sicalDiagnosis iieDiSEASESoj The |"IeARTandJ-UNGS KCTG C(^ Columbia 29nit)ers^ttj> mUeCttpotlmigork College of 3^i}p^imm anb ^urgeonsf %ibxavy Br. Jerome P. Webs'ter IK'./?' ^*i THE PHYSICAL DIAGNOSIS OK IHK DISEASES (JK THE HEART AND LUNGS AND THORACIC ANEURISM D. M. CAMMANN, B.A. Oxon., M.D. ATTENDING PHYSICIAN IN CLASS OF HEART AND LUNGS, DEMILT DISPENSARY; VISITING PHYSICIAN TO THE ORPHANS* HOME AND ASYLUM, ETC. G. P. PUTNAM'S SONS- NEW YORK LONDON 27 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST., STRAND 1891 Copyright, 1891 BY D. M. CAMMANN, B.A. Oxon., M.D. XCbc TRnicfterbocftct press, IRew l|?orft Electrotyped, Printed, and Bound by G. P, Putnam's Sons In Memoriam (}. r. C. AND M. M. W. CONTENTS. PREFACE PAGE. xi. THE L UNGS. SECTION I. EXAMINATION OF THE CHEST REGIONS OF THE CHEST .... POSITION OF THE LUNGS AND OTHER ORGANS INSPECTION PALPATION MENSURATION SUCCUSSION PERCUSSION IN HEALTH Position in Examination — General Remarks — How to Percuss — Varieties of Percussion Reso- nance — Percussion over the Normal Chest. AUSCULTATION IN HEALTH . . . . . Immediate and Mediate Auscultation — How- to Auscultate — Stethoscopes. CHEST ACOUSTICS . Elements of Sound — Consonance — Unison Resonance — Echo. RESPIRATION IN HEALTH VOCAL RESONANCE V I 2 5 9 12 14 15 ^5 21 31 37 VI CONTENTS. SECTION II. PERCUSSION IN DISEASE — RESPIRATORY PERCUSSION, AUSCULTATION IN DISEASE Respiratory and Vocal Sounds — Rales — Ad- ventitious Sounds in the Chest Wall — Facts and Theories in Regard to the Origin of Rales. PAGE 44 SECTION III. ACUTE BRONCHITIS CHRONIC BRONCHITIS CAPILLARY BRONCHITIS LOBAR PNEUMONIA LOBULAR PNEUMONIA PLEURISY EMPYEMA HYDROTHORAX HYDROPNEUMOTHORAX PNEUMOTHORAX EMPHYSEMA ASTHMA . PULMONARY CEDEMA HAEMOPTYSIS . PULMONARY CONGESTION ACUTE MILIARY TUBERCULOSIS PULMONARY PHTHISIS ATELECTASIS AMD PULMONARY COLLAPSE 66 67 70 71 75 75 76 77 78 79 80 81 83 83 96 CONTENTS. VU PULMONARY INFARCTION PULMONARY APOPLEXY . PULMONARY GANGRENE . PULMONARY CANCER 97 97 98 98 THE HEART. SECTION IV. POSITION OF THE HEART INSPECTION PALPATION PERCUSSION AUSCULTATION General Remarks — Sounds of the Heart — Intermittence and Irregularity — Paralysis of the Heart — Reduplication of the Heart Sounds. AUSCULTATORY PERCUSSION General Rules — Table of Averages of Male Hearts. MURMURS SECTION V. General Remarks — Pericardial Murmurs — Valvular Murmurs — Aortic Obstruction — Aortic Regurgitation — Mitral Regurgitation — Mitral Obstruction — Pulmonary Systolic Murmur — Pulmonary Regurgitant Murmur — Tricuspid Regurgitation — Tricuspid Obstruction — Intra- ventricular Murmur — Anaemic Murmur — Com- bination of Murmurs — Variability of Murmurs. 102 117 118 123 137 145 Vlll CONTENTS, SECTION VI. PERICARDITIS . ADHERENT PERICARDIUM HYDROPERICARDIUM HYPERTROPHY . . DILATATION . FATTY DEGENERATION AND INFILTRATION ANEURISM OF THE THORACIC AORTA VENOUS MURMURS, CONGESTION, AND PULSATION THE PULSE THE SPHYGMOGRAPH PAGE . i6o 163 164 164 165 166 167 noN ^73 174 . 176 ILLUSTRATIONS. FIGURE I.- 2. — 3&4.- 5-- 6.- 7.- PAGE 9-- lO.- 12. 13- 14.— Showing Position of Heart, Lungs, and Clreat Vessels. (Sibson) .....•••• Showing Bifurcation of Trachea and Position of Main Bronchi. (Sibson) Monaural Stethoscopes Cammann's Binaural Stethoscope •Cammann's Modified Chest-piece •Alison's Differential Stethoscope ■Cammann's Binaural Hydrophone for Auscultatory Per- cussion ....... ■Cammann's Intracostal Solid Cedar Stethoscope -Showing Position of Heart and Great Vessels. (Qi "Anatomy ") . -Showing Heart, Great Vessels, Diaphragm, etc. posed. (Sibson) -Side View of Heart and Great Vessels. (Sibson) -Right Auricle and Ventricle Exposed Showing Valves. (Quain's " Anatomy ") Base of Ventricular Part of Heart, Showing Relative Position of the Arterial and Auriculo- Ventricular Orifices. (Quain's "Anatomy") . . . • ix Ex- 7 22 23 24 26 28 29 103 105 107 109 no X ILL us TRA TIONS. FIGURE PAGE 15. — Heart and Vessels as Seen from Behind. (Sibson) . iii 16. — Cammann's Cardiometer ...... 116 17. — Diagrammatic Representation of Systolic and Diastolic Murmurs. (Bramwell) ...... 149 18. — Diagrammatic Representation of Systolic and Presystolic Murmurs. (Bramwell) . . . . . .149 19. — Diagrammatic Representation of Systolic, Diastolic,, and Presystolic Murmurs. . (Bramwell) .... 149 20. — Pericardium Containing Fifteen Ounces of Fluid. (Sibson) . 161 21. — Pericardium Containing ^ Pound of Fluid. (Sibson) . 161 22. — Dudgeon's Sphygmograph . . . . .177 PREFACE. This little book is the result of a series of notes originally thrown together for my own instruction and assistance in teaching. By arranging them under proper headings, and adding here and there fresh matter, it is hoped that a work has been prepared that may be of some value. Although I have endeavored to make this a text-book on the physical diag- nosis of diseases of the heart and lungs, it is in one sense fragmentary, as some questions which have especially interested me, or on which a reasonable difference of opinion ex- ists, have been considered more in detail than is usual in such a work. . The author's modification of the Cammann stethoscope and the binaural hydrophone are given more space than from their intrinsic value they deserve. This is not done from any over-estimation of their relative import- xii PREFACE. ance, but because It Is believed to be an authors privilege to fully explain his own Ideas. The averages of the measurements of the heart by auscultatory-percusslon are from tables made by my father, the late Dr. G. P. Cam- mann, and have heretofore only been published In part. The importance of a knowledge of acoustics to the student In physical diagnosis Is not suffi- ciently recognized. A field Is opened In this direction which will repay exploration and assist greatly In the correct Interpretation of physical signs. It has been my endeavor to emphasize this In the following pages. A large number of books and medical jour- nals have been consulted, and If reference were made to each from which assistance has been obtained, these pages would be overloaded with references. I make this general acknowl- edgment and excuse for their omission. D. M. CAMMANN. 19 East 33D Street, New York. THE PHYSICAL DIAGNOSIS f)F THE DISEASES OF THE HEART AND LUNGS. THE LUNGS. SECTION I. EXAMINATION OF THE CHEST. In many cases of disease we can arrive at a correct knowledge of the condition of the patient without employing all the methods of physical diagnosis, but it is best always to make a systematic examination of all parts of the chest, and to use every means which may aid us in diagnosis. In the majority of cases it is not any one physical sign, but the group- ing together of several which indicates the true condition of the parts under examination. Now and then we are obliged to remain in ± DISEASES OF THE HEART AND LUNGS, doubt and await future development before reaching a positive diagnosis, but the number of such cases is not large, and a careful exam- ination will clear up many doubtful points. REGIONS OF THE CHEST. Authors have divided the chest into regions in various ways. The divisions are of no great importance, as the many bony landmarks over the thorax furnish a ready means of locating physical signs. The following is the division usually given : Supraclavicular Region. — The shape Is tri- angular. The inner boundary is the edge of the trachea ; the upper, a line from the outer third of the clavicle to the upper rings of the trachea ; the lower, the clavicle. Clavicular Regio7i. — The region comprises the inner two-thirds of the clavicle. Infraclavicular Region. — The region is bounded by the clavicle above and the lower border of the third rib below ; inside by the edge of the sternum, and outside by a vertical line from the junction of the middle and outer third of the clavicle. EXAMINATION OF THE CHEST. 3 Mammary Region. — Bounded above by the lower border of the third rib ; below by the lever border of the sixth rib; inside by the sternum, and outside by a line continuous with the outer boundary of the infraclavicular region. Inframafnmary Region. — Bounded above by the sixth rib ; below by the edges of the false ribs ; inside by the sternum, and outside by the prolonged outer boundary of the mam- mary region. Suprasternal Region. — The space above the notch of the sternum. Upper Sternal Region. — The portion of the sternum lying above a line joining the lower borders of the third ribs. Lower Sternal Region. — The sternum below the lower border of the third ribs. Axillary Region. — Bounded by the axilla above ; below by a line continuous with the lower border of the mammary region ; in front by the outer border of the infraclavicular and mammary regions ; behind by the external edge of the scapula. Infra-axillary Region. — Bounded above by 4 DISEASES OF THE HEART AND LUNGS. the axillary region ; below by the edges of the false ribs ; in front by the inframammary, and behind by the infrascapular regions. Suprascapular and Scapular Regions. — These have the same boundaries as the fossae of the scapula. Interscapular Region. — Bounded inside by the spines of the dorsal vertebrae ; outside by the inner edge of the scapula ; above by the second and below by the sixth ribs. Infrascapular Region. — Bounded above by the inferior angle of the scapula and the seventh dorsal vertebra ; below by the twelfth rib ; outside by the posterior edge of the infra- axillary region ; inside by the spine. POSITION OF THE LUNGS AND OTHER ORGANS. In the supraclavicular region are found the apex of the lung, the subclavian and carotid arteries, and the subclavian and jugular veins. On the right side, in front, the border of the lung extends almost vertically near the median line to the sixth rib, where it takes an abrupt turn, the lower border lying about on a level with the sixth rib, but varying in position from ^^.v Figure i. showing position of heart. lungs, and great vessels. (sibson.) 6 DISEASES OF THE HEART AND LUNGS. an Inch to an inch and a half with respiration. The upper border of the liver, covered by the right wing of the diaphragm, extends as high as the fourth rib, the lung becoming thinner from this point down to its sharp edge. Be- hind the right sterno-clavicular articulation is the innominate artery, while the subclavian artery crosses at the outer edge of the clavicu- lar region. The main bronchus — wider, shorter, and less oblique than the left — lies behind the second costal cartilage, while running close to the sternal border are the superior cava and arch of the aorta, and below the heart extends about an inch to the right of the sternum. The notch above the sternum contains the trachea, and at the lower right side the innomi- nate artery. In some persons the arch of the aorta reaches into this space. Over the upper sternal region the lungs nearly touch, and behind lie the ascending and transverse por- tions of the arch of the aorta ; the pulmonary artery from its origin to the bifurcation ; the aortic and pulmonary valves ; and at the level of the second ribs the trachea with its bifurca- tion. Behind the lower sternal region are a Figure 2. showing bifurcation of trachea and. position of main bronchi. (SIBSON.) _ 8 DISEASES OF THE HEART AND LUNGS. part of the heart, and below a portion of the liver and sometimes of the stomach. On the left side, the edge of the lung lies behind the sternum, and, extending downward and outward from about the fourth costal cartilage, leaves the heart uncovered over a space of variable size, and, reaching the fifth rib, crosses downward and inward to the sixth rib. Behind the clavicle, and deeply seated and almost at right angles with the bone, are the carotid and subclavian arteries. A little below the second costal cartilage lies the main bronchus, while in front, at the edge of the sternum, is the pulmonary artery. The base of the heart lies behind the lower border of the third rib. The heart is superficial as we pass downward. The lower part of the inframam- mary region is occupied by the stomach, the anterior edge of the spleen, and a portion of the left lobe of the liver. The axillary and infra-axillary regions con- tain the lungs, and below, on the right side, the liver, and on the left the spleen and stomach. The lung occupies the regions in the pos- terior portion of the chest, the lower border EXAMINATION OF THE CHEST. 9 extending to the tenth rib, the left lung reach- ing a little lower than the right, and both varying in position considerably during respira- tion. The main bronchus and bronchial glands are contained in the region between the scap- ula and spine, and on the left side the oesoph- agus and descending aorta. The bifurcation of the trachea is in the median line, with some inclination to the right. On the right side, below the tenth rib, is the liver, and on the left side intestines at the inner and the spleen at the outer part. Close to the spine, and more on the left than on the right, the kidney encroaches on this region. INSPECTION. A matter of no little importance is that the patient be in a good light, so that the whole chest is clearly seen. In a systematic examination, first look carefully over the chest for any thing wrong about the skin, or deformity in shape. The healthy adult chest measures more transversely than in the antero- posterior diameter. This proportion may be reversed, as in those who are '' pigeon- lO DISEASES OF THE HEART AND LUNGS. breasted," without being necessarily associated with a diseased condition of the lungs. In children the two diameters are nearly equal, so that the chest is almost circular. The two sides should be nearly symmetrical and expand equally. In right-handed persons the right side is usually somewhat the larger, the reverse being the case in the left-handed. Respirations vary in a healthy chest from six- teen to twenty per minute, and expiration is shorter than inspiration. In children the breathing is more rapid. The average rate at birth is forty-four per minute, and at five years of age twenty-six, which becomes reduced to the average frequency between fifteen and twenty years of age. In males the expansion of the upper is not as marked as of the lower part of the chest and abdomen (abdominal respiration) ; in females the upper part ex- pands more (thoracic respiration), and this difference between the sexes is much increased by the tight corsets so universally worn by women. Do not be deceived by rapid breathing, which is not always the result of thoracic EXAMINA TION OF THE CHEST, 1 1 disease. Differences in position or in degrees of activity, functional nervous disorders, peri- tonitis, the pressure of abdominal tumors, ascites, paralysis of the diaphragm, or gas in the intestines influence the rapidity, or the respirations may be slow and labored or irregu- lar from lesions of the cerebro-spinal system. Notice particularly flatness or bulging of the chest wall or of the intercostal spaces. Re- traction and want of free motion over one or both sides lead us to suspect the presence of old pleuritic adhesions. Pleuritic adhesions, however, may be present over limited areas on one or both sides, and cripple the lungs to a considerable degree without occasioning any marked retraction. In acute pleurisy, expan- sion over the affected side is often almost entirely lacking owing to the pain excited by every effort at respiration. But pain alone, from pleurodynia or from intercostal neuralgia without any lesion of the lung or pleura, may produce the same result. When respiration is painful the pleuritic adhesions are not put on the stretch, or the friction between the two surfaces of the pleura is reduced to a mini- 12 DISEASES OF THE HEART AND LUNGS. mum, and the pleurisy may be easily over- looked. A bulging of the lower part of the chest and a widening of the intercostal spaces indicates the presence of a considerable amount of fluid in the pleural cavity, while if the whole chest, and more especially the upper half, is bulging and rounded or ''barrel- shaped," emphysema is certainly present. An obstruction in the larynx causes a sinking In of the intercostal spaces during inspiration. In health the veins are not usually visible be- neath the skin, but in certain conditions, not necessarily connected with disease of the lungs, the veins of one or both sides may be promi- nent. PALPATION. Palpation is chiefly useful in confirming knowledge acquired by other means, but some- times in doubtful cases the hand assists us In reaching a correct diagnosis. By its aid we estimate the expansion of the chest, the char- acter of vibrations and impulses, and the tensity and size of tumors. When the Intercostal spaces over the lungs are gently tapped with the tip of the finger a EXAMINATION OF THE CHEST. 1 3 feeling of springiness or elasticity is experi- enced, and over the liver a sense of resistance from the solid organ beneath. This resistance or elasticity varies with changes in the lung tissue or in the pleura. In children and in thin persons the elasticity is most marked. By causing the patient to speak when the hand or the ear is placed on the chest, we feel the vibrations of the voice, the vocal fremitus, with more or less distinctness through the chest wall. The vocal fremitus is naturally most marked in the upper anterior portions of the chest, in the lateral regions, and behind and below the scapulae. As so many condi- tions influence the conduction of sonorous vibrations in the chest, as, for example, the diseased condition of the lungs or pleurae, also the loudness or coarseness of the voice, and as vocal fremitus depends upon such conduction, a slight difference in the two sides, without the presence of other physical signs, cannot be taken as evidence of a diseased condition of the lung. Vocal fremitus is naturally more marked under the riofht than under the left clavicle, and not uncommonly is more pro- 14 DISEASES OF THE HEART AND LUNGS. nounced over the whole of the right than over the left lung. MENSURATION. Mensuration is useful when we wish to keep an accurate record of cases or com- pare the expansion of the chest from time to time. Measurements should always be made at the same level so as to be available for purposes of comparison. A convenient level is at the sixth costo-sternal articulation between the vertebral spinous processes and the median line in front. We must remember that in health the two sides of the chest vary considerably, and that in right-handed persons the right side is half an inch or more wider than the left. To com- pare the two sides it is necessary that the measurements be taken during the same stage of respiration in both, and the best time is when the patient holds his breath at the end of expiration. A number of instruments have been invented for estimating the expansion of the chest during the respiratory act. PERCUSSION. 15 SUCCUSSION. Succusslon is almost exclusively employed in one disease, pneumo-hydrothorax. It con- sists in giving the trunk of the patient a slight, quick shake while the ear is applied to the chest. PERCUSSION. Position in E xaminatio7i. — For the back, fold the arms over the chest, clasping the shoulders with the hands, and bend slightly forward. For the front, clasp the elbows with the hands behind the back. For the lateral regions, clasp the hands over the head. In this way the muscles are made thinner and firmer and transmit sound best. Always see that the position of both sides is the same. The stage of respiration should be noted when comparing the two sides, as the percussion note varies with the amount of air in the lungs and with the degree of tension of the lung tissue. Avenbrugger introduced the method of per- cussion about the middle of the last century, but through the labor of Corvisart, nearly thirty years later, it first became generally known. Now its practice is general, and skill 1 6 DISEASES OF THE HEART AND LUNGS. in its use is by many supposed to be easily ac- quired, yet no less an authority than Laennec has told us that '' percussion yields exact re- sults in the hands of those only who bring to its exercise experience, dexterity, and much attention." In fact, one skilled in percussion can at pleasure elicit a good resonance or a dull sound over a chest perfectly healthy. The same result is often involuntarily obtained by the unskilful ; some cannot elicit sufficient sound without striking hard enough to give the patient pain. The fingers are the best instruments for percussion, and with them too it is easy at the same time to measure the re- sistance or the elasticity of the underlying tis- sue. Apply the palmar surface of the third phalanx of a finger of one hand directly to the skin, the rest of the finger being raised above the surface. In this way we obtain the per- cussion note over a smaller area than if the entire length of the finger is laid upon the chest. With a little practice the finger can be bent sufficiently. With one or two fingers of the other hand strike perpendicularly, gently, and quickly, keeping the fingers bent but im- PERCUSSION. 1 7 movable, and giving the blow from the wrist, as you would strike the key of a piano. Do not strike hard. Usually in the normal chest a light tap is sufficient to elicit the percussion note. When the chest-wall is thicker than common, or the costal cartilages rigid and less vibratile, forcible percussion may be required, but this is equally true for superficial as for deep-seated parts. The finger should be placed parallel to the ribs, but when the inter- costal spaces are narrow, or the fat or muscles covering the ribs are thick, this is not of much importance. Do not go on hammering too long, but compare by two or three quick strokes each region with the corresponding region on the other side. Over the clavicles we may practise immediate percussion — that is, strike directly upon the bone without the in- tervention of a pleximeter. Bear in mind that the main point you want to find out by percus- sion is whether one part of the pulmonary tissue is more solid than another. If you any- where find a change in the percussion note, percuss around that spot and mark out the ex- tent of the abnormal resonance. 1 8 DISEASES OF THE HEART AND LUNGS. Varieties of Percussion Resonance. — Over the normal chest and abdomen are obtained dul- ness, flatness, puhnonary resonance, and tym- panitic resonance. Pulmo7iary Resonance is heard over healthy lung. It is a low-pitched sound of variable intensity and considerable duration. Its quality is pulmonary. The percussion note will vary considerably even with the lungs in a normal condition, owing to the difference of elasticity of the chest-walls, and the varying thickness of the superficial tissues, so that each chest may be said to have its own normal percussion note, which differs more or less from all others. Dulness. — The quality is imperfectly pul- monary, and the pitch is high but has wide limits of variation. The duration varies with the pitch. The intensity is not great. It always indicates the presence of air. There is a sense of resistance to the percussing finger.' ^ The terms dulness and flatness as understood in this work are by some authors included under the common term dulness. In the latter case great dulness or extreme dulness is equivalent to flatness. Dulness as here understood may be slight and approach pulmonary resonance on the one hand, or it may be high-pitched and approach PERCUSSION. 19 Flatness, — The quality is flat. It is a high- pitched sound of short duration and feeble intensity. Typical flatness is obtained by per- cussing the thigh. It indicates a body free from air, and is heard over the solid viscera. The resistance to the percussing finger is greater than in dulness, and depends upon the firmness of the body percussed. Tyinpaiiitic Resonance. — ^The quality is tym- panitic. The pitch varies and the intensity is considerable. To produce tympanitic reso- nance requires a cavity of considerable size filled with air which is not in a condition of high tension. It is heard over the stomach and intestines. Sternal Resonance. — It is a variety of pul- monary resonance, but of higher pitch and greater intensity. The sternum acts as a sounding-board, intensifying the sounds pro- duced by percussing over it. Percussion over the Nor^nal Chest. — Per- cussion over the healthy chest elicits dulness flatness on the other, and it will therefore be readily perceived that the term includes a pretty wide range. It would be advantageous if some standard could be fixed of different degrees of dulness, to which all variations could be referred. 20 DISEASES OF THE HEART AND LUNGS. in the supraclavicular region. Over the clavicle we obtain pulmonary resonance slightly modified by the bone. The infra- clavicular region yields pulmonary resonance, and is usually taken as the standard for com- parison with sounds heard over other parts of the chest. The pitch is somewhat higher on the right than on the left side, and on both sides immediately under the clavicle than over the second rib. In the right mammary region is dulness over the liver from the fourth rib, increasing on passing downward, and similarly on the left side, dulness over the heart, increasing from the third rib downward. The inframammary region gives flatness on percussion on both sides, changing to dulness over the upper portion when the lungs are fully expanded, and on the left side we may have tympanitic resonance from the stomach. Over the upper part of the sternum we have pulmonary resonance, somewhat modified by that bone, and on passing downward the pitch is raised by the heart and great vessels which produce dulness. In the axillary regions is pulmonary resonance on the right side down A USCUL TA TION, 2 1 to the fifth rib ; from the fifth to the seventh, dulness ; and below the seventh to the free border of the ribs, flatness ; on the left side, pulmonary resonance to the seventh rib ; below, flatness. Behind, dulness in the scapu- lar and suprascapular regions, and pulmonary resonance in the interscapular and infrascapu- lar regions. AUSCULTATION. Auscultation of the respiratory and voice sounds may be practised with the ear, and is then called immediate, or with the stethoscope, when it is called mediate auscultation. If the ear alone is used, only a single layer of cloth- ing should cover the chest. The ear should be applied gently and firmly, allowing the head to rise and fall with the respiration. By pressing the side of the head as well as the ear against the chest, the hearing is rendered more acute, although the physical signs are not so well localized. The credit of bringing the stethoscope into practical use belongs to Laennec. He hit upon the idea accidentally by using a roll of 22 DISEASES OF THE HEART AND LUNGS. paper held in his hand. The stethoscope of Laennec, which was nothing but a long hollow tube open at both ends, has been much rn o d i fi e d in Figure 3. shape, but the MONAURAL STETHOSCOPE. pHnciple Te- mains the same, the binaural being nothing more than the monaural adapted for the use of two ears instead of one. The principle of the telephone has lately been utilized for the stethoscope. Hollow stethoscopes are best for listening to sounds produced over the lungs. Solid cedar stethoscopes are useful for purposes of auscultatory percussion, but the binaural instrument will answer nearly as well. The best binaural stetho- scope is the one in- vented by Dr. G. P. Cammann. It is figure 4. light, durable, easily monaural stethoscope. carried, and a good conductor of sound. The attachment of a rim of soft rubber, as de- AUSCULTATION. 23 vised by Dr. Snelling, is of advantage in some cases for applying it more closely to the inequalities of the chest. Oval chest-pieces are also made which enable the end of the stethoscope to be pressed into the intercostal spaces. In the latest instruments the rubber band is replaced by a spring concealed in the screw which binds the two tubes of the steth- oscope together. Figure 5. cammann's binaural stethoscope. A modification of the chest-piece of Cam- mann's binaural stethoscope was devised by the author. The instrument differs from the latter in this, that in the chest-piece is a circu- lar chamber open on the side applied to the chest. The inner and outer walls of this chamber are circular and nearly half an inch apart, the inner wall being the expanded ex- tremity of the tube leading from the chest to 24 DISEASES OE THE HEART AND LUNGS. the ears, and the outer being the outer wall of the chest-piece, which, arching above and join- ing the inner wall, forms the roof of the cham- ber. The rims of the inner and outer walls lie in the same horizontal plane, so that when the Figure 6. cammann's modified chest-piece. Instrument is applied to the chest the chamber is closed on every side. Connected by a small tubular opening with this chamber is a hollow rubber bulb, and by pressure and relaxation of pressure by the hand upon this bulb, the air in the hollow chamber is AUSCULTATION. 2 5 exhausted, and the stethoscope is held against the chest by the pressure of the external air. The tube conveying the sounds to the ear passes through the rubber bulb just above the chest-piece. The advantages of this are two- fold : it gives compactness to the instrument, and the rubber bulb acts as a resonator to the passing sounds. Some of the practical advantages in the use of the modified chest-piece are that it is brought into the closest possible contact with the chest wall, and that the sounds conveyed to the ear pass through two hollow chambers, the one in the chest-piece and the rubber bulb, both of which act as resonators and increase their intensity. Not only is the in- tensity of the sound greater than with the ordi- nary stethoscope, but the true quality is better brought out. The heart sounds are more intense and the murmurs more readily recog- nized. The bronchial sounds are more bron- chial, and the true character of sounds heard over cavities is better appreciated. Another advantaofe of the instrument is that the two hands of the auscultator are left free to prac- 26 DISEASES OF THE HEART AND LUNGS. tise the method of auscultatory percussion. If the stethoscope be applied without press- ing upon the rubber bulb, it may be used in the same way as the ordinary instrument. The modified portion is made so that it can be screwed on or removed at pleasure from a stethoscope that has the usual movable chest- piece.' Figure 7. Alison's differential stethoscope. The differential stethoscope of Scott Alison is similar in mechanism to Cammann's, but has two chest-pieces — one for each ear, enabling the sounds from different regions of the chest to be conveyed to the two ears at the same time. The value of this stethoscope has been /^ N. V. Med. Jour., Jan. 3, 1885. An instrument similar in principle is figured by Constantin Paul in his book on " Diseases of the Heart." A USCUL TA TION. 2/ a matter of considerable controversy. It is claimed to be capable of offering aid to diag- nosis in two ways : (i) by the consecutive observation of the sounds of two regions of the chest by the different ears, and (2) by their simultaneous observation. We can listen over different parts of the chest with either ear by removing one or the other chest-piece, and thus can compare the sounds heard over different regions with great rapidity, and de- tect slight differences which might escape us in a prolonged examination. If we listen at two points simultaneously, and sound of the same quality but of different intensity is heard at each point, the weaker is eclipsed or nulli- fied, and thus, by the eclipsing of a weaker impression through one ear by a stronger im- pression through the other, differences may be recognized which might otherwise escape de- tection. When hearing is impaired in one ear, this stethoscope cannot be used satisfactorily. I have not found it of much practical value. The hydrophone is another instrument de- vised by Alison. It consists of an india-rubber bag about the size of a large watch, and filled 28 DISEASES OF THE HEART AND LUNGS, with water. The hydrophone may be employed as an instrument by itself or in aid of the stetho- scope. The increase of sound varies much with the material through which it is conducted. With firm, non-flexible, or solid steth- oscopes, the hydrophone acts as a damper and dim- inishes sound. The more a stethoscope becomes a mere air instrument and departs from the character of a solid conducting me- dium, the more water adds to its acoustic value. This may explain why such op- posite results have been obtained in the use of the hydrophone by different observers. The author has devised an instrument for ausculta- tory percussion. It is sim- ilar to the binaural stetho- FlGURE 8. cammann's binaural hy drophone for auscul- tatory percussion. A USCUL TA TION, 29 scope, but closed at both ends and filled with water, thus carrying out the principle of Ali- son's hydrophone in another form. The two tubes leading from the ears to the flexible portion of the stethoscope are of hard rub- ber. The chest-piece is similar to that al- ready described. The central circular open- ing, the termination of the tube leading from the ears, is closed by a soft-rubber dia- phragm. The ear-pieces are hollow, very thin, Figure 9. cammann's intracostal solid cedar stethoscope. and made of hard rubber. In the chest-piece of the binaural hydrophone is a small metal tube which opens internally into the central tube of the chest-piece about a quarter of an inch above the rubber diaphragm. This is closed by a stopcock. The instrument is filled by placing the stopcock under a faucet, or attaching a rubber tube and pouring in the water, the rubber caps at the other end being partially unscrewed and allowing the enclosed 30 DISEASES OF THE HEART AND LUNGS. air to escape through perforations in the screws. No bubbles of air should be allowed to remain. With a little care and proper manipulation it can be easily filled. Value of the Stethoscope.^ — In considering the value of the stethoscope, it is taken for granted that the instrument used is reliable, and that the auscultator knows how to use it. Some skilful auscultators advocate its continual use ; others equally skilful advise that it be used only occasionally. The cause of this dif- ference of opinion probably lies partly in dif- ference in the acuteness of hearing and the extent of the training of different observers, and partly is a matter of habit. That the habitual use of the stethoscope does after a time render the sense of hearing less acute to the sounds heard over the chest in immediate auscultation is, I think, an undoubted fact. Yet the stethoscope is a valuable instrument, and although not always needed, often we cannot attain to a full knowledge of a case without making use both of mediate and im- ^ " Handbook of the Medical Sciences," Wm. Wood & Co.; article " Stethoscope," by the author. A use UL TA TION, 3 1 mediate auscultation. Often a doubtful or half-heard sound has been clearly brought out and appreciated by the use of the stethoscope ; but still oftener, I think, has a sound scarcely suspected with the stethoscope been made evident by the immediate application of the ear. It requires some practice to become accustomed to its use, especially to that of the binaural instrument. In the latter some sounds are exaggerated, while others are impaired, and the distinctness and simplicity are lacking that are attained by the use of the ear or the monaural instrument. It is an acoustic fact that sounds are better heard with two ears than with one, and virtually the double stetho- scope enables us to place two ears on the chest at the same time. The value of the stethoscope for purposes of modesty, cleanliness, and convenience, and for examining the supraclavicular and axillary regions, which cannot readily be reached by the ear, is obvious, and needs only to be men- tioned to be appreciated. Value of a Knowledge of Acoustics. — The student will find that if he be familiar with 32 DISEASES OF THE HEART AND LUNGS. the science of acoustics he will obtain a firmer grasp of his subject, and be assisted consider- ably in studying the sounds heard over the chest. Although the subject cannot be con- sidered at any length in this place, it may be permitted to recall some of the laws which will assist us in analyzing and comparing the sounds we are considering. In analyzing sounds we recognize the acoustic elements termed quality, intensity, pitch, and duration. These elements are to be considered in sounds heard on percussion and on auscultation. In the latter a fifth element is to be added, rhythm, which refers to the recurrence of sounds, whether they are regular or irregular. The Quality of a sound is that by which it is distinguished from all other sounds, and is due to the different intensities of the harmo- nies or secondary tones which accompany the fundamental note of a vibrating body. A note sounded on two bodies may be the same in intensity, pitch, and duration, but the quality will be different. The Intensity or loudness of sound is in flu- A USCUL TA TION. 3 3 enced by the following causes: (i) The amplitude of the vibrations. (2) The dis- tance of the sonorous body from the ear ; e. g., a cavity separated from the periphery by healthy lung may be appreciated with diffi- culty. (3) The density of the medium through which the sound is conveyed ; e. g., consolidated lung readily conveys bronchial sounds, and a cavity surrounded with consoli- dated lung is readily appreciated. On the other hand the consolidation of centric pneu- monia, removed from the periphery by healthy lung, may not be readily recognized. (4) The direction of the currents of air or fluid ; e. g., in health the bronchial element of the respira- tion is heard in inspiration, and not in expira- tion, because in inspiration the current of air is carried along the larger bronchi towards the ear, and the bronchial sounds naturally follow the same direction, but in expiration the reverse is the case. In mitral regurgita- tion the sound of the column of back-rushing blood is projected directly into the ear to the left of the seventh dorsal vertebra. (5) The proximity of other sonorous bodies ; e. g., 34 DISEASES OF THE HEART AND LUNGS. rales are intensified by the proximity of a cavity. The sternum, acting as a sounding- board, may convey heart murmurs to a con- siderable distance. The heart-sounds near the apex are tympanitic in quality if the stomach be distended with gas and fluid. Pitch means the same as the term does in music. The pitch depends upon the number of vibrations in a given time. The pitch of the percussion note over the small intestine is higher than over the stomach, because a cavity containing a small amount of air gives a greater number of vibrations a second than a cavity containing a large amount. If the cavity be distended and the compression of the contained air in- creased, the percussion note will be raised in pitch, because with increased compres- sion the number of vibrations is increased. So at the end of inspiration the percussion note over the lungs is higher than at the end of expiration, because, although the amount of air in the lungs is greater, the compression of the air and the tension of the lung tissue is at the same time increased. A USCUL TA TION, 3 5 Some of the causes upon which depends the pitch of the sounds produced by air pass- ing through the bronchi are, the caHbre of the tube, its smoothness or roughness, the velocity of the air current, and the condition of the surrounding tissues. Consonance. — Consonance is from the Latin consono, I sound together. When a musical note is sounded upon the strings of a guitar, a second guitar near-by will produce a note of the same pitch, the one reinforcing the other. This is known .in music as consonance, and is true of all sounding bodies in the neigh- borhood of other sounding bodies producing a note of the same pitch. Thus the voice is reinforced by sounding bodies responding to its vibrations, as, for example, in issuing from the mouth it is increased in volume and force by throwing the air in the adjacent cavities into simultaneous vibration. Skoda attri- butes bronchial breathing and bronchophony heard over consolidated lung to consonance due to the altered condition of the bronchi. This theory is rejected by most authorities, who attribute the phenomena to the better 36 DISEASES OF THE HEART AND LUNGS. conduction of sound by the increased density of the lung. With our present knowledge it is difficult to say how far consonance assists in the reinforcement of thoracic sounds, but neighboring parts undoubtedly modify them, and the liver, stomach, and intestines have such an influence. Unison Resonance, — By unison resonance is meant the reinforcement which occurs in the box of a guitar when notes are produced by its strings, or when a tuning-fork is held upon a table instead of in the air. There can be little doubt that in the same way the thoracic walls assist in the reinforcement of sound. Echo. — By echo is meant the repetition of sounds. It is a probable cause of their reinforce- ment. Existing theories fail to explain some of the phenomena of echoes, and we scarcely yet understand the laws by which they are gov- erned. In some cases of posterior consoli- dation in one lung, bronchial breathing and bronchophony have been heard at a distant point over the other lung. This has been ex- plained by the laws of echo. RESPIRATION IN HEALTH. 37 RESPIRATION IN HEALTH. In the respiration in health, inspiration is three or four times longer than expiration. Expiration as heard over the chest of old per- sons is usually considerably longer than this. Inspiration is of considerable duration and intensity, of low pitch and pulmonary quality. It is of a soft, breezy character, neither liquid nor dry, increasing in intensity at first, but again decreasing before the end of the inspira- tory act. Expiration is harsher and lower- pitched, and of considerably less intensity. It is heard at the beginning of the expiratory act, but is lost before it is one third or at most one half over. In about one in four of healthy persons expiration is not heard at all. We recognize that the sound produced in respiration is not a single element, but is com- posite, and in certain regions of the chest or under certain conditions one or the other element may predominate. Considerable dif- ference of opinion still exists as to the causes that produce the respiratory murmur. The controversy cannot be entered into here, but 38 DISEASES OF THE HEART AND LUNGS. the question will be considered from a purely clinical standpoint. The two elements of which the respiratory murmur is composed are the bronchial, caused by air friction in the larger bronchial tubes, and the vesicular ele- ment, produced in the lung proper/- Various and conflicting theories have been advanced as to the cause of the vesicular murmur, but in the present state of our knowledge of thoracic physics none of the views that have been advanced are capable of demonstration (Walshe). The bronchial element, which is heard with greatest intensity in inspiration and feebly or not at all in expiration, is some- what high-pitched and harsh. It is most marked in children and is then called ''puerile breathing." It may be increased in the adult by forced respiration. In the adult it is specially noticeable under the right clavicle and in the interscapular regions. The vesicu- lar murmur is soft, low-pitched, of little in- tensity, and heard both in inspiration and ^ Learning believes the respiratory murmur to be composed of two murmurs, which he calls the true respiratory and the broncho-respira- tory, and that each may be isolated. — " Diseases of the Chest," New York, 1887. RESPIRATION IN HEALTH. 39 expiration, increasing in the one and decreas- ing in the other. It is absent in young children and is not fully developed until maturity. A change in the form of the chest or a thick layer of muscles or fat may render this murmur difficult of recognition. Vocal Resonance. — If the ear be placed upon a healthy chest while the person speaks, the vibrations of the voice are heard without dis- tinct phonation as a buzzing, vague, and distant sound. Its quality will vary with the person's voice. It is low-pitched and most intense in those having a deep, low-pitched voice. The phonation, however, is more distinct when the voice is high-pitched. Over the larger bronchi at the upper part of the sternum in front and in the interscapular regions behind, the vocal resonance is more concentrated and intense than over the re- mainder of the chest. Its intensity is usually greater over the right lung than over the left. If the person be made to whisper, the sound is conveyed to the ear as a slight and distant puff or merely as an exaggeration of the ex- piratory sound. Coughing produces a sharp, 40 DISEASES OF THE HEART AND LUNGS. quick sound which jars the whole chest. What we learn by auscultation of the voice is chiefly of value to confirm knowledge acquired by other means. Vocal Fremitus Is the vibrations of the voice felt through the chest walls. Vibrations of a coarser and more violent character are needed for its production than for the production of vocal resonance.' ^ The former is supposed to depend upon the vibrations transmitted through solid tissues, the latter mainly upon the column of air in the trachea and bronchial tubes vibrating after the fashion of an organ- pipe. — Stone : " Cromian Lectures," Lancet, Aug. 9, 1879. SECTION II. PERCUSSION IN DISEASE. The general remarks already made in regard to percussion apply equally to percussion in health and in disease. Whatever be the nature of the disease, its area will either be sharply defined or not. In the former case little diffi- culty will be experienced in mapping out its limits. In the latter we may be in some doubt, and it will assist us to rapidly percuss over the suspected area so as to compare the different parts as quickly as possible. A change in the density of the lung, in the amount of air present, in the thickness of the pleura, or the presence of fluid, will cause a change in the percussion note, and we may estimate the extent of these changes not only by the sound elicited, but by the feeling of resistance expe- rienced by the fingers. 41 42 DISEASES OF THE HEART AND LUNGS. We may obtain exaggerated pulmonary res- onance, dulness, flatness, amphoric resonance, tympanitic resonance, and cracked-pot reso- nance. Exaggerated Pulmonary Resonance. — The pitch is lower and the intensity and duration greater than in normal pulmonary resonance. It is heard over a lung doing extra work, in emphysema, and in cases of marked anaemia. Dulness may be increased where it is nor- mally present, or present in abnormal situa- tions. It indicates a decrease in the amount of air, or interference with the normal vibra- tions of the lung tissue. Dulness varies within pretty wide limits : it may be slight, and only a little higher pitched than pulmonary reso- nance ; or, on the other hand, well marked, and only a little lower in pitch than flatness. It is heard over consolidated lung, fluid in the pleural cavity, thickened pleura, emphysema, aneurism, hypertrophy of the heart. Flatness. — It indicates a solid body of con- siderable size. It is heard over large pleuritic effusion, pleura very much thickened, consoli- PERCUSSION IN DISEASE. 43 dated lung when pressed firmly to the chest wall, tumors, aneurisms. Tympanitic Resonance is heard over cavities and in pneumothorax. It may be transmitted through consolidated or compressed lung from the stomach or intestines. The resonance re- sembling tympanitic, heard over lung partially collapsed and containing fluid, has a pulmo- nary character, is less metallic than, and can be distinguished from, tympanitic resonance. Amphoric Resonance is heard over large cav- ities. The greater the compression of the air and tension of the walls in the cavity, the higher the pitch. Cracked-pot Sotind. — The quality is metallic, and the pitch varies with the size of the cavity. It is heard over cavities communicating with a bronchial tube by a small opening, and resem- bles the sound produced by striking the hands loosely clasped against the knees. It is heard best when the patient's mouth is open. Some- times it is observed in healthy children whose chest walls are thin and elastic. Respiratory Percussion. — The percussion note varies at the end of a full inspiration and 44 DISEASES OF THE HEART AND LUNGS. a prolonged expiration, and to this method of diagnosis Da Costa has given the name of res- piratory percussion. At the end of a full held inspiration in a normal chest the sound is in- creased in intensity and raised in pitch, while at the end of a forced expiration the reverse is the case. In emphysema the change in the percussion note between the extremes of respiration is scarcely appreciable. In the early stage of phthisis dulness is best detected by percussing the patient with his mouth open during a fixed expiration, and the difference between the two sides becomes manifest during a held inspira- tion. As the consolidation becomes greater dulness is little influenced by respiration, while over a cavity a tympanitic percussion note be- comes dull with a held inspiration. Over a compressed lung dulness becomes less with a held inspiration. . AUSCULTATION IN DISEASE. In disease the respiratory sounds over the normal lung may be modified, or adventitious sounds may be heard. Sometimes a single AUSCULTATION IN DISEASE. 45 physical sign will be pathognomonic, but in the great majority of cases it is only by group- ing together the various physical signs, and even drawing upon clinical histories and our pathological knowledge, that we are enabled to arrive at a correct diagnosis. Harsh Respiration is the bronchial element of the respiration of the healthy adult exagger- ated, and is produced in the normal chest by increasing the rapidity of the breathing. In children it is normally present and is then called puerile respiration. The vesicular ele- ment of the respiration may be unchanged or diminished. Harsh respiration may be heard in inspiration alone, or in inspiration and ex- piration, and in the latter case it may be of higher pitch and of greater intensity in one than in the other. Harsh respiration when it becomes marked approaches bronchial breath- ing in character, and there is no strict dividing line where the one ends and the other begins. Harsh respiration indicates slight condensa- tion or consolidation of the lung, dryness of the mucous membrane of the bronchi, plastic exudation into the pleura sufficient to slightly 4.6 DISEASES OF THE HEART AND LUNGS. compress the lung beneath, and even consider- able consolidation if there be healthy lung be- tween it and the chest wall. Feeble Respiration. — The respiration is di- minished in intensity and perhaps in pitch. Either the bronchial or the vesicular element of the respiration may be suppressed, or one or both be faintly heard. It is observed over lung in which the expansion is diminished by pain, with obstructions in the larynx or trachea, over pleuritic adhesions binding the lung to the chest wall, and with paralysis of the dia- phragm or costal muscles. Suppressed Respiration. — It is observed when little or no air enters the lungs. No sound is heard, or at most only a slight sound at the end of inspiration. It Is due to the same causes carried to extremes as feeble res- piration. Prolonged Expiration. — Expiration is longer than inspiration. Usually a change in quality and pitch accompanies the lengthened expira- tion. It Is due to want of freedom of the passage of air from the lungs, from loss of re- siliency of lung tissue, or from some mechanical AUSCULTATION IN DISEASE. 47 obstruction. When these two causes are com- bined, as in the loss of resiliency in emphy- sema, together with the mechanical obstruction of inspissated mucus from bronchitis, we have the greatest prolongation. Cogged-wheel Respiration, — The respiration is interrupted or jerking in character and may occur both with inspiration and expiration. Sometimes it is not heard throughout the whole of the inspiration but during the first or last part. It may be heard over both lungs or over a part of one lung, and is supposed to be due to mucus adhering to the walls of the swollen bronchi, causing obstruction to the free passage of air. In some cases it is a purely nervous phenomenon, unconnected with any disease of the lungs. In cases where the interruptions were synchronous with the movements of the heart, they have evidently been due to pericordial adhesions. It has been observed in phthisis, incipient pleurisy, pleu- rodynia, hysteria, intercostal neuralgia. Bro7ichial Respiration. — The pitch is high. Expiration is as long or longer and higher pitched than inspiration. The quality is bron- 48 DISEASES OF THE HEART AND LUNGS. chial. It is the natural bronchial breathing which, owing to morbid conditions, is readily conveyed to the ear. Sometimes it is diffused, of no great intensity, and distant from the ear ; at others intense, metallic in character, and di- rectly under the ear. It is heard over con- solidated and compressed lung, excessively thickened pleura, dilated bronchi, and cavities. Cavernotis Respiration is hollow and blowing in character and low-pitched. Expiration is almost invariably lower pitched than inspira- tion. It is heard over cavities and largely dilated bronchi. The cavity must contain little or no fluid, be near the surface, have free communication with a bronchus, and have flaccid walls. Amphoric Respiration is a sound of a musi- cal character, like that produced by blowing into an empty bottle. It may be humming and low-pitched, or metallic and high-pitched, the pitch varying with the size of the cavity. It is heard over cavities. Typical amphoric respiration is heard over large cavities with tense walls. Metallic Tinkling is a short, clear, high- AUSCULTATION IN DISEASE. 49 pitched, metallic sound resembling that pro- duced by letting drops of water slowly fall Into a decanter partially filled with fluid, or by breathing Into the water through an elas- tic tube. It is usually heard towards the end of Inspiration, but rarely with any considera- ble number of consecutive respirations. A uniform conclusion as to the cause of metallic tinkle has not been reached. It Is probably produced In cavities containing fluid, either by drops of fluid falling from the roof, or by bubbles of air passing through the fluid, or rales generated in communicating bronchial tubes may be echoed with metallic tinkle. It is most often produced by coughing or speak- ing, and is heard over large cavities and in hydropneumothorax. The peculiar and rare form of breathing, known as Cheyne-Stokes respiration^ occurs in many different diseases, but most frequently in those of the brain and^ heart. It indicates a depressed condition of the nervous system, and is usually followed by a fatal result. It consists in a pause, during which respiration entirely ceases ; this is followed by respira- 50 DISEASES OF THE HEART AND LUNGS. tions which at first short and shallow become gradually deeper, and then again shorter and shallower until they come to a standstill. In well-marked cases this whole cycle of changes takes from one to one and a half minutes. The Voice in Disease. — The knowledge ac- quired by vocal resonance in disease is not of much importance, although occasionally useful in confirming conclusions reached by other means. Exaggerated Vocal Resonance. — The inten- sity of normal resonance is increased without any change in quality. It is heard over lung slightly consolidated or compressed, or over lung bound to the chest wall by pleuritic ad- hesions. Diminished Vocal Resonance is caused by some interference with the conveyance of sound, either by obstruction in the bronchi or removal of the lungr from the chest wall. It occurs in pleuritic effusions, pneumothorax, emphysema. Suppressed Vocal Resonance Is observed over large pleuritic effusions, in pneumothorax and emphysema. AUSCULTATION IN DISEASE, 5 1 Bronchophony. — It is high-pitched and of variable intensity, almost metallic in quality, concentrated, and near the ear. The articula- tion of the words is not appreciated. It occurs over consolidated lung, cavities, or dilated bronchi. y^gophony is a variety of bronchophony peculiarly tremulous, cracked, ringing, and muffled in character, and has been compared to the bleating of a kid. It is of short dura- tion, usually persistent, although it does not accompany every spoken word even of the same pitch. It is appreciated best in patients with a vibrating voice, and most commonly heard behind, nearly on a level with the angles of the scapulae. It is observed in some cases of pleurisy with effusion at or a little below the level of the fluid, but not usually with a large accumulation of fluid. When loose cellular adhesions hold the lung to the chest and the layer of fluid between is thin it is sometimes heard quite extensively. Pectoriloquy is an exaggerated bronchophony in which not only the sound of the voice but the articulation of the words is conveyed $2 DISEASES OF THE HEART AND LUNGS. through the chest wall. It occurs over cavi- ties or consolidated lung. When heard over a cavity, the cavity is probably of moderate size, empty, with firm walls, near the surface, attached to the chest walls by adhesions, and freely communicating with a bronchus. Heard over consolidation, it is evidence that the consolidation lies between the chest wall and a main bronchus. Amphoric Voice has the same quality and meaning as amphoric respiration. Whispering is heard but faintly over a healthy chest. In disease it is absent if the transmission of sound be interfered with, as in emphysema and in pleurisy with effusion, or it may be heard distinctly in conditions favoring the transmission of sound, as in consolidation, in enlarged bronchi, and over cavities, and we may have whispering pectoriloquy. The resonance produced by cough is dimin- ished or increased under conditions interfering with or favoring the transmission of sound. By auscultating at the time of the cough and during the deep inspiration that the patient naturally takes afterwards, physical signs are RALES. 53 often discovered that might otherwise escape notice. Vocal Ft efnihis may be increased or dimin- ished, and does not always correspond with the increase or diminution of the voice. It may be increased by pulmonary consolidation or pleuritic adhesions, and is diminished by fluid or air in the pleura. If the consolidation be considerable and little air be admitted into the lung, vocal fremitus is not felt. RALES. The respiratory sounds hitherto considered have been morbid changes of normal breath and voice sounds. Rales are certain adven- titious sounds produced within the chest, never present in health, and heard with respiration or the movements of the heart. Rales are crepitant, subcrepitant, coarse, gurgling, sibilant, and sonorous. Pleuritic friction may also be considered in this connection. Crepitant Rales are fine, sharp, dry crackles all of the same size, usually heard with inspira- tion, and resemble the sound produced by a lock 54 DISEASES OF THE HEART AND LUNGS. of hair forcibly rubbed between the thumb and forefinger, or by salt when thrown on the fire. Subcrepitant Rales are moderate and un- equal sized, moist or dry, rather quick crackles. Coarse Rales are moist or dry, bubbling, of unequal size, and larger than subcrepitant rales. Sometimes a single sharp, high-pitched metallic click is heard with the respiration or the movements of the heart. Gurgling Rales are large, moist, unequal- sized bubbles, sometimes metallic in character. The death rattle is an example of this rale. Sibilant Rales are whistling or hissing in character, dry, high-pitched, and varying con- siderably in intensity and duration. Sonorous Rales are snoring in character, dry, low-pitched, varying much in intensity and duration. Sibilant and sonorous rales are produced within the bronchi, the sonorous usually in the larger and the sibilant in the smaller. The others, crepitant, subcrepitant, coarse, and gur- gling rales, may be of intrapulmonary or intra- pleural origin. The time is not long past when all rales RALES. 55 were supposed to be of intrapulmonary origin, but the labors of Learning in this country and of Walshe and Sir Andrew Clark in England, have demonstrated beyond doubt that rales are produced within the pleurae, and have even led us to doubt if crepitant and subcrepitant rales are ever of intrapulmonary origin. Besides sounds that are produced either within the lung or pleurse there are others — friction sounds, which have their origin in the pleurse, and have the quality of grazing, rub- bing, grating, creaking, or rumbling, most in- tense in inspiration, single, continuous, or divided and jerking, lasting for a considerable time, or changing from hour to hour. The grazing is only heard at the commencement of pleurisy when the membrane becomes dry. Later, when the epithelium has fallen off and the surface becomes roughened, rubbing or grating sounds are heard, and may occur not only early but after the morbid condition has continued for some time. Usually not before the disease has become chronic, are creaking, rumbling sounds heard. The creaking re- sembles that produced by new leather, and 56 DISEASES OF THE HEART AND LUNGS, may also originate within the lung from the wall of a chronically thickened bronchus or a cavity in the lung tissue. We can judge some- what of the age of the adhesions by the char- acter of the rales. With a slight exudation of delicate plastic material we may only obtain a few fine rales which are heard with difficulty, or with an abundance of exudation we have a shower of crepitant rales. When the adhesions are not so delicate we have subcrepitant rales. When the adhesions are old and firm we may obtain dry, coarse rales, and the creaking already described. With meshes of plastic matter infiltrated with serum we have moist, coarse, and gurgling rales. When these r^les are produced in the pleura immediately over a cavity in the proper acoustic condition, they may become metallic in quality and Increased in Intensity by the cavity acting as a resonator. Rales due to adhesions between the surfaces of the pleura are most apt to occur at the end of inspiration ; when due to plastic exudation, they are most often heard towards the middle or end of inspiration, but may also occur with expiration. RALES. 57 Adventitious Sounds in the Chest Wall. — The muscular action going on in the chest wall gives rise in some persons to a peculiar buzzing sound called muscular sussurus. Its amount does not seem to depend upon the muscularity of the individual. It is increased by exertion, is continuous, and seems rather augmented in intensity when the breath is held. It may be removed over most parts of the chest by relaxing the muscles. Rales are sometimes produced by pressing the stethoscope against hair on the surface, or by emphysematous or oedematous subcutane- ous tissue, or we may be deceived by the crepitus of a fractured rib. The sounds pro- duced by the swallowing of saliva, by intestinal borborygmi, or the metallic tinkling sometimes heard over a stomach containing gas and fluid, and transmitted to the ear through the lungs, will, with a little care, be readily traced to their proper source. Facts and Theories in Regard to the Origin of Rales. — A lengthy consideration of the origin of rales would be out of place in this work, but on account of its interest and im- 58 DISEASES OF THE HEART AND LUNGS. portance the subject may be briefly con- sidered. It is difficult to draw a sharply defined line between facts and theories. We may draw logical conclusions from a group of facts which will be accepted by every candid mind ; we may, on the other hand, draw conclusions which are nothing^ more than the wildest theories. We cannot listen to rales and then view the site of their production, and even in those cases where we obtain a post-mortem examination a short time " after auscultation our observations may seem equally to support conflicting views. Sibilant and sonorous rales, it is generally conceded, are produced by diminution in the calibre of the larger bronchi, either by the presence of viscid mucus or some other obstruction. Coarse or mucous rales and gurgling rales, it is also conceded, are pro- duced in the larger bronchi by the passage of air through a more or less fluid secretion, but it is also claimed that rales identical in charac- ter are of intrapleural origin. Crepitant and subcrepitant rales were generally supposed to be produced within the lung, but it is now be- RALES. 59 lieved by many of the best auscultators that rales similar, if not identical, in character are of intrapleural origin, and some believe that they are always so. Reasoning from analogy, the subcrepltant rales are believed to have their origin in the smaller bronchi in the same way that coarse rales are produced in the larger, by the passage of air through secretion, and experimenters have demonstrated that by injecting liquids into the bronchi, rales are produced. Still reasoning from analogy, it is believed that crepitant rales, being smaller than coarse or subcrepitant rales, are produced by the pas- sage of air through exudation in the air-cells, and also probably in the terminal bronchi. Some authors claim that the exudation must be aqueous or serous, and that a mucilaginous mixture will not produce the rales ; others say that they are only produced by a mucilaginous exudation, and both sides bring forward ex- periments and arguments in support of their views. Another view is that the air-cells collapse during expiration, and during inspira- tion the sudden separation of their aggluti- 6o DISEASES OF THE HEART AND LUNGS, nated walls produces rales, and It is argued that a similar sound is produced by pulling apart two" fingers previously gummed together by their palmar surfaces, by applying the tongue to and gradually detaching it from the roof of the mouth, or by inflating the collapsed lungs in the dead body, the walls of the alveoli be- ing in contact after death. ^ A third view is that the rales are produced in the parenchyma of the lung itself by the sudden and forcible expansion of the pulmonary tissue glued to- gether by the viscid exudation with which it is infiltrated.^ In support of this latter view are urged the usual dryness and sharpness of the sound, its resemblance to the minute rup- ture of tissues, and the absence of bubbling character ; its occasional presence throughout inspiration, and sometimes only at its close, according as infiltration of the viscid exuda- tion more or less prevents expansion of the vesicles. We can readily understanci, too, why this rale should usually occur in inspiration, as the rapid expansion would be more apt to ' Guttmann : " Physical Diagnosis," New York, 1880. ■^ " Diseases of the Lungs," Walshe, 4th edition. RALES. 6i produce It than the comparatively slow and passive contraction. A fourth view is that both subcrepitant and crepitant rales are pro- duced within the pleura, and that coarse and gurgling- rales are produced both in the bron- chi and in the pleura. Many of the arguments urged in favor of the production of rales in the parenchyma of the lung apply equally to their origin within the pleura. The stretching of pleuritic adhe- sions or the friction of two plastic surfaces might readily produce the same sounds as the expansion of lung tissue infiltrated with exu- dation ; and we can easily understand why the rales would more commonly occur in inspira- tion when the adhesions would be put on the stretch or when the plastic material would be subjected to the most pressure ; in fact, all the conditions for producing rales are more favor- able in the pleura than in the lung tissue. Many cases are on record in which rales, crepitant, subcrepitant, coarse, and gurgling, were heard a short time before death, and on post-mortem examination pleuritic exudation was found in the same situation, while the 62 DISEASES OF THE HEART AND LUNGS, lung beneath, in some cases, was not diseased, and in others was consolidated, so that no air could have entered the lung in the neighbor- hood where the rales were heard/ Carefully recorded cases do not disprove this view. The cases recorded by Laennec ^ and by Louis ^ show that crepitant and subcrepitant rales were only heard over the site of pleuritic adhesions. In opposition to the view that crepitant and subcrepitant rales are produced in the smaller bronchi and the air-vesicles, it may be urged that it would be necessary for the respiration to have considerable force in these situations, or at least that a current of air must pass in and out with each respiration. But physiology teaches that this does not occur. The change that takes place in the air in the air-cells and smaller bronchi is not by currents of foul air passing out in expiration and currents of fresh ^ " Primitive Dry Pleurisies," Sir Andrew Clark, Lancet, April ii, 1885. " Diseases of the Chest," Learning, N. Y., 1887. " Diseases of the Lungs," Walshe, 4th ed., p. 120. " Pathological Anatomy," Delafield, p. 31. ■^ Laennec on " The Chest." ^ Louis on " Phthisis." RALES. 63 air passing In with Inspiration, but the change is governed by the well-known law of the dif- fusion of gases. "• By diffusion," says Foster,^ '' the new or tidal air gives up Its oxygen to and takes car- bonic acid from the old or stationary air. In this way, by the ebb and flow of the tidal air, and by diffusion between it and the stationary air, the air In the lungs is being constantly renewed." That such Is the case is evident from the fact that only about one tenth of the air in the lungs is changed in each respiration. When one lung is crippled by disease the other lung does extra work, as is evidenced by harsh respiratory murmur over the unaffected side, and the diseased lung receives less air than usual at each respiration. And yet it is over such a lung, receiving a small amount of air, and In which there can be little or no current in the smaller bronchi and air-vesicles, that crepitant and subcrepitant rales are often heard. That rales may arise from the sudden separation of the cohering walls of the air-cells * Foster, "Physiology," London, 1887, p. 219. 64 DISEASES OF THE HEART AND LUNGS. is contrary to the teachings of physiology. The air-cells do not collapse in expiration ; nine tenths of the air in the lungs at the end of inspiration remains at the end of expiration. That rales may arise in air-cells partially filled with exudation by the separation of their ad- hering sides seems more probable. But it must be remembered that little air enters the parts of the lung where the exudation has taken place ; there can be little or no current ; the lung is crippled, and expansion and con- traction take place to a very limited extent. If, however, the current of air were sufficient to produce these fine rales, there would be no reason why they should not be heard in expi- ration as well as in inspiration, as the air that would pass through the fluid in inspiration would have to pass through it again in expi- ration. Rales which we know are produced by air passing through fluid are heard both in inspiration and expiration. These fine rdles, however, are rarely heard in expiration. The fact that similar rales may be produced by injecting liquids into the bronchi only proves that certain sounds may be generated under RALES. 65 certain conditions, and is nothing more than presumptive evidence. Crepitant rales are produced by throwing salt into the fire, or by rolling a lock of hair between the fingers. The view that the seat of the finer rales is in the smaller bronchi and air-vesicles is open to grave objection ; that their seat is in the parenchyma of the lung or in the pleura is much more plausible, and the knowledge that we have lately gained of the physical signs of pleuritic exudation would seem to point to the pleura as the frequent if not the only seat of crepitant and subcrepitant rales, as well as a sharer with the bronchi in the production of coarse and gurgling rales. SECTION III. ACUTE BRONCHITIS. Percussion — Normal. Auscultation. — Owing to the limited area involved, or the large size of the tubes, bron- chitis may run its course without any physical signs. The only auscultatory sign may be a slight harshness of the bronchial element of the respiration, or it may be harsh, loud, and raised in pitch. With the dry stage sibilant and sonorous rdles may be heard, and with the presence of secretion coarse and gurgling rales, the sibilant and sonorous rales either remaining or disappearing. The rales are distant from the ear, and disappear or change position on coughing. They may be few or so abundant as to mask the respiration. CHRONIC BRONCHITIS. The conditions usually described under this title vary from simple bronchitic lesions to 66 CAPILLARY BRONCHITIS. 6/ those In which the peribronchial and pul- monary tissues, are involved, or the bronchi themselves dilated (bronchiectasis). Percussion. — Percussion is normal, or if the peribronchial tissue is sufficiently implicated the pitch is raised. A dilated bronchus gives the same percussion note as a phthisical cavity. Auscultation. — We have the same signs as in acute bronchitis, namely, harsh respiration, sometimes approaching bronchial ; sibilant, sonorous, coarse, and gurgling rales, the rales being few or abundant, more or less distant from the ear, and changing position on cough- ing. The respiration maybe feeble, and creak- ing, leathery sounds may be heard from the thickened bronchi. A dilated bronchus gives the physical signs of a cavity, and the differ- ential diagnosis from a phthisical cavity is rarely possible from the physical signs alone. CAPILLARY BRONCHITIS. Percussion. — No r mal. Auscultation. — Subcrepitant rales on in- spiration and expiration. If the views in regard to the intrapleural 68 DISEASES OF THE HEART AND LUNGS. origin of rales discussed in an earlier part of this work are accepted, then the subcrepitant rale can no longer be considered a sign of capillary bronchitis, but of the presence of pleuritic exudation. LOBAR PNEUMONIA. First Stage or Stage of Engorgement. Inspection. — Movement on the affected side is diminished. At first the sputa are frothy mucus, which floats on the surface of water. Later it becomes viscid and so tenacious that it adheres to the bottom of the vessel contain- ing it. The sputa may be tinged with blood and be brick-dust color or very dark and prune- juice color. The sputum is often character- istic. Percussion. — The percussion note is raised in pitch, the variation in the pitch depending upon the extent of lung involved and its dis- tance from the periphery. Auscultation. — The vesicular element of the respiration is muffled ; the bronchial element slightly exaggerated. Crepitant rales are often LOBAR PNEUMONIA. 69 heard with inspiration in this stage. They are signs of pleuritic exudation. Second Stage or Stage of Consolidation. Inspection. — Expansion diminished on the affected side. Palpation. — Vocal fremitus increased or occasionally, with extensive consolidation, diminished. Percussion. — Dulness more or less marked, according to the extent of lung involved and its nearness to the periphery. If the consoli- dation be distant from the surface, with healthy lung tissue lying between, little or no dulness is perceptible. Auscultation. — Bronchial breathing and bronchophony. The more complete the con- solidation, the more marked are the physical signs. The heart sounds are also conveyed with increased intensity. If the consolidation is separated from the chest wall by healthy lung tissue and the area of consolidation is small, bronchial breathing and bronchophony may not be heard, but the vesicular element of the respiration will be feeble. 70 DISEASES OF THE HEART AND LUNGS. Third Stage or Stage of Resolution. At first the signs are the same as in the preceding stage. Percussion. — Dulness, gradually decreasing. A considerable time often elapses before the percussion note becomes normal, especially with extensive pleuritic exudation. Auscultation. — A gradual change takes place from bronchial to harsh, and finally to nor- mal respiration and bronchophony disappears. The Crepitant rale or the "• rale redux " is often heard in this stage. It is a sign of pleurisy. Coarse rales are more or less abundant. LOBULAR PNEUMONIA. The consolidation of lobular pneumonia if extensive enough produces the same physical signs as lobar pneumonia — namely, dulness on percussion, and on auscultation harsh or bron- chial respiration, with increased vocal reso- nance or bronchophony and increased vocal fremitus. The pneumonia is usually accom- panied by bronchitis with both fine and coarse rales. The areas of consolidation may be so small and disseminated as to give no appre- PLEURISY. 71 clable physical signs. If there is accompany- ing emphysema, increased pulmonary reso- nance may be present over the upper part of the chest. PLEURISY. Pleurisy with the Exudation of Fibrin. Inspection. — Early in the disease, with dry- ness of the pleural surface, inspection shows a diminution in the respiratory movements, especially over the affected side, and with the appearance of plastic exudation the diminution is more marked. Percussion. — Pulmonary resonance or dul- ness. When the exudation is thin the pitch of the percussion note is only slightly in- creased. With a thick layer of plastic exu- dation the dulness is marked. Auscultation. — With dryness of the pleural surface the respiratory murmur is feeble, muf- fled, and jerky, with occasionally a friction sound, and with the appearance of exudation a friction sound is frequently present. A vari- ety of rales, crepitant, subcrepitant, coarse, 72 DISEASES OF THE HEART AND LUNGS. and gurgling, are heard directly under the ear. They may all, or only one variety of rale, be present in the same case. If the pleurisy is diaphragmatic or mediastinal, the rales are more distant from the ear or not heard at all. If the adhesions are between the peri- cardium and the lung or chest wall, the rales may be synchronous with the movements of the heart and heard when the breath is held. With no motion of the affected side rales are absent. Vocal resonance may be increased or diminished. The plastic exudation may be almost imme- diately re-absorbed ; or the adhesions become firmer, the lung is bound to the chest wall or the mediastinum, the pericardium adheres to the lung, the heart becomes displaced, and functional murmurs may arise and lead to error in diagnosis. A variety of fine, coarse, dry, moist, crackling r^les and creaking may be heard, or the lung may be so firmly bound to the chest wall as to allow little stretching of adhesions and rales will be absent and respiration feeble. Expiration may be pro- longed. PLEURISY. 73 Pleurisy with Effusion. Pleurisy may run its course with or without the production of fluid. Inspection. — Motion over the affected side is restrained, with bulging of the intercostal spaces. Mensuration. — The affected side is enlarged. Palpation. — Absence of vocal fremitus over the fluid. Percussion. — Over the fluid, flatness ; at the level of the fluid, dulness ; over the lung, pul- monary resonance, tympanitic in character. If the effusion is moderate in quantity, and not confined by adhesions, the line of dulness is curved, being lowest next to the spine, highest in the axillary region, and lower towards the sternum. If the effusion of fluid is large, flatness is observed over the whole of the affected side. If there is compression without hepatization of the lung, a decided clearness of the percussion note is noticeable at the end of inspiration (Da Costa). Auscultation. — Over the fluid the respiratory and voice sounds and vocal fremitus are ab- sent, ^gophony may be heard at the level 74 DISEASES OF THE HEART AMD LUNGS. of the fluid. Above the fluid and over the compressed lung we have harsh respiration, or bronchial breathing and bronchophony. The bronchial breathing and bronchophony are dis- tant, muffled, and non-metallic in character. If the effusion is large, no sounds are heard except at the apex, under the clavicle, and by the side of the spine. If the layer of fluid is thin and the lung bound to the chest wall by loose adhesions, the respiratory and voice sounds are heard over the fluid, but are feeble and distant. The respiration over the unaf- fected side is exaggerated. With change of position the level of the fluid is changed un- less it is confined by adhesions. The heart is displaced if the effusion is considerable, to the right if the effusion is on the left side, and vice versa. When absorption of the fluid occurs the bulging of the affected side gradually disap- pears. The percussion note slowly becomes normal, but dulness may remain permanently if the pleura is much thickened or if the con- densation of the lung tissue remains. The respiratory and voice sounds, at first feeble, HYDROTHORAX. 75 become more distinct, and when the surfaces of the pleura come in contact a friction sound is heard, crepitating or creaking in character. EMPYEMA. The physical signs are the same as in pleurisy with effusion, namely, enlargement over the affected side and bulging of the intercostal spaces, flatness over and dulness at the level of the fluid, and pulmonary or tympanitic resonance above, absence of voice and breath sounds over the fluid, bronchial breathing and bronchophony or harsh respiration over the lung, and sometimes aegophony at the level of the fluid. If the effusion, is abundant it may pulsate with the movements of the heart, — -pulsating emphysema. Puncture by the hypodermic nee- dle demonstrates the presence of pus. HYDROTHORAX. Hydrothorax is an accumulation of fluid in the pleural cavity. It is bilateral, although more fluid may be on one side than on the other. The physical signs are the same 76 DISEASES OF THE HEART AND LUNGS. as in pleurisy with effusion and empyema. The level of the fluid is changed by altering the position of the patient, which is not always the case in the last two diseases, owing to the presence of plastic matter. HYDROPNEUMOTHORAX. Hydropneumothorax is an accumulation of air and fluid In the pleural jcavlty. Inspection. — Distention of the affected side, and bulging of the intercostal spaces. Absence of respiratory movements. Palpation. — Absence of vocal fremitus. Percussio7i. — Flatness below, and tympanitic resonance above, the level of the fluid. Auscultation. — Below the level of the fluid, absence of breath and voice sounds. If the layer of fluid Is thin, the compression and dis- placement of the lung being prevented by adhesions, feeble respiratory and vocal sounds may be heard. Above the level of the fluid, amphoric respiration and voice and metallic tinkling are usually present. The amphoric sounds and metallic tinkling may be heard together, or either may occur alone and at PNE UMO THORA X. // different times in the same case. They denote an opening from the lung into the pleural cavity, and the intensity and pitch vary con- siderably with the tension of the chest walls and of the contained air and with the size of the opening. Succussion. — By resting the ear upon the chest and abruptly shaking the patient, we hear a metallic, splashing sound, which is the characteristic sign of the disease. PNEUMOTHORAX. Pneumothorax is an accumulation of air in the pleural cavity. Inspection. — Distention of the affected side, and immobility during respiration. Palpation. — Vocal fremitus feeble or sup- pressed. Percussion. — Tympanitic resonance. The pitch varies with the amount of air, the ten- sion of the walls of the cavity, and the com- pression of the contained air, the resonance sometimes being metallic or amphoric in character. Auscultation. — Respiratory and voice sounds 78 DISEASES OF THE HEART AND LUNGS. are suppressed if the amount of air in the pleural cavity is large, but may be feebly heard if the amount is small. The heart sounds are obscurely transmitted. With an opening in the pulmonary pleura allowing the air to pass in and out, amphoric or cavernous respiration is heard. EMPHYSEMA. Inspection. — When vesicular emphysema is not extensive nor far advanced, no change or only a slight bulging is observable. In ad- vanced cases bulging occurs above and below the clavicles, with prominence of the intercos- tal spaces, giving the chest the characteristic round or "barrel-shaped" appearance, while the lower part of the thorax is drawn in. The chest has somewhat the appearance that it has normally at the end of a full inspiration, and expansion and contraction are scarcely per- ceptible, while inspiration is labored, chiefly abdominal, the lower part of the thorax being drawn in instead of expanded with each in- spiration. In some well marked cases, more especially in old people, the lung is atrophied and no projection of the chest wall is observed. ASTHMA. 79 Palpation. — Vocal fremitus Is increased, di- minished, or unchanged. The apex beat of the heart may be absent or lower than normal. Percussion. — The pulmonary quality of the percussion note is diminished and more or less tympanitic. It has been called vesico-tym- panitic. The pitch may be raised or lowered, and depends upon the condition of the lung and degree of distension and tension of the chest wall. The percussion notes differ slightly at the extremes of respiration. Auscultation. — Expiration is prolonged usu- ally to a marked degree ; inspiration is short- ened or even suppressed, the pitch of both being lower than in health. Respiratory sounds are feeble. In some cases the bronchial ele- ment of the inspiration is exaggerated and we have harsh respiration. Vocal resonance is unchanged, increased, or diminished. The heart sounds are feeble, and in general and advanced emphysema the organ itself is pushed downward. ASTHMA. Between the paroxysms either the physical signs are normal, or those of emphysema or bronchitis, or of both are present. So DISEASES OF THE HEART AND LUNGS, Inspection. — ^During the paroxysm the chest is distended in a condition of extreme inspira- tion, and the respiration is labored, with little change in the size of the thorax during the respiratory acts. The respirations are pro- longed, so that only about half the normal number occur per minute. Palpation. — Vocal fremitus normal. Percussion. — Normal or exaggerated pulmo- nary resonance. Auscultation. — The respiratory murmur is jerking or irregular. The vesicular element is feeble or suppressed ; the bronchial element usually feeble or suppressed, but in some cases exaggerated. Sibilant and sonorous rales of varying intensity, pitch, and quality, are heard all over the chest and sometimes even at a distance. Coarse, moist rales of bron- chitis or pleurisy may be present. PULMONARY (EDEMA. Inspection. — Respiration labored. Palpation. — Vocal fremitus may be slightly increased. Percussion. — With a small amount of serum HEMOPTYSIS. 8 1 in the lung little or no dulness is observed, but if the infiltration is considerable dulness becomes marked. Auscultation. — The vesicular element of the respiratory murmur is feeble or absent. The bronchial element is either feeble or harsh. Coarse, moist rales are heard, and often crepi- tant rales. Crepitant rales are usually given as a sign of pulmonary oedema, but if their origin is ad- mitted to be in the pleura, they can no longer be recognized as a sign of this condition. Their occurrence is easily accounted for by the fact that pleuritic exudation is a frequent accompaniment of oedema of the lungs. HAEMOPTYSIS. Haemoptysis is not a disease, but a symptom of disease, and accompanies many different conditions. In the great majority of cases it is due to a weakening or loss of tonicity in the walls of the blood-vessels of the bronchi or to their rupture, which allows the blood to pass through, sometimes in considerable quantities. By some interference with the 82 DISEASES OF THE HEART AND LUNGS, circulation, such as occurs in phthisis or cardiac disease, the vessels are unduly filled and the blood is forced through the bronchial walls. Sometimes breaking down of lung tissue and actual rupture of large blood- vessels occur. The blood expectorated may be bright red or dark in color. After having lain for a considerable period in the bronchial tubes or in cavities in the lungs before being expectorated it is frequently dark-colored or almost black. On auscultation large and small bubbling rales may often be heard. Bleeding may occur from other parts and lead us to suppose that it is from the lungs. When it comes from the mouth, throat, or nose, the fact can usually be determined by examining those parts. The blood from. the posterior nares is generally in clots and dark- colored, and unaccompanied by cough. If it be from the stomach, it is vomited, has an acid smell, and is commonly dark-colored ; in this case the nausea and vomiting precede the hemorrhage. If in bleeding from the lungs nausea and vomiting occur, they come after the hemorrhage has commenced. PULMONARY PHTHISIS. 83 PULMONARY CONGESTION. Many authors assert that pulmonary con- gestion cannot be recognized by physical signs. Percussion. — The pitch of the normal per- cussion note is lowered. Auscultation. — The vesicular element of the respiration is feeble and muffled. The bron- chial element is of raised pitch and decreased intensity. ACUTE MILIARY TUBERCULOSIS. Miliary tubercles may be present in the lungs even in considerable abundance without giving any physical signs, and it then becomes necessary to make our diagnosis by other means. In some cases, however, in addition to the symptoms the percussion note Is low- ered in pitch, and on auscultation the vesicu- lar element of the respiration is feeble and the bronchial element harsh. PULMONARY PHTHISIS. In no disease is a careful consideration of the history of the patient of more Importance 84 DISEASES OF THE HEART AND LUNGS. to enable us to arrive at a correct interpreta- tion of the physical signs. The modern classification of phthisis into fibroid, catarrhal, and tubercular has with most authors superseded the old view that all phthisis is tubercular. In many cases, in what- ever way the initial stage began we find later the three conditions of catarrh, of fibroid indu- ration, and of tuberculous deposits existing together. The physical signs of fibroid phthisis in its earlier manifestations are the same as in chronic bronchitis and pleurisy with thickened pleura and pleuritic adhesions. Later, fibroid induration of lung tissue, the presence of caseous masses, their softening and the forma- tion of cavities give the same physical signs as the other forms of phthisis. For purposes of physical diagnosis it is con- venient to consider cases of phthisis in three groups : 1. Those in which the disease first gives evidence of its presence by physical signs. 2. Those in which the disease has advanced to well marked consolidation or softening. PULMONARY PHTHISIS. 85 3. Those In which cavities exist. I. Inspection In the first group gives little In- formation. In the majority of cases phthisis begins at the apex. The supra- and Infra- clavicular regions are unchanged or slightly flattened, unless the consolidation Is consider- able. Marked flattening with slight consolida- tion is evidence of the presence of pleuritic adhesions. Expansion on the affected side Is noticeably Interfered with early In the case. The lack of expansion is a more valuable sign in females than in males, it being naturally more limited In the latter under the clavicles. The slight and momentary elevations of skin produced in some persons by a sharp tap on the chest wall, and known as myoidema, are seen not only with phthisis but In other condi- tions as well. Palpation. — Sometimes we notice lack of expansion best by palpation. Vocal fremitus Is increased to a trifling degree, usually more noticeably In men than in women. Remem- ber that vocal fremitus is normally more marked under the right than under the left clavicle. 86 DISEASES OF THE HEART AND LUNGS. Percussion. — Slight dulness and increased resistance to the percussing finger at either apex are valuable signs. These signs are im- portant either behind or in front in the supra- and infra-clavicular regions, where they are more commonly observed on account of the comparative thinness of the chest wall, and the dulness is earliest noticed at the inner third of the latter. Recollect that the percussion note Is relatively somewhat duller under the right clavicle than on the opposite side in the nor- mal chest, and also that deformity, or any po- sition of the patient which destroys the sym- metry of the two sides, affects the percussion note. Lateral curvature of the spine produces dulness on the side towards which it is directed. Slight dulness is a more valuable sign in the female than in the male. Localized pulmonary emphysema sometimes gives us Increased pul- monary resonance over the affected portion of the lung. Auscultation. — The results obtained by aus- cultation vary widely In different cases. Changes In the respiration In the suprascapu- lar region or above or below the clavicle, and PULMONARY PHTHISIS. 8/ not extending downward for any considerable distance, are often of more importance than corresponding changes over other regions. In commencing phthisis the vesicular element of the respiration is feeble ; the bronchial is feeble or almost suppressed, or harsh, raised in pitch, and heard with considerable intensity in inspiration and with less intensity and lower pitch in expiration, or both the pitch and in- tensity may be increased in expiration. The degree of harshness varies within wide limits from a slight change from normal respiration to extreme harshness approaching bronchial breathing. In the latter case expiration is harsher and higher-pitched than inspiration, and expiration may be considerably prolonged. The character of the respiration is not the same over wide areas, but in some localities near the apices may be harsh and in others feeble. In forming an opinion the normal difference between the two apices must not be forgotten. Prolonged expiration when accom- panied with change of quality and of pitch is an important sign, but otherwise, more espe- cially under the right clavicle and in women, is ^S DISEASES OP THE HEART AND LUNGS, not of great value. Breezy, wavy, cog-wheeled respiration, when localized and when we can exclude the presence of pleuritic adhesions as a cause, Is a corroborative sign of sorrie value. Vocal and whispering resonance and vocal fremitus are usually Increased, but these signs are somewhat uncertain and their absence is not of much significance. The heart sounds conveyed to the apex with abnormal Intensity, more especially the first sound heard with greater Intensity at the right than at the left apex. Is corroborative evidence of phthisis. Besides the signs of early phthisis, already mentioned, valuable accessory evidence Is often obtained from pneumonia, bronchitis, emphy- sema, and pleurisy, localized at the apex. 2. When the disease becomes more advanced, consolidation occurs over sufficient areas to give well-defined physical signs, and still later the consolidation softens and breaks down. Inspection. — Depression above and below one or both clavicles, becoming In time marked. Increased frequency of the respirations, with less mobility of the chest over the affected parts, more especially at the apices. PULMONARY PHTHISIS. 89 Percussion. — Dulness, often wooden or tubu- lar in character, is marked and widespread, according to the extent of the consolidation. Auscultation. — Small areas of consolidation, separated from the chest wall by healthy or emphysematous lung, will give signs that have already been considered ; but considerable areas of consolidation, extending to the sur- face of the pleura, give bronchial breathing, bronchophony, and bronchial whisper, all vary- ing in intensity in different cases, more es- pecially the latter two signs. Rales are heard, often metallic and high-pitched, moist or dry, and produced either in the pleura or within the lung. 3. After cavities are formed, we have addi- tional physical signs. A small cavity filled with fluid, or even with air, more especially if it be some distance from the surface, cannot invariably be recognized. Inspection. — The signs remain the same as before. Exceptionally there is less depression or even bulging of the chest wall over the cavity, and more marked expansion with the respirations. 90 DISEASES OF THE HEART AND LUNGS. Percussion, — Dulness, tympanitic, amphoric, and cracked-pot resonance. The percussion note varies with the condition of the cavity and of the surrounding parts. If normal lung tissue intervenes between a small cavity and the chest wall, percussion elicits pulmonary resonance, and if the cavity be surrounded by sufficient induration,* or full of fluid, the percus- sion note is dull. Large cavities near the chest wall give tympanitic, amphoric, or cracked- pot resonance. Large cavities with thin walls, more especially if the walls are tense by adhe- rence to the costal pleura, give amphoric res- onance. Cracked-pot resonance is a sign that an open bronchial tube leads into the cavity.^ Attscultation. — Bronchial, cavernous, and amphoric respiration, metallic tinkling, vocal and whispering bronchophony, pectoriloquy, and gurgling rales. ^ A cracked-pot sound is heard over the chest of some children in whom the chest walls are thin and yielding, and the air is therefore easily expelled from the bronchial tubes by percussion. Still more rarely is this possible in adults. Instances are recorded by Walshe of cracked-pot sound heard over consolidation with a small cavity, not larger than a walnut, an inch or two distant ; also over the consolida- tion of pneumonia, and also under the clavicle in cases of pleurisy with effusion. PULMONARY PHTHISIS. 9 1 Bronchial breathing is only heard over small cavities. Cavernous respiration is heard over large or small cavities and amphoric over large cavities, the former when the walls are soft and yielding, the latter when they are tense and unyielding. The pitch varies with the size of the cavity and the tension of its walls. Metallic tinkling is sometimes heard over cavities of large size. Large- or small-sized gurgling rales may be heard over cavities. Rales produced within the pleura are inten- sified by the cavity beneath. Vocal and whispering bronchophony and pectoriloquy are heard over cavities, but vary in intensity, and may be feeble or absent. The heart sounds may be heard with increased intensity over cavities, more especially over those at the apices of the lungs. The determining of the size, form, and condition of cavities} — In some cases, at the 1 It is perhaps sufficient for the general practitioner to be able to recognize the presence of a cavity, and any attempt to go further may be considered by some as an over-refinement in diagnosis, " but is it not rather an attempt at a scientific interrogation of nature in the cause of suffering humanity ? "—Dr. G. P. Cammann's posthumous papers. In my remarks upon cavities, I have borrovi^ed somewhat extensively from a paper by my father published after his death. 92 DISEASES OF THE HEART AND LUNGS. time of the examination the cavity is filled with fluid, and therefore impossible to recog- nize by physical signs, as practically no cavity is there. If, then, the rational signs indicate the presence of a cavity, it will be well either to change the time for seeing the patient from morning to evening or vice versa, or else to cause the patient to change his position long enough to partially or wholly empty the cavity. The size and form of a cavity can be pretty accurately determined by auscultation and per- cussion, or better by auscultatory-percussion. Sometimes several cavities will be connected together, each one having its own character- istic signs. If a bronchus opens into a cavity, empty, with firm, unyielding walls, the respiratory sound will be low-pitched, prolonged, and with a sensible jar from the vibration of its walls. If the cavity contains fluid, as it may If the opening Into the bronchus be above the floor, or even if the opening be in the floor and ex- ceedingly small, the sound will be raised in pitch and the jar of the vibrating walls dimin- ished, while if the opening be in the floor PULMONARY PH THISIS. 93 bubbles will be heard breaking in the cavity, resounding and amphoric in character. If the cavity have flexible walls and be empty, the cavernous respiration will be unaccompanied by the jar of vibrating parietes, will be short, and sometimes have a flapping character. With fluid there will be gurgling, more or less raised in pitch according to the amount of the fluid. If the opening into a cavity be through a bronchus in the side wall, and the bronchus is pervious on both sides, the air will pass through the cavity. If the cavity be empty, with unyielding walls, and surrounded by dense lung tissue, the sound will be loud and blow- ing, with a sensible jar. If the walls be yield- ing and soft the sound will still be blowing, but softer in character and without the jar. With fluid there will be coarse, moist, and gurgling rales, and the blowing will be loud and the jar diminished if the walls are firm ; and if the walls be yielding the blowing will be less loud, softer, and sometimes have a flapping character, while the jar will be absent. We can often gain valuable knowledge from 94 DISEASES OF THE HEART AND LUNGS. change In the position of the patient. If a patient coughs equally In any position we know that he has a cavity or cavities so placed that In whatever position he may be secretion is continually being poured into the bronchial tubes. If he coughs most In the erect position, and Is for a time relieved by reclining, he has a cavity so placed that In the former position it is continually discharging Into the bronchial tubes, while In the latter the cavity ceases to discharge, and until It Is filled to overflowing the patient has rest. If he coughs most when reclining and little when up, the reverse Is the case. If the patient lies on one side and coughs continually In that position, by lying on the opposite side he may obtain rest until the cavity fills to overflowing. If the cough only occurs in the morning after a quiet night the cavity is so situated that it ceases to discharge when he reclines, but when he rises empties itself and then causes more or less cough during the day according to the amount of the secre- tion. If a cavity be partially filled with fluid, we can often determine the position of the opening by changing the position of the patient, PULMONARY PHTHISIS. 95 and so bringing the opening above or below the surface of the fluid, developing in either case the appropriate physical signs. The cough will also be modified by the size of the opening from the cavity, whether it be large or small. In the former the secretion will flow readily, while in the latter some time will elapse before the discharge commences, or perhaps it will have to be forced out by over-distension of the cavity. The consist- ence of the secretion will also affect the ra- pidity of the flow, a thick secretion requiring a larger opening to flow from the cavity with the same rapidity as a thin fluid. We may have more than one opening, so that the air can enter by one while the secretion flows from another. If the cavity have firm walls, the secretion may ov\y flow when the cavity is distended. If the walls be elastic, the action of the lungs upon them may continually empty the cavity. The physical conditions may change from time to time by new openings or new cavities being formed, and by carefully studying these changes we may do much for the comfort of the patient. 96 DISEASES OF THE HEART AND LUNGS. Bacillus of Tuberculosis. — The presence of the bacillus of tuberculosis in the sputa is a valuable aid in diagnosis, and is often the first positive evidence of the presence of phthisis. ATELECTASIS AND PULMONARY COLLAPSE. The lungs are normally in a condition of atelectasis in foetal life. After birth the air may partially or totally fail to enter some of the alveoli. If the condition is acquired after the lung has been fully expanded it is called pulmonary collapse or compression. So small a portion of the lung may be deprived of air, and at the same time be so far removed from the surface of the chest that the condition is not appreciable by physical signs, or we may detect only a slight feebleness or muffling of the respiration. Other cases in which more extensive areas are involved show on inspec- tion lack of expansion and a sinking in of the lower part of the chest with inspiration. Percussion. — Dulness, slight or marked, ac- cording to extent of area involved. If com- pensatory emphysema is developed around the PULMONARY APOPLEXY. 97 collapsed areas, we have the percussion note of emphysema. Atiscttltation,—T\\^ vesicular element of the respiration is feeble or absent, while the bron- chial element is feeble, absent, or harsh, or with considerable areas involved we have bronchial breathing, bronchophony, and in- creased vocal fremitus. Rales due to bron- chitis may be heard. PULMONARY INFARCTION. We may have no physical signs, or the vesic- ular element of the respiration may be feeble, or localized dulness on percussion may occur over the seat of the infarction, and on auscul- tation harsh or bronchial respiration. PULMONARY APOPLEXY. Effusion of a considerable or larore amount of blood from a ruptured pulmonary artery with laceration of the lung tissue. This condition may give no physical signs. With large effusion inspectio7i and palpation give no signs except that vocal fremitus may be decreased. The percussion note may be I 98 DISEASES OF THE HEART AND LUNGS. somewhat dull, and on a^tscultation the breath and voice sounds feeble and muffled over the area corresponding to the extravasation. Moist bronchial rales may be heard. If there be ac- companying pneumonia, appropriate physical signs are developed. PULMONARY GANGRENE. The physical signs are not characteristic. They are those of consolidation over an area more or less extended according as the gan- grene is circumscribed or diffused. Bronchitis and pleurisy may be associated with this con- dition. Later, signs of a cavity appear. CANCER OF THE LUNGS. Any variety of cancer may occur in the lungs. It is usually secondary. The lungs alone may be affected, or disease of the bron- chial glands and tumors of the mediastinum also be present. The endless variety of posi- tion and shape which the cancerous masses may assume cannot be considered in detail. Their pressure upon the nerves, blood-vessels, air passages, organs, and chest wall gives ap- CANCER OF THE LUNGS. 99 proprlate symptoms. The bronchial glands, if enlarged sufficiently, give the physical signs of mediastinal tumors. The miliary form of cancerous growths in the lungs often cannot be recognized. The vesicular element of the respiration may be feeble, and we have the signs of bronchitis. If the growths be nodular, the physical signs will vary with the size, position, and number of the nodules. By inspection, if the growth be con- siderable, the chest may be seen to expand, but not uniformly, and motion over the affected side is diminished or abolished. Vocal fremi- tus may be diminished or absent. The percussion note is more or less dull. On aus- cultation respiratory and voice sounds may be feeble or absent, or bronchial breathing and bronchophony may be heard. The voice sounds, however, vary considerably. The heart sounds may be transmitted with in- creased intensity. By attscttltatory-percttssion, percussion being practised in front and auscul- tation behind, or the reverse, the percussion note will be high-pitched and of great inten- sity, and some idea can be formed of the posi- I(X) DISEASES OF THE HEART AND LUNGS. tion and size of the mass, especially if it touch the chest wall at any point. With cancerous infiltration we have retrac- tion of the affected side. If the pleura be involved a friction sound, or the physical signs of plastic exudation, or fluid in the pleural cavity are present. The signs of a mediastinal tumor are some- what similar to those of masses within the lungs. If it encroaches upon the chest wall local bulging is observed and vocal fremitus is absent, unless the mass lies upon the trachea or a large bronchial tube. If it lies upon the aorta or heart we have a transmitted impulse. The pei^cussion note is usually dull, but we may have the transmitted percussion note of adjacent parts. We may on auscultation hear nothing, or feeble respiratory sounds, or simi- lar sounds to those heard over consolidated lung on account of the mass pressing upon a main bronchus and transmitting bronchial breathing and bronchophony. The heart sounds may be conveyed with great intensity and a murmur produced by pressure upon the aorta or pulmonary artery. By auscultatory' CANCER OF THE LUNGS, lOI percussion the tumor can readily be mapped out if it touch the chest wall, or by auscultating in front or behind and percussing on the opposite side of the chest we can estimate from the intensity and character of the sound the size and position of the tumon THE HEART. SECTION IV. POSITION OF THE HEART. An acquaintance with the positions of differ- ent organs, and the changes in position which they may undergo under varying circumstances in health, is often necessary in order to appre- ciate the presence of morbid conditions. The results obtained from the dissection of frozen bodies have been taken as absolute guides, but Sibson has clearly demonstrated that such re- sults are not applicable to the living body. To describe the heart as occupying one position is a mere expression of a dead anatomy. It is con- tinually changing with its own movements and with each act of respiration, and is differently situated in well and poorly developed chests. Average Position. — Let us now consider one position, which is, as nearly as may be, the mean between extreme variations that the I02 Figure io. SHOWING POSITION OF HEART AND GREAT VESSELS. (qUAIN's "ANATOMY."^ i(j3 104 DISEASES OF THE HEART AND LUNGS. heart occupies in the chest of a well-formed, healthy person, and call this the average posi- tion. The heart lies obliquely within the cavity of the chest, with a general direction from the base downward, forward, and to the left to the apex. Nearly one third lies in the right cavity of the chest or to the right of the median line, and two thirds on the left side. The transverse diameter of the heart in its widest part equals about one half the breadth of the thoracic cavity, and in its antero- posterior diameter occupies most of the space between the sternum and the vertebrae. The upper border lies behind the third left costal cartilage and the sternum at the same level. The apex is situated in the fifth intercostal space, within a vertical line passing through the nipple, or about two and a half Inches from the middle line of the sternum. The right border extends in a curved line from the base to the lower border, reaching at its farthest point to the right about one inch from the edge of the sternum. The lower border of the heart passes from the extremity of the right border behind the sixth right costal Figure ii. SHOWING HEART. GREAT VESSELS, DIAPHRAGM, ETC., EXPOSED. (SIBSON.) 105 I06 DISEASES OF THE HEART AND LUNGS. cartilage near the sternum slightly downward, and to the left behind the ensiform cartilage about a half an inch below the lower end of the sternum, and terminates at the apex, The left border extends from the apex and lies for the greater part behind or to the left of a vertical line passing through the nipple. The base of the heart is formed by the auricles, the right auricle lying behind the sternum between the third costal cartilages and ex- tending downward for a considerable distance to the right of that bone. The appendix of the left auricle lies behind the third left costal cartilage. The right ventricle forms the greater part of the front of the heart and is wedged in as it were between the right auricle which lies to the right, and a little above, and the narrow edge of the left ventricle which forms the left border of the heart ; the right ventricle itself forming the lower border. The only portion of the left ventricle seen from In front Is a narrow strip running from the appendix of the left auricle above to the apex, widest near Its middle behind the fourth inter- costal space, where It Is about one fifth of the Figure 12. sidf view of heart and great vessels. (^sibson.) 107 I08 DISEASES OF THE HEART AND LUNGS. breadth of the heart, and narrowing from this point towards either extremity. When the heart is in the position just de- scribed the mitral orifice lies behind the left half of the sternum, on a level with the fourth cartilage and its intercostal space, the aortic orifice lying behind the left half of the ster- num, on a level with and extending partly into the third intercostal space. The pul- monary orifice lies behind the third left costal cartilage and the adjoining edge of the ster- num, while the tricuspid orifice is behind the right half of the sternum, on a level with the fifth costal cartilage. Jf we consider the valvular orifices with re- gard to the position from before backwards, the tricuspid is found to be farthest in front, or most superficial, the pulmonic is next be- hind, the aortic orifice third in order, and the mitral the farthest back. The aorta at its commencement lies con- cealed in the heart and first comes into view behind the sternum, on a level with the third costal cartilages, its right border lying behind or a little to the left of the right border of the Figure 13. right auricle and ventricle exposed showing valves. (QUAIN'S "anatomy.") 109 no DISEASES OF THE HEART AND LUNGS. Sternum, and its left border, partially over- lapped by the pulmonary artery, lying some- what to the right of the left border of that bone. As it ascends it bears to the right and lies partially behind the second costal cartilage. Figure 14. hase of ventricular part of heart, showing relative position OF THE ARTERIAL AND VENTRICULAR ORIFICES. (QUAIN's "ANATOMY.") 5. TRICUSPID ORIFICE. 6. MITRAL ORIFICE. 7. PULMONIC ORIFICE, 8. AORTIC ORIFICE. ^ Looking at the heart from behind, the lower boundary of the left ventricle is about on a level with the spine of the ninth and the upper part of the body of the tenth dorsal I'lGURE 15. HEART AND VESSELS AS SEEN FROM BEHIND. (SIBSON.) Ill 112 DISEASES OF THE HEART AND LUNGS. vertebrae. The boundary line separating the heart and the great vessels and passing over the upper border of the left auricle lies in front of the spine of the fifth and lower bor- der of the body of the sixth dorsal vertebrae. The mitral orifice is in front of and to the left of the spines of the sixth and seventh and the bodies of the seventh and eighth dorsal verte- brae, or a little above a line joining the Inferior angles of the scapulae. The orifice looks tow- ards the apex of the left ventricle in a direc- tion towards the left, forward, and slightly downward, so that in mitral Incompetence the column of blood Is regurgitated from left to right, backward and slightly upward. Variations i^i the Position of the Heart. — Although the mean position, as it were, has just been described, the heart Is continually changing, and a knowledge of these varia- tions is absolutely necessary to the clinical worker Not only Is the organ Itself moving and changing Its form by its own contractions and relaxations, but the chest Is varying in dimensions with the respiratory acts. During the systole of the ventricles the auricles are THE HEART. II3 distended with blood, while the walls of the ventricles contract and the apex of the heart passes forward, upward, and to the right. Dur- ing diastole the reverse occurs, the auricles shrink while the ventricles become distended, and the apex falls downward, backward, and to the left. The position of the heart in rela- tion to the walls of the chest changes with each respiratory act. With a forced inspira- tion the heart descends with the diaphragm for about an inch, while the anterior and la- teral walls of the chest ascend, so that at the end of inspiration the apex lies behind the seventh costal cartilage, while the base lies on the line of the lower boundary of the third intercostal spaces. At the end of a forced expiration, on the other hand, the apex is often felt in the fourth intercostal space, while the upper boundary of the base lies on a line joining the second intercostal spaces. The impulse of the right ventricle, which at the end of expiration is perceptible to the left of the lower end of the sternum, is at the end of inspiration felt in the epigastrium ; when the respiration is not forced, the cardiac move- 114 DISEASES OF THE HEART AND LUNGS, ments, in both directions, are within narrower limits. In strong, well developed persons leading an active life, the amount of reserve air in the lungs is always considerable, the chest is broad and deep, and the position of the heart with reference to the chest wall is low, or, in other words, the normal position approaches that which the heart naturally assumes at the end of inspiration. On the other hand, in feeble, poorly developed persons, the reserve air in the lungs is small in amount, the chest is narrow and shallow, the diaphragm lies high, and the position of the heart is high, or approaches that naturally occupied at the end of expiration. In women, especially in those who lead a seden- tary life and spend most of the time sewing, the heart is apt to lie high, the apex perhaps being felt in the fourth intercostal space. In those women, too, who wear tight corsets, although the upper part of the chest may be well developed and expand freely, the diaphragm will lie high and the apex be correspondingly elevated. In children the situation of the heart is naturally high. The position varies THE HEART, II5 somewhat in the same individual at different times. Thus after great and prolonged exer- tion, when more blood has passed through the heart, and the lungs have been fully expanded, the heart is relatively low, while, on the other hand, after prolonged rest, when a compara- tively small amount of air has entered the lungs, its position is relatively high. The extent to which the heart is covered by the lungs in front varies greatly not only in different people, but in the same person during respiration. The size of the superficial or un- covered area is in inverse ratio to the size of the lungs. Striking as nearly as may be an av- erage between the extreme boundaries of this superficial cardiac region, the upper boundary may be described as lying behind the fourth left costal cartilage, the right behind the left half of the sternum on a level with the fifth costal cartilages ; passing to the left for about two inches the left boundary is reached. These three sides of the superficial cardiac region are bounded by the lungs ; below lie the dia- phragm, stomach, and liver. Inspection. — The form of the healthy chest Il6 DISEASES OF THE HEART AND LUNGS. is familar to every one. A slight bulging over the cardiac region and depression below are sometimes observed in health. The apex beat may be seen in the fifth interspace, about mid- way between the sternum and a vertical line from the nipple, as a brief, regular raising of the integument over a space not exceeding an Figure i6. cammann's cardiometer. inch square. The lower border of the pecto- ralis major muscle is a guide to the position of the fifth rib. In thin persons the apex beat is distinct, but in the fleshy scarcely perceptible. The position of the apex, however, is variable ; it rises and falls with the respiration ; it changes with the position of the patient, and is raised THE HEART. W/ by a distended stomach or intestines, or by any cause which elevates the diaphragm. In the robust it is low, while in feeble, narrow- chested persons it lies high. When the heart is low the impulse of the right ventricle can be seen in the epigastrium. In disease a bulging over the region of the heart may be caused by hypertrophy, or by fluid in the pericardium. Pericardial adhesions may occasion a drawing in of the chest wall with each apex beat. The apex may be dis- placed upward, downward, or to either side. The causes of such displacement lie in enlarge- ment of the heart itself, in pressure from without, as in the case of abdominal tumors or pleuritic effusion, or in contraction of adhesions. Palpation. — The sense of touch is of more value than sight in physical diagnosis. The apex beat can often be felt in fat persons, or when the heart is acting feebly, when its posi- tion cannot be seen. The impulse, too, may be analyzed and the force measured. At times two impulses can be felt — the one systolic, the other diastolic. The sounds of the heart may Il8 DISEASES OF THE HEART AND LUNGS. be felt — the one a long and dull, the other a short and distinct vibration. '' The motion is due to the play of the valves, and disappears with their destruction." (Da Costa.) The impulse is felt best when the patient is sitting or standing and leaning forward, and its force is temporarily increased by exercise or forced respiration. Digestion or mental emotion have the same effect. In females with large breasts it is often difficult to detect the apex beat. The breast should be raised to allow the fingers more nearly to approach the chest-wall. Hypertrophy increases the force and extent of the beat. In dilatation it is diffused and feeble. Fatty degeneration or a feeble condi- tion of the system weaken the apex beat, as does also a portion of the lung intervening between the apex and the chest wall. With adherent pericardium the impulse may be con- fused and split up, as it were, into several parts. A thrill may be felt at the apex. Percussion. — The general rules applicable to percussion will be found in an earlier part of this work, and need not be repeated. They apply equally to percussion over the heart and over THE BEAR.T. II9 the lungs. The outline of the heart can be detected readily by auscultatory-percussion, if not by percussion. The percussion note over the superficial area of the heart is dull. The shape is irreg- ularly quadrangular. The dimensions of the area vary inversely with the size of the lungs. In fact the variation is so great, not only with the respiration and in different individuals in health, but also in disease of the heart itself and of the lungs, that any attempt to define the boundaries of the space is but an approxi- mation to the truth. The percussion note is lowered in pitch in passing from the liver to the heart. Where the heart is covered by the lungs, is found dulness on percussion. It is best to begin percussing over the lungs and gradually approach the edge of the heart. The percussion note is not at first much raised In pitch, but becomes more and more dull as the superficial area is reached. Sometimes it is impossible to find the border by percussion. Usually the upper border of the heart Is behind the third left costal cartilage, and the lower border below the sternum behind the xiphoid 120 DISEASES OF THE HEART AND LUNGS. appendix. To find the latter by percussion is difficult or impossible, but all that is practically necessary is to find the other three. The right boundary at the level of the fourth rib extends to the right of the sternum about one inch, and the left border behind or to the left of a vertical line through the nipple. If these points and the position of the apex be ascer- tained we can draw a pretty accurate inference as to the size of the heart. The heart in its natural condition Is about equal in size to the closed hand of the individual, and by placing the hand upon the chest it may be made to assume a position closely corresponding to the position of the heart beneath. (Laennec.) Considerable changes In the position of the heart and therefore in the percussion note are compatible with health, as will be seen by referring to the previous pages. To properly appreciate the meaning of the sounds elicited by percussion we must be able to analyze them and to understand the acoustic laws by which they are governed. In every percussion note the acoustic elements termed quality, intensity, pitch, and duration are to be THE HEART. 121 considered. Acoustic laws have been briefly glanced at with auscultation of the lungs, and the remarks there made apply equally to the sounds elicited by percussion and auscultation of the heart. It is sometimes of importance to mark out the area of aortic dulness. This is simply a rounded projection above the heart and con- tinuous with the cardiac dulness. Over the innominate artery scarcely any appreciable change is produced in the percussion note, while over the left carotid and left subclavian arteries no change whatever is perceptible. This is due to what is called the inflection of sound, by which sonorous waves embrace a non-resonant body on all sides and render the dulness of a small one inappreciable. (Balfour.) The area of cardiac dulness may be de- creased in emphysema or by pleuritic adhe- sions binding the lung to the chest wall, or less commonly by atrophy of the heart. In cases of air in the pericardium dulness is dimin- ished or entirely lost and replaced by tym- panitic resonance. The area of dulness is 122 DISEASES OF THE HEART AND LUNGS. Increased by enlargement of the heart, hyper- trophy or dilatation, or by pericardial effusion. In the latter the diilness is triangular or pear-shaped, the base lying below. If the effusion is small the lateral area of dulness Is increased in the upright position over the lower part of the prsecordial region. With considerable fluid the extent of dulness is most increased vertically, while if the effusion is large and is chronic enough to have allowed dilatation of the pericardial sac, the transverse diameter of the dulness is sometimes enor- mously increased. If the pericardium is bound to the chest wall by adhesions, the area of cardiac dulness may be unchanged and the apex remain in the same situation throughout respiration. In hypertrophy of the heart, the dulness is most marked in its length in hyper- trophy of the left ventricle, the apex being displaced downward and to the left, while in hypertrophy of the right ventricle the increase of dulness is greatest laterally. In dilatation the area of dulness is increased most markedly in the horizontal axis of the heart, to the right when the right side is Involved, and to the left A USCUL TA TION. 1 2 3 when the left side Is implicated. Frequently dilatation and hypertrophy occur together. The area of dulness may be increased by con- solidation or contraction of lung over the heart. The absence of pleuritic and peri- cardial adhesions, or at least their non-inter- ference with the free action of the heart and the lungs in the neighborhood, may be deter- mined by the changes in the position of the heart and in the area of superficial dulness during respiration. The heart may be pushed to either side by pleuritic effusion on the opposite side, or drawn to either side or up- ward by the contraction of adhesions between the pleura and pericardium, or between the latter and the chest wall. AUSCULTATION. From the time of Laennec auscultation has been a most valuable aid In diagnosis. Without It many morbid changes now clearly and sharply 'defined would be obscure. In our day the under-estimation of its value need not be apprehended. The tendency is rather to neglect other aids to diagnosis 124 DISEASES OF THE HEART AND LUNGS, without which it is often impossible to have a just appreciation of conditions that we are called upon to treat. Auscultation may be practised with the ear or the stethoscope. A consideration of both methods, of the stetho- scopes to be used, and of other matters apper- taining to the subject will be found under the head of auscultation of the lungs. It seems almost superfluous to say that the sounds heard over the healthy heart, their dura- tion, quality, pitch, and intensity, should be- come thoroughly familiar, and yet the study of the organ in health is constantly neglected. We should hold firmly to those signs only which are fixed exponents of certain conditions, and look with suspicion upon doubtful signs upon which diagnoses are too often based. The correct interpretation of physical signs may often be learned from books, but famili- arity with the signs themselves can only be acquired from the living subject. " To a per- son," says Billing, **who has never heard the sound of a common gong, describe it until he says he thinks he understands it, then let him hear it, and he will tell you that it is very A USCUL TA TION. 1 2 5 unlike what he imagined. Precisely the same would happen to any person who should read about auscultation before applying his ear to a healthy chest. " I n studying the sounds heard over the heart in health and disease, we should continually bear in mind that *' sound is propa- gated according to the same laws, through organic as through inorganic matter, through living as through dead bodies " (Skoda). And by applying these laws, together with the results of observation and experience, it is seldom, indeed, that we cannot arrive at a satisfactory interpretation of physical signs. The Sounds of the Heart. — Two sounds occur with the movements of the heart. The first is prolonged, heavy, and lower- pitched than the second, and synchronous with the systole of the ventricles, the apex beat, and the closure of the auriculo-ven- tricular valves, while the second is short, sharp, and higher-pitched than the first, and synchronous with the diastole of the ventri- cles and the closure of the aortic and the pulmonary valves. It was one of Broussais* pupils who first passed a curved needle through 126 DISEASES OF THE HEART AND LUNGS. a flap of the aortic valve, thus aboHshing the second sound and at the same time estabHsh- ing its cause and the fallacies of a consider- able number of theories upon the subject. Unfortunately it has not been feasible to demonstrate the cause of the first sound in the same way, and as a natural consequence many theories have arisen. It is generally admitted that several elements make up the first sound, and that these are mingled in varied proportions over different points of the cardiac region. Two of these elements are the bruit from the muscular contraction of the cardiac fibres and the closure of the au- riculo-ventricular valves, and another is the blow of the apex against the chest wall. The friction of the blood against the walls of the ventricles and the surfaces of the valves, as well as its impact against the blood in the aorta with each systole, may be another ele- ment. Little attention has been paid to the part that the chordae tendineae play in the pro- duction of the sound, but, without doubt, it is a matter deserving consideration. When the auriculo-ventricular valves close, both they A USCUL TA TION. 1 2 / and their chordae tendinese become tense, and both take a part In the production of sound. It is not improbable that the chordae them- seves are the main producers of sound, and that the valves act chiefly as diaphragms to intensify it. The action of the chordae may be perfectly illustrated by alternately loosen- ing and tightening a piece of ribbon held be- tween the fingers of the two hands. '' A short piece of ribbon by this sudden tension will give out a sharp and distinct sound ; a longer one will yield a sound which is more dull and prolonged " (Dalton). The sounds follow each other in regular succession, with a short interval of silence between the first and the second, and an inter- val about three times as long between the second and the first. Both sounds are heard over the praecordial region, but vary in differ- ent situations. The left side of the heart, on account of its greater muscular power, produces the largest proportion of the first sound, and therefore it is conducted through the chest wall with the greatest intensity at the moment, and at the point that the apex beat of the left 128 DISEASES OF THE HEART AND LUNGS. ventricle occurs. Passing to the right, over the xiphoid appendix, the first sound produced by the right side of the heart is heard, shorter and higher-pitched than that at the left apex. The second sound, produced by the closure of the aortic valves, is heard best over the second right costal cartilage and its intercostal space. The reason of this is that the aorta approaches the chest wall in this situation. The sound produced by the closing of the pulmonary valve may be isolated in the second left inter- costal space next to the sternum ; it is lower in pitch than the aortic second sound. The intensity of the heart sounds and the area over which they are heard vary considerably with the force of the heart's action, with inspiration and expiration, and the conducting power of the surrounding media. They are sometimes tympanitic in quality in the neighborhood of the apex, when the stomach is distended with gas and fluid. In patients excited by an ex- amination, the first sound often has temporarily a high-pitched metallic ring. The normal heart sounds are often conveyed with abnormal intensity over the chest. In A USCUL TA TION. 1 29 children, owing to the vibratile nature of the parietes, they are readily conveyed, and espe- cially over the lower part of the left inter- scapular region ; and similarly is this the case in narrow-chested, thin adults. On the other hand, in deformed chests they are often con- veyed with diminished intensity. The normal heart sounds, when heard over an abnormal area, indicate disease of the lungs, pleura, or aorta. The lungs, filled as they are with air, are poor conductors of vibrations, but when compressed, solidified, or bound to the chest wall by adhesions, they convey sound more readily. Cavities, by acting as resona- tors, may increase the intensity of the heart sounds, the solidified lung tissue by which they are surrounded assisting in the conveyance. Either or both sounds of the heart may be exaggerated. The first sound at the apex is exaggerated, or, more properly speaking, changed in quality, becoming sharp, clear, high-pitched, and of shorter duration in dila- ^ tation of the ventricles. When the dilatation is accompanied by marked thinning of the walls and tissue degeneration, the first sound 9 130 DISEASES OF THE HEART AND LUNGS. becomes feeble and ill-defined, as in other affections which diminish the force of the muscular contraction. In hypertrophy the first sound is prolonged and increased in in- tensity. It may have a ringing, metallic character, and this is sometimes observed in health, when the force of the heart's action is increased. Thickening of the valves, or de- posits on them or on the chordae tendinese or pericardial adhesions, may alter the first sound, even if the changes have not been sufficient to produce murmurs. The second sound over the aortic or pulmonary valves may be accen- tuated by obstruction to the passage of the blood in either artery. In some cases of anaemia the aortic second sound is clear and distinct. When the edge of the valve is thickened, a mufHing of the sound is often noticed before the changes have been sufficient to produce a murmur. Interfnittence and Irregularity of the Heart, — We may have irregularity in the force of the cardiac impulse and irregularity in time. Intermittence is the simplest form of irregu- larity in time. It consists in the omission of A USCUL TA TION. 1 3 1 a pulsation, the next occurring at the usual time, and the cardiac rhythm remaining un- changed. Instead of one pulsation two or three may be omitted, or sometimes one, at others two or three pulsations. These Inter- missions may occur with every second beat or at longer intervals. Irregularity In the time and force of the cardiac pulsations may happen alone or accompanied with intermittence. The intervals between the beats are uncertain and of varying lengths and the beats themselves are of unequal strength. This Irregularity may have a certain regularity about It — that is, the irregularity of one minute may be like the irregularity of the previous minute, or there may be such a combination of irregular inter- missions and unequal pulsations, of forcible and feeble beats, as to resemble the changes of a kaleidoscope, in which every turn produces some new combination. Irregularity and intermittence of the heart's action, and especially intermittence, are often observed In persons having no organic cardiac lesion and who enjoy good health. Intermit- tence may be merely a constitutional peculi- 132 DISEASES OF THE HEART AND LUNGS. arity or a purely nervous phenomenon, excited by strong emotions, by terror, anxiety, pain, or fatigue, and has been known to follow rail- way accidents and shipwreck. It may be pro- duced by indigestion, and this is a frequent cause in children. In such cases it is usually temporary and passes away in a few hours or days. It is sometimes, however, persistent, lasting for weeks or months, or even remaining permanently, but the intervals between the in- termissions will grow longer. Not infrequently iregularity accompanies valvular lesions or gout. Intermittence and even irregularity are not of themselves necessarily signs of serious importance, but with a marked feebleness of the impulse, and especially if the contraction of the ventricle is ineffectual, they are early signs of weakness of the heart, — signs that the weakened left ventricle does not react to the ordinary stimulus of the blood thrown into it by a single contraction of the auricle, but waits until a second or even a third contrac- tion has supplied it with more blood. In such cases it is a sign of valvular disease, more es- pecially of mitral regurgitation, with dilatation, AUSCULTATION. 1 33 degeneration, and loss of tonicity of the mus- cular wall of the ventricle. Intermittence or irregularity in the aged, with a feeble and dif- fused impulse, and atheromatous vessels, indi- cates that an hypertrophied heart has under- gone degenerative changes, is unable to recover power, and may at any moment cease to act. If feebleness of the pulsation has been deter- mined by weakness of the pulse, as well as of the apex beat, you are far advanced towards the diagnosis of degeneration of the heart walls. Do not, however, be too hasty in your conclusions if the apex beat is feeble or imper- ceptible to the touch. Such feebleness may be due to an emphysematous lung overlapping the heart, to thickness of the chest wall, or more rarely to pericardial effusion. Ausculta- tion will enable you to fix the exact spot of the apex beat, if you fail by palpation. In cases of intermittence and irregularity, besides being on the lookout for weakness of the heart's action, observe the effect of exertion. An irregularity merely nervous is scarcely in- fluenced by exercise. The pulse is naturally quickened, but the irregularity is often dimin- 134 DISEASES OF THE HEART AND LUNGS. ished rather than increased. The irregularity due to cardiac disease is notably increased by a slight exertion, such as walking briskly. If exertion causes the patient distress, notice its character. Little or none occurs in irregular- ity from nervous causes, while with cardiac dila- tation or degeneration the distress is marked. The nervous system plays an important part in the production of irregularity, whether in its slightest or most marked manifestations. The ganglia of the heart, which are found scattered over its surface as well as through the muscular walls, are storehouses of nervous energy, and also co-ordinate the cardiac move- ments in accordance with the requirements of the body. The sympathetic system seems to act as an accelerating agency to the ganglia, not only increasing the frequency but the force of the heart's action. The pneumo- gastric, on the other hand, by means of its inferior cardiac branch, slows the heart's action. The superior cardiac branch, passing to the medulla, regulates the movements of the arterioles. When, by a rise in the arterial tension, the heart is oppressed with work, this A USCUL TA TION. 1 3 5 nerve Is thrown into action, and, acting upon the arterioles through the medulla, causes their dilatation, thus lowering the blood pressure and relieving the overburdened heart. Paralysis of the Heart. — In some cases shock or violent emotion, instead of producing irregularity or intermlttence, fatally arrests the heart's action. This probably never oc- curs In perfectly sound persons, but has happened so often with those not known to labor under any cardiac disease as to make it a possible event to any one past middle life. The same result may occur in diph- theria, cerebro-splnal meningitis, typhus fever, and some other diseases. Reduplication of the Heart Sounds is a sub- ject more interesting than important. Instead of a single first sound, we may have two, or two second sounds instead of one ; or In Its rarest form we have four sounds — two first and two second. Usually we have reduplica- tion of one sound, and reduplication of the second Is by far the most common. The most plausible theory of the cause of reduplication of the first sound ascribes It to the non- J 36 DISEASES OF THE HEART AND LUNGS. synchronous contraction of the ventricles. Reduplication of the second sound is due to the closing of the aortic and pulmonary valves at different times. Either valve may close first. Reduplication is sometimes a symptom of disease when it is often perma- nent, but may occur in perfect health, and is then usually inconstant, appearing one mo- ment and disappearing the next. In fact, it is merely an exaggeration of a phenomenon which, if carefully sought for, may be de- tected in every one : reduplication of the first sound occurring at the end of expiration or commencement of inspiration ; reduplication of the second sound occurring at the end of inspiration and the commencement of expira- tion. These normal reduplications depend upon the variations in pressure produced by the respiratory movements at the origin of the arterial and venous systems. Reduplication of the second sound is frequently associated with mitral stenosis and aortic regurgitation. In the former it is due to the pulmonary congestion always present in these cases, which so increases the blood pressure in the A USCUL TA TOR Y-PER C USSION, 1 3 7 pulmonary artery as usually to accentuate and sometimes hasten the closing of the valves and so cause the pulmonic to anticipate the aortic second sound. AUSCULTATORY-PERCUSSION. The method of auscultate ry-percusslon was devised by Dr. G. P. Cammann, and the sub- ject presented to the profession in a care- fully prepared paper by Dr. Cammann and Dr. Clark.^ Auscultatory-percussion is a combination of the methods of auscultation and percussion by auscultating the chest with the ear or the stethoscope at the same time that percussion is practised. Its value hinges upon the fact that, if the percussion note of any organ or of any part of the body is conveyed to the ear through a more or less homogeneous medium, the true quality is better appreciated than If it be conveyed through air. The value of various media for conveying sound differs greatly, but need not here be discussed. If It Is attempted to locate the lower border of the heart by per- ^ New York Quarterly your, of Med. and Surg. ^ J^ly> 1840. 138 DISEASES OF THE HEART AND LUNGS, cussion, Its accomplishment Is difficult for all and impossible for many persons. So similar are the percussion notes of the liver and heart that we are often In doubt as to the line of demarkation. But by auscultatory-percussion, after a little practice, this line Is readily found. Thus it may be demonstrated not only that each organ has Its own percussion note, which differs from the percussion note of every other organ In health, but also that the percussion note of an organ In which morbid changes have occurred differs from that of the same organ In health. This fact will, I think, in the future, lend additional value to aus- cultatory-percussion. The method is useful in mapping out aneurisms of the aorta, in measuring an enlarged spleen when the bor- ders of the liver and spleen are in contact, in measuring the liver In cases of ascites. In de- termining the position of the upper, lower, and outer borders of the kidney, and in disclosing its absence when that organ Is floating, in measuring abdominal tumors, and in locating the heart In pulmonary emphysema, and in pleurisy with effusion, etc. AUSCUL TA TOR Y-PERCUSSION. 1 39 In such cases Its value Is recognized, but I would suggest its usefulness also in detecting changes from the normal percussion note co- incident with morbid changes in the organs themselves. In cases of fatty degeneration of the heart I have found that by auscultatory- percussion the sound conveyed to the ear was duller, and had lost the ringing, metallic char- acter which distinguishes the normal heart. A dilated heart with little or no hypertrophy will also give an altered percussion note, but in the latter case the difference between the percussion notes over the heart and over the lungs is less marked than with a fatty heart. The change in the percussion note in morbid conditions of the liver and kidneys has not been studied very fully. The subject has, however, been sufficiently investigated to lead me to believe that this method may be of value in detecting morbid changes in the liver, and possibly in the kidneys. More attention has been directed to the measurement of the heart than to that of any other organ. For purposes of comparison it is best that all the measurements be made on 140 DISEASES OF THE HEART AND LUNGS. certain fixed lines. The original investigators found it most convenient to find eight points on the border of the heart at the extremities of four diameters. The four diameters are : 1. The. vertical, running to the left of the sternum and the root of the aorta. 2. The transverse, at right angles to the above near its centre. 3. The right oblique, from the right auricle to the apex on a line drawn from the right shoulder to the apex. 4. The left oblique, at right angles to the last named. All the diameters intersect each other at one point near the centre of the heart. Be- tween these eight points the outline of the heart can be readily drawn. In the original investigations these points were first marked on the cadaver. Sharp- pointed steel needles were then inserted, and the external parts removed. Usually the needles passed between the pericardial sac and the heart or just grazed the latter. When the right auricle was distended with blood, the needle at this extremity of the right A USCUL TA TOR Y-PERCUSSION. 1 4 1 oblique diameter frequently passed from one line to half an inch within the border of the heart, on account, probably, of coagulated blood being a poor conductor of sound, and the wall of the auricle being so thin as to have little effect on the percussion note. Having demonstrated the practicability of the method on the cadaver, the heart was next measured in the living subject. Here it was found that the measurement of the diameters in the dead body could not be taken as the standard of comparison for the measurement of those in the living. The reason is obvious ; diastole occupies a longer time than systole, and therefore the measurement will usually be made during diastole. At this time the cavi- ties of the heart are partially or entirely filled with blood ; in the cadaver, on the other hand, it is rarely that all the cavities are equally filled ; one or two may be distended and the others empty. It is found, however, that, although the diameters taken singly are use- less for purposes of comparison, if the sum of the diameters be taken they closely correspond. The average of the sum of the diameters in 142 DISEASES OE THE HEART AND LUNGS. the living adult male from the measurements of a large number of cases is sixteen and five- sixths inches. In practising this method, the stethoscope should be placed next to the skin, and on that part of the chest with which the organ to be examined comes in contact. The percus- sion should be gentle, moving the percussing finger to and fro in the neighborhood of the stethoscope. A strong percussion note soon fatigues and confuses the ear. Better results are attained with than without a pleximeter. The osseous sound from the ribs or the sternum sometimes is a source of embarrass- ment, but may generally be obviated by the use of an oval extremity to the stethoscope, fitting between the ribs. The ordinary bin- aural instrument answers in most cases, or the binaural hydrophone or solid cedar stetho- scope may be used. In comparing the sounds audible by auscul- tatory-percussion, we find that the sound heard over bone is high-pitched, somewhat prolonged, and slightly ringing, and of great intensity, striking the ear with even painful force. That A USCUL TA TOR Y-PERCUSSION. 143 Averages of Sum. lit hJ C>0 CO M M 0^ M _0 '-' mvOOOOO c'mmmmmmmm Averages of Left Oblique Diameter, J 10 OCO c Averages of Transverse Diameter. .5 '-'(N n^ i-i «i» M M J'^mCOmOmmm , a" ci to en -^ c<-) en en c Averages of Vertical Diameter. Averages from Middle of Sternum to Nipple. u5 . d N en rt- rj- tJ- Tt '^ c Averages from Second to Sixth Rib. JO^comOOi-ii-i .cncnrj-TJ-ioxriTfT^ . c Averages from Acromion to Acromion. Cfl' |o .5 M T-llWrJlN |TH'-00C>0>-iO M -fvnvn-i-tncnM fc/3 < ^- iomOOOOO J^ >>< M c^ en •'^ mvo §• .—1 u c4 1> s u l-l t« • J I >H S n c3 (1) G >^ r, (U JJ> ■^3 <3J C _cn Tl V4 Ph OS Tt a f/i ,.^ t/i -. (U S h biO s :3 rt OJ > 15 ■t-i ;-i c3 c3 >, ^ ^ ^ t/! 42 j:: ^ C :i CL,