COLUMBIA LIBRARIES OFFSITE Hi AMU '-'.II MM '. M AHhAhl; :64116751 RC76 .B83 1 883 A pocket book of phy v':>]cal])]ackosis Columbia ®nibers;it|>x Almost unknown unless congenital, semi-lunar valves ( Regurgitation J ^ Valvular diseases of the left heart : f TIME. I Post-diastolic, presystolic. Roughening or obstruction ^ Auriculo-systolic — occurs at Mitral valves J end of diastolic period. [ Mitral direct. Regurgitation { Systolic. ™''' Roughening or obstruction i c 4. r {TIME. Diastolic at commencement of diastolic period. The quality and pitch of murmurs are not indicative of the extent of the lesion. A most insignificant lesion may be manifested by a loud murmur, while a most serious lesion may give rise to a very insignificant murmur. The best method of estimating the gravity of murmurs indicative of valvular lesion, is by noticing the degree of change in the cavity in which the murmur is generated ; and by estimating the degree of diminution of cardiac propulsive power, as manifested by a failing circulation. Aortic murmurs are more frequent in persons of middle age and advanced life than in the young. Direct injury to the valves, resulting from laborious avocations, also pro- longed high arterial tension, or atheroma, are more often the antecedents of the disease than rheumatism. This is espe- cially true of aortic regurgitation. Mitral disease is more directly the most serious complication of acute rheumatism, SOUNDS AND MURMURS. 149 or the rheumatic diathesis. The rule is, however, not unvarying. Young persons suffer from aortic disease, par- ticularly aortic obstruction, and old persons frequently pre- sent a long-standing mitral lesion. Another point of interest relates to the pitch of murmurs. Mitral murmurs, especially if recent, are usually low-pitched, blowing sounds; aortic murmurs are usually high-pitched, cooing or grating sounds. The character of the pathological deposit bears a direct relation with the pitch of the murmur. If the auriculo-ventricular or semi-lunar valves become cal- careous, or spiculae project into the circulation, the murmur may become roughened and ringing. A murmur may replace entirely the normal sound, or some portion of the normal sound may remain. In the latter case, the destruction of a valve is not so complete. Degenerations of the heart and weakness of cardiac muscular power can sometimes abolish a murmur previously distinct, the murmur reappearing if the cardiac power increases under treatment. The mitral murmurs resulting from acute rheumatic endocar- ditis may vanish in time, as the swelling subsides, and the edges of the valve again approximate normally. More com- monly, the lesion increases in direct relation with the lapse of time and the tension maintained within the ventricle. If care is taken to conserve a minimum degree of intra- ventricular tension, by constant supervision (especially of the habits of life), the rapidity of the progress of the lesion is much reduced. Care must also be observed to prevent a repetition of attacks of acute rheumatism, each of which tends to aggravate the mischief. All cardiac 7nu7iiiurs, like the cardiac sounds, can be heard at the base, and follow the law which prescribes their location of maximum ijitensity to that situation of the chest at which the cavity in which they are p7'o- duced approaches juost directly the swface of the chest. They are subject to another geiieral law, viz., that they are propa- 150 PHYSICAL DIAGNOSIS. gated in the direction of the blood curi-ent by which they are developed. Murmurs may obscure the normal sounds, but sometimes more or less of the latter may persist ; this especially occurs in diseases of the aortic valves, and in such cases one may infer a degree of valvular competency. A thrill is a purring tremor, or vibration, distinguished by palpation in the prsecordial region. Thrills may be de- veloped in the praecordial sac, and are then known as pericardial frictions. Thrills may also occur within the heart or great blood vessels. Endocardial thrills are coinci- dent with the systolic or diastolic periods. They are developed by the whirling of the blood stream over rough- nesses on degenerated valves, or at contracted valvular ori- fices, or, again, by roughnesses in the walls of the great vessels. A thrill is, therefore, developed in the same manner as a murmur, but only a small proportion of thrills are suffi- ciently violent to be sensible to palpation, so that very few audible murmurs are associated with thrills. They follow the same laws of location of maximum intensity as the audible murmurs. Both murmurs and thrills are frequently present in mitral obstruction. Thrills connected with mitral regurgitation are far from common. At the base of the sternum thrills may proceed from the aorta or the right ven- tricle. Both systolic and diastolic thrills can be recognized over the aortic region ; their presence (excluding pericardial friction) indicates atheroma, aortic dilatation or saccular aneurism. The violence of the thrill, as of a murmur, can be increased by exertion. Thrills detected in the veins of the neck indicate a narrowed venous calibre, occasionally, from pressure. CHAPTER III. MITRAL REGURGITATION. MITRAL OBSTRUCTION. TRICUSPID REGURGITATION. Mitral Regurgitation. Auscultation. This murmur is usually the result of rheumatic endocarditis. The valves are so altered that they cannot completely close the auriculo- ventricular orifice. When the process of inflammation affects the mitral valve, the recoil of blood within the ventricle dur- ing the systole impinges violently upon it, and the mischief is thus increased. To differentiate a mitral murmur we pro- ceed as follows : Having heard a murmur at the base of the lung, auscult the aortic cartilage and then the apex. If the murmur be generated by regurgitation through the mitral valve, the murmur will be loudest at the apex. The next step will be to time the murmur, which can be done by noting that it is synchronous with the apex beat, or the carotid pulse \ in other words, we time it as we would the first sound. Frequently, in initial lesions of the mitral valve in acute rheumatism, the murmur will not be transmitted outside the apex; but if there is much regurgitation, the murmur will be transmitted in the direction of the blood current, e. g. , back into the auricle, through the pulmonary vein into the lungs. The murmur can be traced to two sites on the chest, one the axilla (since the tissues covering the chest wall are thinnest at this point), and the other at the angle of the left scapula and the vertebral column. In the axilla always listen above the line of the apex beat ; a recent murmur can often be heard at this point which may not be transmitted as far as the scapula. Sometimes the amount of swelling is only suffi- cient to thicken the first sound, or develop a slight murmur, heard at the apex and for a short distance outside ; in this 151 152 PHYSICAL DIAGNOSIS. case the amount of regurgitation is slight, and if the lesion occur in a case of acute rheumatism, the murmur may disap- pear after a time. A moderate lesion, if associated with much calcareous degeneration, may give origin to a murmur which may be transmitted to a great distance. Sometimes, when there is considerable regurgitation, mitral murmurs may be transmitted to the angle of the right scapula or right axilla. The murmur of mitral regurgitation may also be heard at the ensiform or the aortic cartilages, or over the auricle, but is evidently not so pronounced as in the line of the blood cur- rent, by which the murmur is developed. The pulmonary artery second sound is often accentuated, and the aortic sec- ond sound weakened. Exceptions. Mitral regurgitation may exist in cases of ex- treme dilatation or degeneration of the heart muscle, and yet so little blood may regurgitate through the mitral valve at each systole, that a murmur is not developed. In these cases a murmur may return as the heart systole improves under rest and treatment. Sometimes a murmur may be heard in the erect but not in the recumbent posture, because of the in- creased action of the heart when the patient is standing or walking. In all these cases evidences of venous congestion prevail. Effects of Alitral Regurgitatio?i. The diagnosis of a mitral regurgitation is incomplete unless the study is interlaced with a consideration of the local and general consequences of val- vular cardiac disease, and the gravity of the lesion must be deduced from the effects upon the cardiac substance and from the signs of falling circulation in the general system. The local effects of valvular disease find their primary expression upon that cavity of the four which is most directly affected by the abnormal circulation ; afterward the adjacent cardiac cavities become more or less involved. The first demand of mitral insufficiency is an increase of propulsive power in the MITRAL REGURGITATION. 153 ventricular systole. Hypertrophy is the response, but in most cases hypertrophy is inadequate to remedy the lesion permanently, or even for any considerable period. This arises, partly, from the fact that hypertrophy tends to force the blood through the abnormally patulous orifice, at the same time that it increases the force of the current into the aorta. The largest amount of blood naturally passes into the aorta, since the aortic is the larger orifice — and for a time the hypertrophy is compensatory. But all the while the in- creased power of the systole tends to increase, little by little, the regurgitation and widen the abnormal valvular orifice. It soon transpires that the aorta is inadequately filled — a condition fruitful of evil, because the coronary arteries are imperfectly filled by the imperfect aortic systole, and dilatation with fatty degeneration ensues. How rapidly, will depend on the de- gree of mitral lesion. The left auricle, in i- Moderate Enlargement of Left Ventricle. 2. M early Normal Right Ventricle. (Drawn from cases of long standing Specimen.) lesion, becomes hypertrophied and dilated ; next ensues repletion of the pulmonary vein, with subsequent congestion of the lungs, with hypertrophy, and dilatation of the right ventricle. Enlargement of the right auricle occurs in its turn, with a more or less pronounced repletion of the entire venous system throughout the body. The results of mitral disease upon the system at large in- CARDIAC LESIONS IN MITRAL REGURGITA- TIONS. 154 PHYSICAL DIAGNOSIS. elude congestion of the liver and kidneys as the most import- ant lesions in the chain. The liver is. enlarged, and may- pulsate synchronously with the systole. Mesenteric conges- tion, with symptomatic indigestion from imperfect glandular functional activity, tympanites, ascites, hemorrhoids, are all incidents of this sketch. The renal congestion manifests itself by albuminuria, followed by anasarca, which com- mences in the feet and legs ; a reverse of initial kidney dropsy, which begins in the cellular facial tissues. General anasarca is succeeded by effusions into the serous sacs, ascites, hydrothorax. Hydrothorax is either bilateral, or, if unilate- ral, it is usually disposed upon the left side of the chest, perhaps, because the enlarged heart presses upon the internal thoracic veins on the left side. Since both hepatic, mesen- teric and renal congestion is evidenced by symptoms — query : what are the symptoms of pulmonary engorgement? The reply is, intercurrent attacks of haemoptysis. Moreover, the pulmonary congestion is a fruitful harbinger of catarrhs, excited by atmospheric influences ; so we add to the list bronchitis, more or less grave, as a frequent complication. Later in case oedema of the lungs occurs, as little by little the hepatic and renal activity is reduced, and the circulation is stored with imperfectly elaborated or eliminated nitrogenous materials ; the suiferer is consequently liable to any form of serous inflammation, and finally to a possible death from uraemia. Te?'minations of Mitral Regurgitation. The grave symp- toms linked with mitral disease indicate that its dura- tion must be largely measured by the number of complica- tions, and the rapidity of their advent. Death, it is true, may suddenly terminate the scene, as the result of cardiac failure, but more frequently the^patient succumbs to some of the incidental complications. The procession of complica- tions is influenced by the avocations of the patient, the MITRAL REGURGITATION. 155 presence or absence of syphilitic poisoning, the alcoholic habit, or the recurrence of endocarditis. The severity of the lesion, of course, has a primary and potential influence. Age is also a factor of peculiar import. Even serious mitral lesions in the very young are modified and sometimes vanish as maturity approaches. Inspection and Palpation in Mitral Regurgitation. These AREA OF CARDIAC DULLNESS IN A CASE OF MITRAL REGURGITATION. (From Photograph.) methods can be practiced simultaneously. The apex cardiac impulse is concentrated and lower than normal, but not usually so low as in disease of the aortic valves. When dila- tation exists the impulse can be distinguished more outward and to the left than downward. The impulse is diffused, often undulating, because more of the ventricular wall impinges against the chest. 156 PHYSICAL DIAGNOSIS. Percussion in Mitral Regurgitation. There is never as much hypertrophy as in aortic disease, but dilatation occurs early. The transverse dullness is increased in proportion to the dilatation of the left ventricle ; the vertical in pro- portion to the hypertrophy. Mitral Obstruction. Auscultation. The auriculo-ven- tricular valvular orifice may also be roughened or obstructed. The form of obstruction is so uniform that it has suggested the possibility that the lesion is congenital, rather than the result of endocarditis. The question is plausible enough to lead one carefully to study the history of each case of mitral obstruction. There is no doubt, however, that, in common with other lesions, it usually arises from endo- carditis* The shape of the mitral orifice merits special notice. The average circumference of the normal orifice is about four inches ; the form is oval, with correspondingly narrow long diameter. In disease, this orifice is seriously modified. The chorda tendineae and the valve may be thickened, stiffened into a rigid mass, and the leaflets fused so as to form a more or less conical tube, its smaller extremity opening into the ventricle ; sometimes the orifice is extremely small, slit-like or '' button-hole," admitting only the little finger, or even a pen handle through it. The valve may be encrusted with calcareous salts causing roughening of the auriculo ventricu- lar orifice without much obstruction. The effect on the auriculo-ventricular aperture is, of course, opposite to that of regurgitation. Presystolic murmur is associated with both stenosis and roughening, but is best developed if stenosis exists. Dr. Flint has very concisely set forth the cardinal points connected with pre-systolic murmur, as follows : — "(ist.) There are two varieties of murmur, rough and soft. MITRAL OBSTRUCTION. 157 *^ (2d.) The rough murmur is vibratory or blubbering. It is imitated closely by producing with the expired breath sono- rous vibrations of the lips or of the tongue. The softness of the second variety is bellows-like, resembling that of other soft cardiac murmurs. This murmur may vary in pitch and intensity, but as a rule it is low and weak. ''(3d.) The rough murmur is due to the vibrations of !he curtains of the mitral valve caused by the passage of the blood from the auricle into the ventricle. The soft murmur, like other bellows murmurs, may be due to contraction of the orifice through which the blood passes, or to the roughness of the surface over which it flows. ''(4th.) A rough presystolic murmur in general denotes a mitral obstructive lesion ; the obstruction due to adhe- sion of the mitral curtains leaving a contracted orifice, the curtains remaining flexible. A presystolic soft murmur de- notes either a contracted orifice, or roughness of the endo- cardial membrane. "(5th.) A rough presystolic murmur exceptionally is pro- duced when there is no mitral lesion, aortic regurgitation existing whenever the murmur is thus produced.. The pro- duction of this murmur without mitral lesion may be ex- plained by the physical conditions incident to aortic injury taken in connection with the mechanism of the murmur. "(6th.) A rough presystolic murmur is not always present in connection with contraction of the mitral orifice, and by reference to the physical conditions, together with the mech- anism of the murmur, its absence in certain cases may be satisfactorily explained." The time or the rhythm with which the murmur occurs has been variously designated by the terms, presystolic, auriculo- systolic, post-diastolic, or simple mitral obstructive murmur. K 158 PHYSICAL DIAGNOSIS. -ist sound. -Long presystolic murmur -Diastolic period. -2d sound. -Shorter presystolic murmur. — 2d sound. -ist sound. -Long pause. -Diastolic sound. -Short pause. The murmur may include the entire diastolic period, if the obstruction is ex- treme ; on the other hand, it may only occur at the end of the diastole, imme- diately before the systole, thus meriting two of the terms, post-diastolic or pre- systolic. Custom has ap- plied the term diastolic to the murmur of aortic regurgitation ; in reality this murmur occurs at the com- mencement of the diastole, so the best term for the murmur of mitral obstruc- tion or roughening is pre- systolic. The facts are, that at the end of_ the diastolic period both auricles contract, to express from their cavities the last remnants of blood and complete the filling of the ventricles. If mitral obstruction or roughening exist, it is evident that the murmur thereby generated will occur just before the systole, before the apex or carotid impulse, after the second sound. The murmur has in most cases two centres of equal intensity. The one corresponding with the auricle, the other with the apex, to which it is carried by the blood cur- rent. It must be remembered that at the time the murmur is produced the apex is not applied to the chest wall until the systole occurs. Perhaps this explains the fact that the mur- mur is best heard a little within the line of the apex beat ; whereas in mitral regurgitation with systolic murmur, the sound is conducted to the ear when the ventricle is in approx- imation with the chest wall. A mitral murmur may some- — Systolic sound. MITRAL OBSTRUCTION. 159 times be heard just outside the apex, because the ventricle may be both hypertrophied and dilated. Presystolic murmur is localized, and is not often transmitted from the apex, be- cause the blood current is immediately diverted into the aorta by the ventricular systole. Thus it happens that the murmur is, as it were, clipped or cut off short at the apex. In regard to the cases in which there is a murmur with a centre of maximum intensity over the auricle, we must remem- ber that in health the left auricle is placed beneath the right, so that in cases of simple roughening of the auricular surface of the mitral valves the murmur may not be loudly heard over this cavity. But if true stenosis exist, one of the earliest consequences will be the enlargement, by hypertrophy and dilatation, of the left auricle, and the murmur will then be heard over the area included by the auricle. Concerning the exceptional transmission of presystolic murmurs into the axilla, or posteriorly, as reported by Dr. Andrews,"^ we recognize that such transmission is a possible, but an unlikely event. In his cases there may have been pulmonary consolidation, or pleural adhesions, or the mur- murs may have been exceptionally loud. In mitral obstruction there is always a marked accentuation of the pulmonary artery second sound, due to increased blood pressure in the pulmonary artery. The first sound may also become so valvular that it can easily be confounded with the pulmonary second sound, were we not guided by the ventric- ular impulse. Two explanations of this accentuation of the first sound may be offered. By one, we note that the blood pressure in the right ventricle is increased relatively with the elevation of the blood pressure in the pulmonary circulation, so that the tricuspid valves close with an intensified sound, audible over both ventricles. By the other hypothesis, if the obstruction be extreme, very little blood reaches the cavity of *St. Bartholomew's Hospital Report, 1877. 160 PHYSICAL DIAGNOSIS. the left ventricle at the time of the systole. We must, there- fore, subtract from the first sound the blood element, and a portion of the muscular element, leaving either a valvular sound, as heard in typhoid fever, or a dull, blurred sound, as the valves may be much more thickened than roughened. While the first sound is often accentuated, it is also frequently irregular, without sufficient cardiac degeneration to account for the irregularity. Reduplication of the first and second sounds is an occa- sional' concomitant, explicable by the fact that the over- ^ filled right ventricle and pulmonary artery lead to right ventricular, or pul- monary artery sys- tole, prior to left 3 ventricular or aortic systole. Disappearance of Presystolic Murmur. In certain instances CARDIAC ENLARGEMENT IN MITRAL OBSTRUC- the murmur of prC- TION. I. Enlarged Left Auricle. 2. Enlarged Right Ventricle. systolic rhythm may 3. Left Ventricle. Drawn from Specfmen. ~ Vauish, tO reappear, perhaps, in a few days. In these cases the auriculo-ventricular opening is apt to be very small, and the thickened valves are not traversed by sufficient blood to occasion enough vibra- tion to produce a murmur. Position also materially influences the development of murmur in mitral obstruction. It can be heard in the upright, but not in the recumbent posture; sometimes the reverse is true. Rest in bed may render a presystolic murmur inaudible. MITRAL OBSTRUCTION. 161 Double Mitral Murmur. Mitral obstruction and regurgi- tation, with double see-saw murmur, is not infrequent. In these cases the presystolic murmur often merges into the systolic murmur, which is apparently prolonged. Effects of Mitral Obstruction. Dilatation and hypertrophy of the auricle may become extreme, owing to long continued and serious mitral obstruction. The normal prsecordial area may be filled by the dilated auricle, and the left ventricle may be correspond- ingly depressed and displaced. In some cases the enlarged auricle presents a tumor causing bulg- ing of the upper part of the prgecordial area. The hyper- trophy and dilatation exceed the similar condition in mitral regurgitation. In mitral obstruction outline of cardiac dullness in a case we often find very marked hypertrophy and dilatation of the right ventricle, and, for a time, better compensation exists than in mitral regurgitation. Inspection in Mitral Obstruction. The outline of the left ventricle is normal. The prsecordia is often enlarged over its upper portion and to the right of the sternum, instead of OF MITRAL OBSTRUCTION. (From a Photograph of a child, set. 8 years.) 162 PHYSICAL DIAGNOSIS. the ventricle increased downward and to the left, observed in mitral regurgitation or aortic disease. Palpation in Mitral Obstruction. Marked irregularity is a frequent symptom. Impulse at left apex feeble ; impulse of right ventricle at xiphoid cartilage increased. When dilata- tion occurs, impulse becomes feeble. Percussion in Mitral Obstruction. Transverse area of dull- -^ ENLARGED CARDIAC AREA IN A CASE OF MITRAL OBSTRUCTION. (From Photograph.) ness often increased to right of sternum and also above the fourth rib to the left of the sternum. Ter?7iinatio7is in Mitral Obstructio7i. Left auricular and right ventricular hypertrophy is more thoroughly compen- satory than in cases of mitral insufficiency, and the compen- sation lasts longer. But transitory respiratory embarrassment, due to variations of the pulmonary circulation, is more fre- TRICUSPID REGURGITATION. 168 quent than in mitral regurgitation. The associated dyspnoea becomes more severe if the compensative power is exceeded, because the lesion is, de facto, more grave. The pulmonary- capillaries are continually overcharged with blood, so that slight increase in pulmonary blood pressure produces serious effects. Bronchitis of asthmatic type and cardiac asthma are frequent concomitants, and so is haemoptysis and pulmonary congestion. The general series of phenomena outlined in the clinical history incident to mitral regurgitation find a parallel in the history of mitral obstruction. Palpitation and Dyspnoea in Mitral Obstructio7i are more common than in other forms of organic heart disease. The causation is explained chiefly by venous repletion of the lungs and right ventricle, and partly by variations in the pulmonary vaso-motor tonus. The Prognosis in Mitral Obstruction is controlled by the preponderance of hypertrophy over dilatation, and this is true of the prognosis of valvular disease in general. The Pulse of both Mitral Obstruction and Regurgitation is apt to be small in volume, but in mitral obstruction the percussion wave is smaller than in mitral regurgitation, because there is less hypertrophy of the left ventricle. The pulse is also fre- quently very irregular in rhythm, especially during attacks of pulmonary congestion. The irregularity in these cases is probably due to a want of synchronous action between the right and left ventricles, due to the repletion of the former. Tricuspid Regurgitation.* This is possible as the re- sult of a primary lesion, but is more frequent secondarily, in consequence of {a) stenosis or obstruction of the pulmonary orifice; (^) valvular diseases of the left side of the heart ; (^j from various diseases of the lungs, especially emphysema, * Tricuspid stenosis is very rare. A valuable paper on this subject may be found in the London Lancet for April and May, 1881, by Dr. Bedford Fenwick. 164 PHYSICAL DIAGNOSIS. hypertrophic or atrophic, and cirrhosis; {d) from simple dilatation of the right ventricle in consequence of fatty de- generation ; (iuit 175 175 176 Carotid Pulsation 194 178 Cavities of the nature of Ab- 173 scesses 78 167 " by Bronchial Dilatation... 77 170 " Phthisical 78 158 " Rales in 98 204 " Mistaken for Pneumo- 143 thorax 134 103 Corrigan Pulse 169 105 Cracked-pot Resonance 80 104 172 Death. Causes of in Aortic 72 Disease 171 203 " " Mitral 154, 163 Degeneration. Dilatation. Car- 50 diac 143, 195 216 Diastolic Murmurs r68 118 " Table of 148 66 iJisappearance of Mitral Mur- 81 mur 152 47 " Presystolic Murmur 160 85 " Tricuspid " 164 61 Dropsy. Cardiac and Renal... 142 156 " in Mitral Disease 154 151 Dyspnrea. Cardiac, 35 I 163, 186, 197, 220 31 Egophony 121 Embolism. (See Thrombosis). 89 Emphysema. Atrophic <^o Tib 226 INDEX. Emphysema. General Pul- monary 83 " Respiratory Percussion of, 138 " Unilateral 89 Empyema 129 Epigastric Pulsation. Table of causes of 88 Etiology of Cardiac Disease, 141, 143 Fatty Degeneration 199 Feeble Breathing in Advancing Consolidation 67 " Summai-y of causes of,.., 68 Fremitus. Friction 215 " Vocal, in Acute Catarrhal Pneumonia 51 " " Absent 118 " " in Advancing Con- solidation 69 " " in Croupous Pneu- monia 48 " " in Incipient Phthisis 62 " " Normal 37 Friction Fremitus 215 " Sound 216 Gangrene around Cavities. 76 Hsemothorax 1 30 Heart. Dilatation of the... 143, 195 " Dimensions of Healthy... 223 " Tables of Displacements of the 203 " Functional Disease 183 " Hypertrophy, or Dilata- tion in Valvular Dis- ease 153, 161, 164, i7o " Irregular, Intermittent 183 " Pain (see Angina). " Palpitation 85 Hemorrhagic Infarction 72 Hydrothorax 1 24 Hypertrophy. Cardiac 142, 193 " Eccentric or Dilated 193 Hypostatic Congestion 72, loi PAGE Inspection in Acute Pericarditis 217 " " Pleurisy.... 113 " Advancing Consolidation 69 " Emphysema 86 " Incipient Phthisis 63 " Mitral Regurgitation 155 " " Obstruction 161 " Tricuspid Regurgitation.. 166 " Unilateral Enlargement... 89 " Rules for performing 39 Intercostal Neuralgia 75, 123 Irregularity of the Heart. ...183, 162 Mediastinal Disease 135 Mensuration. Rules for per- forming 38 " in Advancing Consolida- tion 71 " in Pleural Effusions 114 " in Unilateral Enlarge- ment 89 Metallic Tinkle in Pneumotho- rax 132 Mitral Regurgitation 151 " Effects of 152 " " Terminations of 154 " Obstruction 156 " " Terminations of 162 Movements of Intercostal Tis- sues 87, 113, 116 Murmurs. Definition and Char- acteristics of 147 " Aortic Stenosis 148, 167 " Regurgitant. 148, 168 " Cardiac 147 " Conduction of 149 " due to Aortic Valv. Di-^. contrast with Aneurism, 172 " due to Aneurism 175, 176 " " Atheroma 172 " Arterial 181 " Double Mitral 161 " Functional 180 " Mitral Obstructive... 148, 156 " " Regurgitant... 148, 151 " Tricuspid 164 " Venous 181 INDEX. 227 PAGE Neuralgia (See Intercostal). Neurosal Cardiac Disease (See Angina). QEdema of the Lungs loi Palpation. Rules for Perform- ing 37 " in Acute Pleurisy liS " in Croupous Pneumonia.. 48 " in Mitral Regurgitation... 155 " in Mitral Obstruction 162 " in Pericarditis 215 *' in Tricuspid Regurgita- tion 166 Palpitation of the Heart 185 Paracentesis of Pericardium 221 Pectoriloquy 82 Percussion. Auscultatory 30 " Rules for Performing 23 " Respiratory 29 " of Cavities 79 " over the Clavicle 30 " in Acute Pleurisy 116 " in Acute Catarrhal Pneu- monia 50 " in Advancing Consolida- tion 64 " in Croupous Pneumonia.. 46 " in Emphysema 84 " in Incipient Phthisis 61 " in Mitral Regurgitation,.. 156 " in Mitral Obstruction 162 " in Pericarditis 213 " in Tricuspid Regurgita- tion 166 Pericarditis. Acute 213 " Chronic 220 " Differential Diagnosis 218 " Pulse in 216 " Terminations of 219 Pericardium. Paracentesis of.. 221 Phthisis. Advancing Consoli- dation, or Chronic 64 " Early Diagnosis of 61, 64 *' Formation of Cavities in 76-79 PAGE Phthisis. Fibroid 56, 70 " Interstitial, or Cirrhosis... 56 " Morphology of 53 " Situation at which devel- oped "55 " Syphilitic 56 " Venous and Arterial Mur- murs in 182 Phthisical or Flat Chest 40 Pigeon Breast 41, 88 Pleurisy. Acute iii " Chronic 125 " Differential Diagnosis 123 " with Effusion 114 " Relation to Phthisis 55 Pleurodynia. (See Intercostal Neuralgia). Pneumothorax 131 " Auscultatory Percussion in 132 Pneumonia. Acute Catarrhal,. 50 " Croupous, Acute Lobar... 44 " Desquamative 54 " Terminations in Acute Catarrhal 51 " Terminations in Croup- ous 49 Presystolic Murmurs. Table of 148, 156 Pulmonary Diseases. Princi- ples of Classification 43 Pulse. (See Sphygmograph). " Dicrotism of 206 " Gaseous 205 " Inequality of , 206 Rachitic Chest 41, 88 Riles. Classification of 92 " Diagnosis between Pleu- ral and Intra-Pul- monary 96 " Moist or Mucous, Sub- crepitant 93 " Sibilant and Sonorous, Crepitant 94 " Friction 95 " Significance of 97 " in Acute Catarrhal Pneu- monia 51, 98 228 INDEX. PAGE Rales in Croupous Pneumonia 47, 98 " in Acute and Chronic Bronchitis 98 " in Capillary Bronchitis... 100 " in Cavities 98 " in Hypostatic Conges- tion loi, 72 " in Incipient Phthisis.... 62, 97 " in CEdema loi Reduplication of Sounds 184 Renal Disease in Etiology of Atheroma 143 " in Etiology of Cardiac Dropsy 142 Resonance. Cracked-pot 80 " Definition of 25 " Exaggerated 28 " Influence of the Tissues on 28 " Normal Pulmonary 27 '* " Vocal 36 " Over the Clavicle 30 " Vocal in Acute Pleurisy., 119 " " in Advancing Con- solidation 69 " " in Acute Catarrhal Pneumonia 51 " " in Croupous Pneu monia 48 " " in Cavities 82 " " in Incipient Phthisis 62 Respiratory Percussion 138 " Murmur. Auscultation of Normal 30 " " Cheyne Stokes 105 " " Normal Dis- tribution of... 34 PAGE Respiratory Murmur. Rhythm in, 74, 61, 67, 31 Rheumatism in the Etiology of Cardiac Disease 141, 213 Rhythm in Advancing Con- solidation 67 " Variations of Cardiac, 183, 185 Sounds. Definition of Car- diac 1 44 •' Table of Feeble and Ac- centuated 205 Syphilitic Phthisis 56 Syphilis in relation to Aneurism, 143, 173. See also Arterial Lesions 143, 167 Sphygmograph. Use of 207 Systolic Murmurs, 150, 164, 167 " Table of 148 Stethoscope 36 Tension. Arterial 204 Thrills 150 " in Aortic Aneurism 174 " Pericardial 215 Thrombosis. Arterial 192 " Cardiac 190 Tricuspid Regurgitation 163 " Eff"eclsof 164 Tuberculosis. Acute Miliary. 56, 106 Tuberculous Thorax 40 Tumors of the Mediastinum.... 136 Valvular Disease. Causes of... 141 Venous Murmurs 181 " Pulse 165 Voice. Auscultation of 36 " Whispered 37 THE PQUIZ-COMPENDS? A NEW SERIES OF COMPENDS FOR STUDENTS. For Use in the Quiz Class and when Preparing for Examinations. Price of Each, Bound in Cloth, $1.00 Interleaved, $1.25. Based on the most popular text- books, and on the lec- tures of prominent professors, they form a most complete set of manuals, containing information nowhere else collected in such a condensed, practical shape. The authors have had large experience as quiz masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. The arrangement of the subjects, illustrations, types, etc., are all of the most improved fomi, and the size of the books is such that they may be easily carried in the pocket. No. 1. ANATOMY, (niustrated.) A Compend of Human Anatomy, By Samuel O. L. Potter, m.a., m.d., U. S. Army. With 63 Illustrations. " The work is reliable and complete, and just what the student needs in reviewing the subject for his examinations." — The Physi- cian and StirgeorCs Investigator , Buffalo, N. Y. "To those desiring to post themselves hurriedly for examination, this little book will be useful in refreshing the memory." — New Orleans Medical and Surgical Journal: "The arrangement is well calculated to facilitate accurate memo- rizing, and the illustrations are clear and good." — North Carolina Medical yournal. Nos. 2 and 3. PRACTICE. A Compend of the Practice of Medicine, especially adapted to the use of Students. By Dan'l E. Hughes, M.D., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliar}- Passages, Liver, Kidneys, etc., and General Diseases, etc. Part II. — Diseases of the Respiratory System, Circu- latory System, and Nervous System ; Diseases of the Blood, etc. *^* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the THE ? QUIZ-COMPENDS Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and includ- ing a number of new prescriptions. They have been compiled from the lectures of prominent Professors, and reference has been made to the latest writings of Pro- fessors Flint, Da Costa, Reynolds, Bartholow, Roberts and others. " It is brief and concise, and at the same time possesses an accu- racy not generally found in compends." — ^as. 31. French, M.D., Ass't to the Prof, of Practice , Medical College of Ohio, Ciftcinnati. " The book seems very concise, yet very comprehensive. . An unusually superior book." — Dr. E. T. Bruen, Demonstrator of Clinical Medicine , U'niversity of Pennsylvania, " I have used it considerably in connection with my branches in the Quiz-class of the University of La." — f. H. Bemiss, New Orleans. " Dr. Hughes has prepared a very useful little book, and I shall take pleasure in advising my class to use it." — Dr. George W. Hall, Professor- of Practice, St. Louis College of Physicians and Surgeons. No. 4. PHYSIOLOGY. A Compend of Huinan Physiology, adapted to the use of Students. By Albert P. Brubaker, m.d.. De- monstrator of Physiology in Jefferson Medical College, Philadelphia. " Dr. Brubaker deserves the heartj' thanks of medical students for his Compend of Physiology. He has arranged the fundamental and practical principles of the science in a peculiarly inviting and accessible manner. I have already introduced the work to my class." — Maurice N. Miller, M.D., Instructor in Practical His- tology , formerly Dejnonitrator of Physiology , University City of New York. " ' Quiz-Compend' No. 4 is fully up to the high standard estab- lished by its predecessors of the same series." — Medical Bulletin, Philadelph ia . "I can recommend it as a valuable aid to the student." — C. N. Pllinwood, M.D., Professor of Physiology, Cooper Medical Col- lege, San Francisco. " This is a well written little book." — London Lancet. No. 5. OBSTETRICS. A Compend of Obstetrics. For Physicians and Students. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women, in Starling Medical College, Columbus. Illustrated. " We have no doubt that many students will find in it a mosl val- uable aid in preparing for examination." — The American Journal of Obstetrics. " It is complete, accurate and scientific. The very best book 01 its kind I have seen." — jf. S. Knox, M.D.., Lecturer on Obstetrics Rush Medical College, Chicago. THE ? QUIZ-COMPENDS ?. " I have been teaching in this department for many years, and am free to say that this will be the best assistant I ever had. It is ac- curate and comprehensive, but brief and pointed." — Prof. P. D. Yost, Si. Louis. No. 6. MATERIA MEDICA. A Compend on Materia Medica and Therapeutics, with especial reference to the Physiological Actions of Drugs. For the use of Medical, Dental, and Pharma- ceutical Students and Practitioners. Based on the New Revision (Sixth) of the U. S. Pharmacopoeia, and in- cluding many unofficinal remedies. By Samuel O. L. Potter, M.A.jM.D., U. S. Army. " I have examined the little volume carefully, and find it just such a book as I require in my private Quiz, and shall certainly re- commend it to my classes. Your Compends are all popular here in Washington." — John E. Brackett, M.D., Professor of Materia Medica and Therapeutics , Howard Medical College, Washington. " Part of a series of small but valuable te.xt-books. . . . While the work is, owing to its therapeutic contents, more useful to the medical student, the pharmaceutical student may derive much use- ful information from it." — N. Y. Pharmaceutical Record. No. 7. CHEMISTRY. A Compend of Chemistry. By G. Mason Ward, m.d.. Demonstrator of Chemistry in Jefferson Medical Col- lege, Philadelphia. Including Table of Elements and various Analytical Tables. " Brief, but excellent. ... It will doubtless prove an admirable aid to the student, by fixing these facts in his memory. It is worthy the study of both medical and pharmaceutical students in this branch." — Pharmaceutical Record, Nezv York. No. 8. VISCERAL ANATOMY. A Compend of Visceral Anatomy. By Samuel O. L. Potter, m.a., m.d., U. S. Army. With 40 Illustrations. *:{:* This is the only Compend that contains full descriptions of the viscera, and will, together with No. i of this series, form the only complete Compend oi Anatomy published. No. 9. SURGERY. Illustrated. A Compend of Surgery; including Fractures, Wounds, Dislocations, Sprains, Amputations and other opera- tions, Inflammation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Eye, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., with 43 Illustra- tions. 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The page headings are so indexed that the reader is enabled to find at once the disease wanted ; its synonyms, classification, varie- ties, description, etc., with the course of treatment recommended by the best authorities, and is referred, by number, to the several prescriptions that have proved most efficacious. These prescrip- tions are also arranged so that they can be easily referred to, with directions how to use them, when to use them, and what diseases they are generally used in treating. The directions for cooking foods and preparing poultices, lotions, etc., are very full. The work will be found specially useful to students and young physi- cians. ROBERTS' PRACTICE OF MEDICINE. Recommended as a Text-book at University of Pennsylvania, Long Island College Hospital, Yale and Harvard Colleges, Bishop' s College, Montreal, University of Michigan, and over twenty other Medical Schools. A HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. By Frederick T. Roberts, m.d., m.r.c.p.. 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