassified Adventitious Sounds. 
 Metallic Tinkling. 
 Locality. 
 
 Normally, it may be heard at times over the 
 
 stomach. 
 Abnormally, over the pleural cavity contain- 
 ing air and fluid, especially w^hen com- 
 municating with a bronchus above the 
 level of the fluid. 
 Cause : the dropping of fluid in a cavity con- 
 taining fluid and air. 
 
METHODS OF PHYSICAL DIAGNOSIS. 89 
 
 Character. 
 
 Qualify, sihx'ry, tinkling, or splashing. 
 Fitch J high. 
 
 Intensity, slight, but variable. 
 Rhythm, either in inspiration or expiration, 
 or during cough, or occasionally inde- 
 pendent of them. 
 Condition, pneumo-hydrothorax, pulmonary 
 abscess, et€. 
 Splashing- or Succussion Sound. 
 
 Locality, same as that of metallic tinkling. 
 Cause, splashing of fluid within an air-con- 
 taining cavity, heard when the body is 
 shaken, with the ear of the examiner against 
 the surface, over the part. 
 Chaeacter, splashing. 
 
 Condition, pneumo-hydrothorax or pneumo- 
 pyothorax. 
 Bell Sound. 
 
 Locality, it is heard over a large air-contain- 
 ing cavity. 
 Cause : with the ear against the cavity, per- 
 cussion is made upon the chest at the oppo- 
 site side of the cavity, two coins being used 
 as plexor and pleximeter ; the sound heard 
 is due to the vibration of the air within the 
 cavity. 
 Character, ringing, hollow, metallic. 
 Condition, pneumothorax. 
 SOUNDS PRODUCED BY THE CIRCULATORY 
 MECHANISM. 
 CARDIAC SOUNDS. 
 
 Normal Cardiac Sounds. 
 First Sound of the Heart. 
 
 Cause of the first sound : it is chiefly due to 
 the closure of the auriculo-ventricular valves 
 
90 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 (mitral and tricuspid). To a slight extent 
 this sound may also be due to contraction 
 of the walls of the ventricle in systole^ the 
 impulse of the apex against the chest-wall, 
 and the rush of blood through the ven- 
 tricles. 
 Elements of the first sound. 
 
 Mitral element, heard best at the apex, and 
 behind at the angle of the scapula. It is 
 slightly louder than the tricuspid. 
 Tricuspid element, heard best at the lower 
 end, a little to the left, of the sternum. 
 Character of the first sound. 
 
 Quality, " lubb,^^ dull, soft, booming. 
 Pitchy lower than that of the second sound. 
 Intensity, greatest at the apex beat, varying 
 with the strength of the heart, the condi- 
 tion of the valves and cavities, and the 
 amount of tissue interposed between the 
 heart and the listening ear. 
 Duration, long as compared with the second 
 
 sound. 
 Rhythm, systolic, synchronous with the sys- 
 tole of the ventricles, the apex beat, and 
 carotid pulse ; preceded immediately by 
 the long pause, succeeded immediately by 
 the short pause. 
 Second Sound of the Heart. 
 
 Cause of the second sound : it is chiefly due 
 to the closure of the semilunar valves, aug- 
 mented by the vibration of the neighboring 
 parts. 
 Elements of the second sound. 
 
 Aortic element, heard best in the second 
 intercostal space, close to the right of the 
 sternum. 
 
METHODS OF PHYSICAL UIAOyOSIS. IJl 
 
 Puhnonic element, heard l)e.st in the second 
 intercostal space to the left of the ster- 
 num ; not so loud as the aortic. 
 Character of the second sound. 
 
 Quality, "dupp," sharp. 
 
 Fitch, higher than that of the first sound. 
 
 InteiiHity, greatest at the base of the heart ; 
 variable like the first sound. 
 
 Duration, shorter than the first sound. 
 
 RJn/tJim, it is preceded immediately by the 
 short pause, and succeeded immediately 
 by the long pause. The relation of the 
 first and second sounds with the inter- 
 vening pauses may be represented thus : 
 
 "lubb," — "dubb," . 
 
 Modifications of the Xonnal Heart Sounds, 
 Modification of the First Sound, in 
 Intensity and duration. 
 
 Diminished intensity of the first sound, from 
 Weakness of the heart as a result of — 
 
 1. General diseases, fevers, chronic 
 wasting disorders, aneurysm, etc. 
 
 2. Local diseases of the heart : fatty 
 degeneration or infiltration ; atrophy, 
 amyloid, or fibroid degeneration ; 
 valvular disease ; pericardiac effu- 
 sion, etc. 
 
 Interposition of tissues, as in emphysema, 
 pleuritic effusion, thick chest- walls from 
 fat or muscle. 
 Increased intensity and duration of the first 
 sound ; it may be 
 Longer in duration, loud and booming, 
 as in hypertrophy of the left ventricle 
 from cirrhotic kidney ; aortic stenosis 
 and sometimes in aortic aneurysm, or 
 
92 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Shorter in duration and sharper, as in 
 case of thin chest-walls, emotional ex- 
 citement, physical exertion, onset of 
 febrile disease. 
 Quality : the first sound may be impure ; it 
 may be sharper or duller than usual, more 
 flapping or clacking. 
 Khythm. ^ 
 
 Reduplication. 
 
 Cause : non-synchronous action of the 
 mitral and tricuspid valves, or possibly 
 non-synchronous action of the cusps of 
 either valve. 
 Character, as related to the second sound ; 
 it may be represented thus : " lubb,'^ 
 "lubbV' — ^^dupp," — — . 
 Frequency : it is not uncommon, but the 
 second or diastolic sound is more fre- 
 quently reduplicated than the first or 
 systolic sound of the heart. 
 Significance : it is usually temporary, but 
 may be permanent ; it is either physio- 
 logical or pathological, and it is not 
 peculiar to any particular lesion or con- 
 dition. 
 Irregularity may involve time or intensity, 
 
 or both. 
 Intermittency or dropping of the first sound. 
 Modification of the Second Sound. 
 Intensity. 
 
 Diminished intensity of the second sound 
 
 from 
 
 Diminished power of the right or left 
 
 ventricle, by which less blood is thrown 
 
 into the aorta and pulmonary artery, 
 
 producing less tension in them, and 
 
METHODS OF PHYSICAL DIAGNOSIS 93 
 
 hence, less forcible recoil of their elas- 
 tic walls, and less sudden and forcible 
 closure of the semilunar valves. 
 
 1. General debilitating diseases, or 
 
 2. Local diseases impairing the 
 strength of the heart or elasticity 
 of the main arteries. 
 
 Stenosis of the mitral or tricuspid orifices 
 or of the orifices of the aortic or pul- 
 monary artery, reducing the tension in 
 those vessels. 
 Lesion of the pulmonary or aortic valves 
 impairing their closure. 
 Increased intensity or accentuation of the 
 second sound. 
 Pulmonic second sound may be accen- 
 tuated as a result of increased tension 
 in the pulmonary artery from hyper- 
 trophy of the right ventricle; ob- 
 structed pulmonary circulation depend- 
 ent upon pulmonary disease or valvular 
 disorder of the left heart. 
 Aortic second sound may be accentuated 
 as a result of increased tension in the 
 aorta from hypertrophy of the left ven- 
 tricle or obstruction in the aortic or 
 general circulation : chronic renal dis- 
 ease and some cases of aortic an- 
 eurysm. 
 Quality : the second sound of the heart may 
 be sharper or duller, or flopping or more 
 booming in character. 
 Rhythm. 
 
 Reduplication of the second sound. 
 
 Cause : non -synchronous action of the 
 aortic and pulmonic valves, or possibly 
 
94 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 non-synchronous action of the cusps of 
 either of these valves. 
 Character, as related to the first sound it 
 may be represented thus: "lubb," 
 — " dupp/^ " dupp/^ — . 
 Frequency and significance (vide redupli- 
 cation of the first sound). 
 Irregularity and ^ 
 
 Intermittency of the second sound (vide first 
 sound of the heart). 
 Abnormal Cardiac Sounds or 3Iiir7nwrs, 
 Exocardial Murmurs. 
 
 Pericaediac friction sounds. 
 
 Locality, over the prsecordia, usually best 
 heard over the base of the heart, or over 
 the junction of the left fourth costal car- 
 tilage with the sternum. 
 Cause, inflammation of the pericardium 
 causing roughness and dryness of the 
 membrane in the first and at the end 
 of the third stage. 
 Character. 
 
 Quality, rubbing, grating, rasping, creak- 
 ing- 
 Intensity, variable, increased by forced 
 expiration, by pressure of the steth- 
 oscope, and by forward inclination of 
 the patient. They seem to be more 
 superficial than endocardial murmurs. 
 Rhythm, independent of respiration and 
 synchronous with systole or diastole, 
 or both. 
 Pericardiac splashing and churning 
 sounds have been heard occasionally in 
 cases of sero- or pyo-pneumo-pericardium. 
 Pleuro-pericardiac friction sounds similar 
 
METHODS OF PHYSICAL DIAGNOSIS. 
 
 95 
 
 in character to pleuritic friction sounds, but 
 produced by the motion (jf the heart in sys- 
 tole, causing to-and-f'ro rubbing of the in- 
 flamed pleura. The pleura alone, or both 
 the pleura and pericardium, may be in- 
 volved in the inflammation. 
 
 SVC 
 
 Fig. 8.— Normal blood-currents in the heart and relative position of the ventri- 
 cles, auricles, and great vessels. IVC, inferior vena cava; SVC, superior vena 
 cava ; RA, right auricle : TV, tricuspid valves ; R V, right ventricle : P, pulmonary 
 valves ; PA, pulmonary artery ; Pv, pulmonary veins ; LA, left auricle ; MV, mitral 
 valves ; LV, left ventricle ; A, aortic valves ; Aa, arch of aorta. j;From Page.) 
 
 Pneumo-pericardiac or cardio-pulmonary 
 sounds are soft blowing murmurs of rare 
 occurrence, produced by the motion of the 
 heart in forcing air from an adjacent pul- 
 monary cavity, the air supposedly being ex- 
 pelled from the cavity in systole and return- 
 ing during diastole. 
 Endocardial Murmurs include organic and in- 
 organic, 
 
96 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Organic endocardial murmurs include val- 
 vular and non-valvular. 
 Valvular, organic, endocardial murmurs in- 
 clude systolic and diastolic. 
 Systolic, organic, valvular murmurs in- 
 clude those of the right and those 
 of the left heart. 
 
 Time ( Direct f Aortic, 
 
 of < (Obstructive). 1 Pulmonic 
 ■ t Indirect JK;iH 
 
 ;tive). 1 
 iitant). ' 
 
 ^^^m^^^^^^M Short tei^pi 
 
 p^jgi|i^l|j^Mg^]^j^^j^l|^i^^ interval, p^eg^^g^ 
 
 Systole. Time 
 
 of 
 murmurs. 
 
 Systole of auricles. 
 
 Y-i t:/^ r Aortic. Time f Mitral. 
 
 '~~ Direct 
 
 (Obstructive). 
 
 ../ r Aortic. Time fl 
 
 ™* I Indirect , of I 
 
 , I (Regurgitant). murmurs. | 
 
 ™""- [Pulmonic. (Presystolic.) [' 
 
 Tricuspid. 
 Indirect ' Direct 
 
 (Regurgitant). (Obstructive), 
 
 Fig. 9.— Diagram showing the time of valvular murmurs in the cardiac cycle. 
 The cardiac cycle is divided into tenths. The first sound occupies four-tenths ; the 
 short interval, or silence between first and second sounds, occupies one-tenth ; the 
 second sound occupies two-tenths ; the long interval following second sound occu- 
 pies three-tenths ; the systole of the ventricles occupies the time of the first sound 
 and the short interval. 
 
 Relation of murmurs to the heart-sound : murmurs may precede, occur with, or 
 take the place of the heart-sounds. Their time is indicated in the diagram by 
 arrows. 
 
 1. Of the left heart. 
 
 (a) Mitral systolic, indirect, or re- 
 gurgitant murmurs. 
 Cause : insufficiency of the mitral 
 valve from 
 
 Tearing or perforation of a cusp. 
 
 Inflammatory retraction of the 
 cusps. 
 
 Rigidity of the cusps. 
 
 Vegetations, preventing closure. 
 
 Rupture or shortening of the 
 chordae tendinese. 
 
 Dilatation of the left ventricle 
 without compensatory length- 
 ening of the chordae. 
 
METHODS OF PHYSICAL DIAGNOSIS 97 
 
 Spasm of the cokimnse carnete. 
 Usual accompanying symptoms 
 and signs : 
 
 Pulse, compressible and m<n-e or 
 less irregular. 
 
 Indications of pulmonary, he- 
 patic, and renal congestion 
 with oedema of the feet and 
 ankles are common in cases 
 of non-compensation. 
 
 Enlargement of the left heart, 
 with especial increase in trans- 
 verse diameter. 
 
 Pulmonic second sound accen- 
 tuated. 
 Character of the murmur of mitral 
 regurgitation : 
 
 Quality, apt to be blowing and 
 soft. 
 
 Rhythm, systolic, accompany- 
 ing, or replacing, the first 
 sound of the heart at the 
 apex. 
 
 Intensity, varies in different 
 cases, but the loudness of a 
 murmur is not proportionate 
 to, and does not indicate the 
 severity of the lesions causing 
 it. This is equally true of 
 all organic murmurs. 
 Area of maximum intensity is at 
 
 the apex. 
 Propagation of the murmur is fre- 
 quently to the left of the apex ; 
 
 it is often heard at the lower 
 
 angle of the scapula, but is not 
 
98 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 usually heard at the base of the 
 heart, and is never transmitted 
 into the carotids. The trans- 
 mission of murmurs to the left 
 of the apex depends upon the 
 following factors : 
 Time : whether or not it occurs 
 when the apex of the heart 
 strikes the chest- wall (systole). 
 Enlargement of the heart. 
 Position of the heart relative to 
 the transverse diameter of the 
 chest-cavity. 
 Condition of the left lung. 
 Thickness of the chest-wall. 
 Intensity of the murmur. 
 Frequency of the murmur of mitral 
 regurgitation, it is the most fre- 
 quent of all valvular murmurs. 
 (6) Aortic systolic, direct murmur. 
 Cause : 
 
 Obstruction at the orifice, 
 guarded by the aortic semi- 
 lunar valve due to thickening 
 and rigidity of the cusps from 
 fibroid, calcareous, or athero- 
 matous change ; vegetations ; 
 adhesion of the cusps ; indu- 
 ration and contraction of the 
 fibrous ring or margin of the 
 aortic opening ; congenital 
 malformation (rare). 
 Simple roughening of the cusps. 
 Marked dilatation of the aorta 
 immediately beyond the val- 
 vular opening, the latter re- 
 
METHODS OF PHYSICAL DIAGNOSIS. 99 
 
 maining relatively normal in 
 size. 
 Usual accompanying symptoms 
 and signs in cases of marked 
 obstruction : 
 
 Pulse : hard, wiry, small, but 
 regular unless the heart be 
 greatly embarrassed. 
 
 Thrill or fremitus often felt over 
 the base of the heart, espe- 
 cially over the aortic area. 
 
 Evidence of cerebral anaemia 
 not uncommon ; 
 
 Enlargement of the left heart ; 
 
 Pulmonic second sound, feeble ; 
 and 
 
 Aortic second sound, feeble or 
 inaudible. 
 Character of the aortic direct mur- 
 mur : 
 
 Quality, usually harsh when due 
 to stenosis or marked obstruc- 
 tion, otherwise it is apt to be 
 soft. 
 
 Rhythm, systolic, with the first 
 sound. 
 Area of maximum intensity : the 
 
 right, second intercostal space 
 
 close to the sternum, sometimes 
 
 over the left interspace or over 
 
 the upper part of the sternum 
 
 at the same level. 
 Propagation, into the arteries of 
 
 the neck and down the sternum, 
 
 and toward the apex, but with 
 
 diminished intensity. It is also 
 
100 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 frequently heard when loud, be- 
 hind to the left of the fourth 
 dorsal vertebra, but is not usually 
 transmitted to the left of the 
 apex. 
 2. Of the right heart (systolic, organic, 
 valvular murmurs). 
 (a) Tricuspid systolic, indirect or re- 
 gurgitant murmur. 
 Causes may be similar to those of 
 mitral regurgitant murmur, but 
 usually it results from relative 
 incompetency of the valve in 
 dilatation of the right ventricle, 
 secondary to diseases of the 
 lungs or serious lesions of the 
 left heart. 
 Usual accompanying symptoms 
 and signs : Commonly pulmon- 
 ary diseases or lesions of the left 
 precede those of the right heart ; 
 the associated manifestations are 
 often those of 
 
 Congestion of the brain and 
 abdominal organs; pulsa- 
 tion of the 
 Jugular and sometimes of the 
 Hepatic veins. 
 
 Enlargement of the right 
 heart and usually of the 
 left. 
 Pulmonic second sound,feeble. 
 Character of the murmur of tri- 
 cuspid regurgitation : 
 Quality, blowing. 
 Rhythm, systolic, with or re- 
 
METHODS OF PHYSICAL DIAGNOSIS. 101 
 
 placing the first .sound of 
 t!ie heart. 
 Area of niaximura intensity, the 
 tricuspid area at the end of and 
 along the left side of the sternum: 
 Propagation very limited ; if any- 
 where, it is transmitted to the 
 right, sometimes even to the 
 axilla. It is not heard at the 
 apex or behind or over the ca- 
 rotids, and is seldom audible 
 above the third rib. 
 Frequency : it is com])aratively 
 rare, and very uncommon, from 
 primary lesion of the tricuspid 
 valve. 
 (6) Pulmonic, systolic, direct mur- 
 mur. 
 Cause : usually obstruction from 
 conditions somewhat similar to 
 those affecting the aortic orifice ; 
 rarely are lesions of this valve 
 the result of rheumatism. They 
 are generally congenital. 
 Usual accompanying symptoms 
 and signs : 
 Enlargement of the right heart ; 
 Evidence of venous engorge- 
 ment; 
 Bruit de diahle occasionally 
 
 heard over the jugulars. 
 Pulmonic second sound weak. 
 Character of the murmur of pul- 
 monic obstruction : 
 Quality, variable, apt to be 
 harsh. 
 
102 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Rhythm, systolic, accompanying 
 the first sound. 
 Area of maximum intensity : in 
 the left second intercostal space 
 close to the sternum. 
 Propagation occasionally toward 
 the left shoulder, never toward 
 the apex nor along the aorta. 
 It is not heard over the lower 
 part of the sternum, nor be- 
 hind. 
 Frequency : very rare. 
 Diastolic, organic, valvular murmurs. 
 1. Of the left heart. 
 
 (a) Mitral diastolic (presystolic), di- 
 rect murmur. 
 Cause : obstruction of the mitral 
 opening. This murmur may 
 possibly occur, according to 
 Flint, without mitral lesion, 
 where there is aortic regurgita- 
 tion with marked, dilatation of 
 the left ventricle. 
 Usual accompanying symptoms 
 and signs : 
 Pulse, in marked cases, small. 
 Purring thrill or fremitus, pre- 
 systolic and most distinct at 
 the apex, not uncommon. 
 Evidence of pulmonary engorge- 
 ment. 
 Enlargement of the left auricle. 
 Pulmonic second sound accen- 
 tuated. 
 Character of the murmur of mitral 
 stenosis : 
 
METHODS OF PHYSICAL DIAGNOSIS. 103 
 
 Quality, har.sli, churning, grind- 
 ing, blubbering. 
 Duration, it is apt to be longer 
 
 than other murmurs. 
 Rhythm, diastolic (presystolic), 
 probably occurring in auricu- 
 lar systole. 
 Area of maximum intensity : at 
 the apex beat or half an inch 
 above it. Usually louder when 
 the patient is erect. 
 Propagation limited : not trans- 
 mitted to the left of the apex, 
 nor into the arteries of the 
 neck, nor is it heard behind. 
 Frequency : common. 
 {h) Aortic, diastolic, indirect, regurg- 
 itant murmur. 
 Cause : insufficiency of the valve 
 from much the same causes as 
 those producing mitral insuffi- 
 ciency, except those referring to 
 the chordae tendinese. 
 Usual accompanying symptoms 
 and signs : 
 Pulse full, strong, and collapsing 
 in diastole ; forcible beating 
 of the 
 Carotids. 
 Capillary pulsation in marked 
 
 cases. 
 Enlargement of the left heart, 
 with perhaps secondary en- 
 largement of the right. 
 Character of the murmur of aortic 
 regurgitation : 
 
104 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Quality, s(^ft, blowing, rushing, 
 
 and occasionally musical. 
 Rhythm, diastolic, accompany- 
 ing, or replacing, or imme- 
 diately following the second 
 sound of the heart.. 
 
 Area of maximum intensity : in 
 the right second interspace, or 
 over the sternum at the level of 
 the second costal cartilage, fre- 
 quently in the left, second in- 
 terspace, and sometimes at the 
 xiphoid cartilage. 
 
 Propagation : down the sternum 
 to the epigastrium ; to the apex, 
 where it is sometimes very loud 
 and conveyed to the left ; to the 
 arch of the aorta and into the 
 carotids ; and behind, along the 
 right side of the spinal column. 
 It may be heard occasionally 
 even in the radial and femoral 
 arteries. The area of diffusion 
 is greater than that of any other 
 murmur. 
 
 Frequency : it stands third in order 
 of frequency. 
 2. Of the right heart. 
 
 (a) Tricuspid, diastolic (presystolic), 
 direct murmur. 
 
 Cause : obstruction at the tricuspid 
 opening (vide aortic and mitral 
 stenosis). 
 
 Usual accompanying symptoms 
 and signs : those of systemic 
 venous engorgement. Some- 
 
METHODS OF PHYSICAL DIAGNOSIS 105 
 
 times there is a fremitus to \)e 
 felt over the right heart. 
 
 Character of the murmur of tri- 
 cuspid obstruction : 
 Quality, harsh. 
 Rhythm, presystolic. 
 
 Area of maximum intensity : over 
 the lower two-thirds of the 
 sternum. 
 
 Propagation : may be toward the 
 base faintly, but never toward 
 the apex ; it is not heard above 
 the base. 
 
 Frequency : extremely rare. 
 (6) Pulmonic, diastolic, indirect, re- 
 gurgitant murmur. 
 
 Cause : insufficiency of the pul- 
 monic valve, usually following 
 pulmonary diseases or serious 
 lesions of the left heart. 
 
 Usual accompanying symptoms 
 and signs are those of the ante- 
 cedent lesion ; evidence of venous 
 engorgement ; enlargement of 
 the right heart. 
 
 Character of the murmur of pul- 
 monic regurgitation : 
 Quality, soft, blowing. 
 Rhythm, diastolic, accompany- 
 ing or replacing the second 
 sound. 
 
 Area of maximum intensity : over 
 the left, second intercostal space. 
 
 Propagation : downward toward 
 the xiphoid cartilage. 
 
 Frequency : rare. 
 
106 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Non-valvula7'y organic murmur. 
 
 Intra-ventriciilar or iiitra-auricular mur- 
 murs. 
 Cause : roughening of the endocardial 
 lining in acute endocarditis ; rarely 
 it may be due to a tendinous cord 
 stretched across the ventricle (con- 
 genital) ; or cardiac aneurysm ; or an 
 abnormal congenital opening between 
 the two cavities, patulous foramen 
 ovale. 
 
 Usual accompanying symptoms and 
 signs : none constant, though they 
 may be those of acute endocai'ditis. 
 Character of the organic, intra-ven- 
 tricular murmur : 
 Quality, variable, usually soft. 
 Rhythm, systolic. 
 Area of maximum intensity at or 
 
 near the apex. 
 Propagation : limited. 
 Frequency : quite common in acute 
 endocarditis. 
 Inorganic, or functional, endocardial 
 
 MURMURS. 
 
 Inorganic valvular murmurs. 
 
 Systolic, inorganic, valvular murmurs. 
 1. Of the left heart. 
 
 {a) Mitral, systolic, inorganic, re- 
 gurgitant murmur. 
 May occur purely from functional 
 incompetence without actual 
 lesion of the valve. Its charac- 
 ter does not differ from the or- 
 ganic murmur. Such a murmur 
 may appear and disappear with- 
 
METHODS OF PHYSICAL DIAGNOSIS. 107 
 
 out previous, accompanying, or 
 subsequent evidence of endo- 
 carditis. 
 Frequency : it is comparatively 
 rare. 
 (b) Aortic, systolic, inorganic mur- 
 murs. 
 Cause : antemia. 
 
 Accompanying symptoms and 
 siffus, those of 
 Ansemia : pallor, lassitude, weak 
 
 pulse, 
 Venous hum over the jugulars, 
 
 and frequently an 
 Arterial, systolic murmur, pro- 
 duced in the carotids which 
 is usually of different quality 
 and pitch from the cardiac 
 murmur. 
 No cardiac enlargement is present 
 or other sign of valvular lesion. 
 Character : 
 Quality, soft. 
 Rhythm, systolic. 
 Area of maximum intensity : over 
 the base of the heart, above the 
 third rib, frequently in the aortic 
 area. 
 Propagation occurs into the arch 
 of the aorta and the carotids ; 
 frequently a louder murmur pro- 
 duced in, and heard over the 
 carotids, may accompany it. 
 Frequency : the inorganic, aortic, 
 systolic murmur is more com- 
 mon than the organic. 
 
108 PHYSICAL DIAGNOSIS OF THE CHEST 
 
 2. Of the right heart. 
 
 (a) Tricuspid, inorganic, regurgitant 
 murmur. 
 Cause : functional incompetence 
 of the tricuspid valve, similar 
 to that of the mitral valve. 
 (h) Pulmonic, systolic, inorganic mur- 
 mur. 
 Cause : anaemia. 
 
 Character: similar to that of the 
 aortic, systolic, inorganic mur- 
 mur. 
 Area of maximum intensity is over 
 
 the pulmonary area. 
 Propagation is limited : it is not. 
 transmitted above the base of 
 the heart, but may be accom- 
 panied by an anaemic murmur 
 produced in the carotids, which 
 is frequently of different quality 
 and pitch. 
 Diastolic, inorganic murmur of both left 
 and right heart are very rare and prac- 
 tically unimportant. 
 Inorganic, non-valvular murmurs are in- 
 definite and unimportant. 
 VASCULAR SOUNDS, sounds heard over the vessels. 
 Arterial Sounds. 
 
 Normal Arterial Sounds. 
 
 Diastolic second sound of the heart 
 may be transmitted into the aorta and 
 carotids. (It may be impure or entirely 
 wanting.) 
 Over the aorta and commonly over the 
 carotid and subclavian arteries is to be 
 heard a systolic, indistinct, rushing sound 
 
METHODS OF PHYSICAL DIAGNOSIS 109 
 
 produced by the blood pulsating through 
 the arteries. 
 
 Over the Subclavian arteries at the end 
 of inspiration a systolic, blowing murmur 
 may be frequently heard in health. 
 
 Over the abdominal aorta and crural 
 arteries is sometimes to be heard a pulsating 
 sound, corresponding in rhythm to the pulse 
 in those arteries. 
 
 Over the small vessels nothing is to be 
 heard. 
 
 Pressure of the stethoscope over any of 
 the large arteries may produce a murmur 
 occurring with the local pulsation. 
 
 Over the anterior fontanelle and some- 
 times over the carotids of children, between 
 the ages of three months and six years, 
 a blowing, systolic murmur, of variable 
 intensity, is frequently heard, ^'cerebral 
 blowing." 
 
 Over the uterus in the latter months of 
 pregnancy, uterine souffle, from entrance of 
 blood into the dilated arteries of the uterus. 
 Abnormal Arterial Sounds. 
 
 Over the aorta, carotid, and subclavian 
 ARTERIES may be heard systolic and diastolic 
 murmurs produced at the aortic orifice of 
 the heart ; in aneurysm of these vessels a 
 systolic whizzing or blowing murmur may 
 be heard over them, rarely a diastolic mur- 
 mur in aortic aneurysm. 
 
 Over the crural, brachial, radial, and 
 ULNAR ARTERIES, and cvcn the peroneal 
 and dorsalis pedis, a murmur may be heard 
 with the pulse in the respective vessels in 
 some cases of aortic insufficiency. 
 
110 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Over the crural arteries a systolic mur- 
 mur may sometimes be heard in anaemia and 
 chlorosis and in high fever (as well as occa- 
 sionally in health). 
 
 Over the crural arteries a double mur- 
 mur, diastolic and systolic, may be heard in 
 some cases of aortic insufficiency (Traube) ; 
 exceptionally in mitral stenosis (Weil) ; in 
 lead-poisoning (Matterstock) ; and in preg- 
 nancy (Gerhardt). 
 
 Over the crural arteries, also, in many 
 cases of aortic insufficiency, a double mur- 
 mur may be produced by the pressure of the 
 stethoscope over the artery, "Duroziez's 
 double murmur." This can only occur with 
 a large, quick pulse. 
 
 Over the subclavian artery a systolic 
 murmur (sometimes normal, as when due to 
 pressure of the stethoscope) may be pro- 
 duced by pressure of tumors on the vessel ; 
 traction by lung in fibroid disease of the 
 apex. 
 Venous Sounds, bruit de diable. 
 Normal Venous Sounds. 
 
 Over the jugular vein, most frequently 
 the right, a venous hum, whistling, or rush- 
 ing sound is exceptionally heard in health, 
 either continuous or rhythmically syn- 
 chronous with diastole or inspiration. It 
 may be produced sometimes by pressure of 
 the stethoscope, or by turning the person's 
 head to the opposite side. 
 
 Over the crural vein, occasionally in 
 health, especially in thin persons, a sound 
 may be heard, produced by sudden straining 
 effi^rts or coughing (Friedreich). 
 
METHODS OF PHYSICAL DIAGNOSIS, 111 
 
 Abnormal Venous Sounds. 
 Over the jugular vein. 
 
 In tricuspid inmfficieiwy a systolic murmur 
 
 may sometimes be heard. 
 In ancemia and chlorosis a venous hum more 
 or less continuous is often present over 
 this vessel, associated with a systolic, 
 blowing murmur in the carotids. Venous 
 murmurs arising in the cervical veins and 
 in the intratlioracic venous trunks may 
 exceptionally be conducted to tlie heart, 
 simulating valvular murnuirs. 
 Cause uncertain. 
 Character. 
 
 Quality : whizzing, rushing, or hum- 
 ming (like a singing top). 
 Duration : intermittent or constant, but 
 
 disappearing with the anaemia. 
 Intensity : loudest over the right jug- 
 ular, with the patient erect and the 
 head turned to the left. The in- 
 tensity is increased during ventricu- 
 lar diastole, during inspiration, by 
 moderate pressure of the stethoscope, 
 and by quickening of the circulation. 
 Over the crural veins, exceptionally, in 
 tricuspid insufficiency may be heard a double 
 sound, indicating first auricular then ven- 
 tricular contraction (Friedreich) ; this is not 
 easily distinguished from like murmurs pro- 
 duced in the crural artery. 
 
 SUCCUSSION. 
 The succussion or splashing sound is produced in a cavity 
 which contains both fluid and gas, by shaking the patient. 
 Normally, it may sometimes be heard over the stomach; 
 
112 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 pathologically, it is a sign of pneumo-hydrothorax. The 
 character of the sound is like that produced when a small 
 keg, partly filled with liquid, is shaken {vide p. 89). 
 
 PHONOMETKY. 
 
 The tuning-fork may aid in the detection of changes which 
 have affected intrathoracic organs. ^If it be vibrated and 
 placed over normal lung its sound is accentuated; if over 
 airless parts its sound is attenuated. 
 
 PHYSICAL SIGNS IN THE DISEASES OF THE 
 
 CHEST. 
 
 Note. — A clear understanding of the morbid anatomy of 
 a disease is essential to an appreciation of its physical signs. 
 In the following synopsis, therefore, each disease, with a few 
 exceptions, is introduced by a definition epitomizing its gross 
 pathology. In the enumeration of the signs discovered by 
 the several methods of objective examination the order will 
 be followed, as far as practicable, as indicated in the preced- 
 ing pages — viz. under inspection, color, nutrition, size, form, 
 posture and movements, etc. 
 
 DISEASES OF THE CHEST-WALL. 
 
 PLEURODYNIA AND INTERCOSTAL NEURALGIA. 
 Definition. 
 
 PLEURODYNIA is a thoracic, rheumatic myalgia. 
 IKTEJRCOSTAL NJEUMALGIA is a functional or 
 organic affection' of the intercostal nerves, chiefly 
 manifested by pain and localized points of tenderness, 
 and usually affecting women. 
 
SIGNS IN THE DISEASES OF THE CHEST. 113 
 
 Signs. 
 
 INSPECTION shows 
 
 ANiCMIA commonly present. 
 
 RESPIRATION in severe oases shallow and more or 
 
 less rapid as evidence of ])ain. 
 MOVEMENTS OF THE BODY restricted to avoid 
 pain, especially in pleurodynia. 
 PALPATION may reveal 
 IN PLEURODYNIA — 
 
 Tenderness on pressure, more or less diffuse when 
 superficial muscles are involved. 
 IN INTERCOSTAL NEURALGIA— 
 
 Tenderness in from one to three Isolated points 
 (Valleix's). 
 Behind, near the dorsal vertebrae. 
 Laterally, in one or more intercostal spaces along 
 
 the axillary line. 
 Anteriorly, in one or more intercostal spaces 
 near the sternum or over the epigastrium. 
 PERCUSSION shows— 
 
 ABSENCE OF DULNESS. unless there be compli- 
 cating or causative disease of the lungs, pleurae, or 
 circulatory organs. 
 AUSCULTATION yields— 
 
 NORMAL VESICULAR RESPIRATION, except slightly 
 diminished in intensity or interrupted owing to re- 
 stricted movements. 
 ABSENCE OF PLEURITIC SOUNDS and of crepitant 
 rales. 
 
 SWELLINGS AND TUMORS OF THE CHEST-WALL. 
 
 Definition : these include inflammatory and granuloma- 
 tous affections and tumors. 
 
 Signs : the varying color, size, sliape, location, tenderness, 
 consistence, and movability of each aflPection, whether 
 originating from or involving bone, cartilage, or soft 
 
114 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 parts, are properly considered in works on general sur- 
 gery. Suffice it to say here, that the usual respiratory 
 and vocal sounds are to a degree obscured over them 
 and vocal fremitus correspondingly enfeebled. The ab- 
 sence of positive signs of intrathoracic disease is sug- 
 gestive of one or the other of these affections. 
 
 EMPHYSEMA OF THE CHEST-WALL. 
 
 Definition : a rare affection characterized by inflation of 
 the subcutaneous areolar tissue with air or other gas. It 
 is usually associated, when marked, with a like involve- 
 ment of the cervical and abdominal region, and it may 
 extend over the entire body. 
 Signs. 
 
 INSPECTION may reveal — 
 PALENESS of the surface. 
 
 PUFFIN ESS, tending to obliterate the usual depres- 
 sions and prominences. 
 APEX BEAT absent. 
 PALPATION reveals — 
 
 PECULIAR SENSE OF YIELDING or softness, with 
 crepitation fremitus felt by the finger tips pressed 
 upon the surface. 
 AUSCULTATION 
 
 CREPITANT SGUNDS.myriad, fine, and somewhat 
 similar to the rales in pneumonia, heard when 
 the ear or stethoscope is pressed upon the surface. 
 
 DISEASES OF THE BEONCHI, PLEUE^, LUNGS, AND 
 MEDIASTINUM. 
 
 ACUTE AND SUBACUTE BRONCHITIS. 
 
 Definition : inflammation of the mucous membrane lining 
 the larger and medium-sized tubes of both lungs. The 
 early dryness and swelling is followed by more or less 
 profuse secretion. 
 
SIGNS IN THE DISEASES OF THE CHEST 115 
 
 Signs. 
 
 INSPECTION reveals little abnormal except— 
 RESPIRATORY MOVEMENTS slightly accelerated. 
 COUGH at first dry, harsh, with scanty secretion, later 
 
 moist (loose), rattling. 
 DYSPNCEA rarely, except from retained secretion in 
 the tubes, as in infants, the aged, or tlie enfeebled. 
 rALPATION reveals— 
 
 SURFACE TEMPERATURE and pulse slightly mod- 
 ified. 
 VOCAL FREMITUS normal. 
 
 RHONCHAL FREMITUS in case of considerable secre- 
 tion, especially in children, or in adults with thin 
 chest- Avails. 
 PERCUSSION. 
 
 RESONANCE normal. 
 
 SLIGHT DULNESS rarely, over lower part of the 
 chest, due to accumulation of bronchial secretion, 
 though this may be removed by expectoration. 
 A USCULTATION, 
 
 RESPIRATORY SOUNDS apt to be somewhat harsh 
 
 over the larger tubes. 
 VESICULAR MURMUR may be more or less sup- 
 pressed over parts of the lungs supplied by bronchi 
 partially or wholly occluded by mucus. 
 VOCAL RESONANCE normal. 
 ADVENTITIOUS SOUNDS. 
 
 Dry Bales common in the first stage, slightly ob- 
 scuring the vesicular murmur. 
 Moist Males (large and small) may be heard bilat- 
 erally in varying numbers after the first day or 
 so, with the occurrence of hypersecretion. These 
 are variable in intensity, location, and time, and 
 are apt to disappear upon cough, and upon deej) 
 inspiration or forced expiration. A few dry rales 
 may occur with them. 
 
116 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 CAPILLARY BRONCHITIS. 
 
 Definition: inflammation extending from the larger to 
 
 the smaller tubes (bronchiolitis). 
 Signs. 
 
 INSPECTION, in addition to the usual visible signs 
 of acute bronchitis^ reveals the age. 
 AGE, young children or the aged. 
 EXPRESSION of anxiety or distress common. 
 CONGESTION and a more or less bloated appearance 
 
 of the face sometimes seen. 
 LIVIDITY of the face becomes more or less evident, 
 both from want of proper oxygenation of the blood 
 and its undue accumulation in the right heart, lead- 
 ing to a fatal termination. 
 AL/E NASI dilated in the struggle for air. 
 THE CHEST in a young child may be notably dis- 
 tended at the anterior upper and middle part from 
 acute compensatory emphysema, which disappears 
 if recovery occurs. 
 GENERAL RESTLESSNESS. 
 
 DYSPNCEA, amounting sometimes to orthopnoea, and 
 HYPERPNCEA, amounting to 60 or 70 respirations per 
 minute in children. 
 PALPATION. 
 
 THE SURFACE IS HOT, and later may be covered 
 
 with clammy perspiration. 
 THE PULSE rapid, weak. 
 PERCUSSION may obtain 
 NORMAL RESONANCE, or 
 
 EXAGGERATED RESONANCE over the upper lobes 
 owing to emphysema, which compensates for occlu- 
 sion of the many small bronchi with collapse of 
 their terminal air-vesicles. 
 AUSCULTATION, usually the signs of 
 
 GENERAL BRONCHITIS of the larger tubes, and in 
 addition 
 
SIGNS TN THE DISEASES OF THE CHEST. 117 
 
 SIBILANT RALES, very a})iiii(laiit early in the disease, 
 
 replaced latei- by 
 SUBCREPITANT RALES, both bilateral. 
 
 CHRONIC BRONCHITIS. 
 
 Definition : prolonged inflammation of the bronchial 
 mucous membrane. This means derangement of secre- 
 tion, thickening and irregularity of the surface, hyper- 
 trophy of the muscular and fibrous coats, with final 
 atrophy and fibrosis, eventuating in bronchiectasis, 
 asthma, or emphysema. 
 Signs : largely those of acute and subacute bronchitis. 
 THE CHIEF CONTRAST is in the greater number 
 of moist rales and the relatively few dry rides in the 
 chronic affection. As the disease may tend to 
 EMPHYSEMA, and frequently to more or less 
 ASTHMA, the signs are correspondingly modified. 
 THE ABSENCE of emaciation, pallor, tachycardia, 
 hyperpnoea, and other evidences of phthisis is espe- 
 cially important. 
 
 PLASTIC BRONCHITIS. 
 
 Definition : an acute or chronic inflammation of the bronchi, 
 chiefly characterized by the exudation of fibrinous mat- 
 ter, with the formation of plastic casts in the smaller, 
 sometimes involving the larger tubes. 
 
 Signs : those of ordinary bronchitis, with the evidence 
 of partial or complete obstruction of some of the bronchi, 
 detected by the absence or diminution of the respiratory 
 sounds over the affected parts and dulness over collapsed 
 lung. 
 
 BRONCHIECTASIS. 
 
 Definition : dilatation of the bronchial tubes with more 
 or less associated bronchitis, fibrosis, and emphysema. 
 
118 PHYSICAL DIAG2^0SIS OF THE CHEST. 
 
 Signs. 
 
 IWSrECTION, 
 
 DEPRESSION OF INTERCOSTAL SPACES and 
 RIGIDITY OF THE CHEST- WALL, more or less 
 
 marked, commonly unilateral. 
 RESPIRATORY MOVEMENTS somewhat limited. 
 COUGH with 
 
 EXPECTORATION, usually very profuse, purulent, 
 and offensive. At times more profuse in certain 
 postures. 
 PALPATION gives 
 
 SIGNS VARYING greatly from time to time with the 
 amount of secretion retained in the bronchiectatic 
 cavities. 
 Phonchal FreniiUis may be present. 
 Vocal Fremitus may be abnormally increased over 
 a cavity if large, and freely communicating with 
 the upper air-passages ; diminished when the com- 
 munication is closed. 
 
 pehcussiox. 
 
 DULNESS usual over the affected lung; most com- 
 monly over the right, middle and lower lohes. It 
 is sometimes removed or diminished by free ex- 
 pectoration, or replaced by vesiculo-tympanitic, 
 cracked-pot, or amphoric resonance. 
 A USCUL TA TIOJV. 
 
 RESPIRATORY MURMURS sometimes 
 
 Suppressed over Cavities, w hile respiratory sounds 
 
 are apt to be harsh and exaggerated. 
 Broncho-vesicular or JBroncho-cavernous respira- 
 tion may be obtained over a part after free ex- 
 pectoration, where before no sounds were present. 
 VOCAL AND WHISPER SOUNDS may suffer like 
 
 changes. 
 ADVENTITIOUS SOUNDS are usually present in the 
 form of 
 
SIGNS I^' TlIK LISEASES OF THE CHEST. 110 
 
 Hales, moist and dry, and 
 
 Gtfi'f/les, both of which are varial)h* in character 
 and time. 
 
 ASTHMA. 
 
 Definition : a neurosis of tlie respiratory mechanism, char- 
 acterized cliiefly by paroxysms of dyspnoea probably 
 due to s])asm of the annular bronchial muscles. 
 Signs during a paroxysm. 
 INSPECTION, 
 
 POSTURE, standing or sitting with elbows on the 
 
 knees or resting upon some support. 
 EXPRESSION OF ANXIETY and distress. 
 NOSTRILS dilated, MOUTH open. 
 PERSPIRATION profuse, commonly. 
 STERNO-CLEIDO-MASTOID MUSCLES rigid and 
 
 prominent. 
 CYANOSIS of the face and neck may become very 
 
 marked, conjunctivae congested. 
 CHEST approaches the barrel-shape or inflated type 
 
 in cases of long standing or great frequency. 
 CHANGES OF POSTURE usually very deliberate. 
 RESPIRATORY MOVEMENTS restricted. 
 
 Dl/sjJiioefc (orthopnoea) chiefly expiratory, and res- 
 piration not necessarily increased in rate, but 
 may be decreased. 
 lusxyiratory 3Ioieineiifs short and quick. 
 Exjnratory Movements prolonged. 
 PALPATION, MENSURATION, and PERCUS- 
 SION signs not specially significant except when 
 emphysema has develope<.l. 
 PULSE small, feeble, and rapid in proportion to the 
 deficient aeration of the blood and overdistention 
 of the right heart. 
 SURFACE OF THE BODY cold and moist (clammy). 
 A use UL TA TION gives 
 
120 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 COG-WHEEL RESPIRATION, harsh. 
 RALES. 
 
 Dri/ (sonorous and sibilant). 
 Chiefly in Expiration. 
 Over Whole Chest. 
 Obscuring" Vesicular Murmur. 
 Loud enough, usually, to be heard at a distance 
 from the patient (wheezing). 
 Moist (large and small, subcrepitant), 
 
 In the Later Stage in proportion to the bron- 
 chitis with accompanying secretion. 
 
 EMPHYSEMA OF THE LUNGS. 
 
 Definition : an abnormal inflation of the lung from loss 
 of elasticity, overdistention of the air-vesicles, and in 
 pronounced cases more or less destruction of the alveolar 
 walls by rupture, with accumulation of air in the inter- 
 lobular connective tissue. 
 Signs : in senile emphysema, where atrophy of the lungs 
 is the chief feature, and in moderate emphysema, there 
 is little change in the shape of the chest. 
 INSPECTION in well-marked cases. 
 
 FACE apt to be dusky and frequently more or less 
 swollen. 
 Eyes prominent and watery, conjunctivae injected. 
 LipSf end of Nose, and Tonifjiie bluish. 
 Nostrils dilated. 
 ALONG ATTACHMENT OF DIAPHRAGM there is 
 frequently a zone of dilated venous capillaries, 
 though this is not peculiar to emphysema. 
 POSTURE, stooping. 
 
 STERNO-CLEI DO- MASTOIDS tense and prominent. 
 NECK apparently shortened and thick, owing to the 
 
 elevation of the' sternum and shoulders. 
 SHOULDERS elevated and drawn forward. 
 FORM of the chest barrel-shaped. 
 
SIGNS TN THE DISEASES OF THE CHEST. 121 
 
 General Cmitour rounding out. 
 
 Upper Part of Htermitn, 
 
 Infra-clavicular and Mammary Re(/ions prom- 
 inent. 
 
 Antero-posterior Curvattire of the spine increased^ 
 and therefore 
 
 Antero-posterior Diatneter of the eliest increased. 
 May be even greater than the transverse. 
 
 Vertical Diameter apt to be decreased. 
 
 Loiver Part of Chest usually contracted, but it 
 may be dilated, with a wide obtuse costal angle. 
 
 Intercostal Spaces wide, especially at the upper 
 part of the chest. 
 
 Supra-clavicular fossae may be deepened or shal- 
 low, or bulging, especially during cough. 
 
 ScapuUe separated widely. 
 
 Deep Transverse Depression sometimes present 
 across the abdomen at the level of the twelfth 
 rib, especially during expiration. 
 
 General Emaciation, 
 RESPIRATORY EXPANSION diminished. 
 
 Breathing Chiefly Diaphragmatic. 
 
 Ribs and Sternum move upward and forward as 
 if made of one piece. 
 
 Intercostal Spaces and supra-clavicular fossse fall 
 in markedly during forced inspiration, and bulge 
 out during expiration and cough. 
 
 False Ribs and neighboring interspaces retract 
 during inspiration. 
 
 Dyspnoea more or less persistent and exaggerated 
 by attacks of bronchitis, asthma, and on ex- 
 ertion. 
 
 Inspiratory Act short and quick. 
 
 Eix^piratory Act distinctly prolonged. 
 APEX BEAT of heart not usually visible, except in 
 
 the area of cardiac flatness ; the pulsation of the 
 
122 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 enlarged right ventricle is connnnnicated to the epi- 
 gastrium through the left lobe of the liver. 
 JUGULARS prominent, and sometimes pulsate. 
 PALPATIOJV. 
 
 SKIN dry and harsh. 
 
 VOCAL FREMITUS frequently enfeebled, but it may 
 
 be normal or exaggerated. 
 APEX BEAT rarely palpable ; frequently there is a 
 systolic impulse in the lower sternal and epigastric 
 regions. 
 MENSUHATION shows the barrel 
 SHAPE of the chest and 
 
 DIMINISHED RESPIRATORY EXPANSION. 
 rERCUSSION yields 
 
 HYPER- RESONANCE, bilateral ; in exaggerated cases 
 
 the note is high-pitched, vesiculo-tympanitic. 
 AREA of pulmonary resonance reaches lower than 
 normal, and may extend to the costal margin, less- 
 ening the dulness over the heart, liver, and spleen, 
 and encroaching upon or obliterating the areas of 
 flatness. 
 AUSCULTATION, 
 
 RESPIRATORY SOUNDS. 
 Length. 
 
 Inspiratory Sound delayed and shortened. 
 Expiratory Sound prolonged, and may be two 
 or three times as long as the inspiratory. 
 Quality f Pitch, and Intensity. 
 
 In typical cases both sounds are low in pitch, 
 soft, breezy in quality, and diminished in in- 
 tensity, but frequently they are harsh and 
 blowing. 
 ADVENTITIOUS SOUNDS. 
 
 Dry Crackling or crumpling at the end of inspira- 
 tion and beginning of expiration, supposed to be 
 produced in the wall of the vesicles. 
 
STONS TN THE DISEASES OF THE CHEST. \2-\ 
 
 VOCAL RESONANCE is iiicroased, <limiiiislic(l, or 
 
 iioi'iiial. 
 HEART SOUNDS usually feeble, those at the apex 
 displaced downward and to the right, sometimes 
 distinct in the epigastrium. 
 Pulmonary (second) sound usually distinct, and 
 
 may be accentuated. 
 Mifrmui's of relative tricuspid insufficiency may 
 
 be heard when there is great dilatation of the 
 
 right ventricle. 
 
 ATELECTASIS. 
 
 Definition : congenital (apneumatosis) or acquired col- 
 lapse of the lung. 
 Signs. 
 
 INSPECTION usually discovers the subject a 
 WEAK SICKLY INFANT. 
 PALLOR or DUSKINESS of the surface. 
 EMACIATION and evident great prostration. 
 RESPIRATORY MOVEMENTS feeble. 
 
 Hijperpnoea, in children 60 to 80 per minute, 
 
 common. 
 BJiythm of Mespiration altered, the pause follow- 
 ing instead of preceding inspiration. 
 mjspnwa marked without relatively proportionate 
 
 lividity. 
 Petraction of the Intercostal Spaces and Loiver 
 
 Pibs marked during inspiration. 
 Ifi the Newly-born apneumatosis is denoted 
 by shallow, rapid respiration, feebleness of 
 the cry, dyspnoea, especially evident in in- 
 ability to nurse properly, and absence of 
 cough. 
 PALPATION. 
 
 EXTREMITIES cold. 
 PULSE feeble and rapid. 
 
124 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 VOCAL FREMITUS normal or slightly exaggerated 
 
 over the base of both lungs. 
 PERCUSSION is less satisfactory in children than in 
 
 adults. 
 NORMAL RESONANCE, if the collapsed vesicles are 
 
 so few or small and scattered as to be marked by the 
 
 resonance of adjacent over distended lung. 
 DULNESS more or less marked over the affected 
 
 parts where of considerable area. 
 A USCULTA TlOJSr, 
 
 VESICULAR MURMUR frequently normal where the 
 
 percussion note remains normal. It is diminished^ 
 
 and the breathing harsh and broncho-vesicular over 
 
 large patches of collapsed lung. 
 RALES are usually numerous except in apneumatosis. 
 
 LOBAR PNEUMONIA. 
 
 Definition : an acute infectious disease, characterized 
 locally by inflammation of the lung, clinically mani- 
 fested in three stages. 
 FIRST STAGE, EKGOBGEMEKT. 
 SECOJSrn stage, consolidation (red and gray 
 
 hepatization). 
 THIRD ST A GE, PBOGRESSIVE BESOL UTION 
 Signs : for convenience the signs of the three stages will 
 be considered under each of the methods of physical 
 examination. The signs of the first stage are usually 
 present within the first twenty-four hours unless the 
 pneumonia is central. 
 INSPECTION. 
 
 POSTURE is often on the affected side. 
 CIRCUMSCRIBED FLUSH, mahogany colored, over 
 
 one or both cheeks. 
 GENERAL PALLOR, occasionally at the onset the face 
 
 has a dusky hue ; later sallow. 
 LIPS, deep red at first, they become cyanosed with 
 
SIGNS IN THE DISEASES OF THE CHEST. 125 
 
 greatly disturbed circulation and pale at the 
 crisis. 
 HERPES labialis very frequent (50 per cent, of cases, 
 Osier) ; at times herpes on cheeks, nose, and eyelids. 
 SUDAMINA accompany profuse sweating. 
 JAUNDICE, more or less marked, is common and an 
 early sign, not apparently related to hepatic en- 
 gorgement, but probably due to duodenitis. 
 EXPRESSION anxious, eyes bright at first, later dull 
 
 or expressionless. 
 INTERCOSTAL SPACES not filled out as in pneumo- 
 
 or hydrothorax. 
 RAPID LOSS OF FLESH apparent in a few days. 
 DELIRIUM active, violent, or low and muttering. 
 SUBSULTUS TENDINUM attends the great prostra- 
 tion of the " typhoid state." 
 CONVULSIONS may usher in the attack in children. 
 RESPIRATORY MOVEMENTS of the affected side 
 restricted, markedly so in extensive consolidation 
 of the lower lobe ; exaggerated movements of the 
 healthy side. In double pneumonia respiratory 
 movements largely diaphragmatic and inferior 
 costal. 
 
 Hyperpnoea always present^ 30 to 80 per minute. 
 Ratio between respiration and pulse, 1 to 2 or 
 even 1 to 1.5. 
 Di/S2)ncea frequent, panting in character. 
 Inspiratory Act short and superficial. 
 Expiratory Act often associated with a grunt, 
 especially in children. Dyspnoea depends 
 upon various factors : 
 Amount of lung involved. 
 Rapidity of iNVOLVEiNrENT, 
 Fever, 
 Pain, and 
 Derangement of the nervous system. 
 
126 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Cough frequent, short, hacking, dry in the first 
 stage, loose during resolution. 
 MENSUMATION may show, in the second stage, a 
 very slight increase in the volume of the affected side 
 during expiration. 
 PALPATION discovers the 
 
 SKIN usually hot and dry till the crisis, but it may 
 
 be moist from the onset (a favorable sign). 
 PRESSURE may elicit deep-seated tenderness. 
 VOCAL FREMITUS in the 
 
 First Stage is not affected ; in the 
 Second Stage, greatly increased over the consolida- 
 tion, unless this be central or pleuritic effusion 
 covers it, or the large and medium-sized bronchi 
 become blocked (massive pneumonia), or if 
 there is complicating bronchitis with free secre- 
 tion. 
 Third Stage, progressive return to the normal 
 type. 
 FRICTION FREMITUS maybe obtained in some cases 
 
 owing to accompanying pleuritis. 
 LOCATION OF APEX BEAT may show the heart 
 
 slightly displaced away from the affected side. 
 PULSE, 
 Ma2)idity. 
 
 In Mild Cases, from 90 to 120. 
 In Severe Cases, from 120 to 160. 
 In Children, 100 to 200. 
 Volume and Tension, 
 At Onset it is full, bounding. 
 After the Third or fourth day it becomes com- 
 pressible, small, weak, and may be dicrotic 
 and intermittent in unfavorable cases. 
 In Old Ag-e'the radial pulse is not reliable, and 
 the pulse should be taken at the apex beat. 
 PERCUSSION, 
 
SIGNS IN THE DISEASES OF THE CHEST. 127 
 
 FIRST STAGE. 
 
 JJulness increasing at the end of the first stage ex- 
 cept in central pneumonia. The note may some- 
 times be vesiGulo-tyinpanitlc. 
 SECOND STAGE. 
 
 Marked Dulness over the consolidation witli a 
 sense of resistance to the pleximeter finger, less 
 than in pleurisy with effusion. 
 Hjlper-resonance over the healthy parts. 
 Tympmiitic Note occasionally, 
 
 Over Healthy Lung- adjacent to consolidation. 
 Over a Consolidated Upper Lobe due to con- 
 duction of resonance from the trachea and 
 main bronchi. 
 Cracked-pot Note occasionally over relaxed lung 
 adjacent to the consolidation. 
 THIRD STAGE. 
 
 Dulness slowly diminishing with progressive reso- 
 lution ; normal resonance established only after 
 weeks. 
 AUSCUL TA TION. 
 
 RESPIRATORY SOUNDS are — 
 
 Early in the First Stage feeble, and apt to be dry 
 
 and somewhat harsh over the affected part. 
 Later it becomes broncho-vesicular. In the 
 Second Stage. 
 
 Bronchial Breathing", provided the large bronchi 
 
 are patulous. 
 Exaggerated Breathing over the healthy lung. 
 Third Stage. 
 Breathing becomes broncho-vesicular, approach- 
 ing the normal. 
 VOCAL SOUNDS. 
 First Stage normal. 
 Second Stage. 
 
 Bronchophony and frequently 
 
128 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Pectoriloquy are characteristic of complete con- 
 solidation, 
 -^gophony not uncommon about the upper level 
 of the fluid if little pleuritic effusion accom- 
 pany the consolidation, voice sounds being ab- 
 sent or indistinct below. 
 Third Stage. 
 Bronchophony and Pectbriloquy give place to 
 exaggerated vocal resonance approaching the 
 normal sounds. 
 ADVENTITIOUS SOUNDS. 
 First Stage. 
 
 Crepitant Rales, lasting usually from 12 to 24 
 hours. These may be 
 Absent. 
 
 (1) If stages follow each other rapidly. 
 
 (2) In pneumonia complicating rheumatism. 
 
 (3) In lobes secondarily attacked. 
 
 (4) They are absent oftener in pneumonia 
 of children than in adults. 
 
 Second Stage. 
 
 Subcrepitant Rales may or may not be present. 
 Third Stage. 
 
 Crepitant Rales return, ^' crepitant rale redux/' 
 
 but are largely obscured by the coarser 
 Subcrepitant Rales, which are frequently accom- 
 panied by a few dry rales and more or less 
 large mucous rales. 
 
 LOBULAR OR BRONCHO-PNEUMONIA. 
 
 Definition : this is essentially an inflammation of termi- 
 nal bronchi, with their branches and surrounding air- 
 vesicles, which make up the pulmonary lobules. It 
 occurs in the course of bronchitis, extending to tlie 
 finer tubes, and is manifested in isolated or in groups of 
 lobules. These show interstitial inflammation of both 
 
SIGNS IN THE DISEASES OF THE CHEST. 129 
 
 tubes and air-cells, both being filled with a muco- 
 purulent secretion. 
 Signs : these are not distinctive unless there is considera- 
 ble consolidation, and even then rarely sufficient for 
 diagnosis without the aid of history and symptoms. 
 INSJ^ECTIOK shows the patient usually 
 AN INFANT or in ADVANCED AGE. 
 FACE PALE and ANXIOUS, becoming CYANOTIC in 
 
 severe cases. 
 EMACIATION very rapid. Chest bilaterally retracted 
 at the lower part, where there is extreme pulmo- 
 nary collapse in children. 
 DYSPNCEA marked. 
 
 Inspiration often shortened and 
 Expiration lengthened . 
 HYPERPNCZA constant. 
 
 RESPIRATORY MOVEMENTS DEFICIENT. 
 Slight expansion of the ribs. 
 
 Elevation of the chest-wall at the upper part, and 
 retraction of the soft parts and louver ribs on 
 inspiration. 
 COUGH dry, hacking, non-paroxysmal, painful. 
 RESTLESSNESS and jactitation in children gives 
 place to lethargy with advancing consolidation and 
 obstruction of the bronchi. 
 PALPATIONT may elicit 
 
 VOCAL FREMITUS, slightly increased over small 
 
 areas, where neighboring lobules are consolidated. 
 PULSE often reaches 140 to 150 per minute; small, 
 compressible, feeble after the first twenty-four 
 hours. 
 PERCUSSION. 
 
 DULNESS more or less marked, but in patches usually, 
 bilateral and limited to the posterior and lower 
 regions of the chest; sometimes unilateral. 
 HYPER-RESONANCE over upper and anterior part 
 
 9 
 
130 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 of chest where functional emphysema occurs in the 
 corresponding part of the lungs. 
 AUSCULTATION, 
 
 VESICULAR MURMUR feeble. 
 
 BRONCHO-VESICULAR and bronchial respiration. 
 
 VOCAL FREMITUS exaggerated. 
 
 RALES, moist and high-pitched over the lower part 
 of the chest, irregular in tiihe and place. 
 
 UNDEFINED MUCOUS CLICKS, on forced respira- 
 tion. Signs of emphysema are frequently found over 
 the anterior and upper part of the chest. 
 
 PULMONARY TUBERCULOSIS. 
 
 Definition : this affection is extremely varied in its pri- 
 mary location and manner of development, and there- 
 fore needs a few words of introduction. 
 
 It is characterized etiologically by the entrance 
 of tubercle bacilli into the lungs with the respired 
 air or through the lymphatic or blood-vessels. 
 Pathologically, therefore, the initial tubercle 
 may result early in (1) bronchial ideeration, or 
 the initial lesion may be in the small tubes of 
 one or more lobules, giving the usual early catar- 
 rhal signs of (2) tubercular bronchiolitis, as so 
 often manifested at one or the other apex, and 
 followed pari j^cissu by the signs of consolida- 
 tion as the neighboring vesicles become involved. 
 Again, sudden rupture of a bronchial lymphatic 
 gland or other tuberculous focus, with aspiration 
 of its infectious contents into the bronchi of 
 many lobules, may result in rapidly developing 
 (3) caseous lyaeumoniay involving more or less 
 of one lobe. Finally, the entrance of a large 
 number of tubercle bacilli into the circulation, 
 from a primary systemic focus, and their wide 
 dissemination in the lung (as well as in many 
 
S1G2^S IN THE DISEASES OF THE CHEST. 131 
 
 other organs), results in (4) acute nilllarij tuber- 
 culosis, the pulmonary signs of which are insig- 
 nificant. 
 
 The morbid conditions which may appear in the 
 course of pulmonary tuberculosis, more or less 
 slow in its progress, are tubercular bronchitis, 
 lobular and lobar consolidation, the formation 
 of cavities, compensatory emphysema, fibrosis 
 and calcification, bronchiectasis, oedema, collapse, 
 and pleiiritis, with or without effusion or pneumo- 
 thorax. 
 Signs of pulmonary tuberculosis, beginning as a broncho- 
 pneumonia. 
 INITIAL OR CATARRHAL STAGE before the 
 
 advent of consolidation. 
 INSPECTION. 
 
 Color and Niitritiofi may not be much affected. 
 
 Flat or ^^ Alar Cheaf more or less marked in 
 many cases. 
 
 JVo Abnormal Local Retraction of the chest as yet. 
 
 Respiratory Expansion of one or the other apex 
 may be slightly deficient or apparently lagging 
 as compared to the other. 
 
 No Hyperpnoea as yet. 
 PALPATION and mensuration negative, or 
 
 Pulse rate slightly increased, and 
 
 Respiratory Expansion deficient at one apex. 
 PERCUSSION negative. 
 AUSCULTATION. 
 
 Respiratory Murmur frequently feeble, having 
 interrupted or cog-wheel rhythm, and accom- 
 panied by 
 
 Subcrepitant Rales, which may be feeble, few, 
 and distant at an early stage, but become more 
 distinct. Later and sometimes early the respira- 
 tory murmur may be harsh, occasionally there are 
 
132 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 A Few Sibilant Rales. 
 
 A Mucous Click or friction or indistinct crumpling 
 sound may be heard. 
 STAGE OF COJVSOLIlPATIOlsr {tuberculosis). 
 
 INSPECTION yields, in addition to the signs of the 
 first stage, 
 
 Pallor and Emaciation, 
 
 Hectic Flush, and frequently very red lips. 
 
 Tenia Versicolor, common on the surface of the 
 thorax and other parts. 
 
 Betraction of the supra-clavicular and infra- 
 clavicular region at the affected apex. 
 
 jUjperxrnoea, superficial breathing and a tendency 
 to oough on deep inspiration. 
 
 Apeoc Beat enlarged in area and abnormally rapid. 
 PALPATION. 
 
 Skin hot and dry, or apt to be bathed in perspira- 
 tion. 
 
 Bespiratory Movements diminished. 
 
 Vocal Fremitus increased over consolidation. It is 
 normally greater at the right apex than the left. 
 Vocal fremitus may be diminished if the pleura 
 is greatly thickened over the consolidated lung. 
 
 Pulse rate usually above a hundred. 
 PERCUSSION. 
 
 Dtilness above and over the clavicle, or in the 
 supra-scapular region, early ; proportionately 
 more extensive with the advance of consolida- 
 tion. The two apices should be percussed while 
 the patient holds his breath after full inspira- 
 tion, especially to elicit the presence of but slight 
 dulness. 
 Dulness corresponds to tlie consolidation in any 
 
 part of the lung. 
 Deep-seated consolidation with overlying normal 
 lung may not be detected. 
 
SIGNS IN THE DISEASES OF THE CHEST. 133 
 
 A small portion of superficial ('oiisolidation, with 
 iindc'i'lying and surrounding overdistended 
 lung, may not be easily detected. 
 Dulness in any case may be in part due to the 
 simple acute pneumonia surrounding tuber- 
 cular consolidation, which may clean up, leav- 
 ing only the smaller area of dulness due to 
 the tubercular part. 
 Tympanitic liesonanre at times may be obtained 
 over consolidation adjacent to the trachea. 
 AUSCULTATION. 
 
 Respiratory Sounds are apt to be harsh and 
 broncho-vesicular or purely bronchial, according 
 to the amount of consolidation. 
 Whisj)er and Vocal Mesouance are apt to be ex- 
 aggerated and bronchial. The latter amounts to 
 pectoriloqny when the consolidation surrounds a 
 large bronchus. 
 Heart Sounds are apt to be exaggerated over neigh- 
 boring consolidation, and the second pulmonic 
 sound is frequently accentuated. 
 Adventitious Souitds are more or less numerous. 
 Rales large and small, dry and moist, often pe- 
 culiarly sticky in character. 
 Friction Sounds are often present^ due to cir- 
 cumscribed plenritis. 
 STAGE OF THE FOB3IATION OF CAVITIES, 
 INSPECTION show^s usually — 
 
 Pronounced Ancemia and Emaciation, and in 
 exaggerated cases signs of poor circulation, such 
 as local cyanosis of lips, nose, and extremities. 
 Cluhhiny of the Fingers. 
 
 Face is apt to bear the impress of prolonged 
 wasting illness, drawn haggard expression (ex- 
 ceptionally cavities may be formed in cases 
 apparently healthy). 
 
134 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Marked Depression of the chest from retraction 
 of the aflPected lung. 
 
 Hespiratorj/ Movements limited, on the affected 
 side and abnormally rapid. 
 
 Apex Beat rapid, weak, and frequently displaced 
 toward the affected side. 
 PALPATION. 
 
 Vocal Fremitus increased oVer a cavity if empty 
 and freely communicating with a bronchus. 
 
 Mhonchal and Friction Fremitus commonly 
 present. 
 
 Fulse small, compressible, feeble, and rapid. 
 PERCUSSION in the stage of cavities (see also pages 
 68 and 69). 
 
 JDulness of consolidation is modified by the res- 
 onance of a cavity. 
 
 Am2)horic or Cracked-2)ot Resonance when a 
 cavity communicates more or less freely wdth a 
 bronchus. The resonance disappears w^th the 
 filling of a cavity with fluid. Sometimes even 
 a large cavity communicating freely with a 
 bronchus gives dulness or cracked-pot resonance 
 when the patient^s mouth is closed, but marked 
 amphoric resonance with the mouth open (see 
 Wintrich's change of sound, p. 69). 
 
 Small cavities deeply located are not easy and are 
 often impossible to locate by percussion. 
 
 Numerous Isolated Cavities at the apex without 
 much fibrosis or pleuritic thickening may give 
 resonance not far from the normal vesicular res- 
 onance, in contrast to the auscultatory signs. 
 AUSCULTATION in the stage of cavities when the 
 cavity is empty and freely communicates with a 
 bronchus. 
 
 jRespiratory Sounds, 
 
 Cavernous Respiration, soft blowing or puffing 
 
SIGNS IN Tin: DISEASES OF THE CHEST. 135 
 
 in character, the expiratory sound pn)l(»ii<^e<l 
 and l()\v-j)itched. 
 Broncho-cavernous Respiration, when tlie cav- 
 ity is not large and is snrroiinded ])y consoli- 
 dation. 
 Amphoric Respiration, wliich is more metallic 
 and resonant than cavernous respiration, is 
 heard in exceptional cases. 
 Vocal and WJiisperinf/ Sounds correspond in 
 change to the respiratory somids. Vocal res- 
 onance amounts to pectoriloquy. If the cavity 
 is filled with fluid or its opening closed none of 
 these sounds may be heard. 
 Adventitious Sounds. 
 
 Rales, dry and moist and gurgling. 
 Metallic Tinkling-, occasionally. 
 In most cases of advanced phthisis the pulmonary 
 signs of all three stages may be present, de- 
 pending upon the pathological condition of 
 the part. 
 
 FIBROID PHTHISIS. 
 
 Definition : a chronic inflammatory affection of the lung 
 characterized pathologically by more or less hyperplasia of 
 the peribronchial, inter-alveolar, and inter-lobular con- 
 nective tissue and pleura, which in contracting encroaches 
 upon the lumen of vessels and air-passages. The fibrosis 
 is accompanied by degenerative processes and often by 
 tuberculosis. The signs in a typical case are, therefore, 
 out of proportion to the relatively mild symptoms, which 
 are those of chronic bronchitis. 
 Signs. 
 
 INSPECTION may reveal — 
 
 NUTRITION and COLOR but little changed. 
 FLATTENING OR RETRACTION of the chest-wall 
 over the affected side. 
 
136 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 DEPRESSION OF THE CORRESPONDING SHOUL- 
 DER, influencing posture. 
 
 DYSPNOEA may or. may not be apparent. 
 
 COUGH frequent and variable. 
 
 RESPIRATORY MOVEMENTS limited on the affected 
 side ; increased on the opposite side except late in 
 the case, after the unaffected lung has become em- 
 physematous. 
 
 HEART dislocated toward the contracted lung, as 
 evidenced by the apex beat. 
 rALBATION frequently elicits — 
 
 EXAGGERATED VOCAL FREMITUS over the con- 
 tracted lung, though the greatly thickened pleura 
 and contracted bronchi may diminish vocal fremitus 
 in some cases. 
 
 PULSE more or less rapid according to the inter- 
 ference with respiration or the amount of infection 
 or fever present. 
 PERCUSSION gives— 
 
 DULNESS over the affected part. 
 
 EXAGGERATED RESONANCE on the sound side, fre- 
 quently extending across the mid-sternal line and 
 to the limits of the pleural cavity (to the costal 
 arch) below. 
 AUSCULTATION gives— 
 
 BRONCHIAL BREATHING and BRONCHOPHONY, 
 and frequently feeble respiration on the affected 
 side. Vesicular murmur absent. 
 
 EXAGGERATED OR NORMAL breathing on the 
 sound side. 
 
 VOCAL RESONANCE more or less bronchial over 
 the affected side. 
 
 ADVENTITIOUS SOUNDS variable. 
 
 RALES dry or moist are common. 
 
SIGNS IN THE DISEASES OF THE CHEST. \:U 
 
 PULMONARY HYPER/EMIA. 
 
 Definition : excess of blood in tiie puhiionary vessels 
 
 (active or passive). 
 Signs not distinct, apart from sudden dyspnoea and otlier 
 
 signs of pulmonary oedema. 
 
 PULMONARY CEDEMA. 
 
 Definition : a serous transudate into the vesicular and 
 interstitial tissues of the lung. It usually affects the 
 most dependent parts of the lungs. 
 Signs. 
 
 INSPECTIOX and PALPATION, 
 CYANOSIS. 
 HYPERPNCEA. 
 
 DYSPNCEA (sudden in occurrence). 
 COUGH \yith frothy sputum. 
 
 SIGNS OF GENERAL DROPSY and its causative 
 disease, such as ansemia, cardiac disease, or scor- 
 butus, may be present. 
 PERCUSSIOX. 
 
 DULNESS over the lower portion of one or both 
 lungs. 
 A USCULTATION, 
 
 R ESP! R ATO RY MURMUR vesicular or slightly bron- 
 cho-vesicular, but feeble. 
 RALES abundant, fine, subcrepitant, usually heard 
 
 both in expiration and inspiration. 
 VOCAL RESONANCE normal, or it may be slightly 
 
 increased. 
 PULMONIC SECOND SOUND is apt to be accen- 
 tuated. 
 
 PULMONARY HEMORRHAGE. 
 Bronchial Hemorrhage. 
 
 DEFINITION: hemorrhage from the ^yall of a 
 bronchial tube or the trachea. 
 
138 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 SIGNS: often none at all, except congh and Ii?emopty- 
 sis. During hemorrhage and for hours following 
 it, may be found 
 RALES large and small, moist in character, over the 
 
 same part of the chest, and 
 FEEBLE RESPIRATION and perhaps slight dulness. 
 Pulmonary Apoplexy. 
 
 DEFIJS ITION : extravasation of blood from a rup- 
 tured vessel into the lung tissue. It is rare, and 
 usually occurs in the lower lobes. 
 SIGNS^ 
 
 INSPECTION usually reveals if the hemorrhage is 
 large. 
 Di/spnwa with cough and hcemoptysis. 
 PALPATION practically negative. 
 PERCUSSION. 
 
 Dulness more or less extensive unless the patches 
 of hemorrhagic infarcts are few and small or 
 deeply seated. 
 AUSCULTATION reveals — 
 JEarlpf 
 
 Rales, moist, large and small, and possibly crepi- 
 tant in the region of the hemorrhage, previous 
 to coagulation. 
 Later, after coagulation, the 
 
 Respiratory Murmur is apt to be feeble or 
 suppressed, especially with the blocking of a 
 bronchus of large size. 
 Bronchial Breathing* and Voice may be more 
 or less marked in some cases. 
 
 PULMONARY THROMBOSIS AND EMBOLISM. 
 Definition. 
 
 PULMONAItY THROMBOSIS is a gradual ob- 
 struction of a pulmonary artery (venous radical) or 
 one of its branches by a clot formed in situ. 
 
SIGNS IN THE DISEASES OF THE CHEST. 139 
 
 PULMONARY EMBOLISM is a siulden bbjcking 
 of a pulmonary vein or bronchial artery by a foreign 
 body, usually a fragment of a vegetation from a car- 
 diac valve or a fragment of a thrombus from some 
 of the systemic veins. 
 
 Signs. 
 
 INSPECTION and PALI* A TION may reveal dys- 
 pnoea, cyanosis, and rapid heart, and possibly pulsa- 
 tion of the jugulars. 
 
 PERCUSSION may elicit exaggerated resonance over 
 the depleted area resulting from increase of air in the 
 cells corresponding to the decrease of the blood in 
 their walls. 
 
 AUSCULTATION. 
 
 RESPIRATORY MURMUR feeble or suppressed in 
 the same area. 
 
 PULMONARY ABSCESS. 
 
 Definition : a circumscribed collection of pus within the 
 
 lung. 
 Signs. 
 
 INSPECTION may reveal — 
 
 PALLOR, EMACIATION, and evidences of pyrexia 
 
 and prostration. 
 DEPRESSION OF THE CHEST-WALL may be 
 present, with atrophy of the intercostal muscles 
 over a cavity Avhere this is large and super- 
 ficial. 
 DYSPNOEA, COUGH, and sometimes marked bulging 
 of the intercostal spaces over the cavity during 
 cough. 
 PALPATION. 
 
 VOCAL FREMITUS. 
 Decreased at first, and 
 
 Increased over the cavity when large, superficial, 
 and freely communicating with a bronchus. 
 
140 PHYSICAL DIAGNOSIS OF THE CHEST. ■ 
 
 PERCUSSION, 
 
 DULNESS circumscribed or general in case of pneu- 
 monia, giving place to tympany over the cavity if 
 of sufficient size (see p. 68). 
 AUSCULTATION 
 
 RESPIRATORY MURMUR feeble or absent, or some- 
 times bronchial over the abscess. . 
 
 INDISTINCT RALES, and after escape of the pus the 
 
 SIGNS OF A CAVITY. 
 
 PULMONARY GANGRENE. 
 
 Definition : necrosis of lung-tissue, accompanied by de- 
 composition. It may occur in one or more sharply 
 defined foci, varying from the size of a pea to that of a 
 hen's eggy usually in the periphery of the lower lobe. 
 More rarely it is diffuse, involving more or less of one 
 lobe or the whole of one lung. 
 Signs are not distinctive, as the same may be present in 
 other forms of phthisis. 
 
 The odor of the breath is well-nigh pathognomonic. 
 INSPECTION 
 COUGH. 
 
 Temporary in circumscribed gangrene. 
 Persistent in the diffuse form. 
 HYPERPNCEA largely in proportion to the amount 
 
 of lung involved. 
 CIRCUMSCRIBED DEPRESSION of the chest-wall 
 toward recovery. 
 PALPATION 
 
 VOCAL FREMITUS normal, absent, or increased. 
 PERCUSSION. 
 
 DULNESS or flatness over the gangrenous foci, and 
 surrounding consolidation if sufficiently extensive. 
 AMPHORIC OR CRACKED -POT resonance with the 
 formation of cavities in case the patient survive. 
 A USCUL TA TION 
 
SIGNS IN THE DISEASES OF THE CHEST. 141 
 
 RESPIRATORY MURMUR absent, or feeble bronchial 
 breathing over the foci, largely dei)en(lent upon the 
 openness of the corresponding larger tubes. 
 
 AMPHORIC or CAVERNOUS RESPIRATION, with 
 the formation of cavities, if freely communicating 
 with a large bronchus. 
 
 ADVENTITIOUS SOUNDS. 
 
 Rales moist in character are apt to be present. 
 Gurgling Sounds with the formation of cavities. 
 
 PULMONARY CANCER. 
 
 Definition : sarcoma or carcinoma of the lung rarely 
 primary, and when secondary either involving the part 
 by contiguity from primary affection of neighboring 
 organs, as the cesophagus and liver, or metastasis, as 
 emboli from a distant focus. 
 Signs : these vary with the character, extent, and location 
 of the tumor. The signs may be those of bronchitis, 
 pneumonia, or tuberculosis in any of its stages. Nodular 
 cancer may give few or all of the following : 
 INSPECTION. 
 CACHEXIA evident. 
 
 LOCAL enlargement of superficial veins. 
 RETRACTION of the chest-wall, depending upon col- 
 lapse of the lung. 
 BULGING or fulness when the tumor is large or ac- 
 companied by pleuritic effusion. 
 PALPATION. 
 
 VOCAL FREMITUS feeble or absent. 
 PERCUSSION. 
 
 DULNESS or flatness over the lung, or possibly nor- 
 mal resonance surrounded by dulness. 
 A use UL TA TION. 
 
 RESPIRATORY SOUNDS feeble or possibly bronchial. 
 VOCAL SOUNDS feeble, sometimes bronchophony. 
 ADVENTITIOUS SOUNDS, rales, etc., variable. 
 
142 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 ENLARGED BRONCHIAL GLANDS. 
 
 Definition : enlargement of the lymphatic glands which 
 lie at the bifurcation of the trachea and about the main 
 bronchi is rare as an independent disorder, and is chiefly 
 of interest as a local manifestation of tuberculosis or 
 malignant growths or syphilis. 
 Signs. 
 
 INSPECTION, \ 
 
 EMACIATION and hectic flush and other visible evi- 
 dences of tubereulosis may be present. 
 CERVICALVEINS may be distended. 
 CYANOSIS present when there is marked pressure 
 
 upon large venous radicles. 
 RESPIRATORY MOVEMENT deficient on one side as 
 
 a result of pressure upon a main bronchus. 
 COUGH dry, ringing, paroxysmal, a common sign. 
 DYSPNCEA common. 
 rALPATION. 
 
 TENDERNESS in the inter-scapular region near the 
 fourth or fifth rib is occasionally present. 
 PEBCUSSION. 
 
 DULNESS over the glands when they are greatly en- 
 larged. Dulness uniform over one side may result 
 from pulmonary collapse from occlusion of the 
 main bronchus. 
 AUSCUL TA TION usually discovers — 
 
 MURMURS, arterial and venous, from pressure upon 
 
 corresponding vessels. 
 RESPIRATORY SOUNDS feeble or absent on one 
 side, owing to pressure on the main bronchus. 
 Deep respiration may develop sounds not present 
 in ordinary respiration. 
 VOCAL SOUNDS also diminished for the same reason. 
 ADVENTITIOUS SOUNDS, rales are apt to be present 
 owing to the secretion within the tubes as a result 
 of bronchitis. 
 
SIGNS IN THE DISEASES OF TILE CHEST. ll.j 
 
 HYDATID CYSTS OF THE LUNG. 
 
 Rare, usually secondary to hydatids of the liver. Signs 
 fairly distinct when the cysts are large. 
 Signs. 
 
 INSPECTION, 
 
 DECUBITUS upon the sound side. 
 
 SLIGHT BULGING of the intercostal spaces over the 
 
 cyst, and possibly slight 
 ENLARGEMENT of the affected side. 
 RESPIRATORY MOVEMENT limited on the affected 
 side and increased on the sound side. 
 PALPATION, 
 
 VOCAL FREMITUS absent over the cyst. 
 FLUCTUATION may sometimes be detected when the 
 cyst is large and superficial. 
 PERCUSSION. 
 
 DULNESS or flatness circumscribed over the cyst, sur- 
 rounded by resonance. Dulness unchanging with 
 posture of patient. 
 A USCULTA TION, 
 
 RESPIRATORY MURMUR absent over areas of flat- 
 ness, normal or slightly broncho-vesicular imme- 
 diately around it. 
 
 PLEURISY, acute, subacute, and chronic. 
 
 Definition : an inflammation of the pleura, characterized 
 locally by early dryness of the pleuritic surfaces, fol- 
 lowed by the exudation of fibrinous lymph and more or 
 less fluid. The latter is attended by proportionate com- 
 pression of the lung, displacement of the organs, and 
 interference with normal functions. There may be more 
 or less complete resolution or crippling of the limg by 
 thickening of the pleura and adhesions, with permanent 
 disarrangement of normal organic relations. 
 
 Signs. 
 
 AT THE ONSET of an attack. 
 
144 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 INSPECTION. 
 Posture usually on the sound side to relieve pres- 
 sure from the inflamed pleura. 
 Hyiferpnwa due to 
 Fever, or in 
 
 Compensation for shallow respiration. 
 Limited 3Iovement (slight) on the affected side to 
 
 avoid pain. 
 Increased Movement on the sound side. 
 PALPATION may elicit — 
 
 Friction Fremitus on the affected side. 
 
 Surface Temperature possibly higher on affected 
 
 side. 
 Tenderness or pain upon deep pressure on affected 
 side. In diaphragmatic pleurisy pain may be 
 elicited at the tenth rib at the insertion of the 
 diaphragm. 
 PERCUSSION negative except for the production of 
 
 pain. 
 AUSCULTATION. 
 
 Vesicular Murmur on the affected side. 
 Diminished in intensity and duration owing to 
 
 the restrained respiratory movements. 
 Rhythm Disturbed, jerky, cog-wheel. 
 Friction Sounds, 
 Pleuritic. 
 
 Area circumscribed or diffused. 
 Time, Avith inspiration and expiration, but 
 most marked in the former and broken and 
 jerky in rhythm. 
 Chaeacter, superficial and fine, grazing or 
 coarse, creaking ; or grating, rasping, or 
 sawing in sound. 
 Pleuro-pericardiac Friction Sounds. 
 
 Area usually most distinct at the apex 
 or along the right or left border of th^ 
 
SIGNS IN THE DISEASES OF THE CHEST 145 
 
 heart, where the pleurisy is adjacent to the 
 heart. 
 Time, synchronous with the heart's motion, 
 and accompanied by others (coarser) during 
 respiration. 
 Character, usually fine, grazing. 
 Bronchial Hales from coexisting bronchitis (in- 
 cidental). 
 WHEN THERE IS MODEMATE EFFUSION— 
 e. g., at the level of the fifth rib in front, not suf- 
 ficient to markedly displace organs or change con- 
 tour of the thorax. 
 INSPECTION. 
 
 Posture on either side or back. 
 Hespiratory Movement limited on the affected 
 side, now due in part to compression of the lung. 
 Hyperpnma and perhaps dyspnoea. 
 PALPATION. 
 
 Hestricted Respiratory Movements. 
 Vocal Fremitus enfeebled over the effusion. 
 MENSURATION. 
 
 Slight loss of respiratory expansion. 
 PERCUSSION. 
 
 Beginning Dulness over the fluid, first noticeable 
 
 in the infra-scapular and infra-axillary regions. 
 Dulness just below the level of the fluid merging 
 
 into flatness below. 
 Elasticity wanting as felt by the pleximeter finger. 
 Upper Line of Dulness not horizontal in the erect 
 posture, but highest in the axillary region, de- 
 scending in front and behind, forming the letter 
 S curve posteriorly. 
 Slight Change in level takes place slowly in change 
 from the erect posture to recumbency, and vice 
 ve7'sd, where no limiting adhesion exists above 
 the effusion. 
 
 10 
 
146 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 AUSCULTATION. 
 
 Respiratory Sounds feeble and distant or absent 
 over the fluid, except in children, where they 
 may be distinctly broncho-vesicular. 
 Immediately Above the level of the fluid re- 
 spiratory sounds are exaggerated or broncho- 
 vesicular and harsh. 
 Over the Sound Lung* Exaggerated respiratory 
 sounds corresponding to increased function. 
 Vocal Itesonance. 
 Over the Fluid, diminished or absent. 
 At the Upper Border of the fluid occasionally 
 
 segophony may be heard. 
 Elsewhere normal. 
 WHEN THE EFFUSION IS LARGE IN 
 AMOUNT. 
 INSPECTION. 
 
 Posture, usually on or toward the afl^cted side to 
 
 give the unobstructed lung free play. 
 Tailor, from anaemia, and 
 
 Emaciation usually present, not necessarily marked. 
 Cyanosis of the lips, chin, end of nose, and tips 
 
 of extremities not infrequent. 
 Unilateral Enlargement of the chest on the af- 
 fected side, especially the lower half. 
 Nipple and Scapula farther from the median 
 
 line. 
 Shoulder elevated. 
 Lower Intercostal Spaces widened and filled out, 
 
 rarely bulging. 
 Hypochondrium prominent on the afl'ected side, 
 
 especially if this be the right. 
 Hi/perjynwa,^ and usually dyspnoea, very marked 
 
 on slight exertion. 
 Mespiratory Movements markedly restricted on 
 the affected side, increased on the sound side. 
 
SIGN& IN THE DISEASES OF THE CHEST. 117 
 
 Apex Beat displacjcd to the riglit or left away from 
 the effusion. 
 PALPATION ill large pleuritic effusion. 
 
 Itesfi'icted Movement and Enlargement of the 
 
 affected side. 
 Intercostal Spaces widened and filled out. 
 A Sense of Fltict nation sometimes obtained by 
 applying the finger to the intercostal spaces and 
 making percussion on the opposite aspect of the 
 affected side. 
 Vocal Fremitus absent over the fluid, except in 
 children, where it may be present over effusions 
 of considerable size. It may be conducted 
 through the effusion along the line of an exten- 
 sive adhesion or band. Posteriorly it may some- 
 times be conducted for some distance over the 
 effusion from the sound side by the chest-wall as 
 a medium. 
 Apex Beat displaced. 
 
 Pulse accelerated, small in volume, low^ in tension, 
 especially in large effusions of the left side. It 
 is apt to be irregular in both time and force. 
 Tender Points of intercostal neuralgia not infre- 
 quently present. 
 MENSURATION. 
 
 Enlargefnent and loss of movement on the affected 
 side. 
 PERCUSSION in large pleuritic effusion. 
 
 Flatness over a large part of the affected side. 
 In the Larg-est Effusions all resonance disap- 
 pears except over a limited area (dulness) in 
 the upper inter-scapular region, over the com- 
 pressed lung. Flatness may extend across the 
 sternum, encroaching on the opposite lung. 
 In Rig-ht-sided Effusions the liver dulness is de- 
 pressed, sometimes depressed even to the navel. 
 
148 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 In Left-sided Effusions flatness extends to the 
 
 margin of the ribs^ masking the spleen or 
 
 depressing it in the abdomen, and obliterating 
 
 stomach tympany in the so-called semilunar 
 
 space of Traube. 
 
 Vesiculo-tympanitie note may be present in the 
 
 supra-scapular and supra-clavicular region 
 
 (Skoda). This is owing to a loss of pulmonary 
 
 tension, or to vesicular emphysema, or possibly 
 
 to the formation of vapor in the pleuritic space. 
 
 Cracked-j)ot resonance sometimes in infra-clavicular 
 
 region. 
 Cardiac Duhiess may be found to the right of 
 the sternum. 
 AUSCULTATION in large pleuritic effusion. 
 
 Mesijlratory and vocal sounds wholly absent over 
 the affected side, except feeble bronchial sounds 
 in the inter-scapular region over the compressed 
 lung. These are absent in extreme cases. 
 Tfliisjyer Resonance sometimes distinct over sero- 
 fibrinous effusions, but absent over pus (Baccelli). 
 Position of Heart can frequently be made out by 
 the relative distinctness of its sounds, when its im- 
 pulse is invisible and cardiac dulness uncertain. 
 Systolic Murmurs may be heard over the heart, 
 which disappear after aspiration or absorption 
 of the effusion. 
 AFTER RESORPTION OF THE EFFUSION 
 when the effusion has been long present. 
 INSPECTION. 
 
 Affected Side shows — 
 
 Circumscribed Depressions or more general 
 
 retraction. 
 Displacement of the Intra-thoracic organs by 
 retraction of the lung and fibrous pleuritic ad- 
 hesions. 
 
SIGNS IN THE DISEASES OF THE CHEST. 149 
 
 Shoulder lowered on the affected side. 
 Intercostal Spaces narrow. 
 Scapulae may project in a wing-like manner. 
 Spinal Column, scoliosis toward the sound side. 
 
 Sound Side shows exaggerated normal condition. 
 PALPATION. 
 
 Apex Beat displaced. 
 
 Vocal Fremitus exaggerated, or diminished when 
 the main bronchi are contracted or the pleura 
 is greatly thickened. 
 
 Pulse, normal in rate and force where the contracted 
 luncr has not become tubercular. 
 PERCUSSION. 
 
 Dulness over the contracted lung. 
 
 Hyiyer-reso7iance over the sound lung, which may 
 extend across the mid-sternal line even to the 
 parasternal line. 
 AUSCULTATION. 
 
 Mesinratory Sounds diminished on the affected 
 side and more or less bronchial. On the sound 
 side respiratory sounds exaggerated, or dimin- 
 ished and vesicular when emphysema has devel- 
 oped. 
 
 PNEUMOTHORAX and PNEUMO-HYDROTHORAX. 
 Definition : an accumulation of air or other gases outside 
 the lung in the pleural cavity. The lung, unless bound 
 by adhesions, retracts and finally exists as a collapsed, 
 nearly airless, fleshy mass at the upper and back part 
 of the chest-cavity. There comes to be more or less 
 fluid, serous or purulent, at the lower part of the cavity 
 (pneumo-hydrothorax or pneumo-pyothorax). 
 Signs. 
 
 INSPECTION^. 
 
 PALLOR and EMACIATION characteristic of advanced 
 phthisis. 
 
150 PHYSICAL PIAGNOSIS OF THE CHEST. 
 
 CYANOSIS may be marked when perforation oc- 
 curs. 
 
 E N LA R G E M E N T of the affected side. 
 
 INTERCOSTAL SPACES wide and full, or bulging, 
 and do not recede on inspiration. 
 
 HYPERPNCEA and DYSPNOEA amounting to ortho- 
 pnoea, especially at the line of perforation. These 
 may subside except on exertion. 
 
 RESPIRATORY MOVEMENT lost on the affected side, 
 increased on the sound side. 
 
 APEX BEAT displaced usually to the opposite side of 
 the chest. 
 JPALPATIOJV, 
 
 VOCAL FREMITUS, feeble or absent over the aifected 
 side. 
 
 SUCCUSSIONFREMITUS when present, characteristic 
 of pneumo-hydrothorax. 
 
 PULSE feeble and rapid. 
 MEWS UBA TlOJSr, 
 
 ENLARGEMENT OF THE AFFECTED SIDE. 
 rEBCUSSION, 
 
 OVER THE AIR more or less tympany, varying in 
 pitch according to the amount of air present and 
 the degree of tension. Amphoric resonance when 
 a large opening communicates with a bronchus. 
 When the air is under great tension, as in cases 
 where the opening has a valve-like action, the per- 
 cussion note may be positively dull. 
 
 OVER THE FLUID flatness at the lower part of the 
 chest according to the amount present. The upper 
 line is horizontal and straight, and changes with 
 the posture of the patient. 
 
 OVER THE SOUND SIDE hyper-vesicular resonance. 
 AUSCULTATION. 
 
 RESPIRATORY and VOCAL SOUNDS. 
 Over the Air vesicular murmur absent. 
 
SIGNS IN THE DISEASES OF THE CHEST. 151 
 
 Respiratory, Vocal and Whisper Sounds wlioii 
 present are amphoric, l)at may be feeble. All 
 respiratory and vocal sounds are absent if the 
 opening into a bronchus is closed. 
 
 Over the Fluid they are absent. 
 
 Over the Compressed lAing, at the upper inter- 
 scapular region. Respiratory and \'ocal sounds 
 are feeble, but bronchial wlien present at all. 
 
 Over the Sound Sidr puerile res])iration. 
 ADVENTITIOUS SOUNDS. 
 
 Rales when present over the aifected side are me- 
 tallic in character. 
 
 Metallie Tinkling when fluid drops from the upper 
 part of a cavity into the fluid ; it may also be due 
 to the bubbling of air through the fluid when 
 it rises above the mouth of the opening into a 
 bronchus. 
 
 Suceussion splashing sounds, upon agitation of the 
 fluid by shaking the body, have a metallic quality. 
 
 Bell or Coin Sound is produced as the ear is ap- 
 plied to one aspect of the afi^ected side while per- 
 cussion is made by two coins used as j^lexor and 
 pleximeter (see page 89). 
 
 FALSE PNEUMOTHORAX. 
 
 Definition : the term has been applied to subdiaphragmatic 
 air-containing abscess cavities, usually on the right side, 
 between the liver and diaphragm, occasionally on the 
 left. They originate from perforating ulcers in the wall 
 of the stomach or duodenum. 
 
 Signs of a limited pneumothorax are sometimes present. 
 
 DIAPHRAGMATIC HERNIA gives signs similar to those 
 of pneumothorax, such as 
 Evidence of Displaced Heart and compressed lung. 
 Tympanitic Resonance. 
 
152 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Respiratory Sounds absent. 
 
 Metallic Tinkling may be absent. 
 
 Sudden Disappearance or advent of signs due to return 
 
 of the bowel to the abdominal cavity or to the abnormal 
 
 position. 
 Borborygmi characteristic. 
 
 HYDROTHORAX. 
 
 Definition : a serous transudate (non-inflammatory) into 
 the pleural cavity. It is usually a part of general 
 dropsy, but may occur with but slight oedema of the 
 lower extremities. 
 
 In renal disease and anaemia it is usually bilateral. 
 In heart disease it is commonly unilateral, but if 
 
 bilateral is apt to be unequal on the two sides. 
 In venous obstruction it may be either unilateral or 
 
 bilateral. 
 Signs. 
 
 INSPECTION frequently reveals 
 
 CYANOSIS, profuse perspiration. 
 
 EXPRESSION of anxiety. 
 
 DYSPNCEA, orthopnoea, even without exertion ; respir- 
 atory movements limited. 
 
 ABSENCE OF INFLAMMATORY SIGNS. 
 PALPATION reveals 
 
 NO TENDERNESS or rise of temperature. 
 PEBCUSSION and AUSCULTATION demonstrate 
 
 signs of unilateral or bilateral effusion, similar to 
 
 those in pleurisy, without the presence anywhere of 
 
 friction sounds or other evidences of inflammation. 
 
 Hy^EMOTHORAX. 
 
 Definition : an effusion of blood into the pleural cavity 
 
 as distinguished from hemorrhagic pleurisy. 
 Signs largely those of hydrothorax, with evidence in the 
 pallor and effect on the circulation of considerable loss 
 of blood. 
 
SIGNS TN THE DISEASES OF THE PERWAUDIUM. 153 
 
 DISEASES OF THE PERICARDIUM, HEART, 
 AND GREAT VESSELS. 
 
 RARE AFFECTIONS OF THE PERICARDIUM, essen- 
 tially undemonstrable during life, even Avith the help of 
 history and symptomatology. These include 
 
 Absence or Defects of the Pericardium. 
 
 Tumors, Hydatids, and Syphilis of the pericardium. 
 
 PERICARDITIS. 
 
 Definition : inflammation of the pericardium. 
 Signs. 
 
 INSPECTIOm 
 
 EXPRESSION of anxiety common ; expression of pain 
 upon change of posture or deep pressure over the 
 heart. 
 
 POSTURE, usually in dorsal semi-recumbency. 
 
 VENOUS distention (ectasia) in the neck in rare cases 
 where effusion makes pressure upon the superior 
 vena cava. 
 
 PRECORDIAL REGION prominent. 
 
 In Children^ owing to the pliancy of the chest- 
 wall.- 
 In Adttlts, rare, though it may be present with 
 effusion of 12 to 15 ounces. Potain saw it with 
 much less. 
 
 INTERCOSTAL DEPRESSIONS, may be obliterated, 
 or bulging of intercostal spaces may be present 
 over a large pericardiac effusion (paresis of the in- 
 tercostal muscles). 
 
 BULGING OF EPIGASTRIUM occasionally present 
 with a large effusion, though it does not occur 
 early, owing to the ready displacement of the lungs 
 before much lowering of the diaphragm is effected. 
 
 STUPOR, DELIRIUM, CONVULSIONS, and COMA 
 
154 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 may occur in the late stage, Avith cardiac failure 
 and venous stagnation. 
 DYSPNOEA is usually present both early and late. 
 APEX BEAT. 
 
 Forcible and rapid, and increased in area in the 
 
 first stage. 
 WeaJi^ or absent in recumbency, but may, in the 
 presence of effusion, become both visible and pal- 
 pable in forward inclination of the body, as in the 
 knee-elbow posture. Weakness of the apex beat 
 may also be due to simple weakening of the car- 
 diac muscle, usually late. 
 PALPATION, 
 
 PULSE not necessarily affected, except in rate, even 
 when the heart is under considerable pressure from 
 effusion. 
 APEX BEAT elevated apparently, and changed with 
 
 posture. 
 FRICTION FREMITUS common in the early stage. 
 PEJRCUSSION, 
 
 IN THE FIRST STAGE negative. 
 IN THE SECOND STAGE, 
 
 Dulness corresponds largely to the amount of 
 effusion. 
 Early, it is usually first to be detected at the 
 base of the heart in the second interspace, and 
 to the right of the sternum in the fifth inter- 
 space (this is a very important sign). A quan- 
 tity of fluid less than four ounces may not be 
 recognizable. 
 Later, dulness extends to the left of the apex beat. 
 In laege effu>sions flatness and dulness occur 
 in a triangular area, with its apex extending 
 above the base of the heart, the base below, 
 and extending far to the right of the sternum 
 and to the left of the mammillary line. 
 
SIGNS IN THE DISEASES OF THE I'ERICARDIUM, 155 
 
 Dulness in recumbency becomes much in- 
 creased in area in the upright posture, and 
 may cause bulging of intercostal spaces 
 which before were sunken. 
 A use UL TA TIOX, 
 FRICTION SOUNDS. 
 
 Time synchronous with cardiac movements ^^too 
 and fro," systolic and diastolic. They may at 
 times disappear for a few beats and return. 
 They occur independent of respiration, but 
 may be somewhat influenced by respiration. 
 They may be present for the first few hours, 
 or may last during the greater part of the 
 disease, and reappear after resorption of the 
 effusion. 
 Sedtf over the precordia, usually first heard over 
 the base, but may be loudest at the apex or over 
 the right ventricle. 
 Chxiracter. 
 
 Quality, grazing, rough, harsh, or soft, and at 
 
 times squeaking. 
 Intensity variable, may be heard at a distance 
 from the chest, may be increased by pressure 
 of the stethoscope or by exercise, and may be 
 influenced by respiration. 
 Duration : they disappear with the occurrence 
 
 of effusion or adhesion. 
 Propag-ation : they are feebly transmitted, and 
 are usually confined to the precordia. 
 HEART SOUNDS. 
 
 Early, normal but rapid. 
 
 Later, weakened, with the occurrence of a large 
 effusion, which at first muffles them and later 
 weakens them by weakening the heart muscle. 
 Arrhythmia may occur with weakening of the 
 heart muscle by pressure or adhesions. 
 
156 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 RESPIRATORY SOUNDS. 
 
 Bronchial breathing may be developed over lung 
 adjacent to and compressed by the effusion. It 
 may disappear with change of posture to reap- 
 pear over other parts. 
 
 MEDIASTINO-PERICARDITIS. 
 
 Definition : inflammation leadings to adhesion between 
 the parietal layer of the pericardium at the base and 
 the wall of the chest or mediastinal tissue. In such 
 cases the two layers of the pericardium are apt to be ad- 
 herent. Fibrous bands or adhesions may implicate the 
 great vessels at the base, and also the pleura and 
 diaphragm. 
 Signs. 
 
 INSPECTION may show— 
 
 INTERCOSTAL SPACES retracted wdth each systole. 
 DYSPNCEA, ARRHYTHMIA, and weakening of the 
 apex beat, and other signs of pericarditis may be 
 present. 
 INSPIRATORY SWELLING OF THE JUGULARS has 
 been noticed, probably from compression of the 
 innominate vein or superior vena cava. 
 PALPATION, 
 
 PULSUS PARADOXUS has been noticed in some cases 
 (see page 54). Pulse may be irregular. 
 PERCUSSION. 
 
 AREA OF CARDIAC FLATNESS may be increased, 
 since adhesion of the pericardium to the chest-wall 
 prevents expansion of the lung in front of the heart. 
 AREA OF CARDIAC DULNESS may be increased as 
 an indication of cardiac enlargement following de- 
 generation. 
 AUSCULTATION. 
 
 MURMURS, systolic aortic, or pulmonic, most marked 
 on inspiration, may be heard in some cases. 
 
SIGNS TN THE DISEASES OF THE PERICARDIUM. 157 
 
 HYDRO-PERICARDIUM. 
 
 Definition : Herons transiidate (iion-inflamraatory) into 
 the pericardium, usually as a part of a general dropsy. 
 Signs similar to those of pericarditis with effusion, minus 
 the features dependent upon inflammation and pyrexia. 
 
 Hy€:MO-PERICARDIUM. 
 
 Definition : effusion of blood into the pericardium, 
 
 usually sudden onset, with local 
 Sig'ns similar to those of hydro-pericardium. 
 
 PYO-PERICARDIUM. 
 
 Definition : purulent effusion into the pericardium. 
 Signs, those of inflammatory effusion. 
 
 PNEUMO-PERICARDIUM. 
 
 Definition : gas in the pericardium. Usually it is ac- 
 companied by fluid (pneumo-pyo-pericardium). Onset 
 usually sudden. 
 Signs. 
 
 INSPECTIOm 
 
 EXPRESSION anxious or pained. 
 CYANOSIS, sudden collapse. This may be due to 
 pressure upon the great vessels at the base of the 
 heart. 
 PRECORDIAL PROTRUSION of the chest-wall and 
 
 bulging of the intercostal spaces. 
 DYSPNCEA. 
 PALPATION, 
 
 PULSE rapid, weak, small, and may be irregular. 
 APEX BEAT absent, or may become visible and pal- 
 pable upon forward inclination of the body. 
 PERCUSSION. 
 
 TYMPANITIC RESONANCE over the air in the upper 
 
 part of the cavity. 
 FLATNESS over the fluid. The relative position of 
 these changes with the change of posture. 
 
158 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 A USCULTATION, 
 
 FRICTION SOUNDS, metallic in quality, sometimes 
 audible. 
 
 METALLIC TINKLING, or gurgling, splashing, churn- 
 ing sounds, metallic in quality, sometimes heard, 
 even by the patient or others. 
 
 HEART SOUNDS, metallic in timbre. 
 
 CONGENITAL ANOMALIES OF THE HEART AND 
 GREAT VESSELS. 
 Definition : the heart may be 
 TOO SMALL or 
 
 TOO LARGE, or may occupy various 
 ABNORMAL JPOSTTIONS. 
 ITS CA VITIES may be too small or too large, or may 
 
 be crossed by abnormal bands ; also 
 THE SEPTA between them may be deficient, or foetal 
 
 openings may remain patulous. 
 THE AORTA and PULMONARY ARTERY may 
 be abnormally small. 
 Signs : many of these abnormalities have existed during 
 a part or the whole life without discoverable symptoms 
 and signs. Usually they show at some time physical 
 evidences, of which the following are the chief: 
 INSPECTION, 
 
 CYANOSIS, early in occurrence, is the most marked 
 sign of congenital cardiac deformity, though its 
 presence is not diagnostic, and its absence does not 
 always exclude a defect. It is not infrequently 
 entirely absent, slight in amount, or late in de- 
 velopment. Some cases of congenital cyanosis 
 may be due to abnormality of the pulmonary 
 capillaries. 
 FAULTY DEVELOPMENT OF THE BODY is a natural 
 
 eifect of a defective heart. 
 PRECORDIAL PROTRUSION is common. 
 
SIGNS IN THE DISEASES OF THE HEART. 159 
 
 ABNORMAL CARDIAC ACTION, arrhythmia and the 
 
 signs of (cardiac; enhirgement. 
 DYSPNOEA. 
 PALP A TION. 
 
 PRECORDIAL THRILL not uncommon. 
 A UHCULTA TION. 
 
 MURMURS may indicate 
 
 Pafiifous Ductus Arteriosus, 
 Seat. 
 
 P08TEKIORLY in the left interscapular region 
 at the level of the third and fourth dorsal 
 vertebrae. 
 Time, systolic. 
 Character. 
 Intensity. 
 
 Increased on inspiration. 
 Diminished on expiration. 
 Uniform on holding the breath. 
 Patulous Foramen Ovale (according to Sansom). 
 Seat. 
 
 Anteriorly at the level of the third and 
 fourth costal cartilages, to the left of the 
 sternum. 
 Time, systolic and presystolic murmurs present. 
 Perforation of the Inter-ventricular Septum 
 (according to Roger). 
 Seat. 
 
 Upper third of the precordial space about the 
 third interspace. 
 Character. 
 
 Limited area, not propagated, unaffected by 
 respiration or posture. 
 
 CARDIAC ATROPHY. 
 
 Definition : a degenerative loss of muscular volume, gen- 
 erally as a result of arterio-sclerosis, which, however, 
 
160 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 usually causes cardiac enlargement, exceptionally atrophy. 
 It accompanies general marasmus from disease or age, 
 and results in diminution in the actual size of the heart, 
 unless dilatation occurs. 
 Signs. 
 
 INSPECTION. 
 
 GENERAL signs of marasmus and poor blood-supply. 
 LOCAL. 
 
 Apeoc Beat faint or absent, even under emotional 
 excitement, which tends to render it more visible 
 and palpable. 
 PALPATION. 
 
 APEX BEAT and PULSE weak. 
 PERCUSSION. 
 
 CARDIAC DULNESS diminished in both deep and 
 superficial areas. Allowance must be made for the 
 lung in all cases. 
 An Enlarged Heart overlapped by lung may sliow 
 
 but little dulness. 
 Marked Emjihysenia may obliterate all dulness 
 of the heart whether of normal size or en- 
 larged. 
 Retraction of the Lung with displacement of the 
 heart may increase relative flatness and dul- 
 ness. 
 AUSCULTATION. 
 
 HEART SOUNDS will depend upon the strength of 
 the heart muscle. 
 First Soundy especially weak or absent at the apex. 
 Second Sound, pulmonic distinct, aortic apt to be 
 weak. 
 
 CARDIAC HYPERTRpPHY. 
 
 Definition : muscular thickening of the walls of one or 
 more cavities of the heart. It rarely occurs without 
 some degree of enlargement (dilatation of the cavities). 
 
SIGNS IN Tin: DISEASES OF THE HE ART. IHl 
 
 Signs. 
 
 INSPECTION. 
 
 PROMINENCE OF THE PRECORDIA in children. 
 APEX BEAT. 
 
 Force increased. 
 
 Area increased ; sometimes movement of the wliole 
 
 precordia. It extends to the left of normal. 
 EpifjaMric Pulsation strong in hypertrophy of the 
 right ventricle. 
 CAROTIDS beat forcibly. 
 PALPATION confirms inspection. 
 PULSE regular, full, and forcible. 
 PERCUSSION. 
 
 CARDIAC DULNESS increased to the right of the 
 sternum in hypertrophy of the right ventricle, and 
 markedly to the left of normal if the left or both 
 ventricles are enlarged. 
 CARDIAC FLATNESS increased in area from dis- 
 placement of the lung. 
 A USCLLTA TION. 
 
 In the absence of valvular lesions the heart sounds 
 are apt to be sharp, loud, and often peculiarly 
 ringing. 
 
 HYPERTROPHY WITH DILATATION gives more pro- 
 nounced evidences of enlargement, but the signs otherwise 
 are similar as long as hypertrophy compensates. 
 
 CARDIAC DILATATION. 
 
 Definition : abnormal increase in the size of one or more 
 of the cavities of the heart, whether the walls are atten- 
 uated or normal. 
 Sig-ns. 
 
 INSPECTION reveals — 
 
 EVIDENCES OF POOR CIRCULATION. 
 11 
 
162 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 JUGULAR VEIN varicosed, and pulsating with marked 
 dilatation of the right heart. 
 - APEX BEAT absent or very weak and undulatory in 
 character^ with no definite point of maximum in- 
 tensity. 
 PALPATION, 
 
 PULSE and APEX BEAT weak and rapid and fre- 
 quently irregular. 
 PERCUSSION shows— 
 
 DULNESS and flatness increased. 
 A TJSCUL TA TION, 
 
 HEART SOUNDS soft^ feeble, apt to be abrupt, and 
 frequently of equal length. 
 Second Sound may be inaudible at the apex and the 
 First Sound reduplicated. 
 Arrhythmia frequently present. 
 MURMURS if present are apt to be of slight intensity. 
 
 MYOCARDITIS. 
 
 Definition : difl^use or circumscribed inflammation of the 
 wall of the heart. 
 
 Acute, ending in suppuration, resolution, or fibrosis. 
 
 Chronic, commonly considered as including various 
 degenerations which are prone to accompany and fol- 
 low inflammation. It may result from atheroma, cal- 
 cification, thrombosis, or embolism of the coronary 
 artery, with resulting infarction, which may be 
 hemorrhagic, anaemic, or infected. The chronic form 
 is apt to accompany pericarditis or endocarditis. The 
 eifect in some cases depends upon direct local work 
 of micro-organisms, in others upon toxins or toxal- 
 bumins. 
 Signs, 
 
 SIGNS OF ACUTE lIYOCAIiniTIS : this form is 
 present typically in typhoid fever, and also may be 
 present in diphtheria, scarlet fever, cerebro-spinal 
 
SJGJ^S IN THE JJJi^EASES OF THE HEART. 163 
 
 meningitis, variola, erysipelas, and in acute endo- 
 carditis and pericarditis. 
 
 In addition to the signs of these diseases a few or 
 many of the following may be present : 
 INSPECTION. 
 JPalloi'. 
 
 I>ys2}fKBa and Sighing Respiration, 
 Ape;r. Beat absent. 
 PALPATION. 
 
 Coldness of the extremities. 
 
 Pidse feeble, often extremely irregular (arrhythmia). 
 PERCUSSION. 
 
 Cardiac Dulness normal unless dilatation or peri- 
 cardial effusion is j^resent. 
 AUSCULTATION. 
 Ar7'hythniia. 
 Tachycardia. 
 
 Heart Sounds muffled. They are apt to assume 
 the foetal type. 
 SIGNS OF CHRONIC MYOCARDITIS. 
 INSPECTION and PERCUSSION. 
 
 The signs of weak heart as in the acute form ; also 
 Cyanosis and (JEdenia of the Eoctremities. The 
 signs of acute febrile disease absent. 
 PALPATION. 
 Pulse shows — 
 
 Marked Arrhythmia present early and frequently 
 
 persistent, but little influenced by drugs. 
 Irritability of the Heart upon slight excitement 
 or exertion. 
 AUSCULTATION. 
 
 Heart Sounds muffled, indistinct, irregular. 
 First Sound reduplicated not infrequently. 
 
 CARDIAC LIPOMATOSIS, or fatty infiltration of the 
 heart. 
 
164 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Definition: an accumulation of fat upon the heart. This 
 
 is usually a part of general obesity, although it may 
 
 occur occasionally in lean persons. 
 
 In modeeate amount it has little or no effect upon 
 the heart's function, though the amount consistent 
 with health varies with age, habits, constitution, etc. 
 
 When excessive, and deposits take place not only on 
 the surface, but infiltration occurs between the muscle 
 fibres, the result is hampering of the heart's action, 
 and finally pressure-atrophy with true fatty degenera- 
 tion, to which the resulting symptoms and signs are due. 
 
 CARDIAC FATTY DEGENERATION. 
 
 Definition : a more or less localized or disseminated retro- 
 gressive change of the muscular fibres of the heart into 
 fat, almost without exception associated with hyaline 
 and fibroid degeneration. 
 Signs : these become evident only when degeneration has 
 become sufficient to cause dilatation from weakening of 
 the muscular wall. 
 INSPECTION may reveal 
 
 ARCUS SENILIS and other signs of age. 
 VENOUS STASIS and evidence of insufficient blood- 
 supply to the organs. 
 CEDEMA of the extremities is present in the late 
 
 stage. 
 DYSPNOEA may be pronounced on slight exertion. 
 PALBATION 
 
 PULSE feeble, especially when the arm is held high. 
 It is frequently irregular in both time and force, 
 and may be slow. In a late stage it is always 
 rapid. 
 FEMCUSSION. 
 
 CARDIAC DULNESS, superficial and deep, increased. 
 A USCULTA TION, 
 
 HEART SOUNDS weak, and are apt to be modified 
 
SIGNS IN THE DISEASES OF THE HEART. IGo 
 
 and obscured by relative imiriniirs (dependent u[)(jn 
 dilatation). 
 ARRHYTHMIA and, late, delirium cordis. 
 
 RUPTURE OF THE HEART, traumatic or non-traumatic. 
 Non-traumatic or spontaneous rupture of the heart occurs 
 suddenly in case of degenerative changes, the weakened 
 heart-wall being subjected to some sudden strain whether 
 from mental or physical cause. It may occur in such a 
 heart during perfect tranquillity of mind and body. 
 The Signs obtainable are but few, owing to the sudden- 
 ness of the accident. The person may, with or without 
 an outcry, fall at once into collapse, or, as occurs not 
 infrequently, live several hours, manifesting 
 CYANOSIS, COLD SWEATS, DYSPNCEA, with, 
 perhaps, convulsions and coma. In other cases, where 
 the rupture is at first small, there may be attacks of 
 nausea, vomiting, anxiety, vertigo, syncope, with or 
 without evidence of anginal pain. 
 
 SYPHILIS OF THE HEART may show no signs, and 
 when present they do not diifer from those of myo- 
 carditis and degeneration from other causes. 
 
 ANEURYSM OF THE HEART. 
 
 Definition : though cardiac dilatation is in so far a species 
 of aneurysm, the term is limited to localized attenuation 
 of the wall, acute or chronic, with circumscribed dilata- 
 tion which may be distinctly saccular. 
 
 Signs : usually neither the subjective nor objective features 
 are distinctive, and the disease may be latent, revealed 
 only by autopsy after sudden death, otherwise the signs 
 are apt to be those of myocarditis. More or less 
 CYANOSIS, 
 DYSPNGEA, 
 AMBHYTHMIA, 
 
166 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 TACHYCABDTA and other .signs of weak heart. Ex- 
 ceptionally there is evidence of pulsating tumor and 
 increase of cardiac dulness. 
 
 DIASTOLIC MIBMUMS have been heard, probably 
 due to the regurgitation of blood from the aneurysmal 
 sac. 
 
 THROMBOSIS OF THE HEART (ante-mortem). 
 
 Definition : formation of a clot within the cavities of the 
 heart. This is usually adherent to its walls, and some- 
 what firmly enmeshed among its tendinous and mus- 
 cular bands, but it may form polypoid structures or non- 
 adherent floating masses. 
 
 Two FACTORS usually combine to its occurrence : 
 A retarded circulation. 
 
 A toxic condition of the blood or local diseased foci 
 
 upon the wall of the heart. 
 
 Signs : the process may not be apparent during life. 
 
 When the coagula interfere with the valves, or detached 
 
 masses form emboli, the symptoms and signs may vary 
 
 widely. The diagnosis is usually impossible. 
 
 TUMORS OF THE HEART. 
 
 Carcinoma usually secondary, by extension from neigh- 
 boring structures. 
 
 Sarcoma more rare. 
 
 Myomata and Fibromata occasional. 
 SIGJVS very uncertain. 
 
 PARASITES, such as Cysticercus and Echinococcus, 
 are relatively rare, and their diagnosis usually impossible, 
 except from their recognition in other organs and the 
 presence of cardiac disturbance of more or less gravity. 
 
 NEUROSES OF THE HEART. The so-called cardiac 
 neuroses do not j)roperly claim notice here. 
 
SIa^'s js TUK diskasks of tjif hi: art. jgv 
 
 Angina PECToras and Palpitation are siilyective. 
 Bradycardia and Tachycardia and Arrhythmia 
 are considered under the pulse. 
 
 ACUTE ENDOCARDITIS. 
 
 Definition : inflammation of the endocardium largely con- 
 fined to the valves. It may be 
 
 Simple, characterized by the growth upon the valves 
 of vegetations of granulation tissue, capped with 
 fibrin and accom])anied by subendothelial, small- 
 celled infiltrati(jn. The tendency of this is to 
 resolution by absorption of tlie vegetation with 
 nodular thickening and contraction. 
 Malignant or ulcerative endocarditis is marked by 
 connective tissue vegetative proliferation, accom- 
 panied by necrosis with ulceration or suppuration. 
 In either case the vegetations may be carried away 
 as emboli, to form corresponding simple or infective 
 infarcts. 
 Signs. 
 
 ,S JOJV^ OF SIMPLE ENDOCARDITIS : these, apart 
 from the symptoms and history, are not characteristic. 
 Many cases are latent, with but little or no evidence 
 of cardiac trouble. When the disease is confined to 
 the wall of the heart (not involving the valves) signs 
 are usually absent. 
 In addition to the evidences of the primary disease 
 INSPECTION may reveal — 
 Facial anxiety. 
 
 Apex Beat is apt to be increased in force and area 
 in the beginning. 
 PALPATION elicits— 
 
 Pid.se full, l)ounding, and perhaps irregular. 
 PERCUSSION negative in uncomplicated cases. 
 AUSCULTATION may be negative, even with marked 
 lesions ; but a soft 
 
168 PHYSICAL DIAONOStS OF THE CHEST. 
 
 Systolic llnrmuvy usually at the apex, is common. 
 Heduplication of the Second Sound may be 
 
 present. 
 SIGNS IN ULCERATIVE ENDOCAMDITIS. 
 NOT DISTINCT apart from the septic or typhoid 
 manifestations which are usually present as a part 
 of the causative affection. In such cases the pres- 
 ence of endocardial murmiirs with other signs of 
 valvular disease, and the evidences of embolic 
 processes, point strongly to the diseases in question. 
 
 CHRONIC ENDOCARDITIS. 
 
 Definition : it is essentially a sclerosis of the valves which 
 produces deformity with more or less consequent ob- 
 struction or incompetence. 
 Signs : when the disease is confined to the wall of the 
 heart (rare) it may show no signs. Even valvular 
 disease may not be recognizable by signs during life. 
 INSPECTION may disclose more or less of the fol- 
 lowing : 
 ANXIETY. 
 
 CYANOSIS of the prolabia and of the nose, chin, 
 cheeks, and tips of the ears is common in mitral 
 regurgitation ; marked when incompetence occurs. 
 PALLOR of the face, especially in aortic and mitral 
 
 obstruction. 
 ICTERUS common, and may be extreme, in case of 
 
 secondary duodenal catarrh. 
 CEDE MA of the extremities, progressing upward in 
 
 case of cardiac weakness. 
 PRECORDIAL PROMINENCE sometimes present in 
 
 children with cardiac enlargement. 
 APEX BEAT. 
 
 Position : displaced to the left and downward. 
 Strength: weak and invisible in dilatation; im- 
 moderately strong in hypertrophy. 
 
SIGNS JN THE DISEASES OF THE HEART. lOtJ 
 
 CAROTIDS show excessive beating in hypertrophy 
 and in aortic regurgitation. 
 
 JUGULAR PULSE is present in marked tricuspid re- 
 gurgitation. 
 
 DYSPNCEA on exertion amounting to orthopna'a in 
 advanced cases. 
 rALrATIOX. 
 
 APEX BEAT displaced with enlargement of the ven- 
 tricles. 
 
 PULSE. 
 
 (Joinpresaihle, weak and small in cardiac incom- 
 petence and frequently irregular. 
 Full, bounding, powerful in hy])ertrophy. 
 Diastolic Collapsing, in aortic regurgitation. 
 Small, ff'h'i/ in aortic obstruction. 
 
 FREMITUS, or thrills, correspond to the seat of the 
 murmur. Most frequent in mitral obstruction, pre- 
 systolic, at the apex ; less frequently in aortic ob- 
 struction, at the base ; rarely with regurgitant mur- 
 murs ; common over the subclavians and carotids (sys- 
 tolic) in aortic regurgitation. (See Fremitus, p. 59.) 
 rEBCUSSIOJ^. 
 
 OUTLI N E OF TH E H EART is extended to the left and 
 right in enlargement of the organ, according to the 
 cavities affected. Often it is difficult, sometimes 
 impossible, to make out by percussion the actual 
 size. Evidence of enlargement is an imj^ortant 
 sign in differentiating from functional murmurs. 
 A use UL TA TIOK. 
 
 THE HEART SOUNDS may be 
 Iteplaced by murmurs. 
 
 Modified in character, muffled, accentuated, or 
 Reduplicated, or otherwise more or less 
 fJhanged in Hhf/thm. 
 
 MURMURS usually accompany lesions. (See the 
 various Valvular Lesions.) 
 
170 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 QaaUttj. 
 
 Obstructive murmurs usually liarsli and high- 
 pitched. 
 
 Regurgitant murmurs apt to be blowing and 
 soft. Either of them may be musical or 
 soft, like whispered " who/' or creaking or 
 grating. 
 Intensity and Duration, 
 
 Sometimes Very Faint even with serious lesions. 
 All murmurs are apt to become weak with 
 weak heart action, grave lesions being in such 
 cases not infrequently unaccompanied by mur- 
 murs. Sometimes indistinct murmurs become 
 loud or of changed quality and pitch after ex- 
 ercise or the administration of cardiac tonics. 
 In tumultuous action of the heart, especially 
 with arrhythmia, all sounds may be confused, 
 and murmurs only become audible after car- 
 diac stimulation. 
 
 Sometimes Murmurs are so Loud as to be 
 heard at a distance from the patient. 
 
 Certain Postures may intensify or bring out a 
 murnnir. Asoulay recommends dorsal pos- 
 ture, head flexed, chin in contact with the 
 chest, arms elevated, thighs and legs flexed on 
 the abdomen. Sitting or Standing posture 
 may intensify murmurs. 
 
 According to Gerhardt, in beginning aortic insiiflBciency 
 a murmur which may be absent in recumbency may be 
 heard in the upright posture, while the reverse is true in 
 beginning mitral insufficiency. 
 
 PitcJi varies with the lesion, and the tension and 
 rapidity of circulation. It is of value in 
 diflerentiating between two murmurs occur- 
 ring at the same time. 
 
 TiTne refers to the relation in the cardiac cycle. 
 
SIa^'S IN THE DISEASES OE THE HEART. 171 
 
 Systolic refers to the contraction of the ventri- 
 cles (the auricles being ignored), and hence con- 
 comitant with or destroying the first sound, 
 and witli the apex beat and carotid pulse. 
 Indirect or Regurgitant. 
 
 Mitral and Tricuspid. 
 Direct or Obstructive. 
 Aorfic and Pulmonic. 
 Diastolic refers to the dilatation of the ventri- 
 cle, hence not with first sound, apex beat, and 
 carotid pulse. 
 Direct, Obstructivp]. 
 
 Mitral and Tricuspid, occurring in the latter 
 part of diastole just before systole (hence 
 presystolic). 
 Indirect or Regurgitant. 
 
 Aortic and Pidmonic, occurring in the first 
 part of diastole, taking the place of the re- 
 spective aortic and pulmonic second sound. 
 Transmission or Diffusion. 
 
 Extent : the murmur of aortic regurgitation may 
 be heard very widely from its seat, even as 
 low as the femoral vessels, though rarely. A 
 murmur may be very limited in diffusion, as 
 in mitral obstruction (heard only about the 
 apex). A murmur must necessarily be loud 
 to be well transmitted. 
 Medium of transmission. 
 The Vessels. 
 
 The Aorta and its branches transmit the mur- 
 murs of both aortic obstruction and re- 
 gurgitation, which are therefore frequently 
 heard above the base of the heart and 
 posteriorly along the left side of the ver- 
 tebral column, especially above the fifth 
 dorsal vertebra. 
 
172 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 The Pulmonary Artery carries the pulmonic 
 obstructive murmur up under the second 
 left interspace, hence it is not widely dif- 
 fused. 
 The Sternum and Kibs. 
 
 Loud Aortic Murmurs are frequently trans- 
 mitted down the sternum owing to tlie 
 comparative pro:5^imity of the vessel to 
 the bone over it. 
 Mitral Systolie Murmurs are transmitted to' 
 the left along the ribs from the apex, 
 which strikes the chest-wall at the time 
 they are produced. 
 The Diaphragm doubtless transmits the mnr- 
 mur of aortic regurgitation. The murmur 
 is produced during diastole while the left 
 ventricle is in most intimate contact with 
 the diaphragm, the blood being directed 
 downward toward it. The murmur is there- 
 fore transmitted along the diaphragm to its 
 attachment at the end of the sternum, and 
 along the costal arch close to the left of the 
 sternum. Here it is frequently heard with 
 greatest intensity. 
 The Blood Current within the heart. In 
 general, murmurs are transmitted best in 
 the direction in which the blood is flowing 
 at the time the murmur occurs. 
 In Mitral Obstruction the murmur is carried 
 into the ventricle toward the apex with 
 the blood-current. It is not usually trans- 
 mitted to the left, because the apex is not 
 in contact with the chest- wall at the time. 
 In Mitral Regurgitation the murmur is un- 
 doubtedly carried into the auricles with 
 the blood, as may be verified in some 
 
SIGNf^ IN THE DISEASES OF THE HEART. 173 
 cases where this lesion is complicated by 
 
 CONSOLIDATION OP THE LUNG at the 
 
 base of the heart, ^vhich transmits the 
 murmur to the surface at that point, or 
 where there is retraction of the lung un- 
 covering the auricle anteriorly. The 
 normal lung, owing to the oblique posi- 
 tion of the heart, is relatively thick over 
 the base, and does not transmit the mur- 
 mur. 
 Seat of a murmur : the place of its greatest intensity. 
 Valvular Lesions. 
 
 AORTIC INSUFFICIENCY, 
 
 DEFINITION : a defect of the aortic valve, allow- 
 ing regurgitation into the left ventricle during 
 diastole. 
 SIGNS. 
 
 Insjyection. 
 
 Pace usually pale. 
 
 Precordial Reg-ion is apt to be prominent in 
 
 children, in cases of long standing. 
 Apex Beat. 
 
 Area enlarged, reaching to the left, it may be 
 
 even to the mid-axillary line.^ 
 Force of impact, increased where compensa- 
 tion is good, sometimes shaking the chest 
 markedly or agitating the entire trunk. 
 Systolic Retraction of an intercostal space 
 over the apex, occasionally present. It may 
 be due to retraction of the lung and action 
 of the heart in systole. 
 Carotids and other arteries pulsate violently and 
 
 distinctly collapse in diastole. 
 Capillary Pulse (Quincke) may be seen in a line 
 of artificial hypenemia drawn upon the sur- 
 face, and in the bed of the finger-nails, fundus 
 
174 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 of the eye, and in the mucous membrane when 
 slightly pressed beneath a glass slide. 
 
 Rhythmical Swelling" of the Uvula (Miiller) 
 may sometimes be seen. 
 
 Faint Venous pulse has been seen in the hand 
 and arm (Quincke) — rare. 
 Palpation reveals also 
 
 Apex Beat displaced, area enlarged, and force 
 usually increased. 
 
 Fremitus. 
 
 Diastolic Thrill is rarely felt over the base 
 
 of the heart in the aortic area. 
 Systolic Thrill commonly felt over the 
 carotids and subclavian arteries. 
 
 Pulse : " water hammer/^ '^ pistol/^ ^' collapsing " 
 in diastole. When the wall of the left ven- 
 tricle is strong the pulse is full, bounding, and 
 sudden in systole, but falls away from the 
 finger, leaving an apparently empty artery, in 
 diastole. This is especially marked when the 
 arm is held high, owing to the eifect of gravity 
 on the fall of blood directly toward the ven- 
 tricle. Examine the arm in both the high 
 and low positions and note the difference. 
 Percussion. 
 
 Cardiac Dulness over an increased area, de- 
 fining the border of the heart far to the left 
 of the nipple line. 
 
 Cardiac Flatness much increased in area from 
 enlargement of the heart and crowding back 
 of the lung (see p. 160). 
 
 Dulness may be marked in the left second inter- 
 space in case of relative aortic insufficiency 
 from dilatation of the aorta at its beginning. 
 Auscultation, 
 
 Murmur. 
 
SIGNS IN THE DISEASES OE THE HEART. 175 
 
 Time : diastolic, with or obscuring the second 
 
 sound. 
 Seat : in the aortic area, second right inter- 
 space, sometimes over the sternum at this 
 level, occasionally over the lower end of the 
 sternum and costal arch close to the left, 
 over the attachment of the diaphragm. In 
 the latter case, I believe the nmrmur is 
 transmitted along the diaphragm (see p. 172). 
 Charactp:r. 
 
 Quality usually somewhat soft, gushing, or 
 swishing. Occasionally rough where de- 
 posits have occurred upon the valves. It 
 may be musical, and especially is it apt 
 to be so in relative insufficiency (Groedel). 
 Intensity and pitch variable. It is usually 
 loudest with large openings ; sometimes 
 loudest with the arms elevated. Cases 
 have been reported where the murmur 
 was intermittent. 
 Duration, long. 
 Propagation. 
 
 Down the Sternum, owing to the proximity 
 
 of the aorta to this bone over it. 
 Toivard the Apex, down the left ventricle. 
 Along the Diaphragm to the lower part of 
 the sternum and the costal arch close to 
 the left. 
 Above the Base of the heart, along the ves- 
 sels. When the murmur is loud it may 
 be very widely disseminated, even to the 
 main arteries of the extremities (rare). 
 Associated Murmurs. 
 
 Aortic Systolic murmur may often be heard, 
 though insufficiency more frequently ex- 
 ists aloue than stenosis. 
 
176 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Mitral Systolic murmur frequent on account 
 of relative mitral insufficiency from di- 
 latation of the left ventricle. The 
 murmur of aortic insufficiency may be 
 absent where there is a marked insuffi- 
 ciency of the mitral valve (Timofejew 
 and Bolkin). 
 
 Presystolie Murmur sometimes heard at the 
 base, and may be accompanied by a frem- 
 itus. 
 
 The cause is uncertain, but probably it is due to 
 vibration by the current from the auricle of the 
 larger segment of the mitral valve, previously 
 floated out by the refluent blood from the aorta. 
 
 Systolic Murmurs are usually heard over the 
 carotids and subclavians accompanied by 
 a fremitus, both probably due to the sud- 
 den systolic filling of these vessels, which 
 were j^reviously emptied in diastole. Both 
 murmur and thrill over a subclavian may 
 disappear when the arm is raised above 
 the head. 
 
 Double Murmurs (systolic and diastolic) are 
 sometimes heard over the larger arteries, 
 such as the femoral. 
 Heart Sounds. 
 
 Mitral and Tricuspid first sounds intact if 
 the corresponding valves are competent. 
 
 Aortic Second sound destroyed. 
 
 Pulmonic Second sound normal or obscured 
 by the loud aortic murmur. It is only ac- 
 centuated with disturbed compensation, re- 
 sulting in relative mitral insufficiency and 
 pulmonary engorgement. Tliis accentua- 
 tion disappears with failing compensation 
 of the right ventricle. 
 
SIGNS IN THE DISEASES OF THE HEART. 177 
 
 A on TIC OBS TR LCTI ON. 
 
 DEFINITION : a defect of the aortic valve interfering 
 with the current from the left ventricle into the 
 aorta. 
 SIGNS. 
 
 Ins2Jection, 
 
 Face is apt to be pale. 
 
 Precordial Reg-ion may be prominent where car- 
 diac enlargement occurs in childhood. 
 Apex Beat displaced downward, sometimes to 
 the sixth interspace and somewhat to the 
 left. 
 Area and force variable. 
 
 Carotids and other arteries show but little pul- 
 sation. 
 PaljKition, 
 
 Apex Beat, when hypertrophy is good, is marked 
 
 as contrasted with the small pulse. 
 Preraitus, systolic thrill sometimes felt in the 
 aortic area in pure aortic stenosis, which is 
 rare. 
 Pulse tardy, slow, small, and sometimes very 
 hard and wiry. 
 JPercussion. 
 
 Cardiac Dulness increased downward and to 
 the left. 
 Auscultation, 
 Murmur. 
 
 Time, systolic, with the first sound. 
 
 Seat, aortic area. 
 
 Character. 
 
 Quality apt to be harsh, strident, sometimes 
 
 whistling or hissing. 
 Intensity and pitch vary in different cases. 
 Duration long, o\ving to the relatively slow 
 discharge of the ventricle. 
 
 12 
 
178 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Propagation. 
 
 Above the Base, into the carotids. 
 Toward the Apex, and when loud 
 Doicn the Sternum. 
 Associated Murmurs. 
 
 Aortic Diastolic murmur is usually present, 
 as pure stenosis without regurgitation is rare. 
 Heart Sounds. 
 
 Mitral and Tricuspid sounds normal, the 
 former often peculiarly loud, unless rela- 
 tive mitral insufficiency exists as a result 
 of dilatation of the ventricle. 
 Aortic Second sound feeble. 
 Pulmonic Second, normal or accentuated. 
 MITRAL INSUFFICIENCY. 
 
 definition: a defect of the mitral valve allowing 
 
 regurgitation into the left auricle daring systole. 
 SIGNS. 
 
 liispection reveals but little abnormal, while com- 
 pensation is efficient, except the signs of hyper- 
 trophy in greater or less degree. When com- 
 pensation fails, the visible signs are cyanosis, 
 oedema, dyspnoea, cough, etc. 
 Palpation during loss of compensation may reveal 
 Pulse weak, small, rapid, and more or less irreg- 
 ular. 
 Apex Beat usually to the left, owing to enlarge- 
 ment of the right heart and slight hypertrophy 
 of the left ventricle. 
 Percussion usually shows cardiac enlargement both 
 to the right and left. Dulness may be found as 
 high as the second rib, to the left of the sternum, 
 owing to enlargement of the left auricle. 
 Auscultation. 
 Murmur. 
 
 Time, systolic, destroying the mitral first sound. 
 
SIGNS IN THE DISEASES OF THE HEART. 179 
 Seat at the apex. 
 
 Rarely it is heard with great, if not with equal inten- 
 sity at the base, about two inches to the left of the sternum. 
 This is thought (Naunyn) to be due to the propagation of 
 the sound with the blood as it rushed into the point 
 of the ajjpendix of the left auricle, which in some cases, 
 when enlarged, curves around and lies in front of the 
 pulmonary artery. 
 
 Character. 
 
 Quality usually soft, blowing, like the whis- 
 pered " who,'' occasionally rough, musical, 
 hissing, or rasping, etc. 
 Pitch and Intensity variable. 
 Duration: it may last up to the second 
 sound. 
 Propagation commonly to the left of the 
 apex, and when loud may be heard pos- 
 teriorly at the lower angle of the scapula ; 
 it is not usually heard at the base, and not 
 above the base nor over the sternum. 
 Heart Sounds. 
 
 Second Pulmonic sound accentuated, owing 
 to increased tension in the pulmonary artery, 
 but the accentuation disappears when the 
 compensatory hypertrophy of the right ven- 
 tricle fails. 
 MITBAL STENOSIS, 
 
 DEFINITION : a defect of the mitral valve, inter- 
 fering with the current from the left auricle into 
 the ventricle. 
 SIGNS. 
 
 Inspection, 
 
 Pallor of face and 
 
 Cyanosis, more or less marked as compensation 
 
 fails. 
 Epigastric Pulsation from enlargement of the 
 right heart. 
 
180 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 Taljyation, 
 
 Fremitus, or thrill, presystolic, not infrequent at 
 
 the apex. 
 Pulse apt to be small and weak. When com- 
 pensation fails it becomes rapid and extremely 
 arrhythmic in both time and force. 
 Percussion. 
 
 Dulness often • in the second interspace to the 
 left of the sternum over the dilated auricle, 
 and dulness also evident to the right of the 
 sternum and to the left of the normal line 
 when enlargement of the right ventricle is 
 marked. The left ventricle enlarges if at all 
 by atrophy and dilatation from poor nutrition, 
 but no hypertrophy occurs in it. 
 Ausciiltcition, 
 Murmur. 
 
 Time, presystolic, in the latter part of diastole, 
 ending in the first sound or in a systolic re- 
 gurgitant murmur, which frequently is asso- 
 ciated with it. 
 Seat at the apex, sometimes just above and 
 slightly to the left, because the left ven- 
 tricle is displaced, backward to a degree and 
 to the left, by the greatly enlarged right ven- 
 tricle, which in this case gives the apex beat. 
 Chaeacter. 
 
 Quality, rough, rumbling. 
 Pitch, Duration, and Intensity variable. It 
 is a relatively prolonged murmur. 
 Propagation very limited. It is usually 
 confined to a small area at the apex, and is 
 not heard far to the right or left or at the 
 base. 
 Associated Murmurs. 
 
 Mitral Systolic regurgitant murmur is 
 
SIGNS IN THE DISEASES OF THE HEART. 181 
 
 usually present, as obstruetion rarely oeeurs 
 without producing some incompetence of 
 the valve. 
 
 Pulmonic Diastolic murmur from relative 
 insufficiency of the pulmonary valve, due to 
 continuous high pressure in the pulmonary 
 artery. This is lieard only when the right 
 ventricle is powerful, and may be absent 
 when there is relative tricuspid insufficiency. 
 
 Tricuspid Systolic murmur from relative 
 insufficiency of that valve. When compen- 
 sation of the right ventricle fails the heart 
 becomes extremely rapid and irregular, and 
 the sounds and murmurs faint, a condition 
 termed delirium cordis. 
 Heart Sounds. 
 
 Mitral first sound, when not destroyed by an 
 accompanying murmur of regurgitation, is 
 intact and seemingly terminates the mur- 
 mur. 
 
 Tricuspid first sound is often peculiarly 
 loud. 
 
 Pulmonic second sound is accentuated in case 
 the right ventricle is hypertrophied. Ac- 
 centuation disappears with failing compen- 
 sation of the right ventricle. 
 
 Aortic second sound is apt to be faint. 
 
 Eeduplication of the second sound is fre- 
 quent, probably from the difference in ten- 
 sion in the pulmonary artery and aorta. 
 PULMOJNAMY INSUFFICIENCY. 
 
 definition: a defect of the pulmonary valve allow- 
 ing regurgitation into the right ventricle during 
 diastole. It is usually congenital, but may be a 
 part of a general endocarditis, or relative from 
 dilatation of the pulmonary artery at its beginning. 
 
182 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 SIGNS. 
 
 Inspection. 
 
 Apex Beat displaced to the left. 
 Pulsation frequently visible in the 
 
 Second Left Interspace. Pulsation of the 
 Right Ventricle between the ensiform car- 
 tilage and costal arch. 
 PaliJation, 
 
 Fremitus, diastolic thrill over the second left 
 
 interspace, occasional. 
 Pulse, generally regular but not large. May be 
 variously affected, owing to the lesions of other 
 valves usually present. 
 Percussion. 
 
 Dulness of the enlarged right ventricle to the 
 right and left of the sternum. 
 Auscultation, 
 Murmur. 
 
 Time diastolic, replacing the second pulmonic 
 
 sound. 
 Seat at the base in the second interspace. 
 Character not peculiar, except that it is in- 
 creased in intensity during expiration (Ger- 
 hardt). 
 Propagation limited ; not transmitted into 
 the cervical vessels. Being usually loud, it 
 may be heard over the whole heart, distinct 
 over the right ventricle. 
 Associated Murmurs. 
 
 Tricuspid Systolic murmur from relative 
 insufficiency is apt to occur. 
 
 At a distance from the heart may occasionally be 
 heard on inspiration an interrupted vesicular respira- 
 tion, possibly due to pulmonary capillary pulse, anal- 
 ogous to the collapsing capillary pulse of aortic re- 
 gurgitation (Gerhardt). 
 
SIGNS IN THE DISEASES OF THE HEART. 183 
 
 Heart Sounds. 
 
 Mitral and Aortic sounds apt to be weak. 
 Pulmonic Second destroyed by the murmur. 
 Tricuspid accentuated, if hypertrophy of the 
 right ventricle be adequate and no relative 
 insufficiency of the tricuspid valve occurs. 
 P UL3IONA R Y S TEN OS IS, 
 
 DEFINITION : a defect of the pulmonary valve in- 
 terfering with the systolic current from the right 
 ventricle. It is among the very rarest of acquired 
 lesions, but most frequent of the congenital valve 
 lesions, and usually associated with other anomalies. 
 SIGNS. 
 
 Tiisj^eeflon reveals deranged circulation and mal- 
 formation and general arrest of development. 
 Eyes prominent ; Lips thick, red. 
 Superficial Veins enlarged. 
 Cyanosis often extreme. 
 Thorax narroAv and precordia prominent. 
 Abdominal Protrusion. 
 
 Fing-er Ends clubbed, blue ; nails curved, thick. 
 Cardiac Impulse displaced and often increased 
 
 so as to agitate the chest. 
 Dyspnoea common. 
 JPaljKition, 
 
 Fremitus in the second left interspace. 
 Apex Beat displaced. 
 Pulse weak. 
 
 Surface, and especially the extremities, cold. 
 Percussion, 
 
 Enlarg-ed Right Ventricle, giving dulness to the 
 right of the sternum. 
 Atiscultation. 
 Murmur. 
 
 Time, systolic, with the first sound. 
 Seat, second left interspace. 
 
184 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 TRICUSPID INSUFFICIENCY. 
 
 definition: a defect of the tricuspid valve allow- 
 ing regurgitation into the right auricle during sys- 
 tole. Except in foetal life, it is usually relative, 
 consecutive to valve lesions which have caused 
 dilatation of the right ventricle. 
 SIGNS. 
 
 Inspection. 
 
 Face is apt to show more or less cyanosis. In 
 marked insufficiency of long standing with fail- 
 ure of compensation there is marked cyanosis 
 with 
 CEdema of the extremities. 
 Ectasia of the superficial vessels. 
 Prominence of the epigastric and right hypo- 
 chondriac regions occurs from enlargement of 
 the liver. 
 Dyspnoea. 
 Pulsation of the right ventricle evident at the 
 
 ensiform cartilage and epigastrium. 
 Jugular Pulsation present in well-marked cases. 
 
 The venae cavse and innominate vein have no valve, but 
 for the production of jugular pulsation this vein must be 
 sufficiently dilated to overcome the valve at its root, which 
 otherwise long resists the backward pressure. 
 
 Time, systolic. 
 
 Seat, most marked on the right side. The bulb 
 of the jugular first pulsates. Sometimes it 
 may be seen just above the clavicle outside 
 the sterno-cleido-mastoid. When the inter- 
 nal jugular pulsates the external does also. 
 
 Intensity : it only occurs with a relatively 
 powerful right ventricle. 
 Pressure easily obliterates all pulsation above 
 
 the point of its application. 
 It is greatest during inspiration. 
 
SIGNS IN THE DISEASES OF THE HEART. 185 
 
 Hepatic Venous Pulsation is better felt than 
 
 seen. 
 Femoral Vein may pulsate if its valve (Eus- 
 tachian) has been overcome by the dilatation 
 of the vessel. 
 JPalpation. 
 
 Apex Beat weak. 
 
 Pulse weak, rapid, unless compensation is good. 
 Hepatic Venous Pulsation may occur, since 
 these veins have no valves. 
 Time, systolic. 
 Seat, chiefly in the left lobe, as it is most 
 
 easily expanded. 
 Intensity and character like that of an 
 erectile tumor. 
 Percussion. 
 
 Cardiac Dulness increased, and may be obtained 
 
 well to the right of the sternum. 
 Hepatic Dulness increased. 
 Auscultation. 
 Murmur, 
 
 Time, systolic, taking the place of the tricuspid 
 
 first sound. 
 Seat at the ensiform cartilage or the lower 
 
 half of the sternum. 
 Chaeacter. 
 
 Quality usually soft, blowing. 
 Intensity and pitch not peculiar. The mur- 
 mur may be absent, and is often difficult 
 to make out in the presence of several as- 
 sociated murmurs. It is commonly over- 
 looked. 
 Propagation distinct to the 
 
 Right of the Sternum, sometimes even as far 
 
 as the axillary line. 
 Into the Jugular Vein, where the mur- 
 
186 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 mur is loud and the venous pulse well 
 marked. 
 Associated Murmurs of the aortic and mitral 
 
 valves are usually present. 
 Heart Sounds. 
 
 Mitral sound usually destroyed by incom- 
 petence of the valve. 
 Tricuspid sound absent. 
 Aortic sound may be present, but is weak. 
 Pulmonic sound weak from the low tension 
 in the pulmonary artery. 
 TRICUSPID STENOSIS, 
 
 definition: a defect of the tricuspid valve inter- 
 fering with the presystolic current (auricular sys- 
 tole) into the right ventricle. It is exceedingly 
 rare, and is usually of foetal origin. 
 SIGNS : it is generally accompanied by other con- 
 genital lesions which mask it. 
 Inspection, 
 
 The signs are those of extreme systemic venous 
 stasis. 
 Palpation, percussion, and auscultation signs not 
 distinctive. So rare is this affection that the 
 characteristics of the accompanying murmur, 
 if present, are not definitely settled. Hypo- 
 thetical ly it has been described as 
 Time, presystolic. 
 Seat, tricuspid area. 
 Propagation limited to the right side of the heart. 
 
 FUNCTIONAL ENDOCARDIAL MURMURS. 
 
 These are due chiefly to aneemia and transient causes, 
 such as fever, excitement, etc. 
 Time, systolic ; diastolic murmurs are usually organic. 
 Seat, usually the base of the heart in the pulmonary area ; 
 
 sometimes the aortic area ; occasionally at the apex. 
 
SIGNS IN THE DISEASES OF THE AORTA. 187 
 
 Character, usually soft, blowing in quality. 
 Propagation very limited. 
 Associated Signs those of 
 
 ANjEMIA, nervous excitement. 
 
 HEART normal in size, its sounds all present, though 
 they may be slightly modified. 
 
 ANEURYSM OF THE AORTA (THORACIC). 
 
 Definition : a fusiform or saccular dilatation of the aorta 
 in any part of its course, above the diaphragm. Its en- 
 largement causes pressure, disturbing and destructive 
 to neighboring organs. 
 Signs. 
 
 INSPECTION may reveal 
 
 AN INFLAMED AREA of reddened, thin, glazed skin 
 covering the site of the aneurysm, if this has by 
 pressure come sufficiently near the surface. 
 LIVIDITY of the face, neck, and upper extremities 
 from pressure upon venous trunks. Lividity and 
 oedema, when sudden in occurrence, may be due to 
 rupture into one of the great venous trunks. 
 TURGESCENCE and VARICOSITY of the superficial 
 veins points to deep-seated interference with venous 
 trunks. 
 EXPRESSION : the eyeballs may become prominent; 
 expression of distress may indicate the more or less 
 continuous boring pain commonly present. 
 LOCALIZED CEDE MA results from pressure upon the 
 superior vena cava or innominate vein. It may be 
 absent from establishment of collateral circulation. 
 Capillary turgescence may produce 
 A THICK FLESHY COLLAR at the base of the neck, 
 which may be unilateral. 
 
 These pressure signs may of coarse be produced by other 
 conditions, such as tumors, swellings, inflammatory contraction, 
 thrombosis, etc. 
 
188 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 INEQUALITY OF THE PUPILS, or persistent bilateral 
 myosis, may result from pressure upon the sym- 
 pathetic nerve trunks or branches. Pupil may be 
 contracted on the affected side. 
 EMACIATION and ENFEEBLEMENT progressive. 
 ENLARGEMENT or^BULGING common at the site 
 of the aneurysm ; variable in size. 
 Site. 
 
 None Present when the Aneurysm is located 
 at the Valves of Valsalva. The signs in 
 this case are apt to be obscure. 
 Bulg-ing" to the Right of the Sternum in the 
 second interspace, sometimes extending far into 
 the infra-clavicular and mammary region, is 
 apt to occur from aneurysm of the ascending 
 portion, if large. More rarely it appears to 
 the left of the sternum at a corresponding 
 level. The sternum may be perforated. 
 Bulging" at the Upper Part of the Sternum 
 and adjacent infra-clavicular region results 
 from aneurysm of the transverse portion. 
 Bulging Posteriorly, below the level of the 
 fourth rib, to the left of the vertebral column, 
 may result from aneurysm of the thoracic 
 aorta. Very rarely it appears to the right of 
 the vertebral column. Frequently there is an 
 absence of a tumor. 
 PULSATION, if visible, at the site of an aneurysm. 
 Time, systolic (with apex beat). 
 Character f expansile in all directions, not simply 
 lifting as from a tumor lying upon a large artery. 
 Intensity : to detect slight pulsation the light must 
 be good. It may sometimes be detected by look- 
 ing across the surface. 
 
 Divergence of two projecting objects with each pulsation 
 may reveal an otherwise slight expansion — e. g. stick upon 
 
SIGNS AY THE DISEASES OF THE AORTA. 189 
 
 the surface over the suspected part two small strips of paper, 
 so that they may project several inches at right angles from 
 the surface. 
 
 DEFICIENT MOVEMENT in the arteries of the left 
 .side may be seen, especially in aneurysm of the 
 transverse part. 
 
 PULSATION OF THE CAROTIDS may be exaggerated. 
 
 APEX BEAT is apt to be displaced d(jwnward and 
 somewhat to the left with corresponding dislocation 
 of the heart. 
 
 EPIGASTRIC PULSATION may be marked with en- 
 largement of the right heart as a result of disturbed 
 pulmonary circuit. 
 
 RESPIRATORY MOVEMENT may be deficient or ab- 
 sent on one side, usually the left, from pressure on 
 the main bronchus. 
 
 DYSPNOEA and HYPERPNCEA, amounting to ortho- 
 pnoea, may be present, either due to laryngeal paresis 
 or to interference with the lungs, trachea, or bronchi 
 (especially in aneurysm of the transverse portion). 
 
 COUGH a frequent sign with or without profuse secre- 
 tion, variable. 
 PALPATIO^. 
 
 AREA OF TENDERNESS over the aneurysm not in- 
 frequent, and there may be tender points charac- 
 teristic of intercostal neuralgia. 
 
 CONSISTENCE of the tissue over an aneurysm may 
 be soft, yielding, and even fluctuating when cartilage 
 and bone have been destroyed. 
 
 THRILL systolic over the tumor a frequent sign, some- 
 times very early obtained by pressure of the fingers 
 in the supra-sternal notch. 
 
 IMPULSE obtained over the tumor usually 
 Systolic, 
 
 Diastolic Shock (usually slight) may also be pres- 
 ent, due to the falling back of an unusual volume 
 
190 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 of blood against the aortic valve, which must be 
 competent to give it. (Diastolic shock absent in 
 insufficiency of the aortic valve.) 
 RADIAL and CAROTID pulse, or both, may be un- 
 equal in volume on the two sides owing to j)ressure 
 on the innominate artery or one of its branches, or 
 to obstruction by coagulum. 
 THE SUPERFICIAL ARTERIES, temporals, radials 
 frequently show rigidity, inelasticity, un evenness, 
 or tortuosity as a part of general atheroma. 
 PULSATION OF THE ABDOMINAL ARTERY and its 
 branches may be very weak in a large aneurysm of 
 the descending part of the thoracic aorta. 
 TRACHEAL TUGGING is sometimes an early sign. 
 Dr. Wm. Ewarts's method of examination : 
 
 Patient seated, head thrown back against exam- 
 iner as he stands behind. Trachea gently 
 stretched by pressure made with tips of both 
 index fingers placed under the lower edge of 
 the cricoid cartilage. Sensation of traction or 
 tugging downward is felt with each heart-beat. 
 VOCAL FREMITUS may be diminished over the an- 
 eurysm or over the lung, the main bronchus of 
 which is obstructed. 
 PEMCUSSION must be made gently in case of sus- 
 pected aneurysm for fear of causing embolism. 
 DULNESS is present over the aneurysm. 
 SENSATION OF RESISTANCE to the pleximeter 
 may be less than over consolidated lung unless the 
 aneurysm is filled with fibrin. 
 DULNESS OVER THE LUNG maybe present also 
 when the main bronchus is compressed and the cor- 
 responding lung congested or collapsed. Dulness 
 over a part of the lung in which consolidation is 
 due to pressure or to tuberculosis, which is apt to 
 set in where the pulmonary artery is compressed. 
 
SIGNS IN THE DISEASES OF THE AORTA. 191 
 
 THE HEART is not usually enlarged when the aortic 
 valve is unaffected, but it may be displaced. 
 A use UL TA TION, _ 
 
 MURMUR is present in about half the cases. Fre- 
 quently absent in saccular aneurysm (Douglas 
 
 Powell). 
 
 Systolic Bruit most common. In some cases a 
 murmur may only be detected by placing the 
 chest-piece of the stethoscope in the patient's 
 mouth, his lips being closed about it (Sansom). 
 The murmur is then conveyed by the trachea. 
 
 Drummond, of New Castle, has noted a systolic murmur 
 over the trachea, possibly due to expulsion of air at each 
 distention of the aneurysmal sac against the trachea. 
 
 diastolic Murmur may sometimes be heard over 
 a saccular aneurysm independent of aortic re- 
 gurgitation, the sepond aortic sound of the heart 
 being clear and loud. This murmur may be due 
 to the elastic recoil of the wall of the sac forcing 
 the blood back into the aorta, as represented in 
 the following diagram : 
 
 Fig. lO.-Illustrating the elastic recoil of an aneurysmal sac, producing a 
 diastolic murmur. 
 
 Diastolic Murmur of Aortic Insufficiency, taking 
 the place of the second aortic sound, is frequently 
 present in aneurysm involving the valves of Val- 
 salva. 
 VENOUS HUM in the neighborhood of the aneurysm 
 may be produced by pressure against a large vein 
 or perforation into the vein. It is continuous, and 
 apt to be accentuated with each systole. 
 
192 PHYSICAL DIAGNOSIS OF THE CHEST. 
 
 SECOND AORTIC SOUND is frequently accen- 
 tuated and of a ringing, drumming, or clanging 
 character, unless replaced by the murmur of in- 
 sufficiency. 
 RESPIRATORY AND WHISPER AND VOCAL sounds 
 may be 
 Bronchial over a compressed lung or over the 
 
 aneurysm when resting upon the trachea. 
 Diminished or Absent over a whole lung when 
 the main bronchus is compressed. 
 Forced Inspiration may in such cases give dis- 
 tinct respiratory sounds, absent on ordinary 
 respiration. 
 
 COARCTATION OF THE AORTA. 
 
 Definition : a contraction or partial stenosis of the aorta 
 
 (rare). 
 Signs. 
 
 INSPECTION VQ\Q?X^ evidence of cardiac hypertrophy, 
 dilatation of the arch of the aorta and carotid and 
 subclavian arteries, and dilatation and tortuosity of 
 the superficial arteries. 
 rALPATION 
 
 FEEBLE PULSATION in the abdominal aorta and in 
 
 the arteries of the lower extremities. 
 FREMITUS over the large arteries of the head, neck, 
 and upper extremities. 
 rERCUSSION negative. 
 AUSCULTATION. 
 MURMUR. 
 
 Quality harsh. 
 Pitch high. 
 
 Intensity usually loud. 
 Time, systolic or diastolic (post-systolic). 
 Proj)agation into the subclavian and carotid ar- 
 teries, and it may be heard posteriorly. 
 
SIGNS IN THE DISEASES OF THE ARTERIES. 193 
 
 ANEURYSM OF THE PULMONARY ARTERY. 
 Very rare, and difficult of diagnosis, even with the aid of 
 
 subjective manifestations. 
 Signs which have been obtained. 
 INSPECTION. 
 CYANOSIS marked. 
 DROPSY. 
 
 DYSPNCEA pronounced. 
 PULSATING swelling limited to the second interspace 
 to the left of the sternum, where aneurysms of the 
 ascending aorta are not as likely to present as those 
 of the descending aorta, which commonly present 
 posteriorly. 
 PALPATION, systolic thrill. 
 AUSCUL TA TION. 
 
 MURMUR, systolic or diastolic, and not propagated 
 above the clavicle. 
 
 ANEURYSM OF THE INNOMINATE ARTERY. 
 Signs diffi9r from those of aortic aneurysm in 
 
 LOCATION : it presents to the right of the sternum, 
 in the region of the inner end of the clavicle. 
 
 PRESSUBE signs referable to the recurrent laryngeal 
 nerve, oesophagus, and trachea are not so apt to occur 
 as in aortic aneurysm. 
 
 COMPMESSION, by the examiner, of the carotid and 
 subclavian arteries diminishes the pulsation of aneur- 
 ysm of the innominate artery, but does not affect aortic 
 aneurysm appreciably. 
 
 13 
 
INDEX. 
 
 Adventitious sounds, 85 
 ^gophony, 82 
 Alar chest, 36 
 Amphoric breathing, 75 
 
 cough, 84 
 
 resonance, 68 
 
 whisper, 83 
 Aneurysm of the innominate ar- 
 tery, 193 
 
 pulmonary artery, 193 
 Angle of Lewis, 32 
 Aorta, aneurysm of the, 187 
 
 coarctation of the, 192 
 
 landmarks of the, 30 
 
 sounds over the, 108, 109 
 Aortic insufficiency, 173 
 
 obstruction, 117 
 
 pulsation, 46 
 in the epigastrium, 50 
 
 valves, 29 
 Apex beat, 28, 47 
 
 in emphysema, 121 
 Apneumatosis, 123 
 Apnoea, 41 
 Arterial movements, 45 
 
 sounds, 108, 109 
 Asphyxia, 41 
 Asthma, signs of, 119 
 Atelectasis, 123 
 Atrophy, cardiac, 159 
 Auscultation, 70, 72 
 Axillary lines, 23 
 
 Barrel-shaped chest, 36, 121 
 
 Bell sound, 89 
 
 Blood currents and murmurs, 172 
 
 Bone resonance, 65 
 
 Bradycardia, 55 
 
 Breathing, abnormal, 40 
 
 amphoric, 76 
 
 bronchial, 74 
 
 broncho-cavernous, 75 
 
 cavernous, 75 
 
 cog-wheel, 78 
 
 exaggerated, puerile, 76 
 
 feeble, 77 
 
 interrupted, 78 
 
 laryngeal, 74 
 
 metamorphosing, 75 
 
 normal, 59 
 vesicular, 75 
 
 rapidity of, 40 
 
 suppressed, 77 
 
 vesiculo-cavernous, 75 
 Bronchial hemorrhage, 137 
 Bronchiectasis, 117 
 Bronchi, diseases of^ 114 
 
 primary, 28 
 Bronchitis, 114-117 
 Bronchophony, 81 
 Broncho-pneumonia, 128 
 Bruit de diable, 110 
 
 Capillary bronchitis, 116 
 pulse, 46, 173 
 
 195 
 
196 
 
 INDEX. 
 
 Cardiac atrophy, 159 
 
 dilatation, 161 
 
 diseases, 153 
 
 dulness, 29, 160 
 
 fatty degeneration, 164 
 
 flatness, 29 
 
 fremitus, 58 
 
 hypertrophy, 160 
 
 lipomatosis, 163 
 
 movements, 47 
 
 rupture, 165 
 
 sounds, 89 
 modified, 91 
 Carotids, pulsation of, 46 
 Cavernous breathing, 75 
 
 cough, 84 
 
 whisper, 83 
 Cavity, cracked-metal resonance 
 in, 70 
 
 in pulmonary tuberculosis, 131, 
 134 
 Cerebral blowing, 108 
 Chest, form of, 35 
 
 size of, 34 
 Chest- wall, diseases of, 112 
 Cheyne-Stokes respiration, 42 
 Cog-wheel respiration, 78 
 Collapsing pulse, 174 
 Color, 38 
 Costal arch, 20 
 
 breathing, 39 
 Cough, varieties of, 83, 84 
 Cracked-metal resonance, 70 
 Crepitant rtles, 84 
 
 in pneumonia, 128 
 Crumpling sounds, 87 
 
 Diaphragm and murmurs, 172 
 Diaphragmatic breathing, 39 
 
 hernia, 151 
 
 pleurisy, 144 
 
 Diastolic murmurs, 102 
 
 shock in aneurysm, 189 
 Diseases of the chest, 112 
 
 heart, 153 
 
 lungs, 143 
 
 pericardium, 153 
 Ductus arteriosus, patulous, 159 
 Dulness, cardiac, 29, 160 
 
 hepatic, 30 
 
 splenic, 31 
 
 in pulmonary tuberculosis, 132 
 
 pleurisy, 145 
 
 pericarditis, 154 
 Dyspncea, 40 
 
 in atelectasis, 123 
 
 asthma, 119 
 
 pneumonia, 125 
 
 Emphysema, pulmonary, 120 
 
 of the chest- wall, 114 
 Emphysematous chest, 36, 121 
 Empyema pulsans, 49 
 Endocardial murmurs, 95 
 Endocarditis, 167 
 Enlarged bronchial glands, 142 
 Epigastric pulsation, 50 
 Eupncea, 39 
 
 Exocardial murmurs, 94 
 Expiratory sound prolonged, 79 
 
 Fatty heart, 163 
 Fibroid phthisis, 135 
 Fissures of the lungs, 25 
 Flatness, 51 
 
 cardiac, 29 
 
 hepatic, 30 
 
 in pleurisy, 147 
 
 splenic, 31 
 Fontanelle, sounds over the, 108 
 Foramen ovale, patulous, 159 
 Form of the chest, 36 
 
INDEX. 
 
 197 
 
 Fremitus, 58-60, 169 
 Friction sounds, 88 
 
 pericardiac, 94, 155 
 
 pleuritic, 144 
 
 pleuro-pericardiac, 94 
 Friedreich's change of sound, 69 
 Functional murmurs, 186 
 Funnel breast, 36 
 
 Gerhardt's change of sound, 69 
 
 HiEMO-PERICARDIUM, 157 
 
 Hsemothorax, 152 
 Harrison's groove, 37 
 Heart, aneurysm of the, 165 
 
 congenital anomalies of the, 158 
 
 diseases of the, 153 
 
 fatty, 163 
 
 landmarks of the, 28 
 
 neuroses of the, 166 
 
 parasites of the, 166 
 
 relation to the lungs, 29 
 
 rupture of the, 165 
 
 sounds (see Cardiac), 89 
 
 in pulmonary tuberculosis, 133 
 
 syphilis of the, 165 
 
 thrombosis of the, 166 
 
 tumors of the, 166 
 
 valves of the, 29 
 Hepatic dulness, 30 
 
 flatness, 30 
 
 venous pulsation, 46 
 Herpes in pneumonia, 125 
 Hydatid cysts of the lung, 143 
 Hydro-pericardium, 157 
 Hydrothorax, 152 
 Hyperpnoea, 40 
 Hypopnoea, 41 
 
 Innominate artery, aneurysm 
 of the, 193 
 landmarks of the, 30 
 
 Inspection, 33 
 Inspiratory sound, 79 
 Intercostal neuralgia, 112 
 Interrupted Wintrich's change of 
 
 sound, 69 
 Interval in respiration, 78 
 
 Jugular murmur. 111 
 Jugulars, inspiratory swelling of 
 the, 156 
 presystolic pulsation of the, 45 
 
 Landmarks of the chest, 23 
 Lines of reference, 23 
 Liver, landmarks of the, 30 
 
 relation to the lungs, 30 
 Lobar pneumonia, 124, 128 
 Lungs, diseases of the, 114 
 
 fissures of the, 25 
 
 landmarks of the, 24 
 
 lobes of the, 26 
 
 outline of the, 24 
 
 relation to the liver, 30 
 
 Mammillary lines, 23 
 Mediastinum, diseases of the, 114 
 Mediastinal pericarditis, 156 
 ! Mensuration, 61 
 Metallic tinkling, 88 
 Metamorphosing breathing, 75 
 Mitral insufficiency, 178 
 
 stenosis, 179 
 
 valve, 30 
 Movements, 39, 51 
 
 cardiac, 47 
 
 circulatory, 45 
 
 respiratory, 39 
 Murmurs, aneurysmal, 191 
 
 aortic diastolic, 103 
 systolic, 103 
 j cardiac, 94 
 1 diastolic, 102 
 
198 
 
 INDEX. 
 
 Murmurs, endocardial, 95 
 
 exocardial, 94 
 
 functional endocardial, 186 
 
 inorganic, 106 
 
 mitral diastolic, 103 
 systolic, 96, 172 
 
 non-valvular, organic, 106 
 
 pulmonic, 101 
 
 transmission of, 171 
 
 tricuspid diastolic, 104 
 systolic, 100 
 Myocarditis, 162 
 
 Neuroses of the heart, 166 
 Normal vesicular breathing, 73 
 dulness, 56 
 
 Nutrition, 83 
 
 Organic murmurs, 96 
 Orthopnoea, 42 
 
 PALPATIO!^, 50 
 
 Para-sternal lines, 23 
 Pectoriloquy, whispering, 83 
 Percussion, 61-63 
 Pericardiac friction sounds, 94 
 
 splashing sounds, 94 
 Pericarditis, 153 
 Phonometry, 112 
 Pigeon-breast deformity, 36 
 Pleurae, diseases of the, 143 
 Pleurisy, cracked-metal resonance 
 
 in, 70 
 Pleurodynia, 112 
 Pleuro-pericardiac friction sounds, 
 
 94, 144 
 Plexor and pleximeter, 61 
 Pneumo-hydrothorax, 149 
 Pneumo-pericardiac sounds, 95 
 Pneumo-pericardium, 157 
 Pneumothorax, false, 151 
 Posture, 37 
 
 Posture in asthma, 119 
 
 in lobar pneumonia, 124 
 
 in pleurisy, 116, 144, 145 
 Precordial bulging in pericarditis, 
 153 
 
 pulsation, 49 
 Pulmonary abscess, 139 
 
 apoplexy, 138 
 
 arterial pulsation, 46 
 
 artery, aneurysm of the, 193 
 
 cancer, 141 
 
 capillary pulse, 182 
 
 hemorrhage, 137 
 
 hyperaemia, 137 
 
 gangrene, 140 
 
 insufficiency, 181 
 
 oedema, 137 
 
 resonance exaggerated, 65 
 
 sounds in auscultation, 72 
 
 stenosis, 183 
 
 thrombosis, 138 
 
 tuberculosis, 130 
 Pulsation of the epigastrium, 50 
 Pulse, capillary, 46 
 
 collapsing, 174 
 
 characteristics, 51-55 
 
 dicrotic, 54 
 
 in asthma, 119 
 
 broncho-pneumonia, 129 
 lobar pneumonia, 126 
 
 radial, 51 
 
 ''water hammer," 174 
 Pulsus bigeminus, 54 
 
 paradoxicus, 54 
 
 trigeminus, 54 
 Pyo-pericardium, 157 
 
 Quincke's pulse, 46 
 
 Rales, varieties of 85 
 in asthma, 120 
 
INDEX. 
 
 199 
 
 Rales in broncho-pneumonia, 130 
 
 in lobar pneumonia, 128 
 Regions of the chest, 1-8 
 Resonance, amphoric, 68 
 
 cracked-pot, 70 
 
 exaggerated vesicular, Qd 
 
 tympanitic, 67 
 
 vesicular, 64 
 
 vocal, 80, 
 Respiration (see Breathing), 39 
 Respiratory change of sound, 69 
 
 expansion in emphysema, 121 
 
 sounds, 72-78 
 Rhachitic chest, 36 
 
 rosary, 36 
 Rhonchal fremitus, 59 
 Ribs, landmarks of the, 32 
 
 Scapula, landmarks of the, 32 
 Shoemaker's breast, 36 
 Sibilant rales, 86 
 Size of the chest, 34 
 Sonorous r^les, 86 
 Sound, bell, 89 
 
 elements of, 63 
 Sounds, auscultatory, 72 
 
 cardiac, 89 
 
 cough, 83 
 
 friction, 88 
 
 percussion, 63 
 
 pleuritic, 144 
 
 pulmonary, 72 
 
 succussion, 89, 111 
 
 tussive, 83 
 
 vascular, 108 
 
 venous, 110, 111 
 
 whispering, 83 
 Spinal curvatures, 37 
 Spleen, landmarks of the* 31 
 Sternal lines, 23 
 
 Stethoscopes, 70, 71 
 
 Subclavian artery, sounds over 
 
 the, 100, 109 
 Swellings of the chest-wall, 113 
 
 Tachycardia, 56 
 Thrombosis of the heart, 166 
 Trachea, 27 
 " Tracheal tone," 67 
 
 "tugging," 190 
 Tricuspid insufficiency, 184 
 
 stenosis, 186 
 
 valve, position of, 29 
 Tuberculosis, acute miliary, 131 
 Tumors of the chest-wall, 113 
 
 heart, 166 
 Tussive or cough sounds, 83 
 Tympany, 67 
 
 Valleix's points of tenderness, 
 
 113 
 Valves, cardiac, 29 
 Valvular lesions, 173 
 
 murmurs, 96 
 Vascular sounds, 108 
 Venous hum. 111 
 
 in aneurysm, 191 
 
 pulsation, 45, 174 
 
 sounds, 110 
 Vertebrae, landmarks of the, 31 
 Vesicular resonance, 64 
 
 respiration, 73 
 interrupted, 182 
 Vesiculo-tympany in pleurisy, 108 
 Vocal fremitus, 60 
 
 sounds, 80 
 
 Whisper, amphoric, 83 
 
 cavernous, 83 
 William's tracheal tone, 67, 69 
 Wintrich's change of sound, 69 
 
A TEXT-BOOK 
 
 OF 
 
 Materia Medica, Therapeutics, 
 
 AND 
 
 Pliarmacology. 
 
 BY 
 GEORGE F. BUTLER, Ph. G., M. D., 
 
 Professor of Materia Medica and of Clinical Medicine in the 
 College of Physicians and Surgeons, Chicago; Professor of 
 Materia Medica and Therapeutics, Northwestern Uni- 
 versity, Woman's Medical School, etc. 
 
 A HANDSOME OCTAVO VOLUME OF 858 PAGES. 
 ILLUSTRATED. 
 
 Prices: Cloth, $4.00 net; Sheep or Half- 
 Morocco, $5.00 net. 
 
 A clear, concise, and practical text-book, adapted for 
 permanent reference no less than for the requirements 
 of the class-room. The arrangement is believed to be 
 at once the most philosophical and rational, as well as 
 that best calculated to engage the interest of those to 
 whom the academic study of the subject is wont to offer 
 no little perplexity. 
 
 Special attention has been given to the Pharmaceuti- 
 cal section, which is exceptionally lucid and complete. 
 
 Sent post-paid on receipt of price. 
 
 W. B. SAUNDERS, Publisher, 
 
 925 Walnut St., Philadelphia, Pa. 
 
Saunders' New Aid Series of Manuals. 
 
 A MANUAL 
 
 OF 
 
 SYPHILIS 
 
 AND THE 
 
 VENEREAL DISEASES. 
 
 BY 
 
 JAMES NEVINS HYDE, M. D., 
 
 PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, 
 CHICAGO, 
 
 AND 
 
 FRANK H, MONTGOMERY, M. D., 
 
 LECTURER ON DERMATOLOGY AND GENITO-URINARY DISEASES, RUSH MEDI- 
 CAL COLLEGE, CHICAGO. 
 
 PEOFUSELY ILLUSTRATED. 
 
 DOUBLE NUMBEE. PEIOE, $2.50 NET. 
 
 This Manual is intended as a thoroughly practical 
 guide, and represents the latest knowledge of the 
 Venereal Diseases which are included under the heads 
 of Syphilis, and Gonorrhoea and its complications, 
 with very complete instructions for their diagnosis 
 and carefully prepared instructions for their treat- 
 ment, cure, and alleviation. 
 
 The illustrations (some of which are colored) have 
 been selected with the greatest possible care, and 
 with the view of elucidating the text. 
 
 Sent post-paid on receipt of price. 
 W. B. SAUKDERS, Publisher, 
 
 9!i5 Walnut Street, I'hiladelphia, JPa. 
 
SatMiders' New Aid Series of Manuals, 
 
 A MANUAL 
 
 OF 
 
 THE MODERN THEORY AND TECHNIQUE 
 
 OF 
 
 SURGICAL 
 
 ASEPSIS. 
 
 BY 
 
 CARL BECK, M.D., 
 
 Visiting Surgeon to St. Mark's Hospital and to the Ger- 
 man Poliklinik, New York City, etc. 
 
 A Handsome Post -Octavo Volume of over 300 
 
 Pages, containing 65 Illustrations in 
 
 the Text and iz Plates. 
 
 ' ' While the leading idea in this Manual has been to 
 write a practical book that would in a measure meet 
 the deficiency of the larger works on the subject, vet 
 theory could not be entirely omitted, inasmuch as 
 most of the technique of modern wound treatment is 
 founded upon experiments conducted in the labora- 
 tory. An important feature of the book is that a 
 stricter line of demarcation than usual is drawn be- 
 tween wounds aseptically performed by surgeons and 
 those otherwise inflicted. In the latter category anti- 
 sepsis asserts its prerogatives, but only as subordinate 
 to asepsis. ' ' — Excerpt from Preface. 
 
 Sent post-paid on receipt of price. 
 W. B. SAUNDERS, Publisher, 
 
 925 Walnut Street, Philadelphia, Pa. 
 
NOW BEADY, VOLUME FOB 1896, 
 
 AMERICAN YEAR-BOOK OF MEDICINE and SURGERY. 
 
 Edited by GEORGE M. GOULD, A. M., M. D. 
 
 Assisted by Eminent American Specialists and Teachers. 
 
 S 
 
 <to •— 
 
 .5 Notwithstanding the rapid multiplication of medical and surgical works. 
 
 ^ still these publications fail to meet fully the requirements of the general physician^ ^ 
 
 ^ inasmuch as he feels the need of something more than mere text -books of well- S^ 
 
 5« known principles of medical science. Mr. Saunders has long been impressed ^ 
 
 ,^ with this fact, which is confirmed by the unanimity of expression from the pro- '^ 
 
 S fession at large, as indicated by advices from his large corps of canvassers. <5 
 
 bi This deficiency would best be met by current journalistic literature, but most ^ 
 
 t^ practitioners have scant access to this almost unlimited source of information, <«♦. 
 
 ^ and the busy practiser has but little time to search out in periodicals the many ^ 
 
 ^ interesting cases whose study would doubtless be of inestimable value in his :; 
 
 O practice. Therefore, a work which places before the physician in convenient k 
 
 ^ form an epitomization of this literature by persons competent to pronounce upon ^ 
 
 ^ The Value of a Discovery or of a Method of Treatment X 
 
 «i cannot but command his highest appreciation. It is this critical and judicial ^ 
 
 .^ function that will be assumed by the Editorial staff of the " American Year- 
 
 '^ Book of Medicine and Surgery." ^ 
 
 g It is the special purpose of the Editor, whose experience pecuUarly qualifies «. 
 5^ him for the preparation of this work, not only to review the contributions to (jig 
 ' American journals, but also the methods and discoveries reported in the leading § 
 ^ medical journals of Europe, thus enlarging the survey and making the M'ork ^ 
 ^ characteristically international. These reviews will not simply be a series of "* 
 S undigested abstracts indiscriminately run together, nor will they be retrospective <» 
 -6 of " news " one or two years old, but the treatment presented will be synthetic g- 
 '^ and dogmatic, and will include only what is new. Moreover, through expert * 
 ^ condensation by experienced writers these discussions will be 
 
 Comprised in a Single Volume of about 1200 Pages. 
 The work will be replete with original and selected illustrations skilfully 
 reproduced, for the most part in Mr. Saunders' own- studios established for the 
 purpose, thus ensuring accuracy in delineation, affording efficient aids to a right 
 comprehension of the text, and adding to the attractiveness of the volume. 
 Prices : Cloth, ^^6.50 net; Half Morocco, ^7.50 net. 
 
 W. B. SAUNDERS, Publisher, 
 
 925 Walnut Street, Philadelphia. 
 

 
 •/"*?'*■•'.'■*■ 
 
 ..« 
 
 ,.-•1