:'•■ C^J in ti|]? (Eitg of Npui fork (Unllrgr nf ^baBtrtauB mih ^urgrouB Ifram tljp ICibrarii nf aiI)urri)tU (Harmalt. M. i. ^rfBpntpb by tijr Exlpntr (Cluli of Npui ^nrk • ■'^:::^Y^ :it ^ ■^^s '■*>v ■'-X'^e^' ■r^^^^^ ^r-^^i^^; .,V\ :nV «5 ^ T^iizJ /-T" J^^i^. A HANDBOOK OF Physical Diagnosis OF Diseases of tlie Organs of Respiration and Heart, and of Aortic Aneurism BY R. C. M. PAGE, M.D., Professor of General Medicine and Diseases of the Chest in the New York Polyclinic ; Visiting Physician to St. Elizabeth's Hospital, the Polyclinic Hospital, and the North Western Dispensary, Department of Diseases of the Heart and Lungs ; Member of the New York Academy of Medicine ; Hono- rary Vice-President of the Congress held in Paris, 1888, for the Study of Tuberculosis, etc., etc. mixtX ^Axtion NEW YORK: J. H. VAIL & CO., 21 ASTOR PLACE 1891 Copyright by R. 0. M. PAGE, M.D. 1889. PRESS OF THE rUIlLISHERS' I'RINTING COMPANY, 157-159 WILLIAM STREET, NEW YORK. ALFRED L LOOMIS, M,D., LL.D., WHOSE THOROU&H AND SYSTEMATIC TBACHIHG-^ AS WELL AS MAISi Y ACTS OF KINDNESS, ARE GRATEFULLY REMEMBERED, IS RESPECTFULLY DEDICATED BY THE AUTHOR 3748? PEEFACE f Iisr compliance with the requests of students this vohime is now placed before the medical profession. In it I have endeavored to treat the important subject of Physical Diagnosis from a logical standj^oint, — the deductions in each case being drawn chiefly from j)er- sonal observation. By this means I have, in many in- stances, furnished the all-impOrtant missing links that necessarily occur in a mere printed list of physical signs, however ingeniously arranged. The student is thus saved much valuable time that would otherwise be lost in attempting to supply those links unaided. Besides a consideration of the physiology and normal anatomy of the organs involved, brief mention of eti- ology and pathology has been found necessary in many cases, as well as the proper classification of disease. There is but little original to be offered at present on the subject of Physical Diagnosis, but whenever I have/thought that I had cause to differ with even the most eminent writers on this subject, I have not hesi- tated, with due resjDect to them, to do so. To Dr. Henry Macdonald, lol East 31st Street, IS'ew vi PREFACE. York City, I am greatly indebted for the illustrations, most of which are original and copied from life, or path- ological specimens. R C. M. Page, M.D. 31 West 38rd St., New YpRK City May, 1889. COI^TEI^TS, CHAPTER I. The Chest in Health— Regions— Methods of Physical Ex- amination — Inspection —Palpation — Fremitus — Per- cussion — Palpatory Percussion — Quality of Sound its most Important Property, as compared with Pitch, Duration and Intensity — Auscultation — Normal Res- piratory Murmur — Normal Pectorophony, or Vocal Resonance over the Chest — Other Methods of Physical Examination — Succussion — Auscultatory Percussion — Autophonia — Phonometry 1 CHAPTER II. Diseases in which the Convection of the Breath and Voice Sounds may be Obstructed in the Bronchial Tubes, and Refracted in the, Lungs as much as, or more than, in Health, with Corresponding Diminution or Sup- pression of Fremitus, Respiratory Murmur, and Pec- torophony — Bronchitis — Adventitious Sounds — Asth- ma — Emphysema — Pulmonary Congestion and CEdema — Certain Forms of Atelectasis (Apneumatosis) . . 35 CHAPTER III. Diseases in which the Breath and Voice Sounds are Con- ducted with more Force than in Health with Corre- sponding Inci'ease of Fremitus, Respiratory Murmur, and Pectorophony — Bronchial Breathing — Broncho- phony— Solidification of Lung Tissue — Pneumonia — viii CONTENTS. PAGE Pulmonary Consumption— Cancer— Hydatid Disease— Hfemorrhagic Infarction— Pulmonary Hemorrhage . 69 CHAPTER IV. Diseases in which the Breath and Voice Sounds are Inter- rupted in their Transmission to the Chest Walls with Consequent Diminution or Absence of the Fremitus, Respiratory Murmur, and Pectorojihony — Pleurisy — Thickened Pleura — Pleuritic Effusion— Pyothorax or Empyema — Hydrothorax — Pneumothorax — Htemo- thorax — Pneumo-hydrothorax 135 CHAPTER V. Summary of Adventitious Sounds — Classification of Rales — Friction Sounds — Splashing Sounds — Changes Pro- duced by Disease in the Respiratory Murmur and Vo- cal Resonance — Pectorophony and Pectoriloquy . . 159 CHAPTER VI. The Heart — Outline on the Chest Walls — Position of the Valves — Normal Sounds — Valvular Lesions — Endocar- dial Murmurs, Organic and Functional— Mitral Mur- murs — Pericardial Murmurs — Intra-ventricular Mur- nmrs — Tricuspid Murmurs — Aortic Murmurs — Venous Hum — Pulmonic Murmurs — Antemic Murmurs — Endo- carditis — Pericarditis — Hydropericardium — Myocar- ditis—Hypertrophy — Dilatation — Fatty Heart — Atro- phy — Exophthalmic Goitre — Angina Pectoris— Cardiac Diseases that Cause Sudden Death — Functional Dis- eases — The Sphygmograiih — Aortic Aneurism . . 183 PHYSICAL DIAGNOSIS. CHAPTER I. THE CHEST IN HEALTH. Physical Diagnosis is the art of distinguisMng health from disease, and one disease from another by means of the physical signs presented in each case. It approaches nearer to an exact science than any other branch, and may truly be termed the mathematics of medicine. It embraces various methods of examina- tion, including the use of instruments to be hereafter described. The Physical Signs of health, as well as of disease, are those that are to be recognized by the examiner's special senses, particularly sight, touch and hearing. There are certain physical signs characteristic of health and others that belong respectively to individual dis- eases. In order to understand the physical signs of disease it is evidently necessary first to know them in health. Then, by the application of principles of well-known physical laws, a logical and correct conclusion may be arrived at in each case, which is more reasonable than 2 PHYSICAL DIAGNOSIS. to attempt to commit isolated facts to memory, only to be forgotten. For tlie sake of convenience the chest walls are marked ont into different regions, the limits of which, though arbitrary, should always be made with due re- gard to the anatomy of the underlying thoracic organs. There are an anterior, posterior, and two lateral regions of the chest, and each of these is subdivided into other regions. Anterior Region. — This is divided into two similar parts, right and left, and a middle part. The right and left parts comprise, each from above down, the following regions: 1, suxDra-clavicular ; 2, clavicular; 3, sub-clavicular (infra-clavicular, supra- mammary); 4, mammary, and 5, sub- mammary (infra- mammary, hypochondriac). The middle part is di\'ided into the, 6, supra-sternal; 7, superior (upper) sternal, and 8, inferior (lower) sternal regions. The supra-clavicular region is triangular in shape and is situated above the clavicle. It is bounded below by the upper border of the clavicle, within by the lower 2Dortion of the sterno-mastoid muscle, and without by a line drawn from the inner end of the outer fourth of the clavicle to a point on the sterno-mastoid muscle cor- responding with the upj)er ring of the trachea. On both sides the aj^ices of the lungs rise into the neck above the sternal ends of the clavicles, according to Gray, about an inch and a half, but in persons with long necks as much as two inches; in women rather higher than in men, and on the right side than the left. The clavicular region corresponds to the inner three- fourths of the clavicle. The sub-clavicular region (also called infra-clavicu- EEGIONS OF THE CHEST. 6 lar, or siipra-mammary) is bounded within by the edge of the sternum (sternal line), without by a line let fall perpendicular from the inner end of the outer fourth of the clavicle, and continuous with the anterior axillary line; above by the lower border of the clavicle, and below by the upjjer border of the third costal cartilages and ribs, corresponding exactly Avith the base of the heart. In order to find the upper border of the third ■fe / A Fig. 1. — 1. Supra-clavicular Region; 3. Clavicular; 3. Sub-clavicular; 4. Mammary; 5. Sub-mammary; 6. Supra-sternal; 7. Superior Sternal; 8. Inferior Sternal Region. rib, especially in fat people, feel for the horizontal ridge on the sternum that marks the line of union be- tween the manubrium and gladiolus. At this point, on either side, is the articulation of the second costal cartilage with the sternum. Immediately below is the de^Dression between the second and third ribs, or the second intercostal space, the u^Dper border of the third rib, as well as lower border of the second being dis- tinctly felt. The right and left second intercostal 4 PHYSICAL DIAGNOSIS. spaces, called respectively aortic and pulmonary, have special significance in the study of the heart, as Ave shall see. The sub-clavicular regions are chiefly occu- jyied by lung tissue, but the right primitive bronchial tube, larger than the left, more superficially situated an- teriorly, and given off higher up, causes important dif- ferences in the physical signs of the two regions, as will be fully described. The study of these two regions in health is of the first importance, the more so as tuber- cular pulmonary consumption usually manifests itself first in one or the other. The mammary region is bounded above by the upper border of the third rib, below by the upper bor- der of the sixth rib, within by the edge of the sternum (also called the sternal line), and without by the anterior axillary line which is continuous with the outer boun- dary of the region above. The heart is chiefly situated in the left mammary region, the apex-beat correspond- ing to a point between the fifth and sixth ribs, one inch and a half below, and half an inch within the left nipple. Gray and others, however, place it two inches below, and one inch within the left nipple. The super- ficial area of cardiac dullness lies almost wholly within the left mammary region. The right mammary region extends down to the liver, the lower border of the former exactly coiTesponding with the upper border of the latter. The sub-mammary region (infra-mammary, hypo- chondriac) is bounded above by the ux)per border of the sixth rib, below by the free margin of the ribs; within it comes almost to a point at the edge of the sternum and without it is bounded by the anterior ifeEGIOiS'S OF THE CHEST. 5 axillary line. The region on the right side is occupied by the right lobe of the liver. On the left side, we have the left lobe of the liver and the large end of the stomach. The outer boundary of the region on the left side corresiDonds to the anterior border of the spleen from the ninth to the eleventh ribs. Between these two regions is the epigastrium. The supra-sternal region lies above the supra-sternal notch and between the supra-clavicular regions. In it lies the trachea, but by firm pressure downward with the finger, the ^^atient's head being inclined for- w^ard, ]3ulsations of the transverse portion of the arch of the aorta may be felt, especially in the case of an- eurism. The superior sternal region (api^er sternal) corre- sponds to that x^ortion of the sternum above the line of the upper border of the third ribs. The inferior sternal region (lower sternal) corresponds to that part of the sternum below that line. Posterior Region. — This is divided on each side, from above down, into the, 1, supra-scajDular; 2, scapu- lar, and 3, sub-scajDular (infra-scapular) regions, and between the. scapulae is, 4, the inter-scaiDular region. The supra-scapular region corresponds to the supra- spinous fossa of the scaj^ula, and is occupied by lung tissue. The scapular region corresponds to the infra-si^i- nous fossa of the scapula, and is also occupied by lung- tissue. It is much larger than the former, and extends, according to Gray, down to the eighth rib. The inter-seapular region is situated between the scaiDulfe on both sides of the spinal column, which di- 6 PHYSICAL DIAGNOSIS. vides it into the inter-scapular regions of the right and left sides. It extends downward to a line drawn hori- zontally from the inferior angle of one scapida to the other. In front and on each side of the spinal column in this region the bronchi enter the lungs, the right bronchus opposite the fourth dorsal vertebra, accord- FiG. 2.— 1. Supra-scapular Region; 2. Scapular; 3. Sub-scapular; 4. Inter-scapular Region. ing to Gray, and left opposite the fifth, about an inch lower. The sub-scapular (infra-scapular) region is bounded above by the lower borders of the scapular and inter- scax)ular regions, below by the lower border of the twelfth rib, within by the spinal colunui and outside by the j)osterior axillary line. EEGIONS OF THE CHEST. Lateral Regions. — These are divided, right and left> into, 1, the axillary and, 2, sub-axillary (infra-axillary) regions. The axillary region corresponds to the axilla. Fig. 3.— 1. Axillary Eegion ; 2. Sub-axillary Region. It is bounded below by a line connecting the lower border of the mammary region with the lower border of the scapular region ; in front by the anterior axillary 8 PHYSICAL DIAGNOSIS. line and behind by the posterior axillary line. They are both occupied by lung substance. The sub-axillary (infra-axillary) region is bounded, below by the lower border of the twelfth rib, above by the lower border of the axillary region, in front by the anterior axillary line and behind by the posterior axil- lary line. On the right side is the liver, on the left is the spleen and large end of the stomach. A line drawn perpendicularly downward from the middle of the axilla is called the middle axillary line, or simply the axillary line. It is important in connection Avith aspiration or drainage in case of pleuritic effusion, whatever be the character of the latter. Other lines de- scribed by authors, but less frequently mentioned per- hajDS, are the mammillary line, drawn perpendicularly through the nipple on either side; the sternal line, cor- responding AAith either edge of the sternum; the j)ara- sternal line, drawn between and i:»arallel with the two preceding; the scapular line, drawn vertically through the inferior angle of the scapula, and the vertebral line, right and left, on each side of the sj^inal column. The methods adopted in the physical examination of the chest are, princi2)ally, inspection, palpation, per- cussion, and auscultation. There are other methods of less importance to be described hereafter. The use of the thermometer, or calormetation, as well as the ex- amination of the sputa, are well-known methods of I)hysical examination. I. Inspection. Inspection is the act of looking at the patient, and naturally comes first in order. In examining the chest iisrsPECTioisr. 9 in health the patient should ordinarily be strippea to the waist in a warm and comfortable room, and should stand in the erect position, the heels near each other and on the same line, the arms being dropped loosely by the side. The front of the chest should be inspected first. For this jDurpose the observer should stand di- rectly in front of the patient and at a convenient dis- tance for inspection. It is rare to find a perfectly symmetrical chest even in health. The right side may be a little larger than the left, especially in right-handed people with extra develoi:)ment of muscle, as among carpenters and black- smiths. IN'ot infrequently one shoulder is lower than the other owing to occupation, as is sometimes the case among hod-carriers and tailors; or to previous fracture of the clavicle, or curvature of the spine. Such deviations from the perfect symmetry of the chest may be compatible with perfectly healthy lungs. The apex- beat of the heart may, or may not, be seen, depending a good deal uj)oia. the thickness of the chest walls. There is general and even exi}ansion on both sides dur- ing insiDiration, forced or quiet, and respiratory move- ments are not usually more noticeable on one side than on the other. Abdominal respiration is more notice- able in men, superior costal respiration in women. The upper part of a woman's chest expands more on inspira- tion than a man's to allow for child-bearing, the dia- phragm in men being a more powerful and important muscle of resiDiration than in women. On the other hand, abnormal centres of jDulsation, the jpresence of tumors, abnormal bulging or flattening of the chest walls, and exaggerated respiratory movements on one 10 PHYSICAL DIAGNOSIS. side with climinution of those movements on the other, would indicate disease. For examination posteriorly the patient may be turned around, but should stand in the same erect jDosi- tion. Sometimes a slight lateral curvature of the sx^ine may be noticed, owing to the greater traction of the stronger muscles of one side drawing it in that direc- tion. The shoulders may not be on the same level, as already stated. The scapulse should move evenly dur- ing respiration, as a rule, but there are excej)tions. In choreic children, for instance, nervous and hysterical women, or those who chance to be in a nervous condi- tion from the abuse of alcohol, tobacco, or the like, to say nothing of impostors who have heard lectures on the subject, we may find very uneven movements of the chest walls, and especially the scaj)ulae, though the organs of respiration be j)erfectly healthy. The un- even movements due to these causes, however, instead of being uniform, as in disease, usually vary and change from one side to the other. When one side steadily and uniformly expands more than the other to any noticeable extent, it is usually indicative of disease, as we shall see hereafter. In lateral inspection the patient should place the hands on the head. Abnormal bulging or retraction of the sides would indicate disease. But these are ob- served better from the front, or x)osterioiiy, than the side. II. Palpation. Palpation is the act of feeling, and has reference to the special sense of touch. It is the second step in the PALPATION. 11 regular order of examination. It is usually performed by laying tlie jjalms of the hands on the patient, but it is sometimes convenient to j)alpate with the ear in com- bination with auscultation. The palms of the hands, when they are used, should previously be warmed, if necessary, and then laid gen- tly, and lightly, on corresponding xjarts of the chest walls at the same time. This is usually sufficient, but some prefer to apply the hands alternately, or even to cross them, with or without closing the eyes, so as to make the test in every way, in doubtful cases. It is important that the examiner should stand directly in front of, or behind, the patient, according to circum- stances, in order to perform this act v>dth proper care. For palpating in front, the patient should stand erect, as for inspection. But when palpating posteriorly, the patient should cross the arms in front and gently grasp the left shoulder with the right hand and the right shoulder Avith the left hand, keeping the elbows close in to the body, which should be bent slightly forward. In this position the scapulae are moved out of the way and the tissues on the back rendered more tense. Vocal Fremitus. — What is the object of i)alpation? Chiefly to ascertain the presence or absence of vocal fremitus, which is the vibration, thrill, or jarring of the chest walls caused by the sound of the voice. And if present, to know whether it is abnormally increased or diminished. Fremitus, or jarring of the chest walls, may be pro- duced in various ways and is designated accordingly. If produced by the voice it is called vocal fremitus or voice thrill. From the fact that the chest walls vibrate 12 PHYSICAL DIAGNOSIS. it is sometimes called pectoral thrill. As vocal fremi- tus is the kind of fremitus by far the most commonly observed and referred to, it is often called fremitus simply, without being specified as vocal fremitus. It is more or less generally felt over the whole chest, but more marked on the patient's right side, as will be presently described at length. Other kinds of fremitus are tussive (or tussile) fremi- tus produced by the cough, and of use perhaps when the voice is much impaired or lost; rhonchal (or rhon- chial) fremitus caused by large rales, or gurgles, and more or less localized at that point ; friction fremitus, sometimes felt over a pleuritic friction ; and splashing fremitus produced by succussion in case of large cavi- ties containing air and fluid, as in pneumohydrothorax. Besides detecting fremitus we may also, by means of ptalpation, be enabled to accurately count the number of respirations to the minute, should it be impossi- ble to do this by inspection. For this purpose the hand should be lightly applied to the abdomen in men, or the upi^er j>ixvt of the chest in women, for reasons already stated By i^alpation also we may be enabled to locate the apex-beat of the heart, and ascertain the character, frequency and rhythm of its movements, as well as of the radial pulse. To a very limited extent we may also conjecture the amount of expansion and contraction of the chest walls during respiration, but these are better told by inspection or measurement if necessary. The surface temperature should be noted. To detennine the presence or absence of the vocal fremitus in any given case by palpation, it is necessary, of course, for the i^atient to make use .of the voice. PALPATION. 13 For this purpose the patient should pronounce some- what loudly the words " one, two, three," during the act of palpation, and repeat them as often as necessary. Any short simple phrase would answer the purpose, • but these words are as good as any others, and besides they have the sanction of time-honored custom. Some, however, prefer the w^ords, " ninety-nine," or "nine- teen." The reason for speaking these words, or some simple phrase, is chiefly because they can be repeated over and over again on the same key by any one. This is very important. In ordinary conversation on any subject the key, or pitch, of the voice being constantly changed, the fremitus varies accordingly. The lower the pitch of the voice the more marked, as a rule, will be the resulting fremitus. It is important to understand that the normal vocal fremitus is more marked in the right than the left sub- clavicular region. In other words there is normal ex- aggerated vocal fremitus in the right sub-clavicular region of the healthy chest. How is this very impor- tant fact to be explained? Simply because the right primitive bronchial tube being larger than the left, a larger volume of voice is conveyed into the right lung than the left. The trachea, about four and a half inches in length, extends from the lower part of the larynx on a level with the fifth cervical vertebra to opposite the third dorsal, where it divides into the two primitive bronchi, right and left. The right bronchus, shorter, more hori- zontal, and larger than the left, enters the right lung opposite the fourth dorsal vertebra, just behind the upper border of the second costal cartilage of the right 14 PHYSICAL DIAGNOSIS. side. The left bronclius, longer, more oblique, and smaller than the right, passes under the arch of the aorta and enters the left lung opposite the fifth dorsal vertebra, one inch lower than the right. Moreover, the sej)tum between the two is to the left of the median line, so that foreign bodies getting into the trachea naturally drop into the right bronchus or main chaii- FiG. 4. — Division of the Trachea into the two Primitive Bronchi, showing the Right Bronchus much larger than the Left and given off higher up. (Schematic Diagram.) nel. It is reasonable to suppose, therefore, that a larger amount or volume of the voice is conveyed into the right lung, especially the upper part, than the left, and hence more vocal fremitus is obtained on the right side. For the same reason more fremitus is felt posteriorly in the inter-scapular region of the right side, as also slightly more in the riglit sub-scapular region than the left. There being no lung tissue over the superficial PALPATION. 15 area of cardiac dullness in the left mammary region, and over the liver, in front, below the sixth rib, we do not exi)ect to find ninch fremitus at those points nsu- ally, and then only so much as may be extended there by the chest walls. The normal spleen and kidneys do not perceptibly affect the fremitus. Over the scapulae the fremitus is interrupted more or less by the bone which intervenes. The amount of vocal fremitus differs in different healthy individuals, as it depends for its production on certain important factors. These may be embraced chiefly under two heads: (1) the character of the voice and (2) the conditions of the chest walls. In the first place, a loud, low-pitched, harsh voice will, other things equal, cause more vocal fremitus than a high- pitched soft voice. For this reason men have more fremitus as a rule than women, and grown people more than children. The bass notes of the large pipes of an organ produce more fremitus, or jarring, than the high notes, the vibrations of the former being more power- ful and longer. And in like manner the bass viol produces more fremitus or jarring, than the violin. Secondly, the chest walls. A person with chest walls covered with fat, or extra development of muscle, will, other things equal, have less vocal fremitus than one with thin chest walls, unencumbered with those tissues, thin chest walls requiring less force to be thrown into vibrations. In a man having a loud bass voice and a large chest, with thin chest walls, we should expect to find the vocal fremitus well marked, but more on his right side, for reasons already given. On the other hand, we may not be able to detect any vocal fremitus 16 PHYSICAL DIAGNOSIS. whatever in a fat, small-chested woman with a high- pitched soft voice. It is of the greatest importance to know that in health the vocal fremitus, usually ob- tained, is always relatively exaggerated on the patient's right side. The same amount of fremitus on the left side would probably indicate more or less consolidation of lung tissue. In marked deforaiities of the chest, however, such as those caused by marked spinal curva- tures, exceptions to the rule are usually met with in all the methods of physical examinations, though the lungs be perfectly healthy. This is what might be ex- pected, but it is well to bear it in mind. Finally, and what is difficult to explain, the vocal fremitus appears to be very slightly increased when the patient is in the recumbent iDosition, a fact of very little practical im- portance, as it is not usually noticeable. III. Percussion. Percussion is the act of striking the patient one or more blows, to obtain accurate information regarding the underlying parts, and is the third step in the regular order of the physical examination of the chest. It should be performed gently so as not to cause pain to the patient. Although the history of inspection and palpation appears to be nowhere stated, it is well known that Auenbrt^ggeu was the author of per- cussion. He was born in Gratz, Styria, in 1722, and practiced medicine in Vienna, where he died in 1809. He discovered the value of percussion while engaged in the study of a case of empyema. He, however, made use of immediate percussion only, and pub- lished his views on that subject in 1761. But it PEKCU8SION. 17 was not until Piorry of Paris invented the pleximeter in 1828 that mediate percussion was brought into gen- eral nse. Piorry also drew attention to the increiised sense of resistance which accomi^anies the dull sound elicited by percussing solidified lung tissue, and lience one of the advantages of palpatory percussion, with the finger as a pleximeter, over other methods. The percussion hammer was invented by Wintricii in 1841, and when employing this instrument, instead of the Fig. 5.— Percussion Hammers and Pleximeters. fingers, it is necessary frequently to use a pleximeter made of ivory or other material, which may be flat or otherwise. A solid piece of ivory about two inches long, a little larger than an ordinary lead pencil, and shaped somewhat like an hour glass, is useful some- times in percussing just above and below the clavicles in cases of marked depression in those regions, and be- tween ribs, in some cases when it would be difficult to apply the finger, or other pleximeter. To perform pal- patory percussion, a finger of the left hand is placed as a pleximeter firmly against the chest walls and hori- 18 PHYSICAL DIAGNOSIS. zontally Ibetween ribs, rather than vertically. Then with one or more fingers of the right hand (in right- handed persons) curved so as to bring their tips in con- tact with the pleximeter, and moving the wrist joint only, three to five, short, sharp blows, are rapidly de- livered, which j)rodnce a certain sound. The pleximeter should be applied alike on both sides of the chest and the blows should be delivered with equal force. These rules are equally applicable when the percussion ham- mer and ivory pleximeter are used. The percus- sion sound difl'ers for different parts of the healthy chest, and is composed of four elements or properties, (1) quality or timbre; (2) pitch; (3) duration or length, and (4) intensity or amount. Of these properties by far the most important is quality. Quality enables us to tell one kind of a sound from another regardless of all other proj^erties. AYe thus distinguish the sound of a drum from the blowing of a horn and these two from piano music. It is not by the pitch, intensity or duration, that we recognize the sound of the drum, but by the quality of the sound. And so for all other musical instruments. The drum may be small and give a high-xiitched sound. Or it may be large and give a low-pitched sound. Or the jDitch may vary with tightening or loosening the head of the same drum. While the pitch maj^ vary infinitely, the quality remains the same. In percussing over healthy vesicular lung tissue we know that the sound elicited is the normal vesicular, or i)ulmonary resonance, simply by the quality of the sound produced. The , pitch will vary in different healthy people. A person with a large chest will give PERCUSSION, 19 a lower pitched note j)erliai)s than one with a small chest, and of two chests of the same size, that one will give a higher note the walls of which are more tense or thick than the other. Yet the quality may be the same for all. In percussing over the liver, deltoid muscle, or any solid substance, the quality of the note is dull ; over fluids inclosed in thin walls it is flat ; and over a cavity with tense walls and containing air it may be tympanitic. If it be a large cavity, the pitch will be low, and if a small one, other things equal, it will be high, relatively, yet it will be tympanitic in both cases. It is the quality of the percussion note, then, that helps us to distinguish the healthy from the pathological condition, and one pathological condition from another. Pitcli as an attribute of chest sounds was first brought forward by Dr. Walter H. Walshe, of London, about 1850. It is not possible for all to distinguish slight differences in pitch, as it is a natural gift, and belongs to those who have, what is called, an ear for music. Even then it requires cultivation and practice. On the other hand, every one can recognize one quality of sound from another. Pitch is often of use in dis- tinguishing different degrees of the same class. Thus a high-pitched tympanitic percussion note gives the idea of a smaller cavity, with tenser walls, than low-pitched tjrmpanicity, although the quality in both cases would be the same. A large area of solidification would yield a higher pitched percussion note than a small one, though the quality in each case would be dull. There are, however, different degrees of dullness, and the more marked the quality of dullness is, the higher will be 20 PHYSICAL DIAGNOSIS. the pitch. Where the dullness is very slight the pitch is of great importance, otherwise it is not. Ordinary respiration does not affect the percussion note, since we obtain the average quality of the sound during percussion. If, however, the patient be directed to take a deep inspiration and hold the breath, the note may be a little different then from one made at the end of a full expiration. In the foiTuer case the resonance is exaggerated, but the j^itch varies for dif- ferent cases, sometimes higher and sometimes lower than at the end of a full expiration, according to the tension of the chest walls and the volume of air inhaled. A chest with little expansive power may be made very tense on forced inspiration without increasing the vol- ume of air in proportion. Here the j)itch would be higher at the end of inspiration. If volume exceeded tension it would be lower. It is not surprising, there- fore, to find even eminent authors differing on this rather unimportant point. Duration^ or length, as an element or property of sound, varies with the pitch. The higher the pitch the shorter the duration or length, and the lower the pitch the longer \\ill be the duration. Intensity, or amount, as already stated, is used in two senses. In percussion the intensity signifies the amount in the sense of amplitude or volume. The lower the pitch, therefore, the longer the duration and the greater the intensity, or volume, of the x)ercussion note. ^Normal percussion resonance therefore is lower in pitch, longer in duration, and of greater intensity (volume) than dullness which is higher in pitch, shorter in duration and of less intensity (volume). A large PERCUSSION. 21 cavity giving low-pitched tympanicity emits a more intense percussion note than a small one giving high- pitched tympanicity. All these elements or properties of sound are important, but quality, as already stated, is first, and iiitch second, the duration and intensity being secondary to pitch. Let us now examine the different percussion sounds obtained in percussing different regions of the healthy chest ; marked deformities being excex)ted, as already stated, when speaking of palpation. Great care should be observed in symmetrically arranging the patient so as to be able to compare one side with the other under the same conditions. If we percuss in the left sub- clavicular (infra-clavicular) region a certain sound is obtained termed the normal vesicular resonance, or the normal j^ulmonary resonance. The quality is ves- icular, or pulmonary, due to the presence of normal vesicular, or pulmonary tissue. The pitch is some- what low, the duration and intensity (volume) being in proportion. In the right sub-clavicular (infra- clavicular) region we obtain a note very slightly duller in quality, somewhat higher in pitch, shorter in dura- tion, and of less intensity (volume). This fact is of the utmost importance, since slight dullness on percussion is one of the earliest signs of incipient phthisis, due to incomplete consolidation. Three reasons are given for this difference. (1) The right pectoral muscles being more developed and thicker in right-handed i)ersons would naturally cause the note to be slightly duller on the right side than the left. Should the patient be left handed the note may be slightly duller on the left side but not always. We then look for some other 22 PHYSICAL DIAGNOSIS. reason. (2) The right lobe of the liver acting as a solid foundation for the right lung is regarded by some as the cause for a higher percussion note on the right side than the left, the left lung being in relation with the large end of the stomach. The heart being situated chiefly on the left side, however, this theory is disputed and even rejected by some. (3) Lastly the difference is said by some to be due to the difference in the anatom- ical arrangement of the bronchial tubes. The right bronchial tube being larger, and situated higher up, than the left, gives us broncho-pulmonary, or broncho-vesicu- lar tissue, to deal with in which the bronchial element is more marked than in the same region on the left side. And it is not improbable that bronchial tubes with their muscular coats and more or less connective tissue, occupying space that is taken up in the left side by air cells, would give a slightly duller note. Flint, however, states that they probably raise the pitch by imparting to the note a slightly tympanitic quality of high pitch. The resonance obtained by immediate percussion on the clavicles is not always indicative of the true condi- tion of the lungs underneath, and hence is not to be de- pended on. The properties of the note will vary with the length and shape of the bone. For these reasons a slightly duller note is often obtained over the left clavi- cle than the right, in perfectly healthy chests. The mammary regions being covered over with more adipose tissue than those above or below in connection with the mammary glands which are also more or less developed, the note in these regions would naturally be less resonant than in tliose above. Moreover in the PERCussioisr. 23 left mammary region we have within the line of the left nipple the deep and siqierficial areas of cardiac dullness, the former extending into the right mammary region about half an inch to the right of the sternum. Along the lower margin of tne right mammary region we find the line of deep hepatic dullness. The right hypochondriac (infra-mammary) region being occupied by the right lobe of the liver we obtain here marked hejpatic dullness. It should not be called flatness, however, as that quality is obtained by per- cussing over fluids contained in thin walls. In the upper part of the left hypochondriac region and at its outer boundary we may obtain some dullness from the left lobe of the liver and anterior border of the spleen, but owing to the larger end of the stomach the percus- sion note, especially under forcible percussion, is often tympanitic. Over the sternum dullness by means of gentle percussion is usually obtained on account of the bone. But forcible percussion over the trachea and bronchi down to the line of the upper border of the third ribs will give tympanicity or rather bandbox resonance. Below the third ribs the heart and liver cause dullness. In percussing the posterior regions of the chest the patient should assume the same position as for palpa- tion, so as to get the scapulae as much out of the way as possible and render the tissues tense. In the supra- scapular regions forcible percussion elicits pulmonary resonance to a certain extent, but it is muffled by the thick covering of over-lying tissues. This is even more the case in the inter-scapular regions. Over the scapu- lar regions the bone interferes with the resonance. In 24 PHYSICAL DIAGNOSIS. the sub-scapular (infra-scapular) regions, however, we get pulmonary resonance down to the lower limit of the lungs, which is the tenth rib on both sides. The note, however, is slightly duller and consequently higher pitched in the right sub-scapular region than the left, both on gentle and forcible percussion. The right muscles of the back being usually thicker than the left, and the right lobe of the liver affording a solid substance against which we percuss on the right side, fully account for this difference. The lungs only ex- tend down to the tenth ribs on the vertebral lines (both sides of the spinal column), so that below those ribs there is usually marked dullness. In ]percussing the lateral regions the patient should place on the head the hand of the side percussed. In the axillary regions of both sides we get loud pulmonary resonance. In the sub-axillary (infra-axillary) region of the right side we come down to hepatic dullness on the axillary line, between the seventh and eighth ribs, and it continues down to the eleventh. In the same region on the left side there is some dullness on percussion over the spleen from the ninth to the eleventh ribs. Forcible percussion in this region, however, may elicit tympa- nicity from the large end of the stomach. In children the percussion note is usually more reso- nant than in adults, owing to their thin chest walls. In women, for the same reason and on account of their superior costal respiration, the resonance is more marked than in men, especially in the upper part of the chest; while in the aged, the chest walls becoming more and more rigid, and the lungs smaller in volume, less resonance is to be expected as a rule. AUSCULTATION. 25 IV. Auscultation. Auscultation is the act of listening, and may be done immediately by placing the ear directly against the chest, or mediately by the intervention of a stetho- scope. In the former case a thin soft towel, or other similar material, may be used to cover up the chest. Fig. 6.— Stethoscopes. A. Ford's silent circular spring. B. Screw for regulating ear-pressure. The same observations regarding the position of the patient in palpating, or j)ercussing, apply here. Hippocrates, 460-375 B.C., was the first to make use of auscultation as a procedure in physical diagnosis, but only to the limited extent of hearing the splashing of fluid by succussion, in the case of pneumohydro- thorax. It was not until 1816 that Laennec, of the IS'ecker Hospital, in Paris, invented the stethoscope 26 PHYSICAL DIAGNOSIS and Urst gave to auscultation the value which it now possesses. In 1840 Dr. Camman, of New York City, invented the binaural stethoscope. The ear pieces of this instrument should fit jDroperly, and the spring, or elastic, may be guarded by a screw so as to regulate the pressure in the ears, otherwise injury to the ears must follow sooner or later. The moderate use of the stetliosco2:)e for locating heart murmurs is good, but in other cases the ear is to be x^referred when possible. In the auscultation of the healthy chest we listen for the breath sounds and the voice sounds ; the respira- tory murmur and the pectorophony, or vocal resonance as heard over the chest. The i:)atient should be directed to clear the throat if necessary and not to make anj'' sux)erfluous noise in breathing. Normal Respiratory Murirmr. — If now we place the ear or stethoscope to the chest while the patient breathes with a moderate amount of force, we hear the normal respiratory murmur, or breath sound, which for reasons already given is more marked in women than in men, esj)ecially in the upper part of the chest. This normal respiratory murmur is a more or less composite sound in which the larynx, trachea, bron- chial tubes, air vesicles, and perhaps other elements ai-e concerned. It differs for different regions of the chest and is designated according to the predominating qual- ity present. In the left sub-clavicular region, for in- stance, we have the type of the normal A'esicular respii-a- tory murmur, the vesicular (rustling, breezy) quality predominating on account of the presence of the pul- monary vesicles or air-cells. In rhythm the length of the insi)iration of the nonnal vesicular respiratory AUSCULTATIOISr. 27 murmur is about four times the length ojl exj)iration and continuous with the latter. Inspiration is vesicu- lar (breezy or rustling) in quality, of a certain pitch, which may be regarded as somewhat low, and of a cer- tain intensity, which varies in different healthy chests. The expiration when present is always continuous with inspiration, but is absent, according to Flint, in about one-fourth of the cases. This is esp)ecially true with men, particularly on the left side. Expiration is blowing in quality and lower in pitch than insi)ira- tion. Guttmann truthfully states that this resjDira- tory murmur may be imitated by properly adjusting the lips (nearly closing them) and drawing in and ex- Fig. 7. — Normal Vesicular vespiratory murmur. pelling air through them on the proper key with due regard to duration. In fact any respiratory murmur may be imitated in the same way, as in whispering a tune. The reason why exi^iration is shorter than in- siDiration, according to Walshe, is because in the latter instance fhe air current is directed toward, in the former from, the ear of the auscultator. Either in- spiration or expiration or both may be wavy in x)er- fectly healthy chests. We find it in the hysterical and nervous. Palpitation of the heart may cause it, especially on the left side. Even wdien interrupted, cog- wheeled, or jerky, it is not necessarily associated with incipient phthisis. The normal respiratory murmur heard in the right sub-clavicular region differs somewhat from that heard M 28 PHYSICAL DIAGIS^OSIS. in the left. On the right side the bronchus imparts to it a bronchial element not heard on the left. In other Avords we have the normal vesiculo-bronchial respiratory murmur on the right side, a fact of the utmost inqDortance, especially when taken with the other physical signs in this region, all of which very closely resemble those of incipient j)hthisis. In this vesiculo-bronchial murmur the chief characteristics are that expiration is prolonged, raised in pitch, and some- what tubular in quality, and the murmur as a whole is more intense (exaggerated) than it is on the left side. Insi)iration is also slightly higher in pitch and less vesicular in quality than on the left side. In the supra-sternal region by placing the stetho- scoi)e over the trachea we get the nornial tracheal breathing, and in the inter-scajDular region, esj^ecially of the left side, as the left primitive bronchus is more deeply situated than the right, we obtain the normal bronchial breathing over the site of the left primitive bronchus. In this both inspiration and expiration are tubular in quality. The bronchial respiratory murmur resembles the tracheal but is less intense. Over the larynx we have the normal laryngeal breathing. Over the liver and superficial area of cardiac dullness, w^here no lung tissue exists, we hear no respiratory murmur, unless it may be transmitted along the chest walls. Over the scapuhe the murmur is weak or absent on ac- count of the intervening bone. The normal vesicular respiratory murmur besides being heard in the left sub-clavicular region is also heard in both axillary re- gions and the sub-scapular regions. The respiratory murmur may also be heard in the supra-clavicular and AUSCULTATION. 29 supra- scapular regions. In any locality it may become exaggerated, supplementary, or hypervesicular in cer- tain cases where one lung or portion of a lung is doing extra work for a short time. In children before the vesicular element of the lungs has become fully devel- oped and also owing to their thin chest walls, the res- piratory murmur is termed puerile. It is less vesicular and more intense than in adult life, but is not neces- sarily therefore harsh. In old age the murmur be- comes less intense and the rhythm changed, inspira- tion being shortened and expiration j^rolonged. Normal PectoroiDTiony (chest voice), vocal resonance, or voice sound over the chest, in health is the sound produced by the patient's voice as heard through the chest walls. It is a distant, diffused, indistinct sound, being more or less buzzing. The ear or stethoscope, preferably the ear, should be applied to the chest and the patient directed to speak out the words one, two, three, repeating them as often as necessary. N'ormal pectorophony (chest voice) or vocal reso- nance, differs in different healthy people according to the character of the voice and the conditions of the chest walls, and for different localities, just exactly like the normal vocal fremitus. What has been already stated about the latter, therefore, equally applies to the former. It is normally exaggerated (slightly increased) in the patient's right sub-clavicular region and else- where, like the fremitus. 450 PHYSICAL DIAGNOSIS. SUMMARY OF THE PHYSICAL SIGNS OF THE HEALTHY CHEST. 1. Inspection.^- A perfectly symmetrical chest is rare. The shoulders may not be on the same level, and there may be slight lateral curvature of the spine. The apex- l)eat of the heart may or may not be visible, according, chiefly, to the thickness of the chest walls. There is equal and general exj^ansion of the chest walls on both sides during insiDiration. Superior costal respiration is noticeable in women, abdominal respiration in men. The scapuhe move evenly, except, for instance, in nerv- ous people. 2. Palpation. — The normal vocal fremitus varies in different people, depending on the character of the voice and the conditions of the chest walls. It is, how- ever, more perceptil^le all over the i)atient's right side than the left and is especially exaggerated in the right sub-clavicular, inter-scapular, and sub-scapular regions, since the right bronchial tube, larger than the left, conducts a larger volume of voice to the right side. The apex-beat of the heart is usually, but not always, felt. 3. Percussion. — We obtain normal pulmonary res- onance in the left sub-clavicular region, both axillary regions, and the left sub-scapular region. In the right sub-clavicular and sub-scajDular regions the note is slightly duller than in those regions of the left side, owing chiefly to the difference in the thickness of the muscles. Over the liver and superficial area of car- diac dullness we o})tain marked dulhiess. Over the spleen in the left sub-axillary region, from the ninth to HEALTHY CHEST — SUMMARY. 31 the eleventh ribs on the axillary line, there is slight dullness mingled not infrequently with ventral tyiu- panicity. In the scax)u]ar and inter-scapular regions the resonance is interfered with by the intervening bone and muscles. 4. Auscultation. — In the left sub-clavicular, both axillary and sub-scapular regions, we hear the normal vesicular respiratory murmur. In the right sub-cla- vicular region we hear the normal vesiculo-bronchial respiratory murmur owing to proximity to the right primitive bronchus. Over the larynx, trachea and bronchi we hear the respiratory murmur characteristic of those organs. Over the liver and superficial area of cardiac dullness the respiratory murmur may be en- tirely absent unless transmitted there by the chest walls. The normal pectorophony (vocal resonance over the chest) is exaggerated in the right sub-clavicular region and is also more intense in the right inter-scap- ular and sub-scajpular regions than the left for the same reason that the fremitus is. From the foregoing observations we deduce the following differential summary of the physical signs as obtained in the right and left sub-clavicular re- gions in the healthy chest: (1) Inspection is chiefly negative. (2) Palpation gives exaggerated vocal frem- itus on the patient's right side. (3) Slight dullness on percussion in the patient's right side, the pitch being slightly raised. (4) Upon auscultation we find vesiculo-bronchial respiratory murmur and exagger- ated pectorophony (vocal resonance) on the patient's right side. In other words, we have in the right sub- clavicular region of the healthy chest all the signs of \ 32 PHYSICAL DIAGNOSIS. incomplete consolidation of lung tissue as seen in the early stage of phthisis, except some adventitious sound, such as crepitant, or sub-crepitant rales, or the mucous or intra-pleural click. " Without a practical knowledge of these points of disparity," says Flint, " error in di- agnosis can hardly be avoided." In cases of doubt the siDuta should be examined by an expert for the tuber- cle bacillus, though it is not always found at this early Gtage. OTHER MEANS EMPLOYED IX PHYSICAL DIAGNOSIS. Mensuration, or measurement, may be of use in comparing the two sides of the chest in repose, or dur- ing inspiration and expiration, or to ascertain the total amount of expansibility of the chest. Even in these cases inspection is usually sufficient. Moreover, a dis- eased jjerson can sometimes, by practice, expand the chest walls more than a healthy one who has not prac- ticed. It is of use sometimes in ascertaining the size of the chest in proportion to the height. Thus a man 5 feet 6 inches high should measure around the chest, on a level \Adth the sixth costo-sternal articulations, 37^ inches ; 5 feet 8 inches high, 38^ inches ; 5 feet 10 inches high, 39|^ inches; 6 feet high, 41 inches, and so on. Tliree inches is good expansion of a healthy chest on full inspiration, although the healthiest i^erson may not be able to expand the chest oxer two inches Avith- out practice, while it may be i)ossible with practice to expand it six inches. Various instruments, such as the stethometer, spirometer, and cyrtometer, have been used for mensuration. Tlie ordinary tape-line, however, is good enough for j^ractical purposes. VAEIOUS METHODS. 33 Auscultatory-Percussion, was invented by Dr. Cam- man, of ]N'ew York, about 1840. It combines ausculta- tion by means of the stethoscope with percussion. While the stethoscope is firmly pressed over the heart, for instance, percuss gently at the same time. As soon as the percussion reaches the border of the heart the quality and pitch of the note is changed at once. It is a much more delicate test than the ordinary method of percussion, and is especially useful in diagnosing thoracic aneurism. It may also be used for accurately determining the boundaries of the heart, liver, and other organs of the body. Unless performed correctly and carefully, however, it is misleading. A pleximeter, small enough to be pressed down between the ribs, should be used, otherwise we always obtain the dull percussion resonance of the superficial adipose, or other tissue, instead of that of the underlying organs. Sicccussion, invented by Hipxoocrates, 460-375 B.C., consists in shaking the patient while the ear is at the same time applied to the patient's chest. By this means the splashing sound of fluid characteristic of pneumo-hydrothorax is detected, as will be fully de- scribed. Paracentesis Thoracis, or Tlioracentesis^ in cases of extensive pleuritic effusions, whether of serum or pus, was first brought before the profession in a prac- tical manner by Trousseau, of Paris, about 1835. After his death it fell into disuse, but was revived in 1852 by Dr. Bowditch, of Boston, Massachusetts, who clearly pointed out the indications for the operation, as will be mentioned when speaking of that subject. More re- cently by means of the hypodermic syringe the exist- 3 34 PHYSICAL DIAGNOSIS. ence and character of pleuritic effusions can be estab- lished with certainty. Other less important procedures are autophonia, the method by musical vibrations, and phonometry. Autophonia was first brought into notice by the late M. Hourmann, who " connected peculiarities in the resonance of the observer's own voice (as he speaks with the ear applied to the chest directly, or by the intervention of the stethoscope) with certain definite conditions of density of the parts beneath." The method by musical vibrations originated with Drs, Stone and Grabham (London Lancet, vol. i., 1867, p. 114), and consists in " communicating a musical im- pulse to the air in the bronchial i^assages by forcibly inspiring through a tube or pitch-i)ipe containing a free reed. The note emitted is directly conveyed to the i)arts under observation." Phonometry is a metliod described by Baas. It consists in " i^lacing a tuning fork on the surface of the chest or abdomen, and determining by the inten- sity or feebleness of the tone it gives, the condition of the subjacent organs." The best instrument for this purpose is Blake's tuning fork with a small spring hammer attached. The usual method of per- cussion, however, is much to be preferred. Having become thoroughly and practically ac- quainted with the physical signs obtained by examin- ing the healthy chest, the student is now prepared to consider the physical signs of various diseases. CHAPTEE II. BRONCHITIS. Diseases in which the breath and voice sounds are refracted (broken up, diffused) within the lungs as much as, or more than in healtli, with consequent normal or diminished vocal fremitus, respiratory murmur, and pectorophony. — Obstruc- tion in the bronchial tubes to the convection of sound, with consequent diminution or suppression of the latter. — Ad- ventitious sounds. Bronchitis is the inflammation of the mucons mem- brane lining the larger or medium-sized bronchial tubes, but when the smaller or ultimate bronchial tubes be- come the seat of the disease it is called capillary bron- chitis. In neither case are the air cells affected unless as a complication. As independent primary diseases they are general or bilateral, local bronchitis being usually caused by and secondary to some other disease, tubercle, aneurism, or neoplastic growth for instance, or surgical injury. The physical signs of bronchitis, apart from compli- cations, are as follows : Inspection. — This yields chiefly a negative result. Usually there is no perceptible difference from health in the size and shape of the chest and character of the respiratory movements. Especially is there no differ- ence in the respiratory movements of the two sides, when compared with one another, but both expand alike. 36 PHYSICAL DIAGNOSIS. Palpation. — This also gives negative results gener- ally. The vocal fremitus is usually normal, or it may be slightly diminished if the bronchial tubes are much obstructed by mucus, so that the voice sound is not conveyed by them as freely as in health. In rare cases a large tube, the left primitive bronchus, for instance, the right being usually too large, or a large branch of either, becomes stopped up by a plug of viscid mucus, with diminution or even absence of the vocal fremitus over the corresponding area. Coughing may remove the plug and then the fremitus immediately returns. In case of coarse mucous rales, especially with thin chest walls, rhonchal fremitus may be present. Percussion. — This also yields negative results, the air cells in uncomplicated bronchitis being unaffected and full of air. Sometimes the resonance may even be exaggerated owing to the abnormal distention of the air cells with air. This, however, will be explained when speaking of emphysema. In old cases of bron- chitis where the inllammation has extended so as to give rise to peri-bronchial thickening or interstitial in- flammation, more or less dullness on percussion will result from those complications. Auscultation. — The respiratory murmur may be weakened if the tubes are much obstructed with mucus, or, if a large tube be plugged up as already described, the respiratory murmur may be entirely absent for the corresponding area. Upon coughing and removing the obstruction the respiratory murmur immediately re- turns. When heard, however, its quality is the same as in health as a rule. It may, however, be a little harsh (rough) if the mucous membrane of the larger BRONCHITIS— KALES. 37 bronchi is mncli roughened where the tidal air rubs against it instead of gliding smoothly and without much friction, as in health. Expiration will be more or less prolonged in proportion to the amount of ob- struction in the tubes, the force of ordinary expiration being weaker than that of inspiration. PectoroiDhony (vocal resonance over the chest) is usually normal, but may be slightly diminished like the vocal fremitus. Relatively the vocal fremitus and pectorophony are the same as in health in comparing one side with the other. Rales (rattles) are usually heard in bronchitis and belong to the adventitious or foreign sounds. These never exist nntil produced by disease. Adventitious sounds are abnormal from beginning and are not modi- fied normal sounds. Their presence, therefore, always indicates some abnormal condition. (See Summary of Adventitious Sounds, ChaiD. Y.) The rales heard in bronchitis may be dry or moist. There are two varieties of dry rales, the sonorous and sibilant. Sonorous rales are loud, low-pitched, dry rales made in the larger bron- chial tubes. The sibilant are high-pitched, whistling rales made in the smaller tubes, or in larger tubes if the constriction be sufficient. They are heard in the early or dry stage of bronchitis and asthma, and are du3 to irregularity in the calibre of the tubes from spasmodic constriction of the muscular coats, or tume- faction of the lining mucous membrane. Sometimes they are also caused, undoubtedly, by the vibration of viscid mucus, and hence are changed with coughing. Moist bronchial rales are divided into three varieties. Those made in the larger bronchial tubes are large bub- 38 PHYSICAL DIAGNOSIS. bling rales heard both on inspiration and expiration, and are called mucous rales. Those made in the medium-sized bronchial tubes are called sub-mucous rales. They are also bubbling rales heard both on inspiration and expiration, but are liner and higher pitched than the mucous rales. Lastly we have the sub-crepitant rales made in the liner bronchi. Fig. 8.— Bronchial Rales, mr, Mucous rales; smr, sub-mucous rales; so; sub-crep- itant rales; cr, crepitant rales; t, tumefaction; s, spasmodic stricture of bronchial tube. These are fine moist rales, heard chieHy on inspiration, though occasionally they are heard on expiration also. All of these rales may be present together, or only one or more varieties. They may be abundant, scant, or even absent at times. In the latter case, coughing may develop them. When present they usually change with or even without coughing, are more or less irregu- lar in size, and are attended with more or less ex- pectoration. In this way tliey differ from intra-i)leural BRONCHITIS. 39 moist rales, which are usually local, do not change with couching, are uniforai and superficial, and attended with little or no expectoration. The patient should be directed to clear the throat to avoid laryngeal and tracheal rales, the sound of which may be conveyed to the ear through the bronchial tubes and air cells. Other adventitious sounds are the crepitant rales made in the air cells, intra-pleural rales, mucous and intra-pleural click, gurgles, metallic (amphoric) tinkle, friction sounds, splashing sounds, and certain crackling and crumpling sounds called indeterminate rales, to be .described each in its proper x)lace. (See also Summary of Adventitious Sounds, ^. 159, Chap. V.) Capillary Broncliitis is the inflammation of the mucous membrane lining the smallest or ultimate bron- chial tubes, the air cells still remaining unaffected ex- cept as a complication. It occurs most frequently in children. It is also seen among the aged and others having enfeebled heart's action, and hence may occur in the course of long-continued diseases of a typhoid character. ' The physical signs are, in general, similar to those of ordinary bronchitis. Ins])ection^ however, may reveal increased frequency of respiratory movements and sometimes more or less cyanosis, especially about the cheeks, ears, tip of the nose, lips, and fingers. (See Atelectasis and Lobular Pneumonia.) Palpation generally yields negative results, or the fremitus may be diminished or even absent from ob- struction of the tubes, as already stated. 40 PHYSICAL DIAGNOSIS. Percussion. — The percussion note may be normal, or it may be, and frequently is, exaggerated from tem- porary over-distention of the air cells. This is due to the fact that forced expiratory efforts empty chiefly the larger bronchi but have very little influence over the air cells. Hence, so far as the air cells are con- cerned, inspiration is a more forcible act than expira- tion. The air passes by the mucous obstruction into the air cells more easily than it gets out, and so accu- mulates in the air cells and distends them. On the other hand, if the patient is very feeble, as is not infre- quently the case with sick children or the aged, or those suffering with typhoid fever, the air cells may collapse, giving rise to atelectasis instead of a tempo- rary over-distention or emphysema. In such cases there is not power enough on inspiration to overcome the ob- struction in the tubes, and the air in the cells becomes absorbed, the oxygen disappearing flrst and then the carbonic acid. Such a complication would give some dullness on percussion and is often mistaken for pni-u- monia. AusGiiUatlon usually reveals the presence of line sub-crepitant rales in great abundance, over both sides, and esjjecially low down posteriorly, owing to gravita- tion of the mucus, in many instances, to that ])art. Other rales may also be present at the same time. The respiratory murmur, if heard at all, would be about normal in quality, with expiration more or less pro- longed, owing to the obstacle to the free escape of air. Usually it is so weak, however, owing to its not being freely conveyed by tubes that are obstructed with mucus, that it may be obscured entirely by the rales- CAPILLARY BRONCHITIS. 41 Sometimes the obstruction is so complete that it is sui^pressed. Pectorox)hony (vocal resonance over the chest) is usually normal, but may be diminished like the fremitus. If exaggerated, or markedly increased, it would indicate pneumonia. Differential Diagnosis of bronchitis. This is not usually difficult. Being a bilateral affection with no physical sign of material value, excejDt the detection of various rales more or less over both sides of the chest by auscultation, it is readily distinguished from acute lobar pneumonia which, besides being usually attended with severe constitutional symptoms, is gen- erally unilateral and confined to one lobe, usually the lower lobe of the right lung. Moreover, owing to solid- ification of lung tissue in pneumonia, we usually ob- tain marked increase of fremitus on palpation, marked dullness on percussion over the part affected, and on auscultation hear bronchial breathing and bron- chophony, as will be fully explained. In caj)illary bronchitis the inflammation may extend here and there in spots into the air cells, giving rise to lobular pneumonia, which is also called catarrhal or broncho-pneumonia. It is often difficult to detect mi- nute spots of lobular pneumonia. If in the course of capillary bronchitis, respiration becomes hurried, with exaggerated movements of the alfe nasi and rise in tem perature, it is fair to infer that lobular pneumonia has occurred, even if it be to such a small extent that other signs are wanting. But if, in addition, there are in- crease of fremitus, dullness on percussion, which should be gently performed on children in order to detect it, and bronchial breathing over one or more spots, the 42 PHYSICAL DIAGNOSIS. diagnosis of pneumonia would be complete. Atelecta- sis due to capillary bronchitis would also give some dullness on percussion, but it would be symmetrically bilateral and there would be sucking in of the inter- costal and supra-clavicular spaces on inspiration, with no extra rise in temperature (see Atelectasis). The presence or absence of chlorides or albumen in the urine in these cases are of little or no value as aids to diagnosis. ASTHMA. Asthma is described by authors as a reflex neurosis. It is characterized by recurrent paroxysms of violent dyspnoea, due to spasm of the muscular coats of the bronchial tubes, or tumefaction of their mucous mem- brane from cai)illary vaso-motor disturbance, or both. It attacks both sexes at all ages, but men are affected by it twice as often as women, being more exposed to the causes. It requires for its production three factors : (1) a sensitive area of mucous membrane, (2) an abnor- mally sensitive nerve centre, and (3) an external irri- tant. Given all three of these factors simultaneously and an attack of asthma is i)roduced, and it cannot be produced by any two without the third. The sensitive area of mucous membrane may be situ- ated in the naso-pharynx, bronchial tubes, or stomach. The irritant applied to either of these points may be reflected back to the lungs along the pneumogastric nerve, giving rise to naso-pharyngeal asthma, bronchi- tic asthma or peptic asthma. Cardiac ASthma is also described, but this would jiroperly come under the head of bronchitic asthma, owing to the bronchitis re- ASTHMA. 43 suiting from the heart disease. The second factor, the abnormally sensitive nerve centre, may be inherited or acquired by long-continued application of the initant to the sensitive area of mucous membrane. Not only this, but one sensitive area of mucous membrane may give rise to a second area, so that naso-pharyngeal, or even peptic asthma, for example, may become bron- chitic asthma. Of external irritants, which constitute the third factor in this disease, dust of some sort is the most common. But there are a great variety of ex- ternal irritants, some of them giving different names to the disease, as hay asthma, and the like. Naso-pharyngeal asthma is very closely allied to what is known as hay fever. In the latter case the sensitive area of mucous membrane in the nares is situ- ated more anteriorly than in asthma, and by reflex action the branches of the facial nerve are involved, giving rise to lachrymation, sneezing, and other symp- toms of hay fever. Sometimes hay fever and asthma may occur at the same time. The irritants in cases of pejjtic asthma are certain kinds of food, and in bron- chitic asthma, fog, cold with dampness, and changeable weather, often give rise to an attack. The physical signs of asthma during an attack are as follows : Inspection shows labored respiration. Usually the patient sits up and leans forward m order to breathe more freely. The shoulders are elevated and brought forward, the countenance is pale or dusky, and during respiration the exj)iratory act is seen to be j)rolonged. During inspiration, which is usually deferred, short, and sometimes jerking, the supra-clavicular, and supra- 44 PHYSICAL DIAGNOSIS. sternal fossae, scrobiculus cordis or pit of the stomach, and the intercostal spaces are more or less sucked in and depressed, because the lungs do not become inflated to a degree corresiDonding to the enlargement of the thoracic cavity. After the paroxysm is over, nothing abnormal is to be observed, unless there be some com- 13lication, as vesicular emphysema. Palpation. — Rhonchal fremitus may be 'detected owing to the rales (rhonchi) which are present. Yocal fremitus may be unchanged, or slightly dimin- ished, owing to the emphysematous condition of the lungs rendering them more refractive of sound than in health. It may be also diminished by the obstruction in the bronchial tubes from spasm and mucus, thus rendering the tubes imperfect conveyors of the voice sound. Percussion. — Exaggerated resonance on percussion is the rule, owing to the emphysematous condition of the lungs. Auscultation. — Dry rales of various kinds are heard, but chiefly on exj)iration, which is much prolonged, while inspiration is so short as to scarcely give time enough for these rales to be thoroughly developed. Sometimes they are loud enough to be heard by the patient and the friends in the room. As the paroxysm declines, and increased secretion occurs, various moist rales may be heard, the mucous, sub-mucous, and sub- crepitant. Sometimes moist rales are piesent with dry rales from the iirst. The rales are usually heard over both sides of the chest, or they may be heard only on one side, or here and there in spots, but changing about from place to place. The respiratory murmur, if ASTHMA. 45 heard, would be little changed in quality, if any, but it is usually obscured by rales, or it may be weakened or entirely suppressed, owing to obstruction in the tubes and refraction in the lungs. The rhythm of res- piration is changed, expiration being much prolonged. The reason for this, as well as the emphysematous condition of the lungs, is the obstruction in the bron- chial tubes partly from spasm and partly from mucus. Fig. 9. — Diagram showing Enlargement of the Air-cells during a paroxysm of Asthma owing to spasm of the Bronchial Tubes. The force of inspiration as affecting the air-cells is greater, as already stated, than the force of expiration. Hence air passes in by the obstruction in the finer tubes more easily than it passes out. Hence its accu- mulation in the cells behind the obstruction and hence the prolonged effort in the attempt to expel it. It is not the inspiration of fresh air so much as it is the effort to expel impure air that constitutes the chief difficulty in a paroxysm of asthma. Instead of inspira- tion being to expiration as 4 :1 as in health, the rhythm, as Walshe observes, is often reversed and is as 1 :4, vdth 46 I'lIYSICAL DIAGNOSIS. expiration sometimes loud and hissing, owing to spasm of the bronchi. Fig. 10.— Respiration Murmur in Asthma. After the paroxysm is over, Dronchiul rales of vari- ous kinds, both dry and moist, may be i^resent for a few hours, or even several days. Pectorophony (vocal resonance) may be normal or somewhat diminished like the fremitus. Differential Diagnosis. — Proper attention to the physical signs and history of the case will usually en- able one to make the diagnosis of asthma with cer- tainty. The suddenness of its onset and departure, the labored breathing with expiration markedly pro- longed, the rales so abundant and loud, the absence of purulent expectoration and fever, and the suddenness with which it sometimes yields to remedies, at once distinguish it from bronchitis of any kind. In em- physema the dyspno'a is constant instead of paroxys- mal, owing to organic change, besides other physical signs described in connection with that disease (see Emphysema). In some cases of heart disease there are paroxysms of dyspnoea, but they are usually shorter than those of asthma and are unattended with the characteristic prolonged expiration of the latter dis- ease. In spasmodic and other affections of the larynx there is change in the voice, and if wheezing be present, it is located at that point. Moreover, in laryngeal spasm, inspiration and not expiration is prolonged and EMPHYSEMA. 47 labored. This may be true of i)olypus in the trachea. In pulmonary ffidema there is dyspnoea, but there is also some dullness on percussion over the seat of the oedema, which is usually situated on both sides at the most dependent portion of the lungs posteriorly. Over the same region also may be heard liquid crepitant rales at the end of inspiration. The dyspnoea, instead of being sudden or paroxysmal, comes on gradually, increasing with the oedema, which may be due to heart disease or associated with dropsy. In hydrothorax, which is a symptom of general dropsy, there is flatness on percussion over the pleural cavities (up to the level of the fluid) instead of extra resonance, and the dys- pnoea gradually, but steadily becomes more and more urgent with increase of the droiDsy, as in oedema. In pulmonary hypostasis occcuring in old age with enfeebled heart, the dyspnoea is like that due to oedema. EMPHYSEMA OF THE LUNGS. Emphysema, or inflation of the lungs, is of two classes : (1) interstitial, where the air escapes through rupture into the interstitial pulmonary tissue; (2) vesicular, where there is excess of air in the pulmonary vesicles, causing them to be abnormally distended. Interstitial emphysema (inter-lobular, extra-vesicu- lar, extra-alveolar) occurs from rupture of the walls of the air-cells as in the expiratory efforts of violent coughing, in whooping-cough for example, also from parturient efforts, blows, falls, and wounds of the lungs from various causes. Or it may occur in connection with softening and breaking down of tubercle. The 48 PHYSICAL DIAGNOSIS. air escapes into the connective tissue of the Inngs be- tween the lobules and under the pleurae. Sometimes it passes through the posterior mediastinum into the subcutaneous tissues of the neck, face, and sides, where it crepitates under the hand during palpation. It is impossible to make a diagnosis unless the air reaches the subcutaneous tissue, and in no case is there any special treatment for it. The escaped air soon becomes absorbed. Vesicular (alveolar) emphysema consists of two vari- eties: (1) vicarious emphysema, and (2) general em- physema. Vicarious (compensating) emphysema affects one lung or part of a lung from over work due to crippling of the other lung or part of lung. In old pleurisy, for instance, where extensive effusion or adhesions renders the affected side almost immovable, the other lung be- comes vicariously emphysematous from over work. In lobular pneumonia or collapse of some air-cells, other air-cells near by may become emphysematous in the same way. Even in acute lobar pneumonia the un- affected lobes of the same side may become temporarily or acutely emphysematous to a certain extent. In pul- monary consumption also, crippling of certain areas of lung tissue may give rise to slight emphysema of others; not marked, however, as respiration in con- sumption is usually shallow and rapid, and the volume of blood much diminished. All vicarious emphysema is evidently brought about by excessive inspiration. There is no obstruction to expiration necessarily, and the patient endeavors to inhale as much air as if both lungs were intact. Hence inspiration is overdone, with EMPHYSEMA. 40 consequent abnormal distention of the remaining vesi- cles, and the resulting vicarious emphysema w^ill be acute or chronic according to the condition that gives rise to it. General (substantive) emphysema is also of two vari- eties: (1) small-lunged and (2) large-lunged emphysema. Small-lunged emphysema (atrophous, phthisical, se- nile) is usually found among those well advanced in years and it may or may not follow the large lunged variety. The volume of the lungs has become much reduced owing to atrophy of the intercellular tissue, though the air-cells have become larger, in many cases, by coalescence. It is simply a condition mostly be- longing to old age. , General large-lunged (hypertrophous) vesicular em- physema remains for consideration. It is a very seri- ous disease and occurs in men more frequently than in women, the former being more exposed to the causes ; and in northern, cold, changeable climates more fre- quently than in warm regions of a uniform tempera- ture, owing, perhax)s, to the greater prevalence of bron- chitis and asthma in the former. Owing to the length of time required to produce the disease, it is rarely seen before thirty years or middle life. Fat people appear to be more predisposed to it than the thin. Heredity undoubtedly plays an important part among predisposing causes. The disease is usually brought about in one of four ways: (1) by obstructed forcible expiration, (2) forced insiDiration, (3) deformity of the chest, and lastly (4) by inherited predisposition. (1) Obstructed forcible expiratory effort is by far the most frequent cause. For this reason it is found among 4 50 PHYSICAL DIAGNOSIS. laborers who are engaged habitually in haivy lifting or straining. In this act the glottis is closed and the abdominal muscles are contracted upon the intestines with great power, which forces the diaphragm up and compresses the air into the upper lobes of the lungs, so that in such cases the upper lobes are chiefly affected, particularly, according to Flint, the left. In the same way players on wind instruments and persons affected with chronic bronchitis, especially the dry bronchitis associated with gout, in which violent fits of coughing habitually occur, may have the disease. The act of coughing simply consists of more or less sudden and violent expiratory efforts with the glottis closed. Chil- dren not infrequently have more or less temporary em- physema from whooping-cough. (2) In some cases the disease is caused by forced inspiration. Here a chronic bronchitis extending to the smaller tubes precedes the emj)hysema instead of being developed afterward. Inspiration being more forcible than expiration, as far as the air-cells are con- cerned, the air passes in by the obstruction of viscid mucus more easily than it j^asses out, so that it accu- mulates in the air-cells and distends them. In these cases we find the lower portion of the thorax enlarged sometimes, as well as the upper. (3) According to Freund, in some oases the character- istic deformity (barrel shape) of the chest in large- lunged emphysema occurs first, the lungs afterward becoming distended so as to fill up the vacuum. Such cases, however common in Germany, are very rare in America, if indeed they ever occur. In some cases of deformity of the chest, due to rickets, for instance, or EMPHYSEMA. 51 curvature of the spine from some cause, a local em- physema may occur, one lung or part of a lung becom- ing distended to fill out one side or portion of the thoracic cavity enlarged by bulging. (4) Lastly, in certain instances the disease may occur without any mechanical or other known cause, but is simply due to inherited predisposition. This consists in an inherent weakness of the cell walls, perhaps from defective innervation and nutrition, and they yield, in the ordinary avocations of life, without any abnormal force applied. The dyspnoea and abnormal state of the heart that necessarily accompany marked cases of this disease re- quire brief notice. There are three factors in the production of the dys]3- noea: (1) rigid dilatation of the thorax, (2) loss of ca- pillary area in the lungs, and (3) crippling of the dia- j)hragm. The lung tissue has lost its resiliency and the costal cartilages have become permanently elevated, everted, and hardened, the spaces between them being widened. They have lost their elastic recoil, so that the chest is in a state of rigid dilatation. For this reason air is not expelled properly, and impure air, therefore, accumulates in the lungs causing dyspnoea. In the sec- ond place, many capillary blood-vessels in the lungs be- come obliterated by over stretching. Indeed many of the alveolar septa, on which clusters of these capillaries hang, undergo wasting and perforation, and finally dis- ajDpear. From loss of capillary area the blood is brought in less quantity in contact with the air in the ceUs, impure as it is. This second factor is, therefore, a potent one for the production of dyspnoea. More- 52 PHYSICAL DIAGiSrOSIS. over as the blood now has fewer channels left for it in Avhicli to pass through the lungs, the right ventricle of the heart has more work thrown back on it and hence becomes enlarged (dilated and hypertrophied). As the disease progresses, should relative insufficiency of the tricuspid valves ensue, jugular pulsation and cardiac dropsy may occur. Lastly, the crippling of the dia- phragm is probably the most important factor in the production of dyspnoBa. The volume of the lungs being increased sometimes enormously, the diaj)hragm is permanently pushed doAvn, as is also the heart. 0^^dng to more or less gastro-intestinal catarrh from passive hj^ersemia due to obstruction to the venous circulation, there is always more or less dyspepsia ^^'ith wind in the stomach. The diaphragm, the most impor- tant muscle of respiration a man possesses, is thus put between two splints. From want of use it becomes atrophied. The physical signs of general large-lunged (hyper- trophous) emphysema are as follows : Inspection. — The countenance may be more or less dusky or cyanotic in proportion to the extent and progress of the disease. In the later stages jugular pulsation, due to tricuspid insufficiency, may be ob- served at the root of the neck on the patient's right side (see Jiigular Pulsation). As obstructed forcible expiratory effort is the most frequent cause, so the upper intercostal spaces are usually seen to be widened owing to the fixed elevation and eversion of the upper costal cartilages and ribs, like the elevated slats of a shutter. The upper part of the sternum is prominent, bulging forward,' so as to increase the antero-posterior, EMPHYSEMA. 53 or sterno-vertebral diameter. The shoulders are ele- vated and brought forward owdng to habitual dyspnoea, and the spinal column is more or less anteriorly curved. The whole makes up the so-called barrel-shaped chest. Where the disease has been caused by forced inspira- tion, the lower portion of the thorax is also enlarged with widening of the lower intercostal spaces also. Epigastric pulsation, due to enlarged and lowered right ventricle, is usually noticeable. The apex-beat is generally carried downward and outward, but fre- quently cannot be found, being buried under lung tis- sue. During forced respiration the thorax moves up and down more or less like a fixed case, instead of ex- panding and contracting as in health. During the effort of deep inspiration the tupra-clavicular spaces may be drawn in, the lungs not expanding any more while the thoracic walls are raised up. During \T.olent cough- ing a tumor is sometimes seen to rise up from each of the flattened supra-clavicular fossse. This, according to Memeyer, is due to the sudden filling up of the si- nuses of the jugular veins during coughing, which im- mediately become empty when the cough ceases. It is more probably due to lung tissue suddenly distended u^Dward during violent coughing. Palpation. — Tlie lungs, owing to distention of the air-cells, become more positive refractors or diffusors of sound than in health. Hence the vocal fremitus is usually diminished, and sometimes even absent. More- over, owing to bronchitis, which is almost invariably present in emphysema, either as a cause of the disease or result of the obstruction to the pulmonary circula- tion, the bronchial tubes may be more or less obstructed 64 PHYSICAL DIAGNOSIS. with mncus, thus rendering them imperfect conveyors of sound. Rigidity of the chest walls and loss of resili- ency of lung tissue also lessen the vibrations. If the bronchitis gives rise to such complications as peri-bronchial thickening, with spots and threads of interstitial induration, the fremitus will be increased over corresponding localities, on account of the more homogenous and better conaucting medium for the voice sound (see Solidified Lung Tissue). Epigastric pulsation is usually felt, and sometimes the apex-beat of the heart displaced down and out. According to some authors it is carried inward toward the epigastrium, but it is difficult to see how it could get there unless the heart be raised up. The cardiac pulsations, and consequently the radial pulse, are often intermittent in this disease, owing perhaps to the ex- tra work thrown on the heart, so that it has to rest every now and then. Dyspepsia, due to gastric venous congestion, and acting reflexly along the pneumogas- tric nerve, may also cause it. Percussion. — Resonance is exaggerated on percus- sion, especially over the upper lobes in front and par- ticularly on the patient's left side. Flint terms this resonance vesiculo-tymj^anitic. That is to say it is neither purely vesicular nor tympanitic, but a mixture of the two. Biermer, of Zurich, Switzerland, calls it band-box resonance. This is especially the case over the lower posterior and left lateral regions. The pitch of the percussion note in this disease is, according to some authors high, while others maintain that it is low. The truth is the pitch varies in different cases accord- ing to the tension of the walls and the volume of air EMPHYSEMA. 55 contained. If the walls are tense without much in- crease in volume of air the pitch will be high. If vol- ume is greater in proportion to tension the pitch will be low. But the quality will be the same in all cases. Variations in pitch, while the quality is the same, may be simply illustrated in a number of ways. The bass Fig. 11.— General Hypertrophous Vesicular Emphysema. drum, for instance, yields a lower-x)itched tympanicity than the snare drum, yet the quality of tympanicity is the same for both. Drums of the same size with equal tension elicit tympanicity on percussion and the pitch of the note will be the same for all. But if the tension varies the pitch will differ accordingly, greater tension producing higher pitch than if the tension be dimin- ished. The same drum will give a higher or lower 56 PHYSICAL DIAGNOSIS. j)itched note on percussion, according as the head is tightened or loosened. The quality of the note in every case, however, will be tympanitic. The superficial area of cardiac dullness is diminished or may be absent altogether, only deep dullness on forcible percussion remaining. In certain cases of atroj^hous emphysema in advanced life, with hardened costal cartilages and peri-bronchial thickening from long-continued bronchitis, the per- cussion note in some places may be dull or even wooden in character, especially if the percussion be gentle. Auscultation. — The lungs being more positive refrac- tors of sound even than in health the respiratory mur- mur will be weakened, and if the bronchial tubes are, in addition, obstructed by mucus, owing to the bronchi- tis usually present, the respiratory murmur may be absent. Not unfrequently it is obscured by bronchial rales of various kinds. When the murmur is audible the inspiration is somewhat shorter than in health by being deferred, that is, the first part of inspiration is not heard, being too feeble. It is somewhat lowered in jiitch usually and is continuous with expiration, which is often prolonged, not so much from obstruction as from the weakening of the expiratory forces. The diaphragm is permanently depressed, the pulmonary tissue has lost its resiliency and the costal cartilages their elastic recoil. These expiratory forces have be- come so weakened, therefore, that expiration has to be performed chiefly by contraction of the muscular coats of the bronchial tubes, which are non-striated or invol- untary muscular tissue, and have become more or less h57)ertrophied. Consequently expiration is prolonged, EMPHYSEMA. 57 but otherwise it is relatively the same as in health, being lower in pitch than inspiration and blowing in quality. Should spasm of the tubes exist due to asthma, with which the disease is frequently associated, the expiration will be about four times longer than in- spiration, otherwise it will not be so much prolonged. Owing to the distended condition of the lungs the heart sounds are usually muffled and feeble. But on ac- count of hypertrophy of the right ventricle the second sound of the heart may sometimes be heard more dis- tinctly (accentuated) over the pulmonary than the aor- tic inter-space. As dilatation of the ventricle progres- ses, however, the accentuation becomes less. Should tricuspid insufficiency occur, the corresponding muraiur may be heard over the ensiform cartilage (see Tricuspid Regurgitation). Bronchial rales of various kinds, as already stated, may be present in varying quantity. Pectorophony (vocal resonance) is diminished, as a rule, for the same reasons that the fremitus is less. "When the vocal resonance and fremitus are increased or vary, it is due to some comjDlication, as stated when speaking of palpation. Differential Diagnosis. — Pneumothorax, or air in the pleural cavity, is the only disease that might be mistaken for emphysema, but even here a careful at- tention to the physical signs and history of the case renders the diagnosis usually easy. General vesicular emphysema affects both lungs, wdiereas pneumothorax is nearly always unilateral. Emphysema is developed gradually, pneumothorax comes on suddenly. In the latter disease exaggerated respiratory movements are 58 PHYSICAL DIAGNOSIS. observed on the unaffected side, while these movements on the affected side are diminished or almost entirely absent, with more or less bulging on that side. In gen- eral emphysema there are the barrel-shaped deformity of the chest, with the thoracic walls moving up and down as a solid case during respiration. In general emphysema the heart is displaced downward and usu- ally outward, with epigastric pulsation due to the low- ered and enlarged right ventricle. In pneumothorax the heart is displaced laterally, as a rule, and in a direction opposite to the pressure. Percussion yields tympanicity over pneumothorax, whereas the resonance is only exaggerated (vesiculo-tympanitic, band-box) and distributed over both sides of the chest in general emphysema. On auscultation the respiratory murmur is changed in rhythm in emphysema, and Aveakened, but in ^pneumothorax it is usually absent over the affected l^art. Pneumothorax from any cause is always an acute affection, coming on suddenly and lasting only a few hours or days. Effusion then takes place giving rise to pneumo-hydrothorax (or pneumo-pyothorax), to be detected by the splashing sound heard on succussion. Emphysema is more slowly developed, is usually clironic, and for these and the other physical signs already mentioned, vicarious emphysema, affecting one side, is readily distinguished from pneumothorax. Pleurisy, j)neumonia, and hydrothorax, although caus- ing dyspnoea, also yield dullness on percussion and other physical signs altogether different from those of emphysema. In phthisis there is also dyspnoea, but the signs of consolidation of lung tissue are entirely different from those of emphysema. ATELECTASIS. 59' ATELECTASIS. Atelectasis (apneiimatosis, pulmonary collapse) is a disease characterized by collapse or imperfect dilatation of the pulmonary vesicles, and is the very opposite condition to emphysema. It is usually situated at the periphery and not the interior of the lungs, but otherwise the site and extent of area differ according to the cause in each particular case. Atelectasis may be congenital or acquired. In the first place the foetal lungs are in a j)liysiological state of atelectasis, but this disappears as soon as the child is born and breathes freely, all the conditions being favorable. Anything, therefore, that interferes with the resj)iration of the child at birth may cause more or less congenital atelectasis. Among these causes may be mentioned premature birth, in which case there is not only weakness of the muscles of res- piration, but also a want of irritability of the respira- tory centre. Accidental plugging of the respiratory tract with mucus, binding the newly born child too tightly, so that the movements of the diaphragm are interfered with, and prolonged and complicated labor, including accidents to the cord, may give rise to con- genital atelectasis. Acquired atelectasis may be due to (1) obstruction,, (2) compression, or it may be (3) marasmic. 1. Atelectasis due to obstruction is sometimes the result of cai^illary bronchitis occurring in weak infants. The calibre of the tubes is diminished by the swollen mucous membrane and becomes obstructed by the se- cretion of fluid due to inflammation. Owing to weak- 60 PHYSICAL DIAGNOSIS. ness of the inspiratory muscles of such Aveak infants the obstruction is not overcome by inspiration, and the air already in the cells becomes absorbed, the oxygen first, and then the carbonic acid. Collapse of the cells results. But where the child is strong enough, or among adults, emphysema results instead of atelectasis, as inspiration would then be strong enough to over- come obstruction, biit the air could not escape — expira- tion being weaker than inspiration with regard to the air^ cells. In these cases atelectasis is found on both sides over the lower and posterior parts of the lungs, and extending usually in a narrow space up by the sides of the spinal column, disappearing toward the apices. Other causes of obstruction may be blood clots, fibrinous exudations, bronchial stricture, and pressure on a tube by enlarged lymphatics or other tumors. The atelectasis would then occur in areas correspond- ing to the distribution of the compressed tubes. 2. Atelectasis may be due to compression of the perii)hery of the lungs, as in pleurisy or pericarditis with effusion, enlargement of the heart, aneurismal or other tumors, hydrothorax, and deformities. Here the site of the atelectasis will, of course, depend on the cause in each case. 3. Finally, we may have what Eichhorst terms maras- mic atelectasis. Whatever diminishes the irritability of the respiratory centre, and weakens the muscles of respiration will contribute to the atelectatic state. Hence we sometimes find it in typhoid or other pro- longed and wasting fevers, paralysis, and brain affec- tions. In such cases the position of the body should not be allowed to remain unchanged during too great ATELECTASIS. 61 a length of time. Otherwise certain parts of pulmo- nary tissue, from want of respiratory movement, become more or less devoid of air, which has become partly or w^holly absorbed, leaving atelectasis. The most de- j)endent portion of the lungs are the most frequently affected in marasmic atelectasis. Physical Signs. — In congenital atelectasis, inspec- tion usually shows retraction of the epigastrium and sinking in of the intercostal spaces on inspiration. This is owing to the fact that the lungs fail to expand sufficiently to fill up the thoracic cavity during inspira- tion, and hence the yielding j)ortions of the chest walls are sucked in by that act. The breathing is rapid and shallow, with the interval between inspiration and ex- piration instead of between expiration and inspiration as it is in health. Palpation shows no increase of vocal fremitus as a rule, the collapsed air-cells still acting as a refractive medium of sound, thus differing from solidification due to inflammation or compression, when it conducts sound with corresponding increase of vocal fremitus. On gentle percussion there is some dullness, not as much as in solidification. If atelectasis be ex- tensive, slight tympanicity from bronchial tubes may result. On auscultation the respiratory murmur is weakened or suppressed instead of being bronchial, as would be the case in solidification from inflammation or compression. This is also due to the fact that the collaj)sed cells refract sound instead of conducting it. Hence also, pectorophony (vocal resonance) is also diminished or weakened. Occasionally, according to Walshe, there is a little dry rhonchus, probably due to coincident bronchitis. 62 PHYSICAL DIAGNOSIS. In acquired atelectasis the physical signs depend ujion the cause. In obstruction and marasmic atelec- tasis various rales may usually be heard, in addition to the signs already mentioned, owing to the bronchitis present. Obstructions would also be an additional cause for weakened or diminished pectorophony, frem- itus, and resj)iratory murmur. But in compression atelectasis, the physical signs are more like those of solidified lung tissue, in which the part affected be- comes a conductor instead of a refractor of sound (see Physical Signs of Lobar Pneumonia). Palpation, ac- cordingly, shows increased vocal fremitus over the com- pressed lung, dullness on percussion, and bronchial breathing with bronchoj^hony on auscultation. The physical signs of the cause of the compression, as aneurism, pleurisy, and the like, will also be present. Differential Diagnosis. — Pneumonia is attended with fever, atelectasis is not. Retraction of the e^Digas- trium and intercostal spaces during inspiration is more noticeable in atelectasis than in pneumonia. The bron- • chial breathing and bronchoi^hony of pneumonia are not observed in any but compression atelectasis, and then the cause of the compression will be apparent. The dullness on percussion in all but compression ate lectasis is usually slight and symmetrical. In lobar pneumonia it is unilateral, and in lobular pneumonia a spot of dullness on one side does not necessarily, or usually, have its exact counterpart on the opposite side, as Loomis truly states. According to Grailey Hewitt, extensive deposit of miliary tubercle may be mistaken for atelectasis, but the former is accompanied by fever and emaciation, and perhai)s the parents of PULMONARY CONGESTION. 03 tlie child have a tuberculous his tor}'. In hemorrhagic infarction the etiology differs, and besides the percus- sion dullness, and rales, there is bloody expectoration. Compression atelectasis might be mistaken for one of its causes, pleurisy with effusion. But the effusion occurs at the bottom of the thorax, the compression of lung above. Over the effusion there is a well-marked line of dullness (or flatness) with diminution or absence of the respiratory murmur, vocal fremitus and reso- nance, and these signs often change with position of the patient. Over the compressed lung the fremitus and resonance would be increased, as the compressed lung would be a better conductor of sound than in health. The breathing, instead of being absent, would be bronchial. To set all doubt at rest, exploratory puncture with the hypodermic syringe may be resorted to. In all cases of compression atelectasis, the cause should be ascertained, if possible. PULMONARY CONGESTION AND CEDEMA. Pulmonary hypersemia (or congestion) is character- ized by excess of blood in the lungs and may be (1) active, (2) passive, or (3) hypostatic. 1. Active hypersemia (congestion, affluxion, or flux- ion) of the lungs, may affect any part of the lungs. It may be caused by direct irritation of lung tissue either from the action of cold or inhalation of irritants, or anything that will cause inflammation. Or it may be due to excessive heart's action from any caase like hy- pertrophy, emotion, stimulants, or violent effort. It occurs also as a collateral fluxion, some capillaries be- ing over-distended, due to obstruction in others, as seen 64 PHYSICAL DIAGNOSIS. in the immediate vicinity of inflammatory foci, in pneu- monia for instance. It may also be caused by rarefac- tion of air in the lungs, as occurs in croup on account of violent efforts at insj)iration with the glottis obstructed. 2. Passive hypersemia is caused by mitral obstruc- tion or regurgitation. In the former the blood is pre- vented from escaping from the lungs properly, and in the latter it is forced back upon the lungs. In either case the pulmonary capillaries are over-filled. This is usually described as mechanical or obstructive hyper- gemia, but as it is also passive there is no necessity for a separate description of it. This form of congestion often leads to brown induration of the lungs (cardiac pneumonia so-called). Enfeebled heart's action, as oc- curs in typhoid fever, puerperal fever, pyaemia, and in certain centric nervous diseases favors the occurrence of passive hyperemia, because the left heart having more work to do than the right, fails to empty the pul- monary capillaries as rapidly as they are filled. Hence they become congested. 3. Hypostatic hypergemia (congestion) is also a pas- sive congestion due to enfeebled heart, but has an addi- tional cause for its jDroduction, and that is the retention of the body in one position for a long time, as may occur in typhoid fever, paralysis, and fractures, especially among the aged, requiring them to remain in one posi- tion for a long time. Hypostatic congestion is so named because it is a stasis of tlie under part, or a congestion affecting the most depending parts, and hence is usu- ally found posteriorly in both lower lobes. Hence the necessity for changing the position of such patients oc- casionally. PULMONAKY CONGESTION. 65 The physical signs of i)iilmonary congestion are simi- lar to those seen in the first stage of lobar pneumonia, before any exudation has taken place. Iiujyection. — Dyspnoea will usually be observed, and it will be marked in proportion to the amount of con- gestion. In certain cases of hypostatic congestion, however, owing to want of irritability in the respiratory centre, as may occur in the course of protracted illness of a typhoid character, dyspnoea may not be x)resent to noticeable degree. In both passive and hypostatic congestion there may be more or less cyanosis. The sitting, rather than recumbent posture, is usually pre- ferred by the patient. Palpation. — The vocal fremitus is usually normal or even diminished, as the air-cells are in a slightly em- physematous condition, owing to tumefaction of mucous membrane and diminution in calibre of the entrances into the air passages, or termini of the bronchioles. For this reason air enters somewhat more freely than it escapes, as similarly occurs in asthma. The lungs, therefore, being equally as good, or better refractors of sound than in health, the fremitus, as already said, will in some cases be diminished. Percussion. — As might be expected from the slightly emphysematous condition of the affected part, the i^er- cussion resonance may be exaggerated. Yery often, however, it is normal. Tymj^anicity is spoken of by some authors, but it is rare. That quality of X)ercussion sound might be obtained in case of very thin chest walls and marked tension of the pulmonary tissue. Should cracked-j)ot resonance be obtained it would have no connection with the condition of the lungs, 5 66 PHYSICAL DIAGNOSIS. but would be due to concussion of air in the bronchi, as sometimes occurs in children in health and others with thin and yielding chest walls, or to concussion of air in the naso-i)harynx. Auscultation. — The respiratory murmur may be weakened for obvious reasons, or it may be normal, de- pending on the amount of obstruction at the entrance into the air-cells. Expiration may be slightly prolonged as in asthma. Pectorophony (vocal resonance) would be normal or diminished like the fremitus. The only adventitious sound that would be due to the conges- tion, would be a very fine sibilant rale heard on expira- tion, and this may be absent. Any other adventitious sound would indicate complication, such as oedema, or the occurrence of inflammatory exudation, both of which would give rise to the crej^itant rale heard at the end of inspiration. Differential Diagnosis. — This, according to Walshe, is based on the association of sudden dyspnoea and general anxiety with the positive and negative phys- ical signs just enumerated, slightly increased circular measurement of the chest, due to moderate distention of air-cells, exaggerated percussion resonance, and the absence of signs of pleurisy and iDueumonia. PULMONARY CEDEMA. Pulmonary oedema, or dropsy of the lungs, occurs when the i)ulmonary vesicles become the seat of a serous transudation. In some cases the fluid extends into the smaller bronchi, and in others the interstitial tissue may become infiltrated. As a result of the last condition splenization (Loomis) of the lung occurs. PULMONARY (EDEMA. 67 Usually the transuded fluid is colorless, but sometimes it is rose colored from being tinged with blood. Pul- monary oedema is not a primary disease, but is always secondary to, and symptomatic of, some other condi- tion, congestion from some cause as already described, or general dropsy. In the latter case a transudation of the watery parts of the blood takes place, not from the pressure of hyjpersemia (congestion), but from the mor- bidly increased permeability of the blood-vessels. The location of the oedema will be influenced by the cause in each case. It may be confined to a small spot at any part of one lung, or it may extend over a lobe or entire lung, or even both lungs. Usually, however, it is found low down posteriorly on both sides, as the causes which place it there are most fre- quent — passive and hypostatic congestion — and also because it is more readily discovered there than in other localities. It may evidently occur in both sexes at all ages. Inspection^ as in congestion, shows more or less dyspnoea, according to the extent of the oedema. The dyspnoea is more urgent than in congestion for the same amount of lung tissue involved. Cyanosis may be observed in some cases. The iDatient usually prefers the sitting posture. Palpation. — The fremitus is usually unchanged, as the air-cells still contain some air and may be even weakened as in congestion. According to Walshe, however, in well-marked cases the fremitus may be slightly increased. Percussion yields more or less dullness as a rule. Before the oedema is well marked the air-cells may be 68 PHYSICAL DIAGNOSIS. slightly more distended with air than before, as in con- gestion. For this reason the percussion note may be exaggerated. But as the cells become more filled with fluid and contain less air, the percussion note becomes duller. Tympanicity and cracked-x)ot resonance are among the possibilities here as elsewhere. Auscultation. — The respiratory murmur and pecto- rophony (vocal resonance) are either normal or weak- ened, as in congestion, or else increased in intensity in well-marked cases. During insiDiration, loud, liquid, crepitant rales are heard over the sire of the oedema, and this is the chief physical sign. They are bubbling rales made in the air-cells and are not intrapleural. In some cases, sub-crepitant rales are also heard. Differential Diagnosis. — The chief points of differ- ence between the physical signs of congestion and oedema of the lungs are that in oedema, slight dullness on percussion and loud liquid crepitant rales on auscul- tation are obtained. In congestion the percussion reso- nance is exaggerated and there are no rales until oedema or exudation occurs. In the latter case the crepitant rale is much finer and not so liquid as in oedema. From hydrothorax oedema is distinguished by the fact that the line of dullness in hydrothorax usually changes with position of the patient. The dullness in hydrothorax is also much more marked and may even be fiat, and crepitant rales will not be heard over the seat of the transudation. In capillary bronchitis there is more or less fever and the sputa are different, being more tenacious and scant than in oedema. Moreover in capillary bronchitis the percussion resonance is ex- aggerated instead of dull. CHAPTER III. Diseases in which the breath and voice sounds are conducted to the chest walls with consequent increased vocal fremitus, respiratory murmur and pectorophony. — Bronchial breath- ing and bronchophony. — Solidified lung tissue. Pneumonia, or pneumonitis, signifies inflammation of lung tissue, and consists of three varieties according to the iDathological condition: (1) lobar, (2) lobular, and (3) inter-lobular, pneumonia. Each of these varieties is also known by other names, as will be seen. Hypo- static pneumonia, so-called, may be either lobar or lobular (see Hypostatic Congestion of the Lungs). LOBAR PNEUMONIA. Lobar pneumonia, so named from the fact that this variety of the disease usually affects a whole lobe, or even more, may be primary or secondary. It is com- monly an acute disease, although in somewhat rare cases it may become subacute or even chronic. It is characterized by inflammation of the mucous mem- brane lining the air-cells, and this inflammation in some cases may even extend uj) into the bronchioles, the reverse process of what occurs in lobular pneu- monia. From the character of the exudation it is some- times called croupous pneumonia, a term first applied by Rokitansky. According to Yirchow and others, however, this term should only be axox^lied to those 70 PHYSICAL DIAGNOSIS. cases that result from laryngeal croup, and in other cases, the exudation being fibrinous, it should be called fibrinous pneumonia. On the other hand, Hoffmann, Flint, and some French authors, regard neither as cor- rect, and suggest pneumonic fever as the true definition. The disease is known among the laity in New England, and other parts of the United States, as lung fever. Again, owing to its affecting the parenchyma, or secre- ting structure of the lung, it is sometimes called paren- chjTuatous pneumonia, although this is true also of lobular pneumonia. Acute primary lobar (croupous, croupal, fibrinous^ exudative, parenchymatous) x^neumonia, peripneumo- nia or pneumonic (lung) fever, is said by some to be an infectious disease or sj)ecific fever, of which the lung affection is only a local manifestation. By others it is claimed to be a local inflammation with resulting symp- tomatic fever. It is also yet a matter of dispute as to why it usually affects the lower lobe of the right lung. Advocates of the infectious theory say that the right primary bronchus being larger than the left, pneumo- cocci are drawn into the right lung in greater abun- dance than into the left, and naturally drift downward toward the most dei^ending x^ortions. The order of frequency with which the different lobes are attacked is as follows: lower lobe of right lung, lower lobe of left lung, middle lobe of right lung, upx)er lobe of right lung, upper lobe of left lung. Or it may extend from one lobe to another on the same side, or it may attack two lobes on different sides. In the latter case it is said to be double pneumouia. In cases where an upper lobe is primarily attacked, it usually LOBAR PNEUMONIA. 71 occurs among the aged or those addicted to intemper- ance, especially just after or during a debauch, pneu- monia iDotatorum (Huss). Exposure incident to the intoxicated state, added to the debilitated condition caused by hard drinking, may in some measure account for it. The disease aifects both sexes at all ages, but men more frequently than women, owing chiefly to differ- ence in habits, occupation and mode of life. In more than three thousand cases collected by Barry, nearly five times more men than women were affected. The proportion is usually estimated at about three to one. According to Schramm this proportion is reversed in old age. However this may be, it appears that the dif- ference is not so marked at those ages when the sexes live under similar conditions. In regard to age, according to GrisoUe, Wilson Fox and others, although lobular pneumonia, when it does occur, is found chiefly among children and old people, yet these two classes are subject also to lobar pneumo- nia as well. Lobar pneumonia is, according to the same authors, very frequent in infancy, especially during the first two years of life, less common between infancy and twenty years of age, quite frequent from twenty to forty, less so from forty to sixty, and very frequent after sixty years of age. According to Loomis, nine-tenths of all deaths after the sixty-fifth year are caused by lobar j)neumonia. Lowering vitality from any cause, such as improper and insufficient food, exhaustioji from overwork, intemperance, or previous illness, and living in ill- ventilated and damp apartments, predisposes to 72 PHYSICAL DIAGXOSIS. it. One attack also predisposes to a second or more, although subsequent attacks are generally not so severe as the first. Cardiac diseases that obstruct the j)ulmonary circu- lation favor an attack. Tlie disease is more common in variable climates than in those of uniform tempera- ture, and hence is not met with in the tropical or polar but in the temperate regions, and hence also it is more prevalent at certain seasons of the year. Epidemic influenza appears to exert an influence in the produc- tion of pneumonia. Exposure to wet and draughts of cold ai^pears to act as an exciting cause in some cases. Inhalation of chemical irritants, injuries, and foreign bodies in the air passages, may also act as exciting causes in a small proportion of cases. Tilten found that in 320 cases, only 4.5 per cent, were connected with traumatism. Secondary lobar pneumonia occurs as an intercurrent affection in the course of some exhausting disease, as chronic malaria, Bright's disease of the kidneys, dia- betes melitus, and also in such diseases as measles, scarlet fever, small-pox, erysipelas, typhoid and tj^phus fever, rheumatism and pya3mia. Hypostatic; pneumonia, when it occurs, succeeds hy- postatic congestion, which is a passive congestion tak- ing place in the most dependent jiortions of the lungs, and hence is frequently bilateral. It may be lobar or lobular (see Congestion of the Lungs). It is due to im- perfect cardiac function from valvular lesion, or cardiac- enfeeblement from some cause, and hence is seen in tlie aged and infirm, or in the course of typhoid fever or LOBAR PNEUMONIA. 73 other exhausting disease with the body in one i:)osition for too great a length of time. It may also follow ex- cessive loss of blood from injuries, parturition and the like. On the other hand, pneumonia rarely affects the lungs in emphysema, probably on acount of loss of capillary area with diminished circulation of blood in the lungs in that disease. Stages of Lobar Pneumonia. — It is usually divided into three stages, not counting incubation, Avhich, ac- cording to different authors, varies from a few hours to two or three weeks. The first stage, or that of congestion, varies usually from a few hours to twenty-four hours. The second stage, or that of red hepatization or solidification, lasts in ordinary cases about four or five days, so that the crisis, as indicated by the sudden fall in temperature, occurs from the fifth to the eighth day. The third and last stage is that of gray hepatization or resolution, and lasts about eight days, so that by the end of the second week from the commencement of the disease, the patient, in ordinarily favorable cases, is rapidly con- valescent. The duration of the different stages, how- ever, is subject to many variations. The i)liysical signs usually become apparent wdthin twenty-four to forty- eight hours from the first symptoms of the attack, but, according to Wilson Fox, they may be delayed three or four days, showing that the pneumonia was proba- bly central at first. If it remain central no marked lohysical signs may be observed at all, but such cases must be very rare. The physical signs of the different stages are usually as follows : 74 PHYSICAL DIAGNOSIS. Inspection. First Stage. — Diminution of respira-. tory movements on the affected side, and exaggerated respiration on tlie unaffected side. Also marked ab- dominal breathing if there be no diaphragmatic pleu- risy and the diaphragm be left free. Pain in the side is usually j)resent, and, if severe, the respiration Avill be jerking, the patient favoring the affected side on each inspiration. The respiratory movements are in- creased in frequency. The apex-beat of the heart, if noticed at all, will be in its normal position unless dis- placed by some complication. The cheeks are usually red, sometimes only one, and that on the affected side, which is simply a coincidence. The patient may lie on the affected side at first, so as to restrain the move- ments of that side if the pain is severe, as well as to allow free motion on the unaffected side. Afterward the dorsal decubitus, or half-sitting posture, is usually preferred. Palpation. First Stage. — The vocal fremitus is nor-" mal or even diminished before exudation commences. But soon it becomes exaggerated over the affected lobe, which is rapidly becoming a better conductor and less of a refractor of the voice sound, as the air-cells be- come obliterated. Complications like thickened j^leura, or pleurisy with effusion over the site of the pneumonia, obstruction in the bronchi by pressure from some cause, or from plugging with viscid mucus, or diminishing their calibre by the congestion, would cause the fremi- tus to be diminished or absent. The skin is usually liot and diy, x>ulse increased in frequency, 80, 100, 120, and the apex-beat of the heart, if felt, would be in the normal position, unless displaced by complication. PLATE I. Acute Lobar Pneumonia — Lower Lobe RigKt Lung. First Stage, Congestion. Crepitant Rale. DRAWN BY H.MACDONALO M.O. N.Y. LOBAR PNEUMOlSriA. 7o Percussion. First Stage. — Slight dullness is some- times observed early in this stage, but sometimes the resonance may be exaggerated or even tympanitic, and occasionally cracked-pot resonance is noticed (see Tym- panitic Resonance, and Cracked-pot Resonance). Gutt- mann and Eichhorst account for tympanicity and cracked-pot resonance in this stage and the third by "relaxation of the pulmonary parenchyma, which is filled with fluid containing air, and sometimes to con- cussion of air in the bronchi." According to Walshe, exaggerated resonance is more frequent than slight dullness in this stage. If the disease be central or a small area involved there will be no change in the per- cussion note from health. This diminished vocal frem- itus and exaggerated percussion resonance is due to the slightly emj)hysematous condition of the air-cells as already mentioned, on account of obstruction to the exit of air from the air-cells owing to swelling of mu- cous membrane in the air passages, which, however, is not sufiicient to prevent the entrance of air. Auscultation. First Starge. — In the earliest period of engorgement the respiratory murmur may be weak- ened, owing to obstruction due to swelling of the mu- cous membrane. Soon, however, it begins to lose its vesicular quality and becomes vesiculo-bronchial. Over the healthy i)ortions it may be somewhat exaggerated. Crepitant rales are sometimes, not always, heard over the affected lobe. They are heard at the end of in- si)iration, very rarely on expiration (Walshe), and are fine crackling rales which sound like rubbing a lock of hair between the thumb and finger over the ear, or like ihe crackling of fine salt when thi'own ui^on the fire. 76 PHYSICAL DIAGNOSIS. There are two theories as to their mode of production. One is that they are produced in the air-cells by the sep- aration of the agglutinated cell-walls at the end of in- spiration or by viscid exudation and air in the cells, or stretching of the inter- vesicular tissue ; and the other is that they are line, dry, j^leuritic friction rales, and are only present when the pleura is involved. During the latter jynvt of inspiration, when the pleural mem- branes rub together, the visceral and parietal, instead of their gliding noiselessly on each other as in health, there is ]3roduced an abundance of fine crackling fric- tion rales. Both of these views are still held by differ- ent authors. It is more probable, however, that the old theory is the correct one, that they are produced in the air-cells, however closely they may be imitated by pleuritic rales. They are uniform in size and are not changed by coughing, nor do they disappear until the second stage, reappearing in the third, and hence termed the rale redux. Pectorophony (vocal resonance over the chest), like the fremitus, may be normal or even diminished at first, but soon it usually becomes exaggerated. The chief physical sign in the first stage is the crepi- tant rale, heard at the end of inspiration and over the affected lobe when present, but it is sometimes absent, and very often the disease has passed already into the second stage before the case is seen. Other rales and adventitious sounds may be j^resent, owing to complica- tions Inspection. Second. Stage. — This gives a similar result as in the first stage. The respiratory movements are increased in frequency, being shallow and pant- LOBAR PNEUMONIA. 77 ing, more or less restrained on the affected side and in- creased on the other, especially during a full insj^ira- tion. Diaphragmatic resj)iration will be x>rominent unless restricted by pain. Palpation. Second Stage:— The vocal fremitus is usually markedly increased over the solidified lobe. This is owing to the fact that the solidified lung tissue affords an unbroken, homogeneous medium for the conduction of waves of sound, instead of refracting them, and hence they reach the chest walls with much greater force, with consequent increase of fremitus, than in health, where the air-cells act as a powerful re- fracting medium. When, however, a whole lung be- comes solidified, with obstructions of the bronchi, so that the voice sound cannot enter the lung, the vocal fremitus may be diminished or even absent. The same is true if the bronchi be obstructed from any cause, or if the thickened pleura, or pleurisy with effusion, exist on the same side. Percussion. Second Stage. — The note is usually markedly dull in quality over the affected lobe, and consequently the pitch is high, the duration short, and the intensity or amount, in the sense of volume or amplitude, diminished. The percussion resonance is somewhat exaggerated over the healthy lung tissue, especially over the adjoin- ing border of the next lobe. This is due to a tempo- rary vicarious emphysema which varies in different cases. The boundaries of dullness and resonance in pneu- monia do not change with position of the patient. When the whole lower lobe is affected the line of dull- 78 PHYSICAL DIAGNOSIS. ness in front extends upward and outward along the interlobar fissure. Occasionally the peroussion reso- nance over the solidified lobe may be tympanitic, or even cracked-pot, according to Guttmann. In the upper lobes, this Skodaic resonance of tympanicity, obtained sometimes while percussing over solidified lung tissue, (or even effusion), is due to proximity to the primitive bronchi or the trachea, or both. Tympanicity in such cases, however, would be attended with a sense of re- sistance on palpatory percussion, which would not be felt on percussion in the case of x)neumothorax, for in- stance. Over the lower lobes Skodaic tympanicity is often due to the fact that the force of the jjercussion blow extends to an empty stomach or transverse colon, es- pecially in children, or " relaxed pulmonary paren- chyma near the solidified portion." According to Gutt- mann the cracked-pot resonance, very rarely met with in this stage, is due to sudden expulsion of air from the larger bronchi leading to the affected lobe. It might probably be also due to concussion of air in large bronchi, or the trachea if the seat of the disease be in the upper lobes, and is usually noticed in children or those with thin and yielding chest walls. Auscultation. Second Stage. — The respiratory mur- mur as heard over the solidified lung tissue is known as broncliial breathing. It is simply laryngo-tracheal breathing conveyed along the bronchial tubes to the solidified tissue, and by the latter it is raised in pitch and conducted with considerable force to the chest walls, unmodified by air-cells. It has, therefore, not acquired any vesicular, breezy, or rustling quality, but PLATE II. Acute Lobar Pneumonia — Lower Lobe Right Lung. Secqnd Stage, Red Hepatization or Complete Solidification, Vocal Fremitus markedly increased. Bronchial Breathing and Bronchophony. DRAWN BY H.MACDONALO M.D.N.Y. LOBAR PNEUMOISriA. 79 simi^ly remains intensely tubular usually, and liigli- pitclied, both on inspiration and exi)iration. The lat- ter is usually higher j)itched than inspiration because of the natural conformation of the larynx. Inspiration is unfinished, so that this form of respiratory murmur is said to be divided, and the interval between inspira- tion and expiration will be marked in proportion to the amount of solidified lung. Inspiration and expiration are, therefore, not continuous, and expiration is as long as inspiration, or even longer. Owing to the shallow, panting respiration in pneumonia, both the inspiratory and expiratory murmurs are, however, rather short. Bronchial breathing may be represented somewhat by the following diagram: Fig. 12. — Bronchial Breathing. Bronchial breathing is more intense than the normal respiratory murmur in the sense of concentrated amount. It sounds something like blo^\'ing gently across the mouth of the stethoscope. A close imitation of it may be obtained, as Guttmann aptly suggests, by placing a piece of liver, which resembles hepatized lung- tissue, in a tin or other tube, with a thin membrane over each end, and listening' through it to tracheal breathing. Although Dr. AValshe and others describe this murmur as being sometimes blomng in quality, it is always more tubular than blowing, and the latter de- scription is misleading. It is always tubular, but more 80 PHYSICAL DIAGNOSIS, markedly and distinctly tubular sometimes than at others. Pectorophony (vocal resonance) is greatly increased in intensity in the sense of concentrated amount, not volume; and as the voice usually (not speech) is only heard, it is called bronchophony (bronchial voice). This term was first applied by Laennec, of Paris (about 1820), in contradistinction to his pectoriloquy (chest- speech). The latter is usually low-pitched and refers to the ar- ticulate words often heard over cavities. But some- times, as is well known, we hear the articulate words (bronchiloquy) over consolidation. Should the voice be whispered, as Flint suggested, we should get whispered bronchophony, or whispered bronchiloquy over consoli- dated lung tissue, as the case might be. Bronchophony (or bronchiloquy) is necessarily high- pitched, because the voice sound, in case of consolida- tion, passes from one medium into a denser medium with shorter vibrations and consequently raised pitched. Normal pectorophony (vocal resonance) is a dis- tant, diffused, indistinct, somewhat low-pitched, buz- zing sound. Bronchophony (and bronchiloquy) is just the reverse, being near, concentrated, distinct, and high-pitched. When whispered it is tubular in quality, cavernous Avhisper being often low-pitched, and blowing. In percussion the low note is more in- tense in the sense of volume, but in bronchophony (and bronchiloquy), which is higli-pitched, the intensity is increased in the sense of concentrated amount. Should thickened pleura or effusion intervene, both bronchial breathing and bronchophony may be weak and distant, and the respiratory murmur may even be LOBAIi PNEUMONIA. 81 entirely inaudible. So may whispered bronchophony, but if the patient speaks loud enough bronchophony will be heard. It will, however, be distant and weak. Aegophony (goat's voice), according to some authors, is heard in this stage, being due to fluid in bronchi that are surrounded by solid tissue. It is quite rare, being more often heard in pleurisy with effusion (see Pleurisy). The heart sounds may be conducted to the chest walls with markedly increased intensity, especially if the disease be on the left side. No rales or other ad- ventitious sounds are heard unless due to comx)licating bronchitis or other disease. Third Stage. — During this stage of gray hepatization or resolution, in favorable cases, there is a gradual re- turn to the normal physical signs. At first they re- semble those of the second stage, but soon inspection shows a return of the normal respiratory movements of the chest walls. On palpation the vocal fremitus diminishes over the affected part until it becomes nor- mal, and the marked dullness on percussion gradually yields to normal resonance. Tympanitic and even cracked- j)ot resonance, as already explained, may, how ever, occur in this stage. On auscultation, bronchial breathing first becomes vesiculo-bronchial, then normal, and bronchoj)hony yields to exaggerated pectorophony (vocal resonance) which subsequently becomes normal. Subcrepitant and crepitant rales — the latter termed the rale redux, or rale that has come back, having disap- peai-ed in the second stage — are usually present until resolution is conajDlete. Abscess and gangrene are rare terminations. In both there are signs of a cavity, with symptoms of general collapse. The former is also at- 82 PHYSICAL DIAGNOSIS. tended with profuse expectoration of xdus, the latter with foetid prune-juice expectoration. Differential Diagnosis. — In cases of central pneu- monia with healthy x^eripheral cell tissue the diagnosis may be very difficult. Such cases are comparatively rare, however, and in addition to the history of the disease the character of the sputa would be of great service. In oedema and hyj^ostatic congestion loud liquid crepitant rales are heard, usually on both sides posteriorly and low down, or wherever the most de- pendent portions happen to be, and the sputa, though blood-stained, are abundant and watery instead of the characteristic rusty colored viscid sputa of pneumonia. These affections, besides being frequently associated with some other disease, are also unaccompanied by the chill, pyrexia and pain of jmeumonia, and there is slight instead of marked dullness, with absence of bronchial breathing and bronchophony. Lobular pneumonia, inter-lobular pneumonia, and tubercular consumption, besides tumors of various kinds, aneurismal, syphilitic, or carcinomatous, as well as enlargements of the sjjleen and liver, may give more or less signs of abnormal solidification within the thoracic cavity, but absence of the characteristic sputa of lobar i)neumonia, as well as the general symptoms of that disease, with attention to the physical signs as already detailed, will usually lead to a correct diagnosis. The vocal resonance and fremitus will be diminished or absent, and bronchial breathing and bronchophony will be wanting usually over enlarged liver and spleen. Acute pleurisy with effusion gives different physical signs from pneumonia, and it is by these alone that a PLATE III. Xr^rf'C^-^ Acute Lobar Pneumonia — Lower Lobe Right Lung. Third Stage, Gray Hepatization or Resolution. Crepitant (Rale Redux) and Subcrepi- tant Rale. DRAWN BY H.MACDONALO M.D.H.Y. LOBAR PNEUMONIA. 83 positive diagnosis can be made. Otherwise it very closely resembles pneumonia in some resi)ects. In jDneumonia the solidified lung tissue acts as a conduc- tor, but pleurisy with effusion (and even thickened j)leura) acts as an interrupter of sound, as a diaphragm or partition placed between the examiner and the pa- tient's voice sound. Consequently, while in pneumonia the vocal resonance and fremitus are. both markedly increased with bronchial breathing and bronchial voice (bronchophony), in pleurisy with effusion the vocal resonance and fremitus will be usually diminished or even absent, as also the respiratory murmur. The line of dullness or flatness in j^leurisy increases downward, and, moreover, often changes with x^osition of the pa- tient, but does not in pneumonia. In cases of doubt the hypodermic syringe as an asj^irator would set the matter at rest, but this step is hardly ever necessary. Hemorrhagic infarction may be attended with crepi- tant and subcrepitant rales, but it comes on suddenly and usually in connection with heart disease, and some- times pyaemia. Sudden dyspnoea occurring in these diseases, with a small circumscribed area of dullness surrounded by rales, without notable increase of tem- perature, the expectoration, if any, being usually dark colored, would indicate infarction. Symptoms of ty- phoid and typhus fever, meningitis, and delirium tre- mens, might be the cause of over-looking pneumonia, the real source of the trouble. Hence the necessity of a careful j)hysical examination when such sjmiptoms are observed in children, old people, drunkards, or strangers, whose habits and previous condition are un- known. Secondary and hypostatic pneumonia may 84 PHYSICAL DIAGNOSIS. easily escape detection unless physical examination be carefully resorted to and the patient watched. LOBULAR PNEUMONIA. Lobular pneumonia is the inflammation of the lining membrane of the air-cells of one or more lobules. The difference between this and lobar pneumonia was first pointed out by Barthez and Rilliet in 1838, although its true jDathology was not clearly shown until 1844, when Legendre and Bailly first proved it. Until then it was frequently confounded with atelectasis. As it is usu- ally secondary to bronchitis and due to the extension of the latter into the air-cells here and there in spots, it is also called Broncho-Pneumonia, or Catarrhal Pneu- monia.. From the fact that it affects infants more fre- quently than it does adults, it is also called by some In- fantile Pneumonia. This does not imply, however, that lobar pneumonia does not also attack infants, for it is more common even among them, according to many authorities, than lobular j)neumonia. The latter dis- ease also attacks the aged, so that it is met with during the extremes of life, and among others with enfeebled or crippled heart from some cause. It may occur, how- ever, at any age, and with either sex. It is not infre- quently met with in connection with capillary bron- chitis during the course of such diseases as measles, scarlet fever, diphtheria, small-pox, and typhoid fever, and it is sometimes secondary to pyaemia. Hypostatic pneumonia occurring in the course of exhausting dis= eases, as already remarked when speaking of lobar pneumonia, is often of the lobular variety, with a ten- dency, however, to spread. From wliat has been said, LOBULAK PISTEUMOXIA 85 lobular pneumonia may occur on one side or it may be scattered about over both lungs. The physical signs are often obscure from the nature of the case. They are usually bilateral, but not neces- sarily symmetrical and to the same degree. Irmpection usually shows in children panting and shallow respiration, the inspiration being short and ex- piration somewhat prolonged. There are exaggerated movements of the alse nasi. The upper portion of the chest heaves, the lower portion and abdominal walls being sometimes drawn in during inspiration, but the supra-clavicular and intercostal spaces are not drawn in so much as in atelectasis. Cyanosis to a variable de- gree may be observed in cases where the disease ex- tends over a considerable area. Palpation. — Increased vocal fremitus may be de- tected if the consolidation is sufficiently extensive, but otherwise it will be unchanged. Percussion elicits dullness in proi^ortion to the amount of consolidation, and the dullness will be over the seat of the disease, usually posteriorly over the lower lobes. It is not infrequently bilateral, but thfe dullness is not necessarily obtained over symmetrical areas, as usually occurs in atelectasis. Sometimes exag- gerated resonance due to emphysema of cells near by, obscures the dullness, and even tympanicity on percus- sion, as already explained, is sometimes obtained. The percussion should be gentle, and the finger is the best pleximeter in these cases to detect the feeling of resist- ance afforded -by solidified lung tissue. Auscultation.— In addition to the bronchial rales due to the co-existing bronchitis, there may be heard . 86 PHYSICAL DIAGNOSIS. bronchial breathing and bronchoj^hony if there be suffi- cient amount of consolidation. Differential Diagnosis. — The disease, if confined to one or a few small foci, may entirely escape detection. If, however, in the course of capillary bronchitis there is a sudden rise of temperature and increased dyspnoea, it is fair to infer that lobular pneumonia to some extent has occurred, even if the usual physical signs are want- ing. If the disease is extensive, it may be confounded with lobar pneumonia or atelectasis. From the former it is distinguished by the absence of the characteristic physical signs of that disease, extending over a whole lobe on one side, as well as by the history of the case and course of the disease. In atelectasis, due to capil- lary bronchitis, the fremitus is not increased, except in compression, and the dullness is not so pronounced as in lobular pneumonia. If a spot of dullness on one side does not correspond to one on the other side, according to Loomis, it is in favor of lobular pneumonia. Instead of bronchial breathing and bronchox^hony in atelectasis, due to capillary bronchitis, the respiratory murmur is weakened or inaudible, and vocal resonance, if changed at all, is diminished. Subcrepitant rales are not heard as a rule over collapsed lung in atelectasis, but nearly always in lobular pneumonia. In atelectasis the signs are often temporary and may disappear with change of position or deep inspiration, the cells becoming imme- diately inflated with air again. In pneumonia also the, temperature rises, in atelectasis it does not. INTEELOBULAK PNEUMOiNIA. 87 INTERLOBULAR PNEUMONIA. Interlobular or interstitial j)neunionia is inflamma- tion of the interstitial connective tissue of the lungs, and is a chronic disease from the first. Hence it is also termed chronic pneumonia. Owing to the shrinkage that follows usually, it was termed by Corrigan cir- rhosis of the lungs. Other names are knife-grinder's or i^otter's lung, sclerosis, schirrus, and fibroid degen- eration of the lungs. According to Niemeyer, it is one of the most frequent diseases. In most cases, however, it has been confounded with fibroid j)hthisis (p. 107), the tubercle bacillus being now found in nearly all cases of what was formerly supposed to be and de- scribed as chronic pneumonia. Interlobular pneumonia occurs rarely, and is then secondary to some other disease, notably chronic me- clianical bronchitis from inhalation of irritating parti- cles, acute lobar and lobular (broncho-) pneumonia, and sometimes pleurisy. Although it may attack both sexes at all ages, it is more commonly found among men at middle life or past, naturally, from difference in exposure to the cause and length of time usually re- quired for its development. Occurring among coal miners, it is called by Zenker anthrakosis pulmonum. In these cases the affected portion of the lungs becomes black from inhalation of coal dust. From inhalation of iron dust, as among knife-grinders, it is called siderosis pulmonum. In other cases where the dust inhaled arises from the 88 PHYSICAL DIAGNOSIS. handling of cotton, grain, or tobacco, for instance, or in such occupations as brusli-making, carpet or silk weav- ing, stone cutting and the like, the disease is generically termed by Zenker pneumonokoniosis. In such cases both lungs may be affected, but more frequently it occurs only on the right side, owing to the fact that the right primitive bronchial tube being larger than the left, more dust is inhaled into the right lung than the left. The disease may also result from extension of chronic pleuritic inflammation or from a prolonged attack of lobar or lobular pneumonia, neo- plastic growths, and surgical injuries. In these cases the interlobular induration would be situated accord- ing to the locality of the original disease or injury. Fi- nally, according to Walshe, syphilis and alcoholism, if not direct causes, appear to favor the development of the disease. An acute suppurative interlobular (interstitial) pneu- monia sometimes, but rarely, occurs. It cannot be dis- tinguished during life from pulmonary abscess. It may occur in spots or it may burrow along the peri- bronchial tissue, and is then called pneumonia dis- secans (Eichhorst). It occurs in exhausted persons, and may result from severe cases of lobar or lobular pneumonia, empyema, or injuries. Interlobulaivpneumonia, like flbroid phthisis, almost invariably leads to more or less dilatation of bronchial tubes— bronchiectasis. These bronchiectatic cavities may not be distinguished even anatomically from those occurring in chronic phthisis, but in the latter case the tubercle bacillus is characteristic. The physical signs of this disease very closely resem- PULMONARY GANGREXE AND ABSCESS. 89 ble tliose of fibroid phthisis {]). 131), to whicli the stu- dent is referred. PULMONARY GANGRENE AND ABSCESS. Pulmonary Gangrene, or mortification and putrefac- tion of lung tissue, may be circumscribed or diffuse, affecting a lobule, a lobe, or an entire lung. It occurs more frequently perhaps in the course of lobar pneu- monia than any other disease, and for that reason is found more frequently among men than women be- tween twenty and forty, and on the right side, espe- cially the lower lobe of the right lung. It may, however be found in either sex at any age. Its seat is on the surface rather than the interior of the lung. Lowered vitality from any cause, such as improper or insufficient food, alcoholism, and bad hygienic surroundings, pre- dispose to it. It is therefore usually found among the laboring and destitute classes. Besides being met with in the course of lobar pneumonia, as already stated, it may result as an extension from putrid bronchiectatic cavities, or septic bodies or food entering the bronchi and undergoing putrefaction, as in the case of the late Emperor Frederic of Prussia. Sometimes it is caused by septic embolism, as may occur in diphtheria, hepatic abscess, epidemic dysentery, and pyaemia, and some- times it is the direct result of surgical injuries. Inasmuch as gangrene is preceded by inflammation, the physical signs are those of solidification at first, as already described, and of broken-down tissue resulting in a cavity afterward (see Cavities, Phthisis, Third Stage). As soon as gangrene occurs, there are symp- toms of collapse, but a positive diagnosis cannot be 9() PHYSICAL DIAGNOSIS, made until communication between broken-down gan- grenous tissue and a bronchial tube is established so that the sjiuta can be examined. The foetid odor and prune- juice color of the sputa are unmistakable. In case of a small area of centric gangrene, however, the disease may entirely be overlooked. Differential Diagnosis. — The j3eculiar foetid and discolored expectoration of pulmonary gangrene, con- taining, as it does, decomposed bronchial plugs and shreds of pulmonary tissue, usually enables one to dis- tinguish gangrene of the lungs from jDutrid bronchitis, empyema that has ulcerated into bronchial tubes, ab- scess, or phthisical cavities. The etiology of pulmonary abscess is similar to that of pulmonary gangrene. In pneumonia it is rare, oc- curring about once in fifty cases according to Huss, but more frequently in pneumonia of the upper than lower lobes, and in this respect it differs from gangrene. The physical signs, like those of gangrene, are the signs of consolidation until communication between the abscess and bronchial tubes is established, when there will be profuse expectoration of pus, followed by signs of a cavity (which see). There are also symptoms of col- lapse, as in gangrene, but not so marked. CANCER OF THE LUNGS. Cancer of the Lungs may be primary or secondary — usually the latter. In the fomier case the cause is the same as that of primary (;ancer occuriing in other or- gans, and is unknown. Heredity is probably the most important factor in its i)roduction, although seventy- five per cent, of all the deaths among the Schneebergeii CANCER OF THE LUNGS. 91 Cobalt miners is, according to Eiclihorst, the resnlt of primary pulmonary cancer. It develops among them at about the age of forty, and after they have been work- ing in the mines for about twenty years. It is thought to be due to the irritation produced by the inhalation of arsenic in the cobalt ore. For this reason, and be- cause the right bronchial tube is larger than the left, and situated higher up, it affects the upper lobe of the right lung most frequently, and occurs in men oftener than in women, and after several years of exposure to the cause,, as in the case of anthrakosis pulmonum and the like (p. 87). It infiltrates the pulmonary tissue, and not infrequently cancerous enlargement of mediastinal glands co-exist. Secondary cancer of the lungs follows cancer in some other part. According to Walshe, other authors, and my own observation, it is secondary in the lungs, espe- cially where the testicles have been the seat of the pri- mary affection. It usually affects both lungs, unequally of course, and is nodular, the nodules varying in size from a pin's head to a child's head. In many cases there are evidences of cancer in other organs, various glands being enlarged. Encei^haloid (medullary) can- cer is the most common form of the disease in the lungs, although scirrhus, mixed, and other varieties are also found. Although any form of cancer of the lungs affects men most commonly from twenty to forty years of age, it may be found in both sexes at all ages. There are other neoplastic growths that are found in connection with the lungs, but cancer is by far the most important. They are fibromata, lipomata, en- chondromata, osteomata, melanotic tumors, dermoid 92 PHYSICAL DIAGNOSIS. cysts, myxomata and licematomata. They are rarely distinguished during life, as the symptoms they pro- duce are v^y vague. The physical signs of pulmonary cancer are as follows : Inspection. — Retraction of the chest walls over the affected parts is usually noticed, with diminution of resj)iratory movement on that side, especially in case of primary infiltrated cancer of the lungs. In the secondary, nodular form, bulging of the chest walls with displacement of the heart may be observed, if there be a large tumor. The cancer may also appear externally on the chest walls. The sputa are reddish- brown or currant-jelly, usually, and contain cancer cells. Palpation. — The vocal fremitus, owing to consolida- tion from infiltration or pressure, is usually increased. But occasionally, especially in the secondary or nodu- lar form, a large bronchus may be pressed upon by the tumor, and the voice may be so obstructed as not to be conveyed by the bronchial tube to the affected part. In such a case the fremitus would be diminished or absent over the corresponding area. The same re- sult might be obtained by complete displacement of lung tissue by a large tumor. Percussion. — There is dullness, slight or marked, according to the extent of infiltration or size of the nodides. It is usually irregular in outline and does not change with position of the patient, and sometimes extends across the median line on account of co-existing enlargement of mediastinal glands. In case of break- ing down of cancerous tissue or tubercle, with which it is sometimes associated, signs of resulting cavity would be i^resent (see Cavity). CANCER OF THE LUNGS. 03 Auscultation. — Owing to consolidation of lung tissue, due to infiltration or pressure, bronchial breathing and bronchophony are usually heard. If a bronchus be obstructed by pressure from a large nodule, however, the respiratory murmur and whispered voice would be weakened or even suppressed and absent for a corre- sponding area to which the tube is distributed. The same result would also be obtained in case of displace- ment of lung tissue by a tumor. Should consolidation be incomplete, vesiculo-bronchial breathing and exag- gerated vocal resonance only would be heard over the affected part. In case a cavity is formed by breaking down of tissue or dilatation of a tube, the respiratory murmur over it would be blowing in quality, and there would be other signs of a cavity (see Phthisis, Third Stage — Cavities). Until softening has occurred, rales are not commonly heard in cancer of the lungs. Differential Diagnosis. — Primary infiltrated cancer may be mistaken for other diseases that cause retrac- tion of the chest, as chronic phthisis, pleurisy with retraction after absorption of the fluid, and syphilitic infiltration of the lungs. Either form of cancer may be mistaken for thoracic aneurism, especially as can- cerous enlargement of mediastinal glands not infre- quently co-exists. The secondary or nodular form of cancer may even be mistaken for pleurisy with effusion, if the tumor be large enough, indeed they frequently exist together. Fibroid and catarrhal phthisis usually begin in the upper lobes, and, like 2')rimary infiltrated cancer, may affect only the right lung. But in cancer 94 PHYSICAL DIAGNOSIS. the disease runs a more rajjid course and dullness on l)ercussion may, as AValshe truly states, extend across the median line on account of co-existing cancerous mediastinal growths. The sj)uta in cancer are charac- teristic, being like currant jelly and containing cancer cells instead of tubercle bacilli. The cancerous cachexia is soon established and cancer may also appear else- where. In either disease the heart may be displaced, but it is usually much more so in phthisis, especially of the fibroid variety. Pain and dyspnoea occur earlier in cancer and are also usually more prominent. On the other hand, rales are heard in the earliest stages of phthisis, especially of the catarrhal form, whereas in cancer they are not usually heard before softening of cancerous tissue occurs. By that time the cachexia and other signs of cancer, already mentioned, are so well marked that the diagnosis is comparatively easy. As the disease progresses the characteristic cancerous sputa and absence of high temj)erature in cancer would aid in a correct diagnosis. In chronic pleurisy with retraction there is cough, but with little exjiectoration usually. The vocal fre- mitus, respiratory murmur, and \vhisx)ered voice in j^leu- ris}' are diminished or absent, and ordinary vocal reso- nance, or pectoroiDhony, is also diminished. There are no inward pressure signs on the trachea and a?sophagus in i^leurisy. The dullness in jDleurisy, much more reg- ular in outline than in cancer, is usually found at the base of the lungs, posteriorly, and does not extend across the median line; and the disease is generally slow in its j^rogress. The revei-se is usually true in cancer, the physical signs of which, as a rule, arc found CAXCEIi OF THE LUNGS. 95 ill tlie front and upper part of the tliorax, rather than XJOSterioiiy and Jow down. The history of the case, tlie character of tlie sputa, the cacliexia and the greater severity of the symptoms in cancer would also aid in a correct diagnosis. In jjleuritic effusion, besides dif- ferences already mentioned, the physical signs often change with iDOsition of the patient, which probably never occurs in case of cancer. Should the cancer give rise to pleurisy with effusion, the latter, according to Bowditch, is always bloody. The character of the ef- fusion in doubtful cases is easily told by means of the hypodermic syringe. In syjjhilitic infiltration there would be the history of syphilis, other syx)hilitic lesions would probably be present, and improvement would rapidly follow anti- syj)hilitic treatment. Thoracic aneurism usually occurs in men at middle life or past, or in either sex in old age. Cancerous en- largement of mediastinal glands, the lungs becoming- invaded afterward, occurs mostly in women between twenty and thirty. But cancer of the lungs with co- existing mediastinal tumors often appears in men also about middle life. Both aneurism and cancer may cause dulness on percussion across the median line and inward pressure signs, and be attended by cardiac dis- placements and murmurs, but in cancer, besides the cancerous cachexia and sxouta, there are often disten- tion of superficial thoracic veins, with oedema of the chest, arms, and face, which never occurs from thoracic aneurism. Moreover, in all cases of cancer of the lungs evidences of cancer in other organs may sometimes be obtained on careful examination. 96 PHYSICAL DIAGNOSIS. \ HEMORRHAGIC INFARCTION OF THE LUNGS. Hemorrhagic infarction of the kings is cu'cnmscribed pnhnonary ai)oplexy due to embolism. (1.) Most com- monly there is plugging of a branch of the pulmonary artery by an embolus, followed by transudation (dia- pedesis) of blood into the parts formerly supplied by the obstructed twig. (2.) More rarely it is produced by rupture of a branch of the pulmonary artery, due to intense liyi)er?emia around the obstruction, and fatty degeneration of the vessel. The blood in these cases, according to Rindfleisch, finding its way into the air- cells and bronchi of the part, rapidly coagulates and the process ceases. (3.) Finally, in other cases no known cause for the infarction can be found, all trace of an embolus having disappeared. After complete obstruc- tion of a twig of the pulmonarj^ artery by an embolus, the parts beyond the plug, including air-cells, bronchi- oles, and interstitial tissue, become the seat of hemor- rhagic infiltration, how? According to Cohnheim, this is accomplished by the arterial blood being forced back- ward, or regurgitated, from the capillaries of the pul- monary veins into the excommunicated capillaries of the obstructed twig of the pulmonary artery. The latter do not rupture usually, but allow a diapedesis (transudation) of blood through their walls, which have become abnonnally permeable, owing to the disturb- ance of their integrity by the embolism. Besides this, they pi'obably allow leakage of arterial blood more readily than venous blood to which they had been ac- customed. It was formerly thought that the infarction in these cases was always due to rupture of capillaries, HEMORRHAGIC INFARCTION OF THE LUNGS. 97 simply from intense liyperffimia, as might occur in mitral disease, without taking the embolus into ac- count. But this did not explain why the infarction was limited to such abrux:)tly and well-defined areas, sometimes a single lobule. The true exi^lauation in these cases is that, owing to mitral obstruction or re- gurgitation, there follows sooner or later dilatation of the right ventricle. At first it is dilated hypertrophy, but in time dilatation becomes prominent, and not being properly compensated by hypertrophy, the blood- current becomes sluggish. In this condition, thrombi, or firm clots of venous blood, may form in the right heart, especially in the musculi pectinati, of the right auricular appendix, or between the columnse carnese of the right ventricle, near the apex. From these thrombi, emboli becoming detached, cause infarctions in the lungs by their direct transmission along the pulmo- nary artery. Emboli, besides originating in the right side of the heart, from dilatation, may enter the systemic venous circulation from any p)art of the body, and, passing through the right heart, produce infarction in the lungs. In fractures, or other severe injuries, of the skull, af- fecting the diploe, otitis giving rise to inflammation of the petrous portion of the temporal bone, and throm- bosis of the cerebral sinuses from any cause, emboli may enter through the superior vena cava into the right side of the heart. In like manner emboli may become detached from thrombi formed in any of the peripheral veins, as sometimes occurs in typhoid or other fevers; also in cases of thrombosis of uterine or ovarian veins, 98 PHYSICAL DIAGNOSIS. and even the iliac or renal veins from pressure of large uterine fibroid and other tumors. When the emboli are septic, metastatic abscess usu- ally occurs, instead of infarction, or rapidly follows it. Emboli originating in the portal circulation, as some- times occurs in haemorrhoids or dysentery, are likely to produce infarctions in the liver. Those coming from the lungs, or left side of the heart, alfect the brain, spleen, or kidneys. Hemorrhagic infarction may only affect a single lobule, or there may be several infarctions simultane- ously in one or both lungs. From the fact that the branches of the pulmonary artery become smaller as we approach the surface of the lung, infarctions are found more commonly at the periphery than in the interior of the lungs. For the same reason also, central infarc- tions are more extensive than peripheral. Naturally the infarcted areas are somewhat pyramidal in shape, with their bases toward the periphery. The physical signs of infarction are as follows : Inspection. — There is dyspnoea, which ux)on inquiry will be found to have come on suddenly and unex- pectedly. The dyspnoea will be in jDroportion to the amount of infarction. Where the latter is small, it may be entirely overlooked. But when extensive, the respiratory movements will be increased in frequency, and the breathing may be labored. The sputa are somewhat characteristic, being brownish-red, and darker colored than those of lobar pneumonia. Palpation. — The vocal fremitus is usually increased, unless the infarction be central or comj)licated by pleu- risy. PULMONARY APOPLEXY. 99 Percussion. — There will be dullness on percussion unless the infarction is central or very small, in which cases there may be little or no dullness. Auscultation. — In case of extensive peripheral in- farction, bronchial breathing and bronchophony may be heard over the seat of the part affected. Crepitant and subcrepitant rales are also usually heard. In some cases there may be no physical signs, owing to the small extent of infarcted area, its central location, or existing complications, like pleurisy, for instance. The heart should always be examined. Differential Diagnosis. — By means of sudden dysp- noea, localized spots of dullness, if any exist, crepitant and subcrepitant rales, and especially the slight rise in temperature with the characteristic brownishired sputa, which last for a. much longer period than in pneumo- nia, the co-existence of heart disease, especially old mitral obstruction or regurgitation, and the etiology in general, it is usually possible to make a diagnosis. The sputa of cancer of the lungs resemble those of infarc- tion, but the former contain cancer cells, and there would be the cancerous cachexia, and other signs already mentioned. According to Loomis, the sputa of hydatid disease of the lungs may also resemble those of infarction, but in the former case the discovery of hooklets would be decisive. PULMONARY APOPLEXY. Pulmonary apoplexy, or escape of blood into the pulmonary tissue, may be circumscribed or diffuse. In the former case, as we have already seen, when due to embolism, it is called infarction. But it may also occur 100 PHYSICAL DIAGNOSIS. locally from causes wliicli lead to rupture of pulmo- nary capillaries, either by over-distending tliem or weak- ening their walls, or both, without embolism. These causes are fully considered in speaking of hyperemia and hfemoiDtysis (which see). In diffuse apoplexy, the pulmonary tissues become more or less destroyed by the extravasated blood, which has escaped from rupture of one or more large vessels. Sometimes the hemorrhage is confined within the lung substance, at other times, from rupture of, the pleura, the blood may be discharged into the pleural sac. Diffuse pulmonary apoplexy may be due to surgical injury, or rupture of large vessels due to previous athe- romatous degeneration, or in the course of gangrene, cancer, or thoracic aneurism. It occurs more frequently among men than women, for the obvious reason that they are more exposed to the cause. Besides j)rofuse haemoptysis and symptoms of collapse, bubbling rales of various kinds would be heard over the chest before the blood coagulated. If the patient lived, then after coagulation of blood there would be signs of more or less consolidation. After absorption of the clot and re- covery has taken place, the signs would again become normal, unless a cavity, cicatrized tissue, or some other abnormal condition remained. Generally, however, the patient dies before physical examination can be made or any treatment be adopted. HEMOPTYSIS. Haemoptysis is the expectoration of blood, pure, or mixed with other matters, but always in quantity sufficient to be seen with the naked eye. In order to HEMOPTYSIS. 101 constitute true haemoptysis, the blood must come from the larynx, trachea, bronchi, or pulmonary tissue, or, accordiug to Walshe, from any part of the resjjiratory tracts below the epiglottis. It occurs more frequently among men than women, and from fifteen to thirty-five years of age. It is rare in children and old j^eople. In general terms, wounds or other injuries, ulcerative processes, over-distention of caj^illaries from any cause, and weakness of their walls, owing to perverted nutri- tion, are more or less causative of hsemoptysis, as well as hemorrhage from other organs. In addition to these there are certain local causes to be considered. Laryngeal or tracheal hemorrhage is not a very fre- quent source of haemoptysis, nor is it usually copious. At most the sputa are tinged or streaked with blood. It is due sometimes to severe catarrhal hypersemia (con- gestion), but is more frequently caused by ulcerative processes of some kind, such as syphilitic, cancerous, or tuberculous, and sometimes it is due to the presence of aneurism. Bronchial hemorrhage is the most frequent source of hsemoptysis. Besides ulcerative causes, especially in connection with mediastinal tumors and thoracic aneurism and traumatism, the cai)illaries may become over-distended and rupture from intense hypereemia, as in severe bronchitis, mitral obstruction and regur- gitation, or excessive action of the heart from hyper- trophy or stimulants. Rupture of cajnllaries from weakness of their walls is seen in the hemorrhagic di- athesis (hsemophilia), which appears to be hereditary, scurvy, scrofula, and rickets, and in chronic interstitial nexDhritis (cirrhotic kidney), with hypertrophy of the 102 PHYSICAL DIAGNOSIS. left ventricle and brittleness of the arterioles througli- ont the body. It may also occur, for the same reason, in the course of typhoid fever, malarial fevers, and the exanthemata which sometimes assume a hemorrhagic character. Profuse haemoptysis from bronchial hemorrhage may also occur in tuberculous patients before there are any physical signs of tubercle. After the disease has be- come established, it is usually easy to account for the hemorrhage, but, according to Walshe, " the very early hfemoptyses of tubercle remain anatomically unex- plained." It is, however, due to fatty degeneration or tubercular ulceration of the blood-vessels. Vicarious bronchial hemorrhage with haemoptysis sometimes takes the place of the menses, but even here the women are probably phthisical. Lastly, pulmonary hemorrhage as a source of hsemop- tysis is next in frequency to bronchial. They are pro- duced by similar causes and often exist together. In addition to causes already mentioned, it occurs to a slight extent in acute lobar pneumonia, and hence the characteristic rusty colored sputa in that disease. It may be due to rarefaction of air during violent inspira- tory efforts with the glottis obstructed, as in croup. In fact, intense congestion from any cause may pro- duce it (see Pulmonai-y Congestion). It may occur also in the course of hydatid disease, cancer, gangrene, abscess, and pulmonary consumption in any stage. After cavities are formed in the latter disease, large vessels ramifying on their walls, or ex- tending through them, first become aneurismal, and then may rupture, giving rise to profuse haemoptysis HEMOPTYSIS. 103 which may speedily prove fatal. According to Eich- horst, pulmonary hemorrhage may also be of nervous origin, and occurs among the insane, in chorea, epilepsy, hypochondriasis, and in various cerebral and spinal diseases. It occurs also in pulmonary infarction as well as diffuse apoplexy of the lungs from any cause, as previously mentioned (see Infarction and Diffuse Apoplexy of the Lungs). The physical signs have reference only to those cases where an appreciable amount of blood is contained in the respiratory tracts. They differ during the flow of blood and after coagulation has taken place. Inspection during the flow of blood. Besides seeing the blood expectorated, there may be more or less dyspnoea, increased frequency of resx3iration, and pallor of the surface, if the haemoptysis is profuse. Palpation and Percussion at this stage usually give negative results. Rhonchal fremitus, however, may be present. Auscultation. — Moist bubbling rales of various sizes may be heard in the different bronchial tubes. Even crepitant rales are sometimes heard. The vocal resonance is generally unchanged. But after coagulation has taken place, all the physical signs will usually be those of consolidated lung tissue, and in proportion to the amount of coagulated blood and the area involved. Differential Diagnosis. — It is necessary to distin- guish haemoptysis from bleeding from the mouth and pharynx, epistaxis, and hsematemesis. Careful examination of the mouth and pharynx will readily exclude them as sources of the bleeding. The 104 PHYSICAL DIAGNOSIS. same is true for bleeding from the nose. Even in cases occurring during the night when some of the blood is swallowed, or gets into the pharynx during sleep, there are apt to be evidences of nose bleeding. Moreover the blood hawked up in these cases is dark and mingled with nasal secretions and is unattended by any pre- vious symptoms or cough. In hasmatemesis (vomiting of blood) the blood is vomited up, and is usually dark and clotted, and mingled with food and acid. In cancer of the stomach, however, it resembles coffee grounds from being partly digested, and in ulcer of the stomach the vomiting of fresh, liquid blood, may be profuse. But in all cases hsematemesis is usually preceded by symptoms referable to the epigastric re- gion, such as severe pain after eating, and nausea. In haemoptysis the blood coughed up is usually bright red, frothy, pure or mixed with sputa, is alkaline, and haemoptysis is usually preceded by symptoms refer- able to the chest, such as a sense of constriction, pain, and a warm tickling sensation behind the sternum. In gastric hemorrhage also, the stools may be black (me- laena) from the i)resence in them of dark blood. Occa- sionally when gastric hemorrhage is jjrof use, the blood is alkaline and bright red, as in some cases of ulcer of the stomach, and, on the other hand, in lia3moptysis it may sometimes be dark and clotted, but the symptoms referable to the stomach and chest in each case respect- ively, will usually lead to a correct diagnosis. The seat of the hemorrhage in haemoptysis depends on the particular cause in each case. As bronchial and pulmonary hemorrhage are often due to the same cause and may exist together, it would be very difficult, if ECHINOCOCCI, OR HYDATIDS OF THE LUNGS. 105 not impossible, in all cases to distinguish between the two. Bronchial hemorrhage, however, is much more frequent than pulmonary. ECHINOCOCCI, OR HYDATIDS OF THE LUNGS. Echinococci, or hydatids of the lungs, as well as of other organs of the body, occur usually where dogs are plentiful, as in Iceland, Australia and other countries. No locality can be said to be free from the disease Avhere there are dogs and open water for drinking pur- ]poses, since it is through infected water that the disease is most frequently contracted. Eggs or scolices of the taenia echinococcus may also be inhaled, or car- ried to the mouth by the fingers, and so enter the body. '\'Vlien taken into the stomach, as in drinking in- fected water, they are carried by the portal circulation into the liver, where they usually locate first, esjDecially the right lobe. From thence they may migrate into the lungs, pericardium, p)leural cavities, peritoneum, stomach, and intestines. They generally enter the lower lobe of the right lung from the liver, directly through the diaphragm, and hence the frequency with which they are found in that locality. But instead of this, they may also find their way, by the hei)atic veins, into the inferior vena cava, and so through the right heart into any part of one or both lungs. When in- haled they are more apt to attack the upper lobe of the right lung, as I saw with Drs. Goetz and Riverdin, in the case of a lad eighteen years of age, in the County Hospital in Geneva, Switzerland, during a visit there in the month of August, 1888. This case will be re- 106 PHYSICAL DIAGNOSIS. ferred. to again when speaking of pleurisy (see Pleurisy with Effusion — Diagnosis, p. 147). The physical signs differ according as lung tissue is compressed or one or more cysts are superficial and extensive. In the latter case, besides dyspnoea, hae- moptysis and emaciation as the case jDrogresses, there may be bulging of the chest walls with displacement of the heart and liver. The dullness may extend across the median line, with diminution or even absence of the resj)iratory murmur and vocal fremitus over the seat of dullness. In other cases, compression of the lung may give in- creased vocal fremitus, bronchial breathing and bron- cho]ohony at some point. Should the contents of the cyst be expectorated, signs of a cavity may result. Differential Diagnosis. — Physical signs of jDleurisy with effusion at the upper instead of the lower part of the thorax should alw^ays be regarded with suspicion. But a positive diagnosis in any case can only be made when a cyst ruptures and scolices or hooklets are found in the sputa. At the same time if a hydatid cyst is suspected and it is sufficiently near the surface, some of the fluid aspirated by means of the hypodermic syringe may be found to contain scolices and hooklets. PHTHISIS. Phthisis is tuberculosis, and as now accepted implies pulmonary tuberculosis, a disease caused by a sjiecific virus, the germ of which is Koch's tubercle bacillus^ and infectious under conditions to be mentioned. It is usually a chronic disease, the forms of which may be reduced to two according to the tissues chiefly involved: (1) catarrhal arid (2) fibroid. PHTHISIS. 107 CatarrJialpMliisis (caseous phthisis, tubercuhir lob- ular pneumonia) is the most common form observed, and it usually appears first at the top of the lungs, but not always. Beginning in the bronchioles, it extends into the air cells and along the air passages. From caseous necrosis and softening, cavities result. This form occurs usually between twenty and thirty, and in women somewhat earlier than in men (p. 113). Fibroid phthisis also usually begins in the bron- chioles, but extends along the lymphatics to the pul- monary interstitial connective tissue, producing shrink- age and bronchiectasis as with interlobular pneumonia (p. 87). It occurs more frequently in men and from thirty to forty, and is usually more chronic in its course than the catarrhal form (p. 131). Phthisis is said to be acute when its progress is rapid. In such cases it may a^^pear to begin as a lobar pneu- monia, but its nature soon becomes apparent (phthisis florida, galloping consumption, tuberculous or scrofu- lous pneumonia). When asociated with extensive he- patization, the acute form is termed by Williams, of London, acute tuberculo-pneumonic XDlithisis. When the larynx is XDrimarily the seat of tubercle, it is called laryngeal i)lithisis, or better, tuberculous laryngitis, although primary tuberculous laryngitis is not a com- mon affection. When hemorrhage is an early and prominent symptom it is sometimes called hemorrhagic phthisis. Acute miliary (general, disseminated) tuberculosis af- fects various organs and tissues simultaneously. There is usually previous tubercular lesion from which bacilli in large numbers are absorbed into the blood through 108 PHYSICAL DIAGNOSIS. lymi:)liatics or unocchided veins. It usually runs a rapid course, and somewhat resembles typhoid fever, the chest signs present, if any, being those of bronchi- tis with marked dyspnoea. The temperature usually runs high, but may fall below normal. The disease is rapidly fatal as a rule, and often not to be detected during life. On post-mortem examination, not only the lungs, but the pleurae and other organs may be found to be studded with miliary tubercles. The following brief summary of conclusions is based upon the transactions of the Congress for the Study of Tuberculosis, lield in Paris during the month of July, 1888. 1. True tubercle generally (not always) contains the bacillus that was first supposed to exist by Bouchard, of Paris, in 1880, but afterward discovered by Koch, of Berlin, in 1882. All other substances — products of inflammation in connection with other conditions than tubercle (caseous for example), and occurring in non- tuberculous subjects — do not contain Koch's tubercle bacillus. That is the true difference between tubercle and such other products. When true tubercle does not contain the bacillus, it is because the latter has been liberated and escaped, oAving to breaking down of tissue by pathological process, or else the tubercle yet contains only germs of undeveloped bacilli. True tu- berculous virus, therefore, though it may not contain Koch's tubercle bacillus, is, nevertheless, capable of re- producing itself by inoculation, under the usual con- ditions, by reason of bacillary germs. Any other sub- stance than tubercle that contains Koch's tubercle bacillus, or its germs (caseous products, for example, PiiTiiisis. 109 which have become infected by the bacillus, or its germs, as may occur in tuberculous subjects), can also produce true tuberculosis by inoculation. Other sub- stances, however, aj)art from tuberculous subjects, and not containing Koch's tubercle bacillus or its germs, cannot directly produce true tuberculosis. Koch's tubercle bacillus thrives best at a temperature of 98"" F. to 100° F., and is capable of jDroliferation be- tween 86° F. and 104° F., although it may live far be- yond these extremes. It remains virulent in running water at a temperature of 60° F., for six weeks, and in stagnant water, of the same temperature, for eighteen weeks ; in dried sputa for a month. It attacks the lungs by preference, although no tissue is exempt from it. 2. Koch's tubercle bacillus is the cause, not the re- sult, of tuberculosis, inherited or acquired, however this fact may yet be doubted or disputed by some. In case of inheritance, not only may there be narrow chest, feeble health, or other predisposition, but the disease may be actually and directly transmitted to the ovule by spermatozoa infected with bacillary germs. 3. Tuberculosis is a contagious disease under certain conditions, especially those that tend to produce low- ered vitality, such as overwork, insufficient food, viti- ated atmosphere, and prolonged ill health from any cause, and is transmissible even between man and ani- mals by the digestive tract, as was first proved by the experiments of Chauveau, in 1868, through uncooked tuberculous food, especially cow's milk and beef. Also by the resj)iratory tract, through infected air, as was proved by Yillemin in 1869, and Tappeiner in 1876-77. Hence the necessity for strict sanitary measures as a 110 PHYSICAL DIAGNOSIS. means of prophylaxis. True tuberculous virus is also transmissible by inoculation, by subcutaneous injec- tion, or through the integument stripped of its epider- mis, as was proved by Yillemin in 1869 ; and also in the following ways : By other mucous membranes than those already mentioned, as the conjunctival and gen- ito-urinary; by dermatoses which destroy the epider- mis ; through the sudoriparous and sebaceous glands ; and, finally, through wounded and absorbing surfaces. 4. In the early diagnosis of doubtful or suspected cases of pulmonary tuberculosis in man, Koch's tuber- cle bacillus should be sought for in the sputa by an expert, as the general practitioner has neither the time, experience, nor the j)roper instruments for it. Even then it is not always possible to find the bacillus at first, because it may not yet have been liberated, or only its germs may exist. To verify it, two or three lower animals (guinea-jDigs, or rabbits, for instance) may be put under the necessary devitalizing conditions, inoculated with the suspected sputa, and killed at varying intervals after a month or more. If it is the disease in question, some tubercles, containing Koch's tubercle bacillus, will usually be found in various organs. 5. No practical means for destroying Koch's tubercle bacillus in patients has yet been discovered, although various methods have been employed. "^ 6. The management of tuberculosis in man at the present time should therefore be directed toward two~ * As we go to press Koch is said to have discovered the cure for tuberculosis. PHTHISIS. Ill objects: (1) Propliylaxis in all its relations to the dis- ease, and (2) treatment by medicines only as synii)toms arise that require it. (Report of R. C. M. Page, M.D., Delegate from the New York Academy of Medicine to the Congress held in Paris, July, 1888, for the Study of Tuberculosis in Man and Animals. New York Medi- cal Record, Oct. 18th, 1888.) From what has already been said it is seen that tuber- culosis is a disease, the germ of which is the bacillus discovered by Koch in 1882, and that it manifests itself in various ways, most frequently as pulmonary tuberculosis or phthisis. But instead of this, or with it, sometimes it manifests itself as acute miliary tuber- culosis, or tubercular peritonitis, meningitis, or pleu- ritis, and the like. Pleurisy is thought by some to be productive of phthisis. While it may be a cause of interlobular (in- terstitial, chronic) jjueumonia from extension of pleu- ritic inflammation, it cannot be directly productive of phthisis unless the pleurisy be of tuberculous origin, as may sometimes hai)pen. In by far the greater number of these cases, however, the disease begins in the lungs and extends to the pleura, the affection of the latter being only symptomatic of the former which has been overlooked or not even suspected. Non- tuberculous pleurisy can only give rise to phthisis in- directly by lowering vitality and limiting respiratory movements so as to render the patient more susceptible to tuberculous infection. In like manner chronic pneu- monia and bronchitis may act as predisposing causes, the latter also favoring the lodgment of bacilli by rouo-hening the bronchial mucous membrane. 112 PHYSICAL DIAGNOSIS. The disease attacks both sexes at all ages, but is seen most frequently among those between twenty and thirty. As already stated, anything that tends to lower vitality XDredisj^oses to it. In addition to what has already been said under this head, may be men- tioned insufficient light, damiD localities, previous dis- ease, mental anxiety, rapid child-bearing, lactation, venereal excess, menstrual disorders, and the like. Occupations necessitating inhalation of irritating par- ticles would not of themselves produce fibroid phthisis, although they act powerfully as predisposing causes. According to Flint, those who already have general emphysema, or cardiac disease, are not so subject to pulmonary consumi:>tion of any kind. A much-vexed question has been the relation between scrofula, so called, and tubercle. According to Flint, those who suffer from scrofulous affections of the cer- vical lymphatic glands are not liable to pulmonary tuberculosis. " Assuming," says Flint, " the scrofulous and tuberculous cachexia to be the same, as is claimed by some, it seems to be exhausted by deposit in the glands of the neck, and is not likely to occur after- ward." The truth is, there is no such thing as scrofula, but it is tuberculosis in which the bacilli are confined to the lymphatic system, where they become destroyed or modified. On the other hand, they thrive in the lungs and proliferate rapidly. In phthisis the disease usually begins at the apices, but as to whether the apex of one lung is more fre- quently affected than the other is not a settled matter. As in most cases, however, the disease is started by inhalation of air containing bacilli, the ajiex of the PLATE IV. Tubercular Pulmonary Consumption. Microscopic Specimen from Sputa containing (b) Bacilli, (a) Alveolus, (e c) Endothelioid Cells, fep. c) Epithelial Cells, Lung Tissue stained with Methyliri Blue — Bacilli with Gentian Violet. MOUHJID /mo DRAWN BY H.MACOONALD M.D. N.Y. CATAIIUIIAL J'lITIIISIS, THUEE STAGES. 113 right lung is probably the one most often primarily affected, the right bronchial tube, as so often stated, being larger than the left. But the reasons why the apices are affected primarily appear to be: (1) injury to the vessels here from imperfect circulation and stag- nation of blood, exposure, and strain from coughing or lifting, giving rise to exudation ; (2) limited respiratory motion with imperfect ventilation and non-absorption of exudations — conditions all of which favor the lodg- ment of bacilli. 1. CATARRHAL PHTHISIS. Catarrhal jDhthisis (caseous x^hthisis, caseous infiltra- tion, broncho-pneumonic phthisis, bronchitic phthisis, tuberculous lobular pneumonia) is one of the two varie- ties of chronic phthisis. It may assume various forms, but as commonly met with is usually divided into three stages: 1. A stage of incomplete consolidation of lung-tissue with more or less localized secondary bronchitis, usually of the smaller tubes, lobular pneumonia, or circumscribed pleurisy, or all three. 2. A stage of complete consolidation of lung-tissue, commenc- ing softening, and one or all of the attending complications mentioned. 3. The breaking down of tissue and the formation of cavities. All the complications mentioned are more frequently jDresent in this stage. Inspection. First Stage. — This may give negative results. Usually, however, even in this stage, expan- sion of the chest over the affected portion may not be as well marked as on the healthy side, especially on deep inspiration. There may also be some slight flat- tening over the affected part, and when at the apex, the clavicle on the affected side may be more prominent than the other. The respiratory movements are some- 114 PHYSICAL DIAGNOSIS. what increased in frequency, and the apex-beat of the heart will be more raj)id than in health, but in the nor- mal position, unless displaced by some complication. Though the appetite is usually poor, even in this stage, emaciation is not yet usually noticeable. Palpation. First ^tage. — The vocal fremitus is usu- ally exaggerated (slightly increased) over the affected part, since the latter now conducts the voice sound bet- ter than in health. As solidification becomes complete so does the fremitus increase, owing to obliteration of air-cells, by which the affected part becomes a more homogeneous medium for the conduction of sound, in- stead of refracting it as in health. It should not be forgotten, however, that the vocal fremitus is normally exaggerated under the patient's right clavicle in health, on account of proximity to the large right primitive bronchial tube, by which the voice sound is conveyed with considerable force to that region. The skin is usually unnaturally warm and dry. The apex-beat of the heart is felt to be more rapid than in health, as also the pulse. Percussion. First Stage.— There is the quality of slight dullness on percussion over the affected part, with consequent slight raise in the pitch, shortening of the duration, and diminution of the intensity (or amount) of the note in the sense of volume. But slight dullness is obtained in health in the right subclavicu- lar region, on account of the right muscles being thicker than the left, and other reasons already stated (see Percussion of the Chest in Health. Chap. I.). Myoidema (muscle swelling) is a knot that rises up from the surface of the chest, in some cases, after a CATAKIIHAL PHTHISIS, FIRST STAGE. 115 sharp blow upon the latter immediately with the point of the finger. It may be observed now, but is more marked in tlie later stages, when emaciation is more noticeable. It was first observed by Stokes, of Dublin, about 1830, but was so named by Lawson Tait, of Birm- ingham (Dublin Jour. Med. Science, 1871, vol. 52, p. 316) It is obtained over the pectoral muscles chiefly, but sometimes also over the deltoid, and muscles of the back. It is due to muscular irritability, as may occur with emaciation from any cause, and was at first called by Schiff and others " idlo-rauscular contractil- ity." It was thought to be pathognomonic of phthisis at one time, even in the absence of other signs, but at present it is regarded as of little value, and is observed to occur in other diseases, as typhoid fever, and dij)h- theria, and indeed I believe it may be obtained in some •cases wdiere there is perfect health. Auscultation. First Stage. — The resj)iratory mur- mur over the affected part has now lost its purely vesic- ular quality, the vesicles or air-cells of the diseased part having been more or less obliterated by the pres- ence of tubercles, causing pressure and local inflamma- tion. The breathing is therefore a mixture of bronchial and vesicular or broncho- vesicular, as Flint termed it. As Da Costa says, however, it is better to call it vesic- ulo-bronchial, that being the order in which the two qualities occur. Inspiration is increased in intensity, in the sense of concentrated amount, being conducted with more force by the affected tissue than in health. It is less vesicular than in health, and slightly raised in pitch. It is barely finished, and hence is not quite continuous with expiration. The more complete the 116 PHYSICAL DIAGNOSIS. consolidation and the greater the area, the more un- finished and shorter will be inspiration. This, as well as bronchial breathing, therefore, is said to be divided. Expiration is as long as or longer than inspiration, it is as intense, the pitch is as high or higher, and the qual- ity is more tubular. This vesiculo-bronchial murmur Fig. 13.— Vesiculo-bronchial Breathing. was formerh^, and is now, by some termed rude, be- cause it is more intense than normal. Others speak of it as harsh or rough breathing, all of which are unde- scriptive of the true characteristics. Either inspiration or expiration or both may be wavy, jerking, cog- wheeled, or interrupted, as one may choose to tenn it. This variation is thought by some to be due to the sud- den passage of air through some point or points of stricture in the bronchial tubes, due to pressure from tubercles or obstruction from mucus. But it is also found in perfectly healthy lungs among some, for in- stance, who have j)alpitation of the heart, or are nerv- ous from any cause. It is not at all uncommon among women, men addicted to the abuse of alcohol or to- bacco, the choreic, and other nervous subjects. It is of great importance to remember that the normal vesic- ulo-bronchial breathing is heard in the right subcla- vicular region, owing to the proximity to the large right bronchial tube. Pectorophony (vocal resonance), like the fremitus, is exaggerated (slightly increased) over the affected part. Adventitious sounds are usually heard over the affected part in the first stage of iDhthisis, and it is by CATARRHAL PHTHISIS, SECOND STAGE. 117 means of these, chiefly, that we are enabled to make an early diagnosis, esj^ecially if the seat of the disease be at the right apex. Along with tubercle there will be a localized capillary bronchitis, a spot of pneumonia, or perhaps pleuritis. For that reason we are almost sure to hear some subcrepitant, crepitant, or intra-pleural rales. Sometimes there may be a single click heard, during inspiration especially. It is called the mucous click, and is said to be due to the forcible separation of an agglutinated tube or overcoming mucous or other obstruction by air during inspiration. It is probably of intra-ioleural origin sometimes. Any of these localized adventitious sounds, in addi- tion to the other physical signs mentioned, and the history of the case, would render it almost certain that the case was one of phthisis. The tubercle bacillus will rarely be found in the sputa at this early stage, even by an expert, because it will not usually have been liberated, or only bacillary germs may yet exist. But in case of doubt the sputa should be examined by an expert if j)ossible. Regarding the early diagnosis of the disease, it is seen from the physical signs presented, that it is more readily made when the disease affects the left apex, since all of the early iDhysical signs, except the local- ized adventitious ones, already exist in the patient's right subclavicular region in health. * Second Stage. — We have now to deal with complete solidification of lung tissue of variable extent, com- mencing softening, and local complications (p. 113). * See also Hwrnoptysis, p. 102. Unless caused by heart disease or injury, it is probably due to phthisis (Flint). 118 PHYSICAL DIAGNOSIS. Inspection. Second Stage. — The ex2:)ansion of the chest walls over the affected part is more markedly dhninished on inspiration than in the hrst stage, and the difference between the respiratory movements of the unaffected and diseased sides is more noticeable. Flattening over the affected portion, dne to retraction of the diseased lung tissue, is usually noticeable in this stage. If it occurs at the apex, the clavicle usually projects and is noticeably prominent. Respiratory movements are increased in frequency and rather shal- low, and the ajDex-beat of the heart is usually quite visible, owing to emaciation, which now generally be- comes noticeable. The apex-beat of the heart may be in the normal position, but is not infrequently displaced by traction due to pleuro-pericardial adhesion. Palpation. Second Stage. — The vocal fremitus is usually noticeably increased on account of the better conducting power of the consolidated lung tissue. If, however, a large-sized bronchial tube leading to the affected part becomes obstructed, so that it ceases to convey the voice sound, the fremitus may be dimin- ished, or even absent. Upon coughing and removing the plug, the fremitus at once returns. Thickened pleura or effusion intervening, would also cause the fremitus to be diminished or absent. The apex-beat of the heart may be felt to be abnormally frequent and feeble, as also the radial pulse. The surface of the body is usually felt to be dry and unnaturally warm. Percussion. Second Stage. — Dullness on percussion is the rule, and this quality will be marked in propor- tion to the extent of consolidation. The more marked the dullness, the higher will be the pitch, the shorter CATAKRITAL PHTHISIS, SEOOXD STAGi:. 119 the duration, and the less the intensity Of the percus- sion note, in the sense of volume. It happens, how- ever, once in a great while, that Skodaic resonance (tympanicity in connection with solidification or effu- sion) is obtained. This requires rather forcible percus- sion over solidification near a large bronchial tube, the trachea, an empty stomach or transverse colon, where the force of the percussion blow extends to them from the solidified tissue, which acts on the j)rinciple of a solid pleximeter, like the finger, or other solid percus- sion medium, and is consequently attended with a feel- ing of resistance. Even cracked-pot resonance, due to the concussion of air in such localities, is sometimes, though rarely, obtained. Over the unaffected j)arts the percussion resonance may be exaggerated, owing to the presence of a certain amount of vicarious emphysema, which, however, never becomes marked, as the volume of blood becomes much diminished in this wasting dis- ease. Myoidema is more noticeable in this stage than the first. Auscultation. — The breathing over the consolidated lung tissue now becomes bronchial, all vesicular quality having disappeared with the air-cells. Both inspiration and expiration are tubular in quality and high pitched, expiration being the higher. Expiration is also as long- as inspiration, or longer, and the two are separated, or divided, by inspiration being unfinished. This respira- tory murmur as a whole is more intense than normal in the sense of concentrated amount, and expiration is more intense than inspiration. Both are somewhat short owing to the shallow breathing. 120 PHYSICAL DIAGNOSIS. Pectorophony (vocal resonance) is usually markedly increased over the consolidated part, and becomes bronchophony (bronchial voice). Should the speech (articulate words) be heard also, it might be called bronchiloquy (instead of pectoriloquy, which also ap- plies to cavities). The whispered voice would give whispering bronchophony or whispering bronchiloquy, as the case might be. Should a large tube leading to the part be obstructed, or there exist thickened pleura or effusion, the breath and voice sounds would be diminished or absent, like the fremitus under the same conditions. As some parts of the diseased lung will probably be in the first stage, or incomplete con- solidation, the physical signs belonging to that stage may be looked for about the periphery of the seat of complete consolidation. Or both lungs may be affected with different stages. Localized adventitious sounds are also heard about the affected part in this stage. They are more marked usually than in the first stage, and consist of bronchial moist rales of various kinds, and sometimes intra-pleural rales. The crej^itant rale, if present, would usually be obscured by other louder rales. Owing to commencing softening and breaking down of lung tissue, and perhaps pleuritic complica- tions, certain crackling and crumpling rales, called in- determinate, may be heard sometimes. Third Stage. — In this stage, cavities are formed. But in addition to cavities, there may be portions of lung tissue yet in conditions of complete and incom- plete solidification, so that we may have all three stages present at once. Besides these, the usual secondary inflammations also exist, such as localized bronchitis CATARRHAL PHTHISIS, THIRD STAGE. 121 and pleuritis. We therefore usually have a compli- cated pathological condition to deal with, and hence, although rules usually hold good, we are not to be surj)rised at variations and exceptions. Inspection. Third Stage. — The conditions already observed in the second stage will be jpresent, but usu- ally to a more marked degree. There are emaciation, rai^id and shallow respiration, usually marked depres- sion or flattening of the chest walls over the affected part, diminution of respiratory movements, especially on the affected side, and prominence of the superficial veins. When the ajjex is the seat of the disease, the supra- and infra-clavicular spaces are markedly de- pressed, as a rule, with corresponding prominence of the clavicle. Why are the superficial veins usually so prominent? Not so much on account of obstruction in the pulmonary circulation, because, as already stated, the volume of the blood in this wasting disease is much diminished, nor is the obstruction to the pulmonary circulation so great as it is in general hypertrophous (large-lunged) emphysema. Yet in the latter disease the superficial veins are not so prominent as in the third or even second, stage of i)ulmonary consumption. The true reason seems to be, that in consumption, as ema- ciation progresses, the vessels become more and more prominent, owing to the absorption of the fat around them. The impulse of the heart, which beats rapidly, is usually visible by reason of emaciation of the chest walls. The apex-beat may be in the normal position, but it is not unfrequently displaced, sometimes markedly, not usually from pressure, however, but from traction, due to pleuro-pericardial adhesion and retraction of 1^^ PHYSICAL DIAGNOSIS. the lung. This is especially the case when the left lung is affected. Walshe mentions a case where the apex-beat was, found under the left clavicle. It may be in either axillary line. Occasionally insj^ection yields almost negative results, even in this stage, the disease having become tempora- rily arrested, and the patient improved in general health for the time being. (See HcB^uoptysis, j). 102.) Palpation. Third Stage. — The vocal fremitus is in- creased over the affected part, as a rule, owing to the consolidated lung tissue near the ca\dty. But in rare instances the increase may be due to re-enforcement of the voice by echo in the cavity, a phenomenon of tlie consonance of sounds. All the conditions necessary for this, however, are rarely present at the same time. Sometimes, instead of being increased, the fremitus may be diminished, or even absent, for reasons alreadj^ enu- merated, such as obstruction in a large bronchial tube leading to the affected part, thickened jDleura, effusion, or intervening healthy lung tissue, in case of a very small, deep-seated cavity. Rlionchal fremitus due to gurgles, or other adventitious sounds, is sometimes felt, the thinness of the chest walls, due to emaciation, fav- oring its production. The apex- beat of the heart is usually felt, though feeble and rapid. The skhi is usually hot and dry, and the radial pulse, like the heart, of course, frequent and feeble. Percussion. TJiird Stage. — Dullness on percussion is the rule, especially gentle percussion, the consolida- tion around the cavity which contains more or less fluid generally, and the (condition of the pleura being favor- able for its production. There are, however, exceptions. CATARRHAL PHTHISIS, THIRD STAGE. 123 (1) Cracked-pot resonance is sometimes obtained. It is not known why it was ever termed cracked-X)ot, for it does not sound like percussing a cracked pot. The sound is in most cases due to the sudden forcing of air out of a cavity through a somewhat small ox)en- ing communicating with a bronchial tube. The pa- tient's mouth should be open, otherwise the air will not be driven out with sufficient force to produce th& sound. It requires a cavity, superficially located, at the upper part of the thorax, with tense but yielding walls, and a sharp percussion blow. It is best obtained in emaciated women, as their chest walls are more yielding than those of men. The sound is exactly imi- tated, not by striking a cracked pot, but by clasping the two hands together, so that the palms form a cav- ity, and striking the back of one hand or the other on the knee wdth considerable force. Children do this to imitate the sound of money in their hands, and for this reason it is sometimes called the money chink res- onance. But as it sounds very little more like the chink of money than it does like striking a cracked pot, and as the latter has the sanction of age as well as the name of Laennec associated Avith it, there ajopears to be no good reason as yet for changing it. Instead of being caused by the sudden escape of air from a ca\dty, it appears, in rare instances, to be due to concussion of air in some hollow viscus. Cracked-pot resonance is not constant, as the conditions for its production ra'p- idly change, such as plu'gging of the opening with mucus, filling of the cavity with fluid, and so on. In the first case coughing may dislodge the plug, and the sound will reappear. 124 PHYSICAL DIAGNOSIS. (2) Tympanitic resonance (drum sound) may be ob- tained by percussing rather forcibly over a large closed cavity filled with air, and having tense and rather un- yielding walls. The pitch and other properties of the note will vary with the size of the cavity and the ten- sion of its walls. (3) Amj)horic resonance (jug sound) is obtained by percussing, rather forcibly, over a cavity situated super- ficially at the upper part of the thorax, and having hard, smooth, and unyielding walls, empty or nearly so, and communicating freely with a bronchial tube — in other words a jug-like cavity (latin word amphora, signifying a jug, jar, or bottle) which acts as a resonant chamber. This amphoric percussion resonance may also be called metallic, the former having reference to the shape of the cavity, the latter to the metallic quality of the sound. In order to produce it the patient's mouth should be open during percussion, otherwise the sound would not be produced any more than by striking an empty jug with its mouth tightly corked. It is imi- tated exactly by percussing over the buccal cavity with the cheeks and lips tense, and the mouth partly open. The pitch varies in different cases, owing to different causes, as already explained, but the quality remains the same. Gairdner and Finlayson found that over such cavi- ties, and especially in pneumo-hydrothorax, a marked amphoric or metallic resonance is i^roduced by means of percussing with one coin on another coin (fifty-cent piece for instance), as a pleximeter, anteriorly, while the auscultator listened i)osteriorly — the so-called bell- CATARRHAL PHTHISIS, THIRD STAGE. 125 metal test. These cavities are usually situated high up toward the clavicle. (4) Flatness on percussion may be obtained over a large superficial cavity filled with fluid. (5) Normal resonance may be obtained on gentle percussion over a deex^-seated small cavity, if healthy lung tissue intervene. If the examination be made posteriorly and laterally, however, as well as in front, the cavity will usually be found. Myoidema, as already described, is usually notice- able in this stage, and especially on the front of the chest. For producing it, a sharp blow, delivered di- rectly with the point of the finger, is required. It is of little value as a physical sign. Auscultation. Tldrd Stage. — As a rule, cavernous breathing is heard over the cavity. That is, the respi- FiG. 14. — Diagram Showing Cavernous Breathing. ratory murmur is blowing in quality both on inspira- tion and expiration, giving the idea, as Flint correctly states, of air passing in and out of a hollow space. The pitch is usually lower than normal, expiration being lower, and as long as, or longer, than inspiration, and the two continuous. But the pitch, of course, varies with the size of the cavity, the tension of its walls, and so on. A large cavity, other things equal, would give a lower-ijitched cavernous respiratory murmur than a small one. Exceptions to this general rule are: (1) it 12Q PHYSICAL DIAGNOSIS. may be cavemo-broncliial. Here we have a mixture, in various proportions, of cavernous and bronchial breathing, owing to the presence of a cavity, perhaps rather small, and a good deal of consolidated lung tis- sue at the same time. Flint was the first to observe this variety of abnormal respiratory murmur, and termed it broncho-cavernous. That it does exist in rare in- stances cannot be denied. But in the few cases where I have noticed it, the bronchial element came last, so that I have usually described it as caverno-bronchial breathing. (2) Amphoric respiration, or jug breathing, is the respiratory murmur heard over a jug-shaped cav- ity, and sounds like blowing across, or into, the mouth of an empty jug or bottle. The cavity must have hard, smooth walls, and a large mouth, and be empty or con- tain but little Huid. Amphoric breathing is heard over the same kind of a cavity that yields amphoric reso- nance on percussion, although the two may not always exist at the same time, in any given case. The Vocal Resonance is best appreciated when the patient whispers. As a rule, cavernous whisper (whis- pering cavernophony) is heard over a cavity. That is, a whisjoer of l:)lowing quality, and rather low pitch, differing in the latter respect from bronchial whisper, which must be high x>itched, as we have seen. The pitch, usually low, varies, however, with the size of the cavity, the amount of solidified tissue, and so on. Fectoriloqwj. — In some cases, instead of cavernous whisper, the articulate words may be heard, and then it is usually called whisj^ering pectoriloquy. Now pectoriloquy means literally chest speech, and was first applied by Laennec to the vocal resonance heard CATAKIIIIAL PHTHISIS, THIRD STAGE. 127 over cavities wlien the articulate words were heard. Not that one is able to carry on a conversation with a patient through a cavity, but when only a distinct syllable or two may be heard in some simj^le X)hrase. But pectoriloquy in the same sense is sometimes heard over consolidated lung tissue, or even in health, as well as over a cavity. Pectoriloquy, therefore, is a general term for exiDressing a class of vocal resonance, of which there are several varieties. Bronchiloquy may there- fore be used, it seems to me, to express that variety of pectoriloquy sometimes heard over consolidated lung tissue, and caverniloquy when heard over a cavity. In- deed, Guttmann maintains that bronchophony and pec- toriloquy are practically identical. So they are, if we mean that it is possible sometimes to obtain bron- chial x)ectoriloquy. But bronchophony and bronchilo- quy are both necessarily high x^itched, as we have seen (Lobar Pneumonia, second stage), whereas Flint's whis- pering pectoriloquy (caverniloquy), as well as cavern- ous whisper (whispering cavernophony) and cavernous breathing, are usually low pitched and blowing in qual- ity, instead of being tubular. AmphoroxDhony and am- phoriloquy (amphoric voice and speech), whispered or otherwise, are sometimes heard over a cavity, and sound like speaking out loud, or whispering, into the mouth of an empty jug or bottle. Amx)horic echo is simply the reverberation of the voice, cough, or breath sound, in such a cavity. The same sort of cavity is re- quired for amphorophony or amx3horiloquy as in the case of amphoric resonance on x^ercussion, amphoric resxDiration, and metallic or amphoric tinkle. ^gox3hony (goat's voice) may also be heard in some 128 PHYSICAL DIAGNOSIS. rare cases, but this will be fully considered when speaking of pleurisy. It is nothing more than distant, tremulous bronchophony ; distant on account of some intervening medium, and tremulous from the presence of fluid thrown into vibration by the voice. Should the articulate words be heard, it would constitute what may be termed tremulous bronchiloquy. Adventitous Sounds. Third Stage. — As a rule gur- gles are heard. These are coarse, bubbling rales, made in the cavity, more particularly on inspiration, since the air enters the cavity with more force than it leaves it. For this reason the fluid in the cavity is stirred up more on inspiration than expiration. If the cavity be small, the gurgles may be fine. They therefore vary with the size of the cavity and the amount and consistency of the contained fluid. Their pitch also depends upon the amount of solidified tissue, which condition, as already stated, causes them to be raised in pitch. Whenever rales are mentioned as being gurgles, however, it is understood that a cavity is present. Metallic tinkle is sometimes heard. Laen- nec compared this sound to the dropping of water from a height into a metallic basin, and termed it me- tallic tinkle. It is also compared, by some, to the dropping of a pin into an empty bottle. But the idea of dropping anything is wrong, since metallic tinkle is probably never, in any case, produced by the droj)- ping of anything. In the first place, the fluid in a cav- ity is generally slimy, and will slide down the walls of a cavity rather than drip off. In the second place, the cavity is too small to hear fluid drop from the vault into fluid underneath, even if it did drop instead PLATE V. Phthisis Pulmonalis; Third Stage, showing Cavity with Gurgles, Upper Lobe of Right Lung. 3Y H.MACDONALO M.D. N .Y. CATAintllAL PHTHISIS, THIKD STAGE. 129 of sliding. But this distance would further be dimin- ished by the tenacity of the fluid, which would allow it to string down part of the way before it broke ofi'. This dripping theory, therefore, it seems to me, must be abandoned, especially in so small a cavity as that usually found in the lungs. It is, in fact, produced by the bursting of bubbles of a small amount of viscid fluid in a cavity containing air, and which is a resonant chamber, the same in which we get amphoric breath- ing and amphoric voice. Metallic tinkle is usually heard most distinctly on inspiration. It may be heard while the patient holds the breath, if a bubble previ- ously formed now bursts. Not all the bubbles will produce metallic tinkle, but only those that burst with a sound in consonance with the echo of the cavity. Metallic tinkle, in other words, is purely a phenomenon of the consonance of sounds. It is not constant, but apjDears and disappears in the same patient, according to the conditions necessary for its production. It is simi)ly the occasional musical echo of some adventi- tious sound (a gurgle, usually) in a reverberating cavity possessing the qualities of amphoricity. Bronchial rales of various kinds are usually present also, owing to the localized secondary bronchitis. They are usually of the moist class, and may be subcrepitant, submucous, or mucous. The subcrepitant and submu- cous are most common. Intra-pleural rales and friction sounds may also be present. In addition to these there may be, and often are, indeterminate rales ; that is to say, certain crackling and crumpling adventitious sounds, partly dry and partly moist, and due to the breaking down of tissue. The crex)itant rales, if pres- 9 130 PHYSICAL DIAGNOSIS. ent, would probably be obscured by other and louder sounds. Differential Diagnosis. — This rests chiefly upon the physical signs of more or less consolidated luno; tissue and cavities, with secondary local inflammation, affecting the upper part of the lungs preferably. Bron- chitis is a general, bilateral disease and gives no signs of solidification. Cancer of the lungs does this, but the dullness often extends across the median line, owing to co-incident enlargement of mediastinal tumors, and the sputa are currant jelly. There is also the want of hec- tic fever in cancer. Old pleurisy, with effusions, may be mistaken for phthisis, especially if the examination be confined to the apices of the lungs. But flatness on percussion, changing with position of the i)atient, due to effusion, will be found at the lower part of the thorax in pleurisy. Absence of respiratory murmur over the seat of disease, as well as other signs of effu- sion, will also be noticed (see Pleurisy). In cases of dou])t the hypodermic syringe may be used. Only the first stage of phthisis offers room for doubt about the diagnosis as a rule. Then the signs of incom- plete consolidation, so fully described, together with any of the localized adventitious sounds will usually lead to a correct conclusion. The discovery of the bacillus under the microscope would be conclusive, but the general practitioner need not expect to be able to do this, since he has generally neither the time, the proper instruments, nor the experience. FIBROID 1>IITJ1ISIS. 131 2. FIBROID PHTHISIS. Inspection. — There is retraction over the affected part, which may be at the upper region of the thorax on the riglit side, for reasons already mentioned. The shoulder is usually lowered on the affected side, but not so much as in pleurisy with retraction, and the respiratory movements on that side are diminished or even absent, especially if pleuritic adhesions be pres- ent also, as is often the case. If the other lung be un- affected it becomes more or less enlarged, as also healthy portions of the affected lung, from vicarious emphysema. The apex beat of the heart is often dis- placed, sometimes greatly so. When the right lung is affected, the apex beat of the heart may sometimes be found in the right axilla. This is due to great shrinkage of the right lung and emphysematous en- largement of the left, and often pleuro-pericardial ad- hesions add to it by traction. Should the left lung be affected, the apex beat may be found displaced as far as the left axillary line. The shrinkage of the thorax is usually horizontal, with decrease in the antero-x)os- terior as well as other horizontal diameters. But it also sometimes settles down, especially the upper part, with decrease of vertical diameter. Tn these cases the apex of the heart, if not otherwise displaced, will be found between the fourth and fifth ribs instead of the iiftli and sixth. The intercostal spaces are sometimes much narrowed. Palpation. — The vocal fremitus is increased over the indurated tissue, unless there be obstruction in the 132 PHYSICAL DIAGNOSIS. tubes from stricture or other cause, or interruption due to thickened i^leura, when it may be diminished or even absent. Tlie fremitus, therefore, thougli increased usually in proportion to the consolidation, may vary for different cases. The apex beat may be felt out of its normal position or not, according as the heart is disi)laced or not. Percussion. — There is usually marked dulness on percussion over the indurated lung and exaggerated resonance over the emphysematous portions. OAving to induration of lung-tissue, narrowing of intercostal spaces, and hardening of the ribs, the dulness is some- times termed wooden, and there is great feeling of re- sistance to the finger on i)alx)atory percussion, as Piorry first noticed. Hence, as often before remarked, one of the advantages of joalpatory percussion over all other methods. Sometimes, if there be a large bronchiectatic cavity, tympanitic, cracked-pot, or other resonance indi- cative of a cavity may be obtained (pp. 123-125). The line of hepatic dullness will be unusually high uj) if the vertical diameter of the thorax be much shortened (pp. 136, 148). Auscultation. — Bronchial breathing and broncho- phony will be heard over the contracted lung unless convection of the sounds of the respiratory murmur and voice by the broncliial tubes into the part be ob- structed by stricture of the bronchi, or i)lugging of them with viscid mucus, or other cause. Or else there niay be interruption of these sounds from thickened pleura. In either ca se the respiratory murmur and whis- j)ered voice will be weak or suppressed over the corre- sponding area, but the voice, if uttered loud enough, will FIBKOID PHTHISIS. I'SS surely be heard, though the resulting bronchophony may be distant or weak. Should bronchiectatic cavity be present, as generally occurs in the course of the dis- ease, the signs would indicate it as already described (p]3. 125-129). No cardiac murmur, unless it already exists, necessarily accompanies displacement of the heart. Owing to obstruction to the pulmonary circu- lation the right ventricle becomes somewhat enlarged with accentuation of the second sound over the pul- monary (second left) interspace (pp. 188, 189). Owing to diminution of the volume of blood in this wasting disease, however, these signs will not be so well marked as in general large-lunged emphysema, where there is not only marked obstruction to the pulmonary cir- culation, but also a full volume of blood not infre- quently, to be driven through the lungs. Differential Diagnosis. — Unless this disease affects both lungs it may be impossible to distinguish it from chronic (interlobular, interstitial) pneumonia, which is nearly always unilateral. In the pneumonia, patients do not have so much fever, retain more strength, and do not become so rapidly and markedly emaciated. Moreover, they do not suffer from the hoarseness and diarrhoea due to tubercular disease of the larynx and intestines that frequently occur in fibroid phthisis. The tubercle bacillus is not so abundant in fibroid phthisis as in the catarrhal form, and its discovery, though decisive, is often difficult and even impos- sible. Fibroid phthisis is said to affect the upper lobes by preference, while the pneumonia is usually basic. Pleurisy with retraction may be difficult to differen- 134 PHYSICAL DIAGNOSIS. tiate. Indeed, both are not infrequently j)resent, so that by shrinkage of the puhnonary interstitial connective tissue and compression by the contracting and enor- mously-thickened j)leura, the lung may become as small as a man's fist. But in pleurisy there are no signs of cavities as in fibroid phthisis, and in the former there are diminution or absence of the respiratory murmur and fremitus, the very opposite being the case in con- solidation of lung unless there be obstruction due to bronchial stricture and the like. The heart is not so much displaced in j)leurisy, and in the latter disease tlie patient is also usually in better general condition and with less cough and expectoration. In cancer of the lung, in addition to the cancerous cachexia, dullness over the affected i)art may extend across the median line, with inward pressure signs on the trachea and oesophagus due to cancerous enlarge- ment of mediastinal lymphatic glands. The percus- sion dullness from solidified lung-tissue, on the con- trary, never extends across the median line. The sputa in the two diseases would also differ. Compression atelectasis from pleuritic effusion, aneu- rismal or other tumors, deformities, and the like (p. 60), may be readily differentiated by careful examination and ascertaining the cause of the atelectasis. During the recent Berlin Medical Congress, Profes- sor Ewald, of Berlin, expressed the opinion that chronic pneumonia is phthisis, the reason why it is chronic being due to the presence of the tubercle bacillus. Ac- cording to Williams, tlie tubercle bacillus is nearly always found even in the so-called potter's and knife- grinder's lung and similar diseases. CHAPTER IV. Diseases in which the breath and voice sounds are interrupted in their transmission to the chest walls, with consequent diminu- tion, or absence, of vocal fremitus, respiratory murmur, and pectorophony. — Diseases of the pleurse. — Thickened pleurae. — Fluid or air, or both, in the pleural cavities. PLEURISY. Pleurisy, or pleuritis, is inflammation of one or both plenrse. These, consisting of two layers, \dsceral and costal, form a closed sac on each side. These sacs do not communicate, but approach each other closely be- hind the median line of the sternum, from a point cor- resiDonding with the upper borders of the second costal cartilages, to the upjier borders of the fourth, where they diverge. The left pleura turns obliquely do^\^l- ward and outward, but within the left nii^ple to the fifth cartilage, leaving a jDortion of the heart uncovered — the superficial area of cardiac dullness; thence in- ward to the upper border of the sixth, where it turns outward again to the lower border of the sixth costal cartilage on the left mamillary line ; thence to the lower border of the eighth, on the left axillary line; the ninth ril:* on the scapular line (or line let fall perpen- dicularly from the inferior angle of the scapula), and the tenth rib on the vertebral line (close to the spinal column). The right pleura continues down behind the median line of the sternum to the upper border of the sixth I'SQ PHYSICAL DIAGNOSIS. costal cartilage where it turns off nearly at right angles along the npper border of the liver. On the right axil lary line the right pleura reaches down to the upper border of the eighth rib, on the scapular line the ninth rib, and on the Aertebral line the tenth rib. The following is a summary of the lower limits of the pleurse: Left Pleura. — On sternal line, upper border of fourth costal cartilage. On mamillary line, low^er border of sixth. On axillary line, lower border of eighth rib. On scapular line, ninth rib. On vertebral line, tenth rib. Rigid Pleura. — On sternal line, upper border of sixth costal cartilage. On mamillary line, the same. On axillary line, upper border of eighth rib. On scapu- lar line, the ninth rib. On vertebral line, tenth rib. These limits vary somewhat with deep inspiration, also in emphysema, effusion of fluids into the pleural sacs, pneumothorax, and the like. The chief function of the pleurae is to furnish a small amount of lubricating material within the sacs, so that the layers can easily, and witliout noise, glide on each other, and thus facilitate respiratory move- ments. In this respect they resemble the synovial membrane of a large joint. And as anchylosis affects a joint, so are pleuritic adhesions injurious in proportion as they are extensive, and restrict the movements of respiration. Pleurisy may be divided into two classes: (1) dry pleurisy, and (2) pleurisy with effusion. Of each of these classes there are three varieties, (1) acute, (2) sub- acute, and (3) chronic. Dry pleurisy.^ circumscribed pleurisy, pleurisy with PLEURISY. 137 scant fibrinous exudation, or pleurisy without effu- sion, is a very common affection and often escapes notice. It is usually this class of pleurisy that is found in connection with pulmonary consumption, where the inflammation crops out here and there in spots on the perijjhery of the lung. Or it may be secondary to ex- tension of inflammation from cancer or other neoplas- tic growths. It may be caused by fracture of a rib or other surgical injury, or it may be due to exposure to a draught of cold, and, flnally, it may come on with- out any known cause. In idiopathic dry pleurisy the physical signs are few. Usually there is jerking respi- ration or a catch in the breath, as it is called, owing to the sharp pain in the side. This pain is usually near one nipple or the other. On palpation the fremitus is unchanged, owing to the small extent of the affection, and the slight ]3athological change x)roduced. This con- sists in a small spot of thickening or roughening of the pleura. Sometimes if there be scant fibrous exudation, a point of adhesion may result. The pulse is not ac- celerated and there is no fever. The percussion res- onance is normal. On auscultation a slight pleuritic friction or crex)itation may be heard, especially on in- spiration. In a few days, however, this may have dis- appeared. When no adventitious sound is present it might be a question as to whether the affection was dry pleurisy, pleurodynia or intercostal neuralgia. But dry pleurisy invariably has only one point of pain, Avhicli the patient can locate with the point of the finger. In intercostal neuralgia there are usually three points of tenderness ; near the spinal column, at the anterior ex- tremity of the nerve, and about its middle. Besides 138 PHYSICAL DIAGNOSIS. this tlie patient will probably give the history of previ- ous attacks of neuralgia in other localities as well as intercostal. In ^pleurodynia, or myalgia, there is ex- treme tenderness in the muscles of the side. The pa- tient shrinks from touch, and there is pain on motion. Lumbago, or other muscular rheumatism, is often as- sociated. Pleurisy toith effusion is inflammation of the pleura, attended vdXh sero-fibrinous effusion into the sac as the result of interstitial exudation. It may be primary or secondary, and either of these may be acute, subacute or chronic. The latter disease is sometimes described as empyema (pyothorax), but this wuU be de- scribed separately, and by chronic j)leurisy with effu- sion will be meant old cases of pleurisy with sero-fibri- nous, or serous, effusion. Acute pleurisy with effusion, lasts about two weeks, usually, and, like acute lobar pneumonia, has three stages. Undoubtedly, in many cases, the exciting cause is exposure to cold and wet, wdien it is said to be primary, although some predisposing cause, notably lowered vitality, must also exist. According to Lan- douz3% of Paris, many of these cases of pleurisy d fri- gore, so-called, are merely symptomatic of latent tuber- culosis and are not piimary. This is probably true for Paris, but not all climates, as I have learned from personal experience, as well as by inquiry at the Bromj)ton Hospital in London, and other hosiDitals. Acute pleurisy with effusion may occur secondarily in the course of articular rheumatism, Bright's disease of tlie kidneys, scarlet fever, measles and pysemic con- ditions. PLEURISY. 139 The first stage of acute pleurisy with effusion is the dry stage of congestion, and lasts from a few hours to twenty-four hours, or, in some cases, even longer. The second stage, that of effusion, lasts about five days on the average. The amount of liquid effused is not usually so great as in the subacute or chronic form, and is more fibrinous. The third stage, that of absorption, usually begins by the eighth day, and in about two weeks, in an ordinary case, recovery may be said to be complete. Tlie phys- ical signs differ according to the stage of the disease. First Stage. — The physical signs are similar to those of dry pleurisy already described, only more severe, as the disease under consideration is more extensive. Inspection.— ThQ patient lies on the affected side, since by this means the respiratory movements of that side would be restricted, while those of the unaffected side would be free. But with all precautions the resi^i- rations will be jerking, due to pain in the side. The respiratory movements are restricted on the affected side, somewhat exaggerated on the opposite side. Palpation. — The vocal fremitus will be unchanged or very slightly diminished, ovdng to the slight thick- ening of the pleura from congestion. But in persons with thin chest walls a friction fremitus over the dis- eased pleura may sometimes be felt. Percussion would yield normal resonance or slight dullness if the i^leura be slightly thickened by the con- gestion. Auscultation. — The respiratory murmur would be disturbed in its rhythm by the jerking due to pain, but its quality would be normal ; so would the i3ectoroph- 140 PHYSICAL DIAGNOSIS. ony (vocal resonance), but both wonld be somewhat diminished in intensity, due to slight thickening of the pleura from congestion. A pleuritic- friction sound is usually heard on inspi- ration, expiration, or both. Honore, of Paris, in 1819, was the first to call attention to this adventitious sound and to point out its true pathological significance. All intra-pleural adventitious sounds are heard usu- ally more distinctly on inspiration than on expiration, since the two layers of pleurae are brought closer and more forcibly together in the former act than in the latter. Those due to rubbing together of opposing roughened surfaces, and stretching of adhesions, are often heard only on inspiration, while intra-pleural rales, due to viscid exudative material, or perverted secretion, are often heard both on insi^iration and ex- piration, and simulate verj^ closely bronchial and other moist rales. Pleuritic friction may sound like the creaking or rubbing together of leather, or treading in deep, crusty, snow. Or it may be merely grazing or crepitating. Distinct pleuritic friction sounds are not infrequently interrupted, that is to say, there may be two or three consecutive friction sounds during in- spiration, expiration, or both. If the chest walls are thin and the friction well marked, a localized friction fremitus may be felt on palx)ation as already stated. Second Stage. — After effusion has taken place, we obtain the physical signs to be described in connection with chronic (subacute) pleurisy, with effusion (p. 142). They are chiefly those of interrupted transmission of sound, due to the presence of fluid in the pleural cavity acting as a partition or diaphragm, as well as flatness PLEURISY. 141 or marked dullness on percussion over the site of the effusion. Third Stage. — After absorption has sufficiently pro- gressed, the friction sound, which had disai^peared during effusion, reappears— ;/r?*c^/6> redux. This also finally disappears in favorable cases, as the conditions producing it clear up, and the physical signs again be- come those of health. An all-important question arises in connection with this disease. When must the chest be tapped? If life be threatened, owing to great effusion, tap at once. Do not draw off all the fluid, however, but only enough to allow the patient to breathe easily. But unless symp- toms of suffocation are urgent, and they very rarely are, do not draw any of the fluid off before the end of the third week. Why? Because if the fluid be dra^\^l off too early, and before active inflammation has sub- sided, adhesion of the two layers of the pleura will re- sult, which would be one of the most unfortunate termi- nations that the disease could possibly have. The fluid in the sac keejDS the two layers apart. To draw it off too early would not only thwart nature, but would be malpractice. According to Potain, of Paris, and others, only in rare and urgent cases should any fluid be with- drawn before the twenty-flrst day of the disease, and even then, only a part of it. Subacute pleurisy with effusion usually results from a badly managed case of the acute variety, or in cases where the iDatient is in bad condition when attacked, or iDerhaps is tuberculous. Chronic pluerisy \n.i\\ gi^eat effusion is described by many authors as subacute. It rarely follows the 142 PHYSICAL DIAGNOSIS. acute form, but is usually chronic from tlie first, and is not infrequently of tuberculous origin. The patient may not complain of pain in the side at all. Usually there is a hacking reflex cough, without much ex- pectoration. The appetite is poor and emaciation follows, attended sometimes by hectic fever. The pa- tient applies to a physician, who, being satisfied to ex- amine the apices of the lungs only, finds signs of con- solidation from compression at one apex, and hastily makes a diagnosis of phthisis simply. Had he taken the trouble to examine the patient carefully down to the waist, he would have found pleuritic effusion with the following physical signs: Inspection. — Usually there are bulging of the inter- costal spaces over the seat of effusion, which is always at the lower part of the thorax, displacement of the apex of the heart laterally, in a direction opposite to the seat of pressure from the effusion, and diminution of respiratory movements on the affected side in pro- portion to the amount of effusion, with exaggerated respiratory movements on the unaffected side. Col- lapse not infrequently follows removal and absorption of the fluid and the other side now appears abnormally large, partly from comparison with the collapsed side, but partly also because the lung has become actually larger in volume from vicarious emphysema. Where the case is not of long standing, however, and the pa- tient has chest walls covered with fat and luuscle, the bulging f)ver the alTected part may not be observable. Such a case ap- plied to me in May, 1885. He was a fire-stoker, aged thirty-two. The chest was perfect in outline. Upon my advice he applied to the late Prof. E. D. Hudson, whom I then assisted at the New York Polyclinic. Aspiration proved that the right pleural cavity PLEURISY. 143 contained an abundance of sero-fibrinous fluid. In this case the effusion was due to tuberculosis, as post-mortem examination proved, nearly two years afterAvard. Palpation. — Tlie vocal fremitus is diminished or ab- sent over the effusion, according to its amount. Above the level of the effusion, where the lung is in a condi- tion of compressed atelectasis, the fremitus is increased. These signs may evidently change with position of the patient, unless the lung is tixed in its iDosition by ad- hesions. The apex-beat of the heart may be felt out of its normal position. It sometimes happens that a spot of fremitus is felt somewhere over the seat of effusion. This is due to the telephoning of the voice to the spot along a string of adhesion, or else it may be extended by a rib, as in case of a heart murmur. Intercostal fluctuation may sometimes be felt. Percussion. — Over the fluid there is flatness on per- cussion, unless the chest walls are thick, in which case marked dullness will be elicited, as the walls themselves will give out some resonance, like the thigh, or the del- toid muscle. But where the chest walls are thin and the fluid abundant, flatness, or absence of resonance, except what is obtained out of the finger as a pleximeter and the chest walls, is the rule. Besides, there is also a feeling of resistance to the finger on palpatory percus- sion in these cases. Tlie upper line of the fluid, instead of being j)erfectly level, is, according to some, curved somewhat like the letter S, forming what is termed the curved line of Ellis. It is lowest in front, highest at the side, and averaged between the two i)osteriorly. This line changes with i^osition of the patient unless prevented by adhesions. Over the compressed lung 144 PHYSICAL DIAGNOSIS. there is dullness on percussion, but not infrequently under the clavicle on the side of effusion we obtain tym- panicity (Skodaic resonance). This occurs more fre- quently in front than behind. The true cause of this tympanicity was lirst exx)lained by Skoda. The pul- monary vesicles being obliterated by compression, as well as the ultimate bronchial tubes, the compressed pulmonary perii)hery is gathered around a bundle of dilated bronchial tubes that form an irregular cavity, which yields tympanicity on percussion. There is ex- aggerated percussion resonance over the other lung, ow- ing to its being in a state of vicarious emphysema. It sometimes happens that tympanicity, or even cracked- pot resonance, may be obtained over the seat of effusion. This is especially true in case of children. This is ow- ing to the fact that the force of the percussion blow ex- tends to the stomach, transverse colon or some neigh- boring viscus distended by air. Very gentle percus- sion, therefore, in children, is necessary to avoid tym- panicity. The cracked-pot sound, if obtained, would be due to concussion of air in some hollow viscus, and not to its forcible escape. Auscultation. — In listening over the seat of the effu- sion the respiratory murmur is diminished or, generally, absent. This is due to the fact that the lung is pressed away from the site of effusion, which not only does not conduct the breath and voice sounds but interrupts them. The pleural cavity, containing fluid, acts like a partition. The thicker the partition the less distinctly does sound pass through it. Sometimes, however, owing to a string of adhesion, bronchial breathing may be telephoned to a spot somewhere over the site of effusion, PLEURISY. 14^ or else it may be transmitted there along a rib. Above the seat of effusion and over the comi3ressed lung we hear bronchial breathing. But occasionally cavernous breathing is heard over the seat of percussion tym- 23anicity. Over the other lung the breathing becomes ex- aggerated, owing to the extra work that lung has to do. Fig. 15.— Diagram showing Pleurisy with Effusion, Compressed Lung, a String of Adhesion from the Compressed Limg to Thoracic Wall, Dilated Bronchi and Dis- placement of Organs to the opposite side. Pectorophony (vocal resonance ) is very much dimin- ished over the effusion, but is not entirely absent if the voice of the patient is loud enough. The whispered voice, like the respiratory murmur, is usually absent. But in speaking out loud, distant or weak broncho- phony is heard. If this distant bronchophony is trem- ulous, due to vibrating fluid, it is called jegophony (goat's voice), ^gophony is usually obtained where 10 146 PHYSICAL DIAGI^OSIS. the effusion is not great, otherwise the bulk of fluid cannot be thrown into vibration. It is heard most com- monly about the lower angle of the scapula, along the npper border of the fluid, when it is at that point. A thin stratum of encapsulated fluid may also be thro^^Ti into tremulous \dbrations by the voice, thus causing segophony. Thickened Pleura. — It not infrequently happens that after effusion has disappeared the pleura remains thickened. Indeed it is of common occurrence to ex- amine patients with only thickened jDleura without effusion. In these cases the thickened pleura also acts as an interrupter to the transmission of sound. The respiratory murmur, i^ectorophony (vocal resonance), and fremitus are also diminished, and percussion dull- ness is noticeable, in proportion to the thickening. A string of pleuritic adhesion, however, may transmit sound on the principle of a telephone. But extensive 13leuritic thickening is a different condition, which acts rather as a diaphragm, or partition, than a telephone. Differential Diagnosis. — The diagnosis of idiopathic dry pleurisy, from pleurodynia and intercostal neu- ralgia, has already been considered. The diagnosis be- tween acute pleurisy with effusion and acute lobar pneumonia is readily made, generally. In pleurisy with effusion there is interruption to the transmission of sound and the respiratory murmur, and the vocal resonance and fremitus over the affected part are di- minished or absent, but markedly increased in pneu- monia. The line of flatness or dullness in pleurisy often changes with position of tlie patient, but never in pneu- monia. In cancer of the lung there are signs of consoli- PLEURISY. 147 dation, usually at the upper and front part of the lung with increased conducting power, the dullness often extending across the median line, o^\dng to cancerous enlargement of mediastinal glands. In pleurisy with effusion, the affection is at the lower part of the thorax posteriorly, with interruption to transmission of sound and consequent diminution or absence of resjjiratory murmur and fremitus. The line of dullness in cancer does not change with position of the patient. In phthi- sis we also have signs of consolidation and increased con- duction power of lung tissue, instead of the interrup- tion of transmission of sound, as in pleurisy. In old cases of pleuritic effusion and compressed lung it is only carelessness should the physician confine his ex- amination to the top of the lung and omit the lower part of the thorax. Thoracic aneurism has been mis- taken for pleurisy with effusion, but such cases are very rare (see Aneurism). Hydatid disease of the lungs may be mistaken for pleurisy with effusion. Such a case has aready been alluded to (see Hydatid Disease of the Lungs, p. 109). There were signs of effusion in the upper part of the right pleural cavity. The location excited suspicion, as pleurisy usually affects the lower part of the thorax. Under the microscope some of the aspirated fluid showed the presence of hooklets and scolices. In any case of doubt the hypodermic syringe may be used to test the presence or absence of fluid. The differentiation of pleurisy with effusion from enlargement of the liver and spleen is sometimes difficult. The upper limits of the liver have been already given. 148 PHYSICAL DIAGjS^OSIS. being the same as the lower limits of the right lung and pleura. The lower limits of the liver correspond to the free margin of the ribs in the right hypochon- driac region, the tenth interspace on the right axil- lary line, and the eleventh rib on the scapular line, be- low which it is lost in the dorsal muscles. The liver usually enlarges dowTiward, but sometimes iipward, especially, according to Niemeyer, in case of abscess or hydatid disease. If the case be one of simple enlargement of the liver ui:)ward, the line of percussion dullness will extend up higher in front than behind, the organ ascends and descends during respiration, the respiratory sounds posteriorly though feeble, are not, according to Da Costa, entirely absent, and the heart, if displaced at all, is pushed upward. The signs do not change with position of the patient, as they often (not always) do in pleurisy with effusion. In the latter disease, occurring on the right side, the liver may be pushed down, giving dullness on loercussion below the ribs. But, with the patient in the sitting or standing position, the line of dullness will extend up as high jjosteriorly as in front, and the liver does not move up and down during respiration, but it is permanently depressed. Moreover, a small yielding interval may be usually felt between the lower border of the ribs and a normal liver that has been pushed down by fluid, whereas no such sj^ace exists in case of enlargement of the liver downward. According to Niemeyer, the normal dullness of the spleen is from the upper margin of the eleventh rib, along the axillary line, to the ninth rib ; anteriorly to a line drawn from the anterior end of the eleventh rib PLEURISY. 149 to tlie nipple ; but x^osteriorly it cannot be defined from the dullness of the left kidney, but its greatest thick- ness from before back, is about two inches. The spleen usually enlai'ges downward and forward, and then may be felt below the ribs in the abdominal cavity. But according to Memeyer and others it may extend upward, rarely higher than the fifth rib, without going below the margin of the ribs at all, even in cases of de- cided enlargement. Intestines distended with gas, and the like, push it upward and backward as in typhus, but if it enlarges upward, as in intermittent fever, it extends toward the axilla. The heart is pushed up- ward, and not sidew^ays, the latter usually being the case in large pleuritic effusion. The enlarged spleen moves up and down perceptibly during respiratioii, the level of dullness changing an inch sometimes on respiratory percussion, accordingly as percussion occurs at the end of a full inspiration or expira- tion. The area of dullness is less when the patient lies on the right side in enlarged sjDleen, but it does not otherwise change with i^osition of the i^atient as is often (not always) the case in pleuritic effu- sion. In enlarged spleen, the resj)iratory sounds are feeble over the part, but, according to Da Costa, the vocal vibrations are mostly unimi)aired, whereas they are usually absent in effusion. The rational signs of the case and i^revious history, with reference to pleu- risy, intermittent fever, and the like, will aid in arriving at a correct diagnosis. Lastly the hypodermic syringe may be used to test the presence or absence of fluid in the pleural ca\dty. Extensive plastic (adhesive) pleurisy without effusion would, among other points of differ- 150 PHYSICAL DIAGISTOSIS. ence, cause no fullness of the chest- walls, like enlarged liver or spleen, and might even produce contraction. In case of effusion into the pleural cavity it may be- come necessary to perform the operation of paracen- tesis thoracis (thoracentesis, tapping, or aspirating the chest). This may be done by means of Potain's as- pirator, or better still, i^erhaps, by Dieulafoy's instru- ment. I have had a guard, regulated by a screw, fitted Fig. 16.— Potain's Aspirator, and Needle with Movable Guard O. to the needles used by myself. By this means the needle cannot accidentally penetrate any deeper than is necessary to draw off the fluid. "Where shall we puncture ? According to Bow- ditch, find the inferior limit of the sound lung be- hind and tap two inches higher than this on the pleuritic side, at a point in a line let fall peri:)en- dicularly from the (inferior) angle of the scapula. Push in the intercostal space here with the point of the finger, and plunge in the needle quickly and firmly PLEURISY. 151 at the depressed part, in order to get through, false membranes. If no fluid be obtained here, puncture a little higher up and further toward the axillary line. Bowditch's point of puncture has the advantage over all others of allowing the pleural sac to be entered at the most dependent point, with less risk of perforating the diaphragm and causing peritonitis, though it possesses the disadvantage of obliging the patient to be in a sit- ting posture, if that be any, instead of the recumbent, during the operation. Fraentzel, of Berlin, prefers a point haK way between the mammillary and axillary lines in the fifth interspace on the left side, and in the fourth on the right, the pa- tient being in the recumbent position. Aufrecht, of Mag- deburg, prefers a point on the axillary line in the fourth interspace on both sides, the patient being recumbent. Puncturing the diaphragm with resulting fatal peri- tonitis has occurred in this operation by penetrating the chest-walls too low down. In general, the puncture should be made on the axillary line, between the fifth and sixth ribs on the left side, and between the fourth and fifth ribs on the right side to avoid the liver. In what cases, speaking of adults, shall the operation be performed, and how much fluid be withdrawn? Ac- cording to Anstie (Reynold's System of Medicine) it should be done (1) in all cases where the fluid fills one pleura and begins to compress the other lung; (2) in all double pleurisies where the total fluid would about fill one pleural cavity ; (3) in all cases of large amount of effusion where there have been one or more fits of orthopnoea ; (4) in all cases where the fluid is purulent, and (5) in all cases where fluid, occupying at least half 152 PHYSICAL DIAGNOSIS. of a pleural canity, lias existed for a month and shows no signs of being absorbed. Neither Bowditch, Murchison, nor Anstie recommend to withdraw all the fluid, but only so much as will substantially relieve the mechanical distress caused by pressure. In most cases that is all that is necessary to excite the natural process of absorption. They all stop the withdrawal of fluid the moment the patient begins to complain of constricting pain in the chest or epigas- trium. Fraentzel, of Berlin, operates usually when the fluid reaches uj) to the third rib, and oedema of the other lung is threatened. He takes out about flf ty ounces of fluid and repeats the oj)eration in three to five days when necessary. Aufrecht recommends (1) that a trial puncture by Pravaz's syringe be made before operating. The ordi- nary hypodermic syringe with a perfectly fitting piston and carefully adjusted long needle (disinfected) is sufiicient. (2) If there is reason to believe that less than forty -five ounces of fluid will be discharged, the opera- tion had better be usually left undone. (3) 'Not more than eighty ounces of fluid should be evacuated. (4) The thoracentesis should not be repeated unless a vital indication demand it. (5) The operation of drawing off part of the fluid should be performed in all cases of large effusions as soon as the patient is seen, irre- spective of the degree of temperature. Other authors draw off the fluid at an earlier date than any of those mentioned, and do not hesitate to withdraw it all. In case of empyema (pyothorax) a pennanent drain- age tube, securely fastened to prevent its droj)i3ing into HYDROTHORAX — EMI» V KM A. 153 che pleural cavity, promises better results than repeated aspiration. The tube may be introduced through a free opening as low down as the seventh intercostal sj)ace on the axillary line, whereas the trocar (needle) should not be pushed into the i)leural cavity lower down than already mentioned. HYDROTHORAX. Hydrotliorax is a dropsical and non-inflammatory affection, in which there is fluid in both jjleural cavities. It is the result of a serous transudation and not of an inflammatory exudation, and is usually associated with general dropsy from some cause. Hydroperitoneum and hydro-pericardium may exist at the same time. Tlie physical signs are similar to those of pleurisy with effu- sion, the later being generally unilateral, however, and hydrotliorax bilateral. For this reason the heart is not noticeably displaced in hydrothorax, unless it be pushed dowm. Hydrotliorax is, of course, unattended by fric- tion sounds. EMPYEMA. Empyema, pyothorax, or suppurative pleurisy, is a disease characterized by pus in the pleural cavity. It may be due to traumatism, or an abscess opening into the pleural cavity from the liver, abdomen, the chest walls, or the lung. When it occurs without any of these causes it is probably due to some constitutional vice or to exhaustion of vitality. But why j)leuritis should sometimes result in sero-fibrinous, and at other times in purulent effusion, is not exactly known. The physical signs are almost identical with those of 154 PHYSICAL DIAGNOSIS. pleurisy with non-purnlent effusion. There is usually more emaciation in empyema, and the signs generally are more grave. But the only means of making a posi- tive diagnosis is by withdrawing some of the fluid with the hypodermic syringe, or other aspirating instrument. HEMOTHORAX. Hsemothorax, or blood in the pleural cavity, may be due to traumatic causes, or it may result from cancer of the pleura or rupture of aneurism into the pleural sac. Very rarely it is caused by the withdrawal of fluid from the pleural cavity, causing rupture of vessels by the sudden removal of the pressure to which they had become accustomed. Wounding the intercostal artery by the aspirating needle may sometimes produce it. The physical signs of blood in the pleural cavity are similar to those of pleurisy with effusion, Neither in hydrothorax nor hsemothorax are there friction sounds. The former is usually bilateral, hsemothorax unilateral. In lijemothorax, also, the symptoms are sudden and urgent, whereas hydrothorax is always in- sidious. PNEUMOTHORAX. Pneumothorax is a disease in which there is air in the pleural cavity. Generally it is unilateral. It may be due to traumatic causes, such as penetrating wounds of the thorax, injury to a lung from the end of a fract- . ured rib, and the like. Or it may be due to openings into the pleural cavity from rupture or ulceration of the stomach or cpsophagus, and from the lungs in the course of empyema, abscess, or hydatid disease. Ac- PNEUMOTHORAX. 1 5.5 cording to Walshe, however, ninety per cent, of all cases of pneumothorax are caused by the escax^e of air from the lungs into the pleural cavity, due to breaking down of tubercle. It is very doubtful if gas ever orig- inates spontaneously in a closed pleural cavity. The physical signs are as follows: Inspection. — Dyspnoea and anxious countenance are usually noticeable. Sometimes there is more or less cyanosis. Bulging and want of respiratory movement on the affected side with displacement of the heart in the opposite direction, are marked in proportion to the amount of air in the pleural cavity. Respiratory movements on the unaffected side are exaggerated. If the opening be valvular, so that air enters the pleural sac without escaping, the dyspnoea becomes extreme, and all the signs are marked. Palpation. — The vocal fremitus is diminished or ab- sent, according to the amount of air in the pleural cav- ity. The heart may be felt displaced and beating rapidly. Percussion. — Over the affected side there is tympani- tic resonance on percussion. The pitch will be high or low according to the volume of air in the pleural cav- ity and the tension of the chest walls. Over the other lung, exaggerated resonance is due to the extra work it is doing, and the state of vicarious emphysema. Auscultation. — ^The respiratory murmur over the affected side is usually diminished or absent, unless there are string-like adhesions. The vocal resonance is also diminished, and some- times, according to Walshe, has a metallic (amphoric) quality. 156 rJIYSICAL DIAGNOSIS. Tlie tympanicity on percussion at once distinguishes it f I'oni fluid in the j^leural cavity from any cause. The diagnosis of i^neumothorax from em]6hysema, has al- ready been considered. (See Emphysema.) PNEUMO-HYDROTHORAX. Pneumo-hydrothorax, or hydro-j^neumothorax, as the name indicates, signifies air and fluid both in the pleural cavity. According to some authors, the fluid is always purulent, and they describe it as pneumo- pyothorax, or pyo-pneumothorax. As pneumothorax is always followed by inflamma- tion tmd effusion into the i3leural cavity within a few hours, or a day or two at most, the etiology of one dis- ease applies also to the other. Iimpecthyn. — Dysj)n(pa and anxious countenance, Avith bulging and want of resj^iratory movement of the affected side and displacement of the heart, may be noticed, as in pneumothorax or pleurisy with effusion. If the opening into the pleural cavity be valvular, so that air enters more readily than it escapes, the signs are more marked. Tliis may occur at different times in the course of the disease. Palijatio.h. — The vocal fremitus is diminished or ab- sent on the aff(M'ted side. The heart may be felt out of its normal position. Per6'W5.5/o??.— Above the level of the fluid the note is tympanitic, as in pneumothorax. Over the fluid there is marked dullness or flatness, as in pleurisy with effusion or hydrothorax. Not infrequently about the union of the two there is amphoric (jug, metallic) res- onance on percussion. The line of dullness or flat- PNEUMO-HYDROTHORAX. 157 ness and tympanicity, changes markedly with position of the patient. In these cases, also, the iipper end of the iluid is horizontal, instead of being slightly curved as in pleurisy with effusion. Auscultation. — The respiratory murmur is weakened or absent, or else it is amphoric (jug, metallic). The Fig. 17. — Diagram of Pneumohydro-thorax, showing fluid and air in riglit pleural cavitj', right lung compressed and displacement of organs to the opposite side. Also the supposed dropping of fluid. vocal resonance is also weakened, or sometimes am- phorophony, or even amphoriloquy, may be present. BuGGUSsion. — This is the act of shaking the patient wdiile auscultating at the same time. On succussion the splashing sound of the fluid in the cavity is heard, often by the patient as well as the physician. Metallic {amphoric, jug) tinkle is often heard in this disease, and by many it is supposed to be ]3roduced by 158 PHYSICAL DIAGNOSIS. the droiDping of fluid from above into the fluid below. It may be x)ossible that in such a large cavity as is usu- ally represented, fluid may have sufficient distance to fall to produce the sound; but even here it is more probably due to the bursting of bubbles formed by in- spiration, or by shaking the patient. The distinctive sign of the disease, and one which prevents its being mistaken for any other, is the splashing sound of the fluid in the cavity heard on succussion. It is impos- sible to obtain this sound in simj)le pleurisy with effu- sion, since there is no air in the cavity, and hence the fluid there cannot be shaken any more than it could be in a bottle, or other vessel, filled up to the cork. In all suspected cases, succussion should be tried. CHAPTER y. Summary of adventitious sounds, and of the changes in the nor- mal respiratory murmur and vocal resonance produced by disease. Adve]s^titious sounds, as previonsly stated, are wholly new and abnormal sounds ]Drodnced by disease, and are not modified normal sounds. They have been variously divided and arranged by different authors, but for simplicity as well as convenience they may be classified into (1) rales or rhonchi, (2) friction sounds, and (3) splashing sounds. I. RIles. Rales, or rhonchi (rattles), have also been grouped differently by different authors, but they may be re- duced to three varieties: (1) dry, (2) moist, and (3) in- determinate. Each of these varieties will now be con- sidered separately. 1. Dry RIles. There may be many varieties of dry rales, but two are sufficient to include them all: (1) the sonorous and (2) the sibilant. Sonorous Hales are loud, low-pitched, dry rales, made on inspiration, expiration, or both. They may be produced in the larynx, trachea, or larger bronchi. In the larynx they may be caused by si)asm of the glottis, as observed in laryngismus stridulus, croup, and 160 PHYSICAL DIAGNOSIS. wliooping-cougli, growths within the larynx, and press- ure on the recurrent larjTigeal nerve from aneurism or other tumor. In the trachea they may be due to press- ure without from some tumor, aneurism for examx)le, or gTowths within, as polypi, or oedema, inflammatory exudation, or constriction due to old cicatrices and the like. Such rales are termed stridor, and the breath- ing is said to be stridulous. If the pressure, or ob- struction, or constriction, be sufficiently marked, sibi- lant as well as sonorous rales may be produced f n these localities. These rales made in the larynx or trachea are, however, conveyed all over the chest usually, and should be differentiated by means of the stethoscope ; an easy matter, as they are much louder at the site of their production than elsewhere Sonorous rales are made iii the larger bronchi from narrowing of their calibre by external pressure from some tumor, strict- ure due to old inflammation, spasm of the muscular coats, or tumefaction of the lining mucous membrane, or else ("he vibration of viscid mucus within the tubes. These rales are generally transient, and change on coughing. For this reason, it would appear that they are more frequently due to varying spasm oi- vibrating mucus that is removed by coughing. Where the cause is permanent, the rales are few in number, and often changeable, though less so, showing that even in these cases, ^dbrating mucus, from localized irritation, is often an important factor. Both sonorous and sibilant rales are heard, especially in the early or dry stage of bron- chitis and in spasmodic asthma. In the latter disease they are also sometimes said to be mewing and chiri^ing. Sibilant rales are high pitched, whistling, dry rales, MOIST RALKS. 161 made on inspiration, expiration, or both. As already remarked, they may be made in the larynx or trachea, if the calibre be diminished sufficiently. For the same reason they may also be made in the larger bronchi. Usually, however, they are made in the smaller bronchi. The causes of their production are the same as for the sonorous or snoring rales, and, like them, are heard es- PiG. 18. — Sonorous and Sibilant Rales. SnE, riouorous Rales ; SbR, Sibilant Rales. pecially in the dry stage of bronchitis, and in an attack of asthma. They are also changeable, being heard more distinctly now in one place and then in another. 2. Moist Rales. These may occur in the larynx, trachea, bronchi, air- cells, or in the pleural cavities. Laryngeal and tracheal rales may also be moist as well as dry. Moist tracheal rales occurring just before death, as they often do, are 11 162 PHYSICAL DIAGNOSIS. commonly called death rattles. These rales may also be heard over the chest, and their locality should be differentiated by means of the stethoscope. In cases where rales of any kind are heard over the chest, the patient should be directed to clear the throat, so as to get rid, if possible, of any laryngeal or tracheal rales that might exist. Many varieties of moist rales occurring in the bron- chi are described by various authors, but three are suffi- cient to include them all: (1) mucous, (2) submucous, and (3) subcrepitant. Mucous rales are large, moist, bubbling rales made in the larger bronchi, and are heard both on inspira- tion and expiration, since the tidal air acts on the fluid in the tubes both on entering and leaving them. These rales are usually attended with expectoration, and they change about on coughing. Fluid of any sort in the larger bronchial tubes will give rise to mucous rales, whether it be mucus, blood, or pus. We therefore find them in such diseases as bronchitis, unless the secretion be very scant, certain cases of pulmonary hemorrhage, abscess, and pulmonary consumption. In general bron- chitis the rales are bilateral, but usually few in number. If not heard at all on first listening, they may be de- veloped by coughing. In other diseases where the bronchitis would be local, the rales would also be lo- calized. Submucous rales are moist, bubbling rales, rather- smaller than the mucous, and are made in the medium- sized bronchi. They are also heard both on inspiration and expiration, are attended with expectoration, and are changed by coughing. They are produced in the MOIST RALES. 163 same way, and are due to the same causes, as the mu- cous rales (see fig. 8, p. 38). 8itbcrepitant rales, or muco-crepitant rales, are the finest moist bronchial rales, and are made in the finer (ultimate) bronchial tubes, chiefly on inspiration, and are not as easily changed as the mucous and submucous by coughing. This is accounted for by the fact that in- spiration is a greater force than expiration, as affecting the finer tubes and air-cells. Hence the mucus in these localities is overcome with greater force on inspiration than expiration, and the subcrepitant rales are conse- quently produced on inspiration rather than expira- tion. They may be, and often are, entirely wanting during expiration. Instead of being caused by the bursting of very fine bubbles, these rales are sometimes caused by the forcible separation of agglutinated tube walls, and then they are invariably heard only on in- spiration. In capillary bronchitis they are heard on both sides, usually posteriorly and low down. In pul- monary oedema they are also sometimes heard as the serous fluid enters the tubes (see (Edema). The rale also occurs in the third stage of lobar pneumonia, due to secondary local bronchitis and liquefying exudation. In pulmonary hemorrhage from any cause these rales are produced if blood enters the finer tubes, and hence are often heard in hemorrhagic infarction. Pus in these finer tubes also gives rise to it, whether the pus be due to purulent bronchitis, rupture of an abscess, or perforation from empyema. This rale is also the adventitious sound usually heard in the first stage of phthisis, although it may evidently occur in any stage. Crepitant rales are made in the air-cells, and are the 164 PHYSICAL DIAGNOSIS.- only vesicular rales that exist. They are very fine, uniform, crackling rales, heard only at the (tip) end of inspiration, and are anchanged by coiighing. They are caused by the forcible separation of agglutinated cell walls, as in the first stage of lobar pneumonia, or agitation of thin fluid in the air-cells, as in pulmonary a?dema. They are heard also in the third or resolving stage of lobar imeumonia, where it is known as the rale redux, or rale that has returned, or come back. The crej)itant rale, then, and not the subcrepitant, as is so often erroneously stated, is the rale redux, or re- turned rale. The subcrepitant rale is not a j)^i't of the physical signs of any stage of pneumonia but the third, in which it has not come back, but is heard for the first time. The crepitant rale, however, which was heard in the first stage', and lost in the second after the air-cells had become obliterated, now comes back, or is redux, in the third stage. The crepitant rales heard in pulmonary oedema are louder and more liquid in quality than those of pneumonia. The crepitant rale may also be heard in pulmonary consumption in any stage, if the conditions for its production exist, and other adventitious sounds, usually present, are not so loud as to obscure it. Mucous Cliclx. — A single fine, high-pitched moist click that is usually unchanged by cough, may be heard at or near the end of inspiration over incomplete consol- idation in the first stage of i^hthisis. As Loomis says,^ it sounds like an isolated subcrepitant rale. When it is really of mucous origin, it is no doubt due to the sud- den passage of air through a fine bronchial tube ob- structed by pressure without, due to tubercle, for in- MOIST rIlES. lOo stance, or viscid mucus within. It is a very important adventitious sound in the commencement of pulmo- nary consumption. But may it not sometimes also be of pleuritic origin? Gurgles are moist, bubbling rales made in a cavity, and are large or small, or low and high pitched, accord- ing to the size of the cavity and amount of consolidated tissue intervening. They are made either during in- spiration or expiration, but inasmiich as the air usu- ally enters a cavity with more force than it leaves, gur- gles are consequently apt to be louder on insi3iration than expiration. Sometimes they are heard only on insj)iration. Moreover, during inspiration, the direc- tion of the current is toward the ear of the listener, in- stead of from it, as in expiration. If the cavity be full of fluid there may be no gurgles. None will be heard, also, if the cavity be empty, or if the opening into it be such as to prevent fluid from being agitated by the air entering or leaving it. If the opening into the cavity becomes stopped with a plug of viscid mucus, a clot of blood, or other material, gurgles which were heard before now immediately cease. On coughing and re- moving the obstruction they at once return. (See col- ored jjlate showing cavity.) Metallic Tinkle, or Amfplioric Tiiikle. — If the cavity, whether it be ]Dulmona,ry or intra-pleural, have hard, smooth walls, and be of sufficient size to act as a reso- nant chamber, in other words, if it be an amphoric cav- ity, and if it contain a small amount of viscid fluid with the tube opening under it or into it, so as to pro- duce explosion of bubbles, metallic, or am^Dhoric tinkle is apt to result. Or it may be produced by the vibra- 166 PHYSICAL DIAGNOSIS. tion of viscid mucus. It is usually heard most dis- tinctly on inspiration, like ordinary gurgles, and is not constant. It often disappears on coughing, or it may be developed by coughing. According to Walshe, such adventitious sound need not be situated in the cavity at all, if it be near enough so that the sound shall be echoed in the cavity. Metallic tinkle is also sometimes produced by sjieaking or coughing. It is probably never due to dropping of iluid in a pulmonary cavity, since there could hardly be distance enough for it to fall with sound sufficiently distinct to be heard. Even in pneumo-hydrothorax, metallic tinkle may be re- garded as a musical rale of amphoric quality, j)roduced by the bursting of bubbles rather than the dropping of fluid. For that reason it has been classified with the moist rales. Intra-pleural Moist Bales. — Pleuritic friction sounds are easily distinguished from other adventitious sounds ; but occasionally we hear sounds, evidently of intra- pleural origin, that exactly imitate moist bronchial or vesicular rales. Some authors go so far as to say that the crepitant, as well as the subcrepitant rale, is al- ways intra-pleural. In the same way other intra- pleural adventitious sounds, resembling mucous and submucous rales, are sometimes heard, so that, as Da Costa says, no human ear can tell the difference by the quality alone. How are we to distinguish between them? This subject has already been alluded to (see Bronchitis). If the rales are localized, unilateral, unchanged by coughing, jDeripheral and superficial, and unattended with expectoration, they are usually intra-pleural. If, on the other hand, they are bilateral, INTRAPLEURAL rIlES. 167 changed by cough, attended with more or less expecto- ration, deep-seated, and generally distributed over the chest, they are almost surely bronchial. But how can we distinguish the crepitant rale made in the air-cells from the intra -pleural crex)itation ? Sometimes it is difficult or even impossible. This, however, does not necessarily make the two identical any more, for in- stance, than it makes thoracic aneurism and pleurisy with effusion identical, because one has been mistaken for the other until i^ost-mortem examination revealed the true state of the case. In pulmonary oedema we have the crepitant rale bilateral and low down poste- riorly. There is also watery expectoration and the cause of oedema (see CEdema). Intra-pleural crepitation is rarely bilateral, and then is unattended with expec- toration, unless there be complication. In the first and third stages of lobar pneumonia it is more difficult to say that the rale is not intra-pleural. Even in these cases the rale sometimes follows the outline of the lobe too closely to say that it is always intra-pleural. Intra-j^leural moist rales do not require actual in- flammation of the pleurae for their production. Per- verted nutrition of the membrane from any cause may give rise to a viscid, glutinous secretion, instead of the normal lubricating material, so that the pleurae, in- stead of gliding noiselessly on each other during respi- ration, will produce sounds which, as already stated, may be, and often are, identical in quality with vesicu- lar, bronchial, tracheal, or laryngeal moist rales. 108 PHYSICAL DIAGNOSIS. 3. IlSTDETERMIXATE RaLES. Indeterminate rales include all other rales not em- braced in the foregoing classes and varieties. They are crackling and crumpling sounds, partly moist and partly dry, produced on inspiration or expiration, or both, and it is impossible to determine with certainty whether they are of intra-pleural, pulmonary, or bron- chial origin. Flint states that they are found usually early in phthisis. They may be heard during any stage, but particularly, perhaps, after the disease has advanced sufficiently to give rise to broken-down tissue and complicated pathological conditions. The follow- ing table in regard to rales may be of use : 1. Dry Rales. Rales or Rhonchi. ■{ '6 classes 2. Moist Rales. Indetermi- nate Rales. Stridor— produced in the Larynx. Sonoi'ous — produced in the Large Bronchi. Sibilant — produced in the Small Bronchi. ' Laryngeal — produced in theLarynx. Tracheal— produced in the Trachea. Mucous — produced in the Large Bronchi. Submucous — produced in the Medi- um Sized Bronchi. Subcrei^itant — produced in the Small Bronchi. Crepitant — jn-oduced in the Air-cells or vesicles. Mucous Click — produced in a Small Bronchus. Gurgles — produced in Cavities (pul- monary). Metallic (amphoric) Tinkle — pro- duced in Cavities Interi)leural moist rales which may simulate any of the above moist rales. Partly moist, jiartly dry, crackling and crumpling sounds, whose exact origin and mode of pro- duction are unknown. FRICTION SOUNDS — SPLASHING SOUNDS. 1G9 II. Friction" Sounds. Friction sounds are due to pleuritic inflammation. Their true patliological signiUcance was tirst pointed out about 1819 by Honore, of Paris, a contemporary of Laennec. The membrane, which in health was moistened with a lubricating secretion, so that the two opposite layers glided noiselessly upon each other dur- ing respiration, now becomes dry and rough, or agglu- tinated. For this reason, grazing, rubbing, rasping, grating, rumbling, or creaking sounds may be pro- duced. The sounds are heard chiefly on inspiration, and are usually interrupted, so that several may occur, during one inspiration. They are also heard sometimes during expiration. As already stated, pleuritic friction sounds are heard more distinctly usually on inspira- tion than expiration (p. 140). As Flint correctly states, these sounds are usually more distinctly heard after removal of the fluid, if any exist, than before, as the surfaces of the i:»leurfe are by that time more roughened than at flrst. These friction sounds are of variable duration, depending upon the pathological condition. When well marked, esjoecially in those having thin chest walls, friction fremitus may be felt on palj)ation. III. Splashing Sounds. Succussion is the act by which sx^lashing sounds are produced. It consists in shaking the patient while the ear is placed to the chest. By this means the splash- ing of fluid in a cavity containing air and fluid is heard, as in pneumo-hydrothorax (or xmeumo-pyothorax). It might be iDossible, also, in a large pulmonary ca\i.ty 170 PHYSICAL DIAGNOSIS. containing air and fluid. It is usually, however, pathognomonic of pneumo-hydro (or pyo) thorax. CHANGES IN THE RESPIRATORY MURMUR. I. Changes of Intensity. The sound of the respiratory murmur, as well as of the voice, arrives at the chest walls in health, first, through convection along the tubes, and secondly, re- fraction (diffusion) in the air-cells. But for this refract- ing power of the healthy lungs, due to the presence of the air-cells, the intensity of the resj)iratory murmur and of the voice sounds would be greatly increased, as -occurs in solidification. On the other hand, the sounds would be diminished or absent, according to the amount of obstruction in the tubes to convection, increased re- fraction, as in emphysema, and interruption, as in pleu- ritic thickening or effusion. We see, then, that these, as well as other sounds on their way to the chest walls, may, according to the con- ditions present, be subjected to (1) convection, (2) ob- struction, (8) refraction (diffusion), (4) conduction, and (5) interruption. On the chest walls, or along strings of adhesion, they may be transmitted, or extended. In health, then, when convection along the tubes is perfect, and there is only normal refraction (diffusion) in the air-cells, we hear the normal respiratory murmur, Avhicli will be laryngeal, tracheal, bronchial, vesiculo- bronchial, or vesicular, according to the locality. The intensity of this murmur A\ill be weakened or suppressed (also termed diminished or absent); (1) in proportion to obstruction to convection in the tubes, •either from growths, nuicus, ims, blood, or other ob- CHANGES IN THE KESPIKATORY MURMUR. 171 stacles within, or stricture, from old infiammation or compression of the tubes from aneurism, cancer, hyda- tids, or some other cause ; (2) increased refracting (dif- fusing) power in the lungs, due to dilatation of the air- cells, as in chronic general emphysema; or (3) inter- ruption from pleuritic thickening or effusion. Second- arily, it would be modified also by interference with the proper expansion of the lungs and chest walls from pain, pleuritic adhesions, and deformities. The intensity may be slightly increased (exaggerated) in two ways. First, without any change in quality or rhythm, as when one lung or part of a lung is tempo- rarily mcariously emphysematous from doing extra work, owing to crippling of the other lung or part of a lung. It is simply louder than normal, and is sometimes termed hyper-vesicular or supplementary. It differs somewhat from puerile breathing, which is heard in children under the age of xouberty, whose lungs are not develoi:)ed in proportion to their bronchial tubes. Both are loud (rude), but the puerile respiratory murmur has more of a bronchial element in it. N'either are necessarily harsh (rough), this quality depending on the roughness of the mucous membrane lining the larger bronchial tubes, and caused by the friction of the tidal air Secondly, it may be slightly increased (exaggerated), with change in the quality and rhythm, as seen in the vesiculo-bronchial breathing, due to incomplete consol- idation with corresponding increase of conduction, and diminution of refraction, in the lungs, owing to oblit- eration, in part, of some air-cells; as seen in the first stage of phthisis pulmonalis. 172 PHYSICAL DIAGNOSIS. The intensity of the murmur will be markedly in- creased if refraction is replaced by conduction ; in other Avords, if the air-cells are replaced by solidified lung tissue, as occurs, for instance, in the second stage of lobar pneumonia, which offers a homogeneous medium for the conduction of sound. II. Rhythm. Prolonged expiration and divided respiration are the two principal changes in the rhythm. In the normal vesicular respiratory murmur, inspiration is about four times longer than expiration, and the two are continu- ous. Moreover, expiration is lower in pitch than in- spiration. Now, in a paroxysm of asthma, and in chronic emj^hysema, the expiration is prolonged, but is not usually changed in pitch or quality. In a par- oxysm of asthma the expiration is not only prolonged, but inspiration is much shortened by being deferred, that is to say, it is not heard in the commencement. The rhythm in such a paroxysm is Just the reverse of what it is in health, that is to say, expiration is four times longer than inspiration, or even longer. In em- physema, expiration is also prolonged and inspiration deferred, but it is never observed that expiration is four times longer than inspiration, unless there be also marked obstruction to the exit of air from the presence of mucus, or other cause. In bronchitis, also, expiration is prolonged in proportion to the obstruction from mucus, especially in capillary bronchitis; but the respiratory murmur is not otherwise changed, unless in some cases it may become harsh or rough (see Changes in Quality). In asthma and bronchitis, the RHYTHM. 173 expiration is prolonged, because of obstruction to the egress of air, either from spasm of the muscular coats of the tubes, or mucus within the tubes, or tumefaction of the bronchial mucous membrane. In general em- physema, on the other hand, expiration is prolonged on account of the rigid dilatation of the thorax, caused by loss of resiliency of lung tissue, rigidity of the cos- tal cartilages, and crippling of the diaphragm, leaving the muscular coats of the bronchial tubes to perform the act. If obstruction in the tubes, due to co-existing bronchitis, also is well marked, the expiration will be still more prolonged, but usually the expiration of em- physema is not so much prolonged as to be four times the length of inspiration, as in a paroxysm of asthma, where obstruction is marked on account of spasm as well as mucus and tumefaction. The reason for pro- longed expiration in such cases has already been fully explained (see Asthma). In consolidation of lung tissue, expiration is also prolonged, but the murmur in these cases differs from those just mentioned by having the i)itch always raised, on account of its passing from one medium to a denser medium, with shorter vibrations and the quality changed. Instead of being blowing in quality, it is more or less tubular. The prolongation is not due so much to the criiDpling of the expiratory forces, or to obstruction to the egress of air, as it is to the fact that the incomi)letely or completely solidified lung tissue, being a better conducting medium, enables one to hear the murmur more distinctly and for a greater length of time. The respiratoiy munnur may be divided — that is, 174 PHYSICAL DIAGNOSIS. the inspiration and expiration may not be continuons. This is usually, if not always, due to consolidation to a certain degree. In case of incomplete consolidation, inspiration and expiration are not continuous, by insiDi- ration being unfinished. The gap between the two will be marked in proportion to the extent and complete- ness of consolidated tissue. When a whole lobe is consolidated, as in the second stage of lobar pneumo- nia, for instance, the break between inspiration and expiration is well marked. Wavy, jerky, or cog- wheeled respiratory murmur is sometimes heard in the first stage of phthisis. It is usually attributed to the sudden overcoming of strict- ure or obstruction in a bronchial tube, from pressure of tubercle, or mucus within. This, however, is doubt- ful, since it is often heard in perfectly healthy chests of those who are nervous, hysterical, or have palpitation. It is more often due to ^palpitation of the heart than any- thing else, and is oftener heard in women than men. Taken by itself as a physical sign of disease of the lungs, it is worthless. It is usually heard on inspira- tion, but may also be heard on expiration, or both. III. Quality. Besides being changed in intensity and rhythm, the respiratory murmur may also be changed in quality. Instead of its being jDurely vesicular in quality, as heard over the left subclavicular region, it may become . vesiculo-bronchial. The late Dr. Austin Flint termed it broncho-vesicular, but, as Da Costa suggests, the order of occurrence, as actually heard, being first vesi- cular and then bronchial, it is more correct to call it QUALITr. 175 vesiculo-bronchial. It was formerly, and is now by some, termed rude (loud) respiration. Others, again, call it harsh or rough. Neither of these terms is de- scriptive of the true condition, nor is the murmur neces- sarily harsh, rough, or even rude. A resiDiratory mur- mur is harsh or rough if the mucous membrane of the larger tubes is in a harsh or rough condition, so that the tidal air, by friction against it, in i)assing in and out, has the quality of harshness or roughness imparted to it. For this reason, any respiratory murmur, exclud- ing the purely normal vesicular, may be harsh or rough. In vesiculo-bronchial breathing, expiration is pro- longed, raised in pitch, and more or less tubular in quality, in proportion to obliteration of air-cells, by which the vesicular element is lessened, as in incom- plete consolidation from some cause, or proximity to bronchial tubes. For the latter cause, we obtain a nor- mal vesiculo-bronchial breathing in the right sub- clavicular region of a healthy chest. Vesiculo-bron- chial breathing is also among the early signs of phthisis, while consolidation is incomplete. Bronchial breathing is significant of com^Dlete con- solidation of lung tissue, as in the second stage of lobar pneumonia. Here all vesicular quality is lost, and both inspiration and expiration become tubular in quality. Expiration is as long as inspiration, or longer; the pitch of both is raised, expiration being usually higher than inspiration, and the intensity is greatly increased in the sense, not of volume, but concentrated amount. It sounds somewhat like blowing across the mouth of the stethoscope. It may be imitated by put- ting a piece of liver in a tin, or other tube, covering 176 PHYSICAL DIAGNOSIS. both ends witli a tliin membrane, and then listening through it to tracheal respiration. Over a cavity we usually hear cavernous breathing, wliich is blowing in quality, giving the idea, as Flint states, of air passing in and out of a hollow space. It differs from bronchial breathing by being usually low pitched and blo\\dng in quality, whereas bronchial breathing is necessarily high pitched, the sound of the murmur having ];)assed from one medium to a denser medium, and tubular in quality. Both are more intense than the normal re- spiratory murmur, but cavernous breathing is more in- tense in the sense of volume, bronchial breathing in concentrated amount. When consolidated lung tissue is extensive near a cavity, there is sometimes heard a mixture of cavern- ous and bronchial qualities, or the caverno-bronchial breathing. Flint was the first to describe this kind of respiratory murmur, and termed it broncho-cavernous. In nearly all the cases cavernous quality comes first, and is followed by the bronchial, though there is no reason why this should always be so. For this reason, however, it is termed caverno-bronchial, rather than broncho-cavernous. Should the cavity be large, situated near the apex, and have hard, smooth walls, a free oi)ening communi- cating with a bronchial tube, and not contain much fluid, amphoric respiration, or jug-breathing, may be heard. It sounds like blowing into the mouth of an empty jug (amphora) or bottle. The pitch of this breath sound will vary with the size of the cavity, its mouth and other conditions, but it is by its quality, not pitch, that it is distinguished. PECTOROPHONY. 177 CHANGES IN THE PECTOROPHONY OR VOCAL RESO- NANCE. The sounds of the patient's voice, as heard over the larynx, trachea, or any part of the chest walls by the auscultator, may be divided into two classes: (1) that in which only the voice is heard, and (2) when speech or articulation is heard. To the first class the termina- tion ophony {phonos, voice) is applied, to the latter, iloquy (speech). The sound of the voice, therefore, as normally heard over the larynx, is termed normal laryngophony, and over the trachea, normal tracheoph- ony or trachophony. As the speech is oftener heard in these localities than the voice simply, so do we more frequently hear normal laryngiloquy and normal tra- chiloquy over these organs. I. Pectoeophont. Pectorophony, or chest voice, is the sound of the voice, or the vocal resonance, heard over the chest, without our being able to distinguish the articulate words as spoken by the patient. Normal pectorophony, or normal vocal resonance, as it is more commonly called, when heard over pul- monary vesicular tissue, is a distant, diffused, indis- tinct, buzzing sound, with a somewhat low pitch, cor- responding to the pitch of the patient's voice. A low-pitched, loud, harsh voice, other things equal, yields more intense pectorophony than a highq^itched, weak voice, in the sense of volume. For this reason, men usually have normally more intense pectorophony than women, and grown people of both sexes than 12 178 PHYSICAL DIAGNOSIS. children. Thin chest walls, other things equal, also favor the production of pectorophony. Diminislied ijectoroijliony^ or weakened vocal reso- nance, occurs in those cases where there is obstruction in the bronchi to the convection (conveyance) of the voice sound, as in bronchitis with abundant mucous secretion, j^us or blood, polypi, stricture of the bron- chi, from old inflammation, or their compression from some cause, as cancer, aneurism, hydatids, and other tumors. Also when there is increased refractive poAver of the lungs, as in chronic general emphysema, with permanent dilatation of the aii-cells, or when there is interrui)tion to the transmission of the voice from pleuritic thickening or effusion. In some of these cases, whispering pectorophony may be entirely absent or suppressed. In general, the same conditions for weakening or suppressing the respiratory murmur apj)ly to the whisj^ered voice. Exaggerated ^pectorophony^ or exaggerated vocal resonance, occurs when the intensity is increased from any cause. It is heard normally in the right sub- clavicular region, on account of proximity to the right bronchial tube, as already stated. But it is also heard over incomplete solidification of lung tissue, owing to the better conducting power of the latter. It is there- fore one of the early signs of incipient phthisis. Under these conditions, the sound of the voice is nearer, less diffused, and more distinct and intense, in the sense, of concentrated amount. Bronchial pectorophony, bronchophony, or bron- chial voice, is heard when all vesicuhir quality is lost, owing to comjjlete solidification of lung tissue. The PECTOROPHONY. 179 voice sound comes to the ear of the auscultator directly from the bronchial tubes, through the solidified lung tissue. It is near, concentrated, and distinct, or the very ox)j)osite of normal pectorophony (vocal reso- nance). The pitch of bronchophony is necessarily high, owing to the transition of the sound from one medium to a denser medium. In some instances, bronchophony, instead of being near and strong, sounds as if it were distant and weak. Weak or distant bronchophony is caused by the inter- vention usually of pleuritic thickening or effusion. Obstruction to convection in the bronchi from com- pression, or stricture, or a plug of viscid mucus, might cause bronchophony to be weakened or ■ even sup- pressed. JEgo2ohony, so named from its resemblance to the bleating of a goat, is bronchophony made tremulous by vibrating fluid in the pleural cavity usually, though it may occur in some rare cases of pulmonary cavities and other disease. It is more of a clinical curiosity now than it is of any real value, since, in cases of doubt and necessity, the aspirating needle may be used to determine the presence of fluid. Besides being tremu- lous, gegophony is more or less weakened by the pleuri- tic conditions present. It also usually possesses a nasal quality for some reason. Cavernous voice, or cavernopliony, is heard when listening over a cavity. It differs from bronchophony, for while the latter is high-pitched and tubular in quality, with an increased intensity in the sense of concentrated amount, cavernophony is often low 180 PHYSICAL DIAGNOSIS. pitched, sepulchral in quality, and has its intensity increased in the sense of volume. Amphoric tioice, or ampltorophony (Jug voice), is simply cavernoi)hony possessing the quality of am- phoricity, and resembles the sound of the voice in an empty jug or other vessel. It has a peculiar ringing, metallic, or amphoric quality, and may be attended, like the breathing, or the cough, by amphoric, or me- tallic echo. The terms amphoric and metallic are used to convey the same idea, the former referring to the particular kind of cavity, the latter to the material, which imparts the quality to sounds. Should the patient whisper instead of speaking out loud, as was first recommended by the late Dr. Austin Flint, we would have some variety of whispering pectorophony. In some cases, it might be absent or suppressed; in others, exaggerated, and then Flint termed it exagger- ated bronchial ^^'hisper. In the same way we would have whispering bronchophony, cavernous whisper or whispering cavernophony, and amphoric whisper or whispering amphorophony. The following table gives a summary of the voice sounds: Laryiigophony Tracheophony ' Normal Pectorophony, or vocal resonance. Diminished or weak (tlie whisper may be absent or suppressed). Exa{?s*^rated (slifj^htly increased). Pectorophony -J Bronchophony — bronchial voice (may be weak). iEgopliony — goat's voice (tremulous). Cavernophony — cavernous voice. Amphorophony — amphoric (jug) voice. II. Pectoriloquy. Pectoriloquy, or chest speech, is the speech (articu- late words) of the p;itiT[)hilis, lead poisoning, gout, PLATE VII. R.A Fig. A R.V. Normal Heart. FiG.B. Mitral Regurgitation- showing enlar9ement of LA.LV & RV. FiG.C, FiG.D. LA. R.V. R.A L.V. R.V. Mitral Obstruction.- Showing Aortic Obstruction & Regurgitation. enlaraement of LA 8f RV. Showing enlargement of LV. REFERENCE. ■R.A. Right Auricle. R.V. Right Ventricle. LA. Left -'<- L.V. Lejt -"- DRAWH BY H.MACDONALD M.D. N.Y. VALVULAR LESIOXS OF THE HEART. 193 erysipelas, Bright's disease of the kidneys, and other diseases, or it may be due to pyemia, or surgical in- jury, or, finally, it may occur independently. In the latter case it is termed idiopathic endocarditis. Such cases are, however, very rare. Valvular lesions, es- pecially aortic insufficiency, may also be due simply to violence, as in lifting. Endocarditis during foetal life attacks the right side of the heart, because, in that state, the right side of the heart has more work to do than the left. For the same reason endocarditis attacks the left side of the heart after birth. It is extremely improbable, that, as Richardson, of London, states, the blood receives a poison in the lungs after birth, which it takes directly to the left heart, causing endocarditis of the left side of the heart ; but by the time it gets back to the right heart, the poison has lost its virulence. If it be due to poison only, the right heart should be poisoned instead of the left, for the blood is supposed to be purified in the lungs, instead of being poisoned there. Endocarditis does not necessarily leave traces behind, but it usually does. It may, however, affect the valves or orifices, or, they remaining intact, it may leave some lesional traces on the wall within the ven- tricle at some point, or ^ooints. From what has been said of foetal endocarditis, we conclude that children with valvular lesions of the tri- cuspid or pulmonary valves were born with them, though they may not have been discovered for several years afterward, when the changes in the heart pro- duced would make the signs more observable. But relative (or secondary) insufficiency of the tricuspid valves occurs in persons after they are born. This is 13 194 PHYSICAL DIAGNOSIS. due, not to inflammation, but to enlargement of the riglit ventricle (dilated liypertropliy) as in general em- physema, and mitral obstruction or regurgitation, where, owing to the dilated hypertrophy of the right ventricle, the tricuspid valves presently fail to close the orifice, on account of their being mechanically sep- arated too widely. Order of Frequency of Valmtlar Lesions. — All agree that mitral regurgitation is the most common. Regarding mitral obstruction authors disagree. Dr. Walshe i^laces it last of the valvular lesions in the left heart, but I am disposed to think it is often present with regurgitation. The following is the order of fre- quency, according to Dr. Walshe : (1) Mitral regurgitation, (2) aortic obstruction, (3) aortic regurgitation, (4) mitral obstruction, (5) tricus- pid regurgitation (relative included), (6) pulmonarj^ obstruction (most frequent inflammatory of the right heart), (7) pulmonary regurgitation (very rare), and (8) tricuspid obstruction (hardly known). I, myself, have never observed a case of pulmonary regurgitation, and tricuspid obstruction is, probably, only recognizable on post-mortem, examination, if it should ever occur. Valvular lesions, instead of existing singly, may be, and often are, combined. Order of Frequency of Combinations. — According to Walshe they are as follows : (1) Mitral regurgitation and aortic obstruction, both giving rise to systolic murmurs. (2) Aortic obstruction and regurgitation. (3) Mitral regurgitation and aortic regurgitation. (4) Mitral regurgitation, aortic obstruc- tion and regurgitation. (5) Mitral obstruction and re- CARDIAC MURMURS. 195 gurgitation, and so on. From the foregoing, it will be observed that obstruction and regurgitation may, and do, exist at the same orifice. This is jDerfectly true, for while the orifice may be constricted, the valves may be prevented from closing by being fixed oi)en by adhesion. As already mentioned, in a general way, valvular le- sions usually produce enlargement of the heart. It may now be further stated that each valvular lesion is followed by enlargement, peculiar to itself. This is of the greatest im^Dortance in making a diagnosis, and should never be lost sight of by the examiner. In speaking of enlargement, also, not only is dilatation, or hypertrophy, meant, but both— dilated hypertrophy, or hypertrophous dilatation. Now as to whether dilatation occurs first and hyper- trophy afterward, authors again disagree. It seems reasonable that the two should proceed together, until the time arrives when hypertrophy ceases. Then un- compensated dilatation alone remains. Tliat is the usual, inevitable tendency, if the patient lives long enough and does not die meantime of some complica- tion or fatal intercurrent disease. The particular enlargements (hypertrophous dilata- tions, or dilated hypertrophies) following the various lesions respectively, will be considered with each case of valvular disease. Caediac Murmues. Cardiac murmurs are adventitious sounds heard in connection with the heart in addition to, or in the ]3lace of, those sounds that exist in health. When due to organic disease they are termed organic murmurs. 19G PHYSICAL DIAGNOSIS. But when due to anaemia or perverted cardiac action they are said to be inorganic, or simply functional. Either of these two classes of murmurs may originate without or within the heart, the former being termed pericardial (exocardial), the latter endocardial mur- murs. They may also exist together or separately. Endocardial Murmurs. Valvular lesions usually give rise to enlargement of the heart, and are generally accompanied by permanent murmurs. The latter assist greatly in making a correct diagnosis in each case, according to their location, areas of conduction and transmission, and also by their rhythm or time of occurrence with regard to the sounds of the heart. The properties, or elements, of mui^mur- sounds (quality, pitch, intensity, and duration) are also of some importance, particularly the quality, but these are secondary to other considerations, as will be seen. The loudness or feebleness of a murmur does not indi- cate the amount or gravity of the lesion giving rise to it. This is better told by the change in the form and size of the heart produced, and other considerations to be noted. The fact that a murmur is heard about the heart is no sign of itself that the heart is diseased at all, since there are many murmurs that are independent of actual cardiac disease, however closely they may imi- tate true organic cardiac murmurs. It is the business of the examiner to distinguish between them, as can usually be done by careful and intelligent observation. There are other considerations, therefore, far more im- portant than the mere fact of the presence of a mur- mur in connection with the examination of the heart. MITRAL MURMURS. 197 Individual murmurs usually have certain points of maximum intensity, as well as areas of convection, con- duction, or transmission, provided they are of the aver- age intensity. But it sometimes happens that any murmur may be so loud as to be heard all over the body, whereas that which is usually the loudest mur- mur may be, or become, so feeble as to be heard with difficulty, if at all, at its point of maximum intensity. We will now consider the murmurs and other physical signs characteristic of valvular lesions, in the regular order of their occurrence. Murmurs heard loudest at the Apex. — Mitral Murmurs. We have already shown that there are four points on the front of the chest wall whera the various heart- sounds and murmurs may be heard respectively in their maximum intensity. Mitral murmurs, for instance, are heard loudest at the apex, tricuspid murmurs over the ensiform cartilage, aortic murmurs usually over the aortic interspace, and j^u^lnionary murmurs over the pulmonary interspace. Omitting pericardial and pleuro-cardial friction sounds, to be presently considered, there are five mur- murs heard only, or loudest, at the apex, and are con- sequently referable to the mitral orifice and left ventri- cle. Four of these murmurs are systolic in time, and one prsesystolic. The four systolic murmurs are the mitral regurgitant, intra-ventricular, dynamic, and cardio-respiratory. Of these, the mitral regurgitant and intra-ventricular murmurs are organic, the dynamic and cardio-respiratory being inorganic, or functional. 198 PHYSICAL DIAGNOSIS. The prsesystolic murmur is also organic, being due to mitral obstruction. Of these five mitral apex murmurs, therefore, three are organic and two are inorganic, or functional. Comj)are the following table: Mitral or Apex Murmurs Mitral Regurgitant Intra- Ventricular, r systolic i n^„^i„ j geu.,o.ie origm. Cardio-respiratory. Praesj'stolic . . Mitral Obstructive. Mitral Reguegitatiox. Mitral regurgitation (reflux, insufficiency) is the most frequent of all valvular lesions of the heart. It is usu- ally a primary result of endocarditis, although it may be relative or secondary to aortic regurgitation, or even marked aortic obstruction, which might lead to such dilated hj-pertrophy of the left ventricle that the mitral valves would become insufficient. Such cases are, how- ever, compai-atively rare, and, as already said, it is nearly always the direct result of endocarditis affecting the mitral valves themselves. Mitral regurgitation leads to the following change in the form of the normal heart: (1) enlargement (dilated hypertrophy) of the left auricle ; (2) enlargement of the left ventricle, and (3) enlargement of the right ventricle. It is easy to understand why the left auricle and right ventiicle become enlarged. The blood regurgi- tating back into the left auricle during ventricular sys- tole, instead of going on through the aortic orifice, gives the left auricle increased work to do, and it nec- essarily becomes enlarged (dilated hj7)ertrophy). In the same way, the blood forced back on the lungs gives the right ventricle more work to do in driving blood MITRAL REGURGITATION. 199 through the hmgs. But just why the left ventricle be- comes enlarged also, the mechanism is not so clear. As Walshe says, the enlargement of the left ventricle in these cases " is plainly supplemental ; though it is difficult to see how a condition that makes regurgita- tion more forcible, can tend to ])alance the evils arising from it." In regard to this point, my attention was called by my clinical assistant, Dr. William C Rives, to A'^ierordt, of Leipsic, who, says truly, that " the left ventricle first becomes dilated from having blood under abnormally high pressure, and increased in quantity, driven into it during its diastole by the enlarged left auricle. The ventricle then becomes hypertrophied in order to dispose of this extra quantity of blood, partly forward into the aorta, and partly backward into the left auricle." Tliat seems to be the correct view of the matter, but whatever theories there may be about it, one thing is certain, and that is that in mitral regurgi- tation the left ventricle becomes enlarged in some way from overwork. Another iDoint is not to be overlooked. The second sound of the heart is louder, usually, than normal over both the pulmonary and aortic interspaces (second in- terspaces on the left and right side of the sternum re- spectively). But as heard over the puhnonary inter- sjpace it is often somewhat louder (accentuated) than that heard over the aortic interspace, the latter being the weaker of the two, owing to regurgitation at the mitral orifice. The reason for this accentuation of the second sound of the heart over the pulmonary inter- space is obvious. Owing to enlargement (dilated hy- 200 PHYSICAL DIAGNOSIS. pertrophy) of the riglit ventricle, the blood is thrown with increased force into the pulmonary artery, and owing to increased tension in that vessel, the valves close more forcibly, until relative tricuspid insufficiency occurs. This phenomenon is still more marked in mi- tral obstruction, as we shall see. The radial pulse will be found also in mitral regur- gitation to be irregular in size, sometimes large, some- times small, and generally compressible. It may also intermit, but irregular rhythm is not peculiar to any valvular lesion, as we shall see when speaking of ir- regular rhythm in general (p. 264). Fig. 23.— Diagram of Sphygmographic Tracing of Pulse in Mitral Regurgitation. (Walshe.) In the early existence of mitral i-egurgitation, before enlargement has had time to occur, as in other lesions, or toward the end, when there are dilation and feeble- ness of action, with perhaps pulmonary infarctions and other comj)lications that are likely to arise, the phys- ical signs are not usually so clear. But in general they are as follows : Inspection. — The apex-beat is usually visible, owing to its force from enlargement, and is observed to be disi)laced downward and outside of the mammillary line, indicating enlargement of the left ventricle. This is of the utmost importance in tlie diagnosis of this disease. The heart's impulse is usually seen to be more MITRAL REGURGITATION. 201 forcible than normal. Sometimes, in persons with thin chest walls, left auricular impulse is observed in tlie pulmonary (left second) interspace, and will be one of two kinds : (1) systolic, if communicated to the auricle from the ventricle; or (2) prsesystolic (auriculo-sys- tolic), if due to hypertrophy of the auricle. As the case progresses, jugular pulsation on the right side of the neck may be observed, due to relative tricus- FiG. 24.— Diagram of the Heart iu Mitral Regurgitation. Left Ventricle, Left Auricle, and Right Ventricle are seen to be Enlarged— compare normal heart. pid insufficiency from enlargement of the right ven- tricle. Palpation. — The apex-beat will be felt downward and outward away from its normal x^osition, and the heart's impulse will be felt to be generally increased in force. Pulsation near the ensiform cartilage is some- times seen and felt, and is due to enlargement and forcible action of the right ventricle. The latter sign is not so well marked here as in general emphysema, when the right ventricle alone is enlarged, and the 202 PHYSICAL DIAGNOSIS. wliole heart is also pushed down by the increased vol- ume of the lungs. Purring Thrill. — In some cases of mitral regurgita- tion, a systolic j)urring thrill is distinctlj^ felt, especially if the palm of the hand is placed very lightly over the lower prsecordium. It is usually felt in the fourth in- terspace, on or near the mammillary line. Purring thrill here, as in other cases of valvular disease, depends for its production upon three abnormal factors: (1) in- creased capacity of the heart, (2) increased propelling force, and (3) an abnormal orifice. It will not be pro- duced by increased force and an abnormal orifice alone. Besides hyx)ertrophy, there must also be enlargement of the cavity of the heart, \^dth a certain amount of thinness of its walls, as seen after dilatation has oc- curred to some extent. With increased capacity and force, and a stream of blood driven through a button- hole orifice, for instance, thrill is almost certain to oc- cur. But it may also be due in some instances, I think, to a ribbon-like vegetation, with one end free and vi- brating in the course of the blood current. HoAvever this may be, thrill is not a constant phenomenon. It will disappear from changes in the orifice, or after hy- pertrophy ceases to compensate, and the walls of the heart become weak. The disappearance of thrill, there- fore, after it has once been present, would seem to be not always a favorable sign. Percussion. — The areas of both deep and superficial . dullness are enlarged, the latter especially, downward and to the left. Dullness over the left auricle, especi- ally among those with thin chest walls, is more marked MITRAL KEGURGITATIOX. 20:} and extends beyond the normal limits already men- tioned. AicsGultation. — A blowing systolic murmur is heard, but loudest at the apex, for reasons ah-eady given (p. 189), and the second sound of the heart is usually more or less accentuated over the pulmonary (left second) interspace, since the enlarged right ventricle would cause greater tension in the pulmonary artery, with consequently more forcible closure of the pulmonary valves than would be the case in the aorta. After tri- cuspid insufficiency occurs, this accentuation is not so marked. This murmur has various other names, such as mitral systolic, mitral indirect, and mitral insuffi- cient. The mitral regurgitant (systolic, indirect, insuffi- cient) murmur is, as already stated, usually blowing in quality, and occurs with, or takes the place of, the first (systolic) sound of the heart. It also occurs, therefore, with the apex -beat. By paying attention to the last named point, the time of the murmur can usually be fixed, even if the heart's rhythm be irregu- lar. The following diagram represents the mitral re- gurgitant murmur : n-pli dup Musical Murmurs. — Sometimes these and other murmurs are musical, instead of possessing a blowing, blubbering, rough, or other quality. This quality is of no particular import, but simply indicates that " prom- inent spiculse or fibrinous particles, of vibratile charac- ter, project into the current, or else that rigid vibratile edges bound a narrow, chink-like opening " (Walshe). 204 PHYSICAL DIAGNOSIS. Area of Transinisslon. — If the murmur be a very feeble one, as may occur in cases of long standing, with marked dilatation of the heart and feebleness of its action, especially if the chest walls be thick and fleshy, it may be heard only at the apex, and then with diffi- culty. But if it be heard anywhere it will usually be at the apex, which is composed of the left ventricle, the right ventricle being in front of the body of the left. But if the mitral regurgitant murmur be a very loud one, especially if it be musical, as sometimes hap- pens with any murmur, as already described, then it may not only be heard at the apex, but all over the chest. The average mitral regurgitant murmur may, however, besides being heard loudest at the apex, be also heard over three other localities: (1) posteriorly, between the inferior angle of the scapula and body of the eighth dorsal vertebra, or thereabouts; (2) along the left lateral base of the chest ; and (3) over the left auri- cle and to the left of it. In the first case, we are listen- ing directly over the site of the mitral valves, and this is perhaps the only case in which we listen directly over the site of the valves of the heart for sounds in connection with them. Though usually heard behind at that point, it is not necessarily heard there. The murmur may be too weak, as already stated; or the patient may have an emphysematous lung interj^osed; or, as in the case of a lady from Canada, whom I exam- ined, the murmur was distinctly heard behind, until accidentally falling ill with pleurisy with effusion, the murmur disappeared posteriorly, and though she made a fair recovery from the j^leurisy, the murmur never again returned to that point. Enlarged bronchial MITRAL REGURGITATlOlSr, 2()o glands aud other acoustic impediments evidently might prevent such a murmur from being heard behind. (2) Besides hearing the mitral regurgitant murmur at the heart's apex, and posteriorly over the mitral valves, it is sometimes, not always, transmitted from the apex along the ribs to the left; but it is not so transmitted to the point behind that has been men- tioned. Why is it that this murmur is sometimes heard transmitted along the ribs to the left, and some- times not? There are two classes of causes. First and chiefly, if the right ventricle becomes very much en- larged, it acts as a wedge between the left ventricle and the chest wall, and pushes the left ventricle back so far that it is impossible for the ribs to take up the sound. In these cases it will be very distinct posteriorly, not so much as is usual at the apex, and not heard at all to the left. Such conditions would indicate a very large right ventricle. The second class of causes would be pleurisy with effusion, thickened pleura, emphysema, or some other acoustic impediment. (3) Lastly, if the left auricle be greatly enlarged and the murmur be communicated to it, the murmur may be heard in the third and even second, interspace on the left of the sternum, over the site of the left auricle, and thence transmitted to the left axilla. Diagnosis of Mitral Regurgitation. — If the exist- ence of mitral regurgitant murmur can be established, the diagnosis is complete. But the extent of the lesion here, as elsewhere, cannot be accurately estimated by the properties of the murmur, but by the amount of cardiac enlargement produced. Pericardial (exo-cardial) friction sounds are super- 206 PilYSICAL DIAGNOSIS. ficial, rubbing, churning, grazing or creaking in quality, are not transmitted beyond the limits of the heart, change in intensity with position of the patient in leaning forward or backward, or by pressure with the stethoscope, and have no fixed relation in time to the heart-sounds. Pleuro-cardial, or pleuritic friction sounds, near by, may be kept up by the heart's impulse, and do not necessarily cease upon holding the breath, but are easily distinguished by their quality and the circumscribed area to which they are limited. There remain three other systolic apex murmurs, which may very closely imitate the mitral regurgitant, and it is necessary to know how to distinguish them. They are (1) intra- ventricular murmurs, termed also by Flint and others the mitral systolic non-reguigitant murmur, (2) dy- namic, and (3) cardio-respiratory murmurs. Intra-ven- tricular murmurs are organic, whereas the dynamic and cardio-respiratory murmurs are inorganic, or func- tional. (1) Intra-ventricular murmurs, when they exist, are usually so feeble that they may be heard at the apex only, or base. In either case they are always systolic, and due to lesions somewhere within the ven- tricle, instead of affecting the orifices or valves. Some of the intra-ventricular murmurs are heard only at the apex, others at the base, others again more or less over the whole heart. They are due to loughening of the ventriculai' endocardium, misattachnient of a chord, fibrinous shreds across the blood current, thickening and roughening of cliords, twisting of columnar carne^e, inflammatory vegetations on the wall of the ventricle, MITKAL REGURGITATION. 207 and cardiac ventricular aneurism. In the latter case the ventricle is enlarged, and it may be impossible to make a diagnosis ; but in all other cases of intra- ven- tricular murmurs the diagnosis is easy, since the cause of their production is not a cause for enlargement or perceptible interference with the circulation. The mur- murs of this variety are usually weak, and for that reason only are restricted to a spot over the apex, and are not transmitted anywhere, or heard posteriorly. The x^rognosis in the two cases would be entirely differ- ent. For whereas mitral regurgitation is usually fatal in course of time, owing to pulmonary congestion, sec- ondary tricusx>id insufficiency, hemorrhagic infarctions of the lungs, and cardiac droi)sy, intra-ventricular lesions may be of little or no imi3ortance, though suffi- cient to produce a murmur. (2) Dynamic Murmurs. — These murmurs are due to some perverted action of the heart, and are observed sometimes in choreic subjects. The heart is a volun- tary muscle, and hence subject to choreic, irregular movements, like other voluntary muscles. Conse- quently, during systole, some of the column^e carneae twitch and x)ull the mitral valves open, causing a faint murmur, which is only audible at the apex. Not only so, but it is not necessarily associated with left ven- tricular, or other cardiac enlargement, and, moreover, the dynamic murmur from this cause is very incon- stant, dependent, as it is, upon choreic movements which are absolutely uncertain. It is sometimes found, also, in those who are nervous from other causes, as among hysterical women, tobacco smokers, and rarely among those nervous from abuse of alcohol. It is also 208 PHYSICAL DIAGNOSIS. heard sometimes in epilei)tic subjects. But in all such cases the murmur is weak, and hence limited to the apex usually, is not necessarily attended with enlarge- ment of the heart, and, above all, is inconstant. Dynamic murmurs, instead of being of neurotic ori- gin, may also be due to anaemia. ISTo truly hsemic murmur is ever heard at the apex, unless produced by heart clot, which is very rare. But hsemic munnurs due to the watery condition of the blood are heard only at the base and over the pulmonary interspace, unless caught up by the aorta, and are caused by watery venous blood, as will be considered fully when speak- ing of basic murmurs. That anaemia does give rise indirectly, or dynamically, to a systolic apex murmur, besides causing all cardiac murmurs to be louder than they would be otherwise, by increasing vibratility of tissues, cannot be denied. But such a systolic apex murmur should not, strictly speaking, be termed an anaemic murmur, but a dynamic murmur due to anae- mia. Tlie mode of its production is as follows: The heart becomes flabby, and the papillary muscles become weak from fatty degeneration, according to Guttmann and others, thus allowing the mitral valves to recoil too far, so as to cause a slight backward leakage; or else temporary dilatation from auccmia may allow a vortiginous (eddying) movement of the blood within the ventricle, or misdirection of its current, sufficient to give rise to a systolic munnur. The masturbator's systolic apex murmur, described by Walshe, and attributed by him to nervous in- fluence, may also be due to the anaemic condition of the patient. MITRAL OHSTllUCTIOiV. 209 By curing such patients of their anaemia by means of iron and nutritious diet, these murmurs will disap- X)ear, it is true, but even then they are not to be regarded as true hsemic murmurs, though venous hum be also l)resent, but as dynamic murmurs due to the anaemic condition. The venous hum in the neck, with which they are usually associated, will be fully considered in connection with basic heart murmurs. (3) Cardio-respiratory murmicrs are always sys- tolic, and heard at the end of a full insj^iration, as the heart's impulse may force air out of some vesicles or cavities near by, with a sound that sometimes imitates the cardiac systolic murmur; or the respiratory mur- mur itself may sound like a heart murmur during sys- tole. Simply have the i)atient hold the breath after €X]piration, and the imitation heart murmur at once ceases. It is always a good rule, during auscultation of the heart, to have the patient hold the breath at least once for each point examined. MiTEAL ObSTRUCTIOjVT. Mitral obstruction (constriction, stenosis) is said by some authors to be idiox)athic, or congenital, and not traceable to j)revious rheumatic endocarditis, or other disease. In these cases it chiefly affects women and children. But it not infrequently does result from rheumatic endocarditis in the young of both sexes. Aortic, rather than mitral lesions, are apt to occur after middle life. Mitral obstruction leads to enlargement (1) of the left auricle, and (2) of the right ventricle, and by en- 14 210 PJIVSICAL DIAG.NOSIS. largement is meant here, as elsewhere, dilated hyper- trophy. The difference in enlargement, therefore, in mitral obstruction and regurgitation, is the left ventricle. In obstruction it is not only not enlarged, but, on the con- ti'ary, somewhat smaller than normal, from diminished volume of blood entering it ; but in mitral regurgita- tion it is enlarged, as already mentioned. In mitral obstruction the left auricle becomes enlarged, from the Fig. 25.— Enlargement of the Left Auricle and KiKlit Ventricle iu Mitral Obstruction. effort to drive blood through an o])structed orifice, and the blood, being prevented from leaving the lungs freely, the i-ight ventricle becomes enlarged from the extra task of driving the blood through them. The fact that the left ventricle is not enlarged in mitral ob- struction is of the greatest imj)ortance in making a correct diagnosis. The second sound of the heart is usually accentuated in the i)Tdmonary intersi)ace, for I'easons already given (p. 199), and weakened in the aortic interspace, for the reason that the left ventricle MITKAL OBSTRUCTION. 211 is somewhat atrophied, with consequent diminished tension in the aorta. The difference is more marked here than in mitral regurgitjition. In addition to this accentuation, the second sound is also reduplicated at the base in about one third of all cases, as the ^Dulmonary valves close not only more forcibly than the aortic, due to increased tension in the pulmonary artery, from enlargement of the right ventricle, but also earlier than the aortic valves, for the same reason. The radial pulse is not noticeably aifected in mitral obstruction, nor is the heart's rhythm necessarily dis- turbed, but is generally regular. The physical signs of mitral obstruction are : Inspection. — The apex-beat, if seen at all, will usu- ally be within the mammillary line, as the left ventricle is not enlarged. It may be pushed out a little, how- ever, by enlargement of the right ventricle. The apex- beat will be observed to be not more forcible, i^erhaps, than in health. But there may be observed in those having thin chest walls a left auricular systolic im- pulse over the left third interspace, owing to enlarge- ment of the left auricle. This impulse immediately precedes the a^Dex-beat, and with regard to the latter is prgesystolic. Pulsation of the enlarged right ventricle will not be observed usually, unless the heart be lowered from some cause, when it will be observed near the end of the ensiform cartilage, as in general vesicular em- physema. Mitral obstruction occurring in children appears to be not infrequently associated with the so-called pigeon- breast. The flattening is especially well-marked in 212 PHYSICAL DIAGXOSIS. the lower prsecordial region on tlie left of the sternum. ^ATiether this is mere coincidence in a certain number of cases, or due to atrophy of the left ventricle, or to lack of nutrition in general, from imperfect cardiac function, is not exactly known. As the case progresses and relative insufficiency of the tricuspid valves occurs, due to excessive dilated hypertrophy of the right ventricle, jugular pulsation on the right side of the neck, and afterward also on the left side, will be observed. Then follows cardiac dropsy, commencing in the feet. .Palpation. — The ai^ex-beat may be felt to be not markedly displaced or increased, and there may be some pulsation near the end of the ensiform cartilage, due to enlargement of the right ventricle, if the heart be sufficiently lowered. But what is most distinctive is the presystolic thrill often felt about the left fourth interspace. By i^lacing the palm of the hand lightly over the part, the thrill may be felt immediately before the apex-beat, and it is characteristic of mitral ob- struction, though not always present. It is due to the forcible contraction of the enlarged left auricle in its endeavor to force the blood through an obstructed ori- fice. The general mode of production is the same here as in regurgitation (which see, p. 202) and elsewhere, and, like that, is not permanent. Auricular impulse, pr^esystolic in time with regard to tlie apex-beat, is sometimes felt. Percussion. — The area of dullness over the left auri- cle and right ventricle is enlarged, but what is known as the superficial area of cardiac dullness is not so much enlarged as in mitral regurgitation, since in mi- MITEAL OBSTRUCTION. 213 tral obstruction the left ventricle is not enlarged, and a small part of the superficial area of dullness is nor- mally formed of the left ventricle. Auscultation. — A blubbering j)r^systolic murmur, like vibrating the letter r with the tongue, or vibra- ting the flaccid lips by blowing forcibly (expiration) through them while they are closed (Flint), is usually heard loudest at the apex, and limited to that region, though it may be conveyed up to the fourth interspace by the blood current, and in some rare cases is so loud as to be heard behind — in fact, all over the chest. The second sound of the heart is usually accentuated over the pulmonary interspace. The murmur has various names, such as prsesystolic, direct, constrictive, stenotic, and so on. As the murmur in regurgitation is termed regurgitant, so in obstruction it may be called obstruct- ant or obstructive. The mitral obstructive (direct, stenotic, constrictive, prsesystolic) murmur is usually blubbering in quality, as akeady stated, and unless it is blubbering it is usu- ally absent altogether, for this is the only organic heart murmur that may appear and disappear. All other organic heart murmurs are permanent. The reason why it is blubbering, as Flint explains, is because of the vibration of the free edges of the valves, the orifice between them being narrow and bottonhole-like. It is like throwing the flaccid lips into vibration, by forcibly expelling the breath while the mouth is gently closed, which, as Flint truly states, " represents not only the characteristic quality of the murmur, but the mode of its production." AVhen the edges of the mitral valves, instead of being flaccid, become fixed from inflamma- 214 PHYSICAL DIAGNOSIS. tion, the murmnr ceases and regurgitation follows. It also ceases if the circulation is feeble, but in that case it may return with thrill on exercising. The follow- ing diagram represents the mitral obstructive mur- mur : r-r-nh dup I 1 I 1 I This blubbering murmur at the apex, according to Flint, is sometimes due to aortic regurgitation, causing a secondary, or relative, mitral obstruction. In this case the edges of the healthy mitral valves are thrown into vibration slightly by the blood from the left auri- cle, while they are being closed by the backward press- ure of blood due to aortic regurgitation. This is differ- ent from the aortic diastolic regurgitant murmur that is sometimes transmitted faintly to the apex. The mitral obstructive murmur is never due to anae- mia, or any other functional or inorganic cause. It is always an organic murmur, due usually to mitral ob- struction primarily, and rarely to aortic regurgitation, which causes a secondary, or relative mitral obstruction. The idea that there is no such thing, in fact, as a mitral obstructive (presystolic, direct, stenotic, constrictive) murmur, but that it is really regurgitant, originated, it api:)ears, with Barclay. Dickinson and others have followed Barclay in this notion, but Gairdner, Balfour, Bristowe, Flint, Loomis, and many others have demon- strated quite clearly that Barclay and his followers were mistaken. For according to Bristowe, for in- stance, if the mitral ()l)structive (prfesystolic, direct, stenotic, constrictive) murmur is really regurgitant, due to prolonged contraction of the ventricle, then in MITRAL OBSTKUCTIOX. 215 aortic obstruction there ought also to be a ju'sesystolic aortic obstructive murmur, a clear case of reductio ad ahsurdum. Moreover, jyost-mortem examination sets the whole matter at rest in favor of the mitral prse- systolic (obstructive) murmur. This murmur was pointed out, in 1841, by Gendrin, of Paris, who called it prsesystolic. It was first claimed to be due to mitral obstruction by Fauvel, of Paris, in 1843. In 1861, Gairdner, of Glasgow, named it left auriculo systolic murmur. It is also sometimes called post-diastolic. Guttmann calls it a diastolic murmur. Flint, however, makes the mitral diastolic murmur to be different from the mitral praesystolic murmur proper, and says that it is caused by the rush of blood through and over abnormal structures before the auricle con- tracts. It is simply a part of the same murmur, and may be said to be a distinction without a difference. It is simi)ly the first part of a i)rolonged mitral ob- structive murmur, which occupies the whole of diastole instead of being merely prjesystolic. Area of Transmission. — The mitral obstructive murmur is usually limited to the region of the apex, or conveyed u^^ the ventricle to the fourth interspace, unless it is very loud, when, in some cases, it may also be heard iDOsteriorly. Why is not this murmur usu- ally heard posteriorly at a point between the inferior angle of the scapula and body of the seventh or eighth dorsal vertebra, as in the case of mitral regurgitation? Simply ])ecause the murmur, being made in the direc- tion of the blood current, and not against it, is not held at the mitral orifice long enough to be heard, but is at once carried down to the aj^ex, where it is heard. On 216 PHYSICAL DIAGNOSIS. the other hand, the mitral regurgitant murmur is con- veyed backward toward the ear, when auscultating posteriorly, and it is held there long enough to l^e heard. Why is not the mitral obstructive (prsesystolic, direct, stenotic, constrictive) murmur transmitted along the chest walls to the left, as in the case of mitral re- gurgitant murmur? Simply because in mitral obstruc- tion, the left ventricle is not enlarged and the right ventricle, which does become enlarged, and is in front of the left, wedges off the latter from the chest walls, so that it does not come near enough for them to pick up the sound of the murmur. The murmur also is prsesystolic, and occurs before the apex could reach the chest walls, even if the enlarged right ventricle were not between the apex and the chest walls. Diagnosis. — Mitral obstructive murmur would not be mistaken for mitral regurgitant, but that sometimes the cardiac rhythm is so irregular, and the sounds may so nearly resemble each other, that it is difficult to tell the first sound from the second. In these cases, as well as where the rhythm is perfectly regular, the changes effected in the form and size of the heart are not to be overlooked. For besides the fact that mitral obstruct- ive murmur is pra^systolic in time, limited to the apex, and blubbering in quality, while mitral regur- gitant is systolic in time, usually heard behind, as well as at the apex, sometimes transmitted along the left lateral base of the chest, and blowing in quality, it, must not be forgotten that in mitral obstruction the left ventricle is not enlarged, Avhile in mitral regurgi- tation it is enlarged, with corresponding displacement of the apex-beat downward and outward, usually out- MITRAL REGURGITATION AND OBSTRUCTION. 217 side of the mammillary line. Aortic regurgitant sounds, though sometimes conveyed to the apex, are attended with enlarged left ventricle, besides being purely diastolic in time, and are not heard loudest at the apex. A rather faint mitral presystolic murmur may some- times be heard, due to relative or secondary obstruc- tion to the onward flow of blood in some rare cases of aortic regurgitation. The mitral murmur in such cases is not usually attended with api^reciable enlargement of the right ventricle, and accentuation of the second sound in the pulmonary interspace, but there is great enlargement of the left ventricle which does not occur in mitral obstruction. Mitral Regurgitation and Obstruction. This combination of lesions not infrequently exists, for it is perfectly clear that while the mitral ori- fice is constricted the valves may be prevented from closure by adhesion. In such a case there would be both regurgitation and obstruction at the same orifice. Usually, there is but one murmur in these cases, the mitral regurgitant, since, as already remarked, the mi- tral obstructive murmur usually ceases when the free edges of the valves become fixed and cannot vibrate. Sometimes, however, both murmurs are heard, the prfe- systolic and systolic — the former at the apex and trans- mitted upward with the blood current toward the fourth intersx:)ace, the latter also at the apex, but trans- mitted around toward the left, and sometimes heard posteriorly. The left ventricle, the left auricle, and 218 niYSICAL DIAGNOSIS. right ventricle are enlai-gecl, and the second sound is more or less accentuated in the j)ulmonary interspace. Tricuspid Regurgitation. Tricusj^id murmurs are usually so feeble that they are aiidible, as a rule, only over the ensiform cartilage. And inasmuch as the tricuspid obstruction (praisys- tolic, direct, stenotic, constrictive) murmur is so rare that it may practically be thrown out altogether, there remains only the tricuspid regurgitant murmur to be sought for in connection with suspected tricuspid lesions. Tricuspid regurgitation (reflux, insufficiency) is commonly secondary or relative to enlargement (di- lated hypertroi)liy) of the right ventricle, due to mitral regurgitation or obstruction, or to general vesicular emphysema. In all of these cases, as we have seen, the right ventricle in time becomes enlarged from the extra work i)ut upon it in order to drive forwai'd an impeded pulmonary circulation. After a while, in some of these cases, not all, the tricuspid valves become so wideh^ separated that tricuspid regui'gitation with jugular pulsation and cardiac dropsy result. Primary or actual tricuspid regurgitation sometimes is met \vith, and then it is the result of foetal endo- carditis, as has already been referred to. It leads to enlargement of the right ventricle. The tricuspid re- gurgitant murmur is systolic in time and blowing in quality, but is usually so feeble that, as has already been stated, it is confined to a small area over the ensi- form cartilage. Sometimes the aortic regurgitant mur- mur is so transmitted down the sternum that it is TRICUSPID REGURGITATIOISr. 210 heard only over the ensiforni cartilage, but tricusjiid regurgitant murmur is systolic, while aortic regurgitant is diastolic in time. The latter is also accompanied by enlargement of the left ventricle and other signs to be described. The mitral regurgitant murmur is systolic in time, but it is heard loudest at the apex and trans- mitted to the left, besides being usually heard pos- teriorly. It sometimes exists with tricuspid regurgita- tion, so that the two murmurs run into each other. In this case the other signs of tricuspid regurgitation are to be considered, such as jugular jDulsation, cyanosis, cardiac dropsy and pulmonary oedema. The character of the radial pulse is not affected by valvular disturb- ances of the right side of the heart. The rhythm is, however, sometimes irregular, especially in general vesicular emphysema (p. 266). There are no intra- ven- tricular, dynamic, or cardio-respiratory murmurs to be considered usually in differentiating the tricuspid re- gurgitant murmur. Should any such case arise, the same rules hold good in regard to them, and peri- cardial, or pleuro-cardial, friction sounds, as in mitral regurgitation, to which the reader is referred. Jugular Pulsation. — This phenomenon was first observed by Lancisi, of Rome, in 1728. It is usually systolic, but is sometimes also pr?esystolic. Systolic jugular pulsation is accounted for as follows: In tricuspid insufficiency from any cause, venous blood is forced back during systole through the tricuspid orifice into the right auricle, and against the column of blood in the ven;e cavse. The superior vena cava, right vena innominata, and right internal jugular vein, form a sort of consolidated, straight, trunk line, so to speak, 220 PHYSICAL DIAGNOSIS. and there is no valve in the way until we come to the lower end of the internal jugular vein, just at the root of the neck. Consequently, this systolic i)ulsation of venous blood always first occurs on the right side at the root of the neck. After that valve gives way, the pulsation extends up to the second valve, and finally Fig. 26.— Jugular Pulsation. Position and Relation of the Veins of the Neck. may reach the angle of the jaw. Meantime, it begins to apj)ear also on the left side, but not so forcibly, as the backward shock has to go round a curve. In time, all the veins about the neck may participate in this curious phenomenon. Slight systolic jugular pulsation may, according to Bamberger, sometimes be observed on the right side, at the root of the neck, even when the tricusxjid valves are not actually insufficient. In right ventricular enlargement a slight backward shock AORTIC MURMUKS. 221 may even be imparted through the tricuspid valves themselves. Pr?esystolic jugular pulsation is sometimes seen in cases of right auricular overflow, during contraction of the right auricle, and just before systole of the right ventricle, but it is rare. It sometimes occurs in tricus- pid insufiiciency, but tricuspid obstruction would also favor its production. Tricuspid Obstructiois". This lesion is very rare, and even when it is present there is usually no murmur heard with it. This is probably owing to the feebleness of the venous blood current as compared with the arterial, and the weak- ness of the right auricle as compared with the left. Usually, it is only on post-mortem examination that tricuspid obstruction is found to have existed. Should there be any murmur present it would be presystolic, as in the case of mitral obstruction, but the murmur would be limited to the region of the en- siform cartilage. The right auricle would be likely to become enlarged, but no particular change in the form and size of the heart is known. The radial pulse would be unaffected. Murmurs heard loudest at the base. Aortic Murmurs. We have seen that we listen over the apex and ensi- form cartilage, respectively, in order to hear mitral and tricuspid murmurs in their maximum intensity. We 222 PHYSICAL DIAGNOSIS. now come to a third point on tlie front of the chest walls, \\-hich is the aortic interspace, or the right second intersi)ace, being that between the second and third costal cartilages, on the right of the sternum. Here we listen for murmurs referable to the aortic orifice in their maximum intensity (pp. 187, 188). Omitting pericardial and pleuro-cardial friction sounds, already described under mitral regurgitation (j). 198), there are seven basic murmurs heard only, or loudest, over the aortic interspace, and are consequently referable to the aortic orifice, the aorta itself, or the left ventricle. Five of these murmurs are systolic in time, and two diastolic. The five systolic murmurs are the aortic obstructive, intra-arterial, intra- ventricu- lar, dynamic, and cardio-resi3iratory. Of these, the aortic obstructive, intra-arterial, and intra- ventricular murmurs are organic, the dynamic and cardio-respira- tory being inorganic, or functional. The diastolic mur- murs in this case, as in others, are always organic. Of these seven aortic basic murmurs, therefore, five are organic and two are inorganic, or functional. Compare the following table: Aoi'tic Basic Murmuis Sytolic Diastolic Aortic Obstructive. Iiitni-Artei'ial. Intra- Vontriciilar. Dynamic i Neurotic Origin. ( Due to Anaemia. ^ Cardio-respiratory. j Aortic Regurgitant. ( Intra-Arterial (aortic non- regurgitant). By comparing this table with that of mitral aj)ex murmurs (p. 198), we have here, in addition, the intra- arterial 111 II rill urs. We also have the aortic systolic AORTIC OBSTRUCTION. 22'S obstructive murmur in place of tlie mitral systolic re- gurgitant murmur, and tlie aortic diastolic regurgitant instead of the mitral i^r^esystolic (or diastolic, as it is called by Guttmann) obstructive murmur. In other words, the mitral regurgitant and aortic obstructive murmurs are systolic, while the mitral obstructive and aortic regurgitant are chiefly diastolic in time. Aortic Obstruction. Aortic obstruction (constriction, stenosis) is the cause of enlargement of only the left ventricle, as a rule. It is the least harmful of all valvular lesions. The reason for enlargement of the left ventricle in this disease is obvious, as it has more work to do to drive blood through the obstructed aortic orifice, and the degree of enlargement will be in projDortion to the amount of ob- struction. The second sound over the pulmonary inter- space remains normal, as the right ventricle is not af- fected, but the second sound over the aortic interspace is weak, owing to the obstruction and diminished amount of blood thrown into the aorta. The first sound at the apex may be strong. The radial pulse is regular, as a rule, but in marked cases it is small, hard, and rigid. The physical signs are : Inspection. — The apex-beat is displaced downward and outward from its normal locality, in proportion to enlargement of the left ventricle. The cardiac impulse is usually seen to be more forcible than normal. Palpation.— The apex-beat is felt to be somewhat displaced downward and outward, and to be increased in force. Basic systolic thrill is sometimes felt, but 224 PHYSICAL DIAGNOSIS. only in those cases where dilated hypertrophy is well marked. Percussion. — The area of dullness is enlarged, es- pecially the area of suj^erhcial dullness, and the quality is more markedly dull, of course, in proportion to the amount of cardiac enlargement and disx)lacement of pulmonary tissue. Auscultation. — The first sound is usually normal or louder, but the second sound over the aortic interspace /iV Fig. 27. — Aortic Obstruction and iiegurgitatiou, showing Enlargement of Left Ventricle. is weak, for reasons already given. A systolic basic murmur is heai-d, which has various names, such as aortic direct, obstructive, stenotic, and so on. This aortic obstructive (direct, stenotic, constrictive, sys- tolic) murmur is heard loudest, not directly over the site of the aortic valves (p. 188), but over the aortic or second interspace near the right edge of the sternum, where the most pronnnent joart of the bulge of the aorta lies (Gray). The murmur is systolic in time, like the mitral regurgitant, and occurs with the first sound, AORTIC OBSTRUCTION. 225 or rather just before the second. It may be represented by the following diagram : nv vh- ^iic A7^ea of Transmission. — Though heard loudest over the aortic interspace, the murmur, if loud enough, and is caught up by the sternum, may be transmitted along that bone from one end of it to the other. Besides this, it is often conveyed by the arteries into the neck, and sometimes may even be heard behind over the aorta on the left side of the spinal column. If it be loud enough, as when it is musical sometimes, it may be heard all over the chest. In rare cases it is heard equally loudly over the pulmonary interspace, simply because the pulmonary artery takes up the sound from the aorta, owing to their unusual proximity. But if the murmur is very feeble it will with difficulty be heard, even at the aortic interspace as sometimes hap. pens. The loudness or feebleness of the murmur will give little or no true idea of the real extent of the lesion. The murmur is rendered more distinct by walking rapidly, or in case there be co-existing anae- mia. In all cases of doubt as to whether a murmur be present or not it is well to have the patient walk brisldy up and down the room several times, and then auscul- tate immediately upon stopping. Sometimes, however, a purely dynamic murmur may be j)roduced by this means. Diagnosis of Aortic Obstruction. — There are other systolic murmurs to be heard at the base that very closely resemble the true aortic obstructive, just as there are systolic murmurs at the apex to imitate the 15 226 PHYSICAL DIAGNOSIS. true mitral regurgitant. Omitting the pericardial and cardio-pleuritic adventitious sounds already differen- tiated when speaking of mitral regurgitation (p. 206), there remain the (1) intra-arterial and (2) intra- veii- tricular organic murmurs, besides the inorganic, or functional murmurs, (3) the djTiamic, and (4) the cai- dio-respiratory. (1) Intra-arterial Murmurs.- — These are organic sys- tolic basic murmurs, due to roughening of the lining membrane of the ascending portion of the aorta, in- flammatory vegetations, co-arctation (bending together) of the aorta, slight constriction, sacculation or pouch- ing of the vessel near the heart, and i)ressure on the aorta near its origin from tumors or fluid in the jDeri- cardial sac. Though sufficient to produce a systolic basic murmur, they might not materially interfere with the outward flow of blood, so that the left ventricle is, in such cases, not usually enlarged, whereas in aortic obstruction, unless of very recent occurrence, it is en- larged. Where no enlargement is observable, the his- tory of a recent attack of endocarditis would be of service; otherwise, it might be difficult, if not impossi- ble, to make an absolutely correct diagnosis, even by the pulse as traced with the spliygmograph, since it is but little altered in aortic obstruction. Intra-arterial murmurs are invariably loudest over the site where they are produced, as in case of aneurismal murmurs. It might so happen that the cause of the murmur might be situated in the pulmonary artery, but caught up by the aorta. For that reason, it is thought better to term them intra-arterial than intra-aortic murmurs. (2) Intra-ventricidar J/^^rmtirs.— The same remarks AORTIC OBSTllUCTION. 227 apply here as when speaking of mitral regurgitation, (p. 206). Instead of the aortic orifice being affected by the endocarditis, a lesion somewhere within the ventri- cle ( intra- ventricular) may have been produced, suffi- cient to give rise to a systolic murmur, heard only, or loudest, over the aortic interspace. It is differentiated from aortic obstruction, not by the quality, pitch, or other properties of the murmur, but by the fact that if the murmur be purely intra-ventricular, the left ventri- cle is not enlarged. (3) Dynamic Murmurs. — These murmurs are caused by perverted action of the heart, and may be of neurotic or anaemic origin, as described when speaking of them in connection with mitral regurgitation (p. 207), They occur more commonly at the base than the apex, but are always systolic in both localities. In a word, dias- tolic heart murmurs are organic, and all functional, or inorganic murmurs are systolic. These dynamic aortic systolic murmurs of neurotic origin are distinguished here, as elsewhere, by their being inconstant. They are observed not only among the choreic, nervous, and hysterical, but often among athletes, during or immediately after violent exercise. A perfectly healthy person, esioecially a young girl, after violently running up steps, will often have a tem- porary dynamic basic aortic systolic murmur. Some- times it is pulmonic also. A murmur may be some- times produced, also, with pressure of the stethoscope with those having thin and yielding chest walls, as among children. Such dynamic murmurs are told by their being inconstant, and by their not being neces- sarily associated with hypertrophy of the left ventricle. 228 PHYSICAL DIAGNOSIS. Dynamic aortic systolic murmurs may also be due to anaemia, as in the case of apex murmurs. Tliey are distinguished by their not being necessarily associated with the left ventricular enlargement; by other and co-existing signs of anaemia, of which venous hum (soon to be fully described) is one" of the most impor- tant ; by the non-existence of other murmurs ; and by their disappearing under projner treatment for anaemia. (4) Cardio-respiratory murmurs, so-called, are thrown out by having the patient hold the breath, and they then cease at once, as already described when sj)eaking of mitral regurgitation (which see). The aortic regurgitant murmur, having a different area of transmission, and occurring in diastolic time instead of systolic, besides other signs to be described, need not be dwelt upon here. Sometimes aortic obstruction is so marked that the left ventricle will, in time, become so enlarged as to cause the mitral valves to be some- what relatively insufficient, giving a slight mitral sys- tolic regurgitant murmur at the apex; but this con- dition appears to be somewhat rare. Anaemic murmurs are usually placed here, so that a few remarks in regard to them at once become neces- sary. According to some authors, they are always produced at the aortic orifice. The theory is that in anaemia the heart muscle becomes weak and flabby, and stretches so that the cavities of the heart are larger than normal, while the tough rings around the orifices remain the same. Enlarged cavities, the ori- fices remaining normal, is relatively the same thing as normal cavities and constricted orifices, so that such a so-called anaemic murmur is, after all, simply a sort of AORTIC OBSTRUCTION. 229 temporary obstruction murmur, in other words, a dy- namic murmur due to anaemia, and not j)urely a blood, or lisemic murmur. Purely hsemic murmurs, due to anaemia, are heard over the pulmonary interspace rather than the aortic. Sometimes, it is true, they are caught up by the aorta, just as aortic organic obstructive murmurs are some- times caught up by the pulmonary artery when the two press closely on each other. 'Not only are these I)ulmonary hsemic murmurs sometimes caught up by the aorta, but by it they may be and are, sometimes, conveyed into the arteries of the neck. Frequently, these murmurs in the arteries of the neck, however, are not conveyed there, but are simply created by pressure from the stethoscope disturbing the regular- ity of the calibre of the artery. How are basic dynamic murmurs due to anaemia to be distinguished from aortic obstructive murmurs, both being systolic? IN'ot by their quality, pitch, or other properties, albeit murmurs dependent on anaemia for their production are usually lower in pitch, softer, more blowing in quality, and more diffused about the base of the heart, but are not transmitted so far as in the case of obstruction. But this is not always the case. The real difference is that aortic obstruction causes enlargement of the left ventricle, whereas anae- mia does not, although palpitation from chronic anae- mia may give rise to a somewhat general enlargement of the heart from overwork long continued. Or else the enlargement Avould be due to dilatation from anae- mia, with feeble impulse, but in either case it would be general instead of limited to the left ventricle, as is 230 I'JIYSICAL DIAGNOSIS. usually the case in aortic obstruction. Only in rare cases of long standing does aortic obstruction give rise to relative (secondary) mitral regurgitation with se- quential enlargement of the left auricle and right ven- tricle. Dynamic murmurs, due to anaemia, whether heard at the ai)ex or base, are also associated with other signs of anaemia, among which venous hum may be mentioned here. Venous hum., or bruit de diahle, is a continuous though remittent roaring sound, heard over certain large veins, as the jugulars, subclavian, and femoral veins. From the fact that the sound is continuous it is readily distinguished from an arterial murmur. It is most convenient to listen for it in the neck, and it is best heard over the junction of the internal jugular and subclavian veins. Turn the patient's head to one side and elevate the chin, so as to render the tissues tense on that side of the neck. Now place the stetho- scope over the point mentioned, just at the root of the neck, and the continuous roar of venous hum (not rhythmical tracheal breathing) will be distinctly heard, usually in an anaemic person, especially a young anae- mic woman. Pressure with the finger, or otherwise, over the vein on the distal side of the stethoscope causes the hum to cease at once. Remove the pressure and it immediately returns. Guttmann, of Berlin, thinks that venous hum is due to the vortiginous (eddying, whirling) movement of blood in the ampulhe (bidbs) formed by the union of the internal jugular and subclavian veins. The volume of blood, he thinks, is smaller in anaemia, and the am- l)ull{e remain the same size, as they are adherent to AORTIC OBSTRUCTION. 231 the surrounding connective tissue. This would allow space in the ampulhe for the vortiginous or eddying movement of the blood, as mentioned. According to Guttmann, venous hum is also heard more frequently and with greater intensity on the patient's left side of the neck, since the curved direction that the blood has to take on the left side would produce more vortiginous movement. Not infrequently, however, it is heard loudest on the patient's right side of the neck, and sometimes, indeed, when it cannot be heard at all on the left. In the first place, it is highly improbable that the ampullae would be prevented from contracting, and becoming accommodated to the diminished volume of blood, by their being adherent to surrounding and rather loose connective tissue. In the second place, venous hum does not appear to be due to the vortigi- nous movement of venous blood, since it is produced best where the blood has a straight and rapid course in large veins, and for that reason is heard best, or only, on the right side of the ]3atient's neck. There are vari- ous other theories about the production of venous hum. According to Fothergill, many ingenious hypotheses have been raised regarding the causation of venous hum, but none as yet have been accepted. According to Walshe, the comj^osition of the blood in the ansemic state cannot be overlooked. It appears that watery venous blood is soniferous, while arterial blood, under the same conditions, is not, the exact reason for which does not apiDear to be known. It would seem, there- fore, that venous hum depends upon the- character of the venous blood in the anaemic state, rather than upon 232 PHYSICAL DIAGNOSIS. the supposed vortiginons movement of the blood in ampullae, the vibration of valves of veins, and so on. Aortic Regurgitation. Aortic regurgitation (reflux, insufficiency) is the cause of great enlargement of the left ventricle only, as a rule. Should relative insufficiency of the mitral valves occur, the left auricle, and, in time, possibly, the right ventricle also, would become enlarged, though the patient would hardly live long enough in such a marked case. It is one of the most hopeless and fatal of all valvular lesions of the heart. Walshe places it fourth in the order of relative gravity, but, leaving out tricuspid regurgitation, I should be in- clined to place it first. The reason why the left ventricle becomes enlarged in aortic regurgitation is obvious. The blood regurgi- tating back into tlie ventricle simply gives it double w^ork to perform. The first sound of the heart may he louder than normal, or it may be absent. In other words, it varies, dex)ending, no doubt, upon the amount of dilatation and whether or not it has brought about relative mitral insufficiency. The second sound over the pulmonary intersj)ace is usually normal, unless the right ventricle becomes sequentially enlarged from rela- tive insufficiency of the mitral valves, and then the second sound over the pulmonary interspace will be accentuated. Over the aortic interspace the second sound is taken up by the aortic regurgitant murmur which occurs with it, being diastolic in time. The pulse of aortic regurgitation is characteristic. Owing to enlargement of the left ventricle, the blood is driven AORTIC REGURGITATION. 233 with great force into the aorta, })iit as that artery empties itself in two directions at once, back into the left ventricle and forward into the cajjillaries, the pidse, which started with such a thump, suddenly collapses from not being sustained, so that it is sometimes called collapsing, vanishing, unsustained, locomotive, or water- hammer 2-)nlse, There are various names by which it is known, and w^e have good authorities for them, but it would appear that v^ater-hammer is the one now most commonly used. The physical signs of aortic regurgi- tation are: (See fig. for Aortic Obstruction.) Inspection. — The apex-beat is carried down and out, owing to enlargement of the left ventricle. The heart's imjDulse is usually seen to be more forcible than nor- mal. There is usually pulsation in the arteries about the neck, and all over the body where the arteries are superficially located and visible. If the patient be di- rected to hold the arm up, not infrequently the radial, ulnar, and other arteries of the upper extremity are seen to pulsate as in arterial sclerosis. Palpation. — ^The apex of the heart is felt disjDlaced downward and outward, and sometimes basic diastolic Fig. 28.— Sphygmograpliic Tracing of Aortic Regurgitation Pulse. thrill is felt. The radial pulse is unsustained, or col- lapses under the finger. The sphygmograpliic tracings of this impulse are characteristic. Percussion.— HYns, shows an increased area of cardiac 234 PHYSICAL DIAGNOSIS. dnllness, due to enlargement of the left ventricle. It may be still more increased if there be relative mitral insufficiency and consequent enlargement of the left auricle and also right ventricle. Auscultation. — This reveals the presence of the char- ticteristic aortic regurgitant murmur. It is diastolic in time, and occurs with, or takes the place of, the sec- ond sound of the heart. It is sometimes termed the aortic indirect or insufficient murmur. The aortic re- gurgitant (indirect, insufficient, diastolic) murmur may be represented by the following diagram : up tn-j)h I 1 • I 1 -I The quality of the murmur varies, but in most cases it apj)ears to be harsher and higher-pitched than the aortic obstructive murmur. Sometimes they exist to- gether, forming what may be termed steam-tug mur- mur, /wo — cJiee. The combination is usually best heard on the sternum about the fourth or lifth cartilage. Area of Transmission. — The aortic regurgitant mur- mur is directed back from the current of blood, and- for that reason is not usually heard so plainly in the aortic interspace as it is over the sternum about the fourth cartilage. It is sometimes heard onl^^ at the lower end of the sternum. Sometimes it is conveyed backward to the apex of the heart, where it is to be distinguished by its diastolic time, diminished intensity, and the en- larged left ventricle, from mitral obstructive murmur- (which see). If the murmur is loud enough, the ster. num will catch up the sound, so that it may be heard from one end of that bone to the other. Occasionally, the pidmonai'y artery takes up the murmur from its AORTIC OBSTRUCTIOX A^^D IlEGURGITATION^. 235 j)roximity to tlie aorta, so that pulmonary regurgita- tion may be imitated (p. 239). Sometimes it is heard behind along the spinal column, but it may be loud and musical, so as to be heard as soon as one enters the room, and may be so audible to the patient as to prevent sleep. Diagnosis of Aortic Regurgitation. — This is based upon the characteristic unsustained (water-hammer, collai^sing, locomotive) aortic regurgitant pulse, en- largement of the left ventricle, and the accompanying diastolic regurgitant murmur. The latter, in rare cases, may be imitated by a murmur caused by rough- ness with dilatation of the ascending portion of the aorta. The late Dr. Austin Flint speaks of this as an aortic diastolic non-regurgitant, or prediastolic, mur- mur. It is usually preceded by an aortic direct mur- mur, but not always. This imitative murmur is not necessarily associated with enlargement of the left ven- tricle, and the pulse characteristic of aortic regurgita- tion is wanting. These diastolic murmurs may, in rare cases, be heard only at the lower end of the sternum, like tricusxDid regurgitation, but the latter being sys- tolic in time, the diagnosis is easy. Aortic Obstruction and Regurgitation. This combination of lesions is second in the order of frequency, according to Walshe. Separately or to- gether, they cause enlargement of the left ventricle. When both lesions exist at the same time, the left ven- tricle is enlarged and there are two murmurs, the sys- tolic obstructive and the diastolic regurgitant already described. The two are often heard together, especially 286 PHYSICAL diaujS"0!sis. on the sternum, usually about the fourth or lifth car- tilage, and form what may be termed the steam-tug murmur, lioo — cliee^ hoo standing for the obstructive, and chee for the regurgitant murmur. Pulmonary Murmurs. We listen over thQ apex, ensiform cartilage, and aortic interspace, respectively, for mitral, tricuspid, and aortic murmurs in their maximum intensity. We now come to the fourth and last point on the front of the chest walls, the pulmonary intersx)ace, where we listen for pulmonary murmurs in their maximum in- tensity. The pulmonary interspace is the second inter- sjjace, or the interspace between the second and third costal cartilages, at the left edge of the sternum. Theo- retically, we would have the same number of murmurs here as over the aortic interspace, with the addition of the purely anaemic or haemic murmur. But pulmonic diastolic regurgitant murmur is so rare that it may be X)ractically thrown out altogether. Of the systolic pul- monary murmurs the same remarks would ajiply here to intra-ventricular, intraarterial, dynamic, and cardio- respiratory murmurs, as when describing aortic systolic murmurs. There remain two pulmonary murmurs, therefore, the pulmonary obstructive, and the aniemic. Pulmonary Obstruction. Pulmonary obstruction (constriction, stenosis) is not commonly observed among adults. It is due to foetal endocarditis in which the right, instead of the left side of the heart is affected, as already stated (p. 193). Children are therefore born with pulmonary valvular PULMONAKY OBSTRUCTIOX. 287 lesions, when they have them, and usually die early. It gives rise to a basic systolic murmur, as in the case of aortic obstruction, but heard on the left side of the sternum over the j)ulmonary (second) interspace in its maximum intensity, instead of on the right. The pulse is not affected by it. It leads to more or less enlarge- ment of the right ventricle. The diagram representing this murmur is the same as for aortic obstruction. The area of transmission is the same as for the aortic obstructive murmur so far as the sternum is concerned, but beyond that it differs materially. It is not con- veyed up into arteries of the neck, but back in the lungs by the pulmonary artery, and for that reason, when loud, is heard behind over both sides of the backs of children having thin chest walls. It is also trans- mitted out toward the left shoulder sometimes. In a case of a girl of fourteen now under my observation, the murmur is so loud as to be heard distinctly all over the chest, though loudest and most distinct over the pulmonary interspace. Systolic basic thrill is some- times felt, as in aortic obstruction. How are we to tell it from the anaemic or other mur- mur? Simply because it is usually ' associated with more or less cyanosis or blue disease (morbus cseru- leus), owing to the venous congestion over the body. Walshe says that true pulmonary obstructive murmur is very rare, except in cases of cyanosis. Fits of dysp- noea are likely to occur any time, owing to the lungs not being properly supxDlied with blood. Cyanosis it- self does not give rise to a murmur as anaemia does. True anaemic or haemic murmurs due to a watery condition of the blood are always systolic, and perhaps 288 ' PHYSICAL DIAGNOSIS. always basic. They are also apparently pulmonic in- stead of aortic, although they may sometimes be taken up by the aorta when the two vessels are in close con- tact with each other. May not these murmurs be nothing more than venous hum in the pulmonary artery, thrown into rhythm by j)roximity to the heart? It is true that they do not always co-exist with venous hum in the neck, but that may be because the venous blood travels differently in those vessels. Another supposed cause of systolic anaemic murmurs heard over the pulmonary interspace would not be mentioned here but for the fact that Balfour's name is connected with it, although, according to Flint, it did not originate with Balfour, but with Naunyn. The latter thought that the murmur was not to be attrib- uted to the pulmonary orifice at all, biit was due to a slight mitral regurgitation due to weakness of the heart from anaemia, with an accompanying mitral systolic anaemic murmur, not loud enough to be heard at the apex but loud enough to be taken ui3 by the left auricular appendix, which had also become dilated and enlarged from anaemia! Yet in mitral regurgitation with a loud murmur and the left auricle very much more enlarged than in anaemia, the trans- mission of the murmur to this point is very rare, as already stated (see Mitral Regurgitation). Flint, per- hai)s Justly, characterizes such reasoning as strained. Vierordt, of Leij^sic, states that the exjilanation of. these cardiac anaemic murmurs is very difficult, and thinks that in many cases Sable's suggestion might be available, that these murmurs may arise from the large vessels concealed in the thorax. pulmonary regurgitation. 289 Pulmonary Regurgitation. Pulmonary regurgitation (reflux, insufficiency) is such a rare disease tliat it is hardly v/orth mentioning. If it occurred it would give rise to a j)nlmonary regur- gitant murmur, which would be diastolic in time, and could not be confounded with any functional or inor- ganic murmur. As Flint states, a diagnosis could be made when other signs went to show the existence of pulmonary and the absence of aortic regurgitation. Diastolic thrill might be felt in both. But the pulse, of course, would be different, being unaffected by pul- monary regurgitation, and collapsing in the aortic lesion. Jugular pulsation would occur in time, with enlargement of the right ventricle in pulmonary regur- gitation, together with cyanosis and cardiac dropsy, none of which are characteristic of aortic regurgitation. As the disease is so rare, however, it is perhaj)s really more of a clinical curiosity than of any practical value. Relative Gravity of Valvular Lesions. According to AValshe, the following is the order of relative gravity of valvular lesions: (1) tricuspid re- gurgitation, (2) mitral regurgitation, (3) mitral obstruc- tion, (4) aortic regurgitation, (o) pulmonary obstruction, (6) aortic obstruction. Yery little is known about pul- monary regurgitation and tricuspid obstruction. Neither of the first three mentioned i:)roduce what is generally understood as sudden death from heart dis- ease. But all three are dangerous, from such complica- tions as pulmonary congestion, hemorrhagic infarction 240 PHYSICAL DIAGNOSIS. (p. 101), cardiac dropsy, and pulmonary oedema, which are likely to occur. But in aortic regurgitation not only is thoracic aneurism likely to be j^roduced from the tremendous force with which the blood is thrown into the aorta (p. 271), and sudden death from cerebral apoplexy, but there is also liability to sudden death due to failure of the heart's action from some cause, sup- posed to be, by some, failure of blood to be conveyed by the nutrient arteries of the heart. For these reasons it would appear that aortic regurgitation, well-marked, is among the most dangerous of all valvular lesions of the heart. Endocaeditis. Endocarditis, as already said, occurs most frequently in the course of acute articular rheumatism, especially among the young, but it may also occur in the course of any other disease, or independently. During foetal life it attacks the right side of the heart, but after birth it attacks the left side, as already stated (p. 193). It usually results in valvular disease of some kind (mitral regurgitation, most frequently with consequent enlarge- ment), or else some lesion elsewhere within the ventri- cle, or finally it may possibly end in complete recovery. The physical signs of endocarditis are based chiefly on auscultation. Inspection usually is negative. Pal- pation is usually also negative, but may reveal the fact that the heart's action and pulse are excited, and sometimes irregular. If it be the first attack, percus- sion dullness will be very slightly, or not at all, in- creased in extent, as the heart will not be appreciably enlarged. Upon auscultation the sounds Avill be nor- mal or perhaps slighth' inci-ensed in intensity, except PERICARDITIS. 241 at the site of the murmur, which will be heard at the apex or over the aortic interspace. The mui-mur occurs early in the disease, and is systolic in time and blowing in quality. It is due to roughening of the surface or deposit of lymph on or near the valves of the mitral or aortic orifices. The positive proof, according to Flint, is the presence of a mitral systolic murmur occurring during an attack of rheumatism If it be aortic it is in many cases inorganic. The mitral systolic murmur need not show actual regurgitation as yet, or it may be purely intra-ventricular. But if the left ventricle be eiilarged and endocarditis be suspected, it will not be the first attack, since the enlargement will be due to mitral regurgitation from a previous endocarditis. Pericarditis. Pericarditis usually occurs in connection with acute articular rheumatism, tubular nephritis, pleurisy, syiDhilis, j)neumonia, tubercle, or cancer. Of course it may be due to surgical injury also, but it is rarely, if ever, an idiopathic affection. It is usually attended with more or less effusion, and is divided into three stages. In the first stage (congestion) the action of the heart is irritable and forcible. The area of dullness is as yet unchanged. Auscultation uniformly reveals the pres- ence of a pericardial (exocardial) friction sound. En- docardial murmurs may also exist. But pericardial (exocardial) friction murmurs are superficial, rubbing, churning, clicking, or creaking, never blowing, whis- tling, or roaring, and are limited to the cardiac region, and often vary in intensity with iDOsition of the patient, or pressure w^ith ear or stethoscope, and occur inde- 16 242 PHYSICAL DIAGNOSIS. pendently of the heart sounds — that is, not fixed. Endocardial murmurs, on the contrary, are fixed in their time of occurrence with regard to the heart sounds, and are often conveyed or transmitted over cer- ii\. Fig. 29.— Diagram, Pericarditis with Effusion. tain areas, as already described. The second stage of pericarditis (effusion) is characterized by the eifusion of liquid— acute hydro-pericarditis. Inspection now shows prominence of the pr^ecordial PERICARDITIS. 243 region in proportion to tlie amount of effusion, dimi- nution, or absence, of the apex-beat, and diminution of the resr)iratory movements on the left side. Palpation. — The a^^ex-beat is raised upward and outward to the left, is feeble or suppressed, and may change with position of the patient. If not felt when the patient is on the back, it may be perceptible if the patient leans forward. An undulating impulse is sometimes felt, and the epigastrium may be bulging from dex^ression of the diaphragm. Percussion. — The area of prsecordial dullness is en- larged. If the effusion be great this area is found to be wider below than above, on account of the shape of the pericardial sac. It may extend down to the seventh rib and up to the first rib, and from nipple to nipple, or even further. Auscultation. — The pericardial friction sounds have now disa^opeared, since the two surfaces cannot rub together. The heart sounds are feeble and heard bet- ter at the top of the sternum than elsewhere, as the effusion occupies less space there than below. Some- times a basic systolic murmur, due to pressure of the effusion on the aorta, is heard. The respiratory mur- mur, pectorophony (vocal resonance), and vocal fremi- tus are diminished or absent over the central portion of the cardiac region. The third stage is that of ab- sorption. The friction sound returns— /rz'c^zo redux — the heart sounds become more distinct, and there is a gradual return to health in favorable cases. In other cases it may become subacute or chronic. Chronic pericarditis may be attended with adhe- sions simx)ly, or there may be adhesions with hypertro- 244 PHYSICAL DIAGNOSIS, phy or atrophy (which see), or there may be chronic pericarditis with effusion, termed chronic hydro-peri- carditis. The physical signs of chronic hydro-pericar- ditis are similar to those of the acute variety just described. Pneumo-Jiydro-pericarditis, air and fluid in the peri- cardium, is rare, but may possibly result from decom- position of liquid effusion, or, usually, from perforation communicating with the oesophagus or lungs. In these cases the heart's action is accompanied by metallic (amphoric) tinkling, amphoric (metallic) buzzing, and splashing like a water-wheel (Walshe), HcBmo-pericardium, or blood in the pericardium, may result from cancer, scurvy, and the hemorrhagic tendency, or surgical injury, and rupture of aneurism. If the patient lived long enough the blood, while fluid, would give the same signs as hydro-pericarditis. Hydro-pericardium, or dropsy of the pericardium, is merely associated with general dropsy from Bright's disease of the kidneys, or some other cause, without inflammation of the pericardium. The physical signs are those of hydro-pericarditis, already described. P7Leumo-2)ericardium, or air in the pericardium, is due to gas arising from post-mortem changes, as a rule, and is rarely, if ever, seen during life, and pneumo- hydro-pericardium, if such a thing could exist during life, would give the same physical signs as pneumo- hydro-pericarditis, already described. Myocarditis. Myocarditis, or carditis, signifies inflammation of the heart muscle itself. When present it is usually associ- HYPERTROPHY OF THE HEART. 245 ated with endocarditis or, more frequently, with peri- carditis. In the acute form, the pain in the cardiac region is extreme, the pulse rapid and weak. In the chronic fomi, the symptoms are those of a weak heart, with want of correspondence between the heart and pulse beat. Neither form is diagnosticated during life. Hypertrophy of the Heart. Hypertrophy of the heart differs from hyperplasia. In the former case the existing anatomical elements are enlarged, in the latter their number is increased (Flint). In both cases the heart is enlarged. Hyi^ertrophy may be general, or limited to one or more of its comj)artments. In the latter case the left ventricle is by far the most frequently affected, then the left auricle, then the right ventricle, and lastly the right auricle may sometimes be somewhat enlarged. Again, the hypertroi^hy may be concentric, simple, or eccentric. In the first case the walls are thickened and the cavities become smaller. This is so rare that it is more theoretical than practical, and may be thrown out altogether. Simple enlargement is not common either - — that is, thickening of the walls — the cavities remain- ing the same. Indeed, hypertrophy or enlargement of the heart from any cause is so uniformly of the eccen- tric ^'ariety, that, unless otherwise specified, enlarge- ment of the heart will always be meant to be eccentric hypertroi^hy — that is, hypertrophy ^^dtll dilatation, usually termed hyxDertrox^hous dilatation, or dilated hypertrophy. Of the causes of enlargement of the heart, {l)valvu- lar lesions, as previously stated, are the most frequent. 246 PHYSICAL DIAGNOSIS. Moreover, each of these lesions gives rise to its o^^^l characteristic enlargement, which will be marked in proportion to the degree of the lesions. Thus, mitral regurgitation causes enlargement (dilated hypertrophy) of the left auricle, left ventricle, and right ventricle in the order named. Mitral obstruction causes enlarged left auricle and right ventricle. Aortic obstruction gives rise to enlarged left ventricle and aortic regurgi- tation also, only the enlargement is usually more marked in aortic regurgitation ; and in either case, but especially in aortic regurgitation, there may occur rela- tive insufficiency of the mitral valves, with consequent enlargement of the left auricle, if not the right ventri- cle, also, in time. Pulmonary (pulmonic) obstruction or regurgitation will lead to enlargement of the right ventricle as would also tricuspid regurgitation, relative, or resulting from foetal endocarditis, while tricuspid obstruction would cause enlargement of the right auri- cle only. (2)Br/r/7ifs Disease of the Kidneys. — In the chronic interstitial variety there is enlargement of the left ven- tricle only, and this is not due to valvular lesion but simply to the fact that the left ventricle has extra work to perform in overcoming the obstruction due to the lessened calibre {lumen) of the arterioles through- out the body. In the chronic tubular variety of Bright's disease of the kidneys, there is liability to in- flammation of serous membranes generally, the endo-. cardium included, with resulting valvular lesion. En- largement of the heart, therefore, in chronic tubular nephritis is usually' due to valvular lesion, resulting from an endocarditis. lIYPEKTKOPnY OF THE HEART. 247 (3) General Vesicular Empliyseina. — In this case there is enlargement of the right ventricle, owing to obstruction to the pulmonary circulation. (4) ExopMlialTnic goitre, called also cardio-thyroid exophthalmos, Basedow's, or Graves' disease. Here we have general cardiac enlargement due to over nourish- ment from vaso-motor dilatation of the nutrient vessels of the heart. According to Niemeyer, Bamberger, and others, the nutrient vessels of the heart in this disease are enlarged from vaso-motor dilatation due to some disturbance of the cervical ganglia of the sympathetic nervous system (see Exophthalmic Goitre). (5) Palpitation from anemia, or other cause, may give rise to enlargement of the heart from its overwork. Tlie alcoholic habit probably acts somewhat in this way. Habit, mode of life, occupation requiring pro- longed muscular exertion, as among athletes, and the like, also enlarge the heart to a certain extent, as well as excessive venery. The x^hysical signs of hypertro- phy of the heart with dilatation are usually more marked than they are when simple hypertrophy alone exists. They are: Inspection. — The enlargement is always more to the patient's left than right, and the line of the base is rarely, if ever, changed. The extent of the visible im- pulse is increased, and there is more or less prominence of the prsecordial region. The apex-beat is also seen to be more forcible than normal, and it may be as low as the ninth rib and outside the mammillary line. En- largement of the right ventricle pushes the apex fur- ther to the left than normal, but the apex is also low- ered Avhen the left ventricle is enlarged. 248 PHYSICAL DIAGNOSIS. Palpation. — The impulse is heaving and lifting in character, with or without thrill, and its area is in- creased. Hypertroi)hy of the right ventricle usually gives a strong epigastric impulse. ^\Tien the left ven- tricle is hypertrophied the apex-beat is carried down and out. Prjesystolic impulse is sometimes felt over an hypertrophied left auricle, as may occur in mitral disease. The radial pulse in hypertrophy of the right side of the heart is not appreciably affected in character. But in hjqDertrophy of the left ventricle without regurgita- tion or obstruction, the radial pulse is full, prolonged, and sustained. Percussion. — Both areas of dullness are increased, laterally and vertically. General enlargement may give dullness on percussion from the third to the eighth rib, and from an inch to the right of the sternum to two or three inches outside the left nipple. Walshe mentions a case where enlargement (dilated hypertro- phy) of the heart was so extensive as to be mistaken for pleurisy of the left side with effusion. Hypertro- phy of the left ventricle gives dullness usually beyond the left nipple ; of the right ventricle, considerably to the right of the sternum. In hjqDertrophy of the left auricle the area of dullness over that portion is en- larged and more marked. Auscultation . — The first sound, dull, muffled, pi'o- longed, diffused over a larger area than in health, and increased in intensity, may indeed so closely resemble a slight systolic murmur as to make it sometimes diffi- cult to decide; and the second sound is also louder and more diffused than in health. If munnurs are DILATATIOX OF THE IIKAKT. 249 present they will more or less obscure, or take tlie place of the heart sounds. There is diminution or absence of the respiratory murmur over the precordial space. Hypertrophy of the right auricle rarely occurs, and then it is due to tricusj)id regurgitation usually, as tricusi3id obstruction (stenosis, constriction) is almost "unknown during life (AValshe). Dilatation of the Heart. Dilatation of the heart may be one of three kinds : (1) hyiDertrophous dilatation, or dilated hypertrophy, which is the most common form, and just considered ; (2) sim]ple dilatation, where the walls remain the same but the cavities are enlarged ; and (3) attenuated dila- tation (Walshe), where the cavities are not only en- larged, but the walls are thinner than normal. It is the last variety that requires our attention. Attenu- ated dilatation, or dilatation witJioiit compensating Jiyperti'opliy, is a hopeless disease. It may result from valvular lesion, or general vesicular emphysema, where dilatation and hypertrophy of certain parts occur to- gether, ]producing the various enlargements character- istic of those diseases, as already fully described. Presently the time arrives, however, when hypertroj)hy ceases to compensate, and then the case becomes one of dilatation, since, evidently, enlargement cannot con- tinue to go on indefinitely. In other cases dilatation occurs from inherent weakness of the heart niuscle itself, in other words, from no known cause. Thoracic aneurism causes dilatation in so far as it is a cause of ■obstruction to the outflow of blood, and in this way 250 PHYSICAL DIAGNOSIS. acts as valvular lesion would. But the underlying cause of aneurism, if it be gout, syphilis, or lead i^ois- oning, may cause weakness of the heart muscle also, and thus favor dilatation. The physical signs of car- diac dilatation are: I}iS2:)ectlon.—T\ie visible area of the apex-beat, if in- deed it be visible, is increased without any particular point of maximum intensity. Dyspnoea and cyanosis are sometimes observed, especially after attempted ex- ertion. Palpation. — Tlie cardiac impulse is feeble, its area is increased, rarely is there any thrill, but rather an un- dulating motion over the prsecordial region, especially if there be mitral regurgitation. The radial pulse is feeble, sometimes irregular, small, and compressible. Percussion. — The area of cardiac dullness is in- creased in the direction of the part dilated, or generally increased if the dilatation affect the whole heart. In the latter case it is oval or somewliat square in shape, instead of being triangular, M^th the base dowuAvard, as in pericarditis with effusion. A liscultatlon. — Both sounds are short, abrupt, feeble, and equal in duration, the second being often inaudi- ble at the apex. The post-systolic or first period of silence is prolonged. Endocardial murmurs, when present, are indistinct. The respiratory murmur is diminished or absent over the precordial region, owing to the cardiac enlai'gement. Fatty DK(n<:xKKATioN^ of the Heart. Fatty heart is of two kinds, (1) tliat in which the fat is added to the organ without or within, or between its FATTY DEGTF TIIK HKAK'I'. 205 appears to be no valvular lesion, in spite of the state- ment of authors, that is characterized by any particular palpitation or irregular rhythm. Cardiac arterial scle- rosis, fatty metamorphosis (Quain's), fibrosis, and aneu- rism of the heart, on the other hand, are productive of paroxysms of pal^^itation and irregular rhythm of every known kind. They are to be known by the physical and other signs of those diseases already described — never losing sight of the pain in the left arm. The causes of functional palpitation and irregular rhythm may be stated to be very much as Walshe has said. (1) Centric. — Chorea, epilepsy, hysteria, and cerebral and spinal irritation from any causes, especially cerebral irritation attended by insomnia, as from over study. The boy pianist, Joseph Hoffmann, recently was pre- vented from giving concerts in this city at the instance of the Society for the Prevention of Cruelty to Child- ren, one of the signs of his overwork being, as was testified to by one of his attending physicians, inter- mittent pulse, which j)roved to be due to cerebral as well as spinal irritation from overwork, both mental and bodily. (2) Rejiex, or Eccentric Causes. — They include dys- pepsia in all its forms; intestinal irritation from worms or any other cause; articles of diet, as coffee, tea, and alcohol with many peoi)le; genito-urinary irritation, as seen in cases of gonorrhoea, cystitis, uter- ine catarrh, old stricture, ovarian diseases, and sach like, including piles, fissure of the rectum, rectitis and proctitis. (3) Blood Poisoning and Ancemia. — Tobacco un- doubtedly plays a very important part in the produc- 266 PHYSICAL DIAGNOSIS. tion of heart diseases, both functional and organic. ExcejDt it be cocaine, there is, j)ei'haps, no more j)erni- cioiis habit than the tobacco habit, especially, it is said, the smoking of cigarettes, ^ot all is positively known about the baneful effect of tobacco on the heart yet, but enough is knoA\Ti to make it certain that it causes pali)itation, irregular rhythm, and cardiac ar- terial sclerosis with fatal angina pectoris. The mode in which this last condition is brought about from the tobacco habit is not certainly known, but it is so all the same. By tobacco habit is meant not one cigar or cigarette a day, or even two. Different j)eople are dif- ferently affected by it. One or two cigars per day is habit for some, while others may smoke several, besides chewing. The worst cases of jjoisoning, and the so- called tobacco hearts, occur among tenement-house girls in this city who make cigars or cigarettes, or strip to- bacco, as it is called. Especially in the winter does this occur, when they work with the windows closed and are inhaling the dust and fumes of tobacco. Irregular rhythm, palx)itation, and an^Emia are common among those girls. Besides tobacco, there are the poisons of opium, malaria, and also of syphilis, lead, gout, rheumatism, and Bright's disease of the kidneys. . (4) MecJianical. — AYe see this in general emphysema, where, owing to obstruction to the i)ulmonary circula- tion, the heart becomes tired, and not only becomes irregular in I'hythui at times, l)ut often intermits so a« to take a rest. In pressure from tight lacing, effusions from pleui'isy, in jmeumothorax, ovarian and other tumors, i^regnancy, jineurism, and such like causes, the heart may palpitate, or intermit. In treating these THE SPIIYGMOGRAPH. 267 symptoms, therefore, tlie necessity of first ascertaining the cause in each case, with a view to its removal, if possible, is ?4Dparent. The Sphygmograph. The sphygmograph is an instrument used in obtain- ing graphic representations of the x^ulse. In like man- ner the cardiograph is used with regard to the impulse of the heart. Both instruments require great care in their use, as well as experience. Much time is often consumed in endeavoring to obtain these tracings, and as they are often quite unnecessary in making a diag- nosis such instruments are not likely to be of much value to the average practitioner. A few remarks re- garding the sphygmograph may not, however, be out of place. There are many of these instruments in use, but perhaps Marey's or Dudgeon's is as good as any. In fact, Dudgeon's is very readily applied, more so, in my experience, than any of the rest. According to Walshe, a pulse trace consists in a series of figures representing the successive cardiac circuits, or revolu- tions. Each figure consists of three parts for consideration : (1) the percussion stroke (up-stroke, line of ascent), (2) the apex, and (3) the downstroke (line of descent). The percussion, or upward stroke shows the force and character of the j)ulse beat during ventricular systole. The apex is broad, medium or sharply pointed, accord- ing as the pulse is more or less sustained, so that it is broad in hypertrox)hy, the valves being perfect, but jiointed in aortic regurgitation. Just as the point of the tracer falls a little, it rises again, forming what is 268 PHYSICAL DIAGNOSIS. termed the tidal wave. The percussion-stroke (up- stroke), the apex, and the tidal wave all belong to the first sound and systole. Now comes the first period of silence, and the point of the tracer immediately drops into the aortic notch at the same time that the second sound is jiroduced. Then follows the second period of rest, corresponding to the remainder of the downward- stroke (line of descent), marked first by the dicrotic wave, secondly, sometimes by a tricotic wave, or if there are many such waves, this part of the line of de- scent becomes polycrotic, or tremulous. Dicrotism, as well as tricotism, or even polycrotism, is due simx)ly to the elastic recoil of the arteries, and need not be due to any abnormal condition, especially dicrotism. With the normal pulse, the percussion (up) strokes should be of the same length, so that the base, or respiration line, as it is called, of all the figures should be even and hori- zontal, as well as the apex line. In disease, however, these lines are subject to great irregularity. The sphygmographic tracings characteristic of various car- diac diseases are given at the time of describing those diseases, to which the I'eader is referred. Aoinir Aneitris.a[. The aorta is divided anatomically into three parts: (1) arch, (2) thoracic aorta, and (3) abdominal aorta. The arcli consists of three portions, (1) ascending, (2) transverse, and (3) descending portion. (1) The ascend- ing portion of the arch, about two inches long, arises from the upx)er part of the left ventricje, on a level with the lower border of the left third costal cartilage, and behind the left edge of the sternum, behind and a AOKTIC ANEURISM. 269 little beloAv, as well as to the right of the origin of the l^ulmonary artery (p. 187). It passes obliquely upward and to the right, to the upx:)er border of the right second costo-sternal articulation. A needle pushed into the second interspace on the right, close to the right edge of the sternum, would penetrate the most prominent bulge of this portion of the aorta, and hence this siDace, as stated before, is termed the aortic inter- sj)ace. (2) The transverse portion of the arch com- mences at the upper border of the right second costo- sternal articulation, and arches from right to left, and from before backward, in front of the trachea and oesophagus, to the left side of the body of the third dorsal vertebra. (3) The descending i)ortion of the arch extends from the left side of the body of the third dorsal vertebra down to the lower border of the left side of the body of the fourth dorsal vertebra. The tlioracic aorta commences at the left lower bor- der of the fourth dorsal vertelbra, and ends in front of the body of the last (twelfth) dorsal vertebra, at the aortic oi^ening in the diaphragm, where it becomes abdominal. Tlie abdominal aorta commences at the aortic oi^en- Ing of the diaphragm, in front of the body of the last (twelfth) dorsal vertebra, and descending a little to the left side of the vertebral column, terminates on the body of the fourth lumbar vertebra, commonly a little to the left of the median line, where it divides into the two common iliac arteries (Gray). Aneui'isni signifies a dilatation. According to Walshe, it is, in its widest sense, a local increase of calibre of an artery. Aortic aneurism, therefore, is a 270 PHYSICAL DIAGNOSIS. local increase of calibre, or a dilatation of tlie aorta in some j)art of its course. If it affect tlie aorta in any j)art of its course within the thorax, it is termed tho- racic aneurism, whether it be any portion of the arch, or thoracic aorta. It is termed abdominal aneurism when it affects the abdominal aorta in any i)art of its course. Classification. — There are various classifications of aortic aneurism, but the simplest is always the best. There are two classes, (1) dissecting and (2) circum- scribed. (1) Dissecting aortic aneurism usually be- longs to old age, and affects both sexes alike. It is caused by weakening and rupture of the internal and middle coats of the artery from fatty metamorphosis due to senile decay. Inasmuch as aneurism is said to be false when all the coats of the artery are not dilated but some are ruptured or worn through, all dissecting aortic aneurisms are necessarily also false. Dissecting aneurism would also be said to be sacculated, fusiform, and the like, according to the shape assumed. (2) Circumscribed aortic aneurism is usually a man's disease, and occurring generally at middle life or past. Four fifths of the cases of thoracic, and about ninety per cent, of abdominal circumscribed aneurism, occur in men from forty to fifty years of age. This is due to the difference from Avomen in the mode of life and occupation. About five per cent, of the cases occur before thirty, and in all such cases observed by me there has been a clear history of syphilis. Circumscribed aneurism may be false or true, ac- cording as to whether or not some of the coats have sustained solution of continuity from some cause. Tlie AORTIC ANEURISM. 271 inner and middle coats usually give way in false aneu- rism, so that the sac is chiefly formed by the outer coat. But in case of wounds, the outer coat may yield, allowing the middle coat to protrude, gi^'ing rise to what is termed hernial false aneurism. If all the coats are ruptured, from wounds or disease, a diffuse or, bet- ter, consecutive aneurism may result. AVhen due to injury they usually occur in the case of smaller vessels than the aorta, since in the latter case the patient would be likely to bleed to death before the aneurism could be formed. Wherever they occur they usually become circumscribed. Other varieties are fusiform, cylindrical, or globular. Generally, however, circum- scribed aneurism is irregular in shape, causing it to be sacculated. And inasmuch as only the outer coat is often left to form the sac in such cases, circumscribed sacculated aneurism is also usually false. In the fusi- form variety, or where there is slight and regular dila- tation, the aneurism is not infrequently true. Etiology. — Two classes of causes favor the produc- tion of aneurism: (1) increase of blood pressure, and (2) diminution of resisting power in the walls of the ves- sel. (1) Increase of blood pressure is caused by heavy lifting or straining, occupations necessitating long- continued effort, comx^ensating hypertrophy of the left ventricle in aortic regurgitation, and intemperance. The course of the artery must also be taken into con- sideration. The pressure will not be so great at any given XDoint in an artery whose course is straight as it would be when the artery is curved. The sharper the curve is the greater will be the pressure, and this is always directed against the periphery. This is remark- 272 PHYSICAL DIAGNOSIS. al)l;r well illustrated in cases of aortic aneurism. Of 880 cases collected by Sibson, 632 affected the arcli, while only 71 occurred in the thoracic aorta, which is straight, as %Aill be fully described presently. (2) Tlie walls of the artery are Aveakened by surgical injuries, or by constitutional disease tending to produce arteri- tis, inherited or acquired. Of these causes, syphilis stands at the head and front. Lead poisoning proba- bly comes next. Then follow gout, rheumatism, and renal disease. Sometimes predisposition to aneurism seems to be inherited, so that it Avill be handed down from parents to children for several generations. Relative Frequency of Site. — Of 880 cases collected by Sibson, 87 were situated in the sinuses of Valsalva, 193 in the ascending portion of the arch, 140 in the ascending and transverse j^ortion of the arch, 120 in the transverse portion of the arch, 20 in the transverse and descending portion of the arch, and 72 in the de- scending portion of the arch. That is to say, of 880 cases of aortic aneurism, 632 occurred in the arch alone. Of these, 420 cases occurred in the ascending portion, 140 in the transverse, and 72 in the descending I)ortion of the arch. The thoracic aorta was affected in only 71 cases, and the abdominal aorta in 177. The principal reason for this marked difference in the frequency of aneurism in the parts of the aorta, as just given, is owing to the course which the vessel takes. In the arch, of course, and especially the ascending and transverse portions, the blood pressure is much greater than where the vessel is straight. Not only that, but the arch is nearest to the heart to re- ceive all its force. In the descending portion of the AOETIC ANEURISM. 278 arcli the number of cases was only 72, and in the tho- racic aorta, only 71, both on account of the straight course of the vessel, and differing only by one case. But when we come to the abdominal aorta the number rises to 177. Here the artery is much more exposed to injury than it is in the thoracic cavity. Moreover, the abdominal aorta is subject to be bent on itself, or — AORW. — fincH oF/laK7/f . 632 Tomj:, - '77 eso. Fig. 31.— Schematic Diagi-am of Relative Frequency of Site of Aortic Aneurism. 23ut on the stretch, or twisted, and, in a word, to be changed in its direction with every movement of which the body is susceptible. In heavy lifting, \\T?estling, the performances of athletes, and the effort at recover- ing one's position when suddenly thrown off the bal- ance by simple accident, all iDut a strain on the ab- dominal aorta, the habitual reception of which not only tends to make that vessel brittle, but often is the immediate cause of abdominal aneurism. Bartholow 18 274 PHYSICAL DIAGNOSIS. states that he has never known a case of abdominal aneurism that could not be directly traced to some act of violence. Symptoms. — In thoracic aneurism these may com- mence suddenly, as if something had given way, but much more frequently they come on gradually, with failing health. There is pain, which is usually fixed, but radiating. Pain is one of the first and most fre- quent symptoms of aortic aneurism in any part of the vessel. It may and often does, exacerbate and remit, but it is usually an early and a x^ersistent symptom. It is usually deep seated, extending through from before back. Instead of actual i^ain it is sometimes described by the patient as a feeling of soreness limited to a small area. Besides pain, there are dyspnoea, with more or less hoarse, stridulous cough, and alteration of voice. The dyspnoea is of two kinds, (1) constant and increasing and also (2) paroxysmal. The constant and increasing dyspnoea of course is due to the grow- ing aneurismal tumor pressing upon and displacing imi)ortant j)ortions of the organs of respiration. The paroxysmal dyspnoea, however, occurs in three ways: (1) it may be due to spasm of the glottis, owing to irri- tation of the recurrent laryngeal nerves from pressure of the aneurism; (2) paralytic closure of the glottis from paralysis of these nerves from pressure of the aneurismal tumor; and (3) pressure on the trachea with accumulation of mucus at that point. Paralytic closure of the glottis, due to pressure from the tumor, is neces- sarily a dangerous and often fatal symptom. The greater the effort at inspiration, the more completely are the walls of the larynx sucked together. Dys- AORTIC AXEUKISM. 275 phagia from i)ressiire on the cpsophagus is not common, but headache due to obstruction to the return circula- tion of the bhjod is not infrequent. Sometimes there is disordered vision, owing to the change produced in the size of one or both pupils from i^ressure by the aneurismal tumor on the sym];)athetic nerves. One or both may be contracted or dilated, according as the sympathetic nerves are irritated or paralyzed. Slight haemoptysis is of ordinary occurrence, the blood being mingled with the sputa. This slight haemoptysis is due to bronchial congestion or pulmonary irritation, and is totally different from the rush of blood due to ruj)ture of the sac. The patient gradually loses flesh and often has a careworn, wearied appearance. We see, therefore, that in thoracic aneurism, inward press- ure signs, as they are termed, are always more or less prominent. In abdominal aneurism, on the other hand, with the exception of pain, which is present here as well as in thoracic aneurism, there are very few symp- toms to be described by the patient. The onset of abdominal aneurism is, however, usually sudden. In- deed, Bartholow states that in all the cases of abdominal aneurism observed by him, the onset was sudden and definite, and traced to some act of violence, as sudden lifting of a heavy weight, wrestling, falling, or the like. Physical Signs. — These differ according to the part of the aorta affected, the arch, the thoracic aorta, or the abdominal aorta. We wiU therefore consider them in their regular order. 276 PHYSICAL UIAGjS^OSIS. I. The Arch of the Aorta. Inspection. — At lirst, inspection may be purely nega- tive. But after the aneurismal tumor has become suffi- ciently increased in size, a local bulging, or pulsating tumor, synchronous in its pulsations mtli the heart's systole, is usually observed at the right edge of the sternum in the second intersi)ace, when the ascending portion of the arch is affected. This is by far the most common site for aneurism of the arch, since the ascend- ing portion is most frequently affected. The tumor gradually increases downward to the right, pushing the apex of the heart downward and to the left. If the transverse portion of the arch is affected, the tumor may push forward the top of the sternum. Or it may appear on the left of the sternum, or at the base of the neck, according to the x3ortion of the arch affected, and other circumstances. Pulsation may sometimes be noticed even in the interscapular region of the left Bide, if the descending portion of the arch be affected. The aneurismal tumor does not always i)ulsate. This occurs when the sac is filled to a great extent with fibrin, through which a small stream of blood flows, and especially if the descending portion of the arch be affected and the heart is weak. If the aneurism press on the superior vena cava, there will be enlargement of the veins on both sides of the neck, with more or less lividity of the face. But if the tumor press on one innominate vein only, enlargement of the veins and lividity of the face will be observed on the correspond- ing side only. Tlie patient is not infrequently observed to have lost somewhat in flesh. THE ARCH OF THE AORTA. 277 Palpation. — Two centres of iDiilsation, synchronous with systole, are usually felt, one due to the impulse of the heart, the other to the aneurism. The pulsation caused by the aneurism is usually accompanied by thrill, unless the sac is greatly filled with fibrin. In Fig. 32. — Aneurism of Ascending Portion of Arch in a German woman, set. 48. Death from Ruptm-e into Pericardial Sac. that case, thrill may be, and usually is, entirely absent. Indeed, in these cases, also, the systolic impulse of the tumor may be so feeble that it can scarcely be observed. In aneurism of the transverse portion of the arch the pulse is weaker at the left wrist, and on the left side of 278 PHYSICAL DIAGNOSIS. the liead and neck, than the right. This was beauti- fully illustrated in a i)atient recently examined at my request by Drs. Edward G. Janeway, Francis Delafield, Alfred L. Loomis, and John A. Wyeth, of this city. The patient was sent to Mt. Sinai Hospital, where Dr. Wyeth ligated the left common carotid and left sub- clavian arteries with every prospect of success, but the patient unfortunately died of pneumonia and syphilitic pulmonary dex)Osits. Post-inortem examination showed the absolute accuracy of the diagnosis of aneurism of the transverse portion of the arch extending to the Junc- tion of the descending portion. There was no dysphagia, but the aneurismal sac, tilled with fibrin, was adherent to the trachea for about an inch and a half, causing most distressing dyspnoea. In these cases, as also hap- pens sometimes in aneurism of the descending portion of the arch, the i:)ulsation of the aneurism may be felt in the suprasternal notch by pressing the finger well down into it mtli the patient's head bent forward. The vocal fremitus over the tumor is usually dimin- ished or absent, according to the size of the aneurism and displacement of lung tissue. Pressure on a large bronchial tube also may so obstruct the convection of the voice sound that the vocal fremitus may be entirely absent over the corresponding area. Percussion. — This should be gently performed over the tumor, otherwise it causes great suffering to the jiatient, to say nothing of the danger of rupture of the aneurismal sac. For this reason auscultatory percus- sion is the best method, since it is performed very gent- ly. Dullness is elicited over and immediately around the tumor, and the dullness will be marked in propor THE AECH OF THE AORTA. 279 tion to the size and locality of the tumor. If it be small and deep seated, the quality of the percussion note may be very little changed. On the other hand, if the tumor be large and superficial the quality may be nearly or quite flat. It is of great importance to observe whether the dullness extends continuously out toward the acromial angle, over pulmonary tissue, or across the median line. The latter sign would be a sure indication of the presence of a tumor of some sort in the mediastinum. If the descending or transverse portions of the arch be affected, but especially the de- scending, dullness on percussion may be obtained in the interscapular region of the left side. Auscultation. — The aneurismal sounds usually pres- ent are most audible directly over the tumor. The aneurismal systolic shock is usually accompanied by a bruit, or murmur, w^hich is louder than the heart sounds and usually lower in pitch, especially when blowing in quality. The bruit or murmur may, however, be rasx3- Ing or filing in quality, and then the pitch may be high. Sometimes it is roaring or whistling. Besides the systolic bruit, there may be also a dias- tolic murmur, wdiich is usually softer than the first, and causing with it the to-and-fro sound. The aneurismal bruit is usually heard in front, but it is sometimes even heard posteriorly, in the interscapular space of the left side, if the descending portion of the arch be affected. There is diminution or absence of the respiratory mur- mur over the tumor, and pressure on a bronchial tube may produce atelectasis for a corresjponding area of pulmonary tissue (see p. 60). Owing to the i:)resence usually of secondary localized bronchitis and a little 280 PHYSICAL DIAGNOSIS. solidified lung tissue from pressure or local inflamma- tion near the tumor, rales, bronchial breathing, bron- chox)hony, and increased vocal fremitus over a corre- sponding small area, may be obtained. Diagnosis. — To differentiate between aneurism of the three portions of the arch we must bear in mind, first, that the ascending portion is by far more fre- quently afl'ected than the others, the transverse portion being next in order, and, lastly, the descending portion. When the ascending portion of the arch is the seat of the aneurism, the tumor, as already stated, usually ax3- pears in the second interspace at the right edge of the sternum, and gradually increases downward to the right, pushing the apex of the heart downward and to the left. Occurring in the transverse portion, it j^ushes, the manubrium forward or appears at the left of the sternum. Aneurism of the transverse jDortion of the arch causes a weaker pulse at the left wrist and on the left side of the head and neck than on the right, with pulsation in the suprasternal notch, and sometimes dullness on percussion, even in the interscapular region of the left side. Pressure on the trachea and oesophagus is more marked in these cases also. In case of aneurism of the descending portion of the arch of the aorta, there are pain in the interscapular region of the left side, dull- ness on j)ercussion; and sometimes a pulsation is ob- served there, with a bruit on auscultation. Pulsatiofi may also be sometimes felt in the suprasternal notcli from aneurism of the descending portion of the arch, but not so distinctly as when the transverse portion is affected. THE ARCH OF TJIE AOIITA. 281 Arteria Innominata. — Aneurism of this vessel pul- sates behind, or above, the inner part of the clavicle, causes weaker pulse on the right side than the left, and is rarely attended with dysphagia or tracheal pressure, but more frequently with pain or paralytic symptoms in the right arm. Pulsation of this aneur- ism diminishes or ceases from compression beyond the tumor. Consolidation of pulmonary tissue from phthisis or syphilis, would give rise to dullness, which, however, would extend outward to the acromial angle, but not across the median line. There would also be wanting the inward pressure signs of aneurism. In the case of suspected pulmonary syphiloma, the failure of i:)roper antisyphilitic treatment would rather favor the i^res- ence of aneurism. Cancer of lungs may be associated with cancer of the mediastinal glands, Avhich, becoming enlarged, would give rise to dullness that extended across the median line. But infiltrated cancer causes retraction of the chest walls instead of bulging, and there are no inward pressure signs. The cancerous cachexia and appear- ance of cancer elsewhere would establish the diagnosis. Mediastinal tumors are the most difficult to differ- entiate. But unless associated with infiltrated cancer of the lungs or elsewhere, they usually occur in women under twenty-five, which aneurism rarely, if it ever does. Such tumors are usually also associated with currant-jelly (cancerous) expectoration, distention of the siiperficial veins on the chest, sometimes oedema of the chest and arm, and they may also exist elsewhere. Conrctation and stricture of the .aorta will o-ive rise 282 PHYSICAL DIAGNOSIS. to a systolic murmur, but they cause no bulging to be observed on inspection, no dullness on j)ercussion, and no pressure signs. They usually result from syphilis, and coarctation is sometimes a congenital malforma- tion. Pulsating empyema is easily distinguished by the equality of the radial pulse, the absence of murmurs and thrill, as well as of tracheal, oesophageal, and laryngeal symi^toms. It might occur to the j)ractitioner to explore with a fine needle in order to set the ques- tion at rest, but this should not be done unless abso- lutely necessary, which is rarely the case, since emboli might be detached which would prove to be trouble- some, if not fatal. Pericardial effusion gives rise to prominence of the precordial region, with more or less dyspnoea some- times, and marked dullness on percussion; but the area of dullness is somewhat triangular, with the base down, aneurism, perhaps, never. Subperiosteal abscess of the sternum may cause some prominence of the sternum, with dullness on percus- sion, but the inward j^ressure signs and all other signs of aneurism are wanting. Cardiac hypertrophy causes only one centre of mo- tion ; Avhen aneurism is j)resent there are usually two. The aneurism may be situated, however, very close to the heai-t, and associated with aortic regurgitation and enlargement of the left ventricle. The absence of pressure signs and the presence of drojDsy both fa^•or cardiac disease. In aol'tic regurgitation, also, the pulse characteristic of that disease, and felt equally at both wrists, would l)e against aneurism. thoeacic aorta. 283 11. Thoracic Aorta. Aneurism of the thoracic aorta is not so easily recog- nized as when it occurs in the ascending and transverse portions of the arch. From a number of cases reported by Deputy-coroner Jenkins, of this city, and referred to by Dr. H. M. Biggs in a very interesting paper on this subject, read before the Section in Practice, New York Academy of Medicine, in February, 1888, it ap- pears that not infrequently the cause of sudden death was due to rupture of unsuspected aneurism of the thoracic aorta. Owing to the position of the vessel, the i)hysical signs are referable to the left side of the spinal column rather than the right, though an excep- tion to this rule is rarely met with. Pain in this case, as elsewhere, is one of the symptoms, and usually con- sists of a gnawing sensation felt in the dorsal vertebrae. These may become eroded in time, and give rise to curvature of the spine. Bulging in a few cases may be noticed posteriorly, but dullness on jDercussion, over a circumscribed area, corresponding to the aneurism, is much more frequent. On auscultation a bruit may be heard, but is often absent. Owing to want of physical signs the aneurism often escapes detection, as already stated. Laryngeal symptoms are, of course, usually wanting, but there may be dysphagia from pressure on the oesophagus. The disease may be mistaken for pleurisy with effusion in some instances, so that the exploring needle alone could enable one to distinguish between them. 284 PHYSICAL DIAGNOSIS. III. Abdominal Aorta. The symptoms in this case have reference to pressure on abdominal organs. Pain, as in aneurism elsewhere, is one of the first symx3toms. It may be local, or it may extend along the branches of the lumbar j)lexus. Jaundice from pressure on the bile duct is not common, but sometimes occurs. Changes in the urine from pressure on the renal vessels is even more rare. But nausea and vomiting are not infrequent, due to press- ure against the stomach. Insx>ecUoii. — This is usually negative in its results, but in case of an emaciated j)atient, pulsation of the tumor may be visible in the recumbent dorsal position. Palpation. — A pulsating tumor is usually felt some- what to the left of the median line. The XDulsation is synchronous with the cardiac systole, and is described as expansile in character — that is, it exjDands in all directions under the grasp of the hand. Thrill may also be present. Some authors describe this pulsation as post systolic, or coming just after the systole of the heart. Others regard it as purely systolic. Percussion. — If the tumor is of considerable size there is dullness on percussion. But this is the least constant physical sign, owing to the presence of gas in the neighboring viscera. Auscidtatlon. — A systolic bruit may or may not be present here as elsewhere. If the tumor be well filled^ with fibrin there Avill be no bruit. Diastolic bruit is rare, but when present is thought to be diagnostic of the presence of aneurism. Pulsation of the abdominal aorta may be mistaken ABDOMINAL AOliTA. 285 for abdominal aneurism. But in the former case the pulsation will be along the course of the vessel, giving, under palpation, the sense of a pulsating cord rather than an expansile tumor. The fact that such jjulsa- tions of the aorta usually occur in young and nervous women with thin abdominal walls, rather than in middle-aged men, also is against aneurism. Pulsating tumors may also simulate aneurism and be even accompanied by a bruit. But by placing the patient in the knee-chest position the pulsation at once ceases if it be not aneurism, since the tumor simply gravitates away from the aorta and no longer has its pulsations imparted to it. In case of a young hysteri- cal Avoman, recently examined by me at the Polyclinic, there was a distinct pulsating tumor felt over the ab- dominal aorta. The pulsation immediately ceased in the knee-chest position, and as she gave the history of constiiDation, I concluded that it was a case of impacted faeces. A dose of castor oil confirmed the diagnosis, by causing a large evacuation of the bowels and disap- pearance of the tumor. In this case I may add that the tumor had a distinctly boggy feeling, and was not expansile, but simjply thumping under palpation. THE END, Il^DEX. Abdominal aorta, 284. respiration, 9. Abscess of the lungs, 89. Accentuation of heart sounds, 211. Acute miliary tuberculosis, 107. Adventitious sounds, 37. Adhesions, pleuritic, 146. ^gophony, 127, 145, 179. Amphoric (jug, metallic) breathing, 126, 176. echo, 180. resonance, 124. tinkle, 128, 158, 165. voice, 180. Ansemic murmurs, 228, 237. Aneurism of aorta, 268. of the heart, 362. Angina pectoris, 257. Anterior region, 2. Anthrakosis pulmonum, 87. Aorta, 187. Aortic interspace, 190. murmurs, 222. obstruction, 223. and regurgitation, 235. regurgitation, 232. valves, 188. Apex murmurs, 197. Apices affected by tubercle, 113. Apneumatosis, 59. Apoplexy, pulmonary, 99. Arch of aorta, 276. Aspiration, 151. time for, 141. Aspirator, Potain's, 150. Areas of cardiac dullness, 185. Asthma, 42. Atelectasis, 59. Atrophous emphysema, 49. Atrophy of the heart, 252. Auenbrugger, 16. Auscultation, 25. Auscultatory percussion, 33. Autophonia, 34. Axillary line, 8. region, 7. Bacillus, Koch's tubercle, 106, 110, 117, 130, 134. Barry, 71. BasedoAv's disease, 253. Bell-metal resonance, 128. Bigemenny, 264. Blood-currents, 186. Bronchi, division of primitive, 14. Bronchial breathing, 79, 119, 175. hemorrhage, 101. respiratory murmur, nor- mal, 28. rales, 37, 162. Bronchitis, 35. Bronchiloquy, 80, 127. 178, 181. Bronchophony, 80, 120, 145. Broncho-cavernous breathing, 126. Broncho-pneumonia, 84 Bruit de diable, 230. 288 IjS^DEX. Calormetatiox, 8. Camraan, 25. Cancer of the lungs, 90. Capillary bronchitis, 39. Cardiac aneurism, 262. dropsj', 253. dullness, 185. murmurs, 195. thrill, 202. Cardio-respiratory murmurs, 209, 228. Catarrhal phthisis, 107, 113. pneumonia, 84. Cavernous breathing, 125, 145, 176. Caverno-bronchial breathing, 126. Cavernous voice, 179. Cavities, 121-130., Chronic pneumonia, 87, 134. Circulation, 186. Clavicular resonance, 22. Cog-wheeled respiration, 27. Cohnheim, 96. Compensatory emphysema, 48. Congestion of the lungs, 63. Congress at Paris, report on, 108. Consumption of the lungs, 106. Cracked-pot resonance, 123. Crepitant rales, 76, 163. Croui>ous pneumonia, 70. Cyanosis, 237. Dilatation of the heart, 195, 249. Divided respiratory murmur, 173. Dry pleurisy, 137. rales, 159. Duration of sound, 20. Dynamic nmrmurs, 207, 227. Dyspnoea in emphysema, 51. ECHINOCOCCI, 105. Effusion, aspiration for, 150. Eichhorst, 60. Elements of sound, 18. EmboUsm, 97. Emphysema, 47. Empyema, 153. Endocardial murmurs, 196. Endocarditis, 193, 240. Exophthalmic goitre, 2.53. Fatty heart, 250. Fibrosis of the heart, 262. Fibroid phthisis, 107, 131, First sound of the heart, 190. Flatness, 129. Fox, Dr. Wilson, 71. Fremitus, 11. Freund, 50. Friction fremitus, 12. Frictio redux, 141. Friction sounds, 140, 169. Functional cardiac diseases, 263. Gangrene of the lungs, 89. Gravity of valvular lesions, /iOO. Graves' disease, 253. Grisolle, 71. Gurgles, 128, 165. H^Mic murmurs, 237. Hsemopericarditis, 244. Haemoptysis, 100. Hsemothorax, 154. Hay fever, 42. Heart, 183. diseases, sudden death from, 260. displaced in phthisis, 121. in emphy.sema, 53. Hemorrhage from the lungs, 102, 117. Hemorrhagic consumption, 107. infarction, 96. Hydatids of the lungs, 105. Hydro-pericardium, 244. INDEX. 289 Hydro-pericarditis, 244. Hydrothorax, 153. Hydro-pneuuio (pyo-) thorax, 157. Hypertrophy of the heart, 195, 245. Hyi^ertrophous emphysema, 49. Hypochondriac region, 4. Hypostatic congestion, 64. pneumonia, 72. Indeterminate rales, 129,168. Infarction, 9fi. Infantile pneumonia, 84. Infra-axillary region, 7. clavicular region, 5. mammary region, 4. scaiaular region, 6. Inspection, 8. Intermittent pulse, 2G4. Inter-scapular region, 5. Intra-arterial murmurs, 226. plural rales, 39, 129, 140, 166. ventricular murmurs, 206, 226. Irregular rhythm (heart), 264. jjulsation, 219. Koch's tubercle bacillus, 108. as an aid to early diagno- sis, 110, 117, 130. Laennec, 25. Laryngeal breathing, 28. phthisis, 107. Lateral regions of the chest, 7. Lobar pneumonia, 69. Lobular pneumonia, 84. Loomis, 71, 278. Mammary region, 4. Mammillary line, 8. Marasmic atelectasis, 60. Mensuration, 32. Metallic tinkle, 128, 158, 165. Mitral obstruction, 209. regurgitation, 198. and obstruction, 217, regurgitant pulse, 200. Moist rales, 161. Mucous rales, 38, 162. Mueo-crepitant rales, 163. Mucous click, 164. Murmurs of the heart, 195, Musical heart murmurs, 203. Myocarditis, 244. Myoidema, 114. NoRMAii respiratory murmur, 26, 170, 172. vesiculo-bronchial breath- ing, 28. vesicular resonance, 18. vocal resonance, 13. (Edema of the lungs, 66. Operation for aspiration, 151, Outline of the heart, 184. Palpation, 10. Palpatory percussion, 17. Palpitation of the heart, 263. Paracentesis thoracis, 33. Parasternal line, 8. Pectoriloquy, 126, 180. Pectorophony, 29, 177. Percussion, 16. Pericardial sounds, 241. Pericarditis, 241. Physical diagnosis, 1. signs, 1. Phthisis, 106. Phonometry, 34. Piorry, 17, Pitch of sound, 18. Pleurisy a cause or result of phthisis ? Ill, 138. classification of, 136. Pleurae, boundaries of, 136, function of, 136. Pleurisy, article on, 135. 290 INDEX. Pleurisy, dry, 137. acute with effusion, 138. subacute, chronic, 141. Plexinietev, 17. Pneumonia, 69. lobular, 84. "" inter-loVmlar, 87. Pneunio-hy(lrf>thorax, 156. Pneuniothovax, 154. Pneuuionokoniosis, 88. Posterior regions of the chest, 5. Puerile respiration, 2.9, 171. Pulmonary apoplexy, 99. collapse. 59. ' consvniiption, 106. congestion, Co. hemorrhage, 102. interspace, 190. (artery) murmurs, 236. oedema, 66. obstruction, 236. regurgitation, 239. Pulse, intermittent, 264. Purring thrill, 202. Puncture in pleurisy, 151. Pyo-pneumothorax, 157. QUAlN's fatty heart, 250. Quality of sound, 18. Rales (rhonchi), 37, 160. Rale redux, 81. Reduplication of heart sounds, 211. Regions of the chest, 2. Regional percussion, 21. Respiratory percussion, 20, 149. murnuir, normal, 27. changes in, 170, 176. Rlionchal fremitus, 12. Rhythm of the heart, 192. irregular, 264. Rude respiration, 116, 175. Scapular line, 8. region, 5. Scrofula, relations to tubercle, 112. Sibilant rales, 37, 160. Siderosis pulmonum, 87. Skodaic resonance, 78, 144. Sonorous rales, 37, 160. Sounds of the heart, 190, 192. Splashing sounds, 169. Sphygmograph, 267. Sputa, 8. Steam-tug heart murmurs, 234. Sternal line, 3, 8. Stethoscopes, 24, 25. Stokes, 115. Stridor, 160. Stridulous breathing, 160. Sub-axillary region, 8. Sub-clavicular region, 2. Sub-crepitant i-ales, 38, 162. Sub-scapular region, 5. Sub-mucous rales, 38, 162. Sub-mammary region, 4. Succussion, 33, 157, 169. Sudden death from heart dis- ease, 260. Summary of signs in health, 30. Superficial veins, 121. Superior costal respiration, 9. sternal region, 5. Supra-clavicular region, 2. Supra-scapular region, 5. Supra-sternal region, 5. Tait, Dr. Lawsox, 115 Thermometry, 8. Thickened pleura, 146. Thoracentesis, 33. Thoracic aneurism, 283. Thrill, purring, 202. Thrombosis, 97. Tinkle, metallic (amphoric), 128, 158, 165. Tobacco heart, 258, 259, 266. Tracheal rales, 162. Trachiloquy, 182. Tricui