KC7C.3 College of J^ljpjsidans; anb ^urgeonji Hibrarp Auscultation and Percussion. Teque auscultantem palpantem et percutientem Pectora, sic morbi ducere signa vident. E Carmine Roherti Bridges De iiosocoinio Sti Bartolomaci Londincnsi. Auscultation and Percussion : TOaETHER WITH THE OTHER METHODS OF PHYSICAL EXAMINATION OF THE CHEST. BY SAMUEL GEE, M.D., FELIA)W OF THE ROYAL COLLEGE OF PHY3ICIAXS, AND PHYSICIAN TO SAINT BARTHOLOMEW'S HOSPITAL. FOURTH EDITION. LONDON : SMITH, ELDEE, & CO., 15, WATERLOO PLACE 1893. LONDON : BRADBURY, AGNEW, & CO. LD., PRINTERS, WHITEFRIARS. )2n TO THE MEMORY OF LAENNEC. E TENEBRIS TANTIS TAM CLARVM EXTOLLERE LVMEN QVI PRIMVS POTVISTI ILLVSTRANS PECTORIS ANTRVM TE SEQVOR GALLAE GENTIS DECVS INQVE TVIS NVNC FIXA PEDVjM PONO PRESSIS VESTIGIA SIGNIS NON ITA CERTANDI CVPIDVS QYAM PROPTER AMOREM QVOD TE IMITARI AYEO. TABLE OF CONTENTS. Introductory Chapter Page 1 PART THE FIRST. Chap. I. Method of Examination . . . . 3 ,, 11. Inspection 4 Sect. I. Shape of Chest at Rest . . 4 Art. I. Shape in Health . 6 m I. Typical Shape . 6 II. Subtypical Shapes . 10 i. Alar chest . 11 ii. Flat chest 12 iii. Transverse Constriction U iv. Pigeon breast . 16 V. Rickety breast . 19 Art. II. Shape in disease . 20 •U I. Bilateral changes . 21 i. Enlargement . . 21 ii. Diminution . 25 viii CONTENTS. Chapter II. — continued. Page '^ II. Unilateral changes 26 i. Enlargement . . . 26 ii. Diminution 29 TI III. Local changes 31 i. Bulging . 31 ii. Shrinking . 32 Cup-shaped depression 32 Sect. II. Movements of Chest . 34 Art. I. Movements of Respiration 34 m I. In Health .... 34 II. In Disease ' . . . 36 i. Inspiratory Dyspnoea . 36 ii. Expiratory Dysj)noea 37 iii. Non-expansive Inspiration . 37 iv. Respiration wholly Thoracic 38 V. Respiration wholly Abdominal 38 Art. II. Movements of the Heart 38 U I. In Health .... . 39 i. The Impulse . . 39 ii. Recession .... . 40 ^ II. In Disease . 40 i. The Impulses . 40 o. Of the apex-beat . 41 jB. Of the conus arteriosus 42 y. Of the right auricle 42 ii. Recession .... . 43 Art. III. Movements wholly unnatural . . 44 CONTENTS. ix Page Chap. III. Palpation . . . . • • 45 Sect. I. Lungs and Pleurse . . . . 45 Art. I. Yocal Thrill 45 t I. In Health 45 II. In Disease ...... 46 Art. II. Pleural Friction . . . . 47 III. Fluctuation 47 Sect. II. Heart and Pericardium 48 Art. I. Impulses . . . . • • 48 m I. Systolic 48 II. Diastolic 50 III. Prsesystolic . . . . . 50 Art. II. Valvular Thrills 51 III. Pericardial Friction . 53 IV. Fluctuation .... 54 Sect. III. Large Vessels .... 54 Chap. IV. Percussion ..... 55 Sect. I. Introductory . . . . . 55 Art. I. Historical ..... 55 II. Method 58 i. Immediate Percussion . . 58 ii. Mediate Percussion . . 59 Art. III. Theory . 60 ^ I. Percussion Sounds . 61 Class I. Percussion Tones . 61 I. Loudness . . 61 II. Duration . 62 CONTENTS. Chapter IV. — continued. Page III. Pitch .... 62 Tympanitic, pulmonal, tra- cheal and osteal tones . 62 IV. Tone 64 Clearness and Dulness . . 64 Class II. Percussion Noises . 65 III. By-sounds 65 I, Metallic Eing 65 II. Cracked-Pot Sounc [ 65 ^ II. Physical Conditions of — I. Percussion Tones 66 II. Pei'cussion Noises . 72 III. By-sounds . 72 ^ III. Percussion Resistence . 74 Percussion Thrill 75 Superficial and Deep Percussion 75 Sect. 11. Percussion of Chest in Health . 76 Art. I. Pulmonary Regions 76 TI I. Resonance and Resistence 76 II. Extent .... . 78 Art. II. Cardiac Region . 79 III. Mediastinal Region 81 Sect. III. Percussion of Chest in Disease . 81 Art. I. Pulmonary Region 81 Tl I. Percussion Sound . 82 Class I. Increased Resonances . 82 II. Diminished Resonances 83 CONTENTS. xi Chapter IV. — continued. Page Class III. By-Sounds . . 85 ^ II. Percussion Eesistence . 85 III. Extent .... 85 Art. II. Cardiac Region . 86 1. Area diminished . 86 ii. Area increased . 86 Art. III. Mediastina .... . 87 Chap. V. Auscultation . . . . . 88 Sect. I. Introductory .... . 88 Art. I. Historical .... 88 II. Methods .... 91 III. Murmurs in general . . 94 Sect. II. Lungs and Pleurae . 95 Art. I. Vocal Resonance 96 m I. Theory .... 96 i. Muffled vocal resonance 97 ii. Bronchojjhony 97 Pectoriloquy and .^Egophony 99 II. Physical Conditions 101 III. Vocal Resonance in Health 109 IV. Vocal Resonance in Disease . 109 Resonance of Cough and Cry 112 Art. II. Respiratory Sounds 112 11 I. Theory 112 i. Vesicular breathing 112 ii. Bronchial breathing . . . 114 Cavernous and tubular . 115 Souffle voile . . . . 116 xii CONTENTS. Chapter V. — continued. Page U II. Physical Conditions . 117 III. Respiratory Sounds in Health . . 120 IV. Respiratory Sounds in Disease 121 V. Rales 122 i. Crepitant 123 ii. Mucous .... . 125 iii. Sonorosibilant 126 iv. Doubtful .... 126 Art. III. Pleural Sounds . 127 H I. Friction Sounds 127 II. Amphoric Sounds 129 i. Amphoric hum 130 ii. Metallic tinkle 131 iii. Bell sound 131 iv. Splashing sound . 132 V. Physical conditions . 132 Appendix to Section II. . . . 134 i. Peritonseal friction . 134 ii. Shoulder-joint friction . 134 iii. Shoulder-blade friction 135 iv. Muscular rumble . 135 Sect. III. Heart and Pericardium . 135 Art. I. Sounds in Health . 137 Loudness and Accentuation 138 II. Sounds in Disease 139 ^ I. Murmurs . . . . . 140 Class I. Cardiac Murmurs . 141 i. Place 143 CONTENTS. xiii Chapter V. — continued. Page ii. Time . . . . 146 iii. Meaning . . . . 148 iv. Loudness , . . . 149 V. Keduplication 151 i. Simi)le 151 ii. EedupJication Murmurs. 152 a Of first sound 153 )8 Of second sound . 153 Class II. Vascular Murmurs 154 ^ II. Pericardial Sounds . . . 155 I. Friction .... 155 II. Waterwheel sounds 157 Appendix to Section III. .... 158 •U I. Pulsatile Pulmonary Sounds 158 II. Pulsatile Friction Sounds 160 III. Metallic Jingle . ... 161 Chap. VI, Appendix to Part I. . . . . 162 Sect. I. Auscultation of Arteries 162 I. Conducted sounds .... 162 II. Sounds produced in situ . . . 162 ^ I. Spontaneous .... 162 i. Aneurysmal . . . . 162 ii. Subclavian .... 163 •[I II. Factitious 163 i. Systolic .... 163 ii. Diastolic . . . . 164 Sect. II. Inspection of Veins of Neck . 165 ^ I. Fulness of Veins . . . . 165 xiv CONTENTS. Chapter VI. — continued. Page IT II. Venous Pulsation . . . .166 Sect. III. Auscultation of Veins of Neck . . 172 ^ I. Continuous Venous Hum . , . 172 II. Intermitting Murmurs . . . . 173 Sect. IV. Epigastric Pulsation . . .173 V. Position of Diaphragm . . . 175 m I. In Health . . . .176 II. In Disease 176 Sect. VI. Position of Mediastinum . . 177 VII. Other Vascular Murmurs . . . 180 VIII. Puncture of the Chest . . .181 IX. Conduction of Respiratory Sounds . 184 Auscultation of (Esophagus . .185 PART THE SECOND. Chapter I. Pulmonary Catarrh, or Bronchitis . . 186 II. Pulmonary ffidema .... 191 III. Pulmonary Congestion . . . . 193 IV. Pulmonary Haemorrhage . . . 194 V. Pulmonary Emj)hysema , . . . 195 VI. Pulmonary Atrophy . . .197 VII. Asthma '. 198 VIII. Pulmonary Collapse .... 200 IX. Plugging of Trachea or Bronchus . , 204 X. Pleurisy ...... 206 XI. Pneumothorax . . . . . . 208 I. Closed Hydropneuraothorax . . 208 CONTENTS. XV Chapter XI. — continued. Page II. Fistulous Empyema . . . . 211 III. Loculated Pneumothorax . .212 ly. Pure Pneumothorax . . . . 212 XII. Hydrothorax 215 XIII. Pleurisy with Eflfusion . . . . 216 XIV. Empyema 229 XV. Adherent Pleura 234 XVI. Pneumonia 236 I. Lobar Pneumonia . . . . 236 II. Lobular Pneumonia . . . 240 XVII. Destructive Pneumonia and Pulmonary Gangrene . . . . . . 241 XVIII. Embolic Pneumonia or Pysemic Infarctus 243 XIX. Pulmonary Tuberculosis . .... 244 XX. Pulmonary Phthisis . . . .246 XXI. Pulmonary Cancer . . . . . 251 XXII. Pulmonary Hydatids . . . .254 XXIII. Pulmonary Actinomycosis . . . . 256 XXIV. Dilatation of the Bronchi . . .257 XXV. Pulmonary Cirrhosis 258 XXVI. Hypertrophy of the Heart . . .260 XXVII. Dilatation of the Heart . . . . 262 XXVIII. Pericarditis 265 XXIX. Pericardial Eflfusion 267 XXX. Pneumopericardium . . . .273 XXXI. Adherent Pericardium . . . . 274 XXXII. Mitral Regurgitation .... 275 XXXIII. Mitral Obstruction 278 xvi CONTENTS. Chapter. Page XXXIV. Aortic Regurgitation . . . .282 XXXV. Aortic Obstruction 286 XXXVI. Tricuspid Regurgitation . . . .287 XXXVII. Tricuspid Obstruction . ... 288 XXXVIII. Pulmonary Regurgitation . . .289 XXXIX. Pulmonary Obstruction . . . . 291 XL, Murmurs of Uncertain Nature . . 292 XLI. Malformations of the Heart . . . 295 XLII. Mediastinal Tumours . . . .297 XLIII. Aneurysm of the Thoracic Aorta . . 299 XLIV. Other Intrathoracic Aneurysms . . 305 I. Innominate Artery . . . . 305 II, Pulmonary Artery . , . 306 Index 309 PHYSICAL EXAMINATION OF THE CHEST. INTEODUCTOEY. PHYSICAL EXA]\[INATION AND PHYSICAL SIGNS. ~r)HYSICAL Examination relates to those -*- Phsenomena which a pei'son examining can discover for himself, and without help from the person examined. Most parts of the body may undergo a physical examination ; the immediate results thereby obtained are called Physical Signs.^ The present book is devoted to an exposition ^ ' ' When a man hath so often observed like antecedents to be followed by like consequents, that ■whensoever he seeth the antecedent, he looketh again for the consequent ; or ■when he seeth the consequent, maketh account there hath been the like antecedent ; then he calleth both the ante- cedent and the consequent, sijna one of another." Hobbes : Human Nature, Chap. IV. par. 9. Cf. Computation or Logic, Chap. 11. , par. 2. G.A. B 2 INTRODUCTORY. of the methods and results of physical examiua- tion of the organs contained in the thorax namely, of the lungs and pleura?, the heart and pericardium, and the mediastinum, including the large bloodvessels. The First Part treats of the physical signs considered in the abstract ; the pure science of the physical signs. The Second Part treats of the physical signs considered in their subservience to the discovery of disease ; the applied science of the physical signs. PART THE FIRST. CHAPTER I. METHOD OF EXAMIXATIOX. O UPPOSE a patient with the chest exposed, ^ ready to undergo a physical examination : the physician first of all carefully surveys the chest with his eye, this is Inspection : next, with his hand, this is Palpation : he next strikes the chest. Percussion : and lastly he puts his ear upon the chest, Auscultation. Whenever convenient, the patient should remove all clothes from the upper part of the body down to tlie waist, and stand opposite to the physician. Needful deviations from this rule will be suggested by the good sense of the examiner at the proper time. h 2 CHAPTEE II. IXSPECTIOX. INSPECTION discovers the shape of the chest. First ; the shape such as it is Avhen the thorax is at rest ; that is to say, at the end of an ordinary expiration and during the diastole of the heart. Secondly ; the ceaseless tenipo- rar}' changes in shape which the chest undergoes during life, in consequence of the respiratory and circulatory movements. SECTION I. SHAPE or THE CilEST AT HEST. A transverse section of the chest u])on a hori- zontal plane approaches to the figure of an ellipse ; betNveen the long and short axes of which (that is to say, between the breadth ar.d depth of the chest) there is a certain proportion. Knowledge of this proportion is the key to knowledge of the shape of the chest in health, and the unilateral and bilateral chanizes which SB APE OF CHEST. 5 that shape undergoes in diyease. Changes in the length or height of the chest from above downwards, changes in the direction of the ribs, in the width of the intercostal spaces, in the size of the costal angle, in the arching of the spine and sternum, in the height of the shoulders, and in the projection of the shoulder blades; all these have a definite relation to changes in the sliape of the horizontal ellipse. AMien the axes of the ellipse are nearly equal in length, and the horizontal plane is nearly circular in outline, the chest is short from above downwards (the floating ribs being excluded from consideration), the ribs approach the hori- zontal, the intercostal spaces in front are nar- row, the costal angle is obtuse or open, the sternum is arched, the shoulders are high, and the scapultc lie flat on the ribs. On the other hand, in proportion as the transverse axis of the ellipse exceeds in length the anteroposterior, the chest becomes long, the ribs slope downwards, the intercostal spaces in front are wide, the costal angle is acute, the sternum is straight, the shoulders are low, and the corners of the shoulder-blades project from the ribs. The former is the chest of inspiration or expansion, the latter is the chest of expiration or contraction. C INSPECTIONS. Article I. — Shape ix Health. We may conceive an idea or a type of what the perfect human chest should be. But the ideal shape is seldom realised : deviations from the type are present in nearly all persons, who Fi.'. I. Circumfeionce = SO eeiitimetLis. Tr.-.jisversc seel ion of healthy adult chest upon level of !-teriioxii)hoid articulation. nevertheless may be in soundest health. The more important of these deviations will be described under the title of subtypical. H L — THE TYPICAL SHAPE. In new born children the axes of the ellipse TYPICAL SHAPE. 7 are almost equal; the thorax is nearly as deep as it is broad, and is not far from circular. As growth proceeds the breadth of the chest increases more quickly than the depth ; so that, FiR. 2. Circumference = 40'5 centimeters. Transverse section of chest of an infant aged months. (A circle drawn within the tracing for the sake of comparison.) by the time the child has cut his milk teeth, a strongly elliptical shape is established. The disproportion between the axes becomes greater and greater (but with diminishing rate of yearly increase) until the body is fully developed. After maturity no further changes occur. 8 INSPECTION. until those morbid conditions, -which arc the almost necessary companions of old age, begin, in most persons, to alter the typical shape, and to make the chest acquire, in the second child- hood, much the same figure that it had in tlie first. The Cyrtometer is an instrument by means of which the shape of the chest may be exactly ascertained and registered. Originated, both in notion and in name, by Felix Andry,^ it was by Woillez^ that the cyrtometer was first made really usefid in physical diagnosis. I have introduced a cheap and perfect cyrtometer which consists of two pieces of composition gas- pipe, drawn out to a diameter of the eighth of an inch, and united by a piece of caoutchouc tubing. The instrument, after having been accurately applied to a given circumference of the chest, is removed, and will then afford a tracing of that circumference. The composition alloy is slightly, though but slightly, resilient : wherefore it is well to determine the antero- posterior diameter of the chest by means of ^ Manuel de diagnostic des maladies du ccenr : Paris, 1813. A book whici) I have not been able to procure, - llecherches cliuiques .sur I'cniploi d\m nouveau procede de mensuration dans la i>leurt'bie. Paris, 1857. TYPICAL SHAPE. 9 calipers, and so to correct the cyrtometer before tracing the outline. The arms must hang by the sides of the chest while the cyrtometer is adapted thereto : for when the arms are raised or held forward the shape of the chest is changed. It is needless to add that the cyrtometer is the best means of measuring the chest. In order to illustrate the statements juct made respecting the different shapes of the thorax at different ages, I will give some actual measurements, taken upon the level of the sternoxiphoid joint, and so calculated that the circumference always = 100. Ago. Actual ciirumference. Ratio of (liainetevs ' to circiuuference. Aiitcro- 1 Trans- i posterior. ! A-er-se. 3 months... 2 years 34 years 48 years 1 4f inches (37 "50. ) ... 18 „ (45 -750.)... 295 ,, (75c.) 35 „ (89c.) 26 29 26 32 26 35 \ 27 31 The chests measured were all perfectly healthy, saving the last, which was emphysematous. The semicircumference of the right half of the chest is usually a trifle greater than that of tlie left ; the maximum of difference, on the nipple level, being an inch and a quarter. The nipples 10 INSPECTION. are seated on tlio fourth interspaces. The manubrium joins the body of the sternum at an angle, level with the second rib ; the angulus Ludovici/ which affords an easy and trustworthy guide in counting the ribs. It is convenient to regard the chest as mapped out by certain vertical lines, whereby we can indicate the exact longitudinal situation of any physical sign. The following vertical lines ^vill be found sufficient : the midsternal, right or left side-sternal, parasternal (i.e. midway between the side-sternal and nipple lines), nipple, mid- axillary, scapular (i.e. the angle), and the verte- bral ofroove. The horizontal level or latitude is indicated by reference to the clavicles, ribs, intercostal spaces, nipples, and sternoxiphoid articulation. ^ II. — SUBTYnCAT. SHAPES. There are certain deviations from the typical shape of the chest which are present in a large number of persons free from any disease of the thoracic organs. And, partly for this very ^ The origin of this term is uncertain : it is commonly supposed to refer to P. C. A. Louis, but I liave not met ■with the least allusion to the sternal ridge in any of his writinf's. THE ALAR CEEHT. 11 reasoU, but chiefly because these deformities indicate puhnonaiy disease in the past, or a tendency to it in the future, they are Avorthy of all our attention. They are of five kinds, to wit, the alar or pterygoid, the flat, the trans- versely constricted, the pigeon, and the rickety chests. i. The Alar Chest. — Tt has been knoAvn from of old that many persons predisposed to phthisis Fig. 3. i5c C'ircumrerence = 59-5 centimeter?. Alar Thorax. Tracing taken from a child. The dotted line indicates the shape of the chest of a healthy child of the same size. The circumfe- reniiai measurement refers to the alar thorax. manifest their predisposition by an unnaturally small chest. Projection of the angles of the scapulae, so as to look like wings, is one sign of the small capacity of these chests, which are 12 IXSPUCTION. therefore called alar or pterygoid." The thorax of phthinodes (persons predisposed to phthisis) is, as Galeii^ S'^js, narrow and shallow ; the anteroposterior diameter is especially small. This diminntion in capacity is brought about by drooping, or undue obliquity of the ribs, hence the shoulders fall, and the length of the thorax from above downwards is increased; it is the falling of the shoulders which causes the alar appearance. Tlie pterygoid chest is often accompanied with a prominent throat, as Aretaus''^ says, due to a long neck, and the head beino; carried undulv forwards. ii. The Flat Chest. — The diminution in capacity pi-esented by the alar chest does not necessitate any great change in the outline which a horizontal plane of the thorax natiir- alh' presents. But sometimes not only the size of tlie sectional area but its shape also is chauijed, bv the cartilages of the true ribs losing their curve and becoming straight. In which case the chest looks quite flat in front instead of being rounded, the horizontal ellipse is flattened from before backwards, nay sometimes the ' Hippocrates : Epkleni'cs, bk. vi. sect. iii. par, 10. - Comment, in Hippocr. Epidem. i. pag. C2 (edit. Kiihn). *• Cans, ct sign. morb. cliron. bk. i, ch. 8, THE FLAT CHEST. 13 sternum is depressed below the level of the car- tilages so that a section would be somewhat kidney-shaped, the cartilages being curved in the wrong direction. In other respects the flat chest mostly presents the characters of the alar thorax ; but this is not always the case, inasmuch as the alar appearance is duo to increased obliquity of the ribs and falling of the shoulders, conditions which are not always present even in a well- marked flat chest, the diminution of capacity being otherwise brought about. Both the phthinoid chests (alar and flat) are often modified in shape by the presence of the transverse constriction to be hereafter described. And both are, as Van Swieten^ says, essentially the same as the actually phthisical chest, but deformed to a less degree ; moreover the loss of fat and muscle -which occurs in phthisis makes all the characters described more obvious. The phthinoid chests are Natural deformities, the tendenc^' to which is born Avitli the indivi- dual and inseparable from him. I now come to the Accidental deformities of the chest, those which have been produced by actual disease subsequent to birth.- ^ Comment, iu Apbor. 1198. - "Xaturalcm fovmationcm cam appello qure sit cum 14 INSPECTION. iii. Transverse Constriction of the Chest. — • A deformity from which few persons are wholly free. It consists in a depression, more or less deep, of the chest Wcills in front, Avhich passes outwards and slightly downwards, on both sides, level with the xiphoid cartilage, and ceases gra- dually towards the rnid-axillary line. Produced during childhood, the groove simply persists in after years. Its immediate cause is an impediment to the inspiration of air sufficient to fill the whole of the lungs. In the chapter on inspiratory dyspnoea it is explained that the upper part of the chest can be expanded and kept expanded much more powerfully than the lower part can be. Hence when the diaphragm descends and the thorax, for any reason, cannot hold out against the vacuum which wovdd other- wise be thus created, the lower part of the chest is the first to yield to the atmospheric pressure upon it from without. This comparatively feeble expansion of the lower thorax becomes manifest wlien, during inspiration, an insutH- cient supply of air enters the lungs in conse- quence of obstruction in the respiratory passages. poctorc coastri;to, loiigo collo, ct Imnicrifj alatis ; acciJeut- alera vero qua; sit cuiu curvitate scu di«tortione pectovis." Morton: Phthi^?iologia ; l>k. ii. c^'lnp. i. Lonl. 10S9, TRANSVERSELY CONSTRICTED CHEST. 15 What air can enter goes to the part of the chest most powerfully kept exj^anded, so that the feeble lower thorax gets little or none, and succumbs to the external pressure. Catarrh is that ob- stniction in most cases. Nor need the catarrli be at all severe, or the impediment at all great, inasmuch as a necessary concurrent cause of the groove is found in the yielding character of the ribs during infancy and early childhood, and especially of ribs rendered (as they so often are) jDr^eternaturally 3nelding by rickets. When the impediment is severe and pro- tracted, the depression, although proportionally great, ceases to exist alone ; other deformities are produced, a pigeon breast, or a cup-like holloAV. But when the deformity stops short of a pigeon breast, that is, when the depression is not so great as to involve the whole of the front base of the thorax from the xiphoid level down- wards, it is the abdominal viscera which deter- mine the position of the sulcus by maintaining the expansion of the base of the chest. The de- pression occurs as low down as possible, namely, immediately above the upper surface of the abdominal viscera, or what comes to the same thing, the sulcus corresponds to the vault of the 16 INSFECTIOX. diaphragm. This fact led Harrison' to propose the sulcus as au easy means of determining the upper margin of the liver. But be it remem- bered that the groove indicates what was the upper margin of tlie liver in early life ; and although the relationship of the parts concenied is scarcely altered in adult age, excepting from disease, yet any change in the position of the liver, after the furrow has been formed, docs not change the position of the furrow itself. iv. The Pigeon Breast. — The essential cha- racter of the pigeon breast is a straightening of the true ribs in front of their angles. Connected with this deviation from the natural shape arc two otlier changes, namely, first, that the sternum is thrown forwards, and next, that the greatest transverse diameter of the chest recedes towards the costal angles, that is, that the liorizontal section tends to pass from the ellipse into the triangle. The cause of pigeon breast is a long existing or frequently recurring impediment to free in- spiration while the ribs are yielding, that is, during childhood ; and especially when they are prccternaturally yielding, that is, when rickety. Chronic pulmonary catarrh (including ' Lyinloa ^Fc;!. Giiz. for ISGO, vul. xix. pp. GOD ami 77(3. PIGEON BREAST. 17 hooping cough) and chronic enlargement of the tonsils are common causes of pigeon breast : by watching the chest of a child during the long-drawn inspiration of hooping cough, the deformity may be seen in process of formation. Obstructed indraught of air renders forced inspiration needful : forced inspiration over- Fi-. 4. Circumference = 57 "u centimeters. Pigeon Breast. Tracing taken from a child of seven years. Dotted line indicates natural shape at same age. expands the upper thorax : over expansion of the thorax is marked by protrusion of the sternum, a necessa^ry character of pigeon breast. The production of the peculiar note of that deformity, the straightened ribs, is not so easily understood. We have to explain why forced inspiration should produce, sometimes a G.A. C 18 INSPECTION. simply dilated chest with arched ribs, and othertimes the more complex deformity with straightened ribs, called pigeon breast. Some- thing more than mere softness of ribs must be concerned : for either shape may be produced in the youngest children, under conditions which seem to be the same in both cases, although the results differ, But obstruction to inspiration was pronounced to be the cause of the transversely constricted chest. And so a pigeon breast is mostly accom- panied . by a well-marked transverse sulcus : as a part of which transverse constriction, the xiphoid cartilage becomes bent back so as to form a more or less sharp angle at the bottom of the sternum ; a condition which increases the similarity to a pigeon's breast. The transverse furrow, I say, is well marked ; in fact, very often there is a depression of the whole anterior half of the thorax below the xiphoid level ; in which case, the straightening of the false ribs, in front of the angles, is carried to an extreme degree. The costal cartilages of a pigeon breast are often more prominent on the right side than on the left : a condition sometimes connected with more or less scoliosis in the dorsal vertebra? ; sometimes dependent upon the f^ict that where niCKETY CHEST. 19 on the right side is liinir, free to dilate, tliere, on the left side, lies the heart. V. The lliCKETY Chest. — Rickets, on account of the part which it takes in the generation of the transversely constricted and of the pigeon chest, has already been alluded to more than once : it remains to show how rickets alone may produce deformity of the chest. Fi- ■>. R Circurufercnce = 42-75 centimeters. Rickety Chest. D /tted line in'licates shape of chest in an iuf.mt of about the same age. Rickets is a disease of infancy, and infants cannot but have a respiration chiefly abdomi- nal, because of the circular shape of their thorax, wdiich does not admit of further horizontal ex- pansion. When the diaphragm descends and rarefies the air contained in the lungs, the rickety ribs, not being able to hold out until P 2 20 INSPECTION, the chest is completely distended by fresh air passing in through tlie glottis, yield in their softest parts to the atmospheric pressure from ^vithout, and are bent inwards. Inasmuch as the softest parts of the ribs are at and near their costochondral articulations, a shallow longi- tudinal groove is formed on each side of the chest, more or less parallel with the sternum and ending just above the costal margin : a groove which may be formed without the least direct impediment to the entry of air through the air-passages. Deformities of the chest which are purely rickety tend to disappear to a remarkable degree as the health improves : deformities of more complex nature are more permanent. Article II. — Shape ix Disease. Having described the deviations from tlie natural shape of the chest which are compatible with a healthy state of its contents, I now come to those changes in shape which indicate disease of the thoracic viscera. Changes of this latter kind may be reduced into three classes, namely, bilateral, unilateral, and local. Tlie former two clashes of change indicate disease of the MLATERAL ENLARGEMENT. 21 lungs or pleiinc : the last class of change may be caused by disease of lungs, heart, serous mem- branes, or mediastina. ^ I. — BiLlTERAL CHANGErS IX SHAPE : are of two kinds, enlargement and diminution. i. Bilateral Enlargement. — By the deepest inspiration (in other words, by the greatest eleva- tion and rotation of the ribs) no considerable modification can be produced in the proportion between the length of the two axes of the hori- zontal ellipse. In order to render further en- largement of the thorax possible the ribs must change their shape ; they become more curved : the axes of the ellipse tend to become equal ; the ellipse tends to pass into the circle ; changes which are explained by the fact that of all figures possessing a periphery of fixed and cer- tain length, the circular is that which includes the greatest area ; depart from the circle in any way and the area becomes less. In order to produce bilateral enlargement of the chest, forced inspirations must be incessantly repeated for a length of time sufficient to expand the thorax to a degree beyond that which is possible by a single forced inspiration of a healthy chest. 'i2 INSPJECi'lON'. The cxperinient indicated by the annexed dia- gram (fig. 6) illustrates this point. Enlargement of the chest signifies enlai-gc- ment of its contents : and the only disease which TiL'. G. Horizontal section of chest of a cliiM two years old. (7 = rhost at rest. b = chest after fullest exiansiori possible of lungs. c = clicst alter forcible injection of air intobotli pleural cavities. Anteroposterior diameters : ('. = 10-20. h = 11 -Tc. c = 12-2C. Circumferences : « - 4T-iic. b ~ i^:c. c = 48 'oC. fulfils this condition is emphysema of the Iniigs. In a Avell-marked case of em])hysema, then, the tliorax is in a state of distension beyond ■what could have been produced during health by the deepest inspiration. The chest is almost cylindrical or semi-globular, arched before and BILATERAL ENLARGEMENT. 23 behind. The arching is usually most marked in the sternum, and is simply the result of the fact that the sternum is less able to move for- FiL Bilateral Enlargement of Emphysema. Inner line = emi)hysematous chest. Outer line = a circle drawn to show how nearly the eiaphyse- niatous approaches the circular shape. Dotted line = natural adult chest. Actual measurements in centimeters : Circumference = nat. 89' emphys. 87*75 Transverse = ,, 2\)-G ,, 27-25 Anteroposterior = ,, 22*25 ,, 2.3 •4 wards aboA'e than below : the manubrium and body of the breast-bone become bent at the augulus Ludovici. But sometimes the spine is much more arched than the sternum, and this may be the case to such an extent, in a thorax 24 inspection: highly emphysematic, that the sternum shall be nearly straight, and the front of the chest apparently flat, in consequence of the shoulders being thrown forwards by the stooping of the vertebrcC. Bilateral enlargement sometimes involves the whole length of the thorax, and then the carti- lages of the false ribs are everted, and tin costal angle is greatly increased in size. But sometimes the enlargement affects the chest above the xiphoid level only; the parts below being tolerably natural, or even depressed : when they arc depressed, the transverse con- striction is well marked, and the costal angle is diminished in size. The cause of this retraction of the lower chest has already been explained (see p. 14). This complex shape is often due to subsequent bilateral distension of the upper part of a chest which was wholly pigeon breasted early in life. Men whose employment demands unwonted exertion of arms and slioulders, sawyers for instance, tend to acquire a bihitc rally dilated chest, apart from any disease of the lungs. Habitual stooping is attended by a shape of chest which much resembles emphj'sematous enlargement. Vertebral caries sometimes goes BILATERAL DIMINUTION. 25 farther still, and reverses the natural shape of the chest, so that the anteroposterior diameter comes to exceed the transverse (fig. 8). FiK. S Shape of Chest in Angulak Curvature. Circumference = 79 'To centimeters. Transverse diameter =22' ,, Anteroposterior diameter = 26'd ,, Tracing taken from a man aged fifty-two years. ii. Bilateral Diminution. — The diminution is greater than can be produced in a healthy chest by the deepest expiration. The characters of the chest are in all points the same as those of 26 INSPECTION. the flat plitliinoid cliest but to a higher degree. Phthisis is the disease in which m-cat diminution of both sides of tlie thorax occurs. % 11. UNILATERAL CHANGES IX SHAPE. These, like the bilateral, consist in enlarge- ment and diminution. i. UXILATERAL ENLARGEMENT.— Thc UOtcS of bilateral enlargement already given arc applic- able to enlargement of one side only of the chest. The side enlarged, compared with the other, will present these characters : shape rounder ; antero- posterior diameter longer ; length from above downwards diminished, shoulder raised ; spine curved towards unaffected side. T say that tlie length of the cliest from above down- wards (thc vertical diameter) is diminished, and this is true, provided that the floating ribs be excluded from consideration : let anyone who doubts this statement inject the pleura of a dead subject with air, and watch the changes which ensue. The anteroj^osterior enlargement becomes very obvious when the physician stands behind tlie patient so as to look obliquely over his shoulders and the front of his chest. In children the best notion of the enlargement and XJNILATEllAL ENLARGEMENT. 27 roundness of the afTccted side is gained by grasp- ing both sides with the two liands, the thumbs being placed tip to tip upon the spines of the vertebrae. Circumferential measurements of the two sides arc often made, but be it remembered, first, that considerable increase in the sectional area of the chest may occur, and the length of the periphery remain the same, by the passage of the elliptical form into the circular : and next that the displacement of the mediastinum, which accompanies unilateral enlargement, thrusts the heart into the unaffected side. Add this con- sideration, too, that the walls of the healthy side must follow the anteroposterior projection of the diseased side : and then it will be plain Avhy, as a matter of fact, the perimeter of the ex- panded side often measures very little more, nay even less, than that of the side which is not diseased. The cyrtometer alone, by indicating shape as well as circumference, affords us the true means of recording the amount of a unilateral enlargement. The causes of unilateral enlargement are increase in the size of the lung or effusion of fluid into the pleura. Increase in the size of one lung occurs in vicarious hypertrophy com- pensatory of chronic disease whereby the other 28 INSPECTION. lung is put out of play : unilateral hyper- trophous empliysema, the other lung being healthv, is not found. Effusion of fluid into the ri^'. 0. 3r7u iti-5 Unilateral enlargement of cliest (rij,'lit side); artificially produced by injecting air into the right i)lcural cavity. Unbroken line — outline before injection. IJroken linu = outline after moderate iri:cTi()X. line. In many old people the heart lies low, so as to beat against the sixth interspace. By a deep inspiration the impulse can be depressed half an inch. By lying upon the left side the position of tlie impulse shifts to the nipple line or beyond it. By lying upon the right side the position of the impulse becomes uncertain.^ The Extent of the visil^le impulse (the heart beating quietly) is small, not greater than a square inch. The Force of the impulse is best estimated by palpation." ii. IIecessiox of the Chest Walls. — Is oc- casionally percei)tible, during the systole, in the third, fourth, or even the fifth intercostal spaces on the left side, close to the sternum : this, especially in persons who are very thin. U II. movements IX DISEASE. i. The Impulses. — Three kinds of impulse are seen in disease : namely the apex-beat proper, more or less changed in its characters : an im- ^ The very uncommon case of transposition of the viscera, and the still more uncommon case of congenital malposition of the heart only, may be alluded to here. 2 The topic of epigastric pulsation is discussed in chap, 6, sect. 4, MOVEMENTS OF HEART. 4l pulse of some part of the rii. If the cavity cominunicale with a bronchus, the size may most likely be less. THEOItY. 73 babies, is believed by Wiiitrich ' to take place in the glottis, when the quick and hard blow suddenly sends compressed air between the vocal cords, whereby they are thrown into irregular vibrations, ii. In like manner the cracked-pot sound which heavy percussion, upon yielding chests, produces in healthy lungs during mere expiration, is probably glottidean. iii. Another kind is but a variety of the metallic ring, and is associated with it, being produced, in air-containing cavities not wholly closed, when percussion causes a sudden condensation of the air, and so jars the tone. The mouth of the cavity enables the pressure within and without to be quickly equalised. To shut the mouth and nose prevents the pro- duction of a cracked-pot sound, but the metallic ring remains." iv. It is likely that the sudden rush of air, through the opening spoken of, is attended by a hiss which heightens the effect of the cracked-pot sound, v. A sound, practically indistingiiishable from the cracked-pot sound, is that to which Piorry has given the name of "humoral,"^ and which is said to be sometimes 1 Einleitung, p. 36. " Walshe : Diseases of lungs. 3rd edit. p. SO. ^ Percussion mediate, p. 31. 74 FEJWUSSIO^'. produced by percussion over cavities wliich con- tain both li(piid and air. The sound in question is a sort of percussion -rale, due to sphishing of the liquid in the cavit}^ A bladder, holding both air and water, if strongly percussed just below the surface of the water, yields a humoral sound. ^ HI. — PERCUSSION RESISTENCE. The sense of resistence felt by the percussing fingers is greater or less in proportion to the greater or less compressibility of the part per- cussed. Hence solids and liquids are very resistent ; air-containing parts much Jess so. It is by this means that a person percussing learns more from his percussion than does a bystander. Corvisart first drew attention to this sign ; Piorry, working out the subject, at last almost came to exalt the tactile sensations of percussion above the acoustic. But, apart from all exaggeration, there is no doubt that the sense of resistence not only re-inforces, as we may say, the sense of want of tone, but also enables us to distinguish between certain states which agree in yielding absolute dulness to per- cussion. 'J'lie great resistence of a liquid effu- sion, and the change which we often perceive on THEORY. 75 passing from the heart to the liver, are examples of this truth. Percussion Thrill. A peculiar quivering sen- sation, called by Piony the hydatid thrill,^ is sometimes produced by percussion. The finger feels as if it were repelled several times in suc- cession by a sort of elastic resistence or fluctua- tion. Most likely the onl}- physical conditions needful to the production of this thrill are a sac tightly full of thin liquid. JSTo doubt these con- ditions are fulfilled by most hydatid cysts ; but even a stomach, filled with water and hung up, will yield a thrill to percussion. Superficial and Deep Percussion. Before pro- ceeding to apply these principles to the practice of the percussion of the chest in health and disease, it will be proper to say a few words uj)on what are called Superficial and Deep per- cussion. By progressively increasing the force of the blow from the gentlest tap to the hardest the patient can bear, we influence progressively deeper layers of the part percussed. For ex- ample : gentle percussion will elicit as clear a pulmonary note an inch or two below the right nipple as above the nipple; but hard, heavy percussion w^ill produce a tone which is much 1 Son liydatiqiie : Percussion mediate, p. 32. 7fi PEJtCUSSION. less long and loud in the former than in the latter spot, the true explanation being this : not that deep percussion brings out hepatic dulness below the nipple, but that, while gentle percus- sion influences only a small depth of lung, which depth exists as well below the nipple as above it, deep percussion, influencing a much greater de2:)tli of lung, shows, by a marked difference in the length and loudness of the sounds, that a certain thickness of lung does not exist over the liver but does exist above it. SECTION II. TERCUSSIOX OF 'J'HE CHEST IX HEALTH. The pulmonary, cardiac, and mediastinal regions must be separately considered. Article I. — The Pulmonary Regiox. H L — rULMOXARY RESOXAXCE AND RESISTEXCE. i. Typical. — Frequent experiment wpon the healthy chest is the means by which to fix in the mind an idea of the sound and resistence aff'orded by percussion of the pulmonary regions. When disease aff*ects one side only we possess in the other side a standard of health to which we PULMONAliY REGION {HEALTH). 77 may refer ; even ^vlien both lungs are afFected, but one more than the other, comparison is still useful : wherefore, to contrast the same parts of the two sides of the chest becomes an important rule in the practice of percussion. ii. Sub-Typical. — But certain deviations from the type are compatible with a state of perfect health ; deviations for the most part due to the thoracic walls. The sound produced by per- cussion over the sternum, clavicles, ribs, and scapular spines, partakes of the osteal character. Ossification of the cartilages produces the same effect. The greater the quantity of soft tissue, mnscular or adipose, which covers the thorax, the greater the muffling of the sub-tympanitic resonance. Hence the percussion-note of tlic chest is clearer in front and at the sides than behind, clearer in thin persons than in fat ; it is sometimes almost impossible to get any sound deserving the name of resonant by percussing the backs of fat flabby people. When the chest- walls are yielding, heavy percussion of the front of the chest will produce the cracked-pot sound. During the long deep cxj^iration which attends coughing or screaming, the chests of children become much less resonant than natural. Any part of the chest-walls which is stiffly arched 78 PEBCUSSIOK. bears off the force of the percussion-blow from the iinderlviiiQ^ oro-ans, and thus weakens more or less the impulse which '"avc '^wish to impart to them. ^ II. — EXTENT OF PULMONARY REGIOX. The region which yields a pulmonary note extends from the very apex of the 'thorax on each side, as low as the sixtli rib in front, tlie seventh at the sides, and the tenth or eleventh behind. But sundry viscera encroach upon these limits. (i.) The Heart causes a certain extent of non- resonance in the anterior part of the chest ; see next page, (ii.) The Liver can, by hard per- cussion, be detected on the right side as high as the fifth or even the fourth intercostal space in front, and ninth or tenth rib behind, (iii.) The Spleen on the left half of the chest, below the sixth rib laterally, modifies the percussion sound, (iv.) The Stomach, especially when distended w ith gas, affords its own resonance to percussion of the lower part of the left side of the thorax as high, it may be, as the fourth rib, in the lateral region. CARDIAC BEGION (HEALTH), 79 Article II. — The Cardiac Region. The extent of cardiac percussion clulness Avill differ according to the force used in percussion, whether slight or great. Gentle percussion de- tects dulness only -svlierc the heart is uncovered by lung ; this is the area of superficial dulness. Stronger percussion detects the dulness of the heart where it lies behind the lung ; this is the area of deep dulness : and it only is indicative of the size of the heart. i. The Superficial area is roughly triangular in shape, the right side of the triangle being the midsternal line from the level of the fourth chondrosternal articulation downwards, the hy- potenuse being a line drawn from the same articulation to a point immediately above th<3 apex-beat, the base being a line drawn from immediately below the apex-beat to the point of meeting between the upper limit of liver dulness and the midsternal line. The area of superficial dulness is much diminished by a deep inspiration, much increased by the patient lying upon the left side (the same position which displaces the impulse to the left), and not much affected by the patient lying upon the right side. ii. The Deep area reaches upwards as high So FEBCUS8I0N. as the third rib (in children even as high as the second interspace); to the left about a finger's breadth to the left of the impulse ; and to the right as far as a little beyond the right margin of the sternum. But, in truth, the right limit of cardiac dulness is not very trust- worthy, the osteal and conducted pulmonary notes interfering much with the cardiac percus- sion-sound. No doubt it is sometimes quite easy to be able to discover the lower margin of the heart by percussion : sometimes a heightening of pitch and increase of resistence are tolerably well marked on passing from the heart to the liver; sometimes there is a distinct band of faint resonance between the two organs; and sometimes, in passing from the hepatic to the cardiac region, one becomes sensible of a slight increase in the intensity of dulness, and a most distinct increase in resistence, owing probably to comparative thinness of the left lobe of the liver, and its position over the stomach. When the heart and liver dulnesscs pass indistinguish- ably into each other, we must be content with assuming the lower margin of the heart to cor- respond with a line drawn from a little below the apex-beat of the heart to the point of PULMONARY llEGION (DISEASE). 81 meeting between the right limit of cardiac dulness and the upper limit of hepatic dulness, bearinij in mind how intimate is the connection between the heart and liver by means of the vena cava. Article III. — The Mediastinal Eegiox. The contents of the mediastinmn in the healthy state do not affect the percnssion-note in any way. SECTION TIT. PERCUSSION OF THE CHEST IX DISEASE. Article I. — The Pulmonary Region. Auenbrugger's Dictum. — If, over the fore- described, pulmonary region, we perceive not the fore-described pulmonary sound, equal on both sides, the force of percussion being equal, we may predicate the existence of disease where the sound is unnatural.^ This is Auenbrugger's . dictum, and comprises the whole theory of percussion. ^ "Si igitur ex prgs.lictis locis sonoris non percipitur sonus manifestus, utriqiie lateri agqualis, eidem percussionis intensitati conformis, morbosum quid in pectore latere significat." laventum Novum. § 11. G.A. a 82 PEBCUHSION. 51 I. — PULMONARY PERCUSSION-SOUND. The typical pulmonaiy-iiote may be departed from by increase or by diminution of its reson- ance. Hence two classes of unnatural sounds. Class I. — Increased Resonances. The resonance is increased by the tone be- coming tympanitic (p. 62) or clear. Istly. Tympanitic Resonance, mostly muffled, seldom or never clear, occurs when the sonorous column of air is greater than natural, a condition present in pneumothorax, and in some states of lung not easily specified. 2ndly. Clear resonance, sub-tj'mpanitic or tracheal, is afforded by the following con- ditions : — ■ i. a. Lung which is relaxed as a whole by pleural effusions, or l)y tumours or enlarged organs without the lung. But, inasmuch as the relaxed lung amid these circumstances cannot keep up its contact with the whole of its chest-wall, the extent of the clear percussion- note is small, ft. I.ung around sharply-defined pulmonary consolidations, y. Lung in which solid or lifpiid exudations are intimately min- PULMONAPiY REGION (DISEASE). 83 gled with air-containing tissue : hence the clear tracheal tones sometimes yielded by catarrh, cedema, congestion of the lung, pneumonia at its very outset or during resolution, phthisis and tubercle. ii. Cavities, filled wholly or mainly with air, when at the surface of the lung, or, if deeply- seated, separated from the surface by dense solid tissue, may afford a clear sub-tympanitic or tracheal tone. iii. Solid masses, coming to the surface, and closely connected with large air-tubes, some- times yield a clear tracheal tone : pneumonia and pulmonary tumours may exemplify this fact. Class II. — Diminished Resoxaxces. The resonance is diminished when the note becomes weaker and shorter, or more muffled. When absolute tonelessness is present, it is vain to draw (so far as the sound is concerned) any further distinctions. When a certain amount of tone is preserved, it is not only possible but useful to distinguish the degree of clearness and the height of pitch. The following conditions are attended bv diminution of pulmonary resonance : — - g2 84 PEECUSSION'. i. Extreme distension of the lung with air. Hence we should never percuss a chest whilst the patient is coughing or holding his breath. ii. Liquid and solid exudations into the lung which do more than relax it. Catarrh, oedema, congestion, pneumonia, induration, phthisis, often illustrate this fiict ; haemorrhagic in- farctus, cancerous and other tumours more seldom. iii. Collapse of the lung. iv. Liquid exudations into the pleura, whereby the lung is deprived of air, and is moreover separated from the chest- wall. But liquid is a good conductor of sound. Were resonant material behind the elTiision, percussion would briho' forth tone. The dulncss shows that there is no resonant material behind the effusion ; in other words, that the hmg is deiDrived of air. That the dulness of a pleural effusion greatly depends upon the state of the underlying lung is proved by these facts, a. A considerable pleural effusion may co exist with a percussion- sound muffled in tone but far from absolutely dull. /3. Wlien patients who are put under the influence of chloroform witli a view to para- centesis, struggle and scream, or simply breathe deeply, parts which before were wholly dull to Pulmonary region {disease). 85 percussion become resonant ; yet, puncture these parts, and liquid freely flows, y. When pleural effusion has been removed by absorption or drainage, the dulness sometimes continues to be almost or quite as great as ever, the lung remaining unexpanded. Dense false membranes have the same effect. Class III. — ^Metallic By-souxds. I. The Metallic King may sometimes be heard on percussion of pneumothorax, and of very large j^ulmonary cavities containing air. II. The sundry causes of the Cracked-Pot sound have been already set forth (p. 72). ^ II. — PULilOXARY PERCUSSION RESISTENCE. Whatever diminishes the elasticity of the part percussed increases the sense of resistence to percussion. Wherefore massive consolidation of the lung, liquid pleural effusions, and extreme distension of lung or pleura with air, afford a feeling of resistence more or less increased. ^ III. — EXTENT OF PULMONARY REGION. Over the cardiac region, percussion is em- 86 PEBCiJSSlO^\ ployed in order that we may learn whether the lung has shrunken away from the heart, or covers it, or whether the pleura contains air. In the diagnosis of adherent pleura, of phthisis, and of emi)hysema of the left lung, these signs become useful. The discovery of the position of the dia- phragm and mediastinum, depends chiefly upon percussion. These subjects will be discussed hereafter. Article II. — The Cardiac Regiox. Disease of the heart itself diminishes or in- creases the area of cardiac dulness. i. The area is diminished in the very uncom- mon case of [)ncumopericardium, clear resonance superseding the natural dulness. Atrophy of the heart does not much affect tlie area of dulness. ii. The area is increased in enlargement of the heart, and in pericardial effusion : for the diagnosis between these conditions the reader is referred to the second part. Moreover, the area of dulness may be alto- gether displaced, in consequence of displacement of the heart (p. 41). CARDIAC UEGION (DISEASE). 87 Article III. — The Mediastina. Dilatation of tlie large vessels, aueuiysms, and solid tumours in the mediastinum are sometimes the cause of more or less dulness to percussion "where there should be resonance ; as will be further shown in the second part. ■*' Pulsa, diguo.scci'c cautus Quid sol id urn crcpct." Persius : V. '2i. CHAPTER Y. AIT3CULTATI0X. SECTION I. INTRODUCTORY. Article I. — Historical. AUSCULTATION existed not before Laeiniec ; and " clinical observation, though never blind, had been always deaf.'^ True, a few passages are found in the writings of earlier physicians ^ which speak of sounds heard in the ^ The foUoAving are the chief notices of auscultation which I have found in authors older than Laennec : — i. Rales. Hippocrates, Progn. § 14 : De Morbis : ii. § Gl. Caelius Aurelianus, Acut. Morb. lib. ii. cap. 14. ii. Leather sound of pleural friction, and sound of lung sliock. Ilippoc. de Morbis : ii. § 59 ; ibid. iii. § 7. iii. Succussion-splash. Hippoc. de Morbis : i, §§ 6, 15 ; ii. § 47 ; iii. § 1(3. De Intern. Affect. § 23. Coacte Pnenot. 424. De Locis in Homine : § 14. iv. Metallic tinkle. Willis : Phar. rat. part II. ; sect. i. : cap. 13. 1674. V, Pneumonic crepitation. Van Swieten : Comment, in Aphor. 826 : 1745. vi. Respiration bruissante. Double : Senieiologic gene- rale, vol. ii. p. 31 : 1817. Sec an amusing tale of Double's ntSfORICAL. 89 chest, but tlie observations remained mere curiosities, Avbolly "without influence upon prac- tical medicine. It is interesting to mark tlie dawning of the great discovery. Corvisart had studied the different forms of enhirgement of the heart, and had endeavoured to distinguish between active and passive enlargement; to this end the character of the impulse was carefully observed. Bayle, a disciple of Cor- visart, was in the habit of applying to the heart-region his ear rather than his hand,^ inasmuch as a heaving impulse is more readily claim to tlie discovery of auscultation, in Lond. ^led. Gaz. vol. xi. : p. 1S9. vii. Heart sounds are briefly alluded to by Forestus (died 1597. 0pp. omnia; edit. 1653 : vol. ii. p. 241), Harvey (De motu cordis ; cap. v.), Stalpart vander Wiel (Observ. rar. i. obs. 36), and others. The clearest account of a murmur is that by James Douglas (Phil. Trans, for 1715 : No. 344 : quoted by Norman Moore. St. Barthdl. Hosp, Eep. vol. 26, p. 165). See also Eutherford, as quoted by Allan Burns (Dis. of Heart, 1S09 : p. 187 ; a case of mitral disease). viii. Sounds of foetal heart. Mayor : quoted by Laennec, ii. p. 459. ^ "I have found this method nowhere alluded to, and Bayle was the first whom I saw employ it, when we followed the practice of Corvisart together. The professor himself never put his head to the chest." Auscultation mediate, 2me edit., vol, i. p. 5. Do AUSCULTATION. detected thereby, be the reason what it may. Laemiec, Bayle's friend and fellow-student, adopted the same method. Laennec had under- gone a fifteen years' training in the hospitals of Paris, when, in 1816, he "was consulted " bj- a young person who presented the general symp- toms of disease of the heart, and in whom pal- pation and percussion gave no information, on account of the patient's fatness. Her age and sex forbade an examination of the kind just mentioned (by putting the head to the chest), when I remembered a well-known acoustic fact, that if the ear be npplied to one end of a plank, it is easy to hear a pin's scratching at the other.^ I conceived the possibility of employing this property of matter in the present case. I took a quire of ])aper, I rolled it very tight, and applied one end of the roll to the prsecordial region ; then leaning my ear on the other end, I was surprised and pleased to hear the beating of the lieart much more clearly than if I had applied my ear directly to the chest."- He had ' This remark wouUI seem to imply tliat Laennec had put his head to llic clicst. in order "to hear the beating" of the lieart : a jdirase which he constantly uses : compare Auscultation mediate : vol. ii. pp. 385 sqq. - Auscultation mediate : vd. i. i>. 7. Montaigne's Methods. 91 discovered auscultation. At tlie Hopital Neckcr he explored the new world gained for science ; and in 1818 he read a "Memoir upon Ausculta- tion by divers acoustic instruments employed as means of investigation in the diseases of the thoracic viscera^ and especially in pulmonary Phthisis." In 1819 he published the first edition of his book on Mediate Auscultation ; ^ and, in 1826, the second. Article II. — Methods of Auscultation. It was by means of an instrument- that Laeunec was enabled to discover the powers of Auscultation. Since his day the stethoscope has been discarded by many persons, who, pre- ferring immediate to mediate auscultation, apply (Essays, ii. chap. 37) remark tliat "the physicians have no speculum matrieis by %yhich to discover our bi'ains, hings, and liver," has ceased to be true with respect to the lungs : the stethoscope is our speculum pectoris. ^ Eene Theophile Hyacinthe Laennec : De T Auscultation mediate ou traite du diagnostic dcs maladies des pouraons et du coeur, fonde principalement sur ce nouveau moyen d" exploration. Paris, 1819. For title of second edition, see p. 51. - One of those instances of the door or gate (in Bacon's phrase : Nov. Org. ii. chap. 39) "which assist the opera- tion of the senses,"' 92 AUSCULTATION: the ear directly to the chest. And doubtless the sounds are heard loudest in this way ; they are weakened by conduction through a stetho- scope. However, the drawbacks to immediate auscultation are great, and chiefly these : the impossibility of listening to every patient's chest without tlie interposition of some kind of vestment, which, besides being a bad conductor of sound, gives rise to divers noises of its own ; the impossibility of applying the ear to every portion of tlie chest ; the impossibility of localising sounds with sufficient accuracy. Moreover, we must not take for granted that the ear, applied directly to the chest, will needs conduct the sounds more truly than will a stethoscope. Heart-sounds and murmurs, in particular, often acquire by immediate ausculta- tion, a booming, indistinct character Avhich does not belong to them. When this is the case, what we lose in mere loudness by using the stethoscope is well repaid by the greater definiteness of what we hear. No doubt a person may become a skilful auscultator who listens with his unassisted ear ; but let mediate auscultation ever be considered the rule of practice, and immediate the exception ; the physician making of the stethoscope, not a STETHOSCOPES. 93 crutch, but a staff, which he uses when he has it, yet when he has it not he does not want it. Stethosco23es are soUd (rods) or tubular (pipes) ; tubular stethoscopes are rigid or flexible j flexible stethoscopes are single or bin- aural ; so that there are four kinds of stetho- scopes in use. Solid stethoscopes are made of wood ; rigid tubular stethoscopes of wood, gun- metal or vulcanite ; flexible stethoscopes of caoutchouc. A flexible stethoscope conducts wdiolly by the column of air contained within the tube ; when the pipe is plugged, it conducts no longer. fScarcely need it be said that rigid pipes conduct partly by the bore and partly by the tube ; and that solid rods conduct wholly by the solid. To compare the rigid with the binaural stetho- scope would require much more time and study than the subject seems to deserve : a man rightly prefers that stethoscope to which he is most accustomed. The following pages relate to auscultation with a rigid stethoscope, tubular or solid. U AUSCULTAIION, Article III. — Murmurs ix General. A murmur is a sound produced by the flow of fluid, liquid or gaseous, along a tube. Fluid flowing, however swiftly, along a tube of equal caliber throughout, produces no sound. The condition necessary to the production of an onward murmur is a sudden change in the caliber of the tube. I. Onward MuR.Mua. — A jet of fluid flowing swiftly enough, out of a narrow orifice into a wider space, is called a fluid vein.^ The mole- cules of a fluid vein are agitated by movements which cause the vein to vibrate, and which arc productive of sound. The loudness of the sound depends upon the swiftness of the flow : the quality of the fluid, and the size of the orifice are of import only inasmuch as they exert an in- fluence upon the swiftness of the flow. The sound is carried farthest in the direction of the flow, hence the name onward murmur." II. Backward ^[urmur. — Fluid flowing, how- ever swiftly, from a wider into a narrower S])ace, ' Felix Sivart : Annales de cliiinie et de pliy.sique : 2ii'l series, vol. oO. p. 3^7. Taris, 1833. - CliauYcau : Gazette med. de Paris. 18r»8, pp. 247, ct s'lq. i MVEMUHH IN GENERAL. 95 produces no sound. Ijiit if the stream break, swiftly enough, upon a bevelled edge, like unto that of a whistle, the fluid becomes vibrating and sonorous. If the bevelled edge surround a con- siderable constriction within the tube, the sound is carried farthest in a direction against the flow of fluid : hence the name, backward murmur.^ III. Musical Murmurs. — Murmurs of either kind sometimes acquire the character of tone ; these are called musical murmurs. i. A musical murmur is usually due to the consonance of a solid, which pl-iys the part of the reed in an instrument, and which is set in vibration by the sonorous fluid stream. ii. A musical murmur is sometimes due to vibration of the fluid vein alone ; especially when the tube is ciu'ved so as to form a semi- circle just beyond the constriction which causes the fluid vein. SECTION II. AUSCULTATION OF THE LUXGS AND PLEUR.E. Auscultation of the surface of the chest is practised wdth reference to three kinds of sounds : i. the Voice, as it is heard over the ^ Bergeon : Des causes et du mecanisme dii bruit de ouflae, p. 25, Paris, 1868. 96 AUSCULTATION. thorax : ii. the sounds of Breathing : and iii. the sounds produced in the Pleura. Article I. — Thoracic Vocal Sounds. The voice, as it is heard by auscultation, is usually called the Vocal Resonance : a phrase which we inherit from Laennec, and v/hich in- volves a theory not yet discussed. It is useful to study the vocal resonance before the respira- tory sounds; inasmuch as the origin of the sound is, in the former case, clear and indisputable, but, in the latter case, not so. Let us follow the historical order : the first fact which Laennec discovered by auscultation concerned the vocal resonance. U I. THEORY OF VOCAL RESONAXCE. The prime distinction between the different kinds of vocal resonance lies in the degree of change which the tone of the voice has under- gone by the time it reaches the surface of the chest. Whence two classes of vocal resonances ; the muffled (or more changed), and the clear (or less changed \ Clear vocal resonance, being usually heard over the large air-tubes, is also called bronchophony. rOGAL RESONANCE. 07 The term, clear, as applied to vocal resonance, expresses a complex notion. Using words which will be explained a few pages onwards, vocal resonance may be called clear in respect either of the fundamental tone of the voice, or of th articulated over-tones. The fundamental tone clear in proportion as it retains its musical laryngeal character ; and the articulated over- tones are clear just in proportion as they are distinct ; after transmission through the lung. i. Muffled Vocal Eesoxaxce. — The ear, applied to the chest of a person who is speaking, perceives a humming or buzzing sound : the laryn- geal tones have lost their clearness, and distinct- ness : their loudness also is much diminished : so that a weak voice is not heard at all. ii. Clear Vocal Kesoxaxce, or Broncho- PHOXY. — What vocal resonances shall be deemed clear enough to form a class apart from muffled vo3al resonances is an arbitrary arrangement. The line is drawn at that amount of clearness which the voice possesses in a certain proportion of perfectly healthy persons, when listened to in the upper part of the interscapular regions. There, in some people, we hear nothing dif- ferent from what we hear over the rest of the chest ; but in some we hear a vocal resonance g,a, h 98 AUSCULTATION. which is comparatively clear, that is to say, which approaches more nearly in character to the sounds heard over the larynx or pharynx. Bronchophony then I define to include the clearest vocal resonance ever heard over the healthy chest, and all degrees of clearness greater than this. For disease sometimes affords thoracic vocal sounds which are far clearer than any heard in health ; sounds which are not more muffled than tho ie heard over the larynx. And, just as the least clear vocal resonance, which can be called bronchophonic, is that which is heard over the healthy bronchi ; so does auscul- tation of the larynx afford a standard of the most clear vocal resonance. For it is seldom possible that the voice should be heard over the chest, in health or in disease, with greater loud- ness or clearness than over the larynx. The clearness of vocal resonance is not de- pendent upon its loudness ; the weakest sounds may be as strongly bronchophonic as the loudest. Indeed, with respect to articulated sounds, the two cliaracters (.f clearness and loudness arc often opposed, so tliat tlie broncho- phonic resonance is rendered indistinct by its loudness ; the ground-tone of the voice drowns the articulated over-tones. When this is the VOCAL BESONANCE. 90 case, we must seek to set aside the element of loudness : a consideration which leads us on to the topic of Whispered Bronchophon3\ Xow whispering is articulation pure and simple. And the bron- chophony of whispering is often clearer than that of the voice loud as usual. Sometimes bronchophony cannot be detected at all unless the patient whisper. Pectoriloquy. The name given by Laennec to that physical sign which was the subject of his earliest publication relative to auscultation. Pectoriloquy, having been the first-fruits of his discovery, no wonder that he always clung with affection to the name and sign. Laennec meant by pectoriloquy, a very clear vocal resonance having two characters ; first, the being conveyed, as it w^ere, along the bore of the stethoscope to the ear of the observer : next, the being heard over a very small space of the chest. Loudness of the vocal resonance has nothing to do with pectoriloquy; a whisper may possess the two notes of apparent transmission and exact circum- scription. But the distinction drawn by Laennec between pectoriloquy and bronchophony is un- satisfactory. The desire of making pectoriloquy to be a sign pathognomonic of accidental cavity K 2 100 A UlSCULTA TION. within the king led Laennec to speak of perfect, imperfect, and doubtful pectoriloquy : now he himself confesses that he could not distinguish doubtful pectoriloquy from bronchophony. In short, he wavered in his own definition ; a fact known to his pupils.^ If we are to retain the word pectoriloquy in use, it can only be by taking it to signify strictly breast-speech, that is to say, bronchophony which is especially clear and dis- tinct in respect of the articulated over-tones. iEgophony. Another and somewhat similar kind of bronchophony is that which Laennec called eegophony, in order to indicate its like- ness to the bleating of a goat : still closer is the comparison which he makes between segophony and the voice of Punch. Laennec's idea of cego- phony, like that of pectoriloquy^, was confused by his desire to make the sign pathognomonic ; he thought it indicative of pleural effusion. His own pupils could not follow him : " nor will we ; for ?cgophony is nothing but bronchophony with a nasal quality more marked than usual. Vocal resonances are mostly heard best by auscultation with the ear alone : sometimes, ^ Harrison : Lond. Med. Gaz. 1836 : vol. xix. p. 457. 2 Piorry : Percussion mediate, p. 84, VOCAL RESONANCE. 101 indeed, the stethoscope altogether fails to con- duct them. The same is true of auscultation of a pitchpipe's sounds. Vocal resonance, though useful chiefly as a confirmation of the notions acquired by auscul- tation of the respiratory sound, sometimes pos- sesses an independent value. When a patient breathes so as to produce scarcely any sound, or breathes noisily, or otherwise unnaturally, then we call in the aid of vocal resonance to remove our difficulties. A kind of artificial vocal reson- ance is produced by causing the patient to sound a pitch-pipe during auscultation. H II. — PHYSICAL CONDITIONS OF VOCAL RESONANCE. Vocal resonance has been defined to signify the voice as it is heard upon the surface of the chest. Wherefore two points demand examina- tion : What is the voice ? How does it reach the surface of the chest 1 The larynx is a reed instrument which is capable of sounding a fundamental tone. In speaking, sundry overtones are produced along with the chief tone. The vocal chords may vary the pitch of the tone they produce, but no change 102 A USCULTATION. in the quality (timbre, clangtint) of the sound can be effected in the larynx itself. That is to say, the larynx cannot articulate. The mouth, however, by varying its shape, can be made to resound to different laryngeal tones ; and it is to different associations of these tones, occurring in the mouth, that articulation is due.^ The next consideration concerns the manner in which the voice reaches the surface of the chest. The sonorous undulations generated within the glottis and articulated above it, pass upwards and downwards ; and just as the pharyngeal vault, the nasal fossre, and the mouth play the part of an arched roof, so does the trachea that of a speaking-trumpet. The inner surface of the windpipe reflects the vocal vibra- tions which would otherwise diverge and con- fines them in the tube, so that the voice is carried in all its fulness down the windpij^e ; and would be heard at the bifurcation of the trachea, as well as in the mouth, were it not for two circumstances, n^miely, that the current of air is in a direction reverse to the propagation of the sound, and that the articulated tones have ^ Tyndall : Sound, pp. 197 scq. See a curious anticipa- tion of this doctrine in Shaftesbury's Cliaracteristicks : Soliloquy, part 3, sect, 1. First publisheil in 1710, VOCAL llEl^ONAlstCE. 103 to pass tlirougli the narrow glottis. Hence two causes of change in the thoracic voice to begin with. But the analogy of the speaking-trumpet ceases at the bifurcation of the trachea. Clear vocal resonance is not heard, in healthy peo})le, beyond the neighbourhood of the larger bronchi : natural bronchophony ceases there. We have now to consider the physical conditions of the lungs. First of all we must remember that they are ke^^t in a state of permanent openness or distension which favours the conduction of sound along the air-columns within the tubes. But, on the other hand, the progressively in- creasing number of air-tubes renders the sound they conduct to any "given spot progressively weaker : the voice is no longer confined within a single cylindrical tube, but is spread out and diffused by an enormous number of minute diverging tubes, having a total sectional area very much greater than that of the single tube whence they spring. Probably the diminishing rigidity of the walls of the bronchia diminishes their reflective power : probably the increasing surface of tissue exposed to the sonorous vibra- tions increases the conduction of those vibra- tions, by the tissues away from the air-columns. 104 AUSCULTATION. Wherefore tlie A'oicc, heard over the surface of the lungs, has lost both in clearness and loud- ness, is both weak and muffled. But why is the bronchophony of the larger tubes not heard above the vesicular vocal resonances ? Because the pulmonary tissue in its naturally distended state, consisting of incessant alternation of air and membranous walls, is a bad conductor of sound, whether as to loudness or to clearness of tone ; and the bronchophony must pass straight through the lung. Accidental Broxchophoxy and Pecto- HiLOQUY. — Accidental bronchophony is the name given by Laennec ^ to the bronchophony which is heard at a spot where nothing beyond muffled vocal resonance would be heard in a healthy chest. Accidental bronchophony is due to in- creased conducting or reflecting power in the lung tissues. i. Increased Conduction. — We have learned that vocal resonance, heard at the surface of the lung, is muffled in consequence of having to pass through badly conducting material, namely, the air vesicles and bronchiola. Now the conducting power is increased by whatever increases the ^ Auscultation mi''<]i;itc vol. i. p. (k'. Vocal hesonanc^. io5 homogeneity of the structure of the huig, or, in other words, by whatever makes the lung ap- proach nearer to simple solid or to simple air. The former case only, that of solidification, will be discussed in this place : the latter case of aerifaction, is complicated by conditions of reflection. Solidification includes collapse of the lung, exudations into it, and new growths. Simple collapse brings the larger bronchia nearer to the surface, and so promotes bron- chophony. Such is not the case in exudative consolidations, yet they also increase the lung's conducting power. The note of a pitch-pipe, sounded between the lips, is heard much more clearly over pneumonic lung than over healthy lung. A solid nodule, close to a large bronchium on the one side, and reaching the surfiice of the lung, has been known to conduct (perhaps to magnify) the bronchial voice so well as to render it deserving of the name of pectoriloquy.^ A coincident pleural efi'iision brings in a new ele- ment of heterogeneity. The sonorous columns of air in the bronchia have to give up their vibrations to the condensed lung, which yields them in turn to the fluid contained in the ^ Walshe : Diseases of lungs, p. 147. 103 AUSCULTATION. pleural sac ; from the fluid effusion they have to pass through the solid Avails of the chest. Yet liquid is a good conductor of sound : over a serous pleural effusion -sve may sometimes hoar accidental bronchophon}- so clear that avc can distinguish any number the patient speaks. Nevertheless the bronchophony often becomes weakened and muffled. Moreover, it sometimes becomes changed in quality by passage through the pleural fluid, that is to sa}^ it becomes ?ego- phonic or amphoric, according as the fluid is liquid or aerial. ii. Increased Keflection. — The voice is con- veyed along and within the air tubes, by constant reflection of its sound-waves. In the spongy structures reflection ceases, so far as the human ear is concerned. But if they be re- placed by a cavity, not beneath the bronchia in reflecting power, bronchophony will take the place of a muffled vocal resonance. If the cavity be large, and its inner surface apt for reflection, the bronchophony (" reverbs a hollowness ") acquires a prolonged hollow and reverberating character, which, when very well marked, takes part in making up the sign of Pectoriloquy, as before defined. Accidental Bronchophony is oftentimes clearer VOCAL RESONAKCE. 107 than the natural bronchophony heard over the vertebra prominens, sometimes clearer than the tracheophony heard just above the sternum, very seldom clearer than the laryngophony heard over the larynx, never clearer than the voice from the mouth. ^Egophouy. — i. Laennec believed that the smaller bronchia, especially those with Avails bereft of cartilage, become flattened by a pleural effusion, so as to behave like the reed of a bassoon or hautboy. Thus the bronchial tree becomes a sort of wind instrument termi- nated by a multitude of reeds in which the vocal resonance quivers.^ ii. Wintrich believed that the ordinary nasal character in bron- chophony is due to a strong vibration of the walls of bronchia so small that it is accom- panied by actual collision of their opposed internal surfaces. The vibrating column of air, broken incessantly, yet too rapidly for the in- tervals to be distinguished by the ear, imparts a nasal sound. When the interruptions to the sound become sensible to the ear, they yield the bleating character." iii. Stone believed that it is not the pure laryngeal fundamental tone of ^ Laennec : Auscultation mediate, vol. i, p. 79. ' Wintrich ; Einleitung, pp. 119, 146 scq. 108 A USCULTA TIOK. the voice which aftbrds regophony, but only the articulated over-tones, Avhether whispered or spoken aloud. A layer of fluid in the pleura, while it stops the larger and coarser vibrations of the ground-tones, lets pass the finer and closer undulations of the high harmonics.^ iv. For my own part I believe that fegophony is no more than a high manifestation of the nasal quality of bronchophony : that nasal bronchophony is really a rhinophony," which acquires its nasal character by resonance of the voice w^ithin the pharyngeal vault : and that a liquid effusion acts, not improbably, in the manner indicated by Stone. To conclude : excepting a few uncommon cases of pectoriloquy (p. 106) it seems that resonance (in the strict acoustic sense) has nothing to do witli the production of vocal resonances in health or disease ; that in fact the phrase, vocal resonance, can be continued in use only with the distinct understanding that the word resonance is emploj'cd in a sense quite 'peculiar to the nomenclature of ausculta- tion. 1 W. II. Stone : St. Thonas' Hosp. Reps. 1871, vol. H. p. 187. ' A term of Laennec'.s : A use. inal. i. \^. I'JG, VOCAL RESONANCE. 109 ^ III. — VOCAL RESONANCE IN HEALTH. Vocal resonance over the pulmonary regions h weak and muffled. Behind, opposite the trachea and the bronchial bifurcation (over the upper dorsal spines), bronchophony is heard in many healthy persons : a circumstance probably accounted for by the fact that only solids inter- vene between the windpipe aild the surface of the body at the spot indicated. Under the clavicles, near the sternum, the vocal resonance (especially on the right side, and in women) is often bronchophonic. The voice, in women and children, often cannot be heard over a large part of the chest. U IV. — VOCAL RESONANCE IN DISEASE. 1. Increased Clearness of Resonance : Acci- dental Bronchophony. — i. Whatever increases the conducting power of the spongy structure of lung increases the clearness of vocal resonance. It has been already shown that the conducting power of lung is increased by whatever diminishes the heterogeneity of its structure. Diminution of the quantity of air contained in a part of the lung, diminution of the number of alveolar septa ; either of these changes will be attended by in- 110 A USGULTATION. creased homogeneity. For these reasons it will be apparent why consolidation of lung and cavity are the two causes of accidental bronchophony. Consolidation of lung includes simple collapse, ha^morrhagic infarctus, pneumonia, cirrhosis, phthisis, tubercle, and cancer. Cavities are due to phthisis, dilatation of bronchi, gangrene, or great emphysema. ii. Cavity, however, often introduces a new clement into the case, namely, increased reflec- tion. But let it be re-iterated that, in practice, the bronchophony of cavity cannot be distin- p-uished, with absolute certainty, from that of consolidation. iii. Collapse of lung, attended by bron- chophon}'', will be extensive enough to include large open air-tubes. And this is seldom tlie case, unless the collapse be due to pleural effu- sion, liquid or aerial. So that in this case, vocal resonance, whether bronchophonic or not, be- comes subject to conditions imposed upon it b}'' the divers kinds of pleural effusion : for instance, bronchophony sometimes becomes a?gophonic, sometimes amphoric. Yet simple changes in the degree of loudness and clearness of vocal resonance are more connnon, especially in the case of liquid effusion. VOCAL BESONANCE. Ill 2. Diminished Clearness of Resonance is an iniimportant sign, except it be known to have supervened upon resonance unnaturally clear. And, in such cases, the soniferous power of the bronchi is at fiiult, in consequence of collapse, or of obstruction by mucus, blood, or exudation. 3. Pectoriloquy was deemed by Laennec to be the infallible sign of an accidental cavity within the lung (pp. 99, 106), a proposition by no means so universally true as he thought. Yet we may accept it as a rule to which there are exceptions : for instance, small superficial con- solidations, closely connected with large bron- chia, may increase vocal resonance by true con- sonance, after the manner of a sounding board, so as to yield perfect pectoriloquy, A lesion, which causes pectoriloquy, lies at the surface of the lung. ^Egojjhony was deemed by Laennec to be the infallible sign of a thin layer of liquid in the pleural sac. Our pathognomonic signs are so few that we may well regret to think how many considerations forbid us to accept this doctrine as being universally true. In the first place, it is not easy to define segophony with exactitude (p. 100). Again, mere consolidation (such as that left after complete absorption of pleural 112 AUSCULTATION. effusion) \vill sometimes afford "well-marked segophony. Lastly, it certainly does not always attend thin layers of liquid in the pleural sac. Resonance of Cough and Cry. In infants the thoracic resonance of the cry sometimes affords useful evidence of disease ; for instance, the cry heard through hepatised lung is strongly bronchophonic. In like manner, the resonance of cough sometimes acquires value whan other siecns are absent. Much of Avhat has been said of the voice applies to the cough and cry. Article IL — Respiratory Sounds. 51 i. theory of respiratory sounds. The fundamental division of respiratory sounds is the same as that of vocal resonances. The respiratory sound, heard over the larger air-tubes, differs, by the possession of a certain quality, from that heard over the spongy structure of lung. Wherefore the former is called Bronchial, and the latter Vesicular breathing. i. Vesicular Breathing.' — The ear, applied ^ Term suggested by Meriadec Laennec to replace the " bruit respiratoire pulmonaire " of Rene Laennec. Notes et additions, kc. Paris, 1836 : p. 18. nESPIIiATOIlY SOUNDS. 113 to the breathing chest, detects a sound which may be defined by the negative property of not possessing the bronchial quality. Wherever breathing king is in contact with the chest-wall, there we hear this sound. Its inspiratory por- tion has a duration equal to that of the inspira- tory movement ; the expiratory portion follows after the shortest possible interval, has a dura- tion only one-fourth or one-fifth of that of the inspiratory sound, and is much less loud than it. The sound is loud in proportion to the rapidity and depth of the breathing. The louder the sound the greater becomes the relative duration of the expiratory portion : but mere prolongation of expiratory sound (the breathing remaining vesicular) is a sign of no importance. Sometimes the tranquil breathing of adults is unattended by expiratory sound. Sometimes, especially in fat middle-aged women, the breath sound can be hardly heard at all. Loud vesicular breathing was called Puerile by Laennec.^ Sometimes the inspiratory sound, instead of being continuous, is divided into three or four distinct parts : sometimes the expiratory sound likewise is duplicate : this is called jerking ^ Auscultation mediate, vol. i. pp. -49 et sqq. U. A. 1 114 AUSCULTATION. breathing : a sign of uncertain cause and no importance. Sometimes the chest is felt to bcavc with in- spiration before any sound is heard : this has been called deferred inspiration. Sometimes the expiratory movement is f)ro- longed in consequence of obstruction to expira- tion ; when this is the case, the sound is pro- longed also. ii. Bronchial Breathing. — Bronchial breath- ing, like bronchophony, is heard about the seventh cervical, and three or four upper dorsal vertebnc in many healthy persons : especially in tliose "who are thin, in women, and in children.^ Bronchial breathing is distinguished from vesi- cular breathing by the possession of a special (juality of sound, -which is best called hollow or reverberating. - * Laennec : Auscultation mt'tliate, vol. i. pp. '^5, i'6. - Laennec : Auscultation mediate, vol. i. p. 55. But as P. ]\I. Latham says, "The sounds can only be leai-nt by the practice of listening to them. It is nseless to describe them. They are simple perceptions of sense, which no ■words can make plainer than tliey are, when the ear has once become familiar with them. I must leave you to be your own self-instructors, and recommend you to be con- stantly practising auscultation for the purpose." Discai^es ( f tlic Heart : Lc<-turc 1, liESritiA TOR Y SO LINDS. 115 The loudness of bronchial breathing is an un- mportant property : the special quality is as avcII marked in weak respiratory sounds as in the loudest ; nay, loudness of sound often j^i'oves an impediment to the detection of that quality which alone constitutes the note of bronchial breathing. The expiratory sound, although usuall}^ less loud than the inspiratory, often mani- fests the special quality better. Not that this is always the case, sometimes (but not often) the bronchial quality is possessed by the inspiratory sound in a higher degree than by the exj)iratory. Sometimes (but seldom) the expiration of bronchial breathing is wholly inaudible, the inspiratory sound being, at the same time, highly bronchial : a proof, were proof needed, that prolonged expiration is no essential pro- perty of bronchial breathing. Bronchial breathing sometimes loses its pe- culiar quality by conduction through stetho- scopes of a certain make : and an instrument with a bore too large is especially likely to bring about this unfortunate result. In such a case immediate auscultation must be practised. Laennec^ gave the name Cavernous to that ' Auscultation mediate, vol. i. p. r.7. 1 2 116 A USCULTATION. kind of breathing which possesses the bronchial or hollow quality in a high degree : not that cavernous breathing always indicates cavity. Another kind of bronchial respiration, which has been named Tubular/ is characterised by a well-marked whiffing quality. It is most fre- quently heard over hepatised lung. By the name of souffle or puff, Laennec"- de- signated a phicnomenon sometimes superadded to bronchial, cavernous, or tubular breathing. The air during inspiration seems to be drawn away from the ear of the observer, and during expiration to be puffed back again : a sign of no importance. By the name of souffle voile, or veiled puff, Laennec^ designated a phsenomenon which it has puzzled his successors to identify. It is a modi- fication of the puff, he says, in Avhich each vibra- tion of voice, cough, or breathing seems to shake a sort of mobile veil placed between a lung cavity and the observer s ear. Skoda^ believed that Laenncc referred to the condition of an ^ The word tubular was fir.st used by Laeiiuoc, with respect to the cough. Auscultation meJiate, vol. i. p. 90. - Auscultation iniMliato, vo^ i. pp. .')8. 421, i'lo. •■' Ibid. pp. i»9, 213, 421, 12;3, -149. ' Markhaiii's translation, p. 99. UEHPIRATOHY >SOUXm. 117 inspiratory breathing sound, indistinct at its commencement, and suddenly becoming bron- chial. Skoda's veiled pufF is not very un- common.^ ^ II. PHYSICAL CONDITIONS OF RESPIRATORY SOUNDS. The physical conditions of vocal resonance, as already set forth, and those of the breathing sounds are very much alike. The main ques- tion, which we have now to treat, concerns the source of the breathing sounds ; that is to say, the mariner in which they are produced. I may as well at once declare that, for my ow^n part, I hold to Beau's doctrine in this matter.- Let the reader call to mind the fact that whispered ^ All reference to some terms in frequent use (sucli as harsh, coarse, rough) applied to breathing sound, has been eschewed, because their meaning is ill-defined and not cor- respondent with clear and distinct ideas. Even supposing that any such word denote a definite quality of sound, unless it signify some certain and constant condition of lung, to recognise the sound is useless. But when we read about "la rudesse de I'inspiration, qui devient rapeuse, granu- leuse, au lieu d'etre legere, moelleuse, et caressante a I'oreille,'' we seem to have passed beyond common sense into mere fancy and fine writing. 2 Beau : Archives gen. de Med. Aug. 1S34, 118 A UtiOULTATlON. Bounds (in other words, sounds produced by respiration in the inactive glottis) are audible all over the chest, and he will then be more read}" to agree that it is at least possible, not to say probable, that the ordinary unwhispered respiratory sounds are produced in the same place. The lungs in the chest are distended : the tubes are all open, apt for conduction and reflection. The passage of breath through the narrow glottis into wider spaces above and below, produces sonorous fluid veins inspiratory and expiratory. This glottidean breathing mur- mur, modified by resonance in the pharyngeal vault above and the windpipe below, is con- ducted down the air tubes just as the loud or whispered voice is carried. And all that lias been said concerning the conduction and reflec- tion of vocal resonance applies to the respiratory sounds. It is convenient to look upon the glottis as the only source of tlie breath-sound.^ But, ap- ^ "The facts are not easy of explanation. Reasoning resembles the universal solvent of the alchemist ; if wo believe nothing but what will withstand the attack of our logic, ve shall believe very little. Yet it is desirable, in spite of reasoning, to hold some opinion concerning the source of the breathing sounds, and as the result of Irng experience in teacbing students, I can s^ny that the simple HESFinATORY ^UiryjjS. 119 plying the general principles of riiurmur-prodiic- tion, as before laid down, to the air-passages, we must admit that the nose, mouth, throat, any unevenness of the windpipes, the bifurcation of tubes, and the mouths of air-sacs, must all be deemed possible causes of onward or back- ward murmurs. Bronchial breathing is the glottidean sound as heard in the larger bronchia. Vesicular breath- ing may be supposed to lose the bronchial hollow quality in consequence of the badly conducting material (the spongy texture of lung) through which the sounds have to pass. Puerile breath- ing implies louder glottic sounds than usual and a very open state of lung. Cavernous breathing is bronchial breathing rendered more intense by the reverberation of a cavity. Tubular breath- ing is hard to explain ; we do not know how it acquires its peculiar whiffing character.^ The glottic theory is sufficient for all practical purposes. ATlietlicr the theory be true is another thing, hut 'tis so like truth, 'twill serve our turn as well."' St. Bartholomew's Hospital Eeports, vol. xxvi. p. 105. ^ Perhaps the following hypothesis meets the case. "When disease consolidates the air-vesicles and bronchiola proceed- ing from a larger air-tube, and so converts it into a cavity with unbroken walls, it becomes capable of resonance. A current of air, passing across the mouth of such a tube, 120 AUSCULTATION. puff probably shows that the seat of the bron- chial breathing is near the surface. Skoda's veiled puff is most likely due to sudden removal of an obstruction in the tube, which communi- cates with a cavity. ^ III. — RESriRATORY SOUNDS IX HEALTH. The breath-sound is vesicular over the whole of the pulmonary regions : excepting that bron- chial breathing is to be heard between the scajDulse in many persons; sometimes under the right clavicle also (especially in women); and sometimes, yet seldom, under the left. The loudness of breathing sounds differs very much in different people. In children, the respiratory sound is loud or puerile ; a fact to be explained by the frequency of their respiration, and by the thinness of their chest walls. Crei)itation due to collapse is sometimes heard, especially at the bases of the lungs, and at the beginning of an examination; a few deep breaths remove this rale, when it is not due to disease. produces a flutter there, and a certain jiulse of tliis flutter is taken up by the resounding cavity, and raised into a de- finite sound. An effect concurrent with loth inspiration and expiration. BE^PIKATORY HOUNDS. 121 ^ IV. RESPIRATORY SOUNDS IN DISEASE. I. AVeak respiration indicates weak production or conduction of the glottic murmur. What- ever obstructs the air passages within, whatever compresses them without, whatever interferes with movement of the chest, will produce weak respiration; which, in other respects, may be vesicular or may be bronchial. II. Loud respiration indicates good production and conduction of the glottic murmur. When local and a consequence of disease, the breath- ing is often obstructed in some part of the lungs other than that where the loud respiration is heard. III. Bronchial respiration, heard where natur- ally the breathing is vesicular, indicates oblitera- tion of the damping spongy structure of the lung : obliteration which may be brought about in two ways : — i. By collapse of air-sacs, or by exudation into them, or by both processes combined. The pulmonary substance, thus rendered more homo- geneous, is better fitted to convey the bronchial sounds to the surface. Pneumonic, phthisical, tubercular, heemorrhagic, cancerous consolida- tion ; collapse, simple, congestive, or oedema- 122 A UI^CULTA TlOX. tous ; and cirrlio.sis of lung ; iiU produce this effect. ii. By destruction of air-sacs : Avliereby the vesicular structure is replaced by large cavities capable of reverberation. Phthisis, and dilata- tion of bronchi, are the most frequent lesions belonging to this class. AVherefore, in short, consolidations and cavities are the chief causes of bronchial breathing, as also of bronchophony. iii. The case of consolidation, Avhether mere collapse or other, is sometimes complicated by a concurrent pleural effusion. Under these .cir- cumstances, somewhat depends upon the kind of the effusion, V)ut more upon the state of the lung. The sounds in the solid lung are either weak or bronchial, as before explained. A liquid effusion simply conducts the breath sounds, thereby weakening them more or less. An aerial effusion either simply weakens the sounds, or imparts to them an amphoric hinn. ^ v. RALES. The natural breath-sound having been de- scribed, and also the changes in that sound which arc due to disease, we now come to Rales, HALES. 123 or sounds which are produced -svithiii the king by respiration, and which are wholly additional to the natural or morbid breath sound. Hale/ rhonchus, rattle ; these words are synonymous. I shall retain the classification adopted by Laennec, and also his nomenclature, because I believe that his distinctions are of practical value in diagnosis, and that his names are as good as any others. Rales are of three kinds : crepitant, mucous, and sonorosibilant. I. Crepitant Rale. — A rale which has been well compared to the sound produced by rubbing a lock of the hair between the fingers close to the ear." Crepitation of this kind is heard during inspiration, sometimes throughout the whole of it, sometimes towards the end of it only : sometimes, but seldom, crepitation is expirator}' also. Pneiuiionia, collapse, and oedema of the lung, are the three conditions which afford crepitant rale. Its occurrence in collapsed lung, during a deep-drawn breath, explains the condition necessary to the produc- ^ A French Teutonic word : essentially the same as the English word, rattle, 2 Williams: Lond. Med. Gaz. vol. xxi. ^. 275; vol. xxii. p. 261. 124 A r^sV 'ULTA TIOX. tion of inspiratory crepitation in most cases ; namely, tlie opening up of collapsed air-sacs.^ Disseminated collapse of single air-vesicles is an important part of the changes consequent upon pneumonia and pulmonary oedema, as any one who will inflate the uncut engorged or oedema- tous lung of a child ma}" easily discover. In- flation of the lung in such cases will bring out an immense number of air-sacs, which were before invisible because collapsed, and which collapse again directly the air is allowed to escape : the transparent, non-pigmented tissues of a child are particularly favourable for this experiment. In pneumonia so soon as hepa- tisation becomes dense the collapse cannot be removed l)y any pressure of air. Sometimes, doubtless, crepitation is a very fine mucous rale. Indeed, the main distinction of crepitant from mucous rale, so far as concerns the sounds alone, lies in the shortness or smallness of each cre- pitus, and, what is mostly associated herewith, the large number of crepitations attending each inspiration." ^ Van Swieten : Comm. in Aitlior. § 826. " bigratus in pectore strepitus, qui fit a vcsiculis pulmonum siccis hiucque creintantibiis instar corii aiefacti, diim inspirando cxten- diintur," vol. ii. p. 724, Lugd. Batav., 1745. - After the example set by P. M. Latham and Watson, HALE^. 125 II. Mucous Kale. — This rale includes all sounds which seem to be due to the passage of air through mucus or other liquids contained in the air passages. The notion received is cer- tainly, for the most part, that of bubbles burst- ing; sometimes the sound is crackling rather than bubbling in character. Mucous rale is sub- divided into varieties, according to the following considerations : — i. The apparent size of the bubbles : so small as to approach the crepitant rale (subcrepitant), so large as to deserve the name of gurgling, and all intermediate sizes. ii. The clearness of the rale ; the rale being sometimes more or less obscure,^ on account of weakness of the respiration ; a deeper breath (when this is possible) bringing out a rale much more distinct. iii. The reverberation of the rale : when this character is well marked, the rale is called caver- nous." Eeverberating mucous rale indicates the same physical conditions as do reverberating (cavernous) breathing or voice. the term crepitation is still used by many, so as to include mucous rale. ^ Rale obscur : Laennec : Ausc. med., vol. i. p. 103. * Laennec : Auscultation mediate, vol. i. p. 99. 126 AUSCULTATION. III. Sonorous and Sibilant Rales. — These are rales ^vhicll are more or less accurately de- scribed by such words as snoring, cooing, whist- ling ; low-pitched sounds being called sonorous (rhonchus), and high-pitched, sibilant (sibilus). Sounds of this kind are due to local narrowing of the air-passages ; most commonly by mucus, in v\-hich case a cough, which dislodges the mucus, removes the rale. Paljjable vibration often concurs with these rales. IV. Doubtful Rales. — The respiratory sound is sometimes attended ])y sounds not compre- hended in any species of rale hitherto dcscri])ed, and doubtful both as to situation and signifi- cance. I allude particularly to two kinds of sounds. First : sundry Creaking sounds, not seldom heard at the apices of the lungs, and possibly due to creaking of ])leural adhesions, but possibly also produced in the tissue of the lung itself.' Secondly ; the Dry crepitant rale with great bubbles, as Laennec- named a sound resembling that produced by inflating a dried bladder, and due, he supposed, to distension ' Bruit ou rule de froissement i)ulinonaire. Fournet : Rcclierchcs cliniqiics, vol. i/p. 172. Paris, 1839. - Auscultation niriliatc, vol. i. jip. 3 0G, 008, 043. r.nui^ : >ri'Tns. nar3'^ second sound (heard over the second HEART SOUNDS. 139 left interspace) implies an absolute increase of loudness, and not a mere relatively greater loudness as compared with the aortic second sound (heard over the second right interspace). For it may be that the aortic sound is deficient in loudness, the pulmonary sound remaining natural. But this distinction between absolute and relative, no doubt highly rational, cannot always be made in practice. Accentuation of the pulmonary second sound often indicates increased tension of the walls and valves of the 23ulmonary artery ; the greater tension being due to congestion of the lungs, such as occurs especially in disease of the mitral orifice. More- over, in such cases, this accentuation is probably a sign that the tricuspid valve remains compe- tent, and that the right ventricle contracts with proper force ; when valve or ventricle fails, the accentuation may be expected to disappear. Finally, the pulmonary second sound is some- times strongly accentuated when there are no reasons for suspecting disease of heart or lungs. Article II. — Heart-Sounds in Disease. Sounds, heard over the heart -region, and morbid in character, are of two kinds : mur- 140 AUSCULTATION. murs and pericardial sounds. The discovery of murmurs was made by Laennec.^ Several physicians seem to have made the discovery of pericardial sounds ; the earliest published refer- ence to them is found in a book written by Collin.= IF I. — MURMURS. Any fundamental change in the character of a heart-sound, or any superadded sound heard over the heart region, constitutes a murmur : pericardial sounds excepted. So that it comes to this : we fix a notion in our mind of the healthy heart-sounds : and when we hear a sound over the heart which tallies not with ' Auscultatiou mediate, 1st edit. vol. ii. p. 214. " Des diverges methodes d'exploration de la poitrine et dc leiir application au diagnostic de ses maladies, 1824. Peri- cardial sounds (called craquement de cuir neuf) are spoken of on pp. 64 and 115. Collin was Laennec's chef de clinique; but Laennec disbelieved in pericardial friction sound: Ausc. med., 2nd edit. 1826, vol. ii. p. 446. P. M. Latham discovered a sound which lie deemed to be due to pericarditis, at St. r>artholomew's Hospital in 1826 : see Hope: Treatise, 3rd edit. p. 72, 1839. See also Latham's own book, vol, i., p. 101, for a history of the successive discoveries by which endocardial and exocardial murmurs came at length to be distinguished. Latham himself (i. p. 124) assigns the credit of finally establishing the doctrine of pericardial friction to Watson and Stokes. CARDIAC MURMUIiS. 141 the notion, we say, this sound is either a mur- mur or a pericardial sound. The diagnosis be- tween these two kinds of morbid sound will be considered under the head of pericardial sounds. The physical conditions of murmur have been already explained (p. 94). In health, the re- spective sizes of the orifices and cavities of the heart are adjusted so that no sound is produced by blood-currents. But whatever contracts an orifice, whatever dilates a cavity, whatever estab- lishes an orifice or a cavity where naturally none should be, will disturb the even flow of blood, and produce vibration and a murmur.^ The prime division of murmurs, audible over the heart, is drawn between those which are referable to the heart itself, its walls, orifices, cavities, and contained blood ; and those which are referable to the great vessels next the heart. Hence the distinction between cardiac and vas- cular murmurs. Class I. — Cardiac Murmues. The physical conditions of murmur are ful- filled, in the case of the heart, at its orifices, and there only : at least we know little or nothing ^ Corrigan : Inquiry, etc. Lancet, Ap. 4, 1829. 142 A USCULTATION. of cardiac murmurs, "wliicli are due to any other condition than that of fluid veins produced at orifices. But we cannot affirm this doctrine to ])e universally true, -without much hesitation, Avhen we bear in mind how great the obscurity which hangs over the nature of many heart- murmurs. The orifices of the heart are of two kinds, some are provided with valves, and some are not. i. Valvular Orifices. — Each valvular orifice both admits the blood and shuts it off; and, whether open or closed, ma}- give rise to mur- nnir. Murmur arises at an open orifice when its size is too small with respect to the cavity beyond : that is to say, the orifice is narrowed, or the cavity is dilated, or both these morbid states concur. Murmur arises at a closed orifice (or say rather, at an orifice which naturally should be closed), when it is not closed, but lealis, and allows the blood partly to pass back into the cavity whence it came. Murmurs pro- duced at an open orifice, and in the natural current of tlic blood, are called ouAvard, obstruc- tive, or constrictive murmurs : murnuirs pro- duced at a closed orifice, and against the natural current of the blood, arc called back- ward or regurgitant murmurs. CARDIAC MUmiUFiS. 143 ii. NON-YALYULAR OrIFICES. 'I'o ^vit, tllG orifices of the venae cavae, of the pulmonary veins, and the perforations of the auricular or ventricular septum found in congenital malfor- mations, or established after birth. But these non-valvular orifices are very seldom the seat of murmur, Murmar may perhaps arise at the mouth of a large vein ^Yhen the related auricle is much enlarged, and the rush of blood is strong.^ An open foramen ovale has sometimes seemed to be a cause of murmur, different, in different cases, as to the place and time where it is best heard. Perforation of the base of the septum ventriculorum may be attended by loud murmur. Murmurs were once characterised according to their acoustic qualities, whether blowing, filing, rasping, sawing ; but these are vain distinctions ; in order to render murmurs serviceable in the diagnosis of disease we now regard two only of their properties, namely, their Place and Time. I. — Place of Cardiac Murmurs. In general, a murmur is heard best at that point of the surface of the body wdiich is nearest ^ See Markham's case, before cited (p. 43). 144 AUSCULTATION. to the orifice thereat the murmur is generated. So that it becomes important to determine the relation which the orifices of the heart bear to the chest -wall. The Puhnonary orifice lies behind the second left interspace, close to the sternum : the Aortic orifice lies on the same level, behind the sternum : the Tricuspid orifice reaches from the sternal end of the third left intercostal space to that of the fifth right rib ; the Mitral orifice lies on a level Avith the upper border of the third left cartilage, close to the edge of the sternum, and slightly behind it. And let it be noted that the mitral orifice lies much more deeply than the rest.^ But murmurs are not always conducted the shortest way to the surface. The conducting power of the tissues interposed between a valve and the chest- wall, and the direction of the blood current, have much to do with determining the point at which a murmur is heard loudest. i. The influence of superjacent tissues is well exemplified in the case of aortic and mitral murmurs. Both orifices of the left heart lie deep in the chest. The aorta becomes most * Sibson (Reynolds' System of Medicine, vol. iv. p. 14, 1877) seems to differ from most anatomists in bis doctrine concerning the position of tbe valves. CARDIAC MUBMUItS. 145 superficial just above its valves, and is there almost iu contact with a good conductor of sound, the sternum : wherefore aortic murmurs are well conducted up and down the sternum, and along the attached cartilages : so that, in fact, an aortic murmur is sometimes heard louder at the xiphoid cartilage than at the second in- tercostal space. The mitral orifice, buried be- neath heart and lung tissues, may be said, for purposes of auscultation, to become most super- ficial where the cavity of the left ventricle becomes most superficial, that is to say, at, or just above the apex of the heart ; and here, as a rule, mitral murmurs are heard loudest. ii. The influence of the blood-current (or of convection, as it has been called) is exemplified by both mitral and aortic murmurs. Obstructive and regurgitant aortic murmurs are well con- veyed by the blood along the arteries, and a regurgitating murmur may be conveyed by the reflux of blood towards the apex of the left ven- tricle. Mitral regurgitant murmur is sometimes conveyed by reflux into the auricle, so as to be heard over the third left cartilage. When the heart is displaced — that is to say when the relation between its valves and certain points of the chest-wall is changed — the place of G.A. L 146 AUSCULTATION. murmurs is likewise changed. This and many other difiiculties and doubts, which we meet with in the exact location of murmurs produced at the different valvular orifices, will be discussed in the second part. II. — Time of Cardiac Murmurs. A complete cycle of the heart's action may be divided into four periods, i. Auricular period : not attended in health by any sound : auricles contracting. ii. Ventricular period : accom- I^anied by first sound : ventricles contracting, iii. Arterial period : attended by second sound : aorta and pulmonary artery contracting, iv. The period during which the heart is at rest : unless they are right who maintain Galen's doctrine of an active ventricular diastole. The subject requires a further develoi3ment, thus : — Relative dura-) Auricular Terigd. Ventricular Period. Arterial Period. Rest. -^^ , — ■ tion. V Pulse = 60. ) ^V ■I i f u ^cuspid Valves-] C sigmoid open shut, open shut. Sounds first. second. Murmurs 1 pra?syslolic' systolic diastolic. CARBIAC MURMURS. U1 The time of murmurs is determined in two "ways ; by reference to the sounds and to the impulse of the heart. i. By reference to the sounds^ murmurs are most accurately timed. When both heart- sounds are heard, it will not be difficult to say that a murmur precedes, accompanies or follows a certain sound. When one sound only is heard, we have to find out whether it be the first or second sound, and this is not always easy. When one sound only is heard at the apex, tw^o sounds are sometimes heard at the base : the sound wanting at the apex is commonly the second. When neither sound is heard at the apex, one sound (esjDecially the second) or both sounds may be heard at the base. ii. By reference to the impulse. Murmurs which accompany the impulse may be deemed systolic, in the absence of evidence to the con- trary. Yet be it borne in mind that the impulse is not strictly systolic, but is also praesystolic and post-systolic (p. 39). iii. Less trustworthy means of determining the time of a murmur are these. By reference to the arterial pulse, especially in the neck. By refer- ence to a valvular thrill, if any there be, in which case, the thrill and murmur being due to L 2 148 A U^CULTATION. the same vibration, whatever the relation of the thrill to the impulse, such will be the relation of the murmur also. The time of some murmurs is not constant. This is true of mitral murmurs in particular : a murmur, prsesystolic when the patient is first seen, may become systolic before long. But more of this hereafter (pt. ii., chap. 32). III. — Meaning of Cardiac Murmurs. i. Systolic murmurs referable to the Auriculo- Ventricular (or cuspid) oriiices indicate reflux of blood : to the Arterial (or sigmoid) orifices indicate constriction or obstruction at or just above the orifice, unevenncss of the conus arteriosus, dilatation of the aorta or of the pulmonary artery, or perforation of the septum ventriculorum. ii. Diastolic (and precsytolic) murmurs pro- duced at the Cuspid orifices indicate constric- tion or obstruction of the orifice : at the Sigmoid orifices indicate reflux of blood, or dilatation of the vessel above the valve. But the matter is not nearly so simple as this. Just as the nature of the first sound is more doubtful than that of the second, so is the CARDIAC MURMURS. 140 nature of systolic murmurs more uncertain than that of diastolic (and prsesystolic) murmurs. Diastolic (and praesystolic) murmurs indicate in most cases, if not in all, permanent structural (organic) disease. But systolic murmurs are often temporary and unattended by any other evidence of heart-disease : indeed, as will be shown here- after, their meaning is often doubtful. IV. — Loudness of Cardiac Murmurs. i. Some murmurs, which are audible whilst a patient is lying, become much less loud or even disappear when he sits or stands. This is especially the case with mitral and tricuspid murmurs. The reason of the occurrence is not understood.^ But cue thing is clear, namel}^, that we must examine our patients in both upright and lying postures before we pro- nounce concerning the presence or absence of murmur. Many mistakes are due to neglect of this rule. ii. Pressure upon the heart region sometimes makes a murmur weaker. On the other hand, pressure upon the upper part of the sternum or 1 Elliotson: Lond. Med, Gaz, for 1833: vol. xii, p. 373. 150 AUSCULTATION. over the pulmonary artery ^vill beget a systolic murmur in some young persons.^ iii. The loudness of some murmurs is under the influence of breathing ; thus, a systolic apex murmur may be louder during inspiration than during expiration ; and a tricuspid systolic mur- mur may become inaudible at the beginning of expiration. iv. Murmurs are loudest sometimes when the heart beats forcibly, sometimes when it beats quietly ; they are sometimes inaudible except at these respective times. In a doubtful case, it should always be a rule (if possible) to end by examining the heart when it has been made to throb by exertion. V. The loudness of a murmur depends much upon the swiftness of the blood-current ; hence, when the current is weak and slow there may l)e no murmur, even although the valvular disease is great. AVhatever weakens the con- traction of the heart weakens the current : hence a murmur often becomes inaudible in the course of infectious fevers, in asA'stoly, in the dying state, and in other such conditions. In short, murmurs are apt to be very vari- ' 1*. \r. Latham : Diseases of Heart, 1846, vol. i. p. G2, I REDUFLICATION OF SOUNDS. 151 able : they come and go, they shift their place and time, in a manner which makes it seldom safe to depend upon a single examination.^ V. — Reduplication of Heart-Sounds. A heart-sound is said to be reduplicated when, instead of being a single sound, it seems to be broken in two, doubled or repeated. Some- times the sound is completely doubled, that is to say, in the place of one sound there are heard two sounds, with a distinct interval be- tween them. But more often the reduplication is incomplete, or subintrant, that is to say, before the first portion of the doubled sound is concluded, the second begins. I. Simple Reduplications. — Most reduplica- tions seem indeed to be nothing more than repetitions of a natural heart-sound, first or second, as the case may be. The component elements of the sound are sundered more or less, and do not exactly concur in point of time. Reduplication of the second sound, for instance, is believed to show that the pulmonary and ^ Murmurs (especially musical uiurmui's) and even loud lieartsounds can sometimes be heard at a distance from tlie hest : see Moore's paper (referred to on p. 89, note). 152 .4 UHCULTATION. aortic sigmoids do not close at the same time : if we would fain go further and understand why they do not shut simultaneously, we find our- selves beset by doubts and guesses. The con- ditions of the first sound being uncertain, it is not safe to attempt an explanation of its redupli- cations. Reduplications are constant or incon- stant ; they attend every beat of the heart, or some beats only. Constant reduplication some- times indicates serious disease, for instauce, the second sound is often doubled at the base of the heart in the case of obstruction at the mitral orifice. But reduplication is usually inconstant, intermittent, the sound being doubled with some beats of the heart, and not with others. This intermittence is found to bear a close rela- tion with the movements of breathing : so that the first sound doubles at the end of expiration and the beginning of inspiration; the second, at the end of inspiration and the beginning of expiration.' The second sound is much more frequently reduplicated than the first. IT. liEDUPLiCATiGN MuRMURS. — Wcrc rcdupli- cations all of this simple kind, they would hardly need much notice, liut some seeming redupli- * A fact first noted by Rchafer : see Caustatt's Jahresbei'iclit for 1S50, vol. ii. p. 100. BEDUFLICATION MUBMUBS. 153 cations of a heart-sound are indeed murmurs ; that is to say, a murmur is added to the heart- sound, or a murmur is split into two sounds, so as to simulate simple reduplications.^ False Reduplication of Second Sound. — Bouil- laud - was the first to describe a bruit de rappel, (strictly called in English, cantering ^), that is, a seeming reduplication of the second sound, heard at the apex-beat. A praesystolic murmur also is usually present ; whether this be so or not in a given case, the double sound is to be looked upon as being a divided diastolic murmur, and a token of mitral constriction. In fact, cantering sometimes alternates with a diastolic apex-mur- mur ; that is to say, a prolonged diastolic mur- mur, which is the more constant sign of a mitral constriction, will disappear from time to time, and be replaced by well-marked cantering. ^ False Reduplication of First Sound. — Potain (L'Union med., vols. XX., xxi., 1875-6) describes a bruit de galop, in -which the first sound seems to be doubled ; the seeming reduplication being due to a weak praesysfcolic sound, which is well beard at the apex-beat only. This kind of cantering is, he thinks, a sign of granular kidneys. I have never been able to satisfy myself that Potain is right. " Traite : 2me edit,. ISll : vol. i. p. 210, and vol. ii, p. 315. ^ Comijailson made by C. J. E. Williams : Diseases of Chest : 1th ed. 1810, p. 211 : of. p. 275. ]54 AUSCULTATION. Class II. — Vascular Murmurs. There are murmurs which, though heard over the heart region, are believed to be produced not in the heart itself but in a large vessel near it. They are either of uncertain nature or of un- common occurrence. i. A murmur, systolic, loudest in the aortic or pulmonary region, often occurs in the state of anaemia. Forasmuch as it is still a matter of debate whether the murmur be valvular or vascular, and whether it be always due to one and the same condition, the further considera- tion of this topic will be most conveniently deferred to the second part (chapter 40). ii. A murmur, diastolic, loudest in the aortic region, is sometimes (but seldom) associated with rigidity and dilatation of the aorta, the valves being healthy (part ii. chapter 34). iii. A murmur, diastolic, loudest in the pul- monary region, is sometimes (but seldom) due to openness of the ductus arteriosus (part ii. chapter 41). iv. A murmur, diastolic, loudest over the fourth left cartilage, may be due to an opening formed between aortic aneurysm and the pulmonary artery.^ ' Wii'.le : Medico-chir. Traus., vol. xliv. p. 211. FEBICAIiDIAL ^OUND^. 155 ^ II. PERICARDIAL SOUNDS. No sound is produced by the movement of healthy pericardial surfaces upon each other. In diseased states of the pericardium two kinds of sounds may be heard : friction sounds, and sounds due to the presence of air and liquid in the cavity. I. PERICARDIAL FRICTION. — It is Convenient to consider pericardial friction sounds Avith reference to their diagnosis from endocardial sounds. The most important diagnostic cha- racters of friction sounds are these : — i. The special equality sometimes suffices for the diagnosis, being distinctly rubbing or scraping : but often enough this quality is ill- marked or absent. ii. Friction sounds are mostly of limited extent, heard over a small portion only of tlie heart region, especially at its base ; they do not follow the laws laid down with regard to the points of greatest intensit^^, and the conduction of endocardial murmurs. Indeed, there is no part of the heart-region where friction sounds may not be heard loudest. A loud friction sound will be heard, not only all over the heart-region but even all over the front of the chest, nay even at the angle of the 156 A USCULTATION. scapula: thougli, in these latter cases, there is mostly marked and sudden "weakening of the sound so soon as we pass away from its place of origin. Friction sound, like murmur, may, when very loud, be audible at a distance from the patient's body. Friction-sounds, which at first, on account of their place and their quality, simulate murmurs, sometimes shift their place, BO as to become loudest at spots where murmurs are seldom heard loudest. A sound which shifts its place from day to day is pericardial, iii. Friction sound is mostly systolic and diastolic, being loudest in the systole ; sometimes systolic only, or even diastolic only. A sound, which is at one time systolic and anon diastolic, is peri- cardial, iv. Friction-sounds are r.ot intermit- tent like reduplications, v. The luichanged heart-sounds are sometimes heard through friction, vi. Friction-sounds often give a notion of superficiality, be it explained as it may. vii. Palpable vibration sometimes attends them, viii. Their loudness is sometimes increased, sometimes decreased, sometimes stopped, by deep inspiration, ix. Their loudness is some- times increased, sometimes decreased, by pres- sure. X. Friction-sounds may be modified by change in position of the body. Their place of PEllICAEDIAL SOUNDS. 157 greatest loudness may be thus made to change : this is very characteristic. Friction sound some- times disappears when the patient sits up, pos- sibly on account of a small quantity of fluid which comes forward so as to separate the peri- cardial surfaces : but it has been shown that the same change in position sometimes removes endocardial murmurs (p. 149). Friction sound, not to be heard otherwise, is sometimes pro- duced when the patient lies upon his left side, whereby the position of the heart is much changed. Whatever roughens the pericardium can pro- duce friction sound : excessive vascularity, exudations, haemorrhages, adhesions, and white patches. II. WATER-WHEEL AND SIMILAR SOUNDS. — In the uncommon condition of effusion of liquid and air nigh to the heart, whether within the pericardium or outside it, peculiar sounds are heard. Sometimes they resemble am2Dhoric j)leural sounds, namely, amphoric hum (attend- ing heart-sounds or friction), metallic tinkling, and splashing. Sometimes the sound is like a rale, bubbling or gurgling. Sometimes the sound is clacking or chopping, like the noise made by the floats of a water-wheel (bruit de 158 A USCULTATIOIS^. moulin).^ All these sounds are alike in this, that they depend upon movements of the heart, are independent of breathing movements, and persist when the breath is held. When the pericardium is uninjured, the sound does not last more than three or four days. Appendix to Section III. There are sounds which, although dependent upon movement of the heart, are neither cardiac murmurs nor pericardiac friction sounds. % I. Pulsatile Pulmonary Sounds, that is to say, pulmonary sounds produced or altered by movement of the heart or of the great vessels. - i. The respiratory sounds of the healthy left lung may be so affected by movement of the heart as to simulate its murmurs. The condi- tions of this occurrence are not well understood : pleural adhesions, such as to fix the lung over the pericardium, are often present. The diag- nosis lies, not in the quality of the sounds, but in the fact that they concur with a certain ^ First described by Dricheieau : Arch. gen. de med., A" serie, tome iv. : 1844: p. 334. - Laennec : Auscultation mediate, vol ii. p. 446, de- scribes altered breathing sounds and crepitation. PULSATILE PULMONARY SOUNDS. lo9 respiratory movement, as well as with a certain cardiac movement. They are mostly systolic and inspiratory ; less often diastolic, or expira- tory. They nsually cease to be produced when the breath is held. They are sometimes heard only in the upright posture of the body : but as a rule they are rendered less loud, or they even disappear, on changing the lying posture for the erect. ii. The respiratory sounds of a cavity (phthi- sical, bronchial, or pneumothoracic), may be altered by the movements of the heart or aorta in a similar manner. These false murmurs also are mostly inspiratory and systolic, or systolic and diastolic; seldom expiratory. They are heard best over the cavity, but they are some- times conducted far, even over the w^hole chest. And, in the case of phthisical cavity, even along the windpipe to the mouth, so as to be heard at a distance from the patient, when the mouth is opened widely (pulse-breath, p. 160). The cavity is either close upon the heart and aorta, or is con- nected with them by a solid mass (such as solidi- fied lung, or enlarged lymphatic glands), which is apt to convey the cardiac movements. In cases of phthisis, a strong aortic impulse can sometimes be felt where the false murmur is heard : for 160 A USCULTA TION. instance, in the third right intercostal space, close to the sternum.^ iii. Rales also may be produced, and especially crepitation. It is systolic, and is most likely due to the entry of air into vesicles partly or wholly collapsed, the movement of the heart causing a local inspiration in the portion of lung which lies upon the pericardium. The crepita- tion ceases to be produced when the breath is held after a deep expiration. ^ II. Pulsatile Friction Sound generated in the pleura, of both respiratory and cardiac rhythm, sometimes is heard. Friction heard behind or alongside the sternum, from the second to the sixth rib, is most likely peri- cardial. When a friction sound is heard at ^ By listeuiug to the open luoutb of a person breathing quietly, a gentle pi;ffing sound can sometimes be heard to attend each beat of the heart during expiration. This Pulse-breath was described first by Radclyffe Hall (Med. Chir. Trans, for 1862 : vol. 45, p. 167), and afterwards by David Drummond (Brit. Med. Journ. Oct. 21, 1882 : p. 773). Drummond auscultates Avith a peculiar stethoscope, one end being put into the patient's mouth : by this means a pulse-breath (or oral whiff) can be heard in healthy peoi)le when the heart is beating forcibly. The diseases which favour the occurrence of pulse-breath are aneurysm of the aorta, and cavity within the lung. The sound, when loud, can be heard by auscultation of the trachea. PULSATILE rLEURAL SOUNDS. ir,l other parts of the heart-region, the diagnosis is not easy : pleural friction usually ceases when the breath is held, but this is not always the case ; and there is no doubt that true pericardial friction may sometimes be stopped in that manner. IT III. By the name of Metallic Jingle, Laennec^ meant the sound which is heard when the stethoscope is applied to the chest, whilst some bony part near by (such as the clavicle or spine) is percussed. When the palm of the hand is put over the ear and the back of the same hand is tapped, we hear a very loud metallic jingle. A sound of the same kind is sometimes heard when we listen to a heart which is beating forcibly : in this case, it is commonly supposed that the stroke upon the ribs causes the sound. For my own part, I suspect that resonance of the meatus auditorius externus has much to do with the production of a metallic jingle. Auscultation as applied to the large vessels of the mediastina will be treated of hereafter. ^ Auscultation mediate, vol. i. p. 114, and vol. ii, p. 445; cliquetis metallique. Ausculta, et compone meis sermonibus era. Thomas Watson: Meliboeus. G.A. M CHAPTEB VI. APPENDIX TO PART I. SECTION I. AUSCULTATION OF ARTERIES. TWO kinds of souiuls are heard by ausculta- tion of arteries : conducted sounds, and murmurs produced in the part ausculted. I. Conducted Sounds. — The heart's sounds and murmurs, especially the second sound, and aortic or mitral murmurs, are conducted along the arteries ; not usually, however, farther than the carotids and subclavians. Yet very shrill diastolic murmurs produced at the aortic orifice, may sometimes be heard so far away as in the radials. II. Murmurs Produced in the Spot Aus- culted. — These are either spontaneous or factitious. IF I. Spontaneous Arterial Murmurs. — These are aneurysmal or subclavian. i. Aneurysmal. — The systolic murmur which is sometimes produced in an aneurysm, is be- ARTERIAL MURMURS. 163 lieved to be due to formation of a fluid vein at the mouth of the aneurysm. Formation of a fluid vein requires that the cavity containing fluid blood be considerably wider than the mouth of the sac, and that the blood current be swift enoug]). ii. Subclavian. — A systolic murmur, seated in the subclavian artery, is often heard below the clavicles, mostly on the left side. The murmur is often inconstant or temporary. Forasmuch as it cannot be said to denote any form of disease, it seems to be unnecessary to discuss the conditions under which the sound is supposed to occur. ^ II. Factitious Arterial Murmurs, due to compression of an artery by the stethoscope, are systolic or diastolic. i. Systolic Murmur. — In healthy persons, a slight compression of the larger arteries will generate a soft murmur, systolic with reference to the left ventricle. In some forms of disease, notably in hypertrophy of the left ventricle and in chlorosis, firmer pressure makes the murmur harsh and whizzing. More- over, under these conditions, a murmur is producible in the smaller arteries ; such as the volar. M 2 164 ARTERIAL MURMURS. ii. Diastolic Miirnnir has long been known ; ^ but Duroziez was the first to study it more par- ticularly.* It is best heard in the femoral artery, and attends a certain degree only of pressure : a degree which must be discovered in each case by varying the amount of force used to compress the vessel. A loud systolic murmur precedes the softer diastolic sound. It is often present in cases of aortic regurgitation ; and is probably due to reflux of blood along the artery, during the ventricular diastole. A certain amount of pressure upon the artery above the spot ausculted renders the systolic murmur louder; the reason being that a second fluid vein is thus produced. The diastolic murmur is rendered louder by compression of the artery below the spot ausculted, probably because diastolic reflux is favoured thereby. Yet double femoral murmur sometimes occurs apart from any signs of valvular disease : in this case the condition has been supposed to lie in a highly dicrotic pulse ; the diastolic murmur correspond* ing with the secondary j^ulse wave. 1 Bouillaiul : Traiti' : 2ine c'd., 1841, vol. i., p. 228. - Duroziez: Arch. gen. de mcd. : series v., vol. xvii. 1861. To contemplate the vast extent of literature devoted to this very insignificant topic is amazing and amusing. INSPECTION OF JUG UL Alt VEINS. 165 It is necessary to bear in mind that diastolic murmur, produced at the aortic orifice, is some- times conveyed to great distances along the arteries. Bat diastolic murmur of this kind requires no compression of the artery to make it audible. SECTION II. INSPECTION OF VEINS OF NECK. What examination of the arterial pulse is to detection of diseases of the left heart, such is examination of the veins to detection of diseases of the right heart. Inspection of the veins of the neck is directed to two points ; the fulness of the veins, and the movements Avhich the contained blood undergoes. ^ I. — FULNESS OF THE VEINS. In health the external jugular alone is visible, and even that vein, oftentimes, only in the lying- posture. In disease both veins are sometimes dilated to the size of a finger. Overfilling of the veins is either transitory or permanent. i. Transitory overfilling accompanies powerful expiratory movements ; which produce such an amount of pressure within the intrathoracic 166 INSPECTION OF JUGULAR VEINS. veins, that the valves at the mouths of the jugiihxr veins are shut, and the blood flowing- down from above cannot pass into the inno- minata. Inspiration reverses all this ; the veins are emptied, and collapse. Repeated transitory overfilling of the veins is followed at last by permanent dilatation of them, a fact seen in patients who suffer from chronic pul- monary catarrh. If in these persons when there is no cough and the veins are invisible, we place our finger just above the clavicle so as to ob- struct the external jugular vein, it at once swells up and manifests the amount of its dila- tation ; which may be taken as a mark of the degree to which the patient's tissues have suffered in consequence of cough. ii. Permanent overfilling of the jugulars is mostly associated with overfilling of the right auricle ; but, obviously, any obstruction to the upper vena cava, or to the innominata (by com- pression, thrombosis, or stricture) will have tlie same effect. % II. — MOVEMENTS WITHIN THE VEINS. Besides the respiratory movements which have ju^it been described, the blood within the veins VENOUS FULSATIOX. 167 often undergoes movements which are dependent upon the heart's contractions. The most obvious kind of venous pulsation is that seen in veins visibly distended. There is a degree of dis tension which checks pulsation : for this reason, pulsation sometimes attends only the upright posture of the body, when the veins are less distended ; and disappears in the lying posture, when the distension becomes greater. More- over, pulsation of the jugular veins can often be seen, when the veins themselves are quite in- visible; just as the pulse at the wrist can be felt, but not the artery of a healthy man. There is usually no difficulty in distinguishing this venous pulse ; it is less decisive and definite, more fluttering and quivering (dicrotous, tri- crotous) than the arterial pulse ; and the finger, put upon the pulsating vessel, stops, but seldom feels, the pulsation. Venous pulsations are prsesystolic or systolic. i. Praesystolic pulsation ^ of the jugular veins may be sometimes seen in persons who are free from disease of the heart. Ansemia and the horizontal posture favour this pulsation. It is followed by a systolic emptying of the vein. ^ First noted by PopLam : Dublin Quart. Journ. Med. Sc. 1855: vol. xix., p. 469. 168 iy;SFEt'TlON OF JUGULAR VEINi^. This prft'systolic pulse is believed to be due to suddeu arrest of the onward venous flow during the auricular systole : the systolic emptying to the sudden auricular diastole. Pr8es3^stolic jugular pulsation in disease may be due to regurgitation of blood into the vein. ii. Sj'stolic pulsation in the veins is due to the ventricular systole, indirectly or directly. A direct s^^stolic pulsation signifies a reflux of blood out of the ventricle ; the tricuspid valve being incompetent. When the valve is com- petent, we may call the pulsation indirect. a. Indirect systolic pulsation is explained in different ways, and perhaps is not always due to the same cause. It has been suj^posed that the tricuspid valve is raised, by the ventricular systole, into a sort of dome, convex towards the auricle ; and hence an impulse backwards to the blood in the venous system ; counteracted, how- ever, luiless the overfilling of the veins be great, l)y the diastole of the auricle. It has been suggested that in some cases the systolic filling of the aorta compresses the distended intra- thoracic veins, and thus produces a movement in the jugulars. /i. Direct systolic pulsation, being due to propulsion of a wave of blood from the right VENOUS PULIATION. IGO ventricle into the jugular veins, requires that both tricuspid and venous valves be incom- petent.^ It is easy to ascertain whether the venous valves are competent or not; namely, by compressing the veins in the upper part of the neck, and observing whether they are filled with blood from below or not. But it is not so easy to determine reflux through the tricuspid valve ; that is, to distinguish between direct and indirect systolic pulsation. The difference is only one of degree : pulsation is less marked when indirect than when the tricuspid valve is incompetent : for in the latter case blood is pumped out of the ventricle into the veins under strong pressure. In both cases, however, systolic jugular pulsation is an important sign of an affection of the right heart : for even if, in a given patient, there are no grounds for supposing the tricuspid valve to be incompetent, ^ Job, M. Lancisii, De motu cordis et aneurysmatibus. LugJ. Bat, 1740. Propos. Ivii. " Inquivere meclianicani rationem, ob quam in dilatationibus radicis Cavse, Auri- culse, et VeDtriculi dextri, ii^sse vense Jugulares vicissira dilatentiir, fluctuent, mirisque niodis agitentur, et con- cidant." Tlio cause is asserted to be a regurgitation of blood through the tricuspid valve. Lancisi refers to Hom- bert as having made the same observation in a paper pub- lished in the Proceedings of the Parisian Academy of Sciences in 1704. See also Stokes ; Diseases of Heart, 1854 : p. 199. 170 INSPECTION OF JUiWLAB. VEINS. the pulsation indicates an engorged state of the right chambers, such as will dilate them, if it continue. For this reason, in mitral disease, jugular pulsation often precedes any evidence which percussion affords of secondary distension of the right heart. When the pulse is very strong, it is sometimes palpable, or even thrill- ing.' By Bamberger, Friedreich,^ and others, the sphygmograph has been applied to jugular veins, pulsating in cases of diseased heart. The venous pulse has thereby been found to be dicrotous ; but dicrotous in a manner different from the arterial pulse. The venous dicrotism occurs in the rise of the blood- wave. The first or smaller impulse coincides with the auricular contraction ; the second or chief impulse Avith the systole of the ventricles. Sometimes there is an impulse at the very end of the fall of the pulse-wave : supposed to indicate repletion of the cavities of the right heart, a sudden stop being put to the entry of more blood. * In the case of rupture of aortic aneurysm into the vena cava superior, systolic pulse and thrill are present in the veins of the neck. 2 Bamberger: Wiirzburg. med. Zeitsch., vol. iv. p. 232. Friedreieli ; Deutsch. Arch, fiir klin. Med., vol. i. p. 241. VENOUS PULSATION. 171 Fi- 13. Fig. 14. RACINGS OF JUGUL.\ PCLSATION : FROM FrIILOREIC 172 AUSCULTATION OF JUGULAR VEINS. SECTIOX III. AUSCULTATION OF VEINS OF NECK. By means of a stethoscope placed upon the side of the neck, there is often to be heard a humming sound ; which was first referred to the veins by Ogier Ward.^ This venous hum is usually continuous ; but other murmurs, which are intermittent, are sometimes heard in the veins. IF I. The Continuous Venous Hum, although especially well heard in chlorotic patients, occurs in many healthy persons. Pressure with the stethoscope is doubtless a frequent cause of the murmur. But a venous hum, in chlorotic persons, is independent of pressure, and is believed to depend upon anatomical conditions. The internal jugular vein is adherent, at its lower end, to the cervical fascia, in such a manner that, when the venous system shrinks in capacity and adapts itself to a lessened bulk of blood the part of the vein spoken of cannot shrink, and so becomes relatively dilated : hence a sonorous fluid vein.^ The more rapid the flow ' On the bruit du diuble. Lond. Med. Gaz. 1837, p. 7. 2 Cliauvcau : Gaz. nu'd. de Paris : 1858 : pp. 340 et seq. KPIGASTPJC PULIATION. 173 of blood the louder the hum : hence it is louder in the erect than in the lying posture ; and is stopped by Avhatever produces stagnation of blood in tlie vein. Hence, also, in most cases, although the munnur is continuous, yet it is subject to rhythmical increase of loudness ; both during the inspiratory draught of blood from out the veins ; and during the ventricular systole, that is, during the auricular diastole, when the venous current begins again to flow freely. H II. Intermitting Venous ^lurmurs, pra3- systolic, systolic, diastolic, have been described, but many are doubtful and none of the least importance.^ SECTION lY. EPIGASTRIC PULSATION. % I. Pulsation of the epigastrium depends upon — ^ See Parrot: Arch. gen. de Med., June, 1867, p. 649* Also Friedreich, Krankheiten des Heriens, 2nd edit. p. 96 \ Ringer & Sainsbury: Lancet for 1891, yol. ii. , pp. 1,212 and 1.268, and for 1892, vol. i., pp. 740 and 790. ^Murmurs heard in the femoral veins have been studied by Schreiber (Deutsch. Arch, fiir klin. Med. vol. 28, p. 243), Beau (Traite, p. 416) and Friedreich (Berlin klin. "Woch. for 1874, No. 48 p. 611). 174 EPIGASTBIC PULSATION. I. Conduction thereto of the impulse of the henrt : i., when it is beating more strongly than usual : ii., when it is dilated : iii., when it lies lower than natural ; a condition mostly due to depression of the diaphragm (p. 177); iv., when it is displaced to the right (p. 42). II. Pulsation of the abdominal aorta, or of the creliac axis, or of an aneurysm, or of a tumour seated upon the abdominal aorta. III. Regurgitation of blood into the hepatic veins, consequent upon dilatation of the right heart, and causing systolic pulsation of the liver; a pheenomenon first observed by Fried- reich.^ He^^atic pulsation was noted so long ago as the time of Senac ; but the older physicians believed that the liver merely con- veyed an impulse from the heart, vena cava, or aorta. The distinction between the two kinds of pulsation, conducted and refluent, depends upon the following considerations, i. Whether the heart or any adjacent organ be pulsating powerfully and extensively : it is seldom difficult to distinguish between the slow, gentle venous pulse, and the quick, strong heart impulse, ii. Whether there be signs of tricuspid disease, and, * See Maliot : Dos battcraents du foie : Paris, 1869. POSITION OF DIAPHRAGM. 175 ill particular, whother the jugular veins afford a regurgitant pulse, iii. When paracentesis for ascites has been performed and the abdominal alls are left very flabby, the liver can some- times be grasped, and felt to expand, like an erectile tumour, at the time of impulse. IT II. Recession of the epigastrium, systolic, occasionally simulates pulsation, and when well marked is probably due to pericardial adhe- sions.^ SECTION V. POSITION OF DIAPHRAGM. In many diseases of the chest, it becomes an important element in diagnosis to ascertain the position of the diaphragm. Strictly speak- ing, we determine the lower limits of the lungs and heart, the upper limits of the liver, spleen and stomach, and deduce the position of the diaphragm from these data. For this purpose all the means of physical examination are more or less serviceable, but percussion is especially useful.^ * Associated, in Copland's case (Diet. pract.Med., vol. ii,, p. 214), with cup-sliaped depression of the sternum. - Gerhardt : Der Stand des Diaphraginas : Tubingen, 1860. 176 POSITION OF DTAFHRAGM. ^ I. In Health. — By inspection, the position Avliicli the diaphragm held before puberty may be roughly determined (p. 16). By palpation, the position of the heart's apex-beat, and the point where vocal vibration ceases, are ascer- tained. By percussion, the lung, at the end of an ordinary inspiration, is found to reach, in the sternal line the lower border of the sixth rib, in the nipple line tlie upper border of the seventh rib, in the axillary line the lower border of the seventli rib, in the scapular line the ninth rib, and in the spinal groove the eleventh rib. The lung, during quiet breathing, fills not the whole pleural cavity, but leaves it unoccupied at the part most distant from the bifurcation of the bronchi, namely, at the semicircular channel formed by the chest wall and the diaphragm where it shelves downwards to be attached to the ribs. This unoccupied portion of the pleural sac has been named the complemental space ; there the costal and diaphragmatic pleursc are in contact. ^ II. In Disease. — The disease may be such as to afford an obvious impediment to j^hysical diagnosis, by destroying the resonance of the parts above the diaphragm. Which is the case in solidification of the lower lobe of the lung. POSITION OF DIAPHEAGM. 177 and in liquid j^leural effusion. When the lung is solidified, vocal thrill, if present, will assist us, inasmuch as it fixils rapidly beyond the pulmonary region. When liquid is present in the lower part of the pleura, it is impossible to do more than guess where the level of the diaphragm may be. The diaphragm lies high in : — contraction of the lung, distension of the abdomen, paralysis of the diaphragm. The diaphragm lies low in : — hypertrophous emphysema of the lungs, pleural effusions, dilatation of the heart, pericardial effusions, intrathoracic tumours, spasm of the diaphragm. A greatly enlarged heart or an abundant pericardial effusion may depress the diaphragm so much as to produce a tense swell- ing in the epigastrium.^ Depression of the right "wing of the diaphragm sometimes depresses the right lobe of the liver in such a manner that the left lobe is tilted upw^ards and raises the apex-beat of the heart. SECTION VI. POSITION OF MEDIASTINUM. The position of the mediastinum is deter- mined in the same manner as the position of ^ Auenbmgger : Inveutum Novum, § 46. G.A. J^ 178 POSITION OF MEDIASTINUM. the diaphragm, namely, by ascertaining the position of the organ which is most intimately connected with the mediastinum, that is the heart. By palpation we discover the position of the apex-beat of the heart : by percussion we are enabled to confirm the notions acquired by palpation, and to map out the position assumed by the heart. The mediastinum is displaced in unilateral pulmonary or i:»leural disease; and the displacement is either towards or away from the seat of disease. The mediastinum is dis- placed towards the seat of disease when one lung- is shrunken : this is especially seen in phthisis, cirrhosis, and collapse, but also, to a less extent, in an adherent pleura. The mediastinum is displaced away from the seat of disease, in uni- lateral pleural effusions of liquid or gas. When the effusion is liquid we possess an additional means of determining the position of the me- diastinum, to wit, percussion of the sternal region above the heart. The upper part of the sternum naturally yields a clear resonance : under the pressure of a copious liquid effusion into either pleura, the mediastinum bulges so much towards the unaffected side, as to afford absolute dulncss to percussion in the sternal region, and even some.what beyond it. POSITION OF MEDIASTINUM. 179 Intrathoracic tumours sometimes displace the heart. The disphicement of the mediastinum, which takes place in unilateral pleural efifusions, is not at first due to pressure exerted by the effusion.' The lungs, in health, are in a state of distension which is kept up by excess of atmospheric pres- sure from within ; the thoracic walls bearing off the atmospheric pressure from without. The elasticity of the lung is continually striving to overcome this distension, as is manifested by the relaxation of the lung which ensues when the internal and external atmospheric pressures are etj[ualised. The distended lungs of the healthy chest, with their elasticity in full play, drag upon the mediastinum ; which, however, maintains its natural position, because the forces on both sides are equal. But if the elastic traction of one lung be destroyed by relaxation or collapse, the other lung, no longer counterbalanced, itself relaxes as much as pos- sible, and draws the mediastinum away from the middle line. ^ Powell : Med, Times and Gaz., Jan., Feb. 1869. Also : Med. Chir. Trans., vol. 59, p. 165: 1876. N 2 180 OTHER VASCULAR MURMURS. SECTION YII. OTHER VASCULAR MURMURS. Very probable though the occurrence of murmurs within the vessels of the lungs may be, yet the fact has not been often proved. In the right supraspinous fossa of a phthisical patient, Gerhardt heard, beside bronchial breath- ing and ringing rales, a systolic whiff; which was explained, post mortem, by the existence of a dilated branch of the pulmonary artery, run- ning across a cavity, and expanded in one spot to a small aneurysm/ Between the scapulae and vertebrae Immermann once heard systolic murmurs, due to constriction of the pulmonary arteries at their entry into the lungs, and just beyond ; constriction caused by induration of the pulmonary tissue.- Murmurs of similar character, and presumed to be of similar origin, have been heard by many other persons. Murmurs, having the character of vascular murmurs, are often heard below the, clavicles and behind the manubrium stcrni. These 1 Lehrbuch, 3rd edit. pp. 218, 270. ' Deutsch. Arch, fiir klin. Med., vol. v. 1869. PUNCTURE OF CHEST. 181 murmurs seem to be sometimes arterial, some- times venous ; but it is seldom possible to attain any certainty respecting the particular vessel in which they arise. SEOTION YIII. PUXCTURE OF CHEST. Since the discovery of auscultation, no more important addition has been made to our means of physical examination than the method of probing the chest by puncture.^ The end proposed is to detect collections of liquid within the chest ; pleural effusions, peri- cardial effusions, and hydatid cysts. The instrument employed is a small glass syringe, holding half a drachm or a drachm, and fitted with a hollow steel needle an inch and a half or two inches long, and as fine as is consistent with due strength. The place chosen for puncture is that where liquid is supposed to be : due regard being paid ^ The practice of puncturing the chest by a fine needle and for the purpose of diagnosis, as distinguished from l^aracentesis thoracis, was introduced by Thomas Davies : see his Lectures on diseases of the lungs and heart ; London, 1835: p. 344. 182 PUNCTURE OF CHEST. to the anatomy of parts within, so as to beware of wounding the heart, diaphragm, or large vessels. i. When a pleural effusion is suspected, the puncture should be made where the signs of disease arc most marked. But, if possible, let the sj^ot chosen be somewhere between the angle of the scapula and the edge of the pec- toralis major, and not much ])clow the nipple level. The bare suspicion of a ])leural effusion, however small it seem to be, is a sufficient reason for exploring the chest by puncture, in- asmuch as we know that to pierce the lung with a fine needle is harmless. Indeed I may say, as the outcome of a very large experience, that I do not remember a single patient to have »;een left the worse for a puncture made to detect a suspected pleural effusion. ii. Puncture is of much less use in the diagnosis of pericardial eft'usion. Wc dare not puncture upon the bare suspicion that a pericardial effusion may be present; we re- quire that its presence should first of all be rendered most highly probable by other means of physical examination. But these other means do not always enable us to distinguish between pericardial effusion and dilated heart; PUNCTURE OF CHEST. 183 yet, if we resort to the exploring needle to clecar up our doubt, we know that puncture of a dilated heart may kill the patient. Where- fore the greatest care is necessary. The rule is to puncture through the fifth left interspace an inch from the edge of the sternum. But the operator must use his discretion : by reference to published cases it will be seen that puncture has been successfully made in the third, fourth, fifth, sixth or seventh left interspaces, and in the third or fifth right interspaces.^ iii. When a hydatid cyst is suspected, the rule seems to be to pierce the lung with a long needle : at least this is the practice in Australia, where the disease is common.- The needle may enter a phthisical or other suppurating cavity within the lung, and the syringe draw off a little pus or muco-pus. When the diaphragm is much pushed upwards by a large abscess between it and the liver, and when, as is often the case, an empyema of the lower 1 Samuel West : ]\red. Chir. Traus. vol. 66, p. 235. - S. Dougan Bird : On hydatids of the lung. 2ud edit, Melbourne, 1877. Says that puncture for hydatids of the lung was first described by R. F. Hudson, in the Australian iSlad. Journal for April, 1861. Aspiration of a pulmonary hydatid is by no means free from danger : see Trans. Clin. Soc. vol. xxiv,, p. 73. 184 CONDUCTION 01" SOUNM. part of the right pleural cavity also is present, the exploring needle sometimes passes right through pleural empyema and diaphragm, so as to obtain pus from the abdominal empyema only. Subcutaneous emphysema sometimes follows puncture of the chest, either in old pleural adhesions or in pneumothorax. SECTION IX. C'OXDUCTIOX OV rur.MOXARY AND PLEURAL .SOUXD8. Unnatural respiratory sounds, heard by aus- cultation, are sometimes conducted to a distance from their place of origin. This is true of un- natural breathing sounds, of rales, and even (but seldom) of friction sounds. Thus a sound arising on one side of the chest may be heard on the other side, arising at the apex may be heard lower down, arising behind may be heard in front, arising in the larynx or trachea may be heard all over the chest. The sounds lose in loudness by conduction, and this fact is the guide to their })lace of origin : where the sound is loudest, there it arises. For the identification of a conducted sound with the original sound it is necessary that they both possess the same AUSCULTATION OF (ESOPHAGUS. 185 qualities, although the former be the less loud.^ ^ See Skerritt: Brit. Med. Journ., Nov. 22, 1884: p. 1005. Auscultation of the CEsophagus is practised in two ways. i. The x^atient's chest is auscultated along the course of the oesophagus, whilst he is swallowing a mouthful of liquid (see W. Hamburger : Klinik der Oesophaguskrank- heiten : 1871. Also. Mackenzie, Dis. of Throat and Nose : 1884: Yol. ii. , p. 7). ii. A flexible tube, passed down the gullet, is attached to a stethoscope ; whereby neighbouring organs, especially the heart, can be listened to through the oesophagus (see Richardson; Asclepiad, No. 36: 1892: p. 371. Also, Hoffmann : Central blatt filr klin. Med. Dec. 3, 1892). PART THE SECOND. CHAPTER I. PULMONARY CATARRH, OR BRONCHITIS. ^ 1. ivESPiiiATOKY sounds Weakened, and rales these are the signs of catarrh. % I. Weakening of respiratory sound is gene- ral or local : that is to say, the whole of both lungs, or only a part of them, is so affected, i. Local w^eak breathing is by far the commoner condition ; is due to the presence of mucus in the tubes ; may amount to complete suppression of sound ; is usually moveable in seat ; and of short duration at any spot. ii. General weak breathing is due to swelling of the mucous membrane, or to weakened respiratory move- ments. IF II. Kales are of two kinds, sonorosibilant and mucous. Both kinds hide the respiratory sound more or less. i. Sonorous and sibilant FULMONARY (JATABBH. 187 rale indicates local incomplete obstruction of the larger air-passages by mucus. It often happens that this sound arises in the larynx and is thence conducted through the lungs : in this case, a cough, by removing the mucus, removes the rale. ii. Mucous rale indicates the presence of mucus in the tubes of the lung itself. The seeming size of the rale is usually proportionate to the size of the tube wherein the rale is pro- duced. Mucous rale requires that the respira- tion be fairly vigorous : when the ebb and flow of air are much impeded the rale is imperfectly developed (obscure rale) : a deep breath will sometimes change obscure into distinct rale. AVhen no rales are heard, even although the expectoration is profuse, the excessive secretion probably comes from the largest windpipes. § II. i. Uncomplicated pulmonary catarrh is bilateral, affecting both lungs : mucous rale, when present, is most abundant behind and at the bases of the lungs, or indeed exists there only. Yet now and then, and in simple b]'onchitis too, abundant rale is heard for a short time in one lung only. However, per- sistent localisation of the signs of catarrh to one lung, or to a portion of lung other than the base, is an almost sufticient proof that the 188 PULMONARY CATARRH. catarrh is determined upon the part affected by some additional disease, ii. Severe pulmonary catarrh is attended, especially in very young or rickety children, by signs of inspiratory dyspnoea (p. 36), namely recession of tlie epigastrium, of the ribs and cartilages below the nipples, and of the supraclavicular spaces, iii. In the same class of patients, acute emphj'sema or insufflation of the lungs is sometimes rapidly produced ; it is indicated by bulging of the front of the chest.' iv. The percussion-note is often impaired, for a few days, even over the whole of a lung ; more commonly over a part only, especially the apices, the lower lobes, and tlie middle lobe of the right lung : associated collapse being the usual cause. On the other hand, in both children and adults, patches of unnaturally clear resonance may be met with ; probably due to local relaxa- tion of lung-tissue, v. When catarrh is com- plicated by scattered solidifications of the lungs (especially lobular pneumonia and miliary tuber- culosis) the rales acquire a sharp reverberating quality. Dilated tubes produce the same effect, but this lesion is very uncommon compared with scattered consolidations, vi. The deform i- ^ 'Tejorante iDassionc thorax etlam extantior fict. " Caelius Aurelianus : Acut. morb. lib. ii. cap. 27, H 144. PULMONABY CATAHRH. 180 ties, produced by catarrh, are sometimes per- manent : and have been already described under the names of pigeon breast, cupping of the lower part of the chest in front, and bulging of the upper part of the chest in front. § III. i. OEdema of the lungs, blood and diphtheritic exudations in the air-tubes, and miliary tuberculosis, cannot be distinguished from simple catarrh by the physical signs alone, ii. Pneumothorax is simulated when the main bronchus of a lung is completely plugged by mucus ; an accident sometimes met with in the stupor of cerebral diseases, sometimes occur- ring rather suddenly in the course of simple bronchitis. The breath-sound is suppressed over the greater part or the whole of one side, and the percussion-note is clear. But the dis- placed mediastinum and amphoric signs of pneumothorax are wanting, iii. Plugging of a main bronchus by anything but mucus is usually a severer condition : the signs being the same, the diagnosis depends on other circumstances.^ iv. The rale of pleurisy is sometimes mistaken for a simple catarrhal rale : pleuritic rale how- ever is mostly unilateral." ^ See chapter ix. - See chapter x. 190 rULMONAUY CATARBH. The physical signs of that form of chronic bronchitis which is characterised by the expec- toration of fibrinous casts, are sometimes the same as those of catarrhal bronchitis, local or universal. But very often there are no morbid signs at all, the disease being of small extent. On the other hand, when the bronchial exudation is considerable, collapse of a large portion of lung ensues, with corresponding physical signs. ^ ^ See cljaiJter viii. CHAPTER II. PULMONARY (EDEMA. THE simplest kind of pulmonary oedema is that which occurs acutely in the course of renal dropsy : it is to this form of oedema that the following remarks especially apply. The other kinds of oedema of the lungs are usually more or less complicated with other pulmonary lesions, such as the chronic bronchitis and brown induration of cardiac dropsy. § I. The physical signs of pulmonary oedema are chiefly those which denote the presence of thin liquid in the air-passages. II I. The respiratory sound is hidden by the rales. Bronchial breathing sometimes is heard in compact oedema, apart from any compression of the lung by hydrothorax. H II. Mucous rales, small in size, often sharp and reverberating. True crepitation, either in patches here and there, or much more extensive so as to involve the whole of one or both lungs, is sometimes present. § II. i. Pulmonary oedema is bilateral sooner 192 PULMONABY (EDEMA, or later, but it may attack one lung some hours before the other, ii. Hjdrothorax is a complication almost constant ; and also bilateral, unless obliteration of one pleural cavity by ad- hesion render the effusion necessarily unilateral, iii. Great inspiratory dyspnoea is sometimes pre- sent ; attended, it may be, b}^ extreme recession of the infra-mammary regions, even when hydro- thorax also is present. Inflation of the front of the lungs often ensues, such as to cause the heart's dulncss to disappear, iv. Percussion note unaffected : or somewhat diminished in resonance : or unnaturally clear in patches where the subjacent lung happens to be relaxed in consequence of the oedema or hydrothorax. Dulness to percussion, at the bases of the chest in proportion to the hydrothorax : yet consider- able pleural effusion will sometimes yield no percussion dulness, even when the diaphragm and liver are depressed so much as to distend the abdomen, v. Dilatation and pulsation of the jugular veins may sometimes be seen. § III. The diagnosis of pulmonary oedema from pulmonary catarrh depends more upon the symptoms than upon the physical signs. Com- pact or solid oedema affords dulness to percussion and bronchial breathing, and thus simulates pneumonia. CHAPTEB III. PULMONARY CONaESTIOX. § I. The only physical sign which has been supposed to indicate simple pulmonary conges- tion consists in accentuation of the cardiac second sound over the second left interspace close to the sternum ; in other words, the pul- monary second sound is louder than the aortic. It is in diseases of the mitral orifice that this sign is most often met with, and it is of some value when taken in this connection (p. 138). § II. Passive pulmonary congestion is usually associated with catarrh and its physical signs. Other complications, also common, are collapse, oedema, hydrothorax, and hsemorrhagic infarctus. § III. Brown induration of the lungs is a consequence of chronic congestion. Some im- pairment of percussion resonance, especially over the lower lobes and on the left side, is the only sign relative to this lesion. G.A. CHAPTER IV. PULMONARY HEMORRHAGE. ^ I. The physical signs of a moderate bron chial hyemorrhage are simply rales due to the presence of blood in the tubes : when the blood is expectorated as fast as poured out, there will not even be rales. § II. Hsemorrhagic solidification of the lung, when extensive enough (not less than three inches in diameter at the surface) yields the j)hysical signs which would be expected, namely, dulness to percussion and bronchial breathing. Hsomorrhagic infarctus is usually complicated by chronic catarrh and congestion, with their consequences. CHAPTER Y. PULMONARY EMPHYSEMA. Y pulmonary emphj^sema is meant a pvo- gressive dilatation of the air-sacs and destruc- tion of their septa, associated with increase in the bulk of the lung ; hjpertrophous emphysema, § I. The signs indicate enlargement of both lungs, i. Bilateral enlargement of thorax, ii. Depression of diaphragm, involving depression of heart, liver, spleen, and stomach : cardiac epigastric pulsation is a very early sign. iii. Extension of lung in front of heart : whereby the area of superficial cardiac dulness is diminished or al^olished, and the heart's impulse and sounds become enfeebled, iv. Bulging of lungs above clavicles, especially during cough or powerful expiration. § II. i. Emphysema is always bilateral, unless one lung be otherwise diseased so as to forbid its expansion. When one lung is indurated, or greatly collapsed from unyielding pleural adhe- sions, it is common to find emphysema of the 2 196 PULMONARY EMPHYSEMA, other lung. ii. The respiratory movements tend to assume the characters described under the name of non-expansive inspiration and expiratory dyspnoea, iii. The percussion-note tends to fall in pitch, that is to say, to become tympanitic ; the muffling mostly remains un- changed, or is even increased, although some- times the note becomes clear in places, iv. The respiratory sound is usually weakened, in conse- quence of the non-expansive inspiration. And the expiratory sound is often greatly prolonged, in consequence of the expiratory dyspnoea, v. Friction sound may possibly be produced by distended subpleural sacculi. vi. Muscular rumbling is sometimes heard, vii. Emphysema is often associated with pulmonary catarrh, and the physical signs are changed accordingly. Dilatation of the heart is a consequence of long- standing emphysema. § III. Emphysema has been confounded with pneumothorax. But bilateral pneumothorax is incompatible with life, and emphysema is bila- teral. Moreover, amphoric signs are never present in emphysema. CHAPTER VI. PULMONARY ATROPHY. A TROPHY of the lungs, with enlarged air-sacs, ■^ -^ occurs as a part of general senile atrophy, or as a consequence of previous pulmonary disease, especially arrested phthisis. § I. There arc no physical signs essentially belonging to the lesion. § II. Its accidental characters are these : i. Shape of chest uncertain, except that it is not bilaterally enlarged, ii. But it has all the fixed and inexpansible look of emphysema ; the sterno- mastoid muscles stand out strongly against the sunken supra-clavicular spaces, unless they be bulged by a forcible expiration, iii. Diaphragm depressed ; epigastric pulsation. iv. Heart covered by lung. v. Tympanitic percussion note over front of chest : the note is less reso- nant behind, vi. Signs of catarrh are common. § III. To these characters add the negative condition, that there are no definite signs of other disease ; and we have all the conditions which render physical diagnosis of pulmonary atrophy possible in a patient wdiose symptoms point to disease of the lungs. CHAPTER VII. ASTHMA. § I. The ph^'sical signs proper to asthma ; or, in other -words, the signs of an asthmatic paroxysm, i. Expiratory dyspnoea ; expiration forced and greatly prolonged ; ^ lower parts of chest fixed and immoveable ; no abdominal movements of respiration, or hardly any. This is the rule : but the signs of dyspnoea (that is to say, the powerful movements) may be more marked during inspiration than during expira- tion ; the dyspnoea being of inspiratory type, and denoted by considerable inspiratory ex- pansion of the upper chest, associated with great recession of the lower chest and of the root of the neck. ii. Chest bilaterally dilated during the paroxysm : diaphragm depressed. iii. Breath sounds weakened, sometimes ahnost inaudible. iv. Sonorous and sibilant rales ' " Anthony Henly's Fanner dying of {in Asthma, said, "Well, if I can get this Breath once out, III take care it shall never get in again." Swift's Miscellanies, vol. i. p. 263. ASTHMA. 109 common : mucous rales also towards the end of the attack, v. Heart sounds very weak, being heard through mflated lung. § II. Li the intervals of the paroxysm, the patient usually affords signs of pulmonary emphysema, atrophy, or catarrh. CHAPTER VIII. PULMONARY COLLAPSE. § I. Collapse of a few vesicles is indicated when deep inspiration brings out crepitant rale, audible for a few breaths only, and then heard no more for a time : a sign common at the base of the lung, back or front. § II. Collapse of larger portions of lung re- quires, for diagnosis, two conditions, namely, that the collapse be extensive, and in contact with the chest wall. ^ I. Extensive collapse of this kind sometimes occurs acutely. A lesion most common in young children, and especially in children feeble or rickety, and suffering from pulmonary catarrh, hooping cough, croup, or disease of the brain. The signs are much the same as those of sudden plugging of a large bronchus (chap. 9), and are dependent upon solidified and contracted lung. i. The base or even the whole of one side of the chest is shrunken, ii. Movements on the same side much impaired, iii. Dulness to percussion rVLMONARY COLLAPSE . 201 over the collapsed part : and sometimes a tracheal note in the parts around, iv. When the front of the left lung is collapsed, the heart is uncovered, and its area of percussion dulness increased. When the left lower lobe is collapsed, the heart is displaced to the left. When the right lower lobe is collapsed, the heart is displaced to the right, and the liver rises, v. Bronchial breathing over the area of dulness : or simply weak breathing if there be much mucus in the tubes. vi. Rales are usually present j and will be quite gurgling in character, if the collapse surround large tubes, such as those at the root of the lung. The diagnosis from pneumonia is sometimes im- possible at first. U 11. Extensive collapse may be developed more gradually, i. The conditions and the signs are sometimes the same as those of the acute collapse just described, ii. In typhoid fever we sometimes meet with signs, due to simple tempo- rary collapse, but which, when discovered in a patient examined for the first time, may be thought due to phthisis : namely, dulness to percussion at one apex, weak or puerile breath- ing there, and universal sonorous or mucous rales : signs which last not more than a day or two- 202 PULMONAUY COLLAPSE. iii. Collapse of the right lower lobe is sometimes dependent upon great enlargement of the liver ; collapse of the left lower lobe sometimes occurs in dilated heart or pericardial effusion. The diagnosis from pleural effusion depends upon the result of puncturing the chest, iv. Cirrhosis is apt to supervene upon that chronic collapse which is secondary to any form of pleurisy. Chronic collapse and cirrhosis cannot be distinguished during life ; for w^hich reason Laennec ^ called them both by the name of carnification (see chap. 25). The signs of both diseases are those of solidified and contracted lung. a. If the carnification involve only a portion of the lung (as is usually the case), this portion is the lower lobe : and the corresponding signs are, contrac- tion of the chest, especially of its lower part ; diminished resonance to percussion : bronchial or cavernous breathing ; and signs of catarrh, and sometimes of dilated bronchi. The heart tends to be displaced more or less towards the con- tracted side. The diagnosis from pleural efifu- sion depends chiefly upon the result of puncture. The diagnosis from tubercular phthisis depends upon the fact that the lower part of the lung is affected, upon microscopical examination of the ^ Ausc. med., 2iul edit. vol. ii., p. 224. PULMONARY COLLAPSE. 203 sputa, and upon the ^vliole history of the case. ft. If the carnification involve a whole lung (^Yhich is seldom the case), the affected side is shrunken and the opposite side distended, the dulness to percussion is absolute, vocal vibration weak, breathing sounds weak, whether bronchial or not j the heart becomes dilated. If the left lung be carnified, the heart will be extensively uncovered, and its pulsations widely visible. If the right lung be carnified, the heart may be so completely imbedded in the same lung, as to be undiscoverable during life. Extreme shrinkiog of the right lung may in other cases cause the heart to lie so wholly in the right side of the chest, and uncovered by lung, that congenital malposition of the heart is simulated. The diagnosis between a lung entirely carnified and a pleural effusion depends upon puncture : in the case of a concealed or displaced heart, puncture must obviously be made with caution ^ St. Barthol. Hosp. Reps., vol. xxviii. p. 1 : 1892. CHAPTER IX. PLUGGING OF TRACHEA OR BRONCHUS. BSTRUCTION within the trachea must obviously be very incomplete. But a main bronchus, or a large branch thereof, may be completely plugged for a considerable time : it is to this condition that the following remarks for the most part relate. § I. The earlier signs of a plugged bronchus are : i. Inspiratory dyspnoea, attended by imper- fect movements of the chest walls, on the affected side. Inspiratory recession of the base of the chest may involve both sides, even when one bronchus only is obstructed.^ ii. Percussion note not much affected at first ; but it tends to lose clearness of tone if the obstruction continue and collapse ensue. iii. Respiratory sounds weakened, or even abolished according to the completeness of the plugging, iv. A whistling sound or rale (rhonchus, sibilus, stridor), inspira- tory and expiratory, produced at the scat o ^ See St. L'art. Hosp. Reports, vol. xvi. p. 53 : 1880. i PLUGGING OF WINDPIPE. 205 obstruction, the plugging being incomplete. The rale is usually loud, and heard over a great extent of chest : the seat of the obstruction is not necessarily nearest to the spot where the rale is heard loudest, y. A palpable thri]], due to the same vibration as the rale ; inspiratory or expiratory ; felt over one side or both. § II. The later signs of a plugged bronchus are due, first to simple collapse of the affected part of lung, and afterwards to destructive pneumonia. The signs are: i. Permanent recession of the chest wall is common ; when unilateral, the other side is sometimes distended. Yet the shape of the chest is not always altered ; it is in a few cases quite natural. Corresponding displacement of mediastinum and diaphragm, ii. Immobility of affected side. iii. Percussion tone over the affected part much impaired ; it may be, -to absolute dulness. iv. The auscultation signs depend greatly upon the degree of bronchial obstruction ; sometimes there is little or no breathing sound ; sometimes there are bronchial or cavernous breathing, and rales more or less cavernous.^ ^ See cliapters viii. and xvii. CHAPTER X. PLEURISY. ALTHOUGH pleurisy cannot exist without inflammatory effusion, 3'et the term, pleurisy with effusion, is applied to those cases only which are attended by liquid effusion ; these will be discussed hereafter. The present chapter relates to pleurisy attended by effusion of coagulable lymph onl3\ ^ I. Pleurisy of this kind is often very local. The sign, not always present, is local friction sound. The resonance of the affected part of the chest may or may not be somewhat in>paired. § II. Pleurisy of this kind is sometimes universal, involving the whole of one pleura, i. The affected side is retracted, it may be con- siderably, and moves much less freely than in health. ii. The percussion-note is raised in pitch and muffled, over the greater part or the whole of the side. The sense of resistence is increased. When the disease affects tlie left side, the superficial area of cardiac dulness is PLEURISY, 207 extended, iii. The respiration generally is weak, and attended by friction sound (especially in the coraplemental space), or by -wide-spread rale, indistinguishable from the mucous rale of catarrh or phthisis. At places the breath-sound may be bronchial, in all degrees of intensity, up to perfect cavernous resonance, iv. Add to the physical signs hectic fever, and we can understand why pleurisy of this kind is often mistaken for phthisis more or less advanced. However, the pleuritic patients recover completely, without a vestige of disease left behind, save haply a slight unilateral retraction of the chest, or a cuplike depression. Whenever the signs of a case of supposed phthisis are in some respects peculiar ; whenever they indicate advanced and extensive disease but limited to one side of the chest ; whenever cavernous signs are heard in unusual places ; it is well to weigh the possibility of simple pleurisy. As a rule, the signs of pleurisy are more marked in the lowermost part of the chest, and the signs of phthisis at the upper part. CHAPTER XI. PNEUMOTHORAX. rpHE varieties of pneumothorax are these : — 1st. Air and liquid in the cavity : i. Cavity large : a. closed . . . Hydi-o-pneumothorax. $. with external fistula. Fistulous Empyema, ii. Cavity small . . . Loculated Pneumothorax, 2nd. Air alone in the cavity . Pure Pneumothorax. Art. I. — Closed Hydropxeumothorax. § I. Its physical signs are these : — Unilateral distension of chest, tympanitic percussion sound, weakened respiration and amphoric phaino- mena. H I. Distension of the chest is indicated by : — i. Unilateral enlargement ; sometimes so great as to cause an excess of three inches in the semi- circumference on the affected side. ii. Dej^res- sion of the diaphragm ; sometimes so great as to force the upper surface of the liver altogether below the level of the costal margin in front. FNE U2I0TH0IUX. 209 and to produce a band of tympanic resonance in the abdomen, aboYC the Uver dulness. iii. Dis- phicement of the mediastinum towards the un- affected side occurs almost instantaneously in perforative pneumothorax ; at first due no doubt to traction exerted by the lung of the opposite side ; but before long the air in the pneumo- thorax comes to exert positive pressure upon the mediastinum (p. 179). ^ 11. The percussion-sound falls in pitch and increases in duration, that is to say, becomes tympanitic in proportion to the distension of the pleura. The note, however, remains muffled ; and, in fact, when the distension is extreme, the muffling approaches dulness. The metallic ring is very seldom heard unless the ear be applied to the chest (by auscultation) during percussion : and thus heard, the metallic ring is nothing but the bell sound. Where liquid is present, non- resonance will be found : the liquid effusion is free, moveable, and changes its position with change in the position of the body. IF 111. The respiratory sound is weakened in proportion to the collapse of the lung. Some- times collapse is so complete, that no breathing is audible, except in the vertebral groove. When the lung has been solidified by previous G.A. P 210 PNEUMOTRORAX. disease, so that collapse cannot ensue, a respira- tory sovind, more or less loud and bronchial or amphoric, will be heard all over the pneumo- thorax. ^ IV. Amphoric signs, indicative of a large cavity, are present. Puncture of the pleura, even when it does no more than make pressure equal within and without the chest, (the pneu- mothorax remaining) will sometimes remove amphoric hum and bell-sound for a time. i. Amphoric hum attends the sounds of breath- ing, coughing, or talking. And let it not be supposed that amphoric respiration is necessarily due to air passing out of the lung into the pleural cavity and back again : on the contrary, this is seldom the case ; the breath sounds heard are pulmonary sounds, and acquire their amphoric quality by transmission through the pneumo- thorax, ii. Metallic tinkling may be present, iii. The bell-sound is the most constant sign of pneumothorax. iv. Succussion splash occurs when the quantity of liquid is considerable. § II. Inspiratory movement of the affected side is non expansive : vocal thrill is diminished, or even abolished. The respiration on the un- affected side is puerile. AVhcn pneumothorax is sccondaiy to phthisis, the apex of the lung often PNEVMOTHOBAX. 211 remains adlierent. In an old pneumothorax a large ulcerous opening is sometimes formed between the cavity and a large air- tube : there- upon, all active distension of the side ceases. In rare cases air is effused into the pericardium as well as into the pleura, whereby the signs indiccitive of displaced mediastinum are apt to be lost. § III. Xo disease of the chest affords signs more characteristic than those of pneumothorax, or can be discovered with greater ease and certainty, or is more often overlooked. The chief cause of this frequent failure in diagnosis is the fact that the observer is misled by the resonant percussion note into an assumption that the affected side is natural, and so into neglect of auscultation whereby alone pneumo- thorax can be discovered. Art. II. — Fistulous Empyema : Bififers from a closed hydropneumothorax in that the affected side is distended very slightly or not at all, or more frequently is contracted. Consequently the signs due to a large air-con- taining cavity are seldom present. v 2 ^12 PNEUMOTHORAX. Art. III. — LocuLATED Pneumothorax : Is most often met with at the base of one pleura. The cavity usually contains pus as well as air : whether amphoric signs be present or not, depends upon the amount of air. The signs sometimes vary with the position of the patient; thus, in the lying posture amphoric signs may be detected, which are quite absent, and replaced by the ordinary signs of empyema, in the upright posture. Pyopneumothorax of the base is often secondary to an emphysema- tous abscess below the diaphragm (p. 213). A loculated pneumothorax, which communicates with a large bronchus through a fistulous ulcer of the lung, can hardly be distinguished from a cavity formed within the lung. Art. IV. — Pure Pneumothorax : Is uncommon and mostly due to injury. The physical signs are the same as those of a closed hydropneumothorax, excepting those which depend upon the presence of liquid. Rupture of the diaphragm, on the left side, is apt to be followed by a state of things which PNEUMOTHORAX. 213 has been mistaken, during life, for pneumo- thorax.' The stomach and colon pass up into the pleurtil sac ; they become greatly distended with gas ; the lung collapses. Hence displace- ment of the mediastinum, such that the heart beats to the right of the sternum ; tympanitic percussion note over nearly the whole of the left side ; and great weakening or abolition of the breathing sounds there. The bell-sound Avill probably, the metallic tinkle and succussion splash may possibly, be present. Enough, in this place, to have pointed out the necessity for a cautious diagnosis. In a case of great contraction of the left lung, (due to phthisis), the distended stomach has been known to mount so high into the thorax, as to lead to the diagnosis of pneumothorax.^ An abscess below the diaphragm may become partly filled with air, and may so raise the 1 Butlin : St, Earth ol. Hosp. Reps. vol. xi. p. 255. See also Brinton : ibidem, vol. xix., p. 285 : who suggests that a clue to diagnosis may be found by noting the immobility of the abdomen on the affected side, as indicative of dia- phragmatic paralysis. Congenital deficiency of half the diaphragm produces similar results : seePolaillon, Union Medicale, no. 97 : 1881. 2 Riegel : quoted in Revue des sc. med,, vol. xxvi. : p. 139. 214 PNEUMOTHORAX. diaphragm, the pleura remaining uninjured, as to afford not only a tympanitic percussion note over the lower part of the chest, hut also some of the amphoric signs of pneumothorax. The breathing and heart sounds, conducted from the thorax, sometimes (not always) acquire amphoric quality by transmission through the air-cavity. A more constant auscultation-sign is the boll- sound. An air-containing sac between the liver and diaphragm, as contrasted with loculated pneumothorax of the right base, tends to cause much less displacement of the heart to the left, and much more displacement of the liver down- wards. But the position of the liver cannot always be determined, (and perhaps is not always much changed) when the air lies, for the most part, between the liver and the front part of the diaphragm and abdominal wall.^ Sub- phrenic abscesses are sometimes accompanied l)}^ thoracic empj-ema, the diaphragm being perforated or not ; if perforated, there is a pyopneumothorax also. ' See Coiiplanil : I'.iit. Mcil. Joiini. Mar. 23, 18S9 : G3> CHAPTER XII. HYDROTHORAX. HYDROTHORAX and oedema of the lungs, pleural and pulmonary dropsy, often co- exist. Hydro thorax tends to be bilateral, although the quantity of effusion is not always equal on both sides. And, being bilateral, the fluid cannot occupy more than a portion of the pleural cavities. i. When pulmonary oedema also is present, it is possible for great inspiratory dyspnoea, such as to simulate laryngeal obstruction, to concur with copious hydrothorax. ii. The diaphragm is depressed : the base of the thorax expanded : the position of the mediastinum remains un- changed, iii. Dulness to percussion co-extensive with the effusion, iv. Respiratory sound and vocal resonance either simply weak or feebly bronchial, over the regions where the percussion note is dull : sometimes a little mucous rale. CHAPTER XIII. PLEURISY WITH EFFUSION. PLEURISY with eflfusioii is usually unilateral. Its courso may be divided into periods of increase, height, and decline. § 1. Period of increase. 1] I. The earliest sign of pleurisy going on to effusion may be either friction sound or pleuritic rale (p. 207). The friction is usually very local : its common situation being over the base of the lung, in front or at the side. The rale is more extensive, and is sometimes heard over the whole of one side of the back. 51 II. More frequently, however, the earliest signs are those of liquid effusion : the same s'gns speedily supersede any friction sound or l^leuritic rale which may have preceded them. The liquid tends to collect, as soon as formed, in the lowest place : what constitutes the lowest place depends upon the attitude assumed by the patient while effusion is going on. At first, when the quantify is small, the lung is simply PLEURISY WITH EFFUSION. 217 relaxed, and swims uj)on the effusion : but as the hquid accumulates it compresses the lung, and renders it more or less empty of air. i. The great sign of liquid effusion is a co-extensive dulness to percussion. This dulness is not wholly due to the effusion, but is partly dependent upon associated collapse of lung ; that is to say, a layer of liquid an inch or more thick would transmit percussion resonance of the lung, were the lung resonant (p. 84), Dulness begins at the lowest part of the chest behind, above the complemental space (p. 176) ; the note being natural elsewhere. AVhen the effusion rises higher than the angle of the scapula, the lung will have relaxed to such an extent as to give a clear subtympanitic or tracheal note above the nipple of the same side in front : a sign not always present even in cases watched day by day from the onset. Whether, by further increase in the quantity of the fluid, the whole back become dull before the front is so at all, or whether the upper level of the fluid be comparatively horizontal, depends upon the attitude assumed by the patient while the effusion was going on. Hence, when the efi'usion is small, the dulness may be wholly posterior, and sharply defined in front by the posterior axillary line, the lateral 218 PLEURISY WITH EFFUSION. region remaining resonant. On the other hand, the upper limit of a duhiesy which occupies the lower and not the hinder part of the chest, often rises higher in the axillary region than in the back. Even when absolute dulness is confined to the base, there is usually some impairment of resonance all over the back on that side. The dulness over the effusion may be far from absolute. The anterior clear resonance, when present, is sometimes of cracked-pot quality, ii. In proportion to the amount of effusion, the side is enlarged, diaphragm depressed, and medias- tinum displaced. Yet even this rule is not constant : the heart may remain unmoved by an effusion of not less than a quart of serum into one pleura, iii. Vocal thrill is diminished where dulness to percussion exists, and is wholl}^ abolished in great distension of the side. iv. The respiration is at first weakly vesicular, and sometimes remains so throughout the disease. But mostly the breathing soon becomes bron- chial ; sometimes even before the dulness becomes absolute. With progressive increase of effusion, the bronchial breathing tends to become less and less loud until, at last, it is wholly suppressed. But sometimes, although tlie quantity of fluid be very great, loud PLEURISY WITH EFFUSION. 219 bronchial breathing is heard all over tlie affected side : the fact beiiic: that the loudness Fici. 15. Course of Pleukisy wnii Effusion, left side. Outer line — linrizontal section, before pnracentesis. Middle line (d(itLed) — four days after i:aracerjtesis. Imier line (dotted) - three wctks alter i:aracontesis. depends, not inyersely upon the quantit}- of fluid effused, but directly upon the openness of the air-tubes, v. Vocal resonance weak and bronchial in much the same manner as the respiratory sound. When the effusion is partial, ^\ith clear resonance in front, the Ironchophony is sometimes ccgophouic about the 220 PLEURISY WITH EFFUSION. angle of the scapula, vi. By percussing the chest in front with two coins, and auscultating behind as for the bell-sound (p. 131), a pleural effusion will sometimes be found to transmit a clear metallic sound quite unlike that heard through healthy or solid lung.^ § 11. The effusion at length reaches its height. This sometimes will not be until the pleural cavity is tensely full ; or the effusion may stop at any point short of that extreme. When the quantity of fluid on the left side is very great, the left half of the diaphragm is occasionally depressed to such an extent that not only can the lower margin of the spleen be felt, but even its upper margin, in fact its whole outline. At the same time, the thrusting of the heart and mediastinum into the right side of the thorax may cause the right wing also of the diaphragm to be depressed to an almost equal degree ; a point ascertained by examination of the liver. Percussion, moreover, may show that the liquid reaches beyond -the edge of the sternum on the other side of the chest. A small protrusion, in the lateral region, distended during expiration, ' Pitres; see Eritisli :\rea. Journ. Ap, 3, 1886. This sign was described, undei' the name of *'signe de sou," by Sieur in a These de Paris (1883) which I have not seen. PLEUBISY WITH EFFUSION. 221 receding during inspiration, and due to perfora- tion of the pleura and intercostal space, may be met with, even in moderate serous effusion. When the effusion is partial, its position does not shift easily or at all with changes in the position of the body. The semi-circumference is sometimes actually less on the diseased than on the healthy side (fig. 18). Lastly, it is often by no means easy to guess at the quantity of the effusion : the physical signs will sometimes seem to indicate a large or a small effusion, and paracentesis will prove the contrary. § III. Period of decline. When a pleural effusion undergoes absorption, or is discharged by paracentesis, the following series of physical signs are noted. The diaphragm and mediastinum go back towards their natural position : to follow the retreating organs is the best means of marking the progress of absorption, so long as the quan- tity of the effusion remains great. The distension of the affected side becomes less j and accurately to register this fact is a most important service rendered by the cyrtometer. When the effu- sion has so far diminished that the lung again comes into contact with the chest-wall, percus- sion usually enables us to follow the falling level 222 PLEURISY WITB EFFUSION. Fi-. IG. COURSH OF AN EFFUSION INTO THE LeFT PlKL'RA : KKOM DaMOI.SEAU. aa=liiiiits of effusion, heart, liver, and spleen, when latient lirst seen. h b = sanie on first clay of treatment. c c = secoriil day. d r; = third day. e c = fourth day. ■//=tifth day. fj (/ = niorning of sixtll daj*. i = eveninf; oif sixth day. /t/i = last limits of ellusioii previous to disappearance, i.e., on tenth day. .V y s = lowcr limit of pleura. PLEUUmY WITH EFFlfSTO^\ 223 Fig. 17. U / Course of an Effusiox i^^to the Lrft Pleura : FROM DAMOiaEAU, 224 PLEURISY WITH EFFUSION. of fluid. And, at the same time, auscultation will sometimes inform us when and where actual contact of the opposed surfaces of the pleura has occurred ; friction sound being heard. With reference to the percussion signs more particularly. Dulness, practically absolute, and due to the unexpanded lung, often remains for a long time after perfect adhesion has occurred. The manner in which the effusion is absorbed is not constant : as a rule, the diminishing effusion follows a course more or less like that indicated in the annexed sketches. ^ The upper surface of the liquid, when it reaches as high as two inches above the nipple, is horizontal : when lower than this point, the dulness forms irregular parabolic curves, which become smaller and smaller, and last of all disappear at the lowest parts of the thorax. The fluid is mostly absorbed in the following order : from the vertical groove near the root of the lung ; from the supramammary region ; from the rest of the vertebral groove and infrascapular region ; from the infra- mammary region ; and lastly from the lower lateral region ; concerning which point it is important to remember that the lowest part of the pleural cavity, in the upright position, is ' Dainoiseau : Arch. gen. deMed.: Oct. 1843: p. 129. PLEURISY WITH EFFUSION. 225 in the axillary line. The curve of the sinking fluid is sometimes double, as happened to be the case with the patient represented in the draiving. And indeed we must be prepared to find the residue of liquid in almost any part of the chest. Disappearance of effused liquid at any spot is sometimes attended, for a day or two, by friction sound, indicative of restored contact be- tween the pleural surfaces : redux friction, as it is usually called. A large serous effusion is sometimes absorbed, not from above downwards according to the rule, but equally all over the side at once ; friction or pleuritic rale becoming audible all over the side at once. The latest physical sign, dependent upon ab- sorption, is the retraction of the affected side. Cup-like sinking of the lower part of the sternum occasionally ensues. In some cases these de- formities tend to disappear gradually, in others they are permanent. The luug sometimes remains wholly unexpanded and carnified : the signs of this condition are described on p. 202. A systolic murmur, having the characters of a pulmonary obstructive murmur, sometimes concurs with pleural effusion : disappearance of the effusion being attended by disappearance G.A. Q 228 FLEUEISY WITH EFFUSION. of the murmur.^ A permanent murmur of the same kind is sometimes heard when one side of the chest is left contracted after pleurisy. § IV. The Diagnosis. The crucial test of pleural effusion consists in puncture of the chest (p. 181). When pus is very thick, it cannot be drawn through a fine needle : in this case a larger aspirating trocar and cannula must be used. The false membranes around an old em- pyema are sometimes extraordinarily thick and tough : when the needle is felt to enter tissue of this kind, it must be pushed on boldly, and pus will almost certainly be reached, i. Cancer of the lung closely resembles pleural effusion in respect of the physical signs. But cancer does not often cause enlargement of the aflfected side : nor does the dulness of cancer usually follow the laws which have been laid down with regard to pleural effusion, ii. Quickly-growing sarcoma, within a pleural cavity, has been known to distend the side of the chest, to displace the heart and diaphragm, and altogether to simulate large pleural effusion, except in the results of puncture.^ iii. Hydatid tumours within the chest are not common : their characters v/ill be 1 Phillips : Lancet, May 25, 1889, p. 1025. 2 De Havilland Hall : Clin. Soc. Trans, vol. xiii. p. 200. PLEUPJt^Y WITH EFFUSION. 227 described hereafter, iv. Chronic collapse or cirrhosis of one lung, in whole or in part, cannot be distinguished from pleural effusion, except by puncture. Collapse of the lower lobe of the left lung, dependent upon dilatation of the heart or pericardial effusion, is not easily distinguished from moderate pleural effusion, except by punc- ture. V. Acute pneumonia is seldom confounded with pleural effusion unless the tubes of the pneumonic lung be plugged with mucus, so that conduction of the breathing sounds is obstmcted. But acute pleurisy with effusion is often wrongly supposed to be pneumonia. Much weight must be allowed to the fact that pleurisy with effusion tends to enlarge the chest, alter its shape, and displace the diaphragm and mediastinum ; and that pneumonia does not. vi. But with destruc- tive pneumonia, tubercle, and actinomycosis of the lower lobe it is different : diagnosis of these lesions from chronic loculated pleural effusion is often impossible except by puncture. And even in puncture may lurk a fallacy already alluded to, namely, that the needle may draw off a small quantity of pus from a suppurating cavity. ■ vii. Hepatic tumours, especially hydatids and abscesses, sometimes reach so high in the chest as closely to simulate pleural effusion on the right Q 2 228 PLEURISY WITH EFFUSION. side. The clue to diagnosis lies in the detection of hepatic enlargement by abdominal examination, and in the results of puncture, viii. To divS- tinguish an abscess situated between the liver and the diaphragm is difficult : such an abscess will displace the heart less and the liver more than will an empyema. But both hepatic and subdiaphragmatic abscesses are often complicated with loculated empyema at the base of the right chest : in cases of this kind a trocar will some- times pass right through the empyema and diaphragm into the abdominal abscess ; the diaphragm lying high in the chest in spite of the empyema.^ ix. Densely coagulated ha3mo- thorax has been mistaken for empyema. ^ 1 See pp. 213 and 230. - Watson : Principles and practice of pLysic : 4th edit vol. ii. p. 117. 1857. CHAPTER XIV. EMPYEMA. § I. Empyema of a whole pleural cavity affords the physical signs which have been described under the head of pleurisy with effusion. Often enough the distension of the affected side is anything but great : the heart for instance may be very little displaced, a fact which is sometimes due to pleural adhe&ion over the pericardium. The signs of pneumoempyema (pyopneumothorax) and of fistulous empyema have been already described. § II. Small collections of pus in the pleura are sometimes enclosed in dense adhesions : loculated empyemata. U I. These partial empyemata occur in the following situations : i. Most commonly in the back of the pleural cavity, or between the lung and the diaphragm : the latter, or diaphragmatic empyemata, are usually larger behind than in front, ii. Less commonly in the lateral region, in the antei'ior region, between the lung and 2.30 EMPYJi:MA. pericardium, or between the lobes of the lung, iii. Sometimes there are many small empyemata in one pleural cavity : sometimes there is a loculated empyema on each side. ^ II. These partial empyemata are often complicated : when diaj^hragmatic, with subdia- phragmatic and hepatic abscess : when on the left side, with purulent pericarditis.^ Empyema on the right side of a person who has lived in the tropics, and who has suffered from dysen- tery or hepatitis, is very often associated with deep abscess of the liver. IT III. The physical signs of local empyema are these, i. Chest contracted on the affected side ; or contracted above and distended below ; or there may be a local bulging ; in the axillary region, bulging is common, ii. Breathing move- ments of the pleuritic side diminished. A pointing empyema sometimes moves with breathing, bulging with expiration and flilling with inspiration. iii. Heart sometimes dis- ^ Subdiaphragmatic abscess is often due to perforation by ulcer of some part of the alimentary canal ; stomach, duodenum, or appendix vermiformis: and the i)rimary disease may be latent, so that the abscess is the first thing to be discovered. Abscess around the kiduey may, in like manner, be first of all made manifest as a subdiaphragmatic abscess. EMPYEMA. 231 placed, often not. Liver sometimes displaced downwards in diaphragmatic empyema : how- ever, even in a large supradiaphragmatic em- pyema on the right side, the liver may not be depressed. Stomach note, when the left side is affected, often reaches high, say to the nipple level, iv. Percussion note sometimes impaired over whole of affected side, sometimes not. When the empyema is superficial, dulness at the spot : but not always absolute dulness, the tone of underlying or neighbouring lung being conducted by the effusion. Indeed over a very small empyema, there is sometimes no dulness at all. The dulness, not being due to the pleural effusion simpl}^ (p. 84), affords no measure of the extent and capacity of the empyema : dulness, absolute and almost uni- versal, maybe associated with a small empyema, the signs being chiefly due to collapsed and adherent lung. v. Respiration usually simply weak all over the affected side : sometimes bronchial where the empyema is superficial. Crackling rales are common. ^ IV. The diagnosis has been discussed in the last chapter. When empyema is complicated with catarrh, the resemblance to tuberculosis, local or general, is great. 232 EMPYEMA. § III. Pulsating Empyema : empyema which pulsates rhythmically with the heart.^ H I. The empyema is commonly very large, occupies and fills the left pleural cavity, i. In a few cases, the pleural effusion (usually purulent, seldom serous) nowhere points or bulges through the chest wall. The pulsations are sometimes seen and felt over almost the whole of the side, but mostly they are limited to the normal heart region (that is to say, on the left of the sternum), or to the lowest three or four left interspaces, ii. More commonly the empyema points in one or two places, which alone pulsate. This bulging occurs in the normal heart region, or in the lowest interspaces : twice has the protrusion been seen in the loin below the ribs. The bulg- ing is never larger than an orange. H II. In all cases of this kind, whether bulg- hig or not, the heart is much displaced to the right : pericarditis may concur, but usually the heart is healthy. Auscultation of the pulsating part may detect conducted heart sounds. Pal- pation detects no thrill and no expansion like that of aneurysm. IT TIL Paracentesis greatly helps the diagnosis. ' Comby : De Tempyeme pulsatile : Paris, 1882: has col lecte'l rao.st recorded instances of pulsating empyema, EMFYEMA. 233 By removing part of the liquid the pulsation ceases : but the heart does not return to its natural position, being fixed by external peri- cardial adhesions. IT IV. The effusion is mostly chronic, and the lung wholly collapsed. Pneumothorax some- times concurs : in this case the pulsation is con- veyed by the liquid only. ^ V. The diagnosis is from intrathoracic aneurysm, and from the very uncommon con- dition of a pulsating cancerous tumour. Aortic aneurysm and pulsating empyema may concur. ^ VI. Very seldom the empyema does not fill the whole pleural cavity but is loculated and enclosed in adhesions. This kind of pulsating empyema always bulges, it may be to the right of the sternum, but still in close neighbourhood to the heart. CHAPTER XY. ADHERENT PLEURA. § I. Very densely adherent pleurae are at- tended by the signs of unilaterally contracted Fig. IS. Unilateral Retraction of Left Sid of Chest consequent UPON AN Adherent Pleura. chest. The percussion sound will be impaired? and the breath sound weakened, over a large part of the affected side. Sometimes the signs ADHERENT PLEURA. 235 of chronic collapse or of cirrhosis of lung are present. § II. But much looser adhesions^ such as are so often unexpectedly found post mortem, and which influence the percussion and auscultation of the chest in no respect, may be sometimes discovered by the cyrtometer, when one pleura only is obliterated (fig. 18). § III. Eecovery from pleural effusion or em- pyema is sometimes complete, so far as physical signs are concerned ; the most careful examina- tion failing to discover contraction of the chest, or any other sign of past disease. CHAPTER XVI. PNEUMONIA. ACUTE pneumonia is of two kinds, lobar and lobular; tlie solidification being, in the former case massive, and in the latter dissemi- nated. Art. I. — Lobar Pneumonia. § I. The earliest distinctive signs are those which depend upon hepatisation. Of the en- gorgement, which precedes hepatisation, there are no constant signs. Crepitation certainly is no such sign ; for it is a rale which may appear at any period of the disease, and which in many cases does not appear at all : seldom are conso- lidation-signs presided by crepitation ; and they do not always follow it. Other precursors of the distinctive signs are met with now and then ; mucous rales, and well-marked pleural friction. The signs of hepatisation sometimes appear quite late in the disease, for instance on the fifth or sixth dav of the fever, or even not until PNEUMONIA. 237 the defervescence. Indeed there may be no physical signs whatever in the course of a disease which resembles pneumonia in all other parti- culars. § II. Hepatisation of the lung is characterised by dulness to percussion, bronchial breathing, and bronchophony, i. In persons whose chest- walls are resilient, the dulness may be less absolute than that afforded by pleural liquid effusion, cancer of the lung, or dense tubercular consolidation. A. muffled tubular note some- times best expresses the character of the per- cussion sound. Clear tubular percussion note sometimes precedes the hepatisation dulness. When islets of unsolidified lung are imbedded in the surface of the hepatised tissue, they afford clear tubular resonance, or even a cracked- pot sound. A cavity, or large bronchus, sepa- rated from the surface by a thin layer of pneumonic lung, will produce the same effects, ii. The bronchial breathing of pneumonia some- times differs from that commonly met wdth in other diseases by being more whiffing, tubular in short. However, even in genuine lobar pneumonia, the bronchial breathing is not sel- dom of the ordinary softer kind. The broncho- phony is mostly of a sniffing kind. All breath- 238 FNEUMONTA. ing sound and vocal resonance may be absent over hepatised lung : this condition is either fleeting or lasting ; when fleeting, it is due to obstruction of the larger tubes by mucus, which a cough can remove ; when lasting, the air-passages probably contain solid exudation or coagula. In infants the bronchophonic cry is often the only auscultation- sign which can be obtained, iii. Nigh unto the area of bronchial breathing and dulness, true crepitation is some- times heard, over lung whose percussion tone is good, and which may or may not afterwards become dull. Reverberating mucous rales are sometimes present. Friction sounds also. iv. In lobar pneumonia of the lower half of a lung, the chest, on that side, is expanded to the state of deep inspiration ; but this expansion is less than that of a pleural effusion ; moreover, pneumonia never displaces the heart or the diaphragm, v. Pneumonia of the upper part of the lung is sometimes attended by the clearest tracheal percussion note in front on the same side. vi. Hepatised lung is sometimes felt to throb rhythmically with the heart. Laennec ^ believed that the solid lung simply conducted ' Auscult. mediate : 2nd edit. vol. ii. p. 388. I'NEUMONIA. 230 the heart's movements : Graves^ held that the dilated vessels of the engorged lung pulsate. § III. Hepatisation mostly undergoes reso- lution ; which is characterised by progressive diminution in the bronchial quality of the breathing, by the occurrence of mucous rales and by gradual restitution of the pulmonary percussion-note. Abundant true crepitation may be heard during this stage. The percussion- note may become tracheal and clear for a day or two. Much impaired resonance often re- mains for a long time after all the acuteness of the pneumonia has passed away. Occasionally the solidified tissue softens rapidly down into an abscess^ a condition which does not admit of diagnosis. Unresolved pneumonia passes into cirrhosis. Pleural effusion (especially empyema) is a sequel not uncommon. § IV. The diagnosis of lobar pneumonia mainly relates to acute pleurisy with effusion. When breathing sounds are not heard over hepatised lung, a pleural effusion is somewhat simulated. Much more often is an acute pleural effusion, not very large, supposed to be pneu- monia. In either case, if the diagnosis cannot othenvise be attained, a puncture should be 1 Clinical lectures : 2nd edit. vol. ii. p. 39. 240 PNEUMONIA. made. The two diseases sometimes concur. Collapse of lung (p. 201) and acute solid oedema (p. 192) may simulate pneumonia. Art. II. Lobular Pneumonia. Severe catarrhal or diphtheritic bronchitis occurring in children, old people, or debilitated persons, is very apt to be accompanied by lobular pneumonia. If the pneumonic foci be discrete, the signs are not more than those due to the catarrh. If the foci be confluent over a considerable extent of lung, dulness to percus- sion, bronchial breathing, and sharp reverberat- ing rales may be heard : over the middle lobe of the right lung for instance. CHAPTER XVII. DESTRUCTIVE PKEUMONIA AND TULMONARY GANGRENE. "TXESTRUCTIVE pneumonia due to plugging -L/ of a bronchus has been abeady described (p. 205). The same lesion may be produced by compression of a bronchus by a tumour of some kind, usually aneurysmal or cancerous. The primitive pneumonic consolidation tends to ulceration and excavation, or to gangrene. Dilatation of the tubes is common. The signs relating to the affected lung are : dulness to percussion ; and, at first, weakness, in any degree up to total loss, of vocal thrill, vocal resonance, and breathing sounds. Later on, signs of excavation, altogether like those of phthisis, may appear; bronchial breathing, bronchophony, and gurgling rales. The diag- nosis from pleural effusion depends chiefly upon the result of puncture. Tubercular phthi- sis is to be distinguished by microscopic exami- nation of the sjjuta. G.A. R 242 DESTRUCTIVE PNEUMONIA. The diagnosis of Pulmonary Gangrene, wliat- evcr be its cause, depends chiefly upon the characters of the sputa, namely, the foetor, and the pulmonary elastic tissue to be seen by microscopic examination. When the patch of gangrene is large and single, the signs are the same as those just narrated : when the gan- grenous spots are many, small, and scattered through the lung (a result of embolism), the auscultation and percussion-signs are those of diffused catarrh. The diagnosis is from other diseases attended by stinking expectoration, namely : from local empyema (by puncture) ; from phthisis (by microscopical examination of sputa) ; from dilated bronchi, with or without surrounding consolidation of lung ; from mere bronchitis ; and from abscess of the bronchial glands, which opens into tlie air-tubes. CHAPTER XVIII. EMBOLIC PXEUMONIA, OR PYEMIC INFARCTUS. U I. The physical signs are chiefly due to attendent pleurisy, namely : friction sound over any part of the chest ; or signs of pleural effusion at the base, dulness to percussion and bronchial breathing.^ IT II. The solidification itself may be large enough to afford signs. A superficial infarctus the size of a walnut, will yield, in a lean adult or a child, distinct dulness to percussion and bronchial breathing. Innumerable small scattered lesions, whether solid or purulent, yield the signs of bronchitis and nothing more. IT III. Pneumothorax may follow the bursting of a pysemic abscess. ^ Plugging of a large pulmonary artery, by a dislocated venous thrombus, is followed by signs of oedema in the part of lung affected, when the patient has recovered from the immediate shock of the embolism. B 2 CHAPTER XIX. PULMONARY TUBERCULOSIS. ACUTE or chronic pulmonary tuberculosis, if scattered, that is to say, not going on to massive consolidation or phthisis, seldom affords physical signs which have any direct relation to the tubercle. IF I. Latent. The lesion is sometimes wholly latent ; a most copious eruption of miliary tubercle being found after death in lungs which during life yielded no physical signs of disease whatever. IT II. Bronchitic. Another form of the lesion is bronchitic, the tubercles being either miliar}'- or crude ; and the signs, diffused over both lungs, are these : Percussion-note eitlier un- altered, or somewhat raised in pitch, the resis- tence being increased at the same time. Breatli sounds weak ; sometimes faintly bronchial here and there. Mucous rales, which are sometimes sharp and reverberating, sometimes not : now and then, fine inspiratory crepitation. Signs of PULMONAEY TUBERCULOSIS. 245 a more maj^sive consolidation of a portion of the lung are sometimes present. Indeed there are all degrees between the bronchitic form of tuber- culosis and common phthisis. ^ III. Pneumonic. Acute pulmonary tuber- culosis sometimes takes on a pneumonic form ; that is to say, massive tubercular consolidation occurs so rapidly as to afford crepitant rale, and most of the signs of lobar pneumonia. CHAPTER XX. PULMONARY PHTHISIS. ~pY pulmonary phthisis is meant massive -■-^ tubercular consolidation which tends o ulceration. § I. The physical signs of phthisis depend upon these particulars : the consolidation itself; diminished bulk of the solidified part ; the localisation of rales in the solidified part ; and the formation of cavities. IF I. i. Consolidation is indicated by diminu- tion of percussion resonance ; the pitch of the note rises and its clearness diminishes until, in some cases, absolute dulness is reached, ii. In the earlier stage of progressive solidification the respiratory sound is simply weak (an important sign) ; later on, it becomes more and more bron- chial. The bronchial breathing, which at first is due to consolidation of the spongy structure, afterwards becomes intensified (or cavernous) by the formation of cavities. In rare cases, when the solidification is very dense and massive PULMONARY FJITIIISIS. 247 and not jet excavated, the respiration cannot bo heard at alL ^ IT. Diminution in the bulk of the solidified part occurs early in the disease, and is attended by contraction of the corresponding region of the chest. When the left upper lobe is affected, the superficial area of cardiac dulness "v\'ill be increased. That form of phthisis which ends in cirrhosis, affords the most marked shrinking of the chest : in these cases displacement of the mediastinum and of the heart, and elevation of the diaphragm occur. *[[ III. Fixed localisation of mucous (crackling, bubbling, subcrepitant) rales in a limited portion of lung, is an early and important sign of phthisis. At first more or less obscure in pro- portion to the weakening of the respiration, the rales gradually become clear and reverberating (or cavernous) as consolidation and ulceration proceed. ^ IV. The diagnosis of cavity demands that it be near the surface, not smaller than a walnut, and containing for the most part air. i. Under these conditions the formation of a cavity is sometimes attended by a change of the previously dull percussion sound into a clear tone. When this is the case, the pitch of the tone may vary 2t3 PULMONARY PHTHISIS. according to the openness of the patient's mouth and to his posture ; but these are niceties of little or no importance.^ ii. A large cavity is sometimes attended by bulging of that part of the chest-wall which had previously been sunken, iii. The bronchial quality of tlie respiratory sound is always well marked in an empty cavity : the rales are large and resonating (cavernous). iv. The veiled puff is believed by some to be a sign of cavity, v. Practically the physical diagnosis of excavation mostly comes to this, that, in progressive phthisis, a cavity is pre- sumed to be present where the bronchial breath- ing is most intense, vi. Very large cavities may afford amphoric percussion-note, amphoric hum, metallic tinkling and splashing ; but seldom a bell sound. Indeed, amphoric signs are uncommon in phthisis: and yet a phthisical cavity may be so completely cleaned out and distended with air, as to yield all the amphoric sounds, to displace the heart greatly, and to simulate pneumothorax very closely. § II. i. The chest of persons j)redisposed to phthisis is usually phthinoid ; and that of per- ' Wintrich : Einlcitiing, p. 23. Gerhardt : Deutsche Klioik for 1859 : p. 108. Also Wv.rzburg. Verhandhingen. Neue Folge. vol. ix. p. 1. 1875. PULMONARY PHTHISIS. 249 sons actually phthisical, flat. Inasmuch as phthisis seldom involves both lungs to an equal extent, unilateral retraction of the chest is mostly present. A much m.ore local shrinking commonly occurs where the phthisical processes are most advanced. Occasionally the thorax is of emphysematous shape : this is the case when phthisis is engrafted upon emphysema, or •when emphysema follows retrograde phthisis, ii. Cracked-pot sound is sometimes begotten by percussion over phthisical consolidation, both when a cavity is present and when it is not. Clear tracheal resonance sometimes attends incipient phthisis, when there is no reason to suspect cavity ; a sufficient explanation is not forthcoming. iii. Sounds other than obvious rales, creaking and rubbing sounds, are not uncommon, and are most likely produced in the solidified tissues themselves ; sometimes, how- ever, undoubted transitory friction is heard. Collapse crepitation may be heard over phthi- sical lung. iv. The coexistence of a diffused pulmonary catarrh, or of emphysema, or of laryngeal disease, is a great impediment to the physical diagnosis of phthisis. Generally speak- ing, the physician should examine a patient, supposed to be a phthisical, several times before 250 PULMONAIiY PHTHISIS. giving a positive opinion, v. Aneurysmal dila- tation of a branch of the pulmonary artery, contained in a phthisical cavity, has been known to give rise to shrill sj^stolic murmur audible in the suprascapular fossa. ^ Murmurs produced in the subclavian artery are not uncommon, vi. The respiration in the unaffected parts of the lungs is puerile, provided it be not modified by the presence of catarrh. The loudness of the puerile breathing sometimes leads the inexpert to predicate disease just in that one part where the lung remains healthy. § III. The diagnosis between phthisis and some forms of catarrh, pleurisy, pneumonia, pulmonary cancer, hydatid, cirrhosis, and my- cosis, is discussed in the chapters w^liich deal with those diseases.^ ^ See -p. 159 for the pulsatile sounds of cavity : and note on p. 160 for pulse-breath. ^ Pneumoconiosis (dust disease of the lung), if not tuber- cular, cannot be distinguished from phthisis by the physical signs alone. If syphilis, in rare cases, affect the lungs, a clinical history of the disease remains to be written. CHAPTER XXI. PULMONARY CANCER. U I. What has been said of pneumonia and tubercle, is true of cancer ; that small dissemi- nated consolidations cannot be discovered by physical examination. ^ 11. Tlie signs of massive cancer are, in general, absolute dulness to percussion, dimi- nished or absent vocal thrill, immobility of the chest on the affected side, and weak or absent breath-sound. When a large open bronchus is intimately connected with the cancerous mass, bronchial breathing will be heard. H III. Cancer sometimes causes remarkable contraction of a whole lung : in such cases, pleural effusion almost necessarily follows. The physical signs are those of the effusion : but the diagnosis can sometimes be made by the dis- covery of cancer elsewhere, and, in particular, of large hard glands above the collar bone (on one or both sides) or in the armpit. H IV. i. Phthisis is simulated by cancer of 252 PULMONARY CANCER. the apex of one lung, especially when it breaks down into cavities/ Physical diagnosis in such a case becomes possible only when the cancer involves the mediastinum, or spreads in a man- ner unlike the phthisical process, or affects other remote organs, ii. It has been already pointed out (p. 226) that very large cancerous tumours of the lung afford signs which for the most part closely resemble those of pleurisy with effusion. But cancer, unless of quickest growth, does not enlarge the chest; and may even cause it to be contracted. The mediastinum and diaphragm are seldom displaced. Nevertheless, a quickly- growing tumour sometimes sprouts so as to displace the heart or depress the diaphragm. When dulness begins not at the bottom of the chest ; when there is a great extent of absolute dulness in front, and none behind ; when, in the midst of a great extent of dulness, we detect one or more small insulated patches of resonance (haply quite clear or even cracked-pot) ; we may debate the existence of solid tumour. The crucial test is puncture, iii. Mediastinal cancer (chap. 42), and pericardial or pleural effusions often concur with pulmonary cancer, iv. Can- 1 J. R. Bennett: Brit. Mod. Journal. 1870, pp. 565 .S'^iq. FVLMONAIiY CANOEH. 25.3 cerous tumour of the lung, near to the heart or aorta, may (hke mediastinal tumour) pulsate, and also yield a systolic murmur, it is said.^ In such a case, the diagnosis from aortic aneurysm might be very difficult. 1 Stokes : Diseases of the chest: 1837 : p. 378. Cancer of upper lobe of left lung, causing ijnlsation and murmnr behind manubrium sterni and its neighbourhood : the pulsa- tion probably not in vessels of new-growth, but conducted from pulmonary artery. CHAPTEK XXII. PULMONARY HYDATIDS. ^ T. A HYDATID cyst may be buried so deeply within the lung as to be altogether beyond the reach of physical examination. ^ U, A moderately large cyst is indicated by an area of percussion dulness not smaller than the palm of the hand, always rounded in shape, with a sharp outline, and situated most com- monly in the lateral or infraclavicular regions.^ Over this dull space, vocal thrill and breathing sounds are absent. Beyond the dull space, both percussion and breathing sounds are natural : portions of lung may be relaxed, just as in pleural effusion, so as to yield a percussion resonance unnaturally clear. Local hemispheri- cal bulging sometimes occurs. Local friction also. ^ IIL A very large hydatid cyst will yield most of the signs of partial or total pleural effusion, namely, unilateral distension of the 1 S. Dougan Bird : already cited (p. 183). PULMONARY HYDATIDS. 255 chest, displacement of the diaphragm and mediastinum, duhicss to percussion, and weak or absent breathing sound. Puncture of the chest is the most decisive means of diagnosis. The method has already been described (p. 183). Hydatid liquid escapes ; unless the cyst have suppurated, in which case the diagnosis from empyema depends upon detection of echinococcus booklets or hydatid membrane. IT IV. The cyst often bursts into the air- tubes : hydatid fluid, hydatid membrane, blood or pus being expectorated. A large suppurating cyst, with a free opening in the bronchia, simulates pulmonary phthisis.-^ IT V. The cyst has been known to burst into both the bronchia and the pleura, and so to cause a hydropneumothorax.- ^ Greenfield : Clin. Soc. Trans, vol. x. p. 103. 1877. 2 Case quoted from Mercier by Trousseau : Clinique Medicale, vol. i. p. 711. 2nd edit. 1865. CHAPTEB XXIII. PULMONARY ACTINOMYCOSIS. IF I. The physical signs of actinomycosis of the lung are dependent upon solidification. Hence, dulness to percussion ; breathing sound Aveakened at the beginning, and afterwards bronchial or even cavernous : mucous rales concur. H II. When these signs are detected at the apex or middle of the lung, they vill probably at first be thought to indicate tubercle, chronic pneumonia, collapse or cirrhosis. Actinomj'cosis of the base of the lung simulates pleurisy with effusion, and is indeed sometimes attended by pleural effusion : if no effusion be found by puncture, then some one of the chronic con- solidations named above will be suspected. The diagnosis cannot be made until the fungus is discovered in the sputum, or until the growth perforates the wall of the chest. CHAPTER XXIV. DILATATIOX OF BROXCHI. 51 I. The joli^^sical signs afforded bv a saccu- lated bronchus are almost identical with those of a phthisical cavity. The diagnosis depends upon the sj-mptoms. The conditions needful for the discovery of a bronchial sac by percussion and auscultation are these : that the cavity be of a certain size, near the surface, surrounded by condensed lung, and containing air as well as liquid. Rapid change in the physical signs, con- sequent upon profuse expectoration, is important evidence of dilated bronchus. ^ II. Sometimes the bronchiectasis is mul- tiple, that is to say, many tubes in one or both lungs are dilated. In this case al;o, the dicig- nosis is especially from phthisis ; inasmuch as numerous dilated tubes, separated by cirrhosed tissue fp. 258), will jield dulness to percussion, and the signs of cavity, namely, caverncus breathing, pectoriloquy, and cavernous rales. G,A. c CHAPTER XXV. PULMONAHY CIRRHOSIS. IRRHOSIS, sclerosis, or grey induration com- monly affects a portion only (and that usually the base) of one lung ; seldom affects a Avhole lung ; and both lungs more seldom still. ^ I. The physical signs depend upon the solidification and shrinking of the lung which cirrhosis causes. i. The solidification signs are : — percussion dulness more or less absolute : breathing sounds either simply Aveak, or bronchial in any degree up to most highly marked cavernous breathing : vocal resonance unaffected, or simply weakened, or broncho- phonic, ii. The signs of unilateral or local shrinking have been already described in several places (pages 29, 32, 203). ^ II. Other lesions are apt to complicate cirrhosis, i. Catarrh, with its attendent rales in the affected part. ii. Dilatation of the air- tubes, affording the signs discussed in the fore- going chapter, iii. Adhesion of the pleural sur- PULMONARY CIBRHOSIS. 259 faces by a thick and tight membrane : almost certainly present when unilateral contraction of the chest is great, iv. In very chronic cases ; emphysema of the other lung, and dilatation of the heart. ^ III. Diagnosis from tubercular phthisis cannot be attained by physical examination alone : chronic consolidation of the base of a lung is more likely to be cirrhotic than tubercular.^ Any question of pleural effusion must be determined by puncture. Simple chronic collapse (whether dependent upon past pleurisy or not) cannot be distinguished from cirrhosis : Laennec included both lesions under the name of carnification : the physical signs have been fully described in the chapter on pulmon- ary collapse (p. 202). ^ St, Barthol. Hosp. Reps. vol. xxviii., p. 1. S ti CHAPTER XXYI. HYPERTROPHY OF THE HEART. THE heart is said to be hypertrophied ^vlien tlic quantity of its muscular tissue is in- creased. The sign is a heaving impulse. Which is best felt at or just above the apex-beat ^vhcn hypertrophy affects the left ventricle ; and a little to the left of the lov;er part of the sternum when hypertrophy affects the right ventricle ; of hypertrophy of the auricles there i^i no certain sign. The heaving impulse may be countervailed or concealed by conditions sucli as these ; feeble action of the heart, degenera- tion of its texture, emphysematous lung over the heart, and very fat chest "walls : v>herefore heaving impulse is far from being a constant sign of hypertropliy. When the right ventricle is liypertrophied, tlie conducted ejiigastric im- pulse is strong. When the left ventricle is hypertrophied, the apex of the heart sometimes reaches fiirther to the left than natural, partly HYPEILTIWPHY OF TEE HEART. 261 perhaps in consequence of elongation of the aorta associated Avith the hypertrophy. A sharp whizz is heard in the arteries under a certain degree of pressure by the stethoscope 3 and the pulsation may be strong enough to raise the observer's head, at the same time. CHAPTER XXVir. DILATATION OF THE HEART. ^ I. The signs of dilated heart are these : i. Bulging of the heart region (p. 31). ii. Ex- tension of the deep-seated area of cardiac per- cussion dulness, along a horizontal line ; to the right when the right cavities, and to the left "vvhen the left cavities are dilated. The dull space usually remains oval in shape ; a point upon which the diagnosis between an enlarged heart and a pericardial effusion greatly depends. Yet the deep dulness of dilated heart may be sometimes extended upwards so as to reach the first left cartilage, and to assume a shape more or less triangular. iii. The apex-beat moves with the dilatation and extended dulness to the left ; they all sometimes reach to the left as far as the axillary line. iv. An enlarged heart tends to displace the lungs, and so to come into contact with a larger space of the chest-wall ; hence an impulse more extensive than natural. IT II. The diaphragm is depressed ; sometimes, but seldom, so much that a liver of natural size DILATATION OF THE HEART. 263 Yvz. 10. 9 / ;' \ fO ,' DiAGBAM SHOWING DILATATION OP THE RlGHT SiDE AND OP THE LEFT SiDE OF THE Heart : from Von Dusch. 264 DILATATION OF THE HEART. may seem to be enlarged. Dilatation of the right cavities is usually accompanied by over- filling and pulsation of the jugular veins (p. 168). A dilated right auricle has been known to pro- duce a systolic impulse in the fifth right inter- space, two inches from the sternum (p. 42). Chronic collapse of the lower lobe of the left lung is sometimes caused by dilated heart (p. 203). ^ III. Dilatation of the heart maybe simulated by pericardial effusion ; by intrathoracic tumour (aneurysmal or not) above the base of the heart, or pushing the heart forwards against the front of the chest ; by mere increased extent of con- tact between the heart and the chest wall, de- pendent upon shrinking of the left lung ; by consolidation of the anterior part of either lung ; and by local pleural effusion. But difficulty in the diagnosis seldom arises except in the case of pericardial effusion (p. 270). Dilatation of the heart is usually associated with signs of valvular disease. The apex-beat may be displaced to the left, not only by dilatation of the left ventricle, but also by dilatation of the right heart alone, by elongation of the aorta, displacement of the mediastinum to the left, and elevation of the diaphragm (p. 41). CHAPTER XXVIII. PERICARDITIS. ryiHE physical signs of pericarditis deiDcnd upon -*- inflammatory effusion into the pericardium. When the quantity of exudation is small, it cannot be discovered, unless it cause a friction- sound (p. 155). For this reason, a friction- sound is usually the earliest sign of pericarditis. When the quantity of exudation is large, it is discovered by means of percussion (p. 267). Disappearance of friction-sound is due either to progressing liquid effusion, or to adhesion of the inflamed surfaces, or perhaps to absorption of exudation, or to diminution of hypercemia. But friction is not always abolished even by large liquid effusion. On the other hand, there will sometimes be no friction, even when the pericardium is full of coagulable lymph v>^ith very little serum. And lastly, pericarditis is some- times wholly undiscoverable either by percussion or by auscultation : the lymph may be too soft to yield friction-sound and a liquid eft'asion (even 266 PERICARDITIS. of some ounces) may lie behind the heart so as not to affect the area of its percussion clulness. It is sometimes hard to decide whether fric- tion-sound, heard over the heart region, is pleural or pericardial. Pleural friction may be developed by movement of the heart alone, and pericardial friction may be under the influence of breathing movements (pp. 128, 156, 160). CHAPTER XXIX. PERICARDIAL EFFUSION. INCRExiSE in the area of cardiac dulness is the sign, not only of dilated heart, but also of effusion (of serum, pus, or soft and bulky- lymph) into the pericardium. The two diseases, however, do not extend the area of dulness in the same manner ; hence the means of diagnosis between them. Dilatation of the heart has been already spoken of : it remains to describe the signs of pericardial effusion. § I. The first extension of percussion dulness occurs at the base of the heart, where the great vessels enter, and where the pericardium hangs loosely round them, and is most distensible. At the beginning, the dulness is increased chiefly upwards, so as to reach the second left rib, between the sternum and the parasternal line. A larger effusion will extend the dulness at the base transversely, so as to reach from the right side-sternal, or parasternal, line to the left nipple line, and as high, it may be, as the first rib. 268 PEllICAEDIAL EFFUSION. Hitherto there will have been little change in the signs afforded by that part of the pericar- dium which is close upon the diaphragm. How - ever, farther increase of effusion, after it has ■ distended the pericardial sac around the vessels, will dilate the pericardial sac around the heart. Hence, progressive increase in transverse dul- ness below the base of the heart, and corre- sponding displacement of the lungs, until, in an extreme effusion, the non-resonant space will reach from the right nipple line to the left axil- lary line, and up to the top of manubrium sterni, the whole left front being dull. In all pericardial effusions, whether great or small, it is upward extension of dulness which affords the chief means of diagnosis from enlargement of the heart, g 11. Pericardial effusion may, as already said, lie wholly behind the heart, and be undis- coverable, even when there arc no old adhesions in the sac to account for this peculiarity. Lung, G-mph3''sematous or not, and air-distended, lying in front of the pericardium, will obviously inter- fere with the development of percussion dulness, such as just described. Dulness behind the manubrium sterni is sometimes not present, even although the pericardium, distended with PERICARDIAL EFFUSION. 269 liquid and uncovered by lung, lie there : the reason being that the liquid conducts a clear note from tlie trachea or neighbouring lung. Acute dilatation of the heart's cavities some- times concurs Avith pericarditis, and will, when associated with small effusion around the vessels at the base of the heart, give physical signs of large effusion. Chronic dilatation of the heart will produce the same effect, v>'hon the peri- cardial sac is everywhere obliterated by old adhesions, except at the base around the large vessels, and effusion takes place there. § III. When effusion is limited to the base of the heart, the apex-beat and left limit of dulness will correspond 3 but when the cardiac portion of the pericardium is distended by liquid, the dulness will reach beyond and to the left of the apex-beat. At the same time the impulse is weakened ; it may finally become imperceptible even when the patient is lying upon his face. An impulse, wholly impalpable in the supine posture, may be well felt in the erect. Bulging of the heart region is consequent upon large pericardial effusion as well as upon dilated heart, especially in the young. In a few cases of excessive distension, a sort of undulation has been seen ; comparable with pulsating empyema. 270 PERICARDIAL EFFUSION. The heart sounds are weakened more or less, and may become ahnost or quite inaudible : a con- dition which must be due to weak action of the heart as well as to the effusion. § IV. The lung around a distended pericar- dium is relaxed. A large effusion sometimes exerts so much pressure upon the bronchial tubes, especially the left, as to cause more or less extensive collapse of the corresponding lung (pp. 202, 264). Great bulging of the left lung- apex above the clavicle, dependent upon pericardial effusion, has been noted. ^ The cervical veins are sometimes very full. The diaphragm is depressed, and therewith the liver and the spleen : - seldom is the depression so great as to produce swelling of the epigastrium.^ The diaphragm may be paralysed ; if it be, the epigastrium sinks inwards during inspiration. § V. The diagnosis is from dilatation of the heart ; aneurysms, abscesses, or other media- stinal tumours ; consolidation of the front parts of the luDg ; and pleural effusion, i. From dilatation of the heart the diagnosis depends mainly upon the different shapes of the area of ^ Graves: Clinical Lectures, 2110! edit. vol. ii. p. 176, 2 Senac : Traite, 2ncl edit. vol. ii. p. 3G4. 17S3. •^ Auenbrugger's luventum Novum, § 40. PERIGABDIAL EFFUSION. 271 percussion dulness in the two diseases. Yet it cannot be denied that a dilated heart some- times yields that upward extension of dulness which is the chief note of pericaidial effusion : hence the instances, not very few, of the heart having been pierced in an attempt to clraw^ off a non-existent pericardial effusion. On the other hand, much horizontal extension of percussion dulness to the right of the sternum, in cases of pericardial effusion, will sometimes lead to the mistaken diagnosis of dilated heart. So that the whole history and all the physical signs must be pondered in a difficult case. The com- bination of dilated heart and pericardial effusion has been already spoken of (p. 269). Puncture of the pericardium is never performed as a mere means of diagnosis (p. 182). ii. From aneurys- mal and mediastinal tumours the diagnosis depends upon careful comparison of all the physical signs of the two diseases. Pericardial effusion seldom affords signs of pressure upon the innominate veins or recurrent laryngeal nerve. iii. From consolidation of lung the diagnosis depends mainly upon the auscultation signs, iv. Loculated pleural effusion, situated exactly over the heart and only there, seldom occurs. Large effusion into the left pleura may 272 PERICABDIAL EFFUSION. ciiuse bulging of the chest in the heart region, such as to raise the question of a concurrent pericardial effusion : for pleurisy on the left side and pericarditis are often associated. The diagnosis depends mainly upon the result of paracentesis, and emptying the left pleurn, whereby alone can the signs of pericardial effusion become manifest. CHAPTEB XXX. PNEUMOPERICARDIUM. rriHE percussion note, over the heart region, -*- is clear (and sometimes attended by a metalUc ring) when the patient is lying : when he sits ujo or leans fonvard, the sound becomes dull. A cracked-pot sound has been noted. The auscultation signs are these : i. Amphoric quality of the heart sounds. ii. Friction sound, if present, acquires the character of metallic tinkling. ^ iii. When the pericardium contains liquid as well as air, the water-wheel sound (p. 157) is heard. It is sometimes so loud as to hide the heart sounds, or even to be audible without auscultation. iv. Succussion splash has been heard in cases of the same kind. 1 Graves : Clinical medicine, 1843 : p. 824. Hepatic abscess which opened into both stomach and pericardium. G.A. CHAPTEE XXXI. ADHERENT PERICARDIUM. rpHERE are no certain signs of adherent peri- -■- cardium.^ When the pericardium adheres closely, not only to the heart within, but also (by means of comitant pleural adhesion) to the walls of the chest in front and to the spinal column behind, the following signs may be pre- sent, i. Systolic recession of the apex- beat, associated with a distinct impulse : a sign which even if well marked cannot be wholly depended upon (p. 43). ii. Deep inspiration does not diminish the area of superficial cardiac dulncss ; docs not depress the apex-beat ; and is attended by recession of the epigastrium," consequent upon the fixedness of the pericardial portion of the diaphragm : but these are signs rather of external than of internal pericardial adhesion : however pericardial and neighbouring pleural adhesions often concur. In universal tough pericardial adhesion, it is common enough that the signs are no more than those of attendent dilatation of the heart and its cuspid orifices. ' For a recent essay upon this topic sec Ord : St. Thomas' Ho>:p. Rep., vol. xvii. p. 187 : 1887. - See Laeunec : vol. ii. p. 6(55. CHAPTEE XXXII. MITRAL REGURGITATION. ^ I. A MURMUR, replacing or immediately following the first sound, and heard louder at or just above the apex-beat than over any other part of the heart region, indicates regurgitation through the mitral orifice.^ The murmur is often heard well at the angle of the left scapula : is sometimes louder there than at the apex-beat; is sometimes indeed heard at the anirle of the O scapula only, and not at all at the apex-beat. The murmur is often heard well, or even heard loudest, over the second left intercostal space or third left cartilage, at one or two inches from the left edge of the sternum : behind which spot lies the tip of the left auricular appendix, whereinto the murmur is supposed to be con- ^ "The opinion of the permanent patency of a cardiac opening from any cause, as a source of the teliows-sonnd, I heard first from Dr. James Johnson. "Who originally sus- pected it I cannot say."' Elliotson : On the recent improve- nients, etc., 1830 : p. 20. Hope claims the discovery for himself : Treatise, 4tli edit. p. xxvi. and p. 70. T 2 276 MITRAL liEGUIlGITATJON. veyed by the regurgitation. The murmur is sometimes heard over a very small space at the apex-beat, and nowhere else. On the other hand, the murmur is sometimes conveyed far away from the heart, so as to be audible over the head or sacrum, for example. ^ II. Incompetence of the mitral valve is not always attended by a definite murmur : this is especially the case when the heart is much dilated and unable to contract duly upon its contents : wherefore mitral murmur often dis- appears before death. Moreover, under any circumstances, mitral murmurs are of all mur- murs most variable : they disappear and reappear in an inexplicable manner. They are sometimes affected by breathing, being weakened or even becoming inaudible, during inspiration : and this when no question arises of pulsatile respiratory murmur (p. 158). Systolic apex thrill (p. 52) and accentuation of the pul- monary second sound (p. 138) are often to be noted. IF III. Mitral regurgitation is usually due to disease of the valvular cusps. But not always so : no doubt the orifice is sometimes simjjly dilated, partaking in primary dilatation of the heart (not secondary to valvular disease) : in MITRAL REGURGITATION, 277 which case the relative shortening of the musculi papiUares and chordse tendinese will increase the incompetency of the cusps. More- over, it is probable that debility or degeneration of the musculi papillares or of the muscular sphincter which surrounds the mitral orifice,^ is sometimes a cause of regurgitation, apart from valvular disease or dilatation. ^ IV. Permanent mitral regurgitation pro- duces hypertrophous dilatation of the left cavities of the heart, congestion of the lungs, and lastly dilatation of the right cavities. 1 Ludwig and Hesse : quoted by MacAlister : Eenaarks on the form and mechanism of the heart. Brit. Med. Joiirn., Oct. 28, 1882. CHAPTER XXXIII. MITRAL OBSTRUCTION. ^ I. A MURMUR, after the second sound and before the first, heard louder at or near the apex-beat than over any other part of the heart region, indicates obstruction at the mitral orifice. The murmur is usually prcesystolic, that is to say, it is immediately followed, without any interval, by the first sound. ^ The murmur is sometimes diastolic, that is to say, it immedi- ately follows the second sound ; there being a distinct interval between the murmur and the first sound.^ The murmur is sometimes so pro- longed as to fill up the whole time between the second and first sounds. The murmur is some- times double, both diastolic and proesystolic, ^ The connection between presystolic murravirsanJ mitial obstruction was discovered by Fauvel : Memoire, etc. Ar- chives gen. de Med., series iv, vol. i. p. 1. 1843. 2 It has been plausibly suggested tliat mitral diastolic murmur is due to the ventricular diastole, and presystolic murmur to the auricular systole. J. L. Gibson : Lancet for Apr. 19, 1884, p. 730. MITRAL OBSTRUCTION. 279 with a distinct interval between its two parts. The murmur, whether prsesystolic or diastolic, is seldom heard at the angle of the scapula. ^ II. A prresystolic murmur sometimes passes indistinguishably into a systolic murmur (due to associated regurgitation) ; sometimes the first sound is well heard between the prsesystolic and systolic murmurs ; but usually a loud first sound is heard, and no systolic murmur. A diastolic murmur is mostly attended by a systolic mur- mur. A systolic murmur will sometimes be heard at the angle of the scapula (or indeed all over the back) when the only murmur audible at the apex-beat is praesystolic.^ The murmur attending mitral obstruction is sometimes un- doubtedly systolic only ; that is to say, the murmur proper to the obstruction is not heard, bat only the concomitant regurgitant murmur. The first sound is loud, and mostly seems to put a sudden stop, as it were, to the prcesystolic murmur. The second sound is usually, but not always, inaudible at the apex-beat. IF III. The murmur of mitral obstruction may be variable : for instance, a prsesystolic murmur, followed by a loud first sound and no 1 In a case of this sort, I found that the middle line of the axilla exactly seimrated the areas of the two murmurs. 280 MITRAL OBSTRUCTION. second sound, may give way for a time to a s3^stolic murmur with first and second sounds then the proesystolic murmur will reappear, "while the systolic murmur and second sound vanish. All murmurs will disappear when the heart is exliausted and unable to expel its con- tents : in this state, the first sound also usually disappears. The influence of posture upon prse- systolic murmurs has been already discussed (p. 149) : no examination of the heart is com- plete if the patient have not been ausculted in both upright and lying posture. Lastly, the murmur sometimes disappears in a manner which cannot be explained. IT IV. i. Reduplication of the second sound at the base of the heart (p. 151) is common, ii. The bruit de rappel (p. 153) at the apex is to be deemed a divided diastolic murmur, iii. A thrill often attends the murmur : either prsesystolic and running up into the impulse; or diastolic, alternating with the impulse, and accompanied by a back stroke. The thrill is sometimes strong when the murmur is weak, iv. Diastolic aortic murmur is often well heard at the apex, but the diagnosis is seldom difficult when all the signs and symptoms of the case are pondered. MITRAL OBSTRUCTION. 281 IT V. A mitral prsesystolic murmur signifies permanent structural disease of the valve. The only exception to this rule is the case (first noted by Austin Flint) ^ of prsesystolic apex murmur occurring in aortic regurgitation and apart from disease of the mitral valve. The explanation of this fact is uncertain. Mitral and tricuspid obstruction (p. 288) often concur. In mitral obstruction, overfilling of the left auricle and pulmonary congestion are carried to a high degree. Hence hypertrophous dilatation of the left auricle, and dilatation of the right heart. ^ In 1862 : see a paper by liim in Lancet for March 8, 1884 p. 418. A few other physicians have met with similar cases : see Lees, American Journal Med. Sci., Nov. 1890. CHAPTER XXXiy. . AORTIC REGURGITATION. ^ I. A MURMUR, replacing or immediately fol- lowing the second sound, and heard at the second right interspace and along the stcrniimj indicates regurgitation through the aortic valve. ^ i. The second sound is sometimes well heard at the second right interspace : even when this is not the case, the second sound is usually heard at the second left interspace, ii. The murmur is often best heard at the lower end of the ster- num (and especially a little to the left thereof), iii. The murmur is often, but certainly not always, conducted to the apex : is sometimes heard there better tiian elsewlicre, and thus ^ Incompetency of the aortic valves was known to morbid anatomists long before tlie discovery of auscultation. Hodgkin seems to have been the first to discuss the lesion from the clinical point of view. His papers, " On retro- version of the valves of the aorta," were read before the Hunterian Society on Feb. 21, 1S27, and Feb. 18, 1829, and were published in the Lend. Med. Gazette for March 7, 1829. SeeWilks: Note, etc. : Guy's Hosp. Reps., series iii. vol. xvi. p. 209. 1871. Hodgkin mentions the dia* stolic murmur, which Corrigan, in his paper, published in 1832, does uot. AORTIC RMWMGITATION. 283 simulates the diastolic murmur of mitral ob- struction (p. 278). iv. The murmur is often conducted into the arteries near the heart, the carotids and subclavians, so as to be well heard below both clavicles : but this is not always so. V. The murmur is sometimes best heard over the second left interspace or third left cartilage. This means that the heart is displaced to the left ; most likely in consequence of elongation of the aorta ; the apex-beat will be found to the left of the nipple line. The diagnosis from pulmonary regurgitation depends much upon the characters of the pulse, vi. The murmur sometimes possesses a loud whining or cooing character ; and will be audible in all the larger arteries, even so far away as the radials ; all over the front of the chest ; in the left axilla, and at the angle of the left scapula ; by the ear placed nigh to, but not upon, the chest ; and lastly, by the patient himself, vii. A systolic basic murmur also is commonly present ; or at any rate the first sound is not clear. This systolic murmur is certainly not always due to obstruction at the mouth of the aorta, but is probably sometimes the result of a mere relative constriction of the orifice, connected with positive dilatation of the ascending aorta, viii. The 284 AORTIC liECWHGITATION. diastolic murmur may disappear when the heart falls into a state of asystoly, or inability to expel its contents. H IL A diastolic thrill, at the second right interspace, is sometimes present. In the dis- placement of the heart to the left just spoken of, the thrill may be felt in the second or third left interspace. ^ III. Hypertrophy of the left ventricle usually ensues : hence the heaving impulse, mostly but not always present : hence the fre- quency of dilatation of the ascending aorta ; the elongation of the arteries ; and the intensity of the arterial systolic murmur. Diastolic arterial murmur (p. 164) is often present. But of all arterial signs, a jerking pulse ^ is the most important. It may be present even when there is no hypertrophy of the ventricle. Nay more, the heaving impulse, and all the arterial signs are sometimes absent, when a distinct diastolic murmur in the aortic region would 1 "Apres avoir remarque I'abattement de ses yeux, la bouffissure, et la paleur de son visage, j'examinai son pouls qui me jjarut fort plein, fort vite, dur, int'gal, et si fort que I'artcre de I'un et I'autre bras frappait le bout de mes doigts autant que I'auroit fait une corde fort tendue et violemment eVjranb'e." Histoire de Jean Cliifort (case of disease of aortic sigmoids) : Vieussens. QSuvres fran9oises, 1715. AORTIC UEGUEGITATION, 285 seem to render the nature of the disease quite certain. Yet, in cases of this kind, it may happen that there is no regurgitation, no disease of the sigmoids, and no dilatation of the ring to which they are attached : nothing more than dilatation and rigidity of the ascending aorta. ^ Pulsatile flushing of the lips, finger-nails and other parts (capillary pulse) sometimes accom- panies the jerking pulse. % IV. i. A result of aortic regurgitation, less common than hypertrophy of the left ventricle, is dilatation thereof. In which case the mitral orifice partakes in the dilatation ; and becomes regurgitant ; the cusjds remaining unchanged : all the results of mitral regurgitation follow. The aortic and mitral valves are often simul- taneously diseased, so that the flaps of both valves are altered in structure, ii. The occur- rence of prsesystolic apex murmur in cases of aortic regurgitation, and apart from disease of the mitral valve, has already been mentioned (p. 281). iii. When mitral obstruction and aortic regurgitation concur, the diagnosis of both lesions is often difficult ; the signs of one tend to override those of the other. ^ See Finlayson : Brit. Med. Journal, Feb. 28, 1885, p. 423. CHAPTER XXXV. AORTIC OBSTRUCTIOX. ^ I. The murmur present in cases of aortic obstruction is systolic, and heard loudest in the second right intersiDace. But many of the murmurs commonly called functional or inor- ganic possess these characters (p. 293). Where- fore it is necessary to the diagnosis of aortic obstruction that the murmur be loud and long, and attended by a heaving impulse indicative of hypertrophy of the left ventricle,^ and by a pulse which is small even when the heart is beating strongly : moreover the signs of aneurysm must be absent. IT II. A systolic thrill, felt on the right side of the base of the heart, is often present. 5[ III. Aortic obstruction is usually com- plicated with regurgitation ; even when there is no diastolic murmur, the aortic second sound is muffled, weakened, or absent. ^ Traube (Gcsammelte Bcitiiige : vol. ii. p. S3]) has publislied tv/o cases of uncomplicated aortic obstruction in which the heart's impulse was imperceptible : and this weakened impulse (provided that no other cause thereof be present) he considers to be important evidence of aortic obstruction. CHAPTEK XXXVI. TRICUSPID PxEGURGITATION. ^ I. A MURMUR, systolic, and heard best over the lower part of the sternum, or a little to the left thereof, may be due to tricuspid regurgita- tion. The valvular disease is mostly consequent upon dilatation of the right heart : and a dilated heart usually contracts weakly : hence, in many cases of tricuspid regurgitation, there is no corresponding murmur. The murmur is not conducted far from the spot mentioned ; is not heart in the armpit or at the angle of the left scapula : and sometimes is not heard in the upright, but in the lying posture onlj. ^ 11. More important are the signs which the jugular veins (p. 168), and the liver (p. 174) afford. Yet it must be confessed that jugular pulsation may be quite invisible, even in great incompetency of the tricuspid valves with hypertrophy of the right ventricle : the valve at the mouth of the vein being probably competent in this case. A systolic thrill at the epigastrium is said to have been pre- sent in a few cases. The associated dilatation of the right heart cannot always be made out by percussion, because of pulmonary emphysema. CHAPTER XXXVII. TRICUSPID OBSTRUCTIOX. ^ I. A PRiESYSTOLic miirmur, heard over a space defined by a line drawn from the fourth right chondrosternal joint downwards along the right margin of sternum to the tip of the ensiform cartilage, thence to the sixth left chondrosternal joint, and thence to the fourth right chondrosternal joint; is the sign of tricuspid obstruction/ U II. Prsesystolic thrill may be felt over the same area. The heart's percussion dulness is much extended to the right, because of the dilatation of the right auricle consequent upon the tricuspid disease. The jugular veins are distended, but seldom pulsate. ^ Bedford Fenwick : Lancet, 1881, vol. i. pp. 653 sqq. Tricuspid obstruction is always attended by mitral obstruc- tion : and, in half the cases, by aortic disease, obstructive or regurgitant, Eight-nintlis of the cases of tricuspid obstruction are female. CHAPTER XXXVIII. PCLMOX AK Y E ECIURGITATIOX. ^1 I. This, the most uncommon of all valvular diseases,^ is attended by a diastolic murmur, heard loudest in the second left interspace and along the sternum, or loudest sometimes at the ensiform cartilage. Simplicity of doctrine requires that this should be the area of the murmur, but experience tells that the second right interspace may possibly be the place of greatest loudness." Moreover, aortic regurgitant murmurs are some- times loudest over the second left interspace (p. 283). Wherefore diagnosis between pul- monary and aortic reflux is not so easy as might at first appear. The two regurgitations may even be associated. But when either semilunar valve alone regurgitates, the presence or absence of the jerking pulse and of the other arterial signs of aortic disease, is the means of attaining a correct opinion. ^ Barie : Arch. gen. tic med. for 1891, vols. i. and ii. - Diick'voi-th : Clinical Trans., vol. xxi., p. IS. G.A. U 290 PULMONARY REGURGITATION, ^ II. A diastolic thrill is sometimes present. A systolic murmur, not always due to obstruc- tion, may occur in pulmonary regurgitation just as in the corresponding aortic disease. ^ in. Dilatation of the right ventricle, and impeded systemic venous circulation, with dilata- tion and pulsation of the jugulars, are possible consequences. Dilatation of the pulmonary artery is sometimes indicated by pulsation of the second and third left intercostal spaces. CHAPTER XXXIX. PULMONAEY OBSTRUCTIOX. rp HE murmur of pulmonary obstruction is -^ systolic, and heard loudest on the third rib, or in the second or third left interspace, close to the sternum.^ A systolic thrill may be felt at the same spot. A loud murmur will be con- ducted far in all directions, even to the back. Hypertrophy of the right ventricle supervenes ; so that it is not until the obstruction becomes great, or the heart's contractions begin to fail in vigour, that there is any stagnation in the general venous system. ' Ormerod: Edin. Med. and Surg. Journ. no. 166. 1846. U 2 CHAPTER XL. .MURMUES OF UNCERTAIN NATURE. TjIROM the earliest times of auscultation it has -^ been known that some murmurs are tem- porary in duration and not indicative of perma- nent disease of the hearts These murmurs are always systolic, and taken by themselves alone, they cannot be distinguished from systolic mur- murs due to valvular disease ; for the areas, over which temporary murmurs are heard loudest, are the same as those which have been allotted to murmiu's indicative of permanent valvular disease. And the temporary murmurs are probably dependent upon conditions essentially the same as those to which the corresponding- permanent murmurs are due : that is to say, temporary murmurs (beiug systolic) are generated at tlic semilunar orifices by obstruc- tion, and at the cuspid orifices by regurgitation : hence four kinds of mui*mur. ' These mnnmirs have been called functional, anocmio, hseniic munnurs ; luit no name yet dcviftcd for thcra is satisfactory. MURMURS OF UNCERTAIN NATURE, 293 Temporary murmur is apt to accompany — i. Blood-dyscrasia3 : especially ancemia, however produced ; sometimes jaundice, ii. Palpitations of the heart, iii. Pressure upon the chest over the base of the heart (p. 149). iv. Pregnancy. V. A loud murmur sometimes springs up in dying persons, the heart being found natural after death. I. Pulmonary and aortic murmurs. The common temponiry murmur has the characters of obstruction at a semilunar orifice, especially the pulmonary : and the common cause is anaemia. These murmurs are heard, sometimes over a very limited and sometimes over a very extensive space : sometimes in the back, especially between the left scapula and the spine : ^ they are louder in the recumbent than in the erect posture, and may even be audible in the recumbent posture alone. Strong beat- ing of the heart will somtimes make them louder, or will even bring out a murmur which is inaudible when the heart is quiet. Pulsation in the second interspace, is sometimes felt, and, in rare cases, is so strong as to raise a suspicion of aneurysm. Signs of dilatation of the heart 1 A. E. Garro.1 ; St. Bartliol. Hosp. Reports : v ], xxvii, p. 34. 294 MUBMUBS OF UNCEBTAIN NATUBE. (apex-beat displaced to left and increased extent of percussion dulness) are usually present. No satisfactory acoustic explanation of these mur- murs lias yet been given. 11. Mitral and tricuspid murmurs are likewise attended by signs of dilated heart : tricuspid murmurs by distension and pulsation of the jugular veins also. Anaemia is a common cause of these murmurs : jaundice may be attended by a mitral systolic murmur/ and pregnancy by a tricuspid systolic murmur.^ Debility of the heart, with secondary dilatation of its chambers and apertures, with relaxation of its valvular sphincters, and consequent valvular regurgita- tion, seems to afford a satisfactory explanation of most temporary murmurs of this kind. 1 Legg : On the bile, etc, 1880 : p. 306. 2 Money: Med. Chir. Trans., vol. Ixv., p. 87. c CHAPTER XLI. MALFuRMATIOXS OF THE HEART. ONGENITAL malformation of the heart is usually discovered easily enough : but not so the precise kind of malformation. We may attempt a diagnosis for Avhich our data are mostly insufficient, but we shall seldom advance beyond a guess. 1. The heart region is sometimes bulged, es- pecially in older patients, ii. The impulse is often heaving, often diffused, sometimes hardly palpable, iii. The apex-beat is commonly dis- placed to the left, and is also lower than natural, iv. Extension of percussion dulness to the right is not uncommon, v. A murmur, systolic, and heard loudest over the pulmonary region (from the second to the third left interspace, close to the sternum), is common : the murmur is very local, or heard over the heart region, or con- ducted more or less extensively over the chest. Much less common murmurs are these : diastolic in pulmonary region, with or without systolic : 290 MALFOBMATIONS OF THE HEART. systolic at left apex : systolic at epigastrium, or just above and to the left thereof : and pro- bably others which I have not met with. Some- times the murmur disappears just before death. Sometimes there is no murmur at all. vi. A thrill often, not always, coincides with the mur- mur ; being best felt where and when the murmur is loudest ; and being very local or con- ducted more or less widely, vii. Signs in the jugular veins are uncommon.' ^ Perforation of the upper part of the septum ventricu- lorum is su^jposed (Roger : EechercLes, etc. Bulletin de I'acad. de med. Oct. 21, 1879) to be indicated by a long inurnmr, beginning with the systole, and covering both sounds of the heart, which are nowhere to be heard. The murmur is loudest about the middle of the heart, and is conducted widely and equally in all directions. The murmur is attended by a thrill, but by no other signs of heart disease. A specimen in St. Bartholomew's Museum (no. 1320) seems to show that a murmur i^ossessing all these characters may lie due to constriction of the orifice of the ijulmouary artery, apart from any perforation of the ventricular sei)tum. Permanent openness of the ductus arteriosus is attended by a diastolic murmur, loudest over the pulmonary valves (p. 154). Permanent openness of the furamcn ovale is thought to be attended bv a murmur. CHAPTER XLII. MEDIASTINAL TOJOURS : XCLUDING mediastinal abscesses, and enlaro-ement of the thymus, or of the bronchial glands. i. A large and quickly- growing tumour, or abscess, sometimes causes protuberance of the front of the chest near the sternum : and this s\Yclling may pulsate so as to simulate aneurysm, ii. The heart may be dis- placed do^vn^Yards, upwards, or to either side ; or may be pressed forwards, iii. Vocal yibra- tion diminished or absent oyer the area of dul- ness to percussion, iv. Great percussion dulness and resistence will be found oyer a tumour which is in contact with the chest- wall, either in front (behind, and alongside the sternum) or behind, displacing or inyolving one or other lung : except that small tumours, connected with the trachea or a bronchus, will afford a clear, tracheal note. y. The tumour, when small, may or may not conduct sounds generated in its yicinity ; bronchial breathing, bronchophony, and the 298 MEDIASTINAL TUMOUBS. heart's sounds : when kirge, no sound wil. be heard over the tumour. vi. Sometimes a sj'stolic murmur at the base of the heart is pro- duced by pressure, and so an aneurysm may be simulated. vii. Signs of obstruction to the large veins are common, viii. Signs of obstruction to the trachea or a bronchus ; of collapse of the lung; of destructive or gangrenous pneumonia; of pleurisy with effusion ; and of pericarditis ; often complicate the signs proper to tumour, ix. Tumour, or abscess, or secondarily enlarged glands, may be felt above the collar bone. X. There are no phj'sical signs of tuberculous disease of the bronchial glands (strictly so-called), namely, those in the roots of the lungs and the bifurcation of the trachea : whereas disease of the tracheal glands often affords dulness to per- cussion alongside the manubrium sterni, and sometimes a swelling to be felt deep in the neck, behind the clavicle.^ ' On Emijliysema of the JMediastinura : see Miiller, Berlin kliu. Wochenschr. Mar. 12, 1888 : p. 205. CHAPTER XLIII. ANEURYSM OF THE THORACIC AORTA. § I. Aortic aneuiysm must be large enongli to come into contact with the chest-walls in order to yield an}^ physical signs directly dependent upon itself. Earliest to appear are the signs afforded by palpation and percussion.-^ ^ I. Palpation detects pulsations and thrills. The Pulsation is systolic, synchronous with the latter part of the heart's impulse. A slight diastolic shock, or even a strong diastolic impulse, can sometimes be felt. When the aneurysm contains much coagulum, the pulsa- tion is weak or even absent, i. Aneurysm of the ascending aorta touches the chest-wall first in the second right interspace close to the ^ Aneurysm of a Yalsalvian sinus seldom affords dis- tinctive physical signs. Pdsating tumour is present in about seven per cent, of tlie cases, one half being to the right, and one half to the left of the sternum. Murmur is common, and due to regurgitation through the aortic or pul- monary valves. Sibson : Medical Anatomy, fasciculus v. 1858: p. 2. 300 ANEUBYSM OF AOBTA. steniuni : as the tumour enlarges, the pulsation extends upwards towards the clavicle and manu- brium sterni, or downwards along the right margin of the sternum, haply as low as the fourth, or even fifth, interspace, ii. Aneurysm of the transverse aorta first comes to the surface behind the upper part of the sternum, and afterwards extends far away towards the left, iii. Aneurysm of the descending aorta, at its upper part, points below the first left rib, and thence extends downwards to the second space, iv. Aneurysm of the lower part of the thoracic aorta lies upon the left side of the dorsal verte- brae and may cause pulsation there. The pulsa- tion is sometimes attended by systolic or dias- tolic Thrill. ^11. Percussion discovers dulness in the same situations : namely, behind the second and third ribs along the right side of the sternum ; behind the manubrium sterni ; to the left side of the sternum ; and along the left side of the dorsal vertebrrc. The aneurysmal dulness is sometimes continuous with the cardiac dulness, sometimes not. H nr. Inspection sometimes discovers a tumour in a position corresponding with that of the palpation and percussion signs. In shape the A^^BUliYSM OF AORTA. GOi tumour is hemispherical, except that it is some times uneven Avhen constricted by resistent fibres in overlying parts, or when the aneurysm itself is nodular. Aneurysm of the descending aorta may be so great as to push the scapula outwards. ^ IV. Auscultation does not aftbrd much help to diagnosis : there will be a first and second sound, or a systolic and diastolic murmur, or a first sound and diastolic murmur, or a systolic murmur and a second sound, or a single sound or murmur, or no kind of sound at all. The sounds are probably those of the heart conducted : the systolic murmur is due to the passage of blood through a relatively narrow mouth into a wider cavity, whether an aneurys- mal sac or a dilated aorta; the diastolic murmur is either a conducted murmur produced by regurgitation at the mouth of the aorta, or is due to the passage of blood out of a sac dining its contraction, or is inexplicable. Sj'stolic mur- mur is Avell heard over the trachea ; is some- times louder over the trachea than at the base of the heart; and may, in rare cases, be heard over the trachea and not over any part of the chest. ^ Murmurs, when loud, may be conducted far away, along the arteries. 1 Dnimmond : r-rit. ]\[cd. .Jouin. Oct. 21, 18S2 : ]}. 7 To. 302 AN^UMYSM OF AOliTA. § II. Uniform dilatation of the ascending aorta is attended by extension of percussion dul- ness to the right of the sternum (level with the second and third cartilages) and behind the manubrium stern i. Elongation of the aortic arch forces the base of the heart downwards and to the left ; so that the apex-beat comes to be lower and more external than natural.^ § III. Aneurysmal tumour, like other medi- astinal tumours, will compress neighbouring viscera, i. Pressure upon the trachea causes noisy breathing (stridor), audible at a distance from the patient, ii. Pressure upon the bronchus, commonly the right, also causes stridor : by auscultation, the sound will be loudest where ^ W. S. Oliver was tlie first to describe a sign which has since been called Tracheal Tugging. He tells us to " place the patient in the erect position, and direct him to close his mouth and elevate his chin to the fullest extent, then grasp the cricoid cartilage between the finger and thumb, and use gentle upward pressure on it, when, if dilatation or aneurism exist, the pulsation of the aorta will be distinctly felt trans- mitted tlirough the trachea to the hand." (Lancet, Sep. 21, 1878: p. 40G.) A slight degree of tugging cannot be depended upon as a sign of aneurysm : but well-marked tugging is believed by R. L. Macdonncll (Lancet, Mar. 1891 ; pp. 535, 650) to indicate aneurysm of the transverse aorta, so situated as to press downwards upon the left bronchus, or adjacent part of the iraclujn. ANEURYSM OF AORTA. 303 the second rib joins the sternum/ iii. Pressure upon the root of the lung produces collapse, dilated bronchi, or destructive pneumonia, iv. Pressure upon the spongy structure of the lung produces relaxation or collapse of the part involved. v. Pressure upon the vena cava superior or vena innominata is attended by the signs of venous obstruction, vi. The heart is liable to sundry displacements, thus : dilatation of the ascending aorta usually implies elongation thereof, whereby the heart is forced downwards and to the left : a large tumour of the trans- verse aorta produces the same effect : a very large tumour of the descending aorta will push the heart towards the right : a tumour behind the heart will press it against the front wall of the chest. § IV. Anastomotic aortic aneurysm j that is to say, which opens into a neighbouring part of the circulating system, i. Into the vena cava superior : the signs are indicative of venous obstruction and of aneurysm of the ascending- aorta ; in some cases there have been observed a systolic thrill and murmur in the veins of the neck, and a thrill and loud systolic murmur (or ^ See note on p. 160, concerning pulse-breath. 30 i AXEUIIYSM OF AORTA. a continuous hum but loudest during the systole) at or below the second right cartilage, ii. Into the right auricle; no signs more definite than those of an aortic aneurysm and of venous obstruction, iii. Into the right ventricle ; no definite signs, iv. Into the pulmonary artery : systolic and long diastolic murmur at fourth left rib ; no natural sounds there ; diastolic thrill at the same spot ; diastolic murmur inaudible at the apex-beat ; pulsation and thrill in the caro- tids (p. 154). § V. Aortic aneurysms are simulated by pul- sating mediastinal tumours or abscesses (p. 297), and pulsating empyema (p. 232). Aneurysms, which do not pulsate and which are silent, simulate tumours of another kind. CHAPTER XLIY. OTHER INTRATHORACIC ANEURYSMS. § I. — ANEURYSM OF THE INNOMINATE ARTERY. ^ I. Dilatation of that part of the artery which is nearest to the heart is always associated with aneurysm of the ascending aorta, and is not attended by any distinctive signs. IT II. Dilatation of the distal part of the artery affords these signs following : i. A pulsating tumour, which comes up, between the origins of the sterno-niastoid muscle, from behind the right sterno-clavicular articulation, is due to an inno- minate aneurysm : provided there be no signs of aortic disease ; for aortic aneurysm may rise into the same position. The head of the clavicle may be dislocated, ii. If there be, over the tumour, a systolic murmur, it is conducted into the right carotid, but not into the left. iii. Pressure upon one or both of the innominate veins is common.^ ^ Cockle : ]Meclico-chir. Trans.,, vol. 50, p. 459. 1S(37, G.A. X 306 INTRATHOBACIC ANEURYSMS. § II. ANEURYSM OF THE PULMONARY ARTERY. A very uncommon disease, seldom discover- able during life. Yet these signs are said to have been noted : i. More or less swelling about the second and third left interspaces, nigh the sternum, ii. Systolic, and sometimes diastolic impulse there, iii. Some dulness to percussion, iv. Very loud sounds or murmurs, especially systolic, in the same place, v. Consecutive lesions relate to the right, rather than to the left, heart. NOTE. In the foregoing pages I have taken great pains with the terminology ; and I have used technical words with strict adherence to their original meaning. I have not taken upon myself to pervert the meaning of words already well defined, nor have I invented new words to denote signs already well denominated. Much of the difficulty of teaching auscultation and percussion to students is due to neglect of these plain rules, which everyone who use 3 technical terms may b3 expected to follow, or to give good reasons for not following. X 2 INDEX. Abscess : mediastinal. See Mediastinal. Subdiaphrag- matic and hepatic, 213, 227, 230 : diagnosis from pleural effusion, 183 : from pneumothorax, 213 Accentuation of pulmonary second sound, 133 Actinomycosis of lung, 256 : diagnosis from pleural effu- sion, 227 Adherent pericardium. See Pericardial adhesion Adherent pleura. See Pleural adhesion Aegophony, 100, 107, 111 Aerifcxction of lung, 105, 109, 122 Alar chest, 11 Arax»horic auscultation sounds, 129 : hum, 130, 133 : percussion tones, 65, 70, 85 : vocal resonance, 106. See Bell sound. Metallic tinkle. Splashing sound Ansemia. See Cachexia Anapnograph, 35 Anastomotic aortic aneurysm. See Aneurysm Andry, cyrtometer, 8 Aneurysm : bulging of chest, 31 : murmurs, 162 : com- pression of bronchi, 241 : simulated by other medias- tinal tumours, 296 ; by cancer of lung, 253 : by pul- • sriting empyema, 232, 233 : anastomotic of aorta, 53, 154, 303 : aortic, 299 : of innominate artery, 305 : intrapulmonary, 180, 250 : of pulmonary artery, 306 : of Yalsalvian sinus, 299 Angular curvature. See Ky[iho,si3 310 INVEX. Angiilus Ludovici, 10 Aorta. Sec Aneurysm, Dilatation, Elongation Aortic murmurs : conduction of, 144, 145, 162, 165, 282 Aortic obstruction, 286 : thrill, 52 Aortic orifice, situation, 144 Aortic regurgitation, 282 : thrill, 52 : arterial murmur, 162 Aran, sound of lung shock, 129 Aretaeus : alar chest, 12 Arteries, auscultation and murmurs, 162 Articulation of voice, 102 Ascites : effect on respiratory movements, 38 : displaces heart, 41 Asthma, 193 : expiratory dyspnoea, 37 Asystoly, 150, 276, 280, 284 Atrophy of lungs, 197 AuENBRUGGER discovcrs percussion of chest, 55 : method of percussion, 58 : pulmonary percussion tone, 63 ; no- menclature, 64 : dictum, 81 ; epigastric swelling, 177 : pericardial effusion, 270 Auricle, impulse, 42 : rupture of aneuijsm into, 304 Auscultation, 88 ; history, 88 : methods, 91 : lungs 95 : voice, 96 : breathing, 112 : pleura, 127 : heart, 135 : pericardium, 155 : arteries, 162 ; jugular veins, 172 : oesophagus, 185 ; aneurysms, 301. Se2 Table of Contents. Baas, tuning fork in percussion, 60 Buck stroke of heart, 50 Bacon, quoted, 91 Bamberger: jugular pulsation, 170 Barie, pulmonary regurgitation, 289 Beau, theory of breathing sounds, 117 : expiratory murmur in femoral vein, 173 Bell sounl, 131, 133 INDEX. 311 ]5KNNf:TT, iutratlioracic cancer, 252 Bkkgeon, murmurs, 95 Bird, hydatids of lung, 183, 254 BouiLLAUD, bruit derappel, 153 ; diastolic femoral murmur, 177 Bricheteau, water-wheel sound, 157 Brinton, rupture of diaphragm, 213 Bronchi, compression, 241, S02 : obstructed, shape of chest, 31. S(c Dilatation, Plugging Bronchial breathing, 114, 119, 120, 121 Bronchial glands, enlargement, 298 Bronchitis, plastic, 190. See Catarrh Bronchophony, 97, 104, 109 Brown induration of lungs, 193 Bruit de rappel, 153 Bruit skodique, 63 Bulging of chest, 31 : in hydatids, 254 : in aneurysm, 300, 305, 306 : in pleural effusion, 220, 230, 232, 233 EuTLiN, rupture of diaphragm, 213 Caclexia : arterial murmurs, 163 : venous murmurs, 172 : murmur at base of heart, 154, 293 : mitral murmur, 294 : tricuspid murmur, 294. See Murmurs of doubt- ful nature Caelius Aurelianus, rales, 88 : bulging of chest in bronchitis, 188 Cancer of lung, 251 : shape of chest, 31 : movements of chest, 38 : vocal thrill, 47 : diagnosis from pleural effusion, 226 Cantering action of heart, 153 Cardiac, See Heart Cardiograph, 49 Carnification of lung, 202, 259 Carswell, second sound of heart, 136 312 INDEX. Catarrh of lungs, 1S6 : shape of chc;t, 15, 16, 18S : movements of chest, 37 : iu acute tuberculosis, 241 : simulated by pleurisy, 207 Cavernous brccathing, 115, 119 : rales, 125 : signs in pleurisy, 207 Cavity iu lung, signs of, 247 : percussion sound, 83 : bron- chophony, 103, 110 : bronchial breathing, 122 : amphoric signs, 129 : pulsatile sounds. 159 : vascular murmurs, 180 Chauveau. cardiograph, 19 : murmurs, 91 : venous hum, 172 Chest, shape, -1 : movements, 31 : puncture, 181. See Table of Contents Children, shape of chest, 6 : position of heart, 39 : per- cussion note, 66, 73, 77 Chlorosis. See Cachexia Cirrhosis of lung, 258, 202 : shape of chest, 30 : displace^) heart, 42 : diagnosis from pleural effusion, 227 : in phthisis, 247 : in dilated bronchi, 257 : following collapse, 202 Clar, life of Auenbrugger, 56 Clearness of i)ercussion tones, 64, 82 : of vocal resonance, 97 Cockle, aneurysm of innominate artery, 305 Collapse of lung, 200 : sha]5e of chest, 31 : crepitant rale, 120, 123 : in pulmonary catarrh, 188 : in bi-onchial obstruction, 205 : in dilated heart, 264 : iu pericai'dial effusion, 270 : in aneurysm, 303 : diagnosis from pleural cffu-sion, 227 CoLLix, pericardial friction, 140 CoMBY, pulsating empyema, 232 Comjjlementary space of pleura, 176 Conduction of sound by lung, 104 : of muruiars, 144 : of pulmonary and pleural sounds, 200 Con estion of lungs, 193 INDEX. 313 Cousonancc, G9 Constrictive murmurs, 142 Conus arteriosus, impulse, 42 Convectiou of murmurs, 145 CoPLAXB, cup-like hollow, 175 CouRiGAx, murmurs, 141 CoRViSART, discovers valvular thrill, 51 : discovers Auen- brugger, 56 : method of pcrcussicu, 59 : percussion i-esistence, 74 Cough, thrill, 47 : resonauce, 112 CouPLAxp, subphrenic abscess, 214 Cracked-pot sound, 65, 72 : in pleural effusion, 21S : in pneumonia, 237 : in phthisis, 249 : in cancer, 252 : in pneumopericardium, 273 Creaking rales, 126 : in phthisis, 249 Crepitant rale, 120, 123 : pulsatile, 160 : in cedema of lung, 191 : iu collapse of lung, 200 : in pneumonia, 237 : in phthisis, 249. Sec Dry crepitant rale Croup, cup-like depression, 32 Cry, resonance, 112 : in pneumonia, 23S Cuj)-shaped depression, 32 : in pleurisy, 207, 225 Cyrtometer, S DA>ioiSEAr, pleural effusion, 224 Davies, Thos. puncture of chest, 181 Deep percussion, 75 Deferred inspiration, 114 Deformities of chest. Sec Chest Destructive pneumonia. 205, 241 : diagnosis from pleurisy, 227 Diaphragm, position, 175: in health, 176: in disease, 176 : depression, 17 7 : elevation, 177 : rupture, 212 : relation to transverse constriction of chest, 16 : paralysis, 35 : congenital deficiency, 213. /Sec Abscess, subd iaphragmatic 314 INDEX. Diaotolic, defiuition, 38 : thvi]ls,52, 53, 280, 284, 290 : im- pulse, 50, 290 : heart murmurs, 146, 148, 278, 282, 289 : arterial murmurs, 154, 164 : venous murmur, 173 Dilatation of aorta, 154, 284, 302 Dilatation of bronchi, 257 : in destructive pneumonia, 241 Dilatation of heart, 262 : shape of chest, 31 : epigastric pulsation, 174 : diagnosis from pericardial effusion, 270. Sec Enlargement of heart Diphtheritic bronchitis, 189, 240 Displacement of heart. See Heart Double, respiration bruissante, 88 Douglas, heart murmur, 89 Drummoxd, pulse-breath, 160, 301 Dry crepitant rale with great bubbles, 126 DucHKNNE, shoulder-blade friction, 135 Duckworth, pulmonary regurgitation, 289 Ductus arteriosus, murmur in, 154, 296 Dulness of percussion sounds, 72, 83 Duration of percussion tones, 62 DuRoziEZ, quoted, 136 : diastolic arterial raurmui*, 164 Dyspnrea, inspiratory, 36, 192 : expiratory, 37 : in asthua, 198 Eliiotson, heart murmurs, 149, 275 Elongation of aorta, 261, 283, 302 Emphysema of lungs, 195 : shape of chest, 22 : move- ments of chest, 37 : friction, 128, 129 : acute, 188 : associated with phthisis, 249 Empyema, 229 : shape of ches^, 28, 31 : movement of chest, 37 : fistulous, 211 : loculated, 229 : pulsating 232 : diagnosis from destructive pneumonia, 241 : after pneumonia, 239 Enlargement of heart: position of impulse, 41, 42: depression of diaphragm, 177. Set Dilatation. Hyper- tropliy INDEX. 315 Epigastric pulsation, 173 : recession, 175 Exjiiration, shape of chest, 5 Expiratory dyspncea. See Dyspnoea Exploratory puncture of chest, 181 Fauvel, prsesystolic murmurs, 278 Femoral vein, expiratory murmur in, 173 Fenwick, tricuspid obstruction, 238 FixLAYSON, rigid aorta, 285 Fistulous empyema, 211 Flames, sensitive, 60 Flat chest, 12 Flikt, prtesystolic apex murmur, 281 Fluctuation, pericardial, 54, 269 : pleural, 47 Fluid veins, 94 Foramen ovale, murmurs at, 143 Forbes, translation of Auenbrugger, 56 FoPvESTUs, heart sounds, 89 FouRNET, froissement pulmonaire, 126 Friction, pericardial, 53, 140, 265 : simulated by pleural friction, 129, 266 : pleural, 47, 127 : pulsatile, 160 : simulated by peritoneal friction, 134 : shoulder-blade, 135 : shoulder-joint, 134 Friedreich, jugular pulsation. 170 : venous murmurs, 173 : expiratory murmur in femoral vein, 173 : pulsation of liver, 174 Fulness of percussion sounds, 62 Gairdner, friction of emphysema, 129 : tricuspid obstruc- tion, 53 G-ALEN, alar chesty 12 : pericardial fluctuation, 54 Galvagni, shoulder-blade friction, 135 Gangrene of lung, 242. See Destructive pneumonia Garroi), a. E. antemic murmurs, 293 316 INDEX. Gkrh.vrdt, resonators, 60 : position of diaphra^'ra, 175 : intrapulmoaary aneurysmal murmur, ISO : A^ariable pitch of percussion tones in cavity, 248 GiB.JOX; murmurs of miti'al obstruction, 278 GrowERS, slioulder-joint friction, 134 Graves, depressed sternum, 33 : pulsating pneumonia, 239 : pericardial effusion, 270 : pncumoporicardiuai, 273 Ga;;E.\FiELi), hydatid of lung, 255 Gray induration of lunj. Sec Cirrhosis Gurgling rale, 125 Ilitmorrhage from and into lung, 194 Hsemorrhagic infarctus of lung, 194 Hiemotliorax. See Pleural effusion IIaldaxi:, tricuspid obstruction, 53 Hall, D3 Ilavilland, intrathoracic sarcoma, 226 Hall, Kadclyffc, pulse- breath, 160 Hamburger, auscultation of tesophagus, 1S5 Haruisox, sulcus, 16 : pectoriloquy, 100 Harvey, heart sounds, 8 J Heart, auscultation, 135 : bulging, 31 : displacement, 41, 42 : palpitation, 49 ; percussion, 79, 86 : sounds, 137 : thrills, 51. See Aortic obstruction and regurgi- tation, Asystoly, Dilatation, Enlargement, Hypertroidiy, Impulse, Malformations, Mitral obstruction and re- gurgitation. Movements, ]l»Iurmurs, Pulmonary obstruc- tion and regurgitation. Reduplication, Second sound, Tricuspid obstruction and regui'gitation, Valvular Hernia of lung, 31 Hippocrates, alar chest, 12 : auscultation by, 88 History of aortic regurgitation, 282 : auscultation, S3 : friction sound, 127, 140 : mitral obstruction, 278 : percussion, 55 ; physical signs of heart, 135, 1-10 : tricuspid regurgitation, 169 Hobbes, on signs, 1 INDEX. 317 HoDGKiN, aortic regurgitaut nuirnuir, 282 HoFFMAXN, auscultation of a'sophagus, IS.'i Honoril, pleural friction, 127 Hooping-cough, pigeon breast, 17 : cupping, 32 Hope, back stroke, 50 : regurgitant niurruurs, 27o Humeral percussion-note, 73 Hydatid tliiill. 75 Hydatids of lung, 254 : shape of chest, 28, 31 : diagnosis from pleural effusion, 226 : puncture, 183 Hydropericardium, See Pericardial effusion Hydropneumopericardium, 157, 273 Hydropneumothorax, 48, 208, 255 Hydrothorax, 215 : with cedema of lungs, 192 Hypertrophy of heart, 260, 284 : bulging of chest, 31 : recession of chest, 43 : impulse, 49, 50 : arterial mur- mur, 163. Sec Dilatation, Enlargement Immerminn, intrapulmonary vascular murmurs, 180 Impulse of aneurysms : of aorta, 299 : innomicata, 305 ; pulmonary artery, 306 Impulse of heart : systolic of apex, 39, 41 : of conus arte- riosus, 42 : of right auricle, 43 : diastolic, 50 ; pra?- systolic, 50 Induration of lung, brown, 193 : grey, 258. See Cirrhosis Infarctus of lung, hismorrhagic, 194 : pyemic, 243 Innominate artery, aneurysm. See Aneuiysm Inspection of chest, 4, See Table of Contents Inspection of jugular veins, 165 Inspiration, shape of chest ir, 5 : non-expans've, 37 Inspiratory dyspncea. See Dyspncca Intrapulmonary aneuiysm. See Aneurysm Jerking breathing, 113 JoHxsox, James, regurgitant murmurs, 275 318 INDEX. Jugular veins, inspection, 165 : pulsation, 166 : ausculta- tion, 172 KoLiSKO, metallic tinkle, 13-3 Kyphosis, shape of chest, 24 Laennec, M. vesicular breathing, 112 Laennec, R. T. H. discovers auscultation, 90 : tegophony, 100, 107, 111 : amphoric hum, 130 : bell sound, 131 : bronchial bi'eathing, 114 : bronchophony, 104 : carni- fication of lung, 202 : cavernous breathing, 115 : cavernous rale, 125 : cracked-pot sound, 66 : dry crepitant ra!e with big bubbles, 126 : heart's impulse, 49 : heart murmurs, 135 : metallic jingle, 161 : metallic tinkle, 131, 133 : obscure rale, 125 : pectoriloquy, 99, 111 ; pleural friction, 127, 129 : puerile breathing, 113 : pufF, 116 : pulsatile pulmonary sounds, 158 : pulsating pneumonia, 238 : rales, 122 : tubular cough, 116 : valvular thrill, 51 : veiled puff, 116 Lancisi, pulsating jugular veins, 169 Laryngeal obstruction, depression of sternum, 32 ; simu- lated by hydrothorax, 215 Laryngeal sounds of breathing, 118 Latham, quoted, 114 : ausc dtation of heart, 136, 140 : effect of pressure, 150 Lees, quoted, 281 Legg, murmur in jaundice, 294 Liver, depression, 177 : percussion dulness, 78 : pulsation, 174 : relation to constriction of thorax, 16 : tumours, diagnosis from i)leural effusion, 227. Sre ^\bsce3s, Subdiaphragmatic Lobular pneumonia. See Pneumonia Loculated empyema. Sec Emi^yema. Loculated pneumo- thorax. See Pneumothorax Loudness of sound, 01 INDEX, 319 Louis, angulus Ludovici, 10 : on empliyscmatous crepita- tion, 126 LrcwiG and Hesse, closure of cuspid orifices, 277 Lungs, auscultation, 95 : conducting power, 104: elasticity, 179 : palpation, 45 : percussion. 71, 76, 82 : relaxed, 71, 82 : vascular murmurs in, 180. See Actinomycosis, Aerifaction, Aneurysms, Atrophy, Brown induration. Catarrh, Cavity, Cirrhosis, Collapse, Congestion, Diph- theritic bronchitis, Emphysema, Gangrene, Grey indu- ration, Hsemovrhage, Hernia, Hydatids, Induration, Infarctus, CEdema, Phthisis, Plugging, Pneumoconiosis, Pneumonia, Solidification, Syphilis, Tuberculosis MacAlister, murmurs of debility, 277 Macdoxnell, tracheal tugging, 302 Mackenzie, auscultation of ce:opliagus, 185 Mahot, hepatic pulsation, 174 ^Malformation of heart, 295 ]\[arey, cardiograph, 49 ]\Iarkham, dilated auricle, 43 IMayor, sounds of fretal heart, 89 i\Ieasurement of chest, 9, 27. Sec Cyrtometer Mediastinal abscess, 297: tumour, 297: emphysema, 293 ]\rediastinum, position, 177 Membranous bronchitis, 190 ]\[ercier, hydatid of lung, 255 ^Metallic jingle, 161 Metallic ring, 65, 70, 72, ^;^, 132 ]\retallic tinkle, 131, 133 ]\[itral murmurs, 145 : valve, position, 144 Mitral obstruction, 278 : thrill, 53 : and aorLic regurgitation, 285 : and tricuspid obstruction, 288 ]\litral regurgitation, 145, 277: thrill, 52: with aortic regurgitation, 285 Mokey, lieart murmurs in pregnp.ncy, 294 320 INDEX, ^MOXTAIGXK, quuteil, 00 Moore, liyper trophy of lieavt. ^H ^loRTOx, shapes of chest, 14 Movements of respiration, 3-1 : of heart. 38,. 4S Mucons rale, 125 ^Muffled percussion sounds, 64, S3 Mullur, emphysema of mediastinum, 293 ]\rurmurs, in generr^l, 94 : aneurysmal, 162, 301 : arteiial, 162 : cardiac, 141 : subclavian, 163 : vascular in lungs, 180 : venous, 172 Murmurs of doubtful nature ; at base of heart, 154, 225 : in general, 292 Muscular ramble, 135 Nasal bronchophony, 100, lOS Obscure rale, 125 Obstructive murmurs, 142 (Edema of lungs, 191, 215 : crepitant rale, 123 CEsophagus, auscultation, 1S5 Old people, shape of chest. 8 : position of heart, 40 Oligaemia. See Cachexia Oliver, tracheal tugging, 302 Ord, adherent pericardium, 274 OuMEROD, E. L. pulmonary obstructive murmur, 291 Osteal percussion tone, 63 Piiljjation, 45. Sec Table of Contents Parasternal line, 10 Parrot, venous murmur*, 173 Pectoriloquy, 99, 104, 111 Percussion, 55, See Table of Contents Pericardial adhesion, 291 : recession of chest wall, 43 : recession of epigastrium, 175 : cup shaped depression. INDEX. 321 Pericardial eflfusion, 267 : bulging of chest, 31 : move- ments of cliest, 38 : fluctuation, 54 : puncture, 182 Pericardial friction. See Friction Pericarditis, 265 : in empyema, 230 Peritonitis, movements of cliest, 38 : friction, 134 Phillips, murmur at base of heart in pleural effusion, 226 Phthinoid chests, 12, 13 Phthisis pulmonalis, 246 : shape of chest, 26, 30, 32 : movements of chest, 38 : displacement of heart, 42 : vocal thrill, 47 : uncovers heart, 86 : vascular mur- murs, 180 : puncture of cavity, 183 : pneumothorax, 210 : diagnosis from jpleurisy with effusion, 227 : simu- lated by collapse of lung, 201, 202 : by pleurisy, 207 : by loculated pneumothorax, 212 : by cancer of lung, 251 : by dilated bronchi, 257 : by actinomycosis, 256 : by cirrhosis of lung, 259. See Destructive pneumonia Physical examination, 1 : method of, 3 : signs, 1 Pigeon breast, 16 : followed by emphysema, 24 PiORRT, theory of percussion, 57 : method, 59 : osteal tone, 63 : humoral sound, 73 : percussion resistence, 74 : hydatid thrill, 75 : ^gophony, 100 Pitch of tones, 62 Pitch-pipe, use of, 101 PiTRES, signe de sou, 220 Plessigraph, 60 Pleural adhesion, 234 : shape of chest, 30, 32 : movement of chest, 38 ; heart uncovered, 86 : mediastinum dis- placed, 178 Pleural effusion, 216 : shape of chest, 27, 31 : movement of chest, 38 : displacement of heart, 42 : vocal thrill, 46 : relaxation of lung, 82, 84 : percussion dulness, 84 : depression of diaphragm, 177 : displacement of mediastinum, 178 : puncture of chest, 182 : bronchial breathing, 122 : diagnosis from collapse, 202, 203 : from pneumonia, 239 : from hydatids, 254 : from G.A. Y 322 INDEX. cancer, 252 : from actiuomycosis, 25G : from peri- cardial effusioji, 271 : iu contracting cancer of lung, 251. See Emi^yema, Hydrothorax, Pleurisy, Pneumo- thorax Pleural friction. See Friction Pleural sounds, 127 Pleurisy, 206 : with eifusion, 216 : movements of chest, 38 : rale, 189, 207 : simulates i^htliisis, 207 : in embolic pneumonia, 243 : diagnosis from cancer, 252. Sec Empyema, Pleural effusion. Pleural adhesion Pleximeter, 59 Plugging of trachea and bronchi, 204 : diagnosis from catarrh, 189 : shape of chest, 31 : movements of chest, 37 Pneumatometer, 35 Pneumoconiosis, 250 Pneumonia, 236 : lobar, 236 : lobular, 210 : destructive, 241 : gangrenous, 241 : embolic, 243 : crepitant rale, 123 : after plugged broncbi, 205 : diagnosis from pleural effusion, 227, 239 : simulated by acute tuber- culosis, 245 : by cedema, 192. See Destructive pneumonia Pneumopericardium, 86, 131, 273 Pneumothorax, 208 : shajje of chest, 28 : movements of chest, 38 : percussion tone, 68, 82 ; amphoric sounds, 129 : false murmurs in, 159 : simulated by catarrh, 189 : by i)hthisis, 248 : diagnosis from emphysema, 196 : loculated, 212 : in embolic pneumonia, 243 : in pulsa- ting emi^yema, 233 : in hydatid, 255 PoLAiLLON, congenital defect of diaphragm, 213 PovHAM, pra3systolic jugular pulsation, 167 Position of body, effect on murmurs, 149 PoTAiN, reduplication of heart sounds, 153 Powell, displacement of mediastinum, 179 INDEX. 323 Prsesystolic impulse, 50 : murmurs, 146, 148, 278, 288 : XJulsation in jugulars, 167 : thrills, 53 : venous mur- murs, 173 Pregnancy, heart murmurs, 294 Pressure, efi'ect on murmurs, 149 Pterygoid. See Alar Puerile breathing, 113, 119 Puffin breathing, 116, 120. See Veiled puff Pulmometer, 35 Pulmonal percussion tones, 63 Pulmonary. See Lungs Pulmonary apoplexy. See Haemorrhage Pulmonary artery, position of orifice, 144 : embolism of, 243 : rupture of aortic aneurysm into, 304. See Aneurysm Pulmonary obstruction, 291 : thrill, 52 Pulmonary percussion sound, 76, 82 Pulmonary region, percussion of, 76, 81 Pulmonary regurgitation, 289 : thrills, 52 Pulmonary shock, sound of, 129 Pulmonary veins, murmurs, 143 Pulsatile crepitation, 160 : pleural friction, 160 : respiratory sound; 158 Pulsating cancer, 253 Pulsating empyema, 232 Pulsating pneumonia, 238 Pulsation, aneurysmal, 299 : epigastric, 173 : jugular veins, 166 Pulse-breath, 160 Puncture of chest, 181 : in pleural effusion, 226 : in hydatid disease, 255 Pyemic infarctus of lung, 243 Pyopneumothorax, 208, 212 324 INDEX. Eales, 122: amphoric, 133 : pleuritic, 189, 207, 216: pulsatile, 160 Ransome, stethometry, 35 Recession, epigastric, 175 : of chest in heart region, 40, 43. See Inspiratory dyspnoea Reduplication, heart sounds, 151 : murmurs, 152 Regurgitant murmurs, 142 Relaxation of lung, 70 Resistence in percussion, 74, 85. See Percussion in Table of Contents Resonance in percussion, 68. See Tone, Vocal resonance Resonators, 60 Respiration, movements, 34 : wholly abdominal, 38 : wholly thoracic, 38 : sounds, 112 : effect on heart murmurs, 150 : pulsatile sounds, 158 Reynaud, pleural effusion, 46 : pleural friction, 128 Rhinophony, 108 Rhonchus, 123, 126 Richardson, auscultation of cesophagus, 185 Rickets, shape of chest, 19 : causes pigeon breast, 16 : con- stricted chest, 15 : pulmonary catarrh, 188 Ringer, signs in veins of neck, 173 Roger, perforate septum ventriculorum, 296 Savart, fluid veins, 94 SciiAFER, reduplication of heart sounds, 152 ScnREiBER, venous murmurs, 173 Scoliosis, shape of chest, 18, 31 Second sound, accentuated pulmonaiy, 138, 193 Senac, pericardial effusion, 270 : pericardial fluctuation, 54 : pulsation of liver, 174 Septum ventriculorum, perforate, 143, 148, 296 Shaftesbury, quoted, 102 Shock, pulmonary. See Pulmonary shock Shoulder-blade friction, 135 INDEX. 325 Shoulder-joint friction, 134 Shrinking, local of chest, 32 Sibilant rale, sibilus, 126 SiBSON, peritonseal friction, 134 : position of heart valves, 144 : aneurysm of Valsalvian sinus, 299 Signe de sou, 220 Skerritt, conduction of sounds, 185 Skoda, theory of percussion, 57 : full sounds, 62 : tympan- itic sounds, 62 : veiled pufF, 116, 120 : metallic tinkle, 133 Solidification of lung, 105, 109, 121 Sonorous rale, 126 Souffle. See Puff Sound, in general, 61. See Heart, Percussion, Respiration Spirometer, 35 Splashing sound, pleural, 132, 133 : pericardial, 157 Spleen, percussion dulness, 78 : in pleural effusion, 220 Sputa, stinking, 242 Stethograph, 35 Stethometer, 35 Stethoscope, 91 Stokes, pulsating cancer of lung, 253 Stoll, percussion, 56 Stomach, percussion, 65, 78 Stone, segophony, 107 Subclavian murmurs, 163, 250 Subcrepitant rale, 125 Subtympanitic percussion sound, 63 Succussion splash, palpable, 48. See Splashing sound Superficial percussion, 75 Swift, quoted, 198 Syphilis of lung, 250 Systolic impulses, 39, 41, 48 : heart murmurs, 146, 148, 277, 286, 287, 291 : recession of chest, 40, 43 : thrills, 52 : venous murmurs, 173 : jugular pulsa- tion, 168 : arterial murmurs, 162 326 INDEX. Thoracometer, 35 Thrill, aneurysmal, 300, 303 : percussion, 75 : valvular, 51 : vocal, 45 Thymus, enlarged, 297 Tinkle. See Metallic tinkle Tone, 61, 64, 6Q Tonsils, enlarged, cause pigeon breast, 17 Trachea, compression by aneurysm, 802. See Plugging Tracheal percussion tones, 63, 82 Tracheal tugging, 302 Transverse constriction of chest, 14 Traube, on aortic obstruction, 286 Tricuspid obstruction, 288 : thrill, 53 Tricuspid regurgitation, 287 : venous pulse, 169, 174 Tricuspid valve, position, 144 Trousseau, bell sound, 132 Tubei'culosis of lungs, 244 : simulated by empyema, 231. See Phthisis Tubular breathing, 116, 119: j)ercussion tones. See Tracheal Tumours, abdominal, movements of chest, 38. See Aneu- rysm, Cancer, Hydatids, Mediastinal Tuning fork, 60 Tympanitic tone, 62, 82 Tyndall, sound, 61 Valsalvian sinus, aneurysm. See Aneurysm Valves of heart, 144 Valvular murmurs, 142 : thrills, 51 Van Swieten, alar chest, 13 : crepitant rale, 88, 124 Veiled puff, 116, 120 Veins. See Femoral, .Jugular, Pulsation, Venous Vena cava, rupture of aneurysm into, 170, 303 : murmurs, 143 INDEX. 327 Venous hum, 172 : pulsation, 165 Ventricle, rupture of aneurysm into, 304 Vesicular breathing, 112, 119 ViEUSSENS, pulse of aortic regurgitation, 284 Vocal resonance, 96 : thrill, 45 Voice, 101 Wade, anastomotic aortic aneuiysm, 154 Walshe, cracked-pot sound, 73 : emphysematous friction 129 : pectoriloquy, 105 Ward, venous hum, 172 Water-wheel sound, 157, 273 Watson, hcemothorax, 228 West, S. paracentesis of pericardium, 183 Whispered bronchophony, £9 Whooping cough. See Hooping cough Williams, cantering, 153 : crepitant rale, 123 : tracheal tone, 63 Willis, Thos., metallic tinkle, 88, 131 WiNTRiCH, tuning fork, 60 : Skoda's terminology, 63 : cracked-pot sound, 73 : -segophony, 107 : variable pitch of cavernous percussion tones, 248 Woillez, cyrtometer, 8 THE END. BRADBURY, AGNEW, & CO. LD., PRINTERS, WHITEFRIARS. R076.3 Gaa G?.7 1893