"WC n\ 'O-l Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseondiagnoOOsahl A TREATISE ON DIAGNOSTIC METHODS OF EXAMINATION BY PROF. DR. HERMANN SAHLI DIRECTOR OF THE MEDICAL CLINIC, UNIVERSITY OF BERN EDITED, WITH ADDITIONS, BY FRANCIS P. KINNICUTT, M.D. PROFESSOR OF CLINICAL MEDICINE AT COLUMBIA UNIVERSITY (COLLEGE OF PHYSICIANS AND SURGEONS), NEW YORK; PHYSICIAN TO THE PRESBYTERIAN HOSPITAL AND NATH'L BOWDITCH POTTER, M.D, VISITING PHYSICIAN TO THE CITY HOSPITAL AND TO THE FRENCH HOSPITAL, NEW YORK Authorized Translation from the Fourth Revised and Enlarged German Edition PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1906 Set up, electrotyped, printed, and copyrighted September 1905. Copyright, 1905, by W. B. Saunders & Company. Reprinted February 1906. ELECTROTYPEO BY PRESS OF WE8T00TT i THOMSON. PHILAOA. "• °- SAUNDERS COMPANY EDITORS' PREFACE. The first edition of Professor Sahli's treatise, " Clinical Methods of Investigation," was published in 1894, and was immediately recognized as a master- work in this field. A second edition appeared in 1899, a third in 1902, and a fourth during the present year (1905). The present translation of the last edition was undertaken to render easily available to English-speaking students of medicine a work too little known in this country and England. The distinguished Swiss Professor has chosen the title " Lehrbuch der klinischen Untersuchungs-Methoden " — a title which inadequately expresses the great scope of the work. Not only are all methods of examination for the purpose of diagnosis exhaustively considered, but the explanation of clinical phenomena is given and discussed from physiological as well as pathological points of view, with a thoroughness which has not been attempted in any clinical work which has yet appeared. Its great value will at once be recognized. It has seemed wise to publish the translation practically as the original came from the pen of its author. A few notes have been added, especially where methods are described which difier from those commonly employed by American and English clinicians. A brief review of the investigations of American and English observers on the value of the clinical estimation of blood-pressure, with the description of some newly devised or modified instruments for this purpose, has been written by Dr. Theodore C. Janeway. We are indebted to Dr. C. P. Flint, of this city, for a considerable part of the labor in translation, also to Drs. Lewis F. Frizzell and H. D. Meeker for assistance in revising the manuscript. For various notes and assistance in special chapters of the book, we are indebted to the following-named gentlemen, whose respective initials will be found at the end of the notes they have added : Prof. Joseph Collins, Professor of Nervous and Mental Diseases at the Post-Graduate Medical School ; Dr. Charles Norris, Instructor in Bacteriology and Hygiene at Columbia University Medical School ; Dr. H. C. Jackson, Assistant Professor of Physiological Chemistry at the University and Bellevue Medical School ; Dr. Arnold Knapj>, Professor of Ophthalmology at Columbia University Medical School ; and Dr. W. Sohier Bryant, Instructor in Diseases of the Ear at the Post-Graduate Medical School. PREFACE TO THE FOURTH EDITION. An idea of the entire contents of the present edition is best obtained by consulting the systematic table of contents on page 15. The bringing out of new editions is very much like keeping a large building in good condition — -no sooner have a certain number of repairs been completed so that the agent congratulates himself on getting a little rest, than he is obliged to begin again. After so many changes had been found necessary in former editions, it was my intention to bring out the present (fourth) edition without much alteration or addi- tion ; but this intention I was forced to abandon. As in preceding editions, I have again endeavored to lay equal stress on all the various branches of internal medicine : for I hold that all specialization in internal medicine, aside from those branches which must necessarily remain separate on account of the special surgical technic which they demand, is unjustifiable and destructive of that symmetry which should be an essential feature of medical education. Aside from numerous minor changes in subject-matter and arrange- ment, I may mention the most important additions by which I have endeavored to increase the value of the book. The section on sphygmography contains a full account of the changes made by Jaquet as well as myself in the older Jaquet sphygmograph. These modifications correct the excessive vibration of the instrument and, I may venture to say, render it in every way satisfactory. In the chapter on sphygmomanometry a new clinical pocket-manometer of my own is described. In the section on the venous pulse, mention is made of Volhard's recent work and his method of determining the phases of the venous pulse. Numerous other changes and additions in the chap- ter on physical diagnosis I shall pass over without mentioning. Much has been added also to the paragraphs relating to the examination of the digestive apparatus. I may mention, for example, Reissner's improve- ment of Liitke-Martius's method of determining the hydrochloric acid in the gastric juice ; Reissner's method of determining the chlorids for the early diagnosis of cancer of the stomach ; an improvement on the Hehner-Malay method of determining acidity ; an improvement of Mett's digestion -test by Nirenstein and Schiff; a refutation of the objections to _my method of butyrometric examination of the stomach, with a few improvements of the method ; certain newer methods for determining the " crude motility " of the stomach and for diagnosing pyloric stenosis ; a description of a special platform, which is both movable and capable of being heated, and is designed for examining feces for amebse, etc. ; and, finally, a table containing the rarer forms of 10 PREFACE TO THE FOURTH EDITION. tapeworm occurring in man. Some of the new features in the chapter on the examination of the urine are : the method of separating the urine ; Seliwanow's reaction for levulose • Bial's method of testing for pentoses ; a discussion of the controversy in regard to the nature of the mucin-like body in the urine ; the quantitative determination of urochrome after Klemperer ; the determination of urea after Schondorff; Hopkin, Folin, and Shaffer's method of determining uric acid ; detailed direc- tions for titrating the urine with phosphates ; and the quantitative determination of indican in the urine. Kjeldahl's method is discussed more in detail than in the preceding editions. Magnus-Levy's investi- gations in regard to oxybutyric acid in the urine are also mentioned at greater length. The important recently published investigations by IMoritz in regard to titration of fluids containing phosphates, particularly urine and gastric juice, are described in an appendix, which also contains a discussion of the question whether the recent attempt to substitute the conception of concentration of the ions of hydrogen for that of the titri- metric acidity is justifiable. Osmotic pressure and the cryoscopy of the urine are discussed at length. In connection with urinary sediments, Liebermann and Posner's methods of staining urinary sediments are described. In the chapter devoted to the bacteriology of the sputum the micro- coccus catarrhalis, as well as the bacillus of plague, anthrax, and glanders, is described. Wanner's investigations in regard to the amount of albu- min contained in the sputum are mentioned. The chapter on the examination of the blood has been thoroughly revised so as to harmo- nize with the results of the most recent investigations. Some of the things are new and mentioned for the first time, such as my hemometer ; Breuer and Turk's cell for counting leukocytes ; Jenner's method of staining ; the volume-quotient of the red blood-cells after Capps ; a discussion of rouleau-formation and the net of fibrin in recent blood preparations ; erythremia or polycythemia ; and, finally, the methods of determining the osmotic pressure and the viscosity of the blood. In the section dealing with the behavior of the blood in infectious diseases, mumps, varicella, and whooping-cough have been added to the list. The chapter on leukemia has been revised in accordance with the more recent books on the subject, and acute myelemia is also discussed in addition to acute lymphatic leukemia. The relation of lymphatic leukemia and the pseudoleukemias to the remaining forms of lymphomatosis is dis- cussed on the basis of Turk's system of lymphomatosis. A new table has been added to the section on hematology. In connection with methods of examination of the upper air passages there wall be found a short account of bronchoscopy. Under the head ()f examination of the esophagus are mentioned Mikulicz's experiments in determining the pressure in the esophagus ; Eumpel's experiment ; and other matters relating to the diagnosis of diffuse dilatations of the esophagus, a sub- ject which has been much discussed in recent literature. In the chapter on exploratory puncture, the controversy in regard to the nature of the mucin-like body found in the fluid obtained by puncture ; the significance PREFACE TO THE FOURTH EDITION. 11 of the chylous nature of that body ; cytodiagnosis (so called) ; and the question of the osmotic pressure of the puncture fluid are discussed. Among the additions in the section devoted to the examination of the nervous system may be mentioned : the expansion of the paragraph on associated movements ; the adoption of an explanation of my own for the intention tremor ; the disturbance of speech and the forced laugh in multiple sclerosis ; the peculiar electrical reactions described by Placzek in certain cases of chronic peripheral palsy of long standing ; the mus- cular atrophy seen in afi'ections of the central motor neuron ; a new scheme of pupillary reaction superseding Bechterew's, which appeared in the last edition and which has shown itself to be inadequate ; Schir- mer's studies in testing the pupillary reaction ; Fragstein and Kempner's pupil-tester for determining hemiopic pupillary rigidity ; v. Bezold's modification of Rinne's experiment, with reference to the Zimmermann- Helmholtz controversy in regard to the significations of the auditory ossicles ; Weber's and Schwabach's experiments ; a chapter on cerebral disturbances of sensation, with special reference to the distinction between cerebral disturbances with an anatomic basis and hysterical hemianesthesia ; sensation in cattle ; and, finally, a chapter on vertigo. The section on aphasia has been remodeled on the basis of a different theory in regard to the speech tract from that adopted in former editions. It is suggested that the expressions " transcortical," " cortical," and " subcortical," which are really incorrect, be replaced by the terms " transcentral," " central," and " subcentral." There has also been added a chapter on certain disturbances allied to aphasia, such as asym- bolia, apraxia, amusia, mental deafness, and mental blindness ; also a chapter on spinal hemiplegia. The description of the functions of the bladder and rectum takes account also of the doctrine of sympathetic centres for the bladder and rectum and ejaculation centres, as described in the more recent work of L. R. Miiller. The neurological section, as well as other portions of the book, has been enriched by a number of new illustrations. Finally, the appendix on the modern methods of analyzing arhythmia of the pulse after Engelmann, Wenkebach, and Hering also contains a number of changes and additions. In spite of these very considerable additions the size of the book has not been greatly increased, as some of the older methods, which were mentioned in former editions but have not stood the test of time, have been eliminated. I received suggestions from various quarters to include a;-ray examination ; but I could not bring myself to do so, because I wish to confine myself to those methods the technic of which I am myself sufficiently familiar with to give personal advice based on my own experience ; and while I do make use of a^-ray examination for the diagnosis of internal diseases, I do not attend to the technic myself, and, therefore, do not consider myself a competent radiologist. Another reason for excluding .r-ray technic in a work like the present, which is intended for the general education of the physician, is that rr-ray exami- nations can only be made by a limited number of practitioners, who, in order to do so, must go through a special training. The same may be 12 PREFACE TO THE FOURTH EDITION. said of cystoscopy. It is true that I practise this method myself, but I have not had sufficient practice and experience to justify the effort to teach it to others. Finally, I cannot refrain from repeating in this place that this work is not a mere compilation. On the contrary, in almost every subject what I have written is based on my experience ; many of the theories advanced and the cases reported are my own, and if they have not been utilized by me for original contributions to the medical journals, it is partly on account of lack of time and partly a personal aversion to hack-writing in medicine. I mention this matter because the present work practically never enjoys the honor of being quoted. I believe an explanation of this is to be found in the tendency which prevails at the present time, and which does not tend to further the symmetrical progress of our science, to make the journals and periodicals the sole depositaries of medical literature, and because it is usually presumed that text-books, aside from the systems which are now so popular and have so many names on their title-pages, are mere compilations and do not contain anything new. It is assumed that if an author had anything important and new to say he would have brought it out on the " bourse " of periodical literature. Personally, I take a different view, and the cor- rectness of my remarks is shown, among other things, by the fact that a well-known author not so very long ago (in the Deutsche medicinische Wochenschrift, Volume 1903, page 716), in speaking of certain sources of error in the auscultation of the lungs, states that among current text- books the present is the only one that devotes a short chapter to this subject, based probably on an address by Treupel delivered in the Yerein der Freiburger Arzte. Thus, without taking the trouble to investigate, the author takes it for granted that a text-book cannot contain any new ideas and observations that have not been published elsewhere. If he had tried to inform himself on the point, he would have found that the chapter in my text-book to which he refers appeared almost in exactly the same form in the first edition in 1894 — /. e., four years earlier than the time when the address to which he refers as being my source wa^^ printed. '^ HERMANN SAHLI. CONTENTS PAGE Introduction » . . . 17 History and Objective Examination ............. 17 General Condition of the Patient 23 Posture in Bed 23 Gait and the Attitude . 27 Development and State of Nutrition 27 Body Weight 28 Configuration of the Thorax 30 Size and Shape of the Head 36 Examination of the Skin 38 Color of the Skin 38 Moisture of the Skin ; Sweat Excretion 47 Swelling and Edema of the Cutaneous and Subcutaneous Tissues . 48 Emphysema of the Skin 52 Cutaneous Hemorrhages 52 Collateral Circulation in the Skin 55 Trophic Affections of the Skin 59 Acute Exanthemata ; Cutaneous Diseases ; Dermatitis Medica- mentosa 59 Other Cutaneous Manifestations Important from the Diagnostic Standpoint 63 Determination of the Body Temperature . 63 The Thermometer 65 Method of Taking the Temperature 65 The Normal Body Temperature 66 Febrile Temperatures 67 Prognostic Significance of High Temperatures 67 The Fever Course 68 Subnormal Temperatures 75 Character of the Respiration 77 Frequency of Respiration under Physiologic Conditions 77 Normal Types of Breathing 77 Pathologic Variations in the Type of Respiration 77 Diaphragm Phenomenon and Allied Appearances (Litten's Sign) . 78 Asymmetric Respiration and Pathologic Inspiratory Retraction of the Chest 79 Abnormalities in Frequency and Rhythm of the Respiration ... 80 Dyspnea 83 Spirometry and Pneumatometry 93 Character of the Voice under Pathologic Conditions ... 94 13 14 CONTENTS PAGE Cough 95 Localized Prominence of the Chest in Coughing '98 Palpation, Sphygmography, and Sphygmometry of the Arte- rial Pulse 98 Palpation of the Pulse 99 Sphygmography 109 Sphygmomanometry (Tonometry) 134 Visible Phenomena of Motion in the Vessels 144 Capillary Pulse . 144 Eespiratory Phenomena of Motion iu the Veins 145 Different Varieties of Venous Pulse 147 Percussion 173 Percussion in General ; Instruments 153 Quality of the Percussion 155 Topographic Percussion 159 Comparative Percussion 197 Auscultation 217 Auscultation in General ; Instruments 217 Auscultation of the Perspiratory Organs 219 Auscultation of the Heart 244 Auscultation of the Vessels 282 Auscultation of the Abdomen 286 Palpation of the Lungs and Pleura 287 Determination of Fluctuation and Changes of Resistance in the Thorax 287 Abnormal Pulsations in the Region of the Lungs and Pleura . . 287 Testing the Vocal (Tactile) Fremitus 288 Inspection and Palpation of the Heart Region (Precordia) . 289 Heart Beat and Apex Beat 289 Other Pulsations in the Precordia and its Keighborhootl .... 299 Palpation of Cardiac Murmurs 301 Inspection and Palpation of the Abdomen 301 Inspection of the Abdomen . 301 Palpation of the Abdomen 304 Diagnosis of Individual Valvular Lesions, of Aortic Aneu- risms, AND OF Pericarditis 314 Foundations of the Pathologic Physiology of Valvular Lesions . . 314 Individual Valvular Lesions 321 Aneurism of the Aorta 345 Pericarditis 347 Graphic Expressions for the Physical Signs in Pulmonary Cases 348 Examination of the Stomach and Stomach Contents .... 353 Methods of Examination without Employing the Stomach Tube . 354 Methods of Examining the Stomach Avith the Aid of the Stomach Tube 364 CONTENTS 15 PAGE Examination of the Intestine and Feces 415 Local Examination of the Rectum 415 Ueinary Examination 449 Amount of Urine 449 Frequency of Urination 451 Specific Gravity of the Urine 451 Transparency of the Urine 452 Color of the Urine 453 Odor of the Urine 455 Reaction of the Urine 455 Separation of the Urines of the Two Kidneys 457 Qualitative Chemical Examination of the Urine 458 Quantitative Urinary Analysis 504 Sediments and Turbidity of the Urine 553 Examination of the Sputum 578 Amount of Sputum 579 Consistence of the Sputum 579 Reaction of the Sputum 579 Color and Transparency of the Sputum 579 Air Content of the Sputum 582 Sputum Strata 582 Odor of the Sputum 583 Characteristic Gross Appearances of the Sputum 583 Microscopic Examination of the Sputum . 586 Chemical Examination of the Sputum 605 Chief Characteristics of the Most Important Types of Sputa . . . 605 Examination of the Blood 609 Method of Obtaining Blood for Examination 610 Quantity of the Blood ; Diagnosis of Hydremic Plethora . . . .611 Specific Gravity of the Blood 612 Reaction of the Blood 613 Coagulation Time of the Blood 615 Determination of the Hemoglobin in the Blood 616 The Counting of Blood-corpuscles 624 Other Morphologic Relations of the Blood 631 Condition of the Blood in the Most Impoi'tant Blood-diseases . . 659 Chemical Examination of the Blood 671 Widal's Serum Test in Typhoid Fever 675 Examination of the Mouth and Pharynx 677 Examination of the Esophagus 687 Laryngoscopy and Tracheoscopy ; Autoscopy of the Larynx AND Trachea 693 Examination with the Aid of a Mirror 693 Direct Examination of the Larynx, Trachea, and Bronchi , . . 698 Bronchoscopy 700 Combined Laryngoscopy 701 Rhinoscopy 701 Ophthalmoscopy 703 16 CONTENTS PAGE Exploratory Punctures and Harpooning , .707 Exploratory Punctures 707 Details of Exploratory Punctures in Different Diseased Conditions . 721 Harpooning 728 rontgen-ray examinations 729 Examination of the Nervous System 738 General Part 738 Psychical Examination 738 Examination of Motility 741 General Discussion of the Methods of Testing the Sensibility . 756 Examination of the Reflexes ,■.. . 776 Examination for Trophic Disturbances 788 Examination of Disturbances of Secretion 796 Edema in Nervous Diseases 797 Method of Testing the Mechanical Irritability of Nerves and Muscles . 797 Method of Testing the Electric Irritabilitv of Nerves and Muscles " 798 Special Part 821 Examination of the Different Cranial Nerves . 821 The Characteristics of Motor Hemiplegia ; Pseudobulbar Symp- toms 876 Cerebral Disturbances of Sensation 878 Vertigo . . " 880 Cerebral Localization 884 The Disturbances of Speech 888 Disturbances Related to Aphasia; Asymolia; Amimia ; Apraxia ; Amusia ; Psychic Deafness ; Psychic Blindness . 901 Spinal Hemiplegia 903 Pathologic Gaits and Postures . 908 Special Points in Reference to the Examination of the Spinal Nervous System 910 Appendix 948 Routine Plans 948 Illustrations 955 Supplement 955 Analysis of the Irregular Pulse 955 Acidimetric Titration of Fluids which Contain Alkaline Earths and Ammonia Salts in Addition to Salts of Phosphoric Acid . . . 965 Index . 967 INTRODUCTION. HISTORY AND OBJECTIVE EXAMINATION. To diagnose correctly any given case of sickness, it is customary to question the patient or his friends upon his subjective and objective symptoms of ilhiess and upon their manner and course of develop- ment. This testimony obtained from the patient or friends is called the history. It may be divided into two parts : first, the history in the narrow sense of the term, including the patient's story of his illness up to the time the physician sees him ; and, second, his account of his present symptoms, an account which must always be supplemented by an objective examination. The answers to the questions obtained in the history frequently furnish sufficient evidence to make a compara- tively accurate diagnosis without examining the patient. Countless ex- amples might be mentioned in illustration ; for instance : A patient says that a few days before, when in apparently good health, he was suddenly seized with a severe chill and a stabbing pain upon one side of his chest, and that ever since then he has been feverish and short of breath, coughing, and expectorating rusty sputum. With such a story a physician would naturally make the diagnosis of croupous pneumonia. Before attempting any objective examination, merely by skilfully directing his questions, in this way can an experienced physician obtain a fair idea of the disease, even in cases where the evidence is less conclusive than in the above example, although an exact diagnosis can be made only after completing the objective examination ; for many diseases furnish only subjective symptoms. There are even cases in which the history affords the only clue to diagnosis. A ripe experience is requisite in order properly to utilize the history in making a diagnosis. A com- plete knowledge of the pictures of all the diseases which might enter into consideration in any given case is very essential in selecting the proper questions, as well as a keen critical power in interpreting the value of the evidence given in the history, since otherwise unessential facts might be made conclusive points in a diagnosis. Only years of experi- ence can overcome one very constant difficulty — the varying individuality of patients. An hysteric society woman describes to her physician symptoms which, in a sturdy laborer, would be properly attributed to pathologic changes ; but the adept practitioner understands that such complaints are nothing more than the expression of the peculiar, sen- sitive and exaggerating mental condition of an hysteric person, and so does not lay too much stress upon their significance. Vice versd, a stolid, callous peasant often complains very little even when afflicted with a serious disease ; or, again, a patient normally sensitive may be so 2 17 1 8 INTB OD UCTION. benumbed by a disease that he does not complain at all. In the latter instance the great contrast between the subjective well-being and the objective visible disease frequently suggests a very unfavorable prognosis. Without depreciating the value of the statements of the patients and their friends, it is evident from what we have said that the methods of objective examination, with which this book is concerned, contain the most essential elements in diagnosis. Although I have illustrated the possibility and the occasional necessity of making a diagnosis merely from the history, yet I could as easily mention innumerable instances where the most skilled practitioner could not form an approximate conception of the disease without the most searching physical examination. Even in the simplest of cases no physician should neglect the precaution of examining his patient carefully, including in such an examination all the organs. For, on the one hand, some organic diseases do not excite sub- jective symptoms ; and, on the other hand, along with some organic changes which annoy the patient sufficiently to lead him to consult his physician, may go others of the greatest importance of which he has no suspicion and which the objective examination first discloses. Objective examination includes a number of different methods, some depending on mere observation, but others requiring especial technical, chemical, or physical aids. The beginner must very early acquire facility in all these methods of examination. Their mastery will furnish the groundwork for acquiring extended experience in clinical observation upon the symptomatology, the course, and the prognosis of disease, and for obtaining reliable data for therapy. A FEW SUGGESTIONS FOR TAKING HISTORIES. It is very difficult to give any detailed directions which will be generally effective in taking a history. In serious diseases only an able and experienced physician is capable of performing this task thoroughly, and he will need to utilize his entire medical training. Since we shall mention in the appendix upon special diagnosis most of the methods made use of in history -taking, in the following paragraphs we need only give a few rules to serve as a framework for the beginner to broaden and build upon as his knowledge and experience grow. Few persons are so mentally constituted as to communicate to the physician simply and directly the medically important facts of their ail- ment. Most patients relate a mass of unimportant matter and say nothing about the essentials, and only skilfully planned questions will prevent the patient or his relatives from irrelevancy. But a patient should never feel that he is being guided, nor that his physician does not enter with interest and sympathy into all the minute details of his trouble. Put- ting a mild curb upon the patient's volubility does not mean that one should concern one's self exclusively with the typical and characteristic symptoms of disease ; because many things apparently immaterial in the eyes of the beginner, who knows a disease only as a scheme, have really considerable interest and a great importance. Even many conditions which have apparently nothing at all to do with the medical aspect of HISTORY AND OBJECTIVE EXAMINATION. 19 the case — for example, occupation, family aifairs, etc. — are very helpful in comprehending the clinical picture, especially the etiology and, with it, the treatment. In short, the patient should be led to relate neither too much nor too little. It is quite as important that the physician himself should be accurate in framing his questions. It is easy enough to ask too little, but dif- ficult to ask too much or to question too minutely, not only on account of the multiplicity of the appearances of disease to be mastered, but even more on account of the danger of considering any important point as proved after a few hasty questions. In the writer's opinion this is the most frequent and serious fault which the beginner perpetrates ; e. g., a feverish patient is asked if he has had a chill, because such a symptom would suggest a definite disease, pneumonia. Without much thought most patients answer this question in the affirmative ; but more careful questioning develops the fact that the supposed chill is in reality only the slight chilly feelings accompanying nearly all feverish diseases. In the typical chill of pneumonia the patient's teeth chatter, and he shakes as if immersed in ice water. This is quite a diiferent symptom in its significance from the slight shivering of fever. The patient's statement that he has had a chill is not sufficient ; we must inquire more particularly as to the nature of the chill. Often enough patients betray their mistake by using the word chill in the plural. Similar errors may arise from the statements patients make in regard to many other symptoms or long-standing diseases. The names they give to their former illnesses are especially apt to be incorrect and often occasion serious errors, for many are diagnoses made by the laity and many others are incorrect ; e. g., most cases of so-called " meningitis " which have been cured. Again, patients with tuberculosis often mis- name an acute exacerbation of their disease as " influenza "; further, so-called " catarrh of the stomach " is usually an early manifestation, or at least a forerunner, of tuberculosis. " Rheumatism " is another diagnosis which must always be looked upon a little skeptically. Fre- quently enough the clinical picture shows that the so-called " rheu- matism " is a manifestation of tuberculosis, or of pleurisy, etc. Simi- larly, many other names of diseases, such as " nervous fever," "joint rheumatism," " dysentery," if accepted without criticism and without minute interrogation, may lead to errors in diagnosis. The best way to avoid such mistakes is to disregard names given by the patient and to make one's own diagnosis by establishing as objectively and accurately as possible the symptoms of the preceding disease. A further and just as serious a fault is the tendency of many begin- ners to start from a preconceived notion of the diagnosis and to extract from the patient all possible facts in the history which will coincide with this supposed disease. To recognize this fault should be sufficient to effectually avoid it. We can hardly ask too detailed questions as to the influences of heredity, inquiring accurately concerning parents, brothers, sisters, chil- dren, uncles, and aunts. An inquiry as to whether this or that disease 20 INTR OD UCTION. has occurred in the patient's family will usually elicit a negative reply. To determine the facts accurately the disease in question must be quite specifically designated, possibly even a summary of the symptoms de- tailed. A patient may deny the occurrence of pulmonary disease in his family ; but should we ask if either parent had a chronic cough, had expectorated blood, or lost a good deal of weight, we can fre- quently enough become convinced that one or the other suffered from tuberculosis. In regard to neuropathic taint we must question very accurately and particularly. For example, an epileptic will practically always deny the occurrence of any nervous disease in his family. We may, how- ever, obtain a positive reply by asking whether his father, mother, brother, sister, uncle or aunt was epileptic, if they had suffered from nervous attacks, or if they had been nervous or mentally affected in some other way. If the histories are difficult to obtain or if patients contradict them- selves, it is advisable to repeat questions later on, thus frequently clear- ing up some complicated point. The repetition of our task with stupid and prattling patients, unfortunately, obtains for us little more than renewed contradictions. Even this is a relative gain, for at least we discover how little we can trust them, and draw no false conclusions. In general, good history-taking requires much diplomacy, tact, and knowledge of people and of medicine. A physician should never allow a patient to feel that he is in a hurry. The public considers that the physician has time for everything and everybody. Sit quietly, even if you are sitting upon hot coals ; and wait for a favorable moment to interrupt, in a diplomatic way, the flow of talk. An excellent medical precept is not to fatigue a patient seriously ill with too thorough ques- tioning, but to obtain as much as possible from the relatives, or to leave parts of the history until a later period. Furthermore, it is always advisable to discuss with the patient alone facts which he might wish to conceal from others. Finally, the beginner puts only a small part of the necessary questions, not realizing how much must be asked in order to make a complete history. Few rules can be given, but the following table will probably be of considerable service : Scheme for History-taking. Date ; personal statements (name, age, position, occupation, resi- dence) ; condition — i. e., married or not ; complaint ; onset of the present illness ; a description of the symptoms in the order of their appearance. Etiology. — More exact information about the occupation and mode of life, injuries, strains, taking cold, errors in diet, etc. Infectious diseases in the neighborhood. Previous treatment and course of disease. Past History. — Any antecedent disease like the present? If so, course of same. Injuries. Other earlier diseases; infectious diseases; and of these especially : joint rheumatism, scarlet fever, measles, whoop- ing-cough, typhoid fever, erysipelas, malaria, sore throat, gonorrhea, syphilis. Previous symptoms of disease : Edema ; dyspnea ; cough ; HISTORY AND OBJECTIVE EXAMINATION. 21 expectoration ; expectoration of blood ; palpitation of heart ; difficulties of urination and alterations in the urine ; constipation ; diarrhea; icterus; vomiting ; vomiting of blood ; abnormalities of hunger and thirst ; headache ; marked changes of weight. In the female sex : chlorosis ; pregnancies ; births ; menstrual or gynecologic difficulties. All these symptoms and conclusions which the past history furnishes must be analyzed in the same way as the symptoms of the present disease. (See 2. Complaint.) Heredity. — THE GENERAL ROUTINE OF A PATIENT'S EXAMINATION. The following plan the author considers an excellent method for a routine examination ; the order of the questions being the natural and practical one. The individual observer may expand the scheme in ac- cordance with the contents of the work in question. 1. Expression of countenance and general deportment of the patient ; voice; speech; psychical behavior. 2. Complaint. (See Scheme for History-taking.) Kind of sich feeling f Weakness f Loss of flesh f Disturbances associated with the nervous system f Disturbances in connection with the organs of respiration f Dyspnea, constant or paroxysmal ? The exciting cause of the par- oxysms ? Breathing slow or rapid during attack of dyspnea ? Cough, with or without expectoration ? Characteristics of the ex- pectoration ? Admixture of blood ? Peculiarities of the latter ? Subjective sensation respecting the source of the expectoration (throat, larynx, nose?). Pain with breathing ? Its location ? Disturbances in Connection with the Circulation. — Palpitation, con- stant or paroxysmal ? Apparent exciting cause of the paroxysm (agita- tion, exertion, or posture) ? Palpitation accompanied by sensation of pain (left arm, back, precordia) ? Palpitation accompanied by dyspnea ? Subjective sensation of arrhythmia {i. e., tripping or skipping of the heart beat)? Edema? Amount of urine? Disturbances of the Digestion. — Appetite ? Pain ? Influence of the ingestion of food and drink upon the pain ? Time of onset of pain — soon after eating — during the night — in a fasting condition ? More exact location and radiation of pain (back, right shoulder) ? Nausea ? Vomiting? Amount and character of the vomitus (mucus, blood, food) ? Its taste (sour, bitter) ? Time of vomiting (pointing to reten- tion or not) ? Belching (sour, bitter, rancid) ? Bowels : Constipation ? How often do the bowels move ? Movements painful ? Character of feces : Color ? Large scyballse, abnormally small lumps ? Distention of abdomen and other discomforts when constipated? Flatulence? Diarrhea : Frequency, consistence, color, amount of each dejection ? Pain in defecation ? Tenesmus ? Bloody or slimy evacuations ? Evi- dences of hemorrhoids ? Disturbances of the Urinary Apparatus. — Bladder or kidney pain ? Radiation of the pain ? Tenesmus of bladder ? Amount of urine ? 22 INTRODUCTION. Conspicuous qualitative changes of the urine (cloudy, bloody, smoky) ? Passing of stone, gravel or sand ? Other Disturbances. — Fever? Night-sweats? Headache? Thirst? Insomnia (and its apparent cause) ? 3. History proper, in conformity with the above plan. 4. Examination propjer, which should cover the following points : Build, development, and nutrition. Temperature, frequency of pulse and of respiration. Characteristics of Skin. — Bloating, edema, color (pallor, cyanosis, icterus), eruptions, pigmentation, scaling, strise, final confirmation of other external diseases (joiut-afiFections, erysipelas, etc.). Head and Neck. — Mucous membranes, especially conjunctivae, tongue, gums, pharynx, tonsils, herpes labialis, glands, goiter? Cer- vical veins (their dilatation or pulsation). Respiratory Apjpiaratus. — Dyspnea ; its character, polygopnea, oli- gopnea, inspiratory or expiratory, stridor, shape of thorax, type of breathing, breathing excursions, diaphragm phenomenon, drawing in of thorax, topographic and comparative percussion and auscultation of the lungs, fremitus. Circulatory Apparcdus.^ — Inspection and palpation of the precordia. Visible and palpable pulsation over that area. Location of apex beat. Thrills. Percussion and auscultation of the heart. Exact examination of the pulse. Rapidity, rhythm, fulness, tension, resistance of artery wall, conformity of the frequency of the radial pulse with that of the cardiac pulsation. Exact examination of the venous pulse. Ausculta- tion of the arteries. Liver pulse. Capillary pulse. Digestive Ap)paratus. — Inspection and palpation of the abdomen; its shape and fulness ; visible peristalsis ; sensitiveness to pressure, pal- pable tumors, resistances. Palpation and percussion of the stomach, intestines, liver, gall bladder, spleen, and peritoneum. Inspection of the vomitus and of the feces. Urinary Apparatus. — Manner of urination ; palpation of the kid- neys and bladder ; percussion of bladder. Catheterization. Character of urine ; amount ; color ; cloudiness ; specific gravity ; testing for albumin and sugar. Sp>ecial Examinations tvhich may be Necessary or even the Most Im- jjortant of All in a Given Case. — Examination of the nervous system in accordance with the plan to be mentioned later. Rhino-, laryngo-, oph- thalmo-, otoscopic examination. Testing the blood, including counting the corpuscles, estimating the hemoglobin, and the microscopic examina- tion of the fresh and stained blood. Microscopic examination of the sputum, of the urine, of the vomitus, and of the feces. Bacteriologic examinations. Sphygmography and sphygmomanometry. Examina- tion of the esophagus. Examination of the stomach by means of the stomach tube (distending with gas, a test meal). Distention of the colon for the demonstration of kidney tumors. Examination of the rectum ; of the male and female genitalia. Needle punctures. ^ In a routine examination the pulse is usually examined before the heart. GENERAL CONDITION OF THE PATIENT. 23 It is the province of special pathology or of special diagnosis to interpret the signs of disease discovered in this manner, to weigh their mutual values, and to unify them into a definitely conceived disease of etiologic, functional, or anatomic nature. GENERAL CONDITION OF THE PATIENT. POSTURE IN BED. The general deportment of a patient is the first thing which attracts our attention and influences our judgment as to his condition. In many cases even the patient's relatives will reveal whether the illness is serious or slight. Ordinarily, physicians see seriously sick patients in bed, while those with slight ailments walk about. Yet there are countless exceptions. Sometimes seriously ill patients go to bed only at the last extremity ; and, as is well known, patients may walk about even during the height of typhoid fever or pneumonia. Vice versd, many patients take to their beds on account of very slight ills. These peculiarities depend upon the social position and the em- ployment of a patient, and upon the great diiference in the individual susceptibility to sickness. Besides, we must remember that even very slight ailments which always run a favorable course are sometimes associ- ated with such distressing symptoms that the patient is compelled to take to his bed. Despite such exceptions, we may say that certain diseases necessitate rest in bed, others are ambulatory. Patients with the acute exanthemata are commonly found in bed by the physician because they feel very ill. The same is true of circulatory disturbances, peritonitis, meningitis, pneumonia, and acute inflammatory rheumatism. It is ordinarily easy enough to determine whether the patient keeps his bed on account of feeling ill, weak, and perhaps feverish, or on account of dyspnea, pain, or other difficulties, which are increased by walking about. THE EXPRESSION. The expression is of great diagnostic importance, enabling the skilled physician to draw conclusions as to the subjective feelings and the men- tal condition of the patient. The terms commonly applied to the expres- sion — suffering, anxious, painful, careworn, uneasy, very ill, agitated, dulled, stupid, flustered — are perfectly plain without further explanation. Feverish patients present a characteristic appearance ; sometimes they have a peculiar animated look, at other times an exceptional depression of the mimic faculty, often combined with glistening eyes, a feverish redness, and an increased turgidity of the skin of the face. The facial expression of a patient suffering from dyspnea is quite as distinctive, dependent upon peculiarities in the aj^pearance of the skin (cyan- osis, edema) and upon the mimic elements. The dilatation of the 24 GENERAL CONDITION OF THE PATIENT. nares (see later), combined with the open mouth, is especially character- istic. (See p. 49 for a description of the typical fades Hippocratica.) The unusual expression of tetanus, called the risus sardonicus (sardonic laugh),^ has been variously described. While the mouth is distorted as in laughing, the upper part of the face, especially the brow, is wrinkled, just as in the expression of trouble or sorrow. Tetanus poison appar- ently contracts the muscles of the entire facial territory and causes a combined stimulation of practically antagonistic muscles. MENTAL CONDITION. A patient's facial expression and his demeanor during our question- ing furnish the best means of estimating his mental condition. ACTIVE AND PASSIVE POSTURE IN BED. A critical observer obtains diagnostic points from noticing the position which the patient assumes in bed. The less the general feel- ings are affected, the more natural and unconstrained is his j)Ose. He tosses about, pushes the pillows straight, and shifts his attitude when one position has become uncomfortable. This is called an active posi- tion in bed (active dorsal or lateral posture). On the contrary, very weak, helpless, or unconscious patients appear very differently. Their attitude is lax, essentially controlled by the laws of gravity. Should such a patient slide down against the footboard, he would remain lying there, for he is incapable of drawing himself up, even if the position be very uncomfortable and his breathing embarrassed. This is called a passive position in bed (passive dorsal or lateral posture). CONSTRAINED ATTITUDES. Some very characteristic postures are almost diagnostic of certain diseases. For example : respiratory, cardiac, or renal affections associ- ated with much dyspnea prevent a patient lying upon his back : in the first place, because the accessory muscles of respiration can be used to advantage only in the sitting posture, with the spine fixed and some- times the arms ; in the second place because, if fluid has accumulated in the abdominal cavity, the sitting posture partially relieves the diaphragm of its pressure ; ^ and finally, because the influence of gravity possibly relieves the venous congestion of the brain and of tlie respiratory center in particular. With extreme dyspnea, the so-called "orthopnea," a patient cannot lie down, but, exhausted, is obliged to sit erect, bracing himself with his elbows and forearms upon the arms of his chair in an endeavor to utilize the accessory muscles of respiration and, if fluid be present in the abdomen, to avoid pressure of the anterior surface of the ^ This name is derived from " sardone," a poisonous plant of the ancients, the inges- tion of which produced such an expression. ^ Except, of course, when an enormously distended abdomen is crowded by the thighs- in the sitting posture. POSTURE IN BED. 25 thighs upon the distended abdomen. It is worth remembering that the accumulation of a considerable quantity of blood in the veins of the lower extremity may afford some relief to the lungs and the heart, so that elastic bandages around the legs, temporarily shutting off a con- siderable amount of venous blood, may enable the patient to lie down, even though for a very short time. Constrained lateral positions are very suggestive, for they almost always depend upon unilateral affections of the thoracic viscera. If on account of pulmonary infiltration or of compression by a pleural effusion the function of one lung is abolished, the patient usually lies upon the affected side, in order to afford the sound lung the freest possible expan- sion. Should there be much pain, such a position is generally reversed, because the weight of the body increases the pain ; but sometimes when Fig. 1.— Case of cerebrospinal meningitis. Photograph taken from above ; patient lying asleep. Marked retraction of neck, flexion of thighs and legs (Harlem Hospital, i)r. R. G. "Wiener). the pain depends practically upon the breathing the patient will lie upon the affected side, and so limit the respiratory excursion by par- tially fixing the painful side with the body weight. In heart diseases, and sometimes in health, one side is more comfortable than the other to lie on. The position which dislocates the heart, the great vessels, and the mediastinum most, thereby rendering the breathing difficult, will be avoided. -Lying on one side will sometimes relieve a patient who is perpetually tormented with a cough when in the dorsal decubitus. As one can easily imagine, in pulmonary cavities with constantly re- newed secretion certain positions will aggravate a cough if the secre- tions are being continually poured out upon the healthy bronchial mucous membranes. In some positions the cavity would become en- tirely filled before any overflow would excite the paroxysm of coughing. 26 GENERAL CONDITION OF THE PATIENT. The latter then completely empties the cavity, thus affording the patient a temporary rest. The diagnosis of a cavity would be strongly sug- gested by such history. With colic, with cardialgia, and sometimes with intestinal obstruc- tion patients generally prefer to lie upon the abdomen, because the tension of the distended intestines is diminished or their position shifted and the pain relieved ; but in peritonitis the abdomen is so sensitive to pressure that the dorsal decubitus is assumed. On account of the epi- FiG. 2. — Adiposity : The enormous accumulation of fat over and within the abdomen simulates a collection of ascitic fluid. gastric tenderness, it is comparatively rare to find a patient with a gas- tric ulcer lying upon the abdomen, unless such a position frees the ulcer from the contact or pressure of the gastric contents — e. g., if situated upon the posterior wall. Patients with lieadache sometimes prefer to lie upon the abdomen. The characteristic positions of patients suffer- ing from cerebrospinal meningitis or wry-neck depend upon cramp-like contractions of certain groups of muscles ; some peculiar paralytic positions, upon paralyses of muscles. DEVELOPMENT AND STATE OF NUTRITION. 27 GAIT AND THE ATTITUDE. An alert, erect attitude and a rapid walk usually signify good physical condition, while a stooping, relaxed posture with a slow, fatigued gait indicates that the person is seriously ill or mentally depressed. (For a description of various characteristic gaits see Examination of the Nervous System.) DEVELOPMENT AND STATE OF NUTRITION. A robust, vigorous or muscular physique means that the bodily dimen- sions are rather above the normal, whereas a weakly or puny physique would indicate the contrary. The subcutaneous fatty layer (panniculus adiposus) is perhaps of even more importance than the muscles in esti- mating the state of nourishment. The former varies within normal limits in accordance with the age, sex, and occupation of patients. Corpulency is generally associated with a weak musculature. Nursing infants possess an extremely well-developed layer of fat ; during childhood it gradually diminishes, and in the third or fourth decade increases again, while at old age it finally diminishes. A marked tendency to corpu- lency is often observed in women especially after the menopause. Most chronic diseases are accompanied by a noticeable deteriora- tion of the general nutrition. This is due either to lack of appetite, and, hence, insufficient food, to defective assimilation, or to excessive Fig. 3.— Pronounced emaciation in a chronic disease. Case of multiple myeloma (New York City- Hospital). combustion of the food assimilated. Emaciation is particularly evident in chronic 'febrile and digestive diseases, and becomes most pronounced in severe and prolonged typhoid fever, in phthisis, in carcinoma, espe- cially esophageal carcinoma, and in certain types of diabetes mellitus. In these diseases the musculature suffers a loss almost as rapidly as the fatty tissue. Marked emaciation nearly always suggests chronicity. 28 DEVELOPMENT AND STATE OF NUTRITION. BODY WEIGHT, Observation of weight over a certain length of time furnishes an excellent guide to the state of nutrition. Minute cautions in regard to the accuracy of the scales, weight of diiferent clothes, etc., are hardly necessary to enumerate. Unless accurately estimated the weight is of no value. It is more accurate to weigh the body always either before or after eating, since a hearty meal will often make a difference of one or more pounds. General edema or the accumulation of fluid in one of the large serous sacs will considerably increase a patient's weight, while free catharsis, diuresis or diaphoresis will rapidly diminish it. Careful comparative weighing in these cases furnishes very good evidence of the progress of the disease. Infants should be weighed weekly, to keep track of their nutrition. The normal weight of the newborn is (females) 3000 gm. (6 lbs.) to (males) 3500 gm. (7 lbs.) (Uffelmann). During the first three or four days of life there is a physiologic loss of 200 to 300 gm. (J lb.). Ger- hardt ^ cites the following table : 1st month 25 gm. Daily increase in 7th month 15 gm 2d 23 " u " 8th 11 13 " 3d " 22 " a " 9th " 12 " 4th " 20 " a " 10th a 10 " 5th " 18 " a " 11th u 8 " 6th " 17 " li " 12th a 6 " Quetelet's table (an extract from which is inserted below) does not take into account the weight of the clothes, this has been estimated to be in men about ^ and in women about J^ of the total weight; although, of course, such figures must vary considerably : Male. Female. Newborn 3.1 kg. ( 6.83 lbs.) 3.0 kg. ( 6.61) 1st vear 9.0 " ( 19.84 " ) 8.6 " ( 18.96) 2d " " 11.0 " ( 24.25 " ) 11.0 " ( 24.25) 3d " 12.5 " ( 27.56 " ) 12.4 " ( 27.34) 4th " 14.0 " ( 30.86 " ) 13.9 " ( 30.64) 5th " 15.4 " ( 33.95 " 15.3 " ( 33.73) 6th " 17.8 " ( 39.'24 " ) 16.7 " ( 36.82) 7th " 19.7 " ( 43.43 " ) 17.8 " ( 39.24) 8th " 21.6 " ( 49.62 " ) 19.0 " ( 41.89) 9th " 23.5 " 51.81 " ) 21.0 " ( 46.30) 10th " 25.2 •' ( 55.56 " ) 23.1 " ( 50.93) 11th " 27.0 " ( 59.52 " ) 25.5 " ( 56.22) 13th " 33.] " ( 72.79 " ) 32.5 " ( 71.65) loth " 41.2 " ( 90.83 " ) 40.0 " ( 88.18) 17th " 49.7 " (109.57 " ) 46.8 " (103.18) 19th " 57.6 " (126.98 " ) 52.1 " (114.86) 20th " 59.5 " (131.17 " ) 53.2 " (117.28) 25th " 66.2 " (145.94 " ) 54.8 " (120.81) 30th " 66.1 " (145.72 " ) 55.3 " (121.91) 60th " 61.9 " (136.46 " ) 54.3 " (119.71) 70th " 59.5 " (141.17 " ) 51.5 " (113.54) ^ Gerhardt, Lehrbuch der Kinderkrankheiten, 1881, p. 2. BODY WEIGHT. 29 MENSURATION. An individual's general development must be judged by comparisons between his age, weight, and height. Quetelet ' is also responsible for the following table : Newborn 1st year 2d 3d 4th 5th 6th 7th 8th 9th 10th 11th 13th 15th 17th 19th 20th 25th 30th 40th 60th 70th Male. Female. 50.0 cm . (].8 -i 49.4 cm. (1.7 ft.) 69.8 (2.3 69.0 ' ' (2.3 " ) 79.1 (2.7 " ) 78.1 ' ' (2.7 ") 86.4 (2.10 " ) 85.4 ' (2.10 'M 92.7 (3.— ") 91.5 ' ' (3.- " ) 98.7 (3.3 ") 97.4 ' ' (3.2 " ) 104.6 (3.5 " ) 103.1 ' ' (3.5 ") 110.4 (3.7 " ) 108.7 ' ' (3.7 " ) 116.2 (3.10 ") 114.2 ' (3.9 ") 121.8 (4.0 ") 119.6 ' (3.11 ") 127.3 (4.2 ") 124.9 ' (4.1 ") 132.5 (4.4 ") 130.1 ' ' (4.3 ") 142.3 (4.8 ") 140.0 ' ' (4.7 " ) 151 3 (5.0 f5.3 (5.5 148.8 " (4.11 154.6 " (5.1 " ) 159.4 " 1 165.5 ") 157.0 ' ' (5.1 " 1 167.0 (5.6 " ) 157.8 ' ' (5.2 u \ 168.2 (5.6 ") 157.4 ' ' (5.2 " ^ 168.6 (5.6 ") 158.0 ' ' (5.2 " ) 168.6 (5.6 " ) 158.0 ' (5.2 ") 167.6 (5.6 ") 157.1 ' ' (5.2 ") 166.0 (5.5 ") 155.6 ' (5.1 ") Circumference of the Chest. — The chest measurement fur- nishes a very good idea of the state of development. It is used in many countries in examining army recruits. Frohlich ^ recommends the following method : The measuring tape is to be applied horizontally at the level of the nipples in front and just beneath the angles of the scapulae behind while the arms are held horizontally. The measure- ments during extreme inspiration and again during extreme expiration are to be recorded, the difference representing the chest expansion. He found among recruits that the average in men of twenty years was, for expiration 82 cm. (32| in.), for inspiration 89 cm. (35f in.), and the chest expansion 7 cm. (2f in.), and he attaches considerable diagnostic importance to these figures, because he noted that in emphysema, in phthisis, and pleural effusions the circumference, especially during ex- piration, was increased, while the chest expansion was diminished, and this diminution might persist for some time after the disease has subsided. The chest expansion is diminished if the costal cartilages become ossified (the so-called Bryson's sign). This is often the case in exophthalmic goiter. ' Anthropometrie, 1870. '^ H. Fi-olich, Die -Brustmessung im Dienste der Medicin, Leipzig, 1894. ography is quoted here. A full bibli- 30 DEVELOPMENT AND STATE OF NUTRITION. CONFIGURATION OF THE THORAX. NORMAL SHAPE OF THE CHEST. A normal chest, such as one sees so beautifully illustrated in the masterpieces of classic statuary, should be symmetric, the surface well rounded, without sharp corners or depressions ; the intercostal spaces only visible between the lower ribs ; the subcostal angle about 90° ; the sternum nearly straight in profile, without a decided angle between the corpus and the manubrium ; and the sternovertebral somewhat shorter than the transverse diameter. The gradual increase in the horizontal diameters of the thorax should form a sort of pyramid, with its base below, but the graduation should not be too marked, and the shoulder girdle, or in females the breast, should offset this difference. The shoulders should be nearly horizontal, the scapulae lying flat against the back, clavicles not too prominent, and the supra- and in- ^ fraspinous fossae not too deep. PATHOLOGIC SHAPES. Emphysematous Chests. — These abnormal forms depend upon an emphy- sematous enlargement of the lungs ; and they possess one feature in common — the thorax seems abnormally widened and \ . J prominent. The sagittal diameter is gen- I # erally increased and the subcostal angle ^ .^\, more obtuse than in the normal thorax. Fig. 4.-Emphyseniatous chest When the emphysema is diffused over the GenemiHospfS' *^'^^''^^^^'^"" entire lung or when mostly limited to the lower chest, the thorax looks as if in a normal position of deep inspiration ; but when caused by forced expi- ration (coughing) the emphysema is situated more in the upper chest, because the respiratory power acts more upon the lower parts of the thorax. Then the upper thoracic aperture appears enlarged and the so-called "barrel chest" is produced. These are the two different types. The Paralytic Thorax. — Contrasted with the emphysematous thorax, the so-called paralytic thorax is abnormally flat, long and some- times narrow ; the ribs, both in front and behind, have a marked down- ward direction ; the intercostal spaces are widened ; the subcostal angle is very acute ; the supra- and infraclavicular fossae are deep ; the inter- costal muscles and those of the shoulder girdle are feebly developed (hence the name) ; and the shoulder blades project noticeably, like wings, because of a weakness of the muscles, especially of the serratus magnus. This type of chest is observed frequently in iveakly or cachectic individ- uals, very commonly in phthisis. It was formerly considered as a coy FIGURATION OF THE THORAX. 31 predisposing cause of consumption, and is now frequently spoken of as " the phthisic chest." Scoliotic, Kyphotic, and Scoliokyphotic Thoraces. — These terms are applied to twists and deformities of the chest which are observed as a sequence of spinal curvature. They are often quite pro- nounced. It is often difficult to detect such deformities from the front ; but by noting the low stature, the short thorax, and the marked breadth of shoulders an experienced eye can generally discover them. Rachitic Chests. — Rickets is responsible for many chest deform- f^ Fig. 5.— Paralytic chest (phthisis) (Dr. W. H. Smith, Massachusetts General Hospital). Fig. 6.— Paralytic chest (phthisis) (Dr. W. H, Smith, Massachusetts General Hospital). ities, although often very slight ones. Perhaps the most characteristic is the keel-shaped prominence of the sternum called pectus carinatum (pigeon breast). It is associated with a compression of the anterior diagonal horizontal diameter and an increase in the sternovertebral diameter of the chest (Fig. 8). A transverse groove (Harrison's groove) often marks the insertion of the diaphragm to the ribs. The so-called " rachitic rosary," a beaded enlargement at the line of junction of the bony ribs with their costal cartilages, can be felt as well as seen. It generally disappears in later childhood. The other rachitic deformities may persist, or they may become modified to a greater or less extent. 32 DEVELOPMENT AND STATE OF NUTRITION. Boat-shaped Chest of Syringomyelia. — Pierre Marie and Asti6 ^ described, under the name of " thorax en bateau," a depres- sion of the upper portion of the anterior chest-wall, which, so far as we know, is only observed in syringomyelia. The cavity lies in the median line, as if sunk against the spinal column, and extends downward as far as the lower edge of the pectoralis major ; it may be as deep as 5 cm. The atrophy of the pectorals and of the other muscles takes no part in producing this appearance. Funnel-shaped Chest and Cobbler's Chest. — The true fun- FiG. 7.— Right scoliosis (Moore). nel-shaped chest is either congenital or else develops in early infant life, gradually and without any known cause. It consists of a funnel-shaped depression of the lower end of the sternum, which frequently reaches quite deeply into the interior of the chest. It may lead to circulatory or respiratory disturbances resembling those observed in kyphoscoliosis. Cobblers may acquire a very similar deformity, due to the constant pressure against the lower end of the sternum. The cobbler type is, however, limited to the inferior portion of the sternum, or even to the xiphoid process alone. ^ Soc. mid. des hdpitaux, 19, ii., 1897. CONFIGURATION OF THE THORAX. 33 Asymmetry of the Chest Due to Disease of the Thoracic or Abdominal Viscera. — An expansion or a contraction of one chest- half may result from various affections of the thoracic viscera — e. g., a large pleural exudate, a pneumothorax, or even to a slight extent a croupous pneumonia. The alteration may be general over one entire side or localized. The affected side may be the larger or the smaller. A considerable pleural effusion or a pneumothorax produces an enlargement of the affected side of the thorax, an obliteration of the intercostal spaces, a dis- FiG. 8.— Pigeon breast (Dr. R. C. Cabot, Massachusetts General Hospital). location outward of the nipple and of the scapula, a convexity of the spine toward the affected side, and an elevation of that shoulder. The last two deformities, both probably due to an alteration of the center of gravity, make the patient look as if he were carrying a weight on the affected side. The lower thorax may be enlarged by a decided increase in the size of the liver or spleen. Such an enlargement will become still more noticeable if tympanites or ascitic fluid distends the abdomen enough to prevent the dropping of the enlarged liver or spleen. An aortic aneurism or an intrathoracic tumor may cause a localized enlarge- ment of the thorax. This will be situated at the point of contact of the growth with the thoracic wall. Actual contact is not, however, necessary, because, ev^en when the growth or aneurism is merely in close proximity to the wall, a localized bulging will be caused by the diminution 34 DEVELOPMENT AND STATE OF NUTRITION. in the intrathoracic negative pressure — e. g., an aortic aneurism, even when covered by the lung, will cause a local prominence. Neither does a pleural effusion need to be under positive pressure, as is so commonly supposed, in order to enlarge the affected side of the urpura. They are, however, unlike purpura, found most abundantly upon the trunk. They frequently exhibit the bite-mark as a dark spot in the center of the hemorrhage, and when Fig. 14.— Emphysema of left breast and chest-wall, due to broken ribs (Massachusetts General Hospital). fresh they are surrounded by a hyperemic zone, the color of which will disappear upon pressure. 2. Spontaneously in all severe cachexias and infections which are associated with a hemorrhagic diathesis ; particularly as a characteristic symptom in the various types of purpura, in grave anemias, especially in pernicious anemia, leukemia and scurvy, in acute yellow atrophy of the liver, in phosphorus-poisoning, in ulcerative endocarditis, in pyemia, and in the terminal stages of certain cases of jmlmonary tid:>erculosis. 3. In the hemorrhagic forms of the ac^ide exanthemata, : scarlet fever, measles, small-pox. These are notoriously more serious and critical 54 EXAMINATION OF THE SKIN. than the ordinary types, especially in " black small-pox/' where the hemorrhage occurs in the interior of the pustules ; and still more so in that rare, very fatal form, " purpura variolosa," where extensive cuta- neous hemorrhages occur without the formation of any rash. But there are some cases of measles and scarlet fever which are not much more serious than the ordinary cases, although they are shown to be hemor- rhagic, by the fact that the coloration of the rash does not entirely Fig. 15.— Purpura (New York City Hospital). disappear upon pressure, and that even into the convalescence slight remains of the rash still show as a pigmentation. Erythema nodosum (contusiformi) not infrequently simulates bruises of the skin, presenting rather extensive cutaneous hemorrhages upon the extensor surface of the extremities. 4. From marhed venous stasis, especially when accompanied by severe paroxysms of cough, which suddenly increase the congestion — e.g., jjertussis — where hemorrhages in the mucous membranes, particu- larly in the conjunctivae, are not uncommon. PLATE 2. Purpura (New York City Hospital). COLLATERAL CIRCULATION IN THE SKIN. 55 COLLATERAL CIRCULATION IN THE SKIN. A visible distention of veins or arteries in the skin often suggests some deep-seated obstruction to the circulation — e. g. : I. The collateral circulation (arterial), when the aorta is occluded at the isthmus. (See Congenital Heart Diseases.) II. The collateral circulation (venous) upon the anterior thoracic wall. This is of some importance in diagnosing mediastinal or pulmo- FiG. 16. — Collateral circulation iu the abdominal wall (New York City Hospital). nary tumors, which compress the big veins within the chest, especially the vena cava superior and inferior. Here the intercostal and internal mammary veins dilate and furnish a channel of communication between the two vena cavse when either one is occluded. III. The very striking collateral circulation in the abdominal wall caused by thrombosis of both iliac veins or of the vena cava inferior (Fig. 17). The blood from the lower extremities, and even from the kidneys, reaches the thorax by way of distended tortuous veins, which are arranged longitudinally, and are more pronounced upon the sides than upon the front of the abdomen. This selection of the sides of 56 EXAMINATION OF THE SKIN. the abdomen is of some importance in distinguishing this form of ob- struction from the next. TV. The collateral circulation caused by obstruction of the portal veins (cirrhosis of the liver or portal thrombosis, Fig. 18). In the latter case it is furnished by anastomoses between the tiny veins at the root of the mesentery and those of the peritoneal covering and suspensory liga- ments of the liver, even sometimes by a patent vena umbilicalis. In Fig. 17.— Collateral circulation in thrombosis of the vena cava inferior. this latter type of anastomosis the distended veins of the abdominal wall are apt to be very characteristically arranged about the navel, forming the so-called " caput meduste." Figs. 17 and 18 illustrate the diagnostic distinction between the distention of the abdominal wall veins, due in the one case (Fig. 17) to obstruction in the vena cava, and in the other case (Fig. 18) to obstruc- tion in the portal system. Numerous exceptions make this distinction COLLATERAL CIRCULATION IN THE SKIN. 57 less valuable for diagnostic purposes — e. g., when ascites follows portal stasis the presence of the fluid in the peritoneal cavity will naturally produce a secondary obstruction in the vena cava, and the veins of the sides of the abdomen will also become distended. In any of these cases of collateral venous circulation it is always important to determine the direction of flow of the venous blood. This Fig. 18.— Collateral circulation in thrombosis of the portal vein or in hepatic cirrhosis. is readily done, particularly when the valves of the veins are intact, by emptying the blood from the vein by means of pressure with the fingers, and then, when the pressure is removed, by watching, first at one end and then at the other end of the vein, to see from which direction the blood comes first. If there are no valves or if the valves are incompe- tent this test is valueless, because the blood would stream back with equal rapidity from either end. 58 EXAMINATION OF THE SKIN. A very fine dendritic, irregular enlargement of the thoracic skin veins is often observed in all chronic affections of the lungs and pleurae, especially when adhesions are present between the two pleural surfaces. It probably represents a collateral circulation between the lung and skin. In the very chronic forms of phthisis it is observed frequently, and then quite often in the supraspinous fossa. Nearly twenty years ago the writer described a zone of small dilated skin veins which are arranged dendritically and extend in the form of a band about 1 to 3 cm. broad along the anterior lower border of the lung and over the superficial cardiac dulness.^ It has no especial path- ologic significance, because it is also observed in perfectly healthy indi- viduals ; but clinically it represents a rough picture of the position of the lung borders. It may be situated either within or without the pulmo- nary margins, but is generally nearby, unless modified in some fashion, as by pleural adhesions. Percussion-results prove that a low position of this zone corresponds to emphysema of the lungs. It is very difficult to explain the appearance of this zone of vessels, but, with- out question, it is due to a difference in pressure between the inside and the outside of the chest-wall. Suppose we take the region where the zone of vessels marks the internal pulmonary hepatic boundarj\ Above the intrathoracic pressure is negative, and below the intra-abdominal pressure is positive, which, of com-se, in and of itself explains nothing. Respiration, however, alters the pressure relations (see p. 7 7, et seq. ). It produces a distinctive change of shape in the chest-wall, as evidenced by the normal sinking in of the lower intercostal spaces and by the so-called diaphragm phenom- enon. Both these conditions furnish an inspiratory, localized, girdle-shaped depres- sion of the ch'^st-wall, which must occasion a rhythmic obstruction to the venous blood-current, because the supei-ficial veins of the part are compressed by the ex- ternal atmospheric pressure. Now it is conceivable that this rhythmic constriction may give rise to an area of small distended veins. Perhaps a similar explanation would account for the formation of the zone which suiTOunds the heart, because evidently similar differences in pressure exist at that portion of the chest-wall against which the heart beats and at that portion against wdiich the lung rests. In fact, one oftentimes sees an inspiratoiy depression surrounding the cardiac area, quite similar to that about the margin of the lung. Local variations in pressure caused by the maximum distention of the heart, and its minimum size dtu'ing systole, would also influence the circulation in the thoracic wall. Paroxysms of coughing were formerly considered to be the most important, if not the sole, cause of this vascular distention. They probably do exert a considerable influence, because during a cough the strong positive pressm-e from the inside causes a marked congestion of the subplem-al and subperitoneal veins. This in turn reacts upon certain cutaneous veins which are connected with the subserous veins, and the congestion will be marked along the lines of attachment of the diaphragm. The latter, to a certain extent, acts as a watershed for the venous blood, flowing upward and downward. Everyone wdth a cough does not present this zone of veins, so that we must assume as another factor in its origin a certain indefinite abnormal distensibihty of the smallest vessels. As a matter of fact, it is found oftenest in such patients as exhibit a similar tendency to the formation of dendritic venous dilatations in other parts of the skin. ^ Ueber das Vorkommen und die diagnostische Bedeutung einer Zone ektasierter fein- ster Hautgef asse in der Nahe der unteren Lungengrenze, Corr.-Bl. f. Schw. Aerzte, 1885. TROPHIC AFFECTIONS OF THE SKIN. 59 TROPHIC AFFECTIONS OF THE SKIN. The so-called " decubitus " and the trophic disturbances accompany- ing nervous aifectious will be considered later under Examination of the Nervous System. Clubbed fingers, the peculiar swellings of the terminal phalanges of the fingers, are observed in congenital heart disease, in chronic pul- monary diseases, most frequently in bronchiectasis and empyema (hence the name empyema fingers), and less often in phthisis. The deformity may develop within a few weeks, and then disappear again when the causal disease has decidedly improved. In the more chronic cases even Fig. 19.— Clubbed fingers: Chronic phthisis (New York City Hospital). the bones share in the deformities. The tendons are also affected, though less decidedly. As yet we have little accurate information in regard to the mode of oriofin. ACUTE EXANTHEMATA; CUTANEOUS DISEASES; DER- MATITIS MEDICAMENTOSA. Although the scope of this book does not include the subject of skin diseases and the acute exanthemata, it seems fitting, from the standpoint of diagnosis, to descril)e the rash of typhoid fever, herpes febrilis, miliaria, and the medicinal eruptions. 60 EXAMlSATIOy OF THE SKIN. ROSE SPOTS (Roseola). These are small, round, very slightly elevated, hvperemic, rose-red spots, varying in size from that of a pin-head to that of a small pea. They appear after the beginning of the second week of typhoid fever. They are sparingly scattered over the abdomen, more rarely over the chest, back, and lower extremities. Though most marked at the height of the fever, they may persist throughout the whole duration, and even after convalescence. Eelapses are frequently accompanied by a fresh Fig. 20.— Skiagraph of hand of patient with clubbed fingers (New York City Hospital). crop of spots. Their hyperemic nature is shown by their immediate disappearance under the pressure of the finger, only to reappear instantly when the pressure is removed. From the rash of acne, rose spots are diiferentiated by the ab.sence of a decided center. This tip in acne is caused by some cutaneous gland or hair follicle, or by a suppuration starting in one of them. The opening of a cutaneous gland or hair follicle only rarely is found occupying the center of a rose spot, or a vesicle tipping the center. In doubt we can generally find in a case of typhoid fever other absolutely characteristic rose spots elsewhere upon PLATE 3. Typhoid spots (rose spots) in the region of the umbilicus (natural size). A Rose spots in a case of typhoid fever, showing distribution upon the trunk. The three spots upon the face are rather unusual. ACUTE EXANTHEMA TA , 61 the abdomen. The spots usually pass through a cyclic development, ripening in the course of two or three days and then fading aNvay, Avhile in the meantime new spots have sprung up in other places. In a doubtful case it is often advisable to mark out with a skin pencil the few spots that appear, in order to observe them carefully at each visit. For although rose spots may never appear during the entire course of some few cases of typhoid fever, the positive evidence of this peculiar rash is perhaps the safest diagnostic sign of the disease. (See Plate 3.) HERPES FEBRILIS. This consists of a group of vesicles, J to 2 cm. in diameter, situated upon a slightly inflamed base. The watery content of each vesicle rapidly becomes purulent and turbid, and the vesicle then either bursts or dries up, leaving an irregular scaly crust upon a somewhat reddened Fig. 21.— Herpes cervicalis : Cerebrospinal meningitis (Dr. E. G. Cutler, Massachusetts General Hospital). background. Although they may appear anywhere upon the face, nose, cheek, lip, or ear, they develop most frequently on the outer edge of the lip. According to their position they are called herpes labialis, facialis, nasalis, frontalis, and auricularis. The eruption generally appears at the beginning of febrile diseases ; rarely in the latter stages. It is most common in those fevers with a rapid onset, particularly in croupous pneumonia. [Howard ^ has very recently been able to demonstrate in two cases of labial and nasal herpes and herpes of the body occurring in acute lobar pneumonia pathologic changes in the posterior-root ganglia, the Gasserian ganglia, and the skin. The changes are apparently identical 'Howard, Am. Jour. Med. ScL, Feb., 1903. "62 EXAMINATION OF THE SKIN. with those shown by Head and Carpenter ^ to be invariably associated with herpes zoster. From evidence available at the present date, it is probable that lesions identical in character and similarly localized are present in the herpes of other infectious diseases, arid in the light of our present knowledge, that the lesions of the sensory ganglia, nerves, and skin are due to the action of the soluble toxins of various micro-organisms. — Ed.] Herpes is very rarely observed in typhoid fever. There is a certain type of slight ephemeral fever, with nothing objective to be discovered except the increased temperature and herpes, which is termed febris herpetica. Herpes, as a rule, is considered a favorable prognostic sign. Our ex- perience in the use of streptococcus toxin in the treatment of malignant tumors proves that herpes febrilis depends upon a toxic action. It is common in malaria, cerebrospinal fever, and meat-poisoning; and therefore a sign of some value in the diagnosis of these affections from typhoid. MILIARIA (PRICKLY HEAT); SUDAMINA. Under this head are included various eruptions of tiny vesicles developing most frequently upon the abdomen and chest and usually associated with profuse perspiration. It is generally supposed that this eruption is due to the plugging of the orifices of the sweat glands with swollen epithelium and to the formation of small retention cysts, some of which may be associated with a slight inflammatory reaction in the neighborhood. Three main types are to be distinguished : Miliaria crysfallina (sudamina ; crystal rash) : absolutely transpar- ent vesicles, resembling a dew drop and without reddened base. Miliaria alba : vesicles with slightly turbid contents upon a faintly reddened base. Miliaria rubra : small red papules with a faintly developed vesicle in the center. This type is apt to itch. Miliaria vesicles are generally situated close together. DERMATITIS MEDICAMENTOSA (DRUG ERUPTION). Numerous medicinal agents have the peculiarity of exciting in certain individuals eruptions which resemble urticaria, measles or even scar- let fever. The rash generally fades promptly and disappears when the drug is omitted. Examples of such drugs are most of the antipyretics, especially antipyrin, antifebrin, phenacetin ; not infrequently sodium salicylate ; many preparations of balsams — e. g., balsam of copabia ; and mercury used externally, or, in rare cases, internally. The injection of antitoxin produces an eruption resembling urticaria, measles or scarlet fever very closely. lodid of potash is apt to produce a rash which may closely resemble erythema multiformi or to bring out a purulent acne- like eruption which may be confounded with syphilis or small-pox. The prolonged administration of considerable doses of bromid of potash fre- quently causes an eruption very much like acne. It is usually localized ^ Head and Carpenter, Brain, 1900, Part III. OTHER CUTANEOUS MANIFESTATIONS. 63 upon the face and chest, and an experienced observer generally distin- guishes it by its marked nodular infiltration and bluish appearance. It may develop into suppurating sores covered with crusts which resemble chancroids, and which persist in the resemblance even microscopically by exhibiting a marked overgrowth of epithelium. OTHER CUTANEOUS MANIFESTATIONS IMPORTANT FROM THE DIAGNOSTIC STANDPOINT. Striae. — The striae caused by the stretching of the skin in edema, their resemblance to strise gravidarium, and their persistence for some time after the edema has disappeared or even permanently, have already been noted on page 49. Similar striae may appear from the rapid accumulation or disappearance of the subcutaneous fat. Any cause which rapidly increases the size of the abdomen, such as preg- nancy or the growth of tumors, may produce these striae. Desquamation. — In cachexia and emaciated conditions one fre- quently observes a diffuse bran-like scaliness covering the skin of the trunk and extremities (pityriasis tabescentium). A characteristic lam- ellar desquamation of the skin, usiially most conspicuous upon the palmar surfaces of the feet and hands, occurs after scarlet fever ; a characteristic bran-like desquamation, after measles ; a more crust-like desquamation, after small-pox ; and a flaky desquamation, after ery- sipelas. F'liruiiculosis, as a complication of some general disorder, such as diabetes, is of diagnostic interest to clinicians ; otherwise, it concerns only skin specialists. Scars. — The forms of various scars may be of some importance in considering the past history of a patient — e. g., marks of vaccination, of small-pox, of furunculosis, of carbuncle, of lupus, of inguinal buboes, of tubercular glands, and the bean-shaped scars of serpiginous syphilides. Unfortunately even a slight scar very rarely persists to show the site of the primary sore of syphilis. Surgical operations, various therapeutic measures, such as moxas, cautery, venesections, leeches, Baunscheidtis- mus, and epispastics, and wet-cupping leave behind permanent charac- teristic scars. They may be important in marking the dates of previous illness. DETERMINATION OF THE BODY TEMPERATURE. Physicians in ancient times recognized as a principal symptom of fever an increase in the temperature of the blood. But the amount of fever was measured by the acceleration of the pulse. About the middle of the last century Traube, v. Biirensprung, and Wunderlich perfected the methods for taking the body temperature, considering it one of the essential points to be observed in an examination. Since 64 DETERMINATION OF THE BODY TEMPERATURE. their time the tendency has been to consider that an increase of the body temperature is the essential sign of fever. The classical symptoms of fever include, in addition : weakness, malaise, anorexia, thirst, digestive and psychic disorders, rapid breath- ing, alteration in the amount of urinary excretion, and especially " con- sumption of the body." Some, though not all, of the above-mentioned symptoms may be produced by an artificial overheating of the body. Certain of them, however, by no means run parallel to the increase of temperature ; for sometimes, either with or without antipyretics, the temperature may drop without any especial imj^rovement in the other symptoms. Hence, an increase of body temperature is the most important and constant ac- companiment of what we call fever, and to-day the terms are used inter- changeably. But still we must not neglect the associated phenomena of the febrile system-complex in determining the severity of an attack, because they are partly independent of the temperature, and are some- times much more important than the amount of temperature increase. Before the use of thermometers physicians estimated the temperature by the sense of touch. Though generally this is a perfectly satisfactory method of telling whether or not fever is present, many mistakes may arise. The hand appreciates only the temperature of the skin. This is not always parallel to the internal temperature of the body or of the blood ; because the skin temperature evidently depends not only upon the temperature of the blood, but also upon the amount of blood in the skin at a given time, as well as upon the conditions of heat radiation. For example, during a chill the cutaneous temperature is sometimes dimin- ished as a result of a contraction of the peripheral vessels, while the blood temjjerature, as shown by the thermometer, is increased.^ Conversely, the cutaneous temperature of perspiring patients seems increased, pro- vided evaporation and subsequent cooling is prevented by their being wrapped up, because the skin contains an increased amount of blood. Yet the internal temperature need not be raised. These possible sources of error make it plain that thermometers are essential for the accurate determination of the temperature relations. Nevertheless, palpation of the skin is of some value in disclosing the condition of the cutaneous cir- culation. It is oftentmies accurate, provided that evaporation, chill, and profuse perspiration can be excluded. Perhaps the best place for such palpation, when the patient is in bed, is the back ; for there the tem- perature must be nearly the same as that of the blood. In spite of a high temperature, the skin need not feel very hot to the physician's hand if the room temperature is low and the skin, as well as the blood itself, has been cooled by the surrounding air. This is a point especially to be remembered for the diagnosis of ambulatory typhoid. ^ According to Liebermeister, fever depends npon an alteration in the temperature regulation. Either heat production or heat radiation, one or both, are affected. This view has been supported by more recent experiments (Hildebrandt, Stern, and othei-s). During a chill it is supposed that the cutaneous temperature is not diminished actually, but only relatively, com])ared with the internal temperature, and that the cutaneous sensibility in response to this relation replies by the excitation of a sensation of chilliness. METHOD OF TAKING TEE TEMPERATURE. 65 THE THERMOMETER. The thermometer carried by practising physicians is a mercury in- strument, subdivided in England and America, according to the Fahren- heit scale, from 95° to 115°, and on the Continent, according to the Cel- sius scale, from 20° to 45°. To convert Fahrenheit into Celsius and vice versa : A° Celsius = (f a + 32)° Fahrenheit, or A° Fahrenheit = (a — 32) |° Celsius. A variety of small clinical thermometers can be obtained in America or in ^England (perhaps the best are the English make). They are very accurate, so that an explanation of the method of correcting and tabu- lating their errors is hardly necessary. [The one-minute Hick's max- imum clinical thermometer, furnished with a prismatic lens to magnify the column of mercury, is perfectly satisfactory. — Ed.] The cylindric is ordinarily more convenient than the old-fashioned spheric bulb. The so-called " maximum " thermometers in most common use to-day require vigorous shaking to ])ush the mercury down below the normal point. Then the mercury remains at whatever height it may reach until shaken down again. METHOD OF TAKING THE TEMPERATURE, The temperature is ordinarily taken by placing the bulb of the ther- mometer beneath the side of the tongue and instructing the patient to keep the lips tightly closed during the necessary interval (one to five minutes). In some cases it may be necessary to obtain the temperature in the axilla, and, whenever in doubt, in the rectum or vagina. It is hardly necessary to caution a physician to be most careful in disinfecting the thermometer after each time it is used. In many of the hospitals in Germany they employ a large thermom- eter, leaving it in the axilla from fifteen to twenty minutes. With comatose, stupid or violently delirious patients or with patients suffering from severe dyspnea or from nasal obstruction sufficient to impede breathing, the temperature must be taken in the rectum or vagina. [The ordinary one-minute clinical thermometer is sufficiently accurate when used in the mouth, and absolutely so in the rectum. — Ed.] In any case the temperature should be measured at least twice a day, and under many conditions every two to four hours. When the morn- ing and evening temperatures are taken, the morning commonly repre- sents the temperature between 7 and 9 o'clock, and the evening between 4 and 6 o'clock, which furnishes a practical maximum and minimum without disturbing the patient's sleep (see pp. 66 and 68). The tem- perature is ordinarily indicated upon temperature charts ruled either for every two hours or merely for morning and evening. The normal line is generally printed more deeply or in another color. (See Figs. 28 and 29 for a convenient method of indicating night and day tem- peratures.) 5 6^ DETERMINATION OF THE BODY TEMPERATURE. The temperature curve alone sometimes suffices to make a diagnosis with considerable certainty ; as, for instance, in typhoid fever, pneumo- nia, chronic tuberculosis, malaria, and suppurative processes. Even a single estimation of the temperature will often throw considerable light upon the diagnosis. Simulation may be excluded if there is decided fever. THE NORMAL BODY TEMPERATURE. The normal temperature is 0.2° to 0.5° C. (0.4°-l° F.) higher in the rectum or vagina than in the axilla, von Barensprung gives the following figures as the normal mean in the axilla at the various ages : First 10 days 37.75° C. (99.95° F.). Up to puberty 37.43° C. (99.37° F.). 15 to 20 years 37.19° C. (98.94° F.). 21 to 70 " 36.85° C. (98.93° F.). 80 years 37.26° C. (99.07° F.). These, of course, are the daily averages. The daily variation of temperature in a normal person is shown in Fig. 22. The minimum of Hours of the day. iHHBBB BBBH BBBBBBBBBBBBWBBBBBBBI S9| ■■■■■■■■■■■a ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■SS'S'SSBBBSB! ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■B55SS ■■^■■^■■■■■■■■■■■■■■■^■■■■■■— ■■■■■■;■■■■■■ ■■■■ ■»■■■■■■■ Fig. 22.— Daily curve of the normal body temperature (Liebermeister). temperature is observed in the first few hours after midnight ; its first maximum is reached during the forenoon, generally between 9 and 10 o'clock ; it falls again before the midday meal, rises and reaches a sec- ond, the proper maximum, some time between 5 and 8 o'clock in the evening; it then begins to fall till the first minimum is reached. The periodicity of the normal temperature curve probably depends primarily upon the change between waking and sleeping. At least there have been numerous examples of people accustomed to reversing the day, sleeping in the daytime and working in the night, in whom the temper- ature variation is reversed. Food and physical exercise influence the temperature. Mountain- climbing, for example, has raised the temperature in normal individuals as high as 40° C. (104° F.). The temperature of the external air has some effect upon the body temperature. Sometimes just before a thun- der shower a slight rise has been noted in normal individuals. Lieber- meister's chart shows that the daily variation amounts to 1° C. (1.8° F.), comparing the absolute maximum and minimum, but to not more than 0.5° C (0.9° F.) comparing the difference between the morning temper- FEBRILE TEMPERATURES. 67 ature at 8 or 9 o'clock and the evening temperature at 5 o'clock.^ An evening temperature of 37.4° C. (99.32° F.) is within physiologic limits ; although in consumptives it would probably correspond to a rectal temperature of 38° C (100.4° F.), and so indicate fever. [Unless otherwise stated these temperatures are mouth temperatures. —Ed.] FEBRILE TEMPERATURES, Wunderlich has computed the following fever scale : I. Normal temperatures, 37.0°-37.4° C. (98.6°-99.3° F.). II. Subfebrile temperatures, 37.4° -38.0° C. (99.3°-! 00.4° F.). III. Febrile temperature : («) Slight fever, 38.0°-38.4° C. (100.4°-101.1° F.). (6) Moderate fever, 38.5-39.0° C. (101.3°-102.2° F.) in the morning to 39.5° C (103.1° F.) in the evening, (c) Considerable fever, up to 39.5° C. (103.1° F.) in the morning to 40.5° C. (104.9° F.) in the evening. {d) High fever, above 39.5° C. (103.1° F.) in the morning and above 40.5° C. 104.9° F.) in the evening. Hyperpyrexia. — Very unusual temperatures, 41° or 42° C. (105.8° or 107.6° F.) are spoken of as hyperpyrexia. Teale's case (injury to the spine and recovery) is the highest recorded temperature, 50° C. (122° F.). At the Insel Hospital, Berne, a patient with typhoid fever, who subsequently recovered, once exhibited a temperature of 45° C (113° F.). Similar cases are quoted in literature as medical curiosities. A temperature above 42° C. (107.6° F.) is rare to-day, because we now have at our command more efficient means of combat- ting fever. Stern has recently given to the term hyperpyrexia a general pathologic signifi- cance, limiting it to those cases in which the heat regulating apparatus is insuffi- cient, in contradistinction to febrile temperatures where the regulating apparatus is capable of preventing a further increase or an undue cooling-off. Hyperpyrexia includes, therefore, the excess of temperature added to fever by insufficient heat radiation. We do not really know in every case whether fever is injurious or bene- ficial; but it is evident that hyperpyrexia is a dangerous surplus of heat, and therefore to be controlled therapeutically. Stern considers that true fever may be distinguished clinically from hyperpyrexia by the fact that when the temperature of a patient with fever is reduced hj means of a cold bath a reaction takes place directly (chilliness, shivering), whereas no such reaction occurs in hyperpyrexia, nor does the patient experience any discomfort. However, we may still consider almost any excessive temperature under the heading of hyperpyrexia. PROGNOSTIC SIGNIFICANCE OF HIGH TEMPERATURES* Although a certain significance can be attributed to the height of the temperature, we must be very guarded in making the prognosis of a disease, and not assume that every high fever is necessarily fatal. In general a typhoid fever with a high temperature curve is more severe ^ Debcynski, ref. in Hermann's Handhuch der Phyaiohgie, 1882, vol. TV., p. 323. Further, U. Mosso : Experienze fatte per invertire le oscillazioni diurne della terapera- tura neiruomo sano. Laboratorio di fisiologia nella R. Universita di Torino, 7th ed. 68 DETERMINATION OF THE BODY TEMPERATURE. than one with a low range, and in the same patient an increase of tem- perature generally coincides with some more serious condition or with a complication. The bearing of a certain height of temperature upon the prognosis varies greatly in different diseases. In malarial fever, for example, the temperature may be extremely high without rendering the prognosis more serious ; or again, quite innocent throat affections in children are responsible for temperatures of 40° C. (104° F.) or more. Unverricht ^ has published a collection of abnormally high tempera- tures in which, nevertheless, recovery followed. THE FEVER COURSE, DAILY VARIATIONS OF THE FEVER; THE FEBRILE TYPE. The daily course of temperature in any case of fever lasting one or more davs is usually much the same as in healthy individuals. If the curve pictured upon page 66 were elevated one or two degrees throughout it would correspond accurately enough to the daily variation of many a fever. But in numerous febrile diseases the maximum or minimum point may appear at a different time ; for example, the maximum point may occur in the forenoon or at midday. Again, the daily vari- ations may be much greater than in a normal individual, or in the morning the patient's temperature may be normal and in the evening elevated two or three degrees. It is therefore evident that to obtain the accurate temperature of a patient with fever we must not be content w^ith measuring the temperature at morning and night alone, but take it at regular, shorter periods, such as once in two hours or once in four hours. An irregular fever is often first discovered by taking the temperature at an unusual time ; for example, late at night. A very good indication of the amount of fever is, of course, the patient's feelings ; he generally feels worse when he has most fever. Various types are distinguished according to the variation of the fever during the day. In prolonged or continued fevers the daily oscil- lations rarely vary more than in a normal individual — /. e., not more than 1° C. (1.8° F.). In remittent fevers the daily variation is more than 1° C. (1.8° F.). In intermittent or interrupted fevers the daily minimum is normal or below normal. Since malaria is now so com- monly called intermittent fever, it is perhaps advisable to designate this type as interrupted fever. COURSE OF FEVER FOR LONGER PERIODS ; COURSE OF FEVER EST A RESTRICTED SENSE OF THE WORD; THE FEVER CURVE IN DIFFERENT DISEASES. The fever type, meaning more particularly the daily variations, is of less diagnostic importance than the so-called course of fever or fever curve, including a longer period of observation. '^ Unverricht, " Ueber das Fieber." Sammlung klinischer Vortrdge, No. 159, p. 724, 1896, Breitkopf and Hlirtel. THE FEVER COURSE. 69 EPHEMERAL VARIETIES OF FEVER (SINGLE-DAY FEVERS) (FEBRICULA). Ordinarily these are either well-known infections whose nature is shown partly by the objective examination, partly by the prevalence of an epidemic of similar cases, but which run an abnormally rapid or abortive course ; or else slight infections of some unknown origin, or else are caused by temporary digestive disorders, or else due to some nervous influence, such as hysteria or mental excite- ment ; children, as is well known, exhibit a rise of temperature from very insig- nificant causes ; in the beginning of an ephemeral fever a diagnosis is almost impossible — so that the height that the temperature reaches will often cause appre- hension. Under this heading is included the fever which appears after catheterization, whose origin we do not perfectly understand, and the brief fever following asejjttG operations. The latter is to be explained by purely psychic influences, such as anxiety as to the result of the operation, by the toxic action of the chloroform, or Day of Disease 1 a 3 ■f r 6 7 8 9 /o // /s. 13 70 60 SO ^0 30 Zo P /60 l'i-0 no loo do 60 104" lOf 10Z° 101 100 sr 38° S6° N •? <■? A S-, . / \ t?/ 1 ■^^ \ 1 \ / , \ • / \ ^' I -^ Ac \i ^ / \ 1 ' \ ^t \ ^- .V f \ / \ \ 1 *,_ -^ CD ■ — ; 3 "^ I S-^ifK"^- — 7 s A "^ § ji 1'. — — X. •° ^^ ^-•~-:^ X "A " ^ %^^::-'-'^ 7 r ^ ^ •••..— — : t "^ > ^ ^\:^----=^ _ t '-'' '^ ■^ ^ ^~~~->. V =! -C f^ -^S-'- r ' o >^ ■■^"■""— a,. V "<> t *Cl ...■ . .-■ ^ r " 1^ ^ ""^z:- V ' t a . •-■■,- ' r - 'z : r "^ > ^i-' -^ t ' i ^:^-s. t "^ - r c 'j '■■•-" -L L 5 s '^ ■^'-' - h- 2 ^ •••-.-~-~,^ - ^^ "^ £ ^ ^^"' h- - o \ '^ ^ ^1 •ii-" ? ■■ 3 Kl '^--^ V -§ o CV ..--^---^ y - £ \ *^ s« •■•■ ---'^^ Y "•- 5 --■<-T \ '-- i y ..--'^ / ^ ■•- IT" ~-. ^^ ^^ '- 1 ^ ^ie'"' -^ " ^ ^ ^ :.-•-- V "■" 1 K^ ■•■ -^ \ -'- "^ "^ ^-" -*'' / " ^ ^_" <^ -' -4 •-. "■-•^ _S^ - ^i 1- °^ 1 1 *^ s 1 ^ T "^ "^ ""^ k 1 ^ ^ i; 1 f^i 5 S ! 5 « i 3 ^ Q «^ as rapidly as it developed, usually accompanied by a profuse perspiration. This sudden drop in the temperature, so characteristic of pneumonia, is called the crisis. Lysis, in contradistinction, signifies a' gradual drop of temperature during two or three days. The latter is rarely observed in croupous pneumonia, but very com- THE FEVER COURSE. 71 monly in many other febrile diseases. A protracted crisis is a transitional type between the two. An interrupted crisis is a critical drop of temperature interrupted by a transitory rise, A pseudocrisis is one in which a critical fall is rapidly followed by a rise and persistence of the fever. A decided rise of temperature associated ■with a marked disturbance of the patient's general condition, the so-called per- turbatic critica, sometimes precedes the crisis. All of these conditions may be variously combined in pneumonia (Fig. 23). So far as the fever is concerned, erysipelas resembles it veiy closely. THE COURSE OF TYPHOID FEVER. The temperature of typhoid fever is characterized by a gradual stepladder-like onset, so that each evening it reaches a little higher point than the evening before. F. 106° 1 2 D a5 3 rs Of F 3 re r. 6 7 i. i c. -4|0 1 A -^_ Q 11 I > k J i ' -40 I 1 1 i 1 / 1 \ y \ \ 1 . -39* 1 f \1 A \ A I n \ \ -37 \ -1 -J Initial fever. Eruptive fever. Fig. 25. — Fever curve in measles. The initial stage lasts four to seven, days ; it is followed by a period of continued high temperature without much of any diurnal variation, the so-called fastigium, (seven to ten days) ; and then by a period of remittent fever, the amphibolic stage, F. 1 5 [ I )a 4 ys f 6 .'er 7 i [ 0. / f _ [p t\ . J _ \r _ A _ _ 104° - ? — — jC Y7 H — — — — — -40* 1^ r y s _ _ _ _ / L _ _ _ -'— — — ' — — X -| 4 — — — — -39" 1 / 1 V - ~ 1 _ - , — — — — ' — ^ — —J — 1 L 1 L - ^ l Exanthem. Fig. 26.— Temperature curve in scarlet fever. 72 DETERMINATION OF THE BODY TEMPERATURE, ios° 40* 3S« Initial rise. Suppuration temperature. Fig. 27. — Temperature curve in small-pox. in whicli the diurnal variations are very marked, often with a difference of several degrees. This lasts five to ten days and merges into the de/ervescing stage, which is as Fig. 28.— Temperature in intermittent quotidian. gradual as the initial rise. The chart on page 70 (Fig. 24) shows this peculiar temperature curve better than we can describe it. THE FEVER COURSE. 73 TEMPERATURE CURVE OF MALARIAL FEVER. The curve of malarial fever (Figs. 28 and 29) is characterized by a critical rise and fall of the temperature every two or three days, associated with the other symptoms of an acute disease. In typic cases the patient feels quite well during the interval ; the rise of temperature occurs very suddenly, is accompanied by a marked chill, and is followed later by a sudden drop and a profuse perspiration. The various types are named quotidian, tertian, and quartan fever. As a rule, in malaria the attacks repeat themselves at exactly the same hour. Numerous excep- tions do, however, occur ; in the anticipating variety, the attack of fever appears a little earlier each day ; in the postponing variety, a little later each day. 74 DETERMINATION OF THE BODY TEMPERATURE. CURVE IN RECURRENT FEVER. As in malaria so in relapsing fever the temperature curve consists of a number of individual attacks. Each attack and each interval, however, persist for several days in recurrent fever (Fig. 30). The relapses may be repeated several times, but finally become shorter and less severe, until complete defervesence takes place. RELAPSES. In any acute infectious disease there may be a recrudescence of the specific symptoms, and especially of the fever, after convalescence has apparently begun. Such recrudesences are most common in typhoid. They should not, of course, be 4 5 6 7 Days of Fever. 8 9 10 11 12 13 14 15 Ifi 17 18 19 20 1 . L L_ V 107 » 106" 105' H- ^ ? ^ I ± EiE J t p= J_ _ - -L J_ ^ ( 1 - _ z E r L J _ z E -41° 104° 103° 102° 101° 100° 89° 9S° S7° z z E _ E z — E - E: t E = z A E 1 z 1 E E 1 ^ E E E ztz ^ E E : _ E z - - E I E - z E - zt i •39° .33« -37° _ E E ± r z E g E z z z ^ E z ztz z z zlz ^ 1 ^z 1 1 ^ 1 -38" 1 First apyrexia. First relapse. Second apyrexia. FiG. 30.— Temperature of recurreut fever (Wunderlich). confused with the individual attacks in febris recurrens or malaria, nor with any complication of the original disease ; as, e. g., an otitis in measles or scarlet fever. HECTIC FEVER. This is the typic fever of chronic tuberculosis. It generally persists a con- siderable length of time and is of a remittent or interrupted character, mth sud- den rises and falls. The minimum temperature is usually in the morning and the maximum in the evening, or the opposite type may occur — inverted hectic fever. A two-hour chart exhibits a very irregular course, with many slight rises and lalls throughout the day. PUS. OR SUPPURATIVE FEVER t ERRATIC CHILLS IN PYEMIA, ULCERATIVE ENDOCARDITIS, AND GALL-STONES ; CHILLS IN INFARCTIONS. Though often resembling the chart of hectic fever, that of suppura- tion is generally more irregular in the time and the degree of the exacer- bations. In pyemia the fever frequently occurs in very intense paroxysms, accompanied by severe chills resembling malaria, except that they are more irregular. Closely related to these so-called erratic chills of py^- SUBNORMAL TEMPERATURES. 75 mia are the chills which appear in ulcerative endocarditis and in gall- stone affections. Non-purulent infarctions are associated with a similar, though a less pronounced, chill. ATYPICAL FEVER. In some diseases there is no type to the temperature course, so that, although the clinical picture is sufficiently constant, the temperature Days of Fever. 4 5 6 7 103 \OZ 101 100 -39' 38' -37* -36° Fig. 31.— Hectic fever in phthisis. chart alone would furnish very little information of the nature of the disease. Examples are diphtheria and septic -processes. SUBNORMAL TEMPERATURES. These are quite as important clinically as febrile temperatures. "VVunderlich considers anything below 36.25°C. (95.25 °F.) a sub- normal temperature. Marked depressions of temperature are noted : 1. In the prolonged action of intense cold.^ A temperature of 27° C. (80.6 °F.), as in a case of freezing, is not necessarily fatal. 2. Following a pronounced critical fall of temperature in fever. After the crisis in pneumonia the temperature often drops to 34° or 35° C. (93.2° or 95° F.). 3. In so-called " collapse," where there is a sudden fall in the temper- ature. This occurs in very sick patients (especially those with fever), and is associated with marked weakness, numbness, rapid pulse, profuse per- ' Compare Glaser, " Ueber Vorkommen und Ui-sachen abnormale niedriger Korpertem- peraturen, Inauguraldissertation," Bern, 1878; and Janssen-Quincke, " Ueber subnormale Korpertemperaturen," D. Arch. J. klin. Med., vol. liii., p. 247. 76 DETERMINATION OF THE BODY TEMPERATURE. spiration, etc. The crisis in pneumonia is sometimes mistaken for a collapse. The pulse, however, in the latter is weak and rapid ; whereas in the former it remains of good strength, and diminishes in frequency proportionally to the fall in the temperature. Collapse is a precursor of death. The accompanying symptoms are usually attributed to crit- ical weakness. Vasomotor inhibition may also be a factor. 4. Sometimes after a severe hemorrage; in chronic heart and lung diseases, which lead to imperfect aeration of the blood (cyanosis), and R P_T_ 70 GO SO 30 HO 140 IZO roo 80 m° m° /of 101° /00° 93° 1 / /\ / ; /\ A / 1 / > A / I / ^ ./ \ / V \/ i ; .". ,'\ < ,•" ,■' .-■ \ / i 1 I 1 1 1 • 1 1 -'"'■^ 1 ..-' 1 1 ' 1 1 Fig. 32.— Pulse, temperature, and respiration in collapse. therefore to insufficient oxidation of the various processes throughout the body ; further, in chronic wasting -diseases (carcinoma of the esophagus), where metabolism is reduced to a minimum; m sclerema neonatorum; and finally in mentally afflicted patients, especially of the melancholic type. Prolonged subnormal temperatures accompanying such conditions as are mentioned above always indicate a grave diminution of the metab- olism or some equally serious disturbance of the heat regulation. CHARACTER OF THE RESPIRATION. 11 CHARACTER OF THE RESPIRATION. FREQUENCY OF RESPIRATION UNDER PHYSIOLOGIC CONDITIONS. Hutchinson quotes the normal respiratory frequency in adults as between 16 and 24, or about 1 to every 4 pulse-beats. Quetelet gives for the newborn an average of 44, for the iive-year old child 26, respi- rations to the minute. It is a good plan to count the respirations while apparently feeling the pulse, because the patient's attention might otherwise modify the rate. For greater accuracy, the number of respirations should be counted dur- ing an entire minute. Physical exertion will increase the rate of respiration ; lying down or sleep will diminish it somewhat. A stomach distended by food and drink increases the rapidity of the respiration because the dia- phragm excursion is thereby somewhat limited. Irritation of the skin may increase or diminish the rate of respiration. Psychic or sensory impressions, movements, clearing the throat, eating, drinking, or smok- ing will alter the rapidity of the respiration. Before considering that a certain rate of respiration is pathologic we must therefore bear in mind all these physiologic variations. NORMAL TYPES OF BREATHING. The distention of the lungs with air takes place partly by means of raising the ribs and sternum and rotating the former outward and up- ward, and partly by depressing the diaphragm. Although in every- body both these factors take part in the movement of respiration, yet one or the other is apt to be more prominent, thus producing a more costal or a more diaphragmatic (i. e., abdominal) type of breathing. Women commonly breath costally ; men, costo-abdominally. This selec- tion, which seems to depend upon the formation of the chest, is naturally very suitable during pregnancy, when the diaphragmatic excursions are interfered with. A child's breathing is essentially costal. PATHOLOGIC VARIATIONS IN THE TYPE OF RESPIRATION. Either the costal or the diaphragmatic element may be implicated and so alter the type of respiration. I/imitation of Diaphragmatic Breathing. — The excursions of the diaphragm may be impeded by some mechanical interference with its descent — e. g., by a paralysis of its muscular structure ; by an ab- normal flattening of its vault (in certain types of emphysema) ; by pain- ful breathing ; by any increase in the abdominal contents — i. e., preg- nancy, meteorism, abdominal tumors, ascites. Any inflammation in the vicinity of the diaphragm — e. g., pleurisy, pericarditis, peritonitis — will 78 CHARACTER OF THE RESPIRATION. limit the excursions of the diaphragm, partly on account of the pain and partly from a slight paralysis of the muscle fibers of the dia- phragm (especially in diffuse peritonitis, on account of the disturbances in the circulation following the inflammation). Actual diaphragmatic paralysis occurs in viultiple neuritis, in progressive muscular atrophy, etc. In any of the above instances the costal breathing may appear to be in- creased at the expense of the abdominal effort. I/imitation of Costal Breathing-. — Costal respiration may be interfered with in a mechanical way by extensive ossification of the costal cartilages (ankylosis of the articulations of the ribs in arthritis deformans, etc.). Under such conditions the costal type in women and children and the costo-abdominal type in men may become purely abdominal. DIAPHRAGM PHENOMENON AND ALLIED APPEAR- ANCES (LITTEN'S SIGN), Litten ^ called attention to this almost forgotten sign, analyzed a series of cases, determined its practical significance, and named it the " diaphragm phenomenon." (Plate 4). It consists of a horizontally placed shadow observed with inspiration near the lower pulmonary edge, most constantly anterolaterally, but occasionally running in a ring around the whole chest. This shadow seems to slip downward, corresponding to the inspiratory descent of the pulmonary margin, as shown by percussion. It is very fittingly named, because, as a matter of fact, it is the most distinctly visible evidence of the depression of the diaphragm. Normally, the moving shadow begins above in the sixth intercostal space, descends with superficial inspiration one to one and one-half intercostal spaces, and with deep inspiration two to three spaces. It intersects the ribs at an acute angle. To show it most distinctly, the patient should lie as flat as possible (without extra support for his head) and with his feet toward the window, so that the region between the sixth rib and the costal margin is lighted obliquely. The observer should stand between the patient's feet and the window, with his eye at a distance of 3 or 4 feet and at an angle of about 45 degrees with the lower thorax. Provided the patient breathes deeply and the light, although not necessarily strong, slants sufiiciently, the phenomenon is generally plain. Even a candle light may be sufiicient, but a very difluse light is unfavorable. There is no corresponding expiratory sign. The flattening of the lower intercostal spaces fi-om below upward during expiration is of quite different significance. The explanation of Litten' s sign is comparatively simple. As the diaphragm in its descent begins to peel off from the thorax and both widens and deepens the complimentary pleural sinus, it exerts a suction upon the intercostal spaces just below the margin of the lung. This produces the shadow. It is evident that no analogous process will occur during expiration, because the elevation of the diaphragm is regulated only by the elastic retraction of the lung. In health, particularly in lean individuals, the diaphragm phenomenon is a nearly constant •appearance. Marked development of fat or muscle or edema of the thoracic wall will prevent its appreciation, and even under perfectly physiologic conditions it may be sought for in vain. Its presence proves that at the particular place where it is observ'ed the diaphragm and the lung lie against the thoracic wall, both freely movable; its absence points to the opposite conclusion. Therefore it cannot be made out opposite pneumonic infiltrations nor in those places in pleurisy where the exudation is situated, or where the lung is adherent to the chest, nor in hydro- or pneumothorax, etc. Litten has called attention to the fact that this sign is of great value in differentiating an empyema from a subphrenic abscess; it is absent in the "^ DeuUch. med. Woch., 1892, No. 13. Das Zwerchfellphanomen und seine Bedeu- tung fill- die Praxis, Deutsche Aerztezeitung, 1895, No. 1. Verhandl, dea Cony.f. inn. Med., 1895. PLATE 4. V P'i}K^"u«'^ P^P°°^f"0P (Litten's sign), from a patient with fibroid phthisis of left Inn? fXew lorK Lity Hospital), ihe linear shadow has been emphasized in the reproduction of the photo- «^^i: -f'"'',.^'/'^'"''''^"-— ^'nte the height of the shadow and the slight concavity of the abdomen correspondini,' to the respiratory phase. -• a'^''''''"" -'^««/J"'a<''-'« — ^'at■e the descent of the linear shadow and the slight change of con- tour ot abdomen corresponding to the respiratory phase. 3. Deep Impiratiou.—yote the further descent of the linear shadow and the rigid abdomen corresponding to the respiratory phase. Although the arti.st has intensified the shadow in the reproduction, the excursion of tlie rio-ht lung and right side of the diaphragm were so pronounced in this patient that the distance oetween the shadows in the extreme positions of respiration was greater than has been repre- sented. The patient s left lung was practically useless : hen<.'e the abnormal extent of the right lung s excursion. " . INSPIRATORY RETRACTION OF THE CHEST. 79 former but present in the latter. ^ Under some conditions the diaphragm phenomenon may facilitate a distinction between pneumothorax and diaphragmatic hernia. A broken or irregular shadow is said to point to partial adhesions of the diaphragm to the thorax-wall. The extent of the diaphragm phenomenon will furnish some idea as to the excursion of the lung in emphysema and phthisis. Paralysis of pai-ts sup- plied by the phrenic nerve is associated with an absence of the diaphragm phenom- enon. Since this sign is by no means absolutely constant in healthy individuals, it is evident that its absence upon one side alone is much more important than upon both sides. We must be careful not to confuse the diaphragm phenomenon with two other conditions which exhibit shadows in the same area — viz., the visible depression of the lower ribs with expiration and the retraction of the lower intercostal spaces with inspiration. The former, being expiratory, is easily differentiated from the diaphragm phe- nomenon ; but the latter, being inspiratory, is more difficult to distinguish. The lower intercostal spaces situated along the attachment of the diaphragm are under a positive intra-abdominal pressure when the latter is in a position of expiration, whereas they are exposed to a negative intrathorax pressure when the diaphragm is depressed by inspiration, and therefore they are retracted in the same way as the diaphragm. The physiologic retraction of the lower intercostal spaces as a whole will thus present a descending shadow easily to be confounded with the Litten sign, but a careftil observation will detect the difference. The shadow of the Litten sign is linear, passing through the intercostal spaces as a line, while the shadow of the physiologic retraction of the intercostal spaces is more diffiise, each space, one after another, becoming shaded in toto. Very often also the descending character of the inspiratory retraction cannot be recognized at all, because the diaphragm in its con- traction exerts a suction upon those intercostal spaces from which it has not yet separated. A further distinction is, that an exactly opposite movement from below upward takes place during expiration — i. e. , an expiratory bulging. This does not occur in the diaphragm phenomenon. The depression in stenosis of the air passages, and the essentially identical peripneumonic retraction, differ from this physiologic retraction in that the appear- ances are very much more marked in the former, affect the ribs as well, and are not confined. to the intercostal spaces in the territory of the diaphragm. ASYMMETRIC RESPIRATION AND PATHOLOGIC INSPI- RATORY RETRACTION OF THE CHEST. An obstruction to respiration which affects but one lung will cause asymmetric breathing ; the diseased side will make a less extensive ex- cursion and will also lag somewhat behind the healthy side. The con- ditions which may give rise to such a unilateral limitation of breathing are : the various types of pulmonary infiltration (pneumonia, phthisis, tumors) ; pleurisy with effusion or pleurisy merely with the formation of fibrous bands and tough adhesions ; and pericarditis with -effusion. Asymmetric respiratory excursions may be appreciated by inspection, but they will oftentimes be much better appreciated by palpation. With one hand placed upon each side, the examiner can at the same time appreciate an asymmetry of the chest contour. The chest, half of whose mobility is diminished, may be either expanded or contracted, as ex- plained upon p. 34 et seq. Compare p. 86 e^ seq. for the occurrence of inspiratory retraction in ' It is well, however, not to lay too much stress upon this statement, because, althoug:h cases have been demonstrated, we can as yet scarcely be sure that the diaphragmatic movement is not sometimes impeded by a subphrenic abscess. r 80 CHARACTER OF THE RESPIRATION. the jugulum (suprasternal fossa), epigastrium, and flanks with stenosis of the upper air passages. But similar local retractions occur without any stenosis over parts of the lung area where the normal inspiratory distention of the lung is prevented by atelectasis or by infiltration. This retraction, especially when it occurs quickly and violently (as with dyspnea), is due to the variation in the inspiratory negative pressure within the interior of the chest, which draws in the more expansible portions of the lung along with the overlying portions of the chest wall under the influence of the external atmospheric pressure. AVe see this particularly well marked in the catarrhal pneumonia of children, whose soft and more flexible chests favor the retraction. It is called a " peripneumonic retraction " or a " pjerijmeumonic groove." It is usually situated in the lateral and anterior region of the chest along the lower lung border, even when the pneumonia is, as usual, situated in the back. This probably depends upon the fact that the stiif infiltration located in the back interferes mechanically to a certain extent with the excursions of the lung margins at the sides and in the front, and that the anterior and lateral portions of the chest are especially flexible. Peripneumouic retractions are, however, sometimes observed posteriorly, near the inferior pulmonary margin. The direct pull of the diaphragm, just as in stenosis of the upper air passages, may, in addition to these mechanical factors, help to create a peripneumouic depression (see p. 87). The epigastrium and the jugulum, too, may be retracted in a similar way in pneumonia, so that in small children the diagnosis of croup is not infrequently suggested. The inspiratory stridor, and hoarseness of the voice and of the cough in the latter ordinarily facilitate a distinction, Peripneumouic retraction must not be confounded with the normal inspiratory depression of the lower intercostal spaces, the explanation and differentiation of which have been discussed upon page 7S et seq. D. Gerhardt^ has recently called attention to another cause of inspirator}' re- traction of the lower thoracic margin. Besides the diaphragm's well-known eflfect upon the inferior surface of the lung, Ducherme demonstrated that by resting on the abdominal contents and moving over the parts contained in its vault, as over a roller, it has in inspir.-ition the action of lifting the margin of the thorax. If this decided elevation of the lower ribs is prevented by immobility of the costal articula- tions or by the horizontal jjosition of the ribs, as in some emphysematous chests, or by the lack of any firm point of attachment of the abdominal contents in enteroptosis, then during inspiration the contraction of the diaphragm will depress the chest- wall inward. ABNORMALITIES IN FREQUENCY AND RHYTHM OF THE RESPIRATION fnot Including Dyspnea). Alterations in the frequency of respiration depend for the most part upon difficulties of pulmonary aeration or upon increased demands upon the lung, and will therefore be considered and explained with the symp- tom-complex of dyspnea in the following chapter. Only in very rare ^Zeit.f. klin. Med., 1896, vol. xxx., Nos. 1 and 2. ABNORMALITIES IN FREQ UENCY AND RHYTHM OF RESPIRA TION. 81 instances are changes in the frequency of breathing independent of dyspnea. To this group belongs the diminution of respiratory frequency (oligopnea) found in certain conscious states, especially in severe brain affections (meningitis, hemorrhage, or in tumors of the brain) ; uremia ; diabetic coma ; severe infections ; some cases of poisoning ; and in a similar way in the final agony. Irregularity of the respiration may be noted as well in any one of these conditions. Unquestionably these disturbances are distinctly dependent upon an alteration in the function of the respiratory center. Either one of two very characteristic types of pathologic breathing, each one associated with a change in the rhythm, may arise under ex- actly similar conditions instead of the slowed respiration just mentioned. These are the so-called Biot's or meningeal and the Cheyne-Stokes respiration. Biot's respiration, especially common in meningitis, may also occur in other cerebral disorders and in other grave general conditions. It is characterized by very decided pauses in the breathing, which last from several seconds to half a minute or longer. They are more or less periodic, but at times repeat themselves irregularly. It is a phenomenon of grave prognostic significance. Cheyne-Stokes respiration is characterized by similar long pauses in the breathing. It differs, however, from the above by the fact that the breathing begins very slowly and superficially after the pause, gradually increases in depth and intensity to a maximum, diminishes again, and finally stops entirely, thus producing another respiratory pause. It is, therefore, a distinctly periodic type of respiration. It occurs under similar conditions to the Biot's meningeal respiration, especially in grave affections of the brain, of the respiratory and of the circulatory organs, and quite frequently in arteriosclerosis and chronic nephritis. Although more frequently observed in the unconscious, it is not uncom- mon even when consciousness is maintained, especially in patients with chronic respiratory or circulatory disorders. In these affections con- sciousness oftentimes oscillates with the respiration, is periodically obliterated during the pause, and returns again when respiration is resumed. There are other phenomena more or less characteristic. During the pause in the breathing the rate of the pulse may be decidedly slowed, its tension may be altered, and the pupils may be contracted. Very often, though by no means always, patients have a subjective sense of dyspnea during the period of increasing respiration ; and if unconscious during the pause, they are awakened, as they express it, by a sensation of suf- focation or dyspnea. Cyanosis usually accompanies the onset of the •dyspnea, and it may sometimes even increase with the augmentation of the breathing. With some patients Cheyne-Stokes respiration occurs only during sleep. Medicinal doses of morphin usually intensify the phenomenon and may even originate the condition. Generally speaking the prognostic significance is very grave, although not invariably fatal. According to the severity of the causal condition, the symptom is either 82 CHARACTER OF THE RESPIRATION. a transitory sign which rapidly disappears, or else one directly preceding; death. Only in cardiac or renal disease has it ever been observed to persist for some months. The explanation of Cheyue-Stokes respiration is still not wholly agreed upon. It is indisputable that, like meningeal breathing, it de- pends upon a diminished excitability of the respiratory center. This seems to be the only part of the explanation beyond a doubt. Traube's original theory assumed that the symptom arises when the excitability of the respiratory center is so decidedly diminished by the insufficient supply of oxydized blood resulting from the circulatory disturbance that,, at a certain moment coinciding with the first breathing pause, there is no longer a sufficient physiologic stimulus to arouse the respiratory move- ments. With the cessation of respiration the blood becomes still more- decidedly venous. This irritates the respiratory center intensely, so that,, despite its diminished susceptibility, breathing begins again. This in turn diminishes the venous character of the blood, and the breathing gradually becomes weaker in proportion to the oxidation of the blood. Traube's explanation does not make it very clear why the breathing increases gradually nor why the second respiration is stronger and deeper than the first. For as soon as breathing begins, the venous character of the blood must immediately lessen the respiratory center's irritation, and so the second respiration should be weaker. Traube explains that the first breath is so diminutive that it cannot afPect the venous character of the blood, and so cannot lessen the irritation to the respiratory center ;. but that, on the contrary, the irritation increases despite the return of breathing, until it (the irritation) reaches a maximum. Such a hypothesis will explain the peculiarity that the patient appears most cyanotic and complains most of the subjective sensation of dyspnea during the period of increasing respiration. Another objection to Traube's explanation is that after an improved supply of oxygenated blood has once restored the respiratory center's normal excitability, there is no apparent reason for the breathing's fading away again. If we believe with Traube that the respiratory center's asphyxia is the sole cause of its diminished ex- citability, the objection cannot be answered. If, however, we regard the diminished excitability as entirely or partially independent of the circulatory disturbance and more self-dependent, the objection loses its force. Evidently, then, if the blood is better aerated, the intense irri- tant to the respiratory center will be removed, although the latter's sensibility has not been improved. Hence, the breathing will gradually diminish in frequency in proportion to the improvement in the oxidation of the blood. With these modifications, Traube's theory seems plausible enough. Partly on account of the difficulties mentioned above, numerous other 'explanations of Cheyne-Stokes respiration have been advanced. We will only mention two of these which are the most generally known — viz., Filehne's and Rosenbach's. Filehne's hypothesis, beginning with the pause in respiration, as- sumes that the venous condition of the blood irritates the vasomotor DYSPNEA. 83 centers and so produces a spasm of the cerebral vasomotors. There- fore the respiratory center, whose irritability has already been reduced, becomes anemic. This anemia acts as a further irritant to respiration. As soon as the breathing has again oxygenated the blood sufficiently, the vasomotor spasm vanishes, but the respiratory stimulus is not sufficient to induce breathing, hence the pause reappears. Filehne's theory is more complicated than Traube's ; the same objections apply to it ; and more accurate investigations seem to have completely disproved any such re- lationship between the vasomotor system and Cheyne-Stokes breathing. Rosenbach maintains that the periodicity of this type of breathing results simply from an abnormal fatigue of the respiratory center, but that this fatigue should not be confused with a diminished irritability. The center is active for a time, works against a gradually increasing difficulty, finally stops entirely, and begins its activity again only after the pause has to some extent recuperated its powers. It seems doubt- ful whether we can assume that such recuperation of the respiratory center occurs during the breathing pause, while the respiratory irritant persists. The laws of fatigue in the central nervous system are, how- ever, so imperfectly understood that this objection to Rosenbach's ex- planation is not sufficient to make us reject it entirely. At all events it has the advantage of depending upon the same law that applies to the other organs — that periodic activity usually arises as a result of fatigue. Most types of increased respiratory frequency (polypnea) necessitate an increased demand upon the respiratory activity, and will therefore be discussed in the following section on dyspnea. We should, however, mention the fact that increased frequency of breathing may arise from purely nervous causes — e. g., in hysteric people and in certain cases of cerebral disease. DYSPNEA, The term dyspnea applies to a large group of variations in respira- tory activity, which, in spite of considerable diversity in detail, have this in common, that they serve to promote the object of breathing — i. e., the proper oxidation of the blood — despite all kinds of obstacles. On this account, the breathing of dyspnea is generally increased in frequency or in depth. The obstructions to breathing are, however, sometimes insurmountable, so that neither a frequent nor a deep type of breathing is possible — e. g., in marked stenosis of the air passages. Therefore quickened breathing must not be considered absolutely the distinction of dyspnea. The only definition which will apply clinically to all cases is that dyspnea is an increased respiratory exer- tion produced by obstruction to breathing or by increased demands upon the blood-oxidizing process. This does not coincide with the explana- tion frequently given, that dyspnea is identical witli quickened breath- ing, which is unquestionably inaccurate from the clinical standpoint, for not every case of quickened respiration is dyspnea, nor is the breath- ing quickened in every case of dyspnea. As we shall see, there are types of dyspnea with quickened and others with retarded respiration. 84 CHARACTER OF THE RESPUiATION. To conform with the definition cited above and to avoid any misunder- standing, it is advisible to apply the terms polypnea to quickened and oligopnea to retarded breathing. The word dyspnea is, however, employed in still another significa- tion to express the subjective sensation of oppressed breathing possessed by patients with objective dyspnea. Ordinarily, subjective and objec- tive dyspnea go hand in hand ; but exceptions do occur. For under certain conditions, despite the presence of some obstruction which is responsible for an objective dyspnea, breathing may continue so satis- factorily that the patient does not experience any shortness of breath, because the aeration of the blood proceeds as completely as ever, owing to the modification of the respiratory movement. Again, despite a very pronounced objective dyspnea which is by no means adequate for blood- aeration, as evidenced by the accompanying cyanosis, a patient may have become so accustomed to it (see 93) or his sensorium may be so be- numbed that he has no appreciation of subjective dyspnea. It is a very benevolent provision of nature that in the death agony, where the breath- ing is difficult, the brain becomes, as it were, so narcotized by the car- bon dioxid intoxication that it no longer appreciates the sensation of the struggle for breath. Conversely, the objective dyspnea may be almost or entirely overshadowed by the intense ''air hunger." Examples are the so-called " precordial terror " of melancholies, which (because the individual locates the sense of anxiety in the chest) we prefer to con- sider as a purely subjective dyspnea. Again, some nervously organized individuals will complain of a transitory desire to draw an extra deep breath ; they have the sensation of dyspnea without any evidence of obstructed l3reathing. In other words, it is a purely cerebral phenom- enon, of which they instinctively try to rid themselves by taking a long breath. Hence, it is important to differentiate sharply betw^een objective dvspnea — i. e., difficult and hence modified breathing — on the one hand, and subjective dyspnea, or the sensation of lack of air, on the other. Sometimes breathing modified by dyspnea will be accompanied by subjective dyspnea, but at other times this is not the case. Cyanosis, like subjective dyspnea, is not always proportional to the degree of objective dyspnea, for in one case the objective dyspnea may be sufficient to regulate the proper aeration of the blood and to bring conditions back more or less to a normal standpoint ; whereas in other cases this is not possible for the organism. The occurrence of decided objective dyspnea witliout cyanosis is a clinical proof that the intensity of the respiratory^ movement does not depend exclusively upon the grade of aeration of the blood, but may be produced directly by some ob- struction to breathing without the appearance of cyanosis. A similar proof is flir- nished by the dyspnea which follows physical exertion. This in no way depends upon an "excess of carbon dioxid nor upon a deficiency of oxygen in the blood so long as the breathing and the circulation remain sufficient. To aerate the blood properly under adverse circumstances the or- ganism avails itself of an increase either in the frequency or in the DYSPNEA. 85 depth of the respiration. With an increase in the depth of the indi- vidual breaths, the frequency may be either accelerated, normal or slowed. There are, therefore, various types of dyspnea, but generally we find that it modifies the normal breathing in that way which seems best adapted to meet the existing deficiencies. In the following we shall characterize the kinds of objective dyspnea occurring in different diseases. VARIOUS TYPES OF DYSPNEA. 1. Dyspnea Caused by Painful Breathing-. — Patients are not infrequently prevented from drawing a deep breath on account of the pain associated with each respiratory movement in certain pulmonary, and especially pleural, disorders, in affections of the intercostal muscles (rheumatism, trichinosis) and of the diaphragm and its vicinity (perito- nitis). The breathing then becomes superficial and, to satisfy the demand, more frequent — in other words, dyspnea results. In this instance the obstruction is functional, not mechanical.^ 2. Dyspnea Due to a Diminution in the Breathing Surface of the I/Ung or to a Mechanical I^imitation of the Respira- tory Bxcursions of the I/Ung. — The two factors ordinarily occur together. Under this heading are included all affections of the pul- monary parenchyma which lead to a diminution of the air contents of the lung — i. e., all sorts of pulmonary infiltration ; all conditions which limit the capacity of the thorax, such as pleuritic effusions, pneumo- tliorax, intrathoracic tumors, lateral curvature, upward displacement of the diaphragm ; further, all conditions which decrease the respiratory excursions, such as brown induration and emphysema (with regard to emphysema, see p. 90 et seq.), as well as paralyses and spasms of the respiratory muscles. In any of the above conditions each breath aerates the lung less efficiently than normally, with a resulting dyspnea and increased fre- quency of respiration. Under some conditions the demand for air will be completely satisfied, so that in spite of the interference with respira- tion neither cyanosis nor any sense of dyspnea (subjective) ensues. Under other conditions the compensation is not always complete, es])e- cially when any increased demand for air arises, so that physical exer- tion will occasion cyanosis and a subjective sense of dyspnea. If such. an interference with breathing is unilateral — e.g., infiltration or a pleuritic exudation — the dyspnea can be partially overcome by deeper breathing of the healthy side (vicarious respiration), as well as by the increased frequency of respiration. (See p. 80 et se,q. concerning local depressions of the thorax in this variety of respiratory interference.) 3. Dyspnea Due to General Circulatory Disturbances. — Non-compensated valvular lesions may be regarded as a type. Here ' In this connection the editors wish to call attention to a type of dyspnea associated with a remarkable slowing of the respiration which is sometimes observed in pneumonia when the accompanying pleurisy excites intense pain with each respiration. 86 CHARACTER OF THE RESPIRATION. the chief factor is the stasis or congestion — i. e,, the circulation is slowed and the blood accumulates in the veins whether the difficulty affects the left, right, or both sides of the heart. As a consequence of the retarded current the different organs receive less arterial blood in a certain time and retain more venous blood ; and since the respiratory center is also affected by this disturbance, more rapid and deeper breathing results. The conditions become more complicated when the circulatory trouble originates in the left heart, because the congestion then includes not only the general systemic veins, but also the pulmonary veins, thus adding another cause for dyspnea — namely, a marked distention of the pul- monary capillaries with blood. It was formerly assumed that this dila- tation of the alveolar vessels impaired respiration by diminishing the amount of air in the lung. But this conception was shown to be incor- rect by V. Basch's experimental investigations upon pulmonary con- gestion, for he proved, on the contrary, that the lung overdistended with blood contains more air because the distention of the alveolar vessels also increases the circumference of the alveoli. Nevertheless, the proc- ess in question does impair respiration, because the lung, stiffened by the distention with blood, becomes more and more permanently fixed in the position of inspiration and expands but little. Pulmonary rigidity acts as a direct impediment to breathing (Category 2, p. 85) and increases the respiratory rate. If it is persistent, its effect is intensified by the formation of the so-called " brown induration." In opposition to this mechanical theoiy of pulmonary rigidity we would em- phasize the work of Krause, who found that, in spite of the engorgement of the lung, the respiratoiy excursion may even be increased. In this case the dyspnea is to be explained by the fact that "the respiratoiy surface of the dilated pulmonary vessels is relati^-ely decreased in comparison with their contents. When the lung is affected paroxysmally by pronounced engorgement with blood and rigidity, in disturbances of cardiac activity, the result- ing attacks are named " cardiac asthma." This term is often wrongly applied to any kind of dyspnea which appears in heart disease. These paroxysms of cardiac asthma are brought on sometimes by exertion, sometimes by increased flow of blood to the lung in the recumbent pos- ture, sometimes by altered innervation at the moment of falling asleep, and sometimes by entirely unknown causes. Pulmonary rigidity and brown induration arise in mitral diseases, especially when compensation is good — i. e., when the right ventricle does its work well. For this reason patients with a mitral lesion, des- pite good compensation, experience dyspnea, even with very moderate exertion. As a further cause of dyspnea may be added the bronchial catarrh that almost always accompanies circulatory disorders. 4. Dyspnea Dependent Upon Obstruction of the Upper Air Passages. — Any obstruction in the large upper air passages makes breathing difficult because it furnishes a resistance to the entrance of air and to the inspiratory pull of the respiratory musculature. The latter must therefore perform more work. It is evident that under these DYSPNEA. 87 •circumstances an increase in the rate of breathing would be not only very difficult, but also of little avail, while on the other hand, simple reflection shows that slowed breathing would more readily overcome the obstruc- tion. But to supply the requisite amount of oxygen the breathing must be deeper as well. And this is sometimes observed to be the method which patients adopt to overcome obstruction in the larger air passages, but only when there is sufficient inspiratory power to entirely overcome the impediment in breathing. Lacking such power, the economy is obliged to depend more and more upon the less efficient means of increasing the rapidity of the breathing, which, of course, becomes superficial, but that it is always suited to the particular kind of mechan- ical obstruction is shown by the fact that the increased frequency is slight in comparison with the extent of the respiratory obstruction, since too rapid breathing would be of no avail. This peculiar type may be termed dyspnea with a tendency to slowed breathing. The frequency or the depth of the breathing preponderates, depending upon the relation between the stenosis and the respiratory power. It is observed in stenosis of the pharynx from swelling of the tonsils ; in retropharyngeal abscess ; in true and pseudocroup ; in edema and in spasms of the glottis ; in paralysis of the abductors of the vocal cords ; in stenosis of the larynx or trachea from tumors or foreign bodies ; in obstruction of the trachea from external compression (glands of the neck, aneurism, €tc). If the stenosis is situated in one of the main bronchi, it will depend again upon the degree of obstruction whether the dyspnea is com- bined with slowed or accelerated breathing. If the lung upon the affected side can still be made use of, the dyspnea will be of the former type ; but if the healthy lung must do all the work, the breathing will be rapid. In either case the economy selects the more advantageous method. Thus, in all the conditions in question, the demand for air will be supplied, and the subjective dyspnea and cyanosis avoided, unless, of course, the obstruction is too great. When the obstruction in the upper air passages is very considerable, and when, despite the changes in respiration resulting from the dyspnea, the lung can no longer completely fill itself with air again, the chest " pumps empty," so to speak. During inspiration an abnormally rare- fied space is found in the lung, and the lateral flexible portions of the chest-wall, the epigastrium, the supraclavicular fossae, and the supraster- nal notch (jugulum) sink in under the influence of the external atmo- spheric pressure. There is another cause for depression of the lower lateral chest regions in this form of dyspnea. As a result of the empty pumping, the vault of the diaphragm is not depressed with inspiration, but may even be sucked upward. Besides, as a result of the stenosis, the ribs can not be lifted up by the diaphragmatic action (described by Duch- enne, p. 80), and so the contraction of the diaphragm practically accom- plishes nothing but drawing in its points of attachment to the ribs. This pathologic retraction of the lower lateral portion of the entire chest-wall must not be confounded with the purely physiologic retrac- 88 CHARACTER OF TEE RESPIRATION. tion of the lower intercostal spaces in inspiration (see p. 79). The differentiation is easy enough. In the latter only the lower intercostal spaces along the line of the diaphragm are affected, and there is never any retraction of the ribs nor of the epigastrium. The retraction of stenosis is observed most distinctly in children because their chests are very flexible. It is very common in croup. A peculiar stridor or a sort of whistling, due to the passage of air through a narrowed place, is a most characteristic accompaniment of dyspnea caused by stenosis of the upper air passages. It is ordinarily heard much more distinctly with inspiration than with expiration. In laryngeal croup the stridor is due to the membrane covering the vocal cords. The inspiratory accentuation of the stridor is explained by assum- ing that, in spite of the inspiratory opening of the glottis, the vocal cords are not materially separated, and that as a result of their slanting, roof- like position they are approximated still more closely, valve fashion, by the pneumatic tug of inspiration. Hence, the obstacle to inspiration is greater than to expiration. This explanation is probably correct for cases of laryngeal croup. Nevertheless, the same inspiratory increase of stridor is observed in other types of stenosis of the upper air passages where we cannot assume the result of any such valve-like effect in the larynx — e. g., from obstruction either above or below the larynx (retropharyngeal abscess, goiter, etc.). The probable explanation of such cases is that the obstruction prevents the free ingress of air during the inspiratory effort at a moment when suction is exerted upon the surrounding parts by the external atmospheric pressure, so that the trachea is constricted below the sternum (iusjDiratory retraction of the jugulum, suprasternal notch). Therefore, any obstruction in the upper air passages, even if not actually located in the larynx, acts much more effectually during inspiration than during expiration. In other words, the dyspnea is essentially inspirator^-. Another factor may influence this inspiratory accentuation of the stridor. The velocity of the air current in inspira- tion is much greater than in expiration, which is passive, depending upon the elasticity of the lungs and the thorax. The importance of this factor is sho^vn by the fact that as soon as patients with stenosis of the upper air passages experience a sufficient increase in the respira- tory obstruction to necessitate their employing the help of abdominal pressure, the expiratory stridor will become more marked, and may even outweigh the inspiratory stridor. 5. Dyspnea in Bronchitis. — The types of bronchitis which usually lead to dyspnea are chiefly those affecting the smaller bronchi. The dyspnea is caused by the stenosis of the bronchial lumen, due to swelling of the mucous membrane and to secretion. The stenosis affects so many places that ordinary breathing is insufficient and dyspnea arises. This tv^pe of dyspnea varies with the conditions which prevail. If the stenosis affects only a small number of bronchi, simple increase of the breathing rate will usually overcome the difficulty. The stenosed areas are not benefited much by this method, but the uninvolv^ed por- tions receive more air, and so the effect of the disturbance is equalized. DYSPNEA. 89 This type of dyspnea then comes under our second heading. If the sten- osis affects a large number of bronchi, the breathing varies according to whether the bronchial closure is quite complete and insurmountable, as in capillary bronchitis proper, or whether it is incomplete and still con- querable by the respiratory effort, as in diffuse dry bronchitis of the medium-sized tubes. In the former variety, of which capillary bronchitis is a type, the chief effect is again merely a diminution of the breathing surface, so that, as before, dyspnea with rapid respiration results. This, of course, only assists bronchial areas which still remain patent. In the second type, however, where we suppose that most if not all of the medium-sized bronchi are stenosed, although only moderately so, the respiratory effort must attempt to get a sufficient quantity of air through the constricted areas into the pulmonary tissue proper. This can gen- erally be best accomplished by an abnormally deep respiration, very much as in stenosis of the upper air passages, especially of the larynx. And just as in these cases, the respiratory accommodation and the fre- quency of the individual efforts will vary according to the amount of obstruction as compared with the respiratory force available. In rare instances even a slowing of respiration may result. More frequently, however, we merely observe a certain tendency to retardation in that the increase in rate does not correspond to the degree of constriction, and this increase is comparatively slight as contrasted with the amount of subjective dyspnea and cyanosis. The passage of air through these constricted areas is often associated here, as well, with a stridor — i. e., a stenotic noise which may perhaps be heard at a considerable dis- tance from the patient. This type of dyspnea in bronchitis presents, therefore, a prolongation of expiration and stridor, chiefly expiratory, and so can be distinguished from the other retarded type or laryngeal dyspnea, where expiration is of normal length and the stridor is chiefly inspiratory. These two points of distinction, which are responsible for the appli- cation of the name expiratory to this type of dyspnea, require some further explanation. The prolongation of expiration is easily under- stood, because even under normal conditions expiration is longer than inspiration, and, of course, the increased resistance caused by the bron- chial stenosis must be felt more during expiration, since the excitation of dyspnea produces, first of all, marked increase of the inspiratory power. To be sure, if the dyspnea is pronounced, the expiratory exer- tion must be also increased by the participation of abdominal pressure in the expiratory act, so that the lungs will then be emptied somewhat more quickly by the active expiratory compression of the thoracic con- tents than by the influence solely of elasticity. This extra abdominal pressure, however, will also compress the small bronchi still more ; hence the prolongation of expiration as compared with inspiration, and the increase of expiratory stridor. Increased expiratory stridor may be present without the participation of abdominal pressure. For if the elastic retraction of the lung is interfered with by stenoses in the bronchi, the latter will be still more compressed by this elastic expiratory move- 90 CHARACTER OF THE RESPIRATION. ment just as by abdominal pressure. Hence, abdominal pressure is not absolutely necessary for the increased expiratory stridor. All sorts of intermediate types occur between this type of retarded breathing with prolonged expiration and expiratory stridor on the one hand, and the type in which the breathing is simply increased in frequency on the other. These types will vary according to the preponderance of bron- chial stenosis or of the available respiratory power. 6. Dyspnea in Bronchial Asthma. — According to the modern conception, bronchial asthma depends upon a stenosis of the smaller bronchi, due to spasm of the bronchial muscles. Hence, it corresponds exactly to dyspnea in the type of bronchitis just discussed, that with moderate stenosis of the bronchi. The breathing is retarded and expiration is prolonged and combined with stridor (so-called expiratory dyspnea). The absolute number of respirations may be diminished ; or an increase in rate which would correspond to the amount of subjective dyspnea may be prevented. This depends upon the degree and the extent of the bronchial muscles' spasm. Therefore, in bronchial asthma we may observe either a diminished, normal, or increased respiratory frequency. The conditions are analogous to those in emphysema (see next section). 7. Dyspnea in i^mphysema. — Pulmonary emj)hysema causes dyspnea because the lung is in a permanent condition approximating the inspiratory position, and because with inspiration and expiration it makes but small excursions from this position. Besides this, pronounced emphysema destroys numerous alveolar septa and their capillaries, thus diminishing the breathing surface very extensively. For this reason the dyspnea of pure uncomplicated emphysema is evidenced by rapid and superficial respiration. When the patient is quiet the disturbance re- mains slight, but when some physical exertion makes extra demands upon the respiration the dyspnea increases very decidedly. As a rule, patients with emphysema appear for the treatment of marked dyspnea only when this affection is complicated by a bronchitis (usually the dry variety). Consequently, in emphysema the same influences which we have just discussed in bronchitis tend to render the respiration now quicker and now slower. The tendency to retardation is very pro- nounced, because the bronchitis complicating the emphysema is usually diffuse and produces a stenosis of most of the bronchi. The loss of elasticity in the emphysematous lung especially promotes a retardation of breathing and prolongation of expiration. But the dyspnea in emphy- sematous bronchitis is not always associated with a slowing of respira- tion, for the system will accommodate itself to the respiratory obstruc- tion with or without an increase of respiration, depending entirely upon the proportion between the loss of elasticity in the lung, the degree of bronchial stenosis, and the respiratory power. As a matter of fact, in the bronchitis ot emphysema there is very often a certain amount of in- crease in the frequency of breathing. Still, the subjective oppression out- weighs the slight increase so decidedly that, unless we count, the impres- sion is made that the respirations are slow, although actually 20 to 25 a minute. In some cases this tendency to retardation leads to an actual DYSPNEA. 91 diminution in the number of respirations ; in other cases, only to a lack of any increase ; in still another class of cases, to an increase in respira- tions which is but slight in proportion to the subjective dyspnea. Thus, the bronchial dyspnea of the emphysematous may be characterized as a dyspnea Avith a prolonged expiration and expiratory stridor (so-called expiratory dyspnea) and also with a more or less pronounced tendency to a diminution in the frequency of the breathing. These conditions are unchanged if, as is often the case, the emphysema is complicated with bronchial asthma. 8. So-called Uremic Dyspnea of Nephritis. — This exhibits no uniform symptom-complex. In individual cases, and particularly if retarded breathing and prolonged expiration occur, we are justified in assuming the existence of some true uremic phenomenon — i. e., an actual bronchial asthma due to uremia. Many diagnostic conditions in neph- ritis are, however, erroneously considered uremic. They depend rather more upon some cardiac disorder, upon the accompanying bronchial catarrh, or upon a beginning pulmonary edema, etc. Corresponding to the diversity in causation, these types of dyspnea vary decidedly in their character. 9. Febrile Dyspnea. — A febrile elevation of the body temperature is nearly always combined with an increase in respiratory frequency. Even the artificial application of heat to the body will, increase the res- piratory rate, so that it seems plausible that the irritation of warmer blood upon the respiratory center is responsible for the febrile rise of the respiratory rate. However, the frequency of respiration in febrile diseases with exactly the same degree of temperature may differ widely, so that the nature of the toxin probably exerts some direct influence upon the respiratory center. The increased respiratory frequency in fever probably corresponds to an increased demand upon the metabolism. Therefore, according to our definition (p. 83), we are correct in speaking of febrile dyspnea as well as of febrile polypnea. The respiratory frequency found with a certain degree of fever varies with each individual case. Experience shows that, unless some respira- tory complication exists, only the severe types of fever increase the respiratory frequency very noticeably. Fig. 24, the curve of an uncom- plicated typhoid, illustrates the usual ratio between temperature and respiration rate. 10. Anemic Dyspnea. — Exaggerated Breathing in Diabetic Coma. — Dyspnea occurs in anemia (oligochromemia) because the availa- ble amount of hemoglobin is so small that only the most complete aeration will be sufficient to supply the demand for oxygen. With no mechani- cal impediment to respiration, the organism can adapt itself very com- pletely to the altered conditions. This is accomplished by a simultaneous increase in the frequency and in the depth of respiration. The resulting dyspnea produces a peculiar clinical picture, for the respirations are not only very rapid, but also of maximum depth. This tyjie is observed especially in pernicious anemia ; rarely, however, in other disorders. 92 CHARACTER OF THE RESPIRATION. The same type of breathing is observed in diabetic coma.^ We do not know its cause, so that it seems doubtful if we should consider it as actual dyspnea (in the sense of p. 83, et seq.) — i. e., analogous to anemic dyspnea. However, the outn-ard resemblance of the two phenomena makes such a supposition possible (diminution of the hemoglobin oxidation capacity in diabetic coma). 11. << Mixed" Dyspnea — Inspiratory and Expiratory. — Thus far we have been discussing the various factors which determine the different types of objective dyspnea. Two main types occur : (1) breath- ing with increased frequency and (2) slowed breathing with increased depth. In the former " mixed dyspnea " inspiration and expiration seem equally accelerated. In the latter, inspiration and expiration are affected differently ; in some cases the inspiration, in others the ex- piration appearing prolonged. One type is termed " inspiratory dysp- nea," the other " expiratory " ; because in the one it is principally in- spiration, and in the other expiration, which is rendered more difficult. In this connection compare the paragraphs on the types of dyspnea in obstruction of the upper air passages in bronchitis, in emphysema, and in asthma. Inspiratory dyspnea can usually be distinguished im- mediately by inspiratory, expiratory dyspnea, by expiratory stridor, without necessarily estimating the length of the two phases in respira- tion. If the examiner is inclined to do this he should remember that normally expiration lasts longer than inspiration (4:1). AUXILIARY OR ACCESSORY BREATHING; FORCED ATTITUDES EST DYSPNEA. In all types of dyspnea the economy ordinarily employs all the available aid to lighten the burden of the respiration. In this way a number of muscles are used for breathing which, under normal condi- tions, serve other purposes. These are the so-called accessory respira- tory muscles, chiefly the scaleni, trapezius, levator angulse scapulae, sterno- cleidomastoid, sternothyroid, thyrohyoid, serrati, and the pectorals. The last five mentioned muscles may serve as inspiratory muscles, because their usual fixed attachment to the chest is made the mobile point, the other end becoming stationary. We have already considered upon page 24 how the erect posture facilitates the task of these accessory muscles (orthopnea), and the im- portance of constrained lateral positions with a unilateral obstruction to breathing. The abdominal muscles are the only ones employed as accessory muscles to expiration. Naturally they are chiefly active in expiratory dyspnea, but they may also be utilized to advantage in mixed and in inspiratory dyspnea to accelerate expiration and thus to facilitate a new inspiration. If the dyspnea is very pronounced various other accessory muscles to respiration may be called into play. Their activity is of certain diagnostic importance, although it must be acknowledged that they do not materially assist the respiration. The facial muscles of expression are examples. During inspiration they distend the openings of the 1 Kussmaul, D. Arch. J. klin. Med., vol. iv., 1874. SPIROMETRY AND PNEUMATOMETRY. 93 mouth, and especially of the nose, to a maximum. The patient thus presents quite a characteristic and pitiful appearance. This dilatation of the alae nasse is especially pronounced in small children with pnelimonia. Such a maximal distention of the entrances to the respiratory tract may sometimes be of real value in diagnosis ; but it ordinarily means that some effect of the vigorous respiratory stimulation has been transferred to related muscle groups. RELATION OF OBJECTIVE DYSPNEA TO CYANOSIS AND TO SUBJECTIVE DYSPNEA; HABITUATION TO RESPIRATORY OBSTRUCTION AND TO DYSPNEA. Objective dyspnea serves to diminish both cyanosis and the sub- jective sense of dyspnea. This task is not always performed equally well. The more completely the dyspnea aerates the blood, the less danger to the individual ; but cyanosis can only be entirely overcome when the obstruction to inspiration is slight. Wherever a marked obstruc- tion occurs, some little (oftentimes considerable) cyanosis must persist. The economy then performs its functions with blood rich in carbonic acid and poor in oxygen, and the dyspnea only succeeds in preventing a progressive deterioration of the blood. In cases of chronic dyspnea the economy may become more or less accustomed to the cyanosis. This is evidenced not only by the relatively good maintenance of the other body functions, but also 'because the sense of subjective dyspnea — " air hun- ger" — gradually and progressively disappears. Conversely, with the same degree of respiratory obstruction, the quicker the latter develops, the more intense the subjective dyspnea. Pneumothorax furnishes one of the most striking examples of the economy's power of adaptation to respiratory obstruction. After the sudden onset of the respiratory obstruction, both the objective and sub- jective dyspnea are at first very pronounced, but soon diminish. In pneumothorax this does not merely depend upon a simple adjustment of the economy to cyanotic blood any more than in other conditions. For in this type, as in many others, the disturbance itself is lessened by a number of complicated, equalizing factors which proceed especially from the circulatory system. This also becomes plain from the dimi- nution of objective dyspnea. We need scarcely add that dyspnea with a slight degree of cyanosis suggests a far better prognosis than dyspnea with pronounced cyanosis. SPIROMETRY AND PNEUMATOMETRY. Spirometry and pneumatometry — i. e. , the mensuration of the vital capacity and of the respiratory pressure variations in the upper air passages — have not as yet acquired any great diagnostic importance. This failure is due to the great difficulties in technic and to the pronounced influence of practice in those examined. Read- ers who wish to study thoroughly this method of examination should consult text- books upon physiology and several of the original works upon pneumatometiy. ' 1 P. Bonders, Zeit. f. rat. Med., N. F., vol. iii., 1853, p. 287 el seg. ; Waldenberg, " Die Manometrie der Lunge, oder Pneumatometi'ie als diagnostische Methode," Berlin, klin. Woch., 1871, N. 45; Eichhorst, D. Arch. J. klin. Med., 1873, vol. xi., p. 268; Biedert, ibid., 1876, vol. xviii., p. 115; Rollet, ibid.,\o\, xix., p. 284; Neupaur, ibid.,yo\. xxiii., p. 481. 94 CHARACTER OF VOICE UNDER PATHOLOGIC CONDITIONS. The pneumoscope described by Blocb' seems to be the most useful for clinical purposes. This instrument calculates the respiratory power without determining the respiratory pressure manometrically, but by estimating the minimum diameter of a breathing cannula held in the mouth, through which a sufficient quantity of air may be breathed. More accurate information of the respiratoiy mechanism can usually be obtained by directly measuring the thoracic excursions with a tape measure than by spirometry or pneumatometry (see p. 29, et seq.). CHARACTER OF THE VOICE UNDER PATHOLOGIC CONDITIONS. Pathologic alterations in the voice arise partly from demonstrable disorders of the vocal organ proper (the larynx) and partly from other influences, either direct affections of, or disorders indirectly connected with, the respiratory apparatus. We shall mention here only such altera- tions of the voice as are of some diagnostic importance. If the expiratory current of air does not make the vocal cords vibrate normally the voice will be "hoarse'' — e.g., in all inflammations, ulcer- ations, tumors, or paralyses of the cords. A hoarse voice always indi- cates some affection of the larynx and necessitates a laryngoscopic examination. If combined with inspiratory dyspnea, hoarseness is very suggestive of laryngeal obstruction. It may, however, be due to some general condition — e. g., the loss of the cords' normal tone, in weak cachectic patients. Again, it may result from a fit of violent coughing. Here a paresis of the tensors of the cords is caused by the marked stretching of the cords during the glottis closure which precedes the cough. The hoarseness in phthisis, therefore, does not always mean an ulceration of the larynx or cords. The voice is frequently lost in hysteric aphonia without preliminary hoarse- ness; whereas a similar loss of voice is always preceded or introduced by hoarseness if the aphonia is due to anatomic changes in the larynx. This is a point of some diagnostic importance. The voice may acquire a nasal twang as a result of alterations in the conditions of resonance in the mouth or nasal cavity. We distin- guish a closed or stopped from an open nasal voice. The former is observed when the nasopharynx or the nasal cavity itself is obstructed by any pathologic products, such as tumefactions of the mucous mem- brane, polypi, adenoids. The latter, the " open nasal voice," is observed when anything prevents the normal closure between the nasal cavity and the mouth — e. g., palate paralysis, cleft palate, syphilitic affections of the palate, etc. Aphonia (lack of voice) results either from an inability to approx- imate the vocal cords or from a prevention of the normal vibration. It may be preceded by hoarseness. The voice is, moreover, very dependent upon the general condition and upon the thoracic organs. Patients who are very ill usually have a weak voice, corresponding to their general muscular weakness. In diseases of the respiratory and circulatory organs the voice is affected by ' Arch, de Physiol.,lS97 , p. 1. COUGH. 95 the disturbed respiratory excursions and by the various sorts of dyspnea. In many patients with heart disease the voice — i. e., the cord tonus — is a very delicate indicator of the condition of their general circulation — it becomes weak and feeble when they fail, and full and sonorous when they improve. In painful aifections of the lungs or pleura and in peri- tonitis the voice becomes characteristically feeble, soft, and often broken. Cholera patients speak with a " toneless " voice (vox cholerica), and the moribund with a faint, scarcely audible voice. [Further reference will be made to these and similar points in the section on Auscultation (bron- chophony)] . COUGH. A COUGH consists of a single or of a consecutive series of explosive expiratory movements produced by abdominal pressure, which result in overcoming the preliminary closure of the glottis. It is a very im- portant reflex act, serving the purpose, on the one hand, of expelling any foreign bodies which may have become lodged in the respiratory passages, and, on the other hand, of expectorating any material which may have accumulated there from some pathologic process — e. g., bronchial or alveolar secretions, eifused blood, pus which has perforated into the bronchi, disintegrated necrotic or tubercular lung material, etc. A cough may be excited from various places in the body. The commonest type of cough is one in which the reflex arises from the region supplied by the sensory branches of the vagus. Experimental investigations have shown (especially Nothnagel's) that irritation of the laryngeal mucous membrane above the vocal cords produces spasmodic closure of the larynx, but no cough. Coughing will, however, be induced if the irritation aifects the parts heloio the vocal cords. The most sensitive areas are the interarytenoid mucous membrane and the region of the bifurcation of the trachea. Coughing may also be excited from any other part of the tracheal, as well as from all parts of the bronchial, mucous membrane, but not from the pulmonary parenchyma proper. Experimental results do not agree as to whether a cough can be excited directly from the pleura ; but it seems probable, judging from experience with individuals whose pleura has been opened. These are the most important sources of coughing, but there are other less common ones. In some individuals coughing may be pro- duced by irritatipn of the pharynx or of the base of the tongue, or occasionally of the esophagus. Coughing has been observed very ex- ceptionally to result from tickling the external auditory canal (auricular branch of the vagus) or from manual pressure upon the spleen or liver. Some people cough as soon as their feet become cold or whenever their body surface is exposed. This suggests the therapeutic value of warm clothing in diseases complicated with a cough. The existence of a 96 COUGH. stomach cough is very doubtful, although the lay public believe in it very thoroughly. Cough has not as yet, however, been experimentally excited from the stomach, and the so-called stomach cough which is so common in drunkards can probably be most satisfactorily explained by assuming that an affection of the pulmonary passages is combined with the stomach disorder. Nervous Coilg"]i. — The so-called nervous cough merits a few words. We cannot deny the possibility of a nervous cough if we con- sider that a cough can be produced by an abnormal excitability any- where in the course of the coughing reflex arc. When such reflex excitability is accentuated sufficiently, even physiologic irritants may cause a cough. As a matter of fact, a purely nervous cough is a very rare occurrence, and should only be diagnosed as such when it is observed in an exquisitely nervous or hysteric person, and when at the same time it differs decidedly from the ordinary type of cough. Under no circum- stances is such a diagnosis justifiable from exclusion — i. e., because the cough is the only sign of disease of the respiratory tract that can be made out from physical examination. It is well known that a cough frequently precedes all other signs of tuberculosis by weeks, often by months. (See under Barking Cough). Much more frequent than a purely nervous cough is one which is disproportionate to its cause — i. e., secretion or inflammatory irritation of the air passages — on account of an abnormal excitability of the coughing reflex. In such cases soothing remedies afford great relief. On account of the rarity of other causes, a cough is usually an important symptom for the recognition of some state of pathologic irri- tation in the region of the respiratory branches of the sensory vagus. This irritation is in many cases produced by the accumulation of secretion in the air passages. Experience teaches us that a cough caused by accumulation of secretion differs from the other types of cough. This difference is often appreciated by the laity. Its task, which is gener- ally fulfilled, is to remove the secretion. It thus acquires a peculiar ring, recognized as a combination of the noise of the cough explosion with the noise of the moving secretion, (See later Rales, Rattling.) Such a cough is called a moist or loose COUgfh as contrasted with a dry cough., in which either the secretion is too tenacious to be set in motion or no secretion exists. The acoustic distinction between a moist and a dry cough is of considerable diagnostic importance, because the secretion is by no means always expelled from the mouth by the cough, and so appreciated by the patient and the examiner, but very frequently after leaving the larynx is unconsciously sw^allowed. There are certain other important peculiarities in a cough which may point to the cause of the disease. The peculiar rough barking cough observed in simple laryn- gitis is characteristic of swelling without marked ulceration of the vocal cords. Here the voice may be clear, but it is usually very hoarse or aphonic. The barking tone is probably due to the swelling of the false cords which aid in closing the glottis. A similar barking is sometimes COUGH. 97 observed in the cough of hysteric individuals. Here the laryngoscopic examination proves that it is due to some abnormal innervation with- out any swelling. With a certain amount of practice one can really cough with a bark by adding phonation to the cough impulse. Like most other hysteric phenomena it can be reproduced voluntarily. If not associated with swelling of the larynx, a barking cough suggests its hysteric nature. If the margin of the vocal cords is irregular from deposition of secretion or from ulceration, the cough is equally rough but not bark- ing, and the voice is hoarse. If the closure of the glottis is imperfect on account of marked ulceration of the cords or on account of paraly- sis of the approximating muscles, or, if there is paresis of the expira- tory muscles or general debility, the cough is noiseless. This peculi- arity is observed in phthisis of the larynx, in paralysis (bulbar paralysis, myelitis), in any patient who is severely ill or weak. If a patient is unable to approximate the glottis perfectly, he may instead be compelled to close the mouth for the purpose of coughing, and then the resonation from the distended buccal cavity will furnish a very hollow ring to the cough. Such a hollow ringing is so generally observed in advanced phthisis that even the laity appreciate its prognostic significance. A hacking" cough consists of a series of very weak, frequently repeated coughing explosions. It is to be attributed to the mildness of the irritant, which in these cases is usually continuous and is not dependent upon any great amount of secretion. A hacking cough is most commonly observed in chronic catarrh of the upper air passages, in pharyngitis and laryngitis, and especially in beginning pulmonary tuberculosis ; hence its importance. Conversely, violent coughing paroxysms are observed in acute, intensely irritated conditions of the air passages from acute inflammations or from foreign bodies in the air passages ; in " swallow- ing the wrong way "; in affections of the air passages associated with a profuse secretion, especially where cavities or bronchiectatic dilations empty themselves periodically (see p. 25), and finally in ivhooping-cough. In the last-mentioned affection we may attribute the cause to the abun- dant production of glary mucus and to the increased irritability of the nervous coughing mechanism. The " whoop,'' so important for diag- nosing this disease, is a resounding crowing or whistling inspiration combined with a spasm of the glottis, and separates individual groups of coughing attacks. The glottis spasm is evidently due to some radiation of the irritation from the coughing center to the neigh- boring structures of the central organ, and depends merely upon the intensity of the irritation. During violent coughing paroxysms of other diseases we sometimes observe resonant inspirations very much like this whoop, but so rarely that the " crowing inspiration " is the most important diagnostic sign of whooping-cough. Vomiting sometimes complicates very intense coughing paroxysms ; it is due to the central diffusion of the irritation. Hemorrhage into the skin or mucous membranes, unconsciousness, 7 98 ARTERIAL PULSE PALPATION, SPHYGMOORAPHY, ETC. or even epileptic convulsions may be produced by the general venous congestion due to compression of the intrathoracic veins. A physician must be very careful in taking the history of a patient in regard to coughing. So long as the cough or the hacking causes neither inconvenience nor discomfort, patients, especially the phthisical, persistently deny that they cough even when the physician hears the hack himself. By imitating the sound and movements of such a "hack," a physician can sometimes get the patient to acknowledge that he does ' ' hack, ' ' but that he never considered it a cough. It must, however, be acknowledged that some cases of phthisis or bronchitis with very intense inflammation of the lungs occur without any cough or even a "hack." Here the secretion is probably brought up to the vocal cords by the ciliary motion of the mucous membrane; and is then removed by ' ' clearing the throat." If, as frequently happens, the secretion is swallowed, the patients neither cough nor even expectorate. LOCALIZED PROMINENCE OF THE CHEST IN COUGHING. As a result of the marked positive pressure and variations in the chest interior which are combined with the act of coughing, certain pli- able portions of the thorax may be pushed forward at the commence- ment of the coughing spell in quite a remarkable way. If the glottis is closed, expiratory pressure distends the upper part of the chest chiefly, because the expiratory power attacks the lower thoracic aperture. In coughing, therefore, we generally observe a bulging forward of the upper intercostal spaces and apices of the lungs. Such bulging is especially prominent in emphysema because the pulmonary resistance is impaired. The portion of the lung situated above the level of the clavicles shows an increase in volume, so that during a cough in emphysema we frequently notice that large swellings are produced above the clavicles. This phenomenon should not be confounded with the distention of the jugular veins during a cough, which is also often- times quite pronounced (p. 146 et .seg.). If the lung tissue is infiltrated and shrunken, coughing will evidently not produce such an inflation. Hence, a careful inspection of the supraclavicular fossae sometimes furnishes important conclusions as to the condition of the apices in beginning tuberculosis. PALPATION, SPHYGMOGRAPHY, AND SPHYGMOME- TRY OF THE ARTERIAL PULSE. Examination of the arterial pulse is of great diagnostic importance because it informs us of many things, such as the cardiac innervation the force of the heart, the blood -pressure, and the condition of the peripheral arteries, and sometimes suggests the existence of valvular diseases of the heart or of fever. Many individual peculiarities must be considered and various methods employed to recognize them. The commonest method and the one employed almost exclusively by practitioners is manual palpation of the arterial pulse. Sphygmography and sphygmomanometry are less used. Auscultation of the arterial pulse is much less important. PALPATION OF THE PULSE. 99 PALPATION OF THE PULSE, Any superficially placed artery may be utilized for the purpose of palpation ; but we nearly always choose the same vessel, so as to have a certain uniform standard, experience, and practice in judging of the pulse. On account of its accessibility, the radial artery is usually selected. It is palpated between the styloid process of the radius, or the tendon of the supinator longus and the tendon of the flexor carpi radialis. An anomalous position of the artery or of the tendons will, of course, necessitate our trying another place. In doubtful or difficult cases the two radials should be compared, so as not to attribute some abnormality really due to local causes to an alteration in the entire cir- culatory condition. One radial not infrequently seems smaller than the other, while in reality it is merely a small branch which lies in the ordinary place of the radial, and the main trunk takes some abnormal course. The best method of palpating the pulse is to put the tips of three adjoining fingers of the more adept hand along the artery and to vary the pressure. With every heart beat the artery is found to expand and to lift the fingers. This lifting is what we call the pulse. Palpation with one or two fingers is sufficient to determine the frequency and the rhythm; but we need three fingers for judging the form of the pulse wave and the height of the blood-pressure. CHARACTER OF THE ARTERIAL WALL. Palpation of the arterial wall permits us to determine whether arterial sclerosis is present or not, and whether the pulse wave is modi- fied by any factors in the wall itself. The most important thing to determine is the amount of elasticity — i. e., the rigidity of the arterial tube. This can be most effectually determined by rolling the artery back and forth under the finger and by running the finger along the length of the artery, at the same time being careful to prevent the influence of the blood-current by occluding the artery with another of the fingers. The artery is soft and elastic in young and healthy individuals ; but in arteriosclerosis or where the blood-pressure is permanently raised by an increase of the vasomotor tonus (chronic nephritis, lead-poisoning) we can often distinctly appreciate the increased resistance of the walls. The tortuous character of the artery so frequent in these conditions is produced by a fresh de- posit of histologic elements in its wall. At the same time some arteries may be tortuous without any arteriosclerosis — e. g., the temporal arteries. The deposit of lime in the wall, which is observed in very pronounced cases of arteriosclerosis, can be felt very distinctly as rough, hard irregularities. Although palpation is diagnostically important in de- termining the existence of arteriosclerosis of the peripheral arteries, it does not necessarily show whether the aorta, coronary arteries, or other deep-seated vessels are normal or not. The arteriosclerotic changes may 100 ARTERIAL PULSE PALPATION, SPHYGMOGBAPHY, ETC be very unevenly distributed, and the radial artery is one which shows no marked predilection for arteriosclerosis. Therefore, to demonstrate arteriosclerosis we should palpate as many as possible of the superficial arteries. Arteriosclerosis must not be absolutely excluded, even when the results of palpation are negative. A persistently high-tension pulse is one of the most reliable indications of dif- fuse arteriosclerosis when the examination shows no other cause for it (nephritis). CHARACTERS OF THE PULSE. FREQUENCY OF THE PULSE. The pulse frequency — i. e., the number of beats in a minute — is estimated by counting the radial pulse. It is advisable to count an irregular pulse for at least one minute and then to repeat, for otherwise the count may not be accurate. If repeated counts furnish different figures, the extremes should be noted. A great many influences affect pulse frequency, so that it is advisable to estimate the rate under conditions which are as nearly alike as pos- sible, or, in case this cannot be done, to make allowance for the action of these influences in forming an opinion. In sensitive people any mental excitement whatsoever decidedly influences the pulse rate. The physician's entrance is enough to cause a marked rise in the pulse, so that at the bedside it is advisable to delay counting the pulse until after having conversed with the patient for awhile. Any bodily exertion or movement increases the pulse rate. After running, gymnastics, fencing, or mountain-climbing the rate may be very greatly increased and still be within physiologic bounds. Even the quieter motions in bed, voiding urine, or evacuating the bowels, materially increases the pulse rate in very sensitive or very ill patients. After moderate activity the increase in rate soon subsides, but after prolonged, fatiguing exertion it may persist for some time. The pulse rate, furthermore, depends upon the position of the body. After lying down, sitting up increases the frequency ; so does standing up after sitting. This rise may be only transitory, due to the muscular exertion attendant upon the change of position, or to some extent permanent so long as the position is maintained. Guy found that in fasting, healthy men who had previously rested, the pulse rate was 66 to the minute while prone, 71 while sitting, and 81 when standing. Digestion of food increases the pulse rate for several hours during the period of digestion, the amount of increase varying according to the quantity of food. The daily variations of the pulse are only partly due to the influence of the meals ; for daily variations approximately parallel to the daily variations of temperature are observed even in fasting indi- viduals. They usually amount to only a few beats. Generally speaking, a high blood-pressure produces a slowing of the pulse, a low blood-pressure an increase in its rate. There are, however, many exceptions to this rule, although it undoubtedly possesses some physiologic importance. Marey PALPATION OF THE PULSE. 101 attributes the increased pulse rate in standing up as contrasted with lying down to the difference in blood-pressure. This, he believes, is much higher in the recum- bent posture. Respiration usually influences the pulse rate ; during inspiration it is increased, during expiration diminished. Coughing or Valsalva's experiment produces a marked increase in the pulse rate. In the latter the increased frequency persists longer than the increased intrathoracic pressure. The time of life has a very distinct influence upon pulse frequency. Rollet ^ quotes the following figures, collected from various observers, as averages : Pulse beats Pulse beats Age. to minute. Age. to minute. End of fetal life 144-133 10th to 15th year 91-76 Newborn and 1st year of life 143-123 20th-60th " 73-69 Vierordt ^ gives the following detailed table for childhood : Pulse beats Pulse beats Age. per minute. Age. per minute. 1 year 134 7-8 years 94.9 1-2 years 110 8- 9 " 88.8 2-3 " 108 9-10 " 91.8 3-4 " 108 10-11 " 87.9 4-5 " 103 11-12 " 89.7 5-6 " 98.0 12-13 " 87.9 6-7 " 92.1 13-14 " 86.8 The pulse rate practically diminishes with the advancing years until the age of sixty, after which time it begins to increase again slightly. Sex also has some influence. According to Guy, women average 7 to 8 beats a minute more than men of the same age. In individuals of the same age and sex the pulse rate varies according to the height ; it is slower in tall than in short persons. Sometimes the pulse count at the wrist is less than over the heart. In such an event the latter must be the accurate measure of the heart's frequency, and we naturally conclude that the cardiac power has be- come afi^ected, so that some of the pulse waves are not transmitted to the peripheral arteries. Such an omission of individual beats makes the pulse sequence irregular, so that the examiner then turns to the heart. If the radial pulse is perfectly regular we should not think of the existence of any difference between it and the heart-beat unless only every other beat was strong enough to be transmitted to the radial ar- tery, such as in the rare condition called pulsus alternaus and bigem- inus, heart bigeminus, hemisystole, systolia alternans (see later section upon Cardiac Impulse). The pulse frequency, like the body temperature, can be conveniently represented upon a chart in the form of a curve. The variations of both can thus be very accurately compared at a glance. Increase of Pulse Frequency ; Tachycardia. — Fever is one of the most common causes of an accelerated pulse rate. The tempera- ^ Hermann, Handhuch der Physiologie, vol. iv., 1. ="11. Vierordt, "Daten und Tabellen," Jena, G. Fischer, 1888. 102 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. ture and the pulse curve in fever usually run parallel. Liebermeister estimated that the pulse frequency was increased by about eight beats for every degree of temperature. So long as pulse and febrile disturb- ance run parallel in this way, such a harmonious preservation of the functions may be regarded as relatively favorable. On the other hand, the more the acceleration of the pulse exceeds the elevation of tempera- ture the graver the prognosis, because too rapid a pulse rate usually means some serious damage to the circulation, either to the heart or to the vasomotor system. If the patient is resting quietly a pulse of 140 to 160 in fever is always of grave significance. Under various condi- tions of fever the pulse frequency and the temperature may follow an P T lor- lOZ'- izo JO(f. 9f- 100 9S' J \ 1 \ \ I \ J 1 \ / 1 \ / \ \ / \ 1 V \ \ \ 1 \ \ 1 V 1 I 1 <>, / \ 1 \l V V 1 1 * A 1 t \ 1 » 1 ' '^\ * 1 'k\ 80 ^7° 9^- 60 Si'. \ / "^i 1 >' r\ ! >-\ 1 ^ I =^\ 1 -<' Fig. 33. — Relation of temperature aud pulse frequency In tuberculous meningitis. entirely different course. Such a divergence of the curves is of very great diagnostic importance. A high temperature with a slow pulse is observed chiefly in febrile brain diseases, in which the pressure upon the brain is responsible for the slowing of the pulse as in tubercular menin- gitis (Fig. 33) ; again in a combination of a febrile disease with a car- diac disturbance which causes brachycardia (adiposity, sclerosis of the coronary arteries, myocarditis). The converse, a high pulse rate with an abnormally low temperature, is characteristic of the symptom complex of acute circulatory weakness included in the name collapse (see Fig. 32). There are numerous other exceptions to this rule of parallelism of the two curves, although most of them are less pronounced than the example just cited — e. g., in typhoid fever the pulse frequency is noto- PALPATION OF THE PULSE. 103 riously moderate as compared with the height of the temperature (see Fig. 24). This pecuharity is often serviceable in differentiating typhoid fever from acute miliary tuberculosis or septicopyemia. For in the last two mentioned the pulse rate is almost always accelerated as much as, if not out of proportion to, the rise of temperature. Conversely, in pulmonary tuberculosis a very high pulse rate is frequently observed with only a moderate rise of temperature or even with no rise at all. Yet the rectal is often unexpectedly higher than the mouth temperature. Children usually exhibit a relatively rapid pulse rate with fever. A rapid pulse rate is, furthermore, found in affections of the heart or of the nerves. Valvular diseases in the stage of disturbed compensation — endocarditis, pericarditis, exophthalmic goiter, nervous palpitation, ner- vous tachycardia, dislocation of the heart by processes in its vicinity which limit the space — all of these diseases are or may be associated with a more or less considerable increase of the pulse rate, to a certain extent proportional to the severity of the affection. Very imperfect explana- tion has been found for the cause of the increased pulse rate in these cases. The author considers that the cause of the increased pulse frequency in the clinical picture of so-called " paroxysmal tachycardia " is due to an epileptoid discharge in the neighborhood of the cardiac accelerating nerves, although he realizes that such an opinion is at variance with Martius. An increased pulse rate also occurs combined with all sorts of pain. Under some conditions not yet understood the reverse sometimes takes place — i. e., a slowing of the pulse (see p. 104). The reflex influence upon the cardiac nerves is the probable cause in both cases. Atropin and alcohol are the two most important of the numerous poisons which accelerate the rate of the heart. Not infrequently, under pathologic conditions, the acceleration of the pulse due in a healthy individual to physiologic influences (p. 100 et seq.) may reach an excessive degree so far as duration and intensity are con- cerned. This always points either to some damage to the heart itself or to its nervous system. Thus, in chlorotics or in other weakly individuals even very slight exertion (stair climbing) will greatly increase the pulse rate ; and this increase usually is associated with the subjective sense of palpitation of the heart or of dyspnea. Diminution of the Pulse Rate (Bradycardia ; Brachy- cardia). — A noticeably slow pulse does occur, although rarely, as an individual, non-pathologic peculiarity in a healthy person. A very pronounced slowing of the rate, to as low as 20 or less beats to the minute, is observed pathologically in certain diseases of the heart muscle, especially in the "fatty " infiltrated heart and in sclerosis of the coronary arteries. A slight degree of retardation is sometimes observed in com- pensated aortic stenosis. Cachectic individual usually exhibit not only a low temperature but also a slow pulse rate (carcinoma of esophagus, etc.). Similar results are observed in convalescence. A temporary slowing of the pulse (to a little below normal) is often found in acute febrile diseases after the crisis. When, despite the criti- 104 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. cal drop of temperature, the pulse remains high, there is always reason to suspect a " pseudocrisis " (see Fig. 23). In certain painful aifections (e. g., gall-stone colic, lead-colic) a slowing of the pulse is more fre- quently observed than an increase. Icterus often produces retardation, due to the toxic action of the biliary salts. This, however, usually disappears when the jaundice is prolonged, either because the heart becomes accustomed to the intoxication, because the production of the biliary salts is diminished, or because their elimination is more complete. The slowing of the pulse in acute cerebral pressure is of particular diagnostic importance (meningitis (Fig. 33), fracture of the skull). Chronic cerebral pressure usually does not cause any slowing of the pulse unless acute exacerbations occur. Shock sometimes causes an excessive slowing of the pidse. Rapid emptying of peritoneal or pleu- ritic effusions sometimes diminishes the pulse rate.^ Some drugs (digi- talis, etc.) produce a slowing of the pulse. PULSE RHYTHM. Under normal conditions the pulse is regular or rhythmic — i. e., the individual pulse waves follow each other at equal intervals of time. Only slight transitory deviations from such regularity come within physiologic limits, and then principally under conditions which modify the pulse frequency as well. More pronounced irregularities of the sequence of beats, or arrhythmia, are probably all pathologic, and indi- cate either some distinct lesion of the heart or some purely functional disturbance of its activity, such as occurs in all sorts of conditions with or without cardiac weakness. We may differentiate between an absolutely irregular pulse (pulsus irregularis), which is usually at the same time much increased in rate (delirium cordis), and a partially irregular pulse. In one type of the latter the irregularities are uneven — i. e., the intervals between the beats are sometimes shortened and sometimes lengthened without any sign of regularity. In the other type of the partially irregular pulse the irreg- ularities are periodic — i. e., they follow each other at regular and definite intervals. Irregularities of rhythm are nearly always associated wnth inequality of the individual pulse waves—/, e., a pulsus irregularis is at the same time a pulsus inequalis. It is therefore advisable to defer the consider- ation of the various types of irregular pulse until after we have studied and understood the differences in quality of the individual beat. (See Sphygmography, p. 122 et seq., and p. 130 et seq.). CHARACTERS OF THE INDIVIDUAL PULSE BEAT. The proficiency which different observers attain in the determination of the quality of the individual beat by palpation varies decidedly with their practice and skill. He who is less adept may obtain more accurate 1 Much more frequently a lupid weak pulse is the immediate result of tapping the chest or abdomen ; the retardation follows later. — Ed. PALPATION OF THE PULSE. 105 information by employing sphygmography or sphygmomanometry. In addition to the regularity, the qualities which every physician should recognize by palpation without any especial instrument are : the size, the celerity, the tension, and dicrotism. Si^e of the Pulse ; Pulse Volume. — By size we mean the extent of the excursion which the arterial wall makes under the influ- ence of the pulse wave. With a large, full pulse (pulsus magnus) this excursion is considerable ; in a small, weak pulse (pulsus parvus) the excursion is small. (As to the significance of and the alterations in the volume of the pulse and the variations in the size of the individual waves, see Sphygmography, p. 124 et seq.) What we designate as the pulse volume Marey calls its strength, and with a certain amount of justice; because, of course, the vital power of the rise corre- sponds to the size of the pulse wave — i. e., to the amount of matter set in motion. This corresponds to the terminology employed in describing wave motion, where the strength of a vibration is measured by its amplitude. For clinical purposes, how- ever, the author prefers the term "volume," because the word "strength" would often suggest that we were expressing a certain opinion about the heart's activity or power, and this is by no means always the case, as we shall see later (see Sj)hyg- mography). Celerity of the Pulse. — By celerity is meant the rapidity of the rise and subsidence of the individual pulse wave. A quick pulse (pulsus celer) is one whose wave rises quickly and descends quickly ; a sluggish pulse (pulsus tardus) is one whose wave rises slowly and descends slowly. Upon the fingers a pulsus celer produces the impression of a quick, sharp rap. This peculiarity is appreciated most distinctly when the pulse wave is at the same time of considerable volume. Therefore, what is often called a pulsus celer is generally a full pulse as well. The pulse of aortic insufficiency is the most striking as well as the commonest ex- ample of a pulsus celer. It very frequently can be appreciated even by the eye as a very striking pulsation of the artery, and the diagnosis of aortic insufficiency made correctly at a distance. The rapidity of the ascent and that of descent of the pulse wave do not take an equal part in producing this "rapping" sensation. For although the rapidity of the rise may be recognized without any particular training, it requires considerable practice to recognize the quickness of the drop. Von Frey claims that the rapidity of the descent of the pulse wave can be estimated only by means of the sphygmograph and not by palpation. But the author believes that an expert physician can perfectly well dif- ferentiate between a pulse whose sharp, bounding quality is due only to a rapid onset of the wave and a pulse with a rapid descent as well as ascent. The terms " pulsus celer " and " pulsus tardus " are especially well adapted to the cases in which both limbs of the pulse wave are either steep or blUnt. Where either the ascent or the descent alone is rapid or slow this peculiarity should be specified. Thus, a pulse may be celer in. its ascent and twdus in its descent. Such an applica- tion of the terms " celer " and " tardus " to the same pulse is no con- tradiction. These conditions are explained more fully upon p. 124 by Sphygmography. (Figs. 47-51.) 106 ARTERIAL PULSE, PALPATIOX, SPHYGMOGRAPHY, ETC. Pulse Tension. — Consideration of Blood-pressure. — We consider under the term '• pulse teusion " the qualities of the indi- vidual pulse wave which show the amount of pressure in the arteries. The difficulty is, however, that the term blood-pressure may be under- stood in quite different ways. The physiologist ordinarily uses the word to mean the average or mean blood-pressure as estimated by the usual manometers. But the maximum or systolic and the minimum or dias- tolic blood pressure must also be considered. In a healthy man or animal the variations of blood-pressure from the average are very slight, and so we ordinarily speak of '' blood-pressure " without further remark when we strictly mean average blood-pressure. AVe do not know, how- ever, whether the systolic variations in pressure under pathologic conditions are so very slight. Sphygmographic and sphygmomanometric obser- vations (see later) seem to show that they are considerable. Therefore, under pathologic conditions, the systolic or maximum, the average or mean, and finally the diastolic or minimum pressure should be considered separately. The writer believes that many apparent contradictions in palpatory, sphygmographic, and mauometric estimations of pressure (see p. 135) can be explained by a disregard of such conditions. A more distinct and uniform conception of the terms expressing the pulse tension is therefore essential, and these terms should be clinically correl- ative to blood-pressure. Just as we distinguish between a maximum, middle, and minimum blood-pressure, so should we differentiate between a maximum or systolic, an average or mean, and a minimum or diastolic tension of the arteries. The ordinary definition that tension is the measure of the amount of finger pressure which is necessary to compress the artery is not accurate, and is, therefore, inadequate to teach us how to palpate pulses correctly. It is better to define the maximum tension of an artery as the amount of force which is necessary to prevent the transmission of the pulse wave to the peripheiy,^ the minimum tension as the power necessary to compress an artery during cardiac diastole, and the average or mean tension as a certain average amount of power which will suffice to close the artery between systole and diastole. A disregard of the various meanings of the term arterial tension thus ex- plains the variations in the description of one and the same pulse, one observer calling the tension high, another calling it low. As the manner of palpating an artery varies, so do conclusions as to the pressure conditions in the artery differ. Usually (although only partly justifiably) most importance is attached to the maximum or systolic ten- sion of the artery. This is determined (" dynamic " procedure of taking the pulse) by palpating the arteiy with three adjoining fingers along the long axis of the vessel. The distal finger compresses the artery so that no recurrent pulse wave can reach the vessel from the periphery. The proximal finger exerts a gradually increasing pressure upon the artery until the middle finger, which should rest quite gently upon the vessel, can no longer feel the wave. The power used is the measure of the (heart) ' See the following pages for the doubts alx)ut identifying this exercise of power with the systolic pressure. PALPATION OF THE PULSE. 107 systolic or maximum tension of the artery. This procedure is imitated by von Basch's method of sphygmography (p. 134 est eq.). The physical accuracy of his method of determining the systolic pressure — i. e., the correctness of identifying the amount of pressure employed with the sys- tolic pressure — is questionable (p. 135). The same doubt applies to this dynamic method of palpation, for the reason that, besides the systolic increase of pressure, the vital energy of the pulse wave has an impor- tant influence upon the result obtained (p. 1 35 et seq.). This vital energy is closely dependent upon the size of the pulse wave (p. 135 et seq.), and the size in turn by no means runs parallel with the blood-pressure ; in fact, it is often inversely proportional to the latter. We have not only the systolic blood-pressure to overcome in the procedure, but, generally speaking, a much greater pressure, because the recoil of the pulse wave at the compressed point of the artery acts very much as a water-ram. On account of the size of the pulse wave, the excess of energy employed above the systolic pressure is oftentimes greatest with a low blood-pressure. Consequently this dynamic method is frequently re- sponsible for questionable results, for it is often hard to compress an artery if the pulse is full (large), even though the tension is low, while conversely, a small (weak) pulse may frequently be easily compressed even if the blood-pressure is high. The following " static " method for determining the minimum or diastolic arterial tension is probably more reliable. If the fingers exert but slight pressure in palpating the artery we notice that the appreciable pulsatory excursions of the artery are usually small, and that they in- crease as soon as the pressure is increased until a maximum excursion is reached. After this point still greater pressure again diminishes the size of the pulse. The amount of pressure necessary to produce a maximum excursion corresponds, in all probability, to the minimum or diastolic pressure in the artery. This may be explained as follows : The reason why the excursion of the artery increases as we increase the pressure upon its wall is evidently because a part of the pulsatory in- crease in pressure is absorbed by the tense arterial wall when the artery is not compressed ; whereas, if we remove the tension from the arterial wall, by contrapressure, the pulse wave will be transmitted to the palpa- ting finger with a minimum amount of loss. The greatest excursion will evidently coincide with the comjjlete relaxation of the arterial wall at the onset of the pulse wave — i. e., when the pressure exerted cor- responds to the minimum pressure of the artery. Besides this, when pressure is brought to bear upon the artery from without which exactly corresponds to the minimum arterial pressure, or, more strictly speaking, is the slightest ajnount in excess of it, the artery will then be occluded at the instant of the arrival of the pulse wave, and, of course, the latter will back up considerably from reflections, so that the excursion of the wall will be increased in this way too. Any compression above this point will, of course, diminish the excursion again, since the pulse wave will no longer be capable of overcoming the resistance of the pressure fingers. The digital pressure exerted to produce the greatest 108 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. pulse excursion possible by this method is considered as the measure of the minimum arterial pressure. It is important to estimate the size of the arterial excursion, and not its strength or force. Beside these unavoidable inaccuracies we can readily appreciate the fact that an especial skill in appreciating the relations of pressure accrues to the careful clinician only after years of practice and a long experience in contrasting and remembering diiferences in pressure. Another difficulty is that, according to Pascal's law (law of hydraulic pressure), the amount of pressure necessary to compress an artery is proportional not only to the arterial pressure, but also to the diameter of the artery. On account of such varied and manifold difficulties in judging arterial tension, it is advisable to supplement palpation by sphygmography (p. 129 et seq.). Custom has come to employ the expression " hard " or " tense " pulse (pulsus durus) as synonymous with increased arterial tension, and " soft " or " relaxed " pulse (pulsus mollis) with diminished tension. Of course, we must not confuse these with the same terms applied to qualities of the arterial wall (softness versus rigidity of the artery) (p. 99). Again, these terms may at one time be applied to the systolic, at another to the diastolic, pressure. In nephritis and arteriosclerosis the diastolic as well as the systolic pressure is ordinarily increased ; iu fever usually the diastolic is low while the systolic is more frequently high ; in disturbances of compensation systolic and diastolic pressure are both low. Dicrotic Pulse. — We speak of a pulse as being dicrotic when a second wave follows immediately after the principal rise. (The nature of this will be discussed under Sphygmography, p. 113 et seq. and p. 129 et seq.) A dicrotic pulse furnishes a certain sense of after beating to the pal- pating finger. It is usually associated with diminution of the minimum pressure. Both the primary and the secondary wave are felt to be greatest when the palpating finger presses only slightly ; therefore a dicrotic pulse is best appreciated with gentle pressure. This can be readily understood from the explanation given of the excursion of the arteries (p. 106 et seq.). The beginner is apt to employ too great press- ure to recognize readily such a condition. Combined Qualities of the Pulse. — We have a number of terms which refer to a pulse which comprises two or more of the qualities already described. Of these we shall mention only those in most common use : pulsus fortis, strong pulse = large + tense (see also p. 105) ; pulsus plenus, full pulse ^ large and medium hard ; pulsus debilis s. inanis, weak or feeble pulse = small + weak ; pulsus undosus = large + soft ; pulsus serratus == large + tense + rapid ; pulsus vibrans = very large + very tense. This name is applied because the so-called elasticity eleva- tions (see p. 116) may be distinctly appreciated by palpation. These terms are fitting enough, but I'ather unnecessary. Instead of employing them, it is better for a beginner to mention the individual qualities one after another. The Latin terms are sometimes combined. For instance, we speak of a pulsus tardodicrotus or a pulsus magnodurus, etc. Such 8PHYGM0GRAPHY. 109 combination terms are practical enough in themselves, but some of them are not sufficiently clear, considering the double meaning of the terms " celerity " and " tension " (see above). In general a detailed descrip- tion is better than an attempt to describe the pulse by one word. There are some terms employed to characterize peculiarities of a sequence of beats and not of individual beats. These terms as well as further details about pulse peculiarities will be described in connection with the Sphygmographic Curves (p. 122 et seq.). SPHYGMOGRAPHY, Sphygmography is the method of registering the pulse wave of some peripheral vessel, generally the radial artery, upon a moving surface (usually smoked paper) by means of a special instrument, the sphygmo- graph. Vierordt constructed the first sphygmograph, and since then a great many impi'oved instruments have appeared. Most of them, however, have retained Vierordt' s principle of transmission by means of a lever. The best known and most frequently employed sphygmographs are : Marey's, for a long time the only one used clinically ; Landois', Sommerbrodt's, Riegel's, Dudgeon's, Jaquet's, and v. Frey's. Dud- FiG. 34.— V. Frey's sphygmograph. geon's apparatus has been a favorite in recent years, because with it curves of considerable excursion are easily traced. Jaquet's is an im- provement upon this pattern, including a really excellent mechanism for marking intervals of time. v. Frey's sphygmograph,^ also a very excellent instrument, is depicted in Fig. 34. It possesses this advantage over other instruments : the motions of the pulse are transmitted to the writing-lever as simply as possible. ^ V. Frey, Die Untersuchung des Pulses, Berlin, 1892, J. Springer. 110 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. The method of employing this instrument is as follows : The most superficial part of the radial artery is marked upon the wrist with a skin-pencil; and the apparatus is adjusted so that the "pelotte" im- pinges exactly over the indicated artery, and wnth the drum toward the elbow. It is then fastened to the forearm by means of the carrier or slide, S, with a strap. The carrier (Fig. 35) is fastened separately with the hooks that are attached for this purpose. The screw Sch serves to fix the strap. Loosening screw 2 makes it possible to move the entire apparatus upon the " carrier " This is very convenient for the purpose of adjusting the "pelotte" more accurately. By means of screw 3 we attempt to regulate the amount of pressure upon the pad until the lever needle begins to make excursions. The apparatus is then firmly fixed in place by tightening screw 2. The drum has, of course, been removed from the apparatus before this, covered with wax paper, smoked ^ by revolving over a flame, and then replaced upon the clock mechanism, U. By turning key 1 the Fig. 35. — The carrier or slide of v. Frey's sphygmograph. drum can be moved so that the bent point of the registering-needle rests lightly upon the smoked paper. The height of its excursion and, hence, of the curve can be regulated by turning screw 3, w^hich controls the tension of the " pelotte." The clockwork is then started by means of the lever which is visible behind the writing-lever H, to the right of the drum. The drum revolves and the bent point of the needle registers the sphygmographic curve upon the smoked drum. The drum is then taken off again, the paper carefully cut off, separated from the drum, and fixed in shellac or in a 10 per cent, solution of dammar bal- sam in benzin. The part E, which has not yet been described, is a small electromagnet with a registering-needle attached to the anchor, so that it registers upon the drum. AVhen connected with an electric cur- rent, intervals of time or signals may be indicated in the same way as is customary in physiologic experiments. When it is not being used it may be disconnected. V. Frey has recently modified his sphygmograph ; and, it would seem, very advantageously. The chief improvement is the substitution of a delicate metal ^ A pointed gas flame is perhaps the best source for smoking, or a kerosene lamp, or a piece of burning camphor. "We must be careful not to smoke too thickly, because the friction between the registering-needle and the drum would be so great that the curve would be disturbed. SPHYGMOGRA PHY. Ill spring for the joint connections, so that the motions of the registering-needle are less angular. Besides this, the drum is connected with a Jaquet's chronometer works, so that the time intervals are pictured. The curve may, of course, be regis- tered by means of air transmissions ujjon a kymographion placed at some distance. Jaquet's sphygmograph^ (Fig- 36) consists of a metal frame, Dp, to which is sewed a cuff, B,B, for attaching to the wrist. The sphvgmo- graph proper, Ar, is attached to the frame. The window cut out of the frame is to be applied accurately along the radial artery (previously marked out with a pencil), and the cuff then strapped around the wrist (|uite tightly. The sphygraograph proper is set into the frame by hook- ing into the hinge, p; and then the connection of the two parts is effected by pressing down at r and tightening the screw m. The pulse- registering apparatus consists of a short, broad spring, which presses upon the artery and transmits its movements to the registering-needle by means of the lever system ef. The screw m also serves to adjust the registering-needle at the desired height upon the smoked strip of paper. By screwing it down the spring d is pressed against the artery. The screw c is connected with an " eccentric " contrived to increase or diminish the pressure upon the spring. The amount of pressure can be determined by noting the position of the figures upon the screw. With this mechanism the instrument can be adjusted with practically equal pressure in each case, and taken away from the frame and reapplied in the same case without alteration of the pressure. Jaquet's instrument, like Dudgeon's, writes upon a flat and not upon a curved surface, as most other sphygmographs do. Another advantage consists in the very slight and constant amount of friction between the writing needle and the paper, so that there is very little trouble in adjusting the registering part of the apparatus. The paper is horizontal ; it need not be especially strong ; and it may easily be 40 or 50 cm. long. The little box a contains the clockwork which moves the strip of paper, p. This is started by pressing down on lever 6. The rate that the paper moves may be increased from 1 to 4 cm. in a second by altering the position of lever a. The slower motion produces a curve which presents a better general idea ; the more rapid motion, one which may be more accurately analyzed. This rate of motion may be altered while the sphygmograph is in action. The box a also contains a stop-watch connected with the time-registering mechanism, 8. The latter consists of a small pen which registers a mark upon the margin of the smoked ribbon every fifth of a second (Fig. 39). The old'style of the Jaquet sphygmograph, illustrated in Fig. 36, has the disadvantage that the individual parts of the pulse-registering mech- anism are not connected firmly enough to insure their constant contact with every change in the rate of motion. At e and d the movements of the lever system are transmitted by loose joints. This is not a dis- advantage when the excursions are slow, since the parts are held in contact by the metallic ball which is visible at the top of the apparatus. When the excursions are rapid (increased frequency of the pulse, great ^ Described in Zeit.f. Biol, vol. xxviii., N. F. x. Manufactured by Scbiile, Mechanic to Physiologic Institute of Basel. 112 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. elevation of the pulse), however, the oscillations of this mechanism may give rise to errors. These consist particularly of the appearance of artificial elevations in the pulse curve, dependent entirely upon the apparatus. One part of the lever system may advance independently until it meets with resistance ; then, at the moment of the occurrence of this resistance, there is a jolt of the writing-lever, which appears as an artificial elevation in the curve, with no existence whatever in the pulse wave. In addition to the occurrence of these artificial elevations, Fig. 36.— Jaquet's sphygmochronograph (old style). the oscillation dependent upon the defective connections of the parts of the lever system also causes an increase in the height of the curve. As we shall subsequently learn (p. 125), it is difficult under any circum- stances to gain an idea of the volume of the pulse from the height of the curve, and this error of oscillation renders the employment of the sphygmograph for this purpose still more questionable. A further source of error is the fact that the rate of motion of the needle at the moment .when the individual parts of the lever system are not in contact is SPHYGMOGRA PHY. 113 dependent upon the weight of the small metallic ball. Jaquet himself has criticised these faults of his apparatus, the lever system of which he copied from the Dudgeon sphygmograph, and has recently attempted to overcome them by a rearrangement of the recording mechanism, of which he gives the following description,^ aided by the accompanying diagrammatic drawing (Fig. 37) : " The movements of the needle a are transmitted to the bent lever c c by means of a wedge-shaped blade, 6. The upper portion of the bent lever is marked at s by a carefully made screw-thread which works in a corresponding cog-wheel, bearing the writing-lever. The contact between the screw-thread and the cog-wheel is insured by a spring (e), which constantly presses the lever c c against the cog-wheel. In addition to this the bent lever c c does not turn upon an axis passing through its angle, as in the old instrument, but about the point /, and the axis of rotation is replaced by a short, flat watch spring, which insures the contact between the lever c and the edge b. This spring is so short that individual oscillations are not to be feared, since the length of such an oscillation is less than -^^ of a second, and is consequently trivial in comparison to the velocity of the pulse- registering mechanism. This spring also renders unnecessary the eccentric of the old instrument, since its tension is sufficient to overcome the resistance which the stretched skin offers to contact with the pulsating artery. The ratio of transmission in the short arm •of the lever cc is 1:2, and that between the cog- wheel and the writing-lever 1 : 50, so that the total enlargement amounts to 1 : 100." An artificial pulse has been constructed by Lan- gendorflP, upon a principle first employed by Donders, in which a revolving eccentric transmits to the pin of the sphygmograph excursions similar to those of Fig. 37.— Diagram to j_*i*iT ji ,1 r> .^ • 1 explain the improved an arterial pulse. Jaquet, by the use of this mech- mechanism in the reg- anism, found that his modified sphygmograph records quIt'T^hVlmochro- the movements of the pulse accurately and without os- °ograph. cillation for all of the velocities usually encountered in sphygmography. In spite of the marked improvements obtained by these changes, it seems to the writer that the construction of the modified Jaquet sphyg- mograph is still open to some objections, and particularly because there is not a firm connection between the blade b and the lever arm c (Fig. 37) ; if the velocity is very great or the pulse rate very rapid, the parts c and b may become separated, and thus still produce artificial elevations in the curve. The oscillating pad is a further disadvantage of the old instrument which has not been overcome in the new modifi- cation. In both the old and the recent models this pad is connected to the spring a 6 by a loose joint. This naturally simplifies the applica- tion of the spring to the artery, but from the lack of a firm connection it may also produce distortions of the curve. In order to obviate these faults the author had mechanic Schiile, who executed the improvements 1 Miinch. med. WocL, 1902, No. 2. 8 114 ARTERIAL PULSE, PALPATION, SPHYGMOQRAPHY, ETC. in Jaquet's modified sphygmograph, attach the pad firmly to the spring, as in Marey's and v. Frey's sphygmographs, and also connect the arm / c of the bent lever with the blade 6 by a small wire stirrup, which passes over the lever from the profile of the blade, so that any separa- tion of the blade and the lever is rendered impossible. This mechan- ism was recommended to the author by mechanic Schtile ; it acts like a hinge joint, but possesses none of its disadvantages. By these modifi- cations the entire lever system has been united into a firm whole, in which no displacement is possible without implicating the entire system, and which must consequently accurately represent the movements of the arterial wall, disregarding the possibility of the oscillation of the entire system, a condition that the author has been able to exclude, for the velocities ordinarily encountered in sphygmography, by tests with Bonder's artificial pulse. The jointed connection of the edge with the bent lever has the additional advantage that we may employ the eccen- tric of the original apparatus, which the author sorely missed in the improved Jaquet sphygmograph, since it not only greatly facilitated the application of the sphygmograph and rendered possible the necessary variations in the tension of the spring, but also permitted us to ob- tain in every pulse-tracing exactly the same amount of tension of the spring with the same position of the pencil. The writer believes that Jaquet's sphygmograph, with these different improvements, now an- swers all reasonable requirements. It, of course, produces lower curves than the old model, on account of the suppression of oscillation. Me- chanic Schiile, of the Physiologic Institute at Basel, adds the described improvements to the old Jaquet sphygmograph for 28 to 35 francs, ac- cording to the condition of the instrument, and also furnishes the modi- fied sphygmograph at the original price of 165 francs. Compare p. 123 et seq. in regard to the degree of tension which is de- sirable upon the spring. EXPLANATION OF A NORMAL PULSE CURVE; FACTORS WHICH INFLUENCE ITS FORM. The curves obtained with the good modern sphygmographs usually correspond quite uniformly. Fig. 38 represents a normal pulse curve of the radial, the artery which is commonly selected. This illustrates what we have already learned from palpation, that the pulse wave is composed of a steep ascending and a rather slanting descending limb. Palpation alone might lead us to believe that the ascending and descend- ing limbs of the wave present smooth lines, but sphygmographic tracings show a number of small elevations in the descending limb (so-called catacrotic elevations). Similar irregularities which may appear under pathologic conditions in the ascending limb are termed anacrotic eleva- tions. A pulse with catacrotic elevations is termed catacrotic; one with anacrotic elevations, anacrotic. The normal pulse has usually three distinct catacrotic elevations, and is therefore catatri erotic. The significance of the individual parts of the pulse curve, especially of these elevations, has created much SPHYGMOGRAPHY. 115 discussion. Marey and Landois, and recently Hiirthle, v. Frey, and Krehl, have taken the most active part in the dispute. To understand the pulse curve we must, first of all, avoid confusing the progressive motion of the blood with the wave motion. This dif- ference is very clearly illustrated by E. H. Weber's well-known expres- sion, " Unda non est materia progrediens sed forma materiae progrediens." In palpating a pulse or in employing a sphygmograph we study exclu- sively the wave motion of the blood. Of course, the wave motion has some connection with the conditions of the blood-current, but only indirectly. The pulse of a peripheral artery is a wave motion which has reached this vessel by transmission to the periphery of the primary wave arising in the aorta, long before the blood whose impulse produced the pri- mary aortic wave has reached the artery. The rate of transmission of the wave motion of the blood is quite rapid, according to E. H. Weber about 9 m. a second. As we should expect from what has just been said, an aortic curve (from an animal) corresponds very closely to the human radial curve. It rises quickly, and falls oif gradually with secondary waves and depressions. To understand the radial curve thoroughly, it is well to begin by analyzing the aortic curve. The wave Fig. 38.— The normal radial pulse curve (Riegel). motion in the aorta is evidently due to the fact that during the " expul- sion period " of systole the blood-content of the aorta is increased. After- ward, when the aortic valves have closed, this increase is carried toward the periphery by the increased tension of the aortic wall. Thus the ascending limb of the aortic curve evidently corresponds in general to the so-called "expulsion time" — i. e., the period during which blood flows from the heart into the aorta. The summit of the pulse curve, however, does not correspond exactly to the end of the "expulsion time " — i. e., to the closure of the semilunar valves. On the contrary, the " expulsion time " is probably extended over into a part of the descending arm of the curve, because the flow of blood into the aorta is being diminished, so that the aorta is being partially emptied toward the periphery all the time. The end of systole is, then, not marked in a pulse curve, but lies in the descending limb of the curve, somewhere near the summit. The descending limb of the curve thus includes this remnant of the "expulsion time" plus the whole period during which the semi- lunar valves of the aorta are closed — /. e., that part of systole which lasts after the close of the semilunar valves (Martins " persisting in- terval ") ; the whole of diastole ; and the so-called " closure time " of 116 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. systole. Hence, the descending limb is more than diastolic ; but for the sake of brevity it may be called diastolic. The secondary elevation of the descending limb, which is designated a in Fig. 38, is usually distinguished from the others by being very distinctly marked. If it is still further developed the pulse becomes dicrotic. It is therefore called the " dicrotic elevation or wave," and is pretty generally considered to be a " recoil elevation," coiuciding with Laudois' theory of its origin. His theory is as follows : At the moment when the primary positive wave leaves the aorta — i. e., when the stretched aortic wall, in virtue of its elasticity, retracts again — this elastic contraction exerts an impulse upon the column of blood. This impulse strikes the closed semilunar valves, is reflected back, and passes through the aorta centrifugally to all the peripheral vessels in the form of a second positive pressure wave. In cases where the duration of each pulse wave is sufficiently long for a complete formation of the pulse curve, the recoil wave may, in its turn, produce another second recoil wave. This second recoil elevation may be recognized by the fact that it follows about as quickly after the recoil elevation as the latter did after the primary wave. Landois considers that b and c (Fig. 38), which are smaller eleva- tions, are elasticity elevations — i. e., due to individual vibrations of the arterial wall which are not transmitted from the blood-column to the arterial wall, but, conversely, from the arterial wall to the blood-column. (See p. 118 et seq. for a criticism of this conception of the secondary elevations.) From experiments witli rubber tubes Landois ^ states the following laws about botb kinds of secondary" elevations : 1. The further the artery- is from the heart, the later the recoil elevation appears in the diastolic portion of the cur\-e. 2. In the same artery, the further from the heart we apply the sphygmograph, the less pronounced is the recoil elevation. 3. The recoil elevation is so much the more pronounced at the heart the shorter (sharper) the primary wave, and vice versa. The duration of the primary wave being equal, one of large volume produces a stronger recoil wave than one of small volume. If, however, such a large voluminous wave persists for some time, while a small wave lasts only a short time, the latter will produce the larger recoil eleva- tion. The deciding factor is thus always the bre^-ity — i. e. , the celerity of the primary wave. 4. Other things being equal, the recoil elevation is larger the lower the mean arterial pressure. 5. The further fi-om the heart the examined artery is, the more marked are the elasticity' elevations in the descending limb of the curve. 6. An accentuation of the mean pressure in the arterj' will increase the number of the elasticity elevations upon the descending limb and at the same time bring them nearer the summit of the curve. 7. When the mean blood-pressure is very low, the elasticity elevations disap- pear entii-ely. 8. In diseases of the vessels which affect or destroy the elasticity of the artery, the elasticity elevations are either much diminished or else disappear entirely. The following assertions may be ventured in regard to the varying shapes of ^ Die Lehre vom Arterienpuls, 1872. SPHYGMOGRAPHY. 117 the entire curve. They are based partly upon experimental investigations by Marey, Landois, and others with tubes, and partly upon clinical observations : 1. Other things being equal, the curve is lower the higher the mean blood- pressure, and vice versa. This can easily be understood, because under a high blood- pressure the arterial wall is already so tense even during diastole that the increase in pressure during systole can produce but a very small excursion. When, on the contrary, the pressure is low, the artery easily yields to the wave. Of course, this does not apply to those cases where the high pressure is produced by a large systole (left-sided cardiac dilatation and hypertrophy in compensated heart affections), nor where a low pressure is due to a small systole (disturbances of compensation ) . 2. Other things being equal (the same blood-pressure), the pulse cui-ve is higher the larger the systole, and vice versa. 3. Other things being equal (equal systole and equal blood-pressure), the ascend- ing limb of the curve is steeper the quicker systole takes place. 4. Other things being equal, a low mean blood-pressure produces both a steep ascent and a steep descent — i. e., a pointed curve (celerity of curve in toto). Con- versely, a high blood-pressure produces a slanting rise and gradual descent (tardi- ness of curve). 5. Other things being equal, rigid arterial walls (like high blood-pressure) pro- duce low curves with slanting ascent and gradual descent (tardiness). On the contrary, delicate elastic arteries (like low blood-pressure) produce curves with steep ascents and descents (celerity).^ Fig. 39.— Reduction of a sphygmogram to Its simplest form. The above curve was taken with a Jaquet's instrument, the four waves at the left while the paper was moving slowly; the three at the right while moving rapidly. The time intervals are shown in the notched line above (0.2 seconds). As a matter of clinical experience, however, it must be acknowledged that only the descending limb of the curve is affected by either arterial rigidity or blood- pressure, for the great working capacity of the heart is sufficient to make the rise of the curve steep even with rigid arteries and with a high blood-pressure. All these statements possess more theoretic than diagnostic interest. Anacrotic elevations occur only under pathologic conditions. Landois has come to the following conclusions concerning them : Anacrotic elevations — i. e., secondary elevations in the ascending limb of the curve (Fig. 49) — are elasticity elevations. They depend upon similar influences to those which cause the ordinary elasticity elevations of the descending limb. The reason that anacrotic elasticity elevations are so rarely obser\'ed is because, as a rule, the ascending limb is so steep that elasticity elevations could not be reproduced in it. Hence, all the factors which tend to retard the rise of the curve are capable of producing anacrotic elevations, especially when these factors referred to also favor the formation of elasticity rises (compare above and p. 131). The shape of the curve is decidedly influenced by the frequency of the cardiac action, because a quick sequence of the chief wave makes a complete formation of secondary waves in the descending limb impossible. At the moment that the sys- tolic rise of a new wave begins, all secondary elevations disappear in the great rise of the new wave; although otherwise they would have developed in the descending ^ A very good way of judging the real shape of a curve with many elevations is to divide each elevation in half and then join the points by a dotted line, as in Fig. 39. 118 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. limb of the preceding wave. Curves with a slow sequence of beats are therefore generally richer in secondary elevations. An illustration of the action of the fre- quency of beats uj^on the pulse wave is the change of a febrile dicrotism of the pulse to hyperdicrotism (compare Fig. 51). The facts mentioned above may be considered correct. At the same time Landois' explanation of the origin of secondary elevations is not generally accepted. Both v. Frey and Krehl have recently attacked it. These investigators studied the pressure curve by an artificially produced current impulse upon an animal's fresh aorta (left in situ). They registered simultaneously the manometric pressure curve from the beginning of the aorta and from the celiac axis. They found by a detailed examination that each individual secondary elevation may be explained by the fact that the primarily produced variations in pressure are reflected, as it were, from the periphery to the center and then back again to the periphery. Under certain conditions they may traverse this path repeatedly in the curve. According to this there would be neither recoil nor elasticity elevations ; the so-called waves (even the anacrotic elevations) would be nothing more than centrifugal or centrip- etal reflections of the principal wave, which interferes with it in vari- ous ways as well as with each other, v. Frey and Krehl claim that these elevations, and especially the dicrotic rise in every vascular area, are due to centrifugal and centripetal impulses, but in diiferent and complicated ways. They characterize the dicrotic rise practically as a reflected wave which arises late, and which is therefore very distinctly marked from the main wave ; whereas they characterize the so-called elasticity waves which precede the dicrotic rise merely as waves derived by reflection of the main wave from points closer together, so that they are partly confluent with the main wave. Further, they characterize the elasticity elevations which come after the dicrotic rise as waves of reflection, like the latter, but arriving late and becoming less and less distinct toward the end of the curve, because the distance they traverse progressively increases. It is questionable whether these theories will explain the relationship between the height of the blood-pressure and the so-called elasticity elevations and the dicrotic waves. But v. Frey and Krehl found that an increase of the blood- pressure pushed the reflected waves nearer to the main summit of the curve {i. e. , in the sense of time), because the rate of transmission of the waves increases with the blood-pressure. This explains the fact that those reflection waves which are situated nearest to the main summit (which are ordinarily described as elasticity elevations i, and which include the anacrotic elevations, occur chiefly when the blood-pressure is high. It also explains the fact that with a low blood-isressure a reflection wave as a so-called dicrotic wave arrives veiy late and that it is characterized by being very distinctly formed, because at this moment tlie tension of the arterial wall is low enough for the wall to make quite a marked excursion. So we see that as a matter of fact these relations between blood-pressure and the form of the curve may be explained by the theory of the reflection of the secondary elevation. INFLUENCE OF BREATHING UPON THE PULSE CURVE. It has long been known that deep breathing may have some influence upon the pulse curve. This influence is chiefly due to the changes of arterial pressure which occur in the two phases of respiration. The respiratory increase in pressure SPHYGMOGRAPHY. 119 manifests itself in a sphygmographic tracing by an elevation of the whole cun-e ' and by an alteration in the shape of the individual beat (the latter corresponds to what was said in 4, 5, and 6, p. 116 et seq. ) — viz., a diminution of the dicrotic rise, an increase of the elasticity elevations. Authors difier very materially, however, as to whether the variations in press- ure which are evident in a sphygmographic tracing belong to inspiration or to ex- piration. The reason for such a difference of opinion is that the factors which alter the blood during respiration are manifold ; they frequently produce opposing results, and the final effect varies according to the way that the breathing progresses. The most important influence of breathing upon the blood-pressure is probably to be found in the change of diameter of the pulmonary vessels. They become wider during active inspiration and narrower during expiration.'-* Consequently, so long as the dilating pulmonary vessels receive an excess of blood at the beginning of inspiration, the greater circulation must receive less blood (because the size of the diastole, and with it that of the systole, is dimin- ished), and so the blood-pressure will fall. However, in the second pai't of in- spiration the pulmonary circulation through the dilated pulmonary vessels improves ; this in turn favors both diastole and systole, and eventually the greater circulation, and so increases the blood-pressure. During expiration the reverse occurs. The pulmonary vessels become narrower ; they therefore empty a part of their blood into the greater circulation ; the diastole and the systole of the left heart becomes fuller and the pressure increases. As soon, however, as the pulmonary vessels have become empty, the increased resistance in the lung will be felt as a factor in diminishing the diastole of the left side and the pressure in the general circulation will be reduced. Therefore, under these conditions blood-pressure falls during the first half and increases during the second half of insijiration ; whereas, conversely, pressure in- creases during the first half and diminishes during the second half of expiration. Hence, a maximum of pressure occurs at the beginning of expiration ; a minimum, at the beginning of inspiration. These rules, however, apply only to very slow and deep breathing. Only the initial effect of the change of diameter of the pul- monary vessels is felt during rapid breathing — viz. , expiration increases the press- ure, inspiration diminishes it. Hence, I'espiration influences blood-pressure in two opposite ways, according to its rapidity. And especially in pathologic cases, where the breathing is abnormal, it is evident that the two types may be merged beyond recognition, so that we are unable to formulate any fixed rule for the relation of the sphygmogram to the respiratory phases. This is one of the causes for the diversity of opinions found in literature. As a matter of fact, we have considered only the most important factor by which respiration affects the arterial pressure — namely, the varying diameter of the pulmonary vessels, whereas in reality the conditions are much more complicated ; for example, we might consider the influence of the varying intrathoracic pressure upon the heart and upon the great intrathoracic vessels, the effect of varying intra-abdominal jjressure upon the vessels of the abdominal cavity, which changes with respiration, and ftirther the changes of the vasomotor tonus synchronous with respiration, etc. Nevertheless, it may be stated, as a rule, that in the sphygmographic tracing (Fig. 40) deep and slow breathing increases the pressure during inspiration and diminishes it during expiration ; whereas deep and rapid breathing produces the reverse effect. The pulse frequency is often accelerated during inspiration. Corresponding to the mode of origin of the variations in pressure, the individual beats which coincide with the increase in pressure are greater than those which correspond to its de- crease.^ ' This sign is, however, ambiguous, because the pelotte of the sphygmograph rests not only upon tlie artery, but also upon the vense comites, and, of coui-se, any increased dilatation of the latter will also lift the registering-lever. '' The conditions differ in the case of the artificial respiration employed in animal experiments. * For further information see Tigerstedt, Lehrhuch der Physiologie c/e.s Krieslaufes, 1893, p. 453 et mj. 120 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPIIY, ETC. It should also be noted that the lower the arterial pressure, the more decided are the effects of respiratory influence upon the pulse curve, since thoracic aspiration naturally causes a greater increase of arterial pressure when the arteries are comparatively empty than when they are full. Such imperfect filling of the arteries generally, but not always, coincides with low pressure. Upon the other hand, with a low arterial pressure the arteries may be even abnormally distended — e. g., when the low pressure depends upon dilatation of the arteries with a good volume of circulating blood. Arterial pressure in itself is consequently not responsible for the occurrence of pronounced respiratory variations in the pulse curve, but for the volume of blood contained in the arteries. To this extent the occurrence of max'ked inspiratory variations in the pulse curve possesses a certain interest in our consideration of circulatory conditions. The influence of respiration upon the pulse curve is naturally more pronounced if the respiration produces great variations in intrathoracic pressure. As a result Fig. 40. — The influence of deep and slow breathing upon a normal pulse curve : R, Respiration curve, inspiration above ; P, pulse curve ; T, time curve (intervals = 0.5 seconds) (Rollet). of this we observe particularly pronounced variations of the pulse curve in stenoses of the air passages and in all conditions, like pneumonia and pleurisy, in which the equalization of the intrathoracic and extrathoracic air pressures is disturbed. Respiration exerts a particularly pathologic influence upon the pulse curve when, as the result of intrathoracic adhesions (particularly in the mediastinum), inspiration or expiration exerts an abnormal traction or pressure upon the veins leading to the heart, by which the blood is more or less withheld from the vessels during one of the respiratory phases (pulsus paradoxicus, cicatricial mediastinitis, see p. 126 etseq.). Under normal conditions the influence of respiration upon the pulse curve is slight and scarcely perceptible even in the sphygmogram, so that when marked inspiratory variations are present in the pulse curve we should look for one of the above-mentioned pathologic factors. Superficial breathing has no especial influence upon the sphygmogram. OTHER FACTORS WHICH INFLUENCE THE PULSE CURVE. 1. Diminution of the amount of blood. This produces a diminution and a delay in the elasticity elevations and a decided prominence of the recoil elevation. Venesection for therapeutic purposes may sometimes be sufficient to accomplish this effect. 2. An intermitting cardiac activity diminishes the arterial pressure during the intermission of the pulse. Consequently the pulse wave following upon the pause presents signs of diminished pressure — i. e., the elasticity elevations are weaker and delayed and there is dicrotism. 3. Elevating an extremity diminishes, depressing it increases, the arterial SPHYGMOGBAPHY. 121 pressure in the part. Consequently the sphygmogram of an elevated area shows more distinct dicrotism and slighter elasticity elevations than that of a horizontal or dependent area. 4. Compressing the larger vascular trunks produces an increase of pressure in the other pulsating vessels. This is shown in a well-known way by the sphyg- mogram. 5. An interference with the venous flow from an extremity acts in an opposite way. The arterial pressure in the supplying artery increases, and its sphygmo- gram is correspondingly altered. The rise of the curve as a whole is, however, partly due to the distention of the congested veins (see p. 118). We are indebted to Landois and Marey for most of these statements. DIAGNOSTIC SIGNIFICANCE OF THE PULSE CURVE. At first observers were naturally inclined to overestimate the value of sphygraographic tracings for the diagnosis of pathologic conditions, but to-day most clinicians have gone to the opposite extreme. As a matter of fact, sphygmography is more than an interesting amusement ; it is really a valuable help in the interpretation of circulatory changes. But the factors which influence its shape are so numerous that many different circulatory conditions may be responsible for an identical sphygmogram ; so that even in a cardiac case we are not justified in making a diagnosis merely from the type of the curve. Even the curve of aortic insufficiency, one of the most characteristic of all curves, cannot be considered as pathognomonic of this affection ; exactly the same type may occur without any valvular mischief. Still, the sphyg- mogram is valuable in the diagnosis of many conditions, provided that other symptoms are given their proper value, and provided that the clinician possesses considerable technical skill in making the tracings and a very accurate knowledge of the significance of the sphygmographic curve and of the way it may be modified by various factors. Such a knowledge can only be obtained by studying physiologic works. ^ One of the main objections to making use of the sphygmogram for diagnostic purposes has been that all the variations in the curve attrib- uted upon p. 116 et seq. to the arterial tension — i. e., to the general blood- pressure — can be produced by local changes in the vasomotor tone of the artery examined with a uniform blood-pressure. Of course, if this objection were correct, sphygmography would practically be relegated to a useless place. Mosso is chiefly responsible for this objection. He found that the pulse curve could be changed by local thermic applica- tion — e. g., the local application of heat to the arm dilates the vessels and produces a pulse curve characteristic of low tension, while local cold produces a curve characteristic of high tension. But a closer ex- amination of Mosso's curves shows that such changes are quantitatively quite insignificant, and apply much more to the height of the curve than to its shape. Variations in the pressure acting upon the vessels ^ We mention especially Landois, Die Lehre vom Arterieupuls, 1872 ; Marey, La Circulation du Sane/, 1881 ; Grashey, Die Wellenbewef/ung elastischer Rbhren und der A rterienpuls des Menschen, Leipzig, F. C. W. Vogel, 1881; v. Frey, Die Untersuehung des Pulses, Berlin, J. Springer, 1892 ; Mosso, Die Diac/nostilc des Pidses in Bezug avf die localen Verdnderungen dessetben, Leipzig, Veit & Co., 1879. 122 ARTERIAL PULSE, PALPATION, SPHYGMOQRAPHY, ETC. from without produce but an insignificant effect upon the shape of the 23ulse curve. This Mosso easily determined in his investigations, which were made with a water sphygmograph. The writer has become con- vinced that it is extremely difficult to alter very materially the shape of the individual beats by such local thermic influences, either in the sphygmogram or in the tachogram.^ Besides, where the changes are pronounced, it is not possible to exclude the effect upon the general blood-pressure which can be produced reflexly by the local application of heat or cold. In fact, where the greatest alterations were observed the patients reacted to the thermic changes with sensations of heat and cold. The author has never been able to change a high tension to a dicrotic pulse, or the reverse, by purely local influences of so moderate a degree that a general influence could at the same time be excluded. The general character of the pulse curve remains the same even after a more extensive application of heat or cold to the arm. The difficulty in influencing the character of the curve is well illustrated by making tracings with a different amount of pressure upon the spring. Although the height of the curve as a whole, and that of the secondary curves, will be influenced, neither the general shape of the curve nor the number and position of the secondary elevations will be effected in the least. This remains true even if the artery is almost compressed at the periphery, and such a compression would apparently be quite similar to the effect of a sharp vasomotor contraction there. This fact convinced v. Frey that the best way to employ the sphygmograph was with a very strong pressure of the spring, thus avoiding any excessive swinging of the registering lever. The more frequently and carefully one employs the sphygmograph, the more one is convinced that it registers the condition of the general — i. e., the aortic — circulation, and that it is but slightly influenced by local vasomotor influences. The sphygmogram is, first of all — and herein lies its clinical value — the expression of the form which the pulse wave assumes under the circulatory conditions of press- ure and resistance in the aorta and its large branches. Another thing worth remembering is this, that excessive vasomotor conditions, such as Mosso employed (local baths, violent muscular motions, etc.), rarely affect the ordinary radial heat. If they did we should notice other evi- dences of vasomotor action, such as an increased temperature or red- ness of the skin. The radial vasomotor tonus of an individual ordi- narily clothed and reasonably quiet in all probability varies but little from the average value, which depends upon the condition of the general circulation. One practical difficulty with the sphygmograph is that in one case, even under physiologic conditions, the pulse curve may present several pecu- liarities which in another case would signify some pathologic variations. Hence, a sphygmogram is more practically useful in following the circu- latory conditions in the same patient — i. e., for what might be termed functional diagnosis of circulatory disturbances — than for ordinary diag- ' E. Balli, Ihber den Einduss von Erwdmumj unci Abfciihlmig der Haul ciitf das Flam- mentachogramm, J. A. D., Bern, 1896. SPHYGMOGRAPHY. 123 nostic purposes. It is of decided assistance in studying more closely the therapeutic action of certain measures upon the circulation and of determining the more rational plan of treatment in a given case. Jaquet's sphygmograph is especially suitable for this purpose, not only because an accurate time-measuring apparatus is attached, but also be- cause the amount of pressure upon the spring can be reproduced each time exactly the same. Another advantage is that the examiner can make at each trial five different curves (corresponding to the five degrees of tension in the spring, and so compare them with five others). This will prevent misjudging rather insignificant local variations of vasomotor tension. The increased pressure on the spring evidently has the same effect on the circulation of the hand as a marked increase of tonus of the radial artery. After a little practice one can take five such tracings very rapidly. There is still quite a diiference of opinion whether high or low curves present the more correct picture. Since the modern instru- ments do not permit much swinging, the high curves seem rather more suitable, because they show that the sphygmograph was very perfectly applied, and because their results are perhaps better for comparison in dilferent patients as well as in the same patient. It is evident that the excursions of the registering-needle will be the highest when the ten- sion upon the spring either just balances or is but very slightly in ex- cess of the minimum (cardiac diastolic) pressure in the artery (see p. 107). On the one hand, this is because the transmission of the sys- tolic increase of pressure to the sphygmograph is not interfered with by the relaxed arterial wall ; and, on the other hand, because with such an amount of pressure the artery will be closed during the passage of the trough of the pulse wave, so that the next wave will back up consid- erably, and consequently the rise will be magnified, just as with a hy- draulic press. Comparing the various pulse curves with each other, especially under those well-definable conditions, is really very valuable. FREQUENCY OF THE PULSE IN THE SPHYGMOGRAM. With Jaquet's and with v. Frey's latest sphygmograph, both of which are furnished with a time-marking apparatus, we can estimate the frequency of the pulse very accurately merely by the sphygmographic tracing. RHYTHM OF THE PULSE. A pulse-tracing shows the pulse rhythm at a glance, and much more accurately than it can be described. A regular pulse is one in which the individual waves follow each other at exactly equal intervals of time. Where this is not the case the pulse is termed irregular. If the ir- regularity is complete we call it a pulsus irregularis, without further comment. A pulsus intermittens is one in which, after a regular number of waves, one beat from time to time is omitted. A pukus intereidens is one in which a small beat is inserted into a regular sequence of beats. The so-called bigeminus (Fig. 41) and trigeminus (Fig. 42) represent periodically irregular pulses. In the former 2 beats, and in the latter 3 beats, are grouped together and separated from the preceding and 124 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. following beats by a somewhat longer interval. Their curves usually do not reach the base line between the groups of 2 or 3 beats, so that the sphygmogram looks like a two- or three-peaked curve. The clinical significance of the periodically irregular pulse (see p. 104) is that of a slight degree of irregularity. We have no accurate informa- tion as to the mode of origin of the various irregular rhythms. Fig. 41.— Pulsus bigeminus sequalis (Riegel). [In an exhaustive recent work by Wenckebach ^ a masterful demon- strative explanation is given of many of the most puzzling of heart symptoms. The various types of arrhythmia are considered. It may only be said in this place that he accepts without reservation the myo- genic theory of the heart's action as opposed to tlie neurogenic — /. e., that the ordinary rhythm of the heart is independent of its nervous con- nections, the muscle fibers possessing all the attributes necessary for the rhythmic production of the heart's work. Fig. 42.— Pulsus trigeminus sequalis (Riegel). The editors earnestly recommend a study of the work to all interested in heart studies. A slight criticism may be made that Wenckebach does not give the credit due to English observers in the same field of work (see the Appendix). — Ed.] (Compare "the practical examples" (p. 133) with regard to the possibility of differentiating a " sufficient " from an " insufficient " heart by the irregularity in the sphygmogram.) VOLUME OF THE PULSE IN THE SPHYGMOGRAM. According to our definition on p. 105, the volume of the pulse is represented by the height of the primary curve summit above the base of the curve. Other things being equal, it is evident that the volume 1 Die Arhythmie als Ausdruck besiimmter Funktionsstorungen des Herzens, by K. F. Wenckebach, Groningen, Leipzig, 1903. SPHYGMOGRAPHY. 125 of the pulse depends upon the amount of blood M^hich is thrown into the artery during systole. If this systolic amount of blood is equal, the volume of the pulse then depends upon the facility with which the arterial wall gives way to the wave motion of the blood — i. e., on the one hand, upon the passive tension of the artery as determined by the blood-pressure, and, on the other hand, upon the active tension of the muscularis of the artery. The volume of the pulse — /. e., the height of the sphygmographic curve — also depends very decidedly upon the size of the surface of the artery (according to Pascal's law of the hydraulic press). Provided the systole of the left heart is equal and the blood- pressure is equal, the larger the diameter of the radial artery the higher the spring of the sphygmograph will be raised, and hence the larger the pulse. The frequency of the pulse also influences the height of the sphygmograra. If the pulse is rapid a part of the descending limb of the curve will be cut off by the following wave. So many factors in- fluence the volume of the pulse in ways which we cannot perfectly determine from the appearance of the curve itself, that the mere volume of the pulse is of very uncertain diagnostic significance. In the follow- ing cases, provided the tracings compared are all of a maximum height, the volume of the pulse is of some significance : 1. When the size of the individual beat varies in any one pulse curve we may be sure that the larger beat corresponds to a larger expul- sion — i. e., is preceded by a more complete diastole of the heart — and that the smaller beat corresponds to a smaller expulsion. 2. If the same patient's pulse becomes fuller and of higher tension when examined with the same sphygmograph (secondary rises nearer the chief elevation, p. 116, 6, 128 et seq.), then we are justified in assum- ing that a greater systolic expulsion is the cause. Fig. 43.— Pulsus alternans (Eichhorst). On the other hand, if the full pulse is at the same time of diminished tension, then its increased size may depend upon the flaccidity of the arterial tube-i-i. e., upon diminished blood-pressure. The following terms refer to the size of the pulse : Pulsus equalis and inequalis (the latter is usually a pulsus irregularis as well) ; )>M/x?t.s inequalis periodicus. The most interesting types of the latter are the pulsus alternans (Fig. 43), pulsus bigeminus alternans (Fig. 44), and pulsus paradoxus (Fig. 45). Inequality of the pulse is of similar clinical importance as irregu- larity (see p. 104), and is usually found combined with it. Periodic 126 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. inequality means the same thing as a slight degree of inequality. The pulsus paradoxus, a poorly chosen name, was first described by Griesin- ger/ and later by Kussmaul, as a constant symptom of indurative mediastinitis. Its peculiarity is that during inspiration the pulse becomes feeble or else cannot be felt at all. Kussmaul explains it as due to an inspiratory pull upon the veins leading to the heart by the intrathoracic adhesions. From the explanation given at p. 118 et seq. it follows that this symptom can have no pathognomonic importance in the diag- nosis of indurative mediastinitis. From the physiologic significance of Fig. 44. — Pulsus bigeminus alternans (Eichhorst). the phenomenon as there explained, it is not surprising that it has been observed also in pericarditis, in valvular disease, in weak heart, in pneumonia, in pleurisy, and in stenoses of the air passages (laryngeal and tracheal stenoses, obliterative bronchitis). Even when the heart and lungs are absolutely normal, it is possible that respiration may pro- duce some evident eifect upon the pulse, although this is not usually the case, as we have previously pointed out on p. 120. It seems to the writer that the pulsus paradoxus is of value in the diagnosis of indurative pericarditis only when there is a concomitant inspiratory engorgement of the jugular veins, a symptom which indi- cates a stenosis of the jugular veins during inspiration. Fig. 45.— Pulsus paradoxus : E, Beginning of expiration ; /, beginningof inspiration (Kussmaul). The typical pulsus paradoxus (Fig. 45) is copied from Kussmaul's original communication. It especially seems to the writer to possess no diagnostic importance whatsoever. As is easily seen from the figure, the pulsus paradoxus is just twice as frequent as the respirations, so that expiration always coincides with one beat and inspiration with the other. If the breathing is energetic this relation will naturally emphasize the physiologic factors described on p. 118. As a matter of fact the breathing is rapid, so that under the circumstances, according to p. 119, even if the circulation is normal, the pulse shows more or less distinctly an inspiratory decrease or even a disappearance. Besides, from what ' Widenmann, Beitrag zur Diagnose der Mediastinilis, Tubingen, 1856. SPHYGMOGRAPHY. 127 has been mentioned on p. 119, it is evident that under certain circum- stances, and practically independent of the frequency of the respiration, a noticeable diminution or even an omission of the pulse may be observed even during expiration. Such a phenomenon could just as well be called a " pulsus paradoxus," and it certainly has just as little significance in the diagnosis of any definite disease. Although all these phenomena of an alteration in the pulse from respiratory influences coincide with the occurrence of a low arterial pressure (p. 120), we are not justified in diagnosing any one definite disease, such as pericarditis or mediastinitis, but merely a deficient general peripheral circulation. CELERITY OF THE PULSE IN THE SPHYGMOGRAM. The celerity of a pulse is a quality which we can appreciate by pal- pation (p. 105). It is also plainly represented in the sphygmographic curve. Both ascending and descending limbs of a pulsus celer are steep and the summit is sharp. On the contrary, both limbs of a true j^uisus tardus are sloping ; the curve is flat and the summit blunt (Fig. 47). Fig. 46.— Pulsus celer in aortic insufficiency (Paegel). Either limb of the curve may exhibit the signs of celerity or tardiness, while the other limb either is not affected or may exhibit the opposite condition. In this case our description must include the character of each limb. For the method of determining by construction the sliape of the general curve, or of the main summit in the case of polycrotic Fig. 47.— Pulsus tardus in aortic stenosis (Striimpell). curves, see Fig. 39. The ascending limb of aortic insufficiency (Fig. 46) is steep because a large mass of blood is suddenly expelled from the dilated left ventricle into the aorta ; and the descending limb is also steep because, on account of regurgitation of the blood into the left ventricle, the negative stage of the wave is introduced abnormally 128 ARTERIAL PULSE, PALPATION, SPH TOMOGRAPHY, ETC. rapidly. Conversely, the ascending and descending limbs of aortic stenosis are oblique ; it is a typical pulsus tardus (Fig. 47). Here the rise as well as the drop of the curve takes place slowly because the sys- tolic impulse is deadened and prolonged at the seat of stenosis. In relaxed vessels — /. e., in fever — the rise as well as the drop is usually quick (see p. 116). The dicrotic febrile pulse is therefore usually a pulsus cder (Fig. 51). With high arterial tension the descending limb of the curve is usually quite gradual and oblique (p. 116). The rise is generally rapid and steep on account of the energetic cardiac action. Fig. 48.— Senile pulse in arteriosclerosis (Riegel). This is the type of pulse which is usually observed in old people with arteriosclerosis (Fig. 48). Nevertheless a very decided degree of arterio- FiG. 49.— Pulse in advanced arteriosclerosis : Slow ascent and descent of the wave ; anacrotism— only 32 beats to the minute (taken with Jaquet's instrument). sclerosis (Fig. 49) is generally accompanied by a gradual rise. In nephritis (Fig. 50) the rise is steep and the descent slow, but the pulse Fig. 50.— Pulse in chronic nephritis. differs from that of arteriosclerosis by the great number of secondary elevations. Although the general shape of the sphygmogram gives some idea of the arterial pressure and the way the blood flows into the arteries, and from them to the periphery, yet neither the descent nor the ascent of the curve is absolutely diagnostic. In the first place, the height of the curve influences the slant of the descending limb; and, as a rule, we are unable to interpret the significance of variations in the height (p. 125). Again, the frequency of the pulse decidedly modifies the slant SPHYGMOGRAPHY. 129 of the descending limb, because if a pulse is rapid a portion of its descending limb is simply cut off by the following wave, so that the height of the curve seems lessened. Even in aortic insufficiency the value of the slant of the descending limb is rather more for demonstra- tion than for diagnosis. The slant of the ascending limb is almost as variable. The steepness of its ascent does not, in itself alone, give us accurate information concerning the quickness of the rise of the pulse wave. The only really accurate way of determining the celerity of the rise of the ascending limb, and this is of decided importance in pro- nounced arteriosclerosis or in aortic stenosis, is to measure the length of the time-registering line between the base of the rise and its summit. We must, of course, remember that this time interval should not be confounded with the duration of the cardiac systole, for systole (p. 115) extends beyond the main elevation. It should be observed that as a result of the fact that the duration of the ascent of the pulse curve does not correspond with the duration of the delivery of the blood into the aorta, the demonstration of the characteristic pulse of aortic stenosis is frequently unsuccessful, since the duration of the ascending limb of the curve is shortened by the rapid flowing of the blood toward the periph- ery. The pulse simply seems small, but does not present the typical characteristics of the pulsus tardus. To the best of the writer's knowl- edge, attention has not been previously directed to this evident explana- tion of the frequent absence of the pulsus tardus in aortic stenosis. TENSION OF THE PULSE IN THE SPHYGMOGRAM (POLYCROTISM ; DICRO- TISM; ANACROTISM). The secondary elevations of the descending limb (p. 116 ef seq.) are most significant in attempting to estimate from the pulse-tracing the tension of the pulse — i. e., the mean blood-pressure. Elasticity eleva- tions which are pronounced or which arise early in the curve [according to V. Frey's and Krehl's conception (p. 118) the early reflex waxes — i. e., secondary elevations near the summit] or anacrotic elevations (p. 117) generally indicate a high mean blood-pressure. The converse — i. e., the so-called dicrotic wave (p. 116) — is usually more pronounced with a loio mean blood-pressure (p. 116). Where none of the secondary elevations, either from their size or their position, can be considered as a dicrotic wave, we are justified in assuming that numerous and pro- nounced secondary elevations are more in favor of a high pressure ; because, according to Landois, these numerous elevations should be regarded as elasticity elevations, and according to v. Frey's and Krehl's idea, powerful and, at least in part, early reflex waves. Compare IIQ et seq. and 122 in regard to the general form and size of the pulse under variable mean pressure. The type of the pulse curve with varying arterial pressure may be represented as follows : 1. Normal Pressure.- — Both the elasticity elevations and the dicrotic wave, moderately develo])ed ; the latter, however, only slightly different from the elasticity elevations (see Fig. 38). 9 130 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPEY, ETC. 2. Low Pressure. — Elasticity elevations disappear, dicrotism in- creases, and eventually becomes transformed into monocrotism ; the height of the pulse is increased — i. e., it becomes a pulsus celer, except when the low pressure is due to a weak, slight systole (Fig. 51, 6, c, d, e). ^ 3. High Pressure. — Elasticity elevations increase in size and num- ber ; they are situated nearer the summit (Figs. 45 and 52) or even on the ascending limb of the curve (anacrotic) ; the descending limb, and in rare cases the ascending limb, are oblique (tardus) ; the height of the curve is generally low except when the high pressure is due not to in- creased resistance alone, but to a strong, full systole as well. If the a. Normal with beginning dicrotism. 6. Hypodicrotism. c. Dicrotism. d. Hyperdicrotism. e. Monocrotism. Fig. 51.— Increasing dicrotism finally transformed into monocrotism (Riegel). blood-pressure is very high, and especially if it is due to arteriosclerotic resistance, not only the dicrotic rise disappears, but even the elasticity elevations fade away more or less completely, because the arterial wall has become stiffened, either on account of the firm contractions of its muscularis or on account of the anteriosclerotic changes. A mono- crotic pulse finally results. Fig. 49 represents such a slow, low, and almost monocrotic sphygmogram ; but there still remain some indica- tions of elasticity elevations visible especially in the ascending limb (anacrotism). In this schematic grouping the relation of the size and the celerity of the pulse curve to the blood-pressure has only a theoretic significance, SPHY'GMOGRA PHY. 1 31 because the qualities of size and celerity in the sphygmogram (pp. 124 and 127) possess only slight diagnostic value. Furthermore, merely counting the elasticity elevations is not always sufficient to determine the height of the blood-pressure, because the pulse frequency always plays a part. With a frequent pulse the curve is not completely developed ; so that a part of the descending limb and the elasticity elevations contained in it will not show. The development of a dicrotic wave is best studied in a febrile pulse, because dicrotism usually goes hand in hand with a diminution of the vascular tension. The higher the fever, the more hilly the dicrotic wave is developed, and the further dis- tant is it from the main summit of the curve (Fig. 51, a, b, c, d). The individual steps of this change have received separate names. If the dicrotic elevation begins before the descending limb reaches the base of the curve, the pulse is called Ay^jo- dicrotic (Fig. 51, 6). It is strictly dicrotic when the dicrotic wave starts only after the descending limb reaches the base line. If the dicrotic wave occurs still later — i. e., in the ascending limb of the following wave — ^the pulse is then termed " hyperdicrotic " (Fig. 51, d). This peculiarity may arise either because the dicro- tic wave is retarded or because the following wave, coming so rapidly, cuts off the descending limb of the dicrotic wave. If in Fig. 51, c, the ordinary dicrotic pulse, we imagine that the individual beats follow more closely one after the other, then " hyperdicrotism " results (Fig. 51, d). If the dicrotic wave is still further re- tarded or, what amounts to the same thing, if the rate of the pulse is still further increased, a monocrotic wave results (Fig. 51, e). This monocrotism with relaxed vessels and low pressure differs from the monocrotism of high pressure (Fig. 49). In the latter the tense or rigid arterial wall cannot produce any considerable sec- ondary elevations. The j^ulse wave is here usually low and the pulse very slow. Typical examples of high-tension pulse curves are the arteriosclerotic pulse (Fig. 49), the nephritic pulse (Fig. 45), and the tense pulse in lead colic (Fig. 52). Anacrotic elevations (p. 118) probably occur only with high blood-pressure. Fig. 52.— Tense pulse in lead colic : Some of the waves anacrotic (Riegel). Fig. 52 shows anacrotism in some of the summits, and it is also suggested in the curve of Fig. 49. Eounded summits (Fig. 48) probably signify anacrotism (con- sisting of several anacrotic elevations). The rigidity of the artery prevents it from being distinctly indicated. Similarly, rounded tops which slant off toward the descending limb should probably be imagined as confluent catacrotic elasticity ele- vations. Sometimes the rounded top is flattened like a plateau. But the signifi- cance is probably not changed. SPECIFIC SPHYGMOGRAMS. When the sphygmograph was first employed, it was believed that pathogno- monic pulse curves would be found to characterize certain affections, especially car- diac cases. But such a belief has not been justified. Not even the curve of aortic insufficiency can be considered specific of this disease, for in fever and in exoph- thalmic goiter, without any leak at the aortic valve, a very pronounced pulsus celer is often observed. The pulse curve of mitral lesions is less suggestive or certain, although in some instances it is of decided assistance in the diagnosis. A serious 132 ARTERIAL PULSE, PALPATION, SPH TOMOGRAPH Y, ETC. error was formerly made in the attempt to find characteristic signs in the curve during the time of disturbed compensation. This is evidently the least favorable time, because if comjjensation is affected to any extent the pulse will always be a small pulse and of low tension ; and such a condition might be due to the valve lesion alone, without any disturbance of compensation, v. Noorden^ has par- ticularly emphasized the necessity of utilizing well-compensated cases in order to obtain characteristic curves, and believes that compensated mitral stenosis exhibits Fig. 53. — Tense pulse in compensated mitral stenosis (v. Noorden). a high-tension pulse, whereas compensated mitral insufficiency exhibits a low- tension pulse (Figs. 53 and 54). V. Noorden accounts for this phenomenon by assuming that in mitral steno- sis an increased arterial tone aids in maintaining the compensation. The arterial Fig. 54.— Lack of tension of the pulse in compensated mitral insuificiency (v. Noorden). system is thus sufficiently filled and the pressure preserved despite the small sys- tole. On the contrary, in mitral insufficiency the compensation is favored by vaso- motor relaxation of the vessels, which diminishes the resistance in the arterial system. In this way a much larger proportion of the left ventricular contents can be utilized by the circulation, and a correspondingly smaller portion returns into the left auricle. These peculiarities are, the writer believes, more simply explained as follows : In mitral stenosis there is no reason for any diminution of the arterial pressure ; whereas in pronounced mitral insufficiency a high arterial pressure can- not i^ossibly occur because of the regurgitation of the blood into the left auricle. If the circulation should be appi'oximately normal in such a marked degree of mitral insufficiency, in spite of the low arterial pressure, it is an indication that the vasomotor tone of the general circulation is lowered, a fact which has a compensa- tory significance, and to this extent v. Noorden is correct. A FEW PRACTICAL EXAMPLES TO ILLUSTRATE THE APPLICATION OF THE SPHYGMOGRAPH. The deductions which may be made from the sphygmogram as to the condition of the circulation are well illustrated in Fig. 55, a and b, and Fig. 56 a, and b. They represent tracings taken (a) from a case of distur]:)ed compen.sation and {b) from the same case after compensation has been re-established by the employment of digitalis. The comparison of curves in Fig. 55, a, and Fig. 57 is very interesting from a ^ C'harite-Annalen, 15 Jahrgang. SPHYGMOGRA PHY. 133 diagnostic standiDoint. Both curves show an irregular pulse, but with these differences : The curve in Fig. 57 in general, and the small interposed beats, represent a pulse of high tension, whereas the pointed single elevations of the curve in Fig. 55, a, point in general to a low degree of tension. The arterial pressure sinks quickly, especially in the little beats ; this is evident from the dicrotism and from the depression of the Fig. 55.— Sphygmogram from a patient with mitral insufficiency, to demonstrate the action of digitalis : a, Before the administration of digitalis— circulation decidedly affected, radial pulse 128, cardiac beats 172; 6, after the employment of digitalis— circulation practically normal. base of the curve. The latter fact alone points to an insufficient systole as compared with the curve in Fig. 57, where the cardiac apparatus is evidently sufficient. The type of irregularity illustrates another difference between the two curves. In Fig. 55, a, the size of the individual pulse wave certainly in some places seems to be independent of the size of the preceding interval, whereas in Fig. 57 the size Fig. 56.— Sphygmogram from a patient with emphysema and cardiac dilatation, to demonstrate the action of digitalis: a. Before the administration "of digitalis— circulation decidedly affected, pulse about 100; b, after 2 gra. of digitalis — circulation normal, pulse 70. of the individual beat is directly proportional to the duration of the preceding in- terval. The first type of irregularity, according to my experience, always points to cardiac insufficiency of a kind that can be helped by employing digitalis. This drug will improve the flow of blood through the cardiac muscle itself, and so help the disturbed innervation which is the cause of the arrhythmic condition. The irregularity represented in Fig. 57 is quite different. Here the difference 134 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. in volume of the beats is a direct sequence of the irregularity. Because the left ventricular diastolic filling is brief, the succeeding pulse must be smaller, even if the cardiac power is entirely sufficient. This type of irregularity, therefore, does Fig. 57.— Arrhythmic sphygmogram in cardiac sufficiency. not point to cardiac insufficiency, and so in itself presents no indication for the use of digitalis. The size and the high tension of the individual pulse wave evident in Fig. 57 would be another reason for the uselessness of digitalis in this case. SPHYGMOMANOMETRY (TONOMETRY). The sphygmograph furnishes only relative information of the height of the arterial pressure ; hence v. Basch ^ attempted to construct an instrument to meas- ure the arterial pressure upon the intact human body. He had succeeded, approxi- mately, with the sphygmomanometer. Potain has since modified v. Basch' s more modern instrument. V. Basch attempted to copy the method of estimating pulse ' ' tension ' ' with the finger (p. 106) by measuring instrumentally the amount of pressure required to suppress the jjulse wave. Waldenburg and Talma had attempted to obliterate the pulse in the artery by compressing the artery by weights or springs. The size of the surface pressed upon Avas neglected in these experiments, so that their re- sults are of no particular value. To obviate this difficulty, v. Basch employed a so-called air pelotte — i. e. , a thin rubber membrane tied like a bladder over a metal cylinder, filled Avith air and connected with a manometer. With this mechanism the size of the surface pressed upon makes no difference; the manometer reading will always be the same. For, according to hydrostatic laws, the amount of press- ure indicated by the manometer is that exerted upon each point of the surface of the pelotte. V. Basch has recently made a practical improvement in the shape of the pelotte. Fig. 58 represents the instrument in its new form: A, the manometer; Fig. 58.— v. Basch's sphygmomanometer. B, the pelotte; C, the connecting tube. By means of the cock, D, the entire system is filled with air under a low pressure, ^ so that the pelotte is but slightly tense and the two closing membranes bulge a trifle. 1 Berlin, klin. Woch., 1887; Arch, de phydohcjie, 1889, Ser. 5, vol. i., p. 556, and vol. ii., p. 300. , , , ^ v. Basch formerly filled the cylinder with water. Air was first employed by Potain, and has the advantage of doing away with hydrostatic pressure, and so enablmg us to disregard the level of the manometer in reference to the pelotte. SPHYGMOMANOMETRY [TONOMETRY). 135 The employment of this instrument is very simple. The course of the artery to be examined is first marked upon the skin ; one of the bulging membranes of the jDelotte is placed upon the artery, and the manometer is laid upon the bed at the side of the patient. The examiner then attempts to estimate the amount of pressure (read upon the manometer scale) necessary to obliterate the pulse periph- eral to the pelotte. This he does by palpating with one finger, while with another he prevents any anastomotic pulse from entering the artery. This method will determine the arterial pressure at least approximately ; perhaps more accurately if the manometer is read at the moment when the jjulse reappears after the press- ure has been gradually diminished. The method is, of course, entirely subjective, as its accuracy must depend upon the examiner's sense of touch. To obviate this difficulty, V. Basch has attemj^ted to substitute the sense of sight. A rubber band is rather loosely 2:)laced over the radial artery and a small pin stuck in it, so that the excursions of the pin are plainly visible. If the pin stops moving the pulse is considered absent. According to the writer's experience, this device is not always successful. Two factors combine to prevent this method from accurately measuring the true arterial pressure. In the first place, the wall of even an empty artery remains open, so that a certain, though small, amount of the pressure exerted represents that employed to com23ress the arterial tube ; and, in the second place, the tissues covering the artery must interfere to a slight extent with the accurate application of the pelotte, so that the instrument must register a somewhat higher pressure than actually exists. V. Basch's experiments, however, show that both these factors' combined can- not cause a deviation of the real values from those recorded of more than about 10 to 15 mm. Tigerstedt^ gave a very unfavorable opinion of the value of this method, because he found a much greater deviation. In the j^revious editions of this book the author shared this view, but feels obliged to withdraw his criticism since he has used the improved air pelotte as illustrated in Fig. 58. As a matter of fact, the results given by the old pelotte wei-e not very reliable, for reasons which cannot be here given in detail. The temporal artery is the most conve- niently situated for this measurement ; the radial next, provided that it is com- pressible against the lower end of the radius. In the former v. Basch found that the pressure varied from 90 to 120 mm. Hg. ; in the latter, from 110 to 160. The author's own estimations at the radial have usually been from 160 mm. ujsward. Potain's investigations {loc. cit.) show that these figures correspond to the max- imum pressure variations during a pulse wave — i. e., to the systolic pressure. Another reason to doubt the accuracy of this method is the following : Since dynamic processes — that is, moving masses — are chiefly concerned, we must con- sider the vital power of the pulse wave according to the laws of the hydraulic press. Now, it is well known that when a current is compressed by some obstruc- tion, a far greater force is developed above the point of resistance at the moment of compression than the corresponding amount of lateral pressure of an unresisted flowing fluid. This arises from the transformation of the pressure of velocity into lateral pressure. The hydraulic press or ram depends upon this ])rinciple. Con- sequently a large j^ulse wave, even with low arterial pressure, will force its way through under the compressing pelotte, owing to the greater amount of " energy," while a smaller pulse wave, even with higher arterial tension, will be completely obstructed, because the latter possesses less energy. Again, the portion of the wave which passes through under the pelotte will be felt longer if the pulse is large than if it is small and hard to feel, even though of high tension. This objec- tion agrees with Potain's results {loc. cit.), according to which the values found with the V. Basch instrument correspond to the maximum (systolic) pressure, l)nt do not furnish any information of the mean or of the minimum pressure. This only means that the manometric values depend upon the potential energy of the individual jiulse wave. With this proviso the method may be of some clinical use, but we must not imagine thattlie values tluis determined correspond with the read- ^ Lehibach der Pliysiohijie des Kreialaufef, Leipzig, 1893. 136 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. ings of a mercury manometer connected directly with an artery. It is commonly supposed that these systolic values, to be sure, are not so very different from the mean arterial pressure. But although the well-known kymographion curves with the mercury manometer seem to show that the systolic pressure varies but little from the mean pressure, at the same time these curves are not at all applicable for estimating the extent of pressure variations, because the inertia of the mercury column prevents its registering the variations correctly. As a matter of fact, we know very little about normal variations of blood-pressure in man and animals, and still less about the size they may attain in pathologic conditions. In fever, for example, on account of the large, bounding jsulse waves, V. Basch's sphygmomanometer may indicate high figures, although the sphygmographic curve shows relaxation of the vessels and a low (mean) arterial pressure. Such peculiar contradictions, which have thus far been at- tributed entirely to the fault in the sphygmogram and never to the really much less reliable sphygmomanometer, can only be explained by assuming that under these con- ditions there exists a very much greater difference between minimum and maximum or between mean and maximum pressure in the arteries than is generally accepted. The writer believes that the mean arterial pressure in fever is probably low, corresponding to the shape of the sphygmo- gram, in spite of the fact that v. Basch's instrument in- dicates high values, on account of the large and powerful systole in consequence of free flow of blood through the relaxed vessels. Should these views be confirmed, the clinical value of sphygmography will be increased at the expense of sphygmomanometry. At all events, the writer recommends the greatest caution in the clinical use of v. Basch's instrument. (See p. 106 for the real significance of the term arterial tension or blood-pressure. ) The author has recently made what he believes to be an improvement in v. Basch's instrument by increasing the diameter of the air pelotte from scarcely 2 cm. to 3- 4 cm. This greatly aids us in securing pneumatic pressure upon the artery ; while with the small pelotte of v. Basch there is danger of compressing the vessel by the resistant portion of the caoutchouc near the rim of the pelotte or by the rim itself. As it has been my experience that the metal manom- eter of the shops is not very accurately graduated, and that, although it may be correct originally, the values- of the scale gradually change, I have constructed a pocket mercury manometer, which may be easily trans- ported, is absolutely correct, and has the additional ad- vantage of being cheap. ^ This manometer may also be employed for any other manometric method, in the Riva-Rocci sphygmomanometer, for example (see p. 137, et seq.), for the measurement of the pressure of pleural exudates, and, in virtue of its fine caliber, for the measurement of the pressure of the cerebro- spinal fluid in lumbar puncture. (See section upon Exploratory Puncture. ) The instrument is illustrated in Fig. 59, and consists simply of a U-shaped manometer in which one branch can be elongated by inserting a glass tube, the -connection being accurately ground. The caliber is sufficiently large to exclude the disturbing element of capillarity, and yet not large enough to require a great quantity of mer- cury. Owing to the accurate adaptation of the two tubes, it is unnecessary to use the greasy materials usually employed to secure the perfect adjustment of glass 1 The instrument is manufactured by the optician Biichi, in Bern. Fig. 59.— Sahli's pocket mercury manometer. SPHYGMOMANOMETRY {TONOMETRY). 137 stop-cocks, and the mercury is consequently kept in much better condition. When the instrument is to be employed, the elongation a 6 is inserted, and the pelotte of V. Basch's instrument (preferably the enlarged form, as described upon page 134 ; see Fig. 58) is connected with c by a tube. The pressure exercised upon the artery by the pelotte is transmitted to the shorter branch of the manometer. The elongated branch is so divided that it gives the pressure directly in centimeters, every half-centimeter being marked as a unit. In such a manometer, as is well known, the pressure is obtained by multiplying the height of the ascending column by two, because the mercury falls exactly as far in one branch as it rises in the other. The manometer must be accurately filled with mercury to the zero mark. The ampulla e is for the purjjose of preventing the throwing of the mer- cury out of the shorter branch by a sudden diminution of pressure, and the am- pulla b acts in a similar manner when the pressure is suddenly increased by careless manipulation of the pelotte. The instrument may be packed and transported by removing the elongating tube a b, and plugging the openings a and c with rubber corks. I formerly employed glass stop-cocks for this purpose, but owing to their fragility and the necessity of using a lubricant to render them air-tight, I have found that they were not well adapted to the purpose. The entire instrument may be packed in a handy, well-cushioned case, which is made large enough to also hold the pelotte for von Basch's instrument. Since the mean blood-pressure is so important for diagnosis, a.s well as for de- termining the efiiciency of certain therapeutic agents, it is very fortunate that so many physiologists have recently turned their attention toward devising some simple and accurate method of measuring it. Such methods have been described by Mosso, Hurthle, v. Frey, Eiva-Rocci, and Gartner. The Riva-Rocci and the Gartner instruments are the only ones which have proved to be practically valuable. The detailed descriptions of the others in previous editions of this book have consequently been omitted in the present one. The principle of Eiva-Rocci' s sphygmomanometer ^ is the same as that of v. Basch's. It measures the amount of pressure necessary to obliterate the pulse peripheral to a point of constriction. A pneumatic pressure is used as in v. Basch's instrument. The practically important modification consists in substituting for the single pelotte to press upon the artery a pneumatic cuff which encircles the upper arm, and the cavity of which connects with a rubber bulb. Since the upper arm contains only a single bone, inflation of the cuff will interrupt all the arterial supply to the forearm in a perfectly equal way. The cufl^ should be made of some firm mackintosh cloth, or, if of elastic rubber, it should be securely fastened to a lining of material which will not stretch. This is to prevent the loss of a part of the pressure from any eccentric inflation or dis- tention of the wall. Fig. 60 represents the apparatus. The i^atient's upper arm is inserted into the cuff (a). The latter is connected with a mercury manometer {b), and through it with a double rubber bulb (c). By pumping at c the cuff" can be made to encircle the upper arm tightly, and the amount of pressure employed can be read in mm. of mercury upon the vertical tube of the manometer. This pressure is increased until the radial pulse disappears. The cuff", about 4 cm. wide, should be so adjusted as to fit the arm rather snugly without compressing it. The latter purpose is accomplished by a clamp, as is rej^resented in Fig. 60. The instrument was tested experimentally both by Riva-Rocci and by Gumprecht.^ The muscles should be well relaxed, because compression through thick muscles does not affect the result. The same objection applies to the ])rinci- ple involved in this method as was mentioned in discussing v. Basch's instrument (p. 1 35). The amount of pressure found depends not only upon the median arterial pressure, but also very decidedly upon the energy of the pulse wave, and with it upon the size of the pulse volume. For these reasons, and perhaps also partly on account of the resistance to compression which the muscles of the upper arm afford, ^ Riva-Rocci, Un nuovo sfigmomanonietro, Torino, 1896 ; Frascati e Comp. Tecnica della sfigmomanometria, Gnz. Med., di Torino, 1897, Nos. 9 and 10. ^ Zeits.f. klin. Med., 1900, vol. xxxix., parts 5 and 6. 138 ARTERIAL PULSE, PALPATION, SPHYGMOQRAPHY, ETC. the figures which the writer has found in a great many attempts have always been very high. Normal individuals furnish a value of 150 to 160 mm. Hg., and the arteriosclerotic and nephritic as high as 230 to 250 mm., or even higher. Although all these values may be relatively too high, nevertheless the instrument possesses a distinct advantage in being purely objective as compared with v. Basch's (see ^. 135). This may be realized by making several tests, one after the other, when it will be seen that they are almost invariably the same. This is especially apt to be the case if at each attempt the pressure is raised beyond the point at which the pulse cannot be felt, and then, when, as a result of the yielding of the rubber tubes and connec- tions, the pressure falls slowly, the point is noted at which the pulse begins to appear again. In this way the attention is not distracted by the need of pumping, and the method is still more objective and quite exact. Of course, for a control it is advisable to note the point at which increasing jiressure causes the pulse to vanish. The writer has frequently attempted to supplant the palpation of the pulse by the objective method of sphygmography, making short curves at different pressures until the needle makes but a straight line. It has advantages in demonstrating to a clinic. One caution should be added. Pronounced congestion, pain, and even cutaneous Fig. 60.— Riva-Rocci's sphygmomanometer. hemorrhage may result from employing the instrument to measure very high press- ure — e. g., above 230 mm. The transportable mercury manometer of Sahli, described upon p. 136, may also be employed in connection with the Riva-Rocci pneximatic arm-band, rendering this excellent instrument much handier and more practical. Led by v. Recklinghausen,^ a number of authors have pointed out that the cuff of Riva-Rocci's instrument is too narrow. They came to this conclusion from the fact that different pressure values are obtained when a wider cuff is emi^loyed. It is clear that if the cuff is too narrow the inflation produces a marked distortion, both of the cuff itself and of the surface of the arm, which endangers the trans- mission of the aerostatic pressure, since a certain fractional part of the manometric . pressure is consumed in producing the aerostatic tension of the cuff and the tension of the tissues pressed upon. The cuff of the original Riva-Rocci instrument was 4^ cm. in width. These authors now demand a cuff 32 cm. wide. It is clear, however, that this not only makes the instrument more clumsy, but also renders the closure of the cuff more difficult and less secure. Additional errors also arise from the fact that such a broad cuff does not act upon an approximately cylindric surface, owing to ^ V. Recklinghausen, Arch. f. exper. Pathol, u. Pharm., 1901, vol. xlvi., parts 1 and 2; Hansen, Deiii. Arch. /. klin. Med., 1900, vol. Ixvii. SPHYGMOMANOMETRY {TONOMETRY). 139 the irregular contour of the arm. Martin ' has found that a cuff 10 cm. in width suffices for all cases. In the writer' s opinion a great deal depends upon the manner in which the cuff is applied. If the cuff is emptied and applied accurately to the skin without the exercise of any pressure, cuflFs only 5 to 6 cm. in width remain so flat during inflation that the transmission of the pressure is complete and the results are as accurate as they can well be from the nature of the procedure. We should banish the illusion that this procedure is of equal value with manometry upon the exposed and divided artery. Gartner's tonometer ^ depends upon a similar principle. It estimates the press- ure which is required to interrupt the peripheral circulation. Gartner makes use of the color of the ti^) of the finger instead of feeling the j)ulse to determine the condition of the peripheral circulation. His instrument consists of a small pneu- matic compression ring, whose cavity is connected with a mercury or spring man- ometer and with a rubber bulb. The pneumatic ring is constructed of a metal hoop 1 cm. high and 2J cm. in diameter. A rubber membrane lines this hoop, and with the latter surrounds an air space communicating with the manometer and bulb. The pneumatic ring is first slipped over the second phalanx of the little finger without pressure. The projecting end phalanx is then made bloodless by a rubber compressor like a glove finger, or by a ring cut out of a rubber tubing, rolled upon the finger as far as the pneumatic ring. This compression is kept up UJitil the pressure in the pneumatic ring has been raised by means of the bulb sufficiently to keep the blood from returning to the finger ; then the compressor is removed. The finger-tip now appears as pale as a corpse. By gradually releas- ing the pressure from the rubber bulb the finger becomes colored again. As a matter of fact, the finger assumes a cyanotic color, and so facilitates the differentia- tion. This is because the veins will still be compressed at the moment the digital arteries open under the arterial blood-jsressure. This pressure at which the blood again streams into the finger can be regarded as equivalent to the blood-pressure in the digital arteries. In cases where the capillaries of the finger-tip are much contracted, it may happen that the finger-tip will not be properly colored after the release of the pressure on the arteries. In such cases Gartner accomplished his purpose by relaxing the tonus of the fine vessels by producing an artificial congestion by a pressure of 20 to 40 mm., Hg., with the pneumatic ring for a half minute, and so paralyzing the vessels just before repeating the test. Gartner assumes that the pressure in the small digital arteries difiers but little from that in the radial. Of course, the measurement will be decidedly influenced by the height of the fingers, so that he recommends that the test be undertaken with the fingers at the height of the heart. Without question, Gartner's instrument offers certain advantages over Riva-Rocci' s. One of the most important consists in the avoidance of the unfortunate confusion between the static and dynamic conception of both Riva-Rocci' s and v. Basch's instruments. Even here, how- ever, although the pulse wave plays an insignificant part, it is not the mean blood-pressure which is measured, but a blood-pressure which closely approximates the maximum. Another advantage seems to the writer to be that it depends ujjon relations which are appreciated by the keenest of our senses — namely, the sense of sight. Gartner also considers that the resistance of the arterial wall, which especially in arteriosclerosis plays so important a part, influences the measurement less in the small finger arteries than in the large vessels. Another advantage is that the patient does not have to be undressed when Gartner's method is employed. The normal pressure values Gartner has estimated vary between 90 arid 105 mm. There is only one objection to his method, and he does not deny it, nor has he been able to obviate it as yet. This is that the readings are decidedly influenced by the resistance of the tissues of the finger-tips. This resistance is very different in 1 Munch. Med. WocL, 1903, No. 24, p. 1021. ^G. Gilrtner, Ueber einen neuen Blutdruckmesser (Tonometer), Wien. Med. Presse, 1899, jSTo. 26. L. Schulmeister (Vienna) and F. Hugershofif (Leipzig) make the instru- ments. 140 ARTERIAL PULSE, PALPATION, SPHYGMOGRAPHY, ETC. a laborer's hand and in a lady's hand. In the writer's opimon this source of error is so considerable that it discounts the value of the entire procedure, and the description of certain technical modifications of this method ^ will consequently be omitted, since they do not obviate this chief fault. [Within the last few years the usefulness of blood-pressure determi- nation has been quite generally recognized in America. Both here and in England new instruments have been brought forward, some of which represent a distinct advance over any of those previously mentioned, and merit separate description. Hill and Barnard's sphygmometer^ appeared a little after Eiva-Rocci's, and uses the same method of circular compression. It does not, how- ever, measure the pressure required to obliterate the pulse (systolic or maximum pressure), but, like Mosso's, the point of maximal pulsation (diastolic or minimal pressure). This is accomplished by the employ- ment of a delicate spring tambour, graduated in mm., Hg., as the man- ometer (Fig. 61) shows the apparatus. The cuff, a hollow bag, 4|^ cm. Fig. 61.— Hill and Barnard's sphygmometer. wide, with an outer leather armlet, is buckled around the arm, and connected with the manometer by a screw-joint. The pressure is then raised by means of the hand-pump until the needle shows diminishing excursions on the dial. Then, by unscrewing a valve in the stem of the pump, the pressure is allowed to fall gradually, while the needle is closely watched. Its oscillations increase for a time to a maximum, then, after remaining the same for a short time, rapidly decrease. The last point at which they remain maximal represents the minimum arterial pressure, as already described. Hill thought that the midpoint of maxi- mum oscillation was equivalent to the mean arterial tension, but this has been proved inaccurate. The instrument is well constructed, light, and compact. It has two great drawbacks. One is the narrowness of the cuff, for reasons which will follow. The other is, that so delicate 1 See Martin, Milnch. med. Wock, 1903, No. 24, p. 1021. 2 Hill, L., Barnard, H., Rrit. Med. Jour., 1897, vol. ii., p. 904. Made by J. Hicks, London ; Agents for the United States, Oelschlager Bros., 42 East 23rd St., New York City. SFHYGMOMANOMETE Y {TONOMETR Y.) 141 a manometer needs constant standardizing by comparison with a mer- cury one, and soon becomes inaccurate. Fig. 62.— Riva-Rocci sphygmomanometer as modified by Cook. To ln}litor Fig. 63.— Erlanger's sphyguiomaiiometer. Hill and Barnard's so-called ixx'ket sphygmometer is hardly more than a clinical toy. Oliver's dynamometer^ cannot be recommended 1 Oliver, George, Jour, of PhynioL, 1897-98, vol. xxii, p. 51. 142 ARTERIAL PULSE, PALPATIOy, SPHYGMOGRAPHY, ETC. because it possesses all the faults of v. Basch's method of applying the pressure by a pad over the artery. In America, Cook rendered a great service by so modifying the Riva- Rocci apparatus as to make it inexpensive and easily carried/ thus se- curing for it a much more extended apj^lication. His instrument so closely resembles its oirginal in the technic of its use that it needs no further description. Two American instruments are now made with a 12 cm. cuff, Er- langer's and Janeway's. The former ^ is, undoubtedly the most accurate and valuable sphygmomanometer yet constructed. It gives readings both of systolic (maximum) and diastolic (minimum) pressure, and therefore makes possible the calculation of exact mean arterial pressure. Fig. 63 shows the apparatus in perspective. Besides the manometer, compressing armlet, and inflator it contains a somewhat elaborate reading mechanism and iNy^mographiondrum. This mechanism consists of the tambour, the interior of which is con- nected with the air chamber inside the glass bulb G. This air chamber has no other openings while the record is being made, but automatically Fig. fi4.— Janeway's sphygmnmanometer. connects with the outer air throiigh the tube E and the stop-cock C when rapid changes in pressure are made, ^vhich might damage the tam- bour. The ptilse waves are transmitted through the tube to "PS" and cause variations in volume of the rubber bulb B. These pulsations of B are, of course, reproduced by the air within C, and thus carried to the tambour, which inscribes them on the smoked cylinder. The purpose of the rubber bulb B is to shield the tambour from too sudden and great variations of pressure. The stop-cock is an important mech- anism, but cannot be described intelligently without mechanical draw- ings. It is easily understood from the instrument itself. Unfortu- nately this apparatus is too bulky to be carried far, and is more com- plicated than desirable for strictly clinical Mork. For purposes of Cook, Jour. Am. Med. Assoc, 1903, vol. xL, p. 1199. crer. J., Am. Jour, oj Physiol., 1904, vol. x.. Proceed, of Am. Physiol. Soc, p. 14. 2 K-lan SPHYGMOMANOMETR Y {TONOMETR Y). 143 physiologic experiment on human beings, and whenever very accurate readings of both pressures are desired, it should be the choice. Janeway's sphygmomanometer' is shown in Fig. 64. Its special feature is the portable U-tube manometer attached to a case, into which it folds for carrying. The whole when closed measures lOJ x f x If in., and with cuff and inflator weighs 2 J pounds. The armlet is a hollow rub- ber bag, 12x18 cm., loosely covered and attached to an outer leather cuff, 15 X 33 cm., which fastens by two straps with friction buckles. For inflation a Politzer bag with valve is used. £" is a stop-cock pro- vided with a needle valve, by which the pressure can be reduced gradu- ally. The method of getting the systolic pressure is practically the same as with Riva-E,occi's sphygmomanometer, the pressure being raised by squeezing the inflator until the radial pulse is lost, then gradually lowered until it returns. The reading at the moment of Fig. 65. — Stanton's sphygmomanometer. return represents the systolic pressure. In addition, an approximate determination of the diastolic pressure can be made by noting the press- ure at which the mercury shows the greatest pulsation (see sphyg- momanometer). This is done by allowing the pressure to fall 5 to 10 mm. at a time after the return of the pulse has been detected, and observing at least 10 pulsations at each point. After a certain level (in normal pulses 25 to 40 mm. below the systolic pressure) the extent of the oscillations diminishes rapidly. The lowest point at which it re- mains maximal is the diastolic lateral pres.sure. The estimation of the two pressures is the only clinical method of computing mean arterial pressure, and has considerable diagnostic value in cases of aortic insuf- ^ T. C. Janeway, The Clinical Study of Blood-pressure, New York, 1904, D. Apple- ton & Co. , p. 89. 144 VISIBLE PHENOMENA OF MOTION IN THE VESSELS. ficiency and hypertension, where the elevation of systolic is much more marked than that of diastolic pressure. The remaining American instrument, Stanton's,^ is shown in Fig. 65. The manometer consists of a metal cistern (C) connected with a glass upright tube and scale (D), which can be unscrewed for carrying. The armlet is a hollow rubber bag, 3^ in. (8 cm.) wide and 16 in. long, closed at both ends, and attached to an outer cuflp of thick canvas, reinforced by tin strips. While it has not the width necessary for ab- solute accuracy, it nevertheless suffices for the vast majority of cases. A single rubber bulb is used for inflation. At A is a stop-cock, and at B a screw valve for the gradual lowering of pressure. With this sphygmomanometer systolic pressure may be measured and diastolic pressure approximately estimated, as already described with Janeway's apparatus. It is a portable and convenient clinical instrument. — T. C. J.] VISIBLE PHENOMENA OF MOTION IN THE VESSELS. CAPILLARY PULSE, UxDEE normal conditions the blood flows smoothly and without a pulse in the capillaries, because the resistance in the smallest arteries completely deprives the pulse wave of its energy at this point, or because, as V. Frey and Krehl believe, the pulse wave is completely reflected centripetally (see p. 117 et seq.). Under some conditions, however, the pulse is transmitted to the capillaries, and becomes evident to inspection in the form of a pulsating reddening and blanching of the parts in question. Whatever facilitates the entrance of a pulse wave into the capillary areas, or whatever renders the flow into the veins dif- ficult, will, of course, favor the production of a capillary pulse. The larger the pulse wave and the more it approaches the type of " pulsus celer," the more the conditions for a capillary pulse are favored. A capillary pulse is sometimes observed over hyperemic, and especially over inflammatory, areas — e. g., over felons. Very frequently the patient himself appreciates the increased pulsation in inflammatory parts as a throbbing pain. The capillary pulse due to a pulsus celer, especially in aortic insufficiency, is of far greater interest. This is a very common, although not a constant, sign in this valvular lesion. It is perhaps best appreciated by observing the alternate blusliing and pallor at the finger-nail. Sometimes enough pressure upon the anterior part of the nail-bed to blanch the nail brings out the margin between red and white which oscillates with systole. The capillary pulse in aortic insufficiency may be very frequently appreciated at other places which are characterized by their redness — e. g., ears, lips, cheeks. 1 W. B. Stanton, Univ. of Penna. Med. Bull., 1903, vol. xv., p. 466. RESPIRATORY PHENOMENA OF MOTION IN THE VEINS. 145 A clean glass slide lightly pressed upon the extended lower lip will sometimes bring out the capillary pulse when it cannot be appreciated at the finger-nail. Another useful device is to rub a spot upon the forehead until it is hyperemic and then look for an alternation of red- ness and pallor. Contrary to many statements, a capillary pulse is by no means path- ognomonic of aortic insufficiency. Any condition which will produce a " pulsus celer " (exophthalmic goiter, fever, chlorosis) will be apt to show a capillary pulse. Even in health it may sometimes be observed. Yet although not absolutely pathognomonic of aortic insufficiency, it is so common in this lesion and so rare in other conditions that the sign really possesses considerable diagnostic significance. The sign becomes most distinct during the stage of compensation. The retinal vessels will also show a visible pulsation by the ophthalmoscope w^hen a capillary pulse is visible elsewhere. RESPIRATORY PHENOMENA OF MOTION IN THE VEINS, The respiratory variations in the interior of the thorax, as is well known, influence the venous circulation very distinctly. Inspiration favors, expiration retards the flow of venous blood. This influence is Fig. 66.— Veii'jus engorgement during forced expiration— case of plitliisis (New York ruv Hospital). ordinarily not evident in the visible veins with superficial breathing, but forced breathing will produce an inspiratory diminution and expi- ratory increase in these veins, and if they are already distended bv con- gestion the change will become still more evident. Both conditions are usually present in dyspnea. 10 146 VISIBLE PHENOMENA OF MOTION IN THE VESSELS. Intrathoracic variations in pressure become more distinct during coughing or other exertions of abdominal pressure. The intrathoracic pressure then becomes markedly positive. A coughing paroxysm or straining after a deep inspiration produces a prolonged distention and a subsequent sudden collapse of the veins, most plainly seen in the neck. When this periodic congestion is frequently repeated, especially in patients who suffer from chronic cough, a permanent dilatation of the veins, especially of the jugular, may result, so that with coughing or straining not only is cyanosis very marked, but the whole lower portion of the neck becomes swollen. The "bulbs" of the jugular vein may appear a» large swellings, either just inside or outside of the insertion of the sternocleidomastoid (Fig. 66). The bulging of the supraclavic- FiG 67.— Enlargement of jugular vein in a case of leukemia with enlarged mediastinal glands (Dr. Joseph Collins, New York City Hospital). ular fossse during a cough, therefore, should not always be regarded as a distention of the lung apices (p. 98 et seq.). In very rare cases the reverse condition is observed — i. e., a disten- tion of the veins during inspiration and a collapsing or a diminution during expiration ; this always suggests that during inspiration some mechanical compression of the veins exists within the chest interior. This phenomenon has been described as a sign of fibrinous mediastinitis, like the pulsus paradoxus (see p. 126). It may, however, depend upon the effect of inspiratory pressure or traction upon the large veins leading to the heart, due to interference with the mobility of the thoracic con- tents (pericarditis, pleuritis, mediastinal tumors). DIFFERENT VARIETIES OF VENOUS PULSE. 147 DIFFERENT VARIETIES OF VENOUS PULSE. DIFFERENTIATION OF VENOUS PULSATION FROM ARTERIAL PULSE. When the distended veins become distinctly visible (in venous pulse the external jugular veins are chiefly concerned), it is generally a simple matter to distinguish between their pulsation and that of the neighboring arteries. The pulsation of some deeply seated vein (internal jugular) which cannot be directly observed is much more difficult to determine. But even then the venous pulse can be easily recognized, particularly by the large area of pulsation involved corresponding to the large size of the vein, also by the slow, undulating transmission of the beat, and by the very moderate amount of power to be felt in the pulsation, depend- ing upon the slight amount of tension of the venous contents. If the pulsation is transmitted from an artery to a vein, compression of the vein will not affect the pulsation peripheral to the point of compression, and sometimes the resulting congestion will make the pulsation even more distinct. An accentuation of the pulsation from compression otherwise occurs only with the very rare penetrating pulse (see p. 152). PHYSIOLOGIC VENOUS PULSE. (Negative Venoas Pulse; Systolic Venous Collapse; Venous Undulation; Negative Centrifugal Venous Pulse; The Presystolic Variety of the Negative Venous Pulse.) The arterial pulse wave usually disappears in the capillaries — i. e., it is reflected centripetally (see p. 144 et seq.), so that the blood no longer pulsates but flows uniformly in the venous radicals. Nevertheless under both physiologic and pathologic conditions peculiar pulsations synchro- nous with cardiac action are frequently observed in the greater veins lying near the chest (almost exclusively in the jugular veins). In the following sections we shall describe several pathologic varie- ties of this pulsation. One type of venous pulse must, however, be considered absolutely physiologic, because it is constantly observed after exposing the vein in healthy animals, and because perfectly normal indi- viduals sometimes show it. That this venous pulse is not observed in everybody is due to the fact that in some people the jugular veins are not visible or are seen only with considerable difficulty. Conversely, this physiologic venous pulse can naturally be seen with especial readi- ness if the veins have become more noticeably distended by congestion. The physiolof/ie venous pulse can be distinguished from the pathologic varieties to be considered later by the circumstance that compression of the vein by the finger obstructs the pulsation above the point of pressure, while below the compression the pulsation either disappears or diminishes, but never increases. This central obliteration or diminution of the pulse wave proves beyond a doubt that the pulse wave is not thrown 148 VISIBLE PHENOMENA OF MOTION IN THE VESSELS. back into the veins from the heart. The peripheral disappearance of the pulse wave proves that it cannot be a wave transplanted from an artery to the vein. The only remaining hypothesis is that the cardiac activity does not force the blood back into the veins, but that the continuous blood- current is rhythmically retarded and accelerated. This type of a ve- nous pulse is generally called a negative venous pulse, because it depends upon the transmission of a negative trough or suction wave from the heart to the vein (see below). It is also sometimes termed an undula- tion on account of its appearance. Probably the reason that the undu- lation does not cease entirely centrally from the point of compression, as we should naturally expect from our supposition of its origin, is because it is almost impossible to compress the vein sufficiently to pre- vent the influx. The diminution may be rendered more distinct by com- pressing the subclavian as well as the jugular vein. The internal jugular should always be compressed, never the external jugular alone. The fact that the venous valves are intact does not in any way prevent the transmission of the physiologic venous pulse toward the periphery (e. g., Fig. 68.— Physiologic (negative) venous pulse (Riegel). from the " bulbus " to the vena jugularis), because it is a negative wave motion which traverses the vein in the direction of the valve openings, according to the laws of wave motion.^ Fig. 68 represents a sphygmogram of the curves of the carotid pul- sation taken simultaneously with the curves of the physiologic venous pulsation (Riegel). The latter is both visible and palpable in the ex- ternal as well as in the internal jugular. Comparing the two, it is evi- dent that the venous collapse corresponds to the rise of the carotid pulse, or, roughly expressed, the physiologic venous pulse is cardiodias- tolic. Hence the name " systolic venous collapse." If we neglect the peculiar wave (c') in the ascending limb of the venous curve, the normal venous pulse can be easily explained by as- suming that the venous reflux depends largely upon the condition of the right auricular contraction. For auricular diastole (ventricular systole) seems to favor the reflux, and auricular systole (ventricular diastole) seems to check it. Estimating the time relations in Fig. 68 shows, however, that any such simple explanation is insufficient and ^ Of. Tigerstedt, Lehrbuch der Physiologic des Kreislaufes, 1893, p. 367. DIFFERENT VARIETIES OF VENOUS PULSE. 149 impossible. Besides, other influences synchronous with the heart beat aifect the venous qirculation — viz., first the state of contraction of the right ventricle or the suction effects, and second the effect of the so-called auxo- and raeiocardia — /. e., the intrathoracic variations in pressure produced by the systolic diminution and diastolic increase in the size of the heart. Although cardiac systole does exert a certain amount of suction and the diastole exerts pressure upon the interior of the thorax, it is impossible to explain the alternation of the venous with the arterial pulse without considering all the other factors which have any influence. Before submitting his own explanation, the writer wishes to insert the following in connection with Fig. 68 : The point a, where the carotid wave begins to rise, does not correspond (as is generally accepted) to the commencement of ventricular systole, but to the begin- ning of the expulsion time. The beginning of systole must therefore be located a little earlier. Point a' in the venous pulse curve corre- sponds to the same moment of time as the point a in the carotid curve. Beginning at this point, we can explain the venous pulse as follows : At the moment (a) the total volume of the heart is diminished, meiocardia occurs and an intrathoracic suction action is combined with it ; at the same time the auricle dilates, and consequently the conditions for the flow of venous blood are the most favorable. A venous collapse ex- pressed in line a' b' is therefore the natural eff'ect and explains itself. The diastole of the ventricle begins a little beyond the point 6, at a point not indicated upon the descending limb of the carotid curve. From this point it is difficult to explain the curve, because during ven- tricular diastole various contradictory influences affect the flow of ve- nous blood into the veins — viz., the diastolic suction power of the right ventricle,^ diastolic auxocardia, with an exactly opposite action, further the contraction of the ventricle, which backs up the blood in the veins at the end of diastole, and finally the part of ventricular systole (called the closure time) which immediately precedes the ascending limb of the carotid curve, which really does prevent the entrance of the blood, although it does not diminish the intrathoracic pressure. All these factors, except the suction power of the ventricle, tend to obstruct the venous flow and to produce the congestion in the jugular veins expressed in the ascending limb h' a' , which fades only at the onset of the expulsion time. The secondary elevation at (c') of the ascending limb is, however, not explained. Its position corresponds very satisfactorily with the supposition that it is due to the presystolic contraction of the right auricle producing a backing-up in the veins." We must, however, be well acquainted with its peculiarities to avoid confounding it with the two following varieties of venous pulse. It is evident from our explanation of its origin that to recognize the diastolic character of the venous pulse it is essential to contrast the height of the venous pulse apex with the apex of the carotid pulse {i. e., in regard to ' Expressed better, the diastolic release of the obstacle to the blood's entrance. ' Compare the scheme of the time sequence of the cardiac phases, in Bernstein, Lehrbuch der Physioloc/ir, 1894, p. 61, Fig. 13. 150 VISIBLE PHENOMENA OF MOTION IN TEE VESSELS. the time) and not with the cardiac apex beat. This is because the apex beat of the heart coincides with the " closure time," and so still belongs to auxocardia, and more nearly corresponds in point of time to the apex of the venous pulse than does that of the cardiac pulse. (See p. 152 for further assistance in distinguishing the physiologic from the pathologic venous pulses.) It has been shown by Riegel that an accentuated negative venous pulse can occur under pathologic conditions from an increased contrac- tion of the auricle. In these cases the presystohc serration, .correspond- ing to the auricular contraction, is the larger, and may be so pronounced that the entire venous pulse has the character of a presystolic pulse. This variety is seen particularly in marked degrees of venous congestion and in cases of pericardial exudates. Although it was formerly supposed that liver pulsation always belonged to the category of the so-called positive centrifugal venous pulse (see following paragraph), Volhard has shown that it is very fre- quently such an accentuated negative venous pulse as has just been described. To obtain his proof he employed the procedure of mano- metric comparison described on p. 152. POSITIVE CENTRIFUGAL 1 (REGURGITATING) VENOUS PULSE; LIVER PULSATION. A positive centrifugal venous pulse is only observed with tricuspid insufficiency. It arises in this valvular lesion because during systole the blood is forced back into the right auricle, and from there into the veins. Its elevation corresponds to cardiac systole, as will be readily recognized by a simultaneous sphygmographic representation of the jugular and carotid pulse. A positive venous pulse curve differs considerably from a negative venous pulse curve. A few secondary elevations are to be seen in its ascending limb, probably because the factors which produce the physio- logic venous pulse are felt here, too, and so interfere with the actual regurgitation ; perhaps also because the positive venous pulse, although it is systolic, does really pi'ecede the onset of the carotid beat a little. Of course, the regurgitation of the blood through the insufficient tricuspid valve begins at the beginning of systole — i. e., at the " closure time " (here with reference to the right ventricle), and not, like the arterial pulse, at the " expulsion time." Hence, it would naturally precede the arterial pulse a little. If the valves at the upper end of the jugular bulb close properly, 1 The term centrifugal venous pulse has only one meaning here. The positive cen- trifugal pulse corresponds to a positive (lise) wave of centrifugal couree, and is con- trasted with a positive centripetal pulse, which comprises a positive wave of centripetal course. At the same time the pathologic venous pulse of tricuspid insufficiencv consid- ered here as a centrifugal pulse should hardly be contrasted with the physiologic variety considered as a centripetal pulse, because the latter is also centrifugal — /. c, it also pro- ceeds from the heart, and passes through the trunk of the vein toward the periphery. The only difference between the positive centrifugal venous pulse discussed here and the phys'iologic or negative pulse consists in the fact that in the latter a negative wave (trough) is transmitted centrifugaliy. DIFFERENT VARIETIES OF VENOUS PULSE. 151 the positive pulse will be chiefly apparent in the bulb (bulbous pulse). There may, however, be a slight wave transmitted to the periphery, because the closure of the bulbous valves only prevents the actual regur- gitation of blood and not its wave-like motion. The latter, a positive wave, in closing the bulb valves produces above them, from the backing up, a positive w^ave of exactly the same shape. Consequently, by care- fullv watching a bulbous pulse we can appreciate that the veins do pulsate above the bulb valves, but decidedly less than below. The difference is that as far as the valves a real backward motion or regurgitation of the blood can be plainly observed, but above the valves only the w^ave motion started by the reflux. Under such conditions a distinct systolic tone may sometimes be produced over the bulbous valves by the shock of the regurgitated blood (jugular valve sound, see Auscultation of the Veins). V^ery frequently, however, as the result of congestion, the venous valves become insufficient, so that the positive venous pulse may be seen just as distinctly in the upper part and in the small branches of the jugular vein as over the bulb itself. Another difference between the positive centrifugal venous pulse and Fig. 69.— Positive centrifugal (regurgitating) venous pulse (Riegel). the negative physiologic venous pulse is that the rise of the former occurs approximately at the same time as that of the carotid pulse. Again, when the pulsating vein is compressed, the positive centrifugal venous pulse persists, and sometimes even becomes accentuated centrally, but disappears peripherally from the seat of pressure. The appearance of the regurgitating venous pulse is not infrequently limited to the jugular vein ; but in ])ronounced cases the veins of the extremities may also pulsate. A pulsation in the liver veins is especially important in the diagnosis of tricuspid insufficiency. The liver venous pulse can be appreciated by palpating the liver, which is usually much enlarged in tricuspid insufficiency. The exam- iner should palpate as far as possible to the right of the median line, so as to avoid confusion with an epigastric pulsation or with an aortic pulsation, which is sometimes transmitted to the liver. (See later section upon Palpation and Inspection of the Cardiac Kegion.) To avoid such errors it is especially important to be convinced that the pulsation is really expansile — {. e., that the volume of the liver increases inter- mittently. This can generally be best accomplished by firmly grasping the edge of the liver, or by employing bimanual palpation, one hand 152 VISIBLE PHENOMEXA OF MOTION IN THE VESSELS. behind pressing the liver forward against the other hand in front. Ad arterial liver pulse sometimes occui's in aortic insufficiency as a result of the "pulsus celer." It can be distinguished from the venous liver pulse only by a careful consideration of all the other conditions. The writer once demonstrated an inflammatory liver pulse over the left lobe of the liver as the result of a cholangitis following gall-stone colic. Duroziez's double murmur (see later) was heard over this lobe. The pulsation and the mur- mur both disappeared after several weeks, and the autopsy revealed a purulent cholangitis at the place in question and several miliary abscesses in the liver. POSITIVE CENTRIPETAL OR PENETRATING VENOUS PULSE. This rare type of venous pulse is produced when the arterial wave possesses sufficient force to penetrate the capillaries and transmit a pulsating motion to the venous radicals. The phenomenon depends upon conditions similar to those pro- ducing the capillary pulse, and has been found chiefly in aortic insufficiency. Quincke, however, believes that a capillary pulse does not always accompany a penetrating venous pulse ; but, on the contrary, that we may be unable to appre- ciate the pulse wave in the capillaries because it is spread over too great an area, whereas the constriction that the venous radicals under favorable pressure condi- tions oppose to the course of the current may cause the pulse to again become visible. This type of venous pulse occurs especially with an arterial ' ' pulsus celer." It does not appear in the jugular vein, but in the small veins of the extremities. Compression will obliterate the pulse in the central portion, but not in the peripheral part of the vein. DIASTOLIC VENOUS COLLAPSE (Friedreich). This very rare phenomenon was described by Friedreich in connection with systolicr etraction of the cardiac region from pericardial adhesions. (See later Palpation and Inspection of the Cardiac Region. ) The diastolic recession of the chest-wall produces a diastolic suction within the thorax, and this is supposed to cause the veins to collapse. It is, so to speak, the reverse of the negative or physiologic venous pulse. In the latter the vein is distended during diastole ; in the phenomenon described by Friedreich the distention occurs during systole. Therefore it may be easily confounded with the positive centrifugal (regurgitating) venous pulse, which is also systolic. Compressing the vein will, however, readily settle the question, for the diastolic venous collapse acts not like a positive centrif- ugal, but like a negative venous pulse — ;'. e., it disappears, or is at least much diminished, centrally to the point of compression. VOLHARD'S PROCEDURE FOR DETERMINING THE PHASES OF THE VENOUS PL^LSE; PRACTICAL DIFHCULTIES IN DISTINGUISHING THE DIFFERENT KINDS OF VENOUS PULSE ; COMBINED VENOUS PULSE. In view of the great difficulty in recognizing the phases of a venous pulse by the eye and hand, and the technical details necessary for its graphic representation, Volhard ^ has furnished a clever and simple procedure by means of which we can easily determine the time of a venous pulse in reference to the carotid pulsation. By means of small glass funnels, one of which is placed over the pulsating vein (or the liver) and the other upon the carotid, Volhard transmits the movements of the pulse to two water manometers which are filled with differently colored fluids and placed side by side. It can then easily be determined whether the fluids are displaced in the same or in opposite directions. The quickness of the movement is also an indication as to whether we have to do with a positive or with a negative pulsation (collapse) of the vein. On account of the influence of ' Congr.f. inn. Med., 1902, p. 402. PERCUSSION. 153 inertia the water must be at the same level in both manometers. The length of the column of air, however, is immaterial, since the air waves are transmitted with the same velocity as sound. In the author' s experience the procedure some- times gives very clear results, but it frequently fails owing to the difficulty of separating the venous pulse completely from the transmitted movement of the carotid. Although the preceding distinctions apparently render the differentiation of the different kinds of venous pulse perfectly plain, we are nevertheless frequently confused in practice, especially because many venous pulses are combined phe- nomena. It has already been noted that the positive regurgitating venous pulse is frequently combined with the signs of the physiologic venous pulse because, naturally, with a tricuspid insufficiency the physiologic undulations of the veins would not disappear. The typical character of the positive regurgitating venous pulse must then be determined by means of the time relation of the pulse to the cardiac phases and by the results of the compression test. Even the physiologic venous pulse is frequently deformed because the carotid pulse imparts itself to the venous contents and antagonizes the venous pulse, both in its time phase and in the relation to the action to the compression test. In many of these cases it is absolutely impossible to determine definitely the nature of the venous pulse. PERCUSSION. PERCUSSION IN GENERAL; INSTRUMENTS. The examination of the human body by means of percussion (or striking) plays an especially important role in the modern diagnostic methods of internal medicine. The condition of the or^an or orrans underlying the spot percussed is determined or, at least, inferred from the sound produced. We accredit the discovery of this method to the Vienna physician Auenbrugger, for in the year 1761 a description of it appeared in his work, Inventum Novum. However, the method was not generally employed until after Corvisart, Napoleon I.'s body physician, translated Auenbrugger's work into the French (1808) and appended extensive observations of his own as commentaries. Manifold modifica- tions, theoretic confirmations, and symptomatic improvements were then added to the method by a great number of authors, of whom we need only mention Piorry, the inventor of the pleximeter ; Barry, the inventor of the percussion hammer ; Wintrich, Skoda, and Traube. Hence, although the method is already more than a century old, it really only became the common property of physicians during the second half of the nineteenth century. To-day percussion and auscultation have be- come the corner-stone of diagnosis. The student must learn both at the very beginning of his clinical experience. There are copntless methods of percussion. Originally only imme- diate percussion was employed — i. e., the striking of the surface of the body directly with the tips of the fingers. But where the body- covering is soft such a method will elicit only indistinct and impure sounds, and therefore to-day we almost exclusively use mediate per- cussion — i. e., either a finger of the other hand or a specially constructed 154 PERCUSSION. instrument — the " pleximeter " — is inserted between the striking finger and the surface of the body. The " plexor " is a small hammer furnished with a rubber tip. It may be substituted for the striking finger. In mediate percussion we may use either : (1) Finger-finger percus- sion, (2) finger-pleximeter percussion, or (3) plexor-pleximeter percussion. Individual taste or habit w^ill generally determine a preference for one of these methods. There are certain differences and advantages in each of them, although we may be skilful or awkward with any one of them. The finger-finger percussion is the most difficult to learn ; but in many cases it furnishes more accurate results than the pleximeter percus- sion, because the inherent note of the pleximeter is liable to confuse the percussion tone. Consciously or unconsciously, the sense of touch in the finger-finger percussion aids the sense of hearing (palpation percussion).^ But the chief advantage is that the physician is independent of instru- ments, which may be readily forgotten, mislaid, or broken. The finger pleximeter, and especially the plexor-pleximeter percussion methods, are much easier to learn, and greater differences of sound may be more readily demonstrated and appreciated by a larger circle of listeners; nevertheless, a percussion note which is loud enough to be heard at considerable distance is generally faulty (see below). A physician should be familiar with all three methods ; and he should be able to control his own results by applying first one and then the other, for despite the utmost care and great skill, the subjective character of the method often in difficult cases leaves a doubt in the mind of the exam- iner. A plexor and pleximeter are of no great advantage in the em- ployment of the plexor-pleximeter method (p. 158), because we can substitute a bit of wood, a pencil, or the like for the flexor, and a coin or another bit of wood for the pleximeter. In certain cases — e. g. , for determining slight pathologic dulness in the chest or abdomen or for differentiating the deep cardiac dulness — mediate percussion is to be recommended as a control. The examiner thus avoids too strong pressure of the pleximeter or of the finger of the left hand, a very common fault with begin- ners. Mediate percussion is generally made by striking with the tips of the four fingers and thumb of the right hand arranged like a pyramid.^ In percussing the lung apices beneath the clavicles the bone serves as a pleximeter, and the middle finger of the right hand as the plexor. Only continued practical experience can teach the technic of percus- sion, and but few rules are worth stating. The percussion stroke should be made perpendicular to the surface of the part percussed. In finger percussion the nail of the percussing finger should be cut short, and the blow should be struck with the pulp of the last phalanx in such a manner that not only the direction of the stroke but also the axis of the last phalanx is perpendicular to the plex- imeter and to the surface of the body part percussed. A perpendicular stroke is essential for producing a good, equal note. It is especially ' [The fine appreciation of variations in resistance to the pleximeter finger is of almost equal importance to the recognition of variations in resonance. — Ed.] '^ [Most American clinicians use the middle finger of the right hand as the plexoi and the middle or first finger of the left hand as the pleximeter. — Ed.] QUALITY OF THE PERCUSSION. 155 difficult for the beginner unless he is a piano player. Both in plexor and in finger percussion the stroke should be light, short, and elastic, pro- duced by merely bending the wrist joint, at the same time avoiding any cramped position of the hand or lingers. Percussion should be light or superficial and even (see p. 163). The so-called strong or deep per- cussion should also be quite delicate, so that the note cannot be heard at any great distance. The pleximeter — i. e., the linger to be struck — should be placed with its palmar side upon and in close contact with the surface of the body and parallel to the border to be differentiated. Only slight pressure should be employed, because strong pressure even with light (super- ficial) percussion will cause a diffuse vibration of the body, and so simulate the effect of a stronger (deep) percussion. Instead of the usual pleximeter, a bit of firm, gray erasing rubber, cut about 1 cm. wide, 1 cm. thick and 4 cm. long, will answer the pur- pose well if the physician is not skilled in finger percussion. Like the finger, such a pleximeter has practically no intrinsic curve ; it can be easily bent to conform to the curves of the chest-wall, and it can be struck with the hard end of the hammer or with the finger. In percussing a child's body very much less force must be used than for the adult. (See Deep and Superficial Dulness.) QUALITY OF THE PERCUSSION. RESONANT AND DULL TYMPANITIC AND NON-TYMPANITIC PERCUSSION NOTES. Even a layman, percussing different regions of the body surface, is able to recognize that one part furnishes a resonant, another part a dull, note. An accurate differentiation between resonant and dull notes, or between different grades of resonance, is the groundwork of percussion. A typically resonant note can be obtained by percussing over the lung ; a typical dull note, by percussing over great muscle masses — e.g., the thigh. Experience has taught us that resonant notes are produced over organs containing air ; dull notes over organs without air, quite irre- spective of whether they are solid or filled with fluid. Therefore per- cussion, on the one hand, defines the boundaries of the different organs ; and, on the other hand, by changes in the resonance of the note, deter- mines any increase or decrease of air contained in the organ. The less air, other conditions remaining the same, the duller the note. The resonance of the note also varies decidedly with the deep diameter of the air-containing organ — i. e., the diameter in the direction of the percus- sion stroke. The thicker the layer of air the more resonant the note. The influence of the tension of the wall surrounding the air cavity upon the resonance of the note will l^ mentioned later. We apply the term loud, clear or resonant as contrasted with faint, dulled, dull or flat to the percussion notes of the ordinary living body. When a resonant note is modified by a dulled note, we speak of the presence of dulness; a note which is neither very resonant nor very 156 PERCUSSION. dull is called relatively dulled ; an absolutely dull note, on the contrary, absolutely dulled ov flat. The terms absolute and relative dulness have a corresponding signification. In defining the quality of a percussion note many modern authors employ the terms short and long as synonymous with dull and resonant. Theoretically this is not quite correct, because the latter expressions characterize the intensity of the note ; whereas short and long refer, on the contrary, to its duration, and the latter must depend upon the size of the vibrating mass. The length of a musical instru- ment' s note is of very essential importance to the tone and value of the instrument. A musical ear can, in fact, easily dilFerentiate this peculiarity of duration in a per- cussion note. However, in the relations of percussion which concern us a resonant note is almost always long and a dull note short. The exceptions to this rule have no special diagnostic importance, so that the expressions short and long may as well be eliminated. A consecutive series of note qualities range in countless gradations between the two limits resonant and dull, the differences depending upon the amplitude of the note vibrations. There are, however, other very- important differences of quality which we must heed and which depend upon variation in the form and number of vibrations. The most im- portant of the latter is the distinction between tympanitic and non-tym- panitio resonant notes. This distinction is illustrated by comparing in a healthy person the note obtained over the lung with that obtained over the air-containing abdominal viscera. The pulmonary note is resonant, but not tympanitic. The note over the stomach and intestines is reso- nant, but also tympanitic. Both tympanitic and non-tympanitic notes are really noises in the purely physical sense ; but in tympanitic notes the vibrations are sufficiently periodic (1 e., tuneful) for the ear to be able to compare their number with the number of vibrations of other sounds ; in short, to be able to recognize a certain pitch. This theoretic differentiation between tympanitic and non-tympanitic notes will not make the matter much clearer to a beginner ; but in a practical demonstration a musical ear will very readily appreciate the distinction between the resonant but non-tympanitic lung note and the true tym- panitic note of the bowels. No sharply defined boundary really exists between tympanitic and non-tympanitic notes. Various explanations have been adduced to show how at one time an air-containing organ furnishes a resonant non-tympanitic note, and at another time a resonant tympanitic note ; but most of these explana- tions have no trustworthy physical basis and are not tenable. Physicists have thus far busied themselves very little with this acoustic question. A discussion of the so-called theories of the tympanitic and non- tympanitic notes may therefore well be omitted, and merely the facts mentioned as to when the non-tympanitic note of an air-containing organ is transformed into a tympanitic note, and vice versd. Experience teaches us that a non-tympanitic note will be transformed into a tympanitic note when the tension of the air within the organ diminishes — i. e., when its wall is relaxed ; and the converse is also true, that with an increase in tension a tympanitic will be transformed into a non-tympanitic note. If we inflate a pig's bladder while at the same QUALITY OF THE PERCUSSION. 157 time we percuss over the bladder, we shall notice that up to a certain point of distention the note is tympanitic, but with further inflation non-tympanitic. During the transformation of a non-tympanitic into a tympanitic note its intensity or sonority increases ; in other words, the note first becomes hyperresonant before it becomes tympanitic. The essential characteristic of a tympanitic note, as has been said, is a certain definite pitch, so that naturally we can distinguish a low tym- panitic from a high tympanitic note, and gradations between the two. Different tone heights (pitch) cannot be distinguished easily in non- tympanitic notes. The pitch of a percussion note depends upon various factors, above all upon the tension of the wall enclosing the air space and upon the size of the latter. It is self-evident that more than one of the qualities discussed may characterize the same percussion note. Thus, e. g., we may speak of a relatively dulled high tympanitic note ; or of a resonant low tympanitic note. The following scheme of the tone qualities described above may be useful : resonant (clear) relatively dulled absolutely dulled (dull, flat) (generally long, full) (relatively faint) (generally short, dead). ..A ■ .. ..A' tympanitic non-tympanitic tympanitic non-tympanitic .A .A high low. high low. There are two other specific tone qualities M^hich must be mentioned — viz., metallic resonance and the " crached-pot " sound or cracked-pot resonance. METALLIC RESONANCE. Metallic resonance means a peculiar quality of the percussion note, which is best characterized by its name. It can be imitated by percuss- ing one's own distended cheeks with a plexor and pleximeter. Its metallic character depends upon an individual metallic overtone of a definite pitch, which can be appreciated sometimes during the entire duration ; sometimes, however, only at the end of the sound. In the latter case we speak of it as a metallic after-resonance. .We are especially indebted to Wintrich for experiments upon metal- lic resonance. He showed that this sound arises only when large air spaces are percussed. These may be closed or open ; but if open the orifice must be relatively narrow — i. e,, in proportion to the cross- section of the cavity. The inner surface of the cavity-wall must be comparatively smooth ; because, according to Wintrich, metallic reso- nance depends essentially upon the reflection of the air waves which percussion sets into vibration within the cavity. This produces the high inharmonious overtones responsible for the metallic character of the sound. The thinner the walls the easier the metallic character can be appreciated. If the walls of the cavity are yielding (flexible), metallic resonance will not result unless they are under a certain moderate tension. Again, 158 PERCUSSION. a cavity must be of a certain size to produce metallic resonance ; accord- ing to Wintrich, its greatest diameter must be at least 6 cm. Small cavities very rarely furnish metallic resonance. The metallic resonance noted in percussing the normal human body is in most cases so faint that it can be appreciated only Avhen the ear is very near or is connected with the percussed area by means of -a stethoscope (auscultatory percussion). The easiest way to appreciate metallic resonance is by means of the " stick-pleximeter " method. In this method Ave percuss with the handle of the plexor upon a bit of stick, a coin, or some other firm object placed upon the body, and at the same time auscult with the stethoscope in the immediate neighborhood. By the reverberation of its high overtones the resulting shrill noise seems particularly to favor the production of a metallic resonance. Metallic resonance may accompany non-tympanitic as well as tympanitic notes ; but in the former case it can be appreciated only by the aid of the stick-pleximeter method of percussion. Metallic resonance can be elicited sometimes over physiologic cavi- ties — e. g., the stomach and intestines ; sometimes over pathologic col- lections of air — e. g., lung cavities, pneumothorax, pneumopericardium. If the metallic resonating cavity contains fluid as well as air, change of the patient's position may alter the pitch of the metallic resonance. This is because its pitch depends partly upon the greatest diameter of the air cavity, which would be altered by the shifting of the relative positions of the fluid and the air (see p. 213). CRACKED-POT RESONANCE. (Bruit de Pot Fele; Noise of the Spinning-top, of the Chink of Coins.) This peculiar clanging or rattling percussion noise can be simulated by filling the hand with coins, shutting it tight enough to allow only a slight space for the coins to move, and then shaking the hand ; or, in another way, by clasping the hands together firmly, leaving a slight air space between, and then striking the back of one hand against the knee. The force of the blow will expel some air through the narrovr chink between the hands. Another inethod is to strike a hollow rubber ball with a narrow opening vigorously enough to expel some air with each stroke. Such experiments, as well as the conditions in the chest which are responsible for the phenomenon, make it probable that the cracked- pot sound observed in man is a stenotic murmur, made by the percussion blows expelling air quickly through a narrow slit-like opening. (See p. 213 for its diagnostic significance.) TOPOGRAPHIC PERCUSSION. 159 TOPOGRAPHIC PERCUSSION. PERCUSSION CHARTS; SUPERFICIAL AND DEEP DULNESS OF ORGANS; LIGHT AND STRONG PERCUSSION; SITUATION OF THE ORGANS; ORIENTATION POINTS AND LINES. Topographic percussion means the determination of the boundaries of the organs of the body by means of percussion. By this method we attempt to project the boundaries of the organs upon the body surface ; and to represent these relations conveniently in the history sheets the Horizontal Mamillary line. Fig. 70.— Chart of anterior bodv-half. borders are sketched upon a chart of the human body, with a skeleton drawn in.side. Fig.«. 70, 71, and 72 show such percussion charts. Per- haps they would be still more convenient if they were double the size. Since every man's skeleton is not of the same shape, it is advisable to represent by some mark {e. g., a cross) the boundary points which are 160 PERCUSSION. quite normal in their relation to the skeleton (see Fig. 79). Such a chart is rarely absolutely accurate. The possibility of employing topographic bounding of organs which are situated in part one over the other depends upon the fact that some are filled with air and some are solid. A solid organ gives a dull, a hollow organ a resonant, note. In rare cases the qualitative variations of the resonant note can be utilized for defining the boundaries. For example, we can differentiate the resonant but non-tympanitic note of the lung, or the low tympan- itic note of the stomach, from the high tympanitic note of the intestine. But naturally the dif- ferences are often very slight, and the qualities of the resonant notes merge into each other without sharp boundaries, so that the dis- tinction is by no means easy. The first essential for utiliz- ing topographic percussion is to localize the percussion stroke. Where the boundaries to be defined are superficial — that is, where they lie directly under the body-wall — the lightest possible percussion will evidently suc- ceed best. As soon as we per- cuss more vigorously, the vibra- tions will be strongly transmitted over the boundaries, producing a mixed note. Therefore, it is a good general rule that to appre- ciate superficial boundaries tee should percuss as lightly as pos- sible. In other words, the per- cussion should be gentle enough not to produce any note at all over solid tissues. Then the same strength of percussion will produce a very plain, resonant note just as soon as we encroach upon the edge of an organ containing air — »»« Liygr. >-and line of diaphragm. Fig. 74.— Position of the thoracic and upper abdominal viscera from in front : a b. Boundary of right pleural cavitj^ ; c d, boundary of left pleural cavity ; ef, edge of right lung ; cj h, edge of left lung; i, upper incisura lobularis (right lung) : k, lower incisura lobularis (right lung) ; !, left incisura loljularis ; 'm n right, « o lovrer, p o left border of heart ; q, mediastinal sinus situated between the pleural boundaries and the incisura eardiaca of the anterior edge of the left lung; r, highest point of the liver, overlapped by lung; s, lower edge of liver; t pars eardiaca, u pars pylorica, v small curvature, w large curvature, of the stomach (modified from Luschka-Weil). icle. The lowest of the ribs which is directly attached to the sternum (true ribs) is the seventh. The first of the " floating ribs " — i. e., those with tlieir tips freely suspended — is the eleventh. In counting the vertebral spines we generally begin with the seventh cervical. Its prominence when the head is bent forward (vertebra prominens) makes it easy to recognize. Where three vertebral spines are quite prominent in this region, the 166 PEBGUSSION. seventh is usually in the middle. Where the seventh cannot be posi- tively determined, the vertebra should be counted from below — i. e., from the fifth lumbar vertebra upward. The lower angle of the scapula, wdth the arms hanging, ordinarily corresponds to the seventh rib and the seventh dorsal vertebra. The base of the xiphoid cartilage can be •^——^^^-—^ Pulmonary border. .-•___._____ Pleural boundary and incisurEe interlobulares. ••....-...-i..... Stomach and kidney. • " Liver and spleen. Fig. 75.— Position of the thoracic and upper abdominal viscera from the left side : a b, Lower edge of the left lung ; a c, lower boundary of the pleural cavity ; d e, incisura interlobularis ; /, edge of the left lobe of the liver; n posterior, ft anterior end of the spleen in its oval form, in the rhomboid form it pushes itself in between the anterior (g I) and the posterior {p K) edge of the piece (I h) ; k, convex edge of the left kidney ; I, splenic lung angle : m, splenic kidney angle : n, the part of the greater curvature of a moderately distended stomach lying against the wall (from Luschka-Weil). utilized in topography, but its tip varies considerably in length and position, and is therefore unreliable. Besides the skeletal parts we make use of so-called orientation lines. These are vertical lines which intersect the ribs at certain angles. They are the follo\ving (see Figs. 70, 71, and 72): 1. The anterior and the posterior median line. 2. The right and the left sternal line — draAvn vertically through the edges of the sternum. 3. The right and the left parasternal line — drawn halfway between the sternal border and the nipple. TOPOGRAPHIC PERCUSSION. 3 67 4. The right and the left mammillary line (or nipple lines) — drawn perpendicularly through the nipple. 5. The middle, the anterior, and the posterior axillary line — drawn through the middle, the anterior, and the posterior edge of the axilla. 6. The right and the left scapular line — drawn perpendicularly through the inferior angle of the scapula, with the arm hanging down. The position of the mammillary line is inconstant both in men and in women. The so-called midclavicular line, which is dropped perpen- Lung borders. Pleural boundaries and incisurse interlobulares. Kidney. Liver and spleen. Fig. 76.— Position of the viscera from behind: ah, Lower lung border; c rf, lower pleural boundary ; c and /, incisure interlobulares ; at ig) on the right side it is divided into the sulcus interlobularis dextra superior and inferior ; h, spleen ; i, lower liver edge ; k, left kidney ; I, right kidney (from Lusehka-Weil). diciTlarly from the middle of the clavicle, is therefore a more accurate landmark. A horizontal mammillary line is sometimes employed ; that is, a horizontal line on the surface of the thorax, drawn through the nipples. Its position is, of course, influenced by the height of the nipples. In men these are usually found to be between the fourth and fifth or upon one of these ribs (rarely between the £fth and the sixth ribs), about 10 cm. distant from the lower thoracic edge, and about 16 cm. from the lower edge of the clavicle. 168 PERCUSSION. The terms used in topographic anatomy are usually serviceable in topographic percussion — such as supra- and infraclavicular grooves, supra- and infraspinatous fossae, interscapular space, epigastrium, hypo- chondrium, mesogastrium, hypogastrium, etc. (see Figs. 77 and 78). TOPOGRAPHIC PERCUSSION OF THE LUNGS. NORMAL LUNG BORDERS. The boundaries of the lungs move normally with respiration ; hence we must distinguish, on the one hand, an expiratory, and, on the other, an inspiratory position. This distinction is especially important for Fig. 77.— Topographic areas of trunk— anterior view. determining the mobility of the lung edges. In general, the median position of the lung borders when the patient breathes superficially is sufficient for most purposes. The excursions of the lungs are then hardly greater than the limits of error which are inherent in percussion. The boundaries designated as normal correspond to such a median posi- tion of the lung edges. We usually determine the inferior boundaries of the patient's right lung (the lung-liver boundary) anteriorly while he is lying down ; pos- teriorly, while he is sitting or standing. Such a boundary line inter- sects the parasternal and midclavicular lines at the upper edge of the sixth rib ; the axillary lines, at the eighth to ninth ribs ; the scapular TOPOGRAPHIC PERCUSSION. 169 Fig. 78. — Topographic areas of trunk— posterior view. Fig. 79.— Normal percussion boundaries of the lungs, liver and spleen, and Traube's space- anterior view. 170 PERCUSSION. lines, at the tenth rib ; the posterior median line, at the eleventh verte- bral spine. The border, therefore, runs very nearly horizontal (see Figs. 79 and 80). The precordial edge of the left lung forms a segment, within which the heart lies directly against the thoracic wall. This segment corre- sponds to the so-called superficial carcUae dulness (Figs. 79 and 85). The border of the lung bounding this area lies above at the left edge of the sternum, upon the fourth rib, and runs from there horizontally to the left ; Fig. -Percussion boundaries of the lung, liver and spleen, and Traube's space— from the left side. at the parasternal line it curves downward to the level of the sixth rib. and then takes the same course as the inferior border of the right lung. For practical purposes we may assume that the inferior lung edge, with the exception of this segment over the heart, follows practically a hori- zontal course upon both sides. The edge of the left lung can be easily and accurately diiferentiated by the superficial cardiac dulness ; but farther to the left the loud, resonating stomach is a])t to confuse the percussion. From the axillary line backward the defining of the edge of the lung becomes easier again, because the spleen, the powerful TOPOGRAPHIC PERCUSSION. Ill muscular masses of the quadratus lumborum, and the lumbar limb of the diaphragm lie below the lung. The anterior lung borders run almost vertically beneath the sternum (Fig. 74). It is impossible to percuss them, because only a small space exists between them, and because an exact localization of the percussion stroke upon the sternum is very difficult. The bone vibrates to per- cussion more or less as a whole, like a great pleximeter, and transmits the vibration widely over the surface. The superficial cardiac dulness can be percussed accurately only when a considerable part of that bone overlies or is bounded by a dull-sounding tissue (see Figs. 88, 91). For this reason the right border of the superficial cardiac dulness ordi- FiG. 81.— Apical percussion : Lines above clavicle at normal height. narily corresponds to the left edge of the sternum, and hence has little diagnostic importance. The apices of the lungs form slightly voluminous cones covered by very thick layers of muscle, which render the upper pulmonary bounda- ries much more difficult to determine as linear projections than the lower. Moreover, the trachea lies in such close proximity to the lung apices that percussion is very liable to set this in vibration. Hence the difficulty of properly percussing the apices. Figs. 79 and 81 represent the boundary lines of the lung apices in individuals who are neither too muscular nor too fat. The highest point of the upper lung border lies from 3 to 5 cm. above the clavicle. [In a recent paper ^ Dr. R. W. Philip, Physician to the Victoria Hospital for Consumption, has called attention to the significance of ' Practitioner, London, vol. xvii., 1903. 172 PERCUSSION. the supraclavicular triangle in relation to early apical changes. He believes, from a large number of observations, that the mean of lung resonance above the clavicle is at least 1 J in. (4 cm.) ; that frequently it is over 2 in. (5J cm.). Assuming that lung resonance may be determined in the healthy subject over an area of three fingers' breadth above the clavicle. Dr. Philip believes that apical changes are often overlooked by limiting percussion to a single finger's breadth above the clavicle, a method Fig. 82.— Apical percussion; Line above left clavicle 1V$ cm. below normal ; left apex dull (New York City Hospital). which obtains with many examiners. The editors' experience corre- sponds with Dr. Philip's. The accompanying photographs (Figs. 81-83) illustrate a normal extent of pulmonary resonance above both clavicles ; a decided limita- tion of the resonance above the left clavicle in a case of pulmonary tuberculosis at the left apex ; and the method of percussing the apices from behind. AVe have intentionally omitted any reference to so-called " tidal percussion of the apices." Its value has not been settled beyond dispute. — Ed.] The lung borders vary somewhat according to the age of the patient. For ex- ample, in old people the lung-liver boundary is situated somewhat lower (about one intercostal space ) . The superficial cardiac dulness is often somewhat dimin- ished and situated about one intercostal space lower than in young adults. This change depends upon the diminished elasticity of the senile lung. Many authors denote this change as senile emphysema, provided nothing else abnormal is de- tected. The writer doubts if such nomenclature is correct, and has been unable TOPOGRAPHIC PERCUSSION. 173 to determine a higher level of the pulmonary edge in children than in perfectly healthy adults.^ ACTIVE AND PASSIVE MOBILITY OF THE LUNG BORDERS UNDER NORMAL AND UNDER PATHOLOGIC CONDITIONS. Vigorous respiration will depress the luDg borders several centimeters during inspiration and elevate them the same distance during expiration [active mobility'). Percussion will very plainly demonstrate this. In the axillary line the extreme positions of the lung border may reach 4 cm. Fig. 83.— Method of apical percussion. above and below the mean, so that the total excursion may be as much as 8 cm. Litten's diaphragm phenomenon (p. 78 6^ seq.) is the visible expression of such excursions. Deep inspiration may almost or entirely obliterate the superficial cardiac dulness. Change in a patient's position will demonstrate a jjossive mohiUty of the lungs. Changing from the dorsal decubitus to the erect posture may elevate the lung-liver boundary (or very rarely depress it). In some cases no change is noted. This variable result probably depends upon the preponderance of one of two opposing factors which influence the position of the diaphragm : 1, the weight of the liver ; and 2, the increased abdominal pressure due to the contraction of the abdominal muscles in the upright posture. If the abdominal walls are tense enough to contract vigorously in sitting and stauding, a slightly higher position of the inferior lung boundary seems to be the rule, because the intra- ^ Sahli, Die topographische Percussion im Kindesalier, Bern, Dalp'scbe Buchhandlung (now Schmid, Franche and Cie.), 1881. 174 PEECUSSION. abdominal pressure will be increased. Whereas if the abdominal walls are relaxed — e.g., with the characteristic pendulous abdomen — the oppo- site effect will be observed, because the weight of the liver will depress the diaphragm. Changing from the dorsal decubitus to a lateral posture will depress the pulmonary border of the uppermost lung about 3 or 4 cm. at the axillary lines. A deep inspiration while this position is retained may bring the border about 9 cm. lower than in the dorsal decubitus with median respiratory position ; and with a full expiration the lung border may under some circumstances make an excursion of as much as 13 cm. By means of all these different types and degrees of lung mobility, it is generally possible to demonstrate the clinically important sign of dimin- FiG. 84.— Normal percussion boundaries— from behind. ished or absent lung mobility. The mobility of the lung border is dimin- ished in (1) pulmonary emphysema and in (2) par^iaZ consolidations of the lung. Although the percussion note may not be noticeably dulled if these consolidations are scattered, such a condition may be suspected from the immobility of the border. (3) Firm pleuritic adhesions be- tween pulmonary and costal pleura also prevent mobility. Some examiners attempt to demonstrate pleuritic adhesions of the lung edge by percussing below the border determined during quiet breathing while the patient breathes deeply. If the loudness of the note is much increased with inspiration, they then claim that the lung edges are freely mobile. This method of examination, according to the author's experience, often causes error. Even if the lung is quite adhe- TOPOGRAPHIC PERCUSSION. 175 rent, the intensity of the note beneath the lung border is abnost certain to increase during inspiration. Such an increase does not necessarily prove a descent of the boundary, but merely suggests a thickening or an inflation of the lung edge. In other words, a greater accumulation of air at or near the pulmonary edge influences the note below it, because even with the lightest percussion it is not possible to absolutely localize the percussion stroke. A much better method for demonstrating mobility of the pulmo- nary border is to determine the boundary in the position of extreme inspiration while the patient holds his breath, mark it on the chest, and then do the same during extreme expiration. ABNORMAL POSITION OF THE LUNG BOUNDARIES. Under pathologic conditions the lung boundaries may be extended as well as contracted. Extension of the lung boundaries occurs in emphysema, where the lung-liver boundary may reach down to the eighth rib in the right mid- clavicular line, to the ninth or tenth rib in the axillary line, and to the twelfth vertebra behind in the posterior median line ; in fact, quite to the inferior limit of the thorax. The emphysematous increase may sometimes be plainly demonstrated even at the lung apex, and over the superficial cardiac dulness, which may be either entirely or almost oblit- erated. Both the active and the passive mobility of the borders in emphysema are diminished on account of the permanent inspiratory position of the diaphragm and a certain fixity of the lung so character- istic of the disease. Emphysema ordinarily is developed upon both sides, and, as a rule, quite uniformly ; but a partial emphysema does occur (perhaps incorrectly called vicarious emphysema), in which the changes are localized at the lung borders. Even in the common type of pulmonary emphysema the pulmonary distention is not always uni- form. Frequently percussion shows that the emphysema is limited to the region over the heart, whereas the inferior lung border is not any lower than normal. This is often seen in fat or dropsical individuals, apparently because the increased abdominal contents crowd the diaphragm upward. In a similar manner the pulmonary boundaries are also extended in attacks of bronchial asthma and in obstructive bronchitis because there is a greater resistance to the emptying than to the filling of the lungs. For analogous reasons, when a bronchus is narrowed the afi'ected pul- monary lobe is dilated. Certain cardiac affections, particularly mitral lesions, lead to pulmo- nary dilatation, the lungs being permanently engorged with blood and in the condition of so-called cardiac lung rigidity ; brown induration is usually present as well. The lungs in these cases resemble those of emphysema, since they are dilated, their elasticity is partly lost, and they make but slight excursions. The lung borders in enteroptosis (p. 192) are nearly always depressed. Retraction of the lung border results from the crowding of the lung 176 PERCUSSION. edges by the neigbboring parts. 1. The diaphragm will be pushed upward by all conditions which increase the intra-abdominal pressure — e.g., meteorism, ascites, abdominal tumors (especially if situated at the convexity of the liver). Negative intrathoracic pressure will therefore be diminished ; so the lungs must be retracted, not only upward, but concentrically in all directions, from in front backward and toward the hilus, even enough to expose the heart to a considerable extent. 2. An enlarged heart (or a pericardium filled with fluid) can also crowd the lungs aside enough to increase the superficial cardiac dulness. (See Heart Percussion.) If such a crowding is very marked, the resulting diminution of negative intrathoracic pressure will elevate the inferior lung borders. 3. All processes associated with a pulmonary shrinking may occasion a retraction of the lung boundaries — e. ^., the chronic forms of tuberculosis, which produce a connective-tissue retraction of the lungs ; and cases of pleurisy in which, after the absorption of the exudate, the expansion of the compressed portion of the lung is pre- vented by the formation of a firm connective-tissue coating. The shrink- ing usually proceeds concentrically in such conditions, so that the lungs are often retracted on all sides ; that is, as much over the heart as at the inferior borders, and sometimes even at the upper borders, toward the hilus. Chronic tuberculosis frequently leads to a retraction of the pul- monary apex. Therefore the demonstration of a unilateral low position of the superior lung border is of special importance for the early diag- nosis of apical tuberculosis. (See Editor's Note, p. 172, and Fig. 81.) We must remember that the normal positions mentioned above are only averages, and that abnormally long or short chests would naturally modify the position of the lung borders in relation to the ribs, while the condition could in no way be considered pathologic. Errors in this respect, especially in relation to the diagnosis of emphysema, frequently occur in practice. They cannot be avoided by definite rules, but only by practical experience and by the development of a geometric vision. TOPOGRAPHIC PERCUSSION OF THE HEART. NORMAL SUPERFICIAL AND NORMAL DEEP CARDIAC DULNESS. Superficial cardiac dulness is the dulled area which corresponds to the segment of the left lung about the heart (Figs. 79 and 85). Its extent really tells more about the position of the lung edge than about the size of the heart. Nevertheless, if the heart is enlarged or if the pericardium becomes distended with fluid, the edges of the lung will be pushed back and the superficial cardiac dulness increased. Certain cau- tions are necessary to prevent mistakes in estimating the size of the heart or pericardium from the extent of this superficial cardiac dulness. For example, despite an enlarged heart, the superficial cardiac dulness is not necessarily increased in emphysema, even when the lung edges in the neighborhood of the heart are fixed by pleuritic adhesions. The deep dulness is more important in estimating the size of the heart and the contour of the pericardium. The deep cardiac dulness will never TOPOOBAPHIC PERCUSSION. 177 be very intense, but is always modified (a so-called relative dulness). The beginner often finds it very difficult to determine. The superficial cardiac dulness, on the contrary, is frequently absolute, and therefore easier for the beginner's ear to appreciate. Both varieties of dulness should therefore be mapped out upon the chest. The superficial often confirms the results of the deep percussion. The form and size of the superficial dulness, also called the small cardiac dulness, have already been described in the section on Topo- graphic Percussion of the Lungs (see Fig. 79, p. 169 et seq.). Fig. 85 represents the relations of the superficial and the deep or great cardiac dul- ness in the average healthy adult. The boundaries of the latter run from Fig. 85. — Superficial and deep cardiac dulness under normal conditions. the upper edge of the third left rib nearly parallel to the border of the superficial cardiac dulness, bend toward the left in a bow-shape, with the convexity outward, become perpendicular slightly inside the mid- clavicular line, and end near this point at the apex beat. The heart is bounded below by the liver, so that the deep dulness, like the super- ficial, merges into the hepatic dulness and cannot be differentiated from it. Where the liver is covered by intestines filled with air, or where it is pushed upward to the right, superficial percussion will generally evoke a loud tympanitic tone just below the heart. Most authors limit the right boundary of the deep dulness at the left sternal border ; never- theless, according to the writer's experience, the majority of healthy adults show a slight dulness up to the right sternal border (Fig. 85). But in many cases the whole extent of the sternum furnishes such a 12 178 PERCUSSION. loud tone that the deep cardiac dulness is really limited by the left sternal border. (See Topographic Percussion of the Lungs.) These individual peculiarities depend upon the vibration of the sternum, upon the thickness of the layer of lung covering the heart, etc. In determin- ing the upper borders of the deep dulness, the fact that the sternum trans- mits the blow so deeply necessitates a light percussion. Both the superficial and the deep dulness are smaller in the aged than in younger adults, because the lungs of old people cover the heart more extensively. In children both varieties of dulness are, on the con- trary, larger, because the amount of lung tissue which covers the heart is thinner, and so the sphere of acoustic action of the percussion blow reaches the solid organ earlier. This distinction is shown by comparing Figs. 73 and 86. Fig. 73 pictures the relation of the acoustic sphere of action of the percussion blow in adults ; Fig. 86, in children. In the latter it is plain that the deep dulness will sometimes be larger than the organ itself ; whereas in adults, and even more noticeably in older people, per- cussion can only include a portion of the entire size of the heart. Long Fig. 86.— Relations of the size of the acoustic sphere of the action of the percussion blow in children (see Fig. 73) practice will prevent mistakes, but even then we must employ the other examination methods, such as palpation of the apex beat. Variations of the thoracic dimensions in different individuals make the conclusions to be drawn from deep cardiac percussion still more doubtful. The heart boundaries are ordinarily mapped out in accord- ance with the orienting lines of the body — e. g., the position of the left border of the heart in reference to the mammillary line. This some- times leads to erroneous conclusions. Although, as a rule, the left border of the deep cardiac dulness lies somewhat inside the mammillary line, it is self-evident that if the mammillary line is pushed inward even a normal heart would reach outside. Even the midclavicular line is not absolutely constant, because the length of the clavicle varies, and ■with it the breadth of the thorax. If the sternum is broad, a dulness be- yond the right sternal edge would be more significant than if the sternum is narrow. Hence the importance of the absolute size of the cardiac dulness. At the Bern Clinic we always measure its horizontal diameter in the third and fourth intercostal spaces, and the distance of the left and right margins of dulness from the anterior median line. Riess ^ has 1 Zelt.f. klin. Med., 1888, vol. xiv., p. 12. TOPOGRAPHIC PERCUSSION. 179 estimated the normal figures from averages upon a large number of measurements in medium-sized healthy adults, as follows : Distance of the right border of the deep cardiac dulness from the anterior median line : Third intercostal space 2| cm. ; fourth intercostal space 3f cm. Distance of the left border of the deep cardiac dulness from the median line : Third intercostal space 4| cm. ; fourth intercostal space 7i cm. Total width of the deep cardiac dulness : Third intercostal space 7^ cm. ; fourth intercostal space 11;^ cm. These figures seem to the writer rather too small. Cardiac percussion can sometimes be simplified by directing the patient to bend forward or to take a deep inspiration. Before an attempt to estimate the deep cardiac dulness in women with promi- nent breasts, the patient or a nurse must first push the left mamma upward and to the left. ACTIVE AND PASSIVE MOBILITY OF THE SUPERFICIAL AND DEEP CARDIAC DULNESS. The heart borders, like those of the lungs, change their position actively with respiration and passively with change of the patient's position. Active mobility concerns only the respiratory overlapping of the heart by the lung edges, whereas passive mobility influences the position of the heart as well as of the lung borders. The boundaries described above are estimated during quiet breathing in the dorsal decubitus. Deep inspiration diminishes the size of both superficial and deep cardiac dulness more or less decidedly. Forced expiration produces the opposite effect, and in rare cases may bring the superficial dulness to the right of the right sternal edge, the right edge of the lung retreating so far. Therefore percussion during forced ex- piration (without exerting abdominal pressure) will sometimes reveal the true size of a heart which is extensively covered by the lungs. In the left lateral posture the heart falls to the left and displaces the anterior edge of the left lung. The anterior edge of the right lung is only exceptionally found beyond the left sternal edge, because its excur- sion is normally limited by the line of the pleura beneath the sternum (see Fig. 74). Therefore in left lateral positions both the superficial and the deep cardiac dulness are increased to the left. In right lateral positions the opposite displacement occurs. Both the deep and the superficial dulness will reach beyond the right of the sternum, while the superficial dulness to the left of the sternum may entirely disappear. Changing from the recumbent to the sitting posture does not produce any constant change in the form or size of the cardiac dulness. Both the superficial and the deep dulness may seeui somewhat more intense in the upright posture. If the patient bends forward both are increased, because the heart pushes the lungs aside, approximating itself more completely to the anterior thoracic wall. Where emphysema or thick 180 PEBCUSSWN. thoracic walls obscure the percussion in the recumbent posture, sitting up and bending forward may be helpful. To prevent mistakes the patient must be careful not to bend sidewise or twist his back, for we must remember that in such a position a normal heart will furnish a broader and more intense dulness. The absolute measures of the mobility of the superficial and the deep cardiac dulness vary so much with the individual that the figures would be superfluous. PATHOLOGIC CHANGES IN THE SUPERFICIAL AND DEEP CARDIAC DULNESS. Diminution of tlie Superficial and Deep Cardiac Dulness. In advanced emphysema, in left-sided pneumothorax, in pneumocardiay. and in precordial emphysema both the superficial and the deep cardiac dulness may be either diminished or entirely disappear. The cardiac atrophy which is sometimes observed at the autopsy table is too slight to be recognized by percussion. Ernp>hysema also causes an especially, low position of the cardiac dulness, on account of the deep position of the diaphragm. Frequently no deep cardiac dulness can be made out, and the superficial, if present, may appear only at the fifth or even the sixth rib. In left-sided pneumothorax we should expect that at least a part of the superficial cardiac dulness would persist, because the normal division line of the pleurae, which would divide the superficial cardiac dulness in half, shifts (Fig. 74). As a matter of fact, however, left pneumothorax almost always dislocates the heart, the division line, and with it the mediastinum, so far to the right that the superficial cardiac dulness to the left of the sternum may entirely disappear. In right-sided pneumothorax (Fig. 99) the air resonance may overlap the left edge of the sternum, in consequence of the mediastinum being pushed to the left, so that the superficial cardiac dulness will appear to be narrowed from the right. The demonstration of cardiac dislocation (p. 188) will suggest and explain this condition. Percussion elicits an abnormally resonant metallic note (often tympanitic) over the area of cardiac dulness in pneumopericardium and p>recordial emphysema. The pericardial sac in the former ordinarily contains fluid as well as air ; this becomes evident when the patient sits up, for the lower portion of the abnormally resonant area becomes dull, the fluid following the laws of gravity. (The auscultatory signs will be mentioned later.) With marked gaseous distention of the intestine or of the stomach, even careful percussion may elicit a tympanitic note over the area of superficial cardiac dulness, because the vibrations are transmitted to the abdominal contents. But very gentle percussion, in which the plex- imeter is applied only by its own weight, and perhaps best with the patient bending forward, will probably enable us to demonstrate the superficial cardiac dulness, and so to differentiate tympanites from the overlapping of the heart by air-containing tissue. A deep cardiac dul- ness in such cases is difficult, if not impossible, to obtain. TOPOGRAPHIC PERCUSSION. 181 Enlargement of the Superficial and Deep Cardiac Dulness. Enlargement of the Cardiac Dulness from Abnormalities of the I/Ung" Borders. — Both the superficial and the deep cardiac dulness will be increased if the heart pushes back the anterior lung boundary, or if some anatomic process in the latter (infiltration or atelectasis) adds a dull tone of its own to the cardiac dulness. The increase of cardiac dulness does not then depend upon any alteration of the heart's size. Such conditions can be properly interpreted only by carefully considering the entire clinical picture, and by making use of other methods of examination. The most frequent examples are jndmo- naiy contraction and the concentric retraction of the lung, or an upward dislocation of the diaphragm from marked ascites, meteorism, and the like (see pp. 175 and 176). Increase of the Cardiac Dulness from Actual Increase of the Si^e of the Heart or of the Pericardial Contents. — Here the superficial and the deep cardiac dulness are generally increased Fig. 87.— Precordial buli^in.Lr: I'.nlar.L'rd ln^ail and liver;